78.05 Predictors of Anastomotic Leak after Colorectal Surgery in a Texas-Mexico Border Population

Posted on January 18, 2016

A. H. Othman1, A. Morales-Gonzalez1, M. Zuber2, V. Olivas1 1Texas Tech University Health Sciences Center,Surgery,El Paso, TX, USA 2Texas Tech University Health Sciences Center,OB GYN,El Paso, TX, USA

Introduction: To identify predictors of anastomotic leak (AL) in patients undergoing partial or total colorectal resection and anastomosis.

Methods: A retrospective cohort study was conducted at a single urban academic hospital in El Paso, Texas. Adults who underwent a partial or total colorectal resection with an ileo-colonic, colo-colonic, colo-rectal, ileo-rectal, colo-anal or ileo-anal anastomosis, between 2002 and 2012 were eligible for inclusion in the sample. Our cohort was composed of 537 procedures performed on 510 patients. Logistic regression using backward elimination was used to identify predictors of an AL. Adjusted odds ratios (OR) for AL, 95% confidence intervals (CI), and P values were calculated assuming statistical independence.

Results: The overall AL rate was 10.4%. Of the 510 patients, 88% were of Hispanic ethnicity. 37.5% of the patients who experienced AL and 25.0% of those who did not, were diabetic (P=0.04). The final regression equation contained two predictors: diabetic status and the type of resection. Diabetics were more likely to experience AL: adjusted OR=1.97 (95% CI: 1.07-3.63, P=0.03). Patients whose type of resection was colo-anal vs. ileo-colonic were more likely to develop an AL: adjusted OR=4.85, 95% CI: 1.33-17.69, P=0.02).

Conclusion: Diabetes and colo-anal anastomosis are associated with a higher risk of AL and should be considered and evaluated in the pre-operative surgical planning.

78.06 Colon vs Rectal Surgery: A Comparison of Outcomes.

Posted on January 18, 2016

S. Groene1, C. Chandrasekera1, T. Prasad1, A. Lincourt1, B. T. Heniford1, V. Augenstein1 1Carolinas Medical Center,Division Of Gastrointestinal And Minimally Invasive Surgery,Charlotte, NC, USA

Introduction: Rectal resections are considered a challenging part of colorectal surgery due to anatomy and difficulties in obtaining critical views and angles during anastomoses. For this reason, it is felt that there is an increased risk of post-operative complications with rectal resections compared to only colon resections. The aim of this study was to compare outcomes of patients who underwent rectal resections versus colon resections.

Methods: Review of the Carolinas Medical Center (CMC) NSQIP data for colorectal resections performed from 2013 to 2015 was conducted. Procedures were categorized as rectal vs colon based on CPT codes. Demographics, pre-operative co-morbidities, minor and major complications were evaluated using standard statistical methods.

Results: There were 637 patients in the sample; 219 patients underwent rectal resections and 418 colon resections. Patients undergoing rectal resections were younger (58.9±12.2 vs 61.7±15; p=0.001) with no differences in BMI, gender or race. Those undergoing rectal resections had lower rates of diabetes (11.4% vs 19.4%; p=0.04), COPD (3.2% vs 7.9%; p=0.02), and fewer emergent cases (3.6% vs 15.8%; p<0.001). Pre-operatively, they had lower ventilator use (1.4% vs 5%; p=0.03), transfusions (1.8% vs 8.8%; p<0.001) and sepsis (2.3% vs 10.3%; p<0.001). Rectal resections were more often done laparoscopically (78.3% vs 59.6%; p<0.001). Post-operatively, those undergoing rectal resections had lower rates of pneumonia (PNA) (0.5 vs 2.9%; p=0.04), transfusions (12.3 vs 22%; p=0.003), sepsis (5% vs 10.5%; p=0.02), decreased 30 day mortality rate (1.4% vs 5.3%; p=0.02) and a shorter length of stay (8.7±8.3d vs 10.2±9.5d; p=0.02). After controlling for pre-op ventilator use and COPD, multivariate analysis (MV) indicated no significant difference in post-op PNA between the 2 groups. After controlling for pre-op transfusions and sepsis, MV analysis indicated no significant difference in post-op transfusions between the 2 groups. After controlling for pre-op sepsis, emergent case status and ASA class, MV analysis indicated no significant differences in post-op sepsis, 30 day mortality or LOS between the 2 groups. There were no significant differences in post-operative surgical site infections, deep infections, UTIs, cardiac or renal disease, DVTs/PEs, anastomotic leaks, unplanned returns to the OR, and death after 30 days between the 2 groups.

Conclusion: Patients undergoing rectal resections had fewer co-morbidities, underwent more laparoscopic and fewer emergent cases. They had fewer post-operative complications upon initial review of the data, though after controlling for ASA, pre-op sepsis and transfusions, emergent status and COPD, there were no significant differences between the groups. Rectal resections and colon resections appear to carry a similar risk of complications.

78.07 Effect of SCIP Guidelines on Outcomes of Colorectal Patients.

Posted on January 18, 2016

S. Groene1, C. Chandrasekera1, T. Prasad1, A. Lincourt1, B. T. Heniford1, V. Augenstein1 1Carolinas Medical Center,Division Of Gastrointestinal And Minimally Invasive Surgery,Charlotte, NC, USA

Introduction: The Surgical Care Improvement Project (SCIP) was instituted as a means to improve outcomes after surgery. One specific area of intended improvement was post-operative surgical site infections (SSI). The aim of this study was to compare the outcomes in colorectal patients who received antibiotics per SCIP guidelines versus those that did not.

Methods: A list of 44 patients at our institution where SCIP antibiotic measures were not followed between 2012-2014 was obtained. Twelve of these patients were in our NSQIP database and we used the results from NSQIP to determine demographics, pre-op co-morbidities and post-op outcomes. For the other 32 patients, a chart review was conducted to determine similar variables. We also excluded any NSQIP patients with sepsis or dirty wounds as they met SCIP exclusion criteria. Standard statistical methods were used to compare the data for the 44 non-compliant patients to the remaining SCIP-compliant patients in the NSQIP database.

