57.18 Video Gaming Influence on Technical Abilities Amongst Surgical and Non-Surgical Residents.

Posted on January 18, 2018

J. Lam1, C. Maeda1, T. Suzuki1, T. Pham1, D. Bernstein1, B. Sandler1, G. Jacobsen1, S. Horgan1  1University Of California – San Diego,Minimally Invasive Surgery,San Diego, CA, USA

Introduction:  Video games are ingrained into popular culture. They have been a strong presence for several decades and are a staple of modern day society. It has been established that having skill in video gaming correlates with improved skill in laparoscopic surgery. However, there has not been much data collected on the types of video game genres that are played, and if there is a belief that video games improve your ability to perform technical procedures. We hypothesize there may be a difference between surgical vs nonsurgical specialties regarding the type of video games that are played, as well as the amount of time dedicated to gaming. Our secondary aim is to assess if having a history of gaming effects perceived ability to perform technical procedures.

Methods:  A questionnaire was provided to surgical (n=45) and non-surgical residents and fellows (n=50), to assess video gaming experiences.  Analysis of demographic data, past and current gaming experience, and preference of genre was performed. Statistical analysis comparing surgical and non-surgical groups was performed using Chi-square test. 

Results: There were no significant demographic differences between the surgical and nonsurgical groups. Both groups had similar distribution in age, gender, and post-graduate year (PGY). The top three genres of video games played in the surgery group were roleplaying games (21%), shooter games (17%), and strategy games (12%). The top three genres in the non-surgical group were shooter games (19%), role-playing games, (18%), and fighting games (13%). There was no statistical difference in the genres of video games played by the two groups. In comparing the surgical and nonsurgical groups, there was a statistical difference in the belief that video gaming improved your technical ability (p-value = 0.036). Also, the average maximal amount of hours played per week was higher in those who believed that video games improved their technical ability (median 20 hrs/week). 

Conclusion: Surgical and non-surgical residents have similar patterns of video game play and types of video games that are played. However, surgical residents feel that their video gaming experiences improve their technical abilities. Also, increased gaming history correlated with perceived improvement of technical skills in performing procedures in both groups.

 

57.16 A Novel Cadaver-Based Model for Negative Pressure Therapy Training

Posted on January 18, 2018

C. B. Horn1, A. Coleoglou Centeno1, M. M. Frisella1, C. M. Donald1, G. V. Bochicchio1, S. R. Eaton1, J. P. Kirby1, L. J. Punch1  1Washington University,Department Of Surgery,St. Louis, MO, USA

Introduction:  Negative pressure therapy (NPT) is an increasingly important tool in the healing and management of soft tissue injuries, infections and wounds. However there are few hands-on training models available to teach the necessary skills for the safe and effective application of NPT.  As part a Visiting Preceptorship in Acute Care Surgery, we attempted to develop a cadaveric model, for use in training on NPT application.

Methods: The course consisted of didactic instruction by practicing physicians, operating room demonstration of NPT application and a hands-on laboratory consisting of cadaveric models of common scenarios where NPT could be applied. Two cadavers were prepared for each course. Each cadaver received a 10 centimeter laceration to the right leg, a 10cm x 3cm x 3cm debridement to the right inguinal region, medial and lateral left leg fasciotomies and a 15 x 6 superficial lesion. One cadaver received a laparotomy and was simply left open. The other cadaver received a midline laparotomy with cannulation of the bowel and debridement of the abdominal wall soft tissue so as to create an enteroatmospheric fistula (EAF) with subsequent closure of the fascia. Teams of two physician assistants (PAs) or nurse practitioners (NPs) and course facilitator applied NPT to all injuries. Course surveys were completed by all participants.

Results: Wounds were successfully created to simulate skin graft donor sites (figure 1), necrotizing soft tissue infections post debridement, partially closed fasciotomies (figure 2), open abdomens, lacerations and EAF (figure 3). NPT was successfully applied to all models by participating PA and NPs.  All 9 (100%) participants completed course surveys; 8 (88.9%) participants stated that the course would change their clinical care; 9 (100%) participants rated the lab as “excellent” overall. 

Figure 1. 1a. Lower extremity skin donor site model. 1b. Partially closed fasciotomy model. 1c. Enteroatmospheric fistula model. Note exposed loop of small bowel. 

Conclusion: We have developed a cadaveric model for use in NPT application training for a variety of clinical situations. The initial response to the training was positive, however we acknowledge significant methodological limitations, including lack of pre- and post- course comparison and lack of evaluation of NP and PA competency. Future work will aim to evaluate this model’s effect on trainee competence.

 

57.17 The Use of Virtual Humans for Team Training in the Operating Room

Posted on January 18, 2018

W. Goering1, J. W. Menard1, A. Deladisma1, M. Dimachk1, J. Wood3, B. Lok3, S. Lampotang4, A. Wendling2, A. Cordar3, D. S. Lind1  1University Of Florida-Jacksonville,General Surgery,Jacksonville, FL, USA 2University Of Florida-Jacksonville,Anesthesia,Jacksonville, FL, USA 3University Of Florida-Gainesville,Computer & Information Science & Engineering,Gainesville, FL, USA 4University Of Florida-Gainesville,Anesthesia,Gainesville, FL, USA

Introduction: Time constraints limit the ability to bring all OR team members together simultaneously to practice group communication skills. We hypothesize that virtual humans (VHs) can model behavior and scenarios for healthcare providers to learn communication and teamwork skills in the operating room (OR).  Therefore, we constructed and piloted an interactive team training exercise involving multiple VHs that represent essential OR team members.  To determine the initial face validity and realism of the VH interaction, volunteers participated in a surgery safety checklist scenario with the virtual team members.

