Pre-hospital caloric deficits in surgical patients.

BACKGROUND: The timing, route, and amount of nutrition for surgical patients with substantial caloric deficits remain active areas of study. Current guidelines are based on in-hospital days NPO after admission to the hospital. This historic process neglects the multiple days of caloric deficit patients experience prior to hospital admission. AIM: To determine the impact of pre-hospital caloric deficit (PHCD) for surgical patients on their outcomes. METHODS: 313 patients admitted with a diagnosis of small bowel obstruction, pancreatitis, or diverticulitis were analyzed for their PHCD's. PHCD's were estimated using patient-reported days with significant emesis, and absent oral intake. Patients with PHCD's were compared to patients with no PHCD for length of stay, status on discharge, disposition, and 30-day readmission rate. RESULTS: There were 313 patients and 42% of the patients were male. The median age was 65 years. Median number of days sick prior to hospital admission was 1 (IQR: 1 to 2). Median PHCD was 1882 kcal (IQR: 1355 to 3650). Median number of days NPO while in-hospital was 3 (IQR: 2 to 5). Median in-hospital caloric deficit was 4268 kcal (IQR: 2825 to 6610). No significant association was observed between discharge disposition, complication rate, ambulatory status, 30-day readmission rate and PHCD. In-hospital caloric deficit was associated with complications after surgery (p < 0.0001). CONCLUSION: Small PHCD's in patients with SBO's, pancreatitis, or diverticulitis do not negatively affect their outcomes. Further research of patients with large PHCD's is needed to best treat surgical patients at risk for malnutrition.

Do It to Them, Not to Me: Doctors' and Nurses' Personal Preferences Versus Recommendations for End-of-Life Care.

BACKGROUND: The emotional toll and financial cost of end-of-life care can be high. Existing literature suggests that medical providers often choose to forego many aggressive interventions and life-prolonging therapies for themselves. To further investigate this phenomenon, we compared how providers make medical decisions for themselves versus for relatives and unrelated patients. METHODS: Between 2016 and 2019, anonymous surveys were emailed to physicians (attendings, fellows, and residents), nurse practitioners, physician assistances, and nurses at two multifacility tertiary medical centers. Participants were asked to decide how likely they would offer a tracheostomy and feeding gastrostomy to a hypothetical patient with a devastating neurological injury and an uncertain prognosis. Participants were then asked to reconsider their decision if the patient was their own family member or if they themselves were the patient. The Kruskal-Wallis H, Mann-Whitney U, and Tukey tests were used to compare quantitative data. Statistical significance was set at P < 0.05. RESULTS: Seven hundred seventy-three surveys were completed with a 10% response rate at both institutions. Regardless of professional identity, age, or gender, providers were significantly more likely to recommend a tracheostomy and feeding gastrostomy to an unrelated patient than for themselves. Professional identity and age of the respondent did influence recommendations made to a family member. CONCLUSIONS: We demonstrate that medical practitioners make different end-of-life care decisions for themselves compared with others. It is worth investigating further why there is such a discrepancy between what medical providers choose for themselves compared with what they recommend for others.

Risk Factors for Early Readmission After Acute Pancreatitis: Importance of Timely Interventions.

