The American Surgeon
Published By SAGE Publications
Improved Perceptions of Education and Wellness Among General Surgery Residents and Faculty After the Implementation of Outpatient Scribes
Background Recent studies have revealed a high rate of burnout among general surgery (GS) residents. Efforts to design and implement interventions to mitigate fatigue in surgical trainees are critical. Our aim was to assess the educational and wellness impact of outpatient scribe utilization at an academic GS residency program. Methods Electronic surveys were sent to 38 GS residents and 15 faculties who used outpatient scribes for at least 12 months. Questions were scored on a 5-point Likert scale with answers of “Strongly agree” or “Agree” representing affirmative responses. Results Thirty residents and 14 faculty completed the survey, resulting in an 83% overall response rate. Twenty-eight (93%) residents and 12 (86%) faculty believed that scribes decrease the daily workload of trainees. Twenty-seven (90%) residents felt that scribes allow them more time to focus on patient care and improve the quality of their surgical education. Ninety-three percent of residents (n = 28) and faculty (n = 13) believed that scribes enhance resident well-being. Twenty-four (80%) residents reported that scribes help improve adherence to duty hour restrictions. Twenty-five (83%) residents believed that utilizing scribes is an effective fatigue mitigation strategy for surgical training programs. Conclusion Our findings demonstrate that the implementation of an outpatient scribe program at an academic GS residency program may enhance resident education and wellness.
Background Social determinants of health challenge in at-risk patients seen in safety net facilities. Study design We performed a retrospective review of surgical oncology specialty clinic referrals at a safety net institution evaluating referral compliance and times to first appointment and initiation of definitive treatment. Main outcomes measured included completion of initial visit, initiation of definitive treatment, time from referral to first appointment, and time from first appointment to initiation of definitive treatment. Results Of 189 new referrals, English was not spoken by 52.4% and 69.4% were Hispanic. Patients presented without insurance in 39.2% of cases. Electronic patient portal was accessed by 31.6% of patients. Of all new referrals, 55.0% arrived for initial consultation and 53.4% initiated definitive treatment. Malignant diagnosis ( P < .0001) and lack of insurance ( P = .01) were associated with completing initial consultation. Initiation of definitive treatment was associated with not speaking English ( P = .03), malignant diagnosis ( P < .0001), and lack of insurance ( P = .03). Times to first appointment and initiation of definitive treatment were not significantly affected by race/ethnicity, language, insurance, treatment recommended, or electronic patient portal access. Conclusion Access to surgical oncology care for at-risk patients at a safety net facility is not adversely affected by lack of insurance, primary spoken language, or race/ethnicity. However, a significant proportion of all patients fail to complete the initial consultation and definitive treatment. Lessons learned from safety net facilities may help to inform disparities in health care found elsewhere.
Factors Affecting One-Year Outcomes After Major Lower Extremity Amputation in the Vascular Quality Initiative Amputation Registry
Introduction Major lower extremity amputation (LEA) results in significant morbidity and mortality. This study identifies factors contributing to adverse long-term outcomes after major LEA. Study Design Amputations in the Vascular Quality Initiative (VQI) long-term follow-up database from 2012 to 2017 were included. Multivariable logistic regression determined which significant patient factors were associated with 1-year mortality, long-term functional status, and progression to higher level amputation within 1 year. Results 3440 major LEAs were performed and a mortality rate of 19.9% was seen at 1 year. Logistic regression demonstrated that 1-year mortality was associated with post-op myocardial infarction (MI) (odds ratio (OR) 1.7, CI 1.02-2.97, P = .04), congestive heart failure (CHF) (OR 1.9, confidence interval (CI) 1.56-2.38, P < .001), hypertension (HTN) (OR 1.31, CI 1.00-1.72, P = .05), chronic obstructive pulmonary disease (COPD) (OR 1.36, CI 1.13-1.63, P < .001), and dependent functional status (OR 2.01, CI 1.67-2.41, P < .001). A decline in ambulatory status was associated with COPD (OR 1.36, CI 1.09-1.68, P = .006). Dependent functional status was protective against revision to higher level amputation (OR .18, CI .07-.45, P < .001). Conclusion In the VQI, 1-year mortality after major LEA is nearly 20% and associated with HTN, CHF, COPD, dependent functional status, and post-op MI. Decreased functional status at 1 year was associated with COPD, and progression to higher level amputation was less likely in patients with dependent functional status.
