Pediatric Emergency Care Coordination in EMS Agencies: Findings of a Multistate Learning Collaborative.

BACKGROUND: In 2017, the Health Resources and Services Administration's Maternal Child and Health Bureau's Emergency Medical Services for Children program implemented a performance measure for State Partnership grants to increase the percentage of EMS agencies within each state that have designated individuals who coordinate pediatric emergency care, also called a pediatric emergency care coordinator (PECC). The PECC Learning Collaborative (PECCLC) was established to identify best practices to achieve this goal. This study's objective is to report on the structure and outcomes of the PECCLC conducted among nine states. METHODS: This study used quantitative and qualitative methods to evaluate outcomes from the PECCLC. Participating state representatives engaged in a 6-month collaborative that included monthly learning sessions with subject matter experts and support staff and concluded with a two-day in-person meeting. Outcomes included reporting the number of PECCs recruited, identifying barriers and enablers to PECC recruitment, characterizing best practices to support PECCs, and identifying barriers and enablers to enhance and sustain the PECC role. Outcomes were captured by self-report from participating state representatives and longitudinal qualitative interviews conducted with representative PECCs at 6 and 18 months after conclusion of the PECCLC. RESULTS: During the 6-month collaborative, states recruited 341 PECCs (92% of goal). Follow up at 5 months post-collaborative revealed an additional recruitment of 184 for a total of 525 PECCs (142% of the goal). Feedback from state representatives and PECCs revealed the following barriers: competition from other EMS responsibilities, budgetary constraints, lack of incentive for agencies to create the position, and lack of requirement for establishing the role. Enablers identified included having an EMS agency recognition program that includes the PECC role, train-the-trainer programs, and inclusion of the PECC role in agency licensure requirements. Longitudinal interviews with PECCs identified that the most common activity associated with their role was pediatric-specific education and the most important need for PECC success was agency-level support. CONCLUSION: Over the 6-month Learning Collaborative, nine states were successful in recruiting a substantial number of PECCs. Financial and time constraints were significant barriers to statewide PECC recruitment, yet these can be potentially addressed by EMS agency recognition programs.

A Comfort Measures Only Checklist for Critical Care Providers: Impact on Satisfaction and Symptom Management.

PURPOSE: This quality improvement project created a guide for critical care providers transitioning patients to comfort measures only encouraging communication, collaboration, and shared decision making; ensuring management of patients' end-of-life symptoms and needs; and enhancing provider satisfaction by improving structure and consistency when transitioning patients. DESCRIPTION OF THE PROJECT: Interviews conducted with staff in intensive care units revealed opportunities to improve structure and processes of transitioning patients at the end of life. A subcommittee of experts designed a checklist to facilitate interdisciplinary conversations. Impact on provider satisfaction and symptom management was assessed. Presurveys circulated used a Research Electronic Data Capture tool. A checklist was implemented for 3 months, and then postsurveys were sent. Charts were audited to identify improvement in symptom management and compared with retrospective samples. OUTCOMES: Clinical improvements were seen in communication (12%), collaboration (25%), shared decision making (22%), and order entry time (17%). In addition, 72% agreed the checklist improved structure and consistency; 69% reported improved communication, collaboration, and shared decision making; 61% felt it improved knowledge/understanding of patient needs; and 69% agreed it improved management of patient symptoms. CONCLUSION: After checklist implementation, staff felt more involved and more comfortable, and reported more clarity in transitioning patients; no improvement in patient outcomes was realized.

Differential Ventilation Using Flow Control Valves as a Potential Bridge to Full Ventilatory Support during the COVID-19 Crisis.

