52.20 Falls From Tree Stands While Hunting: A Rural Trauma Center’s Experience

Posted on January 31, 2019

L. Keeney1, S. Armen1, S. Allen1  1Penn State University College Of Medicine,Trauma Acute Care And Critical Care Surgery,Hershey, PA, USA

Introduction:
Hunting is a popular sport in the United States, and a fall from a tree stand is the most common mechanism of injury among hunters.  In the past 19 years the rate of tree stand falls among hunters in Pennsylvania has increased. This study aimed to describe typical demographics, injuries sustained and hospital course among hunters in Pennsylvania who suffered a fall from a tree stand.

Methods:
A retrospective descriptive analysis of patients who fell from a tree stand over a 10 year period was conducted using the institutional database at a rural Level 1 trauma center.  Data collected included patient demographics, injury severity score (ISS), vital signs on arrival, injuries sustained, hospital length of stay (LOS), and percent requiring admission to the ICU.

Results:
Of the 57 patients 100% were male with a mean age of 48.7+15.7. Mean ISS was 16.2+8.1 with 95% of patients requiring admission and 25% requiring admission to the ICU.  Vital signs on arrival were relatively normal with a mean systolic blood pressure of 137.1+27.2 mm Hg, pulse of 86.7+13.8, respiration rate of 20.1+4.6, and a median Glasgow Coma Score of 15.  The most frequent injuries include spinal fractures (23%), closed head injury (23%) and extremity fractures (12.3%). 95% of patients required hospital admission and mean LOS was 6.6+5.7 (range: 1-25 days) with nearly 25% requiring admission to the intensive care unit.

Conclusion:
Falls from a tree stand while hunting lead to severe injury that result in prolonged hospitalization and frequently require admission to the ICU.  It is vital to understand common injury patterns and trends in hospital course to raise awareness about tree stand safety.  Hunters and producers of tree stands should understand the magnitude of injury suffered from these falls and aim to improve tree stand safety procedures in order to mitigate hunting related injuries due to falls from tree stands. 
 

52.18 Targeting Provider Beliefs and Practices to Improve Opioid Stewardship

Posted on January 31, 2019

H. F. Thiesset1,2, R. Y. Kim1, V. L. Valentin2, K. Schliep2, L. Gren2, C. A. Porucznik2, L. C. Huang1  1University Of Utah,Department Of Surgery,Salt Lake City, UT, USA 2University Of Utah,Department Of Family And Preventive Medicine,Salt Lake City, UT, USA

Introduction:

In light of the growing opioid epidemic, the over-prescription of opioids after surgery has been targeted as one method to reduce opioid diversion, prompting several groups to publish guidelines for surgical providers. Adoption and compliance with these guidelines will require buy-in from providers. However, little is known about the beliefs and practices of surgical providers regarding to patients’ pain, opioids, and prescribing patterns.

Methods:

We developed and distributed a 35-item survey to measure the beliefs, attitudes, and practice patterns of surgical providers regarding opioid prescribing. The survey was distributed to providers in five departments at a single tertiary academic medical center. Characteristics were generated. Additionally, we assessed awareness of and self-reported compliance with national standards for the prescription of opioids.

Results:

Preliminary results showed that the majority of respondents were male (56%). Seventy-eight (49%) respondents identified as attending physicians, while seven (5.1%) were fellows, twenty-five (18.2%) residents, 32 (23.4%) advanced practice clinicians, and 3 (2.2%) midwives. 56% of respondents reported being worried about patients having pain on nights and weekends when pharmacies were not open. 43% felt that it was difficult for patients to see providers for follow-up and opioid refills. 26% agreed that it is easier to give more opioids to minimize potential obstacles for post-operative pain control. A majority (53%) responded that they were more concerned about saving the patient's life than the possibility of opioid addiction. Although 44% felt that rural patients had trouble filling opioid prescriptions because of long travel distances, only 5% reported giving more pills to rural patients compared to urban patients. In contrast, 18% gave more pills to cancer patients than to non-cancer patients.

The majority of providers (51.1%) do not provide counseling regarding the use of opioids and only 20% provided their patients with a tapering schedule. 47% of providers said that they currently use the CDC guidelines for opioid prescribing in their practices, while 18% were unaware of the guidelines. 80% of providers responded that they do not have adequate time to counsel patients regarding opioid use and disposal. When asked who should be responsible for counseling patients about opioid disposal, 42% felt that pharmacists should be responsible for counseling. 67% of providers felt that patients were ultimately responsible for opioids and their proper disposal.

Conclusion:

Wide variation in the beliefs, attitudes, and practices exist among surgical providers. Despite previously reported evidence suggesting that surgical providers are over-prescribing opioids, providers often feel that they do not have the time nor hold primary responsibility for opioid stewardship. Further research is needed to develop and implement effective interventions for opioid stewardship after surgery.

52.17 Evaluation of Preventable Risk Factors for Trauma Mortality in Western Kenya

Posted on January 31, 2019

K. Carpenter1, C. H. Keung1,2, E. Rutto2, E. Chepkemoi2, J. Hogan3, H. W. Li1,4, J. Kisorio2  1Indiana University School Of Medicine,Department Of Surgery,Indianapolis, IN, USA 2Moi University,Department Of Surgery And Anaesthesiology,Eldoret, UASIN GISHU COUNTY, Kenya 3University of Alberta,Office Of International Surgery,Edmonton, ALBERTA, Canada 4Indiana University School Of Medicine,Indianapolis, IN, USA

Introduction:
Ninety percent of the 5 million annual deaths from traumatic injuries occur in low- and middle-income countries (LMICs). Kenya is one such nation, with limited trauma prevention policies and infrastructure. Road traffic accidents (RTAs), in particular, are a frequent cause of traumatic injury and subsequent mortality which continue to increase in incidence. This loss disproportionately impacts young people. Moi Teaching and Referral Hospital (MTRH) is a national tertiary referral hospital in Eldoret, Kenya, serving Western Kenya. In order to characterize the scope of traumatic injuries in this region, a prospective trauma registry was implemented at MTRH in September 2017. The purpose of this study was to identify how preventable risk factors affect mortality in RTAs in order to provide evidence-based recommendations for primary and secondary trauma prevention efforts.

