Robotic Technology in Emergency General Surgery Cases in the Era of Minimally Invasive Surgery.

Importance: Although robotic surgery has become an established approach for a wide range of elective operations, data on its utility and outcomes are limited in the setting of emergency general surgery. Objectives: To describe temporal trends in the use of laparoscopic and robotic approaches and compare outcomes between robotic and laparoscopic surgery for 4 common emergent surgical procedures. Design, Setting, and Participants: A retrospective cohort study of an all-payer discharge database of 829 US facilities was conducted from calendar years 2013 to 2021. Data analysis was performed from July 2022 to November 2023. A total of 1 067 263 emergent or urgent cholecystectomies (n = 793 800), colectomies (n = 89 098), inguinal hernia repairs (n = 65 039), and ventral hernia repairs (n = 119 326) in patients aged 18 years or older were included. Exposure: Surgical approach (robotic, laparoscopic, or open) to emergent or urgent cholecystectomy, colectomy, inguinal hernia repair, or ventral hernia repair. Main Outcomes and Measures: The primary outcome was the temporal trend in use of each operative approach (laparoscopic, robotic, or open). Secondary outcomes included conversion to open surgery and length of stay (both total and postoperative). Temporal trends were measured using linear regression. Propensity score matching was used to compare secondary outcomes between robotic and laparoscopic surgery groups. Results: During the study period, the use of robotic surgery increased significantly year-over-year for all procedures: 0.7% for cholecystectomy, 0.9% for colectomy, 1.9% for inguinal hernia repair, and 1.1% for ventral hernia repair. There was a corresponding decrease in the open surgical approach for all cases. Compared with laparoscopy, robotic surgery was associated with a significantly lower risk of conversion to open surgery: cholecystectomy, 1.7% vs 3.0% (odds ratio [OR], 0.55 [95% CI, 0.49-0.62]); colectomy, 11.2% vs 25.5% (OR, 0.37 [95% CI, 0.32-0.42]); inguinal hernia repair, 2.4% vs 10.7% (OR, 0.21 [95% CI, 0.16-0.26]); and ventral hernia repair, 3.5% vs 10.9% (OR, 0.30 [95% CI, 0.25-0.36]). Robotic surgery was associated with shorter postoperative lengths of stay for colectomy (-0.48 [95% CI, -0.60 to -0.35] days), inguinal hernia repair (-0.20 [95% CI, -0.30 to -0.10] days), and ventral hernia repair (-0.16 [95% CI, -0.26 to -0.06] days). Conclusions and Relevance: While robotic surgery is still not broadly used for emergency general surgery, the findings of this study suggest it is becoming more prevalent and may be associated with better outcomes as measured by reduced conversion to open surgery and decreased length of stay.

Alert-Triggered Patient Education Versus Nurse Feedback for Nonadministered Venous Thromboembolism Prophylaxis Doses: A Cluster-Randomized Controlled Trial.

Background Many hospitalized patients are not administered prescribed doses of pharmacologic venous thromboembolism prophylaxis. Methods and Results In this cluster-randomized controlled trial, all adult non-intensive care units (10 medical, 6 surgical) in 1 academic hospital were randomized to either a real-time, electronic alert-triggered, patient-centered education bundle intervention or nurse feedback intervention to evaluate their effectiveness for reducing nonadministration of venous thromboembolism prophylaxis. Primary outcome was the proportion of nonadministered doses of prescribed pharmacologic prophylaxis. Secondary outcomes were proportions of nonadministered doses stratified by nonadministration reasons (patient refusal, other). To test our primary hypothesis that both interventions would reduce nonadministration, we compared outcomes pre- versus postintervention within each cohort. Secondary hypotheses were tested comparing the effectiveness between cohorts. Of 11 098 patient visits, overall dose nonadministration declined significantly after the interventions (13.4% versus 9.2%; odds ratio [OR], 0.64 [95% CI, 0.57-0.71]). Nonadministration decreased significantly (P<0.001) in both arms: patient-centered education bundle, 12.2% versus 7.4% (OR, 0.56 [95% CI, 0.48-0.66]), and nurse feedback, 14.7% versus 11.2% (OR, 0.72 [95% CI, 0.62-0.84]). Patient refusal decreased significantly in both arms: patient-centered education bundle, 7.3% versus 3.7% (OR, 0.46 [95% CI, 0.37-0.58]), and nurse feedback, 9.5% versus 7.1% (OR, 0.71 [95% CI, 0.59-0.86]). No differential effect occurred on medical versus surgical units. The patient-centered education bundle was significantly more effective in reducing all nonadministered (P=0.03) and refused doses (P=0.003) compared with nurse feedback (OR, 1.28 [95% CI, 1.0-1.61]; P=0.03 for interaction). Conclusions Information technology strategies like the alert-triggered, targeted patient-centered education bundle, and nurse-focused audit and feedback can improve venous thromboembolism prophylaxis administration. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03367364.

