Stepwise training program: A novel practice schedule for laparoscopic suturing.

Purpose: We establish stepwise training program in which laparoscopic suturing is broken down to discrete steps. The purpose is to evaluate the learning outcomes of stepwise training program. Materials and methods: Volunteer participants were enrolled from medical students and surgical trainees. Students took two courses of 2-h stepwise training, and a post-course (1st & 2nd) test was taken after each course; trainees took one course of stepwise training with a pre-course (1st) and a post-course (2nd) test. Attending surgeons took the test as control. Learning outcomes were assessed with laparoscopic suturing competency assessment tool (LS-CAT) and suturing time. Results: There were 10 students, 8 trainees and 6 surgeon controls. Suturing time and LS-CAT scores significantly improved between the 1st and 2nd test (p < 0.01). In the both tests, suturing time and LS-CAT scores of students and trainees were similar. In the 1st test, surgeons had significantly better performance in suturing time and LS-CAT score than students and trainees; in the 2nd test, the LS-CAT scores of students and trainees were similar to the surgeon controls. Conclusions: Stepwise program effectively enhances laparoscopic suturing skill for medical students and surgical trainees. Catch-up effect was demonstrated in medical students with stepwise training.

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

BACKGROUND: 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. METHODS: 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. RESULTS: 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%. DISCUSSION: 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.

The role of ECMO in the management of congenital diaphragmatic hernia.

Congenital diaphragmatic hernia (CDH) is the most common indication for extra-corporeal membrane oxygenation (ECMO) for neonatal respiratory failure. CDH management is evolving with advanced prenatal diagnostic imaging modalities. The risk profiles of infants receiving ECMO for CDH are shifting towards higher risk. Many clinicians are developing and following clinical practice guidelines to standardize and optimize the care of CDH neonates. Despite these efforts, there are significant differences in the practice patterns among ECMO centers as to how and when they choose to initiate ECMO for CDH, when they believe repair is safe, as well as many other nuances that are based on center experience or style. The purpose of this report is to summarize our current understanding of the new and recent developments regarding management of infants with CDH managed with ECMO.

Differences in Outcomes Based on Sex for Pediatric Patients Undergoing Pyloromyotomy.

BACKGROUND: Males and females are known to have varied responses to medical interventions. Our study aimed to determine the effect of sex on surgical outcomes after pyloromyotomy. MATERIALS AND METHODS: Using the Kids' Inpatient Database for the years 2003-2012, we performed a serial, cross-sectional analysis of a nationally representative sample of all patients aged <1 y who underwent pyloromyotomy for hypertrophic pyloric stenosis. The primary predictor of interest was sex. Outcomes included mortality, in-hospital complications, cost, and length of stay. Regression models were adjusted by race, age group, comorbidity, complications, and whether operation was performed on the day of admission with region and year fixed effects. RESULTS: Of 48,834 weighted operations, 81.8% were in males and 18.2% were in females. The most common reported race was white (47.3%) and most of the patients were ≥29 days old (72.5%). There was no difference in the odds of postoperative complications, but females had a significantly longer length of stay (incidence rate ratio, 1.28; 95% confidence interval [95% CI], 1.18-1.39; P ≤ 0.01), higher cost (5%, 95% CI, 1.02-1.08; P ≤ 0.01), and higher odds of mortality (odds ratio, 3.26; 95% CI, 1.52-6.98; P ≤ 0.01). CONCLUSIONS: Our study demonstrated that females had worse outcomes after pyloromyotomy compared with males. These findings are striking and are important to consider when treating either sex to help set physician and family expectations perioperatively. Further studies are needed to determine why such differences exist and to develop targeted treatment strategies for both females and males with pyloric stenosis.

Attitudes and Beliefs of Pediatric Surgical Specialists on Costs of Care and High Deductible Health Plans.

