07.08 ACGME Duty Hour Reforms Do Not Impact Outcomes in General and Vascular Surgical Patients

Posted on January 18, 2016

N. Tehrani1, S. Wetzel1, M. John1, H. Sanfey1, S. Desai1 1Southern Illinois University School Of Medicine,Springfield, IL, USA

Introduction:

Outcomes associated with the 2003 and 2011 Accreditation Council for Graduate Medical Education (ACGME) duty hour reforms have not been evaluated for patients undergoing index general and vascular surgical procedures. The aim of this study was to evaluate the association between the 2003 and 2011 ACGME duty hour reforms with operative complications, length of stay, mortality, and cost of care. The association between month of the year and outcomes was also evaluated.

Methods:

The 1998-2012 National Inpatient Sample (NIS) was used to identify patients with acute cholecystitis who underwent laparoscopic cholecystectomy, unruptured abdominal aortic aneurysm (AAA) who underwent open repair, or right-sided colon cancer who underwent open right hemicolectomy (RHC). Only teaching hospitals were included in the sample. Patients transferred from another institution, emergency cases, and ruptured AAA were excluded. Control charts and special cause variation were utilized to identify variance in outcomes of over three standard deviations by month and year.

Results:

A total of 15,762 patients underwent laparoscopic cholecystectomy, 23,840 underwent open AAA, and 20,255 underwent RHC over the study period. The overall rate of operative complications decreased in the post-2011 duty hour reform period compared to the post-2003 and pre-duty hour reform periods (P<0.05). LOS also decreased for laparoscopic cholecystectomy and RHC (P<0.05), and also decreased for open AAA once a risk-adjusted analysis was completed (P<0.05). Inpatient mortality and cost of care were not significantly different between the various years for each surgical procedure. Special cause variations of over three standard deviations were not related to either ACGME duty hour reforms or month of the year.

Conclusion:

While there was a decrease in the rate of complications and LOS over time, there was not an association with the institution of ACGME duty hour reforms in either 2003 or 2011, indicating that these changes likely happened for other reasons (i.e. improvement in quality of care, refinement of surgical procedures, etc.). There is also no association between month of the year and patient outcomes, indicating that any positive or negative impact upon patients of interns starting their training is negligible.

07.09 Outpatient Infusion Protocol Decreases Readmission Rates in Post-operative Bariatric Patients

Posted on January 18, 2016

J. L. Salluzzo1, J. Moore2, L. Burke2, K. E. Roberts1, G. Nadzam1, A. J. Duffy1 1Yale University School Of Medicine,Gastrointestinal Surgery,New Haven, CT, USA 2Yale New Haven Hospital,Gastrointestinal Surgery,New Haven, CT, USA

Introduction:

Readmission for dehydration is a common complication of bariatric surgery. Preoperative patient education and postoperative diet plans in bariatric surgery centers emphasize strategies to optimize postoperative oral hydration. Despite this, the Metabolic and Bariatric Surgery Quality Improvement Program (MBSAQIP) national database notes readmission rates for dehydration 1.3% and 1% for Laparoscopic Roux-en-y Gastric Bypass(LRYGB), and 1.7% and 1.3% for Laparoscopic Sleeve Gastrectomy(LSG) for 2013 and 2014, respectively. Dehydration after bariatric surgery is a patient safety issue. In addition to clinical concerns, dehydration and associated inpatient medical costs present a financial burden to hospitals.

We identified dehydration readmissions as a potentially reducible complication in our institution. In 2014, we initiated a quality improvement project to develop an outpatient rehydration protocol at an infusion center.

In addition to standard post-operative follow-up, at-risk patients are identified via routine post-discharge phone calls from bariatric inpatient nurses. The patients are asked screening questions regarding hydration status and oral intake. Patients are then evaluated by bariatric practice APRN. Clinically stable dehydrated patients undergo same day lab work and outpatient fluid resuscitation. A post-infusion evaluation is performed. The patient is followed as an outpatient or admitted to the hospital, as appropriate. We hypothesized that implementation of an outpatient infusion protocol would decrease hospital readmissions related to dehydration in post-bariatric surgical patients.

Methods:

Retrospective review of patients who underwent LSG and LRYGB at an academic teaching hospital in 2013 and 2014 who presented with dehydration. The number of readmissions for dehydration in 2013 (pre protocol) and 2014 (post protocol) was determined, as was the number of patients managed via the infusion center. These data are compared to MBSAQIP national data.

Results:

In 2013, 3.0% of LRYGB (5 of 164) patients and 2.4% of LSG (5 of 212) patients required readmission for dehydration (2.6% overall). After implementation of the infusion center in 2014, 13 patients were identified in screening: 2 were readmitted directly, on protocol, 11 patients were referred for infusions; 7 were managed as outpatients, 4 were readmitted. 0.9% of LRYGB (1 of 110) patients and 1.7% of LSG (5 of 303) patients required readmission (1.45% overall).

Conclusion:

Implementation of a coordinated outpatient rehydration protocol for post-bariatric surgical patients reduced the readmissions at our institution by 40% (44% rate reduction). These rates of readmission compares favorably to national risk-adjusted MBSAQIP benchmarks. We anticipate institutional cost savings from adoption of this protocol.

07.10 Missed Opportunities for Intervention Prior to Fall in Elderly Patients

Posted on January 18, 2016

C. D. Minifee1,2, C. E. Wade1,2,3, J. Holcomb1,2,3, S. D. Adams1,2,3 1Center For Translational Injury Research,Houston, TEXAS, USA 2University Of Texas Health Science Center At Houston,Houston, TX, USA 3Memorial Hermann Hospital,Trauma Surgery,Houston, TX, USA

Introduction: Approximately 33% of elderly people (aged ≥ 65 years) experience a fall each year. With the rapidly aging population, the incidence of injury from ground level falls has surpassed that for motor vehicle crashes. Although most falls cause minor injuries, 20-30% are severe resulting in significant physical impairment, and elderly hospitalized for severe fall-related injuries have a 50% mortality rate. Many health and environmental factors contribute to fall risk in the elderly, however the most predictive risk factor is a prior fall. The CDC has emphasized the importance of injury prevention through identification of risk and intervention. In patients with severe injuries due to a fall, we determined the incidence of fall assessment and prevention during previous hospital encounters.

