Identifying Factors Associated With Code Status Changes After Emergency General Surgery.

INTRODUCTION: Surgical emergencies are time sensitive. Identifying patients who may benefit from preoperative goals of care discussions is critical to ensuring that operative intervention aligns with the patient's values. We sought to identify patient factors associated with acute changes in a patient's goals using code status change (CSC) as proxy. METHODS: A retrospective analysis of single-institution data for patients undergoing urgent laparotomy was performed. Patients were stratified based on whether a postoperative CSC occurred. Parametric, nonparametric, and regression analyses were used to identify variables associated with CSC. RESULTS: Of 484 patients, 13.8% (n = 67) had a postoperative CSC. Patients with postoperative CSC were older (65 versus 60 years, P < 0.001). Odds of CSC were significantly higher in patients who were transferred between facilities (odds ratio [OR] 2.1), had a higher Charlson Comorbidity Index (3-4: OR 3.9, 5+: OR 6.8), and had a higher quick sequential organ failure assessment score (2: OR 5.0; 3: OR 38.7). Patients with anemia (OR 1.9) and active cancer (OR 3.0) had higher odds of CSC. CONCLUSIONS: Timely intervention in emergency general surgery may result in high-risk interventions and subsequent complications that do not align with a patient's goals and values. Our analysis identified a subset of patients who undergo surgery and have a postoperative CSC leading to transition to comfort-focused care. In these patients, a pause in clinical momentum may help ensure operative intervention remains goal concordant.

Utilization of Palliative and Hospice Care Among Pancreatic Cancer Patients at an Academic Center.

INTRODUCTION: Pancreatic ductal adenocarcinoma has the lowest 5-y relative survival of all solid tumor malignancies. Palliative care can improve the quality of life of both patients and their caregivers. However, the utilization patterns of palliative care in patients with pancreatic cancer are unclear. METHODS: Pancreatic cancer patients who were diagnosed between October 2014 and December 2020 at the Ohio State University were identified. Palliative care and hospice utilization and referral patterns were assessed. RESULTS: Of the 1458 pancreatic cancer patients, 55% (n = 799) were male, median age at diagnosis was 65 y (interquartile range [IQR]: 58, 73), and most were Caucasian (n = 1302, 89%). Palliative care was utilized by 29% (n = 424) of the cohort, with the initial consultation obtained after an average of 6 ± 9 mo from diagnosis. Patients who received palliative care were younger (62 y, IQR: 55, 70 versus 67 y, IQR: 59, 73; P < 0.001) and more frequently members of racial and ethnic minorities (15% versus 9%; P < 0.001) versus those who did not receive palliative care. Among the 344 (24%) patients who received hospice care, 153 (44%) had no prior palliative care consultation. Patients referred to hospice care survived a median of 14 d (95% CI, 12-16) after hospice referral. CONCLUSIONS: Only 3 out of 10 patients with pancreatic cancer received palliative care at an average of 6 mo from initial diagnosis. More than two out of every five patients referred to hospice had no previous palliative care consultation. Efforts to understand the impact of improved integration of palliative care into pancreatic cancer programs are needed.

Uncovering patient safety considerations in laparoscopic cholecystectomy using cognitive task analysis.

INTRODUCTION: Educating residents on laparoscopic operations requires direct teaching and deliberate practice. Attending surgeons are often systematic when performing surgery, which creates a challenge when instructing surgery residents. The aim of this study was to use cognitive task analysis to expand laparoscopic cholecystectomy into microsteps reflecting expert surgeon cognition (perceptions, assessments, decisions, etc.) throughout the operation such that these could be better formalized and conveyed to residents in educational materials or assessments and to attending surgeons as teaching scripts. MATERIALS AND METHODS: One surgeon, a surgical resident, and a human factors specialist conducted cognitive task analyses with three expert general surgeons and one hepatobiliary surgeon using semi-structured interviews. These interviews expanded an existing task model of laparoscopic cholecystectomy to specifically add patient safety aspects including injury prevention, risk management, and complication detection for each step. Interview analysis resulted in an expanded task diagram. RESULTS: Cognitive task analysis expanded the current laparoscopic cholecystectomy task model from 19 to 97 microsteps. In addition to microsteps, an additional major step was identified, the planning step or step zero. Steps with the greatest number of microsteps included dissection with 15 microsteps and intraoperative cholangiogram with 10 microsteps. DISCUSSION: Laparoscopic cholecystectomies are complex operations with multiple microsteps. Identification of these steps can lead to explicit strategies that can improve training of surgeons, with an end towards efficacy and safety. The identification of a planning step prior to beginning the operation is a significant finding that should arguably be included in all future cognitive task analyses regardless of operation or procedure, to emphasize to trainees what senior surgeons have learned through experience. These findings inform the development of interventions for surgical training and evaluation of competency.

