26.01 Surgeons Overestimate Post-operative Complications and Death.

Posted on January 25, 2017

K. Pei1, J. Healy1, K. A. Davis1  1Yale University School Of Medicine,Surgery,New Haven, CT, USA

Introduction:

 

Assessing post-operative morbidity and mortality is largely based on experience and published statistics. Projections of complications and death have critical implications for counseling patients preoperatively, particularly for challenging patients. We hypothesize that resident and attending surgeons overestimate complications and death after surgery for complex surgical patients. 

Methods:

General surgery residents and attending surgeons at an urban, tertiary, academic medical center were invited to participate in an online assessment.  Seven complex clinical scenarios were presented to participants via anonymous, online modules.   For each scenario, participants estimated the likelihood of any morbidity, mortality, surgical site infection, pneumonia, and cardiac complications on a 0-100% scale. Scenarios were representative of a diverse General Surgery practice including colectomy, duodenal ulcer repair, inguinal hernia repair, perforated viscus exploration, small bowel resection, cholecystectomy, and mastectomy.   Participant responses were compared to risk adjusted outcome measures by the American College of Surgeons National Surgical Quality Improvement Project (NSQIP) online calculator.   Responses were reported as means with 95% confidence intervals, differences in participant responses and NSQIP estimates were reported as absolute percentage differences of the mean.  This study was approved by the institutional Human Investigation Committee.

Results:

101 Residents and 48 Attending Surgeons (trained in General Surgery) were invited. Overall response rate was 73.8% for all participants.  For all 7 clinical scenarios, there was no significant difference between resident and attending estimates of morbidity or mortality.  There was significant variation in estimates among participants with wide 95% confidence intervals.  Overall, the mean percentages of the estimates were 25.8-30% over NSQIP estimates for morbidity and mortality.

Conclusion:

General surgery residents and attending surgeons did not significantly differ in their estimate of post-operative complications and death; however, both groups grossly overestimated risks in complex surgical patients.  These results demonstrate broad variance in and near universal overestimation of predicted surgical risk when compared to national, risk adjusted models.

21.08 Inflammatory Cytokine Regulation of Extracellular Matrix Results in Attenuated Renal Fibrosis

Posted on January 25, 2017

X. Wang1, P. Duann1, C. Lu1, C. Moles1, H. Li1, M. Fahrenholtz1, M. Rae1, Y. Dhamija1, J. Cheng2, S. Balaji1, S. Keswani1  1Baylor College Of Medicine,Surgery,Houston, TX, USA 2Baylor College Of Medicine,Medicine,Houston, TX, USA

Introduction:

Renal fibrosis is a pathological characteristic of chronic kidney disease (CKD), which affects nearly 700 million patients globally, and is a product of aberrant inflammation and extracellular matrix (ECM) deposition. Patients with CKD are associated with a three-fold or higher mortality rate compared to the general population. We have previously shown a novel role for interleukin-10 (IL-10) in dermal fibrosis, beyond its accepted anti-inflammatory role. In this role, IL-10 regulates the ECM, specifically hyaluronan (HA), and TGFβ isoforms, which are crucial for regenerative tissue repair. However, the roles of IL-10 and HA in renal fibrosis are not completely elucidated. We hypothesize that IL-10 might regulate HA and TGFβ expression in the kidney, and attenuate renal fibrosis in murine unilateral urethral obstruction (UUO) model. 

Methods:
Primary renal fibroblasts (FB) were isolated from 8-10 week-old male C57BL/6J (WT) mice. IL-10 (200 ng/ml) with or without hyaluronidase (HYAL, 1.5 unit/ml) was added to cultures. HA matrices were analyzed by particle-exclusion assay at 24h. Gene expression of HA synthases 1, 2, and 3 (HAS1-3), hyaluronidases 1 and 2 (HYAL1-2) and TGFβ-1 were assessed by qPCR at 1, 2, 3 and 6 h. 8 weeks C57BL/6J (WT) and IL-10 KO male mice were injected with lenti-IL-10/ lenti-GFP (1×1010 IU) under the kidney capsule. Three days after the injection, unilateral ureteral obstruction (UUO) was performed. UUO/sham kidneys and serum were collected at 14 days after UUO for RNA, ELISA, and immunohistochemical (IHC) analysis. n=3/treatment group; p-values by ANOVA.

Results:
In vitro, IL-10 resulted in an upregulation of HAS-1,2, and 3 expression at 2h after treatment, and a significant downregulation of HYAL 1, 2 and TGFβ-1. IL-10 resulted in a 1.88-fold increase in HA-rich matrix formation at 24h, and the effect was abolished by HYAL treatment (p<0.05). In vivo, IL-10 KO mice demonstrated more fibrosis than WT mice. Lenti-IL-10 treatment resulted in less dilated tubules and decreased kidney fibrosis, as well as reduced α-SMA expression as compared to lenti-GFP treated kidneys in both WT and IL-10 KO mice. The HA level in serum was 1.7-fold higher in lenti-IL-10 treated mice as compared to lenti-GFP treated (p<0.05) (Fig.1).

Conclusion:
Our data demonstrates that IL-10 regulates HA metabolism and TGFβ expression of renal FB in vitro, and is effect of IL-10 is validated in the UUO model. The endogenous IL-10 is essential for normal kidney integrity against excessive fibrosis with UUO injury. This previously unreported mechanism for IL-10 regulation of ECM in the kidney may have a significant impact for future therapies to ameliorate kidney fibrosis.

20.12 eCART Before the Hearse: Predicting Severe Adverse Events in Over 30,000 Surgical Inpatients

Posted on January 25, 2017

B. Bartkowiak1, A. M. Snyder1, A. Benjamin2, A. Schneider2, N. M. Twu1, M. M. Churpek1, D. P. Edelson1, K. K. Roggin2  1University Of Chicago,Department Of Medicine,Chicago, IL, USA 2University Of Chicago,Department Of Surgery,Chicago, IL, USA

Introduction:  Postoperative clinical deterioration on the wards is associated with increased morbidity, mortality, and cost.  Early warning scores (EWSs) have been developed to detect inpatient clinical deterioration and trigger rapid response activation more generally, but little is known about the specific application of EWSs to postoperative inpatients.

