16.03 Factors Associated with Readmission and Length of Stay Following Gastric Bypass

Posted on December 22, 2014

S. X. Sun2, C. Hollenbeak3, A. Rogers1,2  1Penn State Hershey Medical Center,Minimally Invasive Surgery,Hershey, PA, USA 2Penn State Hershey Medical Center,General Surgery,Hershey, PA, USA 3Penn State Hershey Medical Center,Outcomes Research And Quality,Hershey, PA, USA

Introduction:
Interest is growing in preventing readmissions as payers start to link reimbursement to readmission rates.  The purpose of this study was to assess factors that contribute to 30-day readmission rates for patients undergoing gastric bypass for obesity and determine whether these readmissions may be preventable. 

Methods:
Data from the Pennsylvania Health Care Cost Containment Council (PHC4) were queried for all patients undergoing elective gastric bypass for obesity in 2011 (n=4,505). The outcomes measured were length of stay (LOS) and 30-day readmission. Univariate comparisons between characteristics of readmitted (n=298) and non-readmitted patients were performed using t tests and chi-square tests. Readmission was modeled using logistic regression; LOS was modeled using linear regression and controlled for potential confounders.  

Results:
Of the 298 (6.6%) patients who were readmitted, the most common cause for readmission was bleeding (11.84%) followed by infection (8.88%), and abdominal pain (7.89%). On multivariate analysis, African American race, open gastric bypass, and history of myocardial infarction or rheumatoid arthritis were associated with increased odds of readmission within 30 days of the index hospitalization. Longer LOS was also predictive of readmission (OR 1.10, p=<0.0001). Determinants of LOS were assessed using linear regression. Patients who were above age 51, and those with history of congestive heart failure, peripheral vascular disease, and kidney disease were more likely to have longer lengths of stay. Black race, open surgery, and discharge to an extended care facility were also predictive of prolonged hospital stays. 

Conclusion:
This study showed that the most common causes of 30-day readmission following elective gastric bypass was bleeding, infection and abdominal pain. Black race, open surgery and comorbid conditions, such as heart disease, were associated with higher odds of readmission and longer lengths of stay. Even though it is difficult to alter patient comorbidities, our results show that it may be beneficial to optimize these comorbid conditions before gastric bypass surgery as this may lead to lower readmission rates and shorter lengths of stay. 
 

16.04 Analysis of Internet Information on Lateral Lumbar Interbody Fusion

Posted on December 22, 2014

R. Belayneh1, A. Mesfin2  1Howard University College Of Medicine,Washington, DC, USA 2University Of Rochester School Of Medicine And Dentristry,Orthopaedic Surgery,Rochester, NY, USA

Introduction:
The Internet is a common resource for health and medical information. Previous studies have shown the Internet’s shortcomings in presenting comprehensive information regarding surgical procedures. Lateral lumbar interbody fusion (LLIF) is a surgical technique that is being increasingly used. To our knowledge, there are no studies evaluating the quality of information available on the Internet regarding LLIF. The purpose of this study is to examine information on the Internet about LLIF and determine the completeness and accuracy of the information provided.

Methods:
The top 35 websites providing information on the “lateral lumbar interbody fusion” from four search engines (Google, Yahoo, Bing, DuckDuckGo) were identified. 140 websites were evaluated. Each website was categorized based on authorship (academic, private, medical industry, insurance company, other) and we analyzed: appropriate patient inclusion and exclusion criteria, surgical treatment alternatives, non-surgical treatment alternatives, claimed benefits, complications and risks, industry-sponsored literature, peer-reviewed literature, description and diagram of procedure, direct contact information of the author, and date of last update. 

Results:
78 unique websites were identified after excluding duplicate and inaccessible websites. 46.2% of websites were authored by a private medical group, 26.9% by an academic medical group, 5.1% by biomedical industry, 2.6% by an insurance company, and 19.2% by other sources. 68% of websites reported patient inclusion criteria and only 24.4% reported exclusion criteria. Benefits of LLIF were reported in 69.2% of websites and 36% of websites reported potential complications of LLIF. Alternative surgical options were discussed in 50% of websites and non-surgical options were discussed in 7.7% of websites. 21.8% of websites contained references to peer-reviewed literature while 32.1% contained industry-sponsored literature.

Conclusion:
Overall, the quality and completeness of information regarding LLIF on the Internet is poor.  The majority (46.2%) of Internet information on LLIF is provided by private medical groups. Only 36% of websites discuss potential complications of LLIF and most of the cited literature (32%) is from the biomedical industry.  Spine surgeons and spine societies can assist in improving the quality of the information on the Internet regarding LLIF.
 

16.05 Risk Factors for Pediatric Surgical Readmissions: An Analysis of the Pediatric NSQIP Database

Posted on December 22, 2014

G. M. Taylor1, M. C. Shroyer1, A. B. Douglas1, R. T. Russell1  1University Of Alabama At Birmingham, Children’s Of Alabama,Pediatric Surgery,Birmingham, AL, USA

Introduction: Hospital readmissions account for a large proportion of health care expenditures. The patient characteristics associated with surgical readmissions in children help define preoperative patient risk factors, which may be modifiable but also may be used for preoperative family counseling.  The objective of this study was to characterize readmission rates and factors associated with readmission among children following surgery.

Methods: The Pediatric National Surgical Quality Improvement Project (NSQIP) is a multicenter clinical registry from 50 participating sites collecting data to measure the quality of children's surgical care. The 2012 Pediatric NSQIP public use file (PUF) was queried for pediatric general surgical patients who had an unplanned readmission in 2012.  Detailed patient and case characteristics were analyzed.  Univariate and multivariate logistic regression were utilized to identify patient characteristics, clinical variables, and comorbidities predictive of unplanned readmissions.

