08.08 Characterizing Cancer-patient Sentiments Through Social Media: A Pattern-matched Twitter Analysis

Posted on January 18, 2016

W. Crannell1, E. Clark1, T. James1, C. Jones1, J. Moore1 1University Of Vermont College Of Medicine / Fletcher Allen Health Care,Surgery,Burlington, VT, USA

Introduction: Twitter is a well-known online micro-blogging social media device that currently has 302 million monthly active members. The service allows for the users to send small messages called ‘tweets,’ that are limited to 140 characters. With the increasing popularity of social media, such as Twitter, there has been wide recognition that meta-data are a very significant source of information. Increasingly, patients are utilizing Twitter as an outlet for their medical concerns, and thus we decided to test the twittersphere as a potential means by which to collect and analyze patients’ health sentiments in regards to cancer and surgical care.

Methods: A large sample of English tweets from March 2014 through December 2014 with imbedded location coordinates were obtained from the Twitter database. Using regular expression software pattern matching, the tweets were filtered by cancer diagnosis. For each cancer-specific tweetset, individual patients were extracted and the content of the tweet was categorized. The patients’ Twitter identification numbers were used to gather all tweets for each patient, and happiness values for patient tweets were calculated using a quantitative hedonometric analysis.

Results:The most frequently tweeted cancers were: breast (n=15421, 11% of total cancer tweets), lung (n=2928, 2.0%), prostate (n=1036, 0.7%) and colorectal (n=773, 0.5%). Patient tweets pertained to treatment course (n=73, 26%), diagnosis (n=65, 23%), and then surgery/biopsy (n=42, 15%). Computed happiness values for each cancer diagnosis revealed higher average happiness values for thyroid (h_avg =6.1625), breast (h_avg =6.1485) and lymphoma (h_avg =6.0977) cancers, and lower average happiness values for pancreatic (h_avg =5.8766), lung (h_avg =5.8733) and kidney (h_avg =5.8464) cancers. Data pertaining to cancer surgery tweets (n=1629, 1.1% of data set), show that patients (n=202) were more likely to express negative sentiments pre-operatively and more likely to express positive sentiments post-operatively.

Conclusion: The study confirms that patients are expressing themselves openly on social media about their illness and that unique cancer diagnoses are correlated with varying degrees of happiness. Twitter can be employed as a tool to identify patient needs and as a means to gauge the cancer patient experience. Tweets authored by patients are rich in content pertaining to active oncological and surgical treatment. These tweets differ in sentiment with respect to the patients’ operative date and tweets could thus allow for following patients through their treatment journey, potentially highlighting opportunities for improvement in surgical healthcare delivery. This is essential in order to maximize care and patient experience in an era in which patient satisfaction is increasingly being tied to reimbursement.

08.10 Surgeon-Patient Expectation Gap; Bigger Than We Thought?

Posted on January 18, 2016

R. N. Willis1, B. Edwards1, R. G. Sawyer1, M. D. Williams1 1University Of Virginia,Dept. Of Surgery,Charlottesville, VA, USA

Introduction:
Physicians and hospitals are frequently subject to performance measurements that are increasingly linked to reimbursement. Not least among these is Patient Satisfaction (PS). Previous reports have shown that PS is driven less by clinical outcome, and more by hospital and post-operative experiences of care. Ironically, research has shown that increased PS is correlated with better clinical outcomes and more appropriate use of the health care system. The aim of this study was to determine if the patient and surgeon expectations of recovery from surgery to are aligned.

Methods:
A 15-question Likert-style survey given to the patient and surgeon was deployed prospectively immediately following the conclusion of the pre-operative clinic visit. The survey encompassed multiple aspects of the patient’s recovery from perception of health and wellness to anticipated pain medication requirements, to length of expected recovery. All patients were 18 years of age or older.

Results:
Statistical analyses were conducted using Wilcoxon Signed Rank test and McNemar’s test as appropriate. The results were predominately non-parametric using a Likert Survey. Surgeons expected patients to feel more prepared for surgery (p=0.001), be more likely to walk the day after surgery (p=0.01) have better tolerance of surgery (p=0.03) and a more likely ultimate return to activities of daily living (p=0.002) than patients did. Whereas patients expected both more pain (p=0.006), less/ no need for narcotics (p=0.05) than surgeons.

Conclusion:
Our study demonstrates that in our sample population, surgeons and patients have significantly different expectations of important outcomes immediately after the conversation that should ideally set those targets. There is an opportunity to educate both patients and surgeons as to expectation and goal setting related to elective surgery.

08.11 Qualitative surgical research – why isn't it being published in surgical journals?

Posted on January 18, 2016

A. C. Robinson1, J. R. Appelson1, N. R. Changoor1, W. A. Davis1, A. H. Haider1, M. A. Morris1 1Brigham And Women’s Hospital, Harvard Schools Of Medicine And Public Health,Department Of Surgery,Boston, MA, USA

Introduction:

Recently, researchers have recognized the need for qualitative research in surgery, because it offers a toolset to understand lived experiences and the influence of social context in the healthcare setting. However, few studies have described the current state of qualitative surgical research. The present study is a comprehensive literature scope of qualitative surgical research to identify: (a) common approaches to qualitative surgical research; (b) gaps in the literature to inform future qualitative inquiry.

Methods:

We searched PubMed using ‘surgery’ and 7 qualitative methodology search terms (Grounded Theory, Constant Comparative, Phenomenology, Content Analysis, Discourse Analysis, Case study, Ethnography). Exclusion criteria included: mixed-methodology, literature/systematic reviews, non-surgical studies, and non-English language studies. Extracted data included: methodology (e.g. grounded theory, case study), methods (e.g. interviews, observations), surgical specialty (e.g. transplant, surgical oncology) and participant population (e.g. patient, family, provider). Four researchers extracted study information for relevant abstracts, and a fifth researcher independently reviewed 10% of abstracts to determine inter-rater reliability.

