76.01 Factors Affecting General Surgery Resident Satisfaction On Cardiothoracic Rotations

Posted on December 22, 2014

A. Lussiez1, J. Bevins1, A. Plaska1, V. Rosin1, R. Reddy1  1University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA

Introduction:  Exposure to cardiothoracic (CT) surgery in general surgery training has decreased, requiring a more dedicated curriculum design for shorter rotations. We sought to assess the relationship between rotation satisfaction and length of rotation, mentorship and mistreatment.

Methods:  A survey was forwarded through 15 general surgery coordinators to residency alumni that graduated between 1999 and 2014 asking about their CT rotations during general surgery. Frequency distributions for categorical variables were examined to identify patterns, trends and characteristics among the graduate respondents. A Wilcoxon rank-sum test was used to assess statistical significance of ordinal level ratings of satisfaction and quality of mentorship to assess potential factors that could influence scores. Statistical significance was defined as p<0.05.

Results: 78 graduates responded. 76% (59) were men, and 78% (61) completed post surgery fellowship training. Adequate exposure to certain procedures during their rotation was associated with increased satisfaction. In particular, adequate exposure to thoracotomy incisions (p<0.001), empyemas (p=0.001), lung cancer care (p=0.001), mediastinal tumors and cysts (p=0.037), SVC (p=0.039) and minimally invasive chest surgery (p=0.002) improved rotation satisfaction. Respondents who reported good/very good mentorship were also more satisfied than those that reported neutral/poor/very poor mentorship (p<0.001). Reporting mistreatment was associated with decreased satisfaction (p=0.004) and associated with poorer mentorship (p<0.001) during the CT rotation. Length of rotation was not associated with improved levels of satisfaction nor was it associated with an improvement in the quality of mentorship.

Conclusion: Our results indicate that overall rotation satisfaction is positively associated with procedure exposure and mentorship, negatively associated with mistreatment and not associated with rotation length. We show that short rotations with focused clinical exposure and invested mentors can maximize resident satisfaction. These specific markers of rotation quality are useful in curricular design.

 

76.02 Improving the Night Float Experience

Posted on December 22, 2014

A. S. Weltz1, D. G. Harris1, C. M. Kariya1, N. O’neil1, A. Cimeno1, S. Kavic1  1University Of Maryland,General Surgery,Baltimore, MD, USA

Introduction:  Night float (NF) rotations are a common mechanism to provide hospital service coverage in compliance with the residency duty hour regulations.  Since implementation of the residency work-hour restrictions in 2003 and 2011 that were intended to reduce resident fatigue, NF has been widely adopted, but the effects of NF on surgical training are uncertain.  We surveyed general surgery residents to study the educational value of NF, and hypothesized that NF is detrimental to surgical education.  

Methods:  This was a voluntary quality improvement survey of categorical and preliminary residents in a general surgery residency program at a tertiary academic medical center.  Institutional NF experiences include four PGY-1 and two PGY-3 rotations.  The survey was performed at the end of the 2013 – 2014 academic year using an online instrument with a 5 point Likert format ranging from strongly disagree to strongly agree, plus questions with free-text responses.

Results: Of 54 residents, 28 (52%) responded to the survey.  The majority (82%) had been on at least 1 NF rotation, and 50% had at least 3 rotations.  While only 22% of residents enjoyed NF to any degree, 57% agreed or strongly agreed that NF has positive overall educational value, and 92% meet duty hour requirements during NF.  Additional, self-reported positive aspects included the opportunity for increased autonomy, ability to focus on clinical care and a more regular schedule.  However, only 15% reported adequate service/education balance, 11% had satisfactory evaluation of their admissions by a supervising resident or attending, and just 4% had adequate operative experience during NF.  Although intended to reduce fatigue, adequate rest and work/life balance were reported in only 36% and 18% of residents, respectively.

Conclusion: Night float facilitates surgical service coverage and duty hour compliance, and may provide an important opportunity for greater independent responsibility.  However, the educational value is limited by inadequate operative experience, service/training balance, and resident evaluation.  While some of these problems may be program and institution specific, these limitations likely reflect inherent difficulties in integrating NF rotations into the surgical curriculum.  If NF remains a practical necessity because of duty hour restrictions, these rotations need to be restructured with a formal didactic and clinical curriculum designed to enhance educational value.

 

76.04 General surgery resident self-censorship in recording duty hours: A qualitative study

Posted on December 22, 2014

M. J. Erlendson1, L. S. Lehmann4, F. G. Javier1, K. A. Davis2, M. R. Mercurio3, C. Thiessen2  1Yale University School Of Medicine,New Haven, CT, USA 2Yale University School Of Medicine,Department Of Surgery,New Haven, CT, USA 3Yale University School Of Medicine,Department Of Pediatrics,New Haven, CT, USA 4Brigham And Women’s Hospital,Department Of Medicine,Boston, MA, USA

Introduction: The impact of work hour regulations on curtailing residents’ duty hours remains unclear. Previous single-institution studies suggest that residents under-record their hours. To our knowledge, this is the first multi-center study to qualitatively evaluate resident accuracy in the self-reporting of duty hours.

Methods: This multicenter qualitative study utilized semi-structured half-hour interviews of randomly selected general surgery interns and chief residents at 13 US institutions. Phone interviews were recorded, transcribed, and de-identified. Qualitative analysis was conducted using standard major and minor coding protocol with Dedoose.

