The impact of post-operative enteral nutrition on duodenal injury outcomes: A post hoc analysis of an EAST multicenter trial.

BACKGROUND: Leak following surgical repair of traumatic duodenal injuries results in prolonged hospitalization and oftentimes nil per os(NPO) treatment. Parenteral nutrition(PN) has known morbidity; however, duodenal leak(DL) patients often have complex injuries and hospital courses resulting in barriers to enteral nutrition(EN). We hypothesized EN alone would be associated with 1)shorter duration until leak closure and 2)less infectious complications and shorter hospital length of stay(HLOS) compared to PN. METHODS: This was a post-hoc analysis of a retrospective, multicenter study from 35 Level-1 trauma centers, including patients >14 years-old who underwent surgery for duodenal injuries(1/2010-12/2020) and endured post-operative DL. The study compared nutrition strategies: EN vs PN vs EN + PN using Chi-Square and Kruskal-Wallis tests; if significance was found pairwise comparison or Dunn's test were performed. RESULTS: There were 113 patients with DL: 43 EN, 22 PN, and 48 EN + PN. Patients were young(median age 28 years-old) males(83.2%) with penetrating injuries(81.4%). There was no difference in injury severity or critical illness among the groups, however there were more pancreatic injuries among PN groups. EN patients had less days NPO compared to both PN groups(12 days[IQR23] vs 40[54] vs 33[32],p = <0.001). Time until leak closure was less in EN patients when comparing the three groups(7 days[IQR14.5] vs 15[20.5] vs 25.5[55.8],p = 0.008). EN patients had less intra-abdominal abscesses, bacteremia, and days with drains than the PN groups(all p < 0.05). HLOS was shorter among EN patients vs both PN groups(27 days[24] vs 44[62] vs 45[31],p = 0.001). When controlling for predictors of leak, regression analysis demonstrated EN was associated with shorter HLOS(ß -24.9, 95%CI -39.0 to -10.7,p < 0.001). CONCLUSION: EN was associated with a shorter duration until leak closure, less infectious complications, and shorter length of stay. Contrary to some conventional thought, PN was not associated with decreased time until leak closure. We therefore suggest EN should be the preferred choice of nutrition in patients with duodenal leaks whenever feasible. LEVEL OF EVIDENCE: IV.

Outcomes among trauma patients with duodenal leak following primary versus complex repair of duodenal injuries: An Eastern Association for the Surgery of Trauma multicenter trial.

BACKGROUND: Duodenal leak is a feared complication of repair, and innovative complex repairs with adjunctive measures (CRAM) were developed to decrease both leak occurrence and severity when leaks occur. Data on the association of CRAM and duodenal leak are sparse, and its impact on duodenal leak outcomes is nonexistent. We hypothesized that primary repair alone (PRA) would be associated with decreased duodenal leak rates; however, CRAM would be associated with improved recovery and outcomes when leaks do occur. METHODS: A retrospective, multicenter analysis from 35 Level 1 trauma centers included patients older than 14 years with operative, traumatic duodenal injuries (January 2010 to December 2020). The study sample compared duodenal operative repair strategy: PRA versus CRAM (any repair plus pyloric exclusion, gastrojejunostomy, triple tube drainage, duodenectomy). RESULTS: The sample (N = 861) was primarily young (33 years) men (84%) with penetrating injuries (77%); 523 underwent PRA and 338 underwent CRAM. Complex repairs with adjunctive measures were more critically injured than PRA and had higher leak rates (CRAM 21% vs. PRA 8%, p < 0.001). Adverse outcomes were more common after CRAM with more interventional radiology drains, prolonged nothing by mouth and length of stay, greater mortality, and more readmissions than PRA (all p < 0.05). Importantly, CRAM had no positive impact on leak recovery; there was no difference in number of operations, drain duration, nothing by mouth duration, need for interventional radiology drainage, hospital length of stay, or mortality between PRA leak versus CRAM leak patients (all p > 0.05). Furthermore, CRAM leaks had longer antibiotic duration, more gastrointestinal complications, and longer duration until leak resolution (all p < 0.05). Primary repair alone was associated with 60% lower odds of leak, whereas injury grades II to IV, damage control, and body mass index had higher odds of leak (all p < 0.05). There were no leaks among patients with grades IV and V injuries repaired by PRA. CONCLUSION: Complex repairs with adjunctive measures did not prevent duodenal leaks and, moreover, did not reduce adverse sequelae when leaks did occur. Our results suggest that CRAM is not a protective operative duodenal repair strategy, and PRA should be pursued for all injury grades when feasible. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Multiyear experience with mobile online platform for documentation of acute care surgery fellows supervision.