Methods: Three virtual human teammates were assembled using a 40 inch 1080 pixel television mounted on a rolling stand with an HDMI connection to a Dell computer with Microsoft Kinect 2 software. The setting for all of the interactions was an actual OR in the outpatient surgical center (OSC) at the University of Florida – Jacksonville. The verbal responses of the VHs were controlled by a Wizard of Oz technique but VHs displayed normal speech, eye contact, facial expressions and movements when interacting with participants.

Results: Eleven medical professionals (4 Surgeons, 3 Nurses, 2 Medical Students and 2 Anesthesiologists) volunteered to participate in the mixed reality scenario.  Following the VH simulation activity, participants completed a survey regarding the face validity and realism of the interaction.

Conclusion: We created an interactive Virtual Human scenario aimed to teach and enhance communication skills in the operating room.  A pilot study with medical students, nursing, anesthesia, and surgery personnel demonstrated high face validity for the interaction with the virtual teammates.  The VHs were perceived by human teammates as real OR team members in the surgical safety checklist scenario and if generally applicable, may be useful for healthcare providers from diverse backgrounds to enhance team communication skills to improve patient safety

 

57.15 Surgical Skills Olympiad: A Four-Year Experience in a General Surgery Residency

Posted on January 18, 2018

A. D. Caine1, A. Kunac1, J. Schwartzman1, A. M. Merchant1, D. H. Livingston1  1Rutgers New Jersey Medical School,General Surgery,Newark, NJ, USA

Introduction:

Resident competition has been shown to increase usage of simulators for skills training and resident performance on simulation tasks. We examined the four-year experience with our “Surgical Skills Olympiad” at a large academic surgical residency in the Northeast. We hypothesize that residents perform better at Olympiad tasks since its implementation due to the competitive nature of the event.

Methods:

Surgical Olympiad is a yearly competition between teams formed with members of each post graduate year (PGY) class. Competition tasks are PGY specific: knot tying for PGY-1, basic FLS for PGY-2, hand-sewn bowel anastomosis for PGY-3, vascular anastomosis for PGY-4 and advanced laparoscopic skills for PGY-5. Competition task scores over a four-year period (2014-2017) were analyzed. In addition, a survey of teaching faculty who participated in Olympiad was conducted.

Results: 

Ten faculty members responded to the survey, for a response rate of 62.5%. Fifty percent of respondents felt that the caliber of surgical skills demonstrated at Olympiad has increased since its implementation. Ninety percent agreed that Surgical Olympiad is a good way for residents to assess their skills against their peers. Over four years there was an improvement in mean scores for knot tying (p<0.05), bowel anastomosis (p=0.08), and advanced laparoscopic skills (p<0.05).

Conclusion: 

Faculty perceive improvement in resident surgical skills since the adoption of Surgical Skills Olympiad and objective measures of resident skills suggest that the annual competition has led to improved performance. More data is needed to assess simulator use before and after Olympiad and long term surgical skill retention.

 

57.11 A Video-Based Coaching Intervention to Improve Surgical Skill in Fourth Year Medical Students

Posted on January 18, 2018

M. B. Alameddine1, M. Englesbe1, S. Waits1  1University Of Michigan,Surgery,Ann Arbor, MI, USA

Introduction:  For senior medical students pursuing careers in surgery, specific technical feedback is critical for developing foundational skills in preparation for residency. This pilot study seeks to assess the feasibility of a video-based coaching intervention to improve the suturing skills of fourth year medical students. 

Methods:  Fourth-year medical students pursuing careers in surgery were randomized to intervention vs. control groups and completed two video recorded suture tasks. Students in the intervention group received a structured coaching session between consecutive suturing tasks, while students in the control group received no coaching in between suture tasks. Each coaching session consisted of a video review of the students’ first suture task with a faculty member that provided directed feedback regarding technique. Following each suturing task, students were asked to self-assess their performance and provide feedback regarding the utility of the coaching session. All videos were de-identified and graded by an independent faculty member for evaluation of suture technique. 

Results: All students who completed the coaching session (n=16) would definitely recommend the session for other students. 94% of the students strongly agreed that the exercise was a beneficial experience, and 75% strongly agreed that it improved their technical skills. Based on faculty grading, those in the control group demonstrated greater average increases in all domains of bimanual dexterity, efficiency, tissue handling, and consistency in between baseline and follow up tasks when compared to the intervention group. Conversely, on student self-assessments, those in the intervention group had greater subjective improvements in all domains of bimanual dexterity, efficiency, tissue handling, and consistency compared to the control group. Subjective, free-response comments centered on themes of becoming more aware of hand movements when viewing their suturing from a new perspective, and the usefulness of the coaching advice. 

Conclusion: This pilot study demonstrates the feasibility of a video-based coaching intervention for senior medical students. Students who participated in the coaching arm of the intervention noticed improvements in all domains of technical skill and noted that the experience was overwhelmingly positive. Although greater average improvements were seen in the control group based on faculty assessments, this result may be attributed to coached students trying new skills for the first time after being instructed on technique. In summary, video-based review shows promise as an educational tool in medical education as a means to provide specific technical feedback. 

 

56.17 Value Driven Healthcare Education: A Needs Assessment At A General Surgery Residency Program

Posted on January 18, 2018

V. Martinez-Vargas1,2, B. Smith1  1University Of Utah,Division Of Vascular Surgery,Salt Lake City, UT, USA 2University Of Puerto Rico School Of Medicine,San Juan, Puerto Rico, USA

Introduction:

Accrediting bodies in medical education have recognized the importance of physician competence in value-driven healthcare (VDH) concepts, including quality improvement, patient safety, service, and cost-containment. A complete VDH curriculum in general surgery residency does not exist and little is known about graduates’ perceived need for this program. The objective of this study was to describe the perceptions of general surgery residency program graduates regarding the need for education in VDH.

