Readmissions After Traumatic Brain Injury in the Nationwide Readmissions Database.

INTRODUCTION: Readmissions after a traumatic brain injury (TBI) can have severe impacts on long-term health outcomes as well as rehabilitation. The aim of this descriptive study was to analyze the Nationwide Readmissions Database to determine possible risk factors associated with readmission for patients who previously sustained a TBI. METHODS: This retrospective study used data from the Nationwide Readmissions Database to explore gender, age, injury severity score, comorbidities, index admission hospital size, discharge disposition of the patient, and cause for readmission for adults admitted with a TBI. Multivariable logistic regression was used to assess likelihood of readmission. RESULTS: There was a readmission rate of 28.7% (n = 31,757) among the study population. The primary cause of readmission was either subsequent injury or sequelae of the original injury (n = 8825; 29%) followed by circulatory (n = 5894; 19%) and nervous system issues (n = 2904; 9%). There was a significantly higher risk of being readmitted in males (Female odds ratio: 0.87; confidence interval [0.851-0.922), older patients (65-79: 32.3%; > 80: 37.1%), patients with three or more comorbidities (≥ 3: 32.9%), or in patients discharged to a skilled nursing facility/intermediate care facility/rehab (SNF/ICF/Rehab odds ratio: 1.55; confidence interval [0.234-0.262]). CONCLUSIONS: This study demonstrates a large proportion of patients are readmitted after sustaining a TBI. A significant number of patients are readmitted for subsequent injuries, circulatory issues, nervous system problems, and infections. Although readmissions cannot be completely avoided, defining at-risk populations is the first step of understanding how to reduce readmissions.

A closed surgical intensive care unit organization improves cardiac surgical patient outcomes.

Background: Intensive care unit (ICU) organization is a critical factor in optimizing patient outcomes. ICU organization can be divided into "OPEN" (O) and "CLOSED" (C) models, where the specialist or intensivist, respectively, assumes the role of primary physician. Recent studies support improved outcomes in closed ICUs, however, most of the available data is centered on ICUs generally or on subspecialty surgical patients in the setting of a subspecialized surgical intensive care unit (SICU). We examined the impact of closing a general SICU on patient outcomes following cardiac and ascending aortic surgery. Methods: A retrospective cohort of patients following cardiac or ascending aortic surgery by median sternotomy was examined at a single academic medical center one year prior and one year after implementation of a closed SICU model. Patients were divided into "OPEN" (O; n=53) and "CLOSED" (C; n=73) cohorts. Results: Cohorts were comparable in terms of age, race, and number of comorbid conditions. A significant difference in male gender (O: 60.4% vs. C: 76.7%, P=0.049), multiple procedure performed (O: 13.21% vs. C: 35.62%, P=0.019), and hospital readmission rates was detected (O: 39.6% vs. C: 9.6%, P=0.0003). Using a linear regression model, a closed model SICU organization decreased SICU length of stay (LOS). Using a multivariate logistic regression, being treated in a closed ICU decreased a patient's likelihood of having an ICU LOS greater than 48 hours. Conclusions: Our study identified a decreased ICU LOS and hospital readmission in cardiac and ascending aortic patients in a closed general SICU despite increased procedure complexity. Further study is needed to clarify the effects on surgical complications and hospital charges.

A multi-institutional study from the US ROPE consortium examining factors associated with endocrine surgery exposure for general surgery residents.

BACKGROUND: Prior analyses of general surgery resident case logs have indicated a decline in the number of endocrine procedures performed during residency. This study aimed to identify factors contributing to the endocrine operative experience of general surgery residents and compare those who matched in endocrine surgery fellowship with those who did not. METHODS: We analyzed the case log data of graduates from 18 general surgery residency programs in the US Resident Operative Experience Consortium over an 11-year period. RESULTS: Of the 1,240 residents we included, 17 (1%) matched into endocrine surgery fellowships. Those who matched treated more total endocrine cases, including more thyroid, parathyroid, and adrenal cases, than those who did not (81 vs 37, respectively, P < .01). Program-level factors associated with increased endocrine volume included endocrine-specific rotations (+10, confidence interval 8-12, P < .01), endocrine-trained faculty (+8, confidence interval 7-10, P < .01), and program co-location with otolaryngology residency (+5, confidence interval 2 -8, P < .01) or endocrine surgery fellowship (+4, confidence interval 2-6, P < .01). Factors associated with decreased endocrine volume included bottom 50th percentile in National Institute of Health funding (-10, confidence interval -12 to -8, P < .01) and endocrine-focused otolaryngologists (-3, confidence interval -4 to -1, P < .01). CONCLUSION: Several characteristics are associated with a robust endocrine experience and pursuit of an endocrine surgery fellowship. Modifiable factors include optimizing the recruitment of dedicated endocrine surgeons and the inclusion of endocrine surgery rotations in general surgery residency.

