Feeding Tube Clinic Effect on Nutrition.

BACKGROUND: Optimizing nutrition is essential for recovery after major surgery or severe illness. Feeding tubes (FT) can be placed in patients limited by oral enteral nutrition. Given the myriad of locations in which these procedures are performed (radiology, intensive care unit, and endoscopy suite), routine follow-up is challenging. The purpose of this study was to evaluate the impact of an FT clinic on nutrition. We hypothesized that enrollment in the FT clinic would result in improved nutritional outcomes. METHODS: Retrospective review of Veteran Affairs Medical Center patients with FTs placed from January 2010 to January 2020. Demographics and body mass index (BMI) were recorded. Serum albumin recorded within 1 month of tube placement was compared to within 1 month of tube removal, death, or at the end of the study period. FT clinic participation required at least 2 visits. Indications for FT placement and duration were recorded. Patients were excluded when both BMI and albumin values were incomplete, and if FTs were placed for decompression. RESULTS: Ninety-three patients underwent FT placement during the study period; 5 (5%) were excluded. The average age was 64.8±9.7 years, with the majority being male, 85 patients (97%). Eighteen (20%) patients were seen in the FT clinic (FTC) and 70 (80%) were managed outside of FTC (nFTC). There were no differences in age, gender, or indication for FT. Mean albumin increased 0.42±0.85 g/dL in the FTC group versus -0.07±0.72 g/dL in the nFTC group (P=0.037). The FTC group BMI increased, 0.38 kg/m2 vs. -1.48 kg/m2 in nFTC patients, P=0.041. The FTC patients maintained their tubes longer (36.5 vs. 7.0 mo, P=0.0014). CONCLUSIONS: Patients managed in a dedicated FT clinic experienced an improvement in their serum albumin values and increases in their BMI. In addition, they also maintained their FTs longer. To optimize nutrition and reduce weight loss, patients who require FTs should be enrolled in a dedicated FT clinic.

Preoperative Risk Factors for Discharge to Facility After Surgery in Geriatric Patients.

BACKGROUND: The Geriatric Surgery Verification Program (GSV) was developed to address perioperative care for patients ≥75 years, with a goal of improving outcomes and functional abilities after surgery. We sought to evaluate preoperative factors that place patients at risk for inability to return home (ie, discharge to a facility). METHODS: Retrospective review of patients ≥75 years old who underwent inpatient surgery from January 2018 to December 2022 at a referral Veterans Administration Medical Center enrolled in the GSV program. Preoperative factors included fall history, mobility aids, housing status, function, cognition, and nutritional status. Postoperative outcomes were discharge designations as home and home with services compared to a facility (skilled nursing facility and acute rehab). Exclusion criteria included preoperative facility residence, cardiac surgery, hospital transfer, postoperative complications, hospice discharge, or in-hospital mortality. RESULTS: 605 patients met inclusion criteria and 173 (29%) excluded as above. Of the remaining 432 patients, mean age was 79 ± 5 and the majority were male, 426 (99%). The majority of patients were discharged home, 388 (90%), compared to a facility, 44 (10%). Patients with a fall history (OR: 2.95, 95% CI: 1.56, 5.57), utilizing a mobility aid (OR: 6.0, 95% CI: 2.8, 12.83), were partial or totally dependent (OR: 4.83, 95% CI: 2.29, 10.17), or who lived alone (OR: 2.57, 95% CI: 1.08, 6.07) had higher rates of discharge to a facility. DISCUSSION: Preoperative mobility compromise and functional dependence are associated with higher rates of discharge to a facility. These preoperative factors are possibly modifiable with multidisciplinary care teams to decrease risks of facility placement.

Evaluation of veteran community care outcomes after coronary artery bypass grafting: a retrospective pilot cohort.

