Increasing the Rate of Venous Thromboembolism Chemoprophylaxis Administration Using the Electronic Medical Record.

Introduction: Venous thromboembolism (VTE) remains a leading cause of preventable harm among hospitalized patients. Pharmacologic VTE prophylaxis reduces the rate of in-hospital VTE by 60%, but medication administration is often missed for various reasons. Electronic medical record (EMR) prompts may be a useful tool to decrease withholding of critical VTE chemoprophylaxis medications. Methods: In August 2021, an EMR prompt was implemented at a tertiary referral academic medical center mandating nursing staff to contact a provider for approval before withholding VTE chemoprophylaxis. A pre-intervention group from August 2020 to August 2021 was compared to a post-intervention group from August 2021 to August 2022. Rates of VTE chemoprophylaxis withholding were compared between the groups with a P < .01 considered significant. Results: A total of 16,395 patients prescribed VTE chemoprophylaxis were reviewed, with 13,395 (81.7%) receiving low molecular weight heparin. Of the 16,395 patients included, 10,701 (65.3%) were medical and 5694 (34.7%) were surgical. Patients in the pre-intervention cohort (n = 8803) and post-intervention cohort (n = 7592) were similar in hospital length of stay and duration of DVT prophylaxis. In the post-intervention group, the frequency of surgical patients with at least one missed dose had increased by 4.2% (P = .002), with the trauma and acute care surgery (TACS) show an increase of 6.6% (P < .001). However, the frequency of medical patients and non-TACS patients with missed doses decreased by 3.1% (P = .002) and 1.0% (<.001), respectively. Conclusions: EMR prompts appear to be a low-cost intervention that increases the rate of VTE prophylaxis administration among medical and elective surgery patients.

Implementation of a novel peer review academy by Surgery and the Association of Women Surgeons.

BACKGROUND: A novel Peer Review Academy was developed as a collaborative effort between the Association of Women Surgeons and the journal Surgery to provide formal training in peer review. We aimed to describe the outcomes of this initiative using a mixed methods approach. METHODS: We developed a year-long curriculum with monthly online didactic sessions. Women surgical trainee mentees were paired 1:1 with rotating women surgical faculty mentors for 3 formal peer review opportunities. We analyzed pre-course and post-course surveys to evaluate mentee perceptions of the academy and assessed changes in mentee review quality over time with blinded scoring of unedited reviews. Semi-structured interviews were conducted upon course completion. RESULTS: Ten women surgical faculty mentors and 10 women surgical trainees from across the United States and Canada successfully completed the Peer Review Academy. There were improvements in the mentees' confidence for all domains of peer review evaluated, including overall confidence in peer review, study novelty, study design, analytic approach, and review formatting (all, P ≤ .02). The mean score of peer review quality increased over time (59.2 ± 10.8 vs 76.5 ± 9.4; P = .02). In semi-structured interviews, important elements were emphasized across the Innovation, Implementation Process, and Individuals Domains, including the values of (1) a comprehensive approach to formal peer review education; (2) mentoring relationships between women faculty and resident surgeons; and (3) increasing diversity in the scientific peer review process. CONCLUSION: Our novel Peer Review Academy was feasible on a national scale, resulting in significant qualitative and quantitative improvements in women surgical trainee skillsets, and has the potential to grow and diversify the existing peer review pool.

Ultrasound may safely replace chest radiograph after tube thoracostomy removal in trauma patients.

INTRODUCTION: A chest radiograph (CXR) is routinely obtained in trauma patients following tube thoracostomy (TT) removal to assess for residual pneumothorax (PTX). New literature supports the deference of a radiograph after routine removal procedure. However, many surgeons have hesitated to adopt this practice due to concern for patient welfare and medicolegal implications. Ultrasound (US) is a portable imaging modality which may be performed rapidly, without radiation exposure, and at minimal cost. We hypothesized that transitioning from CXR to US following TT removal in trauma patients would prove safe and provide superior detection of residual PTX. MATERIALS AND METHODS: A practice management guideline was established calling for the performance of a CXR and bedside US 2 h after TT removal in all adult trauma patients diagnosed with PTX at a level 1 trauma center. Surgical interns completed a 30-minute, US training course utilizing a handheld US device. US findings were interpreted and documented by the surgical interns. CXRs were interpreted by staff radiologists blinded to US findings. Data was retrospectively collected and analyzed. RESULTS: Eighty-nine patients met inclusion criteria. Thirteen (15%) post removal PTX were identified on both US and CXR. An additional 11 (12%) PTX were identified on CXR, and 5 (6%) were identified via US, for a total of 29 PTX (33%). One patient required re-intervention; the recurrent PTX was detected by both US and CXR. For all patients, using CXR as the standard, US displayed a sensitivity of 54.2%, specificity of 92.3%, negative predictive value of 84.5%, and positive predictive value of 72.2%. The cost of care for the study cohort may have been reduced over $9,000 should US alone have been employed. CONCLUSION: Bedside US may be an acceptable alternative to CXR to assess for recurrent PTX following trauma TT removal.

Intraoperative Methadone Reduces Postoperative Opioid Requirements in Nuss Procedure for Pectus Excavatum.

