47.20 Conversion Disorder Causing Prolonged Hospitalization after Incisional Hernia Repair

Posted on January 18, 2018

S. Markowiak1, S. Perz2, R. Daniel3, B. Moloney3, O. Ekwenna2, J. Ortiz1  1University Of Toledo,Department Of Surgery,Toledo, OHIO, USA 2University Of Toledo,Department Of Urology,Toledo, OHIO, USA 3University Of Toledo,Department Of Psychiatry,Toledo, OHIO, USA

Introduction:

Altered mental status following surgical procedures is a relatively common phenomenon and can have many different etiologies including metabolic, infectious, neurologic and psychologic causes. A thorough evaluation of all possible etiologies is necessary to adequately treat the patient and prevent further comorbidities. Introduction:

Methods:
Case Report.

Results:
A 66-year-old man with a history of bipolar disorder underwent repair of an incision hernia at the site of a previous renal transplant. He did well initially, but on post-operative day three he had become significantly more lethargic. His interactions with his surroundings quickly declined until he was in a catatonic state. He was evaluated in the emergency department and initially admitted to a psychiatric hospital. On post-operative day seven he was not taking anything orally. He was transferred to the hospital for enteric feeds, medication administration and medical work-up. His infectious disease, metabolic and neurologic evaluations revealed no cause for his mental status. His mental status was attributed to a conversion disorder associated with his history of bipolar depression in response to the physiologic stress of surgery. Medical therapy was unsuccessful and he was ultimately treated with electroconvulsive therapy which led to substantial improvement and return to normal function.

Conclusion:
Psychiatric disease can lead to significant post-operative morbidity. It is important to evaluate all possible causes of altered mental status before attributing symptoms entirely to psychiatric causes. Early involvement of all relevant specialists can lead to early and aggressive treatment and limit comorbidities associated with prolonged hospital stay.
 

47.16 Healthcare Reform in Maryland: The Influence of Global Budgets on Emergent Ventral Hernia Repair

Posted on January 18, 2018

S. R. Kaslow1, M. Stem2, J. K. Canner1, G. L. Adrales2  1Johns Hopkins Surgery Center For Outcomes Research,Department Of Surgery,Baltimore, MD, USA 2Johns Hopkins School Of Medicine,Baltimore, MD, USA

Introduction

In January 2014 Maryland enacted a Global Budget Revenue (GBR) system in which all payers and hospitals are connected in a fixed payment capitated system to improve access to preventive care and care coordination. Many determinants of health addressed by GBR are also predictors of emergent ventral hernia repair (VHR). We aimed 1) to investigate associations between GBR implementation and the proportion of VHRs performed emergently, and 2) to study how implementation impacted risk factors of emergent VHR.

Methods

Patients with a diagnosis of ventral hernia who underwent surgical repair were identified in the Maryland Health Services Cost Review Commission patient-level case mix data from 2011 through Q3 2015, excluding trauma diagnoses. Patients were stratified into two groups: pre- and post-GBR implementation. Multivariable logistic regression was used to identify risk factors for emergent VHR performed pre- and post-implementation and to assess the impact of GBR on emergent cases.

Results

A total of 8,938 patients were identified. 3,770 (42.2%) patients underwent an emergent procedure: 2,517 (68.0%) pre- and 1,253 (33.9%) post-implementation. The proportion of emergent VHRs remained the same after implementation (33.2% in 2011-2013 vs. 33.6% in 2014-2015, p=0.71). Adjusted analysis showed that implementation had no significant impact on requiring an emergent procedure (OR 1.01, 95% CI 0.92-1.11, p=0.81). The patient risk factors for emergent VHR (age ≥75, Black race, Charlson Comorbidity Index, insurance) did not change dramatically after GBR implementation. However, a Charlson score of 2 or higher was associated with emergent VHR before implementation (Score 0: Ref; Score 2: OR 1.27, 95% CI 1.07-1.52, p=0.01; score ≥3: OR 1.30, 95% CI 1.10-1.53, p<0.001), while a score of 1 or higher was associated with emergent VHR after implementation (score 1: OR 1.32, 95% CI 1.09-1.60, p=0.01; score 2: OR 1.35, 95% CI 1.06-1.72, p=0.02; score ≥3: OR 1.75, 95% CI 1.38-2.20, p<0.001). Additionally, median income in the highest two quartiles had a lower risk of emergent VHR before implementation (1st quartile: Ref; 3rd quartile: OR 0.68, 95% CI 0.58-0.79, p<0.001; 4th quartile: OR 0.74, 95% CI 0.63-0.87, p<0.001); this association was not statistically significant in the post-implementation period.

Conclusion

GBR implementation had no significant impact on emergent VHR or the factors associated with emergent VHR. However, lower risk patients (i.e. lower Charlson Comorbidity score) were more likely to undergo emergent VHR after GBR implementation which may be due to surgical trends other than GBR such as watchful waiting. While higher income was protective against emergent VHR before implementation, the association between income and emergent VHR was not present after GBR implementation. Additional study is needed to determine if GBR improved access to care and lessened the impact of income or if there were other contributing factors.

47.17 Inpatient Opioid Prescription Trends Among Laparoscopic Surgeons at a Mid-Atlantic Medical Center

Posted on January 18, 2018

Z. Sanford1, A. Broda1, A. Weltz1, I. Belyansky1  1Anne Arundel Medical Center,Department Of Surgery,Annapolis, MD, USA

Introduction:
Unintentional poisoning has become the leading cause of injury-related fatalities in the United States and many of these are directly from prescription opioids.  A lack of guidelines for opioid prescription in surgical management may lead to variations in amount of medication prescribed to patients.

Methods:
A retrospective review focusing on differences in prescribing habits of surgeons as a function of case frequency was performed for all patients undergoing laparoscopic cholecystectomy and laparoscopic inguinal hernia repair from January 2014 to June 2017.  Inpatient medication was adjusted to Morphine Milligram Equivalents (MME).

