Cultural competency and ethical behavior for collaboration in limited-resource settings: Guidelines from the Society of University Surgeons Academic Global Surgery Committee and the Association for Academic Global Surgery.

BACKGROUND: There are an increasing number of global surgery activities worldwide. With such tremendous growth, there is a potential risk for untoward interactions between high-income country members and low-middle income country members, leading to programmatic failure, poor results, and/or low impact. METHODS: Key concepts for cultural competency and ethical behavior were generated by the Academic Global Surgery Committee of the Society for University Surgeons in collaboration with the Association for Academic Global Surgery. Both societies ensured active participation from high-income countries and low-middle income countries. RESULTS: The guidelines provide a framework for cultural competency and ethical behavior for high-income country members when collaborating with low-middle income country partners by offering recommendations for: (1) preparation for work with low-middle income countries; (2) process standardization; (3) working with the local community; (4) limits of practice; (5) patient autonomy and consent; (6) trainees; (7) potential pitfalls; and (8) gray areas. CONCLUSION: The article provides an actionable framework to address potential cultural competency and ethical behavior issues in high-income country - low-middle income country global surgery collaborations.

Evaluating Global Surgery Partnerships From Low and Middle Income Country Perspectives.

INTRODUCTION: Little is known about perceptions of low-income and middle-income country (LMIC) partners regarding global surgery collaborations with high-income countries (HICs). METHODS: A survey was distributed to surgeons from LMICs to assess the nature and perception of collaborations, funding, benefits, communication, and the effects of COVID-19 on partnerships. RESULTS: We received 19 responses from LMIC representatives in 12 countries on three continents. The majority (83%) had participated in collaborations within the past 5 y with 39% of collaborations were facilitated virtually. Clinical and educational partnerships (39% each) were ranked most important by respondents. Sustainability of the partnership was most successfully achieved in domains of education/training (78%) and research (61%). The majority (77%) of respondents reported expressing their needs before HIC team arrival. However, 54% of respondents were the ones to initiate the conversation and only 47% said HIC partners understood the overall environment well at arrival to LMIC. Almost all participants (95%) felt a formal process of collaboration and a structured partnership would benefit all parties in assessing needs. During the COVID-19 pandemic, 87% of participants reported continued collaborations; however, 44% of partners felt that relationships were weaker, 31% felt relationships were stronger, and 25% felt they were unchanged. CONCLUSIONS: Our study provides a snapshot of LMIC surgeons' perspectives on collaboration in global surgery. Independent of location, LMIC partners cite inadequate structure for long-term collaborations. We propose a formal pathway and initiation process to assess resources and needs at the outset of a partnership.

The First Generation of Asian American Pediatric Surgical Trainees in North America.

INTRODUCTION: Pediatric surgical trainees come from diverse races and ethnicities. However, Asian-Americans (AAs) including West, South, and East Asians may represent a unique group of individuals. We sought to identify any unique challenges and experiences. METHODS: Pediatric surgical trainees were identified from, "The Genealogy of North American Pediatric Surgery: From Ladd to Now" and "Celebrating 50 Years: Canadian Association of Paediatric Surgeons/Association Canadienne de Chirurgie Pediatrique". A database was compiled, and AAs identified who completed their pediatric surgical training on or before 1980. Personal interviews and online sources provided further information. RESULTS: Of 635 pediatric surgical trainees in North America (NA) there were 49 AA trainees (7.7%). There was insufficient information for seven, thus leaving 42 (41 male, one female) for review. The region of Asia of origin included 16 East, 16 West, and 10 South. Thirty-seven (88.0%) had moved to NA for training. The most frequent training programs included seven from Toronto and four each at Buffalo, Detroit, Pittsburgh, and Chicago (Children's Memorial). Thirty-five (83%) trainees spent most of their careers in NA while 7 (17%) practiced in their home country. CONCLUSIONS: The first AA pediatric surgical trainees voiced few examples of discrimination but indicated needs to adjust to the NA culture and often confusion over non-Western names. Mentorship was valued and gratitude expressed over the opportunity offered to train in NA. While some had intended to return to their home countries, plans changed due to meeting spouses or political turmoil. Many of those reviewed sought each other out at national meetings.

Reducing Disposable Surgical Items: Decreasing Environmental Impact and Costs at a Children's Hospital, a Pilot Study.