Methods:  We aimed to assess the accuracy of three general EWSs for predicting severe adverse events (SAE) in postoperative inpatients. We conducted a retrospective cohort study of adult patients hospitalized on the wards following operative procedures at an academic medical center in the United States from 11/2008 to 1/2016.  We compared the Modified Early Warning Score (MEWS), National Early Warning Score (NEWS), and the electronic Cardiac Arrest Risk Triage (eCART) score. The maximum scores from postoperative ward locations were used for analysis. SAE were defined as ICU transfer, ward cardiac arrest, or ward death in the postoperative period.  Accuracy was evaluated using the area under the receiver operating characteristic curve (AUC).  Patients with multiple operations were censored at the start of the second procedure.

Results: Of the 30,009 patient admissions included in the study, 4% (n=1,530) experienced a SAE a median of 2 days (IQR; 0.3-5.6) following the procedure.  Patients who experienced a SAE reached higher maximum scores during their postoperative stay with the following median (IQR) values: eCART, 58 (12-159) vs 12 (7-23); MEWS, 4 (3-6) vs 3 (2-3); and NEWS, 9 (7-11) vs 6 (4-7).  The accuracy for predicting the composite outcome was highest for eCART (AUC 0.80 [CI; 0.79-0.81]), followed by NEWS (AUC 0.77 [CI; 0.75-0.78]), and MEWS (AUC 0.75 [CI; 0.74-0.77]); see figure. Of the individual vital signs and labs, high respiratory rate was the most predictive (AUC 0.70) and high temperature the least (AUC 0.48).

Conclusion: EWSs are predictive of SAEs in postoperative surgical patients. eCART is significantly more accurate in this patient population than both NEWS and MEWS. Future work validating these findings multi-institutionally and determining whether the use of eCART improves the outcomes of high-risk post-operative patients is warranted.

18.20 The Energy Leadership Index: A Tool to Measure and Improve Resident Wellbeing

Posted on January 25, 2017

E. S. Lee1, J. S. Tieman1, J. R. Damian1, C. Martinez1, D. Boggs1, V. N. Nfonsam1, H. McClafferty2, T. Leighn3, L. A. Neumayer1, T. S. Riall1  1University Of Arizona,Department Of Surgery, College Of Medicine,Tucson, AZ, USA 2University Of Arizona,Arizona Center For Integrative Medicine,Tucson, AZ, USA 3Well Beyond Ordinary,Portland, OR, USA

Introduction:  Surgeon burnout is a potential threat to the future workforce. Measuring wellbeing and teaching self-awareness during residency has the potential to decrease future burnout. The Energy Leadership Index (ELI) is an attitudinal assessment that helps individuals create self-awareness about their perceptions, attitudes, and behaviors. The ELI measures an average resonating level (ARL), which reflects their current level of self-awareness. This insight improves their ability to self-monitor and self-coach their thoughts, emotions, and behaviors in real time. Our goal was to evaluate the baseline mean and range of ARLs among surgical residents and correlate ARLs with: 1) burnout, 2) perceived stress, 3) depression, and 4) satisfaction in 14 different areas of life.

Methods:  As part of a novel Wellbeing and Resiliency Program, residents at a single General Surgery Residency Program took the ELI assessment as well as the Maslach Burnout Inventory (MBI), the Perceived Stress Scale (PSS), and the Beck Depression Inventory (BDI). The ARL is reported on a 1-7 scale. Based on population-based norms for the ELI, the ARL was categorized as high catabolic (<2.50), low catabolic (2.50-2.99), very low anabolic (3.00-3.24), low anabolic (3.25-3.49), moderate anabolic (3.50-3.99), and high anabolic (≥4.0). Pearson’s R was used to measure the correlation between the ARL and the MBI, PSS, and BDI.

Results: 49 of 50 general surgery residents completed the surveys. The mean ARL was 3.16±0.24 (range 2.62-3.61). The ARL was low catabolic in 22.4%, very low anabolic in 32.7%, low anabolic in 36.7%, and moderate anabolic in 8.2% of residents. Increasing ARL was positively correlated the MBI professional efficacy score (R=0.63, p<0.001), and negatively correlated with the MBI exhaustion score (R=-0.54, p<0.001), the MBI cynicism score (R=-0.43, p=0.007), the PSS score (R=-0.36, p=0.03), and the BDI score (R=-0.54, p=0.001). Means across ARL categories are shown in the Figure. Fewer than 30% of surgical residents were satisfied with work-life balance (10.2%), time management (20.4%), health and wellness (22.4%), energy levels (24.5%), and feelings of personal freedom (28.6%). Higher ARLs were associated with satisfaction in leadership ability (p=0.03), work relationships (p=0.006), personal freedom (p=0.03), and spiritual wellbeing (p<0.001).

Conclusion: Our data demonstrate a need to improve resident wellbeing. Lower ARLs on the ELI were correlated with increased symptoms of burnout, increased perceived stress, and increased depression scores. Since professional coaching interventions have been shown to improve ARLs, a formal ELI-based coaching program has the potential to improve resident wellbeing.

18.19 I Need an Intraoperative Resident Feedback System STAT! – Using Smart-Phones for Evaluations

Posted on January 25, 2017

A. B. Schneider1, A. J. Benjamin1, A. Suah1, P. Roach3, M. Posner1, J. Matthews1, N. Schindler2, K. K. Roggin1  2Northshore University Health System,Department Of Surgery,Evanston, IL, USA 1University Of Chicago,Department Of Surgery,Chicago, IL, USA 3Captain James A. Lovell Federal Health Care Center,Surgery,Chicago, IL, USA

Introduction:

Consistent and effective evaluation of resident operative performance poses an ongoing challenge for surgical education.  A decade ago, we designed and introduced the Surgical Training and Assessment Tool (STAT) to track trainee operative performance.  However, in recent years we have noticed decreased compliance with the use of STAT and hypothesized that this reflected problems with ease of use and time lag to submission of evaluations.  We designed a resident survey to critique STAT and then used the responses to develop an updated system, STAT 2.0, that was smart-phone accessible and could provide our residency program with enhanced feedback on professionalism, intraoperative communication and trainee-to-trainee teaching.

 

 

Methods:

General surgery residents at our institution were surveyed regarding their perceptions of STAT using a 5-point Likert scale (1=strongly disagree, 5=strongly agree).  Our program then developed a proprietary web-based, mobile accessible evaluation platform.  The questions assessed each resident’s medical knowledge, technical skills, intraoperative communication, and professionalism.  Questions on attending participation based on the Zwisch scale, case complexity and overall grade were also asked.  At the conclusion of each case both the operating resident (self-reflection) and attending completed an evaluation of the resident’s performance.  In the event of a teaching assistant (TA) case, the junior resident was evaluated by both the attending surgeon and the chief resident.  Descriptive statistics were performed on the evaluation data and survey.

