76.18 A Survey of Surgical Educators’ Perceptions of Public Health Training

Posted on December 22, 2014

A. R. Joshi1,2, H. Miller1, G. Kowdley3, C. Are5, P. Termuhlen4  2Thomas Jefferson University,Surgery,Philadelphia, PA, USA 3Saint Agnes Hospital,Surgery,Baltimore, MD, USA 4Medical College Of Wisconsin,Surgery,Milwaukee, WI, USA 5Nebraska Medical Center,Surgery,Omaha, NE, USA 1Einstein Healthcare Network,Surgery,Philadelphia, PA, USA

Introduction:  Public Health is the science of preventing and treating disease on a societal level.  Recently, a consortium of organizations have begun to examine public health training (PHT) during general surgery residency training.  In order to make recommendations for changing future PHT in surgical education, we analyzed the current state of PHT in general surgery residency programs in the US.  

Methods:  We conducted an online 24-question anonymous e-mail survey to target surgeon educators about their opinions on PHT in surgery.

Results: A total of 48 surgical educators completed the survey, representing 20% of the 250 general surgery training programs nationwide.  51% were university programs and 49% community programs.  72% were urban, 4% rural, and 23% suburban.  The minority of respondents offered specialized exposure to public health.  6% had formally integrated PHT into their core curriculum.  91% reported that fewer than 25% of their residents had a significant interest in public health training.  89% reported that their residents were at least somewhat satisfied with the current level of PHT in their institutions.  65% of the respondents were interested in expanding PHT for their residents.

Conclusion: There are increasing external pressures on surgical educators to incorporate PHT into residency programs.  These educators believe that their trainees are generally satisfied with the current level of PHT, but are themselves interested in increasing PHT in their programs.  With the advent of a Milestones-based evaluation system, it will be important to define surgery-specific aspects of PHT that can be incorporated into surgical training.

 

76.19 So, you want to be a global surgeon? International opportunities at 239 US residency programs.

Posted on December 22, 2014

J. J. Wackerbarth1,8, P. Numann5, R. Maier4, S. M. Wren3, A. L. Kushner2,6,7  1University Of Washington School Of Medicine,Seattle, WA, USA 2Johns Hopkins Bloomberg School Of Public Health,Dept Intl Health,Baltimore, MD, USA 3Stanford University,Dept. Surgery,Palo Alto, CA, USA 4University Of Washington,Dept. Surgery,Seattle, WA, USA 5State University Of New York Upstate Medical University,Dept. Surgery,Syracuse, NY, USA 6Columbia University College Of Physicians And Surgeons,Dept. Surgery,New York, NY, USA 7Surgeons OverSeas,NY, NY, USA 8Johns Hopkins Bloomberg School Of Public Health,Baltimore, MD, USA

Introduction:  Interest in international health is growing among surgical residents and medical students. Increasingly, applicants to surgical training programs look to see if they can incorporate structured international experience and programs into their training. Despite this, many general surgical residency programs lack a formal international component or insufficiently promote global surgery programs and experiences.   We hypothesized that the majority of programs do not have formal global health training or do not provide the information to prospective applicants regarding electives or programs in an easily accessible manner.  

Methods:  Individual general surgery program websites and the ACS “So, You Want to Be a Surgeon” tool were used to evaluate 239 general surgical residencies in the United States. The residency homepages were examined for specific mention of international or global health programs.  Further examination was conducted for any mention of formal surgical electives, global health concentrations or pathways. Ease of access was also considered and graded as accessible if available within two links of the homepage. Using the search window, “global surgery” and “international health”  were individually queried to identify other resources or programs. 

Results: The majority of general surgery residency program websites in the United States do not have any mention of international or global surgery programs or opportunities on their homepage that are easily accessible. Out of 239 programs, 23 (9.6%) were found to have mention of any sort of international experience on their homepage, and 39 (16.3%) were found to have information about international electives accessible at all.  Thirty-two residencies (13.4%) had dedicated programs, pathways, or surgery specific centers for global health. Of those with information available, 42% were scored as easily accessible.  Compared to community based programs, academic centers were more likely to have information about international opportunities on their homepage (11.9% vs. 6.9%) and more likely to have a dedicated program or pathway website (20.7% vs. 4.0%). 

Conclusion: General surgery residency programs do not effectively or easily communicate international opportunities for prospective residents through web-based resources. Interest continues to grow in an increasingly global world of medicine, to optimize training and recruit potentially a group of the most dedicated providers of the future, programs should enhance the  international surgery opportunities and ease of access.

 

76.20 The Addition of Spaced Learning to a General Surgery Residency Program

Posted on December 22, 2014

H. A. Prentice1, J. M. Wright1, P. Graling1, J. M. Dort1, J. J. Moynihan1  1Inova Fairfax Hospital,Department Of Surgery,Falls Church, VA, USA

Introduction: The addition of a research and statistics curriculum in 2011 showed significant improvement in general surgery residents’ scores on American Board of Surgery In-Training Examination (ABSITE) questions related to research methodology and statistics. Yet even with this improvement, there is still room for further achievement as there is a strong correlation between scores on the ABSITE and performance on board qualifying exams. Further, retention of knowledge on research and statistics has yet to be assessed. The purpose of this study is to evaluate whether knowledge retention of a research and statistics curriculum improves after implementation of spaced learning via Qstream as part of the resident training.

Methods: Starting in July 2014, educational lectures will be given monthly by the Inova Fairfax Hospital (IFH) Department of Surgery Biostatistician; with attendance at the lecture series being mandatory for all residents. Following each lecture, residents will be sent questions related to the respective lecture to answer via the web-based tool Qstream to enhance retention of knowledge learned during the didactic lecture. Knowledge retention will be assessed by change in exam scores from a baseline exam given prior to the first lecture and a follow-up exam given one month after the final lecture. Means and medians will be calculated for the percentage of correct answers and change in exam score for knowledge retention.

Results: All 21 IFH general surgery residents were included in the study. At baseline, average score on a 15 question research and statistics assessment was 8.3 (55.4%). Lowest scores were for a question regarding accounting for confounding during analysis and necessary components for power calculations (only 14.3% of residents answered correctly for both questions). Since the first lecture, 14 residents (66.7%) have started the questions via Qstream.

