Palliative Care Training During Surgical Critical Care Fellowship: A Preliminary Needs Assessment at a Major Academic Center.

Surgical palliative care (PC) facilitates communication between surgeons and patients/family about prognosis, symptom control, and therapeutic goals. Surgical critical care (SCC) fellows are at the forefront of the intensive care team; thus, we aim to assess previous and ongoing experiences in delivering PC by surveying fellows at a large academic center. Seventeen surveys were completed in which 59% of fellows reported no previous PC education. Six fellows (35%) reported participating in goals of care/end-of-life (GOC/EOL) discussions "a few times a year" during residency, while 41% responded the same for transitioning patients to comfort-focused care (CFC). When asked if respondents felt comfortable facilitating GOC/EOL discussions prior to fellowship, 7 (41%) answered "disagree" or "strongly disagree." Most fellows reported that more training in navigating GOC/EOL discussions (88%) and transitioning patients to CFC (76%) is needed. This assessment demonstrates variability in fellows' prior PC exposure and a strong desire for more structured training.

Association of Gender and Operative Feedback Quality in Surgical Residents.

OBJECTIVE: Feedback is critical for learning, however, gender differences exist in the quality of feedback that trainees receive. For example, narrative feedback on surgical trainees' end-of-block rotations differs based on trainee-faculty gender dyads, with female faculty giving higher quality feedback and male trainees receiving higher quality feedback. Though this represents evidence of gender bias in global evaluations, there is limited understanding of how much bias might be present in operative workplace-based assessments (WBAs). In this study, we explore the quality of narrative feedback among trainee-faculty gender dyads in an operative WBA. DESIGN: A previously validated natural language processing model was used to examine instances of narrative feedback and assign a probability of being characterized as high quality feedback (defined as feedback which was relevant as well as corrective and/or specific). A linear mixed model was performed, with probability of high quality feedback as the outcome, and resident gender, faculty gender, PGY, case complexity, autonomy rating, and operative performance rating as explanatory variables. PARTICIPANTS: Analyses included 67,434 SIMPL operative performance evaluations (2,319 general surgery residents, 70 institutions) collected from September 2015 through September 2021. RESULTS: Of 36.3% evaluations included narrative feedback. Male faculty were more likely to provide narrative feedback compared to female faculty. Mean probabilities of receiving high quality feedback ranged from 81.6 (female faculty-male resident) to 84.7 (male faculty-female resident). Model-based results demonstrated that female residents were more likely to receive high quality feedback (p < 0.01), however, there was no significant difference in probability of high quality narrative feedback based on faculty-resident gender dyad (p = 0.77). CONCLUSIONS: Our study revealed resident gender differences in the probability of receiving high-quality narrative feedback following a general surgery operation. However, we found no significant differences based on faculty-resident gender dyad. Male faculty were more likely to provide narrative feedback compared to their female colleagues. Further research using general surgery resident-specific feedback quality models may be warranted.

Bringing Back the Art of Medicine to Surgery.

In a relatively short period of time, the need for incorporating primary surgical palliative care into surgical education and residency curriculum has become apparent. This provides an opportunity for growth for surgeons and surgical residents and a method to explore spirituality and wholeness of the patient. It also has the potential for increasing the sense of fulfillment that residents and surgeons alike can drive from caring for complex surgical patients. Given the significant constraints of today's graduate medical education world, there remain challenges that must be overcome when designing curricula and incorporating surgical palliative care into practice and resident education. The Surgical Palliative Care Society brings hope for the future of this specialty and encourages multidisciplinary discussions about the practice of, education in, and research on surgical palliative care.

Optimal timing and outcomes among COVID-19 patients undergoing tracheostomy.