Results:
In a cohort of twenty-two surgeons, twenty-two performed laparoscopic cholecystectomy and ten performed laparoscopic inguinal hernia repair.  Patients undergoing laparoscopic cholecystectomy (n = 1,890) presented with a mean age, BMI, and ASA score of 50.9 years, 31.4 kg/m2, and 2.3, respectively, with a procedure time of 57.0 minutes, hospital LOS of 2.2 days, and opioid pain prescription of 12.6 MME per day.  14.5% of patients did not receive any opioid pain control and daily prescribed doses ranged from 0-521.1 MME.  Patients undergoing laparoscopic inguinal hernia repair (n = 821) presented with a mean age, BMI, and ASA score of 57.0 years, 27.0 kg/m2, and 2.1, respectively, with a procedure time of 61.6 minutes, hospital LOS of 1.1 days, and opioid pain control of 6.6 MME per day.  30.8% of patients did not receive any opioid pain control and daily prescribed doses ranged from 0-91.4 MME.  In both the laparoscopic cholecystectomy (p < 0.0001) and laparoscopic inguinal hernia repair (p < 0.0064) subgroups surgeons demonstrated consistent prescription patterns individually within their own practice however there were significant differences among inter-surgeon prescribing patterns of postoperative opioid pain control.

Conclusion:
Prescribing habits of MME are based solely on personal preference and the professional discretion of prescribing physicians resulting in significant inter-surgeon variability in daily-prescribed MME after laparoscopic cholecystectomy and laparoscopic inguinal hernia.
 

47.13 Do Surgeons and Patients Value Shared Decision Making in Pediatric Surgery?

Posted on January 18, 2018

E. M. Carlisle1,2, L. A. Shinkunas2, L. C. Kaldjian2  1University Of Iowa Hospitals And Clinics,Department Of Surgery, Division Of Pediatric Surgery,Iowa City, IA, USA 2University Of Iowa,Carver College Of Medicine, Program In Bioethics And Humanities,Iowa City, IA, USA

Introduction: Shared decision making (SDM) is frequently touted as the preferred approach to patient counseling. Some have even gone so far as to suggest that SDM improves quality of care and reduces healthcare costs. Despite such enthusiasm for SDM, little data exist regarding whether patients prefer SDM over a more physician-guided approach during complex surgical decision making. Even fewer data exist regarding surgeon attitudes toward SDM. Such issues may be especially pronounced in pediatric surgery given the complex decision-making triad that exists between patients, parents, and surgeons. In this systematic review we identified studies that address patient/parent and surgeon attitudes toward SDM in pediatric surgery.

Methods: We conducted a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) based systematic review of articles published in Medline, EMBASE, and Cochrane databases that evaluated surgeon and patient/parent preferences toward SDM in pediatric surgery. The search strategy was developed in conjunction with a medical librarian. Two investigators independently reviewed all identified articles to determine if they met inclusion criteria. Studies were included if they specifically investigated attitudes of surgeons or patients/parents toward SDM in pediatric surgery. Articles in the following categories were excluded: reviews, letters to the editor, editorials, suggested models of care, patient education handouts, decision making tools, devices, or articles without full text available.

Results: The search yielded 8368 articles. 784 duplicate articles were removed yielding 7584 articles for title/abstract review. If it was unclear whether an article should be included in the final analysis based upon review of title/abstract, the full text was reviewed. Our search strategy identified only 40 papers that specifically addressed SDM in pediatric surgery.  Analysis of the articles is in progress and will include assessment of the following domains: surgeon sub-specialty, study location, clinical dilemma/decision needed, surgeon attitude toward SDM, patient/parent attitude toward SDM, and mention of decisional conflict or regret.

Conclusion: Despite recommendations that SDM is the best approach to clinical counseling in that it may improve quality of care and reduce healthcare costs, relatively few studies exist that address patient, parent, and surgeon satisfaction with SDM in pediatric surgery. Such research is imperative as it is quite possible that patients/parents may prefer a more physician-guided approach to complex surgical decision making. It is also reasonable to investigate whether surgeons believe SDM is an effective approach to discussions regarding surgery or whether they believe patient counseling would be more effective if more guidance was expected.  Further research is required to gain a more complete understanding of how surgeons can best counsel patients/parents during decision making in pediatric surgery. 

 

47.14 Decision Making in Advanced Surgical Illness: The Surgeons Perspective in Shared Decision Making

Posted on January 18, 2018

R. S. Morris1, J. Ruck2, A. Conca-Cheng2, T. Smith2, T. Carver1, F. Johnston2  1Medical College Of Wisconsin,Surgery,Milwaukee, WI, USA 2Johns Hopkins University School Of Medicine,Surgery,Baltimore, MD, USA

Introduction:  While surgical patients increasingly have more comorbid disorders and older age, surgeons face difficult decisions in emergent situations. Little is known about surgeon perceptions on the shared decision making process in these urgent settings.

Methods:  Twenty semi-structured interviews were conducted with practicing surgeons at two large academic medical centers. Thirteen questions and two case vignettes were used to assess participant perceptions, considerations when deciding to offer surgery and communication patterns with patients and families.

Results:Thematic analysis revealed six major themes and numerous subthemes related to end-of-life decision-making for critically ill patients: responsibility for the decision to operate, futility, surgeon judgment, surgeon introspection, pressure to operate and costs of surgery. Futility was universally reported as a contraindication to surgical intervention. However, an inability to definitively declare futility led some participants to emphasize patient self-determined risk-benefit analysis to determine whether to proceed with surgical intervention. Other participants who felt their gestalt about futility was reliable described greater comfort communicating to a patient that their condition was not amenable to surgery and reserved the right to refuse surgical intervention. Most participants desire objective metrics to determine risk and futility in order to more clearly communicate with patients and families, and perhaps temper the pressure to operate from external sources. 

Conclusion:Due to external pressures and uncertainty, some providers err on the side of continuing care despite suspected futility. Surgeons with greater experience and those who report more institutional support of their decisions are often more able to withstand external pressures, feel confident in their assessments of futility, and guide patients and their families away from futile interventions. Greater support from colleagues, institutional culture, research literature, and objective measures of futility can support surgeons in shared decision making and providing the best care for their patients. 

 

47.15 Provider Attitudes and Methods of Preoperative Surgical Risk Assessment

Posted on January 18, 2018

H. Qiu1, M. Bronsert1,2, L. A. Crane3, R. A. Meguid1,4  1University Of Colorado School Of Medicine,Surgical Outcomes And Applied Research Program,Aurora, CO, USA 2University Of Colorado School Of Medicine,Adult And Child Consortium For Health Outcomes Research And Delivery Science,Aurora, CO, USA 3University Of Colorado Denver School Of Public Health,Department Of Community And Behavioral Health,Aurora, CO, USA 4University Of Colorado School Of Medicine,Department Of Surgery,Aurora, CO, USA

Introduction:

Preoperative surgical risk assessment is a critical aspect of surgical decision making. However, techniques employed by surgical team members vary from sole reliance on clinical experience to use of formal risk analysis tools. We aim to better understand the prevalence of and barriers to the use of formal preoperative surgical risk analysis tools.

