Equity on the frontlines of trauma surgery: An #EAST4ALL roundtable.

BACKGROUND: Inequity exists in surgical training and the workplace. The Eastern Association for the Surgery of Trauma (EAST) Equity, Quality, and Inclusion in Trauma Surgery Ad Hoc Task Force (EAST4ALL) sought to raise awareness and provide resources to combat these inequities. METHODS: A study was conducted of EAST members to ascertain areas of inequity and lack of inclusion. Specific problems and barriers were identified that hindered inclusion. Toolkits were developed as resources for individuals and institutions to address and overcome these barriers. RESULTS: Four key areas were identified: (1) harassment and discrimination, (2) gender pay gap or parity, (3) implicit bias and microaggressions, and (4) call-out culture. A diverse panel of seven surgeons with experience in overcoming these barriers either on a personal level or as a chief or chair of surgery was formed. Four scenarios based on these key areas were proposed to the panelists, who then modeled responses as allies. CONCLUSION: Despite perceived progress in addressing discrimination and inequity, residents and faculty continue to encounter barriers at the workplace at levels today similar to those decades ago. Action is needed to address inequities and lack of inclusion in acute care surgery. The EAST is working on fostering a culture that minimizes bias and recognizes and addresses systemic inequities, and has provided toolkits to support these goals. Together, we can create a better future for all of us.

Evaluation of the Performance of ACS NSQIP Surgical Risk Calculator in Emergency General Surgery Patients.

The ACS NSQIP Surgical Risk Calculator is designed to estimate the chance of an unfavorable outcome after surgery. Our goal was to evaluate the accuracy of the calculator in our emergency general surgery population. Surgical outcomes were compared to predicted risk. The risk was calculated with surgeon adjustment scores (SASs) of 1 (no adjustment), 2 (risk somewhat higher), and 3 (risk significantly higher than estimate). Two hundred and twenty-seven patients met the inclusion criteria. An SAS of 1 or 2 accurately predicted risk of mortality (5.7% and 8.5% predicted versus 7.9% actual), whereas a risk adjustment of 3 indicated significant overestimation of mortality rate (14.8% predicted). There was good overall prediction performance for most variables with no clear preference for SAS 1, 2, or 3. Poor correlation was seen with SSI, urinary tract infection, and length of stay variables. The ACS NSQIP Surgical Risk Calculator yields valid predictions in the emergency general surgery population, and the data support its use to inform conversations about outcome expectations.

The Golden Opportunity: Multidisciplinary Simulation Training Improves Trauma Team Efficiency.

OBJECTIVE: Every trauma patient has a golden hour, and resuscitation efficiency within that hour has large implications for patients. We instituted simulation based trauma resuscitation training with the hypothesis that it would improve trauma team efficiency. METHODS: Five simulation training sessions were conducted with immediate debriefing. Metrics collected in actual trauma resuscitations before and after simulation training included time of primary and secondary surveys and time to computed tomography (CT) scan. Study participants were from multidisciplinary specialties involved in trauma resuscitations as well as former trauma patients from the Trauma Survivors Network. RESULTS: Seventy-three patients undergoing trauma resuscitations were screened and 67 patients were included. Time to CT scan and secondary survey completion were significantly reduced in actual trauma patient activations following implementation of the curriculum (reduction of 23 to 16 minutes for CT scan p < 0.05, and reduction from 14 to 6 minutes for secondary survey, p < 0.05). Time to primary survey completion did not change (5 minutes). CONCLUSIONS: Multidisciplinary simulation training was associated with improved trauma team efficiency in the form of reduced assessment time. As emergency department length of stay is an independent predictor of hospital mortality following trauma activation, team-based simulation training has the potential to improve patient outcomes. Multidisciplinary involvement was a key factor, and Trauma Survivors Network involvement brought credibility from the patient perspective.

Cervical spine collar clearance in the obtunded adult blunt trauma patient: a systematic review and practice management guideline from the Eastern Association for the Surgery of Trauma.

BACKGROUND: With the use of the framework advocated by the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group, our aims were to perform a systematic review and to develop evidence-based recommendations that may be used to answer the following PICO [Population, Intervention, Comparator, Outcomes] question:In the obtunded adult blunt trauma patient, should cervical collar removal be performed after a negative high-quality cervical spine (C-spine) computed tomography (CT) result alone or after a negative high-quality C-spine CT result combined with adjunct imaging, to reduce peri-clearance events, such as new neurologic change, unstable C-spine injury, stable C-spine injury, need for post-clearance imaging, false-negative CT imaging result on re-review, pressure ulcers, and time to cervical collar clearance? METHODS: Our protocol was registered with the PROSPERO international prospective register of systematic reviews on August 23, 2013 (REGISTRATION NUMBER: CRD42013005461). Eligibility criteria consisted of adult blunt trauma patients 16 years or older, who underwent C-spine CT with axial thickness of less than 3 mm and who were obtunded using any definition.Quantitative synthesis via meta-analysis was not possible because of pre-post, partial-cohort, quasi-experimental study design limitations and the consequential incomplete diagnostic accuracy data. RESULTS: Of five articles with a total follow-up of 1,017 included subjects, none reported new neurologic changes (paraplegia or quadriplegia) after cervical collar removal. There is a worst-case 9% (161 of 1,718 subjects in 11 studies) cumulative literature incidence of stable injuries and a 91% negative predictive value of no injury, after coupling a negative high-quality C-spine CT result with 1.5-T magnetic resonance imaging, upright x-rays, flexion-extension CT, and/or clinical follow-up. Similarly, there is a best-case 0% (0 of 1,718 subjects in 11 studies) cumulative literature incidence of unstable injuries after negative initial imaging result with a high-quality C-spine CT. CONCLUSION: In obtunded adult blunt trauma patients, we conditionally recommend cervical collar removal after a negative high-quality C-spine CT scan result alone. LEVEL OF EVIDENCE: Systematic review, level III.