Defining a Framework and Evaluation Metrics for Sustainable Global Surgical Partnerships: A Modified Delphi Study.

OBJECTIVE: The aim of this study was to use expert consensus to build a concrete and realistic framework and checklist to evaluate sustainability in global surgery partnerships (GSPs). BACKGROUND: Partnerships between high-resourced and low-resourced settings are often created to address the burden of unmet surgical need. Reflecting on the negative, unintended consequences of asymmetrical partnerships, global surgery community members have proposed frameworks and best practices to promote sustainable engagement between partners, though these frameworks lack consensus. This project proposes a cohesive, consensus-driven framework with accompanying evaluation metrics to guide sustainability in GSPs. METHODS: A modified Delphi technique with purposive sampling was used to build consensus on the definitions and associated evaluation metrics of previously proposed pillars (Stakeholder Engagement, Multidisciplinary Collaboration, Context-Relevant Education and Training, Bilateral Authorship, Multisource Funding, Outcome Measurement) of sustainable GSPs. RESULTS: Fifty global surgery experts from 34 countries with a median of 9.5 years of experience in the field of global surgery participated in 3 Delphi rounds. Consensus was achieved on the identity, definitions, and a 47-item checklist for the evaluation of the 6 pillars of sustainability in GSPs. In all, 29% of items achieved consensus in the first round, whereas 100% achieved consensus in the second and third rounds. CONCLUSIONS: We present the first framework for building sustainable GSPs using the input of experts from all World Health Organization regions. We hope this tool will help the global surgery community to find noncolonial solutions to addressing the gap in access to quality surgical care in low-resource settings.

Postoperative morbidity and mortality in pediatric indigenous populations: a scoping review and meta-analysis.

Mounting evidence suggests that childhood health is an important predictor of wellness as an adult. Indigenous peoples worldwide suffer worse health outcomes compared to settler populations. No study comprehensively evaluates surgical outcomes for Indigenous pediatric patients. This review evaluates inequities between Indigenous and non-Indigenous children globally for postoperative complications, morbidities, and mortality. Nine databases were searched for relevant subject headings including "pediatric", "Indigenous", "postoperative", "complications", and related terms. Main outcomes included postoperative complications, mortality, reoperations, and hospital readmission. A random-effects model was used for statistical analysis. The Newcastle Ottawa Scale was used for quality assessment. Fourteen studies were included in this review, and 12 met inclusion criteria for meta-analysis, representing 4793 Indigenous and 83,592 non-Indigenous patients. Indigenous pediatric patients had a greater than twofold overall (OR 2.0.6, 95% CI 1.23-3.46) and 30-day postoperative mortality (OR 2.23, 95% CI 1.23-4.05) than non-Indigenous populations. Surgical site infections (OR 1.05, 95% CI 0.73-1.50), reoperations (OR 0.75, 95% CI 0.51-1.11), and length of hospital stay (SMD = 0.55, 95% CI - 0.55-1.65) were similar between the two groups. There was a non-significant increase in hospital readmissions (OR 6.09, 95% CI 0.32-116.41, p = 0.23) and overall morbidity (OR 1.13, 95% CI 0.91-1.40) for Indigenous children. Indigenous children worldwide experience increased postoperative mortality. It is necessary to collaborate with Indigenous communities to promote solutions for more equitable and culturally appropriate pediatric surgical care.

Operating room use for emergency general surgery cases: analysis of the Patterns of Complex Emergency General Surgery in Canada study.

BACKGROUND: Access to the operating room (OR) is variable among emergency general surgery (EGS) services, with some having dedicated EGS ORs, and others only a shared queue. Currently in Canada, only a limited number of acute care surgery services have dedicated daytime operating room (OR) access; hence, we aimed to describe the burden of after-hours EGS operating in Canada and differences associated with OR access. METHODS: In this multicentre retrospective cohort study, we used data from a previously conducted study designed to evaluate nonappendiceal, nonbiliary disease across 8 Canadian hospitals. We performed a secondary analysis to describe booking priorities and timing of operative interventions, compare sites with and without access to a dedicated EGS daytime OR, and identify differences in morbidity and mortality based on timing of operative intervention. RESULTS: Among 1244 patients, operations were performed during weekday daytime in 521 cases (41.9%), in the evening in 279 (22.4%), on the weekend in 293 (23.6%) and overnight in 151 (12.1%). Operating room booking priority was more than 2 hours to 8 hours in 657 cases (52.8%), more than 8 hours to 24 hours in 334 (26.9%) and more than 24 hours to 48 hours in 253 (20.3%). Substantial variation in booking priority was observed for the same preoperative diagnoses. Sites with dedicated EGS ORs performed a greater proportion of cases during daytime versus overnight compared to sites without dedicated EGS ORs (198/237 [83.5%] v. 323/435 [74.2%], p = 0.006). No significant differences in outcome were found between cases performed during the daytime, evening and overnight. CONCLUSION: We found considerable variation in OR booking priority within the same preoperative diagnoses among EGS patients in Canada. Sites with dedicated EGS ORs performed more cases during weekday daytime compared to sites without dedicated EGS ORs; however, this study showed no evidence of compromised outcomes based on OR timing.

Socioeconomic status does not influence the presentation of patients with inguinal hernia at an urban Canadian teaching hospital.

