Risk Factors for Major Pregnancy Complications in Female Cardiothoracic Surgeons.

OBJECTIVE: To describe the incidence of and risk factors for pregnancy complications in female cardiothoracic surgeons compared to women of similar sociodemographic profiles. SUMMARY BACKGROUND DATA: Female cardiothoracic surgeons often postpone childbearing, but little is known about their pregnancy outcomes. METHODS: A self-administered survey was distributed to US cardiothoracic surgeons/trainees in 2023. Surgeons with ≥1 live birth were queried on maternal work hours during pregnancy and major antenatal pregnancy complications. Male surgeons answered on behalf of non-surgeon childbearing partners (female non-surgeons). RESULTS: The study included 255 surgeons (63.53% male; 36.47% female). Compared to female surgeons, male surgeons more often had partners who were not employed outside the home (25.64% vs. 13.33%, P<0.001). Female surgeons were older than female non-surgeons at first live birth (34.494.41 vs. 31.454.16, P<0.001), more often worked >60 hours/week during pregnancy (70.33% vs. 14.08%, P<0.001), and more often had pregnancy complications (45.16% vs. 27.16%, P=0.003; OR 1.78, 95%CI:1.01-3.13). Among female surgeons, 18.28% reduced work hours during pregnancy. During their third trimester, 54.84% worked >6 overnight calls/month and 72.04% operated >12 hours/week. Age35yrs (OR 3.28, 95%CI 1.27-8.45) and operating >12 hours/week during the third trimester (OR 3.72, 95%CI 1.04-13.30) were associated with pregnancy complications. CONCLUSIONS: Female cardiothoracic surgeons are more likely to experience major pregnancy complications than non-surgeon partners of their male peers. Long operative hours during pregnancy and older maternal age are significant risk factors for pregnancy complications. To advance gender equity, policies to protect maternal-fetal health and facilitate childbearing during training and early career are needed.

Association of High BMI With Morbidity and Mortality in Common Emergency General Surgery Procedures.

INTRODUCTION: Emergency general surgery (EGS) patients are at increased risk for postoperative morbidity and mortality. Obesity is a risk factor for poor outcomes in this population. Our study aimed to explore the association of body mass index (BMI) with postoperative outcomes in patients requiring common EGS procedures. METHODS: A retrospective review of the 2018-2020 National Surgical Quality Improvement Program database identified patients undergoing four common EGS procedures: large bowel resection, small bowel resection, cholecystectomy, and appendectomy. Patients were classified by BMI: normal weight (18.5-24.9 kg/m2), obesity classes I (30-34.9 kg/m2), II (35-39.9 kg/m2), III (40-49.9 kg/m2), and IV (≥50 kg/m2). Main outcomes of interest were major adverse event (MAE) and mortality. RESULTS: From 2018 to 2020, a total of 82,540 patients underwent one of four common EGS procedures. On unadjusted analysis, obesity class IV had higher mortality rates compared to classes I-III (6.2% vs 3.1%, P < 0.001). Patients in obesity classes I-III had lower odds of MAE and death relative to those of normal weight. Compared to other patients with obesity, those in obesity class IV were at increased risk of MAE (odds ratio 1.27; 95% confidence interval 1.13-1.44) and death (odds ratio 1.69; 95% confidence interval 1.34-2.13). CONCLUSIONS: Patients with varying degrees of obesity have different risk profiles following common EGS procedures. While patients in lower obesity classes had reduced odds of adverse outcomes, those with BMI ≥50 kg/m2 were particularly at greater risk for postoperative morbidity and mortality. This vulnerable population warrants further investigation and increased vigilance to ensure high-quality care.

Patients Lost to Follow-up After Injury: Who are They and What are Their Long-Term Outcomes?

