title: Identification of opportunities for quality improvement and outcome measurement in pediatric otolaryngology.
abstract: OBJECTIVE
  Despite increased emphasis on measuring safety outcomes and quality indicators for surgical care, little is known regarding which operative procedures should be prioritized for quality-improvement initiatives in pediatric otolaryngology.
  
  
  OBJECTIVE
  To describe the 30-day adverse event rates and relative contributions to morbidity for procedures in pediatric otolaryngology surgery using data from the American College of Surgeons' National Surgical Quality Improvement Program Pediatric database (ACS-NSQIP-P).
  
  
  METHODS
  Analysis of records contained in the ACS-NSQIP-P 2011-2012 clinical database. The ACS-NSQIP-P is a nationwide risk-adjusted, clinical outcomes-based program aimed at measuring and improving pediatric surgical care. Fifty hospitals participated in the 2011-2012 ACS-NSQIP-P program. Medical records of patients who underwent tracked otolaryngologic procedures were accrued in the ACS-NSQIP-P database. These were inclusive of specific otolaryngologic surgical procedures and do not represent the entire spectrum of pediatric otolaryngology surgical procedures.
  
  
  METHODS
  Individual 30-day adverse events, composite morbidity, composite serious adverse events, and composite hospital-acquired infections were compiled. Clinically related procedure groups were used to broadly evaluate outcomes. Procedures and groups were evaluated according to their relative contribution to otolaryngologic morbidity and their incidence of major complications.
  
  
  RESULTS
  A total of 8361 patients underwent 1 of 40 selected otolaryngology procedures; 90% were elective; 76% were performed on an outpatient or ambulatory basis; and 46% were American Society of Anesthesiologists (ASA) class 2 cases. Individual 30-day adverse event rates were highest for return to the operating room (4%), surgical site infection (2%), pneumonia (1%), sepsis (1%), and reintubation (1%). The highest rates of composite morbidity were seen for tracheostomy in patients younger than 2 years (23%), airway reconstruction (19%), and tympanoplasty with mastoidectomy (2%). Airway reconstruction procedures had the highest rates of composite serious adverse events (16%), followed by tracheostomy (13%) and abscess drainage (5%). Tracheostomy (31%) and airway reconstruction (16%) made the largest relative contributions to composite morbidity rate of the procedures studied. Tracheostomy in patients younger than 2 years had the highest composite hospital-acquired infection rate (14%), followed by airway reconstruction procedures (11%) and tympanoplasty with mastoidectomy (2%).
  
  
  CONCLUSIONS
  While the overall rate of major postoperative morbidity in pediatric otolaryngology is low, areas for targeted quality-improvement interventions include tracheostomy, airway reconstruction, mastoidectomy, and abscess drainage. Measurement of outcomes specific to otolaryngologic procedures will be necessary to further identify and measure the impact of quality-improvement initiatives in pediatric otolaryngology.
authors.affiliation: Division of Otolaryngology, Children's National Medical Center, Washington, DC.
authors.forename: Rahul K
authors.initials: RK
authors.lastname: Shah
authors.affiliation: Department of Surgery, Icahn School of Medicine at Mount Sinai Medical Center, New York, New York3Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles.
authors.forename: Anne M
authors.initials: AM
authors.lastname: Stey
authors.affiliation: Department of Otolaryngology-Head and Neck Surgery, Nationwide Children's Hospital, Columbus, Ohio5Wexner Medical Center, The Ohio State University, Columbus, Ohio.
authors.forename: Kris R
authors.initials: KR
authors.lastname: Jatana
authors.affiliation: Department of Surgery, Boston Children's Hospital, Boston, Massachusetts7Harvard Medical School, Boston, Massachusetts.
authors.forename: Shawn J
authors.initials: SJ
authors.lastname: Rangel
authors.affiliation: Department of Otolaryngology, Johns Hopkins University School of Medicine, Baltimore, Maryland9Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.
authors.forename: Emily F
authors.initials: EF
authors.lastname: Boss
mesh_terms: D000293:Adolescent; D001980:Bronchi / Q000601:surgery; D002648:Child; D002675:Child, Preschool; D003428:Cross Infection / Q000453:epidemiology; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D008416:Mastoid / Q000601:surgery; D009225:Myringoplasty; D013517:Otorhinolaryngologic Surgical Procedures / Q000009:adverse effects / Q000592:standards*; D017063:Outcome Assessment, Health Care; D058996:Quality Improvement; D019651:Plastic Surgery Procedures; D014139:Tracheostomy; D014433:Tympanoplasty