A comparative analysis of video-based surgical assessment: is evaluation of the entire critical portion of the operation necessary?

BACKGROUND: Previous studies of video-based operative assessments using crowd sourcing have established the efficacy of non-expert evaluations. Our group sought to establish the equivalence of abbreviating video content for operative assessment. METHODS: A single institution video repository of six core general surgery operations was submitted for evaluation. Each core surgery included three unique surgical performances, totaling 18 unique operative videos. Each video was edited using four different protocols based on the critical portion of the operation: (1) custom edited critical portion (2) condensed critical portion (3) first 20 s of every minute of the critical portion, and (4) first 10 s of every minute of the critical portion. In total, 72 individually edited operative videos were submitted to the C-SATS (Crowd-Sourced Assessment of Technical Skills) platform (C-SATS) for evaluation. Aggregate score for study protocol was compared using the Kruskal-Wallis test. A multivariable, multilevel mixed-effects model was constructed to predict total skill assessment scores. RESULTS: Median video lengths for each protocol were: custom, 6:20 (IQR 5:27-7:28); condensed, 10:35 (8:50-12:06); 10 s, 4:35 (2:11-6:09); and 20 s, 9:09 (4:20-12:14). There was no difference in aggregate median score among the four study protocols: custom, 15.7 (14.4-16.2); condensed, 15.8 (15.2-16.4); 10 s, 15.8 (15.3-16.1); 20 s, 16.0 (15.1-16.3); χ2 = 1.661, p = 0.65. Regression modeling demonstrated a significant, but minimal effect of the 10 s and 20 s editing protocols compared to the custom method on individual video score: condensed, + 0.33 (- 0.05-0.70), p = 0.09; 10 s, + 0.29 (0.04-0.55), p = 0.03; 20 s, + 0.40 (0.15-0.66), p = 0.002. CONCLUSION: A standardized protocol for video editing abbreviated surgical performances yields reproducible assessment of surgical aptitude when assessed by non-experts.

Frailty assessment: from clinical to radiological tools.

Frailty is a syndrome of cumulative decline across multiple physiological systems, which predisposes vulnerable adults to adverse events. Assessing vulnerable patients can potentially lead to interventions that improve surgical outcomes. Anaesthesiologists who care for older patients can identify frailty to improve preoperative risk stratification and subsequent perioperative planning. Numerous clinical tools to diagnose frailty exist, but none has emerged as the standard tool to be used in clinical practice. Radiological modalities, such as computed tomography and ultrasonography, are widely performed before surgery, and are therefore available to be used opportunistically to objectively evaluate surrogate markers of frailty. This review presents the importance of frailty assessment by anaesthesiologists; lists common clinical tools that have been applied; and proposes that utilising radiological imaging as an objective surrogate measure of frailty is a novel, expanding approach for which anaesthesiologists can significantly contribute to broad implementation.

Comparison of bedside screening methods for frailty assessment in older adult trauma patients in the emergency department.

BACKGROUND: Frailty is linked to poor outcomes in older patients. We prospectively compared the utility of the picture-based Clinical Frailty Scale (CFS9), clinical assessments, and ultrasound muscle measurements against the reference FRAIL scale in older adult trauma patients in the emergency department (ED). METHODS: We recruited a convenience sample of adults 65 yrs. or older with blunt trauma and injury severity scores <9. We queried subjects (or surrogates) on the FRAIL scale, and compared this to: physician-based and subject/surrogate-based CFS9; mid-upper arm circumference (MUAC) and grip strength; and ultrasound (US) measures of muscle thickness (limbs and abdominal wall). We derived optimal diagnostic thresholds and calculated performance metrics for each comparison using sensitivity, specificity, predictive values, and area under receiver operating characteristic curves (AUROC). RESULTS: Fifteen of 65 patients were frail by FRAIL scale (23%). CFS9 performed well when assessed by subject/surrogate (AUROC 0.91 [95% CI 0.84-0.98] or physician (AUROC 0.77 [95% CI 0.63-0.91]. Optimal thresholds for both physician and subject/surrogate were CFS9 of 4 or greater. If both physician and subject/surrogate provided scores <4, sensitivity and negative predictive value were 90.0% (54.1-99.5%) and 95.0% (73.1-99.7%). Grip strength and MUAC were not predictors. US measures that combined biceps and quadriceps thickness showed an AUROC of 0.75 compared to the reference standard. CONCLUSION: The ED needs rapid, validated tools to screen for frailty. The CFS9 has excellent negative predictive value in ruling out frailty. Ultrasound of combined biceps and quadriceps has modest concordance as an alternative in trauma patients who cannot provide a history.