BACKGROUND: Socioeconomic status (SES) has been shown to influence the outcomes of surgical pathologies in areas with unequal access to health care. The purpose of this study was to measure the effect of SES on the urgency for inguinal hernia repair in an area with purported equitable access to health care in the context of a universal health care system. METHODS: We included all adult patients who underwent surgical management of an inguinal hernia between 2012 and 2016 at 2 urban academic centres. We measured the SES using the Vancouver Area Neighbourhood Deprivation Index (VANDIX) score. RESULTS: We included 2336 patients: 98 emergency surgery and 294 elective surgery cases. We matched patients without replacement on age, sex and American Society of Anesthesiology score, using optimized propensity score matching at a ratio of 1 case to 3 controls. We found no significant correlation between lower SES and emergency surgical management (p = 0.122). Secondary analysis assessed the impact of SES on morbidity and length of stay. We found no significant difference in the rate of complications, length of stay and recurrence by SES category. Patients from lower SES brackets had increased odds for readmission (odds ratio 1.979; 95% confidence interval 1.111-4.318). CONCLUSION: We found no correlation between a low SES and the need for emergency inguinal hernia repair, but found an increased rate of readmission in patients from lower SES brackets. This finding should be further scrutinized through a deeper dive into the barriers to access to nonacute care settings, such as home care.

Management of blunt cerebrovascular injuries at a Canadian level 1 trauma centre: Are we meeting the grade?

BACKGROUND: Untreated blunt cerebrovascular injuries (BCVIs) are associated with high rates of death and disability due to stroke. We assessed alignment of clinical practice at our centre with current recommendations for management of BCVIs and examined rates of new and recurrent in-hospital stroke. METHODS: We retrospectively reviewed the BC Trauma Registry to identify all adult (age > 18 yr) patients with trauma with BCVIs at the largest level 1 trauma centre in British Columbia, Canada, from Apr. 1, 2013, to Mar. 31, 2018. We evaluated the registry, hospital databases and patient charts to assess alignment with guidelines for early initiation of appropriate antithrombotic therapy and follow-up imaging, and to ascertain short-term outcomes. RESULTS: A total of 186 patients met the inclusion criteria. Just over half of BCVIs (97 [52.2%]) were Biffl grade 1-2. The majority of patients were treated with acetylsalicylic acid monotherapy (144/162 [88.9%]) or low-molecular-weight heparin (2/162 [1.2%]). Although guidelines recommend repeat imaging at 7-10 days to reassess the injury and guide duration of therapy, only 61/171 patients (35.7%) underwent repeat imaging within 7 days. Neuroimaging within 3 months after injury showed brain infarction in 29 patients (15.6%). CONCLUSION: Antithrombotic therapy was initiated in the majority of eligible patients with BCVIs, but completion of follow-up imaging and documentation of clear outpatient care plans were suboptimal. This finding shows the need for routine multidisciplinary management to facilitate standardization of care for this complex population.

Resuscitative endovascular balloon occlusion of the aorta in Canada: a context-specific position paper from the Canadian Collaborative for Urgent Care Surgery (CANUCS).

SummaryResuscitative endovascular balloon occlusion of the aorta (REBOA) is a well-described intervention for noncompressible torso hemorrhage. Several Canadian centres have included REBOA in their hemorrhagic shock protocols. However, REBOA has known complications and equipoise regarding its use persists. The Canadian Collaborative on Urgent Care Surgery (CANUCS) comprises surgeons who provide acute trauma care and leadership in Canada, with experience in REBOA implementation, use, education and research. Our goal is to provide evidence- and experience-based recommendations regarding institutional implementation of a REBOA program, including multidisciplinary educational programs, attention to device and care pathway logistics, and a robust quality assurance program. This will allow Canadian trauma centres to maximize patient benefits and minimize risks of this potentially life-saving technology.

Failure to rescue in emergency general surgery in Canada.

BACKGROUND: The risk of death after a postoperative complication - known as failure to rescue (FTR) - has been proposed to be superior to traditional benchmarking outcomes, such as complication and mortality rates, as a measure of system quality. The purpose of this study was to identify the current FTR rate in emergency general surgery (EGS) centres across Canada. We hypothesized that substantial variability exists in FTR rates across centres. METHODS: In this multicentre retrospective cohort study, we performed a secondary analysis of data from a previous study designed to evaluate operative intervention for nonappendiceal, nonbiliary disease by 6 EGS services across Canada (1 in British Columbia, 1 in Alberta, 3 in Ontario and 1 in Nova Scotia). Patients underwent surgery between Jan. 1 and Dec. 31, 2014. We conducted univariate analyses to compare patients with and without complications. We performed a sensitivity analysis examining the mortality rate after serious complications (Clavien-Dindo score 3 or 4) that required a surgical intervention or specialized care (e.g., admission to intensive care unit). RESULTS: A total of 2595 patients were included in the study cohort. Of the 206 patients who died within 30 days, 145 (70.4%) experienced a complication before their death. Overall, the mortality rate after any surgical complication (i.e., FTR) was 16.0%. Ranking of sites by the traditional outcomes of complication and mortality rates differed from the ranking when FTR rate was included in the assessment. CONCLUSION: There was variability in FTR rates across EGS services in Canada, which suggests that there is opportunity for ongoing quality-improvement efforts. This study provides FTR benchmarking data for Canadian EGS services.

Trauma Training Courses and Programs in Low- and Lower Middle-Income Countries: A Scoping Review.