Results:

A total of 2,017 articles were reviewed. After removing duplicates, 39.4% articles were deemed relevant (N=795; κ = 0.74). The most common methodologies included: phenomenology (33.2%), grounded theory/constant comparative method (30.8%), and content analysis (24.7%). The most common approaches were interviews (82.8%) conducted with patients (62.3%). Sample sizes varied widely within methodologies (mean: 27, range: 1-797). The most common surgical specialties were transplant (14.8%) and surgical oncology (13.6%). Overall, 36.4% of studies were published in nursing journals, and 9% in surgical journals. Fewer than half of studies were published before 2011, thus over half have been published in just the last four years (52.3%).

Conclusions:

Our results suggest that qualitative surgical research is gaining in popularity despite the majority of relevant studies being published in non-surgical journals. Notably, nearly two-thirds of studies utilized only two of the seven methodological approaches (grounded theory and phenomenology). Further surgical qualitative research should take advantage of a greater variety of approaches to provide insight into rare phenomena and social context. For example, qualitative inquiry can inform complex issues, such as health disparities and training needs that are relevant to the increasingly diverse patient and healthcare professional populations.

08.12 When Low Risk Operations Fail: The Frequency & Predictors Of Unexpected Deaths In Surgical Patients

Posted on January 18, 2016

J. D. Bohnen1, N. F. Sangji1,2, E. P. Ramly3, H. M. Kaafarani1,2, K. D. Lillemoe1, D. C. Chang1,2 1Massachusetts General Hospital, Harvard Medical School,Department Of Surgery,Boston, MA, USA 2Codman Center For Clinical Effectiveness In Surgery,Massachusetts General Hospital,Boston, MA, USA 3Oregon Health And Science University,Department Of Surgery,Portland, OR, USA

Introduction:

Deaths among low-risk surgical patients represent an important quality improvement challenge and a potential malpractice risk. While there are many predictive models and calculators targeting overall mortality in surgical populations, a focused analysis of these ‘unexpected’ deaths may provide valuable information.

Methods:

The national ACS-NSQIP database from 2011-2012 was analyzed for all general and vascular surgery patients. NSQIP-calculated 30-day mortality risk was dichotomized at different levels, and the optimal cutoff point for ‘low’ vs. ‘high’ risk patients was established by the Youden Index, at which point the sum of sensitivity and specificity was maximized. Patients below the Youden-Index-derived mortality risk threshold were deemed low-risk (i.e. expected survivors); low risk patients who died within 30 days were considered ‘unexpected deaths’. Multivariable logistic regression models were constructed to identify perioperative predictors of unexpected deaths.

Results:

A total of 601,631 patients were analyzed. There were 8627 deaths overall (1.43%). The Youden-Index-derived cutoff point for ‘expected’ vs. ‘unexpected’ deaths occurred at a calculated pre-operative mortality risk of 1.4%. There were 994 deaths among low-risk patients (994/513702, or 0.19%), representing 11.5% (994/8627) of all deaths. In multivariable regression analyses, 19 unique variables were found to be independent predictors of unexpected deaths; the five strongest were: ASA 4 [OR=12.01, 95% CI: 5.09 – 28.33, p<0.001]; ascites [OR=2.74 (1.21 – 6.20), p=0.015]; history of CHF [OR=2.64 (1.58 – 4.39), p<0.001]; WBC > 25 [OR=3.32 (1.54-7.15), p=0.002]; preoperative weight loss [OR=2.69 (1.81 – 4.01), p<0.001].

Conclusion:

More than 11% of deaths in the surgical population occurred in low-risk patients and may be considered ‘unexpected’. The frequency and predictors of unexpected deaths provide new insights into the make-up of this unique patient group. These patients should be prioritized for directed quality improvement efforts.

08.13 Novel Approaches to Facilitate Statewide Surgical Quality Improvement: Development of the ISQIC

Posted on January 18, 2016

A. R. Dahlke1, A. Yang1, J. Johnson1, K. O’Leary3, L. Kreutzer1, P. R. Farrell1, J. Thomas1, R. Love1, A. Halverson1, M. Williams2, K. Y. Bilimoria1 1Northwestern University,Surgical Outcomes And Quality Improvement Center,Chicago, ILLINOIS, USA 2University Of Kentucky,Center For Health Services Research,Lexington, KENTUCKY, USA 3Northwestern University,Hospital Medicine,Chicago, IL, USA

Introduction: The Illinois Surgical Quality Improvement Collaborative (ISQIC) was developed to improve the quality of surgical care across the state. Our objectives were to (1) assess the needs, barriers and resource gaps to quality improvement in Illinois, (2) develop and implement novel approaches to facilitate Quality and Process Improvement (QI/PI), and (3) develop an extensive evaluation plan to examine the effectiveness of program implementation.

Methods: Fifty-three hospitals in Illinois were surveyed about their QI/PI needs and resources (Resource Survey), Board/leadership involvement in QI, safety culture (Safety Attitudes Questionnaire-SAQ), and the baseline knowledge of QI among individual clinicians and QI personnel (Quality Improvement- Knowledge Assessment Tool-QIKAT). In addition, hospital site visits were conducted for in-depth qualitative assessments of QI resources and barriers. A combination of novel and evidence-based approaches were developed and implemented across all 53 ISQIC hospitals. A mixed-methods approach was created to triangulate data from surveys, ethnographic observations, semi-structured interviews, focus groups, artifact analyses and process mapping to measure the effectiveness of each newly implemented approach to QI.

Results:From the Resource Survey, hospitals commonly listed issues with insufficient financial resources, implementation of QI projects, communication and buy-in from leadership, and engagement among physicians. Hospital site visits revealed that surgeons were unsure how to lead QI programs or act upon data, whereas hospital administrators were concerned about startup costs associated with QI programs. Approximately 85% of respondents (n=950) for the SAQ rated their hospital favorably for teamwork and safety climate, but reported less favorably for perceptions of management and employee engagement. The average baseline test score (n=150) for knowledge of QI approaches from the QI-KAT was 65%. To address the QI/PI needs, 21 novel approaches, grouped into 5 domains: guided implementation, education, comparative reports, networking, and funding, were implemented at each hospital (Table 1). Continuous evaluation using the tools developed to measure the effectiveness of each of the 21 individual approaches have allowed for iterative modification and improvement of approaches.

Conclusion:By evaluating hospitals’ needs, barriers, resources, and baseline QI/PI knowledge, we were able to design 21 approaches to facilitate rapid and effective QI in Illinois. Continuous evaluation and iterative improvement of the 21 approaches has allowed us to tailor these initiatives to local differences at individual hospitals.

