Repeat abdominal computed tomography scans after pediatric blunt abdominal trauma: missed injuries, extra costs, and unnecessary radiation exposure.

PURPOSE: We hypothesized that pediatric blunt trauma patients, initially evaluated at nontrauma centers with abdominal computed tomography (CT) scans, often undergo repeat scans after transfer. This study was designed to quantify this phenomenon, assess consequences, and elucidate possible causes. METHODS: This article is an institutional review board-approved, retrospective chart review of pediatric blunt abdominal trauma patients transferred to a level I trauma center from 2002 to 2007 and evaluated with abdominal CT at the trauma center or at a referring facility. RESULTS: A total of 388 patients met the study criteria, with 6 patients being excluded because of inability to verify outside records resulting in study group of 382 patients. Of those 382 patients, 199 (52%) underwent abdominal CT before transfer. Thirty-six (18%) of those 199 patients underwent repeat CT scanning at our level I trauma center. Of these 36 patients, 19 (53%) were transferred without their outside CT scans, with 10 (53%) of these 19 having significant abdominal injuries. Of the remaining 17, 6 (17%) had repeat scans to assess changes in vital signs, or patient condition, or because of inadequate outside imaging. The remaining 11 (30%) were repeated despite an acceptable outside CT and no change in patient condition. Only 2 of 11 resulted in changed management. Additional radiation delivered from these repeat scans totaled 180 mSv, and additional patient charges totaled more than $110,000. There was an apparent trend toward increased repeat scanning (from 6.7% in 2002 to 16.7% in 2007). CONCLUSIONS: Abdominal CT scans, for evaluation of pediatric blunt trauma, are frequently repeated after transfer from outside hospitals. In many cases, repeat scans provide useful diagnostic information. However, more than 80% of repeat scanning is potentially preventable with better education of transport personnel (paramedics, emergency medical technicians, and nurses) and emergency department physicians.

Does hospital type affect pyloromyotomy outcomes? Analysis of the Kids' Inpatient Database.

BACKGROUND: Pyloromyotomy is a common operative procedure performed on infants. The purpose of this study was to determine if hospital type affects lengths of stay (LOS), charges, and morbidity. METHODS: Patients undergoing pyloromyotomy were identified in the Kids' Inpatients Database from 2000, 2003, and 2006. Freestanding children's hospitals (CH) were compared with children's units within general hospitals (CUGH) and general/nonchildren's hospitals (GH). RESULTS: Of the 10,969 patients, 25% received care at 30 CH, 35% received care at 94 CUGH, and 40% received care at 662 GH. Adjusted LOS were 2.41 days for CH, 2.75 days for CUGH, and 2.82 days for GH (P < .01). Adjusted mean charges were $11,160 for CH, $12,284 for CUGH, and $10,197 for GH (P = .01). CH had the lowest unadjusted complication rate at 1.2% compared with 1.6% at CUGH and 2.2% at GH (P < .01). GH were more likely to have patients with prolonged LOS (> or =4 days) compared with CH after adjusting for patient and hospital factors (odds ratio [OR], 1.7; 95% confidence interval [CI], 1.2-2.5). After accounting for LOS, CUGH were more likely to have higher charges (> or =$11,057) compared with CH (OR, 3.4; 95% CI, 1.03-11.18). The adjusted mean charges rose from $7,733 in 2000 to $11,335 in 2003 and to $14,572 in 2006 (P < .01). CONCLUSION: CH had the shortest LOS and lowest complication rates. Despite a higher complication rate and longer LOS, GH had the lowest charges. There is an opportunity to identify best practices, to improve quality, and to lower costs for pyloromyotomy in the United States, regardless of hospital type.

Patent ductus arteriosus ligation in premature infants: who really benefits, and at what cost?

PURPOSE: Patent ductus arteriosus (PDA) ligation in premature infants has been shown to have low surgical morbidity and mortality. Ligation goals include prompt improvement in cardiorespiratory failure, with rapid wean from mechanical ventilation; less risk of prolonged mechanical ventilation and subsequent chronic lung disease (CLD); and survival to discharge. This study was designed to examine true morbidity after ligation and elucidate which preoperative factors might predict favorable outcomes. METHODS: Institutional review board-approved retrospective review of 197 infants less than 38 weeks of gestational age (GA), undergoing PDA ligation via thoracotomy between January 1, 1992, and January 1, 2004. Chronic lung disease defined as need for supplemental oxygen at 36 weeks corrected GA. Student t and chi2 tests were used. RESULTS: Mean GA was 27 weeks (range, 23-35 weeks), birth weight was 957 g (range, 440-3170 g); infants underwent ligation at 16 days of life (range, 1-132 days). Duration of surgery was 50.5 minutes (range, 13-150 minutes). Mean postoperative times were 27 days to extubation, 60 days to wean from supplemental oxygen, and 84 days to discharge. Early extubation (within 10 days of ligation) occurred in only 54 patients (30%). Only 44 (22%) survived to discharge without CLD. Forty patients (20%) died, with respiratory failure the most common cause (70%). In general, early extubation, survival without CLD and survival to discharge were associated with greater GA and birth weight, higher Apgar scores, greater age and weight at surgery, no preoperative intraventricular hemorrhage, lack of ventilator dependence, and lower ventilator settings (P < .05). Preoperative amount and duration of indomethacin use, chest x-ray findings, and echocardiographic assessment of ductus size did not predict favorable outcomes (all P > .05). CONCLUSIONS: Most premature infants currently undergoing PDA ligation at our institution do not experience the anticipated rapid improvements in cardiorespiratory status and go on to develop CLD. Few preoperative variables (including radiographic and echocardiographic assessments) definitively predict outcomes.

The influence of advanced radiographic imaging on the treatment of pediatric appendicitis.

PURPOSE: Since 1998, the use of advanced radiographic imaging with computed tomography (CT) and/or diagnostic ultrasound (US) has increased dramatically for the diagnosis of acute appendicitis in children. This study investigates the impact of this imaging on the evaluation, management, and outcome of pediatric patients who underwent appendectomy for suspected appendicitis. METHODS: Retrospective review of 197 consecutive children with a preoperative diagnosis of acute appendicitis, from January 2002 through May 2004, undergoing appendectomy at a university-affiliated community hospital by pediatric and general surgeons. RESULTS: Patients were divided into two groups: imaged (n = 106; 54%) and nonimaged (n = 91; 46%). Groups were similar with respect to age, sex, temperature, white blood count, and insurance status. Ninety-seven imaged patients had CT, 6 had US, and 3 had both CT and US. Seventy-one percent of imaging studies were ordered by emergency department physicians and 24% by treating surgeons. Average wait from emergency department triage to operative incision for the imaged and nonimaged groups was 12.1 and 5.4 hours, respectively (P < .0001). Both groups had similar perforation rates (imaged: 15.1%, nonimaged: 14.6%). Negative appendectomy rates were 10.4% (imaged) and 4.4% (nonimaged). Average hospital charges were 11,791 dollars (imaged) and 9360 dollars (nonimaged) (P = .001). Time on antibiotics, complication rates, and length of stay were similar for both groups. CONCLUSIONS: More than half of pediatric patients with suspected appendicitis now undergo advanced imaging and experience a significant delay in surgical treatment with a 26% increase in hospital charges and no clear-cut improvement in diagnostic accuracy nor outcome, when compared with evaluation by the treating surgeons.