Up Close and Personal: A Statewide Collaborative's Effort to Get Individual Surgeon Quality Improvement Data to the Practitioner.

Ranking of surgeons and hospitals focuses on procedure volume and hospitality. The National Surgical Quality Improvement Program provides vetted outcomes of surgical quality and therefore can direct improvement. Our statewide collaborative's analysis creates personalized surgeon data to drive quality improvement. Statewide National Surgical Quality Improvement Program data generated specific measures from 103,656 general/vascular cases and identified individual surgeon's outcome of occurrences and length of procedure. We assumed a normal distribution and called the top 2.5 per cent as exemplars and the bottom 2.5 per cent as outliers. For length of operation, a standard duration was calculated, and identified outliers as longer than the 95th percentile of the upper confidence interval/procedure. Since 2009, sharing best practice reduced statewide mortality rate by 31.5 per cent and postoperative morbidity by 33.3 per cent. For length of surgery, long outliers have more complications (urinary tract infection, organ space/surgical site infection, sepsis, septic shock, prolonged intubation, pneumonia, deep venous thrombosis, deep incisional infection, and wound disruption). No significant trends in surgeon performance were seen over 24 months. A statewide collaborative has resulted in substantial risk-adjusted reductions in surgical morbidity and mortality. These results of the individual surgeon demonstrate best practices are shared, a proven tool for improvement in our collaborative.

How slow is too slow? Correlation of operative time to complications: an analysis from the Tennessee Surgical Quality Collaborative.

BACKGROUND: The Tennessee Surgical Quality Collaborative analyzes NSQIP data from 21 participating hospitals. The Tennessee Surgical Quality Collaborative has reduced surgical complications, but causative factors are unclear. We sought to correlate surgical duration with complications to reveal mitigating strategies. STUDY DESIGN: Risk-adjusted Tennessee Surgical Quality Collaborative data on 104,632 general and vascular cases had a standard duration for 35 procedures (eg, breast, colectomy) calculated and NSQIP outcomes complication rates recorded. We derived a marginal time risk for each extra hour of operative time and reported per 1,000 cases. RESULTS: Procedures taking <95% upper confidence standard time limit (n = 99,741) were deemed "not long" and had significantly fewer urinary tract infections, organ-space surgical site infection, sepsis/septic shock, prolonged intubation, and pneumonia. "Long" cases had increased rates of these complications and also deep venous thrombosis, deep incisional infection, and wound disruption. Per 1,000 cases, there were 116 occurrences per operating room hour. Surgical site infections occurred in 14.4/1,000 cases per hour; risk started at 42 minutes of operative time. Death, pneumonia, and prolonged intubation saw their risks begin before the operation. The highest marginal time risk was for sepsis, occurring 16.6 times per additional hour of operative time over standard. Studying only the 25,146 clean procedures, a significant correlation (p < 0.001) to operation duration persisted, despite an occurrence incidence of 4.5%. CONCLUSIONS: Duration of operation correlates with complications and time longer than a statewide established standard carries higher risk. To reduce risk of complications, these data support expeditious surgical technique and preoperative pulmonary training, and offer accurate outcomes assessment for patient counseling based on case duration. These data can be used directly to counsel individual surgeons to improve outcomes.

Using the National Surgical Quality Improvement Program and the Tennessee Surgical Quality Collaborative to improve surgical outcomes.

BACKGROUND: Led by the Tennessee Chapter of the American College of Surgeons, in May 2008 a 10-hospital collaborative was formed between the Tennessee Chapter of ACS, the Tennessee Hospital Association, and the BlueCross BlueShield of Tennessee Health Foundation. We hypothesized that by forming the Tennessee Surgical Quality Collaborative using the National Surgical Quality Improvement Program (NSQIP) system to share surgical process and outcomes data, overall patient surgical outcomes would improve. STUDY DESIGN: All NSQIP data from the 10-hospital collaborative for the time periods January to December 2009 (period 1) and January to December 2010 (period 2) were collected. Data on 20 categories of postoperative complications and 30-day mortality were compared between periods. Complication comparisons and hospital costs associated with complications were calculated per 10,000 procedures. Statistical analysis was performed by Z-test. RESULTS: There were 14,205 total surgical cases in period 1 and 14,901 surgical cases in period 2. Between periods (per 10,000 cases) there were significant improvements in superficial surgical site infections (-19%, p = 0.0005), on ventilator longer than 48 hours (-15%, p = 0.012), graft/prosthesis/flap failure (-60%, p < 0.0001), acute renal failure (-25%, p = 0.023), and wound disruption (-34%, p = 0.011). Although mortality (per 10,000) was higher in period 2 (237.6 vs 232.3), no statistical difference was noted. Net costs avoided between these periods were calculated as $2,197,543 per 10,000 general and vascular surgery cases. CONCLUSIONS: Data organization and scrutiny are the initial steps of process improvement. Participation in our regional surgical quality collaborative resulted in improved outcomes and reduced costs. Although the mechanisms for these changes are likely multifactorial, the collaborative establishes communication, process improvement, and frank discussion among the members as best practices are identified and shared and standardized processes are adopted.

