93.17 Seatbelt use in females of child bearing age at an urban safety-net level one trauma center

Posted on January 31, 2019

D. Scantling1,2, A. Schmidt1,2, A. Saif1,2, M. Jankowski1,2  1Drexel University College of Medicine,Department Of Surgery,PHILADELPHIA, PA, USA 2Hahnemann University Hospital,Trauma And Surgical Critical Care,PHILADELPHIA, PA, USA

Introduction:
Safety restraint system use is known to improve maternal and fetal outcomes in pregnant females. Factors associated with seatbelt use in females of childbearing age are largely unstudied despite global public health endeavors to increase use. We sought to uncover risk factors for not using a restraint system in this vulnerable cohort.

Methods:
A retrospective chart review of all female patients aged 15 to 35 years presenting from 2007-2017 was performed using our institutional level one trauma database. Age, pregnancy, insurance status (commercial/private, Medicaid plan and uninsured) and race were examined in unmatched data. A matched cohort was created based upon age, race and insurance status with blinding to belt use during matching (2 non-pregnant to 1 pregnant). Differences in restraint use were then examined using Mann-Whitney U and Fisher’s exact test.

Results:
779 patients met inclusion criteria, of which 140 were pregnant. In unmatched data, there was no difference in belt use with regard to age, race or insurance type. Overall belt use was 59%. 25% of patients were uninsured and 39% utilized a Medicaid plan. Pregnant patients were statistically more likely to wear belts (71% vs 57%, p = 0.0031). In matched data, this difference was upheld (71% vs 58.4%, p = 0.017).

Conclusion:
Pregnancy may have induced increased seatbelt use and safe behavior in our population. More study is needed to confirm our findings. Overall restraint use is quite poor in our population and these patients stand to benefit from additional public health education programs.
 

93.14 Various Approaches For Community Consultation In An EFIC Trial

Posted on January 31, 2019

J. M. Podbielski1, E. E. Fox1, J. B. Holcomb1, J. A. Harvin1, C. E. Wade1  1McGovern Medical School at UTHealth,Surgery/McGovern Medical School,Houston, TX, USA

Introduction: Clinical trials in trauma often require the use of exception from informed consent (EFIC). Despite federal regulations for emergency research under EFIC existing for 20 years, there is little information about EFIC best practices in the literature. In our extensive experience coordinating multicenter randomized trials in trauma populations, EFIC requirements regarding community consultation and public disclosure and the interpretation of the requirements by local institutional review boards (IRB) vary widely. This analysis describes the variation in community consultation and public disclosure activities in one multicenter trial.

Methods: 12 North American Level 1 trauma centers participated in the Pragmatic, Randomized Optimal Platelet and Plasma Ratios Trial (PROPPR) utilizing the EFIC process. The sites were required to conduct community consultation and public disclosure based on their local IRB requirements. The clinical coordinating center provided templates for a power point presentation for in-person meetings, script for telephone surveys and a press release to all sites to revise as needed for their site-specific IRB requirements. All results were reviewed by the local IRBs and HRPO prior to final approval to begin enrollment. 

Results:67% of the responding centers’ local IRBs required more than one method to complete the community consultation process. The number of methods required ranged from 2 to “as many as possible” with an average of 4. Methods included in-person meetings, telephone surveys, social media (Facebook and/or Twitter), presentations at community events (festivals, health fairs), radio and TV interviews, advertising, articles, websites, and flyers or advertisement in public areas (buses, subways, schools, fitness centers). The most frequently used method was printed media formats (75%) followed by in-person meetings (67%), and advertisements and websites (58% each). 50% utilized social media and telephone surveys. The average time from initiation of community consultation to final approval after community consultation was completed was 116 days with a range from 62 to 204 days. Costs ranged from $0 to $30,000 with a mean of $10,600, not including personnel effort. The research coordinators concluded that social media and booths/presentations at community events are the most effective way to reach a larger percentage of the general population.

Conclusion:High levels of variation in community consultation/public disclosure methods and costs related to EFIC exist among institutions participating in a multicenter trial. Providing information to as many people as possible is essential therefore using multiple methods of notification can expedite the process and possibly reduce cost and effort.  

 

93.13 Significant Decrease in Focus Found in Surgeons After Shift Work

Posted on January 31, 2019

Y. P. Puckett1, T. Pham1, R. Richmond1, C. Ronaghan1  1Texas Tech University Health Sciences,Surgery,Lubbock, TX, USA

Introduction:  Eye-tracking is a research tool that is more accessible than ever. Eye movement recordings can provide dynamic measurement of a person’s visual attention and focus. We performed a prospective analysis on physician focus and attention before and after a shift utilizing a low-cost, visual tracking device. 

Methods:  Single institution prospective study was performed on surgical residents and attending physicians (APs). The visual tracking device was utilized to compare differences in attention before and after 12 and 24 hour surgical residency shift to assess for possible neurological impairment. The test stimulus is a target that moves clockwise in a circular trajectory for 10 seconds. Pupil tracker is utilized to measure focus and attention. Classifications of the test results ranged from 1-4 (Low Average (1.0), Average (2.0), High Average (3.0), Superior (4)). Paired t-test was used to assess for statistically significant difference. 

Results: A total of 21 subjects were tested before and after a 12 or 24 hour shift of clinical duties. Females comprised 61.9% of the population. The mean age was 33.7 (SD9.5). PGY-1 accounted for 52.4% of population, PGY-2 (9.5%), PGY-3 (4.8), PGY-4 (19.0%) and APs (14.3%). Focus score overall decreased by a mean of 0.62 or 22.8% for all physicians. APs had the biggest score drop (49.8) %, followed by PGY-4 (25%). There was no statistically significant difference in focus between a 12 and 24 hour shift. Clinicians over age 30 had a mean score decrease of 0.786 (28%) (p=0.010) while those younger than 30 had a decrease in focus score of 0.289 (10.9%) (p=0.456).

Conclusion: Senior surgical residents and attendings appeared to be impacted by shift work the most while junior residents displayed resilience in focus during call. There may be a trend in decline of focus and attention span with increasing age. Future work will focus on correlating physician burnout with declining attention scores.