Results: 18,643 cases were analyzed from the 2012 Pediatric NSQIP PUF file. Of these, 1111 patients (6%) experienced unplanned readmissions within 30 days of surgery.  Significant preoperative variables/comorbidities associated with readmission are included in Table 1. In addition, children in the older age groups (30 days-6months, 6 months-2 years, 2-5 years, 5-12 years, and > 12 years) were more likely to be readmitted than those < 30 days old.  Variables in the model that did not predict readmission included race, a preoperative diagnosis of diabetes, cerebral palsy, chronic lung disease, cystic fibrosis, major/severe cardiac risk factors, enteral or parenteral nutritional support at the time of operation, history of prematurity, and emergent/urgent operation. Infectious complications were the reason for 40% of unplanned readmissions.

Conclusions: Certain patient risk factors and comorbidities were associated with an increased risk of unplanned readmission. Though we may not be able to directly affect these risk factors, we can utilize them to counsel high risk patients and their families preoperatively about the likelihood of readmission due to these risk factors.  Infectious complications were the most common reason for readmission.

16.06 Variability in Surgical Skin Preparation Adherence in Common Pediatric Operations

Posted on December 22, 2014

J. M. Podolnick2,3,4, L. R. Putnam2,3,4, S. Sakhuja2,3,4, C. M. Chang2,3,4, M. T. Austin2,3,4, K. P. Lally2,3,4, K. Tsao2,3,4  4Children’s Memorial Hermann Hospital,Houston, TX, USA 2University Of Texas Health Science Center At Houston,Department Of Pediatric Surgery,Houston, TX, USA 3Center For Surgical Trials And Evidence-based Practice,Houston, TX, USA

Introduction:

Skin antisepsis agents are commonly used in an effort to decrease surgical site infections (SSI). However, surgeon preference, anatomical site considerations, and patient age may influence proper agent utilization. Despite institutional adoption of evidence-based guidelines, we hypothesized that adherence to skin preparation guidelines is variable in pediatric operations.

Methods:

A retrospective cohort study of eight common pediatric operations (laparoscopic appendectomy, fundoplication, gastrostomy tube placement, pyloromyotomy, laparoscopic cholecystectomy, abscess incision and drainage, inguinal hernia repair, and stoma takedown) was performed to evaluate the skin prep agents utilized over a one year period.  The skin prep used for each operation was recorded as well as patient age, gender, operative time, prep nurse, surgeon, and anatomical site of prep (torso, extremity, pelvis/perineum). Correct prep agent was determined based on adherence to our institutional guidelines based on best-evidence and best-practice in pediatric hospitals. Logistic regression and the chi squared test were performed; p<0.05 was considered significant.

Results:

183 cases were reviewed with an overall adherence of 58% to skin prep guidelines. Adherence was highest for laparoscopic appendectomies and laparoscopic cholecystectomies (92% and 96%, respectively) and lowest for inguinal hernia repairs and stoma takedowns (32% and 8%, respectively). A total of five different skin prep agents or combinations were used with at least two different agents/combinations used per case type; all five were used for appendectomies during the study period (Table). Factors associated with non-adherence included type of operation, surgeon, and patient age.

Conclusion:

Significant variability in adherence to correct skin prep guidelines exists for common pediatric operations. Contributing factors include type of operation, surgeon, and patient age. Consistent practice and adherence to evidence-based guidelines for skin preparation requires targeted interventions in order to optimize skin antisepsis and minimize risk of SSI.

16.07 ~~Hospital Departmental Variation in Children’s Surgical Outcomes

Posted on December 22, 2014

A. M. Stey1, B. L. Hall2,6, M. Cohen2, C. Y. Ko2,5, S. Rangel4, K. Kraemer2, R. Moss3  1Mount Sinai,New York, NY, USA 2American College Of Surgeons,Chicago, IL, USA 3Nationwide Childrens Hospital,Columbus, OHIO, USA 4Boston Children’s Hospital,Boston, MA, USA 5University Of California Los Angeles,Los Angeles, CA, USA 6Washington University In Saint Louis,Saint Louis, MO, USA

~~Introduction: Institution wide efforts in quality improvement have improved patient safety across disciplines. Achieving improvements in surgical outcomes may be dependent on department specific factors. The aim of this study was to determine if outcomes in children’s surgical subspecialties within the same institution were similar or different to outcomes in general pediatric surgery.

Methods: 2011-2012 ACS-NSQIP-P data were sorted into six specialties; general surgery, plastics, urology, otolaryngology, orthopedics and neurosurgery among 50 hospitals. 30-day composite morbidity (occurrence of 17 postoperative complications) was the primary outcome. Multivariate hierarchical models were used to estimate risk-adjusted hospital odds ratio of morbidity for each specialty. Spearman correlation, ranking of these odds ratios was performed. General surgery was treated as the reference since it had the largest case volume.

Results: Correlations in an institutions general surgery outcomes, and specialty outcomes were moderate (R=0.3-0.5, p<0.01) with the exception of orthopedics (R=0.1, p=0.5). Median difference in hospital performance rank between general surgery and specialties ranged from 8-14 ranks. Median difference in hospital decile performance ranking ranged from 1-3 deciles. 1-2 hospitals ranked in the best decile in general surgery were also in the best decile in specialty care for a 20-40% concordance in best decile designation.  0-2 hospitals ranked in the worst decile in general surgery were also in the worst decile in specialty care for a 0-40% concordance in worst decile designation. There was some overlap in risk adjusted specialty performance within hospitals but outlier departments within hospitals were observed (Figure).

Conclusion:  There is variability in surgical outcomes between specialties within the same institution. This suggests that unique department specific factors may drive surgical outcomes.  Every hospital likely has an area which could be the focus of quality improvement.

 

Figure Legend:

Odds ratio is given in order for general surgery, urology, otolaryngology, plastics, neurosurgery and orthopedics for each hospital ranked by dummy identifier.
 