08.14 Timing of Blood Cultures in the Evaluation of Postoperative Fever

Posted on January 18, 2016

L. R. Copeland-Halperin1, H. Prentice1, J. Dort1 1Inova Fairfax Hospital,Surgery,Falls Church, VA, USA

Introduction: Postoperative bacteremia is a common complication of surgery. Traditional teaching holds that fever beyond the fourth postoperative day (POD #4) warrants blood culture, yet supportive evidence is scant. We gathered data from patients with postoperative blood cultures to assess whether the POD on which a maximum temperature (Tmax) occurred predicted positive culture results.

Methods: We reviewed records at a large tertiary care hospital in Northern Virginia of all non-pregnant adult patients who had blood cultures drawn within the first 10 days after surgical procedures in 2013. Differences in culture yield in relation to the POD on which fever occurred were assessed using Fisher’s exact test.

Results: There were 5,418 blood cultures in 1,693 patients. Preliminary results based on 808 cultures from 306 patients (mean age 61.8 years, 51.9% women) identified 51 (6.3%) with organisms. Of these, 40 (4.9%) identified potential pathogens, while 11 were likely contaminants. The Tmax (mean 100.3°F, range 94.5°F-104.1°F) prompting the greatest number of blood cultures occurred on POD #1 (n=162; 20.3%), but only 1 culture on this day was actually positive (0.6%) (Figure 1). The Tmax most frequently associated with positive cultures (14.3%) occurred on POD #6. Most positive cultures (75.0%) were drawn when Tmax occurred on POD #4 or later (p <0.001).

Conclusion: The POD on which Tmax prompted blood cultures varied widely, and the overall yield of cultures was low. Pathogens were more often identified when Tmax occurred on POD #4 of later. Considering the yield and value of blood cultures, more judicious use of this resource could reduce the cost of postoperative care. Analysis of the complete dataset may identify other clinical predictors of pathogenic blood culture results and promote more efficient resource utilization.

08.15 Understanding Barriers to Efficiency in Robotic Surgery

Posted on January 18, 2016

B. T. Fry2, L. W. Hess3, M. Jain1, J. T. Anger1, R. Avenido1, B. Gewertz1, K. Catchpole1 1Cedars-Sinai Medical Center,Los Angeles, CA, USA 2University Of Michigan Medical School,Ann Arbor, MI, USA 3Pennsylvania State University,Eberly College Of Science,University Park, PA, USA

Introduction:

Robotic surgery offers advantages over conventional operative approaches but may also be associated with higher costs, additional risks, and new challenges. Surgical flow disruptions (FD) are defined as ‘deviations from the natural progression of an operation,’ and have been empirically associated with surgical errors, adverse events, and inefficiency. Understanding the etiology of FD in robotic surgery will help target training techniques and identify opportunities for improvement. This study explored the relationships between surgeon console time (SCT), the number and types of FD, resident involvement, and other contextual parameters.

Methods:

Thirty-two robotic surgery operations were observed over a six-week period at one 900-bed surgical center. Ten cases prior to this sampling were used to train two researchers and ensure high inter-rater reliability.

The researchers observed FD throughout the time the patient was in the operating room. Each FD was designated with the time and a descriptor, and was then classified into one of 11 different categories: communication, coordination, external interruptions, training, equipment, environment, patient factors, surgical decision making, instrument changes, psychomotor error, and robot console switch. SCT, resident involvement, robot model, and procedure type were also recorded.

Multi-variable statistics were used to evaluate the effects of these parameters on SCT and the number of FD.

Results:

Eight sacrocolpopexies, 21 prostatectomies, and 3 nephrectomies were observed. The mean number of FD was 48.2 (95% CI 38.6-54.8), and mean SCT was 163mins (95% CI 148-179). The Da Vinci S robot model was used in 14 cases, and the Si model was used in 18 cases. Nineteen cases involved residents, and 13 did not.

There was a mean of 60.8 FD (95% CI 47.8-73.8) in resident cases and 29.8 FD (95% CI 22.1-37.5) in non-resident cases. Resident cases demonstrated mostly training, equipment, and robot switch FD, whereas non-resident cases demonstrated mostly equipment, instrument change, and external interruption FD. A linear regression (r2=0.34) demonstrated that residents had a significant effect on number of FD (p<0.002), whereas robot model and procedure type demonstrated a non-significant effect.

The mean SCT with residents was 165.8mins (95% 149.7-181.9) and without residents was 160.2mins (95% CI 130.1-190.3). A linear regression model (r2=0.35) found resident involvement and robot model to be non-significant parameters, while procedure type (p<0.001) and total FD (p<0.034) significantly affected SCT.

Conclusion:

Resident involvement significantly increased the number of FD but did not affect SCT. This suggests that the FD encountered in resident training may not significantly affect operating time. Other FD, such as equipment issues or external interruptions, may be more impactful. Limiting these specific FD should be the focus of performance improvement efforts.

08.16 Since When Did Observation of Cancer Become Acceptable Treatment?

Posted on January 18, 2016

M. M. Dua1, T. B. Tran1, K. Hwa2, C. Cho-Phan3, G. A. Poultsides1, B. C. Visser1 1Stanford University,Surgery,Palo Alto, CA, USA 2VA Palo Alto Health Care System,Surgery,Palo Alto, CA, USA 3Stanford University,Medicine,Palo Alto, CA, USA

Introduction: Hepatobiliary malignancies are complex cases that require treatment through surgical, locoregional, and systemic therapies. Improved outcomes are observed when these cases are discussed among tumor boards and treated by multidisciplinary referral centers. We hypothesize there is significant delay in referral of many patients with primary hepatobiliary malignancies to tertiary multidisciplinary teams. The purpose of this study was to identify areas of mismanagement leading to delayed referral and treatment of hepatobiliary malignancies.

Methods: A retrospective review was performed of the patients referred to Liver Tumor Board from 2012-2014. Treatment recommendations were made by representatives from surgical oncology, hepato-pancreato-biliary (HPB) surgery, transplant surgery, interventional radiology, radiation oncology and medical oncology. Gross areas of mismanagement were defined as: 1) serial imaging of growing hepatobiliary tumors; 2) dismissal of imaging with overt tumors and negative biopsy; 3) failure to establish follow-up after identification of index tumor; and 4) failure to refer patients with resectable tumors. Referring institution characteristics were analyzed to determine risk factors for delayed referral.

