Evaluation of Tiered Surgical Triage For Cohen Children’s Medical Center Operating Rooms Jonathan Guevara1 , Jessica Goldbeck2, Danielle Sargeant3 BSN, PNP and Jose Prince MD, FACS, FAAP 1,3 1Donald
Background Cohen Children’s Medical Center (CCMC) is the flagship pediatric hospital for Northwell Health located in New Hyde Park, New York. CCMC is the largest American College of Surgeons (ACS) verified Level 1 Pediatric Trauma Center in New York State. In the years 2018-2019, 11,196 pediatric surgeries were performed. Of these 29.3% were cases that were not originally scheduled, otherwise known as addons. These add-ons at CCMC are scheduled on a “first-come, first-served basis” unless the add-on is a life-threatening emergency which requires immediate intervention. The level of acuity for surgical add-ons is currently not the primary factor in determining the order in which add-ons are completed. This can occasionally lead to unintended consequences with concerns for increased risk of complications, delay in definitive treatment, and frustration for both the provider and patient. Limited research has been conducted to evaluate optimal surgical triage protocols (1), although there are disease specific recommendations for optimal surgical intervention (ex. Appendectomies) (2). In this study, we aimed to identify areas of improvement for surgical triage at CCMC. We identified different surgical cases and calculated the time to surgery (TTS) to see if our current add-on practices meet suggested guidelines.
Methods • Diagnoses requiring surgical intervention with varying levels of acuity were selected. These included severe trauma (level 1 trauma), testicular torsion, midgut volvulus, and appendectomy. • A study period was defined for each type of case and the TTS was calculated for each surgery in the time period retrospectively. • Start time was defined for each clinical condition. TTS was calculated using different start points for each type of surgery. For instance, the start point for level 1 traumas was the time the patient was seen in the emergency room. For testicular torsions, the start time was the time that a diagnosis was communicated from the radiology team to either the urology service or emergency department. • The end point for each surgery was the time that the patient was checked into the operating room (OR). • The ideal goal was selected based on suggested guidelines.
References 1. Kluger, Y., Ben-Ishay, O., Sartelli, M. et al. World society of emergency surgery study group initiative on Timing of Acute Care Surgery classification (TACS). World J Emerg Surg 8, 17 (2013). 2. Cameron DB, Williams R, Geng Y, Gosain A, Arnold MA, Guner YS, Blakely ML, Downard CD, Goldin AB, Grabowski J, Lal DR, Dasgupta R, Baird R, Gates RL, Shelton J, Jancelewicz T, Rangel SJ, Austin MT. Time to appendectomy for acute appendicitis: A systematic review.. 2018 Mar;53(3):396-405.
and Barbara Zucker School of Medicine at Hofstra/Northwell 2Long Island Jewish Medical Center 3Cohen Children’s Medical Center
Results
Conclusions Figure 1: Time to Surgery for Level 1 Traumas Seen in 2019 at CCMC. Time to surgery was calculated as the difference between the time the patients were taken to the operating room and time the patients were seen in the emergency room. N = 7
• The median time to surgery for testicular torsions in 2018-2019 was 96.2 mins. Of the 50 cases of testicular torsion treated in 2018-2019, 13 resulted in orchiectomy. • The median time to surgery for level 1 traumas was 69 mins. This is 39 mins over the proposed goal of 30 mins. • The median time to surgery for Ladd procedures in 2018-2019 was 125 mins. This is 65 mins over the proposed goal of 60 mins. • The median time to surgery for appendectomies in April 2019 was 372.5 mins. This is below the proposed goal of 720 mins.
Future Direction Figure 2: Time to Surgery for Testicular Torsions Treated at CCMC in 20182019. Time to surgery was calculated as the difference between the time the patients were taken to the operating room and the read back time of the latest ultrasound suggestive of testicular torsion. N = 50
Figure 3: Time to Surgery for Ladd Procedures Performed at CCMC in 2018-2019. Time to surgery was calculated as the difference between the time the patients were taken to the operating room and the read back time on the latest imaging study suggestive of midgut volvulus. N = 11
Figure 4: Time to Surgery for Appendectomies Performed at CCMC in April 2019 . Time to surgery was calculated as the difference between the time the patients were taken to the operating room and the time antibiotics were first administered. N = 32
Figure 5: Proposed Classification System for Surgical Triage. We propose implementing a tiered classification system that considers the level of acuity of add-ons. This classification was created by the World Society of Emergency Surgery (1).
• TTS should be calculated following implementation of a tiered approach and compared with the TTS before implementation. • In addition to dedicating an OR for level 1 traumas, we propose dedicating an OR for add-ons following the construction of new OR space.
Acknowledgments We would like to thank the Klar Leadership Development and Innovation Management Program for supporting this work. We would also like to thank Dr. Barrie Rich and Dr. Charlotte Kvasnovsky for their assistance in data collection. Additionally, we would like to thank Dr. Andrew Hong and Dr. Vincent Parnell for their guidance with this project.