Conclusion: As a validated tool developed by researchers at Harvard Medical School for increasing knowledge retention for up to two years, Qstream can deliver educational material and reinforce education over spaced intervals of time so the learner critically thinks about the material content rather than relying on rote memorization. Our baseline assessment has shown there is room for improvement in resident research and statistics comprehension. It is hoped improvements will be observed at the end of the curriculum in December and be retained through follow-up assessment after the curriculum is over.

 

77.01 Do Trauma Nurses Know (and Trust) their Physician Colleagues?

Posted on December 22, 2014

N. Ho1, G. Kurosawa1, A. Wei1, E. Lim1, S. Steinemann1,2  1University Of Hawaii,John A. Burns School Of Medicine,Honolulu, HI, USA 2The Queen’s Medical Center,Honolulu, HI, USA

Introduction:  

Efficient teamwork requires knowledge of members’ capabilities and task domains. In modern trauma teams, multiple levels of “physician” practitioners (medical students, residents, fellows, attendings and physicians’ assistants – “PAs”) may create confusion. We hypothesized that trauma nurses (TRNs) lack detailed knowledge of team members’ abilities, and that TRNs and surgeons may have discordant perceptions of responsibilities during resuscitations.

Methods:  

A survey was conducted at a Level II Trauma Center which includes medical students, residents, surgical critical care fellows (Fellows) and PAs on the trauma team. TRNs enrolled in a trauma refresher course gave informed consent to participate and were asked their knowledge of the education, clinical training and need for supervision of team members. TRNs then ranked, on a 7-point Likert-type scale, their perception of responsibility for 17 resuscitation tasks.  TRN perceptions were compared (via two sample t tests) to those of attending trauma surgeons.

Results:

42 TRNs (100%) and 9 surgeons (90%) participated. Only 4% of TRNs knew the minimum clinical years training of first-year residents (PGY1s), Fellows and PAs. 90% of TRNs underestimated the clinical experience of PAs by an average of 2-fold; 61% underestimated the experience of PGY1s and Fellows.

88% of TRNs correctly identified the need for medical student, PGY1 and PA supervision for specific procedures or patient conditions.  However, 92% of TRNs thought mid-level residents should be supervised for tube thoracostomy, a procedure typically performed by mid-level residents without direct supervision.

TRNs and attending surgeons differed in perception of responsibility for most resuscitation tasks with both groups assigning significantly more responsibility to their own profession (Table).

Conclusion:

Our study demonstrates a gap in TRN understanding of the education and experience of surgical trainees and PAs, and a perceived need for additional procedural supervision of mid-level residents. Both TRNs and attending trauma surgeons maintained “ownership” of a number of trauma resuscitation tasks. This could conceivably result in inefficiency and duplication of diagnostic procedures or interventions.  Further education regarding trauma team members’ training and ability, and attention to nontechnical “teamwork” skills (e.g. pre-briefing, role assignments, communication) may be warranted to reduce redundancy and confusion.

77.02 Integrated Vascular Surgery Resident Satisfaction

Posted on December 22, 2014

K. D. Dansey1, M. Wooster1, M. Shames1  1University Of South Florida College Of Medicine,Vascular Surgery,Tampa, FL, USA

Introduction:  The integrated vascular surgery residency is still in its infancy relative to other training paradigms.  As such, the SVS Resident and Student Outreach Committee continues to seek ways to improve the program and resident satisfaction. Several existing studies have attempted to assess resident satisfaction; however, these studies primarily focused on two specific areas—general surgery residency and the ACGME work hour restrictions. This is the first survey to assess and quantify the level of satisfaction among the integrated vascular surgery residents. The goals of this survey include identifying stronger rotations to ensure that all programs are maximizing their educational potential and providing a foundation in constructing new vascular programs. 

Methods:  A 13-question survey was electronically distributed to the members of the SVS Resident listserv. The survey gauged the level of satisfaction with faculty, nonvascular surgery rotations, educational curriculum, operative experience, and interaction with the respective institutions’ general surgery program.  Each question was reviewed and approved by an SVS appointed committee. The questions were a combination of multiple choice, free response and 5-point Leichardt scale. Satisfaction was defined as a score of three or higher on a five-point scale.  

Results: Of the eligible vascular residents, only 26/173 have responded (0% PGY-1, 38% PGY-2, 27% PGY-3, 8% PGY-4, 27% PGY-5).  The majority of trainees reported satisfaction with the faculty, general surgery peers, educational experience, and amount of vascular surgery in the first two years.  Critical Care (mean score 4.3), Cardiothoracic (mean score 4) and Trauma/Acute Care Surgery (mean score 3.8) rotations were most commonly deemed highly beneficial to their training. Minimally invasive rotations (mean score 1.8), podiatry (mean score 2), and bariatric surgery (mean score 2) were more consistently felt to be less beneficial. Eighty percent reported 50-75% of their cases are endovascular. Eighty-eight percent reported that the general surgery program director is accommodating to the vascular surgery residents requests.  The lowest overall resident satisfaction was with simulation experience (83%), amount of vascular surgery in the first two years (77%), and vascular lab curriculum (88%). 

Conclusion: The results of this survey reveal that the majority of responders are satisfied with their residency experience. Cardiothoracic and critical care exposures are the experiences most universally deemed beneficial to overall education, whereas other rotations have more diverse responses, suggesting very program-specific distinctions between the services.  As a whole, we have room to improve on simulation and vascular lab exposure for resident education. 

 

77.03 The Women in Medicine Summer Intensive: Analysis of a Professional Development Curriculum

Posted on December 22, 2014

A. Jordan2, B. Hughes2, K. Kim1  1University Of Chicago,Department Of Medicine,Chicago, IL, USA 2University Of Chicago,Pritzker School Of Medicine,Chicago, IL, USA

Introduction:

The Women in Medicine Summer Intensive is a research endeavor that seeks to evaluate the efficacy of a mentoring intervention focused on professional development for women medical students.

Two cohorts (n=22) were annually chosen from a competitive pool of first year women medical students to participate in an 8 week intensive consisting of biweekly meetings: one student-led and the other faculty-led. Each week of the intervention focused on a salient professional skill identified by a participant, which was explored via roundtable discussion, skill exercises, and lecture-based formats.