BACKGROUND: During the COVID-19 pandemic, ventilator sharing was suggested to increase availability of mechanical ventilation. The safety and feasibility of ventilator sharing is unknown. METHODS: A single ventilator in pressure control mode was used with flow control valves to simultaneously ventilate two patients with different lung compliances. The system was first evaluated using high-fidelity human patient simulator mannequins and then tested for 1 h in two pairs of COVID-19 patients with acute respiratory failure. Patients were matched on positive end-expiratory pressure, fractional inspired oxygen tension, and respiratory rate. Tidal volume and peak airway pressure (PMAX) were recorded from each patient using separate independent spirometers and arterial blood gas samples drawn at 0, 30, and 60 min. The authors assessed acid-base status, oxygenation, tidal volume, and PMAX for each patient. Stability was assessed by calculating the coefficient of variation. RESULTS: The valves performed as expected in simulation, providing a stable tidal volume of 400 ml each to two mannequins with compliance ratios varying from 20:20 to 20:90 ml/cm H2O. The system was then tested in two pairs of patients. Pair 1 was a 49-yr-old woman, ideal body weight 46 kg, and a 55-yr-old man, ideal body weight 64 kg, with lung compliance 27 ml/cm H2O versus 35 ml/cm H2O. The coefficient of variation for tidal volume was 0.2 to 1.7%, and for PMAX 0 to 1.1%. Pair 2 was a 32-yr-old man, ideal body weight 62 kg, and a 56-yr-old woman, ideal body weight 46 kg, with lung compliance 12 ml/cm H2O versus 21 ml/cm H2O. The coefficient of variation for tidal volume was 0.4 to 5.6%, and for PMAX 0 to 2.1%. CONCLUSIONS: Differential ventilation using a single ventilator is feasible. Flow control valves enable delivery of stable tidal volume and PMAX similar to those provided by individual ventilators.

Patient at Risk: Emergency medical service providers' opinions on improving an electronic emergency information form database for the medical care of children with special health care needs.

BACKGROUND: Patient at Risk (PAR) is an online database using an emergency information form (EIF) that parents of children with special health care needs (CSHCN) complete to store their child's medical information. Emergency medical service (EMS) providers can then access PAR during medical emergencies or for pre-planning. PAR was active for over 10 years but use by patients and EMS was limited. OBJECTIVE: To determine EMS perspectives on why PAR was not used to its full potential and how to improve PAR for EMS. METHODS: Seven questions regarding PAR were developed and presented in focus groups at 32 fire/ambulance houses in southeast and central Wisconsin from June to August 2017. Responses were transcribed and reviewed for themes. RESULTS: 146 EMS providers participated and 11% were aware of PAR. Many did not use PAR because of a lack of follow up or barriers such as limited internet access, inconvenience, other urgent responsibilities, and not knowing when to use PAR. Solutions to these issues include developing or purchasing new technology, involving the dispatch operator in PAR, and returning to a paper-based EIF. The EIF layout and content received very positive reviews with few changes suggested. Most providers felt PAR was important because it would help them provide better care and feel more comfortable treating CSHCN. CONCLUSION: Despite technological and logistical barriers, EMS providers want online EIF databases for pre-planning and utilization during ambulance runs so they can practice more informed and focused care, especially for vulnerable and medically challenging CSHCN.

A Society of Gastrointestinal and Endoscopic Surgeons (SAGES) statement on closed social media (Facebook®) groups for clinical education and consultation: issues of informed consent, patient privacy, and surgeon protection.

INTRODUCTION: Closed social media groups (CSMG), including closed Facebook® groups, are online communities providing physicians with platforms to collaborate privately via text, images, videos, and live streaming in real time and optimize patient care. CSMG platforms represent a novel paradigm in online learning and education, so it is imperative to ensure that the public and patients trust the physicians using these platforms. Informed consent is an essential aspect of establishing this trust. With the launch of several of its own CSMG, Society of Gastrointestinal and Endoscopic Surgeons (SAGES) sought to define its position on CSMG platforms and provide an informed consent template for educating and protecting patients, surgeons, and institutions. METHODS: A review of the literature (2012-2018) discussing the informed consent process for posting clinical scenarios, photography, and/or videography on social media was performed. Pertinent articles and exemplary legal counsel-approved CSMG policies and informed consent forms were reviewed by members of the SAGES Facebook® Task Force. RESULTS: Eleven articles and two institutional CSMG policies discussing key components of the informed consent process, including patient transparency and confidentiality, provider-patient partnerships, ethics, and education were included. Using this information and expert opinion, a SAGES-approved statement and informed consent template were formulated. CONCLUSIONS: SAGES endorses the professional use of medical and surgical CSMG platforms for education, patient care optimization, and dissemination of clinical information. Despite the growing use of social media as an integral tool for surgical practice and education, issues of informed consent still exist and remain the responsibility of the physician contributor. Responsible, ethical, and compliant use of CSMG platforms is essential. Surgeons and patients embracing CSMG for quality improvement and optimized outcomes should be legally protected. SAGES foresees the use of this type of platform continuing to grow.

Myotomy length informed by high-resolution esophageal manometry (HREM) results in improved per-oral endoscopic myotomy (POEM) outcomes for type III achalasia.

