RESUMEN
OBJECTIVES: Uncontrolled bleeding is the leading cause of preventable death after a traumatic event, and early intervention to control bleeding improves opportunities for survival. It is imperative to prepare for local and national disasters by increasing public knowledge on how to control bleeding, and this preparation should extend to both adults and children. The purpose of this study is to describe a training effort to teach basic hemorrhage control techniques to early adolescent children. METHODS: The trauma and emergency departments at a combined level I adult and level II pediatric trauma center piloted a training initiative with early adolescents (grades 6-8) focused on 2 skills: packing a wound and holding direct pressure, and applying a Combat Application Tourniquet. Students were evaluated on each skill and completed presurveys and postsurveys indicating their likelihood to use the skills. RESULTS: Of the 194 adolescents who participated in the trainings, 97% of the students could successfully pack a wound and hold pressure, and 97% of the students could apply a tourniquet. Before the training, 71% of the adolescents indicated that they would take action to assist a bleeding victim; this increased to 96% after the training. CONCLUSIONS: Results demonstrate that basic hemorrhage control skills can be effectively taught to adolescents as young as 6th grade (ages 11-12 years) in a small setting with age-appropriate content and hands-on opportunities to practice the skills and such training increases students' perceived willingness to take action to assist a bleeding victim.
Asunto(s)
Hemorragia , Torniquetes , Adolescente , Adulto , Niño , Hemorragia/prevención & control , Humanos , Instituciones Académicas , Estudiantes , Centros TraumatológicosRESUMEN
BACKGROUND: Patients who take aspirin and sustain traumatic intracranial hemorrhage (tICH) are often transfused platelets in an effort to prevent bleeding progression. The efficacy of platelet transfusion is questionable, however, and some medical societies recommend that platelet reactivity testing (PRT) should guide transfusion decisions. The study hypothesis was that utilization of PRT to guide platelet transfusion for tICH patients suspected of taking aspirin would safely identify patients who did not require platelet transfusion. METHODS: This was a retrospective study of patients with blunt tICH who received PRT for known or suspected aspirin use between June 2014 and December 2017 at a level I trauma center. Chart abstraction was conducted to determine home aspirin status, and PRT values were used to classify patients as therapeutic or nontherapeutic on aspirin. Differences were assessed with Kruskal-Wallis and chi-square tests. RESULTS: 157 patients met study inclusion criteria, and 118 (75%) patients had documented prior aspirin use. PRT results were available approximately 1.7 h (IQR: 0.9, 3.2) after arrival. Upon initial PRT, 70% of patients were considered inhibited and 88% of those patients had aspirin documented as a home medication. Conversely, 18% of patients with home aspirin use had normal platelet reactivity. Clinically significant worsening of the tICH did not significantly differ when comparing those who received platelet transfusion with those who did not (8% versus 7%, P = 0.87). CONCLUSIONS: Platelet reactivity testing can detect platelet inhibition related to aspirin and should guide transfusion decisions for head injured patients in the initial hours after trauma.
Asunto(s)
Aspirina/efectos adversos , Hemorragia Intracraneal Traumática/terapia , Inhibidores de Agregación Plaquetaria/efectos adversos , Transfusión de Plaquetas/normas , Anciano , Anciano de 80 o más Años , Pruebas de Coagulación Sanguínea , Progresión de la Enfermedad , Femenino , Humanos , Hemorragia Intracraneal Traumática/sangre , Hemorragia Intracraneal Traumática/diagnóstico , Masculino , Persona de Mediana Edad , Agregación Plaquetaria , Guías de Práctica Clínica como Asunto , Estudios RetrospectivosRESUMEN
BACKGROUND: Trauma centers are challenged to have appropriate criteria to identify injured patients needing a trauma activation; one population that is difficult to triage is injured elderly patients taking anticoagulation or antiplatelet (ACAP) medications with suspected head injury. OBJECTIVE: The study purpose was to evaluate a hospital initiative to improve the trauma triage response for this population. METHODS: A retrospective study at a Level I trauma center evaluated revised trauma response criteria. In Phase 1 (June 2017 to April 2018; n = 91), a limited activation occurred in the trauma bay for injured patients 55 years and older, taking ACAP medications with evidence of head injury. In Phase 2 (June 2018 to April 2019; n = 142), patients taking ACAP medications with evidence of head injury received a rapid emergency department (ED) response. Primary outcomes were timeliness of ED interventions and hospital admission rates. Differences between phases were assessed with Kruskal-Wallis tests. RESULTS: An ED rapid response significantly reduced trauma team involvement (100%-13%, p < .001). Compared with Phase 1, patients in Phase 2 were more frequently discharged from the ED (48% vs. 68%, p = .003), and ED disposition decision was made more quickly (147 vs. 120 min, p = .01). In Phase 2, time to ED disposition decision was longer for patients who required hospital admission (108 vs. 179 min, p < .001); however, there were no significant differences between phases in reversal intervention (6% vs. 11%, p = .39) or timeliness of reversal intervention (49 vs. 118 min, p = .51). CONCLUSION: The ED rapid response delivered safe, timely evaluation to injured elderly patients without overutilizing trauma team activations.
