Pediatric Operating Room Research Articles

Assessing use of the WHO surgical safety checklist for pediatric surgery in Senegal: A nationwide survey

Introduction The World Health Organization (WHO) introduced the surgical safety checklist (SSC) to reduce postoperative morbidity and mortality; however, its use in low- and middle-income countries is still low. Methods We conducted a survey from January 2 to 22, 2024, in public hospitals’ pediatric surgery departments and units in Senegal to assess the use of the WHO SSC or an adapted version. Results The participation rate was 100% (23 hospitals), with 11 second-level hospitals (47.8%) and 10 (43.5%) having at least two pediatric surgeons. All hospitals had an anesthetist nurse, and 18 hospitals (78.3%) had at least two scrub nurses. For the surgical workload, 14 hospitals (60.9%) had five to 10 surgical interventions weekly. Eleven hospitals (47.8%) had training on use of the SSC, and 8 of the 23 hospitals (34.8%) used the SSC. The WHO SSC nonutilization was mainly due to a lack of training in nine hospitals (60%) and SSC unavailability in five hospitals (33.3%). Members of 22 hospitals (95.6%) were available for training on use of the SSC. Conclusion The WHO SSC is poorly used in pediatric operating rooms of public hospitals in Senegal. The main reasons for nonutilization are remediable.

On the psychological effects of child-like space design on preschoolers under anesthesia: A qualitative study.

In this study, a pediatric hospital was selected as the study setting, to investigate the effects of the environment of a pediatric operating room child-friendly space on preschool children under anesthesia. Interviews were conducted in pediatric hospitals through anesthesia of preschool children. This study randomizing children between the ages of 1 and 7 years (seven males, five females, mean age 3.8 years, standard deviation 0.7). Twelve participants took part in this interview, which was an in-depth interview of preschoolers' perceptions of anesthesia using generalized data analysis to assess young children's perceived preferences and sensitivity to the environment. Preschoolers' preferences for feeling under anesthesia are reflected in four main areas. (1) Interesting and engaging environment. (2) Humanized design, free of fear and unfamiliarity. (3) Caring, patient, and compassionate care by healthcare professionals. (4) High cooperation of the child and good doctor-patient relationship. The key findings of this study may help designers and clinicians to design a toddler-friendly built environment where pediatric hospital child-friendly spaces are designed to benefit their health and maximize their cooperation and psychological recovery.

Evaluation of Noise Exposure Levels in Pediatric ENT Operating Rooms.

Operating room (OR) sounds may surpass noise exposure thresholds and induce hearing loss. Noise intensity emitted by various surgical instruments during common pediatric otolaryngologic procedures were compared at the ear-level of the surgeon and patient to evaluate the need for quality improvement measures. Cross-sectional study. Single tertiary care center. Noise levels were measured using the RISEPRO Sound Level Meter and SoundMeter X 10.0.4 at the ear level of surgeon and patient every 5minutes. Operative procedure and instrument type were recorded. Measured noise levels were compared against ambient noise levels and the Apple Watch Noise application. Two hundred forty-two total occasions of noise were recorded across 62 surgical cases. Cochlear implantation surgery produces the loudest case at the ear-level of the patient (91.8Lq Peak dB; P < .001). The otologic drill was the loudest instrument for the patient (92.1Lq Peak dB; P < .001), while the powered microdebrider was the loudest instrument for the surgeon (90.7Lq Peak dB; P = .036). Noise measurements between surgeon and patient were similar (P < .05). Overall agreement between the Noise application and Sound Level Meter was excellent (intraclass correlation coefficient of 0.8, with a 95% confidence interval ranging from 0.32 to 0.92). Otolaryngology OR noises can surpass normal safe thresholds. Failure to be aware of this may unwittingly expose providers to noise-related hearing loss. Mitigation strategies should be employed. Quality improvement measures, including attention to surgical instrument volume settings and periodic decibel measurements with sound applications, can promote long-term hearing conservation. Otolaryngology OR noises can surpass normal safe thresholds. Failure to be aware of this may unwittingly expose providers to noise-related hearing loss. The duration, frequency of exposure, and volume levels of noise should be studied further. Mitigation strategies should be employed. Quality improvement measures, including attention to surgical instrument volume settings and periodic decibel measurements with sound applications, can promote long-term hearing conservation.

