Economic Impact of COVID-19 on a Free-Standing Pediatric Ambulatory Center.

Background: Operating safely throughout the coronavirus disease 2019 (COVID-19) pandemic has required surgical centers to adapt and raise their level of readiness. Intuitively, additional expenses related to such adaptation may have resulted in an increase in the cost of surgical care. However, little is known about the magnitude of such an increase, and no study has evaluated the temporal variation in the costs of care throughout the pandemic. The aim of the current study was to evaluate the impact of COVID-19 on the cost of surgical and anesthetic care in a free-standing, pediatric ambulatory care center. Methods: We performed a retrospective review of the electronic medical record (EMR) and financial data for pediatric ambulatory settings between 2019 and 2020 (April - August) from our tertiary care children's hospital. The primary outcomes were the inflation-adjusted surgical cost for elective tonsillectomy, adenoidectomy, and tympanostomy tubes (BTI) placement procedures in children less than 18 years of age. These data were obtained from financial databases and aggregated into categories including anesthesia services, operating room services, recovery room services, and supply and medical devices. Results: Costs per case to provide care were significantly higher following the COVID-19 pandemic in 2020 compared to 2019 across all services: anesthesia ($1,268 versus $1,143; cost ratio (CR): 1.11, 95% confidence interval (CI): 1.08 - 1.14, P-value < 0.001), operating room ($1,221 vs. $1,255; CR: 1.03, 95% CI: 1.02 - 1.04, P-value < 0.001), recovery room ($659 vs. $751; CR: 1.14, 95% CI: 1.10 - 1.18, P-value < 0.001), and supply ($150 vs. $271; CR: 1.81, 95% CI: 1.26 - 2.6, P-value = 0.001). There was an overall increase in healthcare service costs in 2020, with significant fluctuations in the early and mid-year months. Conclusion: Our study identified specific economic impacts of COVID-19 on free-standing pediatric ambulatory centers, thereby highlighting the need for innovative practices with cost containment for sustainability of such specialized centers when dealing with future pandemics related to COVID-19 or other viral pathogens.

Current Trends in Mortality Attributable to Racial or Ethnic Disparities in Post-Surgical Population in The United States: A Population-Based Study.

Background: No study has contextualized the excess mortality attributable to racial and ethnic disparities in surgical outcomes. Further, not much effort has been made to quantify the effort needed to eliminate these disparities. Objective: We examined the current trends in mortality attributable to racial or ethnic disparities in the US postsurgical population. We then identified the target for mortality reduction that would be necessary to eliminate these disparities by 2030. Methods: We performed a population-based study of 1,512,974 high-risk surgical procedures among adults (18-64 years) performed across US hospitals between 2000 and 2020. Results: Between 2000 and 2020, the risk-adjusted mortality rates declined for all groups. Nonetheless, Black patients were more likely to die following surgery (adjusted relative risk 1.42; 95% CI, 1.39-1.46) driven by higher Black mortality in the northeast (1.60; 95% CI, 1.52-1.68), as well as the West (1.53; 95% CI, 1.43-1.62). Similarly, mortality risk remained consistently higher for Hispanics compared with White patients (1.21; 95% CI, 1.19-1.24), driven by higher mortality in the West (1.26; 95% CI, 1.21-1.31). Overall, 8364 fewer deaths are required for Black patients to experience mortality on the same scale as White patients. Similar figures for Hispanic patients are 4388. To eliminate the disparity between Black and White patients by 2030, we need a 2.7% annualized reduction in the projected mortality among Black patients. For Hispanics, the annualized reduction needed is 0.8%. Conclusions: Our data provides a framework for incorporating population and health systems measures for eliminating disparity in surgical mortality within the next decade.

Continued challenges in pediatric anesthesia during COVID-19 in 2022: An international survey from the pediatric anesthesia COVID-19 collaborative.