Asunto(s)
Servicios Médicos de Urgencia , Heridas y Lesiones , Anciano , Servicio de Urgencia en Hospital , Humanos , Persona de Mediana Edad , Estudios Retrospectivos , Centros Traumatológicos , TriajeRESUMEN
BACKGROUND: Injured older adults often receive delayed care in the emergency department (ED) because they do not meet criteria for trauma team activation (TTA). This is particularly dangerous for the increasing number of patients taking anticoagulant or antiplatelet (AC/AP) medication at the time of injury. OBJECTIVES: The present study examined improvements in processes of care and triage accuracy when TTA criteria include an escalated response for older anticoagulated patients. METHODS: A retrospective study was performed at a Level I trauma center. The study population (referred to as A55) included patients aged 55 years or older who were taking an AC/AP medication at the time of injury. Study periods included 11 months prior to the criteria change (Phase 1: July 2013-May 2014; n = 107) and 11 months after the change (Phase 2: July 2014-May 2015; n = 211). Differences were assessed with Kruskal-Wallis and chi-squared tests. RESULTS: More A55 patients received a full or limited TTA after criteria were revised (70% vs. 26%, p < 0.001). Undertriage was reduced from 13% to 2% (p < 0.001). The trauma center significantly decreased time to first laboratory result, time to first computed tomography scan, and total time in ED prior to admission for A55 patients arriving from the scene of injury or by private vehicle. CONCLUSION: Criteria that escalated the trauma response for A55 patients led to reductions in undertriage for anticoagulated older adults, as well as more timely mobilization of important clinical resources.
Asunto(s)
Anticoagulantes/efectos adversos , Defensa Civil/métodos , Geriatría/métodos , Centros Traumatológicos/tendencias , Accidentes por Caídas/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Anticoagulantes/uso terapéutico , Distribución de Chi-Cuadrado , Defensa Civil/tendencias , Servicio de Urgencia en Hospital/organización & administración , Femenino , Geriatría/tendencias , Humanos , Masculino , Persona de Mediana Edad , Medio Oeste de Estados Unidos , Inhibidores de Agregación Plaquetaria/efectos adversos , Inhibidores de Agregación Plaquetaria/uso terapéutico , Sistema de Registros/estadística & datos numéricos , Centros Traumatológicos/organización & administración , Triaje/métodos , Triaje/normasRESUMEN
BACKGROUND/AIM: Midface fractures are commonly present and difficult to diagnose in trauma patients. The objective of this study was to determine clinically accessible indicators of midface fracture. MATERIAL AND METHODS: A case-control study design was used to determine clinical indicators of midface fracture. Population source was a level I trauma center registry for years 2007-2009. Cases had a documented midface fracture. Patient and trauma characteristics were compared between cases and controls. Multivariate logistic regression analysis determined significant indicators of midface fracture. RESULTS: Study sample included 83 cases and 83 frequency-matched controls. Cases had a total of 211 fractures with a median of two midface fractures per person. Common fractures were orbital (41%), malar and maxillary (28%), and nasal bones (19%). Patients with midface fracture were significantly different than patients without midface fracture in severity of injury and were more likely to have a traumatic brain injury. Significant clinical indicators of fracture were maxillary sinus opacification, ethmoid sinus opacification, forehead laceration, periorbital contusion, epistaxis, and injury mechanism (P < 0.05). Patients with midface fracture had a 63 times greater odds for maxillary sinus opacification. The multivariable model correctly classified the presence and absence of midface fracture in 95% of study sample. CONCLUSIONS: Determined indicators of midface fracture provided a high level of discrimination in fracture status. Indicators can be used by clinicians to help detect possible midface fractures. Future prospective research on midface fracture indicators can assist in establishing their generalizability and impact on fracture detection, care, and outcomes.