Results:

The survey was completed by 26 of the 46 clinical and laboratory surgical residents (response rate: 56%).  The responses are detailed in table one.    

Our program piloted the new evaluation system over a one-month period.  The median time for individual evaluation completion was 1 minute [1 – 3 minutes].  TA cases accounted for 33% of all evaluations.  The residents tend to rate themselves at least 20% lower than the attending in technical skills, intraoperative communication and overall grade.  The level of attending participation was shared by both groups.  The senior residents rated the case as “more complex” than the attending surgeon in more than 25% of the evaluations. 

Conclusions:

General surgery residents at our institution desire an operative evaluation system that is concise and easily accessible through mobile devices.  The STAT 2.0 evaluation system is facile and appears promising to provide trainees and the residency program with valuable feedback related to resident performance, attending participation, intraoperative communication and professionalism. 

18.16 The Quality In-Training Initiative: Giving Residents Data to Learn Clinical Effectiveness

Posted on January 25, 2017

M. M. Sellers1,2, M. Fordham3, C. W. Miller3, C. Y. Ko3, R. R. Kelz1  1Hospital Of The University Of Pennsylvania,Center For Surgery And Health Economics Department Of Surgery,Philadelphia, PA, USA 2Mount Sinai School Of Medicine,Department Of General Surgery,New York, NY, USA 3American College Of Surgeons,National Surgical Quality Improvement Program,Chicago, IL, USA

Introduction: Residents are supposed to review data on their clinical effectiveness to learn self-assessment and strive for continuous quality improvement.  Identification of meaningful data has been a challenge for program directors.  The Quality In-Training Initiative (QITI) collects information on resident participation in operations captured by the ACS NSQIP. This study sought to examine data available for resident education in the QITI component of the ACS NSQIP and to compare differences across participant(P) and non-participant(NP) academic sites.

Methods: Starting in 2013, QITI sites were taught to link individual cases in the NSQIP database with participating resident(s). Cases could be tagged with principle operative resident, resident service team, and/or post-graduate year (PGY) of the operative resident. Free text comments on resident performance were solicited from patients at 30 days post-op. Individual resident and team reports with associated patient outcomes can be generated by P sites for use in graduate medical education. NP sites collect PGY data only. Descriptive statistics of cases captured from July 2013 through June 2016 were analyzed centrally.  Differences in case collection between P and NP sites were compared using the Wilcoxon rank-sum test. 

Results:163 sites captured 417816 cases (range 1 to 9775). 68% of all cases captured had resident participation indicated by PGY (n=285435). An additional 9.5% had fellow participation indicated (n=39798). The most common cases tagged with PGY were laparoscopic appendectomy (n=17082, 6.0%) and laparoscopic cholecystectomy (n=15502, 5.4%). Specialty cases were collected for orthopedics (n=38793; 9.3%), vascular (n=34912; 8.4%), gynecology (n=22275; 5.3%), neurosurgery (n=18046; 4.3%), urology (n=15800; 3.8%), and plastic surgery (n=9556; 2.3%). There were 74 P sites (45%) and 89 NP sites (55%).  A median of 2141.5 cases (IQR: 1027.5,3730.8) were captured per P site compared to a median of 2307 (IQR: 785,3068) per NP site (p=0.32). P sites recorded 9.27 teams per site, with a median of 113 (IQR: 18,520) cases per team.  Reports allow residents to assess individual and team performance over time and enable comparison with other residents of the same PGY locally and at P sites in aggregate. (See Figure 1)

Conclusion:Identifying resident participation in captured NSQIP cases is feasible on a large scale. The time for extra data collection does not diminish the quantity of cases abstracted when compared to NP sites. Types of captured cases reflect national case mix and can be extended to multiple specialties. The reports yield information on resident effectiveness in patient care and can be used in conjunction with other tools to promote continuous quality improvement.

 

18.14 Guiding Resident Autonomy Through Constructive Friction

Posted on January 25, 2017

G. Sandhu1, V. C. Nikolian1, C. P. Magas1, D. C. Sutzko1, N. Matusko1, R. M. Minter2  1University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA 2University Of Texas Southwestern Medical Center,Department Of Surgery,Dallas, TX, USA

Introduction:  Resident operative autonomy has become increasingly limited secondary to hospital demands for efficiency, medico-legal provisions, alterations in duty hours, and increased supervision requirements. These factors have directly contributed to a decreased sense of autonomy for many surgical trainees. To counteract this growing trend, further assessment and optimization of faculty-resident intraoperative interactions is necessary to ensure that entrustment decisions can progressively advance residents toward supervised autonomy. We sought to identify differences in entrustment behaviors exhibited by faculty and resident surgeons using a newly developed and validated instrument, OpTrust. 

Methods:  Research team members observed elective general, vascular, plastic, and thoracic surgery cases performed at a single academic institution. Following observation, resident and faculty members were independently assessed across various domains (e.g. types of questions asked, operative planning, instruction, problem solving, and leadership) related to operative entrustment. Behaviors were quantified using a 4-point scale (from 1 = low entrustability to 4 = full entrustability) for each dyad in order to identify entrustment differences as a function of resident training level. 

Results: From September 2015 to June 2016 we assessed 89 surgery cases using OpTrust. Mean entrustment scores were calculated for each case, revealing significant differences in entrustment behaviors during cases performed by junior residents (PGY1-2), with faculty displaying significantly more entrustment during these operations. No significant differences were identified during cases performed by senior residents (PGY4-5). High entrustability was only identified in cases performed by fellows.

Conclusion: Positive differences in entrustment can stimulate residents to improve their surgical skills in ways they may not be inclined to do so on their own, through the concept of constructive friction. In our study, we identify the greatest margin for constructive friction in cases performed by junior residents. These differences in entrustment behavior decrease as residents progress through training. Improvements in faculty entrustment behaviors should continuously target constructive friction in order to accelerate the acquisition of surgical autonomy of trainees during residency. 

18.13 Surgical Trainees as Teachers: A Self-Reflection Exercise Using the Teaching Perspectives Inventory

Posted on January 25, 2017

C. F. McNicoll1, P. P. Patel1, P. J. Chestovich1, G. L. Allenback1, D. A. Kuhls1, J. L. Baynosa1, G. K. Shen1, J. J. Fildes1  1University Of Nevada School Of Medicine,Surgery,Las Vegas, NV, USA

Introduction:  

Residents and fellows provide significant medical student clinical education during general surgery clerkships, even though they may have limited formal training as educators. The Teaching Perspectives Inventory (TPI) is a validated tool to assist teachers of any discipline understand their role, responsibility, and dominant and recessive teaching perspectives. This study investigated the impact of the TPI self-reflection exercise on surgical trainees’ confidence and effectiveness as educators.

