Quantifying Procedure-level Prophylaxis Misutilization in Pediatric Surgery: Implications for the Prioritization of Antimicrobial Stewardship Efforts.

OBJECTIVE: To quantify procedure-level inappropriate antimicrobial prophylaxis utilization as a strategy to identify high-priority targets for stewardship efforts in pediatric surgery. BACKGROUND: Little data exist to guide the prioritization of antibiotic stewardship efforts as they relate to prophylaxis utilization in pediatric surgery. METHODS: This was a retrospective cohort analysis of children undergoing elective surgical procedures at 52 children's hospitals from October 2015 to December 2019 using the Pediatric Health Information System database. Procedure-level compliance with consensus guidelines for prophylaxis utilization was assessed for indication, antimicrobial spectrum, and duration. The relative contribution of each procedure to the overall burden of noncompliant cases was calculated to establish a prioritization framework for stewardship efforts. RESULTS: A total of 56,845 cases were included with an overall inappropriate utilization rate of 56%. The most common reason for noncompliance was unindicated utilization (43%), followed by prolonged duration (32%) and use of excessively broad-spectrum agents (25%). Procedures with the greatest relative contribution to noncompliant cases included cholecystectomy and repair of inguinal and umbilical hernias for unindicated utilization (63.2% of all cases); small bowel resections, gastrostomy, and colorectal procedures for use of excessively broad-spectrum agents (70.1%) and pectus excavatum repair and procedures involving the small and large bowel for prolonged duration (57.6%). More than half of all noncompliant cases were associated with 5 procedures (cholecystectomy, small bowel procedures, inguinal hernia repair, gastrostomy, and pectus excavatum). CONCLUSIONS: Cholecystectomy, inguinal hernia repair, and procedures involving the small and large bowel should be considered high-priority targets for antimicrobial stewardship efforts in pediatric surgery.

Influence of Oral Antibiotics Following Discharge on Organ Space Infections in Children With Complicated Appendicitis.

OBJECTIVE: To compare postdischarge rates of organ space infections (OSI) in children with complicated appendicitis between those receiving and not receiving oral antibiotics (OA) following discharge. SUMMARY BACKGROUND DATA: Existing data regarding the clinical utility of extending antibiotic treatment following discharge in children with complicated appendicitis are limited. METHODS: Retrospective cohort study of children ages 3 to 18 years undergoing appendectomy for complicated appendicitis from January 2013 to June 2015 across 17 hospitals participating in the NSQIP-Pediatric Appendectomy Pilot Collaborative (n = 711). Multivariable mixed-effects regression was used to compare postdischarge OSI rates between patients discharged with and without OA after propensity matching on demographic characteristics and disease severity. A subgroup analysis was performed for high-severity patients (multiple intraoperative findings of complicated disease or length of stay≥6 d). RESULTS: The overall rates of OA utilization and OSI following discharge were 57.0% (hospital range: 3-100%) and 5.2% (range: 0-16.7%), respectively. In the propensity-matched analysis of the entire cohort, use of OA was associated with a 38% reduction in the odds of OSI following discharge compared with children not discharged on OA (4.2% vs. 6.6%, OR 0.62 [0.29, 1.31], P = 0.21). In the high-severity matched cohort (n = 324, 46%), use of OA was associated with a 61% reduction in the odds of OSI following discharge (4.3% vs 10.5%; OR 0.39 [0.15, 0.96], P = 0.04). CONCLUSIONS: Use of oral antibiotics following discharge may decrease organ space infections in children with complicated appendicitis, and those presenting with high-severity disease may be most likely to benefit.

Ceftriaxone Combined With Metronidazole is Superior to Cefoxitin Alone in the Management of Uncomplicated Appendicitis in Children: Results from a Multicenter Collaborative Comparative Effectiveness Study.

