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

Posted on January 31, 2019

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

Introduction:

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

Methods:

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

Results:

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

Conclusion:

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

 

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

Posted on January 31, 2019

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

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

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

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

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

52.03 Classifying Preoperative Opioid Use for Surgical Care

Posted on January 31, 2019

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

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

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

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

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

 

52.02 Exploring Barriers to Opioid Disposal After Surgery

Posted on January 31, 2019

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

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

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

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

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

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

Posted on January 31, 2019

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

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

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

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

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

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

Posted on January 31, 2019

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

Introduction:  

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

Methods:

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

Results:

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

Conclusion:

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

51.19 Utility of 3D Laparoscopy in Spleen Conserved Surgery in Traumatic Spleen Rupture

Posted on January 31, 2019

Y. He1, G. Chen1, G. Li1, L. Zou1  1Guangdong hospital of TCM,Zhuhai Campus,GUANGZHOU, GUANGDONG, China

Introduction: To analyze the feasibility and safety of utilizing 3D laparoscopy in spleen repair surgery in acute grade ? /?? traumatic spleen rupture. 

Methods: Retrospective analyze 6 patients with acute impatent abdominal trauma which confirmed grade ?/? traumatic spleen rupture by 3D laparoscopy exploration, and treated with laparoscopic spleen repairment by suture in our center from January 2017 to June2018. We analyzed the parameters of perioperative period and summarized the operative experience.

Results: One patient composed with liver rupture while another with jejunum rupture. All repairments of spleen and other organ by suture under 3D laparoscopy were successfully completed without conversion to splenectomy or open surgery. No patient suffered from postoperative intrabdominal bleeding or need secondary abdominal exploration. The average time for spleen repairment is 24±13min, average amount of abdominal drainage in the first 24hours after surgery is 55±33ml, and average postoperative hospitalization days are 6±2.5 day.

Conclusion: 3D laparoscopy providing more magnified view and guarantee more accurative manipulation which make spleen repairment by suture feasible and safe in a less invasive way for grade ?/? traumatic spleen rupture. Also, any other composing intrabdominal organ impairment is feasible to detect and manipulate with 3D laparoscopy.

51.18 Acute Necrotizing Pancreatitis: Has Conservative Management Replaced Surgery?

Posted on January 31, 2019

F. Mannan1, R. C. Gill1, A. R. Alvi1  1The Aga Khan University Hospital Karachi,General Surgery,Karachi, SINDH, Pakistan

Introduction:
The main purpose of this study was to review the trends in management of patients presenting with acute necrotizing pancreatitis (ANP) over the last seven years and its effect on morbidity and mortality.

Methods:

A retrospective cohort study was conducted on all patients presenting with the diagnosis of acute necrotizing pancreatitis presenting to the Aga Khan University Hospital in between the year 2008 to 2015. The study population was broadly categorized in to two groups based on the way these were managed. The first group consisted of patient who underwent surgery for acute necrotizing pancreatitis while the second group was composed of those who were conservatively managed.  Patient outcomes were assessed in terms of hospital stay, complication rates and in-hospital mortality. Data was analysed using SPSS version 20. Comparison of outcomes between two groups was done using chi-square test, Fischer exact test or t-test wherever applicable. A p-value of less than 0.05 was considered statistically significant.

Results:

A total of n=110 patients were included in the study with 68% (n=75) males and 32% (n=35) females. Nasojejunal route was found to be the most commonly utilized route of feeding in these patients consisting of around 49% (n=54) patients with forty percent (n=44) tolerating direct oral diet. The outcomes in both these groups in terms of hospital stay, complication rate, and in hospital mortality were not found to be statistically significant. The conservative group however was significant in terms of cost-effectiveness which was shown by a p value of (0.035). The management of this clinically important disease over the years showed an increased trend towards conservative approach in our institute.

Conclusion:

Our study further substantiates the recent global trend of conservative approach towards managing patients with acute necrotizing pancreatitis as reflected in the recent available literature. Though both our study groups were comparable in terms of hospital stay, complications and mortality but conservative measures were seen to be more cost effective in the long term.

 

51.17 Application of intraoperative ultrasound in complicated laparoscopic cholecystectomy

Posted on January 31, 2019

L. Guowei1, Z. Liaonan1, H. Yaobin1, C. Guobin1, L. Guowei1  1Guangdong hospital of TCM, Zhuhai Campus,Guangzhou, GUANGDONG, China

Introduction: To measure the biliary tract relationship of gallbladder triangle in complicated laparoscopic cholecystectomy, avoiding right hepatic pedicle and common bile duct injury.

