43.05 Assessing Knowledge of Biostatistics Among Residents and Medical Students

Posted on January 31, 2019

P. Kandagatla1, A. Worden1, A. Woodward1, A. H. Gupta1  1Henry Ford Health System/Wayne State University,Department Of Surgery,Detroit, MICHIGAN, USA

Introduction:  Previous studies have shown a lack of required biostatistical knowledge among residents. There are few data on the departmental variation of biostatistical knowledge among residents. Furthermore, there is a paucity of data comparing residents and medical students. We hypothesized that residents’ biostatistical knowledge varies across departments and there are individual characteristics that may serve as predictors for increased knowledge.

Methods:  We surveyed residents and medical students rotating at our institution. The survey tool included questions on demographics, prior biostatistics exposure, educational history, and confidence in biostatistics. The remainder of the survey included a previously validated 17-question biostatistics quiz. Descriptive statistics are used to summarize the responses. Univariate and bivariate analyses were done to compare means and calculate correlation, respectively. Multivariate analysis was performed to derive independent predictors of increased knowledge.

Results: A total of 218 participants completed the survey. Twenty-five (11.5%) were medical students and 193 (88.5%) were residents. The overall mean (SD) percent correct on the quiz was 48.3% (14.5%), and average correct was not different between students and residents(50.4% SD 13.2% vs 48.2% SD 14.6%, p = 0.45). There was a significant difference in the mean scores across all departments (range: 39.2-58.1%, p<0.01), which included Anesthesia, Emergency Medicine, Family Medicine, General Surgery, Internal Medicine, Neurosurgery, Ob/Gyn, Orthopedic Surgery, Radiology, and Urology. Ninety-three (42.7%) participants had a prior epidemiology course, 133 (61.0%) had a biostatistics course, and 117 (53.7%) had an evidence-based medicine course. There was no significant difference in the mean scores between those that had each type of course compared to those that did not. There was no significant correlation between average journal articles read per week (r = 0.09, p = 0.2), previous research publications (r = 0.12, p = 0.08), number of biostatistics didactics (r = -0.07, p = 0.33), and level of training (r = -0.01, p=0.84) with percent correct. Journal club attendance, however, was correlated with performance (r = 0.22, p<0.01). Confidence in participants’ understanding of statistical terms (r = 0.11, p = 0.11) was not correlated with performance. Linear regression revealed journal club attendance (b = 1.5, 95% CI 0.11-2.88, p = 0.03) and number of articles read per week (b = 2.8, 95% CI 0.11-5.45, p = 0.04) to be the only significant independent predictors for increased performance.

Conclusion: There was a significant variation in biostatistical knowledge across residency departments. Future educational interventions attempting to increase knowledge of biostatistics should perhaps focus on increasing journal club attendance and regular reading of medical literature. 

 

43.04 Identifying Naturalistic Coaching Behavior among Practicing Surgeons in the Operating Room

Posted on January 31, 2019

J. C. Pradarelli1,4, M. Delisle2,4, A. Briggs3, D. S. Smink1, S. J. Yule1,5  1Brigham And Women’s Hospital,Surgery,Boston, MA, USA 2University of Manitoba,Surgery,Winnipeg, MB, Canada 3Dartmouth Medical School,Surgery,Lebanon, NH, USA 4Ariadne Labs,Boston, MA, USA 5STRATUS Center for Medical Simulation,Boston, MA, USA

Introduction: Opportunities to improve surgical performance are limited for practicing surgeons; surgical coaching is one strategy to address this need. To develop peer coaching programs that integrate with surgical culture, a better understanding is needed of how surgeons routinely discuss performance in an operative context. The aim of this study was to identify examples of naturalistic coaching behavior among practicing surgeons operating together by categorizing intraoperative discussion with existing coaching principles.

Methods:  As part of a “co-surgery” quality improvement program, 20 faculty surgeons at a single academic hospital were randomized into 10 co-surgery dyads, comprising an “attending” and an “assistant” surgeon, who performed 1 operation together. Intraoperative discussion was transcribed in real time. De-identified transcripts were co-coded systematically by 2 researchers. Deductive reasoning was applied to categorize data into themes based on existing principles of surgical coaching: 1) self-identified goals, 2) collaborative analysis, 3) constructive feedback, and 4) peer learning support. Surgical coaching principles were cross-referenced with surgical coaching content, including technical skills (respect for tissue, exposure, instrument handling, time and motion, and flow of operation) and non-technical skills (situation awareness, decision-making, communication/teamwork, and leadership). A c-coefficient was calculated to assess the strength of the association between pairs of themes (range 0 to 1, with 0 meaning no co-occurrence and 1 meaning that the themes always occurred together).

Results: Overall, 44 coaching examples were identified in 10 operations. Of the 4 principles of surgical coaching, only self-identified goals and collaborative analysis were identified consistently in naturalistic conversations between two practicing surgeons in the operating room. Self-identified goals were most associated with discussions regarding “instrument handling,” “tissue exposure,” and “flow of operation” for technical skills (c-coefficient: 0.14, 0.17, 0.15, respectively) and “situation awareness” for non-technical skills (0.13). Collaborative analysis was most strongly associated with discussions regarding “respect for tissue” and “flow of operation” for technical skills (0.42 and 0.38, respectively) and “communication/teamwork” for non-technical skills (0.52).

Conclusion: In naturalistic conversations between practicing surgeons in the operating room, numerous examples of innate coaching behavior were identified that focus on intraoperative performance, including self-identified goals and collaborative analysis. However, prominent gaps were also observed in the natural behavior of surgeons with respect to coaching principles. For example, constructive feedback and peer learning support were rarely, if at all, identified. Surgical coaching programs will need to address these gaps to train surgeons as effective surgical coaches.

43.03 Timing of Surgery and Internal Medicine Clerkships and Surgery Shelf Exam Scores

Posted on January 31, 2019

A. Phares1, C. Sauder1, E. Salcedo1, D. Leshikar1, C. Irwin1, G. Middleton2, H. Phan1  1University Of California – Davis,Department Of Surgery,Sacramento, CA, USA 2University Of California – Davis,Office Of Medical Education,Sacramento, CA, USA

Introduction:
The third-year of medical school is a stressful time for students as they transition from the classroom to the clinics and wards. Students strive to perform well clinically with their patients and teams as well as academically on their assignments and exams. Many students believe that rotation sequence effects their success. At UC Davis, students interested in surgery believe that completing the internal medicine (IM) clerkship before the surgery clerkship will help improve their surgery shelf exam scores. We hypothesized, despite our students’ impressions, that students who completed the IM clerkship prior to the surgery clerkship did not receive higher surgery shelf examination scores than the students who did not.