Health care consumers are burdened with rising out-of-pocket medical expenses. Surgical specialists' experience and attitude towards patients' out-of-pocket costs and the influence of these factors on healthcare utilization are unknown. Our aim was to define the pediatric surgeons' experience with the financial concerns of their patients. Members from the American Academy of Pediatrics Sections on Plastic Surgery, Surgery and Urology were surveyed. Analysis of variance was used to investigate practice differences. Two hundred and eighteen out of 973 surgeons representing 38 states completed the survey. Nearly half of the surveyed surgeons did not know if cost was a determinant for their patients' choice in surgical facility, or if parents compared costs prior to the visit. Eighty four per cent of the surgeons would consider patient costs if medically appropriate, to entertain less costly alternatives, and adjust surgical scheduling to decrease economic burden. Most pediatric surgical specialists are unaware if out-of-pocket costs influenced patients' preoperative decisions. Nonetheless, they are sympathetic to the issue. As the financial burden of health care shifts to consumers, our survey indicates that surgeons are open to candid discussion surrounding finances and may alter recommendations accordingly if appropriate.

Population-Based Validation of a Clinical Prediction Model for Congenital Diaphragmatic Hernias.

OBJECTIVE: To examine the external validity of a well-known congenital diaphragmatic hernia (CDH) clinical prediction model using a population-based cohort. STUDY DESIGN: Newborns with CDH born in California between 2007 and 2012 were extracted from the Vital Statistics and Patient Discharge Data Linked Files. The total CDH risk score was calculated according to the Congenital Diaphragmatic Hernia Study Group (CDHSG) model using 5 independent predictors: birth weight, 5-minute Apgar, pulmonary hypertension, major cardiac defects, and chromosomal anomalies. CDHSG model performance on our cohort was validated for discrimination and calibration. RESULTS: A total of 705 newborns with CDH were extracted from 3 213 822 live births. Newborns with CDH were delivered in 150 different hospitals, whereas only 28 hospitals performed CDH repairs (1-85 repairs per hospital). The observed mortality for low-, intermediate-, and high-risk groups were 7.7%, 34.3%, and 54.7%, and predicted mortality for these groups were 4.0%, 23.2%, and 58.5%. The CDHSG model performed well within our cohort with a c-statistic of 0.741 and good calibration. CONCLUSIONS: We successfully validated the CDHSG prediction model using an external population-based cohort of newborns with CDH in California. This cohort may be used to investigate hospital volume-outcome relationships and guide policy development.

Complications of pediatric cholecystectomy: impact from hospital experience and use of cholangiography.

BACKGROUND: Complications after cholecystectomy in children are poorly characterized. The aim of this study was to assess risk factors for major surgical complications for children undergoing cholecystectomy. STUDY DESIGN: All children 4 to 18 years old with gallbladder disease who underwent cholecystectomy from 1999 to 2006 were identified from the California Patient Discharge Database. Patient, hospital, and surgical factors were analyzed using multivariate logistic regression analysis to identify factors predictive of bile duct injury (BDI) and postoperative ERCP. RESULTS: A cohort of 6,931 children treated at 360 hospitals was evaluated. Most children underwent cholecystectomy at a non-children's hospital (84%). Intraoperative cholangiogram (IOC) was performed in 2,053 (30%) children. Of 5,101 children tracked through the year after cholecystectomy, 153 (3%) required readmission for surgical complications. Bile duct injury occurred in 25 (0.36%) children, and postoperative ERCP was performed in 711 (10%) children. Older age (odds ratio = 0.80; 99% CI, 0.67-0.95) was associated with decreased risk of BDI. Increased hospital tendency for routine IOC use was associated with increased likelihood of BDI (odds ratio = 12.92; 99% CI, 1.31-127.15). Receiving surgical care at a children's hospital was associated with a decreased likelihood of postoperative ERCP (odds ratio = 0.39; 99% CI, 0.23-0.66). As anticipated, choledocholithiasis, cholecystitis, IOC, and laparoscopic cholecystectomy were associated with increased risk of postoperative ERCP (p < 0.01). CONCLUSIONS: Serious complications and readmissions from pediatric cholecystectomy are uncommon. Surgeons performing cholecystectomy in young children must have an elevated concern about BDI. Routine IOC or surgical volume might not be helpful in lowering BDI rates.

