9.17 Schizophrenia is Associated With Increased Length of Stay After Open Ventral Hernia Repair

Posted on January 18, 2018

E. M. Lo2, S. S. Awad1, C. Chai1, K. I. Makris1, L. W. Chiu1, N. Becker1, L. Gillory1, D. S. Lee1  1Baylor College Of Medicine,Department Of Surgery,Houston, TX, USA 2Baylor College Of Medicine,School Of Medicine,Houston, TX, USA

Introduction:   Due to a complex interplay of psychosocial factors, schizophrenia has been associated with worse outcomes following major surgery. This association has not been previously studied for open ventral hernia repairs.

Methods:   Data from the National Inpatient Sample (NIS) from years 2012-2013 were analyzed.  ICD-9 procedure codes were used to identify discharge records for patients who underwent an open ventral hernia repair (OVHR).  Using the Clinical Classification Software provided by the Healthcare Cost and Utilization Project (HCUP), we then identified patients with “schizophrenia and other psychotic disorders”.  Age, gender, length of stay, disposition destination, race, hospital bed size, hospital location/teaching status, and Charlson Comorbidity Index (CCI) were collected for each patient. T-tests, Fisher’s Exact tests and linear and logistic regression were used for analysis.

Results:  We identified 17126 patients who underwent OVHR of which 131 had schizophrenia and 16995 did not. The two groups were similar in terms of age (p=0.292), race (p=0.443), hospital bed size (p=0.218), hospital location/teaching status (p=0.981), and CCI (p=0.152). Schizophrenic patients had a longer length of stay (7.62±0.65 days vs. 5.3±0.055 days, p=0.0002). Fewer schizophrenic patients returned home after surgery (63.36% vs. 78.46% (p=0.0001)) while a greater number of schizophrenic patients required transfer to a short-term hospital or nursing facility (21.37% vs. 6.4% (p<0.0001)). A linear regression model found that length of stay for schizophrenic patients was more than 2 days longer (2.25, 95% CI 1.02-3.49, p<0.0001).

Conclusion:  Longer length of stay and increased reliance on nursing facilities and short term hospitals for post-surgical care increase healthcare costs and seem to indicate that patients with schizophrenia and psychoses lack adequate psychosocial support for optimal post-operative recovery.  Improved multidisciplinary discharge planning that includes social work and inpatient psychiatry may decrease length of stay and increase discharges to home, thus reducing the cost of care.

 

9.16 Nationwide Comparison of Laparoscopic Versus Open Treatment of Adhesive Small Bowel Obstruction

Posted on January 18, 2018

J. L. Buicko1, J. Parreco1, M. A. Lopez1, R. Rattan1, M. A. Lopez-Viego1, R. A. Kozol1  1University Of Miami,Palm Beach General Surgery Residency,Atlantis, FL, USA

Introduction:

Most prior large population-based studies comparing laparoscopic and open surgery for adhesive small bowel obstruction have found more favorable outcomes with laparoscopic surgery. However, these studies were limited in comparison of readmission rates. The purpose of this study was to compare outcomes after surgery for adhesive small bowel obstruction including readmissions to different hospitals across the US.

Methods:

The Nationwide Readmission Database for 2013-2014 was queried for all patients aged 18 years or older with a primary diagnosis of small bowel obstruction and undergoing enterolysis. Patients with diagnoses related to non-adhesive causes of small bowel obstruction were excluded. Groups were created based on the type of surgery: open, laparoscopic, and laparoscopic converted to open. Outcomes of interest were: small bowel repair/resection, length of stay (LOS) > 7 days, in-hospital mortality, readmission within 30 days, and readmission within 30 days to a different hospital. Univariable logistic regression was performed for these outcomes and the variables with p<0.05 were used for multivariable logistic regression. Results were weighted for national estimates.

Results:

There were 65,283 patients who underwent operative treatment for adhesive small bowel obstruction. Open surgery was used to treat 83.2%, laparoscopic surgery alone was used in 13.4%, while 3.3% were laparoscopic converted to open. The laparoscopic approach was associated with reduced risk for small bowel resection or repair (OR 0.42, p<0.01). Laparoscopic converted to open was associated with an increased risk for small bowel resection or repair (OR 1.38, p<0.01). Risk of mortality was decreased with laparoscopic surgery (OR 0.52, p<0.01) and cases converted to open (OR 0.62, p=0.01). Risk for LOS >7 days was also decreased with laparoscopic surgery (OR 0.28, p<0.01) while there was no difference between open and converted cases (OR 1.05, p=0.39). Laparoscopic surgery was also associated with a decreased risk for readmission (OR 0.70, p<0.01) and there was no difference between open and converted cases (OR 1.08, p=0.30).

Conclusion:

Outcomes after surgery for adhesive small bowel obstruction, including readmission rates, are more favorable for laparoscopic surgery. Additionally, laparoscopic converted to open outcomes are similar to open alone. 

 

9.14 Operating Room Staff and Surgeon Documentation Curriculum Improves Wound Classification Accuracy

Posted on January 18, 2018

K. E. Epler1, S. Schrader1, J. Gorvetzian1, J. Romero1, R. Schrader3, A. Greenbaum2, R. McKee2  1University Of New Mexico,School Of Medicine,Albuquerque, NEW MEXICO, USA 2University Of New Mexico,Department Of Surgery,Albuquerque, NEW MEXICO, USA 3RMS Biostatistics Services,Albuquerque, NEW MEXICO, USA

Introduction:
Misclassification of wounds in the operating room can have adverse effects on surgical site infection (SSI) reporting and reimbursement. The aim of this study was to measure the effects of a curriculum on documentation of surgical wound classification (SWC) for operating room staff and surgeons. 

Methods:
Accuracy of SWC was determined by comparing SWC documented by operating room (OR) staff during the original operation to SWC determined by in-depth clinical chart review.  Patients 18 years or older undergoing inpatient surgical procedures met inclusion criteria; dental and endoscopic procedures were excluded. A SWC curriculum was implemented during OR staff meetings and surgeon conferences over 4 months. SWC posters were placed in all adult ORs. The accuracy of SWC documentation was retrospectively assessed in 248 randomly selected surgeries during a 5-week period prior to curriculum implementation and compared to 5 weeks of prospective data for 242 cases after the intervention.  Changes in SWC accuracy were assessed pre- and post-intervention using the kappa coefficient.  A p-value for change in agreement was computed by comparing pre- and post-intervention kappas. A power analysis was done.