Methods: We analyzed 21 patients with different cholecystitis received laparoscopic cholecystectomy between Jun. 2018 and Jul. 2018 in our center. Intraoperative ultrasound was performed on gangrenous cholecystitis, atrophic cholecystitis, and porcelain gallbladder. The shortest distance between the gallbladder bed and the right hepatic pedicle was recorded, and the complications were recorded.

Results:14 cases of all?gangrenous cholecystitis, the average distance was 0.543±0.062cm, 5 cases of all, the average distance of atrophic cholecystitis was 0.372±0.033cm, 2 cases of porcelain gallbladder, the average distance was 0.34±0.02cm, and the average distance of 21 cases was 0.483± 0.094 cm, no postoperative jaundice and postoperative biliary fistula in all cases.

Conclusion: Intraoperative ultrasound for complex laparoscopic cholecystectomy can avoid the right hepatic pedicle injury and increase the safety of cholecystectomy. It may reduce the risk of postoperative complications.

 

51.15 Post-Operative Biliary Type Symptoms after Cholecystectomy. A Real Entity or just Nuisance Value?

Posted on January 31, 2019

E. Krombholz1, L. G. Collins1, W. Joyce1,2  1Galway Clinic,Surgery,Galway, Ireland 2Royal College of Surgeons,Dublin, Ireland

Introduction:
Right upper quadrant pain (RUQ) can persist after successful laparoscopic cholecystectomy (LC). This can cause patient distress and significant diagnostic and therapeutic challenges.

Methods:
A retrospective review of 210 consecutive patients undergoing cholecystectomy by a single surgeon was completed. Demographics, indication for procedure, type of procedure, final diagnosis and further treatment were reviewed. The presence and etiology of persistent RUQ post-operative pain was evaluated in this patient group.

Results:
The data of 210 patients was assessed. Conversion to open surgery was 4.4% (n=9). Planned open surgery was 1.9% (n=4). There were no postoperative deaths or major complications. 8.37% (n=17) of patients reported persistent RUQ pain post-operatively. Within this patient subgroup, 13 patients underwent LC and 4 patients underwent open surgery. The primary causes of persistent post-operative pain in this patient subgroup were musculoskeletal (53% ,n=9), neuropathic (12%, n=2), common bile duct stone (6%, n=1), and no cause found (12%, n=2).

Conclusion:
This study demonstrated that post-cholecystectomy pain syndrome is a real entity affecting 8% of this study cohort. The primary cause of post-operative pain was found to be musculoskeletal in origin. However for one patient in this cohort, the primary cause of pain was a common bile duct stone. Therefore, it is essential that post cholecystectomy patients with persistent RUQ pain are fully investigated to ensure that biliary pathology is not missed.
 

51.14 Perioperative Management and Outcomes Following Cesarean Section in Rural Rwanda

Posted on January 31, 2019

C. Mazimpaka1, E. Uwitonze1, T. Cherian2, B. Hedt-Gauthier2, R. Riviello2,3, S. Hakizimana1,5, Z. El-Khatib4, G. Magdalena2, K. Sonderman3, C. Habiyakare5, F. Kateera1, T. Nkurunziza1  1Partners In Health,Kigali, KIGALI, Rwanda 2Harvard School Of Medicine,Global Health And Social Medicine,Brookline, MA, USA 3Brigham And Women’s Hospital,Boston, MA, USA 4Karolinska Institutet,Public Health Sciences,Stockholm, STOCKHOLM, Sweden 5Ministry of Health,KIGALI, KIGALI CITY, Rwanda

Introduction: Cesarean sections (c-sections) are essential in reducing maternal and neonatal deaths. There is a paucity of research regarding c-section care and outcomes in rural African settings. This study aimed to describe the characteristics of women receiving c-sections at Kirehe District Hospital (KDH) in rural Rwanda, the clinical care provided to them, and the maternal and neonatal outcomes

Methods: This cross-sectional study included all adult women who are residents of Kirehe District and received c-sections at KDH during April 1-September 30, 2017. Demographic and clinical characteristics of these women were extracted from the mother study dataset, and newborn outcomes data were retrospectively extracted from medical charts. Descriptive analyses were performed and frequency and percentages were reported

