83.08 Leadership Amongst Regional And National Surgical Organizations: The Tides Are Changing

Posted on January 31, 2019

S. M. Krise1, I. A. Etheart2, A. T. Perzynski3, K. J. Conrad-Schnetz4  1Ohio University,Heritage College Of Osteopathic Medicine,Cleveland, OH, USA 2West Virginia School of Osteopathic Medicine,Lewisberg, WV, USA 3MetroHealth Medical Center,Cleveland, OH, USA 4Cleveland Clinic,Cleveland, OH, USA

Introduction:  Leadership amongst regional and national organizations is a key opportunity to obtain scholarly activity which is essential for attaining academic advancement. Data has been reported showing gender disparity in scholarly activity, specifically in publication status and NIH grants, with women having decreased rates compared to male colleagues (Awad 2017, Svider 2014). Gender disparity in leadership of surgical organizations is important to examine given this relationship. Our objective was to examine the differences between male and female leadership within surgical organizations. 

Methods:  Credentials were obtained through an Internet search of organization websites. Variables included organization type, leadership role, gender, advanced degree, medical school graduation year, publications, and employment at an academic institution. A bivariate analysis was performed between genders. A p-value < 0.05 was considered statistically significant.

Results: 532 leaders were identified in 43 surgical organizations. There was a statistically significant difference in the number of male and female leaders (73.3% vs 26.7%, p=0.012). Women were most likely to hold the role of Other (35.5%) and least likely to be Vice-President (10.5%) and President-Elect (13.8%). In line with other research, women had a decreased publication rate than male colleagues (85.2% vs 93.1%, p=0.005). Women had a higher rate of advanced degrees than men (24.8% vs 16.7%, p=0.035). Women were found to be involved earlier in their careers than men (4.9 years, 95% CI 4.1-7.8 years, p<0.01). OB/GYN organizations were the only organization type to show gender parity with 55% of leader roles held by women. Vascular surgery (0%), ENT and General Surgery (13%), and Thoracic Surgery (15%) had the least female representation in leadership. 

Conclusion: Male and female leaders are nearly equal in their credentials with women having less publications, but more advanced degrees; yet women are under-represented in leadership of surgical organizations. Our data show women are involved earlier in their careers in conflict to the belief that women hold off on career pursuits due to family planning and work/life balance. Data have shown that it takes women longer to reach Full Professor than men (Abelson 2015). This knowledge could lead women to be more aggressive in their leadership endeavors, explaining their early involvement. Since a higher rate of women hold lower level leadership roles, they must continue to be mentored and encouraged into higher leadership positions. Surgical organization leadership should be re-examined in the future to identify if gender parity is reached with more women holding higher level leadership roles. 

 

50.01 Outcomes of a Protocol-Guided Approach to Management of Adhesive Small Bowel Obstruction

Posted on January 31, 2019

K. C. Brown1, D. Burneikis1, G. Morris-Stiff1, T. Capizzani1  1Cleveland Clinic,Digestive Disease & Surgery Institute,Cleveland, OH, USA

Introduction: This retrospective study evaluated the outcomes of an evidence-based protocol for management of adhesive small bowel obstruction (aSBO) at an academic, high-volume referral center.

Methods:  

An evidence-based protocol for management of patients with aSBO was developed after thorough literature review. The protocol prescribed serial abdominal exams, nasogastric tube decompression, goal-directed maintenance fluid resuscitation, and electrolyte correction for patients without signs of bowel compromise. Patients failing to progress in the first 48 hours underwent contrasted small bowel follow through (SBFT) study. If SBFT demonstrated obstruction, patients were offered operative intervention; otherwise, they were continued to be observed until resolution of symptoms.

Between April 2014 and October 2015, patients admitted with aSBO were managed according to our evidence-based protocol. In October 2015, the Acute Care Surgery (ACS) service was restructured from a service run by 6 primary ACS surgeons to a service managed by 13 surgeons of varying specialties on a rotating schedule. This transition allowed for direct comparison of protocol-based and non-protocol management of aSBO. Our administrative database was queried for all ACS admissions assigned Diagnosis Related Group (DRG) codes associated with small bowel obstruction. Patients with incarcerated hernias, intraabdominal malignancy, and surgery within 30 days prior to admission were excluded. We compared the outcomes of the protocol-guided group to a non-protocol group admitted between April 2016 and October 2017. Primary outcomes of interest included length of stay, operative intervention rate, days from admission to operative intervention, and 90-day readmission rate.