Systematic Undercoding of Diagnostic Procedures in National Inpatient Sample (NIS): A Threat to Validity Due to Surveillance Bias.

BACKGROUND AND OBJECTIVES: Health services research often relies on readily available data, originally collected for administrative purposes and used for public reporting and pay-for-performance initiatives. We examined the prevalence of underreporting of diagnostic procedures for acute myocardial infarction (AMI), deep venous thrombosis (DVT), and pulmonary embolism (PE), used for public reporting and pay-for-performance initiatives. METHOD: We retrospectively identified procedures for AMI, DVT, and PE in the National Inpatient Sample (NIS) database between 2012 and 2016. From January 1, 2012, through September 30, 2015, the NIS used the International Classification of Diseases, Ninth Revision (ICD-9) coding scheme. From October 1, 2015, through December 31, 2016, the NIS used the International Classification of Diseases, Tenth Revision (ICD-10) coding scheme. We grouped the data by ICD code definitions (ICD-9 or ICD-10) to reflect these code changes and to prevent any confounding or misclassification. In addition, we used survey weighting to examine the utilization of venous duplex ultrasound scan for DVT, electrocardiogram (ECG) for AMI, and chest computed tomography (CT) scan, pulmonary angiography, echocardiography, and nuclear medicine ventilation/perfusion () scan for PE. RESULTS: In the ICD-9 period, by primary diagnosis, only 0.26% (n = 5930) of patients with reported AMI had an ECG. Just 2.13% (n = 7455) of patients with reported DVT had a peripheral vascular ultrasound scan. For patients with PE diagnosis, 1.92% (n = 12 885) had pulmonary angiography, 3.92% (n = 26 325) had CT scan, 5.31% (n = 35 645) had cardiac ultrasound scan, and 0.45% (n = 3025) had scan. In the ICD-10 period, by primary diagnosis, 0.04% (n = 345) of reported AMI events had an ECG and 0.91% (n = 920) of DVT events had a peripheral vascular ultrasound scan. For patients with PE diagnosis, 2.08% (n = 4805) had pulmonary angiography, 0.63% (n = 1460) had CT scan, 1.68% (n = 3890) had cardiac ultrasound scan, and 0.06% (n = 140) had scan. Small proportions of diagnostic procedures were observed for any diagnoses of AMI, DVT, or PE. CONCLUSIONS: Our findings question the validity of using NIS and other administrative databases for health services and outcomes research that rely on certain diagnostic procedures. Unfortunately, the NIS does not provide granular data that can control for differences in diagnostic procedure use, which can lead to surveillance bias. Researchers and policy makers must understand and acknowledge the limitations inherent in these databases, when used for pay-for-performance initiatives and hospital benchmarking.

What Does Venous Thromboembolism Mean in the National Surgical Quality Improvement Program?

