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Minneci PC, Bergus KC, Lutz C, Aldrink J, Bence C, Breech L, Dillon PA, Downard C, Ehrlich PF, Fallat M, Fraser JD, Grabowski J, Helmrath M, Hertweck P, Hewitt G, Hirschl RB, Kabre R, Lal DR, Landman M, Leys C, Mak G, Markel T, Pressey J, Raiji M, Rymeski B, Saito J, Sato TT, St Peter SD, Cooper J, Deans K. Reducing Unnecessary Oophorectomies for Benign Ovarian Neoplasms in Pediatric Patients. JAMA 2023; 330:1247-1254. [PMID: 37787794 PMCID: PMC10548301 DOI: 10.1001/jama.2023.17183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 08/17/2023] [Indexed: 10/04/2023]
Abstract
Importance Although most ovarian masses in children and adolescents are benign, many are managed with oophorectomy, which may be unnecessary and can have lifelong negative effects on health. Objective To evaluate the ability of a consensus-based preoperative risk stratification algorithm to discriminate between benign and malignant ovarian pathology and decrease unnecessary oophorectomies. Design, Setting, and Participants Pre/post interventional study of a risk stratification algorithm in patients aged 6 to 21 years undergoing surgery for an ovarian mass in an inpatient setting in 11 children's hospitals in the United States between August 2018 and January 2021, with 1-year follow-up. Intervention Implementation of a consensus-based, preoperative risk stratification algorithm with 6 months of preintervention assessment, 6 months of intervention adoption, and 18 months of intervention. The intervention adoption cohort was excluded from statistical comparisons. Main Outcomes and Measures Unnecessary oophorectomies, defined as oophorectomy for a benign ovarian neoplasm based on final pathology or mass resolution. Results A total of 519 patients with a median age of 15.1 (IQR, 13.0-16.8) years were included in 3 phases: 96 in the preintervention phase (median age, 15.4 [IQR, 13.4-17.2] years; 11.5% non-Hispanic Black; 68.8% non-Hispanic White); 105 in the adoption phase; and 318 in the intervention phase (median age, 15.0 [IQR, 12.9-16.6)] years; 13.8% non-Hispanic Black; 53.5% non-Hispanic White). Benign disease was present in 93 (96.9%) in the preintervention cohort and 298 (93.7%) in the intervention cohort. The percentage of unnecessary oophorectomies decreased from 16.1% (15/93) preintervention to 8.4% (25/298) during the intervention (absolute reduction, 7.7% [95% CI, 0.4%-15.9%]; P = .03). Algorithm test performance for identifying benign lesions in the intervention cohort resulted in a sensitivity of 91.6% (95% CI, 88.5%-94.8%), a specificity of 90.0% (95% CI, 76.9%-100%), a positive predictive value of 99.3% (95% CI, 98.3%-100%), and a negative predictive value of 41.9% (95% CI, 27.1%-56.6%). The proportion of misclassification in the intervention phase (malignant disease treated with ovary-sparing surgery) was 0.7%. Algorithm adherence during the intervention phase was 95.0%, with fidelity of 81.8%. Conclusions and Relevance Unnecessary oophorectomies decreased with use of a preoperative risk stratification algorithm to identify lesions with a high likelihood of benign pathology that are appropriate for ovary-sparing surgery. Adoption of this algorithm might prevent unnecessary oophorectomy during adolescence and its lifelong consequences. Further studies are needed to determine barriers to algorithm adherence.