 

Methods:

A 20-question survey was designed, piloted in 10 surgical and anesthesia providers, and refined before administration. The web-based survey was disseminated via email and in person at a single academic hospital to surgical and anesthesiology staff and residents. A total of 12 questions were on risk assessment attitudes and techniques and 8 were on demographics (Figure 1). Results were analyzed with descriptive statistics (Chi-square or Fisher’s exact p value).

 

Results:

We administered the survey to a convenience sample of 50 surgical and anesthesia providers. Despite 88% of those surveyed reporting the importance of preoperative risk assessment as very or critically important (p<0.001) and 80% of those surveyed reporting discussion of risk preoperatively either most or all of the time (p<0.0001), only 76% of practitioners spend between 0-9 minutes communicating risk preoperatively, and 46% spend 0-4 minutes (p<0.001). When asked about use of 4 formal risk analysis tools, 64-94% of practitioners never use them (p<0.0001). On the contrary, prior experience is reported mostly or always to be a source of preoperative risk assessment (90% surveyed, p<0.0001). Survey of barriers preventing use of formal risk analysis tools identified 4 significant findings: time, electronic health record integration, inaccessibility during patient visit, and trust of accuracy were all reported as moderate to significant barriers by 94%, 74%, 88%, and 80% of respondents, respectively (all p-values <0.001).

 

Conclusion:

Although the prevalence of preoperative risk discussion is high, usage of formal risk analysis tools are infrequent and non-uniform amongst providers. The majority of practitioners relied on prior experience alone for preoperative risk evaluation. Statistically significant barriers against use of formal risk analysis tools include lack of time, lack of electronic health record integration, inaccessibility during patient visit, and lack of trust of tool accuracy. Given the data collected, we conclude there is limited use and significant barriers to use of formal preoperative risk analysis tools, and that time spent discussing surgical risks preoperatively is low despite the importance placed on it by surgical providers. Methods to surpass these barriers might increase the use of formal preoperative risk analysis tools.

47.12 Pediatric Thyroidectomy and Neck Dissection for Differentiated Thyroid Cancer: A Systematic Review

Posted on January 18, 2018

A. L. Madenci1, R. W. Frank2, B. C. Stack2, J. J. Shin1  1Brigham And Women’s Hospital,Boston, MA, USA 2University Of Arkansas,Little Rock, AR, USA

Introduction: The appropriate extent of thyroidectomy and lymph node dissection (LND) for children with well-differentiated thyroid carcinoma (WDTC) remains unclear. Management strategies may differ from those for adults. We conducted a systematic review to evaluate if children with WDTC have different survival, recurrence, or complication rates based on extent of thyroid resection and neck dissection.

Methods: We performed a computerized search of MEDLINE and Embase from 1966 to August 2017, supplemented with manual searches. Inclusion criteria were studies of patients diagnosed with WDTC at age <21 years, which evaluated thyroid resection and/or LND. Independent reviewers extracted data, with outcomes of survival, recurrence, postoperative complications, study designs, and potential confounders.

Results: Forty-nine criterion-meeting studies included 3821 pediatric patients who underwent resection of WDTC, including total thyroidectomy (TT; n=2512), subtotal thyroidectomy (STT; n=460), and lobectomy (n=725), with some patients undergoing multiple procedures. There were no prospective studies. Among studies comparing TT to STT, none detected a significant difference in overall survival (OS) (0/19 studies, 0%) and one detected a higher DFS after TT (1/12, 8%). Recurrence results were mixed (2/13, 15% detected decreased recurrence after TT; 1/13, 8% detected decreased recurrence after STT), and complications were similar among all studies. Among studies comparing TT to lobectomy, none (0/13, 0%) detected a significant difference in OS, one detected significantly increased DFS after TT (1/7, 14%), two detected significantly decreased recurrence after TT (2/8, 25%), and none (0/2, 0%) detected a significant difference in complications. Comparing STT and lobectomy, none reported a difference in OS (0/6, 0%), DFS (0/4, 0%), recurrence (0/3, 0%), or complications (0/1, 0%). Additionally, 17 studies reported outcomes following LND. Of the two small stage-specific studies limited to N+ patients, neither (0/2, 0%) detected a significant difference in OS or recurrence with LND, compared to no LND. Among 15 studies evaluating LND that were not stage-specific, none reported a difference in OS (0/4, 0%). One (1/5, 20%) study reported a significantly decreased DFS among N+ patients who underwent LND, compared to N0 who did not undergo LND (P<0.001). Recurrence results were mixed: 2/12 (17%) studies reported increased recurrence after LND, 6/12 (50%) reported no difference, and 3/12 (25%) reported decreased recurrence after LND. Two (3/7, 43%) studies documented significantly higher complication rates after LND.

Conclusion: In this systematic review of thyroidectomy and LND for pediatric WDTC, studies were generally underpowered and not stage specific. These retrospective results were mixed with respect to OS, DFS, recurrence, and post-operative complications.

47.09 Specialists’ Obligation to Provide Feedback to Referring Physicians: A Systematic Ethical Analysis

Posted on January 18, 2018

A. G. Antunez2,3, L. Dossett1,2  1Michigan Medicine,Department Of Surgery,Ann Arbor, MI, USA 2Institute For Health Policy And Innovation,Ann Arbor, MI, USA 3University Of Michigan Medical School,Ann Arbor, MI, USA

Introduction:
Surgical specialists are uniquely positioned to identify errors that have occurred during a patient’s diagnosis or treatment prior to referral. Specialists describe significant discomfort and physician and profession-centered barriers to giving feedback to the providers responsible for these errors. This analysis uses an ethical framework grounded in professional values to assess specialists’ obligations to communicate with referring physicians regarding pre-referral errors.

Methods:
We systematically explored the relevant principles from modern professional ethics literature, and applied them to cases where specialists discover the error of a referring physician. We explored these principles in the context of case studies described in previous qualitative work.  

