S. Morad Hameed MD MPH

All Publications

• Prognostic Factors Associated with Venous Thromboembolism Following Traumatic Injury: A Systematic Review and Meta-Analysis. The journal of trauma and acute care surgery Tran, A., Fernando, S. M., Rochwerg, B., Hameed, M. S., Dawe, P., Hawes, H., Haut, E., Inaba, K., Engels, P. T., Zarychanski, R., Siegal, D. M., Carrier, M. 2024

  Abstract

  Trauma patients are at increased risk of venous thromboembolism (VTE), including deep venous thrombosis (DVT) and/or pulmonary embolism (PE). We conducted a systematic review and meta-analysis summarizing the association between prognostic factors and the occurrence of VTE following traumatic injury.We searched the EMBASE and MEDLINE databases from inception to August 2023. We identified studies reporting confounding adjusted associations between patient, injury or post-injury care factors and risk of VTE. We performed meta-analyses of odds ratios (ORs) using the random effects method and assessed individual study risk of bias using the QUIPS tool.We included 31 studies involving 1,981,946 patients. Studies were predominantly observational cohorts from North America. Factors with moderate or higher certainty of association with increased risk of VTE include older age, obesity, male sex, higher injury severity score, pelvic injury, lower extremity injury, spinal injury, delayed VTE prophylaxis, need for surgery and tranexamic acid use. After accounting for other important contributing prognostic variables, a delay in the delivery of appropriate pharmacologic prophylaxis for as little as 24 to 48 hours independently confers a clinically meaningful two-fold increase in incidence of VTE.These findings highlight the contribution of patient predisposition, the importance of injury pattern, and the impact of potentially modifiable post-injury care on risk of VTE after traumatic injury. These factors should be incorporated into a risk stratification framework to individualize VTE risk assessment and support clinical and academic efforts reduce thromboembolic events among trauma patients.Study TypeSystematic Review & Meta-Analysis.Level II.

  View details for DOI 10.1097/TA.0000000000004326

  View details for PubMedID 38548736

• Rate of Neoplasia in Patients with Complicated Acute Appendicitis Managed Nonoperatively Lie, J. J., Nabata, K., Zhang, J., Zhao, D., Hameed, M., Dawe, P., Hamilton, T. SPRINGER. 2024: S14

  View details for Web of Science ID 001185577500024

• Prognostic factors associated with risk of stroke following blunt cerebrovascular injury: A systematic review and meta-analysis. Injury Tran, A., Fernando, S. M., Rochwerg, B., Hawes, H., Hameed, M. S., Dawe, P., Garraway, N., Evans, D. C., Kim, D., Biffl, W. L., Inaba, K., Engels, P. T., Vogt, K., Kubelik, D., Petrosoniak, A., Joos, E. 2024; 55 (3): 111319

  Abstract

  BACKGROUND & OBJECTIVES: Blunt cerebrovascular injury (BCVI) includes carotid and/or vertebral artery injury following trauma, and conveys an increased stroke risk. We conducted a systematic review and meta-analysis to provide a comprehensive summary of prognostic factors associated with risk of stroke following BCVI.METHODS: We searched the EMBASE and MEDLINE databases from January 1946 to June 2023. We identified studies reporting associations between patient or injury factors and risk of stroke following BCVI. We performed meta-analyses of odds ratios (ORs) using the random effects method and assessed individual study risk of bias using the QUIPS tool. We separately pooled adjusted and unadjusted analyses, highlighting the estimate with the higher certainty.RESULTS: We included 26 cohort studies, involving 20,458 patients with blunt trauma. The overall incidence of stroke following BCVI was 7.7%. Studies were predominantly retrospective cohorts from North America and included both carotid and vertebral artery injuries. Diagnosis of BCVI was most commonly confirmed with CT angiography. We demonstrated with moderate to high certainty that factors associated with increased risk of stroke included carotid artery injury (as compared to vertebral artery injury, unadjusted odds ratio [uOR] 1.94, 95% CI 1.62 to 2.32), Grade III Injury (as compared to grade I or II) (uOR 2.45, 95% CI 1.88 to 3.20), Grade IV injury (uOR 3.09, 95% CI 2.20 to 4.35), polyarterial injury (uOR 3.11 (95% CI 2.05 to 4.72), occurrence of hypotension at the time of hospital admission (adjusted odds ratio [aOR] 1.32, 95% CI 0.87 to 2.03) and higher total body injury severity (aOR 5.91, 95% CI 1.90 to 18.39).CONCLUSION: Local anatomical injury pattern, overall burden of injury and flow dynamics contribute to BCVI-related stroke risk. These findings provide the foundational evidence base for risk stratification to support clinical decision making and further research.

  View details for DOI 10.1016/j.injury.2024.111319

  View details for PubMedID 38277875

• Extracorporeal life support in trauma: Indications and techniques JOURNAL OF TRAUMA AND ACUTE CARE SURGERY Lee, A., Romano, K., Tansley, G., Al-Khaboori, S., Thiara, S., Garraway, N., Finlayson, G., Kanji, H. D., Isac, G., Ta, K., Sidhu, A., Carolan, M., Triana, E., Summers, C., Joos, E., Ball, C. G., Hameed, S. 2024; 96 (1): 145-155

  Abstract

  Clarity about indications and techniques in extracorporeal life support (ECLS) in trauma is essential for timely and effective deployment, and to ensure good stewardship of an important resource. Extracorporeal life support deployments in a tertiary trauma center were reviewed to understand the indications, strategies, and tactics of ECLS in trauma.The provincial trauma registry was used to identify patients who received ECLS at a Level I trauma center and ECLS organization-accredited site between January 2014 and February 2021. Charts were reviewed for indications, technical factors, and outcomes following ECLS deployment. Based on this data, consensus around indications and techniques for ECLS in trauma was reached and refined by a multidisciplinary team discussion.A total of 25 patients underwent ECLS as part of a comprehensive trauma resuscitation strategy. Eighteen patients underwent venovenous ECLS and seven received venoarterial ECLS. Nineteen patients survived the ECLS run, of which 15 survived to discharge. Four patients developed vascular injuries secondary to cannula insertion while four patients developed circuit clots. On multidisciplinary consensus, three broad indications for ECLS and their respective techniques were described: gas exchange for lung injury, extended damage control for severe injuries associated with the lethal triad, and circulatory support for cardiogenic shock or hypothermia.The three broad indications for ECLS in trauma (gas exchange, extended damage control and circulatory support) require specific advanced planning and standardization of corresponding techniques (cannulation, circuit configuration, anticoagulation, and duration). When appropriately and effectively integrated into the trauma response, ECLS can extend the damage control paradigm to enable the management of complex multisystem injuries.Therapeutic/Care Management; Level IV.

  View details for DOI 10.1097/TA.0000000000004043

  View details for Web of Science ID 001126412700010

  View details for PubMedID 37822113

• UBC Reticulum: a province-wide network promoting surgical excellence and continuous improvement of general surgery in British Columbia. Canadian journal of surgery. Journal canadien de chirurgie Balmes, P., Hwang, H., Hameed, S. M. 2023; 66 (4): E399-E402

  Abstract

  The University of British Columbia's (UBC) Division of General Surgery is a diverse group, including both academic and community surgeons. Since its launch in 2019, the UBC Reticulum website has been a transformative tool in engaging general surgeons, fellows, residents, students and researchers through its many features and user-created content, such as its messaging board, Netter, and Connect feature, which connects members based on their specialty, location, procedures and interests. Reticulum also serves as a valuable repository of educational resources and is instrumental in the division's goal of improving continuing medical education; the Reticulum mentorship grant program provides financial support for practising surgeons pursuing peer-mentorship projects. UBC Reticulum serves as a model for how to coordinate surgical education, research and quality improvement within diverse provincial divisions.

  View details for DOI 10.1503/cjs.004123

  View details for PubMedID 37500105

  View details for PubMedCentralID PMC10396344

• 5 Slides in 5 Minutes: Incorporating CanMEDS Competencies on Acute Care Surgery JOURNAL OF SURGICAL EDUCATION Harnden, K., Hintz, G., Hameed, S., Stuart, H. 2023; 80 (6): 762-766

  Abstract

  The University of British Columbia (UBC) Division of General Surgery developed an initiative entitled "5-in-5s" to improve educational opportunities on the Acute Care Surgery (ACS) service. We examined whether 5-in-5s are felt to be a valuable teaching tool, and evaluated their ability to incorporate CanMEDS competencies within the General Surgery program.A web-based survey was distributed to all general surgery trainees and staff on ACS that have participated in 5-in-5s.A total of 37 responses were collected (62% response rate). All respondents felt 5-in-5s were valuable overall. Four of the seven CanMEDS competencies were evaluated. About 100% felt their knowledge was positively impacted by presenting, and 80% by attending alone. About 71% of respondents agreed that 5-in5s provided opportunities for health advocacy, 50% for collaboration, and 36% for leadership.We identified 5-in-5s as a valuable teaching method and a novel approach to integrate CanMEDS competencies into ACS training.

  View details for DOI 10.1016/j.jsurg.2023.03.008

  View details for Web of Science ID 001009461500001

  View details for PubMedID 37127511

• The unrestricted global effort to complete the COOL trial. World journal of emergency surgery : WJES Kirkpatrick, A. W., Coccolini, F., Tolonen, M., Minor, S., Catena, F., Gois, E., Doig, C. J., Hill, M. D., Ansaloni, L., Chiarugi, M., Tartaglia, D., Ioannidis, O., Sugrue, M., Colak, E., Hameed, S. M., Lampela, H., Agnoletti, V., McKee, J. L., Garraway, N., Sartelli, M., Ball, C. G., Parry, N. G., Voght, K., Julien, L., Kroeker, J., Roberts, D. J., Faris, P., Tiruta, C., Moore, E. E., Ammons, L. A., Anestiadou, E., Bendinelli, C., Bouliaris, K., Carroll, R., Ceresoli, M., Favi, F., Gurrado, A., Rezende-Neto, J., Isik, A., Cremonini, C., Strambi, S., Koukoulis, G., Testini, M., Trpcic, S., Pasculli, A., Picariello, E., Abu-Zidan, F., Adeyeye, A., Augustin, G., Alconchel, F., Altinel, Y., Hernandez Amin, L. A., Aranda-Narváez, J. M., Baraket, O., Biffl, W. L., Baiocchi, G. L., Bonavina, L., Brisinda, G., Cardinali, L., Celotti, A., Chaouch, M., Chiarello, M., Costa, G., de'Angelis, N., De Manzini, N., Delibegovic, S., Di Saverio, S., De Simone, B., Dubuisson, V., Fransvea, P., Garulli, G., Giordano, A., Gomes, C., Hayati, F., Huang, J., Ibrahim, A. F., Huei, T. J., Jailani, R. F., Khan, M., Luna, A. P., Malbrain, M. L., Marwah, S., McBeth, P., Mihailescu, A., Morello, A., Mulita, F., Murzi, V., Mohammad, A. T., Parmar, S., Pak, A., Wong, M. P., Pantalone, D., Podda, M., Puccioni, C., Rasa, K., Ren, J., Roscio, F., Gonzalez-Sanchez, A., Sganga, G., Scheiterle, M., Slavchev, M., Smirnov, D., Tosi, L., Trivedi, A., Vega, J. A., Waledziak, M., Xenaki, S., Winter, D., Wu, X., Zakaria, A. D., Zakaria, Z. 2023; 18 (1): 33

  Abstract

  Severe complicated intra-abdominal sepsis (SCIAS) has an increasing incidence with mortality rates over 80% in some settings. Mortality typically results from disruption of the gastrointestinal tract, progressive and self-perpetuating bio-mediator generation, systemic inflammation, and multiple organ failure. A further therapeutic option may be open abdomen (OA) management with negative peritoneal pressure therapy (NPPT) to remove inflammatory ascites and attenuate the systemic damage from SCIAS, although there are definite risks of leaving the abdomen open whenever it might possibly be closed. This potential therapeutic paradigm is the rationale being assessed in the Closed Or Open after Laparotomy (COOL trial) ( https://clinicaltrials.gov/ct2/show/NCT03163095 ). Initially, the COOL trial received Industry sponsorship; however, this funding mandated the use of a specific trademarked and expensive NPPT device in half of the patients allocated to the intervention (open) arm. In August 2022, the 3 M/Acelity Corporation without consultation but within the terms of the contract canceled the financial support of the trial. Although creating financial difficulty, there is now no restriction on specific NPPT devices and removing a cost-prohibitive intervention creates an opportunity to expand the COOL trial to a truly global basis. This document describes the evolution of the COOL trial, with a focus on future opportunities for global growth of the study.The COOL trial is the largest prospective randomized controlled trial examining the random allocation of SCIAS patients intra-operatively to either formal closure of the fascia or the use of the OA with an application of an NPPT dressing. Patients are eligible if they have free uncontained intraperitoneal contamination and physiologic derangements exemplified by septic shock OR severely adverse predicted clinical outcomes. The primary outcome is intended to definitively inform global practice by conclusively evaluating 90-day survival. Initial recruitment has been lower than hoped but satisfactory, and the COOL steering committee and trial investigators intend with increased global support to continue enrollment until recruitment ensures a definitive answer.OA is mandated in many cases of SCIAS such as the risk of abdominal compartment syndrome associated with closure, or a planned second look as for example part of "damage control"; however, improved source control (locally and systemically) is the most uncertain indication for an OA. The COOL trial seeks to expand potential sites and proceed with the evaluation of NPPT agnostic to device, to properly examine the hypothesis that this treatment attenuates systemic damage and improves survival. This approach will not affect internal validity and should improve the external validity of any observed results of the intervention.National Institutes of Health ( https://clinicaltrials.gov/ct2/show/NCT03163095 ).

  View details for DOI 10.1186/s13017-023-00500-z

  View details for PubMedID 37170123

  View details for PubMedCentralID PMC10173926

• Factors associated with recurrent appendicitis after nonoperative management. American journal of surgery Lie, J. J., Nabata, K., Zhang, J. W., Zhao, D., Park, C. M., Hameed, S. M., Dawe, P., Hamilton, T. D. 2023; 225 (5): 915-920

  Abstract

  The objective of this study is to identify predictors for recurrent appendicitis in patients with appendicitis previously treated nonoperatively.This is a prospective cohort study of all adult patients with appendicitis treated at a tertiary care hospital. Patient demographics, radiographic information, management, and clinical outcomes were recorded. The primary outcome was recurrent appendicitis within 6 months after discharge from the index admission. Given the competing risk of interval appendectomy, a time-to-event competing-risk analysis was performed.Of the 699 patients presenting with appendicitis, 74 were treated nonoperatively (35 [47%] were women; median [IQR] age, 48 [33,64] years), and 21 patients (29%) had recurrent appendicitis. On univariate and multivariate analysis, presence of an appendicolith on imaging was the only factor associated with a higher risk of recurrent appendicitis (p = 0.02).The presence of appendicolith was associated with an increased risk of developing recurrent appendicitis within 6 months.

  View details for DOI 10.1016/j.amjsurg.2023.03.005

  View details for PubMedID 36925417

• The next frontier of acute care general surgery: fellowship training CANADIAN JOURNAL OF SURGERY Engels, P. T., Lee, J., Rice, T. R., Nenshi, R., Ball, C. G., Hameed, M., Widder, S., Minor, S., Ahmed, N., Parry, N., Vogt, K., Joos, E., DeGirolamo, K., Kirkpatrick, A., Lampron, J., Ahmed, N., Bos, C., Neto, J., Schellenberg, M., Hilsden, R., Ball, C., Dawe, P., Kim, M., Rao, J., Allen, L., Gomez, D., Nantais, J., Sadler, E., Grushka, J., Miller, S., D'Souza, K., Bradley, N., Mueller, S., Koloszsvari, N., Nadler, A., Leslie, K., Gordon, M., Boone, D., Hameed, M., Tung, L., Mador, B., Gillman, L., Van Heest, R., Mason, S., Rice, T., Park, L., Quigley, S., Minor, S., Parry, N., Strickland, M., Ziesmann, M., Roberts, D., Moffat, B., Walser, E., Khwaja, K., Wells, M., Nenshi, R., Murphy, P., Lester, E., Leslie, K., Smith, S., Leeper, R., Jayaraman, S., Wong, E., Roswell, E., Canadian Collaborative on Urgent 2023; 66 (1): E42-E44

  Abstract

  Acute care surgery (ACS) is an area of surgical specialization within general surgery and a model for clinical care delivery that has proliferated over the last 2 decades. Models of ACS in Canada exist in both academic and community settings and are used to manage patients in need of emergency general surgery (EGS) care, with or without the provision of trauma care. The implementation of the ACS model has changed the landscape of patient care, surgical education and the workforce, providing an option for some general surgeons to exclude EGS care from their regular practice. The rise of ACS as a concentration of surgical skill and content expertise has resulted in the establishment of dedicated ACS fellowship training programs. This is a landmark in the evolution of general surgery, as well as a stepping stone on the path to improving patient care, surgical education and scholarly endeavour in this field.

  View details for DOI 10.1503/cjs.020821

  View details for Web of Science ID 000928562200001

  View details for PubMedID 36731912

  View details for PubMedCentralID PMC9904803

• Operating room use for emergency general surgery cases: analysis of the Patterns of Complex Emergency General Surgery in Canada study CANADIAN JOURNAL OF SURGERY Meschino, M. T., Vogt, K. N., Allen, L., Saddik, M., Nenshi, R., Van Heest, R., Saleh, F., Widder, S., Minor, S., Joos, E., Parry, N. G., Murphy, P. B., Ball, C. G., Hameed, M., Engels, P. T., CANUCS Canadian Collaborative Urge 2023; 66 (1): E13-E20

  Abstract

  Access to the operating room (OR) is variable among emergency general surgery (EGS) services, with some having dedicated EGS ORs, and others only a shared queue. Currently in Canada, only a limited number of acute care surgery services have dedicated daytime operating room (OR) access; hence, we aimed to describe the burden of after-hours EGS operating in Canada and differences associated with OR access.In this multicentre retrospective cohort study, we used data from a previously conducted study designed to evaluate nonappendiceal, nonbiliary disease across 8 Canadian hospitals. We performed a secondary analysis to describe booking priorities and timing of operative interventions, compare sites with and without access to a dedicated EGS daytime OR, and identify differences in morbidity and mortality based on timing of operative intervention.Among 1244 patients, operations were performed during weekday daytime in 521 cases (41.9%), in the evening in 279 (22.4%), on the weekend in 293 (23.6%) and overnight in 151 (12.1%). Operating room booking priority was more than 2 hours to 8 hours in 657 cases (52.8%), more than 8 hours to 24 hours in 334 (26.9%) and more than 24 hours to 48 hours in 253 (20.3%). Substantial variation in booking priority was observed for the same preoperative diagnoses. Sites with dedicated EGS ORs performed a greater proportion of cases during daytime versus overnight compared to sites without dedicated EGS ORs (198/237 [83.5%] v. 323/435 [74.2%], p = 0.006). No significant differences in outcome were found between cases performed during the daytime, evening and overnight.We found considerable variation in OR booking priority within the same preoperative diagnoses among EGS patients in Canada. Sites with dedicated EGS ORs performed more cases during weekday daytime compared to sites without dedicated EGS ORs; however, this study showed no evidence of compromised outcomes based on OR timing.