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Affiliation(s)
- Peter C. Minneci
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute and Division of Pediatric Surgery, Department of Surgery, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus
- Now with Department of Surgery, Nemours Children’s Hospital–Delaware Valley, Nemours Children’s Health, Wilmington, Delaware
| | - Katherine C. Bergus
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute and Division of Pediatric Surgery, Department of Surgery, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus
| | - Carley Lutz
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute and Division of Pediatric Surgery, Department of Surgery, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus
| | - Jennifer Aldrink
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute and Division of Pediatric Surgery, Department of Surgery, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus
| | - Christina Bence
- Division of Pediatric Surgery, Department of Surgery, Children’s Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee
| | - Lesley Breech
- Division of Pediatric Surgery, Department of Surgery, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Patrick A. Dillon
- Division of Pediatric Surgery, Department of Surgery, St Louis Children’s Hospital, Washington University School of Medicine in Saint Louis, St Louis, Missouri
| | - Cynthia Downard
- Division of Pediatric Surgery, Norton Children’s Hospital, University of Louisville School of Medicine, Louisville, Kentucky
| | - Peter F. Ehrlich
- Section of Pediatric Surgery, Department of Surgery, C. S. Mott Children’s Hospital, University of Michigan Medical School, Ann Arbor
| | - Mary Fallat
- Division of Pediatric Surgery, Norton Children’s Hospital, University of Louisville School of Medicine, Louisville, Kentucky
| | - Jason D. Fraser
- Division of Pediatric Surgery, Department of Surgery, Children’s Mercy Kansas City, University of Missouri Kansas City School of Medicine, Kansas City
| | - Julia Grabowski
- Division of Pediatric Surgery, Department of Surgery, Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Michael Helmrath
- Division of Pediatric Surgery, Department of Surgery, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Paige Hertweck
- Division of Pediatric Surgery, Norton Children’s Hospital, University of Louisville School of Medicine, Louisville, Kentucky
| | - Geri Hewitt
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute and Division of Pediatric Surgery, Department of Surgery, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus
| | - Ronald B. Hirschl
- Section of Pediatric Surgery, Department of Surgery, C. S. Mott Children’s Hospital, University of Michigan Medical School, Ann Arbor
| | - Rashmi Kabre
- Division of Pediatric Surgery, Department of Surgery, Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Dave R. Lal
- Division of Pediatric Surgery, Department of Surgery, Children’s Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee
| | - Matthew Landman
- Division of Pediatric Surgery, Department of Surgery, Riley Hospital for Children, Indiana University Health, Indianapolis
| | - Charles Leys
- Division of Pediatric Surgery, Department of Surgery, American Family Children’s Hospital, University of Wisconsin School of Medicine and Public Health, Madison
| | - Grace Mak
- Section of Pediatric Surgery, Department of Surgery, Comer Children’s Hospital, The University of Chicago Medicine, Chicago, Illinois
| | - Troy Markel
- Division of Pediatric Surgery, Department of Surgery, Riley Hospital for Children, Indiana University Health, Indianapolis
| | - Joseph Pressey
- Division of Pediatric Surgery, Department of Surgery, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Manish Raiji
- Section of Pediatric Surgery, Department of Surgery, Comer Children’s Hospital, The University of Chicago Medicine, Chicago, Illinois
| | - Beth Rymeski
- Division of Pediatric Surgery, Department of Surgery, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Jacqueline Saito
- Division of Pediatric Surgery, Department of Surgery, St Louis Children’s Hospital, Washington University School of Medicine in Saint Louis, St Louis, Missouri
| | - Thomas T. Sato
- Division of Pediatric Surgery, Department of Surgery, Children’s Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee
| | - Shawn D. St Peter
- Division of Pediatric Surgery, Department of Surgery, Children’s Mercy Kansas City, University of Missouri Kansas City School of Medicine, Kansas City
| | - Jennifer Cooper
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute and Department of Pediatrics, Nationwide Children’s Hospital, Columbus, Ohio
| | - Katherine Deans
- Department of Surgery, Nemours Children’s Hospital–Delaware Valley, Nemours Children’s Health, Wilmington, Delaware
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Doucet J, Shatz DV, Kaplan LJ, Bulger EM, Capella J, Kuhls DA, Fallat M, Remick KN, Newton C, Fox A, Jawa R, Harvin JA, Blake DP, Bukur M, Gates J, Ficke J, Gestring ML. Are trauma surgeons prepared? A survey of trauma surgeons' disaster preparedness before and during the COVID-19 pandemic. Trauma Surg Acute Care Open 2023; 8:e001073. [PMID: 37564125 PMCID: PMC10410846 DOI: 10.1136/tsaco-2022-001073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 05/26/2023] [Indexed: 08/12/2023] Open
Abstract
Objective US trauma centers (TCs) must remain prepared for mass casualty incidents (MCIs). However, trauma surgeons may lack formal MCI training. The recent COVID-19 pandemic drove multiple patient surges, overloaded Emergency Medical Services (EMS) agencies, and stressed TCs. This survey assessed trauma surgeons' MCI training, experience, and system and personal preparedness before the pandemic compared with the pandemic's third year. Methods Survey invitations were emailed to all 1544 members of the American Association for the Surgery of Trauma in 2019, and then resent in 2022 to 1575 members with additional questions regarding the pandemic. Questions assessed practice type, TC characteristics, training, experience, beliefs about personal and hospital preparedness, likelihood of MCI scenarios, interventions desired from membership organizations, and pandemic experiences. Results The response rate was 16.7% in 2019 and 12% in 2022. In 2022, surgeons felt better prepared than their hospitals for pandemic care, mass shootings, and active shooters, but remained feeling less well prepared for cyberattack and hazardous material events, compared with 2019. Only 35% of the respondents had unintentional MCI response experience in 2019 or 2022, and even fewer had experience with intentional MCI. 78% had completed a Stop the Bleed (STB) course and 63% own an STB kit. 57% had engaged in family preparedness activities; less than 40% had a family action plan if they could not come home during an MCI. 100% of the respondents witnessed pandemic-related adverse events, including colleague and coworker illness, patient surges, and resource limitations, and 17% faced colleague or coworker death. Conclusions Trauma surgeons thought that they became better at pandemic care and rated themselves as better prepared than their hospitals for MCI care, which is an opportunity for them to take greater leadership roles. Opportunities remain to improve surgeons' family and personal MCI preparedness. Surgeons' most desired professional organization interventions include advocacy, national standards for TC preparedness, and online training. Level of evidence VII, survey of expert opinion.