Results: Of the 621 women included in the study, most were 25-34 years old (45.7%; n=284), married (42.2%; n=262), had only primary education (67.5%; n=419), and were farmers (75.7%; n=470). Burundian refugees from Mahama Refugee Camp comprised 13% (n=86) of the study population. The most common indication for c-section was a previous c-section (31.9%, n=198), followed by acute fetal distress (30.8%, n=191). About 68% spent 3 days or less at the hospital post-surgery and over 95% did not have any postoperative complications prior to discharge. Approximately 10% of neonates were admitted to the neonatal unit, with the most common reason being neonatal infection (59.6%, n=31)

Conclusion: Our findings shed light on c-section deliveries at a rural district hospital in sub-Saharan Africa. KDH represents a typical rural health facility serving residents with low economic and education level. Unique to KDH catchment population is refugees from Mahama Refugee Camp. Previous c-section as the primary indication for c-section will result in high future demand for this surgery. This highlights the need to explore appropriateness and uptake of Vaginal Birth After Cesarean in rural district hospitals.

 

51.13 Effect of ASA Class 3 & 4 in Elective Inguinal Hernia Repair and Surgical Site Infections

Posted on January 31, 2019

B. A. Farber1,2, D. H. Midura1,2, P. Sreeramoju1,2  1Albert Einstein College Of Medicine,Surgery,Bronx, NY, USA 2Montefiore Medical Center,Surgery,Bronx, NEW YORK, USA

Introduction: Inguinal hernia repair is one of the most common general surgical procedures performed worldwide. The American Society of Anesthesiologists (ASA) physical status classification system is widely used as a system to predict perioperative risk, with ASA class 3 and 4 being high risk for elective surgery. We hypothesized that elective hernia repairs on patients with ASA Class 3 and 4 would have no increased risk of surgical site infections or perioperative morbidity or mortality.

Methods: We performed a retrospective review of National Surgical Quality Improvement Program (NSQIP) data generated from our institution. Data of patients older than 18 years of age undergoing elective inguinal hernia repair between January 2014 and December 2017 was reviewed. Patients were stratified based on American Society of Anesthesiologists (ASA) physical status classification system. Categorical variables were assessed using Fishers exact test.

Results:Two hundred fourteen patients were identified during our study period. Median age was 61 years (Range = 19-94 years) and 91% (n=195) were male. One hundred fifty one patients (71%) were ASA 1-2, and 63 patients (29%) were ASA 3-4. Surgical site infections were not found to be significantly increased when stratifying based on ASA classification 1-2 vs 3-4 (p=0.29). There were no mortalities during our study period.

Conclusion:Elective inguinal hernia repairs are safe, and higher ASA class patients do not experience higher rates of morbidity or mortality. 

 

51.12 Inguinal Hernia Repair Outcomes and Morbidity: Local vs General Anesthesia, A Retrospective Review

Posted on January 31, 2019

J. Favela1, T. Phung2, M. Argo1, S. Huerta1,2  1University Of Texas Southwestern Medical Center,Dallas, TX, USA 2VA North Texas Health Care System,Dallas, TX, USA

Introduction:
Open inguinal hernia repair is one of the most common procedures done around the world and in the United States. While using general anesthesia has been the norm for many years, new anesthetic modalities such as local and regional anesthesia are gaining popularity. This is a retrospective chart review assessing the differences in morbidity as well as operative and perioperative time between local and general anesthesia in open inguinal hernia repairs (OIHR) all performed by a single surgeon at a single Veteran’s Hospital. We hypothesize the use of general anesthesia concurs no benefit when compared to local anesthesia when it comes to overall patient morbidity.

Methods:
A comprehensive chart review of all 1146 patients who underwent an OIHR performed by a single surgeon was completed. Parameters recorded included patient demographics (BMI, age), patient comorbidities, operative times (preoperative holding time, surgical time, operating room time, and Post Anesthesia Care Unit (PACU) time), and postoperative surveillance including (inguinodynia, recurrence, and morbidity). Patient morbidity was subdivided into distinct categories including: wound hematoma, infection, urinary retention, pain, and other. A Chi-Square analysis was completed to assess the difference between inguinodynia, recurrence, and morbidity in the two anesthesia groups. A paired two sample t-test was used assess the difference in operative and perioperative time.