 

Methods:  

Surgical trainees at our institution completed the internet-based 45-question TPI and subsequent self-reflection exercise concerning their roles, responsibilities, and perspectives as educators. Participants completed a 17-question pre- and post-intervention survey that used 5-point Likert items to assess their attitudes, confidence, and knowledge regarding medical student education. For each resident, evaluations completed by medical students across 3 categories and on a 5-point scale were compiled for the semesters before and after the intervention. Means and differences between survey responses and evaluations were analyzed using the paired samples, independent samples, and one sample t-tests in SPSS version 23. Post hoc comparisons were made by level of training (post-graduate year 1-2 v. 3-7), gender, and age (≤ 29 v. > 29).

 

Results: 

All participants (n=21) felt that their role in medical student education was important. Before the intervention, the majority believed that they positively impacted students’ general surgery knowledge (95%), exam results (90%), and career choice (86%). Although a majority (67%) of participants agreed that medical student evaluations are helpful in adjusting their teaching strategies, only 41% believed that students provide useful feedback. After the intervention, 76% felt confident providing an excellent educational experience, and 81% found the TPI useful in examining their teaching philosophy. However, no significant change was seen in overall confidence in teaching ability (3.67 v. 3.81, p=0.2). Senior trainees (n=12) felt more confident than juniors (4.2 v. 3.3, p=0.02) in teaching medical students, and trainees over age 29 (n=9) were more confident than younger trainees (4.2 v. 3.5, p=0.04). No significant differences in medical student evaluations of the residents were found following the intervention (4.77 v. 4.75, p=0.8).

 

Conclusion: 

Surgical residents and fellows acknowledge their heavy involvement in medical student education, and strongly believe that they positively impact students. The majority of trainee educators seek helpful evaluations to improve their teaching and found the TPI to be useful in examining their teaching philosophy. However, the resident’s average teaching performance did not appear to change following the intervention, as measured by medical student evaluations. Larger studies may define the TPI’s effects in improving medical student education.

18.12 Beyond 250: A Comprehensive Strategy to Maximize the Operative Experience for Junior Residents

Posted on January 25, 2017

J. M. Healy1, M. W. Maxfield1, D. J. Solomon1, W. E. Longo1, P. S. Yoo1  1Yale University School Of Medicine,Department Of Surgery,New Haven, CT, USA

Introduction:  Among surgical educators, the multitude of duty hour restrictions have led to widespread concern regarding the adequacy of operative experience during residency.  This concern is exacerbated when the demands of service and education are imbalanced, as is commonly seen during junior resident rotations.  To address this issue, the American Board of Surgery (ABS) recently instituted guidelines stating that residents must perform “a minimum of 250 operations by the end of the PGY-2 year for applicants who began residency in July 2014 or thereafter”.  At our institution, a series of programmatic and institutional changes were implemented to augment the junior resident operative experience and to exceed compliance with this mandate.

Methods:  Operative data from ACGME case logs for categorical and non-designated preliminary interns at Yale-New Haven Hospital were identified for 5 consecutive academic years, 2011 until 2016. American Board of Surgery In-Training Exam (ABSITE) scores were collected in an anonymous fashion.  In response to the ABS requirement for 250 cases, our program systematically instituted a number of changes to augment the junior resident operative experience for the 2015-2016 academic year: minimization of night float, identification of new surgical opportunities within the institution, efficient utilization of midlevel care providers, identification of rotations with sub-optimal operative experiences, maximizing rotations with involvement of junior residents in the OR, and systematic review of case logs and progress.

Results: After the 250-case rule was announced and the above changes were implemented, average total cases for residents completing PGY-2 increased from 176 to 330 (ANOVA, p<0.001). Specifically, there was an 18% increase for interns (p=0.059) and a 118% increase for PGY-2 residents (p<0.001). There were statistically significant increases in the number of skin and soft tissue cases, vascular cases, endoscopy, and complex laparoscopic cases.  There was no difference in case volumes for senior residents during this time. There was a statistically significant decrease in the weeks of night float in 2015-2016 (5.7 vs 3.4; p=0.04). There was no significant difference in mean ABSITE percentile score for the groups studied before and after the intervention.

Conclusion: Prior to the implementation of these interventions, our program would have had 0% compliance with the 250 junior resident case rule.  Within 12 months of implementation, total case volumes for residents completing PGY-2 were increased by 88%—far exceeding minimum standards.  100% programmatic compliance was achieved.  Our program’s experience exemplifies how a mandate from the ABS can lead to programmatic changes that improve the experience of the surgical house officer. 

 

18.11 Using Simulation to Assess Indirect Supervision Readiness for ACGME Common Program Requirements

Posted on January 25, 2017

J. A. McClintic1, C. L. Snyder1, K. M. Brown1  1University Of Texas Medical Branch,Department Of Surgery,Galveston, TEXAS, USA

Introduction:
The Accreditation Council for Graduate Medical Education (ACGME) has issued Common Program Requirements to assure patient safety through appropriate intern supervision during the transition from student to doctor. However, there are no established assessment tools to measure readiness for indirect supervision. Traditionally, faculty or senior residents distribute responsibility as they feel appropriate for each junior resident. Boot camps are often used to train interns, but there is a need for valid, standardized tools to assess residents' indirect supervision readiness.

Methods:
Surgical interns (n=21) completed six individual simulations and two team simulations following "intern boot camp". Residents (n=4; PGY-3,4) and third-year medical students (n=27) completed one of the simulations as part of their curriculum. These simulations were scored with the use of checklists. As an additional measure for comparison, surgical faculty and upper level residents overseeing the interns during their first two months were surveyed to evaluate the interns' readiness for indirect supervision. Post "intern boot camp" surveys were also analyzed for interns' views on the assessments.

