Hospital and he's an associate professor of medicine at Harvard Medical School. He completed his undergraduate education and medical degree at the University of Alabama and his residency in pediatrics at the University of Utah and then obtained his master's in public health from Harvard's school public health and then came on staff here at Boston's Hospital. Here at Boston Children's Hospital he is the director of the Complex Care Service. He also serves on our perioperative surgical home executive committee. On a national level, Dr. Berry is the founder and director of the Complex Care QI Research Collaborative which is a national collaborative spanning eight children's hospitals. He is also founder and director of the Post-AQ Care Health Services Research Collaborative for Children with Medical Complexity for the Children's Hospital Association. He's done an extensive amount of research on improving care for children with medical, medically complex conditions and his work has actually provided much of the foundation for the creation of the clinical field of pediatric complex care. As you can imagine, he is one of the leading experts in this field. Thank you again, Dr. Berry for speaking us, seeking to us today and I will turn to you. Fantastic. Laura, thank you so much for the introduction to our chairs, Dr. Scrovero and Fishman and to our anesthesiology critical care pain medicine and surgery, division, chiefs and executive leadership and to all of you guys for joining in today. Thank you so much for the opportunity to speak to you about a patient population that I care so very deeply about. I know that many of you do as well, children with medical complexity. I'm a broadcasting live here from my administrative office at 21 Autumn Street. I'd so much prefer to be with you guys in person today, but I'll try with this virtual presentation to be as compelling and as interesting as possible, especially for the first half of it because my children at home are zoom bombing here as they're eating breakfast, watching their dad talk. So the goals of this presentation today are to convey my general pediatric and hospitalist perspectives on the current and ideal states of periodic care for children with medical health. So to do that, I'll focus on three areas. Number one, the population attributes of these children and the importance of surgery for them. Number two, their period operative risks, what we can do to address and identify them. And three, period operative care management, what that means for these children and how we can strive for ideal period operative care. Before we get started, I just want to acknowledge the sources of funding that support, a lot of the work you're going to be hearing about today, especially from the agency for healthcare research and quality in the Children's Hospital Association. And most importantly, I want to acknowledge all of my period operative mentors, folks in anesthesiology, especially Lin-Ferrari and Isabelle Leighi and surgery, Sean Rangel and Dr. Emmons, critical care hospital medicine, our medical specialty programs, general pediatrics, Joanne Cox, Kathleen Conroy, our complex care and rainbow teams, palliative care and medical ethics, patients and families, and last but not least, the bio-statusitions, informaticists and systems engineers, all who have helped me over my 16 years here at Children's to embrace the care of children with medical complexity and to do what I can to help them. So huge thanks to all of you guys. All right, so let's get started just thinking about the population attributes of children with medical complexity and the importance of surgery for them. So let's start off with the clinical case. I want you guys to think about a 12-year-old boy with carbohydrate deficient, like a protein syndrome and underlying metabolic condition, who has the following comorbidities. Chronic coagulopsy, insta-drenal disease, herbal palsy, epilepsy, hypothyroidism, obstructive sleepatinny, dilated or agrute, osteopenia, and progressive scoliosis. This child is also assisted with a gastro-digunal tube for nutrition hydration. He's trained and he's on 19 chronic medications. Beyond that, he lives with parents who are struggling with marital employment and financial difficulties, largely stemming from all of his caregiving burden. And now, because his stiliotic curve is progressing, he's under consideration for posterior spine fusion with Dr. Emmons. Now, if Dr. Emmons summons our complex care help, pre- or post-opathy for this kit, and we review this child's past medical and social history, we're going to think, yeah, this kit really is pretty medically complex. But even beyond these clinical attributes, the healthcare team of this child is also complex. 20-plus providers involved in this child's care, tons of specialists, folks in the community side, all making recommendations to the child and family that they're struggling to keep track up and to keep up with. Even beyond the healthcare team, the healthcare record of this child is complex. If we were back in the days of paper records going down into the Fagan sub-basement, this kit would take up like an entire Benzworth. And the pre-op care coordination team is going to be going through page-by-page of all these records to identify and address all the perioperative risks this child may have. Well, they do that, and this child finally reaches their day of surgery. His case is assigned to Dr. McCann, and she must give him an ASAPS classification score. She thinks to yourself jokingly, huh, maybe I should just give this kit a one, because he really is not that more complex than any of the other kids I've been taking care of with Dr. Emmons for the last 20 years. But then she remembers two recent articles published by Lynn Ferrari and Isabelle Leahy and Anesthesia and Analogiesia saying that perioperative providers, especially Anesthesia's