INTRODUCTION: Trauma patients are at high risk for loss to follow-up (LTFU) after hospital discharge. We sought to identify risk factors for LTFU and investigate associations between LTFU and long-term health outcomes in the trauma population. METHODS: Trauma patients with an Injury Severity Score ≥9 admitted to one of three Level-I trauma centers, 2015-2020, were surveyed via telephone 6 mo after injury. Univariate and multivariate analyses were performed to assess factors associated with LTFU and several long-term outcomes. RESULTS: Of 3609 patients analyzed, 808 (22.4%) were LTFU. Patients LTFU were more likely to be male (71% versus 61%, P = 0.001), Black (22% versus 14%, P = 0.003), have high school or lower education (50% versus 42%, P = 0.003), be publicly insured (23% versus 13%, P < 0.001), have a penetrating injury (13% versus 8%, P = 0.006), have a shorter length of stay (3.64 d ± 4.09 versus 5.06 ± 5.99, P < 0.001), and be discharged home without assistance (79% versus 50%, P < 0.001). In multivariate analyses, patients who followed up were more likely to require assistance at home (6% versus 11%; odds ratio [OR] 2.23, 1.26-3.92, P = 0.005), have new functional limitations (11% versus 26%; OR 2.91, 1.97-4.31, P = < 0.001), have daily pain (30% versus 48%; OR 2.11, 1.54-2.88, P = < 0.001), and have more injury-related emergency department visits (7% versus 10%; OR 1.93, 1.15-3.22, P = 0.012). CONCLUSIONS: Vulnerable populations are more likely to be LTFU after injury. Clinicians should be aware of potential racial and socioeconomic disparities in follow-up care after traumatic injury. Future studies investigating improvement strategies in follow-up care should be considered.

Parental Support Policies and Benefits: A Surgical Training Program Report Card of Transparency.

OBJECTIVE: This study aimed to investigate the transparency of parental benefits available to US surgical residency applicants. BACKGROUND: Medical students prioritize work-family balance in specialty selection. Those applying to surgical residency programs also place a significant value on parental leave policies when deciding where to train. However, little is known about the amount of information that surgical training programs publicly offer to potential applicants regarding family support policies. METHODS: Publicly available websites for 264 general surgery training programs were accessed to determine the availability of information on parental benefits. Twenty-six "items of transparency" included types of leave, contract flexibility, salary, lactation, and childcare support. Programs with fewer than the median items of transparency were contacted to inquire about additional public resources. Academic programs were stratified by their associated medical school rankings in the US News & World Report. RESULTS: A total of 144 (54%) programs were academic and 214 (81.4%) had male program directors. The median number of items of transparency was 8 (29.6%). Of the 131 programs contacted, 33 (25.9%) replied, and 2 (6.1%) improved their transparency score. Academic programs associated with medical schools in the upper third of the rankings were more likely to have ≥8 items of transparency (70.8% vs. 45.6%; P =0.002). In the adjusted analysis, academic programs [odds ratio (OR): 3.44, 95% confidence interval (95% CI): 1.87-6.34], those with female program directors (OR: 2.09, 95% CI: 1.01-4.33), and those located in the Western (OR: 3.13, 95% CI: 1.31-7.45) and Southern (OR: 2.45, 95% CI: 1.21-4.98) regions of the country were more likely to have ≥8 items of transparency. CONCLUSIONS: There are significant deficits in publicly available information related to parental benefits for many surgical training programs, which may impact applicants' decision making. Attracting the most talented candidates requires programs to create and share policies that support the integration of professional and personal success.

Value of Ambulatory Modified Radical Mastectomy.