  View details for DOI 10.1503/cjs.008120

  View details for Web of Science ID 000905232500001

  View details for PubMedID 36596587

  View details for PubMedCentralID PMC9829034

• Penetrating cardiac trauma. Surgery open science Lee, A., Hameed, S. M., Kaminsky, M., Ball, C. G. 2023; 11: 45-55

  Abstract

  This chapter summarizes approaches to hemorrhage control in penetrating cardiac trauma, an injury that is a true test of trauma systems integration, trauma center readiness, teamwork, decision-making, technical excellence, and multidisciplinary trauma care.

  View details for DOI 10.1016/j.sopen.2022.11.001

  View details for PubMedID 36466048

  View details for PubMedCentralID PMC9713325

• Technical considerations in the management of penetrating cardiac injury. Canadian journal of surgery. Journal canadien de chirurgie Ball, C. G., Lee, A., Kaminsky, M., Hameed, S. M. 2022; 65 (5): E580-E592

  Abstract

  Penetrating cardiac injuries require rapid diagnosis, efficient exposure and nuanced technical approaches, within a framework of highly coordinated and integrated multidisciplinary care. Acute care surgeons, with both strategic and technical expertise, are ideally positioned to address the potentially devastating consequences of these injuries. The aim of this narrative review is to offer a technical approach to the rapid evaluation, exposure, operative repair and postoperative care of penetrating cardiac injuries. A comprehensive review of the cardiac trauma literature, dating back to 1970, has provided a detailed toolbox of approaches to subxiphoid pericardial windows, resuscitative thoracotomy, median sternotomy, pericardiotomy, aortic clamping, cardiac hemorrhage control, cardiac repair, coronary artery injuries, pericardial closure, drain placement, chest wall closures, damage control thoracic procedures and immediate postoperative cardiac care, all based on fundamental physiological principles and anatomical considerations.

  View details for DOI 10.1503/cjs.008521

  View details for PubMedID 36302130

  View details for PubMedCentralID PMC9451503

• Emergency surgical consultation for cancer patients: identifying the prognostic determinants of health WORLD JOURNAL OF SURGICAL ONCOLOGY Taqi, K., Kim, D., Yip, L., Laane, C., Rana, Z., Hameed, M., Hamilton, T., Stuart, H. 2022; 20 (1): 232

  Abstract

  Patients with malignancy often require urgent surgical consultation for treatment or palliation of disease. The objective of this study is to explore the prognostic determinants affecting care in acute cancer-related surgical presentations and the effect on patient outcomes.This is a retrospective review of patients referred to the acute general surgery (ACS) service at a tertiary hospital for management of cancer-related problem from July 2017 to September 2018. Patient demographics, course in hospital, and survival were recorded. Multivariant logistic regression and Kaplan-Meier estimates were performed. One hundred eighty-nine patients were identified (53% female) with a mean age of 65.9 years. Forty-two patients (22%) were newly diagnosed with cancer on presentation, and 94 (50%) patients had metastatic disease. Cancer staging was completed in 84% of patients, and 65% had multidisciplinary team (MDT) assessment during their hospital stay. Surgery was performed on 90 (48%) patients, of which 31.2% was with palliative intent. Overall mortality was 56% with 30- and 60-day mortality of 15% and 22%, respectively. The adjusted odds ratio (OR) for a 60-day mortality was high in patients presenting with new cancer diagnosis (OR 3.18, 95% CI 1.18-9.02, p=0.03), metastatic disease (OR 5.11, 95% CI 2.03-12.85, p=0.001), or systemic therapy on presentation (OR 3.46, 95% CI 1.30-9.22, p=0.013).Emergency surgical referral is common in patients with malignancy. Surgical decision making can be challenging due to the heterogeneity of this population and their associated comorbidities. Optimizing prognostic determinants such as goal-directed palliative care, MDT discussions, and bridging to systemic therapy can improve patient outcomes.

  View details for DOI 10.1186/s12957-022-02694-z

  View details for Web of Science ID 000824896300001

  View details for PubMedID 35820927

  View details for PubMedCentralID PMC9277930

• Resuscitative endovascular balloon occlusion of the aorta in Canada: a context-specific position paper from the Canadian Collaborative for Urgent Care Surgery (CANUCS) CANADIAN JOURNAL OF SURGERY Bradley, N. L., Leeper, W., Roberts, D., Ball, C. G., Beckett, A., Engels, P., Joos, E., Khwaja, K., Kirkpatrick, A., Lampron, J., Minor, S., Parry, N., Rezende, J., Widder, S., Ahmed, N., Gillman, L., Gomez, D., Hameed, M., Kim, M., Murphy, P., Nenshi, R., Rice, T., Vogt, K. 2022; 65 (3): E310-E316

  Abstract

  SummaryResuscitative endovascular balloon occlusion of the aorta (REBOA) is a well-described intervention for noncompressible torso hemorrhage. Several Canadian centres have included REBOA in their hemorrhagic shock protocols. However, REBOA has known complications and equipoise regarding its use persists. The Canadian Collaborative on Urgent Care Surgery (CANUCS) comprises surgeons who provide acute trauma care and leadership in Canada, with experience in REBOA implementation, use, education and research. Our goal is to provide evidence- and experience-based recommendations regarding institutional implementation of a REBOA program, including multidisciplinary educational programs, attention to device and care pathway logistics, and a robust quality assurance program. This will allow Canadian trauma centres to maximize patient benefits and minimize risks of this potentially life-saving technology.

  View details for DOI 10.1503/cjs.015319

  View details for Web of Science ID 000832862600001

  View details for PubMedID 35545282

  View details for PubMedCentralID PMC9259435

• The Kampala Trauma Score: A 20-year track record JOURNAL OF TRAUMA AND ACUTE CARE SURGERY Rosenkrantz, L., Schuurman, N., Hameed, M. S., Boniface, R., Lett, R. 2022; 92 (6): E132-E138

  Abstract

  Quantifying the severity of traumatic injury has been foundational for the standardization of outcomes, quality improvement research, and health policy throughout the evolution of trauma care systems. Many injury severity scores are difficult to calculate and implement, especially in low- and middle-income countries (LMICs) where human resources are limited. The Kampala Trauma Score (KTS)-a simplification of the Trauma Injury Severity Score-was developed in 2000 to accommodate these settings. Since its development, numerous instances of KTS use have been documented, but extent of adoption is unknown. More importantly, does the KTS remain useful for determining injury severity in LMICs? This review aims to better understand the legacy of the KTS and assess its strengths and weaknesses. Three databases were searched to identify scientific papers concerning the KTS. Google Scholar was searched to identify grey literature. The search returned 357 papers, of which 199 met inclusion criteria. Eighty-five studies spanning 16 countries used the KTS in clinical settings. Thirty-seven studies validated the KTS, assessing its ability to predict outcomes such as mortality or need for admission. Over 80% of these studies reported the KTS equalled or exceeded more complicated scores at predicting mortality. The KTS has stood the test of time, proving itself over the last twenty years as an effective measure of injury severity across numerous contexts. We recommend the KTS as a means of strengthening trauma systems in LMICs and suggest it could benefit high-income trauma systems that do not measure injury severity.

  View details for DOI 10.1097/TA.0000000000003567

  View details for Web of Science ID 000799472300003

  View details for PubMedID 35195097

• Socioeconomic status does not influence the presentation of patients with inguinal hernia at an urban Canadian teaching hospital CANADIAN JOURNAL OF SURGERY Laane, C., Chen, L., Rosenkrantz, L., Schuurman, N., Hameed, M., Joos, E. 2022; 65 (2): E282-E289

  Abstract

  Socioeconomic status (SES) has been shown to influence the outcomes of surgical pathologies in areas with unequal access to health care. The purpose of this study was to measure the effect of SES on the urgency for inguinal hernia repair in an area with purported equitable access to health care in the context of a universal health care system.We included all adult patients who underwent surgical management of an inguinal hernia between 2012 and 2016 at 2 urban academic centres. We measured the SES using the Vancouver Area Neighbourhood Deprivation Index (VANDIX) score.We included 2336 patients: 98 emergency surgery and 294 elective surgery cases. We matched patients without replacement on age, sex and American Society of Anesthesiology score, using optimized propensity score matching at a ratio of 1 case to 3 controls. We found no significant correlation between lower SES and emergency surgical management (p = 0.122). Secondary analysis assessed the impact of SES on morbidity and length of stay. We found no significant difference in the rate of complications, length of stay and recurrence by SES category. Patients from lower SES brackets had increased odds for readmission (odds ratio 1.979; 95% confidence interval 1.111-4.318).We found no correlation between a low SES and the need for emergency inguinal hernia repair, but found an increased rate of readmission in patients from lower SES brackets. This finding should be further scrutinized through a deeper dive into the barriers to access to nonacute care settings, such as home care.

  View details for DOI 10.1503/cjs.007920

  View details for Web of Science ID 000821594400001

  View details for PubMedID 35477678

  View details for PubMedCentralID PMC9188802

• Failure to rescue in emergency genera surgery in Canada CANADIAN JOURNAL OF SURGERY Minor, S., Allen, L., Meschino, M. T., Nenshi, R., van Heest, R., Saleh, F., Widder, S., Engels, P. T., Joos, E., Parry, N. G., Murphy, P. B., Ball, C. G., Hameed, M., Vogt, K. N., Canadian Collaborative Urgent Care 2022; 65 (2): E215-E220

  Abstract

  The risk of death after a postoperative complication - known as failure to rescue (FTR) - has been proposed to be superior to traditional benchmarking outcomes, such as complication and mortality rates, as a measure of system quality. The purpose of this study was to identify the current FTR rate in emergency general surgery (EGS) centres across Canada. We hypothesized that substantial variability exists in FTR rates across centres.In this multicentre retrospective cohort study, we performed a secondary analysis of data from a previous study designed to evaluate operative intervention for nonappendiceal, nonbiliary disease by 6 EGS services across Canada (1 in British Columbia, 1 in Alberta, 3 in Ontario and 1 in Nova Scotia). Patients underwent surgery between Jan. 1 and Dec. 31, 2014. We conducted univariate analyses to compare patients with and without complications. We performed a sensitivity analysis examining the mortality rate after serious complications (Clavien-Dindo score 3 or 4) that required a surgical intervention or specialized care (e.g., admission to intensive care unit).A total of 2595 patients were included in the study cohort. Of the 206 patients who died within 30 days, 145 (70.4%) experienced a complication before their death. Overall, the mortality rate after any surgical complication (i.e., FTR) was 16.0%. Ranking of sites by the traditional outcomes of complication and mortality rates differed from the ranking when FTR rate was included in the assessment.There was variability in FTR rates across EGS services in Canada, which suggests that there is opportunity for ongoing quality-improvement efforts. This study provides FTR benchmarking data for Canadian EGS services.

  View details for DOI 10.1503/cjs.008820

  View details for Web of Science ID 000820193200001

  View details for PubMedID 35318241

  View details for PubMedCentralID PMC9259385

• Improving Surgical Quality for Patients With Mental Illnesses: A Narrative Review ANNALS OF SURGERY Afford, R. M., Ball, C. G., Sidhu, J. A., Sekhon, M. S., Hameed, M. S. 2022; 275 (3): 477-481

  Abstract

  The aim of this study was to identify disparities in care for surgical patients with preexisting mental health diagnoses.Mental illness affects approximately 6.7 million Canadians. For them, stigma, comorbid disorders, and sequelae of psychiatric diagnoses can be barriers to equitable health care. The goal of this review is to define inequities in surgical care for patients with preexisting mental illness.We searched OVID Medline, Pubmed, EMBASE, and the Cochrane review files using a combination of search terms using a PICO (population, intervention, comparison, outcome) model focusing on surgical care for patients with mental illness.The literature on mental illness in surgical patients focused primarily on preoperative and postoperative disparities in surgical care between patients with and without a diagnosis of mental illness. Preoperatively, patients were 7.5% to 40% less likely to be deemed surgical candidates, were less likely to receive testing, and were more likely to present at later stages of their disease or have delayed surgical care. Similar themes arose in the postoperative period: patients with mental illness were more likely to require ICU admission, were up to 3 times more likely to have a prolonged length of hospital stay, had a 14% to 270% increased likelihood of having postoperative complications, and had significantly higher health care costs.Surgical patients with preexisting psychiatric diagnoses have a propensity for worse perioperative outcomes compared to patients without reported mental illness. Taking a thorough psychiatric history can potentially help surgical teams address disparities in access to care as well as anticipate and prevent adverse outcomes.

  View details for DOI 10.1097/SLA.0000000000005174

  View details for Web of Science ID 000827250600013

  View details for PubMedID 34417360

• A framework for role allocation in education, research and leadership services in Canadian academic divisions of general surgery: a modified Delphi consensus. Canadian journal of surgery. Journal canadien de chirurgie Reid, M., Lee, A., Leslie, K., Feldman, L. S., Hameed, S. M., Kirkpatrick, R., Lovrics, P. J., MacDonald, P. H., Pace, D., Shaw, J. M., Swallow, C. J., Pagliarello, G., Bigam, D. L., Porter, G., Mathieson, A., McFadden, N., Lapointe, R., MacLean, T., Kuziemsky, C., Balaa, F. 2022; 65 (1): E73-E81

  Abstract

  Moving toward a funding standard similar to that for clinical services for roles essential to the functioning of education, research and leadership services within divisions of general surgery is necessary to strengthen divisional resilience. We aimed to identify roles and underlying tasks in these services central to sustainable functioning of Canadian academic divisions of general surgery.Between June 2018 and October 2020, we used a 4-step modified Delphi method (online survey, face-to-face nominal group technique [n = 12], semistructured telephone interview [n = 8] and nominal group technique [n = 12]) to achieve national consensus from an expert panel of all 17 heads of academic divisions of general surgery in Canada on the roles and accompanying tasks essential to education, research and leadership services within an academic division of general surgery. We used 70% agreement to determine consensus.The expert panel agreed that a framework for role allocation in education, research and leadership services was relevant and necessary. Consensus was reached for 7 roles within the educational service, 3 roles within the research service and 5 roles within the leadership service.Our framework represents a national consensus that defines role standards for education, research and leadership services in Canadian academic divisions of general surgery. The framework can help divisions build resiliency, and enable sustained and deliberate advances in these services.

  View details for DOI 10.1503/cjs.021120

  View details for PubMedID 35115320

  View details for PubMedCentralID PMC8820837

• Inviting a friend to evaluate potential grade III pancreatic injuries: Are they truly occult, or simply missed on CT? CANADIAN JOURNAL OF SURGERY Ball, C. G., Clements, T. S., Kirkpatrick, A. W., Vogt, K., Biffl, W., Hameed, M. 2021; 64 (6): E677-E679

  Abstract

  Traumatic inuries to the pancreas are notoriously challenging to diagnose and treat. Detecting a main pancreatic ductal injury can be particularly difficult on screening computed tomography (CT). Twenty-four blinded faculty clinicians from 4 differing specialties and 6 institutions reviewed 9 video CT cases of potential pancreatic ductal injuries. Clinician performance in detection of confirmed grade III pancreatic injuries varied widely among specialties. This heterogeneity confirms the critical need for multidisciplinary care and image interpretation for even "minor" (i.e., not grade IV or V) potential pancreatic injuries to optimize outcomes for injured patients. The ubiquitous availability of electronic devices allows real-time collegial second opinions to be easily available.

  View details for DOI 10.1503/cjs.001421

  View details for Web of Science ID 000734548400001

  View details for PubMedID 34933945

  View details for PubMedCentralID PMC8711555

• Transport Time and Mortality in Critically Ill Patients with Severe Traumatic Brain Injury. The Canadian journal of neurological sciences. Le journal canadien des sciences neurologiques Sy, E., Amram, O., Baer, H. J., Hameed, S. M., Griesdale, D. E. 2021; 48 (6): 817-825

  Abstract

  Severe traumatic brain injury (TBI) is a major cause of morbidity and mortality in critically ill patients. Pre-hospital care and transportation time may impact their outcomes.Using the British Columbia Trauma Registry, we included 2,860 adult (≥18 years) patients with severe TBI (abbreviated injury scale head score ≥4), who were admitted to an intensive care unit (ICU) in a centre with neurosurgical services from January 1, 2000 to March 31, 2013. We evaluated the impact of transportation time (time of injury to time of arrival at a neurosurgical trauma centre) on in-hospital mortality and discharge disposition, adjusting for age, sex, year of injury, injury severity score (ISS), revised trauma score at the scene, location of injury, socio-economic status and direct versus indirect transfer.Patients had a median age of 43 years (interquartile range [IQR] 26-59) and 676 (23.6%) were female. They had a median ISS of 33 (IQR 26-43). Median transportation time was 80 minutes (IQR 40-315). ICU and hospital length of stay were 6 days (IQR 2-12) and 20 days (IQR 7-42), respectively. Six hundred and ninety-six (24.3%) patients died in hospital. After adjustment, there was no significant impact of transportation time on in-hospital mortality (odds ratio 0.98, 95% confidence interval 0.95-1.01). There was also no significant effect on discharge disposition.No association was found between pre-hospital transportation time and in-hospital mortality in critically ill patients with severe TBI.

  View details for DOI 10.1017/cjn.2021.5

  View details for PubMedID 33431101

• Does drainage or resection predict subsequent interventions and long-term quality of life in patients with Grade IV pancreatic injuries: A population-based analysis. The journal of trauma and acute care surgery Ball, C. G., Biffl, W. L., Vogt, K., Hameed, S. M., Parry, N. G., Kirkpatrick, A. W., Kaminsky, M. 2021; 91 (4): 708-715

  Abstract

  Clinical equipoise remains significant for the treatment of Grade IV pancreatic injuries in stable patients (i.e., drainage vs. resection). The literature is poor in regards to experience, confirmed main pancreatic ductal injury, nuanced multidisciplinary treatment, and long-term patient quality of life (QOL). The primary aim was to evaluate the management and outcomes (including long-term QOL) associated with Grade IV pancreatic injuries.All severely injured adult patients with pancreatic trauma (1995-2020) were evaluated (Grade IV injuries compared). Concordance of perioperative imaging, intraoperative exploration, and pathological reporting with a main pancreatic ductal injury was required. Patients with resection of Grade IV injuries were compared with drainage alone. Long-term QOL was evaluated (Standard Short Form-36).Of 475 pancreatic injuries, 36(8%) were confirmed as Grade IV. Twenty-four (67%) underwent a pancreatic resection (29% pancreatoduodenectomy; 71% extended distal pancreatectomy [EDP]). Patient, injury and procedure demographics were similar between resection and drainage groups (p > 0.05). Pancreas-specific complications in the drainage group included 92% pancreatic leaks, 8% pseudocyst, and 8% walled-off pancreatic necrosis. Among patients with controlled pancreatic fistulas beyond 90 days, 67% required subsequent pancreatic operations (fistulo-jejunostomy or EDP). Among patients whose fistulas closed, 75% suffered from recurrent pancreatitis (67% eventually undergoing a Frey or EDP). All patients in the resection group had fistula closure by 64 days after injury. The median number of pancreas-related health care encounters following discharge was higher in the drainage group (9 vs. 5; p = 0.012). Long-term (median follow-up = 9 years) total QOL, mental and physical health scores were higher in the initial resection group (p = 0.031, 0.022 and 0.017 respectively).The immediate, intermediate and long-term experiences for patients who sustain Grade IV pancreatic injuries indicate that resection is the preferred option, when possible. The majority of drainage patients will require additional, delayed pancreas-targeted surgical interventions and report poorer long-term QOL.Epidemiology/Prognostic, Level III.