Measuring the Interprofessional Health of the Pediatric Cardiovascular Operating Room Work Environment.

Pediatric cardiac surgery is complex and has significant risk, requiring interprofessional teamwork for optimal outcomes. Unhealthy work environments have been linked to poor patient outcomes, staff dissatisfaction, and intention to leave. We describe the interprofessional health of pediatric cardiovascular operating room (CVOR) work environments in the United States and the establishment of a healthy work environment (HWE) benchmark score. Utilizing the American Association of Critical Care Nurses Healthy Work Environments Assessment Tool (HWEAT), interprofessional staff from 11 pediatric CVORs were surveyed. Responses were aggregated, summarized, and stratified by role to examine differences. The following phase used an e-Delphi approach to obtain expert consensus on a benchmark target. Across 11 centers, 179 (60%) completed surveys were reviewed. The interprofessional mean HWEAT score was 3.55 (2.65-4.34). Mean scores for each standard were within the "good" range. Participants reported the highest scores for effective decision-making, with a mean of 3.69 (3.00-4.20). Meaningful recognition scored lowest, mean 3.26 (2.33-4.07). When stratified, surgeons reported higher overall HWE scores (M = 3.79, SD = 0.13) than nurses (M = 3.41, SD = 0.19; P = 0.02, two-tailed). The proposed benchmark was 3.50. This is the first time the American Association of Critical Care Nurses HWEAT has been used to describe the interprofessional health of work environments in pediatric CVORs in the United States. The targeted benchmark can support pediatric CVOR improvement strategies. Creating and sustaining an HWE is an interprofessional opportunity to support high-quality patient outcomes and clinical excellence.

Cost-effectiveness of a pediatric operating room installation in Sub-Saharan Africa.

The unmet need for pediatric surgery imposes enormous health and economic consequences globally, predominantly shouldered by Sub-Saharan Africa (SSA) where children comprise almost half of the population. Lack of knowledge about the economic impact of improving pediatric surgical infrastructure in SSA inhibits the informed allocation of limited resources towards the most cost-effective interventions to bolster global surgery for children. We assessed the cost-effectiveness of installing and running two dedicated pediatric operating rooms (ORs) in a hospital in Nigeria with a pre-existing pediatric surgical service by constructing a decision tree model of pediatric surgical delivery at this facility over a year, comparing scenarios before and after the installation of the ORs, which were funded philanthropically. Health outcomes measured in disability-adjusted life years (DALYs) averted were informed by the hospital's operative registry and prior literature. We adopted an all healthcare payor's perspective including costs incurred by the local healthcare system, the installation (funded by the charity), and patients' families. Costs were annualized and reported in 2021 United States dollars ($). The incremental cost-effectiveness ratios (ICERs) of the annualized OR installation and operation were presented. One-way and probabilistic sensitivity analyses were performed. We found that installing and operating two dedicated pediatric ORs averted 538 DALYs and cost $177,527 annually. The ICER of the ORs' installation and operation was $330 per DALY averted (95% uncertainty interval [UI] 315-336) from the all healthcare payor's perspective. This ICER was well under the cost-effectiveness threshold of the country's half-GDP per capita in 2020 ($1043) and remained cost-effective in one-way and probabilistic sensitivity analyses. Installation of additional dedicated pediatric operating rooms in Nigeria with pre-existing pediatric surgical capacity is therefore very cost-effective, supporting investment in children's global surgical infrastructure as an economically sound intervention.

Promoting surgical smoke management in a pediatric operating room: a best practice implementation project.

