Secondary Overtriage of Trauma Patients: Analysis of Clinical and Geographic Patterns.

BACKGROUND: The purpose of a trauma system is to match patients' needs with hospitals' ability to care for them, recognizing that the highest levels of care cannot be provided in all locations. This means that some patients will need to be transferred from a local facility to a higher level of care. Unnecessary transfers are expensive and inconvenient to patients and families. The aim of this study is to analyze the pattern of secondary transfers in a regional trauma system. METHODS: This is a retrospective analysis. We included patients aged 16 y and older who were transferred to University of Alabama at Birmingham Hospital between 2014 and 2018. We conducted bivariate and multivariate logistic regression analysis to identify clinical and organizational predictors of requiring a critical intervention, early discharge, intensive care unit admission, and mortality. Rather than treating each injury as isolated, we analyzed injury patterns. RESULTS: A total of3824 patients met the inclusion criteria. Of them, 664 patients (17.4%) required a critical intervention, 635 (16.6%) were discharged within 24 h, 1356 (35.5%) were admitted to the intensive care unit, and 172 (4.0%) patients died. Univariate and multivariate analyses revealed many positive associations, with regard to injury pattern, originating center, and insurance status. CONCLUSIONS: There are patterns in the data, and further study is required to understand drivers of secondary overtriage, and how we might be able to address this problem. Reducing the number of unnecessary transfers is a difficult task, which will require engagement at all levels of the trauma system.

An assessment of the online presentation of MIS fellowship information for residents.

INTRODUCTION: Residents often utilize internet resources to evaluate and search for fellowship programs within their desired field. The presence of these resources and the information available through them has the potential to influence applicant decisions. The objective of this study was to analyze the online MIS fellowship information relevant to resident applicants provided by the Fellowship Council Directory (FCD) and institutionally based program webpages. MATERIALS AND METHODS: The programs evaluated were chosen based on their inclusion in the FCD, the accrediting body for MIS fellowships. The FCD provides each program a template through which program directors detail information for applicants. This information is publicly accessible through the directory, with each program having a specific page. These webpages were assessed for the presence or absence of 21 previously established individual content criteria. In addition, the presence or absence of a functional link to an institutionally based, program-specific webpage was determined. These program-specific, institutional webpages were then independently accessed via Google® search and separately assessed for the presence or absence of the same 21 previously established content criteria. RESULTS: In total, the FCD listed 144 programs. Each program had a dedicated page within the directory itself with 104 (72%) having functional links listed. Ninety-six (66.6%) of the FCD links were identified as being specific webpages to the fellowship program, verified through a Google® search. Less than half of the programs fulfilled over 50% of identified criteria through the FCD templated directory, with one-third of programs listed failing to provide any program-specific information via a webpage outside the FCD. CONCLUSION: Information available online for MIS fellowship programs is lacking, with many institutionally supported webpages absent altogether outside of the FCD. Templated formats seem to assist in this deficiency, but should be used cautiously as they also can potentially omit relevant information.

Evaluation of Accredited Trauma, Surgical Critical Care, and Acute Care Surgery Fellowship Websites.

OBJECTIVES: Surgical residents are increasingly pursuing fellowships and rely heavily on fellowship programs' web sites as a primary source of information. Accessibility, quality, and content of a program web site can encourage or deter an applicant from applying to a particular program. The goal of this study was to perform an analysis of trauma, surgical critical care, and acute care surgery fellowship program web sites. MATERIALS AND METHODS: A list of trauma, surgical critical care, and acute care surgery fellowship programs was obtained from the Eastern Association for the Surgery of Trauma (EAST) web site. The existence of a functional hyperlink in the EAST program directory and a systematic Google search was assessed to determine web site accessibility. Twenty-one content criteria were used to evaluate accessible web sites. RESULTS: The EAST directory contained 102 fellowship programs. Ninety-one programs had web sites accessible through a Google search. No web site contained all 21 criteria. Only 29 web sites contained at least half of the evaluated content criteria. The most common data point included was program description (97%), while role of seeing patients in clinic (4%) was the least common criteria present. CONCLUSIONS: Many programs in the EAST directory lack functional links and accessible web sites. Content that has been deemed important to applicants is lacking in varying degrees. Incorporation of this missing content may benefit both applicants and programs, allowing for more informed decision-making when choosing a program, thus promoting better fit of fellows with programs during the application process.