  View details for DOI 10.1097/TA.0000000000003313

  View details for PubMedID 34559164

• Understanding the barriers and facilitators to trauma registry development in resource-constrained settings: A survey of trauma registry stewards and researchers INJURY-INTERNATIONAL JOURNAL OF THE CARE OF THE INJURED Rosenkrantz, L., Schuurman, N., Arenas, C., Jimenez, M. F., Hameed, M. S. 2021; 52 (8): 2215-2224

  Abstract

  The implementation of trauma registries has proven a highly effective means of injury control. However, many low and middle-income countries lack trauma registries. Those that have trauma registries vary widely in terms of both implementation and structure. We sought to identify the most common barriers that stand in the way of sustainable trauma registry implementation, and the types of strategies that have proven successful in overcoming these barriers.We conducted a questionnaire of trauma registry stewards and researchers in LMICs.Twenty-two individuals responded to the questionnaire representing trauma registry experiences across thirteen LMICs. The most common barriers to trauma registry implementation identified included staffing, funding, and stakeholder engagement. Many different strategies for addressing these barriers were discussed. Those mentioned by multiple respondents included the need for a trauma registry champion, fostering strong stakeholder relationships, and improving efficiency of data collection.Though trauma registry implementation and structure may differ from place to place, there are many shared barriers and facilitators that can be learned from. Identifying these common experiences can help create a repository of knowledge that can better serve those looking to implement their own trauma registries in similar settings.

  View details for DOI 10.1016/j.injury.2021.03.034

  View details for Web of Science ID 000693204800001

  View details for PubMedID 33832705

• VA-ECMO as a salvage strategy for blunt cardiac injury in the context of multisystem trauma. BMJ case reports Misselbrook, G. P., Hameed, S. M., Garraway, N., Al-Lawati, R. 2021; 14 (4)

  Abstract

  A 47-year-old man sustained multisystem injuries after being struck by a vehicle travelling at high speeds. Shortly after admission to the emergency department he suffered a ventricular tachycardia/ventricular fibrillation cardiac arrest lasting 30 min. Investigations following return of spontaneous circulation raised suspicion for an anterolateral ST-elevation myocardial infarction. Despite his major traumatic injuries the patient was transferred for percutaneous coronary intervention uncovering a complete thrombosis of the ostium of the left anterior descending artery. Immediately following coronary revascularisation, the patient developed cardiogenic shock resulting in a multidisciplinary decision to place the patient on veno-arterial extracorporeal membrane oxygenation (VA-ECMO). The management of cardiogenic shock due to acute myocardial infarction with VA-ECMO and multiple traumatic injuries were often at odds with each other, resulting in a series of challenging decisions on timing of surgery and anticoagulation. The patient was liberated from VA-ECMO after 72 hours and continues rehabilitation in hospital.

  View details for DOI 10.1136/bcr-2020-241034

  View details for PubMedID 33832936

  View details for PubMedCentralID PMC8039235

• Time to operating room matters in modern management of pancreatic injuries: A national review on the management of adult pancreatic injury at Canadian level 1 trauma centers Joos, E., de Jong, N., Ball, C. G., Quigley, S., Trottier, V., Masse, M., Engels, P. T., Rao, J., Gillman, L. M., Visser, R., Widder, S., Hameed, M. S., Vogt, K. N. LIPPINCOTT WILLIAMS & WILKINS. 2021: 434-440

  Abstract

  Pancreatic injuries are rare, difficult to diagnose, and complex to manage despite multiple published guidelines. This study was undertaken to evaluate the current diagnosis and management of pancreatic trauma in Canadian trauma centers.This is a multi-institutional retrospective study from 2009 to 2014 including patients from eight level 1 trauma centers across Canada. All patients with a diagnosis of pancreatic trauma were included. Demographics, injury characteristics, vital signs on admission, and type of management were collected. Outcomes measured were mortality and pancreas-related morbidity.Two hundred seventy-nine patients were included. The median age was 29 years (interquartile range, 21-43 years), 72% were male, and 79% sustained blunt trauma. Pancreatic injury included the following grades: I, 26%; II, 28%; III, 33%; IV, 9%; and V, 4%. The overall mortality rate was 11%, and the pancreas-related complication rate was 25%. The majority (88%) of injuries were diagnosed within 24 hours of injury, primarily (80%) with a computed tomography scan. The remaining injuries were diagnosed with ultrasound (6%) and magnetic resonance cholangiopancreatography (MRCP) (2%) and at the time of laparotomy or autopsy (12%). One hundred seventy-five patients (63%) underwent an operative intervention, most commonly a distal pancreatectomy (44%); however, there was great variability in operative procedure chosen even when considering grade of injury.Pancreatic injuries are associated with multiple other injuries and have significant morbidity and mortality. Their management demonstrates significant practice variation within a national trauma system.Therapeutic/care management, level V; Prognostic and epidemiological, level IV.

  View details for DOI 10.1097/TA.0000000000003025

  View details for Web of Science ID 000625400000007

  View details for PubMedID 33617195

• Shared care in surgery: Practical considerations for surgical leaders. Healthcare management forum Reid, M., Lee, A., Urbach, D. R., Kuziemsky, C., Hameed, M., Moloo, H., Balaa, F. 2021; 34 (2): 77-80

  Abstract

  The recent COVID-19 pandemic has highlighted limitations in current healthcare systems and needed strategies to increase surgical access. This article presents a team-based integration model that embraces intra-disciplinary collaboration in shared clinical care, professional development, and administrative processes to address this surge in demand for surgical care. Implementing this model will require communicating the rationale for and benefits of shared care, while shifting patient trust to a team of providers. For the individual surgeon, advantages of clinical integration through shared care include decreased burnout and professional isolation, and more efficient transitions into and out of practice. Advantages to the system include greater surgeon availability, streamlined disease site wait lists, and promotion of system efficiency through a centralized distribution of clinical resources. We present a framework to stimulate national dialogue around shared care that will ultimately help overcome system bottlenecks for surgical patients and provide support for health professionals.

  View details for DOI 10.1177/0840470420952485

  View details for PubMedID 32869664

• Impact of interhospital transfer on patient outcomes in emergency general surgery Allen, L., Vogt, K., Joos, E., van Heest, R., Saleh, F., Widder, S., Hameed, M., Parry, N. G., Minor, S., Murphy, P. MOSBY-ELSEVIER. 2021: 455-459

  Abstract

  Emergency general surgery patients are at an increased risk for morbidity and mortality compared to their elective surgery counterparts. The complex nature of emergency general surgery conditions can challenge community hospitals, which may lack appropriate systems and personnel. Outcomes related to transfer have not been well-established. We aimed to compare postoperative outcomes of patients who were transferred from another hospital to a center with dedicated acute care surgery services with patients admitted directly to the acute care surgery centers.We performed a secondary analysis of a national, multicenter review of emergency general surgery patients undergoing complex emergency general surgery at 5 centers across Canada. The primary outcome was the development of any complication. The adjusted odds of postoperative complication was assessed using logistic regression, controlling for age, comorbidities, duration of stay before transfer, American Society of Anesthesiologists classification, and booking priority.A total of 1,846 patients were included in the study, and 176 (9.5%) were transferred. Of these 21% (n = 37) underwent an operative procedure, and 15% (n = 27) underwent an operation at the transferring center. Transferred patients were more likely to have at least 1 comorbidity (68% vs 57%; P = .004), were classified as greater urgency on arrival (<2 hours booking priority, 43% vs 17%; P < .001), had a greater American Society of Anesthesiologists classification (American Society of Anesthesiologists ≥3 = 81% vs 65%; P < .001), a greater duration of operation (119 vs 110 minutes; P = .004), and were more likely to undergo a second operation (28% vs 14%; P < .001) compared to patients directly admitted to an acute care surgery center. On univariate analysis, transferred patients had greater rates of complications (48% vs 31%; P < .001), mortality (14% vs 7%; P = .005), and admission to the intensive care unit (22% vs 12%; P < .001). Transfer status remained an independent predictor of complication (odds ratio 1.9 [95% confidence interval 1.3-2.7]; P < .001) and intensive care unit admission (odds ratio 1.9 [95% confidence interval 1.2-3.0]; P = .007), but not mortality (odds ratio 1.1 [95% confidence interval 0.6-1.9]; P = .79) on regression analysis.Complex emergency general surgery patients transferred to acute care surgery centers may have worse outcomes and greater use of resources compared to those admitted directly. This finding has clinically and financially important implications for the design and regionalization of acute care surgery services as well as resource allocation at acute care surgery centers.

  View details for DOI 10.1016/j.surg.2020.08.032

  View details for Web of Science ID 000608497000035

  View details for PubMedID 33268072

• A systematic review of global surgery partnerships and a proposed framework for sustainability. Canadian journal of surgery. Journal canadien de chirurgie Jedrzejko, N., Margolick, J., Nguyen, J. H., Ding, M., Kisa, P., Ball-Banting, E., Hameed, M., Joos, E. 2021; 64 (3): E280-E288

  Abstract

  Background: Building surgical capacity through global surgery partnerships (GSPs) between high and low- and middle-income countries (LMICs) is a rising global health focus. Our aim was to conduct a systematic review to characterize strategies employed by GSPs to build capacity and promote sustainability and to propose a novel reproducible model for sustainability.Methods: We conducted a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. We searched PubMed, EMBASE, Medline and African Journals Online to identify all peer-reviewed articles published between 2000 and 2016 that described GSPs between partners from the United States or Canada or both and partners from LMICs. We excluded papers that described nonsurgical GSPs, unilateral GSPs (e.g., humanitarian missions) or military initiatives. Descriptive features were analyzed, with a focus on attributes that promote sustainability. We then proposed criteria for sustainability on the basis of the themes that emerged from our review.Results: Our search retrieved 3580 abstracts, which were then independently reviewed by 4 authors. A total of 128 papers (3.6%) met the inclusion criteria. They described GSPs in 68 countries on 5 continents. Among the GSPs, 21.9% demonstrated community engagement and 51.6% included multidisciplinary collaboration. Surgical training or education was provided in 81.3% of GSPs. Although 64.8% of GSPs collected data, only 53.1% reported project-related outcomes. A total of 55.5% had bilateral authorship for publications, and 28.9% had multisource funding. Only 1 GSP fulfilled all 6 of our criteria for sustainability.Conclusion: In this systematic review we identified 6 pillars that are indicators of sustainability: community engagement, multidisciplinary collaboration, education and training, outcomes reporting, bilateral authorship and multisource funding. We propose that future GSPs should build on a foundation of bilateral ideas and expertise exchange, that they should have defined and measurable objectives, that they should engage in continuous evaluation of program outcomes and that they should take a thoughtful and transparent approach to sustained capacity building.

  View details for DOI 10.1503/cjs.010719

  View details for PubMedID 33908733

• The use of computed tomography during the COVID-19 pandemic: Its place in the diagnostic algorithm for acute surgical patients. The journal of trauma and acute care surgery D'Souza, K., Huynh, C., Khasanova, E., Nicolaou, S., Mayo, J. R., Hameed, S. M., Joos, E. 2020; 89 (5): e135-e139

  View details for DOI 10.1097/TA.0000000000002898

  View details for PubMedID 32769954

• Patterns of complex emergency general surgery in Canada. Canadian journal of surgery. Journal canadien de chirurgie Vogt, K. N., Allen, L., Murphy, P. B., van Heest, R., Saleh, F., Widder, S., Minor, S., Engels, P. T., Joos, E., Nenshi, R., Meschino, M. T., Laane, C., Lacoul, A., Parry, N. G., Ball, C. G., Hameed, S. M. 2020; 63 (5): E435-E441

  Abstract

  Most of the literature on emergency general surgery (EGS) has investigated appendiceal and biliary disease; however, EGS surgeons manage many other complex conditions. This study aimed to describe the operative burden of these conditions throughout Canada.This multicentre retrospective cohort study evaluated EGS patients at 7 centres across Canada in 2014. Adult patients (aged ≥ 18 yr) undergoing nonelective operative interventions for nonbiliary, nonappendiceal diseases were included. Data collected included information on patients' demographic characteristics, diagnosis, procedure details, complications and hospital length of stay. Logistic regression was used to identify predictors of morbidity and mortality.A total of 2595 patients were included, with a median age of 60 years (interquartile range 46-73 yr). The most common principal diagnoses were small bowel obstruction (16%), hernia (15%), malignancy (11%) and perianal disease (9%). The most commonly performed procedures were bowel resection (30%), hernia repair (15%), adhesiolysis (11%) and débridement of skin and soft tissue infections (10%). A total of 47% of cases were completed overnight (between 5 pm and 8 am). The overall inhospital mortality rate was 8%. Thirty-three percent of patients had a complication, with independent predictors including increasing age (p = 0.001), increasing American Society of Anesthesiologists score (p = 0.02) and transfer from another centre (p = 0.001).This study characterizes the epidemiology of nonbiliary, nonappendiceal EGS operative interventions across Canada. Canadian surgeons are performing a large volume of EGS, and conditions treated by EGS services are associated with a substantial risk of morbidity and mortality. Results of this study will be used to guide future research efforts and set benchmarks for quality improvement.

  View details for DOI 10.1503/cjs.011219

  View details for PubMedID 33009902

  View details for PubMedCentralID PMC7608705

• Optimal treatments for hepato-pancreato-biliary trauma in severely injured patients: a narrative scoping review. Canadian journal of surgery. Journal canadien de chirurgie Streith, L., Silverberg, J., Kirkpatrick, A. W., Hameed, S. M., Bathe, O. F., Ball, C. G. 2020; 63 (5): E431-E434

  Abstract

  Hepato-pancreato-biliary (HPB) injuries can be extremely challenging to manage. This scoping review (8438 citations) offers a number of recommendations. If diagnosis and therapy are rapid, patients with major hepatic injuries who present in physiologic extremis have high survival rates despite prolonged hospital stays. Nonoperative management of major liver injuries, as diagnosed using computed tomography, is typically successful. Adjuncts (e.g., angioembolization, laparoscopic washouts, biliary stents) are essential in managing high-grade injuries. Injury to the extrahepatic biliary tree is rare. Cholecystectomy is indicated for all gallbladder trauma. Full-thickness common bile duct injuries require a hepaticojejunostomy, although damage control remains closed suction drainage. Injuries to the pancreatic head often involve concurrent trauma to regional vasculature. Damage control necessitates drainage after stopping hemorrhage. Injury to the left pancreas commonly requires a distal pancreatectomy. Outcomes for high-grade pancreatic and liver injuries are improved by involving an HPB team. Complications are multidisciplinary and should be managed without delay.

  View details for DOI 10.1503/cjs.013919

  View details for PubMedID 33009897

  View details for PubMedCentralID PMC7608711

• A Prospective Evaluation of the Utility of a Hybrid Operating Suite for Severely Injured Patients: Overstated or Underutilized? Annals of surgery Carver, D., Kirkpatrick, A. W., D'Amours, S., Hameed, S. M., Beveridge, J., Ball, C. G. 2020; 271 (5): 958-961

  Abstract

  The primary objective of this study was to evaluate the utility, clinical impact, and work flow of a new trauma hybrid operating theater.The potential utility and clinical benefit of hybrid operating theaters are increasingly postulated. Unfortunately, the clinical outcomes and efficiencies of these environments remain unclear.All severely injured patients who were transferred to the hybrid suite for emergent intervention between 2013 and 2017 were compared to consecutive prehybrid patients. Standard statistical methodology was employed (P < 0.05 = significant).One hundred sixty-nine patients with severe injuries (mean ISS = 23; hemodynamic instability = 70%; hospital/ICU stay = 12 d; mortality = 14%) were transferred urgently to the hybrid suite. Most were young (38 yrs) males (84%) with blunt injuries (51%). Combined hybrid trauma procedures occurred in 18% of cases (surgery (82%) and angiography (11%) alone). Procedures within the hybrid suite included: laparotomy (57%), extremity (14%), thoracotomy/sternotomy (12%), angioembolization of the spleen/pelvis/liver/other (9%), neck (9%), craniotomy (4%), and aortic endostenting (6%). Compared with historical controls, use of the hybrid suite resulted in shorter arrival to intervention and total procedure times (P < 0.05). A clear benefit for survival was evident (42% vs. 22%).Availability of a hybrid environment for severely injured patients reduces time to intervention, total procedural duration, blood product transfusion and salvages a small subset of patients who would not otherwise survive. The cost associated with a hybrid suite remains prohibitive for many centers.

  View details for DOI 10.1097/SLA.0000000000003175

  View details for PubMedID 30601253

• A 30-day prospective audit of all inpatient complications following acute care surgery: How well do we really perform? Canadian journal of surgery. Journal canadien de chirurgie Ball, C. G., Murphy, P., Verhoeff, K., Albusadi, O., Patterson, M., Widder, S., Hameed, S. M., Parry, N., Vogt, K., Kortbeek, J. B., MacLean, A. R., Engels, P. T., Rice, T., Nenshi, R., Khwaja, K., Minor, S. 2020; 63 (2): E150-E154

  Abstract

  Acute care surgery (ACS) and emergency general surgery (EGS) services must provide timely care and intervention for patients who have some of the most challenging needs. Patients treated by ACS services are often critically ill and have both substantial comorbidities and poor physiologic reserve. Despite the widespread implemention of ACS/EGS services across North America, the true postoperative morbidity rates remain largely unknown.In this prospective study, inpatients at 8 high-volume ACS/EGS centres in geographically diverse locations in Canada who underwent operative interventions were followed for 30 days or until they were discharged. Readmissions during the 30-day window were also captured. Preoperative, intraoperative and postoperative variables were tracked. Standard statistical methodology was employed.A total of 601 ACS/EGS patients were followed for up to 30 inpatient or readmission days after their index emergent operation. Fifty-one percent of patients were female, and the median age was 51 years. They frequently had substantial medical comorbidities (42%) and morbid obesity (15%). The majority of procedures were minimally invasive (66% laparoscopic). Median length of stay was 3.3 days and the early readmission (< 30 d) rate was 6%. Six percent of patients were admitted to the critical care unit. The overall complication and mortality rates were 34% and 2%, respectively. Cholecystitis (31%), appendicitis (21%), bowel obstruction (18%), incarcerated hernia (12%), gastrointestinal hemorrhage (7%) and soft tissue infections (7%) were the most common diagnoses. The morbidity and mortality rates for open surgical procedures were 73% and 5%, respectively.Nontrauma ACS/EGS procedures are associated with a high postoperative morbidity rate. This study will serve as a prospective benchmark for postoperative complications among ACS/EGS patients and subsequent quality improvement across Canada.

