APRICOT-Mamba: Acuity Prediction in Intensive Care Unit (ICU): Development and Validation of a Stability, Transitions, and Life Sustaining Therapies Prediction Model.

On average, more than 5 million patients are admitted to intensive care units (ICUs) in the US, with mortality rates ranging from 10 to 29%. The acuity state of patients in the ICU can quickly change from stable to unstable, sometimes leading to life-threatening conditions. Early detection of deteriorating conditions can assist in more timely interventions and improved survival rates. While Artificial Intelligence (AI)-based models show potential for assessing acuity in a more granular and automated manner, they typically use mortality as a proxy of acuity in the ICU. Furthermore, these methods do not determine the acuity state of a patient (i.e., stable or unstable), the transition between acuity states, or the need for life-sustaining therapies. In this study, we propose APRICOT-M (Acuity Prediction in Intensive Care Unit-Mamba), a 1M-parameter state space-based neural network to predict acuity state, transitions, and the need for life-sustaining therapies in real-time among ICU patients. The model integrates ICU data in the preceding four hours (including vital signs, laboratory results, assessment scores, and medications) and patient characteristics (age, sex, race, and comorbidities) to predict the acuity outcomes in the next four hours. Our state space-based model can process sparse and irregularly sampled data without manual imputation, thus reducing the noise in input data and increasing inference speed. The model was trained on data from 107,473 patients (142,062 ICU admissions) from 55 hospitals between 2014-2017 and validated externally on data from 74,901 patients (101,356 ICU admissions) from 143 hospitals. Additionally, it was validated temporally on data from 12,927 patients (15,940 ICU admissions) from one hospital in 2018-2019 and prospectively on data from 215 patients (369 ICU admissions) from one hospital in 2021-2023. Three datasets were used for training and evaluation: the University of Florida Health (UFH) dataset, the electronic ICU Collaborative Research Database (eICU), and the Medical Information Mart for Intensive Care (MIMIC)-IV dataset. APRICOT-M significantly outperforms the baseline acuity assessment, Sequential Organ Failure Assessment (SOFA), for mortality prediction in both external (AUROC 0.95 CI: 0.94-0.95 compared to 0.78 CI: 0.78-0.79) and prospective (AUROC 0.99 CI: 0.97-1.00 compared to 0.80 CI: 0.65-0.92) cohorts, as well as for instability prediction (external AUROC 0.75 CI: 0.74-0.75 compared to 0.51 CI: 0.51-0.51, and prospective AUROC 0.69 CI: 0.64-0.74 compared to 0.53 CI: 0.50-0.57). This tool has the potential to help clinicians make timely interventions by predicting the transition between acuity states and decision-making on life-sustaining within the next four hours in the ICU.

Incorporating Patient Values in Large Language Model Recommendations for Surrogate and Proxy Decisions.

BACKGROUND: Surrogates, proxies, and clinicians making shared treatment decisions for patients who have lost decision-making capacity often fail to honor patients' wishes, due to stress, time pressures, misunderstanding patient values, and projecting personal biases. Advance directives intend to align care with patient values but are limited by low completion rates and application to only a subset of medical decisions. Here, we investigate the potential of large language models (LLMs) to incorporate patient values in supporting critical care clinical decision-making for incapacitated patients in a proof-of-concept study. METHODS: We simulated text-based scenarios for 50 decisionally incapacitated patients for whom a medical condition required imminent clinical decisions regarding specific interventions. For each patient, we also simulated five unique value profiles captured using alternative formats: numeric ranking questionnaires, text-based questionnaires, and free-text narratives. We used pre-trained generative LLMs for two tasks: 1) text extraction of the treatments under consideration and 2) prompt-based question-answering to generate a recommendation in response to the scenario information, extracted treatment, and patient value profiles. Model outputs were compared with adjudications by three domain experts who independently evaluated each scenario and decision. RESULTS AND CONCLUSIONS: Automated extractions of the treatment in question were accurate for 88% (n = 44/50) of scenarios. LLM treatment recommendations received an average Likert score by the adjudicators of 3.92 of 5.00 (five being best) across all patients for being medically plausible and reasonable treatment recommendations, and 3.58 of 5.00 for reflecting the documented values of the patient. Scores were highest when patient values were captured as short, unstructured, and free-text narratives based on simulated patient profiles. This proof-of-concept study demonstrates the potential for LLMs to function as support tools for surrogates, proxies, and clinicians aiming to honor the wishes and values of decisionally incapacitated patients.