INTRODUCTION: High-resolution esophageal manometry (HREM) is essential in characterizing achalasia subtype and the extent of affected segment to plan the myotomy starting point during per-oral endoscopic myotomy (POEM). However, evidence is lacking that efficacy is improved by tailoring myotomy to the length of the spastic segment on HREM. We sought to investigate whether utilizing HREM to dictate myotomy length in POEM impacts postoperative outcomes. METHODS: Comparative analysis of HREM-tailored to non-tailored patients from a prospectively collected database of all POEMs at our institution January 2011 through July 2017. A tailored myotomy is defined as extending at least the length of the diseased segment, as initially measured on HREM. RESULTS: Forty patients were included (11 tailored versus 29 non-tailored). There were no differences in patient age (p = 0.6491) or BMI (p = 0.0677). Myotomy lengths were significantly longer for tailored compared to non-tailored overall (16.6 ± 2.2 versus 13.5 ± 1.8; p < 0.0001), and for only type III achalasia (15.9 ± 2.4 versus 12.7 ± 1.2; p = 0.0453), likely due to more proximal starting position in tailored cases (26.0 ± 2.2 versus 30.0 ± 2.7; p < 0.0001). Procedure success (Eckardt < 3) was equivalent across groups overall (p = 0.5558), as was postoperative Eckardt score (0.2 ± 0.4 versus 0.8 ± 2.3; p = 0.4004). Postoperative Eckardt score was significantly improved in the tailored group versus non-tailored for type III only (0.2 ± 0.4 versus 1.3 ± 1.5; p = 0.0435). A linear correlation was seen between increased length and greater improvement in Eckardt score in the non-tailored group (p = 0.0170). CONCLUSIONS: Using HREM to inform surgeons of the proximal location of the diseased segment resulted in longer myotomies, spanning the entire affected segment in type III achalasia, and in lower postoperative Eckardt scores. Longer myotomy length is often more easily achieved with POEM than with Heller myotomy, which raises the question of whether POEM results in better outcomes for type III achalasia, as types I and II do not generally have measurable spastic segments.

Treatment of Achalasia with Per-Oral Endoscopic Myotomy: Analysis of 50 Consecutive Patients.

BACKGROUND: Peroral endoscopic myotomy (POEM) has become an acceptable incisionless treatment for achalasia based on encouraging outcomes in multiple series worldwide. This report reflects our early experience. METHODS: Data were collected prospectively on all patients undergoing POEM between June 2011 and April 2016 under IRB approval. Diagnosis of achalasia was confirmed by standard preoperative work-up. Primary outcome was symptom relief, measured by Eckardt score. Secondary outcomes were operative time, length of stay (LOS), adverse events, failure, and recurrence. RESULTS: Fifty patients were included; 30 were female. Mean age was 55.7 ± 17.7 years. Mean BMI was 29.5 ± 9.2. Median OR time was 133.5 minutes (range 70-462); average myotomy was 13.1 ± 2.3 cm. One early case was converted to a laparoscopic Heller myotomy due to extensive submucosal fibrosis from a recent Botox injection. Two cases were aborted; one due to extensive submucosal fibrosis and the other to intraoperative capnopericardium. Median LOS was 1 day (range 0.8-8). Two major complications occurred: intraoperative cardiac arrest due to capnopericardium and postoperative submucosal hemorrhage. There were no deaths. Mean postoperative Eckardt score was 1.0 ± 1.9 (range 0-8) at 2-6 weeks (vs. preoperative score 7.7 ± 2.8; P < .0001); mean dysphagia component 0.35 ± 0.28 (vs. preoperative score 2.6 ± 0.7; P < .0001). Two recurrences were identified, both at 6 months. CONCLUSIONS: POEM is a safe and durable treatment for achalasia in the short term. We demonstrated marked improvement of symptoms in all completed cases. There was an acceptable serious adverse event rate of 4%, failure of 6% due to patient selection, and recurrences occurring in only 4% of cases.

Comparison of peritoneal closure versus non-closure in laparoscopic trans-abdominal preperitoneal inguinal hernia repair with coated mesh.