INTRODUCTION: United States landfill waste generated in the operating room (OR) is estimated to be three billion tons per year. The goal of this study was to analyze the environmental and fiscal impact of right-sizing surgical supplies at a medium-sized children's hospital using lean methodology to reduce physical waste generated in the operating room. METHODS: A multidisciplinary task force was created to reduce waste in the OR of an academic children's hospital. A single-center case study, proof-of-concept, and scalability analysis of operative waste reduction was performed. Surgical packs were identified as a target. Pack utilization was monitored during an initial pilot analysis for 12 d then followed by a focused 3-week period, capturing all unused items by participating surgical services. Items discarded in more than 85% of cases were excluded in subsequent preformed packs. RESULTS: Pilot review identified 46 items in 113 procedures for removal from surgical packs. Subsequent 3-week analysis focusing on two surgical services, and 359 procedures identified a potential $1,111.88 savings with elimination of minimally used items. Over 1 y, removal of all minimally used items from seven surgical services diverted two tons of plastic landfill waste, saved $27,503 in surgical pack acquisition-costs, and prevented the theoretical loss of $13,824 in wasted supplies. Additional purchasing analysis has resulted in another $70,000 of savings through supply chain streamlining. Application of this process nationally could prevent >6000 tons of waste in the United States per year. CONCLUSIONS: Application of a simple iterative process to reduce waste in the OR can result in substantial waste diversion and cost savings. Broad adoption of such a process to reduce OR waste could greatly reduce the environmental impact of surgical care.

Pediatric Trauma Care Standardization: A Statewide Survey of Trauma Providers and Program Managers.

INTRODUCTION: Rural-urban disparities in pediatric trauma outcomes are well documented. However, few studies examine how differences in setting and resources impact rural providers' approach to trauma. We sought to understand the provider experience in managing injured children across our state and assess the potential for standardization of care. METHODS: A statewide cross-sectional survey was distributed to trauma providers and program managers through the American College of Surgeons, the Oregon Medical Board lists, and the State Trauma Advisory Board. Topics included pediatric management processes, challenges, and transfer or admission procedures. Rural-urban commuting codes were used to categorize responses. RESULTS: Of the 350 individuals who sent the survey, 68 responded (response rate 19%), representing 67% of trauma-verified hospitals and 72% of Oregon counties. Fifty-six respondents (82%) care for injured children, with 58% practicing rurally and 22% at critical access hospitals. Rural providers experienced lower trauma volumes (<1 patient/month, 63% versus 0%, P < 0.001), more difficulties obtaining pediatric-appropriate material resources (44% versus 30%), and challenges caring for infants/toddlers (25% versus 17%). Despite 77% of rural providers stating that <10% of patients had multisystem injuries, they described using full-body CT often (41% versus 10%, P = 0.007). Transfer interruptions were common (93%), with 44% having cancelled a transfer. The majority supported admission/transfer (85%) and imaging (82%) protocols. CONCLUSIONS: Rural providers experience lower pediatric trauma volumes, greater material-resource issues, and discomfort with traumatically injured small children. Lack of care standardization may lead to reliance on full-body CT, and potentially complex/avoidable transfers. Adoption of standardized protocols could facilitate a state-wide collaborative approach to pediatric trauma management.

Application of a Thoracic CT Decision Rule in the Evaluation of Injured Children: A Quality Improvement Initiative.

BACKGROUND: Differences in injury patterns in children suggest that life-threatening chest injuries are rare. Radiation exposure from computed tomography increases cancer risk in children. Two large retrospective pediatric studies have demonstrated that thoracic computed tomography can be reserved for patients based on mechanism of injury and abnormal findings on chest radiography. OBJECTIVE: Implement a decision rule to guide utilization of thoracic computed tomography in the evaluation of pediatric blunt trauma, limiting risk of unnecessary radiation exposure and clinically significant missed injuries. METHODS: A protocol for thoracic computed tomography utilization in pediatric blunt trauma was implemented using a Plan-Do-Study-Act cycle at our Level I pediatric trauma center, reserving thoracic computed tomography for patients with (1) mediastinal widening on chest radiography or (2) vehicle-related mechanism and abnormal chest radiography. We modified our resuscitation order set to limit default imaging bundles. The medical record and trauma registry data were reviewed for all pediatric blunt trauma patients (younger than 18 years) over a 30-month study period before and after protocol implementation (May 2017 to July 2018 and February 2019 to April 2020), allowing for a 6-month implementation period (August 2018 to January 2019). RESULTS: During the study period, 1,056 blunt trauma patients were evaluated with a median (range) Injury Severity Score of 5 (0-58). There were no significant demographic differences between patients before and after protocol implementation. Thoracic computed tomography utilization significantly decreased after implementation of the protocol (26.4% [129/488] to 12.7% [72/568; p < .05]), with no increase in clinically significant missed injuries. Protocol compliance was 88%. CONCLUSIONS: Application of decision rules can safely limit ionizing radiation in injured children. Further limitations to thoracic computed tomography utilization may be safe and warrant continued study due to the rarity of significant injuries.

