Joaquim M. Havens

Use of National Burden to Define Operative Emergency General Surgery.

IMPORTANCE Emergency general surgery (EGS) represents 11% of surgical admissions and 50% of surgical mortality in the United States. However, there is currently no established definition of the EGS procedures. OBJECTIVE To define a set of procedures accounting for at least 80% of the national burden of operative EGS. DESIGN, SETTING, AND PARTICIPANTS A retrospective review was conducted using data from the 2008-2011 National Inpatient Sample. Adults (age, ≥18 years) with primary EGS diagnoses consistent with the American Association for the Surgery of Trauma definition, admitted urgently or emergently, who underwent an operative procedure within 2 days of admission were included in the analyses. Procedures were ranked to account for national mortality and complication burden. Among ranked procedures, contributions to total EGS frequency, mortality, and hospital costs were assessed. The data query and analysis were performed between November 15, 2015, and February 16, 2016. MAIN OUTCOMES AND MEASURES Overall procedure frequency, in-hospital mortality, major complications, and inpatient costs calculated per 3-digit International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes. RESULTS The study identified 421 476 patient encounters associated with operative EGS, weighted to represent 2.1 million nationally over the 4-year study period. The overall mortality rate was 1.23% (95% CI, 1.18%-1.28%), the complication rate was 15.0% (95% CI, 14.6%-15.3%), and mean cost per admission was

The excess morbidity and mortality of emergency general surgery.

13 241 (95% CI,

22q13 Deletion Syndrome: An Update and Review for the Primary Pediatrician

12 957-

Defining Rates and Risk Factors for Readmissions Following Emergency General Surgery

13 525). After ranking the 35 procedure groups by contribution to EGS mortality and morbidity burden, a final set of 7 operative EGS procedures were identified, which collectively accounted for 80.0% of procedures, 80.3% of deaths, 78.9% of complications, and 80.2% of inpatient costs nationwide. These 7 procedures included partial colectomy, small-bowel resection, cholecystectomy, operative management of peptic ulcer disease, lysis of peritoneal adhesions, appendectomy, and laparotomy. CONCLUSIONS AND RELEVANCE Only 7 procedures account for most admissions, deaths, complications, and inpatient costs attributable to the 512 079 EGS procedures performed in the United States each year. National quality benchmarks and cost reduction efforts should focus on these common, complicated, and costly EGS procedures.

The Role of Nontechnical Skills in Simulated Trauma Resuscitation

BACKGROUND Emergency general surgery (EGS) carries a disproportionate burden of risk from medical errors, complications, and death compared with non-EGS (NEGS). Previous studies have been limited by patient and procedure heterogeneity but suggest worse outcome in EGS patients because of preoperative risk factors. The aim of this study was to quantify the excess burden of morbidity and mortality associated with EGS by controlling for patient-specific factors. We hypothesized that EGS is an independent risk factor for morbidity and mortality. METHODS We retrospectively analyzed data from the American College of Surgeons-National Surgical Quality Improvement Program. Fourteen procedures common to both EGS and NEGS from 2008 through 2012 were included. Patients were stratified based on emergency status. The primary outcome was death within 30 days of operation. Secondary outcomes were postoperative complications. Variables from the American College of Surgeons-National Surgical Quality Improvement Program preoperative risk assessment were analyzed. &khgr;2 and Wilcoxon signed-rank tests were used to compare variables. Multivariate logistic regression was used to identify independent risk factors for mortality and complications. RESULTS Of 66,665 patients, 24,068 were EGS and 42,597 were NEGS. Mortality was 12.50% for EGS patients and 2.66% for NEGS patients (p < 0.0001). Major complications occurred in 32.80% of EGS patients and 12.74% of NEGS patients (p < 0.0001). When preoperative variables and procedure type were controlled, EGS was independently associated with death (odds ratio, 1.39; p = 0.029) and major complications (odds ratio, 1.31; p = 0.001). CONCLUSION EGS is an independent risk factor for death and postoperative complications. The excess morbidity and mortality of EGS are not fully explained by preoperative risk factors, making EGS an excellent target for quality improvement projects. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III.

