64.16 Management and prognosis of elderly breast cancer in Japan, retrospective cohort study

Posted on January 18, 2016

A. Yamada1, K. Narui1, S. Adachi1, H. Shima2, K. Kida2, S. Sugae2, M. Tanabe3, Y. Ichikawa4, K. Takabe5, T. Ishikawa6, I. Endo2 1Yokohama City University Medical Center,Breast And Thyroid Surgery,Yokohama, KANAGAWA, Japan 2Yokohama City University Graduate School Of Medicine,Gastroenterological Surgery,Yokohama, KANAGAWA, Japan 3Yokohama City University Medical Center,Pathology,Yokohama, KANAGAWA, Japan 4Yokohama City University Graduate School Of Medicine,Oncology,Yokohama, KANAGAWA, Japan 5Virginia Commonwealth University,Surgical Oncology,Richmond, VA, USA 6Tokyo Medical University Hospital,Breast Surgery,Shinjuku, TOKYO, Japan

Introduction: Japanese population is increasingly aging. Standard of care for elderly patients is controversial. The aims of this study are to clarify tumor characteristics, management, and prognosis of elderly breast cancer patients.

Methods: This is a retrospective single-center cohort included 647 of elderly (older than 65 years) among 2288 patients who underwent surgery between May 1993 to June 2014. The patients were divided into three groups according to age, younger than 64 (young), from 65 to 74 (young-old), and older than 75 (old-old).

Results:Elderly patients had advanced stage at diagnosis (stage III and IV =11.6: 11.4: 15.2%), no difference in estrogen/progesterone-receptor (hormone receptor: HR) positive (83.1: 80.7: 82.4%), and less HER2 positive tumors (14.1: 10.1: 7.8%). They were more likely to undergo mastectomy (44.4: 42.1: 51.5%) and to omit axillary surgery (0.2: 0.7: 2.1%). Among entire patients, elderly patients were less likely to receive adjuvant systemic therapy (92.5: 91.3: 76.6%) and radiotherapy after breast conserving surgery (91.6: 85.0: 22.9%) compared with their younger counterparts. Among HR positive patients, more than 90% of patients received adjuvant hormone therapy (97.0: 96.0: 91.9%), and less likely to receive chemotherapy (46.4: 28.4: 10.1%), however 5 years disease free survival are not different among age (90.5: 89.8: 92.5%). On the other hand, among HR negative patients, elderly patients, especially old-old, were less likely to receive to chemotherapy (89.3: 82.0: 38.2%) and had shorter 5 years DFS (74.2: 77.5: 65.0%).

Conclusion:Prognosis did not differ despite the variation of treatments among age in HR positive patients. On the other hand, patients between 65 and 74 were likely to receive almost same treatment as younger than 64 and had similar prognosis, whereas patients older than 75 were less likely to receive aggressive systemic treatment and resulted in worse prognosis in HR negative patients.

64.11 Efficiency Interventions Improve Staff Satisfaction with Operating Room Turnover Times

Posted on January 18, 2016

A. J. Douglas2, B. Pankratz2, J. Fenne2, R. I. Shoff2, C. P. Heise2 2University Of Wisconsin,School Of Medicine And Public Health,Madison, WI, USA

Introduction: There is debate in the literature about the usefulness of improving operating room (OR) turnover time since translation into cost savings or increased revenue is inconsistent. However, turnover time is rated by staff as a significant source of inefficiency and dissatisfaction in the OR. Increasing OR staff satisfaction by decreasing turnover times may itself be valuable by improving employee retention and workplace atmosphere. Our objective is to examine the impact of quality improvement (QI) efforts aimed at decreasing time between surgeries on OR efficiency and staff satisfaction.

Methods: OR turnover efficiency improvements were implemented in inpatient surgery at an academic hospital. From 2012-2014, turnover times were tracked both before and after efficiency implementation and a staff satisfaction survey was distributed yearly to OR nurses, surgeons, and anesthesiologists. Statistical analysis of survey results included t-tests and one-way analysis of variance (ANOVA).

Results: Average turnover time decreased 5 minutes total, from 43 to 38 minutes (a 12% reduction in turnover time). Staff satisfaction with turnover times increased across all disciplines (p < 0.05), and overall mean increased from 1.94 ± 0.88 to 3.15 ± 1.35 (p < 0.001), with 1 = ‘poor’ and 5 = ‘outstanding.’ Satisfaction increased among nurses by 1.21 ± 0.22 (p < 0.001), surgeons by 1.22 ± 0.27 (p < 0.001), and anesthesiologists by 1.25 ± 0.41 (p = 0.005).

Conclusion: With LEAN improvement efforts we demonstrated moderate improvements in turnover times in the inpatient setting. Even modest reductions resulted in increased OR staff satisfaction with turnover. While time saved was unlikely to accommodate an extra surgical case, minimizing turnover time remains a sensible target for hospitals due to the positive effects on staff satisfaction.

64.12 Early Attending Surgeon Presence in the OR Suite Increases OR Efficiency

Posted on January 18, 2016

A. Clark1, J. L. Rabaglia1, A. P. Dackiw1, W. D. White1, F. Nwariaku1, S. A. Holt1, S. C. Oltmann1 1University Of Texas Southwestern Medical Center,Dallas, TX, USA

Introduction
Some surgical cases involve complex, pre-incision preparation in the operating room(OR). When a consistent team is not available, and/or when multiple trainees are involved, oversight by an experienced individual can facilitate a timely start. Thyroid, parathyroid and adrenal procedures represent cases in which patient positioning, ultrasonography, nerve monitoring, and/or vascular access for hormone measurements during the procedure may occur before the operation can start. The study hypothesized that early attending presence in the OR expedites surgery start time, improving OR efficiency and decreasing cost.
Methods
Patients undergoing thyroid, parathyroid or adrenal procedures at an urban teaching hospital were selected. Time points were recorded, and calculated as hours:minutes. Cost per minute (m) of OR time was $54. Patients were classified as in the OR ≤10m prior to attending arrival or >10m prior to attending arrival. Data are presented as mean ± SD.
Results
227 cases were performed over 14 months. Thyroidectomy was most common (n=166, 73%), with 54 parathyroid (25%) and 10 adrenal (4.4%) procedures. Combined thyroid and parathyroid procedures occured for 7. 89% were female patients, and a mean age 48±15.
128 patients (56%) were in the OR ≤10m prior to attending arrival and 99 patients (44%) were >10m (0:03±3 vs. 0:35±14, p<0.01). Gender distribution was equivalent (p=1.0). ≤10m patients were older (50±15 vs. 46±14, p=0.04). Adrenal cases were equivalent (5% vs. 4%, p=1), while ≤10m included more parathyroid (32% vs. 15%, p<0.01) and fewer thyroid cases (66% vs. 82%, p<0.01).
≤10m procedures started sooner after patient arrival in OR (0:40±11 vs. 1:03±19, p<0.01). Associated OR costs per minute were $2,206±614 vs. $3,430±1065 (p<0.01), or $1,202 savings before the operation even began in the ≤10m group.

