Timing is Everything: Surgical Outcomes for SARS-CoV-2 Positive Patients.

BACKGROUND: A debate remains on how long to postpone surgery after testing positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We aimed to determine surgical outcomes at different time points after a positive SARS-CoV-2 test. METHODS: This cohort study included non-preoperative critically ill adult surgical patients from 5/2020-5/2021 and a subset of SARS-CoV-2 positive patients 15-30 days before surgery from 5/2020-12/2021. Demographics, comorbidities, surgical variables, and outcomes were compared between SARS-CoV-2 positive patients within 50 days before surgery to SARS-CoV-2 negative surgical patients. Cases were stratified based on the timing of SARS-CoV-2 positivity before surgery in days (< 15, 15-30, > 30). Outcomes were compared between strata and against SARS-CoV-2 negative controls. A multivariable model was built to determine the association that the timing of SARS-CoV-2 positivity has on the odds of a major complication. RESULTS: The SARS-CoV-2 positive cohort had 262 patients compared to 1,840 SARS-CoV-2 negative patients. Timing strata contained 145 (< 15 days), 53 (15-30 days), and 64 (> 30 days). The SARS-CoV-2 positive group had a higher incidence of comorbidities (87.4% vs. 57.2%) and underwent more emergent surgery (45.7% vs. 9.3%). The odds of major complications in patients positive for SARS-CoV-2 before surgery were 1.88 (1.13-3.15) (< 15 days), 0.43 (0.14-1.30) (15-30 days), and 0.98 (0.44-2.21) (31-50 days) times the odds in SARS-CoV-2 negative surgery patients when controlling for other variables. CONCLUSION: Timing of SARS-CoV-2 positivity before surgery has an impact on major complications. In certain cases, it may be appropriate to postpone surgery 14 days after SARS-CoV-2 positivity.

Environmental Chemicals and their Association with Hyperparathyroidism.

BACKGROUND: The incidence of hyperparathyroidism has increased in the USA. The previous work from our institution detected environmental chemicals (EC) within hyperplastic parathyroid tumors. The National Health and Nutrition Examination Survey (NHANES) is a program designed to assess the health status of people in the USA and includes measurements of EC in serum. Our aim was to determine which EC are associated with elevated parathyroid hormone (PTH) and calcium levels within NHANES. METHODS: NHANES was queried from 2003-2016 for our analysis with calcium. A separate subgroup was queried from 2003-2006 that included PTH levels. Subjects with elevated calcium, and elevated PTH and normal Vitamin D levels were identified. Wilcoxon rank sum tests were used to analyze levels of EC in those with elevated calcium, and those with elevated PTH in the subgroup. All EC with p < 0.05 were then included in separate multivariate models adjusting for serum vitamin D and creatinine for PTH and albumin for calcium. RESULTS: There were 51,395 subjects analyzed, and calcium was elevated in 2.1% (1080) of subjects. Our subgroup analysis analyzed 14,681 subjects, and PTH was elevated without deficient Vitamin D in 9.4% (1,377). Twenty-nine different polychlorinated biphenyls and the organochlorine pesticides hexachlorobenzene, transnonachlor, oxychlordane, and p,p'-dichlorodiphenyldichloroethylene (DDE) were found to be associated with elevated calcium and separately with elevated PTH (all p < 0.05). CONCLUSION: In NHANES, 33 ECs were found to be associated with elevated calcium as well as elevated PTH levels on our subgroup analysis. These chemicals may lead us toward a causal link between environmental factors and the development of hyperparathyroidism and should be the focus of future studies looking at chemical levels within specimens.

The distance of the primary intimal tear from the left subclavian artery predicts aortic growth in uncomplicated type B aortic dissection.

