Inter-specialty collaboration in the formalization of a new foregut subspecialty

Historical context and converging market conditions present a unique opportunity to study the factors contributing to the formalization of foregut, or upper gastrointestinal, surgery as a new subspecialty in United States healthcare. The aim of this study was to examine the justifications of those pursuing the formalization of a foregut subspecialty and to extract lessons for healthcare leaders on the evolving relationships between competing providers. This was a qualitative, cross-sectional study consisting of interviews, secondary survey data, and observation of society meetings between October 2018 and June 2019. Thirty interviews with healthcare professionals were conducted, transcribed, and analyzed for themes using qualitative coding software. Themes were correlated with observational field notes and archival data and compared against established social theories on professions and medical specialization. Analysis revealed that traditionally competing surgeons and gastroenterologists articulate a professional need to qualify foregut surgical expertise based on superior knowledge and outcomes, to define the allocation of certain tasks and procedures, and to foster collaboration across specialties. Converging market conditions precipitate individual and organizational decisions to pursue formal specialization. Participants in the formalization of this subspecialty should consider the history of professional competition and turf wars to achieve meaningful collaboration. Advocacy for multi-specialty societies and organizational movements could be a model for reduced conflict in other specialties as well.

Faktor Determinan Fertilitas Remaja di Provinsi Nusa Tenggara Timur

Introduction: Adolescent fertility caused various negative consequences starting from the occurrence of adolescent fertility include health, social and economic impacts. Purpose: to study the determinants of adolescent fertility in the Province of East Nusa Tenggara. Methods: This study uses secondary survey data in the 2017 IDHS. The sample was adolescents aged 15-19 years who were recorded as selected samples in East Nusa Tenggara Province as many as 401 adolescents. Analysis using multiple logistic regression with predictive factor model. Results: The highest aOR value is marital status 17.25 (95% CI 6.60-45.04). Education only finished elementary school aOR 4.94 (95%CI 1.08-22.45). Never accessed the internet aOR 3.37 (95%CI 0.85-13.37). For every 1 year increase in adolescent age, the odds increased by 3.32 (95% CI 1.71-6.46) or 19 years old had the highest odds. Didn’t work aOR 3.00 (95% CI 0.71-12.66). Living in rural areas aOR 2.55 (95%CI 0.53-12.13). Low knowledge of family planning methods has an AOR of 0.26 (0.05-1.22). Conclusion: The determinants of adolescent fertility in NTT Province are age, education, occupation, marital status, place of residence, internet use and knowledge of family planning methods.

Continued Relevance of Initial Temperature Measurement in Trauma Patients

Objectives Hypothermia occurs in 30-50% of severely injured trauma patients and is associated with multiple metabolic derangements and worsened outcomes. However, hypothermia continues to be under-diagnosed which leads to inadequate triage and treatment in trauma patients. Our study set out to determine if hypothermia is an independent predictor of mortality in trauma patients. Methods We retrospectively reviewed data of all trauma activation patients over a 5-year period. Data were collected on patient demographics, initial core temperature, Glasgow Coma Scale (GCS) on presentation, and injury severity score (ISS). Patients were then stratified into groups based on presenting temperature, ISS, and GCS. Outcomes compared were mortality, blood products received, and intensive care unit (ICU) length of stay. Correlations and logistic regression were used to test the hypotheses. Results Survival and temperature data were reviewed on 15,567 patients. Initial temperature was not significantly associated with ICU length of stay or blood products transfused ( P = .21 and P = .08, respectively). However, odds ratio of mortality in hypothermic patients (<35°C) compared to normothermic patients (35-39°C) was 3.95 (95% CI 2.90-5.41). When controlling for GCS and ISS, separately, temperature remained an independent predictor of mortality. Conclusions Hypothermia is an independent risk factor for mortality in trauma patients. It remains crucial to obtain accurate presenting temperatures in trauma patients in order to triage and treat hypothermia. Based on our data, obtaining core temperatures and rapidly treating hypothermia continues to be a vital part of the secondary survey of trauma patients.

Major trauma

This chapter discusses the management of major trauma. Trauma is the leading cause of death in the first four decades of life, and every minute, more than nine people die from injuries and violence. Trimodal distribution of death implies death from injury occurs in one of three time periods: first peak (within seconds to minutes), second peak (within minutes to several hours), and third peak (after several days to weeks). The ‘golden hour’ refers to the period when medical care can make the maximum impact on death and disability. A systematic, rapid initial assessment is essential and this includes preparation, triage, primary survey (ABCDE), resuscitation, secondary survey, continued monitoring, and reevaluation and definitive care. The chapter then looks at the advanced trauma life support (ATLS) system. It also considers thoracic injuries, abdominal trauma, vascular injuries, and head injuries.

