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• W4300963008 abstract "Franz, AM, Martin LD, Liston DE, Latham GJ, Richards MJ, Low DK. In Pursuit of an Opioid-Free Pediatric Ambulatory Surgery Center: A Quality Improvement Initiative. Anesth Analg. 2021 Mar 1;132(3):788-797. https://doi.org/10.1213/ANE.0000000000004774.Editorial Comment: The authors present a quality improvement initiative to reduce intra-operative opioid administration at a pediatric-specific tertiary care ambulatory surgery center [1]. Motivating factors for this initiative were dual challenges of a specific intravenous opioid shortage overlying the more generalized landscape of the current opioid epidemic. Upon gaining multi-modal stakeholder engagement, the working group implemented a series of Plan-Do-Study–Act cycles building off of a successful initiative focused on tonsillectomy and adenoidectomy. The key components of the intervention included addition of dexmedetomidine, nonsteroidal anti-inflammatory drugs, and regional blocks. Notably for urologic cases, this bundle included caudal or ilioinguinal blocks (groin cases) and caudal or pudendal blocks UTongoing data acquisition and analytics via a home-grown proprietary vendor to track intra-operative and post-operative opioid doses, pain scores, and other key outcomes.Over an 18-month period, the authors tracked intra-operative opioid administration via statistical process control charts, which aided in rapid interpretation and response to key changes in outcomes. This process enabled a series of improvement cycles in order to obtain the key outcomes seen within the study. Across 10,948 surgeries performed over this timeframe, the authors noted a decrease in intra-operative opioid administration from 84% in 2017 to 8% in 2019. Additionally, postoperative morphine administration (i.e. rescue dose analgesic control) was noted to decrease from 11% to 6%. Meanwhile, total anesthetic time, post-operative anesthetic unit time, and use of rescue medications for nausea and vomiting remained unchanged.The authors have leveraged a powerful data repository system to track use of protocolized elements, pain scores, and post-operative pain rescue efforts. Seamless data integration is an essential tool for sustainable quality improvement efforts, which rely upon continuous tracking of processes and outcomes to measure and react to changes over time.Take Home Message: One must be mindful of how the changes within the course of hospital care could impact the course of post-discharge care [2]. A substantial hurdle to such an enterprise is integrating such measures (i.e. discharge opioid prescriptions, post-discharge pain scores, and post-operative phone calls) within the electronic health record. A central axiom of quality improvement councils “you can only change what you can measure”. The authors of this effort have capitalized on voluminous intra- and peri-operative data to measure their outcomes. Structuring an integrated data management system for capturing post-discharge data points will be a key initiative in comprehensive quality improvement efforts including but not limiting to opioid reduction strategies.References[1]A.M.FranzL.D.MartinD.E.ListonG.J.LathamM.J.RichardsLow DK. In Pursuit of an opioid-free pediatric ambulatory surgery center: a quality improvement initiativeAnesth Analg1322021788797Franz AM, Martin LD, Liston DE, Latham GJ, Richards MJ, Low DK. In Pursuit of an opioid-free pediatric ambulatory surgery center: a quality improvement initiative. Anesth Analg. 2021;132:788-797.[2]S.HechtN.V.HalsteadP.BoxleyM.A.BrockelK.O.RoveOpioid prescribing patterns following implementation of Enhanced Recovery after Surgery (ERAS) protocol in pediatric patients undergoing lower tract urologic reconstructionJ Pediatr Urol17202184 e184 e8Hecht S, Halstead NV, Boxley P, Brockel MA, Rove KO. Opioid prescribing patterns following implementation of Enhanced Recovery after Surgery (ERAS) protocol in pediatric patients undergoing lower tract urologic reconstruction. J Pediatr Urol. 2021;17:84 e1–84 e8.Chun B, Colaco M, Fox JA, Cannon GM, Schneck FX, Chaudry R, Villanueva J. Salvage Surgery Rates for Pediatric Testicular Torsion: Comparison of the Pre- and Post-Quality Metric Eras. J Urol. 2022 Aug;208(2):441-447. https://doi.org/10.1097/JU.0000000000002677.Editorial Comment: The authors harness a large administrative dataset, the Pediatric Health Information System (PHIS) database, to evaluate rates of orchiectomy associated with testicular torsion [1]. Of the participating PHIS hospitals, the authors chose 38 who had continued to report through the study period (January 2010–December 2019) and linked these institutions to their respective US News and World Report (USNWR) “Best Children's Hospitals” score for testicular torsion, a scoring metric of a maximum of 2 points if >90% of torsion patients have a time from emergency department registration to operating room of <4 h.Using both diagnosis and procedure codes from the International Classification of Diseases, Ninth and Tenth revisions, authors reviewed children presenting with testicular torsion, aged 1–18 years within study cohort hospitals from 2010 to 2019. The authors use the year 2015 as an important cut-point, representing the introduction of the testicular torsion time benchmark to the USNWR ranking system. The proportion of patients receiving orchiectomy, based