Results:
Inaccurate documentation of surgical wound class decreased from 33% to 21% after curriculum implementation (Kappa improved from 0.54 to 0.70; p = 0.001). Classification accuracy improved across all wound classes; however, class III and IV wounds were more frequently misclassified and to a higher degree than class I and II wounds, both before and after the intervention (see figure). 

Conclusion:
Implementation of a multidisciplinary documentation curriculum resulted in a significant decrease in SWC documentation error. Improved accuracy of SWC reporting will facilitate a better assessment of SSI risk in a complex patient population.  
 

9.15 Patient Reported Outcomes as Basis for Optimization of Pain Medication after Emergency Surgery

Posted on January 18, 2018

P. Moolchandani1, D. Kumar1, S. McGriff1, E. Alore1, M. A. Davis1, J. Ward1, S. Gordy1, J. W. Suliburk1, M. Hoffman1  1Baylor College Of Medicine,Houston, TX, USA

Introduction: Use and abuse of narcotic pain medicine has come to the forefront of the national healthcare crisis. Post-surgical patients experience acute pain as a result of their operation and require appropriate pain management. The amount and degree of ambulatory medications prescribed is variable and there is little data to guide physicians. The purpose of this study was to evaluate post-operative pain after routine laparoscopic appendectomy or cholecystectomy via patient reported outcome scores. We hypothesized that improved ambulatory collection of patient reported data would facilitate better understanding of patient pain management needs.

Methods: We prospectively enrolled 39 patients: 15 patients undergoing laparoscopic appendectomy and 24 undergoing cholecystectomy as a result of urgent admission. A cloud-based SMS platform was used to obtain patient reported outcomes on pain each day for 10 days post discharge. Patients were asked via text message to report their pain 0 – 10 each day, with 10 being the worst. Discharge physicians were blinded to patient enrollment in the study. Type and amount of discharge pain medication, demographics, need for readmission, return to emergency department, 30-day complications, and need for additional pain medication at clinic follow up were recorded.

Results: Average age was 36 + 9 years, 64% female. For non-complicated laparoscopic appendectomy and cholecystectomy, there was a downward trend in average pain score per day for the first 10 days, with a large decrease from day 3 to day 4 (Table 1). Patient response rate declined by 30% from day 1 to day 10 (Table 1). Practitioners uniformly prescribed tramadol at discharge with 92% of patients receiving a 3.75 day supply and 8% receiving a 7.5 day supply. In our cohort, there were 2 patients with complications (nausea, wound infection), each returning to the ED and one requiring readmission. There were no patients who required additional pain medication at clinic. 

Conclusion: Patients post-appendectomy had consistently higher levels of pain postoperatively. However, both groups reported a substantial decrease in pain score on post discharge day 4. In this study, the majority of prescribing patterns observed adequately reflected patient reported pain needs. This data supports a short duration of prescription non-oxycodone/non-hydrocodone containing pain medications to cover 4 days post discharge in order to sufficiently manage postoperative pain.  This approach can easily be used to determine ambulatory needs of patients undergoing other types of surgery to generate specific data to assist providers with optimal prescribing post-surgery.

9.12 Variation in Opioid Prescribing Among Surgical Residents, Faculty, and Physician Assistants

Posted on January 18, 2018

R. Howard1, J. Lee1, J. Vu1, J. Waljee1, C. Brummett1, M. Englesbe1  1University Of Michigan,Ann Arbor, MI, USA

Introduction:  Although recent studies show patients consume less than 30% of opioids prescribed after common surgical procedures, it is unknown how prescribing varies with the level of training of the prescriber. We hypothesized that opioid prescribing after laparoscopic cholecystectomy would vary significantly based on the level of the prescribing provider. 

Methods:  In this retrospective, single-center study, we identified patients undergoing elective laparoscopic cholecystectomy from 2015-2016. Postoperative opioid prescriptions represented in miligrams (mg) of oral morphine equivalents (OME) written at discharge were compared between surgical residents, faculty, and physician assistants (PAs). One-way ANOVA was used to evaluate the effect of provider level on the amount of opioid prescribed.

Results: A total of 170 patients were identified. All received postoperative opioid prescriptions at discharge. Surgical residents, faculty, and PAs prescribed 247.5±98.5 mg, 264.4±120.5 mg, and 357.1±180.7 mg, respectively (Figure 1), equivalent to 50, 53, and 71 tablets of hydrocodone/acetaminophen 5/325 mg. Provider level had a significant effect on opioid prescribing (p=0.03), which remains significant after controlling for chronic opioid use among patients (p=0.05). A Tukey post hoc test revealed that PAs prescribe significantly more opioids than residents (p=0.03).

Conclusion: Provider level has a substantial impact on opioid prescribing after laparoscopic cholecystectomy, with PAs prescribing significantly more compared to residents. As we develop evidence-based recommendations to standardize prescribing and reduce opioid excess after surgery, it will be crucial to communicate changes to all members of the surgical team.

 

9.13 Travel and Clinic Time for Postoperative Visits after Laparoscopic Appendectomy or Cholecystectomy

Posted on January 18, 2018

K. Harkey1, N. Kaiser1, K. Mayr2, C. E. Reinke1  2Carolinas Healthcare System,Informatoin & Analytics Services,Charlotte, NC, USA 1Carolinas Medical Center,Department Of Surgery,Charlotte, NC, USA

Introduction: Cost of surgical care for patients involves both direct and indirect costs.  The time investment required for routine postoperative care has not been previously studied.  We evaluated the travel time to the clinic and the percent of time at the clinic spent with the surgical team.  This quality improvement project aimed to quantify the time investment required by patients for postoperative clinic visits after laparoscopic cholecystectomy or laparoscopic appendectomy.

