PAPS Best of the Best Winner

Anyone else have trouble getting to all the academic meetings this past year? At stay current, we knew that there was groundbreaking practice changing research that we were missing out on. And so on April 8th, we held the first ever best of the best event. We got the best of the best from all over the world coming today to see who really is the best in pediatric surgery. Selected presentations from pediatric surgical societies including Papps, Caps, IPEG, Absa and Upza competed in a head to head event for the overall title of best to the best in pediatric surgery. With such incredible research is presented in all over the corners of the earth. So this is the place to come where we can finally see all the best stuff. We're having a fun time doing it, but really the purpose is so that we can share ideas all over the world and not be living in silos. This novel event included presentations, expert discussion, and a few last minute punches to determine the true best to the best. The finalists certainly came out swinging. Let's see what Pap's finalist brought into the ring with a presentation by Sophie Carr. So next we have Sophie Carr from British Columbia presenting on optimizing skin antisepsis for neonatal surgery. And afterwards we'll hear some commentary from Dr. Rebecca Rentia from Mercy Children's Hospital in Kansas City. Hi everyone. Thank you for this opportunity to present our work on optimizing skin antisepsis for neonatal surgery. My name is Sophie Carr and I'm a fourth year medical student at the University of British Columbia. I will be discussing off-label use of a topical antiseptic in this presentation, but have no other relevant disclosures. Surgical site infections are a costly yet modifiable source of morbidity, particularly within the neonatal population. Preoperative skin antisepsis is one of the primary prevention strategies routinely performed to reduce the risk of SSIs. A growing body of evidence in adults suggests that chlorhexidine, gluconate, and isopropyl alcohol provide superior protection against SSIs than Providone. Equivalent data does not yet exist for the neonatal surgical population, but CHG antisepsis is commonly used for invasive non-surgical procedures in Nicks and for prevention of newborn nosocomial infections in developing countries. Although commonly used within the neonatal population, current product labeling discourages CHG IPA antisepsis in infants under two months of age, as there is limited safety data and concerns around adverse effects, particularly skin injuries. As part of a multiprong strategy targeting SSI reduction at BC Children's Hospital, we undertook a quality improvement project with the following aims. Number one, establish an evidence basis for safe surgical skin antisepsis in neonates. Number two, implement a neonatal CHG IPA skin antisepsis protocol. And three, evaluate the safety and effectiveness of this protocol. Through much collaboration with our team, engagement with stakeholders, surveying of other institutions and literature reviews, we developed the neonatal skin antisepsis protocol. Inclusion was limited to general surgery patients only with 34 weeks post-conception age and 1500 grams as the lower age and weight limits. The yellow table outlines which solution was used based on age cutoffs, either 2% or 0.5% CHG. Skin integrity was assessed using a validated tool called the neonatal skin condition score. And an analysis comparing pre and post implementation data was subsequently performed to assess protocol effectiveness. This is our data collection sheet front and back, which followed patients on the protocol from the operating room to the NIQ. Implementation of the protocol occurred in February 2020 and was preceded by education of both OR and NQ staff. A total of 50 patients were included, none of which experienced adverse skin prep outcomes. 8% developed SSIs within the 30day post-op period compared to 14% in the matched retrospective podone cohort. A comparison of SSI rates between the CHG versus PI cohort revealed no significant difference. Zooming back out a bit, this project has engaged stakeholders in neonatal surgical quality improvement work. It has informed the development and implementation of a neonatal CHG IPA surgical skin prep protocol. And it has led to collaboration with other Canadian Niquit pediatric sites who are looking to implement a similar protocol. These project outcomes all play into our end goal of improving patient care through ensuring safety and improving clinical outcomes. Thank you very much for your time, and with that, I will conclude my presentation. Dr. Carr, what a fantastic presentation. I think this really speaks to every pediatric surgeon and anybody taking care of neonatal children. There's really a wide range of topical anesthetic preparations that are um antiseptic preparations that are used in neonatal surgery and the formulations are really variable and um there's even between the different types of formulations, there's many variations. I wonder um what the level of contamination was between some of the different neonatal cases and then how did you determine your weight cutoffs and were there any other parts of a bundle? Because usually when stakeholders become involved, the entire process of surgical site infections is evaluated in great detail. Um, also the the cutoffs, I'm really curious about how you determined the formulation because there's many different formulations of chlorhexidine, uh how you determined those. Great presentation. Thanks again. Thanks very much for the questions, Dr. Renti and the commentary. Um, in response to your first question uh with regards to contamination of cases, majority of them were class two, so clean contaminated cases, which is um really more in keeping with the literature in terms of adult um SSI reduction and use of CHG antisepsis. Um, there were a few uh contaminated cases, but the majority of were clean contaminated. Um, and in terms of our uh lower uh age and weight cutoffs. That was something we spent a great deal of time kind of discussing and and and trying to figure out where was the best place to start. Um, our priority was really to ensure ensure safety as this was a quality improvement project and so uh wanting to uh take fairly conservative lower age and weight cutoffs uh for our first kind of go around of this initiative. Um, our protocol was largely modeled um off of well a number of different sources, but the primary source was the McGill uh protocol used in Quebec, Canada. And they used a lower age uh cutoff of 28 weeks gestational age um with a lower weight cutoff of a 100 gra or sorry, 1,000 grams. Um, so we decided to start at a more conservative place, recognizing that we were excluding a large portion of our neonatal surgery patients, um and then uh hopefully in future, um projects kind of expand that pool and and do so in a very cautious, careful way. um, as the primary or concern is really the adverse skin reactions uh with less than 28 weeks gestational age being the primary population affected by those in the literature. Um, and yes, this was this project really stemmed from our wider quality improvement initiatives um tackling our SSI rates within neonatal surgery at BC Children's Hospital. So, um this was conducted in conjunction with a number of different initiatives. Um, uh including evidently our antibiotic prophylaxis and so optimizing that, um using adhererent uh draping to ensure we weren't contaminating in the field. and then um for our class two clean contaminated cases, uh using a um uh clean closure bundle. Um, so changing our gloves uh prior to closure um and really taking a multipronged uh approach to targeting our SSI rates. I might have missed it, but what was your SSI rate before you performed this study? And was the um the bundle where you changed your gloves or had a closing protocol? Um, was that also part of the pre protocol? Like the control before you started the study. Right. So, um, I minute I to have that data off the top of my head um as this was um uh we we didn't have it as a perfect control as it was really just one of the additional initiatives that we added in. Um, uh so we didn't do a direct comparison. This was more of uh trying to ensure safety within in using that antiseptic solution. Um, however, we did do look at um uh a retrospective cohort when we were using podine in the same population and um the SSI rate, though there was no statistical difference was 14% as compared to eight. In a very small group. This was only just 50 50 patients, so it's hard to really show any significant difference. Sophie, we have we have 30 seconds left and I want you to do a rapid fire answer here. 10 seconds 10 seconds. Rapid fire answer from the audience. First of all, was your decrease in SSI statistically significant? Yes or no? No. Okay. And the other question was, which procedures did you use chloraprep and which did you not? Um, so all general surgery cases that um didn't have a any open exposed mucosa or in which the patient evidently was allergic to CHG or IPA. Okay. Phenomenal, great discussion. Got it right under the bell sort of, a little over the bell. blows after the bell. Uh, so back to your corners.