Evaluation and management of blunt traumatic aortic injury: a practice management guideline from the Eastern Association for the Surgery of Trauma.

BACKGROUND: Blunt traumatic aortic injury (BTAI) is the second most common cause of death in trauma patients. Eighty percent of patients with BTAI will die before reaching a trauma center. The issues of how to diagnose, treat, and manage BTAI were first addressed by the Eastern Association for the Surgery of Trauma (EAST) in the practice management guidelines on this topic published in 2000. Since that time, there have been advances in the management of BTAI. As a result, the EAST guidelines committee decided to develop updated guidelines for this topic using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework recently adopted by EAST. METHODS: A systematic review of the MEDLINE database using PubMed was performed. The search retrieved English language articles regarding BTAI from 1998 to 2013. Letters to the editor, case reports, book chapters, and review articles were excluded. Topics of investigation included imaging to diagnose BTAI, type of operative repair, and timing of operative repair. RESULTS: Sixty articles were identified. Of these, 51 articles were selected to construct the guidelines. CONCLUSION: There have been changes in practice since the publication of the previous guidelines in 2000. Computed tomography of the chest with intravenous contrast is strongly recommended to diagnose clinically significant BTAI. Endovascular repair is strongly recommended for patients without contraindications. Delayed repair of BTAI is suggested, with the stipulation that effective blood pressure control must be used in these patients.

Participant perspectives on a department of surgery faculty mentoring program.

BACKGROUND: Mentorship in academic medicine serves to promote career advancement and job satisfaction. This study was to evaluate the initial results of a faculty mentorship program in an academic Department of Surgery. METHODS: A faculty mentorship program was initiated in July 2015 with 63 participants. Junior faculty mentees (n = 35) were assigned senior faculty mentors (n = 28). After three years, an electronic survey was administered and the results analyzed. RESULTS: Response rate was 67% (n = 42). 34 (81%) respondents had met with their mentor/mentee at least once. Topics discussed included: research (76%), leadership (52%), work-life balance (45%), and promotion (5%). Mentees endorsed achieving promotion (n = 2), increasing research productivity (n = 2), and obtaining national committee positions (n = 2). 61% of mentors and 53% of mentees felt they benefitted personally from the program. Actionable improvements to the mentorship program were identified including more thoughtful pairing of mentors and mentees with similar research interests. CONCLUSIONS: Participants felt the mentorship program was beneficial. Further investigation regarding the optimization of the mentor-mentee pairing is warranted to maximize the benefits from structured mentorship in academic surgery.

Creation of standardized tools to evaluate reporting in health research: Population Reporting Of Gender, Race, Ethnicity & Sex (PROGRES).

Despite increasing diversity in research recruitment, research finding reporting by gender, race, ethnicity, and sex has remained up to the discretion of authors. This study developped and piloted tools to standardize the inclusive reporting of gender, race, ethnicity, and sex in health research. A modified Delphi approach was used to develop standardized tools for the inclusive reporting of gender, race, ethnicity, and sex in health research. Health research, social epidemiology, sociology, and medical anthropology experts from 11 different universities participated in the Delphi process. The tools were pilot tested on 85 health research manuscripts in top health research journals to determine inter-rater reliability of the tools. The tools each spanned five dimensions for both sex and gender as well as race and ethnicity: Author inclusiveness, Participant inclusiveness, Nomenclature reporting, Descriptive reporting, and Outcomes reporting for each subpopulation. The sex and gender tool had a median score of 6 and a range of 1-15 out of 16 possible points. The percent agreement between reviewers piloting the sex and gender tool was 82%. The interrater reliability or average Cohen's Kappa was 0.54 with a standard deviation of 0.33 demonstrating moderate agreement. The race and ethnicity tool had a median score of 1 and a range of 0-15 out of 16 possible points. Race and ethnicity were both reported in only 25.8% of studies evaluated. Most studies that reported race reported only the largest subgroups; White, Black, and Latinx. The percent agreement between reviewers piloting the race and ethnicity tool was 84 and average Cohen's Kappa was 0.61 with a standard deviation of 0.38 demonstrating substantial agreement. While the overall dimension scores were low (indicating low inclusivity), the interrater reliability measures indicated moderate to substantial agreement for the respective tools. Efforts in recruitment alone will not provide more inclusive literature without improving reporting.