Results:
All 8 simulations for 21 interns were completed over the course of 2 3-hour sessions with 3 faculty per session. Of the six individual simulations four had complete data for 21 interns. 12 of the interns passed all four stations, 7 failed one of the four stations, and 2 failed three of the four. The interns' mean simulation performance (12.7) was significantly higher than the medical students' mean (10.5) with a p-value of 0.018. When the inters' mean was compared to the PGY-3,4 residents' mean (10.8) there was not a significant difference (p=0.16). The resident and faculty response rate for the survey was low (15%) and showed little correlation (R=-0.22) to the intern’s individual performance. 40% of the respondents were unable to evaluate the intern's ability to manage a patient in cardiac or respiratory arrest and 16% were unable to evaluate the intern's ability to manage critically ill patients.  77% of the intern surveys reported the simulated patient assessments were either valuable or extremely valuable.

Conclusion:
Simulation was able to demonstrate 7 interns with areas of weakness and 2 with serious deficiencies prior to them entering the patient care setting. The resident and faculty surveys also indicated that the traditional methods of observation are not sufficient to evaluate interns in every category of indirect supervision over the period of a month. Simulation offers an efficient means to fulfill the ACGME indirect supervision requirements in a standardized fashion. However, a prospective study with additional institutions is warranted to provide further validity and standardization for simulation as an assessment tool for indirect supervision readiness.

18.10 Through The Eyes of an Expert: A Comparison of Surgeon Gaze Behaviours During Gastric Bypass

Posted on January 25, 2017

S. Erridge1, H. Ashraf1, S. Purkayastha1, A. Darzi1, M. H. Sodergren1  1Imperial College London,Department Of Surgery & Cancer,London, London, United Kingdom

Introduction:  Bariatric surgery has been shown to significantly decrease the physiological and economic burden of obesity in select groups of patients. Eye tracking presents a novel tool that may objectively profile skill levels in surgery. The primary objective of this study was to identify differences in gaze behaviours between expert and junior surgeons performing a laparoscopic roux-en-y gastric bypass (LRYGB). 

 

Methods:  This prospective observational study utilised lightweight eye tracking apparatus to determine the difference in gaze behaviours between expert (>75 cases performed) and junior surgeons (<75 cases) at defined stages of LRYGB. Primary endpoints were normalised dwell time [%] and fixation frequency [count/s]. Secondary endpoints were blink rate [count/s], maximum pupil size [mm], and rate of pupil change [mm/s].

Results: A total of 20 cases (12 junior, 8 expert) were analysed. Experts showed a prolonged dwell time on the screen during angle of His dissection [91.20% (Range: 83.40-94.40) vs 68.95 % (59.80-87.60); p=0.001], formation of the retrogastric tunnel [91.50% (85.80-95.50) vs 73.60% (34.60–90.50); p=0.001], and gastric pouch formation [86.95% (83.60-90.20) vs 67.60% (37.10–80.00); p<0.001]. Juniors had a greater blink frequency throughout all recorded segments (p<0.01). Juniors had a larger maximum pupil size during all operative segments (p<0.01). Rate of pupil change was greater in juniors in the set-up stage and all analysed operative segments (p<0.01).

Conclusion: These results suggest that experts display more focused attention on significant stimuli. They also experience a reduced mental workload alongside having higher concentration during the procedure. This has the potential for future use in the validation of surgical skill in high stakes assessment.

 

18.09 Single-Site Robotic Cholecystectomy and Robotics Training: Should We Start in the Junior Years?

Posted on January 25, 2017

R. I. Ayabe1, A. Parrish1, C. Dauphine1,2, D. M. Hari1,2, J. Ozao-Choy1,2  1Harbor UCLA Medical Center,Department Of Surgery,Torrance, CA, USA 2David Geffen School Of Medicine At UCLA,Los Angeles, CA, USA

Introduction: Single-site robotic cholecystectomy (SSRC) using the da Vinci Si Surgical System™ achieves a superior cosmetic outcome with a nearly scarless single umbilical incision. We previously showed that SSRC is a safe procedure to introduce in a public teaching hospital after appropriate faculty and resident training. Here we sought to determine the most appropriate level of residency training at which to introduce SSRC.

 

Methods: 98 patients underwent elective SSRC with a general surgical resident as the primary console surgeon between August 2015 and August 2016. Patients were divided into two groups based on the resident’s level of training: second and third years (junior residents) vs fourth and fifth years (senior residents). Data on age, gender, race, BMI, comorbidities, total operative time, conversion to laparoscopic or open surgery, and complications were examined. The Student’s t-test and X2 test were used to analyze continuous and categorical data, respectively.

Results: Junior residents performed 54 SSRC cases, while senior residents performed 44 cases. There were no significant differences in age, gender, race, BMI, or comorbidities between the two groups. There was no significant difference in mean operative time between junior and senior residents (92.7 min for junior residents vs 98.0 min for senior residents, p = 0.254) There were no intraoperative complications in the junior resident group and one intraoperative complication, an enterotomy during abdominal entry, in the senior resident group. Overall, there was no significant difference in complication rate between the two groups (3.7% for junior residents vs 2.3% for senior residents, p = 0.68). There were no conversions to laparoscopic or open cholecystectomy.

Conclusion: As robotic surgery becomes more common across multiple surgical disciplines, it has become increasingly important to expose residents to this technology early in their training. SSRC provides a valuable opportunity to introduce surgical residents to robotic surgery. This data suggests that it is safe and feasible to begin training residents in SSRC as early as the second year of residency.

18.08 The Impact of Procedural Training on Pregnancy and Maternity Outcomes in Residents and Fellows

Posted on January 25, 2017

R. E. Scully1, N. Melnitchouk1, J. Davids2  1Brigham And Women’s Hospital,Boston, MA, USA 2University Of Massachusetts Medical Center,Worcester, MA, USA

Introduction: Procedural specialization requires prolonged training times and demanding schedules that have the potential to negatively affect pregnancy and maternity outcomes. The impact of these factors has not been well described.

Methods: Data from 739 U.S. female resident and fellow level physicians was gathered via an anonymous, IRB-approved online survey. Univariate analysis was performed using Chi-squared and Student’s T-test.  A multivariable model was constructed to determine whether procedural status predicted increased rates of assisted reproduction use, pregnancy complications, or early breast feeding cessation.