Methods: We performed a retrospective review of adult (≥65 years of age) trauma patients with severe injury (any AIS ≥ 3) admitted to our Level I center after a ground-level fall in 2014. We reviewed inpatient and clinic records to identify patients with previous admissions to our hospital, and recorded fall risk assessments and prevention efforts.

Results: Of 5448 admissions, 214 patients met the inclusion criteria. The median age was 79 (65-98), and 47% were male with an average ISS of 21 (16-42) and mortality 22%. After chart review, previous admissions were found in 39 (18%), most within 10 years. All 2014 admissions were for severe head injury (AIS > 3) and had a median length of stay of 6 days. Median age was 80 (65-98), 54% were male, and the average ISS was 22 with mortality of 10%. The 39 patients had a total of 66 prior encounters, an average of 1.7 per patient. Prior admissions were for injuries (fall, MVC, stroke) and medical illness (cardiac, cancer, infection). Fall education or intervention was not documented in 68% of the patient encounters and in 4 of the 12 patients with a known history of falls.

Conclusion: As people age, physiological changes and illness affect gate and balance, increasing the risk for falls. Patients with falls are known to be at highest risk for subsequent falls, and potentially fatal injury. We have demonstrated that our institution only documented appropriate risk identification and intervention in 46% of high risk patients. Many elderly patients presenting with a major fall-related injury had not received appropriate intervention during previous encounters, which demonstrates a missed opportunity for injury prevention.

07.06 Defect Reduction And Quality Improvement Through Lean Management Of Rigid Endoscopy Equipment

Posted on January 18, 2016

W. Stehr1, E. K. Sinclair2 1UCSF Benioff Children’s Hospital Oakland,Division Of Pediatric Surgery,Oakland, CA, USA 2UCSF Benioff Children’s Hospital Oakland,Quality Built In,Oakland, CA, USA

Introduction: Rigid bronchoscopy and rigid esophagoscopy for removal of foreign bodies, are delicate and often emergent procedures. The equipment needed for these procedures is complex and very much dependent on the size of the patients. Many hospitals encounter challenges related to the management, maintenance and emergent assembly of this equipment. For the past 30 years this equipment at our Children’s Hospital was maintained in an ‘endoscopy cart’ with 6 drawers. Similar items like lenses or graspers were collocated in the same drawer. This system was prone to problems, as the instruments in the drawers were difficult to manage. The cart was located outside of the Sterile Processing Department (SPD), which led to a lot of variability and required additional operators for maintenance. It was our goal to create a safer and more standardized way of maintaining this equipment using the Toyota Lean management principles.

Methods: As a surrogate measure of motion and possible breakage, we measured the number of drawers that needed to be opened and how many lenses and instruments needed to be touched for a setup. We also measured whether the operating room (OR) technician was able to produce a functioning setup for a patient of a certain age and weight, and the time to completion of the setup. We then performed a 2 day workshop including surgeons, staff from OR and SPD, following the Toyota Lean principles and subsequently repeated the measurements.

Results: We performed (n=7) pre-workshop measures. These showed averages of 9.7 drawers opened, 4.6 lenses touched, 9.7 instruments touched, and a time to setup of 325 seconds. None of the setups were functional. After observation of the process the system was changed to a mobile open-shelf system containing patient-age specific instrument trays. The age groups (0-6 months; over 6 months) were chosen based on our utilization over the past 2 years. Matching sizes of lenses, scopes and graspers were color labeled and collocated in the trays. Immediately after the improvement workshop, different OR technicians produced the following numbers: For a complete setup 0 drawers needed to be opened, 2 lenses touched, 4 instruments touched, and average time to setup was reduced to 105 seconds. All setups were functional. These improvements have been sustained for 2 years.

Conclusion: Despite initial hesitancy to change an established but broken system, this improvement work was made possible through engagement of the key stakeholders. We applied Toyota Lean principles (visual management, kit building, less over processing and elimination of waste) to mistake proof the management and assembly of this delicate and high-risk endoscopy equipment. Our work lead to a 3fold reduction of setup time and 100% improvement of defect free equipment assembly. The new tray system requires less time for management and setup and has reduced the defect rate, even by less experienced operators, to near zero.

07.07 Improving Quality Improvement Knowledge and Engagement Through Mentorship

Posted on January 18, 2016

R. L. Hoffman1, R. R. Kelz1 1Hospital Of The University Of Pennsylvania,Philadelphia, PA, USA

Introduction: Multiple competing priorities make integrating busy surgical residents into quality improvement (QI) activities very difficult. We sought to create a mentorship program in order to create a bi-directional forum for increasing QI awareness and knowledge and to facilitate a culture of continuous quality improvement.

Methods: At the start of the 2014 academic year, a natural experiment in quality education was performed. Each PGY1 categorical surgical resident in a large university-based academic program was paired with a faculty mentor who was also a representative to a unit-based clinical leadership (UBCL) team. The ACS NSQIP QITI Practical QI Curriculum was distributed to both faculty and residents and participation in QI activities was encouraged, however no additional didactics were given. A 15-point surgery-specific modified QI-Knowledge Application Tool was administered at the start and end of the year. Informal feedback on participation in QI activities was also solicited.

Results: On average, the 7 pairs met four times over a 9 month period. Fourteen participants completed the pre-program knowledge test, 10 completed the post-test. There was significant improvement over the time period (mean pre: 10.4 (2.6), post: 12.2 (1.3) p<0.05). Mentors had a higher mean pre-program score (11.3) than residents (9.4, p=0.2), but residents had higher mean post-program scores (12.6 vs 11.8, p=0.4). All participants demonstrated an improved understanding of the importance of risk-adjustment in benchmarking (57% pre, 100% post). Participant responses illustrated the fundamental need for data in the QI process, but lacked a practical understand of discrete data sources. Five of 7 residents attended UBCL meetings and had QI projects in development. Surgical trainees reported difficulty with consistent attendance at UBCL meetings given constraints on time.