BACKGROUND: Despite improvements in the diagnosis and care of acute pancreatitis, the mortality, morbidity, and long-term complications of this disease currently account for an annual cost of $10 billion in the United States. Lack of high-quality consolidated clinical data about this ever-increasing national and global burden makes it challenging to be able to recognize at-risk populations and intervene to avoid early readmission (ER) (i.e., readmission within 30 d of hospital discharge or ER). METHODS: We reviewed the National Readmission Database for 2016. We retrieved 25,476 ER out of a total of 188,757 patients admitted with acute pancreatitis (ICD-10 diagnosis of K85), alive at discharge. Patients younger than 18 at the time of initial admission were excluded. Diagnostic characteristics and procedures performed were extracted from ICD-10 data. Based on patient demographics and the diagnostic and procedural profiles from their initial admission, we identified clusters of risk factors for ER using agglomerative hierarchical clustering. These are depicted in a correlation matrix. RESULTS: Acute pancreatitis is associated with a 13.5% overall ER rate. Certain pre-existing chronic diseases, particularly cardiovascular disease diagnoses and interventions at initial presentation increase the odds of ER. In contrast to interventions on the pancreas, interventions on the biliary system correlated with lower odds of ER. Furthermore, the earlier the biliary system intervention was performed during the initial hospitalization, the lower the odds of ER. We identified five clusters of interrelationships: age/comorbidity cluster, cirrhosis cluster, sepsis/pulmonary complication cluster, biliary intervention cluster, and high-risk of mortality cluster. CONCLUSIONS: We identified several potentially modifiable risk factors for ER of patients hospitalized with acute pancreatitis, which included timing of biliary interventions. Furthermore, we identified clusters of interrelationships that further illuminate which complications tend to occur concomitantly and ultimately contribute to ER. By identifying risk factors and elucidating their interactions, we have improved our understanding of this highly morbid disease and offer potential points of intervention to reduce ER.

Using Concurrent Complication Reporting to Evaluate Resident Critical Thinking and Enhance Adult Learning.

OBJECTIVE: Critical thinking and accurate case analysis is difficult to quantify even within the context of routine morbidity and mortality reporting. We designed and implemented a HIPAA-compliant adverse outcome reporting system that collects weekly resident assessments of clinical care across multiple domains (case summary, complications, error analysis, Clavien-Dindo Harm, cognitive bias, standard of care, and ACGME core competencies). We hypothesized that incorporation of this system into the residency program's core curriculum would allow for identification of areas of cognitive weakness or strength and provide a longitudinal evaluation of critical thinking development. DESIGN: A validated, password-protected electronic platform linked to our electronic medical record was used to collect cases weekly in which surgical adverse events occurred. General surgery residents critiqued 1932 cases over a 4-year period from 3 major medical centers within our system. These data were reviewed by teaching faculty, corrected for accuracy and graded utilizing the software's critique algorithm. Grades were emailed to the residents at the time of the review, collected prospectively, stratified, and analyzed by post-graduate year (PGY). Evaluation of the resident scores for each domain and the resultant composite scores allowed for comparison of critical thinking skills across post-graduate year (PGY) over time. SETTING: Data was collected from 3 independently ACGME-accredited surgery residency programs over 3 tertiary hospitals within our health system. PARTICIPANTS: General surgery residents in clinical PGY 1-5. RESULTS: Residents scored highest in properly identifying ACGME core competencies and determining Clavien-Dindo scores (p < 0.006) with no improvement in providing accurate and concise clinical summaries. However, residents improved in recording data sufficient to identify error (p < 0.00001). A positive linear trend in median scores for all remaining domains except for cognitive bias was demonstrated (p < 0.001). Senior residents scored significantly higher than junior residents in all domains. Scores > 90% were never achieved. CONCLUSIONS: The use of an electronic standardized critique algorithm in the evaluation and assessment of adverse surgical case outcomes enabled the measure of residents' critical thinking skills. Feedback in the form of teaching faculty-facilitated discussion and emailed grades enhanced adult learning with a steady improvement in performance over PGY. Although residents improved with PGY, the data suggest that further improvement in all categories is possible. Implementing this standardized critique algorithm across PGY allows for evaluation of areas of individual resident weakness vs. strength, progression over time, and comparisons to peers. These data suggest that routine complication reporting may be enhanced as a critical thinking assessment tool and that improvement in critical thinking can be quantified. Incorporation of this platform into M&M conference has the potential to augment executive function and professional identity development.

Cleaning Up the MESS: Can Machine Learning Be Used to Predict Lower Extremity Amputation after Trauma-Associated Arterial Injury?

