Statewide assessment of surgical outcomes and the acute care surgery model.

BACKGROUND: The acute care surgery (ACS) model has been widely implemented with single institution studies demonstrating improved outcomes. Recent multicenter studies have raised questions about the economics and efficacy of ACS. This study compares traditional and ACS outcomes across an entire state. METHODS: A retrospective review of Virginia's Health Information administrative database was completed. Adults admitted with appendicitis or cholecystitis between 2008 and 2014 were included. Hospital administration was contacted to determine surgical model. To compare patient characteristics, t-test and chi-square analyses were used. Total charges and length of stay (LOS) differences between ACS and traditional were examined using generalized linear models, whereas logistic regression was used for the presence of complications and 30-day mortality. RESULTS: Overall, the ACS model showed an increased proportion of uninsured patients with a higher rate of comorbidities. In the appendicitis subgroup, (n = 22,011; ACS n = 1993), ACS patients had higher total charges ($30,060 versus $28,460, P = 0.013), longer LOS (3.31 versus 2.92 d, P < 0.001), and higher chance of complications (odds ratio [OR] = 1.2, P = 0.016) and mortality (OR = 2.4, P = 0.029). After adjustment for comorbidities and insurance, mortality was no longer significantly different. In the cholecystitis group (n = 6936; ACS n = 777), ACS patients had a longer LOS (4.55 versus 4.13 d; P = 0.009) without significant differences in mortality, complications, or cost. There were no significant differences after adjustment for patient characteristics. CONCLUSIONS: ACS patients in Virginia have a higher rate of medical comorbidities and uninsured status, with slightly worse outcomes than the traditional model for appendicitis. Further studies to determine which patients benefit the most from ACS are warranted.

Type of Prior Operation Does Not Predict Surgical Intervention for Small Bowel Obstruction.

Background: Patients with prior abdominal surgeries are at higher risk for intra-abdominal adhesive tissue formation and subsequently higher risk for small bowel obstruction (SBO).Purpose: In this study, we investigated whether surgical intervention for SBO was more likely following specific types of abdominal surgeries.Research Design: With retrospective chart review, we pooled data from 799 patients, ages 18 to 89, admitted with SBO between 2012 and 2019. Patients were evaluated based on whether they underwent surgery or were managed conservatively. They were further compared with regard to past surgical history by way of type of abdominal surgery (or surgeries) undergone prior to admission.Results: Of the 799 patients admitted for SBO, 206 underwent surgical intervention while 593 were managed nonoperatively. There was no significant difference in number of prior surgeries (2.07 ± 1.56 vs 2.36 ± 2.11, P = .07) or in number of comorbidities (2.39 ± 1.97 vs 2.65 ± 1.93, P = .09) for surgical vs non-surgical intervention. Additionally, of the operations evaluated, no specific type of abdominal surgery predicted need for surgical intervention in the setting of SBO. However, for both surgical and non-surgical intervention following SBO, pelvic surgery was the most common type of prior abdominal surgery (45% vs 43%). There are significantly more female pelvic surgeries in both the operative (91.4% vs 8.6%, P < .0001) and nonoperative groups (89.9% vs 10.2%, P < .0001).Conclusion: Ultimately, no specific type of prior operation predicted the need for surgical intervention in the setting of SBO.

Indications for Readmission for Small Bowel Obstruction: A Comparison of Medical vs Surgical Service Admission.

Small bowel obstruction (SBO) impacts the health care system and patient quality of life. Previously, we evaluated differences between medical and surgical admissions in the management of SBO. This study investigates indications for readmission based on original admission to medical (MS) or surgical services (SS). A retrospective chart review was performed for 799 patients aged 18 to 89 admitted between 2012 and 2019 with a diagnosis of SBO. Patient characteristics examined included length of stay (LOS), prior abdominal operations, prior SBO, use of small bowel follow through imaging, operative intervention, mortality, and 30-day readmission. There was no difference in readmission rates in patients originally admitted to MS or SS (13.2% vs 12.7%, P = .86). Patients admitted to SS were more likely to be readmitted for recurrent SBO (39% vs 8.6%, P = .006). Patients admitted to MS were more likely to be readmitted for other reasons (73.9% v. 40.2%, P = .004). In the MS cohort, 30.4% (7 patients) had surgery during their initial admission for SBO, and none of those patients were readmitted for recurrent SBO (rSBO). In the SS cohort, 23% had surgery during their initial admission and 31.6% were readmitted for rSBO (P = .002). Patients admitted to SS were more likely to be readmitted for rSBO and to require surgery. Patients admitted to MS were more likely to be readmitted for other reasons. None of the MS patients who had surgery were readmitted for SBO. 31.6% of SS patients who had surgery were readmitted for SBO.