INTRODUCTION: This international survey explored the ongoing impact of COVID-19 on pediatric anesthesiology. It assessed COVID-19's impact on the practice of pediatric anesthesiology, staffing, job satisfaction, and retention at the beginning of 2022 and addressed what should be done to ameliorate COVID-19's impact and what initiatives hospitals had implemented. METHODS: This survey focused on five major domains: equipment/medication, vaccination/testing, staffing, burnout, and economic repercussions. Pilot testing for questionnaire clarity was conducted by members of the Pediatric Anesthesia COVID-19 Collaborative. The survey was administered by e-mail to a representative of the 72 collaborative centers. Respondents were instructed to answer based on their institution's practice from February through April of 2022. Descriptive statistics with 95% confidence intervals are reported. RESULTS: Seventy of seventy-two institutions participated in this survey (97% response rate). Fifty-nine (84%) were from the United States, and 11 (16%) included other countries. The majority experienced equipment (68%) and medication (60%) shortages. Many institutions reported staffing shortages in nursing (37%), perioperative staff (27%), and attending anesthesiologists (11%). Sixty-two institutions (89%) indicated burnout was a frequent topic of conversation among pediatric anesthesiologists. Forty-three institutions (61%) reported anesthesiologists leaving current practice and 37 (53%) early retirement. Twenty-eight institutions (40%) canceled elective cases. The major suggestions for improving job retention included improving financial compensation (76%), decreasing clinical time (67%), and increasing flexibility in scheduled clinical time (66%). Only a minority of institutions had implemented the following initiatives: improving financial compensation (19%), increased access to mental health/counseling services (30%), and assistance with child or elder care (7%). At the time of the survey, 34% of institutions had not made any changes. CONCLUSION: Our study found that COVID-19 has continued to impact pediatric anesthesiology. There are major discrepancies between what anesthesiologists believe are important for job satisfaction and faculty retention compared to implemented initiatives. Data from this survey provide insight for institutions and departments for addressing these challenges.

Prevalence of COVID-19 and Risk Factors for Infection Among Pediatric Anesthesia Patients: A Report From the PEACOC Research Network.

BACKGROUND: The Pediatric Anesthesia COVID-19 Collaborative (PEACOC) is a research network to advance the care of children during the pandemic. Here we calculate the prevalence of coronavirus disease 2019 (COVID-19) among children undergoing anesthesia, look at prevalence in the population data from the Centers for Disease Control and Prevention (CDC), and assess independent risk factors for infection. METHODS: This was a multicenter, retrospective, observational study. Children aged 28 days to 18 years scheduled for anesthesia services at 12 centers requiring universal COVID-19 testing from March 29, 2020 to June 30, 2020 were included. COVID-19 positivity rates among those tested were plotted and trends were assessed using the Cochran Armitage test of trend. Independent risk factors were explored using multivariable logistic regression. RESULTS: Data were collected and analyzed on 33,320 anesthesia encounters including 265 children with COVID-19. Over the study period, the rates of infections in the pediatric anesthesia population did not demonstrate a significant trend. In the general population, there was a significant downward trend in infection rates ( P < .001). In exploratory analysis, multivariable risk factors for a COVID-19 positive test were Black/African American race, Hispanic ethnicity, American Society of Anesthesiologists (ASA) physical status III or above, overweight and obese body mass index (BMI), orthopedic cases, abdominal cases, emergency cases, absence of injury and trauma, and West region (all P < .05). CONCLUSIONS: Rates of COVID-19 in pediatric anesthesia patients were consistently lower than in the general population. Independent risk factors of a positive test for children were identified. This is the first time universal testing for a single infectious disease was undertaken on a wide scale. As such, the association of infection with surgical case type or emergency case status is unprecedented.

Enhanced Recovery After Surgery: A Quality Improvement Approach.

Enhanced recovery after surgery (ERAS) protocols exist to optimize perioperative care for patients of all ages. The efficacy of ERAS protocols has been studied in various surgical specialties, including pediatric surgery and otolaryngology, but its role in pediatric otolaryngology has not been widely demonstrated in the literature. This review article attempts to assess the current state of ERAS within otolaryngology, pediatric surgery, and more specifically, pediatric otolaryngology to identify opportunities for future development and utilization.

Patient Characteristics Associated with NPO (Nil Per Os) Non-Compliance in the Pediatric Surgical Population.