Methods: We performed prospective data collection of patient visits at a surgical clinic and retrospective determination of the distance and travel time required for each visit.  Patients presenting after a laparoscopic appendectomy or laparoscopic cholecystectomy were identified and an independent observer recorded discrete time points of the visit: check-in, patient in-room, surgical team member in-room, surgical team member out of room, patient discharge.  Travel time and distance was determined between each patient’s home address and our clinic address using road network speed limit and mileage analysis.  Geospatial information software (ArcGIS, Network Analysis Extension) calculated the individual drive times & distances for each patient to the clinic; those times and distances were then summarized.

Results:86 patients were identified as having scheduled 88 follow-up appointments.  Mean age was 48 years, 55% were female, and 63% were presenting after a cholecystectomy.  Of the scheduled appointments, 85% were successfully completed, 13% were a “no-show” and 2% of them were cancelled by the patient 2-3 days prior to their scheduled appointment.  Patients spent an average of 51 minutes in our clinic (range 25-116) and on average 21% of that time was spent with a surgical team member (range 2%-52%).  The mean one-way travel distance to our clinic was 29 miles and the mean travel time was 37 minutes.

Conclusion: For patients who have scheduled follow-up appointments after an appendectomy or cholecystectomy in an emergency general surgery clinic, a relatively small percent of their clinic time is spent with the surgical team member.  When looked at as a percentage of total visit time—including travel—the time investment required for this visit with a surgical team member is substantial.  This does not account for additional time costs of parking and locating the clinic.  15% of scheduled appointments were either cancelled with short notice or the patient did not show up, creating inefficiencies in our surgical clinic and likely representing a low patient-perceived ratio of benefit to burden.  This data demonstrates need for development of novel methods of providing follow-up care for surgical patients to improve patient-centeredness.

 

9.10 NSQIP is Better at Identifying General Surgery Patients at High Risk for Readmission than LACE

Posted on January 18, 2018

A. M. Khokar1, V. M. Plant1, J. H. DeAntonio1, W. B. Rothstein1, B. C. Ruch1, J. D. Bennett1, L. G. Wolfe1, B. Kaplan1, S. Jayaraman1  1Virginia Commonwealth University,General Surgery,Richmond, VA, USA

Introduction: Readmissions are costly and often preventable. Identifying patients at high risk for readmission can allow for more targeted interventions. Validated readmission risk calculators such as LACE (Length of stay, Acuity, Comorbidity, Emergency department visits) and American College of Surgeons National Surgical Quality Improvement Program (NSQIP) are available but have not been compared in general surgery patients. One key difference between these two calculators is consideration of the type of procedure the patient is undergoing. The NSQIP calculator requires a CPT code, age, gender, comorbidities, and acuity of case whereas LACE only includes more general variables. We hypothesized that NSQIP is better at identifying high risk general surgery patients who are likely to be readmitted than LACE. 

Methods:  In this retrospective case control study, all patients who had an elective operation (bariatric, GI, and surgical oncology) at a tertiary referral center over 6 months in 2016 were identified. Of these patients, patients who were readmitted within 30 days of discharge and an equivalent number of non-readmitted patients were randomly selected as controls for comparison. LACE and NSQIP were used to determine risk categories and correlated to proportion of patients readmitted. Patients were divided into low (0-5%), moderate (5.1-12.1%), and high risk (greater than 12.1%) based on LACE. Fisher exact test and logistic regression were used to determine statistical significance.  

Results: Of 345 patients, 26 patients were readmitted (7.5%) and in this group, LACE identified 7.4%, 52%, and 41% as low, moderate, and high risk, respectively and NSQIP identified 7.4%, 37% and 56% as low, moderate, and high risk, respectively. NSQIP had a linear relationship and identified a greater proportion of readmitted patients as high risk compared to LACE (p=0.011; p<0.05). NSQIP was more likely to identify readmitted patients as high risk than moderate risk compared to LACE (OR 8.4 with 95% CI 1.5 to 46.1, p=0.0008 vs OR 3.0 with 95% CI 0.8 to 11.8, p=0.0488). Of the controls, LACE identified 19%, 65%, and 15% as low, moderate, and high risk, respectively, whereas NSQIP identified 50%, 38%, and 12% as low, moderate, and high risk, respectively. Again, NSQIP had a linear relationship and identified low risk patients better than LACE but this was not statistically significant (p=0.63).  

Conclusion: The NSQIP risk calculator appears to identify general surgery patients at high risk for readmissions better than LACE which may be too general for this patient population. Both appear to be similar at identifying low risk patients.  Prospective studies comparing these calculators will be essential in the future to address postoperative readmissions.

9.11 The Art and Science of Surgery: Do the Data Support the Banning of Surgical Skull Caps?

Posted on January 18, 2018

A. J. Rios-Diaz1, G. Chevrollier1, H. Witmer2, C. Schleider1, M. Pucci1, S. Cowan1, F. Palazzo1  1Thomas Jefferson University,Department Of Surgery,Philadelphia, PA, USA 2Thomas Jefferson University,Sidney Kimmel Medical College,Philadelphia, PA, USA

Introduction: Joint Commission (JC) recommendations mandate the prohibition of the use of surgical skull caps in favor of bouffant and helmet headwear. In the second half of December 2015, this was implemented at our institution with the theoretical goal of decreasing surgical site infections (SSIs). However, supporting data are limited and have been questioned in recent studies and by our departmental leadership. We aimed to assess the impact of this intervention on SSI occurrence at our institution.

Methods:  Using our institutional American College of Surgeons National Surgical Quality Improvement Program (NSQIP) General and Vascular procedure-targeted data, we identified patients undergoing any surgical procedure classified as clean or clean-contaminated during a twelve-month period before and after implementation of the surgical headwear policy. Patients without complete 30-day follow up were excluded. Cases with active infection at the time of operation were excluded. Vascular surgery operations were excluded due to the implementation of a separate intervention to decrease SSIs during the study period. Patients were grouped according to timing of the operation in relation to policy change (before or after). Descriptive statistics focused on proportions, and adjusted logistic regression models were used to investigate the association of alternative headwear use with any type of SSI. Models were adjusted for potential confounders that included demographics and clinical characteristics (age, gender, race/ethnicity, obesity, diabetes, steroid use, smoking status, cancer, procedure urgency, wound classification). Statistical significance was set at p < 0.05.