BACKGROUND: Patients who require mechanical ventilation secondary to severe COVID-19 infection have poor survival. It is unknown if the benefit of tracheostomy extends to COVID-19 patients. If so, what is the optimal timing? METHODS: Retrospective cohort study within a large hospital system in the United States. The population included patients with COVID-19 from January 1, 2020 to September 30, 2020. In total, 93,918 cases were identified. They were excluded if no intubation or tracheostomy, underwent tracheostomy before intubation, <18 years old, hospice patients before admission, and bacterial pneumonia. In total, 5,911 patients met the criteria. Outcomes between patients who underwent endotracheal intubation only versus tracheostomy were compared. The primary outcome was inpatient mortality. All patients who underwent tracheostomy versus intubation only were compared. Three cohort analysis compared early (<10 days) versus late (>10 days) tracheostomy versus control. Eight cohort analysis compared days 0-2, days 3-6, days 7-10, days 11-14, days 15-18, days 19-22, and days 23+ to tracheostomy versus control. RESULTS: There was an overall inpatient mortality rate of 37.5% in the tracheostomy cohort compared to 54.4% in the control group (P < .0001). There was an early tracheostomy group inpatient mortality rate of 44.7% (adjusted odds ratio 0.73, 95% confidence interval 0.52-1.01) compared to 33.1% (adjusted odds ratio 0.44, 95% confidence interval 0.34-0.58) in the late tracheostomy group. CONCLUSION: COVID-19 patients with tracheostomy had a significantly lower mortality rate compared to intubated only. Optimal timing for tracheostomy placement for COVID-19 patients is 11 days or later. Future studies should focus on early tracheostomy patients.

Practice Patterns of Transesophageal Echocardiography Use Among Trauma Patients: A Multi-Institutional Retrospective Study.

Transesophageal echocardiography (TEE) can be utilized for hemodynamic monitoring and resuscitation. In order to study the pattern of TEE use in trauma patients, a multi-institutional retrospective cohort study was performed comparing adult trauma patients who underwent TEE or those who underwent traditional invasive hemodynamic monitoring (TIHM). TIHM was defined as the use of arterial line, central venous line, or pulmonary artery catheter without TEE. Mortality rates were obtained and multivariable logistic regression was used to risk adjust for age, gender, race, insurance status, Glasgow coma scale (GCS), ICD Injury severity score (ICISS). Compared to TIHM group, more patients in TEE group had a history of congestive heart failure (CHF) or chronic pulmonary disease (CPD). Mortality rate was lower in the TEE group 7 versus 23% (P-value < .0001). After adjusting for GCS and ICISS in multivariable analysis, inpatient mortality was significantly lower in the TEE cohort.

The Morbidity and Mortality Assessment Tool (MMAT): Design and Proof of Concept.

BACKGROUND: Morbidity and Mortality Conference (MMC) is a traditional quality assessment tool among surgical residencies to evaluate complications within their care and to integrate and educate best practices. Unfortunately, it is difficult to validate and measure loop closure as a result of MMC. This may result in repeating past mistakes or worse, becoming a meeting of anecdotal experiences. The goal of this study is to present results from a morbidity and mortality assessment tool (MMAT) which provides a means of measuring and tracking factors related to those surgical complications discussed within the MMC. MATERIALS AND METHODS: Three years of MMC presentations were organized into a database and further divided and organized into variables which included case by the class year of the presenting resident, service line, month the case was presented, and potential contributing factors. Contributing factors considered for each case were categorized as: Systems-Based, Direct Patient Care, and Interpersonal Communication. Contributing factors were assigned to cases by a review committee consisting of residents and faculty members. RESULTS: The lack of knowledge, technical error, lack of experience, lack of supervision, failure to communicate with team members were present in greater than 10% of the presented cases. There was a "July Effect" in the Trauma service, where there was a statistically significant difference between the percentage of cases presented that involved Failure to Communicate errors when compared with the remainder of the year. CONCLUSIONS: MMAT allows longitudinal collection of data from each MMC to recognize patterns that facilitate improvements in systems of care and institutional memory.

Development and validation of a bladder trabeculation grading system in pediatric neurogenic bladder.