Methods:
Data were collected prospectively on all patients presenting to MTRH primarily for acute traumatic injuries beginning in September 2017. Trauma registry data were retrospectively reviewed for patients involved in RTAs. Pedestrians struck were excluded. Data collected included mechanism of injury. Exposures of interest were seatbelt use, helmet use, and alcohol consumption. The outcome of interest was all-cause mortality within 30 days of presentation to MTRH. After patients with missing exposure data were excluded, Chi-square analysis and odds ratios were calculated using SAS 9.4.

Results:
Between September 2017 and April 2018, 1841 patients presented to MTRH following a traumatic injury. Of these, 870 patients were involved in an RTA. Exposure data was unknown or not recorded for 339 patients. 389 patients were involved in motorcycle accidents. Of these, only 10 patients (2.6%) were wearing a helmet at the time of the injury. No mortalities were recorded among helmeted patients. Unhelmeted patients had a 7.79% mortality rate and 2.5 greater odds of dying, though this was not significant (95% CI: 0.14-44.68, p=0.6002). 463 patients sustained injuries in RTAs involving automobiles. Only 2 (0.4%) were restrained and these both survived. Mortality among unrestrained patients was 7.1%. No significant relationship between seatbelt use and mortality was identified (p=0.2833). 17.2% of RTA injuries involved alcohol use. These patients had increased odds of mortality compared to those who had not consumed alcohol, which was not statistically significant (OR 1.41, 95% CI 0.65-3.09, p=0.3841). 

Conclusion:
Seatbelt and motorcycle helmet use is exceedingly rare among trauma patients in Western Kenya, while alcohol use is high. No mortalities were recorded among patients using a seatbelt or wearing a motorcycle helmet. Trauma prevention efforts in Western Kenya should target all three of these risk factors. More thorough patient data collection will be necessary to accurately monitor the success of such programs.

 

52.16 Nationwide trends in laparoscopic synchronous resection of colon cancer with liver metastasis

Posted on January 31, 2019

S. T. Lumpkin1, P. D. Strassle1,2, L. N. Purcell1, N. Lopez3, K. B. Stitzenberg1  1University Of North Carolina At Chapel Hill,Surgery,Chapel Hill, NC, USA 2University Of North Carolina At Chapel Hill,Epidemiology,Chapel Hill, NC, USA 3University Of California – San Diego,Surgery,San Diego, CA, USA

Introduction: Minimally invasive synchronous resection of primary colon cancer and metastatic liver lesions has been proven safe and effective. We hypothesized that the proportion of synchronous resections performed laparoscopically has increased.

Methods: Using the National Inpatient Sample (NIS) from 2009-2015, we identified all adult patients with colon cancer undergoing colon resection alone and those undergoing a synchronous colon and liver resection based on ICD-9 codes.  We compared the pace of laparoscopic uptake in the synchronous resection cohort to our control group, colon resections. All surgeries were classified as either laparoscopic or open. The yearly incidence of laparoscopic procedures was calculated using Poisson regression. Chi-square and Wilcoxon tests were used to compare patient and hospital characteristics.  

Results: Overall, 86,520 patients with colon cancer were identified, 55,766 underwent colon resections alone and 754 underwent synchronous resections. Wedge resections composed 50% of liver procedures. Laparoscopic procedures constituted 27,158 (49%) of the colon resections and 161 (21%) of synchronous resections, p<0.0001. Laparoscopic procedures have increased significantly in both colon resection (42% to 54%) and synchronous resections (11% to 32%) between 2009 and 2015, p<0.0001 and p=0.006, respectively, (Figure), although there was no significant difference in the pace of uptake of laparoscopy between groups (p=0.09).  Robotics composed 3% of all operations, and robot use was similar between colon resection and synchronous resections (p=0.13). Among synchronous resections, patients undergoing laparoscopic and open procedures were similar in regards to age (p=0.26), sex (p=0.69), race/ethnicity (p=0.28), insurance status (p=0.52), median household income (p=0.30), Charlson Comorbidity Index (p=0.19), and hospital size (p=0.95). However, significant differences were seen across colectomy procedure (p=0.004), liver procedure (p=0.0001), and hospital region (p=0.04). Specifically among synchronous resections, a laparoscopic approach was more likely performed in patients undergoing a left hemicolectomy (29% vs. 17%), liver ablation (32% vs. 18%), and among patients having surgery in the West (30% vs 19%). Laparoscopic approach was significantly less common among patients undergoing right hemicolectomy (19% vs. 25%, p=0.049). No difference was seen across teaching hospital status (21% vs. 24%, p=0.36).

Conclusions: Laparoscopic synchronous resection of colon and liver disease for colon cancer is becoming increasingly popular nationwide. The type of colon resection and liver procedure performed may guide a surgeon’s operative approach. There are also regional differences in practice patterns.

52.15 Family Can Hurt You the Most: Examining Perpetrators in Multiple Casualty Events

Posted on January 31, 2019

L. McLafferty1, J. Abolarin1, H. Carmichael1, C. G. Velopulos1  1University Of Colorado Denver,Department Of Surgery,Aurora, CO, USA

Introduction:

Recently, multiple casualty events, particularly mass shootings, have become a focus of media attention.  Because these events are heavily publicized, this can lead to the impression that school shootings and other rampages resulting in the deaths of strangers are typical. We hypothesized that many multiple homicides actually involve victims known to the perpetrator, such as family members or intimate partners.

Methods:
We analyzed homicides from the National Violent Death Reporting System (NVDRS) from 2003 to 2015.  We examined multiple homicide events (involving two or more victims), including those that were followed by suicide of the perpetrator or death by legal intervention (law enforcement). When the relationship between the perpetrator and victims was unknown, narratives were examined for evidence to classify incidents into categories including drug related, robbery or burglary related, argument or retaliation related, or mental health related incidents.

Results:
We identified 2425 incidents involving a total of 5,424 homicide victims, indicating that 9.3% of all homicide victims in NVDRS were killed in events that involved at least two victims.  Of these events, 13.8% (n=341) were homicides followed by suicide of the perpetrator.  Many of these incidents involved intimate partners or family members of the victims (n=741, 30.6%).  For those where the victims and the suspect were not family members (n=1684), homicides appeared to have been related to a combination of drug-related (n=247, 14.7%), robbery or burglary-related (n=289, 17.2%), argument or retaliation related (n=320, 19.0%).  Few of these events were related specifically to a mental health crisis (n=39, 2.3%) resulting in the deaths of multiple strangers. Only 31 incidents (1.3%) involved 5 or more victims. Of these, many still involved family members or intimate partners (n=14, 45%).  Of the mass casualty events involving strangers (n=, a larger portion were related to mental health (n=6, 35%).

