Survey Results

2022

Perspectives and Practices in Palliative Care of Pediatric Surgical Patients Among Pediatric Surgeons

Purpose: Seriously ill children comprise a substantial portion of both the pediatric surgical and pediatric palliative care (PPC) populations, and there is significant overlap between them. However, the nature of interactions and collaborations between them remains unknown, and the role of surgeons in the provision of PPC undefined. This study explored pediatric surgeons’ and palliative care pediatricians’ experiences with and attitudes about palliative care in pediatric surgical patients as a first step in identifying opportunities to enhance collaboration and communication between these two groups.

Response Rate: an anonymous survey was electronically distributed to attending physician members of the American Pediatric Surgical Association (APSA) and the Pediatric Interest Group of the American Academy of Hospice and Palliative Medicine (AAHPM) with 8% and 20% response rates, respectively.

Results:

Practices in Caring for Seriously Ill Children and Palliative Care Utilization

*Almost half of surgeons (43%) report consulting the PPC service often for children with serious, life-limiting or life-altering illnesses, but the majority (67%) of PPC clinicians said that they are rarely or never consulted by surgeons in these cases.

*For life threatening conditions where cure is possible but may fail, surgeons were more likely to say that the time of deterioration was an appropriate time for PPC consultation (30% vs 17%), whereas PPC clinicians were more likely to suggest that the time of diagnosis was the appropriate time (54% vs 34%).

*In a hypothetical scenario involving a patient with severe neurologic impairment and a surgically treatable congenital anomaly, 65% of surgeons were likely to recommend repair versus 25% of PPC clinicians, the majority of whom (62%) answered that they were unsure, as their recommendation would depend on the expected recovery and the patient/family's goals.

Perspectives on Palliative Care

*Pediatric surgeons and PPC clinicians agreed that PPC need not only be involved when patients are actively dying; that palliative care and invasive surgical interventions are not mutually exclusive; and that talking about death does not make patients more discouraged.

*The two groups diverged on whether invasive measures such as ECMO or mechanical ventilation could be considered a form of palliative care, with many surgeons disagreeing (59%) and PPC clinicians mostly agreeing (66%).

*The most reported barrier to PPC consultation by surgeons was the concern that parents would think the surgical team was giving up on their child (29%).

*Pediatric surgeons reported that they would most benefit from additional training in management of parental psychological distress (43%), patient physical distress (31%), and discussions of goals of care (26%) and prognosis (25%).

Conclusions:

While pediatric surgeons value PPC involvement, surgical culture and misperception of parental resistance to PPC involvement lead to palliative care consultation when illness acuity and severity are high, the possibility of curability is low, and death seems imminent. Barriers to PPC use and self-reported knowledge gaps in PPC provision may be mitigated by formalized PPC training for surgeons, specifically in areas in which surgeons desire more PPC skills (i.e. understanding patient and family priorities in care, managing patient and parental psychological distress, and treating non-surgical symptoms). Development of evidence-based and even disease-specific palliative care-oriented support paradigms could also facilitate concurrent PPC provision alongside disease-directed therapy in the care of seriously ill surgical patients.

Publications: presented at 2023 APSA meeting; manuscript under review in Journal of Pediatric Surgery

Main Contact: Danielle Ellis, MD MTS ([email protected])

Pediatric Surgeon Perceptions on Operating Room Environmental Stewardship and Current Institutional Climate-Smart Actions

Background: Operating rooms generate significant greenhouse gas emissions. Our objective was to assess current institutional climate-smart actions and pediatric surgeon perceptions regarding environmental stewardship efforts in the operating room.

Methods: A survey was distributed to members of the American Pediatric Surgical Association in June 2022. The survey was piloted among ten general surgery residents and two professional society cohorts of pediatric surgeons. Comparisons were made by demographic and practice characteristics.

Results: Survey response rate was 15.9% (n ¼ 160/1009) and included surgeons predominantly from urban (n ¼ 93/122, 76.2%) and academic (n ¼ 84/122, 68.9%) institutions. Only 9.8% (n ¼ 12/122) of pediatric surgeons were currently involved in operating room environmental initiatives. The most common climate-smart actions were reusable materials and equipment (n ¼ 120/159, 75.5%) and reprocessing of medical devices (n ¼ 111/160, 69.4%). Most surgeons either strongly agreed (n ¼ 48/121, 39.7%) or agreed (n ¼ 62/121, 51.2%) that incorporation of environmental stewardship practices at work was important. Surgeons identified reusable materials/equipment (extremely important: n ¼ 61/129, 47.3%, important: n ¼ 38/129, 29.5%) and recycling (extremely important: n ¼ 68/129, 52.7%, important: n ¼ 29/129, 22.5%) as the most important climate-smart actions. Commonly perceived barriers were financial (extremely likely: n ¼ 47/123, 38.2%, likely: n ¼ 50/123, 40.7%) and staff resistance to change (extremely likely: n ¼ 29/123, 23.6%, likely: n ¼ 60/123, 48.8%). Regional differences included low adoption of energy efficiency strategies among respondents from southern states (n ¼ 0/26, p ¼ 0.01) despite high perceived importance relative to other regions (median: 5, IQR: 4e5 vs median: 4, IQR 4e5, p ¼ 0.04).

Conclusions: While most pediatric surgeons agreed that environmental stewardship was important, less than 10% are currently involved in initiatives at their institutions. Opportunities exist for surgical leadership surrounding implementation of climate-smart actions.

