General Surgery Resuscitation Preference Documentation: A Quality Improvement Initiative.

BACKGROUND/PURPOSE: Documentation of resuscitation preferences is crucial for patients undergoing surgery. Unfortunately, this remains an area for improvement at many institutions. We conducted a quality improvement initiative to enhance documentation percentages by integrating perioperative resuscitation checks into the surgical workflow. Specifically, we aimed to increase the percentage of general surgery patients with documented resuscitation statuses from 82% to 90% within a 1-year period. METHODS: Three key change ideas were developed. First, surgical consent forms were modified to include the patient's resuscitation status. Second, the resuscitation status was added to the routinely used perioperative surgical checklist. Finally, patient resources on resuscitation processes and options were updated with support from patient partners. An audit survey was distributed mid-way through the interventions to evaluate process measures. RESULTS: The initiatives were successful in reaching our study aim of 90% documentation rate for all general surgery patients. The audit revealed a high uptake of the new consent forms, moderate use of the surgical checklist, and only a few patients for whom additional resuscitation details were added to their clinical note. CONCLUSIONS: We successfully increased the documentation percentage of resuscitation statuses within our large tertiary care center by incorporating checks into routine forms to prompt the conversation with patients early.

The Need for Health Policy Training for Surgeons.

BACKGROUND: Improvements in surgery at a systems level can be mediated by effective health policy. METHODS: We reviewed three contemporary challenges in surgical care to understand the potential role of health policy. RESULTS: The pandemic-related backlog, and international economic and logistical challenges to surgical care may be improved through policy change and advocacy by surgeons. CONCLUSIONS: A surgeon-policy expert training pathway and professional role will ensure surgeons contribute meaningfully to health policy development.

Next-Generation Remote Hand Assessments: Cross-Platform DIGITS Web Application.

Purpose: We have previously developed DIGITS, a platform for remote evaluation of range of motion, dexterity, and swelling of fingers for reducing barriers to accessing clinical resources. The current study was aimed at evaluating DIGITS across different devices with varied operating systems and camera resolutions using a single person's hands. Methods: Our team has now developed a web application version of the DIGITS platform, which makes it accessible on any device that is equipped with a camera, including computers, tablets, and smartphones. In the present study, we aimed to validate this web application by comparing flexion and extension measurements on the same person's hands using three different devices with cameras of different resolutions. The absolute difference, SD, standard mean error, and intraclass correlation coefficient were calculated. Additionally, equivalency testing was performed using the confidence interval approach. Results: Our findings indicated that the differences in degree measured between the devices ranged from 2° to 3° when digit extension was assessed (all hand landmarks are visible in the camera's direct view) and from 3° to 8° when digit flexion was assessed (some of the hand landmarks are hidden from view). The intraclass correlation coefficient of individual trials ranged from 0.82 to 0.96 for extension and 0.77 to 0.87 for flexion across all devices. Additionally, within a 90% confidence interval, our data showed equivalency with measurements using three different devices. Conclusions: The absolute differences were within an acceptable 9° tolerance for measurements taken between devices for flexion and extension. Equivalency was observed for measurements of finger range of motion taken using DIGITS, regardless of devices, platforms, or camera resolutions. Clinical relevance: In summary, the DIGITS web application has good test-retest reliability to generate data on finger range of motion for hand telerehabilitation. DIGITS can reduce costs to patients, providers, and health care facilities for conducting postoperative follow-up assessments.

Airway registries in primarily adult, emergent endotracheal intubation: a scoping review.

BACKGROUND: Emergency Department (ED) airway registries are formalized methods to collect and document airway practices and outcomes. Airway registries have become increasingly common in EDs globally; yet there is no consensus of airway registry methodology or intended utility. This review builds on previous literature and aims to provide a thorough description of international ED airway registries and discuss how airway registry data is utilized. METHODS: A search of Medline, Embase, Scopus, Cochrane Libraries, Web of Science, and Google Scholar was performed with no date limitations applied. English language full-text publications and grey literature from centres implementing an ongoing airway registry to monitor intubations performed in mainly adult patients in an ED setting were included. Non-English publications and publications describing airway registries to monitor intubation practices in predominantly paediatric patients or settings outside of the ED were excluded. Study screening for eligibility was performed by two team members individually, with any disagreements resolved by a third team member. Data was charted using a standardized data charting tool created for this review. RESULTS: Our review identified 124 eligible studies from 22 airway registries with a global distribution. We found that airway registry data is used for quality assurance, quality improvement, and clinical research regarding intubation practices and contextual factors. This review also demonstrates that there is a great deal of heterogeneity in definitions of first-pass success and adverse events in the peri-intubation period. CONCLUSIONS: Airway registries are used as a crucial tool to monitor and improve intubation performance and patient care. ED airway registries inform and document the efficacy of quality improvement initiatives to improve intubation performance in EDs globally. Standardized definitions of first-pass success and peri-intubation adverse events, such as hypotension and hypoxia, may allow for airway management performance to be compared on a more equivalent basis and allow for the development of more reliable international benchmarks for first-pass success and rates of adverse events in the future.

Modeling the Role of Wnt Signaling in Human and Drosophila Stem Cells.

The discovery of induced pluripotent stem (iPS) cells, barely more than a decade ago, dramatically transformed the study of stem cells and introduced a completely new way to approach many human health concerns. Although advances have pushed the field forward, human application remains some years away, in part due to the need for an in-depth mechanistic understanding. The role of Wnts in stem cells predates the discovery of iPS cells with Wnts established as major pluripotency promoting factors. Most work to date has been done using mouse and tissue culture models and few attempts have been made in other model organisms, but the recent combination of clustered regularly interspaced short palindromic repeats (CRISPR) gene editing with iPS cell technology provides a perfect avenue for exploring iPS cells in model organisms. Drosophila is an ideal organism for such studies, but fly iPS cells have not yet been made. In this opinion article, we draw parallels between Wnt signaling in human and Drosophila stem cell systems, propose ways to obtain Drosophila iPS cells, and suggest ways to exploit the versatility of the Drosophila system for future stem cell studies.

An embryonic system to assess direct and indirect Wnt transcriptional targets.

During animal development, complex signals determine and organize a vast number of tissues using a very small number of signal transduction pathways. These developmental signaling pathways determine cell fates through a coordinated transcriptional response that remains poorly understood. The Wnt pathway is involved in a variety of these cellular functions, and its signals are transmitted in part through a ß-catenin/TCF transcriptional complex. Here we report an in vivo Drosophila assay that can be used to distinguish between activation, de-repression and repression of transcriptional responses, separating upstream and downstream pathway activation and canonical/non-canonical Wnt signals in embryos. We find specific sets of genes downstream of both ß-catenin and TCF with an additional group of genes regulated by Wnt, while the non-canonical Wnt4 regulates a separate cohort of genes. We correlate transcriptional changes with phenotypic outcomes of cell differentiation and embryo size, showing our model can be used to characterize developmental signaling compartmentalization in vivo.