BACKGROUND: There is currently no standard for documenting supervision of acute care surgery (ACS) fellows. To accomplish this goal, we developed a web-based survey that is accessible via mobile platform. We hypothesize that our mobile access survey is an effective, reproducible tool for assessing fellow clinical performance. METHODS: A retrospective review from 2016 to 2022 of all data captured in an encrypted database on all ACS fellows at our institution was performed. Supervision was defined as: Type 1 direct face-to-face, Type 2a immediately available in-house, Type 2b available after notification via phone with remote electronic medical record access, and Type 3 retrospective review. Data were collected by supervising faculty using a web-based clinical performance survey created by fellowship program leadership. Survey data collected included clinical summary, trainee, proctoring faculty, clinical service, operative/nonoperative, supervision type, Zwisch autonomy scale, time to input data, and graduate medical education milestone performance. Data were analyzed using descriptive statistics. RESULTS: A total of 883 proctoring events were identified, including the majority as Type 1 (97.4%). Trauma comprised 64% of evaluations. Fifty-two percent of the proctoring events were surgical cases. Complexity was graded as average (77%), hardest (16%), basic (7%). Guidance included supervision only, 491 of 666 (74%), with 26% requiring faculty intervention. Fellow performance was graded as average (66%), above average (31%), and below average/critical deficiency (3%). Graduate medical education performance was available for 247 of 883 interactions identifying 31 events with potential for improvement. Average evaluation completion time: 2 minutes (n = 134). CONCLUSION: A mobile web-based survey is a convenient and reliable tool for documenting ACS fellow clinical activity and was effectively used by all ACS faculty to record supervision. A combination of clinical and objective data is useful to determine ACS fellows' performance and to provide targeted education and remediation. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

Establishing a core outcomes set for massive transfusion: An Eastern Association for the Surgery of Trauma modified Delphi method consensus study.

BACKGROUND: The management of severe hemorrhage has changed significantly over recent decades, resulting in a heterogeneous description of diagnosis, treatment, and outcomes in the literature, which is not suitable for data pooling. Therefore, we sought to develop a core outcome set (COS) to help guide future massive transfusion (MT) research and overcome the challenge of heterogeneous outcomes reporting. METHODS: Massive transfusion content experts were invited to participate in a modified Delphi study. For Round 1, participants submitted a list of proposed core outcomes. In subsequent rounds, panelists used a 9-point Likert scale to score proposed outcomes for importance. Core outcomes consensus was defined as >85% of scores receiving 7 to 9 and <15% of scores receiving 1 to 3. Feedback and aggregate data were shared between rounds. RESULTS: From an initial panel of 16 experts, 12 (75%) completed three rounds of deliberation to reevaluate variables not achieving predefined consensus criteria. A total of 64 items were considered, with 4 items achieving consensus for inclusion as core outcomes: blood products received in the first 6 hours, 6-hour mortality, time to mortality, and 24-hour mortality. CONCLUSION: Through an iterative survey consensus process, content experts have defined a COS to guide future MT research. This COS will be a valuable tool for researchers seeking to perform new MT research and will allow future trials to generate data that can be used in pooled analyses with enhanced statistical power. LEVEL OF EVIDENCE: Diagnostic Test or Criteria; Level V.

Prior Antibiotic Exposure Is Associated With Reoperation After Elective Non-colorectal Surgery.