Adrenal and parathyroid had equivalent attending time in the OR prior incision between ≤10m and >10m (p=0.98 and p=0.80). However, patient time in OR prior incision for adrenal cases (0:58±7 vs. 1:42±30, p<0.01) and parathyroid cases (0:39±9 vs. 1:06±13, p<0.01) were shorter in the ≤10m group. This equates to $2,416±477 in savings for adrenal and $1,458±244 for parathyroid cases. For thyroid, attending time in OR prior incision was longer in ≤10m than >10m (0:37±11 vs. 0:24±14, p<0.01), but cases still started sooner (0:40±11 vs. 1:00±17, p<0.01). This equates to $1076±120 in savings per thyroidectomy.

Conclusion
Early attending presence in the OR shortens time to incision, decreasing costs. For parathyroid and adrenal cases, this does not require additional time from the attending surgeon. In ORs without consistent teams or with multiple trainees, early attending presence in the OR improves OR efficiency and results in significant cost savings.

64.13 Analysis of Retracted Articles in the Surgical Literature

Posted on January 18, 2016

E. G. King1, I. Oransky2, T. E. Sachs1, D. B. Flynn3, A. Farber1, J. A. Kalish1, B. M. Krafcik1, J. J. Siracuse1 1Boston University School Of Medicine,Department Of Surgery,Boston, MA, USA 2The Center For Scientific Integrity And New York University Arthur L. Carter Institute,,New York, NY, USA 3Boston University,Alumni Medical Library,Boston, MA, USA

Introduction: Retractions of scientific articles represent attempts to correct the literature. Our goal was to examine characteristics of retracted surgery-related papers.

Methods: NCBI Pub-Med database was queried using ‘surgery,’ ‘surg,’ or ‘surgical’ and ‘retracted’ or ‘retraction.’ Unrelated and non-retracted articles were excluded. Article, journal, and retraction details were recorded.

Results: There were 186 retracted surgical papers identified from 1991-2015. Average time to retraction was 3.6 years. Retracted papers were most often seen in general (25.8%), cardiac (22%), and orthopedic (10.2%) surgery. Articles were related to anesthesia and basic science in 32% and 11% cases, respectively. Authors were most commonly from the United States (21.5%), Germany (19%) and Japan (16%). Median impact factor (IF) of retracted papers was 2.4 (0.27-12.48).

Retraction reasons were 1) content related: duplication (34%), falsified data (15%), data errors (9%), plagiarism (8%), and 2) administrative: IRB concerns (19%), author dispute (9%), copyright (2%). No reason was given in 8% and 24% were behind a paywall (requiring payment to view notice). Median IF was higher for administrative than content-related reasons (3.42 vs. 2.12, P<.01). Plastic surgery, transplant surgery, basic science, non-anesthesia content, and publisher were predictive of a paywall for the retraction (P<.01). IF, content, and publisher did not predict whether a reason for the retraction was given.

Conclusion: The majority of surgical retraction notices have a reason listed and do not require payment to read. These findings provide a baseline analysis for surgeons to identify reasons for retraction and to focus on areas for improvement in transparency.

64.09 Improved Surgeon First Case On Time Starts Enhance OR efficiency and Cost Savings

Posted on January 18, 2016

A. J. Douglas2, R. Shoff2, G. D. Kennedy2, C. P. Heise2 2University Of Wisconsin,School Of Medicine And Public Health,Madison, WI, USA

Introduction: Decreasing under-utilized time in the operating room (OR) has been suggested as a means of achieving meaningful cost reductions for hospitals. One proposed method is to improve on time first case starts in the OR, though related financial analysis is lacking. The purpose of this study is to determine the downstream effect and financial impact of improving on-time starts for the first case of the day in the outpatient operating room at an academic teaching institution.

Methods: The Department of Surgery set a goal to decrease first case delays, specifically those attributable to surgeons. On time starts were defined as those beginning within 10 minutes of the scheduled start time. Beginning in fiscal year (FY) 2014, major efforts were made to improve surgeon related first start delays. On-time start percentage and over-utilized time were measured in the outpatient surgery setting and cost was estimated using a per-minute OR direct cost value. Fisher's exact chi square test was used to assess proportional differences in first case delay percentage between FY 2013 and 2014. An independent samples t-test was performed to analyze pre-post changes in mean monthly over-utilized time.

Results: At baseline, the rate of first-case delays in the Department of Surgery was 7.5%.Post improvement efforts, this rate improved to 4.8% (p < 0.05). The Department of Surgery saw a 51% drop in over-utilized time, corresponding to 998 fewer minutes that ORs ran past 5 pm.. The monthly average over-utilized time in the Department of Surgery decreased by 84 minutes per month (p < 0.05, 95% CI [22,146]). These improvements were estmated to translate into an average direct cost savings of $1,300.00 per month.

Conclusion: Improving on-time first case starts by promoting surgeon timeliness is associated with decreases in over-utilized time at the end of the OR day. While direct cost-savings in the outpatient surgery setting may be minimal, decreasing over-utilized time does have some financial benefit and likely improves the work environment by avoiding overtime staffing issues.

64.10 Telemedicine to Assess Ileostomy Output: A Feasibility Trial

Posted on January 18, 2016

B. Bednarski1, M. Katz1, J. Papadopoulos2, N. You1, M. Rodriguez-Bigas1, J. Skibber1, S. Matin2, G. Chang1 1University Of Texas MD Anderson Cancer Center,Surgical Oncology,Houston, TX, USA 2University Of Texas MD Anderson Cancer Center,Urology,Houston, TX, USA

Introduction:
Ileostomies are a routine part of the care of rectal cancer patients, but are associated with significant risk for dehydration, readmission, and acute kidney injury. Telemedicine has proven beneficial in decreasing readmission in chronic medical illnesses such as chronic heart failure, but its utility in the management of surgical patients is not well studied. The purpose of this study was to evaluate the feasibility of teleconferencing in the assessment of ileostomy output.

