Amber Trickey, PhD, MS, CPH is Senior Biostatistician of the S-SPIRE Center. She supports multidisciplinary teams in research design, implementation, and analysis. In over 15 years of health services research, with 8 years focused in surgery, Dr. Trickey has collaborated with diverse investigators, including attending physicians, residents, nurses, psychologists, and engineers. Dr. Trickey obtained degrees in epidemiology and biostatistics, evaluated data quality in trauma care, and led data validation studies using a surgical registry (NSQIP) and administrative claims. Dr. Trickey has contributed to public and private grants on surgical safety, simulation-based training, team communication, error disclosure, and quality metrics.
Education & Certifications
BS, Tulane University, Biomedical Engineering (2003)
MS, University of Texas School of Public Health, Epidemiology (2008)
PhD, University of Texas School of Public Health, Epidemiology, Biostatistics, Health Services Research (2012)
CPH, Certification in Public Health, National Board of Public Health Examiners, Public Health (2008)
Professional Affiliations and Activities
Chapter Leader, University of Texas School of Public Health, Institute for Healthcare Improvement Open School (2009 - 2011)
Member, Research & Development Committee, American College of Surgeons Accredited Education Institutes (2016 - 2018)
Member, AcademyHealth (2017 - Present)
Undertreatment of primary hyperparathyroidism in a privately insured US population: Decreasing utilization of parathyroidectomy despite expanding surgical guidelines.
BACKGROUND: Primary hyperparathyroidism is associated with substantial morbidity, including osteoporosis, nephrolithiasis, and chronic kidney disease. Parathyroidectomy can prevent these sequelae but is poorly utilized in many practice settings.METHODS: We performed a retrospective cohort study using the national Optum de-identified Clinformatics Data Mart Database. We identified patients aged ≥35 with a first observed primary hyperparathyroidism diagnosis from 2004 to 2016. Multivariable logistic regression was used to determine patient/provider characteristics associated with parathyroidectomy.RESULTS: Of 26,522 patients with primary hyperparathyroidism, 10,101 (38.1%) underwent parathyroidectomy. Of the 14,896 patients with any operative indication, 5,791 (38.9%) underwent parathyroidectomy. Over time, there was a decreasing trend in the rate of parathyroidectomy overall (2004: 54.4% to 2016: 32.4%, P < .001) and among groups with and without an operative indication. On multivariable analysis, increasing age and comorbidities were strongly, inversely associated with parathyroidectomy (age 75-84, odds ratio 0.50 [95% confidence interval 0.45-0.55]; age ≥85, odds ratio 0.21 [95% confidence interval 0.17-0.26] vs age 35-49; Charlson Comorbidity Index ≥2 vs 0 odds ratio 0.62 [95% confidence interval 0.58-0.66]).CONCLUSION: The majority of US privately insured patients with primary hyperparathyroidism are not treated with parathyroidectomy. Having an operative indication only modestly increases the likelihood of parathyroidectomy. Further research is needed to address barriers to treatment and the gap between guidelines and clinical care in primary hyperparathyroidism.
View details for DOI 10.1016/j.surg.2020.04.066
View details for PubMedID 32654861
Frailty Increases Reinterventions for Surgical Site Infections After Infrainguinal Bypass Procedures
MOSBY-ELSEVIER. 2020: E152
View details for Web of Science ID 000544100700232
The Affordable Care Act Is Associated With Increased Coverage and Decreased Charges, but Limited Improvement in Access to Vascular Surgery for Medicaid Patients
MOSBY-ELSEVIER. 2020: E247–E248
View details for Web of Science ID 000544100700375
- Reply to the Letter to the Editor: How Accurate Are the Surgical Risk Preoperative Assessment System (SURPAS) Universal Calculators in Total Joint Arthroplasty? Clinical orthopaedics and related research 2020
Compounding Benefits of Sentinel Lymph Node Biopsy for Perineal Melanoma: A Population-Based Retrospective Cohort Analysis.
Annals of plastic surgery
2020; 84 (5S Suppl 4): S257–S263
INTRODUCTION: Sentinel lymph node biopsy (SLNB) in the treatment of melanoma is known to provide valuable prognostic information. However, there is no literature describing an overall or disease-specific survival (DDS) benefit of SLNB. In the perineum, melanoma is often more advanced at presentation with current treatment guidelines translated from nonanatomic specific melanoma. As a result, there is little understanding surrounding the role of SLNB in melanoma of the perineum. Our objective is to better understand the therapeutic benefits of SLNB in perineal melanoma.METHODS: The Surveillance, Epidemiology, and End Results program is a large population-based cancer registry including survival data from millions of patients in the United States. The registry was used to generate patient data for analysis from 2004 to 2016. Inclusion criteria included melanoma of the perineum; Breslow depth of 0.80 mm or greater and less than 0.80 mm with ulceration; SLNB or no intervention; clinically negative nodal disease; and available overall survival data.RESULTS: For 879 patients from 2004 to 2016 with perineal melanoma, significant predictors of reduced survival include older than 75 years, Clark level IV-V, Breslow depth of greater than 4.00 mm, positive ulceration status, regional and distant nodal micrometastases, and clinically positive nodes on presentation. Aggregates for overall survival (OS) and disease-specific survival (DSS) were improved with implementation of SLNB. The 5-year survival rates with SLNB versus no SLNB were 54.0% and 43.0% for OS (P = 0.001) and 57.8% and 53.1% for DSS (P = 0.044). Stratification by Breslow depth yielded significant OS and DSS advantage for greater than 1.00 to 2.00 mm (21.3% benefit, P =0.021, and 16.8% benefit, P = 0.044) and greater than 4.00 mm (30.3% benefit, P = 0.005, and 21.0% benefit, P = 0.007) Breslow depths.CONCLUSIONS AND RELEVANCE: Sentinel lymph node biopsy may provide therapeutic benefits in addition to prognostic information for melanoma of the perineum through an increase in 5-year OS.
View details for DOI 10.1097/SAP.0000000000002388
View details for PubMedID 32282396
Frailty as measured by the Risk Analysis Index is associated with long-term death after carotid endarterectomy.
Journal of vascular surgery
OBJECTIVE: The role of carotid endarterectomy (CEA) continues to be debated in the age of optimal medical therapy, particularly for patients with limited life expectancy. The Risk Analysis Index (RAI) measures frailty, a syndrome of decreased physiologic reserve, which increases vulnerability to adverse outcomes. The RAI better predicts surgical complications, nonhome discharge, and death than age or comorbidities alone. We sought to measure the association of frailty, as measured by the RAI, with postoperative in-hospital stroke, long-term stroke, and long-term survival after CEA. We also sought to determine how postoperative stroke interacts with frailty to alter survival trajectory after CEA.METHODS: We queried the Vascular Quality Initiative CEA procedure and long-term data sets (2003-2017) for elective CEAs with complete RAI case information. For all analyses, the cohort was divided into asymptomatic and symptomatic carotid stenosis. Scoring was defined as not frail (RAI<30), frail (RAI 30-34), and very frail (RAI ≥35). Mortality information through December 2017 was obtained from the Social Security Death Index. Multivariable models (logistic and Cox proportional hazards regressions) were used to study the association of frail and very frail patients with the outcomes of interest. In a post hoc analysis, we created Kaplan-Meier curves to analyze patient mortality after CEA as well as after postoperative stroke.RESULTS: Of the 42,869 included patients, 17,092 (39.9%) were female, and 38,395 (89.6%) were white. There were 25,673 (59.9%) patients assigned to the asymptomatic stenosis group and 17,196 (40.1%) patients in the symptomatic stenosis group. Frailty was not associated with perioperative or long-term postoperative stroke. The risk of long-term mortality was significantly higher for frail (hazard ratio, 1.9 [1.7-2.3]) and very frail (hazard ratio, 3.1 [2.6-3.7]) asymptomatic patients; symptomatic frail and very frail patients also had a two to three times increased risk of long-term mortality. Frail and very frail patients had two to three times the risk for long-term mortality compared with patients who were not frail. Postoperative stroke negatively affected the mortality trajectory for all patients in the cohort, regardless of frailty status.CONCLUSIONS: RAI score is not associated with postoperative stroke; however, frail and very frail status is associated with decreased long-term survival in an incremental fashion based on increasing RAI. RAI assessment should be considered in the preoperative decision-making for patients undergoing CEA to ensure long-term survival and optimal surgical outcomes vs medical management.
View details for DOI 10.1016/j.jvs.2020.01.043
View details for PubMedID 32169359
Prevalence and Factors Associated With Low-Value Preoperative Testing for Patients Undergoing Carpal Tunnel Release at an Academic Medical Center.
Hand (New York, N.Y.)
Background: Routine preoperative screening tests before low-risk surgery cannot be justified if the risks to patients are not outweighed by benefits. Several studies and professional guidelines suggest avoiding screening tests prior to minor operations. We aimed to assess the prevalence and patient characteristics associated with low-value preoperative tests (LVTs) prior to carpal tunnel release (CTR) at an academic medical center. Methods: From electronic medical records, we identified patients aged ≥18 who underwent CTR from 2015 to 2017. We determined the occurrence of 9 common LVTs, such as complete blood count (CBC), basic metabolic profile (BMP), and electrocardiogram (ECG), in the 30 days prior to CTR. Multivariable logistic and Poisson regression were used to identify factors associated with receiving any LVT and the number of LVTs, respectively. Results: Among 572 patients, 248 (43.4%) had at least 1 LVT. The most common tests were ECG (31.3% of CTRs), CBC (27.3% of CTRs), and BMP (23.6% of CTRs). Patient factors associated with higher odds of receiving LVT included older age, higher Elixhauser comorbidity score, and general or regional anesthesia (vs monitored anesthesia care). Conclusions: Low-value preoperative tests were frequently received by patients undergoing CTR and were associated with anesthesia type, age, and number of comorbidities. Although our study focused on CTR, these results likely have implications for other commonly performed low-risk procedures. These findings can help guide efforts to improve the quality and value of surgery for carpal tunnel syndrome and facilitate the development of strategies to reduce LVT, such as audit feedback and provider education.
View details for DOI 10.1177/1558944720906498
View details for PubMedID 32100568
Pancreatic grade 3 neuroendocrine tumors behave similarly to neuroendocrine carcinomas following resection: a multi-center, international appraisal of the WHO 2010 and WHO 2017 staging schema for pancreatic neuroendocrine lesions.
HPB : the official journal of the International Hepato Pancreato Biliary Association
BACKGROUND: In 2017, the WHO updated their 2010 classification of pancreatic neuroendocrine tumors, introducing a well-differentiated, highly proliferative grade 3 tumor, distinct from neuroendocrine carcinomas. The aim of this study was to investigate the clinical significance of this update in a large cohort of resected tumors.METHODS: Using a multicenter, international dataset of patients with pancreatic neuroendocrine lesions, patients were classified both according to the WHO 2010 and 2017 schema. Multivariable survival analyses were performed, and the models were evaluated for discrimination ability and goodness of fit.RESULTS: Excluding patients with a known germline MEN1 mutation and incomplete data, 544 patients were analyzed. The performance of the WHO 2010 and 2017 models was similar, however surgically resected grade 3 tumors behaved very similarly to neuroendocrine carcinomas.CONCLUSION: The addition of a grade 3 NET classification may be of limited utility in surgically resected patients, as these lesions have similar postoperative survival compared to carcinomas. While the addition may allow for a more granular evaluation of novel treatment strategies, surgical intervention for high grade tumors should be considered judiciously.
View details for DOI 10.1016/j.hpb.2019.12.014
View details for PubMedID 32081540
Positive and Negative Independent Predictive Factors of Weight Loss After Bariatric Surgery in a Veteran Population.
INTRODUCTION: Factors predicting outcomes after bariatric surgery are yet to be elucidated. We aim to characterize patient-level factors that predict midterm weight loss.METHODS: A database of bariatric surgery at a Veterans Affairs (VA) hospital was retrospectively reviewed. Patient characteristics including age, race, sex, median zip code household income, and distance to the VA bariatric center were analyzed for relationships with percent excess body mass index loss (%EBMIL). Univariate and multivariate analyses were conducted to identify factors independently associated with weight loss after accounting for follow-up time, using stepwise variable selection. A multivariable mixed effects linear regression model was constructed with random intercepts for repeated measures by veteran and fixed effects for time, patient, and procedural characteristics, including comorbidities.RESULTS: A total of 1124 observations were analyzed for 340 bariatric patients. Most were male (77%), white (73%); mean age was 53.2years and mean preoperative BMI was 43.9kg/m2. Follow-up ranged from 99% at 1year, 54% at 5years, and 24% at 10years, with a mean of 6.9years for Roux-en-Y gastric bypass (RYGB) and 3.5years for laparoscopic sleeve gastrectomy (LSG). RYGB (p<0.001) and female (p=0.016) predicted greater %EBMIL up to 10years after surgery. African American race and higher comorbidity burden predicted poorer %EBMIL (p=0.008, p=0.012, respectively). Analysis of individual comorbidities demonstrated that type 2 diabetes was most strongly associated with poorer %EBMIL (p=0.048).CONCLUSION: RYGB and female sex are independent predictors of greater midterm weight loss after bariatric surgery. African American race and a high burden of comorbidity are predictive of poorer weight loss. Neither zip code median income nor distance from bariatric center was associated with weight loss.
View details for DOI 10.1007/s11695-020-04428-0
View details for PubMedID 32009214
Assessment of Risk Analysis Index for Prediction of Mortality, Major Complications and Length of Stay in Vascular Surgery Patients.
Annals of vascular surgery
INTRODUCTION: Frailty is a risk factor for adverse postoperative outcomes. We aimed to test the performance of a prospectively-validated frailty measure, the Risk Analysis Index (RAI) in vascular surgery patients and delineate the additive impact of procedure complexity on surgical outcomes.METHODS: We queried the 2007-2013 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to identify six major elective vascular procedure categories (carotid revascularization, abdominal aortic aneurysm [AAA] repair, suprainguinal revascularization, infrainguinal revascularization, thoracic aortic aneurysm [TAA] repair, and thoracoabdominal aortic aneurysm [TAAA] repair). We trained and tested logistic regression models for 30-day mortality, major complications and prolonged length of stay (LOS). The first model, "RAI", used the RAI alone; "RAI-Procedure (RAI-P)" included procedure category (e.g., AAA repair) and procedure approach (e.g., endovascular); "RAI-Procedure Complexity (RAI-PC)" added outpatient versus inpatient surgery, general anesthesia use, work relative value units (RVUs), and operative time.RESULTS: The RAI model was a good predictor of mortality for vascular procedures overall (C-statistic 0.72). The C-statistic increased with the RAI-P (0.78), which further improved minimally, with the RAI-PC (0.79). When stratified by procedure category, the RAI predicted mortality well for infrainguinal (0.79) and suprainguinal (0.74) procedures, moderately well for AAA repairs (0.69) and carotid revascularizations (0.70), and poorly for TAAs (0.62) and TAAAs (0.54). For carotid, infrainguinal, and suprainguinal procedures, procedure complexity (RAI-PC) had little impact on model discrimination for mortality, did improve discrimination for AAAs (0.84), TAAs (0.73), and TAAAs (0.80). While the RAI model was not a good predictor for major complications or LOS, discrimination improved for both with the RAI-PC model.CONCLUSIONS: Frailty as measured by the RAI was a good predictor of mortality overall after vascular surgery procedures. While the RAI was not a strong predictor of major complications or prolonged LOS, the models improved with the addition of procedure characteristics like procedure category and approach.
View details for DOI 10.1016/j.avsg.2020.01.015
View details for PubMedID 31935435
How Accurate Are the Surgical Risk Preoperative Assessment System (SURPAS) Universal Calculators in Total Joint Arthroplasty?