The incidence of benign and malignant neoplasia presenting as acute appendicitis.

Acute appendicitis remains the most common surgical emergency encountered by the general surgeon. It is most often secondary to lymphoid hyperplasia, however it can also result from obstruction of the appendiceal lumen by a mass. We sought to review our experience with neoplasia presenting as appendicitis. We retrospectively reviewed all patients admitted with the diagnosis of appendicitis to our Acute Care Surgery Service from July 1, 2007 to June 30, 2009. Patient demographics, duration of symptoms, lab findings, computed tomography findings, and pathology were all analyzed. Over the 2-year period, 141 patients underwent urgent appendectomy. Ten patients (7.1%) were diagnosed with neoplasia on final pathology, including four women and six men with a mean age of 46.9 years and mean duration of symptoms of 12.6 days. Final pathology revealed four colonic adenocarcinoma; three mucinous tumors; one carcinoid; one endometrioma; and one patient had a combination of a mucinous cystadenoma, a carcinoid tumor, and endometriosis of the appendix. Six patients had concurrent appendicitis. Colonic and appendiceal neoplasia are not unusual etiologies of appendicitis. These patients tend to present at an older age and with longer duration of symptoms.

The Glove Made from Love: A History of Surgical Attire.

The development of surgical attire is well documented in historical photographs and evolved in response to the changing understanding of aseptic and antiseptic techniques. Surgeons throughout time remained significantly opposed to changes in attire, and it was over a century that we evolved from wearing black frock coats to the current attire of today. Interestingly, surgical attire remains a source of controversy even today, with a recent argument regarding skull versus bouffant caps that was quite publicly debated.

Barriers to Colonoscopy in an Uninsured Patient Population-A Quality Improvement Project.

Colorectal cancer remains common, with the "80 per cent by 2018" initiative proposed by the National Colorectal Cancer Roundtable. This study was designed to examine obstacles for patients who did not receive their scheduled colonoscopy, focusing on the impact of insurance status. Retrospective chart review was carried out on patients who did not complete their colonoscopy as scheduled from January 2013 to June 2017. The control group consisted of patients who completed their scheduled colonoscopy. One hundred and seventy five patients missed 200 colonoscopies. The most common reasons for cancellation were patient illness (16%), no-show (14%), no prep carried out (13%), inadequate prep (10%), and no transportation (11%). The canceled patients were significantly more likely to have the combination of no insurance and no Primary Care Provider (PCP) (13% vs 4%, P = 0.008), personal history of cancer (22% vs 12%, P = 0.02), and higher rates of prior GI issues (78% vs 50%, P < 0.001). The canceled group had a significantly lower history of colon polyps (37% vs 53%, P = 0.006). Difficulty with the bowel prep in addition to lack of insurance and poverty likely does create a barrier, even in a system that has a safety net, atop other issues such as transportation and inability to miss work playing a role.

Insulin requirements in the intensive care unit in response to infection.

Infectious complications in the intensive care unit (ICU) are classically identified when an elevated temperature triggers obtaining cultures. Elevated temperature, however, is a nonspecific marker of infection and may occur well into the course of the infection. The goal of this study was to evaluate whether escalating insulin demands may serve as an earlier marker for infection. A retrospective review of a prospective database from a trauma ICU over a 6-month period was done for all patients who developed infection while in the ICU. All patients in the ICU are placed at admission on an intensive insulin protocol with target blood glucose levels between 80 and 110 mg/dL. Data were collected on infection, insulin needs, blood glucose levels, temperature, white blood cell count, and antibiotic use. Twenty-four infections were identified, with 16 pneumonias, four bloodstream infections, and four urinary tract infections. Twelve of the 24 patients had increasing insulin needs in the 3 days preceding their infection diagnosis, with nine of the 12 requiring continued escalation of insulin needs from preinfection Day 3 to 2 to 1 (D3, D2, D1). In five of the 12 patients, the escalation of insulin dose preceded the elevated temperature, and in three of the 12 patients, the escalation preceded elevation of the white blood cell count above 12. For all 24 patients, the average insulin dose increased steadily, from 1.8 U/hr on D3 preinfection to 2.5 U/hr D2 and 3.1 U/hr D1. Infection does seem to be preceded by escalating insulin demands in many patients. A prospective study to evaluate the value of increased insulin demand as a marker for developing infection is warranted.