Methods:
Deidentified academic data for all third-year UC Davis School of Medicine medical students from 2012-2017 were collected. Data included undergraduate GPA, MCAT scores, USMLE Step 1 scores, and NBME shelf exam scores for surgery. Students who did not complete all six core clerkships during the standard third-year time frame were excluded. The average shelf exam scores were analyzed using a 2-tailed t-tests both in aggregate and by individual rotation slot. Z-scores were also calculated for the average shelf exam scores by rotation slot.

Results:
Data from 424 students were included in the study. 214 students completed the IM clerkship before the surgery clerkship and 206 did not. Average undergraduate GPA, MCAT scores, and USMLE Step 1 scores were compared between the two groups, and no significant differences were found. In aggregate, average shelf exam scores of students who completed the IM clerkship prior to the surgery clerkship were significantly higher than those of students who did not (77.0% vs 73.8%, p value < 0.001). Additionally, average shelf exam scores for all students increased over the academic year. When the average shelf exam scores for the two groups were analyzed by rotation slot, no significant difference was found between the two groups (Table 1).

Conclusion:
When the shelf exam scores were analyzed in aggregate, students who completed the IM clerkship before the surgery clerkship scored higher on their surgery shelf exams. However, the surgery shelf scores were higher as the academic year progressed. Students who completed the surgery clerkship later in the academic year were more likely to have completed the IM clerkship already. When examining the two groups by rotation slot, we found no difference between the students who had already completed the IM clerkship and those who had not. These data suggest that students' scores on the surgery shelf exam are related to experience gained and are independent of the timing of the IM rotation in relation to the surgery rotation.
 

43.02 Utilization of Nurse Practitioners Improves Surgical Resident Education and ABSITE Scores

Posted on January 31, 2019

A. Hussain1, D. Golden1, S. Casos1, L. Mitchell1, S. Tsirgotis1, J. Ragan1, A. Pamula1, J. Miner1, B. Cagir1, R. Behm1  1Guthrie Clinic,General Surgery,Sayre, PA, USA

Introduction: The American Board of Surgery In Training Examination (ABSITE) is a proven marker for successful first time passing of both the qualifying and certifying general surgery board examinations. Resident work hour restrictions and protected didactic time limit the residents’ ability to perform clinical duties. Nurse practitioners (NPs) have been shown to positively impact patients’ outcomes and overall hospital costs when utilized on an Acute Care Surgery (ACS) service. We describe a model of adding NPs to a busy ACS service in order to protect resident didactic time and decrease resident work load thereby improving resident education and ABSITE scores.

Methods: With declining board pass rates in our general surgery residency program, a new educational model was created increasing protected didactic time four-fold and protecting an hour at the end of the day to finish all work prior to handoffs. The addition of 3 full and one part time NP allowed the ACS service to function nearly independent of residents. The NPs provided ICU, trauma activation and emergency general surgery coverage during resident protected time. They also absorbed some of the resident daily workload allowing the ACS service to focus on resident education rather than clinical responsibilities. ABSITE scores were evaluated before and after these changes.

Results: Only those ABSITE scores earned before and after the implementation of the program reform were included. Eleven residents’ scores met inclusion criteria. To analyze pre-and post-intervention ABSITE scores, we used a mixed model with time and level-of-training as fixed effects and each resident as a random effect. We showed that the effect of taking the test before or after the intervention was not significantly different between the levels of training; however, when simply controlling for the main effect of level of training, we showed a significant and similar increase in scores after the intervention for all levels of residents (standard score increased 77.3; p=0.001, percent correct increased 5.9; p=0.0023 and percentile increased 23.8 p=0.0229). Prior to the reform, 45% of the residents' ABSITE scores were below the 35th percentile putting them at risk of failing their board exams on the first try. After the reform, no residents were below the 35th percentile.

Conclusion: Utilization of NPs on an ACS service has previously shown to have a positive impact on patient outcomes and overall hospital costs. We have shown NPs are vital to a training program as they provide critical patient care coverage allowing the residents the time needed to learn and prepare for surgical board examinations. 

 

43.01 Use of Natural Language Processing to Interpret Resident Performance Evaluations

Posted on January 31, 2019

K. L. Abbott1, C. M. Harbaugh2, N. Matusko2, G. Sandhu2, P. G. Gauger2, J. V. Vu2  1University of Michigan Medical School,Ann Arbor, MI, USA 2University of Michigan,Department Of Surgery,Ann Arbor, MI, USA

Introduction: Residents receive feedback from performance evaluations in the form of quantitative scores and qualitative comments. Quantitative scores can quickly be compared with other numerical ratings, but they may lack adequate meaning and often show little variation over time. Qualitative comments may be highly specific, but it is difficult to recognize or analyze trends in comments dispersed across evaluations. We explored the use of natural language processing (NLP) to interpret qualitative data with the goal of generating high-yield, easily accessible feedback.

Methods: We examined faculty and peer evaluations for general surgery residents training at a single academic institution from 2008-2017. Evaluations assessed nine performance domains using rating scales and a free text field. NLP uses artificial intelligence to interpret language, and sentiment analysis is a type of NLP that extracts information related to opinions—for example, negative or positive feeling. We used the Google application programming interface for NLP to generate sentiment scores for qualitative evaluations. To characterize performance scales, we calculated Cronbach’s α and completed exploratory factor analysis. To ascertain the relationship between performance ratings and sentiment scores, we calculated a Pearson correlation coefficient. To graphically represent word frequency and sentiment score, we generated word clouds for an example resident.

Results: We analyzed 3,467 performance evaluations from 18 residents, averaging 192 evaluations per resident. The nine performance questions had high inter-item reliability (Cronbach’s α = 0.97). Exploratory factor analysis indicated that the nine domain questions measured a single construct. Averaged domain rating and evaluation-level sentiment score were weakly correlated (r = 0.36, 95% CI = 0.32-0.39, p < 0.001). The words “instruction” and “understanding” had negative sentiment in the PGY-1 word cloud, but did not appear in the PGY-5 word cloud. The word “leader” in the PGY-5 word cloud had a frequency of 5 and an average sentiment score of 0.54 (range 0-0.9), but did not appear in the PGY-1 word cloud.

Conclusion: Our results demonstrate that NLP can be used to process valuable qualitative information not captured by performance ratings. Thematic analysis of qualitative data is labor-intensive, but NLP facilitates rapid aggregation and visualization of qualitative data from multiple sources. These methods could be used to aggregate changing or contradictory information from multiple evaluations and present trainees with feedback that helps them identify strengths and specific areas for improvement.