Methods:

Pre- and post-intervention analysis was conducted via quantitative and qualitative surveys of the first cohort to ascertain degree of comfort with skill based professional development. Quantitative statistics and qualitative coding were used to analyze Likert scale rankings of skill confidence and constructed responses gathered from both the first cohort (n=7) and nonparticipant students (n=111). Pre- and post-intervention analysis of the second cohort will be performed following conclusion of the intensive in August 2014.

Results:

In the first cohort, professional development skills addressed in the curriculum included maintaining self, negotiation, assertiveness, career trajectory, self-advocacy, eliciting and receiving feedback, leadership, and managing career opportunities. Intervention participants (n=7) showed statistically significant increases in confidence post-intervention for 12 out of the 15 professional skills surveyed (3 skills: p-value <0.05; 9 skills: p-value <0.01). When compared to non-participant peers (n=34), intervention participants (n=7) showed statistically significant differences in confidence for 7 out of the 15 professional skills (p-value <0.01).

Conclusion:

Through direct interaction with senior faculty, participants were able to identify gender-specific considerations for the adoption of professional skills. Both qualitatively and quantitatively, women medical students felt more capable professionally as a result of their experience in this intervention. The active participant-based curriculum moved the relationship between student and faculty into an action and skill-focused exchange and is a practical approach to meeting the need for women-specific professional development programming, which may be particularly salient for recruitment of women students into surgical and surgical subspecialty fields.

75.07 Is delaying surgery in acute appendicitis acceptable?

Posted on December 22, 2014

N. Kincaid1, M. Yanagisawa1, L. Burkhalter2, R. Foglia1  1University Of Texas Southwestern Medical Center,Division Of Pediatric Surgery,Dallas, TX, USA 2Children’s Medical Center,General Surgery,Dallas, Tx, USA

Introduction:  Management of acute appendicitis traditionally required urgent operation. The aim of this study is to determine what effect a moderate delay in performing an appendectomy has on rate of perforation and length of stay (LOS).
 

Methods: After IRB approval, medical records between Jan. and Dec. 2011 were reviewed for all pediatric patients who had an appendectomy with a diagnosis of appendicitis in one children’s hospital system. Interval and negative appendectomies were excluded. Data includes gender, age, and these time points: ED arrival, decision for surgery, start of surgery, and discharge. Delay in operation was assessed using time elapsed between surgical decision and start of surgery. There were two groups: Group P patients who underwent prompt operation in <6 hrs. and Group D patients whose surgery was delayed ≥ 6 hrs. Operative delay was either due to postponing a night (9:00pm to 4:00am) surgery or other scheduling conflicts. LOS is calculated from ED arrival to discharge. Data is expressed as X ± sd, significance is noted at p<0.05.

Results:  There were 871 patients, 534 boys, 337 girls, and their age was 10.5±3.6 years. 244(28%) patients had perforated (PA) and 627(72%) had non-perforated appendicitis (NPA). There were 599(69%) Group P patients with an average delay of 2.0±1.6 hours and 272(31%) Group D patients with an average delay of 8.8±2.6 hrs. The perforation rate was 31% in Group P and 22% in Group D (p<0.02).

In PA, there were183 Group P patients delayed 1.9±1.6 hours with a LOS of 102.3±63.7 hrs. and 61 Group D patients delayed 8.8±2.8 hrs., with a LOS of 112.5±58.9 hrs. (p=NS). In NPA, 416 Group P patients had a delay of 2.1±1.7 hours and a LOS of 30.1±19.6 hrs. The 211 Group D patients, with a delay of 8.9 ± 2.6 hrs., had a 31% longer LOS of 39.3 ± 27.4 hrs. (p<0.01) (see table 1). There were 173(82%) patients in Group D whose surgeries were postponed overnight. They had a maximal LOS of 40.6±27.5 hrs. with p<0.01 compared to Group P.

Conclusion:A moderate (6 hr) operative delay for appendicitis doesn’t increase risk of perforation. The fact that perforation rate was lower (22% vs 31%) in those whose surgery was delayed does not mean that surgery should be delayed to decrease the perforation rate! These findings may reflect the surgeon’s judgment to operate early in selected cases. In NPA, a moderate delay prolonged LOS by 31%; and in PA, a 10 hour delay didn’t prolong the LOS. Hospitals are increasingly focused on LOS. Efforts should be directed towards optimizing hospital resource utilization, having a refreshed operative team, and doing what is best for patients.
 

75.08 Developing patient-centric discharge instructions to prevent readmissions after colorectal surgery

Posted on December 22, 2014

L. Li2, B. W. Trautner1,2, B. A. Campbell1, L. I. Herman1, V. Poppelaars1, D. H. Berger1,2, D. Anaya1,2, S. S. Awad1,2, A. Naik1,2  1Michael E. DeBakey VA Medical Center,Houston HSR&D COIN IQUEST,Houston, TX, USA 2Baylor College Of Medicine,Houston, TX, USA

Introduction: Approximately 16% of major bowel surgeries result in a re-hospitalization. Many of these re-hospitalizations are preventable if warning signs are brought to the attention of physicians at an early stage. A patient-friendly set of discharge instructions, or an after hospital care plan (AHCP), can provide a common language for patients and providers to recognize and communicate about the warning signs in a timely manner. Our purpose was to perform qualitative analysis of patient interviews concerning two components of our AHCP, the warning signs (WS; Figure 1A) and the everyday care instructions (ECI; Figure 1B) to determine whether our materials were communicating the intended information effectively.

Methods: We had previously developed the WS and ECI content with a panel of domain experts. An iterative design approach was used to develop the single-page color format for each document. We then conducted a series of semi-structured interviews with 7 patients who had undergone colorectal surgery within the 2 prior weeks. Six research personnel performed a thematic analysis of interview transcripts through card sorting.  Cluster analysis of themes used the “Jaccard Index” as a metric of distance. Patient response themes were derived from the “clusters” of patient responses (using a 0.33 distance threshold) identified by the research personnel.