Clinical orthopaedics and related research
BACKGROUND: Surgical outcome prediction models are useful for many purposes, including informed consent, shared decision making, preoperative mitigation of modifiable risk, and risk-adjusted quality measures. The recently reported Surgical Risk Preoperative Assessment System (SURPAS) universal risk calculators were developed using 2005-2012 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), and they demonstrated excellent overall and specialty-specific performance. However, surgeons must assess whether universal calculators are accurate for the small subset of procedures they perform. To our knowledge, SURPAS has not been tested in a subset of patients undergoing lower-extremity total joint arthroplasty (TJA).QUESTIONS/PURPOSES: How accurate are SURPAS models' predictions for patients undergoing TJA?METHODS: We identified an internal subset of patients undergoing non-emergency THA or TKA from the 2012 ACS-NSQIP, the most recent year of the SURPAS development dataset. To assess the accuracy of SURPAS prediction models, 30-day postoperative outcomes were defined as in the original SURPAS study: mortality, overall morbidity, and six complication clusters-pulmonary, infectious, cardiac or transfusion, renal, venous thromboembolic, and neurologic. We calculated predicted outcome probabilities by applying coefficients from the published SURPAS logistic regression models to the TJA cohort. Discrimination was assessed with C-indexes, and calibration was assessed with Hosmer-Lemeshow 10-group chi-square tests and decile plots.RESULTS: The 30-day postoperative mortality rate for TJA was 0.1%, substantially lower than the 1% mortality rate in the SURPAS development dataset. The most common postoperative complications for TJA were intraoperative or postoperative transfusion (16%), urinary tract infection (5%), and vein thrombosis (3%). The C-indexes for joint arthroplasty ranged from 0.56 for venous thromboembolism (95% CI 0.53 to 0.59 versus SURPAS C-index 0.78) to 0.82 for mortality (95% CI 0.76 to 0.88 versus SURPAS C-index 0.94). All joint arthroplasty C-index estimates, including CIs, were lower than those reported in the original SURPAS development study. Decile plots and Hosmer-Lemeshow tests indicated poor calibration. Observed mortality rates were lower than expected for patients in all risk deciles (lowest decile: no observed deaths, 0.0% versus expected 0.1%; highest decile: observed mortality 0.7% versus expected 2%; p < 0.001). Conversely, observed morbidity rates were higher than expected across all risk deciles (lowest decile: observed 12% versus expected 8%; highest decile: observed morbidity 32% versus expected 25%; p < 0.001) CONCLUSIONS: The universal SURPAS risk models have lower accuracy for TJA procedures than they do for the wider range of procedures in which the SURPAS models were originally developed.CLINICAL RELEVANCE: These results suggest that SURPAS model estimates must be evaluated for individual surgical procedures or within restricted groups of related procedures such as joint arthroplasty. Given substantial variation in patient populations and outcomes across numerous surgical procedures, universal perioperative risk calculators may not produce accurate and reliable results for specific procedures. Surgeons and healthcare administrators should use risk calculators developed and validated for specific procedures most relevant to each decision. Continued work is needed to assess the accuracy of universal risk calculators in more narrow procedural categories based on similarity of outcome event rates and prevalence of predictive variables across procedures.
View details for DOI 10.1097/CORR.0000000000001078
View details for PubMedID 31904684
PATIENT DECISION APPRAISAL IN STAGE III COLORECTAL CANCER TREATMENT
SAGE PUBLICATIONS INC. 2020: E93–E94
View details for Web of Science ID 000509275600085
Body Image Disturbance and Obsessive-Compulsive Disorder Symptoms Improve After Orthognathic Surgery.
Journal of oral and maxillofacial surgery : official journal of the American Association of Oral and Maxillofacial Surgeons
Although body image disturbance (BID), anxiety, depression, and obsessive-compulsive disorder (OCD) are the most common comorbid psychological conditions among patients presenting for orthognathic surgery (OS), little is known about whether psychological symptoms relate to facial deformity or how symptoms change after OS. To fill these knowledge gaps, this study investigated preoperative and postoperative psychological symptoms and preoperative baseline facial deformity in patients who underwent OS.This study included 49 patients who underwent OS by a single surgeon between 2011 and 2018. The patients completed validated psychological tests to assess symptoms of anxiety (Beck Anxiety Inventory), depression (Patient Health Questionnaire-9), BID (BID Questionnaire, BIDQ), and OCD (Florida Obsessive-Compulsive Inventory). In addition, we measured severity of preoperative facial deformity with the Facial Aesthetic Index (FAI). We compared preoperative and postoperative symptoms using univariate nonparametric Wilcoxon signed rank tests. We tested associations between the 4 types of preoperative psychological symptoms and baseline Facial Aesthetic Index category using Spearman's rank correlations.Postoperatively, both BIDQ scores (median 2 to 1.2, P < .001) and Florida Obsessive-Compulsive Inventory scores (median number of OCD symptoms 1 to 0, P < .001) decreased, whereas anxiety and depression symptoms showed no change (P > .45). Preoperative BIDQ was significantly associated with the severity of the facial deformity (ρ = 0.32, P = .025; median BIDQ: mild FAI = 1.0, severe FAI = 2.1).Our results show that patients with more severe facial deformity have a higher BID preoperatively and that both BID and OCD improve after OS. Interestingly, anxiety and depression symptoms did not change after OS.
View details for DOI 10.1016/j.joms.2020.07.021
View details for PubMedID 32810443
Are EMS bypass policies effective implementation strategies for intravenous alteplase for stroke?
Implementation science communications
2020; 1: 50
Stroke is a leading cause of disability and the fifth leading cause of death in the USA. Intravenous alteplase is a highly effective clot-dissolving stroke treatment that must be given in a hospital setting within a time-sensitive window. To increase the use of intravenous alteplase in stroke patients, many US counties enacted policies mandating emergency medical service (EMS) paramedics to bypass local emergency departments and instead directly transport patients to specially equipped stroke centers. The objective of this mixed-methods study is to evaluate the effectiveness of policy enactment as an implementation strategy, how differences in policy structures and processes impact effectiveness, and to explore how the county, hospital, and policy factors explain variation in implementation and clinical outcomes. This paper provides a detailed description of an Agency for Healthcare Quality and Research (AHRQ)-funded protocol, including the use of the Consolidated Framework for Implementation Research (CFIR) in the qualitative design.We will construct the largest-ever national stroke database of Medicare enrollees (~ 1.5 million stroke patients) representing 896 policy counties paired with 1792 non-policy counties, then integrate patient-, hospital-, county-, and state-level covariates from eight different data sources. We will use a difference-in-differences analysis to estimate the overall effect of the policy enactment on intravenous alteplase use (implementation outcome) as well as key patient outcomes. We will also quantitatively examine if variation in the context (urban/rural status) and variation in policy features affect outcomes. Finally, a CFIR-informed multiple case study design will be used to interview informants in 72 stakeholders in 24 counties to identify and validate factors that enable policy effects.Policies can be potent implementation strategies. However, the effects of EMS bypass policies to increase intravenous alteplase use have not been rigorously evaluated. By learning how context and policy structures impact alteplase implementation, as well as the barriers and facilitators experienced by stakeholders responsible for policy enactment, the results of this study will inform decisions regarding if and how EMS bypass policies should spread to non-policy counties, and if indicated, creation of a "best practices" toolkit.
View details for DOI 10.1186/s43058-020-00041-5
View details for PubMedID 32885206
View details for PubMedCentralID PMC7427915
- Reply to the Letter to the Editor: How Accurate Are the Surgical Risk Preoperative Assessment System (SURPAS) Universal Calculators in Total Joint Arthroplasty? Clinical orthopaedics and related research 2020; 478 (8): 1948–49
The Comprehensive AO CMF Classification System for Mandibular Fractures: A Multicenter Validation Study.
Craniomaxillofacial trauma & reconstruction
2019; 12 (4): 254–65
The AO CMF has recently launched the first comprehensive classification system for craniomaxillofacial (CMF) fractures. The AO CMF classification system uses a hierarchical framework with three levels of growing complexity (levels 1, 2, and 3). Level 1 of the system identifies the presence of fractures in four anatomic areas (mandible, midface, skull base, and cranial vault). Level 2 variables describe the location of the fractures within those defined areas. Level 3 variables describe details of fracture morphology such as fragmentation, displacement, and dislocation. This multiplanar radiographic image-based AO CMF trauma classification system is constantly evolving and beginning to enter worldwide application. A validation of the system is mandatory prior to a reliable communication and data processing in clinical and research environments. This interobserver reliability and accuracy study is aiming to validate the three current modules of the AO CMF classification system for mandible trauma in adults. To assess the performance of the system at the different precision levels, it focuses on the fracture location within the mandibular regions and condylar process subregions as core components giving only secondary attention to morphologic variables. A total of 15 subjects individually assigned the location and features of mandibular fractures in 200 CT scans using the AO CMF classification system. The results of these ratings were then statistically evaluated for interobserver reliability by Fleiss' kappa and accuracy by percentage agreement with an experienced reference assessor. The scores were used to determine if the variables of levels 2 and 3 were appropriate tools for valid classification. Interobserver reliability and accuracy were compared by hierarchy of variables (level 2 vs. level 3), by anatomical region and subregion, and by assessor experience level using Kruskal-Wallis and Wilcoxon's rank-sum tests. The AO CMF classification system was determined to be reliable and accurate for classifying mandibular fractures for most levels 2 and 3 variables. Level 2 variables had significantly higher interobserver reliability than level 3 variables (median kappa: 0.69 vs. 0.59, p <0.001) as well as higher accuracy (median agreement: 94 vs. 91%, p <0.001). Accuracy was adequate for most variables, but lower reliability was observed for condylar head fractures, fragmentation of condylar neck fractures, displacement types and direction of the condylar process overall, as well as the condylar neck and base fractures. Assessors with more clinical experience demonstrated higher reliability (median kappa high experience 0.66 vs. medium 0.59 vs. low 0.48, p <0.001). Assessors with experience using the classification software also had higher reliability than their less experienced counterparts (median kappa: 0.76 vs. 0.57, p <0.001). At present, the AO CMF classification system for mandibular fractures is suited for both clinical and research settings for level 2 variables. Accuracy and reliability decrease for level 3 variables specifically concerning fractures and displacement of condylar process fractures. This will require further investigation into why these fractures were characterized unreliably, which would guide modifications of the system and future instructions for its usage.
View details for DOI 10.1055/s-0038-1677459
View details for PubMedID 31719949
Surgery, Stomas, and Anxiety and Depression in Inflammatory Bowel Disease: A Retrospective Cohort Analysis of Privately Insured Patients.
Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland
AIM: Inflammatory bowel disease (IBD) patients are diagnosed with anxiety/depression at higher rates than the general population. We aimed to determine the frequency of anxiety/depression among IBD patients and temporal association with abdominal surgery and stoma formation.METHODS: We conducted a retrospective cohort study in adult IBD patients using difference-in-differences methodology using a large commercial claims database (2003-2016). Outcomes were anxiety/depression diagnoses before and after major abdominal surgery or stoma formation.RESULTS: We identified 10,481 IBD patients who underwent major abdominal surgery, 18.8% of whom underwent stoma formation, and 41,924 nonsurgical age- and sex-matched IBD controls who were assigned random index dates. Rates of anxiety and depression increased among all cohorts (p<0.001). Surgical patients had higher odds of anxiety (one surgery: adjusted odds ratio 6.90, 95% confidence interval [6.11-7.79], p<0.001; 2+ surgeries: 7.53 [5.99-9.46], p<0.001) and depression (one surgery: 6.15, [5.57-6.80], p<0.001; 2+ surgeries: 6.88 [5.66-8.36], p<0.001) than nonsurgical controls. Undergoing multiple surgeries was associated with a significant increase in depression from pre- to post-time periods (1.43, [1.18-1.73, p<0.001). Amongst surgical patients, stoma formation was independently associated with anxiety (1.40, [1.17-1.68], p<0.001) and depression (1.23, [1.05-1.45], p=0.01). New ostomates experienced a greater increase in postoperative anxiety (1.24, [1.05-1.47], p=0.01) and depression (1.19, [1.03-1.45], p=0.01) than other surgical patients.CONCLUSIONS: IBD patients who undergo surgery have higher rates of anxiety and depression than nonsurgical patients. Rates of anxiety and depression increase following surgery. Stoma formation represents an additional risk factor. These findings suggest the need for perioperative psychosocial support services.
View details for DOI 10.1111/codi.14905
View details for PubMedID 31713994
Effect of Acute Stroke Care Regionalization on Intravenous Alteplase Use in Two Urban Counties.
Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors
Importance: Intravenous alteplase is an effective treatment for acute ischemic stroke and is significantly underutilized. It is known that stroke centers with accreditation provide higher intravenous alteplase treatment, and therefore, policies that increase the number of certified stroke centers and the number of acute ischemic stroke patients routed to these centers may be beneficial. Objective: To determine whether increasing access to primary stroke centers (regionalization) led to an increase in intravenous alteplase use in acute ischemic stroke patients. Design: An observational, longitudinal study to examine treatment trends with log-link binomial regression modeling to compare pre-post policy implementation changes in the proportions of patients treated with intravenous alteplase in two counties. Setting: Two urban counties, Santa Clara and San Mateo, in the western region of US that regionalized acute stroke care between 2005 and 2010. Participants: Patients with primary or secondary diagnosis of stroke were identified from the statewide patient discharge database by International Classification of Diseases (ICD-9) codes. We linked ambulance and hospital data to create complete patient care records. Main outcomes and measures: Stroke treatment, defined as a documented primary procedure code for intravenous alteplase administration (ICD-9: 99.10). Results: In Santa Clara County, intravenous alteplase was administered to 35 patients (1.7%) in the pre-regionalization period and 240 patients (2.1%) in the post-regionalization period. In San Mateo County, intravenous alteplase was administered to 29 patients (1.3%) in the pre-policy period and 135 patients (3.2%) in the post-policy period. After regionalization of stroke care, intravenous alteplase increased two-fold in San Mateo County [adjusted RR 2.20, p = 0.003, 95% CI (1.31, 3.69)] but did not show any statistically significant change in Santa Clara County [adjusted RR 1.10, p = 0.55, 95% CI (0.80, 1.51)]. In the post-regionalization phase, when compared with Santa Clara County, we found that San Mateo County had greater change in paramedic stroke detection, higher number of transports to primary stroke centers and more frequent use of intravenous alteplase at stroke centers. Conclusions: Our findings suggest that greater post-regionalization improvements in San Mateo County contributed to significantly better county-level thrombolysis use than Santa Clara County.
View details for DOI 10.1080/10903127.2019.1679303
View details for PubMedID 31599705
Simplifying Hospital Quality Comparisons for Vascular Surgery Using Center-Level Frailty Burden Rather than Comorbidities
ELSEVIER SCIENCE INC. 2019: S163–S164
View details for Web of Science ID 000492740900304
- Delayed Fasciotomy Is Associated with Higher Risk of Major Amputation in Patients with Acute Limb Ischemia ANNALS OF VASCULAR SURGERY 2019; 59: 195–201
Something for everyone: the benefits of longitudinal mentorship with the application of the acquisition of data for outcomes and procedure transfer (ADOPT) program to a SAGES hands-on colectomy course.
Continued professional development of surgeons remains a challenging and unstandardized enterprise. The Continuing Education Committee of SAGES created the Acquisition of Data for Outcomes and Procedure Adoption (ADOPT) program, incorporating a standardized training approach into hands-on courses with a year-long longitudinal mentorship experience. To evaluate the program's transferability to other procedures following its successful application to a SAGES hernia course, the ADOPT method was applied to the SAGES 2017 laparoscopic colectomy course. Participant data included demographics, training and experience, as well as pre-and post-course self-reported colectomy case volumes and procedure confidence. Confidence levels were for techniques taught in the course using a 5-point scale: 1=not confident at all to 5=completely confident. Participants reported confidence in the following skills for laparoscopic right and left colectomy: (1) formulating an operative plan, (2) identifying proper anatomical planes and isolating anatomic structures, and (3) competently conducting the technical steps of the procedure. A total of 18 surgeons enrolled in the SAGES 2017 Colon Program, 10 of whom completed the 6-month post-course questionnaire (56%). Participants reported significantly higher confidence in all skills at 6months compared to pre-course (p≤0.015). Most participants (60%) reported an increase in the number of procedures performed. The lowest pre-course case volume group (≤5 annual cases, n=5 6-month survey responders) demonstrated a trend for increased procedure volume post-course (5.6 vs. 2, p=0.057). The overwhelming majority of survey respondents (90%) felt either "confident" or "extremely confident" performing the procedures learned (range 80-100% across tasks). Participants found the program to be an advantageous method of becoming competent and confident in performing these procedures. The application of the ADOPT program to the laparoscopic colectomy course was successful in increasing surgeon confidence and demonstrated a trend in improving surgeon procedure counts in the novice participant group.
View details for DOI 10.1007/s00464-019-06900-0
View details for PubMedID 31218420
- Frailty as Measured by the Risk Analysis Index Predicts Long-Term Death After Carotid Endarterectomy MOSBY-ELSEVIER. 2019: E62
- The Impact of Frailty on Failure to Rescue Following Elective Abdominal Aortic Aneurysm Repair MOSBY-ELSEVIER. 2019: E124–E125
Association of Frailty and Postoperative Complications With Unplanned Readmissions After Elective Outpatient Surgery.