For Veterans who cannot be seen in a timely fashion or must travel long distances to be seen, the Veterans Health Administration (VHA) offers funded care in the community. The use of this program has rapidly increased; however, there have been no systematic evaluations of surgery specific metrics such as perioperative complications, mortality and timeliness of care. To evaluate this in cardiac surgery patients, we compared veterans undergoing coronary artery bypass grafting in the community to those remaining within the VHA. We identified 78 patients during calendar year 2018 meeting inclusion criteria. 41 underwent surgery in the community versus 37 in the VHA. There were no significant differences in baseline demographics including age, sex, race, ethnicity, comorbidities and surgical risk scores. With regard to perioperative outcomes, veterans who underwent surgery within the VHA had lower infection rates (17% vs. 0%, p = 0.008) and 30-day emergency department utilization (22% vs. 5%, p = 0.04). A longer median postoperative inpatient stay was also seen within the VHA (8 days vs. 6 days, p < 0.001). These findings suggest that the VHA may better serve Veterans and prevent adverse events after CABG, at the expense of prolonged hospitalization. More study is needed to validate the findings of this pilot study.

Clin-STAR corner: Practice-changing advances at the interface of surgery and geriatrics.

Older adults who undergo major operations are at high risk for complications, disability, and death. The physio-social compromises unique to older adults are not routinely assessed and managed in the perioperative setting. Currently, the most practice-changing topic nationally in geriatric surgery is the implementation of comprehensive, multidisciplinary geriatric care pathways to provide age-friendly care for older adults throughout their perioperative course. This review presents three recently published articles focused on defining evidence-based outcomes associated with implementation of a comprehensive geriatric surgery program for older adults undergoing major inpatient operations. These studies serve as the initial evidence evaluating the efficacy and effectiveness of comprehensive perioperative geriatric surgery programs. Each study was chosen due to their high potential for meaningful impact for both clinicians and healthcare systems looking to improve their surgical care of older adults.

Outpatient surgery postoperative ambulation and emergency department utilization.

BACKGROUND: The ability to ambulate is an important indicator for wellness and quality of life. A major health event, such as a surgery, can derail this ability, and return to preoperative walking ability is a marker for recovery. Self-reported walking measurements by patients are subject to bias, thus wearable technology such as activity monitors have risen in popularity. We evaluated postoperative ambulation using an accelerometer in outpatient general surgery procedures with the hypothesis that those patients with less postoperative ambulation were at risk for adverse outcomes. METHODS: A retrospective review of patients undergoing outpatient abdominal surgeries from November 2016 to July 2019 at a Veteran Affairs Medical Center. Patients wore an accelerometer preoperatively and postoperatively to measure their ambulation (steps/day). Outcome measures were 30-day readmissions and Emergency Department (ED) utilization. Postoperative ambulation was defined as daily percentages of their preoperative baseline. Patients without preoperative baseline data, > 3 missing days or any missing days prior to reaching baseline were excluded. RESULTS: One-hundred-six patients underwent outpatient abdominal surgery. Twenty-two patients were excluded. Patients stratified into adult (18-64 years, 44 patients, 52%) and geriatric (≥ 65 years, 40 patients, 48%) cohorts. Geriatric patients were less likely to meet their preoperative baseline by postoperative day 7, 35% vs 61%, p = 0.016. Adult patients who failed to meet their preoperative baseline in first postoperative week had higher ED utilization; 4 (24%) vs 1 (4%), p = 0.04. Geriatric patients who failed to meet their baseline trended toward increased ED utilization; 5 (19%) vs. 1 (7%), p = 0.31. CONCLUSION: Patients aged < 65 who fail to return to their preoperative daily step count within one week of outpatient abdominal surgery are 6× more likely to be seen in the ED. Postoperative ambulation may be able to predict ED utilization and recovery after outpatient surgery.

Telehealth for general surgery postoperative care.