OBJECTIVE: To compare rates of surgical site infection between the 2 most commonly utilized narrow-spectrum antibiotic regimens in children with uncomplicated appendicitis (ceftriaxone with metronidazole and cefoxitin alone). SUMMARY OF BACKGROUND DATA: Narrow-spectrum antibiotics have been found to be equivalent to extended-spectrum (antipseudomonal) agents in preventing surgical site infection (SSI) in children with uncomplicated appendicitis. The comparative effectiveness of different narrow-spectrum agents has not been reported. METHODS: This was a multicenter retrospective cohort study using clinical data from the Pediatric National Surgical Quality Improvement Program Appendectomy Collaborative Pilot database merged with antibiotic utilization data from the Pediatric Health Information System database from January 2013 to June 2015. Multivariable logistic regression was used to compare outcomes between antibiotic treatment groups after adjusting for patient characteristics, surrogate measures of disease severity, and clustering of outcomes within hospitals. RESULTS: Eight hundred forty-six patients from 14 hospitals were included in the final study cohort with an overall SSI rate of 1.3%. A total of 56.0% of patients received ceftriaxone with metronidazole (hospital range: 0%-100%) and 44.0% received cefoxitin (range: 0%-100%). In the multivariable model, ceftriaxone with metronidazole was associated with a 90% reduction in the odds of a SSI compared to cefoxitin [0.2% vs 2.7%; odds ratio: 0.10 (95% confidence interval 0.02-0.60); P = 0.01]. CONCLUSIONS: Ceftriaxone combined with metronidazole is superior to cefoxitin alone in preventing SSIs in children with uncomplicated appendicitis.

Leveraging the Combined Predictive Value of Ultrasound and Laboratory Data to Reduce Radiation Exposure and Resource Utilization in Children with Suspected Appendicitis.

BACKGROUND: Previous investigation has shown that the combined predictive value of white blood cell count and ultrasound (US) findings to be superior to either alone in children with suspected appendicitis. The purpose of this study was to evaluate the impact of a diagnostic clinical pathway (DCP) leveraging the combined predictive value of these tests on computed tomography (CT) utilization and resource utilization. METHODS: Retrospective cohort study comparing 8 mo of data before DCP implementation to 18 mo of data following implementation. The pathway incorporated decision-support for disposition (operative intervention, observation, or further cross-sectional imaging) based on the combined predictive value of laboratory and US data (stratifying patients into low, moderate, and high-risk groups). Study measures included CT and magnetic resonance imaging utilization, imaging-related cost, time to appendectomy, and negative appendectomy rate. RESULTS: Ninety-seven patients in the preintervention period were compared with 319 patients in the postintervention period. Following DCP implementation, CT utilization decreased by 86% (21% versus 3%, P < 0.001). Mean time to appendectomy decreased from 8.5 to 7.2 h (P < 0.001), and the negative appendectomy rate remained unchanged (5% versus 4%, P = 0.54). Magnetic resonance imaging utilization increased following pathway implementation (1% versus 7%, P = 0.02); however, median imaging-related cost was significantly lower in the postimplementation period ($283/case to $270/case, P = 0.002) CONCLUSIONS: In children with suspected appendicitis, implementation of a DCP leveraging the combined predictive value of white blood cell and US data was associated with a reduction in CT utilization, time to appendectomy, and imaging-related cost.

Leveraging the Incidence, Burden, and Fiscal Implications of Unplanned Hospital Revisits for the Prioritization of Prevention Efforts in Pediatric Surgery.

OBJECTIVE: To characterize procedure-level burden of revisit-associated resource utilization in pediatric surgery with the goal of establishing a prioritization framework for prevention efforts. SUMMARY OF BACKGROUND DATA: Unplanned hospital revisits are costly to the health care system and associated with lost productivity on behalf of patients and their families. Limited objective data exist to guide the prioritization of prevention efforts within pediatric surgery. METHODS: Using the Pediatric Health Information System (PHIS) database, 30-day unplanned revisits for the 30 most commonly performed pediatric surgical procedures were reviewed from 47 children's hospitals between January 1, 2012 and March 31, 2015. The relative contribution of each procedure to the cumulative burden of revisit-associated length of stay and cost from all procedures was calculated as an estimate of public health relevance if prevention efforts were successfully applied (higher relative contribution = greater potential public health relevance). RESULTS: 159,675 index encounters were analyzed with an aggregate 30-day revisit rate of 10.8%. Four procedures contributed more than half of the revisit-associated length of stay burden from all procedures, with the highest relative contributions attributable to complicated appendicitis (18.4%), gastrostomy (13.4%), uncomplicated appendicitis (13.0%), and fundoplication (9.4%). Four procedures contributed more than half of the revisit-associated cost burden from all procedures, with the highest relative contributions attributable to complicated appendicitis (18.8%), gastrostomy (14.6%), fundoplication (10.4%), and uncomplicated appendicitis (10.2%). CONCLUSIONS AND RELEVANCE: A small number of procedures account for a disproportionate burden of revisit-associated resource utilization in pediatric surgery. Gastrostomy, fundoplication, and appendectomy should be considered high-priority targets for prevention efforts within pediatric surgery.

Development and Implications of an Evidence-based and Public Health-relevant Definition of Complicated Appendicitis in Children.

