Replacing the Scalpel With a Computer Mouse: An Evaluation of Time Spent on Electronic Health Record for Plastic Surgery Residents and Its Impact on Resident Training.

BACKGROUND: Following the integration of the electronic health record (EHR) into the healthcare system, concern has grown regarding EHR use on physician well-being. For surgical residents, time spent on the EHR increases the burden of a demanding, hourly restricted schedule and detracts from time spent honing surgical skills. To better characterize these burdens, we sought to describe EHR utilization patterns for plastic surgery residents. METHODS: Integrated plastic surgery resident EHR utilization from March 2019 to March 2020 was extracted via Cerner Analytics at a tertiary academic medical center. Time spent in the EHR on-duty (0600-1759) and off-duty (1800-0559) in the form of chart review, orders, documentation, and patient discovery was analyzed. Statistical analysis was performed in the form of independent t tests and Analysis of Variance (ANOVA). RESULTS: Twelve plastic surgery residents spent a daily average of 94 ± 84 minutes on the EHR, one-third of which was spent off-duty. Juniors (postgraduate years 1-3) spent 123 ± 99 minutes versus seniors (postgraduate years 4-6) who spent 61 ± 49 minutes (P < 0.01). Seniors spent 19% of time on the EHR off-duty, compared with 37% for juniors (P < 0.01). Chart review comprised the majority (42%) of EHR usage, followed by patient discovery (22%), orders (14%), documentation (12%), other (6%), and messaging (1%). Seniors spent more time on patient discovery (25% vs 21%, P < 0.001), while juniors spent more time performing chart review (48% vs 36%, P = 0.19). CONCLUSION: Integrated plastic surgery residents average 1.5 hours on the EHR daily. Junior residents spend 1 hour more per day on the EHR, including more time off-duty and more time performing chart review. These added hours may play a role in duty hour violations and detract from obtaining operative skill sets.

Outcomes among trauma patients with duodenal leak following primary versus complex repair of duodenal injuries: An Eastern Association for the Surgery of Trauma multicenter trial.

BACKGROUND: Duodenal leak is a feared complication of repair, and innovative complex repairs with adjunctive measures (CRAM) were developed to decrease both leak occurrence and severity when leaks occur. Data on the association of CRAM and duodenal leak are sparse, and its impact on duodenal leak outcomes is nonexistent. We hypothesized that primary repair alone (PRA) would be associated with decreased duodenal leak rates; however, CRAM would be associated with improved recovery and outcomes when leaks do occur. METHODS: A retrospective, multicenter analysis from 35 Level 1 trauma centers included patients older than 14 years with operative, traumatic duodenal injuries (January 2010 to December 2020). The study sample compared duodenal operative repair strategy: PRA versus CRAM (any repair plus pyloric exclusion, gastrojejunostomy, triple tube drainage, duodenectomy). RESULTS: The sample (N = 861) was primarily young (33 years) men (84%) with penetrating injuries (77%); 523 underwent PRA and 338 underwent CRAM. Complex repairs with adjunctive measures were more critically injured than PRA and had higher leak rates (CRAM 21% vs. PRA 8%, p < 0.001). Adverse outcomes were more common after CRAM with more interventional radiology drains, prolonged nothing by mouth and length of stay, greater mortality, and more readmissions than PRA (all p < 0.05). Importantly, CRAM had no positive impact on leak recovery; there was no difference in number of operations, drain duration, nothing by mouth duration, need for interventional radiology drainage, hospital length of stay, or mortality between PRA leak versus CRAM leak patients (all p > 0.05). Furthermore, CRAM leaks had longer antibiotic duration, more gastrointestinal complications, and longer duration until leak resolution (all p < 0.05). Primary repair alone was associated with 60% lower odds of leak, whereas injury grades II to IV, damage control, and body mass index had higher odds of leak (all p < 0.05). There were no leaks among patients with grades IV and V injuries repaired by PRA. CONCLUSION: Complex repairs with adjunctive measures did not prevent duodenal leaks and, moreover, did not reduce adverse sequelae when leaks did occur. Our results suggest that CRAM is not a protective operative duodenal repair strategy, and PRA should be pursued for all injury grades when feasible. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Mechanism of Injury and Age Predict Operative Intervention in Pediatric Perineal Injury.