Designing the "match of the future": challenges and proposed solutions in the interview and match phase of the UME-GME transition.

This review focuses on the interview and match process with the purpose of broadly reviewing challenges in the current surgical residency selection process, detailing potential solutions, and identifying future avenues of investigation.

Transition from trainee to educator in the operating room: A needs assessment and framework to support junior faculty.

BACKGROUND: Transitioning from trainee to attending surgeon requires learners to become educators. The purpose of this study is to evaluate educational strategies utilized by surgeons, define gaps in preparation for operative teaching, and identify opportunities to support this transition. METHODS: A web-based, Association of Surgical Education approved survey was distributed to attending surgeons. RESULTS: There were 153 respondents. Narrating actions was the most frequently reported educational model, utilized by 74% of junior faculty [JF] (0-5yrs) and 63% of senior faculty [SF] (>6yrs). Other models used included educational time-outs (29% JF, 27% SF), BID teaching model (36% JF, 51% SF), and Zwisch model (13% JF, 25% SF). Compared with 91% JF, 65% SF reported struggling with instruction (p < 0.001). Five themes emerged as presenting difficulty during the resident to attending transition: lack of relationships, ongoing learning, systems-based, cognitive load, impression management. CONCLUSIONS: Our results represent a needs assessment in the transition from learner to educator in the OR.

High value care education in general surgery residency programs: A multi-institutional needs assessment.

BACKGROUND: The ACGME mandates that residency programs provide training related to high value care (HVC). The purpose of this study was to explore HVC education in general surgery residency programs. METHODS: An electronic survey was distributed to general surgery residents in geographically diverse programs. RESULTS: The response rate was 29% (181/619). Residents reported various HVC components in their curricula. Less than half felt HVC is very important for their future practice (44%) and only 15% felt confident they could lead a QI initiative in practice. Only 20% of residents reported participating in a root cause analysis and less than one-third of residents (30%) were frequently exposed to cost considerations. CONCLUSION: Few residents feel prepared to lead quality improvement initiatives, have participated in patient safety processes, or are aware of patients' costs of care. This underscores the need for improved scope and quality of HVC education and establishment of formal curricula.

What is global surgery? Identifying misconceptions among health professionals.

BACKGROUND: Global surgery has emerged as a new field within academic surgery. Despite attempts to provide a common definition, it is unclear whether health professionals understand what is meant by the term "global surgery." This study aims to characterize current understanding of global surgery among healthcare workers. METHODS: One hundred medical students, residents, physicians, nurses, and allied health professionals were interviewed on their perceptions of global surgery using a six-question qualitative survey. Responses were coded and analyzed for common themes. RESULTS: Sixty-one percent of participants did not know the meaning of global surgery. Those under age 40 were more likely to relay an accurate definition. Of participants with knowledge of global surgery, 44% had previous exposure to global health and 85% expressed interest in global health or surgery. CONCLUSIONS: Although often used in academic surgical settings, the term "global surgery" is not well-understood among health professionals. There is no clear consensus on what it means to be a global surgeon or what constitutes a successful career in global surgery.

Missed surgical intensive care unit billing: potential financial impact of 24/7 faculty presence.