BACKGROUND: Recent antibiotic exposure has previously been associated with poor outcomes following elective surgery. The purpose of this study is to evaluate the impact of prior recent antibiotic exposure in a multicenter cohort of Veterans Affairs patients undergoing elective non-colorectal surgery. METHODS: This is a retrospective cohort study of the Veterans Affairs Surgical Quality Improvement Program, including elective, non-cardiovascular, non-colorectal surgery from 2013 to 2017. Outpatient antibiotic exposure within 90 days prior to surgery was identified from the Veterans Affairs outpatient pharmacy database and matched with each case. Primary outcomes included serious complication, any complication, any infection, or surgical site infection. Secondary outcomes included 30-day mortality, length of stay, and Clostridioides difficile infection. RESULTS: Of 21,112 eligible patients, 2885 (13.7%) were exposed to antibiotics within 90 days prior to surgery with a duration of 7 (IQR: 5-10) days and prescribed 42 (IQR: 21-64) days prior to surgical intervention. Compared to non-exposed patients, exposed patients had higher unadjusted complication rates, increased length of stay, and rates of return to the operating. Exposure was independently associated with return to the operating room (OR: 1.39; 99% CI: 1.05-1.84). CONCLUSIONS: Among Veterans, recent antibiotic exposure within 90 days of elective surgery was associated with a 39% increase in the odds of return to the operating room. Further work is needed to evaluate the effects of antibiotic exposure and dysbiosis on surgical outcomes.

Regional ethics of surgeon resuscitation for organ transplantation after lethal injury.

BACKGROUND: Trauma patients may present with nonsurvivable injuries, which could be resuscitated for future organ transplantation. Trauma surgeons face an ethical dilemma of deciding whether, when, and how to resuscitate a patient who will not directly benefit from it. As there are no established guidelines to follow, we aimed to describe resuscitation practices for organ transplantation; we hypothesized that resuscitation practices vary regionally. METHOD: Over a 3-month period, we surveyed trauma surgeons practicing in Levels I and II trauma centers within a single state using an instrument to measure resuscitation attitudes and practices for organ preservation. Descriptive statistics were calculated for practice patterns. RESULTS: The survey response rate was 51% (31/60). Many (81%) had experience with resuscitations where the primary goal was to preserve potential for organ transplantation. Many (90%) said they encountered this dilemma at least monthly. All respondents were willing to intubate; most were willing to start vasopressors (94%) and to transfuse blood (84%) (range, 1 unit to >10 units). Of respondents, 29% would resuscitate for ≥24 hours, and 6% would perform a resuscitative thoracotomy. Respect for patients' dying process and future organ quality were the factors most frequently considered very important or important when deciding to stop or forgo resuscitation, followed closely by concerns about excessive resource use. CONCLUSION: Trauma surgeons' regional resuscitation practices vary widely for this patient population. This variation implies a lack of professional consensus regarding initiation and extent of resuscitations in this setting. These data suggest this is a common clinical challenge, which would benefit from further study to determine national variability, areas of equipoise, and features amenable to practice guidelines.

Use of posterior component separation and transversus abdominis release in trauma and emergency general surgery patients: a case report and review of the literature.

Posterior component separation with transversus abdominis release and implantation of synthetic mesh in the retromuscular space is a durable type of repair for many large incisional hernias with recurrence rates consistently less than 10%. The purported advantage of biologic prostheses in contaminated fields has recently been challenged, and the concern for placing synthetic mesh in contaminated fields may be overstated. There are almost no data specifically addressing the use of this type of repair for chronic incisional hernias in trauma and emergency general surgery patients, so research is needed on this patient population. In this review, a case of a trauma patient receiving posterior component separation with transversus abdominis release and implantation of synthetic mesh for a chronic incisional hernia resulting from a gunshot wound to the abdomen is presented, the technique is explained, and relevant literature is reviewed.

Effectiveness and safety of continuous neuromuscular blockade in trauma patients with an open abdomen: A follow-up study.

BACKGROUND: Neuromuscular blocking agents (NMBA) have been associated with decreased time to fascial closure following damage control laparotomy (DCL). Changes in resuscitation over the last decade bring this practice into question. METHODS: A retrospective cohort study of adults who underwent DCL between 2009 and 2015 was conducted at an ACS-verified level 1 trauma center. The study group (NMBA+) received continuous NMBA within 24 h of DCL. Data collected included demographics, resuscitative fluids, mortality, and complications. The primary outcome was time to fascial closure. Factors associated with abdominal closure were determined by ordinal logistic regression. RESULTS: There were 222 patients included (NMBA+ 125; NMBA- 97). Demographics were similar, including median age (NMBA+ 36; NMBA- 39 years) and ISS (NMBA+ 29; NMBA- 34). There was no difference in median time to closure (NMBA+ 2; NMBA- 2 days) or the incidence of complications (NMBA+ 64%; NMBA- 59%). In a regression model, NMBA exposure was not associated with time to abdominal closure. CONCLUSIONS: In adult trauma patients requiring DCL, continuous NMBA did not affect the time to abdominal closure.