Results: Eight interns and 6 chief residents participated in this study; 6 were women and 8 were men. Thirteen house officers reported under-recording work hours; half began under-recording in the first month of internship. A majority reported under-recording an average of 5-10 hours weekly. Concern about jeopardizing program accreditation was the most commonly expressed reason for under-recording work hours (7/14). The importance of educational experience (5/14), not dumping work onto other residents (5/14), and patient care (5/14) were frequently described. Residents justified under-reporting by appealing to their autonomous decision to take on more work. For example, “I was taking care of a critically ill patient and I didn’t think that the team could handle it without me but I made that choice, so I take those hours off.” Other residents described expectations: “I see all my seniors working as hard as I do so I don’t feel comfortable asking for extra time off,” “We have a culture here…when you’re…on overnight you stay all the way through rounds in the morning.” Seven residents reported under-recording to fly below the radar: “I don’t need to bring any attention to myself on that front.” A few feared attendings’ responses to recorded violations: “We all take the same shortcuts in order to decrease retribution or attending or program director anger.” “[Publicly identifying residents who violated duty hour rules] degenerated into a venue for public shaming… to have everybody know that you’re the one who’s causing a problem and putting the program in jeopardy and you’re the one who’s gonna get yelled at.” Two residents reported that they were explicitly told to lie. “I think there’s a lot in surgery about being honest and telling the truth otherwise you’re an ineffective resident, you’re an ineffective doctor, and so I refused to lie until I was told to. So I told him if he wants me to lie, he has to tell me to lie, so he did.”

Conclusion: Most under-recording resulted from self-censorship mediated by internalization of professional norms and a desire to maximize educational opportunities; a minority feared external consequences. Understanding factors that influence resident recording will inform the development of policies that address the conflict inherent in resident self-reporting of hours.

76.05 Preparing Incoming Interns for Patient Handoffs: Is Training During Residency Too Little Too Late?

Posted on December 22, 2014

J. Peschman1, J. Paul1, T. Webb1, P. Redlich1  1Medical College Of Wisconsin,Division Of Surgical Education,Milwaukee, WI, USA

Introduction: With implementation of ACGME duty hour restrictions an increased reliance on night float systems and cross coverage has occurred. Therefore, developing methods for evaluating and improving an incoming intern’s ability to perform effective information transmission during patient handoffs is crucial to enhance patient safety. To this end, we have surveyed incoming interns since the new duty hour implementation about their handoff training during medical school and conducted dedicated handoff training sessions during our PGY-1 Protected Block Curriculum (PBC) prior to their start on July 1st.

Methods: Interns have completed surveys and training sessions since 2012. The formal handoff training sessions occurred prior to their start date and included assigned background reading, a didactic session, and a practical exercise. Direct assessment was conducted of each intern’s ability to correctly identify 3 key and essential points required for transmission during mock handoffs using standardized patient scenarios prior to and following the didactic session. Follow up surveys were completed at 2.5 months to evaluate their experiences with handoffs and handoff training.

Results: Over 3 years, 41 interns representing 25 medical schools participated. Interns reported only 28% of their medical schools provided formal handoff training. This rate increased from 15% to 56% from 2012 to 2014. Over 90% reported having observed or participated in handoffs on clinical rotations. Comparing the 2012, 2013 and 2014 classes, the average incoming comfort level with providing a handoff increased each year; 2.8±1.0 (SD), 3.4±0.9, 3.5±0.7 (1-5 scale 5=Very Comfortable). 89% of intern pairs transmitted and identified at least 2 of 3 key points during mock handoffs prior to the didactic session compared to 100% after the session. Comfort levels increased to 3.6±1.0, 3.7±0.8, and 4.0±0.0 following the training session over the three years. At 2.5 months follow up, 58% wished they had more training during medical school, 23% wanted additional training during the PBC, and 50% felt patient care had been jeopardized by poor handoffs in their recent clinical experience.

Conclusion: Changes to duty hours provide unique patient care challenges that require effective handoffs. Despite limited formal training prior to residency, most interns have enough baseline experience to perform reasonably well in mock patient handoffs. Dedicated teaching sessions just prior to residency only moderately improved resident comfort compared to medical school experiences. Most concerning, after less than 3 months of clinical experience, half of interns can identify instances where patient safety was jeopardized by poor handoffs possibly explaining why most wished they had more prior training. These results highlight the need for new efforts focused on enhanced handoff training in medical school that can be reinforced during residency.

 

76.06 Determining the Reliability of Evaluating Basic Technical Skills by Inexperienced Non-Physicians

Posted on December 22, 2014

S. Ahad1, M. Sheley2, B. Dyniewski2, C. J. Schwind2, M. L. Boehler2, I. Hassan1  1University Of Iowa,General Surgery,Iowa City, IA, USA 2Southern Illinois University School Of Medicine,Surgery,Springfield, IL, USA

Introduction: The phase 1 curriculum of the American College of Surgeons (ACS) and the Association of Program Directors in Surgery (APDS) includes eleven basic surgical skills training modules. After completing training, performances are intended to be scored by surgical faculty through direct observation or video-taping using the ACS/APDS verification of proficiency (VOP) checklist. We hypothesized that, if trained by an expert, an inexperienced non-physician could reliably evaluate these basic technical skills using the VOP checklist.

Methods: PGY1 resident videos from one-handed surface knot tying (n=24), simple interrupted suturing (n=17) and central line venous access (CVL) (n=18) were evaluated using the ACS/APDS VOP checklists by one expert and four inexperienced non-physicians (2 medical students and 2 clinical nurse instructors). Evaluations (n=295) were compared using chi-square, analysis of variance and intraclass correlation (ICC).

Results: We found near perfect inter-rater agreement for determining overall proficiency for suturing and CVL (ICC=0.96) (P<.001, 95%CI 0.79-0.99) and very good agreement for knot tying proficiency (ICC=0.76) (P<.001, 95%CI 0.48-0.86). Individual checklist items that showed agreement were objective in nature (i.e. hands crossed, accurate placement of suture, appropriate site for venipuncture) (ICC range from 0.64-0.96). While individual items that required judgment and interpretation of quality (e.g. smooth transition between knots, appropriate tension, economy of motion) had little to no inter-rater agreement (ICC range -0.06-0.18).

Conclusion: With training, inexperienced non-physicians can adequately determine overall global proficiency but they may lack necessary experience to recognize some of the more subjective items measuring proficiency on the ACS/APDS VOP checklists.