Yodhis and Children's Hospitals, tend to under-call complexity. It's almost like the medical complexity is invisible, because it's the only patients that we take care of. And so Dr. McCann upgrades her ASAPS score from 1 to a 4. At the same time, Dr. Ran Gell is overlooking the ORR cases for the day and recognizes this kit because he put a G-tube on him a few years ago. He decides to plug this kit into his online ACS Niskwip Pediatric Risk Calculator to see what postoperative outcomes might be projected. And he finds that this child has an above-average chance of outcome for everything that's measured by Niskwip. And this kit has a 36% chance of experiencing any major postoperative complication. Knowing that, Dr. Ran Gell wishes Dr.'s mechanical and M.M. Godspeed as they proceed through the case for the day. So in my mind, this is a hallmark example of a child with medical complexity that now has a perioperative need undergoing a high resurgence. I want you to think about this kit as I progress through today's discussion. And I'll bring him up several times for important places for you to remember him. On a population level, when we think about children with medical complexity, we think of kids with the following clinical attributes. Having a lifelong, life-limiting, chronic condition that's severe enough that it affects multiple body systems and significantly impairs that children's functioning, their ability to eat, to breathe, to digest food, to walk, to talk. These children have serious healthcare needs, polypharmacy, lots of multiple medication use, durable medical equipment supplies, an immediate specialist to help maintain their health. To get these healthcare needs met, they engage the health system all the time and they are the highest health resource utilizers of all children. Now, we estimate the U.S. population prevalence of children's medical complexity at less than 1% of all children, probably in the order of 2 to 4 per thousand. That estimates that around half a million children with complexity in the United States. But because these kids engage the health system so much, they account for 30% of all pediatric healthcare costs across the continuum. We estimate that around maybe around a hundred billion dollars spent annually on these children and the breakdown that spending is interesting. About 1% of it goes to home care, 2% to primary care, including primary care medical homes, 3% to the ED, 13% medications pharmacy, 25% especially care, and almost half of it goes to inpatient care. Now, notably absent from this list is perioperative care. There have been a few studies that have tried to quantify this. I still think there's more work to be done to really figure out how much spending is attributable to perioperative care and children with complexity in the United States. I love children and I love to study like that to try to quantify it. Suffice it to say it's got to be a substantial amount. You know, these kids have particular gravitas with me as a hospital is taking care of them on the inpatient setting. We're in our children's hospitals. These children account for 55% of all pediatric inpatient costs. And when you carve out admissions for post-operative care for recovery, children with no complexity account for 67% of all pediatric inpatient post-operative in our nation's children's hospitals. So small population size, ginormous impact on the healthcare system. I take it for granted sometimes of practicing medicine here along with you guys an acquiring a children's hospital that has such a high volume of these kids and is clinically proficient in take care of them. You know, across the country, we suspect it around 86% of inpatient surgeries for children with no complexity requiring admission for post-operative recovery occurs in children's hospitals. 92 freestanding nonchillant hospitals operating on these kids nationally or more with immediate inpatient surgical volume of around 2100 cases for inpatient recovery annually. You just contrast that with the remaining 14% of kids that are being operated on in over 1400 nonchillant hospitals with immediate inpatient surgical volume for these kids of eight annually. And if you boil down into specific surgeries like spine fusion for neuromuscular scoliosis, the median annual hospital volumes is two. So it just goes to show how important regionalization is for these children. The importance of the American College of Surgeons Children's Surgery verification program that so many of you have been working on to assure that these kids have good, clinically proficient care and high volume centers. The reason why myself and my complex care colleagues are interested in surgery for these children is because the vast majority of not all of our kids in our complex care service have undergone a major surgery at some point in their life. And we very much enjoyed helping in the preoperative care for these children and taking care of the hundreds of kids annually that we serve on our inpatient complex care service. Neurosurgical procedures, CSF fluid diversion procedures, failure and later insertions, backlifant pumps, general surgery, the ostomy suite, G2, G2, psychostomy, iliostomy, orthopedic procedures, spine fusion, hip surgery, otolaryngology, cranium facial urologic, and everything in between. I just want to say from the medicine side of experience being taken care of these kids, how much of a big impact this surgery has for them. We perceive surgery as probably one of the most if not the most powerful intervention to improve health functioning quality of life for our children. It's amazing to see our kids come out of surgery with a correct, econgenital anomaly, a chronic health problem that's been mitigated entirely or palliated efficiently effectively. Surgery is such an integral component of longitudinal care management for our children. We see it as an expected life-cours