Results: There were 563 patients in the sample and 44 did not receive antibiotics per SCIP guidelines. Of these 44 patients, 3 did not receive SCIP appropriate pre-op dosing of antibiotics within 1 hour of incision, 25 did not receive the SCIP appropriate antibiotic and 16 were non-compliant with post-op antibiotic duration. There were no significant differences between the groups in age, BMI, race, gender, hypertension, heart failure, ASA class, or ventilator use. There were no significant differences in superficial SSI, deep incisional SSI, organ space infection, pneumonia, UTIs, DVT/PEs, MIs, post-op transfusions or sepsis, unplanned return to the OR, 30 day mortality or length of stay between the 2 groups. Those in the non-adherent group had higher rates of pre-op diabetes (27.3% vs 15%; p=0.03), COPD (15.9% vs 5.2%; p=0.003) and pre-op renal failure (9.1% vs 0.2%; p<0.001). Post-operatively, those who were not SCIP adherent had higher rates of acute renal failure (6.8% vs 0.2%; p=0.002), unplanned intubations (9.1% vs 2.1%; p=0.02) and deaths after 30 days (4.6% vs 0.4%; p=0.03).

Conclusion: Overall, colorectal patients who were non-compliant with SCIP antibiotic measures had higher rates of diabetes, COPD and pre-op renal failure. They also had higher rates of post-op renal failure, unplanned intubations and death after 30 days. However, there were no differences in infectious outcomes between the groups, which may suggest that SCIP non-compliance with antibiotic measures may not lead to clinically significant differences in infectious outcomes.

78.08 Comparing access to surgical care between Sweden and Zambia using geospatial mapping tools

Posted on January 18, 2016

M. P. Vega1,5, A. N. Bowder1,2,5, N. P. Raykar1,3,5, F. Oher1, J. G. Meara1,5, E. Makasa6 1Program In Global Surgery And Social Change, Harvard Medical School,Department Of Global Health And Social Medicine,Boston, MA, USA 2University Of Nebraska Medical School,Omaha, NB, USA 3Beth Israel Deaconess Medical Center,Department Of Surgery,Boston, MA, USA 5Boston Children’s Hospital,Department Of Oral And Plastic Surgery,Boston, MA, USA 6Permanent Mission Of The Republic Of Zambia To The United Nations In Geneva & The Ministry Of Health,Lusaka, , Zambia

Introduction: One of the The Lancet Commission on Global Surgery’s six indicators for global surgery systems strengthening is the percent of a country’s population within two hours of a facility that can provide the Bellwether procedures (1). Previous work by the Commission focused on estimating access to surgical care through geospatial mapping of surgical providers in nine countries (2). Given the general availability of information on hospital locations, we wished to use surgical facility location to determine the upper bound of a country’s population with access to surgical care within two hours, and compare differences between a high-resource country (Sweden) and a low-resource one (Zambia).

Methods: We gathered surgical facility data from Zambia’s Ministry of Health List of Health Facilities in Zambia (3). We included 1st, 2nd and 3rd level hospitals offering of surgical services in our analysis. Surgical facilities in Sweden were identified from the Swedish National Board of Health and Welfare and publicly available online resources (4). Google Maps Engine was used to locate the identified surgical facilities and to create two-hour driving zones around each location. Finally, the Socioeconomic Data and Applications Center Population Estimation Service was used to estimate the population living within each access zone (5).

Results: We identified 77 hospitals in Sweden and 100 hospitals in Zambia, which provided general surgery care. An estimated 99.52% of the Swedish population lives within two hours driving distance to a surgical facility, as compared to 74.28% of the Zambian population. Geographic size of these nations and road conditions and driving times influence these numbers.

Conclusion: Sweden and Zambia have disparate but high proportions of their population that live within two hours, driving distance, of a surgical facility. However, ease of transportation to these facilities, workforce availability and functionality, and affordability of surgical services will determine true access to surgical care. Nonetheless, knowledge of the distribution of surgical facilities in relation to population distribution is critical information for health systems planning. Geospatial mapping of surgical facilities should be used in conjunction with contextual differences in geography, seasonal variation in road quality, population access to vehicular transportation, and distribution of vulnerable populations to direct investments into new surgical facilities or to optimize existing ones.

78.09 Contribution of Short Term Surgical Missions to Total Surgical Care Delivery in a District Hospital

Posted on January 18, 2016

A. V. Gore1, C. M. McGreevy1, M. K. Gyakobo2, Z. C. Sifri1 1Rutgers – NJMS,Newark, NJ, USA 2Tetteh Quarshie Memorial Hospital,Mampong-Akuapem, AKUAPEM NORTH DISTRICT, Ghana

Introduction: Lack of access to surgical care in low-income countries (LIC) creates an enormous burden of surgical disease, contributing to preventable death and disability. The impact of short-term surgical missions (STSM) on the delivery of surgical care to communities in LIC is largely unknown. We sought to investigate the relative contributions of repeat STSM to the total surgical care delivery at a district hospital in eastern Ghana.

Methods: Retrospective review of case logs from two 10-day STSM sponsored by the International Surgical Health Initiative (ISHI) in September 2013 and August 2014 were compared to those from Tetteh Quarshie Memorial Hospital (TQMH) over the intervening months. Data collected included age, sex, operation(s) performed, findings, type of anesthesia, and emergent cases. Data presented as mean ± SD or percentage of total as appropriate; p<0.05 considered significant.

Results: Over this 1-year period, a total of 225 procedures were performed on 187 patients at TQMH. ISHI teams performed 100 procedures on 94 patients and local teams performed 125 procedures on 93 patients. ISHI teams operated on significantly more females, (47% vs. 31%; p= 0.028) and older patients (46±17 vs. 40±20 years; p = 0.027). 24% of cases undertaken by local surgeons involved multiple procedures, as compared to 6% of ISHI cases (p=0.0009). Local teams performed 21 emergent operations (23%) as compared to 1 (1%) by ISHI team (p = 0.00005). The three most common case types were inguinal hernia repair (45%), mass excision (22%), and ventral hernia repair (15%) for ISHI teams and inguinal hernia repair (39%), ventral hernia repair (12%), and appendectomy (10%) for local teams.

Conclusion: Repeat STSM to a district hospital can contribute about 50% of the surgical care provided to the local community. While the types of cases performed by both teams were similar, the international team performed more surgeries on older patients and more women, whereas the local team performed more emergency and multi-procedure cases. While STSM may not permanently increase the capability of local practitioners to alleviate the surgical burden seen in LIC, they make a significant and immediate impact on these communities. Long-term sustainable solutions are needed to support these surgical efforts, potentially doubling the surgical care delivery in rural communities and allowing for the dissemination of surgical skills and knowledge.