BACKGROUND: Injury is the leading cause of morbidity and mortality in low- and lower middle-income countries (LMICs). Trauma training is a cost-effective way to improve injury outcomes. Several trauma programs have been implemented in LMICs; however, their scope and effectiveness remain unclear. In this review, we sought to describe and assess the current state of trauma training in LMICs. METHODS: We searched MEDLINE, Embase, Global Health, Cochrane Library, and ProQuest Dissertations & Theses Global for trauma training courses in LMICs. An additional gray literature search was conducted on university, governmental, and non- governmental organizations' websites to identify trauma-related postgraduate medical education (PGME) opportunities. RESULTS: Most studies occurred in sub-Saharan Africa and participants were primarily physicians/surgeons, medical students/residents, and nurses. General and surgical trauma management courses were most common, followed by orthopedic trauma or plastic surgery trauma/burn care courses. 32/45 studies reported on participant knowledge and skills, 27 of which had minimal follow-up. Of the four studies commenting on cost of courses, only one demonstrated cost-effectiveness. Three articles evaluated post-course effects on patient outcomes, two of which failed to demonstrate significant improvements. Overall, 43.0% of LMICs have PGME programs with defined trauma competency requirements. CONCLUSIONS: Current studies on trauma training in LMICs do not clearly demonstrate sustainability, cost-effectiveness, nor improved outcomes. Trauma training programs should be in response to a need, championed locally, and work within a cohesive system to demonstrate concrete benefits. We recommend standardized and contextualized trauma training with recertifications in LMICs for lasting and improved trauma care.

A systematic review of global surgery partnerships and a proposed framework for sustainability.

Background: Building surgical capacity through global surgery partnerships (GSPs) between high and low- and middle-income countries (LMICs) is a rising global health focus. Our aim was to conduct a systematic review to characterize strategies employed by GSPs to build capacity and promote sustainability and to propose a novel reproducible model for sustainability. Methods: We conducted a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. We searched PubMed, EMBASE, Medline and African Journals Online to identify all peer-reviewed articles published between 2000 and 2016 that described GSPs between partners from the United States or Canada or both and partners from LMICs. We excluded papers that described nonsurgical GSPs, unilateral GSPs (e.g., humanitarian missions) or military initiatives. Descriptive features were analyzed, with a focus on attributes that promote sustainability. We then proposed criteria for sustainability on the basis of the themes that emerged from our review. Results: Our search retrieved 3580 abstracts, which were then independently reviewed by 4 authors. A total of 128 papers (3.6%) met the inclusion criteria. They described GSPs in 68 countries on 5 continents. Among the GSPs, 21.9% demonstrated community engagement and 51.6% included multidisciplinary collaboration. Surgical training or education was provided in 81.3% of GSPs. Although 64.8% of GSPs collected data, only 53.1% reported project-related outcomes. A total of 55.5% had bilateral authorship for publications, and 28.9% had multisource funding. Only 1 GSP fulfilled all 6 of our criteria for sustainability. Conclusion: In this systematic review we identified 6 pillars that are indicators of sustainability: community engagement, multidisciplinary collaboration, education and training, outcomes reporting, bilateral authorship and multisource funding. We propose that future GSPs should build on a foundation of bilateral ideas and expertise exchange, that they should have defined and measurable objectives, that they should engage in continuous evaluation of program outcomes and that they should take a thoughtful and transparent approach to sustained capacity building.

Contexte: Le renforcement de la capacité chirurgicale au moyen de partenariats internationaux en chirurgie (PIC) entre les pays à revenu élevé et ceux à revenu faible ou intermédiaire (PRFI) prend de plus en plus de place en santé mondiale. Nous avons donc réalisé une revue systématique pour caractériser les stratégies de renforcement de la capacité et de promotion de la pérennité employées dans le cadre des PIC, ainsi que pour proposer un modèle de pérennité novateur et reproductible. Méthodes: Pour notre revue systématique, nous avons suivi le modèle Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Nous avons interrogé les bases de données PubMed, Embase, MEDLINE et African Journals Online pour trouver tous les articles évalués par des pairs publiés entre 2000 et 2016 présentant des PIC conclus entre des organismes des États-Unis ou du Canada (ou les 2) et des organismes de PRFI. Nous avons exclu les articles portant sur des partenariats internationaux dans un domaine autre que la chirurgie, les PIC unilatéraux (p. ex., missions humanitaires) et les initiatives militaires. Nous avons analysé les caractéristiques descriptives des partenariats, en particulier les attributs favorisant leur pérennité. Nous avons ensuite proposé des critères de pérennité en fonction des thèmes dégagés dans la revue systématique. Résultats: Les 3580 résumés recensés lors de la recherche initiale ont été évalués de façon indépendante par 4 auteurs. Au total, 128 articles (3,6 %) répondaient aux critères d'inclusion. Ces articles présentaient des PIC impliquant 68 pays de 5 continents. De ces PIC, 21,9 % comportaient une mobilisation communautaire, et 51,6 %, une collaboration multidisciplinaire. Une formation ou un enseignement relatif à la chirurgie était fourni dans 81,3 % des cas. Si 64,8 % des PIC comprenaient une collecte de données, seuls 53,1 % ont produit des rapports sur les issues du projet. En tout, 55,5 % des PIC avaient conclu une entente de paternité bilatérale pour la publication, et 28,9 % avaient bénéficié d'un financement multisource. Un seul PIC répondait aux 6 critères de pérennité établis. Conclusion: Six indicateurs de pérennité ont été dégagés dans le cadre de cette revue systématique : mobilisation communautaire, collaboration multidisciplinaire, éducation et formation, production de rapports sur les issues, entente de paternité bilatérale et financement multisource. Les futurs PIC devraient reposer sur un échange d'idées et de connaissances, avoir des objectifs définis et mesurables, évaluer sans cesse les issues du programme et adopter une approche réfléchie et transparente quant au renforcement continu de la capacité.

Acute care surgery, trauma and disaster relief: a clinical exchange between the University of British Columbia and the Mexican Red Cross.