event so much so that pre and post-operioperative care proficiency is now an essential core competency for anyone going into the field of complex care pediatrics. All right, so I hope that gives you a good background about the population attributes of children of complexity and their importance of surgery in that population. Let's move on now to talking about perioperative risk for these children. I'm preaching to the choir here, but when you consider all of the laundry list of possible perioperative adverse events that these kids can experience, it is a sobering list. The airway, respiratory things, hematologic, malfunctions of endulating medical devices, all of the infections, surgical site pneumonia's UTIs, all the harm that we can call. So these patients post-operatively, if we don't manage their medications and their equipment well, the skin stuff, it's a heavy list of things to consider. And I feel like so much of our perioperative work is trying to identify these risk factors and to address them. Now, we probably on the medicine side oversimplify the way that we think about these risk factors, but we tend to try to categorize them into two big buckets. Those that influence the child's physiologic fragility and the intrinsic surgical risk associated with their procedure. Let's talk a little bit more about these. Under physiologic fragility, we think about all the children's multi-morbidities, their co-existing chronic conditions affecting every organ system, all the involving medical devices that they have going into surgery. There's free-response fluid shunts, their back-lifton pumps, vagal under stimulators, pacemakers, all that. Every chronic method that could be on, and of course, their nutritional status. On the intrinsic surgical risk side, we think about the duration of anesthesia exposure, all the fluid volume fluctuations that are going to occur associated with the surgery, and of course, the tissue manipulation and damage and related no-susceptive pain that's going to occur with the surgery itself. So for every kid, you're just sneaking through how all these things add up to influence whether the child's going to experience a post-operative adverse or better not. So now I decide to walk you through a few examples of this bringing in some patient 360 and pediatric health information systems data that we have access to. So let's start off thinking about post-operative pneumonia and UTI with children with medical deplexia undergoing various irritation loss deotomy, hip surgery. We know that the, as the number of co-existing chronic conditions of these children increase so do their rates of post-operative UTI and pneumonia. 13% of kids with 10 or more co-existing chronic conditions are going to develop a post-op pneumonia or UTI. That's 1 in 8 kids, and the comorbidities of these children have to stack up to influence that risk are pretty heavy. That blephscy and trostomy reflux, scoliosis, asthma, sleep apnea, neurogenic bladder, malnutrition, etc. Now when these kids get pneumonia or UTI, it wreaks havoc on their post-operative course. It adds on a median 6 to 8 days of length of stay post VDRO across our nation's children's hospitals and tax on additional $26, $28,000 in charges. The reason why it takes so long for these children to recover from these things is because in pneumonia and UTI just, they just disrupt the children's other co-existing chronic conditions. It lowers the children's seizure threshold. It causes their guts to shut down, they get aliases and it makes their pain control so challenging to work with, especially when you're going back and forth between intro and IV pain management and all of that. The pneumonia and UTI is such a big deal on these kids that we've looked now more into the root causes of what's causing them, and unfortunately we're finding that we're the culprit a lot of the times. We're inducing UTI with our fully catheter management plans, opioid-induced urinary retention, or even causing this kids to aspirate postoperatively if we over sedate them, if we're too aggressive with our intral stimulation, if we get behind on fluids and they become dehydrated and as secretions become more thick, or if we're just not providing sufficient pulmonary clearance and pulmonary toilet regimen for them postoperatively. So pneumonia and UTI, big outcomes for these children and much more into doing this space to help avoid them in these children. A second outcome to focus on is length of stay. Such an important outcome now, especially in COVID times with our social distancing policies and single occupancy rooms. Even thinking about length of stay for high volume short-stay procedures, like tons select to be in children with medical complexity, obviously most kids not even embedded for tons like me, but going through our pathway, kids with medical complexity might be. We hope that they just stay for a day. However, if you start to tack on asthma, epilepsy, mental health conditions, chronic respiratory conditions, then the adjusted odds of these children staying in the hospital for additional days through a nice ordinal regression here derived by Steven Stoffa just increases. You know, we know about all these comorbidities ahead of time before these kids enter go surgery. So we really are ideally positioned to predict how long these kids are going to stay in the hospital and to plan for that with our utilization and bed management. Third example to think through is just hospital readmission. For so many of our kids with medical complexity, we often say that recovery really does begin when these children lead the hospital. Takes weeks and months for them to recover a lot sometimes from their surgeries and they're at risk for running into health demise and needing to come back into the hospital. Multi morbidity plays such a big role in the likelihood of 30-day readmission rates of these children