Preliminary Evaluation of a Novel Rigid Bronchoscopy Simulator.

PURPOSE: Emergent retrieval of airway foreign bodies (AFBs) in children remains a priority skill set for pediatric surgeons. In the setting of low procedural volume, simulation-based education with deliberate practice is essential to ensure trainees reach expected surgical competency. The purposes of this work were to (1) create a realistic rigid bronchoscopy for AFB retrieval simulation model and (2) to evaluate preliminary validity evidence of a novel simulator for the use of training and assessing pediatric surgical trainees' rigid bronchoscopy skills. METHODS: After institutional review board exemption determination, 18 participants performed AFB retrieval of two different objects on a novel simulator that represented an 18-month-old pediatric tracheobronchial airway. Participants reported their experience and comfort level, and rated the simulator across two domains-Authenticity and their Ability to perform tasks. Authenticity was measured by 23 items across five subdomains (Visual Attributes, Materials' Response, Realism of Experience, Value and Relevance, and Global Value). Participants who had previously performed ≥10 rigid bronchoscopies were categorized as "experienced," while those reporting <10 were considered "novice." Validity evidence relevant to test content and internal structure was evaluated using a many-facet Rasch model. RESULTS: Novice surgeons (n = 12) had previously performed a mean of 2.7 (±2.0) rigid bronchoscopies, compared to 15.4 (±7.7) by experienced surgeons (n = 6). For both models, the Value and Relevance subdomain received the highest ratings (observed average [OA] = 3.9, while Materials' Response received the lowest (OA <3.0). Participants' Global Value rating for this model was consistent with "requires minor improvements before it can be considered for use in rigid bronchoscopy training." CONCLUSIONS: We successfully designed, assembled, and evaluated a novel pediatric rigid bronchoscopy model for AFB retrieval. The model was considered as relevant to educational needs and valuable as a testing and training tool. With recommended improvements, the model could be used for implementation with a Mastery Learning curriculum.

Regionalization of Pediatric Surgery: Trends Already Underway.

INTRODUCTION: This study aims to characterize the delivery of pediatric surgical care based on hospital volume stratified by disease severity, geography, and specialty. Longitudinal regionalization over the 10-year study period is noted and further explored. METHODS: The Kids' Inpatient Database (KID) was queried from 2000 to 2009 for patients <18 years undergoing noncardiac surgery. Hospitals nationwide were grouped into commutable regions and identified as high-volume centers (HVCs) if they had more than 1000 weighted procedures per year. Regions that had at least one HVC and one or more additional lower volume center were included for analysis. Low-risk, high-risk neonatal, and surgical subspecialties were analyzed separately. RESULTS: A total of 385,242 weighted pediatric surgical admissions in 33 geographical regions and 224 hospitals were analyzed. Overall, HVCs comprised 33 (14.7%) hospitals, medium-volume center (MVC) 33 (14.7%), and low-volume center (LVC) 158 (70.5%). The four low-risk procedures analyzed were increasingly regionalized: appendectomy (52% in HVCs in 2000 to 60% in 2009, P < 0.001), fracture reduction (63% to 68%, P < 0.001), cholecystectomy (54% to 63%, P < 0.001), and pyloromyotomy (65% to 85%, P < 0.001). Neonatal surgery showed significant regionalization trends for tracheoesophageal fistula (66% to 87%, P < 0.001) and gastroschisis (76% to 89%, P < 0.001). CONCLUSIONS: This is the first large-scale, multi-region analysis to demonstrate that pediatric surgical care has transitioned to HVCs over a recent decade, particularly for low-risk patients. It is important for practitioners and policymakers alike to understand such volume trends in order to ensure hospital capacity while maintaining an optimal quality of care.

Improving surgical care for children through multicenter registries and QI collaboratives.

The role of the healthcare organization is shifting and must overcome the challenges of fragmented, costly care, and lack of evidence in practice, to reduce cost, ensure quality, and deliver high-value care. Notable gaps exist within the expected quality and delivery of pediatric healthcare, necessitating a change in the role of the healthcare organization. To realize these goals, the use of collaborative networks that leverage massive datasets to provide information for the development of learning healthcare systems will become increasingly necessary as efforts are made to narrow the gap in healthcare quality for children. By building upon the lessons learned from early collaborative efforts and other industries, operationalizing new technologies, encouraging clinical-community partnerships, and improving performance through transparent pursuit of meaningful goals, pediatric surgery can increase the adoption of best practices by developing collaborative networks that provide evidence-based clinical decision support and accelerate progress toward a new culture of delivering high-quality, high-value, and evidenced-based pediatric surgical care.