Safety in Surgery

Safety is a top priority at The Children's Hospital of Philadelphia. It is the basis of everything we do and every decision we make regarding your child's care. Nowhere is safety more important than during surgery — when your child is often at his most vulnerable.

Our surgeons will always use the least invasive approach possible to repair a defect or injury and help your child recover as quickly as possible.

Before surgery: care coordination

Before surgery, we work to ensure your child is as healthy and strong as possible. By taking precautions before surgery, we can help speed your child's recovery after surgery and reduce the risk of infection or any long-term side effects.

Depending on your child’s condition, we may recommend a nutritional or exercise program be started before surgery to build your child’s strength. For example, we may request your child stop taking any over-the-counter medications or herbal remedies, which may interfere with anesthetics or medications needed before, during or after surgery.

If your child has health issues beyond the orthopedic condition being treated, our orthopedic team will work closely with your child’s other healthcare providers to coordinate care.

During surgery: minimizing risks

With any surgical procedure, there are general risks and procedure-specific risks. Our goal is to minimize, if not eliminate, those complications.

Surgical site infections are a very real issue in the United States. As many as 5 percent of patients undergoing surgery in the U.S. will experience a surgical site infection, leading to an increased risk of serious health complications, more days in the hospital, and increased healthcare costs.

At CHOP, we employ numerous best practices before, during and after surgery to decrease the risk of infection and increase positive outcomes.

Continuous anesthesia monitoring

Before surgery, it is natural for you to be concerned about the effects of anesthesia on your child. At CHOP, the anesthesiologists who care for your child are fellowship-trained in pediatric anesthesia and well versed in providing anesthesia to children.

The surgical team at CHOP employs many best practices to:

  • Minimize the chance of a bad reaction to the anesthetic
  • Reduce the opportunity for post-operative pneumonia and infection
  • Promote wound healing

Perioperative antibiotics

National studies by CHOP physicians and groups like the American Academy of Orthopaedic Surgeons (AAOS) have shown that using preventative antibiotics within one hour before surgery on patients without known infections has reduced the incidence of infection.

While giving patients perioperative antibiotics is considered routine for many orthopedic procedures, CHOP surgeons continue to research the best antibiotics to use, and the best route of administration.

Advanced navigation and imaging

Our surgical team uses the latest, high-tech imaging equipment — such as StealthStation® and O-arm® Surgical Imaging — to provide real-time images to aid surgeons and staff in safe placement of instruments and to support their decision-making during surgery.

By seeing exactly where they are operating, our team functions more accurately, reduces the amount of radiation exposure to your child, and shortens the time your child is under anesthesia.

Ongoing monitoring during surgery

Our surgical and clinical teams continually monitor your child's brain and muscles during surgery. Any member of the team can call a "time out" to reassess the patient or address any issues that develop during surgery.

Our team uses highly specialized monitoring called transcranial motor evoked potentials (TcMEP). TcMEP monitoring stimulates the motor cortex and descending motor axons of the patient's brain. Muscles responses in the child’s arms and legs give clinicians feedback almost instantaneously. It is currently one of the most effective ways to evaluate the patient’s motor pathways. This is especially important during spinal surgery.

After surgery: coordinated follow-up

After surgery is over, there are several ways the orthopedic team at CHOP works to ensure your child’s safety and comfort.

Pain management

Immediately after surgery, your child may have some discomfort, but our professionals in the Newborn/Infant Intensive Care Unit and the Pediatric Intensive Care Unit are specially trained to manage the pain of babies and children. Our goal is to keep your child as comfortable and safe as possible.

Depending on the age and developmental stage of your child, we may give him or her patient-controlled analgesia (PCA) for the first few days after surgery. This is an intravenous way to deliver pain medication to your child without repeated injections or pills. Your older child or teen can push the PCA to safely receive pain medication when needed.

Postoperative clinical pathways

Postoperative clinical pathways are standardized order sets developed by our team after reviewing best practices at CHOP and across the nation. Each order set for orthopedic patients is used to reduce variations in care.

The pathways serve as a framework so each patient receives the direct care he or she needs in the hospital and after discharge. Standardized clinical pathways have led to significant reductions in the length of hospital stays, more efficient management of hospitalized patients, and better outcomes for patients.

Long-term follow-up care

In most cases, your child will see the orthopedic surgeon about one to two weeks after surgery, then again at three and six months post-surgery. Annual monitoring by trained clinicians is strongly encouraged because some orthopedic conditions can reoccur — even after being successfully treated. It is important for your child to see a physician regularly, especially if any symptoms reoccur.

During follow-up visits, X-rays and other diagnostic testing may be needed to closely monitor your child’s health and ensure there are no lingering effects from surgery or other treatments.

Continued research

Orthopedic surgeons, physicians and researchers at CHOP continue to investigate new diagnostic tools, new treatment approaches and ways to make surgery safer for all children with orthopedic conditions. CHOP orthopedic physicians continue to produce award-winning research to stay on the cutting-edge of patient clinical care and safety.

Our attention to research-based practices, and our individualized attention to your child's condition and specific needs, produces excellent results.