Results: There were 1,901 patients undergoing 1,950 procedures during the study period with 767 (39.3%) before and 1183 (60.7%) after the headwear policy measure was adopted. The most common procedures overall were colectomy (18.2%), pancreatectomy (13.5%) and ventral hernia repair (9.9%). The overall rate of any SSI was 5.4%, with no difference before and after policy implementation (5.3% vs. 5.5%; p=0.81). SSIs by type were also comparable (see the Table). Multivariate analysis controlling for age, gender, race/ethnicity, obesity, diabetes, smoking status, steroid use, cancer diagnosis, and type of wound classification showed no association between implementation of this new policy and SSI occurrence (Odds Ratio 1.12 [95% Confidence Interval 0.74-1.72]; p=0.57).

Conclusion: At our institution, the strict implementation of bouffant and helmet headwear with removal of skull caps from the operating room was not associated with decreased SSIs for clean and clean-contaminated cases. These data question the validity of this JC guideline.

 

9.08 Lack of Correlation Between Patient Satisfaction Scores and Surgeon Morbidity and Mortality Rates

Posted on January 18, 2018

T. M. Khan1, J. J. Aalberg1, A. Ofshteyn1, S. Subramaniam1, C. M. Divino1  1Icahn School Of Medicine At Mount Sinai,Division Of General Surgery, Department Of Surgery,New York, NY, USA

Introduction:
Patient satisfaction scores have emerged as important metrics in the delivery of high quality health care. While the association between patient satisfaction and clinical outcomes such as performance on Surgical Care Improvement Program measures have been previously investigated, how these subjective satisfaction scores relate to individual surgeon performance is less well documented. In this study, we evaluated this relationship by comparing patients’ satisfaction with their physician providers as measured by the Hospital Consumer Assessment of Healthcare Provers and Systems survey (HCAHPS) with the morbidity and mortality rates of the individual treating surgeons.

Methods:
Completed HCAHPS surveys for patients treated by surgeons practicing MIS/Bariatric, General Abdominal, Colorectal, and Surgical Oncology at an urban, tertiary care, academic medical center between July 1, 2015 and September 31, 2016 were reviewed retrospectively. Responses to the HCAHPS questions pertaining to patient satisfaction with physicians (namely: 1. during this hospital stay, how often did doctors treat you with courtesy and respect? 2. how often did doctors listen carefully to you? and 3. how often did doctors explain things in a way you could understand?) were recorded. The categorical responses to these questions were converted to numerical scores (Always = 4, Usually = 3, Sometimes = 2, Never = 1), and the average scores were calculated for each attending surgeon. The 30-day mortality and risk-adjusted complication rates during the same time frame for each surgeon were abstracted from the institutional Morbidity and Mortality database. The Pearson correlation coefficient was then calculated to evaluate the relationship between satisfaction score and surgeon performance.

Results:
HCAHPS survey results from 736 patients treated by 30 attending surgeons were reviewed. Overall, surgeons scored favorably in the survey, with aggregate average scores of 3.84, 3.80, and 3.77 (out of maximum 4 corresponding to "Always") for the questions "how often did doctors treat with courtesy/respect,” “how often did doctors listen carefully to you,” and “how often did doctors explain in way you could understand,” respectively. Satistically significant correlation was not observed between the average satisfaction scores and the complication and mortality figures for individual surgeons (Table 1).

Conclusion:
Patient satisfaction with their physician providers as measured by HCAHPS does not correlate with individual surgeon morbidity and mortality rates.

9.09 Mesh Repair Not Standard During Inguinal Hernia Surgery in Northern Ghana

Posted on January 18, 2018

M. G. Katz1, E. Yenli2, D. Bandoh2, F. Gyamfi3, A. Jalali5, R. E. Nelson4, R. R. Price1, S. Tabiri2  1University Of Utah,Department Of Surgery,Salt Lake City, UT, USA 2University For Development Studies,Department Of Surgery,Tamale, NORTHERN REGION, Ghana 3Holy Family Hospital,Department Of Surgery,Berekum, BRONG AHAFO, Ghana 4VA Salt Lake City Healthcare System/University Of Utah,Division Of Epidemiology,Salt Lake City, UT, USA 5University Of Utah,Department Of Economics, Health Economics,Salt Lake City, UT, USA

Introduction: Surgical conditions are a major source of global disease burden, and Africa has the highest rate of Disability-Adjusted Life-Years (DALYs) due to surgical conditions of any global region. Certain surgical procedures, including inguinal hernia repair, have been demonstrated to be cost-effective with DALYs averted rivalling other public health interventions. Ghana has a high prevalence of inguinal hernias (IH) with low repair rates. Untreated IH may present emergently as incarcerated or strangulated, leading to increased morbidity, mortality, and burden on the healthcare system. In a previous study, 65% of IH repaired in Kumasi, Ghana are performed emergently compared to 5-10% reported in high-income countries. When performed electively, suture repair is often used in low and middle-income countries despite multiple randomized controlled trials and meta-analysis demonstrating lower recurrence (2% vs 4.9%) and less pain with mesh repair. Cost of mesh and surgeon education have been identified as barriers in southern Ghana, although little is known for the rest of the country. The purpose of our study was to assess the current state of IH repair in northern Ghana.

Methods: A survey tool was used to capture patient demographics, presentation and characteristics of hernia repair. From January 2013 to January 2017 operative reports from 23 hospitals in northern Ghana were collected. All males above 18 years were included. Data was analyzed using multivariate logistic regression to determine predictors of mesh use.

