Improving Pediatric Surgery Quality by Widely Adopting an Evidence-based Protocol: An Effort of the Pediatric Surgery Quality Collaborative.

Abstract

This study aimed to demonstrate wide adoption of an evidence-based, short-course antibiotic protocol in pediatric complicated appendicitis, and assess impact of protocol adoption across multiple institutions. Short-course antibiotics for intra-abdominal infection with source control is an evidence-based practice not widely used in children. The Pediatric Surgery Quality Collaborative (PSQC), a partnership of National Surgical Quality Improvement Program-Pediatric (NSQIP-P) hospitals, proposed a short-course protocol for patients with complicated appendicitis postappendectomy. This observational quality improvement study was conducted at 36 PSQC hospitals (7/1/2023-6/30/2024). A protocol recommending 4+/-1 antibiotic days (IV+PO) was proposed. Patients across hospitals were grouped by protocol versus usual care. Primary outcome was total antibiotic days. Secondary outcomes included 30-day surgical site infection (SSI). Multivariable regressions with propensity scoring and inverse probability of treatment weighting were utilized. The protocol was adopted by 21 hospitals; 15 continued usual care. Across hospitals, 1934 patients were analyzed: 1046 protocol, 888 usual care. The median age was 10 years (IQR: 7.3-13.2), 59% were male. Thirty-day SSI rate was 13% (91% organ space). In multivariable regression, the protocol group had fewer antibiotic days (RR: 0.69, 95% confidence interval [CI]: 0.62-0.78): mean of 5.8 days versus 8.4 for usual care, a difference of 2.6 fewer antibiotic days (95% CI: 1.73-3.37). Multivariable regression showed no difference in 30-day SSI rates between groups (12.7% vs. 13.6%) (OR: 0.96, 95% CI: 0.63-1.47). This PSQC effort demonstrates widespread standardization of care and quality improvement in pediatric surgery through multicenter adoption of an evidence-based, short-course antibiotic protocol. Protocol adoption was associated with fewer antibiotic days without increasing 30-day SSI.