OBJECTIVE: To characterize the influence of intraoperative findings on complications and resource utilization as a means to establish an evidence-based and public health-relevant definition for complicated appendicitis. SUMMARY OF BACKGROUND DATA: Consensus is lacking surrounding the definition of complicated appendicitis in children. Establishment of a consensus definition may have implications for standardizing the reporting of clinical research data and for refining reimbursement guidelines. METHODS: This was a retrospective cohort study of patients ages 3 to 18 years who underwent appendectomy from January 1, 2013 to December 31, 2014 across 22 children's hospitals (n = 5002). Intraoperative findings and clinical data from the National Surgical Quality Improvement Program-Pediatric Appendectomy Pilot Database were merged with cost data from the Pediatric Health Information System Database. Multivariable regression was used to examine the influence of 4 intraoperative findings [visible hole (VH), diffuse fibrinopurulent exudate (DFE) extending outside the right lower quadrant (RLQ)/pelvis, abscess, and extra-luminal fecalith] on complication rates and resource utilization after controlling for patient and hospital-level characteristics. RESULTS: At least 1 of the 4 intraoperative findings was reported in 26.6% (1333/5002) of all cases. Following adjustment, each of the 4 findings was independently associated with higher rates of adverse events compared with cases where the findings were absent (VH: OR 5.57 [95% CI 3.48-8.93], DFE: OR 4.65[95% CI 2.91-7.42], abscess: OR 8.96[95% CI 5.33-15.08], P < 0.0001, fecalith: OR 5.01[95% CI 2.02-12.43], P = 0.001), and higher rates of revisits (VH: OR 2.02 [95% CI 1.34-3.04], P = 0.001, DFE: OR 1.59[95% CI 1.07-2.37], P = 0.02, abscess: OR 2.04[95% CI 1.2-3.49], P = 0.01, fecalith: OR 2.31[95% CI 1.06-5.02], P = 0.04). Each of the 4 findings was also independently associated with increased resource utilization, including longer cumulative length of stay (VH: Rate ratio [RR] 3.15[95% CI 2.86-3.46], DFE: RR 3.06 [95% CI 2.83-3.13], abscess: RR 3.94 [95% CI 3.55-4.37], fecalith: RR 2.35 [95% CI 1.87-2.96], P =  < 0.0001) and higher cumulative hospital cost (VH: RR 1.97[95% CI 1.64-2.37], P < 0.0001, DFE: RR 1.8[95% CI 1.55-2.08], P =  < 0.0001, abscess: RR 2.02[95% CI 1.61-2.53], P < 0.0001, fecalith: RR 1.49[95% CI 0.98-2.28], P = 0.06) compared with cases where the findings were absent. CONCLUSION AND RELEVANCE: The presence of a visible hole, diffuse fibrinopurulent exudate, intra-abdominal abscess, and extraluminal fecalith were independently associated with markedly worse outcomes and higher cost in children with appendicitis. The results of this study provide an evidence-based and public health-relevant framework for defining complicated appendicitis in children.

Intravenous Versus Oral Antibiotics for the Prevention of Treatment Failure in Children With Complicated Appendicitis: Has the Abandonment of Peripherally Inserted Catheters Been Justified?

OBJECTIVE: To compare treatment failure leading to hospital readmission in children with complicated appendicitis who received oral versus intravenous antibiotics after discharge. BACKGROUND: Antibiotics are often employed after discharge to prevent treatment failure in children with complicated appendicitis, although existing studies comparing intravenous and oral antibiotics for this purpose are limited. METHODS: We identified all patients aged 3 to 18 years undergoing appendectomy for complicated appendicitis, who received postdischarge antibiotics at 35 childrens hospitals from 2009 to 2012. Discharge codes were used to identify study subjects from the Pediatric Health Information System database, and chart review confirmed eligibility, treatment assignment, and outcomes. Exposure status was based on outpatient antibiotic therapy, and analysis used optimal and full matching methods to adjust for demographic and clinical characteristics. Treatment failure (defined as an organ-space infection) requiring inpatient readmission was the primary outcome. Secondary outcomes included revisits from any cause to either the inpatient or emergency department setting. RESULTS: In all, 4579 patients were included (median: 99/hospital), and utilization of intravenous antibiotics after discharge ranged from 0% to 91.7% across hospitals. In the matched analysis, the rate of treatment failure was significantly higher for the intravenous group than the oral group [odds ratio (OR) 1.74, 95% confidence interval (CI) 1.05-2.88; risk difference: 4.0%, 95% CI 0.4-7.6%], as was the rate of all-cause revisits (OR 2.11, 95% CI 1.44-3.11; risk difference: 9.4%, 95% CI 4.7-14.2%). The rate of peripherally inserted central catheter line complications was 3.2% in the intravenous group, and drug reactions were rare in both groups (intravenous: 0.7%, oral: 0.5%). CONCLUSIONS: Compared with oral antibiotics, use of intravenous antibiotics after discharge in children with complicated appendicitis was associated with higher rates of both treatment failure and all-cause hospital revisits.