 

93.12 Evaluation of Noninvasive Hemoglobin Measurements in Trauma Patients: a Repeat Study

Posted on January 31, 2019

G. B. Jost1,3, C. E. Wade1,2,3, L. J. Moore1,2,3, J. M. Podbielski1,3, M. D. Swartz1,4, J. B. Holcomb1,3  1McGovern Medical School at UTHealth,McGovern School Of Medicine,Houston, TX, USA 2McGovern Medical School at UTHealth,Memorial Hermann Red Duke Trauma Institute,Houston, TX, USA 3McGovern Medical School at UTHealth,Center For Translational Injury Research,Houston, TX, USA 4McGovern Medical School at UTHealth,School Of Public Health,Houston, TX, USA

Introduction:
Reliable, accurate, and non-invasive hemoglobin measurements would be useful in the trauma setting. The aim of this study was to re-examine the ability of the Masimo Radical 7 in this setting after recent hardware and software improvements.

Methods:
Level 1 Trauma patients were prospectively enrolled in the study over a 9-month period with the goal of obtaining 3 paired data points from 150 patients admitted to the ICU or IMU. Hospital laboratory hemoglobin values were compared with cyanomethemoglobin (HiCN) and Masimo device hemoglobin values using comparison plots and Bland-Altman analysis.

Results:
A total of 380 patients were enrolled in the study with 150 of those being admitted to the ICU or IMU. Comparison of hospital lab hemoglobin and HiCN (n = 494) found a correlation of R2 = 0.92. Comparison of ICU and IMU hospital lab hemoglobin and Masimo device hemoglobin (n = 218) found a correlation of R2 = 0.27. Bland-Altman analysis of the 218 ICU and IMU hospital hemoglobin and Masimo device hemoglobin values had a bias of 0.505 g/dL with 95% of values within the limits of agreement of 4.06 g/dL to -3.60 g/dL.

Conclusion:
The Masimo Radical 7 device has the potential to provide timely, useful clinical information, but it is not currently able to serve as an initial noninvasive diagnostic tool for trauma patients. There was poor correlation between hospital lab hemoglobin and Masimo device hemoglobin, and because of that, the Masimo Radical 7 should not be used to evaluate hemoglobin levels in trauma patients to guide care.
 

93.09 Surgery for Breast Cancer: Locally Advanced Breast Cancer Management in Myanmar, a Developing County

Posted on January 31, 2019

S. Myint1, T. Lwin1, A. L. Kushner2,3, W. Yee1, K. Khaing1, S. Mon1, T. Lwin1  1university of medicine (1), Yangon,Department Of Surgery,Yangon, YANGON, Myanmar 2Columbia University College Of Physicians And Surgeons,New York, NY, USA 3Johns Hopkins Bloomberg School Of Public Health,Department Of International Health,Baltimore, MD, USA

Introduction:
Breast cancer is a global problem and management in low income countries is difficult. Myanmar, with a population of 60 million is one of the poorest. Most surgical care is performed in the capital Yangon. To improve breast cancer care, we evaluated the management of locally advanced breast cancer (LABC).

Methods:

Patient charts for surgical admissions with a diagnosis of breast cancer from January 1 to December 31, 2013 at the Yangon General Hospital and the New Yangon General Hospital were reviewed. Data were recorded for patients with a diagnosis of LABC.

Results:
A total of 225 breast cancer patients were identified with 105(47%) diagnosed with LABC. Thirty two (30%) were younger than 45 and 7 (7%) older than 65. Biopsy was: fine needle in 10, incisional biopsy in 36, core needle in 50, and wedge biopsy in 9. On histology, 90(86%) invasive ductal carcinoma and 15(14%) invasive lobular. Estrogen receptors were positive in 46%, progesterone receptors positive in 44% and Her2µ positive in 45%. All patients underwent a mastectomy. Adjuvant therapy was given to 80, neo-adjuvant to 10 and 28 had hormonal. Postoperatively 34 developed a seroma and 7 had a surgical site infection.

Conclusion:
LABC contributes to a large proportion of breast cancer cases in Myanmar leading to significant surgical morbidity. With earlier diagnosis morbidity and mortality can be reduce. Breast cancer awareness should be promoted and screening programs warrant exploration. Also ongoing evaluation of surgical care for these patients and additional research is warranted.
 

93.08 Gender Equity in International Surgical Outreach: 10 Years of Mission Volunteers

Posted on January 31, 2019

V. Padmanaban1, A. Tran1, A. Gore2, P. Johnston1, S. Pentakota1, Z. C. Sifri1  1New Jersey Medical School,Department Of Surgery,Newark, NJ, USA 2University Of Colorado Denver,Department Of Surgery,Aurora, CO, USA

Introduction:  

Opportunities for the provision of surgical care in resource-poor settings are increasingly available to surgical residents and attending surgeons. While substantial gender inequity exists in the surgical workforce, these disparities are not described in the arena of surgical outreach. Therefore, we aim to study the contributions of female surgical attendings and residents to short term surgical missions (STSMs) in a single volunteer non-governmental organization over 10 years.

Methods:  

We performed a comprehensive review of STSMs conducted by the International Surgical Health Initiative (ISHI) from 2009-2018. Volunteer surgeons, anesthesiologists, emergency and medical physicians, and nurses were recruited from academic and non-academic institutions throughout the country.

Volunteer data was organized by gender, trainee status, site of mission, number of missions completed and duration of service. Mission sites included Guatemala, Haiti, Peru, Philippines, Bangladesh, Sierra Leone, and Ghana. Data was analyzed based on gender distribution at an individual level and a volunteer-mission level. Chi-square tests for categorical variables and Wilcoxon two-sample t-tests were used to analyze mission participation.

Results:

We studied a total of 23 STSMs carried out by ISHI volunteers over a period of 10 years. All 227 volunteers were included, 139 (61%) of whom were female. Non-surgical volunteers including anesthetists, internists, emergency physicians, and nurses were more likely to be female compared to surgical volunteers as an aggregate of attendings and residents (67% vs. 41%, p < 0.01). Nurses comprised the largest subgroup of volunteers, with 96 (42%) in total, of whom 82% were female. Of 22 surgical attendings, 8 (36%) were female; of 37 surgical residents, 18 (49%) were female with no significance noted on statistical comparison.

There were no gender differences noted by predilection for mission location. No gender differences were observed by average of missions completed or propensity for repeat missions (defined as greater than one mission). On subset analysis of mission participation by surgical volunteers, female surgical volunteers completed an average of 1.6 missions, while their male counterparts completed 2.1 missions, with no significant difference.