BACKGROUND: Modified radical mastectomy (MRM) still is largely performed in inpatient settings. This study sought to determine the value (expenditures and complications) of ambulatory MRM. METHODS: Health Care Utilization Project (HCUP) state databases from 2016 were queried for patients who underwent MRM. The study examined rates of 30-day readmission for surgical-site infection (SSI) or hematoma, charges by index care setting, and predictors of 30-day readmission. RESULTS: Overall, 8090 patients underwent MRM: 5113 (63 %) inpatient and 2977 (37 %) ambulatory patients. Compared with the patients who underwent inpatient MRM, those who underwent ambulatory MRM were older (61 vs. 59 years), more often white (66 % vs. 57 %), in the lowest income quartile (28 % vs. 21 %), insured by Medicare (43 % vs. 33 %) and residents in a small metro area (6 % vs. 4 %) (all p < 0.01). Of the 5113 patients treated as inpatients, 126 (2.5 %) were readmitted, whereas 50 (1.7 %) of the ambulatory patients were readmitted (p = 0.02). The adjusted charge for inpatient MRM without readmission was $113,878 (range, $107,355-120,402) compared with $94,463 (range, $86,021-102,907) for ambulatory MRM, and the charge for inpatient MRM requiring readmission was $159,355 (range, $147,142-171,568) compared with $139,940 (range, $125,808-154,073) for ambulatory MRM (all p < 0.01). This difference remained significant after adjustment for hospital length of stay. Adjusted logistic regression showed that the ambulatory setting was protective for readmission (odds ratio, 0.49; 95 % confidence interval, 0.35-0.70; p < 0.01). CONCLUSIONS: The analyses suggest that ambulatory MRM is both safe and less expensive. The findings advocate that MRM, a last holdout of inpatient care within breast surgical oncology, can be transitioned to the ambulatory setting for appropriate patients.

Impact of hospital characteristics on best-practice adherence for gallstone pancreatitis: a nationwide analysis.

BACKGROUND: Current guidelines recommend cholecystectomy during the index admission for gallstone pancreatitis, and a growing body of evidence indicates that patients benefit from cholecystectomy within the first 48 h of admission. We examined the impact of hospital characteristics on adherence to these data-driven practices. METHODS: We queried the National Inpatient Sample for patients admitted for gallstone pancreatitis between October 2015 and December 2018. Patients who underwent same-admission cholecystectomy were identified by procedure codes. Cholecystectomies within the first two days were classified as early cholecystectomies. Multivariable logistic regression was used to determine the association between hospital characteristics and adherence to these practices. RESULTS: Of 163,390 admissions for gallstone pancreatitis, only 90,790 (55.6%) underwent cholecystectomy before discharge. Mean time from admission to cholecystectomy was 2.9 days; 27.0% of patients (44,005) underwent early cholecystectomy. Odds of same-admission cholecystectomy were highest in large hospitals (OR 1.21, 95% CI 1.13-1.28), urban teaching centers (OR 1.33, 95% CI 1.21-1.46), and the South (OR 1.70, 95% CI 1.57-1.83). Odds of early cholecystectomy did not vary with hospital size, urban-rural status, or teaching status but were highest in the West (OR 1.98, 95% CI 1.80-2.18). CONCLUSION: Best-practice adherence for cholecystectomy in gallstone pancreatitis remains low despite an abundance of evidence and clinical practice guidelines. Active interventions are needed to improve delivery of surgical care for this patient population. Implementation efforts should focus on small hospitals, rural areas, and health systems in the Northeast region.

Patients' perceptions of the post-pancreatectomy discharge process.

BACKGROUND: Complications after pancreatectomies contribute to poor outcomes. Patients are expected to identify signs/symptoms leading to these complications but may be poorly educated on how to identify them. We assessed the impact of an educational tool on patient perceptions of, and satisfaction with the discharge process, and its effect on readmission rates. METHODS: A prospective cohort study with retrospective chart review including patients who underwent pancreatic resection was undertaken. An interactive educational module (iBook) that provided information about the procedure, possible complications, and peri-discharge information was implemented. English-speaking patients were equally divided into the pre- and post-iBook cohorts. Primary outcome was patients' satisfaction with discharge; Secondary outcomes were 30- and 90-day readmission rates. RESULTS: 100 patients were included. Mean age was 65.5 ± 12.6, 46% were female, and 92.3% were white. Most patients underwent Whipple procedures (72%), and distal pancreatectomies (26%). In the post-implementation group, 92% were satisfied with the discharge process, and 89% reported it was a good tool. There were no statistical differences in 30- and 90-day readmission rates between cohorts. CONCLUSION: The iBook positively impacted patients' satisfaction and preparedness for discharge. Readmission rates were not statistically significantly impacted but could be investigated with further studies of greater sample sizes.