Trauma Providers' Perceptions of Frailty Assessment: A Mixed-Methods Analysis of Knowledge, Attitudes, and Beliefs.

OBJECTIVES: Quality improvement in geriatric trauma depends on timely identification of frailty, yet little is known about providers' knowledge and beliefs about frailty assessment. This study sought to understand trauma providers' understanding, beliefs, and practices for frailty assessment. METHODS: We developed a 20-question survey using the Health Belief Model of health behavior and surveyed physicians, advanced practice providers, and trainees on the trauma services at a single institution that does not use formal frailty screening of all injured seniors. Results were analyzed via mixed methods. RESULTS: One hundred fifty-one providers completed the survey (response rate 92%). Respondents commonly included calendar age as an integral factor in their determinations of frailty but also included a variety of other factors, highlighting limited definitional consensus. Respondents perceived frailty as important to older adult patient outcomes, but assessment techniques were varied because only 24/151 respondents (16%) were familiar with current formal frailty assessment tools. Perceived barriers to performing a formal frailty screening on all injured older adults included the burdensome nature of assessment tools, insufficient training, and lack of time. When prompted for solutions, 20% of respondents recommended automation of the screening process by trained, dedicated team members. CONCLUSIONS: Providers seem to recognize the impact that a diagnosis of frailty has on outcomes, but most lack a working knowledge of how to assess for frailty syndrome. Some providers recommended screening by designated, formally trained personnel who could notify decision makers of a positive screen result.

Does mesenteric venous imaging assessment accurately predict pathologic invasion in localized pancreatic ductal adenocarcinoma?

BACKGROUND: Accurate prediction of mesenteric venous involvement in pancreatic ductal adenocarcinoma (PDAC) is necessary for adequate staging and treatment. METHODS: A retrospective cohort study was conducted in PDAC patients at a single institution. All patients with resected PDAC and staging CT and EUS between 2003 and 2014 were included and sub-divided into "upfront resected" and "neoadjuvant chemotherapy (NAC)" groups. Independent imaging re-review was correlated to venous resection and venous invasion. Sensitivity, specificity, positive and negative predictive values were then calculated. RESULTS: A total of 109 patients underwent analysis, 60 received upfront resection, and 49 NAC. Venous resection (30%) and vein invasion (13%) was less common in patients resected upfront than those who received NAC (53% and 16%, respectively). Both CT and EUS had poor sensitivity (14-44%) but high specificity (75-95%) for detecting venous resection and vein invasion in patients resected upfront, whereas sensitivity was high (84-100%) and specificity was low (27-44%) after NAC. CONCLUSIONS: Preoperative CT and EUS in PDAC have similar efficacy but different predictive capacity in assessing mesenteric venous involvement depending on whether patients are resected upfront or received NAC. Both modalities appear to significantly overestimate true vascular involvement and should be interpreted in the appropriate clinical context.

Cardiac Perforation by Migrated Fractured Strut of Inferior Vena Cava Filter Mimicking Acute Coronary Syndrome.

We present a rare late complication after inferior vena cava filter (IVC) placement. A 52-year-old woman with an IVC presented with sudden onset of chest pain. Cardiac catheterisation and echocardiography revealed an embolised IVC filter strut penetrating the right ventricle. Endovascular retrieval was considered but deemed unsafe due to proximity to the right coronary artery and concern for migration to pulmonary circulation. Urgent removal of the strut was performed via sternotomy. The postoperative course was uneventful. Two weeks later, she was asymptomatic. Minimally invasive approaches have been described for retrieval of intact IVC filters that have migrated to the right heart but not for embolised filter fragments. We recommend traditional sternotomy as the preferred method of retrieval as it limits the likelihood of further migration or trauma.

Utilization of a non-preserved cadaver to address deficiencies in technical skills during the third year of medical school: a cadaver model for teaching technical skills.