Conclusion:

Overall, female volunteers contribute substantially to surgical missions, representing over half the volunteers. Non-surgical volunteers are more likely to be female compared to surgical volunteers, in part due to the number of female nurses. Female surgeons contribute in parity with male surgeons when examining number of missions and propensity for repeat missions. This study found no gender inequity among surgical volunteers in this humanitarian organization. Additional studies of other surgical non-governmental organizations are needed to confirm these findings.

93.06 Global Health Conundrum: Ethnic Diet and Diverticular Disease Burden

Posted on January 31, 2019

K. Lung1, J. Yun2, D. Vyas1,3  1California Northstate University College of Medicine,Elk Grove, CA, USA 2Touro University of California,Vallejo, CA, USA 3San Joaquin General Hospital,Department Of Surgery,French Camp, CA, USA

Introduction:  Diverticular disease (DD) is among the most prevalent conditions in Western societies with incidence steadily increasing worldwide, resulting in mounting financial burden to healthcare systems globally. With this comes a notable rise in the total costs and hospitalizations attributable to DD. Once considered a phenomenon of Western cultures, DD has been increasingly documented in countries with historically low prevalence rates, such as Japan and Thailand. In today’s society, the blending of various ethnic cultures and diets across the globe has obfuscated our previous understanding of DD prevalence trends internationally. With the rise of DD worldwide, it is increasingly important to assess its prevalence, especially in non-Western societies where there is a growing influence of a Westernized diet.

Methods:  Literature search was performed using Pubmed, MEDLINE, and Scopus databases using MeSH terms: ‘diverticular disease’, ‘diverticulosis’, ‘diverticulitis’, and ‘dietary fiber’ with the Boolean operator ‘AND’ (all synonyms were combined with the Boolean operator ‘OR’). DD was defined as complications due to colonic diverticulosis, including lower gastrointestinal bleeding, inflammation, abscess, fistula, perforation, and death, as diagnosed via CT scan, barium enema, or histology post-operatively. Articles describing patients with surgical findings consistent with colorectal cancer were excluded. Retrospective and prospective population studies were used to determine prevalence in Western and non-Western countries.

Results: Data for DD prevalence rates of major nations (patients > age 50) were categorized as high (>40%), moderate (20-39%), low (5-19%), and very low (<5%). Countries with the highest prevalence were the most industrialized nations, notably the United Kingdom (47%) and the United States (41.7%). Japan (20.3%) and Thailand (28.5%) had moderate prevalence rates, while South Korea (12.1%), Mexico (6.65%), and Kenya (5.3%) recorded lower overall prevalence. China (1.97%) and India (4.4%) had the lowest prevalence rates. 0.77% of the global population are considered to have high DD prevalence (>40%), while 0.19% are considered to have very low DD prevalence (<5%).

Conclusion: With increasing global immigration and cultural and dietary assimilation, the etiology of DD, once considered related to ethnic dietary patterns, is called into question as possible genetics may be at play. Long-term this may influence the current prevalence trends, hence, it is important to identify potential factors that may mitigate DD incidence in high prevalence countries, while tempering possible increases within the low prevalence countries.

 

93.05 Risk Factors for Length of Stay and Readmission in Rural Ghana

Posted on January 31, 2019

D. J. Morrell1, B. S. Hendriksen1, L. Keeney1, X. Candela2, T. E. Arkorful4, P. Ssentongo5, R. H. Darko4, J. S. Oh1, C. S. Hollenbeak3, F. Amponsah4  1Penn State Health Milton S. Hershey Medical Center,Department Of Surgery,Hershey, PA, USA 2Penn State University College Of Medicine,Hershey, PA, USA 3The Pennsylvania State University,Department Of Health Policy And Administration,University Park, PA, USA 4Eastern Regional Hospital,Koforidua, EASTERN REGION, Ghana 5The Pennsylvania State University,University Park, PA, USA

Introduction:
Increased length of stay (LOS) and readmission represent significant economic burden on patients and families faced with surgical disease in low- and middle-income countries given limited surgical access, infrastructure, and variable insurance status. This study aims to identify risk factors of LOS and readmission in order to better direct future interventions in postoperative care in rural Ghana.

Methods:
Data for exploratory laparotomy procedures were obtained from surgical case logs collected at a regional referral hospital in Eastern Region, Ghana from July 2017 to June 2018. This information was compared with the hospital electronic medical record to collect demographic data, laboratory values, and outcomes. Multivariable analyses were used to model LOS and readmission controlling for potential confounders.

Results:
The study included 346 exploratory laparotomy procedures (286 adult, 60 pediatric) for various surgical diseases. Average age at surgery was 40 and males accounted for 65% of all procedures. 40% of patients were uninsured. Hemoglobin levels were measured on admission for 71% of patients and 44% of those patients were anemic. The major indications for surgery were appendicitis (31%), intestinal obstruction (23%), perforated peptic ulcer disease (12%), and trauma (7%). The overall LOS for adult and pediatric patients were 7.2 and 6.9 days respectively. Surgery for intestinal obstruction and major abdominal trauma resulted in increased LOS by 4.6 and 4.1 days respectively (p<0.001, p=0.031). Anemia increased LOS by 3 days (p=0.002). Rate of readmission for adults was 9.4% and 8% for pediatric patients. Patients with national health insurance had 2.7 times greater odds of being readmitted (OR=2.7, p=0.04) and those with anemia had 3.9 times greater odds of being readmitted (OR=3.9, p=0.002).

Conclusion:
Anemia represents a risk factor for both increased length of stay and readmission. Major abdominal trauma is also a risk factor for increased LOS. Future interventions aimed at preventing and treating anemia and improving trauma care may decrease some of the post-operative burden placed on patients and their families.

93.04 Eliminating the learning curve: the case for the recessed video stylette in global surgery.

Posted on January 31, 2019

A. N. Bowder2, R. Amin1, L. McCormick3, S. Siddiqui1,3  1Children’s Hospital Of Wisconsin,Pediatric Surgery,Milwaukee, WI, USA 2Medical College Of Wisconsin,General Surgery,Milwaukee, WI, USA 3Brio Device,Ann Arbor, MICHIGAN, USA

Introduction: There is a paucity of anesthesia providers worldwide. This severe shortage in the global surgery workforce has left billions of people without access to surgical care. A recent study by the World Federation of Societies of Anesthesiologists surveyed 153 countries and found there to be a limited number of physician anesthesia providers (PAP) in low and middle-income countries (LMICs). In the African and South East Asian Regions alone, there are on average 1.36 and 1.20 PAP. The global community continues to search for innovative solutions aimed at safely decreasing the discrepancy between anesthesia providers and the burden of surgical disease. We propose that the creation of an intuitive and safe intubation tool could be integral to increasing the anesthesia workforce globally.