Methods:

We developed a survey to assess recent surgery residency graduates’ perceptions of the VDH education they received during training, as well as the importance of knowledge and skills in VDH in their current clinical practice.  Survey items were developed through discussion with VDH experts and the survey was piloted with current residents for clarity.  The survey was emailed to graduates of the University of Utah General Surgery Residency program who completed residency from 2012-2016 (n=23). Data were collected using REDCap (Research Electronic Data Capture).  Descriptive statistics and qualitative analysis were applied to summarize results.

Results:

Thirteen of the 23 graduates responded to the survey (57% response rate).   Half of respondents felt that they received formal instruction in VDH during residency, but 11 (85%) agreed that the amount of instruction on VDH was adequate.  All respondents were involved in a Quality Improvement (QI) project during residency, and 8 respondents (60%) led one.  Only 8 respondents (63%)  described their QI project as a positive experience.  Eleven respondents (85%) felt that they had adequate skills and knowledge to lead a QI effort. When asked what an ideal VDH curriculum would include, the majority felt that cost containment, patient safety, and QI should be included (11 [85%], 10 [77%],and 9 [62%], respectively), while 6 (46%) wanted the opportunity to lead a QI project.  Qualitative analysis of free text responses revealed lack of understanding of QI methods and frustration with being asked to “do more work” during residency.  The majority of respondents agreed that knowledge and practical skills in VDH are important to their day-to-day clinical practice (92% and 77% respectively).

Conclusion:

While recent general surgery residency graduates value knowledge in VDH concepts in their current practice, many did not have a positive experience with QI projects and even fewer expressed interest in leading QI efforts.  Given that QI work is valued by modern health care systems, our results suggest a need to improve our existing VDH training program.  Follow-up studies collaborating with other institutions would help assess the scope of this problem.

 

56.18 Analysis of Instructional Behaviors in Robotic Surgery

Posted on January 18, 2018

S. N. Chu1, C. A. Green2, H. Chern2, P. O’Sullivan2,3  1University Of California – San Francisco,School Of Medicine,San Francisco, CA, USA 2University Of California – San Francisco,Department Of Surgery,San Francisco, CA, USA 3University Of California – San Francisco,Department Of Medicine,San Francisco, CA, USA

Introduction:  Surgical robotics has rapidly emerged in minimally invasive surgery with adoption and expansion into many surgical disciplines. Surgical educators are pressed to integrate robotic training during residency to adequately equip surgical trainees. However, they lack insight about appropriate operative instruction with robotics. We conducted a wet lab using live tissue and robotic technology to observe the instructional behaviors of attendings teaching residents in a robotic environment.

Methods:  At the beginning of the 2017 academic year, senior surgical residents at the University of California, San Francisco completed a four-hour session receiving hands-on experience manipulating live porcine tissue using the da Vinci Surgical System (Intuitive Surgical, Sunnyvale CA). Residents first worked through a series of tissue manipulation drills and then completed a variety of surgical procedures (cholecystectomy, ventral hernia repair, sigmoid colectomy). Instructors, one-on-one, guided residents with the stipulation that they could not touch the operative console. Chen has developed a taxonomy of operating room teaching behaviors for open and laparoscopic surgery. We developed a structured observational form using these teaching behaviors and three independent observers documented instructional behaviors in real time. Through content analysis, researchers summarized the types and frequencies of these behaviors.

Results: Six instructors taught six residents. Instructors represented surgical specialties of colorectal, thoracic, bariatric and general surgery. Four faculty had 2-8 years of robotic experience and two teaching residents had less than a year of experience. Instructors predominantly and consistently used three distinct teaching behaviors, comprising over 75% of all behaviors used to instruct residents. The three behaviors were: verbal direction or re-direction, explaining thought process or decision and complimenting. Instructors employed this subset and frequency of behaviors regardless of specialty area or level of experience. Additionally, instructors displayed higher frequency of active versus passive teaching methodologies (i.e. proactive questioning).

Conclusion: Instructors consistently used a distinct set of teaching behaviors to guide their robotic surgical teaching that varied significantly from those seen in open and laparoscopic cases. Given the constraints of the individual robotic console, which consequently requires instruction from the periphery, experienced surgeons cannot employ many common instructional techniques such as directly pointing out anatomical structures with fingers or instruments or indirectly with a camera, which constitute two of the most highly used instructional behaviors in an open or laparoscopic setting. Further qualitative analysis of successful robotic teaching methodologies will provide guidance for instructional methods and evidence-based curriculum for teaching in this new environment.

56.16 Early Autonomy May Contribute to an Increase in General Surgical Workforce

Posted on January 18, 2018

M. P. Taylor1, M. A. Quinn1, J. Burns1  1East Tennessee State University College Of Medicine,Department Of Surgery,Johnson City, TENNESSEE, USA

Introduction:  Nationally, 85% of general surgery graduates pursue fellowships reducing the incoming general surgical workforce. The Association of American Medical Colleges predicts a shortage of 41,000 general surgeons by 2025. In recent studies, lack of confidence appears to be a major factor contributing to resident decision to pursue fellowship.  We evaluated the level of confidence, level of autonomy, and decision to pursue fellowship at a hybrid academic/community program that historically produces 70% general surgeons.

Methods:  An anonymous survey was sent to current residents and attending surgeons at our institution. Participants responded to questions on their experiences of resident autonomy and level of confidence in technical skills using Likert scales along with simple polar questions. Descriptive statistics were calculated.

Results: There were 28 residents (90%) and 15 attending surgeons (54%) that responded. Most attendings (64%) reported during their third year of residency they began performing the majority (more than 75%) of their major cases as surgeon junior (>50% of the case performed independently) while current residents (55%) reported they were performing the majority of their major cases as a second year resident. Attendings reported that upon graduation from residency, they felt fairly comfortable performing major cases independently (64%) and none (0%) reported feeling very comfortable. Most current residents (90%) reported upon graduation they will feel very confident (45%) or fairly confident (45%) performing major cases independently. No residents reported they would not feel confident (0%).  33% of our current chief residents and only 34% of the total general surgery residents at this institution plan to pursue fellowships. 67% of responding surgeon faculty were fellowship trained. 

