Peter Juviler, MD - Best of the Best in Pediatric Surgery 2024

OK, so time for the last heat of the day. That's right. It's been a great day and we're just about to wrap it up. Can't wait to see who wins overall. Um, and so now we will talk about the American Society. So we've have APSA, the American Pediatric Surgical Association, and AAP, the American Academy of Pediatrics. Let's see what we have coming up. Awesome. So first we have Doctor Peter Jubiler representing ABSA with the word reduction in unplanned intubations after Children's Surgery, a Quality Improvement Project. So let's watch it. Here we present a QY project based on opioid stewardship and extubation readiness, resulting in reduction of unplanned intubation events in our neonatal intensive care unit. Initially presented at ABSA annual meeting 2023. My name is Peter Juveler. I'm a general study resident at the University of Rochester Astra Memorial Golano Children's Hospital. Here you can see the rest of our authors. We have no conflicts of interest related to this project. And we have no specific funding to disclose. Postoperative unplanned intubation is associated with mortality in pediatric patients with neonate status identified as an independent risk factor. In 2017 and 2018, our children's hospital was identified as a negative outlier in NICO pediatric for unplanned intubation events, and we formed an improvement team in response. Data from this Pareto chart of unplanned intubation events in relation to age informed our planning phase. Greater than 85% of unplanned intubation events were seen in children less than 1 year old. This information targeted our efforts towards this age group, the majority of whom are treated in the neonatal ICU. This project took place at our 68 bed NICU within our Quaternary academic Center. Our team formed in summer of 2018 excavation checklist and post-op pain management guide implemented in September 2019 with data presented through June 2022. Here is a key driver diagram with this project highlighted in orange. Our smart aim was to reduce post-op unplanned intubation events in the NICU by 25% in one year. Primary drivers of over sedation and excavation readiness yielded secondary drivers. Which led to change ideas. The pain guideline consisted of minimizing opioids and opioid infusions and prescribing all patients acetaminophen for 48 to 72 hours post-op. The 10 item extubation checklist had no individual requirement for yes or no response and was completed and signed as part of the medical record. Baseline data consisted of 200 children with 145 children post intervention. There is no difference in the following demographics and comorbidities, all of which have been identified as risk factors for unplanned intubation. Age, prematurity, operative time greater than 120 minutes, malignancy, CNS abnormality, oxygen, nutrition support, and ASA class. Following our intervention, NICU unplanned intubation decreased, resulting in a 76% reduction in events. Post-op opioid prescribing between 0 and 48 hours also decreased. Morphine equivalent decreased from 39.5 to 7.9. Patients receiving opioids decreased from 85 to 51%. Patients receiving opioid infusion decreased from 65 to 21%, and post-op acetaminophen prescription increased from 25 to 90%. This control chart, which is a U chart, displays the number of NICU post-op unplanned intubation events per patient by quarter. The average proportion of postoperative unplanned intubation events decreased from 0.27 to 0.07 events per patient, which equates to 11 fewer unplanned intubation events per year. Checklist adherents reached the team's goal of 80%. There was no difference in balancing measures, including hospital length of stay and pneumonia rate. Mortality decreased from 6.5 to 0.7%. 2 of 13 mortalities experienced an unplanned intubation event pre-intervention versus 0 of 1 post-intervention. Ultimately, consensus plus cognitive aid appears to have decreased neonatal ICU unplanned intubation rate with a checklist to guide provider extubation discussions, plus the post-op pain management guideline to reinforce non-opioid pain control. The intervention was associated with decreased mortality. To our knowledge, no attempt to reduce these events has been described in the pediatric population. Our evidence supports the existence of a relationship between unplanned intubation and mortality, though unplanned intubation may not affect mortality directly. Thank you very much. Awesome. Welcome, uh, Doctor Drugler. Amazing presentation. Um, so I have a question. Which specialties and who were the people involved in this, uh, improvement management? Cause it seems it requires a group. Yeah, for sure. Um, I think that was one of the biggest strengths of this project because we had a pediatric surgeon leading it, but we had multiple representatives from the NICU, um, ENT and anesthesia as well as nursing. Um, and med students too, so we had a lot of good perspectives to sort of um to figure out how best to address that issue. Awesome, and do you require like, um? A different path for fellows residents, like how do you include them in this, um, protocol? Uh, in terms of like the working group, um, the work, well, the working group, we have met at least monthly, um, over the course of the project just to get updates and um. So everyone was sort of on the same team, on the same level, and Yeah, I think that that helps when everyone's sort of working together to figure out a problem and sort of getting rid of the hierarchy and the quality improvement group is kind of, it's kind of nice because you get lots of different ideas. That's really cool. Todd, you're mutant. We have a question from the audience about how the ET tubes are secured, uh, and what are the, uh, just moved, says, uh, and what are the plans to sustain, sustain and spread, I guess, Uh, I'm assuming that means sustain the, the improvement as opposed to it then filtering going back to the way it was before. And how do you get this into other applications? I mean, I think this concept will have broader applications than even just unplanned intubations. Yeah, so the, the ET tube actually falling out prematurely was a relatively small proportion of what we actually found was to be driving the unplanned um intubation. OK. So, and we, we just secure them with, uh, I think they just secure them with tape. Just like a standard securement, um, but really what we found was that patients maybe a day or two later after they were like chosen to be extubated on, on purpose, um, then required reintubation, um, and we thought that that was a, had a lot to do with sedation. So the education mostly was related to the sedation being the. The the causative factor. Yeah, the big, the two big things are were minimizing post-op opioids and everyone got acetaminophen, which is not the case previously. And then the second thing was that the extubation checklist, which there wasn't like a certain score that you needed to get to be extubated, but it, it went through a list of things that everyone could discuss and say, you know, air leak, no air leak, you know, the things that we sort of know. Um, have potential to influence successful extavation, but where there's not really a good score to prove it, but at least everyone was on the same page in terms of understanding the potential risks of extubating at that time versus waiting. It's interesting. There's been a, a massive reduction in opioid use in the teenagers after elective surgery, and no one even really uses them anymore, but the neonates are probably slow to follow, and now we need to apply the same, same shift to them as well. So, congrats. Thank you for presenting. It's a great paper. Thank you for having me.