Asunto(s)
Huesos Faciales/lesiones , Traumatismos Faciales/diagnóstico , Fracturas Craneales/diagnóstico , Adulto , Anciano , Área Bajo la Curva , Lesiones Encefálicas/etiología , Estudios de Casos y Controles , Traumatismos Faciales/clasificación , Traumatismos Faciales/epidemiología , Femenino , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Fracturas Craneales/complicaciones , Centros Traumatológicos , Índices de Gravedad del TraumaRESUMEN
PURPOSE: To examine hospital discharge destinations for Hispanic and non-Hispanic white patients treated for traumatic brain injury. METHODS: Retrospective cohort study with patient matching. FINDINGS: Ethnicity status not determined a significant predictor of discharge destination (P = .2150). Patient hospital length of stay determined a significant predictor of discharge destination (P = .0072), with every 1 day increase in length of stay, resulting in a 12% increase in odds of being discharged to care facility. CONCLUSIONS: Study data suggest that length of stay can predict discharge destination for both Hispanic and non-Hispanic white patients in a medium-sized trauma center in the Midwest.
Asunto(s)
Lesiones Encefálicas , Hispánicos o Latinos/estadística & datos numéricos , Alta del Paciente/estadística & datos numéricos , Centros Traumatológicos/estadística & datos numéricos , Población Blanca/estadística & datos numéricos , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Lesiones Encefálicas/etnología , Lesiones Encefálicas/enfermería , Lesiones Encefálicas/terapia , Educación Continua en Enfermería , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Adulto JovenRESUMEN
UNLABELLED: The objective was to determine if proper application of the Stretch, Wrap, and Tuck Tourniquet (SWAT-T) would stop arterial flow and would occur with minimal training. METHODS: Fifteen undergraduates watched a 19 second video three times, practiced twice, and applied the tourniquet to volunteers at 10 locations: 3 above the elbow or knee and 2 below. RESULTS: Successful occlusion (60 second Doppler signal elimination) was more frequent than proper stretch (96 versus 75), more frequent on arms than legs (59 versus 37), and achieved before completed application (16 +/- 8 versus 33 +/- 8 seconds; each p < 0.05). Proper stretch (correct alteration of shapes printed on the tourniquet) was more frequent on legs than arms (30 versus 45; p <0.05). Applications were rated Easy (101), Challenging (37), Difficult (12) with discomfort None (53), Little (62), Moderate (34), Severe (1). The 8 appliers with <70% proper stretch rates received 10 minutes additional training and then retested at mid upper arm, mid-thigh, and below knee (24 applications) for improved proper stretch and occlusion (5 versus 18 and 10 versus 20; p < 0.01). CONCLUSIONS: Proper application of the SWAT-T is easy and can stop extremity arterial flow but requires some training for many appliers.
Asunto(s)
Actitud del Personal de Salud , Auxiliares de Urgencia/educación , Hemorragia/terapia , Capacitación en Servicio/métodos , Medicina Militar/educación , Personal Militar/educación , Torniquetes , Diseño de Equipo , Femenino , Humanos , Masculino , Estudios Prospectivos , Estados Unidos , Adulto JovenRESUMEN
The operating room continues to be the location where surgical residents develop both technical and nontechnical skills, ultimately culminating with them being capable of safe and independent practice. The process of intraoperative instruction is, by necessity, moving from an apprentice-based model where skills are acquired somewhat randomly through repeated exposure and evaluation is done in a global gestalt fashion. Modern surgical education demands that intraoperative instruction be intentional and that evaluation provides formative and summative feedback. This chapter describes some best practice approaches to intraoperative teaching and evaluation.
