Related Experiment Video
Updated: Sep 7, 2025
Intra-Operative Neural Monitoring of Thyroid Surgery in a Porcine Model
Published on: February 11, 2019
Unexpected Benefits in Single Institution Experience With Successful Implementation of a Standardized Perioperative
Kristina Cossen1, Matthew T Santore2, Kara K Prickett3
1Pediatric Endocrinology, Emory University SOM, Children's Healthcare of Atlanta, Atlanta, GA.
Insights
Implementing an Electronic Medical Record protocol for pediatric total thyroidectomies significantly improved perioperative care. This quality improvement initiative led to better management of hypocalcemia and reduced permanent hypoparathyroidism rates.
Area of Science:
- Pediatric Surgery
- Quality Improvement Science
- Endocrinology
Background:
- Pediatric total thyroidectomies require meticulous perioperative management to prevent complications like hypocalcemia.
- Standardizing care protocols can enhance patient outcomes in pediatric surgical procedures.
Purpose of the Study:
- To evaluate the impact of an Electronic Medical Record (EMR) protocol on perioperative management and outcomes of pediatric total thyroidectomies.
- To assess the effectiveness of quality improvement initiatives in improving patient care and reducing complications.
Main Methods:
- A retrospective review compared 122 baseline pediatric total thyroidectomies with 121 subsequent thyroidectomies managed via an EMR protocol.
- Key process measures included postoperative serum calcium and parathyroid hormone (PTH) levels, preoperative iodine administration, and postoperative calcium supplementation.
- Four Plan-Do-Study-Act (PDSA) cycles were implemented to refine the protocol, focusing on various aspects of care, including calcitriol administration.
Main Results:
- All perioperative process measures showed significant improvement, with postoperative serum calcium and PTH measurements reaching 100% and 97% adherence, respectively.
- Preoperative iodine administration for Graves disease improved from 72% to 94%, and postoperative calcium carbonate administration increased from 36% to 100%.
- There was a notable trend towards lower rates of severe hypocalcemia (11.6% to 3.4%) and a reduction in permanent hypoparathyroidism from 20.5% to 10%.
Conclusions:
- Standardizing perioperative care for pediatric total thyroidectomies using an EMR protocol led to substantial improvements in patient management.
- The quality improvement project yielded unexpected positive outcomes, including reduced rates of hypocalcemia and permanent hypoparathyroidism.
- This initiative highlights the value of focused quality improvement in pediatric surgical settings for enhancing patient safety and care.
Introduction:
To illustrate how quality improvement can produce unexpected positive outcomes.
Methods:
We compared a retrospective review of perioperative management and outcomes of baseline 122 pediatric total thyroidectomies to 121 subsequent total thyroidectomies managed by an Electronic Medical Record protocol in a large, free-standing children's healthcare system. Process measures included serum calcium measurement 6-12 hours postoperatively; parathyroid hormone measurement 6 hours postoperatively; preoperative iodine for Graves disease, and postoperative prophylactic calcium carbonate administration. In addition, we completed 4 Plan-Do-Study-Act (PDSA) cycles, focusing on implementation, refinement, usage, education, and postoperative calcitriol administration. The primary outcome included transient hypocalcemia during admission.
Results:
All perioperative process measures improved over PDSA cycles. Measurement of postoperative serum calcium increased from 42% at baseline to 100%. Measurement of postoperative PTH increased from 11% to 97%. Preoperative iodine administration for Graves disease surgeries improved from 72% to 94%. Postoperative calcium carbonate administration increased from 36% to 100%. There was a trend toward lower rates of severe hypocalcemia during admission over the subsequent PDSA cycles starting at 11.6% and improving to 3.4%. With the regular review of outcomes, surgical volume consolidated among high-volume providers, associated with a decrease in a permanent hypoparathyroid rate of 20.5% at baseline to 10% by the end of monitoring.
Conclusions:
In standardizing care at 1 large pediatric institution, implementing a focused quality improvement project involving the perioperative management of transient hypocalcemia in total thyroidectomy pediatric patients resulted in additional, unanticipated improvements in patient care.