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Affiliation(s)
- Jay Doucet
- Department of Surgery, University of California San Diego Health System, San Diego, California, USA
| | - David V Shatz
- Department of General Surgery, UC Davis Medical Center, Sacramento, California, USA
| | - Lewis J Kaplan
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Eileen M Bulger
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | | | - Deborah A Kuhls
- Kirk Kerkorian School of Medicine, University of Nevada Las Vegas, Las Vegas, Nevada, USA
| | - Mary Fallat
- Department of Surgery, University of Louisville, Louisville, Kentucky, USA
| | - Kyle N. Remick
- Department of Surgery, Uniformed Services University School of Medicine, Bethesda, Maryland, USA
| | | | - Adam Fox
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Randeep Jawa
- Department of Surgery, Stony Brook University, Stony Brook, New York, USA
| | - John A Harvin
- Department of Surgery, UT Health, Houston, Texas, USA
| | - David P Blake
- Division of Acute Care Surgery, Inova Health System, Falls Church, Virginia, USA
| | - Marko Bukur
- Bellevue Hospital Center, New York, New York, USA
| | - Jonathan Gates
- Department of Surgery, Hartford Hospital, Hartford, Connecticut, USA
| | - James Ficke
- Department of Orthopedic Surgery, The Johns Hopkins University, Baltimore, Maryland, USA
| | - Mark L Gestring
- Department of Surgery, University of Rochester, Rochester, New York, USA
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Remick K, Smith M, Newgard CD, Lin A, Hewes H, Jensen AR, Glass N, Ford R, Ames S, Cook J, Malveau S, Dai M, Auerbach M, Jenkins P, Gausche-Hill M, Fallat M, Kuppermann N, Mann NC. Impact of individual components of emergency department pediatric readiness on pediatric mortality in US trauma centers. J Trauma Acute Care Surg 2023; 94:417-424. [PMID: 36045493 PMCID: PMC9974586 DOI: 10.1097/ta.0000000000003779] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Injured children initially treated at trauma centers with high emergency department (ED) pediatric readiness have improved survival. Centers with limited resources may not be able to address all pediatric readiness deficiencies, and there currently is no evidence-based guidance for prioritizing different components of readiness. The objective of this study was to identify individual components of ED pediatric readiness associated with better-than-expected survival in US trauma centers to aid in the allocation of resources targeted at improving pediatric readiness. METHODS This cohort study of US trauma centers used the National Trauma Data Bank (2012-2017) matched to the 2013 National Pediatric Readiness Project assessment. Adult and pediatric centers treating at least 50 injured children (younger than 18 years) and recording at least one death during the 6-year study period were included. Using a standardized risk-adjustment model for trauma, we calculated the observed-to-expected mortality ratio for each trauma center. We used bivariate analyses and multivariable linear regression to assess for associations between individual components of ED pediatric readiness and better-than-expected survival. RESULTS Among 555 trauma centers, the observed-to-expected mortality ratios ranged from 0.07 to 4.17 (interquartile range, 0.93-1.14). Unadjusted analyses of 23 components of ED pediatric readiness showed that trauma centers with better-than-expected survival were more likely to have a validated pediatric triage tool, comprehensive quality improvement processes, a pediatric-specific disaster plan, and critical airway and resuscitation equipment (all p < 0.03). The multivariable analysis demonstrated that trauma centers with both a physician and a nurse pediatric emergency care coordinator had better-than-expected survival, but this association weakened after accounting for trauma center level. Child maltreatment policies were associated with lower-than-expected survival, particularly in Levels III to V trauma centers. CONCLUSION Specific components of ED pediatric readiness were associated with pediatric survival among US trauma centers. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
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Affiliation(s)
- Katherine Remick
- From the Department of Pediatrics (K.R.), Dell Medical School at the University of Texas at Austin, Austin, Texas; Department of Pediatrics (M.S., H.H., S.A., M.D., N.C.M.), University of Utah School of Medicine, Salt Lake City, Utah; Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine (C.D.N., A.L., J.C., S.M.), Oregon Health & Science University, Portland, Oregon; UCSF Benioff Children's Hospitals, Department of Surgery (A.R.J.), University of California San Francisco, San Francisco, California; Department of Surgery (N.G.), Rutgers New Jersey Medical School, Newark, New Jersey; Oregon EMS for Children Program (R.F.), Oregon Health Authority, Portland, Oregon; Departments of Pediatrics (M.A.) and Emergency Medicine (M.A.), Yale University School of Medicine, New Haven, Connecticut; Indiana University School of Medicine, Department of Surgery (P.J.), Indianapolis, Indiana; Departments of Emergency Medicine (M.G.-H.) and Pediatrics (M.G.-H.), David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California; Department of Surgery (M.F.), University of Louisville School of Medicine, Louisville, Kentucky; and Departments of Emergency Medicine (N.K.) and Pediatrics (N.K.), University of California Davis School of Medicine, Sacramento, California