Methods: We performed an IRB-approved single center prospective comparison of mannequin intubation by medical students using an articulating video stylet (AVS) and the Olympus bronchoscope. The device used first was alternated between consecutive participants to account for any learning effect.  Five successful intubations were completed with each device.  Time to intubation was measured from when the participant picked up the instrument until the tip had passed beyond the vocal cords.  The number of passes to successful intubation was also recorded.

Results:A total of 19 participants were recruited. The learning curve was noted to be less steep with the AVS (Table1). Intubation time was significantly shorter with use of the AVS. The mean intubation time for the AVS was on average 25.2 seconds less than for the bronchoscope (P<0.0001).  Additionally, more than one attempt were only required in 6% of the intubations using AVS compared to 18% with the bronchoscope (P=0.0057).

Conclusions:This study demonstrates the feasibility of creating an intubation device with little to no learning curve when performed in a standardized mannequin. These results merit continued development. We also will need to complete larger research trials aimed at validating our findings and evaluating the clinical safety of this device. If we are able to prove that the AVS is able to safely, decrease the learning curve in the clinical setting it has the potential to address the shortage of anesthesia providers promptly. Over fifty percent of countries surveyed reported 4 or more years of training required for a PAP. If we are able to decrease this training time even slightly we can make great strides towards reducing the overall burden of surgical disease. Furthermore, this innovative technology can be used by the global community as they develop sustainable task shifting models for non-physician anesthesia provide in LMICs

 

93.02 Geriatric Trauma in Santa Cruz, Bolivia

Posted on January 31, 2019

E. Ludi1, E. Foianini2, J. Monasterio3, S. South1, M. Boeck4, M. Swaroop1  1Feinberg School Of Medicine – Northwestern University,Division Of Trauma And Critical Care,Chicago, IL, USA 2Clinica Foianini,General Surgery,Santa Cruz De La Sierra, SANTA CRUZ, Bolivia 3Gobierno Departamental Autónomo,Department Of Health,Santa Cruz De La Sierra, SANTA CRUZ, Bolivia 4University Of California – San Francisco,Division Of Trauma And Critical Care,San Francisco, CA, USA

Introduction: Worldwide, the population older than age 60 years is expected to double by 2050 and triple by 2100. Those greater than 80 years old are expected to triple by 2050 and increase by seven times in 2100. The aging population of Latin America is predicted to increase from 7.1% in 1990 to 12.5% by 2050. Research from high-income countries demonstrates that trauma in the geriatric population (GP) is associated with higher morbidity and mortality secondary to comorbid conditions and decreased physiologic reserve. Minimal research exists on the prevalence and mechanisms of injury in the GP in low- and middle- income countries (LMICs), and no studies exist in Latin American LMICs, such as Bolivia.

Methods:  Patient data was collected in the Emergency Department (ED) of six hospitals in Santa Cruz, Bolivia participating in the Panamerican Trauma Society Trauma Registry from October 1, 2015 to July 31, 2018. Inclusion criteria were all patients presenting with trauma. Data were coded with Microsoft Excel and analyzed with SAS v9.4. Comparisons were made between the GP, age greater than 65 years, and the younger population (YP): ages 18-64 years.

Results: N=8,796 patients were entered in the trauma registry over the 34 month period. Age was recorded for N=7,912 (90.0%) of patients. Ten point one percent (N=797) of patients were aged 65 years or greater, and N=4,989 (63.1%) were aged 18-64 years. Among the GP, 43.7% were male, as opposed to 69.5% of the YP being male (p <0.0001). Only 0.04% of GP presented with alcohol involved in the trauma in contrast to 18.2% of the YP (p <0.0001). A large majority of the GP presented with falls (N=542, 69.8%) versus 1,638 (32.8%) in the YP (p < 0.0001). Motor vehicle crashes were the second most common in both populations representing N=64 geriatric injuries (8.0%) and N=886 (17.8%) YP injuries. The GP most commonly had isolated injuries of the pelvis or hip (21.9% vs. 1.9% of the YP, p <0.0001) and the upper extremity (21.8% vs 25.5% of the YP, p = 0.06). In contrast to the GP, the YP more commonly presented with polytrauma (YP 20.3% vs 11.6% of the GP, p<0.0001). Regarding ED disposition, the majority of patients were discharged home in both patient populations (GP 50.6% vs YP 58.0%, p=0.01), but the GP was more likely to be admitted to the hospital, 38.0% vs 26.8% (p<0.0001). There was no statistically significant difference in ICU admission (GP 1.03% vs YP 0.65%, p = 0.31) or mortality (GP 0.30% vs YP 0.29%, p=0.99).

Conclusion: As overall life expectancy improves, the number of geriatric patients presenting with trauma will increase. The geriatric trauma population in Bolivia is mostly female, who typically present after falls with isolated hip injuries, and more commonly require hospital admission as compared to their younger counterparts. Understanding how geriatric patient presentations differ compared to the YP can inform prevention methods, hospital resource distribution, and discharge planning.

93.01 Appendicitis Presentation and Outcomes at a Public Referral Hospital in Ghana

Posted on January 31, 2019

L. K. Keeney1, B. S. Hendriksen1, D. J. Morrell1, X. Candela2, T. E. Arkorful5, P. Ssentongo4, J. S. Oh1, C. S. Hollenbeak4, F. Amponsah5  1Penn State Health Hershey Medical Center,Hershey, PA, USA 2Penn State University College Of Medicine,Hershey, PA, USA 4Pennsylvania State University,State College, PA, USA 5Eastern Regional Hospital,Koforidua, Ghana

Introduction:
Appendicitis is a burdensome surgical disease for patients in low-middle income countries which have limited surgeons, infrastructure, and financial health coverage. Laparoscopy is often not feasible, so patients typically undergo exploratory laparotomy. This study aims to better understand common presentations and outcomes of appendicitis in rural Ghana to identify areas for future interventions.