Preventing Infections

Surgical site infections are a very real issue in the United States. Two to 5 percent of patients undergoing inpatient surgery in the U.S. will experience a surgical site infection (SSI), leading to more days in the hospital, increased healthcare costs, and an increased risk of serious health complications.

Here’s a brief overview of what we do at The Children’s Hospital of Philadelphia to decrease the chance your child will experience a surgical site infection.

Preoperative

Before surgery, we are concerned with skin colonization — that is — any germs that may be on or in your child’s body before he or she is taken to the operating room (OR).

Safety techniques we employ include:

  • Home baths — preoperative bathing with a product containing chlorhexidine
  • Identifying MRSA — routine screening for Methicillin-resistant Staphylococcus aureus and treat it before surgery when possible

Intraoperative

During surgery, we are concerned with a number of factors: skin colonization, the OR environment and your child’s physiology.

Safety techniques we employ include:

  • Dedicated spine deformity teams
  • Locally delivered antibiotics in spine surgery
  • Limited OR traffic
  • Appropriate choice of antiseptic
  • Perioperative antibiotics
  • Appropriate hair removal (no razors)
  • Limiting the number of people in the operating room
  • Creating a sterile field near the incision site
  • Using the appropriate surgical technique and equipment
  • Continuously monitoring the patient for temperature, glucose, blood pressure and other factors depending on the surgical procedure

For detailed information about safety in the operating room, see CHOP's surgical safety checklist. 

Post operative

After surgery, we are concerned with your child’s physiology and wound care.

Safety techniques we employ include:

  • Practicing good hand hygiene
  • Assessing the wound at regular intervals
  • Applying appropriate wound dressing — and dressing changes — to protect the wound and maximize healing
  • Continuing to monitor the patients’ temperature, blood glucose, blood pressure and other vital statistics which can serve as early warning signs of infection

Surgical Safety Checklist

The Children's Hospital of Philadelphia regularly assesses and updates its best practices to keep all children as safe as possible during surgery.

We want you to know how we are going to keep your children safe in the operating room — when they are often at their most vulnerable.

Before the induction of anesthesia

1.    Sign in is initiated by the anesthesiologist

2.    The circulating nurse and anesthesiologist will verify the following:
   •   
The patient’s identity (with two patient IDs)
   •   The patient’s weight
   •   The patient's physical status according to American Society of Anesthesiologists' classification system
   •   Any allergies the patient has
   •   The procedure(s) being done that day
   •   That the site of the procedure is marked

3.    When applicable, the circulating nurse and anesthesiologist will also address:
   •   
Alternate induction technique (i.e. parental presence, rapid sequence, difficult airway/intubation)
   •   Pain management (regional or patient-controlled analgesia)
   •   Special catheter placement (central venous, arterial, urinary)
   •   Malignant hyperthermia risk
   •   Hypothermia risk
   •   The risk of deep-venous thrombosis (DVT) prophylaxis (if patient is 14 or older and the procedure is expected to last more than 45 minutes)
   •   Patient positioning
   •   Inpatient bed requirements

Before the procedure starts

1.    Appropriate patient positioning, with all bony prominences padded to minimize the risk of pressure ulcers

2.    A time-out is initiated by the surgeon or anesthesiologist 

3.    All team members are introduced by name and role

4.    For all procedures, the following information is reviewed:
   •   Patient's name
   •   Procedure(s) being done, site of the surgery, side of the body
   •   Matching signed consent forms
   •   Pertinent medical history, medications or implants
   •   Initial count of materials (sponges, needles and other instruments) 
   •   Fire risk (low, medium or high) 
   •   Medications and solutions are typed/labeled
   •   Equipment sterilization is confirmed
   •   Antibiotic prophylaxis (whether it is required or not required, the time given, and re-dosing schedule)

5.    The procedure team will additionally review the following when applicable to the patient's procedure:
   •   Relevant imaging/studies available
   •   Special equipment/implants available
   •   Expected case duration
   •   Critical events
   •   Estimated blood loss
   •   Blood product availability

6.    Then the team stops. This is a final check before the procedure starts. Are there any questions or concerns from anyone in the OR?

Before the patient leaves the OR

1.    Sign out is initiated by the circulating nurse.

2.    The circulating nurse verifies sign-out with the surgery and anesthesia teams.

3.    For all procedures, the following information is verified and recorded:
   •   Name of procedure(s) completed
   •   The patient's wound classification based on the size and depth of the incision
   •   Final sponge, needle and instrument counts are correct
   •   Any specimens collected for testing are correctly handled, labeled and documented
   •   The patient's status (i.e. critical, stable) and post-op destination (i.e. recovery room, ICU, patient room)

4.    For some procedures, additional details are necessary, must be recorded and reported to appropriate staff. These include: 
   •   Any problems with equipment before, during or after the procedure 
   •   The patient's fluid balance (i.e. fluids administered or lost during the procedure, urine output, estimated blood loss)
   •   Post-procedure management of the patient (i.e. transport equipment, surgical concerns, medical/anesthesia concerns, pain control)
   •   Post-operative imaging procedures (in some cases)

Reviewed by Keith D. Baldwin, MD, MPH, MSPT, John P. Dormans, MD, FACS on March 19, 2014