08.02 Improved Compliance with Foley Care Guidelines Following the Implementation of a Patient Dashboard

Posted on January 18, 2016

M. Scerbo1, J. Holcomb1 1University Of Texas Health Science Center At Houston,Houston, TX, USA

Introduction: Compliance with recommended guidelines is associated with improved patient outcomes, however achieving high levels of compliance has proven difficult in clinical practice. The creation of automated clinical decision support systems (CDSS) to assist with guideline compliance has been met with the criticism due to failure to follow human factors principles. A patient dashboard that displays integrated information automatically extracted from the electronic health record has recently been implemented in our surgical intensive care unit (ICU). The status of compliance with certain bundles of care is displayed in a color-coded fashion (green-good, red-bad); the contribution to the cognitive load of the user and alarm fatigue is minimal as it does not generate any noise, page or text. We hypothesized that the presence of a real-time, color-coded passive display of compliance status would improve compliance rates with Foley care guidelines in our surgical ICU.

Methods: This observational study was conducted in a 23-bed surgical ICU. Compliance with Foley care guidelines were evaluated pre-implementation (2 months) and post-implementation (1 month) of a real-time display of compliance status. A compliance score was calculated by dividing the total number of interventions achieved by the total number of opportunities for interventions and is expressed as a percentage. For this study, the numerator is the total number of nursing shifts in which patients with a Foley received the proper Foley care. The denominator is the total number of nursing shifts in which a patient had a Foley. Foleys that were inserted and discontinued within one 12-hour shift and in and out catheters were excluded from the analysis. Compliance rates were evaluated overall, as well as day/night shifts and weekend/weekday shifts. Categorical variables were analyzed using the Pearson’s χ2 test and with simple logistic regression.

Results: The overall pre-implementation compliance rate was 90% (1631/1810), compared with post-implementation compliance rate of 94% (792/843). The implementation of a passive display of compliance status via the patient dashboard was associated with increased compliance with Foley care guidelines (OR 1.7, 95% CI 1.2-2.4, p = 0.001).

Conclusion: The introduction of a color-coded, consistently present display reporting the compliance status improved compliance rates with Foley care guidelines. This assistance occurred without changing the workflow, requiring additional action from the user or increasing physician alerts, phone calls/pages, or noise. Future analysis will include impact on patient outcomes.

08.03 Unplanned 30-Day Readmissions in Orthopedic Trauma

Posted on January 18, 2016

D. Metcalfe1, O. A. Olufajo1, C. Zogg1, A. J. Rios Diaz1, A. H. Haider1, M. B. Harris2, M. J. Weaver2, A. Salim1 1Harvard Medical School,Center For Surgery And Public Health,Boston, MA, USA 2Brigham & Women’s Hospital,Department Of Orthopedic Surgery,Boston, MA, USA

Introduction:

30-day hospital readmission is used as a quality metric in some pay-for-performance frameworks, such as the CMS Readmissions Reduction Program (CRRP). There are plans to extend the CRRP to selected surgical populations. However, the odds of unplanned readmission have been shown, in some surgical settings, to be associated with lack of insurance and Black race. These characteristics are also associated with greater odds of injury, which raises the possibility that trauma centers will be unfairly penalized by extension of the CRRP to include injured patients.

This study characterized the reasons for, and factors associated with, unplanned 30-day readmission of orthopedic trauma patients. We also sought to understand whether it is sufficient to limit measurement of readmissions to the hospital at which patients were initially treated by exploring the proportion that were readmitted to other hospitals.

Methods:

Hospital admissions for fracture and/or dislocation (ICD-9-CM 800-839) were extracted from the California State Inpatient Database (SID) 2007-2011, which is an all-payer dataset that captures 98% of hospital admissions. Isolated rib, skull, and facial fractures were excluded. Unplanned readmissions to any hospital in California were tracked using a unique statewide identifier. Multivariable logistic and generalized linear regression models were used to identify independent associations with readmission. The covariates within these models were age, sex, race, payer status, admission source, weekend admission, Injury Severity Score (ISS), Charlson Comorbidity Index (CCI), hospital bed size, trauma center designation, and teaching hospital status.

Results:

There were 416,568 orthopedic trauma admissions to 391 different hospitals. The population was predominantly older (mean age 63.9, SD 23.6), white (71.5%), male (59.5%), and funded by public insurance (63.9%). Severely injured patients (≥15) accounted for only 3.3% cases. 27,008 (6.5%) were readmitted within 30 days, 27.6% of which to a different hospital. Factors significantly associated with 30-day readmission were older age (>65 adjusted odds ratio 1.32, 95% CI 1.24-1.41), Black race (aOR 1.18, 1.10-1.26), public insurance (aOR 1.40, 1.27-1.54), greater comorbidity burden (CCI >2 aOR 1.09, 1.77-1.89), and spine fracture (aOR 1.38, 1.31-1.45). Major reasons for readmission included cardiopulmonary disease (25.9%), procedural complications (12.8%), and musculoskeletal problems (8.5%).

Conclusion:

Many orthopedic trauma readmissions are for cardiopulmonary disease and potentially unrelated to the quality of their index hospitalization. Penalties for unplanned readmissions risk unfairly penalizing hospitals that serve disadvantaged communities and treat a high proportion of trauma patients. Future work should aim to determine the proportion of readmissions that are truly avoidable given optimal trauma and medical care.

08.04 Bundled Payments for Acute Care: Potential Savings or Need for Further Reform?

Posted on January 18, 2016

F. Gani1, J. E. Efron1, E. C. Wick1, S. H. Fang1, B. Safar1, J. Hundt1, T. M. Pawlik1 1Johns Hopkins University School Of Medicine,Surgery,Baltimore, MD, USA

Introduction: The Bundled Payments for Care Improvement initiative (BPCI) was proposed by the Centers for Medicare & Medicaid Services (CMS) in an effort to obtain and reward a greater value of care. In contrast to the traditional fee-for-service paradigm, under the BPCI hospitals are reimbursed a DRG-specific bundled payment including physician and inpatient fees for a single episode of care. Still in its infancy, little is known regarding the potential effects of the BPCI on hospital payments and net margins. Therefore, this study aimed to investigate the potential effects of the BPCI on net margins among Medicare patients undergoing colectomy at a tertiary care hospital.

Methods: Medicare enrollees undergoing elective colectomy between 2009 and 2013 were identified using DRG and ICD-9-CM diagnosis codes. Total hospital costs and net payments were inflation adjusted and reported as 2013 dollars. Multivariable linear regression analysis was performed to calculate risk-adjusted, DRG-specific hospital costs and payments for each patient. Net margins were calculated as the difference between total hospital costs and total payments received.