on the presence of the procedural codes, was compared as the primary outcome.Evaluating 890 patients, the authors noted a significant increase in immediate testicular salvage in the post-metric timeframe (70.9% vs 58.4%, p < 0.001). Notably, this increase in testicular salvage was driven largely by improvements in health care systems who improved upon their USNWR torsion metric score over the same timeframe (50.9% vs 64.7%, p = 0.01). Meanwhile, hospitals which received the best possible score were noted to have a non-significant increase in their salvage rates over the same timeframe.Take Home Message: The ritualistic experience of US News and World Report (USNWR) participation for the pediatric urologist can be characterized by an annual cycle of outcome and resource bean-counting followed by celebration and/or self-reflection upon the rankings release, punctuated by occasional and often valid academic critiques of the system's methodology. Several recent publications have maligned the USNWR methodology, often drawing from administrative data sets to reveal a discordance between USNWR self-report and administratively-captured outcomes [2,3]. So how can we reconcile the valid critiques and continued criticisms of the USNWR system with the possibility that these reports may also be driving improvements in care? For one, the testicular torsion reporting measures ask about the process of evaluation, rather than the surgical outcome of testicular salvage. This approach serves as a potential roadmap for future iterations of such reports, potentially extending to additional facets of pediatric urology as well No doubt measuring surgical outcomes is a vital part of the improvement process but must be done so on a platform with internal consistency and validity. Perhaps the value of the UNSWR ranking system is when it highlights and motivates the paths to quality care as opposed to self-reported outcomes themselves.References[1]B.ChunM.ColacoJ.A.FoxG.M.CannonF.X.SchneckR.ChaudhrySalvage surgery rates for pediatric testicular torsion: comparison of the pre- and post-quality metric ErasJ Urol2082022441447Chun B, Colaco M, Fox JA, Cannon GM, Schneck FX, Chaudhry R, et al. Salvage Surgery Rates for Pediatric Testicular Torsion: Comparison of the Pre- and Post-Quality Metric Eras. J Urol. 2022;208:441-447.[2]A.A.ShahR.M.CareyJ.A.BrantG.E.TasianJ.B.ZiembaAn analysis of the US News & World report methodology for attribution of specialty care in otolaryngology and urologyOtolaryngol Head Neck Surg1642021336338Shah AA, Carey RM, Brant JA, Tasian GE, Ziemba JB. An Analysis of the US News & World Report Methodology for Attribution of Specialty Care in Otolaryngology and Urology. Otolaryngol Head Neck Surg. 2021;164:336-338.[3]H.G.PohlS.RanaB.M.SpragueM.BeamerH.G.RushtonDiscrepant rates of hypospadias surgical complications: a comparison of US News & World Report and Pediatric Health Information System® data and published literatureJ Urol2032020616623Pohl HG, Rana S, Sprague BM, Beamer M, Rushton HG. Discrepant rates of hypospadias surgical complications: a comparison of US News & World Report and Pediatric Health Information System® data and published literature. The Journal of Urology. 2020;203:616-623.Melnyk R, Saba P, Holler T, Cameron K, Mithal P, Rappold P, Wu G, Cubillos J, Rashid H, Joseph JV, Ghazi AE. Design and Implementation of an Emergency Undocking Curriculum for Robotic Surgery. Simul Healthc. 2022 Apr 1;17(2):78-87. https://doi.org/10.1097/SIH.0000000000000596.Editorial Comment: Despite the rapid increase in robotic procedures within the last decade, few institutions have protocols to improve reaction times and comfort with emergency robotic undocking. The authors surveyed robotic surgeons and operating room staff regarding experiences with emergency undocking and preferred methods of training. They subsequently designed and implemented a simulation curriculum for an emergency robotic undocking protocol (ERUP) and assessed its efficacy and fidelity [1].Multidisciplinary teams consisting of surgeons, first assists, and circulating nurses were presented with a high-fidelity hydrogel model of a retroperitoneal tumor abutting a perfused major vessel. During the simulation, teams encountered major vascular bleeds and unrecoverable robotic faults which necessitated open conversion. Following initial simulation, the teams completed video modules of the ERUP curriculum. The authors surveyed the participants regarding simulation realism and cognitive load. Participant demographics, action scores, confidence scores, knowledge scores of ERUP, electrodermal activity (test of participant stress) were assessed. Surgical parameters including estimated blood loss (EBL), time to bleeding control, and undocking times were recorded. Data points were gathered before and after curriculum implementation and 6 months later to assess knowledge retention.Of the 38 robotic team members (20 surgeons and 18 OR staff) surveyed, only 34% had experience with ERUP, and only 42% received ERUP training. Participants indicated that “full immersion simulation” and “self-paced online course” were preferred methods of training. Simulation significantly improved mean confidence scores and knowledge scores from 49.8 ± 25.7 to 87.3 ± 10.8 points and 61.2 ± 11.9 to 76.5 ± 12.7 points, respectively. Overall error occurrences decreased between simulations. Time to