BACKGROUND: Telehealth utilization rapidly increased following the pandemic. However, it is not widely used in the Veteran surgical population. We sought to evaluate postoperative telehealth in patients undergoing general surgery. METHODS: Retrospective review of Veterans undergoing general surgery at a level 1A VA Medical Center from June 2019 to September 2021. Exclusions were concomitant procedure(s), discharge with drains or non-absorbable sutures/staples, complication prior to discharge or pathology positive for malignancy. RESULTS: 1075 patients underwent qualifying procedures, 124 (12 â€‹%) were excluded and 162 (17 â€‹%) did not have follow-up. 443 (56 â€‹%) patients followed-up in-person (56 â€‹%) vs 346 (44 â€‹%) via telehealth. Telehealth patients had a lower rate of complications, 6 â€‹% vs 12 â€‹%, p â€‹= â€‹0.013. There were no significant differences in ED visits, 30-day readmission, postoperative procedures or missed adverse events. CONCLUSION: Telehealth follow-up after general surgical procedures is safe and effective. Postoperative telehealth care should be considered after low-risk general surgery procedures.

Stray energy injury during robotic versus laparoscopic inguinal hernia repair: a randomized controlled trial.

BACKGROUND: Stray energy transfer from monopolar instruments during laparoscopic surgery is a recognized cause of potentially catastrophic complications. There are limited data on stray energy injuries in robotic surgery. We sought to characterize stray energy injury in the form of superficial burns to the skin surrounding laparoscopic and robotic trocar sites. Our hypothesis was that stray energy burns will occur at all laparoscopic and robotic port sites. METHODS: We conducted a prospective, randomized controlled trial of patients undergoing elective unilateral inguinal hernia repair at a VAMC over a 4-year period. Surgery was performed via transabdominal preperitoneal approach either laparoscopic-assisted (TAPP) or robotic-assisted (rTAPP). A monopolar scissor was used to deliver energy at 30W coagulation for all cases. At completion of the procedure, skin biopsies were taken from all the port sites. A picro-Sirius red stain was utilized to identify thermal injury by a blinded pathologist. RESULTS: Over half (54%, 59/108) of all samples demonstrated thermal injury to the skin. In the laparoscopic group, 49% (25/51) samples showed thermal injury vs. 60% (34/57) in the robotic group (p = 0.548). The camera port was the most frequently involved with 68% (13/19) rTAPP samples showing injury vs. 47% (8/17) in the TAPP group (p = 0.503). There was no difference in the rate of injury at the working port site (rTAPP 53%, 10/19 vs. TAPP 47%, 8/17; p = 0.991) or the assistant port site (rTAPP 58%, 11/19 vs. TAPP 53%, 9/17; p = 0.873). CONCLUSIONS: Stray energy causes thermal injury to the skin at port sites in the majority robotic laparoscopic TAPP inguinal hernia repairs. There is no difference in stray energy transfer between the laparoscopic and robotic platform. This is the first study to confirm in-vivo transfer of stray energy during robotic surgical procedures. More study is needed to determine the clinical significance of these thermal injuries.

Losing weight to achieve joint or hernia surgery: is the intragastric balloon the answer?

BACKGROUND: Obesity is an epidemic, with its accompanying medical conditions putting patients at increased risk of postoperative complications. For patients undergoing elective surgery, preoperative weight loss provides an opportunity to decrease complications. We sought to evaluate the safety and efficacy of an intragastric balloon in achieving a body mass index (BMI) < 35 kg/m2 prior to elective joint replacement or hernia repair. METHODS: Retrospective review of all patients who had intragastric balloon placement at a level 1A VA medical center from 1/2019 to 1/2023. Patients who had a scheduled qualifying procedure (knee/hip replacement or hernia repair) and had a BMI > 35 kg/m2 were offered intragastric balloon placement to achieve 30-50lbs (13-28 kg) weight loss prior to surgery. Participation in a standardized weight loss program for 12 months was required. Balloons were removed 6 months after placement, preferentially concomitant with the qualifying procedure. Baseline demographics, duration of balloon therapy, weight loss and progression to qualifying procedure were recorded. RESULTS: Twenty patients completed intragastric balloon therapy and had balloon removal. Mean age 54 (34-71 years), majority (95%) male. Mean balloon duration was 200 ± 37 days. Mean weight loss was 30.8 ± 17.7lbs (14.0 ± 8.0 kg) with an average BMI reduction of 4.4 ± 2.9. Seventeen (85%) patients were successful, 15 (75%) underwent elective surgery and 2 (10%) were no longer symptomatic after weight loss. Three patients (15%) did not lose sufficient weight to qualify or were too ill to undergo surgery. Nausea was the most frequent side effect. One (5%) patient was readmitted within 30 days for pneumonia. DISCUSSION: Intragastric balloon placement resulted in an average 30lbs (14 kg) weight loss over 6 months allowing more than 75% of patients to undergo joint replacement or hernia repair at an optimal weight. Intragastric balloons should be considered in patients requiring 30-50lbs (13-28 kg) weight loss prior to elective surgery. More study is needed to determine the long-term benefit of preoperative weight loss prior to elective surgery.