Asunto(s)
Competencia Clínica , Retroalimentación Formativa , Cirugía General/educación , Internado y Residencia/métodos , Procedimientos Quirúrgicos Operativos/educación , Enseñanza , Humanos , Estados UnidosRESUMEN
INTRODUCTION: Antiplatelet medication use continues to rise in an aging population, and these agents can have a deleterious effect for patients with traumatic intracranial hemorrhage (tICH). The purpose of the current investigation is to assess the safety and efficacy of using platelet reactivity testing (PRT) to direct platelet transfusion for tICH patients. PATIENTS AND METHODS: A Level I trauma center adopted a targeted platelet transfusion guideline using PRT to determine whether platelets were inhibited by an antiplatelet medication (aspirin or P2Y12 inhibitors). Non-inhibited patients were monitored without platelet transfusion, regardless of severity of the head injury. The guideline was analyzed retrospectively to evaluate patient outcomes during the study period (June 2014-December 2016). All patients sustained blunt tICH and received a PRT for known or suspected antiplatelet medication use. Differences were assessed with Kruskal-Wallis and Fisher's Exact tests. RESULTS: 166 patients met study inclusion criteria. PRT results indicated that 48 patients (29%) were not inhibited by an antiplatelet medication, and 92% of those patients (n = 44) were spared platelet transfusion. Seven percent (n = 11) of all patients had a clinically significant progression of the head bleed, but this did not differ by inhibition or transfusion status. Implementation of this guideline reduced platelet transfusions by an estimated 30-50% and associated healthcare costs by 42%. CONCLUSIONS: A targeted platelet transfusion guideline using PRT reduced platelet usage for patients with tICH. If appropriately tested, results suggest that not all tICH patients taking or suspected of taking antiplatelet drugs need platelet transfusion. Platelet reactivity testing can significantly reduce healthcare costs and resource usage.
Asunto(s)
Plaquetas/fisiología , Traumatismos Craneocerebrales/terapia , Inhibidores de Agregación Plaquetaria/uso terapéutico , Pruebas de Función Plaquetaria , Transfusión de Plaquetas , Centros Traumatológicos , Procedimientos Innecesarios , Adulto , Anciano , Plaquetas/efectos de los fármacos , Femenino , Adhesión a Directriz , Humanos , Masculino , Persona de Mediana Edad , Activación Plaquetaria/efectos de los fármacos , Inhibidores de Agregación Plaquetaria/efectos adversos , Transfusión de Plaquetas/estadística & datos numéricos , Guías de Práctica Clínica como Asunto , Valor Predictivo de las Pruebas , Estudios RetrospectivosRESUMEN
BACKGROUND: Trauma has long been considered unpredictable. Artificial neural networks (ANN) have recently shown the ability to predict admission volume, acuity, and operative needs at a single trauma center with very high reliability. This model has not been tested in a multicenter model with differing climate and geography. We hypothesize that an ANN can accurately predict trauma admission volume, penetrating trauma admissions, and mean Injury Severity Score (ISS) with a high degree of reliability across multiple trauma centers. METHODS: Three years of admission data were collected from five geographically distinct US Level I trauma centers. Patients with incomplete data, pediatric patients, and primary thermal injuries were excluded. Daily number of traumas, number of penetrating cases, and mean ISS were tabulated from each center along with National Oceanic and Atmospheric Administration data from local airports. We trained a single two-layer feed-forward ANN on a random majority (70%) partitioning of data from all centers using Bayesian Regularization and minimizing mean squared error. Pearson's product-moment correlation coefficient was calculated for each partition, each trauma center, and for high- and low-volume days (>1 standard deviation above or below mean total number of traumas). RESULTS: There were 5,410 days included. There were 43,380 traumas, including 4,982 penetrating traumas. The mean ISS was 11.78 (SD = 6.12). On the training partition, we achieved R = 0.8733. On the testing partition (new data to the model), we achieved R = 0.8732, with a combined R = 0.8732. For high- and low-volume days, we achieved R = 0.8934 and R = 0.7963, respectively. CONCLUSION: An ANN successfully predicted trauma volumes and acuity across multiple trauma centers with very high levels of reliability. The correlation was highest during periods of peak volume. This can potentially provide a framework for determining resource allocation at both the trauma system level and the individual hospital level. LEVEL OF EVIDENCE: Care Management, level IV.
