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Improving Pediatric Surgery Quality by Widely Adopting an Evidence-Based Protocol: An Effort of the Pediatric Surgery Quality Collaborative
*
Jeannette M. Joly1, *Monica E. Lopez
3, *Erich J. Grethel
7, *Terry Fisher
1, *Krysta M. Sutyak
1, Martin L. Blakely
1, *Seokhun Kim
2, *Charles Green
2, *Jeffrey M. Burford
8, *Nicole Chandler
6, *Kathryn Danko
7, *Raquel Gonzalez
6, *Laura Jorg
4, *Andrew Nuibe
9, *Daniel K. Robie
5, *Amanda Skaggs
4, *Regan Williams
10, Kevin P. Lally
11Pediatric Surgery, University of Texas Health Science Center at Houston, Houston, TX; 2Institute for Clinical Research and Learning Health Care, McGovern Medical School, Houston, TX; 3Pediatric Surgery, Vanderbilt University School of Medicine, Nashville, TN; 4Perioperative Services, Dayton Children's Hospital, Dayton, OH; 5Surgery, Dayton Children's Hospital, Dayton, OH; 6Pediatric Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL; 7Pediatric Surgery, Dell Children's Medical Center, Austin, TX; 8Pediatric Surgery, Arkansas Children's Hospital, Little Rock, AR; 9Pediatric Infectious Disease, Inova Health System, Fairfax, VA; 10Pediatric Surgery, The University of Tennessee Health Science Center, Memphis, TN
Objectives: Studies show intraabdominal infections with source control are adequately treated with a short, 4-day course of antibiotics. This evidence-based practice has not been adopted in children, for whom care remains highly variable. We proposed a protocol for short-course antibiotic therapy after appendectomy for complicated appendicitis through the Pediatric Surgery Quality Collaborative (PSQC), a national partnership of children’s hospitals, using National Surgical Quality Improvement Program-Pediatric (NSQIP-P) data. We hypothesized that hospitals would adopt the protocol and reduce antibiotic exposure without increasing surgical site infections (SSI).
Methods: This prospective observational study included 36 sites: 15 continued usual care, 21 adopted the protocol over time. The protocol recommended 4 (+/-1) antibiotic days (IV + PO) after appendectomy. Site data were obtained from NSQIP-P procedure-targeted and custom variable fields. Patients were grouped to usual care or protocol groups. At protocol sites, patients treated prior to adoption were grouped to usual care, those treated after were grouped to protocol. Demographics, American Society of Anesthesiologists (ASA) class, sepsis grade, preoperative white blood cell (WBC) count, procedure duration, and postoperative fever were collected. Outcomes were antibiotic days and 30-day SSIs. Univariate analyses compared group characteristics; clinically relevant variables that differed between groups (p<0.2) were included in multi-level models using mixed-effects negative binomial and logistic regression, clustered by site and adjusted for sex, ASA class, sepsis grade, and procedure duration.
Results: We included 1918 patients: 880 usual care, 1038 protocol. Median age was 10.0 (IQR 7.2,13.1) and body mass index (BMI) was 19.2 (IQR 16.3,23). The cohort was 59% male, 68% white, 40% Hispanic. Most frequent ASA class was 2 (57%). Systemic inflammatory response syndrome (SIRS) occurred in 68%. The overall 30-day SSI rate was 13% (91% were organ space infections). Univariate comparisons of group characteristics are summarized in TABLE. In mixed-effects models using completed data (84%), the protocol group had fewer antibiotic days (RR 0.65, 95% CI 0.57-0.74; p<0.01); average antibiotic days were 5.8 for protocol and 8.9 for usual care, a risk difference of 3.1 days (95% CI 2.17-4.07, p<0.01). The logistic regression model did not reveal a difference in 30-day SSI rate between groups (12.6% vs 13.8%) (OR 0.90; 95% CI 0.59-1.37).
Conclusion: Many children’s hospitals accepted and adopted an evidence-based protocol for short-course antibiotic therapy, highlighting a novel mechanism for meaningful pediatric quality improvement in surgical care. Protocol adoption was associated with a significant reduction in antibiotic use without increasing SSIs. Next steps will focus on scaling up protocol implementation to increase standardization of care and promote antibiotic stewardship in pediatric surgery.
TABLE. Univariate comparisons of group characteristics.
| Group Characteristics | Usual Care Group
(n=880) | Protocol Group
(n=1038) | p-value |
| Age, years (IQR) | 10.1 (7.3,13.2) | 10 (7.2,13.0) | 0.43 |
| Sex, male (%) | 521/851 (61.2%) | 595/1038 (57.3%) | 0.09 |
| BMI (IQR) | 19.2 (16.4,23.0) | 19.1 (16.2,23.0) | 0.45 |
| Race | | | <0.01 |
| White (%) | 626/873 (71.6%) | 679/1038 (65.4%) | 0.14 |
| Black (%) | 62/873 (7.1%) | 60/1038 (5.8%) | 0.86 |
| Asian (%) | 9/873 (1.0%) | 21/1038 (2.0%) | 0.03 |
| Other (%) | 75/873 (8.6%) | 150/1038 (14.5%) | <0.01 |
| Unknown (%) | 83/873 (9.5%) | 113/1038 (10.9%) | <0.01 |
| Hispanic Ethnicity | | | <0.01 |
| Yes (%) | 345/880 (39.2%) | 427/1038 (41.1%) | <0.01 |
| No (%) | 514/880 (58.4%) | 549/1038 (52.9%) | 0.28 |
| ASA Classification | | | <0.01 |
| ASA class 1 (%) | 356/840 (42.4%) | 306/1038 (29.5) | 0.05 |
| ASA class 2 (%) | 423/840 (50.4%) | 641/1038 (61.8%) | <0.01 |
| ASA class 3 (%) | 56/840 (6.7%) | 88/1038 (8.5%) | 0.01 |
| ASA class 4 (%) | 5/840 (0.6%) | 3/1038 (0.3%) | 1 |
| Sepsis Grade | | | <0.01 |
| None (%) | 209/880 (23.8%) | 277/1038 (26.7%) | <0.01 |
| SIRS (%) | 634/880 (72.0%) | 674/1038 (64.9%) | 0.27 |
| Sepsis (%) | 34/880 (3.9%) | 84/1038 (8.1%) | <0.01 |
| Septic shock (%) | 3/880 (0.3%) | 3/1038 (0.3%) | 1 |
| Preoperative WBC count (IQR) | 17 (13.6,20.4) | 17 (13.7,21.0) | 0.51 |
| Procedure duration, minutes (IQR) | 57 (39.0,69.0) | 54.5 (39.0,65.0) | 0.06 |
| Presence of postoperative fever (%) | 31/846 (3.7%) | 39/1038 (3.8%) | 0.92 |
Discrepancies in denominators represent missing data in that variable category.
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