Incidence and Relative Burden of Surgical Site Infections in Children Undergoing Nonemergent Surgery: Implications for Performance Benchmarking and Prioritization of Prevention Efforts.

OBJECTIVE: To establish surgical site infection (SSI) performance benchmarks in pediatric surgery and to develop a prioritization framework for SSI prevention based on procedure-level SSI burden. BACKGROUND: Contemporary epidemiology of SSI rates and event burden in elective pediatric surgery remain poorly characterized. METHODS: Multicenter analysis using sampled SSI data from 90 hospitals participating in NSQIP-Pediatric and procedural volume data from the Pediatric Health Information System (PHIS) database. Procedure-level incisional and organ space SSI (OSI) rates for 17 elective procedure groups were calculated from NSQIP-Pediatric data and estimates of procedure-level SSI burden were extrapolated using procedural volume data. The relative contribution of each procedure to the cumulative sum of SSI events from all procedures was used as a prioritization framework. RESULTS: A total of 11,689 nonemergent procedures were included. The highest incisional SSI rates were associated with gastrostomy closure (4.1%), small bowel procedures (4.0%), and gastrostomy (3.7%), while the highest OSI rates were associated with esophageal atresia/tracheoesophageal fistula repair (8.1%), colorectal procedures (1.8%), and small bowel procedures (1.5%). 66.1% of the cumulative incisional SSI burden from all procedures were attributable to 3 procedure groups (gastrostomy: 27.5%, small bowel: 22.9%, colorectal: 15.7%), and 72.8% of all OSI events were similarly attributable to 3 procedure groups (small bowel: 28.5%, colorectal: 26.0%, esophageal atresia/tracheoesophageal fistula repair: 18.4%). CONCLUSIONS: A small number of procedures account for a disproportionate burden of SSIs in pediatric surgery. The results of this analysis can be used as a prioritization framework for refocusing SSI prevention efforts where they are needed most.

Opioid Use, Disposition, and Parent Satisfaction Following Common Pediatric Surgical Procedures.

INTRODUCTION: There is wide variability in prescribing practices among providers, even for patients undergoing the same operations. Our study aims to analyze the variation in opioid prescription practices using a patient-centered approach to establish more appropriate prescribing guidelines for health care providers. METHODS: We conducted phone surveys 30 days after surgery to assess patient-reported opioid use. Over a two-year collection period, we identified patients that had undergone common outpatient pediatric surgery procedures in our 4-surgeon group. Included in the survey tool was the narcotic prescribed (if any), the amount used, and patient/family rating of pain control. RESULTS: We collected data for 189 separate procedures (88 umbilical hernias, 30 laparoscopic inguinal hernias, 2 open inguinal hernias, 41 appendectomies, 15 laparoscopic cholecystectomies, and 13 pectus bar removals). Patient age ranged from less than 1 month to 246 months. 83.5% of patients had a narcotic prescribed. The average number of doses used was 4, ranging from 0 (11.3%) to 30 (1.5%). 72.6% of families surveyed felt pain control was appropriate. However, 19.6% did feel they received too much pain medication. 10.6% reported completing their entire prescription; however, only 13.6% of families with excess narcotics reported proper disposal. CONCLUSIONS: Despite heightened awareness of the opioid epidemic, there is still a poor understanding of appropriate pain control regimens in the pediatric surgical population. We demonstrate that most patients are discharged home with excess opioids and that many families save the leftover pills/liquid. Further research and education are encouraged to limit the use of opioids in standard pediatric surgical procedures.

Clinical practice guidelines for pediatric appendicitis evaluation can decrease computed tomography utilization while maintaining diagnostic accuracy.