Main Contacts: Dr. Gwyneth Sullivan, Dr. Mehul Raval

Publications: Journal of Pediatric Surgery

ABSTRACT PREVIEW: A NATIONAL SURVEY EXPLORING COMMUNICATION AND BIAS AMONG PEDIATRIC SURGEONS

Purpose:

Collaboration among pediatric surgeons represents a foundational strength of the specialty and manifests across multiple domains, from patient care to professional development. Unconscious biases among pediatric surgeons undermine this collaboration with wide-ranging consequences, including: (1) impaired communication during complex patient care coordination; and (2) discordance between the needs of diverse pediatric surgical practices and the strategic priorities of their national organizations. We designed a survey to explore the impact of bias on the practice of pediatric surgery.

Method:

A REDCap survey was distributed via email to APSA members in July, 2022. Participants were queried regarding communication processes surrounding patient referrals. Bias was explored between surgeons and regarding APSA committee membership, leadership positions, educational opportunities, and major events. Statistical analyses included chi square tests of independence.

Results:

We received responses from 239 of 1,443 survey recipients (17%), including 72 community-based pediatric surgeons. Discordance regarding care coordination was observed between the proportion of surgeons believing they initiate appropriate communication (86-95%), versus the proportion reporting they receive high-quality communication (52-60%). 21-30% report experiencing professional bias regarding APSA-related activities, with 57-78% identifying their practice environment as a driver of that bias. Community-based pediatric surgeons were more likely than academic surgeons to experience bias when interfacing with different practice environments (67% vs 41%, P=0.0004). Compared to academic- based pediatric surgeons, fewer community-based surgeons reported receiving communication via preferred routes when referring patients to higher levels of care (41% vs 62%, P=0.03).

Conclusion:

Differences in pediatric surgical practice environments represent a significant driver of professional biases and appear to disproportionately impact community-based surgeons. The impact of bias on pediatric surgical collaboration may be obviated through (1) targeted efforts promoting equitable representation of all practice environments in the leadership composition of pediatric surgical organizations, and (2) systematic frameworks that promote reliable communication around pediatric surgical care coordination.

Main Contact: Dr. Ellen Reynolds

Discontinuation of the OriGen® dual-lumen right atrial cannula decreased venovenous ECMO usage in neonates and older children: A survey of the American Pediatric Surgical Association 

Introduction: Dual-lumen cannulas for venovenous (VV)-ECMO are widely used in pediatric patients. The popular OriGen® dual-lumen right atrial cannula was discontinued in 2019 without a comparable replacement. 

Methods: A survey covering VV-ECMO practice and opinions was distributed to attending members of the American Pediatric Surgical Association.  

Results: 137 pediatric surgeons responded (14%).  Prior to discontinuation of the OriGen®, 82.5% offered VV-ECMO to neonates, and 79.6% cannulated with the OriGen®. Following its discontinuation, those that offered only venoarterial (VA)-ECMO to neonates increased to 37.6% from 17.5% (p=0.0002).  An additional 33.8% changed their practice to sometimes use VA-ECMO when VV-ECMO was indicated.  Reasons for not incorporating dual-lumen bi-caval cannulation into practice included risk of cardiac injury (51.7%), inexperience with bi-caval cannulation in neonates (36.8%), difficulty with placement (31.0%), and recirculation and/or positioning problems (27.6%).  For the pediatric/adolescent population, 95.5% of surgeons offered VV-ECMO prior to OriGen® discontinuation.  Few switched to exclusive VA-ECMO (1.9%) when the OriGen® was discontinued, but 17.8% of surgeons began to incorporate selective use of VA-ECMO.   

Conclusion: Discontinuation of the OriGen® cannula drove pediatric surgeons to alter their cannulation practices, dramatically increasing VA-ECMO use for neonatal and pediatric respiratory failure.  These data may suggest a need for targeted education accompanying major technological shifts. 

The Effect of Business in Medicine Impacts our Delivery of Pediatric Surgical Care

Responding pediatric surgeons generally understand that medicine is a business in the U.S. However, pediatric surgeons’ knowledge of the nuances of business practices and their impacts on stakeholders, including patients, families, healthcare systems, and payers, is variable, highlighting an opportunity for educational efforts among pediatric surgeons to increase their understanding of stakeholder impacts. There is an opportunity to facilitate educational sessions at national meetings with topics related to the economics and business of pediatric surgery. Some pediatric surgeons may find such information helpful. The responses to this survey also underscore the financial stress present within US healthcare systems, likely leading to increased difficulty in performing emergent and urgent cases and significant staffing constraints in the OR. Although the pandemic worsened these stresses, they are likely to continue. The responses to this survey may influence policymakers and advocates for pediatric surgical patients and favorably impact the quality of surgical care provided to children.

2021

Pediatric Surgeons' Current Knowledge and Practices of Obtaining Assent from Adolescents for Elective Reconstructive Procedures

Purpose: Adolescents develop their decision-making ability as they transition from childhood to adulthood. Participation in their medical care should be encouraged through obtaining assent, as recommended by the American Academy of Pediatrics (AAP). We aim to define the current knowledge of AAP recommendations and surgeon practices with respect to assent for elective reconstructive procedures.

Methods: An anonymous electronic survey was distributed to North American pediatric surgeons and fellows through the American Pediatric Surgical Association membership (n=1353).