Results:

Warning Signs: Patients first noticed the colors, warning signs, and heading. Patients understood that the green zone indicated “that everything is going well,” the yellow zone indicated “things you need to look out for,” and that the red zone indicated that a doctor needed to be seen right away. Patients rated the clarity of the information on this page, from 1 (lower) to 5 (higher), at an average of 4.7 (SD=0.5).

Everyday Care Instructions: The thematic analysis of patient responses to our open-ended questioning about the ECI page revealed that patients first noticed the instructions, and heading. Patients understood that the information on this page indicated that patients need to “Get moving” and that they needed to “Keep up with it.” Patients rated the clarity of the information on this page, from 1 (lower) to 5 (higher), at an average of 5.0.

Conclusion: The patient interviews and thematic analysis indicate that colorectal surgery patients understand the information provided and approve of the manner in which it is presented in the AHCP. Thus, the AHCP has the potential to help reduce preventable hospital readmissions following colorectal surgery through improving early recognition of and attention to early warning signs.

75.09 Morbidity and Mortality in Patients after Skull Base Reconstruction: Analysis of the NSQIP Database

Posted on December 22, 2014

K. Kim1, A. Ibrahim1,2, P. Koolen1, N. Seyidova3, S. Lin1,2  1Beth Israel Deaconess Medical Center,Division Of Plastic Surgery,Boston, MA, USA 2Beth Israel Deaconess Medical Center,Division Of Otolaryngology-Head And Neck Surgery,Boston, MA, USA 3Medical University Of Vienna,Vienna, , Austria

Introduction:
The primary aims of reconstructive surgery following resection of skull base tumors are 1) separation of the central nervous system from the aerodigestive tract, 2) reestablishment of orbital and oral cavities, and 3) restoration of the 3-dimensional appearance of bony and soft tissues.Numerous reconstruction methods have been employed and their pros and cons examined. Developments in surgical technique have made it possible to operate on lesions that were previously deemed inoperable. However, despite these technical advancements in addition to improved preoperative radiographic assessment of tumor extent and postoperative care, complications remain an inherent problem in this patient population.

Methods:

We reviewed the 2005-2012 ACS-NSQIP databases to identify patients undergoing skull base surgery. Bivariate analysis was done to compare preoperative variables and postoperative outcomes between the reconstruction group and non-reconstruction group. Chi-square tests were used for categorical variables and t-tests for continuous variables. The odds ratio of respective reconstruction methods was determined to assess their impact on postoperative complications. Multiple logistic regression analysis predicted the influence of preoperative and operative variables on postoperative outcomes. 

Results:

479 patients were included in our study; 199 patients received concurrent reconstruction. There was no statistically significant difference in wound complication, morbidity, length of total hospital stay and mortality between the two groups. The reconstruction cohort showed significantly longer operative times (416.45 ±207.585 minutes vs. 319.99 ±222.813 minutes, P=0.001) and higher return to the operating room rate (13.6% vs. 6.1%, P=0.005). Reconstruction using pedicled flap is associated with increased odds of wound complications (OR=4.937, P=0.023), and microsurgical reconstruction with return to the operating room (OR=2.212, P=0.015). Logistic regression implicated dyspnea, diabetes mellitus, functional status and tumor involving central nervous system as predictors for complications in our patient population. 

Conclusion:
This is the first comprehensive analysis of reconstruction following skull base surgery using the ACS-NSQIP registry. Additional measures involved in flap reconstruction are associated with an increase in operation time and return to OR rate but not postoperative complications, morbidity, and mortality. 
 

75.10 Impact of Hospital Case Volume of Robotic-assisted Laparoscopic Prostatectomy on Patient Safety

Posted on December 22, 2014

T. L. Kindel1, D. Lomelin1, J. Jolley1, C. Krause1, N. Bills1, D. Oleynikov1  1University Of Nebraska Medical Center,General Surgery,Omaha, NE, USA

Introduction:   Robotic-assisted laparoscopic prostatectomy (RALP) is the most commonly performed robotic-assisted surgical procedure in the USA.  Robotic-assisted surgeries have a shorter learning curve than laparoscopy due to enhanced range of motion, increased tactile feedback, and 3-D imaging. The learning curve for RALP has traditionally been described by operating time, intraoperative blood loss, conversion rate, or margin-negative specimens.  The number of cases to reach optimal performance varies by metric from 25 cases for technical proficiency to 200 cases for physician confidence.  This study examines the RALP learning curve by comparing the peri- and post-operative complication rate (PCR) with regard to institutional case volume over time.

Methods:  A retrospective, cross-sectional study was performed of the Healthcare and Utilization Project National Inpatient Sample (HCUP NIS) database from 2009-2011. The database was queried based on the concurrent ICD-9 codes for prostate cancer (185), radical prostatectomy (60.5) and laparoscopic robotic assistance (17.42).  PCR was defined by the 21 most common RALP surgical complications.  Hospital volume was calculated as the number of RALPs performed per year. Demographics and procedure data collected included patient age, co-morbidities, and length of stay. ANOVA was used to compare demographics and median tests investigated patient status (complicated, uncomplicated) by hospital volume and hospital volume by complications rates of ≤10%. Linear-by-linear association and regression analysis were conducted for trends.  Association, regression analysis, and hospital volume compared to complications rate of ≤10% excluded institutions with <10 cases/year and no complications. 

Results: 28,438 RALP surgeries were identified from 2009-2011 (2009, n=9,384; 2010, n=8,532; 2011, n=10,522).  Mean patient age was 61.48 years.  Length of stay did not change over time.  The mean number of pre-existing chronic conditions was lower in 2009 than in 2010 or 2011 (p<0.001). Despite this increase in patient co-morbidities,  RALP PCR for all hospitals, regardless of volume, decreased over time from 14% to 9.7% (r2=0.79, p<0.001).   The average PCR decreased with increasing hospital volume, plateauing at 10%.  Across years, an estimated hospital volume of ≥196 cases/year predicted a ≤10% PCR. The median institutional RALP volume achieving a ≤10% complication rate was 54 (IQR: 29-97) cases/year.  Hospitals with ≤10% PCR had a greater volume of surgeries than those with a PCR >10% (p<0.001).

