Making the financial case for a surgeon-directed critical care ultrasound program.

BACKGROUND: We sought to demonstrate that a well-staffed, surgeon-directed, critical care ultrasound program (CCUP) is financially sustainable and provides administrative and educational support for point-of-care ultrasound. METHODS: The CCUP provides a clinical service and training as well as conducts research. Initial costs, annual costs (C), revenue (R), and savings (S) were prospectively recorded. Using data from the first 3 years, we calculated the projected C, R, and S at 5 years. We determined CCUP sustainability by C < R and C < R + S at 3 years and 5 years. RESULTS: During 36 months, the CCUP covered four surgical intensive care units (55 beds). Start-up costs included one basic and one cardiovascular device per 25 beds and a data storage system linking reports and images to the electronic medical record ($203,650). Billing increased threefold from Years 1 to 3, with a 21% increase between Years 2 to 3. Yearly costs included 0.5 full-time equivalent (FTE) sonographer and 0.2 FTE surgeon ($106,025); this was increased to 1 FTE and 0.25 FTE, respectively, for Years 4 and 5. The total 3-year cost was $521,725 and projected to be $863,325 by Year 5. The total 3-year revenue was $290,775 and projected to be $891,600 at 5 years. The total 3-year savings associated with the CCUP was $600,035 and is projected to be $1,194,220. With the use of the C < R, the CCUP meets operating expenses at Year 3 and covers overall cost at 5 years. If savings are included, then the CCUP is sustainable by its third year and is potentially profitable by Year 5. CONCLUSION: A surgeon-directed CCUP is financially sustainable, addresses administrative issues, and provides valuable training in point-of-care ultrasound.

Blunt hollow viscus and mesenteric injury: still underrecognized.

BACKGROUND: Despite the availability of more accurate imaging modalities, specifically multidetector computed tomography (MDCT), the diagnosis of non-ischemic (NI-) and ischemic (I-) blunt hollow viscus and mesenteric injury (BHVMI) remains challenging. We hypothesized that BHVMI can be still missed with newer generations of MDCT and that patients with I-BHVMI have a poorer outcome than those with NI-BHVMI. METHODS: We performed an eight-year retrospective review at a level 1 trauma center. Ischemic-BHVMI was defined as devascularization confirmed at laparotomy. Non-ischemic-BHVMI included perforation, laceration, and hematoma without devascularization. The sensitivity of each generation of MDCT for BHVMI was calculated. Potential predictors and outcomes of I-BHVMI were compared to the NI-BHVMI group. RESULTS: Of 7,875 blunt trauma patients, 67 patients (0.8 %) were included in the BHVMI group; 13 patients did not have any CT findings suggestive of BHVMI (sensitivity 81 %), and 11 of them underwent surgical intervention without delay (<5 h). Newer generations of MDCT were not associated with higher sensitivity. Patients with I-BHVMI had a significantly higher rate of delayed laparotomy ≥ 12 h (23 % versus 2 %; p = 0.01) and a significantly longer length of hospital stay (median 14 versus 9 days; p = 0.02) than those with NI-BHVMI. CONCLUSIONS: Even using an advanced imaging technique, the diagnosis of I-BHVMI can be delayed, with significant negative impact on patient outcome.

A survey of critical care training amongst surgical residents: will they be ready?

BACKGROUND: Residents' duty-hour limitations and the trends towards closed-staffing for surgical critical care (SCC) have reshaped educational paradigms. No study has yet addressed the impact of these changes on resident SCC training. In our study, we investigated residents' experiences and perceptions of SCC education and practice. METHODS: At the end of the academic year 2007-2008, we distributed anonymous surveys to categorical general surgery residents in a large, university-based residency. All dedicated SCC rotations are currently completed by the end of PGY3. The survey measured residents' ratings of teaching, experiences, satisfaction, and self-assessed comfort with common SCC diseases and procedures. RESULTS: The response rate was 78% (n = 52/67). At the time of the survey, the 52 respondents had completed 9.3 +/- 4.5 wk of SCC rotations. Despite no rotations beyond PGY3, senior residents (PGYs 4/5) reported significantly greater SCC training time (13.1 versus 7.8 wk) and comfort managing SCC diseases and procedures than juniors (PGY 3). Attendings were rated the most effective didactic teachers, and senior residents the most effective procedural teachers. The mean education satisfaction score was 3.9 +/- 0.9 (5 = extremely satisfied). Residents anticipated performing minimal SCC management of their own patients, but most felt that SCC-trained surgeons should manage critically ill surgery patients. Seniors reported greater SCC fellowship interest (19% versus 0%). The addition of acute care surgery increased interest in 30% of respondents. CONCLUSIONS: Senior residents reported greater comfort with SCC management despite the lack of senior SCC rotations, whilst dedicated training time for junior residents appears to be declining. Residents wish subspecialist care for their critically ill patients, but the low interest in SCC fellowships suggests future physician shortages in this subspecialty.