Methods:
Data on laparotomies performed at a public surgical referral center in rural Ghana between July 2017 and June 2018 was obtained. Surgical log books and corresponding patient electronic medical records were reviewed to extract demographic data, clinical findings, and outcomes. All exploratory laparotomy operations were included if the record was complete. Appendicitis was identified as the indication for surgery retrospectively through the medical record diagnosis, operative note, or recorded surgical findings. 

Results:
Appendicitis was the post-operative diagnosis in 107 out of 346 (31%) exploratory laparotomy operations reviewed.  Of appendicitis cases, males accounted for 68%. The average age was 32, with 60% of cases occurring in adults ages 18 to 60. Nearly 40% of these patients did not have insurance. Laboratory values were obtained in 70% of cases of appendicitis. Of those with lab values, 37% were found to be anemic and 48% had a leukocytosis. Perforations of the appendix were identified in 59% of cases and were more common in married patients (p=0.0055). Length of stay for patients with perforations was significantly longer than those without perforations (5.2 vs 3.5 days, p=0.0003).  Readmission within 30 days was also more frequent in cases of perforation (7.9% vs 6.8%, p=0.0468). Overall mortality (0.9%) and the rate of surgical site infections (10.3%) did not differ between perforated and non-perforated appendicitis.

Conclusion:
Appendicitis represents a significant surgical burden in Ghana and many patients requiring appendectomy are uninsured. Presentation with perforation is common and results in worse outcomes. Future studies identifying modifiable risk factors of perforation and interventions for earlier diagnosis of appendicitis are warranted.
 

92.20 Laparoscopic versus Open Hernia Repair: Is There a Disparity by Race?

Posted on January 31, 2019

A. Salous1, K. Sweeney1, J. Coleman1, C. D’Adamo2, V. Ahuja1  1SInai Hospital of Baltimore,Surgery,Baltimore, MD, USA 2University Of Maryland,Baltimore, MD, USA

Introduction: Hernia repair is one of the most commonly performed operations in general surgery.  The last two decades witnessed increased utilization of the laparoscopic approach for repair of ventral and inguinal hernias.  However, the trends in these approaches continue to emerge and are still presently unclear.  The purpose of this study is to examine the patient characteristics and outcomes of open versus laparoscopic hernia repair.

Methods: A retrospective review of all inguinal and ventral hernia were identified using CPT codes as the principle operation from 2007 to 2017 using ACS NSQIP database.  This database can identify outpatient and inpatient surgery with 30 days follow up. The primary outcome was the patient characteristics by type of repair.  The secondary outcome was complications with statistical significance calculated using chi square in the difference by laparoscopic vs open by patient characteristics, type of surgery and preoperative variables.

Results: A total of 504,824 met the criteria with 338,319 open and 166,505 laparoscopic.  By operation type, open was preferred for both inguinal 69.6% and ventral hernia 64.5% (p <0.01).  Open was the most utilized in other race (73.5%), blacks (68.6%), then white (63.5%) (p<0.01) and the patients were older (open 58.1 years vs. laparoscopic 55.4 years). Open approach had higher complications 5.6% compared to laparoscopic 2.5% with wound infection 2.7% vs. 0.7% (p<0.001).  The trend in outcomes by open vs. laparoscopic was seen by patient hospital setting with inpatient 15.5% vs. 7.5% and outpatient 2.0% vs. 1.5% respectively.   Complications were higher in black patients in both inguinal and ventral hernia repair regardless of the approach.  Open repair had higher complication rates compared to laparoscopic (white 6.3% vs 2.6%, black 7.0% vs 3.1%, other 4.5% vs 2.4% respectively) (p=0.02).

Conclusion: The study findings show that inguinal and ventral hernia repair operations benefit from a laparoscopic approach.  There is a race disparity with open repair being more common in black and other race patients while laparoscopic approach is seen in white patients. The trend in complications by race highlight the choice of open vs laparoscopic repair. 

 

92.19 Emergency Laparotomy Survival Following Inter-Hospital Transfer: a Retrospective Audit.

Posted on January 31, 2019

M. E. Gramlick1, J. Hampton1, G. Francis2, M. Holmes1, G. Sullivan1,2, J. Gani1,2, P. Pockney1,2  1John Hunter Hospital,Department Of Surgery,Newcastle, NSW, Australia 2University of Newcastle,School Of Medicine And Public Health,Newcastle, NSW, Australia

Introduction:
There is currently no data to evaluate survival outcomes for patients who require an emergency laparotomy but present to a hospital with no acute general surgical service. Hunter New England Local Health District (HNELHD) in New South Wales, Australia provides health services to a geographical area of 50,882 square miles, and includes many hospitals which do not provide an acute surgical service. This study evaluates the difference in survival outcomes for patients presenting to a hospital with or without acute general surgical services.

Methods:
A retrospective audit was performed on patients who underwent an emergency laparotomy in HNELHD between January 1st 2016 and December 31st 2017. Data was obtained from paper- and electronic-based medical records, and entered in to a REDCap online research database platform. The data was then filtered to look at patients who presented to a hospital with no acute general surgical service, and required transfer to a larger hospital with acute general surgery capability. This group was compared to patients who had presented directly to a hospital with an acute general surgical service. The data was analysed using Fisher’s exact test. 

Results:
410 patients were included in the study after excluding patients aged <18 years, or those undergoing non-emergent or diagnostic procedures. 56 (13.6%) of these patients required transfer from a non-surgical to acute surgical hospital prior to their operation. The 30 day mortality of patients requiring inter-hospital transfer was 21.4% versus 7.9% for those directly admitted to an acute surgical hospital (p=0.0056). 

Conclusion:
There is a large disadvantage in survival outcomes for patients who require an emergency laparotomy but present in the first instance to a hospital without acute general surgical services. These results highlight the need for further assessment of factors impacting survival outcomes in patients requiring inter-hospital transfer before surgery, in order to facilitate improvements in resource allocation and distribution across wide geographical regions.
 

92.18 Hospital, Payor and Patient Impacts on Outcomes in Urgent, High Risk Laparoscopic Cholecystectomy

Posted on January 31, 2019

E. Kwon1, C. Jones1, E. Haut1, J. V. Sakran1, A. J. Kent1  1The Johns Hopkins University School Of Medicine,Department Of Surgery,Baltimore, MD, USA

Introduction:
Laparoscopic Cholecystectomy (LC) is one of the most commonly performed surgeries in the U.S. This study aimed to determine which patient, hospital, and payor characteristics are associated with differences in mortality, hospital utilization, and total billed charges in urgently treated patients with high mortality risk or medical complexity.