Acute Diverticulitis Outcomes in the Acute Care Surgery Model.

BACKGROUND: The acute care surgery (ACS) model has been widely implemented, with single institution studies demonstrating improved outcomes but multicenter studies questioning the efficiency. Acute care surgery programs care for sicker and more economically disadvantaged patients. This study compares outcomes between ACS and traditional models in the management of diverticulitis across an entire state. STUDY DESIGN: The Virginia Health Information administrative database for adults discharged with diverticulitis from January 2008 through September 2015, was reviewed. Patient characteristics were analyzed and compared between ACS and traditional models. Outcome differences were compared using logistic regression. RESULTS: We reviewed 23,943 admissions, with 2,330 (9.7%) patients cared for in ACS programs. The ACS patients were more likely to be uninsured (10.6% vs 6.8%, p < 0.0001) or covered by Medicaid (5.5% vs 3.4%, p < 0.0001), and the ACS hospitals cared for a higher percentage of minority patients than in the traditional programs (30.4% vs 19.8%, p < 0.0001). Operative rates were higher in ACS hospitals (14.7% vs 11.8%, p < 0.0001), as were rates of complicated diverticulitis (24.5% vs 20.3%, p < 0.0001). The ACS patients had significantly higher rates of comorbidities. After adjusting for patient comorbidities and demographics, ACS patients had a higher rate of complications (odds ratio [OR] 1.36, p = 0.0017). However, there was no difference in mortality, length of stay, or costs. When comparing only operative patients, there were no outcome differences after adjusting for patient factors. CONCLUSIONS: Acute care surgery patients present to the hospital with more severe disease, higher rates of medical comorbidities, and lower socioeconomic status. Once patient factors are accounted for, outcomes are equivalent for operative patients in either model. Acute care surgery hospitals provide high quality and efficient care to sicker and more complex patients than traditional programs.

Central line simulation: a new training algorithm.

Recent development of a partial task simulator for central line placement has altered the training algorithm from one of supervised learning on patients to mannequin-based practice to proficiency before patient interaction. There are little data published on the efficacy of this type of simulator. We reviewed our initial resident experience with central line simulation. Education to proficiency using the CentralLine Man simulator is completed by all interns during orientation. At the completion of training, te residents were asked to complete a voluntary, anonymous questionnaire with a 5-point Likert scale as well as open-ended questions. Additionally, the residents were asked to maintain a log of the initial 10 central lines placed. Retrospective review of the questionnaire and logs were done with analysis of simulator experience as well as initial line experience. Seventeen trainees completed the central line simulation course and returned the initial survey. Before the course, the trainees had placed an average of 0.4 internal jugular (IJ) and 1 subclavian (SC) line. On the simulator, an average of 3 SC attempts and 2.5 IJ attempts led to resident comfort with the procedure. On the first attempt, the vessel was accessed after an average of 1.5 SC and 1.9 IJ needlesticks, which improved to 1 SC and 1.3 IJ by the fifth simulated attempt. A total of 4 pneumothorax and 5 carotid sticks were done. Overall, the residents were highly satisfied with the course with an average score of 4.8 for didactics, 4.8 for equipment, 4.5 for the mannequin, and 4.8 for practice opportunity. Nine of the 11 residents who completed logs felt the simulation improved performance on the patient. On the first patient attempt, an average of 1.8 needlesticks was done with an average of 1.3 by the tenth line. For the first patient line documented in the logs, comfort with the anatomy was rated 3.8 with comfort with the procedure rated 2.8. Central line simulation before actual performance on patients is useful and well regarded by the trainees, suggestive of a transference effect. Prospective evaluation is needed to further determine the impact of simulation on resident performance as well as patient outcomes.