Methods:
An IRB-approved, prospective clinical trial was conducted at a single institution from November, 2014-June, 2015. Patients >18 years of age undergoing surgery with the potential for a new ileostomy were eligible. Teleconference rounds were conducted during their postoperative stay using Face Time on iPad2 tablets within a HIPPA compliant network. Teleconference rounds were followed immediately by in-person rounds. The attending surgeon evaluated the character of the ileostomy output via teleconference and subsequent in-person assessment utilizing 5-point likert scales: one rated thin to thick and one based on comparison to food products. The primary endpoint of feasibility was defined as 90% agreement between the teleconference and in-person assessments. Patient and physician satisfaction surveys were recorded. Secondary endpoints including output volume, need for antidiarrheal medications, and the incidence of dehydration related events (including need for outpatient intravenous fluids (IVFs) or readmission) were assessed.

Results:

Fifty patients were enrolled. Ileostomies were not required at surgery in ten patients who were excluded. Twelve patients did not have paired evaluations of the ostomy output and were unevaluable leaving 28 patient encounters with both teleconference and in-person evaluations. Agreement in the assessment of ileostomy output was 96.4% using the 5-point likert scale rated from thin to thick and 89.3% utilizing a comparison to food-based scale. Eleven patients (27.5%) were readmitted; including five patients for dehydration. An additional 3 patients required outpatient IVFs for an overall 20% rate of dehydration events (readmission or outpatient IVFs). Both patients and physicians viewed the teleconferencing favorably. For patients and physicians, 75% and 86.9%, respectively, felt videoconferencing should be a routine part of post-operative care. Similarly, 90.9% and 87%, respectively, felt comfortable with the use of videoconferencing in outpatient follow up.

Conclusion:
Teleconference evaluation is a feasible, reliable means of assessing ileostomy output with high patient and physician acceptance. While further study in the outpatient setting is warranted, the incorporation of early teleconference assessment after discharge may enable early intervention to improve patient outcomes by preventing dehydration and associated readmission.

64.05 A Public Health Perspective: How Often Does Optimal Care Begin Prior to the Surgical Admission?

Posted on January 18, 2016

R. L. Hoffman1, K. T. Collier1, J. Tong1, S. Dasani1, G. C. Karakousis1, R. R. Kelz1 1University Of Pennsylvania,Philadelphia, PA, USA

Introduction: The healthcare crisis in the United States is ongoing. Great debate exists over the best approach to control costs and improve the quality of care provided to patients. The goal of this study was to examine the association between patient characteristics and the ability to receive optimal patient care from a public health perspective using colorectal cancer as a model.

Methods: A retrospective cohort study was performed using inpatient claims from California and New York (2008-2011) for all patients admitted with a new diagnosis of colon (CC) or rectal cancer (RC). From a public health perspective, optimal care was defined as a patient who was not admitted through the emergency department and underwent surgery within the first 24 hours of admission for a known nonmetastatic CC or RC. Univariate and multivariate regression was used to compare patients who received optimal care to those who did not with planned subset analysis in the surgical cohort by malignancy.

Results: A total of 38,568 patients, 30,580 (79.3%) with CC and 7,988 (20.7%) with RC were identified. There were 5,626 patients with metastatic disease. There were 19,268 (50.0%) patients who had surgery within first 24hrs and 29,868 (77.4%) were not admitted via the emergency department. Optimal care was received by 14,109 (36.9%) patients; 8,807 (29.0%) of CC and 5,302 (67.6%) of RC patients (p<0.001). Patients with commercial insurance had the highest rates of optimal care (42.2%) compared to Medicare (34.6%), Medicaid (30.0%) and self-pay (21.3%; p<0.001). In multivariate analysis race, sex, number of comorbidities and insurance status were significantly associated with the likelihood of receiving optimal cancer care (see table).

Conclusion: Despite numerous public health campaigns to increase awareness of colorectal cancer and available screening modalities, less than 40% of patients receive optimal care leading up to definitive treatment. Future efforts to increase the proportion of patients receiving optimal care will depend on significant buy-in from patients, the physicians they encounter prior to surgery and policies that make compliance with screening recommendations more feasible.

64.06 The Use and Quality of Cost-Utility Analysis in Surgical Research from 1990-2013

Posted on January 18, 2016

A. Benedict1, M. Chenoweth1, H. Jen1 1Tufts Medical Center,Boston, MA, USA

Introduction: Cost-utility analysis (CUA) assesses healthcare interventions by measuring value in terms of incremental cost per quality-adjusted-life-year (QALY) gained. CUA can comprehensively assess a wide range issues in the care of surgical patients. To date, comprehensive assessment of the CUA literature in surgery has not been conducted. The purpose of our study was to investigate the use and quality of CUA in surgical research.

Methods: A comprehensive Cost-Effectiveness Analysis (CEA) Registry, which catalogs more than 4297 peer-reviewed English-language CUAs through 2013, was used. This registry performs yearly systematic review of the CUA literature since 1976 and collects publication information, methodological characteristics, cost effectiveness ratios as well as utility weights from each article. Study characteristics were analyzed over three time periods: 1990-1999, 2000-2009, and 2010-2013. The quality of CUAs in the registry was rated on a 7-point scale. General surgery disciplines (GS) include general, bariatric, cardiothoracic, colorectal, oncologic, pediatric, transplant, trauma, and vascular surgeries. Trends were compared using the Cochran-Armitage trend test and designated significant if p<0.05.