Dissecting malpractice in pancreaticoduodenectomy cases.

BACKGROUND: Medical malpractice is a growing concern for physicians in all fields. Surgical fields have some of the highest malpractice premiums and litigation rates. Pancreaticoduodenectomy (PD) has become a popular procedure; however, it is still associated with significant morbidity and mortality. This study is the first to analyze factors involved in litigation regarding PD cases. METHODS: The Westlaw database was searched for jury verdicts and settlements using the terms "medical malpractice" and "pancreaticoduodenectomy". Twenty-nine cases from 1991 to 2012 were initially collected. Seven entries not involving PD and three duplicate cases were excluded. Nineteen cases were included for analysis. RESULTS: Of the 19 cases included in the analysis, three (15.8%) reached a settlement, three (15.8%) were ruled in favor of the plaintiff, and 13 (68.4%) were ruled in favor of the physician. The average settlement award was $398,333 (range, $195,000-500,000), and the average plaintiff award was $4,288,869 (range, $1,066,608-10,300,000). The most common factors raised in litigation included PD being allegedly unnecessary (47.4%), followed by postoperative negligence and misdiagnosis (36.8% each). CONCLUSIONS: The most common factors present in litigation included the allegation that PD was unnecessarily performed. The cases that are awarded large monetary sums are those that involve continued medical care. Ways to improve patient safety and limit litigation include increasing transparency and communication with a thorough discussion between surgeon and patient of the most common topics of litigation discussed.

Delaying Appendectomy Does Not Lead to Higher Rates of Surgical Site Infections: A Multi-institutional Analysis of Children With Appendicitis.

OBJECTIVES: To investigate the association between time to appendectomy and the risk of surgical site infections (SSIs) in children with appendicitis across multiple NSQIP-Pediatrics institutions. BACKGROUND: Several recently published single institution retrospective studies have reported conflicting relationships between delaying appendectomy and the risk of increasing surgical site infections (SSI) in both children and adults. This study combines data from NSQIP-Pediatrics with institutional data to perform a multi-institutional analysis to examine the effects of delaying appendectomy on surgical site infections. METHODS: Data from NSQIP-Pediatrics between January 2010 and June 2012 for cases of appendectomy for appendicitis at 6 institutions (preoperative characteristics, time of operation, and postoperative occurrences) were combined with data from medical record review (length of symptoms; times of initial presentation, emergency department (ED) triage, and admission; and diagnosis as simple appendicitis (SA, acute) or complicated appendicitis (CA, gangrenous/ruptured)). Cochran-Armitage tests for trend and multivariable logistic regression models were used to evaluate associations between time to appendectomy and SSI. RESULTS: Of the 1338 patients included, 70% had SA and 30% had CA. Postoperative SSIs were more common in CA (5.7% vs 1.2%, P < 0.001). SSI rates did not differ significantly across hospitals (P = 0.17). Compared with patients who did not develop an SSI, patients who developed an SSI had similar times between ED triage and appendectomy (median (interquartile range) 11.5 hours (6.4-14.7) versus 9.7 hours (5.8-15.6, P = 0.36), and similar times from admission to appendectomy (5.5 hours (1.9-10.2) versus 4.3 hours (1.4-9.9), P = 0.36). Independent risk factors for SSI were CA (Odds Ratio (95% CI): 3.46 (1.48-8.10), P = 0.004), longer symptom duration (OR for a 10-hour increase: 1.05 (1.01-1.10), P = 0.02), and presence of sepsis/septic shock (2.70 (1.17-6.28), P = 0.02). CONCLUSIONS: A 16-hour delay from ED presentation or a 12-hour delay from hospital admission to appendectomy was not associated with an increased risk for SSI.

Malpractice in colorectal surgery: a review of 122 medicolegal cases.