Use of an electronic documentation module to improve surgical debriefing effectiveness.

BACKGROUND: Effective communication in the operating room is crucial for patient safety and optimal outcomes. Structured debriefing communication tools can improve team coordination and address recurring safety concerns. During the unique circumstances of the COVID-19 pandemic, this study evaluated an approach to documentation and loop closure that functioned under constrained hospital resources, a loss of capacity for face-to-face provider training and loop closure, and periods of performing only urgent and emergent surgery for which some debriefing elements, like patient disposition and equipment needs, are more dynamic. METHODS: Employing a longitudinal repeated-measures design, this quality improvement study used a newly integrated module within the electronic health record system to document debriefings, which were linked to surveys assessing perceptions of the debriefing process. Data were collected from 56 operating rooms in 3 separate hospital towers during a 3-year period ending December 2023, encompassing 4 reiterative Plan-Do-Study-Act cycles. RESULTS: The study recorded 49,426 surgical debriefings. The overall incidence of debriefing increased 111% during the study period, reaching 88% during the third and final year of the project. Compared with 193 preintervention surveys, 129 postintervention surveys demonstrated increased incidence of perceiving debriefings as very or extremely effective (52% vs 38%, P = .02), greater frequency of discussing whether equipment issues occurred (87% vs 75%, P = .008), and greater frequency of loop closure (46% vs 34%, P = .03) and leadership (Chair or Program Director of Quality) involvement in loop closure activities (14% vs 3%, P = .008) addressing issues identified during debriefs. CONCLUSION: Despite challenges associated with implementation during a viral pandemic, the intervention was associated with increased incidence and perceived effectiveness of documented surgical debriefings, greater frequency of downstream loop closure, and positive impacts on team communication.

Resident and Fellow Performance and Supervision in Surgical Oncology Procedures.

BACKGROUND: Previous research has highlighted concerns among trainees and attendings that general surgery training and fellowship are inadequately preparing trainees for practice. Providing trainees with supervision that matches their proficiency may help bridge this gap. We sought to benchmark operative performance and supervision levels among senior surgery residents (post-graduate year 4 or 5) and fellows performing general surgical oncology procedures. STUDY DESIGN: Observational data were obtained from the Society for Improving Medical Procedural Learning (SIMPL) OR application for core general surgical oncology procedures performed at 103 unique residency and fellowship programs. Procedures were divided into breast and soft tissue, endocrine, and hepatopancreatobiliary (HPB). Case evaluations completed by trainees and attendings were analyzed to benchmark trainee operative performance and level of supervision. RESULTS: There were 4,907 resident cases and 425 fellow cases. Practice-ready performance, as assessed by trainees and faculty, was achieved by relatively low proportions of residents and fellows for breast and soft tissue cases (residents: 38%, fellows: 48%), endocrine cases (residents: 22%, fellows: 41%), and HPB cases (residents: 10%, fellows: 40%). Among cases in which trainees did achieve practice-ready performance, supervision only was provided for low proportions of cases as rated by trainees (residents: 17%, fellows: 18%) and attendings (residents: 21%, fellows 25%). CONCLUSION: In a sample of 103 residency and fellowship programs, attending surgeons rarely provided senior residents and fellows with levels of supervision commensurate to performance for surgical oncology procedures, even for high performing trainees. These findings suggest a critical need for surgical training programs to prioritize providing greater levels of independence to trainees that have demonstrated excellent performance.