An Educational Module to Teach Interprofessional Learner Feedback Skills for Trauma Simulation Events.

BACKGROUND: Peer feedback, or feedback given by a learner to another learner, is an important active learning strategy. Hierarchy and stereotypes may affect interprofessional (IP) learner-to-learner feedback. The aim was to assess the efficacy of an educational module for IP learners in delivering effective feedback during trauma simulations. METHODS: Multiple simulation events designed to improve teamwork and leadership skills during trauma simulations included IP learners (residents and nurses). Participants completed a pre-course educational module on IP peer feedback. The Trauma Team Competence Assessment-24 tool structured feedback. Learners completed pre/post-assessments utilizing IP Collaborative Competencies Attainment Survey (ICCAS). RESULTS: Twenty-five learners participated in the trauma simulations (13 general surgery and 5 emergency residents, 3 medical students, 4 nurses). The majority of learners had either not received any previous training in how to effectively deliver peer feedback (40%) or had engaged in self-directed learning only (24%). Most learners (64%) had delivered peer feedback less than ten times. Learner knowledge and confidence in delivering feedback to fellow IP learners improved after simulations. All learners felt the feedback received was useful to their daily practice (68% agree, 32% strongly agree). All participants agreed that the simulation achieved each of the ICCAS competencies. CONCLUSIONS: Formal education on IP peer feedback is rare. This pilot work demonstrates educational modules with a foundation in validated tools can be effective in improving learner knowledge and confidence in the process. Engaging in IP peer feedback may also serve to flatten hierarchies that can challenge effective interprofessional teamwork.

The community of inquiry framework for virtual team-to-team debriefings during interprofessional trauma simulations.

Purpose: Psychological safety is key to effective debriefing and learning. The COVID-19 pandemic necessitated rapid adaption of simulation events to virtual/hybrid platforms. We sought to determine the effect of utilizing the Community of Inquiry framework (CoI) for debriefing virtually connecting interprofessional learner teams on the psychological safety experienced during trauma simulations. Methods: General surgery (GSR), emergency medicine (EMR) residents, trauma nurses/nurse practitioners and medical students participated in multiple simulation events designed to improve teamwork and leadership skills. Pre-course materials were provided before the event for learners to prepare. Briefings delineating expectations emphasized importance of and strategies employed to achieve psychological safety. Four unique clinical scenarios were run for each simulation event, with a debrief after each scenario. Virtual team-to-team debriefings were structured using the Community of Inquiry (CoI) conceptual framework. All learners completed pre-/post-assessments utilizing Inter-professional Collaborative Competencies Attainment Survey (ICCAS). Results: Twenty-five learners participated (13 GSR, 5 EMR, 3 medical students, 2 trauma APRNs and 2 trauma RNs). Learner assessment found 88% (22) "agreed"/"strongly agreed" that virtual team-to-team debriefing had social, cognitive and educator presence per the CoI domains. However, one GSR and two nurse learners "strongly disagreed" with these statements. Most learners felt the debriefing was effective and safe. All participants "strongly agreed"/"agreed" the simulation achieved ICCAS competencies. Conclusions: Debriefings utilizing a virtual platform are challenging with multiple barriers to ensuring psychological safety and efficacy. By structuring debriefings using the CoI framework we demonstrate they can be effective for most learners. However, educators should recognize the implications of social identity theory, particularly the effects of hierarchy, on comfort level of learners. Developing strategies to optimize virtual simulation learning environments is essential as this valuable pedagogy persists during and beyond the COVID-19 pandemic.

Anatomy Scholars Program for Medical Students Entering a Surgical Residency.

A near-peer teaching experience for upper-level medical students could help prepare them for surgical residency by providing specific education opportunities and exposure to the field of surgery. Five medical students were selected to be near-peer teachers (NPTs) in gross anatomy, and then they reflected on their experiences. The NPTs spent the majority of effort in a teaching role, and reported improved NTS, anatomy knowledge, and dissection skills. MS1s and faculty also reported on the value of the ASP. Further development and evaluation of the ASP may be an excellent opportunity for future surgeons.

Traumatic bilateral ureteral tear in a pregnant woman after a motor vehicle crash: a case report.

Bilateral ureteropelvic junction (UPJ) tears are rare. Trauma can obscure this diagnosis. The objective of this case report is to highlight the rapid diagnosis of this injury and care in the case of pregnancy. A 22-year-old pregnant female was ejected from her car and presented with abdominal pain. The patient got a computed tomography (CT)-chest, abdomen, pelvis (CT-CAP) revealing bilateral ureteral injury, which was confirmed on retrograde cystoscopy. Her injuries were treated with nephrostomy tubes with plans for definitive repair after pregnancy. Fetus remained stable throughout her care and the patient was discharged with no complications. Due to the rapid diagnosis and effective stabilization, the patient and fetus recovered well from the injuries and multiple procedures. While there are many explanations for bilateral UPJ tears, deceleration and hyperextension seem to be the two major mechanisms of this injury.