Methods:
The Maryland Health Services Cost Review Commission database was queried for adult patients who had urgent or emergent LC between 2008-2017 with medical complexity or mortality risk scores of 3 or greater by Medicare APR DRG classification available in the dataset. Open cholecystectomy was excluded to reduce effects of physiologic outliers and operative practice variation.  We examined associations of hospital, patient, and payor characteristics with outcomes of mortality, length of stay (LOS), days in intensive care (IcuLOS), and total charges billed. Multivariate analyses were performed using negative binomial regression modeling, adjusting for individual patient characteristics. Likelihoods reported as adjusted Incidence Rate Ratios (aIRR) were derived from exponentiated negative binomial coefficients.

Results:

We identified a total of 13,885 high-risk patients with urgent LC. As age of the patient increased, LOS, IcuLOS, total charge, and mortality all significantly increased (see table). Mortality was worse in patients who were Asian when compared to White (aIRR=2.23; p<0.05) and in those on Medicare or Medicaid when compared to private insurance (aIRR = 2.26, 2.60; p<0.05). LOS was longer at trauma centers, urban locations, and larger hospitals; African Americans or “other” race and those with Medicare, Medicaid, or “other” insurance also had longer LOS (p<0.001). IcuLOS was increased at urban or trauma centers and at larger hospitals; those on Medicaid had longer IcuLOS (p<0.05). IcuLOS was shorter at academic centers and “other” race. Charges were higher at academic, urban, or trauma centers, larger hospitals; charges were also higher in African Americans or “other” race and in patients with Medicare, Medicaid, or “other” insurance (p<0.001). Self-pay patients had lower charges (aIRR=0.93; p<0.01), and female patients had shorter LOS, shorter IcuLOS, and lower charges.

Conclusion:

Structural hospital, insurance, and demographic factors had substantial and heterogeneous effects on resource utilization, charges, and mortality in high risk patients undergoing urgent LC.  These patterns may reflect racial, economic, and geographic disparities.  Such effects should be taken into consideration in designing policy and systems to care for complex acute general surgical patients.

92.17 Telehealth Delivery of Outpatient Pediatric Surgical Care in Hawai‘i: An Opportunity Analysis

Posted on January 31, 2019

N. R. Laferriere1, M. Saruwatari3, X. Doan3, K. Ishihara1, D. Puapong2, S. Johnson2, R. Woo2  1Tripler Army Medical Center, Department Of Surgery,General Surgery,Honolulu, HI, USA 2Kapi’olani Medical Center for Women and Children,Pediatric Surgery,Honolulu, HI, USA 3University Of Hawaii,John A. Burns School Of Medicine,Honolulu, HI, USA

Introduction: The unique geography of the state of Hawaii presents an unusual challenge regarding access to health care. While the state’s population is spread across six islands, nearly all pediatric surgical care is delivered on O‘ahu, with the majority delivered at the one dedicated children’s hospital. This disproportionately affects the native Hawaiian and Pacific Islander populations as they represent a higher percentage of the population on the neighbor islands, compounding the access to care issues for these traditionally underserved groups. Outpatient clinic visits require patients and a parent/legal guardian to travel to O’ahu for what could be only a 15-minute visit. The direct and opportunity costs of this can be significant. The aim of this study was to identify the number of telehealth candidates to estimate the statewide opportunity for telehealth services for outpatient pediatric surgical care.
 

Methods: This was a retrospective chart review examining all pediatric patients who were transported from other Hawaiian Islands for consultation with a pediatric surgeon on O‘ahu over a 4 year period from Sept 1, 2013- Aug 31, 2017. All patients who traveled from an outer island to O’ahu and were seen in the pediatric surgery clinic at the state’s primary children’s hospital were included in the study. Each patient visit was examined to determine if the visit could have been conducted via telehealth.  Encounters were deemed suitable for telehealth if they did not meet any of the following exclusion criteria: need for admission, need for surgery or invasive procedures within 24 hours, need for additional subspecialty consultations, and need for emergency room evaluation after their visit with the surgeon. Administrative cost data was then used to determine the direct, insurance-based costs of the travel for the encounter. Patient demographics were also analyzed to determine the home island of the patient and their ethnic background.

Results: 1,081 patients were seen in the pediatric surgery clinic at the state’s primary children’s hospital from the outer islands over a 4 year period. Of these patients, 31% (335 patients) met criteria as candidates for telehealth visits with 45% coming from Hawai’i, 28% from Maui, 16% from Kaua’i, 8.4% from Moloka’i, and 1.5% from Lana’i. Most patients were identified as Native Hawaiian or Asian (46% and 29%, respectively). The average cost per trip was $112.53, leading to a potential cost savings of $37,697 over 4 years.

Conclusion: Over 30% of outpatient pediatric surgical encounters met stringent criteria as candidates for telehealth delivery of care. 46% of these patients identified as native Hawaiian. This represents a significant opportunity for direct, travel-based cost savings as well as opportunity cost savings associated with the implementation of telehealth delivery of outpatient pediatric surgical care in Hawai‘i.

 

92.16 High Volume Care – More Myth than Reality?

Posted on January 31, 2019

L. E. Kuo1, T. Uribe-Leitz2, S. Lipsitz2, A. Haider1,2  1Brigham and Women’s Hospital,Surgery,Boston, MA, USA 2Brigham And Women’s Hospital,Center For Surgery And Public Health,Boston, MA, USA

Background:It is well established that high-volume hospitals (HVH) have improved outcomes for various types of operations. In 2015, three major health systems adopted the “volume pledge,” restricting performance of 10 operation types to only high-volume hospitals (HVH) within their systems. However, the frequency of HVH for these procedures at a national level is unknown. Our objective was to assess the proportion of operations performed at HVH and patient characteristics associated with receiving care at these institutions. 