experience. Then we know from the pediatric health information system that the more comorbidities that children have, their higher rates of three-day readmission rates will occur postoperatively for gastrostomy, trache, cerebral spinal fluid diversion procedures, and spinal fusion. You know, we worry about hospital discharge care and readmission so much for our Trilumnexcomplexity on our inpatient conflicts care service that we have developed and installed a postoperative post-discharge home visit program. It's run by one of our senior nurse specialists Sarah Wells who goes into the homes of these children three to four days after discharge and runs over the entire discharge plan, goes through other medications and equipment, and identifies problems. In the first three years that we had this program up and running, she found a problem in a hundred percent of her home visits, chronic medications, and chronic problems with Durga Medical Equipment and supplies account for most of what she was finding. She did what she could do address this and avoid ED visits and re-hospitalization. Really great work. Now, when we have preoperative conversations about risks and benefits a lot with our families, of course they care about conditions specific postoperative adverse events, but they also just want to know in general, how's my kid going to do? What's their course going to be like? Is it going to be rocky or smooth? What's going to happen? Because of that, we prioritize the project assessing postoperative red shoes as measured on the floor after ICU transfer for children with medical complexity undergoing non-cardiac surgery using patient 360 data and leveraging the existing perioperative analytics team from Linfroure's preperioperative care coordination research group. We found from measuring red shoes cardiovascular neurologic respiratory demise that 27 percent of children not going to flex the experience this postoperatively. And we snuck in a classification and regression tree model that would allow us to align all the perioperative risk factors and sequence that determine which kids had the highest likelihood of experiencing red shoes. And those characteristics were undergoing a high and transphysical research rate like spine fusion, having a complex chronic condition like an underlying metabolic disease with the clinical case that I presented to you, and for the child being on 11 or more home chronic medications, 57 percent of kids with these attributes experience red shoes following surgery. Now you may say yeah yeah yeah red shoes highly variable a lot of times it doesn't really mean anything it could be just you know uncontrolled postoperative pain. But look if you know if you're a family member of a child who has an underlying fragile health conditions associated with the metabolic disease like the clinical case that I presented I mean even even small arrangements and postoperative physiological stress and status can lead to that metabolic disease becoming exacerbated. So I do think it's important to even project these more general outcomes and estimate them for our patients and families. Last example here to think through is a nice project involving assessing post-operability and clinical complexity undergoing non-cardiac surgery with the use of the risk assessment of morbidity and pediatric surgery ramp score as you guys know developed by Vivian, Nasir, Jim, Denardo, Steven, Stafa, Lynn, Farah and others have been privileged to be a part of this team as well. Bringing in the children's perioperative risk factors thinking about age whether they're critically ill or not undergoing surgery, information on their comorbidities and their intrinsical surgical risk and through a multivariable logistic regression model establishing a weighted system of points where the ramp score increases from zero to ten or more and their risk of morbidity increases from two up to over 40%. This is nice work. Models well calibrated has great discriminatory value, nice area under the ROC curve and is a great way to think about distinguishing high and low chance of more time morbidity and children with medical complexity. You know, one of the major lessons learned that I found from going through all these projects and what is so cool about all of them is that they all leveraged all this amazing data that we have sitting in our BCH Informatics platform. Patient 360 or electronic data warehouse contains much if not all the information associated with all these risk factors and perioperative adverse events that we can measure. And I think we're in such a prime position to think about how we can integrate big data and all of our predictive analytics expertise here at the hospital to automate the way that we identify and organize risk factors for these children to estimate their outcomes and to use the findings and clinical practice to inform a parapatient families for the experience and to plan for perioperative planning on the hospital level, especially with bad utilization management. I mean, carrying this further, it would be absolutely amazing to have a personalized perioperative risk profile, Informatics-driven nuanced estimation of the rates and likelihoods of relevant postoperative outcomes utilization for every child, prioritized by surgery, anesthesiology, intensive care, complex care, patients and families, whatever outcomes they would want to have and a collective dashboard to view. I mean, this really is mindful of the ACS and this quick pediatric risk calculator, which really is doing that. You know, thinking about how to take this from all the NISQP national data and how can we pair local children's data, especially if we're statistically powered and have sufficient sample size to achieve some stable data coefficients and precise and accurate assessments of the likelihood of postoperative outcomes for these children, I think that would