BACKGROUND: Emergency technical procedures performed by medical students have decreased in the last decade. An Emergency Surgical Skills Laboratory (ESSL) using a non-preserved cadaver was developed in response to address this deficiency. METHODS: A total of 232 students rotating through a 6-week surgery clerkship participated in the ESSL from 1 July 2008 to 1 July 2011. Two four-hour sessions using case-based trauma scenarios in the ESSL served as a model for procedural instruction. Skills taught included basic suturing, intubation, cricothyrotomy, chest tube placement, thoracentesis, venous access, central line, and radial arterial line placement. RESULTS: Students noted that technical proficiency in suturing was obtained during the ESSL sessions in comparison to the emergency department or operating room (p < 0.001) during the 6-week clerkship. During the 6-week rotation only 12 % of students participated in chest tube insertion, 5 % central venous line placement, and 14 % femoral vein blood draw. Finally, 90 % of respondents reported increased understanding and comfort in regard to trauma resuscitation following the ESSL. CONCLUSIONS: Technical procedural proficiency has become increasingly difficult to obtain in medical school due to multifactorial limitations. The ESSL provides an opportunity for developing technical skills needed for emergency situations not otherwise provided during the surgical clerkship.

Association of Brain Atrophy and Masseter Sarcopenia With 1-Year Mortality in Older Trauma Patients.

Importance: Older adults are disproportionately affected by trauma and accounted for 47% of trauma fatalities in 2016. In many populations and disease processes, described risk factors for poor clinical outcomes include sarcopenia and brain atrophy, but these remain to be fully characterized in older trauma patients. Sarcopenia and brain atrophy may be opportunistically evaluated via head computed tomography, which is often performed during the initial trauma evaluation. Objective: To investigate the association of masseter sarcopenia and brain atrophy with 1-year mortality among trauma patients older than 65 years by using opportunistic computed tomography imaging. Design, Setting, and Participants: This retrospective cohort study was conducted in a level 1 trauma center from January 1, 2011, to December 31, 2014, with a 1-year follow-up to assess mortality. Washington state residents 65 years or older who were admitted to the trauma intensive care unit with a head Abbreviated Injury Scale score of less than 3 were eligible. Patients with incomplete data and death within 1 day of admission were excluded. Data analysis was completed from June 2017 to October 2018. Exposures: Masseter muscle cross-sectional area and brain atrophy index were measured using a standard clinical Picture Archiving and Communication System application to assess for sarcopenia and brain atrophy, respectively. Main Outcomes and Measures: Primary outcome was 1-year mortality. Secondary outcomes were discharge disposition and 30-day mortality. Results: The study cohort included 327 patients; 72 (22.0%) had sarcopenia only, 71 (21.7%) had brain atrophy only, 92 (28.1%) had both, and 92 (28.1%) had neither. The mean (SD) age was 77.8 (8.6) years, and 159 patients (48.6%) were women. After adjustment for age, comorbidity, complications, and injury characteristics, masseter sarcopenia and brain atrophy were both independently and cumulatively associated with mortality (masseter muscle cross-sectional area per SD less than the mean: hazard ratio, 2.0 [95% CI, 1.2-3.1]; P = .005; brain atrophy index per SD greater than the mean: hazard ratio, 2.0 [95% CI, 1.1-3.5]; P = .02). Conclusions and Relevance: Masseter muscle sarcopenia and brain atrophy were independently and cumulatively associated with 1-year mortality in older trauma patients after adjustment for other clinical factors. These radiologic indicators are easily measured opportunistically through standard imaging software. The results can potentially guide conversations regarding prognosis and interventions with patients and their families.

Functional Recovery After Lung Resection: A Before and After Prospective Cohort Study of Activity.

BACKGROUND: Postoperative recovery is an important measure in thoracic operations. Personal activity monitors can be used to track progress in the preoperative and postoperative settings. This study investigates associations of preoperative activity, lung resection extent, and operative approach with inpatient and outpatient functional recovery as measured by activity monitors. METHODS: In this prospective observational cohort study, patients undergoing lung resection at a single institution wore activity monitors 30 days before through 30 days after operation (between July 2015 and May 2017). Activity was recorded as steps per day, and each patient served as his or her own baseline. Patients were clustered into three activity level groups. Associations among preoperative and postoperative activity, length of stay (LOS), and operative approach were assessed by using generalized regression models with adjustment for patient demographic and clinical characteristics and operative details. RESULTS: Sixty-six patients comprised the study cohort and were grouped by average preoperative activity: low, 21 patients (31.8%); moderate, 27 patients (40.9%); and high, 18 patients (27.3%). The mean age was 66.1 ± 11.6 years; 32 patients (48.5%) were women. Sex, comorbidity, resection extent, and operative approach did not differ among groups. After adjustment for age, comorbidities, resection extent, operative approach, and complications, higher levels of preoperative activity were independently associated with higher postoperative activity in both inpatient and outpatient settings (ß = 1.11, 95% confidence interval [CI]: 1.00 to 1.22, p = 0.04; ß = 1.18, 95% CI: 1.07 to 1.30, p = 0.001) but not LOS. CONCLUSIONS: LOS is not associated with measures of preoperative or postoperative physical activity after adjustment for several factors. However, the association between preoperative activity and postoperative activity, irrespective of age, operative approach, resection extent, and other factors, offers a potential framework for designing recovery trajectory pathways and intervention development in both postoperative inpatient and outpatient settings.