Results: Of 208 patients, 80 (38%) were grossly mismanaged, most frequently because of definition 1 (49%) and definition 3 (26%). Risk factors for delayed referral included hospitals with less than 200 beds (OR-14.4, p<0.001), hospitals without any tumor board (OR-53, p<0.001), and hospitals without a surgeon specializing in oncology or HPB (OR-21.9, p<0.001). Cholangiocarcinoma was more frequently mismanaged than Hepatocellular carcinoma (OR-3 v 1.7).

Conclusion: The profound delay in referral of many patients with hepatobiliary malignancies compromises outcomes. Efforts to improve physician awareness and understanding of these tumors can facilitate expedited access to multidisciplinary care.

09.09 Sex Bias Exists in Human Clinical Surgical Research

Posted on January 18, 2016

N. A. Mansukhani1, D. Y. Yoon1, K. A. Teter1, V. C. Stubbs1, T. K. Woodruff2,3, M. R. Kibbe1,2 1Northwestern University,Surgery,Chicago, IL, USA 2Northwestern University,Women’s Health Research Institute,Chicago, IL, USA 3Northwestern University,Obstetrics And Gynecology,Chicago, IL, USA

Introduction: Sex is a highly conserved difference between members of the same species, but is a variable that is poorly controlled in clinical research. The objective of this study is to determine if sex bias exists in human clinical surgical research, and identify areas where the greatest and least sex biases exist. We hypothesize that males and females are not included in surgical clinical research in equal numbers, and that data are not reported or analyzed using sex as an independent variable.

Methods: All manuscripts published in Annals of Surgery, American Journal of Surgery, JAMA Surgery, Journal of Surgical Research, and Surgery in 2011 and 2012 were reviewed. Data abstracted included study type, location, number and sex of the subjects, the degree of sex matching, and inclusion of sex-based reporting, statistical analysis, and discussion of data.

Results: Of 2,347 articles reviewed, 1,668 included human subjects. Of these, an additional 365 were excluded on the basis of including animals or cells, studying a sex-specific disease, or not reporting the number of subjects included. Of the remaining 1,303 manuscripts, 17 (1%) were male-only studies, 41 (3%) were female-only studies, 1,020 (78%) included males and females, and 225 (17%) did not document the sex of the subjects studied. Using a liberal 90%, 80%, and 50% criteria for matching inclusion of both sexes, of the manuscripts that included both males and females only 118 (9%), 237 (18%), and 589 (45%) of studies matched the sex of the subjects included. For manuscripts that included both sexes, only 497 (49%) studies reported the data by sex, 432 (42%) analyzed the data by sex, and 299 (29%) included a discussion of sex-based results. Upon analysis of the different surgical specialties, a wide variation in sex-based inclusion, matching, and data reporting existed. Vascular surgery had the most male-only manuscripts (7%), breast surgery had the most female-only manuscripts (59%), surgical oncology included both sexes in the most manuscripts (91%), and breast surgery included both sexes in the least manuscripts (7%). Surgical education documented the sex of subjects in only 53% of publications, whereas thoracic surgery documented the sex of subjects in 95% of publications. Sex-based reporting of data was only performed in 28% of publications in American Journal of Surgery whereas it was performed in 45% of publications in JAMA Surgery.

Conclusion: Our data show that sex bias exists in human surgical clinical research. Few studies included men and women equally, less than one-third performed data analysis by sex, and there was wide variation in inclusion and matching of the sexes between the specialties and the journals reviewed. Because clinical research serves as the foundation for evidence-based medicine, it is imperative that this disparity be addressed because therapies and practice derived from such studies may be specific to only one sex.

09.10 Pediatric Appendicitis: Time to Give Antibiotics

Posted on January 18, 2016

A. G. Antunez1, S. K. Gadepalli1 1University Of Michigan,Pediatric Surgery,Ann Arbor, MI, USA

Introduction: Perforated appendicitis is a cause of major morbidity and reduction of rates can improve patient outcomes. Since appendicitis management is time-dependent, we hypothesized that distance and time traveled to initial evaluation and time to antibiotics impact perforation rates.

Methods: After IRB approval (HUM00095746), we retrospectively reviewed medical records, including from outside institutions (OI), of pediatric appendectomy patients from 2012-2013 at University of Michigan (UM). We collected demographics, zip codes to determine travel distances, insurance, labs, radiology, path reports, times of presentation to various institutions, to antibiotics, and to admission. We excluded patients with atypical findings not consistent with appendicitis and if over 18 years old. Primary outcome was perforated (transmural defect on path) appendicitis. Logistic regression was used to determine effect of distance and travel time and time from evaluation to antibiotics, adjusting for demographics, insurance, and site of primary evaluation with p-value <0.05 deemed significant.

Results: Of 245 appendectomies, 14 were excluded by atypical path and age criteria. Patients were 11.4±3.8yr, male (60.8%), Caucasian (83.6%), and privately insured (70.1%), with 63.2% complicated and 30.7% perforated. Interval appendectomies constituted 13.4% and diagnosis was missed previously in 8.7%. Median time traveled to initial evaluation was 18min(IQR14-25) with median distance of 11.5mi(6.8-17.4). Time for antibiotics from initial evaluation was a median of 5hr(IQR3.4-8.9). Approximately 43% were seen at UM first; there was no difference in gender and race but they were older and privately insured. Patients traveled a longer distance and took more time to be seen, but travel did not affect the rate of complicated or perforated appendicitis. Patients seen at OI first had higher rates of complicated, missed, or perforated appendicitis but received antibiotics later (p=0.003), regardless of age, race, or insurance status. On logistic regression, longer time from evaluation to antibiotics increased likelihood of perforation (OR1.03, p=0.03), when adjusted for age, race, insurance, and location of initial evaluation.

Conclusion: Distance and time traveled to initial evaluation did not increase the risk of perforation; however, the risk significantly increased with delayed antibiotic times. This study suggests that decreasing time to antibiotics during evaluation improves outcomes in pediatric appendicitis. Further prospective studies are needed to confirm our findings and determine what led to delays in antibiotic administration.