Introduction: Cancellation of surgery or delay on the day of service is a huge burden for the patient, family, and healthcare system. Preventable delays impact efficiency and workflow, which may increase costs due to overtime and idle rooms during peak hours. Non-compliance to nil per os (NPO) guidelines remains one of the most common preventable causes for surgical cancellations. The current study sought to investigate and understand patient factors that may be associated with non-compliance to NPO guidelines. Methods: After IRB approval, a retrospective review of completed and cancelled pediatric procedures requiring the use of anesthesia over a 5-year period was performed. Emergency procedures and inpatient surgeries were excluded. Data regarding patient demographics and surgical service were extracted from the electronic medical records for comparison. A logistic regression model was used to identify factors associated with cancellations due to NPO non-compliance. Results: There were 825 cancellations due to NPO non-compliance of 144,049 cases for an incidence of 0.57% over the 5-year period. Patients in the 6-12 year old age range and those who self-identified as non-White or non-English speaking had a higher incidence of cancelling due to NPO non-compliance. Compared to ear, nose, and throat (ENT) procedures, cancellations due to NPO non-compliance were more likely in radiology, dental, and urology procedures. Discussion: Many factors may impact a family's compliance with NPO guidelines. Patient-related factors included those who self-identified as non-White or non-English speaking. Patients having ENT surgery were less likely to have NPO non-compliance than those having radiologic procedures, dental surgery, or urologic surgery. Future interventions focused on these groups may be most effective in limiting day of surgery cancellations.

Comparison of the Fitbit® charge and polysomnography for measuring sleep quality in children with sleep disordered breathing.

BACKGROUND: Due to the cost and inconvenience of polysomnography (PSG), wrist-worn accelerometers have been explored as an alternative method to measure sleep efficacy in children with obstructive sleep apnea (OSA) or sleep-disordered breathing (SDB). We compared the measurement of sleep quality with the Fitbit® charge (Fitbit Inc., San Francisco, CA, USA) compared to PSG in children presenting for sleep studies. METHODS: Children ages 3 to 18 years presenting for PSG with persistent SDB symptoms were enrolled. During PSG, the Fitbit® charge (Fitbit Inc.) was placed on the wrist and time-synchronized with sleep laboratory devices, which were worn while a single-night PSG was performed. Bias and concordance in measurements of total sleep time (TST), total wake time (TWT), and number of awakenings were assessed using paired t-tests, sign-rank tests, and Lin's concordance coefficient. RESULTS: The study cohort included 22 patients (9 boys and 13 girls; 9±3 years). TST was significantly overestimated using the Fitbit® charge (Fitbit Inc.) (difference in means: 30 min; 95% confidence interval [CI] of difference: 3-58; P=0.031), while TWT was underestimated (difference: 23 min; 95% CI: 4-42; P=0.018). All measures showed a lack of concordance between the Fitbit® charge (Fitbit Inc.) and PSG. CONCLUSIONS: The current prospective study confirms that the Fitbit® charge (Fitbit Inc.) overestimates time spent asleep compared to PSG in children with OSA/SDB symptoms, limiting the validity of sleep monitoring with wearable activity trackers appears in these patients.

Pediatric obesity and perioperative medicine.

PURPOSE OF REVIEW: Childhood obesity is a public health emergency that has reached a pandemic level and imposed a massive economic burden on healthcare systems. Our objective was to provide an update on (1) challenges of obesity definition and classification in the perioperative setting, (2) challenges of perioperative patient positioning and vascular access, (3) perioperative implications of childhood obesity, (3) anesthetic medication dosing and opioid-sparing techniques in obese children, and (4) research gaps in perioperative childhood obesity research including a call to action. RECENT FINDINGS: Despite the near axiomatic observation that obesity is a pervasive clinical problem with considerable impact on perioperative health, there have only been a handful of research into the many ramifications of childhood obesity in the perioperative setting. A nuanced understanding of the surgical and anesthetic risks associated with obesity is essential to inform patients' perioperative consultation and their parents' counseling, improve preoperative risk mitigation, and improve patients' rescue process when complications occur. SUMMARY: Anesthesiologists and surgeons will continue to be confronted with an unprecedented number of obese or overweight children with a high risk of perioperative complications.

A survey of the global impact of COVID-19 on the practice of pediatric anesthesia: A study from the pediatric anesthesia COVID-19 Collaborative Group.

