Impact of Multiprofessional Rounds on Critical Care Outcomes in the Surgical Trauma Intensive Care Unit.

Multiprofessional rounds (MPR) represent a mechanism for the coordination of care in critically ill patients. Herein, we examined the impact of MPR on ventilator days (Vent-day), ICU length of stay (LOS), hospital LOS (HLOS), and mortality. A team developed guidelines for MPR, which began in February 2016. Patients admitted between November 2015 and March 2017 with Acute Physiology and Chronic Health Evaluation (APACHE) IV and injury severity scores were included. Outcome data consisted of Vent-day, Vent-day observed/expected ratio (O/E), ICU LOS, ICU LOS O/E, HLOS, HLOS-O/E, and mortality. Linear regression models are constructed to assess statistical significance. A total of 3372 patients were included. Among surgical patients (n = 343 pre-MPR, n = 1675 post-MPR), MPR was associated with decreases in Vent-day O/E (0.74 pre, 0.59 post, P = 0.03), ICU LOS O/E (0.67 pre, 0.61 post, P = 0.01), and HLOS-O/E (1.47 pre, 1.22 post, P = 0.0005). No mortality difference was observed. For trauma patients (n = 221 pre, n = 1133 post), MPR resulted in a reduction in Vent-days (2.2 days pre, 1.6 days post, P = 0.05). However, no differences were observed for Vent-day O/E, ICU LOS O/E, HLOS-O/E, and mortality. Implementation of MPR was associated with improved outcomes for surgical trauma ICU patients. Sustainability of MPR remains a challenge and requires education and engagement.

A review of factors that affect mortality following colectomy.

BACKGROUND: The tightening focus on optimizing surgical outcomes has pushed tracking perioperative mortality to the forefront of interest. The goal of this study is to analyze factors affecting mortality after colorectal resection at a single tertiary care center. MATERIALS AND METHODS: Data were collected from a prospective database for all patients undergoing a colorectal resection at our institution over a 12-y period. Data points included patient demographics, comorbidities, operative details, clinical presentation, postoperative complications, and mortality. RESULTS: A total of 1245 patients were evaluated with 41 deaths (3.3%). Our population was 51% male with an average age of 60.1 ± 15.2 y, mean BMI of 27.5 ± 6.4 kg/m(2), average ASA score of 2.6 ± 0.9, and average of 2.2 ± 1.9 comorbidities. Preoperative factors associated with increased mortality included age, high ASA score, emergent surgery, and the presence of bowel perforation or obstruction (P < 0.05). Intra- and postoperative factors including the transfusion of blood products, length of resection, subtotal colectomy, open versus laparoscopic procedures, the need for reoperation, diagnosis and postoperative complications negatively impact survival (P < 0.05). Stepwise logistic regression demonstrated that high ASA score, emergent procedure, subtotal colectomy, age, obstruction, and open resection as the independent predictors of mortality in a stepwise logistic regression model (P < 0.10). CONCLUSION: Preoperative ASA, emergent procedure, age, open procedure, subtotal colectomy, and obstruction were the independent predictors of mortality in our review. Preoperative optimization and counseling of elderly patients with a high ASA score and/or those requiring an emergency operation should be utilized by surgeons in an effort to improve surgical mortality and patient education.

Mopeds: the legal loophole for repeat driving while intoxicated offenders.

BACKGROUND: Mopeds have less stringent licensing laws than automobiles. Moped operators in motorized vehicle collisions (MVCs) exhibit significantly higher rates of driving while intoxicated (DWI) and higher blood alcohol levels than automobile or motorcycle operators. This study evaluates the public safety issue of DWI recidivism among moped operators. METHODS: Moped operators evaluated after MVCs were identified from 2007 to 2009. Demographics, hospital data, and Department of Motor Vehicles records were reviewed. RESULTS: Sixty-five moped operators were evaluated. Thirty-two (49%) had a positive blood alcohol level, 29 (45%) had a previous DWI, and 21 (72%) of those were repeat offenders. Twenty-five (38%) had a revoked license at the time of injury. Of these, 19 (76%) incurred multiple revocations. Twenty-two (34%) showed prior charges of driving with a revoked license (DWRL), with 15 (68%) incurring multiple DWRL charges. CONCLUSIONS: Moped operators are often intoxicated at the time of injury and represent a public safety hazard. The majority are recidivists with multiple alcohol-related traffic charges. Current laws allow repeat offenders the sustained opportunity to operate motorized vehicles. Re-evaluation of current moped laws is needed to keep habitual offenders off the road.

