Implementation of a Vascular Acute Care Surgery Model is Associated with Improved Surgeon Efficiency and Two-Year Mortality After Lower Extremity Intervention.

OBJECTIVE: Vascular surgeons work long, unpredictable hours with repeated exposure to high-stress situations. Inspired by general surgery acute care surgery models, we sought to organize the care of vascular emergencies with the implementation of a vascular acute care surgery (VACS) model. Within this model, a surgeon is in-house without elective cases and assigned for consultations and urgent operative cases on a weekly basis. This study examined the impact of a VACS model on postoperative mortality and surgeon efficiency. METHODS: This was a retrospective cohort analysis of institutional Vascular Quality Initiative data from July 2014 - July 2023. Patients undergoing lower extremity bypass, peripheral vascular intervention, or amputation were included. There was a washout period from January 2020 - January 2022 to account for COVID-19 pandemic practice abnormalities. Patients were separated into pre- or post-VACS groups. The primary clinical outcomes were 30-day and 2-year mortality. Secondary clinical outcomes included 30-day complications and 30-day and 1-year major adverse limb events (MALE). Separate analyses of operating room data from July 2017 - February 2024 and fiscal data from fiscal year 2019 - fiscal year 2024 were conducted. A washout period from January 2020 - January 2022 was applied. Efficiency outcomes included monthly relative value units (RVUs) per clinical fraction full-time equivalent (cFTE) and daytime (0730-1700, Monday-Friday) operating room minutes. Patient factors and operative efficiency were compared using appropriate statistical tests. Regression modeling was performed for the primary outcomes. RESULTS: There were 972 and 257 patients in the pre- and post-VACS groups, respectively. Pre-VACS patients were younger (66.8±12.0 vs 68.7±12.7 years, p=0.03) with higher rates of coronary artery disease (34.6% vs 14.8%, p<0.01), hypertension (88.4% vs 82.2%, p=0.01), and tobacco history (84.4% vs 78.2%, p=0.02). 30-day mortality (2.4% pre- vs 0.8% post-VACS, p=0.18) and Kaplan-Meier estimation of 2-year mortality remained stable after VACS (p=0.07). VACS implementation was not associated with 30-day mortality but was associated with lower 2-year mortality hazard on multivariable Cox regression (hazard ratio: 0.5, 95% confidence interval: 0.3-0.9, p=0.01). Operative efficiency improved post-VACS (850.0 [765.7, 916.3] vs 918.0 [881.0, 951.1] RVU/cFTE-month, median [inter-quartile range], p=0.03). Daytime operating minutes increased (469.1±287.5 vs 908.2±386.2 minutes, p<0.01), while non-daytime minutes (420.0 [266.0, 654.0] vs 469.5 [242.0, 738.3] minutes, p=0.40) and weekend minutes (129.0 [0.0, 298.0] vs 113.5 [0.0, 279.5] minutes, p=0.59) remained stable. CONCLUSIONS: A VACS model leads to improvement in surgeon operative efficiency while maintaining patient safety. The adoption of a vascular acute care model has a positive impact on the delivery of comprehensive vascular care.

Implementation of a vascular acute care surgery service model is associated with decreased surgeon burnout.

OBJECTIVE: Vascular surgeons have one of the highest rates of burnout among surgical specialties, often attributed to high patient acuity and clinical workload. Acute Care Surgery models are a potential solution used among general and trauma surgeons. METHODS: This is a retrospective analysis of prospectively collected Accreditation Council for Graduate Medical Education survey results from faculty and residents before and after implementation of a vascular Acute Care Surgery (VACS) model. The VACS model assigns a weekly rotation of an attending surgeon with no elective cases or clinic responsibilities and a monthly rotating resident team. Residents and attendings are in-house to cover all urgent and emergent vascular daytime consultations and procedures, whereas nights and weekend coverage remain a typical rotating schedule. Survey question results were binned into domains consistent with the Maslach Burnout Inventory. RESULTS: Both residents and faculty reported an increase in median scores in Maslach Burnout Inventory domains of emotional exhaustion (Faculty: 2.9 vs 3.4; P < .001; Residents: 3.1 vs 3.6; P < .001) and faculty reported higher personal accomplishment scores (Faculty: 3.3 vs 3.8; P = .005) after the VACS model implementation. CONCLUSIONS: A VACS model is a tangible practice change that can address a major problem for current vascular surgeons, as it is associated with decreased burnout for faculty and residents through improvement in both emotional exhaustion and personal accomplishment. Improved longitudinal assessment of resident and faculty burnout is needed and future work should identify specific practice patterns related to decreased burnout.

Evaluation of Mixed Reality Technologies for Remote Feedback and Guidance During Transrectal Ultrasound Biopsy Simulation: A Prospective, Randomized, Crossover Study.

OBJECTIVE: To compare equivalency of remote to in-person training during simulated transrectal ultrasound-guided prostate biopsy, we combined three technologies (mixed reality [MR] software, smart glasses, and hydrogel simulation model). Taken together, telemonitoring harnesses data streaming to provide real-time supervision and technical assistance for surgical procedures from an expert at a remote geographical location. METHODS: Nineteen students were randomized into two groups (MR-first and in-person-first) and proctored to measure prostate volume and perform 14-biopsies over seven sessions: pretest, two MR/in-person-guided training sessions, mid-test, crossover into two in-person/MR-guided training sessions, and post-test. MR sessions utilized Vuzix smart glasses with MR software (HelpLightning) to share the student's first-person perspective and Zoom to project the ultrasound screen to a remote instructor. Training and test sessions utilized single-color and seven-color prostate models, respectively. Accuracy of biopsy cores from test sessions were compared. Perception of instruction following each training session using 5-point Likert scales across five domains was assessed. Preference of instruction modality was assessed qualitatively. RESULTS: Comparison of mid-test performance following two training sessions was similar across the two groups (MR-first 63.8% vs in-person-first 57.6%, P = .340). Following crossover, difference in post-test performance of the MR-first group and the in-person-first group approached significance (MR-first 80.2% vs in-person-first 70.8%, P = .050). Student evaluation of MR and in-person instruction following training sessions was similar across the five metrics. CONCLUSION: MR-based remote learning is equally effective when compared to traditional in-person instruction.