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1.
Ann Surg ; 277(3): 423-428, 2023 03 01.
Artículo en Inglés | MEDLINE | ID: mdl-34520422

RESUMEN

OBJECTIVES: To explore the surgeon-perceived added value of mobile health technologies (mHealth), and determine facilitators of and barriers to implementing mHealth. BACKGROUND: Despite the growing popularity of mHealth and evidence of meaningful use of patient-generated health data in surgery, implementation remains limited. METHODS: This was an exploratory qualitative study following the Consolidated Criteria for Reporting Qualitative Research. Purposive sampling was used to identify surgeons across the United States and Canada. The Consolidated Framework for Implementation Research informed development of a semistructured interview guide. Video-based interviews were conducted (September-November 2020) and interview transcripts were thematically analyzed. RESULTS: Thirty surgeons from 8 specialties and 6 North American regions were interviewed. Surgeons identified opportunities to integrate mHealth data pre- operatively (eg, expectation-setting, decision-making) and during recovery (eg, remote monitoring, earlier detection of adverse events) among higher risk patients. Perceived advantages of mHealth data compared with surgical and patient-reported outcomes included easier data collection, higher interpretability and objectivity of mHealth data, and the potential to develop more patientcentered and functional measures of health. Surgeons identified a variety of implementation facilitators and barriers around surgeon- and patient buy-in, integration with electronic medical records, regulatory/reimbursement concerns, and personnel responsible for mHealth data. Surgeons described similar considerations regarding perceptions of mHealth among patients, including the potential to address or worsen existing disparities in surgical care. CONCLUSIONS: These findings have the potential to inform the effective and equitable implementation of mHealth for the purposes of supporting patients and surgical care teams throughout the delivery of surgical care.


Asunto(s)
Grupos Raciales , Telemedicina , Humanos , Tecnología Biomédica , Canadá , Investigación Cualitativa
2.
Ann Surg ; 277(2): e280-e286, 2023 02 01.
Artículo en Inglés | MEDLINE | ID: mdl-34238811

RESUMEN

OBJECTIVE: The aim of this study was to estimate the association between estimated glomerular filtration rate (eGFR) and acute myocardial infarction (AMI) or death after ambulatory noncardiac surgery. SUMMARY BACKGROUND DATA: People with chronic kidney disease (CKD) commonly undergo surgical procedures. Although most are performed in an ambulatory setting, the risk of major perioperative outcomes after ambulatory surgery for people with CKD is unknown. METHODS: In this retrospective population-based cohort study using administrative health data from Alberta, Canada, we included adults with measured preoperative kidney function undergoing ambulatory noncardiac surgery between April 1, 2005 and February 28, 2017. Participants were categorized into 6 eGFR categories (in mL/min/1.73m 2 )of ≥60 (G1-2), 45 to 59 (G3a), 30 to 44 (G3b), 15 to 29 (G4), <15 not receiving dialysis (G5ND), and those receiving chronic dialysis (G5D). The odds of AMI or death within 30 days of surgery were estimated using multivariable generalized estimating equation models. RESULTS: We identified 543,160 procedures in 323,521 people with a median age of 66 years (IQR 56-76); 52% were female. Overall, 2338 people (0.7%) died or had an AMI within 30 days of surgery. Compared with the G1-2 category, the adjusted odds ratio of death or AMI increased from 1.1 (95% confidence interval: 1.0-1.3) for G3a to 3.1 (2.6-3.6) for G5D. Emergency Department and Urgent Care Center visits within 30 days were frequent (17%), though similar across eGFR categories. CONCLUSIONS: Ambulatory surgery was associated with a low risk of major postoperative events. This risk was higher for people with CKD, which may inform their perioperative shared decision-making and management.


Asunto(s)
Procedimientos Quirúrgicos Ambulatorios , Insuficiencia Renal Crónica , Adulto , Humanos , Femenino , Persona de Mediana Edad , Anciano , Masculino , Estudios Retrospectivos , Estudios de Cohortes , Insuficiencia Renal Crónica/complicaciones , Insuficiencia Renal Crónica/epidemiología , Tasa de Filtración Glomerular , Riñón , Alberta/epidemiología
3.
Pediatr Surg Int ; 39(1): 108, 2023 Feb 10.
Artículo en Inglés | MEDLINE | ID: mdl-36759361