Telehealth Follow-Up After Inguinal Hernia Repair in Veterans.

INTRODUCTION: Telehealth has been increasingly utilized with a renewed interest by surgical specialties given the COIVD-19 pandemic. Limited data exists evaluating the safety of routine postoperative telehealth follow-up in patients undergoing inguinal hernia repair, especially those who present urgent/emergently. Our study sought to evaluate the safety and efficacy of postoperative telehealth follow-up in veterans undergoing inguinal hernia repair. METHODS: Retrospective review of all Veterans who underwent inguinal hernia repair at a tertiary Veterans Affairs Medical Center over a 2-year period (9/2019-9/2021). Outcome measures included postoperative complications, emergency department (ED) utilization, 30-day readmission, and missed adverse events (ED utilization or readmission occurring after routine postoperative follow-up). Patients undergoing additional procedure(s) requiring intraoperative drains and/or nonabsorbable sutures were excluded. RESULTS: Of 338 patients who underwent qualifying procedures, 156 (50.6%) were followed-up by telehealth and 152 (49.4%) followed-up in-person. There were no differences in age, sex, BMI, race, urgency, laterality nor admission status. Patients with higher American Society of Anesthesiologists (ASA) classification [ASA class III 92 (60.5%) versus class II 48 (31.6%), P = 0.019] and open repair [93 (61.2%) versus 67 (42.9%), P = 0.003] were more likely to follow-up in-person. There was no difference in complications, [telehealth 13 (8.3%) versus 20 (13.2%), P = 0.17], ED visits, [telehealth 15 (10%) versus 18 (12%), P = 0.53], 30-day readmission [telehealth 3 (2%) versus 0 (0%), P = 0.09], nor missed adverse events [telehealth 6 (33.3%) versus 5 (27.8%), P = 0.72]. CONCLUSIONS: There were no differences in postoperative complications, ED utilization, 30-day readmission, or missed adverse events for those who followed-up in person versus telehealth after elective or urgent/emergent inguinal hernia repair. Veterans with a higher ASA class and who underwent open repair were more likely to be seen in person. Telehealth follow-up after inguinal hernia repair is safe and effective.

Robotic stray energy with constant-voltage versus constant-power regulating electrosurgical generators.