Results:
Based on the analysis we conducted, there is no significant difference in recurrence (p = 0.297), inguinodynia (p = 0.467), or morbidity (p = 0.128) between local and general anesthesia. Within the morbidity group, only wound hematoma was significantly decreased in the local anesthetic group (p = 0.003). A significant decrease in the preoperative and postoperative time was observed when local anesthesia was utilized in place of general anesthesia. On average pre-operative holding times decreased by 16 minutes (p = 0.001). Postoperative (or PACU) time decreased by 37 minutes (p < 0.0001). Operative time decreased by an average of 8 minutes, but this was not statistically significant (p = 0.46).

Conclusion:
While this data set is limited to the experience of a single surgeon at a single hospital, there is sufficient evidence to suggest local anesthesia reduces preoperative and postoperative time and resources. Furthermore, local anesthesia does not appear to be inferior with regards to patient outcomes including: inguinodynia, recurrence, and other complications.
 

51.11 Acute Care General Surgery at a Free-Standing Cancer Center. Are There Any Benefits?

Posted on January 31, 2019

C. R. Ledet1, D. A. Santos1, A. R. Limmer1, H. M. Gibson1, B. D. Badgwell1  1University Of Texas MD Anderson Cancer Center,Surgical Oncology,Houston, TX, USA

Introduction:
Cancer is the second leading cause of death in the United States. Recently, cancer patients have benefited from advancements in both diagnostic tools and therapies, which often extend both disease-free and overall survival.  As a result, a number of cancer patients are living longer with solid and hematologic malignancies.  Cancer patients frequently require general surgical consultation for conditions that arise during their treatment, or as a consequence of therapy.  In addition, general surgeons are frequently consulted for long-term complications of oncologic surgery.  However, acute care general surgery services are infrequently described in cancer centers that are not affiliated with a general hospital.  The purpose of this study was to determine the clinical presentation and management associated with cancer patients requiring acute care general surgery consultation at a free-standing cancer center.

Methods:
We performed a retrospective review of the general surgery consult database at our free-standing cancer center from 10/2015-8/2017.  All patients included in the database are patients that have a suspicion of cancer, actively being treated for malignancy or in long-term surveillance. Clinical, demographic, and treatment variables were extracted for patients undergoing general surgical consultation.  The wait time for outpatient vascular access placement was recorded to evaluate a change during the study period.

Results:
In 2015, the acute care general surgery service was initiated at our institution.  There was a 60% increase in general surgical consults during the study period (212 vs. 542 consults). Over 95% of the general surgical cases were elective outpatient surgeries, while only 2-4% of cases were emergent.  In 2017, almost 50% of the elective cases were comprised of vascular access placement for chemotherapy. With the addition of acute care surgeons, the average wait time for vascular access decreased by more than 50%, median wait time in 2015, 2.2 days ( 1.9-4.3 days) vs. 0.96 days (0.56-2.33 days) in 2017.  Open and minimally invasive inguinal, umbilical, parastomal and ventral hernias constituted 21% of the surgical practice followed by cholecystectomy (with/ without intraoperative cholangiogram) which comprised 10% of cases.  Other common indications for consultation that were less than 10% of the practice included excisional lymph node biopsies for disease diagnosis, splenectomy, skin and soft tissue excisions and feeding tube access. 

Conclusion:
 Acute care general surgeons play a unique role at dedicated cancer centers by providing surgical expertise for cancer patients during their diagnosis, treatment, and survivorship period.  This study demonstrates the service viability and increased efficiency of general surgeon integration into a free-standing cancer center.      

 

51.10 Perianal Abscess: When Should Surgeons Get Involved?

Posted on January 31, 2019

S. Shraga1, O. Zayko1,2, B. Silverstein1, A. Gruessner1, T. Schwartz1  1Kings County Hospital Center, Brooklyn, NY, USA 2SUNY Downstate, General Surgery, Brooklyn, NY, USA

Introduction:

Perianal abscess is a common presenting complaint in the Emergency Department. Incision and drainage(I&D) is the standard of care for this disease. Despite adequate drainage there is a high recurrence and complication rate. In our busy inner city hospital, emergency physicians(ED) as well as general surgeons(GS) perform bedside I&D of perianal abscesses. Our aim is to analyze differences in patient demographics, management and outcomes based on type of provider performing I&D. 

Methods:

 A retrospective review of electronic medical records(EMR) of patients with bedside drainage of perianal abscess over a five year period(2010-2016). EMR’s were reviewed to evaluate differences in patient demographics and outcomes for those with drainage done by ED versus GS. Statistical analysis was done using chi-square and Fisher’s exact tests. Multivariate analysis was used to build predictive models.