Conclusion: Our study showed that our residents appear to have earlier levels of autonomy and greater levels of confidence than that experienced by our practicing surgeons when they were residents. Though we were not able to determine if this difference was statistically significant it would be worthwhile to further investigate and determine if this finding is due to chance, varying confidence levels, or type of training module implemented at our institution.  Our unique program continues to graduate the majority of our surgical residents into successful general surgery practice and variables contributing to this success merit further investigation.

 

56.15 Surgical Education for the Millennial Generation: Transforming ABSITE Learning in the 21st Century

Posted on January 18, 2018

N. Leigh1, M. Passeri1, G. Kim1  1St. Luke’s Roosevelt Hospital Center,Surgery,New York, NY, USA

Introduction: Millennial surgeons have unique traits which can be targeted with novel educational techniques. A “flipped classroom” model of education, consisting of self-directed learning with an interactive resident-run educational conference, was instituted to supplement traditional lecture-based teaching methods. We hypothesized that tailoring education to millenial learners would improve American Board of Surgery In-Training Examination (ABSITE) scores.

Methods: A single center prospective study was conducted at Mt. Sinai St. Luke’s-Roosevelt Hospital, New York. All residents enrolled in the Mt. Sinai St. Luke’s-Roosevelt Accreditation Council for Graduate Medical Education (AGCME)-accredited General Surgery Residency Program during academic years 2015-17 (n=28) were included. A weekly conference, termed General Surgery Club, tailored specifically towards the characteristics of millennial learners and run entirely by residents, was introduced to the existing curriculum in 2015. Membership was voluntary. Self-directed reading was encouraged. Sessions were moderated by resident volunteers. Post-session summary guides were written by residents and left open for collaborative updates on our cloud system. ABSITE percentile scores from 2015 were compared to 2016 and 2017, before and after the introduction of General Surgery Club.

Results: There was an improvement in members’ ABSITE percentile scores from 2015 to 2017 after the introduction of General Surgery Club. Members, when compared with non-members, achieved better overall scores in 2016 (66% vs. 60%) and 2017 (69% vs. 42%). They demonstrated continued improvement with an overall percentile increase of 19% compared with a 16% decrease in non-members. 83% of members compared with 44% of non-members had 1 or more improving scores.

Conclusion: The addition of a resident-run conference tailored to millennial learners, was associated with a significant and consistent improvement in ABSITE scores over a 3 year period.

56.12 Design and Implementation of Surgical Resident Simulation Curriculum via Novel Myotomy Model

Posted on January 18, 2018

B. P. Blackwood1, B. R. Veenstra1, A. Wojtowicz1, S. Pillai1, J. M. Velasco1  1Rush University Medical Center,General Surgery,Chicago, IL, USA

Introduction:  Initially, simulation in surgical education merely focused on technical skills. Recently, the application of deliberate practice theory and individualized adult learning has been shown to be relevant in obtaining higher levels of performance, leading to skill acquisition and professional expert development. Our objective was to design, develop, and implement a novel syllabus to educate residents in the operative management of achalasia and pyloric stenosis.

Methods:  Kern six-step approach was used to identify objectives, target learner needs and develop individualized learning opportunities. A syllabus, based on Kolb learning theory, was created which included both web based cognitive material and individual reflective assessment. We built an inanimate model replicating upper abdominal and chest structures with mesh and silicone based materials. A fresh, 2.5cm in diameter raw sausage, cored out to a 3mm layer was inserted in either the esophagus or the pylorus, representing the muscular layer. Finally an inflated balloon was placed within the core of the sausage.  A senior pediatric surgeon, four general surgeons, and two thoracic surgeons reviewed, tested, and revised the model via an open myotomy simulation. We then evaluated fifteen senior surgery residents.

Results: The cost for construction and assembly of the base model was $289.53. The senior faculty felt that the model provided a reliable and realistic simulation of the key steps required to perform an open myotomy. Residents agreed that this was a high fidelity and realistic model for the practice of performing a myotomy. Furthermore, surgical residents felt inclusion of web based cognitive material followed by individualized assessment on a simulation model facilitated progressive surgical mastery. 

Conclusion: Despite changes in surgical education leading to time constraints, surgical residents are still expected to perform advanced surgical procedures. Our model provides a low cost, reproducible, and realistic simulation for residents, easily adaptable to laparoscopy. Furthermore, it allowed us to successfully implement a novel curriculum to address performance of a myotomy as part of the operative management of achalasia and pyloric stenosis. This curriculum lends itself to individualized learning by applying deliberate practice principles in the acquisition of surgical skills in a stepwise fashion, to facilitate advancement to expert state. 

 

56.07 Understanding the Use of Video in Surgical Education

Posted on January 18, 2018

J. L. Green1, P. Bittar1, V. Suresh1, A. Allori2  1Duke University Medical Center,School Of Medicine,Durham, NC, USA 2Duke University Medical Center,Division Of Plastic, Maxillofacial & Oral Surgery,Durham, NC, USA

Introduction: Training surgical residents in the modern age comes with many challenges. Concerns over duty hour restrictions and limited exposure to essential operations suggest that innovative solutions are needed for proper resident education. The use of surgical video has great potential to enhance training by demonstrating surgical anatomy and procedures, facilitating assessment, and improving feedback. Although there are a variety of uses for video in surgical education, there is little information about which applications of this technology are most effective. The objective of this study was to systematically review the literature for the use of video based technology in surgical residency training and provide evidence based guidelines for its effective use.