Lack of Workplace Support for Obstetric Health Concerns is Associated With Major Pregnancy Complications: A National Study of US Female Surgeons.

OBJECTIVE: We sought to assess whether lack of workplace support for clinical work reductions during pregnancy was associated with major pregnancy complications. BACKGROUND: Surgeons are at high risk of major pregnancy complications. Although rigorous operative schedules pose increased risk, few reduce their clinical duties during pregnancy. METHODS: An electronic survey was distributed to US surgeons who had at least 1 live birth. Lack of workplace support was defined as: (1) desiring but feeling unable to reduce clinical duties during pregnancy due to failure of the workplace/training program to accommodate and/or concerns about financial penalties, burden on colleagues, requirement to make up missed call, being perceived as weak; (2) disagreeing colleagues and/or leadership were supportive of obstetrician-prescribed bedrest. Multivariate logistic regression determined the association between lack of workplace support and major pregnancy complications. RESULTS: Of 671 surgeons, 437 (65.13%) reported lack of workplace support during pregnancy and 302 (45.01%) experienced major pregnancy complications. Surgeons without workplace support were at higher risk of major pregnancy complications than those who had workplace support (odds ratio: 2.44; 95% confidence interval: 1.58-3.75). Bedrest was prescribed to 110/671 (16.39%) surgeons, 38 (34.55%) of whom disagreed that colleagues and/or leadership were supportive. Of the remaining surgeons, 417/560 (74.5%) desired work reductions but were deterred by lack of workplace support. CONCLUSIONS: Lack of workplace support for reduction in clinical duties is associated with adverse obstetric outcomes for surgeons. This is a modifiable workplace obstacle that deters surgeons from acting to optimize their infant's and their own health. To ensure the health of expectant surgeons, departmental policies should support reduction of clinical workload in an equitable manner without creating financial penalties, requiring payback for missed call duties, or overburdening colleagues.

The Surgeon's Perceived Value of Patient-reported Outcome Measures (PROMs): An Exploratory Qualitative Study of 5 Different Surgical Subspecialties.

OBJECTIVE: To understand the surgeon's perceived value of PROMs in 5 different surgical subspecialties. SUMMARY OF BACKGROUND DATA: PROMs are validated questionnaires that assess the symptoms, function, and quality of life from the patient's perspective. Despite the increasing support for use of PROMs in the literature, there is limited uptake amongst surgeons. Furthermore, there is insufficient understanding of the surgeons' perceived value of PROMs. The aim of this study is to understand how surgeons perceive value in PROMs. METHODS: We conducted an exploratory qualitative study to understand the perceived value of PROMs from the perspective of surgeons in various subspecialties. Per convenience sampling, we conducted semi-structured interviews with 30 surgeons from 5 subspecialties across 3 academic medical centers. The surgical subspecialties included bariatric surgery, breast oncologic surgery, orthopedic surgery, plastic and reconstructive surgery, and rhinology. Interviews were transcribed, coded, and evaluated with thematic analysis. RESULTS: Surgeons endorsed that PROMs can be used to enhance clinical management, counsel patients in the preoperative and postoperative settings, and elicit sensitive information from patients that otherwise may go undetected. Obstacles to PROMs use include failure to generate actionable data, implementation obstacles, and inappropriate use of PROMs as a performance metric, with concerns regarding inadequate risk adjustment. CONCLUSIONS: Establishing an effective PROMs program requires an understanding of the surgeon's perspective of PROMs. Despite obstacles, different subspecialty surgeons find PROMs to be valuable in different settings, depending on the specialty and clinical context.

The Long Road to Parenthood: Assisted Reproduction, Surrogacy, and Adoption Among US Surgeons.