Conclusion: Involvement of resident and faculty pairs has a tremendous potential to influence the development of a sustainable culture of quality within a program. By facilitating faculty-resident mentorship with a QI focus, knowledge for both parties improves, and clinically active residents can be successfully incorporated into the QI structure. Next steps will focus on building a didactic component to enhance delivery of the curriculum and validation of the assessment tool.

07.02 Are We Missing the Near Misses in the Operating Room?

Posted on January 18, 2016

E. C. Hamilton1,2, D. H. Pham1, A. N. Minzenmayer1, L. S. Kao3, K. P. Lally1,2, K. Tsao1,2, A. L. Kawaguchi1,2 1University Of Texas Health Science Center At Houston,Department Of Pediatric Surgery,Houston, TX, USA 2Children’s Memorial Hermann Hospital,Pediatric Surgery,Houston, TX, USA 3University Of Texas Health Science Center At Houston,General Surgery,Houston, TX, USA

Introduction:

Electronic hospital variance reporting systems are plagued by underreporting. Variances include near misses (unplanned events that fail to cause patient harm, but had the potential to do so) and adverse events (unplanned events cause actual patient harm). To capture as many variances as possible, we have both electronic and handwritten variance reporting systems in place. The purpose of this study is to prospectively evaluate variances that occur in our pediatric operating room and to compare these variances to the two established incident reporting systems in our hospital.

Methods:

In this prospective observational study, trained individuals directly observed pediatric perioperative patient care for six weeks to identify near misses and adverse events in domains including timeout, medication, equipment, blood bank, surgical counts, and isolation. These direct safety observations were compared to the handwritten perioperative variance reporting system and the electronic hospital variance reporting system. All observations were analyzed and categorized into an additional six safety domains (adverse event, near miss, safety process issue, non-safety issue, indeterminate, good job) and five variance categories (equipment/supplies, knowledge/attitude, policies/process, environment, operations, other). The chi-square test was used, and p-values <0.05 were considered statistically significant.

Results:

Out of 211 observed cases, 137 near misses were identified by trained observers, while 57 handwritten variance reports and 8 electronic reports were filed during the same time period. Only 2 of 137 observed events were also reported in the handwritten or electronic system. Five observed adverse events were not reported in either of the two incident reporting systems. Safety observers were more likely to recognize timeout and equipment variances (graph). Both handwritten variance cards and safety observers identified numerous policy and process issues. The electronic variance system was used infrequently and most often to report intentional incorrect counts. All systems addressed knowledge/attitude and policy/process issues most often and there were no differences for frequency of safety categories (P=0.19).

Conclusion:

Despite multiple reporting systems, near misses and adverse events are vastly underreported. By identifying and addressing near misses, the underlying causes of system and processes can be corrected before they lead to an adverse event. Efforts need to be made to lessen barriers to variance reporting in order to improve patient safety.

07.04 Resident Feedback in General Surgery Bleeds over into Trauma

Posted on January 18, 2016

B. D. Lau1,3, M. B. Streiff2, D. B. Hobson1, P. S. Kraus4, D. L. Shaffer1, V. O. Popoola1, D. T. Efron1, E. R. Haut1 1Johns Hopkins University School Of Medicine,Surgery,Baltimore, MD, USA 2Johns Hopkins University School Of Medicine,Medicine,Baltimore, MD, USA 3Johns Hopkins University School Of Medicine,Health Sciences Informatics,Baltimore, MD, USA 4Johns Hopkins University School Of Medicine,Pharmacy,Baltimore, MD, USA

Introduction: Venous thromboembolism (VTE) prevention is one of the most frequent targets for patient safety and quality improvement in hospitals. In 2013, we began providing individualized feedback to general surgery residents about their VTE prophylaxis prescribing habits which has improved VTE prevention on the general surgery services. We hypothesized that this feedback would also improve VTE prophylaxis prescription by the same residents during non-general surgery rotations. The purpose of this study was to investigate the indirect, or ‘halo,’ effect of providing individualized feedback to residents regarding prescription of appropriate VTE prophylaxis.

Methods: This retrospective cohort study compared appropriate VTE prophylaxis prescription for all patients admitted to the adult trauma service from July 1, 2012 – May 31, 2015 at a Level 1 trauma center. On October 1, 2013, we began providing monthly feedback to general surgery residents regarding their VTE prophylaxis prescribing habits while on general surgery rotations. Data were not provided about off-service practice nor to any other prescribers within the hospital. We compared performance of surgery residents rotating on the adult trauma service before and after they began receiving individualized feedback. We also compared the performance of general surgery residents to all other prescribers (e.g. non-categorical interns, rotating residents, nurse practitioners) who wrote VTE prophylaxis orders on the adult trauma service during the study period.

Results: During the study period, 931 patients were admitted to the adult trauma service and assessed using the trauma-specific risk assessment tool. During the 15-month pre-feedback period, surgery residents wrote appropriate VTE prophylaxis orders for 78.5% trauma patients and other prescribers wrote appropriate orders for 75.4% patients, p=0.441. Surgery residents’ ordering practice for trauma patients significantly improved during the 20-month post-feedback period (94.5% vs 78.5%, p<0.001). Practice significantly improved among other prescribers during the post-feedback period, as well (84.3% vs 75.4%, p=0.036); however, practice was significantly better among surgery residents compared with other prescribers (94.5% vs 84.3%, p=0.001).

Conclusion: Individualized resident feedback has been shown to directly improve VTE prescribing practice. We found a beneficial ‘halo’ effect for other patients treated by those residents. There is a secondary, albeit smaller, ‘halo’ effect for patients treated by prescribers who may be aware of the feedback project despite not directly receiving feedback. Individualized feedback regarding practice habits should be implemented for all providers.

