Povidone-iodine intra-abdominal irrigation versus no irrigation in pediatric perforated appendicitis: A secondary economic analysis of a Bayesian randomized controlled trial.

BACKGROUND: A pilot randomized controlled trial (RCT) conducted in children (2-17 â€‹y) with perforated appendicitis demonstrated an 89% probability of reduced intra-abdominal abscess (IAA) rate with povidone-iodine (PVI) irrigation, compared with no irrigation (NI). We hypothesized that PVI also reduced 30-day hospital costs. METHODS: We conducted a retrospective economic analysis of a pilot RCT. Hospital costs, inflated to 2019 U.S. dollars, were obtained for index admissions and 30-day emergency visits and readmissions. Cost differences between groups were assessed using frequentist and Bayesian generalized linear models. RESULTS: We observed a 95% Bayesian probability that PVI reduced 30-day mean total hospital costs ($16,555 [PVI] versus $18,509 [NI]; Bayesian cost ratio: 0.90, 95% CrI, 0.78-1.03). The mean absolute difference per patient was $1,954 less with PVI (95% CI, -$4,288 to $379). CONCLUSIONS: PVI likely reduced the IAA rate and 30-day hospital costs, suggesting the intervention is both clinically superior and cost saving.

Older Patients With Asymptomatic Primary Hyperparathyroidism: Should Criteria for Surgery Be Expanded?

Context: Patients with primary hyperparathyroidism (PHPT) can present with variable signs, symptoms, and end-organ effects. Clinical practice guidelines influence referral for consideration of parathyroidectomy. Objective: This study compared the demographic, biochemical, and symptom profile and examine indications for surgery in patients older than 50 years who underwent parathyroidectomy to determine how changes to current guidelines may affect recommendations for parathyroidectomy. Methods: A retrospective review was conducted of patients age 50 years or older who underwent initial parathyroidectomy for sporadic PHPT from 2012 to 2020. Patients were classified by indications for surgery per guideline criteria (classic, asymptomatic, and no criteria met) and age group (AG): 50 to 59 years; 60 to 69 years; 70 years or older. Patients were treated at a high-volume tertiary medical center by endocrine surgeons. Results: Of 1182 patients, 367 (31%) classic and 660 (56%) asymptomatic patients met the criteria for surgery. The most common indications for surgery were extent of hypercalcemia (51%), osteoporosis (28%), and nephrolithiasis (27%). Of the 155 (13%) patients who did not meet the criteria, neurocognitive symptoms (AG1: 88% vs AG2: 81% vs AG3: 70%; P = .14) and osteopenia (AG1: 53% vs AG2: 68% vs AG3: 68%; P = .43) were frequently observed regardless of patient age. If the age threshold of younger than 50 years was expanded to 60, 65, or 70 years, an additional 61 (5%), 99 (8%), and 124 (10%) patients in the entire cohort would have met the guideline criteria for surgery, respectively. Conclusion: Expanding current guidelines for PHPT to include a broader age range, osteopenia, and neurocognitive symptoms may allow for earlier surgical referral and evaluation for definitive treatment.

Healthcare Utilization Among Infants Discharged From the Neonatal Intensive Care Unit: A Descriptive Cost Analysis.

The cost of readmissions of neonatal intensive care unit (NICU) graduates within 6 months and a year of their life is well-studied. However, the cost of readmissions within 90 days of NICU discharge is unknown. This study's objective was to estimate the overall and mean cost of healthcare use for unplanned hospital visits of NICU graduates within 90 days of discharge A retrospective review of all infants discharged between 1/1/2017 and 03/31/2017 from a large hospital system NICUs was conducted. All unplanned hospital visits (readmissions or stand-alone emergency department (ED) visits) occurring within 90 days post NICU discharge were included. The total and mean cost of unplanned hospital visits were computed and adjusted to 2021 US dollars. The total cost was estimated to be $785 804 with a mean of $1898 per patient. Hospital readmissions accounted for 98% ($768 718) of the total costs and ED visits for 2% ($17 086). The mean cost per readmission and stand-alone ED visit were $25 624 and $475 respectively. The highest mean total cost of unplanned hospital readmission was noted in extremely low birth weight infants ($25 295). Interventions targeted to reduce hospital readmissions after NICU discharge have the potential to significantly reduce healthcare costs for this patient population.