Hospital type as a metric for racial disparities in pediatric appendicitis.

BACKGROUND: Appendiceal perforation (AP) is a marker of health care disparities. We propose that racial disparities in children, as measured by AP, may change according to the type of hospital in which a child receives care. STUDY DESIGN: Children 2 to 18 years old, with appendicitis diagnosed from 1999 to 2007, were retrospectively reviewed from the California Patient Discharge Dataset and sorted by community, children's, and county hospitals. Risk of AP within and between hospital types was analyzed with multivariate logistic regression controlling for hospital and patient level factors. RESULTS: Overall, 107,727 children (white, 36%; Hispanic, 53%; black, 3%; Asian, 5%; other, 8%) were treated at 386 California hospitals (community, 74%; children's, 17%; county, 10%). Hispanic (odds ratio [OR] 1.23, 99% CI 1.16 to 1.32) and Asian (OR 1.34, 99% CI 1.19 to 1.52) children treated at community hospitals experienced increased risk of AP compared with white children. Hispanic children cared for at children's hospitals also exhibited increased odds of AP (OR 1.18, 99% CI 1.05 to 1.33). Odds of AP did not differ by race within county hospitals. When comparing AP risk between hospital types, black children treated at county (OR 1.12, 99% CI 0.90 to 1.38) and children's (OR 2.01, 99% CI 1.18 to 3.42) hospitals exhibited increased odds of AP compared with black children treated at community hospitals. CONCLUSIONS: These results underscore differential patterns of AP at the hospital level and deserve immediate attention because they may reflect far larger disparities in access and quality of care for children in California. Future interventions aimed at eliminating racial disparities in children must account for racial differences in access to timely diagnostic and surgical intervention for rapidly progressive and preventable clinical conditions such as AP.

Postoperative complications and health care use in children undergoing surgery for ulcerative colitis.

OBJECTIVES: Medical and surgical approaches toward children with ulcerative colitis (UC) vary and have differing implications for health care use. The goal of this study was to define hospital use and complications for children with UC before and after staged restorative proctocolectomy. PATIENTS AND METHODS: A retrospective study of the California Patient Discharge Dataset from 1999 to 2007 of children aged 2 to 18 years with UC who underwent colectomy was performed (N = 218). Surgical staging was determined alongside hospital type (children's vs non-children's) and surgical case volume. Postoperative complications and hospital length of stay were analyzed using multivariate regression. RESULTS: The cohort was mostly male (56%) and white (80%), had private insurance (78%), and underwent colectomy at a children's hospital (62%). Overall, 65% required a separate hospital admission before admission for colectomy. Single-, 2-, and 3-stage procedures were performed in 19 (9%), 144 (66%), and 38 (17%) children. The mean admissions per patient were 1.8 ± 2.4 before colectomy and 0.7 ± 1.6 after surgical completion. Surgical complications occurred in 100 (49%) children, with 39% being attributed to postoperative infection. Children with public insurance (odds ratio, 2.18; 95% confidence interval, 1.0-4.85) and those who underwent colectomy at a non-children's hospital (odds ratio, 2.53; 95% confidence interval, 1.0-6.37) had increased likelihood of surgical complications. Finally, nonwhite race, surgical staging, and undergoing colectomy at a low- or medium-volume hospital resulted in prolonged hospitalization (P < .05). CONCLUSIONS: Children with UC who undergo colectomy use a large number of hospital resources before surgery and exhibit decreased hospital use after surgical completion. Children undergoing colectomy at children's and high-volume hospitals experience fewer surgical complications and shorter hospitalization.

