Optimizing combat readiness for military surgeons without trauma fellowship training: Engaging the "voluntary faculty" model.

BACKGROUND: Appropriate operative volume remains a critical component in mitigating surgical atrophy and maintaining clinical competency. The initiation of military-civilian surgical partnerships (MCPs) has been proposed for addressing knowledge, skills, and abilities (KSA) metrics to address concerns over operational readiness and the low acuity experienced by military surgeons. This study investigates the first partnership for Navy surgical staff at a nonacademic Military Treatment Facility (MTF) with a regional academic Army Military Treatment Facility (AMTF) and a civilian, nonacademic level II trauma center devised to improve operational readiness for attending surgeons. We hypothesize that a skill sustainment MCP will allow military surgeons to meet combat readiness standards as measured by the KSA metric. METHODS: A memorandum of understanding was initiated between the Navy Military Treatment Facility (NMTF), the AMTF, and the level II civilian trauma center (CTC). The single military surgeon in this study was classified as "voluntary faculty" at the CTC. Total case volume and acuity were recorded over an 11-month period. Knowledge, skills, and abilities metrics were calculated using the standard national provider identifier number and the novel case-log based method. RESULTS: A total of 156 cases were completed by a single surgeon over the study period, averaging 52 cases per institution. Significantly more KSAs were obtained at the CTC compared with NMTF (5,954 vs. 2,707; p < 0.001). Significantly more emergent cases were observed at the CTC compared with the MTFs (χ 2 = 7.1, n = 96, p < 0.05). At a single site, AMTF, a significant difference in the calculated KSA score, was observed between the national provider identifier and case-log methods (5,278 vs. 3,297; p = 0.04). CONCLUSION: The skill sustainment MCP between NMTF and CTC increased surgical readiness and exposed surgeons to increased operative acuity. The voluntary faculty model reduces direct litigation exposure and encourages clinical competency for military surgeons while remaining a deployable asset to the global military effort. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

A Randomized Trial Comparing Antibiotics with Appendectomy for Appendicitis.

BACKGROUND: Antibiotic therapy has been proposed as an alternative to surgery for the treatment of appendicitis. METHODS: We conducted a pragmatic, nonblinded, noninferiority, randomized trial comparing antibiotic therapy (10-day course) with appendectomy in patients with appendicitis at 25 U.S. centers. The primary outcome was 30-day health status, as assessed with the European Quality of Life-5 Dimensions (EQ-5D) questionnaire (scores range from 0 to 1, with higher scores indicating better health status; noninferiority margin, 0.05 points). Secondary outcomes included appendectomy in the antibiotics group and complications through 90 days; analyses were prespecified in subgroups defined according to the presence or absence of an appendicolith. RESULTS: In total, 1552 adults (414 with an appendicolith) underwent randomization; 776 were assigned to receive antibiotics (47% of whom were not hospitalized for the index treatment) and 776 to undergo appendectomy (96% of whom underwent a laparoscopic procedure). Antibiotics were noninferior to appendectomy on the basis of 30-day EQ-5D scores (mean difference, 0.01 points; 95% confidence interval [CI], -0.001 to 0.03). In the antibiotics group, 29% had undergone appendectomy by 90 days, including 41% of those with an appendicolith and 25% of those without an appendicolith. Complications were more common in the antibiotics group than in the appendectomy group (8.1 vs. 3.5 per 100 participants; rate ratio, 2.28; 95% CI, 1.30 to 3.98); the higher rate in the antibiotics group could be attributed to those with an appendicolith (20.2 vs. 3.6 per 100 participants; rate ratio, 5.69; 95% CI, 2.11 to 15.38) and not to those without an appendicolith (3.7 vs. 3.5 per 100 participants; rate ratio, 1.05; 95% CI, 0.45 to 2.43). The rate of serious adverse events was 4.0 per 100 participants in the antibiotics group and 3.0 per 100 participants in the appendectomy group (rate ratio, 1.29; 95% CI, 0.67 to 2.50). CONCLUSIONS: For the treatment of appendicitis, antibiotics were noninferior to appendectomy on the basis of results of a standard health-status measure. In the antibiotics group, nearly 3 in 10 participants had undergone appendectomy by 90 days. Participants with an appendicolith were at a higher risk for appendectomy and for complications than those without an appendicolith. (Funded by the Patient-Centered Outcomes Research Institute; CODA ClinicalTrials.gov number, NCT02800785.).

Day versus night laparoscopic cholecystectomy for acute cholecystitis: A comparison of outcomes and cost.

BACKGROUND: Recent studies have suggested higher complication and conversion to open rates for nighttime laparoscopic cholecystectomy (LC) and recommend against the practice. We hypothesize that patients undergoing night LC for acute cholecystitis have decreased hospital length of stay and cost with no difference in complication and conversion rates. METHODS: A retrospective review of patients with acute cholecystitis who underwent LC from October 2011 through June 2015 was performed. Complication rates, length of stay, and cost of hospitalization were compared between patients undergoing day cholecystectomy and night cholecystectomy. RESULTS: Complication rates and costs did not differ between the day and night groups. Length of stay was shorter in the night group (2.4 vs 2.8 days, p = 0.002). CONCLUSIONS: Performing LC for acute cholecystitis during night-time hours does not increase risk of complications and decreases length of stay.

Comparison of outcomes of patients with acute appendicitis between an acute care surgery model and traditional call coverage model in the same community.

BACKGROUND: This study compared outcomes, patient flow, and cost between an acute care surgery (ACS) and traditional call model (TRAD) for acute appendicitis in the same community and time period. METHODS: Patients who underwent appendectomy from 7/1/2012 to 6/30/2014 were retrospectively reviewed. An ACS and TRAD were compared. Demographic data, outcomes, cost, and time intervals were compared. RESULTS: Of the 945 patients reviewed, the ACS group had more perforated appendicitis on preoperative computed tomography scan (9% vs 3%, P < .001) and pathology (23% vs 10%, P < .001). The TRAD group had more negative appendectomies (6% vs 1%, P < .001). In nonperforated appendicitis, time to discharge was shorter with ACS (16.4 vs 30.2 hours, P < .001), and mean cost was less (P < .001). Complications were similar. CONCLUSIONS: ACS was superior for management of acute appendicitis with shorter time from consultation to operation, shorter time to discharge if nonperforated, and decreased cost.