OHSU MViPS

ImportanceStandardized perioperative pathways are increasingly used in surgery to reduce unwarranted variation, promote evidence-based practice, and improve patient outcomes, yet pediatric implementation has lagged, with most studies focused on single conditions or institutions. Broader evaluation of multiprotocol, multi-institution initiatives is needed.ObjectiveTo evaluate the association of the Minimizing Variance in Pediatric Surgery (MViPS) program with clinical outcomes, length of stay (LOS), and cost.Design, Setting, and ParticipantsThis cohort study was conducted from October 2012 to November 2021 at 2 academic pediatric tertiary referral centers in Oregon. Data analysis was completed in May 2024. Pediatric surgery patients treated for protocol-specified conditions or procedures, with age cutoffs varying by protocol (typically <18 years). Exclusions included failure to meet protocol criteria, nonpediatric surgery management, and insufficient documentation.InterventionImplementation of standardized perioperative protocols targeting a range of pediatric surgical conditions.Main Outcomes and MeasuresOutcomes included LOS, total hospital costs (THC), complications, and protocol compliance. LOS was characterized as study LOS, defined as postprocedure LOS for patients who underwent a procedure and total hospital stay for those who did not, and total LOS, representing the entire period of hospitalization. Hospital days and cost differences were calculated from total LOS and THC.ResultsA total of 1081 pediatric surgery patients were included (519 postprotocol and 562 preprotocol; median [IQR] age, 3 [0-10] years; 668 [62%] male). No significant demographic differences were found between preprotocol and postprotocol groups. Protocol compliance was 82% (426/519). Complication rates were similar between groups, but study LOS was 23% shorter in the postprotocol group (incidence rate ratio [IRR], 1.23; 95% CI, 1.11-1.38; P < .001), with a reduction of an estimated 191 hospital days. THC was 10% lower in the postprotocol group (IRR, 1.10; 95% CI, 1.01-1.20; P = .03), with an estimated reduction of $266 709. Extrapolation to 3167 patients treated according to protocol since the end of the study (up to April 2024) reveals an estimated reduction of $2 236 583 and 1584 hospital days.Conclusions and RelevanceIn this study, the MViPS initiative was associated with reduced THC and LOS while maintaining outcomes. These findings support the value of standardized protocols in improving pediatric surgical outcomes and efficiency across institutions.

Background: Employing an institutional initiative to minimize variance in pediatric surgical care, we implemented a set of perioperative bundled interventions for all colorectal procedures to reduce surgical site infections (SSIs). Methods: Implementation of a standard colon bundle at two children's hospitals began in December 2014. Subjects who underwent a colorectal procedure during the study period were analyzed. Demographics, outcomes, and complications were compared with Wilcoxon Rank-Sum, Chi-square and Fisher exact tests, as appropriate. Multivariable logistic regression was performed to assess the influence of time period (independent of protocol implementation) on the rate of subsequent infection. Results: One hundred and forty-five patients were identified (preprotocol=68, postprotocol=77). Gender, diagnosis, procedure performed and wound classification were similar between groups. Superficial SSI rates declined from 11.8% to 2.6% (p=0.03) after protocol implementation. Organ space SSI rate and overall complication rate were not significantly different between groups. Multivariable logistic regression demonstrated that the reduction in superficial SSI was not explained by time period alone. Length of stay and cost were similar between groups. Conclusion: Implementation of a standard pediatric perioperative colon bundle can reduce superficial SSIs. Larger prospective studies are needed to evaluate the impact of colon bundles in reducing complications, hospital stay and cost. Level of evidence: III - Retrospective cohort study.