Conclusion: ~~As hospital volume increases, PCR decreases and patient safety improves.  The average estimated PCR decreased over the study period with ≥196 cases/year predicting a ≤10% PCR.  The PCR plateaued at 10% with little predicted benefit of volumes ≥196 cases/year. This creates a novel, evidence-based benchmark to improve clinical outcomes for hospitals performing RALP.

 

75.11 A Multi-phase Surgical Checklist Requires a Multi-phased Approach

Posted on December 22, 2014

L. Putnam1,4,5, S. Sakhuja1,4,5, C. M. Chang1,4,5, J. M. Podolnick1,4,5, R. Jain2,5, M. Matuszczak2,5, N. Wadhwa2,5, M. T. Austin1,4,5, L. S. Kao4,6, K. P. Lally1,4,5, K. Tsao1,4,5  5Children’s Memorial Hermann Hospital,Houston, TX, USA 6University Of Texas Health Science Center At Houston,Department Of General Surgery,Houston, TX, USA 1University Of Texas Health Science Center At Houston,Department Of Pediatric Surgery,Houston, TX, USA 2University Of Texas Health Science Center At Houston,Department Of Pediatric Anesthesia,Houston, TX, USA 3University Of Texas Health Science Center At Houston,Medical School,Houston, TX, USA 4Center For Surgical Trials And Evidence-based Practice,Houston, TX, USA

Introduction:

The World Health Organization has promoted utilization of the surgical safety checklist (SSC) as a 3-phase communication tool: pre-induction, pre-incision, and operative debriefing. With the introduction of our pediatric SSC, we demonstrated significant improvement in adherence to the pre-incision phase through a multi-year, multifaceted intervention program directed at stakeholder education, process standardization, and iterative feedback during each phase. Similar efforts were not directed at the pre-induction and operative debriefing components of the SSC.  We hypothesized that adherence to the pre-induction and operative debriefing components would be significantly less than to the pre-incision phase of the SSC.

Methods:

From June to August 2014, a direct observational study was conducted during which trained observers within pediatric operating rooms documented completion of checkpoints within all three phases: 11 pre-induction, 14 pre-incision, and 11 debriefing checkpoints. Adherence was defined as verbal confirmation of each checkpoint. Kruskal-Wallis and chi-squared analysis was performed; p-values <0.05 were considered significant.

Results:

224 pre-induction, 247 pre-incision, and 259 debriefing phases of the checklist were observed, including 201 cases in which all three phases were observed. Adherence to the pre-incision phase was consistently high and similar to the previous year (98% and 96%, respectively). However, the pre-induction and operative debriefing phases were significantly worse (Figure). Checkpoint adherence ranged from 9-88% (pre-induction), 93-100% (pre-incision), and 45-88% (debriefing). The lowest checkpoint adherence for both the pre-induction and the debriefing phases was for the announcement of the checklist/debrief (4% and 43%, respectively). The highest checkpoint adherence during the pre-induction phase was noted for verification of surgical and anesthesia consents (88%) whereas confirmation of the procedure and site (86%) had the highest checkpoint adherence during the debriefing.

Conclusions:

Multifaceted interventions have significantly improved adherence to the pre-incision portion of the SSC, yet the pre-induction and debriefing phases of the checklist remain suboptimal. From our previous experience, this lack of adherence may stem from lack of education, process standardization, and performance feedback. Applying similarly targeted interventions towards the pre-induction and debriefing phases of the checklist is required to improve adherence and optimize the benefits of the SSC.

75.12 Surgical Safety Checklist Fidelity: Are We Doing What We Should?

Posted on December 22, 2014

L. R. Putnam1,4,6, C. M. Chang1,4,6, J. M. Podolnick1,4,6, S. Sakhuja1,4,6, R. Jain2,6, M. Matuszczak2,6, M. T. Austin1,4,6, L. S. Kao4,5, K. P. Lally1,4,6, K. Tsao2,4,6  6Children’s Memorial Hermann Hospital,Houston, TX, USA 1University Of Texas Health Science Center At Houston,Department Of Pediatric Surgery,Houston, TX, USA 2University Of Texas Health Science Center At Houston,Department Of Pediatric Anesthesia,Houston, TX, USA 3University Of Texas Health Science Center At Houston,Medical School,Houston, TX, USA 4Center For Surgical Trials And Evidence-based Practice,Houston, TEXAS, USA 5University Of Texas Health Science Center At Houston,Department Of General Surgery,Houston, TX, USA

Introduction:

Consistent and meaningful completion of surgical safety checklists (SSC) has not been widely documented, but it has been shown to require ongoing educational efforts. Adherence to all the checkpoints does not mean they are being completed as they are intended to be (high fidelity). We hypothesized that adherence to the SSC would be significantly higher than actual fidelity within our operating rooms despite our ongoing educational efforts.

Methods:

From June to August 2014, trained observers within pediatric operating rooms documented the completion of 14 pre-incisional checklist checkpoints. The verbal completion of each checkpoint was noted as adherence whereas the correct completion of each checkpoint as defined a priori was noted as fidelity. Fidelity was measured for 7 of the 14 checkpoints as these 7 could be reliably measured and represented enhanced SSC tasks. The fidelity checkpoints included: all personnel quiet and attentive, team member identification, anesthesia induction concerns, prophylactic antibiotics, all equipment available, site marking verification, and essential imaging for surgical sites involving laterality. Chi-square and Student’s t-test were utilized; p-values <0.05 were considered significant.

Results:

247 pre-incisional checklists were observed during the study period. Adherence to all 7 checkpoints was significantly higher than fidelity (97% vs 86%, p<0.01), with checkpoint adherence ranging from 94-100% and checkpoint fidelity from 66-96%. The checkpoint with the highest adherence was team member identification (100%) and with the highest fidelity was anesthesia induction concerns (98%). Imaging for lateral cases had the lowest adherence (94%) and all quiet during the timeout had the lowest fidelity (66%). Adherence was significantly higher than fidelity for each of the 7 checkpoints except for anesthesia induction concerns and essential imaging for lateral cases (Figure).

Conclusion:

Despite nearly 100% adherence to the pre-incisional phase of the SSC within our institution, the fidelity with which it is completed remains suboptimal. Completion of checkpoints does not always reflect purposeful execution. In order to achieve optimal effectiveness, SSC performance should be monitored for adherence to all checkpoints as well as for meaningful intent. 