 

76.07 Research Training During Residency May Cost General Surgeons at Least 6.3% of Lifetime Wealth

Posted on December 22, 2014

Z. C. Dietch1,2, S. E. Bodily2, B. Schirmer1, R. Sawyer1  1University Of Virginia,Department Of Surgery,Charlottesville, VA, USA 2University Of Virginia,Darden School Of Business,Charlottesville, VA, USA

Introduction: Two years of dedicated time for research (DTR) has been a fixture of traditional academic general surgery training programs. However, concerns with the current format for general surgery training and the declining availability of research funding have prompted debate about the appropriate role of DTR during residency. In particular, longer training raises costs to residents, who forgo the earning potential of attending surgeons by extending the duration of training. We hypothesized that DTR during surgical residency represents a large opportunity cost for a general surgeon’s total expected lifetime wealth (ELW).

Methods: A pro-forma financial model for a general surgeon’s ELW was developed to simulate annual earnings from age 18 through 65, accounting for the costs of undergraduate education, medical school, earnings during residency, earnings following training, pre-tax and after-tax savings, and taxes. Expected annual inflation and annual returns on investment were accounted for using mean-reverting models developed with historic inflation and market performance data. Monte Carlo simulation was performed using Crystal Ball (Oracle, Fusion Edition) to conduct 10,000 trials per scenario. Base-case and alternative scenarios were constructed to model the effects of five-year (FY) and seven-year (SY) training programs on ELW. Sensitivity analysis determined that the incremental difference in ELW was sensitive to real wage growth and ELW were assessed under different scenarios of annual real wage growth.

Results: In the FY model with 0% annual real wage growth, mean ELW totaled $11.52 million after adjusting for inflation. In the SY model, mean ELW was reduced by $728,768 (95% CI $(2,197,154)-$(310,617)) to $10.79 million, representing a reduction of 6.33% of ELW. Sensitivity analyses demonstrate that negative real wage growth increases the relative opportunity cost of dedicated research time (Table).

Conclusion: Trainees who extend surgical training to complete dedicated time for research may incur a significant opportunity cost and reduction in ELW. The percentage magnitude of this cost is exacerbated by real wage decline. Medical students and surgical trainees should understand the financial sacrifices associated with SY versus FY training. Given the financial implications of DTR, trainees would be best served by utilizing DTR only when it directly supports career aspirations, such as a career in academic surgery. Residency program leadership and surgical training governing organizations should consider structural reforms to training programs to ensure that the timing and nature of DTR better align with the career goals of individual trainees.

76.09 Recent Trends In Medical Student Career Choices: Is The Affordable Care Act in Jeopardy?

Posted on December 22, 2014

L. Liao1, K. Sirinek1, K. Sirinek1  1University Of Texas Health Science Center At San Antonio,San Antonio, TX, USA

Introduction: Recently, U.S. medical student career choices have changed.  Several studies have implicated student loan debt powering a shift to more financially lucrative specialties following graduation from medical school. This study evaluated a two-decade trend of career choices by 3,660 medical students at one allopathic School of Medicine (SOM) and the 2012 NRMP data for 15,712 U.S. medical school graduates.

Methods: The data were obtained from the SOM reports for students in the NRMP match for twenty years and the 2012 NRMP results for the country.  For the SOM, the second decade results were compared to the first decade and then to the 2012 NRMP data for the country.  Results were analyzed by Chi Square (P<0.05).

Results:Compared to the first decade, the percentage of students matching for the second decade had increased but not significantly for General Surgery (5.3 to 6.6%), Surgical Specialties (7.6 to 9.1%).  Obstetrics/Gynecology (6.5 to 8.0%) Pediatrics (12.1 to 13.6%), and Diagnostic Radiology (3.2 to 4.2%).  The number of students pursuing Primary Care (Family Medicine, Internal Medicine, OB/GYN, Pediatrics) decreased significantly (13.7%) Table.  Family Medicine accounted for most of the Primary Care decrease (22.1 to 9.1) P<0.001, while Internal Medicine also decreased (22.3 to 18.6%) P<0.01.  Students matching to hospital based residencies increased (P<0.001), mainly secondary to increases in Anesthesia (7.0 to 10.7%) and Emergency Medicine (3.9 to 5.5%) (P<0.001). The last decade career choices at this School of Medicine mirror the 2012 national match statistics of 15,712 United States medical school graduates for each and every specialty (P=NS).

Conclusion:The increased appeal of a career in both Anesthesia and Emergency Medicine may reflect life-style issues as well as financial considerations.  If the trend away from primary care by U.S. medical school graduates had been purely financial, a greater shift to Surgery should have been seen.  Instead, General Surgery only increased 1.3% while the Surgical Specialties only increased 1.5%.  To stay on par with the 20yr U.S. population growth (25%), the percentage of U.S. medical graduates pursing general surgery should have increased from 6.0% to 7.5%.  The shortage of both primary care physicians and general surgeons with an increasing, aging U.S. population will adversely impact health care, potentially crippling implementation of the Affordable Care Act.  Financial incentives to entice students to pursue these two specialties are urgently needed to avert this potential physician/surgeon manpower catastrophe.

 

76.10 Relationship of a Second Professional Degree to Research Productivity of General Surgery Residents

Posted on December 22, 2014

P. M. Shah1, B. L. Edwards1, Z. Dietch1, R. G. Sawyer1, A. T. Schroen1  1University Of Virginia,General Surgery,Charlottesville, VA, USA

Introduction: Many general surgery residents interrupt clinical training for research pursuits.  After the inception of the Masters in Clinical Research (MS-CR) and Masters of Public Health (MPH) degree programs at our affiliated university in 1997 and 2003, respectively, an increasing number of residents are obtaining these degrees during dedicated research time (DRT).   In an era of decreasing research funding, we aim to determine whether attaining an additional degree during DRT impacts research productivity.  We hypothesize that time required to obtain a second degree during DRT decreases resident publication productivity.

Methods: All consecutive categorical general surgery residents from cohorts graduating in 2007 – 2015 were evaluated, which includes all our residents obtaining a second degree during DRT.  Pubmed queries identified number of journal publications for each resident during and after DRT, limited to one-year post residency graduation.   Residents without DRT and those with advanced degrees prior to residency were excluded.  DRT varied between 1 and 3 years, typically between clinical years II and III.  To standardize DRT variation, publication number was divided by the total sum of DRT plus remaining clinical years and one post graduation year. Median publications were compared between residents by receipt of a second degree.  