Background: Our objective was to establish a sustainable educational partnership and clinical exchange between the trauma services at Vancouver General Hospital (VGH) and the Mexican Red Cross hospital in Mexico City (Hospital Central de la Cruz Roja [HCCR] Polanco). Methods: In 2017, a general surgery resident in postgraduate year 4 travelled from VGH to HCCR Polanco for the initial exchange, followed by a trauma fellow. The surgical case volumes in a month at VGH and a month at HCCR Polanco were compared. At the end of the exchange, a 36-item Likert style questionnaire was administered to the Mexican surgeons and residents who interacted with the Canadian resident and fellow during the exchange. Results: The most commonly performed procedures on the VGH acute care surgery service were laparoscopic cholecystectomy (35%) and laparoscopic appendectomy (17%). The most commonly performed procedures on the VGH trauma service were chest tube insertions (24%) and tracheostomies (24%). The most commonly performed procedures at HCCR Polanco were surgery for penetrating abdominal trauma (19%) and extremity trauma (13%). The survey results indicated that the costs of travel and accommodation were obstacles to future exchanges. All survey respondents wanted to continue collaborating with Canadians on clinical and research endeavours, felt that hosting Canadian residents was a valuable experience and felt that visiting VGH would also be valuable. Conclusion: Canadian surgical trainees gained valuable exposure to operative trauma during the exchange. The mix of operations performed at VGH and HCCR Polanco was vastly different; therefore, the exchange broadened the trainees' surgical experience. There was a unanimously positive response to the exchange among the Mexican survey respondents. This exchange is part of a long-term collaboration between our surgical centres.

Contexte: Notre objectif était d'établir un partenariat pédagogique et un échange clinique durables entre les services de traumatologie de l'Hôpital général de Vancouver (VGH) et de l'hôpital de la Croix-Rouge mexicaine à Mexico (Hospital Central de la Cruz Roja [HCCR] Polanco). Méthodes: En 2017, un résident R4 en chirurgie générale du VGH s'est rendu au HCCR Polanco pour l'échange inaugural; un fellow en traumatologie l'a suivi peu après. Les volumes de cas de chirurgie par mois dans les 2 hôpitaux ont été comparés. À la fin de l'échange, les chirurgiens et les résidents mexicains qui ont interagi avec le résident et le fellow canadiens ont répondu à un questionnaire en 36 points s'apparentant à l'échelle de Likert. Résultats: Les interventions les plus fréquemment effectuées au service chirurgical d'urgence du VGH étaient la cholécystectomie laparoscopique (35 %) et l'appendicectomie laparoscopique (17 %); au service de traumatologie, les plus fréquentes étaient l'insertion d'un drain thoracique (24 %) et la trachéotomie (24 %). Au HCCR Polanco, les interventions chirurgicales les plus courantes étaient la chirurgie pour un traumatisme abdominal pénétrant (19 %) et un traumatisme aux extrémités (13 %). Les résultats du questionnaire suggèrent que les coûts associés aux déplacements et à l'hébergement seraient un obstacle pour les échanges futurs. Cela dit, tous les répondants ont dit vouloir poursuivre leur collaboration avec les Canadiens dans des projets cliniques et de recherche, considérer que l'accueil de résidents canadiens était une expérience profitable et qu'ils gagneraient à se rendre eux-mêmes au VGH. Conclusion: Durant l'échange, les chirurgiens en formation canadiens ont reçu une exposition précieuse à la chirurgie traumatologique. Puisque la nature et la fréquence relative des opérations effectuées au VGH étaient très différentes de celles observées au HCCR Polanco, l'échange a contribué à diversifier l'expérience chirurgicale des apprenants. Tous les répondants mexicains au questionnaire avaient une expérience positive de l'échange. Le programme fait partie d'une collaboration à long terme entre les 2 centres chirurgicaux.

Morbidity and mortality conferences in general surgery: a narrative systematic review.

Background: In medical and surgical departments around the world, morbidity and mortality conferences (MMC) serve dual roles: they are cornerstones of quality-improvement programs and provide timely opportunities for education within the urgent context of clinical care. Despite the widespread adoption of MMCs, adverse events and preventable errors remain high or incompletely characterized, and opportunities to learn from and adjust to these events are frequently lost. This review examines the published literature on strategies to improve surgical MMCs. Methods: We searched OVID Medline, PubMed, Embase and CENTRAL. We defined our combination of search terms using a PICO (population, intervention, comparison, outcome) model, focusing on the use of MMCs in general surgery. Results: The MMC literature focused on 5 themes: educational value, error analysis, case selection and representation, attendance and dissemination. Strategies used to increase educational value included limiting case presentation time to 15-20 minutes, mandatory brief literature reviews, increasing audience interaction, and standardizing presentations using a PowerPoint template or SBAR (situation, background, assessment, recommendation) format. Interventions to improve error analysis included focused discussion on causative factors and taxonomic error analysis. Case selection was improved by using an electronic clinical registry, such as the National Surgery Quality Improvement Program, to better capture incidence of morbidity and mortality. Attendance was improved with teleconferencing. Dissemination strategies included MMC newsletters, incorporating MMCs into plan-do-check-act cycles, and surgeon report cards. Conclusion: Greater standardization of best practices may increase the quality improvement and educational impact of MMCs and provide a baseline to measure the effect of new MMC format innovations on the clinical and educational performance of surgical systems.