Conclusion:
In our examination of multiple casualty events, we found that many of these still involve a single perpetrator killing an intimate partner and/or other family members, event for events with more than 4 victims. While the scenario of a single perpetrator with mental health issues going on a “shooting rampage” resulting in the deaths of multiple strangers is certainly more common in mass casualty incidents, it is rare overall.  Because this type of mass shooting event has recently been a focus of media attention, it is important to remember that these widely publicized incidents may not be typical of homicides involving multiple victims in the United States.

52.14 Risk Score for Post-Surgical Sustained Opioid Use

Posted on January 31, 2019

M. A. Chaudhary1, N. Bhulani1, D. Sturgeon1, N. K. Kwon1, E. D. Jager1, T. P. Koehlmoos2, A. J. Schoenfeld1, A. H. Haider1  1Brigham And Women’s Hospital,Center For Surgery And Public Health,Boston, MA, USA 2Uniformed Services University Of The Health Sciences,Bethesda, MD, USA

Introduction:
Post-surgical opioid prescription is widely maintained to be associated with the burgeoning opioid epidemic. Literature on appropriate post-surgical opioid prescription practices are now making way into policy. Stratification tools for identifying patients at risk of sustained opioid use are not available. In this context, we sought to generate a robust risk-score for identifying post-surgical patients susceptible to sustained opioid use.

Methods:
The Military Health System Data Repository (MDR) was queried for TRICARE claims data (2006-2014). Adult (18-64 years) patients who underwent one of 10 common general surgical, cardiovascular, orthopedic or urological procedures were included in the study. Opioid use 6 months prior to the index procedure and up to 6 months following discharge was assessed. A 75% random sample was generated from the study cohort for model generation and the remaining 25% sample was used for internal validation. Multivariable logistic regression models were utilized determine the predictors of sustained opioid use and a 100-point risk-score was generated using variables available at hospital discharge. C statistic and calibration curves were used to determine model performance.

Results:
A total of 86,356 patients records were included in the study. Among these, 64,767 randomly selected records were used for risk-score generation and 21,589 for internal validation. A total of 7.4% (n=6,365) of patients met criteria for sustained use after the index surgical procedure. The logistic regression model using only variables available at discharge provided robust identification of sustained post-surgical opioid use (area under the receiver operator curve=0.73). The risk-score included the following variables: age [{25-34, score (s):4}{35-44, s:6}{45-54, s:5}{55-64, s:4}], sex (female, s:4), race (non-white, s:-2), lower socio-economic status (s:7), prior opioid use (s:26), comorbid diagnosis [{diabetes, s:5}{depression, s:5}{anxiety, s:7}], procedure type [{urological, s:4}{orthopedic, s:7}], ICU admission (s:5), length of stay (>3 days, s:4) and discharge disposition (non-home discharge, s:13). The risk-score was further categorized based on the likelihood of sustained opioid use (Table). The risk-score performance in the validation sample was at par with the test sample.

Conclusion:
This study developed and validated a risk-score for sustained post-surgical opioid use that may have significant utility for clinical practice in discharge planning and engagement of pain management services for at-risk patients. Timely identification and appropriate outpatient care planning may reduce the incidence of sustained post-surgical opioid use in these patients.
 

52.13 An Uncontrolled Donation After Cardiac Death Program Improves Access to Kidney Transplantation

Posted on January 31, 2019

R. Choudhury1, H. B. Moore1, K. Prins1, T. Nydam1  1University Of Colorado Denver,Transplant Surgery,Aurora, CO, USA

Introduction:  Uncontrolled donation after cardiac death (uDCD) is a novel method to increase the supply of kidney allografts.  As opposed to controlled DCD (cDCD), uDCD remains an underutilized practice in the United States.  Its use in Europe, primarily Spain, has largely been restricted to out of hospital cardiac arrests (OHCA) with limited volumes of recoverably allografts.  Given the high amount of unsuccessful resuscitations following trauma arrests (URTA) in the United States, various groups have suggested that this population should be included in a uDCD program.  Estimates vary as to the number of potential kidney allografts which could be gained with this method.  Furthermore, the impact on the rate of transplant and overall survival for a patient currently on the kidney transplant waitlist are unknown.  The objective of this study was to estimate the impact of uDCD on the rate of transplant, chance of remaining on dialysis, and death for end stage renal disease (ESRD) patients on hemodialysis in the United States.  

Methods:  A decision analytic Markov state transition model was created using medical decision-making software (DATA 3.5, TreeAge Software, Inc., Williamstown, MA) in order to simulate three clinical scenarios for a group of 60,000 ESRD patients on hemodialysis who do not have access to a living donor (20,000 in each group).  Three clinical scenarios were modeled: 1) Reject uDCD: Patients are on kidney transplant waitlist and will never accept a uDCD kidney, 2) OHCA simulation: On waitlist and will accept a OHCA uDCD kidney if available, whose availability is estimated from the high volume uDCD European center (Spain), and 3) UTRA simulation: On waitlist and will accept a URTA uDCD kidney if available, whose local availability is estimated from the experience of high volume level one trauma center in the United States (Denver Health).  Markov model transition probability were calculated from the literature for “Reject uDCD” and OHCA simulations, and were derived from chart review of Denver Health Medical Center for the UTRA simulation.

Results: A UTRA uDCD program increases the rate of patients who are transplant at five years (24.3%, UTRA vs 21.3%, OHCA, vs 20.2%, Reject uDCD).  Furthermore, patients who remain on dialysis are also reduced in the UTRA simulation.  However, 5 year all-cause mortality is similar among groups (28.1%, 28.2%, 28.3%).

Conclusion: uDCD improves access to transplant for ESRD patients on the kidney transplant waitlist.  However, all-cause mortality is similar for patients who reject uDCD suggesting that careful patient selection is required to match a potential uDCD kidney allograft to patients who would likely not be offered a transplant by any other means such that net utility may be gained.
 