Results:Of 38 residents with DRT in the study period, 2 residents already had advanced degrees, leaving 36 eligible for analysis.  Of these, 8 obtained an MS-CR, 3 received MPH degrees and 1 completed a Ph.D. Total publications ranged from 2-76 for residents earning second degrees and 1-38 for residents who did not.  Of 12 residents completing degree programs, median publication number per year (any authorship) was 3.57 (IQR 2.33, 5.33) compared to 2.55 (IQR 1.58, 3.47) in residents not pursuing a postdoctoral degree (p=0.06). There was no significant difference in median number of 1st and 2nd author publications by receipt of second degree (Table 1).   

Conclusion:Although a trend towards greater number of publications was seen among residents earning a second degree, there was no statistically significant difference in research productivity between residents obtaining postdoctoral degrees during DRT compared to their counterparts.  Our study demonstrates that residents pursuing a second degree are not hindered in their publication productivity despite the time investment required by the degree program. Additional research is needed to determine if formal research training through a second degree corresponds to sustained scholarly productivity beyond residency.

74.11 Acute Cholecystitis in Octogenarians: Determinants of Readmission and Inpatient Outcomes

Posted on December 22, 2014

A. Kothari1,2, M. Zapf1, J. Driver1, T. Markossian2, P. Kuo1  1Loyola University Chicago Stritch School Of Medicine,Surgery,Maywood, IL, USA 2Loyola University Chicago Stritch School Of Medicine,Public Health Sciences,Maywood, IL, USA

Introduction: The management of acute cholecystitis in octogenarians represents a unique challenge. We sought to determine if patient-level characteristics could be used to develop a tool to predict 30-day readmissions, non-operative management (cholecystostomy), and surgical complications.

Methods: We queried the Healthcare Cost and Utilization Project (HCUP) Florida State Inpatient Database (2009-2011) to define our population of interest. Included were all patients ≥80 years old presenting with acute cholecystitis. Excluded were patients with complicated cholecystitis, acalculus cholecystitis, and common bile duct obstruction. Patient factors included: age, co-morbidities, conditions present on admission, nutrition status, and point of origin. Outcomes of interest included: 30 day re-admission, length of stay, post-operative complications, cost, and timing of surgery.

Results:A total of 36,769 patients presented with acute cholecystitis from 2009-2011. Patients ≥ 80 years old (3,579/36,769) defined our study population. When compared to patients ≤65 years old (n=24,693), octogenarians had a higher rate of 30-day readmission (14.5% vs 6.4%, p<0.0001), were less likely to undergo surgical intervention (70.7% vs 91.8%, p<0.0001), and had more major surgical complications (5.8% vs 2.6%, p<0.0001). In the octogenarian sub-population, chronic anemia (OR 1.31, [1.06,1.61]*) and coronary artery disease (OR 1.24, [1.02,1.51]*) were independent predictors for readmission within 30 days. Independent factors predicting against cholecystectomy included CHF (OR 0.65, [0.54,0.78]*), PVD (OR 0.66, [0.0.52,0.84]*), acute kidney injury (OR 0.50, [0.39,0.64]*), and sepsis on presentation (OR 0.58, [0.45,0.73]*). Factors predicting major surgical complications included congestive heart failure (OR 1.76, [1.14,2.69]*), electrolyte abnormalities (OR 2.49, [1.65,3.77]*), renal failure (OR 1.75, [1.13, 2.72)*], and weight loss <10 lbs (OR 6.91, [3.62, 13.15]*). *=95% C.I.

Conclusion:Understanding the factors influencing the inpatient course of octogenarians presenting with acute cholecystitis offers areas for intervention with the goal of improving outcomes. Developing a prediction tool based on this data may reduce readmissions and guide clinical decision-making. 

 

74.12 Postoperative Complications Predict 30-Day Readmission in Elderly General Surgery Patients

Posted on December 22, 2014

J. D. Dieterich1, C. Divino1  1Mount Sinai School Of Medicine,Divison Of General Surgery, Department Of Surgery,New York, NY, USA

Introduction:  

Since the enactment of the Affordable Care Act, unplanned patient readmissions have become increasingly scrutinized. Readmissions place a large economic burden on hospitals and negatively impact the quality of life for patients. Elderly patients, in particular, suffer a disproportionate amount of complications from any kind of hospitalization, including readmissions. This study seeks to identify risk factors in this population that predispose them to an unplanned readmission within 30 days following index surgery.

Methods:  The National Surgical Quality Improvement Program (NSQIP) database was used to select patients 65 and older, who underwent general surgery procedures in 2012. Patient demographics, comorbidities, complications, and readmissions were analyzed. NSQIP measures 30-day readmissions starting from the date of surgery. However, Medicare tracks readmissions 30 days after hospital discharge. To compensate for the variable patient length of stay, a Cox regression survivorship model was employed for multivariate analysis. 

Results: Nine thousand four hundred and eighty three patients were reviewed. Seven hundred and seventy (7.8%) had an unplanned readmission within 30 days of their operation. Cox regression revealed five different independent predictors of unplanned readmission within 30 days. They are: any postoperative complication (p<0.001, 1.34 Hazard Ratio (HR), 1.16-1.68 95% Confidence Interval (CI)), operation time (p=0.004, 1.001 HR, 1.000-1.002 95% CI), age (p=0.01, 1.02 HR, 1.01-1.03 95% CI), esophageal varices (p=0.013, 12.12 HR, 1.68-87.30 95% CI), and CNS tumor (p=0.004, 20.86 HR, 2.67-163.28 95% CI).

Conclusion: Using Cox regression to adjust for patient length of stay, any complication, age, esophageal varices, CNS tumors, and operation time all independently increased the rate of unplanned readmissions. These results may urge providers to monitor or retain elderly surgery patients who suffer a postoperative complication.
 