Surgical treatment of adrenal tumors during pregnancy.

While most adrenal tumors are identified incidentally and are non-functional, hormone-secreting tumors can cause morbidity and mortality. Hemodynamic lability and hypertension in pregnancy are associated with worse maternal and fetal outcomes. Achieving a diagnosis of hormone excess due to adrenal tumors can be clinically more difficult in the gravid patient due to normal physiologic alterations in hormones and symptoms related to pregnancy. This review focuses on some nuances of the diagnostic work-up, perioperative care, and surgical management of adrenally-mediated cortisol excess, primary aldosteronism, and pheochromocytoma and paraganglioma in the pregnant patient.

Barriers to Transition to Home From the Neonatal Intensive Care Unit: A Qualitative Perspectives of Parents and Healthcare Providers.

The objective of this study was to explore the challenges faced by parents of former neonatal intensive care unit (NICU) patients in transitioning home from parents' and healthcare providers' perspective. We conducted semistructured individual and group interviews with parents of former NICU patients and healthcare providers. Themes from the individual interviews framed the group interviews' contents. The group interviews were recorded and transcribed, and thematic analysis was performed to identify themes. We conducted individual and group interviews with 16 parents and 33 inpatient and outpatient providers from November 2017 to June 2018. Individual interview participants identified several barriers experienced by parents when transitioning their infant home from the NICU including parental involvement and engagement during NICU stay and during the discharge process. Further exploration within group interviews revealed opportunities to improve discharge communication and processes, standardization of parental education that was lacking due to NICU resource constraints, support for parents' emotional state, and use of technology for infant care in the home. Parents of NICU patients face serious emotional, logistical, and knowledge challenges when transitioning their infant home from the NICU. Understanding and mitigating the challenges of transitioning infants from NICU to home require multistakeholder input from both parents and providers.

Medullary thyroid carcinoma: recent advances in identification, treatment, and prognosis.

Medullary thyroid carcinoma (MTC) is a neuroendocrine tumor that represents <5% of all thyroid malignancies and is generally more aggressive than differentiated thyroid cancer. The aim of this study is to provide an update, through review of clinical studies of patients with MTC published between January 1, 2016, and June 1, 2021, on recent advances in the diagnosis and treatment of MTC. This review focuses on updates in biochemical testing, imaging, hereditary disease, surgical management, adjuvant therapies, and prognosis. Recent advances reviewed herein have sought to diagnose MTC at earlier stages of disease, predict when patients with a hereditary syndrome may develop MTC, use functional imaging to assess for distant metastases, perform optimal initial surgery with appropriate lymphadenectomy, employ targeted systemic therapies for patients with progressive metastatic disease, and better predict patient-specific outcomes.

Let the right one in: High admission rate for low-acuity pediatric burns.

BACKGROUND: The purpose of this study was to characterize emergency pediatric burn care triage at a tertiary children's hospital to identify targets for quality improvement. METHODS: A retrospective review of patients <18 years with primary burn injuries who presented to a children's emergency department in 2016 was conducted. Demographic and injury characteristics were recorded. Low acuity was defined by size (<5% total body surface area burn), depth (not third degree), and no need for conscious sedation for debridement. Multiple logistic regression was used for analysis. RESULTS: A total of 309 pediatric burn patients were triaged in the emergency department. Patients were typically young (median 3.3 years), male (59%), Hispanic (47%), publically insured (77%), and transferred in (65%). Scalding was the most common mechanism (59%). Though most burns were small (median 2% total body surface area), not deep (

Hospital type predicts computed tomography use for pediatric appendicitis.