covert decreased by 96 s. Although not statistically significant, time to bleeding control decreased by 39 s and EBL decreased by 500 ml. The simulation achieved similar mental workload and task complexity as live operations. At 6 months post-simulation, mean knowledge and confidence scores were still higher compared to pre-simulation but the difference did not reach statistical significance, suggesting need for refresher courses.Take home Message: Although rare, emergency undocking and open conversion may be necessary in catastrophic events during robotic surgeries. Despite the significant impact of these infrequent episodes, few institutions have established protocols or simulation training for these events. A dedicated ERUP curriculum and simulation with a high-fidelity model can improve operative team confidence and knowledge in reacting to these rare but devastating situations and reduce error occurrences. Given the rarity of these situations, successful and high-fidelity training also offers opportunity for repetition and development of a baseline level of confidence in management to prevent chaos and panic during these stressful events.Reference[1]R.MelnykP.SabaT.HollerK.CameronP.MithalP.RappoldDesign and implementation of an emergency undocking curriculum for robotic surgerySimul Healthc1720227887Melnyk R, Saba P, Holler T, Cameron K, Mithal P, Rappold P, et al. Design and Implementation of an Emergency Undocking Curriculum for Robotic Surgery. Simul Healthc. 2022;17:78-87.Bailey K, Lee S, de Los Reyes T, Lo L, Cleverly K, Pidduck J, Mahood Q, Gorter JW, Toulany A. Quality Indicators for Youth Transitioning to Adult Care: A Systematic Review. Pediatrics. 2022 Jul 1; 150(1): e2021055033. https://doi.org/10.1542/peds.2021-055033.Editorial Comment: The authors performed a systematic review of articles evaluating quality indicators of transition from pediatric to adult care for children with chronic illnesses. They investigated illness specific and non-illness specific quality indicators developed using consensus-building methodology and identified gaps in knowledge that warrant further investigation [1].Eligible articles were selected from multiple databases and gray literature using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines from earliest available to July 9, 2021. Studies were included if they focused on pediatric to adult care transition, evaluated transition using process, structure, or outcome indicators, and used robust consensus-building methodology. Studies were excluded if they did not evaluate the transition process in general, if the development process for quality indicators was not described or deemed rigorous, if articles were not in English, or if they did not focus on measurable quality indicators. Quality indicators from the studies were extracted and evaluated using the AGREE II-QI instrument, which was modified from a validated tool used to evaluate clinical guidelines (AGREE II). A total of 4581 titles and abstracts was screened, 321 full texts reviewed, and 9 studies included in the study.Of the 9 articles extracted, five were illness specific and yielded 62 quality indicators; four were not disease specific and yielded 107 quality indicators. Of these quality indicators, 43% were patient level, 30% provider level, 18% health system level, and 8.3% caregiver level. While all studies included multidisciplinary panels of health care providers, only 4 included patients and 3 included parents/caregivers as stakeholders during investigation of quality indicators. The most common themes of the indicators included transition education, continuity of care, satisfaction, self-management while few focused on outcomes of transition and life-skills. Critical evaluation of the indicators by the AGREEII-QI tool resulted in low scores across all domains, especially in applicability suggesting challenges in evaluation and practice in the clinical setting.Take home Message: Patients with complex urologic conditions such as spina bifida, bladder exstrophy, prune belly syndrome, and persistent cloaca undergo rigorous urologic care and sometimes various reconstructive procedures in childhood. They require lifelong care, but the transition process may be challenging or non-existent for many. Development of effective transition clinics is an area of focus in pediatric urology. Identifying key quality indicators in transition is necessary to ensure that we meet the needs of these patients. Many current quality indicators of transition care have focused on satisfaction, transition education, self-management, and continuity of care. However, many of these measures were not developed with patient/caregiver input. Patient, caregiver, and community and healthy system leader perspectives are critical in developing quality measures in transition of care. Further studies are also needed to better define quality indicators focused on equity of the transition process as well a developmental, psychosocial, and economic aspects of transition.Reference[1]K.BaileyS.LeeT.de Los ReyesL.LoK.CleverleyJ.PidduckQuality indicators for Youth transitioning to adult care: a systematic reviewPediatrics2022150Bailey K, Lee S, de Los Reyes T, Lo L, Cleverley K, Pidduck J, et al. Quality indicators for Youth transitioning to adult care: a systematic review. Pediatrics. 2022;150." @default.
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