Hospital type predicts surgical complications for infants with hypertrophic pyloric stenosis.

Pyloromyotomy is a common surgery performed for hypertrophic pyloric stenosis at community and children's hospitals. To determine hospital-level factors that may affect clinical outcomes, infants requiring pyloromyotomy from 1999 to 2007 (n=8379) were retrospectively reviewed from the California linked birth cohort data set. Hospital case volume and type (community, children's, adult hospital with children's unit) were examined. Surgical complications, prolonged length of stay (LOS), and 30-day readmission were analyzed with multivariate logistic regression. Overall, surgical complications occurred in 166 (2%) infants, 35 (21%) after discharge. Readmission occurred in 285 (3.4%) infants with 69 (24%) admitted to hospitals that did not perform the initial surgery. Infants treated at community hospitals (odds ratio [OR], 2.1; 95% confidence interval [CI], 1.1 to 4.0) experienced an increased likelihood of surgical complications. Odds of surgical complications did not vary by hospital case volume. Prolonged LOS was increased at community hospitals (OR, 1.7; 95% CI, 1.2 to 2.3), low- (OR, 2.1; 95% CI, 1.3 to 3.4), and medium-volume (OR, 1.6; 95% CI, 1.0 to 2.7) hospitals. Hospital type and volume did not impact 30-day readmission. In conclusion, specialized surgical care for infants administered at pediatric centers appears to influence pyloromyotomy complications more than hospital case volume. Institutional components contributing to improved outcomes in specialty centers warrant further investigation.

Does hospital transfer predict mortality in very low birth weight infants requiring surgery for necrotizing enterocolitis?

BACKGROUND: Necrotizing enterocolitis (NEC) is a leading cause of infant mortality, and the most common reason for emergent surgery in very low birth weight (VLBW, < 1,500 g) infants. We investigated whether transfer for higher level of surgical care affects mortality in this population. METHODS: VLBW infants who underwent NEC surgery were reviewed retrospectively from the California Patient Discharge Linked Birth Cohort Database (1999-2007). Transfer for emergent operation was defined as surgery ≤2 days after transfer. Mortality was analyzed with multivariate logistic regression. RESULTS: Overall, 1,272 VLBW infants with surgical NEC were identified, with a 39% mortality. Transfer for operative care occurred in 406 (32%) infants. Unadjusted mortality was not increased for infants who were transferred compared with not transferred (37% vs. 40%; P = .25). Adjusted mortality for infants transferred for operative care did not differ from those who received operative care at their primary neonatal intensive care unit (odds ratio 0.75, 95% confidence interval 0.42-1.32). Lower birth weight, lack of prenatal care, peritoneal drainage as sole surgical intervention, and pulmonary interstitial emphysema/pulmonary hemorrhage were associated with increased odds of mortality (P < .05). CONCLUSION: VLBW infants with surgical NEC do not demonstrate increased risk of mortality when transferred emergently for operative care. Future efforts must engage health professionals caring for this vulnerable population to maximize resource allocation and safety.

Predictors of proctocolectomy in children with ulcerative colitis.