Contexte: Dans les services de médecine et de chirurgie du monde entier, les conférences sur la morbidité et la mortalité (CMM) jouent 2 rôles : elles forment la pierre angulaire des programmes d'amélioration de la qualité de soins et fournissent l'occasion de faire de l'enseignement dans le contexte même des soins cliniques immédiats. Malgré la popularité grandissante des CMM, le nombre d'événements indésirables et d'erreurs évitables demeure élevé ou mal caractérisé et on perd beaucoup d'occasions d'apprendre de ces événements et d'apporter les changements qui s'imposent. La présente revue analyse la littérature publiée sur les stratégies d'amélioration des CMM en chirurgie. Méthodes: Nous avons interrogé OVID Medline, PubMed, Embase et CENTRAL. Nous avons défini nos combinaisons de mots clés à l'aide du modèle PICO (population, intervention, comparaison et résultat [outcome]), en mettant l'accent sur l'utilisation des CMM en chirurgie générale. Résultats: La littérature sur les CMM se concentrait sur 5 thèmes : valeur didactique, analyse des erreurs, sélection et représentation des cas, participation et dissémination. Les stratégies utilisées pour accroître la valeur didactique incluaient limiter la durée des présentations de cas à 15­20 minutes, présenter de brèves revues de la littérature, favoriser les interactions avec l'auditoire et standardiser les présentations au moyen de modèles PowerPoint ou SBAR (situation, background, assessment, recommendation). Les interventions visant à améliorer l'analyse des erreurs incluaient une discussion sur les facteurs causaux et l'analyse des erreurs taxonomiques. La sélection des cas a été améliorée au moyen d'un registre clinique électronique comme le National Surgery Quality Improvement Program, pour mieux suivre l'incidence de la morbidité et de la mortalité. Les systèmes de téléconférences ont amélioré la participation. Parmi les stratégies de dissémination, mentionnons les bulletins sur les CMM, leur intégration aux cycles planifier/faire/vérifier/agir et les relevés de notes des chirurgiens. Conclusion: Une meilleure standardisation des pratiques optimales pourrait améliorer davantage la qualité des soins et augmenter l'impact didactique des CMM en plus d'offrir une base de référence pour mesurer l'effet des nouvelles mesures appliquées aux CMM sur le rendement clinique et didactique des systèmes chirurgicaux.

Patterns of complex emergency general surgery in Canada.

BACKGROUND: Most of the literature on emergency general surgery (EGS) has investigated appendiceal and biliary disease; however, EGS surgeons manage many other complex conditions. This study aimed to describe the operative burden of these conditions throughout Canada. METHODS: This multicentre retrospective cohort study evaluated EGS patients at 7 centres across Canada in 2014. Adult patients (aged ≥ 18 yr) undergoing nonelective operative interventions for nonbiliary, nonappendiceal diseases were included. Data collected included information on patients' demographic characteristics, diagnosis, procedure details, complications and hospital length of stay. Logistic regression was used to identify predictors of morbidity and mortality. RESULTS: A total of 2595 patients were included, with a median age of 60 years (interquartile range 46-73 yr). The most common principal diagnoses were small bowel obstruction (16%), hernia (15%), malignancy (11%) and perianal disease (9%). The most commonly performed procedures were bowel resection (30%), hernia repair (15%), adhesiolysis (11%) and débridement of skin and soft tissue infections (10%). A total of 47% of cases were completed overnight (between 5 pm and 8 am). The overall inhospital mortality rate was 8%. Thirty-three percent of patients had a complication, with independent predictors including increasing age (p = 0.001), increasing American Society of Anesthesiologists score (p = 0.02) and transfer from another centre (p = 0.001). CONCLUSION: This study characterizes the epidemiology of nonbiliary, nonappendiceal EGS operative interventions across Canada. Canadian surgeons are performing a large volume of EGS, and conditions treated by EGS services are associated with a substantial risk of morbidity and mortality. Results of this study will be used to guide future research efforts and set benchmarks for quality improvement.

CONTEXTE: La plupart des études sur les services de chirurgie générale d'urgence (CGU) s'intéressent seulement aux atteintes de l'appendice et de la vésicule biliaire. Pourtant, les chirurgiens du domaine traitent beaucoup d'autres problèmes complexes. L'objectif de l'étude était de décrire le travail chirurgical associé à ces problèmes dans l'ensemble du Canada. MÉTHODES: Notre étude de cohorte rétrospective multicentrique inclut les patients adultes (≥ 18 ans) qui ont subi en 2014 une opération non planifiée pour une atteinte qui ne touchait ni l'appendice ni la vésicule biliaire dans 1 des 7 centres sélectionnés, répartis un peu partout au pays. Nous avons recueilli les données suivantes : renseignements de base des patients, diagnostic, détails de l'intervention, nature des complications et durée d'hospitalisation. Puis nous avons dégagé les facteurs prédictifs de morbidité et de mortalité en appliquant un modèle de régression logistique. RÉSULTATS: L'échantillon totalisait 2595 patients, pour un âge médian de 60 ans (écart interquartile 46­73 ans). Les diagnostics principaux les plus courants étaient l'occlusion de l'intestin grêle (16 %), la hernie (15 %), la tumeur maligne (11 %) et les lésions périanales (9 %). Les interventions les plus fréquentes étaient la résection de l'intestin (30 %), la réparation d'une hernie (15 %), le débridement (11 %) et le débridement de tissus mous ou cutanés infectés (10 %). L'opération a eu lieu le soir ou la nuit (entre 17 h et 8 h) dans 47 % des cas. Le taux global de mortalité à l'hôpital était de 8 %. Des complications sont survenues chez 33 % des patients, dont les facteurs prédictifs indépendants étaient l'âge avancé (p = 0,001), un score ASA (de l'American Society of Anesthesiologists) élevé (p = 0,02) et le transfert à partir d'un autre centre (p = 0,001). CONCLUSION: Cette étude dresse le profil épidémiologique des interventions effectuées par les services de CGU du Canada en présence d'atteintes autres que celles de l'appendice et de la vésicule biliaire. Les chirurgiens du pays font beaucoup d'interventions générales urgentes, pour traiter des affections associées à un risque élevé de morbidité et de mortalité. Les résultats de l'étude guideront les prochaines recherches et serviront de points de référence en matière d'amélioration de la qualité.