JAMA network open
2019; 2 (5): e194330
Importance: Ambulatory surgery in geriatric populations is increasingly prevalent. Prior studies have demonstrated the association between frailty and readmissions in the inpatient setting. However, few data exist regarding the association between frailty and readmissions after outpatient procedures.Objective: To examine the association between frailty and 30-day unplanned readmissions after elective outpatient surgical procedures as well as the potential mediation of surgical complications.Design, Setting, and Participants: In this retrospective cohort study of elective outpatient procedures from 2012 and 2013 in the National Surgical Quality Improvement Program (NSQIP) database, 417 840 patients who underwent elective outpatient procedures were stratified into cohorts of individuals with a length of stay (LOS) of 0 days (LOS=0) and those with a LOS of 1 or more days (LOS≥1). Statistical analysis was performed from June 1, 2018, to March 31, 2019.Exposure: Frailty, as measured by the Risk Analysis Index.Main Outcomes and Measures: The main outcome was 30-day unplanned readmission.Results: Of the 417 840 patients in this study, 59.2% were women and unplanned readmission occurred in 2.3% of the cohort overall (LOS=0, 2.0%; LOS≥1, 3.4%). Frail patients (mean [SD] age, 64.9 [15.5] years) were more likely than nonfrail patients (mean [SD] age, 35.0 [15.8] years) to have an unplanned readmission in both LOS cohorts (LOS=0, 8.3% vs 1.9%; LOS≥1, 8.5% vs 3.2%; P<.001). Frail patients were also more likely than nonfrail patients to experience complications in both cohorts (LOS=0, 6.9% vs 2.5%; LOS≥1, 9.8% vs 4.6%; P<.001). In multivariate analysis, frailty doubled the risk of unplanned readmission (LOS=0: adjusted relative risk [RR], 2.1; 95% CI, 2.0-2.3; LOS≥1: adjusted RR, 1.8; 95% CI, 1.6-2.1). Complications occurred in 3.1% of the entire cohort, and frailty was associated with increased risk of complications (unadjusted RR, 2.6; 95% CI, 2.4-2.8). Mediation analysis confirmed that complications are a significant mediator in the association between frailty and readmissions; however, it also indicated that the association of frailty with readmission was only partially mediated by complications (LOS=0, 22.8%; LOS≥1, 29.3%).Conclusions and Relevance: These findings suggest that frailty is a significant risk factor for unplanned readmission after elective outpatient surgery both independently and when partially mediated through increased complications. Screening for frailty might inform the development of interventions to decrease unplanned readmissions, including those for outpatient procedures.
View details for DOI 10.1001/jamanetworkopen.2019.4330
View details for PubMedID 31125103
- Resident-Sensitive Processes of Care: Impact of Surgical Residents on Inpatient Testing ELSEVIER SCIENCE INC. 2019: 798-+
- Can Machine Learning Methods Produce Accurate and Easy-to-use Prediction Models of 30-day Complications and Mortality After Knee or Hip Arthroplasty? CLINICAL ORTHOPAEDICS AND RELATED RESEARCH 2019; 477 (2): 452–60
- Nonoperative Management of Uncomplicated Appendicitis Among Privately Insured Patients JAMA SURGERY 2019; 154 (2): 141–49
Resident Sensitive Processes of Care: the Impact of Surgical Residents on Inpatient Testing.
Journal of the American College of Surgeons
INTRODUCTION: Healthcare value is a national priority, and there are substantial efforts to reduce overuse of low-value testing. Residency training programs and teaching hospitals have been implicated in excessive testing. We evaluated the impact of surgery residents on the frequency of inpatient testing and investigated potential inter-resident variation.METHODS: Inpatient laboratory and imaging orders placed on general surgery services were extracted from an academic institution from 2014-2016 and linked to National Surgical Quality Improvement Program data. Using negative binomial mixed effects regression with unstructured covariance, we evaluated the frequency of testing orders compared to median utilization, accounting for case, patient, and attending-level variables.RESULTS: 111,055 laboratory and 7,360 imaging orders were linked with 2,357 patients. Multivariable analysis demonstrated multiple significant predictors of increased testing including: postoperative complications, medical comorbidities, length of stay, relative value units, attending surgeon, and resident surgeon (95% confidence intervals >1, p<0.05). Compared to the median resident physician, 47 residents (37.9%) placed significantly more laboratory orders, and 2 residents (1.6%) placed significantly more imaging orders (95% confidence interval >1, p<0.05). Resident identification explained 3.5% of the total variation in laboratory ordering and 4.9% in imaging orders.CONCLUSIONS: Individual surgical residents had a significant association with the frequency of inpatient testing after adjusting for attending, case, and patient-level variables. There was greater resident variation in laboratory testing compared to imaging, yet surgical residents had small contributions to the total variation in both laboratory and imaging testing. Our models provide a means of identifying high utilizers and could be used to educate residents on their ordering patterns.
View details for PubMedID 30660819
Can Machine Learning Methods Produce Accurate and Easy-to-use Prediction Models of 30-day Complications and Mortality After Knee or Hip Arthroplasty?
Clinical orthopaedics and related research
BACKGROUND: Existing universal and procedure-specific surgical risk prediction models of death and major complications after elective total joint arthroplasty (TJA) have limitations including poor transparency, poor to modest accuracy, and insufficient validation to establish performance across diverse settings. Thus, the need remains for accurate and validated prediction models for use in preoperative management, informed consent, shared decision-making, and risk adjustment for reimbursement.QUESTIONS/PURPOSES: The purpose of this study was to use machine learning methods and large national databases to develop and validate (both internally and externally) parsimonious risk-prediction models for mortality and complications after TJA.METHODS: Preoperative demographic and clinical variables from all 107,792 nonemergent primary THAs and TKAs in the 2013 to 2014 American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) were evaluated as predictors of 30-day death and major complications. The NSQIP database was chosen for its high-quality data on important outcomes and rich characterization of preoperative demographic and clinical predictors for demographically and geographically diverse patients. Least absolute shrinkage and selection operator (LASSO) regression, a type of machine learning that optimizes accuracy and parsimony, was used for model development. Tenfold validation was used to produce C-statistics, a measure of how well models discriminate patients who experience an outcome from those who do not. External validation, which evaluates the generalizability of the models to new data sources and patient groups, was accomplished using data from the Veterans Affairs Surgical Quality Improvement Program (VASQIP). Models previously developed from VASQIP data were also externally validated using NSQIP data to examine the generalizability of their performance with a different group of patients outside the VASQIP context.RESULTS: The models, developed using LASSO regression with diverse clinical (for example, American Society of Anesthesiologists classification, comorbidities) and demographic (for example, age, gender) inputs, had good accuracy in terms of discriminating the likelihood a patient would experience, within 30 days of arthroplasty, a renal complication (C-statistic, 0.78; 95% confidence interval [CI], 0.76-0.80), death (0.73; 95% CI, 0.70-0.76), or a cardiac complication (0.73; 95% CI, 0.71-0.75) from one who would not. By contrast, the models demonstrated poor accuracy for venous thromboembolism (C-statistic, 0.61; 95% CI, 0.60-0.62) and any complication (C-statistic, 0.64; 95% CI, 0.63-0.65). External validation of the NSQIP- derived models using VASQIP data found them to be robust in terms of predictions about mortality and cardiac complications, but not for predicting renal complications. Models previously developed with VASQIP data had poor accuracy when externally validated with NSQIP data, suggesting they should not be used outside the context of the Veterans Health Administration.CONCLUSIONS: Moderately accurate predictive models of 30-day mortality and cardiac complications after elective primary TJA were developed as well as internally and externally validated. To our knowledge, these are the most accurate and rigorously validated TJA-specific prediction models currently available (http://med.stanford.edu/s-spire/Resources/clinical-tools-.html). Methods to improve these models, including the addition of nonstandard inputs such as natural language processing of preoperative clinical progress notes or radiographs, should be pursued as should the development and validation of models to predict longer term improvements in pain and function.LEVEL OF EVIDENCE: Level III, diagnostic study.
View details for PubMedID 30624314
Development and validation of a predictive model for American Society of Anesthesiologists Physical Status.
BMC health services research
2019; 19 (1): 859
The American Society of Anesthesiologists Physical Status (ASA-PS) classification system was developed to categorize the fitness of patients before surgery. Increasingly, the ASA-PS has been applied to other uses including justification of inpatient admission. Our objectives were to develop and cross-validate a statistical model for predicting ASA-PS; and 2) assess the concurrent and predictive validity of the model by assessing associations between model-derived ASA-PS, observed ASA-PS, and a diverse set of 30-day outcomes.Using the 2014 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Participant Use Data File, we developed and internally cross-validated multinomial regression models to predict ASA-PS using preoperative NSQIP data. Accuracy was assessed with C-Statistics and calibration plots. We assessed both concurrent and predictive validity of model-derived ASA-PS relative to observed ASA-PS and 30-day outcomes. To aid further research and use of the ASA-PS model, we implemented it into an online calculator.Of the 566,797 elective procedures in the final analytic dataset, 8.9% were ASA-PS 1, 48.9% were ASA-PS 2, 39.1% were ASA-PS 3, and 3.2% were ASA-PS 4. The accuracy of the 21-variable model to predict ASA-PS was C = 0.77 +/- 0.0025. The model-derived ASA-PS had stronger association with key indicators of preoperative status including comorbidities and higher BMI (concurrent validity) compared to observed ASA-PS, but less strong associations with postoperative complications (predictive validity). The online ASA-PS calculator may be accessed at https://s-spire-clintools.shinyapps.io/ASA_PS_Estimator/ CONCLUSIONS: Model-derived ASA-PS better tracked key indicators of preoperative status compared to observed ASA-PS. The ability to have an electronically derived measure of ASA-PS can potentially be useful in research, quality measurement, and clinical applications.
View details for DOI 10.1186/s12913-019-4640-x
View details for PubMedID 31752856
THE IMPACT OF MEDICAID EXPANSION ON TRAUMA-RELATED EMERGENCY DEPARTMENT UTILIZATION: A NATIONAL EVALUATION OF POLICY IMPLICATIONS.
The journal of trauma and acute care surgery
The impact of the 2014 Affordable Care Act (ACA) upon national trauma-related emergency department (ED) utilization is unknown. We assessed ACA-related changes in ED use and payer mix, hypothesizing that post-ACA ED visits would decline and Medicaid coverage would increase disproportionately in regions of widespread policy adoption.We queried the National Emergency Department Sample (NEDS) for those with a primary trauma diagnosis, aged 18 to 64. Comparing pre-ACA (2012) to post-ACA (10/2014 to 09/2015), primary outcomes were change in ED visits and payer status; secondary outcomes were change in costs, discharge disposition and inpatient length of stay. Univariate and multivariate analyses were performed, including difference-in-differences analyses. We compared changes in ED trauma visits by payer in the West (91% in a Medicaid expansion state) versus the South (12%).Among 21.2 million trauma-related ED visits, there was a 13.3% decrease post-ACA. Overall, there was a 7.2% decrease in uninsured ED visits (25.5% vs. 18.3%, p<0.001) and a 6.6% increase in Medicaid coverage (17.6% vs. 24.2%, p<0.001). Trauma patients had 40% increased odds of having Medicaid post-ACA (vs. pre-ACA: aOR 1.40, p<0.001). Patients in the West had 31% greater odds of having Medicaid (vs. South: aOR 1.31, p<0.001). The post-ACA increase in Medicaid was greater in the West (vs. South: aOR 1.60, p<0.001). Post-ACA, inpatients were more likely to have Medicaid (vs. ED discharge: aOR 1.20, p<0.001) and there was a 25% increase in inpatient discharge to rehabilitation (aOR 1.24, p<0.001).Post-ACA, there was a significant increase in insured trauma patients and a decrease in injury-related ED visits, possibly resulting from access to other outpatient services. Ensuring sustainability of expanded coverage will benefit injured patients and trauma systems.Epidemiologic, level III.
View details for DOI 10.1097/TA.0000000000002504
View details for PubMedID 31524835
Comparison of Surgeon Assessment to Frailty Measurement in Abdominal Aortic Aneurysm Repair.
The Journal of surgical research
2019; 248: 38–44
Endovascular abdominal aortic aneurysm repair (EVAR) allows us to intervene on patients otherwise considered poor candidates for open repair. Despite its importance in determining operative approach, no comparison has been made between the subjective "eyeball test" and an objective measurement of preoperative frailty for EVAR patients.Patients undergoing elective EVAR were identified in the Vascular Quality Initiative (VQI) database (2003-2017). Patients were classified "unfit" based on a surgeon-reported variable. Frailty was defined using the VQI-derived Risk Analysis Index, which includes sex, age, BMI, renal failure, congestive heart failure, dyspnea, preoperative ambulation, and functional status. The association between fitness and/or frailty and adverse outcomes was determined by logistic regression.A total of 11,694 patients undergoing elective EVAR were included of which only 18.1% were "unfit," whereas 34.6% were "frail" and overall 43.6% "unfit or frail." Patients deemed "unfit" or "frail" had significantly increased odds of mortality, complications, and nonhome discharge (P < 0.001), and both frailty and unfitness generated negative predictive values for these outcomes greater than 93%. In adjusted logistic regression, the addition of objective frailty significantly improved model performance in predicting nonhome discharge (C-statistic 0.65 versus 0.71, P < 0.001) and complications (0.59 versus 0.61, P = 0.01), but similarly predicted mortality (0.74 versus 0.73, P = 0.99).Preoperative frailty assessment provides a useful objective measure of risk stratification as an adjunct to a physician's clinical intuition. The addition of frailty expands the pool of high-risk patients who are more likely to experience adverse postoperative events after elective EVAR and may benefit from uniquely tailored perioperative interventions.
View details for DOI 10.1016/j.jss.2019.11.005
View details for PubMedID 31841735
Variation in center-level frailty burden and the impact of frailty on long-term survival in patients undergoing elective repair for abdominal aortic aneurysms.
Journal of vascular surgery
Frailty is increasingly recognized as a key determinant in predicting postoperative outcomes. Centers that see more frail patients may not be captured in risk adjustment, potentially accounting for poorer outcomes in hospital comparisons. We aimed to (1) determine the effect of frailty on long-term mortality in patients undergoing elective abdominal aortic aneurysm (AAA) repair and (2) evaluate the variability in frailty burden among centers in the Vascular Quality Initiative (VQI) database.Patients undergoing elective open and endovascular AAA repair (2003-2017) were identified, and those with complete data on component variables of the VQI-derived Risk Analysis Index (VQI-RAI) and centers with ≥10 AAA repairs were included. VQI-RAI characteristics are sex, age, body mass index, renal failure, congestive heart failure, dyspnea, preoperative ambulation, and functional status. Frailty was defined as VQI-RAI ≥35 based on prior work in surgical patients using other quality improvement databases. This corresponds to the top 12% of patients at risk in the VQI. Center-level VQI-RAI differences were assessed by analysis of variance test. Relationships between frailty and survival were compared by Kaplan-Meier analysis and the log-rank test for open and endovascular procedures. Multivariable hierarchical Cox proportional hazards regression models were calculated with random intercepts for center, controlling for frailty, race, insurance, AAA diameter, procedure type, AAA case mix, and year.A total of 15,803 patients from 185 centers were included. Mean VQI-RAI scores were 27.6 (standard deviation, 5.9; range, 4-56) and varied significantly across centers (F = 2.41, P < .001). The percentage of frail patients per center ranged from 0% to 40.0%. In multivariable analysis, frailty was independently associated with long-term mortality (hazard ratio, 2.88; 95% confidence interval, 2.6-3.2) after accounting for covariates and center-level variance. Open AAA repair was not associated with long-term mortality after adjusting for frailty (hazard ratio, 0.98; 95% confidence interval, 0.86-1.13). There was a statistically significant difference in the percentage of frail patients compared with nonfrail patients who were discharged to a rehabilitation facility or nursing home after both open (40.5% vs 17.8%; P < .0001) and endovascular repair (17.7% vs 4.6%; P < .0001).There is considerable variability of preoperative frailty among VQI centers performing elective AAA repair. Adjusting for center-level variation, frailty but not procedure type had a significant association with long-term mortality; however, frailty and procedure type were both associated with nonhome discharge. Routine measurement of frailty preoperatively by centers to identify high-risk patients may help mitigate procedural and long-term outcomes and improve shared decision-making regarding AAA repair.
View details for DOI 10.1016/j.jvs.2019.01.074
View details for PubMedID 31147116
Delayed Fasciotomy is Associated with Higher Risk of Major Amputation in Patients with Acute Limb Ischemia.