Results: 4523 patients underwent IH surgery. The average age was 48, and 4522 patients were male. The majority of cases were performed at district hospitals (70%), followed by regional hospitals (25%), then teaching hospitals (3%). Most were repaired electively (95%), but 1.9% were performed due to obstruction, 2.2% for strangulation. Suture repair was most common (94%) while mesh was used 6% of the time. The operation was performed most often by non-surgeon physicians (68%) while the remaining were performed by surgeons (32%). Spinal anesthesia was used 55%, followed by local (42%) and then general anesthesia (3%). The strongest predictor for mesh repair was surgery being performed in a teaching hospital (OR 7.94, p < 0.001), followed by the procedure being performed by a surgeon (OR 4.54, p < 0.001). Hernia repair at a regional hospital was a negative predictor of mesh use (OR 0.22, p < 0.000) as was emergent surgery (OR 0.56, p = 0.047).

Conclusion: Only 5% of patients presented for emergent IH repair, a rate far less than previously reported in Ghana. The 6% rate of mesh repair is similar to previous studies in Africa. Most repairs in northern Ghana are being performed by non-surgeon physicians who were less likely to use mesh. In light of mesh repair’s status as the gold standard for treatment, future investigation should assess and address barriers to mesh placement during IH repair in northern Ghana.

 

 

9.07 Challenging Discharge Planning over the Weekend Leads to Excessive Length of Stay

Posted on January 18, 2018

C. M. Rajasingh1, L. A. Graham3, J. Richman2,3, M. W. Mell1, M. S. Morris2,3, M. T. Hawn1  1Stanford University,Department Of Surgery,Stanford, CA, USA 2University Of Alabama at Birmingham,Department Of Surgery,Birmingham, AL, USA 3Birmingham VA Medical Center,Birmingham, AL, USA

Introduction:  Prolonged hospital stays contribute to avoidable healthcare costs and negative patient outcomes. We hypothesized that surgical patients discharged to facilities other than home are less frequently discharged on the weekend, leading to longer than expected lengths of stay.

Methods:  The National Veterans Affairs Surgical Quality Improvement Program data on inpatient general and vascular surgery from 2008 to 2014 were merged with laboratory, vital signs, prior healthcare utilization, and postoperative complications data from the VA Corporate Data Warehouse. Patients were stratified into two groups by discharge location: home or facility. Outcomes of interest were day of week of discharge and excess length of stay (LOS).  Excess LOS was defined as the difference between the observed and expected LOS with expected LOS calculated using a stratified negative binomial model adjusted for patient and operative characteristics.

Results: Our sample included 135,875 patients with 92% (N=124,797) discharged home and 8% (N=11,078) discharged to a facility. Patients discharged to a facility were older (mean age 67 vs. 64 years, p<0.001) and more frequently had an ASA class of 4 or 5 (36% vs. 16%, p<0.001). They had higher rates of emergency cases (19% vs. 12%, p<0.001) and pre-discharge complications (16% vs. 7%, p<0.001). Patients discharged to facilities represented a much smaller fraction of patients discharged on Saturday and Sunday than patients discharged during the week (Figure 1). Of patients discharged to facilities, 43% had an observed LOS >1 day greater than expected, and these patients account for a disproportionate fraction of the total number of excess days in the early week (Figure 1).  The average excess LOS for patients discharged to a facility on a Monday, Tuesday, or Wednesday was 1.5 days, compared with 0.3 days for patients discharged to home.

Conclusion: Compared with patients discharged to home, patients discharged to facilities were older with more medical comorbidities, and more often underwent emergent procedures. They were less frequently discharged over the weekend and significantly contributed to excess LOS, especially in the early week. This highlights the challenges with discharge planning over the weekend for complex patients. Improving resources available for weekend discharge planning or anticipating discharge needs earlier may improve efficiency of post-surgery hospital care.

 

9.06 When Non-Operative Management for Acute Diverticulitis Fails: Using ACS-NSQIP for Outcomes Analysis

Posted on January 18, 2018

V. L. Luks1, J. Merola1, H. Dong2, F. Li2, K. Y. Pei1  1Yale School Of Medicine,Department Of Surgery,New Haven, CT, USA 2Yale School Of Medicine,Department Of Biostatistics,New Haven, CT, USA

INTRODUCTION

Management of uncomplicated acute diverticulitis is largely non-operative; however, some patients will require surgery during the same hospital stay. Lacking clear guidelines delineating optimal surgical approach and operative timing in this patient population, these decisions are left to the surgeon’s discretion. There is no information regarding the effect of timing of surgery on surgical site infections, length of stay, and mortality.  The objective of this study was to evaluate the association between time to operation with outcomes of interest in patients who underwent colectomy for acute diverticulitis.

 

METHODS

The 2011-2015 ACS-NSQIP database was examined for patients with diverticulitis who underwent urgent (non elective and non emergent) open or laparoscopic colectomy. Outcomes of interest were analyzed using multivariate logistic regression adjusting for patient characteristics and wound classification (surrogate for Hinchey classification). The primary outcomes of interest were: superficial surgical site, deep incisional, or organ space infection or a wound disruption. Secondary outcomes included post-operative length of stay (LOS) greater than 14 days and in hospital mortality.

 

RESULTS

Among patients with diverticulitis who required urgent surgery, 1,576 underwent laparoscopic and 3,571 underwent open colectomy. Waiting beyond 3 days to operate  was associated with greater risk for post-operative infectious complications (OR=1.24, 95%CI=1.03-1.48, p=0.02, and prolonged post-operative length of stay > 14 days (OR=1.76, 95%CI=1.42-2.19, p<0.01); there was no increased risk of post-operative mortality (OR=1.53, 95%CI=0.94-2.49, p=0.08).

 

CONCLUSION

For patients who do not improve clinically during a trial of non-operative management, waiting beyond 3 days after presentation is associated with worse outcomes following open colectomy among surgical candidates presenting with acute diverticulitis.

 

9.04 Meet Your Surgical Team: The Impact of a Facesheet on Patient Satisfaction

Posted on January 18, 2018

S. R. DiBrito1, R. Craig-Schapiro1, H. Overton1, J. Taylor1, M. Bowring1, E. Haut1, B. C. Sacks1  1Johns Hopkins University School Of Medicine,Baltimore, MD, USA

Introduction: Patients often have an incomplete understanding of the roles of surgical providers and their level of training. Misunderstandings about who comprises the "surgical team" can lead to patient confusion, frustration, and dissatisfaction, thus making it difficult for the patient and surgeon to establish a trusting relationship.