Association of Sociodemographic Factors With Overtriage, Undertriage, and Value of Care After Major Surgery.

Objective: To determine whether certain patients are vulnerable to errant triage decisions immediately after major surgery and whether there are unique sociodemographic phenotypes within overtriaged and undertriaged cohorts. Background: In a fair system, overtriage of low-acuity patients to intensive care units (ICUs) and undertriage of high-acuity patients to general wards would affect all sociodemographic subgroups equally. Methods: This multicenter, longitudinal cohort study of hospital admissions immediately after major surgery compared hospital mortality and value of care (risk-adjusted mortality/total costs) across 4 cohorts: overtriage (N = 660), risk-matched overtriage controls admitted to general wards (N = 3077), undertriage (N = 2335), and risk-matched undertriage controls admitted to ICUs (N = 4774). K-means clustering identified sociodemographic phenotypes within overtriage and undertriage cohorts. Results: Compared with controls, overtriaged admissions had a predominance of male patients (56.2% vs 43.1%, P < 0.001) and commercial insurance (6.4% vs 2.5%, P < 0.001); undertriaged admissions had a predominance of Black patients (28.4% vs 24.4%, P < 0.001) and greater socioeconomic deprivation. Overtriage was associated with increased total direct costs [$16.2K ($11.4K-$23.5K) vs $14.1K ($9.1K-$20.7K), P < 0.001] and low value of care; undertriage was associated with increased hospital mortality (1.5% vs 0.7%, P = 0.002) and hospice care (2.2% vs 0.6%, P < 0.001) and low value of care. Unique sociodemographic phenotypes within both overtriage and undertriage cohorts had similar outcomes and value of care, suggesting that triage decisions, rather than patient characteristics, drive outcomes and value of care. Conclusions: Postoperative triage decisions should ensure equality across sociodemographic groups by anchoring triage decisions to objective patient acuity assessments, circumventing cognitive shortcuts and mitigating bias.

Longitudinal clinical decision support for assessing decisions over time: State-of-the-art and future directions.

Objective: Patients and clinicians rarely experience healthcare decisions as snapshots in time, but clinical decision support (CDS) systems often represent decisions as snapshots. This scoping review systematically maps challenges and facilitators to longitudinal CDS that are applied at two or more timepoints for the same decision made by the same patient or clinician. Methods: We searched Embase, PubMed, and Medline databases for articles describing development, validation, or implementation of patient- or clinician-facing longitudinal CDS. Validated quality assessment tools were used for article selection. Challenges and facilitators to longitudinal CDS are reported according to PRISMA-ScR guidelines. Results: Eight articles met inclusion criteria; each article described a unique CDS. None used entirely automated data entry, none used living guidelines for updating the evidence base or knowledge engine as new evidence emerged during the longitudinal study, and one included formal readiness for change assessments. Seven of eight CDS were implemented and evaluated prospectively. Challenges were primarily related to suboptimal study design (with unique challenges for each study) or user interface. Facilitators included use of randomized trial designs for prospective enrollment, increased CDS uptake during longitudinal exposure, and machine-learning applications that are tailored to the CDS use case. Conclusions: Despite the intuitive advantages of representing healthcare decisions longitudinally, peer-reviewed literature on longitudinal CDS is sparse. Existing reports suggest opportunities to incorporate longitudinal CDS frameworks, automated data entry, living guidelines, and user readiness assessments. Generating best practice guidelines for longitudinal CDS would require a greater depth and breadth of published work and expert opinion.

Wearable sensors in patient acuity assessment in critical care.