Results: Of the 729 individuals, 221 (30.0%) were in procedural fields. In univariate analysis, a higher proportion of trainees in procedural fields were older at the time of first pregnancy (age>30 at time of first pregnancy 52.9% vs 43.1%, p=0.01). The proportion of trainees reporting prolonged time to conceive (>1year for those under the age of 35, >6 months for age 35+ ) was higher in those in a procedural training program (15.4% vs 9.9%, p=0.03). Controlling for age at pregnancy, procedural trainees were significantly more likely to require assisted reproduction (clomid, IUI, IVF) than nonprocedural trainees (OR 1.28, 95%CI 1.01–1.61, p=0.04). In univariate analysis, there was no difference between the proportion of pregnant trainees reporting absence from work (27.0% vs 25.4%, p=0.64); however, procedural residents were more likely to rely on their co-residents to arrange coverage (39.7% vs 34.0%) compared to their chief resident (19.8% vs 29.9%) or department chair(7.4% vs 14.3%, p=0.03). Following delivery, a higher proportion of procedural trainees had short maternity leaves (< 6 weeks of leave following vaginal delivery, < 8 weeks of leave following C-section, 30.5% vs 22.1%, p=0.017). Procedural trainees were also more likely to report that they would have breastfed for longer if their schedules were more accommodating (58.4% vs 50.1%, p=0.04) and were less likely to report that their schedule had been adjusted to allow for pumping (21.6% vs 29.8%, p=0.03). Controlling for age, individuals who became pregnant during procedural training were significantly less likely to report that their decision of specialty was influenced by pregnancy or children (OR 0.24, 95%CI 0.17–0.34, p<0.001), yet they were more likely to report a desire to have chosen a different specialty (OR 1.95, 95%CI 1.40–2.72, p<0.001).

Conclusion: Compared to non-procedural trainees, residents and fellows in procedural training programs have higher rates of infertility, shorter maternity leaves, face challenges with breastfeeding, and are ultimately more likely to express a desire to have chosen a different specialty.  Given these findings, the importance of adequate support for female trainees around pregnancy and maternity cannot be understated, particularly for those in procedural specialties. 

 

18.07 Medical School Boot Camp: Impact on Surgical Skills for Interns

Posted on January 25, 2017

H. Hasan1, M. Malinowski1, M. Goldblatt1, R. Treat1, T. Carver1, L. Olson1, P. Redlich1  1Medical College Of Wisconsin,Milwaukee, WI, USA

Introduction:  The transition from medical student to surgical intern is difficult, generating strong interest in preparing students through “boot camp” training and simulation in medical school. These boot camps increase students’ confidence, but the impact on performance at the start of residency requires further study. We studied basic surgical procedures in interns and compared the skills of those who had boot camp training as medical students to those without a boot camp course. 

Methods:  In our single institution study, twelve interns starting in multiple specialties completed a questionnaire regarding prior boot camp and skills training experiences as fourth-year medical students. During our June, 2016, Protected Block Curriculum, each intern was assessed for suturing (18 one-point items), knot tying (16 one-point items), overall performance (1 five-point item), and quality (1 five-point item) by three surgical faculty members using standardized evaluation forms published by the ACGME. Faculty raters were blinded to the interns’ responses about prior training. The primary outcome of our study is the impact of medical school boot camp on performance of surgical skills. Descriptive statistics are reported with medians (Mdn) and interquartile ranges (IQR). Secondary outcomes included association of various skills via Spearman rho correlations and inter-rater reliability using intraclass correlation coefficients (ICC). All analysis generated with IBM® SPSS® 23.0.

Results: Six out of 12 interns reported previous boot camp training during medical school. Interns in the boot camp group had higher suturing scores (Mdn (IQR)=15.0 (3.2)) than interns without boot camp (Mdn (IQR)=13.0 (5.2)), p<0.048. Knot tying scores trended higher in the boot camp group (Mdn (IQR)=12.0 (4.0) vs. 9.0 (5.3)), but the difference was not statistically significant (p<0.081). Overall performance and quality were similar in the two groups (p<0.34 and p<0.41), respectively. The number of boot camp days, the number of dedicated practice hours, and having “supervised instruction” as a student were not associated with improved scores in any variable. There was a strong association in scores for suturing, knot tying, overall performance and quality (range of Spearman rho=0.63-0.86, all p<0.001). The surgical faculty rated the interns in knot tying (ICC=0.51, p<0.001) and quality (ICC=0.40, p<0.003) in a consistent manner, and somewhat consistently in rating suturing (ICC=0.29, p<0.016) and overall performance (ICC=0.24, p<0.041).

Conclusion: Boot camp training during medical school may improve basic skills performance measured at the start of residency. Boot camp courses in medical schools should be strongly encouraged for students entering surgical specialties. 

 

18.06 Does Case Volume Influence ABSITE Performance?

Posted on January 25, 2017

R. A. Marmor1, E. Hastings2, R. Galzote1, J. T. Unkart1, J. K. Sicklick1, G. R. Jacobsen1  1University Of California – San Diego,Surgery,San Diego, CA, USA 2University Of California – San Diego,Economics,San Diego, CA, USA

Introduction:  Prior research has demonstrated a thought-provoking paradox: despite increasing average case numbers completed during general surgery residency, the rate of passing the ABS Certifying Exam has decreased.  As such, there is a need for better understanding of the relationship between case volume in organ/disease content areas and concurrent resident knowledge in those areas. Our null hypothesis was that there was no association between surgery resident case volumes and ABSITE scores.

Methods:  We obtained ABSITE score reports, ACGME case logs, and USMLE Step 1 scores for all categorical general surgery residents (n=69) in a single academic general surgery program (2010-2015). Multivariate mixed-linear regression was used to identify predictors of ABSITE success including: 1) absolute percent correct; 2) ABSITE percentile score; and 3) index category score created according to ACGME case log classification).  Two coders, blinded to resident identities, reviewed all incorrect ABSITE answers and assigned them to a corresponding case log index category. For each exam year, a list of all organ/disease content area questions was generated from ABSITE reports. Each resident’s index score for a given exam year was calculated as 1 – percent incorrect (defined as the number of questions a resident got wrong in an index category divided by the total number of questions in that category).   

Results: Consistent with several prior studies, USMLE Step 1 scores were significant predictor of ABSITE performance, although this association decreased with training time. On univariate analysis, absolute ABSITE percentage and percentile score did not correlate with total annual case volume as self-reported by residents in ACGME case logs. However, index case volume was a significant predictor of ABSITE index category score (p<0.05) (e.g. increased number of alimentary cases was associated with higher scores on alimentary questions).

Conclusion: For the first time, our study suggests that there is a direct correlation between increased resident performance of cases in defined American Board of Surgery categories and improved performance on the parallel content areas tested during the annual ABSITE. Validation of this finding with a larger sample size is warranted.
 