OBJECTIVES: The objective of this study was to compare usage of computed tomography (CT) scan for evaluation of appendicitis in a children's hospital emergency department before and after implementation of a clinical practice guideline focused on early surgical consultation before obtaining advanced imaging. METHODS: A multidisciplinary team met to create a pathway to formalize the evaluation of pediatric patients with abdominal pain. Computed tomography scan utilization rates were studied before and after pathway implementation. RESULTS: Among patients who had appendectomy in the year before implementation (n = 70), 90% had CT scans, 6.9% had ultrasound, and 5.7% had no imaging. The negative appendectomy rate before implementation was 5.7%. In patients undergoing appendectomy in the postimplementation cohort (n = 96), 48% underwent CT, 39.6% underwent ultrasound, and 15.6% had no imaging. The negative appendectomy rate was 5.2%. We demonstrated a 41% decrease in CT use for patients undergoing appendectomy at our institution without an increase in the negative appendectomy rate or missed appendectomy. The results were even more striking when comparing the rate of CT scan use in the subset of patients undergoing appendectomy without imaging from an outside hospital. In these patients, CT scan utilization decreased from 82% to 20%, a 76% reduction in CT use in our facility after protocol implementation. CONCLUSIONS: Implementation of a clinical evaluation pathway emphasizing examination, early surgeon involvement, and utilization of ultrasound as the initial imaging modality for evaluation of abdominal pain concerning for appendicitis resulted in a marked decrease in the reliance on CT scanning without loss of diagnostic accuracy.

Impact of the Coronavirus (COVID-19) Pandemic on the Care of Pediatric Acute Appendicitis.

BACKGROUND: Appendicitis is the most common abdominal surgical emergency in children. With the rise of the Coronavirus-19 pandemic, quarantine measures have been enforced to limit the viral transmission of this disease. The purpose of this study was to identify differences in the clinical presentation and outcomes of pediatric acute appendicitis during the Coronavirus-19 pandemic. METHODS: A single-institution retrospective assessment of all pediatric patients (<18 years old) with acute appendicitis from December 2019 to June 2020 was performed at a tertiary care children's hospital. Patients were divided into two groups: (1) the Pre-COVID group presented on or before March 15, 2020, and (2) the COVID group presented after March 15, 2020. Demographic, preoperative, and clinical outcomes data were analyzed. RESULTS: 45 patients were included with a median age of 13 years [IQR 9.9 - 16.2] and 35 males (78%). 28 patients were in the Pre-COVID group (62%) and 17 in the COVID group (38%). There were no differences in demographics or use of diagnostic imaging. The COVID group did have a significantly delayed presentation from symptom onset (36 vs 24 hours, P < .05), higher Pediatric Appendicitis Scores (8 vs 6, P = .003), and longer hospital stays (2.2 vs 1.3 days, P = .04). There were no significant differences for rates of re-admission, re-operation, surgical site infection, perforation, or abscess formation. CONCLUSION: During the Coronavirus-19 pandemic, the incidence of pediatric acute appendicitis was approximately 40% lower. These children presented in a delayed fashion with longer hospital stays. No differences were noted for postoperative complications.

Ovary-Sparing Surgery for Ovarian Teratoma in an Infant with Nonbilious Vomiting.

Ovarian teratoma is the most common ovarian tumor in children with an overall incidence of 2.6 cases per 100,000 girls per year. Diagnosis and management are challenging due to its nonspecific presentation, malignancy determination, and need to conserve fertility. A previously healthy 5-month-old female infant presented with fever, abdominal distension, and nonbilious emesis, and an 8.2 × 6.8 × 6.1-centimeter pelvic mass originating from the left adnexa was found on imaging. Due to concern for malignancy and torsion, exploratory laparotomy and ovarian-sparing surgery (OSS) with resection of the mass were performed. Histology showed a grade 1 teratoma. This case illustrates a challenging diagnosis and its symptom overlap with other etiologies in infants. The keys to diagnosing and managing this entity are including ovarian pathology in the differential diagnosis and performing OSS whenever possible. Furthermore, ultrasound follow-up is needed to monitor for ipsilateral and contralateral ovarian tumors later in life.

Procedure-Level Misutilization of Antimicrobial Prophylaxis in Pediatric Surgery: Implications for Improved Stewardship and More Effective Infection Prevention.