General surgery at rural Tennessee hospitals: a survey of rural Tennessee hospital administrators.

Rural communities face an impending surgical workforce crisis. The purpose of this study is to describe perceptions of rural Tennessee hospital administrators regarding the importance of surgical services to their hospitals. In collaboration with the Tennessee Hospital Association, we developed and administered a 13-item survey based on a recently published national survey to 80 rural Tennessee hospitals in August 2008. A total of 29 responses were received for an overall 36.3 per cent response rate. Over 44 per cent of rural surgeons were older than 50 years of age, and 27.6 per cent of hospitals reported they would lose at least one surgeon in the next 2 years. The responding hospitals reported losing 10.4 per cent of their surgical workforce in the preceding 2 years. Over 53 per cent were actively recruiting a general surgeon with an average time to recruit a surgeon of 11.8 months. Ninety-seven per cent stated that having a surgical program was very important to their financial viability with the mean and median reported revenue generated by a single general surgeon being $1.8 million and $1.4 million, respectively. Almost 11 per cent of the hospitals stated they would have to close if they lost surgical services. Although rural Tennessee hospitals face similar difficulties to national rural hospitals with regard to retaining and hiring surgeons, slightly more Tennessee hospitals (54 vs 36%) were actively attempting to recruit a general surgeon. The shortage of general surgeons is a threat to the accessibility of comprehensive hospital-based care for rural Tennesseans.

Program directors' views on general surgery resident travel for transplant rotations.

BACKGROUND: Some program directors in surgery (PDs) must maintain transplant rotations at nonintegrated (away) hospitals. This study investigated the opinions of PDs related to resident travel for transplant surgery experience. METHODS: An Internet-based survey was e-mailed to 251 PDs in the United States. RESULTS: Altogether, 131 PDs (52%) responded. Of those, 66% have a transplant service at integrated hospitals. Small majorities of PDs believed transplant rotations offer a good educational experience (59%) and comply with duty hours (71%). Few PDs believed transplant rotations provide excellent operative experience (47%) and mandate service over education (38%). PDs leading community-affiliated and smaller programs employed away rotations more commonly. Affected PDs used commuting (48%) and purchased temporary housing (52%). Most believed travel is a poor aspect of the experience (78%) and transplant rotations should become an optional component of residency training (60%). PDs using away hospitals more often believed this content area should be eliminated. CONCLUSIONS: Although away transplant rotations minimally impact opinions of PDs related to select educational issues, most PDs challenge the existing paradigm of transplant surgery as essential content.

Fundamentals of liver surgery for the practicing general surgeon.

This review focuses on the common general surgical referral problem of an undefined liver lesion. Understanding the clinical context in which the patient presents allows one to narrow the differential diagnosis and develop a focused evaluation plan. Most often, MRI is the most helpful initial study to define the likely diagnosis. If the appropriate radiologic expertise exists locally, most of the diagnostic evaluation, if not all, is feasible by a practicing general surgeon. Likewise, understanding the fundamentals of liver anatomy and physiology will facilitate the general surgeons' ability to evaluate the patient's imaging and liver reserve to decide whether local surgical care can be done safely. If local care is not available or safe, referral to a hepatobiliary specialist is appropriate. Ultimately, it is most important for the general surgeon contemplating surgery on the liver to understand his or her own limitations and the limits of their institutions' capabilities in providing pre- and postoperative care. It is particularly important to understand the pitfalls associated with decision-making for complex hepatobiliary problems and when considering an operation on anybody with significant intrinsic liver disease. When faced with these scenarios, the practicing general surgeon should always raise the question: "Is this patient better served at a hepatobiliary center or one that offers liver transplant?" If yes, a phone call, if not a referral, to a tertiary center to discuss the case is reasonable before embarking on a potentially hazardous operation.

Education of the rural surgeon: experience from Tennessee.

