206 IMPROVING FALLS ASSESSMENT AND PREVENTION PRACTICES FOR FRAIL OLDER ADULTS IN AN EMERGENCY DEPARTMENT USING BEST PRACTICE GUIDELINES

Background

NICE guidelines are the current gold standard for the management of falls in older persons. The aim was to benchmark the practice of a Frailty At The Front Door (FATFD) team against NICE guidelines.

Methods

All patients referred to and discharged directly by the FATFD team in the emergency department had demographic data entered prospectively by a trained administrator onto excel. Data gathered included age, diagnosis and CFS score. Patient records were accessed to gather assessment and treatment data. Data was analysed using descriptive statistics.

Results

Between January and March 2022, 443 patients were seen of which 48% (n=213) presented due to a fall. 23% (n= 49) were discharged directly from ED. Full clinical information was available for 35% (n=15). The mean(SD) age of those who presented with falls was 84(8) years with a mean(SD) clinical frailty score of 5.6 (0.9). The male to female ratio was 1.5:1. 53% (n=8) patients had a falls assessment in line with NICE guidelines. Fear of falling, perceived unsteadiness and bone health issues were the most commonly-omitted areas. 7% (n=1) patient received falls prevention education or individualised intervention.

Conclusion

The majority of patients received a falls assessment in line with NICE guidelines but 65% of patient data was not available. Data availability is key to service development and a database will be developed for all attendees. A falls education package to address management of visual impairment, home hazard advice, strength and balance training, bone health and individualised patient and family education, including fear of falling, has been developed.

326 USE OF A PHARMACY PRIORITISATION TOOLKIT IN FRAIL OLDER ADULTS PRESENTING TO THE EMERGENCY DEPARTMENT

Background

A Pharmacy Prioritisation Toolkit (PPT) was adapted for use by a front door frailty multidisciplinary team to direct pharmacist review.

Methods

Over a 4-week period pharmacist referrals based on a toolkit used by the team were reviewed. Data was recorded in Excel including age, reason for referral and outcome of Medicines Optimisation Review (MOR). Pharmacy-identified patients were also analysed.

Results

Forty-Five patients were referred by the team using the PPT and 25 were pharmacist-identified for review. Reason for referral were use of high-risk medication (20/45), suspected medication related admission (9/45), chronic kidney disease or acute kidney injury (7/45), specific pharmaceutical concerns (5/45) >10 regular medications (4/45). Of those reviewed, 29 MORs were made. Of patients who were pharmacist identified, 10 MORs were made (53% of patients). The toolkit was retrospectively applied to these patients and would have selected all but 3.

Conclusion

The PPT was successfully used by the team to generate 45 referrals for pharmacist review over a 4-week period. As a result of analysis of these recommendations, antimicrobial prophylaxis for urinary tract infections will be added to the high-risk medicines list on the PPT. Development of the toolkit is ongoing using a plan, do, study, act model with input from all members of the team to further improve both its efficacy and utility.

Laparoscopy versus laparotomy for pediatric ovarian dermoids

BACKGROUND

With increased surgeon comfort using laparoscopy, we hypothesized resection of pediatric ovarian dermoids using laparoscopy would yield a shorter length of stay and no increase in morbidity or recurrence compared to laparotomy.

METHODS

A retrospective review was performed amongst eleven pediatric hospitals. Patients aged 2 to 21 who underwent resection of an ovarian dermoid from 2010 to 2020 were included. Patient characteristics, operative details, and outcomes by approach were evaluated using Chi-squared and Wilcoxon-Mann tests.

RESULTS

466 patients were included, with a median age of 14.4 and median follow-up of 4.0 months. 279 patients underwent laparoscopy (60%), 139 laparotomy (30%), and 48 laparoscopy converted to laparotomy (10%). There were no differences in rates of tumor spillage by approach (p = 0.15). 65% underwent ovarian-sparing surgery and 35% underwent oophorectomy. Length of stay was significantly shorter amongst patients who underwent laparoscopy (1 day versus 2 days for laparotomy and converted, p<0.0001). There were no differences in rates of suspected recurrence or reoperation (p = 0.19 and p = 0.57, respectively).

CONCLUSION

Patients who underwent laparoscopy experienced no differences in the rates of tumor spillage, recurrence, or reoperation and had a shorter length of stay compared to laparotomy. Laparoscopy is an acceptable approach for resection of pediatric ovarian dermoids.

Factors Associated with Torsion in Pediatric Patients with Ovarian Masses

BACKGROUND

Management of ovarian torsion has evolved toward ovarian preservation regardless of ovarian appearance during surgery. However, patients with torsion and an ovarian neoplasm undergo a disproportionately high rate of oophorectomy. Our objectives were to identify factors associated with ovarian torsion among females with an ovarian mass and to determine if torsion is associated with malignancy.

METHODS

A retrospective review of females aged 2-21 y who underwent an operation for an ovarian cyst or neoplasm between 2010 and 2016 at 10 children's hospitals was performed. Multivariate logistic regression was used to assess factors associated with torsion. Imaging data were assessed for sensitivity, specificity, and predictive value in identifying ovarian torsion.