Acuity assessments are vital for timely interventions and fair resource allocation in critical care settings. Conventional acuity scoring systems heavily depend on subjective patient assessments, leaving room for implicit bias and errors. These assessments are often manual, time-consuming, intermittent, and challenging to interpret accurately, especially for healthcare providers. This risk of bias and error is likely most pronounced in time-constrained and high-stakes environments, such as critical care settings. Furthermore, such scores do not incorporate other information, such as patients' mobility level, which can indicate recovery or deterioration in the intensive care unit (ICU), especially at a granular level. We hypothesized that wearable sensor data could assist in assessing patient acuity granularly, especially in conjunction with clinical data from electronic health records (EHR). In this prospective study, we evaluated the impact of integrating mobility data collected from wrist-worn accelerometers with clinical data obtained from EHR for estimating acuity. Accelerometry data were collected from 87 patients wearing accelerometers on their wrists in an academic hospital setting. The data was evaluated using five deep neural network models: VGG, ResNet, MobileNet, SqueezeNet, and a custom Transformer network. These models outperformed a rule-based clinical score (Sequential Organ Failure Assessment, SOFA) used as a baseline when predicting acuity state (for ground truth we labeled as unstable patients if they needed life-supporting therapies, and as stable otherwise), particularly regarding the precision, sensitivity, and F1 score. The results demonstrate that integrating accelerometer data with demographics and clinical variables improves predictive performance compared to traditional scoring systems in healthcare. Deep learning models consistently outperformed the SOFA score baseline across various scenarios, showing notable enhancements in metrics such as the area under the receiver operating characteristic (ROC) Curve (AUC), precision, sensitivity, specificity, and F1 score. The most comprehensive scenario, leveraging accelerometer, demographics, and clinical data, achieved the highest AUC of 0.73, compared to 0.53 when using SOFA score as the baseline, with significant improvements in precision (0.80 vs. 0.23), specificity (0.79 vs. 0.73), and F1 score (0.77 vs. 0.66). This study demonstrates a novel approach beyond the simplistic differentiation between stable and unstable conditions. By incorporating mobility and comprehensive patient information, we distinguish between these states in critically ill patients and capture essential nuances in physiology and functional status. Unlike rudimentary definitions, such as equating low blood pressure with instability, our methodology delves deeper, offering a more holistic understanding and potentially valuable insights for acuity assessment.

The post-septic peripheral myeloid compartment reveals unexpected diversity in myeloid-derived suppressor cells.

Introduction: Sepsis engenders distinct host immunologic changes that include the expansion of myeloid-derived suppressor cells (MDSCs). These cells play a physiologic role in tempering acute inflammatory responses but can persist in patients who develop chronic critical illness. Methods: Cellular Indexing of Transcriptomes and Epitopes by Sequencing and transcriptomic analysis are used to describe MDSC subpopulations based on differential gene expression, RNA velocities, and biologic process clustering. Results: We identify a unique lineage and differentiation pathway for MDSCs after sepsis and describe a novel MDSC subpopulation. Additionally, we report that the heterogeneous response of the myeloid compartment of blood to sepsis is dependent on clinical outcome. Discussion: The origins and lineage of these MDSC subpopulations were previously assumed to be discrete and unidirectional; however, these cells exhibit a dynamic phenotype with considerable plasticity.

TRANSCRIPTOMIC DIFFERENCES IN PERIPHERAL MONOCYTE POPULATIONS IN SEPTIC PATIENTS BASED ON OUTCOME.

ABSTRACT: Postsepsis early mortality is being replaced by survivors who experience either a rapid recovery and favorable hospital discharge or the development of chronic critical illness with suboptimal outcomes. The underlying immunological response that determines these clinical trajectories remains poorly defined at the transcriptomic level. As classical and nonclassical monocytes are key leukocytes in both the innate and adaptive immune systems, we sought to delineate the transcriptomic response of these cell types. Using single-cell RNA sequencing and pathway analyses, we identified gene expression patterns between these two groups that are consistent with differences in TNF-α production based on clinical outcome. This may provide therapeutic targets for those at risk for chronic critical illness in order to improve their phenotype/endotype, morbidity, and long-term mortality.