The routine use of heat-producing tools in the perioperative setting generates surgical smoke. Surgical smoke poses a known health hazard for perioperative staff working in the operating room. The objective of this best practice project was to promote evidence-based practices regarding surgical plume management in a pediatric operating room. This project was guided by the JBI Model of Evidence-Based Healthcare and used the JBI Practical Application of Clinical Evidence System and the Getting Research into Practice audit and feedback strategy to promote evidence-based practices regarding surgical smoke management in a pediatric operating room. Seven audit criteria representing best-practice recommendations were used. A baseline audit was conducted, followed by the implementation of multiple strategies developed by the key stakeholders. The project was finalized with a follow-up audit to determine any changes in compliance with best-practice recommendations. Baseline audit data indicated an average of 41% compliance with best practices across all audit criteria, revealing the need for significant improvement in five of the seven criteria. Three barriers were identified and strategies were implemented, including the development and implementation of an educational module and a surgical smoke exposure risk assessment tool. Follow-up audits showed an overall improvement of 30% among five of the seven audit criteria. This project yielded improvements with best practices for surgical smoke management in the perioperative setting. However, additional work is required to ensure the sustainability of best practices in this setting.

Sterile surgical supply waste identification using asynchronous analysis: Pediatric surgery QI pilot

BackgroundThe operating room (OR) is a major cost and revenue center for a hospital. One of the few modifiable costs in the OR is single-use, sterile surgical supplies (SUSSS). If SUSSS are opened on the scrub table and not used, then they are wasted. High-fidelity SUSSS usage data is important to strategically implement solutions to reduce waste of SUSSS in the OR. OR waste reduction may decrease health systems' carbon footprints and reduce spending. MethodsA convenience sample of general pediatric surgical cases was observed in summer 2021. HIPAA-free images of the surgical scrub table were acquired every 2 s with minimal impact on pediatric OR workflow. These images were asynchronously analyzed to obtain SUSSS usage data for each case. ResultsImage data from three pediatric surgeons performing 41 pediatric surgeries was reviewed. The median cost of unused SUSSS was $13.10 (IQR = $2.73–$47.97) with a range of $0.07 to $489.08 wasted in a single surgery. The mean number of items wasted was 9.3 ± 6.4. The most frequently wasted items were sutures, syringes, towels, paper rulers, and specimen cups. The most expensive sources of waste were laparoscopic trocars, sutures, insufflation needles, drapes, and guidewires. ConclusionsSUSSS that were discarded without being used were successfully identified through the asynchronous analysis of HIPAA-free OR scrub table image data. This may be an opportunity to identify SUSSS waste efficiently without an observer in the OR.

Out-of-pocket costs and catastrophic healthcare expenditure for families of children requiring surgery in sub-Saharan Africa

BackgroundOut-of-pocket healthcare costs leading to catastrophic healthcare expenditure pose a financial threat for families of children undergoing surgery in Sub-Saharan African countries, where universal healthcare coverage is often insufficient. MethodsA prospective clinical and socioeconomic data collection tool was used in African hospitals with dedicated pediatric operating rooms installed philanthropically. Clinical data were collected via chart review and socioeconomic data from families. The primary indicator of economic burden was the proportion of families with catastrophic healthcare expenditures. Secondary indicators included the percentage who borrowed money, sold possessions, forfeited wages, and lost a job secondary to their child’s surgery. Descriptive statistics and multivariate logistic regression were performed to identify predictors of catastrophic healthcare expenditure. ResultsIn all, 2,296 families of pediatric surgical patients from 6 countries were included. The median annual income was $1,000 (interquartile range 308–2,563), whereas the median out-of-pocket cost was $60 (interquartile range 26–174). Overall, 39.9% (n = 915) families incurred catastrophic healthcare expenditure, 23.3% (n = 533) borrowed money, 3.8% (n = 88%) sold possessions, 26.4% (n = 604) forfeited wages, and 2.3% (n = 52) lost a job because of the child’s surgery. Catastrophic healthcare expenditure was associated with older age, emergency cases, need for transfusion, reoperation, antibiotics, and longer length of stay, whereas the subgroup analysis found insurance to be protective (odds ratio 0.22, P = .002). ConclusionA full 40% of families of children in sub-Saharan Africa who undergo surgery incur catastrophic healthcare expenditure, shouldering economic consequences such as forfeited wages and debt. Intensive resource utilization and reduced insurance coverage in older children may contribute to a higher likelihood of catastrophic healthcare expenditure and can be insurance targets for policymakers.