Methods: The authors conducted a systematic review of literature on surgical video in surgical residency education. A literature search was performed of PubMed, EMBASE, ERIC, and Web of Science for comparative data and descriptive information on the use of surgical video in residency education. Information regarding video characteristics and video application were gathered from each article. Articles comparing a video group to a non-video group underwent outcome analysis and quality assessment using the Medical Education Research Study Quality Instrument (MERSQI). Video outcomes were categorized as learning (knowledge change), performance (skill change), and experience (resident perspective).

Results: Of the 1168 papers reviewed, 63 articles met inclusion criteria and provided data on surgical video characteristics and applications. The primary video type was endoscopy (27/63, 42.9%) which was captured using laparoscopy (22/63, 34.9%) or arthroscopy (11/63, 17.5%). Videos were usually viewed post-operatively (44/63, 69.8%) by an attending (31/63, 49.2%) or resident (24/63, 38.1%). Of the included articles, 19 articles compared a video to a non-video group and therefore underwent outcome analysis and quality assessment. When compared to a non-video group, video was associated with improved resident learning (6/6, 100%), performance (13/16, 81.3%), and experience (7/7, 100%).

Conclusion: This review of literature illustrates the utility of video based technology as a tool for surgical education. Video based technology serves as a readily accessible platform for real-time feedback, out-of-OR training, and basic didactics. This review of comparative studies shows that the use of video technology not only has positive impacts on resident learning and performance but also provides trainees with a positive learning experience. In regards to video guidelines, the information from this systematic review suggests that resident video review and supplementing video with other educational tools is beneficial to surgical education. 

 

56.01 Surgical Resident Participation in Daily, ABSITE Preparatory e-Quiz

Posted on January 18, 2018

C. V. Warner1, G. Havelka1, S. Naffouj1, H. Shah1, S. Thomas1, J. Sugrue1, A. Mellgren1, J. Nordenstam1  1University Of Illinois At Chicago,Chicago, IL, USA

Introduction: Weekly didactic conference is part of general surgery residency training. Previous studies report no correlation between conference attendance and American Board of Surgery In-Training Examination (ABSITE) performance. However, studies have demonstrated a structured reading program in addition to weekly ABSITE-style questions improve ABSITE scores. We piloted the implementation of a daily, electronically administered, ABSITE-style quiz and evaluated resident participation.

Methods:  General surgery residents at a single institution were given a survey to determine their study habits. Following this, for one month they received daily emails containing two ABSITE-style questions corresponding to each week’s didactic lecture. The number of quizzes taken and quiz scores were compared to 1) reported methods of studying (comprehensive resource (e.g. textbook/ SCORE) or alternative resource (e.g. review book/question bank) 2) effort in learning (attendance to weekly conference and a bi-weekly ABSITE study session and reported time spent studying) and 3) previous standardized examination performance. 

Results: 21 out of 32 (66%) general surgery residents participated in the survey. This included 17 (n=21, 81%) junior (PGY1, 2 and 3) and 4 (n=11, 36%, p=0.02) senior residents. For clinical duties, most residents (n=12, 57%) read when they encountered an unfamiliar case, but few (n=5, 24%) reported a year round reading schedule. Overall, residents read a median of 360 (range 120-600) minutes/month. 71% (n=15) primarily utilized a comprehensive resource, whereas 29% (n=6) used an alternative resource. In preparation for the ABSITE, most residents (53%, n=10) studied at least 8 weeks in advance, but few (n=4, 19%) followed a year round reading schedule. Residents read a median of 60 (range 30-480) minutes/month for the ABSITE. 69% (n=22) of residents partook of the daily quizzes (median 10 quizzes/resident; range 1-27). There was a trend suggesting a comprehensive resource to study for the ABSITE was associated with better quiz scores (p=0.079). Neither attendance to ABSITE study sessions or conferences, nor time spent studying affected quiz performance. There was no significant correlation between previous USMLE STEP 1 and STEP 2 scores. A positive correlation was noted between previous ABSITE scores and daily quiz scores (r=0.342, p=0.212), but this was not significant. Finally, there was a significant, but small, positive correlation between the number of quizzes taken and quiz score performance (r=0.156, p=0.017).  

Conclusion: This pilot study suggests most general surgery residents are willing to take a daily e-quiz to enhance learning. The use of a comprehensive study resource seems to improve results on quizzes. A long-term study is necessary to determine whether implementation of daily emailed quizzes will influence ABSITE performance or augment study habits. 

 

50.20 Failure to Rescue in Liver and Pancreas Surgery: Is the "July Effect" Real?

Posted on January 18, 2018

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

Introduction: Every July, new medical school graduates begin training and there is significant turnover of residents and other trainees.  There is a question as to whether this affects patient outcomes.  Previous studies have produced mixed results and the effect of resident turnover on failure to rescue (FTR) after liver and pancreatic surgery has not been studied.

Methods:  A retrospective analysis was carried out using the National Inpatient Sample (NIS) from years 2012-2013.  Patients who underwent liver or pancreatic resection were identified using ICD-9 procedure codes.  Major in-hospital complications were identified using ICD-9 codes and included myocardial infarction, pneumonia, cerebrovascular accident, acute renal failure, urinary tract infection, wound complications, sepsis, and pulmonary embolism.  FTR was defined as an in-hospital mortality among patients who had one of these major complications.  Hospital factors (location and teaching status) and month of admission were analyzed using logistic regression to determine if they were associated with increased rates of FTR. 

Results: 13,246 patients were identified.  Of these 3,056 had a complication of which 289 died (FTR = 9.5%). 10,190 patients did not have a complication and of these, 99 died (0.97%, p<0.0001).  When analyzed by month of admission, the rate of FTR ranged from 7.1% (November) to 12.5% (October).  Using logistic regression models, we found that in the entire patient sample, the presence of one or more complications was associated with higher in-hospital mortality (OR 2.36, 99%CI 2.12-2.59, p<0.0001).  In the group that had a major complication, neither hospital teaching status (OR -0.20, 95%CI -0.459-0.060, p=0.132) or month of admission (OR 0.001, 95%CI -0.034-0.036, p=0.962) was associated with higher rates of FTR.