What makes them different? An exploration of mentoring for female faculty, residents, and medical students pursuing a career in surgery.

BACKGROUND: This qualitative study examines the roles of mentoring and gender in choosing and continuing in a surgical career for women across the continuum. METHODS: Semi-structured interviews were held with a purposive sample of 24 female surgical faculty, residents, and aspiring medical students from one institution between November 2018 and January 2019. Interview transcripts were analyzed using traditional thematic analysis methods aided by computerized software. RESULTS: The use of a mosaic approach in seeking mentoring to match one's personal and career-relevant support needs was described frequently. Same-gender role models were more important for early career women, while leadership mentoring and coaching were more desired by later career women. Gender differences in mentoring were identified but some of these differences may apply equally to women and men. CONCLUSIONS: Study findings contribute mentoring insights relevant to both women and men interested in pursuing and thriving in surgical careers.

Defining severe traumatic brain injury readmission rates and reasons in a rural state.

BACKGROUND: Readmissions after a traumatic brain injury (TBI) have significant impact on long-term patient outcomes through interruption of rehabilitation. This study examined readmissions in a rural population, hypothesizing that readmitted patients after TBI will be older and have more comorbidities than those not readmitted. METHODS: Discharge data on all patients 15 years and older who were admitted to an Arkansas-based hospital for TBI were obtained from the Arkansas Hospital Discharge Data System from 2010 to 2014. This data set includes diagnoses (principal discharge diagnosis, up to 3 external cause of injury codes, 18 diagnosis codes using the International Classification of Disease, 9th Edition, Clinical Modifications), age, gender, and inpatient costs. Hospital Cost and Utilization Project Clinical Classification and Chronic Condition Indicator were used to identify chronic disease and body systems affected in principal diagnosis. RESULTS: Of the 3114 cases of significant head trauma, more than two-thirds were attributed to fall injuries, with motor vehicle crashes accounting for 20% of the remainder. The mean length of stay was 6.5 days. 691 of these patients were admitted to an Arkansas hospital in the following year, totaling 1368 readmissions. Of the readmissions, 16.4% of patients were admitted for altered mental status, 12.9% with shortness of breath (SOB), and 9.4% with chest pain. Mental disorders (psychosis, dementia, and depression) and organic nervous symptoms (Alzheimer's disease, encephalopathy, and epilepsy) were the primary source of readmissions. More than one-third of the patients were admitted in the following year for chronic diseases such as heart failure (8.6%), psychosis (5.2%), and cerebral artery occlusion (4.1%). DISCUSSION: This study showed that there is a significant rate of readmissions in the year after a diagnosis of TBI. Complications with existing chronic diseases are among the most reported reasons for admission in this time period, demonstrating the effect severe head trauma has on long-term treatment. LEVEL OF EVIDENCE: Level IV, Retrospective epidemiological study.

Morning report decreases length of stay in trauma patients.

BACKGROUND: Modern acute care surgery (ACS) programs depend on consistent patient hand-offs to facilitate care, as most programs have transitioned to shift-based coverage. We sought to determine the impact of implementing a morning report (MR) model on patient outcomes in the trauma service of a tertiary care center. METHODS: The University of Arkansas for Medical Sciences (UAMS) Division of ACS implemented MR in October 2015, which consists of the trauma day team, the emergency general surgery day team, and a combined night float team. This study queried the UAMS Trauma Registry and the Arkansas Clinical Data Repository for all patients meeting the National Trauma Data Bank inclusion criteria from January 1, 2011 to April 30, 2018. Bivariate frequency statistics and generalized linear model were run using STATA V.14.2. RESULTS: A total of 11 253 patients (pre-MR, n=6556; post-MR, n=4697) were analyzed in this study. The generalized linear model indicates that implementation of MR resulted in a significant decrease in length of stay (LOS) in trauma patients. DISCUSSION: This study describes an approach to improving patient outcomes in a trauma surgery service of a tertiary care center. The data show how an MR session can allow for patients to get out of the hospital faster; however, broader implications of these sessions have yet to be studied. Further work is needed to describe the decisions being made that allow for a decreased LOS, what dynamics exist between the attendings and the residents in these sessions, and if these sessions can show some of the same benefits in other surgical services. LEVEL OF EVIDENCE: Level 4, Care Management.