absolutely be amazing. All right, so let's wrap up now, thinking about ideal perioperative care managed for these children, what that is and what it means to them. You know, when a surgical need arises for many of these children, unfortunately, that often uncovers problems with existing care management that are exposed. And these problems elevate the children's risk of perioperative events. We talked a little bit more about what I mean by this. Up to 50% of children with medical complexity undergoing an elected surgery have a major unaddressed chronic health issue, unrelated to the procedure that's detected preoperatively by the preopt care coordination clinic and the scegeology clinician review team. In the days, the weeks ahead of surgery, these guys are picking up on some major things undiagnosed uncontrolled comorbid conditions, now functioning of involuntal devices, major unmet healthcare needs, the review in the chart, someone's mentioned that this kid needs a polysomniagram needs to be started on noninvasive positive pressure ventilation, chronically at home, two years ago and has never happened. They pick up on things like malnutrition and cry dehydration too. I mean, here's just a recent growth curve of a kid coming through where malnutrition was detected ahead of spine surgery in a child medical complexity. Flat weight gain for over two years has fallen off the curve. So how are these problems being missed? How are we overlooking these? Let's think back to our 12 year old with carbohydrate and efficient glycoprotein syndrome. 20 providers all involved in this child's care and they're largely operating in silos. They're being very thoughtful and providing fantastic care for what they're in charge of. He's thinking about this child's guagulopathy, renal the instational disease, neurology, thinking about the epilepsy, cardiology, the dilated or the group. They're doing a great job with all that. But maybe there's not this comprehensive view across what everybody's doing and thinking about this child's comprehensive health enough to make that health and care optimized. It really begs the question of who, if anyone, can step up and really be in charge of this child's care management longitudinally. We know from national data, from the national survey of children's health that over 40% of children medical complexity do not have a clinician taking charge to manage their care. Why? Takes too much work, too much time and effort. It's not reimburse well. Primary care clinicians, especially on the community side, may feel overwhelmed to do it. That is, don't feel like they had the clinical proficiency to do it. There are lots of children out there that don't have a chronic diagnosis profile that match as well with an existing multidisciplinary program. They're not fitting into a mildly dysplasia program or cerebral palsy or a stopgillatrizia or solid organ transplantation. There's kind of hanging out there. Furthermore, kids may not have local access to a complex care program like our complex care service here, which can be a wrap around service to help manage the care for these children. Here's a heat map of all the post-this charge home residencies of hospitalized children with medical complexity at BCH. As you know, these kids are coming from all over New England and beyond. The more beyond, the more they're coming, the more likely they are likely to have a surgical need of what's drawing them to children. We're relying on all the variation in care from their local health care systems of the quality of care management that they're receiving. We were grateful to partner with our government relations teams here at Children's and other Children's Hospitals across the country through the Children's Hospital Association to pass recently some federal Medicaid policy to increase reimbursement for care management for children's medical complexity through the advancing care for exceptional kids. The ACE Kids Act, this act provides a federal to state of the seven to eight dollars per one. Money match to hopefully infuse dollars directly into the hands of clinicians that want to step up and manage the care for these kids. This legislation passed nearly unanimously in the House and Senate on spring of 2019 and our president signed this into law without any fanfare, no Instagramming, no tweeting, no snap chatting. We have about a year or so before this will come to fruition and will be implemented. And we're eager and are anticipating what this might do to help with care management. But even with federal help like this, we still think that a lot of children are going to come through with perioperative needs who have unmatched care. And that's going to continue to have an impact preoperatively. The children's health and well-being are not going to be optimized going in a surgery. There's going to be last minute scrambling of preoperative clearances to get them ready. It's going to lead to increased stress for families and clinicians to get that done and could lead to surgery cancellations and delays. I mean, now in COVID times, we have a spine canceled and you're trying to find another 12 hours upcoming for Dr. M. As to operate. It's challenging. This unmanage care also has an impact postoperatively. If you don't really have good outpatient care management that you're not going to get great sign-off and handoffs from outpatient to inpatient for these children and our in hospital providers are all ready at risk for inducing some harm in these kids. I mean, you've got to order their chronic medications correctly. The 20s, 30 meds don't mess that up. You can't overlook critical medical equipment supplies that these kids need, especially your spare-ter equipment, coming in on in exoflators and vests and other things. And you've got to be careful not to fail to detect early warning signs of demise and these children that have abnormal baseline health