BACKGROUND: Evidence-based guidelines recommend ultrasound (US) over computed tomography (CT) as the primary imaging modality for suspected pediatric appendicitis. Continued high rates of CT use may result in significant unnecessary radiation exposure in children. The purpose of this study was to evaluate variables associated with preoperative CT use in pediatric appendectomy patients. METHODS: A retrospective cohort study of pediatric patients who underwent appendectomy for acute appendicitis in 2015-2016 at National Surgical Quality Improvement Program for Pediatrics (NSQIP-P) hospitals was conducted. Pediatric (<18 years old) patients who underwent appendectomy for acute appendicitis in an NSQIP-P hospital from 2015 to 2016 were included. Patients were excluded if they underwent interval or incidental appendectomy or did not have a final diagnosis of appendicitis. Variables associated with imaging evaluation, including age, body mass index (BMI), race/ethnicity, gender and hospital of presentation (NSQIP-P vs. non-NSQIP-P hospital) were evaluated. The primary outcome was receipt of preoperative CT. Secondary outcomes include reimaging practices and trends over time. RESULTS: 22,333 children underwent appendectomies, of which almost all were imaged preoperatively (96.5%) and 36% of whom presented initially to a non-NSQIP-P hospital. Overall, US only was the most common imaging modality (52%), followed by CT only (27%), US+CT (16%), no imaging (3%), MRI +/- CT/US (1%) and MRI only (<1%). On regression, older age (>11 years), obesity (BMI >95th percentile for age), and female gender were associated with increased odds of receiving a CT scan. However, initial presentation to a non-NSQIP-P hospital was the strongest predictor of CT use (OR 9.4, 95% CI 8.1-10.8). Reimaging after transfer was common, especially after US and MRI at a non-NSQIP-P hospital. CT use decreased between 2015 and 2016 in non-NSQIP-P hospitals but remained the same (25%) in NSQIP-P facilities. CONCLUSIONS: Though patient characteristics were associated with different imaging practices, presentation at a referral, nonchildren's hospital is the strongest predictor of CT use in children with appendicitis. NSQIP-P hospitals frequently reimage transferred patients and have not reduced their CT use. Novel strategies are required for all hospital types in order to sustain reduction in CT use and mitigate unnecessary imaging. LEVEL OF EVIDENCE: Level III. TYPE OF STUDY: Retrospective comparative study.

Room for "quality" improvement? Validating National Surgical Quality Improvement Program-Pediatric (NSQIP-P) appendectomy data.

INTRODUCTION: Accurate data are essential for the validity of clinical registries. This study aimed to validate NSQIP-P data, assess representativeness, and evaluate risk-adjusted predictive ability at a single institution. METHODS: A prospective appendectomy-specific pediatric surgery research database (RD) maintained by clinical researchers was compared to the NSQIP-P data for appendectomies performed in 2016 at a tertiary children's hospital. NSQIP-P sampled data collected by trained surgical clinical reviewers (SCRs) were compared to matched RD patients. Both datasets used NSQIP-P definitions. Using χ2, datasets were compared by patient demographics, disease severity (simple vs. complicated), and outcomes. RESULTS: 458 appendectomies for acute appendicitis were performed in 2016, of which 250 (55%) were abstracted by SCRs and matched to RD patients. Patient demographics were similar between datasets. Disease severity (NSQIP-P:50% complicated vs RD:31% complicated) and composite morbidity (NSQIP-P:6.0% vs RD:14.4%) were significantly different (both p < 0.01). Demographics and outcomes were similar between matched (n = 250) and unsampled patients in the RD (n = 208). NSQIP-P's risk-adjusted predicted morbidity was significantly lower than morbidity observed in all (n = 458) RD patients (NSQIP-P:9.9% vs RD:14.2%, p < 0.01). CONCLUSIONS: Though constituting a representative sample, NSQIP-P appendectomy data were inconsistent with department data. Discrepancies appear to be the result of underreporting of outcome variables and disease misclassification. TYPE OF STUDY: Retrospective comparative review. LEVEL OF EVIDENCE: Level III.

Tunneled central venous catheters in pediatric intestinal failure: a single-center experience.