Results:
The traditional, four-principle medical ethics framework (autonomy, beneficence, non-maleficence, and justice) has been adapted to modern practice in recent writings on professional ethics in medicine. Modern physicians should be accountable to their colleagues, responsible for their patients’ health, continuously improving their practice, allocating care fairly, and utilizing resources appropriately. Using the principles evoked in these modern codes (Figure 1), we demonstrate that providing feedback about pre-referral errors is an ethical behavior and that in order to fully uphold these values, specialist physicians have a duty to provide feedback to referring providers. The process of giving feedback fulfills a physician’s duty in each of these ethical domains, while failing to do so can harm patients, providers, and the profession. 

Conclusion:
Physicians have an ethical obligation to provide feedback after discovering pre-referral errors. This duty can be derived from the multi-faceted code of modern professional medical ethics. With potential negative repercussions for both parties, specialists may find it difficult to fulfill this obligation. Systems-based professionalism may offer a method of making feedback more commonplace, by providing regular opportunities for referring providers and specialists to dialogue. This may alleviate the discomfort or overcome the physician and profession-centered barriers that prevent specialists from acting on their principled inclinations. 
 

47.10 Ethical Considerations in DCIS: The Role of Breast MRI and Subsequent Outcomes.

Posted on January 18, 2018

L. S. Sparber1, A. B. Warman2, W. Doscher1,3,4  1Northwell Health System North Shore LIJ,Division Of Vascular Surgery, Department Of Surgery,New Hyde Park, NY, USA 2Columbia University,School Of Professional Studies Dept Of Bioethics,New York, NY, USA 3Northwell Health System North Shore LIJ,Department Of Medicine, Division Of Ethics,New Hyde Park, NY, USA 4Hofstra University,School Of Medicine,Hempstead, NY, USA

Introduction: Breast magnetic resonance imaging (MRI) has emerged as a potentially more sensitive imaging modality than traditional mammography, for detecting in situ breast tumors. The question that remains is whether this modality should be universally utilized as all interventions have decisions related to their results?  Quality of life implications and functional outcomes should be considered. It is unclear whether breast MRI has resulted in overtreatment and therefore unnecessary mastectomies in patients with Ductal Carcinoma in situ (DCIS). 

Methods: A comprehensive search for all published clinical studies on the use of MRI and its impact on DCIS management (2010-2017) was conducted using Pub Med and Google Scholar.  The search focused on the value of MRI to guide treatment strategies, including mastectomy rates, the overall benefit of this added imaging modality as well as ethical dilemmas associated with its use.  Keywords searched included: “breast MRI”, “mastectomy”, “DCIS”, “surgical planning” and ethics in all possible combinations.

Results:  Eleven studies involving 3,655 patients have been published. Lallemand et al, reported that routine use of MRI often leads to multiple procedures which have limited benefit. The largest study was reported by Pilewskie et al (2014) involving 2,321 DCIS patients examining loco-regional recurrence. Itakura et al reported increased mastectomy rates in patients undergoing preoperative MRI (p < .001).  In contrast, three studies analyzed the impact of MRI on DCIS mastectomy rates, with Allen et al reporting no significant difference in mastectomy rates if an MRI was performed (p = .62). Pilewskie et al, demonstrated that breast conserving surgery was more successful in the non-MRI group (p = .06), whereas Allen et al and Kropcho et al found the results to not be statistically significant (p = .41 and p = .414, respectively). Doyle et al, reported that use of MRI accurately predicted the extent of DCIS requiring further surgery (p=0.01). All but one study demonstrated that preoperative MRI was not routinely beneficial in DCIS patients.    

Conclusion: Decision making is complex and value-laden in interventions that could lead to body altering procedures. Breast MRI is associated with an increased sensitivity compared to other breast imaging technologies, which may contribute to an increase in unnecessary mastectomies in patients diagnosed with DCIS.  Proportionality, which is the assessment of benefits versus risks, must be considered. Shared decision making between the clinician and the patient is essential in this process. The clinician’s virtue is the source of the principles of non-maleficence and beneficence- both of which aim to honor the patient’s moral status: wanting to help a patient live optimally, while avoiding inflicting harm. Therefore, the issue becomes who decides what is the best medical care for a patient?
 

47.11 Barriers and Enablers to Rural Trauma System Implementation: A Case Study of Hospitals in Scotland

Posted on January 18, 2018

R. D. Adams1, Z. Morrison2, E. Cole1, J. Jansen3  1Queen Mary, University Of London,London, ENGLAND, United Kingdom 2University Of Aberdeen,Aberdeen, SCOTLAND, United Kingdom 3University Of Alabama at Birmingham,Birmingham, Alabama, USA

Introduction: Inclusive trauma systems have been shown to reduce mortality, when compared with exclusive systems. A trauma system is currently being developed in Scotland, a country with large rural areas. However, rural trauma systems face challenges; especially geography and low patient volume. The development of such a rural trauma system is a complex undertaking and understanding the views of service providers will be crucial.

The aim of this study was to conduct an exploratory evaluation, in order to identify key barriers and enablers to the development of an effective trauma system, from the perspective of rural healthcare professionals, to inform the effective implementation of a trauma system.

 

Methods: We undertook an initial scoping study using a qualitative case study research strategy to better understand the perceptions of rural healthcare professionals within a single setting; current trauma services within the North of Scotland due to be integrated into the planned trauma system. The study was conducted across rural general hospitals (RGH) in the North of Scotland, from April to June 2017, using an opportunistic sampling strategy to include hospital-based providers of rural trauma care across the region. Semi-structured interviews were conducted, recorded, and professionally transcribed. Thematic analysis was used to identify and group participant perspectives on the key barriers and enablers to the development of the new trauma system.

 

Results: We conducted 15 interviews with 18 participants (17 doctors and one nurse) across all six RGHs. Participants had a mean of 18 years trauma care experience. 

Study participants described several barriers and enablers, across three themes. The first theme was quality of care and enablers included confidence in basic management, although, a perceived lack of change from current management was seen as a barrier.

The second theme was interfaces with the network, which included enablers, such as, a good interaction with other services and a single point of contact for referral. Barriers included challenges in referring to tertiary care.

The final theme was trauma within the wider healthcare system that included enablers such as an improved transport system, increased audit resource and coordinated clinical training. Barriers perceived were a rural staffing crisis and problematic transfer to further care.