Identifying acute illness phenotypes via deep temporal interpolation and clustering network on physiologic signatures.

Using clustering analysis for early vital signs, unique patient phenotypes with distinct pathophysiological signatures and clinical outcomes may be revealed and support early clinical decision-making. Phenotyping using early vital signs has proven challenging, as vital signs are typically sampled sporadically. We proposed a novel, deep temporal interpolation and clustering network to simultaneously extract latent representations from irregularly sampled vital signs and derive phenotypes. Four distinct clusters were identified. Phenotype A (18%) had the greatest prevalence of comorbid disease with increased prevalence of prolonged respiratory insufficiency, acute kidney injury, sepsis, and long-term (3-year) mortality. Phenotypes B (33%) and C (31%) had a diffuse pattern of mild organ dysfunction. Phenotype B's favorable short-term clinical outcomes were tempered by the second highest rate of long-term mortality. Phenotype C had favorable clinical outcomes. Phenotype D (17%) exhibited early and persistent hypotension, high incidence of early surgery, and substantial biomarker incidence of inflammation. Despite early and severe illness, phenotype D had the second lowest long-term mortality. After comparing the sequential organ failure assessment scores, the clustering results did not simply provide a recapitulation of previous acuity assessments. This tool may impact triage decisions and have significant implications for clinical decision-support under time constraints and uncertainty.

Development and validation of a race-agnostic computable phenotype for kidney health in adult hospitalized patients.

Standard race adjustments for estimating glomerular filtration rate (GFR) and reference creatinine can yield a lower acute kidney injury (AKI) and chronic kidney disease (CKD) prevalence among African American patients than non-race adjusted estimates. We developed two race-agnostic computable phenotypes that assess kidney health among 139,152 subjects admitted to the University of Florida Health between 1/2012-8/2019 by removing the race modifier from the estimated GFR and estimated creatinine formula used by the race-adjusted algorithm (race-agnostic algorithm 1) and by utilizing 2021 CKD-EPI refit without race formula (race-agnostic algorithm 2) for calculations of the estimated GFR and estimated creatinine. We compared results using these algorithms to the race-adjusted algorithm in African American patients. Using clinical adjudication, we validated race-agnostic computable phenotypes developed for preadmission CKD and AKI presence on 300 cases. Race adjustment reclassified 2,113 (8%) to no CKD and 7,901 (29%) to a less severe CKD stage compared to race-agnostic algorithm 1 and reclassified 1,208 (5%) to no CKD and 4,606 (18%) to a less severe CKD stage compared to race-agnostic algorithm 2. Of 12,451 AKI encounters based on race-agnostic algorithm 1, race adjustment reclassified 591 to No AKI and 305 to a less severe AKI stage. Of 12,251 AKI encounters based on race-agnostic algorithm 2, race adjustment reclassified 382 to No AKI and 196 (1.6%) to a less severe AKI stage. The phenotyping algorithm based on refit without race formula performed well in identifying patients with CKD and AKI with a sensitivity of 100% (95% confidence interval [CI] 97%-100%) and 99% (95% CI 97%-100%) and a specificity of 88% (95% CI 82%-93%) and 98% (95% CI 93%-100%), respectively. Race-agnostic algorithms identified substantial proportions of additional patients with CKD and AKI compared to race-adjusted algorithm in African American patients. The phenotyping algorithm is promising in identifying patients with kidney disease and improving clinical decision-making.

Gender differences in autonomy and performance assessments in a national cohort of vascular surgery trainees.