52.12 A Mobile Text App Increases Physician Participation in Safety Reporting in an Academic Medical Center

Posted on January 31, 2019

A. E. Graham1, I. Benjenk1, B. Umapathi1  1George Washington University School Of Medicine And Health Sciences,Washington, DC, USA

Introduction:
The landmark Institute of Medicine report “To Err is Human” was released in 1999 and since then increased attention has been placed on healthcare incident reporting. Despite concerted efforts of hospitals and other organizations, improvements in patient care derived from incident reporting have lagged behind goals. At most hospitals, the overwhelming majority of incident reports are placed by allied providers. However, physician participation is required to get a balanced view of system errors in large academic institutions.  Young physicians in particular need to be involved in reporting, evaluation, and system-based practice change. One of the largest hurdles to physician participation is access to reporting platforms. To address this, a new feature of the hospital’s HIPAA compliant texting application was added in the fall of 2017 so that providers could report incidents on their personal mobile phones instead of going through a computer-based application.

Methods:
The study was conducted at George Washington University Hospital. Monthly total incident reports from pre-intervention January 2017- June 2017 and post-intervention January-June 2018 were reviewed and categorized by method of reporting (computer vs. text) and position of reporter (physician, resident, other). An anonymous survey was given to 39 resident physicians to further evaluate resident participation. Descriptive statistics were performed in Excel and SPSS.

Results:
There was a 70.4% increase in incident reporting between our pre- and post-intervention periods (from 3090 to 5265). In the post-intervention period, 14.25% of incident reports were submitted through secure text message (750 reports). Of the 750, 585 (78%) were from physicians. Of the increase in total incident reporting, 34.4% was due to text message reporting and 26.8% was due to text message reporting by physicians. Of the residents surveyed, 53% reported submitting a report.  Of those who had reported an incident, 95.2% reported it as “very easy” or “fairly easy” to submit a report via text message, as compared to 9.5% who reported it as “very easy” or “fairly easy” to submit a report via computer application (p <0.01). Of those who had reported an incident, 76% reported having submitted more reports via text message than via computer, 14.2% reporting similar amounts, and 9.5% submitting more via computer.

Conclusion:
Institution of a mobile text app significantly increased physician participation in patient incident reporting. Our study shows that physicians, especially resident physicians, are more comfortable with mobile app-based patient safety reporting, and this is a viable model for the future.
 

52.11 Is Laparoscopic Adrenalectomy as Safe as Cholecystectomy? A propensity-matched analysis of NSQIP.

Posted on January 31, 2019

J. Limberg2, K. D. Gray1,2, T. Ullmann1,2, D. Stefanova1,2, B. M. Finnerty1,2, J. L. Buicko1,2, R. Zarnegar1,2, T. J. Fahey1,2, T. Beninato1,2  1New York Presbyterian Hospital,Surgery,New York, NY, USA 2Weill Cornell Medical College,Surgery,New York, NY, USA

Introduction:
Laparoscopic adrenalectomy (LA) is regarded as the treatment of choice for small, functioning tumors of the adrenal cortex.  Despite evidence that surgical cure of primary hyperaldosteronism is superior to medical treatment, there remains reluctance to refer patients for LA, with some recent reports advocating long-term medical management.   Here we aimed to determine whether the safety profile of LA is similar to that of elective laparoscopic cholecystectomy (LC), one of the most commonly performed laparoscopic procedures worldwide.

Methods:
Patients undergoing LA or LC between 2012 and 2015 were selected from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Patients who had a LA for an adrenal adenoma or aldosteronoma were compared to those who had LC for biliary colic. Propensity scores with nearest neighbor matching were calculated to determine propensity of receiving LA controlling for age, gender, race, Hispanic ethnicity, American Society of Anesthesiologists score (ASA) and 5-Factor Modified Frailty Index Score. The 30-day readmission rate, incidence of any post-operative complication, as well as the incidence of specific complications such as myocardial infarction, stroke, sepsis, surgical site infection, pneumonia, unplanned reintubation, renal failure, urinary tract infection, clostridium difficile infection and pulmonary embolism were compared between groups.

Results:
A total of 83,928 patients underwent either LA or LC during the study period. There were 16,480 patients who met the inclusion criteria and were successfully matched (n=1,490 LA, n=14,990 LC). The overall mortality rate was 0.02%, with no difference between groups (p=0.084). After propensity matching, the mean age of patients undergoing LA was 47.5 years compared with 50.5 years in the LC group, and they contained 80.9% and 76.9% female patients, respectively.  More LC patients were Hispanic (15.7% versus 12.9% LA). Patients in both groups had a similar rate of ASA score >3 (25.8% LA versus 24.7% LC) and Frailty Index Score >2 (7.0% LA versus 9.5% LC). There was no difference in the incidence of any post-operative complication between the two groups. The incidence of myocardial infarction (p=0.026) and wound infection (p<0.001 and p=0.002 for superficial and deep, respectively) were increased with LC. There were no statistically significant differences for the other specific post-operative complications between the two matched groups.

Conclusion:
In a propensity-matched comparison of patients from the ACS-NSQIP database undergoing LA and LC, there were no differences in the rate of overall postoperative complications and a slightly increased rate of wound complications and MI in patients undergoing LC.  Physicians should consider LA to have an equivalent risk profile to LC when deciding whether to refer patients to surgery.
 

52.10 Grading Complications of Operative and Non-operative Management of Acute Diverticulitis

Posted on January 31, 2019

A. A. Radwan1, S. Wei1, K. M. Mueck1, C. Wan1, C. E. Wade1, T. C. Ko1, S. G. Millas1, L. S. Kao1  1McGovern Medical School at UTHealth,Acute Care Surgery,Houston, TX, USA

Introduction:  There is no accepted grading system for comparing the risks between non-operative and operative management of surgical diseases. Recently, the Clavien-Dindo score for grading post-operative complications after elective surgery was modified and validated in hospitalized trauma patients who received non-operative and operative management. We hypothesized that this Adapted Clavien-Dindo in Trauma (ACDiT) scale can be used to grade and compare complications in acute diverticulitis patients across management strategies.

Methods:  We performed a retrospective cohort study of patients hospitalized for acute diverticulitis between 2011 – 2016 at a safety-net hospital. Baseline demographics and hospitalization data were collected. ACDiT grades were assigned to all patients. Grades ranged from 0 to 5b; a grade of 0 means no deviation from initial management plan, while a grade of 5b means hospital death despite active treatment. Univariate analysis was performed to compare baseline demographics in non-operatively versus operatively managed patients. ANOVA was used to determine differences in hospital-free days (HFD) based on ACDiT grades. HFD is defined as the number of days spent outside of any healthcare facility within 30 days of the initial admission. Linear regression was performed to assess correlation between ACDiT grades with HFD.