Results:  A total of 220 surgeons and trainees responded (16.3%). 71% of surgeons practice in academic settings and 64% have over 10 years of experience. 49% of surgeons who are familiar with the concept of assent had received formal training on the topic, while 12% of respondents had not heard of assent before. 47% are aware of the 2016 AAP policy statement regarding assent in pediatric patients. 89% always include adolescents as part of the consent discussion, with patient wishes and their developmental age/maturity as the greatest factors influencing the surgeons' decisions. 77% solicit an expression of willingness to accept the proposed care from the patient. The majority (74%) of surgeons perceived patient cooperation/understanding as the biggest barrier to obtaining assent, followed by time (21%) and surgeon familiarity with assent (19%). Over half of respondents would consider proceeding with elective surgery despite the adolescent patient's refusal. Reasons cited include surgeons' perception of medical necessity, perceptions of disease urgency, and lack of patient maturity.

Conclusion: Overall, this survey study indicates that pediatric surgeons understand and practice the principles of assent at a high level when treating adolescent patients in the elective setting, but fewer are explicitly aware of formal policy statements or have received formal training.  It remains a variation in care and thus an area for further provider education and development. While there is no definitive age when the adolescent is ready cognitively and developmentally, participation in assent respects their autonomy, promotes shared decision-making, and exercises their skills and capacity to provide informed consent as adults. Institutional policies regarding assent are warranted to support surgeons in this process.

Publications: Presented at APSA 2022, published in the Journal of Medical Ethics.

Main Contact: Dr. Kathleen van Leeuwen

Who is Practicing Where?: Practice Trends and Motivating Factors Among Pediatric and Rural Surgeons

Purpose: The concentration of pediatric surgeons in urban areas has led to a disparity in surgical care for children in rural parts of North America.  Rural hospitals may not have general surgeons who are able to provide surgical care for pediatric patients further exacerbating this disparity.  We aimed to examine practice patterns and motivations for rural versus urban practice choices among pediatric and rural surgeons.

Methods: An electronic survey was created to elicit data regarding surgeons’ practice environment, demographic and educational information, and motivating variables for practice choice.  This survey was sent to both the APSA and ACS Rural Surgery email distribution lists

Results: A total of 258 pediatric and 16 rural surgeons completed the survey. Amongst pediatric surgeons: 185, 68 and 5 surgeons reported practicing in a urban, suburban/mixed or rural setting respectively.  While a majority of urban and suburban pediatric surgeons provide coverage of satellite clinics, these tend to be less than 50 miles travel distance and the majority of these surgeons did not partner with a rural hospital.  Practice setup was a main factor for job choice.  Four of the rural pediatric surgeons did not intend to practice in a rural location. Furthermore, four of the rural pediatric surgeons were exposed to global surgery rotations in residency while the majority of urban and suburban surgeons did not have a similar experience. 

Conclusions: Pediatric surgeons tend to practice in urban areas. This decision is influenced more by practice characteristics than lifestyle.  Factors such as prior exposure to global surgery rotations as well as academic positions appear to correlate with a decision to practice in a rural setting. Focus on tailoring surgical practices could attract more surgeons to provide surgical care to rural pediatric patients.

The Utilization of Telehealth During the COVID-19 Pandemic: An American Pediatric Surgical Association Survey

• Goal: Telehealth use has grown tremendously during the COVID-19 pandemic, however its impact on pediatric surgical providers is unknown.  This information is important to help determine whether groups such as the American Pediatric Surgical Association (APSA) and the American Academy of Pediatrics (AAP) section on surgery should support its use.  This survey was therefore performed to determine how telehealth implemented during the COVID-19 pandemic has impacted the use of telehealth among pediatric surgery providers, to determine the effects on their clinical efficiency and patient satisfaction, and to determine how the members feel APSA and AAP should support telehealth endeavors in the future.
• Response Rate: The survey was distributed to 1,060 APSA members, and 247 consented to proceed with the survey (23.3% response rate).
• Findings: Of 247 responses, only 49 (19.8%) surgeons endorsed using telehealth prior to the COVID-19 pandemic, while 154 (62.3%) began using telehealth during the pandemic. The most common diagnoses pediatric surgeons were willing to see via telehealth for the initial consult did not necessarily require a physical exam, such as cholelithiasis (55.1%, n=136), and port-a-cath placement (51.8%, n=128).  Conversely, only 41.7% (n=103) of surgeons would see a hernia consult via telehealth, while 23.9% (n=59) said they would not.  The dominant barriers to telehealth utilization identified after the beginning of the pandemic were inability to perform a physical exam (n=115, 46.6%), patient access to technology (n=115, 46.6%), and patient preference (n=87, 35.2%).  The lack of reimbursement as a barrier to telehealth utilization dropped in importance from being identified by 32.0% (n=79) of surgeons prior to the pandemic to only 6.5% (n=16) after. 
  
  The majority of surgeons (60.5%, n=101) felt telehealth had a positive impact on their clinical practice and 161 (74.2%) felt that it had a positive impact on their patients’ satisfaction.  Only 9.9% (n=16) of surgeons felt it had a negative effect on clinical practice, and only 3.7% (n=8) felt it had a negative effect on patient satisfaction. When asked how professional organizations such as APSA or AAP could reduce barriers to telehealth utilization, 68.0%, (n=168) of respondents recommended a policy statement endorsing telehealth to promote reimbursement and support, 61.9% (n=153) supported clarifying reimbursement rules by state and insurer type, and 61.5% (n=152) recommended advocating for policy changes to support reimbursement and implementation.  Writing a guide surrounding best practices for common telehealth consultations (44.9%, n=111) and making a policy statement regarding safe diagnoses to make via telehealth (42.1%, n=104) were less commonly selected.  Lastly, the vast majority of respondents (95.3%, n=205) indicated they would continue to use telehealth after the pandemic ended if it remained reimbursable.
• Conclusions: In conclusion, pediatric surgeons feel that the implementation of telehealth during the COVID-19 pandemic has had an overall positive impact on clinical practice and patient satisfaction, but there are still barriers to implementation.  APSA and AAP could help this implementation by endorsing telehealth to promote reimbursement and support and to better clarify rules by state and insurer type.  An overwhelming majority of pediatric surgeons would continue using this technology if reimbursement policies remain favorable.
• Publications: Published in the Journal of Pediatric Surgery (In press)
• Main Contact:  Dr. Brian Gulack