BACKGROUND: Venous thromboembolism (VTE) affects an estimated 350,000 to 600,000 individuals and causes approximately 100,000 deaths annually in the United States. Postoperative VTE is a core measure reported by The American College of Surgeons' National Surgical Quality Improvement Program (NSQIP). The objective of this research was to assess the validity of VTE events reported by NSQIP. MATERIALS AND METHODS: This is a retrospective analysis using NSQIP data from January 2006 through December 2018 and the electronic health record system data from five adult hospitals in the Johns Hopkins Health System. We included patients aged 18 years and older with a VTE event identified in our NSQIP data set. The main outcome measure was the proportion of valid VTE events, defined as concordant between the NSQIP data set and medical chart review for clinical documentation. RESULTS: Of 474 patients identified in our NSQIP database with a VTE, 26 (5.5%) did not meet the strict NSQIP definition of VTE. Nine had a preoperative history of DVT and no new postoperative event, seven had a negative workup for VTE, six had a peripheral arterial thrombus, two did not receive or refused therapy, one had an aortic thrombus, and one had a venous thrombosis in a surgical flap. CONCLUSIONS: We identified a considerable number of surgical patients misclassified as having a VTE in NSQIP, when did not truly. This highlights the need to improve definition specificity and standardize processes involved in data extraction, validation, and reporting to provide unbiased data for use in quality improvement.

Using electronic health record system triggers to target delivery of a patient-centered intervention to improve venous thromboembolism prevention for hospitalized patients: Is there a differential effect by race?

BACKGROUND: Racial disparities are common in healthcare. Venous thromboembolism (VTE) is a leading cause of preventable harm, and disparities observed in prevention practices. We examined the impact of a patient-centered VTE education bundle on the non-administration of preventive prophylaxis by race. METHODS: A post-hoc, subset analysis (stratified by race) of a larger nonrandomized trial. Pre-post comparisons analysis were conducted on 16 inpatient units; study periods were October 2014 through March 2015 (baseline) and April through December 2015 (post-intervention). Patients on 4 intervention units received the patient-centered, nurse educator-led intervention if the electronic health record alerted a non-administered dose of VTE prophylaxis. Patients on 12 control units received no intervention. We compared the conditional odds of non-administered doses of VTE prophylaxis when patient refusal was a reason for non-administration, stratified by race. RESULTS: Of 272 patient interventions, 123 (45.2%) were white, 126 (46.3%) were black, and 23 (8.5%) were other races. A significant reduction was observed in the odds of non-administration of prophylaxis on intervention units compared to control units among patients who were black (OR 0.61; 95% CI, 0.46-0.81, p<0.001), white (OR 0.57; 95% CI, 0.44-0.75, p<0.001), and other races (OR 0.50; 95% CI, 0.29-0.88, p = 0.015). CONCLUSION: Our finding suggests that the patient education materials, developed collaboratively with a diverse group of patients, improved patient's understanding and the importance of VTE prevention through prophylaxis. Quality improvement interventions should examine any differential effects by patient characteristics to ensure disparities are addressed and all patients experience the same benefits.

Variation in the use of MRI for cervical spine clearance: an opportunity to simultaneously improve clinical care and decrease cost.

BACKGROUND: For years, controversy has existed about the ideal approach for cervical spine clearance in obtunded, blunt trauma patients. However, recent national guidelines suggest that MRI is not necessary for collar clearance in these patients. The purpose of this study was to identify the extent of national variation in the use of MRI and assess patient-specific and hospital-specific factors associated with the practice. METHODS: We performed a retrospective review of the National Trauma Data Bank from 2007 to 2012. We included blunt trauma patients aged ≥18 years, admitted to level 1 or 2 trauma centers (TCs), with a Glasgow Coma Scale <8, Abbreviated Injury Scale >3 for the head and mechanically ventilated for more than 72 hours. Multilevel modeling was used to identify patient-level and hospital-level factors associated with spine MRI use. RESULTS: 32 125 obtunded, blunt trauma patients treated at 395 unique TCs met our inclusion criteria. The mean proportion of patients who received MRI over the entire sample was 9.9%. The proportions of patients at each hospital who received a spine MRI ranged from 0.5% to 68.7%. Younger patients, with injuries from motor vehicle collisions and pedestrian injuries, were more likely to receive MRI. When controlling for other variables, Injury Severity Score (ISS) was not associated with MRI use. Hospitals in the Northeast, level 1 TCs and non-teaching hospitals were more likely to obtain MRIs in this patient population. CONCLUSION: After controlling for patient-level characteristics, variation remained in MRI use based on geography, trauma center level and teaching status. This evidence suggests that current national guidelines limiting the use of MRI for cervical spine evaluation following blunt trauma are not being followed consistently. This may be due to physicians not being up to date with best practice care, unavailability of locally adopted protocols in institutions or lack of consensus among clinical providers. LEVEL OF EVIDENCE: Prognostic and epidemiological, level III.