RESULTS

Of 814 girls with an ovarian neoplasm, 180 (22%) had torsion. In risk-adjusted analyses, patients with a younger age, mass size >5 cm, abdominal pain, and vomiting had an increased likelihood of torsion (P < 0.01 for all). Patients with a mass >5 cm had two times the odds of torsion (odds ratio: 2.1; confidence interval: 1.2, 3.6). Imaging was not reliable at identifying torsion (sensitivity 34%, positive predictive value 49%) or excluding torsion (specificity 72%, negative predictive value 87%). The rates of malignancy were lower in those with an ovarian mass and torsion than those without torsion (10% versus 17%, P = 0.01). Among the 180 girls with torsion and a mass, 48% underwent oophorectomy of which 14% (n = 12) had a malignancy.

CONCLUSIONS

In females with an ovarian neoplasm, torsion is not associated with an increased risk of malignancy and ovarian preservation should be considered.

Sutureless vs sutured abdominal wall closure for gastroschisis: Operative characteristics and early outcomes from the Midwest Pediatric Surgery Consortium

PURPOSE

To report outcomes of sutured and sutureless closure for gastroschisis across a large multi-institutional cohort.

METHODS

A retrospective study of infants with uncomplicated gastroschisis at 11 children's from 2014 to 2016 was performed. Outcomes of sutured and sutureless abdominal wall closure were compared.

RESULTS

Among 315 neonates with uncomplicated gastroschisis, sutured closure was performed in 248 (79%); 212 undergoing sutured closure after silo and 36 undergoing primary sutured closure. Sutureless closure was performed in 67 (21%); 37 primary sutureless closure, 30 sutureless closure after silo placement. There was no significant difference in gestational age, gender, birth weight, total days on TPN, and time from closure to initial oral intake or goal feeds. Sutureless closure patients had less general anesthetics, ventilator use/time, time from birth to final closure, antibiotic use after closure, and surgical site/deep space infections. Subgroup analysis demonstrated primary sutureless closure had less ventilator use and anesthetics than primary sutured closure. Sutureless closure after silo led to less ventilator use/time, anesthetics, and antibiotics compared to those with sutured closure after silo.

CONCLUSION

Sutureless abdominal wall closure of neonates with gastroschisis was associated with less general anesthetics, antibiotic use, surgical site/deep space infections, and decreased ventilator time. These findings support further prospective study by our group.

LEVEL OF EVIDENCE

Level III.

Understanding the Value of Tumor Markers in Pediatric Ovarian Neoplasms

PURPOSE

The purpose of this study was to determine the diagnostic accuracy of tumor markers for malignancy in girls with ovarian neoplasms.

METHODS

A retrospective review of girls 2-21 years who presented for surgical management of an ovarian neoplasm across 10 children's hospitals between 2010 and 2016 was performed. Patients who had at least one concerning feature on imaging and had tumor marker testing were included in the study. Sensitivity, specificity, and negative and positive predictive values (PPV) of tumor markers were calculated.

RESULTS

Our cohort included 401 patients; 22.4% had a malignancy. Testing for tumor markers was inconsistent. AFP had high specificity (98%) and low sensitivity (42%) with a PPV of 86%. The sensitivity, specificity, and PPV of beta-hCG was 44%, 76%, and 32%, respectively. LDH had high sensitivity (95%) and Inhibin A and Inhibin B had high specificity (97% and 92%, respectively).

CONCLUSIONS

Tumor marker testing is helpful in preoperative risk stratification of ovarian neoplasms for malignancy. Given the variety of potential tumor types, no single marker provides enough reliability, and therefore a panel of tumor marker testing is recommended if there is concern for malignancy. Prospective studies may help further elucidate the predictive value of tumor markers in a pediatric ovarian neoplasm population.

TYPE OF STUDY

Retrospective Cohort Review.

LEVEL OF EVIDENCE

Level III.

Factors Associated With Management of Pediatric Ovarian Neoplasms

BACKGROUND

Available evidence supports ovary-sparing surgery for benign ovarian neoplasms; however, preoperative risk stratification of pediatric ovarian masses can be difficult. Our objective of this study was to characterize the surgical management of pediatric ovarian neoplasms across 10 children's hospitals and to identify factors that could potentially aid in the preoperative risk stratification of these lesions.

METHODS

A retrospective review of girls and women aged 2 to 21 years who underwent surgery for an ovarian neoplasm between 2010 and 2016 at 10 children's hospitals was performed. Multivariable logistic regression was used to examine the relationships between the preoperative cohort characteristics, procedure performed, and risk of malignancy.

RESULTS

Among 819 girls and women undergoing surgery for an ovarian neoplasm, malignant lesions were identified in 11%. The overall oophorectomy rate for benign disease was 33% (range: 15%-49%) across institutions. Oophorectomy for benign lesions was independently associated with provider specialty (P = .002: adult gynecologist, 45%; pediatric surgeon, 32%; pediatric gynecologist, 18%), premenarchal status (P = .02), preoperative suspicion for malignancy (P < .0001), larger lesion size (P < .0001), and presence of solid components (P < .0001). Preoperative findings independently associated with malignancy included increasing size (P < .0001), solid components (P = .003), and age (P < .0001).

CONCLUSIONS

The rate of oophorectomy for benign ovarian disease remains high within the pediatric population. Identification of factors associated with the choice of procedure and the risk of malignancy may allow for improved preoperative risk stratification and fewer unnecessary oophorectomies. These results have been used to develop and validate a multidisciplinary preoperative risk stratification algorithm that is currently being studied prospectively across 10 institutions.