Artificial intelligence can predict daily trauma volume and average acuity.

BACKGROUND: The goal of this study was to integrate temporal and weather data in order to create an artificial neural network (ANN) to predict trauma volume, the number of emergent operative cases, and average daily acuity at a Level I trauma center. METHODS: Trauma admission data from Trauma Registry of the American College of Surgeons and weather data from the National Oceanic and Atmospheric Administration was collected for all adult trauma patients from July 2013-June 2016. The ANN was constructed using temporal (time, day of week), and weather factors (daily high, active precipitation) to predict four points of daily trauma activity: number of traumas, number of penetrating traumas, average Injury Severity Score (ISS), and number of immediate operative cases per day. We trained a two-layer feed-forward network with 10 sigmoid hidden neurons via the Levenberg-Marquardt back propagation algorithm, and performed k-fold cross validation and accuracy calculations on 100 randomly generated partitions. RESULTS: Ten thousand six hundred twelve patients over 1,096 days were identified. The ANN accurately predicted the daily trauma distribution in terms of number of traumas, number of penetrating traumas, number of OR cases, and average daily ISS (combined training correlation coefficient r = 0.9018 ± 0.002; validation r = 0.8899 ± 0.005; testing r = 0.8940 ± 0.006). CONCLUSION: We were able to successfully predict trauma and emergent operative volume, and acuity using an ANN by integrating local weather and trauma admission data from a Level I center. As an example, for June 30, 2016, it predicted 9.93 traumas (actual: 10), and a mean ISS of 15.99 (actual: 13.12). This may prove useful for predicting trauma needs across the system and hospital administration when allocating limited resources. LEVEL OF EVIDENCE: Prognostic/epidemiological, level III.

Use of an evidence-based algorithm for patients with traumatic hemothorax reduces need for additional interventions.

BACKGROUND: Concerted management of the traumatic hemothorax is ill-defined. Surgical management of specific hemothoraces may be beneficial. A comprehensive strategy to delineate appropriate patients for additional procedures does not exist. We developed an evidence-based algorithm for hemothorax management. We hypothesize that the use of this algorithm will decrease additional interventions. METHODS: A pre-/post-study was performed on all patients admitted to our trauma service with traumatic hemothorax from August 2010 to September 2013. An evidence-based management algorithm was initiated for the management of retained hemothoraces. Patients with length of stay (LOS) less than 24 hours or admitted during an implementation phase were excluded. Study data included age, Injury Severity Score, Abbreviated Injury Scale chest, mechanism of injury, ventilator days, intensive care unit (ICU) LOS, total hospital LOS, and interventions required. Our primary outcome was number of patients requiring more than 1 intervention. Secondary outcomes were empyema rate, number of patients requiring specific additional interventions, 28-day ventilator-free days, 28-day ICU-free days, hospital LOS, all-cause 6-month readmission rate. Standard statistical analysis was performed for all data. RESULTS: Six hundred forty-two patients (326 pre and 316 post) met the study criteria. There were no demographic differences in either group. The number of patients requiring more than 1 intervention was significantly reduced (49 pre vs. 28 post, p = 0.02). Number of patients requiring VATS decreased (27 pre vs. 10 post, p < 0.01). Number of catheters placed by interventional radiology increased (2 pre vs. 10 post, p = 0.02). Intrapleural thrombolytic use, open thoracotomy, empyema, and 6-month readmission rates were unchanged. The "post" group more ventilator-free days (median, 23.9 vs. 22.5, p = 0.04), but ICU and hospital LOS were unchanged. CONCLUSION: Using an evidence-based hemothorax algorithm reduced the number of patients requiring additional interventions without increasing complication rates. Defined criteria for surgical intervention allows for more appropriate utilization of resources. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Stapled versus hand-sewn: A prospective emergency surgery study. An American Association for the Surgery of Trauma multi-institutional study.