18.05 Can Surgeons Become Effective Coaches? Development of a Rubric for Formative and Summative Evaluation

Posted on January 25, 2017

S. R. Pavuluri Quamme1, H. L. Beasley1, N. A. Brys1, H. N. Ghousseini1, D. A. Wiegmann1, Y. Ma1, J. C. Dombrowski1, G. E. Leverson1, L. L. Frasier1, C. C. Greenberg1  1University Of Wisconsin,Madison, WI, USA

Introduction: Peer surgical coaching is a promising approach for continuing professional development (CPD). The ability of surgeons to learn and apply core coaching principles and techniques is critical to the overall success of this approach to CPD. To date, however, no validated tool exists for reliably assessing coaches’ performance of these activities, making it difficult to evaluate the quality of coaching sessions or to provide formative feedback to coaches regarding their performance. The purpose of this study, therefore, was to develop and initially evaluate a tool for assessing coaching performance during peer surgical coaching sessions.

Methods: A multi-disciplinary team with expertise in surgery, education, human factors engineering, cognitive psychology, executive coaching, qualitative research, and psychometrics used an iterative approach to develop the rubric followed by initial validation. Extensive background research was conducted of the existing literature in coaching principles and approaches to identify the critical domains of coaching that were applicable in surgery. Audio recordings and corresponding transcripts from actual surgical coaching sessions were reviewed and scored by 7 team members independently. The team met to achieve consensus and clarify wording of the rubric until no further changes were required. Once consensus was achieved, 3 team members scored 8 coaching sessions. Gwet’s weighted agreement coefficient (AC) was used to evaluate inter-rater reliability as an initial step in validation.

Results: We identified four domains that are necessary for effective surgical coach performance: 1) shares responsibility, contributes to equal exchange; 2) uses questions/prompts to guide coachee self-reflection/analysis; 3) provides constructive feedback and encouragement; 4) guides goal setting and action planning. A five point scoring scale was designed to measure each of these performance domains as well as overall effectiveness: 1) counter-productive, 2) neutral/ineffective, 3) developing, 4) proficient, 5) exemplary. Detailed descriptions were developed as anchors for the scoring scale. Overall inter-rater reliability was measured at 0.78 AC.

Conclusions: We developed a scoring rubric to evaluate the overall and domain-specific effectiveness of a surgical coach. Initial validation shows good to excellent inter-rater reliability. While further validation is required and ongoing, this rubric can be used to provide feedback for the training and development of surgical coaches and to evaluate fidelity to the coaching model, a critical requirement for research in this area.
 

18.02 Development of a Technical Rating Scale for Laparoscopic Cholecystectomy Based on Expert Consensus

Posted on January 25, 2017

R. Rao1, R. Caskey1, N. Williams1, D. Dempsey1, J. Morris1, K. Dumon1, A. D. Brooks1  1University Of Pennsylvania,Division Of Surgical Education,Philadelphia, PA, USA

Introduction:
Laparoscopic cholecystectomy, the gold standard in the management of gallbladder disease, has received much attention in the field of general surgical education and simulation. However, the optimal way to evaluate surgery residents in performing laparoscopic cholecystectomy within the simulation environment has yet to be determined. We have recently developed a technical rating scale (LCTRS) which is both specific for laparoscopic cholecystectomy and based on previously published expert consensus. This is in contrast to the currently used generic scales like OSATS (Objective Structured Rating of Technical Skills).

Methods:
At our institution, simulation training for laparoscopic cholecystectomy consists of faculty mentored sessions in a simulated OR setting followed by faculty supervised practice on an inanimate model and then concludes with the resident performance of a laparoscopic cholecystectomy on an ex-vivo porcine liver. In order to better evaluate resident performance of this final task we developed a technical rating scale specific for laparoscopic cholecystectomy (LCTRS). To do this, the following critical steps were identified as essential to the performance of a safe laparoscopic cholecystectomy: Starting dissection high on the gallbladder at Calot's triangle, Appropriate retraction and exposure, Understanding of relevant anatomy, Establishing critical view of safety, Appropriate decision to proceed, Securing cystic duct, Safe use of energy devices, and Appropriate tissue handling. The weight of each of these steps was calculated from published expert ratings of the importance of each step and are 1.15, 1.18, 1.11, 1.05, 1.03, 1.03, 1.01 and 1.00 respectively. To evaluate a resident, the performance of each critical step is rated on a Likert scale of 1-4 (1 being below standard, 2 being standard of care, 3 and 4 being above standard) and then weighted appropriately. To test the validity of LCTRS, video recordings were made of six PGY-1 residents performing ex-vivo laparoscopic cholecystectomy. The videos were then evaluated using both LCTRS and OSATS by two independent surgeons.  Inter-rater reliability was calculated using intra-class correlation coefficient. The two scales were then correlated using Pearson’s correlation coefficient.  All scores are reported as the mean± standard error of the mean. 

Results:
The mean resident score using LCTRS was 22.7 ± 1.2. There was excellent correlation between LCTRS and OSATS (r=0.85, p=0.03). The inter-rater reliability for the LCTRS and the OSATS scale were 0.79 and 0.49 respectively.

Conclusion:
The LCTRS for laparoscopic cholecystectomy is both procedure specific and based on expert consensus and is therefore superior to generic rating scales like OSATS.  Future uses of the LCTRS will include the determination of benchmarks necessary for resident progression as well as the tracking of individual resident progress. 
 

16.22 Intraoperative Parathyroid Identification Not Associated with Increased Permanent Hypoparathyroidism

Posted on January 25, 2017

J. Zagzag1, R. Rokosh1, K. S. Heller1, J. Ogilvie1, K. Patel1, A. Kundel1  1New York University School Of Medicine,New York, NY, USA

Introduction:  One major risk of total thyroidectomy is permanent hypoparathyroidism, and this risk may be increased if a central neck dissection is also performed.  This study was undertaken to evaluate whether identification of parathyroid glands intraoperatively during total thyroidectomy (TT) and total thyroidectomy with central neck dissection (TTCND) is related to inadvertent parathyroid gland excision in the final pathologic specimen.  We also assessed the effect of intraoperative and pathologic parathyroid identification on rates of permanent hypoparathyroidism.

Methods:  A retrospective review of all TT and TTCND performed by our endocrine surgery group between 2011 and 2015 was performed. Patients were stratified into two groups, those with 0-2 and those with 3-4 parathyroid glands identified intraoperatively. The presence of any parathyroid tissue in the final pathologic specimen was examined. Intraoperative and pathologic parathyroid identification was correlated with permanent hypoparathyroidism.  Chi-squared test was used for statistical significance.