OBJECTIVE: We sought to characterize demographics, costs, and workplace support for surgeons using assisted reproductive technology (ART), adoption, and surrogacy to build their families. SUMMARY BACKGROUND DATA: As the surgical workforce diversifies, the needs of surgeons building a family are changing. ART, adoption, and surrogacy may be used with greater frequency among female surgeons who delay childbearing and surgeons in same-sex relationships. Little is known about costs and workplace support for these endeavors. METHODS: An electronic survey was distributed to surgeons through surgical societies and social media. Rates of ART use were compared between partners of male surgeons and female surgeons and multivariate analysis used to assess risk factors. Surgeons using ART, adoption, or surrogacy were asked to describe costs and time off work to pursue these options. RESULTS: Eight hundred and fifty-nine surgeons participated. Compared to male surgeons, female surgeons were more likely to report delaying children due to surgical training (64.9% vs. 43.5%, P < 0.001), have fewer children (1.9 vs. 2.4, p < 0.001), and use ART (25.2% vs. 17.4%, P = 0.035). Compared to non-surgeon partners of male surgeons, female surgeons were older at first pregnancy (33 vs 31 years, P < 0.001) with age > 35 years associated with greater odds of ART use (odds ratio 3.90; 95% confidence interval 2.74-5.55, P < 0.001). One-third of surgeons using ART spent >$40,000; most took minimal time off work for treatments. Forty-five percent of same-sex couples used adoption or surrogacy. 60% of surgeons using adoption or surrogacy spent >$40,000 and most took minimal paid parental leave. CONCLUSIONS: ART, adoption, or surrogacy is costly and lacks strong workplace support in surgery, disproportionately impacting women and same-sex couples. Equitable and inclusive environments supporting all routes to parenthood ensure recruitment and retention of a diverse workforce. Surgical leaders must enact policies and practices to normalize childbearing as part of an early surgical career, including financial support and equitable parental leave for a growing group of surgeons pursuing ART, surrogacy, or adoption to become parents.

Sarcopenia Is Associated With Increased Mortality in Patients With Necrotizing Soft Tissue Infections.

INTRODUCTION: Necrotizing soft tissue infections (NSTIs) are surgical emergencies associated with high morbidity and mortality. Identifying risk factors for poor outcome is a critical part of preoperative decision-making and counseling. Sarcopenia, the loss of lean muscle mass, has been associated with an increased risk of mortality and can be measured using cross-sectional imaging. Our aim was to determine the impact of sarcopenia on mortality in patients with NSTI. We hypothesized that sarcopenia would be associated with an increased risk of mortality in patients with NSTI. METHODS: This is a retrospective cohort study of NSTI patients admitted from 1995 to 2015 to two academic institutions. Operative and pathology reports were reviewed to confirm the diagnosis in all cases. Average bilateral psoas muscle cross-sectional area at L4, normalized for height (Total Psoas Index [TPI]), was calculated using computed tomography (CT). Sarcopenia was defined as TPI in the lowest sex-specific quartile. Primary outcome was in-hospital mortality. Multivariate logistic regression was performed to assess the association between sarcopenia and in-hospital mortality. RESULTS: There were 115 patients with preoperative imaging, 61% male and a median age of 57 y interquartile range (IQR 46.6-67.0). Overall in-hospital mortality was 12.1%. There was no significant difference in sex, body mass index (BMI), comorbidities and American Society of Anesthesiologists classification (Table 1). After multivariate analysis, sarcopenia was independently associated with increased in-hospital mortality (Odds ratio, 3.5; 95% Confidence Interval [CI], 1.05-11.8). CONCLUSIONS: Sarcopenia is associated with increased risk of in-hospital mortality in patients with NSTIs. Sarcopenia identifies patients with higher likelihood of poor outcomes, which can possibly help surgeons in counseling their patients and families.

Traumatic Brain Injury: Does Admission Service Matter?