BACKGROUND: Data from the trauma patient population suggests handsewn (HS) anastomoses are superior to stapled (ST). A recent retrospective study in emergency general surgery (EGS) patients had similar findings. The aim of the current study was to evaluate HS and ST anastomoses in EGS patients undergoing urgent/emergent operations. METHODS: The study was sponsored by the American Association for the Surgery of Trauma Multi-Institutional Studies Committee. Patients undergoing urgent/emergent bowel resection for EGS pathology were prospectively enrolled from July 22, 2013 to December 31, 2015. Patients were grouped by HS/ST anastomoses, and variables were collected. The primary outcome was anastomotic failure. Similar to other studies, anastomotic failure was evaluated at the anastomosis level. Multivariable logistic regression was performed controlling for age and risk factors for anastomotic failure. RESULTS: Fifteen institutions enrolled a total of 595 patients with 649 anastomoses (253 HS and 396 ST). Mean age was 61 years, 51% were men, 7% overall mortality. Age and sex were the same between groups. The overall anastomotic failure rate was 12.5%. The HS group had higher lactate, lower albumin, and were more likely to be on vasopressors. Hospital and intensive care unit days, as well as mortality, were greater in the HS group. Anastomotic failure rates and operative time were equivalent for HS and ST. On multivariate regression, the presence of contamination at initial resection (odds ratio, 1.965; 95% confidence interval, 1.183-3.264) and the patient being managed with open abdomen (odds ratio, 2.529; 95% confidence interval, 1.492-4.286) were independently associated with anastomotic failure, while the type of anastomosis was not. CONCLUSION: EGS patients requiring bowel resection and anastomosis are at high risk for anastomotic failure. The current study illustrates an apparent bias among acute care surgeons to perform HS techniques in higher-risk patients. Despite the individualized application of technique for differing patient populations, the risk of anastomotic failure was equivalent when comparing HS and ST anastomoses. LEVEL OF EVIDENCE: Therapeutic study, level II.

Rural Trauma Team Development Course decreases time to transfer for trauma patients.

BACKGROUND: The Rural Trauma Team Development Course (RTTDC) is designed to teach knowledge and skills for the initial assessment and stabilization of trauma patients in resource-limited environments. The effect of RTTDC training on transfers from nontrauma centers to definitive care has not been studied. We hypothesized that RTTDC training would decrease referring hospital emergency department (ED) length of stay (LOS), time to call for transfer, pretransfer computed tomography (CT) imaging rate, and mortality rate. METHODS: We conducted a pre/post analysis of trauma patients who were transferred from rural, nontrauma hospitals from 2012 to 2014. Patients from six rural hospitals that participated in an RTTDC course were compared with a control group of similar centers that did not participate in the course. Primary outcome evaluated was referring hospital ED LOS, which was estimated using a difference-in-differences regression model. Secondary outcomes were time to transfer call, pretransfer CT imaging rates, and mortality. RESULTS: Two hundred fifty-three patients were available for study (RTTDC group, n = 130; control group, n = 123). Demographics, CT imaging, and mortality rates were similar between the two groups. In the primary outcome, the RTTDC group experienced an overall 61-minute reduction in referring hospital LOS (p = 0.02) compared with the control group. The RTTDC group also showed a 41-minute reduction (p = 0.03) in time to call for transfer compared with controls. There were no differences in the secondary outcomes of pretransfer CT scanning rates or mortality. CONCLUSIONS: Rural Trauma Team Development Course training shortens ED LOS at rural, nontrauma hospitals by more than 1 hour without increasing mortality. Future educational and research efforts should focus on decreasing unnecessary imaging prior to transfer as well as opportunities to improve mortality rates. This study suggests an important role for RTTDC training in the care of rural trauma patients and may allow trauma centers to recapture the "golden hour" for transferred trauma patients. LEVEL OF EVIDENCE: Therapeutic/care management study, level III.

Blood transfusion: In the air tonight?