Conclusion: Based on this data, neither the teaching status of the hospital or the month of the year is associated with increased FTR.  Administrative data does have limitations and further prospective studies using control groups of non-teaching hospitals will be necessary to determine whether or not resident turnover is associated with increased FTR.

 

50.17 Impact of Active Opioid Use on Healthcare Costs for Patients with Intestinal Obstruction

Posted on January 18, 2018

V. K. Dhar1, Y. Kim1, D. E. Go1, K. Wima1, A. D. Jung1, A. R. Cortez1, R. S. Hoehn1, S. A. Shah1  1University Of Cincinnati,Department Of Surgery,Cincinnati, OH, USA

Introduction:  The overuse of prescription opioid medications is a growing epidemic in the United States. Recent studies have shown that preoperative narcotic use impacts hospital cost and outcomes in surgical patients, but the underlying reasons are unclear.

Methods:  A single-center retrospective analysis was performed on surgical patients admitted with a diagnosis of intestinal obstruction between 2010 and 2014. Patients were grouped into active opioid and non-opioid user cohorts. Active opioid use was defined as having an opioid prescription interval overlapping the date of admission. Chronic opioid use was defined by duration of opioid use for 90 days or longer. Admission or intervention due to opioid-related illness was determined through consensus decision of two independent, blinded clinicians. Primary endpoint was to analyze the effect of active opioid use on hospital resource utilization.

Results: During the study period, 296 patients were admitted with a primary diagnosis of intestinal obstruction. Active opioid users accounted for 18.6% of patients, with a median length of opioid use of 164 days (IQR 54-344 days). Of these, 18.2% were on multiple narcotics at time of admission and 76.4% met criteria for chronic opioid use. Compared to non-opioid users, active users were found to have increased median length of stay (8 days vs 6 days, p<0.05) and higher hospital costs ($12,241 vs $8,489, p<0.05) during index admission. Subgroup analysis of active opioid users demonstrated that opioid-related conditions were responsible for ten admissions (18.2%) and two readmissions (3.6%). Among active users requiring surgical intervention, three patients (21.4%) underwent exploratory laparotomy with negative findings. 

Conclusion: Active opioid users, comprising 19% of this cohort of emergency acute care surgery patients, are predisposed to avoidable admissions and interventions for opioid-related illnesses. Efforts to address opioid use in the surgical population may improve patient outcomes and overall healthcare spending.

 

50.18 Management of Rib Fracture Patients: Does Obesity Matter?

Posted on January 18, 2018

A. Lichter1, F. Speranza1, W. Rebekah1, P. Parikh1, R. Markert1, G. Semon1  1Wright State University,Dayton, OH, USA

Introduction: Obesity has been on the rise in recent decades and has created a significant burden on health care. Obesity plays significant role in presentation and management of trauma patients, including management of pneumonia in polytrauma patients. However, role of obesity has not been evaluated for chest trauma patients with rib fractures.  This study, aims to determine its impact and management of patients who sustain rib fractures as a result of a traumatic incident.

Methods: This study was approved by Wright State University’s IRB.  All adult trauma patients who sustained blunt chest wall trauma causing rib fractures and were presented at our Level 1 Trauma Center from 2013-2014. were included in the study. All the patients who survived less than 48 hours, had penetrating injuries to the chest, or had a concomitant head injury were excluded.  Obesity was defined as a body mass index (BMI) of ≥30.  Both obese and non-obese groups were compared using Pearson Chi-Square test for categorical variables and Man-Whitney U Test for continuous variables. We compared both these groups after adjusting for Injury Severity Score (ISS) using logistics regression when the assumptions for this test are met.  

Results:  213 patients met the inclusion criteria with an average 3.6 ribs fracture. Consistent with the national average, 64 (30.6%) were obese. Both obese and non-obese groups of patients did not differ in age (61.6 vs. 59.9, p=0.89).  Obese patients had higher ISS (17.0 vs 13.9, p=0.05), and significantly higher ventilator days (2.1 vs. 1.2, p=0.003), ICU Length of Stay (LOS) (3.3 vs. 1.9, p=0.004), and total hospital LOS (9.6 vs. 6.0, p=0.019) than non-obese group, however, the mortality was not significantly different (p=0.37).  Since ISS was higher in obese group, we controlled for ISS and determined that the obese patients were more likely to require mechanical ventilation both before and after controlling for ISS (34.4% vs. 16.1%, p=0.003).

Conclusion:  Rib fractures remain an important focus in obese patients admitted to trauma centers since they are at increased risk for requiring mechanical ventilation and has worse outcomes, although overall mortality is not affected. Rib fracture protocols that focus on increased pain control, aggressive pulmonary toilet regimens and possible early surgical intervention need to be further investigated specifically in obese patients to decrease the associated morbidity and improve outcomes.

50.19 Predictors of 30 Day Readmission Following Percutaneous Cholecystostomy

Posted on January 18, 2018

M. Fleming1, Y. Zhang2,3, F. Liu2,4, J. Luo2, K. Y. Pei1  1Yale University School Of Medicine,Department Of Surgery,New Haven, CT, USA 2Yale University School Of Medicine,Section Of Surgical Outcomes And Epidemiology, Department Of Surgery,New Haven, CT, USA 3Yale School Of Public Health,Department Of Environmental Health Services,New Haven, CT, USA 4Beijing 302 Hospital,Beijing, FENGTAI QU, China

Introduction:
High risk patients undergoing cholecystectomy may experience increased morbidity and mortality. Consequently, percutaneous cholecystostomy (PC) has been utilized as a treatment option for acute cholecystitis in this cohort of patients.  Little is known about incidence of and predictive risk factors for readmission following PC; therefore, we sought to determine predictors of readmission after PC.