Results:

Of 220 patients with perianal abscess 120 were drained at bedside; 97 were drained by GS and 23 drained by ED. Patients drained by ED were younger(p=0.02) and with less systemic signs of infection such as fever(p=0.01). The ED were more likely to use packing(p=0.01) and intravenous antibiotics(p=0.09). ED drainage had increased risk for thirty day complication(OR=10.1)  and thirty day readmission(OR=5.1) using a model that adjusts for patient factors.

Conclusion:

While patients with perianal abscess treated by surgery tend to be sicker; they are less likely to have post procedure complications and readmission.

 

51.09 Mortality of Non-trauma Emergency Laparotomy in an Acute Care Surgery Center.

Posted on January 31, 2019

A. D. Shahait1, A. D. Hollenbeck1, D. Kristl1, H. Dolman1, J. D. Tyburski1, G. Mostafa1  1Wayne State University,General Surgery,Detroit, MI, USA

Introduction:  Emergency laparotomy (ER) is a common operation that deals with a wide range of pathologies. Preoperative optimization is often lacking due to the urgent nature of the disease process. Multiple studies have shown a mortality rate of 14% in ER compared to 1.5-9.8% in elective operations. In this study, we review the outcome of ER at our academic acute care surgery center.

Methods:  A retrospective analysis of all adult patients who underwent non-trauma ER, between January 2008 to December 2013 was conducted. Data included; demographics, clinical features, preoperative laboratory, comorbidities, time to surgery, ICU admission, and 30 & 90 days mortality.     

Results: A total of 234 patients [123 male (52.6%), 111 female (47.4%)] were included. ER was performed within 4 hours (immediate) of presentation in (93) 39.7% ,within 4-12 hours (early) in (53) 25.4%, and within 12-24 hours (late) in (63) 30.1% of patients. Overall mortality was (16) 6.8%, and (15) 6.4% at 30 and 90 days, respectively. Both 30-day and 90-day mortality were significantly higher with chronic obstructive pulmonary disease (p=0.014), blood transfusion (p <0.001), ICU admission (p<0.001), Ventilator days > 4 (p=0.013), hyperlipidemia (p=0.014), heart rate > 90 beat/minute (p=0.003), temperature >38 C or <35 C (p=0.013) and Systolic blood pressure < 90 mmHg (p<0.001). The timing of surgery, gender, age >75 years, ethnicity, cardiovascular diseases, smoking, and body mass index had no impact on mortality.

Conclusion:  ER can be performed with lower mortality than previously reported. Specific predictors of mortality are identified that could improve optimization and be used for risk assessment.

51.08 Evolution of a Scale Based Pay Plan for an Academic General Surgery Division

Posted on January 31, 2019

E. W. Nelson1, M. C. Mone1, C. Ward1, S. R. Finlayson1  1University Of Utah,General Surgery/Surgery,Salt Lake City, UT, USA

Introduction: In response to internal and external pressures to be sustainable, equitable, and transparent, faculty pay models in academic surgery have been evolving.  This review examines the transition from a purely incentive based model to a scale based pay plan and the effects on clinical productivity as measured by relative value units (RVUs) as well as possible impact on recruitment, attrition, compensation, and sustainability.

Methods:  Over a three year transition period (7/2015-6/2018) an academic division of general surgery converted from a purely incentive based pay model to a scale based model.   Beginning on July 1, 2015, faculty salaries of 18 academic general surgeons were renegotiated and fixed at or near the average of the previous four fiscal years, July 2011 – June 2014.  Two full time VA faculty and three faculty with administrative positions were not included.  Over the next 18 months, a graduated scale based on rank and years in rank was developed using 50th % AAMC salary guidelines with refinements for subspecialties based on national standards including AMGA, SVC, and MGMA.  When the scale was implemented on Jan 1, 2017, all faculty salaries above scale were frozen at that level and salaries below scale were adjusted half way to scale with eventual adjustment to full scale pending financial sustainability for the entire group. For comparison, incentive based years included fiscal years 2011 to 2015 and pay scale years were fiscal years 2016-2018. When calculating RVU averages per year, years worked by surgeons included partial years based on date of hire and separation.