42.10 Using a Location-Based Time-Keeping App to Help Track Resident Duty-Hours: A Pilot Study

Posted on January 31, 2019

B. Zhao1, J. Lam1, A. Lee1, G. R. Jacobsen1  1University Of California – San Diego,Surgery,San Diego, CA, USA

Introduction:
Duty-hour limits continue to be an important topic in graduate medical education. Currently, the majority of programs rely in voluntary reporting of duty-hours by trainees. The accuracy of reported hours can be poor because tracking work-hours can be an arduous task for trainees. This can lead to trainees not regularly reporting hours, which can further decrease the accuracy of reported work-hours. In this study, we propose an innovative method to track trainee work-hours using a smartphone app.

Methods:
We performed a pilot study testing the feasibility of an automated, location-based time-keeping smartphone app on 10 general surgery residents at our institution. The app sets “geofences” around specific locations and automatically records work-hours once the user is within the “geofenced” area. Study personnel installed the app on each participants’ smartphones and instructed participants on how to check their work-hours using the app. A hypothetical work-hour record is shown in the Figure. We conducted a pre-installation survey and a post-installation survey 12 weeks later.

Results:
Prior to using the app, 80% of residents stated that it was too time-consuming to report hours and 40% of residents stated that it was difficult to accurately track duty-hours. 60% of residents thought they were under-reporting their duty-hours prior to using the app. However, after using the app, only 1 resident stated that he or she worked more than they previously thought. The frequency of hours-reporting did not change after using the app, with half of the residents stating that they reported hours less frequently than once per month in both surveys. In terms of usability, 80% of residents stated that the app was moderately easy to use and 60% stated that it was moderately accurate. 80% of residents actively used the app to check their duty-hours. Two residents complained that the app was slow to clock-out at times, leading to over-counting of work-hours, and two residents complained that the app was detrimental to their phone’s battery life. After using the app, 60% of residents stated that they were at least moderately likely to allow a location-based app to automatically report their work-hours in the future. 

Conclusion:
Using a location-based time-keeping smartphone app has potential to help residents track duty-hours. The app works in the background and allows residents easy access to their duty-hours. Further work needs to be done to improve the accuracy of the app and further integrate the app with the reporting of duty-hours. This will decrease the burden, and increase the accuracy, of duty-hour reporting for trainees.
 

42.09 Financial Costs of Urology Residency Interviews: Are Underrepresented Minorities at a Disadvantage?

Posted on January 31, 2019

J. Whitley2, B. D. Joyner1,2, K. Kieran1,2  1University Of Washington,Seattle, WA, USA 2Seattle Children’s Hospital,Seattle, WA, USA

Introduction:  Increasing diversity remains a goal of many urology training programs.  Failure to recruit and retain underrepresented minority (URM) applicants has been attributed to a “pipeline” issue, although it is unclear where in the “pipeline” this discrepancy is most pronounced.  Since the cost of residency interviews has been previosuly identified as a potential barrier to some applicants, we wondered whether differential cost might be a factor for URM students applying to urology.  We undertook this study to determine whether the structure of residency interviews at selected top residency programs is associated with differential cost to students at medical schools with high and low URM populations.

Methods:  We identified 22 theoretical applicants: 11 "students" at medical schools with the student body >20% URM ("high-URM"), and 11 "students" at randomly selected medical schools with the student body <15% URM ("low-URM").  We contacted each of 17 "top" urology residency programs to identify interview dates for the 2017-2018 match, created a theoretical interview  schedule for each "student," and calculated the cost of travel (by car for <3 hours drive, otherwise by air) and lodging from each of the 22 medical schools to the 17 residency programs on one of the planned interview dates.  The aggregate costs to "students" at high-URM and low-URM medical schools were compared.

Results:  The median aggregate costs of travel and lodging for "students" attending all 17 interviews was $9189 (range: $7202-13,703) for applicants from high-URM schools and $9035 (range: $6698-$11967) for applicants from low-URM institutions (p=0.81). 

Conclusion:  In the 2017-2018 urology interview season, costs to applicants from high-URM and low-URM institutions are statistically similar.  Absolute cost considerations are unlikely to account for differences in URM representation in top-tier residency programs. Program directors and undergraduate medical education leadership must continue to investigate real and postulated barriers to URM engagement and retention along the pipeline to urology graduate medical education.
 

42.08 The Anatomy of Gun Violence: Curriculum to train surgical residents in the management of gun violence

Posted on January 31, 2019

E. J. Onufer1, D. R. Cullinan1, E. G. Andrade1, P. E. Wise1, M. E. Klingensmith1, L. J. Punch1  1Washington University,Surgery,St. Louis, MO, USA

Introduction: Gun Violence (GV) is a complex public health issue which poses unique challenges to the practice of surgery. The management of GV as a disease engages the surgeon in a wide range of both technical and non-technical skills. The Anatomy of Gun Violence (AGV) curriculum was developed to teach surgical trainees these seemingly disparate skills, training residents to manage gunshot wounds in a contextualized setting. Moving beyond the technical aspects of treating penetrating injuries, this curriculum examines the risks for and experience of GV as well as the need for strong leadership, communication, and empathy in the management of GV.

Methods: The AGV curriculum was delivered over six weeks in the 2017-18 academic year and utilized multiple educational methods including didactic lectures, senior resident lead mock oral examination of junior residents, Stop the Bleed training session, a GV survivor’s personal story, and the Surgery for Abdominal-thoracic ViolencE (SAVE) simulation lab. The lab emphasized team-training in operative management of GV in an animate model, featuring stories of real patients treated by resident teams over the prior year. Content reviewed included epidemiology of GV, patterns of injury, management of critically ill patients, effect of GV on mental health, coordinated systems of care, and the importance of team work in managing of GV. Residents were evaluated via survey to assess skills obtained, team leadership, communication styles, overall experience of the curriculum.

Results: 63 surgical residents experienced the AGV curriculum and 42 completed a survey regarding their experiences (67% response rate). Prior to residency, 10 of 42 (24%) residents reported any type of training related to GV. 71% of residents had never heard someone speak about their experience as a GV survivor, and 89% believed this session positively contributed to their understanding of GV. The SAVE lab was the most highly favored with no significant difference between other portions of the curriculum. Overall AGV was rated highly at 4.9/5.0 with individual components rating 4.5-4.8/5.0 (Figure).

Conclusion: Through simulation, didactic, and immersive sessions, AGV created a simultaneous experience of the technical and non-technical skills necessary to manage the complex GV epidemic. The curriculum was well received in both these areas of competency. This comprehensive approach to GV may represent a unique opportunity to engage surgical trainees in both the treatment and prevention of GV.