Comparison of costs and short-term clinical outcomes of per-oral endoscopic myotomy and laparoscopic Heller myotomy.

OBJECTIVE: Per-Oral Endoscopic Myotomy (POEM) has seen increasing application and comparisons to laparoscopic Heller myotomy (LHM). The aim of the present study was to compare perioperative and short-term outcomes, and costs between the two procedures at a single institution. METHODS: Fifty-one consecutive patients documented in a prospective IRB approved database from January 2014 to December 2017 were included. Perioperative data, pre-operative and 3-month postoperative Eckardt Scores, and cost data were compared. RESULTS: Median hospital stay was comparable between POEM and LHM (1 day each). Complications were minor (Clavien-Dindo 1, 2) and rare in both groups. Median Eckardt scores improved significantly after POEM (5 to 0) and LHM (5 to 0). Normalized median costs were comparable: 14 201 USD (POEM) vs. 13 328 USD (LHM) p = 0.45. CONCLUSIONS: POEM demonstrates comparable clinical outcomes and costs to LHM. Long-term issues related to GERD require ongoing assessment in POEM patients. SUMMARY: In patients with achalasia, extended myotomy of the lower esophageal sphincter offers excellent palliation of symptoms. In the last decades, laparoscopic Heller myotomy (LHM) has been the gold standard. Over the past decade, per-oral endoscopic myotomy (POEM) has seen wide application in specialized centers worldwide. In our patient cohort, we demonstrate, that POEM can be introduced with similar outcomes and costs compared to LHM.

Resident Wellness and Social Support: Development and Cognitive Validation of a Resident Social Capital Assessment Tool.

OBJECTIVE: The purpose of this study is to develop and generate validity evidence for an instrument to measure social capital in residents. DESIGN: Mixed-methods, phased approach utilizing a modified Delphi technique, focus groups, and cognitive interviews. SETTING: Four residency training institutions in Washington state between February 2016 and March 2017. PARTICIPANTS: General surgery, anesthesia, and internal medicine residents ranging from PGY-1 to PGY-6. RESULTS: The initial resident-focused instrument underwent revision via Delphi process with 6 experts; 100% expert consensus was achieved after 4 cycles. Three focus groups were conducted with 19 total residents. Focus groups identified 6 of 11 instrument items with mean quality ratings ≤4.0 on a 1-5 scale. The composite instrument rating of the draft version was 4.1 ± 0.5. After refining the instrument, cognitive interviews with the final version were completed with 22 residents. All items in the final version had quality ratings >4.0; the composite instrument rating was 4.8 ± 0.1. CONCLUSIONS: Social capital may be an important factor in resident wellness as residents rely upon each other and external social support to withstand fatigue, burnout, and other negative sequelae of rigorous training. This instrument for assessment of social capital in residents may provide an avenue for data collection and potentially, identification of residents at-risk for wellness degradation.

The Importance of Age on Short-Term Outcomes Associated With Repair of Giant Paraesophageal Hernias.

BACKGROUND: Older patients have an increased incidence of paraesophageal hernia (PEH) and can be denied surgical assessment due to the perception of increased complications and mortality. This study examines the influence of age and comorbidities on early complications and other short-term outcomes of PEH repair. METHODS: From 2000 to 2016, data of surgically treated patients with PEH were prospectively recorded in an Institutional Review Board-approved database. Only patients whose hernia involved over 50% of the stomach were included. Patients were stratified by age (<70, 70 to 79, ≥80 years of age) and compared in univariate and multivariate analyses. RESULTS: Overall, 524 patients underwent surgical PEH repair (<70: 261 [50%]; 70 to 79: 163 [31%]; ≥80: 100 [19%]). Patients greater than or equal to 80 years of age had higher American Society of Anesthesiologists class, more comorbidities, larger hernias, and higher incidences of type IV PEH and acute presentation. Patients greater than or equal to 80 years of age had more postoperative complications, but not higher grade complications (Clavien-Dindo grade ≥IIIa). Median length of stay was 1 day longer for patients greater than or equal to 80 years of age (5 days versus 4 days for patients <70 and 70 to 79 years of age, respectively). Objective, radiologic hernia recurrence at 4.3 months postoperation was 17.3% and was not increased in the greater than or equal to 80 years of age group. After adjustment for comorbidities and other factors, age greater than or equal to 80 years was not a significant factor in predicting severe complications, readmission within 30 days, or early recurrence. CONCLUSIONS: PEH repair is safe in physiologically stable patients, irrespective of age. Incidence of complications is higher in older patients, but complication severity and mortality are similar to those of younger patients. Patients with giant PEH should be given the opportunity to review treatments options with an experienced surgeon.