Results: On January 1, 2017, when compared to the salary scale, twelve faculty (6 males and 6 females) had previous salaries that were below scale and had annualized adjustments half way to scale.  Overall, adjustments averaged $15,345 with a maximum of $60,000.  Additional salary adjustments for males averaged $11,403 and $19,087 for females.  Between fiscal year 2011 and fiscal year 2018 the division grew by 160%, from 10 (8 males and 2 females) to 26 (16 males and 10 females).  New faculty salaries were determined on scale based on previous academic rank and years in rank.  Over the same period, 5/30 faculty left the division only one of whom had been placed on the salary scale; two recruited to other academic programs, two into private practice, and one transferred to another division. Based on the growth in faculty size, total divisional RVU’s grew from 65,063 in 2011 to 164,096 in 2018.  However, when comparing incentive based years to pay scale years, per faculty average RVU’s/year decreased by 5.5% (7347 vs 6943).

Conclusion: Transition from an incentive based salary plan to a scale based model has had only modest effect on surgeon yearly RVU productivity and faculty attrition.  While the transition to full scale of all faculty awaits financial sustainability, exceptional diverse growth through recruitment has been maintained.

 

51.07 Psoas Muscle Area Predicts Acute Respiratory Distress Syndrome in Acute Pancreatitis

Posted on January 31, 2019

P. Kandagatla1, A. Hodari Gupta1, D. Abbass1, C. Fisher1, B. Knisely2, R. Cho2, N. Schmoekel1, J. Stassinopoulos1  1Henry Ford Health System/Wayne State University,Department Of Surgery,Detroit, MI, USA 2Henry Ford Health System/Wayne State University,Department Of Radiology,Detroit, MI, USA

Introduction:

            Acute Respiratory Distress Syndrome (ARDS) is a serious complication of acute pancreatitis. However, limited literature exists pertaining to patient characteristics that can help predict the development of ARDS among patients with acute pancreatitis. Sarcopenia, based on psoas muscle area on imaging, has been predictive of outcomes after surgery. We hypothesized that sarcopenia would correlate with the development of ARDS in patients admitted for acute pancreatitis.

Methods:

            We performed a retrospective study of patients that were admitted to the ICU for acute pancreatitis at our institution. Patients that did not have a CT of their abdomen were excluded from the study. Patient characteristics including demographics, medical history, BMI, labs at admission, and functional status were collected. An average psoas muscle area for each patient was calculated at the level of L3 and standardized to their height. Sarcopenia was determined by gender-based cutoffs of the psoas areas. We then performed both univariate and multivariate analysis to determine significant covariates in the development of ARDS.

Results:

            We included 218 patients in the study. Of these patients, 32 (14.7%) developed ARDS. In univariate analysis, there was no significant difference in the proportion of patients with ARDS that were sarcopenic (50.0% vs 35.7%, p = 0.12). The mean age was significantly higher in those that developed ARDS (58.0 vs 47.3, p<0.01). There was no difference in gender (59.4% male vs 55.9%, p = 0.72), mean BMI (30.1 vs 29.1, p = 0.52), mean albumin (2.71 vs 2.85, p = 0.48), and mean serum creatinine (2.01 vs 1.52, p = 0.14). Patients with ARDS had a higher proportion of biliary etiology (38.7% vs 14.9%, p < 0.01, history of coronary artery disease (21.9% vs 11.4%, p = 0.01) and COPD (25.0% vs 10.3%, p = 0.02). Patients that developed ARDS also had a lower proportion of functionally independent patients (54.2% vs 80.9%, p<0.01). In multivariate analysis, the only significant predictors for ARDS were the presence of sarcopenia (OR = 5.15, 95% CI: 1.23-21.49) and a history of COPD (OR = 6.60, 95% CI: 1.46-29.96).

Conclusion:

            In our single institute retrospective study, we have found a significant relationship between the presence of sarcopenia based on psoas muscle area and the development of ARDS. Further research on utilizing this simple measurement to risk-stratify patients with acute pancreatitis is warranted.

51.06 Development of an Automated Digital Surgical Safety Checklist to Reduce Surgical Errors

Posted on January 31, 2019

J. Langell1,2,3, J. Ferraro1, M. Young1, C. Mi1, Y. Deng1, C. Swensen1, J. Langell1,2,3  1University Of Utah,Center for Medical Innovation,Salt Lake City, UT, USA 2University Of Utah,Department Of Surgery,Salt Lake City, UT, USA 3VA Salt Lake City Health Care System,Center of Innovation,Salt Lake City, UT, USA

Introduction:

Preventable surgical errors occur in 3-16% of surgeries worldwide and account for >1 million deaths per year. These include wrong site surgeries, wrong procedure, wrong patient, incorrect implant and other so called “never events”. The use of surgical safety checklists (SSC) as a tool to improve surgical communication and planning have been shown to be effective in reducing preventable surgical errors in numerous research studies. Outside of monitored research studies, the effectiveness of SSC drops substantially due to provider complacency and poor compliance.  