Methods:
Patients who had PC from 2013-2014 were identified from the National Readmission Database (NRD) by the Healthcare Cost and Utilization Project (HCUP). A 30-day readmission was defined as a subsequent admission within 30 days following the first admission discharge date. Multivariate logistic regression models using stepwise selection were employed to select significant predictive variables. 

Results:
A total of 3,368 patients were identified with 698 (20.7%) readmissions during the study period. Severity of illness directly correlated with readmission risk at 30 days (moderate loss of function OR 1.60 95% CI 1.11 – 2.30, major loss of function OR 1.76 CI 1.23 – 2.52, extreme loss of function OR 2.37 CI 1.62 – 3.46). Additionally, alcohol use (OR 1.45 CI 1.02 – 2.07), congestive heart failure (CHF, OR 1.26 CI 1.01 – 1.57), depression (CI 1.42 OR 1.08 – 1.86), metastatic cancer (OR 1.56 CI 1.05 – 2.30) and peripheral vascular disease (OR 0.73 CI 0.54 – 0.99) were closely correlated with risk for readmission at 30 days. Uncomplicated diabetes (P = 0.05), hypertension (P = 0.93), obesity (P = 0.61), and renal failure (P = 0.47) were not correlated with risk for readmission.

Conclusion:
Percutaneous cholecystostomy has become a crucial tool for the acute care of high risk patients with cholecystitis. However, a significant proportion of patients are readmitted within 30 days following discharge. These patients may benefit from increase care coordination services starting at their index admission and increased communication with the clinical team once the patient is discharged.  Additional studies are needed to determine optimal timing to interval cholecystectomy.

50.15 Robotic Inguinal Hernia Repair: An Academic Medical Centers Experience with First 200 Cases

Posted on January 18, 2018

V. Tam1, J. Borrebach2, S. Dunn2, J. Bellon2, H. Zeh1, M. E. Hogg1  1University Of Pittsburgh Medical Center,Division Of Surgical Oncology,Pittsburgh, PA, USA 2University Of Pittsburgh Medical Center,Wolff Center At UPMC,Pittsburgh, PA, USA

Introduction:
Over the past 5 years, robotic surgery has acquired an increasing share of general surgery cases. Robotic inguinal hernia repair has been shown to be safe and feasible by single surgeons in small case series, but no studies have assessed the safety and efficacy of robotic inguinal hernia repairs by multiple surgeons across multiple centers. We aimed to evaluate the outcomes of the early experience of over 200 consecutive robotic inguinal hernia repairs performed in an academic multi-hospital system.

Methods:
Consecutive robotic inguinal hernia repairs performed between 12/2015 and 3/2017 were analyzed. Retrospective chart review was performed to collect information pertaining to pre-operative patient characteristics and post-operative outcomes. Hospital records were queried for intra-operative information and readmission records. Descriptive statistics were performed to analyze the cohort.

Results:
Over 15 months, 210 robotic inguinal hernia repairs were performed across 7 hospitals by 16 surgeons. The mean patient age was 57.6 (SD 14.1) years, 91.9% were male, and the mean BMI was 26.8 (SD 4.4). Bilateral hernia repairs were performed on 72 (34.3%) patients. Incarceration was present in 13 (6.3%) patients, 29 (14.3%) had a reoperation for a recurrent hernia, and 46 (23.1%) had a history of any previous abdominal surgery. The mean operative time was 102.3 (SD 38.6) minutes and a resident or fellow trainee was present in the operating room for 87 (41.4%) cases. The only two intra-operative complications reported were a sigmoid serosal tear and one case of excessive blood loss. There were no conversions to open or reoperations. Follow-up was available for 145 (69.0%) patients at a mean length of 17.6 (SD 5.9) days. Minor post-operative complications occurred in 33 (15.7%) patients, including 10 (4.8%) with urinary retention and 9 (4.3%) with scrotal swelling. Of 11 (5.2%) patients who visited the emergency room visit for a procedure-related complication within 10 days after discharge, no patients required readmission. 

Conclusion:
In the largest case series of robotic inguinal hernia repairs to date, early experience in an academic multi-hospital system with resident and fellow trainees produced safe outcomes including no open conversions, reoperations, or readmissions. Rates of minor complications were comparable to those reported for laparoscopic and open surgical approaches. 
 

50.16 Automating Post-Operative Care through Patient-Centered Short Message Service (SMS)

Posted on January 18, 2018

S. C. McGriff1, D. Kumar1, P. R. Moolchandani1, M. K. Hoffman2, M. A. Davis2, J. W. Suliburk2  1Baylor College Of Medicine,Houston, TX, USA 2Baylor College Of Medicine,Michael E. DeBakey Department Of Surgery,Houston, TX, USA

Introduction:  Studies have found that in-person postoperative care for low risk operations is both costly for patients and system and not always necessary. Using text messages could be an inexpensive, patient-centered, and safe method to screen patients for complications. We conducted a study to determine the feasibility of using an automated text message system as a screening tool for need for in-person postoperative follow-up.

Methods:  Patients who underwent a laparoscopic operation for non-complicated appendicitis or cholecystitis were recruited and enrolled into the study on day of discharge. The study population was polled to determine preferences for frequency and time of text messaging. Subjects received text messages tailored for patient-centered screening of warning signs of post-operative complication. If screened positive, the participant’s physician was notified. Participants were asked patient satisfaction questions.