INTRODUCTION: Stray energy from surgical energy instruments can cause unintended thermal injuries. There are no published data regarding electrosurgical generators and their influence on stray energy transfer during robotic surgery. There are two approved generators for the DaVinci Xi robotic platform: a constant-voltage regulating generator (cVRG) and a constant-power regulating generator (cPRG). The purpose of this study was to quantify and compare stray energy transfer in the robotic Xi platform using a cVRG versus a cPRG. METHODS: An ex vivo bovine model was used to simulate a standard multiport robotic surgery. The DaVinci Xi (Intuitive Surgical, Sunnyvale, CA) robotic platform was attached to a trainer box using robotic ports. A 5 s, open-air activation of the monopolar scissors was done with commonly used electrosurgical settings using a cPRG (ForceTriad, Covidien-Medtronic, Boulder, CO) or cVRG (ERBE VIO 300 dV 2.0, ERBE USA, Marietta, GA). Stray energy transfer was quantified as the change in tissue temperature (°C) nearest the tip of the assistance grasper (which was not in direct contact with the active monopolar scissors). RESULTS: Stray energy transfer occurred with both generators. Utilizing common, comparable settings for standard coagulation, significantly less stray energy was transferred with the cVRG versus cPRG (4.4 ± 1.6 °C vs. 41.1 ± 13.0 °C, p < 0.001). Similarly, less stray energy was transferred using cut modes with the cVRG compared to the cPRG (5.61 ± 1.79 °C vs. 33.9 ± 18.4 °C, p < 0.001). CONCLUSION: Stray energy transfer increases tissue temperatures more than 45C in the DaVinci Xi robotic platform. Low voltage modalities, such as cut or blend; as well as a cVRG generator, significantly reduces stray energy. Robotic surgeons can minimize the risk of stray energy injuries by using these low risk modes and/or generator.

Proactive Coaching in General Surgery Internship: Incorporating Well-being Practices into Resident Professional Life.

OBJECTIVE: Coaching can provide learners with space to reflect on their performance while ensuring well-being and encouraging professional achievement and personal satisfaction outside of traditional mentorship and teaching models. We hypothesized that a proactive coaching program for general surgery interns coupled with individualized learning plans would help build foundational skills necessary for residency success and facilitate the incorporation of well-being practices into resident professional life. Here, we present the development, implementation, and outcomes of a novel well-being coaching program for surgical interns. DESIGN AND SETTING: A well-being coaching program was developed and implemented from July 2020 through June 2021 at a single university-based surgical residency program. To assess impact of the coaching program, we designed a mixed-methods study incorporating end-of-program survey results as well as participant narratives from commitment-to-act statements for thematic content. PARTICIPANTS: All 32 general surgery interns participated in aspects of the coaching program. RESULTS: The end-of-program survey was completed by 19/32 (59%) interns and commitment-to-act statements were completed by 22/32 (69%). The majority (89%) of survey respondents "agreed" or "strongly agreed" that the longitudinal intern coaching program helped them reach goals they had set for themselves this academic year; 15/19 (79%) noted that the coaching experience was effective in promoting well-being practices in their life. Well-being and professional goals were identified as major themes in the end-of-the-year commitment-to-act statements. Statements specifically mentioned resources highlighted and skills taught in our coaching program such as mindfulness techniques, gratitude journals, and self-compassion strategies. CONCLUSIONS: Our study illustrates the effectiveness of a coaching pilot program on promoting well-being practices in a university-based general surgery internship and can be a roadmap with proven efficacy and measurable outcomes.

Telehealth follow-up after cholecystectomy is safe in veterans.

BACKGROUND: The COVID-19 pandemic has brought many challenges including barriers to delivering high-quality surgical care and follow-up while minimizing the risk of infection. Telehealth has been increasingly utilized for post-operative visits, yet little data exists to guide surgeons in its use. We sought to determine safety and efficacy of telehealth follow-up in patients undergoing cholecystectomy during the global pandemic at a VA Medical Center (VAMC). METHODS: This was a retrospective review of patients undergoing cholecystectomy at a level 1A VAMC over a 2-year period from August 2019 to August 2021. Baseline demographics, post-operative complications, readmissions, emergency department (ED) visits and need for additional procedures were reviewed. Patients who experienced a complication prior to discharge, underwent a concomitant procedure, had non-absorbable skin closure, had new diagnosis of malignancy or were discharged home with drain(s) were ineligible for telehealth follow-up and excluded. RESULTS: Over the study period, 179 patients underwent cholecystectomy; 30 (17%) were excluded as above. 20 (13%) missed their follow-up, 52 (35%) were seen via telehealth and 77 (52%) followed-up in person. There was no difference between the two groups regarding baseline demographics or intra-operative variables. There was no significant difference in post-operative complications [4 (8%) vs 6 (8%), p > 0.99], ED utilization [5 (10%) vs 7 (9%), p = 0.78], 30-day readmission [3 (6%) vs 6 (8%), p = 0.74] or need for additional procedures [2 (4%) vs 4 (5%), p = 0.41] between telehealth and in-person follow-up. CONCLUSION: Telehealth follow-up after cholecystectomy is safe and effective in Veterans. There were no differences in outcomes between patients that followed up in-person vs those that were seen via phone or video. Routine telehealth follow-up after uncomplicated cholecystectomy should be considered for all patients.