All Politics Are Local: A Single Institution Investigation of the Educational Impact of Residents and Fellows Working Together.

BACKGROUND: Most general surgery residents pursue fellowship; there is limited understanding of the impact residents and fellows have on each other's education. The goal of this exploratory survey was to identify these impacts. MATERIALS AND METHODS: Surgical residents and fellows at a single academic institution were surveyed regarding areas (OR assignments, the educational focus of the team, roles and responsibilities on the team, interpersonal communication, call, "other") hypothesized to be impacted by other learners. Impact was defined as "something that persistently affects the clinical learning environment and a trainee's education or ability to perform their job". Narrative responses were reviewed until dominant themes were identified. RESULTS: Twenty-three residents (23/45, 51%) and 12 fellows (12/21, 57%) responded. Responses were well distributed among resident year (PGY-1:17% [4/23], PGY-2, 35% [8/23], PGY-3 26% [6/23], PGY-4 9% [2/23%], PGY-5 13% [3/23]). Most residents reported OR assignment (14/23, 61%) as the area of primary impact, fellows broadly reported organizational categories (Roles and responsibilities 33%, educational focus 16%, interpersonal communication 16%). Senior residents reported missing out on operations to fellows while junior residents reported positive impacts of operating directly with fellows. Residents of all levels reported that fellows positively contributed to their education. Fellows, senior residents, and junior residents reported positive experiences when residents and fellows operated together as primary surgeon and assistant. CONCLUSIONS: Residents and fellows impact one another's education both positively and negatively. Case allocation concerns senior residents, operating together may alleviate this, providing a positive experience for all trainees. Defining a unique educational role for fellows and delineating team expectations may maximize the positive impacts in this relationship.

Analyzing Outcomes Among Older Adults With Necrotizing Soft-Tissue Infections in the United States.

BACKGROUND: Necrotizing soft-tissue infections (NSTIs) encompass a group of severe, life-threatening diseases with high morbidity and mortality. Evidence suggests advanced age is associated with worse outcomes. To date, no large data sets exist describing outcomes in older individuals, and risk factor identification is lacking. METHODS: Retrospective data were obtained from the 2015 Medicare 100% sample. Included in the analysis were those aged ≥65 y with a primary diagnosis of an NSTI (gas gangrene, necrotizing fasciitis, cutaneous gangrene, or Fournier's gangrene). Risk factors for in-hospital mortality and discharge disposition were examined. Continuous variables were assessed using central tendency, t-tests, and Wilcoxon rank-sum tests. Categorical variables were assessed using the chi-squared and Fisher's exact tests. Statistical significance was defined as P < 0.05. RESULTS: 1427 patient records were reviewed. 59% of patients were male, and the overall mean age was 75.4±8.6 y. 1385 (97.0%) patients required emergency surgery for their NSTI diagnosis. The overall mortality was 5.3%. Several underlying comorbidities were associated with higher rates of mortality including cancer (OR: 3.50, P = 0.0009), liver disease (OR: 2.97, P = 0.03), and kidney disease (OR: 2.15, P = 0.01). While associated with high in-hospital mortality, these diagnoses were not associated with a difference in the rate of discharge to home compared with skilled nursing or rehab. Overall, patients discharged to skilled nursing facilities or rehab had higher rates of underlying comorbidities than patients who were discharged home (3 or more comorbid illness 84.3% versus 68.6%, P < 0.0001); however, no individual comorbid illness was associated with discharge location. CONCLUSIONS: In our Medicare data set, we identified several medical comorbidities that are associated with increased rates of in-hospital mortality. Patients with underlying cancers had the highest odds of increased mortality. The effect on outcomes of the potentially immunosuppressive cancer treatments in these patients is unknown. These data suggest that patients with underlying illnesses, especially cancer, kidney disease, or liver disease have higher mortalities and are more likely to be discharged to skilled nursing facilities or rehab. It is unclear why these illnesses were associated with these worse outcomes while others including diabetes and heart disease were not. These data suggest that these particular comorbid illnesses may have special prognostic implications, although further analysis is necessary to identify the causative factors.