The First Two Years of the Association of Pediatric Surgery Training Program Directors (APSTPD) Transition to Fellowship Course: Lessons Learned and Future Directions.

OBJECTIVE: The first transition to fellowship course for incoming pediatric surgery fellows was held in the US in 2018 and the second in 2019. The course aimed to facilitate a successful transition in to fellowship by introduction of the professional, patient care, and technical aspects unique to pediatric surgery training. The purpose of this study was to evaluate the feasibility and effectiveness of the first two years of this course in the US and discuss subsequent evolution of this endeavor. DESIGN: This is a descriptive and qualitative analysis of two years' experience with the Association of Pediatric Surgery Training Program Directors' (APSTPD) Transition to Fellowship course. Course development and curriculum, including clinical knowledge, soft skills, and hands-on skills labs, are presented. Participating incoming fellows completed multiple choice, boards-style pre- and post-tests. Scores were compared to determine if knowledge was effectively transferred. Participants also completed post-course evaluations and subsequent 3- or 12-month surveys inquiring on the lasting impact of the course on their transition into fellowship. Standard univariate statistics were used to present results. SETTING: The first APSTPD Transition to Fellowship course was held at the Johns Hopkins Hospital in Baltimore, Maryland in 2018, and the second course was held at the Oregon Health and Science University in Portland, Oregon in 2019. PARTICIPANTS: All fellows entering ACGME-certified Pediatric Surgery fellowships in the United States were invited to participate. Twenty fellows accepted and attended in 2018, and fourteen fellows participated in 2019. RESULTS: There were 34 incoming pediatric surgery fellow participants over 2 years. Faculty represented more than 10 institutions each year. Pre- and post-test scores were similar between years, with a significant improvement of scores after completion of the course (67±10% vs 79±8%, p < 0.001). Feedback from participants was overwhelmingly positive, with skills labs being attendees' favorite component. When asked about usefulness of individual course sessions, more attendees found clinical sessions more useful than soft skills (93% vs 73%, p = 0.011). Almost all (90%) of participants reported the course met its stated purpose and would recommend the course to future fellows. This was further reflected on 3 and 12 month follow up surveys wherein 85% stated they found the course helpful during the first few months of fellowship and 90% would still recommend it. CONCLUSIONS: A transition to fellowship course in the US for incoming pediatric surgery fellows is logistically feasible, effective in transfer of knowledge, and highly regarded among attendees. Feedback from each course has been used to improve the subsequent courses, ensuring that it remains a valuable addition to pediatric surgical training in the US.

Management of Anorectal Malformations and Hirschsprung Disease.

Anorectal malformations (ARM) and Hirschsprung disease (HD) are managed with placement of normal intestine within the anal sphincter complex. Long-term complications specific to ARM include fistula remnants, recurrence, urinary reflux with associated chronic renal insufficiency, sexual dysfunction, and fertility difficulties. Complications specific to HD include enterocolitis, persistent or acquired aganglionosis, and internal sphincter achalasia. ARM and HD patients are both at risk of stricture, bowel dysfunction and incontinence, which can have a severe impact on quality of life. Bowel management strategies should be tailored to the patient's specific category of bowel dysfunction.

Virtual curriculum delivery in the COVID-19 era: the pediatric surgery boot camp v2.0.