BACKGROUND: The objective of this study was to quantify prophylaxis misutilization to identify high-priority procedures for improved stewardship and SSI prevention. METHODS: This was a multicenter analysis including 90 hospitals participating in the NSQIP-Pediatric Antibiotic Prophylaxis Collaborative from 6/2019 to 6/2020. Prophylaxis data were collected from all hospitals and misutilization measures were developed from consensus guidelines. Overutilization included use of overly broad-spectrum agents, continuation of prophylaxis >24 h after incision closure, and use in clean procedures without implants. Underutilization included omission (clean-contaminated cases), use of inappropriately narrow-spectrum agents, and administration post-incision. Procedure-level misutilization burden was estimated by multiplying NSQIP-derived misutilization rates by case volume data obtained from the Pediatric Health Information System database. RESULTS: 9861 patients were included. Overutilization was most commonly associated with overly broad-spectrum agents (14.0%), unindicated utilization (12.6%), and prolonged duration (8.4%). Procedure groups with the greatest overutilization burden included small bowel (27.2%), cholecystectomy (24.4%), and colorectal (10.7%). Underutilization was most commonly associated with post-incision administration (6.2%), inappropriate omission (4.4%), and overly narrow-spectrum agents (4.1%). Procedure groups with the greatest underutilization burden included colorectal (31.2%), gastrostomy (19.2%), and small bowel (11.1%). CONCLUSION: A relatively small number of procedures account for a disproportionate burden of antibiotic misutilization in pediatric surgery. TYPE OF STUDY: Retrospective Cohort. LEVEL OF EVIDENCE: III.

Surgical prescription opioid trajectories among state Medicaid enrollees.

OBJECTIVE: The objective of this study was to evaluate opioid use trajectories among a sample of 10,138 Medicaid patients receiving one of six index surgeries: lumbar spine, total knee arthroplasty, cholecystectomy, appendectomy, colon resection, and tonsillectomy. DESIGN: Retrospective cohort. SETTING: Administrative claims data. PATIENTS AND PARTICIPANTS: Patients, aged 13 years and older, with 15-month continuous Medicaid eligibility surrounding index surgery, were selected from single-state Medicaid medical and pharmacy claims data for surgeries performed between 2014 and 2017. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Baseline comorbidities and presurgery opioid use were assessed in the 6 months prior to admission, and patients' opioid use was followed for 9 months post-discharge. Generalized linear model with log link and Poisson distribution was used to determine risk of chronic opioid use for all risk factors. Group-based trajectory models identified groups of patients with similar opioid use trajectories over the 15-month study period. RESULTS: More than one in three (37.7 percent) patients were post-surgery chronic opioid users, defined as the dichotomous outcome of filling an opioid prescription 90 or more days after surgery. Key variables associated with chronic post-surgery opioid use include presurgery opioid use, 30-day post-surgery opioid use, and comorbidities. Latent trajectory modeling grouped patients into six distinct opioid use trajectories. Associates of trajectory group membership are reported. CONCLUSIONS: Findings support the importance of surgeons setting realistic patient expectations for post-surgical opioid use, as well as the importance of coordination of post-surgical care among patients failing to fully taper off opioids within 1-3 months of surgery.

The past, present and future of ACS NSQIP-Pediatric: Evolution from a quality registry to a comparative quality performance platform.

Quality and process improvement (QI/PI) in children's surgical care require reliable data across the care continuum. Since 2012, the American College of Surgeons' (ACS) National Surgical Quality Improvement Program-Pediatric (NSQIP-Pediatric) has supported QI/PI by providing participating hospitals with risk-adjusted, comparative data regarding postoperative outcomes for multiple surgical specialties. To advance this goal over the past decade, iterative changes have been introduced to case inclusion and data collection, analysis and reporting. New datasets for specific procedures, such as appendectomy, spinal fusion for scoliosis, vesicoureteral reflux procedures, and tracheostomy in children less than 2 years old, have incorporated additional risk factors and outcomes to enhance the clinical relevance of data, and resource utilization to consider healthcare value. Recently, process measures for urgent surgical diagnoses and surgical antibiotic prophylaxis variables have been developed to promote timely and appropriate care. While a mature program, NSQIP-Pediatric remains dynamic and responsive to meet the needs of the surgical community. Future directions include introduction of variables and analyses to address patient-centered care and healthcare equity.