07.20 Does Music in the OR Impact Self-Perceived Performance? A Large Multi-Specialty Study

Posted on January 18, 2016

E. Taylor1, S. Lawrence1,2,3, E. Hechenbleikner1,2,3, Y. Hong1,2,3, C. Zheng1,2,3, L. Boyle1,2,3, W. Al-Refaie1,2,3 1Georgetown University Medical Center,Washington, DC, USA 2Georgetown University Medical Center,MH-SORC,Washington, DC, USA 3Georgetown University Medical Center,MGUH,Washington, DC, USA

Introduction: Music in the operating room (OR) has been shown to have diverse effects on physician and staff intraoperative performance. However, its influence on individual performance remains to be explored. This study aimed to identify the self-reported impact of music in the OR on performance in a major metropolitan academic teaching hospital.

Methods: The 10-item questionnaire was developed by a multidisciplinary team on the OR safety committee and sent to 375 OR physicians and staff via an online survey tool. Data were collected anonymously over five weeks. Chi-square analysis and logistic regression were used to analyze factors associated with frequency and self-evaluated impact of music in the OR.

Results: The overall response rate was 53%. Almost half of all respondents (47.5%) aged 30-50; women and men were equally presented in the sample. The majority of respondents (72%) often or always listened to music in the OR; 69% listened to music in the OR chosen by the attending surgeon. Respectively, 73%, 55% and 47% of respondents found music in the OR improved their mood, efficiency and concentration. However, 40% reported that music restricts their communication in the OR. Younger, male and surgeon respondents listen to music in the OR more often than their older, female and non-surgeon colleagues (all P<0.05). Similarly, the adjusted odds ratios showed similar trends predictive of favorable self-reported impact of music in the OR (Table).

Conclusion: This large, multi-specialty survey found that music in the OR improves mood for most participants but has a mixed impact on self-reported efficiency, concentration and communication. To corroborate our results, these trends need to be tested in other OR settings. Our findings encourage future investigation on the impact of music on OR dynamic and safety measures.

07.21 Assessing Patient Navigation Efficacy for Cancer Therapy

Posted on January 18, 2016

C. Jojola1, H. Cheng1, L. Wong1, K. Turaga1, T. C. Gamblin1, F. Johnston1 1Medical College Of Wisconsin,Surgical Oncology/ Surgery,Milwaukee, WI, USA

Introduction: Patient navigation (PN) is a process whereby patients with financial, social, and health-related barriers to care receive a personal escort to assist in overcoming obstacles to achieve timely treatment. The models of PN are diverse, and are often designed to prevent the marginalization of patients of low socioeconomic status and racial/ethnic minority groups. Herein we examine the literature assessing the efficacy of PN for patients with malignancies undergoing treatment.

Methods: The review was conducted according to the recommendations of the Meta-Analysis of Observational Studies in Epidemiology (MOOSE) group with pre-specified inclusion and exclusion criteria. Data abstraction examined efficacy measurements, patient demographics, barriers to access, quality measures and models of patient navigation.

Results:A systematic review was performed by searching PubMed, CINAHL, The Cochrane Library and EMBASE. A total of 4029 citations were collected in Refworks, yielding 27 relevant articles, 19 published papers and 8 abstracts. Navigation was performed for patients with breast, gynecologic, lung, pancreatic, colorectal, and prostate cancer treatment. Four articles do not specify type of cancer treatment. When examining ethnicity, 27.9% Hispanics (SD +/- 15), 30.9% Blacks (SD +/-16), 46.4% Whites (SD +/- 23), 4.6% Asian (SD +/- 3), 9.5% Other (SD +/- 14) participated. Three articles had 100% Native American participation. On average, 60.3% of patients spoke English (SD+/- 22), 44.5% spoke Spanish (SD +/- 13) and 16% fell under the category of Other (SD +/- 13). The average mean age of patients was 58.4 years (SD +/- 6). Analysis of quality measures showed that PN alleviated financial barriers (10 articles), coordination of care (7 articles) and transportation barriers (7 articles). When averaged, the mean days from diagnosis to treatment was 38.54 +/- 16 with PN compared to 45.31 +/- 18 days for the control groups. The median days from diagnosis to treatment was 36 +/- 11 with PN compared to 44.75 +/- 11 days for the non-navigated group (Table 1). Palliative care was not examined in any studies.

Conclusion:: A majority of patients benefitting from PN were a member of a minority racial/ethnic group, and a large portion was non-English speaking. Most patients in PN programs held a breast cancer diagnosis, but colorectal, prostate, and lung cancers were common as well. Overall, patients receiving navigation initiated treatment sooner than did their non-navigated counterparts. The efficacy of PN warrants further study of its various models and exploration of how PN can be expanded to include both curative and palliative treatment for patients.

07.17 Institutional Experience with Concurrent Endocrine and Other Surgical Procedures

Posted on January 18, 2016

R. S. Morris1, T. W. Yen1, A. A. Carr1, S. D. Wilson1, D. B. Evans1, T. S. Wang1 1Medical College Of Wisconsin,Surgical Oncology,Milwaukee, WI, USA

Introduction: The number of endocrine procedures, specifically parathyroidectomy, thyroidectomy, and adrenalectomy, being performed in the United States is increasing.There is a paucity of literature on the feasibility of combining these procedures in patients who may have indications for other surgical procedures.Therefore, the aim of this study was to determine the effect of performing concurrent surgical procedures on postoperative outcomes.

Methods: This is a retrospective review of multiple prospective databases of 2,930 patients who underwent thyroidectomy, parathyroidectomy, and/or adrenalectomy in combination with another procedure, at a single institution. The other procedures included skin, soft tissue, breast or hernia (SSB), abdominal major, abdominal minor, cervical, and ‘Other’. Patient demographics, operative details, and 30-day outcomes were reviewed. ‘Endocrine-specific’ complications included recurrent laryngeal nerve [RLN] injury, hypoparathyroidism, cervical wound infection, hematoma and other. ‘General’ complications included pulmonary or cardiac events and/or complications related specifically to the concurrent procedure.