BACKGROUND: Peritoneal closure during laparoscopic trans-abdominal preperitoneal (TAPP) inguinal hernia repair has been the standard of care to prevent bowel obstruction due to adhesions generated by contact with mesh. However, with newer coated meshes, leaving the peritoneal layer open may be safe. While many studies compare methods of peritoneal flap closure, there is a deficit of literature reporting the outcomes of non-closure. METHODS: A retrospective comparison of peritoneal flap closure versus non-closure during primary laparoscopic TAPP inguinal hernia repair with coated mesh was performed for all patients at Baystate Medical Center meeting inclusion criteria between January 2005 and August 2016. Primary outcome was any procedure-related adverse outcome following repair. Secondary outcomes included operative time, resolution of pre-operative pain and/or gastrointestinal symptoms, and hernia recurrence. RESULTS: Of 231 patients, 55 (24%) underwent peritoneal flap closure and 176 (76%) underwent non-closure. Demographic, comorbidity, and hernia characteristics were comparable between groups with the exception of obesity (p = 0.01), current smoking status (p = 0.05) and hernia side [p = 0.04 (left), 0.0003 (right)]. Mean operative time was higher in the closure group than non-closure (98.1 ± 37.1 min vs. 76.8 ± 32.9, p < 0.0001). No cases were converted to open. Average follow-up was 21.6 ± 23.8 months. Ninety-three percent of closure patients had documented resolution of pre-operative pain versus 94.0% of non-closure (p = 0.81). The closure group experienced a higher percentage of post-operative complications, though this did not reach significance (5.5 vs. 2.3%; p = 0.36). Compared to the closure group, the non-closure groups experienced similar post-operative pain (3.6 vs. 1.2%; p = 0.24) and recurrence rate (1.8 vs. 4.0%; p = 0.68). There were no bowel obstructions, surgical site infections, unplanned readmissions, or unplanned re-operations. CONCLUSIONS: Equivalent patient outcomes were seen for both procedure types post-operatively and during follow-up. Operative times were significantly shorter for non-closure patients. Larger study population and longer follow-up is necessary to evaluate true long-term complication rates in flap non-closure.

Surgical Stabilization of Rib Fractures: A Single Institution Experience.

BACKGROUND: Use of surgical stabilization of rib fractures (SSRF) has increased. Despite compelling small studies, many centers still struggle with determining criteria for intervention. We investigated the benefit of SSRF in our patients compared with nonoperative (NonOp) National Trauma Databank (NTDB) controls, specifically in the older population. STUDY DESIGN: We performed a retrospective comparison of trauma patients with ≥3 and >5 rib fractures, who underwent SSRF at a tertiary care level I trauma center, with nonoperatively managed NTDB controls from equivalent level I centers between 2007 and 2014. The main outcomes measures included mortality, pneumonia, length of stay (LOS), ICU LOS, ventilator use, and tracheostomy rates. RESULTS: Overall, SSRF patients were older, had a higher percentage of respiratory disease, and higher Injury Severity Scores (ISS). Despite more respiratory disease in SSRF patients vs NonOp (p < 0.0001), there was no difference in ventilator usage. Results of SSRF included decreases in mortality (12%, p = 0.008) and pneumonia (13%, p < 0.001) compared with NonOp on propensity score matching. On subgroup analysis of patients 65 years of age or older, ISS was higher in the SSRF group. Mortality was significantly lower for SSRF vs NonOp, even with higher frequency of respiratory disease within the group (p < 0.001). CONCLUSIONS: Patients who underwent SSRF at our institution had improved outcomes despite a higher percentage of respiratory disease, compared with patients who were managed nonoperatively nationwide. Mortality rates improved for patients aged 65 and older, suggesting that this patient population may benefit more from SSRF.

A case report of unexpected pathology within an incarcerated ventral hernia.

INTRODUCTION: Incidence of hernial appendicitis is 0.008%, most frequently within inguinal and femoral hernias. Up to 2.5% of appendectomy patients are found to have Crohn's disease. Elucidating the etiology of inflammation is essential for directing management. PRESENTATION OF CASE: A 51-year-old female with achondroplastic dwarfism, multiple cesarean sections, and subsequent massive incisional hernia, presented with ruptured appendicitis within her incarcerated hernia. She underwent diagnostic laparoscopy, appendectomy, intra-abdominal abscess drainage, and complete reduction of ventral hernia contents. She developed a nonhealing colocutaneous fistula, causing major disruptions to her daily life. She elected to undergo hernia repair with component separation for anticipated lack of domain secondary to her body habitus. Her operative course consisted of open abdominal exploration, adhesiolysis, colocutaneous fistula repair, ileocolic resection and anastomosis, and hernia repair with bioresorbable mesh. She tolerated the procedure well. Unexpectedly, ileocolic pathology demonstrated chronic active ileitis, diagnostic of Crohn's disease. DISCUSSION: Only two cases of hernial Crohn's appendicitis have been reported, both within Spigelian hernias. Appendiceal inflammation inside a hernia sac may be attributed to ischemia from extraluminal compression of the hernia neck. This case demonstrates a rare presentation of multiple concurrent surgical disease processes, each of which impact the patient's treatment plan. CONCLUSION: This is the first report of incisional hernia appendicitis with nonhealing colocutaneous fistulas secondary to Crohn's. It is a lesson in developing a differential diagnosis of an inflammatory process within an incarcerated hernia and management of the complications related to laparoscopic hernial appendectomy in a patient with undiagnosed Crohn's disease.