  View details for DOI 10.1503/cjs.019118

  View details for PubMedID 32216251

  View details for PubMedCentralID PMC7828965

• Maximizing the potential of trauma registries in low-income and middle-income countries TRAUMA SURGERY & ACUTE CARE OPEN Rosenkrantz, L., Schuurman, N., Arenas, C., Nicol, A., Hameed, M. S. 2020; 5 (1): e000469

  Abstract

  Injury is a major global health issue, resulting in millions of deaths every year. For decades, trauma registries have been used in wealthier countries for injury surveillance and clinical governance, but their adoption has lagged in low-income and middle-income countries (LMICs). Paradoxically, LMICs face a disproportionately high burden of injury with few resources available to address this pandemic. Despite these resource constraints, several hospitals and regions in LMICs have managed to develop trauma registries to collect information related to the injury event, process of care, and outcome of the injured patient. While the implementation of these trauma registries is a positive step forward in addressing the injury burden in LMICs, numerous challenges still stand in the way of maximizing the potential of trauma registries to inform injury prevention, mitigation, and improve quality of trauma care. This paper outlines several of these challenges and identifies potential solutions that can be adopted to improve the functionality of trauma registries in resource-poor contexts. Increased recognition and support for trauma registry development and improvement in LMICs is critical to reducing the burden of injury in these settings.

  View details for DOI 10.1136/tsaco-2020-000469

  View details for Web of Science ID 000672553900050

  View details for PubMedID 32426528

  View details for PubMedCentralID PMC7228665

• Morbidity and mortality conferences in general surgery: a narrative systematic review. Canadian journal of surgery. Journal canadien de chirurgie Slater, N., Sekhon, P., Bradley, N., Shariff, F., Bedford, J., Wong, H., Chiu, C. J., Joos, E., Ball, C. G., Hameed, M. 2020; 63 (3): E211-E222

  Abstract

  Background: In medical and surgical departments around the world, morbidity and mortality conferences (MMC) serve dual roles: they are cornerstones of quality-improvement programs and provide timely opportunities for education within the urgent context of clinical care. Despite the widespread adoption of MMCs, adverse events and preventable errors remain high or incompletely characterized, and opportunities to learn from and adjust to these events are frequently lost. This review examines the published literature on strategies to improve surgical MMCs.Methods: We searched OVID Medline, PubMed, Embase and CENTRAL. We defined our combination of search terms using a PICO (population, intervention, comparison, outcome) model, focusing on the use of MMCs in general surgery.Results: The MMC literature focused on 5 themes: educational value, error analysis, case selection and representation, attendance and dissemination. Strategies used to increase educational value included limiting case presentation time to 15-20 minutes, mandatory brief literature reviews, increasing audience interaction, and standardizing presentations using a PowerPoint template or SBAR (situation, background, assessment, recommendation) format. Interventions to improve error analysis included focused discussion on causative factors and taxonomic error analysis. Case selection was improved by using an electronic clinical registry, such as the National Surgery Quality Improvement Program, to better capture incidence of morbidity and mortality. Attendance was improved with teleconferencing. Dissemination strategies included MMC newsletters, incorporating MMCs into plan-do-check-act cycles, and surgeon report cards.Conclusion: Greater standardization of best practices may increase the quality improvement and educational impact of MMCs and provide a baseline to measure the effect of new MMC format innovations on the clinical and educational performance of surgical systems.

  View details for DOI 10.1503/cjs.009219

  View details for PubMedID 32386469

• Mental toughness in surgeons: Is there room for improvement? CANADIAN JOURNAL OF SURGERY Percy, D. B., Streith, L., Wong, H., Ball, C. G., Widder, S., Hameed, M. 2019; 62 (6): 482-487

  Abstract

  Mental toughness is crucial to high-level performance in stressful situations. However, there is no formal evaluation or training in mental toughness in surgery. Our objective was to examine differences in mental toughness between staff and resident surgeons, and whether there is an interest in improving this attribute.We distributed a survey containing the Mental Toughness Index (domains of self-belief, attention regulation, emotion regulation, success mindset, context knowledge, buoyancy, optimism and adversity capacity) among general surgery residents and staff at 3 Canadian academic institutions. Responses were recorded on a 7-point Likert scale. Participants were also asked about techniques they used to help them perform under pressure and interest in further developing mental toughness.Eighty-three of 193 surgeons participated: 56/105 (52.8%) residents and 27/87 (31.0%) staff. The average age was 29 (standard deviation 5) years and 42 (standard deviation 8) years, respectively. Residents scored significantly lower than staff in all mental toughness domains. Men scored significantly higher than women in attention regulation and emotion regulation. Age, staff experience and resident postgraduate year were not significantly associated with mental toughness scores. Twenty residents (36%) and 17 staff (63%) reported using specific techniques to deal with stressful situations; 49 (88%) and 15 (56%), respectively, were interested in further developing mental toughness.Staff surgeons scored significantly higher than residents in all mental toughness domains measured. Both groups expressed a desire to improve mental toughness. There are many techniques to improve mental toughness, and further research is needed to assess their effectiveness in surgical training.

  View details for DOI 10.1503/cjs.010818

  View details for Web of Science ID 000501159400021

  View details for PubMedID 31782646

  View details for PubMedCentralID PMC6877379

• A Canadian strategy for surgical quality improvement CANADIAN JOURNAL OF SURGERY Urbach, D. R., Karimuddin, A. A., Wei, A., Zabolotny, B. P., Lefebvre, G., Walsh, M., Hameed, M., Fata, P., Chaudhury, P., McLeod, R. S., Cleary, S. P. 2019; 62 (6): E16-E18

  Abstract

  The Canadian Association of General Surgeons (CAGS) Board of Directors hosted a symposium to develop a Canadian strategy for surgical quality and safety at its mid-term meeting on Feb. 24, 2018. The following 6 principles outline the consensus of this symposium, which included diverse stakeholders and surgeon leaders across Canada: 1) a Canadian quality-improvement strategy for surgery is needed; 2) quality improvement requires continuous, active and intentional effort; 3) outcome measurement alone will not drive improvement; 4) increased focus on standardization and process improvement is necessary; 5) new, large electronic medical record systems pose challenges as well as benefits in Canadian hospitals; and 6) surgeons in remote and rural hospitals must be engaged using tailored approaches.

  View details for DOI 10.1503/cjs.019318

  View details for Web of Science ID 000501159400003

  View details for PubMedID 31782651

  View details for PubMedCentralID PMC6877378

• The changing face of academic general surgery in Canada: a cross-sectional cohort study CANADIAN JOURNAL OF SURGERY Tran, A., Gawad, N., Martel, A., Manhas, N., Allen, M., Hameed, M., Balaa, F. 2019; 62 (6): 381-385

  Abstract

  Little is known regarding the research and training expectations faced by modern general surgery graduates interested in pursuing academic surgical careers. In this study, we describe the changing face of the Canadian academic general surgeon by outlining the in-residency research productivity and postresidency clinical and academic training trends over time.Our cross-sectional cohort included Canadian academic general surgeons, defined as those with a university-affiliated appointment as assistant, associate or full professor. Academic surgeons were identified by the Royal College of Physicians and Surgeons of Canada online directory as well as directories of university and hospital websites. Data points included institution, faculty appointment and rank, graduation year, graduate education, fellowship training and research productivity.Our cohort included 417 surgeons from 17 Canadian academic institutions. The majority of surgeons were male (72.9%), had completed at least 1 fellowship (72.9%) and had had some form of supplementary research training (51.8%). Surgeons in the cohort had practised a median of 17 (10–27) years. The mean number of total and first-author publications for the participants in this study has increased consistently each decade before the 1980s (p < 0.001). The proportion of academic surgeons completing graduate degrees has increased steadily every decade, reaching a peak of 61.5% for surgeons graduating in the 2010s.The Canadian academic surgeon is becoming increasingly productive in research during residency and is pursuing higher levels of graduate education and more fellowships than ever before. These changes probably correspond to an evolving employment and research funding landscape that places tremendous academic pressure on surgical trainees.

  View details for DOI 10.1503/cjs.016418

  View details for Web of Science ID 000501159400007

  View details for PubMedID 31782294

  View details for PubMedCentralID PMC6877381

• Trauma registry implementation and operation in low and middle income countries: A scoping review GLOBAL PUBLIC HEALTH Rosenkrantz, L., Schuurman, N., Hameed, M. 2019; 14 (12): 1884-1897

  Abstract

  Injury is a major public health crisis contributing to more than 4.48 million deaths annually. Trauma registries have proven highly effective in reducing injury morbidity and mortality rates in high income countries. They are a critical source of information for injury prevention, benchmarking care, quality improvement, and resource allocation. Historically, low and middle income countries (LMICs) have largely been excluded from trauma registry development due to limited resources. Recently, this has begun to change with low-resource hospitals adopting innovative strategies to implement trauma registries. Nonetheless, dissemination of these strategies remains fragmented. Hospitals looking to develop their own trauma registries have no current, comprehensive resource that summarises the implementation decisions of other registries in similar contexts. This scoping review aims to identify where trauma registries are located in LMICs, bringing up to date previous estimates, and to identify the most common approaches to registry implementation and operation in these settings.

  View details for DOI 10.1080/17441692.2019.1622761

  View details for Web of Science ID 000472793200001

  View details for PubMedID 31232227

• Machine learning without borders? An adaptable tool to optimize mortality prediction in diverse clinical settings Christie, S., Hubbard, A. E., Callcut, R. A., Hameed, M., Dissak-Delon, F., Mekolo, D., Saidou, A., Mefire, A., Nsongoo, P., Dicker, R. A., Cohen, M., Juillard, C. LIPPINCOTT WILLIAMS & WILKINS. 2018: 921-927

  Abstract

  Mortality prediction aids clinical decision making and is necessary for quality improvement initiatives. Validated metrics rely on prespecified variables and often require advanced diagnostics, which are unfeasible in resource-constrained contexts. We hypothesize that machine learning will generate superior mortality prediction in both high-income and low- and middle-income country cohorts.SuperLearner, an ensemble machine-learning algorithm, was applied to data from three prospective trauma cohorts: a highest-activation cohort in the United States, a high-volume center cohort in South Africa (SA), and a multicenter registry in Cameroon. Cross-validation was used to assess model discrimination of discharge mortality by site using receiver operating characteristic curves. SuperLearner discrimination was compared with standard scoring methods. Clinical variables driving SuperLearner prediction at each site were evaluated.Data from 28,212 injured patients were used to generate prediction. Discharge mortality was 17%, 1.3%, and 1.7% among US, SA, and Cameroonian cohorts. SuperLearner delivered superior prediction of discharge mortality in the United States (area under the curve [AUC], 94-97%) and vastly superior prediction in Cameroon (AUC, 90-94%) compared with conventional scoring algorithms. It provided similar prediction to standard scores in the SA cohort (AUC, 90-95%). Context-specific variables (partial thromboplastin time in the United States and hospital distance in Cameroon) were prime drivers of predicted mortality in their respective cohorts, whereas severe brain injury predicted mortality across sites.Machine learning provides excellent discrimination of injury mortality in diverse settings. Unlike traditional scores, data-adaptive methods are well suited to optimizing precise site-specific prediction regardless of diagnostic capabilities or data set inclusion allowing for individualized decision making and expanded access to quality improvement programming.Prognostic and therapeutic, level II and III.

  View details for DOI 10.1097/TA.0000000000002044

  View details for Web of Science ID 000449060100014

  View details for PubMedID 30059457

  View details for PubMedCentralID PMC6225991

• Multidisciplinary in-situ simulation to evaluate a rare but high-risk process at a level 1 trauma centre: the “Mega-Sim” approach. Canadian journal of surgery. Journal canadien de chirurgie Bradley, N. L., Innes, K., Dakin, C., Sawka, A., Lakha, N., Hameed, S. M. 2018; 61 (5): 357-360

  Abstract

  Multidisciplinary simulation has been used to successfully teach crisis resource management in operating room and emergency department settings. This article describes a “Mega-Sim” approach using an in-situ simulation that moves among multiple hospital departments to enhance multidisciplinary training and assess institutional response to a rare but high-risk event: trauma in a pregnant patient. It appears that a Mega-Sim can be used to identify systems issues, increase medical knowledge and improve perceptions of teamwork and communication within and among hospital departments.

  View details for DOI 10.1503/cjs.005417

  View details for PubMedID 30247856

  View details for PubMedCentralID PMC6153112

• A day in the life of emergency general surgery in Canada: a multicentre observational study. Canadian journal of surgery. Journal canadien de chirurgie DeGirolamo, K., D'Souza, K., Apte, S., Ball, C. G., Armstrong, C., Reso, A., Widder, S., Mueller, S., Gillman, L. M., Singh, R., Nenshi, R., Khwaja, K., Minor, S., de Gara, C., Hameed, S. M. 2018; 61 (4): 237-243

  Abstract

  Emergency general surgery (EGS) services are gaining popularity in Canada as systems-based approaches to surgical emergencies. Despite the high volume, acuity and complexity of the patient populations served by EGS services, little has been reported about the services' structure, processes, case mix or outcomes. This study begins a national surveillance effort to define and advance surgical quality in an important and diverse surgical population.A national cross-sectional study of EGS services was conducted during a 24-hour period in January 2017 at 14 hospitals across 7 Canadian provinces recruited through the Canadian Association of General Surgeons Acute Care Committee. Patients admitted to the EGS service, new consultations and off-service patients being followed by the EGS service during the study period were included. Patient demographic information and data on operations, procedures and complications were collected.Twelve sites reported resident coverage. Most services did not include trauma. Ten sites had protected operating room time. Overall, 393 patient encounters occurred during the study period (195/386 [50.5%] operative and 191/386 [49.5%] nonoperative), with a mean of 3.8 operations per service. The patient population was complex, with 136 patients (34.6%) having more than 3 comorbidities. There was a wide case mix, including gallbladder disease (69 cases [17.8%]) and appendiceal disease (31 [8.0%]) as well as complex emergencies, such as obstruction (56 [14.5%]) and perforation (23 [5.9%]).The characteristics and case mix of these Canadian EGS services are heterogeneous, but all services are busy and provide comprehensive operative and nonoperative care to acutely ill patients with high levels of comorbidity.

  View details for DOI 10.1503/cjs.013517

  View details for PubMedID 30067181

  View details for PubMedCentralID PMC6066383

• A Systematic Review of the Risks and Benefits of Venous Thromboembolism Prophylaxis in Traumatic Brain Injury. The Canadian journal of neurological sciences. Le journal canadien des sciences neurologiques Margolick, J., Dandurand, C., Duncan, K., Chen, W., Evans, D. C., Sekhon, M. S., Garraway, N., Griesdale, D. E., Gooderham, P., Hameed, S. M. 2018; 45 (4): 432-444

  Abstract

  Patients suffering from traumatic brain injury (TBI) are at increased risk of venous thromboembolism (VTE). However, initiation of pharmacological venous thromboprophylaxis (VTEp) may cause further intracranial hemorrhage. We reviewed the literature to determine the postinjury time interval at which VTEp can be administered without risk of TBI evolution and hematoma expansion.MEDLINE and EMBASE databases were searched. Inclusion criteria were studies investigating timing and safety of VTEp in TBI patients not previously on oral anticoagulation. Two investigators extracted data and graded the papers' levels of evidence. Randomized controlled trials were assessed for bias according to the Cochrane Collaboration Tool and Cohort studies were evaluated for bias using the Newcastle-Ottawa Scale. We performed univariate meta-regression analysis in an attempt to identify a relationship between VTEp timing and hemorrhagic progression and assess study heterogeneity using an I 2 statistic.Twenty-one studies were included in the systematic review. Eighteen total studies demonstrated that VTEp postinjury in patients with stable head computed tomography scan does not lead to TBI progression. Fourteen studies demonstrated that VTEp administration 24 to 72 hours postinjury is safe in patients with stable injury. Four studies suggested that administering VTEp within 24 hours of injury in patients with stable TBI does not lead to progressive intracranial hemorrhage. Overall, meta-regression analysis demonstrated that there was no relationship between rate of hemorrhagic progression and VTEp timing.Literature suggests that administering VTEp 24 to 48 hours postinjury may be safe for patients with low-hemorrhagic-risk TBIs and stable injury on repeat imaging.

  View details for DOI 10.1017/cjn.2017.275

  View details for PubMedID 29895339

• Association Between Real-time Electronic Injury Surveillance Applications and Clinical Documentation and Data Acquisition in a South African Trauma Center. JAMA surgery Zargaran, E., Spence, R., Adolph, L., Nicol, A., Schuurman, N., Navsaria, P., Ramsey, D., Hameed, S. M. 2018; 153 (5): e180087

  Abstract

  Collection and analysis of up-to-date and accurate injury surveillance data are a key step in the maturation of trauma systems. Trauma registries have proven to be difficult to establish in low- and middle-income countries owing to the burden of trauma volume, cost, and complexity.To determine whether an electronic trauma health record (eTHR) used by physicians can serve as simultaneous clinical documentation and data acquisition tools.This 2-part quality improvement study included (1) preimplementation and postimplementation eTHR study with assessments of satisfaction by 41 trauma physicians, time to completion, and quality of data collected comparing paper and electronic charting; and (2) prospective ecologic study describing the burden of trauma seen at a Level I trauma center, using real-time data collected by the eTHR on consecutive patients during a 12-month study period. The study was conducted from October 1, 2010, to September 30, 2011, at Groote Schuur Hospital, Cape Town, South Africa. Data analysis was performed from October 15, 2011, to January 15, 2013.The primary outcome of part 1 was data field competition rates of pertinent trauma registry items obtained through electronic or paper documentation. The main measures of part 2 were to identify risk factors to trauma in Cape Town and quality indicators recommended for trauma system evaluation at Groote Schuur Hospital.The 41 physicians included in the study found the electronic patient documentation to be more efficient and preferable. A total of 11 612 trauma presentations were accurately documented and promptly analyzed. Fields relevant to injury surveillance in the eTHR (n = 11 612) had statistically significant higher completion rates compared with paper records (n = 9236) (for all comparisons, P < .001). The eTHR successfully captured quality indicators recommended for trauma system evaluation which were previously challenging to collect in a timely and accurate manner. Of the 11 612 patient admissions over the study period, injury location was captured 11 075 times (95.4%), injury mechanism 11 135 times (95.9%), systolic blood pressure 11 106 times (95.6%), and Glasgow Coma Scale 11 140 times (95.9%). These fields were successfully captured with statistically higher rates than previous paper documentation. Epidemiologic analysis confirmed a heavy burden of violence-related injury (51.8% of all injuries) and motor vehicle crash injuries (14.3% of all injuries). Mapping analysis demonstrated clusters of injuries originating mainly from vulnerable and low-income neighborhoods and their respective referring trauma facilities, Mitchell's Plain Hospital (734 [10.1%]), Guguletu Community Health Center (654 [9.0%]), and New Somerset Hospital (400 [5.5%]).Accurate capture and simultaneous analysis of trauma data in low-resource trauma settings are feasible through the integration of surveillance into clinical workflow and the timely analysis of electronic data.

