Plastic Surgery amidst the Pandemic: The New York University Experience at the Epicenter of the COVID-19 Crisis.

SUMMARY: The coronavirus disease of 2019 pandemic became a global threat in a matter of weeks, with its future implications yet to be defined. New York City was swiftly declared the epicenter of the pandemic in the United States as case numbers grew exponentially in a matter of days, quickly threatening to overwhelm the capacity of the health care system. This burgeoning crisis led practitioners across specialties to adapt and mobilize rapidly. Plastic surgeons and trainees within the New York University Langone Health system faced uncertainty in terms of future practice, in addition to immediate and long-term effects on undergraduate and graduate medical education. The administration remained vigilant and adaptive, enacting departmental policies prioritizing safety and productivity, with early deployment of faculty for clinical support at the front lines. The authors anticipate that this pandemic will have far-reaching effects on the future of plastic surgery education, trends in the pursuit of elective surgical procedures, and considerable consequences for certain research endeavors. Undoubtedly, there will be substantial impact on the physical and mental well-being of health care practitioners across specialties. Coordinated efforts and clear lines of communication between the Department of Plastic Surgery and its faculty and trainees allowed a concerted effort toward the immediate challenge of tempering the spread of coronavirus disease of 2019 and preserving structure and throughput for education and research. Adaptation and creativity have ultimately allowed for early rebooting of in-person clinical and surgical practice. The authors present their coordinated efforts and lessons gleaned from their experience to inform their community's preparedness as this formidable challenge evolves.

COVID-19 Impact on Surgical Resident Education and Coping.

BACKGROUND: Healthcare systems and surgical residency training programs have been significantly affected by the novel coronavirus disease 2019 (COVID-19) pandemic. A shelter-in-place and social distancing mandate went into effect in our county on March 16, 2020, considerably altering clinical and educational operations. Along with the suspension of elective procedures, resident academic curricula transitioned to an entirely virtual platform. We aimed to evaluate the impact of these modifications on surgical training and resident concerns about COVID-19. MATERIALS AND METHODS: We surveyed residents and fellows from all eight surgical specialties at our institution regarding their COVID-19 experiences from March to May 2020. Residents completed the survey via a secure Qualtrics link. A total of 38 questions addressed demographic information and perspectives regarding the impact of the COVID-19 pandemic on surgical training, education, and general coping during the pandemic. RESULTS: Of 256 eligible participants across surgical specialties, 146 completed the survey (57.0%). Junior residents comprised 43.6% (n = 61), compared to seniors 37.1% (n = 52) and fellows 19.3% (n = 27). Most participants, 97.9% (n = 138), anticipated being able to complete their academic year on time, and 75.2% (n = 100) perceived virtual learning to be the same as or better than in-person didactic sessions. Participants were most concerned about their ability to have sufficient knowledge and skills to care for patients with COVID-19, and the possibility of exposure to COVID-19. CONCLUSIONS: Although COVID-19 impacted residents' overall teaching and clinical volume, residency programs may identify novel virtual opportunities to meet their educational and research milestones during these challenging times.

The digital patient journey solution for patients undergoing elective hip and knee arthroplasty: Protocol for a pragmatic randomized controlled trial.

AIM: To describe a randomized controlled trial (RCT) protocol that will evaluate the effectiveness of a digital patient journey (DPJ) solution in improving the outcomes of patients undergoing total hip and knee arthroplasty. BACKGROUND: There is an urgent need for novel technologies to ensure sustainability, improve patient experience, and empower patients in their own care by providing information, support, and control. DESIGN: A pragmatic RCT with two parallel arms. METHODS: The participants randomized assigned to the intervention arm (N = 33) will receive access to the DPJ solution. The participants in the control arm (N = 33) will receive conventional care, which is provided face to face by using paper-based methods. The group allocations will be blinded from the study nurse during the recruitment and baseline measures, as well as from the outcome assessors. Patients with total hip arthroplasty will be followed up for 8-12 weeks, whereas patients with total knee arthroplasty will be followed up for 6-8 weeks. The primary outcome is health-related quality of life, measured by the EuroQol EQ-5D-5L scale. Secondary outcomes include functional recovery, pain, patient experience, and self-efficacy. The first results are expected to be submitted for publication in 2020. IMPACT: This study will provide information on the health effects and cost benefits of using the DPJ solution to support a patient's preparation for surgery and postdischarge surgical care. If the DPJ solution is found to be effective, its implementation into clinical practice could lead to further improvements in patient outcomes. If the DPJ solution is found to be cost effective for the hospital, it could be used to improve hospital resource efficiency.