16.08 Risk Factors and Preventability in Reducing Early Hospital Readmission after Liver Transplantation

Posted on December 22, 2014

C. E. Rogers1, P. Baliga1, K. Chavin1, D. Taber1  1Medical University Of South Carolina,Transplant Surgery,Charleston, Sc, USA

Introduction:  There is an increasing pressure for hospitals to reduce early hospital readmission (EHR) rates for high-cost, high-risk surgical procedures.  Studies have also shown EHRs to be a measure of inpatient quality of care. 

Methods:  The aims of this study were to determine the predominant risk factors associated with EHR, to develop a risk model and to determine the etiologies, timing and preventability of readmissions in liver transplant (LTX) patients. All patients who received a LTX between Jan 2011 – May 2014 were included. Patients who experienced graft loss within one month after LTX were excluded. 

Results: A total of 207 LTX recipients were included, 48% (n=67) were readmitted within 30 days (EHR). Risk factors for EHR included African American race (13% vs. 38%, p=0.006), primary diagnosis of biliary atresia (1% vs. 8%, p=0.025) and donor history of stroke (33% vs. 54%, p=0.007). Although not statistically significant, diagnosis of hepatitis C (34% vs. 45%, p=0.119), an increase in pre-transplant hemoglobin (10.8 vs. 11.3 gm/dL, p=0.119) and a decrease in serum albumin (3.1 ± 3.1 vs. 2.6 ± 0.8 gm/dL, p=0.188) also correlated with an increased risk for EHR.  A history of a previous liver transplant (10% vs. 0%, p=0.007) and dialysis within a week prior to transplant (8% vs. 2%, p=0.067) appear to be protective against EHR. These 8 factors were then used as variables in a logistic regression analysis to develop a risk model that demonstrated a negative predictive value of 71.4%, a positive predictive value 67.8%, and an overall predictive value of 70.3%. The secondary analysis revealed that of the patients readmitted within 7 days (n=39), 25% were due to known or ongoing medical problems, which were identified, on average, 2 days (range1-4) prior to the EHR and potentially preventable.  Graft loss was significantly higher in LTX with EHR (Figure 1). 

Conclusion: This analysis identified specific factors for EHR that can potentially predict which patients are at high-risk for readmission.  Future analyses should attempt to prospectively validate this model and target the high-risk patients through interventions designed to minimize EHR and improve overall quality of patient care.

 

16.09 The “Halo Effect” in Trauma Centers: Does it Extend to Emergency General Surgery?

Posted on December 22, 2014

N. Nagarajan1, S. Selvarajah1, H. Alshaikh1, F. Gani1, H. Alturki1, A. Najafian1, C. K. Zogg1, D. T. Efron1, E. B. Schneider1, A. H. Haider1  1Johns Hopkins University School Of Medicine,Center For Surgical Trials And Outcomes Research, Department Of Surgery,Baltimore, MD, USA

Introduction:  Trauma Centers (TC) have been shown to have a “halo effect”, resulting in improved outcomes for non-trauma conditions. It remains unclear if these improvements extend to outcomes for emergency general surgery (EGS). Using emergent colectomy in patients with diverticulitis as an index condition, the objective of this study was to compare outcomes between TC and NTC.

Methods:  The Nationwide Emergency Department Sample (2006-2011) was queried for patients (≥16 years) who underwent an emergent colectomy (ICD9: 173*, 457*, 458*) with a primary diagnosis of diverticulitis (ICD9: 562.11, 562.13). Outcomes studied included mortality, total charges (in 2011 dollars) and length of stay (LOS). Mortality in TC and NTC was compared using logistic regression, controlling for age, sex, Charlson Comorbidity Index (CCI), type of insurance, income quartile, partial/total colectomy, presence of peritonitis, perforation, and hospital region, clustering by hospital. Unadjusted total charges and LOS were analyzed with non-parametric tests, then were adjusted for all of the above and mortality. Adjusted total charges and LOS were analyzed using generalized linear models with gamma and Poisson distributions, respectively.  

Results: A total of 25,396 patients were included; of whom 5,189 (20.4%) were treated at TC and 20,207 (79.6%) at NTC. Median age [60 years (IQR: 49-73), p = 0.959] and proportion of females (51.6% vs. 51.3%, p = 0.395) were similar between TC and NTC, but there were significant differences in insurance status (p = 0.027) and median household income (p <0.001) (Table I). Unadjusted mortality at TC did not significantly differ from NTC, median charges and were significantly different (Table I). After controlling for patient, procedure and hospital-level characteristics, the odds of mortality was significantly higher in TC (OR=1.24, 95% CI, 1.02-1.51). Estimated mean charges ($127,801 vs. $116,464, p = 0.004) and LOS (IRR=1.06, 95% CI, 1.05-1.11) were also significantly higher in TC after adjustment.

Conclusion: The improved outcomes reported for other non-trauma conditions in TC were not observed for patients undergoing an emergent colectomy for diverticulitis after accounting for demographic and hospital-level characteristics.  Future research is needed to discern if differences in the clinical course of patients in TC compared to those in NTC are affecting our findings.

16.10 Benchmarking Statewide Trauma Mortality and Using AHRQ's Safety Indicators to Identify Intervention

Posted on December 22, 2014

D. Ang1, S. Kurek1, M. McKenney1, E. Barquist1, E. Barquist1, S. Norwood1, B. Kimbrell1, D. Villarreal1, H. Liu1, M. Ziglar2, J. Hurst1  1University Of South Florida College Of Medicine,Tampa, FL, USA 2Hospital Corporation Of America,Nashville, TENNESSEE, USA

Introduction:   Improving clinical outcomes of trauma patients is a challenging problem at a statewide level, particularly if data from the State’s registry is not publically available.  Promotion of optimal care throughout the State is not possible unless clinical benchmarks are available for comparison.  Using publically available administrative data from the State’s Department of Health and the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSI), we sought to create a statewide method for benchmarking trauma mortality while also identifying a pattern of unique complications that have an independent influence on mortality. 