BACKGROUND: To efficiently capture evaluation and management (E&M) and procedural billing in our surgical intensive care unit (SICU), we have developed an electronic billing system that links to the electronic medical record (EMR). In this system, only notes electronically signed and coded by an attending generate billing charges. We hypothesized that capture of missed billing during nighttime and weekends might be sufficient to subsidize 24/7 in-house attending coverage. METHODS: A retrospective chart EMR review was performed of the EMRs for all SICU patients during a 2-month period. Note type, date, time, attending signature, and coding were analyzed. Notes without attending signature, diagnosis, or current procedural terminology (CPT) code were considered incomplete and identified as "missed billing." RESULTS: Four hundred and forty-three patients had 465 admissions generating 2,896 notes. Overall, 76% of notes were signed and coded by an attending and billed. Incomplete (not billed) notes represented an overall missed billing opportunity of $159,138 for the 2-month time period (approximately $954,000 annually). Unbilled E&M encounters during weekdays totaled $54,758, whereas unbilled E&M and procedures from weeknights and weekends totaled $88,408 ($44,566 and $43,842, respectively). Missed billing after-hours thus represents approximately $530K annually, extrapolating to approximately $220K in collections from our payer mix. Surprisingly, missed E&M and procedural billing during weekdays totaled $70,730 (approximately $425K billing, approximately $170K collections annually), and typically represented patients seen, but transferred from the SICU before attending documentation was completed. CONCLUSIONS: Capture of nighttime and weekend ICU collections alone may be insufficient to add faculty or incentivize in-house coverage, but could certainly complement other in-house derived revenues to such ends. In addition, missed daytime billing in busy modern ICUs can be substantial, and use of an EMR to identify missed billing opportunities can help create solutions to recover these revenues.

Pregnancy is not a sufficient indicator for trauma team activation.

BACKGROUND: Trauma complicates 6% to 7% of all pregnancies. Adverse outcomes are rare when monitoring is normal and early warning signs absent. Trauma systems often use pregnancy as the sole criterion (PSC) for partial trauma team activation. This study compares outcomes of pregnant patients presenting with PSC versus other physiologic, mechanistic, or anatomic (OPMA) activation criteria. METHODS: Three hundred fifty-two consecutive obstetric partial trauma team activation patients (2000-2005) were grouped by length of gestation and evaluated for activation criteria and early maternal and fetal outcomes. Data were analyzed using descriptive statistics and analysis of variance. RESULTS: Patients ranged in age from 16 to 44 (mean age, 28 +/- 6.4) and in weeks gestation between 1 and 40 weeks (mean, 25 +/- 8 weeks). Eighty-two percent had been in vehicle crashes. One hundred eighty-eight (58%) were activated based on PSC and 137 on OPMA. No PSC patient had injuries sufficient to warrant trauma service admission. Ninety-four percent of all PSCs of <20 weeks were discharged home from the emergency department. There were no maternal mortalities. There were four fetal mortalities; two pregnancies were terminally compromised before the trauma event. No patient in the PSC group required admission to the trauma service. There were seven cases of abruption (2%) and 18 cases of vaginal bleeding or discharge (6%). No case of vaginal bleeding or abruption in the first 20 weeks was hypotensive at the scene or on arrival. CONCLUSION: In this study, pregnancy was not an independent predictor of the need for trauma team activation. Standard OPMA trauma activation criteria apply equally to pregnant and nonpregnant patients. These data provide support for more judicious allocation of scarce trauma systems resources.

Estimated height, weight, and body mass index: implications for research and patient safety.