BACKGROUND: Traumatic brain injury (TBI) is common, and significant institutional variation exists with regards to structure and processes of care. Affected patients may be admitted to one of several different services, and this may drive differential care and outcomes. We sought to evaluate differential care and outcomes for patients with isolated mild-to-moderate traumatic brain injury based on admission service. MATERIALS AND METHODS: This is a single-institution retrospective study of all adult (≥18 y old) patients admitted with isolated TBI (AIS ≤1 in all other body regions) over a 3-year period (6/2015-6/2018). Patients who underwent neurosurgical intervention (craniectomy/craniotomy) and those with a head AIS ≥4 were excluded. Patients were assigned to one of three groups based upon admission service: Trauma Surgery, Neurology/Medicine or Neurosurgery. Outcomes evaluated included in-hospital mortality and markers of differential care. We performed multivariate analyses adjusting for patient demographics and clinical characteristics. RESULTS: A total of 401 isolated mild-to-moderate TBI patients were identified. Overall mortality was 1.7%. Adjusted multivariate logistic regression analysis demonstrated no difference in mortality. Patients admitted to Neurosurgery underwent more repeat head CTs and were more likely to receive antiseizure medication in the absence of seizure activity, and those admitted to Neurology/Medicine were less likely to receive venous thromboembolism chemoprophylaxis compared to those admitted to Trauma Surgery. CONCLUSIONS: We identify several important metrics of variation in care received by patients with an isolated mild-to-moderate TBI based upon admission service. These findings deserve further study, and this study may lay the foundation for future efforts at protocolizing care in an evidence-based fashion for this patient cohort.

Frailty Interdisciplinary Pathway: Compliance and Sustainability in a Level I Trauma Center.

BACKGROUND: Frailty is a state of physiological vulnerability that predisposes many older adult trauma patients to poor health outcomes. Specialized care pathways for frail trauma patients have been shown to improve outcomes, but the compliance and sustainability of these pathways have not been reported (Bryant et al., 2019; Engelhardt et al., 2018). METHODS: We retrospectively measured compliance and sustainability during the first 2 years of a frailty pathway for patients 65 years or older at an urban Level I trauma center. Compliance to 19 pathway elements was collected for 279 pathway patients between October 1, 2016, and September 30, 2018. Compliance was analyzed and reported as a percentage of the total possible times each element could have been completed per pathway guidelines. Benchmark compliance was 75% or more. RESULTS: Retrospective 2-year mean overall compliance to all pathway elements was 68.2% and improved from Year 1 (65.0%) to Year 2 (71.4%). Seven elements achieved a mean 75% or more compliance over the 2-year period: frailty screening on admission (92.8%), consultation requests for physical therapy (97.9%), geriatrics (96.2%), and nutrition (92.3%), consultant care within 72 hr of admission (78.0%), delirium screening 3 times daily (76.3%), and daily senna administration (76.0%). Compliance to 10 elements significantly improved from Year 1 to Year 2 and significantly worsened in 2 elements. CONCLUSION: Many standardized geriatric care processes for frail older adult trauma patients can be successfully integrated into routine daily inpatient practice and sustained over time. Multicenter studies are needed to demonstrate how to improve compliance and to understand better which pathway elements are most effective.

Risk Prediction Accuracy Differs for Transferred and Nontransferred Emergency General Surgery Cases in the ACS-NSQIP.

BACKGROUND: Risk prediction accuracy of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Surgical Risk Calculator has been shown to differ between emergency and elective surgery. Benchmarking methods of clinical performance require accurate risk estimation, and current methods rarely account for admission source; therefore, our goal was to assess whether the ACS-NSQIP predicts mortality comparably between transferred and nontransferred emergency general surgery (EGS) cases. MATERIALS AND METHODS: This is a retrospective study using the ACS-NSQIP database from 2005 to 2014including all inpatients who underwent one of seven previously described EGS procedures. The admission source was classified as directly admitted versus transferred from an outside emergency room or an acute care facility. We compared the accuracy of ACS-NSQIP-predicted mortality probabilities using the observed-to-expected (O:E) ratio and Brier score. A subgroup analysis was performed to compare accuracy of high-risk and low-risk procedures. RESULTS: A total of 206,103 EGS admissions were identified, of which 6.97% were transfers. Overall mortality was 3.26% for the entire cohort and 10.24% within the transfer group. The O:E ratios generated by ACS-NSQIP models differed between transferred patients (O:E = 1.0, 95% confidence interval = 0.97-1.02) and nontransferred patients (O:E = 1.12, 95% confidence interval = 1.09-1.14). The Brier score for transferred patients was greater than that for nontransferred patients (0.063 versus 0.018, respectively) showing higher accuracy for nontransferred patients. CONCLUSIONS: The ACS-NSQIP risk estimates used for benchmarking differ between transferred and nontransferred EGS cases. Analyses of the Brier score by the ACS-NSQIP risk calculator demonstrated inferior prediction for transferred patients. This increased burden on accepting institutions will have an impact on quality metrics and should be considered for benchmarking of clinical performance.

