<p><strong>BACKGROUND AND OBJECTIVES: </strong>Cefazolin, a first-generation cephalosporin, is the most commonly recommended antibiotic for perioperative prophylaxis to reduce surgical site infections. Children with a reported penicillin allergy often receive an alternative antibiotic because of a common misunderstanding of the cross-reactivity between these antibiotics. This use of alternative antibiotics in surgical populations have been associated with increased infections, antibiotic resistance, and health care costs. We aimed to increase the percentage of patients with nonsevere penicillin-class allergies who receive cefazolin for antibiotic prophylaxis.</p>

<p><strong>METHODS: </strong>A multidisciplinary team conducted this quality improvement initiative, with a series of 3 plan-do-study-act cycles aimed at children with nonsevere penicillin-class allergies undergoing surgical procedures that require antibiotic prophylaxis. The primary outcome measure was the percentage of surgical encounters among patients with nonsevere penicillin-class allergies who received cefazolin as antibiotic prophylaxis. Statistical process control charts were used to measure improvement over time.</p>

<p><strong>RESULTS: </strong>Approximately 400 children were involved in this project. There was special cause variation and a shift in the center line from 60% to 80% of eligible patients receiving cefazolin for antibiotic prophylaxis, which was sustained for the duration of the project. In the last month, 90% of eligible patient received cefazolin, surpassing our goal of 85%. This improvement has been sustained in the 5 months after project completion. We had no cases of severe allergic reactions in the operating room.</p>

<p><strong>CONCLUSIONS: </strong>Our multidisciplinary education-focused interventions were associated with a significant increase in the use of cefazolin for perioperative antibiotic prophylaxis in patient with penicillin allergies.</p>

<p><strong>BACKGROUND: </strong>Postoperative nausea vomiting (PONV) after elective outpatient surgery can complicate discharge and increase patient suffering. Within our hospital system, there was variability in the use of PONV prophylaxis for patients undergoing anterior cruciate ligament (ACL) reconstruction, which resulted in variable outcomes. To address this variability, we designed and implemented a standardized PONV prophylaxis guideline for the care of this surgical population.</p>

<p><strong>AIM: </strong>We sought to develop and implement a standardized PONV prophylaxis guideline for all patients presenting for elective ambulatory ACL reconstruction with the goal of reducing the rate of emesis to less than or equal to 5%.</p>

<p><strong>METHODS: </strong>We convened a multidisciplinary team to develop a PONV prophylaxis guideline which included administration of dexamethasone, ondansetron, and a low-dose propofol infusion in addition to a femoral and sciatic nerve block and routine ketorolac administration for pain control. Our primary outcome, emesis rate, was tracked using a P-chart. Process measures included use of guideline medications and balancing measures included opioid administration, pain scores, and emergence time.</p>

<p><strong>RESULTS: </strong>We analyzed PONV outcomes for 817 patients from January 1, 2014, to December 31, 2018. The baseline postoperative emesis rate for all anesthetizing locations was 17%. Following, guideline implementation, the emesis rate decreased to 5%. Opioid administration was decreased following guideline implementation. The percentage of patients managed without any perioperative opioids increased from 16% in the baseline group to 38% following guideline implementation. The P-chart suggests that the observed reduction in emesis rate represents special cause variation and this reduction was sustained over a two-year period.</p>

<p><strong>CONCLUSIONS: </strong>Implementation of standard PONV guidelines for adolescents undergoing outpatient ACL reconstruction was associated with lower emesis rates. This reduction in emesis rate may have been due to the concurrent reduction in opioids we observed following guideline implementation.</p>

<p><strong>BACKGROUND: </strong>Children routinely undergo inhalational induction of general anesthesia. Intravenous line placement typically occurs after induction of anesthesia and can be challenging, particularly in infants and young children.</p>

<p><strong>AIMS: </strong>We conducted a retrospective observational study to determine whether there was an association between clear liquid fasting time and the number of peripheral intravenous catheter insertion attempts in anesthetized children. The secondary aim was to identify factors associated with multiple attempts to insert intravenous lines.</p>

<p><strong>METHODS: </strong>After institutional research board approval, we retrieved a data set of all children between 0 months and 18 years who received general anesthesia at our hospital between January 1, 2016, and September 30, 2017. Data included age, gender, weight, race, ASA status, gestational age, number of peripheral intravenous catheter insertion attempts, any assistive device for insertion, and insertion site. Inclusion criteria were mask induction, ASA status 1 or 2, non-emergency, ambulatory surgical procedures and placement of a single intravenous line during the anesthetic.</p>