Asunto(s)
Puntaje de Gravedad del Traumatismo , Redes Neurales de la Computación , Centros Traumatológicos/estadística & datos numéricos , Heridas y Lesiones/epidemiología , Teorema de Bayes , Geografía Médica , Humanos , Estados UnidosRESUMEN
BACKGROUND: Although most surgery residents pursue fellowships, data regarding those decisions are limited. This study describes associations with interest in fellowship and specific subspecialties. METHODS: Anonymous surveys were distributed to 607 surgery residents at 19 US programs. Subspecialties were stratified by levels of burnout and quality of life using data from recent studies. RESULTS: 407 (67%) residents responded. 372 (91.4%) planned to pursue fellowship. Fellowship interest was lower among residents who attended independent or small programs, were married, or had children. Residents who received AOA honors or were married were less likely to choose high burnout subspecialties (trauma/vascular). Residents with children were less likely to choose low quality of life subspecialties (trauma/transplant/cardiothoracic). CONCLUSIONS: Surgery residents' interest in fellowship and specific subspecialties are associated with program type and size, AOA status, marital status, and having children. Variability in burnout and quality of life between subspecialties may affect residents' decisions.
Asunto(s)
Selección de Profesión , Educación de Postgrado en Medicina , Becas , Cirugía General/educación , Adulto , Femenino , Humanos , Masculino , Especialización , Encuestas y Cuestionarios , Estados UnidosRESUMEN
BACKGROUND: Several national initiatives are aimed at training citizens to assist bleeding victims. The purpose of this study was to evaluate an effort to quickly and efficiently teach basic bleeding control techniques to a clinical and nonclinical workforce. STUDY DESIGN: The research study was conducted at 4 hospitals in a mid-sized metropolitan area. In spring 2017, the trauma department at a Level I trauma center set an ambitious goal to provide hands-on training to 1,000 employees during the course of 6 weeks. Trainings occurred in small groups and lasted approximately 6 to 10 minutes, during which time participants were taught and practiced 2 skills: packing a wound and holding direct pressure, and applying a stretch-wrap-and-tuck tourniquet. Participants completed pre- and post-surveys indicating their likelihood to use these skills. RESULTS: More than 1,000 individuals were trained, and there were survey data for 870 participants. More than 40% of participants worked in nonclinical roles and 29% had no first aid or medical training. After completing skills training, 98% of participants indicated that they would be likely to take action to assist a bleeding victim and that they could correctly apply direct pressure or a tourniquet to control severe bleeding. CONCLUSIONS: Results demonstrate that basic hemorrhage control skills can be taught to clinical and nonclinical people in brief, hands-on training. Efforts like this can be deployed across large workplace environments to prepare the maximum number of employees to take action to assist bleeding victims.
Asunto(s)
Competencia Clínica/normas , Educación en Salud/métodos , Hemorragia/terapia , Educación , Conocimientos, Actitudes y Práctica en Salud , Hospitales Urbanos , Humanos , Centros Traumatológicos , Recursos HumanosRESUMEN
Rural trauma education emphasizes that radiologic imaging should be discouraged if it delays transfer to definitive care. With increased capacity for image sharing, however, radiography obtained at referring hospitals (RH) could help providers at trauma centers (TC) prepare for patients with traumatic brain injury. We evaluated whether a head CT prior to transfer accelerated time to neurosurgical intervention at the TC. The study was conducted at a combined adult Level I and pediatric Level II TC with a catchment area that includes rural hospitals within a 150 mile radius. The trauma registry was used to identify patients with traumatic brain injury who went to surgery for a neurosurgical procedure immediately after arrival at the TC. All patients were transferred in from a RH. Differences between groups were assessed using analysis of variance and chi-square. Fifty-six patients met study criteria during the study period (2010-2015). The majority (86%) of patients received head CT imaging at the RH, including a significant percentage of patients (18%) who presented with GCS ≤8. There was no statistically significant decrease in time to surgery when patients received imaging at the RH. CT imaging was associated with a delay in transfer that exceeded 90 minutes. Findings demonstrate that imaging at the RH delayed transfer to definitive care and did not improve time to neurosurgical intervention at the TC. Transfer to the TC should not be obstructed by imaging, especially for patients with severe TBI.