74.13 Severity of Disease and Treatment Choice Do Not Affect Satisfaction in Patients with Diverticulitis

Posted on December 22, 2014

R. K. Schmocker1, L. Cherney-Stafford1, E. R. Winslow1  1University Of Wisconsin,Surgery,Madison, WI, USA

Introduction: Patient satisfaction has been increasingly emphasized. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) and Press Ganey (PG) surveys are widely used to measure patient satisfaction. Despite the financial implications of patient experience scores, little is known about their clinical/structural determinants. Because patients with diverticulitis are admitted to a variety of services and present with a wide spectrum of disease severity, this subgroup offers the opportunity to investigate these relationships. We therefore aimed to determine if clinical or structural factors impact hospital satisfaction in patients admitted with diverticulitis.

Methods: Adult patients who were admitted between 2009-2012 and completed either the HCAHPS or PG surveys were identified using ICD-9 codes for diverticulitis. Retrospective chart review was used to confirm that the admission was for acute colonic diverticulitis, and to collect clinical and structural variables. Correlational analysis demonstrated a highly significant (p < 0.001) association between the overall hospital rating measures for the surveys. Patients were then divided into two groups based on the highest rating given to the hospital (topbox vs non-topbox). Severity of illness was assigned using the Hinchey Classification (HC) and Anatomic Severity of Disease in Emergency General Surgery Grade (EGS).

Results:66 patients were identified with 56% female. The average age was 63±14 yrs, length of stay (LOS) 5±5 days. 74% of patients rated the hospital as topbox. 41% were admitted to a surgical service, and 21% of all patients underwent an operation. Patients admitted to a surgical service, and those who required surgery had a higher severity of disease (all p <0.001). When comparing the topbox to the non-topbox group, the following characteristics were similar: age, LOS, and severity of disease. Interestingly, the choice of treatment modality (surgical, percutaneous, or medical) did not influence satisfaction. Further, patients who required diversion with colostomy had similar satisfaction scores when compared to those with non-operative therapy. Admitting service also did not influence satisfaction. Admission service and treatment type also did not impact satisfaction with physician communication.

Conclusion:Disease severity, intervention type, and admission service do not seem to impact overall satisfaction with hospital care for patients admitted for diverticulitis. This highlights the fact that perhaps other less tangible aspects of in-hospital care may be the primary determinants of hospital satisfaction. Efforts aimed at defining these variables are needed in order to improve patient satisfaction.

 

74.14 The Financial Impact of Intraoperative Adverse Events

Posted on December 22, 2014

A. Larentzakis2, M. Mavros3, E. P. Ramly1, Y. Chang1, G. Velmahos1, J. Lee1, D. Yeh1, H. Kaafarani1  1Massachusetts General Hospital,Trauma, Emergency Surgery And Surgical Critical Care,Boston, MA, USA 2University Of Manchester,General Surgery,Manchester, , United Kingdom 3Washington Hospital Center,General Surgery,Washington, DC, USA

Introduction:

Little evidence currently exists regarding the impact of intraoperative adverse events (iAEs) on healthcare costs. With the hypothesis that iAEs independently increase healthcare costs and patient charges, we retrospectively evaluated the ACS-NSQIP cohort of patients treated at our tertiary academic center.

Methods:

The administrative and ACS-NSQIP databases were carefully matched for all patients having undergone general surgery. The ICD-9-CM based Patient Safety Indicator “Accidental Puncture/Laceration” was used to screen the matched database for iAEs. All iAEs were then confirmed using a standardized review of operative reports. The preoperative, intraoperative and postoperative ACS-NSQIP data variables were supplemented with cost variables including total, direct, indirect, operating room (OR), laboratory, radiology, nutrition and medical therapy charges. Multivariate analyses were performed to study the increased cost in healthcare charges that can be independently attributed to the occurrence of an iAE.
 

Results:
 

Our patient population included 9111 patients, 183 of which were confirmed to have had iAEs. Multivariate analyses controlling for demographics, preoperative co-morbidities/laboratory values, type/approach of surgery, operative complexity (measured in relative value units) and relevant intraoperative factors demonstrated that iAEs independently increased the total admission charges by 41% [95%CI: 30%-52%] (P<0.001). Specifically, the direct, indirect, OR, laboratory, radiology, alimentation and medical therapy charges all increased in the range of 27 to 54% (p<0.001; Table 1).

Conclusion:

In addition to the morbidity incurred by patients, the occurrence of an iAE is associated with major financial costs to the patient and the healthcare system.

 

74.15 Predictors of Surgical Site Infection after Discharge in Patients Undergoing Colectomy

Posted on December 22, 2014

J. T. Wiseman1, S. Fernandes-Taylor1, K. C. Kent1  1University Of Wisconsin,Wisconsin Surgical Outcomes Research Program,Madison, WI, USA

Introduction: Surgical site infection (SSI) after colorectal surgery is one of the most common post-operative complications producing substantial morbidity and mortality. A significant proportion of SSI develops after hospital discharge suggesting that transitional care interventions to detect early SSI may help stem the burden of readmission. Although data are available regarding SSI following colectomy, little is known regarding the classification of patients at high-risk for development of SSI occurring after hospital discharge.

Methods: Patients who underwent colectomy from 2005-2012 were identified from the American College of Surgeons National Surgical Quality Improvement Program Participant Use Files. Patients were categorized as having no SSI, SSI occurring in-hospital, or SSI after hospital discharge. Multivariable logistic regression was performed using pre and perioperative variables to predict in-hospital SSI and post-discharge SSI.

Results: Of the 141,877 patients who underwent colectomy, 14,694 (10.4%) were diagnosed with SSI (4.9% in-hospital; 5.4% post-discharge). Multivariate predictors of both in-hospital and post-discharge SSI include obesity and overweight vs. normal BMI, operative time >4 hours vs. 2-4 hours, smoking, American Society of Anesthesiologists (ASA) classification >2, contaminated vs. clean or clean/contaminated wound classification, steroid use and dyspnea. Multivariate predictors unique to patients who experienced in-hospital SSI include black or other race vs. white race, dirty vs. clean or clean/contaminated wound classification, chronic obstructive pulmonary disease (COPD), and disseminated cancer. Multivariate predictors unique to patients who experienced post-discharge SSI include diabetes and female gender (table).