07.05 What’s Wrong with the Surgical Safety Checklist? Thinking Outside the Checkbox

Posted on January 18, 2016

A. A. Hildebrandt1, L. R. Putnam1,2, M. B. Diffley1, K. M. Caldwell1, S. E. Covey1, A. N. Mizenmayer1, K. T. Anderson1,2, A. L. Kawaguchi1,2, L. S. Kao3, K. P. Lally1,2, K. Tsao1,2 1University Of Texas Health Science Center At Houston,Pediatric Surgery,Houston, TX, USA 2Children’s Memorial Hermann Hospital,Pediatric Surgery,Houston, TX, USA 3University Of Texas Health Science Center At Houston,General Surgery,Houston, TX, USA

Introduction: Three-phase (pre-induction, pre-incision, debriefing) surgical safety checklists (SSC) have been widely adopted as an effective tool for decreasing postoperative morbidity and mortality. However, checklist effectiveness has recently been questioned. We aimed to identify potential flaws in the execution of a local, stakeholder-derived SSC, which could lead to its ineffectiveness.

Methods: From May to July 2015, five trained observers directly observed the completion of 11 pre-induction, 19 pre-incision, and 9 debriefing checkpoints during the three-phase SSC for pediatric operations. All checkpoints were assessed for adherence (checking the box). Of the 19 pre-incision checkpoints, 10 were assessed for high fidelity performance (meaningful completion). These fidelity checkpoints represent complex measurable tasks relying on a high-level of team cohesion and communication for meaningful completion. Inter-rater reliability and chi-squared tests were performed; p-values <0.05 were considered significant.

Results: 212 pediatric operations were observed representing 35 surgeons and 9 surgical subspecialties. At least one phase of the SSC was conducted in 100% of cases. 174 pre-induction, 212 pre-incision, and 199 debrief checklists were evaluated with an average adherence to each checklist of 56%, 95%, and 76%, respectively. For the pre-incision phase, adherence to checkpoint completion ranged from 85-100% and averaged 95%, yet high fidelity performance ranged from 36-98% and averaged 75%. Three pre-incision checkpoints (induction concerns, anticipated case duration, and site marking) were performed most consistently with associated meaningful completion. However, 7 checkpoints were performed at a high frequency (range 85-99%) but had a significantly lower rate of fidelity (range 36-86%, p<0.05). Inter-rater reliability kappa values for pre-induction, pre-incision, and debriefing were 0.68, 0.70, and 0.89, respectively.

Conclusion: Although surgical safety checklists are routinely performed, meaningful execution of each and every step remains suboptimal. Monitoring of implementation fidelity can identify specific processes and checkpoints upon which to focus improvement efforts.

69.21 Enhancing Medical Education and Innovation Through Industry Mentors and Experiential Programs

Posted on January 18, 2016

P. Loftus1, C. Elder1, T. D’Ambrosio2, J. T. Langell1,2 1University Of Utah,School of Medicine, Department Of Surgery,Salt Lake City, UT, USA 2University Of Utah,School Of Business,Salt Lake City, UT, USA

Introduction: Our Bench-to-Bedside (B2B) Medical Technology Innovation Competition was created to teach medical innovation and entrepreneurship principles to medical students and residents through the exploration of new technology solutions for clinical problems. Teams of medical students and residents are paired with graduate-level engineering and business students and given the task of identifying an unmet clinical need. Teams are given access to over 100 university physician mentors and a $500 development fund to evaluate the intellectual property (IP) landscape, prototype their solution, and construct a viable business plan. Each year top teams are awarded over $70K in milestone funding to support further project development. In the first three years of the competition, formal mentorships with academic physicians were provided. An informal survey of teams noted a weakness in their understanding of product-market-fit and regulatory-based product development.

Methods: During the 4th year of the competition we created an industrial advisory board composed of corporate-level executives from national and regional biotechnology companies to address the resource deficiency noted by prior teams. A board member was assigned as a business mentor to each B2B team based on his or her experience and expertise with the clinical problem and technology solution pursued. Each team was also provided periodic access to other board members for short-term consultation on an as needed basis. No other changes were made to the program. We then evaluated the impact of business mentors on participant recruitment, attrition rates, and new venture formation.

Results: Implementation of a business mentorship program resulted in >40 unique industry professionals participating as business mentors to B2B teams. Business mentorship expertise included leadership, product development, marketing, IP and new venture law, regulatory compliance and venture capital acquisition. Compared to the previous competition years, student participation increased >2.5 fold to 189, the number of teams participating to 42 and devices developed also more than doubled to 43, and the number of limited liability companies increased 1.7 fold to 12. Furthermore, the attrition rates dropped 22% from 60% in year three to 38% in year four.

Conclusion: The creation of an industrial advisory board composed of corporate-level executives from national and regional biotechnology companies provided a source of invaluable mentorship to medical student and resident innovation teams. In addition to providing a unique real world business perspective to teams, many board members also provided funding to supported device development, awards and scholarships. Furthermore, the industrial board established an invaluable network of university-industry connections and increased the likelihood of medical solutions succeeding, as evidenced by the increase in student participation, devices developed, and companies formations.

07.01 Creating Confusion: Publically Reported Surgeon Ranking Systems are Inconsistent

Posted on January 18, 2016

L. E. Johnston1, R. K. Ghanta1, B. D. Kozower1, C. L. Lau1, J. M. Isbell1 1University Of Virginia,Division Of Thoracic And Cardiovascular Surgery,Charlottesville, VA, USA

Introduction: Measurement of healthcare quality is rapidly moving from the hospital level to the provider level, with two recent initiatives presenting surgeon rankings based on Medicare data. Previous studies have demonstrated significant differences between hospital ranking systems. We hypothesize that there will be similar differences between surgeon ranking systems, and that hospital specialty ranking will not correlate with the average ranking of its surgeons in a particular specialty.

Methods: The U.S. News & World Report (USNWR) hospital scores in orthopedics, urology, gastroenterology & GI surgery, and cardiac care areas were selected as the basis for comparison. The USNWR scores were averaged, and the top 10 hospitals in each specialty were ranked based on the mean score. Hospitals included in this list were identified in ProPublica’s (PP) Surgeon Scorecard and Consumer’s Checkbook’s (CC) SurgeonRatings.org websites. Both sites analyze physician outcomes based on Medicare billing data from 2009-2013 (PP) or 2009-2012 (CC), and USNWR scores incorporated Medicare data from the same time-frame. For each website we recorded each surgeon's score by specialty area, and these scores were then averaged to generate the mean surgeon score at an institution. The mean surgeon score was then used to rank institution-level performance in order to examine the correlation between the PP and CC rating systems, as well as between each of the two rating systems and USNWR.