Methods: As an ACGME-required residency quality improvement initiative, we conducted a prospective pre-intervention discharge survey of gastrointestinal surgery inpatients from 10/2016-01/2017 to evaluate patient opinions regarding the "surgical team" and other measures of patient satisfaction. The survey consisted of 8 questions on a 5-point Likert scale (1=strongly disagree to 5=strongly agree) in addition to patient demographics. We then introduced a "facesheet", containing team member photos, level of training, and roles [Figure]. We distributed sheets to all surgical inpatients from 02/2017-05/2017. We surveyed these post-intervention patients using the same survey tool. We compared the pre-and post-intervention scores with Mann-Whitney tests and Chi-squared tests after creating binary variables.

Results: We evaluated 153 pre- and 100 post-intervention patients. The two groups did not differ significantly in age, gender, or race. Pre-intervention patients reported median scores of 4 for 5 domains and median of 5 for 3 domains. Post-intervention, median scores were 4 in 3 domains and 5 in 5 domains. The percent of patients answering "Agreed (4) or Strongly Agreed (5)" overall rose from 83% to 88% (p=0.5). Scores for patients agreeing that they knew the "roles" of their providers increased from 72 to 83% (p=0.05) for intervention, and that it was "important" to know who surgical team members were increased from 85 to 94% (p=0.04). Interestingly, there was a trend towards significance in patients feeling more "confident" in their team overall following facesheet distribution (89 to 95%, p=0.09).  

Conclusion: Distribution of facesheets increased patients’ knowledge of the roles of their surgical team members, and the feeling that it was important to know their teams. This intervention is simple, inexpensive, easy to implement, and delivers improvement in the patient experience during surgical admissions. A patient's improved understanding of their inpatient surgical team may be reflected in improved satisfaction scores, and may help foster a stronger patient-physician relationship.

9.05 Converting from Laparoscopic to Open Appendectomy Causes Higher Rates of Surgical Site Infection(SSI)

Posted on January 18, 2018

T. Adediji1,2, L. Rivera1,2, A. Karmaker1,2, M. Wallack1,2, J. Mariadason1,2  1Metropolitan Hospital Center,Surgery,New York, NY, USA 2New York Medical College,Surgery,Valhalla, NY, USA

Introduction: Appendectomy is the commonest emergency surgical operation worldwide, with the majority being performed laparoscopically in the USA now. Laparoscopic appendectomies have comparatively fewer complications including superficial surgical site infection(SSI), although some studies suggest that laparoscopic appendectomies may have a higher risk of organ space SSI. A small percentage of cases require conversion from laparoscopic to open appendectomy, but little is known about the impact of conversion on SSI rates. We postulated that conversion caused a higher SSI rate than both laparoscopic and open appendectomy based on our experience. The purpose of this study was to compare superficial and deep SSI rates for converted, laparoscopic and open appendectomies and if our hypothesis was confirmed, to elucidate possible ways of predicting the need for conversion preoperatively.

Methods: The medical records of all patients undergoing appendectomies at Metropolitan Hospital from January 2004 to December 2011 were reviewed. Cases were divided into laparoscopic, open and converted categories, and the infection rate for each operative method was calculated. Alvarado score and CT findings for cases that required conversion were examined.

Results:In total, 718 cases were reviewed. There were 370 (51.4%) laparoscopic appendectomies, 337 (46.9%) open appendectomies, and 11 (1.5%) converted appendectomies. Laparoscopic appendectomies had a 1.08% rate of superficial SSI (4/370), and a 1.08% rate of deep SSI (4/369). Open appendectomies had a 0.89% rate of superficial SSI (3/337), and a 0.59% rate of deep SSI (2/337). Converted appendectomies had an 18.1% rate of superficial SSI (3/12), and a 9.09% rate of deep SSI (1/11). This difference was statistically significant (p<0.05).

Conclusion: Laparoscopic appendectomies were associated with comparable rates of superficial SSI but higher rates of deep SSI when compared with open appendectomies. The overall rates of superficial SSI (1.25%) and deep SSI (0.97%) in our series were low. Our low superficial SSI rate for open appendectomy may be due to the practice of most surgeons of packing contaminated wounds open with delayed primary closure. Converted appendectomies had the highest infection rates overall when compared with laparoscopic and open appendectomies (p<0.05). This has not been highlighted in the literature previously, and is possibly attributable to the need for multiple incisions, a higher proportion of incisions with primary closures, more advanced disease, and longer duration of surgery. This was not clear from analysis of the 11 cases of converted appendectomy in this series. If a method is created, for predicting which cases would need conversion to open appendectomy, it could help reduce SSI rates.

9.02 Unnecessary Laboratory Utilization in the Postoperative Setting

Posted on January 18, 2018

K. S. Cools1, K. B. Stitzenberg1  1University Of North Carolina At Chapel Hill,Department Of Surgery,Chapel Hill, NC, USA

Introduction:
With the adoption of electronic medical records (EMR), ordering diagnostic tests is easy and useful but has the potential to lead to overuse of testing. The aim of our study is to determine the prevalence and pattern of unnecessary laboratory testing after elective surgery. We hypothesize that the recurring lab ordering pattern leads to higher rates of unnecessary testing.

Methods:

Single-center, cross sectional study of patients admitted for at least one night of non-intensive care unit postoperative care after elective general surgery procedures from 9/2016-11/2016. Patterns of postoperative testing and cost were examined. The necessity of laboratory tests was determined by pre-specified criteria based on the type of laboratory test ordered. Bivariate and multivariate analyses were used to examine factors associated with unnecessary laboratory utilization. Recurring labs are defined as laboratory tests that are ordered to automatically repeat daily. The variable of interest was recurring laboratory orders versus one-time orders.