Pediatric intraoperative cardiopulmonary arrests: A survey to evaluate if Medical Emergency Teams are utilized in pediatric operating rooms.

Studies have shown that standardized code teams may improve outcomes following cardiac arrests. Pediatric intra-operative cardiac arrests are rare events and are associated with a mortality rate of 18%. There is limited data available regarding use Medical Emergency Team (MET) response to pediatric intra-operative cardiac arrest. The purpose of this study was to identify the use of MET in response to pediatric intraoperative cardiac arrest as an exploratory step in establishing evidence-based standardized practice across the hospital for training and management of this rare event. An anonymous electronic survey was created and sent to two populations: The Pediatric Anesthesia Leadership Council, a section of the Society for Pediatric Anesthesia, and the Pediatric Resuscitation Quality Collaborative, a multinational collaborative group, which works to improve resuscitation care in children. Standard summary and descriptive statistics were used for survey responses. The overall response rate was 41%. The majority of respondents worked in a university affiliated, free-standing children's hospital. Ninety-five percent of respondents had a dedicated pediatric MET at their hospital. In 60% of responses from Pediatric Resuscitation Quality Collaborative and 18% of Pediatric Anesthesia Leadership Council hospitals, the MET responds to pediatric intra-operative cardiac arrest; however, the majority of times MET involvement is requested rather than automatic. The MET was found to be activated intraoperatively for situations other than cardiac arrest such as, massive transfusion events, need for extra staff, and for specialty expertise. In 65% of institutions, simulation-based training for cardiac arrest is supported but lacking pediatric intra-operative focus. This survey revealed heterogeneity in the composition and response of the medical response teams responding to pediatric intra-operative cardiac arrests. Improved collaboration and cross training among MET, anesthesia, and operating room nursing may improve outcomes of pediatric intra-operative code events.

Assessment of Surgical Teams’ Teamwork Skills in Pediatric Surgery: A Cross-sectional Study

Background: The operating room is a high-risk environment in which practitioners with different educational backgrounds work together to provide safe care for surgical patients. The surgical team needs to use teamwork skills for safe performance and error prevention. Pediatric surgery is a very sensitive surgery type that needs special psychological skills. Objectives: This study aimed to assess surgical teams’ teamwork skills in pediatric surgery. Methods: This cross-sectional study was conducted on 154 surgical teams working in the pediatric operating rooms of two public hospitals in Shiraz, Iran, during the summer of 2021 using convenience sampling. The data were collected by the Mayo High-Performance Teamwork Scale. An operating room technologist collected the data by observing surgeries. Descriptive statistics were used for the analysis of the data. The data were analyzed using SPSS software (version 22). Results: The mean value of the teamwork score was 1.57 ± 0.20 (out of 2). The total teamwork score was 25.20 ± 3.31 (out of 32). The majority of items had a score of more than average. The team members had the highest score in recognizing a leader. The studied surgical teams had low scores in verbalizing their activities and repeating back the instructions. Conclusions: The overall teamwork score in the studied teams in the pediatric operating rooms was at an acceptable level. However, the studied teams did not do well in team communication behaviors. Interventions, such as educating, standardizing communications, and implementing a pediatric surgical safety checklist, can improve team communication skills.