Effect of Real-time Patient-Centered Education Bundle on Administration of Venous Thromboembolism Prevention in Hospitalized Patients.

Importance: Numerous interventions have improved prescription of venous thromboembolism (VTE) prophylaxis; however, many prescribed doses are not administered to hospitalized patients, primarily owing to patient refusal. Objective: To evaluate a real-time, targeted, patient-centered education bundle intervention to reduce nonadministration of VTE prophylaxis. Design, Setting, and Participants: This nonrandomized controlled, preintervention-postintervention comparison trial included 19 652 patient visits on 16 units at The Johns Hopkins Hospital, Baltimore, Maryland, from April 1 through December 31, 2015. Data analysis was performed from June 1, 2016, through November 30, 2017, on an intention-to-treat basis. Interventions: Patients on 4 intervention units received a patient-centered education bundle if a dose of VTE prophylaxis medication was not administered. Patients on 12 control units received no intervention. Main Outcomes and Measures: Conditional odds of nonadministration of doses of VTE prophylaxis (primary outcome) before and after the intervention on control vs intervention units. Reasons for nonadministration (ie, patient refusal and other) and VTE event rates (secondary outcomes) were compared. Results: A total of 19 652 patient visits where at least 1 dose of VTE prophylaxis was prescribed were included (51.7% men; mean [SD] age, 55.6 [17.1] years). Preintervention and postintervention groups were relatively similar in age, sex, race, and medical or surgery unit. From the preintervention period to the postintervention period, on intervention units, the conditional odds of VTE prophylaxis nonadministration declined significantly (9.1% [95% CI, 5.2%-16.2%] vs 5.6% [95% CI, 3.1%-9.9%]; odds ratio [OR], 0.57; 95% CI, 0.48-0.67) compared with no change on control units (13.6% [95% CI, 9.8%-18.7%] vs 13.3% [95% CI, 9.6%-18.5%]; OR, 0.98; 95% CI, 0.91-1.07; P < .001 for interaction). The conditional odds of nonadministration owing to patient refusal decreased significantly on intervention units (5.9% [95% CI, 2.6%-13.6%] vs 3.4% [95% CI, 1.5%-7.8%]; OR, 0.53; 95% CI ,0.43-0.65) compared with no change on control units (8.7% [95% CI, 5.4%-14.0%] vs 8.5% [95% CI, 5.3%-13.8%]; OR, 0.98; 95% CI, 0.89-1.08; P < .001 for interaction). On intervention units, the conditional odds of nonadministration owing to reasons other than patient refusal decreased (2.3% [95% CI, 1.5%-3.4%] vs 1.7% [95% CI, 1.1%-2.6%]; OR, 0.74; 95% CI, 0.58-0.94), with no change on control units (3.4% [95% CI, 2.7%-4.4%] vs 3.3% [95% CI, 2.6%-4.2%]; OR, 0.98; 95% CI, 0.87-1.10; P = .04 for interaction). No differential effect occurred on medical vs surgical units (OR, 0.86; 95% CI, 0.60-1.23; P = .41 for interaction). There was no statistical difference in the proportion of VTE events among patients on intervention vs control units (0.30% vs 0.18%; OR, 0.60; 95% CI, 0.16-2.23). Conclusions and Relevance: In this study, a targeted patient-centered education bundle significantly reduced nonadministration of pharmacologic VTE prophylaxis in hospitalized patients. This novel strategy improves health care quality by leveraging electronic data to target interventions in real time for at-risk patients. Trial Registration: ClinicalTrials.gov Identifier: NCT02402881.