Management of pediatric appendicitis during the COVID-19 pandemic: A nationwide multicenter cohort study.

BACKGROUND: The COVID-19 pandemic has impacted timely access to care for children, including patients with appendicitis. This study aimed to evaluate the effect of the COVID-19 pandemic on management of appendicitis and patient outcomes. METHODS: A multicenter retrospective study was performed including 19 children's hospitals from April 2019-October 2020 of children (age≤18 years) diagnosed with appendicitis. Groups were defined by each hospital's city/state stay-at-home orders (SAHO), designating patients as Pre-COVID (Pre-SAHO) or COVID (Post-SAHO). Demographic, treatment, and outcome data were obtained, and univariate and multivariable analysis was performed. RESULTS: Of 6,014 patients, 2,413 (40.1%) presented during the COVID-19 pandemic. More patients were managed non-operatively during the COVID-19 pandemic compared to before the pandemic (147 (6.1%) vs 144 (4.0%), p < 0.001). Despite this change, there was no difference in the proportion of complicated appendicitis between groups (1,247 (34.6%) vs 849 (35.2%), p = 0.12). COVID era non-operative patients received fewer additional procedures, including interventional radiology (IR) drain placements, compared to pre-COVID non-operative patients (29 (19.7%) vs 69 (47.9%), p < 0.001). On adjusted analysis, factors associated with increased odds of receiving non-operative management included: increasing duration of symptoms (OR=1.01, 95% CI: 1.01-1.012), African American race (OR=2.4, 95% CI: 1.3-4.6), and testing positive for COVID-19 (OR=10.8, 95% CI: 5.4-21.6). CONCLUSION: Non-operative management of appendicitis increased during the COVID-19 pandemic. Additionally, fewer COVID era cases required IR procedures. These changes in the management of pediatric appendicitis during the COVID pandemic demonstrates the potential for future utilization of non-operative management.

Hypoxic respiratory failure in acute appendicitis: A bronchoperitoneal fistula as the presenting symptom of appendicitis in the setting of pediatric COVID-19.

Symptomatic COVID-19 less frequently affects the pediatric population and is often associated with atypical presenting symptoms. Here we describe a nine-year-old patient who presented with acute hypoxic respiratory failure and was found to have perforated appendicitis, intra-abdominal abscess, and bronchoperitoneal fistula. The rapid progression of this pathology, complex critical care decision making, and ultimate surgical management has not been previously described. Documenting this patient's clinical course and effective treatments may serve to inform and guide the medical community and pediatric care providers as the world continues to combat the COVID-19 pandemic.

Incidence and patterns of persistent opioid use in children following appendectomy.