anyway. So having great sign-out and having guidance on what to watch for is a big deal postoperatively for our providers. All right, so that was the Debbie Downer portion of this talk. I'm going to lift you guys out of that now into more of a positive space as we wrap up just thinking about ideal perioperative care for these children and opportunities for delivering that perioperative care across the entire perioperative episode from when surgery is considered and all the way to when full recovery occurs. In my mind, when I think about the child and family sitting at the center of an episode of perioperative care, I think of four constructs that can be put together in a framework to help us achieve ideal perioperative care. First and foremost, is just thinking about highlighting all of the effective existing perioperative care processes at Boston Children's Hospital that are so great going on in bits and pieces throughout different departments and divisions for children with medical complexity. We've got to figure out how to spread and scale those so that all children receive them. I'll go through a few examples of these in just a minute. I think if we couple that effort bringing in our personalized risk and outcome profile that I talked about the big data predictive analytics ACS and this clip online risk calculator ramps other things to really do a good job of informing families of what they're going to experience. Coupling that with all the great quality and safety initiatives that are going through in surgery and physiology intensive care medicine complex care, especially thinking about early recovery after surgery. Nice recent grant rounds from our cardiovascular colleagues talking about this. This is so arrive to be applied to children with medical complexity thinking about fully management, fluids, hydration, pain management, render restart feeds, all of that e-rast stuff could be fantastically applied to these children. And lastly, thinking about anchoring all this on a platform of perioperative medical education that can help train up especially folks from the medical side that really want to stand up and help and increase the workforce of pediatric clinicians that want to get involved in perioperative care for children with medical complexity. All right, so let's just go through a few examples of BCH care processes pre-operatively that really resonate with me. This is not an, this doesn't encompass all the great work that's happening across the hospital, but these these few in particular I think are great to highlight. The first is just the pre-op care coordination clinics comprehensive health assessment. You know for every child with complexity undergoing an elective surgery that requires inpatient admission that you're going to get a reliable 360 degree review of every social, health, familial, environmental attribute that could affect the children's perioperative safety. These guys are diving deeper into power chart than it's been ever known. They're going into black holes that even Marvin Harper and John Ron don't even know about to pull out all the risk factors that they can find and help address them. Coupling that with a comprehensive review of systems, a full-on, complexity review of all the children's co-existing chronic health conditions are enduling medical devices, all their chronic meds, nutrition, and all the things that they are finding communicating that with existing child's healthcare team, getting the pre-op coherences working through, it's fantastic work. This really resonates with us in the complex care side because we're trying to emulate this comprehensive health assessment on what we do even for our quote unquote annual well child checks that we do for children with medical complexity. If we could spread and scale this upstream three six months of head of surgery, even if we could do a lot more of this from the pediatric standpoint where we have time to address the health issues that we know we're going to arise, that these kids are tucked in by the time they reach the pre-operative care coordination clinic, I think that would be amazing. Second example is just thinking about the baccalaureate and pump programs perioperative navigator role. Kristen Bucks and Ann Morgan, San Gita Malskar, Scalic Stone, have set up such a nice, perioperative experience with a navigator, Kristen and Ann who followed the patient through the entire episode of care. They are clinically proficient in integrating with the outpatient and inpatient teams. They are the point person for the families and clinicians across the entire episode and they're fantastic performing high quality outpatient to inpatient and back inpatient outpatient handoffs for these children. I mean they are embodying what I think is an emerging new role as a clinician, the perioperativeist and obviously there are other examples of this going on through the hospital as well, but I think if every kid we could screen to assess whether they would need an navigator like this through their perioperative episode could be really, really helpful. The third example that I'd like to share is on the inpatient side, just thinking about the inpatientpost.com plus care delivery that's delivered by our advanced practice nurses, Amy Pinkham and Kristen Bardsley. I'm sorry to embarrass them and call them out like this and I know that's a no-no and the field of patient safety and quality when everything is on the systems level and influencing quality but it's patient exposure to Amy and Kristen really does influence the quality of care and the outcomes that children receive. These guys are unbelievable with impeccable medication and equipment reconciliation ordering and management at admission throughout the hospitalization and hospital discharge. They also have a sixth sense and uncanny ability for recognizing subtle yet foreboding deviations from patients baseline