Results: Compared to averaged USNWR institution rankings in orthopedics and urology, PP rankings had correlation coefficients of 0.33 (p=0.4) and -0.59 (p=0.1). CC ranking correlations were -0.15 (p=0.7) for orthopedics, -0.31 (p=0.4) for urology, -0.01 for GI surgery (p=1.0), and 0.36 (p=0.3) for cardiac care compared to USNWR (Figure, panel A). Comparing PP rankings to CC rankings in orthopedics and urology, the correlation coefficients were 0.47 and 0.56 respectively (Figure, panel B). There was no consistent relationship between number of surgeons/procedures ranked and the institutional rankings.

Conclusion: Medicare data used to generate surgeon rankings produces inconsistent estimates depending on methodology. Average surgeon rankings in a specialty do not correlate well with hospital rankings using either of the publicly available surgeon ranking tools. Current ranking systems produce highly variable results that may confuse rather than inform healthcare consumers, and may inappropriately incentivize surgeons to operate only on lower-risk patients in order to improve their ratings.

69.19 Symptoms are preferential to routine studies for post-operative leaks in perforated ulcer repair

Posted on January 18, 2016

C. Carter2, M. Burger1, M. S. O’Mara1,2 1Grant Medical Center,Trauma And Acute Care Surgery,Columbus, OHIO, USA 2Ohio University Heritage College Of Medicine,Athens, OHIO, USA

Introduction:
In evaluating for post-operative leaks in perforated ulcer repair, there is controversy around whether or not routine radiographs should be used. We hypothesize that postoperative contrast studies will effectively identify suture site leaks and help reduce complications by delaying gastric ingestion.

Methods:
316 patients that underwent surgical repair of a perforated ulcer were retrospectively evaluated. 178 of these patients were subjected to a radiographic study post-surgery. Data was recorded based on whether or not these radiographs were ordered due to protocol or secondary to patient symptoms. A chi square analysis, along with an odds ratio, where then performed.

Results:
Of the patients subjected to a planned contrast study, it was found that 5.6% (9/161) were diagnosed with a leak. The remaining 17 patients underwent a radiograph secondary to symptoms where 4 shown leaks (23.5%). A chi-square analysis was performed and statistical significance was found where p= 0.0069. When the contrast study was performed secondary to symptoms, leaks were 5.2 times more likely to be found.

Conclusion:
Postoperative contrast studies effectively identify suture site leaks and help with reducing complications by delaying gastric ingestion. When contrast studies were performed secondary to symptoms, leaks were 5.2 times more likely to be found. Statistical significance was found; therefore it is more effective to use patient symptoms as a guideline for postoperative contrast studies as opposed to prophylactic radiographs.

69.20 Incisional Negative Pressure Therapy in High Risk Laparotomy Incisions is Safe and Effective

Posted on January 18, 2016

N. W. Kugler1, T. Carver1, J. S. Paul1 1Medical College Of Wisconsin,Milwaukee, WI, USA

Introduction: CDC wound classification demonstrates surgical site infection (SSI) occurs in 15-30% of contaminated (class III) and >30% of dirty-infected (class IV) wounds. Several techniques have been utilized to decrease SSI rates in midline laparotomy incisions, however no technique has shown superiority. Evidence suggests incisional negative pressure wound therapy (INPWT) can decrease wound complications but no literature exists regarding INPWT for high-risk laparotomy incisions. We sought to analyze the efficacy of INPWT in the management of high-risk midline laparotomy incisions.

Methods: Retrospective review of adult patients who underwent laparotomy between January 2013 and June 2014 with midline closure utilizing INPWT. Only class III or IV wounds were included. Laparotomy incisions were loosely closed. INPWT set at 125mmHg is placed over oil emulsion impregnated gauze. INPWT is removed after 5 days and the wound left open to air. Records were reviewed for immediate and/or delayed surgical site complications. Primary endpoint was 30-day incisional SSI. Secondary endpoints included other surgical site complications.

Results: One class III and 12 class IV wounds with median of five days INPWT. The class III wound had a small skin dehiscence with no evidence of superficial or deep SSI. Three of 12 patients with a class IV wound developed a superficial SSI. Among class IV wounds, the rate of superficial and deep incisional SSI was 25% and 0% respectively. Overall surgical site complication rate was 41.7%.

Conclusion: INPWT in closure of high-risk midline laparotomy incisions is a safe, effective method of wound closure with equivalent SSI rates to previously described methods.

69.18 Predictors of Mortality in Patients Undergoing Pancreatic Resections in a Tertiary Healthcare Center

Posted on January 18, 2016

L. I. Amodu1, A. Levy1, M. Akerman1, M. Tiwari1, G. Georgiev1, M. Beltran Del Rio1, J. Nicastro1, G. F. Coppa1, E. P. Molmenti1, H. Rilo1 1North Shore University And Long Island Jewish Medical Center,Center For Diseases Of The Pancreas,Manhasset, NY, USA

Introduction: Surgical resection remains the mainstay of treatment for pancreatic cancer and several benign pancreatic conditions. While historically considered to be high-risk and complex procedures, morbidity and mortality from pancreatic resections have decreased dramatically. We carried out this study to determine independent predictors of mortality following pancreatic resection in a single tertiary healthcare institution.

Methods: Clinical data was collected retrospectively from the records of 111 patients who underwent pancreatic resections from 2004-2013. Mortality was ascertained by the use of hospital records, and the publicly accessible social security death master file (SS-DMF). A univariate screen of possible factors associated with mortality was performed using the Fisher’s exact test for categorical variables and the Mann-Whitney test for continuous variables; a multivariate analysis using logistic regression was performed to determine the independent effects of each factor. Area under the ROC curve (AUC) was used to evaluate the predictive accuracy of the chosen model.