Results: Out of the 4297 CUA articles in the CEA Registry, 647 (15.06%) focused on surgical interventions. The number of surgical CUA publications per year increased from 7.6 articles per year in 1990-1999 to 62.3 articles per year in 2010-2013 (p<0.03 for trend; see figure). This rate of increase was dwarfed by the increase in non-surgical CUA publications (26.3 articles per year in 1990-1999 to 395.8 articles per year in 2010-2013; p<0.005). The proportion of CUAs evaluating GS disciplines compared to other surgical subspecialties decreased significantly over time (from 55.2% in 1990-1999 to 41.6% in 2010-2013; p<0.001). The quality of CUAs was similar when comparing GS discipline to non-surgical CUAs (4.47 vs. 4.54, p=0.18). However the quality of GS discipline CUAs was superior compared other surgical subspecialties (4.47 vs. 4.19, p<0.005). There was also a significant increase in the proportion of surgical CUA publications from low- and middle-income countries (0% in 1990-1999 to 5.2% in 2010-2013; p<0.01).

Conclusion: There has been a significant growth in use of cost-utility analysis in surgical research, but the rate of increase still lags behind non-surgical subspecialties. Although the proportion of general surgery CUAs compared to other surgical subspecialties have decreased overtime, the quality of general surgical CUAs was superior. Furthermore, our data also suggest a growing interest in surgical CUAs by low- and middle-income countries.

64.07 Surgeon-Patient Communication during Awake Procedures

Posted on January 18, 2016

K. Guyton1, C. Smith2, A. Langerman1, N. Schindler1,3 1University Of Chicago,Surgery,Chicago, IL, USA 2University Of Chicago,Pritzker School Of Medicine,Chicago, IL, USA 3Northshore University Health System,Surgery,Evanston, IL, USA

Introduction:
Awake surgery offers patients an efficient and cost-effective alternative to procedures under general anesthesia. Surgeon-patient communication during awake procedures is an important component of the overall patient experience and has been inadequately described in the literature.

Methods:
Surgeons who perform a high volume of procedures on awake (no sedation or conscious sedation) patients were identified at two medical centers. Surgeons were contacted via email to participate in audio-recorded semi-structured interviews. Interviews were continued until saturation was reached. Review of transcripts allowed for iterative development of themes by two researchers; discrepancies were resolved by consensus.

Results:
Fifty two percent of surgeons agreed to participate, consisting of 23 faculty from 8 surgical specialties. Surgeons describe the primary drivers to perform awake procedures as decreased physiologic and monetary patient impact and increased procedure efficiency, while anticipated emotional, sensory and physical responses are deterrents. Surgeons emphasize that pre-procedure expectation management and a calm environment are integral contributors to the patient experience. Intra-procedure surgeon-patient communication is focused on providing instructions, verifying patient comfort, alerting the patient to changes in stimulation, diverting patient attention, and using words that do not cause patient alarm. Surgeon communication with staff and trainees is modified with an awake patient: verbal exchanges are minimized and quiet or nonverbal communication is utilized. With less explicit communication, surgeons value working with consistent teams. Trainee presence decreases focus on the patient. All surgeons report an absence of formal training in awake communication skills and report development of their techniques through observation of mentors and trial and error. Numerous surgeons report feeling insecure in their techniques and cite interest in learning other awake communication methods.

Conclusion:
Awake surgical procedures are unique circumstances for doctor-patient communication. Surgeons cite varied techniques to prepare and reassure patients before and during the procedure. Inconsistent education in communication skills results in surgeon insecurity. Challenges with trainee involvement warrant further evaluation of teaching practices, surgeon-trainee communication and the effect on patients during awake procedures. Development of best practices and a formalized curriculum in awake procedure communication would offer surgeons useful guidance for optimizing patient experience.

64.08 A Pilot Surgical Ethics Curriculum for General Surgery Residents

Posted on January 18, 2016

P. Singh1, M. D. Sur1, B. A. Shakhsheer1, P. Angelos1 1University Of Chicago,Surgery,Chicago, IL, USA

Introduction:
Education in clinical medical ethics has been increasingly recognized as a valuable component of surgical education. The Accreditation Council for Graduate Medical Education (ACGME) includes professionalism, defined as adherence to ethical principles, as one of its six core principles. Although most general surgery residency programs currently include some consideration of ethics in their curricula, the content and format for ethics education varies widely. The objective of this study was to develop and evaluate a surgical ethics curriculum specifically for surgical residents that was integrated into the clinical conference schedule.

Methods:
A year-long, IRB-approved curriculum was developed focusing on eight major topics within surgical ethics: informed consent, transplantation, withdrawing and withholding care, surgical training, error disclosure, surgical innovation, surgical research and global surgery. Each topic was presented as a case-based discussion drawing from selected readings with faculty-led moderation and presentation of pertinent clinical issues. Residents participated in pre- and post-test closed-form surveys assessing their attitudes toward ethics education, confidence in their skills in management of challenging ethical situations, and factual knowledge of key concepts in surgical ethics.

Results:
Forty categorical general surgery residents participated in at least one component of the curriculum. Of these, 31 completed the pre-test and 21 completed the post-test; 16 completed both. Although 75% of residents had received formal ethics training previously, 94% believed ethics education to be ‘important’ or ‘very important.’ Prior to participating in the course, residents felt most comfortable with informed consent and least comfortable with advanced directives and do-not-resuscitate (DNR) orders. Residents scored an average of 68.6% (range 52.6–89.5%, n=31) on 19 multiple choice knowledge-based questions on the pre-test and did not significantly improve with the course. Pre-test scores did not correlate with level of residency as compared between junior (PGY 1-2) and senior (PGY 3-5) residents (P=0.42). There was a trend toward improved confidence in all areas at the completion of the curriculum and a significant improvement in confidence managing advanced directives and DNR orders (P<0.001, n=16). Most participating residents responded with ‘somewhat agree’ or ‘strongly agree’ to statements that the course was useful, made an important contribution to their surgical training and was valuable for future residents.

Conclusion:
A surgical ethics curriculum can be successfully implemented as part of general surgery residency and residents value a curriculum that presents relevant issues to their training. Although residents may have received ethics education in the past, an ethics curriculum can help improve their confidence in dealing with a variety of ethical issues.