Process mapping as a framework for performance improvement in emergency general surgery.

BACKGROUND: Emergency general surgery conditions are often thought of as being too acute for the development of standardized approaches to quality improvement. However, process mapping, a concept that has been applied extensively in manufacturing quality improvement, is now being used in health care. The objective of this study was to create process maps for small bowel obstruction in an effort to identify potential areas for quality improvement. METHODS: We used the American College of Surgeons Emergency General Surgery Quality Improvement Program pilot database to identify patients who received nonoperative or operative management of small bowel obstruction between March 2015 and March 2016. This database, patient charts and electronic health records were used to create process maps from the time of presentation to discharge. RESULTS: Eighty-eight patients with small bowel obstruction (33 operative; 55 nonoperative) were identified. Patients who received surgery had a complication rate of 32%. The processes of care from the time of presentation to the time of follow-up were highly elaborate and variable in terms of duration; however, the sequences of care were found to be consistent. We used data visualization strategies to identify bottlenecks in care, and they showed substantial variability in terms of operating room access. CONCLUSION: Variability in the operative care of small bowel obstruction is high and represents an important improvement opportunity in general surgery. Process mapping can identify common themes, even in acute care, and suggest specific performance improvement measures.

CONTEXTE: Les conditions dans lesquelles s'effectuent les interventions chirurgicales d'urgence sont souvent jugées trop pressantes pour que l'on puisse mettre au point des approches normalisées d'amélioration de la qualité. Malgré tout, la schématisation des processus, un concept largement appliqué à l'amélioration de la qualité en milieu manufacturier, est maintenant appliquée en santé. L'objectif de cette étude était de schématiser les processus suivis dans les cas d'obstruction du grêle afin de déterminer les aspects dont la qualité pourrait être améliorée. MÉTHODES: À partir de la base de données pilote du programme d'amélioration de la qualité des chirurgies générales d'urgence de l'American College of Surgeons, nous avons recensé les patients ayant reçu un traitement chirurgical ou non chirurgical pour une obstruction du grêle entre mars 2015 et mars 2016. Nous avons aussi utilisé cette base de données, de même que les dossiers des patients et les dossiers médicaux électroniques, pour schématiser les processus suivis de l'arrivée à l'hôpital jusqu'au congé. RÉSULTATS: Nous avons recensé 88 patients atteints d'une obstruction du grêle (33 soumis à une chirurgie, et 55 à un traitement non chirurgical). Les patients opérés ont présenté un taux de complications de 32 %. Les processus thérapeutiques de l'arrivée au suivi se sont avérés très détaillés et variables en durée; par contre, la séquence de soins était uniforme. Nous avons utilisé des stratégies de visualisation des données pour repérer les goulots d'étranglement au chapitre des soins, ce qui a révélé une variabilité substantielle dans l'accès au bloc opératoire. CONCLUSION: La variabilité observée dans les soins chirurgicaux pour l'obstruction du grêle est élevée et représente une importante occasion d'amélioration en chirurgie générale. La schématisation des processus permet de dégager des thèmes communs, même dans un contexte d'urgence, et met en lumière des possibilités précises d'amélioration du rendement.

What Are the Expected Findings on Follow-up Computed Tomography Angiogram in Post-traumatic Patients With Blunt Cerebrovascular Injury?

PURPOSE: Blunt cerebrovascular injury (BCVI) is a rare but potentially devastating diagnosis. Our study establishes the temporal changes and findings on follow-up imaging. METHODS: For this retrospective, institutional review board-approved study, the hospital trauma registry was queried for all severely injured polytrauma patients who underwent computed tomography angiogram (CTA) scans in the emergency department between January 1, 2010, and December 31, 2016, with injury severity score ≥16, yielding 3747 patients. A total of 128 patients had a follow-up CTA for BCVI. The grade, location, and outcomes of injuries on follow-up imaging were studied. RESULTS: A vehicular collision was the most common mechanism of injury (75%). The majority of patients (61%) had a Glasgow Coma Scale of 10-15. Vertebral fractures were the most common associated injury (57%). The overall incidence of BCVI in our study population was 4.8%. On the initial CTA, 50% of injuries were grade 1, 25.4% were grade 2, 7% were grade 3, 17% were grade 4, and 0.6% were grade 5. For the different grades of injuries, improvement has been documented in 44% with complete healing in 34%, while 51% of injuries remained unchanged from the initial scan. Only 5% progressed to a higher-grade injury. Twelve patients developed strokes with an incidence of 9.4% in patients with a follow-up CTA. CONCLUSIONS: This study can help increase the awareness of radiologists about the evolution patterns of different grades of BCVIs on follow-up CTA for severely injured posttraumatic patients.

Use of Innovative Technology in Surgical Training in Resource-Limited Settings: A Scoping Review.