Current approaches to the management of pneumatosis intestinalis: an APSA membership survey

• Goal:  Given the wide variability in pneumatosis intestinalis etiology and clinical course, our aim was to evaluate how pediatric surgeons currently manage children with PI and how treatment varies based on etiology.  Additionally, we sought to identify opportunities to optimize current PI management strategies. To address these aims, we administered a web-based survey of practicing pediatric surgeons in the United States and Canada.
• Response Rate:  The survey was distributed to 1,508 APSA members; we received 333 survey responses (22% response rate); 174 responses were complete and included in analysis (12% analyzed).
• Findings:  The majority of respondents (77%, n = 134) work primarily at an academic teaching hospital, 16% are hospital employed physicians, 6% work in private practice, and one respondent works primarily at locum tenens positions.  Respondents were well distributed across the US and Canada with 20% from the Northeast, 28% from the South, 22% from the Midwest, 12% from the Mountain West, 12% from the West Coast and 6% from Canada. The median number of surgeons in a group was 6 with a range of 0-22. Median years in practice for respondents was 12 and ranged from 0-45. Survey respondents were asked how frequently they or their partners were consulted for PI, 14% reported more than once a week, 29% about once a week, 41% reported at least once a month, and 16% reported less than once a month. 
  
  For all four scenarios, respondents recommended treatment for PI include a median of 7 days NPO and 7 days antibiotics. The most common antibiotics used for all scenarios were piperacillin-tazobactam, metronidazole, and ceftriaxone except in an infant with congenital heart disease, where ampicillin/gentamicin was more common than ceftriaxone. The use of CT at diagnosis ranged from 7% in CHD to 62% in children with developmental delay. In all scenarios, surgeons would obtain follow up imaging more than 90% of the time. In all scenarios, half of respondents reported they would work up the cause of PI if it recurred. The type of work-up recommended varied by scenario, with most common responses including infectious workup with C. dificile testing for neutropenic enterocolitis and developmental delay, contrast enema for congenital heart disease, and upper GI with small bowel follow-through for intestinal failure. The number of surgeons who said they would operate on a stable patient with pneumoperitoneum differed depending on scenario. Only 41% of surgeons said they would operate on a child with neutropenic enterocolitis and pneumoperitoneum, 71% said they would operate on an infant with HLHS, 60% reported they would operate on a child with intestinal failure, and 56% reported they would operate on a developmentally delayed child with pneumoperitoneum (p<0.001). The perception that a shorter course of antibiotics or NPO would be harmful also varied with scenario. These data are presented in Table 1.  Other data regarding the evaluation and management of PI across the scenarios are also contained in Table 1.
• Conclusions:  In conclusion, pediatric surgeons tend to manage all children with PI in a similar fashion regardless of underlying disease etiology but believe that this treatment approach is suboptimal.  Opportunities for improvement include standardization of care with treatment approach tailored to underlying etiology.  Future research in the form of a prospective randomized controlled trial would be the most likely to change an individual surgeon’s management strategy.
• Publications: One abstracts will be presented at the 2022 APSA Annual Meeting, additional manuscript in progress which will be submitted to the Journal of Pediatric Surgery in the Spring of 2022
• Main Contact:  Dr. Shannon Acker

APSA Committee on Diversity, Equity and Inclusion (DEI) Survey on Member Demographics, Practice, Discrimination and Cultural Understanding

• Goal:  APSA recognizes DEI as a strategic mission of the organization and as fundamental to ensuring optimal surgical care for children. However, current member demographics, experience with bias and discrimination, and cultural awareness of members is unknown. The Committee on DEI and the DEI Empowerment and Governance Taskforce created a survey to better understand the current status of these ideas within the APSA membership and identify targets for future initiatives. 
• Response Rate:  423 responses out of 1558 survey invitations, 27% response rate.
• Findings:  Of respondents, 68% were white; 12% Asian American Pacific Islander (AAPI); 6% Hispanic; 5% multiracial; and 4% Black. Respondents were 63% male. There was no significant difference in racial/ethnic distribution among academic rank, however only 18% of full professors identified as female. 32% of all respondents reported experiencing workplace discrimination, with AAPI (OR 3.8), Black (OR 3.7) and Female (OR 9.3) identities being at highest risk. 12% reported experiencing discrimination within the APSA organization and 7% within APSA Committees.  There was no difference in race, gender, ethnicity, or sexual orientation in those experiencing bias within APSA. Respondents who practice in a community setting were more likely to experience bias in APSA committees (OR 3.6) compared to those who practice in an academic setting.
• Conclusions:  The demographics of respondents are not representative of the broader community of patients served or of current medical student matriculants. There remains substantial gender gap in full academic professors. Experience of workplace bias is pervasive across all identities but more frequently impacts underrepresented racial and gender identities. A continued focus on DEI themes through lectureships and organizational initiatives will highlight this as a pediatric surgical public health issue and protect the health, wellness, and durability of our peers and benefit our patients.
• Publications: Two abstracts will be presented at the 2022 APSA Annual Meeting, additional manuscripts in progress.
• Main Contact:  Dr. Erika Newman, Dr. Cynthia Reyes-Ferral and Dr. Kanika Bowen-Jallow