OBJECTIVES: Few clinical predictors are associated with definitive proctocolectomy in children with ulcerative colitis (UC). The purpose of the present study was to identify clinical predictors associated with surgery in children with UC using a disease-specific database. METHODS: Children diagnosed with UC at age <18 years were identified using the Pediatric Inflammatory Bowel Disease Consortium (PediIBDC) database. Demographic and clinical variables from January 1999 to November 2003 were extracted alongside incidence and surgical staging. RESULTS: Review of the PediIBDC database identified 406 children with UC. Approximately half were girls (51%) with an average age at diagnosis of 10.6 ±â€Š4.4 years in both boys and girls. Average follow-up was 6.8 (±4.0) years. Of the 57 (14%) who underwent surgery, median time to surgery was 3.8 (interquartile range 4.9) years after initial diagnosis. Children presenting with weight loss (hazard ratio [HR] 2.55, 99% confidence interval [CI] 1.21-5.35) or serum albumin <3.5 g/dL (HR 6.05, 99% CI 2.15-17.04) at time of diagnosis and children with a first-degree relative with UC (HR 1.81, 99% CI 1.25-2.61) required earlier surgical intervention. Furthermore, children treated with cyclosporine (HR 6.11, 99% CI 3.90-9.57) or tacrolimus (HR 3.66, 99% CI 1.60-8.39) also required earlier surgical management. Other symptoms, laboratory tests, and medical therapies were not predictive for need of surgery. CONCLUSION: Children with UC presenting with hypoalbuminemia, weight loss, a family history of UC, and those treated with calcineurin inhibitors frequently require restorative proctocolectomy for definitive treatment. Early identification and recognition of these factors should be used to shape treatment goals and initiate multidisciplinary care at the time of diagnosis.

Outcomes of bariatric surgery in adolescents.

PURPOSE OF REVIEW: The review summarizes the recent studies of bariatric surgery outcomes in adolescents. RECENT FINDINGS: Randomized prospective studies demonstrate superior weight loss, resolution of comorbidities, and improvement in quality of life in morbidly obese adolescents undergoing bariatric surgery vs. lifestyle changes alone. The enthusiasm for laparoscopic adjustable banding (LAGB) has been tempered by high reoperation rates. Laparoscopic sleeve gastrectomy (LSG) is a promising procedure for adolescents because it avoids intestinal bypass and implantation of a foreign body; recent data from adult series demonstrate mid-term results comparable with laparoscopic roux-en-y gastric bypass (LRYGB) with an improved safety profile. SUMMARY: Bariatric surgery is superior to lifestyle changes alone in treating adolescent morbid obesity. LRYGB remains the gold-standard operation for both adolescents and adults. Although LAGB and LSG are appealing because they avoid intestinal bypass, long-term studies are needed to fully evaluate their efficacy and safety in the adolescent population.

Closing the gap between insecticide treated net ownership and use for the prevention of malaria.

BACKGROUND: Malaria is the leading cause of morbidity and mortality in children younger than 5 years old and pregnant women in sub-Saharan Africa. Insecticide-treated nets (ITNs) reduce clinical malaria by more than 50% and all cause mortality in young children by 15% to 30%. However, use of these nets is poor across sub-Saharan Africa, limiting the potential impact of this effective tool in the fight against malaria. OBJECTIVE: We sought to improve the use of ITNs using a community-created and -implemented approach, and measure the change in ITN use over the year after implementation. METHODS: Using a community-based participatory research approach, we created and implemented an intervention to improve ITN use in a rural village. Our intervention involved providing hands-on instructions and assistance in hanging of nets, in-home small group education, and monthly follow-up by trained community members. ITN use was measured for all individuals in a subset of the community (61 households, 759 individuals) at baseline and at 6 months and 1 year after distribution. RESULTS: Rates of individual usage increased significantly from 29% at baseline to 88.7% (p < .001) at 6 months and to 96.6% (p < .001) at 12 months. For children under age 5, usage rates increased from 46% at baseline to 95.7% (p < .001) at 6 months and 95.4% (p < .001) at 12 months. CONCLUSION: Our study demonstrates that rapidly achieving and sustaining almost universal ITN usage rates is possible using a community-based approach. Closing the gap between ITN ownership and use will help communities to realize the full potential of ITNs in the prevention of malaria.

Trends and outcomes of adolescent bariatric surgery in California, 2005-2007.