Results: During a 5-month period, 44 patients were screened, 39 patients were enrolled: 24 following cholecystectomy operations and 15 following appendectomy operations; 18 received text messages in English and 21 received text messages in Spanish. 2 participants were readmitted with a complication and both were successfully identified by the automated system. 15% of participants elected to cancel their follow-up appointment. 74% of participants with scheduled follow-up appointments attended their appointment. Participant response rate to text messages for the first 10 days following discharge is summarized in Table 1. Of the participants completing the study, 96% indicated they would use the automated text messages again.

Conclusion: This pilot study has shown that an automated text message system as a screening tool for post-op complication is feasible and safe in a safety-net population. Our system was able to capture progression of relevant symptoms of participants and notify the participant’s physician when warning signs were detected. Furthermore, participants would use the text message system again. Given inconsistent response data, there is opportunity for improvement in patient engagement with the communication system. A larger implementation is warranted to demonstrate clinical utility and cost effectiveness.

 

50.13 The Early Impact of Medicaid Expansion on Insurance Coverage for General Surgery

Posted on January 18, 2018

A. S. Chiu1, R. A. Jean1, J. Ross2, K. Y. Pei1  1Yale University School Of Medicine,Surgery,New Haven, CT, USA 2Yale University School Of Medicine,Internal Medicine,New Haven, CT, USA

Introduction:
In 2014, the expansion of Medicaid under the Affordable Care Act allowed states to extend Medicaid benefits to adults with incomes less than 138% of the federal poverty level. Although the Supreme Court ruled that states could opt out of Medicaid expansion, 26 states and the District of Columbia expanded Medicaid eligibility in 2014, with five more states subsequently doing the same. Medicaid expansion has contributed to a decrease in the number of uninsured patients and an increase in the utilization of primary care services; however, it remains unclear whether this has translated into increased insurance coverage for surgical patients.  

Methods:
The National Inpatient Sample (NIS) is the largest all-payer, nationally representative database in the United States. Discharges for the 10 most burdensome emergency general surgery operations (defined as a combination of frequency, cost, and morbidity), were identified in the NIS between 2010-2014. Weighted averages were used to produce nationally-representative estimates. The primary outcome studied was the distribution of insurance type for surgical patients before and after Medicaid expansion in 2014.

Results:
After Medicaid expansion, the proportion of operative admissions covered under Medicaid rose from 15.5% to 18.5% (p<.001), or by approximately 20%. Over the same time, the proportion of uninsured surgical patients decreased from 8.9% to 6.6% (p<.001). In total this translated into an increase of 32,185 general surgery patients who were covered under Medicaid, and 34,305 fewer uninsured general surgery patients. The percentage of privately insured patients decreased from 40.9% in 2010 to 36.2% in 2014 (p<.001), while the percent of Medicare patients rose from 30.4% to 35.4% (p<.001) over the same period. 

Conclusion:
In the first year of Medicaid expansion alone, data from a nationally representative sample shows that the number of general surgery patients covered by Medicaid increased by more than 30,000, while the number of uninsured general surgery patients fell by nearly 35,000. The proportion of private insurance has also gone down over this period, with a reciprocal rise in Medicare coverage, likely explained by demographic shifts towards an aging population. Continued study is needed to evaluate the ongoing impact Medicaid expansion is having on coverage for surgical patients.
 

50.14 POSTOPERATIVE RESPIRATORY FAILURE: Safer Surgery IMPROVES OUTCOMES

Posted on January 18, 2018

A. L. Lubitz1, J. A. Shinefeld1, T. A. Santora1, A. Pathak1, E. E. Craig1, A. J. Goldberg1, H. A. Pitt1  1Temple University,Philadelpha, PA, USA

Introduction: Postoperative respiratory failure is an uncommon, but deadly and costly complication. Approximately 30% of patients who suffer this complication die, and the excess cost is estimated to be $50,000.00 per patient. The aim of this analysis is to document that a multidisciplinary Safer Surgery approach can reduce the incidence of postoperative respiratory failure.

Methods: Postoperative respiratory failure was monitored in both the Vizient (University HealthSystem Consortium) and the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) databases. In Vizient the Patient Safety Indicator (PSI)-11 documents the observed (O) rate per 1,000 cases, the expected (E) rate per 1,000 cases, and the O/E ratio for postoperative respiratory failure. PSI-11 data were monitored from Fiscal Years (FY) 2014-2017. In the ACS-NSQIP database both unplanned intubation and ventilation greater than 48 hours are reported as odds ratios and deciles. Data in the 10th decile are classified as “Need Improvement” while 2nd to 9th decile outcomes are “As Expected.” Safer Surgery is a multidisciplinary initiative whose aim is to optimize the preoperative, intraoperative and postoperative phases of care. Patient education and preparation are key elements in this program, as are surgeon, anesthesiologist and nursing interventions. The RECOVER mnemonic was developed to emphasize: R-review materials, E-expand your lungs, C-cough and deep breath, O-oral care, V-vary activity, E-eat safely and R-rest with the head of the bed up. Educational materials are distributed to patients in surgery clinics, Preanesthesia Testing (PAT) and via the patient portal of our electronic medical record system. Multimedia educational materials were produced for patients, residents and nursing staff.

Results:Patient Safety Indicator (PSI)-11 O/E Ratio decreased from 1.36 in FY 14, to 0.77 in FY 15, to 0.48 in FY 16 to 0.43 in FY 17 (Table 1). The Observed PSI-11 mortality was 30% in the first 18 months of the analysis and decreased to 15% in the most recent 18 months. These improvements represent a savings of 11 lives and $1.5 million dollars. Both the ACS-NSQIP unplanned intubation and ventilator greater than 48 hours needed improvement in FY 15 (Table 1). Both of these metrics have improved to “As Expected” in FY 16 (Table 1).

Conclusion:A multidisciplinary Safer Surgery program improved postoperative respiratory failure outcomes at an academic medical center. A bundle of preoperative, intraoperative and postoperative best practices resulted in improved respiratory outcomes.

 

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