Implementation and Qualitative Analysis of Peer Support for New Pediatric Gastrostomy Tube Families.

INTRODUCTION: Gastrostomy tube (G-tube) insertion in children has frequent complications, including dislodgment and return to the system, which are associated with emotional burden for caregivers. To address these issues, we developed a peer support program for caregivers of children with new G-tubes and aimed to explore program feasibility and acceptability. METHODS: The G-tube Buddy Program is a peer support program that pairs an experienced G-tube caregiver with new G-tube caregivers. Between April 2022 and December 2022, seven mentors and 21 mentees participated in the program. Five mentors and ten mentees participated in semi-structured focus groups and interviews. Transcripts were analyzed using both inductive and deductive qualitative methods. RESULTS: We identified five prominent domains: peer support relationship dynamics; mentor and mentee-specific factors; determinants of program success; mentor and mentee perception of the program; and suggestions for program improvement. These domains encompassed main themes: support consisted primarily of assistance with daily life and social and emotional support; texting was usually the preferred communication method; mentee satisfaction is rooted in humanness, teaching, and generation of hope; mentors participated due to positive feelings regarding helping new caregivers with financial motivation being less important; and, participants perceived the program as a valuable source of support for new caregivers that complements and expands the reach of care they receive from clinical providers. CONCLUSIONS: A peer support model for families with new G-tubes appears feasible and acceptable from participant perspectives. Responses validate the program's potential to add value to the postoperative care of children with G-tubes and will guide program optimization.

Reduction of Pediatric Gastrostomy Tube Healthcare Utilization and Socioeconomic Disparities: Longitudinal Benefits of Quality Improvement.

BACKGROUND: Disparities in emergency department (ED) utilization after gastrostomy (G-) tube placement were previously demonstrated at our children's hospital. We aimed to reduce postoperative G-tube dislodgements and ED visits with a particular focus on socially vulnerable children. METHODS: Our improvement team implemented a G-tube care bundle (6/2018-9/2019) targeting caregiver preparedness and standardizing care in the pre-, intra-, and post-operative periods. Patients who had G tubes placed between 1/2011-8/2022 were categorized to either pre- or post-intervention groups. Primary outcomes were tracked prospectively. National area deprivation index (ADI) was assigned retrospectively and employed to evaluate social risk. Univariate comparisons were made between pre- and post-intervention groups, and between High ADI (≥80) and Low ADI (<80) subgroups in both pre- and post- intervention periods. We used statistical process control methods to further analyze change over time. RESULTS: 396 children were included (188 pre-intervention, 208 post-intervention). The post-intervention cohort demonstrated a lower rate of outpatient dislodgement at 90 days following G-tube placement (21.3 % vs 10.1 %, p = 0.002) and fewer G-tube-related ED visits per G-tube placed within one year of placement (mean 0.8 visits vs 0.6 visits, p = 0.012). Pre-intervention, children from high ADI neighborhoods had significantly greater healthcare utilization compared to those from lower ADI neighborhoods. Post-intervention, previously statistically significant disparities were no longer present. Outpatient G-tube dislodgements within 90 days were particularly mitigated. CONCLUSIONS: A longstanding quality improvement initiative has led to sustained reductions in overall G-tube-related health care utilization. Care standardization and improvement may mitigate outcome disparities related to socioeconomic advantage. TYPE OF STUDY: Retrospective Comparative Study and Prospective Quality Improvement. LEVEL OF EVIDENCE: Level III.

Predictors of opioid-free discharge after laparoscopic cholecystectomy.

BACKGROUND: Post-discharge opioid requirement after laparoscopic cholecystectomy (LC) is minimal, yet postoperative opioid prescriptions vary and opioid-free discharges are rare. STUDY DESIGN: Adult patients who underwent LC from 01/2019-12/2019 were reviewed. Univariate and multivariable logistic regression analyses were performed to identify predictors of opioid-free discharge. RESULTS: Of 393 included patients, 330 were discharged with opioids (median 12 oxycodone 5 mg pills) and 63 were discharged without opioids. One opioid-free discharge patient called for a prescription. Older age (OR = 1.02, 95% CI = 1.002-1.041) and non-elective procedure (OR = 0.35, 95% CI = 0.2291-0.8521) were independent predictors of opioid-free discharge. CONCLUSION: Significant opportunities for opioid reduction or elimination after discharge from LC exist. Non-elective procedure and older age are predictors of opioid-free discharge, and should be considered when individualizing prescription quantities as surgeons strive to reduce or eliminate opioid overprescription.

Surgical Informed Consent: A Scoping Review of Physician-facing Decision Support Tools.

Objectives: Physician-facing decision support tools facilitate shared decision-making (SDM) during informed consent, but it is unclear whether they are comprehensive in the domains they measure. In this scoping review, we aimed to (1) identify the physician-facing tools used during SDM; (2) assess the patient-centered domains measured by these tools; (3) determine whether tools are available for older adults and for use in various settings (elective vs. emergent); and (4) characterize domains future tools should measure. Methods: Using the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Reviews, Embase, Medline, and Web of Science were queried for articles published between January 2000 and September 2022. Articles meeting inclusion criteria underwent title and abstract review. Eligible studies underwent data abstraction by two reviewers. Results: Of 4365 articles identified, 160 were eligible. Tools to aid in surgical SDM focus on elective procedures (79%) and the outpatient setting (71%). Few tools are designed for older adults (5%) or for nonelective procedures (9%). Risk calculators were most common, followed by risk indices, prognostic nomograms, and communication tools. Of the domains measured, prognosis was more commonly measured (85%), followed by alternatives (28%), patient goals (36%), and expectations (46%). Most tools represented only one domain (prognosis, 33.1%) and only 6.7% represented all four domains. Conclusions and Implications: Tools to aid in the surgical SDM process measure short-term prognosis more often than patient-centered domains such as long-term prognosis, patient goals, and expectations. Further research should focus on communication tools, the needs of older patients, and use in diverse settings.

Provider Perspectives on Early Psychosocial Interventions after Pediatric Severe Traumatic Brain Injury: An Implementation Framework.

This study created a framework incorporating provider perspectives of best practices for early psychosocial intervention to improve caregiver experiences and outcomes after severe pediatric traumatic brain injury (TBI). A purposive sample of 23 healthcare providers from the emergency, intensive care, and acute care departments, was selected based on known clinical care of children with severe TBI at a level 1 trauma center and affiliated children's hospital. Semistructured interviews and directed content analysis were used to assess team and caregiver communication processes and topics, prognostication, and recommended interventions. Providers recommended a dual approach of institutional and individual factors contributing to an effective framework for addressing psychosocial needs. Healthcare providers recommended interventions in three domains: (1) presenting coordinated, clear messages to caregivers, (2) reducing logistical and emotional burden of care transitions, and (3) assessing and addressing caregiver needs and concerns. Specific family-centered and trauma-informed interventions included: (1) creating and sharing interdisciplinary plans with caregivers, (2) coordinating prognostication meetings and communications, (3) tracking family education, (4) improving institutional coordination and workflow, (5) training caregivers to support family involvement, (6) performing biopsychosocial assessment, and (7) using systematic prompts for difficult conversations and to address family needs at regular intervals. Healthcare workers from a variety of disciplines want to incorporate certain trauma-informed and family-centered practices at each stage of treatment to improve experiences for caregivers and outcomes for pediatric patients with severe TBI. Future research should test the feasibility and effectiveness of incorporating routine psychosocial interventions for these patients.