Colorectal

Introduction

Welcome to the APSA Quality and Safety Committee’s Colorectal Toolkit. This page is intended to help anyone who is interested in quality improvement of the management of patients with colorectal diseases, predominantly anorectal malformations and Hirschsprung 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.

Projects

Anorectal Malformations

Primary Children’s Hospital in Utah developed a clinical care pathway for delayed primary repair of rectoperineal or rectovestibular fistulas. They sought to assess the incidence of wound complications in infants undergoing a single-stage PSARP of these types of fistulas beyond the neonatal period (> 30 days of life) and determine if there were identifiable risk factors for wound complications. The pathway excluded patients who underwent a “cutback” procedure. The team’s approach began with dilation of the fistula at the time of diagnosis and repair at approximately 3 months of age, or when the child was over 5 kg. The goal of dilation was not to achieve a specific size, but rather to obtain decompression; passage of a 7 or 8 Hegar twice daily was usually sufficient. Patients were admitted pre-operatively for a bowel preparation using both oral antibiotics and a cathartic (e.g. GoLYTELY®). Rectal irrigations were performed in the operating room with a dilute Betadine solution immediately prior to the start of the operation until the effluent was clear of stool. Post-operatively, patients received intravenous antibiotics for 48 hours and remained NPO, on maintenance intravenous fluid for 4 days, with an ad lib diet initiated on post-operative day 5.

Protocol:

Stakeholders: pediatric surgeons, pediatric surgery fellows, surgical residents, surgical APPs, Primary Children’s Hospital Colorectal Center NPs and nurses, patient caregivers

Challenges and solutions:

  • Education of stakeholders
    • A monthly reminder of the algorithm was given at the pediatric surgery divisional meeting, the algorithm was published on the monthly APP newsletter, rotating residents were educated during orientation to the service.
  • The push to reduce hospital stay challenges the pre-operative admission for bowel prep and the prolonged post-operative course suggested in the protocol.
    • Multi-institutional large-scale demonstration that an accelerated care pathway results in equal or superior outcomes regarding wound complications and functional outcome are needed.

Links to published data (used to develop the protocol): [1][2][3]

Submitted by: Michael D. Rollins, MD

Hirschsprung Disease

While a consensus for the definition of Hirschsprung-Associated Enterocolitis (HAEC) is lacking, the mainstay of treatment includes rectal irrigations with or without antibiotics. This treatment can be effective when initiated in the outpatient setting. Primary Children’s Hospital in Utah implemented a triage algorithm in an effort to standardize care, thus, providing more timely treatment and preventing unnecessary hospital admissions.

Protocol:

Stakeholders: pediatric surgeons, pediatric surgery fellows, surgical residents, surgical APPs, Primary Children’s Hospital Colorectal Center NPs and nurses, patient caregivers

Challenges and solutions:

  • Education of stakeholders
    • A monthly reminder of the algorithm was given at the pediatric surgery divisional meeting, the algorithm was published on the monthly APP newsletter, rotating residents were educated during orientation to the service.

Links to published data (used to develop the protocol): [4][5][6][7]

Submitted by: Michael D. Rollins, MD

Ostomy-Related Initiatives

Gastrointestinal (GI) surgeries represent a significant proportion of the surgical site infection (SSI) burden in pediatric patients, resulting in significant morbidity. Given that Nationwide Children’s Hospital had previously demonstrated that a GI bundle (including preoperative bowel prep, preoperative warming, preoperative cleansing, skin prep, and a closing protocol) decreases SSI rates, length of stay (LOS), and hospital charges, they hypothesized that by targeting the preoperative antibiotics for stoma closures based on organisms found in infected wounds, they could further decrease SSI rates. As such, they implemented a QI initiative titled: Decreasing Surgical Site Infections in Pediatric Stoma Closures. In order to accomplish this project, they held quarterly Quality Improvement (QI) meetings, provided monthly nursing education, educated faculty at monthly meetings, sponsored new resident education sessions, provided handout for easy references and relied on preoperative and postoperative colorectal and pelvic reconstruction (CCPR) ordersets.

Protocol:

A recommended strategy to rollout this project includes:

  • Presenting the PowerPoint at a faculty meeting, and establishing consensus around goals to improve compliance.
  • Sending out education/announcement emails to current residents (and obtaining a schedule of future rotating residents to be emailed upon joining the rotation). Explanation of the initiative should be part of the orientation day agenda.
  • Sending out templated reminder emails to faculty about the current guidelines.
  • Monthly auditing of targeted cases using templates to ensure adherence to guidelines.
  • Sending out templated emails to faculty and residents for non-compliant cases as a reminder, and to assess reasons for non-compliance.

Stakeholders: surgery, QI team, nursing, OR team

Challenges and solutions:

  • Implementation of the change in preoperative antibiotics led to fewer rates of surgical site infections.
  • Anesthesia colleagues were amenable to using the antibiotics per colorectal surgery guidelines.
  • Extensive teaching with the nursing staff resulted in accurate placement of preoperative orders, ensuring antibiotics were always available for the cases.
  • The biggest challenge was resident education, since multiple residents from different hospitals rotate through the pediatric surgery service on a monthly basis. This was overcome by holding multiple educational sessions every month, and by creating a pocket-sized handout for easy reference.