Annals of vascular surgery
Compartment syndrome (CS) is a feared complication after revascularization for acute limb ischemia (ALI), and patients often undergo prophylactic 4-compartment fasciotomy at the time of revascularization to avoid developing CS and its associated complications. However, fasciotomy carries its own morbidity and surgeons may opt against this initially. The subsequent development of CS would mandate fasciotomy in a delayed fashion. We sought to investigate relationships between fasciotomy timing and patient outcomes.Patients who underwent lower extremity revascularization for ALI from 2005-2017 were retrospectively identified from an institutional database. Fasciotomy was classified as either prophylactic (occurring with revascularization) or delayed. Associations between patient characteristics, comorbidities, fasciotomy timing and patient outcomes were evaluated.A total of 138 patients met study inclusion criteria. Forty-two patients (30.4%) underwent fasciotomy, and of these, 8 (19%) were delayed. Patients with higher Rutherford acute limb ischemia classification were more likely to undergo fasciotomy (I 4.2%, IIA 13.2%, IIB 53.3%, p<0.001), and patients with coronary artery disease were less likely (16.1% vs. 83.9% fasciotomy, p=0.003). Ischemia time > 6 hours was noted in 66.7% of patients, though this was not significantly associated with fasciotomy occurrence (≤6 hours 21.7% fasciotomy vs. >6 hours 34.8% fasciotomy, p=0.17). Patients undergoing delayed fasciotomy were more likely to require major amputation within 30 days (50% vs. 5.9%, p=0.002).The decision to perform prophylactic fasciotomy in the setting of ALI is complex. When not performed, the subsequent development of CS requiring delayed fasciotomy appears to be associated with increased risk of major amputation at 30 days. This suggests that a liberal approach to prophylactic fasciotomy at the time of revascularization may improve limb salvage rates.
View details for PubMedID 31034949
The impact of skin allograft on inpatient outcomes in the treatment of major burns 20-50% total body surface area - A propensity score matched analysis using the nationwide inpatient sample.
Burns : journal of the International Society for Burn Injuries
BACKGROUND: Human cadaveric skin (allograft) is used in treating major burns both as temporizing wound coverage and a means of testing wound bed viability following burn excision. There is limited information on outcomes, and clinicians disagree on indications for application in intermediate-sized burns. This study aims to improve understanding of allograft use in 20-50% total body surface burns by assessing current utilization and evaluating inpatient outcomes.METHODS: Discharge data from the Nationwide Inpatient Sample (NIS), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality assessed 3557 major burn patients (>second degree depth and 20-50% TBSA) undergoing operative treatment. Outcomes were evaluated with propensity score matching. The primary outcome was mortality with secondary outcomes including complications, length of stay, total burn operations, and charges.RESULTS: After matching, 771 allografted patients were paired with 1774 controls. Covariate mean standard differences were all <11% after matching. The average treatment effect (ATE) of allograft on inpatient mortality was an increase of 2.8% (95% CI 0.2-5.3%, p=0.041). Allograft ATEs were all significantly higher for secondary outcomes: composite complication index increased 0.13 (95% CI 0.07-0.20, p<0.001), length of stay 8.4days (95% CI 6.1-1.9 days, p<0.001), total burn operations 1.6 (95% CI 1.4-1.9, p<0.001), and total charges $139,476 [$100,716-178,236, p<0.001).CONCLUSIONS: Allograft use in major burns 20-50% TBSA was associated with a significant increase in inpatient mortality. There was a notable correlation with increased inpatient complications, longer length of stay, more burn operations, and greater total charges. Better studies are needed to justify the use of this costly and limited resource in the intermediate sized major burn population.
View details for PubMedID 30527451
Nonoperative Management of Uncomplicated Appendicitis Among Privately Insured Patients.
Importance: Health care professionals have shown significant interest in nonoperative management for uncomplicated appendicitis, but long-term population-level data are lacking.Objective: To compare the outcomes of nonoperatively managed appendicitis against appendectomy.Design, Setting, and Participants: This national retrospective cohort study used claims data from a private insurance database to compare patients admitted with uncomplicated appendicitis from January 1, 2008, through December 31, 2014, undergoing appendectomy vs nonoperative management. Coarsened exact matching was applied before multivariate analysis to reduce imbalance between groups. Data were analyzed from February 12 through May 1, 2018.Exposures: Appendectomy (control arm) or nonoperative management (treatment arm).Main Outcomes and Measures: Short-term primary clinical outcomes included emergency department visits, hospital readmission, abdominal abscess, and Clostridium difficile infections. Long-term primary clinical outcomes were small-bowel obstructions, incisional hernias, and appendiceal cancers. Nonoperative management failure was defined by hospital readmission with appendicitis diagnosis and an appendicitis-associated operation or procedure. Secondary outcomes included number of follow-up visits, length and cost of index hospitalization, and total cost of appendicitis-associated care. Covariates included age, sex, region, insurance plan type, admission year, and Charlson comorbidity index.Results: Of 58 329 patients with uncomplicated appendicitis (52.7% men; mean [SD] age, 31.9 [16.5] years), 55 709 (95.5%) underwent appendectomy and 2620 (4.5%) underwent nonoperative management. Patients in the nonoperative management group were more likely to have appendicitis-associated readmissions (adjusted odds ratio, 2.13; 95% CI, 1.63-2.77; P<.001) and to develop an abscess (adjusted odds ratio, 1.42; 95% CI, 1.05-1.92; P=.02). Patients in the nonoperative management group required more follow-up visits in the year after index admission (unadjusted mean [SD], 1.6 [6.3] vs 0.3 [1.4] visits; adjusted +1.11 visits; P<.001) and had lower index hospitalization cost (unadjusted mean [SD], $11 502 [$9287] vs $13 551 [$10 160]; adjusted -$2117, P<.001), but total cost of appendicitis care was higher when follow-up care was considered (unadjusted, $14 934 [$31 122] vs $14 186 [$10 889]; adjusted +$785; P=.003). During a mean (SD) of 3.2 (1.7) years of follow-up, failure of nonoperative management occurred in 101 patients (3.9%); median time to recurrence was 42 days (interquartile range, 8-125 days). Among the patients who experienced treatment failure, 44 did so within 30 days.Conclusions and Relevance: According to results of this study, nonoperative management failure rates were lower than previously reported. Nonoperative management was associated with higher rates of abscess, readmission, and higher overall cost of care. These data suggest that nonoperative management may not be the preferred first-line therapy for all patients with uncomplicated appendicitis.
View details for PubMedID 30427983
- Nonoperative Management of Appendicitis in Privately Insured Patients ELSEVIER SCIENCE INC. 2018: S156–S157
- Interaction of Frailty and Postoperative Complications on Unplanned Readmission after Elective Outpatient Surgery ELSEVIER SCIENCE INC. 2018: E25
- Resident Sensitive Processes of Care: The Impact of Individual Surgical Residents on Laboratory Testing ELSEVIER SCIENCE INC. 2018: S228–S229
- Coordination of Care in Colorectal Cancer Patients: A Population-Based Study ELSEVIER SCIENCE INC. 2018: S141–S142
Evaluating Surgical Residents' Patient-Centered Communication Skills: Practical Alternatives to the "Apprenticeship Model"
JOURNAL OF SURGICAL EDUCATION
2018; 75 (3): 613–21
The Accreditation Council for Graduate Medical Education (ACGME) requires residency programs to assess communication skills and provide feedback to residents. We aimed to develop a feasible data collection process that generates objective clinical performance information to guide training activities, inform ACGME milestone evaluations, and validate assessment instruments.Residents care for patients in the surgical clinic and in the hospital, and participate in a communication curriculum providing practice with standardized patients (SPs). We measured perception of resident communication using the 14-item Communication Assessment Tool (CAT), collecting data from patients at the surgery clinic and surgical wards in the hospital, and from SP encounters during simulated training scenarios. We developed a handout of CAT example behaviors to guide patients completing the communication assessment.Independent academic medical center.General surgery residents.The primary outcome is the percentage of total items patients rated "excellent;" we collected data on 24 of 25 residents. Outpatient evaluations resulted in significantly higher scores (mean 84.5% vs. 68.6%, p < 0.001), and female patients provided nearly statistically significantly higher ratings (mean 85.2% vs. 76.7%, p = 0.084). In multivariate analysis, after controlling for patient gender, visit reason, and race, (1) residents' CAT scores from SPs in simulation were independently associated with communication assessments in their concurrent patient population (p = 0.017), and (2) receiving CAT example instructions was associated with a lower percentage of excellent ratings by 9.3% (p = 0.047).Our data collection process provides a model for obtaining meaningful information about resident communication proficiency. CAT evaluations of surgical residents by the inpatient population had not previously been described in the literature; our results provide important insight into relationships between the evaluations provided by inpatients, clinic patients, and SPs in simulation. Our example behaviors guide shows promise for addressing a common concern, minimizing ceiling effects when measuring physician-patient communication.
View details for PubMedID 28993121
Clinical Predictors of Positive Postoperative Blood Cultures
ANNALS OF SURGERY
2018; 267 (2): 297–302
To define clinical features of surgical patients in whom postoperative blood cultures are likely to identify pathogens.Bacteremia is a worrisome postoperative complication and blood cultures (BCx) are routinely used for evaluation of postoperative bacteremia, but are costly and not always diagnostic. Better methods are needed to select patients in whom BCx identify pathogens.We reviewed records of patients ≥18 years old with BCx drawn ≤10 days after surgery in 2013 seeking independent predictors of positive cultures by simple and multiple logistic regression models with statistical significance at α = 0.05.Of 1804 BCx, excluding contaminants yielded 1780 cultures among 746 patients for analysis. The yield was low, with only 4% identifying potential pathogens. Positive BCx were most common after cardiac, ear/nose/throat, obstetric, and urologic procedures [odds ratio (OR) =10.3, P < 0.001 vs low-yield procedures: eg, gynecologic, neurosurgical, plastic surgical, podiatric, transplant]. Cultures more often grew pathogens when drawn in association with higher peak temperature (Tmax, P = 0.001) and longer interval from procedure to Tmax (P = 0.001). Antibiotic therapy at time of culture reduced yield (2.9% with vs 5.5% without antibiotics, P = 0.007). Multivariable logistic regression analysis found antibiotics at culture, procedure specialty, Tmax, and postoperative timing of Tmax were associated with blood culture results.Ordering blood cultures based on fever or another single predictor inconsistently identifies pathogens. Our dataset, the largest available, identify clinical predictors in the first 10 postoperative days to guide identification of patients with bacteremia.
View details for DOI 10.1097/SLA.0000000000002077
View details for Web of Science ID 000424031700042
View details for PubMedID 27893534
Tell Me Straight: Teaching Residents to Disclose Adverse Events in Surgery.
Journal of surgical education
2018; 75 (6): e178–e191
The purpose of this effort was to create an educational experience that provided learners a realistic disclosure experience and improved resident confidence discussing an adverse outcome with a patient and family.Residents practiced disclosing a surgical complication to a patient/family with simulated patients (SPs). We paired professional SPs with former patient SPs to present a realistic case. Junior residents were given extra training time before their disclosure of a laparoscopic cholecystectomy conversion to an open procedure; senior residents disclosed a bile duct injury. Residents rated pre and post-module confidence levels, and skills performance using the Disclosure of a Complication Checklist.900-bed tertiary care hospital with surgical residency program and simulation center.General surgery residents (PGY 1-5).Eighteen residents participated in the disclosure module. Analysis of the medians and interquartile ranges of pre and post-module confidence scores showed significant improvement for each individual item and mean score of learners. Residents assessed their completion rates of individual Checklist tasks positively. For example, 94% self-endorsed completion of "explanation of facts," 89% self-endorsed "took responsibility," and 78% self-endorsed "apologized sincerely." Self-rated competence scores from the Checklist were low: 7% indicated they would be "extremely comfortable" entrusting their loved one's care to themselves, 11% rated their ability to explain the facts as "outstanding," and 12% felt they were "outstanding" in their "ability to disclose a complication in a professional manner."Residents received important skills practice in our disclosure training; disclosure confidence increased after participation. Residents scored high on completion of disclosure tasks and low on comfort and proficiency of those tasks. The Checklist provided a useful set of tasks to review and complete in the exercise. Separating residents by PGY level enabled senior residents to experience a more complex scenario and junior residents extra time to practice.
View details for PubMedID 30249514
Exploration of Portal Activation by Patients in a Healthcare System
CIN-COMPUTERS INFORMATICS NURSING
2018; 36 (1): 18–26
A study of patient portal utilization was conducted at a not-for-profit healthcare system in Northern Virginia. The healthcare system serves more than 2 million people each year. The encounters with the portal included 461 700 different patients occurring between July 2014 and June 2015. Univariate analysis and multivariable logistic regression indicated associations between patient portal activation and predictive factors. Multiple findings emerged: patient portal activation was greater for English-speaking patients; differences in portal activation were observed by patient age; and patients who had an identified primary care provider were more likely to use the portal. The implications were that patients who have limited English skills and have economic challenges may be less engaged. This review demonstrates the importance of understanding the population using a patient portal and provides insight for future development on how to engage patients to interact with their providers through the portals.
View details for DOI 10.1097/CIN.0000000000000392
View details for Web of Science ID 000419841900004
View details for PubMedID 29049084
Survivability of Existing Peripheral Intravenous Access Following Blood Sampling in a Pediatric Population.
Journal of pediatric nursing
Although pediatric patients report venipuncture as their most feared experience during hospitalization, blood sampling from peripheral intravenous accesses (PIVs) is not standard of care. Blood sampling from PIVs has long been considered by healthcare personnel to harm the access. In an effort to minimize painful procedures, pediatric nursing staff conducted a prospective, observational study to determine if blood sampling using existing PIVs resulted in the loss of the access. The ability to obtain the sample from the PIV was measured along with patient and PIV characteristics.Specimen collection using 100 existing PIVs was attempted on pediatric inpatients. Each PIV was observed for functionality, infiltration, occlusion, and dislodgement following collection and again in 4h. Frequencies of PIV loss and successful blood sampling were calculated. Patient age, PIV gauge, access site, and PIV age were evaluated for associations with successful sampling using chi-square tests, Fisher's exact tests, and logistic regression.PIV survivability was reported at 99%. The ability to obtain a complete specimen was reported at 76% and found to be significantly related to PIV age and site. Size of PIV and patient's age were not significantly related to successful sampling.Encouraging rates of PIV survivability and collectability suggest blood sampling from PIVs to be a valuable technique to minimize painful and distressful procedures.Nursing practice was changed in this pediatric department. Patients and families are saved the pain and distress of venipuncture. Nurses reported saving time and personal distress by avoiding the venipuncture procedure.
View details for DOI 10.1016/j.pedn.2018.02.009
View details for PubMedID 29525119
Low socioeconomic status is associated with lower weight-loss outcomes 10-years after Roux-en-Y gastric bypass.
Roux-en-Y gastric bypass (RYGB) is the criterion standard operation for weight loss. Low socioeconomic status (SES) is common in the Veteran population undergoing bariatric surgery, but the impact of SES on long-term weight-loss outcomes is not known. We hypothesize that low socioeconomic status is associated with less weight loss after gastric bypass in long-term follow-up.We performed a retrospective review of patients undergoing RYGB at a single Veterans Affairs (VA) hospital. Patients with at least 10 years of follow-up data in the electronic health record were included in the analysis. Weight loss was measured as percent excess body mass index loss (%EBMIL). The primary predictor variable, median household income, was determined using zip codes of patient residences matched to publicly available 2010 U.S. census data. Univariate relationships between income, weight loss, and other patient characteristics were evaluated. We calculated a multivariate generalized linear model of %EBMIL to estimate independent relationships with median household income quartile while controlling for patients' age, race, sex, and VA distance.Complete 10-year follow-up data were available for 83 of 92 patients (90.2%) who underwent RYGB between 2001 and 2007 and survived at least 10 years. The majority of patients were male (79.5%) and white (73.5%). The mean 10-year %EBMIL was 57.8% (SD: 29.5%, range - 36.0% - 132.8%). In univariate analysis, income was significantly associated with race (p < 0.001) and median distance to the VA bariatric center (p = 0.034), but income did not differ by gender (p = 0.73) or age (p = 0.45). Multivariate analysis revealed significantly lower 10-year %EBMIL for patients with the lowest income compared to patients with low-mid income (p = 0.03) and mid-high income (p = 0.01), after controlling for gender, race, age, and VA distance.Low socioeconomic status is associated with lower weight-loss outcomes, 10 years after RYGB. Durable weight loss is observed in all income groups.
View details for PubMedID 29987570
All in: expansion of the acquisition of data for outcomes and procedure transfer (ADOPT) program to an entire SAGES annual meeting hands-on hernia course.