2011 ACGME Duty Hour Limits had No Association With Breast Reconstruction Complications.

BACKGROUND: In 2011, the Accreditation Council for Graduate Medical Education (ACGME) instituted further duty hour restrictions in response to concerns over long work hours and sleep deprivation in trainees and their effects on patient outcomes. The effect of duty hour restrictions on complications after breast reconstruction procedures has not been clarified. MATERIALS AND METHODS: A retrospective cross-sectional analysis was designed. The National Inpatient Sample database was queried in the 2 y before and 2 y after the 2011 duty hour changes. Patients undergoing breast reconstruction, the most common elective admission diagnosis for plastic surgery patients, were selected for analysis. Patient groups were separated by teaching hospitals (THs) and nonteaching hospitals and by pre- and post-ACGME change periods. Surgical complication rates, length of stay, and procedures were analyzed using complex survey-weighted univariate and multivariate logistic regression analysis, with additional sensitivity analysis applied. RESULTS: The number of procedures did not vary significantly in the period after duty hour restrictions in THs (n = 46,188, pre-ACGME versus n = 48,980, post-ACGME). Overall complication rates in teaching (9.54%, pre-ACGME versus 9.04%, post-ACGME; P = 0.561) and nonteaching hospitals (8.54%, pre-ACGME versus 7.70%, post-ACGME; P = 0.319) did not significantly change after the implementation of duty hour changes. On multivariate analysis, surgery performed in resident THs after duty hour changes was not associated with a significant change in overall (odds ratio [OR], 1.03; 95% confidence interval [95% CI], 0.77-1.37; P = 0.857) breast-specific complications (OR, 1.06; 95% CI, 0.77-1.46; P = 0.731) or general complications (OR, 1.11; 95% CI, 0.80-1.54; P = 0.541). CONCLUSIONS: Duty hour restrictions enacted in 2011 were not associated with postoperative complications after breast reconstruction.

The clinical outcomes of pediatric inguinal hernia repairs operated by surgical residents.

BACKGROUND: Inguinal hernia is one of the most common surgical diseases, and surgical residents perform inguinal hernia repairs during pediatric surgery rotation. The aims of this study were to examine the clinical outcomes of pediatric inguinal herniorrhaphy performed by surgical residents and to assess the suitability for surgical training. METHODS: We extracted data on elective unilateral inguinal hernia repairs performed in children between 2014 and 2018. All eligible cases were divided into surgical resident and attending surgeon groups according to the operator. We reviewed medical records retrospectively and compared some clinical indicators between the 2 groups. RESULTS: Of 294 eligible cases, 163 were performed by 37 surgical residents and 131 were performed by 4 attending surgeons. The median operative times in the resident and attending surgeon groups were 30 and 19 min, respectively. Operative time was statistically longer in the resident group (p < 0.001). The complication and recurrence rates in the resident and attending surgeon groups were 11.0% and 11.5%, and 0% and 0.8%, respectively (p = 1.000 and p = 0.466). CONCLUSION: Inguinal hernia repairs could be properly performed by surgical trainees with the assistance of attending surgeons. Hernia operation might provide good opportunities for surgical residents to practice basic surgical skills.

Evaluation of a simulation-based mini-elective on medical student interest in cardiac surgery.

BACKGROUND: Integrated cardiothoracic (CT) surgery training programs are an increasingly popular pathway to train CT surgeons. Identifying and engaging medical students early is important to generate interest and ensure highly qualified applicants are aware of opportunities provided by a career in CT surgery. METHODS: An optional CT surgery "mini-elective" was developed for preclinical medical students consisting of five 2-hour sessions covering major procedures in cardiac surgery. Each session had an inital 1 hour lecture immediatly followed by a hands on simulation component. Sessions were taught by CT surgery faculty and residents. A precourse and postcourse survey was administered to identify interest in and awareness of the field of CT surgery. RESULTS: There were 22 students enrolled in the course who provided precourse surveys, while 21 provided postcourse surveys. CT surgery was a career consideration for 95.4% of students who took the mini-elective. nine percent of the students who had either scrubbed or observed a CT case precourse, increased to 33.3% postcourse (P = .11). With regards to mentorship, 23.8% felt they could easily find a mentor in CT surgery precourse, increasing to 66.7% postcourse (P = .01). Eighty-one percent of students reported that the mini-elective significantly increased their CT knowledge over the standard cardiovascular curriculum, and 100% of those completing the course were "extremely satisfied" with the experience. CONCLUSIONS: A CT surgery mini-elective increased awareness and interest in the field among preclinical medical students. Longitudinal exposure and mentorship provided in programs such as this will be key to the continued recruitment of high-quality medical students to the field.

