Standardized management of pediatric abdominal pain admissions improves patient outcomes – A quality improvement project

Background Children commonly present at the emergency department with abdominal pain and it is challenging to identify urgent surgical conditions. An audit conducted at a tertiary children’s hospital showed that 70% of patients admitted to Department of Pediatric Surgery (PAS) for abdominal pain had non-surgical diagnoses and wide variation in management. Objective Our quality improvement (QI) project aimed to reduce length of stay (LOS) and unnecessary investigations performed for patients admitted to PAS with abdominal pain, without causing complications or delayed diagnosis of surgical conditions. Methods The QI project consists of a standardised management workflow with stringent discharge criteria. We reviewed outcome measures of LOS, number of investigations ordered, compliance to workflow and readmission within 1-week post discharge at the end of each Plan-Do- Study-Act (PDSA) cycle and iteratively improved the workflow following QI principles. Results 61% of patients were admitted to PAS for non-surgical abdominal pain throughout three PDSA cycles conducted. The third cycle showed improved compliance to workflow (80.7%) with reduced median LOS by 1 day, reduced median number of blood, stool and urine investigations by 1 and reduced range of investigations ordered. Readmission and CE attendance rate 1 week after discharge was 1.6% ( n = 3), which was comparable to audit at 2.3% ( n = 4), p = 0.709. Conclusion The workflow reduced LOS, number of unnecessary investigations and variability in investigations ordered, without causing misdiagnosis. It improved patient experience with sizeable cost savings for the patient and the hospital. QI projects can improve patient outcomes by introducing standard protocols that aid clinical management

'It's going to change the way we train': Qualitative evaluation of a transformative faculty development workshop.

10.1007/s40037-021-00687-4Perspect Med Edu

Neuronal defects an etiological factor in congenital pelviureteric junction obstruction?

Introduction: Congenital pelviureteric junction obstruction (PUJO) is one of the most frequent causes of neonatal hydronephrosis. Obstruction at the PUJ has potential severe adverse outcomes, such as renal damage. While pyeloplasty has been established as the definitive treatment, the exact pathophysiology of congenital PUJO remains unknown. Recent research has proposed neuronal innervation defects as an etiological factor in congenital PUJO. We aim to study the expression of various neuronal markers in PUJO specimens compared with controls, and evaluate whether severity of renal disease or dysfunction pre-operatively is related to expression of neuronal markers in resected PUJO specimens. Materials and methods: All consecutive patients who underwent dismembered pyeloplasty at KK Women's and Children's Hospital, Singapore, for intrinsic PUJO from 2008 to 2012 were included. Patients with other co-occurring renal pathologies were excluded. Controls were obtained from nephrectomy patients with Wilm's tumor or other benign renal conditions during the same period. Specimens were stained immunohistochemically with neuronal markers protein gene product 9.5 (PGP9.5), synaptophysin, and S-100, and with CD-117, a marker for interstitial cells of Cajal (Table). Levels of expression of the markers were assessed semiquantitatively (decreased, increased or no change) in comparison with controls by two independent observers. Pre-operative data of patients’ renal anatomical (ultrasonography measurements of renal pelvis size) and functional parameters (differential renal function measured using MAG-3 renal scans) were obtained. Discussion: Thirty-eight PUJO specimens (38 renal units) and 20 controls were studied. Mean patient age at pyeloplasty was 25.3 months (2.9–167.6 months). Median pre-operative pelvic size was 25.0 mm (17.0–50.0 mm). Both PUJO specimens and controls showed great heterogeneity in distribution of innervation. All four immunohistochemical markers were not predictive of significant pre-operative renal pelvis dilation or pre-operative diminished renal function of the operated kidney. Conclusions: There exists marked variability in expression of neuronal markers synaptophysin, PGP9.5, and S-100, and CD-117 in PUJO specimens compared with controls. Our results show no clinical significance of the expression of neuronal markers in predicting degree of pre-operative renal pelvis dilation or differential renal function. The heterogeneity of expression of neuronal markers in PUJO specimens and controls in our population is at variance with prior studies. The etiology of PUJO is likely to be complex and multifactorial. [Table presented