Conclusions: Our data demonstrate that the majority of predictors for SSI after colectomy are similar during both in-hospital and post-discharge periods. This suggests early identification of patients possessing these risk factors at the time of surgery, in particular obesity, may improve both in-hospital wound surveillance and subsequent transitional care efforts to improve wound monitoring and decrease incidence of severe SSI.

74.16 Revision of Roux-En-Y Gastric Bypass for Weight Regain:A Systematic Review of Techniques and Outcomes

Posted on December 22, 2014

I. D. Nwokeabia1, S. Purnell1, S. N. Zafar2, A. C. Obirieze2, G. Ortega2, K. Hughes1,2, T. M. Fullum1,2, D. D. Tran1,2  1Howard University College Of Medicine,Washington, DC, USA 2Howard University Hospital, Howard College Of Medicine,Department Of Surgery,Washington, DC, USA

Introduction: Weight regain has led to an increase in revision of Roux-en-Y gastric bypass (RYGB) surgeries. There is no standardized approach to revisional surgery after failed RYGB. We performed an exhaustive literature search to elucidate surgical revision options. Our objective was to evaluate outcomes and complications of various methods of revision after RYGB to identify the option with the best outcomes for failed primary RYGB.

Method: A systematic literature search was conducted using the following search tools and databases: PubMed, Google Scholar, Cochrane clinical trials database, Cochrane Review Database, EMBASE, and Allied and Complementary Medicine to identify all relevant studies describing revision after failed RYGB. Inclusion criteria comprises of revisional surgery only after the primary RYGB for weight regain.

Results: Of the 1200 articles found, only 799 were selected for our study.  Of the 799, 26 studies, with a total of 987 patients, were included for a systematic review. Of the 26 studies, 6 were conversion to Distal Roux-en-y gastric bypass (DRYGB), 5 were revision of gastric pouch and anastomosis, 6 were revision using an adjustable gastric band, 3 were revision to  biliopancreatic diversion/duodenal switch (BPD-DS), and 6 endoluminal procedures(i.e. stomaphyx). All studies revealed excess weight loss (EWL), varying from 20%–79.4% after 6–60 months follow-up. Mean EWL after revision at 12 months follow-up for DRYGB is 60.8%, gastric pouch revision 54.1%, gastric banding 34.6% and endoluminal procedures 38.1%. In the included cohort of study, major complications occurred in 15.6% (153/987) and minor complications in 13.0% (129/987). Band revision resulted in the lowest complications rate at 0.1% and DRYGB in the highest complication rate 0.4% when compared to the other revisional procedures. The overall mortality rate was 0.005% (5/987).

Conclusion: All 987 patients in the 26 studies reported significant weight loss after surgical revision for failed RYGB. However, of the five surgical revision options considered, revision to band resulted in the lowest mortality rate and the fewest major and minor complications. DRYGB resulted in the highest mean EWL, however it also had the highest complication rate of all the revisional procedures.

 

74.17 The Indications for Transfer to an Acute Care Surgical Tertiary Service

Posted on December 22, 2014

R. C. Britt1, P. W. Davis1, T. J. Novosel1, J. N. Collins1, L. J. Weireter1, L. D. Britt1  1Eastern Virginia Medical School,Surgery,Norfolk, VA, USA

Introduction: Tertiary hospitals with the Acute Care Surgery(ACS) model are increasingly called on by smaller hospitals with fewer resources to assist in providing surgical care for complex patients.  As well, there has been an increase in free standing emergency departments that require surgical consultation.  This study was designed to assess the indications for transfer to the ACS service, including the demographics, patient factors, and outcomes.

Methods: The ER transfer logs as well as the Transfer Center logs at Sentara Norfolk General Hospital were reviewed for a 12 month period for all cases evaluated by the ACS service.  The electronic medical record for each patient was then reviewed for demographics, comorbid conditions, and outcomes.  Billing data was also reviewed to assess patient demographics. Statistical analysis was done using MedCalc© to determine significance.

Results:111 patients with complete data were identified, of which 59 transferred from a hospital and 52 from free-standing ER’s.   Zip code analysis of billing data showed that 360/1080(33%)of ACS patients evaluated during the 12 month period were from more than 10 miles away, with no complete record of transfer for >200 patients.  The patients transferred from another hospital were significantly older with more comorbid conditions, more likely to be discharged to a nursing home, and had a longer length of stay (Table 1).  There was no difference between the two groups in time from evaluation to arrival at our institution or time from initial evaluation to operation. The patients from another hospital were more likely to be transferred for ‘higher level of care’ (78% vs. 4%, p<0.001), while the free-standing ER patients were more likely transferred for ‘surgical evaluation’ (94% vs. 15%, p<0.001).  There was no difference in the percent of patients requiring a procedure (36 vs 29, p=0.73); however, significantly more of the procedures in the hospital transfer group were done by interventional radiology or GI (41% vs 10%, p=0.01).  6% of the patient had no insurance, but there were significantly more Medicare/Medicaid patients in the hospital transfer group (67% vs 35%, p=0.001)and significantly more private insured in the free-standing ER group (59% vs. 22%, p=0.001).

Conclusion:An increasingly complex patient population is being cared for in the tertiary hospitals, with significant difference in populations transferred from free standing ER’s versus other hospitals.  The complexity of patients transferred into tertiary hospitals may have a significant impact on hospital outcomes.   In the era of increasing scrutiny and pay for performance, better infrastructure to monitor the impact of hospital transfers is warranted.