INTRODUCTION: Surgical correction of pectus excavatum by Nuss procedure, commonly referred to as minimally invasive repair of pectus excavatum (MIRPE), often results in significant postoperative pain. This study investigated whether adding intraoperative methadone would reduce the postoperative opioid requirement during admission for patients undergoing MIRPE. METHODS: A retrospective cohort chart review was conducted for 40 MIRPE patients between 2018 and 2020. Patients were stratified into 2 groups: those who received multimodal anesthesia (MM, n = 20) and those who received multimodal anesthesia with the addition of intraoperative methadone (MM + M, n = 20). Data collected included total opioid consumption during hospital stay (morphine milligram equivalents [MMEs]), hospital length of stay (LOS), pain scores, time to ambulation, and time to tolerating solid food. RESULTS: Addition of intraoperative methadone for patients undergoing MIRPE significantly reduced postoperative opioid requirements (MME/kg) during admission (P = .007). On average, patients in the MM group received 1.61 ± .55 MME/kg while patients in the MM + M group received 1.16 ± .44 MME/kg. Hospital opioid (non-methadone) total was also significantly reduced between the MM (1.87 ± .54) and MM + M group (1.37 ± .46), P = .003. There was no significant difference in hospital opioid total MME/kg administered between the groups. There were no significant differences observed in hospital LOS, pain scores, time to ambulation, or time to toleration of solid food. DISCUSSION: Incorporating intraoperative methadone for patients undergoing MIRPE reduced postoperative opioid requirements and hospital opioid (non-methadone) totals without a significant change in pain scores. Patients undergoing the Nuss procedure may benefit from the administration of intraoperative methadone.

Prevention of alcohol withdrawal syndrome in the surgical ICU: an American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus Document.

Alcohol withdrawal syndrome is a common and challenging clinical entity present in trauma and surgical intensive care unit (ICU) patients. The screening tools, assessment strategies, and pharmacological methods for preventing alcohol withdrawal have significantly changed during the past 20 years. This Clinical Consensus Document created by the American Association for the Surgery of Trauma Critical Care Committee reviews the best practices for screening, monitoring, and prophylactic treatment of alcohol withdrawal in the surgical ICU.

Routine Lower Extremity Screening Ultrasound Protocols in Trauma Patients Are Not Cost Effective.

BACKGROUND: Despite prophylaxis, deep vein thrombosis (DVT) and pulmonary embolism remain dreaded complications following traumatic injury and are associated with significant morbidity and mortality. Screening ultrasound (US) protocols have been employed in trauma centers for early detection of lower extremity (LE) deep venous thrombosis. We hypothesized that screening lower extremity venous duplex US would not prove cost effective in our trauma population who receives early pharmacologic prophylaxis. METHODS: Data was collected for one year on all adult trauma patients admitted to the trauma service from December 2019 to 2020. DVT screening US was obtained at 3 days after admission for patients with long bone or pelvic fracture, spinal cord injury, immobility, and/or spinal fracture requiring surgery. Screening US was obtained at 7 days for all others and repeated weekly until discharge. Data was retrospectively collected and analyzed. RESULTS: Exactly 1365 patients met inclusion criteria with median ISS 12 (IQR, 9-17), median age 56 (IQR, 36-73 years), and with majority blunt injuries (90.7%). A total of 1369 screening US were performed finding 27 DVTs (2%). The total cost of screening for the year analyzed amounted to over $270,000 with 50.7 screening US needed to detect 1 DVT. This resulted in an average screening cost of over $10,000 for the detection of a single DVT. DISCUSSION: In trauma patients receiving early pharmacologic prophylaxis, routine LE screening US protocols to detect LE DVT are not cost effective.

Traumatic brain injury patients with platelet inhibition receiving platelet transfusion demonstrate decreased need for neurosurgical intervention and decreased mortality.

BACKGROUND: Platelet dysfunction is known to occur in patients with traumatic brain injury (TBI), and the correction of platelet dysfunction may prevent hemorrhagic progression in TBI. Thromboelastography with platelet mapping (TEG-PM; Haemonetics) evaluates the degree of platelet function inhibition through the adenosine diphosphate (ADP) and arachidonic acid (AA) pathways. We hypothesized that ADP and AA inhibition would improve with the transfusion of platelets in patients with TBI. METHODS: A retrospective review was conducted at a Level I trauma center of all patients presenting with TBI from December 2019 to December 2020. Per a practice management guideline, a platelet mapping assay was obtained on all patients with TBI upon admission. If ADP or AA was found to be inhibited (>60%), the patient was transfused 1 unit of platelets and a repeat platelet mapping assay was ordered. Demographic data, laboratory values, and outcomes were analyzed. RESULTS: Over the 13-month study period, 453 patients with TBI underwent TEG-PM with a protocol adherence rate of 66.5% resulting in a total of 147 patients who received platelets for ADP and/or AA inhibition; of those, 107 underwent repeat TEG-PM after platelets were administered. With the administration of platelets, ADP (p < 0.0001), AA (p < 0.0001), and MA (p = 0.0002) all significantly improved. Of 330 patients with TBI not taking antiplatelet medications, 50.9% showed inhibition in ADP and/or AA. If AA or ADP inhibition was noted on admission, mortality was increased (p = 0.0108). If ADP improved with platelet administration, the need for neurosurgical intervention was noted to decrease (p = 0.0182). CONCLUSION: Patients with TBI and platelet inhibition may benefit from the administration of platelets to correct platelet dysfunction. Thromboelastography with platelet mapping may be implemented in the initial workup of patients presenting with TBI to assess platelet dysfunction and provide prognostic information, which may guide treatment. LEVEL OF EVIDENCE: Therapeutic / Care Management, level III.