Methods: Data for this study was obtained from State’s Agency for Health Care Administration (AHCA). Adult trauma patients were identified as having ICD-9 codes defined by the State. Stepwise logistic regression was used in order to create a parsimonious and predictive inpatient expected mortality model. The expected value of PSIs was created in a similar method using a multivariate model provided by the AHRQ.  Case mix adjusted mortality results were reported as observed to expected ratios (O/E).

Results:There were 37,793 trauma patients evaluated during the study period.  The overall fit of the expected mortality model was very strong at a c-statistic of 0.891.  Eleven out of 25 trauma centers had O/E ratios less than one, or better than expected.  Six statewide PSIs had O/E ratios higher than expected.  The PSI which had the strongest influence on trauma mortality for the State was PSI# 4 or death among surgical Inpatients with serious treatable complications.  Mortality could be further sub-stratified by complications at the hospital level.

Conclusion:This method offers an adjusted benchmarking method which screens at risk trauma centers in the State for higher than expected mortality.  Stratifying mortality based on Patient Safety Indicators may identify areas of needed improvement at a statewide level. 

 

16.11 Massive Transfusion Protocol: From Zero To Hero

Posted on December 22, 2014

I. A. Struve1, E. S. Salcedo1, C. S. Marshall1, J. M. Galante1  1University Of California – Davis,School Of Medicine,Sacramento, CA, USA

Introduction:  The Massive Transfusion Protocol (MTP) facilitates rapid transfusion of blood components for patients in hemorrhagic shock.  MTP implementation is highly resource intensive.  Rapid deployment of all available transfusion service personnel is necessary to prepare and issue blood products promptly.  This study explores factors contributing to appropriate blood product use with MTP activation in a Level 1 Trauma Center.  We aim to establish a quality benchmark for the use of a limited resource.  

Methods:  Records of patients, for whom MTP was activated, from 3-month intervals over three consecutive years, were reviewed.  Data collected includes: ordering specialty, patient location at the time of activation, and units transfused at 6 hours and at 24 hours.  The primary outcome assessed was zero-use rates, which were compared by ordering specialty and patient location at the time of MTP activation.  Zero-use was defined as zero PRBC units transfused at 24 hours following MTP activation. Secondary outcomes assessed were median PRBC units transfused and Crossed-To-Transfused (C:T) ratios, both compared by specialty and location. Categorical variables were compared with the chi-square test and continuous variables with confidence intervals using alpha=0.05.

Results:  MTP was activated for 183 patients. The predominant specialties that activated MTP were emergency medicine (43%), surgery (24%), and anesthesia (22%), The predominant patient locations at the time of MTP activation were the ER (50%) and the OR (43%). Zero-use rates compared between predominant ordering specialties were not significant (p=0.75). Zero-use rates compared between the ER and the OR were significant (p=0.008) (Table 1). When MTP did not result in zero use, only activations made with the patient in the OR results in massive transfusion (MT) (6 units) (Table 1). 

Conclusion:  Patient location at the time of MTP activation is a significant predictor of appropriate MTP use. The OR is superior likely because the source and extent of hemorrhage is directly visualized. In the OR, zero-use rates are lowest and the median number of transfused units are 6 within 6 hours, an accepted definition of massive transfusion.  Using the OR as a model for appropriate MTP activation, we propose a zero-use rate benchmark of 15%. 

 

16.12 Reduced Mortality in Females After Traumatic Hemorrhage: Does It Extend to Non-Traumatic Hemorrhage?

Posted on December 22, 2014

H. Alshaikh1, S. Selvarajah1, N. Nagarajan1, F. Gani1, C. K. Zogg1, H. Alturki1, A. Najafian1, D. T. Efron2, C. G. Velopulos2, E. B. Schneider1, A. H. Haider1  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:  Multiple studies have demonstrated gender dimorphism in survival after trauma-induced hemorrhage. These findings have led to gender based therapeutics such as the administration of progesterone to males after injury. However, the potential survival benefit females may enjoy has not been well studied in non-traumatic emergency situations such as gastrointestinal (GI) hemorrhage. The objective of this study was to examine the association between gender and survival in patients presenting with acute non-traumatic GI hemorrhage using a nationally representative database. 

Methods:  Using Nationwide Inpatient Sample (NIS) data from 2007-2011, adults admitted through the emergency department with GI hemorrhage were identified using ICD-9 diagnosis code (578.*). Patients <18 years of age were excluded as were patients with missing demographic information and elective admissions. Weighted univariate and multivariable logistic regression was done to assess the relationship between gender and in-hospital mortality. The adjusted analysis controlled for demographic factors, hospital characteristics, patient transfer status and patient clinical severity. Severity was assessed using All-Patient Refined Diagnosis-Related Group (APR-DRG) severity scores. 

Results: A total of 809,798 weighted inpatient visits met the inclusion criteria, 51% of patient were female. Mean age was higher for women compared with men (72.1 vs. 65.8, p<0.001). Non-operative intervention was common among therapeutic options, including esophagogastroduodenoscopy (27.5%), small intestine endoscopy (26.5%) and colonoscopy (16.9%). About 43.9% of patients received blood transfusion, with higher proportion of women receiving them (51.7% vs. 48.3%, p<0.001). The proportion of patients with APR-DRG severity scores 1 and 2 (non-severe) was 52.9% for females (95%CI=52.3-53.6) and 52.4% for males (95%CI=51.7-53.1). Women demonstrated 14% lower unadjusted odds of death compared with men (OR 0.86, 95% CI 0.82-0.91). Moreover after adjustment, women demonstrated 22% lower odds of in-hospital mortality compared with men (OR 0.78, 95% CI 0.74-0.82). Alternative regression models were consistent with these results.