42.07 Safety in allowing residents to independently perform appendectomy, a retrospective review

Posted on January 31, 2019

J. R. Barrett1, M. K. Drezdzon1, A. Monawer1, A. P. O’Rourke1, J. Scarborough1  1University of Wisconsin,Acute Care Surgery,Madison, WISCONSIN, USA

Introduction:

The "teaching resident" role provides senior surgical trainees with an excellent opportunity to demonstrate their independence with the intraoperative conduct of certain procedures.  It is not known, however, whether the practice of "two-resident" procedures impacts patient outcomes. 

Methods:

A single-center retrospective review of 500 consecutive patients from May 2016 to December 2017 who underwent appendectomy with the University of Wisconsin Hospital system. The outcomes of "two resident" procedures was compared with those of procedures which included only one resident, after adjustment for patient- and procedure-related factors.

Results:

A total of 303 cases were performed with a single resident, 190 with two residents, and 7 cases were excluded that were performed with no resident present. There were no differences in the incidence of postoperative SSI (7.9% for two resident vs. 7.3% for one resident procedures, P = 0.80), prolonged operation (28.4% for two resident vs. 26.4% for one resident, P = 0.62), or conversion from laparoscopic to open (3.7% for two resident vs. 2.3% for one resident, P = 0.37) between groups, either before or after adjustment for other variables.

Conclusion:

Allowing senior residents to take junior residents through laparoscopic appendectomy procedures does not impact patient outcomes.  Incorporation of this practice into the current entrustable professional activity (EPA) framework of surgical resident education is appropriate.

42.06 The Future of General Surgery Training: A Canadian Resident Nationwide Delphi Consensus

Posted on January 31, 2019

C. Huynh1, N. Wong-Chong2, P. Vourtzoumis3, W. Marini3, S. Lim4, G. Johal1, M. Strickland3, A. Madani5  1University Of British Columbia,Surgery,Vancouver, British Columbia, Canada 2McGill University,Surgery,Montreal, QC, Canada 3University of Toronto,Surgery,Toronto, Ontario, Canada 4University of Manitoba,Surgery,Winnipeg,Manitoba, Canada 5Columbia University College Of Physicians And Surgeons,Surgery,New York, NY, USA

Introduction:
Various pedagogical models have been introduced in an attempt to improve and restructure surgical training. Yet, there remain significant obstacles related to their method of implementation, timing and acceptance. Prior to implementing national guidelines, it is critical to explore residents’ opinions to ensure a successful transition that meets their needs and addresses the practical challenges of reformatting surgical residency. This study aimed to establish a nationwide Delphi consensus statement on the opinions and perceptions of Canadian residents regarding the future of general surgery training.

Methods:
Residents from each Canadian general surgery program participated in a moderated semi-structured focus group using a Nominal Group Technique to discuss issues related to surgical training across three domains: early sub-specialization (streaming), competency-based medical education (CBME), and a dedicated transition-to-practice (TTP) period. Qualitative verbal data was transcribed verbatim, coded, grouped into themes, and synthesized into a list of recommendation statements. Using an online, iterative Delphi survey, these statements were then ranked by a panel of residents on a 5-point Likert scale in terms of agreement. The survey was terminated once consensus was achieved, predefined as ≥2 survey rounds and internal consistency (Cronbach’s α) ≥0.80. Each statement was marked as “positive agreement” (67% majority ranked 4 or 5), “negative agreement” (67% majority ranked 1 or 2), or “no agreement” (neither positive or negative agreement).

Results:
Sixty-six statements were synthesized by 16 members of the Canadian Association of General Surgeons Resident Committee. Forty-nine residents participated in the Delphi consensus (2 voting rounds; Cronbach’s α=0.93). Participants agreed streaming should only be offered in the last clinical years as a bridge to one’s intended career path, and after “core” general surgery milestones and competencies have been achieved. Respondents also agreed there should be an explicit period at the end of residency that allows residents to transition to independent practice, by including rotations tailored to their career path, greater autonomy and patient ownership, opportunities to develop skillsets related to managing and running a practice, and “Resident Clinics”. Panelists agreed that residency should be remodeled to focus on the achievement of standardized competencies and milestones throughout various levels of training, based on residents’ ability to meet specific and measurable metrics. Ten barriers to CBME implementation were identified.

Conclusion:
A nationwide consensus regarding the future of surgical training was established. These findings can be used to implement guidelines and national curricula that meet the needs of residents and address the various challenges that face their training.

42.05 Controlled Substance Prescribing and Education in Orthopedic Residencies: A Program Director Survey

Posted on January 31, 2019

M. Dugan2, M. Crandall1, A. J. Bell3, B. K. Yorkgitis1  1University of Florida- Jacksonville,Acute Care Surgery,JACKSONVILLE, FLORIDA, USA 2Georgetown University School of Medicine,Washington, DC, USA 3University of Florida-Jacksonville,Orthopaedic Surgery,Jacksonville, FL, USA

Introduction:  Opioid misuse is currently plaguing the US.  Efforts to reduce this phenomenon include opioid prescribing education (OPE). Orthopedic residents often prescribe opioids but their education on this task is unknown.  A survey sent to program directors (PDs) assessed the current state of controlled substance (CS) prescribing and education among orthopedic residents.

Methods:  An IRB approved survey was sent via email to orthopedic residency PDs. The survey included program characteristics, knowledge of local PDMP, DEA registration and licensure requirements, perceived value of OPE, polices on prescribing outpatient CS, OPE presence and characteristics.

Results: 163 PDs were successfully offered participation in the survey with 60 (36.8%) completed.  On a 5-point Likert scale (0 not valuable, 5 very valuable), the mean PDs rated the value of OPE to clinical care was 4.3 (SD 0.88) and value to resident training was 4.5 (SD 0.79). Residents were permitted to prescribe outpatient opioids in 54 (90.0%) programs. In which, 41 (75.9%) do not limit which DEA schedule opioid types and 41 (75.9%) allow benzodiazepines. Nine (16.7%) programs require residents to obtain individual DEA registration, 39 (72.2.%) allow use of the hospital’s DEA registration and 6 (11.1%) PDs were unsure about DEA utilization. When queried about their state’s required use of PDMPs, 52 (86.7%) were correctly aware of their state laws, and 6 (10.0%) were not sure about this requirement. Presence of state required opioid education for fully licensed physicians was correctly answered by 43 (71.6%) PDs and 14 (23.3%) were unsure.

Only 28 (46.7%) programs had mandatory OPE.  Six (10.0%) PDs were unsure if OPE was a mandatory. Of programs that do not have a confirmed OPE, 16 (50.0%) were considering adding one.  Programs with an OPE, didactic lecture (21, 75.0%) followed by computer-based programs developed at their hospital (13, 46.4%) were the most common modalities. 17 (60.7%) programs used more than one educational modality.  Time for OPE ranged from <1 hour to > 3 hours with the mode being 1-3 hours (12, 42.8%). When PDs were queried which method would be best for OPE, the most common response was case-based scenarios (17, 28.3%) followed by didactic lectures (15, 25.0%).