75.13 Educational and Team-Building Interventions are Necessary but Insufficient to Change Safety Culture

Posted on December 22, 2014

L. R. Putnam1,5,6, Z. M. Alawadi2,5, R. Jain3,6, M. Matuszczak3,6, L. S. Kao2,5, J. M. Etchegaray4, E. J. Thomas4,5, K. P. Lally3,5,6, K. Tsao1,5,6  6Children’s Memorial Hermann Hospital,Houston, TX, USA 1University Of Texas Health Science Center At Houston,Department Of Pediatric Surgery,Houston, TX, USA 2University Of Texas Health Science Center At Houston,Department Of General Surgery,Houston, TX, USA 3University Of Texas Health Science Center At Houston,Department Of Pediatric Anesthesia,Houston, TX, USA 4University Of Texas Health Science Center At Houston,Department Of Internal Medicine,Houston, TX, USA 5Center For Surgical Trials And Evidence-based Practice,Houston, TX, USA

Introduction

A healthcare institution’s commitment to safety practices can be measured through its safety culture. In 2011, we identified and targeted four domains of our perioperative safety culture for implementation of a multifaceted safety program. We hypothesized that ongoing physician-led educational and team-building activities would continue to improve all domains of our perioperative safety culture in our children’s hospital.

Methods

Pediatric perioperative personnel involved in direct patient care (nurses, scrub techs, anesthesiologists, surgeons) were administered the psychometrically validated Safety Attitudes Questionnaire (SAQ) before and after each 18-month interventional period (baseline, phase 1, phase 2). The 26-question SAQ evaluated 4 domains: safety culture, teamwork, speaking up, and safety rounds. Interventions involved administrative reorganization focused on safety and physician-led educational safety workshops throughout the entire study period in response to baseline findings. Based on the ongoing deficiencies noted at phase 1, additional interventions were implemented that targeted leadership safety rounds and real-time variance reporting. Data are presented as the percent of respondents who slightly or strongly agreed; 80% agreement represents high safety culture. Chi-square analysis was performed.

Results

The SAQ was completed by 48 (39%), 97 (79%), and 63 (75%) pediatric perioperative personnel at baseline, phase 1, and phase 2, respectively. All four domains remain improved or sustained from baseline, but only safety rounds improved from phase 1 to phase 2 (Table). The greatest improvement was in safety rounds, which improved to 43% over the study period, yet it was still the lowest scoring domain. Teamwork remained the highest scoring domain throughout. None of the domains reached the 80% threshold for high safety culture.

Conclusion

Institutional safety culture, as measured by a validated tool, varies over time and is difficult to change despite ongoing, multifaceted strategies targeting specific areas for improvement. Repeated measurements and iterative changes are necessary to sustain and improve safety culture. However, multiple interventions and change cycles are likely needed to achieve the desired results.

75.14 Fundoplications: Highest Rates of Retained Foreign Bodies in Pediatric Abdominal Surgery.

Posted on December 22, 2014

J. Tashiro1, E. A. Perez1, H. L. Neville1, A. R. Hogan1, J. E. Sola1  1University Of Miami,Division Of Pediatric Surgery, DeWitt Daughtry Family Department Of Surgery,Miami, FL, USA

Introduction: Retained foreign bodies (RFB) are a preventable, yet significant source of morbidity and resource utilization in all surgical subspecialties. In 2008, the World Health Organization introduced “Guidelines for Safe Surgery” (WHO/GSS). We sought to examine rates of RFB in children undergoing abdominal surgical procedures.

Methods: The Kids’ Inpatient Database was used to identify cases of RFB using ICD-9-CM codes in children <18 years of age between 1997 and 2009. Cases were further narrowed to abdominal procedures using 549.2 (removal of foreign body from peritoneum). Analyses were performed using standard statistical methods. Cases were weighted to project nationally representative results.

Results: Overall, 107 cases of RFB were identified. Mean age of the cohort was 9.94±6.35 years of age. Average length of stay and total charges were 11.0±11.4 days and 68,502.77±81,365.61 USD, respectively. Rates of RFB have decreased steadily between 2003-2009 (0.09-0.06 per 1,000 abdominal procedures). A comparison of pre-WHO/GSS vs. post-WHO/GSS did not demonstrate a difference in rate of RFB. Fundoplications had the highest rates of RFB (5.97 per 1,000 procedures), followed by gastric procedures (1.31), laparotomy (1.23), bile duct procedures (0.81), lysis of adhesions (0.80), and abdominal wall repair (0.42).

Conclusion: RFB rates have decreased steadily since 2003-2009; however, RFB rates do not demonstrate a difference after WHO/GSS implementation. Higher rates of RFB are associated with fundoplications and other gastric procedures. RFB continue to be an ongoing issue in pediatric surgery that requires further investigation.

75.15 Decreased Traumatic Brain Injury Severity After Improvements in Vehicle Safety Regulations.

Posted on December 22, 2014

B. W. Bonds1,2, M. J. Bradley3,4, S. S. Cai2, D. M. Stein1,2  3Naval Medical Research Center,Regenerative Medicine,Silver Spring, MD, USA 4Walter Reed Army Medical Center,Washington, DC, USA 1R Adams Cowley Shock Trauma Center,Trauma Surgery,Baltimore, MD, USA 2University Of Maryland,School Of Medicine,Baltimore, MD, USA

Introduction:  Motor vehicle collisions (MVC) are one of the main mechanisms for traumatic brain injury (TBI) in the United States.  In 2009, regulations modifying side impact crash testing from the National Highway Traffic Safety Administration were announced which effectively mandated the inclusion of side impact airbags on all vehicles as well as structural reinforcements aimed at minimizing sidewall intrusion.  We sought to determine any effect these changes have had on the mortality, frequency and severity of TBI following MVC. 

Methods:  Data was retrospectively collected over ten years (2004-2013) on all patients admitted to a level one trauma center with a TBI following MVC. Patients were reviewed for severity of brain injury, post-resuscitation Glasgow Coma Scale (GCS), and mortality.  The incidence of mild (GCS 13-15), moderate (GCS 9-12), and severe TBI (GCS ≤ 8) was calculated five years before (2004-08) and after (2009-13) the new regulations with a p-value < 0.05 considered significant.