Conclusion: Females demonstrated significantly lower mortality after emergent GI hemorrhage despite controlling for severity and age. This evidence, in conjunction with other studies that demonstrate lower female mortality in traumatic hemorrhage, should prompt researchers to further investigate potential gender-related physiological pathways that could be altered by novel therapeutic options to improve patient outcomes.

16.13 Evaluation Of A Clinical Management Guideline For Tube Thoracostomy Removal In Trauma Patients

Posted on December 22, 2014

J. A. Marks1, G. Telford1, J. McMaster1, N. D. Martin1, P. Kim1  1University Of Pennsylvania,Division Of Traumatology, Surgical Critical Care And Emergency Surgery,Philadelphia, PA, USA

Introduction:
Recurrent pneumothorax after chest tube removal is a potential complication in trauma patients.  One potential mitigating maneuver is placement of a U-stitch at the skin incision during initial tube placement that is tied down during tube removal.  In this study, we evaluate this performance improvement initiative and its efficacy.

Methods:
At our urban, level one trauma center, we implemented a  Clinical Management Guideline (CMG) mandating U-stitch placement with all chest tubes in January 2012. The CMG further dictates that the procedure is performed by two providers. One provider secures the skin suture, and the second provider maintains an occlusive dressing with Vaseline and dry gauze. The tube is removed at end inspiration, or while patient performs Valsalva maneuver. A chest x ray is performed 4-6 hours after tube thoracostomy is removed.  Data was collected from our prospectively entered performance improvement database comparing pre and post CMG implementation.  

Results:
During the year preceding CMG implementation there were 9 recurrent pneumothoraces requiring reinsertion of a chest tube out of a total of 172 chest tube placements (5.2% recurrence rate).  In the two years after the CMG was instituted, recurrences were reduced to 1 out of 177 (0.6%) and 1 out of 139 (0.7%), respectively (p<0.002) (FIGURE).

Conclusion:
Recurrent pneumothorax after chest tube removal is a significant complication.  Placement of a U-stitch as part of a CMG can significantly reduce this complication.  This CMG should be considered broadly for all traumatic chest tube removals. 
 

16.14 Airway Management of Trauma Patients as an Indicator of Quality in a Pre-Hospital Flight Program

Posted on December 22, 2014

R. Weston1, D. Chesire1, D. Meysenburg1, J. Fortner1, R. Houghton1, K. Solomon1, B. Burns1  1University Of Florida,College Of Medicine,Jacksonville, FL, USA

Introduction:  Airway compromise has been identified as a preventable cause of poor outcomes and death in trauma patients. Given its importance, pre-hospital airway management is vital and can be used as a valuable indicator of critical care quality.  The purpose of this study was to analyze successful pre-hospital airway management performed by helicopter flight staff.    

Methods:  This retrospective chart review evaluated all flight crew airway interventions involving trauma patients between January 1, 2008 through December 31, 2013. Descriptive statistics were used on the number of successful intubations as well as alternative airways.

Results: Of a total of 191 trauma patients requiring airway intervention,  167 were endotracheal intubations (87.4%), 24 were alternative airway intervention such as laryngeal mask airway, combitube or bag valve mask (12.5%). Of the endotracheal intubations, 80.1% were successfully placed by flight crew on their first attempt and the overall success rate was 94.2%. Of the intubations attempted by the flight crew, 43 patients had unsuccessful attempted endotracheal intubation by ground crew.  Of these, the flight crew was ultimately successful at placing an endotracheal tube in  41/43 (95.3%) trauma patients.

Conclusion: High endotracheal success rate by flight personnel suggests that medical air transport is more than just an expedited transport mode to the hospital; it can be considered a mobile critical care unit. The fact that 95.3% of previously attempted airways were “rescued” by the flight crew further demonstrates a higher level of care administered in the field
 

16.15 Missed Tetanus Prophylaxis in Severe Trauma Patients at a Level One Academic Trauma Center

Posted on December 22, 2014

E. O. Pierce1, J. B. Brock1, A. V. Dukes1, C. Stevens1, T. E. Robertson1  1University Of Mississippi,Surgery,Jackson, MS, USA

Introduction:
Tetanus has become an uncommon disease in developed countries due to vaccinations. Appropriate tetanus prophylaxis continues to be a problem, allowing for tetanus cases to still occur in the United States. The Advisory Committee on Immunization Practices (ACIP) recommends that tetanus-prone wounds be given prophylaxis.  Tetanus-prone wounds are contaminated wounds, including abrasions, as well as puncture wounds, avulsions, missiles, crushes, burns or frostbite. The purpose of this study was to determine if there are missed tetanus vaccination opportunities at a level one academic trauma center.

Methods:
A retrospective chart review was performed on severe trauma patients between July 2012 and June 2014. All leveled trauma patients ages 18 and older who met the Trauma Quality Improvement Program (TQIP) inclusion criteria were reviewed. These patients were compared to patients given tetanus prophylaxis in our institution. The results were further evaluated by age of patient, type of trauma (blunt, penetrating, burns), and type of presentation (transfer from outside hospital, direct presentation from the scene).