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4
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Gross TK, Lane NE, Timm NL, Gross T, Hoffmann J, Hsu B, Lee L, Marin J, Mazor S, Paul R, Saidinejad M, Waseem M, Cicero M, Ishimine P, Eisenberg A, Fallat M, Fanflik P, Johnson CW, Kinsman S, Lightfoot C, Macias C, Remick K, Shahid S, Stone E, Wright J, Callahan J, Rey JGD, Joseph M, Mack E, Timm N, Dietrich A, Moore B, Pilkey D, Saidinejad M, Snow S, Tellez S. Crowding in the Emergency Department: Challenges and Recommendations for the Care of Children. Pediatrics 2023; 151:190682. [PMID: 36808290 DOI: 10.1542/peds.2022-060971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2023] Open
Abstract
Emergency department (ED) crowding results when available resources cannot meet the demand for emergency services. ED crowding has negative impacts on patients, health care workers, and the community. Primary considerations for reducing ED crowding include improving the quality of care, patient safety, patient experience, and the health of populations, as well as reducing the per capita cost of health care. Evaluating causes, effects, and seeking solutions to ED crowding can be done within a conceptual framework addressing input, throughput, and output factors. ED leaders must coordinate with hospital leadership, health system planners and policy decision makers, and those who provide pediatric care to address ED crowding. Proposed solutions in this policy statement promote the medical home and timely access to emergency care for children.
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Affiliation(s)
- Toni K Gross
- Division of Emergency Medicine, Children's Hospital New Orleans, Department of Pediatrics, Tulane University and LSU Health Sciences Center, New Orleans, Louisiana
| | - Natalie E Lane
- Department of Emergency Medicine and Department of Pediatrics, Medical College of Georgia, Augusta University, Augusta, Georgia
| | - Nathan L Timm
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Gross TK, Lane NE, Timm NL, Hoffmann J, Hsu B, Lee L, Marin J, Mazor S, Paul R, Saidinejad M, Waseem M, Cicero M, Ishimine P, Eisenberg A, Fallat M, Fanflik P, Johnson CW, Kinsman S, Lightfoot C, Macias C, Remick K, Shahid S, Stone E, Wright J, Callahan J, Gonzalez del Rey J, Joseph M, Mack E, Dietrich A, Moore B, Pilkey D, Saidinejad M, Snow S, Tellez S. Crowding in the Emergency Department: Challenges and Best Practices for the Care of Children. Pediatrics 2023; 151:190683. [PMID: 36806666 DOI: 10.1542/peds.2022-060972] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2023] Open
Abstract
Emergency department (ED) crowding has been and continues to be a national concern. ED crowding is defined as a situation in which the identified need for emergency services outstrips available resources in the ED. Crowding is associated with higher morbidity and mortality, delayed pain control, delayed time to administration of antibiotics, increased medical errors, and less-than-optimal health care. ED crowding impedes a hospital's ability to achieve national quality and patient safety goals, diminishes the effectiveness of the health care safety net, and limits the capacity of hospitals to respond to a disaster and/or sudden surge in disease. Both children and adults seeking care in emergency settings are placed at risk. Crowding negatively influences the experience for patients, families, and providers, and can impact employee turnover and well-being. No single factor is implicated in creating the issue of crowding, but elements that influence crowding can be divided into those that affect input (prehospital and outpatient care), throughput (ED), and output (hospital and outpatient care). The degree of ED crowding is difficult to quantify but has been linked to markers such as hours on ambulance diversion, hours of inpatient boarding in the emergency setting, increasing wait times, and patients who leave without being seen. A number of organizations, including the American College of Emergency Physicians, the Emergency Nurses Association, and the National Quality Forum, have convened to better define emergency metrics and definitions that help provide data for benchmarks for patient throughput performance. The Joint Commission has acknowledged that patient safety is tied to patient throughput and has developed guidance for hospitals to ensure that hospital leadership engages in the process of safe egress of the patient out of the ED and, most recently, to address efficient disposition of patients with mental health emergencies. It is important that the American Academy of Pediatrics acknowledges the potential impact on access to optimal emergency care for children in the face of ED crowding and helps guide health policy decision-makers toward effective solutions that promote the medical home and timely access to emergency care.