PURPOSE: We evaluated the impact of a virtual Pediatric Surgery Bootcamp curriculum on resource utilization, learner engagement, knowledge retention, and stakeholder satisfaction. METHODS: A virtual curriculum was developed around Pediatric Surgery Milestones. GlobalCastMD delivered pre-recorded and live content over a single 10-h day with a concluding social hour. Metrics of learner engagement, faculty interaction, knowledge retention, and satisfaction were collected and analyzed during and after the course. RESULTS: Of 56 PS residencies, 31 registered (55.4%; 8/8 Canadian and 23/48 US; p = 0.006), including 42 learners overall. The virtual BC budget was $15,500 (USD), 54% of the anticipated in-person course. Pre- and post-tests were administered, revealing significant knowledge improvement (48.6% [286/589] vs 66.9% [89/133] p < 0.0002). Learner surveys (n = 14) suggested the virtual BC facilitated fellowship transition (85%) and strengthened peer-group camaraderie (69%), but in-person events were still favored (77%). Program Directors (PD) were surveyed, and respondents (n = 22) also favored in-person events (61%). PDs not registering their learners (n = 7) perceived insufficient value-added and concern for excessive participants. CONCLUSIONS: The virtual bootcamp format reduced overall expenses, interfered less with schedules, achieved more inclusive reach, and facilitated content archiving. Despite these advantages, learners and program directors still favored in-person education. LEVEL OF EVIDENCE: III.

Pediatric surgery milestones 2.0: A primer.

More than twenty years ago, the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties began the conversion of graduate medical education from a structure- and process-based model to a competency-based framework. The educational outcomes assessment tool, known as the Milestones, was introduced in 2013 for seven specialties and by 2015 for the remaining specialties, including pediatric surgery. Designed to be an iterative process with improvements over time based on feedback and evidence-based literature, the Milestones started the evolution from 1.0 to 2.0 in 2016. The formation of Pediatric Surgery Milestones 2.0 began in 2019 and was finalized in 2021 for implementation in the 2022-2023 academic year. Milestones 2.0 are fewer in number and are stated in more straightforward language. It incorporated the harmonized milestones, subcompetencies for non-patient care and non-medical knowledge that are consistent across all medical and surgical specialties. There is a new Supplemental Guide that lists examples, references and links to other assessment tools and resources for each subcompetency. Milestones 2.0 represents a continuous process of feedback, literature review and revision with goals of improving patient care and maintaining public trust in graduate medical education's ability to self-regulate. LEVEL OF EVIDENCE: V.

Social injustice symposium: Urban, rural, and global disparities in access to care.

BACKGROUND: Barriers in access to pediatric surgical care are common in low- and middle-income countries (LMICs), but also exist in high-income countries, particularly in urban and rural areas. METHODS: This article describes "Disparities in Access to Care"-held within the Social Injustice Symposium at the 2020 American Pediatric Surgical Association (APSA) Annual Meeting. RESULTS: This symposium outlined disparities in access to care, illustrated by examples from pediatric trauma and neonatal surgery in U.S. urban, U.S. rural, and non-U.S. global locations (LMICs). Geographic and financial challenges were common to families from the rural U.S. and LMICs. In contrast, families in U.S. urban settings generally do not face geographic barriers, but are often economically and racially diverse and many face complex societal factors leading to poor outcomes. Systemic processes must be changed to improve pediatric surgical health outcomes. CONCLUSION: A comprehensive health system with an equal emphasis on supportive care and surgery is required in all settings. Global collaboration and partnerships can provide an avenue for advocacy and strategic innovation to improve quality of care. LEVEL OF EVIDENCE: Ⅴ.

Academic Global Surgery Curricula: Current Status and a Call for a More Equitable Approach.