Results: There were a total of 260 patients, of which 177 (68%) were non-operatively and 83 (32%) were operatively managed. There were no differences in age, sex, race, Charleston Co-morbidity Index, or intraabdominal drain placement based on management strategy (p > 0.05). Eighty-five (33%) patients developed a complication, of which 78 (92%) complications received ACDiT grades 1 – 3b. There were no patients with ACDiT grade 5. Higher ACDiT grades correlated inversely with less HFD (r = -0.77, p < 0.0001), in the entire cohort (Figure) and individually for non-operative (r = -0.79, p <0.0001) and operative (r = -0.71, p <0.0001) management.

Conclusion: The ACDiT grading system can be used for classifying the severity of complications in hospitalized diverticulitis patients managed non-operatively and operatively and correlates with hospital-free days. ACDiT is a promising tool for weighing the risks of non-operative and operative management.
 

52.09 A Database of Trauma Funding Sources: Application for the Surgeon Health Policy Advocate

Posted on January 31, 2019

S. Lin1, C. Johnson3, A. E. Liepert2  1Oregon Health And Science University,Surgery,Portland, OR, USA 2University Of Wisconsin,Surgery,Madison, WI, USA 3American College Of Surgeons,Division Of Advocacy And Health Policy,Washington, D.C., USA

Introduction:  The implementation of trauma systems is a mainstay in American health care delivery resulting in many saved lives. It is regulated at the state level; however, a database of trauma system legislation and state funding sources has not been compiled in the medical literature. This absence reflects the disconnect physicians experience with legislative and regulatory processes, although they greatly impact the system of care they function within. This study attempts to compile trauma system regulations and funding sources in all 50 states to be used for Surgical Health Policy Advocacy in order to ensure adequate trauma care delivery and parity between and across states.

Methods:  Department of Health offices of each state’s trauma system were contacted via email and telephone. Resultant trauma system data were categorized according to the ability to access trauma system funding data, the presence of a trauma system in the state code, the presence of state statutes addressing trauma funding, the amount of trauma funding and the sources of funding for each trauma system. Data for each group included whether information could be compiled for an individual trauma system, the presence of state statutes addressing creation of a trauma system, the presence of statutes specific to trauma system funding and the total amount in dollars to trauma systems when available. States that underwent ACS trauma systems consultation were also captured.

Results: This taxonomy of trauma system funding was obtained for 24 (48%) states. This was fully compiled in 8 (16%) states, partially compiled in 16 (32%) states and no accurate data was available in 26 (52%) states. Specific legislation creating a trauma system was identified in 43 (86%) states.  No direct legislation of the formation of a trauma system was found in 5 (10%) states. 2 (4%) states do not have legislation creating a trauma system. 18 (36%) states have legislation directly funding their trauma systems, 4 (8%) states have legislation regarding trauma funding. No trauma system funding data was located in 28 (56%) states. Financial contributions ranged from $315,000 in Minnesota in 2011-2012 to $25,899,450 in Arkansas in 2016-2017. ACS Trauma Consultations took place at least once in 33 (66%) states. No correlation between states with these consultations and presence of trauma funding legislation was noted. 

Conclusion: This study demonstrates the difficulty of acquiring legislative information for use in Surgical Health Policy Advocacy efforts. It emphasizes the need for the development of tools to be used to summate and disseminate comprehensive and comparative legislative data and information. Future work to compile data such as this will aid in surgeon led legislative and regulatory advocacy efforts and improve not only systems as a whole but ultimately patient care.  

52.08 Communication Needs Among Staff Caring for Critically Injured: A Qualitative Study

Posted on January 31, 2019

A. M. Stey1,2, P. Liu1, C. Wybourn1,2, T. Bongiovanni1,2, R. Menza1,2, V. Singh1,2, T. Cage1, N. Brennan2, G. Ryan3  1University of California San Francisco,San Francisco, CA, USA 2Zuckerberg San Francisco General Hospital,San Francisco, CA, USA 3RAND Health,Santa Monica, CA, USA

Introduction:  The care of critically injured patients is complex and requires coordination across professionals from a wide range of disciplines including multidisciplinary staff. The aim of this study was to map out existing communication pathways and how they could be improved upon in the intensive care units.

Methods:  A total of 21 semi-structured case-based interviews were performed in an open mixed neuro and surgical intensive care unit in a level 1 trauma urban academic-affiliated safety net hospital. Neurosurgery, trauma surgery team members, neurologists, intensivists, nurses, pharmacists, and respiratory therapists of diverse backgrounds and seniority were interviewed. Interviewees were presented with 4 case scenarios involved decision making around two competing priorities that would require multi-disciplinary communication to determine treatment and timing of intervention and asked to describe what they would do.  The interviews responses were reviewed and range and central tendency are reported. 

Results: The central tendency theme of shared responsibility among all multi-disciplinary staff was identified. There were a range of roles each provider played in the care of critically injured patients. The primary team were the actualizers of decisions and interventions. In addition to the actualizers, two other roles were identified including secondary decision makers and interveners. Secondary decision makers were often consultants whose opinions were perceived as indispensable prior to decision making or intervention.  Interveners were frontline staff who were able to intervene if they felt a decision or intervention were discordant from clinical practice. There did seem to be considerable variation in the extent to which secondary decision makers and interveners could be engaged with the actualizers. A second important theme was the long communication routes among the teams. Typically, communication occurred between frontline staff between the teams and had to travel up and down hierarchies within the team prior to decision regarding treatment were implemented. When patients were gravely ill or disagreements/miscommunication through the standard pathway occurred, staff at the head of the hierarchies would reach out to their homologues directly to shorten the communication route. This seemed to resolve most disagreements due to a perception of mutual respect and perceived importance in the gesture between staff at the head of the hierarchies.

Conclusion: This study identified two themes including shared responsibility and long communication routes among teams. More research is needed to determine how communication could be improved upon both by promoting involvement of secondary decision makers and interveners as well as streamlining communication routes.