Lung protective ventilation strategies: have we applied them in trauma patients at risk for acute lung injury and acute respiratory distress syndrome?

Lung protective ventilation strategies for patients with acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are well documented, and many medical centers fail to apply these strategies in ALI/ARDS. The objective of this study was to determine if we apply these strategies in trauma patients at risk for ALI/ARDS. We undertook a retrospective review of trauma patients mechanically ventilated for > or = 4 days with an ICD-9 for traumatic pneumothorax, hemothorax, lung contusion, and/or fractured ribs admitted from May 1, 1999 through April 30, 2000 (Group 1), the pre-ARDS Network study, and from May 1, 2003 through April 30, 2004 (Group 2), the post-ARDS Network study. Tidal volume (VT)/kg admission body weight, VT/kg ideal body weight (IBW), and plateau and peak pressures were analyzed with respect to mortality. VT/Kg admission body weight and IBW were significantly reduced when comparing Group 1 with Group 2 (9.27 to 8.03 and 11.67 to 10.04, respectively). VT/kg IBW was greater (P < 0.01) for patients who died in Group 1 (13.81) compared with patients who lived (10.29) or died (9.89) in Group 2. Peak and plateau pressures were greater (P < 0.01) in patients who died in Group 1 than patients who lived or died in Group 2. A strict ARDS Network ventilation strategy (VT < 6 mL/kg) is not followed, rather a low plateau/peak pressure strategy is used, which is a form of lung protective ventilation.

Early glucose normalization does not improve outcome in the critically ill trauma population.

Strict control of serum glucose in critically ill patients decreases morbidity and mortality. The objective of this study was to evaluate the effect of early normalization of glucose in our burn and trauma intensive care unit. From January 2002 to June 2005, 290 patients were admitted with serum glucose 150 mg/dL or greater and 319 patients with serum glucose less than 150 mg/dL. The patients with hyperglycemia were more severely injured and more often required operative intervention within the first 48 hours. The patients with hyperglycemia were at increased risk for infection and mortality. Of those 290 patients in the hyperglycemic cohort, 125 patients had early normalization of serum glucose, whereas 165 patients required more than 24 hours to normalize. The early normalization cohort was younger in mean age than the late group, but these 2 groups were similar in injury severity. Correspondingly, there was no difference in the rate of infection. Although hyperglycemia on admission appears to correlate with a worse outcome, early glucose normalization did not affect morbidity and mortality in our critically ill population.

Differences in mental workload between traditional and single-incision laparoscopic procedures measured with a secondary task.

INTRO: The mental workload associated with laparoscopic suturing can be assessed with a secondary task that requires the same visual-spatial attentional resources. The purpose of this study was to use a secondary task to measure the incremental workload demands of single-incision laparoscopic surgery (SILS) procedures versus traditional laparoscopic procedures. METHOD: 12 surgery residents and surgical assistants who had met FLS criteria on an FLS and SILS simulator performed one trial each of peg transfer, cutting, and intracorporeal suturing tasks simultaneously with the secondary task and provided subjective workload ratings using the NASA-TLX. RESULTS: SILS procedures resulted in lower primary and secondary task scores, p < 0.001 and higher workload ratings, p < 0.0001. Suturing resulted in lower primary (p < 0.003) and secondary task scores (p < 0.017) and higher workload ratings (p < 0.017) compared to the other tasks. CONCLUSIONS: SILS procedures were significantly more mentally demanding than traditional laparoscopic procedures corroborated by primary and secondary tasks scores and subjective ratings.

Speed Mentoring: An Innovative Method to Meet the Needs of the Young Surgeon.

