P1.047: The Impact of Hospital Volume on Protocol Adherence in Pediatric Empyema

Background: An extensive body of literature led to the American Pediatric Surgical Association (APSA) guidelines for the management of patients with empyema. According to APSA, chest computed tomography (CT) is reserved for severe cases of empyema; however, the guidelines do not provide specific criteria for its use beyond this general recommendation. While APSA guidelines provide a structured approach to empyema, it remains unclear how consistently they are implemented across institutions. We hypothesized that centers with lower volumes of empyema patients more frequently deviate from national guidelines, particularly by utilizing CT more frequently, without any corresponding benefit in outcomes.

Methods: The Pediatric Health Information System (PHIS) was queried to identify patients aged 3-18 with empyema without fistula between 2016-2023. Patients were included in the study if they underwent chest tube placement or video-assisted thoracoscopy (VAT) within 3 days of admission. Patients were excluded if they had diagnoses of abscess, gangrene, or other empyema-related complications, or if they underwent open thoracotomy. Hospitals (N=48) were categorized into three even groups based on empyema case volume: low-, medium-, and high-volume. Outcomes between these groups were compared using multivariate logistic and Poisson regression models to adjust for potential confounders, including patient demographics and clinical characteristics.

Results: 1,698 patients met inclusion criteria. The average number of empyema cases over the time period at low-, medium-, and high-volume hospitals was 16.5(SD4.5), 30.1(SD5.3), and 75.9(SD36.1), respectively. Patients at high-volume hospitals had 52% lower odds of undergoing a chest CT within 3 days of admission (OR=0.48, 95%CI: 0.34–0.68, p< 0.001; Figure 1). Hospital region, number of hospital beds, and the presence of a pediatric fellowship did not affect the rate of chest CT use. Length of stay and duration of antibiotic use were similar across the hospital volume groups. Additionally, there were no differences in 30-day readmission rates, ICU admissions, or mechanical ventilation use between terciles.

Conclusion: Hospitals with higher empyema case volumes demonstrate closer adherence to APSA guidelines, with lower rates of chest CT compared to lower volume hospitals. There were no differences in specific outcomes, such as readmission rates, ICU admissions, or mechanical ventilation to suggest differences in patient severity across terciles. Additionally, all terciles reported equivalent lengths of stay and antibiotic duration. These findings imply that increased chest CT use in lower volume centers does not reflect differences in patient severity and does not provide additional benefit. Further research is needed to explore the factors driving the variation from guidelines and to determine if similar patterns exist for other complex pediatric surgical conditions.