Extracorporeal Membrane Oxygenation May Improve Outcomes After Resuscitative Thoracotomy: A National Trauma Data Bank Analysis
Background Albeit low survival rates, resuscitative thoracotomy (RT) is considered standard for selected trauma patients. Because it has potential for rapid cardiopulmonary rescue, extracorporeal membrane oxygenation (ECMO) may augment RT. The aim of this study was to identify the impact of ECMO on trauma patients that recently underwent RT after injury. Study Design All patients who underwent RT were identified from the National Trauma Data Bank (2007-2017). Patients were excluded if they died within 60 minutes, underwent delayed ECMO, and/or had missing data. Delayed ECMO group was defined as those patients undergoing ECMO after 1 hour following RT. Results Out of 8 694 272 injured patients, 10 106 (.1%) underwent RT. Median age was 31 years [23-45], 86% male. Penetrating injury was the dominant mechanism (62%). Of these, .6% (23) underwent immediate ECMO. Extracorporeal membrane oxygenation patients were significantly younger (23[17-33] vs. 31[23-46], p .003) and had significantly higher chest abbreviated injury scale scores (5[4-5] vs. 3[3-4], P < .001). Extracorporeal membrane oxygenation patients achieved significantly higher rate of return of spontaneous circulation (96% vs. 70%, p .007) and had nonsignificant trend of improved mortality (52% vs. 63%, p .260). Conclusion Immediate ECMO may be a useful therapeutic modality after RT. It achieves higher ROSC rates with opportunity for improved survival. Future prospective study is warranted.
Patients With Invasive Breast Cancer Who Refuse Treatment: An Analysis of Associated Factors and Impact on Survival
Background Completion of surgical resection and adjuvant/neoadjuvant treatments (chemotherapy, radiation, and endocrine therapy) is necessary to achieve optimal outcomes in invasive breast cancer. The objective of this study was to determine the characteristics of patients refusing treatment and to analyze the impact of refusal on survival. Study Design A retrospective cohort study of invasive breast cancer cases diagnosed 2004-2016 was performed utilizing the National Cancer Database. Results Of 2 058 568 cases comprising the study cohort, .6% refused recommended surgery, 14.1% refused chemotherapy, 5.5% refused radiation, and 6.3% refused endocrine therapy. Patients refusing therapy were older and more likely uninsured; they did not live farther from the treating hospital. Racial disparities were also associated with refusal. Surgery refusal had the highest hazard ratio for mortality (2.7; 95% CI: 2.5-3.0, P < .001) compared to chemotherapy (1.3; 95% CI: 1.3-1.4, P < .001), radiation (1.8; 95% CI: 1.7-1.9, P < .001), and endocrine therapy (1.5; 95% CI: 1.4-1.6, P < .001) independent of race, insurance, receptor status, and stage. Conclusion This study demonstrates significant associations with refusal of breast cancer treatment and quantifies the impact on mortality, which may help to identify at-risk groups for whom interventions could prevent increases in mortality associated with declining treatment.
Background Retained surgical foreign bodies (RFB) are associated with inferior clinical and financial outcomes. The present work examined a nationally representative sample of all major operations to identify factors associated with RFB. Study Design The 2005-2017 National Inpatient Sample was used to identify adults undergoing cardiac, neurosurgical, orthopedic, genitourinary, gastrointestinal, vascular, and thoracic operations. International Classifications of Diseases 9th-10th Revisions diagnosis codes were used to identify instances of RFB. Results Of an estimated 71,445,042 hospitalizations, .02% had a diagnosis of RFB, with decreasing incidence from .03 to .02% over the study period (NPtrend < .001). Relative to vascular operations, gastrointestinal (adjusted odds ratio [AOR] 2.12), thoracic (AOR 1.80), and multi-cavity (AOR 2.17) were associated with greater odds of RFB. Laparoscopic approach (AOR .33) and trauma-associated admission (AOR .52, all P < .001) were associated with reduced odds of RFB. Despite similar mortality, RFB was associated with increased odds of pulmonary infection (AOR 1.62), sepsis (AOR 1.26), and wound infection (AOR 5.15), as well as a 2.3-day increment in length of stay and $7700 in hospitalization costs (all P < .001). Conclusion The development of novel mitigation strategies may reduce the incidence of RFB in high-risk populations, such as those undergoing gastrointestinal, thoracic, and multi-cavity operations.
Background Firearm injuries are the second leading cause of death among youth in the United States. Nonfatal firearm injuries far outnumber fatalities, yet data detailing the recovery and post-injury needs of pediatric patients after hospital discharge are limited. This study evaluated health system support of pediatric patients after firearm injury, from acute hospitalization to outpatient follow-up. Methods We conducted a retrospective chart review of patients <18 years who presented to an urban level 1 trauma center between 2014 and 2019. Cases were categorized as accidental or intentional (stratified as assault-related or “crossfire” injuries). Outcomes included biopsychosocial assessment (BA) utilization, trauma psychology service consultation, and linkage to outpatient services. Results Among 115 patients, 94% were victims of community violence. Black (50%) and Latinx (44%) patients were disproportionately affected, as were males aged 15-16 years (71%). Overall mortality was 8%. Biopsychosocial assessment and trauma psychology consultations occurred in 43% and 20% of cases, respectively. Of eligible patients, 71% received referral to post-hospitalization support services. The most commonly identified needs were counseling, gang intervention, and help with the carceral system. Conclusion Health systems should support long-term recovery of pediatric patients after firearm injury, particularly addressing social and structural determinants of health. Inpatient-to-outpatient linkages should be strengthened, and prospective follow-up is needed.