BACKGROUND: There has been a rapid growth in interest in global surgery. This increased commitment to improving global surgical care, however, has not translated into an equal exchange of surgical information between high-income countries (HICs) and low-income countries (LMICs). In recent years, a greater emphasis has been placed on training local medical personnel in order to increase surgical capacity while simultaneously decreasing reliance on expatriate visitors. Virtual curricular models, simulators, and immersive technologies have been developed and implemented in order to maximize training opportunities in low-resource settings. This study aims to assess and summarize innovative technologies used for surgical training in low-resource settings. METHODS: We conducted a scoping review of the literature from 2000 to 2021. We included both academic and grey literature on surgical education technologies. Searches were performed on Medline and Embase as well as on Google, iOS, and Android app stores. RESULTS: Four main categories of surgical training platforms were identified: web-based platforms, app-based platforms, virtual and augmented reality, and simulation. The platforms were analyzed based on their content, effectiveness, cost, accessibility, and barriers to use. CONCLUSIONS: Virtual learning platforms show potential in surgical training as they are easily accessible, not limited by geography, continuously updated, and evaluated for effectiveness. In order to provide access to educational resources for surgical trainees all around the world, particularly in low-resource settings, increased effort and resources should be dedicated to developing free, open-access surgical training programs . Doing so will promote sustainable and equitable development in global surgical care.

Barriers to Accessing Congenital Heart Surgery in Low- and Middle-Income Countries: A Systematic Review.

BACKGROUND: Congenital heart disease (CHD) is the most common major congenital anomaly. Ninety percent of children with CHD are born in low- and middle-income countries (LMICs), where over 90% of patients lack access to necessary treatments. Reports on barriers to accessing CHD care are limited. Accordingly, it is difficult to design evidence-based interventions to increase access to congenital cardiac surgical care in LMICs. OBJECTIVE: We performed a qualitative systematic review to understand barriers to accessing congenital cardiac surgical care in LMICs. METHODS: We conducted a search of Ovid MEDLINE and CINAHL databases to identify relevant articles from January 2000 to May 2021. We then used a thematic analysis to summarize qualitative data into a framework of preoperative, perioperative, and postoperative barriers. RESULTS: Our search yielded 1,585 articles, of which 67 satisfied the inclusion criteria. Notable preoperative barriers included delayed diagnosis, insufficient caregiver education, financial constraints, difficulty reaching treatment centers, sociocultural stigma of CHD, sex-based discrimination of patients with CHD, and Indigeneity. Perioperative barriers included lack of hospital resources and workforce, need for prolonged hospitalization, and strained physician-patient relationships. Many patients faced barriers postoperatively and into adulthood due to a shortage of critical care resources, inadequate caregiver counseling and patient education, lack of follow-up, and debt from hospital bills and missed work. CONCLUSION: Reducing neonatal and childhood mortality begins with recognizing barriers to accessing health care. Our systematic review identifies and classifies challenges in accessing CHD in LMICs and suggests solutions to major barriers.

Extracorporeal life support in trauma: Indications and techniques.

BACKGROUND: Clarity about indications and techniques in extracorporeal life support (ECLS) in trauma is essential for timely and effective deployment, and to ensure good stewardship of an important resource. Extracorporeal life support deployments in a tertiary trauma center were reviewed to understand the indications, strategies, and tactics of ECLS in trauma. METHODS: The provincial trauma registry was used to identify patients who received ECLS at a Level I trauma center and ECLS organization-accredited site between January 2014 and February 2021. Charts were reviewed for indications, technical factors, and outcomes following ECLS deployment. Based on this data, consensus around indications and techniques for ECLS in trauma was reached and refined by a multidisciplinary team discussion. RESULTS: A total of 25 patients underwent ECLS as part of a comprehensive trauma resuscitation strategy. Eighteen patients underwent venovenous ECLS and seven received venoarterial ECLS. Nineteen patients survived the ECLS run, of which 15 survived to discharge. Four patients developed vascular injuries secondary to cannula insertion while four patients developed circuit clots. On multidisciplinary consensus, three broad indications for ECLS and their respective techniques were described: gas exchange for lung injury, extended damage control for severe injuries associated with the lethal triad, and circulatory support for cardiogenic shock or hypothermia. CONCLUSION: The three broad indications for ECLS in trauma (gas exchange, extended damage control and circulatory support) require specific advanced planning and standardization of corresponding techniques (cannulation, circuit configuration, anticoagulation, and duration). When appropriately and effectively integrated into the trauma response, ECLS can extend the damage control paradigm to enable the management of complex multisystem injuries. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Chest trauma clinical practice guideline protects against delirium in patients with rib fractures.

Introduction: Traumatic rib fractures present a considerable risk to patient well-being, contributing to morbidity and mortality in trauma patients. To address the risks associated with rib fractures, evidence-based interventions have been implemented, including effective pain management, pulmonary hygiene, and early walking. Vancouver General Hospital, a level 1 trauma center in British Columbia, Canada, developed a comprehensive multidisciplinary chest trauma clinical practice guideline (CTCPG) to optimize the management of patients with rib fractures. This prospective cohort study aimed to assess the impact of the CTCPG on pain management interventions and patient outcomes. Methods: The study involved patients admitted between January 1, 2021 and December 31, 2021 (post-CTCPG cohort) and a historical control group admitted between November 1, 2018 and December 31, 2019 (pre-CTCPG cohort). Patient data were collected from patient charts and the British Columbia Trauma Registry, including demographics, injury characteristics, pain management interventions, and relevant outcomes. Results: Implementation of the CTCPG resulted in an increased use of multimodal pain therapy (99.4% vs 96.1%; p=0.03) and a significant reduction in the incidence of delirium in the post-CTCPG cohort (OR 0.43, 95% CI 0.21 to 0.80, p=0.0099). There were no significant differences in hospital length of stay, ICU (intensive care unit) days, non-invasive positive pressure ventilation requirement, ventilator days, pneumonia incidence, or mortality between the two cohorts. Discussion: Adoption of a CTCPG improved chest trauma management by enhancing pain management and reducing the incidence of delirium. Further research, including multicenter studies, is warranted to validate these findings and explore additional potential benefits of the CTCPG in the management of chest trauma patients. Level of evidence: IIb.