Results: Over ten years, 2144 patients were admitted with a TBI secondary to a MVC. There were no significant demographic differences between patients admitted before or after 2009 (Age 39.67 vs 41.15 p = 0.086, Male 61.75% vs 64.07% p = 0.286, ISS 28.85 vs 28.87  p = 0.979, Brain AIS 3.76 vs 3.81 p = 0.119). While incidence of TBI from all causes increased by 15.59% since 2009, MVC as the mechanism of injury leading to hospital admission has declined by 4.70% (25.11% vs 20.41%, p < 0.0001). Severity of head injury also shifted with a reduction in the proportion of severe TBI (42.18% vs 37.09%, p = 0.0343) and an expansion of mild-moderate TBI (3.61% and 1.48% increase respectively).  Early mortality (< 24 hrs of admission) decreased from 51.02% to 33.09% (p = 0.0034), while overall mortality was unchanged (Table 1). 

Conclusion: Further work is needed to show a causal relationship, but since the widespread implementation of improved vehicle safety regulations there has been a significant reduction in severe TBI and proportionately higher rates of mild-moderate TBI after MVC. While overall mortality in this study was unchanged following 2009, those patients critically injured showed a significant improvement in early mortality. 

 

75.16 Communication At The Interface Of Surgery & Critical Care: Finding Ways To Enhance Patient Safety

Posted on December 22, 2014

L. Gotlib Conn1, B. Haas3, B. H. Cuthbertson1,4, A. Amaral1,4, N. Coburn2,5, S. Goddard4, L. Nusdorfer4, A. B. Nathens1,2  1Sunnybrook Research Institute,Evaluative Clinical Sciences/Trauma, Emergency And Critical Care Research Program,Toronto, ONTARIO, Canada 2Sunnybrook Health Sciences Centre,Surgery,Toronto, ONTARIO, Canada 3University of Toronto,Critical Care Medicine,Toronto, Ontario, Canada 4Sunnybrook Health Sciences Centre,Critical Care Medicine,Toronto, ONTARIO, Canada 5Sunnybrook Research Institute,Odette Cancer Research Program,Toronto, ONTARIO, Canada

Introduction:
Ineffective communication between providers in the ICU is associated with a higher rate of errors and harmful effects on provider and patient family relations. Improving communication across providers may significantly enhance patient safety and improve provider-family interactions. To identify opportunities for improvement, we explored communication behaviors and practices between surgical and critical care teams treating trauma/surgical patients in a closed ICU.

Methods:
We conducted a qualitative ethnographic study of communication practices and behaviors of trauma, general surgery, neurosurgery and critical care teams in 3 academic ICUs, totaling 50 hours of observation. Additional data were derived from focused interviews (n=46) with surgeons, intensivists, surgical residents, intensive care fellows and ICU nurses. Data were collected and analyzed iteratively to the point of theoretical saturation.

Results:

Observed communication between surgical and ICU teams focused on negotiating contested boundaries of expertise, patient ownership, and decisional authority. Participants described features of effective communication involving successful negotiation of these boundaries leading to collaborative patient care. Ineffective communication involved poor boundary negotiation leading  to provider frustration and inter-team conflict (figure). Several discrete communication behaviors and practices between surgical and critical care teams were identified; specific behaviors and practices were closely associated with either enhanced or suboptimal communication across teams. In addition, multiple structures and processes of care currently in place were identified as barriers to effective communication between teams, creating delays and gaps in information transfer impacting the quality of patient care. 

Conclusion:

Opportunities exist to improve collaborative communication between surgery and critical care teams.  In addition to targeting specific structures and processes of care, interventions aimed to elucidate competing cultures of care, strengthen provider relationships, and mitigate negative behaviors should be evaluated to address interdisciplinary collaboration with a view to enhancing surgical patient safety in the closed ICU.
 

75.17 Resident and Fellow Surgeons in Thyroid Operations: Does Level of Training Affect Patient Outcomes?

Posted on December 22, 2014

T. M. Madkhali1, M. Rajaie1, H. Chen1, R. S. Sippel1, D. Elfenbein1  1University Of Wisconsin,Endocrine Surgery,Madison, WI, USA

Introduction: Several studies have examined the association of surgical trainee’s involvement in surgical procedures and patient outcomes. While some studies suggest that involvement of residents is associated with longer operative times and more complications, others are contradictory. Data are limited that compare patient outcomes based on involvement of a fellow – someone who has already completed a surgical residency, compared to involvement of a resident. We sought to compare the influence of residents and fellows participating in thyroid operations and determine if there was any difference in patient outcomes.
 

Methods: A retrospective study was performed using our endocrine surgery database between July 2010 and Dec 2013. July 1, 2010 was the starting date of the first endocrine surgery fellow at our hospital. Patients who underwent total thyroidectomy, subtotal thyroidectomy, lobectomy with or without lymph node dissection by endocrine surgeons were included. Patients were grouped by whether the first assistant in the operation was a resident or fellow. Outcomes examined included operative time and perioperative complications. Student t-test and chi-square analysis were used for continuous and categorical variable as appropriate.

 

Results: A total of 798 patients met inclusion criteria: 416 (52%) had a surgical resident assistant and 382 (48%) had a fellow assistant. Fellows were more often involved in complex cases which included completion thyroidectomy and lymph node dissection (70% vs 30%, P = 0.01). Resident or fellow participation were associated with similar numbers of perioperative complications including hypoparathyroidism and nerve injury (P > 0.05).   Both operative time and operating room preparation time did not show any significant differences whether the assistant was a resident or fellow (P > 0.05).

 

Conclusion: Endocrine surgery fellows are more likely to be involved in more complex thyroidectomy cases than general surgery residents.  Having a resident or fellow does not seem to be associated with any differences in outcomes for patients. Furthermore, involvement of fellows is not associated with faster operative times.

 

75.18 Streptococcal Pharyngitis and Appendicitis in Children

Posted on December 22, 2014

J. W. Nielsen1, V. Pepper1, B. D. Kenney1  1Nationwide Children’s Hospital,Pediatric Surgery,Columbus, OH, USA

Introduction: Appendicitis is a common surgical disease in children.  Several other pathologies can mimic appendicitis in children including mesenteric adenitis which has been associated with pharyngitis.  We sought to further understand the link between appendicitis-like symptoms and another common childhood disease, streptococcal (strep) pharyngitis.