health that can occur post-operately. They're the ones that can stand in the doorway of a kid and look over and say this kid's going to get into trouble in the next few hours unless we do X, Y and Z and you better listen to them when they make those recommendations. They're incredible at discharge planning. They start their discharge planning at admission work on it every day to make sure the contingency plans are set, follow up plans are all set, that the plans are feasible and can be executed post-test I just think that all this fantastic care process that these guys are doing should be scalable and we should really be pulling out their brains and playing and play them everywhere we can so that all the children get exposed to such high quality post-operative and patient care. Now we've been fortunate through a grant with the agency for health care we've reached in quality to try to put a lot of these things together to strive for ideal perioperative care for children with an illness or scoliosis and we're going spine fusion. You know from our introductory outcomes analysis we've seen that doing that we've it's a better anesthesiology clearance also largely because of the surgeon's institution of their antibiotic prophylaxis plans and skin preparation plans, surgical site infections have decreased and the children experience faster in hospital recovery with a length of state decrease in reduction in hospital cost. Now the methods and study designs for all this work retrospective, some chart review case control, we'd like to leverage all this preliminary data to go to get into more prospective studies, maybe even some randomization if possible to really quantify the effect that all of this ideal perioperative care can have on poster operative outcomes for these children. With that being said it's the qualitative data in my mind that really resonate and charges to keep moving forward with this. From our qualitative work on patient family experience with this endeavor we had one family who said this. I have to say this procedure spine fusion everybody was prepared and what I love so much was even though it was six month before the procedure already I was getting a call from the team. I was like all right we're starting to get your doctors and team members together and we're starting to get a plan. We found out a lot of things we found out that my shot at sleep apnea, the adhypogenylation, the adeptletal disorder, but having that six months gave us time to find out that extra information and give us time to put these supports in place so that when the day came we were ready that was key and the preparation was A plus. All right thank you for sticking with me as I have conveyed the general pediatric and hospital's perspectives on current and ideal states of perioperative care for chileum medical and leplexity. I hope that you walk away from this presentation thinking more about the population attributes of these children and the importance of surgery for them thinking about their perioperative risk how we can identify and address them and brainstorming ideas about ideal perioperative care management for these children. Look I know that not everybody is jumping up and down to take care of these kids but I can't thank you for everything that you do to keep them safe as they undergo surgery. Please keep up your enthusiasm for these kids they deserve the best perioperative care possible and it's been an absolute privilege to serve these children alongside you here at Austin Children's. Thank you again for your time and your attention and I'm happy to answer any questions that you may have. Thank you Jay for a really outstanding presentation. Are there any comments or questions you'll free to speak up or enter them into the chat box? Laura I like making a comment that is a Steve Fishman. I'm sure there are other questions. I just want to say Jay I hope that your children who are a zoom body are proud of their dad. One might think that watching your presentation would make them motivated to become an anesthesiologist or surgeon to do all the coolest stuff that we do but I want them to know that what you do is really in demand. There are so few people who are willing to put in the effort and the focus and the kindness and the compassion to take care of and help us take care of these most complex media children. So I just want to thank you for what you do. We could not do what we do without you and your teams. So I just want your kids to know that. Thank you, Dad, for Fishman. Jay I'd like to thank you as well. I would just point out what you said about you know taking risk stratification which is incredibly important and incredibly helpful but how do we action that and as you pointed out we really are moving towards a era where we will have more enhanced recovery protocols and care pathways etc and I just encourage everyone that we are looking towards trying to create more of that and I really feel like there's just an unbelievable amount of work and opportunity for people to take the various subcategories of patients and create the ideal pathways power plans etc that will allow us to really increase the quality of what we do and be much more consistent about the way that we provide this care particularly around the immediate period of time frame. I just ask you we also have had instances where the way the medical record works does not ideally inform us about some of the major issues. For instance the metabolic kids receiving an IV that does not contain glucose or that does contain glucose when it shouldn't and it does seem like there's ways in which we could leverage the electronic medical record better to alert us and to make us more aware when we're going in their own direction etc. These kids it has that been a piece of what you all are looking at? Absolutely absolutely I think the I think the champs team the infomax team is so behind