OBJECTIVES: Literature characterizing pediatric perineal trauma is sparse and generally limited to females. The purpose of this study was to characterize pediatric perineal injuries with specific focus on patient demographics, mechanisms of injury, and care patterns at a regional level 1 pediatric trauma center. METHODS: Retrospective review of children aged younger than 18 years evaluated at a level 1 pediatric trauma center from 2006 to 2017. Patients were identified by International Classification of Diseases-9 and 10 codes. Extracted data included demographics, injury mechanism, diagnostic studies, hospital course, and structures injured. The χ 2 and t tests were used to examine differences between subgroups. Machine learning was used to predict variable importance in determining the need for operative interventions. RESULTS: One hundred ninety-seven patients met inclusion criteria. Mean age was 8.5 years. A total of 50.8% were girls. Blunt trauma accounted for 83.8% of injuries. Motor vehicle collisions and foreign bodies were more common in patients aged 12 years and older, whereas falls and bicycle-related injuries were more common in those younger than 12 years ( P < 0.01). Patients younger than 12 years were more likely to sustain blunt trauma with isolated external genital injuries ( P < 0.01). Patients aged 12 and older had a higher incidence of pelvic fractures, bladder/urethral injuries, and colorectal injuries, suggesting more severe injury patterns ( P < 0.01). Half of patients required operative intervention. Children aged 3 years or younger and older than 12 years had longer mean hospital stays compared with children aged 4 to 11 years ( P < 0.01). Mechanism of injury and age constituted more than 75% of the variable importance in predicting operative intervention. CONCLUSIONS: Perineal trauma in children varies by age, sex, and mechanism. Blunt mechanisms are the most common, with patients frequently requiring surgical intervention. Mechanism of injury and age may be important in deciding which patients will require operative intervention. This study describes injury patterns in pediatric perineal trauma that can be used to guide future practice and inform injury prevention efforts.

Quantifying the Impact of Comorbidities on Length of Stay in Geriatric Fall-Related Injuries.

Geriatric patients who fall are among the most common mechanisms of injury presenting to trauma centers. We sought to quantify the impact of various comorbidities on length of stay (LOS) in these patients to identify areas for intervention. A level 1 trauma center's registry was queried for patients ≥65 years old with fall related injuries admitted with LOS greater than 2 days. Over 7 years, 3714 patients were included. Mean age was 80.9 ± 8.7 years. All patients fell from heights of 6 feet or less. Median total LOS was 5 days, interquartile range [3,8]. Overall mortality rate was 3.3%. The most common comorbidities were cardiovascular (57.1%), musculoskeletal (31.4%), and diabetes (20.8%). Multivariate linear regression modeling LOS identified diabetes, pulmonary, and psychiatric diseases associated with longer lengths of stay (P < .05). As trauma centers refine care for geriatric trauma patients, comorbidity management represents an opportunity for proactive intervention.

Creation of a Human Factors Board to Support Well-Being in General Surgery Residents.