OBJECTIVE: Controversy exists about the optimal treatment of acute uncomplicated type B aortic dissection (auTBAD). Optimal medical therapy (OMT) provides excellent short-term outcomes, but long-term results are poor. Ideally, auTBAD patients who will fail to respond to OMT in the chronic phase could be identified and undergo thoracic endovascular aortic repair. The purpose of this study was to identify radiographic predictors of auTBAD patients who will fail to respond to OMT. METHODS: A review of the Emory aortic database from 2000 to 2017 identified 320 auTBAD patients initially treated with OMT. From this cohort, 121 patients with two or more contrast-enhanced imaging scans were available for analysis. These patients were initially divided into groups based on growth of the thoracic aorta ≥10 mm or intervention due to aneurysmal growth: growth (n = 72) and no growth (n = 49). TeraRecon (Foster City, Calif) imaging software was used to analyze characteristics of the primary intimal tear (PIT), false lumen, and overall aortic size. Finally, Cox proportional hazards models were constructed to estimate hazard ratios and to identify predictors of OMT failure. RESULTS: The mean age of all patients was 54 ± 11 years, and 67% were male. Thirty-eight patients (53%) in the growth group underwent intervention. There were no differences between groups in age, hypertension, diabetes mellitus, tobacco abuse, or chronic obstructive pulmonary disease. The distance of the PIT from the left subclavian artery in patients with auTBAD was significantly shorter in the growth group (growth, 27 mm [9-66 mm]; no growth, 77 mm [26-142 mm]; P < .01). Multivariable Cox regression analysis identified the distance of the PIT from the left subclavian artery and a thoracic aortic diameter >45 mm as independent predictors of failure of OMT. Partial false lumen thrombosis was not a predictor of aortic growth. CONCLUSIONS: The distance of the PIT from the left subclavian artery is a predictor of aortic growth in auTBAD. Patients with a primary tear located in zone 3 of the proximal descending thoracic aorta should be monitored closely and may be considered for early thoracic endovascular aortic repair in the setting of auTBAD.

Improving Statewide Post-Operative Sepsis Performance Measurement Using Hospital Risk Adjustment Within a Surgical Collaborative.

Background: The Georgia Quality Improvement Program (GQIP) surgical collaborative participating hospitals have shown consistently poor performance in the post-operative sepsis category of National Surgical Quality Improvement Program data as compared with national benchmarks. We aimed to compare crude versus risk-adjusted post-operative sepsis rankings to determine high and low performers amongst GQIP hospitals. Patients and Methods: The cohort included intra-abdominal general surgery patients across 10 collaborative hospitals from 2015 to 2020. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) sepsis definition was used among all hospitals for case abstraction and NSQIP data were utilized to train and validate a multivariable risk-adjustment model with post-operative sepsis as the outcome. This model was used to rank GQIP hospitals by risk-adjusted post-operative sepsis rates. Rankings between crude and risk-adjusted post-operative sepsis rankings were compared ordinally and for changes in tertile. Results: The study included 20,314 patients with 595 cases of post-operative sepsis. Crude 30-day post-operative sepsis risk among hospitals ranged from 0.81 to 5.11. When applying the risk-adjustment model which included: age, American Society of Anesthesiology class, case complexity, pre-operative pneumonia/urinary tract infection/surgical site infection, admission status, and wound class, nine of 10 hospitals were re-ranked and four hospitals changed performance tertiles. Conclusions: Inter-collaborative risk-adjusted post-operative sepsis rankings are important to present. These metrics benchmark collaborating hospitals, which facilitates best practice exchange from high to low performers.

Accuracy of Trauma Surgeons Prospective Estimation of the Injury Severity Score: A Pilot Study.

Injury Severity Score (ISS) has limited utility as a prospective predictor of trauma outcomes as it is currently scored by abstractors post-discharge. This study aimed to determine accuracy of ISS estimation at time of admission. Attending trauma surgeons assessed the Abbreviated Injury Scale of each body region for patients admitted during their call, from which estimated ISS (eISS) was calculated. The eISS was considered concordant to abstracted ISS (aISS) if both were in the same category: mild (<9), moderate (9-15), severe (16-25), or critical (>25). Ten surgeons completed 132 surveys. Overall ISS concordance was 52.2%; 87.5%, 30.8%, 34.8%, and 61.7% for patients with mild, moderate, severe, and critical aISS, respectively; unweighted k = .36, weighted k = .69. This preliminarily supports attending trauma surgeons' ability to predict severity of injury in real time, which has important clinical and research implications.