BACKGROUND: Pediatric anesthesiology has been greatly impacted by COVID-19 in the delivery of care to patients and to the individual providers. With this study, we sought to survey pediatric centers and highlight the variations in care related to perioperative medicine during the COVID-19 pandemic, including the availability of protective equipment, the practice of pediatric anesthesia, and economic impact. AIM: The aim of the survey was to determine how COVID-19 directly impacted pediatric anesthesia practices during the study period. METHODS: A survey concerning four major domains (testing, safety, clinical management/policy, economics) was developed. It was pilot tested for clarity and content by members of the Pediatric Anesthesia COVID-19 Collaborative. The survey was administered by email to all Pediatric Anesthesia COVID-19 Collaborative members on September 1, 2020. Respondents had six weeks to complete the survey and were instructed to answer the questions based on their institution's practice during September 1 - October 13, 2020. RESULTS: Sixty-three institutions (100% response rate) participated in the COVID-19 Pediatric Anesthesia Survey. Forty-one hospitals (65%) were from the United States, and 35% included other countries. N95 masks were available to anesthesia teams at 91% of institutions (n = 57) (95% CI: 80%-96%). COVID-19 testing criteria of anesthesia staff and guidelines to return to work varied by institution. Structured simulation training aimed at improving COVID-19 safety and patient care occurred at 62% of institutions (n = 39). Pediatric anesthesiologists were economically affected by a reduction in their employer benefits and restriction of travel due to employer imposed quarantine regulations. CONCLUSION: Our data indicate that the COVID-19 pandemic has impacted the testing, safety, clinical management, and economics of pediatric anesthesia practice. Further investigation into the long-term consequences for the specialty is indicated.

A Survey to Define and Predict Difficult Vascular Access in the Pediatric Perioperative Population.

BACKGROUND: Various criteria exist for defining difficult peripheral intravenous (DPIV) cannulation in infants and children. With the help of a survey tool, the characteristics perceived to increase the likelihood of DPIV cannulation amongst anesthesia providers were assessed. METHODS: An individualized survey regarding DPIV which included pediatric anesthesiology faculty and certified registered nurse anesthetists at Nationwide Children's Hospital and anesthesiology faculty members of Wake-up Safe was conducted. Anesthesia provider, patient, and procedural characteristics were expressed as a count and percentage, and compared according to group (faculty, certified registered nurse anesthetists, Wake-up Safe faculty) using analysis of variance. RESULTS: Of the 48 local respondents, 33 (69%) reported age as a contributing factor to DPIV, and 32 (67%) reported weight as a factor. Of the 22 Wake-up Safe respondents, 14 (63%) reported age, and 16 (73%) reported weight as a factor. Patient and procedural characteristics perceived to increased likelihood of DPIV cannulation did not differ by respondent role. The factors most commonly mentioned by local respondents as contributing to DPIV included trisomy 21, neuromuscular disorders, and history of many prior IV cannulations. Among the Wake-up Safe faculty respondents, the most commonly mentioned factors were neuromuscular disorders, trisomy 21, and skin injuries or conditions. CONCLUSION: Age and weight were the two most commonly reported factors from both groups of respondents. Other factors contributing to DPIV included prior history of DPIV, neuromuscular disorders, trisomy 21 and American Society of Anesthesiology status ≥4. Patient and procedural characteristics were perceived to increase the likelihood of DPIV cannulation with no difference among respondents.

The otolaryngologist's and anesthesiologist's collaborative role in a pandemic: A large quaternary pediatric center's experience with COVID-19 preparation and simulation.

There has been a rapid global spread of a novel coronavirus, the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), which originated in Wuhan China in late 2019. A serious threat of nosocomial spread exists and as such, there is a critical necessity for well-planned and rehearsed processes during the care of the COVID-19 positive and suspected patient to minimize transmission and risk to healthcare providers and other patients. Because of the aerosolization inherent in airway management, the pediatric otolaryngologist and anesthesiologist should be intimately familiar with strategies to mitigate the high-risk periods of viral contamination that are posed to the environment and healthcare personnel during tracheal intubation and extubation procedures. Since both the pediatric otolaryngologist and anesthesiologist are directly involved in emergency airway interventions, both specialties impact the safety of caring for COVID-19 patients and are a part of overall hospital pandemic preparedness. We describe our institutional approach to COVID-19 perioperative pandemic planning at a large quaternary pediatric hospital including operating room management and remote airway management. We outline our processes for the safe and effective care of these patients with emphasis on simulation and pathways necessary to protect healthcare workers and other personnel from exposure while still providing safe, effective, and rapid care.