Application of subcutaneous talc in hernia repair and wide subcutaneous dissection dramatically reduces seroma formation and postoperative wound complications.

Wound complications after large ventral hernia repairs when combined with wide subcutaneous dissection (OVHR/WSD) are common (33 to 66%). We evaluate a novel technique of applying talc to wound subcutaneous tissues to decrease wound complications. We accessed our prospectively collected surgical outcomes database for OVHR/WSD procedures performed. Patients were divided into those that did and did not receive subcutaneous talc (TALC vs NOTALC). Demographics intraoperative and outcomes data were collected and analyzed. The study included 180 patients (n = 74 TALC, n = 106 NOTALC). Demographics were all similar, but hernias were larger in the TALC group. TALC patients had their drains removed earlier (14.6 vs 25.6 days; P < 0.001) with dramatic reduction in postoperative seromas requiring intervention (20.8 to 2.7%; P < 0.001) and cellulitis (39.0 to 20.6%; P = 0.007). Short-term follow-up demonstrates significantly higher recurrence rates in the NOTALC group with each recurrence related to infection. The use of talc in the subcutaneous space of OVHR/WSD results in significantly earlier removal of subcutaneous drains, fewer wound complications, and a decrease in early hernia recurrence. Use of talc in the subcutaneous space at the time of wound closure is an excellent technique to decrease wound complications in large subcutaneous dissections.

MOPEDS: Motorized Objects Propelling Ethanol Drinking Subjects.

Mopeds are not subject to the same laws and jurisdiction as cars or motorcycles, including the requirement of a driver's license. We undertook this study to examine the influence of alcohol (ETOH) on moped crashes. We retrospectively reviewed adult moped injuries compared with motor vehicle crashes (MVCs) and motorcycle crashes (MCCs) from 1995 through 2006. Demographics, severity of injury, mortality, and serum ETOH levels were recorded. Data were analyzed using the Student t test for continuous data and the χ² test for proportional data. Motor vehicle crashes accounted for 7186 admissions. MCC and moped crashes numbered 973 and 113, respectively. Although not statistically significant (P = 0.064), moped crashes yielded the highest mortality (9.7%) compared with MCCs (8.5%) and MVCs (6.7%). An increased association of blood ETOH levels with moped crashes, however, was statistically significant (P = 0.004). Serum ETOH levels above 0.05 g/dL were observed in 1681 MVCs (23.4%), 241 MCCs (24.8%), and 44 moped crashes (39%). In this study, we discovered that moped crashes demonstrate a significantly higher ETOH involvement than either MVCs or MCCs representing a previously unrecognized public safety risk.

Resident work hour restrictions impact chief resident operative experience.

Since the institution of the Accreditation Council for Graduate Medical Education resident work restrictions, much discussion has arisen regarding the potential effect on surgical resident training. We undertook this study to examine the effects on resident operative experience. We retrospectively analyzed chief residents' Accreditation Council for Graduate Medical Education case logs before (PRE) and after (POST) the 80-hour work restriction. Overall, 22 resident logs were evaluated, six PRE and 16 POST. Four case categories were examined: total major cases, total trauma operative cases, total chief cases, and total teaching assistant cases. Significance was defined as P < 0.05. Comparing the PRE and POST groups demonstrated a trend toward fewer total major cases (1061 vs 964, P = 0.38) and fewer total trauma operative cases (55 vs 47, P = 0.37). Teaching assistant cases increased from 67 to 91 but also failed to reach significance (P = 0.37). However, further comparison between the PRE and POST groups yielded a statistically significant decrease in the number of total chief cases (494 vs 333, P = 0.0092). The significant decrease in the number of total chief cases demonstrates that the work hour restriction most affected the chief year operative experience. Further evaluation of resident participation in nonoperative facets may reveal additional deficiencies of surgical training under work hour restrictions.