BACKGROUND: The use of prehospital blood transfusion (PBT) in air medical transport has become more widespread. However, the effect of PBT remains unknown. The aim of this study was to examine the impact of PBT on 24-hour and overall in-hospital mortality. METHODS: This is a retrospective cohort study of all trauma patients carried by air medical transport from the scene to a Level I trauma center from 2007 to 2013. We excluded patients who died on the helipad or in the emergency department. Primary outcomes measured were 24-hour and overall in-hospital mortality. Multivariable logistic regressions using all available patient data or the propensity score (for receiving PBT)-matched patient data were performed to study the effect of PBT on these outcomes. RESULTS: Of the 5,581 patients included in the study, 231 (4%) received PBT. Multivariable regression analyses did not show evidence of PBT effect on 24-hour in-hospital mortality (odds ratio [OR], 1.22; 95% confidence interval [CI], 0.61-2.44) and on overall in-hospital mortality (OR, 1.20; 95% CI, 0.55-1.79). In addition, using 1:1 propensity score-matched data, the analysis did not show evidence of PBT effect on 24-hour in-hospital mortality (OR, 1.04; 95% CI, 0.54-1.98) and on overall in-hospital mortality (OR, 1.05; 95% CI, 0.56-1.96). Factors associated with increased 24-hour mortality were advanced age, penetrating injury, increased blood transfusion requirement in the first 24 hours, and decreased Glasgow Coma Scale (GCS) score (p < 0.05). These factors were also associated with overall mortality, in addition to increased Injury Severity Score (ISS) (p < 0.05). CONCLUSION: This is the largest study to date of trauma patients who received PBT and were transported from the scene by air medical transport. Our results show no effect of PBT on 24-hour and overall in-hospital mortality. Previous studies also suggest no benefit of PBT, which is counterintuitive to damage-control resuscitation. Prospective data on PBT are needed to assess risk, cost, and benefit. LEVEL OF EVIDENCE: Therapeutic study, level III.

Survey of trauma surgeon practice of emergency department thoracotomy.

BACKGROUND: There continues to be significant debate in the trauma community regarding the indications for emergency department thoracotomy (EDT). Numerous studies have focused on the duration of arrest in EDT, whereas few have examined other factors that influence surgeon decision-making. We hypothesize that there is continued variability among surgeons in the use of EDT. METHODS: A 13-question web-based survey was distributed to the membership of a large, national trauma association, examining demographics, trauma fellowship completion, trauma center designation, professional organization membership, and annual EDTs performed. Consideration of patient's age, comorbidities, total injury burden, and the use of technological adjuncts-such as ultrasound-was assessed. Respondents were asked when they would perform the procedure after loss of vital signs for blunt and penetrating trauma. Logistic regression determined factors influencing consideration of EDT. RESULTS: Overall 540 of 1,485 surveys were completed (36.4%). Patient age, total injury burden, and comorbidities are considered by 38.5%, 29.1%, and 55.7% of respondents, respectively. Technological adjuncts are used always or most of the time by 64% of respondents. A majority of respondents (51.9%) would perform an EDT for penetrating trauma with loss of vital signs 5 to 10 minutes before arrival. For blunt trauma, the largest group of respondents (47.0%) would perform an EDT only when loss of vital signs occurred in the ED. In addition, 20.6% would never perform EDT for blunt traumatic arrest. CONCLUSIONS: EDT decision-making is more nuanced than previously described. Variation continues in the use of thoracotomy after loss of vital signs, in both blunt and penetrating trauma. For both mechanisms, there remains little consensus on the appropriate duration of arrest before performing EDT after arrest despite published guidelines. A large proportion of surgeons consider other factors such as patient age, total injury burden, and comorbidities in addition to vital signs when deciding to perform an EDT. Technological adjuncts are frequently used by surgeons to determine the need for EDT.

Retained surgical items: a problem yet to be solved.

BACKGROUND: Retained surgical items (RSI) continue to occur. Large RSI studies are few due to low RSI frequency in single institutions and the medicolegal implications. Consequently, RSI risks are not fully defined, with discrepancies persisting among published studies. The goals of this study were to better define risk factors for RSI, to clarify previously discrepant risk factors, and to evaluate other potential contributors to RSI occurrence, such as trainee presence during an operation. STUDY DESIGN: Multicenter case-match study of RSI risk factors was conducted between January 2003 and December 2009. Cases complicated by RSI were identified at participating centers using clinical quality improvement and adverse event reporting data. Case match controls (non-RSI) were selected from same or similar-type cases performed at each respective institution. Retained surgical item risk factors were evaluated by univariate and multivariate conditional logistic regression. RESULTS: Fifty-nine RSIs and 118 matched controls were analyzed (RSI incidence 1 in 6,975 or 59 in 411,526). Retained surgical items occurred despite use of confirmatory x-rays (13 of 27 instances) and/or radiofrequency tagging (2 of 32 instances). Among previously discrepant results, we confirmed that body mass index, unexpected intraoperative events, and procedure duration were associated with increased RSI risk. The occurrence of any safety variance, and specifically an incorrect count at any time during the procedure, was associated with elevated RSI risk. Trainee presence was associated with 70% lower RSI risk compared with trainee absence. CONCLUSIONS: Longer duration of surgery, safety variances, and incorrect counts during the procedure result in elevated RSI risk. The possible positive influence of trainee presence on RSI risk deserves additional study. Our findings highlight the need for zero tolerance for safety omissions, continued study and development of novel approaches to RSI reduction, and establishing anonymous RSI reporting systems to better track both the incidence and risks associated with this problem, which has yet to be solved.