BACKGROUND: The past 5 years have witnessed a concerted national effort to assuage the rising tide of the opioid misuse in our country. Surgical procedures often serve as the initial exposure of children to opioids, however the trajectory of use following these exposures remains unclear. We hypothesized that opioid exposure following appendectomy would increase the risk of persistent opioid use among publicly insured children. STUDY DESIGN: A retrospective longitudinal cohort study was conducted on South Carolina Medicaid enrollees who underwent appendectomy between January 2014 and December 2017 using administrative claims data. The primary outcome was chronic opioid use. Generalized linear models and finite mixture models were employed in analysis. RESULTS: 1789 Medicaid pediatric patients underwent appendectomy and met inclusion criteria. The mean age was 11.1 years and 40.6% were female. Most patients (94.6%) did not receive opioids prior to surgery. Opioid prescribing ≥90 days after surgery (chronic opioid use) occurred in 127 (7.1%) patients, of which 102 (80.3%) had no opioid use in the preexposure period. Risk factors for chronic opioid use included non-naïve opioid status, re-hospitalization more than 30 days following surgery, multiple opioid prescribers, age, and multiple antidepressants/antipsychotic prescriptions. Group-based trajectory analysis demonstrated four distinct post-surgical opioid use patterns: no opioid use (91.3%), later use (6.7%), slow wean (1.9%), and higher use throughout (0.4%). CONCLUSION: Opioid exposure after appendectomy may serve as a priming event for persistent opioid use in some children. Eighty percent of children who developed post-surgical persistent opioid use had not received opioids in the 90 days leading up to surgery. Several mutable and immutable factors were identified to target future efforts toward opioid minimization in this at-risk patient population. LEVEL OF EVIDENCE: III.

New chronic opioid use in Medicaid patients following cholecystectomy.

Background: Commercial insurance data show that chronic opioid use in opioid-naive patients occurs in 1.5% to 8% of patients undergoing surgical procedures, but little is known about patients with Medicaid. Methods: Opioid prescription data and medical coding data from 4,788 Medicaid patients who underwent cholecystectomy were analyzed to determine opioid use patterns. Results: A total of 54.4% of patients received opioids prior to surgery, and 38.8% continued to fill opioid prescriptions chronically; 27.1% of opioid-naive patients continued to get opioids chronically. Patients who received ≥ 50 MME/d had nearly 8 times the odds of chronic opioid use. Each additional opioid prescription filled within 30 days was associated with increased odds of chronic use (odds ratio: 1.71). Conclusion: Opioid prescriptions are common prior to cholecystectomy in Medicaid patients, and 38.8% of patients continue to receive opioid prescriptions well after surgical recovery. Even 27.1% of opioid-naive patients continued to receive opioid prescriptions chronically.

Provider education leads to sustained reduction in pediatric opioid prescribing after surgery.

BACKGROUND: The majority of opioid overdose admissions in pediatric patients are associated with prescription opioids. Post-operative prescriptions are an addressable source of opioids in the household. This study aims to assess for sustained reduction in opioid prescribing after implementation of provider-based education at nine centers. METHODS: Opioid prescribing information was collected for pediatric patients undergoing umbilical hernia repair at nine centers between December 2018 and January 2019, one year after the start of an education intervention. This was compared to prescribing patterns in the immediate pre- and post-intervention periods at each of the nine centers. RESULTS: In the current study period, 29/127 (22.8%) patients received opioid prescriptions (median 8 doses) following surgery. There were no medication refills, emergency department returns or readmissions related to the procedure. There was sustained reduction in opioid prescribing compared to pre-intervention (22.8% vs 75.8% of patients, p<0.001, Fig. (1). Five centers showed statistically significant improvement and the other four demonstrated decreased prescribing, though not statistically significant. CONCLUSIONS: Our multicenter study demonstrates sustained reduction in opioid prescribing after pediatric umbilical hernia repair after a provider-based educational intervention. Similar low-fidelity provider education interventions may be beneficial to improve opioid stewardship for a wider variety of pediatric surgical procedures. LEVELS OF EVIDENCE: (treatment study)-level 3.

Correlation Between Postoperative Antimicrobial Prophylaxis Use and Surgical Site Infection in Children Undergoing Nonemergent Surgery.