Braden scale for pressure ulcer risk predicts rehabilitation placement after pancreatic resection.

BACKGROUND: Patients undergoing pancreatic resection frequently require rehabilitation facilities after hospital discharge. We evaluated the predictive role of validated markers of frailty on rehabilitation facility placement to identify patients who may require this service. METHODS: Single-center retrospective cohort study of patients who underwent pancreatic resection from 2010 to 2015. 90-day morbidity and mortality were calculated. Postoperative validated markers of frailty (Activities of Daily Living scale, Braden scale [assesses pressure ulcer risk, lower scores = higher risk] and Morse fall scale) were evaluated via multivariate regression to identify predictors of discharge to rehabilitation facility. RESULTS: 470 patients with complete data were included. Mean age was 62 and 49.2% were male. Postoperative median length of stay (LOS) was 8 (IQR 7-10). 92 (19.66%) patients were discharged to rehabilitation facilities and 138 (29.49%) patients were readmitted within 90 days. On multivariate analysis, age, sex, LOS > 8 days, inpatient Comprehensive Complication Index (CCI) and initial Braden scale were predictive of rehabilitation placement. CONCLUSION: A marker of frailty routinely collected daily by nursing staff, the Braden scale, is available to help surgeons predict the need for postoperative rehabilitation placement after pancreatic resection. Engaging discharge planning services for at-risk patients may help prevent delayed hospital discharge and should be further evaluated.

Failure to rescue and disparities in emergency general surgery.

BACKGROUND: Racial and socioeconomic disparities are well documented in emergency general surgery (EGS) and have been highlighted as a national priority for surgical research. The aim of this study was to identify whether disparities in the EGS setting are more likely to be caused by major adverse events (MAEs) (e.g., venous thromboembolism) or failure to respond appropriately to such events. METHODS: A retrospective cohort study was undertaken using administrative data. EGS cases were defined using International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic codes recommended by the American Association for the Surgery of Trauma. The data source was the National Inpatient Sample 2012-2013, which captured a 20%-stratified sample of discharges from all hospitals participating in the Healthcare Cost and Utilization Project. The outcomes were MAEs, in-hospital mortality, and failure to rescue (FTR). RESULTS: There were 1,345,199 individual patient records available within the National Inpatient Sample. There were 201,574 admissions (15.0%) complicated by an MAE, and 12,006 of these (6.0%) resulted in death. The FTR rate was therefore 6.0%. Uninsured patients had significantly higher odds of MAEs (adjusted odds ratio, 1.16; 95% confidence interval, 1.13-1.19), mortality (1.28, 1.16-1.41), and FTR (1.20, 1.06-1.36) than those with private insurance. Although black patients had significantly higher odds of MAEs (adjusted odds ratio, 1.14; 95% confidence interval, 1.13-1.16), they had lower mortality (0.95, 0.90-0.99) and FTR (0.86, 0.80-0.91) than white patients. CONCLUSIONS: Uninsured EGS patients are at increased risk of MAEs but also the failure of health care providers to respond effectively when such events occur. This suggests that MAEs and FTR are both potential targets for mitigating socioeconomic disparities in the setting of EGS.

Is there a "weekend effect" in emergency general surgery?