Assessment of Osteoporosis in Injured Older Women Admitted to a Safety-Net Level One Trauma Center: A Unique Opportunity to Fulfill an Unmet Need.

BACKGROUND: Older trauma patients often undergo computed tomography (CT) as part of the initial work-up. CT imaging can also be used opportunistically to measure bone density and assess osteoporosis. METHODS: In this retrospective cohort study, osteoporosis was ascertained from admission CT scans in women aged ≥65 admitted to the ICU for traumatic injury during a 3-year period at a single, safety-net, level 1 trauma center. Osteoporosis was defined by established CT-based criteria of average L1 vertebral body Hounsfield units <110. Evidence of diagnosis and/or treatment of osteoporosis was the primary outcome. RESULTS: The study cohort consisted of 215 women over a 3-year study period, of which 101 (47%) had evidence of osteoporosis by CT scan criteria. There were no differences in injury severity score, hospital length of stay, cost, or discharge disposition between groups with and without evidence of osteoporosis. Only 55 (59%) of the 94 patients with osteoporosis who survived to discharge had a documented osteoporosis diagnosis and/or corresponding evaluation/treatment plan. CONCLUSION: Nearly half of older women admitted with traumatic injuries had underlying osteoporosis, but 41% had neither clinical recognition of this finding nor a treatment plan for osteoporosis. Admission for traumatic injury is an opportunity to assess osteoporosis, initiate appropriate intervention, and coordinate follow-up care. Trauma and acute care teams should consider assessment of osteoporosis in women who undergo CT imaging and provide a bridge to outpatient services.

Older adults and high-risk medication administration in the emergency department.

BACKGROUND: Older adults are susceptible to adverse effects from opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), and benzodiazepines (BZDs). We investigated factors associated with the administration of elevated doses of these medications of interest to older adults (≥65 years old) in the emergency department (ED). PATIENTS AND METHODS: ED records were queried for the administration of medications of interest to older adults at two academic medical center EDs over a 6-month period. Frequency of recommended versus elevated ("High doses" were defined as doses that ranged between 1.5 and 3 times higher than the recommended starting doses; "very high doses" were defined as higher than high doses) starting doses of medications, as determined by geriatric pharmacy/medicine guidelines and expert consensus, was compared by age groups (65-69, 70-74, 75-79, 80-84, and ≥85 years), gender, and hospital. RESULTS: There were 17896 visits representing 11374 unique patients >65 years of age (55.3% men, 44.7% women). A total of 3394 doses of medications of interest including 1678 high doses and 684 very high doses were administered to 1364 different patients. Administration of elevated doses of medications was more common than that of recommended doses. Focusing on opioids and BZDs, the 65-69-year age group was much more likely to receive very high doses (1481 and 412 doses, respectively) than the ≥85-year age groups (relative risk [RR] 5.52, 95% CI 2.56-11.90), mainly reflecting elevated opioid dosing (RR 8.28, 95% CI 3.69-18.57). Men were more likely than women to receive very high doses (RR 1.47, 95% CI 1.26-1.72), primarily due to BZDs (RR 2.12, 95% CI 2.07-2.16). CONCLUSION: Administration of elevated doses of opioids and BZDs in the older population occurs frequently in the ED, especially to the 65-69-year age group and men. Further attention to potentially unsafe dosing of high-risk medications to older adults in the ED is warranted.

Association of Radiologic Indicators of Frailty With 1-Year Mortality in Older Trauma Patients: Opportunistic Screening for Sarcopenia and Osteopenia.