PROBLEM: Demands placed on resident physicians can make it difficult to keep up with personal needs, often affecting well-being. For military pilots, confidential and nonpunitive human factors boards (HFBs) identify pilots' human factors (personal or professional problems that might interfere with the ability to perform effectively) and make recommendations for support. The authors sought to determine the feasibility of establishing an HFB for resident physicians and its utility for general surgery residents. APPROACH: Publicly available information on HFBs was reviewed and translated to the structure of a general surgery residency. An HFB consisting of a faculty member, resident representative, and neutral third party was established for the general surgery residency program (consisting of 42 residents during the study period) at Penn State Health. From January 1 to July 1, 2020, the HFB responded to human factors needs of general surgery residents. Residents could make requests for themselves or another resident. If all HFB members were in agreement that a request was reasonable, the appropriate resource was directed to the requesting resident and funding was disbursed (if applicable) by the third party. OUTCOMES: From January 1 to July 1, 2020, 14 requests were made. Of these, 3 (21%) were made for another resident and 12 (86%) were fulfilled through resources arranged by the HFB. All requests occurred between January 1 and April 1, 2020, likely because of the COVID-19 pandemic. The overall cost of the program was $932.80. NEXT STEPS: The HFB represents an adaptable tool that can meet residents' specific needs as they arise and a mechanism through which residents can receive a tangible response to human factors. Formal feedback is needed to identify areas that could be improved. This structure could be generalized to other graduate medical education programs and physicians at all levels.

Radiologic Imaging Does Not Add Value for Female Pediatric Patients with Isolated Blunt Straddle Mechanisms.

STUDY OBJECTIVES: The purpose of this study was to characterize the utility of radiologic imaging and examination under anesthesia in female pediatric patients with isolated blunt straddle injuries. DESIGN: Retrospective review. SETTING: Single health care system with a children's hospital and level 1 pediatric trauma center. PARTICIPANTS: Female patients aged 1-17 years with blunt straddle injuries from 2006 to 2018. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Radiologic imaging performed, number of patients requiring exam under anesthesia (EUA), number of injuries not identified in patients who did not undergo EUA. RESULTS: The study cohort included 83 patients. Of these, 11 (13%) had imaging performed. Thirty-four patients were managed as outpatients, 28 were discharged from the emergency department without need for intervention, and 49 patients were admitted. Of these, 48 (98%) went to the operating room for exam EUA. No occult injuries were identified on radiologic studies. Imaging was not associated with need for EUA. No missed injuries occurred in children who were not imaged. Two patients who were imaged returned for EUA following evolution of symptoms. CONCLUSION: Radiologic imaging did not add diagnostic value for female pediatric patients with blunt straddle injuries. These data emphasize the importance of EUA with repair and advocates for minimization of radiologic imaging in this patient group.

Biodebridement in the Surgical Intensive Care Unit: Unique Therapy for Unique Patients.

Acute care surgery has evolved to encompass the advanced management of complex nonhealing wounds. Biodebridement has the potential to improve the care of chronic wounds for acute care surgery patients, particularly for patients in the surgical intensive care unit (SICU) with hospital-acquired pressure injuries. A case report of biodebridement using larval maggot therapy in the SICU is presented to illustrate real-world application and progression in wound healing. A review of current research involving biodebridement was conducted. A septuagenarian gentleman sustained a fall resulting in cervical spine fractures with neurological deficits. The patient had a prolonged hospital course in the SICU, complicated by myocardial infarction, respiratory failure requiring tracheostomy, and development of a Stage IV sacral pressure ulcer. The wound base was sharply debrided several times and became refractory to conventional mechanical/chemical debridement techniques. The patient had a prohibitively high risk for the operating room but remained too sensate for further effective bedside debridement. Biodebridement was utilized to create a viable wound base, with improved appearance noted within 2 weeks. A review of the current literature shows biodebridement has numerous benefits in the management of chronic wounds. Biodebridement is a unique therapy that possesses great value for select patients in the SICU. In particular, patients who are too high risk for further operative intervention, but too sensate for ongoing bedside debridement and dressing changes, benefit significantly from this underutilized approach. Further research is needed to solidify the place of biodebridement in the surgical management of chronic nonhealing wounds.

Development of a Standardized Program for the Collaboration of Adult and Children's Surgeons.