Importance: Use of postoperative antimicrobial prophylaxis is common in pediatric surgery despite consensus guidelines recommending discontinuation following incision closure. The association between postoperative prophylaxis use and surgical site infection (SSI) in children undergoing surgical procedures remains poorly characterized. Objective: To evaluate whether use of postoperative surgical prophylaxis is correlated with SSI rates in children undergoing nonemergent surgery. Design, Setting, and Participants: This is a multicenter cohort study using 30-day postoperative SSI data from the American College of Surgeons' Pediatric National Surgical Quality Improvement Program (ACS NSQIP-Pediatric) augmented with antibiotic-use data obtained through supplemental medical record review from June 2019 to June 2021. This study took place at 93 hospitals participating in the ACS NSQIP-Pediatric Surgical Antibiotic Prophylaxis Stewardship Collaborative. Participants were children (<18 years of age) undergoing nonemergent surgical procedures. Exclusion criteria included antibiotic allergies, conditions associated with impaired immune function, and preexisting infections requiring intravenous antibiotics at time of surgery. Exposures: Continuation of antimicrobial prophylaxis beyond time of incision closure. Main Outcomes and Measures: Thirty-day postoperative rate of incisional or organ space SSI. Hierarchical regression was used to estimate hospital-level odds ratios (ORs) for SSI rates and postoperative prophylaxis use. SSI measures were adjusted for differences in procedure mix, patient characteristics, and comorbidity profiles, while use measures were adjusted for clinically related procedure groups. Pearson correlations were used to examine the associations between hospital-level postoperative prophylaxis use and SSI measures. Results: Forty thousand six hundred eleven patients (47.3% female; median age, 7 years) were included, of which 41.6% received postoperative prophylaxis (hospital range, 0%-71.2%). Odds ratios (ORs) for postoperative prophylaxis use ranged 190-fold across hospitals (OR, 0.10-19.30) and ORs for SSI rates ranged 4-fold (OR, 0.55-1.90). No correlation was found between use of postoperative prophylaxis and SSI rates overall (r = 0.13; P = .20), and when stratified by SSI type (incisional SSI, r = 0.08; P = .43 and organ space SSI, r = 0.13; P = .23), and surgical specialty (general surgery, r = 0.02; P = .83; urology, r = 0.05; P = .64; plastic surgery, r = 0.11; P = .35; otolaryngology, r = -0.13; P = .25; orthopedic surgery, r = 0.05; P = .61; and neurosurgery, r = 0.02; P = .85). Conclusions and Relevance: Use of postoperative surgical antimicrobial prophylaxis was not correlated with SSI rates at the hospital level after adjusting for differences in procedure mix and patient characteristics.

Endoscopic balloon dilation for management of stricturing Crohn's disease in children.

BACKGROUND: Crohn's disease (CD) has a multitude of complications including intestinal strictures from fibrostenotic disease. Fibrostenotic disease has been reported in 10%-17% of children at presentation and leads to surgery in 20%-50% of cases within ten years of diagnosis. When symptoms develop from these strictures, the treatment in children has primarily been surgical resection. Endoscopic balloon dilation (EBD) has been shown to be a safe and efficacious alternative to surgery in adults, but evidence is poor in the literature regarding its safety and efficacy in children. AIM: To evaluate the outcomes of children with fibrostenosing CD who underwent EBD vs surgery as a treatment. METHODS: In a single-center retrospective study, we looked at pediatric patients (ages 0-18) who carry the diagnosis of CD, who were diagnosed after opening a dedicated Inflammatory Bowel Disease clinic on July 1, 2012 through May 1, 2019. We used diagnostic codes through our electronic medical record to identify patients with CD with a stricturing phenotype. The type of intervention for patients' strictures was then identified through procedural and surgical billing codes. We evaluated their demographics, clinical variables, whether they underwent EBD vs surgery or both, and their clinical outcomes. RESULTS: Of the 139 patients with CD, 25 (18%) developed strictures. The initial intervention for a stricture was surgical resection in 12 patients (48%) and EBD in 13 patients (52%). However, 4 (33%) patients whom initially had surgical resection required follow up EBD, and thus 17 total patients (68%) underwent EBD at some point in their treatment process. For those 8 patients who underwent successful surgical resection alone, 4 of these patients (50%) had a fistula present near the stricture site and 4 (50%) had strictures greater than 5 cm in length. All patients who underwent EBD had no procedural complications, such as a perforation. Twenty-two (88%) of the treated strictures were successfully managed by EBD and did not require any further surgical intervention during our follow up period. CONCLUSION: EBD is safe and efficacious as an alternative to surgery for palliative management of strictures in selected pediatric patients with CD.

