Analysis of adverse events in pediatric surgery using criteria validated from the adult population: justifying the need for pediatric-focused outcome measures

Abstract

Introduction: Little is known regarding the incidence and financial impact of adverse events associated with the surgical care of children. The purpose of this study was to characterize the epidemiology and resource utilization associated with these events using definitions validated from the adult population.

Methods: We conducted a 6-year audit (Jan 2003-Dec 2008) of adverse events associated with the 100 most common general pediatric surgical procedures from the Pediatric Health Information System database. We audited 23 events as defined by the National Surgical Quality Improvement Project and modified Agency for Healthcare Research and Quality Patient Safety Indicators. Excess length of stay and total hospital charges attributable to events were determined for each procedure after adjusting for confounders.

Results: Overall 30-day incidence of any adverse event was 10.3% in our sample of 331,093 patients. The most common events were transfusions (30% of all events), wound complications (15%), and events associated with central access (11%). The cumulative incidence of serious events including cardiac arrest, stroke, deep venous thrombosis and pulmonary embolish was less than 0.3%. Ten procedures accounted for 62% of all events, and all 10 were associated with significant (P < .01) increases in length of stay and total hospital charges when any event occurred. Circumcisions, soft-tissue biopsies, pyloromyotomies, and repair of abdominal wall hernias accounted for only 3% of events despite comprising nearly 25% of operative volume.

Conclusions: A relatively small number of pediatric surgical procedures contribute to a disproportionate share of adverse events. Although the National Surgical Quality Improvement Project and Agency for Healthcare Research and Quality criteria can identify pediatric procedures associated with a significant risk of morbidity, the relatively high 30-day event rates captured for some procedures may be heavily influenced by underlying co-morbidity profiles not related to the surgical disease or intervention. Furthermore, the validity of applying adult-focused "adverse" event definitions for the pediatric population should be further explored. Collaborative efforts will be needed to develop more clinically meaningful outcome measures for the purpose of quality improvement end points.