Clinical Instructor University of Utah School of Medicine Salt Lake City, Utah, United States
Background: Children with medical complexity (CMC) have chronic conditions that often include neuromuscular scoliosis and/or hip dysplasia warranting surgical intervention. Due to their high medical fragility, CMC have an increased risk of experiencing surgical complications. The current literature describes CMC who undergo spinal fusions; with median length of stay (LOS) of 8 days, 90-day readmission rate of 6%, and complication rates that vary widely (10-70%). In response to this data, our large tertiary care children’s hospital established an interdisciplinary Complex Surgery Collaborative of pediatric medical and surgical subspecialists to pre-operatively evaluate CMC for whom major spine or hip surgeries are being considered. Objective: To describe the experience and baseline performance of a formalized interdisciplinary process of pre-operative management designed to optimize outcomes for CMC. Design/Methods: CMC were identified and referred to the Collaborative from orthopedics. All candidates underwent a consistent evaluation with well defined metrics for assessment of risk. Using administrative data from our EMR, we retrospectively obtained data to describe the CMC who were evaluated by the Collaborative and their outcomes. Results: The Collaborative evaluated n=190 CMC (2019-2023); 169 (89%) had ≥3 Feudtner Complex Chronic Conditions and 15% had a low/very low Child Opportunity Index. To date, 110 CMC (58%) have undergone surgeries, at a mean age of 12.4 years. The mean LOS was 8.6 days (2.2 PICU days); median LOS = 6 days. 34 CMC (31%) had post-operative complications including but not limited to: respiratory insufficiency (n=9), pneumonia (n=8), UTIs (n=3), bacteremia (n=2), and reversible intraoperative cardiac arrest (n=1). 20 (18%) were readmitted within 90 days of hospitalization. 80 CMC have not undergone surgery. 10 (12%) are scheduled for surgery and 31 (39%) are still being evaluated by the Collaborative. The remaining 39 (49%) were declined by either the Collaborative or the family or died prior to procedure.
Conclusion(s): Medical complexity and fragility are defining characteristics of CMC. Complications should be anticipated. An interdisciplinary Complex Surgery Collaborative for CMC provides opportunities to proactively address potential surgical risk factors, identify CMC for whom surgical risk exceeds benefit, educate families, and optimize preoperative health through shared-decision making. Further research is needed to distinguish avoidable from unavoidable post-operative complications and to determine if a standardized referral and evaluation process improves outcomes.