Results:The cohort is comprised of 104 patients (Table 1). Patients were managed by two surgical specialties (general surgery and an additional specialty such as orthopedics, neurosurgery or otolaryngology) in 25 (24%) patients and more than one surgeon in 57 (55%) patients. Overall, 19 (18%) patients had 21 complications, including endocrine-specific complications in eleven (11%) patients. These eleven complications included RLN injury (n=3; 3%), hematoma (n=2; 2%), wound infection (n=1; 1%), transient hypoparathyroidism (n=2; 2%) and other (n=3; 3%). One patient with hypoparathyroidism was treated with oral calcium supplementation; the other patient had a concurrent pancreatectomy and was managed with IV calcium until tolerating an oral diet. The remaining nine ‘general’ complications included pneumonia in a patient who also had RLN injury, postoperative arrhythmia in a patient who also had an additional complication, and six (6%) patients with complications specifically related to the concurrent procedure. The last patient underwent an open adrenalectomy and hysterectomy and developed a midline wound dehiscence, which could not be specifically attributed to either procedure.

Conclusion:This is a review of 104 patients undergoing a surgical endocrine procedure who underwent a concurrent surgical procedure, ranging from skin and soft tissue to major abdominal procedures. Short-term endocrine-specific complications were managed safely, suggesting that concurrent procedures can be considered, when needed, with minimal effect on patient outcomes.

07.18 Exploring the Impact of Marijuana and Trauma

Posted on January 18, 2016

J. Hannallah1, P. Rhee1, K. M. Ibraheem1, N. Kulvatunyou1, T. O’Keeffe1, A. Tang1, R. Latifi1, L. Gries1, D. J. Green1, R. Friese1, B. Joseph1 1University Of Arizona,Trauma Surgery,Tucson, AZ, USA

Introduction: The prevalence of marijuana abuse and dependence has been increasing among adults and adolescents trauma patients in the United States. Several studies have demonstrated effects of marijuana on the outcomes of diseases. The aim of this study was to assess the relationship between the presence of a positive toxicology screen for marijuana and mortality in trauma patients.

Methods: We performed a 5-year (2008-2012) retrospective analysis of adult trauma patients (>18 y/o) using the Arizona State Trauma database. We included patients admitted to the ICU with a positive toxicology screen for marijuana. We excluded patients with positive alcohol or other substance screening. Patient demographics, injury and vital parameters, and toxicology data were collected. Our outcome measures were mortality, ventilator days, and ICU and hospital length of stay. We matched the patients who were positive for marijuana (marijuana positive) to the ones who were negative (marijuana negative) using propensity score matching in a 1:1 ratio controlling for age, injury severity score, and GCS. We compared the outcomes in matched groups.

Results:A total of 24,535 patients were included in our analysis of which 1,938 (969: marijuana positive, 969: marijuana negative) were matched. Rate of positive screening for marijuana was 5.3% in trauma population. Mean age was 31 ± 14, 80% were male, and median ISS [IQR] was 19 [9 – 25]. There was no difference in hospital (6.6 ± 8.6 vs. 7.3 ± 9.0, p=0.09) or ICU (2.9 ± 5.6 vs. 3.4 ± 5.3, p=0.08) length of stay or total ventilation days (2.8 ± 6.5 vs. 2.9 ± 5.3, p=0.88) between the two groups. 37% of the marijuana positive patients were under ventilator compared to 27% of marijuana negative patients (p < 0.001). Patients with positive screening for marijuana had a lower mortality rate (4.7% vs. 7.2%, p=0.04) compared to patients who were negative on toxicology screening.

Conclusion:A positive marijuana screen is associated with decreased mortality in adult trauma patients on ventilator. This association warrants further investigation of the possible physiological effects of marijuana in trauma patients.

07.19 Natural History Of Retained Surgical Items: Building On Cumulative Experience

Posted on January 18, 2016

B. Styskel1, B. Wernick1, R. N. Mubang1, D. M. Sabol1, M. A. Granson1, J. C. Rosenfeld1, S. D. Moffatt-Bruce2, S. P. Stawicki1 1St. Luke’s University Health Network,Department Of Surgery,Bethlehem, PA, USA 2Ohio State University,Department Of Surgery,Columbus, OH, USA

Introduction: Despite tremendous technological and organizational progress over that last three decades, patient safety experts continue the struggle to eliminate ‘never events’. Among the most dreaded surgical misadventures are retained surgical items (RSI). Difficult to intercept, a number of different surgical tools and accessories continue to be ‘left behind’, yet little is known about the natural history of patients who ultimately suffer the consequences of these surgical errors.

Methods: An exhaustive literature search identified a total of 281 case reports and series describing 299 incidents of RSI between 1953 and 2015. All available details regarding each reported case were tabulated and standardized into the following categories: (a) demographics; (b) anatomic location of the retained object; (c) type of retained item; (d) time to identification/removal; (e) associated complications; and (f) pathology findings. Results are presented as descriptive statistics and frequencies.

Results: A total of 299 RSI instances were tabulated. There were 107 males and 192 females, with average age of 47 years. The most common anatomic location was abdominal (113), paraspinal/spinal (33), thoracic (30), pelvic (28), cranial/facial (19), and extremity (12). Surgical sponge was the most common RSI type (180), followed by other types of gauze (64), plastic/tubing (14), surgical instrument (9), and needle (8). Median time to retrieval was 365 days (range, 0 to 16,790 days, 25%-75% IQR 60-1,825 days, Figure 1). Twenty-four cases (8%) involved 2 or more procedures. Almost all (281/299, 94%) objects were removed, and in 52 instances (17%) bowel or other organ resection was required. Median RSI-attributable hospital length of stay was 7 days. Significant complications were reported in 93/299 (31%) cases.

Conclusion: This collected series of RSIs provides an important glimpse into the natural history and patterns of occurrence of these ‘never events’. One in four patients had significant RSI-related complications, and the median length of stay attributable to RSI was 6 days. Majority of RSIs in this series were recognized and removed within 2 years of index operation, with the remainder either remaining asymptomatic and being discovered incidentally at a later time, or becoming symptomatic after a long period of dormancy. These findings corroborate and highlight the need for a national RSI registry.

