Reframing Surgical Care: Understanding Complexity and Promoting Teaming.

Reframing healthcare delivery in terms of the principles of complex adaptive systems has practical implications for addressing the challenges in improving surgical care. In an Integrated Practice Unit (IPU) - such as a surgical service line, a surgical in-patient floor, or an acute care unit - a diverse group of caregivers must interact in a highly interdependent fashion in an environment characterized by ambiguity, uncertainty, and time constraints. Understanding of the concept of teaming and the tenets of relational coordination are crucial to the promotion of a successful patient-centric approach to surgical care.

The impact of children's hospital designation on outcomes in children with malrotation.

BACKGROUND: The benefit of Ladd's procedure for malrotation at a Children's Hospital (CH) has not previously been established. Our aim was to characterize the potential variations in management and outcomes between CH and Non-Children's Hospitals (NCH) in the treatment of malrotation with Ladd's procedure. METHODS: There were 2827 children identified with malrotation and complete information from the Kids' Inpatient Database (2003, 2006, 2009). Outcomes were compared between CH and NCH and evaluated with logistic and linear regressions. Additional propensity score matching was used to balance covariates between CH and NCH. RESULTS: There were 2261 (80.0%) children with malrotation undergoing Ladd's procedures treated at CH; 566 (20.0%) were treated at NCH. In multivariate analysis, CH was associated with a 39% lower odds of resection (p=0.004), with no differences observed for mortality, morbidity and LOS. Comparison of a propensity score matched cohort confirmed these findings, as well as demonstrated no significant differences in associated costs. CONCLUSIONS: The majority of pediatric intestinal malrotation is managed at CH. While measured outcomes of mortality, morbidity, LOS, and costs were not different at NCH, CH was less likely to perform intestinal resection during Ladd's procedure.

Endobronchial occlusion with one-way endobronchial valves: a novel technique for persistent air leaks in children.

PURPOSE: In children, persistent air leaks can result from pulmonary infection or barotrauma. Management strategies include surgery, prolonged pleural drainage, ventilator manipulation, and extracorporeal membrane oxygenation (ECMO). We report the use of endobronchial valve placement as an effective minimally invasive intervention for persistent air leaks in children. METHODS: Children with refractory prolonged air leaks were evaluated by a multidisciplinary team (pediatric surgery, interventional pulmonology, pediatric intensive care, and thoracic surgery) for endobronchial valve placement. Flexible bronchoscopy was performed, and air leak location was isolated with balloon occlusion. Retrievable one-way endobronchial valves were placed. RESULTS: Four children (16 months to 16 years) had prolonged air leaks following necrotizing pneumonia (2), lobectomy (1), and pneumatocele (1). Patients had 1-4 valves placed. Average time to air leak resolution was 12 days (range 0-39). Average duration to chest tube removal was 25 days (range 7-39). All four children had complete resolution of air leaks. All were discharged from the hospital. None required additional surgical interventions. CONCLUSION: Endobronchial valve placement for prolonged air leaks owing to a variety of etiologies was effective in these children for treating air leaks, and their use may result in resolution of fistulae and avoidance of the morbidity of pulmonary surgery.

Determinants of 30-d readmission after colectomy.

BACKGROUND: Readmission after colectomy has become an important metric for measuring quality of care. Our aim was to investigate the impact of patient and hospital characteristics on 30-d readmission rates among patients undergoing colectomies in Pennsylvania. METHODS: Data were obtained from the Pennsylvania Health Care Cost Containment Council, which included all patients undergoing colectomy during 2011 (n = 10,155). Characteristics of non-readmitted and readmitted patients were compared with univariate tests. The primary outcome was 30-d readmission, which was modeled using multivariable logistic regression. RESULTS: Of the 10,155 patients who underwent colectomy, 1492 (14.7%) were readmitted within 30 d of discharge. Readmission was influenced by the underlying diagnosis (P < 0.001). Additionally, readmission was more likely with a Charlson comorbidity index ≥ 2 (odds ratio [OR] = 1.57, P < 0.001), emergent admission (OR = 1.26, P = 0.001), an in-hospital complication (OR = 1.46, P < 0.001), lowest quartile for surgeon volume (OR = 1.24, P = 0.01), and construction of an ileostomy (OR = 2.31, P < 0.001). Factors associated with decreased likelihood of readmission included laparoscopic surgery (OR = 0.73, P < 0.001). No association with hospital volume was found. CONCLUSIONS: A 30-d readmission after colectomy is influenced by numerous patient- and surgeon-related factors. Reducing in-hospital complications, and improving patient education after ileostomy construction, provide substantial targets for intervention. Our data also suggest that there may be a critical range of colectomies performed annually by surgeons, greater than which no additional benefit is conferred in reducing readmissions, but below which there is an increased risk of readmission. Further research is needed to determine the influence of laparoscopic surgery in reducing readmission in equally matched patient populations.

Valuing the subsurface pathogen treatment barrier in water recycling via aquifers for drinking supplies.

A quantitative microbial risk assessment (QMRA) was performed at four managed aquifer recharge (MAR) sites (Australia, South Africa, Belgium, Mexico) where reclaimed wastewater and stormwater is recycled via aquifers for drinking water supplies, using the same risk-based approach that is used for public water supplies. For each of the sites, the aquifer treatment barrier was assessed for its log(10) removal capacity much like for other water treatment technologies. This information was then integrated into a broader risk assessment to determine the human health burden from the four MAR sites. For the Australian and South African cases, managing the aquifer treatment barrier was found to be critical for the schemes to have low risk. For the Belgian case study, the large treatment trains both in terms of pre- and post-aquifer recharge ensures that the risk is always low. In the Mexico case study, the risk was high due to the lack of pre-treatment and the low residence times of the recharge water in the aquifer. A further sensitivity analysis demonstrated that human health risk can be managed if aquifers are integrated into a treatment train to attenuate pathogens. However, reduction in human health disease burden (as measured in disability adjusted life years, DALYs) varied depending upon the number of pathogens in the recharge source water. The beta-Poisson dose response curve used for translating rotavirus and Cryptosporidium numbers into DALYs coupled with their slow environmental decay rates means poor quality injectant leads to aquifers having reduced value to reduce DALYs. For these systems, like the Mexican case study, longer residence times are required to meet their DALYs guideline for drinking water. Nevertheless the results showed that the risks from pathogens can still be reduced and recharging via an aquifer is safer than discharging directly into surface water bodies.