BACKGROUND: Parenteral nutrition for intestinal failure (IF) often requires a tunneled central venous catheter (CVC). The purpose of this study was to characterize complications after CVC placement and contributors to line loss in pediatric IF patients. METHODS: An institutional review board-approved retrospective review of pediatric (<18 y) IF patients who had a silicone tunneled CVC newly inserted or exchanged from 2012 to 2016 in an IF center was conducted. Patient demographics, procedure service (surgery versus interventional radiology), procedure type (new versus exchange), vessel, and complications related to CVCs were evaluated. Complications included dislodgement, infection, break, occlusion/malfunction, and others. An ethanol-lock protocol for silicone CVCs in IF patients was instituted in January 2012. RESULTS: Twenty-nine IF patients with tunneled CVCs were identified with 182 lines and 18,534 line d. Median age at line insertion was 17.1 mo (interquartile range [IQR] 7.6-31.5) with a median of five catheters (IQR 2-8) per patient. There were 19.2 complications per 1000 line d. Occlusions/malfunctions were the most common complication (6.0/1000 line d) followed by breaks (5.6/1000 line d). Median life of catheters was 51.5 d (IQR 21-129). On regression, adjusting for age, insertion service, and procedure type, shorter line life was associated with younger age (P = 0.04) and placement by interventional radiology (P < 0.01). Dislodgement was associated with newly placed lines relative risk 6.5 (95% CI 2.2-28.8). CONCLUSIONS: CVCs in pediatric IF patients have frequent complications and short line lifetimes. Dislodgement of CVC was an unexpectedly common complication with loss of access in newly placed lines. There may be modifiable processes to mitigate CVC complications.

Too much of a bad thing: Discharge opioid prescriptions in pediatric appendectomy patients.

BACKGROUND: Opioid misuse is a public health crisis in the United States. This study aimed to evaluate the discharge opioid prescription practices for pediatric simple appendectomy patients. METHODS: A retrospective review of pediatric appendectomy patients at a tertiary children's hospital was conducted from October 2016 to January 2018. Only patients with simple appendicitis were included. Written opioid prescriptions were found in the electronic medical record (EMR) or through a statewide prescription monitoring database. All dosing data were converted to oral morphine equivalents (OMEs). Analysis of variance and logistic regression were used. RESULTS: During the study, 590 patients underwent appendectomy, of which 371 (62.9%) were diagnosed as having simple acute appendicitis. The majority of patients were prescribed an opioid analgesic (62.5%). Demographics were similar between those who received opioids and those who did not. The OME prescribed per day (range 0.2 to 3.4 mg/kg/day) was highly variable as was duration of prescription (1 to 30 days). Odds of emergency department visit were 3.3 times higher (95% CI 1.3-8.2) in those who received opioids. CONCLUSION: Postdischarge prescription practices for pediatric appendectomy are highly variable. Two-thirds of patients who received narcotics had a higher rate of complications. Greater scrutiny is required to optimize opioid stewardship. TYPE OF STUDY: Retrospective comparative study. LEVEL OF EVIDENCE: Level III.

Enhanced neonatal surgical site infection prediction model utilizing statistically and clinically significant variables in combination with a machine learning algorithm.

BACKGROUND: Machine-learning can elucidate complex relationships/provide insight to important variables for large datasets. This study aimed to develop an accurate model to predict neonatal surgical site infections (SSI) using different statistical methods. METHODS: The 2012-2015 National Surgical Quality Improvement Program-Pediatric for neonates was utilized for development and validations models. The primary outcome was any SSI. Models included different algorithms: full multiple logistic regression (LR), a priori clinical LR, random forest classification (RFC), and a hybrid model (combination of clinical knowledge and significant variables from RF) to maximize predictive power. RESULTS: 16,842 patients (median age 18 days, IQR 3-58) were included. 542 SSIs (4%) were identified. Agreement was observed for multiple covariates among significant variables between models. Area under the curve for each model was similar (full model 0.65, clinical model 0.67, RF 0.68, hybrid LR 0.67); however, the hybrid model utilized the fewest variables (18). CONCLUSIONS: The hybrid model had similar predictability as other models with fewer and more clinically relevant variables. Machine-learning algorithms can identify important novel characteristics, which enhance clinical prediction models.