RESUMEN

PURPOSE: To explore the perceptions, satisfaction, and needs of adolescent surgical patients with their perioperative pathway, including consent, the Safe Surgical Checklist (SSC), and post-operative care. METHODS: We used qualitative methodology to examine adolescent experiences with surgical consent, SSC, and post-operative care. We purposively recruited ten patients aged 13-17 undergoing emergency and elective surgery and obtained consent from parents and patients. Semi-structured interview scripts were co-developed with an adolescent patient advisor, and interviews were performed, recorded, and transcribed verbatim. Thematic analysis was based on grounded theory and Participants were recruited and interviewed until thematic saturation was achieved. RESULTS: Four themes emerged in thematic analysis: (1) Autonomy and Inclusion-Adolescents desire to participate in the consent process, including signing their own consent when appropriate, (2) Value of Repetition-Adolescents value the repetition of information in the pre-operative check and feel safer when the team reinforces the information, (3) Importance of Caregiver Involvement - Adolescents valued their caregivers being involved in critical conversations and decision making, and (4) Importance of Transparency in Communication-Adolescents desire to be directly given information about their surgery post-operatively and not told to parents alone. CONCLUSION: Adolescents are situated uniquely between childhood and adulthood. Adolescents desired to be directly involved in the decision-making process of their surgery, including participation in the SSC and discussion of post-operative complications.


Asunto(s)
Lista de Verificación , Toma de Decisiones , Humanos , Adolescente , Niño , Padres , Cuidadores
4.
Pediatr Surg Int ; 39(1): 210, 2023 Jun 01.
Artículo en Inglés | MEDLINE | ID: mdl-37261599

RESUMEN

BACKGROUND: Parents endure significant stress when their newborns require surgery while in the neonatal intensive care unit (NICU). Our study aims to explore the surgical NICU experience from the parents' perspective and identify areas that may improve this experience. A secondary objective was to integrate their feedback to refine the implementation strategy of the neonatal enhanced recovery after surgery (ERAS®) guideline. METHODS: In December 2019, five surgical NICU parents participated in a focus group. Conversation surrounded parents' perspectives and experiences of the surgical NICU. Inductive analysis was performed to identify data, themes, and concepts that emerged from the discussion. RESULTS: Participants identified four major interrelated themes that impacted the surgical parents' NICU experience. These themes include (1) parental state, both physical and emotional, (2) the altered parental caregiver role which necessitates identifying alternative meaningful parental experiences, (3) the care team dynamic, incorporating consistency and effective communication, and (4) the discharge process which may be significantly eased through graduated, hands-on training. CONCLUSION: Key elements of the neonatal ERAS® guideline address major themes and stressors identified by parents. The parental perspective may help clinicians appreciate the parent surgical NICU experience and assist in improving family-centered care to surgical infants and their families.


Asunto(s)
Unidades de Cuidado Intensivo Neonatal , Alta del Paciente , Lactante , Recién Nacido , Humanos , Padres/psicología , Emociones
5.
Ann Surg ; 275(1): e256-e263, 2022 01 01.
Artículo en Inglés | MEDLINE | ID: mdl-33060376

RESUMEN

OBJECTIVE: To measure the survival among comparable neonates with CDH supported with and without ECLS. SUMMARY OF BACKGROUND DATA: Despite widespread use in the management of newborns with CDH, ECLS has not been consistently associated with improved survival. METHODS: A retrospective cohort study was performed using ECLS-eligible CDH Study Group registry patients born between 2007 and 2019. The primary outcome was in-hospital mortality. Neonates who did and did not receive ECLS were matched based on variables affecting risk for the primary outcome. Iterative propensity score-matched, survival (Cox regression and Kaplan-Meier), and center effects analyses were performed to examine the association of ECLS use and mortality. RESULTS: Of 5855 ECLS-eligible CDH patients, 1701 (29.1%) received ECLS. "High-risk" patients were best defined as those with a lowest achievable first-day arterial partial pressure of CO2 of ≥60 mm Hg. After propensity score matching, mortality was higher with ECLS (47.8% vs 21.8%, odds ratio 3.3, 95% confidence interval 2.7-4.0, hazard ratio 2.3, P < 0.0001). For the subgroup of high-risk patients, there was lower mortality observed with ECLS (64.2% vs 84.4%, odds ratio 0.33, 95% confidence interval 0.17-0.65, hazard ratio 0.33, P = 0.001). This survival advantage was persistent using multiple matching approaches. However, this ECLS survival advantage was found to occur primarily at high CDH volume centers that offer frequent ECLS for the high-risk subgroup. CONCLUSIONS: Use of ECLS is associated with excess mortality for low- and intermediate-risk neonates with CDH. It is associated with a significant survival advantage among high-risk infants, and this advantage is strongly influenced by center CDH volume and ECLS experience.


