Aristithes G. Doumouras

A Crisis of Faith? A Review of Simulation in Teaching Team-Based, Crisis Management Skills to Surgical Trainees

BACKGROUND Team-based training using crisis resource management (CRM) has gained popularity as a strategy to minimize the impact of medical error during critical events. The purpose of this review was to appraise and summarize the design, implementation, and efficacy of peer-reviewed, simulation-based CRM training programs for postgraduate trainees (residents). METHODS Two independent reviewers conducted a structured literature review, querying multiple medical and allied health databases from 1950 to May 2010 (MEDLINE, EMBASE, CINAHL, EBM, and PsycINFO). We included articles that (1) were written in English, (2) were published in peer-reviewed journals, (3) included residents, (4) contained a simulation component, and (5) included a team-based component. Peer-reviewed articles describing the implementation of CRM instruction were critically appraised using the Kirkpatrick framework for evaluating training programs. RESULTS Fifteen studies involving a total of 404 residents met inclusion criteria; most studies reported high resident satisfaction for CRM training. In several CRM domains, residents demonstrated significant improvements after training, which did not decay over time. With regard to design, oral feedback may be equivalent to video feedback and single-day interventions may be as efficacious as multiple-day interventions for residents. No studies demonstrated a link between simulation-based CRM training and performance during real-life critical events. CONCLUSIONS The findings support the utility of CRM programs for residents. A high degree of satisfaction and perceived value reflect robust resident engagement. The iteration of themes from our review provides the basis for the development of best practices in curricula design. A dearth of well-designed, randomized studies preclude the quantification of impact of simulation-based training in the clinical environment.

The Impact of Distance on Triage to Trauma Center Care in an Urban Trauma System

Abstract Background. Urban trauma systems are characterized by high population density, availability of trauma centers, and acceptable road transport times (within 30 minutes). In such systems, patients meeting field trauma triage (FTT) criteria should be transported directly to a trauma center, bypassing closer non–trauma centers. Objective. We evaluated emergency medical services (EMS) triage practices to identify opportunities for improving care delivery. Objective. Specifically, we evaluated the effect of the additional distance to a trauma center, compared with a closer non–trauma center, on the noncompliance with trauma destination criteria by EMS personnel in an urban environment. Methods. This was a retrospective cohort study of adults having at least one physiologic derangement and meeting Toronto EMS field trauma triage criteria from 2005 to 2010. Road travel distances between the site of injury, the closest non–trauma center, and the closest trauma center were estimated using geographic information systems. For patients who were transported to non–trauma centers, we estimated “differential distance”: the additional travel distance required to transport directly to a trauma center. Logistic regression was used to analyze the effect of differential distance on triage decisions, adjusting for other patient characteristics. Results. Inclusion criteria identified 898 patients; 53% were transported directly to a trauma center. Falls, female gender, and age greater than 65 years were associated with transport to non–trauma centers. Differential distances greater than 1 mile were associated with a decreased likelihood of triage to a trauma center. Conclusion. Differential distance between the closest non–trauma center and the closest trauma center was associated with lower compliance with triage protocols, even in an urban setting where trauma centers can be accessed within approximately 30 minutes. Our findings suggest that there are opportunities for reducing the gap between ideal and actual application of field trauma triage guidelines through a process of education and feedback.

Mastery in Bariatric Surgery: The Long-term Surgeon Learning Curve of Roux-en-y Gastric Bypass

Objective: To determine the effect of cumulative volume on all-cause morbidity and operative time. Background: Gastric bypass is an important public health procedure, but it is difficult to master with little data about how surgeon cumulative volume affects outcomes longitudinally. Methods: This was a longitudinal study of 29 surgeons during the first 6 years of performing bariatric surgery in a high-volume, regionalized center of excellence system. Cumulative volume was determined using date and time of the procedure. Cumulative volume was analyzed in blocks of 75 cases. The main outcome of interest was all-cause morbidity during the index admission and the secondary outcome was operative time. Results: Overall, 11,684 gastric bypasses were performed by 29 surgeons at 9 centers of excellence. The overall morbidity rate was 10.1% and short-term outcomes were related significantly to cumulative volume. Perioperative risk plateaued after approximately 500 cases and was lowest for surgeons who had completed more than 600 cases (odds ratio 0.53 95% confidence interval 0.26–0.96 P = 0.04) compared to the first 75 cases. Operative time also stabilized after approximately 500 cases, with an operative time 44.7 minutes faster than surgeons in their first 75 cases (95% confidence interval 37.0–52.4 min P < 0.001). Conclusions: The present study demonstrated the clear, substantial influence of surgeon cumulative volume on improved perioperative outcomes and operative time. This finding emphasizes role of the individual surgeon in perioperative outcomes and that the true learning curve needed to master a complex surgical procedure such as gastric bypass is longer than previously thought, in this case requiring approximately 500 cases to plateau.

Close to home: an analysis of the relationship between location of residence and location of injury.

