Integrating intraoperative physiology data into outcome analysis for the ACS Pediatric National Surgical Quality Improvement Program

Background The Pediatric National Surgical Quality Improvement Program (P-NSQIP) samples surgical procedures for benchmarking and quality improvement. While generally comprehensive, P-NSQIP does not collect intraoperative physiologic data, despite potential impact on outcomes. Aims The aims of this study were (a) to describe a methodology to augment P-NSQIP with vital signs data and (b) demonstrate its utility by exploring relationships that intraoperative hypothermia and hypotension have with P-NSQIP outcomes. Methods Vital signs from 2012 to 2016 were available in a research databank. Episodes of hypotension and hypothermia were extracted and recorded alongside local P-NSQIP data. Multivariable regression analyses were performed to explore associations with undesired outcomes, including: surgical site infection, wound disruption, unplanned return to the operating room, and blood transfusion. Model variables were selected with the Akaike information criterion using 2012-2014 as the training set and validated with receiver operating characteristics analysis using 2015-2016 as the testing set. Results Data from 6737 patients were analyzed, with 43.9% female, median [interquartile range] age 5.8 [1.3-12.4] years, undergoing procedures lasting 118 [75-193] minutes. Hypothermia, observed in 45% of cases, was associated with wound disruption (odds ratio 1.75, 95% CI 1.1-2.83). Hypotension, observed in 60% of cases, was associated with unplanned returns (odds ratio 1.58, 95% CI 1.02-2.51), and transfusions (odds ratio 1.95, 95% CI 1.14-3.52). Surgical site infection, wound disruption, unplanned return, and transfusion models had areas under the receiver operating characteristic curve of 0.69/0.67, 0.59/0.63, 0.78/0.79, and 0.92/0.93 for validation models including hypothermia/hypotension respectively. Conclusion Adding intraoperative vital signs to P-NSQIP data allowed identification of two modifiable risk factors: hypothermia was associated with increased wound disruption, and hypotension with increased blood transfusions and unplanned returns to the operating room. These findings may motivate prospective studies and prompt other centers and P-NSQIP to augment outcome data with intraoperative physiological data.