Asunto(s)
Oxigenación por Membrana Extracorpórea/métodos , Predicción , Hernias Diafragmáticas Congénitas/mortalidad , Puntaje de Propensión , Femenino , Estudios de Seguimiento , Hernias Diafragmáticas Congénitas/diagnóstico , Hernias Diafragmáticas Congénitas/terapia , Mortalidad Hospitalaria/tendencias , Humanos , Recién Nacido , Masculino , Estudios Retrospectivos , Tasa de Supervivencia/tendencias , Estados Unidos/epidemiología
6.
J Surg Res ; 280: 218-225, 2022 12.
Artículo en Inglés | MEDLINE | ID: mdl-36007480

RESUMEN

INTRODUCTION: Clear communication around surgical device use is crucial to patient safety. We evaluated the utility of the Device Briefing Tool (DBT) as an adjunct to the Surgical Safety Checklist. METHODS: A nonrandomized, controlled pilot of the DBT was conducted with surgical teams at an academic referral center. Intervention departments used the DBT in all cases involving a surgical device for 10 wk. Utility, relative advantage, and implementation effectiveness were evaluated via surveys. Trained observers assessed adherence and team performance using the Oxford NOTECHS system. RESULTS: Of 113 individuals surveyed, 91 responded. Most respondents rated the DBT as moderately to extremely useful. Utility was greatest for complex devices (89%) and new devices (88%). Advantages included insight into the team's familiarity with devices (70%) and improved teamwork and communication (68%). Users found it unrealistic to review all device instructional materials (54%). Free text responses suggested that the DBT heightened awareness of deficiencies in device familiarity and training but lacked a clear mechanism to correct them. DBT adherence was 82%. NOTECHS scores in intervention departments improved over the course of the study but did not significantly differ from comparator departments. CONCLUSIONS: The DBT was rated highly by both surgeons and nurses. Adherence was high and we found no evidence of "checklist fatigue." Centers interested in implementing the DBT should focus on devices that are complex or new to any surgical team member. Guidance for correcting deficiencies identified by the DBT will be provided in future iterations of the tool.


Asunto(s)
Quirófanos , Cirujanos , Humanos , Lista de Verificación , Seguridad del Paciente , Comunicación , Grupo de Atención al Paciente
7.
BMC Health Serv Res ; 22(1): 1284, 2022 Oct 25.
Artículo en Inglés | MEDLINE | ID: mdl-36284293

RESUMEN

BACKGROUND: Strategies selected to implement the WHO's Surgical Safety Checklist (SSC) are key factors in its ability to improve patient safety. Underutilization of implementation frameworks for informing implementation processes hinders our understanding of the checklists' varying effectiveness in different contexts. This study explored the extent to which SSC implementation practices could be assessed through the i-PARIHS framework and examined how it could support development of targeted recommendations to improve SSC implementation in high-income settings. METHODS: This qualitative study utilized interviews with surgical team members and health administrators from five high-income countries to understand the key elements necessary for successful implementation of the SSC. Using thematic analysis, we identified within and across-case themes that were mapped to the i-PARIHS framework constructs. Gaps in current implementation strategies were identified, and the utility of i-PARIHS to guide future efforts was assessed. RESULTS: Fifty-one multi-disciplinary clinicians and health administrators completed interviews. We identified themes that impacted SSC implementation in each of the four i-PARIHS constructs and several that spanned multiple constructs. Within innovation, a disconnect between the clinical outcomes-focused evidence in the literature and interviewees' patient-safety focus on observable results reduced the SSC's perceived relevance. Within recipients, existing surgical team hierarchies impacted checklist engagement, but this could be addressed through a shared leadership model. Within context, organizational priorities resulting in time pressures on surgical teams were at odds with SSC patient safety goals and reduced fidelity. At a health system level, employing surgical team members through the state or health region resulted in significant challenges in enforcing checklist use in private vs public hospitals. Within its facilitation construct, i-PARIHS includes limited definitions of facilitation processes. We identified using multiple interdisciplinary champions; establishing checklist performance feedback mechanisms; and modifying checklist processes, such as implementing a full-team huddle, as facilitators of successful SSC implementation. CONCLUSION: The i-PARIHS framework enabled a comprehensive assessment of current implementation strategies, identifying key gaps and allowed for recommending targeted improvements. i-PARIHS could serve as a guide for planning future SSC implementation efforts, however, further clarification of facilitation processes would improve the framework's utility. TRIAL REGISTRATION: No health care intervention was performed.


