Introduction

This topic is intended to help anyone who is interested in quality improvement surrounding Pilonidal Disease.

Available toolkit projects are listed below. Many of the approaches described are evidence based - some are not. These approaches have not been approved by APSA.

see also the APSA systematic review presentation

Minimally Invasive Pilonidal Management

Boston Children’s Hospital

BCH attempted to improve outcomes in pilonidal disease by implementation of a dedicated pilonidal care clinic (PCC), laser hair removal and minimally invasive sinusectomy (i.e. pit picking, Gips procedure) in adolescent patients [1][2].

Protocol

Patients are evaluated in a dedicated clinic by a surgical physician assistant and pediatric surgeon. Extensive patient education is provided and reinforced at every visit. Care focuses on hair removal, improved hygiene and excision of pilonidal pits. The goal of treatment is to decrease recurrence rates with minimal morbidity and life disruption. Patients are treated as follows:

1. Acute, nondraining abscesses are treated with incision and drainage and then soaking and shaving until inflammation resolved.
2. Patients with chronic draining wounds are treated with shaving and soaking until drainage decreases.
3. Once patients have resolved the acute inflammatory phase (no cellulitis, rash, or purulent discharge) they begin treatment protocol.
   1. Laser hair removal (if hirsute) – performed at six week intervals until hair burden is minimal (typically six treatments)
   2. Sinusectomy – excision of pilonidal pits using ~ three mm punch biopsies under local anesthesia in outpatient setting. Sinuses are closed with 4-0 nylon mattress suture. Counter incision to debride lateral tract (exit sites) is made and left open.
      1. Patients with more than four to five pits undergo serial pit excisions over multiple visits.
      2. Buffered lidocaine solution is used to maximize comfort
      3. Patients begin soaking on postoperative day (POD) zero and continue until suture removal
      4. Sutures removed by priary physician on POD 10
      5. Soaking continues until counter incision heals by secondary intention
      6. No activity restrictions or narcotics
      7. Patients who cannot tolerate excision under local undergo pit picking under anesthesia
4. Close clinical follow-up every six weeks until pits removed and hair burden significantly reduced.
5. Recurrences treated promptly with antibiotics with or without incision and drainage.
6. Patients with dehisced wounds from prior surgical treatment are treated with aggressive wound care, appropriate dressing materials and short follow-up intervals. Laser can be initiated (treating only skin and not granulation tissue) if no purulence. This improves wound healing.

Resources

• family education sheet
• home care instructions

Stakeholders: pediatric surgeons, community pediatriciains, emergency room physicians, anesthesia, nursing staff, pharmacy, laser safety committee, quality improvement, department administrator

Challenges and solutions:

1. No hair removal capable laser owned by hospital. Solution: business analysis showed high volume of patients who would utilize this service
2. Difficulty obtaining credentialing for PAs and RNs to perform laser independently. Solution: ultimately approved due to volume
3. Lack of insurance reimbursement for laser. Solution: increased level of billing to level 4 based on time
4. Patients with special needs or psychiatric conditions unable to tolerate outpatient treatment. Solution: perform pit picking under anesthesia and laser under sedation (currently seeking)
5. Patient compliance low with home care regimen. Solution: emphasize patient education, personalizing care for their sports/school/home routine. Follow-up at short intervals has improved compliance.
6. Difficulty tracking patients once care is complete. Solution: develop text based short survey to follow for five-year period (in progress).

Submitted by Hajar Delshad

Additional implementers: David Mooney

Pediatric Surgical Services, The Permanente Medical Group, Kaiser Hospital, Roseville, CA

A protocol was devised for conservative management of pilonidal disease focusing on hygiene and local wound care in the outpatient setting.

Protocol

• provider management protocol

Resources

• family information sheet
• clinic supply list

Stakeholders: surgeons, nurses, nurse practitioners, physician assistants, medical assistants, primary care providers, patients and their families

Challenges and solutions: Setting up uniform clinic flow pathway and sharing EPIC Smart Phrases.

Submitted by Thomas Curran

Additional implementers: Doug Miniati, Jennifer Keller

References