 

74.18 Development of an Approach to Characterize the Complexity of Gastric Cancer Surgery

Posted on December 22, 2014

S. Mohanty1,2, J. Paruch1,3, K. Y. Bilimoria1,4, M. Cohen1, V. E. Strong5, S. M. Weber6  1American College Of Surgeons,Division Of Research And Optimal Patient Care,Chicago, IL, USA 2Henry Ford Hospital,Department Of Surgery,Detroit, MI, USA 3University Of Chicago Pritzker School Of Medicine,Department Of Surgery,Chicago, IL, USA 4Northwestern University Feinberg School Of Medicine,Department Of Surgery, Surgical Outcomes And Improvement Center,Chicago, IL, USA 5Memorial Sloan-Kettering Cancer Center,Department Of Surgery,New York, NY, USA 6University Of Wisconsin School Of Medicine And Public Health,Department Of Surgery,Madison, WI, USA

Introduction:

To allow fair comparisons of hospital quality, most risk adjustment approaches adjust for patient comorbidities and the primary procedure.  However, secondary procedures done at the same time as the index case may increase operative risk and merit inclusion in adjustment models. Including such information could also improve individual patient risk prediction. Our objectives were to evaluate the impact of complexity adjustment on (1)postoperative outcomes, (2)model performance and (3)hospital rankings in gastric cancer surgery. 

Methods:

Using 2007-2012 American College of Surgeons National Surgical Quality Improvement Program data, patients who underwent surgery for gastric adenocarcinoma were identified. Procedure complexity was characterized using secondary procedure CPT© codes and total work relative value units (RVUs).  Regression models were developed to evaluate the association between complexity variables and outcomes. The influence of procedure complexity on model performance and hospital comparisons was examined. 

Results:

Among 3,467 patients who underwent gastrectomy for adenocarcinoma, a secondary procedure was reported for 81.9% of total gastrectomies and 69.6% of partial gastrectomies. The presence of secondary procedures was associated with greater odds for adverse outcomes. For example, patients who underwent a synchronous bowel resection had a higher risk of mortality (OR=2.14, 95%CI: 1.07-4.29) and reoperation (OR=2.09, 95%CI: 1.26-3.47) (Table 1). Model performance was slightly better for nearly all outcomes with complexity adjustment (morbidity c-statistics: standard model, 0.690; RVU model, 0.694; secondary procedure model, 0.701). Hospital ranking did not change significantly after complexity adjustment (mortality, weighted κ 0.84).

Conclusion:

Surgical complexity adjustment improved individual risk prediction but did not appreciably affect hospital rankings. Inclusion of complexity variables into risk prediction tools, such as the ACS NSQIP Risk Calculator, should be considered. 

74.19 Epidemiology of Rectal Cancer Surgeries in the US: 2002-2011

Posted on December 22, 2014

H. Alturki1, S. Fang1,2, S. Selvarajah1, N. Nagarajan1, H. Alshaikh1, F. Gani1, C. K. Zogg1, A. Haider1, E. B. Schneider1  1Johns Hopkins University School Of Medicine,Center For Surgical Trials And Outcomes Research, Department Of Surgery,Baltimore, MD, USA 2Johns Hopkins University School Of Medicine,Department Of Surgery,Baltimore, MD, USA

Introduction: Minimally invasive procedures (laparoscopic and robotic) for the surgical treatment of rectal cancer and have been associated with fewer short-term complications. However, temporal changes in the use of minimally invasive procedures to treat rectal cancer have not been well reported. In this study, changes in the use of minimally invasive techniques to treat rectal cancer were examined across 10 years period. 

Methods:  The Nationwide Inpatient Sample (NIS) from 2002-2011 was examined to identify adults who were surgically treated for a primary diagnosis of rectal cancer using ICD-9 diagnosis and procedures codes. The data were weighted to produce national population-level estimates. Patient and hospital-level characteristics were described by surgical technique: open vs. minimally invasive which included laparoscopic and robotic techniques. Temporal trends for each type of surgical technique were examined. Factors associated with in-hospital mortality, and changes in mortality across the study period were assessed using multivariable regression, controlling for type of procedure as well as patient and hospital-level factors. 

Results: Of 257,994 in-patient who met study criteria, 177,911 (69%) patients underwent open low anterior resection (LAR), 62,889 (24%) open abdominoperineal resection (APR), 9,291 (2%) laparoscopic LAR, 5,227 (3.6%) laparoscopic APR, 2,101 robotic LAR (0.81%) and 575 (0.22%) robotic APR. There was a significant reduction in the proportion of open LAR and APR procedures over the study period, and a concomitant rise in the proportion rectal surgeries performed laparoscopically and robotically (Figure). Minimally invasive procedures were more likely to be performed in male patients, in teaching hospitals, and hospitals located in urban areas (p<.001, all). Over the entire study period, in-hospital mortality was 1.5%; however there was a significant decrease in mortality between 2002 and 2011 (2.0% vs.1.4% respectively, p: <0.05).    

Conclusion: There was a significant increase in the use of minimally invasive procedures over the study period. This is may be due to increasing evidence demonstrating reduced morbidity and mortality among patients undergoing minimally invasive vs. open procedures, as well as increasing surgeon experience with minimally invasive techniques and the development of newer instruments for minimally invasive techniques. However, case presentation, as well as variability in surgeon training and experience, may limit the universal adoption of minimally invasive procedures for the treatment of rectal cancer. 

 

75.03 Safety Risks during OR to ICU Handoffs: Application of Failure Mode and Effects Analysis

Posted on December 22, 2014

L. M. McElroy1,2, R. Khorzad1,2, M. M. Abecassis2, J. L. Holl1,2, D. P. Ladner1,2  1Northwestern University,Center For Healthcare Studies And Center For Education In Health Sciences, Institute For Public Health And Medicine,Chicago, IL, USA 2Northwestern University,Northwestern University Transplant Outcomes Research Collaborative, Comprehensive Transplant Center,Chicago, IL, USA

Introduction: The Joint Commission has reported that up to 70% of intra-hospital transfers result in patient harm, and communication breakdowns are at the root of over 60% of sentinel events. The postoperative patient handoff has been identified as a significant source of medical error, and handoffs to the intensive care unit (ICU) have unique challenges that result in higher rates of patient harm. The goal of this study was to identify patient safety risks during the operating room (OR) to ICU handoff using failure mode and effects analysis (FMEA), a prospective method of risk assessment adapted from other high risk industries. Although FMEA is being increasingly used in healthcare for risk assessment, it has not previously been applied to the patient handoff. 