2020

Workforce Committee Survey of Recent Pediatric Surgery Fellowship Graduates

• Goal:  APSA’s Right Child/Right Surgeon Initiative addresses issues concerning patient access to appropriate pediatric surgical care and workforce distribution.  The APSA Workforce Committee sought to understand the experiences and motivations of recent graduates of Pediatric Surgery Training Programs entering the workforce. 
• Response Rate:  144 responses out of 447 survey invitations, 32% response rate.
• Findings:  91% of respondents participated in dedicated research prior to fellowship, but only 64% perform research during their employment.   23% completed an additional clinical fellowship, but only 54% currently practice within the second field.  When asked to identify the top three factors used to choose a position, the most common responses were “location or geography” (71%), “available mentorship” (53%), and “compensation and benefits” (37%).  Describing their first position, 77% reported working in an academic institution, 78% reported working in a metropolitan/urban area, and 55% reported working in a free-standing children’s hospital.  94% participate in General Surgery resident education, and 49% are faculty within a Pediatric Surgery fellowship.  Overall, 92% of respondents were able to find the type of employment position that they had wanted. 
• Conclusions:  Preferences of recent graduates for jobs in urban, academic settings could contribute to continued disparity in access to pediatric surgeons between urban and rural America and to dilution of experience for urban surgeons.  Possible solutions include alternative incentive programs for employment in less populated areas or new training models for general surgeons in rural areas to train in fundamentals of Pediatric Surgery. 
• Publications:  Abstract presented as part of the 2021 APSA Annual Virtual Meeting.  Manuscript in progress. 
• Main Contact:  Abigail E Martin, MD, [email protected]

Subspecialization in Pediatric Surgery

• Goal: We recently reported the results of a survey of APSA members regarding practice patterns and opinions regarding subspecialization within pediatric surgery. Respondents identified various subspecialities felt to be necessary and beneficial for patient care. This survey further delves into these specific subspecialities, fetal surgery, thyroid surgery and bariatric surgery, to better understand the prevalence, practicality, and potential benefits of specialization within these specific niches in our field.          
  • Response Rate: Of 1015 surveys, we received 405 responses (40%).
  • Findings/Conclusions:
  • Fetal Surgery: Fetal surgery practices were described by 77 self-designated fetal center members. Centers provide prenatal consultation (99%), diagnostic imaging (84%), care/delivery coordination (83%), and/or fetal surgery/procedures (52%). The majority (56%) of fetal programs are directed by surgery and maternal fetal medicine. Pediatric surgeons are represented on the fetal team in 96% of centers. Prenatal consultations are primarily seen by any pediatric surgeon in the group (53%), with the pediatric surgeon on call operating on/caring for the baby postnatally in the majority (64%), regardless of who performed the prenatal consultation. Only 29% of fetal center members performed a fetal operation in the last year. Yearly fetal case numbers vary widely per procedure, with the most common being complex twin procedures and needle-based sclerotherapy.
  • Bariatric/Thyroid surgery: in progress
    • Publications:
    • Fetal – Manuscript published
      • Lopyan NM, Perrone EE, Gadepalli SK, Raval MV, Tsao K, Rich BS.  Current status of subspecialization in pediatric surgery: A focus on fetal surgery.  J Pediatr Surg 2021, online ahead of print.
      • Thyroid & Bariatric  - Abstractsunder review. Manuscripts in progress.
        • Main Contact: Barrie S. Rich: [email protected]

Perioperative Antibiotic Use in Neonatal General Surgery

• Goal: To describe the practice patterns of pediatric surgeons with regard to antibiotic prophylaxis for surgical site infections (SSI) in neonatal surgery. The survey described six neonatal general surgical scenarios. We asked respondents whether they would administer pre- or post-operative antibiotics, type of antibiotics used, and antibiotic duration.
• Response Rate: 12.27%, The survey was distributed to 1271 members, and results were analyzed based upon 156 responses.
• Findings/Conclusions: Overall, we identified areas of consensus, as well as areas where significant variation exists. For example, in gastroschisis, most would initiate antibiotics at the time of silo placement (73%) and continue until definitive closure (87.8%), but there was no consensus on the type of antibiotics administered. In other scenarios, such as tracheoesophageal fistula, 54% would initiate antibiotics less than one hour before surgery, but 40% would start them at the time of diagnosis. These variations were statistically significant when respondents were stratified by hospital type (p=0.0015). There were significant differences in responses to other scenarios stratified by region, years out of practice, and hospital type. This study highlights the necessity for standard guidelines in the use of perioperative antibiotic use in neonates.
• Publications: Abstract under review. Manuscript in progress.
• Main Contacts:
• Pavan Brahmamdam, MD. [email protected]
• Begum Akay, MD. [email protected]
• Samuel K. Osei, MD.   [email protected]
  

Surgical Innovation in Pediatric Surgery

• ​Introduction: Pediatric surgery fellowship applicants are increasingly pursuing research in non-traditional fields.  Surgical innovation fellowships are a relatively new example and their standing among pediatric surgeons is unknown.  This study aims to evaluate the relative value pediatric surgeons place on surgical innovation experience compared to traditional research for pediatric surgery fellowship candidate.  
• Results: 
• Conclusion: Innovation experirence is generally viewed positively by fellowship selection committee members.  However, applicants and mentors within innovation would be benefit from focus on traditional academic outputs to ensure competitiveness.  