Results:
4,319 patients ages 18 and over presented as leveled traumas during the given time period. Of these, 30.2% received the recommended tetanus prophylaxis. 571 of these leveled trauma patients (13%) were greater than 65 years of age and 19.6% of these patients received tetanus prophylaxis. There were 3,314 blunt traumas and 27.8% of these received prophylaxes. There were 945 penetrating traumas and 37.7% of these received prophylaxes. There were 36 burns and 58.3% of these received prophylaxes. 1,586 patients were transferred from outside hospitals and 2,667 were brought in directly from the trauma scene. 13.4% of transfers received prophylaxis and 39.9% of direct responses received prophylaxis

Conclusion:
A large number of trauma patients are not receiving tetanus prophylaxis despite presenting with tetanus-prone wounds. Immunization status could not be gleaned from this retrospective chart review, but most adults after major trauma are unable to recall their immunization status. Patients who were transferred from another center may have received immunization there, but even primary response teams from the scene had only a 40% immunization rate. All penetrating wounds meet vaccination criteria and blunt may or may not include a tetanus prone wound, but considering the risks and benefits of vaccination, it would be reasonable to have all traumas receive tetanus prophylaxis. Major blunt trauma rarely presents without an abrasion. Further research will include provider education and systems improvements to determine the best mechanism to increase vaccination rates. There are missed tetanus vaccination opportunities at this level one academic trauma center.
 

16.16 Structured Interdisciplinary Rounds (SIR) on a Trauma Ward

Posted on December 22, 2014

A. E. Liepert1, D. Segersten1, H. Jung1, A. O’Rourke1, S. Agarwal1  1University Of Wisconsin,Department Of Surgery,Madison, WI, USA

Introduction: Patient satisfaction is becoming an important factor in healthcare reimbursement. Structured interdisciplinary rounding (SIR) has been shown to be effective in improving patient care and satisfaction, but trauma has often been excluded as this population is associated with uncertainty in presentation, hospital course, and outcome. We examined the impact of non-ICU interdisciplinary rounding upon trauma patient satisfaction.

Methods: Over a nine-month period, patient satisfaction scores were reported in the trauma inpatient population before and after intervention of SIR at our ACS verified Level One trauma center. Pre-intervention rounding consisted of separate physician (resident and attending) examination and discussion with patients, whereas the intervention group consisted of bedside rounds with physicians (resident and attending), nursing, pharmacy, nutrition, physical therapy, occupational therapy, and social work. Scripted and practiced communication between team members, patients and families was instituted. Patient satisfaction surveys were mailed to patients at time of discharge, collected, and reported in rolling three month reports. As this was a quality improvement initiative, with aggregate data devoid of patient identifiers, the study is exempt from Institutional Review Board review.

Results: 2339 trauma patients were admitted to the hospital, of which 829 patients were admitted to the trauma care ward, making up 67% of the floor’s total population. From patient satisfaction surveys, patient perception of satisfaction in nursing communication revealed an overall downward trend (83.3% to 76.9%); however, patient perception of physician communication improved (nadir 69.6% to 76.9%).

Conclusion: The implementation of SIR can have an impact upon patient satisfaction in the trauma population. Future studies examining team communication and patient outcome need to be performed to fully evaluate the impact of this intervention.

 

14.07 Rectal bleeding and hidden colorectal diseases in Nepal: A cross sectional countrywide survey

Posted on December 22, 2014

P. Ghimire7, S. Gupta1,2, J. Pathak6, T. P. Kingham2,3, A. L. Kushner2,5, B. C. Nwomeh2,4  1University Of California – San Francisco , East Bay,Surgery,Oakland, CA, USA 2Surgeons OverSeas,New York, NY, USA 3Memorial Sloan-Kettering Cancer Center,Surgery,New York, NY, USA 4Nationwide Children’s Hospital,Pediatric Surgery,Columbus, OH, USA 5Johns Hopkins Bloomberg School Of Public Health,International Health,Baltimore, MD, USA 6Kathmandu Medical College,Kathmandu, , Nepal 7B.P.Koirala Institute Of Health Science,Dharan, , Nepal

Introduction:  Because rectal bleeding is a cardinal symptom of many colorectal diseases including colorectal cancers, its presence alone could give insight into the prevalence of these conditions where direct population screening is lacking. In South Asia, which is home to over one fifth of the world’s population, there is paucity of epidemiologic data on colorectal diseases, particularly in the lower-income countries (LIC) such as Nepal.  The aim of this study is to enumerate the prevalence of rectal bleeding in Nepal and increase understanding of colorectal diseases as a health problem in the South Asian region.

Methods:  A countrywide survey utilizing the Surgeons OverSeas Assessment of Surgical Need (SOSAS) tool was administered from May 25th to June 12th 2014 in 15 of the 75 districts of Nepal, randomly selected proportional to population.  In each district, three Village Development Committees were selected randomly, two rural and one urban based on the Demographic Health Survey methodology.  Individuals were interviewed to determine the period and point prevalence of rectal bleeding, and patterns of health-seeking behavior related to surgical care for this problem.  Individuals aged over 18 were included in this analysis.

Results:  A total of 1350 households and 2,695 individuals were surveyed with a 97% response rate.   Thirty-eight individuals (55% male) of the 1,941 individuals 18 years and older stated they had experienced rectal bleeding (2.0%, 95% CI 1.4% to 2.7%), with a mean age of 45.5 (SD 2.2).  Of these 38 individuals, 30 stated they currently experience rectal bleeding.  Healthcare was sought in 18 participants with current rectal bleeding, with 2 major procedures performed, one an operation for an anal fistula.  For those who sought healthcare but did not receive surgical care, reasons included no need (4), not available (6), fear/no trust (5) and no money for healthcare (1).  For those with current rectal bleeding who did not seek healthcare, reasons included no need (1), not available (2), fear/no trust (6) and no money for healthcare (4).  Twenty-four individuals had an unmet surgical need secondary to rectal bleeding (1.2%, 95% CI 0.8% to 1.8%).

Conclusion:  The Nepal healthcare system at present does not emphasize the importance of surveillance colonoscopies or initial diagnostics by a primary care physician for rectal bleeding.  Our data demonstrate limited access for patients to undergo evaluation of rectal bleeding by a healthcare professional, and that potentially there are people in Nepal with rectal bleeding that may have undiagnosed colorectal cancer.  Further advocacy for preventative medicine and easier access to surgical care in LIC is crucial to avoid emergency surgeries, advanced stage malignancies or fatalities from treatable conditions.