Asunto(s)
Lista de Verificación , Seguridad del Paciente , Humanos , Investigación Cualitativa , Atención a la Salud , Instituciones de Salud
8.
Can J Surg ; 65(4): E527-E533, 2022.
Artículo en Inglés | MEDLINE | ID: mdl-35961660

RESUMEN

BACKGROUND: Frequently occurring in adolescents, osteosarcoma is the most common primary malignant bone disease, with a reported 15% of patients who present with metastasis. With advances in imaging and improvements in surgical care, an updated analysis is warranted on the outcomes of pediatric patients with osteosarcoma. METHODS: We completed a retrospective review of pediatric patients who presented with osteosarcoma between 2001 and 2017, using The Cancer in Young People in Canada (CYP-C) national database. Data on 304 patients aged younger than 15 years were analyzed. RESULTS: The proportion of patients who presented with metastasis was 23.0%. The overall 5-year survival (OS) for patients who presented with metastasis was 37.4%. Overall survival and event-free survival (EFS) were lower in these patients than in patients with localized disease (hazard ratio [HR] 4.3, p < 0.0001 and HR 3.1, p < 0.0001). For patients who presented with metastatic disease, the OS for those undergoing an operative intervention was 44.1% compared with 17.6% for those who did not undergo resection (p < 0.0001). CONCLUSION: The proportion of patients who presented with metastatic osteosarcoma in our population is higher than previously reported. Overall outcomes of patients with metastatic disease have not changed. Our data reaffirm a role for surgical resection in patients with metastasis with a need to explore new treatment strategies to improve the overall prognosis of these patients.


Asunto(s)
Neoplasias Óseas , Osteosarcoma , Adolescente , Anciano , Neoplasias Óseas/cirugía , Niño , Humanos , Osteosarcoma/patología , Osteosarcoma/cirugía , Pronóstico , Estudios Retrospectivos , Tasa de Supervivencia
9.
World J Surg ; 45(5): 1293-1296, 2021 05.
Artículo en Inglés | MEDLINE | ID: mdl-33638023

RESUMEN

BACKGROUND: As surgical systems are forced to adapt and respond to new challenges, so should the patient safety tools within those systems. We sought to determine how the WHO SSC might best be adapted during the COVID-19 pandemic. METHODS: 18 Panelists from five continents and multiple clinical specialties participated in a three-round modified Delphi technique to identify potential recommendations, assess agreement with proposed recommendations and address items not meeting consensus. RESULTS: From an initial 29 recommendations identified in the first round, 12 were identified for inclusion in the second round. After discussion of recommendations without consensus for inclusion or exclusion, four additional recommendations were added for an eventual 16 recommendations. Nine of these recommendations were related to checklist content, while seven recommendations were related to implementation. CONCLUSIONS: This multinational panel has identified 16 recommendations for sites looking to use the surgical safety checklist during the COVID-19 pandemic. These recommendations provide an example of how the SSC can adapt to meet urgent and emerging needs of surgical systems by targeting important processes and encouraging critical discussions.


Asunto(s)
COVID-19 , Lista de Verificación , Cirugía General/organización & administración , Pandemias , Técnica Delphi , Humanos , Organización Mundial de la Salud
10.
Can J Surg ; 64(4): E364-E370, 2021 07 05.
Artículo en Inglés | MEDLINE | ID: mdl-34223740

RESUMEN

Background: In 2017, a provincial guideline was created to fast track and standardize care for pediatric appendicitis in Alberta. We conducted a study to determine the impact of implementation of the guideline at our institution on length of stay (LOS), antibiotic stewardship efforts and costs. Methods: We performed a retrospective review of the charts of all patients younger than 18 years of age who underwent appendectomy at our institution in 2 periods: before guideline implementation (Dec. 1, 2016, to May 31, 2017) and after implementation (Dec. 1, 2017, to May 31, 2018). We compared LOS, duration of antibiotic therapy, 30-day postdischarge complication rates and variable cost between the 2 cohorts. Results: Of the 276 total appendectomy procedures performed, 185 were for simple appendicitis (81 before guideline implementation and 104 after implementation), and 91 were for complicated appendicitis (44 and 47, respectively). The median LOS was shorter in the postimplementation cohort for both simple and complicated appendicitis (15.5 h [interquartile range (IQR) 12-19 h] v. 17.0 h [IQR 13-22 h], p = 0.03; and 3.0 d [IQR 2-4 d] v. 3.0 d [IQR 3-5 d], p = 0.05, respectively). Patients with complicated appendicitis had fewer antibiotic days after guideline implementation; the difference was statistically significant for patients without diffuse peritoneal contamination or abscess formation (p = 0.02). There were no differences between the cohorts with respect to 30-day rates of complications, including emergency department visits, readmission and surgical site infections. After guideline implementation, the average variable cost per patient was reduced by $230, equating to a total average annual cost savings of $75 842 for our institution. Conclusion: The implementation of a provincial guideline aimed at standardizing care in pediatric appendicitis at our institution was associated with shortened LOS, improved antibiotic stewardship efforts and reduced cost of care. Other institutions may replicate our model of a standardized pathway in the management of pediatric appendicitis in an effort to improve the quality of patient care and reduce health care costs.