Results: Mortality at 1, 3, and 5 years was 13.2%, 38.4%, and 45.9% respectively. Multivariate logistic regression found that a history of diabetes mellitus (OR = 6.48, p<0.0026), adenocarcinoma (OR = 8.17, p<0.0003), disease recurrence (loco-regional or distant) after initial resection (OR = 4.25, p<0.0235), and post-operative hypotension requiring vasopressors or inotropes within 30 days of surgery (OR = 12.76, p<0.0138) were associated with mortality (AUC=0.86).

Conclusion:Mortality in patients after pancreatic resection is associated with the primary diagnosis of pancreatic adenocarcinoma, disease recurrence after primary resection, and a history of DM. The only independent predictor not associated with primary pancreatic disease and comorbidity is hypotension requiring vasopressors or inotropes within 30 days after resection. The risk of mortality after pancreatic resection can be decreased by active measures to prevent the occurrence of post-operative hypotension and by rapid treatment when it does occur.

69.15 Contaminated Cases: A Dual Stage Approach to High Risk Ventral Hernia Repair

Posted on January 18, 2016

M. Bobbs1, N. Kugler1, T. Webb1, J. S. Paul1 1Medical College Of Wisconsin,Milwaukee, WI, USA

Introduction: The Modified Hernia Grade System (MHGS) was developed to risk stratify complex ventral hernia repairs. MHGS Grade 3 patients have mesh infections, dirty or contaminated fields, and/or violation of the alimentary tract. Reported surgical site infection rates (SSI) are over 40% following single-stage ventral hernia repair in contaminated fields. We developed a dual-stage (DSVHR) approach for MHGS Grade 3 patients to decrease the SSI and recurrence rates.

Methods: Retrospective review of adult general surgery patients undergoing DSVHR between January 2010 and June 2014. All patients were MHGS Grade 3. Primary endpoint was 30-day superficial and deep SSI. Secondary endpoints included other surgical site occurrences (SSO), 6-month recurrence, and mesh excision rates.

Results:Fifteen patients underwent DSVHR. Mean age was 56 years and median BMI of 38.3 kg/m2. Operative indication included ECF (n=6), ECF with infected mesh (n=2), infected mesh (n=2), and ventral hernia repair requiring bowel resection (n=5). Thirty-one operative procedures were performed with median of 2.5 days between procedures. Midline was re-established in 12 patients; five patients had underlay biologic mesh placement; seven underwent component separation with retrorectus mesh placement [synthetic (n=2), biologic (n=5)]. The remaining patients underwent bridging repair with biologic mesh. One patient developed recurrence after 6 months. One patient had a recurrence of their ECF. Four (27%) patients developed a SSI, four (27%) had a SSO. There were no post-operative mesh infections.

Conclusion: DSVHR in MHGS Grade 3 patients is associated with a lower surgical site infection rate than previously reported for those undergoing single stage repairs.

69.16 Single Institution Phasix Mesh Outcomes in a Population of Primarily Complicated/Recurrent Hernias

Posted on January 18, 2016

D. B. LePere1, M. P. Lundgren2, E. L. Rosato2, K. A. Chojnacki2, D. A. Ehrlich1, S. E. Copit1, P. J. Greaney1 1Thomas Jefferson University,Plastic Surgery,Philadelphia, PA, USA 2Thomas Jefferson University,General Surgery,Philadelphia, PA, USA

Introduction: Phasix is a biologic, fully absorbable polymer recently fashioned into a monofilament mesh scaffold being utilized for ventral hernia repair. The mesh has been shown, in a porcine model, to maintain support of a hernia repair site over a 52 week period. Little literature is available regarding outcomes using Phasix mesh for hernia repair. Early data available includes multi-center data outlining outcomes in a population consisting of a majority of primary hernia repairs. A study was undertaken to evaluate the performance of Phasix in a patient population consisting primarily of complex and recurrent hernias.

Methods: A single-institutional study was undertaken at Thomas Jefferson University Hospital in Philadelphia, PA to review outcomes of 52 patients between September 2014 and July 2015 in a population consisting primarily of complicated and recurrent hernias. Patient data extracted included demographic information, BMI, past medical history, past surgical history, mesh dimensions, operative and hospital course data, complications, and follow-up, including readmission.

Results: Fifty-two patients were identified upon review of our records (27 males, 25 females), all of which received overlay Phasix mesh for hernia repair after primary fascial closure. Thirty-four of the patients were over the age of 50 (65.4%), with an average age of 56.7 years. The average BMI of the population was 32.1, with 5 patients < 25 kg/m2 (9.6%), 16 patients 25 – 29.9 kg/m2 (30.7%), 15 patients 30 – 34.9 kg/m2 (28.8%) and 16 patients > 35 kg/m2 (30.7%). Forty-seven of the patients had ventral hernias (90.4%), 43 were incisional (82.7%), 5 were umbilical (9.6%), and 2 were inguinal (3.8%). Thirty-one of the patients were being treated for recurrent hernias (59.6%). The average surgery lasted 4.46 hours, and the average stay was 3.9 days, with 8 patients requiring readmission (15.4%). Post-operatively, 4 patients' recoveries were complicated by seroma (7.7%), 5 by hematoma (9.6%), 8 by infection (15.4%), 1 by ileus (1.9%), 3 required removal of mesh (5.8%), and 2 experienced recurrent hernias (3.8%), both secondary to post-operative infection.

Conclusion: The outcomes of this data series suggests Phasix is a reliable mesh for complex and recurrent hernia repair with a low recurrence and complication rate.

69.17 Combined Endoscopic Laparoscopic Surgery for Benign Colon Polyps: A Single Institution Cost Analysis

Posted on January 18, 2016

L. Tedesco1, J. Paolino1, L. Chen1, J. Yoo1, M. Kiely1 1Tufts Medical Center,Boston, MA, USA

Introduction: Endoscopic removal of benign colon polyps is not always possible, even with advanced endoscopic techniques. While segmental colectomy has been the traditional therapy for these polyps, this procedure is associated with an increased risk of complications and may be unnecessary given that fewer than 20% of these polyps harbor malignancy. Combined endoscopic laparoscopic surgery (CELS) has emerged as an alternative method to address these polyps. Here, endoscopic removal of complex polyps is facilitated by laparoscopic manipulation of the bowel wall, thereby avoiding a bowel resection and its associated risks. While feasibility, safety, and improved short term patient outcomes have been demonstrated, there has never been an evaluation of cost comparing these two approaches within a single institution.

