Bob Underwood (Host): Welcome to Pediatric Insights: Advances and Innovations with Children's Health, where we explore the latest in pediatric care and research. I'm your host, Dr. Bob Underwood. Children's Medical Center Planos Pectus Clinic received the NSQIP Pediatric Hospital Designation. And today, we're talking to pediatric surgeon, Dr. Adam Alder. About this designation and about pectus care in general. Dr. Alder, welcome to the show.

Adam Alder, MD: Yeah, thanks for having me.

Host: So, let's start with the basics. What exactly are we talking about when we're talking about pectus care?

Adam Alder, MD: So, a pectus chest wall deformity is something that's actually relatively common, and many people have seen this before, but maybe don't know the name. So when the chest wall moves in and it kind of looks scooped out or compressed or deep, we call that pectus excavatum. And for people who have that condition, it can affect them in their lives in various ways, mostly exercise-related symptoms. And what we can do is we can reconstruct the shape of the chest, give the heart and the lungs room to be at their most efficient. And then, people can go on to sort of live normal, happy lives. I think that's the main goal.

The key thing to understand, I think, about this is once you see someone or know someone that has this, you'll see it everywhere. It's like when you buy that car that you don't think anyone has, and then all of a sudden everyone's driving them.

Host: Right. Yeah. So really, it's a question anatomically of volume in the thoracic cavity, right?

Adam Alder, MD: Yeah. And these folks, even though the heart gets pushed on because the chest wall goes towards the back, they're safe to do all the things that I'm a pediatric surgeon. So, they're safe to do all the things that kids do. But it's just they feel like they kind of run into a wall and they can't push past a certain level of performance. And so, it's great to help them be able to work to achieve the things that they want to do. And it's a really satisfying area of my practice.

Host: Yeah, I could see how it would be. I mean, it's really making a difference for these kids. That's awesome. So, this hospital designation highlights your exemplary outcomes, especially when it comes to hospital stays and low opioid prescriptions. So, you're the director of the Center for Pectus and Chest Wall Anomalies at Children's Health. What are some of the things that you've done to improve the hospital stays and decrease the opioid prescriptions?

Adam Alder, MD: Yeah. This is, again, part of my job that I really enjoy, and I spend a lot of time thinking about what do we do to make this experience, this operation and the recovery better for families and for patients. Historically, this was an operation that caused a tremendous amount of pain. In fact, when we looked at our data, we used to keep kids in the hospital four or five days, and then essentially discharge them on around-the-clock narcotics for several weeks. And there have been some significant improvements as it relates to postoperative care and the NSQIP program, which is a national quality program that lets us compare our performance against other peer hospitals. Looking at hospital stays and opioid use are two of the key factors in this particular population. And to find out that we were performing in that group of peer facilities, the best in the nation, we were really excited about that.

Host: As well as you should be. I mean, it's phenomenal. And we're all very aware of opioid use in today's world anyway. And so, to have a decrease in that is really huge. So, what kind of pain management strategies have you really implemented?

Adam Alder, MD: So, there's two main things that have really changed the landscape among people in hospitals where people do this kind of work. The first is an old technique, but one that we've adapted to use for this, and it's something that we adopted six or seven years ago. And what we do, because the nerves that receive those pain signals after we operate in the chest are in a very consistent anatomic position.

We can reliably treat them during the operation using this ice cold probe. This is a technique called cryoablation. Something that's been used in other locations. But in the chest, what it lets us do is quiet the nerves of the chest. And Instead of having four or five days in the hospital and then being discharged on several weeks of narcotics, families and patients are going home the next day, meaning the day after the operation. And some families are not using any narcotics at all. And so, that decrease in opioid exposure leads to both short-term improvements, meaning we see fewer complications. There's tremendous long-term benefits because of that reduction in exposure.

Host: That's phenomenal. So, the decreased hospital stay is really directly related to the pain management as well.

Adam Alder, MD: Yeah. And we aren't the location that invented this, or we're the first people to adopt it, we just recognized that this was a valuable thing. And it's one aspect of the many protocols and standardizations that we have, that we've used others protocols and borrowed techniques from other areas of surgical care, from spine surgery and scoliosis care to other anesthetic techniques. And so, using cryoablation is probably the number one thing that's let us improve this pain management.

But then, the other thing is the use of long-acting local anesthetic. Some new formulations let us do treatments that are four or five days in duration, and those two things make huge impacts in both the ability for patients to breathe and move and be comfortable and get out of the hospital and get back to their lives.

Host: The part about breathing, I think, is incredibly important because when the pain manifests, that's exactly what it is. Every time you take a deep breath, it hurts.

Adam Alder, MD: That's why this was such a hard thing to get through, because you can't stop breathing. There are sort of tremendous consequences to that, right? And so, these patients just suffered and it was a disaster. But now, It's really fantastic as a person who's worked on both sides of that time period to see how happy and how comfortable people are.