Long-term outcomes of pediatric laparoscopic needled-assisted inguinal hernia repair: A 10-year experience.

PURPOSE: Laparoscopic inguinal hernia repair (LIHR) has gained wide acceptance over the past decade, although studies with longer term follow-up are lacking. We present one of the largest cohorts of children undergoing laparoscopic needle-assisted repair (LNAR) with long-term follow-up. METHODS: A clinical quality database was maintained for children ≤14 years of age who underwent laparoscopic needle-assisted repair between 2009 and 2017 with review of follow-up through 2019. De-identified data was reviewed. RESULTS: 1023 patients with 1457 LNAR were included during the 10-year period. Mean age at surgery was 2.56 years (2 days to14 years). The overall hernia recurrence rate was 0.75% (11/1457). A total of four postoperative hydroceles required intervention. Preterm infant repair done <60w post conceptional age had a significantly lower recurrence rate (0.63%) than other patients (0.82%) (p < 0.01). 64.2% of patients had clinical follow-up over a period of 11 years with a mean follow-up of 5.97 years. CONCLUSION: We present a large cohort study of consecutive pediatric laparoscopic hernia repairs followed over an 11-year period. LNAR is safe and effective for term and preterm patients with similar complication rates to other techniques, including open repair. Additionally, our results suggest that preterm infants may have superior outcomes with this method. LEVEL OF EVIDENCE: Level III - Retrospective Comparative Study.

Patterns of dispensed opioids after tonsillectomy in children and adolescents in South Carolina, United States, 2010-2017.

OBJECTIVES: Tonsillectomy (with or without adenoidectomy) is a common pediatric surgical procedure requiring post-operative analgesia. Because of the respiratory depression effects of opioids, clinicians strive to limit the use of these drugs for analgesia post-tonsillectomy. The objective of this study was to identify demographic and medication use patterns predictive of persistent opioid dispensing (as a proxy for opioid use) to pediatric patients post-tonsillectomy. PATIENTS AND METHODS: Retrospective cohort of South Carolina (USA) Medicaid-insured children and adolescents 0-18 years old without malignancy who had tonsillectomy in 2014-2017. We evaluated opioid dispensing pre-surgery and in the 30 days exposure period after hospital discharge. The main outcome, persistent opioid dispensing, was defined as any subject dispensed ≥1 opioid prescription 90-270 days after discharge. Group-based trajectory analyses described post-procedure opioid dispensing trajectories. RESULTS: There were 11,578 subjects representing 12,063 tonsillectomy procedures. Few (3.5%) procedures were followed by persistent opioid dispensing. Any opioid dispensing during the exposure period was associated with an increased odds of persistent opioid dispensing status during the follow up period (OR 1.51 for 1-6 days of exposure and OR 1.65 for 7-30 days of opioid exposure), as was pre-procedure opioid dispensing, having >1 tonsillectomy procedure, and having complex chronic medical conditions. Group-based trajectory analyses identified 4 distinct patterns of post-discharge opioid dispensing. CONCLUSIONS: Any opioid dispensing during the 30 days after tonsillectomy increased the odds of persistent opioid dispensing by > 50%. Multivariable and group-based trajectory analyses identified patient and procedure variables that correlate with persistent opioid dispensing, primarily driven by groups receiving pre-tonsillectomy opioids and a second group who experienced multiple episodes of tonsillectomy.

Interhospital variation of inpatient versus outpatient pediatric burn treatment after emergency department evaluation.