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Affiliation(s)
- Toni K Gross
- Division of Emergency Medicine, Departments of Pediatrics, Children's Hospital New Orleans, Tulane University and LSU Health New Orleans, New Orleans, Louisiana
| | - Natalie E Lane
- Department of Emergency Medicine and Department of Pediatrics, Medical College of Georgia, Augusta University, Augusta, Georgia
| | - Nathan L Timm
- Division of Emergency Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Herrera-Escobar JP, Reidy E, Phuong J, Brasel KJ, Cuschieri J, Fallat M, Potter BK, Price MA, Bulger EM, Haider AH, Bonne S, Brasel KJ, Cuschieri J, de Roon-Cassini T, Dicker RA, Fallat M, Ficke JR, Gabbe B, Gibran NS, Heinemann AW, Ho V, Kao LS, Kellam JF, Kurowski BG, Levy-Carrick NC, Livingston D, Mandell SP, Manley GT, Michetti CP, Miller AN, Newcomb A, Okonkwo D, Potter BK, Seamon M, Stein D, Wagner AK, Whyte J, Yonclas P, Zatzick D, Zielinski MD. Developing a National Trauma Research Action Plan: Results from the long-term outcomes research gap Delphi survey. J Trauma Acute Care Surg 2022; 93:854-862. [PMID: 35972140 DOI: 10.1097/ta.0000000000003747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND In the National Academies of Sciences, Engineering, and Medicine 2016 report on trauma care, the establishment of a National Trauma Research Action Plan to strengthen and guide future trauma research was recommended. To address this recommendation, the Department of Defense funded the Coalition for National Trauma Research to generate a comprehensive research agenda spanning the continuum of trauma and burn care. We describe the gap analysis and high-priority research questions generated from the National Trauma Research Action Plan panel on long-term outcomes. METHODS Experts in long-term outcomes were recruited to identify current gaps in long-term trauma outcomes research, generate research questions, and establish the priority for these questions using a consensus-driven, Delphi survey approach from February 2021 to August 2021. Panelists were identified using established Delphi recruitment guidelines to ensure heterogeneity and generalizability including both military and civilian representation. Panelists were encouraged to use a PICO format to generate research questions: Patient/Population, Intervention, Compare/Control, and Outcome model. On subsequent surveys, panelists were asked to prioritize each research question on a 9-point Likert scale, categorized to represent low-, medium-, and high-priority items. Consensus was defined as ≥60% of panelists agreeing on the priority category. RESULTS Thirty-two subject matter experts generated 482 questions in 17 long-term outcome topic areas. By Round 3 of the Delphi, 359 questions (75%) reached consensus, of which 107 (30%) were determined to be high priority, 252 (70%) medium priority, and 0 (0%) low priority. Substance abuse and pain was the topic area with the highest number of questions. Health services (not including mental health or rehabilitation) (64%), mental health (46%), and geriatric population (43%) were the topic areas with the highest proportion of high-priority questions. CONCLUSION This Delphi gap analysis of long-term trauma outcomes research identified 107 high-priority research questions that will help guide investigators in future long-term outcomes research. LEVEL OF EVIDENCE Diagnostic Tests or Criteria; Level IV.