BACKGROUND: Medical malpractice has become a rising concern for physicians, affecting the cost and delivery of health care. Colorectal procedures account for 24% of all general surgery cases, a high-risk specialty, with 15% of its physicians facing malpractice suit annually. METHODS: The Westlaw legal database was used to identify colorectal malpractice cases. RESULTS: In all, 122 of 230 lawsuits were included in this study. A majority of 65.6% were physician verdicts, 19.7% plaintiff verdicts, and 14.8% reached a settlement. Plaintiff payments were found to be significantly higher than settlement awards. The most common cause of alleged malpractice was failure to recognize a complication in a timely manner (45.1%), followed by damage to surrounding tissues (36.1%). CONCLUSIONS: The most common cause of alleged malpractice was failure to recognize a complication in a timely manner, followed by damage to surrounding tissue. Plaintiff awards were significantly higher than settlement payments. It is important to understand the mechanism of malpractice allegations to better prevent litigation and improve patient care.

Pediatric CT dose reduction for suspected appendicitis: a practice quality improvement project using artificial gaussian noise--part 2, clinical outcomes.

OBJECTIVE. The purpose of this study was to determine the effect of a nominal 50% reduction in median absorbed radiation dose on sensitivity, specificity, and negative appendectomy rate of CT for acute appendicitis in children. MATERIALS AND METHODS. On the basis of a departmental practice quality improvement initiative using computer-generated gaussian noise for CT dose reduction, we applied a nominal dose reduction of 50% to abdominal CT techniques used for bowel imaging. This retrospective study consisted of 494 children who underwent a CT for suspected acute appendicitis before (n = 244; mean age, 133 months) and after (n = 250; mean age, 145 months) the nominal 50% dose reduction. Test performance characteristics of CT for acute appendicitis and impact on the negative appendectomy rate were compared for both time periods. Primary analyses were performed with histologic diagnosis as the outcome standard. Volume CT dose index and dose-length product were recorded from dose reports and size-specific dose estimates were calculated. RESULTS. The nominal 50% dose reduction resulted in an actual 39% decrease in median absorbed radiation dose. Sensitivity of CT for diagnosis of acute appendicitis was 98% (95% CI, 91-100%) versus 97% (91-100%), and specificity was 93% (88-96%) versus 94% (90-97%) before and after dose reduction, respectively. The negative appendectomy rate was 4.5% (0.8-10.25%) before dose reduction and 4.0% (0.4-7.6%) after dose reduction. CONCLUSION. The negative appendectomy rate and performance characteristics of the CT-based diagnosis of acute appendicitis were not affected by a 39% reduction in median absorbed radiation dose.

Warfarin, not direct oral anticoagulants nor antiplatelet therapy, is associated with increased bleeding risk in emergency general surgery patients: implications in this new era of novel anticoagulants: An EAST Multicenter study.

INTRODUCTION: To assess perioperative bleeding complications & in-hospital mortality in patients requiring emergency general surgery (EGS) presenting with a history of antiplatelet (AP) vs. direct oral anticoagulant (DOAC) vs warfarin use. METHODS: Prospective observational study across 21 centers between 2019-2022. Inclusion criteria were age ≥ 18 years, & DOAC, warfarin or AP use within 24 hours of an EGSP. Outcomes included perioperative bleeding and in-hospital mortality. The study was conducted using ANOVA, Chi-square, and multivariable regression models. RESULTS: Of the 413 patients, 221 (53.5%) reported AP use, 152 (36.8%) DOAC use, & 40 (9.7%) warfarin use. Most common indications for surgery were obstruction (23% (AP), 45% (DOAC), 28% (warfarin)), intestinal ischemia (13%, 17%, 23%), & diverticulitis/peptic ulcers (7%, 7%, 15%). Compared to DOAC use, warfarin use was associated with significantly higher perioperative bleeding complication (OR 4.4 [2.0, 9.9]). There was no significant difference in perioperative bleeding complication between DOAC & AP use (OR 0.7 [0.4, 1.1]). Compared to DOAC use, there was no significant difference in mortality between warfarin use (0.7 [0.2, 2.5]) or AP use (OR 0.5 [0.2, 1.2]). After adjusting for confounders, warfarin use (OR 6.3 [2.8, 13.9]), medical history and operative indication were associated with an increase in perioperative bleeding complications. However, warfarin was not independently associated with risk of mortality (OR 1.3 [0.39, 4.7]), whereas intraoperative vasopressor use (OR 4.7 [1.7, 12.8)), medical history & postoperative bleeding (OR 5.5 [2.4, 12.8]) were. CONCLUSIONS: Despite ongoing concerns about the increase in DOAC use & lack of readily available reversal agents, this study suggests that warfarin, rather than DOACs, is associated with higher perioperative bleeding complications. However, that risk does not result in an increase in mortality, suggesting that perioperative decisions should be dictated by patient disease & comorbidities rather than type of antiplatelet or anticoagulant use.