Conclusion: The majority of programs permit residents to prescribe outpatient opioids; less than half provide mandatory OPE.  This survey demonstrated that half of the programs that do not have a mandatory OPE are considering adding it.  Several PDs were unaware if there is a mandatory OPE component in their residency or were unsure about institutional regulations regarding DEA registration utilization as well as local regulations on opioid education and PDMP use.  This study demonstrates a gap in OPE among orthopedic residencies and PDs’ knowledge of regulations regarding CS prescribing. A significant opportunity remains to provide OPE during residency and PD education on policies regarding CS prescribing.

42.04 Evaluating Factors Affecting Surgical Grand Rounds Attendance:

Posted on January 31, 2019

D. M. Carmona Matos1,2, B. Herring1, M. Mandabach1, Z. Aburjania1, A. Chang1, A. Janssen1, H. Chen1, B. L. Corey1  1University Of Alabama at Birmingham,Department Of Surgery,Birmingham, Alabama, USA 2San Juan Bautista School of Medicine,Caguas, Puerto Rico, Puerto Rico

Introduction:  As Surgical Grand Rounds (SGR) have paralleled the evolution of medicine over time, so have the needs of an increasingly diverse group of physicians and trainees. The purpose of this study was to evaluate factors (topic, rank, gender) that may alter attendance to SGR to facilitate the development of SGR that can better meet the needs of the physician workforce.

Methods:  Descriptive data of SGR attendees, speakers, and topics were obtained over the course of 10 months. Each presentation was categorized into the following topics: Education, Healthcare Management and Administration (HM&A), Professionalism, Research, and Treatment Strategies. The total mean attendance and attendance of each academic rank to SGR on topic categories was determined. Academic ranks included Professors, Associate Professors, Assistant Professors, Fellows, Residents, and Students. Further, the respective attendance of males and females to SGR by topic category was determined, then evaluated via chi-square test. Lastly, the average attendance of males and females to SGR given by males/females was calculated and evaluated via chi-square test. 

Results: The mean attendance was highest (116) for SGR on HM&A, while lowest (81) for SGR on Education. The highest/lowest mean attendance to SGR topics by academic rank are as follows: Professors- [Professionalism]/[Education], Associate Professors- [HM&A, Professionalism]/[Education, Research], Assistant Professors- [HM&A]/[Treatment Strategies], Fellows- [HM&A]/[Professionalism, Treatment Strategies], Residents- [Research]/[Treatment Strategies], Students- [Professionalism]/[Education]. While there was no significant difference in attendance within SGR topic categories by gender (p=0.8), the mean attendance of females to SGR given by M/F speakers was 31/30, while the mean attendance of males was 68/56 (p=.04), respectively.   

Conclusion: Marked differences exist in both total attendance to SGR on topic categories and attendance to SGR on topic categories within academic ranks. Further, although the difference in attendance within SGR topic categories by genders was not significant, the difference in male attendance to SGR presented by M/F was. These findings identify trends that can be used to tailor SGR in the future to better serve physicians and students throughout their careers

 

42.03 Perspectives and Priorities of Surgery Residency Applicants in Choosing a Training Program

Posted on January 31, 2019

P. Marcinkowski1, P. Strassle1, T. Sadiq1, M. Meyers1  1University Of North Carolina At Chapel Hill,General Surgery,Chapel Hill, NC, USA

Introduction:
Applicants pursuing surgery residency have a number of variables to prioritize in selecting a training program. We sought to evaluate the importance of various criteria to applicants applying to surgery residency.

Methods:
An anonymous electronic survey was distributed to applicants who interviewed at a single surgery program over a six-year period (Match years 2013-2018). Respondents were asked to categorize the importance of various criteria in considering a training program on a 5-point scale (very important/above average/average/below average/unimportant). Fisher’s exact tests were used to assess whether the percentage of respondents considering each variable ‘more important’ varied across application year (categorized as 2013-2014, 2015-2016, and 2017-2018), sex, medical school region, or medical school type (public vs. private).  A p-value <0.05 was considered statistically significant. All analyses were performed using SAS 9.4 (SAS Inc., Cary, NC).

Results:
176 responses were received (35% response rate). 47% female. 47% were from the Southeast region followed by 20% Midwest, 19% Northeast, 7% Southwest, 6% West. 40% attended private medical schools. 100% of applicants applying 2015-2018 ranked operative experience as very important/above average importance versus applicants applying from 2013-2014 who ranked it very important/above average importance 94% of the time (p=0.04). Applicants applying 2017-2018 ranked non-operative clinical experience very important/above average importance 90.7% of the time compared to 2013-2014 and 2015-2016 who ranked it similarly 77.6% and 73.9% of the time respectively (p=0.04). Applicants from the northeast region ranked research opportunities as very important/above average importance 96.9% of the time compared to the other regions (West: 63.6%, Midwest: 73.5%, Southeast: 75.3%, Southwest: 83.3%) (p=0.02). Otherwise, there was no statistically significant variation in applicant demographics and criteria they believed important to them in choosing a residency program.  Overall, applicants rated resident attitude/relationship (91% very important), faculty attitude (80% very important), resident/faculty relationship (75% very important) and operative experience (89% very important) as the most important characteristics.

Conclusion:
Surgery residency applicants appear to place greatest importance on interpersonal interactions and operative experience over other training program/hospital characteristics. There was some variability depending on the year applied and the region that the applicant applied from, but in general applicants had similar preferences. This information may be helpful to applicants and programs alike as they navigate the application and match process.
 

42.02 The Effect of Gender on Operative Autonomy in General Surgery Residents

Posted on January 31, 2019

S. L. Meyerson1, D. D. Odell1, J. B. Zwischenberger2, M. Schuller1, J. D. Bohnen4, G. L. Dunnington3, L. Torbeck3, J. T. Mullen4, S. P. Mandell5, M. A. Choti6, E. Foley7, C. Are8, E. Auyang9, J. Chipman10, J. Choi3, A. Meier11, D. S. Smink12, K. P. Terhune13, P. E. Wise14, N. Soper1, K. Lillemoe4, J. P. Fryer1, B. C. George15  1Feinberg School Of Medicine – Northwestern University,Department Of Surgery,Chicago, IL, USA 2University Of Kentucky,Department Of Surgery,Lexington, KY, USA 3Indiana University School Of Medicine,Department Of Surgery,Indianapolis, IN, USA 4Massachusetts General Hospital,Department Of Surgery,Boston, MA, USA 5University Of Washington,Department Of Surgery,Seattle, WA, USA 6Banner MD Anderson Cancer Center,Department Of Surgery,Gilbert, AZ, USA 7University Of Wisconsin,Department Of Surgery,Madison, WI, USA 8University Of Nebraska College Of Medicine,Department Of Surgery,Omaha, NE, USA 9University Of New Mexico HSC,Department Of Surgery,Albuquerque, NM, USA 10University Of Minnesota,Department Of Surgery,Minneapolis, MN, USA 11State University Of New York Upstate Medical University,Department Of Surgery,Syracuse, NY, USA 12Brigham And Women’s Hospital,Department Of Surgery,Boston, MA, USA 13Vanderbilt University Medical Center,Department Of Surgery,Nashville, TN, USA 14Washington University,Department Of Surgery,St. Louis, MO, USA 15University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA

Introduction: Despite an increasing number of women in surgery, bias regarding cognitive or technical ability may continue to impact the experience of female trainees differently than their male counterparts. The goal of this study is to examine differences between the degree of operative autonomy given to female and male surgical trainees.