BACKGROUND: Thirty years after the Mangled Extremity Severity Score was developed, advances in vascular, trauma, and orthopaedic surgery have rendered the sensitivity of this score obsolete. A significant number of patients receive amputation during subsequent admissions, which are often missed in the analysis of amputation at the index admission. We aimed to identify risk factors for and predict amputation on initial admission or within 30 days of discharge (peritraumatic amputation [PTA]). STUDY DESIGN: The Nationwide Readmission Database for 2016 and 2017 was used in our analysis. Factors associated with PTA were identified. We used XGBoost, random forest, and logistic regression methods to develop a framework for machine learning-based prediction models for PTA. RESULTS: We identified 1,098 adult patients with traumatic lower extremity fracture and arterial injuries; 206 underwent amputation. One hundred and seventy-six patients (85.4%) underwent amputation during the index admission and 30 (14.6%) underwent amputation within a 30-day readmission period. After identifying factors associated with PTA, we constructed machine learning models based on random forest, XGBoost, and logistic regression to predict PTA. We discovered that logistic regression had the most robust predictive ability, with an accuracy of 0.88, sensitivity of 0.47, and specificity of 0.98. We then built on the logistic regression by the NearMiss algorithm, increasing sensitivity to 0.71, but decreasing accuracy to 0.74 and specificity to 0.75. CONCLUSIONS: Machine learning-based prediction models combined with sampling algorithms (such as the NearMiss algorithm in this study), can help identify patients with traumatic arterial injuries at high risk for amputation and guide targeted intervention in the modern age of vascular surgery.

Predicting respiratory failure after pulmonary lobectomy using machine learning techniques.

BACKGROUND: When pulmonary complications occur, postlobectomy patients have a higher mortality rate, increased length of stay, and higher readmission rates. Because of a lack of high-quality consolidated clinical data, it is challenging to assess and recognize at-risk thoracic patients to avoid respiratory failure and standardize outcome measures. METHODS: The National (Nationwide) Inpatient Sample for 2015 was used to establish our model. We identified 417 respiratory failure from a total of 4,062 patients who underwent pulmonary lobectomy. Risk factors for respiratory failure were identified, analyzed, and used in novel machine learning models to predict respiratory failure. RESULTS: Factors that contributed to increased odds of respiratory failure, such as preexisting chronic diseases, and intraoperative and postoperative events during hospitalization were identified. Two machine learning-based prediction models were generated and optimized by the knowledge accrued from the clinical course of postlobectomy patients. The first model, with high accuracy and specificity, is suited for performance evaluation, and the second model, with high sensitivity, is suited for clinical decision making. CONCLUSION: We identified risk factors for respiratory failure after lobectomy and introduced 2 machine learning-based techniques to predict respiratory failure for quality review and clinical decision-making settings. Such techniques can be used to not only provide targeted support but also standardize quality peer review measures.

Intraoperative Feeding Improves Calorie and Protein Delivery in Acute Burn Patients.

Enteral nutrition support is a critical component of modern burn care for severely burned patients. However, tube feeds are frequently withheld during the perioperative period because of aspiration concerns. As a result, patients requiring multiple operative procedures risk accumulating significant protein-calorie deficits. The objective of this study was to describe our American Burn Association-certified burn center's experience implementing an intraoperative feeding protocol in severely burned patients defined as a cutaneous burn ≥20% TBSA. A retrospective review of patients with major thermal injuries (2008-2013). Thirty-three patients with an average of seven operating room trips (range, 2-21 trips) were evaluated. Seventeen patients received intraoperative enteral feeds (protocol group) and 16 patients did not (standard group). Feeding was performed using an enteral feeding tube placed postpylorically and was continued intraoperatively, regardless of operative positioning. There was no statistically significant difference in mortality between the groups (P = .62). No intraoperative aspiration or regurgitation events were recorded. The protocol group received significantly more calculated protein and caloric requirements, 98.06 and 98.4%, respectively, compared with 70.6 and 73.2% in the standard group (P < .001). Time to goal tube feed infusion rate was achieved on average 3 days sooner in the protocol group compared with the standard group (3.35 vs 6.18 days, P = .008). Early initiation and continuation of enteral feeds in severely burned patients led to higher percentages received of prescribed goal protein and caloric needs without increased rates of aspiration, regurgitation, or mortality.