 

14.08 Designing an International Partnership to Improve Surgical Training in a Low-Income Country

Posted on December 22, 2014

E. Snyder1, V. Amado3, M. Jacobe3, M. Bruzoni1, D. Mapasse3, D. DeUgarte2  1Stanford University,School Of Medicine,Palo Alto, CA, USA 2David Geffen School Of Medicine, University Of California At Los Angeles,Los Angeles, CA, USA 3Eduardo Mondlane University,School Of Medicine,Maputo, MAPUTO, Mozambique

Introduction:  Sub-Saharan Africa has the lowest number of surgeons per population in the world. Mozambique has 0.2 general surgeons per 100,000 people whereas the United States has 7 per 100,000. Mozambique’s few attending general surgeons are not only involved in the training of surgical residents but also in the education of “tecnicos de cirurgia,” non-physician surgical specialists that address Mozambique’s surgeon shortage by performing operations in provincial and district hospitals where surgical care would otherwise be unavailable. The expense and expertise required to improve surgical training are major barriers to increasing surgical capacity in low-income countries. In this study, we reviewed general surgery admissions and operative logs to guide international academic partnership efforts to improve surgical training in Mozambique.

Methods:

A retrospective review was performed of all general surgery logbooks and ward discharge records from August 2012 to August 2013 at a large tertiary care hospital in Mozambique. Local and international partners reviewed the data to identify strategies for improving surgical training and delivery of surgical care.

Results:

2,617 inpatient records and 1,598 major surgical procedures were reviewed. Of patients undergoing surgery, 58% were male and mean age was 39 years. The mortality rate of patients treated in the department was 5.6%, and the mean age of deceased patients was 49 years. Most common conditions contributing to death were sepsis (23%) and HIV (14%). Of 688 elective procedures, the most commonly performed were hernia repair (29%), breast surgery (12%), hemorrhoidectomy (9%), and amputations (9%). Of 910 emergency procedures, the most frequently performed were appendectomy (15%), hernia repair (13%), amputation (12%), and incision and drainage (12%). Overall, 153 (17%) of emergency operations performed were for traumatic injuries. Of the 30 cases involving spleen trauma, 87% resulted in splenectomy. No standardized trauma resuscitation protocol was identified; CT-scan and ultrasound are not routinely available. 36% of hernias were repaired as emergencies. No laparoscopic procedures were performed.

Conclusion:

International partners can support surgical programs in low-income countries by providing funding and expertise to improve surgical skills and research. We recommend a needs-assessment approach in order for collaborative efforts to be contextually appropriate. For Mozambique, these training projects could address the development of a trauma and critical care system, the improvement of the availability of imaging, earlier referral and treatment of hemorrhoids and hernias, and the introduction of minimally invasive treatment strategies to address limited bed space and operative capacity. Our experience could serve as a model for international collaborations focused on increasing surgical capacity and supporting surgical training in other low-income countries.

 

14.09 Sustainable Surgical Care Through Collaboration with Rural Guatemalan Health Promoters

Posted on December 22, 2014

L. S. Foley1, J. Schoen1  1University Of Colorado Denver,Surgery,Aurora, CO, USA

Introduction:  Rural Guatemalans face obstacles limiting healthcare access that are common to impoverished, remote communities: lack of financial resources, limited transportation, discrimination, language barriers, and fear of unfamiliar health centers.  Delivering surgical care within these remote communities is challenging.  We hypothesized that delivery of sustainable surgical treatment is possible through coordination between existing Guatemalan health promoters and visiting surgical teams.  

Methods:  A general surgical team and translators from International Surgical Missions (ISM; Pueblo, CO) have joined with Asociación Compañero Para Cirugía (ACPC, local health promoters) in San Juan Sacatepéquez, Guatemala, through Partners for Surgery (PFS) in October 2012 and 2013.  PFS is a volunteer organization that provides sustainable access to surgery and medical care by connecting indigenous Guatemalan communities and international volunteer teams.  In advance, health promoters screened remote villages for individuals with surgical complaints.   Those identified were transported, along with their family members, to a converted surgical center with communal living quarters.  A Guatemalan family physician performed basic screenings and tests.  ISM provided instruments, medications and surgical care. 

Results: Data from the October 2012 mission were reviewed.  Two general surgeons and two surgical residents performed pre-operative histories and examinations on seventy-seven potential surgical candidates identified by ACPC.  Sixty-six patients (85.7%) were deemed appropriate candidates and underwent surgery over six operative days.  Forty-eight cases (72.3%) were performed under general anesthesia.  Fourteen laparoscopic cholecystectomies were performed without open conversion.   Patients recovered in adjacent living quarters and were transported back to villages.  Health promoters continue visiting villages to identify new surgical patients and anyone with post-operative issues.  Patients in need of surgical attention are transported back to converted surgical center and evaluated by incoming surgical teams.

Conclusion: Sustainable delivery of surgical care in remote Guatemalan regions is possible through coordinated local and international efforts. 

 

14.10 Humanitarian Skill Set Acquisition Trends Among Graduating U.S. Surgical Residents, 2003-2013

Posted on December 22, 2014

D. H. Rothstein4, A. L. Halverson3, M. Swaroop2  2Northwestern University,Trauma And Critical Care Surgery,Chicago, IL, USA 3Northwestern University,Colon And Rectal Surgery,Chicago, IL, USA 4Women And Children’s Hospital Of Buffalo,Pediatric Surgery,Buffalo, NY, USA

Introduction:  While interest in practicing surgery in resource-constrained settings is on the rise among graduating U.S. surgical residents, there is ongoing debate about an optimal humanitarian skill set for surgeons who chose to work in such settings. In addition, increased emphasis on general surgery case exposure at the cost of specialty surgery case exposure has been documented, and may have a negative impact on the breadth of resident training. Review of general surgery resident case logs to gauge experience in specialty surgery may provide insight into residents’ readiness for work in resource-limited settings.  