Methods: In this observational cohort study, we examined five patients who underwent CELS for right colon polyps at a large tertiary care center (Tufts Medical Center, TMC) between April 2014 and July 2015. We compared the cost of CELS to that of ten patients who underwent a traditional laparoscopic right colectomy performed for a colon polyp or cancer during the study period. The cost analysis covered the perioperative period from operating room to hospital discharge. Microcosting estimates were obtained from the literature and applied to our specific operating room time and length of stay data for our cohorts. A modified societal perspective was used as the costing structure, with all cost estimates obtained for university hospital settings. The costing estimates were adjusted using the medical consumer price index to 2014 US dollars.

Results:A total of five patients were taken to the operating room with the intention of performing CELS for right colon polyps. Four out of the five patients successfully underwent CELS surgery. The median length of stay (LOS) for all successful CELS patients was 1 day. LOS for patients who underwent a laparoscopic right colectomy at TMC over the same time period was 4.5 days. The median OR time for successful CELS was 157.5 minutes, compared to 141.5 minutes for a laparoscopic right colectomy. The calculated total cost for a CELS patient was $7,513.10, compared to $14,600.50 for a laparoscopic right colectomy, a 49% cost-savings almost entirely attributable to a difference in length of stay.

Conclusion:In the perioperative period, successful CELS procedures are performed at a lower cost compared to traditional laparoscopic colectomy, with the most significant cost saver being shorter hospital length of stay. This is the first study to directly compare the cost of successful CELS to traditional laparoscopic colectomy in the surgical management of benign colon polyps within a single institution. Future studies will evaluate both short and long term costs using intention to treat analysis and a larger sample size.

69.10 Feeding Gastrostomy in Children with Complex Heart Disease: When is a Fundoplication Indicated?

Posted on January 18, 2016

J. L. Carpenter1, T. A. Soeken1, A. J. Correa1, I. J. Zamora1, S. C. Fallon1, M. J. Kissler1, C. D. Fraser2, D. E. Wesson1 1Texas Children’s Hospital,Division Of Pediatric Surgery, Department Of Surgery,Houston, TX, USA 2Texas Children’s Hospital,Division Of Congenital Heart Surgery, Department Of Surgery,Houston, TX, USA

Introduction: Malnutrition is common among children with complex heart disease (CHD) presumably due to a combination of sub-optimal intake and increased energy expenditure. Feeding gastrostomies are often used to improve the nutritional status of such patients. Many also have evidence of gastro-esophageal reflux (GER), which raises the question of the need for a fundoplication at the time of the gastrostomy insertion. When a gastrostomy is indicated, we generally use the open Stamm method to avoid abdominal CO2 insufflation that may affect venous return to the heart and cause hypercapnia and, because GER tends to resolve in infants and young children, we rarely perform a fundoplication at the time of gastrostomy preferring to use gastro-jejunal (GJ) feeding instead for patients with clinically significant GER. The purpose of this study was to evaluate the subsequent course of a cohort of infants and children with CHD following open Stamm gastrostomy without fundoplication.

Methods: We reviewed our experience with all CHD patients who underwent feeding gastrostomy placement from January 1, 2004 to April 7, 2015. We examined demographic data, cardiac diagnoses, operative details, post-operative complications, and the need for GJ feeding or fundoplication.

Results: An open Stamm gastrostomy was performed in 111 patients. Five additional patients had a fundoplication at the time of gastrostomy placement. Median age at surgery was 37 weeks (range 3 weeks to 13.7 years); average weight was 5.3 ±4.9 kg. Forty-eight patients (43%) had single ventricle physiology, 50 (45%) had biventricular physiology, and 13 (12%) had cardiomyopathy. Thirty-four (30%) patients experienced a total of 37 minor complications, which included tube dislodgement after maturation of the stoma (20), superficial surgical site infection (13), mechanical failure (3), and bleeding (1). Three (3%) patients experienced a major complication defined as a need for return to the OR or peri-operative death (<30 days). Only three (3%) patients required a subsequent fundoplication. At last follow-up (median 7.2 months, range 2 days-6 years), 56 of the 90 (62%) surviving patients continue to receive gastrostomy feeds, of those 7 (13%) patients continue to require GJ feeds.

Conclusion: Children with CHD tolerate an open Stamm gastrostomy well with minimal major complications. GER in CHD patients frequently resolves over time and patients seldom require a subsequent fundoplication. Our experience supports very selective use of fundoplication in infants and children with CHD who require a feeding gastrostomy.

69.11 Stage IV Rectal Cancer: Different Than Colon? A Population Study

Posted on January 18, 2016

M. Ostrowski1, M. Mora-Pinzon2, E. He2, J. Eberhardt2, T. Saclarides2, D. Hayden2 1Loyola University Chicago,Stritch College Of Medicine,Maywood, IL, USA 2Loyola University Medical Center,Department Of Surgery,Maywood, IL, USA

Purpose:
Besides the great difference in the treatment algorithm between colon and rectal cancers, some studies suggest that rectal cancer may affect different populations than colon cancer. We will examine the variation in demographic and socioeconomic factors using a population database.

Methods:
Secondary analysis of the 2011 Nationwide Inpatient Sample (NIS) was performed. Hospital discharges were identified using ICD-9 and ICD-9-CM codes for liver metastases, colon and rectal cancer and colon and rectal resections.