Contexte: En 2017, des lignes directrices provinciales ont vu le jour en Alberta afin d'accélérer et de normaliser les soins pédiatriques pour appendicite. Notre étude visait à déterminer l'effet de leur application, par notre établissement, sur la durée du séjour, la gestion des antibiotiques et les coûts des soins. Méthodes: Nous avons examiné de façon rétrospective le dossier de tous les patients de moins de 18 ans ayant subi une appendicectomie à notre établissement avant l'application des lignes directrices (entre le 1er décembre 2016 et le 31 mai 2017) et après (entre le 1er décembre 2017 et le 31 mai 2018). Les données relatives à la durée du séjour, à la durée de l'antibiothérapie, au taux de complications 30 jours après le congé et aux coûts variables ont été comparées entre les 2 groupes. Résultats: Des 276 appendicectomies totales effectuées, 185 concernaient une appendicite simple (81 avant l'application des lignes directrices et 104 après), et 91, une appendicite compliquée (44 avant l'application et 47 après). La durée médiane du séjour était plus courte dans le groupe postapplication, tant pour l'appendicite simple (15,5 h [écart interquartile (EI) 12­19 h] c. 17,0 h [EI 13­22 h]; p = 0,03) que pour l'appendicite compliquée (3,0 j [EI 2­4 j] c. 3,0 j [EI 3­5 j]; p = 0,05). Les patients qui présentaient une appendicite compliquée avaient une antibiothérapie moins longue après l'application des lignes directrices; la différence était statistiquement significative chez les patients sans contamination péritonéale diffuse ou abcès (p = 0,02). Aucune différence n'a été observée entre les cohortes en ce qui a trait au taux de complications à 30 jours, qui comprenait les consultations à l'urgence, les réadmissions et les infections du site opératoire. L'application des lignes directrices a permis de réduire les coûts variables par patient de 230 $, ce qui représente une économie annuelle moyenne de 75 842 $ pour notre établissement. Conclusion: L'application des lignes directrices provinciales visant à normaliser les soins pédiatriques pour appendicite a été associée, dans notre établissement, à une réduction de la durée du séjour, à l'amélioration de la gestion des antibiotiques et à une diminution des coûts des soins. D'autres établissements pourraient reproduire ce modèle de soins normalisés pour améliorer la qualité et réduire les coûts.


Asunto(s)
Apendicitis/economía , Apendicitis/terapia , Protocolos Clínicos , Guías de Práctica Clínica como Asunto , Alberta , Antibacterianos/uso terapéutico , Programas de Optimización del Uso de los Antimicrobianos , Apendicectomía , Niño , Femenino , Humanos , Tiempo de Internación , Masculino , Pediatría , Estudios Retrospectivos
11.
Can Assoc Radiol J ; 72(4): 797-805, 2021 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-33648355

RESUMEN

PURPOSE: In Canada, ultrasonography is the primary imaging modality for children with suspected appendicitis, yet equivocal studies are common. Magnetic resonance imaging provides promise as an adjunct imaging strategy. The primary objective of this study was to determine the proportion of children with suspected appendicitis and equivocal ultrasound where magnetic resonance imaging determined a diagnosis. METHODS: A prospective consecutive cohort of children aged 5-17 years presenting to a tertiary pediatric Emergency Department with suspected appendicitis were enrolled. Participants underwent diagnostic and management strategies according to our local suspected appendicitis pathway, followed by magnetic resonance (Siemens Avanto 1.5 Tesla) imaging. Sub-specialty pediatric radiologists reported all images. RESULTS: Magnetic resonance imaging was performed in 101 children with suspected appendicitis. The mean age was 11.9 (SD 3.4) years and median Pediatric Appendicitis Score was 6 [IQR 4,8]. Ultrasonography was completed in 98/101 (97.0%). Of 53/98 (54.1%) with equivocal ultrasound, magnetic resonance imaging provided further diagnostic information in 41 (77.4%; 10 positive, 31 negative; 12 remained equivocal). Secondary findings of appendicitis on magnetic resonance imaging in children with equivocal ultrasound included abdominal free fluid (24, 45.3%), peri-appendiceal fluid (12, 22.6%), intraluminal appendiceal fluid (9, 17.0%), fat stranding (8, 15.1%), appendicolith (2, 3.8%), and peri-appendiceal abscess (1, 1.9%). The observed agreement between magnetic resonance imaging results and final diagnosis was 94.9% (kappa = 0.89).