64.02 Pediatric Appendicitis: Is Referral to a Regional Pediatric Center Necessary?

Posted on January 18, 2016

M. M. Hodges1, S. N. Acker2, E. E. Moore3, A. Schubert4, L. R. Hill2, D. A. Partrick2, D. Bensard2,3 1University Of Colorado Denver,Laboratory For Fetal And Reproductive Biology, Division Of Pediatric Surgery, Department Of General Surgery,Aurora, CO, USA 2Children’s Hospital Colorado,Department Of Pediatric Surgery, University Of Colorado School Of Medicine,Aurora, CO, USA 3Denver Health Medical Center,Department Of General Surgery,Aurora, CO, USA 4University Of Colorado Denver,Anschutz Medical Campus,Aurora, CO, USA

Introduction: Acute appendicitis is the most common emergent surgical procedure performed among children in the US, with an incidence exceeding 70,000 cases per year. In large urban centers, appendectomies are often performed by both pediatric surgeons and adult trauma and acute care surgeons (TACS surgeons). We hypothesized that children undergoing appendectomy for acute appendicitis have equivalent outcomes whether a pediatric surgeon or a TACS surgeon performs the operation. To evaluate our hypothesis we analyzed the outcomes of pediatric appendectomy performed by three populations of surgeons; pediatric surgeons operating in a pediatric, tertiary referral center; pediatric surgeons operating in an urban safety-net hospital; and adult TACS surgeons operating in an urban safety-net hospital.

Methods: A retrospective chart review was performed for all patients under 18 years of age, who underwent appendectomy at either a tertiary care children’s hospital (group A, n=100) or an urban safety net hospital between July 2010 and June 2015. The population of patients operated upon at the safety net hospital was further subdivided into those operated upon by pediatric surgeons (group B, n=60) and those operated upon by adult TACS surgeons (group C, n=60). Baseline characteristics and operative outcomes were compared between these three patient populations utilizing one-way analysis of variance (ANOVA) and Chi-squared test for independence.

Results: When comparing the three populations, we found no difference in either the proportion of patients with complicated appendicitis (p=0.05), operative time (p=0.18), postoperative length of stay (p=0.14), rate of infectious complications (p=0.41), or rate of readmission (p=0.50). The three study populations did differ with regard to the mean age of the patients operated upon (group A 9.4±3.6 years [mean± SD], group B 8.3±3.6 years, and group C 12.4±3.6 years; p <0.0005); however, this can be attributed to protocol at the urban safety net hospital requiring patients less than 5 years old be treated by pediatric surgeons. Time from assessment in emergency department to operating room was also longer for patients in group B (13.1±11.0 hours versus 9.8±8.6 hours in group A and 8.3±3.3 hours in group C, p=0.006), and there was a higher rate of open appendectomy among children operated on by both pediatric surgeons and TACS surgeons at the urban safety net hospital versus the children’s hospital (30% in group B and 23.3% in group C versus 3.1% in group A, p <0.0005).

Conclusion: Our data demonstrate that among children undergoing appendectomy, length of stay, risk of infectious complications, and risk of readmission do not differ regardless of whether they are operated upon by pediatric surgeons or adult TACS surgeons, suggesting resources currently consumed by transferring children to hospitals with access to pediatric surgeons could be allocated elsewhere.

64.03 Evidence Based Medicine: The Low Hanging Fruit of Lean Healthcare Implementation

Posted on January 18, 2016

J. T. Langell1, J. T. Langell1 1University Of Utah,Department Of Surgery,Salt Lake City, UT, USA

Introduction: The financial healthcare crisis has significantly reduced operating revenues for healthcare organizations. Hospitals are now seeking better operational efficiency models within their organizations. The successful application of Lean operation principles in manufacturing and other service sectors has resulted in its adoption by several healthcare organizations. Lean focuses on a culture change that promotes creation of a continuous learning organization and empowers all employees to make changes that will ultimately lead to improved customer value. One of the critical aspects of Lean is removing waste from a system to optimize the value equation.

The practice of evidence-based medicine improves the value to patients through the application of proven patient management principles that improve outcomes and may reduce the costs. Historical data shows that even the strongest leels of evidence-based medicine do not have uniform adoption by practitioners, even when mandated and tracked by federal payers and quality organizations. We believe that the uniform application of evidence-based medicine provides a simple and data-driven approach to Lean implementation.

Methods: We performed a literature search of the Cochrane database for evidence-based perioperative surgical care. This identified several publications that conducted a systematic review and meta-analysis of the use of incentive spirometers (IS) to prevent pulmonary complications after abdominal and thoracic operations. The data show that IS provides no efficacy in preventing these complications. We then studied the use of IS in our hospital system including total IS used and annual cost of purchase.

Results: We found broad use of IS and IS-teaching by surgeons across all disciplines in our hospital. A review of IS purchasing noted that our 526 bed tertiary care hospital used a total of 11,051 incentive spirometers in 2013 at a purchase cost of $2.27 each, totaling $25,086. The cost data does not include the additional cost of nursing teaching time, product stocking space or procurement resources. There are 5,686 hospitals registered with the American Hospital Association and 914,513-staffed beds in the US and according to the CDC over 100 million surgical procedures performed in the United States annually. If our medical center’s IS ordering practices and IS costs are relatively representative of US hospitals as a whole, the elimination of IS could save the healthcare system as much as $227,000,000 per year for a product that has evidence it provides no benefit to the general postoperative patient population.

Conclusion: The application of evidence-based medicine has greatly improved clinical outcomes, but has been shown to have variable adoption curves by healthcare practitioners. Here we demonstrate that the application of evidence based medicine can also be use a tool to eliminate financial waste and improve hospital operations.

64.04 How Much Does it Cost? Monetary Implications of Blunt Splenic Injury Management

Posted on January 18, 2016

O. A. Olufajo1,2, Y. Wang2, W. Jiang2, J. Leow2, Z. Cooper1,2, J. M. Havens1,2, R. Askari1,2, A. H. Haider1,2, J. D. Gates1, A. Salim1,2, E. Kelly1 1Brigham And Women’s Hospital,Division Of Trauma, Burn And Surgical Critical Care, Department Of Surgery,Boston, MA, USA 2Brigham And Women’s Hospital,Center For Surgery And Public Health,Boston, MA, USA

Introduction: Splenic artery embolization (SAE) is a well-known adjunct to the non-operative management of blunt splenic injuries (BSI). Although numerous studies have examined clinical outcomes of patients treated with and without SAE, there is a paucity of data that examines the economic impact of these treatment decisions. Our objective was to determine the cost implications of various strategies for non-operative management of BSI.