Increased complications in pediatric surgery are associated with comorbidities and not with Down syndrome itself.

BACKGROUND: Down syndrome (DS) is a genetic condition associated with multiple comorbidities. While physicians may perceive that DS patients have more postoperative complications, the literature remains unclear. This study compared postoperative complications for children with and without DS who underwent abdominal and thoracic procedures. METHODS: The National Surgical Quality Improvement Program Pediatric was queried for patients aged <18 years, who underwent abdominal and noncardiac thoracic operations (by Current Procedural Terminology codes) from 2012 to 2015. The analysis compared patients based on the presence or absence of DS. The primary outcome was a composite of all postoperative complications as defined by the National Surgical Quality Improvement Program Pediatric. The analysis utilized chi-square, Student's t-test, and univariate and multiple logistic regression. RESULTS: There were 91,478 patients included, of which 1476 (1.6%) had a diagnosis of DS. Patients with DS had higher rates of preoperative nutritional support (38.8% versus 15.0%), developmental delay (61.9% versus 10.4%), and cardiac risk factors (76.5% versus 13.8%). The overall rate of postoperative complications was 11.1%, with a greater proportion in DS patients (16.2% versus 10.8%, P < 0.001). On univariate analysis, DS was associated with increased odds of postoperative complications (odds ratio 1.6 95% confidence interval 1.4-1.9) compared with the non-DS group; however, DS was not a risk factor after adjusting for other covariates (adjusted odds ratio 0.86 95% confidence interval 0.7-1.1). CONCLUSIONS: A higher proportion of postoperative complications were observed in patients with DS. However, after adjusting for other risk factors, DS was not an independent risk factor. The increased rate of complications is likely related to the presence of multiple comorbidities in DS.

Utility of standardized discharge criteria after appendectomy to identify pediatric patients requiring intervention after postoperative imaging.

BACKGROUND: The purposes of this study were to evaluate the efficacy of failure-of-discharge criteria and identify the cohort of pediatric patients after appendectomy in whom postoperative imaging would impact management. METHODS: Pediatric patients who underwent an appendectomy from July 2009 to May 2017 were included. Complicated appendicitis was defined based on the intraoperative diagnosis. Postoperative imaging was recommended at postoperative days 5-7 for patients who met at least one criterion of failure of standard management: fever (>38°C), leukocytosis (white blood cell count >12,000/mm3), diet intolerance, or uncontrolled pain by oral analgesics at postoperative day 5. Primary outcomes included any intervention (reoperation, drainage procedures, or change in antibiotics). RESULTS: In all, 3,276 pediatric patients undergoing appendectomy were identified. Of these patients, 12% met at least 1 discharge criterion of failure Most discharge failures (79%) underwent postoperative imaging, such as computed tomography (68%), ultrasonography then computed tomography (20%), or ultrasonography only (12%); 39% of imaging patients required intervention. On multiple logistic regression, 3 criteria (diet intolerance, fever, and leukocytosis), complicated disease, and age were associated with the need for intervention after imaging. The type of imaging modality did not discriminate need for intervention. CONCLUSION: Standardized criteria identifying failure of ability to discharge the patient after appendectomy limits the need for unnecessary imaging. In the management of pediatric appendicitis, a selective approach resulted in a high yield of complications requiring intervention after obtaining postoperative imaging.

Adherence to the Pediatric Preinduction Checklist Is Improved When Parents Are Engaged in Performing the Checklist.

