Quality Improvement, Education, and Outcomes Research in Pediatric Surgery

Abstract

Historically, there has been a great disparity in the advancement of pediatric clinical services and the development of pediatric quality and safety indicators. The development and expansion of pediatric care in the United States began with the opening of the Children’s Hospital of Philadelphia in 1855. Despite this major advancement in the organization and administration of medical care for the pediatric population, a formalized mechanism to specifically address medical errors, quality of care, quality improvement, and longitudinal outcomes analysis did not take form until the middle of the twentieth century. In 1934 Ernest Codman, an orthopedic surgeon, advocated that every hospital should follow patients to determine if their treatment had been successful. Over the past half century, pediatric hospitals have become highly specialized facilities for delivering state-of-the-art medical care. The progression of medical specialization into pediatric subspecialties has led to a commitment to provide the best care possible for pediatric patients.

Appendices

Summary Points

Patient safety events for hospitalized children occur at a comparable rate to hospitalized adults.

There are many safety issues that are unique to children’s health care, which are related to the four Ds of childhood: developmental change, dependence on adults, different disease epidemiology, and unique demographic characteristics.

Medication errors are the most common adverse events in hospitalized patients.

The majority of medication errors are associated with the presence of rotating general surgery residents.

Standardized order sets for common pediatric surgical conditions the use of routine peri-operative order sets reduce the potential for medication error, overall hospital charges, and length of stay.

Surgical morbidity and mortality (M&M) conference has been the most important meeting for surgical education and quality assurance in the surgery department at teaching institutions ever since Ernest Codman developed his “End Results” system at the Massachusetts General Hospital in the early 1900s.

M&M conference remains the cornerstone to fulfilling many of the ACGME competencies, especially practice-based learning and improvement.

The educational value of the surgical M&M conference can be improved by applying several techniques: direct questioning of the audience, more thorough explanation of cases, questions directed to attending surgeons, use of radiographic images, and teaching points specifically made for the medical students in attendance.

The NSQIP, initiated by the United States Department of Veteran’s Affair and adopted by academic medical centers throughout the United States, is designed to measure the quality of adult surgical care within an institution utilizing prospective entry of patient risk and outcome data and the determination of risk-adjusted 30-day outcomes.

Efforts are under way to apply the NSQIP standards to the analysis of patient risk and outcome data at children’s centers.

Editor’s Comment

It is hard to believe that a focus on the issue of patient safety as it relates to the care of children has taken so long to take root in this country, especially when one considers the staggering statistics as it relates to the number of preventable injuries that occur every day. At many children’s medical centers, the boards of trustees have taken ownership of the problem and this has helped to increase awareness and spark entire institutions to action. Every children’s hospital should have a patient safety officer and deputies in every department. Meanwhile, the science of patient safety, though still in its early development, is being developed by pioneers who are applying many of the same techniques that have proved successful in other fields such as aviation and industry. A major advance is the concept that although some medical errors are due to human factors and the ­technological complexity of the medicine, the majority actually appear to be due to predictable and therefore ­preventable system failures. Analysis of errors and near-misses through root cause analyses and multi-disciplinary M&M conferences, without using traditional personal blame tactics, have helped to identify system modifications that should help to prevent similar errors. There are also efforts to make use of available technology such as computer-based medical entry to improve efficiency and minimize errors. Finally, it is clear that improving quality and patient safety follows naturally when medical care is evidence-based and standardized. Nevertheless, these are difficult to institute due to the traditional health-care culture that values physician autonomy, a rigid hierarchy with the physician as “captain of the ship,” and learning by trial-and-error.

The M&M conference is a hallowed tradition in most surgery departments. Modifications in the traditional approach are long overdue and should result in vast improvements in the value of the conference without compromising its traditional usefulness. These modifications include: (1) making it a multi-disciplinary conference; (2) adopting a no-blame format; (3) distinguishing between known and expected complications from true patient safety issues, which should be forwarded to the department patient safety officer for systematic review; (4) discussing near-misses as well as complications; and (5) discussing cases in the context of the available scientific evidence. Finally, there should be a concerted effort to gather data prospectively rather than discuss each case individually and therefore out of context. Though much is to be learned by studying individual data points in depth, it is through the analysis of outcomes data and trends that improvements in the quality and safety of patient care can be realized more quickly and effectively.