Using the National Surgical Quality Improvement Program and the Tennessee Surgical Quality Collaborative to improve surgical outcomes.

BACKGROUND: Led by the Tennessee Chapter of the American College of Surgeons, in May 2008 a 10-hospital collaborative was formed between the Tennessee Chapter of ACS, the Tennessee Hospital Association, and the BlueCross BlueShield of Tennessee Health Foundation. We hypothesized that by forming the Tennessee Surgical Quality Collaborative using the National Surgical Quality Improvement Program (NSQIP) system to share surgical process and outcomes data, overall patient surgical outcomes would improve. STUDY DESIGN: All NSQIP data from the 10-hospital collaborative for the time periods January to December 2009 (period 1) and January to December 2010 (period 2) were collected. Data on 20 categories of postoperative complications and 30-day mortality were compared between periods. Complication comparisons and hospital costs associated with complications were calculated per 10,000 procedures. Statistical analysis was performed by Z-test. RESULTS: There were 14,205 total surgical cases in period 1 and 14,901 surgical cases in period 2. Between periods (per 10,000 cases) there were significant improvements in superficial surgical site infections (-19%, p = 0.0005), on ventilator longer than 48 hours (-15%, p = 0.012), graft/prosthesis/flap failure (-60%, p < 0.0001), acute renal failure (-25%, p = 0.023), and wound disruption (-34%, p = 0.011). Although mortality (per 10,000) was higher in period 2 (237.6 vs 232.3), no statistical difference was noted. Net costs avoided between these periods were calculated as $2,197,543 per 10,000 general and vascular surgery cases. CONCLUSIONS: Data organization and scrutiny are the initial steps of process improvement. Participation in our regional surgical quality collaborative resulted in improved outcomes and reduced costs. Although the mechanisms for these changes are likely multifactorial, the collaborative establishes communication, process improvement, and frank discussion among the members as best practices are identified and shared and standardized processes are adopted.

Duration of time on intensive insulin therapy predicts severe hypoglycemia in the surgically critically ill population.

BACKGROUND: Hypoglycemia has emerged as a barrier to the practice of intensive insulin therapy. Current literature suggests that hypoglycemia occurs at variable rates and has different effects on outcomes in surgical and medical populations. We sought to determine the incidence, independent predictors, and effect on outcome of severe hypoglycemia (≤ 40 mg/dl) in a surgical population. METHODS: A retrospective analysis was performed on all critically ill surgical patients treated with IIT from October 2004 to February 2007. Euglycemia (goal 80-110 mg/dl) was maintained using automated computerized titration of an insulin infusion. The primary outcome of interest was any episode of severe hypoglycemia (≤ 40 mg/dl). Multivariate logistic regression was used to determine the independent predictors of developing severe hypoglycemia. RESULTS: A total of 60,298 data entries (1,118 patients) for glucose were analyzed. There were 64 severe hypoglycemic episodes in 52 patients (4.6% of the patients). There was a significant increase in deaths among patients who experienced at least one episode of hypoglycemia when compared with those who did not (26.9% vs. 15.3%, P = 0.03). Logistic regression revealed that the time spent on the protocol was the best predictor of developing a hypoglycemic event when controlling for other known risk factors of hypoglycemia. CONCLUSIONS: Intensive insulin therapy can be implemented with a low percentage of patients (4.6%) experiencing severe hypoglycemia. Mortality rate was higher for patients experiencing hypoglycemia. The duration of the time spent on the protocol was the best predictor of hypoglycemia, suggesting that hypoglycemia is a mathematic probability of prolonged illness, not a reflection of illness severity or demographic features.