Quantifying and exploring the recent national increase in surgical stabilization of rib fractures.

BACKGROUND: Surgical stabilization of rib fractures (SSRF) has become pivotal in the management of severe chest injuries. Recent literature supports improved outcomes and mortality in severe fracture and flail chest patients who undergo SSRF compared with nonoperative management (NOM). A 2014 National Trauma Data Bank review provided a point prevalence of 0.7% SSRF in flail patients. We hypothesize that this prevalence is increasing and that temporal, regional, and American College of Surgeons (ACS) trauma designation vary in SSRF utilization. METHODS: Retrospective National Trauma Data Bank data were extracted for years 2007 to 2014 for patients with rib fractures. Cases were divided into SSRF versus NOM. SSRF frequencies were analyzed across year, region, and ACS level. Patient demographics, injury severity score, number of fractured ribs, and hospital characteristics were identified for multivariable analysis. RESULTS: Between 2007 and 2014, 687,137 rib fracture patients were identified; 29,981 (4.36%) underwent SSRF. SSRF increased by 76% nationally during the review period (odds ratio [OR], 1.59; 95% confidence interval [CI], 1.50-1.67; p < 0.001). Compared with the north, SSRF was used more in the west (OR, 1.6; 95% CI, 1.57-1.71), south (OR, 1.48; 95% CI, 1.43-1.54), then midwest (OR, 1.4; 95% CI, 1.34-1.46; p < 0.001). Although likelihood of SSRF is higher at ACS Level I (LI) centers compared with Level II (LII) centers (OR, 0.67; 95% CI, 0.65-0.69) or Level III (LIII) (OR, 0.24; 95% CI, 0.22-0.26); p < 0.001), frequency of SSRF increased dramatically at lower-level centers from 2007 to 2014 (LI, 41.4%; LII, 53.6%; LIII, 60.0%).Overall SSRF mortality was 1.58% (NOM, 5.3%; p < 0.001), decreasing significantly between 2007 and 2014 (p < 0.0001). ACS LII had higher mortality than LI (OR, 1.82; 95% CI, 1.39-2.39; p < 0.0001), controlled by Injury Severity Score. CONCLUSION: Utilization of SSRF has risen considerably nationwide. Prevalence varies by region and ACS level. Although greatest growth is occurring at LII hospitals, mortality is also the highest at these centers. Further research is needed to determine the need for regionalization of care and center of excellence designation. LEVEL OF EVIDENCE: Epidemiological study, level III.

Multicenter proficiency benchmarks for advanced laparoscopic suturing tasks.

BACKGROUND: Advanced laparoscopic suturing (LS) tasks were developed based on a needs assessment. Initial validity evidence has been shown. The purpose of this multicenter study was to determine expert proficiency benchmarks for these tasks. METHODS: 6 tasks were included: needle handling (NH), offset-camera forehand suturing (OF), offset-camera backhand suturing (OB), confined space suturing (CF), suturing under tension (UT), and continuous suturing (CS). Minimally invasive surgeons experienced in LS completed the tasks twice. Mean time and median accuracy scores were used to establish the benchmarks. RESULTS: Seventeen MIS surgeons enrolled, from 7 academic centers. Mean (95% CI) time in seconds to complete each task was: NH 169 (149-189), OF 158 (134-181), OB 189 (154-224), CF 181 (156-205), UT 379 (334-423), and CS 416 (354-477). Very few errors in accuracy were made by experts in each of the tasks. CONCLUSIONS: Time- and accuracy-based proficiency benchmarks for 6 advanced LS tasks were established. These benchmarks will be included in an advanced laparoscopic surgery curriculum currently under development.