OBJECTIVE: Gender disparities in surgical training and assessment are described in the general surgery literature. Assessment disparities have not been explored in vascular surgery. We sought to investigate gender disparities in operative assessment in a national cohort of vascular surgery integrated residents (VIRs) and fellows (VSFs). METHODS: Operative performance and autonomy ratings from the Society for Improving Medical Professional Learning (SIMPL) application database were collected for all vascular surgery participating institutions from 2018 to 2023. Logistic generalized linear mixed models were conducted to examine the association of faculty and trainee gender on faculty and self-assessment of autonomy and performance. Data were adjusted for post-graduate year and case complexity. Random effects were included to account for clustering effects due to participant, program, and procedure. RESULTS: One hundred three trainees (n = 63 VIRs; n = 40 VSFs; 63.1% men) and 99 faculty (73.7% men) from 17 institutions (n = 12 VIR and n = 13 VSF programs) contributed 4951 total assessments (44.4% by faculty, 55.6% by trainees) across 235 unique procedures. Faculty and trainee gender were not associated with faculty ratings of performance (faculty gender: odds ratio [OR], 0.78; 95% confidence interval [CI], 0.27-2.29; trainee gender: OR, 1.80; 95% CI, 0.76-0.43) or autonomy (faculty gender: OR, 0.99; 95% CI, 0.41-2.39; trainee gender: OR, 1.23; 95% CI, 0.62-2.45) of trainees. All trainees self-assessed at lower performance and autonomy ratings as compared with faculty assessments. However, women trainees rated themselves significantly lower than men for both autonomy (OR, 0.57; 95% CI, 0.43-0.74) and performance (OR, 0.40; 95% CI, 0.30-0.54). CONCLUSIONS: Although gender was not associated with differences in faculty assessment of performance or autonomy among vascular surgery trainees, women trainees perceive themselves as performing with lower competency and less autonomy than their male colleagues. These findings suggest utility for exploring gender differences in real-time feedback delivered to and received by trainees and targeted interventions to align trainee self-perception with actual operative performance and autonomy to optimize surgical skill acquisition.

Intraoperative hypotension and postoperative acute kidney injury: A systematic review.

BACKGROUND: There is no consensus regarding safe intraoperative blood pressure thresholds that protect against postoperative acute kidney injury (AKI). This review aims to examine the existing literature to delineate safe intraoperative hypotension (IOH) parameters to prevent postoperative AKI. METHODS: PubMed, Cochrane Central, and Web of Science were systematically searched for articles published between 2015 and 2022 relating the effects of IOH on postoperative AKI. RESULTS: Our search yielded 19 articles. IOH risk thresholds ranged from <50 to <75 â€‹mmHg for mean arterial pressure (MAP) and from <70 to <100 â€‹mmHg for systolic blood pressure (SBP). MAP below 65 â€‹mmHg for over 5 â€‹min was the most cited threshold (N â€‹= â€‹13) consistently associated with increased postoperative AKI. Greater magnitude and duration of MAP and SBP below the thresholds were generally associated with a dose-dependent increase in postoperative AKI incidence. CONCLUSIONS: While a consistent definition for IOH remains elusive, the evidence suggests that MAP below 65 â€‹mmHg for over 5 â€‹min is strongly associated with postoperative AKI, with the risk increasing with the magnitude and duration of IOH.

Are we ready for "green surgery" to promote environmental sustainability in the operating room? Results from the WSES STAR investigation.

BACKGROUND: The importance of environmental sustainability is acknowledged in all sectors, including healthcare. To meet the United Nations Sustainable Development Goals 2030 Agenda, healthcare will need a paradigm shift toward more environmentally sustainable practices that will also impact clinical decision-making. The study investigates trauma and emergency surgeons' perception, acceptance, and employment of environmentally friendly habits. METHODS: An online survey based on the most recent literature regarding environmental sustainability in healthcare and surgery was created by a multidisciplinary committee and endorsed by the World Society of Emergency Surgery (WSES). The survey was advertised to the 917 WSES members through the society's website and Twitter/X profile. RESULTS: 450 surgeons from 55 countries participated in the survey. Results underline both a generally positive attitude toward environmental sustainability but also a lack of knowledge about several concepts and practices, especially concerning the potential contribution to patient care. DISCUSSION: The topic of environmental sustainability in healthcare and surgery is still in its infancy. There is a clear lack of salient guidance and knowledge, and there is a critical need for governments, institutions, health agencies, and scientific societies to promote, disseminate, and report environmentally friendly initiatives and their potential impacts while employing an interdisciplinary approach.

