Integrating intraoperative physiology data into outcome analysis for the ACS Pediatric National Surgical Quality Improvement Program.

Abstract

The Pediatric National Surgical Quality Improvement Program (P-NSQIP) samples surgical procedures for benchmarking and quality improvement. While generally comprehensive, P-NSQIP does not collect intraoperative physiologic data, despite potential impact on outcomes. The aims of this study were (a) to describe a methodology to augment P-NSQIP with vital signs data and (b) demonstrate its utility by exploring relationships that intraoperative hypothermia and hypotension have with P-NSQIP outcomes. Vital signs from 2012 to 2016 were available in a research databank. Episodes of hypotension and hypothermia were extracted and recorded alongside local P-NSQIP data. Multivariable regression analyses were performed to explore associations with undesired outcomes, including: surgical site infection, wound disruption, unplanned return to the operating room, and blood transfusion. Model variables were selected with the Akaike information criterion using 2012-2014 as the training set and validated with receiver operating characteristics analysis using 2015-2016 as the testing set. Data from 6737 patients were analyzed, with 43.9% female, median [interquartile range] age 5.8 [1.3-12.4]years, undergoing procedures lasting 118 [75-193]minutes. Hypothermia, observed in 45% of cases, was associated with wound disruption (odds ratio 1.75, 95% CI 1.1-2.83). Hypotension, observed in 60% of cases, was associated with unplanned returns (odds ratio 1.58, 95% CI 1.02-2.51), and transfusions (odds ratio 1.95, 95% CI 1.14-3.52). Surgical site infection, wound disruption, unplanned return, and transfusion models had areas under the receiver operating characteristic curve of 0.69/0.67, 0.59/0.63, 0.78/0.79, and 0.92/0.93 for validation models including hypothermia/hypotension respectively. Adding intraoperative vital signs to P-NSQIP data allowed identification of two modifiable risk factors: hypothermia was associated with increased wounddisruption, and hypotension with increased blood transfusions and unplanned returns to the operating room. These findings may motivate prospective studies andprompt other centers and P-NSQIP to augment outcome data with intraoperative physiological data.