Methods: Patients with BSI were identified in the TRICARE database (2006 – 2010), a healthcare data repository of active and retired U.S. military personnel and their dependents. Patients who were managed non-operatively were classified as either having splenic artery embolization (SAE) or non-invasive management (NIM). Patients were categorized based on their Injury Severity Scores (ISS). Length of hospital stay, readmission rates, and 30 day complication rate (pneumonia, urinary tract infections, ileus/small bowel obstruction, wound infection, sepsis, acute renal failure) were determined. The 30-day costs of patient care (admission, readmission and complications) were calculated. A decision tree was used to determine the cost-effective strategy for various patient groups. Effectiveness was measured using quality-adjusted life years (QALYs).

Results: There were 529 patients who were managed non-operatively: 41 had SAE and 488 had NIM. The majority of patients were male (78%), < 45 years old (79%), with ISS > 15 (54%). Comparing the SAE to the NIM groups showed similar in-hospital complications (9.80% vs. 10.50%, P > 0.99), lower 30-day readmission rates (2.41% vs. 7.99%, P = 0.350), and similar rates of operation on readmission (0.00% vs. 1.40%, P > 0.99). The costs measured in both groups increased as ISS increased. While the costs in the NIM and SAE groups were $5,882 and $18,766, respectively, for ISS <9, the costs were $19,442 and $35,678, respectively, for ISS >25. Incremental cost-effectiveness ratios of SAE vs. NIM were all above the commonly used willingness-to-pay threshold of $50,000/QALY regardless of the ISS (Table), indicating that NIM was cost-effective compared to SAE.

Conclusion: Our study suggests that the cost of SAE, as a strategy for non-operative BSI management, outweighs its benefits. As emphases on cost implications of patient management increase, these findings can prove useful in cost management in BSI patients.

63.21 Time to CT scan for major trauma activation in pediatric population

Posted on January 18, 2016

A. Desai1, H. Alemayehu1, K. Savoie3, R. Barker3, R. F. Williams3, S. Turner2, B. Tjaden2, J. Howard2, P. Aguayo1 1Children’s Mercy Hospital,Surgery,Kansas City, MO, USA 2University Of Kansas Medical Center,Surgery,Kansas City, KS, USA 3University Of Tennessee Health Science Center,Memphis, TN, USA

Introduction: There is a growing body of evidence demonstrating improved outcomes associated with early radiographic evaluation of trauma patients. While there are a number of imaging modality options, the accuracy of CT scan during the diagnostic phase of acute trauma care has been well established. The objective of this study was to compare the time to CT scan as well as time spent obtaining CT scans between pediatric and adult trauma patients.

Methods: We performed a multi-center retrospective review of all trauma activations at two pediatric and two adult level 1 trauma centers from January 2012 to December 2013.

Results: A total of 1,323 (645 adult, 678 pediatric) patients were eligible for review during the study period. There was no significant difference in hemodynamic instability in the trauma bay (42 adult, 56 pediatric, p=0.3). There were, however, a significantly higher number of level 1 activations (227 adult, 118 pediatric, p <0.01), and higher ISS score (13.7±11.8 adult, 12.4±10.8 pediatric, p=0.04) in the adult population. Time to CT scan was significantly shorter in the pediatric population (35±34min pediatric, 46±68 adult, p<0.01). Time spent in CT was also significantly shorter in the pediatric population (22±11 min pediatric, 35±17min, p<0.01).

Conclusion: Although time to CT scan as well as time spent in CT scan was significantly shorter in the pediatric population, the difference was less than 15 minutes. Small difference in time may not be clinically relevant, and may be secondary to higher level of acuity seen in the adult population.

64.01 The Medicare Value-Based Purchasing Program Ranks Hospitals by Total Performance Score

Posted on January 18, 2016

A. Ramirez1, G. Stukenborg1, B. Turrentine1, R. Jones1 1University Of Virginia,Charlottesville, VA, USA

Introduction:

To address Medicare’s escalating costs, decreasing quality, and transparency the US Congress enacted the Patient Protection and Affordable Care Act of 2010 (ACA). Section 3001 of ACA established the Hospital Value-Based Purchasing Program (VBP) to measure the value of healthcare provided by participating hospitals. The VPB established quality indicators for processes, outcomes, patient satisfaction and cost per Medicare beneficiary to estimate value (value=quality/cost) of care provided. The domains above were used to calculate the Total Performance Score (TPS) allowing CMS to rank hospitals. For 2015, the Center for Medicare and Medicaid Services (CMS) withheld 1.5% of each Medicare hospitals’ anticipated annual payment to establish a financial framework for redistribution based upon TPS rank. High quality hospitals are rewarded and lower quality hospitals are punished. Review of the top 100 TPS included 27 physician-owned specialty hospitals (POSH) suggesting possible stratification by hospital type/business model.

Methods:

We reviewed the February 2015 VBP database including hospital name, address, unadjusted and adjusted process, outcome, patient satisfaction, cost, and total performance scores. We chose to compare POSH with all hospitals and POSH with another hospital type, University Hospital Consortium (UHC) members. We used the general linear model to estimate the TPS reported for each hospital as a function of hospital category and categorized by POSH and UHC membership. The statistical significance of the association between TPS and hospital category was assessed using the F test statistic at the threshold of p < 0.05.

Results:

The dataset included 3,089 hospitals with TPS ranging from 92.86 to 6.6 and a mean of 41.7. Of these 92 were identified as POSH and 111 were UHC hospitals. The mean TPS for POSH (64.43) was significantly higher than all other hospitals. Results from the general linear model indicate the estimated mean differences in TPS was 23.45 points higher for POSH (p < 0.0001) compared to all other hospitals. The mean TPS for UHC hospitals (36.89) was significantly lower than all other hospitals. The mean difference in TPS was -4.95 points lower for UHC hospitals (p < 0.0001) compared to all other hospitals.

Conclusions:

The Medicare VBP scoring method can effectively sort participating hospitals. Over time this methodology should improve, particularly with the development of progressively better quality indicators. Application of VBP should incentivize quality improvement and decrease healthcare cost. The observation that POSH had higher than average TPS and UHC hospitals had lower than average TPS requires further study. POSH include predominantly surgical centers while UHC hospitals represent a more heterogeneous patient population with large numbers of chronic disease. The observed differences comment on the need to further explore the impact of healthcare business models on outcomes.