Continuing professional development (CPD) for the surgeon has been challenging because of a lack of standardized approaches of hands-on courses, resulting in poor post-course outcomes. To remedy this situation, SAGES has introduced the ADOPT program, implementing a standardized, long-term mentoring program as part of its hernia hands-on course. Previous work evaluating the pilot program showed increased adoption of learned procedures as well as increased confidence of the mentored surgeons. This manuscript describes the impact of such a program when it is instituted across an entire hands-on course.Following collection of pre-course benchmark data, all participants in the 2016 SAGES hands-on hernia course underwent structured, learner-focused instruction during the cadaveric lab. All faculty had completed a standardized teaching course in the Lapco TT format. Subsequently, course participants were enrolled in a year-long program involving longitudinal mentorship, webinars, conference calls, and coaching. Information about participant demographics, training, experience, self-reported case volumes, and confidence levels related to procedures were collected via survey 3 months prior to 9 months after the course.Twenty surgeons participated in the SAGES ADOPT 2016 hands-on hernia program. Of these, seventeen completed pre-course questionnaires (85%), ten completed the 3-month questionnaire (50%), and four completed the 9-month questionnaire (20%). Nine of ten respondents of the 3-month survey (90%) reported changes in their practice. In the 9-month survey, significant increases in the annualized procedural volumes were reported for open primary ventral hernia repair, open components separation, and mesh insertion for ventral hernia repair (p < 0.001).The expansion of the ADOPT program to an entire hands-on hernia course is both feasible and beneficial, with evidence of Kirkpatrick Levels 1-4a training effectiveness. This expanded success suggests that it is a useful blueprint for the CPD of surgeons wishing to learn new techniques and procedures for their patients.
View details for PubMedID 29717374
Patient Perspectives of Surgical Residents' Communication: Do Skills Improve Over Time With a Communication Curriculum?
Journal of surgical education
2018; 75 (6): e142–e149
We aimed to assess surgical residents' communication confidence and skills, analyze resident feedback on our ongoing communication curriculum, and report feedback-driven updates.Surgical residents care for patients in the clinic and hospital and participate in a communication curriculum. We measure patient perception of resident communication using the Communication Assessment Tool (CAT). We assess resident skills confidence and collect curriculum feedback after each quarterly session.900-bed tertiary care hospital with surgical residency program and simulation center.General surgery residents (PGY 1-5).We collected 353 CAT forms from patients in the clinic and hospital on 27 residents. Overall percent "excellent" scores (primary outcome) was 84%. In multivariate analysis we found a statistically significant increase in individuals' CAT scores over time at a rate of 1% improvement per month (p = 0.02). We observed significant improvement of skill confidence in 9 out of 10 training modules. Resident perception of the curriculum has improved over time with 90% of learners rating the course "A" or "A+" across all years. We updated the curriculum to be more learner-centered by: 1) providing differential scenarios for learner level; 2) engaging chief residents as co-faculty; 3) using both professional and volunteer (former patient) actors as SPs; and 4) refining the flow and timing of module practice.We assessed and analyzed surgical residents' communication skills and confidence over 17 months; both showed significant increase over the course of the communication curriculum. We adapted our curriculum using resident feedback and engagement. Our results suggest that communication training can be an effective tool to improve non-technical skills.
View details for PubMedID 30093327
Morbidity and mortality conference is not sufficient for surgical quality control: Processes and outcomes of a successful attending Physician Peer Review committee
AMERICAN JOURNAL OF SURGERY
2017; 214 (5): 780–85
Physician Peer Review (PPR) is required by The Joint Commission to assure examination of individual and group outcomes. Although surgeons may utilize Morbidity and Mortality (M&M) conference, applying these data to determine Focused Professional Practice Evaluations involves outcomes review. A PPR Committee of senior surgeons was created. This report describes one institution's surgical PPR process and results.A two-year (2014-2015) retrospective review of significant non-trauma complications and unanticipated deaths evaluated by PPR was performed. A faculty questionnaire evaluated perceptions of quality outcomes reporting.Of 395 reviewed cases, almost half (48.9%) demonstrated no care improvement opportunities, 48.6% revealed possible improvements, 2% were deviations from standard of care, and 0.5% represented unacceptable care. Although most surgeons (94%) wanted to know their complication rates, only 41% reported maintaining an outcomes database.As a complement to M&M, PPR is a valuable tool in the evaluation of individual surgical quality and can be the basis for further quality improvement opportunities. This process has been largely successful; only a small number of significant concerns were discovered.
View details for DOI 10.1016/j.amjsurg.2017.04.008
View details for Web of Science ID 000415221700002
View details for PubMedID 28502556
Hands-on 2.0: improving transfer of training via the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Acquisition of Data for Outcomes and Procedure Transfer (ADOPT) program
SURGICAL ENDOSCOPY AND OTHER INTERVENTIONAL TECHNIQUES
2017; 31 (8): 3326–32
Practicing surgeons commonly learn new procedures and techniques by attending a "hands-on" course, though trainings are often ineffective at promoting subsequent procedure adoption in practice. We describe implementation of a new program with the SAGES All Things Hernia Hands-On Course, Acquisition of Data for Outcomes and Procedure Transfer (ADOPT), which employs standardized, proven teaching techniques, and 1-year mentorship. Attendee confidence and procedure adoption are compared between standard and ADOPT programs.For the pilot ADOPT course implementation, a hands-on course focusing on abdominal wall hernia repair was chosen. ADOPT participants were recruited among enrollees for the standard Hands-On Hernia Course. Enrollment in ADOPT was capped at 10 participants and limited to a 2:1 student-to-faculty ratio, compared to the standard course 22 participants with a 4:1 student-to-faculty ratio. ADOPT mentors interacted with participants through webinars, phone conferences, and continuous email availability throughout the year. All participants were asked to provide pre- and post-course surveys inquiring about the number of targeted hernia procedures performed and related confidence level.Four of 10 ADOPT participants (40%) and six of 22 standard training participants (27%) returned questionnaires. Over the 3 months following the course, ADOPT participants performed more ventral hernia mesh insertion procedures than standard training participants (median 13 vs. 0.5, p = 0.010) and considerably more total combined procedures (median 26 vs. 7, p = 0.054). Compared to standard training, learners who participated in ADOPT reported greater confidence improvements in employing a components separation via an open approach (p = 0.051), and performing an open transversus abdominis release, though the difference did not achieve statistical significance (p = 0.14).These results suggest that the ADOPT program, with standardized and structured teaching, telementoring, and a longitudinal educational approach, is effective and leads to better transfer of learned skills and procedures to clinical practice.
View details for DOI 10.1007/s00464-016-5366-z
View details for Web of Science ID 000409037100032
View details for PubMedID 28039640
Two-Year Experience Implementing a Curriculum to Improve Residents' Patient-Centered Communication Skills.
Journal of surgical education
OBJECTIVES: Surgery milestones from The Accreditation Council for Graduate Medical Education have encouraged a focus on training and assessment of residents' nontechnical skills, including communication. We describe our 2-year experience implementing a simulation-based curriculum, results of annual communication performance assessments, and resident evaluations.DESIGN: Eight quarterly modules were conducted on various communication topics. Former patient volunteers served as simulation participants (SP) who completed annual assessments using the Communication Assessment Tool (CAT). During these 2 modules, communication skills were assessed in the following standardized scenarios: (1) delivering bad news to a caregiver of a patient with postoperative intracerebral hemorrhage and (2) primary care gallstone referral with contraindications for cholecystectomy. SP-CAT ratings were evaluated for correlations by individual and associations with trainee and SP characteristics. Surgical patient experience surveys are evaluated during the curriculum.SETTING: Independent academic medical center surgical simulation center.PARTICIPANTS: Twenty-five surgery residents per year in 2015 to 2017.RESULTS: Residents have practiced skills in a variety of scenarios including bad news delivery, medical error disclosure, empathic communication, and end-of-life conversations. Residents report positive learning experiences from the curriculum (90% graded all modules A/A+). Confidence ratings rose following each module (p < 0.001) and in the second year (p < 0.001). Annual assessments yielded insights into skills level, and relationships to resident confidence levels and traits. Communication scores were not associated with resident gender or postgraduate year. Over the course of the curriculum implementation, surgical patients have reported that doctors provided explanations with improved clarity (p = 0.042).CONCLUSIONS: The simulation-based SP-CAT has shown initial evidence of usability, content validity, relationships to observed communication behaviors and residents' skills confidence. Evaluations of different scenarios may not be correlated for individuals over time. The communication curriculum paralleled improvements in patient experience concerning surgeons' clear explanations. An ongoing surgery resident communication curriculum has numerous educational, assessment, and institutional benefits.
View details for PubMedID 28756146
EVIDENCE-BASED PRACTICE: VIDEO-DISCHARGE INSTRUCTIONS IN THE PEDIATRIC EMERGENCY DEPARTMENT
JOURNAL OF EMERGENCY NURSING
2017; 43 (4): 316–21
While a high quality discharge from a Pediatric Emergency Department helps caregivers feel informed and prepared to care for their sick child at home, poor adherence to discharge instructions leads to unnecessary return visits, negative health outcomes, and decreased patient satisfaction. Nurses at the Inova Loudoun Pediatric ED utilized the Johns Hopkins Model of Evidence Based Practice to answer the following question: Among caregivers who have children discharged from the ED, does the addition of video discharge instructions (VDI) to standard written/verbal discharge instructions (SDI) result in improved knowledge about the child's diagnosis, treatment, illness duration, and when to seek further medical care?A multidisciplinary team reviewed available evidence and created VDI for three common pediatric diagnoses: gastroenteritis, bronchiolitis, and fever. Knowledge assessments were collected before and after delivery of discharge instructions to caregivers for both the SDI and VDI groups.Analysis found that the VDI group achieved significantly higher scores on the post test survey (P < .001) than the SDI group, particularly regarding treatment and when to seek further medical care. After integrating the best evidence with clinical expertise and an effective VDI intervention, the team incorporated VDI into the discharge process.VDI offer nurses an efficient, standardized method of providing enhanced discharge instructions in the ED. Future projects will examine whether VDI are effective for additional diagnoses and among caregivers for whom English is not the primary language.
View details for DOI 10.1016/j.jen.2016.11.003
View details for Web of Science ID 000407303200008
View details for PubMedID 28359707
Interrater Reliability of Hospital Readmission Evaluations for Surgical Patients
AMERICAN JOURNAL OF MEDICAL QUALITY
2017; 32 (2): 201–7
Value-based purchasing initiatives have helped shift attention to the accuracy of hospital readmission information at the most clinically detailed level. The purpose of this study was to determine the interrater reliability (IRR) of surgical experts in assessing surgical inpatient readmissions for categorical causes, relation to index procedure, and potential preventability. Cases were selected from the American College of Surgeons National Surgical Quality Improvement Program local database. Of 1840 cases, 156 patients (8.5%) were readmitted within 30 days of the procedure. Surgical site infection was the most common readmission cause (32%), followed by obstruction or ileus (17%). IRR was moderate for readmission cause (60% agreement, κ = 0.51), substantial for readmission in relation to surgical procedure (92%, κ = 0.70), and lowest for potential preventability of readmissions (57%, κ = 0.18). Results suggest that readmission cause and relation to surgical procedure can be determined with moderate to high degree of IRR, while preventability of readmissions may require stricter definitions to improve IRR.
View details for DOI 10.1177/1062860615623854
View details for Web of Science ID 000396202100013
View details for PubMedID 26911664
Talk the Talk: Implementing Commasnication Curriculum for Surgical Residents
JOURNAL OF SURGICAL EDUCATION
2017; 74 (2): 319–28
The Accreditation Council for Graduate Medical Education milestones provide a framework of specific interpersonal and communication skills that surgical trainees should aim to master. However, training and assessment of resident nontechnical skills remains challenging. We aimed to develop and implement a curriculum incorporating interactive learning principles such as group discussion and simulation-based scenarios to formalize instruction in patient-centered communication skills, and to identify best practices when building such a program.The curriculum is presented in quarterly modules over a 2-year cycle. Using our surgical simulation center for the training, we focused on proven strategies for interacting with patients and other providers. We trained and used former patients as standardized participants (SPs) in communication scenarios.Surgical simulation center in a 900-bed tertiary care hospital.Program learners were general surgery residents (postgraduate year 1-5). Trauma Survivors Network volunteers served as SPs in simulation scenarios.We identified several important lessons: (1) designing and implementing a new curriculum is a challenging process with multiple barriers and complexities; (2) several readily available facilitators can ease the implementation process; (3) with the right approach, learners, faculty, and colleagues are enthusiastic and engaged participants; (4) learners increasingly agree that communication skills can be improved with practice and appreciate the curriculum value; (5) patient SPs can be valuable members of the team; and importantly (6) the culture of patient-physician communication appears to shift with the implementation of such a curriculum.Our approach using Trauma Survivors Network volunteers as SPs could be reproduced in other institutions with similar programs. Faculty enthusiasm and support is strong, and learner participation is active. Continued focus on patient and family communication skills would enhance patient care for institutions providing such education as well as for institutions where residents continue on in fellowships or begin their surgical practice.
View details for DOI 10.1016/j.jsurg.2016.09.009
View details for Web of Science ID 000397836000019
View details for PubMedID 27825662
Resident Operative Experience at Independent Academic Medical Centers-A Comparison to the National Cohort.
Journal of surgical education
2017; 74 (6): e88–e94
Independent Academic Medical Centers (IAMCs) comprise one-third of U.S. general surgery training programs. It is unclear whether IAMCs offer qualitatively or quantitatively different operative experiences than the national cohort. We analyzed a large representative sample of IAMCs to compare operative volume and variety, with a focus on low-volume procedures.Accreditation Council for Graduate Medical Education Program Case Reports from 27 IAMCs were collected and analyzed for 3 academic years (2012-2015). IAMCs were compared to the national cohort for specific defined category volumes and selected low-volume cases. One-sample two-way t-tests were calculated comparing IAMC totals to national program averages.IAMCs had a median of 3 chief residents per year (range: 1-6). IAMCs reported significantly more "total major" procedures in 2013-2014 (p = 0.046). Other case totals were statistically similar between IAMCs and the national cohort for "total major", "surgeon chief", "surgeon junior", and "teaching assistant" cases. In 2013-2014, IAMCs reported more laparoscopic complex (138.3 vs. 110.6, p = 0.010) and alimentary tract cases (276.5 vs. 253.5, p = 0.019). IAMC esophagogastroduodenoscopy case totals were higher in 2013-2014 (55.9 vs. 41, p = 0.038) and 2014-2015 (47.8 vs. 41, p = 0.047). IAMCs had fewer pancreas cases than the national cohort in all three years by about three cases per resident (p ≤ 0.026). In 2012-2013 IAMCs reported fewer (by about one) esophagectomy, gastrectomy, and abdominal perineal resections. No differences were observed in the following selected procedures: open common bile duct exploration, inguinal hernia, laparoscopic appendectomy, laparoscopic cholecystectomy, and colonoscopy.The IAMCs studied appear to provide equivalent exposure to specific subcategories mandated by the Accreditation Council for Graduate Medical Education and American Board of Surgery. Graduates of IAMCs gain similar operative experience in low-volume, defined categories when compared to the national cohort. Certain specific cases subject to regionalization pressure are less well represented among IAMCs. This has important implications for medical students applying to surgery residency.
View details for DOI 10.1016/j.jsurg.2017.05.020
View details for PubMedID 28602526
Assessment of Surgery Residents' Interpersonal Communication Skills: Validation Evidence for the Communication Assessment Tool in a Simulation Environment.
Journal of surgical education
2016; 73 (6): e19-e27
Although development of trainees' competency in interpersonal communication is essential to high-quality patient-centered surgical care, nontechnical skills present assessment challenges for residency program directors. The Communication Assessment Tool (CAT) demonstrated internal reliability and content validity for general surgery residents, though the tool has not yet been applied in simulation. The study provides validation evidence for using the CAT to assess surgical residents' interpersonal communication skills in simulation scenarios.Simulations of delivering bad news were completed by 21 general surgery residents during a mandatory communication curriculum. Upon completion of the 10-minute scenario, standardized participants (SPs) assessed performance using the 14-item CAT rating scale and individually provided feedback to residents. Discrete communication behaviors were recorded on video review by a trained blinded observer. The traits emotional intelligence questionnaire short form (TEIQue-SF) was completed by the residents 6 months later. SP-CAT ratings are evaluated with respect to learner characteristics, observed behaviors, and TEIQue results.Surgical simulation center in a 900-bed tertiary care hospital.General surgery residents were targeted learners. Trauma survivors network volunteers served as SPs, acting as a family member of a patient who developed an intracerebral hemorrhage following a small bowel procedure.Discrete communication behaviors were reliably assessed by the observer (interrater reliability with trainer: 89% agreement, κ = 0.77). SP-CAT ratings ranged from 34 to 61. Higher SP-CAT ratings were correlated with positive communication behaviors (Spearman ρ = 0.42, p = 0.056). Total TEIQue was positively related to SP-CAT ratings (ρ = 0.42, p = 0.061). The TEIQue emotionality factor was strongly correlated with SP-CAT ratings (ρ = 0.52, p = 0.016).The CAT demonstrates content validity in a simulation environment with former patients acting as SPs. This study provides validation evidence relating the SP-CAT to discrete observations of communication behaviors by a trained, reliable observer as well as residents' self-reported emotional intelligence traits.