Ceftriaxone with Metronidazole versus Piperacillin/Tazobactam in the management of complicated appendicitis in children: Results from a multicenter pediatric NSQIP analysis.

BACKGROUND: Narrow-spectrum antibiotics have been found to be equivalent to anti-Pseudomonal agents in preventing organ space infections (OSI) in children with uncomplicated appendicitis. Comparative effectiveness data for children with complicated appendicitis remains limited. This investigation aimed to compare outcomes between the most common narrow-spectrum regimen (ceftriaxone with metronidazole: CM) and anti-Pseudomonal regimen (piperacillin/tazobactam: PT) used perioperatively in children with complicated appendicitis. METHODS: Multicenter retrospective cohort study using clinical data from the NSQIP-Pediatric Appendectomy Collaborative database merged with antibiotic utilization data from the Pediatric Health Information System database. Mixed-effects multivariate regression was used to compare NSQIP-defined outcomes and resource utilization between treatment groups after adjusting for patient characteristics, disease severity, and clustering of outcomes within hospitals. RESULTS: 654 patients from 14 hospitals were included, of which 37.9% received CM and 62.1% received PT. Following adjustment, patients in both groups had similar rates of OSI (CM: 13.3% vs. PT: 18.0%, OR 0.88 [95%CI 0.38, 2.03]), drainage procedures (CM: 8.9% vs. PT: 14.9%, OR 0.76 [95%CI 0.30, 1.92]), and postoperative imaging (CM: 19.8% vs. PT: 22.5%, OR 1.17 [95%CI 0.65, 2.12]). Treatment groups also had similar rates of 30-day cumulative post-operative length of stay (CM: 6.1 vs. PT: 6.0 days, RR 1.01 [95%CI 0.81, 1.25]) and hospital cost (CM: $19,235 vs. PT: $20,552, RR 0.92 [95%CI 0.69, 1.23]). CONCLUSIONS: Rates of organ space infection and resource utilization were similar in children with complicated appendicitis treated with ceftriaxone plus metronidazole and piperacillin/tazobactam. LEVEL OF EVIDENCE: Level III: Treatment study - Retrospective comparative study.

Variability, outcomes and cost associated with the use of parenteral nutrition in children with complicated appendicitis: A hospital-level propensity matched analysis.

BACKGROUND/PURPOSE: To examine the influence of parenteral nutrition (PN) on clinical outcomes and cost in children with complicated appendicitis. METHODS: Retrospective study of 1,073 children with complicated appendicitis from 29 hospitals participating in the NSQIP-Pediatric Appendectomy Pilot Collaborative (1/2013-6/2015). Mixed-effects regression was used to compare 30-day postoperative outcomes between high and low PN-utilizing hospitals after propensity matching on demographic characteristics, BMI and postoperative LOS as a surrogate for disease severity. RESULTS: Overall PN utilization was 13.6%, ranging from 0-10.3% at low utilization hospitals (n = 452) and 10.3-32.4% at high utilization hospitals (n = 621). Outcomes were similar between low and high utilization hospitals for rates of overall complications (12.3% vs. 10.5%, OR: 0.80 [0.46,1.37], p = 0.41), SSIs (11.3% vs. 8.8%, OR: 0.72 [0.40,1.32], p = 0.29) and revisits (14.7% vs. 15.9%, OR: 1.10 [0.75,1.61], p = 0.63). Adjusted mean 30-day cumulative hospital cost was 22.9% higher for patients receiving PN ($25,164 vs. $20,478, p < 0.01) after controlling for postoperative LOS. CONCLUSION: Following adjustment for patient characteristics and postoperative length of stay, higher rates of PN utilization in children with complicated appendicitis were associated with higher cost but not with lower rates of overall complications, surgical site infections or revisits. Level of Evidence Level III: Treatment study - Retrospective comparative study.

Influence of symptom duration and WBC profile on the negative predictive value of a nondiagnostic ultrasound in children with suspected appendicitis.

BACKGROUND: The aim of this study was to explore the combined negative predictive value (NPV) of symptom duration and WBC profile in children with a nondiagnostic ultrasound (US) for appendicitis. METHODS: This was a retrospective analysis of children with suspected appendicitis at a single children's hospital from 1/2010 to 3/2018. NPVs based on WBC profile and symptom duration at presentation were calculated individually and combined for children with a nondiagnostic US. RESULTS: 2277 patients were included, of which 1018 (44.7%) had a nondiagnostic US. The NPV of a nondiagnostic US ranged from 83.7% with ≤24 h of symptoms to 94.5% with >72 h of symptoms (p < 0.01). NPV also differed significantly across WBC profiles, ranging from 76.8% when WBC profile was elevated to 97.3% to when WBC profile was normal (p < 0.01). The range of NPVs for a nondiagnostic US was even greater when combining symptom duration and WBC profile, ranging from 73.7% for patients with 24-48 h of symptoms and an elevated WBC profile to 100% for patients with >72 h of symptoms and a normal WBC profile. CONCLUSIONS: Incorporation of symptom duration and WBC profile significantly improves the accuracy and clinical utility of the negative predictive value associated with a nondiagnostic ultrasound. LEVEL OF EVIDENCE: Study of diagnostic test level II: development of diagnostic criteria in a consecutive series of patients and a universally applied gold standard.