63.18 Predictors of Central Venous Line Infection Salvage in Patients with Intestinal Failure

Posted on January 18, 2016

K. D. Nadendla1, M. Shroyer1, L. Wilkinson1, R. Dimmitt2, D. Galloway2, C. A. Martin1 1University Of Alabama at Birmingham,Pediatric Surgery/Surgery,Birmingham, Alabama, USA 2University Of Alabama at Birmingham,Gastroenterology/Pediatrics,Birmingham, Alabama, USA

Introduction: Life threatening central venous line (CVL) sepsis is a primary cause of mortality in patients with intestinal failure (IF). Current Infectious Diseases Society of America (IDSA) guidelines recommend CVL removal for bacteremia. However, many IF patients have limited venous access prompting initial attempts to salvage the line (non-removal of the CVL and antibiotic treatment). Here we describe predictors of line salvage at our institution, a topic which has been poorly understood historically.

Methods: The database for the Georgeson Center for Advanced Intestinal Rehabilitation (GCAIR) at the University of Alabama at Birmingham was queried from 2010-2015 to identify all patients with IF that were admitted for a CVL infection. Demographics and clinical parameters were compared among patients who underwent line removal to patients where the line was salvaged. Results were compared by a student’s unpaired T test.

Results:Forty patients were identified with 125 admissions for CVL infections. Line removal occurred in 71(56.8%) and 54(43.8%) successfully had their lines salvaged. The average age (months) for the removed group was 29.38 and 28.39 for the salvage group. Episodes of life threating sepsis were less frequent among the salvaged group as well as fungemia (p<0.0001). There was no significant difference in the non-fungal organisms cultured, location of the CVL, and number of previous admissions.

Conclusion:With the exception of cases of fungemia, line salvage of infected CVLs should be attempted in patients with IF when clinically possible. General pediatric CVL infection guidelines should be modified for patients with IF with limited venous access to address line salvaging methods.

63.19 The Epidemiology of Supracondylar Elbow Fractures in Children.

Posted on January 18, 2016

J. M. Rinaldi1, M. D. Hatch2, W. L. Hennrikus2 1Penn State Hershey Medical Center,College Of Medicine,Hershey, PA, USA 2Penn State Hershey Medical Center,Department Of Orthopaedics,Hershey, PA, USA

Introduction: Previous authors have reported that skull, rib, and corner fractures, and fractures in young children who have not started walking are highly associated with abuse. The purpose of this study is to determine the epidemiology, etiology, and relationship of supracondylar elbow fractures with child abuse.

Methods: 75 consecutive displaced supracondylar elbow fractures were reviewed to determine specific information about the manner in which the injury occurred. Medical records and radiographs were analyzed for demographic and injury data.

Results: 42 males (56%) and 33 females (44%) were studied. The average age was 6 years (range: 1 year 4 months to 12 years 4 months). 2 patients were 1-2 years of age, 3 were 2-3 years of age, and 70 were older than 3. The left elbow was fractured in 45 cases (60%). 87% were right hand dominant, 9% were left hand dominant, and 4% were too young to determine handedness. 58% injured the non-dominant arm. 24 (31%) were Gartland Type 2 and 52 (69%) were Gartland Type 3 fractures. 1 fracture was open. 8 (11%) fractures had a pucker sign. 11% presented with a nerve palsy. 5% presented without a pulse. 7 patients (9%) presented with an additional ipsilateral distal radius fracture. 64 fractures (85%) were transferred from 27 different outside hospitals in 17 counties, while 11 fractures (15%) presented directly to the ED. 35 fractures (47%) occurred at home, 30 (40%) on the school grounds, 4 (5%) in a gymnasium, 4 (5%) in a park, 1 at a farm show, and 1 in a parking lot. 24 fractures were treated between midnight and 8am, 15 were treated between 8am and 5pm, and 33 were treated between 5pm and midnight. All fractures stemmed from a fall, including: playground equipment 29 (39%), furniture 10 (13%), sports 6 (8%), stairs 3 (4%), bikes 3 (4%), and miscellaneous– running and tripping, falling from a toy ball, sled, tree, wagon, fence, bounce house, van, deck, power-wheels car, ATV, and go-cart. The average time from injury to the call for a transfer was 3 hours 5 minutes; transfer acceptance to arrival at ED– 2 hours 1 min; arrival in ED to OR– 5 hours 14 min; injury to OR– 10 hours 20 min; and time to discharge– 16 hours 39 min. Multiple medical professionals including outside ED physicians and orthopaedic surgeons, local ED physicians, local orthopaedic surgeons, residents, and nurses evaluated each patient. Only 1 patient, the youngest patient in the cohort at 1 year 4 months, injured from a fall at home, was reported for possible abuse and the evaluation was negative.

Conclusion: Pediatric elbow supracondylar fractures occur from accidental falls while children are at play. The mechanism involves a fall on the outstretched hand, hyperextension of the elbow, and fracture of the humeral cortex at the supracondylar location. In this population, child abuse was rarely associated with supracondylar elbow fractures.

63.20 Straddle Injury Management in Female Pediatric Patients: a One Year Retrospective Review

Posted on January 18, 2016

S. Dadjoo1, J. C. Hakim2, M. L. Peterson1, P. I. Abbas1, M. E. Lopez1, M. L. Brandt1, J. E. Dietrich2 1Texas Children’s Hospital,The Michael E. DeBakey Department Of Surgery, Baylor College Of Medicine,Houston, TX, USA 2Texas Children’s Hospital,Department Of Obstetrics And Gynecology, Baylor College Of Medicine,Houston, TX, USA

Introduction:
Straddle injuries in females consist of blunt and/or penetrating trauma to the urogenital area. Treatment of Grade 1 and 2 straddle injuries most often consists of sitz baths, estrogen cream or antibiotic ointment. Surgical repair may be indicated for significant bleeding or deep lacerations. The purpose of this study is to report treatment and outcome of girls <18 years of age with Grade 1 or 2 straddle injuries who were treated as outpatients (< 24 hr observation) in a large, tertiary pediatric hospital.

Methods:
An IRB approved retrospective review of all patients with Grade 1 and 2 straddle injury seen at Texas Children’s Hospital in 2014 was performed. Exclusion criteria included male gender, admission >24 hours or concern for sexual abuse. Data collected included age, time of year, mechanism of injury, management, and outcomes.