Modulating operating room music volume with the CanaryBox: A quality improvement initiative to improve anesthesia clinicians’ response times to alarms to improve quality of anesthetic care

Music is commonly played in the operating rooms and contributes to overall noise level. High noise levels in the operating room, often surpassing the National Institute for Occupational Safety and Health recommendations, affect clinician communication and vigilance. This study's primary aim was to reduce anesthesia provider response time to alarms to improve quality of care to patients undergoing general anesthesia. The aim of this quality improvement project was to reduce anesthesia provider response time to vital sign alarms with the tested intervention of the CanaryBox device to modulate music volume in the OR by August of 2021. Utilizing improvement science methods including the Model of Improvement and tested interventions via the Plan-Do-Study-Act cycles, we utilized the CanaryBox in the pediatric orthopedic operating rooms at Monroe Carell Jr. Children's Hospital at Vanderbilt. This device modulates music volume according to the severity of patient vital sign deviations. Timestamps of onset and response to patient vital sign alarms, recorded by the Philips IntelliVue Information Center system, were collected for 12 control (pre-intervention) and 58 intervention (with the CanaryBox) cases. Median and average response times were calculated for pre- and post-intervention cases. There was an associated decrease (improvement) in average anesthesia provider alarm response times from 30.2 seconds in pre-intervention cases to 23.6 seconds with CanaryBox intervention cases. Improved anesthesia provider response times with implementation of the CanaryBox imply less distraction due to unnecessary noise levels at critical periods. This improved vigilance and decreased response time indicate anesthesia providers deliver higher levels of patient care when the CanaryBox is modulating music volume.

Medication safety in the perioperative setting: A comparison of methods for detecting medication errors and adverse medication events.

The purpose of this study was to evaluate perioperative medication-related incidents (medication errors (MEs) and/or adverse medication events (AMEs)) identified by 2 different reporting methods (self-report and direct observation), and to compare the types and severity of incidents identified by each method. We compared perioperative medication-related incidents identified by direct observation in Nanji et al's 2016 study[1] to those identified by self-report via a facilitated incident reporting system at the same 1046-bed tertiary care academic medical center during the same 8-month period. Incidents, including MEs and AMEs were classified by type and severity. In 277 operations involving 3671 medication administrations, 193 MEs and/or AMEs were observed (5.3% incident rate). While none of the observed incidents were self-reported, 10 separate medication-related incidents were self-reported from different (unobserved) operations that occurred during the same time period, which involved a total of 21,576 operations and approximately 280,488 medication administrations (0.004% self-reported incident rate). The distribution of incidents (ME, AME, or both) did not differ by direct observation versus self-report methodology. The types of MEs identified by direct observation differed from those identified by self-report (P = .005). Specifically, the most frequent types of MEs identified by direct observation were labeling errors (N = 37; 24.2%), wrong dose errors (N = 35; 22.9%) and errors of omission (N = 27; 17.6%). The most frequent types of MEs identified by self-report were wrong dose (N = 5; 50%) and wrong medication (N = 4; 40%). The severity of incidents identified by direct observation and self-report differed, with self-reported incidents having a higher average severity (P < .001). The procedure types associated with medication-related incidents did not differ by direct observation versus self-report methodology. Direct observation captured many more perioperative medication-related incidents than self-report. The ME types identified and their severity differed between the 2 methods, with a higher average incident severity in the self-reported data.

Impact of Upgraded Pediatric Operating Room on Surgical Volume in Africa: Evidence from Burkina Faso

Impact of Upgraded Pediatric Operating Room on Surgical Volume in Africa: Evidence from Burkina Faso

Impact of new dedicated pediatric operating rooms on surgical volume in Africa: Evidence from Nigeria

BackgroundThere is a large unmet children's surgical need in low- and middle-income countries (LMICs). This study examines the impact of installing dedicated pediatric operating rooms (ORs) on surgical volume at National Hospital Abuja, a hospital in Abuja, Nigeria. MethodsA Non-Governmental Organization installed two pediatric ORs in August 2019. We assessed changes in volume from July 2018 to September 2021 using interrupted time series analysis. ResultsTotal surgical volume increased by 13 cases (p = 0.01) in 1-month post-installation, with elective operations making up 85% (p = 0.02) of cases. There was an increase in elective volume by about 1 case per month (p = 0.01) post-installation and the difference between pre-and post-trends was 1.23 cases per month (p = 0.009). The baseline volume of neonatal surgeries increased by 9 cases per month (p < 0.001) post-installation and this difference between pre- and post-trends was statistically significant (p = 0.001). Similarly, one-month post-installation, the cases classified as ASA class >2 increased by 14 (p < 0.001). There was no significant difference between pre-and post-installation mortality rate at about 2% per month. ConclusionsThere were significant changes in surgical volume after OR installation, primarily composed of elective operations, reflecting an increased capacity to address surgical backlogs and/or perform more specialized surgeries. Despite a significant increase in volume and higher ASA class, there was no significant difference in mortality. This study supports the installation of surgical infrastructure in LMICs to strengthen capacity without increasing postoperative mortality.