Methods: A smartphone app was used to collect evaluations of operative autonomy measured using the 4-point Zwisch scale, which describes defined steps in the progression from novice (“Show and Tell”)  through increasing degrees of autonomy (“Active Help” to “Passive Help”) to competent to enter practice (“Supervision Only”). Autonomy was evaluated from both the faculty and resident perspectives. Differences in autonomy between male and female residents were compared using hierarchical logistic regression analysis.

Results: 412 residents and 524 faculty from 14 general surgery training programs evaluated 8900 cases over a 9 month period. Female residents received meaningful autonomy from faculty (“passive help” or “supervision only”) in 46.7% of cases (1053/2253) while male residents received meaningful autonomy in 52.7% of cases (1906/3614, p<0.001). Resident level of training and case complexity were the strongest predictors of autonomy. Even after controlling for potential confounding factors including level of training, intrinsic procedural difficulty, patient-related case complexity, faculty gender, and training program environment, female residents still received less operative autonomy than their male counterparts. The gap between autonomy granted to male and female residents was present from both the faculty and resident perspectives. The largest discrepancy was in the fourth year of training and both male and female faculty surgeons granted less autonomy to female residents.

Conclusion: There is a gender-based difference in the autonomy granted to general surgery trainees. This gender gap may affect female residents’ experience in training and possibly their preparation for practice. Strategies need to be developed to help faculty and residents work together to overcome this gender gap.

 

42.01 Surgical Trainees’ Sense of Responsibility for Patient Outcomes: A Multi-Institutional Appraisal

Posted on January 31, 2019

R. W. Randle1, S. L. Ahle2, D. M. Elfenbein5, A. N. Hildreth4, J. A. Greenberg3, P. J. Schenarts7, J. W. Kempenich6  1University Of Kentucky,Department Of Surgery,Lexington, KY, USA 2Yale University School Of Medicine,Department Of Surgery,New Haven, CT, USA 3University Of Wisconsin,Department Of Surgery,Madison, WI, USA 4Wake Forest University School Of Medicine,Department Of Surgery,Winston-Salem, NC, USA 5University Of California – Irvine,Department Of Surgery,Orange, CA, USA 6University Of Texas Health Science Center At San Antonio,Department Of Surgery,San Antonio, TX, USA 7University Of Nebraska College Of Medicine,Department Of Surgery,Omaha, NE, USA

Introduction:
Surgeon educators express concern about their current ability to impart a strong sense of patient ownership to trainees. We hypothesized that surgical residents’ sense of patient ownership would be associated with their perceived autonomy and other modifiable factors in the modern training environment. We aimed to compare resident and faculty perceptions on residents’ sense of personal responsibility for patient outcomes and to correlate patient ownership with resident and residency characteristics.

Methods:
An anonymous electronic questionnaire surveyed 373 residents and 390 faculty at 7 academic surgery residencies across the U.S. We used a modified version of a validated psychologic ownership scale to measure patient ownership among surgical trainees.

Results:
Respondents included 123 residents and 136 faculty (response rate 33% and 35%, respectively). Overall, 91.1% of resident respondents agreed that faculty modeled strong patient ownership, and 78.0% of faculty agreed that residents took personal responsibility for patient outcomes. 75.6% of residents perceived they felt a similar or higher degree of patient ownership than their faculty, but only 26.4% of faculty agreed. Faculty underestimated the proportion of residents that routinely checked on their patients when “off-duty” or “off-service” (36.8% vs 92.6% per resident report (p<0.001). Faculty and residents perceived that greater operative autonomy provided residents with a higher level of ownership (Figure). Almost all faculty (97.8%) reported providing more autonomy to residents who display strong patient ownership, but only 53.7% provide more autonomy in order to increase ownership.
Higher means on the patient ownership scale correlated with female sex (5.9 vs. 5.5 for males, p=0.009) and advanced PGY level (5.3, 5.5, 5.7, 5.8, 6.1, for PGY1-5, respectively, p=0.02). Additionally, residents who reported that patient outcomes affected their mood when off-duty achieved higher ownership means than those who claimed outcomes did not affect their mood (5.8 vs 4.8, p<0.001). Trainees who perceived better resident camaraderie (p=0.004), faculty mentorship (p<0.001), and that their program provided an appropriate degree of autonomy (p=0.03) felt greater responsibility for patient outcomes.

Conclusion:
Most faculty agree that residents assume personal responsibility for patient outcomes, but many still underestimate residents’ sense of patient ownership. Certain modifiable aspects of residency culture including camaraderie, mentorship, and autonomy are associated with patient ownership among trainees.
 

41.10 Predictors of Delayed Emergency Department Throughput among Blunt Trauma Patients.

Posted on January 31, 2019

B. Steren2, M. Fleming1, H. Zhuo3, Y. Zhang3, K. Pei1,4  1Yale University School Of Medicine,Department Of Surgery,New Haven, CT, USA 2Yale University School Of Medicine,New Haven, CT, USA 3Yale University School Of Medicine,Section Of Surgical Outcomes And Epidemiology,New Haven, CT, USA 4Texas Tech University of Health Sciences Center, School of Medicine,Department Of Surgery,Lubbock, TX, USA

Introduction:  Delayed emergency department (ED) throughput has been associated with increased mortality and increased length of stay (LOS) for various patient populations. Trauma patients often require significant effort in evaluation, work up, and disposition; however, patient and hospital characteristics associated with increased LOS in the ED remain unclear.

Methods:  The Trauma Quality Improvement Project database (2014-2016) was queried for all adult blunt trauma patients. Patients discharged from the ED to the operating room were excluded. Univariate and multivariable linear regression analysis was conducted to identify independent predictors of prolonged ED length of stay, controlling for patient characteristics (age, gender, race, insurance status), hospital characteristics (teaching status, ACS level, geographic region) and injury severity score and abbreviated injury severity score (ISS and AIS).