Asunto(s)
Apendicitis/diagnóstico por imagen , Imagen por Resonancia Magnética/métodos , Adolescente , Apéndice/diagnóstico por imagen , Niño , Preescolar , Estudios de Cohortes , Diagnóstico Diferencial , Femenino , Humanos , Masculino , Estudios Prospectivos , Reproducibilidad de los Resultados , Sensibilidad y Especificidad , Ultrasonografía
12.
World J Surg ; 44(8): 2482-2492, 2020 08.
Artículo en Inglés | MEDLINE | ID: mdl-32385680

RESUMEN

BACKGROUND: Enhanced Recovery After Surgery (ERAS®) Society guidelines integrate evidence-based practices into multimodal care pathways that have improved outcomes in multiple adult surgical specialties. There are currently no pediatric ERAS® Society guidelines. We created an ERAS® guideline designed to enhance quality of care in neonatal intestinal resection surgery. METHODS: A multidisciplinary guideline generation group defined the scope, population, and guideline topics. Systematic reviews were supplemented by targeted searching and expert identification to identify 3514 publications that were screened to develop and support recommendations. Final recommendations were determined through consensus and were assessed for evidence quality and recommendation strength. Parental input was attained throughout the process. RESULTS: Final recommendations ranged from communication strategies to antibiotic use. Topics with poor-quality and conflicting evidence were eliminated. Several recommendations were combined. The quality of supporting evidence was variable. Seventeen final recommendations are included in the proposed guideline. DISCUSSION: We have developed a comprehensive, evidence-based ERAS guideline for neonates undergoing intestinal resection surgery. This guideline, and its creation process, provides a foundation for future ERAS guideline development and can ultimately lead to improved perioperative care across a variety of pediatric surgical specialties.


Asunto(s)
Procedimientos Quirúrgicos del Sistema Digestivo/normas , Recuperación Mejorada Después de la Cirugía , Atención Perioperativa/normas , Cuidados Posoperatorios/normas , Guías de Práctica Clínica como Asunto , Antiinfecciosos/uso terapéutico , Profilaxis Antibiótica , Consenso , Medicina Basada en la Evidencia , Gastroenterología/organización & administración , Humanos , Recién Nacido , Comunicación Interdisciplinaria , Neonatología/organización & administración , Sociedades Médicas
13.
J Surg Res ; 243: 229-235, 2019 11.
Artículo en Inglés | MEDLINE | ID: mdl-31226462

RESUMEN

BACKGROUND: Standardized care may improve outcomes in many diseases including congenital diaphragmatic hernia (CDH). Our study assesses the variability of CDH clinical practice guidelines (CPG) among North American centers. METHODS: North American member institutions of the CDH Study Group and the Pediatric Surgical Research Collaborative were solicited to submit their CDH CPG. Elements from each CPG were collected and classified according to therapeutic purpose. Elements were assigned to umbrella topics of prenatal assessment, delivery plus initial resuscitation, ventilatory and cardiovascular management, therapeutic targets, analgesia, and criteria for transitions in care. Descriptive analyses were performed to characterize the scope and variability of CPGs. RESULTS: Sixty-eight centers provided 40 responses (59%). Of these, 29 (73%) had a CDH CPG, of which 27 were obtained for review. All CPGs had a primary focus of preoperative care. Conventional ventilation was the first-line strategy in all CPGs. Ninety-three percent reported a peak inspiratory pressure limit (mean: 25.2 ± 2 cm H2O). Target oxygenation and ventilatory variables had low coefficients of variation. Two-thirds of CPGs discussed echocardiography, with indications for inhaled nitric oxide, sildenafil, and prostaglandins detailed in 81%, 30%, and 22% of CPGs, respectively. Extracorporeal life support and operative indications were specified in 93% and 59%, respectively, although specific targets for each were highly variable. CONCLUSIONS: This synthesis of North American CDH CPGs identifies areas of both alignment and variability and provides objective data about individual institutional guidelines in CDH care. These data may inform the development of a consensus-based, multi-institutional approach to standardized CDH management in North America.