Results: A total of 821 Medicare enrollees underwent an elective colectomy and met inclusion criteria. The median age of patients was 69 years (IQR 65-74) with 48.7% being male and 67.6% presenting with one or more comorbidity. Postoperative complications were observed among 27.5% of patients. The median length of stay (LOS) was 8 days (IQR 5-14) and over a fourth of patients were discharged with additional care (27.5%). The median risk-adjusted cost among all patients was $25,202 (IQR $17,164-$42,161). Risk-adjusted costs were higher among patients who developed a postoperative complication ($43,489 [IQR $30,325-$70,885] vs. $21,179 [IQR $15,368-$32,307], p<0.001) and among patients with an Observed: Expected LOS>1 ($38,361 [IQR $26,187-$58,631] vs. $17,697 [IQR $13,414-$24,129], p<0.001). The median payment under the fee-for-service structure was $29,684 (IQR $19,609-$47,874) resulting in an overall net margin of $4,557 (IQR $1,254-$8,805), with 18.2% of patients contributing to an overall negative margin. In contrast, under the bundled payment paradigm, the net margin per patient decreased to $3,777 (IQR $-12,219-$11,825, p<0.001) with over 41% of patients contributing to a net negative margin (Figure).

Conclusions: Postoperative complications, length of stay and total hospital costs strongly correlated with hospital costs. Payments under the bundled payments system were lower and the proportion of patients contributing to a net negative margin increased. Further study is warranted to define the impact of bundled payments on quality of care, as well as hospital finances.

08.19 The Association Between Pre-Discharge Complications and Readmissions

Posted on January 18, 2016

M. Morris1,3, L. Graham1,3, J. Richman1,3, R. Hollis1,3, C. Jones1,3, M. Hawn2 1University Of Alabama,Surgery,Birmingham, Alabama, USA 2Stanford University,Surgery,Palo Alto, CA, USA 3Birmingham Veterans Affairs Hospital,Surgery,Birmingham, AL, USA

Introduction:
Post-operative hospital readmission rates are now publically reported and targeted for quality improvement measures. Identifying which readmissions are preventable or unavoidable is challenging. The ability to predict readmission rates at the time of discharge would potentially change clinical practice. We hypothesize that patients experiencing a pre-discharge complication would have increased rates of readmission.

Methods:
We examined all gastrointestinal surgery cases at 120 VA facilities from 2008-2014 with a total hospital length of stay of at least 2 days. Our independent variable of interest was the occurrence of any pre-discharge complication as assessed by the VA Surgical Quality Improvement Program. Our outcome of interest was inpatient readmission within 30 days following hospital discharge. Chi-square tests statistics and t-tests were used to examine differences in bivariate statistics and a multivariate logistic model was used to model 30-day readmission in the population.

Results:
Our sample includes 86,820 procedures among 77,451 patients at 120 VA facilities with an overall readmission rate of (12.3%). In our cohort, 7,927 patients (9.1%) experienced a pre-discharge complication. Superficial wound infection was the most common pre-discharge complication (2.1%), followed by urinary tract infection (1.2%) and reintubation (1.2%). Readmission rates were significantly higher in patients experiencing a pre-discharge complication when compared to those not experiencing an in-hospital complication (17.5% vs 11.8%, p<0.01). Patients who experienced a pre-discharge complication had a longer mean length of post-operative hospital stay (13.5 days) as compared to those without a pre-discharge complication (5.7 days, p<0.01), but were no more likely to experience a post-discharge complication (7.1% vs. 6.6%, p=0.07). In the final adjusted model, pre-discharge complications were only associated with readmission when postoperative hospital stay was less than 7 days (OR=1.4, 95%CI=1.2-1.7), however only 11.5% of patients experiencing an in-hospital complication had a post-operative stay of less than 7 days.

Conclusion:
Occurrence of pre-discharge complications in patients with postoperative length of stay greater than seven days was not associated with readmission suggesting that sequelae of the complication resolve during the prolonged index hospitalization for the majority of admissions.

08.20 Early learners as health coaches for high-risk surgical patients: a pilot study

Posted on January 18, 2016

J. Kaplan1, R. Hofer1, Z. Brinson1, P. Chung2, C. Lucas2, D. Teng3, V. Tang5, J. Broering4, A. Chang2,5, E. Finlayson1 1University Of California – San Francisco,Surgery,San Francisco, CA, USA 2University Of California – San Francisco,School Of Medicine,San Francisco, CA, USA 3University Of California – San Francisco,School Of Nursing,San Francisco, CA, USA 4University Of California – San Francisco,Urology,San Francisco, CA, USA 5University Of California – San Francisco,Geriatrics,San Francisco, CA, USA

Introduction: There are few opportunities for early learners to engage in authentic roles on health care teams. In a new geriatric optimization clinic for frail high-risk surgical patients, first year medical and nurse practitioner students were integrated into an interprofessional team as health coaches.

Methods: Frail surgical patients (those over the age of 80 or over the age of 60 with a geriatric syndrome) with planned elective operations were referred to a new geriatric pre-operative clinic to see a geriatrician, occupational therapist, physical therapist, and nutritionist. Students attended the entire clinic visit with the patient, reviewed the interdisciplinary care plan, attempted to call patients twice weekly preoperatively to promote adherence to care plans, and called weekly in the first month after discharge. They observed surgery and practiced physical exam and presentation skills during the inpatient stay. Students logged all calls and patients filled out health coach satisfaction surveys one week prior to surgery.

Results: In the 6 month pilot period, two first year medical students, one nurse practitioner student, and two research assistants served as health coaches for 32 patients. On average, there were 30 days between the clinic visit and surgery. Patient received an average of 1 call per week. There were 39 instances when health coaches contacted members of the care team, 12 of which were to contact a doctor. These follow up communications were for medication questions, concerning symptoms, or remaining questions from clinic visits. Overall patients were extremely satisfied with the health-coach experience, they felt better prepared for surgery, and would recommend the program to others.

Conclusions: Early medical and nurse practitioner students can serve the important function of health coaches for frail patients preparing for surgery. Students benefited from a unique longitudinal experience and gained skills in communication and care coordination.

08.21 A Survey of the Preferences and Practice of Surgical Hand Antisepsis

Posted on January 18, 2016

B. S. Oriel1,2, K. M. Itani1,3,4 1VA Boston Healthcare System,Surgical Service,West Roxbury, MA, USA 2Tufts Medical Center,Department Of Surgery,Boston, MA, USA 3Boston University School Of Medicine,Department Of Surgery,Boston, MA, USA 4Harvard Medical School,Department Of Surgery,Boston, MA, USA

Introduction:
Products available for surgical hand antisepsis include traditional aqueous scrubs (TAS) and alcohol-based rubs (ABR). As part of a quality improvement initiative, we sought to better understand best practice techniques and preferences among operating room (OR) staff.