Pediatric Airway Management in COVID-19 Patients: Consensus Guidelines From the Society for Pediatric Anesthesia's Pediatric Difficult Intubation Collaborative and the Canadian Pediatric Anesthesia Society.

The severe acute respiratory syndrome coronavirus 2 (coronavirus disease 2019 [COVID-19]) pandemic has challenged medical systems and clinicians globally to unforeseen levels. Rapid spread of COVID-19 has forced clinicians to care for patients with a highly contagious disease without evidence-based guidelines. Using a virtual modified nominal group technique, the Pediatric Difficult Intubation Collaborative (PeDI-C), which currently includes 35 hospitals from 6 countries, generated consensus guidelines on airway management in pediatric anesthesia based on expert opinion and early data about the disease. PeDI-C identified overarching goals during care, including minimizing aerosolized respiratory secretions, minimizing the number of clinicians in contact with a patient, and recognizing that undiagnosed asymptomatic patients may shed the virus and infect health care workers. Recommendations include administering anxiolytic medications, intravenous anesthetic inductions, tracheal intubation using video laryngoscopes and cuffed tracheal tubes, use of in-line suction catheters, and modifying workflow to recover patients from anesthesia in the operating room. Importantly, PeDI-C recommends that anesthesiologists consider using appropriate personal protective equipment when performing aerosol-generating medical procedures in asymptomatic children, in addition to known or suspected children with COVID-19. Airway procedures should be done in negative pressure rooms when available. Adequate time should be allowed for operating room cleaning and air filtration between surgical cases. Research using rigorous study designs is urgently needed to inform safe practices during the COVID-19 pandemic. Until further information is available, PeDI-C advises that clinicians consider these guidelines to enhance the safety of health care workers during airway management when performing aerosol-generating medical procedures. These guidelines have been endorsed by the Society for Pediatric Anesthesia and the Canadian Pediatric Anesthesia Society.

Adenotonsillectomy and postoperative respiratory adverse events: A retrospective study.

OBJECTIVES: Postoperative respiratory adverse events (PRAEs) are known complications following adenotonsillectomy (AT). Clinical data at a single institution were reviewed to investigate the factors that may contribute to PRAEs in the postanesthesia care unit (PACU). The relationship between PRAEs in the PACU and escalation of care, defined as either an unplanned admission for outpatient surgery or unplanned pediatric intensive care unit (PICU) admission, was investigated. METHODS: The perioperative records for all patients who underwent AT from 2016 to 2018 were reviewed. The surgical procedure was performed at both the main campus and the ambulatory surgery center in accordance with the institutional obstructive sleep apnea (OSA) guidelines. Patient characteristics and intraoperative medications were compared. Categorical variables were summarized as counts with percentages and compared using chi-square tests or Fisher's exact tests. Continuous variables were summarized as medians with interquartile ranges and compared using rank-sum tests. Multivariable logistic regression was performed to evaluate the association of intraoperative dosing with the occurrence of PRAEs. RESULTS: The study cohort included 6110 patients. Ninety-three patients (2%) experienced PRAEs in the PACU. Of these 93 patients, 14 (15%) resulted in an escalation of care, nearly all of which were unplanned PICU admissions. PRAEs tended to occur in younger patients, non-Hispanic black patients, and those with a higher American Society of Anesthesiologists (ASA) status. CONCLUSIONS: PRAEs are infrequent after AT at a tertiary institution with OSA guidelines in place. However, when PRAEs do occur, escalation of care may be required. Risk factors include age, ethnic background, and ASA physical status. LEVEL OF EVIDENCE: III.

Weight Gain Trajectory and Pain Interference in Young Adulthood: Evidence from a Longitudinal Birth Cohort Study.