The Boston Marathon Bombing: After-Action Review of the Brigham and Women’s Hospital Emergency Radiology Response

Recent advances in genetic testing can help to provide a specific diagnosis to children born with syndromes that result in congenital anomalies and developmental delay. One such emerging condition is the 22q13 deletion syndrome. With the introduction of subtelomeric fluorescence-in-situ hybridization (FISH) analysis, the 22q13 deletion has become recognized as a relatively widespread and underdiagnosed cause of mental retardation. Primary-care physicians play an important role in the care of children with 22q13 deletion syndrome, from suspecting the diagnosis in a developmentally delayed child through the medical, developmental, and behavioral aspects of their care. Furthermore, they serve as a valuable source of support and advocacy for the family and a resource for other care providers. The remainder of this article addresses the current state of knowledge regarding 22q13 deletion syndrome and offers the primary-care physician a framework in which to provide care and information.

Re-establishing Surgical Care at Port-au-Prince General Hospital, Haiti

IMPORTANCE Hospital readmission rates following surgery are increasingly being used as a marker of quality of care and are used in pay-for-performance metrics. To our knowledge, comprehensive data on readmissions to the initial hospital or a different hospital after emergency general surgery (EGS) procedures do not exist. OBJECTIVE To define readmission rates and identify risk factors for readmission after common EGS procedures. DESIGN, SETTING, AND PARTICIPANTS Patients undergoing EGS, as defined by the American Association for the Surgery of Trauma, were identified in the California State Inpatient Database (2007-2011) on January 15, 2015. Patients were 18 years and older. We identified the 5 most commonly performed EGS procedures in each of 11 EGS diagnosis groups. Patient demographics (sex, age, race/ethnicity, and insurance type) as well as Charlson Comorbidity Index score, length of stay, complications, and discharge disposition were collected. Factors associated with readmission were determined using multivariate logistic regression models analysis. MAIN OUTCOMES AND MEASURES Thirty-day hospital readmission. RESULTS Among 177,511 patients meeting inclusion criteria, 57.1% were white, 48.8% were privately insured, and most were 45 years and older (51.3%). Laparoscopic appendectomy (35.2%) and laparoscopic cholecystectomy (19.3%) were the most common procedures. The overall 30-day readmission rate was 5.91%. Readmission rates ranged from 4.1% (upper gastrointestinal) to 16.8% (cardiothoracic). Of readmitted patients, 16.8% were readmitted at a different hospital. Predictors of readmission included Charlson Comorbidity Index score of 2 or greater (adjusted odds ratio: 2.26 [95% CI, 2.14-2.39]), leaving against medical advice (adjusted odds ratio: 2.24 [95% CI, 1.89-2.66]), and public insurance (adjusted odds ratio: 1.55 [95% CI, 1.47-1.64]). The most common reasons for readmission were surgical site infections (16.9%), gastrointestinal complications (11.3%), and pulmonary complications (3.6%). CONCLUSIONS AND RELEVANCE Readmission after EGS procedures is common and varies widely depending on patient factors and diagnosis categories. One in 5 readmitted patients will go to a different hospital, causing fragmentation of care and potentially obscuring the utility of readmission as a quality metric. Assisting socially vulnerable patients and reducing postoperative complications, including infections, are targets to reduce readmissions.

Analgesic Access for Acute Abdominal Pain in the Emergency Department Among Racial/Ethnic Minority Patients: A Nationwide Examination.

OBJECTIVE Trauma team training provides instruction on crisis management through debriefing and discussion of teamwork and leadership skills during simulated trauma scenarios. The effects of team leaders nontechnical skills (NTSs) on technical performance have not been thoroughly studied. We hypothesized that teams and team leaders NTSs correlate with technical performance of clinical tasks. DESIGN Retrospective cohort study. SETTING Brigham and Womens Hospital, STRATUS Center for Surgical Simulation PARTICIPANTS A total of 20 teams composed of surgical residents, emergency medicine residents, emergency department nurses, and emergency services assistants underwent 2 separate, high-fidelity, simulated trauma scenarios. Each trauma scenario was recorded on video for analysis and divided into 4 consecutive sections. For each section, 2 raters used the Non-Technical Skills for Surgeons framework to assess NTSs of the team. To evaluate the entire teams NTS, 2 additional raters used the Modified Non-Technical Skills Scale for Trauma system. Clinical performance measures including adherence to guidelines and time to perform critical tasks were measured independently. RESULTS NTSs performance by both teams and team leaders in all NTS categories decreased from the beginning to the end of the scenario (all p < 0.05). There was significant correlation between teams and team leaders cognitive skills and critical task performance, with correlation coefficients between 0.351 and 0.478 (p < 0.05). The NTS performance of the team leader highly correlated with that of the entire team, with correlation coefficients between 0.602 and 0.785 (p < 0.001). CONCLUSIONS The NTSs of trauma teams and team leaders deteriorate as clinical scenarios progress, and the performance of team leaders and teams is highly correlated. Cognitive NTS scores correlate with critical task performance. Increased attention to NTSs during trauma team training may lead to sustained performance throughout trauma scenarios. Decision making and situation awareness skills are critical for both team leaders and teams and should be specifically addressed to improve performance.