Inguinal hernia repair in Nigeria: a survey of surgical trainees.

PURPOSE: Africa's inguinal hernia burden is high with large numbers of untreated hernias. Mesh repair is recommended in developed countries, but the best repair in developing countries is unknown. Little is known about knowledge and practice of surgeons in Nigeria performing inguinal hernia repair. Surgical trainees can provide this information. METHODS: A questionnaire-based survey was administered to surgical trainees from all over Nigeria who had attended the West African College of Surgeons' integrated revision course in Jos, on their practice and recommendations concerning elective inguinal hernia repair. RESULTS: One hundred and nine surgical trainees (90.8%) consisting of 78 (71.6%) registrars and 30 (27.5%) senior registrars responded. Thirty-two (29.4%) used antibiotics routinely for inguinal hernia surgery. Ceftriaxone was the most widely used antibiotic (45%). Ninety-two (84.4%) respondents will perform this surgery as day case. Forty (36.7%) respondents stated modified Bassini repair as their preferred method of repair. Mesh repair was recommended by 93 (85.3%) respondents while 65 of 100 respondents (65%) recommended laparoscopic surgery. Of 103 respondents, 93 (90.3%) had performed inguinal hernia repair and 34 (33%), mesh repair. For 56 (51.4%) respondents, the most difficult part of open hernia surgery was sac dissection. CONCLUSIONS: Surgical trainees in Nigeria perform more tissue-based inguinal hernia repair than mesh but majority would recommend both mesh repair and laparoscopic surgery. Majority found sac dissection as the most difficult part of open hernia surgery.

Educational impact of joint replacement school for patients undergoing total hip and knee arthroplasty: a prospective cohort study.

INTRODUCTION: Enhanced recovery programmes for hip and knee arthroplasty surgery have been shown to decrease length of stay and improve patient outcomes in the elective setting. There are limited studies looking at pre-operative patient education alone and its role, however, more recent studies have demonstrated that it can help reduce length of stay and health care costs. The elective orthopaedic unit at Tullamore Hospital was the first unit in the Irish public health system to have a joint school, pre-operative, educational session, and the aim of this study was to assess our patient understanding of this session to ensure a sustained, high level of patient care, quality assurance and educational standards. METHODS: A sample size of n = 51 was calculated to adequately power the study. Final sample size was 57. Data was collected across four joint school sessions. Patients were asked to complete a questionnaire before and after the session. RESULTS: Twenty-seven male (47.3%) and 30 female (52.7%) patients completed the surveys. Mean age overall was 64.5 years. All survey questions except those related to anaesthesia and physiotherapy showed a statistically significant improvement after the joint school session. A total knowledge score was calculated and revealed a statistically significant difference between pre- and post-joint school survey answering (P value < 0.001). CONCLUSION: Our joint school, pre-operative educational session remains a very effective way of delivering content to patients regarding their surgery. Continuous auditing is paramount to its success and there is potential scope for web-based learning as an adjunct to this validated session.

Building a Single-Site Robotic Cholecystectomy Program in a Public Teaching Hospital: Is It Safe for Patients and Feasible for Residents to Participate?

Single-site robotic cholecystectomy (SSRC) accounts for most of the robotic surgery cases performed by general surgeons at our institution since acquiring the da Vinci Si Surgical SystemTM (Intuitive Surgical, Inc., Sunnyvale, CA) in 2014. We sought to determine whether a SSRC program is safe to start in a public teaching hospital and to determine whether resident participation in this procedure is feasible. Data on age, gender, race, BMI, total operative time, length of stay, comorbidities, and conversion from laparoscopic to open surgery were examined for elective SSRC and laparoscopic cholecystectomies (LCs) performed by two faculty surgeons between February 2015 and August 2015. Thirty-eight patients underwent elective SSRC, whereas 27 patients underwent LC. Residents participated as operating surgeons for some portion of the case in 15 SSRC cases and in all LC cases. There were no significant differences in operative time, length of stay, or 30-day readmission rates, regardless of resident involvement. Patients in the SSRC group had a significantly lower BMI (25.8 vs 33.7, P = 0.008). This study suggests that resident participation does not increase complications or total operative time and that SSRC is a safe procedure to start in a public teaching hospital after proper faculty and resident training.