Trauma

Primary assessment in trauma: ABCDE?, Airway?, Breathing?, Circulation?, Secondary survey?, Chest trauma?, Abdominal trauma?, Head trauma?, Spinal trauma?, Limb trauma?, Burns?, Pregnant trauma patients?, Paediatric trauma?

1403 Leadership and Teamwork in The Major Trauma Service – Implementation of A New Approach to Secondary Surveys

Aim Trauma Audit and Research Network (TARN) guidelines at a Major Trauma Centre in Northern Ireland state that all patients admitted with Major Trauma should have a secondary survey completed and documented within 24 hours of admission. Method All patients admitted with major trauma had their medical notes reviewed on discharge to look for evidence of a documented secondary survey. Two audit cycles were completed. The first from January 2018 to April 2018 (n = 38). Following a quality improvement project with specific interventions to improve compliance, including improved communication behaviours and the implementation of a revised trauma booklet, a second cycle was performed from October 2019 to January 2019 (n = 44) Results 58% of group 1 and 75% of group 2 had a documented secondary survey within 24 hours of admission. The interventions therefore resulted in an overall 17% increase in the number of secondary surveys completed within 24 hours. Patients admitted under Orthopaedic care had a significant improvement of 26% between cycles to 89% compliance. Cardiothoracics (33% to 40%), Neurosurgery (14% to 43%) and General Surgery (75% to 66%). Conclusions A quality improvement drive led by the Orthopaedic team involving the education of doctors, improving communication channels and the introduction of revised trauma documentation, resulted in a significant increase in the number of secondary surveys completed within 24 hours. Patients under the care of Orthopaedics were more likely to have a survey completed compared with other specialties. This highlights the need for more education and engagement of other specialities to increase compliance in secondary surveys.

1270 Secondary Survey Documentation in Trauma Patients - A Review Following Implementation of a Dedicated Trauma Ward

Introduction A secondary survey is a detailed head to toe assessment performed in trauma patients following initial primary survey and patient stabilisation. It forms part of the ATLS guidelines and is an important tool in the recognition of patient injury. We performed an audit within the Regional Trauma Unit to assess the standard of documentation of secondary surveys in trauma admissions. We then repeated this audit following staff teaching and the implementation of a dedicated Trauma Ward, with an aim of improving secondary survey documentation and the early recognition and management of associated injuries. Method Admission notes for all trauma patients admitted in the three months prior to the opening of the dedicated Trauma Ward were reviewed for documentation of a secondary survey (n = 30), with the incidence of any missed injuries on follow up recorded. A further audit loop was then performed on all trauma admissions following the opening of the Trauma Ward and trauma staff teaching (n = 52). Results Complete documentation of a full secondary survey improved from 10% to 98% for trauma patient admissions. This also improved early identification of initially missed injuries from the primary survey including extremity fractures, chest trauma, and multi-ligament knee injuries. Conclusions Secondary surveys are an important tool in assessing trauma patients and can help identify significant injuries. The implementation of a dedicated Trauma Ward along with teaching to the trauma staff has led to an improvement in performance of secondary surveys with a direct improvement in identifying associated injuries in trauma patients.

Hubungan Pengetahuan Dengan Keterampilan Perawat Dan Dokter Dalam Penatalaksanaan Primary Survey Pada Pasien Penurunan Kesadaran Di IGD RS Siloam Sriwijaya Palembang Tahun 2018

Pengelolaan pasien dengan penurunan kesadaran memerlukan penilaian cepat dan tindakan tepat untuk menghindari kematian dan kecacatan dengan penatalaksanaan initial assement (penilaian awal) yang meliputi : primary survey (ABCDE), secondary survey (pemeriksaan Head To Toe), reevaluasi berkesinambungan dan terapi definitive. Jenis penelitian kuantitatif dengan pendekatan cross sectional. Teknik pengambilan sampel yang digunakan adalah total sampling dengan jumlah sampel sebanyak 32 responden. Hasil dalam penelitian ini menunjukkan tingkat pengetahuan perawat dan dokter dalam kategori baik yaitu 19 (59,5%), dan hasil keterampilan perawat dan dokter dalam kategori terampil yaitu 25 (78,1%). Berdasarkan uji statistik menggunakan alternatif uji Fisher menunjukkan nilai signifikansi sebesar 0,01 (p ≤ 0,05). Dengan demikian dapat disimpulkan bahwa ada hubungan bermakna antara pengetahuan dengan keterampilan perawat dan dokter dalam penatalaksanaan primary survey pada pasien dengan penurunan kesadaran di IGD RS Siloam Sriwijaya Palembang. Diharapkan penelitian ini dapat bermanfaat untuk memberikan informasi tentang hubungan pengetahuan dan keterampilan perawat dan dokter dalam penatalaksanaan primary survey pada pasien penurunan kesadaran di IGD. Kata kunci : Hubungan Pengetahuan, Keterampilan, Primary Survey