Outcomes after emergency abdominal surgery in patients with advanced cancer: Opportunities to reduce complications and improve palliative care.

PURPOSE To analyze imaging utilization and emergency radiology process turnaround times in response to the April 15, 2013, Boston Marathon bombing in order to identify opportunities for improvement in the Brigham and Womens Hospital (BWH) emergency operations plan. MATERIALS AND METHODS Institutional review board approval was obtained with waivers of informed consent. Patient demographics, injuries, and outcomes were gathered, along with measures of emergency department (ED) imaging utilization and turnaround times, which were compared with operations from the preceding year by using the Wilcoxon rank sum test. Multivariate linear regression was used to assess contributors to examination cancellations. RESULTS Forty patients presented to BWH after the bombing; 16 were admitted and 24 were discharged home. There were no fatalities. Ten patients required emergent surgery. Blast injury types included 13 (33%) primary, 20 (51%) secondary, three (8%) tertiary, and 19 (49%) quaternary. Thirty-one patients (78%) underwent imaging in the ED; 57 radiographic examinations in 30 patients and 16 computed tomographic (CT) examinations in seven patients. Sixty-two radiographic and 14 CT orders were cancelled. Median time from blast to patient arrival was 97 minutes (interquartile range [IQR], 43-139 minutes), patient arrival to ED examination order, 24 minutes (IQR, 12-50 minutes), order to examination completion, 49 minutes (IQR, 26-70 minutes), and examination completion to available dictated text report, 75 minutes (IQR, 19-147 minutes). Examination completion turnaround times were significantly increased for radiography (52 minutes [IQR, 26-73 minutes] vs annual median, 31 minutes [IQR, 19-48 minutes]; P = .001) and decreased for CT (37 minutes [IQR, 26-50 minutes] vs annual median, 72 minutes [IQR, 40-129 minutes]; P = .001). There were no significant differences in report availability turnaround time (75 minutes [IQR, 19-147 minutes] vs annual median, 74 minutes [IQR, 35-127 minutes]; P = .34). CONCLUSION The surge in imaging utilization after the Boston Marathon bombing stressed emergency radiology operations. Process analysis enabled identification of successes and opportunities for improvement in ongoing emergency operations planning.

The truth about trauma readmissions.

t w n c c r n he earthquake that hit Haiti on January 12, 2010 caused n unqualified humanitarian catastrophe. It destroyed elecrical networks; water and sanitation facilities; communiation and transportation systems; and crippled all governental, financial, civil, and social institutions in this lready-fragile state. The Haitian government reports that etween 217,000 and 230,000 people have died and an dditional 300,000 were injured. Within days of the vent, an urgent need for trauma surgeons was identified. e went to help. We expected hardship, but were confient we would do what we could with what we had. Our team arrived in Port-au-Prince 10 days after the uake. Our mission was to restore surgical services to the eneral Hospital at Port-au-Prince. The scene was reminisent of the bombing of Dresden by Allied Forces during orld War II. Nothing was spared. The suffering was palable. The smoke, the heat, the acrid scent of lives lost and odies not recovered overwhelmed the senses. It is in this ontext that we report our experience and the importance f developing the fundamental infrastructure required for ffective pre-, post-, and intraoperative treatment while aintaining basic principles of wound care established ore than a century ago. We believe the lessons we earned are applicable not only to the tragedy in Haiti, but o other natural and manmade disasters in which the need or surgical care greatly exceeds the availability of resources Table 1). L’Hôpital de l’Université d’Etat d’Haiti was the largest ublic hospital in Haiti, treating 169,000 patients annully. More than 50% of the campus was destroyed. Medical olunteers from around the world staffed the makeshift acilities as up to 1,000 patients waited for surgery. In conunction with the Haitian Ministry of Health, Partners in ealth, a Boston-based nonprofit health care association