 

Conclusion: This study provides a multifaceted insight into rural healthcare professionals’ perceptions regarding barriers and enablers to implementing a rural trauma system in Scotland. These included practical issues, such as retrieval, transfer and referral processes. More importantly, there appears to show a degree of uncertainty, discontent and disengagement towards system development, and concerns regarding staffing levels and governance. These issues are unlikely to be unique to Scotland and warrant further study to inform service planning and delivery of rural trauma systems.

47.07 Diabetes is Associated with Prolonged Healing in Patients Undergoing Lower Extremity Amputation

Posted on January 18, 2018

K. Saffaf1, G. S. De Silva1, O. Saffaf1, L. A. Sanchez1, M. A. Zayed1,2  1Washington University In St. Louis,Division Of Vascular Surgery,St. Louis, MO, USA 2Veterans Affairs St. Louis Health Care System,Division Of Vascular Surgery,St. Louis, MO, USA

Introduction:

Over 130,000 major lower extremity amputations are performed in the United States each year for critical limb ischemia (CLI), a severe form of peripheral arterial disease characterized by recalcitrant stenosis, tibial artery calcification, and non-healing, non-salvageable wounds.  Unfortunately, many patients will require re-intervention or re-operation due to surgical site necrosis, wound dehiscence, infection, and poor overall healing. Identifying which specific patient characteristics contribute the most to these complications has proven difficult. We aimed to delineate which patient factors contribute to prolonged wound healing times in a cohort of patients undergoing major lower extremity amputation.

Methods:
A cohort of 17 patients (19 limbs) undergoing major lower extremity amputation for CLI at a single institution were retrospectively reviewed following their operation. Post-operative clinical imaging at 2-4 weeks, 4-6 weeks, and 6-8 weeks were scored for wound healing parameters using a modified Bates-Jensen Wound Assessment Tool. Patients with up-trending scores (poor healing) were deemed to be “Prolonged Healers”, whereas patients with lower scores (appropriate healing) were deemed as “Appropriate Healers” over an 8 week period. Descriptive statistics were analyzed using Mann-Whitney U test and summarized as mean ± SEM, while categorical variables were analyzed using Chi-square analysis

Results:
Chi-square analysis demonstrated diabetes as the only significant variable between the two groups (Prolonged Healers VS Appropriate Healers) (p=0.026). Other variables including smoking status, presence of chronic obstructive pulmonary disease, hypertension, coronary artery disease, chronic kidney disease, etc., demonstrated no significance. There were no differences in age, ASA BMI, ASA, or operative time between the two groups.

Conclusion:
In a small cohort of patients undergoing lower extremity amputation for CLI, we determined that diabetes was significantly associated with prolonged healing times. Other patient specific comorbidities demonstrated no significant association to long-term continuous healing.  Our analysis demonstrates that patients with diabetes should be closely monitored during their post-operative recovery for wound related complications. 
 

47.08 Challenging Ethical Issues in Extremity Amputations: What Role Does a Consult Service Play?

Posted on January 18, 2018

L. S. Sparber1, A. B. Warman2, W. Doscher1,4,5  1Northwell Health System North Shore LIJ,Department Of Surgery, Division Of Vascular Surgery,New Hyde Park, NY, USA 2Columbia University,School Of Professional Studies Dept Of Bioethics,New York, NY, USA 4Northwell Health System North Shore LIJ,Department Of Medicine, Division Of Ethics,New Hyde Park, NY, USA 5Hofstra University,School Of Medicine,Hempstead, NY, USA

Introduction: There is a paucity of published studies that have focused on the role of ethics consultations when patients refuse life saving amputations. Duty based ethics suggest that clinicians guide interventions through proportionality and the duty to the patient to restore health when possible and ease suffering when not. Quality of life implications and functional outcomes should be considered. This pilot study sought to examine the ethical issues that arise when patients facing loss of limb and ultimately life refuse surgical interventions.

Methods: Between July 2009 and June 2016, a retrospective study of all ethics consultations was performed. Demographic and clinical data was collected. There were 1,038 limb amputations performed. Seven patients (0.7%) requiring limb amputations required Ethics consultations. The overall median age was 53 years. Two (28.6%) of the patients were female.  One patient was pediatric. The average length of stay until clinical ethics was consulted was 18.7 days.  Descriptive statistical analysis was utilized to evaluate variations in patient capacity as well as goals of care variations in advanced planning decisions.

Results: The primary outcome was successful mediation of the initial ethical consultation. The time frame from initial consult to surgical intervention was days to months. Of the seven patients, four (57.1%) patients did not have capacity initially. One patient regained capacity. Surgical interventions included below the knee amputation (14.3%); above the knee amputation (28.6%); transmetatarsal amputation (14.3%); debridement (14.3%); multiple limb amputations (28.6%). The secondary outcome was death during incident hospitalization (42.9%).

Conclusion: It is acknowledged that there is a bias towards patients with disabilities, but some may argue that many of the difficulties those with disabilities face are put in place by society at large and are not inherent to their disabilities. What is important is the patient’s perspective of what is good or beneficial for them. The clinician should be able to participate without bias in the shared decision-making process as well as assist the surrogate in the process when the patient does not have capacity.  Treatment considerations should be weighed in light of best interests, benefits, burdens and risk to the patient’s authentic self. The consultation service can assist the team navigate through these ethical concerns. Additional studies are required to validate the findings of this small study.

47.05 Bariatric Surgery Provider Perspectives On Barriers To Severe Obesity Care: A Qualitative Analysis

Posted on January 18, 2018

L. M. Funk1,2, S. A. Jolles1,2, R. L. Gunter2, C. I. Voils1,2  1William S. Middleton VA,Department Of Surgery,Madison, WI, USA 2University Of Wisconsin-Madison,Department Of Surgery,Madison, WI, USA

Background: Nearly 20% of U.S. Veterans are severely obese, yet less than 0.1% undergo the most effective treatment – bariatric surgery. The aim of our study was to assess perceived barriers to severe obesity care among bariatric surgeons and nutritionists who work with bariatric patients.

Methods: We conducted interviews with 16 providers, including 10 bariatric surgeons and 6 registered dieticians (RD) who provide severe obesity care to Veterans. At least two surgeons from each of the five national regions in the VA system participated. RDs were recruited from VA weight management programs in the Great Lakes Health Care System region. Using a semi-structured interview guide, an interviewer asked providers to describe the preoperative and postoperative processes of care and challenges to providing bariatric surgery care within the VA system. All interviews were audio-recorded and transcribed. A directed approach to content analysis was applied. Emergent themes were identified and finalized through a process of consensus among four coders. Participants also completed a demographic questionnaire upon the completion of each interview.