OBJECTIVE: The goal of this study was to evaluate trends, and outcomes of adolescents who undergo bariatric surgery. PATIENTS AND METHODS: Patients younger than 21 years who underwent elective bariatric surgery between 2005 and 2007 were identified from the California Office of Statewide Health Planning and Development database. Multivariate logistic regression was used to identify factors associated with the type of surgery. RESULTS: Overall, 590 adolescents (aged 13-20 years) underwent bariatric surgery in 86 hospitals. White adolescents represented 28% of those who were overweight but accounted for 65% of the procedures. Rates of laparoscopic adjustable gastric banding (LAGB) increased 6.9-fold from 0.3 to 1.5 per 100,000 population (P<.01), whereas laparoscopic Roux-en-Y gastric bypass (LRYGB) rates decreased from 3.8 to 2.7 per 100 000 population (P<.01). Self-payers were more likely to undergo LAGB (relative risk [RR]: 3.51 [95% confidence interval: 2.11-5.32]) and less likely to undergo LRYGB (RR: 0.45 [95% confidence interval: 0.33-0.58]) compared with privately insured adolescents. The rate of major in-hospital complication was 1%, and no deaths were reported. Of the patients who received LAGB, 4.7% had band revision/removal. In contrast, 2.9% of those who received LRYGB required reoperations. CONCLUSIONS: White adolescent girls disproportionately underwent bariatric surgery. Although LAGB has not been approved by the US Food and Drug Administration for use in children, its use has increased dramatically. There was a complication rate and no deaths. Long-term studies are needed to fully assess the efficacy, safety, and health care costs of these procedures in adolescents.

Disparity in management and long-term outcomes of pediatric splenic injury in California.

OBJECTIVE: To determine the impact of evidence-based guidelines on the disparities in management of pediatric splenic injuries (PSI). SUMMARY OF BACKGROUND DATA: Several studies have highlighted a disparity in the utilization of nonoperative management (NOM) for PSI based on hospital and surgeon characteristics. Whether evidence-based guidelines had an impact on mitigating this disparity is uncertain. METHODS: From 1999 to 2006, children < or = 18 years with PSI were extracted from California's Patient Discharge Database (n = 5089). Patient demographics, injury grade, immediate and delayed operations, readmissions, and complications were analyzed. RESULTS: The overall rates of immediate operative management (IOM) decreased significantly from 23% in 1999 to 15% in 2006 (P < 0.001). This decline was attributed entirely to reduction of IOM at non-children's hospitals (NCH) (29% to 20%, P < 0.001). In contrast, IOM rates were low and unchanged at children's hospital (CH) (9%, P = NS). Failed NOM (3.3%), readmissions for complications (0.6%), and operations (0.3%) were rare and unaffected by NOM increase. NCH had increased risk of IOM compared to CH in multivariate analysis (OR: 2.00, 99% CI: 1.09-3.57). The rate of delayed splenic rupture was 0.2%. There were no differences when comparing the rates of readmissions (1.0% vs. 0.4%, P = NS) and readmit operations (0.3% vs. 0.3%, P = NS) between IOM versus NOM. CONCLUSION: A steady increase in the utilization of NOM for PSI in California over time was attributed entirely to changing practices at NCH. Increasing NOM has occurred without a concurrent increase in complications. Delayed splenic ruptures were rare. Although IOM rates at NCH decreased over time, disparity in NOM utilization still exists between NCH and CH.

Hospital readmissions and survival after nonneonatal pediatric ECMO.

