INTRODUCTION: To illustrate how quality improvement can produce unexpected positive outcomes. METHODS: We compared a retrospective review of perioperative management and outcomes of baseline 122 pediatric total thyroidectomies to 121 subsequent total thyroidectomies managed by an Electronic Medical Record protocol in a large, free-standing children's healthcare system. Process measures included serum calcium measurement 6-12 hours postoperatively; parathyroid hormone measurement 6 hours postoperatively; preoperative iodine for Graves disease, and postoperative prophylactic calcium carbonate administration. In addition, we completed 4 Plan-Do-Study-Act (PDSA) cycles, focusing on implementation, refinement, usage, education, and postoperative calcitriol administration. The primary outcome included transient hypocalcemia during admission. RESULTS: All perioperative process measures improved over PDSA cycles. Measurement of postoperative serum calcium increased from 42% at baseline to 100%. Measurement of postoperative PTH increased from 11% to 97%. Preoperative iodine administration for Graves disease surgeries improved from 72% to 94%. Postoperative calcium carbonate administration increased from 36% to 100%. There was a trend toward lower rates of severe hypocalcemia during admission over the subsequent PDSA cycles starting at 11.6% and improving to 3.4%. With the regular review of outcomes, surgical volume consolidated among high-volume providers, associated with a decrease in a permanent hypoparathyroid rate of 20.5% at baseline to 10% by the end of monitoring. CONCLUSIONS: In standardizing care at 1 large pediatric institution, implementing a focused quality improvement project involving the perioperative management of transient hypocalcemia in total thyroidectomy pediatric patients resulted in additional, unanticipated improvements in patient care.

Background: The majority of opioid overdose admissions in pediatric patients are associated with prescription opioids. Post-operative prescriptions are an addressable source of opioids in the household. This study aims to assess for sustained reduction in opioid prescribing after implementation of provider-based education at nine centers. Methods: Opioid prescribing information was collected for pediatric patients undergoing umbilical hernia repair at nine centers between December 2018 and January 2019, one year after the start of an education intervention. This was compared to prescribing patterns in the immediate pre- and post-intervention periods at each of the nine centers. Results: In the current study period, 29/127 (22.8%) patients received opioid prescriptions (median 8 doses) following surgery. There were no medication refills, emergency department returns or readmissions related to the procedure. There was sustained reduction in opioid prescribing compared to pre-intervention (22.8% vs 75.8% of patients, p<0.001, Fig. (1). Five centers showed statistically significant improvement and the other four demonstrated decreased prescribing, though not statistically significant. Conclusions: Our multicenter study demonstrates sustained reduction in opioid prescribing after pediatric umbilical hernia repair after a provider-based educational intervention. Similar low-fidelity provider education interventions may be beneficial to improve opioid stewardship for a wider variety of pediatric surgical procedures. Levels of evidence: (treatment study)-level 3

Introduction: Gastrostomy tube (GT) placement is one of the most common operations performed in children, and it is plagued by high complication rates. Previous studies have shown variation in readmission and emergency room visit rates across different children's hospitals, with both low and high outliers. There is an opportunity to learn how to optimize outcomes by identifying practices at high-performing institutions. Methods: Surgeons and nurses routinely involved in GT care at 8 high-performing pediatric centers were identified. We conducted structured interviews focusing on the approach to GT education, technical aspects of GT placement, and postoperative management. Summary statistics were performed on quantitative data, and the open-ended responses were analyzed by 2 independent reviewers using content analysis. Results: Several common practices among high-performing centers were identified (standardized approach to education, availability by phone and in clinic to manage GT-related issues, and empowering families to feel confident with troubleshooting and dealing with GT problems). There was substantial variation in operative technique and postoperative care. The participants expressed that technical aspects of operative placement and postoperative management of feedings and common complications are not as important as education, availability, and empowerment in optimizing outcomes. Conclusions: We have identified common themes among pediatric centers with favorable outcomes after GT placement. Identifying which components of GT care are associated with optimal outcomes is critical to our understanding of current practice and may help identify opportunities to improve care quality.

Objective Our aim was to implement a standardized US report that included secondary signs of appendicitis (SS) to facilitate accurate diagnosis of appendicitis and decrease the use of computed tomography (CT) and admissions for observation. Methods A multidisciplinary team implemented a quality improvement (QI) intervention in the form of a standardized US report and provided stakeholders with monthly feedback. Outcomes including report compliance, CT use, and observation admissions were compared pretemplate and posttemplate. Results We identified 387 patients in the pretemplate period and 483 patients in the posttemplate period. In the posttemplate period, the reporting of SS increased from 5.4% to 79.5% (p < 0.001). Despite lower rates of appendix visualization (43.9% to 32.7%, p < 0.001) with US, overall CT use (8.5% vs 7.0%, p = 0.41) and the negative appendectomy rate remained stable (1.0% vs 1.0%, p = 1.0). CT utilization for patients with an equivocal ultrasound and SS present decreased (36.4% vs 8.9%, p = 0.002) and admissions for observations decreased (21.5% vs 15.3%, p = 0.02). Test characteristics of RLQ US for appendicitis also improved in the posttemplate period. Conclusion A focused QI initiative led to high compliance rates of utilizing the standardized US report and resulted in lower CT use and fewer admissions for observation. Study of a Diagnostic Test Level of Evidence: 1.

Introduction: Ultrasound (US) is the preferred imaging modality for evaluating appendicitis. Our purpose was to determine if including secondary signs (SS) improve diagnostic accuracy in equivocal US studies. Methods: Retrospective review identified 825 children presenting with concern for appendicitis and with a right lower quadrant (RLQ) US. Regression models identified which SS were associated with appendicitis. Test characteristics were demonstrated. Results: 530 patients (64%) had equivocal US reports. Of 114 (22%) patients with equivocal US undergoing CT, those with SS were more likely to have appendicitis (48.6% vs 14.6%, p  <  0.001). Of 172 (32%) patients with equivocal US admitted for observation, those with SS were more likely to have appendicitis (61.0% vs 33.6%, p  <  0.001). SS associated with appendicitis included fluid collection (adjusted odds ratio (OR) 13.3, 95% confidence interval (CI) 2.1–82.8), hyperemia (OR = 2.0, 95%CI 1.5–95.5), free fluid (OR = 9.8, 95%CI 3.8–25.4), and appendicolith (OR = 7.9, 95%CI 1.7–37.2). Wall thickness, bowel peristalsis, and echogenic fat were not associated with appendicitis. Equivocal US that included hyperemia, a fluid collection, or an appendicolith had 96% specificity and 88% accuracy. Conclusion: Use of SS in RLQ US assists in the diagnostic accuracy of appendicitis. SS may guide cl inicians and reduce unnecessary CT and admissions.