Epidemiology and Post-Discharge Resource Utilization of Isolated Traumatic Brain Injury in Geriatric Patients.

Benchmark data on traumatic brain injury (TBI) are potentially confounded by morbidity and rehabilitation needs associated with coincident extracranial injuries. Using data on isolated head injuries from 13 trauma centers in Georgia over 3 years, we studied the epidemiology and natural history of isolated TBI in geriatric vs non-geriatric patients in order to identify potential areas for quality improvement. We identified 8 512 patients, 3 895 of whom were geriatric. Geriatric patients had higher baseline comorbidity burden, mostly presented after ground level falls, had higher mortality despite equivalent ICU admission rates, and had higher rates of post-discharge resource utilization than non-geriatric counterparts. Geriatric patients are more likely to require post-discharge services and/or facility placement, regardless of pre-injury functional status. These data highlight the importance of streamlined protocols that place an early focus on post-discharge needs and goals of care, informed by cohort-specific prognosis data.

A Self-Sustaining Antibiotic Prophylaxis Program to Reduce Surgical Site Infections.

Background: Our multi-institutional healthcare system had a higher-than-expected surgical site infection (SSI) rate. We aimed to improve our peri-operative antibiotic administration process. Gap analysis identified three opportunities for process improvement: standardized antibiotic selection, standardized second-line antibiotic agents for patients with allergies, and feedback regarding antibiotic administration compliance. Hypothesis: Implementation of a multifaceted quality improvement initiative including a near-real-time pre-operative antibiotic compliance feedback tool will improve compliance with antibiotic administration protocols, subsequently lowering SSI rate. Methods: A compliance feedback tool designed to provide monthly reports to all anesthesia and surgical personnel was implemented at two facilities, in September 2017 and December 2018. Internal case data were tracked for antibiotic compliance through June 2021, and these data were merged with American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) data at the case level to provide process and outcome measures for SSIs. Implementation success was evaluated by comparing protocol compliance and risk-adjusted rates of superficial and deep SSI before and after the quality improvement implementation. Results: A total of 20,385 patients were included in this study; 11,548 patients in the pre-implementation and 8,837 in the post-implementation groups. Baseline patient and operative characteristics were similar between groups, except the post-implementation group had a higher median expected SSI rate (2.2% vs. 1.6%). Post-implementation, antibiotic protocol compliance increased from 86.3% to 97.6%, and superficial and deep SSIs decreased from 2.8% to 1.9% (p < 0.001). The odds of superficial and deep SSI in patients in the post-implementation group was 0.69 (0.57, 0.83) times the odds of superficial and deep SSI in pre-implementation patients while adjusting for age, gender, diabetes mellitus, American Society of Anesthesiologists Physical Status (ASA) classification, wound class, smoking, and chronic obstructive pulmonary disease (COPD). Observed-to-expected ratios of superficial and deep SSI decreased from 0.82 to 0.48 after the intervention. Conclusions: Surgical antibiotic prophylaxis standardization and providing near-real-time individualized feedback resulted in sustained improvement in peri-operative antibiotic compliance rates and reduced superficial and deep SSIs.

Organ-Space Surgical Site Infections: Consequences and Prediction Using ACS-NSQIP.

BACKGROUND: The incidence of organ-space surgical site infections (OSIs) across the US has not decreased to the same extent as superficial and deep surgical site infections (SSIs). This study aimed to highlight the consequences and create a predictive model of OSIs using 2019 NSQIP data. MATERIALS AND METHODS: The primary data source was the ACS NSQIP 2019 Participant Use Targeted File (PUF). Chi-squared and independent t-tests evaluated the association of OSIs and other postoperative complications. Variables of interest for our predictive model included 10 surgery types, 10 relevant preoperative laboratory values, and 26 other variables including demographics and comorbidities. A stepwise logistic regression model fit with OSIs as the outcome was used to calculate the predicted ROC and c-index. RESULTS: A total of 1,076,441 cases submitted from 719 NSQIP-participating sites were included in our analysis, comprised of 16,751 (1.6%) OSIs with a median of 10 days (IQR: 11 days) between surgery and the development of an OSI. Forty-two variables were included in our final multivariable analysis. Esophageal and pancreatic surgeries yielded an approximate 4- and 6-fold higher increase in the odds of OSI, respectively (P < .001). ROC analysis yielded a c-index statistic of 0.846 (Figure 1). Associated consequences of OSIs included hospital readmission (OR = 20.74, 95% CI: 20.094-21.412, p < .001), sepsis (OR = 35.084; 95%CI: 33.75-36.47, p < .001) and higher probabilities of mortality (34% vs. 0.8%, p < .001) and morbidity (16% vs. 5.8%, p < .001). DISCUSSION: OSIs have extensive consequences and may be predictable. These types of infections are multifactorial and require quality surveillance distinct from other SSIs.