Bladder trabeculation (BT) is commonly noted on cystogram images of patients with neurogenic bladder (NB). BT is associated with a hostile bladder often requiring prompt, more aggressive management. We aimed to define and validate a reliable grading system for BT severity. The proposed grading system will improve clinicians and radiologist's communication and serve as a foundation for future studies in the field of NB. The study was conducted in two phases: 1) Development of a grading system for BT and 2) testing of the proposed grading system for reliability and validity. Agreement between raters was assessed using Cohen's Kappa. Inter-rater reliability and intra-rater reliability was assessed using intra-class correlation coefficients (ICC) and Spearman's p (rho) correlation coefficient. The content of the grading system was assessed for face validity by senior pediatric urology and radiology experts. We observed inter-rater reliability with ICC of 0.998 (95%CI 0.996-0.999, p < 0.001), and a Cohen's Kappa ranging from 0.795 to 1.0, p < 0.001 and Spearman's p (rho) correlation coefficient ranging from 0.910 to 1.0, p < 0.001 between raters on the decided grades of BT. In conclusion, we established a defined grading system for BT severity that has substantial inter/intra-rater reliability and validity. This grading system could be useful for improving clinician and radiologist's communication about the status of a child's bladder wall and serve as a foundation for future studies assessing severity of NB.

Face, Content, and Construct Validations of Endoscopic Needle Injection Simulator for Transurethral Bulking Agent in Treatment of Stress Urinary Incontinence.

INTRODUCTION AND OBJECTIVES: Endoscopic injection of urethral bulking agents is an office procedure that is used to treat stress urinary incontinence secondary to internal sphincteric deficiency. Validation studies important part of simulator evaluation and is considered important step to establish the effectiveness of simulation-based training. The endoscopic needle injection (ENI) simulator has not been formally validated, although it has been used widely at University of California, Irvine. We aimed to assess the face, content, and construct validity of the UC, Irvine ENI simulator. METHODS: Dissected female porcine bladders were mounted in a modified Hysteroscopy Diagnostic Trainer. Using routine endoscopic equipment for this procedure with video monitoring, 6 urologists (experts group) and 6 urology trainee (novice group) completed urethral bulking agents injections on a total of 12 bladders using ENI simulator. Face and content validities were assessed by using structured quantitative survey which rating the realism. Construct validity was assessed by comparing the performance, time of the procedure, and the occlusive (anatomical and functional) evaluations between the experts and novices. Trainees also completed a postprocedure feedback survey. Effective injections were evaluated by measuring the retrograde urethral opening pressure, visual cystoscopic coaptation, and postprocedure gross anatomic examination. RESULTS: All 12 participants felt the simulator was a good training tool and should be used as essential part of urology training (face validity). ENI simulator showed good face and content validity with average score varies between the experts and the novices was 3.9/5 and 3.8/5, respectively. Content validity evaluation showed that most aspects of the simulator were adequately realistic (mean Likert scores 3.9-3.8/5). However, the bladder does not bleed, and sometimes thin. Experts significantly outperformed novices (p < 001) across all measure of performance therefore establishing construct validity. CONCLUSION: The ENI simulator shows face, content and construct validities, although few aspects of simulator were not very realistic (e.g., bleeding).This study provides a base for the future formal validation for this simulator and for continuing use of this simulator in endourology training.

Endoscopic correction of vesicoureteral reflux simulator curriculum as an effective teaching tool: Pilot study.