Importance: Assessment of physical frailty in older trauma patients admitted to the intensive care unit is often not feasible using traditional frailty assessment instruments. The use of opportunistic computed tomography (CT) scans to assess sarcopenia and osteopenia as indicators of underlying frailty may provide complementary prognostic information on long-term outcomes. Objective: To determine whether sarcopenia and/or osteopenia are associated with 1-year mortality in an older trauma patient population. Design, Setting, and Participants: A retrospective cohort constructed from a state trauma registry was linked to the statewide death registry and Comprehensive Hospital Abstract Reporting System for readmission data analyses. Admission abdominopelvic CT scans from patients 65 years and older admitted to the intensive care unit of a single level I trauma center between January 2011 and May 2014 were analyzed to identify patients with sarcopenia and/or osteopenia. Patients with a head Injury Severity Score of 3 or greater, an out-of-state address, or inadequate CT imaging or who died within 24 hours of admission were excluded. Exposures: Sarcopenia and/or osteopenia, assessed via total cross-sectional muscle area and bone density at the L3 vertebral level, compared with a group with no sarcopenia or osteopenia. Main Outcomes and Measures: One-year all-cause mortality. Secondary outcomes included 30-day all-cause mortality, 30-day readmission, hospital length of stay, hospital cost, and discharge disposition. Results: Of the 450 patients included in the study, 269 (59.8%) were male and 394 (87.6%) were white. The cohort was split into 4 groups: 74 were retrospectively diagnosed with both sarcopenia and osteopenia, 167 with sarcopenia only, 48 with osteopenia only, and 161 with no radiologic indicators. Among the 408 who survived to discharge, sarcopenia and osteopenia were associated with higher risks of 1-year mortality alone and in combination. After adjustment, the hazard ratio was 9.4 (95% CI, 1.2-75.4; P = .03) for sarcopenia and osteopenia, 10.3 (95% CI, 1.3-78.8; P = .03) for sarcopenia, and 11.9 (95% CI, 1.3-107.4; P = .03) for osteopenia. Conclusions and Relevance: More than half of older trauma patients in this study had sarcopenia, osteopenia, or both. Each factor was independently associated with increased 1-year mortality. Given the prevalent use of abdominopelvic CT in trauma centers, opportunistic screening for radiologic indicators of frailty provides an additional tool for early identification of older trauma patients at high risk for poor outcomes, with the potential for targeted interventions.

The Effect of Computerized Physician Order Entry Template Modifications on the Administration of High-Risk Medications in Older Adults in the Emergency Department.

BACKGROUND: Older adults are more susceptible to adverse events when administered certain medications at doses appropriate for younger adults. OBJECTIVE: The aim of this study was to investigate the effect of default geriatric dosing on computerized physician order entry (CPOE) templates on the subsequent administration of recommended starting doses of opioids, benzodiazepines (BZDs) and non-steroidal anti-inflammatory drugs (NSAIDs) to older adults in the emergency department (ED). METHODS: This was a before-after comparison of the frequency of the recommended starting doses of high-risk medications to adults aged 65 years and older. Computerized records were queried for the administration of the above medication classes in two academic EDs over two similar 4-month periods in 2015 and 2016. Between study periods, the doses of high-risk medications on ED CPOE templates were adjusted for older adults based on established pharmacy guidelines and expert consensus. RESULTS: There was a significant improvement in the rate of recommended dose administration of all medications of interest (27.3 vs. 32.5%, p < 0.001). Not surprisingly, the medications that were maximally impacted were also those most frequently prescribed, with a significant increase in the recommended dosing of opioids (29.0 vs. 35.2%, p < 0.001) accounting for the majority of the change. Although there were no differences in BZDs as a group, there were significant differences in selected BZDs such as midazolam and diazepam. Changes in the recommended dosing of NSAIDs could not be determined due to low numbers of administered doses in both phases of the study. CONCLUSION: Simple changes in the CPOE template resulted in increased administration of the recommended starting doses of high-risk medications to older adults in the ED.

Introduction of a fresh cadaver laboratory during the surgery clerkship improves emergency technical skills.

BACKGROUND: Student acquisition of technical skills during the clinical years of medical school has been steadily declining. To address this issue, the authors instituted a fresh cadaver-based Emergency Surgical Skills Laboratory (ESSL). METHODS: Sixty-three medical students rotating through the third-year surgery clerkship participated in a 2-hour, fresh cadaver-based ESSL conducted during the first 2 days of the clerkship. The authors evaluated students utilizing both surgical skills and written examination before the ESSL and at 4 weeks post ESSL. RESULTS: Students demonstrated a mean improvement of 64% (±11) (P < .001) and 38% (±17) (P < .001) in technical skills and clinical knowledge, respectively. When technical skills were compared between cohorts, there were no differences observed in both pre- and post-testing (P = .08). CONCLUSIONS: A fresh cadaver laboratory is an effective method to provide proficiency in emergency technical skills not acquired during the clinical years of medical school.