Results: The mean provider age was 42.1 (SD=9.8) years; 50% were male and 31% were non-white. The average number of years in practice was 13.7 (SD=8.0); 63% had a dual appointment at a University. Five general barriers to care were identified (Table 1): 1) primary care providers not supporting bariatric surgery; 2) difficulty accessing VA bariatric surgery programs; 3) difficulty meeting preoperative requirements (e.g. weight loss and smoking cessation); 4) difficulty coordinating postoperative care; and 5) patient apprehension about making postoperative lifestyle changes. Three facilitators of bariatric surgery care were identified: 1) patient motivation to improve their long-term quality of life; 2) having social support; and 3) utilizing telehealth.   

Conclusion: Educating referring providers about bariatric surgery options, expanding availability of bariatric surgery services, and standardizing preoperative criteria across centers may increase access and improve coordination of bariatric surgery care within the VA. Expanded use of telehealth also appears to support provision of bariatric surgery in the VA. Implementation and dissemination strategies focused on these areas will be key if bariatric surgery provision expands within the VA.     

 

 

 

47.06 Personal Protective Equipment Needs a Redesign for Trauma Setting

Posted on January 18, 2018

P. Martin-Tuite1, L. Chehab2, B. Alpers3, J. Liao4, A. Sammann2  1University Of California – Berkeley / University Of California – San Francisco,Joint Medical Program,Berkeley, CA, USA 2University Of California – San Francisco,San Francisco, CA, USA 3Stanford University,Palo Alto, CA, USA 4George Washington University School Of Medicine And Health Sciences,Washington, DC, USA

Introduction:  Personal protective equipment (PPE) utilization rates are at a decade low across the healthcare industry. The International Safety Center (ISC) has issued a call to action to increase the rates of PPE utilization among healthcare workers at increased risk of occupational exposure, as recent data from the Exposure Prevention Information Network (EPINet) illuminated especially poor compliance among this cohort. While this applies across all health care settings, it is essential in high-risk environments such as level 1 trauma resuscitations, where the possibility of an occupational exposure is extremely high. The aim of this study is to understand the factors influencing poor compliance with PPE at an urban, safety-net teaching hospital and level 1 trauma center.

Methods:  Human-centered design (HCD) is a well-established research methodology in the design community that uses ethnographic, in-context observations and in-depth interviews to understand the challenges and unmet needs facing stakeholders in a system. We used this approach to conduct 50 hours of live observation of trauma care providers. Workflows and workarounds were identified from video recordings of 15 level 1 trauma resuscitations. We also conducted 35 in-depth interviews with stakeholders including nurses, doctors, technicians and students and identified common themes. Usability testing was performed in context to observe a range of users, from novice to experienced providers, don PPE.

Results: Upon review of 15 video recorded trauma resuscitations, we found that adequate PPE compliance (gown, gloves and face shield) at our institution is low at 29.0%. In interviews, stakeholders identified an inability to either locate or retrieve multiple items stored in inaccessible locations and separate packaging. Furthermore, PPE is a barrier to accessing the trauma patient, and providers express concern leaving the room to retrieve PPE. During usability testing, providers took 90 seconds to don PPE and an additional 30 seconds to don high shoe covers. Through live observations and video recordings, we also observed providers exiting and re-entering the room to retrieve PPE, struggle to remove PPE from packaging, or unfold and hand PPE over patients.

Conclusion: Providers report an understanding of the importance of PPE and cite a desire to wear it, but identify accessibility as the greatest challenge. While common approaches to increasing compliance in healthcare and workforce development tend to focus on incentives, education and training, HCD revealed that there is an important need to redesign PPE, as well as its storage and packaging, for the trauma setting. To help trauma providers increase compliance to wearing PPE, we must design it in such a way that allows them to don rapidly in a time-limited environment, and package and store it in a way that does not interfere with provider workflows.

 

47.03 Justifying Our Decisions About Surgical Technique: Evidence from Coaching Conversations

Posted on January 18, 2018

A. E. Kanters1, S. P. Shubeck1, G. Sandhu1, C. C. Greenberg2, J. B. Dimick1  1University Of Michigan,General Surgery,Ann Arbor, MI, USA 2University Of Wisconsin,Madison, WI, USA

Introduction: Although the quality of an operation depends heavily on operative technique, there’s very little evidence illuminating how surgeons arrive at their intraoperative decisions. Surgical training largely follows an apprenticeship model. This model of learning has the potential to perpetuate surgical knowledge grounded in anecdote rather than surgical literature. The objective of this study was to determine the extent to which practicing surgeons justify their technical decisions based on their experience or based on evidence. 

Methods: This qualitative study evaluated 10 video coaching conversations between 20 bariatric surgeons at the Michigan Bariatric Surgery Collaborative meeting in October 2015. Using grounded theory approach, the coaching dyads were coded in an iterative process with comparative analysis in order to identify emerging themes. We focused on how participants justified specific surgical techniques and decisions as these topics were a common theme identified in each of the coaching transcripts. 

Results: Three major themes emerged during analysis. (1) Most commonly, we found individuals reported modifications in surgical technique after a particularly negative postoperative complication for a single patient. For example, one surgeon reported, “Why did this leak? I had no reason…so that’s when I started to just say, ‘I’m just going to over sew everybody.’” (2) Alternatively, participants were noted to defend use of certain techniques or surgical decisions based on their perceived expert opinion of others. For example, individual surgeons often refer to how they were trained or how they witnessed another surgeon in the field perform a procedure as their impetus for modifying their own technique. (3) Finally, there was a notable lack of referring to evidence in surgical literature or educational programming as a motivation for changing surgical technique.

Conclusion: In this qualitative analysis of coaching conversations we found that practicing surgeons most often justify their surgical decisions with anecdotal evidence and “lessons learned”, rather than deferring to surgical literature to motivate their behaviors. This either represents a lack of evidence or poor uptake of existing data. 
 