Special diagnostics in pediatric urology-Nuclear medicine diagnostics, advanced diagnostics for bladder voiding disorders and imaging diagnostics in the operating room : Tips for the practice part2

The diagnostics and treatment of pediatric urology patients in the clinical routine can be extremely challenging. In contrast to adult patients, the main concerns in the diagnostics of congenital diseases are time consuming examinations and limited options in addition to the expectations of the parents. The exact knowledge of the diagnostic possibilities in association with the correct interpretation of the indications is essential. Simple processes can be much more time consuming because of a lack of compliance, especially in very young children. Sonography is considered the standard for imaging in pediatric urology. Profound knowledge of the embryonal development and also physiological processes throughout childhood contribute to making the correct diagnosis. This article deals with the possibilities of nuclear medicine diagnostics, advanced diagnostics in bladder voiding disorders and finally imaging diagnostics in the pediatric urological operating room.

The Effect of Seamless Nursing During the Whole Nursing Process in Pediatric Operating Room

The Effect of Seamless Nursing During the Whole Nursing Process in Pediatric Operating Room

Pediatric Plastic Surgery Operating Room Block-Time Utilization: A Casualty of Illness.

Optimizing operating room (OR) utilization is a critical component of health care system efficiency. The purpose of our study was to analyze the extent of OR cancellation and its effect on raw utilization of OR block time allotted to surgeons in the pediatric plastic surgery department. The authors retrospectively reviewed the cases of 4 plastic surgeons at a tertiary pediatric hospital between 2018 and 2019. Data collected included patient demographics, type of surgery, time of cancellation, reason for cancellation, length of surgery, and minutes of block time allotted to each surgeon per year. Percent of cases canceled, scheduled times lost, and block times lost were calculated. Surgeons A, B, C, and D scheduled 170, 416, 305, and 474 cases, respectively. Overall, 7% of cases were canceled, 9.1% of scheduled time was lost, and a total of 5.1% of block time was lost due to cancellation. Patients of surgeon A and D were more likely to cancel due to reasons classified as ''other,'' including causes such as failure of nil per os or a family's last-minute decision to forego elective surgery (33.3% and 37.2%, respectively), whereas patients of surgeon B and C were more likely to cancel due to illness (67.9% and 36.4%, respectively). Cancellations negatively impact raw utilization times; if fewer cases are performed, allotted block times are redistributed. Communication with patients in the week prior to surgery may allow for earlier identification of likely cancellations. Future directions include exploring whether particular surgeon characteristics are linked to rate of cancellations.

Standardization of Pediatric Noncardiac Operating Room to Intensive Care Unit Handoffs Improves Communication and Patient Care.