 

52.07 Outcomes following Major Oncologic Operations for non-AIDS Defining Cancers in the HIV Population

Posted on January 31, 2019

A. Chi1, B. E. Adams2, J. Sesti1, S. Paul1, A. Turner1, D. August1,3, D. Carpizo1,3, T. Kennedy1,3, M. Grandhi1,3, S. K. Libutti3, S. Geffner1, R. C. Langan1,3  1Saint Barnabas Medical Center,Surgery,Livingston, NJ, USA 2United States Military Academy,Mathematical Sciences,West Point, NEW YORK, USA 3Rutgers Cancer Institute Of New Jersey,Surgical Oncology,New Brunswick, NJ, USA

Introduction: Human immunodeficiency (HIV) patients are now living longer due to the availability of antiretroviral therapies and non-AIDS defining cancers are becoming more prevalent in this patient population.  However, a paucity of data remains on post-operative outcomes following resection of non-AIDS defining cancers in the HIV population.  

Methods: The National Inpatient Sample was utilized to identify patients who underwent gastrectomy, hepatectomy, pancreatectomy, colectomy or pulmonary resection for malignancy from 2005 to 2015 (HIV, N=52,742; non-HIV, N=11,885,184).  Complications were categorized by international classification of diseases (ICD)-9 diagnosis codes.  The HIV and non-HIV cohorts were matched on type of insurance, household income, zip code and urban/rural setting.  Logistic regression with the Survey Package in R was utilized to assess whether HIV was an independent predictor of post-operative complications. The analysis conducted took into account the sample trend weights and stratification to ensure inferences determined from the sample data are applicable to the population.

Results: Uncorrected data found HIV patients to have an increased rate of complications following colectomy, hepatic lobectomy, pulmonary resection (segmental and lobe), gastrectomy and distal pancreatectomy.  However, univariate and multivariate logistic regression (Table 1) found HIV to only be an independent predictor of complications following pulmonary lobectomy (p=0.011; OR 2.93, 95% CI 1.29-6.73).  There were no observed differences in post-operative mortality. 

Conclusion: Our findings highlight the relative safety of major cancer surgery in the HIV population.  HIV status should not exclusively be used to prohibit oncologic resections however; care providers need be cognizant of the potential increased risk of post-operative complications following pulmonary lobectomy.  Future analysis is planned to further characterize the complications and assess length of stay. These findings are an initial insight into quality of care and outcome metrics on HIV patients undergoing major cancer operations and serve as a platform to assess whether HIV impacts other aspects of the continuum of care.  

 

52.06 Patient-specific Postoperative Opioid Prescribing: A Pre-Post Analysis of an Educational Intervention

Posted on January 31, 2019

H. N. Overton1, V. Valero1, J. F. Griffin1, J. P. Taylor1, K. Giuliano1, A. B. Blair1, B. Moeckli1, R. B. Fransman1, A. Graham1, A. AwadElkarim1, R. Beckman1, S. He1, J. Liu1, S. DiBrito1, M. C. Bicket2, M. A. Makary1, E. R. Haut1, B. C. Sacks1  1Johns Hopkins University School Of Medicine,Surgery,Baltimore, MD, USA 2Johns Hopkins University School Of Medicine,Anesthesiology,Baltimore, MD, USA

Introduction:  Recent data show that 1 in 16 patients become chronic opioid users after undergoing a surgical procedure, and 45% of patients are over-prescribed opioids at the time of hospital discharge compared to their inpatient opioid use. The primary objective of this quality improvement project was to improve rates of appropriate opioid prescribing at discharge at an urban, academic hospital.

Methods:  We performed a retrospective cohort study with pre-post analysis after an educational intervention for surgical residents and discharge nurses. Patients who underwent a surgical procedure and required postoperative inpatient admission were included. An initial month long enrollment was followed by a resident-led educational intervention to individualize prescriptions based on the amount of opioids used in the 24-hours prior to discharge. Additional information on patient age, length of stay, admission status, acetaminophen and/or NSAID scheduled on day prior to discharge, and acetaminophen prescribed at discharge was collected. Patients with Methadone use during the hospitalization and/or at the time of discharge were excluded. The primary outcome was the difference between the total morphine milligram equivalents (MME) used in the 24 hours prior to discharge and the total daily MME prescribed at discharge. The mean differences were compared in the pre- and post-intervention groups. Secondary outcomes were the frequency of scheduled non-opioid pain medication during the inpatient admission and at the time of discharge.

Results: The prescribing patterns for 80 patients in the pre- and 69 patients in the post-intervention group (n=149) were reviewed. There were no significant differences between the pre- and post-intervention groups for any of the selected patient characteristics. The univariate model was determined to be most predictive by stepwise selection. The primary outcome of difference in MME was significantly different between the groups with the post-intervention group having 12.1 times less difference in MME than the pre-intervention group (95% CI: -20.9, -3.2; p=0.01) (Figure). Rates (mean (SD)) of prescribing non-opioid pain medication (Acetaminophen +/- NSAID) did not significantly differ between groups both during the inpatient admission (pre: 0.75 (0.49), post: 0.74 (0.44); p=0.88)) and at the time of discharge (pre: 0.63 (0.49), post: 0.70 (0.46); p=0.37).

Conclusion: An educational intervention for surgical residents and discharge nurses on how to customize the amount of opioids prescribed at the time of discharge resulted in significantly less over-prescription of opioids after surgical procedures. Future work should include optimization of non-narcotic pain medication usage in all settings of post-operative care.

52.05 An Improved Patient Safety Reporting System Increases Behavioral Reports in the Perioperative Setting

Posted on January 31, 2019

M. G. Katz1, W. Y. Rockne2, R. Braga1, S. McKellar1, A. Cochran1,3  1University Of Utah,Department Of Surgery,Salt Lake City, UT, USA 2University Of Utah,School Of Medicine,Salt Lake City, UT, USA 3Ohio State University,Department Of Surgery,Columbus, OH, USA

Introduction:

Healthcare provider behavior, communication, and performance can all lead to mistakes that harm patients. Primary mechanisms of identifying patient safety issues include open communication and non-punitive reporting of near misses and adverse events; therefore patient safety event reporting systems have become a mainstay in identifying safety events and quality problems. We hypothesized that an upgraded reporting system that included the ability to report positive behaviors would increase reporting of behavioral events in the perioperative environment.