Methods:
One-hundred thirty-one anonymous paper surveys were distributed to all surgical and OR personnel who perform surgical hand antisepsis at either one or both of two hospital campuses. Participants represented all surgical specialties. The survey assessed product preference, product-specific patterns of use, hand antisepsis education and product knowledge.

Results:
A total of 97 surveys (74%) were returned; two were incomplete and excluded. The remaining 95 surveys included 44 women (47%), 37 staff surgeons (39%), 29 residents and fellows (31%), and 29 nursing staff (30%). Ninety-five percent confirmed prior use and proper application of both product types, however application times of less than 1 minute for ABR and less than 3-6 minutes for TAS were reported by 10% and 18% of participants, respectively. The application time of each product was most influenced by case-specific wound classification and hand soiling. Among all users, 64% supported having an ABR option available. ABR was favored (52%) and did not differ between physicians and nursing staff (p = 0.67). Respondents preferred ABR for its ease of use (79%) and TAS for its minimal to no side effects (54%). Forty-eight percent had not read the manufacturer's instructions for either product, and over 80% had never received formal in-person training. While 73% of physicians reported familiarity with each product's active ingredients, less than one-third correctly identified alcohol’s concentration of greatest anti-microbial activity or its mechanism of action, and only two-thirds correctly identified chlorhexidine's mechanism of action. Only 3 of 64 physician-respondents reported any familiarity with the Food and Drug Administration's Tentative Final Monograph.

Conclusion:
There were no strong preferences among staff regarding ABR or TAS but ABR was a supported option for surgical hand antisepsis. Preferred product features included ease of use and an acceptable side-effect profile. A definite lack of understanding and education exists regarding product mechanism of action and application. Perceptions of proper use and reported practice were discordant among some staff. The effect of reported practice on surgical site infections should be investigated.

09.01 Racial Disparities in the Use of Laparoscopic Colon Resection Among Medicare Patients

Posted on January 18, 2016

S. R. Thumma1, J. R. Thumma1, A. Ibrahim1, J. B. Dimick1 1University Of MIchigan, Center For Healthcare Outcomes And Policy,Ann Arbor, MI, USA

Introduction: Racial disparities in the use of minimally invasive technology, such as laparoscopic colectomy, are well documented. However, the underlying reasons for these disparities are not well understood. One potential explanation is that minorities receive care in hospitals that are less likely to use minimally invasive approaches. We sought to examine racial disparities in the use of laparoscopic technology for colectomy and explore the contributing factors, including whether the differences in the use of the minimally invasive approach can be explained by the hospitals where minorities receive their care.

Methods: We studied all patients with colon cancer who underwent colectomy (N=112,183, N=1,901 hospitals) in the national Medicare population over 3 years (2010-2012). Univariate and multivariate logistic regression models were used to examine the relationship between race and the use of the laparoscopic approach. In our analyses, we controlled for patient factors (age, gender, race and Elixhauser comorbidities), neighborhood socioeconomic status (SES), and the year of procedure. We present our results stratified by the degree of hospital segregation (i.e., quintiles of the concentration/proportion of blacks in the hospital). Moreover, we assessed the impact of hospitals on the use of laparoscopy by adjusting directly for them using fixed effects models.

Results: In the national Medicare population, 37% of patients received a laparoscopic approach to colectomy. When examining the racial composition of the hospitals where these patients received care, there appeared to be a large degree of racial segregation. For example, the proportion of black patients in a hospital ranged from 0% in the bottom 20th percentile to 49.2% in the top 20th percentile. Black patients were 23% less likely to receive laparoscopic colectomy when compared to non-black patients (OR, 0.77; 95% CI, 0.74-0.80). When each contributing factor was assessed independently using univariate analysis, 36% of the observed disparity in receiving laparoscopic colectomy was explained by the hospitals in which they received care (OR, 0.85; 95% CI, 0.82-0.89) and 39% was explained by SES (OR, 0.86; 95% CI, 0.83-0.89). After adjusting for differences in the hospitals where they received care, SES, and patient factors in a single model, we were able to explain 63% of the observed disparity, leaving 37% of the remaining disparity unexplained. However, even after adjusting for all these factors, black patients were still found to be 9% less likely to receive a laparoscopic colectomy compared to their non-black counterparts (OR, 0.91; 95% CI, 0.87-0.96).

Conclusion: Black patients are less likely than non-black patients to have access to laparoscopic procedures for colon cancer. These disparities are explained in large part by black patients receiving care in hospitals that are less likely to use the minimally invasive approach.

09.02 Using Community Outreach to Gain Insight into Racial Disparities and Cancer Care

Posted on January 18, 2016

R. L. Hoffman1, K. O’Neill2, K. Collier1, C. B. Aarons1, M. K. Lee1, R. R. Kelz1 1University Of Pennsylvania,Philadelphia, PA, USA 2Yale University School Of Medicine,New Haven, CT, USA

Introduction: Outreach programs aimed at reducing disparities in cancer care need to consider the cultural nuances of each community in order to be effective and sustainable. The aim of this study was to gain insight into the beliefs of the local community regarding colon cancer screening and treatment.

Methods: In partnership with a large urban university cancer center, medical students and surgical residents and faculty participated in two community health outreach events focused on cancer prevention, screening and treatment in the surrounding community. Prior to the main educational event, an 11- item survey that addressed commonly held cancer myths and colon cancer knowledge was distributed to all participants. Myth items were adapted from the National Cancer Institute’s ‘Common Cancer Myths and Misconceptions’ website. The survey also collected demographic information and assessed participant willingness to undergo cancer screening (colonoscopy). Myth items were scored on a 5-point Likert scale from ‘strongly agree to strongly disagree,’ and knowledge items were scored as true/false or ‘I don’t know.’ Descriptive statistics and univariate analyses were performed.

Results: There were a total of 256 participants and 188 completed a survey (71% response rate). Attendees were predominantly insured (93%), female (80%) and African American (96%), with a mean age of 61 years (14.0; range 12-95 years). Seven percent of participants were unwilling to undergo a screening colonoscopy; 3% of those age ≤60 years compared to 9% >60 years. Of those unwilling to get a colonoscopy, 33% were male, 92% Black. Of the myths, 25% felt that surgery could cause cancer to spread. Patients ≤60 years old were more likely to believe that surgery could cause cancer spread (64% vs. 35% ≤60yrs; p=0.004). 25% endorsed mistrust in physicians (43% of those ≤60 years, 26% for those >60 years (p=0.03). 18% felt that cancer treatment was worse than the disease. Belief in these myths did not differ by gender. 74% of participants agreed that there were some measures people could take to prevent cancer. 48% were aware of the causes of colon cancer, 49% and 46% misunderstood or didn’t know the definitions of malignant and metastatic, respectively. Males were more unsure of these definitions than females (61% vs 55%, p=0.5 and 70% vs 55%; p=.01).