  View details for DOI 10.1001/jamasurg.2018.0087

  View details for PubMedID 29541765

  View details for PubMedCentralID PMC5875377

• Tele-mentored damage-control and emergency trauma surgery: A feasibility study using live-tissue models AMERICAN JOURNAL OF SURGERY Dawe, P., Kirkpatrick, A., Talbot, M., Beckett, A., Garraway, N., Wong, H., Hameed, S. 2018; 215 (5): 927-929

  Abstract

  Damage-control and emergency surgical procedures in trauma have the potential to save lives. They may occasionally not be performed due to clinician inexperience or lack of comfort and knowledge.Canadian Armed Forces (CAF) non-surgeon Medical Officers (MOs) participated in a live tissue training exercise. They received tele-mentoring assistance using a secure video-conferencing application on a smartphone/tablet platform. Feasibility of tele-mentored surgery was studied by measuring their effectiveness at completing a set series of tasks in this pilot study. Additionally, their comfort and willingness to perform studied procedures was gauged using pre- and post-study surveys.With no pre-procedural teaching, participants were able to complete surgical airway, chest tube insertion and resuscitative thoracotomy with 100% effectiveness with no noted complications. Comfort level and willingness to perform these procedures were improved with tele-mentoring. Participants felt that tele-mentored surgery would benefit their performance of resuscitative thoracotomy most.The use of tele-mentored surgery to assist non-surgeon clinicians in the performance of damage-control and emergency surgical procedures is feasible. More study is required to validate its effectiveness.

  View details for DOI 10.1016/j.amjsurg.2018.01.016

  View details for Web of Science ID 000432469100056

  View details for PubMedID 29397897

• Process mapping as a framework for performance improvement in emergency general surgery CANADIAN JOURNAL OF SURGERY DeGirolamo, K., D'Souza, K., Hall, W., Joos, E., Garraway, N., Sing, C., McLaughlin, P., Hameed, M. 2018; 61 (1): 13-18

  Abstract

  Emergency general surgery conditions are often thought of as being too acute for the development of standardized approaches to quality improvement. However, process mapping, a concept that has been applied extensively in manufacturing quality improvement, is now being used in health care. The objective of this study was to create process maps for small bowel obstruction in an effort to identify potential areas for quality improvement.We used the American College of Surgeons Emergency General Surgery Quality Improvement Program pilot database to identify patients who received nonoperative or operative management of small bowel obstruction between March 2015 and March 2016. This database, patient charts and electronic health records were used to create process maps from the time of presentation to discharge.Eighty-eight patients with small bowel obstruction (33 operative; 55 nonoperative) were identified. Patients who received surgery had a complication rate of 32%. The processes of care from the time of presentation to the time of follow-up were highly elaborate and variable in terms of duration; however, the sequences of care were found to be consistent. We used data visualization strategies to identify bottlenecks in care, and they showed substantial variability in terms of operating room access.Variability in the operative care of small bowel obstruction is high and represents an important improvement opportunity in general surgery. Process mapping can identify common themes, even in acute care, and suggest specific performance improvement measures.

  View details for DOI 10.1503/cjs.004417

  View details for Web of Science ID 000423560500008

  View details for PubMedID 29368672

  View details for PubMedCentralID PMC5785284

• 64-Slice CT compared to MRI to clear cervical spine injury in high-risk GCS &lt; 14 blunt trauma patients admitted to the ICU TRAUMA-ENGLAND McCallum, J., McLaughlin, P., Hameed, M., Kanji, H. D. 2018; 20 (1): 38-45

  View details for DOI 10.1177/1460408617698512

  View details for Web of Science ID 000418557500006

• Canadian benchmarks for acute injury care CANADIAN JOURNAL OF SURGERY Moore, L., Evans, D., Yanchar, N. L., Thakore, J., Stelfox, H., Hameed, M., Simons, R., Kortbeek, J., Clement, J., Lauzier, F., Turgeon, A. F. 2017; 60 (6): 380-387

  Abstract

  Acute care injury outcomes vary substantially across Canadian provinces and trauma centres. Our aim was to develop Canadian benchmarks to monitor mortality and hospital length of stay (LOS) for injury admissions.Benchmarks were derived using data from the Canadian National Trauma Registry on patients with major trauma admitted to any level I or II trauma centre in Canada and from the following patient subgroups: isolated traumatic brain injury (TBI), isolated thoracoabdominal injury, multisystem blunt injury, age 65 years or older. We assessed predictive validity using measures of discrimination and calibration, and performed sensitivity analyses to assess the impact of replacing analytically complex methods (multiple imputation, shrinkage estimates and flexible modelling) with simple models that can be implemented locally.The mortality risk adjustment model had excellent discrimination and calibration (area under the receiver operating characteristic curve 0.886, Hosmer-Lemeshow 36). The LOS risk-adjustment model predicted 29% of the variation in LOS. Overall, observed:expected ratios of mortality and mean LOS generated by an analytically simple model correlated strongly with those generated by analytically complex models (r > 0.95, κ on outliers > 0.90).We propose Canadian benchmarks that can be used to monitor quality of care in Canadian trauma centres using Excel (see the appendices, available at canjsurg.ca). The program can be implemented using local trauma registries, providing that at least 100 patients are available for analysis.

  View details for DOI 10.1503/cjs.002817

  View details for Web of Science ID 000417826300010

  View details for PubMedID 28930046

  View details for PubMedCentralID PMC5726966

• Meta-Analysis on the Impact of the Acute Care Surgery Model of Disease- and Patient-Specific Outcomes in Appendicitis and Biliary Disease JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS Murphy, P. B., DeGirolamo, K., Van Zyl, T., Allen, L., Haut, E., Leeper, W., Leslie, K., Parry, N., Hameed, M., Vogt, K. N. 2017; 225 (6): 763-+

  Abstract

  The acute care surgery (ACS) model was developed to acknowledge the complexity of a traditionally fractured emergency general surgery patient population, however, there are variations in the design of ACS service models. This meta-analysis analyzes the impact of implementation of different ACS models on the outcomes for appendicitis and biliary disease.A systematic, English-language search of major databases was conducted. From 1,827 papers, 2 independent reviewers identified 25 studies that reported on outcomes for patients with appendicitis (n = 13), biliary disease (n = 7), or both (n = 5), before and after implementation of an ACS service. The Newcastle-Ottawa Scale was used to score quality. Outcomes were analyzed using random effect methodology and sensitivity analyses were performed.Significant heterogeneity existed between studies and ACS designs. The overall study quality rating was fair to poor with a moderate risk of bias. After implementation of an ACS service, there was an overall reduction in length of stay by 0.51 days (95% CI -0.81 to -0.20 days) and 0.73 days (95% CI 0.09 to 1.36 days) for appendicitis and biliary disease, respectively. Complication rates were lower after implementing ACS (odds ratio 0.65; 95% CI 0.49 to 0.86 and odds ratio 0.46; 95% CI 0.34 to 0.61). There was no difference in after-hours operating for either appendicitis or biliary disease, except when considering ACS models with dedicated theater time, which favors an ACS model (odds ratio 0.49; 95% CI 0.33 to 0.73) in appendicitis.The ACS model has been shown to benefit acute care surgery patients with improved access to care, fewer complications, and decreased length of stay for 2 common disease processes. The design and implementation of an ACS service can impact the magnitude of effect.

  View details for DOI 10.1016/j.jamcollsurg.2017.08.026

  View details for Web of Science ID 000416487600011

  View details for PubMedID 28918345

• Expanding the scope of quality measurement in surgery to include nonoperative care: Results from the American College of Surgeons National Surgical Quality Improvement Program emergency general surgery pilot Wandling, M. W., Ko, C. Y., Bankey, P. E., Cribari, C., Cryer, H., Diaz, J. J., Duane, T. M., Hameed, S., Hutter, M. M., Metzler, M. H., Regner, J. L., Reilly, P. M., Reines, H., Sperry, J. L., Staudenmayer, K. L., Utter, G. H., Crandall, M. L., Bilimoria, K. Y., Nathens, A. B. LIPPINCOTT WILLIAMS & WILKINS. 2017: 837–45

  Abstract

  Patients managed nonoperatively have been excluded from risk-adjusted benchmarking programs, including the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP). Consequently, optimal performance evaluation is not possible for specialties like emergency general surgery (EGS) where nonoperative management is common. We developed a multi-institutional EGS clinical data registry within ACS NSQIP that includes patients managed nonoperatively to evaluate variability in nonoperative care across hospitals and identify gaps in performance assessment that occur when only operative cases are considered.Using ACS NSQIP infrastructure and methodology, surgical consultations for acute appendicitis, acute cholecystitis, and small bowel obstruction (SBO) were sampled at 13 hospitals that volunteered to participate in the EGS clinical data registry. Standard NSQIP variables and 16 EGS-specific variables were abstracted with 30-day follow-up. To determine the influence of complications in nonoperative patients, rates of adverse outcomes were identified, and hospitals were ranked by performance with and then without including nonoperative cases.Two thousand ninety-one patients with EGS diagnoses were included, 46.6% with appendicitis, 24.3% with cholecystitis, and 29.1% with SBO. The overall rate of nonoperative management was 27.4%, 6.6% for appendicitis, 16.5% for cholecystitis, and 69.9% for SBO. Despite comprising only 27.4% of patients in the EGS pilot, nonoperative management accounted for 67.7% of deaths, 34.3% of serious morbidities, and 41.8% of hospital readmissions. After adjusting for patient characteristics and hospital diagnosis mix, addition of nonoperative management to hospital performance assessment resulted in 12 of 13 hospitals changing performance rank, with four hospitals changing by three or more positions.This study identifies a gap in performance evaluation when nonoperative patients are excluded from surgical quality assessment and demonstrates the feasibility of incorporating nonoperative care into existing surgical quality initiatives. Broadening the scope of hospital performance assessment to include nonoperative management creates an opportunity to improve the care of all surgical patients, not just those who have an operation.Care management, level IV; Epidemiologic, level III.

  View details for PubMedID 29068873

  View details for PubMedCentralID PMC5755591

• Does increased prehospital time lead to a "trial of life" effect for patients with blunt trauma? The Journal of surgical research Clements, T. W., Vogt, K., Hameed, S. M., Parry, N., Kirkpatrick, A. W., Grondin, S. C., Dixon, E., McKee, J., Ball, C. G. 2017; 216: 103-108

  Abstract

  Variance in prehospital time among severely injured blunt trauma patients is dependent upon numerous factors. Effects on subsequent mortality and trauma team activation (TTA) rates are also unclear. The primary aim of this study was to evaluate the relationship between prehospital time and mortality at level I trauma referral centers amongst critically blunt injured patients.This multiinstitutional study from three geographically distinct level I trauma centers analyzed all severely blunt injured patients (Injury Severity Score [ISS] ≥12). The relationship between prehospital time and survival was evaluated. Secondary outcomes included the association between prehospital time and TTA. Standard statistical methodology was used (P < 0.05 = significance).Between January 1, 2011, and January 1, 2016, 5375 severely blunt injured patients (mean ISS = 25; mean length of stay = 16.3 d) were analyzed (center 1 = 3376; center 2 = 2401; and center 3 = 1104). As prehospital time interval increased, overall mortality decreased (0-30 min = 24.1%; 31-60 min = 14.7%; 61-90 min = 10.3%; 91-120 min = 10.4%; 121-150 min = 10.2%; P < 0.05). This pattern was especially strong for patients with an arrival measurement of hypotension, despite corrections for ISS (P < 0.05). TTA and patient outcomes were extremely variable across intervals and centers (P < 0.05).A trial of life effect is present for severely blunt injured patients who arrive with vital signs. Despite arrival measurements of hypotension, patients with prolonged prehospital times have a substantially lower risk of subsequent mortality. This concept should contribute to decision-making with regard to TTA.

  View details for DOI 10.1016/j.jss.2017.04.027

  View details for PubMedID 28807193

• Implementation of Neurocritical Care Is Associated With Improved Outcomes in Traumatic Brain Injury CANADIAN JOURNAL OF NEUROLOGICAL SCIENCES Sekhon, M. S., Gooderham, P., Toyota, B., Kherzi, N., Hu, V., Dhingra, V. K., Hameed, M. S., Chittock, D. R., Griesdale, D. E. 2017; 44 (4): 350-357

  Abstract

  Background Traditionally, the delivery of dedicated neurocritical care (NCC) occurs in distinct NCC units and is associated with improved outcomes. Institution-specific logistical challenges pose barriers to the development of distinct NCC units; therefore, we developed a consultancy NCC service coupled with the implementation of invasive multimodal neuromonitoring, within a medical-surgical intensive care unit. Our objective was to evaluate the effect of a consultancy NCC program on neurologic outcomes in severe traumatic brain injury patients.We conducted a single-center quasi-experimental uncontrolled pre- and post-NCC study in severe traumatic brain injury patients (Glasgow Coma Scale ≤8). The NCC program includes consultation with a neurointensivist and neurosurgeon and multimodal neuromonitoring. Demographic, injury severity metrics, neurophysiologic data, and therapeutic interventions were collected. Glasgow Outcome Scale (GOS) at 6 months was the primary outcome. Multivariable ordinal logistic regression was used to model the association between NCC implementation and GOS at 6 months.A total of 113 patients were identified: 76 pre-NCC and 37 post-NCC. Mean age was 39 years (standard deviation [SD], 2) and 87 of 113 (77%) patients were male. Median admission motor score was 3 (interquartile ratio, 1-4). Daily mean arterial pressure was higher (95 mmHg [SD, 10]) versus (88 mmHg [SD, 10], p<0.001) and daily mean core body temperature was lower (36.6°C [SD, 0.90]) versus (37.2°C [SD, 1.0], p=0.001) post-NCC compared with pre-NCC, respectively. Multivariable regression modelling revealed the NCC program was associated with a 2.5 increased odds (odds ratios, 2.5; 95% confidence interval, 1.1-5.3; p=0.022) of improved 6-month GOS.Implementation of a NCC program is associated with improved 6 month GOS in severe TBI patients.

  View details for DOI 10.1017/cjn.2017.25

  View details for Web of Science ID 000407464200003

  View details for PubMedID 28343456

• Timing of cholecystectomy following endoscopic sphincterotomy: a population-based study. Surgical endoscopy Mador, B. D., Nathens, A. B., Xiong, W., Panton, O. N., Hameed, S. M. 2017; 31 (7): 2977-2985

  Abstract

  Choledocholithiasis is commonly treated initially with endoscopic sphincterotomy, followed by cholecystectomy to definitively address the underlying problem of cholelithiasis. While the benefits of early cholecystectomy have been realized in other populations, the preferred timing for this subset of patients is less well established. We performed a large, population-based analysis to determine the frequency, benefits, and practice variance in regard to early cholecystectomy on a provincial level.Patients undergoing endoscopic sphincterotomy followed by cholecystectomy in British Columbia, Canada, from January 2001 to December 2011 were identified using fee-code billing data. Multiple databases were linked to obtain information on demographics, admissions, procedures, mortality, and census geographic data. Regression analysis was performed for length of stay (LOS) and additional procedures. Outcome data were risk adjusted for age, gender, comorbidities, socioeconomic status, and year of procedure. Variability of early cholecystectomy crude rates across census areas was determined using a funnel plot.There were 4287 eligible patients. Of these, 1905 (44.4%) underwent early cholecystectomy, defined as surgery within 14 days of sphincterotomy. Median interval to cholecystectomy was 2 days for the early cholecystectomy group and 61 days for delayed. There was a significant difference in hospital LOS favoring early cholecystectomy for patients with documented gallstone disease (p < 0.05). Patients initially admitted to a surgical service were more likely to undergo early cholecystectomy (60 vs. 36%, p < 0.001). There was no difference between groups in terms of bile duct injury or mortality. There was wide variability in rates of early cholecystectomy among census areas (range 0-96%) and health regions (range 20-66%) which was not explained by population density or geography.Early cholecystectomy is the ideal approach to gallstone disease post-sphincterotomy. Despite this, a large amount of clinical variance exists in regard to timing of cholecystectomy which seems to be primarily institution dependent.

  View details for DOI 10.1007/s00464-016-5316-9

  View details for PubMedID 27834026

• Data capture and communication during transfers to definitive care in an inclusive trauma system. Injury Bradley, N. L., Garraway, N., Bell, N., Lakha, N., Hameed, S. M. 2017; 48 (5): 1069-1073

  Abstract

  Background trauma survivors in rural areas transferred to urban centers have higher mortality than trauma patients admitted directly to urban centers. Transfer data in trauma registries is important for injury control. Prehospital and early physiologic data may reflect processes of pre-hospital care. British Columbia currently has no standardized process for trauma patient data transfer.We performed a retrospective data analysis for major trauma patients (ISS>15) transferred to a Level I trauma center over a 1year period (n=243). Completion rates of paramedic form and ATLS primary survey variables were extracted. Nominal and interval descriptives were calculated. Documentation rates were considered deficient at <80% and severely deficient <60%. Odds ratios were calculated for primary facility data based on ISS ≥30 vs ISS <30, with 2-sided p-values for confidence intervals RESULTS: Two hundred forty-three patients met inclusion criteria with a mean ISS of 26. Most injured patients were male (79%), the predominant mechanism was blunt (93%) and the average age at injury was 51 years old. Two hundred eighteen patients arrived by Emergency Health Services, and 140 (64%) of EHS pre-hospital forms were transferred with the patient chart. Pre-hospital airway, physiologic data, and GCS completion rates were severely deficient (43-49%). Primary facility data was adequately completed for airway management, systolic blood pressure, and heart rate in (80-83%). Completion rates were deficient for respiratory rate, GCS and temperature (60-77%). An ISS score ≥30 was significantly associated with a lower completion rate for GCS.Overall, documentation for inter-hospital transfer of major trauma patients in BC has significant deficiencies. Physiologic and basic ATLS variables are often omitted in transferred charts. The potential for adverse events is high but performance improvement is achievable. We recommend education, training and a standardized trauma transfer protocol to improve system-wide information transfer.

  View details for DOI 10.1016/j.injury.2016.11.004

  View details for PubMedID 28314465

• Timely Surgical Care for Acute Biliary Disease: An Indication of Quality. Annals of surgery Murphy, P. B., Vogt, K. N., Mele, T. S., Hameed, S. M., Ball, C. G., Parry, N. G. 2016; 264 (6): 913-914

  View details for DOI 10.1097/SLA.0000000000001704

  View details for PubMedID 27828819

• No benefit to surgical fixation of flail chest injuries compared with modern comprehensive management: results of a retrospective cohort study. Canadian journal of surgery. Journal canadien de chirurgie Farquhar, J., Almarhabi, Y., Slobogean, G., Slobogean, B., Garraway, N., Simons, R. K., Hameed, S. M. 2016; 59 (5): 299-303

  Abstract

  Chest wall trauma is a common cause of morbidity and mortality. Recent technological advances and scientific publications have created a renewed interest in surgical fixation of flail chest. However, definitive data supporting surgical fixation are lacking, and its virtues have not been evaluated against modern, comprehensive management protocols.Consecutive patients undergoing rib fracture fixation with rib-specific locking plates at 2 regional trauma centres between July 2010 and August 2012 were matched to historical controls with similar injury patterns and severity who were managed nonoperatively with modern, multidisciplinary protocols. We compared short- and long-term outcomes between these cohorts.Our patient cohorts were well matched for age, sex, injury severity scores and abbreviated injury scores. The nonoperatively managed group had significantly better outcomes than the surgical group in terms of ventilator days (3.1 v. 6.1, p = 0.012), length of stay in the intensive care unit (3.7 v. 7.4 d, p = 0.009), total hospital length of stay (16.0 v. 21.9 d, p = 0.044) and rates of pneumonia (22% v. 63%, p = 0.004). There were no significant differences in long-term outcomes, such as chest pain or dyspnea.Although considerable enthusiasm surrounds surgical fixation of flail chest injuries, our analysis does not immediately validate its universal implementation, but rather encourages the use of modern, multidisciplinary, nonoperative strategies. The role of rib fracture fixation in the modern era of chest wall trauma management should ultimately be defined by prospective, randomized trials.