Results: The protocol and non-protocol groups included 120 and 130 patients, respectively, who met strict inclusion criteria. Patients were well-matched in terms of age, gender, and severity of illness. There was no statistically significant difference between groups with respect to median length of stay (4 days [3-7] vs 4 days [3-7], p=0.781), operative intervention (21.7% vs 32.3%, p=0.081), days to operative intervention (2 days [0.25-3.75] vs 1 day [0-2], p=0.065), or 90-day readmission rate (9.2% vs 13.1%, p=0.436). Complication rates were comparable.

Conclusion: A protocol-guided approach to management of aSBO is safe and leads to a structured practice easily followed by surgical staff. While the use of the protocol resulted in increased utilization of SBFT studies, there was a trend towards a lower rate of operative intervention and fewer readmissions when the protocol was employed.
 

38.07 Pediatric Colorectal Surgery: A Collaborative Approach from a Single Institution

Posted on January 31, 2019

C. Pisano1, I. Sapci1, P. Karam1, M. M. Costedio1, A. L. DeRoss1  1Cleveland Clinic,Digestive Disease Institute/Department Of Pediatric Surgery And Colorectal Surgery,Cleveland, OH, USA

Introduction: Inflammatory bowel diseases (IBD) such as Crohn’s disease and ulcerative colitis are relapsing gastrointestinal disorders commonly presenting in pediatric patients. Due to the chronic nature of these diseases, children with IBD need life-long follow-up, often requiring surgical management. While presenting symptoms are similar, the needs and expectations of treatment may differ between adult and pediatric patients. Patients initially require operations performed by pediatric surgeons, but are then followed by adult colorectal surgeons after the age of 18. The varied age of this population may cause difficulties in surgical management and continuity of care is not always well established. This may create frustration for patients and healthcare providers. There have been models in other fields establishing transitional care from the pediatric to the adult patient. However, there has been little mention of similar efforts in surgery. A collaborative system involving both pediatric and colorectal surgeons may add expertise and improve the overall experiences for pediatric colorectal patients.  We hypothesized that surgeries performed in partnership with both pediatric and adult colorectal surgeons may lead to better outcomes for these patients.

Methods: Data was gathered retrospectively from patients 18 years old or younger who underwent colorectal resections for inflammatory bowel disease between 2010 and 2017 at a single institution. Data included patient demographics (age, gender, BMI, disease, steroid or biologic agent use), type of procedure, surgical approach, specimen extraction site, surgeon involvement (pediatric, colorectal or collaboration), operative time, and estimated blood loss. We analyzed days until passage of flatus and bowel movement, length of stay, type of surgical procedure, and surgical complications.

Results: A total of 117 patients were included in our study. Our data showed that days until flatus (2.27±0.47, p=0.049), first bowel movement (2.64±0.67, p=0.006) and length of stay (4.45±1.51, p=0.006) were the least in collaboration group. Single-incision laparoscopic surgery (SILS), compared to other laparoscopic techniques, was utilized most commonly in collaborative group (77.8% p=0.002). We did not see differences in surgical complication rates when comparing any of the groups.

Conclusion: Our results show improved outcomes in pediatric patients with inflammatory bowel disease when there was collaboration between pediatric and colorectal surgeons in comparison to surgeries performed by pediatric surgeons or adult colorectal surgeons alone. Such structured cooperation may benefit transition of care and other aspects of long-term management in this patient population.

 

35.05 Enhanced Recovery After Surgery (ERAS) Pathway for Patients Undergoing Abdominal Wall Reconstruction

Posted on January 31, 2019

J. S. Colvin1, M. Rosen1, S. Rosenblatt1, A. Prabhu1, D. Krpata1  1Cleveland Clinic,General Sugery,Cleveland, OH, USA

Introduction: Enhanced Recovery After Surgery (ERAS) pathways represent a multi-modal approach to post-operative care, with the goal of improved recovery, outcomes, and value. Patients undergoing abdominal wall reconstruction have lengths of stay of six days on average. We hypothesized that implementation of an ERAS pathway for abdominal wall reconstruction would result in faster recovery and decreased length of stay (LOS).