Conclusion: In the surrounding, predominantly African American community, knowledge of and willingness to undergo cancer prevention strategies was high. However, in participants ≤60 years, in which early detection of cancers is most beneficial, physician mistrust and belief in the surgical spread of cancer was also high. Particularly for cancers where surgery is the mainstay of treatment, surgeon participation in community outreach events is essential in order to minimize barriers to treatment, increase cancer-related knowledge and address disparities in care.

09.03 Racial Disparities in the Receipt of Transdisciplinary Evidence-based Breast Cancer Care

Posted on January 18, 2016

R. Yang1, Y. Ma1, I. Wapnir1, K. F. Rhoads1 1Stanford University,Department Of Surgery,Palo Alto, CA, USA

Introduction:
Disparities in breast cancer have persisted over decades. While survival for White patients has improved, survival in select minority groups has worsened, thus widening the pre-existing gap. Biological factors have been well-studied, but it is not yet known if differences in breast cancer care contribute to worsening racial disparities. We aimed to evaluate differences in the receipt of transdisciplinary evidence-based breast cancer care for racial/ethnic minorities in California (2008-2009).

Methods:
California Cancer Registry (CCR) data were linked to state level inpatient and ambulatory surgery data and used to identify all women with an ICD-03 diagnosis of breast cancer who were treated during the years under study. We identified quality measures reflecting evidence-based care in the diagnosis, surgical treatments, and adjuvant treatments of breast cancer based on current literature and National Comprehensive Cancer Network guidelines. We evaluated the receipt of percutaneous versus excisional biopsy, neoadjuvant chemotherapy for tumor stage T4, chemotherapy for nodal stage N2, radiation therapy following lumpectomy; surgical evaluation of the axilla for stage M0; breast conservation for tumor stage T1 or T2; and breast reconstruction following mastectomy. Differences in receipt of evidence-based care by race/ethnicity were determined using the chi-squared test.

Results:
We identified 42,474 patients with stage I-IV breast cancer. We found that a higher proportion of Black patients (3.1%) underwent excisional biopsy compared to White, Hispanic, and API patients (2.2%, 2.5%, 2.6%, respectively, (p=0.02)). There was no significant difference in the receipt of systemic chemotherapy for nodal stage N2 by patient race (p=0.09). API patients had the lowest rates of neoadjuvant chemotherapy for T4 tumors (24.7%) compared to all other races (Black 28.4%, White 29.8%, Hispanic 42.9%, p=0.007). Radiation following lumpectomy was less frequent for Black (54.9%) and Hispanic patients (60.5%) compared to White (64.9%) and API patients (67.4%, p<0.001). Evaluation of the axilla (either SLNB or axillary dissection) for M0 disease was lower for Black (39.1%), Hispanic (40.6%), and API patients (44.4%) compared to White patients (48.3%, p<0.001). Rates of breast conserving surgery for T1 or T2 tumors were lower among API (45.9%), Hispanic (47.6%), and Black patients (50.1%) compared to White patients (53.4%, p<0.001). Rates of breast reconstruction following mastectomy were lower among Black (34.9%), Hispanic (34.3%), and API patients (36.0%) compared to White patients (40.8%, p<0.001).

Conclusion:

Racial disparities in the quality of care exist across diagnostic, surgical and adjuvant therapies. However, the disparities appear most pronounced within the surgical care. Further studies are needed to determine the drivers of this disparity.

09.04 High Volume Hospitals: Limited Access for Patients with a Lower Income?

Posted on January 18, 2016

N. R. Changoor1,2, J. W. Scott1, G. Ortega2, C. K. Zogg1, L. L. Wolf1, G. Reznor1, E. B. Schneider1, E. E. Cornwell2, A. H. Haider1 1Brigham And Women’s Hospital,Center For Surgery And Public Health,Boston, MA, USA 2Howard University College Of Medicine,Department Of Surgery,Washington, DC, USA

Introduction:
Studies have demonstrated that high volume centers are associated with superior outcomes for multiple cardiac, vascular and oncologic procedures. Racial/ethnic minority patients receive fewer of these procedures at high volume centers, the cause for which remains undetermined. Our study aims to investigate whether disparities in access to high volume hospitals are also associated with patient income.

Methods:
The 2005-2011 NIS was queried for patients with ICD-9-CM procedure/diagnostic codes for oncologic resection of the breast (BrCa), lung (LungCa), esophagus (EsophCa), stomach (GastCa) or colon (ColonCa) as well as for patients who underwent (procedure codes) CABG, AAA repair (AAAR), CEA, total hip replacement (THA), or total knee replacement (TKA). Hospitals treating patients within each operative group were dichotomized into centers that performed greater than 75th percentile (high volume centers) or less than the 25th percentile (low volume centers) of corresponding annual procedures. Median household income for patient's ZIP code was used to stratify patients into income quartile groups. Differences between the highest and lowest income quartiles were used to assess for associated differences in the risk-adjusted odds of presenting to a high-volume center for a given operation. Nationally-weighted, multivariable logistic regression accounted for differences in patient/hospital-level factors and clustering of patients within hospitals.

Results:
A combined total of 2,529,352 patients underwent included operations; most received surgery for BrCa (29.9%), TKA (21.3%) and THA (12.4%). The procedures with the highest proportion of high-income patients presenting to high-volume centers were ColonCa (90.6%), LungCa (74.7%), and BrCa (73.7%), while the procedures with the highest proportion of low-income patients presenting to high-volume centers included CABG (54.5%), AAAR (53.6%) and CEA (53.6%). Risk-adjusted analysis revealed that highest income patients were more likely to receive care at high-volume centers for THA (OR=1.96, CI:1.36-2.82), BrCa (OR=1.69, CI:1.07-2.67) and GastCa (OR=2.28, CI:1.05-4.94) but were less likely to receive care at high-volume centers for AAAR (OR=0.62, CI:0.40-0.95) when compared to lowest income patients. Differences for other procedures were not significant.