PURPOSE: The late effects of treatment with extracorporeal membrane oxygenation (ECMO) in nonneonatal pediatric patients remain unclear. The aims of our study were to better characterize the long-term survival and hospital readmission rates for pediatric patients after ECMO treatment. PATIENTS AND METHODS: From 1999 to 2006, data on children aged 1 month to 18 years who underwent ECMO were extracted from the California Patient Discharge Database. Data from patients with diagnoses of congenital cardiac disease were excluded. We analyzed patient data on initial hospital course, subsequent readmissions, development of long-term morbidities, and long-term survival. RESULTS: The study cohort consisted of 188 children from 13 California hospitals. The median age was 3 years, and 46% of the patients survived to hospital discharge. ECMO indications included acquired heart disease in 81 patients, pneumonia in 56, other respiratory failure in 22, sepsis in 8, trauma in 8, and other indications in 12. Of the 87 survivors, 56 were tracked for a median period of 3.7 years. The readmission rate was 62%, and the mean time to first readmission was 1.2 years. Readmissions for respiratory infections were observed in 34% of the patients and for reactive airway disease in 7%. Neurologically debilitating conditions (epilepsy [7%] and developmental delay [9%]) occurred in 16%. Late deaths occurred in 5% of the children. Readmitted survivors had a cumulative length of readmission hospitalization of 8 days and hospital charge of $43 000. Cox proportional hazard regression demonstrated a positive relationship between treatment-center case volume and long-term survival outcomes (hazard ratio: 0.98 per case; P < .01). CONCLUSIONS: Pediatric ECMO survivors suffered from significant long-term morbidities after initial hospital discharge. More than 60% of these children required subsequent readmissions, and late deaths were observed in 5%. Furthermore, hospitals with high case volumes were associated with improved long-term survival.

Laparoscopic versus open appendectomy in children: outcomes comparison based on a statewide analysis.

BACKGROUND: To compare the differences in hospital utilization and complications between laparoscopic (LA) and open appendectomy (OA) for pediatric appendicitis. METHODS: A retrospective study from 1999 to 2006 of children aged 1 to 18 y with appendicitis, from the California Patient Discharge Database was performed. Children with significant comorbidities were excluded. Initial hospital course, subsequent readmissions, and the need for additional procedures were analyzed. RESULTS: The use of LA increased steadily from 19% in 1999 to 52% in 2006. Overall, 95,806 children were studied. Readmissions were tracked over a median period of 3 y. LA was associated with increased need for postoperative intra-abdominal abscess drainage for both perforated appendicitis (4.9% versus 3.8%, P<0.001) and nonperforated appendicitis (0.6% versus 0.3%, P<0.001) compared with OA. Multivariate regression showed an increased risk of postoperative abscess drainage for children after LA compared with OA (RR 1.81, 99% CI 1.41-2.27). However, the lengths of readmission hospitalizations were the same between the two groups (5.8 versus 5.7 d, P=NS). CONCLUSION: LA has become the preferred operation for pediatric appendicitis. The need for postoperative abscess drainage is small, and laparoscopy appears to increase this risk slightly. However, LA did not affect long-term hospital utilizations.

Creation of inpatient capacity during a major hospital relocation: lessons for disaster planning.

OBJECTIVE: To identify tools to aid the creation of disaster surge capacity using a model of planned inpatient census reduction prior to relocation of a university hospital. DESIGN: Prospective analysis of hospital operations for 1-week periods beginning 2 weeks (baseline) and 1 week (transition) prior to move day; analysis of regional hospital and emergency department capacity. SETTING: Large metropolitan university teaching hospital. MAIN OUTCOME MEASURES: Hospital census figures and patient outcomes. RESULTS: Census was reduced by 36% from 537 at baseline to 345 on move day, a rate of 18 patients/d (P < .005). Census reduction was greater for surgical services than nonsurgical services (46% vs 30%; P = .02). Daily volume of elective operations also decreased significantly, while the number of emergency operations was unchanged. Hospital admissions were decreased by 42%, and the adjusted discharges per occupied bed were increased by 8% (both P < .05). Inpatient mortality was not affected. Regional capacity to absorb new patients was limited. During a period in which southern California population grew by 8.5%, acute care beds fell by 3.3%, while Los Angeles County emergency departments experienced a 13% diversion rate due to overcrowding. CONCLUSIONS: Local or regional disasters of any size can overwhelm the system's ability to respond. Our strategy produced a surge capacity of 36% without interruption of emergency department and trauma services but required 3 to 4 days for implementation, making it applicable to disasters and mass casualty events with longer lead times. These principles may aid in disaster preparedness and planning.