Results: 412,000 patients met inclusion criteria for analysis. When controlling for covariates, an increase in age by 1 year resulted in 0.78 increased minutes in the ED (p<0.0001).  On multivariable linear regression controlling for injury severity and comorbid conditions, non-white race groups, university status and northeast region were associated with increased ED dwell time. Black and Hispanic patients spent on average 41.76 and 40.06 more minutes respectively in the ED room when compared to white patients (p <.0001). Patients seen at University hospitals spent 52.50 more minutes in the ED when compared to community hospitals whereas patients at non-teaching hospitals spent 32.32 fewer minutes (p <.0001). Patients seen in the Midwest spent the least amount of time in the ED, with patients in the South, West, and Northeast spending 44.87, 36.02 and 89.41 more minutes respectively (p <.0001). Non-Medicaid patients at Level 1 trauma centers and those requiring intensive care admission had significantly decreased ED dwell time. Medicaid patients took the longest to move through the ED with Medicare, BlueCross and Private insurance outpacing them by 17.69, 26.67 and 27.11 minutes respectively (p <.0001). Level 1 trauma centers moved patients through the ED fastest, with level II centers experiencing 49.56-minute delays and level III centers experiencing 130.34-minute delays (p <.0001). Not surprisingly, patients admitted to the ICU spent the least amount of time in the ED when compared to those admitted to floor or other (p <.0001).

Conclusion: ED length of stay varied significantly by patient and hospital characteristics.  Medicaid patients and university status were associated with significantly higher ED dwell time, while ACS level verification status had strong correlation with ED throughput. These results may allow targeted quality improvement programs to enhance ED throughput.  

 

41.09 Joint Forces Multi-Theater Spinal Fixation Study

Posted on January 31, 2019

M. Lee2, J. Miner2, C. Micallef2, A. Drury2, J. Whitis2, J. Bini1  1Wright State Physicians,Department Of Surgery,Dayton, OH, USA 2Wright State University,Department Of Surgery,Dayton, OH, USA

Introduction: Many soldiers in support of Operation Iraqi Freedom, Operation Enduring Freedom, and Operation New Dawn sustained unstable spinal injuries requiring placement of spinal hardware. It was most customary to defer fixations of unstable spine injuries to Role 4 and Role 5 military treatment facilities due to concerns for infection risk and related complications; though after an extensive literature search, it was found that there are no current clinical practice guidelines to direct surgeons in the decision to delay fixation. Our objective was to evaluate the practice of placing spinal instrumentation and examine the differences between those patients instrumented in theater versus those with delayed instrumentation.

Methods: Data was gathered from the beginning of Operation Iraqi Freedom/Operation Enduring Freedom with record review from the Armed Forces Health Longitudinal Health Joint Theater Trauma Registry (JTTR), Application (AHLTA), Patient Administration and Biostatisitics Activity (PASBA), and Joint Patient Tracking Application (JPTA). Soldiers with spinal injuries requiring fixation were selected and separated based on spinal instrumentation placed in theater or out of theater. Each group was assessed for development of complications and need for re-operation.

Results:344 soldiers were found to receive spinal fixation; 116 underwent instrumentation in theater while 235 were deferred for out of theater fixation. Those with fixations in theater had a lower overall complication rate in comparison to the out of theater population. In analysis of each individual complication, soldiers who underwent delayed fixation out of theater had higher incidence of PE, DVT, stage 3 and 4 ulcers along with increased rate of infectious processes. Early fixation in theater was related to greater incidence of loss of operative reduction/fixation in comparison to the out of theater counterparts. When comparing complication percentages between both groups, an overall p value for all accounting for all examined complications was found to be 0.9825.

Conclusion:In theater fixation was not associated with greater risk of infection as previously assumed along with lower rates of several other complications. Given these outcomes, early fixation may be favored while understanding these benefits are attenuated by the increase of loss of fixation. In the decision to proceed with early fixation, the instrumentation available along with the training and experience of the surgeon should be other considered factors. 

 

41.08 Can Tracheostomies Be Safely Performed on High Ventiltaor Settings? An Assessment of 690 patients

Posted on January 31, 2019

L. Toelle1, M. Zaza1, S. Leonard1, E. A. Taub1, B. A. Cotton1  1McGovern Medical School at UTHealth,Acute Care Surgery,Houston, TEXAS, USA

Introduction: Early tracheostomy is associated with a reduction in ventilator-associated pneumonia, tracheal stenosis, time spent on ventilator and mortality. Despite these benefits, early tracheostomy is often not performed due to high ventilatory requirements. We hypothesized that patients who undergo tracheostomy under high ventilator settings would have similar complication rates compared to those performed under standard ventilator settings.

Methods:  We performed retrospective review of all tracheostomies performed by Acute Care Surgery Faculty between 01/2015 and 12/2017. Patient demographics, ventilator settings, type (open or closed) and location of tracheostomy (operating room or ICU), and complications were recorded. Patients were divided into HIGH-SETTING and LOW-SETTING. HIGH-SETTING tracheostomies were defined as those on FiO2 >50%, PEEP >10, on PRVC mode, on APRV mode, or on nitric oxide. Complications were defined as: loss of airway, hypoxia requiring intervention, intra-operative ACLS, bleeding requiring return to OR, and death related to procedure. Hypoxia requiring intervention was defined as the need for bagging greater than one minute, any need for chest compressions, or need for emergent bronchoscopy post-procedure. Statistical analysis was performed using STATA 12.1. Continuous data are presented as medians (25th-75th percentile interquartile range, IQR) with comparisons performed using Wilcoxon ranksum. Categorical data are reported as proportions and tested for significance using Fisher’s exact test. 

Results: 690 tracheostomies were performed during this time frame. 154 were HIGH-SETTING tracheostomies, while 536 were LOW-SETTNG. HIGH-SETTING patients were younger (median 53 vs. 57; p=0.028) and more likely to be male (76 vs. 66%; p=0.012). While there was no difference in intra-operative vasopressors drips (2.6 vs. 2.5%; p=0.992), HIGH-RISK tracheostomies were more likely to have a cervical spine fracture with spine immobilization (27 vs. 17%; p=0.008). HIGH-SETTING tracheostomies were more likely to be done through a percutaneous approach than LOW-SETTING tracheostomies (40 vs. 32%; p=0.082). However, there was no difference in whether the procedure was performed in the ICU setting (23 vs. 20%; 0.362). HIGH-SETTING patients were on higher PEEP, had higher FiO2, were more likely to be on advanced ventilator modes, and to have been on inhaled NO2. While there was a trend towards more ACLS interventions with HIGH-SETTING patients, there was no difference in complications overall or individually (TABLE). 