BACKGROUND: Children's hospitals within larger hospitals (CH/LH) have the specific clinical advantage of easily facilitated collaboration between adult and children's surgeons. These collaborations, which we have termed hybrid surgical offerings (HSOs) are often required for disease processes requiring interventions that fall outside the customary practice of children's surgeons. Formal models to describe or evaluate these practices are lacking. METHODS: HSOs within a CH/LH were identified. Principles of systems-engineering were used to develop a standardized model (Children's Hybrid Enhanced Surgical Services [CHESS]) to describe and evaluate HSOs. Face validity was established via unstructured interviews of CH leaders and HSO surgeons. Areas for improved system-wide standardization and programmatic development were identified. RESULTS: HSOs were identified in collaboration with adult bariatric, minimally invasive, advanced endoscopic, endocrine, thoracic, and orthopedic trauma surgical services. The CHESS framework encompassed: 1) quality improvement metrics, 2) credentialing and oversight, 3) transitions of care, 4) pediatric family-centered care, 5) maintenance of the cycle of expertise, 6) continuing medical education, 7) scholarship. While HSOs fulfilled the majority of aforementioned programmatic domains across all six HSO-providing services, areas for improvement included maintaining a cycle of expertise (33%), quality improvement metrics (50%), and pediatric family-centered care (66%).  Additional noted advantages included faster translation of adult innovation to pediatric care and facilitation of emergency interdisciplinary care. CONCLUSION: Formal evaluation of HSOs is necessary to standardize and improve the quality of children's surgical care. Development of a structured framework such as CHESS addresses gaps in quality oversight and provides a basis for performance improvement, patient safety, and programmatic development.

Adult Trauma Patients with Autism Spectrum Disorder: A Case-Control Study to Evaluate Disparities After Injury.

BACKGROUND: Adult trauma patients with autism spectrum disorder (ASD) may have distinct care needs that have not been previously described. We hypothesized that due to differences in clinical care and disposition issues, injured adults with ASD would have increased lengths of stay, higher mortality, and increased rates of complications compared to adults without ASD. METHODS: The Pennsylvania Trauma Outcomes Study database was queried from 2010-2018 for trauma patients with ASD. Case-control matching was performed for two controls per ASD patient accounting for age, gender, injury mechanism, and injury severity score. Primary outcomes included length of stay, mortality, and complication rate. Univariate analysis compared presentation and clinical care between the two groups. Multivariate regression and Kaplan-Meier curves modeled length of stay. Significance was defined as p < 0.05. RESULTS: A total of 185 patients with ASD were matched to 370 controls. Age (mean +/- standard deviation) was 33.4 +/- 16.5 years. Gender was 81.1% male. Mechanisms were 88.1% blunt, 5.9% penetrating, and 5.9% burns. Significant clinical differences identified in patients with ASD vs. case-controls included presenting verbal GCS (median [IQR]) (5 [2] vs. 5 [0], p < 0.01), proportion of patients intubated at presentation (20.0% vs. 13.0%, p = 0.031), and hospital length of stay (4 [6] days vs. 3 [4] days, p = 0.002). Adult patients with ASD were less likely to be discharged home and more often discharged to a skilled nursing facility (p < 0.01). There were no differences in mortality, rates of complications, imaging, or operations. Multivariate regression analysis controlling for demographic and clinical differences revealed the diagnosis of ASD independently contributed 3.13 days (95% Confidence Interval: 1.85 to 4.41 days) to injured adults' length of stay. Kaplan-Meier curves showed injured patients with ASD were less likely to be discharged than case-controls starting from time of admission (log rank test, p < 0.001). CONCLUSIONS: This statewide analysis suggests injured patients with ASD have increased lengths of stay without other clinical or outcome differences. Given significant differences in discharge destination, these findings support early involvement of a multidisciplinary care collaborative. Further research is needed to identify factors that contribute to disparities in care for adults with ASD.

Established Primary Care Provider Improves Odds of Survival to Discharge for Injured Patients.