Conclusion:
The results indicate significant differences in access to high-volume centers associated with income for certain procedures. Varied associations demonstrated might imply important differences in respective patients’ ability and desire to receive care from high-volume centers, which may be dependent on the procedure type. Strengthening referral systems and re-evaluation of in-network referrals may help to increase access to high volume centers by low-income patients.

09.05 Trauma Recidivism in Urban Youths vs Adults

Posted on January 18, 2016

K. Barrera2, L. Lajoie2, A. Chudner2, D. Solomon2, V. Roudnitsky1, T. Schwartz1 1Kings County Hospital Center,Acute Care Surgery,Brooklyn, NY, USA 2SUNY Downstate,Department Of Surgery,Brooklyn, NY, USA

Introduction:
Recurrent violent injury (RVI) has been a topic of interest in trauma with recent reported rates greater than 30%. There has been specific focus on prevention, with many trauma centers implementing violence prevention programs aimed at youth. In these programs, patients are followed by case workers after discharge. Outcomes have been favorable with a trend towards reduction of recurrent injury as well as crime. Although there are several programs that include victims of injury of all ages, several programs target ages 10-30 years as recidivism is more prevalent in youths. The purpose of this study is to examine the differences between younger versus older recidivists to determine if adult recidivists may also benefit from efforts to reduce recidivism.

Methods:
This is a retrospective cohort study of all patients ages 15-60 seen by the trauma team at a single urban trauma center for violent injuries over a six year period. Patients were followed for recurrent injury for a minimum 3 years. Patients that died after first violent injury were excluded. Data collection also included mechanism of injury. Chi-square test, and T Test were used to determine differences in characteristics of recidivism between 15-25 and 25-60 age groups.

Results:
A total of 2642 patients were included in the analysis. This group was further subdivided into two age groups, 15-25 years (n=1300) and 26-60 years (1342). Overall recidivism rate was 11%. In the youth group, recidivism rate was 14% versus 9% in adults (p<0.001). Amongst the youth group, injuries inflicted by gunshot wounds, stab wounds and blunt assault comprised of 35%, 36%, and 29% of injuries respectively. In the adult group, this was 28%, 34%, and 38% respectively. There were no statistically significant differences between mechanisms of injury between the youth and adult groups. There was no significant difference in mean time to recurrence which was 66 months in youths and 62 months in adults (p=0.8). Mean abbreivated injury severity score was 4.8 in youths and 6.1 in adults and was not statistically significant.

Conclusion:
Violent injury prevention programs have focused on at risk youth as typically recidivism is significantly more prominent in this population. Despite a lower recidivism rate in an adult population, the prevalence is substantial. Adults experience similar current injuries when compared to youth in a similar time frame with a similar degree of injury. In urban trauma centers, violent injury prevention programs addressing an adult population may be beneficial in reduction of recurrent violent injury.

09.06 Health literacy and readability analysis of online resources related to lung cancer

Posted on January 18, 2016

K. D. Weiss1, C. R. Vargas1,2, O. Ho2, D. J. Chuang2, B. T. Lee1,2 1Beth Israel Deaconess Medical Center,Department Of Surgery,Boston, MA, USA 2Beth Israel Deaconess Medical Center,Division Of Plastic And Reconstructive Surgery,Boston, MA, USA

Introduction:

The Internet is a medium commonly utilized by patients seeking resources for health information; for many patients it has become the first source of health care information. Studies have shown that understanding supplemental educational material contributes to increased patient involvement and satisfaction. Limited functional health literacy is a potential barrier for access to these materials. Over 30% of the US population has basic to below basic literary skills which can contribute to overall health disparities, negatively impacts outcomes, and is even associated with increased mortality. As such, the National Institutes of Health and American Medical Association have recommended that patient-directed health resources should be written at a sixth-grade reading level. This study evaluates the readability of the most commonly accessed Internet resources on the subject of lung cancer.

Methods:

A search for ‘lung cancer’ was performed using Google and Bing, and the top 10 websites were identified. Location services were disabled and sponsored sites excluded. Relevant articles (n = 109) with patient-directed content available directly from the main sites were downloaded, and their readability was assessed using 10 established methods (Coleman-Liau, Flesch-Kincaid, Flesch Reading Ease, FORCAST, Fry Graph, Gunning Fog, New Dale-Chall, New Fog Count, Raygor Estimate, and SMOG). Readability scores were also grouped by parent website and by topic for comparison.

Results:

The average reading grade level across all sites was 11.2, with a range from 8.8 (New Fog Count) to 12.2 (SMOG). The readability of the material varied when compared by individual website, with a range from 9.2 to 15.2 (Cancer.gov 9.2, Mayoclinic.org 9.4, Cancer.org 9.6, Lung.org 10.1, Cancer.net 10.8, WebMD.com 11, Medicalnewstoday.com 12.2, Lungcancer.org 12.2, Medicinenet.com 13, Wikipedia.org 15.2). Only 10 articles (9%) were written at a 6th grade level or lower by any test and most of these were on the topics of prevention, risk factors, complications, and making treatment decisions.

Conclusion:

The most commonly web accessed patient-directed information about lung cancer consistently exceeds the recommended sixth grade reading level. Readability varies significantly between individual websites allowing physicians to identify and recommend sites according to a patient’s level of health literacy. Minor modifications to existing materials can significantly improve readability of materials while maintaining content for patients with low health literacy.

09.07 Identifying Predictors of Consent for Solid Organ Donation in Appalachia

Posted on January 18, 2016

J. W. Harris1, J. C. Berger1, R. Gedaly1, M. B. Shah1 1University Of Kentucky,Surgery,Lexington, KY, USA

Introduction: Appalachia is a distinct region characterized by high levels of poverty, poor access to healthcare and a high incidence of end stage organ disease. However, there is little reported regarding the availability and characteristics of potential organ donors. There is a need to understand factors that may impact consent for donation in potential donors residing in Appalachia.

Methods: All Appalachian potential donor (APD) referrals to our OPO from 2007-12 were analyzed. Death certificates for each APD were obtained. Demographics, marital status, education, registry status, cause and manner of death, decoupling, family member approached, understanding of hopelessness by family, and hospital region were collected. The US Census Report was used to obtain median county income and poverty rates. An analysis for donation consent was performed.