INTRODUCTION: We aimed to search the literature for global surgical curricula, assess if published resources align with existing competency frameworks in global health and surgical education, and determine if there is consensus around a fundamental set of competencies for the developing field of academic global surgery. METHODS: We reviewed SciVerse SCOPUS, PubMed, African Medicus Index, African Journals Online (AJOL), SciELO, Latin American and Caribbean Health Sciences Literature (LILACS) and Bioline for manuscripts on global surgery curricula and evaluated the results using existing competency frameworks in global health and surgical education from Consortium of the Universities for Global Health (CUGH) and Accreditation Council for Graduate Medical Education (ACGME) professional competencies. RESULTS: Our search generated 250 publications, of which 18 were eligible: (1) a total of 10 reported existing competency-based curricula that were concurrent with international experiences, (2) two reported existing pre-departure competency-based curricula, (3) six proposed theoretical competency-based curricula for future global surgery education. All, but one, were based in high-income countries (HICs) and focused on the needs of HIC trainees. None met all 17 competencies, none cited the CUGH competency on "Health Equity and Social Justice" and only one mentioned "Social and Environmental Determinants of Health." Only 22% (n = 4) were available as open-access. CONCLUSION: Currently, there is no universally accepted set of competencies on the fundamentals of academic global surgery. Existing literature are predominantly by and for HIC institutions and trainees. Current frameworks are inadequate for this emerging academic field. The field needs competencies with explicit input from LMIC experts to ensure creation of educational resources that are accessible and relevant to trainees from around the world.

Applying LEAN Healthcare in Lean Settings: Launching Quality Improvement in Resource-Limited Regions.

BACKGROUND: Lean methodology is frequently utilized in high income settings to maximize capacity and operational efficiency during process improvement (PI) initiatives. To date there has been little published on the application of these techniques in low- and-middle-income countries (LMIC) despite the potential benefits in resource limited settings. We describe a pilot project developed in 2018 to promote sustainable operating theater efficiency at two hospitals in Abuja, Nigeria. This study details the first known attempt to use Lean techniques to improve surgical care systems in LMIC. METHODS: Perioperative committees were established at two Nigerian institutions to evaluate current processes, identify problems, and compile a list of priorities. A physician champion and a PI specialist in conjunction with local physician-partners held a workshop to teach practical applications of PI methodology as part of an ongoing collaboration. Pre and post-workshop surveys were administered, and theme coding was used to categorize free responses. Results were compared with a chi-square test. RESULTS: In total, 42 individuals attended the PI workshop. After the workshop, 37 respondents reported the workshop as valuable both personally and for the perioperative committee (P < 0.001), and all reported that PI methodology could benefit the institution overall. CONCLUSIONS: By identifying stakeholders, holding a workshop to teach tools of PI, and establishing a committee for ongoing improvement, it is possible to implement quality improvement techniques at LMIC hospitals, which may be of future benefit. Sustainability in this project will be facilitated by tele mentoring, and future efforts include expansion beyond the perioperative setting.

Congenital Diaphragmatic Hernia Management: A Systematic Review and Care Pathway Description Including Volume-Targeted Ventilation.

BACKGROUND: Although it is well established that standardized treatment protocols improve outcomes for infants with congenital diaphragmatic hernia (CDH), there remains variance between existing protocols. PURPOSE: The purpose of this article was to review current literature on protocols for CDH management in the preoperative period and to describe a care pathway integrating best practice elements from existing literature with volume-targeted ventilation strategies previously in place at a major tertiary care center in the Pacific Northwestern United States. METHODS/SEARCH STRATEGY: A systematic review of literature was performed according to PRISMA guidelines to identify current publications on CDH protocols and examine them for similarities and differences, particularly regarding ventilation strategies. FINDINGS/RESULTS: Although existing protocols from multiple regions worldwide shared common goals of reducing barotrauma and delaying surgery until a period of clinical stabilization was achieved, their strategies varied. None included volume-targeted ventilation with pressure limitation as a method of avoiding ventilation-induced lung injury (VILI). IMPLICATIONS FOR PRACTICE: Institutions that routinely manage infants with CDH should have a standardized treatment protocol in place, as this is shown to improve outcomes. This may include volume-targeted ventilation with pressure limitation as a successful VILI-limiting strategy. IMPLICATIONS FOR RESEARCH: While standardized protocols have been shown to increase survival rate for infants with CDH, more research is needed to determine what these protocols should include. Specifically, there is a need for future study on the most appropriate ventilation mode for this population.

Analysis of the pediatric surgery fellowship application process using the Thalamus™ database.