View details for DOI 10.1016/j.jsurg.2016.04.016
View details for PubMedID 27216300
Characteristics of Independent Academic Medical Center Faculty.
Journal of surgical education
2016; 73 (6): e48-e53
Little is known about the characteristics of teaching faculty in US surgical residencies based at Independent Academic Medical Centers (IAMCs). The purpose of this study was to survey teaching faculty at IAMCs to better define their common characteristics.An online, anonymous survey was distributed through program officials at 96 IAMCs to their faculty and graduates. Respondents were asked about their demographic information, training history, board certification, clinical practice, and exposure to medical students. Student t-tests and chi-square tests were calculated to evaluate associations between faculty characteristics.Independent Academic Medical Center general surgery training programs PARTICIPANTS: A total of 128 faculty at 14 IAMCs participated in the study.In total, 128 faculty from 14 programs responded to the survey. The mean age of faculty respondents was 52 years and 81% were men. 58% were employed by a nonuniversity hospital, and 28% by a multispecialty practice. 79% of respondents were core faculty. The mean length of time since graduation from surgery residency was 19 years. 86% were currently board certified. 55% of those who were currently board certified had an additional certification. 45% had trained in an IAMC, 50% in an university program, and 5% in a military program. 73% were actively practicing general surgeons, with the majority (70%) performing between 101 and 400 cases annually. The vast majority of faculty (90%) performed <200 endoscopies annually, with 44% performing none. 84% and 35% provided ER and trauma coverage, respectively. 81% listed mentorship as their primary motivation for teaching residents. 23% received a stipend for this teaching. 95% were involved in medical student teaching. Faculty who completed training at university programs had more additional certifications compared with those with IAMC training (67% vs. 43%, p = 0.007). Certification differences by program type were consistent across age and time since residency completion. Age was not associated with residency program type (p = 0.87) nor additional certifications (p = 0.97).IAMC faculty and graduates are overwhelmingly involved in general surgery, and most faculty have additional certifications. 90% of faculty have clinical exposure to medical students. Faculty at IAMCs were as likely to have been trained at an university program as an IAMC. In a time of increasing surgeon subspecialization and anxiety about the ability of 5-year training programs to train well-rounded surgeons, IAMCs appear to be a repository of consistent general surgical training.
View details for DOI 10.1016/j.jsurg.2016.05.006
View details for PubMedID 27321985
Deep vein thrombosis screening and risk factors in a high-risk trauma population
JOURNAL OF SURGICAL RESEARCH
2015; 199 (2): 545–51
Trauma patients requiring acute inpatient rehabilitation are significantly injured, with increased risk for deep vein thrombosis (DVT). We evaluated routine screening for occult DVT in such patients, and analyzed DVT risk factors.Data from level I trauma center patients discharged to a single acute rehabilitation center (ARC) from 2007-2011 were retrospectively reviewed. Routine lower extremity duplex was performed on ARC admission. Follow-up data were collected for patients with occult DVT (ARC DVT). DVT predictors were evaluated using logistic regression.Of 622 patients, 534 (86%) had screening duplex; 26 (4.8%) had an ARC DVT. A majority of 442 patients (71%) received enoxaparin prophylaxis in hospital, for a median 64% of hospital days. Of ARC DVT patients, 17 received full anticoagulation and 16 received vena cava filters. Thirty-seven patients had DVT diagnosed in the hospital (hospital DVT) before discharge to ARC. Hospital DVT and ARC DVT groups were comparable except shorter median hospital length of stay and lower head abbreviated injury scale in ARC DVT patients. On multivariate analysis, increased intensive care unit length of stay, age >65 y, a lower percentage of hospital days receiving chemoprophylaxis, and delayed initiation of chemoprophylaxis were significantly predictive of DVT after adjustment for sex, mechanism, injury severity score, and admission systolic blood pressure. Presence of pelvic fractures and ages 50-65 y also posed an increased risk.The incidence of occult DVT on ARC admission is low in trauma patients. Several risk factors for DVT in the trauma ARC population were identified. Nonselective screening of all trauma patients on admission to ARC is not supported by this analysis.
View details for DOI 10.1016/j.jss.2015.04.069
View details for Web of Science ID 000364433600037
View details for PubMedID 25998183
Applicant Characteristics Associated With Selection for Ranking at Independent Surgery Residency Programs.
Journal of surgical education
2015; 72 (6): e123-9
This study evaluated characteristics of applicants selected for interview and ranked by independent general surgery residency programs and assessed independent program application volumes, interview selection, rank list formation, and match success.Demographic and academic information was analyzed for 2014-2015 applicants. Applicant characteristics were compared by ranking status using univariate and multivariable statistical techniques. Characteristics independently associated with whether or not an applicant was ranked were identified using multivariable logistic regression modeling with backward stepwise variable selection and cluster-correlated robust variance estimates to account for correlations among individuals who applied to multiple programs.The Electronic Residency Application Service was used to obtain applicant data and program match outcomes at 33 independent surgery programs.All applicants selected to interview at 33 participating independent general surgery residency programs were included in the study.Applicants were 60% male with median age of 26 years. Birthplace was well distributed. Most applicants (73%) had ≥1 academic publication. Median United States Medical Licensing Exams (USMLE) Step 1 score was 228 (interquartile range: 218-240), and median USMLE Step 2 clinical knowledge score was 241 (interquartile range: 231-250). Residency programs in some regions more often ranked applicants who attended medical school within the same region. On multivariable analysis, significant predictors of ranking by an independent residency program were: USMLE scores, medical school region, and birth region. Independent programs received an average of 764 applications (range: 307-1704). On average, 12% interviews, and 81% of interviewed applicants were ranked. Most programs (84%) matched at least 1 applicant ranked in their top 10.Participating independent programs attract a large volume of applicants and have high standards in the selection process. This information can be used by surgery residency applicants to gauge their candidacy at independent programs. Independent programs offer a select number of interviews, rank most applicants that they interview, and successfully match competitive applicants.
View details for DOI 10.1016/j.jsurg.2015.04.021
View details for PubMedID 26073713
Factors and Influences That Determine the Choices of Surgery Residency Applicants.
Journal of surgical education
2015; 72 (6): e163-71
We sought to evaluate characteristics of residency applicants selected to interview at independent general surgery programs, identify residency information resources, assess if there is perceived bias toward university or independent programs, and determine what types of programs applicants prefer.An electronic survey was sent to applicants who were selected to interview at a participating independent program. Open-ended responses regarding reasons for program-type bias were submitted. Multivariable logistic regression models were estimated to identify applicant characteristics associated with program-type preference.Independent general surgery residency programs.A total, of 1220 applicants were selected to interview at one of 33 independent programs.In total, 670 surveys were completed (55% response rate). Demographics of respondents were similar to the full invited population. Median United States Medical Licensing Examination Step 1 and Step 2 scores were between 230 to 239 and 240 to 249, respectively. Most applicants reported receiving general information about surgery residency programs and specific information about independent programs from residency program websites. 34% of respondents perceived an imbalanced representation of program types, with 96% of those reporting bias toward university programs.Applicants selected to interview at independent programs are competitive for general surgery training and primarily use residency program websites for information gathering. Bias is common toward university programs for a variety of perceived reasons. This information will be useful in applicant evaluation and selection, serve as a stimulus to update program websites, and challenge independent program directors to work to alleviate bias against their programs.
View details for DOI 10.1016/j.jsurg.2015.05.017
View details for PubMedID 26143518
- Laparoscopic Cholecystectomy Performed by Acute Care Surgeons and General Surgeons AMERICAN SURGEON 2015; 81 (5): E220–E221
Description of the Moderate Brain Injured Patient and Predictors of Discharge to Rehabilitation
ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION
2015; 96 (2): 276–82
To describe patients with moderate traumatic brain injury (TBI) treated and discharged at levels I and II trauma centers in the United States; and to describe the predictors of discharge to rehabilitation after acute care.Retrospective, cross-sectional, descriptive study.Trauma centers.Patients with moderate TBI (N=2087; age range, 18-64 y) as reported in the 2010 National Sample Project.None.Discharge destination (rehabilitation vs home with no services).Multivariate logistic regression models revealed that demographic, clinical, and financial characteristics influenced the likelihood of being discharged to rehabilitation. Increased age, increased severity, Medicare use, longer length of stay, and trauma center locations in the Midwest and Northeast all increased the likelihood of discharge to rehabilitation.The decision to discharge a person with moderate TBI from acute care to rehabilitation appears to be based on factors other than just clinical need. These findings should be considered in creating more equitable access to postacute rehabilitation services for patients with moderate TBI because they risk long-term physical and cognitive problems and have the potential for productive lives with treatment.
View details for DOI 10.1016/j.apmr.2014.09.018
View details for Web of Science ID 000348751800014
View details for PubMedID 25305630
An Evidence-Based Medicine Curriculum Improves General Surgery Residents' Standardized Test Scores in Research and Statistics.
Journal of graduate medical education
2014; 6 (4): 664-668
The application of evidence-based medicine to patient care requires unique skills of the physician. Advancing residents' abilities to accurately evaluate the quality of evidence is built on understanding of fundamental research concepts. The American Board of Surgery In-Training Examination (ABSITE) provides a relevant measure of surgical residents' knowledge of research design and statistics.We implemented a research education curriculum in an independent academic medical center general residency program, and assessed the effect on ABSITE scores.The curriculum consisted of five 1-hour monthly research and statistics lectures. The lectures were presented before the 2012 and 2013 examinations. Forty residents completing ABSITE examinations from 2007 to 2013 were included in the study. Two investigators independently identified research-related item topics from examination summary reports. Correct and incorrect responses were compared precurriculum and postcurriculum. Regression models were calculated to estimate improvement in postcurriculum scores, adjusted for individuals' scores over time and postgraduate year level.Residents demonstrated significant improvement in postcurriculum examination scores for research and statistics items. Correct responses increased 27% (P < .001). Residents were 5 times more likely to achieve a perfect score on research and statistics items postcurriculum (P < .001).Residents at all levels demonstrated improved research and statistics scores after receiving the curriculum. Because the ABSITE includes a wide spectrum of research topics, sustained improvements suggest a genuine level of understanding that will promote lifelong evaluation and clinical application of the surgical literature.
View details for DOI 10.4300/JGME-D-14-00117
View details for PubMedID 26140115
View details for PubMedCentralID PMC4477558
Using NSQIP to Investigate SCIP Deficiencies in Surgical Patients With a High Risk of Developing Hospital-Associated Urinary Tract Infections
AMERICAN JOURNAL OF MEDICAL QUALITY
2014; 29 (5): 381–87
The study objectives were to identify risk factors for surgical patients who develop postoperative urinary tract infections (UTIs) and to characterize urethral catheter practices at the study hospital. Patients from the 2006-2010 institutional National Surgical Quality Improvement Program database were evaluated. Patients with UTIs within 30 postoperative days (n = 116) were compared to patients without UTIs (n = 8685) using multivariable logistic regression. A nested case-control study evaluated the effects of catheter practices on postoperative UTI using conditional logistic regression. Independent predictors of UTI were sex, age, inpatient stay, functional status, renal failure, preoperative transfusion, and preoperative hospital stay. Compared with controls, patients with UTI more often maintained catheters for >2 postoperative days (66% vs 43%, P < .001) and had longer mean catheter duration (11.6 vs 5.1 days, P < .001). Study findings led to institutional recommendations to reduce catheter-associated UTIs. Quality improvement initiatives can increase awareness of performance enhancement opportunities and encourage collaborative, interdisciplinary improvement through shared objectives.
View details for DOI 10.1177/1062860613503363
View details for Web of Science ID 000341284000002
View details for PubMedID 24045369
Are pediatric concussion patients compliant with discharge instructions?
JOURNAL OF TRAUMA AND ACUTE CARE SURGERY
2014; 77 (1): 117–22
Concussions are commonly diagnosed in pediatric patients presenting to the emergency department (ED). The primary objective of this study was to evaluate compliance with ED discharge instructions for concussion management.A prospective cohort study was conducted from November 2011 to November 2012 in a pediatric ED at a regional Level 1 trauma center, serving 35,000 pediatric patients per year. Subjects were aged 8 years to 17 years and were discharged from the ED with a diagnosis of concussion. Exclusion criteria included recent (past 3 months) diagnosis of head injury, hospital admission, intracranial injury, skull fracture, suspected nonaccidental trauma, or preexisting neurologic condition. Subjects were administered a baseline survey in the ED and were given standardized discharge instructions for concussion by the treating physician. Telephone follow-up surveys were conducted at 2 weeks and 4 weeks after ED visit.A total of 150 patients were enrolled. The majority (67%) of concussions were sports related. Among sports-related concussions, soccer (30%), football (11%), lacrosse (8%), and basketball (8%) injuries were most common. More than one third (39%) reported return to play (RTP) on the day of the injury. Physician follow-up was equivalent for sport and nonsport concussions (2 weeks, 58%; 4 weeks, 64%). Sports-related concussion patients were more likely to follow up with a trainer (2 weeks, 25% vs. 10%, p = 0.06; 4 weeks, 29% vs. 8%, p < 0.01). Of the patients who did RTP or normal activities at 2 weeks (44%), more than one third (35%) were symptomatic, and most (58%) did not receive medical clearance. Of the patients who had returned to activities at 4 weeks (64%), less than one quarter (23%) were symptomatic, and most (54%) received medical clearance.Pediatric patients discharged from the ED are mostly compliant with concussion instructions. However, a significant number of patients RTP on the day of injury, while experiencing symptoms or without medical clearance.Care management, level IV. Epidemiologic study, level III.
View details for DOI 10.1097/TA.0000000000000275
View details for Web of Science ID 000338389600031
View details for PubMedID 24977765
Colectomy without mechanical bowel preparation in the private practice setting
TECHNIQUES IN COLOPROCTOLOGY
2014; 18 (1): 45–51
Despite randomized trials and meta-analyses demonstrating the safety of omitting mechanical bowel preparation (MBP) before colorectal surgery, private practice surgeons may hesitate to eliminate MBP for fear of being outside community standards. This study evaluated the safety of eliminating MBP before colectomy in a private practice setting.This prospective observational study included elective abdominal colorectal operations from one surgeon's practice from October 2008 to June 2011. MBP was not routinely utilized after November 2009. Postoperative 30-day complication rates and length of hospital stay were compared in patients with and without MBP. Multivariable regression models were developed to compare outcomes among study groups, adjusting for demographics, diagnoses, procedures, and year.A total of 165 patients were analyzed. Demographics were similar between groups. Laparoscopic procedures were more common in patients without MBP due to increased laparoscopy over time (43 vs. 61 %, p = 0.03). As regards complications, infection rates were similar between groups (MBP 10.5 % vs. no MBP(NMBP) 11.4 %, adj p = 0.57). Patients without MBP had a shorter length of hospital stay (median: 6 vs. 5 days, p = 0.01), but those differences were not statistically significant after adjustment (p = 0.14).Private practice surgeons should embrace evidence-based practice changes and make efforts to quantitatively evaluate the safety of those changes. Omission of MBP for most elective colectomy procedures appears to be safe with no significant increase in complications or length of hospital stay. Because MBP has substantial drawbacks, there is little justification for its routine use in the majority of elective abdominal colorectal procedures.
View details for DOI 10.1007/s10151-013-0990-2
View details for Web of Science ID 000329710100008
View details for PubMedID 23467770
Transcranial Doppler Investigation of Hemodynamic Alterations Associated With Blunt Cervical Vascular Injuries in Trauma Patients
JOURNAL OF ULTRASOUND IN MEDICINE
2013; 32 (10): 1759-1768
Blunt cervical vascular injuries, often missed with current screening methods, have substantial morbidity and mortality, and there is a need for improved screening. Elucidation of cerebral hemodynamic alterations may facilitate serial bedside monitoring and improved management. Thus, the objective of this study was to define cerebral flow alterations associated with single blunt cervical vascular injuries using transcranial Doppler sonography and subsequent Doppler waveform analyses in a trauma population.In this prospective pilot study, patients with suspected blunt cervical vascular injuries had diagnoses by computed tomographic angiography and were examined using transcranial Doppler sonography to define cerebral hemodynamics. Multiple vessel injuries were excluded for this analysis, as the focus was to identify hemodynamic alterations from isolated injuries. The inverse damping factor characterized altered extracranial flow patterns; middle cerebral artery flow velocities, the pulsatility index, and their asymmetries characterized altered intracranial flow patterns.Twenty-three trauma patients were evaluated: 4 with single internal carotid artery injuries, 5 with single vertebral artery injuries, and 14 without blunt cervical vascular injuries. All internal carotid artery injuries showed a reduced inverse damping factor in the internal carotid artery and dampened ipsilateral mean flow and peak systolic velocities in the middle cerebral artery. Vertebral artery injuries produced asymmetry of a similar magnitude in the middle cerebral artery mean flow velocity with end-diastolic velocity alterations.These data indicate that extracranial and intracranial hemodynamic alterations occur with internal carotid artery and vertebral artery blunt cervical vascular injuries and can be quantified in the acute injury phase by transcranial Doppler indices. Further study is required to elucidate cerebral flow changes resulting from a single blunt cervical vascular injury, which may guide future management to preserve cerebral perfusion after trauma.