The rural surgery rotation that is contained within the general surgery residency program at The University of Tennessee College of Medicine-Chattanooga is described in this article. The advantages of this experience, including the extensive endoscopy experience and the close exposure to practicing general surgeons, are also outlined. The rotation receives uniformly positive evaluations from residents at completion, and it has become the primary gastrointestinal endoscopy educational experience in this program. The description serves as a model that can be used by other programs to construct a rural surgery rotation.

Operative experience of residents in US general surgery programs: a gap between expectation and experience.

OBJECTIVE: The purpose of the study was to identify a group of operations which general surgery residency program directors believed residents should be competent to perform by the end of 5 years of training and then ascertain actual resident experience with these procedures during their training. SUMMARY BACKGROUND DATA: There is concern about the adequacy of training of general surgeons in the United States. The American Board of Surgery and the Association of Program Directors in Surgery undertook a study to determine what operative procedures residency program directors consider to be essential to the practice of general surgery and then we measured the actual operative experience of graduating residents in those procedures, as reported to the Residency Review Committee for Surgery (RRC). METHODS: An electronic survey was sent to residency program directors at the 254 general surgery programs in the US accredited by the RRC as of spring 2006. The program directors were presented with a list of 300 types of operations. Program directors graded the 300 procedures "A," "B," or "C" using the following criteria: A--graduating general surgery residents should be competent to perform the procedure independently; B--graduating residents should be familiar with the procedure, but not necessarily competent to perform it; and C--graduating residents neither need to be familiar with nor competent to perform the procedure. After ballots were tallied, the actual resident operative experience reported to the RRC by all residents finishing general surgery training in June 2005 was reviewed. RESULTS: One hundred twenty-one of the 300 operations were considered A level procedures by a majority of program directors (PDs). Graduating 2005 US residents (n = 1022) performed only 18 of the 121 A procedures, an average of more than 10 times during residency; 83 of 121 procedures were performed on an average less than 5 times and 31 procedures less than once. For 63 of the 121 procedures, the mode (most commonly reported) experience was 0. In addition, there was significant variation between residents in operative experience for specific procedures. In virtually all cases, the mean reported experience exceeded the mode, suggesting that the mean is a poor measure of typical experience. CONCLUSIONS: These data pose important problems for surgical educators. Methods will have to be developed to allow surgeons to reach a basic level of competence in procedures which they are likely to experience only rarely during residency. Even for more commonly performed procedures, the numbers of repetitions are not very robust, stressing the need to determine objectively whether residents are actually achieving basic competency in these operations. Finally, the large variations in experience between individuals in our residency system need to be explored, understood, and remedied.

The developing crisis in the national general surgery workforce.

BACKGROUND: The number of surgeons willing to practice general surgery in its traditional form is in decline. One becomes acutely aware of this shortage, as a residency program director, given the many requests for new general surgeons (GS). STUDY DESIGN: From the 7th of February 2007 through the 30th of April 2007, and from May 23, 2007 through August 10, 2007, one program director collected all solicitations and advertised openings sent to him for a new GS. These communications varied from email submissions to formal letters. To assess the economic impact of a GS on a hospital, data were collected from existing recruiting industry surveys, the chief financial officer of a large inner-city teaching hospital, and an individual rural surgeon. RESULTS: There were 140 openings nationally for GSs during the initial study period. During the second study period, there were 149 positions in 40 states. The annual economic worth of a GS was estimated to be between $1.05 million and $2.4 million. CONCLUSIONS: Currently, there is an imbalance in supply and demand for the field of general surgery. If GSs retire or leave small hospitals and cannot be replaced, those hospitals will be threatened with closing. This will strain the large, safety-net hospitals even more. Solutions should include a national workforce survey, allowing hospitals to supplement a surgeon's income, the Residency Review Committee for Surgery should consider an immediate 20% increase in the number of categorical spots in general surgery, and focused recruitment of medical graduates from other countries.

Reproduction of postprandial symptoms with cholecystokinin injection: an indication for cholecystectomy without the presence of gallstones or an abnormal ejection fraction on quantitative cholescintigraphy?

Quantitative cholescintigraphy with cholecystokinin injection is commonly used to assess patients without evidence of cholelithiasis but with functional biliary pain. However, normal results may not always exclude the possibility of pathologic biliary disease. Retrospective review of prospectively collected data on eight patients with biliary colic, no evidence of cholelithiasis, a normal quantitative cholescintigraphy ejection fraction but with reproduction of their specific symptoms on cholecystokinin injection was performed. The mean ejection fraction was 66.2 per cent. All of these patients underwent cholecystectomy with complete resolution of their symptoms. Pathology was abnormal in all cases. Patients with symptoms suggestive of biliary disease with reproduction of these symptoms on cholecystokinin injection may benefit from cholecystectomy even in the absence of abnormally low ejection fraction on quantitative cholescintigraphy.