Characterization of the gender dimorphism after injury and hemorrhagic shock: are hormonal differences responsible?

OBJECTIVE: To characterize the gender dimorphism after injury with specific reference to the reproductive age of the women (young, <48 yrs of age, vs. old, >52 yrs of age) in a cohort of severely injured trauma patients for which significant variation in postinjury care is minimized. DESIGN: Secondary data analysis of an ongoing prospective multicenter cohort study. SETTING: Academic, level I trauma and intensive care unit centers. PATIENTS: Blunt-injured adults with hemorrhagic shock. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Separate Cox proportional hazard regression models were formulated based on all patients to evaluate the effects of gender on mortality, multiple organ failure, and nosocomial infection, after controlling for all important confounders. These models were then used to characterize the effect of gender in young and old age groups. Overall mortality, multiple organ failure, and nosocomial infection rates for the entire cohort (n = 1,036) were 20%, 40%, and 45%, respectively. Mean Injury Severity Score was 32 +/- 14 (mean +/- SD). Men (n = 680) and women (n = 356) were clinically similar except that men required higher crystalloid volumes, more often had a history of alcoholism and liver disease, and had greater ventilatory and intensive care unit requirements. Female gender was independently associated with a 43% and 23% lower risk of multiple organ failure and nosocomial infection, respectively. Gender remained an independent risk factor in young and old subgroup analysis, with the protection afforded by female gender remaining unchanged. CONCLUSIONS: The independent protective effect of female gender on multiple organ failure and nosocomial infection rates remains significant in both premenopausal and postmenopausal women when compared with similarly aged men. This is contrary to previous experimental studies and the known physiologic sex hormone changes that occur after menopause in women. These results suggest that factors other than sex hormones may be responsible for gender-based differences after injury.

Male gender is associated with excessive IL-6 expression following severe injury.

OBJECTIVE: An important and persistent laboratory finding has been that males and females respond differently after traumatic injury and hemorrhagic shock. We have previously presented clinical data showing that male gender is independently associated with a 40% higher rate of multiple organ failure (MOF) and a 25% higher rate of nosocomial infection (NI) after injury; however, the mechanism responsible for this dimorphic response after injury has not been adequately characterized clinically. METHODS: Data were obtained from a multicenter prospective cohort study evaluating clinical outcomes in severely injured adults with blunt hemorrhagic shock. Proteomic analysis of serum inflammatory cytokines, on days 0, 1, and 4 postinjury, was performed on 46 males and 34 females. Repeated measures ANOVA were used to compare serial IL-1beta, TNF-alpha, IL-6, IL-8, and IL-10 serum levels across gender, while controlling for important confounders. Logistic regression modeling was then used to analyze the independent risk of MOF and NI associated with gender. RESULTS: IL-6 serum levels were statistically higher in males relative to females (p = 0.008). This higher level of IL-6 expression in males remained statistically significant over time even after controlling for differences in age, initial base deficit, ISS, and 12-hour blood transfusion requirements (p = 0.025). No differences in IL-1beta serum levels (p = 0.543), TNF-alpha, (p = 0.200) IL-8 (p = 0.107), and IL-10 (p = 0.157) were found. Males had a higher crude incidence of MOF and an 11-fold higher independent risk of MOF. CONCLUSIONS: Persistently elevated IL-6 levels in males are associated with a higher rate of MOF. It is not known if this excessive IL-6 expression in males is causal or only a marker for poor outcome. Further studies are required to elucidate if this early, persistent IL-6 expression is responsible for the gender-based differential outcomes after injury.

Increased risk of death associated with hypotension is not altered by the presence of brain injury in pediatric trauma patients.