Prognostic factors associated with risk of stroke following blunt cerebrovascular injury: A systematic review and meta-analysis.

BACKGROUND & OBJECTIVES: Blunt cerebrovascular injury (BCVI) includes carotid and/or vertebral artery injury following trauma, and conveys an increased stroke risk. We conducted a systematic review and meta-analysis to provide a comprehensive summary of prognostic factors associated with risk of stroke following BCVI. METHODS: We searched the EMBASE and MEDLINE databases from January 1946 to June 2023. We identified studies reporting associations between patient or injury factors and risk of stroke following BCVI. We performed meta-analyses of odds ratios (ORs) using the random effects method and assessed individual study risk of bias using the QUIPS tool. We separately pooled adjusted and unadjusted analyses, highlighting the estimate with the higher certainty. RESULTS: We included 26 cohort studies, involving 20,458 patients with blunt trauma. The overall incidence of stroke following BCVI was 7.7 %. Studies were predominantly retrospective cohorts from North America and included both carotid and vertebral artery injuries. Diagnosis of BCVI was most commonly confirmed with CT angiography. We demonstrated with moderate to high certainty that factors associated with increased risk of stroke included carotid artery injury (as compared to vertebral artery injury, unadjusted odds ratio [uOR] 1.94, 95 % CI 1.62 to 2.32), Grade III Injury (as compared to grade I or II) (uOR 2.45, 95 % CI 1.88 to 3.20), Grade IV injury (uOR 3.09, 95 % CI 2.20 to 4.35), polyarterial injury (uOR 3.11 (95 % CI 2.05 to 4.72), occurrence of hypotension at the time of hospital admission (adjusted odds ratio [aOR] 1.32, 95 % CI 0.87 to 2.03) and higher total body injury severity (aOR 5.91, 95 % CI 1.90 to 18.39). CONCLUSION: Local anatomical injury pattern, overall burden of injury and flow dynamics contribute to BCVI-related stroke risk. These findings provide the foundational evidence base for risk stratification to support clinical decision making and further research.

Interest and applicability of acute care surgery among surgeons in Quebec: a provincial survey.

BACKGROUND: Acute care surgery (ACS) comprises trauma and emergency surgery. The purpose of this new specialty is to involve trauma and nontrauma surgeons in the care of acutely ill patients with a surgical pathology. In Quebec, few acute care surgery services (ACSS) exist, and the concept is still poorly understood by most general surgeons. This survey was meant to determine the opinions and interest of Quebec general surgeons in this new model. METHODS: We created a bilingual electronic survey using a Web interface and sent it by email to all surgeons registered with the Association québécoise de chirurgie. A reminder was sent 2 weeks later to boost response rates. RESULTS: The response rate was 36.9%. Most respondents had academic practices, and 16% worked in level 1 trauma centres. Most respondents had a high operative case load, and 66% performed at least 10 urgent general surgical cases per month. Although most (88%) thought that ACS was an interesting field, only 45% were interested in participating in an ACSS. Respondents who deemed this concept least applicable to their practices were more likely to be working in nonacademic centres. CONCLUSION: Despite a strong interest in emergency general surgery, few surgeons were interested in participating in an ACSS. This finding may be explained by lack of comprehension of this new model and by comfort with traditional practice. We aim to change this paradigm by demonstrating the feasibility and benefits of the new ACSS at our centre in a follow-up study.

CONTEXTE: Les soins intensifs chirurgicaux comprennent la chirurgie traumatologique et la chirurgie d'urgence. Cette nouvelle spécialité a pour but de faire participer les chirurgiens traumatologues et non traumatologues aux soins des patients gravement malades qui nécessitent une chirurgie. Au Québec, il existe peu de services de soins intensifs chirurgicaux et ce concept est encore méconnu de la plupart des chirurgiens généraux. Ce sondage visait à sonder l'opinion et l'intérêt des chirurgiens généraux du Québec au sujet de ce nouveau modèle. of General Surgery, Centre Hospitalier Affilié Universitaire de Québec, Québec, Que. MÉTHODES: Nous avons créé un questionnaire électronique bilingue au moyen d'une interface Web et l'avons envoyé par courriel à tous les chirurgiens inscrits auprès de l'Association québécoise de chirurgie. Un rappel a été envoyé 2 semaines plus tard pour améliorer le taux de réponse au questionnaire. RÉSULTANTS: Le taux de réponse a été de 36,8 %. La plupart des répondants occupaient des postes universitaires et 16 % travaillaient dans des centres de traumatologie de niveau 1. La plupart des répondants ont dit opérer beaucoup et 66 % ont dit pratiquer au moins 10 chirurgies générales urgentes chaque mois. Même si la majorité des répondants (88 %) se sont dits d'avis que les soins intensifs chirurgicaux étaient un domaine intéressant, seulement 45 % ont exprimé le souhait de participer à un service de ce type. Les répondants pour qui ce concept a semblé le moins applicable à leur pratique étaient plus susceptibles d'exercer dans des centres non universitaires. CONCLUSIONS: Malgré un intérêt marqué à l'endroit des soins intensifs chirurgicaux, peu de chirurgiens ont semblé souhaiter participer à un service de ce type. Ce fait peut s'expliquer par la méconnaissance de ce nouveau modèle et par la force de l'habitude associée à la pratique traditionnelle. Nous visons à modifier ce paradigme en démontrant la faisabilité et les avantages d'un nouveau modèle de service de soins intensifs chirurgicaux dans notre centre lors d'une étude de suivi.