trying to make that happen you know we have just all this available health record data for all the patients but not quite yet views that really prioritize the most critical information and distilling it down you know not even one click away where you can access all of that especially for critical contingency plans for fluids and other exposures they could get these kids in trouble and that's got to be the forefront of the record I think at all times not just for perioperative care but for every time we open up the chart to see one of these complex patients. Thank you. This is Lynn I wonder if you might just speak for a sentence or two about the plan for actually implementing the electronic risk calculator for our perioperative patients we're about two years into this working with Dr. Bickle and the bch360 group to actually take all of the different medical information to create a risk profile in advance to do actually what you've described so you've described what we would hope for maybe you can just speak for a second about what the plan actually is. Lynn I think that you've got things set up to really operationalize all of this you know really engineering where we're going to go to find all of these risk factors in our electronic data warehouse how to code all of them up elegant work using our Troy Yang student staff of others from the biostatistics and informatics side and you know some guinea pig trials of what we're going to see coming out very soon I think with a dashboard ability again to distill all this information down and to some type of view that's manageable and not overwhelming and putting those data in front of all the perioperative clinicians and patients and families and see how it goes. I think you've got things engineered now from start to finish of how this is going to come to fruition and I can't wait to see it. John did you have a question? Yeah hey Jay this is Sean so outstanding job as always and so many folks on the call mine I know that Jay is almost as good at brewing his home beer as he has taken care of chronic care and patient and so that says a great deal but no Jay has done some incredible work and we appreciate the shout out to the verification program and this has really increasingly been recognized as a really really really important aspect of care at level one centers in fact as we move forward it's going to be less important of having individual resources versus how those resources work together and in the care complex care patients such as this it's critically important and so it seems like there's a couple of different applications right so one is to really understand the risk profile these patients and what I really didn't appreciate until just a few months ago was how important the backgrounds were of these patients not necessarily what you're doing to them but their comorbidities in terms of outcomes and what was shocking to me is that you use the risk calculator in this clip there's not much of a difference in perioperate risk of those undergoing a 13 level R3Ds versus a G2 the mortality is about 5 and a half percent the risk of an SSI is actually even higher for kids are going G2s because it's a clean contaminated you know operation and so part of this is really understanding what that risk is and preparing for but I think one of the most impressive aspects of data that you showed is actually a decrease in those rates and so a question for you is once we really kind of understand what those risk profiles are will they be any plans to work with individual departments and how to mitigate that risk based on what we do right so for instance in general surgery if this was Cincinnati childrens we probably do in a ton of distance but we don't we do a lot of central access procedures and so will there be any plans to work with individual departments about using that experience with risk mitigation for the spinal cases and try to apply it to the individual cases that we do in collaboration with your department across Boston childrens Sean I think so I mean you know I think it would be hard to kind develop a one-size-fits-all kind of platform and you've got to celebrate and highlight all the nuances of all the individual surgeries and what folks are thinking about across the different departments and divisions and especially leveraging all the expertise and clinical folks involved in order to try to mitigate those risks and you may mitigate them in different ways you know so I do think there's got to be this kind of ground up building that goes you know that that really does speak to all the stakeholders across all the divisions and departments with some type of top down you know approach that would work to meet in the middle to where it's going to work it's not going to be so so higher level that it doesn't it doesn't resonate for specific patients but yet it's not so nuanced that we lose like we were talking about earlier all the sample sizes and everything else if we get too splitting on the patient populations that we lose our predictive power and as Danny worked thanks again for such a great talk Jay thank you Sean. Thank you Jay it's me Erie thank you for a great presentation and thank you for leaving the CCS reviews on Friday it's been a great form and a great learning experience for providing peruepidive TSA care thank you Jay. Mary thank you we've enjoyed learning from you guys so much and and please stay tuned because we want all of our upcoming complex care fellows to hang out with you guys in the pre-op care coordination clinic to learn what you do. I'll write any other questions from anyone or comments at all. Okay I think we might wrap things up then thank you again Jay for taking the time to speak to us today and thank you everyone else for joining in and we'll close things out. Thank you Laura thank you everyone take care.
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