BACKGROUND: Hypotension is a well-known predictor of mortality in pediatric trauma patients. However, it is unknown whether the mortality rate is higher in patients with traumatic brain injury (TBI) than in those without TBI. We hypothesized that systemic hypotension increases mortality in pediatric patients with TBI more than it does in pediatric patients with extracranial injuries only. METHODS: Multivariate logistic regression was used to determine the relationship between hypotension and the risk of death. Patients were then divided into 2 groups: TBI and No-TBI and the model was applied separately to each group. RESULTS: Overall mortality was 2%. After adjusting for confounding variables, hypotension remained a strong independent predictor of mortality. However, the increased risk of death was similar in patients with and without TBI. CONCLUSION: Hypotension is an important predictor of death in pediatric trauma patients. The increased risk of death associated with hypotension is similar with or without traumatic brain injury.

The status of ultrasonography training and use in general surgery residency programs.

BACKGROUND: Effective use of ultrasonography (US) by surgeons was demonstrated a decade ago. Major surgical organizations now require its incorporation into surgical training and practice. But little information about the teaching of US to surgical residents exists. This study assesses the current status of US training in general surgery residency programs. STUDY DESIGN: A survey was mailed to the directors of 255 Accreditation Council for Graduate Medical Education-accredited general surgery residency programs. It questioned whether and how US was taught, who performed the examinations, and the types of US performed. Data were analyzed using chi-square tests comparing university versus community programs and training and practice in trauma US versus training in other US modalities. RESULTS: The response rate was 51% (130 of 255). Ninety-six percent of the programs responding taught US, with no differences between university- and community-based training programs in presence of training. Focused Assessment for the Sonography of Trauma (FAST) instruction was done by 79% (hands-on) and 68% (didactic) of programs that responded. Abdominal, laparoscopic, breast, endocrine, and vascular US were each taught less frequently (22% to 55%). Program directors at university programs reported that their attending surgeons performed FAST and abdominal US more often than their community counterparts (71% and 31% versus 47% and 14%). Program directors reported that university trainees performed laparoscopic, endocrine, and vascular US more often than community surgery residents (47%, 17%, 35% versus 29%, 3%, 19%). Program directors reported that surgery attendings or residents performed trauma and laparoscopic US more often than their radiology counterparts, and radiology attendings or residents performed more abdominal, breast, endocrine, and vascular US. CONCLUSIONS: The majority of general surgery residency programs whose directors responded to this survey are teaching US, but most of the training is in FAST. There is no difference in the reported presence of overall US training between university and community programs. But university programs report that their surgeons or residents performed more US in all areas (other than breast) than their community counterparts reported.

Are resident work-hour limitations beneficial to the trauma profession?

In July 2003, work-hour restrictions were implemented by the Accreditation Council for Graduate Medical Education (ACGME) to limit resident duty hours. Attending surgeon work-hours have not been similarly reduced, and many trauma services have added emergency general surgery responsibilities. We hypothesized that trauma attending/resident work-hour disparity may disincentivize residents from selecting trauma careers and that trauma directors would view ACGME regulations negatively. We conducted a 6-month study of resident and in-house trauma attending self-reported hours at a level I trauma center and sent a questionnaire to 172 national level I trauma directors (TDs) regarding work-hours restrictions. TD survey response rate was 48 per cent; 100 per cent of 15 residents and 6 trauma faculty completed work-hour logs. Attending mean hours (87.1/ wk), monthly calls (5), and shifts > 30 hours exceeded that of all resident groups. Case volume was similar. Residents viewed their lifestyle more favorably than the lifestyle of the trauma attending (Likert score 3.6 +/- 0.5 vs Likert score 2.5 +/- 0.8, P = 0.0003). Seventy-one per cent cited attending work hours and lifestyle as a reason not to pursue a trauma career. Nationally, 80 per cent of trauma surgeons cover emergency general surgery; 40 per cent work greater than 80 hours weekly, compared with < 1 per cent of surgical trainees (P < 0.0001). Most TDs feel that residents do not spend more time reading (89%) or operating (96%); 68 per cent feel patient care has suffered as a result of duty-hours restrictions. Seventy-one per cent feel residents will not select trauma surgery as a career as a result of changes in duty hours. Perceived trauma attending/ resident work-hour disparity may disincentive trainees from trauma career selection. TDs view resident duty-hour restrictions negatively.