View details for DOI 10.7863/ultra.32.10.1759
View details for Web of Science ID 000326357000010
View details for PubMedID 24065257
The impact of missing trauma data on predicting massive transfusion
LIPPINCOTT WILLIAMS & WILKINS. 2013: S68–S74
Missing data are inherent in clinical research and may be especially problematic for trauma studies. This study describes a sensitivity analysis to evaluate the impact of missing data on clinical risk prediction algorithms. Three blood transfusion prediction models were evaluated using an observational trauma data set with valid missing data.The PRospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study included patients requiring one or more unit of red blood cells at 10 participating US Level I trauma centers from July 2009 to October 2010. Physiologic, laboratory, and treatment data were collected prospectively up to 24 hours after hospital admission. Subjects who received 10 or more units of red blood cells within 24 hours of admission were classified as massive transfusion (MT) patients. Correct classification percentages for three MT prediction models were evaluated using complete case analysis and multiple imputation. A sensitivity analysis for missing data was conducted to determine the upper and lower bounds for correct classification percentages.PROMMTT study enrolled 1,245 subjects. MT was received by 297 patients (24%). Missing percentage ranged from 2.2% (heart rate) to 45% (respiratory rate). Proportions of complete cases used in the MT prediction models ranged from 41% to 88%. All models demonstrated similar correct classification percentages using complete case analysis and multiple imputation. In the sensitivity analysis, correct classification upper-lower bound ranges per model were 4%, 10%, and 12%. Predictive accuracy for all models using PROMMTT data was lower than reported in the original data sets.Evaluating the accuracy clinical prediction models with missing data can be misleading, especially with many predictor variables and moderate levels of missingness per variable. The proposed sensitivity analysis describes the influence of missing data on risk prediction algorithms. Reporting upper-lower bounds for percent correct classification may be more informative than multiple imputation, which provided similar results to complete case analysis in this study.
View details for DOI 10.1097/TA.0b013e3182914530
View details for Web of Science ID 000330458600011
View details for PubMedID 23778514
View details for PubMedCentralID PMC3736742
Implications of Medicare procedure volumes on resident education
AMERICAN JOURNAL OF SURGERY
2013; 205 (6): 737–44
Preparation of future general surgeons requires the ongoing assessment of projected case experience.Surgical procedures (2005-2008) were abstracted from the Centers for Medicare and Medicaid Services inpatient National Claims History Part A 100% Nearline File for all general surgeons. The most frequent Medicare surgical procedures and physician caseloads were compared by practice population.Over 5 million procedures were evaluated, with procedures decreasing over time in urban and large rural areas. A total of 15 procedures comprised the top 10 for all population/year categories. The most frequent surgical procedures were similar in rural and urban areas. Rural surgeons' caseloads consisted of a higher proportion of endoscopic procedures.The most common Medicare general surgery procedures are similar across population areas and are required experience for residents. Separate surgical educational programs for urban and rural general surgeons may not be necessary to provide adequate care to rural patients.
View details for DOI 10.1016/j.amjsurg.2012.11.006
View details for Web of Science ID 000319802500018
View details for PubMedID 23540717
A Novel Decision Tree Approach Based on Transcranial Doppler Sonography to Screen for Blunt Cervical Vascular Injuries
JOURNAL OF ULTRASOUND IN MEDICINE
2013; 32 (6): 1023-1031
Early detection and treatment of blunt cervical vascular injuries prevent adverse neurologic sequelae. Current screening criteria can miss up to 22% of these injuries. The study objective was to investigate bedside transcranial Doppler sonography for detecting blunt cervical vascular injuries in trauma patients using a novel decision tree approach.This prospective pilot study was conducted at a level I trauma center. Patients undergoing computed tomographic angiography for suspected blunt cervical vascular injuries were studied with transcranial Doppler sonography. Extracranial and intracranial vasculatures were examined with a portable power M-mode transcranial Doppler unit. The middle cerebral artery mean flow velocity, pulsatility index, and their asymmetries were used to quantify flow patterns and develop an injury decision tree screening protocol. Student t tests validated associations between injuries and transcranial Doppler predictive measures.We evaluated 27 trauma patients with 13 injuries. Single vertebral artery injuries were most common (38.5%), followed by single internal carotid artery injuries (30%). Compared to patients without injuries, mean flow velocity asymmetry was higher for single internal carotid artery (P = .003) and single vertebral artery (P = .004) injuries. Similarly, pulsatility index asymmetry was higher in single internal carotid artery (P = .015) and single vertebral artery (P = .042) injuries, whereas the lowest pulsatility index was elevated for bilateral vertebral artery injuries (P = .006). The decision tree yielded 92% specificity, 93% sensitivity, and 93% correct classifications.In this pilot feasibility study, transcranial Doppler measures were significantly associated with the blunt cervical vascular injury status, suggesting that transcranial Doppler sonography might be a viable bedside screening tool for trauma. Patient-specific hemodynamic information from transcranial Doppler assessment has the potential to alter patient care pathways to improve outcomes.
View details for DOI 10.7863/ultra.32.6.1023
View details for Web of Science ID 000319895500016
View details for PubMedID 23716524
Website Usage and Weight Loss in a Free Commercial Online Weight Loss Program: Retrospective Cohort Study
JOURNAL OF MEDICAL INTERNET RESEARCH
2013; 15 (1): e11
Online weight loss programs are increasingly popular. However, little is known about outcomes and associations with website usage among members of free online weight loss programs.This retrospective cohort study examined the association between website usage and weight loss among members of a free commercial online weight loss program (SparkPeople).We conducted a retrospective analysis of a systematic random sample of members who joined the program during February 1 to April 30, 2008, and included follow-up data through May 10, 2010. The main outcome was net weight change based on self-reported weight. Measures of website usage included log-ins, self-monitoring entries (weight, food, exercise), and use of social support tools (discussion forums, friendships).The main sample included 1258 members with at least 2 weight entries. They were 90.7% female, with mean (SD) age 33.6 (11.0) and mean (SD) BMI 31.6 (7.7). Members with at least one forum post lost an additional 1.55 kg (95% CI 0.55 kg to 2.55 kg) relative to those with no forum posts. Having at least 4 log-in days, weight entry days, or food entry days per 30 days was significantly associated with weight loss. In the multiple regression analysis, members with at least 4 weight entry days per 30 days reported 5.09 kg (95% CI 3.29 kg to 6.88 kg) more weight loss per 30 days than those with fewer weight entry days. After controlling for weight entry days, the other website usage variables were not associated with weight change.Weekly or more frequent self-monitoring of weight is associated with greater weight loss among members of this free online weight loss program.
View details for DOI 10.2196/jmir.2195
View details for Web of Science ID 000315113200018
View details for PubMedID 23322819
View details for PubMedCentralID PMC3636231
Speaking Up and Sharing Information Improves Trainee Neonatal Resuscitations
JOURNAL OF PATIENT SAFETY
2012; 8 (4): 202–9
To identify teamwork behaviors associated with improving efficiency and quality of simulated resuscitation training.Secondary analysis of a randomized controlled trial of trainees undergoing neonatal resuscitation training was performed. Trainees at a large academic center (n = 100) were randomized to receive standard curriculum (n = 36) versus supplemental team training curriculum (n = 62). A 2-hour team training session focused on communication skills, and team behaviors served as the intervention. Outcomes of interest included resuscitation duration, time required to complete a simulated newborn resuscitation, and performance score, determined by evaluation of each of the team's steps during simulated resuscitation scenarios.The teamwork behaviors assertion and sharing information were associated with shorter resuscitation duration and higher performance scores. Each additional use of assertion (per minute) was associated with a duration reduction of 41 s (95% confidence interval [CI], -71.5 to -10.2) and an increase in performance score of 1.6% (95% CI, 0.4-2.7). Each additional use of sharing information (per minute) was associated with a 14-second reduction in duration (95% CI, -30.4 to 2.9) and a 0.8% increase in performance score (95% CI, 0.05-1.5).Teamwork behaviors of assertion and sharing information are 2 important mediators of efficiency and quality of resuscitations.
View details for DOI 10.1097/PTS.0b013e3182699b4f
View details for Web of Science ID 000313586500009
View details for PubMedID 23007245
View details for PubMedCentralID PMC3504644
General Surgery vs Fellowship: The Role of the Independent Academic Medical Center
JOURNAL OF SURGICAL EDUCATION
2012; 69 (6): 740-745
To compare career choices of residency graduates from Independent Academic Medical Center (IAMC) and University Academic Medical Center (UAMC) programs and evaluate program directors' perceptions of residents' motivations for pursuing general surgery or fellowships.From May to August 2011, an electronic survey collected information on program characteristics, graduates' career pursuits, and career motivations. Fisher's exact tests were calculated to compare responses by program type. Multivariate logistic regression was used to identify independent program characteristics associated with graduates pursuing general surgery.Data were collected on graduates over 3 years (2009-2011).Surgery residency program directors.Seventy-four program directors completed the survey; 42% represented IAMCs. IAMCs reported more graduates choosing general surgery. Over one-quarter of graduates pursued general surgery from 52% of IAMC vs 37% of UAMC programs (p = 0.243). Career choices varied significantly by region: over one-quarter of graduates pursue general surgery from 78% of Western, 60% of Midwestern, 40% of Southern, and 24% of Northeastern programs (p = 0.018). On multivariate analysis, IAMC programs were independently associated with more graduates choosing general surgery (p = 0.017), after adjustment for other program characteristics. Seventy-five percent of UAMC programs reported over three-fourths of graduates receive first choice fellowship, compared with only 52% of IAMC programs (p = 0.067). Fellowships were comparable among IAMC and UAMC programs, most commonly MIS/Bariatric (16%), Critical Care/Trauma (16%), and Vascular (14%). IAMC and UAMC program directors cite similar reasons for graduate career choices.Most general surgery residents undergo fellowship training. Graduates from IAMC and UAMC programs pursue similar specialties, but UAMC programs report more first choice acceptance. IAMC programs may graduate proportionately more general surgeons. Further studies directly evaluating surgical residents' career choices are warranted to understand the influence of independent and university programs in shaping these choices and to develop strategies for reducing the general surgeon shortage.
View details for DOI 10.1016/j.jsurg.2012.05.006
View details for Web of Science ID 000311024100012
View details for PubMedID 23111040
Sound Levels, Staff Perceptions, and Patient Outcomes During Renovation Near the Neonatal Intensive Care Unit
HERD-HEALTH ENVIRONMENTS RESEARCH & DESIGN JOURNAL
2012; 5 (4): 76–87
Sound levels, staff perceptions, and patient outcomes were evaluated during a year-long hospital renovation project on the floor above a neonatal intensive care unit (NICU).Construction noise may be detrimental to NICU patients and healthcare professionals. There are no comprehensive studies evaluating the impact of hospital construction on sound levels, staff, and patients.Prospective observational study comparing sound measures and patient outcomes before, during, and after construction. Staff were surveyed about the construction noise, and hospital employee satisfaction scores are reported.Equivalent sound levels were not significantly higher during construction. Most staff members (89%) perceived the renovation period as louder, and 83% reported interruptions of their work. Patient outcomes were the same or more positive during construction. Very low birth weight (VLBW) infants were less likely to require 24+ hours' mechanical ventilation during construction: 54% vs. 59% before (OR = 1.6, p = 0.018) and 62% after (OR = 1.48, p = 0.065); and they required a shorter total period of mechanical ventilation: 3.6 days vs. 8.0 before (p = 0.011) and 9.5 after (p = 0.001). VLBW newborns' differences in ventilation days were mostly in the upper extremes; medians were similar in all periods: 0.6 days vs. 1 day preconstruction and 2 days postconstruction.Construction above the NICU did not cause substantially louder sound levels, but staff perceived important changes in noise and work routines. No evidence suggested that patients were negatively affected by the renovation period. Meticulous construction planning remains necessary to avoid interference with patient care and caregiver work environments.
View details for DOI 10.1177/193758671200500407
View details for Web of Science ID 000309436900007
View details for PubMedID 23224808
Acceptability of narratives to promote colorectal cancer screening in an online community
2012; 54 (6): 405–7
To assess the acceptability of narratives to promote colorectal cancer (CRC) screening among members of an online weight loss community.Members of online weight loss community completed an Internet survey in 2010. Multiple logistic regression models examined demographic and attitudinal correlates of interest in sharing and receiving CRC screening narratives.Participants (n=2386) were 92% female with mean (SD) age 58 (6) years; 68% were up-to-date with CRC screening. Among those who were up-to-date, 39% were interested in sharing their narratives with other members. African-Americans were more likely than other racial groups to be interested in sharing narratives (adjusted OR 2.02, 95% CI 1.14-3.57). Older, married members and those with greater CRC screening worries were less likely to be interested in sharing narratives. Among those not up-to-date, 63% were interested in receiving narratives from online community members, and those with higher perceived salience of CRC screening were more likely to be interested in receiving narratives (adjusted OR 1.86, 95% CI 1.31-2.65).Members of this online weight loss community expressed interest in sharing and receiving narratives for CRC screening promotion. Attitudes and demographic characteristics may predict successful recruitment of those who would share and receive narratives.
View details for DOI 10.1016/j.ypmed.2012.03.018
View details for Web of Science ID 000305378900007
View details for PubMedID 22498021
View details for PubMedCentralID PMC4154343
Team Training in the Neonatal Resuscitation Program for Interns: Teamwork and Quality of Resuscitations
2010; 125 (3): 539–46
Poor communication and teamwork may contribute to errors during neonatal resuscitation. Our objective was to evaluate whether interns who received a 2-hour teamwork training intervention with the Neonatal Resuscitation Program (NRP) demonstrated more teamwork and higher quality resuscitations than control subjects.Participants were noncertified 2007 and 2008 incoming interns for pediatrics, combined pediatrics and internal medicine, family medicine, emergency medicine, and obstetrics and gynecology (n = 98). Pediatrics and combined pediatrics/internal medicine interns were eligible for 6-month follow-up (n = 34). A randomized trial was conducted in which half of the participants in the team training arm practiced NRP skills by using high-fidelity simulators; the remaining practiced with low-fidelity simulators, as did control subjects. Blinded, trained observers viewed video recordings of high-fidelity-simulated resuscitations for teamwork and resuscitation quality.High-fidelity training (HFT) group had higher teamwork frequency than did control subjects (12.8 vs 9.0 behaviors per minute; P < .001). Intervention groups maintained more workload management (control subjects: 89.3%; low-fidelity training [LFT] group: 98.0% [P < .001]; HFT group: 98.8%; HFT group versus control subjects [P < .001]) and completed resuscitations faster (control subjects: 10.6 minutes; LFT group: 8.6 minutes [P = .040]; HFT group: 7.4 minutes; HFT group versus control subjects [P < .001]). Overall, intervention teams completed the resuscitation an average of 2.6 minutes faster than did control subjects, a time reduction of 24% (95% confidence interval: 12%-37%). Intervention groups demonstrated more frequent teamwork during 6-month follow-up resuscitations (11.8 vs 10.0 behaviors per minute; P = .030).Trained participants exhibited more frequent teamwork behaviors (especially the HFT group) and better workload management and completed the resuscitation more quickly than did control subjects. The impact on team behaviors persisted for at least 6 months. Incorporating team training into the NRP curriculum is a feasible and effective way to teach interns teamwork skills. It also improves simulated resuscitation quality by shortening the duration.
View details for DOI 10.1542/peds.2009-1635
View details for Web of Science ID 000275945700018
View details for PubMedID 20156896
Teamwork behaviours and errors during neonatal resuscitation
QUALITY & SAFETY IN HEALTH CARE
2010; 19 (1): 60-64
To describe relationships between teamwork behaviours and errors during neonatal resuscitation.Trained observers viewed video recordings of neonatal resuscitations (n = 12) for the occurrence of teamwork behaviours and errors. Teamwork state behaviours (such as vigilance and workload management, which extend for some duration) were assessed as the percentage of each resuscitation that the behaviour was observed and correlated with the percentage of observed errors. Teamwork event behaviours (such as information sharing, inquiry and assertion, which occur at specific times) were counted in 20-s intervals before and after resuscitation steps, and a generalised linear mixed model was calculated to evaluate relationships between these behaviours and errors.Resuscitation teams who were more vigilant committed fewer errors (Spearman's rho for vigilance and errors = -0.62, 95% CI -0.07 to -0.87, p = 0.031). Assertions were more likely to occur before errors than correct steps (OR = 1.44, 95% CI 1.10 to 1.89, p = 0.008) and teaching/advising occurred less frequently after errors (OR = 0.59, 95% CI 0.37 to 0.94, p = 0.028). Though not statistically significant, there was less information sharing before errors (OR = 0.90, 95% CI 0.77 to 1.05, p = 0.172).Vigilance is an important behaviour for error management. Assertion may have caused errors, or perhaps was an indicator for some other factor that caused errors. Teams may have preferred to resolve errors directly, rather than using errors as opportunities to teach their teammates. These observations raise important questions about the appropriate use of some teamwork behaviours and how to include them in team training programmes.