Addressing an epidemic: Improving guideline-concordant opioid prescribing in surgical patients.

BACKGROUND: Excess postoperative opioid prescribing increases the risk of opioid abuse, diversion, and addiction. Clinicians receive variable training for opioid prescribing, and despite the availability of guidelines, wide variations in prescribing practices persist. This quality improvement initiative aimed to assess and improve institutional adherence to published guidelines. METHODS: This study represented a quality improvement initiative at an academic medical center implemented over a 6-month period with data captured 1 year before and after implementation. The quality improvement initiative focused on prescribing education and monthly feedback reports for clinicians. All opioid-naïve, adult patients undergoing a reviewed procedure were included. Demographics, surgical details, hospital course, and opioid prescriptions were reviewed. Opioids prescribed on discharge were evaluated for concordance with recommendations based on published guidelines. Pre- and postimplementation cohorts were compared. RESULTS: There were 4,905 patients included: 2,343 preimplementation and 2,562 postimplementation. There were similar distributions in patient demographics between the 2 cohorts. Guideline-concordant discharge prescriptions improved from 50.3% to 72.2% after the quality improvement initiative was implemented (P < .001). Adjusted analysis controlling for sex, age, discharge clinician, length of stay, outpatient surgery, and procedure demonstrated a 190% increase in odds of receiving a guideline-concordant opioid prescription on discharge in the postimplementation cohort (adjusted odds ratio 2.90; 95% confidence interval = 2.55-3.30). CONCLUSION: This study represented a successful quality improvement initiative improving guideline-concordant opioid discharges and decreasing overprescribing. This study suggested published guidelines are insufficient without close attention to elements of effective change management including the critical importance of locally targeting educational efforts and suggested that real-time, data-driven feedback amplifies impact on prescribing behavior.

A dedicated feeding tube clinic reduces emergency department utilization for gastrostomy tube complications.

INTRODUCTION: Enteral access is required for a variety of reasons from neuromuscular disorders to dysphagia. Gastrostomy tubes (GTs) can be placed endoscopically, surgically, or radiographically and complications include infection, bleeding, leakage and unintentional removal. Routine post-procedural follow-up is limited by inconsistent guidelines and management by different specialty teams. We established a dedicated GT clinic to provide continuity of care and prophylactic GT exchange. We hypothesized that patients followed in the GT clinic would have reduced Emergency Department (ED) utilization. METHODS: A retrospective review of patients who underwent GT placement from January 2010 to January 2020 was conducted. Baseline demographics, indications for GT placement, number and reason for ED visits and utilization of a multidisciplinary GT clinic were studied. RESULTS: A total of 97 patients were included. The most common indication for placement was dysphagia (88, 91%) and the most common primary diagnosis was head and neck malignancy (51, 51%). The GT clinic is a multidisciplinary clinic staffed by surgeons and residents, dieticians, and wound care specialists and cared for 16 patients in this study. Three patients (19%) in the GT clinic group required ED visits compared to 44 (54%) in the standard of care (SOC) group (p < 0.05). There was an average of 0.9 ED visits per patient (range 0-7) in the GT clinic group vs 1.6 ED visits per patient (range 0-20) in the SOC group (p = 0.34). Feeding tubes were prophylactically exchanged an average of 7 times per patient in the GT clinic group vs 3 times per patient in the SOC group (p < 0.05). CONCLUSION: A multidisciplinary clinic dedicated to GT care limits ED visits for associated complications by more than 50%. Follow-up in a dedicated clinic with prophylactic tube exchange decreases ED visits and should be considered at facilities that care for patients with GTs.