INTRODUCTION: It has been well recognized that simulators are effective tools to teach and evaluate technical skills in laparoscopic surgery. Endoscopic injection for the correction of vesicourteral reflux has a definite learning curve. Surgeon experience has also been demonstrated to have an important role in the outcome of the procedure. Simulated training allows for practice in a realistic setting without the inherent risk of harm to the patient. This stress free environment allows the trainee to focus on the acquisition of surgical skills without worry about surgical outcome. OBJECTIVE: The aim was to validate a porcine bladder simulator curriculum for training and assessment of the surgical skills for the endoscopic correction of vesicoureteral reflux. STUDY DESIGN: We developed a porcine bladder-based dextranomer/hyaluronic acid (Dx/HA) injection simulator consisting of a dissected ex vivo porcine bladder in a polystyrene box with the distal ureters and urethra secured (Figure). We performed content validation by five experienced pediatric urologists. We then organized a simulator curriculum, which included lecture, demonstration, and a 2-h hands-on training on the simulator. Content, discriminant, and concurrent validation of the simulator curriculum were carried out using 11 urology trainees at different levels of expertise. All the trainees were evaluated for each step of the procedure of both their first and last performances on the simulator. RESULTS: Overall, the model demonstrated good content validity by all experts (mean questionnaire score 92%). The simulator curriculum demonstrated a significant improvement in the performance of the trainees between their first and last evaluations (56-92%; p = 0.008). Specific parts of the procedure that showed significant improvement (p < 0.05) were identification of the ureteral orifice, ureteral orifice hydrodistention, first and second injection, and location, size, and depth of the mound after injection. DISCUSSION: The Dx/HA endoscopic injection simulator is an effective training tool to improve the performance of the surgeon carrying out the procedure. This teaching tool may be used to help improve the performance of the surgeon carrying out the procedure. This teaching curriculum may shorten the early learning curve historically associated with the procedure and provide a greater understanding of the technical components of successful endoscopic vesicoureteral reflux correction. Additionally, the implementation of this simulator within the developed curriculum can improve the performance of training urologists in all steps of the challenging technique of Dx/HA needle injection confirming concurrent validity. The next step in evaluation of this surgical skill-training curriculum would be to determine if the improvement in skill performance observed during training translates to improved performance in the clinical realm, or predictive validity. LIMITATIONS: Some small differences exist between the porcine model and human ureteral orifices. In the porcine model the ureteral orifices are located medially and distally in the bladder neck, which make injection more challenging. Participants suggested that after practicing with the simulator endoscopic injection to a human ureteral orifice would be easier. CONCLUSION: The simulator curriculum was able to improve the performance of the surgeon carrying out the procedure during subsequent simulations.

Primary vesico-ureteric reflux: The need for individualised risk stratification.

The management of paediatric primary vesico-ureteric reflux (VUR) has undergone serial changes over the last decade. As this disorder is extremely heterogeneous, and high-quality prospective data are limited, the treatment strategies vary among centres. Current treatment options include observation only, continuous antibiotic prophylaxis, and surgery. Surgical intervention is indicated if a child has a breakthrough urinary tract infection (UTI) while on continuous antibiotic prophylaxis or if there are renal scars present. After excluding a secondary cause of VUR the physician should consider the risk factors affecting the severity of VUR and manage the child accordingly. Those factors include demographic factors (age at presentation, gender, ethnicity) and clinical factors (VUR grade, unilateral vs. bilateral, presence of renal scars, initial presentation, the number of UTIs, and presence of any voiding or bowel dysfunction). In this review we summarise the major controversial issues in current reports on VUR and highlight the importance of individualised patient management according to their risk stratification.

Is the appearance of the dextranomer/hyaluronic acid mound predictive of reflux resolution?

PURPOSE: After endoscopic correction of vesicoureteral reflux, we correlated the appearance of the Deflux® mound with the outcome. MATERIAL AND METHODS: We created an online survey based on 11 primary vesicoureteral reflux cases, including 6 failed and 9 successful procedures in a total of 15 renal units. Cases were selected randomly from our video library. All cases were performed by a single surgeon using the double hydrodistention implantation technique until a satisfactory mound was achieved and corrected. An online survey questionnaire was e-mailed to 234 members of the Society for Pediatric Urology. Each survey question contained a preoperative voiding cystourethrogram image as well as images of the ureteral orifice before and after injection. Respondents were asked to predict whether they thought that the appearance of the Deflux mound would be associated with successful reflux resolution on voiding cystourethrogram 3 months postoperatively. We analyzed the percent of correctly answered questions as well as the sensitivity, specificity and predictive value of the ability of experts to predict the outcome. RESULTS: A total of 104 pediatric urologists responded to the survey. Overall, 66.4% of respondents predicted reflux resolution based on mound appearance, including 66% and 67% who correctly predicted success and failure, respectively. Mean outcome predictability per respondent was 66% (range 26% to 86%). CONCLUSIONS: The appearance of the Deflux mound and lack of hydrodistention at the completion of the procedure are not reliable predictors of outcome. Based on this experience, postoperative voiding cystourethrogram is still required to truly determine reflux resolution.