Surgeon Choice in Management of Pediatric Abdominal Trauma

• ​Goal: To determine factors contributing to pediatric and adult trauma surgeons’ management choices of hemodynamically stable children with suspected non-solid organ abdominal injury 
• Response Rate:  23%
• Findings: Of 394 respondent members of EAST and APSA, 50.3% were pediatric surgeons. In management of three blunt abdominal injury scenarios (isolated, with multisystem injury, and with traumatic brain injury), 32.2%, 49.3%, and 60.7% of surgeons chose operation over observation, respectively. Compared to isolated blunt injury, surgeons were more likely to choose operation for patients with multisystem injury (aOR 2.20, 95%CI: 1.78-2.72) or TBI (aOR 3.60, 95%CI: 2.79-4.66). Pediatric surgeons were less likely to choose operation (aOR 0.32, 95%CI: 0.22-0.44). In management of penetrating injury, 39.1%, 29.5%, and 31.5% of surgeons chose observation, local wound exploration, and laparoscopy, respectively.  
• Conclusions: Large variation exists in management of hemodynamically stable children with suspected hollow viscus injury. Although patient injury characteristics account for some variation, surgeon factors, such as type of surgeon also play a role. Evidence-based practice guidelines should be developed to standardize care.
• Publications: Under review.
• Elissa Butler

2019

APSA wellness task force survey

This survey measured burnout, compassion fatigue and compassion satisfaction among pediatric surgeons. It also described experience with adverse events such as law suits and medical errors resulting in patient harm or death. We asked surgeons to state the Top 3 contributors to physician distress, as well as the Top 3 things their hospital systems were doing well to address distress. We found that 80% of respondents had personally experienced a medical error resulting in significant patient harm or death, and that 54 percent had been sued. Only about a quarter of respondents were satisfied with the institution’s support in the wake of the event. Surgeons attributed lack of support to culture of “shame and blame,” or people just not knowing what to say to provide support. Some surgeons expressed lack of trust in the institution’s ability to support them since the hospital had to look out for its own best interest. 31% response rate.

Themes arising from “Top 3 issues that contribute most to physician distress”:

• Clinical and administrative demands
• Poor leadership and loss of autonomy
• Coworkers and collegiality
• Lack of support and mentorship
• Patient complications
• Work-life balance

Themes arising from “3 best things your institution does to promote physician wellness”:

• Wellness programs and lectures
• Mechanisms to provide relief from clinical burden
• Empower surgeons to partner with administrators in decision-making and problem-solving
• Support after adverse events
• Proper compensation and benefits
• Opportunities for faculty development, research, and teaching

Umbilical Hernia Repair ​

• This survey was developed to provide a better understanding of why pediatric surgeons may differ in their approach to managing asymptomatic umbilical hernias, and to provide insight into how we may reduce practice variation through the establish ment of consensus guidelines.
• Shawn J. Rangel, MD MSCE
• 44% Response Rate 
• Manuscript published

     https://pubmed.ncbi.nlm.nih.gov/33589141/

     https://pubmed.ncbi.nlm.nih.gov/33487463/

     https://pubmed.ncbi.nlm.nih.gov/33454081/

2018

Evidence Based Medicine in Pediatric Surgery

• Goal: We have designed a survey that explores how pediatric surgeons rely on EBM in settings of relative certainty as well as in settings of clinical uncertainty. We hope this brief, 5 to 7 minute survey allows us to gain a better understanding of how pediatric surgeons rely on EBM across a variety of clinical settings so that we may develop tools to enhance decision making and clinical counseling as well as provide a framework for future studies designed to augment training for residents and fellows on incorporation of EBM into clinical practice.
• General conclusions: 96 of respondents (47%) reported no EBM training, 89 (44%) reported EBM training, and 17 (8%) were unsure. EBM trained surgeons rely on literature more than clinical experience (56% vs. 44%; p < 0.01), a difference not appreciated in those lacking EBM training (50.2% vs. 49.8%; p = 0.88). Compared to 12% of fellows, 37% of surgeons with >10yr experience prefer to rely on clinical judgment as opposed to published evidence when discussing rare conditions (p < 0.01).
• Erica M. Carlisle, MD
• 15.6% Response rate 

Current Management of Pilonidal Disease in Pediatric and Adolescent Patients: An APSA Survey 

• Pilonidal disease is often managed by pediatric surgeons. The optimal timing of intervention and type of treatment is not known. As current practice patterns change, we aim to identify current management strategies using a survey of our APSA colleagues.