The Application of a Performance-Based Self-Administered Intra-procedural Checklist on Surgical Trainees During Laparoscopic Cholecystectomy.

INTRODUCTION: Surgical checklists are in use to reduce errors for safer surgery. We aimed to study the effect of a previously designed performance-based self-administered intra-procedural checklist on the performance of trainees during elective laparoscopic cholecystectomy. METHODS: Twenty-four laparoscopic cholecystectomies were enrolled into the study. Six surgical trainees each performed four procedures, two without the checklist and directly followed by two procedures with the checklist. A soft beeping sound reminded each trainee to apply the checklist every 4 min during the procedures. The unedited videos were analysed using the human reliability analysis technique for the number of consequential errors, number of interventions by the trainer, number of instrument movements and time execution. The trainees' satisfaction was assessed on a 5-point Likert scale questionnaire. Nonparametric test was used for data analysis. p value was defined as significant when p < 0.05. RESULTS: Participants performed statistically better with the application of the checklist compared to when no checklist was used, respectively: Median [IQR] total number of errors 1.51 [0.80] versus 3.84 [1.42] (p = 0.002) and consequential errors 0.20 [0.12] versus 0.45 [0.42] (p = 0.005), and the number of instrument movements per time decreased from 11.90 [5.34] to 10.38 [5.16] (p = 0.04). With the introduction of the checklist, the number of interventions by the trainer per time decreased from 2.79 [1.85] to 0.43 [1.208] (p = 0.003). The trainees satisfaction score was 4.5 [1] for the first question, 4 [1] for the second question and 4 [2] for the third question. CONCLUSION: The self-administered intra-procedural checklist improved the performance of surgical trainees and decreased the number of interventions by the trainer during laparoscopic cholecystectomy. The trainees were generally satisfied using the checklist during the procedures.

Changes in surgical training opportunities in Britain and South Africa.

INTRODUCTION: There have been substantial changes in the provision of surgical services and in surgical training over the last twenty years. Consultants now have a much greater role in delivery of care, but concerns have been raised over surgical trainees' lack of experience, particularly with trauma and emergency cases. METHODS: The logbooks of surgical trainees undertaking 6 month posts during 1992-3 and 2009-12 in both the United Kingdom (UK) and South Africa (RSA) were analysed. RESULTS: There was a 50% reduction in total hours worked between the UK posts in 1992-3 and 2011-12. The trainee post in RSA 2009-10 completed 15% more hours than the equivalent UK trainee post. Elective cases predominated in both UK posts (70-83%) whilst in RSA the number of trauma cases was substantial (21-26%). The UK 2011/12 trainee was rarely the primary operator (30%) compared with all other training periods (72-82%). This was due to a combination of relatively less minor and more major elective surgical cases in the recent UK post compared with the historical UK post or either RSA post. CONCLUSION: RSA has consistently offered more exposure to emergency, and especially trauma, surgery than the UK as well as more opportunity to act as primary operator. Re-introduction of "minor operations" lists for junior surgical trainees, acceptance of the importance for trainees to act as the primary operator, maintenance of the traditional "firm" structure and support for trainees who wish to spend a period of time abroad may help to improve clinical training and experience for UK surgical trainees.

A mentorship-based preclinical elective increases exposure, confidence, and interest in surgery.

BACKGROUND: The predicted shortage of surgeons is of growing concern with declining medical student interest in surgical careers. We hypothesized that earlier exposure to operative experiences and the establishment of resident mentors through a preclinical elective would enhance student confidence and interest in surgery. METHODS: We developed a preclinical elective in surgery, which served as an organized curriculum for junior medical students to experience surgery through a paired resident-mentorship model. We assessed student exposure and confidence with clinical activities before and after the elective (N = 24, 100% response rate). We compared these students with a cohort of peers not enrolled in the elective (N = 147, 67% response rate). RESULTS: We found significantly improved confidence (2.8 vs 4.4) and clinical exposure (2.4 vs 4.3) before versus after the elective, with precourse scores equal to matched peers. CONCLUSIONS: This elective incorporates elements that have been shown to positively influence student decision making in surgical career choice. The mentorship model promotes residents as educators, whereas the elective provides a means for early identification of students interested in surgery.