Decreases in daily ambulation forecast post-surgical re-admission.

BACKGROUND: Surgical readmissions are clinically and financially problematic. Our purpose is to determine if a decrease in postoperative ambulation (steps/day) is associated with hospital readmission. METHODS: In this prospective cohort study, patients undergoing elective operations wore an accelerometer activity tracker to measure steps/day for 28 consecutive postoperative days. The primary outcome was hospital readmission. The change in steps/day over two consecutive days prior to the day of the readmission were examined. Predetermined thresholds for decreases of consecutive daily ambulation levels were used to calculate sensitivity and specificity for the outcome of hospital readmission. RESULTS: 215 patients (aged 63 ± 12 years) were included. Readmission occurred in 10% (n = 21). For each of the first 28-postoperative days, the entire cohort had an average daily step increase of 136 ± 146 steps/day (Spearman correlation rho = 0.990; p < 0.001). A decrease in steps for two consecutive days of >50% from the prior day had a 79% sensitivity and 90% specificity for hospital readmission. CONCLUSIONS: A decrease of >50% daily ambulation (steps/day) over two consecutive post-discharge days accurately forecasts hospital readmission. The implications of these findings are that monitoring daily ambulation could serve as a form of outpatient telemetry aiding to forecast post-surgical readmissions.

Early identification of patients at risk for delayed recovery of ambulation after elective abdominal surgery.

BACKGROUND: Recovery of preoperative ambulation levels 1 month after surgery represents an important patient-centered outcome. The objective of this study is to identify clinical factors associated with the inability to regain baseline preoperative ambulation levels 28 days postoperatively. METHODS: This is a prospective cohort study enrolling patients scheduled for elective inpatient abdominal operations. Daily ambulation (steps/day) was measured with a wristband accelerometer. Preoperative steps were recorded for at least 3 full calendar days before surgery. Postoperatively, daily steps were recorded for at least 28 days. The primary outcome was delayed recovery of ambulation, defined as inability to achieve 50% of preoperative baseline steps at 28 days postoperatively. RESULTS: A total of 108 patients were included. Delayed recovery (< 50% of baseline preoperative steps/day) occurred in 32 (30%) patients. Clinical factors associated with delayed recovery after multivariable logistic regression included longer operative time (OR 1.37, 95% CI 1.05-1.79), open operative approach (OR 4.87, 95% CI 1.64-14.48) and percent recovery on POD3 (OR 0.73, 95% CI 0.56-0.96). In addition, patients with delayed ambulation recovery had increased rates of postoperative complications (16% vs 1%, p < 0.01) and readmission (28% vs 5%, p < 0.01). CONCLUSION: After elective inpatient abdominal operations, nearly one in three patients do not recover 50% of their baseline preoperative steps 28 days postoperatively. Factors that can be used to identify these patients include longer operations, open operations and low ambulation levels on postoperative day #3. These data can be used to target rehabilitation efforts aimed at patients at greatest risk for poor ambulatory recovery.

Perioperative Clerkship Design for Students with Physical Disabilities: A Model for Implementation.

OBJECTIVE: Disability inclusion is an important and growing area of focus for medical education that may be stymied by stereotypes about disabilities, lack of knowledge about accommodations for students with physical disabilities, or outdated technical standards that preclude participation of people with mobility disabilities. To support the inclusion of students with physical disability in surgical clerkships, we describe a proactive, progressive approach to the accommodations process for a student with a thoracic spinal cord injury entering a surgical clerkship. DESIGN: Working proactively, medical school leadership, disability professionals and the clerkship team collaborated on the development of reasonable accommodations for a student with a thoracic spinal cord injury entering a surgical clerkship. SETTING: University of Colorado, Department of Surgery and Department of Medical Education, Aurora, CO. PARTICIPANTS: A third-year medical student and faculty from the medical school and surgical clerkship leaders. RESULTS: An M3 student with a thoracic spinal cord injury successfully completed an 8-week surgical clerkship completing all required procedural and clinical skills utilizing reasonable accommodation. The student achieved a grade of honors for the rotation. CONCLUSIONS: Early communication and planning for disability-related adjustments are critical to ensure an accessible experience for students with physical disabilities. The addition of a student with a disability adds to a better understanding of inclusive practices for surgical education and adds to the diversity of thought and experience for the medical education community.