View details for DOI 10.1136/qshc.2007.025320
View details for Web of Science ID 000274641500012
View details for PubMedID 20172885
Heart Rate Variability in Response to Pain Stimulus in VLBW Infants Followed Longitudinally During NICU Stay
2009; 51 (8): 638–49
The objective of this longitudinal study, conducted in a neonatal intensive care unit, was to characterize the response to pain of high-risk very low birth weight infants (<1,500 g) from 23 to 38 weeks post-menstrual age (PMA) by measuring heart rate variability (HRV). Heart period data were recorded before, during, and after a heel lanced or wrist venipunctured blood draw for routine clinical evaluation. Pain response to the blood draw procedure and age-related changes of HRV in low-frequency and high-frequency bands were modeled with linear mixed-effects models. HRV in both bands decreased during pain, followed by a recovery to near-baseline levels. Venipuncture and mechanical ventilation were factors that attenuated the HRV response to pain. HRV at the baseline increased with post-menstrual age but the growth rate of high-frequency power was reduced in mechanically ventilated infants. There was some evidence that low-frequency HRV response to pain improved with advancing PMA.
View details for DOI 10.1002/dev.20399
View details for Web of Science ID 000272671000004
View details for PubMedID 19739134
View details for PubMedCentralID PMC2936240
The behavioral pain response to heelstick in preterm neonates studied longitudinally: Description, development, determinants, and components
EARLY HUMAN DEVELOPMENT
2009; 85 (6): 369–74
Preterm infants often experience multiple painful procedures during their stay in neonatal intensive care units (NICUs). The objectives of this study were to evaluate behavioral responses to heelstick in preterm newborns, characterize developmental changes and the effects of other demographic and clinical variables on the pain response, and estimate the contributions of individual Neonatal Infant Pain Scale (NIPS) behaviors to the summary pain score.A longitudinal study was conducted to evaluate the behavioral responses of 35 preterm newborns to multiple heelstick procedures during their stay in the NICU. Sixty-one video recordings of blood collection by heel lance were evaluated for behavioral pain response using the NIPS. Generalized linear mixed models were calculated to address the study objectives.The increases in NIPS scores from the baseline to the blood draw were highly significant (mean baseline score=3.34, mean blood draw score=5.45, p<0.001). The newborns' pain responses increased an average of 0.23 points on the NIPS scale each week (p=0.002). Lower NIPS scores during the heelstick procedure were associated with four clinical variables: younger post-menstrual age at birth, lower birthweight, mechanical ventilation, and longer length of stay in the NICU. Crying, arousal state, and facial grimace contributed more than 85% of the increase in NIPS scores during the heelstick procedure.While behavioral responses to pain are attenuated in young, severely ill preterm newborns, they can be reliably detected. The most robust pain behaviors are crying, changes in arousal state, and facial grimacing.
View details for DOI 10.1016/j.earlhumdev.2009.01.001
View details for Web of Science ID 000266851700005
View details for PubMedID 19167172
Intensive Care Noise and Mean Arterial Blood Pressure in Extremely Low-Birth-Weight Neonates
AMERICAN JOURNAL OF PERINATOLOGY
2009; 26 (5): 323-329
Noise in neonatal intensive care units (NICUs) may impede growth and development for extremely low-birth-weight (ELBW, < 1000 g) newborns. We calculated correlations between NICU sound levels and ELBW neonates' heart rate and arterial blood pressure to evaluate whether this population experiences noise-induced stress. Sound levels inside the incubator, heart rate (HR), and arterial blood pressure recordings were simultaneously collected for eight ELBW neonates for 15 minutes during the first week of life. Cross-correlation functions were calculated for NICU noise, HR, and mean arterial blood pressure (MABP) recordings for each subject. ELBW neonates' HR and MABP were significantly correlated ( R = 0.16 at 2-second lag time), with stronger correlation apparent for higher-birth-weight ELBW newborns (0.22 versus 0.10). Lower-birth-weight newborns responded to increased noise with HR acceleration from 45 to 130 seconds after noise events, and higher-birth-weight infants initially responded with an HR deceleration at 25 to 60 seconds, then HR acceleration ~175 seconds after noise increased. MABP was not as strongly correlated with NICU sound levels, although some correlation coefficients were slightly outside the 95% confidence interval. Higher-birth-weight newborns' more mature neurological systems may be responsible for stronger correlations between HR and MABP. NICU noise influenced newborns' HR, indicating that these infants hear and respond to NICU sounds. ELBW newborns in the first week of life seem to maintain a relatively stable blood pressure in response to moderate NICU sound levels (50 to 60 dBA).
View details for DOI 10.1055/s-0028-1104741
View details for Web of Science ID 000265577700001
View details for PubMedID 19085678
A randomized clinical trial evaluating silicone earplugs for very low birth weight newborns in intensive care
JOURNAL OF PERINATOLOGY
2009; 29 (5): 358–63
To determine whether very low birth weight (VLBW) newborns (<1500 g) wearing silicone earplugs grow larger and perform better on developmental exams than controls.VLBW newborns (n=34) were randomized to wearing earplugs or not. Hospital outcomes were abstracted from medical charts by research staff masked to intervention status. Fourteen extremely low birth weight (ELBW) newborns (<1000 g) were also evaluated at 18 to 22 months.After adjusting for birth weight, 11 surviving newborns in the earplug group were 225 g (95% CI: 45, 405) heavier at 34 weeks post menstrual age than the 13 controls. Six ELBW earplug infants scored 15.53 points (95% CI: 3.03, 28.02) higher than six controls on the Bayley Mental Development Index. Their head circumferences were 2.59 cm (95% CI: 0.97, 4.21) larger.Earplugs may facilitate weight gain in VLBW newborns. Better outcomes may persist at 18 to 22 months at least in ELBW infants.
View details for DOI 10.1038/jp.2008.236
View details for Web of Science ID 000265853300005
View details for PubMedID 19194455
View details for PubMedCentralID PMC2674530
Noise and Light Exposures for Extremely Low Birth Weight Newborns During Their Stay in the Neonatal Intensive Care Unit
2009; 123 (2): 540-546
The objectives of this study were to characterize noise and light levels for extremely low birth weight newborns throughout their stay in the NICU, evaluate factors influencing noise and light levels, and determine whether exposures meet recommendations from the American Academy of Pediatrics.Sound and light were measured inside the beds of extremely low birth weight newborns (n = 22) from birth to discharge. Measurements were recorded for 20 consecutive hours weekly from birth until 36 weeks' postmenstrual age, biweekly until 40 weeks, and every 4 weeks thereafter. Clinical variables including bed type and method of respiratory support were recorded at each session.Age-related changes in respiratory support and bed type explained the weekly increase of 0.22 dB in sound level and 3.67 lux in light level. Old incubators were the noisiest bed types, and new incubators were the quietest. Light levels were significantly higher in open beds than in incubators. The variations in noise and light levels over time were greatest for open beds. Noise and light levels were much less affected by respiratory support in incubators compared with open beds. A typical extremely low birth weight neonate was exposed to noise levels averaging 56.44 dB(A) and light levels averaging 70.56 lux during their stay from 26 to 42 weeks' postmenstrual age in the NICU. Noise levels were rarely within American Academy of Pediatrics recommendations (5.51% of the time), whereas light levels almost always met recommendations (99.37% of the time).Bed type and respiratory support explained differences in noise and light levels that extremely low birth weight newborns experience during their hospital stay. Noise levels exceeded recommendations, although evidence supporting those recommendations is lacking. Well-designed intervention studies are needed to determine the effects of noise reduction on the development of extremely low birth weight newborns.
View details for DOI 10.1542/peds.2007-3418
View details for Web of Science ID 000262678700017
View details for PubMedID 19171620
Changes in the PQRST Intervals and Heart Rate Variability Associated with Rewarming in Two Newborns Undergoing Hypothermia Therapy
2009; 96 (2): 93-95
Little is known about the effects of hypothermia therapy and subsequent rewarming on the PQRST intervals and heart rate variability (HRV) in term newborns with hypoxic-ischemic encephalopathy (HIE).This study describes the changes in the PQRST intervals and HRV during rewarming to normal core body temperature of 2 newborns with HIE after hypothermia therapy.Within 6 h after birth, 2 newborns with HIE were cooled to a core body temperature of 33.5 degrees C for 72 h using a cooling blanket, followed by gradual rewarming (0.5 degrees C per hour) until the body temperature reached 36.5 degrees C. Custom instrumentation recorded the electrocardiogram from the leads used for clinical monitoring of vital signs. Generalized linear mixed models were calculated to estimate temperature-related changes in PQRST intervals and HRV.For every 1 degrees C increase in body temperature, the heart rate increased by 9.2 bpm (95% CI 6.8-11.6), the QTc interval decreased by 21.6 ms (95% CI 17.3-25.9), and low and high frequency HRV decreased by 0.480 dB (95% CI 0.052-0.907) and 0.938 dB (95% CI 0.460-1.416), respectively.Hypothermia-induced changes in the electrocardiogram should be monitored carefully in future studies.
View details for DOI 10.1159/000205385
View details for Web of Science ID 000266881900004
View details for PubMedID 19252411
View details for PubMedCentralID PMC2957844
Spectral analysis of time series of events: effect of respiration on heart rate in neonates
2009; 30 (1): 43–61
Certain types of biomedical processes such as the heart rate generator can be considered as signals that are sampled by the occurring events, i.e. QRS complexes. This sampling property generates problems for the evaluation of spectral parameters of such signals. First, the irregular occurrence of heart beats creates an unevenly sampled data set which must either be pre-processed (e.g. by using trace binning or interpolation) prior to spectral analysis, or analyzed with specialized methods (e.g. Lomb's algorithm). Second, the average occurrence of events determines the Nyquist limit for the sampled time series. Here we evaluate different types of spectral analysis of recordings of neonatal heart rate. Coupling between respiration and heart rate and the detection of heart rate itself are emphasized. We examine both standard and data adaptive frequency bands of heart rate signals generated by models of coupled oscillators and recorded data sets from neonates. We find that an important spectral artifact occurs due to a mirror effect around the Nyquist limit of half the average heart rate. Further we conclude that the presence of respiratory coupling can only be detected under low noise conditions and if a data-adaptive respiratory band is used.
View details for DOI 10.1088/0967-3334/30/1/004
View details for Web of Science ID 000263031300004
View details for PubMedID 19075368
Effects of hypoxic-ischemic encephalopathy and whole-body hypothermia on neonatal auditory function: A pilot study
AMERICAN JOURNAL OF PERINATOLOGY
2008; 25 (7): 435–41
We assessed the effects of hypoxic-ischemic encephalopathy (HIE) and whole-body hypothermia therapy on auditory brain stem evoked responses (ABRs) and distortion product otoacoustic emissions (DPOAEs). We performed serial assessments of ABRs and DPOAEs in newborns with moderate or severe HIE, randomized to hypothermia ( N = 4) or usual care ( N = 5). Participants were five boys and four girls with mean gestational age (standard deviation) of 38.9 (1.8) weeks. During the first week of life, peripheral auditory function, as measured by the DPOAEs, was disrupted in all nine subjects. ABRs were delayed but central transmission was intact, suggesting a peripheral rather than a central neural insult. By 3 weeks of age, peripheral auditory function normalized. Hypothermia temporarily prolonged the ABR, more so for waves generated higher in the brain stem but the effects reversed quickly on rewarming. Neonatal audiometric testing is feasible, noninvasive, and capable of enhancing our understanding of the effects of HIE and hypothermia on auditory function.
View details for DOI 10.1055/s-0028-1083842
View details for Web of Science ID 000259542200008
View details for PubMedID 18720323
View details for PubMedCentralID PMC2586420
Teaching teamwork during the Neonatal Resuscitation Program: a randomized trial
JOURNAL OF PERINATOLOGY
2007; 27 (7): 409–14
To add a team training and human error curriculum to the Neonatal Resuscitation Program (NRP) and measure its effect on teamwork. We hypothesized that teams that received the new course would exhibit more teamwork behaviors than those in the standard NRP course.Interns were randomized to receive NRP with team training or standard NRP, then video recorded when they performed simulated resuscitations at the end of the day-long course. Outcomes were assessed by observers blinded to study arm allocation and included the frequency or duration of six team behaviors: inquiry, information sharing, assertion, evaluation of plans, workload management and vigilance.The interns in the NRP with team training group exhibited more frequent team behaviors (number of episodes per minute (95% CI)) than interns in the control group: information sharing 1.06 (0.24, 1.17) vs 0.13 (0.00, 0.43); inquiry 0.35 (0.11, 0.42) vs 0.09 (0.00, 0.10); assertion 1.80 (1.21, 2.25) vs 0.64 (0.26, 0.91); and any team behavior 3.34 (2.26, 4.11) vs 1.03 (0.48, 1.30) (P-values <0.008 for all comparisons). Vigilance and workload management were practiced throughout the entire simulated code by nearly all the teams in the NRP with team training group (100% for vigilance and 88% for workload management) vs only 53 and 20% of the teams in the standard NRP. No difference was detected in the frequency of evaluation of plans.Compared with the standard NRP, NRP with a teamwork and human error curriculum led interns to exhibit more team behaviors during simulated resuscitations.
View details for DOI 10.1038/sj.jp.7211771
View details for Web of Science ID 000247533200003
View details for PubMedID 17538634
Longitudinal assessment of heart rate variability in very low birth weight infants during their NICU stay
EARLY HUMAN DEVELOPMENT
2007; 83 (6): 361–66
Maturation of the autonomic nervous system has not been studied in high-risk very low birth weight (VLBW) infants in the first few weeks of life.To characterize developmental changes in autonomic nervous system activity of high-risk VLBW infants from 23 to 38 weeks post-menstrual age by measuring heart rate variability (HRV).In this prospective cohort study 38 infants admitted to Children's Memorial Hermann Hospital NICU were longitudinally followed weekly or biweekly. Heart period data were recorded while infants were resting in active sleep.Growth of spectral power of HRV in low-frequency (0.05-0.25 Hz) and high-frequency (0.25-1.00 Hz) bands was modeled with linear mixed-effects models. The high-frequency power provides a measure of respiratory sinus arrhythmia (RSA).Low-frequency power increases with post-menstrual age, and intubated infants have lower HRV. The increase in low-frequency power is faster (0.50+/-0.12 dB/week) than the increase in RSA (0.17+/-0.09 dB/week).This longitudinal data exhibits developmental maturation of the RSA and of the low-frequency power of HRV in high-risk VLBW infants.
View details for DOI 10.1016/j.earlhumdev.2006.07.007
View details for Web of Science ID 000246654700003
View details for PubMedID 16978804
Noise in contemporary neonatal intensive care
ACOUSTICAL SOC AMER AMER INST PHYSICS. 2007: 2681–90
Weekly sound surveys (n = 63) were collected, using 5 s sampling intervals, for two modern neonatal intensive care units (NICUs). Median weekly equivalent sound pressure levels (LEQ) for NICU A ranged from 61 to 63 dB (A weighted), depending on the level of care. NICU B L(EQ) measurements ranged from 55 to 60 dB (A weighted). NICU B was recently built with a focus on sound abatement, explaining much of the difference between the two NICUs. Sound levels exceeded 45 dB (A weighted), recommended by the American Academy of Pediatrics, more than 70% of the time for all levels of care. Hourly L(EQ)s below 50 dB (A weighted) and hourly L10s below 55 dB (A weighted), recommended by the Sound Study Group (SSG) of the National Resource Center, were also exceeded in more than 70% of recorded samples. A third SSG recommendation, that the 1 s L(MAX), should not exceed 70 dB (A weighted), was exceeded relatively infrequently (< 11% of the time). Peak impulse measurements exceeded 90 dB for 6.3% of 5 s samples recorded from NICU A and 2.8% of NICU B samples. Twenty-four h periodicities in sound levels as a function of regular staff activities were apparent, but short-term variability was considerable.
View details for DOI 10.1121/1.27175001
View details for Web of Science ID 000246378200022
View details for PubMedID 17550168