Methods: Healthcare Cost and Utilization Project 2014 state inpatient databases (SID) from 18 widely geographically distributed states were utilized. International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis and procedure codes were used to identify the 10 operation types with known improved outcomes associated with HVH: bariatric surgery, carotid artery stenting, complex aortic surgery, esophageal cancer resection, total hip replacement, total knee replacement, lung cancer resection, mitral valve repair, pancreatic cancer resection, and rectal cancer resection. Hospital identifiers included in the SIDs assigned each operation to a hospital. Based on published volume pledge thresholds, each hospital was determined to be an LVH or HVH for each operation type. The number of operations performed at HVH versus LVH was calculated for each operation type. Patient characteristics (age, gender, race, median household income quartile, primary payer, and rural/suburban/urban) associated with receiving an operation at HVH were determined for each operation type using univariate analysis. Multivariate regression analyses were performed adjusting for significant covariates. 

Results:The majority of esophageal cancer (72%), lung cancer (51%) and rectal cancer (61%) resections were performed at LVH. The vast majority of bariatric surgery (96%), complex aortic surgery (87%), total hip replacement (87%) and total knee replacement operations (94%) were performed at HVH. For bariatric surgery (60.3%), total hip replacement (56%) and total knee replacement (71%), the majority of performing hospitals were HVH, while for all other operation types, the majority of performing hospitals are LVH. See Table 1. For each of the 10 operation types, there were patient characteristics associated with receiving care at an HVH, and some persisted on multivariate analysis. However, there were no trends consistent between operation types. 

Conclusion:The majority of esophageal cancer, lung cancer and rectal cancer patients are treated at LVH. The majority of hospitals performing the operations studied are not HVH. There remains significant opportunity to centralize these operations to improve patient outcomes. 

92.15 Factors Associated with Interhospital Transfers of Emergency General Surgery Patients from EDs

Posted on January 31, 2019

A. Ingraham1, D. Yang1, J. Havlena1, B. Hanlon1, S. Fernandes-Taylor1, J. Schumacher1, H. Santry2  1University Of Wisconsin,Madison, WI, USA 2Ohio State University,Columbus, OH, USA

Introduction: As the population ages and access to emergency surgical care declines, patients are increasingly being transferred. Most transfers originate from emergency departments (EDs). Guidelines to facilitate timely, appropriate emergency general surgery (EGS) transfers are lacking. We determined patient- and hospital-level factors associated with interhospital transfers of EGS patients originating from the ED.

Methods: Adult EGS patients (defined by American Association for the Surgery of Trauma ICD-9 diagnosis codes) were identified within the 2008-2014 Nationwide Emergency Department Sample (n=47,427,836). Patient- and hospital-level factors were examined as predictors of transfer to another acute care hospital with a multilevel, logistic regression model to assess the effect of risk factors for transfer using weights to provide national estimates. Patient-level factors considered included EGS diagnosis type indicator variables, sex, age, insurance type, zip-code level income, Charlson comorbidity index, and weekend admission. Hospital-level factors included volume (total number of ED visits), trauma center status, non-metropolitan/metropolitan teaching status, region, and hospital ownership.

Results: 893,429 (2%) encounters resulted in a transfer. Transferred patients were on average 56.7±0.4 years old and more likely to have Medicare (45%) than private insurance (27%) or Medicaid (14%). EGS diagnoses most commonly associated with transfer were general abdominal (29% of transferred encounters) and upper gastrointestinal tract (21%) conditions. Transfer was significantly more likely for encounters with select EGS diagnosis groups [resuscitation (Odds Ratio [OR] 23.53, 95% Confidence Interval [CI] 19.56-28.31); cardiothoracic (OR=8.46, CI=7.42-9.65); intestinal obstruction (OR=4.62, CI=4.10-5.19)] than encounters for patients without those conditions. (Table) Hospital-level factors associated with increased odds of transfer included non-metropolitan (vs. metropolitan non-teaching hospitals), Midwestern (vs. Northeastern region), and level III or non-trauma center (vs. levels I or II). Patient factors included older age, male gender, higher comorbidity scores, either Medicare or private insurance, and patients living in zip codes with lower levels of income.

Conclusion: The odds of transfer varies widely by EGS diagnosis even after controlling for important patient and hospital-level factors. Consideration of these factors is a starting point for developing EGS triage criteria based on presenting symptoms as is currently done for myocardial infarctions or cerebrovascular accidents in our nation’s EDs.

 

92.14 Declining geospatial distribution of surgical services across the United States

Posted on January 31, 2019

A. Diaz1, A. Schoenbrunner1, A. Paredes1, J. Cloyd1, T. M. Pawlik1  1Ohio State University,Surgery,Columbus, OH, USA

Introduction:  Despite the increased need and utilization of surgical procedures, Americans often face challenges in gaining access to appropriate health care that may be exacerbated by the closure and consolidation of hospitals. We sought to define trends in the geographic distribution of surgical services in the United States to assess possible geographic barriers and disparities in access to surgical care. 

Methods:  The 2005 and 2015 American Hospital Association (AHA) annual survey was used to identify hospitals with surgical capacity; the data were merged with 2010 Census Bureau data to identify the distribution of the United States population relative to hospital location.  Specifically, geospatial analysis tools were used to examine a service area of 30- and 60-minutes real driving time surrounding each hospital to assess the population living outside a given service area. A major surgery hospital was defined as meeting three of four criteria: bed size ³45, ³upper bound of interquartile range (IQR) for operating rooms and operations per year, and academic medical center. 

Results: While the number of hospitals that provided surgical services slightly decreased over the time periods examined (2005, n=3,791 vs. 2015, n=3,391) (p<0.001), the number of major surgery hospitals increased from 2005 (n=539) to 2015 (n=749).  The number of academic medical centers also increased over time (2005, n=973 vs. 2015, n=1,063)(p<0.001).  In addition, while in 2005 the mean number of ORs per hospital was 7.7 (IQR 2-10), by 2015 the mean number of ORs per hospital had increased to 9.4 (IQR 2-12) (p<0.001). In contrast, the mean annual number of operations per hospital remained the same (2005, n=6,321 (IQR 1,240–8,566) vs. 2015, n=6,600 (IQR 1,291–8,621))(p=0.15).  The geographic location of hospitals that provided surgical services changed over time. Specifically, while in 2005 852 hospitals were located in a rural area, that number had decreased to 679 by 2015 (p<0.001). Furthermore, while 887 hospitals had a critical access hospital designation in 2005 that number had decreased to 827 by 2015 (p<0.001). Of particular note, from 2005 to 2015 there was an 82% increase in the number of people who lived further than 60 minutes from any hospital (p<0.001). However, the number of people who lived further than 60 minutes from a major surgery hospital decreased (p<0.001)(Table).