Pre-surgery education for elective cardiac surgery patients: a survey from the patient's perspective.

BACKGROUND/AIM: Multidisciplinary pre-admission patient education is commonly recommended for elective surgery patients, and may involve the provision of written information and presentations from the health team. However, the occupational therapy role with elective sternotomy patients in our setting is confined to the post-operative period. We aimed to evaluate cardiac surgery patients' perception of the effectiveness and timing of pre-admission multidisciplinary written information and post-operative verbal education provided by occupational therapy. METHODS: This cross-sectional study involved a written survey, which was posted to 375 people who had undergone cardiac surgery in 2009-2010. Questions were designed to elicit patient perceptions of both pre-operative written information and post-operative education relating to post-operative precautions and return to activity received from occupational therapy. RESULTS: There were 118 surveys returned equalling a 31.4% response rate. Eighty-nine per cent of respondents recalled receiving and reading the pre-surgery information booklet, and this was significantly correlated with feeling prepared for the post-operative experience and adherence with precautions (P < 0.0001). Exactly 30.4% of respondents stated that they experienced stress and anxiety in relation to post-operative expectations, and 47.3% felt the information provided in the occupational therapy education sessions would have been more beneficial for their understanding and coping if provided prior to surgery. CONCLUSIONS: Multidisciplinary written pre-surgery education appears to be providing patients with a good understanding of what to expect following surgery. The results suggest that pre-operative verbal education from occupational therapy would assist in reducing anxiety in a subgroup of patients.

Daycase hernia surgery: a missed training opportunity.

INTRODUCTION: Traditionally uncomplicated elective hernia operations were performed by surgical trainees; allowing them to develop key competencies and skills transferable to emergency hernia surgery. Daycase surgical units (DCU) are increasingly accommodating operations that traditionally contributed to operating lists in general elective theatres. We aim to assess whether DCU could help improve training in hernia surgery. SUBJECTS AND METHODS: Operative Room Information System (ORMIS) data was collected retrospectively to identify hernia operations performed at a large NHS hospital between January 2007 and 2012. Data collected included operating surgeon(s), procedure performed and procedure time (PT). Hospital coding records were used to collect data related to patient length of stay (LOS), complications, readmissions and deaths within 30 days of procedure. RESULTS: 4668 hernia operations were performed; 3063 in DCU. 91.5% (n = 2803) were open and 8.5% (n = 260) laparoscopic repairs. Trainees assisted in 24.6% (n = 752) and led 7.8% (n = 238) of cases. Overall, the mean PT for consultant led open hernia operations was 37.44 min (95% CI 36.75-38.12) and 43.07 min (95% CI 40.99-45.16) for trainees (p < 0.05). Subgroup analysis of all hernia operations performed showed no significant difference in PT between consultants and trainees when performing open bilateral inguinal, femoral, epigastric, incisional and laparoscopic hernia operations. There were no differences in LOS, readmissions and death rates within 30 days of the operation. CONCLUSIONS: DCU are an underutilised opportunity for trainees to acquire experience of hernia operations. When given the opportunity to lead hernia operations in DCU, trainees have similar PT and complication rates to consultants in many instances. Trainees should be encouraged to assist and lead hernia cases in DCU under adequate supervision to ensure appropriate competency is achieved and high standards are maintained.

[Information campaigns can reduce unnecessary prolonged time of thirst in elective surgical patients]. / Information kan reducere unødvendig tørstetid hos elektive kirurgiske patienter.

This prospective study was aimed at identifying the time of thirst above the recommended two hours after repeated information campaigns. Elective surgical patients ≥ 15 years of age were eligible to answer the questionnaire in four different periods between which information campaigns were carried out. A total of 765 patients were included. The median time of thirst was reduced from 6.5 hours to 3.0 hours (p < 0.0001) over a two-year period. Repeated interventions were found to be necessary to reduce the period of thirst to the recommended two hours for elective surgical patients.

Is there a learning curve in foot and ankle surgery?