INTRODUCTION: The average age and number of comorbidities is increasing among trauma patients. Primary care providers (PCPs) provide pre-injury diagnosis and management of comorbidities that may affect outcomes for injured patients. The role of primary care in trauma systems is currently unknown. METHODS: Observational retrospective review of an institutional trauma databank from 2013 - 2019. PCP was extracted from the electronic medical record and combined with trauma data. Case-control matching was performed to compare outcomes between patients with and without primary care based on age, injury severity score, sex, and injury mechanism. Mann-Whitney U test, chi-square test, and multivariate regression described differences between subgroups. Primary outcome was difference in mortality rate for injured patients with and without PCPs. RESULTS: Within the study period, 19,096 patients were included. 6,626 (34.7%) had a PCP recorded. Of these, 2,158 were matched in a case-control design. Patients with PCPs had a lower mortality rate (1.6%) compared to patients without PCPs (3.6%, P < 0.01). PCP retention was associated with longer length of stay overall, equivalent rates of complications (5.4% vs. 5.7%, P = 0.63), and similar numbers of ICU and ventilator days. Multivariate logistic regression controlling for case-control factors, insurance, and comorbidities conferred an odds ratio of 2.58 (95% Confidence Interval: 1.59 - 4.19, P < 0.001) for survival to discharge. CONCLUSION: Pre-injury primary care significantly improves the odds of survival to discharge for injured patients. Prospective study of this relationship may identify strategies to promote primary care within health systems.

Lymphatic malformations: a 20-year single institution experience.

PURPOSE: Lymphatic malformations (LMs) are congenital abnormalities which result from disturbances in the embryologic development of the lymphatic system. We sought to determine the characteristics and treatment patterns for LMs in a rural setting, and the effect of a specialized vascular malformations clinic on triage and follow-up. METHODS: This is a retrospective cohort study at a single tertiary care institution. Sixty-two patients were identified; chart review was completed to obtain demographic, surgery/sclerotherapy session and follow-up information. RESULTS: The head/neck region was the most predominant LM location (N = 26, 41.9%), followed by trunk (N = 16, 25.8%), extremity (N = 11, 17.7%), and intraabdominal/retroperitoneal (N = 7, 11.3%). Twenty-eight patients were managed non-surgically, while 21, 7 and 6 patients required surgery, sclerotherapy, or both. Head/neck LMs were the most likely to recur (73%, p = 0.028). Patients seen in specialty clinic had similar duration of follow-up and time to intervention, but were more often below 1 year of age (p = 0.030). Average LM volume among patients with available imaging was much larger in those referred to specialty clinic (73.2 cm3 versus 14.8 cm3, p = 0.022). CONCLUSION: Our experience reiterates not only the wide variety of clinical presentations of lymphatic malformations, but also demonstrates the necessity of multiple subspecialties and their collaboration to achieve prompt and efficacious treatment.

Chemical proteomics with sulfonyl fluoride probes reveals selective labeling of functional tyrosines in glutathione transferases.

Chemical probes have great potential for identifying functional residues in proteins in crude proteomes. Here we studied labeling sites of chemical probes based on sulfonyl fluorides (SFs) on plant and animal proteomes. Besides serine proteases and many other proteins, SF-based probes label Tyr residues in glutathione transferases (GSTs). The labeled GSTs represent four different GST classes that share less than 30% sequence identity. The targeted Tyr residues are located at similar positions in the promiscuous substrate binding site and are essential for GST function. The high selectivity of SF-based probes for functional Tyr residues in GSTs illustrates how these probes can be used for functional studies of GSTs and other proteins in crude proteomes.

Sulfonyl fluoride analogues as activity-based probes for serine proteases.

Enriched with fluoride: To expand on the available tools to interrogate proteases, we explored sulfonyl fluorides as activity-based probes. An alkyne-tagged sulfonyl fluoride covalently modifies members of the S1 family of serine proteases. By applying click chemistry, avidin enrichment and mass spectrometry, we can enrich and identify active endogenous serine proteases from a complex proteome.