Experience with vacuum-pack temporary abdominal wound closure in 258 trauma and general and vascular surgical patients.

BACKGROUND: Temporary closure of an open abdominal wound by vacuum-pack is the method of choice for patients requiring open abdomen management in our institution. We have previously reported our experience with a vacuum-pack in trauma patients and have expanded its use to general and vascular surgery patients. STUDY DESIGN: This is a descriptive study performed through review of medical records of all patients undergoing vacuum-pack closure after celiotomy from January 1999 to May 2006. Clinical and demographic data were collected. RESULTS: Seven hundred seventeen vacuum-pack closures were performed in 258 surgical patients (116 trauma versus 142 general and vascular surgery). The most common indication for open abdomen management was damage control in trauma patients and planned reexploration in general and vascular surgery patients. Total abdominal complication rate was 15.5% (14.7% trauma versus 16.2% general and vascular surgery). Fistulas occurred in 13 (5%), intraabdominal abscesses in 9 (3.5%), bowel obstruction in 3 (1.2%), abdominal compartment syndrome in 3 (1.2%), and evisceration in 1 (0.4%). Two hundred twenty-six patients survived to permanent abdominal wound closure. Of these, 154 (68.1%) patients underwent primary fascial closure of their abdominal wounds. Seventy-two patients (31.9%) required delayed closure. In-hospital mortality rate was 26.0% (25.9% trauma versus 26.1% general and vascular surgery). The cost of vacuum-pack materials is less than $50. CONCLUSIONS: Indication for open abdomen management varied between general and vascular surgery and trauma patients. Complication rates were similar. Primary closure of open abdominal wounds was achieved in 68.4% of patients. Vacuum-pack temporary abdominal wound closure, initially used in trauma patients, continues to demonstrate ease of mastery, effectiveness in patient care and comfort, consistently low associated complication rate, and low cost in both general and vascular surgery and trauma patients.

Rural surgery training: a survey of program directors.

BACKGROUND: Differences have been established between rural and urban surgery with regard to surgeon supply, demographics, and practices. This study attempts to determine the importance and prevalence of rural surgery training in American general surgery residency programs. STUDY DESIGN: A survey was electronically submitted to and completed by surgery program directors in the fall of 2004. Respondents were divided into research or nonresearch programs. Survey items measured attitudes toward the necessity and ideal components of a rural surgery curriculum and whether or not the program had such a curriculum in place. RESULTS: There was a 24.0% survey response rate, with 17.2% of respondents being classified as research programs. Research programs were less likely to believe that it was their mission to train rural surgeons (2.50 versus 4.36, p < 0.001) and were less likely to believe that a shortage of rural surgeons exists. Just over 36% of programs reported having a rural surgery curriculum. Programs that believed training rural surgeons was part of their mission and that believed such a curriculum was necessary to train rural surgeons were more likely to have a rural surgery curriculum in place. CONCLUSIONS: The presence of a curriculum to train rural surgeons is related to the belief that such a curriculum is necessary and that training rural surgeons is part of that residency program's mission. Residency programs have different attitudes and practices with regard to rural surgery training. Development of a rural surgery training designation can help trainees wishing to practice in a rural environment identify the programs best suited to equip them to do so.

How surgical faculty and residents assess the first year of the Accreditation Council for Graduate Medical Education duty-hour restrictions: results of a multi-institutional study.

BACKGROUND: This study examined how surgical residents and faculty assessed the first year of the Accreditation Council for Graduate Medical Education duty-hour restrictions. METHODS: Questionnaires were administered in 9 general-surgery programs during the summer of 2004; response rates were 63% for faculty and 58% for residents (N = 259). Questions probed patient care, the residency program, quality of life, and overall assessments of the duty-hour restrictions. Results include the means, mean deviations, percentage who agree or strongly agree with the hour restrictions, and significance tests. RESULTS: Although most support the restrictions, few maintain that they improved surgical training or patient care. Faculty and residents differed (P < or = .05) on 16 of 21 items. Every difference shows that residents view the restrictions more favorably than faculty. The sex of the resident shaped the magnitude of the gap for 11 of 21 items. CONCLUSIONS: Few believe that duty-hour restrictions improve patient care or resident training. Residents, especially female residents, view the restrictions more favorably than faculty.