Umbilical Access in Neonates and Infants Survey

• This research study is about how pediatric surgeons access the umbilicus for laparoscopic surgery in neonates and infants up to age 3 months. We are interested in whether or not you have experienced any complications during umbilical access. Your participation in this study is voluntary and all responses will remain completely anonymous. Your participation will allow us to inform the pediatric surgical community of current practices in laparoscopic surgery, specifically related to umbilical access, as well as the potential pitfalls to the methods of umbilical access in this patient population.
• ​​Matthew P. Landman, MD, MPH

Activity Restrictions Survey

• Goal of survey: To see what current pediatric surgeons are prescribing for activity restrictions following general surgeries. 
• ​General conclusions: There was a wide variability amongst the pediatric surgery realm. 
• Publications: Yes, but the link is not avaiable at this time. 
• Intersting Findings: We found that 45% of surgeons (293 respondents) believe that there should be 2-3 weeks activity restrictions, whereas only 30% there shouldn't be any. 
• Fizan Abdullah, MD, PhD
• 28.6% Response Rate

Pediatric Rectal Prolapse Survey 

• Many management options exist for the treatment of medically refractory rectal prolapse in children. In order to standardize the surgical management of rectal prolapse, it is important to know what factors play a role in decision-making. To that end, we designed this short survey to characterize current practice patterns. We plan to use these data to gain new insights into the management of pediatric rectal prolapse and to inform future study. 
• ​Francois Trappey, MD

2017

ECMO in CDH

• The survey asked for opinions and preferences surrounding the use of ECMO for the treatment of respiratory failure associated with CDH. The focus is to understand varying practice patterns among providers, across institutions and to examine differences in approaches.
• Goal of survey: Identify current practice patterns regarding the use of ECMO for infants with CDH
• General conclusions: There is a general lack of consensus regarding the use of ECMO in CDH in North America, particularly when it comes to VV-ECMO. 
• Publications: CAPS Abstract, presentation pending
• Intersting Findings: Perhaps the most interesting finding was the differences between neonatologists and surgeons regarding the use of VV-ECMO.
• Items Unanswered or univestingated from survey: Optimal timing of repair on ECMO. 
• Yigit Guner, MD
• 18% Response Rate

Survey of FAST in Pediatric Trauma

• Goal of survey: To examine the current ractice patterns and surgeon attitudes with regard to FAST exam in pediatric trauma. 
• General conclusions: The FAST exam is utilized by the majority of pediatric surgeons who responded (76%), despite recent evidence that it has low sensitivity for intraabdominal injury in stable pediatric patients. FAST was more likely to be used by surgeons at Level 1 trauma centers vs. non-Level 1 facilities (75.2% vs. 57.6%, p=0.02). The implementation of FAST is seldom tracked by permanent records or QI processes. Opinions regarding FAST in children were variable with only 40% reporting they felt it was an important adjunct in pediatric trauma. Overall, respondent attitudes suggest it is most useful in the unstable patient.
• Publications: None as of June 2018
• Intersting Findings: We were somewhat surprised by the prevalence of FAST use among respondents given the ongoing controversy, although this may represent some bias in response by surgeons who use FAST.
• Items Unanswered or univestingated from survey: The sensitivity and utility of FAST in unstable pediatric trauma is incompletely studied and we feel that this is likely the most important application of FAST in children.
• Katherine Baxter, MD

Pediatric Peripheral ECMO Cannulation Technique and Safety Survey

• Goal of survey: The goal of this survey is to characterize varying practice patterns across institutions and providers in ECMO cannulation. We plan to use these results to examine differences in technique and to compare this data with practice recommendations to gain new insights for further study.
• General conclusions: In general, pediatric general surgeons are cannulating for both VA and VV ECMO in the ICU. Most centers are not offering specific ECMO cannulation credentialing, but having this additional certification does not change reported complication rates. VA ECMO is usually performed open and frequently without the use of any imaging guidance (surface landmarks only). VV ECMO on the other hand is often performed percutaneously, usually under guidance from either fluoroscopy, echocardiography or both. Reported estimated complication rates did not vary by cannulation strategy. In older and larger children, the femoral is preferred over the neck with or without the presence of a pre-existing femoral arterial or venous line.
• Publications: None as of June 2018
• Intersting Findings: We were surprised that the different techniques for assessing cannula placement were not associated with different rates of estimated complications, especially rates of needing to reposition the cannula. Additionally, a surprising number of respondents stated that they were experiencing complications up to 25-50% or more than 50% of the time. This was not expected, especially in self-reported numbers, and is concerning. Finally, we were surprised that more people were not using imaging guidance to place the cannulas, when it is readily available.
• Items Unanswered or univestingated from survey: Because this was a survey-type study, more objective data would be important in further assessing the relationship between cannulation strategy and complication rates. Also, it will be important to continue re-evaluating practice patterns as more centers move toward requiring specific credentialing for ECMO cannulation.
• Brian Gray, MD

Spontaneous Pneumothorax Survey

• Goal of survey: To understand current management of primary spontaneous pneumothorax in children and adolescents. 
• General conclusions: The majority of surgeons treat first episode of PSP with chest tube alone.  VATS is offered for a recurrence or if there is persistent air leak with chest tube.  Most surgeons wait 3 days after chest tube placement before considering VATS.  Chest CT is not routinely employed in the workup of PSP and most surgeons do not operate for blebs found incidentally on the contralateral side.  Stapled blebectomy and mechanical pleurodesis are the most commonly performed interventions when VATS is indicated.  
• Publications: None as of June 2018
• Intersting Findings: They did not.  
• Items Unanswered or univestingated from survey: This survey helped us to understand current practice, but not necessarily best practice. Further efforts are needed to identify the best ways to minimize recurrence in PSP.  
• Timothy Lautz, MD
• 29% Response Rate

ECMO - Cannulation Preference Survey

• This brief survey focuses specifically on evaluating femoral cannulation preferences and management by pediatric surgeons. The goal is to use these results to highlight areas of ambiguity in how children are cannulated and managed on ECMO, as well as to design prospective work to improve and simplify the management of these patients.
• Alejandro Garcia, MD
• 21% Response rate 
• JPS Publication 