OBJECTIVE: Speed mentoring has recently been used by several medical organizations as a strategy to establish mentoring relationships, which are felt to be critically important in the development of the surgeon. This study assesses a surgical speed-mentoring program at the 2015 American College of Surgeons (ACS) Clinical Congress. DESIGN: A steering committee designed the speed-mentoring program to match 60 ACS Resident and Associate Society mentees with a mix of junior and senior leadership of ACS. Each mentee met with 5 mentors for 10 minutes each during the 1 hour session. After participation in the activity, surveys were provided to assess the event. The survey included forced-choice questions using Likert-scales as well as open-ended questions. Mentor and mentee responses were compared using Medcalc software using comparison of means and comparison of proportion, with p < 0.05 considered significant. SETTING: The study was undertaken at the 2015 ACS Clinical Congress. PARTICIPANTS: A total of 60 mentors and 49 mentees participated in the inaugural ACS Speed-Mentoring activity. The postactivity survey was completed by 54 mentors (90%) and 39 mentees (79.5%). RESULTS: There was a high level of satisfaction with the activity, with 100% of mentors and mentees stating that they would recommend the activity to a colleague. There was overall high satisfaction with the organization of the session by both the mentors and the mentees although the mentors were more likely to feel that they needed more time for each interaction. More mentees (93%) than mentors (68.5%) felt they were likely to develop a mentoring relationship with one of their matches outside of the organized session. CONCLUSIONS: We demonstrated that a speed-mentoring event at a national surgical meeting offers an effective platform for mentoring and is mutually beneficial to both mentors and mentees. Data collected here will be used to modify and improve the design of future speed-mentoring sessions.

Effects of a retention interval and refresher session on intracorporeal suturing and knot tying skill and mental workload.

BACKGROUND: The effects of refraining from practice for different intervals on laparoscopic suturing and mental workload was assessed with a secondary task developed by the authors. We expected the inability to practice to produce a decrease in performance on the suturing, knot tying, and secondary task and skills to rebound after a single refresher session. METHODS: In total, 22 surgical assistant and premedical students trained to Fundamentals of Laparoscopic Surgery proficiency in intracorporeal suturing and knot tying were assessed on that task using a secondary task. Participants refrained from practicing any Fundamentals of Laparoscopic Surgery tasks for 1 or 5 months. At the time of their return, they were assessed immediately on suturing and knot tying with the secondary task, practiced suturing and knot tying for 40 minutes, and then were reassessed. RESULTS: The mean suture times from the initial reassessment were greater than the proficiency times but returned to proficiency levels after one practice session, F(2, 40) = 14.5, P < .001, partial η2 = .420. Secondary task scores mirrored the results of suturing time, F(2, 40) = 6.128, P < .005, partial η2 = .235, and were moderated by retention interval. CONCLUSION: When participants who reached proficiency in suturing and knot tying were reassessed after either 1or 5 months without practice, their performance times increased by 35% and secondary task scores decreased by 30%. These deficits, however, were nearly reversed after a single refresher session.

Corticosteroid use in the intensive care unit: at what cost?

HYPOTHESIS: Corticosteroid use has a significant effect on morbidity and mortality in the intensive care unit (ICU). DESIGN: Case-control study. SETTING: Burn-trauma ICU in a level 1 trauma center. PATIENTS: All patients who received corticosteroids while in the ICU from January 1, 2002, to December 31, 2003 (n = 100), matched by age and Injury Severity Score with a control group (n = 100). INTERVENTIONS: None. MAIN OUTCOME MEASURES: We considered the following 7 outcomes: pneumonia, bloodstream infection, urinary tract infection, other infections, ICU length of stay (LOS), ventilator LOS, and mortality. RESULTS: Cases and controls had similar APACHE II (Acute Physiology and Chronic Health Evaluation II) scores and medical history. In univariate analysis, the corticosteroid group had a significant increase in pneumonia (26% vs 12%; P<.01), bloodstream infection (19% vs 7%; P<.01), and urinary tract infection (17% vs 8%; P<.05). In multivariate models, corticosteroid use was associated with an increased rate of pneumonia (odds ratio [OR], 2.64; 95% confidence interval [CI], 1.21-5.75) and bloodstream infection (OR, 3.25; 95% CI, 1.26-8.37). There was a trend toward increased urinary tract infection (OR, 2.31; 95% CI, 0.94-5.69), other infections (OR, 2.57; 95% CI, 0.87-7.67), and mortality (OR, 1.89; 95% CI, 0.81-4.40). Patients in the ICU who received corticosteroids had a longer ICU LOS by 7 days (P<.01) and longer ventilator LOS by 5 days (P<.01). CONCLUSIONS: Corticosteroid use is associated with increased rate of infection, increased ICU and ventilator LOS, and a trend toward increased mortality. Caution must be taken to carefully consider the indications, risks, and benefits of corticosteroids when deciding on their use.