OBJECTIVE: Obesity is associated with chronic pain, but the contribution of body mass index (BMI) trajectories over the life course to the onset of pain problems remains unclear. We retrospectively analyzed how BMI trajectories during the transition to adulthood were associated with a measure of pain interference obtained at age 29 in a longitudinal birth cohort study. METHODS: Data from the National Longitudinal Survey of Youth, 1997 Cohort (follow-up from 1997 to 2015), were used to determine BMI trajectories from age 14 to 29 via group trajectory modeling. At age 29, respondents described whether pain interfered with their work inside and outside the home over the past four weeks (not at all, a little, or a lot). Multivariable ordinal logistic regression was used to evaluate pain interference according to BMI trajectory and study covariates. RESULTS: Among 7,875 respondents, 11% reported "a little" and 4% reported "a lot" of pain interference at age 29. Four BMI trajectory groups were identified, varying in starting BMI and rate of weight gain. The "obese" group (8% of respondents) had a starting BMI of 30 kg/m2 and gained an average of 0.7 kg/m2/y. On multivariable analysis, this group was the most likely to have greater pain interference, compared with "high normal weight" (odds ratio [OR] = 1.47, 95% confidence interval [CI] = 1.14-1.88), "low normal weight" (OR = 1.45, 95% CI = 1.13-1.87), and "overweight" trajectories (OR = 1.33, 95% CI = 1.02-1.73). CONCLUSIONS: Obesity and rapid weight gain during the transition to adulthood were associated with higher risk of pain interference among young adults.

Experience with Combining Pediatric Procedures into a Single Anesthetic.

The combination of multiple procedures within a single anesthetic may provide many challenges for the perioperative team. Coordination of specialties, consideration for parental time burdens, and travel expenses as well as limiting multiple anesthetic exposures to the children are pertinent factors to consider when advocating the combination of surgical procedures. METHODS: The electronic medical record at Nationwide Children's Hospital was retrospectively queried to obtain information on patients having a single anesthetic encounter for 2 or more procedures involving 2 or more services over 1 year (July 2015-June 2016). RESULTS: One thousand one hundred twenty patients had 2 procedures during a single anesthetic encounter. The average anesthesia time was 127 ± 102 minutes, and average PACU time was 64 ± 37 minutes. The unanticipated admission rate was 85 of 1,120 cases (7.6%). Five (6%) of the unanticipated admission cases were ASA status 1, 33 (39%) were ASA status 2, and 47 (55%) were ASA status ≥3; compared with 87 (9%), 481 (50%), and 391 (41%) in the group not requiring unanticipated admission (P = 0.032) (see Fig. 1). CONCLUSIONS: These data demonstrate the feasibility of combining several procedures during a single anesthetic encounter and may result in decreased healthcare costs as well as limitation of parental cost and time obligations.

Projecting Cost Containment in the Operating Room Utilizing Incentivized Strategies to Reduce Healthcare Cost.

INTRODUCTION: Streamlining healthcare in United States is of paramount concern while maintaining standards of quality and safety. Incentivizing change may be even more effective in driving such measures. At Nationwide Children's Hospital, we incentivize cost savings directly to the healthcare team member. In this project, we evaluated a simple substitution of a buretrol for Y-type tubing based on weight rather than age cutoffs. METHODS: This was deemed a quality improvement project and therefore exempt from Institutional Review Board approval. We obtained costs of Y-type tubing versus buretrols. We interrogated the electronic medical record to quantify case volume in the main operating room according to age and weight. We calculated our costs to compare our current practice of using buretrol fo age ≤ 12 years and the planned practice of using buretrol for weight < 20 kg. RESULTS: We identified 28,875 children ages 0-12 (60% weight <20kg) and 6,301 children ages 13-18 (0.1% weight <20kg) undergoing procedures in the main operating rooms over a 1-year period.. A unit cost savings of $4.40 substituting Y-type tubing for a buretrol was determined. Transitioning from age-based to weight-based criteria for buretrol use was determined to potentially save $51,260 over the period reviewed. CONCLUSIONS: Simple changes can impact efficiency and cost in healthcare. It is important to consider incentivizing such measures to help drive these changes. In the future, with more incentivized measures, hopefully we can successfully make an impact of efficiency and cost of healthcare in United States without compromising safety or quality.