Results:
There were 3758 admissions for colorectal cancer metastatic to the liver in 2011. The mean age was 62 years (22-102) and the majority of patients were male (56.5%). Patients with stage IV colorectal cancer were 62.7% white, 15.5% black, 10.2% Hispanic, 2.4% Asian/Pacific Islander and 2.2% other. During these admissions, mean length of stay was 5.8 days (0-50). 31.5% (1182) of these admissions were for patients with a primary diagnosis of liver metastasis and a secondary diagnosis of rectal cancer. Patients with stage IV rectal cancer were younger than those with colon (mean age 58.9 vs. 63.6, p=0.000) and seemed more likely to be male, but the difference was not significant (58.2% vs. 55.9% male, p=0.182). Rectal cancer patients were much more likely to be white and less likely to be black than stage IV colon cancer patients (70.0% vs. 59.4%, and 8.8% vs. 18.5%, p=0.000, respectively). They were less likely to live in large metropolitan cities (p=0.000) and more likely to come from zip codes with higher income quartiles (p=0.001). Stage IV rectal cancer patients were also more likely to have private insurance and less likely to have Medicare or Medicaid when compared to colon cancer patients. Admissions were less likely to be urgent or emergent for metastatic rectal cancer (p=0.000) and the mean length of stay was slightly but significantly shorter (5.5 vs. 5.9 days, p=0.042). The majority of these patients did not have surgery during the admission (67.4%).

Conclusion:
Our study show that stage IV rectal cancer patients have varying demographics when compared to colon cancer patients. They are younger, more likely to be white, come from higher socioeconomic status and more likely to have private insurance. Their admissions are more likely to be elective. These findings suggest that patient characteristics and environmental factors may also differentiate colon and rectal cancer when stage IV disease is present and should be considered when establishing practice parameters.

69.12 Axillary Hidradenitis Suppurativa: Natural History and Factors Associated with Recurrence

Posted on January 18, 2016

N. Nweze1, R. Ahuja1, A. Parsikia1, L. Force1, L. Cetrulo1, J. Strain1, A. R. Joshi1,2 1Einstein Healthcare Network,Surgery,Philadelphia, PA, USA 2Jefferson Medical College,Surgery,Philadelphia, PA, USA

Introduction:

Hidradenitis suppurativa (HS) is a chronic, inflammatory cutaneous disease of the apocrine sweat glands, most commonly in the axilla. Surgical treatments for HS include incision and drainage or surgical excision with or without closure.

Methods:

We reviewed 214 patients (with 293 surgical procedures) with axillary HS who underwent surgical intervention. We divided the cohort into two groups based on recurrence, and then compared them.

Results:

The mean age of onset of HS was 32.5 years. Females comprised 84.1% of the cohort. Average BMI was 33.37. 55% of patients smoked. 19.2% of patients had diabetes. 1.9% of patients had a positive MRSA history. 35.5% of patients had bilateral axillary disease, and 9.3% had extra-axillary disease. The vast majority (93.5%) of interventions included excision of the diseased area, with a median area of excision of 78cm2. 45.4% of these wounds were closed, 48.8% were allowed to heal by secondary intention, and 4.8% were treated with a vacuum device. 22/214 (10.3%) of patients had recurrent disease. Closure vs. non-closure was not associated with a proclivity towards recurrence. Recurrence after surgical treatment was significantly associated with extra-axillary disease (p=0.039).

Conclusion:

Patients with HS were overwhelmingly obese and female, and many of them smoked. Surgical excision was the most common intervention, and closure was employed in roughly half of patients. Recurrence after excision, albeit uncommon, was associated with extra-axillary disease, but not closure after excision. These characteristics may be helpful in counseling patients about risk of recurrence and overall prognosis.

69.14 Analysis of Accessibility, Usability, Reliability, and Accuracy of Online Burn Treatment Resources

Posted on January 18, 2016

P. H. Chang1,2, M. Paz3, P. H. Chang1,2 1Shriners Hospitals For Children-Boston,Boston, MA, USA 2Massachusetts General Hospital,Boston, MA, USA 3Northeastern University,Boston, MA, USA

Introduction:
The 2014 National Burn Repository Annual Report states that there were 191,848 reported cases of burn injuries in the United States last year. When injured, patients frequently use online searches to find out the initial treatment for their condition. In this study, 40 websites for burn treatment on two major search engines were identified. The content was analyzed on the accessibility, usability, reliability, and accuracy of the information.

Methods:
The phrases ‘burn treatment’, ‘burn first aid’, ‘burn care’, and ‘how to treat a burn’ were searched on Google and Bing on 2/11/2015 and 4/29/2015, and the top 10 results of each search was recorded. Out of the 40 articles recorded, there are a total of 24 unique articles for Google and 19 for Bing that were analyzed using the LIDA Instrument v.1.2 (Minervation, Ltd.). This instrument uses a series of questions to score the accessibility, usability, and reliability of health websites and then produces an overall rating for that website. Accessibility is defined as whether people can access your website, usability is how easy it is for users to find out the information they want to know, and reliability is whether the website keeps up to date with the best current knowledge. This instrument defines a good website as one that scores a 90% or higher, a moderate website has a score of 50-89%, and a bad website has a score below 50%. To analyze the accuracy of the websites a checklist was created using ABA referral criteria and expert opinion by a trained burn surgeon on treating burns.

Results:

Of the total 24 unique burn treatment websites identified in Google searches, four were from an ABA verified burn center or the ABA itself, the rest of the websites were from medical personnel or made by non medical consumer reports. The average accessibility score was 86% (63-98%), usability was 75% (42-92%), reliability was 64% (20-87%), and the average total score was 78% (62-91%). The average accuracy score for these websites was 55% (3-97%) , and only one of the websites was considered good.

The Bing search engine provided 19 different burn treatment websites. Only one was from an ABA verified burn center. The average accessibility score was 86% (59-98%), usability was 71% (42-92%), reliability was 62% (7-87%), and the average total score was 76% (41-91%).

Between both search engines there was an overlap of 12 websites. In total there were only 31 unique websites, out of these four (12.9%) were from an ABA verified burn center or the ABA itself. Consistently the top two searches were WebMD and Mayo Clinic. From the Google search there were three websites that were considered good, or had a total score of 0.90 or higher; the Bing search produced one good website.

Conclusion:
The majority of burn treatment information is posted online by non-burn surgical specialists. While most websites appear accessible the usability and reliability varies considerably.

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