Asunto(s)
Lesiones Traumáticas del Encéfalo/diagnóstico por imagen , Craneotomía , Hospitales Rurales , Transferencia de Pacientes , Tomografía Computarizada por Rayos X , Centros Traumatológicos , Adulto , Anciano , Lesiones Traumáticas del Encéfalo/cirugía , Femenino , Humanos , Iowa , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de TiempoRESUMEN
BACKGROUND: Uncontrolled hemorrhage is the leading cause of potentially preventable traumatic death. Bleeding victims must receive immediate medical attention to save lives, and the first opportunity to control bleeding after trauma often comes from bystanders. Educating the general public is important for improving outcomes for hemorrhaging victims, and it is imperative for all people, including those with no clinical training, to have the knowledge to respond until trained medical specialists arrive. STUDY DESIGN: An 8-minute educational module was deployed to all hospital employees and included information on the location and contents of hemorrhage control bags in the hospital and how to use the materials in the bags to respond to uncontrolled hemorrhage. A pre-post questionnaire was administered with the module to evaluate effectiveness. McNemar tests were used to compare the responses and evaluate effectiveness of the education. RESULTS: Eighty-four percent of eligible employees (n = 4,845) completed the module and all items on the questionnaires. Three-quarters of respondents provided direct or ancillary care to patients, and one-quarter worked in nonclinical roles. On average, 57% of questions were answered correctly in the pre-questionnaire and 98% were answered correctly in the post-questionnaire. The module was effective for all employees regardless of clinical training. CONCLUSIONS: There is currently no succinct hemorrhage control education available that can be deployed across a large workplace environment. Results demonstrate that the brief learning module was effective in educating all employees in the basics of hemorrhage control. The module could be deployed in clinical and nonclinical settings.
Asunto(s)
Educación Médica , Hemorragia/terapia , Heridas y Lesiones/complicaciones , Adulto , Estudios de Evaluación como Asunto , Hemorragia/etiología , Humanos , Personal de Hospital , Encuestas y Cuestionarios , Centros Traumatológicos , Heridas y Lesiones/terapiaRESUMEN
IMPORTANCE: Previous studies of resident attrition have variably included preliminary residents and likely overestimated categorical resident attrition. Whether program director attitudes affect attrition has been unclear. OBJECTIVES: To determine whether program director attitudes are associated with resident attrition and to measure the categorical resident attrition rate. DESIGN, SETTING, AND PARTICIPANTS: This multicenter study surveyed 21 US program directors in general surgery about their opinions regarding resident education and attrition. Data on total resident complement, demographic information, and annual attrition were collected from the program directors for the study period of July 1, 2010, to June 30, 2015. The general surgery programs were chosen on the basis of their geographic location, previous collaboration with some coauthors, prior work in surgical education and research, or a program director willing to participate. Only categorical surgical residents were included in the study; thus, program directors were specifically instructed to exclude any preliminary residents in their responses. MAIN OUTCOMES AND MEASURES: Five-year attrition rates (2010-2011 to 2014-2015 academic years) as well as first-time pass rates on the General Surgery Qualifying Examination and General Surgery Certifying Examination of the American Board of Surgery (ABS) were collected. High- and low-attrition programs were compared. RESULTS: The 21 programs represented different geographic locations and 12 university-based, 3 university-affiliated, and 6 independent program types. Programs had a median (interquartile range [IQR]) number of 30 (20-48) categorical residents, and few of those residents were women (median [IQR], 12 [5-17]). Overall, 85 of 966 residents (8.8%) left training during the study period: 15 (17.6%) left after postgraduate year 1, 34 (40.0%) after postgraduate year 2, and 36 (42.4%) after postgraduate year 3 or later. Forty-four residents (51.8%) left general surgery for another surgical discipline, 21 (24.7%) transferred to a different surgery program, and 18 (21.2%) exited graduate medical education altogether. Each program had an annual attrition rate ranging from 0.73% to 6.0% (median [IQR], 2.5% [1.5%-3.4%]). Low-attrition programs were more likely than high-attrition programs to use resident remediation (21.0% vs 6.8%; P < .001). Median (IQR) Qualifying Examination pass rates (93% [90%-98%] vs 92% [86%-100%]; P = .92) and Certifying Examination pass rates (83% [68%-84%] vs 81% [71%-86%]; P = .47) were similar. Program directors at high-attrition programs were more likely than their counterparts at low-attrition programs to agree with this statement: "I feel that it is my responsibility as a program director to redirect residents who should not be surgeons." CONCLUSIONS AND RELEVANCE: The overall 5-year attrition rate of 8.8% was significantly lower than previously reported. Program directors at low-attrition programs were more likely to use resident remediation. Variations in attrition may be explained by program director attitudes, although larger studies are needed to further define program factors affecting attrition.