Conclusion: While the number of rural, critical access hospitals decreased over the last decade, the number of large, academic medical centers has increased.  In turn, there has been an almost doubling in the number of people who live outside a 60 minute driving range to a hospital capable of performing surgery. These data highlight the trends of rural hospital closures, consolidation of hospitals, and regionalization of operative procedures that make access to surgery for certain patient populations increasingly challenging. 

 

92.13 Morbid Obesity and Laparoscopic Diaphragmatic Hernia Repair: Good Outcomes But Disparities in Care

Posted on January 31, 2019

M. Y. Chen1, A. Lee3, M. Muthusamy2,4, G. Sugiyama3, P. J. Chung1,2  1State University of New York Downstate Medical Center,Department Of Surgery,Brooklyn, NY, USA 2Coney Island Hospital,Department Of Surgery,Brooklyn, NY, USA 3Zucker School of Medicine at Hofstra Northwell,Department Of Surgery,Hempstead, NY, USA 4Kings County Hospital Center,Department Of Surgery,Brooklyn, NY, USA

Introduction:

Diaphragmatic hernias are responsible for 1 in every 2000 hospital admissions and studies have shown that the laparoscopic abdominal approach confers decreased morbidity and length of stay (LOS). With the rate of morbid obesity in the US rising, we sought to determine whether morbid obesity was associated with worse outcomes in patients that underwent abdominal laparoscopic diaphragmatic hernia repair (DHR).

Methods:

Using the Nationwide Inpatient Sample (2008-2012) we identified adult (≥18 years) patients that underwent laparoscopic abdominal DHR for diaphragmatic hernias. We excluded cases associated with congenital hernias, obstruction, gangrene, non-elective admissions, cases performed during bariatric procedures, and those missing data. Outcomes of interest included LOS, postoperative complications (mechanical, respiratory, digestive tract, cardiovascular, intraoperative), postoperative infections, and death. Risk variables included age, sex, race, comorbidity status (using the validated van Walraven score), morbid obesity, conversion to open procedure, insurance status, income status, hospital region, hospital type, and hospital bed size. We performed univariate analysis comparing morbidly obese patients to control. We performed multivariable analysis, adjusting for all risk factors, using negative binomial regression for LOS and logistic regression for all other outcomes.

Results:

5,964 patients met criteria and 242 (4.06%) were morbidly obese and 19 (0.32%) died. On univariate analysis, there was significant difference in all risk variables except for income status (p=0.1819), hospital type (p=0.3776), hospital region (p=0.05615). On logistic regression, morbid obesity was only independently associated with increased risk of mechanical complications (OR 4.89, p=0.0039). Negative binomial regression showed that morbid obesity was associated with longer LOS (IRR 1.33, p<0.0001). Other variables independently associated with increased LOS included comorbidity status (IRR 13.2, p<0.0001), conversion to open procedure (IRR 2.73, p<0.0001), Asian/Pacific Islander vs White race (IRR 2.04, p<0.0001), self-pay vs Medicare (IRR 1.30, p<0.0001), Medicaid vs Medicare (IRR 1.19, p<0.0001), receiving care at an urban teaching vs rural hospital (IRR 1.17, p<0.0001), and female vs male sex (IRR 1.07, p=0.0052). Receiving treatment in the west vs northeast region was independently associated with decreased LOS (IRR 0.88, p<0.0001).

Conclusion:

In this large observational study, we found that elective DHR via the laparoscopic abdominal approach is safe in patients that are morbidly obese. However, race, insurance status, and hospital region were found to be significantly associated with LOS, and may account for disparities in care. Further prospective studies are warranted to identify ways to mitigate these factors.

 

92.12 A Qualitative Analysis of the Patient and Caregiver Experience with Post-Acute Care After Surgery

Posted on January 31, 2019

S. Kim1, C. McDavid2, J. Turan2, S. J. Knight2, H. Chen2, S. Bhatia2, C. J. Brown2, C. J. Balentine1  1University Of Texas Southwestern Medical Center,Surgery,Dallas, TX, USA 2University Of Alabama at Birmingham,Birmingham, Alabama, USA

Introduction:

Nearly 50% of patients having abdominal surgery will rely on post-acute care (home health, skilled nursing facilities, or inpatient rehabilitation) to complete their postoperative recovery. The purpose of this study was to explore the patient and caregiver experience with post-acute care after abdominal surgery, to identify areas for improvement that could enhance recovery.

Methods:

We conducted separate semi-structured interviews with 7 patients and 6 caregivers who used home health or skilled nursing facilities following abdominal surgery (pancreatectomy, colorectal resection, or small bowel resection). We also interviewed 8 healthcare providers (2 physicians, 2 social workers, 1 case manager, 2 occupational/physical therapists, and 1 physician assistant).

Results:

Mean patient age was 71 years, with 6 patients receiving home health referrals and 1 discharged to a skilled nursing facility. The mean age of caregivers was 66 years, 67% were women, and 3 were spouses, 2 were children, and 1 was a sibling.

Preoperatively, patients and caregivers felt that their surgeons did an excellent job preparing them for surgery and discussing postoperative complications. However, patients and caregivers reported that surgeons rarely addressed the possibility of needing post-acute care and how this could affect patients and caregivers. Postoperatively, patients and caregivers struggled with selecting which home health company or skilled facility should provide their post-acute care, because they lacked information on how to compare the quality of the different providers or facilities. Healthcare providers struggled with recommending which home health companies or skilled facilities would be most suitable for each patient. Most providers lacked information on the quality of facilities or home health, and others felt uncomfortable telling patients which facilities/companies might provide poor quality services.

Most patients and caregivers had a positive experience with post-acute care and were grateful for ongoing assistance with rehabilitation, ostomy management, and coordination of care with their surgeons. Criticisms of post-acute care services were generally limited to poor communication about the goals of care, and concerns about the timing or intensity of treatment.

Conclusion:

A preoperative discussion about the potential need for post-acute care in high risk patients could help patients and their caregivers prepare for the realities of recovery from complex surgery. A better process for helping patients to choose among the different home health companies and skilled facilities that offer post-acute care services could also improve outcomes by ensuring that patients are able to select the provider or facility that offers the best care to address their postoperative recovery needs. In particular, the surgical team would benefit from education about available services and how to counsel patients when making decisions about post-acute care placement.

 

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