  View details for DOI 10.1503/cjs.000515

  View details for PubMedID 27438051

  View details for PubMedCentralID PMC5042715

• An Objective Assessment of the Surgical Trainee in an Urban Trauma Unit in South Africa: A Pilot Study WORLD JOURNAL OF SURGERY Spence, R., Zargaran, E., Hameed, M., Nicol, A., Navsaria, P. 2016; 40 (8): 1815-1822

  Abstract

  Surgical outcomes are provider specific. This prospective audit describes the surgical activity of five general surgery residents on their trauma surgery rotation. It was hypothesized that the operating surgical trainee is an independent risk factor for adverse outcomes following major trauma.This is a prospective cohort study. All patients admitted, over a 6-month period (August 2014-January 2015), following trauma requiring a major operation performed by a surgical trainee at Groote Schuur Hospital's trauma unit in South Africa were included. Multiple logistic regression models were built to compare risk-adjusted surgical outcomes between trainees. The primary outcome measure was major in-hospital complications.A total of 320 major operations involving 341 procedures were included. The mean age was 28.49 years (range 13-64), 97.2 % were male with a median ISS of 9 (IQR 1-41). Mechanism of injury was penetrating in 93.42 % of cases of which 51.86 % were gunshot injuries. Surgeon A consistently had the lowest risk-adjusted outcomes and was used as the reference for all outcomes in the regression models. Surgeon B, D, and E had statistically significant higher rates of major in-hospital complications than Surgeon A and C, after adjusting for multiple confounders. The final model used to calculate the risk estimates for the primary outcome had a ROC of 0.8649.Risk-adjusted surgical outcomes vary by operating surgical trainee. The analysis thereof can add value to the objective assessment of a surgical trainee.

  View details for DOI 10.1007/s00268-016-3503-4

  View details for Web of Science ID 000380054000004

  View details for PubMedID 27091205

• Mobile health technology transforms injury severity scoring in South Africa. The Journal of surgical research Spence, R. T., Zargaran, E., Hameed, S. M., Navsaria, P., Nicol, A. 2016; 204 (2): 384-392

  Abstract

  The burden of data collection associated with injury severity scoring has limited its application in areas of the world with the highest incidence of trauma.Since January 2014, electronic records (electronic Trauma Health Records [eTHRs]) replaced all handwritten records at the Groote Schuur Hospital Trauma Unit in South Africa. Data fields required for Glasgow Coma Scale, Revised Trauma Score, Kampala Trauma Score, Injury Severity Score (ISS), and Trauma Score-Injury Severity Score calculations are now prospectively collected. Fifteen months after implementation of eTHR, the injury severity scores were compared as predictors of mortality on three accounts: (1) ability to discriminate (area under receiver operating curve, ROC); (2) ability to calibrate (observed versus expected ratio, O/E); and (3) feasibility of data collection (rate of missing data).A total of 7460 admissions were recorded by eTHR from April 1, 2014 to July 7, 2015, including 770 severely injured patients (ISS > 15) and 950 operations. The mean age was 33.3 y (range 13-94), 77.6% were male, and the mechanism of injury was penetrating in 39.3% of cases. The cohort experienced a mortality rate of 2.5%. Patient reserve predictors required by the scores were 98.7% complete, physiological injury predictors were 95.1% complete, and anatomic injury predictors were 86.9% complete. The discrimination and calibration of Trauma Score-Injury Severity Score was superior for all admissions (ROC 0.9591 and O/E 1.01) and operatively managed patients (ROC 0.8427 and O/E 0.79). In the severely injured cohort, the discriminatory ability of Revised Trauma Score was superior (ROC 0.8315), but no score provided adequate calibration.Emerging mobile health technology enables reliable and sustainable injury severity scoring in a high-volume trauma center in South Africa.

  View details for DOI 10.1016/j.jss.2016.05.021

  View details for PubMedID 27565074

• Implementing Electronic Surgical Registries in Lower-Middle Income Countries: Experiences in Latin America ANNALS OF GLOBAL HEALTH Dasari, M., Asturias, S., Garbett, M., Zargaran, E., Machain, G., Hameed, M., Puyana, J. 2016; 82 (4): 639-643

  View details for DOI 10.1016/j.aogh.2016.09.007

  View details for Web of Science ID 000390863200007

  View details for PubMedID 27986233

• Severe acute pancreatitis for the acute care surgeon. The journal of trauma and acute care surgery Ball, C. G., Hameed, S. M., Dixon, E., Lillemoe, K. D. 2016; 80 (6): 1015-22

  View details for DOI 10.1097/TA.0000000000001029

  View details for PubMedID 26953759

• A global agenda for electronic injury surveillance: Consensus statement from the Trauma Association of Canada, the Trauma Society of South Africa, and the Panamerican Trauma Society. The journal of trauma and acute care surgery Zargaran, E., Adolph, L., Schuurman, N., Roux, L., Ramsey, D., Simons, R., Spence, R., Nicol, A. J., Navsaria, P., Puyana, J. C., Parry, N., Moore, L., Aboutanos, M., Yanchar, N., Razek, T., Ball, C. G., Hameed, S. M. 2016; 80 (1): 168-70

  View details for DOI 10.1097/TA.0000000000000880

  View details for PubMedID 26683401

• Hepato-pancreato-biliary emergencies for the acute care surgeon: etiology, diagnosis and treatment WORLD JOURNAL OF EMERGENCY SURGERY Butte, J. M., Hameed, M., Ball, C. G. 2015; 10: 13

  Abstract

  Hepatopancreatobiliary (HPB) emergencies include an ample range of conditions with overlapping clinical presentations and diverse therapeutic options. The most common etiologies are related to cholelithiasis (acute cholecystitis, pancreatitis, and cholangitis) and non-traumatic injuries (common bile duct or duodenal). Although the true incidence of HPB emergencies is difficult to determine due to selection and reporting biases, a population-based report showed a decline in the global incidence of all severe complications of cholelithiasis, primarily based on a reduction in acute cholecystitis. Even though patients may present with overlapping symptoms, treatment options can be varied. The treatment of these conditions continues to evolve and patients may require endoscopic, surgical, and/or percutaneous techniques. Thus, it is essential that a multidisciplinary team of HPB surgeons, interventional gastroenterologists and radiologists are available on an as needed basis to the Acute Care Surgeon. This focused manuscript is a contemporary review of the literature surrounding HPB emergencies in the context of the acute care surgeon. The main aim of this review is to offer an update of the diagnosis and management of HPB issues in the acute care setting to improve the care of patients with potential HPB emergencies.

  View details for DOI 10.1186/s13017-015-0004-y

  View details for Web of Science ID 000350850400001

  View details for PubMedID 25767562

  View details for PubMedCentralID PMC4357088

• Intentional injury and violence in Cape Town, South Africa: an epidemiological analysis of trauma admissions data. Global health action Schuurman, N., Cinnamon, J., Walker, B. B., Fawcett, V., Nicol, A., Hameed, S. M., Matzopoulos, R. 2015; 8: 27016

  Abstract

  BACKGROUND: Injury is a truly global health issue that has enormous societal and economic consequences in all countries. Interpersonal violence is now widely recognized as important global public health issues that can be addressed through evidence-based interventions. In South Africa, as in many low- and middle-income countries (LMIC), a lack of ongoing, systematic injury surveillance has limited the ability to characterize the burden of violence-related injury and to develop prevention programmes.OBJECTIVE: To describe the profile of trauma presenting to the trauma centre of Groote Schuur Hospital in Cape Town, South Africa - relating to interpersonal violence, using data collected from a newly implemented surveillance system. Particular emphasis was placed on temporal aspects of injury epidemiology, as well as age and sex differentiation.DESIGN: Data were collected prospectively using a standardized trauma admissions form for all patients presenting to the trauma centre. An epidemiological analysis was conducted on 16 months of data collected from June 2010 to October 2011.RESULTS: A total of 8445 patients were included in the analysis, in which the majority were violence-related. Specifically, 35% of records included violent trauma and, of those, 75% of victims were male. There was a clear temporal pattern: a greater proportion of intentional injuries occur during the night, while unintentional injury peaks late in the afternoon. In total, two-third of all intentional trauma is inflicted on the weekends, as is 60% of unintentional trauma. Where alcohol was recorded in the record, 72% of cases involved intentional injury. Sex was again a key factor as over 80% of all records involving alcohol or substance abuse were associated with males. The findings highlighted the association between violence, young males, substance use, and weekends.CONCLUSIONS: This study provides the basis for evidence-based interventions to reduce the burden of intentional injury. Furthermore, it demonstrates the value of locally appropriate, ongoing, systematic public health surveillance in LMIC.

  View details for DOI 10.3402/gha.v8.27016

  View details for PubMedID 26077146

• Early versus delayed cholecystectomy following endoscopic sphincterotomy for mild biliary pancreatitis. Surgical endoscopy Mador, B. D., Panton, O. N., Hameed, S. M. 2014; 28 (12): 3337-42

  Abstract

  The recommended treatment for patients presenting with mild acute biliary pancreatitis is early cholecystectomy performed during the index admission. However, the data are less clear in regards to patients who undergo endoscopic sphincterotomy prior to surgery. While it has been shown that these patients still benefit from cholecystectomy, the optimal timing of this intervention is not well defined. We hypothesized that delayed cholecystectomy following endoscopic sphincterotomy for mild biliary pancreatitis is associated with significant preventable morbidity.A retrospective chart review was performed at two academic hospitals for patients diagnosed with biliary pancreatitis who underwent endoscopic sphincterotomy followed by cholecystectomy. Patients aged 18 and over admitted from 2006 to 2011 were included, while those with severe pancreatitis were excluded. The primary outcome was biliary complications experienced during the waiting period for cholecystectomy. Secondary outcomes included length of stay, operative complications, and conversion rate. Student t test was used to compare continuous data and Fischer's exact test was used for categorical data.80 patient charts were reviewed. Time to cholecystectomy was 3.3 days (range 0.5-10) in the early group and 141.6 (range 18-757) in the delayed group. The groups were comparable in terms of age and American Society of Anesthesiologists (ASA) classification. 21 of 35 patients (60%) in the delayed group experienced biliary complications compared with 1 of 45 (2%) in the early group (p < 0.001). 14 patients in the delayed group required re-admission (40%) and 5 (14%) required additional procedures. Secondary outcomes were not statistically significant.The data demonstrate a significantly increased biliary complication rate associated with delayed cholecystectomy in this patient population. Early cholecystectomy should be strongly considered for patients with mild biliary pancreatitis even when endoscopic sphincterotomy has been performed pre-operatively.

  View details for DOI 10.1007/s00464-014-3621-8

  View details for PubMedID 24962855

• Impact of Socioeconomic Disparities on Outcomes of Urgent Surgical Care in the United States Edwards, J. P., Dingley, B., Shaheen, A., Ball, C. G., Hameed, M., Grondin, S. C., Dixon, E. ELSEVIER SCIENCE INC. 2014: S100-S101

  View details for DOI 10.1016/j.jamcollsurg.2014.07.239

  View details for Web of Science ID 000342420900208

• Where does our journal fit? Trends in trauma surgery: Analysis of the American Association for the Surgery of Trauma program 1939 to 2012 JOURNAL OF TRAUMA AND ACUTE CARE SURGERY Gamme, G., Hameed, S., Ball, C. G. 2014; 77 (1): 184-185

  View details for DOI 10.1097/TA.0000000000000284

  View details for Web of Science ID 000338389600052

  View details for PubMedID 24977781

• Trauma Surveillance in Cape Town, South Africa An Analysis of 9236 Consecutive Trauma Center Admissions JAMA SURGERY Nicol, A., Knowlton, L. M., Schuurman, N., Matzopoulos, R., Zargaran, E., Cinnamon, J., Fawcett, V., Taulu, T., Hameed, S. M. 2014; 149 (6): 549-556

  Abstract

  Trauma is a leading cause of death and disability worldwide. In many low- and middle-income countries, formal trauma surveillance strategies have not yet been widely implemented.To formalize injury data collection at Groote Schuur Hospital, the chief academic hospital of the University of Cape Town, a level I trauma center, and one of the largest trauma referral hospitals in the world.This was a prospective study of all trauma admissions from October 1, 2010, through September 30, 2011, at Groote Schuur Hospital. A standard admission form was developed with multidisciplinary input and was used for both clinical and data abstraction purposes. Analysis of data was performed in 3 parts: demographics of injury, injury risk by location, and access to and maturity of trauma services. Geographic information science was then used to create satellite imaging of injury "hot spots" and to track referral patterns. Finally, the World Health Organization trauma system maturity index was used to evaluate the current breadth of the trauma system in place.The demographics of trauma patients, the distribution of injury in a large metropolitan catchment, and the patterns of injury referral and patient movement within the trauma system.The minimum 34-point data set captured relevant demographic, geographic, incident, and clinical data for 9236 patients. Data field completion rates were highly variable. An analysis of demographics of injury (age, sex, and mechanism of injury) was performed. Most violence occurred toward males (71.3%) who were younger than 40 years of age (74.6%). We demonstrated high rates of violent interpersonal injury (71.6% of intentional injury) and motor vehicle injury (18.8% of all injuries). There was a strong association between injury and alcohol use, with alcohol implicated in at least 30.1% of trauma admissions. From a systems standpoint, the data suggest a mature pattern of referral consistent with the presence of an inclusive trauma system.The implementation of injury surveillance at Groote Schuur Hospital improved insights about injury risk based on demographics and neighborhood as well as access to service based on patterns of referral. This information will guide further development of South Africa's already advanced trauma system.

  View details for DOI 10.1001/jamasurg.2013.5267

  View details for Web of Science ID 000337909900015

  View details for PubMedID 24789507

• The electronic Trauma Health Record: design and usability of a novel tablet-based tool for trauma care and injury surveillance in low resource settings. Journal of the American College of Surgeons Zargaran, E., Schuurman, N., Nicol, A. J., Matzopoulos, R., Cinnamon, J., Taulu, T., Ricker, B., Garbutt Brown, D. R., Navsaria, P., Hameed, S. M. 2014; 218 (1): 41-50

  Abstract

  Ninety percent of global trauma deaths occur in under-resourced or remote environments, with little or no capacity for injury surveillance. We hypothesized that emerging electronic and web-based technologies could enable design of a tablet-based application, the electronic Trauma Health Record (eTHR), used by front-line clinicians to inform trauma care and acquire injury surveillance data for injury control and health policy development.The study was conducted in 3 phases: 1. Design of an electronic application capable of supporting clinical care and injury surveillance; 2. Preliminary feasibility testing of eTHR in a low-resource, high-volume trauma center; and 3. Qualitative usability testing with 22 trauma clinicians from a spectrum of high- and low-resource and urban and remote settings including Vancouver General Hospital, Whitehorse General Hospital, British Columbia Mobile Medical Unit, and Groote Schuur Hospital in Cape Town, South Africa.The eTHR was designed with 3 key sections (admission note, operative note, discharge summary), and 3 key capabilities (clinical checklist creation, injury severity scoring, wireless data transfer to electronic registries). Clinician-driven registry data collection proved to be feasible, with some limitations, in a busy South African trauma center. In pilot testing at a level I trauma center in Cape Town, use of eTHR as a clinical tool allowed for creation of a real-time, self-populating trauma database. Usability assessments with traumatologists in various settings revealed the need for unique eTHR adaptations according to environments of intended use. In all settings, eTHR was found to be user-friendly and have ready appeal for frontline clinicians.The eTHR has potential to be used as an electronic medical record, guiding clinical care while providing data for injury surveillance, without significantly hindering hospital workflow in various health-care settings.

  View details for DOI 10.1016/j.jamcollsurg.2013.10.001

  View details for PubMedID 24355875

• STARTT: Development of a national, multidisciplinary trauma crisis resource management curriculum-Results from the pilot course JOURNAL OF TRAUMA AND ACUTE CARE SURGERY Ziesmann, M. T., Widder, S., Park, J., Kortbeek, J. B., Brindley, P., Hameed, M., Paton-Gay, J., Engels, P. T., Hicks, C., Fata, P., Ball, C. G., Gillman, L. 2013; 75 (5): 753-758

  Abstract

  Most medical errors are nontechnical and include failures in team communication, situational awareness, resource use, and leadership. Other high-risk industries have adopted team-based crisis resource management (CRM) training strategies to address "nontechnical" skills and to improve human error and safety. Here, we describe the development and evaluation of a national multidisciplinary trauma CRM curriculum.A needs analysis survey was distributed to general surgery program directors across Canada. With the use of this feedback, a course called STARTT [Standardized Trauma and Resuscitation Team Training] was developed and held in conjunction with the Canadian Surgery Forum. Participants completed a precourse and postcourse evaluation exploring changes in attitudes toward simulation and CRM principles using previously validated instruments.Twenty surgical residents, 6 nurses, 4 respiratory therapists, and 11 instructors (trauma surgeons, emergency physicians, nurses, and intensivists) participated. Of the participants, 100% completed the survey. Satisfaction was very high, with 97.5% of the participants rating the course as "good" or "excellent" and 97.5% recommending it to others. The presurvey and postsurvey showed statistically significant improvement in attitudes toward simulation and overall CRM principles (136.3 vs. 140.3 of 170, p = 0.004) following the course, primarily in the domain of teamwork (69.1 vs. 72.0 of 85, p = 0.002).Creation of a national multidisciplinary trauma CRM curriculum is feasible, has high satisfaction among participants, and can improve attitudes toward the importance of simulation and CRM principles with the ultimate goal of improving patient safety and care.

  View details for DOI 10.1097/TA.0b013e3182a925df

  View details for Web of Science ID 000330457900001

  View details for PubMedID 24158191

• Pregnancy among residents enrolled in general surgery: a nationwide survey of attitudes and experiences. American journal of surgery Merchant, S. J., Hameed, S. M., Melck, A. L. 2013; 206 (4): 605-10

  Abstract

  Medical student interest in general surgery has declined, and the lack of adequate accommodation for pregnancy and parenting during residency training may be a deterrent. We explored resident and program director experiences with these issues in general surgery programs across Canada.Using a web-based tool, residents and program directors from 16 Canadian general surgery programs were surveyed regarding their attitudes toward and experiences with pregnancy during residency.One hundred seventy-six of 600 residents and 8 of 16 program directors completed the survey (30% and 50% response rate, respectively). Multiple issues pertaining to pregnancy during surgical residency were reported including the lack of adequate policies for maternity/parenting, the major obstacles to breast-feeding, and the increased workload for fellow resident colleagues. All program directors reported the lack of a program-specific maternity/parenting policy.General surgery programs lack program-specific maternity/parenting policies. Several issues have been highlighted in this study emphasizing the importance of creating and implementing such a policy.