Methods:

At a tertiary university hospital we performed a retrospective assessment of prospectively collected reports from the Patient Safety Net (PSN) event reporting system (2/2010 – 2/2015) and the RL Solutions RL6 system (8/2015-4/2018). 

Results:

Under the PSN system, 13 behavioral events were submitted, averaging 0.8/quarter, compared to the RL6 system, where 81 events were submitted, averaging 7.4/quarter. The average length of reports increased from 61 to 185 words per report. Events were most often reported by nursing staff (66%), while attending physicians were the group most commonly identified as displaying disruptive behavior (36%). The majority of events under both systems (100% and 54% respectively) resulted in no harm according to reporters. 22% of reports under the RL6 system were positive reports; 46% of these positive reports were about physicians. 

Conclusion:

After implementation of an upgraded reporting system that includes an option for positive reporting, the number and length of reports have increased. We believe that a robust reporting system that includes options for positive reporting has contributed to improved feedback on the culture of safety at our institution.

 

52.04 A State-Based Analysis Of Who Provides Emergency General Surgical Care And Whether It Matters

Posted on January 31, 2019

R. Udyavar1, A. Salim1, J. M. Havens1, T. Uribe Leitz1, G. Jin1, A. H. Haider1  1Brigham And Women’s Hospital,Department Of Surgery,Boston, MA, USA

Introduction:
Although the Acute Care Surgery model has gained wide acceptance among hospitals nationwide, patients with emergency general surgery (EGS) diagnoses are cared for by surgeons with variable skill sets and training. We sought to identify the specialties of surgeons treating EGS patients, and characterize the relationship between surgeon specialty and outcomes.

Methods:
Retrospective cohort study examining EGS cases from the Florida State Inpatient Database (SID), 2010-2014. AHA database linkage provided hospital-level variables. Adult patients admitted emergently for seven conditions that account for 80% of the national EGS burden (includes appendicitis, cholecystitis, bowel obstruction, ulcer disease, and conditions leading to colectomy, adhesiolysis, and laparotomy). Surgeon specialty was designated by the proportion of non-EGS cases comprising each surgeon’s annual caseload. Our outcome measures were in-hospital mortality and major complications, adjusting for diagnosis, age, sex, comorbidities, procedures, hospital and surgeon case volume, trauma center designation, teaching status, and bed size were compared among patients treated by general surgeons (who took no trauma call), Trauma/Acute Care surgeons (TACS), and sub-specialists.

Results:
Of the 5,611 surgeons, the majority were general or TACS (see Table). Significant differences in odds of mortality were noted between the reference group (non-trauma general surgeons) and all sub-specialists. Odds of complications were higher among vascular and colorectal surgeons.

Conclusion:
In Florida, EGS care is mostly provided by general surgeons or TACS. Odds of mortality among patients treated by non-trauma general surgeons exceeded those treated by all sub-specialists. Further work is needed to uncover the individual and system-level factors explaining these differences.
 

52.03 Classifying Preoperative Opioid Use for Surgical Care

Posted on January 31, 2019

J. V. Vu1,2, D. C. Cron3, J. S. Lee1,2, V. Gunaseelan1,2, P. Lagisetty4, M. Wixson5, M. J. Englesbe1,2, C. Brummett2,5, J. F. Waljee1,2  1University Of Michigan,SURGERY,Ann Arbor, MI, USA 2Michigan Opioid Prescribing Engagement Network,Ann Arbor, MI, USA 3Massachusetts General Hospital,SURGERY,Boston, MA, USA 4University Of Michigan,Internal Medicine,Ann Arbor, MI, USA 5University Of Michigan,Anesthesiology,Ann Arbor, MI, USA

Introduction:  Preoperative opioid exposure is common, and varies by dose, recency, duration, and continuity of fills. To date, there is little evidence to guide postoperative prescribing need based on prior opioid use. We characterized patterns of preoperative opioid exposure in patients undergoing elective surgery to identify the relationship between preoperative exposure and subsequent opioid fill after surgery.

Methods: We analyzed claims data from Clinformatics® DataMart Database for patients aged 18 – 64 years undergoing major and minor surgery between 2008 and 2015. Preoperative exposure was defined as any opioid prescription filled in the year before surgery. We used cluster analysis to group patients by the dose, recency, duration, and continuity of exposure. Our primary outcome was second postoperative fill within 30 postoperative days. Our primary explanatory variable was opioid exposure group. We used logistic regression to examine likelihood of second fill by opioid exposure group.

Results: Out of 267,252 patients, 102,748 (38%) filled an opioid prescription preoperatively. Cluster analysis yielded 6 groups of preoperative opioid exposure, ranging from minimal (27.6%) to intermittent (7.7%) to chronic exposure (2.7%). Preoperative opioid exposure was the most influential predictor of second fill, with larger effect sizes than other factors even for patients with minimal or intermittent opioid exposure. Increasing preoperative exposure was associated with risk-adjusted likelihood of requiring a second opioid fill compared to naïve patients (minimal exposure: OR 1.49, 95% CI 1.45 – 1.53; recent intermittent exposure: OR 6.51, 95% CI 6.16 – 6.88; high chronic exposure: OR 60.79, 95% CI 27.81 – 132.92, all p-values <0.001).

Conclusion: Preoperative opioid exposure is common among patients who undergo elective surgery. Although the majority of patients infrequently fill opioids prior to surgery, even minimal exposure increases the probability of needing additional postoperative prescriptions compared to opioid naïve patients. Moreover, surgeon prescribing is relatively uniform regardless of preoperative use, suggesting an opportunity to tailor opioid prescribing by patient exposure. Going forward, identifying preoperative opioid use can inform surgeon prescribing and care coordination for pain management after surgery.

 

52.02 Exploring Barriers to Opioid Disposal After Surgery

Posted on January 31, 2019

C. M. Harbaugh2, L. M. Frydrych2, A. B. Coe1, A. N. Thompson1, B. S. Miller2  1University Of Michigan,College Of Pharmacy,Ann Arbor, MI, USA 2University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA

Introduction: Opioids are often prescribed in excess after surgery and patients infrequently dispose of the leftover medication. Excess medications in homes are targets for diversion, placing patients, families and communities at risk for opioid misuse. In this quality improvement study, we explored patient and provider needs to eliminate barriers to opioid disposal.