Global Health Initatives Survey

• The purpose of the survey is to gather details about APSA members' current efforts with pediatric surgeons in low- and middle-incme countries (LMICs) with the aim of identifying and developing sustainable capacity-building collaborations that could be further strengthened by the support of interested APSA members.
• APSA Global Committee
• 0.9% Response rate 

Gastroschisis Survey

• The University of Iowa Department of Pediatric Surgery is conducting a survey to assess the practice patterns of pediatric surgeons regarding the closure of simple gastroschisis. We also seek to understand the locations (NICU, OR, or other) in which surgeons close gastroschisis and any barriers surgeons face in operating in their preferred location.
• Julia Shelton, MD
• 27% Response Rate 

2016

Enhanced Recovery After Surgery

• There is an increasing focus on providing high-value surgical care by improving outcomes while minimizing resource utilization and waste. Enhanced Recovery After Surgery, or ERAS, strategies have garnered significant attention in a variety of adult surgical populations. These perioperative protocols have been found to decrease hospital length of stay, in-hospital costs and complications and have been increasingly adopted by major hospital systems and supported by leading organizations, such as the American College of Surgeons. However, literature evaluating implementation of enhanced recovery protocols in pediatric populations is scant. The limited literature available suggests that ERAS protocols would be safe and effective when applied to the pediatric population. This survey was designed to assess beliefs regarding the applicability of individual enhanced recovery elements extrapolated from adult colon and rectal surgery guidelines.
• Mehul Raval, MD
• 24% Response Rate 
• JPS Publication

APSA AAP ACS Strategic Plan 

• The leadership of the three organizations representing Pediatric Surgery has developed the questionnaire linked below. This effort is part of a strategic initiative to improve communication between our organizations and to plan for the future of our profession. Recognizing that each organization has unique strengths but there is also overlap, we appreciate in advance your willingness to take the time to honestly answer the question.
• APSA Survey
• 41% Response Rate 

Neonates with NEC Survey

• There is wide variation in opinion regarding decisions of whether to proceed with full medical and surgical treatment or comfort care in infants with severe necrotizing enterocolitis and massive bowel loss. In the past decade, long-term outcomes of intestinal failure in children have improved dramatically. We are seeking your thoughts on the optimal care for infants with massive bowel loss from necrotizing enterocolitis. This study is being conducted by neonatologists and pediatric surgeons at Seattle Children's Hospital and University of Washington Medical Center.
• Patrick Javid, MD
• 28% Response Rate 

Satisfaction Survey 

• The APSA Membership and Credentials Committee is sponsoring a job satisfaction survey of our new members who have completed their training within the last five years. Our goal is to identify factors in first employment positions that may have led some people to seek out alternative employment within their first five years of practice. With this information, we hope to be able to identify factors of jobs that are attractive to candidates and lead to fruitful and fulfilling careers, as well as factors that may not be so appealing that would lead candidates to seek employment elsewhere. 
• APSA Membership Committee
• 47% Response Rate

Pulmonary Osteosarcoma Survey

• In an attempt to improve the thoracic surgical care of patients with metastatic osteosarcoma, surgeons in the Children’s Oncology Group (COG) are advocating for a cooperative group study.  This prospective study would collect information on surgical management and clinical outcomes, and to correlate imaging findings with operative findings.  Challenges in this study include the rarity of the problem, the advances in diagnostic imaging over long study periods, changing chemotherapy regimens, and institutional preferences and biases in surgical approach.
• John Doski, MD
• 17% Response Rate
• Used for COG Research Grant 

Safety Attitudes Survey

• In an attempt to define the future safety agenda of the APSA Surgical Quality and Safety Committee, a brief survey has been developed to assess the attitudes, perceptions and practices of the APSA membership surrounding safe surgical care. Furthermore, we hope to identify novel or innovative practices that have been particularly effective at member hospitals so that we may possibly share these with the broader APSA community. In this regard, you will have the option of leaving your contact information at the end of the survey if you wish to tell us more.
• APSA Surgery and Quality Committee
• 38% Response Rate

Workforce Committee Survey of Recent Pediatric Surgery Fellowship Graduates

n  Goal:  APSA’s Right Child/Right Surgeon Initiative addresses issues concerning patient access to appropriate pediatric surgical care and workforce distribution.  The APSA Workforce Committee sought to understand the experiences and motivations of recent graduates of Pediatric Surgery Training Programs entering the workforce. 

n  Response Rate:  144 responses out of 447 survey invitations, 32% response rate.

n  Findings:  91% of respondents participated in dedicated research prior to fellowship, but only 64% perform research during their employment.   23% completed an additional clinical fellowship, but only 54% currently practice within the second field.  When asked to identify the top three factors used to choose a position, the most common responses were “location or geography” (71%), “available mentorship” (53%), and “compensation and benefits” (37%).  Describing their first position, 77% reported working in an academic institution, 78% reported working in a metropolitan/urban area, and 55% reported working in a free-standing children’s hospital.  94% participate in General Surgery resident education, and 49% are faculty within a Pediatric Surgery fellowship.  Overall, 92% of respondents were able to find the type of employment position that they had wanted. 

n  Conclusions:  Preferences of recent graduates for jobs in urban, academic settings could contribute to continued disparity in access to pediatric surgeons between urban and rural America and to dilution of experience for urban surgeons.  Possible solutions include alternative incentive programs for employment in less populated areas or new training models for general surgeons in rural areas to train in fundamentals of Pediatric Surgery. 

n  Publications:  Abstract presented as part of the 2021 APSA Annual Virtual Meeting.  Manuscript in progress. 

n  Main Contact:  Abigail E Martin, MD, [email protected]