07.15 On-Call Paging in the Pre- and Post-Electronic Health Record Era

Posted on January 18, 2016

A. M. Jensen1, P. Pieper2, M. S. Nussbaum1, C. L. Leaphart1 1University Of Florida,Department Of Surgery,Jacksonville, FL, USA 2University Of Florida,College Of Nursing,Jacksonville, FL, USA

Introduction: The electronic health record and limits on resident work hours have altered patterns of communication between physicians and nurses. Effective handoffs between interdisciplinary teams and for teams transitioning from day to overnight call are important safety initiatives promoting quality patient care. Anecdotal evidence suggests that communication is adversely affected by using electronic health records thereby potentially decreasing quality of patient care. To assess the effects of the EHR and limited duty hours on communication patterns and handoffs, we measured paging volume and nature of calls for on-call interns in pre- and post-implementation periods of the EHR.

Methods: After IRB approval, a data dictionary was created to standardize categories of on-call pages to interns. A College of Nursing faculty member, blinded to the purposes of the study, categorized the data dictionary into emergent or non-emergent needs. For on-call interns in General Surgery, a check sheet was created from the data dictionary and reviewed prior to implementation during overnight calls from 5 PM – 6 AM. Volume of pages to on call interns was collated by hour and call type for an 8-week period (May –June 2015). The data dictionary was used to compare call volume and type in a pre- and post-implementation period of the EHR.

Results: Prior to implementation of the EHR, the most common reasons for intern pages were for order clarification (32%, n=82) and pain management (19%, n=50). Highest call volume occurred between 8 PM -2 AM with only 19% of pages (50/260) determined to be for emergent needs. Strikingly, after EHR implementation, Pareto analysis determined the highest reasons for call to be consult-related pages (29%,n=178), pain management (12%, n=74), and abnormal labs/test results/vital signs (12%, n=73), indicating that standardized order sets potentially decrease the need for order clarification. Highest call volume post-EHR implementation occurred between 8 PM – 2 AM with 71% of pages determined as emergent. Consistency of times for high volume paging in the pre- and post-EHR periods was determined to be related to hospital throughput and patient flow from the emergency department and operating room to the surgical floors.

Conclusion: Although limited duty hours and EHR implementation may alter communication patterns between nurses and physicians, standardization of orders may improve clarity of patient needs and quality of care being provided. Future efforts in improving delivery of care may focus on improved order sets with attention to specific patient needs.

07.16 Evaluating Variability in Implementation of Perioperative Time-Outs: Is There Room For Improvement?

Posted on January 18, 2016

S. P. Lawrence1,2, E. M. Hechenbleikner1,2, S. Cane3, L. Boyle1,3, W. B. Al-Refaie1,2,3 1Georgetown University Medical Center,Washington, DC, USA 2MedStar Georgetown Surgical Outcomes Research Center,Washington, DC, USA 3MedStar Georgetown University Hospital,Washington, DC, USA

Introduction: Surgical time-outs have been implemented in operating rooms (OR) to increase adherence to operative safety measures. Hospitals striving to become High Reliability Organizations must maximize safety protocol adherence and better understand sources of variability in heterogeneous OR settings. This study utilized a comprehensive auditing tool to analyze compliance and variation across the perioperative time-out process in a major metropolitan academic medical center.

Methods: Data were collected prospectively by 5 anonymous observers over 10 weeks. The auditing tool was developed by a multidisciplinary OR safety team with key stakeholders from anesthesiology, nursing, and surgery. The tool was a detailed checklist evaluating 3 phases of our time-out process: anesthesia, surgical (incision to closure), and debriefing (end of case before leaving the OR). The anesthesia time-out consisted of 7 criteria, the surgical consisted of 24 criteria, and the debriefing consisted of 10 criteria.

Results: In total, 111 time-outs were observed (anesthesia n=29, surgical n=50, and debriefing n=32). The time-outs were initiated during 50 OR cases across 24 surgeons within 7 surgical service lines. Across all service lines, the percentage of time-out content captured in anesthesia, surgical, and debriefing time-outs was 97%, 82%, and 71%, respectively. Between service lines, there were wide variations in the completion rate of surgical and debriefing time-outs (Table 1). Anesthesia time-outs were performed by an attending physician 86% of the time and occurred prior to induction in 97% of cases. Surgical time-outs were performed by an attending physician 98% of the time and occurred prior to draping in 96% of cases. Debriefing time-outs were always performed by an attending physician. Capture rates of surgical content varied from 16% (asking team members to call attention to any problems seen during the case) to 50% (asking team members to introduce themselves by name and role) to 62% (asking team members to address any special considerations during the case) and 100% (naming the procedure and patient information). Finally, within the debriefing time-out, the name of the procedure and reconciling the surgical tool counts were addressed in 84% of cases, while all other content was completed at or below the rate of the debriefing taking place (69%).

Conclusion: This perioperative auditing tool discovered wide variation in protocol adherence between surgical service lines. This practical checklist will be the basis for future designed interventions to target specialty-specific areas of need to ensure patient safety and surgical team cohesiveness in the operating room.

07.13 Reduction in Arterial Blood Gas Utilization Through Implementation of End-Tidal CO2 Monitoring.

Posted on January 18, 2016

M. A. Wasserman3, J. M. Sternbach3, M. W. Wandling3, M. L. Crandall1,3, N. M. Issa1,3, S. J. Schwulst1,3, K. Y. Bilimoria2,3, M. B. Shapiro1,3, M. Swaroop1,3 1Northwestern University,Department Of Trauma & Critical Care,Chicago, IL, USA 2Northwestern University,Surgical Outcomes And Quality Improvement Center,Chicago, IL, USA 3Northwestern University,Department Of Surgery,Chicago, IL, USA

Introduction:
Despite a lack of scientific evidence, obtaining multiple daily arterial blood gas (ABG) values on non-septic mechanically ventilated patients is commonplace in our Surgical Intensive Care Unit (SICU). Invasive arterial sampling has inherent risks to patients, and frequently may be replaced with less invasive monitoring tools. We aim to decrease ABG utilization for ventilatory monitoring by increasing the use of non-invasive end-tidal CO2 (ETCO2) monitoring.