<p><strong>RESULTS: </strong>9,693 patients were included in the study. 8,869 patients required one insertion attempt and 824 underwent multiple insertion attempts. 50% of patients in the single insertion attempt group had clear liquid fasting time less than 6.9 hours compared to 51.8% of patients requiring multiple attempts. Logistic regression model adjusted for age, ASA status, gender and BMI did not find an association between duration of clear liquid fasting time and rate of multiple insertion attempts for intravenous catheters (OR 0.99, 95% CI 0.98-1.01, P = 0.47).</p>

<p><strong>CONCLUSIONS: </strong>Clear liquid fasting time was not associated with multiple insertion attempts for intravenous line insertion in children receiving general anesthesia. Factors such as patient age, ethnicity, time of day of induction of anesthesia and American Society of Anesthesiologists Physical Status classification show a greater association with the risk of multiple intravenous line insertion attempts.</p>

<p><strong>BACKGROUND: </strong>As high-quality health care becomes increasingly expensive, improvement projects are focused on reducing cost and increasing value. To increase value by reducing operating room (OR) utilization, we studied the effect of a dedicated team approach for posterior spinal fusion (PSF) for scoliosis.</p>

<p><strong>METHODS: </strong>With institutional support, an interdisciplinary, dedicated team was assembled. Members developed standardized protocols for anesthetic management and patient transport, positioning, preparation, draping, imaging, and wake-up. These protocols were initially implemented with a small interdisciplinary team, including 1 surgeon (Phase 1), and then were expanded to include a second surgeon and additional anesthesiology staff (Phase 2). We compared procedures performed with a dedicated team (the Dedicated Team cases) and procedures performed without a such a team (the Casual Team cases). Because of the heterogeneous nature of PSF for scoliosis, we developed a case categorization system: Category 1 was relatively homogeneous and indicated patients with fusion of ≤12 levels, no osteotomies, and a body mass index (BMI) of &lt;25 kg/m, and Category 2 was more heterogeneous and indicated patients with fusion of &gt;12 levels and/or ≥1 osteotomy and/or a BMI of ≥25 kg/m.</p>

<p><strong>RESULTS: </strong>In total, 89 Casual Team and 78 Dedicated Team cases were evaluated: 71 were in Category 1 and 96 were in Category 2. Dedicated Team cases used significantly less OR time for both Categories 1 and 2 (p &lt; 0.001). In Category-1 cases, the average reduction was 111.4 minutes (29.7%); in Category-2 cases, it was 76.9 minutes (18.5%). The effect of the Dedicated Team was scalable: the reduction in OR time was significant in both Phase 1 and Phase 2 (p &lt; 0.001). The Dedicated Team cases had no complications. Cost reduction averaged approximately $8,900 for Category-1 and $6,000 for Category-2 cases.</p>

<p><strong>CONCLUSIONS: </strong>By creating a dedicated team and standardizing several aspects of PSFs for scoliosis, we achieved a large reduction in OR time. This increase in team efficiency was significant, consistent, and scalable. As a result, we can routinely complete 2 Category-1 PSFs in the same OR with the same team without exceeding standard block time.</p>

<p><strong>BACKGROUND: </strong>Posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) is associated with significant pain and prolonged hospitalization. There is evidence that early mobilization and multimodal analgesia can accelerate functional recovery and reduced length of stay (LOS). Using these principles, we implemented a quality improvement initiative to enable earlier functional recovery in our AIS-PSF population.</p>

<p><strong>METHODS: </strong>We designed and implemented a standardized rapid recovery pathway (RRP) with evidence-based management recommendations for children aged 10 to 21 years undergoing PSF for AIS. Our primary outcome, functional recovery, was assessed using statistical process control charts for LOS and average daily pain scores. Our process measures were medication adherence and order set utilization. The balancing measure was 30-day readmission rate.</p>

<p><strong>RESULTS: </strong>We included 322 patients from January 1, 2011 to June 30, 2015 with 134 (42%) serving as historical controls, 104 (32%) representing our transition population, and 84 (26%) serving as our RRP population. Baseline average LOS was 5.7 days and decreased to 4 days after RRP implementation. Average daily pain scores remained stable with improvement on postoperative day 0 (3.8 vs 4.9 days) and 1 (3.8 vs 5 days) after RRP implementation. In the second quarter of 2015, gabapentin (91%) and ketorolac (95%) use became routine and order set utilization was 100%. Readmission rates did not increase as a result of this pathway.</p>

<p><strong>CONCLUSIONS: </strong>Implementation of a standardized RRP with multimodal pain management and early mobilization strategies resulted in reduced LOS without an increase in reported pain scores or readmissions.</p>