Methods:  

We conducted a literature review on surgical safety checklist efficacy and compliance issues and performed observational checklist usability studies and stakeholder review sessions. Output from these reviews and studies were used as design inputs for the development of an automated, digital surgical safety application.  Iterative usability testing and human factors design analysis were then performed on the completed product with input from multiple surgeons, anesthesiologist, nurses and surgical technicians. 

Results: 

A literature review on surgical checklists noted concerns with team engagement, checklist compliancy, lack of participation, failure to complete the entire checklist and lack of accountability and ownership. Our internal analysis demonstrated similar findings, in addition we found that many checklist items were filled out in advance, especially the post-procedure portions. Stakeholder analysis highlighted a need for 1) automation of patient identification, critical characteristics, procedure performed and operative location verification 2) a need to increase team engagement and accountability 3) prevention of user complacency and compliance errors. Data acquired through these studies were used as design inputs to produce a fully functional automated, digital surgical safety checklist application. The final product provided a user-centered design with automated patient identity feature via scannable QR code technology, provided mistake proof checklist question progression and completion, increased team engagement through large monitor projection, and increased accountability through signature capture and electronic medical record documentation. A final usability analysis of the application received uniformly positive feedback for adoption and use by all clinical team members.

Conclusion:

Current paper-based surgical safety checklists suffer from use complacency, poor compliance, low provider engagement and lack of accountability.  Automated digital surgical safety checklist may provide a solution to overcome these barriers and improve the impact of surgical checklists in reducing surgical errors due to poor communication and planning.  

51.05 Local vs. Other Forms of Anethesia for Open Inguinal Hernia Repair: A Meta-Analysis of RCTs

Posted on January 31, 2019

M. B. Argo1, J. G. Favela1, S. Huerta1  1University Of Texas Southwestern Medical Center,General Surgery,Dallas, TX, USA

Introduction: There continues to be variation in the choice of anesthetic technique for open inguinal hernia repair (OIHR) worldwide, which seems to be guided by patient’s satisfaction and surgeon’s preference. The factors determining the use of local anesthetic (LA) compared to spinal (SA) and general (GA) anesthesia remains equivocal as previous data has compared either SA or GA [all others (AO)] to LA. We hypothesize that outcomes and operative room times are superior with LA compared to AO for the repair of OIHR. The present study is an analysis of all randomized controlled trials (RCTs) in patients undergoing OIHR comparing LA to AO.

Methods:  PubMed, MEDLINE, Ovid syntax from 1949 to Jan 2018 , the Cochrane Library, Google, ang Google Scholar were reviewed by two independent reviewers following PRISMA guidelines. We identified 73 potential manuscripts, following exclusion of papers that were not OIHR, did not include anesthesia type, and non-randomized trials, 16 RCT’s were available for inclusion. The parameters evaluated were short-term complications (urinary retention, wound infections, and hematomas), patient satisfaction, length of hospital stay (LOS), total surgical time, total operating room time, and postoperative pain. Review Manager 5.3 was used to test for overall effect between the included studies. 

Results: The use of local anesthesia was favored in the majority of analyses. Overall complication rate favored LA (p=0.12), but only urinary retention was significantly decreased in LA (p=0.002). Both wound infection (p=0.12) and hematoma (p= 0.67) favored OA. Patient satisfaction favored the use of LA (p=0.10). Total surgical time was increased in LA versus OA (p = 0.86; 95% CI [-7.2,8.6]), but the overall operating room time was significantly decreased when LA was used (p<0.001; 95% CI [-18.4,-7.1]). Seven of the ten studies that recorded LOS reported a significant decrease when LA was used.  

Conclusion: This meta-analysis demonstrates that LA is a well-tolerated anesthetic approach for OIHR.  OR times and urinary retentions are significantly improved with LA vs.AO.  LA improves the economic burden by decreasing operating room time and decreasing overall intraoperative and early postoperative costs, which is significant for a procedure performed so frequently.   

 

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