Cost Effectiveness of a Fast-Track Protocol for Urgent Laparoscopic Cholecystectomies and Appendectomies.

BACKGROUND: Fast-track protocols (FTPs) are used to decrease length of stay (LOS) and hospital costs for elective outpatient procedures. Few institutions have implemented FTP for urgent procedures such as laparoscopic cholecystectomy (LC) and laparoscopic appendectomy (LA). STUDY DESIGN: This is a retrospective single-institution cohort study including all patients undergoing urgent LC or LA between July 1, 2010 and May 1, 2013. Exclusion criteria included conversion to open procedure, perforated appendicitis, or procedure related to intra-abdominal injury. Analysis included a comparison of the three study groups: (1) before (PRE) and after (POST) implementation of the fast-track protocol (FTP), (2) fast-track cohort (FT) and non-fast-track cohort (NFT), and (3) those completing the fast-track pathway (FT-C) and those who began but failed to complete the pathway (FT-F). RESULTS: There were significant reductions in LOS between all study groups compared: between PRE (n = 256) and POST (n = 472) cohorts by half a day (2.0 vs. 1.5 days, p < 0.02); between FT and NFT (0.68 vs. 1.82 days, p < 0.01); and FT-C and FT-F (0.49 vs. 1.05 days, p < 0.01). Total hospital charges were significantly reduced in FT compared with NFT ($22,347 vs. $30,868, p < 0.01) with an average savings of $8521. Total hospital charges were decreased in the FT-C compared with FT-F cohorts ($21,971 vs. $22,939, p = 0.3) with an average savings of $968. Readmissions, complications, and satisfaction were similar for all comparison groups. CONCLUSIONS: FTPs for urgent appendectomies and cholecystectomies can significantly reduce hospital costs by reducing LOS without compromising patient outcomes.

A multi-institutional study of the Family Conference Objective Structured Clinical Exam: a reliable assessment of professional communication.

BACKGROUND: To test the value of a simulated Family Conference Objective Structured Clinical Exam (OSCE) for resident assessment purposes, we examined the generalizability and construct validity of its scores in a multi-institutional study. METHODS: Thirty-four first-year (PG1) and 27 third-year (PG3) surgery residents (n = 61) from 6 training programs were tested. The OSCE consisted of 2 cases (End-of-Life [EOL] and Disclosure of Complications [DOC]). At each program, 2 clinicians and 2 standardized family members rated residents using case-specific tools. Performance was measured as the percentage of possible score obtained. We examined the generalizability of scores for each case separately. To assess construct validity, we compared PG1 with PG3 performance using repeated measures multivariate analysis of variance (MANOVA). RESULTS: The relative G-coefficient for EOL was .890. For DOC, the relative G-coefficient was .716. There were no significant performance differences between PG1 and PG3 residents. CONCLUSIONS: This OSCE provides reliable assessments suitable for formative evaluation of residents' interpersonal communication skills and professionalism.

Putting a price on education: hours and dollars for a general surgery curriculum.

BACKGROUND: In 2005, a new curricular model was implemented for general surgery residents and a Division of Education created for administrative support. These changes forced an evaluation of available resources to maintain a new curricular model. METHODS: A retrospective review of resources expended during curricular sessions (June 2007-June 2008) provided to 42 surgical residents was conducted. Resources were evaluated in terms of the number, division, department, and rank of faculty involved. Contact hours and monetary costs were calculated. RESULTS: Total numbers of faculty involved in the postgraduate year (PGY)1, PGY2, and PGY3-5 curriculums were 79, 39, and 22, respectively. Faculty teaching time was 321 hours (PGY1), 187 hours (PGY2) and 36 hours (PGY3-5) for a combined 544 hours. Average teaching time commitment for faculty in the Division of Education was 26.5 hours, compared with 6.7 hours for departmental faculty in other divisions (P = .0002). Total monetary cost was $219,254. CONCLUSIONS: The cost to maintain an educational general surgery curriculum is substantial and administrative support must be considered. Faculty with an explicit teaching commitment and responsibility are needed.

The Surgical Learning and Instructional Portfolio (SLIP) as a self-assessment educational tool demonstrating practice-based learning.

PURPOSE: Time constraints on the teaching and evaluation of residents continue to alter the way in which medical knowledge must be imparted and assessed. Lifelong learning is a component of the practice-based learning competency. A portfolio is one way to assess practice-based learning, but its use is unfamiliar to most surgical programs. The authors describe the evolution of the Surgical Learning and Instructional Portfolio (SLIP) into a worthwhile educational tool. METHODS: In March 2001, the authors began a program to encourage residents to develop a case-based portfolio to document their experience and demonstrate acquisition of knowledge in caring for a variety of surgical diseases. The monthly case topic was chosen by the resident and reported using a template: case history, supporting diagnostic studies, differential diagnosis, final diagnosis with ICD-9 coding, management options, treatment used, 3 lessons learned, embellishment of 1 lesson, and 2 articles supporting the experience. Initially, cases were submitted to the program coordinator and reviewed every 6 months with a faculty advisor to provide feedback. RESULTS: After the first 18 months of this program, resident compliance was less than 50%, satisfaction was low, and formal review did not occur. In July 2004, a single faculty member became responsible for evaluating and providing feedback on the monthly SLIPs. The assignments were handled electronically with feedback delivered within the month via e-mail. SLIP quality as measured by resident compliance and satisfaction improved. CONCLUSION: These SLIPs have matured into a valuable educational tool satisfying multiple ACGME competencies. This portfolio system required direct faculty feedback to become successful.