Asunto(s)
Actitud del Personal de Salud , Selección de Profesión , Cirugía General/educación , Internado y Residencia , Ejecutivos Médicos , Adulto , Femenino , Humanos , Masculino , Persona de Mediana Edad , Encuestas y Cuestionarios , Estados Unidos , Adulto JovenRESUMEN
OBJECTIVE: The Accreditation Council for Graduate Medical Education requires accredited residency programs to implement competency-based assessments of medical trainees based upon nationally established Milestones. Clinical competency committees (CCC) are required to prepare biannual reports using the Milestones and ensure reporting to the Accreditation Council for Graduate Medical Education. Previous research demonstrated a strong correlation between CCC and resident scores on the Milestones at 1 institution. We sought to evaluate a national sampling of general surgery residency programs and hypothesized that CCC and resident assessments are similar. DESIGN: Details regarding the makeup and process of each CCC were obtained. Major disparities were defined as an absolute mean difference of ≥0.5 on the 4-point scale. A negative assessment disparity indicated that the residents evaluated themselves at a lower level than did the CCC. Statistical analysis included Wilcoxon rank sum and Sign tests. SETTING: CCCs and categorical general surgery residents from 15 residency programs completed the Milestones document independently during the spring of 2016. RESULTS: Overall, 334 residents were included; 44 (13%) and 43 (13%) residents scored themselves ≥0.5 points higher and lower than the CCC, respectively. Female residents scored themselves a mean of 0.08 points lower, and male residents scored themselves a mean of 0.03 points higher than the CCC. Median assessment differences for postgraduate year (PGY) 1-5 were 0.03 (range: -0.94 to 1.28), -0.11 (range: -1.22 to 1.22), -0.08 (range: -1.28 to 0.81), 0.02 (range: -0.91 to 1.00), and -0.19 (range: -1.16 to 0.50), respectively. Residents in university vs. independent programs had higher rates of negative assessment differences in medical knowledge (15% vs. 6%; P = 0.015), patient care (17% vs. 5%; P = 0.002), professionalism (23% vs. 14%; P = 0.013), and system-based practice (18% vs. 9%; P = 0.031) competencies. Major assessment disparities by sex or PGY were similar among individual competencies. CONCLUSIONS: Surgery residents in this national cohort demonstrated self-awareness when compared to assessments by their respective CCCs. This was independent of program type, sex, or level of training. PGY 5 residents, female residents, and those from university programs consistently rated themselves lower than the CCC, but these were not major disparities and the significance of this is unclear.
Asunto(s)
Acreditación , Competencia Clínica , Educación de Postgrado en Medicina/métodos , Cirugía General/educación , Autoevaluación (Psicología) , Comités Consultivos , Estudios de Cohortes , Educación Basada en Competencias , Femenino , Humanos , Internado y Residencia/métodos , Masculino , Estudios Prospectivos , Estados UnidosRESUMEN
Independent academic medical centers have been training surgeons for more than a century; this environment is distinct from university or military programs. There are several advantages to training at a community program, including a supportive learning environment with camaraderie between residents and faculty, early and broad operative experience, and improved graduate confidence. Community programs also face challenges, such as resident recruitment and faculty engagement. With the workforce needs for general surgeons, independent training programs will continue to play an integral role.