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Affiliation(s)
- Juan P Herrera-Escobar
- From the Center for Surgery and Public Health (J.P.H.-E., E.R., A.H.H.), Brigham and Women's Hospital, Harvard Medical School, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Department of Biomedical Informatics and Medical Education (J.P.), University of Washington, Seattle, Washington; Division of Trauma, Critical Care and Acute Care Surgery (K.J.B.), Oregon Health and Science University, Portland, Oregon; Department of Surgery (J.C.), University of San Francisco California, San Francisco, California; Department of Surgery (M.F.), University of Louisville, Louisville, Kentucky; Walter Reed Department of Surgery (B.K.P.), Uniformed Services University, Bethesda, Maryland; Coalition for National Trauma Research (M.A.P.), San Antonio, Texas; Department of Surgery (E.M.B.), University of Washington, Seattle, Washington; Office of the Dean, Aga Khan University Medical College (A.H.H.), Karachi, Pakistan
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7
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Doud A, Bond L, Downard C, Vitale G, Fallat M, Foley D, Wright T, Bond S. Management of complicated biliary disease in the pediatric population. Surgery 2021; 171:736-740. [PMID: 34844759 DOI: 10.1016/j.surg.2021.09.041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 08/23/2021] [Accepted: 09/15/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Cholesterol stones and biliary dyskinesia have replaced hemolytic disease as the primary indication for pediatric cholecystectomy. This study looks at the cohort of pediatric patients with complicated biliary disease, defined as choledocholithiasis and/or gallstone pancreatitis, to determine the incidence and best treatment options. METHODS A retrospective review of all cholecystectomies performed over 15 years admitted to the surgical service at a single free-standing children's hospital was performed. Patient factors, indications for cholecystectomy, and final treatment were recorded. Complicated gallbladder disease was defined as having image-confirmed choledocholithiasis or gallstone pancreatitis. High-risk patients were those with imaging that demonstrated definitive choledocholithiasis or cholelithiasis with common bile duct enlargement. Low risk patients were those with cholelithiasis or gallbladder sludge on imaging combined with an elevated bilirubin and/or lipase. RESULTS A total of 695 cholecystectomies were performed over the 15-year time period. Average patient age was 13.4 years. Of the 695 cholecystectomies, 457 were performed for stone disease (66%) (64 hemolytic) and 236 (34.0%) were performed for biliary dyskinesia. Hundred and three (14.8% of all cholecystectomies, 22.5% of those with stone disease) presented with choledocholithiasis and/or gallstone pancreatitis (complicated disease). In high-risk patients, 28/47 (59.6%) underwent endoscopic retrograde cholangiopancreatography/sphincterotomy. In low-risk patients (no choledocholithiasis or common duct enlargement), 13/56 (23.2%) required endoscopic retrograde cholangiopancreatography/sphincterotomy (P < .05). The indication for endoscopic retrograde cholangiopancreatography after cholecystectomy was choledocholithiasis and none of these patients had bile leak complications. CONCLUSION The incidence of pediatric complicated biliary disease due to cholesterol stones is equal to that of adults. These data suggest that a patient with imaging evidence of choledocholithiasis or common bile duct enlargement may require endoscopic retrograde cholangiopancreatography, dependent on clinical course, and this should be strongly considered before cholecystectomy. Those without such radiographic findings can undergo laparoscopic cholecystectomy and have postoperative endoscopic retrograde cholangiopancreatography if needed.
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Affiliation(s)
- Andrea Doud
- Department of Surgery, University of Kentucky College of Medicine, Lexington, KY
| | - Logan Bond
- Hiram C. Polk Jr, Department of Surgery, University of Louisville School of Medicine, KY
| | - Cynthia Downard
- Hiram C. Polk Jr, Department of Surgery, University of Louisville School of Medicine, KY
| | - Gary Vitale
- Hiram C. Polk Jr, Department of Surgery, University of Louisville School of Medicine, KY
| | - Mary Fallat
- Hiram C. Polk Jr, Department of Surgery, University of Louisville School of Medicine, KY
| | - David Foley
- Hiram C. Polk Jr, Department of Surgery, University of Louisville School of Medicine, KY
| | - Tiffany Wright
- Hiram C. Polk Jr, Department of Surgery, University of Louisville School of Medicine, KY
| | - Sheldon Bond
- Hiram C. Polk Jr, Department of Surgery, University of Louisville School of Medicine, KY.
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Wang KS, Cummings J, Stark A, Houck C, Oldham K, Grant C, Fallat M. Optimizing Resources in Children's Surgical Care: An Update on the American College of Surgeons' Verification Program. Pediatrics 2020; 145:peds.2020-0708. [PMID: 32312909 DOI: 10.1542/peds.2020-0708] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Surgical procedures are performed in the United States in a wide variety of clinical settings and with variation in clinical outcomes. In May 2012, the Task Force for Children's Surgical Care, an ad hoc multidisciplinary group comprising physicians representing specialties relevant to pediatric perioperative care, was convened to generate recommendations to optimize the delivery of children's surgical care. This group generated a white paper detailing the consensus opinions of the involved experts. Following these initial recommendations, the American College of Surgeons (ACS), Children's Hospital Association, and Task Force for Children's Surgical Care, with input from all related perioperative specialties, developed and published specific and detailed resource and quality standards designed to improve children's surgical care (https://www.facs.org/quality-programs/childrens-surgery/childrens-surgery-verification). In 2015, with the endorsement of the American Academy of Pediatrics (https://pediatrics.aappublications.org/content/135/6/e1538), the ACS established a pilot verification program. In January 2017, after completion of the pilot program, the ACS Children's Surgery Verification Quality Improvement Program was officially launched. Verified sites are listed on the program Web site at https://www.facs.org/quality-programs/childrens-surgery/childrens-surgery-verification/centers, and more than 150 are interested in verification. This report provides an update on the ACS Children's Surgery Verification Quality Improvement Program as it continues to evolve.