Handoffs are critical points in transitioning care between multidisciplinary teams, yet data regarding intensive care unit (ICU) handoffs in pediatric noncardiac surgical patients are lacking. We hypothesized that standardized handoffs from the pediatric operating room (OR) to the ICU would improve physician presence, communication, and patient care parameters. This quality improvement initiative was performed at a tertiary children's hospital. Stakeholders (anesthesiologists, nurses, intensivists, and surgeons) developed a standardized OR to pediatric and neonatal ICU handoff process based on common goals and outcomes of interest. Baseline data were collected before intervention. Implementation was carried out in 2 phases, phase 1 with a written handoff and Phase 2 with a scripted handoff process. Data collected by trained observers included handoff attendance, distractions, and transfer of essential patient information. As a surrogate for outcomes, patient care parameter data were collected for 6 hours after transfer. After phase 1, surgery and ICU physician attendance increased significantly, distractions decreased, and communication of essential patient data improved. In phase 2 (scripted handoff), attendance continued to rise, distractions remained decreased, and transfer of essential information was still improved compared with baseline. Mean handoff duration did not significantly change throughout the study. Certain patient care parameters (escalation of respiratory support, additional laboratory studies, vasopressor administration, antibiotic administration and timing) remained unchanged compared with baseline. However, the need for resuscitative fluid bolus or blood products significantly decreased after implementation phase 2. Standardized handoffs for pediatric noncardiac surgical patients from the OR to the ICU can improve provider attendance and communication.

A pilot study to determine the incidence, type, and severity of non-routine events in neonates undergoing gastrostomy tube placement

BackgroundNon-routine events (NRE) are defined as any suboptimal occurrences in a process being measured in the opinion of the reporter and comes from the field of human factors engineering. These typically occur well up-stream of an adverse event and NRE measurement has not been applied to the complex context of neonatal surgery. We sought to apply this novel safety event measurement methodology to neonates in the NICU undergoing gastrostomy tube placement. MethodsA prospective pilot study was conducted between November 2016 and August 2020 in the Level IV NICU and the pediatric operating rooms of an urban academic children's hospital to determine the incidence, severity, impact, and contributory factors of clinician-reported non-routine events (NREs, i.e., deviations from optimal care) and 30-day NSQIP occurrences in neonates receiving a G-tube. ResultsClinicians reported at least one NRE in 32 of 36 (89%) G-tube cases, averaging 3.0 (Standard deviation: 2.5) NRE reports per case. NSQIP-P review identified 7 cases (19%) with NSQIP-P occurrences and each of these cases had multiple reported NREs. One case in which NREs were not reported was without NSQIP-P occurrences. The odds ratio of having a NSQIP-P occurrence with the presence of an NRE was 0.695 (95% CI 0.06–17.04). ConclusionDespite being considered a "simple" operation, >80% of neonatal G-tube placement operations had at least one reported NRE by an operative team member. In this pilot study, NRE occurrence was not significantly associated with the subsequent reporting of an NSQIP-P occurrence. Understanding contributory factors of NREs that occur in neonatal surgery may promote surgical safety efforts and should be evaluated in larger and more diverse populations. Level of evidenceIV

Wound Classification Score Discordance in Pediatric Operations - A Quality Improvement Study

Wound classification scores are used to categorize the risk of postoperative infections. It was noted at our academic institution that wound classifications were often inaccurately recorded in the electronic health record. We thus instituted a quality improvement program, hypothesizing that this would improve charting accuracy. On June 1, 2019, we posted the wound classifications in each pediatric operating room (OR), provided OR nurses with teaching, and began including the classification in the postoperative surgeon debriefing. We performed a retrospective chart review of all general pediatric operations from June 19 to December 19 to compare classifications recorded in the electronic health record to the "correct" classification determined by manual review of operating reports. These data were compared with a similar chart review from 2018. To compare the efficacy of nursing versus physician focused changes, we compared our appendectomy data with a nearby community institution where the same group of surgeons practice. Pearson's Chi-squared test was used to report the significance of the differences observed in the concordance proportion, with 95% confidence intervals calculated using the Clopper-Pearson procedure. Overall, 444 pre- and 179 postpractice change charts were reviewed. There were no significant differences pre or postpractice change. At the community institution, we noted a significant improvement in charting accuracy for appendectomies from 3.33% to 44.83%. Despite implementing nursing and physician focused quality improvement practices, there was not a significant improvement in charting accuracy at the academic institution. However, we did note an improvement at the community facility where our pediatric surgeons also practice. We thus suspect that our nursing focused changes may have been inadequate. Future efforts will focus on providing intensive and sustained OR nurse training to help improve the wound classification charting accuracy.