Operating Room Supply Cost and Value of Care after Implementing a Sustainable Quality Intervention.

BACKGROUND: Variability in operating room supply cost is a modifiable cause of suboptimal resource use and low value of care (outcomes vs cost). This study describes implementation of a quality improvement intervention to decrease operating room supply costs. STUDY DESIGN: An automated electronic health record data pipeline harmonized operating room supply cost data with patient and case characteristics and outcomes. For inpatient procedures, predicted mortality and length of stay were used to calculate observed-to-expected ratios and value of care using validated equations. For commonly performed (1 or more per week) procedures, the pipeline generated figures illustrating individual surgeon performance vs peers, costs for each surgeon performing each case type, and control charts identifying out-of-control cases and surgeons with more than 90th percentile costs, which were shared with surgeons and division chiefs alongside guidance for modifying case-specific supply instructions to operating room nurses and technicians. RESULTS: Preintervention control (1,064 cases for 7 months) and postintervention (307 cases for 2 months) cohorts had similar baseline characteristics across all 16 commonly performed procedures. Median costs per case were lower in the intervention cohort ($811 [$525 to $1,367] vs controls: $1,080 [$603 to $1,574], p < 0.001), as was the incidence of out-of-control cases (19 (6.2%) vs 110 (10.3%), p = 0.03). Duration of surgery, length of stay, discharge disposition, and 30-day mortality and readmission rates were similar between cohorts. Value of care was higher in the intervention cohort (1.1 [0.1 to 1.5] vs 1.0 [0.2 to 1.4], p = 0.04). Pipeline runtime was 16:07. CONCLUSIONS: An automated, sustainable quality improvement intervention was associated with decreased operating room supply costs and increased value of care.

Surgical leadership: Ensuring financial stability through growth.

Maintaining financial stability is important for leaders in surgery because it (1) allows consistent, fair (market value) reimbursement for employees, which conveys that they are valued; (2) enables strategic investment in new programs that may not generate direct financial gains but are required; and (3) builds trust with stakeholders outside the department while strengthening the department's position in negotiations. Key strategies that we have used to increase revenue (income) over the past 6 years have been hiring more faculty, advocating for greater operating room and staffing capacity, staffing surgeons at other institutions using affiliation agreements, attempting to shift grant-funded efforts to non-clinical (research) faculty to mitigate National Institutes of Health salary cap penalties, and increasing efforts to identify external funding for educational and administrative tasks performed by surgeons (eg, increasing contact hours with medical students to secure a greater proportion of state general revenue). Using these strategies, our total revenue has increased 66% over the past 6 years, whereas Academic Support Agreement funds from the College of Medicine concurrently have decreased by 75%. Key strategies that we have used for curtailing expenses have been increasing clinic workflow efficiency; shifting advance practice provider contractual expenses and trainee indirect costs to the hospital; focusing on driving down delayed accounts receivable over time; and using net collections to preferentially invest in research likely to receive future external funding, for which indirect costs return to the department. Despite using these strategies, the total expenses of our department have increased 74% over the past 6 years, driven primarily by the doubling of clinic costs and contractual expenses for advance practice providers. These losses could theoretically be offset by (1) increasing billing by advance practice providers who can also facilitate excellent continuity of surgical care while allowing residents and fellows to shift their effort from service toward education and (2) increasing clinic capacity to generate increasing operative volumes. A department's financial stability is affected by complex interactions among several stakeholders, including the College of Medicine, faculty group practices, and hospitals, with competing interests. Leaders in surgery must understand and manage major categories of revenue and expenses to create a financially stable environment in which they can fulfill their multi-prong missions.