BACKGROUND: Weekend admission is associated with increased mortality across a range of patient populations and health-care systems. The aim of this study was to determine whether weekend admission is independently associated with serious adverse events (SAEs), in-hospital mortality, or failure to rescue (FTR) in emergency general surgery (EGS). METHODS: An observational study was performed using the National Inpatient Sample in 2012-2013; the largest all-payer inpatient database in the United States, which represents a 20% stratified sample of hospital discharges. The inclusion criteria were all inpatients with a primary EGS diagnosis. Outcomes were SAE, in-hospital mortality, and FTR (in-hospital mortality in the population of patients that developed an SAE). Multivariable logistic regression were used to adjust for patient- (age, sex, race, payer status, and Charlson comorbidity index) and hospital-level (trauma designation and hospital bed size) characteristics. RESULTS: There were 1,344,828 individual patient records (6.7 million weighted admissions). The overall rate of SAE was 15.1% (15.1% weekend, 14.9% weekday, P < 0.001), FTR 5.9% (6.2% weekend, 5.9% weekday, P = 0.010), and in-hospital mortality 1.4% (1.5% weekend, 1.3% weekday, P < 0.001). Within logistic regression models, weekend admission was an independent risk factor for development of SAE (adjusted odds ratio 1.08, 1.07-1.09), FTR (1.05, 1.01-1.10), and in-hospital mortality (1.14, 1.10-1.18). CONCLUSIONS: This study found evidence that outcomes coded in an administrative data set are marginally worse for EGS patients admitted at weekends. This justifies further work using clinical data sets that can be used to better control for differences in case mix.

An evidence-based intraoperative communication tool for emergency general surgery: a pilot study.

BACKGROUND: Emergency general surgery (EGS) is characterized by high rates of morbidity and mortality. Though checklists and associated communication-based huddle strategies have improved outcomes, these tools have never been specifically examined in EGS. We hypothesized that use of an evidence-based communication tool aimed to trigger intraoperative discussion could improve communication in the EGS operating room (OR). MATERIALS AND METHODS: We designed a set of discussion prompts based on modifiable factors identified from previously published studies aimed to encourage all team members to speak up and to centralize awareness of patient disposition and intraoperative transfusion practices. This tool was pilot-tested using OR human patient simulators and was then rolled out to EGS ORs at an academic medical center. The perceived effect of our tool's implementation was evaluated through mixed-methodologic presurvey and postsurvey analysis. RESULTS: Preimplementation and postimplementation survey-based data revealed that providers reported the EGS-focused discussion prompts as improving team communication in EGS. A trend toward shared awareness of intraoperative events was observed; however, nurses described cultural impedance of discussion initiation. Providers described a need for further reinforcement of the tool and its indications during implementation. CONCLUSIONS: Use of a discussion-based communication tool is perceived as supporting team communication in the EGS OR and led to a trend toward improving a shared understanding of intraoperative events. Analyses suggest the need for enhanced reinforcement of use during implementation and improvement of team-based education regarding EGS. Furthermore work is needed to understand the full impact of this evidence-based tool on OR team dynamics and EGS patient outcomes.

What Patients Look for When Browsing Online for Pancreatic Cancer: The Bait Behind the Byte.

BACKGROUND: Suitability is a patient-centered metric defined as how appropriately health information is targeted to specific populations to increase knowledge. However, suitability is most commonly evaluated exclusively by healthcare professionals without collaboration from intended audiences. Suitability (as rated by intended audiences), accuracy and readability have not been evaluated on websites discussing pancreatic cancer. METHODS: Ten healthy volunteers evaluated fifty pancreatic cancer websites using the suitability assessment of materials (SAM instrument) for the materials' overall suitability. Readability and accuracy were correlated. RESULTS: Ten recruited volunteers (ages 23-63, 50% female) found websites to be on average "adequate" or "superior" in suitability. Surgery, radiotherapy and nonprofit websites had higher suitability scores as compared to counterparts (p ≤ 0.03). There was no correlation between readability and accuracy levels and suitability scores (p ≥ 0.3). Presence of visual aids was associated with better suitability scores after controlling for website quality (p ≤ 0.01). CONCLUSION: Suitability of websites discussing pancreatic cancer treatments as rated by lay audiences differed based on therapy type and website affiliation, and was independent of readability level and accuracy of information. Nonprofit affiliation websites focusing on surgery or radiotherapy were most suitable. Online information should be assessed for suitability by target populations, in addition to readability level and accuracy, to ensure information reaches the intended audience.