BACKGROUND: Previous studies of orthopaedic learning curves have largely described the introduction of new techniques to experienced consultants. End points have usually involved technical considerations. A paucity of evidence surrounds foot and ankle surgery. This study investigates the learning curve during a foot and ankle surgeon's first year, defined by functional outcome. METHODS: 150 patients underwent elective foot or ankle surgery during the whole period. Preoperative and 6 month postoperative functional scores were compared between the first and second 6 month groups. RESULTS: Functional improvement was greater, approaching significance, in the second group (p=0.0605). There was no difference for forefoot cases (p=0.345). Functional improvement was significantly greater in the second group with forefoot cases removed (p=0.0333). CONCLUSIONS: A learning curve exists in the first year of practice of foot and ankle surgery, demonstrated by functional outcome. This is confined to ankle, hindfoot and midfoot, but not forefoot surgery.

Elective surgical referral guidelines--background educational material or essential shared decision making tool? A survey of GPs' in England.

BACKGROUND: To investigate general practitioners' (GPs') attitudes to guidelines for elective surgical referral in England. To understand their use of guidelines, and attitudes to shared decision making in the referral decision. METHODS: A questionnaire was developed which investigated attitudes to and use of guidelines. It was given to a stratified random sample 30% (n = 310) drawn from GP lists of 10 English health districts (primary care trusts (PCTs)). GPs were invited to respond online, by telephone, fax or post. Data were analysed using descriptive statistics and backwards stepwise logistic regression. RESULTS: Responses were representative of GPs in England, but (despite up to 6 contacts per non-responder) the overall response rate was 41.6% (n = 129; with the range across PCTs of 25-61%). Most responding GPs indicated support for referral guidelines but 18% reported that they had never used them. Less than three per cent reported use for most or all referral decisions. The odds of using guidelines decreased with increasing age, with a ten year increase in age associated with halving odds of use (OR = 0.53, 95%CI = 0.29-0.90). Over 50% of GPs wanted good access to electronic guidelines with expert information and advice on guideline availability. Almost all (>89%) GPs agreed with sharing referral decisions with patients. Female doctors (OR = 5.2, 95%CI: 1.02-26.3) were more likely to agree with this than male GPs as were those working in larger compared to small or single handed practices (OR = 5.3, 95%CI: 1.4-19.9). CONCLUSIONS: This group of responding GPs was supportive of guidelines but used them in different ways. Referral guidelines should have an educational component for background reading; include key messages for internalisation and application; and incorporate mechanisms to facilitate accessibility and appropriate shared decision making with patients.

Surgical resident involvement is safe for common elective general surgery procedures.

BACKGROUND: Outcomes of surgical resident training are under scrutiny with the changing milieu of surgical education. Few have investigated the effect of surgical resident involvement (SRI) on operative parameters. Examining 7 common general surgery procedures, we evaluated the effect of SRI on perioperative morbidity and mortality and operative time (OpT). STUDY DESIGN: The American College of Surgeons National Surgical Quality Improvement Program database (2005 to 2007) was used to identify 7 cases of nonemergent operations. Cases with simultaneous procedures were excluded. Logistic regression was performed across all procedures and within each procedure incorporating SRI, OpT, and risk-stratifying American College of Surgery National Surgical Quality Improvement Program morbidity and mortality probability scores, which incorporate multiple prognostic individual patient factors. Procedure-specific, SRI-stratified OpTs were compared using Wilcoxon rank-sum tests. RESULTS: A total of 71.3% of the 37,907 cases had SRI. Absolute 30-day morbidity for all cases with SRI and without SRI were 3.0% and 1.0%, respectively (p < 0.001); absolute 30-day mortality for all cases with SRI and without SRI were 0.1% and 0.08%, respectively (p < 0.001). After multivariate analysis by specific procedure, SRI was not associated with increased morbidity but was associated with decreased mortality during open right colectomy (odds ratio 0.32; p = 0.01). Across all procedures, SRI was associated with increased morbidity (odds ratio 1.14; p = 0.048) but decreased mortality (odds ratio 0.42; p < 0.001). Mean OpT for all procedures was consistently lower for cases without SRI. CONCLUSIONS: SRI has a measurable impact on both 30-day morbidity and mortality and OpT. These data have implications to the impact associated with surgical graduate medical education. Further studies to identify causes of patient morbidity and prevention strategies in surgical teaching environments are warranted.