  View details for DOI 10.1016/j.amjsurg.2012.04.005

  View details for PubMedID 23200987

• Acute general surgery in Canada: a survey of current handover practices. Canadian journal of surgery. Journal canadien de chirurgie Johner, A. M., Merchant, S., Aslani, N., Planting, A., Ball, C. G., Widder, S., Pagliarello, G., Parry, N. G., Klassen, D., Hameed, S. M. 2013; 56 (3): E24-8

  Abstract

  Today's acute care surgery (ACS) service model requires multiple handovers to incoming attending surgeons and residents. Our objectives were to investigate current handover practices in Canadian hospitals that have an ACS service and assess the quality of handover practices in place.We administered an electronic survey among ACS residents in 6 Canadian general surgery programs.Resident handover of patient care occurs frequently and often not under ideal circumstances. Most residents spend less than 5 minutes preparing handovers. Clinical uncertainty owing to inadequate handover is most likely to occur during overnight and weekend coverage. Almost one-third of surveyed residents rate the overall quality of the handovers they received as poor.Handover skills must be taught in a systematic fashion. Improved resident communication will likely decrease loss of patient information and therefore improve ACS patient safety.

  View details for DOI 10.1503/cjs.035011

  View details for PubMedID 23706854

  View details for PubMedCentralID PMC3672440

• Surgical fixation vs nonoperative management of flail chest: a meta-analysis. Journal of the American College of Surgeons Slobogean, G. P., MacPherson, C. A., Sun, T., Pelletier, M. E., Hameed, S. M. 2013; 216 (2): 302-11.e1

  Abstract

  Flail chest is a life-threatening injury typically treated with supportive ventilation and analgesia. Several small studies have suggested large improvements in critical care outcomes after surgical fixation of multiple rib fractures. The purpose of this study was to compare the results of surgical fixation and nonoperative management for flail chest injuries.A systematic review of previously published comparative studies using operative and nonoperative management of flail chest was performed. Medline, Embase, and the Cochrane databases were searched for relevant studies with no language or date restrictions. Quantitative pooling was performed using a random effects model for relevant critical care outcomes. Sensitivity analysis was performed for all outcomes.Eleven manuscripts with 753 patients met inclusion criteria. Only 2 studies were randomized controlled designs. Surgical fixation resulted in better outcomes for all pooled analyses including substantial decreases in ventilator days (mean 8 days, 95% CI 5 to 10 days) and the odds of developing pneumonia (odds ratio [OR] 0.2, 95% CI 0.11 to 0.32). Additional benefits included decreased ICU days (mean 5 days, 95% CI 2 to 8 days), mortality (OR 0.31, 95% CI 0.20 to 0.48), septicemia (OR 0.36, 95% CI 0.19 to 0.71), tracheostomy (OR 0.06, 95% CI 0.02 to 0.20), and chest deformity (OR 0.11, 95% CI 0.02 to 0.60). All results were stable to basic sensitivity analysis.The results of this meta-analysis suggest surgical fixation of flail chest injuries may have substantial critical care benefits; however, the analyses are based on the pooling of primarily small retrospective studies. Additional prospective randomized trials are still necessary.

  View details for DOI 10.1016/j.jamcollsurg.2012.10.010

  View details for PubMedID 23219148

• Are we failing our rural communities? Motor vehicle injury in British Columbia, Canada, 2001-2007. Injury Bell, N., Simons, R. K., Lakha, N., Hameed, S. M. 2012; 43 (11): 1888-91

  Abstract

  In Canada, stratification by geographic area or socio-economic status remains relatively rare in national and provincial reporting and surveillance for injury prevention and trauma care. As injuries are known to affect some populations more than others, a more nuanced understanding of injury risk may in turn inform more effective prevention policy. In this study we assessed rates of hospitalization and death from motor vehicle collisions (MVC) in British Columbia (BC) by socio-economic status (SES) and by rural and urban status between 2001 and 2007. Excess risk in injury morbidity and mortality between different SES groups were assessed using a population attributable fraction (PAF). Over a six-year period rural populations in BC experienced a three-fold increase in relative risk of death and an average of 50% increase in relative risk of hospitalization due to injury. When assessed against SES, relative risk of MVC mortality increased from 2.36 (2.05-2.72) to 4.07 (3.35-4.95) in reference to the least deprived areas, with an estimated 40% of all MVC-related mortality attributable to the relative differences across SES classes. Results from this study challenge current provincial and national reporting practises and emphasize the utility of employing the PAF for assessing variations in injury morbidity and mortality.

  View details for DOI 10.1016/j.injury.2011.07.018

  View details for PubMedID 21839445

• Does operative experience during residency correlate with reported competency of recent general surgery graduates? CANADIAN JOURNAL OF SURGERY Safavi, A., Lai, S., Butterworth, S., Hameed, M., Schiller, D., Skarsgard, E. 2012; 55 (4): S171-S177

  Abstract

  Identification of attributes of residency training that predict competency would improve surgical education. We hypothesized that case experience during residency would correlate with self-reported competency of recent graduates.Aggregate case log data of residents enrolled in 2 general surgery programs were collected over a 12-month period and stratified into Surgical Council on Resident Education (SCORE) categories. We surveyed recent (< 5 yr) residency graduates on procedural competency. Resident case volumes were correlated with survey responses by SCORE category.In all, 75 residents performed 11 715 operations, which were distributed by SCORE category as follows: essential-common (EC) 9935 (84.8%), essential-uncommon (EU) 889 (7.6%) and complex 891 (7.6%). Alimentary tract procedures were the most commonly performed EC (2386, 24%) and EU (504, 56.7%) procedures. The least common EC procedure was plastic surgery (4, 0.04%), and the least common EU procedure was abdomen-spleen (1, 0.1%). The questionnaire response rate was 45%. For EC procedures, self-reported competency was highest in skin and soft tissue, thoracic and head and neck (each 100%) and lowest in vascular-venous (54%), whereas for EU procedures it was highest in abdomen-general (100%) and lowest in vascular-arterial (62%). The correlation between case volume and self-reported competency was poor (R = 0.2 for EC procedures).Self-reported competency correlates poorly with operative case experience during residency. Other curriculum factors, including specific rotations and timing, balance between inpatient and outpatient surgical experience and competition for cases, may contribute to procedural competency acquisition during residency.

  View details for DOI 10.1503/cjs.020811

  View details for Web of Science ID 000307679200006

  View details for PubMedID 22854144

  View details for PubMedCentralID PMC3432245

• Trauma Center Quality Improvement Programs in the United States, Canada, and Australasia ANNALS OF SURGERY Stelfox, H. T., Straus, S. E., Nathens, A., Gruen, R. L., Hameed, S. M., Kirkpatrick, A. 2012; 256 (1): 163-169

  Abstract

  To compare quality improvement (QI) programs of trauma centers in 4 high-income countries.Injury is a leading cause of morbidity and mortality in countries around the world, but patient outcomes vary among countries with similar systems of trauma care.We surveyed medical directors and program managers from 330 trauma centers verified by professional trauma organizations in the United States (n = 263), Canada (n = 46), and Australasia (Australia, n = 18; New Zealand, n = 3) regarding their QI programs. Quality indicators were requested from all centers that measured quality of care. Follow-up interviews were performed with 75 centers purposively sampled across 6 baseline criteria.A total of 251 centers (76% response rate) responded to the survey, with a similar distribution across countries. Trauma centers in the United States were more likely than those in Canada and Australasia to report measuring quality indicators (100% vs 94% vs 93%, P = 0.008), using report cards (53% vs 33% vs 31%, P = 0.033) and benchmarking (81% vs 61% vs 69%, P = 0.019). Centers in all 3 regions primarily used hospital process and outcome measures designed to establish whether care was safe (98% vs 97% vs 75%, P = 0.008), effective (97% vs 97% vs 92% P = 0.399), timely (88% vs 100% vs 92%, P = 0.055), and efficient (95% vs 100% vs 83%, P = 0.082). QI programs were largely local in nature, used different criteria to identify patients under QI purview, and employed diverse quality indicators and improvement strategies. Few centers evaluated the effectiveness of their QI program.This study provides the first international comparison of trauma center QI programs and demonstrates broad implementation in verified trauma centers in the United States, Canada, and Australasia. Significant variation exists in how trauma centers perform QI activities. Opportunities exist for improving and standardizing QI processes.

  View details for DOI 10.1097/SLA.0b013e318256c20b

  View details for Web of Science ID 000306083300026

  View details for PubMedID 22580945

• Temporal trends in the treatment of severe traumatic hemorrhage. American journal of surgery Heidary, B., Bell, N., Ngai, J. T., Simons, R. K., Chipperfield, K., Hameed, S. M. 2012; 203 (5): 568-573

  Abstract

  This study examined the evolution of damage control resuscitation (DCR) and outcomes in severe traumatic hemorrhage (STH) at a large Canadian trauma center.This was a retrospective cohort study of trauma patients admitted to a level 1 trauma center between 2005 and 2010, who received 10 or more units of packed red blood cells within 24 hours of admission. Demographic and clinical findings were compared between survivors and nonsurvivors.Forty-five patients were included. Twenty-five percent of patients were coagulopathic at admission. Early crystalloid use declined over the study period. The mean 24-hour fresh-frozen plasma:platelets:packed red blood cells ratio was 1:1:2. Hemorrhage-related mortality was 69%. No pedestrians survived STH. A total of 1,032 blood product units were used in the first day for nonsurvivors.Principles of DCR crept into clinical practice even before the implementation of a formal STH protocol. DCR appeared to reduce the intensive care unit length of stay but not mortality. STH is associated with heavy use of blood bank resources and high mortality rates. Futility of resuscitative efforts may be predictable by mechanism and early physiological markers.

  View details for DOI 10.1016/j.amjsurg.2011.12.012

  View details for PubMedID 22417848

• The script concordance test as a measure of clinical reasoning: a national validation study Nouh, T., Boutros, M., Gagnon, R., Reid, S., Leslie, K., Pace, D., Pitt, D., Walker, R., Schiller, D., MacLean, A., Hameed, M., Fata, P., Charlin, B., Meterissian, S. H. EXCERPTA MEDICA INC-ELSEVIER SCIENCE INC. 2012: 530-534

  Abstract

  The script concordance test (SCT) is an innovative tool for clinical reasoning assessment. It has previously been shown to be a reliable and valid measure of clinical reasoning among general surgical residents.To determine if the SCT maintained its validity and reliability when administered on a national level.The test was administered to 202 residents (51 R1, 45 R2, 45 R3, 28 R4, and 33 R5) in 9 general surgery programs across Canada.The optimized version of the test had a reliability (Cronbach alpha) of .85. Scores increased progressively from R1 (64.5 ± 7.6) to R2 (69.5 ± 5.8) to R3 (69.9 ± 6.7) to R4 (72.0 ± 6.2) with a dip in the R5s (68.3 ± 8.6). The test was able to differentiate junior (R1+ R2 = 66.8 ± 7.2) from senior residents (R3 + R4 + R5 = 70.0 ± 7.3, P = .001) across all the programs.The SCT maintained its reliability and validity as a measure of intraoperative clinical reasoning among general surgical residents when administered across multiple centers. We believe that the SCT can be developed to measure clinical reasoning in high-stakes national examinations.

  View details for DOI 10.1016/j.amjsurg.2011.11.006

  View details for Web of Science ID 000302913700019

  View details for PubMedID 22450028

• Does direct transport to provincial burn centres improve outcomes? A spatial epidemiology of severe burn injury in British Columbia, 2001-2006. Canadian journal of surgery. Journal canadien de chirurgie Bell, N., Simons, R., Hameed, S. M., Schuurman, N., Wheeler, S. 2012; 55 (2): 110-6

  Abstract

  In Canada and the United States, research has shown that injured patients initially treated at smaller emergency departments before transfer to larger regional facilities are more likely to require longer stays in hospital or suffer greater mortality. It remains unknown whether transport status is an independent predictor of adverse health events among persons requiring care from provincial burn centres.We obtained case records from the British Columbia Trauma Registry for adult patients (age ≥ 18 yr) referred or transported directly to the Vancouver General Hospital and Royal Jubilee Hospital burn centres between Jan. 1, 2001, and Mar. 31, 2006. Prehospital and in-transit deaths and deaths in other facilities were identified using the provincial Coroner Service database. Place of injury was identified through data linkage with census records. We performed bivariate analysis for continuous and discrete variables. Relative risk (RR) of prehospital and in-hospital mortality and hospital stay by transport status were analyzed using a Poisson regression model.After controlling for patient and injury characteristics, indirect referral did not influence RR of in-facility death (RR 1.32, 95% confidence interval [CI] 0.54- 3.22) or hospital stay (RR 0.96, 95% CI 0.65-1.42). Rural populations experienced an increased risk of total mortality (RR 1.22, 95% CI 1.00-1.48).Transfer status is not a significant indicator of RR of death or hospital stay among patients who received care at primary care facilities before transport to regional burn centres. However, significant differences in prehospital mortality show that improvements in rural mortality can still be made.

  View details for DOI 10.1503/cjs.014708

  View details for PubMedID 22564514

  View details for PubMedCentralID PMC3310766

• Pregnancy among residents enrolled in general surgery (PREGS): a survey of residents in a single Canadian training program CANADIAN JOURNAL OF SURGERY Merchant, S., Hameed, M., Melck, A. 2011; 54 (6): 375-380

  Abstract

  Interest in general surgery has declined, and lack of adequate accommodation for pregnancy and parenting may be a deterrent. We explored resident experiences with these issues within a single general surgery program.We surveyed residents enrolled in the University of British Columbia general surgery program from 1997 to 2009 using a Web-based survey tool. Information regarding demographics, pregnancy, postpartum issues and issues pertaining to maternity/parenting policies was obtained. We used the Student t test, Z test and Fisher exact test for statistical comparisons.Of the 81 residents surveyed, 53 responded (65% response rate). There were fewer pregnancies during residency among female residents than among partners of male residents (PMRs; 9 pregnancies for 6 of 25 residents v. 23 pregnancies for 15 of 28 PMRs, p = 0.002). One of 9 pregnancies among female residents and 5 of 23 among PMRs ended in miscarriage (p > 0.99). Female residents and PMRs reported pregnancy-related complications with equal frequency. All female residents breastfed for at least 6 months; however, 67% (4 of 6) felt their resident role prevented them from breastfeeding as long as they would have liked. Most (5 of 6, 83%) pursued a graduate degree or research during their "maternity leave." More than 50% of residents reported that their own workload increased because of a colleague's pregnancy. Many (36 of 53, 68%) were unaware of the existence of any maternity/parenting policy, and most were in favour of instituting such a policy.Resident mothers do not breastfeed for the desired duration, and precluding factors must be explored. Contingency plans are needed so colleagues are not overburdened when pregnant residents cannot perform clinical duties. General surgery programs must have a formal policy addressing these issues.

  View details for DOI 10.1503/cjs.015710

  View details for Web of Science ID 000298285000004

  View details for PubMedID 21939607

  View details for PubMedCentralID PMC3238337

• Are we homogenising risk factors for public health surveillance? Variability in severe injuries on First Nations reserves in British Columbia, 2001-5. Injury prevention : journal of the International Society for Child and Adolescent Injury Prevention Bell, N., Schuurman, N., Hameed, S. M., Caron, N. 2011; 17 (6): 394-400

  Abstract

  Aboriginal Canadians are considered to be at increased risk of injury. The de facto standard for measuring injury risk factors among Aboriginal Canadians is to compare hospitalisation and mortality against non-Aboriginal Canadians, but this may be too broad an approach for injury prevention and public health if it over-generalises injury risk.Data from this study are drawn from the 2001-5 British Columbia Trauma Registry and British Columbia Coroner's Service. Observed and expected hospitalisations and mortality rates on reserves were assessed against three different spatial aggregations of non-reserve reference populations. Data analysis was conducted in a geographical information system using a Poisson probability map.A total of 47 (9.6%) of 487 reserves in British Columbia contained at least one person who was hospitalised or died as a result of serious injury during the study period. Of these, two reserve populations represented 20% (n=19) of all injury morbidity events and 30% (n=22) of all mortality events.Evidence from this study suggests that community-based rather than provincial-based injury reporting is less likely to over-generalise the burden of injury among Aboriginal communities. Community-based surveillance enables researchers to identify why severe unintentional and intentional injury continues to burden some communities but not others and avoids the potentially demoralising and stigmatising effects of current surveillance practices.

  View details for DOI 10.1136/ip.2010.030866

  View details for PubMedID 21441162

• A Predeployment Trauma Team Training Course Creates Confidence in Teamwork and Clinical Skills: A Post-Afghanistan Deployment Validation Study of Canadian Forces Healthcare Personnel JOURNAL OF TRAUMA-INJURY INFECTION AND CRITICAL CARE McLaughlin, T., Hennecke, P., Garraway, N., Evans, D. C., Hameed, M., Simons, R. K., Doucet, J., Hansen, D., Annand, S., Bell, N., Brown, D. 2011; 71: S487-S493

  Abstract

  The 10-day Intensive Trauma Team Training Course (ITTTC) was developed by the Canadian Forces (CFs) to teach teamwork and clinical trauma skills to military healthcare personnel before deploying to Afghanistan. This article attempts to validate the impact of the ITTTC by surveying participants postdeployment.A survey consisting of Likert-type multiple-choice questions was created and sent to all previous ITTTC participants. The survey asked respondents to rate their confidence in applying teamwork skills and clinical skills learned in the ITTTC. It explored the relevancy of objectives and participants' prior familiarity with the objectives. The impact of different training modalities was also surveyed.The survey showed that on average 84.29% of participants were "confident" or "very confident" in applying teamwork skills to their subsequent clinical experience and 52.10% were "confident" or "very confident" in applying clinical knowledge and skills. On average 43.74% of participants were "familiar" or "very familiar" with the clinical topics before the course, indicating the importance of training these skills. Participants found that clinical shadowing was significantly less valuable in training clinical skills than either animal laboratory experience or experience in human patient simulators; 68.57% respondents thought that ITTTC was "important" or "very important" in their training.The ITTTC created lasting self-reported confidence in CFs healthcare personnel surveyed upon return from Afghanistan. This validates the importance of the course for the training of CFs healthcare personnel and supports the value of team training in other areas of trauma and medicine.