Asunto(s)
Hernias Diafragmáticas Congénitas/terapia , Oxigenación por Membrana Extracorpórea , Hernias Diafragmáticas Congénitas/diagnóstico , Humanos , Recién Nacido , Guías de Práctica Clínica como Asunto , Diagnóstico Prenatal , Respiración Artificial , Encuestas y Cuestionarios
14.
Pediatr Surg Int ; 35(6): 631-634, 2019 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-31025092

RESUMEN

The concept of Enhanced Recovery After Surgery (ERAS) has increasingly been embraced by our adult surgical colleagues, but has been slow to crossover to pediatric surgical subspecialties. ERAS® improves outcomes through multiple, incremental steps that act synergistically throughout the entire surgical journey. In practice, ERAS® is a strategy of perioperative management that is defined by strong implementation and ongoing adherence to a patient-focused, multidisciplinary, and multimodal approach. There are increasing numbers of surgical teams exploring ERAS® in children and there is mounting evidence that this approach may improve surgical care for children across the globe. The first World Congress in Pediatric ERAS® in 2018 has set the stage for a new era in pediatric surgical safety.


Asunto(s)
Tiempo de Internación , Atención Perioperativa/métodos , Complicaciones Posoperatorias/prevención & control , Niño , Protocolos Clínicos , Humanos , Guías de Práctica Clínica como Asunto
15.
Ann Surg ; 267(5): 977-982, 2018 05.
Artículo en Inglés | MEDLINE | ID: mdl-28134682

RESUMEN

OBJECTIVE: The objectives of this study were (i) to evaluate infants with congenital diaphragmatic hernia (CDH) that do not undergo repair, (ii) to identify nonrepair rate by institution, and (iii) to compare institutional outcomes based on nonrepair rate. BACKGROUND: Approximately 20% of infants with CDH go unrepaired and the threshold to offer surgical repair is variable. METHODS: Data were abstracted from a multicenter, prospectively collected database. Standard clinical variables, including repair (or nonrepair), and outcome were analyzed. Institutions were grouped based on volume and rate of nonrepair. Preoperative mortality predictors were identified using logistic regression, expected mortality for each center was calculated, and observed /expected (O/E) ratios were computed for center groups and compared by Kruskal-Wallis ANOVA. RESULTS: A total of 3965 infants with CDH were identified and 691 infants (17.5%) were not repaired. Nonrepaired patients had lower Apgar scores (P < 0.05) and increased incidence of anomalies (P < 0.0001). Low-volume centers ("Lo", n=44 total, < 10 CDH pts/yr) and high-volume centers ("Hi", n = 21) had median nonrepair rates of 19.8% (range 0%-66.7%) and 16.7% (5.1%-38.5%), respectively. High-volume centers were further dichotomized by rate of nonrepair (HiLo = 5.1-16.7% and HiHi = 17.6-38.5%), leaving 3 groups: HiLo, HiHi, and Lo. Predictors of mortality were lower birth weight, lower Apgar scores, prenatal diagnosis, and presence of congenital anomalies. O/E ratios for mortality in the HiLo, HiHi, and Lo groups were 0.81, 0.94, and 1.21, respectively (P < 0.0001). For every 100 CDH patients, HiLo centers have 2.73 (2.4-3.1, 95% confidence interval) survivors beyond expectation. CONCLUSIONS: There are significant differences between repaired and nonrepaired CDH infants and significant center variation in rate of nonrepair exists. Aggressive surgical management, leading to a low rate of nonrepair, is associated with improved risk-adjusted mortality.


Asunto(s)
Predicción , Hernias Diafragmáticas Congénitas/cirugía , Herniorrafia/métodos , Sistema de Registros , Femenino , Estudios de Seguimiento , Hernias Diafragmáticas Congénitas/mortalidad , Humanos , Lactante , Recién Nacido , Masculino , Estudios Prospectivos , Tasa de Supervivencia/tendencias , Resultado del Tratamiento , Estados Unidos/epidemiología
16.
BMC Health Serv Res ; 18(1): 210, 2018 03 27.
Artículo en Inglés | MEDLINE | ID: mdl-29580254