Links to published data (used to develop the protocol): [8][9][10][11][12][13][14][15]

Submitted by: Hira Ahmad, MD

Discharge Process in Colorectal Patients

The accuracy of a discharge summary is of paramount importance in the care of complex patients, those with pediatric colorectal diseases are not an exception. Cincinatti Children’s Hospital developed a QI project highlighting the elements of a complete discharge summary for this group of patients. Their goal was to have a complete and accurate discharge summary that included nine bullets: attending provider, indication for admission, discharge diagnosis, procedure(s) during admission, discharge medications, discharge instructions, an outline of the future plan of care, information sent to the PCP, information delivered and reviewed with the family, and scheduled follow up appointment. The project was implemented via a series of presentations used to describe the full project inclusive of a retrospective review and various PDSA cycles.

Protocol:

Stakeholders: pediatric colorectal patients

Challenges and solutions:

  • One of the biggest challenges was the lack of a primary care physician (PCP) for the large number of international patients being cared upon; since in this population, having a PCP is not the norm.
  • Another challenge was the need for “technology” to lead to automatization, such as the requirement of an IT team to create an EPIC build.

Submitted by:Andrea Bischoff, MD

References

For recent research pertaining to the management of patients with colorectal diseases, please refer to references [16][17][18][19].

References

  1. Short SS, Bucher BT, Barnhart DC, et al. Single-stage repair of rectoperineal and rectovestibular fistulae can be safely delayed beyond the neonatal period. J Pediatr Surg. 2018;53(11):2174-2177.  [PMID:29544884]
  2. Kumar B, Kandpal DK, Sharma SB, et al. Single-stage repair of vestibular and perineal fistulae without colostomy. J Pediatr Surg. 2008;43(10):1848-52.  [PMID:18926219]
  3. Chan KW, Lee KH, Wong HY, et al. Outcome of patients after single-stage repair of perineal fistula without colostomy according to the Krickenbeck classification. J Pediatr Surg. 2014;49(8):1237-41.  [PMID:25092083]
  4. Wall N, Kastenberg Z, Zobell S, et al. Use of an enterocolitis triage and treatment protocol in children with Hirschsprung disease reduces hospital admissions. J Pediatr Surg. 2020;55(11):2371-2374.  [PMID:32553451]
  5. Gosain A, Frykman PK, Cowles RA, et al. Guidelines for the diagnosis and management of Hirschsprung-associated enterocolitis. Pediatr Surg Int. 2017;33(5):517-521.  [PMID:28154902]
  6. Frykman PK, Short SS. Hirschsprung-associated enterocolitis: prevention and therapy. Semin Pediatr Surg. 2012;21(4):328-35.  [PMID:22985838]
  7. Pastor AC, Osman F, Teitelbaum DH, et al. Development of a standardized definition for Hirschsprung's-associated enterocolitis: a Delphi analysis. J Pediatr Surg. 2009;44(1):251-6.  [PMID:19159752]
  8. Porras-Hernandez J, Bracho-Blanchet E, Tovilla-Mercado J, et al. A standardized perioperative surgical site infection care process among children with stoma closure: a before-after study. World J Surg. 2008;32(10):2316-23.  [PMID:18509611]
  9. Bucher BT, Warner BW, Dillon PA. Antibiotic prophylaxis and the prevention of surgical site infection. Curr Opin Pediatr. 2011;23(3):334-8.  [PMID:21494149]
  10. Tanner J, Padley W, Assadian O, et al. Do surgical care bundles reduce the risk of surgical site infections in patients undergoing colorectal surgery? A systematic review and cohort meta-analysis of 8,515 patients. Surgery. 2015;158(1):66-77.  [PMID:25920911]
  11. Nordin AB, Sales SP, Besner GE, et al. Effective methods to decrease surgical site infections in pediatric gastrointestinal surgery. J Pediatr Surg. 2017.  [PMID:29108847]
  12. Chandramouli B, Srinivasan K, Jagdish S, et al. Morbidity and mortality of colostomy and its closure in children. J Pediatr Surg. 2004;39(4):596-9.  [PMID:15065035]
  13. Feng C, Sidhwa F, Cameron DB, et al. Rates and burden of surgical site infections associated with pediatric colorectal surgery: insight from the National Surgery Quality Improvement Program. J Pediatr Surg. 2016;51(6):970-4.  [PMID:27018086]
  14. Bucher BT, Guth RM, Elward AM, et al. Risk factors and outcomes of surgical site infection in children. J Am Coll Surg. 2011;212(6):1033-1038.e1.  [PMID:21398150]
  15. Breckler FD, Rescorla FJ, Billmire DF. Wound infection after colostomy closure for imperforate anus in children: utility of preoperative oral antibiotics. J Pediatr Surg. 2010;45(7):1509-13.  [PMID:20638534]
  16. Diederen K, de Ridder L, van Rheenen P, et al. Quality of life and colorectal function in Crohn's disease patients that underwent ileocecal resection during childhood. Eur J Pediatr. 2019;178(9):1413-1421.  [PMID:31327075]
  17. Halleran DR, Lane VA, Leonhart KL, et al. Development of a Patient-reported Experience and Outcome Measures in Pediatric Patients Undergoing Bowel Management for Constipation and Fecal Incontinence. J Pediatr Gastroenterol Nutr. 2019;69(2):e34-e38.  [PMID:30921256]
  18. Harrington AW, Gasior AC, Einarsdottir H, et al. Hirschsprung Disease: The Rise of Structured Transition and Long-term Care. J Pediatr Gastroenterol Nutr. 2019;69(3):306-309.  [PMID:31107797]
  19. Janssen Lok M, Miyake H, O'Connell JS, et al. The value of mechanical bowel preparation prior to pediatric colorectal surgery: a systematic review and meta-analysis. Pediatr Surg Int. 2018;34(12):1305-1320.  [PMID:30343324]
Last updated: November 23, 2022