BACKGROUND: The pediatric surgery fellowship interview process is costly and time intensive. We hypothesized that the increasing number of interviews completed by applicants and programs have become inefficient over time. METHODS: We analyzed pediatric surgery fellowship program and applicant interview data between 2018 and 2020. Cancellations, program fill time, regional analysis of programs and applicants, and program rank list data were also captured. Analyses were performed using descriptive statistics and Chi-Square analysis. RESULTS: Our dataset included 34, 41, and 45 programs, which represented 81%, 91%, and 97% of all programs in 2018, 2019, and 2020, respectively. The median number of interviews completed per program remained constant, while the median number of interviews per applicant increased from 9.0 in 2018 to 13.0 in 2020. For 75% of programs, a program required only 4 or less candidates to fill their position. On average, 96% of program interviews do not result in a matched candidate. CONCLUSIONS: Programs offer interviews out of proportion to the number of positions available, and most applicants attend all interviews offered. We recommend an initial program goal of 20 interviews, which may be achieved by increased use of virtual interviews and the creation of program-level data on ideal applicant profiles.

Minimizing Variance in Gastroschisis Management Leads to Earlier Full Feeds in Delayed Closure.

BACKGROUND: Limited guidance exists regarding appropriate timing for feed initiation and advancement in gastroschisis. We hypothesized that implementation of a gastroschisis management protocol would allow for standardization of antibiotic and nutritional treatment for these patients. METHODS: We conducted a retrospective comparison of patients with simple gastroschisis at two pediatric hospitals before and after initiation of our gastroschisis care protocol. Complicated gastroschisis and early mortality were excluded. The control group extended from January 2012 to January 2014 and the protocol group from July 2014 to July 2016. Variables of interest included time to feed initiation, time to goal feeds, length of stay, and National Surgical Quality Improvement Program-defined complications. We performed a subgroup analysis for primary versus delayed gastroschisis closure. Statistical analyses, including F-tests for variance, were conducted in Prism. RESULTS: Forty-seven patients with simple gastroschisis were included (control = 22, protocol = 25). Protocol compliance was 76% with no increase in complication rates. There was no difference in length of stay or time from initiation to full feeds overall between the control and protocol groups. However, neonates who underwent delayed closure reached full feeds significantly earlier, averaging 9 d versus 15 d previously (P = 0.04). CONCLUSIONS: For infants undergoing delayed closure, the time to full feeds in this group now appears to match that of patients undergoing primary closure, indicating that delayed closure should not be a reason for slower advancement. Additional studies are needed to assess the impact of earlier full enteral nutrition on rare complications and rates of necrotizing enterocolitis.

The first six years of the APSA Travel Fellowship Program: Impact and lessons learned.

INTRODUCTION: The American Pediatric Surgical Association (APSA) travel fellowship was established in 2013 to allow pediatric surgeons from low- and middle-income countries to attend the APSA annual meeting. Travel fellows also participated in various clinical and didactic learning experiences during their stay in North America. METHODS: Previous travel fellows completed a survey regarding their motivations for participation in the program, its impact on their practice in their home countries, and suggestions for improvement of the fellowship. RESULTS: Eleven surgeons participated in the travel fellowship and attended the annual APSA meetings in 2013-2018. The response rate for survey completion was 100%. Fellows originated from 9 countries and 3 continents and most fellows worked in government practice (n=8, 73%). Nine fellows (82%) spent >3 weeks participating in additional learning activities such as courses and clinical observerships. The most common reasons for participation were networking (n=11, 100%), learning different ways of providing care (n=10, 90.9%), new procedural techniques (n=9, 81.8%), exposure to a different medical culture (n=10, 90.9%), and engaging in research (n=8, 72.7%). Most of the fellows participated in a structured course: colorectal (n= 6, 55%), laparoscopy (n=2, 18%), oncology (n=2, 18%), leadership skills (n=1, 9%), and safety and quality initiatives (n=1, 9%). Many fellows participated in focused clinical mentorships: general pediatric surgery (n=9, 82%), oncology (n=5, 45%), colorectal (n=3, 27%), neonatal care (n=2, 18%) and laparoscopy (n=2, 18%). Upon return to their countries, fellows reported that they were able to improve a system within their hospital (n=7, 63%), expand their research efforts (n=6, 54%), or implement a quality improvement initiative (n=6, 54%). CONCLUSIONS: The APSA travel fellowship is a valuable resource for pediatric surgeons in low- and middle-income countries. After completion of these travel fellowships, the majority of these fellows have implemented important changes in their hospital's health systems, including research and quality initiatives, to improve pediatric surgical care in their home countries. LEVEL OF EVIDENCE: This is not a clinical study. Therefore, the table that lists levels of evidence for "treatment study", "prognosis study", "study of diagnostic test" and "cost effectiveness study" does not apply to this paper.