Results:
Of 96 patients that met inclusion criteria, the majority were non-Hispanic White (66.7%), female (58.3%), with a median ASA of 3 and length of stay of 4 days. At least one postoperative lab was ordered in 97.8% of patients and 46.9% had at least one unnecessary test ordered. Recurring laboratory tests were ordered in 30.2% of patients. Complete blood counts (CBCs), chemistries, and coagulation tests were unnecessary in 39.6%, 35.4% and 9.4% of patients, respectively. Patients who had recurring laboratory tests ordered were more likely to have unnecessary CBCs (OR=68.7, 95% CI 14.2-332.0, p<0.001), chemistries (OR=63.9, 95% CI 15.7-260.4, p<0.001), and coagulation studies (OR=5.6, 95% CI 1.3-24.1, p=0.023). Of total hospital costs for these patients, 32.4% was due to unnecessary laboratory tests. Although only 30% of patients had recurring laboratory tests ordered, this group accounted for 90% of the total unnecessary hospital costs. Total hospital costs for unnecessary testing in these 96 patients was $4,973, which would translate to $84,541 excess costs per year.

Conclusion:
Unnecessarily postoperative laboratory testing is common in elective general surgery patients. Patients with recurring laboratory tests ordered in the EMR had a significantly increased likelihood of having unnecessary tests ordered. These unnecessary tests lead to increased hospital and patient costs, increased patient discomfort with additional venipunctures, and potentially further unnecessary testing. A quality improvement intervention aimed at provider ordering patterns and laboratory test education may help to decrease the amount of unnecessary laboratory testing in the postoperative setting.
 

9.03 Let the Right One In: High Admission Rate for Low Acuity Pediatric Burns

Posted on January 18, 2018

G. M. Garwood1, K. T. Anderson1,2, M. Bartz-Kurycki1,2, R. Martin1, D. Supak1, S. Wythe1, R. Gutierrez1, A. L. Kawaguchi1,2, M. T. Austin1,2, K. P. Lally1,2, K. Tsao1,2  1McGovern Medical School, The University Of Texas Health Sciences Center At Houston,Houston, TX, USA 2Children’s Memorial Hermann Hospital,Houston, TX, USA

Introduction: More than 125,000 children with burn injuries present to Emergency Departments (ED) annually in the US, with less than 10% admitted for treatment. Many pediatric burns are small and may be triaged in the ED with appropriate follow-up. The purpose of this study was to characterize pediatric burn care triage at a children’s hospital to identify targets for quality improvement.

 

Methods: A retrospective review of pediatric patients (<18 years) with primary burn injuries who presented to a tertiary, academic children’s ED in 2016 was conducted. Demographics, triage patterns, and injury characteristics (total body surface area (TBSA) percent burn, degree of burn and body location) were recorded. Patients transferred to a burn specialty center for large burns (>30% TBSA) were excluded. Complex areas were defined as burns to the face, hands, feet, genitalia, or major joints. Low acuity was defined by size (<5% TBSA), depth (not 3rd degree), and no need for conscious sedation for debridement. Child Protective Services (CPS) involvement did not require admission if fully evaluated in the ED. Descriptive statistics, chi2, and multivariate logistic regression was used for analysis. Variables were included in regression if p<0.25 on univariate analysis.

 

Results: In 2016, 300 pediatric burn patients were triaged in the ED, with only 4 requiring transfer to a burn specialty center. Patients were typically young (median age 3.2 years, IQR 1.3-7.3), male (59%), non-White Hispanic (46%), and publically insured (76%). The majority of patients were transferred from outside facilities (64%) and arrived by ambulance (74%). Scalding was the mechanism for most injuries (59%), followed by flame (17%) and contact thermal injuries (16%). Most burns were small (median 3% TBSA, IQR 1-5%), not deep (any 3rd degree: 9%), and able to be debrided without conscious sedation (70%). Half of patients (54%) had low acuity injuries of whom 68% were admitted. In the low acuity cohort, arrival by ambulance (p<0.01), CPS involvement (p=0.02), transfer (p<0.01), and burn mechanism (p=0.03) but not complex area involvement (p=0.36), after hour evaluation (p=0.20), or patient demographics- gender (p=0.30), race/ethnicity (0.90), insurance status (p=0.65)- were associated with admission. On multivariate regression, CPS involvement and arrival by ambulance remained associated with admission in low acuity burn patients (table).

 

Conclusion: Though most burns were low acuity, the majority of children were admitted. Social factors may play an important role in triage decisions but there may be an opportunity for improved resource utilization through standardized admission and discharge protocols. 

9.01 ALERT: Your patient refused VTE prophylaxis. Resident role in ensuring VTE chemoprophylaxis

Posted on January 18, 2018

M. Shyu1,2, L. Kreutzer2, K. Y. Bilimoria2,3, A. D. Yang2,3, J. K. Johnson2,3  1Feinberg School Of Medicine – Northwestern University,Chicago, IL, USA 2Feinberg School Of Medicine – Northwestern University,Surgical Outcomes And Quality Improvement Center (SOQIC), Department Of Surgery,Chicago, IL, USA 3Feinberg School Of Medicine – Northwestern University,Center For Healthcare Studies In The Institute For Public Health And Medicine,Chicago, IL, USA

Introduction: Venous Thromboembolism (VTE) is a serious medical condition that results in preventable morbidity and mortality. Optimal VTE prophylaxis in hospitalized patients includes ambulation, mechanical prophylaxis, and chemoprophylaxis; however, patients often refuse chemoprophylaxis which raises their VTE risk. Institutional data highlighted that surgical residents have high rates of unanswered electronic VTE prophylaxis alerts. Our objective was to better understand resident barriers to providing appropriate VTE prophylaxis and responding to alerts.

Methods:  Semi-structured interviews were conducted with 18 preliminary and categorical general surgery residents at one hospital who had received at least 10 alerts over 9 months. The interview shared resident-specific alert response and asked about their understanding of VTE prophylaxis components, barriers to patient communication, and reasons for alert nonresponse. Interviews were recorded and transcribed verbatim. Common themes were identified using a constant-comparative approach. The Theoretical Domains Framework (TDF) was used to study behavioral factors creating barriers to VTE prophylaxis.