RESUMEN

BACKGROUND: The role of the "debrief" to address issues related to patient safety and systematic flaws in care is frequently overlooked. In our study, we interview surgical leaders who have developed successful strategies of debriefing within a comprehensive program of quality improvement. METHODS: Semi-structured interviews of four implementation leaders were performed. The observations, beliefs and strategies of surgical leaders are compared and contrasted. Common themes are identified related to program success and failure. Quality and safety researchers performed, coded and categorized the interviews and coordinated the analysis and interpretation of the results. The authors from the four institutions aided in interpretation and framing of the results. RESULTS: The debriefing programs evaluated were part of comprehensive quality improvement projects. Seven high-level themes and 24 subthemes were identified from the interviews. Themes related to leadership included early engagement, visible ongoing commitment and enforcement. Success appeared to depend upon meaningful and early debriefing feedback. The culture of safety that promoted success included a commitment to open and fair communication and continuous improvement. There were many challenges to the success of debriefing programs. The loss of institutional commitment of resources and personnel was the instigating factor behind the collapse of the program at Michigan. Other areas of potential failure included communication issues and loss of early and meaningful feedback. CONCLUSIONS: Leaders of four surgical systems with strong debriefing programs report success using debriefing to improve system performance. These findings are consistent with previously published studies. Success requires commitment of resources, and leadership engagement. The greatest gains may be best achieved by programs that provide meaningful debriefing feedback in an atmosphere dedicated to open communication.


Asunto(s)
Retroalimentación Formativa , Grupo de Atención al Paciente/organización & administración , Seguridad del Paciente , Mejoramiento de la Calidad/organización & administración , Procedimientos Quirúrgicos Operativos , Comunicación , Atención a la Salud , Investigación sobre Servicios de Salud , Humanos , Relaciones Interprofesionales , Liderazgo , Desarrollo de Programa , Evaluación de Programas y Proyectos de Salud , Investigación Cualitativa , Administración de la Seguridad/organización & administración , Estados Unidos
20.
BMC Pediatr ; 16(1): 147, 2016 08 30.
Artículo en Inglés | MEDLINE | ID: mdl-27577252

RESUMEN

BACKGROUND: Despite the poor independent test characteristics of the white blood cell count (WBC) and neutrophil count (NC) in identifying appendicitis, common clinical decision supports including the Pediatric Appendicitis Score (PAS) and Alvarado Score (AS), require the WBC and NC values. Moreover, blood tests cause discomfort/pain to children and require time for processing results. Scores based on clinical information alone may be of benefit in the pediatric population. The objective of our study was to determine the test characteristics of the PAS and the AS with and without laboratory investigations (mPAS, mAS respectively) as well as the Lintula Score. METHODS: A prospective cohort study of children aged 5-17 years presenting to a pediatric ED with suspected appendicitis. Clinical care of the patient was left to the managing physician. At risk for appendicitis was defined by PAS ≥6; AS ≥5; LS ≥16, as originally described; modified cutoffs were defined as mPAS ≥4; mAS ≥4. Appendicitis was defined as acute inflammation, rupture or abscess of the appendix on pathologic evaluation. Test characteristics for each of the 5 scores were calculated. RESULTS: Of the 180 eligible children, 102 (56.7 %) were female. The average age was 11.2 years (SD 3.1). Appendectomy was performed in 58 (32.2 %) of children, 55 (94.8 %) were positive. For the PAS and mPAS, sensitivity and negative predictive values were similar (80.0 %, 86.4 % vs 87.3 %, 85.1 % respectively). For the AS and mAS, sensitivity and negative predictive values were also similar (85.5 %, 87.1 % vs 83.6 %, 83.3 % respectively). Specificities in the PAS, mPAS, AS and mAS were low (56.0 %, 32.0 %, 43.2 %, 63.0 % respectively). Test characteristics of the LS were poor (59.3 %, 79.2 %, 55.2 %, 81.8 %). CONCLUSIONS: A modified Alvarado and PAS can be used to screen for children at low risk of appendicitis who may be carefully observed at home without the need for laboratory investigation. Translation to primary care settings should evaluate generalizability and determine impact on referral patterns.


Asunto(s)
Apendicitis/diagnóstico , Técnicas de Apoyo para la Decisión , Indicadores de Salud , Adolescente , Biomarcadores/sangre , Niño , Preescolar , Femenino , Humanos , Recuento de Leucocitos , Masculino , Neutrófilos/metabolismo , Variaciones Dependientes del Observador , Valor Predictivo de las Pruebas , Estudios Prospectivos , Medición de Riesgo , Sensibilidad y Especificidad
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