Results: A total of 496 cases included 351 TT and 145 TTCND. At least 3 parathyroid glands were identified intraoperatively in 63% of cases. 37% of final specimens contained unexpected parathyroid glands. Intraoperative identification  of 3-4 parathyroid glands was inversely related to the number of parathyroid glands identified on pathology in TTCND but not TT (RR 0.34, 95%CI 0.17-0.69, p-value 0.003). Parathyroid gland identification intraoperatively had no relationship to rates of permanent hypoparathyroidism in either group (TT 2.2% vs 3.8%, p-value 0.721, TTCND 4.1% vs 0.0%, p-value 0.213). Parathyroid tissue on final pathology had no relation to rates of permanent hypoparathyroidism (3.3% vs 2.5%, p-value 0.138).

Conclusion: Intraoperative identification of parathyroid glands is associated with a lower incidence of unexpected parathyroid gland excision when performing a total thyroidectomy with central neck dissection. Total thyroidectomy with or without central neck dissection, when performed by experienced endocrine surgeons who routinely identify parathyroid glands, was not associated with increased rates of hypoparathyroidism when fewer than three parathyroid glands were identified intraoperatively or when parathyroid tissue was found on final pathology. The identification of parathyroid glands intraoperatively did not result in permanent hypoparathyroidism.

 

16.20 Impact of Symptom Association Probability on Outcomes of Laparoscopic Nissen Fundoplication

Posted on January 25, 2017

A. D. Jalilvand1, S. E. Martin Del Campo1, J. W. Hazey1, K. A. Perry1  1Ohio State University,Columbus, OH, USA

Background: Laparoscopic Nissen fundoplication (LNF) is the gold standard for surgical reflux control in patients with objective evidence of gastroesophageal reflux disease (GERD). Symptom association probability (SAP) score is used with pH testing to correlate symptoms to reflux events, with scores above 95% implying a high correlation to reflux exposure. It is unclear whether these scores impact the outcomes of laparoscopic anti-reflux surgery. We hypothesize that a negative SAP score for typical GERD symptoms in the setting of a positive pH test is not associated with persistent symptoms after LNF.

Methods: We reviewed all patients undergoing LNF for objectively confirmed GERD between May 2011 and June 2016. Patients without pH testing due to complicated GERD or who did not have SAP scores were excluded from this analysis. SAP scores >95% were considered positive and those <95% were considered negative. Reflux symptoms and quality of life were assessed using the Gastroesophageal Reflux Symptom Scale (GERSS) and Gastroesophageal Reflux Disease Health-Related Quality of Life (GERD-HRQL) questionnaires. Baseline and post-operative data were collected in the clinic setting. Data are presented as incidence (%), mean ± SD, or median (IQ range) as appropriate, and a p-value of <0.05 was considered statistically significant.

Results: LNF was performed in 142 patients during the study period with an average age of 48.5 ± 13.5 years, BMI of 31.3 ± 5.6, and 78% (n=111) were female. Median preoperative DeMeester score was 38.5 (28.0-54.4), baseline GERSS was 37.5 (26.0-51.0) and GERD-HRQL was 32 (22.0-37.5). Patient characteristics and baseline symptoms did not differ between positive and negative SAP scores. Positive SAP scores were reported in 63% of patients for heartburn, 64.4% for regurgitation, and 40.9% for chest pain. Compared to baseline, GERSS improved from 36 (26-50) to 8 (2-16, p<0.001) in those with positive SAP for heartburn and 39 (28-54) to 8 (0-13, p<0.001) with negative SAP. GERD-HRQL scores improved from 31.5 (22-37) to 4 (2-8, p<0.001) and 34 (22-39) to 4 (1-11, p<0.001) respectively. Postoperative GERSS (p=0.923) and GERD-HRQL (p=0.600) scores did not differ between groups. Complete resolution of HB was achieved in 86.8% of patients with positive SAP compared to 66.7% of patients with negative SAP for HB (p=0.065). There were no significant differences in postoperative GERSS, GERD-HRQL, or symptom resolution following LNF for patients with positive and negative SAP for regurgitation or chest pain.

Conclusion: LNF achieves excellent symptom control and improves disease-specific quality of life in patients with symptomatic GERD confirmed by pH testing. Negative SAP scores for typical GERD symptoms are not associated with higher GERD symptom scores or reduced disease-specific quality of life following LNF and should not be used to select patients for laparoscopic anti-reflux surgery in this setting. 

15.20 Postoperative Bacteremia: Concordance with Cultures from Other Sites

Posted on January 25, 2017

L. R. Copeland-Halperin1, J. Stodghill1, E. Emery1, A. W. Trickey1, J. Dort1  1Inova Fairfax Hospital,Surgery,Falls Church, VA, USA

Introduction:  Bacteremia is a worrisome postoperative complication. While blood cultures (BCx) are routinely used to evaluate bacteremia, they are costly and may yield conflicting results. We previously reported on the relationship between BCx yield and the timing of culture collection after surgery. Here we present additional analyses of relationships between positive BCx and other cultures obtained concurrently to characterize surgical patients in whom postoperative blood cultures are most likely to identify pathogens.

Methods:  Electronic medical records were reviewed for patients ≥18 years of age who had blood cultures drawn within 10 days after surgical procedures at a referral center in 2013. We collected demographic data and results of cultures of blood, urine, central and peripherally inserted venous catheters, respiratory secretions, wounds, and stool obtained within 24 hours of the highest postoperative temperature before postoperative day 10. Relationships between blood cultures and other culture results were assessed using chi-square tests, or Fisher’s exact tests when assumptions for chi-square were not met.

Results: A total of 1,804 cultures were identified; exclusion of contaminants left 1,780 cultures among 746 patients for analysis. Patients had a mean age of 59 years (range=18-95, SD=16.8). The majority were male (54%). Positive or indeterminate urine and respiratory cultures demonstrated statistically significant associations with positive blood culture results (Table 1). Patterns were similar for wound and stool cultures, but statistical power was limited for those comparisons. Overall, any positive or indeterminate culture increased the likelihood of positive blood culture (9.8% vs. 2.9%, odds ratio=3.58, p<0.001).

Conclusion: These findings from the largest series of its kind help identify clinical predictors associated with early postoperative bacteremia. Specifically, the presence of a positive or indeterminate urine, respiratory, wound, stool, or catheter tip culture significantly increased the likelihood of a positive blood culture. 

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