BACKGROUND: Research suggests that weight influences patient care and outcomes. Health-care providers (HCPs) sometimes rely on patient self-reports or HCP estimates of height and weight. The purpose of this study was to determine the accuracy of self-reported height and weight and HCP estimations of height, weight, and body mass index (BMI) classification when compared with measured height, weight, and calculated BMI. STUDY DESIGN: Attending physicians, residents, and nurses provided height and weight estimates along with BMI categorizations for 110 trauma patients at a large, teaching hospital with a Level I trauma center. Patients provided reports of their heights and weights. Measured heights and weights were obtained with appropriate calibrated devices, and BMIs were calculated. Estimates and categorizations were then compared with measured and calculated values. RESULTS: HCPs were 41% and 53% accurate in estimating height and weight, respectively. Self-reports had higher accuracy (69% and 92%, respectively) but still resulted in a BMI misclassification of 32%. Twenty-two percent of patient self-reports were unobtainable. When HCPs attempted to categorize a patient into a BMI group, the accuracy was 56%. Functioning, calibrated instruments for measuring height and weight were frequently unavailable in relevant hospital locations. CONCLUSIONS: This study demonstrated that HCPs' estimates of height, weight, and BMI category are highly inaccurate. Patient self-reports are better, but are unavailable at times. Objective measurements with calibrated instruments are necessary for accuracy in research studies and for patient safety in clinical practice. Efforts to ensure the availability of calibrated instruments may be necessary in the hospital setting.

Evaluation and management of blunt traumatic aortic injury: a practice management guideline from the Eastern Association for the Surgery of Trauma.

BACKGROUND: Blunt traumatic aortic injury (BTAI) is the second most common cause of death in trauma patients. Eighty percent of patients with BTAI will die before reaching a trauma center. The issues of how to diagnose, treat, and manage BTAI were first addressed by the Eastern Association for the Surgery of Trauma (EAST) in the practice management guidelines on this topic published in 2000. Since that time, there have been advances in the management of BTAI. As a result, the EAST guidelines committee decided to develop updated guidelines for this topic using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework recently adopted by EAST. METHODS: A systematic review of the MEDLINE database using PubMed was performed. The search retrieved English language articles regarding BTAI from 1998 to 2013. Letters to the editor, case reports, book chapters, and review articles were excluded. Topics of investigation included imaging to diagnose BTAI, type of operative repair, and timing of operative repair. RESULTS: Sixty articles were identified. Of these, 51 articles were selected to construct the guidelines. CONCLUSION: There have been changes in practice since the publication of the previous guidelines in 2000. Computed tomography of the chest with intravenous contrast is strongly recommended to diagnose clinically significant BTAI. Endovascular repair is strongly recommended for patients without contraindications. Delayed repair of BTAI is suggested, with the stipulation that effective blood pressure control must be used in these patients.

Splenic artery-to-superior mesenteric artery bypass for chronic mesenteric ischemia--a case report.

Chronic mesenteric ischemia (CMI) is a serious vascular condition that if left untreated may progress to acute ischemia resulting in bowel necrosis and high surgical morbidity/mortality rates. Elective intervention has been shown to prevent this progression and relieve symptoms. Current open surgical intervention involves arterial bypass using a vein or synthetic graft conduit with the inflow originating from the aorta or iliac artery. In some circumstances, the splenic artery provides an additional treatment option for revascularization of the superior mesenteric artery. In certain cases, the splenic artery has several advantages over traditional surgical options. The splenic artery is an arterial conduit much like the internal mammary artery used in coronary artery bypass grafting. These grafts are known for their long-term patency and in selected clinical circumstances are preferred over venous grafts. Because the splenic artery has a natural inflow, only a single vascular anastomosis at the outflow vessel (the SMA) is necessary. This lessens the risk of anastomotic stenosis by decreasing the number of anastomoses created and it makes the procedure shorter in duration. The fact that the inflow is provided by the splenic artery makes cross-clamping of the aorta unnecessary, thereby lessening the risk of producing cardiac ischemia and declamping hypotension. A disadvantage is the risk of splenic ischemia with the possible need for splenectomy. The majority of individuals will have adequate collateral supply to the spleen via the short gastric arteries. The risk to the patient of splenectomy versus the benefits of a less complicated arterial reconstruction with avoidance of aortic cross-clamping must be weighed on a case-by-case basis. Preventing the progression to acute mesenteric ischemia with its increased mortality by timely restoration of adequate vascular supply is an important principle in treating patients with CMI. Controversy still exists over the best treatment option for these patients, whether it be antegrade versus retrograde bypass, single-vessel versus multivessel reconstruction, or open surgical repair versus endovascular intervention. In selected patients, the use of the splenic artery can be considered as an additional option for arterial reconstruction of the SMA.