Conclusion: Tracheostomies can be performed safely on high ventilator settings without increased complications. Careful pateint selection and hightened pre-procedure planning, however, is warranted.
 

41.07 A Simple and Accurate Score to Quantify Injury Severity in Resource-Poor Settings

Posted on January 31, 2019

A. Laytin1, D. Clarke2, M. Gerdin Wärnberg3, V. Kong2, J. Bruce2, G. Laing2, C. Juillard4  3Karolinska Institutet,Solna, STOCKHOLM, Sweden 4University Of California – San Francisco,San Francisco, CA, USA 1Hospital Of The University Of Pennsylvania,Philadelphia, PA, USA 2University of KwaZulu-Natal,Pietermaritzburg, KWAZULU-NATAL, South Africa

Introduction: Injury care is a global health priority with 5 million deaths due to injury per year worldwide, and the burden of injury is especially high in low- and middle-income countries (LMIC). Efforts to strengthen injury care in LMIC benefit from accurate injury scores to quantify injury severity and predict a patient’s likelihood of mortality. The Injury Severity Score (ISS) and Trauma Score-Injury Severity Score (TRISS) are widely used in the US, but require comprehensive anatomic injury data collection that is often impractical in LMIC. We hypothesized that a simple injury score appropriate for resource-limited settings could achieve discrimination and strength of association with in-hospital mortality similar to resource-intensive injury scores.

 

Methods: This study uses data collected in a regional trauma registry in KwaZulu-Natal, South Africa. Data from 2012-2017 were used to compare the discrimination and strength of association with in-hospital mortality of two comprehensive anatomic injury scores—ISS and TRISS—with those of four relatively simple injury scores that rely primarily on physiologic data—Shock Index (SI), Glasgow Coma Score (GCS), Revised Trauma Score (RTS) and Kampala Trauma Score (KTS). Discrimination was assessed with ROC curve analysis. Strength of association with in-hospital mortality was assessed with standardized regression coefficients (β). KTS was developed in Kampala, Uganda in 2000. While uncommon in the US, it has been used as an injury score in several sub-Saharan African countries.

 

Results: Trauma registry data were reviewed for 4,179 patients, disclosing a median age of 30 years, a male preponderance of 84% and a 48% prevalence of penetrating injury mechanisms. Median time from injury to presentation was 13 hours, with an in-hospital mortality rate of 2.5%. TRISS, ISS and KTS had similar discrimination and strength of association with in-hospital mortality, while the other injury scores demonstrated weaker discrimination and strength of association, especially among patients presenting more than 6 hours post-injury.

 

Conclusion: In searching for a robust injury score to deploy in LMIC, KTS evidenced discrimination and strength of association with in-hospital mortality similar to the gold-standard injury scores ISS and TRISS. Using KTS can help to measure changes in outcomes over time, to compare outcomes between LMIC medical centers and to evaluate the impact of performance improvement efforts when calculating ISS or TRISS is not feasible. Presentation delay degraded the utility of the other injury scores that principally rely on physiologic data and may reflect survival bias in that patient population.

 

41.06 Early Imaging Improves Survival for Elderly Patients with Mild Traumatic Brain Injuries

Posted on January 31, 2019

K. M. Techar1, A. Nguyen1, R. M. Lorenzo1, S. Yang1, B. Thielen1, A. Cain-Nielsen2, M. R. Hemmila3, C. J. Tignanelli4,5,6  4University Of Minnesota,Department Of Surgery,Minneapolis, MN, USA 5North Memorial Medical Center,Department Of Surgery,Robbinsdale, MN, USA 6University Of Minnesota,Institute For Health Informatics,Minneapolis, MN, USA 1University Of Minnesota,Medical School,Minneapolis, MN, USA 2University Of Michigan,Center For Healthcare Outcomes And Policy,Ann Arbor, MI, USA 3University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA

Introduction:

Traumatic Brain Injury (TBI) is responsible for 30% of trauma related deaths each year and is a major cause of permanent disability. Head computed tomography (CT) imaging is the gold standard for diagnosis of intracranial bleeding in TBI, however institutional time to imaging varies significantly, especially in patients without signs of acute distress. Studies have shown earlier clinical intervention is associated with improved outcomes. The objective of this study was to identify the optimal imaging time and its impact on outcomes for elderly patients with head trauma who present to the emergency department (ED) without signs of acute distress.

Methods:

Data from a state-wide quality collaborative was used from 2011-2017 at 29 level 1 and 2 trauma centers. Inclusion criteria were: ICD-9/10 codes for head trauma, age≥50, Glasgow Coma Scale (GCS) ≥14, Injury Severity Score (ISS) ≤20, non-full trauma activation, and head CT imaging time within 1.5 hours of arrival, excluding the initial 5 minutes. Direct admissions and patients who arrived with no signs of life were excluded. Lowess plots were generated to evaluate the association of time to head CT on in-hospital mortality. Data was dichotomized based on these findings into early and late CT cohorts. Logistic regression and negative binomial models were fit to the data to evaluate early vs late CT. Models were risk adjusted for age, gender, race, insurance status, pre-injury anticoagulant use, ED blood pressure, Abbreviated Injury Scale, GCS, and ISS. The primary outcome was in-hospital mortality. Hospital-level factors associated with early CT use were evaluated using logistic regression.

Results:

6,336 patients were included in this study. There was significant variation in time to head CT (μ-45 minutes(m), SD-22m). Mortality nadired at 35 minutes on lowess. Each one minute delay in time to head CT was associated with a 2% increase in mortality (OR 1.02, 95% CI 1.01-1.03, p=0.002). Data was dichotomized into early (≤35m, n=2,535) and late (>35m, n=3,801) cohorts. Early patients had significantly reduced in-hospital mortality (OR 0.58 95% CI 0.35-0.95,p=0.03). Early patients on anticoagulant medications were more likely to receive FFP within 4 hours (OR 1.5,p=0.03). Early patients did not have significantly faster times to neurosurgical intervention (IRR 0.76, 95% CI 0.48-1.2, p=0.2) but did have significantly shorter ED length of stay (IRR 0.89, 95% CI 0.87-0.92, p<0.001). Level 2 (OR 0.46, p<0.001), teaching (OR 0.74, p<0.001), and high-volume trauma centers (OR 0.80, p=0.001), were all less likely to provide early head CTs.

Conclusion:

Each one minute delay in head CT for elderly patients with head trauma is associated with a 2% increase in mortality. This may be due to slower delivery of therapeutic interventions such as anticoagulation reversal. Head CT within 35 minutes for elderly patients with head trauma should be evaluated as a potential quality metric.

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