Methods:  We compared Accreditation Council for Graduate Medical Education general surgery resident case logs from 2003 and 2013 for operations thought to be essential for working in resource-constrained settings. Case numbers for specialty operations were compared by unpaired t-test analysis between the two time periods.

Results: Case averages in hand, pediatric, genitourinary, and gynecologic surgery decreased significantly from 2003 to 2013 (range 22-51%; p<0.0001). Orthopedic surgery case averages were unchanged, and plastic and general abdominal surgery case averages increased (range 30-44%; p<0.0001). 

Conclusion: Case mix among graduating U.S. surgical residents has narrowed over the past 10 years. Resident experience in a variety of specialty fields, thought to be essential in resource-constrained settings, decreased markedly over the study period. Residents who intend to work in resource-constrained settings may need to craft individualized residency experiences or pursue post-graduate training in specialty surgery courses to best prepare for such work.

 

14.11 Massive Pleural Fluid Collection in Adult Nigerians: Aetio-epidemiologic Profile and Outcome

Posted on December 22, 2014

K. E. Okonta1, .. O. Ocheli1  1University Of Port Harcourt Teaching Hospital,Cardiothoracic Unit, /Department Of Surgery,Port Harcourt, RIVERS, Nigeria

Introduction: To determine the aetiology and incidence and, comparing the mortality of malignant with non-malignant massive pleural effusion (MPE] in our setting

Methods: Prospective study of all the patients diagnosed of massive pleural effusion for one year in two tertiary federal  Hospitals in southern part of the country, Nigeria. Forty-eight of 101 consecutive  patients with MPE and required Chest Tube Drainage and chemical pleurodesis for malignant MPE. The patients were followed-up two weekly at clinic and phone calls

Results:Forty-eight patients(47.5%) had MPE with a mean age of 43 years + 14.04; 35were females and 13 were males with a ratio of 2.7:1.The cardinal symptoms were dyspnoea in 97.7%, cough in 79.1%,chest pain in 48.8% and weight loss in 39.5%. Eighteen patients(37.5%) had malignancy(11 from metastatic breast cancer and 7 in others).Thirty patients(62.5%) were diagnosed of non-malignant conditions-21(44.9%) from pulmonary tuberculosis. Haemorrhagic effusions were from Malignancy in 12(30.8%), pulmonary tuberculosis in 6(15.4%) and trauma in 3(7.7%); straw-coloured effusion were from malignancy in 9(23.1%), pulmonary tuberculosis in 8(20.1%).Eight of 14 patients diagnosed of malignant MPE died within 6 months. Compared with non malignant MPE, patients with malignant MPE had higher mortality (8/14 versus 0/23 with a p value of 0.000).

Conclusion:Pulmonary tuberculosis and Malignancy are the major contributors to the high incidence of MPE.The presentation of an adult patient with non traumatic haemorrhagic or straw-coloured MPE in this sub-region narrows the diagnosis to pulmonary tuberculosis and malignancy with malignant MPE being marker for short survival rate of 6 months

 

14.12 The Epidemiology of Gastroschisis in Zimbabwe in 2013

Posted on December 22, 2014

J. C. Apfeld2, Z. J. Kastenberg2, N. Macheka1, B. A. Mbuwayesango1, M. Bruzoni2, K. G. Sylvester2, S. M. Wren2  1Harare Children’s Hospital,Department Of Surgery,Harare, HA, Zimbabwe 2Stanford University School Of Medicine,Department Of Surgery,Stanford, CA, USA

Introduction:
Survival for infants with gastroschisis in developed countries has improved dramatically in recent years with mortality rates of 4-7%. Conversely, mortality rates for gastroschisis in Sub-Saharan Africa remain dismal at 40-60%. This study aimed to describe the burden of gastroschisis for the major pediatric hospital in Zimbabwe and to identify pre- and post-admission factors associated with in-hospital survival.

Methods:
We sorted the electronic records at Harare Children’s Hospital for abdominal wall defects (ICD-9 756.7) and cross-referenced the subsequent list with the local neonatal unit register. Paper records for these cases were retrieved from the 5,585 admissions to the neonatal unit in 2013, and clinical data was transcribed into a RedCAP database. Univariate analysis of gastroschisis patients was performed using SAS, and odds ratios were calculated to compare patients who survived versus died.  

Results:
95 infants with gastroschisis were admitted to Harare Children’s Hospital in 2013. The minority(42%) were male, the mean birth-weight was 2208g, and the mean gestational age was 36 weeks. Mean maternal age was 19 years. Ninety-one newborns were outborn (outside of Harare Children’s Hospital), 78 born outside Harare Province, and 25 at home. The time from birth to admission was 11 hours (median 6.5). Eighty of 95 patients died (84.2%). The odds of survival were significantly decreased for infants weighing less than 2,500 grams (OR 0.15, 95%CI: 0.05-0.51), for those born at less than 36 weeks gestation (0.06, CI: 0.01-0.50), and for those born to teenage mothers (0.05, CI: 0.01-0.46). The odds of survival trended towards being decreased for those born before arrival to a hospital (0.16, CI: 0.02-1.34) and for those born outside Harare Province (0.35, CI: 0.10-1.22).

Conclusion:
Gastroschisis mortality at Harare Children’s Hospital (84%) is associated with a number of factors that are well known to increase the risk of infant mortality such as low birth weight and prematurity. The high mortality rate observed in this population, however, is also likely due to a number of potentially modifiable factors. These data highlight an important opportunity for the development of innovative approaches to prenatal diagnosis, transportation, nutritional support, surgical management, and augmentation of the existing neonatal and surgical workforce.
 

« Previous Page
Next Page »