Results: 493 APD referrals were included. 207 consented for donation (CD) and 286 did not consent for donation (DNC). Those who CD were significantly younger (38 vs. 49 years, p<0.001). There were no differences in income. On univariate analysis, APD has lower CD if: age >40 vs <40 (32 vs 60%, p<0.001), high school or less education vs college (41 vs 58%, p<0.05), not registered vs on registry (38 vs 82%, p<0.001), OPO vs local provider vs family mentioned donation (37 vs 41 vs 73%, p<0.001), spouse/siblings/children vs parents approached for donation (35 vs 63%, p<0.001), if family did not understand hopelessness (20 vs 45%, p=0.009), declaration of death and approach for consent not decoupled (22 vs 47%, p<0.001), other cause of death vs trauma (36 vs 57%, p<0.001), medical vs non-medical mechanism of death (34 vs 54, p<0.001). There were no significant differences between race, APD gender and marital status, hospital region, miles from home, gender of family member approached, and poverty levels of APD compared to US and state poverty rates.

On multivariate analysis, predictors of CD were: age <18 years (OR 5.6 p<0.001), age 18-39 years (OR 6.5, p<0.001), college education (OR 3.3, p=0.008), graduate school (OR 4.3, p<0.001), on donor registry (OR 8.3, p<0.001), family mentioned donation (OR 5.6, p<0.001) and decoupling declaration of death from approach for donation (OR 5.8, p<0.001).

Conclusion: It is not surprising that poverty rates do not correlate with donation since Appalachia is generally poorer than numerous other areas. However, several observed factors can help target at-risk groups for poor consent in APD. Higher levels of education, younger age and family awareness of organ donation are independently associated with higher rates of consent. While DMV collaborations are paramount, targeting groups with poor consent rates more directly in their local communities may help increase awareness and donor registration. Additionally, OPO and local provider collaborations may maximize donation during the hospital phase of donation in non-registered APD.

09.08 Racial Disparities in Length of Stay Among Patients Undergoing Lower Extremity Revascularization

Posted on January 18, 2016

F. C. Patel1, M. D. Giglia1, A. Gullick1, M. S. Morris1, B. J. Pearce1, D. I. Chu1 1University of Alabama Birmingham,Department Of Surgery,Birmingham, ALABAMA, USA

Introduction: Racial disparities in surgical outcomes, such as readmissions, have been demonstrated in minority populations. Few studies have examined disparities in length-of-stay (LOS) for vascular procedures. We aim to investigate the role of race in determining LOS for patients undergoing lower extremity revascularization (LER) using a national, surgical outcomes registry.

Methods: We queried the 2012-2013 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) to identify all patients who underwent elective LER and stratified patients by approach (open versus endovascular) and race. Patients were excluded if they had any in-hospital, post-operative complications during their index admission or a 30-day mortality. Chi-square and Wilcoxon Rank Sums tests were used to determine the differences among categorical and continuous variables, respectively. The primary model outcome was total post-operative LOS. Predictors of LOS were identified with multivariate regression using a negative binomial model.

Results: Of 6,843 patients who underwent lower extremity revascularization, 76.2% and 23.8% of patients underwent an open or endovascular approach, respectively. Black patients represented 16.3% of the overall cohort, with women representing 47.5% and 34.3% of black and white patients, respectively. Black and white patients were similar with respect to BMI (27.4 vs. 27.3), ASA class distribution, and functional health. Compared to white patients, black patients were younger (65 vs. 74 years, p<0.05) and had significantly higher rates of smoking, hypertension, dialysis, insulin-dependent diabetes, and steroid use (p<0.05). On adjusted comparison, black patients who underwent an open LER experienced a longer post-operative LOS (4 vs. 3 days, p<0.001) compared to white patients. With an endovascular approach, no significant difference in LOS existed between races (1 vs. 1 day, p>0.05).

Conclusion: Black patients undergoing open LER have a significantly longer LOS in comparison to white patients even with no in-hospital complications. No racial disparities in LOS were observed for patients undergoing LER by endovascular approach. Further investigations will need to examine non-NSQIP elements such as psychosocial, behavioral, and educational factors that may explain disparities in open LER.

08.05 Quality Metrics after Early Mobilization in the PACU in Colorectal Patients: A 6-Month Analysis

Posted on January 18, 2016

M. W. LaPorta1, E. T. Wills1, A. W. Trickey1, P. Graling1, D. B. Colvin1, J. J. Moynihan1, H. D. Reines1 1Inova Fairfax Hospital,Department Of Surgery,Falls Church, VA, USA

Introduction

The importance of early postoperative ambulation has been recognized for decades. Early ambulation is associated with decreased venous thromboembolism (VTE), atelectasis, urinary retention, and length of stay, as well as increased patient satisfaction, improved pain control and return of bowel function. Patients deserve to be active participants in facilitating a safe and swift postoperative recovery. We focused on an early ambulation initiative to reduce postoperative VTE in the colorectal surgery population.

Methods:

Patients ≥18 years of age undergoing elective procedures from one large private colorectal surgery practice were enrolled from October 2014-March 2015. Starting at the pre-surgical visit and continuing in the pre-operative area, patients were educated on the importance of early ambulation on recovery after surgery. Post-anesthesia care unit (PACU) nursing and staff ambulated patients 100 feet within 1 hour of reaching PACU. An interim analysis using retrospective chart review from the Electronic Medical Record and Premier Quality Database compared patient outcomes 6 months pre-implementation versus 6 months post-implementation; outcomes were compared overall then stratified among patients receiving open, laparoscopic, or robotic-assisted procedures. Chi-square or Fisher’s exact tests were calculated with an intent-to-treat analysis. All patients meeting inclusion criteria in the post-ambulation period were included in the analysis, regardless of ambulation status.

Results:

A total of 72 /279 (25.8%) patients successfully ambulated in the PACU. The mean ambulation distance was 128 feet. Team members overcame skepticism related to the safety of this endeavor and the constraints of limited available time for ‘bedside nursing’ by engaging all key stakeholders including: patients and families, perioperative nursing staff, anesthesia services, and the surgical team. Characteristics of pre-implementation patients (N=279) were similar to post-implementation (N=228), including age, body mass index, fall risk scores, surgeons, and procedure types. During the first 6 months of the colorectal mobility initiative, there were no postoperative VTE occurrences, compared to 5 VTE events pre-implementation. Although this reduction does not reach statistical significance, it represents a clinically meaningful improvement and a strong trend (1.8% vs. 0%, p=0.07). Postoperative infections were reduced from 29% to 23% (p=0.09), with a significant infection reduction in laparoscopic procedures (28% vs. 14%, p=0.05).

Conclusion:

Results of the mobility initiative demonstrate that early postoperative ambulation can be accomplished safely. While the observed VTE reduction has not yet achieved statistical significance, meaningful trends have emerged in decreasing VTE and surgical site infections. Large-scale implementation and further evaluation is ongoing at our institution to determine if the trend will continue.

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