Implementation of a Plan-Do-Study-Act framework to reduce unindicated surgical antimicrobial prophylaxis.

PURPOSE: The goal of this study was to use a Plan-Do-Study-Act (PDSA) framework to reduce utilization of unindicated surgical antibiotic prophylaxis (SAP) for clean cases without foreign body implantation. METHODS: This was a pre-post intervention study conducted at a single children's hospital comparing 6 months of retrospective preintervention data to 10 months of prospectively collected postintervention data. Interventions to reduce unindicated SAP included faculty meetings to review guidelines and establish consensus around inclusion criteria, publicizing guidelines with regular email reminders, and conducting ongoing compliance audits to root cause noncompliance. Early unanticipated noncompliant cases were associated with rotating trainees who prescribed SAP routinely without attending knowledge. A second PDSA cycle then included education-based emails targeting residents with mandatory feedback loop closure. RESULTS: Preintervention, 40.4% (107/265) of patients received unindicated SAP. Postintervention, the rate of unindicated SAP decreased to 15.4% (6/39) after the first month and 6.2% (20/323) after 10 months, reflecting an 85% reduction across periods (p < 0.01). There was no difference in the rate of surgical site infections between the pre and postintervention cohorts (0.36% vs. 0.67%, p = 1.00). CONCLUSIONS: Unindicated surgical antibiotic prophylaxis was significantly reduced by implementing a Plan-Do-Study-Act intervention targeting both faculty and trainees. LEVEL OF EVIDENCE: Prospective comparative treatment study, level II.

Contemporary practice and perceptions surrounding the management of asymptomatic umbilical hernias in children: A survey of the American Pediatric Surgical Association.

PURPOSE: To explore variation in perceptions regarding the natural history of asymptomatic umbilical hernias, and to characterize the influence of clinical and nonclinical factors on decision-making surrounding timing of repair. METHODS: This was a survey of the American Pediatric Surgical Association. Branching logic and Likert scale questions were used to explore perceptions surrounding natural history (risk of complications and likelihood of spontaneous closure), preferred age for repair, and influence of anatomic, caregiver, sociodemographic, and biological factors on operative timing. RESULTS: 44% of members completed the survey (371/846). The most common age respondents would consider elective repair was 3 years (37%), although the majority preferred to wait until 4 or 5 years (54%). Most respondents estimated a <1% risk of complications for unrepaired defects, and much greater variability was found in the perceived likelihood of spontaneous closure over time. Decision-making surrounding operative timing was most influenced by anatomic factors (larger defects, proboscoid changes, and interval growth) and parental anxiety surrounding need for emergency surgery, cosmesis, and stigma of parental neglect. CONCLUSION: Practice and perceptions surrounding management of asymptomatic umbilical hernias vary widely. More robust epidemiological data are needed to define the likelihood of spontaneous closure in the context of age and physical exam findings. Collaborative efforts between surgeons and referring providers are also needed to optimize management of caregiver anxiety and expectations surrounding need for surgical referral and repair. LEVEL OF EVIDENCE: Level V (expert opinion).

Variation in surgical management of asymptomatic umbilical hernia at freestanding children's hospitals.

PURPOSE: To examine hospital-level variation in the timing of asymptomatic umbilical hernia repair in children. METHODS: Retrospective analysis of children undergoing umbilical hernia repair at 38 children's hospitals using the Pediatric Health Information System database (01/2013-12/2017). Early repair was defined as surgery performed at 3 years of age or younger. Repairs were categorized as emergent/urgent if associated with diagnostic or procedural codes indicating obstruction or strangulation, or if they occurred within 2 weeks of an emergency department encounter. Multivariable regression was used to calculate hospital-level observed-to-expected (O/E) ratios for early repair adjusting for emergent/urgent repair and patient characteristics. RESULTS: 23,144 children were included, of which 30% underwent early repair (hospital range: 6.9%-54.3%, p ≪ 0.001). Overall, 3.8% of all repairs were emergent/urgent, and higher rates of early repair did not correlate with higher rates of emergent/urgent repair across hospitals (r = -0.10). Following adjustment, hospital-level O/E ratios for early repair varied 8.9-fold (0.19-1.70, p ≪ 0.001). CONCLUSION: Timing of asymptomatic umbilical hernia repair varies widely across children's hospitals, and the magnitude of this variation cannot be explained by differences in patient characteristics or the acuity of repair. Many children may be undergoing repair of hernias that may spontaneously close with further observation. LEVEL OF EVIDENCE: Level III (retrospective comparative study).

