Benchmarks in Pancreatic Surgery: A Novel Tool for Unbiased Outcome Comparisons.

OBJECTIVE: To use the concept of benchmarking to establish robust and standardized outcome references after pancreatico-duodenectomy (PD). BACKGROUND: Best achievable results after PD are unknown. Consequently, outcome comparisons among different cohorts, centers or with novel surgical techniques remain speculative. METHODS: This multicenter study analyzes consecutive patients (2012-2015) undergoing PD in 23 international expert centers in pancreas surgery. Outcomes in patients without significant comorbidities and major vascular resection (benchmark cases) were analyzed to establish 20 outcome benchmarks for PD. These benchmarks were tested in a cohort with a poorer preoperative physical status (ASA class ≥3) and a cohort treated by minimally invasive approaches. RESULTS: Two thousand three hundred seventy-five (38%) low-risk cases out of a total of 6186 PDs were analyzed, disclosing low in-hospital mortality (≤1.6%) but high morbidity, with a 73% benchmark morbidity rate cumulated within 6 months following surgery. Benchmark cutoffs for pancreatic fistulas (B-C), severe complications (≥ grade 3), and failure-to-rescue rate were 19%, 30%, and 9%, respectively. The ASA ≥3 cohort showed comparable morbidity but a higher in hospital-mortality (3% vs 1.6%) and failure-to-rescue rate (16% vs 9%) than the benchmarks. The proportion of benchmark cases performed varied greatly across centers and continents for both open (9%-93%) and minimally invasive (11%-62%) PD. Centers operating mostly on complex PD cases disclosed better results than those with a majority of low-risk cases. CONCLUSION: The proposed outcome benchmarks for PD, established in a large-scale international patient cohort and tested in 2 different cohorts, may allow for meaningful comparisons between different patient cohorts, centers, countries, and surgical techniques.

Implementing ultrasound-guided nerve blocks in the emergency department: A low-cost, low-fidelity training approach.

Background: Managing acute pain is a common challenge in the emergency department (ED). Though widely used in perioperative settings, ED-based ultrasound-guided nerve blocks (UGNBs) have been slow to gain traction. Here, we develop a low-cost, low-fidelity, simulation-based training curriculum in UGNBs for emergency physicians to improve procedural competence and confidence. Methods: In this pre-/postintervention study, ED physicians were enrolled to participate in a 2-h, in-person simulation training session composed of a didactic session followed by rotation through stations using handmade pork-based UGNB models. Learner confidence with performing and supervising UGNBs as well as knowledge and procedural-based competence were assessed pre- and posttraining via electronic survey quizzes. One-way repeated-measures ANOVAs and pairwise comparisons were conducted. The numbers of nerve blocks performed clinically in the department pre- and postintervention were compared. Results: In total, 36 participants enrolled in training sessions, eight participants completed surveys at all three data collection time points. Of enrolled participants, 56% were trainees, 39% were faculty, 56% were female, and 53% self-identified as White. Knowledge and competency scores increased immediately postintervention (mean ± SD t0 score 66.9 ± 8.9 vs. t1 score 90.4 ± 11.7; p < 0.001), and decreased 3 months postintervention but remained elevated above baseline (t2 scores 77.2 ± 11.5, compared to t0; p = 0.03). Self-reported confidence in performing UGNBs increased posttraining (t0 5.0 ± 2.3 compared to t1 score 7.1 ± 1.5; p = 0.002) but decreased to baseline levels 3 months postintervention (t2 = 6.0 ± 1.9, compared to t0; p = 0.30). Conclusions: A low-cost, low-fidelity simulation curriculum can improve ED provider procedural-based competence and confidence in performing UGNBs in the short term, with a trend toward sustained improvement in knowledge and confidence. Curriculum adjustments to achieve sustained improvement in confidence performing and supervising UGNBs long term are key to increased ED-based UGNB use.

New Model for Osteoporosis Risk Screening Using Emergency Department Visits.

Background Even though osteoporosis is the most common bone disease in the United States, it is frequently underscreened and underdiagnosed. In this study, we aimed to utilize the Emergency Department to conduct preemptive osteoporosis risk screening and assess the risk associated with gender and race based on a statistical analysis of survey responses. Methodology Patients >40 years of age presenting at two Emergency Departments were eligible. Consenting patients were asked questions from a modified One-Minute Osteoporosis Risk Test. Modifiable, fixed, and total (modifiable risks + fixed risks) risk sums were calculated. For the association test, chi-square and Wilcoxon rank-sum tests were used. Four total risk categories were created (0-1, 2-3, 4-5, 6+). Odds of being in a higher risk category were analyzed using univariate ordinal logistic regression. Results The prevalence of both a fixed and modifiable risk was 62.2%. Women were more likely than men to report a risk (81.2% vs. 67.5%; p = 0.0043) and to be in a higher risk category (odds ratio (OR) [95% confidence interval (CI)] = 1.63 [1.09-2.45]; p = 0.018). Evidence strongly indicated an unadjusted association of race and modifiable risk category (p < 0.001), with more than half of African Americans (53.0%) in the highest category compared to 26.0% of whites. The total risk was higher in African Americans than whites (OR [95% CI] = 1.75 [1.15-2.67]; p = 0.010). Conclusions Race and gender were associated with specific risk factors. The Emergency Department proved to be a feasible location for conducting health maintenance screenings and should be considered for patient-specific routine osteoporosis risk screenings.