Brent Izu

Predictors of successful implementation of preoperative briefings and postoperative debriefings after medical team training

BACKGROUND The purpose of this study was to examine which factors at a medical team training learning session predict future success in the implementation of preoperative briefings and postoperative debriefings at health care facilities. METHODS A Likert score rating for physician involvement, leadership support, and composition of the implementation team was recorded for 64 VHA facilities at the time of a learning session by 3 medical team training educators. At a mean follow-up period of 8.2 months (standard error, .4 mo), a briefing score was established from quarterly semistructured interviews with the facilitys implementation team. RESULTS In a multivariable regression, leadership involvement at the time of the learning session was the best predictor of future briefing/debriefing success (R = .34, P = .03). CONCLUSIONS Full implementation of the patient safety tool preoperative briefings and postoperative debriefings is dependent on facility leadership support.

The impact of splenic artery embolization on the management of splenic trauma: an 8-year review

BACKGROUND Splenic artery embolization (SAE) is an adjunct to nonoperative management (NOM) of splenic injuries. We reviewed our experience with SAE to identify its impact on splenic operations. METHODS Patients admitted with splenic injuries over an 8-year period were identified and the initial method of management noted (simple observation, SAE, or splenic surgery). The first 4 years (period 1) during which SAE was introduced was compared with the latter 4 years (period 2) when it was used frequently. RESULTS There were 304 patients in period 1 and 416 in period 2. NOM was initial management in 59.9% in period 1% and 60.1% in period 2 (P = 1.0) and failure rates were 5.3% versus 2.9%, respectively (P = .12). More SAE procedures were performed in period 2 -- 13.7% versus 4.9% (P < or = .001) -- and there was a reduction in the proportion of splenic operations -- 35.2% versus 26.2% (P <.01). CONCLUSIONS SAE is associated with a reduction in splenic operations, although it did not alter the failure rate of NOM.

Impact of splenic injury guidelines on hospital stay and charges in patients with isolated splenic injury.

BACKGROUND The purpose of this study was to assess the impact of care guidelines for patients with isolated blunt splenic trauma on length of stay (LOS) and patient charges. METHODS We conducted a review of the hospital trauma registry and identified patients admitted with blunt splenic injury from 2000 to 2007. Splenic injury guidelines were initiated in November 2004. Patients with other major injuries were excluded. Patients were grouped according to their American Association for the Surgery of Trauma (AAST) splenic injury grade, I-V. Hospital LOS, intensive care unit (ICU) LOS, and patient charges before and after the guidelines were compared. RESULTS We identified 137 patients with isolated splenic injuries. Sixty-three patients were admitted before and 70 patients after implementation of the guidelines. ICU and hospital LOS were significantly decreased after the guidelines (ICU LOS, 1.35 days before, 0.80 after [P < .01]; and hospital LOS, 4.17 before, 3.27 after [P < .01]). When grouped by AAST grade, grade II injuries had a decrease in hospital LOS (4.5 before vs 2.29 after; P < .01) and ICU LOS (1.43 before vs 0.29 after; P < .01). Adjusted hospital charges showed no significant increase overall after the guideline implementation (mean hospital charges before

Surgical Practice: Evidence or Anecdote

23,047 vs after,

Effect of the 30-hour work limit on resident experience and education.

24,116; P = .62). CONCLUSION Implementing guidelines for the observation of blunt splenic injury decreased the overall hospital LOS and ICU LOS at our institution, but hospital charges remained the same. Trauma programs should institute splenic injury guidelines to reduce resources needed for the care of isolated splenic injuries.

Effect of the 30-hour work limit on resident case coverage

OBJECTIVES Our objective is to highlight a few surgical practices that are not based on evidence but are still taught in surgical education, and to assess our experience with these practices. DESIGN We identified 3 practices (clamping of nasogastric tubes before removal, bowel preparation before elective colon resection, and elective sigmoid colectomy following 2 bouts of diverticulitis), identified the data supporting each practice, and administered a survey to faculty and residents at our institution. SETTING Wright State University Department of Surgery, Boonshoft School of Medicine, Dayton, Ohio. PARTICIPANTS Twenty-one faculty and 35 residents responded to the survey. RESULTS No studies were found relating to clamping nasogastric tubes before removal. Seven faculty (33%) and 11 residents (31%) used this practice. Two faculty (10%) and 0 residents felt this was an evidence-based practice. Faculty were more likely to have reviewed the evidence (85% vs 40%, p < 0.001). Level 2 evidence has shown bowel preparation did not improve outcomes relating to anastomotic leak, wound infection, or septic complications in elective colon resection. Twenty faculty (95%) and 34 residents (97%) used this practice. Faculty were more likely to believe this to be evidence-based (85% vs 49%, p = 0.01). There has been no level 1 or 2 evidence showing that sigmoid colectomy following 2 bouts of diverticulitis improves morbidity or mortality. Fourteen faculty (70%) and 26 residents (76%) reported using this practice. Twelve faculty (60%) and 21 residents (60%) felt this was evidence-based. CONCLUSIONS Frequent use of surgical practices without evidence support can create a misperception that such practices are evidence-based. Faculty are more likely to change a practice after obtaining continuing medical education, suggesting that residents may need validation by faculty practice of evidence-based procedures before incorporation into their clinical care.