Contemporary postoperative imaging practices among pediatric surgeons for image-guided central venous line placement: A survey of the American Pediatric Surgical Association.

BACKGROUND/PURPOSE: Rare life-threatening complications after central venous line (CVL) placement in children may encourage the routine use of postoperative imaging, despite multiple studies demonstrating the limited utility of this practice. The aim of this study was to investigate the nature of this discordance. METHODS: A 10-question survey was sent to 1,239 members of the American Pediatric Surgical Association (APSA) addressing contemporary practices regarding CVL placement and postoperative imaging. RESULTS: Five hundred eighteen (42%) surveys were completed. The majority of respondents routinely obtain a chest radiograph (CXR) after image-guided CVL placement (52%). Years in practice, operative volume, and practice type were not statistically associated with postoperative CXR usage (all p > 0.05). 'Routine' users were more likely to cite "standard of care" (p < 0.001), position verification (p < 0.001), and complication identification (p < 0.001) as indications for use than those who use CXR selectively. CONCLUSION: Routine use of postoperative CXR after image-guided CVL placement remains common among pediatric surgeons. Significant variation exists in the indication for this study, with considerable disagreement between 'selective' and 'routine' users. Consideration should be given for an APSA standardized guideline utilizing a clinically-driven approach to CVL placement and postoperative imaging to align with evidence-based practice. LEVEL OF EVIDENCE: N/A - descriptive analysis of survey results.

Validation of a venous thromboembolism prediction algorithm for pediatric trauma: A national trauma data bank (NTDB) analysis.

PURPOSE: We sought to validate a risk model to predict venous thromboembolism (VTE) in pediatric trauma through an analysis of a contemporary cohort in the National Trauma Data Bank (NTDB). STUDY DESIGN: Prospective internal validation was performed in 10 randomly stratified samples of children (age 0-17 years) from the NTDB 2013-2016. Model discrimination was determined by calculation of the c-statistic (AUC), and calibration was evaluated through analysis of observed to expected (O:E) ratio. Recalibration was performed with application of a mixed-effects logistic regression. Model parameters were reestimated based on recalibration. RESULTS: Retrospective review identified 481,485 pediatric trauma patients with 729 (0.2%) episodes of VTE. Discriminatory ability of the model in all random cohorts was significant with AUC > 0.93 (p < 0.001). Inadequate calibration was noted in 4 of 10 cohorts and the entire dataset (p < 0.001) with an O:E ratio of 1.79. Model recalibration resulted in similar discrimination (AUC = 0.95) with improved calibration (O:E ratio = 1.33, p < 0.0001). CONCLUSION: Pediatric trauma prediction models can provide useful data for VTE risk stratification in injured children, but these models must be validated and calibrated prior to use. Recalibration of the model in question resulted in improved accuracy in a contemporary NTDB dataset. These data provide an appropriately calibrated and validated model for clinical use. LEVEL OF EVIDENCE: II - Prospective internal validation of a multivariable prediction model.

Establishing best practices for structured NSQIP review.

INTRODUCTION: We describe an institutional program (INR- Interval NSQIP Review), to augment NSQIP utility through structured, multidisciplinary review of surgical outcomes in order to create near 'real-time' adverse event (AE) monitoring and improve surgeon awareness. METHODS: INR is a monthly meeting of quality analysts, surgeons and nursing leadership initiated to validate AE with NSQIP criteria, review data in real-time, and perform in-depth case analyses. Occurrence classification concerns were referred for national NSQIP review. Monthly reports were distributed to surgeons with AE rates and case-specific details. RESULTS: Since implementation, 377/3,026 AE underwent in-depth review. Of those, 7 occurrences were referred for clarification by central NSQIP review. Overall 37 (1.2%) were not consistent with NSQIP-defined AE after INR. Time from occurrence to surgeon review decreased by 223 days (296 vs. 73 days, p = 0.006). DISCUSSION: Structured monthly institutional review of AE prior to submission can create greater transparency and confidence of NSQIP data, reduce time from occurrence to surgeon recognition, and improve stakeholder understanding of AE definitions. This approach can be tailored to institutional needs and should be evaluated for downstream improvement in patient outcomes.