BACKGROUND: The World Health Organization recommends including the parents in completion of the pediatric surgical safety checklist. At our hospital, the preinduction surgical safety checklist is conducted in the preoperative holding with anesthesia, nursing, and often with the parents of children undergoing an operative procedure. We hypothesized that adherence to the preinduction checklist is better when parents are engaged in surgical safety checklist performance. METHODS: An observational study of adherence to the preinduction checklist for nonemergent pediatric operations was performed (2016-2017). Adherence was defined as verbalization of checkpoints. Only checkpoints (patient identification, procedure, site marking, weight, allergies, and NPO status) relevant to parental knowledge were evaluated. Parental engagement was based on: positive body language, eye contact, lack of distractions, and understanding of checkpoints. RESULTS: 484 preinduction surgical safety checklists were observed (interrater reliability >0.7). Partial completion occurred in 55% cases; only 41% checklists were fully completed. Parents were present for 81% of checklists, and more checkpoints were performed when parents were present (5, IQR 4-6) versus absent (2, IQR 1-3, P < .001). Increased preinduction adherence was associated with increased parent engagement by linear regression analysis (1.20, 95%CI 1.05-1.33). Staff confirmed more checkpoints with engaged parents (28-78%) versus when parents were not engaged (1-9%, P < .001 for all checkpoints). CONCLUSION: Overall preinduction surgical safety checklist performance was poor (less than half of checklists fully completed). In contrast, checklist adherence improved with parental presence and engagement during performance of the checklist.

Home Antibiotics at Discharge for Pediatric Complicated Appendicitis: Friend or Foe?

BACKGROUND: The role of home antibiotics (HA) at discharge in children after perforated appendicitis is unclear. This study evaluates the outcomes of complicated appendicitis in patients being discharged with or without HA after initial operation and inpatient treatment. STUDY DESIGN: The 2015 and 2016 NSQIP-Pediatric database was queried for patients younger than 18 years of age with complicated appendicitis. Home antibiotics were prescribed or not (no home antibiotics [NHA]). Patients were stratified based on presence or absence of predischarge surgical site infection (SSI) and postoperative day of discharge (≤5 days or >5 days). The primary end point was 30-day postdischarge composite morbidity, including emergency department visit, readmission, postdischarge reoperation, and SSI. Multivariable logistic regression was used to adjust for baseline covariables. RESULTS: Of 6,412 patients with complicated appendicitis, the majority were discharged with HA (HA 56.4%; NHA 43.6%). Patients receiving HA had higher preoperative leukocytosis, longer procedures, higher incidence of sepsis, more predischarge SSIs, and longer length of stay than the NHA cohort (all p < 0.01), suggesting greater severity of illness. In adjusted multivariable models, HA patients without a predischarge SSI had higher postdischarge morbidity (adjusted odds ratio [aOR] 1.22; 95% CI 1.04 to 1.44), as did HA patients discharged ≤5 days post operation (aOR 1.28; 95% CI 1.04 to 1.57) compared with NHA patients. Composite morbidity was similar between NHA and HA patients with predischarge SSIs (aOR 1.06; 95% CI 0.56 to 2.00) or who were discharged >5 days post operation (aOR 1.14; 95% CI 0.89 to 1.46). CONCLUSIONS: Although the majority of pediatric patients with complicated appendicitis are discharged with HA, NSQIP-Pediatric data suggest there is no evidence of a significant benefit. There might be a cohort of patients with more severe disease who require continued antibiotics.

Advances in perioperative quality and safety.

For decades, safe surgery focused on intraoperative technique and decision-making. The traditional hierarchy placed the surgeon as the leader with ultimate authority and responsibility. Despite the advances in surgical technique and equipment, too many patients have suffered unnecessary complications and suboptimal care. Today, we understand that the conduct of safe and effective surgery requires evidence-based decision-making, multifaceted treatment approaches to prevent complications, and effective communication in and out of the operating room. In this manuscript, we describe three significant advances in quality and safety that have changed the approach to surgical care: the National Surgical Quality Improvement Program, evidence-based bundled prevention of surgical site infections, and the Surgical Safety Checklist.

Decreasing intraoperative delays with meaningful use of the surgical safety checklist.