BACKGROUND: Approaches to burn care in the pediatric population are highly variable and can be targeted as a potential measure in cost-reduction. We hypothesized that institutions vary significantly in treatment allocation of nonsevere burns to either inpatient or outpatient care. METHODS: We queried the PHIS database for fiscal year 2017 to quantify small pediatric burn admissions and Emergency Department visits (ED). The ICD-10 code T31.0 was used to identify burns involving <10% of total body surface area (TBSA). Centers were categorized by burn center status and length of stay, readmissions, and charges were compared. RESULTS: Inpatient versus outpatient management distribution was significantly different across the included pediatric children's hospitals (n = 34, p < 0.00001). When data were analyzed with respect to outpatient care, a bimodal distribution distinguished two groups: high hospital utilizers with an average of 30% outpatient burn care and low-utilizers averaging 87%. Median inpatient charge per patient was greater than 31-fold compared to ED burn management (p < 0.0001). CONCLUSIONS: Variability of inpatient versus outpatient pediatric burn management in small burns was significant. Compared to outpatient burn care, inpatient care is significantly more costly. Implementing protocols and personnel to provide adequate attention to small burns in the ED could be an important cost-saving measure. TYPE OF STUDY: Retrospective analysis. LEVEL OF EVIDENCE: Level III.

Effect of a Standardized Electronic Medical Record Order Set on Opioid Prescribing after Tonsillectomy.

OBJECTIVE: Approximately 5% of children develop new persistent opioid use after tonsillectomy. Critical review of our prescribing practices revealed inconsistent and excessive opioid prescribing after this procedure in children. We sought to improve our practice by using a standardized electronic medical record (EMR)-based order set. METHODS: Retrospective chart review of outpatient tonsillectomy performed before and after institution of an EMR intervention with comparison of opioid and nonopioid analgesic (NOA) prescription characteristics as well as outcomes including hemorrhage and readmission. RESULTS: Analysis of 276 preorder set and 128 post-order set tonsillectomies revealed a significant increase in NOA utilization following initiation of the order set and a significant reduction in doses of opioid prescribed. Due to a change to a stronger opioid in the order set, morphine dose equivalents (MDEs) prescribed were not decreased in the post-order set cohort. Variability between prescriptions and providers was significantly decreased in the post-order set group in terms of doses and MDEs, and dangerously high outlier prescriptions were eliminated. No differences in pain control, postoperative hemorrhage, presentation to the emergency department, or readmission were identified. DISCUSSION: An EMR-based intervention improved the quality and safety of posttonsillectomy opioid prescribing at our institution. Moving forward, this order set provides a platform with which to titrate opioid prescriptions and NOA to optimal pain control and safety levels. IMPLICATIONS FOR PRACTICE: A standardized EMR-based order set can improve the quality of opioid prescribing after tonsillectomy.

Inconsistent and excessive opioid prescribing after common pediatric surgical operations.

OBJECTIVES: Opioid misuse has reached epidemic proportions in the United States. Post-operative opioids have been linked to overdose, diversion, and dependency in adults, but comparatively less is known in children. We evaluated opioid prescriptions following tonsillectomy and hernia repair at our institution. METHODS: Retrospective chart review of all outpatient tonsillectomies and inguinal/umbilical hernia repairs at a single institution. Data on opioid and non-opioid analgesic prescription characteristics and post-operative pain control were reviewed. RESULTS: 470 procedures were reviewed (276 tonsillectomy, 194 hernia repair). In patients with an indication (> 5 years-old in tonsillectomy, > 1 year-old in hernia repair), 85.0% and 85.6% received a post-op opioid prescription, respectively. Mean days' opioid supplied was 6.19 +/- 4.39 days in tonsillectomy and 4.30 +/- 2.94 days for hernia repair. There was significant inter- and intra-provider variation in the days' supplied of post-operative opioid. 90-100% of patients reported adequate pain control at discharge callback regardless of pain control regimen (opioid alone, opioid + non-opioid analgesic, non-opioid analgesic alone). CONCLUSIONS: Significant variation in post-operative prescribing practices was identified as well as overall over-prescription, which will serve as a starting point to institute evidence-based intervention to reduce post-operative opioid misuse after these common pediatric surgical procedures. LEVEL OF EVIDENCE: IV.