National Landscape of General Surgery Mock Oral Examination Practices: Survey of Residency Program Directors.

INTRODUCTION: Mock oral examinations (MOEs) are used within surgery residency programs to prepare trainees for the American Board of Surgery (ABS) Certifying Exam (CE), but little work exists to guide programs in terms of best practices for implementing a general surgery MOE program. This study, endorsed by the Association for Program Directors in Surgery (APDS) Research Committee, aimed to better understand the national scope of current practices for general surgery MOEs. METHODS: General surgery residency program directors (PDs) were invited via the APDS listserv to complete a 27-item survey about their perceptions of the importance and correlates of MOEs, how their exams are structured, implementation barriers, and recent revisions to their MOE program. RESULTS: Of 98 PDs responding to the survey, 94% (n = 92) responded about the characteristics of their formal MOE programs. The majority required upper level resident participation and held the exams 2 to 3 times annually; far fewer involved lower level residents. Most programs structure their MOEs to mimic the CE format with 3 exam rooms (76%), using premade questions (66%), presenting 4 scenarios per room (59%), and using two examiners per room (85%). Most PDs (88%) believed MOEs were very important or essential for surgery trainees, which correlated with their ratings of how important MOEs are to their Clinical Competency Committee for determining resident advancement (r = 0.32, p < 0.002). Common barriers for implementing MOEs were availability of examiners and scenarios. About half indicated making recent or ongoing revisions to improve their MOEs. Many PDs indicated interest in collaborating regionally or nationally on MOE initiatives. CONCLUSIONS: MOEs were largely regarded as a highly valuable tool by PDs to prepare trainees for the general surgery CE. The majority of programs in this study provide a testing experience as similar to the CE as possible, although some variability in the structure of MOEs was identified. PDs also reported significant implementation barriers and a desire for more MOE collaboration.

Money matters: a resident curriculum for financial management.

BACKGROUND: A 2005 survey reported 87% of surgery program directors believed practice management training should occur during residency. However, only 8% of program directors believed residents received adequate training in practice management [1]. In addition to the gap in practice financial management knowledge, we recognized the need for training in personal finance among residents. A literature review and needs assessment led to the development of a novel curriculum for surgery residents combining principles of practice management and personal finance. METHODS: An 18-h curriculum was administered over the 2012 academic year to 28 post graduate year 1-5 surgery residents and faculty. A self-assessment survey was given at the onset and conclusion of the curriculum [2]. Pre-tests and post-tests were given to objectively evaluate each twice monthly session's content. Self-perception of learning, interest, and acquired knowledge were analyzed using the Wilcoxon signed ranks test. RESULTS: Initial self-assessment data revealed high interest in practice management and personal finance principles but a deficiency in knowledge of and exposure to these topics. Throughout the curriculum, interest increased. Residents believed their knowledge of these topics increased after completing the curriculum, and objective data revealed various impacts on knowledge. CONCLUSIONS: Although surgery residents receive less exposure to these topics than residents in other specialties, their need to know is no less. We developed, implemented, and evaluated a curriculum that bridged this gap in surgery education. After the curriculum, residents reported an increase in interest, knowledge, and responsible behavior relating to personal and practice financial management.

Standardizing the culture of trauma rotation handoffs.

OBJECTIVE: One of the General Surgery milestones focuses on effective handoffs between residents as they change shifts. Although the content of handoffs is crucial, we recognized that the culture of handoffs was equally important. After the reorganization of the trauma service at our institution, there were difficulties in maintaining the standardized handoff culture. We analyzed the culture of handoffs on the trauma service to create an environment more conducive to effective handoffs. DESIGN: All trauma activations from 2012 to 2013 were evaluated from our institution's trauma data registry. Data on timing of activations and disposition of the patient were analyzed to understand service work flow. A survey was developed and administered to the residents to assess the culture of trauma handoffs. SETTING: This work occurred at an academic, state-designated level 1 trauma center. PARTICIPANTS: All current residents in the general surgery residency who rotated on the trauma service in the last 5 years. RESULTS: There were 1654 admissions to the trauma service from June 2012 to July 2013. The single busiest hour for trauma admissions (7% of admissions) was the same time the residents were designated to handoff. Interruptions occurred often; 83% of residents indicated that a handoff interruption occurred daily, and 73% indicated a new activation interrupted handoffs weekly. A large majority, 61%, felt patient care was frequently compromised by an ineffective handoff. Similarly, as a direct result of inadequate handoffs, 50% felt uncomfortable answering nurses' pages at night. CONCLUSIONS: The unique situation of the trauma service impaired the handoff culture for residents. Assessment of our trauma activation flow indicates the timing of handoffs was adversely affecting our resident's ability to handoff effectively, requiring interventions to improve the efficacy and safety of handoffs.