Results: Five themes describe resident barriers to VTE chemoprophylaxis provision and alert response: knowledge, setting patient expectations, administration verification, communication of prophylaxis failures, and alert fatigue. These themes map to three TDF domains: knowledge, social/professional role and identity, and environmental context and resources (Table). Residents have misconceptions about the necessity of, and contraindications to, chemoprophylaxis (knowledge). Residents expected nurses to execute orders and notify them of patient refusals (social/professional role and identity). Residents said they educate patients on chemoprophylaxis only if the patient asks questions or refuses the shot and rarely set patient expectations preoperatively. Reasons for nonresponse to alerts included alert de-prioritization and fatigue (environmental context and resources). Residents mostly overestimate personal performance with regard to alert response rate and individual patient refusal rate.

Conclusion: Knowledge, social/professional role and identity, and environmental context and resources affect resident provision of appropriate VTE prophylaxis and alert response. Specific interventions to improve VTE prophylaxis rates and reduce patient refusals will need to address factors identified in our resident-focused study. Future initiatives will use similar methods to explore the perspectives of attending surgeons in VTE prophylaxis provision.

89.16 Surgery of the benign caudate lobe tumors using an anterior transhepatic approach

Posted on January 18, 2018

A. Li1, M. Wu1  1Eastern Hepatobiliary Surgery Hospital,The Second Special Treatment,Shanghai, SHANGHAI, China

 Introduction:

Because caudate lobe tumors are located deep in the hepatic parenchyma, beneath the confluence of the main hepatic veins and between the porta hepatis, and the inferior vena cava (IVC), resecting these tumors is complex procedure. Our aim is report our experience with resection of benign caudate lobe using the anterior transhepatic approach.

Methods:
15 patients with benign focal nodular hyperplasia (n=9) and hemangioma (n=6) tumors underwent resection between January 2006 and December 2013. Mean age of the patients was 36 years.

Results:
All 15 patients underwent total caudate lobectomy via an anterior transhepatic approach. The median diameter of the tumor was 6.7 cm. Mean operative time was 138 minutes and mean intraoperative blood loss was 560 mL. Postoperative surgical complications were seen in 2 of patients. With a follow-up of 38 months, all patients remain well.

Conclusion:

Although a technically difficult operation, resection of the caudate lobe tumors using the anterior transhepatic approach is feasible procedure and can be performed with acceptable operative risk if care is taken with consideration of some key points in techniques

 

89.17 Is ERCP Alone In High Risk Populations Safe? A Case-Control Series

Posted on January 18, 2018

D. Dolan1, J. Aalberg1, C. Divino1, S. Nguyen1  1Mount Sinai School Of Medicine,Surgery,New York, NY, USA

Introduction:  The current standard of care for choledocholithiasis and related conditions is endoscopic retrograde cholangiopancreatography (ERCP) and cholecystectomy (CCY) in the same admission. But we think that high risk patients, especially the elderly with multiple conditions, can be treated with ERCP only and avoid surgery. Surgery carries a significantly higher risk of mortality and morbidity in patients already under significant medical burden. If this group can be managed with ERCP only then the risks of CCY can be avoided. This study will hopefully show surgeons that they have another option in the management of high risk patients.

Methods:  The records of a single, high volume, institution were evaluated for January 1, 2001 to December 21, 3016. Screening was done by ERCP, CCY, and timing of them. 1435 patients met criteria. Data was reviewed for days between ERCP and CCY if both done, initial admission data, baseline clinical factors, and readmission data. High risk patients were defined as over 65 years, two or more significant organ system conditions, over 65 with a single significant organ system condition, or ASA class III or above. Significant condition was defined as requiring prior operation or procedure, requiring device implant, continuous medication delivery, prior cancer, or requiring previous admission for treatment. Two groups were created; patients with ERCP only and patients with ERCP then CCY. The two groups were then case-control matched.

Results: Early data review of the ERCP then CCY group shows 79 patients with sufficient data for analysis. For that group, regardless of if procedures were done in the same admission, median time between procedures was 4 days (mean: 36.6 days, range: 1 day to 855 days). For the 33 patients who didn’t have both procedures done in the same admission the median time between procedures was 26 days (mean: 83 days, range:1 day to 855 days). 38 patients were readmitted with 30 readmitted for biliary disease and 22 of those patients admitted for interval CCY. Further analysis will generate the remaining data of the ERCP with CCY group and the ERCP alone group to allow for comparison between the two groups. 

Conclusion: It is too early to draw final conclusions from our data. However, we believe the data will show that in high risk populations the standard of care can be changed. 5 patients who had an ERCP only and were later readmitted for CCY had their CCY done over 180 days later. 3 of the 5 readmissions were for their CCY. The other readmissions were for aortic valvuloplasty and choledocholithiasis pain without intervention necessary. This demonstrates the potential that these patients could have been managed with ERCP alone as only one patient demonstrated biliary symptoms requiring admission. For high risk patients this could be a lifesaving option by avoiding major surgery. We believe further data analysis will be hopeful and that our hypothesis will be proved.

 

89.15 Surgical treatment of hepatic cancer invading inferior vena cava.

Posted on January 18, 2018

A. Li1, M. Wu1  1Eastern Hepatobiliary Surgery Hospital,The Second Special Treatment,Shanghai, SHANGHAI, China

Introduction:
To explore the surgical manipulation of inferior vena cava (IVC) in the liver cancer involving IVC in order to increase the resection rate and the operative safety. 

Methods:
The clinical data of 53 cases of liver cancer involving IVC undergone resection in our hospital from January 2011 to December 2016 were retrospectively analyzed. 

Results:
All the patients were treated by operation. Management of IVC included partial excision and repairement (15 cases), and stripping (24cases). HCC with tumor thrombus in IVC underwent hepatectomy and withdraw thrombus (14 cases). All the operations were successful without operative death and major complications. The 1-year, 3-year, 5-year survival rates were 93.15%, 57.58% and 28.57%, respectively.

Conclusion:
BUS, CT and MRI were essential for diagnosis and helpful for treatment. MRI can define whether IVC is pressed, invaded, moved, and obliterated. Liver cancer involving IVC can be selectively treated by operation. Resection and reconstruction of ICV is safe, effective and practical. It can increase excision rate remarkably.

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