 

Methods: A universal ERAS protocol for patients undergoing elective abdominal wall reconstruction at the Cleveland Clinic was implemented. The protocol consisted of multi-modal analgesia with transversus abdominis plane (TAP) blocks in addition to both narcotic and non-narcotic oral pain medications. Early feeding and diet advancement as well as goal-directed intravenous fluids were implemented. Bowel regimen, routine labs, and use of drains were also standardized. One hundred consecutive patients undergoing abdominal wall reconstruction with use of our ERAS pathway were compared to a historical cohort. Groups were compared on demographics and clinical characteristics using chi-square, Fisher’s exact, and two sample t-tests.

 

Results: The average LOS was not significantly different after implementation of the ERAS protocol (6.0 ± 8.3 vs 6.0 ± 11.5 days, p=0.96). Time to regular diet was also not significantly different (3.43 ± 2.2 vs 3.6 ± 7.9 days, p=0.57). There was decrease in time to discontinuation of intravenous or epidural patient-controlled analgesia (3.8 ± 6.0 days vs 3.2 ± 4.7 days, p=0.05). There was no increase in readmission rates. In a sub-group analysis, factors associated with a LOS<4 days were hernia width ≤9.5 ± 7.2 cm (p=0.009), operative time ≤2.5 ± 0.85 hours (p=0.001), and pre-operative quality-of-life (HerQles) score ≥59.5 ± 11.7 (p=0.008). 

 

Conclusion: Our study is one of the largest to investigate ERAS protocols for complex ventral hernia repairs.  In this cohort, ERAS failed to reduce LOS.  We were able to identify predictors of a shorter LOS, which included smaller hernia defects, shorter operative times, and higher baseline quality of life scores. This demonstrates which subset of patients may have greater benefit from an ERAS pathway within our practice. 

19.07 QIC: An Interactive, Team-Based Quality Improvement Curriculum for Surgical Residents

Posted on January 31, 2019

J. S. Colvin1, X. Feng1, J. Lipman3, J. French1, V. Krishnamurthy2  1Cleveland Clinic,General Surgery,Cleveland, OH, USA 2Cleveland Clinic,Endocrine Surgery,Cleveland, OH, USA 3Cleveland Clinic,Colorectal Surgery,Cleveland, OH, USA

Introduction:  Incorporation of quality improvement (QI) training is essential to meet the milestones set forth by the Accreditation Council for Graduate Medical Education (ACGME). However, there is currently no standardized curriculum for delivering QI education to residents. With the current training system, educational time must be used efficiently to incorporate all essential components, creating a need for a concise and time-efficient QI curriculum. We aimed to create such a curriculum through the integration of formal didactics and team-based, hands-on learning via the completion of resident-led QI projects relevant to patient care.

 

Methods:  An IRB-approved QI curriculum consisting of four interactive workshops was developed at a surgical residency with 10 categorical graduates annually. The workshops were scheduled over an 11-week period, with each workshop lasting 1.5 hours. The curriculum introduced the various components of QI in a step-wise fashion, with a focus on Plan-Do-Study-Act (PDSA) cycles in the latter sessions. Anonymous and voluntary pre and post-curriculum surveys were administered. Univariate analysis of responses was performed using Fisher’s exact, chi square, and students’ t-tests for categorical and continuous variables when appropriate.

 

Results: Fifty surgical residents participated in the curriculum and four QI projects were completed, with 23 residents completing both pre- and post-curriculum surveys.  Following the curriculum, residents were more confident in their ability to design a QI project (5.7 ± 2.6 vs 7.1 ± 1.9, p=0.02), write a problem statement (6.7 ± 2.5 vs 7.8 ± 1.1, p=0.04), and write an AIM statement (6.7 ± 2.6 vs 7.8 ± 1.2, p=0.04). Residents also improved in their perceived ability to lead a QI project (5.6 ± 2.9 vs 6.9 ± 1.9, p=0.05), knowing the steps to complete a QI project (6.0 ± 2.8 vs 7.4 ± 1.7, p=0.04), and familiarity with basic QI terminology (5.6 ± 2.6 vs 7.0 ± 1.9, p=0.03). There was also a trend towards improvement in the ability to create a process map, how to do a root cause analysis, and how to use data to make improvements.

 

Conclusion: Overall, we found that the curriculum was a success—residents were able to complete QI projects through participation in the curriculum. In addition, there was an improvement in perceived competency and confidence surrounding some of the steps necessary to complete a QI endeavor. The curriculum was well received and the majority of residents who completed the curriculum found it useful. Future areas of investigation include trialing the curriculum over a longer timeline and making the transition to leadership roles for the senior residents. Additionally, the curriculum can be expanded to other institutions and specialties.