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Affiliation(s)
- Kasper S Wang
- Division of Pediatric Surgery, Department of Surgery, Keck School of Medicine, University of Southern California and Children's Hospital Los Angeles, Los Angeles, California;
| | | | - Ann Stark
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Constance Houck
- Division of Perioperative Anesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Keith Oldham
- Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | | | - Mary Fallat
- Department of Surgery, University of Louisville, Louisville, Kentucky
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Owusu-Ansah S, Moore B, Shah MI, Gross T, Brown K, Gausche-Hill M, Remick K, Adelgais K, Rappaport L, Snow S, Wright-Johnson C, Leonard JC, Lyng J, Fallat M. Pediatric Readiness in Emergency Medical Services Systems. Pediatrics 2020; 145:peds.2019-3308. [PMID: 31857378 DOI: 10.1542/peds.2019-3308] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Ill and injured children have unique needs that can be magnified when the child's ailment is serious or life-threatening. This is especially true in the out-of-hospital environment. Providing high-quality out-of-hospital care to children requires an emergency medical services (EMS) system infrastructure designed to support the care of pediatric patients. As in the emergency department setting, it is important that all EMS agencies have the appropriate resources, including physician oversight, trained and competent staff, education, policies, medications, equipment, and supplies, to provide effective emergency care for children. Resource availability across EMS agencies is variable, making it essential that EMS medical directors, administrators, and personnel collaborate with outpatient and hospital-based pediatric experts, especially those in emergency departments, to optimize prehospital emergency care for children. The principles in the policy statement "Pediatric Readiness in Emergency Medical Services Systems" and this accompanying technical report establish a foundation on which to build optimal pediatric care within EMS systems and serve as a resource for clinical and administrative EMS leaders.
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Affiliation(s)
- Sylvia Owusu-Ansah
- Division of Emergency Medical Services, Department of Pediatrics and Emergency Department, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania;
| | - Brian Moore
- Department of Emergency Medicine, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - Manish I Shah
- Section of Emergency Medicine, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Toni Gross
- Department of Emergency Medicine, Children's Hospital New Orleans and Louisiana State University Health New Orleans, New Orleans, Louisiana
| | - Kathleen Brown
- Departments of Pediatrics and Emergency Medicine, School of Medicine and Health Sciences, The George Washington University, Washington, District of Columbia.,Division of Emergency Medicine, Children's National Medical Center, Washington, District of Columbia
| | - Marianne Gausche-Hill
- Departments of Emergency Medicine and Pediatrics, David Geffen School of Medicine, University of California, Los Angeles and Harbor-University of California, Los Angeles Medical Center, Los Angeles, California
| | - Katherine Remick
- San Marcos Hays County Emergency Medical Services, San Marcos, Texas.,Austin-Travis County Emergency Medical Services System, Austin, Texas.,Department of Pediatrics, Dell Medical School, The University of Texas at Austin, Austin, Texas
| | - Kathleen Adelgais
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado
| | - Lara Rappaport
- Department of Pediatric Emergency Medicine and Urgent Care Center, Denver Health Medical Center, Denver, Colorado
| | - Sally Snow
- Pediatric Emergency and Trauma Nursing, Fort Worth, Texas
| | - Cynthia Wright-Johnson
- Emergency Medical Services for Children, Maryland Institute for Emergency Medical Services Systems, Baltimore, Maryland
| | - Julie C Leonard
- Division of Emergency Medicine, Department of Pediatrics, Nationwide Children's Hospital and College of Medicine, The Ohio State University, Columbus, Ohio
| | - John Lyng
- Level I Adult Trauma Center and Level II Pediatric Trauma Center, North Memorial Health Hospital, Minneapolis, Minnesota; and
| | - Mary Fallat
- Division of Pediatric Surgery, University of Louisville and Norton Children's Hospital, Louisville, Kentucky
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Oldham KT, Fallat M, Barnhart D, Derkay C, Deshpande J, Georgeson K, Hirschl R, Houck C, Mooney D, Moss RL, Sawin R, Tuggle D. Reply to a Letter to the Editor. J Pediatr Surg 2015; 50:1434-6. [PMID: 26162971 DOI: 10.1016/j.jpedsurg.2015.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Accepted: 06/07/2015] [Indexed: 10/23/2022]
Affiliation(s)
| | - Keith T Oldham
- American College of Surgeons Committee for Children's Surgery.