Methods:  Over a 4-month period (3/2018-6/2018) at an academic tertiary referral center, a convenience sample of patients undergoing thyroid and parathyroid surgery were administered a 10-item multiple choice questionnaire about prescription opioid use, receipt of opioid disposal education (ODE), frequency of disposal, and barriers to disposal at the 2-week postoperative visit. Providers at multiple levels were administered a 10-item questionnaire evaluating how often they provided ODE and barriers that limited discussion of opioid disposal with patients. Four open-ended questions were included to inform strategies to facilitate successful implementation of ODE. Text responses were coded using inductive analysis to identify themes. Descriptive statistics were used to analyze quantitative data.

Results: Of 131 patients who responded, 62 (47%) filled an opioid prescription, 47 (36%) received more medication than needed, and only 15 (11%) received opioid disposal education. Of the 47 patients with excess medication, 37 (80%) did not dispose of the excess. The perceived barriers preventing disposal were that they planned to but had not yet (49%), kept the medication for future use (19%), were still taking the medication (5%), and did not know how to perform disposal (3%). Surveys were distributed to 167 providers with response rate of 61%, including 20 surgical faculty, 24 trainees, 19 advanced practice providers, 32 nurses, 9 outpatient pharmacists, and 2 medical assistants. Of 107 providers responding, 79 (74%) rarely or never provided ODE. All providers felt it was important to educate patients about proper disposal techniques. Perceived barriers to ODE were lack of awareness (57%), inadequate knowledge to provide education (39%), and time constraints (20%). Common themes emerging from free text responses as potential solutions to facilitate ODE included: (1) Provider education facilitates patient education; (2) Multiple providers should reinforce education across the care continuum; and (3) Standardization of patient resources improves consistency in messaging.

Conclusion: Disposal of excess opioids in this endocrine surgery population is low with multifactorial barriers to opioid disposal perceived by both patients and providers.  Patient engagement and empowerment through education must start with increased ODE of providers. Future work will explore innovative yet simple and achievable methods to facilitate ODE with an endpoint of actual opioid disposal.
 

52.01 Classification Of Intraoperative Complications (CLASSIC): Reliability And Practicability

Posted on January 31, 2019

L. Gawria1,2, N. Gomes3, P. Kirchhoff4, H. Van Goor1, R. Rosenthal5, S. Dell-Kuster2,3,5  1Radboud University Medical Center,Surgery,Nijmegen, GELDERLAND, Netherlands 2Basel Institute for Clinical Epidemiology and Biostatistics,University Of Basel,Basel, BASEL, Switzerland 3University Hospital Basel,Anesthesiology,Basel, BASEL, Switzerland 4University Hospital Basel,Surgery,Basel, BASEL, Switzerland 5University of Basel,Basel, BASEL, Switzerland

Introduction: Prevention of intraoperative complications has received growing attention over the past decade. A clear definition and classification of intraoperative complications is required to capture the burden and achieve consistency in reporting. In a Delphi process, involving international interdisciplinary experts, such a definition and classification of intraoperative complications (CLASSIC) has been developed and retrospectively validated. Recently, an international multicenter cohort study has been conducted to prospectively validate an updated version of CLASSIC [NCT03009929]. The updated classification defines complications as any surgery- or anesthesia-related deviation from the ideal intraoperative course between skin incision and skin closure. It foresees five grades depending on the need for treatment and the severity of the symptoms. A survey including fictitious case scenarios describing intraoperative complications was used as an additional part of the prospective validation to evaluate the reliability and practicability of CLASSIC. This part of the validation is published on behalf of the CLASSIC study group.

Methods: From each of the 18 participating centers, 5 to 10 surgeons and anesthesiologists were invited via email to participate in a web-based survey. The online survey was created using SurveyMonkey®  (www.surveymonkey.com) to allow respondents to complete it anonymously. The survey consisted of 10 fictitious case scenarios describing intraoperative complications. The respondents were asked to assign the corresponding severity grade of CLASSIC. The correct CLASSIC grade for each fictitious case scenario was previously determined by consensus among the investigators using objective interpretation of the definitions. The fictitious case scenarios were intentionally designed to display a wide range of severity grades and medical specialties. To assess reliability the average raw agreement across all 10 case scenarios and the intra-class correlation coefficient were determined. In addition, practicability was evaluated on a 9-point numeric scale with end-anchors "Not practical at all" and "Very practical".

Results: In total, 131 out of 163 physicians, from 18 centers and 12 countries, completed the survey (80% response rate). The physicians consisted of 50 anesthesiologists (38%), 61 abdominal surgeons (47%), and of 20 surgeons from other specialties (15%). The survey showed an intra-class correlation coefficient of 0.75 (95% CI 0.59 to 0.91) and a raw agreement of 61% (IQR 43%-70%). Practicability of CLASSIC was rated as 6 (IQR 5 -7), with 65% of the experts rating 6 or higher.

Conclusion: The survey showed a good reliability and practicability of the updated CLASSIC. We expect this to further increase when physicians become more familiar with the classification. This will eventually contribute to standardized reporting in surgical and perioperative practice and research.

51.20 Acute Gastroduodenal Ulcer Perforation under Laparoscopy Highly Selective Vagotomy and Repair

Posted on January 31, 2019

G. Chen1, Y. HE2, G. LI3, L. ZOU4  1GUOBIN CHEN,ZHUHAI, GUANDDONG, China 2YAOBIN HE,ZHUHAI, GUANDDONG, China 3GUOWEI LI,ZHUHAI, GUANDDONG, China 4LIAONAN ZOU,ZHUHAI, GUANDDONG, China

Introduction:  

To investigate the application value of laparoscopic perforation high selectivity of vagotomy plus repair surgery in the treatment of gastroduodenal ulcer perforation.

Methods:

Retrospective analysis data from January 2017 to July 2017, 53 patients with gastroduodenal ulcer perforation include gastric perforation of 31 cases and 22 cases of duodenal perforation. 25 patient were given laparoscopic perforated high selectivity of vagotomy plus repair surgery (study group) while 28 patients had received single laparoscopic perforation repair surgery (control group).

Results:

More bleeding and longer surgical time happened in study group but the exhaust time and hospitalization time is similar. The study group had higher complete cure rate after three-month regular internal treatment.

Conclusion:

Comparing with laparoscopy repair surgery, the treatment of laparoscopic perforation high selectivity of vagotomy plus repair surgery in gastroduodenal ulcer perforation is safer, more reliable with lower recurrence rate.

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