Service vs education: situational and perceptional differences in surgery residency.

OBJECTIVE: This study determined whether situational or perceptional differences exist when trying to define what constitutes "service" and "education" in surgery residency in relation to the Accreditation Council of Graduate Medical Education (ACGME) survey. DESIGN: An institutional review board-approved, single institute, cross-sectional study was conducted through a survey. Participants were asked to rate common resident tasks. Participants were also asked general questions regarding "service" and "education." SETTING: Wright State University surgery program, Dayton, OH. PARTICIPANTS: The study included 69 participants, which included medical students (19), residents (26), nurses/advanced practitioners (14), and attending surgeons (10). RESULTS: A significantly high number of attending surgeons reported that writing a history and physical examination is educational compared with residents and students. Similar results were found regarding talking with patients/families. Drawing blood and starting peripheral intravenous access were universally rated as service tasks. For laparoscopic cholecystectomy, when the resident had done one previously, it was universally thought educational. When the resident had done more, most attending surgeons thought the task educational, but residents and students thought it much less educational. When analyzing only residents, in talking with families, most interns rated this as service, whereas postgraduate years 2 and 3 reported it as more educational and postgraduate years 4 and 5 ranked it equally as service and educational. Similar results were seen in answering nursing phone calls and writing admission orders. Residents (88%) and attending surgeons (90%) agreed that service is part of residency training. Only 40% of residents, however, stated they know what the term "service" means in regard to the ACGME survey. Overall, 80% of attending surgeons and 44% of residents agree that "service" has not been well defined by the ACGME. CONCLUSIONS: Situational and perceptional differences do exist regarding "service" and "education" in our program, and most participants are unclear about the terms. As the definitions are situational and change with the person queried, then should this be the ACGME standard to assess programs and issue citations?

Surgical residents' knowledge of documentation and coding for professional services: an opportunity for a focused educational offering.

INTRODUCTION: A working knowledge of documentation and coding for physician services (DCPS) is increasingly important for a successful practice. There is no standardized, widely available educational offering available to surgical residents in DCPS. The purpose of this study was to survey surgical residents and attendings for their knowledge of documentation and coding and their opinions about its importance in their training and practice. METHODS: A convenience sample of 60 surgical residents and 46 attendings from 5 surgical residency training programs were administered a written survey on DCPS. RESULTS: The majority of residents were male (60%), in university-based programs (82%), and planned to work in a surgical specialty (55%) A larger proportion of attendings were male (80%) and in general surgery practice (62%), and a smaller proportion was university based (61%). Similar proportions of residents and attendings, 82% and 89%, respectively, stated they had not received adequate training in DCPS. The vast majority of residents (85%) felt they were novices at coding and billing, whereas 61% of attendings stated that they were somewhat knowledgeable. As a group, residents answered 54% of 25 knowledge questions correctly, and attendings answered 77% correctly. Ninety-two percent of residents believed that expertise in DCPS would make a difference in their practice, whereas 80% of attendings stated that this knowledge was currently important to their practice. Similar proportions of residents and attendings, 85% and 87%, respectively, thought that it should be an important part of residency training. CONCLUSIONS: Residents in this survey are aware of the importance of DCPS but feel inadequately prepared for this area of practice. The residents' knowledge of basic concepts in DCPS is marginal. Attendings surveyed had similar opinions and somewhat better knowledge of the subject. A widely available, standardized educational offering on DCPS is needed and should be provided as part of the practice-based core competencies of surgical residency training.