47.04 The Golden Year: How Functional Recovery shapes Tendon Surgery context in Patients with Tetraplegia

Posted on January 18, 2018

C. A. Harris1, M. J. Shauver1, K. C. Chung1  1University Of Michigan,Plastic Surgery, Department Of Surgery,Ann Arbor, MI, USA

Introduction:  Tendon Transfer Surgery can effectively improve hand function for patients with tetraplegia, but remains poorly utilized. Although provider behavior and inconsistent care delivery contribute to low operative rates, there is growing recognition that patients' social and emotional contexts also impact uptake. In particular, evidence suggests that the balance of patients' positive and negative coping behavior can influence their progression to surgery. Yet, how these coping behaviors evolve is not completely understood. This study seeks to probe how patients' early recovery experiences shape their attitudes toward function and identity to impact coping, and ultimately how this shapes their reconstructive context.  

Methods:  We performed a cross-sectional qualitative analysis of nineteen participants with C4-C7 cervical spinal injuries: 9 patients had undergone reconstruction, 10 had not. Semi-structured interviews were conducted using a standardized interview guide focusing on rehabilitation experience, the relationship between function and identity, and how patient experience evolved. Interview transcripts were analyzed using grounded theory methodology and constant comparative analysis. 

Results: The study sample was predominantly male (79%), white (89%), and American Spinal Injury Association Grades A-D were represented. Patients' attitudes toward function were largely shaped by the degree to which they recognized rehabilitation’s necessity, experienced functional gains, and built constructive relationships with their therapists. Poor insurance coverage and financial constraints limited rehabilitation access, and decreased patients' hope for improvement. Function impacted identity through the degree to which it tied participants to a ‘patient’ role. We conceptualized this relationship as two spectra: high vs. low function and strong vs. weak patient identity (Figure 1). Early in recovery (e.g. The Golden Year) patients’ function, roles, and attitudes were fluid, but they solidified over time. How satisfied patients were with these final positions influenced how well they coped.  

Conclusion: This study adds to our understanding of how patients with tetraplegia build their operative contexts. Depicting function and identity as two related axes demonstrates how these domains continually influence each other, while patients' satisfaction with their places on these spectra becomes the starting point for their coping. Our finding that patients eventually established norm based on their solidified function/identity positions suggests that introducing reconstruction during the Golden Year may help prolong patient's receptiveness to surgery. 

47.02 A Qualitative Study of Care Transitions Following Injury in Cameroon

Posted on January 18, 2018

D. C. Dickson1, S. A. Christie1, R. A. Dicker2, A. Chichom-Mefire3, C. Juillard1  1University Of California – San Francisco,Center For Global Surgical Studies,San Francisco, CA, USA 2University Of California – Los Angeles,Los Angeles, CA, USA 3University Of Buea,Department Of Surgery And Obstetrics- Gynecology, Faculty Of Health Sciences,Buea, SOUTHWEST REGION, Cameroon

Introduction:  People living in Cameroon, a lower middle-income country (LMIC), have a higher than average burden of trauma, suffer from more severe injuries, and face substantial barriers to accessing formal health care services. As LMICs improve health infrastructure to care for injury, understanding how patients use and adapt the formal medical system to meet their needs becomes crucial to guide appropriate investments. This study sought to identify and describe how recently injured Cameroonians move within and between formal and informal care systems and what motivates these transitions.

Methods:  Data was collected using semistructured interviews with recently injured people or their adult family members residing in Southwest Region, Cameroon. Participants were recruited from a larger community based survey on injury using stratified purposeful sampling. Interview contents were regularly reviewed to direct further sampling and assess for theoretical saturation. In total, 39 people participated in 34 interviews. Interviews were recorded, transcribed, and, as necessary, translated from local Pidgin into English. Transcripts were iteratively coded by two research team members to identify major themes.

Results: Despite often viewing formal medical care as the best source for treatment after injury, participants frequently described mixing and matching formal and informal care types and sources. Few injured participants were treated with formal care exclusively, and the majority who engaged with formal care at any point left before completing treatment. Reasons given for leaving formal care included: (a) anticipated costs beyond means, (b) unacceptable length of proposed treatment, (c) poorly supported referral to a larger hospital, (d) unsatisfactory treatment progress or outcome, and (e) belief that traditional methods work additively with formal care [Figure]. Factors that motivated people to engage or remain engaged with formal care included: (a) perceived high severity of injury (b) desire for reliable diagnostic tests (c) social support during hospitalization, and (d) financial support from family or others.

Conclusion: Although cost was an important consideration, participants described a range of factors that influenced their decisions and treatment course. These results provide specific opportunities to improve engagement in formal care, such as clarifing expectations around treatment costs and outcomes, and improving and streamlining inter-facility referrals. Given the frequent use of informal care sources, options for engaging informal providers to encourage timely referral should also be explored. Such changes would build on existing positive views of formal care to improve outcomes and reduce morbidity.

47.01 An Innovative Approach To Quality Improvement On A Trauma Surgical Service

Posted on January 18, 2018

A. Sammann1, L. Z. Chehab1, A. Sammann1  1University Of California – San Francisco,Department Of Surgery,San Francisco, CA, USA

Introduction:  Trauma patient rounds are complex, with a high volume of complicated patients in a dynamic environment with competing priorities and workflows. This presents challenges to improving quality, care experience, and resource use as single-method research approaches fail to comprehensively understand these complex systems. We combined the commonly used lean methodology with human-centered design (HCD), a methodology that is well-established in the technology and design community but novel to healthcare. We used this mixed methods approach to understand factors contributing to care team dissatisfaction on daily patient rounds at a safety-net teaching hospital and level 1 trauma center.

Methods:  HCD uses ethnographic observations and in-depth interviews to understand the challenges and needs facing users of a system. We performed observations to identify 'work-arounds' and conducted 22 interviews with a cross-section of care team members (physicians, NPs, RNs, pharmacists, fellows, residents, students), hospital administrators (bed control, AOD), patients and families. Using lean, we performed time observations of 15 rounds, tracking activities related to flow and classified them as ‘clinically relevant’ and ‘non-clinically relevant.'

Results: The greatest source of dissatisfaction with rounds was the perceived inefficiency by care team members. Lean time observations confirmed that 34.2% of time was spent on ‘non-clinically relevant’ activities. Teaching was minimal and interruptions and clarifications were frequent which disrupted the flow of rounds. Through HCD we discovered that rounds were populated by 3 different groups of users: advocates (patients and RNs); learners (students and interns); and doers (residents, NPs and physicians). Each group had a different set of needs and expectations, resulting in disagreement over the purpose of rounds. Advocates wanted to share the patient perspective and understand the care plan; learners wanted to be educated and contribute to decision-making; and doers wanted to create a care plan without compromising quality of patient care.