BACKGROUND Injury surveillance is critical in identifying the need for targeted prevention initiatives. Understanding the geographic distribution of injuries facilitates matching prevention programs with the population most likely to benefit. At the population level, however, the geographic site of injury is rarely known, leading to the use of location of residence as a surrogate. To determine the accuracy of this approach, we evaluated the relationship between the site of injury and of residence over a large geographic area. METHODS Data were derived from a population-based, prehospital registry of persons meeting triage criteria for major trauma. Patients dying at the scene or transported to the hospital were included. Distance between locations of residence and of injury was calculated using geographic information system network analysis. RESULTS Among 3,280 patients (2005–2010), 88% were injured within 10 miles of home (median, 0.2 miles). There were significant differences in distance between residence and location of injury based on mechanism of injury, age, and hospital disposition. The large majority of injuries involving children, the elderly, pedestrians, cyclists, falls, and assaults occurred less than 10 miles from the patient’s residence. Only 77% of motor vehicle collision occurred within 10 miles of the patient’s residence. CONCLUSION Although the majority of patients are injured less than 10 miles from their residence, the probability of injury occurring “close to home” depends on patient and injury characteristics. LEVEL OF EVIDENCE Epidemiologic study, level III.

A population-based analysis of the discrepancy between potential and realized access to trauma center care.

Objective:To explore whether a discrepancy between the availability of trauma services (potential access) and trauma center utilization rates (realized access) exists, with the aim of informing strategies to improve access. Background:Lack of access to trauma center care has frequently been attributed to the geographic distribution of trauma centers. Alternatively, impeded access to trauma center care might be due to suboptimal triage practices in the setting of appropriate resources. Methods:Population-based retrospective cohort study of severely injured adult patients (2002–2010). Potential access to trauma center care was evaluated using network-based spatial analysis of census data and was defined as residing within 1 hour of a trauma center. Realized access to trauma center care was evaluated using population-based data sources and was defined as direct transport from the scene of injury to a trauma center. Concordance between potential and realized access (high, moderate, or low) was evaluated at the county level. Results:Of the population in the study region, 7,340,711 persons (60%) had potential access to trauma center care; persons in 11 counties (22%) had high potential access. Of 26,861 severely injured patients, 10,237 (38%) had realized access to trauma center care; patients in only 4 counties (8%) had high realized access. The concordance between potential and realized access was moderate (weighted &kgr; = 0.49); 63% of counties (n = 7) with high potential access performed worse than expected and had moderate or low realized access. Conclusions:There is limited concordance between potential and realized access. Regions with high potential access had low realized access, and vice versa. This evaluation suggests that strategies to improve access must be based on understanding the distribution of centers and the triage practices used to access trauma care.

Regional Variations in the Public Delivery of Bariatric Surgery: An Evaluation of the Center of Excellence Model.

Objective:We evaluated regional access to bariatric surgery within the high-volume, center of excellence (COE) model of Ontario, Canada. Background:In 2009, Ontario implemented Canadas first regionalized bariatric surgical care system based on a COE. Because of this, a small number of COEs service a large population and geographic area. Methods:This study identified all patients older than 18 years, who received bariatric surgery from April 2009 to March 2012. Morbid obesity-adjusted rates of surgery were then calculated for each neighborhood, and a cluster analysis was performed to determine aggregation of neighborhoods with significantly higher (hot spots) or lower (cold spots) rates of surgery. Ordinal logistic regression was used to identify independent predictors of neighborhood access. Results:The cluster analysis identified 49 cold spot neighborhoods, representing 1.7 million people. Forty of these neighborhoods lie within a relatively small area that contains 3 of the 4 COEs. In the multivariate analysis, for every 100 km from the nearest COE, neighborhoods were 0.88 times as likely to live in a hot spot [95% CI (confidence interval): 0.80–0.97; P = 0.012]. In addition, having a bariatric facility within the same administrative health region as the neighborhood made it almost twice as likely to be a hot spot, odds ratio = 1.75 (95% CI: 1.10–2.79; P = 0.018). Low neighborhood socioeconomic status was not associated with decreased delivery of care. Conclusions:This study identified an unequal delivery of bariatric surgery within Ontario. Both longer distances and not having a bariatric facility within the same health region had significant negative effects. Further research into patient attitudes and referral patterns is required to better characterize these disparities.

A population-based analysis of the drivers of short-term costs after bariatric surgery within a publicly funded regionalized center of excellence system.

BACKGROUND The most significant driver of healthcare utilization for bariatric surgery is the index admission and readmissions within the first 30 days after a procedure. Identifying areas to create efficiencies during this period is essential to decreasing overall healthcare costs. OBJECTIVE The objective of the study was to characterize the short-term costs of bariatric surgery within a regionalized center of excellence bariatric care system. SETTING The Ontario Bariatric Network is a regionalized bariatric care system with 4 high-volume Bariatric Centers of Excellence. METHODS We performed a population-based retrospective analysis including all adult patients who received a bariatric surgical procedure in Ontario from April 2009 until March 2012. Total hospital cost and number of days in hospital was calculated for all index admissions and all readmissions within 30 days of a bariatric surgical procedure. An inverse Gaussian generalized linear model was utilized to model the effect of covariates on costs. A Poisson regression was used to determine the effect on covariates on total days in hospital. RESULTS After multivariable adjustment, the sleeve gastrectomy procedure decreased costs by

Factors Associated With Outcomes and Costs After Pediatric Laparoscopic Cholecystectomy

1447 over gastric bypass (95% confidence interval [CI]

Early crisis nontechnical skill teaching in residency leads to long-term skill retention and improved performance during crises: A prospective, nonrandomized controlled study

1578 to-

A population-based comparison of 30-day readmission after surgery for colon and rectal cancer: How are they different?

1315]); P<.001). This effect increased when adjusting only for preoperative factors with a cost savings of nearly