  View details for DOI 10.1097/TA.0b013e318232e9e7

  View details for Web of Science ID 000297112800017

  View details for PubMedID 22072008

• A matrix for comprehensive surgical education CANADIAN JOURNAL OF SURGERY Jarvis-Selinger, S., Hameed, M., Bloom, S. W. 2011; 54 (5): 296-299

  View details for DOI 10.1503/cjs.036110

  View details for Web of Science ID 000295099900008

  View details for PubMedID 21933524

  View details for PubMedCentralID PMC3195656

• Mass casualty modelling: a spatial tool to support triage decision making INTERNATIONAL JOURNAL OF HEALTH GEOGRAPHICS Amram, O., Schuurman, N., Hameed, S. M. 2011; 10: 40

  Abstract

  During a mass casualty incident, evacuation of patients to the appropriate health care facility is critical to survival. Despite this, no existing system provides the evidence required to make informed evacuation decisions from the scene of the incident. To mitigate this absence and enable more informed decision making, a web based spatial decision support system (SDSS) was developed. This system supports decision making by providing data regarding hospital proximity, capacity, and treatment specializations to decision makers at the scene of the incident.This web-based SDSS utilizes pre-calculated driving times to estimate the actual driving time to each hospital within the inclusive trauma system of the large metropolitan region within which it is situated. In calculating and displaying its results, the model incorporates both road network and hospital data (e.g. capacity, treatment specialties, etc.), and produces results in a matter of seconds, as is required in a MCI situation. In addition, its application interface allows the user to map the incident location and assists in the execution of triage decisions.Upon running the model, driving time from the MCI location to the surrounding hospitals is quickly displayed alongside information regarding hospital capacity and capability, thereby assisting the user in the decision-making process.The use of SDSS in the prioritization of MCI evacuation decision making is potentially valuable in cases of mass casualty. The key to this model is the utilization of pre-calculated driving times from each hospital in the region to each point on the road network. The incorporation of real-time traffic and hospital capacity data would further improve this model.

  View details for DOI 10.1186/1476-072X-10-40

  View details for Web of Science ID 000292190000001

  View details for PubMedID 21663636

  View details for PubMedCentralID PMC3125310

• Clinical review: Canadian National Advisory Committee on Blood and Blood Products - Massive Transfusion Consensus Conference 2011: report of the panel CRITICAL CARE Dzik, W. H., Blajchman, M. A., Fergusson, D., Hameed, M., Henry, B., Kirkpatrick, A. W., Korogyi, T., Logsetty, S., Skeate, R. C., Stanworth, S., MacAdams, C., Muirhead, B. 2011; 15 (6): 242

  Abstract

  In June 2011 the Canadian National Advisory Committee on Blood and Blood Products sponsored an international consensus conference on transfusion and trauma. A panel of 10 experts and two external advisors reviewed the current medical literature and information presented at the conference by invited international speakers and attendees. The Consensus Panel addressed six specific questions on the topic of blood transfusion in trauma. The questions focused on: ratio-based blood resuscitation in trauma patients; the impact of survivorship bias in current research conclusions; the value of nonplasma coagulation products; the role of protocols for delivery of urgent transfusion; the merits of traditional laboratory monitoring compared with measures of clot viscoelasticity; and opportunities for future research. Key findings include a lack of evidence to support the use of 1:1:1 blood component ratios as the standard of care, the importance of early use of tranexamic acid, the expected value of an organized response plan, and the recommendation for an integrated approach that includes antifibrinolytics, rapid release of red blood cells, and a foundation ratio of blood components adjusted by results from either traditional coagulation tests or clot viscoelasticity or both. The present report is intended to provide guidance to practitioners, hospitals, and policy-makers.

  View details for DOI 10.1186/cc10498

  View details for Web of Science ID 000306087200009

  View details for PubMedID 22188866

  View details for PubMedCentralID PMC3388668

• A Population-Based Analysis of Injury-Related Deaths and Access to Trauma Care in Rural-Remote Northwest British Columbia Simons, R., Brasher, P., Taulu, T., Lakha, N., Molnar, N., Caron, N., Schuurman, N., Evans, D., Hameed, M. LIPPINCOTT WILLIAMS & WILKINS. 2010: 11-19

  Abstract

  Injury rates and injury mortality rates are generally higher in rural and remote communities compared with urban jurisdictions as has been shown to be the case in the rural-remote area of Northwest (NW) British Columbia (BC). The purpose of study was to identify: (1) the place and timing of death following injury in NW BC, (2) access to and quality of local trauma services, and (3) opportunities to improve trauma outcomes.Quantitative data from demographic and geographic databases, the BC Trauma Registry, Hospital discharge abstract database, and the BC Coroner's Office, along with qualitative data from chart reviews of selected major trauma cases, and interviews with front-line trauma care providers were collated and analyzed for patients sustaining injury in NW BC from April 2001 to March 2006.The majority of trauma deaths (82%) in NW BC occur prehospital. Patients arriving alive to NW hospitals have low hospital mortality (1.0%), and patients transferring from NW BC to tertiary centers have better outcomes than matched patients achieving direct entry into the tertiary center by way of geographic proximity. Access to local trauma services was compromised by: incident discovery, limited phone service (land lines/cell), incomplete 911 emergency medical services system access, geographical and climate challenges compounded by limited transportation options, airport capabilities and paramedic training level, dysfunctional hospital no-refusal policies, lack of a hospital destination policies, and lack of system leadership and coordination.Improving trauma outcomes in this rural-remote jurisdiction requires a systems approach to address root causes of delays in access to care, focusing on improved access to emergency medical services, hospital bypass and destination protocols, improved transportation options, advanced life support transfer capability, and designated, coordinated local trauma services.

  View details for DOI 10.1097/TA.0b013e3181e17b39

  View details for Web of Science ID 000280010600002

  View details for PubMedID 20622573

• Effects of implementation of an urgent surgical care service on subspecialty general surgery training. Canadian journal of surgery. Journal canadien de chirurgie Wood, L., Buczkowski, A., Panton, O. M., Sidhu, R. S., Hameed, S. M. 2010; 53 (2): 119-25

  Abstract

  In July 2007, a large Canadian teaching hospital realigned its general surgery services into elective general surgery subspecialty-based services (SUBS) and a new urgent surgical care (USC) service (also know in the literature as an acute care surgery service). The residents on SUBS had their number of on-call days reduced to enable them to focus on activities related to SUBS. Our aim was to examine the effect of the creation of the USC service on the educational experiences of SUBS residents.We enrolled residents who were on SUBS for the 6 months before and after the introduction of the USC service. We collected data by use of a survey, WEBeVAL and recorded attendance at academic half days. Our 2 primary outcomes were residents' attendance at ambulatory clinics and compliance with the reduction in the number of on-call days. Our secondary outcomes included residents' time for independent study, attendance at academic half days, operative experience, attendance at multidisciplinary rounds and overall satisfaction with SUBS.Residents on SUBS had a decrease in the mean number of on-call days per resident per month from 6.28 to 1.84 (p = 0.006), an increase in mean attendance at academic half days from 65% to 87% (p = 0.028), at multidisciplinary rounds (p = 0.002) and at ambulatory clinics and an increase in independent reading time (p = 0.015), and they reported an improvement in their work environment. There was no change in the amount of time residents spent in the operating room or in their overall satisfaction with SUBS.Residents' education in the SUBS structure was positively affected by the creation of a USC service. Compliance with the readjustment of on-call duties was high and was identified as the single most significant factor in enabling residents to take full advantage of the unique educational opportunities available only while on SUBS.

  View details for PubMedID 20334744

  View details for PubMedCentralID PMC2845952

• Effect of ambient workload in the intensive care unit on mortality and time to discharge alive. Healthcare quarterly (Toronto, Ont.) Mountain, S. A., Hameed, S. M., Ayas, N. T., Norena, M., Chittock, D. R., Wong, H., Dodek, P. 2009; 12 Spec No Patient: 8-14

  Abstract

  The purpose of this study was to determine the relationship between ambient workload and outcomes of patients in the intensive care unit (ICU). Measures of workload evaluated for each patient on each day of ICU admission were the number of new admissions, ICU census, "code blue" patients not admitted and Acute Physiology and Chronic Health Evaluation (APACHE) II scores and Multiple Organ Dysfunction Scores (MODSs) for admitted patients. Patients were defined as the patient at risk (the "index" patient) and the other patients in the ICU at the same time (the "non-index" patients). Logistic regression (for hospital mortality) and Cox proportional hazards regression (for time to discharge alive) were used to investigate the association between workload and outcomes. In total, 1,705 patients were included. Higher MODSs of non-index patients on the last day of the ICU admission were associated with lower mortality (odds ratio [OR] 0.82 per MODS point, 95% CI 0.72-0.94). A higher number of code blues during the ICU stay was associated with higher mortality (OR 1.18 per event, 95% CI 1.01-1.37). A higher ICU census and MODS of the non-index patients on the day of ICU admission were associated with a shorter time to discharge alive (hazard rate [HR] 1.03 per patient, 95% CI: 1.01-1.06, and 1.07 per MODS point, 95% CI:1.01-1.15, respectively).The association between measures of ambient workload in the ICU and patient outcomes is variable.Future resource planning and studies of patient safety would benefit from a prospective analysis of these factors to define workload limits and tolerances.

  View details for DOI 10.12927/hcq.2009.20961

  View details for PubMedID 19667772

• Access to emergency operative care: a comparative study between the Canadian and American health care systems. Surgery Krajewski, S. A., Hameed, S. M., Smink, D. S., Rogers, S. O. 2009; 146 (2): 300-7

  Abstract

  Canada provides universal health insurance to all citizens, whereas 47 million Americans are uninsured. There has not been a study comparing access to emergency operative care between the 2 countries. As both countries contemplate changes in health care delivery, such comparisons are needed to guide health policy decisions. The purpose of this study is to determine whether or not there is a difference in access to emergency operative care between Canada and the United States.All patients diagnosed with acute appendicitis from 2001 to 2005 were identified in the Canadian Institute for Health Information database and the US Nationwide Inpatient Sample. Severity of appendicitis was determined by ICD-9 codes. Patients were further characterized by age, gender, insurance status, race, and socioeconomic status (SES; income). Univariate and multivariate analyses were performed to determine the odds of appendiceal perforation at different levels of SES in each country.There were 102,692 Canadian patients and 276,890 American patients with acute appendicitis. In Canada, there was no difference in the odds of perforation between income levels. In the United States, there was a significant, inverse relationship between income level and the odds of perforation. The odds of perforation in the lowest income quartile were significantly higher than the odds of perforation in the highest income bracket (odds ratio, 1.20; 95% confidence interval, 1.16-1.24).The results suggest that access to emergency operative care is related to SES in the United States, but not in Canada. This difference could result from the concern over the ability to pay medical bills or the lack of a stable relationship with a primary care provider that can occur outside of a universal health care system.

  View details for DOI 10.1016/j.surg.2009.04.005

  View details for PubMedID 19628089

• Modelling optimal location for pre-hospital helicopter emergency medical services BMC EMERGENCY MEDICINE Schuurman, N., Bell, N. J., L'Heureux, R., Hameed, S. M. 2009; 9: 6

  Abstract

  Increasing the range and scope of early activation/auto launch helicopter emergency medical services (HEMS) may alleviate unnecessary injury mortality that disproportionately affects rural populations. To date, attempts to develop a quantitative framework for the optimal location of HEMS facilities have been absent.Our analysis used five years of critical care data from tertiary health care facilities, spatial data on origin of transport and accurate road travel time catchments for tertiary centres. A location optimization model was developed to identify where the expansion of HEMS would cover the greatest population among those currently underserved. The protocol was developed using geographic information systems (GIS) to measure populations, distances and accessibility to services.Our model determined Royal Inland Hospital (RIH) was the optimal site for an expanded HEMS - based on denominator population, distance to services and historical usage patterns.GIS based protocols for location of emergency medical resources can provide supportive evidence for allocation decisions - especially when resources are limited. In this study, we were able to demonstrate conclusively that a logical choice exists for location of additional HEMS. This protocol could be extended to location analysis for other emergency and health services.

  View details for DOI 10.1186/1471-227X-9-6

  View details for Web of Science ID 000210466600006

  View details for PubMedID 19426532

  View details for PubMedCentralID PMC2685410

• Differences in Hospital Mortality Among Critically Ill Patients of Asian, Native Indian, and European Descent CHEST Khan, N. A., Palepu, A., Norena, M., Ayas, N., Wong, H., Chittock, D., Hameed, M., Dodek, P. M. 2008; 134 (6): 1217-1222

  Abstract

  It is unclear whether race/ethnicity influences survival for acute critical illnesses. We compared hospital mortality among patients of Asian (originating from Asia or Southeast Asia), Native Indian, and European descent admitted to the ICU.Prospective cohort study of patients admitted to three ICUs (January 1999 to January 2006) in British Columbia, Canada. Multivariable analysis evaluated hospital mortality for each ethnic group, adjusting for age, sex, APACHE (acute physiology and chronic health evaluation) II score, hospital, median income, unemployment, and education. To account for differences in case mix, multivariable analysis was also restricted to those patients admitted for the five most common ICU admission diagnoses (sepsis, pneumonia, brain injury, COPD, and ARDS) and adjusted for these diagnoses.Of 7,331 patients, 21% were Asian, 4% were Native Indian, and 75% were of European descent. Crude mortality was 33% for Asian, 30% for Native Indians, and 28% for patients of European descent. After adjusting for potential confounders, Native Indian descent was not associated with an increase in mortality compared to European descent. Asian descent was associated with a significantly higher mortality (odds ratio [OR], 1.22; 95% confidence interval [CI], 1.06 to 1.41; p = 0.005). After adjusting for case mix, this difference was no longer seen. For patients admitted for COPD exacerbation, Asian descent was associated with a substantial increase in mortality (OR, 4.5; 95% CI, 1.56 to 12.9; p = 0.005). There were no significant differences in mortality by race/ethnicity for patients who had any of the other common admitting diagnoses.Patients of Asian and Native Indian descent with acute critical illness did not have an increased mortality after adjusting for differences in case mix.

  View details for DOI 10.1378/chest.08-1016

  View details for Web of Science ID 000261755100019

  View details for PubMedID 18689577

• A model for identifying and ranking need for trauma service in nonmetropolitan regions based on injury risk and access to services JOURNAL OF TRAUMA-INJURY INFECTION AND CRITICAL CARE Schuurman, N., Bell, N., Hameed, M. S., Simons, R. 2008; 65 (1): 54-62

  Abstract

  Timely access to definitive trauma care has been shown to improve survival rates after severe injury. Unfortunately, despite development of sophisticated trauma systems, prompt, definitive trauma care remains unavailable to over 50 million North Americans, particularly in rural areas. Measures to quantify social and geographic isolation may provide important insights for the development of health policy aimed at reducing the burden of injury and improving access to trauma care in presently under serviced populations.Indices of social deprivation based on census data, and spatial analyses of access to trauma centers based on street network files were combined into a single index, the Population Isolation Vulnerability Amplifier (PIVA) to characterize vulnerability to trauma in socioeconomically and geographically diverse rural and urban communities across British Columbia. Regions with a sufficient core population that are more than one hour travel time from existing services were ranked based on their level of socioeconomic vulnerability.Ten regions throughout the province were identified as most in need of trauma services based on population, isolation and vulnerability. Likewise, 10 communities were classified as some of the least isolated areas and were simultaneously classified as least vulnerable populations in province. The model was verified using trauma services utilization data from the British Columbia Trauma Registry. These data indicate that including vulnerability in the model provided superior results to running the model based only on population and road travel time.Using the PIVA model we have shown that across Census Urban Areas there are wide variations in population dependence on and distances to accredited tertiary/district trauma centers throughout British Columbia. Many of the factors that influence access to definitive trauma care can be combined into a single quantifiable model that researchers in the health sector can use to predict where to place new services. The model can also be used to locate optimal locations for any basket of health services.

  View details for DOI 10.1097/TA.0b013e31815efe0e

  View details for Web of Science ID 000257767300010

  View details for PubMedID 18580511

• The demographics of significant firearm injury in Canadian trauma centres and the associated predictors of inhospital mortality. Canadian journal of surgery. Journal canadien de chirurgie Finley, C. J., Hemenway, D., Clifton, J., Brown, D. R., Simons, R. K., Hameed, S. M. 2008; 51 (3): 197-203

  Abstract

  Our primary objective was to evaluate demographic and causal factors of inhospital mortality for significant firearm-related injuries (i.e., those with an Injury Severity Score [ISS] > 12) in Canadian trauma centres.We analyzed data submitted to the Canadian Institute for Health Information (CIHI) in the National Trauma Registry for all firearm-injured patients for fiscal years 1999-2003. Univariate and bivariate adjusting for ISS and multivariate logistic regression were performed.Men accounted for 94% of the 784 injured. In all patients, the percentages of self-inflicted, intentional, unintentional and unknown injuries were 27.8%, 60.3%, 6.1% and 5.7%, respectively. The inhospital fatality rate was 39.8%, with 83% of fatalities occurring on the first day. Two-thirds of patients were discharged home. Univariate and adjusted analysis found that ISS, first systolic blood pressure (BP), first systolic BP under 100, first Glasgow Coma Scale (GCS) score, age over 45 years, self-inflicted injury, intentional injury and injury at home significantly worsened the odds ratio of death in hospital and that police shooting was relatively beneficial. BP under 100, age over 45 years and a low GCS score had an adjusted odds ratio of death of 4.12, 1.99 and 0.64 per point increase, respectively. The multivariate model showed that ISS, BP under 100, first GCS score, sex and self-inflicted injury were significant in predicting inhospital death.A predominance of young men are injured intentionally with handguns in Canada, whereas older patients suffer self-inflicted injuries with long guns. The significant number of firearm deaths, largely in the first day, highlights the importance of preventative strategies and the need for rapid transport of patients to trauma centres for urgent care.

  View details for PubMedID 18682765

  View details for PubMedCentralID PMC2496605

• Objective assessment of surgical decision making in trauma after a laboratory-based course: durability of cognitive skills. American journal of surgery Scott, T. M., Hameed, S. M., Evans, D. C., Simons, R. K., Sidhu, R. S. 2008; 195 (5): 599-602; discussion 602-3

  Abstract

  Because surgical trainees have less exposure to surgical trauma, there is a greater potential of having gaps in decision-making skills. We previously validated a novel assessment tool for decision making in surgical trauma and have documented improvement in resident decision-making skills after a hands-on course. However, brief intensive courses have been criticized for not imparting long-term changes in practice. The purpose of this study was to assess the durability of cognitive skills learned after a 2-day course.Twenty-two residents participated in a 2-day interactive didactic lecture series as well as an animal laboratory focused on practical strategies in dealing with surgical trauma. All participants underwent precourse and immediate postcourse assessment of surgical decision making through a validated short-answer examination. Six months after the course, 12 of these 22 residents completed a third similar examination-the retention test.The retention test showed good reliability (Cronbach's alpha, .81) and construct validity as evidenced by a positive correlation between test scores and postgraduate year level (r = .9, P < .001). There was no significant difference between retention test scores and posttest scores. However, both were significantly higher than pretest scores (P < .05). This did not change after adjusting for differing degrees of difficulty between the examinations.In the context of residency trauma education, there is a measurable positive impact of an intensive, hands-on course on surgical decision making. This impact is durable and cognitive skills persist after the immediate postcourse period. These data support the continued supplementation of traditional residency experiential learning with appropriate laboratory-based skills training.

  View details for DOI 10.1016/j.amjsurg.2007.12.035

  View details for PubMedID 18374888

• Assessing decision making in operative trauma: Development of a novel tool and evaluation of its utility Scott, T. M., Hameed, M., Evans, D., Webber, E., Brown, R., Doucet, J., Simons, R., Sidhu, R. ELSEVIER SCIENCE INC. 2006: S74

  View details for DOI 10.1016/j.jamcollsurg.2006.05.195

  View details for Web of Science ID 000240406800156