Results:
There were 69 girls who met inclusion criteria. The mean age was 6 years (range 2-17). Injuries were most common in May and June (n=18, 26%). The main cause of injury was a fall at home (n=31), fall at school playgrounds (n=24), or a bicycle or scooter injury (n=10). There were no penetrating injuries in this series. 18 pts were transferred from an outside facility. 68% (n=47) of pts were managed solely by an emergency department (ED) physician, and 32% (n=21) were managed by the gynecologic or, less commonly, the surgical service. A consult from the ED was most often requested when pain prevented adequate examination and/or significant bleeding or deep lacerations were present. 15 patients (22%) required surgical repair of lacerations of the perineum, labia, or vaginal introitus− 9/15 were treated in the operating room, 6/15 were treated in the ED under conscious sedation. There were no urethral or rectal injuries. Two patients required post-operative Foley catheters to relieve urinary retention. There were no other complications. The gynecology service prescribed at least 1 medicated cream (bacitracin, estrogen, lidocaine) in all patients, with 2 or more creams used in 71% of patients. Patients treated solely by ED physicians were less likely to receive topical medical therapy than patients treated by the gynecology or surgical service (13/47, 28% vs. 22/22, 100% p<0.0001). No patients were readmitted for further management.

Conclusion:
Grade 1 and 2 straddle injuries are common and most often occur following a fall at home. Significant pain and/or bleeding requires specialty intervention for a careful exam under anesthesia or conscious sedation. The minority of patients (22% in this series) require surgical repair. Clear indications for surgery as well as indications and effectiveness of topical treatments will be most effectively answered in future, prospective trials.

63.16 Adverse Events and Quality Control Measures in the Intra-Hospital Transfer of Pediatric Patients

Posted on January 18, 2016

I. Khurana1, A. G. Antunez1, K. M. Zalewski1, K. Marchetti1, G. C. Ives1, S. K. Gadepalli1 1University Of Michigan,Pediatric Surgery,Ann Arbor, MI, USA

Introduction: Patient transfer to various areas within a hospital is a common yet high-risk activity that can result in morbidity. Mitigating risks involved by using various quality control measures can help reduce injuries; however, studies have predominantly focused on adult and inter-hospital transfers, with relatively little attention given to the more common intra-hospital transfer of pediatric patients. A systematic literature review was conducted to characterize adverse events (AE) encountered during intra-hospital transfers (IHT) of pediatric patients and to examine current quality control measures (QCM).

Methods: Studies investigating IHT of pediatric patients were found in the English-language literature of three databases (PubMed, Embase, and Web of Science), using the help of a medical librarian. We collected relevant outcome measures such as AE and QCM, along with study design and interventions used. Studies meeting inclusion criteria, based on two independent reviewers, were further categorized into the primary outcomes: AE identified and type of QCM. A Cohen’s unweighted kappa was used to determine inter-rater agreement.

Results: Of the initial 43 articles, 12 satisfied inclusion criteria, with a moderate inter-rater agreement on title/abstract review (k=0.54[0.34-0.74]). These studies focused on AE (5), QCM (1), or both (6) [see Table 1]. Only 6 of the 11 investigating AE and 2 of the 7 studies reporting QCM were prospective. A total of 1591 IHT were evaluated prospectively, with physiological deterioration accounting for 71% of reported AE, equipment failure 20%, and interventions required in 9%. These events mostly occurred during transfer between an intensive care unit and other parts of the hospital, and were related to extended duration of transport and sicker pre-transfer status of the patient (ventilation status, PRISM score). AE from human error can be remedied by teamwork and checklists to standardize QCM; while AE from disease processes can be improved by standardization of transfer protocols.

Conclusion: This review highlights the most common AE of pediatric IHT and suggests QCM to improve patient safety. Additional prospective studies to set threshold values for AE and to determine effectiveness of QCM should be conducted. This article impacts hospital policies and QCM used to benchmark and standardize pediatric IHT to reduce AE.

63.14 Rethink Pediatric Nuclear Scans: Cost and Radiation Exposure of DMSA Scans in Children

Posted on January 18, 2016

M. Wang1, J. Michaud1, N. Gupta1, T. Bosemani1, M. Wang1 1Johns Hopkins,Urology,Baltimore, MD, USA

Introduction: Recent initiative set forth by the American Board of Internal Medicine, Choosing Wisely, asks physicians to carefully consider the risk and benefits of medical interventions. We examine our current protocol regarding pediatric patients who present with febrile urinary tract infection, who underwent DMSA scans. Specifically, calculating the added cost when compared to a dedicated pediatric renal ultrasound and the radiation dose associated with each scan.

Methods: DMSA renal scans are often utilized in the evaluation of pediatric patient present with febrile UTI. Given the prevalence of these exams in pediatric urology practice; we sought to quantify the cost, radiation exposure, and relative clinical utility when compared to dedicated pediatric renal ultrasound (RUS) in our patient population.
We conducted an IRB approved retrospective study of children referred to our institution for history of febrile UTIs between the years 2004-2013. Inclusion criteria: 1) children diagnosed with vesico-ureteral reflux (VUR) via voiding cystourethrogram (VCUG), 2) fever > 380 C, 2) urine culture with single organism of >50,000 cfu, and 3) patients who underwent both DMSA and RUS. Cost of each scan including professional and facility fee at our institution, radiation dosage, and radiographic results were analyzed.
Outcome measurements and statistical analysis: Chart review, and radiation dose equivalents were estimate from the Radiation Internal Dose Information Center (Oak Ridge Institute for Science and Education, Oak Ridge, TN).

Results:126 children (102 girls and 24 boys) met the inclusion criteria. The median age at presentation with febrile UTI was 8.1 months. The median age at first DMSA was 10.1 months. A total of 145 RUS and 171 DMSA were performed during the study period. Cost analysis revealed $865/RUS. DMSA $1,062/scan, and $2,115/scan for those children who need anesthetic sedation. The mean cumulative effective dose per patient/ DMSA was 3.75 mSv. This increased to 6.95 mSv for patients who underwent 3 scans. Limitations include retrospective design, tertiary referral center.

Conclusion:Both cost and radiation exposure from DMSA were significant when compared to RUS. Radiation exposure approached that of a pediatric chest CT (2-5 mSv) for a single DMSA.
Radiation exposure in early childhood can have significant impact on future cancer risk. Given the improved sensitivity of newer ultrasounds and comparable cost, efforts should be made to determine which children with urinary tract infection would benefit most from nuclear tests.

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