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Bulger EM, Snyder D, Schoelles K, Gotschall C, Dawson D, Lang E, Sanddal ND, Butler FK, Fallat M, Taillac P, White L, Salomone JP, Seifarth W, Betzner MJ, Johannigman J, McSwain N. An Evidence-based Prehospital Guideline for External Hemorrhage Control: American College of Surgeons Committee on Trauma. PREHOSP EMERG CARE 2014; 18:163-73. [DOI: 10.3109/10903127.2014.896962] [Citation(s) in RCA: 143] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Siow Y, Li S, Lin J, Li X, Lan ZJ, Rao C, Fallat M, Lei Z. Identification of Gubernacular Androgen Responsive Genes in Luteinizing Hormone Receptor Knockout Mice. Biol Reprod 2011. [DOI: 10.1093/biolreprod/85.s1.564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Niermeyer S, Kattwinkel J, Van Reempts P, Nadkarni V, Phillips B, Zideman D, Azzopardi D, Berg R, Boyle D, Boyle R, Burchfield D, Carlo W, Chameides L, Denson S, Fallat M, Gerardi M, Gunn A, Hazinski MF, Keenan W, Knaebel S, Milner A, Perlman J, Saugstad OD, Schleien C, Solimano A, Speer M, Toce S, Wiswell T, Zaritsky A. International Guidelines for Neonatal Resuscitation: An excerpt from the Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: International Consensus on Science. Contributors and Reviewers for the Neonatal Resuscitation Guidelines. Pediatrics 2000; 106:E29. [PMID: 10969113 DOI: 10.1542/peds.106.3.e29] [Citation(s) in RCA: 275] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The International Guidelines 2000 Conference on Cardiopulmonary Resuscitation (CPR) and Emergency Cardiac Care (ECC) formulated new evidenced-based recommendations for neonatal resuscitation. These guidelines comprehensively update the last recommendations, published in 1992 after the Fifth National Conference on CPR and ECC. As a result of the evidence evaluation process, significant changes occurred in the recommended management routines for: * Meconium-stained amniotic fluid: If the newly born infant has absent or depressed respirations, heart rate <100 beats per minute (bpm), or poor muscle tone, direct tracheal suctioning should be performed to remove meconium from the airway. * Preventing heat loss: Hyperthermia should be avoided. * Oxygenation and ventilation: 100% oxygen is recommended for assisted ventilation; however, if supplemental oxygen is unavailable, positive-pressure ventilation should be initiated with room air. The laryngeal mask airway may serve as an effective alternative for establishing an airway if bag-mask ventilation is ineffective or attempts at intubation have failed. Exhaled CO(2) detection can be useful in the secondary confirmation of endotracheal intubation. * Chest compressions: Compressions should be administered if the heart rate is absent or remains <60 bpm despite adequate assisted ventilation for 30 seconds. The 2-thumb, encircling-hands method of chest compression is preferred, with a depth of compression one third the anterior-posterior diameter of the chest and sufficient to generate a palpable pulse. * Medications, volume expansion, and vascular access: Epinephrine in a dose of 0.01-0.03 mg/kg (0.1-0.3 mL/kg of 1:10,000 solution) should be administered if the heart rate remains <60 bpm after a minimum of 30 seconds of adequate ventilation and chest compressions. Emergency volume expansion may be accomplished with an isotonic crystalloid solution or O-negative red blood cells; albumin-containing solutions are no longer the fluid of choice for initial volume expansion. Intraosseous access can serve as an alternative route for medications/volume expansion if umbilical or other direct venous access is not readily available. * Noninitiation and discontinuation of resuscitation: There are circumstances (relating to gestational age, birth weight, known underlying condition, lack of response to interventions) in which noninitiation or discontinuation of resuscitation in the delivery room may be appropriate.
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Nadkarni V, Quan L, Hazinski MF, Deshpande J, Berg R, Burchfield D, Fallat M, Franklin W, Hawkins H, McCloskey K, Terndrup T, Yeh T. Public access defibrillation. AHA Pediatric Subcommittee Emergency Cardiac Care Committee. Circulation 1996; 94:2320-1. [PMID: 8901704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Affiliation(s)
- J M Hutson
- Surgical Research Unit, Royal Children's Hospital Research Foundation, Parkville, Victoria, Australia
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Abstract
Twenty-nine children sustained major arterial injuries secondary to gunshot wounds (nine), blunt injuries (11), penetrating injuries by sharp objects (five), and arteriographic injury (four). The femoral artery was most commonly injured, followed by the brachial, the carotid, subclavian, popliteal, aorta, innominate, and vertebral arteries. We repaired the majority of the arterial injuries by resecting the damaged vessel, with primary anastomosis or interposition grafting when necessary to avoid tension. Postoperative complications included clotted grafts in two patients, which were rendered patent by reoperation. Two children died postoperatively, although both had successful vascular repairs. All vascular repairs were patent at one year, and limb length disparity has occurred in one patient following a nerve injury. Our data indicate that early exploration and repair of all suspected vascular injuries can be accomplished with excellent results, even in young children.
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