Methods:  We performed an FMEA of the OR to ICU handoff of deceased donor liver transplant recipients at a tertiary academic hospital. Using in-person observations and descriptions of the handoff process from a multidisciplinary group of clinicians (transplant surgeons and fellows, anesthesiologists and residents, surgical intensivists, surgical residents, and OR and ICU nurses), a comprehensive map of the process was created. For each step in the process, failures were identified along with frequency of occurrence, causes, potential effects and safeguards. A risk priority number (RPN) was calculated for each failure (Frequency x Potential effect x Safeguard; range 1-least risk to 1000-most risk). 

Results: The FMEA identified 37 individual steps in the OR to ICU handoff process. In total, 81 process failures were identified, 23 of which were determined to be high-risk and 36 of which relied on weak safeguards such as informal human verification. Process failures with the highest risk of harm were lack of preliminary OR to ICU communication (RPN 504), team member absence during handoff communication (RPN 480), transport equipment malfunction (RPN 448), and errors in postoperative electronic order sets (RPN 432).

Conclusion: Based on the analysis, recommendations were made to reduce potential for patient harm during OR to ICU handoffs. These included automated transfer of OR data to ICU clinicians, enhanced ICU team member notification processes and revision of the postoperative order sets. The FMEA revealed steps in the OR to ICU handoff that are high risk for patient harm and are currently being targeted for process improvement. 

 

75.04 Operating Room Staff Perceptions of Risk Factors for Retained Surgical Items (RSI)

Posted on December 22, 2014

C. C. Braxton1, C. N. Robinson1, S. S. Awad1  1Baylor College Of Medicine,Michael E. DeBakey Department Of Surgery,Houston, TX, USA

Introduction: Unintended retention of a surgical item is considered a Serious Reportable Event/“never event” by the National Quality Forum and is a JOINT “sentinel event”. Multiple factors are associated with increased risk for RSI, including emergency operations, involvement of multiple surgical teams, communication breakdown, disruptive activities and lack of adherence to policy. Local perceptions regarding factors that lead to RSI warrant exploration to determine how they contribute to risk of occurrence for this “never event.” The objective of this study was to better understand provider perception of factors that increase the risk for RSI in order to develop interventions addressing misperceptions.

Methods: We created a thirteen-question Likert based survey aimed at determining physician and nurse provider perception of literature-derived risk factors plus other elements thought to increase the likelihood of RSI. Survey questions included queries about issues likely to create risk for RSI such as: reliance on memory to perform surgical counts, distractions occurring at time of closing, use of disorganized instrument trays and disruptions during shift change/handoffs. The survey was administered to surgeons, anesthesiologists, operating room nurses, scrub techs and nurse anesthetists at a quaternary care, high surgical volume VA hospital. Chi squared and student’s ttest were used for statistical analysis. Any question that attained a “not at all likely” response of 20% or greater was considered for possible intervention.

Results:The survey was sent to 104 providers with 66(63%) response rate. The majority of respondents generally agreed (“very likely” or “highly likely”) that queried RSI risk factors would contribute to an RSI event.  Overall four of the thirteen RSI risk factor questions returned greater than 20% “not at all likely” responses prompting intervention.  These included: reliance on memory for counts, haste during the operation, not prolonging the operation to confirm correct counts and presumption that low-risk operations were less important. When physician and nurse responses were compared, only the question regarding presence of multiple surgical teams (physicians 88% yes, nurse 100%, p=.05) was statistically significant. Although it did not reach statistical significance, a greater percentage of physicians expressed concern that distractions in the operating room were an important factor that added to the risk of RSI (91%vs78%, p=0.22).

Conclusion:We identified several areas of intervention to address potentially erroneous perceptions of operating room environmental risk factors for RSI. Emphasis should be placed on avoidance of relying on memory for counts, slowing down processes to accommodate assessment of all instruments/equipment/disposables used during surgery and that correct count procedures are imperative in all surgical cases.
 

75.05 Performance of the Operating Room Time Out by Attending Surgeons Increases Surgical Team Engagement

Posted on December 22, 2014

H. T. Jackson1, J. Lee1  1George Washington University School Of Medicine And Health Sciences,Surgery,Washington, DC, USA

Introduction:

Implementation of surgical site markings, time outs, procedure checklists, and team improvement strategies are all steps that the medical community have taken to improve patient safety in the operating room (OR). Time outs have been shown to improve communication and patient safety in the operating room. While patient safety in the OR is a responsibility of all surgical team members, we believe the surgeon, who ultimately decides when a patient requires surgery, has an increased responsibility to be an active advocate for patient safety. Studies examining the role of the surgeon as the leader of these safety efforts are lacking. 

Methods:

A survey study was undertaken to examine the perceptions of surgical team members (nurses, anesthesiologists, residents, surgeons) about the surgical time out (STO) process. Team members were queried specifically about attending surgeon initiation and completion of the STO checklist. Two-tailed t-test for independent groups was performed to examine differences in perceptions. A parallel observational study of the STO was conducted to determine concordance between perception and observation. Chi square analysis was used to examine associations between engagement and the STO initiation and completion process. Logistic regression was used to examine the association of independent variables in predicting STO engagement.  

Results:

Surgeons reported a significantly higher incidence of self-completion of the STO when compared to anesthesiologists, nurses and residents (Surgeon vs. Anesthesiologist: p <0.0001; Surgeon vs. OR Nurse: p<0.0001; Surgeon vs. Resident: p value= 0.021). The observational study of 138 STOs showed that the STO was initiated and completed by someone other than the surgeon 54% of the time. When the surgeon did initiate and complete the STO, engagement was much higher (p=0.0003). When the surgeon required prompting or did not perform any STO component, the odds of high engagement were reduced by 82% and 88%, respectively (p=.0007, .0004).   

Conclusion:

Surgeon leadership, not just involvement, is a critical component of team engagement in patient safety initiatives in the OR. Encouraging the involvement of the surgeon as the primary team leader in these initiatives could lead to a more optimal and safe OR environment.   

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