Methods: All patients undergoing ultrasound imaging for appendicitis in our emergency department during 2013 were reviewed (n=1572).  A total of 207 patients were identified who underwent both ultrasound for appendicitis and testing for strep pharyngitis (rapid strep test with reflex PCR test if negative).  Demographic and outcomes data between rule out appendicitis patients who underwent strep testing and those who did not were compared.  Chi- square and Fisher's exact tests were performed on categorical variables and T-tests were used for continuous variables with p<0.05 being considered significant.

Results:  Strep testing was more common in younger patients (mean age=8.26 years vs. 10.26 years p<0.001) and evenly matched by gender (104 male, 103 female). Of the 207 patients tested for strep pharyngitis only 8 patients had appendicitis and only 35  (16.9%) patients tested positive for strep pharyngitis.  There were no patients identified who tested positive for both strep pharyngitis and had appendicitis.  Five negative appendectomies were performed in the strep pharyngitis tested group for a negative appendectomy rate of (5/13) 38.5%, compared to 7.7% (23/296) (p=0.003) in the non-test group. Two of the patients with negative appendectomies in the strep testing group had positive strep tests and the remaining 3 were negative.  The appendicitis rate among the strep testing group was lower at 3.8% (8/207) compared to 20% (273/1365) in the non-tested group (p<0.001).

Conclusions: Patients undergoing testing for strep pharyngitis were more likely to be young.  Strep testing was also associated with much lower rates of appendicitis and higher negative appendectomy rates.  No patients undergoing strep testing were positive for both appendicitis and strep pharyngitis.  In cases where patients have sufficient symptoms to warrant testing for strep pharyngitis a diagnosis of appendicitis is less likely. The low rates of positive strep tests and appendicitis suggest that patients with abdominal pain and symptoms of pharyngitis most likely have a viral illness that in most cases does not warrant additional testing.  Prudence must be exercised to correctly diagnose pathology and to avoid unnecessary testing.

75.19 Fluorescence-based Methodology for Measuring Drug Accumulation in Normal Tissue Versus Tumor

Posted on December 22, 2014

J. Fletcher1, J. Warram1, Y. Hartman1, E. De Boer1, E. Rosenthal1  1University Of Alabama School Of Medicine,Otolaryngology,Birmingham, ALABAMA, USA

Introduction:  Fluorescent-based techniques are being introduced to guide surgical excision of cancer.  Antibodies can be covalently conjugated to near-infrared (NIR) dyes to permit real-time, optical localization of cancer in the surgical setting. Successful antibody-dye combinations are not identified by total tumor accumulation, but by the greatest difference between tumor and normal tissue. While this strategy has the potential to achieve complete resection, the accurate characterization of study drugs is essential to understanding binding kinetics of antibody-NIR dye candidates for this technique. 

Methods:  Using tissues obtained from a dose-escalation clinical trial assessing the safety of cetuximab conjugated to a NIR dye (cetuximab-IRDYe800) in patients with head and neck cancer, a novel methodology was explored to normalize for optical-based attenuation to accurately quantify drug uptake within tissues. Tumor and muscle (n=4) specimens were systematically homogenized and a SDS-PAGE assay was performed on cell lysate (40ug) from each sample. In addition, a serial dilution (0.02ug-0.1ng) of cetuximab-IRDye800 was run on a separate gel to serve as a standard. Using a specialized NIR fluorescent scanner designed to image IRDye800 (Odyssey, LICOR, Lincoln, NE), the gels were imaged and mean fluorescent intensity (MFI) from cetuximab-IRDye800 (150kd) bands were quantified in tumor and patient-matched muscle. MFI were compared to the standard curve to determine percentage of cetuximab-IRDye800 injected dose per gram of tissue (%ID/g).

Results: In the lowest cetuximab-IRDye800 dose group, average %ID/g for tumor (2.8×10-6 MFI) was found to be 8-fold greater than %ID/g for muscle (3.5×10-7 MFI). In the higher dose group (2.5-fold dose increase), average %ID/g for tumor (3.2×10-6 MFI) was found to be 3-fold greater than %ID/g for muscle (1.0×10-6 MFI).

Conclusion: Using this technique, the lower cetuximab-IRDye800 dose was shown to be optimal to provide the greatest difference between tumor and muscle tissue. 

 

75.20 The Effect of ERAS in Elective Hip and Knee Arthroplasty

Posted on December 22, 2014

M. Stowers1,2, D. Lemanu1,4, B. Coleman2, A. Hill1, J. Munro1,4  1University Of Auckland,Department Of Surgery,Auckland, -, New Zealand 2Middlemore Hospital,Department Of Orthopaedic Surgery,Auckland, , New Zealand 3University Of Auckland,Auckland Medical School,Auckland, , New Zealand 4Auckland City Hospital,Department Of Orthopaedic Surgery,Auckland, , New Zealand

Introduction: Hip and knee arthroplasty induce significant physiological stress. ERAS has been shown to improve patient outcomes in a range of surgical settings through attenuation of this stress response. A prospective study aiming to hasten recovery and improve patient outcomes in hip and knee arthroplasty was undertaken.

Methods: Patients undergoing elective primary hip or knee replacement surgery at our hospital were consecutively recruited after implementation of our ERAS protocol. Primary outcome was length of stay (LOS) and secondary outcomes included 30-day complications, readmission rates and cost. This study was powered to detect a reduction in LOS of 1 day. These patients were compared to a retrospective cohort.

Results: There were 204 patients who met eligibility criteria (104 ERAS, 100 control). With the exception of ERAS patients having a slightly higher BMI (p<0.05) than the control group all baseline characteristics were similar. Post implementation of ERAS, median LOS was reduced by 1 day (5 control vs 4 ERAS; p<0.001). Short-term complications were similar (p=0.372), as were readmission rates in 30 days (p=0.258). Cost analysis identified ERAS patients to have reduced cost overall.

Conclusion: ERAS in hip and knee arthroplasty has been shown to be safe, effective in improving recovery through shorter day stay and cost effective.

 

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