Asunto(s)
Centros Médicos Académicos/organización & administración , Cirugía General/educación , Internado y Residencia/organización & administración , Competencia Clínica , Educación de Postgrado en Medicina/organización & administración , Cirugía General/organización & administración , Humanos , Internado y Residencia/métodos , Criterios de Admisión Escolar , Estados UnidosRESUMEN
BACKGROUND: Level IV trauma centers are an integral part of inclusive trauma systems, although sparse data exists for these facilities. METHODS: An observational study was conducted using a Midwestern state's inpatient data files to characterize level IV center patients. Injury and severity levels, injury mechanism and/or intent, and distances to nearest tertiary centers were determined. RESULTS: During the study year, 3,346 injured patients were admitted at level IV centers. The median distance to nearest tertiary center was 43 miles. Median patient age was 81 years, and primary injury mechanism was falls. Overall, 22% of patients had an isolated hip fracture. Of moderately injured patients, 64% had an isolated hip fracture, 8% nonisolated hip fractures, and 9% rib fractures without hip fracture. Overall, 30% of patients had a high severity of injury. CONCLUSIONS: A large number of patients were admitted to level IV trauma centers. Patients admitted tended to be elderly and have orthopedic fall injuries. Study results provide important implications for provider education, prevention efforts, need for orthopedic surgical capabilities, and necessity of capturing these data in registries.
Asunto(s)
Admisión del Paciente/estadística & datos numéricos , Centros Traumatológicos/organización & administración , Heridas y Lesiones/terapia , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Incidencia , Iowa/epidemiología , Masculino , Estudios Retrospectivos , Índices de Gravedad del Trauma , Heridas y Lesiones/diagnóstico , Heridas y Lesiones/epidemiologíaRESUMEN
OBJECTIVE: To investigate the level of ionizing radiation exposure among surgical residents and to evaluate resident knowledge, attitudes, and practices regarding exposures. DESIGN: An observational study was conducted using radiation exposure data for surgical residents who wore film badge dosimeters. A cross-sectional survey was electronically administered at the end of the year, examining resident knowledge, attitudes, and practices concerning radiation exposures. SETTING: Community teaching hospital in the Midwest. PARTICIPANTS: Surgical residents who wore a badge for the full calendar year and completed study survey. Excluded were graduating chiefs and interns who only had 6 calendar months of data. RESULTS: A total of 14 surgical residents (100%) were engaged in 168 rotations during study year. Primarily-general surgery (n = 103, 61%), night float (n = 16, 10%), trauma (n = 15, 9%), and vascular (n = 13, 8%). Radiation exposures were greater than a null value during most rotations (i.e., general surgery and night float), with no exposure above occupational thresholds. Certain rotations, namely vascular and trauma, had episodic high exposures. When asked if protective efforts changed during higher-risk rotations, responses revealed they increased (64%) or did not change (36%). A low Cronbach alpha (α = 0.2634) demonstrated that precaution use was not universal and had varied rationale. Percentage of correct radiation knowledge questions was 62%. A multilevel model predicting exposure had a significant multiplicative cross-level interaction term (p < 0.0001) between resident-level exposure and rotation type. CONCLUSIONS: Radiation exposure levels for surgical residents have not been previously investigated. Data demonstrated that surgical residents were not at a greater risk than other medical personnel. However, the study demonstrated detectable radiation exposures that were statistically greater than a null value for the most common rotations. Stochastic and dose-response effects of radiation make any exposure a concern. Attempts to lessen exposures are worthwhile, with study results identifying a need for greater safety precaution education and adherence.
Asunto(s)
Internado y Residencia/métodos , Salud Laboral , Dosis de Radiación , Exposición a la Radiación/efectos adversos , Especialidades Quirúrgicas/educación , Adulto , Competencia Clínica , Estudios Transversales , Educación de Postgrado en Medicina/métodos , Femenino , Hospitales Comunitarios , Hospitales de Enseñanza , Humanos , Iowa , Masculino , Evaluación de Necesidades , Exposición a la Radiación/estadística & datos numéricos , Radiación Ionizante , Estudios Retrospectivos , Medición de RiesgoRESUMEN
The goal of preoperative cardiac evaluation is to screen for undiagnosed cardiac disease or to find evidence of known conditions that are poorly controlled to allow management that reduces the risk of perioperative cardiac complications. A careful history and physical examination combined with the procedure-specific risk is the cornerstone of this assessment. This article reviews a brief history of prior cardiac risk stratification indexes, explores current practice guidelines by the American College of Cardiology and the American Heart Association Task Force, reviews current methods for preoperative evaluation, discusses revascularization options, and evaluates perioperative medication recommendations.