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

Jeannette M Joly; Monica E Lopez; Erich J Grethel; Seokhun Kim; Terry Fisher; Krysta M Sutyak; Martin L Blakely; Charles Green; Jeffrey M Burford; Nicole M Chandler; Kathryn Danko; Raquel Gonzalez; Laura Jorg; Andrew Nuibe; Daniel K Robie; Amanda Skaggs; Regan F Williams; Kevin P Lally

doi:10.1097/SLA.0000000000006820

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

Ann Surg. 2025 Jun 25. doi: 10.1097/SLA.0000000000006820. Online ahead of print.

Authors

Jeannette M Joly^{1

2

3}, Monica E Lopez^{3

4}, Erich J Grethel^{3

5}, Seokhun Kim⁶, Terry Fisher^{1

3}, Krysta M Sutyak^{1

2

3}, Martin L Blakely^{1

2

3}, Charles Green⁶, Jeffrey M Burford^{3

7}, Nicole M Chandler^{3

8}, Kathryn Danko^{3

5}, Raquel Gonzalez^{3

8}, Laura Jorg^{3

9}, Andrew Nuibe^{3

10}, Daniel K Robie^{3

11}, Amanda Skaggs^{3

9}, Regan F Williams^{3

12}, Kevin P Lally^{1

2

3}

Affiliations

¹ Department of Pediatric Surgery, McGovern Medical School at UTHealth Houston and Children's Memorial Hermann Hospital, Houston, TX, USA.
² Center for Surgical Trials and Evidence-Based Practice (CSTEP), McGovern Medical School at UTHealth Houston, Houston, TX, USA.
³ Pediatric Surgery Quality Collaborative, McGovern Medical School at UTHealth Houston, Houston, TX, USA.
⁴ Department of Pediatric Surgery, Vanderbilt University School of Medicine, Nashville, TN, USA.
⁵ Department of Pediatric Surgery, Dell Children's Medical Center, Austin, TX, USA.
⁶ Institute for Clinical Research and Learning Health Care, McGovern Medical School at UTHealth Houston, Houston, TX, USA.
⁷ Department of Pediatric Surgery, Arkansas Children's Hospital, Little Rock, AR, USA.
⁸ Division of Pediatric Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA.
⁹ Department of Perioperative Services, Dayton Children's Hospital, Dayton, OH, USA.
¹⁰ Department of Pediatric Infectious Disease, Inova Health System, Fairfax, VA, USA.
¹¹ Department of Surgery, Dayton Children's Hospital, Dayton, OH, USA.
¹² Department of Pediatric Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA.

PMID: 40560661
DOI: 10.1097/SLA.0000000000006820

Abstract

Objective: 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.

Summary background data: Short-course antibiotics for intraabdominal 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 post-appendectomy.

Methods: 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.

Results: 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. 30-day SSI rate was 13% (91% organ space). In multivariable regression, the protocol group had fewer antibiotic days (RR:0.69, 95%CI:0.62-0.78): mean of 5.8 days vs 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).

Conclusion: 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.

Keywords: antimicrobial stewardship; appendicitis; clinical protocol; multicenter study; pediatrics; quality improvement.