Improving surgical care for children through multicenter registries and QI collaboratives.

The role of the healthcare organization is shifting and must overcome the challenges of fragmented, costly care, and lack of evidence in practice, to reduce cost, ensure quality, and deliver high-value care. Notable gaps exist within the expected quality and delivery of pediatric healthcare, necessitating a change in the role of the healthcare organization. To realize these goals, the use of collaborative networks that leverage massive datasets to provide information for the development of learning healthcare systems will become increasingly necessary as efforts are made to narrow the gap in healthcare quality for children. By building upon the lessons learned from early collaborative efforts and other industries, operationalizing new technologies, encouraging clinical-community partnerships, and improving performance through transparent pursuit of meaningful goals, pediatric surgery can increase the adoption of best practices by developing collaborative networks that provide evidence-based clinical decision support and accelerate progress toward a new culture of delivering high-quality, high-value, and evidenced-based pediatric surgical care.

Variation in bowel preparation among pediatric surgeons for elective colorectal surgery: A problem of equipoise or a knowledge gap of the available clinical evidence?

PURPOSE: Despite rigorous data from adult literature demonstrating that oral antibiotics (OA) reduce infectious complications and mechanical bowel preparation (MBP) alone does not, MBP alone remains the preferred approach among pediatric surgeons. We aimed to explore the nature of this discrepancy through a survey of the American Pediatric Surgical Association membership. METHODS: Surgeons were queried for their choice of bowel preparation, factors influencing their practice, and their impression of the strength and relevance of the adult literature to pediatric practice. RESULTS: Surgeons who used MBP alone (31%) cited a reduction in stool burden and infectious complications as important factors, whereas surgeons choosing not to use OA (70%) reported a lack of benefit in reducing infectious complications as the primary reason. Although 53% of surgeons reported that evidence from adult literature was the most important influence, 73% of surgeons reported there was poor evidence supporting the use of OA (±MBP), and only 25% used a preparation supported by adult randomized data. CONCLUSIONS: Wide variation exists among pediatric surgeons in the perceived utility of MBP and OA. Although the majority of pediatric surgeons cited the adult literature as the strongest influence on their practice, this is not consistent with stated perceptions or practice.

Use of mechanical bowel preparation and oral antibiotics for elective colorectal procedures in children: is current practice evidence-based?

PURPOSE: It is well established through randomized trials that oral antibiotics given with or without a mechanical bowel preparation (MBP) prior to colorectal procedures reduce complications, while MBP given alone provides no benefit. We aimed to characterize trends surrounding bowel preparation in children and determine whether contemporary practice is evidence-based. METHODS: Retrospective analysis of patients undergoing colorectal procedures at 42 children's hospitals (1/2/2007-12/31/2011) was performed. Patients were analyzed for diagnosis, pre-admission status, and inpatient bowel preparation. Bowel preparation was considered evidence-based if oral antibiotics were utilized with or without a MBP. RESULTS: 49% of all patients were pre-admitted (n=5,473), and the most common diagnoses were anorectal malformations (55%), inflammatory bowel disease (26%), and Hirschsprung's Disease (19%). The most common preparation approaches were MBP alone (54.3%), MBP+oral antibiotics (18.8%), and oral antibiotics alone (4.2%), although significant variation was found in hospital-specific rates for each approach (MBP alone: 0-96.1%, MBP+oral antibiotics: 0-83.6%, orals alone: 0-91.6%, p<0.0001). Only 22.9% of all patients received an evidence-based preparation (range by hospital: 0-92.3%, p<0.0001), and this rate decreased significantly during the five-year study period (27.6% in 2007 vs. 17.3% in 2011, p<0.0001). CONCLUSION: According to the best available clinical evidence, less than a quarter of all children pre-admitted for elective colorectal procedures receive a bowel preparation proven to reduce infectious complications.

Pressure induced lung injury in a novel in vitro model of the alveolar interface: protective effect of dexamethasone.

PURPOSE: The lungs of infants born with congenital diaphragmatic hernia suffer from immaturity as well as the short and long term consequences of ventilator-induced lung injury, including chronic lung disease. Antenatal and postnatal steroids are among current strategies promoted to treat premature lungs and limit long term morbidity. Although studied in whole-animal models, insight into ventilator-induced injury at the alveolar-capillary interface as well as the benefits of steroids, remains limited. The present study utilizes a multi-fluidic in vitro model of the alveolar-interface to analyze membrane disruption from compressive aerodynamic forces in dexamethasone-treated cultures. METHODS: Human alveolar epithelial cell lines, H441 and A549, were cultured in a custom-built chamber under constant aerodynamic shear followed by introduction of pressure stimuli with and without dexamethasone (0.1µM). On-chip bioelectrical measurements were noted to track changes to the cellular surface and live-dead assay to ascertain cellular viability. RESULTS: Pressure-exposed alveolar cultures demonstrated a significant drop in TEER that was less prominent with an underlying extracellular-matrix coating. Addition of dexamethasone resulted in increased alveolar layer integrity demonstrated by higher TEER values. Furthermore, dexamethasone-treated cells exhibited faster recovery, and the effects of pressure appeared to be mitigated in both cell types. CONCLUSION: Using a novel in vitro model of the alveolus, we demonstrate a dose-response relationship between pressure application and loss of alveolar layer integrity. This effect appears to be alleviated by dexamethasone and matrix sub-coating.

Assessment of surgical and obstetrical care at 10 district hospitals in Ghana using on-site interviews.

BACKGROUND: For most of the population in Africa, district hospitals represent the first level of access for emergency and essential surgical services. The present study documents the number and availability of surgical and obstetrical care providers as well as the types of surgical and obstetrical procedures being performed at 10 first-referral district hospitals in Ghana. MATERIALS AND METHODS: After institutional review board and governmental approval, a study team composed of Ghanaian and American surgeons performed on-site surveys at 10 district hospitals in 10 different regions of Ghana in August 2009. Face-to-face interviews were conducted documenting the numbers and availability of surgical and obstetrical personnel as well as gathering data relating to the number and types of procedures being performed at the facilities. RESULTS: A total of 68 surgical and obstetrical providers were interviewed. Surgical and obstetrical care providers consisted of Medical Officers (8.5%), nurse anesthetists (6%), theatre nurses (33%), midwives (50.7%), and others (4.5%). Major surgical cases represented 37% of overall case volumes with cesarean section as the most common type of major surgical procedure performed. The most common minor surgical procedures performed were suturing of lacerations or episiotomies. CONCLUSIONS: The present study demonstrates that there is a substantial shortage of adequately trained surgeons who can perform surgical and obstetrical procedures at first-referral facilities. Addressing human resource needs and further defining practice constraints at the district hospital level are important facets of future planning and policy implementation.