Methods:
Through multidisciplinary meetings, educational materials were developed and distributed to all SICU healthcare providers, including nursing staff, respiratory therapists, and surgical residents. This education focused on appropriate ABG utilization, the capabilities of ETCO2 monitoring in managing mechanically ventilated patients, and the practical functionality of the ETCO2 devices. On September 1, 2014 a protocol mandating ETCO2 monitoring for all ventilated patients was implemented in the SICU. Using our institution’s Enterprise Data Warehouse, ABG and ETCO2 monitor utilization data was collected for three months preceding and three months following our intervention.

Results:
Prior to our educational intervention, 5.63 ETCO2 monitor recordings were documented per ventilator-day. Post-intervention, 16.0 ETCO2 recordings per ventilator-day were recorded. This difference was statistically significant (p<0.01) and represented a nearly three-fold increase in ETCO2 monitoring. There was a trend towards decreased ABG utilization following our intervention, though this did not meet statistical significance (4.62 pre-intervention vs. 4.13 post-intervention, p=NS).

Conclusion:
The increase in ETCO2 utilization following our intervention represents the first step in a culture shift away from considerable reliance on ABG values for routine ventilatory monitoring and toward a less invasive monitoring practice. Though there was a trend towards decreased ABG utilization following intervention, failure to reach statistical significance likely reflects a lack of comfort among providers in rapidly abandoning an ingrained practice.

07.14 The World Health Organization Surgical Safety Checklist Improves Post-Operative Outcomes

Posted on January 18, 2016

C. S. Lau1,3, R. S. Chamberlain1,2,3 1Saint Barnabas Medical Center,Surgery,Livingston, NJ, USA 2New Jersey Medical School,Surgery,Newark, NJ, USA 3Saint George’s University,Grenada, Grenada, Grenada

Introduction: The incidence of in-hospital adverse events is about 10%, with a majority of these related to surgery, and nearly half of these considered preventable events. To improve patient safety, the World Health Organization (WHO) developed a checklist to be used at critical perioperative moments (induction, incision, and prior to the patient leaving the operating room (OR)). This meta-analysis examines the impact of the WHO surgical safety checklist on the incidences of overall complications, surgical site infections (SSI), unplanned return to the OR within 30 days, and overall mortality.

Methods: A comprehensive literature search of all published studies assessing the use of the WHO surgical safety checklist in patients undergoing surgery was conducted using PubMed, Cochrane Central Registry of Controlled Trials, and Google Scholar (1966-2015). Keywords searched included ‘World Health Organization’, ‘surgical checklist’, and ‘safety checklist’. Inclusion criteria were the use of the WHO surgical safety checklist in any surgical setting, with pre-implementation and post-implementation surgical outcome data. The incidence of various patient outcomes (total complications, SSIs, unplanned return to the OR within 30 days, and overall mortality) and adherence to safety measures (airway evaluation, use of pulse oximeter, presence of catheter lines, prophylactic antibiotics, confirmation of patient and surgical site, and sponge count) were analyzed.

Results: 10 studies involving 51,125 patients (27,490 prior to implementation and 23,635 patients after the implementation of the WHO surgical safety checklist) were analyzed. The implementation of the WHO surgical safety checklist significantly reduced the risk of total complications by 37.9% (RR = 0.621; 95%CI 0.519 – 0.742; p<0.001), SSIs by 45.5% (RR = 0.545; 95%CI 0.416 – 0.714; p<0.001), unplanned return to OR by 32.1% (RR = 0.679; 95%CI 0.484 – 0.954; p=0.025), and mortality by 15.3% (RR = 0.847; 95%CI, 0.752 – 0.954; p=0.006). There was also a significant increase in adherence to safety measures including airway evaluation, use of pulse oximetry, prophylactic antibiotics when necessary, confirmation of patient name and surgical site, and sponge count.

Conclusions: The use of the WHO surgical safety checklist is associated with a significant reduction in post-operative complications and mortality. The WHO surgical safety checklist is a valuable tool that should be universally implemented in all surgical centers and utilized in all surgical patients. Additional studies are required to determine optimal strategies for implementation of the WHO surgical safety checklist in different healthcare settings and countries.

07.11 Pardon the Interruption: An Observational Study of OR Interruptions

Posted on January 18, 2016

K. M. Caldwell1, L. R. Putnam1,2, S. Covey1, M. Diffley1, A. Hildebrandt1, A. Minzenmayer1, K. T. Anderson1,2, A. L. Kawaguchi1,2, K. P. Lally1,2, K. Tsao1,2 2Children’s Memorial Hermann Hospital,Pediatric Surgery,Houston, TX, USA 1University Of Texas Health Science Center At Houston,Pediatric Surgery,Houston, TX, USA

Introduction: Teamwork and effective communication are principles of safe patient care, especially in surgery. Distractions in the operating room can impair and/or interrupt these hallmarks as well as increase surgeon stress and fatigue, potentially compromising patient safety. However, little is known about the type and frequency of distractions in operating rooms. We aimed to characterize interruptions in pediatric operating rooms in order to identify areas for intervention.

Methods: Over an eight week period, a prospective, direct observational study was performed by five trained observers in an academic children’s hospital. Convenience sampling was performed across all pediatric surgical specialties. The number of phone calls, people entering, pages/text messages, equipment failures, and other events that interrupted workflow were recorded. Interruptions were further defined as essential or non-essential based on their contribution to patient care. Interruptions were analyzed in relation to surgical subspecialty and case duration.

Results: 208 operations were observed with a median (interquartile range) operating time of 40 (19-86) minutes. A total of 1,037 interruptions were recorded with a median of 2 (1-5) interruptions per case. People entering the operating room accounted for the highest proportion of interruptions (61%), where approximately one-third were non-essential (30.5%). Overall, 64% of all the interruptions were non-essential to patient care (Figure). In total, 63% of the operations had at least one non-essential interruption. Interruptions were more frequent as case length increased (median per case; <30 min = 1, 31-60 min = 2, 61-120 min = 4, >121 min = 14).

Conclusion: Non-essential interruptions are common in pediatric operating rooms. The impact of these distractions on patient safety remains unknown. Although no single interruption was observed to cause direct patient harm, patient safety in the operating room may be optimized through awareness, education, and limiting non-essential interruptions. Future interventions should target eliminating non-essential interruptions and minimizing essential ones through prevention and process improvement.

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