Initial Cholecystectomy with Cholangiography Decreases Length of Stay Compared to Preoperative MRCP or ERCP in the Management of Choledocholithiasis.

There are several treatments available for choledocholithiasis, but the optimal treatment is highly debated. Some advocate preoperative endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC) with cholangiography (IOC). Others advocate initial LC + IOC followed by common bile duct exploration or ERCP. The purpose of this study was to determine whether initial LC + IOC had a shorter length of stay (LOS) compared with preoperative magnetic resonance cholangiopancreatography (MRCP) or ERCP. Patients who underwent cholecystectomy between 2012 and 2013 at two institutions were reviewed. Patients were selected if they had suspected choledocholithiasis, indicated by dilated CBD and/or elevated bilirubin, or confirmed choledocholithiasis. They were excluded if they had pancreatitis or cholangitis. There were 126 patients with suspected choledocholithiasis in this study. Of these, 97 patients underwent initial LC ± IOC with an average LOS of 3.9 days. IOC was negative in 47.4 per cent patients, and they had a shorter LOS compared with positive IOC patients (2.93 vs 4.82, P < 0.001). Laparoscopic common bile duct exploration was successful in 64.7 per cent and had a shorter LOS compared with postoperative ERCP patients (P = 0.01). Preoperative MRCP was performed in 21 patients with an average LOS of 6.48 days. Preoperative ERCP was performed in eight patients with an average LOS of seven days. Initial LC+IOC is associated with a shorter LOS compared to preoperative MRCP or ERCP. It is recommended as the optimal treatment choice for suspected choledocholithiasis.

Resident handoff training: initial evaluation of a novel method.

INTRODUCTION: Residencies are required to have a standardized process for transitioning patient care. This study was designed to assess a novel method of training and evaluating handoffs using both a lecture format and standardized patient (SP) interactions. METHODS: Matched group design was used to randomly assign interns to trained versus control groups, with the trained group receiving formal handoff training before SP encounters. The residents evaluated three ER SPs and read four written scenarios and then transitioned patients to an SP acting as a resident. All handoffs were videotaped and scored by two blind raters using a rating scale developed based on specialist's interviews. RESULTS: Thirty-two interns were included in the study. The trained interns performed significantly better with lower scores on patient handoffs (mean = 10.08, SD = 2.46) than the untrained interns (mean = 16.56, SD = 2.79). There was also a significant effect for case, with the ER SP cases (mean = 12.23, SD = 14.41) resulting in better performance than the written cases in both surgery and pediatrics (mean = 14.41, SD = 4.29). CONCLUSIONS: A protocol was designed and implemented for training residents to perform handoffs, with initial results showing that the curriculum is effective.

Intracorporeal suturing: Transfer from Fundamentals of Laparoscopic Surgery to cadavers results in substantial increase in mental workload.

INTRODUCTION: A spatial secondary task developed by the authors was used to measure the mental workload of the participant when transferring suturing skills from a box simulator to more realistic surgical conditions using a fresh cadaver. We hypothesized that laparoscopic suturing on genuine bowel would be more challenging than on the Fundamentals of Laparoscopic Surgery (FLS)-simulated bowel as reflected in differences on both suturing and secondary task scores. METHODS: We trained 14 surgical assistant students to FLS proficiency in intracorporeal suturing. Participants practiced suturing on the FLS box for 30 minutes and then were tested on both the FLS box and the bowel of a fresh cadaver using the spatial, secondary dual-task conditions developed by the authors. RESULTS: Suturing times increased by >333% when moving from the FLS platform to the cadaver F(1,13) = 44.04, P < .001. The increased completion times were accompanied by a 70% decrease in secondary task scores, F(1,13) = 21.21, P < .001. CONCLUSION: The mental workload associated with intracorporeal suturing increases dramatically when trainees transfer from the FLS platform to human tissue under more realistic conditions of suturing. The increase in mental workload is indexed by both an increase in suturing times and a decrease in the ability to attend to the secondary task.