Georgia Quality Improvement Programs Multi-Institutional Collection of Postoperative Opioid Data Using ACS-NSQIP Abstraction.

BACKGROUND: Excessive postoperative opioid prescribing contributes to opioid misuse throughout the US. The Georgia Quality Improvement Program (GQIP) is a collaboration of ACS-NSQIP participating hospitals. GQIP aimed to develop a multi-institutional opioid data collection platform as well as understand our current opioid-sparing strategy (OSS) usage and postoperative opioid prescribing patterns. METHODS: This study was initiated 7/2019, when 4 custom NSQIP variables were developed to capture OSS usage and postoperative opioid oral morphine equivalents (OMEs). After pilot collection, our discharge opioid variable required optimization for adequate data capture and was expanded from a free text option to 4 drop-down selection variables. Data collection then continued from 2/2020-5/2021. Logistic regression was used to determine associations with OSS usage. Average OMEs were calculated for common general surgery procedures and compared to national guidelines. RESULTS: After variable optimization, the percentage where a total discharge prescription OME could be calculated increased from 26% to 70% (P < .001). The study included 820 patients over 10 operations. There was a significant variation in OSS usage between GQIP centers. Laparoscopic cases had higher odds of OSS use (1.92 (1.38-2.66)) while OSS use had lower odds in black patients on univariate analysis (.69 (.51-.94)). On average 7 out of the 10 cases had higher OMEs prescribed compared to national guidelines recommendations. CONCLUSION: Developing a multi-institutional opioid data collection platform through ACS-NSQIP is feasible. Preselected drop-down boxes outperform free text variables. GQIP future quality improvement targets include variation in OSS use and opioid overprescribing.

The Impact of the COVID-19 Pandemic on Burn Admissions at a Major Metropolitan Burn Center.

The impact of the coronavirus disease 2019 (COVID-19) pandemic on admission patterns and outcomes at a burn center is still largely unknown. The aim of this study was to determine how the COVID-19 pandemic affected the epidemiology of burn admissions at a major metropolitan burn center. This retrospective cohort study examined how the COVID-19 pandemic affected burn volumes and time to presentation. All burn admissions were included from January 20 to August 31 for the years 2020, 2019, and 2018. The COVID-19 pandemic group included admissions from January 20, 2020 to August 31, 2020 and was compared to the nonpandemic group comprised of admissions from January 20 to August 31 in 2018 and 2019. Subgroup analysis was performed according to meaningful dates during the COVID-19 pandemic including the first U.S. COVID-19 case, shelter-in-place, and state reopening orders. Admission volumes were 403 patients in the COVID-19 pandemic group compared to a mean of 429 patients in the nonpandemic group, which correlated to a 5.8% decrease in volume during the pandemic. The pandemic group showed an increase in time to presentation of 1 day (P < .0001). Subgroup analysis demonstrated stable admission volumes and an increase in time to presentation of 1 day (P < .0001) at each time point. During shelter-in-place orders, there were higher rates of second/third-degree burns and operative burns (94.7 vs 56.3% and 45.6 vs 27%, P < .0001, P = .013). During the pandemic, there were stable admission volumes, delayed time to admission, and an increase in operative burns during shelter-in-place orders. This reinforces the need to maintain appropriate burn center staffing and resources during the COVID-19 pandemic.