Background Glycemic control is an important aspect of critical care because derangements are associated with morbidity and mortality. Patients at highest risk for hypoglycemia in the surgical intensive care unit (SICU) are incompletely described by existing literature. Our objective was to delineate this high-risk patient population in our SICU. Study Design In this single-center, retrospective, observational study, SICU patients admitted from June 1, 2019 to July 31, 2020 with ≥1 episode of hypoglycemia (blood glucose <60 mg/dL) were included. Results There were 41 hypoglycemic events in 27 patients, comprising an incidence of 1.5% among SICU patients. The most common admission diagnoses were cirrhosis (n = 13, 48%), polytrauma (n = 12, 44%), multisystem organ failure (n = 11, 41%), diabetes mellitus (n = 9, 33%), and soft tissue infection (n = 8, 30%). Four high-risk populations were identified: patients in multisystem organ failure (MSOF) (n = 11, 41%); those who were nil per os (NPO) (n = 10, 37%); patients receiving long acting subcutaneous insulin, for example, Lantus (n = 3, 11%); and those on continuous intravenous insulin infusions (n = 3, 11%). After multi-disciplinary peer review, most hypoglycemic events (n = 16, 59%) were deemed iatrogenic. Conclusions Hypoglycemia is rare in surgical critical care. When it does occur, patients are typically in MSOF, NPO, on long acting subcutaneous insulin or continuous insulin infusions, have soft tissue infections, or have acute or chronic liver failure. Increased vigilance with frequent blood glucose monitoring in these high-risk patients may reduce the risk of hypoglycemia in the SICU.
Background As the number of households with dogs in the United States has increased, so has the incidence of dog bites. Contemporary analysis of nationwide epidemiological data regarding such injuries is scarce. The purpose of this study is to describe dog bite injury patterns and related surgical interventions with a focus on differences between pediatric and adult age groups. Study Design This is a retrospective study (2015-2017) using the National Trauma Data Bank. 10 569 patients were included. Results Of these, 4729 (44.7%) qualified as pediatric (age ≤ 12 years) and 5840 (55.3%) qualified as adults (age ≥ 13 years). Pediatric patients were more frequently admitted with facial injuries (78.1% vs. 29.3%, P < .01) and facial fractures (4.8% vs. 2.5%, P < .01), and had a higher incidence of facial bone surgical procedures (1.3% vs. .5%, P < .01). Adult patients were more frequently admitted with upper extremity injuries (65.8% vs. 21.2%, P < .01) and upper extremity vascular arterial injuries (2.3% vs. .2%, P < .01) with a higher incidence of upper extremity arterial procedures (1.3% vs. .2%, P < .01). Conclusion This study demonstrates the contrast in injury patterns from dog bite between adults and children. These findings can dictate injury prevention policies and prepare clinicians to treat dog bite victims.
Background We sought to develop a novel Prehospital Injury Mortality Score (PIMS) to predict blunt trauma mortality using only prehospital variables. Study Design The 2017 Trauma Quality Improvement Program database was queried and divided into two equal sized sets at random (derivation and validation sets). Multiple logistic regression models were created to determine the risk of mortality using age, sex, mechanism, and trauma activation criterion. The PIMS was derived using the weighted average of each independent predictor. The discriminative power of the scoring tool was assessed by calculating the area under the receiver operating characteristics (AUROC) curve. The PIMS ability to predict mortality was then assessed by using the validation cohort. The score was compared to the Revised Trauma Score (RTS) using the AUROC curve, including a subgroup of patients with normal vital signs. Results The derivation and validation groups each consisted of 163 694 patients. Seven independent predictors of mortality were identified, and the PIMS was derived with scores ranging from 0 to 20. The mortality rate increased from 1.4% to 43.9% and then 100% at scores of 1, 10, and 19, respectively. The model had very good discrimination with an AUROC of .79 in both the derivation and validation groups. When compared to the RTS, the AUROC were similar (.79 vs. .78). On subgroup analysis of patients with normal prehospital vital signs, the PIMS was superior to the RTS (.73 vs. .56). Conclusion The PIMS is a novel scoring tool to predict mortality in blunt trauma patients using prehospital variables. It had improved discriminatory power in blunt trauma patients with normal vital signs compared to the RTS.