BACKGROUND: Purposeful completion (fidelity) more than simple adherence to items in the surgical safety checklist may improve operating room efficiency and patient safety. The purpose of this study was to evaluate intraoperative delays and correlate them with adherence and fidelity to the preincision surgical safety checklist. METHODS: Trained observers evaluated surgical safety checklist compliance during 3 observation periods from 2014-2016. Degree of adherence, checkpoint verbalization, fidelity, and meaningful completion were assessed. Delays were categorized as missing or malfunctioning equipment, staff error, and medication issues. Descriptive statistics, analysis of variance, logistic regression, χ2 and Student t test were used to analyze results. RESULTS: Of the 591 cases observed, 19% (n = 110) had at least one documented, intraoperative delay. The majority of delays were related to missing (50%) or malfunctioning (30%) equipment. Compared with cases without delays, cases with delays did not have a different mean degree of adherence (96.3 ± 7.6% vs 95.6 ± 5.8%, P = .36). Degree of fidelity was different between cases with and without delays (mean fidelity 77.1 ± 14.9% vs 80.5 ± 7.14.2%, P = .03). CONCLUSION: The preincision SSC is a communication tool offering an opportunity to discuss potential concerns and anticipated intraoperative needs. Fidelity rather than adherence to the surgical safety checklist seems to diminish intraoperative delays.

Debriefing: the forgotten phase of the surgical safety checklist.

BACKGROUND: The debriefing phase of the surgical safety checklist (SSC) provides the operative team an opportunity to share pertinent intraoperative information and communicate postoperative plans. Prior quality improvement initiatives at our institution focused on the preincision phase of the SSC; however, the debriefing phase has not been evaluated. We aimed to assess adherence to the debrief checklist at our institution and identify areas for improvement. MATERIALS AND METHODS: An observational study was conducted from 2014 to 2016 with a convenience sample of pediatric surgery cases at an academic children's hospital over 8-wk periods annually to evaluate the debriefing checklist across 14 subspecialties. Intraoperative team members' adherence to eight prespecified checkpoints was assessed. Descriptive statistics, Pearson's chi square, Kruskal-Wallis rank test, and Cohen's kappa for interrater reliability were used (P < 0.05 was significant). RESULTS: A total of 603 cases were observed (2014 n = 191; 2015 n = 195; 2016 n = 217). The debriefing checklist was conducted in 90.6%, 90.3%, and 94.9% of observed cases each year respectively with the median number of checklist items completed relatively unchanged (8, 7, and 7, range 0-8). However, the checklist was only fully completed in 55%, 48%, and 50% of cases over the study period (P = 0.001) with no debriefing at all in approximately 9% of cases in 2014 and 2015 versus 5% in 2016 (P < 0.001). Interrater reliability annually was >0.65. CONCLUSIONS: Despite slight increases annually in overall compliance to the debriefing checklist, only half of all checklists were completed in full. Future efforts to augment adherence are needed and will include interventions targeting the debriefing phase and increasing operating room efficiency.

Outcomes assessment of combination face lift and perioral phenol-croton oil peel.

BACKGROUND: Face-lift surgery when combined with perioral phenol-croton oil peel is an underappreciated tool for face rejuvenation. The procedure results in significant central face skin tightening and wrinkle reduction. METHODS: A retrospective review of 47 consecutive patients who underwent simultaneous face lift and perioral peel was performed. The objective measures used to evaluate the change in appearance of the patients included (1) a validated patient satisfaction questionnaire, (2) an evaluation of apparent age, and (3) an evaluation of perioral wrinkles by independent reviewers using a validated model. The assessment of apparent age was performed as follows: preoperative and postoperative photographs were shown randomly to six reviewers, who were asked to estimate the patient's age. The apparent age was compared with the patient's actual age, and the reduction in apparent age was calculated. Improvement in perioral rhytides was evaluated by using the Glogau classification system (range, 1 to 4). RESULTS: Survey results documented overall patient satisfaction, which was rated as 6.5 on a scale of 1 to 7 (with higher scores indicating greater satisfaction). Patients' postoperative apparent age estimate was 8.2 years younger than their real age (p=0.0002). The Glogau classification system score demonstrated a mean reduction of 1.15 (3.3 preoperatively as compared with 2.15 postoperatively, p<0.0001). CONCLUSION: Outcomes measurements, including patient satisfaction, objective evaluation of wrinkle improvement, and significant reduction in apparent age, document the power of this technique. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.