A Multidisciplinary High-Risk Surgery Committee May Improve Perioperative Decision Making for Patients and Physicians.

Background: Surgeons must evaluate and communicate the risk associated with operative procedures for patients at high risk of poor postoperative outcomes. Multidisciplinary approaches to complex decision making are needed. Objective: To improve physician decision making for high-risk surgical patients. Design: This is a retrospective review of patients presented to a multidisciplinary committee for three years. Setting/Subjects: Evaluation of patients was done in a single-center U.S. veterans affairs (VA) hospital. All patients who were considered for surgery had a VA Surgical Quality Improvement Program (VASQIP) risk calculator 30-day mortality >5%. Measurements: Thirty-day and one-year mortality were measured. Results: Seventy-six patients were reviewed with an average expected 30-day mortality of 14.2%. Forty-two patients (57%) had a recommended change in the care plan before surgery. Fifty-four patients (71%) proceeded with surgery and experienced a 30-day mortality of 7.4%. Conclusions and Relevance: Multidisciplinary discussion of high-risk surgical patients may help surgeons make perioperative recommendations for patients. Implementation of a multidisciplinary high-risk committee should be considered at facilities that manage high-risk surgical patients.

The impact of the COVID-19 pandemic on family medicine residency training.

BACKGROUND: Family physicians have played a unique clinical role during the COVID-19 pandemic. We hypothesized that the pandemic would be associated with significant deleterious effects on clinical activity, educational training, personal safety and well-being. OBJECTIVE: We conducted a national survey to obtain preliminary data that would assist in future targeted data collection and subsequent evaluation of the impact of the pandemic on family medicine residents and teaching faculty. METHODS: An anonymous online survey of residents and faculty was distributed via the Association of Family Medicine Residency Directors list serve between 5/21/2020 and 6/18/2020. Survey questions focused on clinical and educational activities, safety and well-being. RESULTS: One hundred and fifty-three residents and 151 teaching faculty participated in the survey. Decreased clinical activity was noted by 81.5% of residents and 80.9% of faculty and the majority began conducting telehealth visits (97.9% of residents, 91.0% of faculty). Distance learning platforms were used by all residents (100%) and 39.6% noted an overall positive impact on their education. Higher levels of burnout did not significantly correlate with reassignment of clinical duties (residents P = 0.164; faculty P = 0.064). Residents who showed significantly higher burnout scores (P = 0.035) and a decline in levels of well-being (P = 0.031) were more likely to participate in institutional well-being support activities. CONCLUSIONS: Our preliminary data indicate that family medicine residents and teaching faculty were profoundly affected by the COVID-19 pandemic. Future studies can be directed by current findings with focus on mitigation factors in addressing globally disruptive events such as COVID-19.

Family physicians have played a unique clinical role during the COVID-19 pandemic. We hypothesized that the pandemic would be associated with significant deleterious effects on clinical activity, educational training, personal safety and well-being. Towards setting a foundation for further studies, we conducted a national survey to obtain preliminary data that would assist in future targeted data collection and subsequent evaluation of the impact of the pandemic on family medicine residents and teaching faculty. Our preliminary data indicate that family medicine residents and teaching faculty were profoundly affected by the COVID-19 pandemic in all domains studied. Future studies can be directed by current findings with focus on mitigation factors in addressing globally disruptive events such as COVID-19.