Conclusion: By mixing methods using lean and HCD processes, we are able to gain a more comprehensive understanding of the system- and human-centered factors affecting rounds on a trauma surgical service. The system measures efficiency as a function of work and time, and lean demonstrated that our rounding process was inefficient as much of the time spent was on ‘non-clinically relevant’ work. Humans measure efficiency by the speed with which they can get their needs met. If their needs remain unmet, the experience is inefficient and satisfaction remains low. HCD allowed us to understand these subtleties and to classify the different needs of our user groups. To adequately address complex environments, we need to understand the strains on both the system and its users so that we can create sustainable quality improvement programs.

46.18 NIFTP Reclassification and Its Impact on Thyroid Malignancy Rate and Treatment

Posted on January 18, 2018

M. Mao1, T. Joyal2, O. Picado1, D. Kerr2, J. Lew1, J. Farra1  1University Of Miami Leonard M. Miller School Of Medicine,Division Of Endocrine Surgery, DeWitt Daughtry Family Department Of Surgery,Miami, FL, USA 2University Of Miami Leonard M. Miller School Of Medicine,Department Of Pathology,Miami, FL, USA

Introduction: The reclassification of a proportion of follicular variant papillary thyroid carcinoma (FVPTC) to noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) may have significant implications for patients and physicians.  NIFTP may change overall malignancy rates and minimize extent of surgical treatment. This study reviews overall malignancy rate, FNA cytopathology, and treatment of a surgical cohort of patients with a diagnosis of FVPTC reclassified as NIFTP.

Methods: A retrospective review of 847 patients who underwent thyroidectomy at a single institution from January 2010 to April 2016 was performed. Overall rate of thyroid malignancy was determined, and further subdivided into those with papillary thyroid cancer (PTC) and its follicular variant. The subgroup with FVPTC (n=181) was re-reviewed by an endocrine pathologist for reclassification to NIFTP. Thirty-five patients were excluded from the analysis due to inability to retrieve the pathology slides (n=22) or the lesion being too small to assess infiltrative pattern (n=13). Further review of patients reclassified as NIFTP was performed for preoperative FNA cytopathology, extent of thyroidectomy, central neck dissection (CND), and postoperative radioactive iodine (RAI) treatment.

Results: Of 847 patients who underwent thyroidectomy, 495 patients had a thyroid cancer, yielding a 58% malignancy rate. The majority were PTC (n= 454, 92%). FVPTC was identified in 181 patients, of which 146 patients underwent pathology re-review for NIFTP. There were 32 cases (22%) reclassified as NIFTP, reducing the overall malignancy rate to 55%. Within the NIFTP cohort, pre-operative FNA cytopathology revealed the following: 3% Bethesda I, 31% Bethesda II, 35% Bethesda III, 19% Bethesda IV, 9% Bethesda V, and 3% Bethesda VI. Overall, 66% of the NIFTP cohort had Bethesda classifications III-VI. Among NIFTP patients, 16 underwent total thyroidectomy and 16 underwent thyroid lobectomy, of which 12 had completion thyroidectomies (75%). Twenty patients (63%) underwent CND, and 9 underwent postoperative RAI treatment (28%). 

Conclusion: A significant proportion of FVPTC patients were reclassified as NIFTP. The implementation of this classification may decrease overall institutional thyroid malignancy rates.  The majority of reclassified NIFTP cases were from Bethesda III-VI categories, which suggests a need to reassess the predicted malignancy rates within the Bethesda System for Reporting Thyroid Cytopathology (BSRTC) categories. When a NIFTP is found on final pathology, surgeons should regard this diagnosis as an indolent tumor requiring no further surgical or medical treatment as these patients have been shown to derive no long term benefit from completion thyroidectomy or RAI.

 

46.19 IS A THYROID NODULE IN A PATIENT WITH GRAVES' DISEASE ASSOCIATED WITH A HIGHER RISK OF CANCER?

Posted on January 18, 2018

H. H. Shi1, C. R. McHenry1,2  1Case Western Reserve University School Of Medicine,Cleveland, OH, USA 2MetroHealth Medical Center,Cleveland, OH, USA

Introduction:  A thyroid nodule in a patient with Graves’ disease has traditionally been thought to have a high risk of malignancy. The purpose of this study was to determine the frequency of a thyroid nodule in patients with Graves’ disease and the rate of malignancy in patients with a clinically apparent dominant thyroid nodule.

Methods:  A retrospective review of all patients with Graves’ disease who underwent thyroidectomy from 1990-2016 was completed. The number of patients operated on with an associated dominant nodule was determined. Pathology reports were reviewed for documentation of incidental thyroid nodules. Age, sex, nodule size, thyroid uptake and scan, ultrasound findings, and fine needle aspiration biopsy results were determined. Incidental occult papillary microcarcinoma was not considered in the determination of rate of malignancy. Data was analyzed using Student’s t-test and Chi-square test.

Results: There were 218 patients with Graves’ disease who underwent thyroidectomy. 92 (42%) patients had one or more thyroid nodules documented on final pathologic examination of the thyroid gland, including 41 (19%) who had a clinically significant dominant nodule with a mean size of 3.0 ± 2.4 cm that was evaluated preoperatively with fine needled biopsy (n=25; benign 12, AUS 8, follicular neoplasm 3, suspicious for papillary cancer 1 and papillary cancer 1) and/or thyroid scintigraphy (n=18, 16 with a hypo- or isofunctioning nodule).  Patients with a thyroid nodule were older (43 ± 13 yrs vs. 37 ± 11 yrs, p<0.001) and more likely to have an occult papillary microcarcinoma [5 (1%) vs. 1 (1%), p=0.039]. Only 2 (5%) of the 41 patients with a dominant nodule had a clinically significant thyroid cancer.

Conclusion: Thyroid nodules occurred in 42% of patients with Graves’ disease, however, most are incidental and clinically insignificant. Clinically significant nodules were present in 18% with a 5% rate of cancer. Our results show that patients with Graves’ disease and a thyroid nodule do not appear to have a higher rate of thyroid cancer than the general population with a thyroid nodule. 

 

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