Host: Yeah. That's awesome. It really is. About how long does it take for a pediatric patient to kind of get back to normal activity postoperatively?

Adam Alder, MD: We'll generally tell them to expect about six to eight weeks. Before they're back to full speed recovery. You know, most of these patients are active teenagers, many are participants in sports, both organized and unofficial kind of unorganized sports activities. So, we'll get them back as soon as we can, but that's generally about six to eight weeks.

Host: Sure. So, you're chief of surgery at Children's Medical Center, Plano, as well as Associate Professor of Surgery at UT Southwestern. What other kind of quality metrics do you track at your facility, especially around the pectus care?

Adam Alder, MD: Yeah. So, we follow very closely multiple things. We follow very closely infection risks because we are using hardware as a part of this procedure. We follow very closely infectious complications like pneumonia. We kind of already addressed a little bit about breathing. There's other things like blood loss or time in the hospital.

Again, the key things that I think we have made an effort to really focus on, that length of stay in the hospital and this opioid use stuff. They're really surrogates for how well we're controlling pain. And that this particular arena is the most important thing in preventing postoperative complications and having people have a very positive experience.

Host: Right. Because you mentioned pneumonia and that pain management, the ability to take a deep breath and to clear your airway is one of the biggest ways to prevent a secondary pneumonia after a surgery like this.

Adam Alder, MD: Yeah, that and being able to get out of bed and move. Those are probably the two big things that we really are encouraged by.

Host: And so, with this NSQIP designation on a national level, you're among the best.

Adam Alder, MD: Yeah, the NSQIP program, I think, is a very valuable resource. I don't know how many of the listeners really know that much about it. It was something that came up in the '80s in the VA system of all places, and then became more widely used, and we've long participated in the pediatric version of it since about 2013. And it continues to get better and better as they have additional facilities joined. So, I think there's about 120 or 130 facilities in the country that participate now.

But what they're able to do is risk stratify the data that we send so that when we compare our performance against the performance of other facilities, it's a true apples to apples type comparison. So to find out that among the best of the best in the country that we have the shortest hospital stay and the lowest opioid use was really in some ways a tremendous reinforcement or a tremendous accolade for us just recognizing the success of all of the people that participate in this.

I'd love to take full credit that this is all based on stuff I do, but it's really a huge team effort to include our program manager, other surgeons in the group, the nurses in the clinic, the perioperative staff, the OR staff. And so, it's really a tremendously valuable group effort to make this kind of thing happen. And Children's Health, frankly, is a huge supporter and we couldn't have done it without their kind of hospital administrative support.

Host: Yeah. I think we find more and more that the great advances in healthcare like this are team efforts. It's not just one person. It's working together and organizing. So, key takeaways, if there are other pectus surgeons who are looking to optimize their hospital stays in opioid use, what would you want them to have as a key takeaway from this discussion?

Adam Alder, MD: I think that there are a couple of really critical takeaways. The first is utilization of these non-opioid pain strategies. And if surgeons or programs evaluate things like long-acting local anesthetic or cryoablation approaches, they should evaluate whether that works for them at their facility. But those were hugely beneficial for us.

And then, the second piece is a lot of standardization, meaning the medications, the protocols for in the operating room, for postoperative care and for return to full activity. Again, like I said, we have borrowed and used stuff from everywhere we can think of and kind of come up with stuff. We're happy to share. If anybody has an interest in contacting me or the program, it's not proprietary. We've borrowed a lot of it and we want to just make sure that the patients get the best care. Those are the two things I can think of.

Host: That is awesome. Do you have any other quality improvement initiatives that are currently underway to further enhance or improve this kind of care?

Adam Alder, MD: Yeah. In the pectus program, we have several things looking at these recovery approaches, meaning what's the best way to get back to full activity. And we work with the Andrews Institute and their physical therapy group as a really valuable partner in this. Then to try to figure out the optimal strategy in the operating room to make sure that we are having excellent outcomes, meaning the space and shape for the lungs, but the appearance as well of the chest is really satisfactory to patients.

Host: Anything you'd like to add?

Adam Alder, MD: We would really like to just reiterate. This is a huge team effort. And I want to make sure that, I give the appropriate shout out so that people understand how valuable they are. So, the folks on the inpatient side, the outpatient side, really, as you mentioned, medicine today is really a team sport. And I get to be on the podcast, but it really is because of the efforts of a lot of people.

Host: That's a great shout out. Thanks for being on today. We really appreciate this is valuable information.

Adam Alder, MD: Yeah, thanks for having me.

Host: And to our audience, thanks for listening to Pediatric Insights: Advances and Innovations with Children's Health, where we explore the latest in pediatric care and research. You can find more information at childrens.com. And if you found this podcast helpful, please rate and review or share the episode and please follow Children's Health on your social channels.