Trends in the use of surgical antibiotic prophylaxis in general pediatric surgery: Are we missing the mark for both stewardship and infection prevention?

BACKGROUND: The purpose of this study was to assess compliance with antimicrobial spectrum guidelines in the use of surgical antibiotic prophylaxis (SAP) in pediatric surgery. METHODS: A retrospective cohort study of children undergoing elective clean-contaminated and clean surgical procedures with foreign body implantation using the Pediatric Health Information System database (10/2015-6/2018) was performed. Compliance rates with consensus guidelines surrounding appropriate spectrum of SAP coverage were calculated for each procedure. Undertreatment was defined as the use of SAP with inappropriately narrow coverage (or omission altogether), while overtreatment was defined as inappropriately broad coverage. RESULTS: Eight procedure groups including a total of 15,708 patients were included. Overall, 44% of cases received inappropriate prophylaxis, of which 58% were considered undertreatment and 42% overtreatment. Procedures with the highest rates of overtreatment included small bowel procedures (77%), colorectal procedures (29%), and hepatobiliary procedures (20%), while the highest rates of undertreatment were associated with placement of tunneled central venous catheters and ports (43%), hepatobiliary procedures (24%), and colorectal procedures (20%). CONCLUSION: Noncompliance with the recommended spectrum of coverage for surgical antibiotic prophylaxis is common in pediatric surgery, with both over and undertreatment being common themes. Improved compliance is needed to optimize both antibiotic stewardship and infection prevention. TYPE OF STUDY: Treatment study. LEVEL OF EVIDENCE: Level III.

Association of Sociodemographic Factors With Adherence to Age-Specific Guidelines for Asymptomatic Umbilical Hernia Repair in Children.

Importance: Current guidelines recommend delaying repair of asymptomatic umbilical hernia in children until after age 4 to 5 years to allow for spontaneous closure. Objective: To examine the association of sociodemographic factors with adherence to age-specific guidelines for asymptomatic umbilical hernia repair in children. Design, Setting, and Participants: In this multicenter retrospective cohort study, children 17 years and younger who underwent umbilical hernia repair from January 2013 to June 2018 at 47 freestanding children's hospitals participating in the Pediatric Health Information System database were eligible for study inclusion. Children who underwent multiple procedures, repair of recurrent hernias, or had missing sociodemographic data were excluded. Exposures: Early umbilical hernia repair was defined as repair at 3 years or younger. Emergent or urgent presentation was defined as repair performed during the same encounter or within 2 weeks of an emergency department visit, respectively. Patients were categorized by sex, race/ethnicity, insurance type, income quintile, and presence of complex chronic conditions. Main Outcomes and Measures: Multivariable mixed-effects logistic regression was used to evaluate the association of sociodemographic factors with the odds of early repair after adjusting for emergent or urgent presentation and hospital-level effects. Results: Of the 25 877 included children, 13 817 (53.4%) were female, 14 143 (54.7%) had public insurance, and the median (interquartile range) age was 5.0 (3.0-6.0) years. Following adjustment, increased odds of early repair was associated with public insurance (public vs commercial insurance: odds ratio [OR], 1.46; 95% CI, 1.36-1.56; P < .001), lower income (lowest vs highest income quintile: OR, 1.48; 95% CI, 1.33-1.65; P < .001), and female sex (female vs male sex: OR, 1.20; 95% CI, 1.13-1.27; P < .001). Children with public insurance in the lowest income quintile had 2.2-fold increased odds of early repair compared with children with commercial insurance in the highest income quintile (OR, 2.15; 95% CI, 1.93-2.40; P < .001). Sociodemographic factors were not associated with increased odds of early repair in the subgroup of children who underwent early repair following emergent or urgent presentation. Conclusions and Relevance: Public insurance, lower income, and female sex are independently associated with repair of asymptomatic umbilical hernias in children earlier than recommended by current guidelines. These children may be at greater risk of undergoing repair of umbilical hernias that may spontaneously close with further observation.