Rebecca C. Britt

Initial Implementation of an Acute Care Surgery Model: Implications for Timeliness of Care

BACKGROUND In July 2007, we introduced an acute care surgery service to an academic department of surgery staffed in a prearranged, dedicated rotation by critical care-trained surgeons to address all emergency department, inpatient, and transfer consultations. This study is designed to evaluate the impact on patient care and describe the case-mix experienced. STUDY DESIGN A retrospective review was done of a prospectively collected database encompassing all patients evaluated. Diagnosis, operations performed, and times of operations were recorded. RESULTS Eight hundred sixty-one patients were evaluated. Four hundred ten patients (47.6%) had 500 operations; 368 (72.8%) were performed in the operating room and 132 (26.2%) at the bedside. Respiratory failure and malnutrition (n = 130), soft-tissue infection (n = 115), abdominal pain (n = 97), biliary (n = 94), bowel obstruction (n = 78), diseases of the colon (n = 49), and appendicitis (n = 46) were the most common diseases seen. The most common operations performed included incision and drainage (n = 61); tracheostomy or percutaneous gastrostomy, or both (n = 125); cholecystectomy (n = 53); appendectomy (n = 41); colectomy (n = 34); and complex abdominal wound care (n = 43). In the year before implementation, 55.4% of emergent procedures were performed between 7:30 am and 5:30 pm, compared with 70% after implementation (p = 0.0002). Procedures performed after 5:30 pm decreased from 44.6% to 30%. CONCLUSIONS Implementation of an acute care surgery service has been positive in terms of facilitating the ability to provide more timely care by increasingly using the daytime operating room and providing a breadth of consultative and operative experience to the participating academic surgeons and trainees.

The impact of central line simulation before the ICU experience

BACKGROUND This study was designed to evaluate whether resident performance of placing central lines improved after simulation training on newly available partial-task simulators. METHODS This study was designed as a prospective, randomized controlled trial of standard training versus simulated training using CentralLine Man (SimuLab, Seattle, WA, USA). After receiving a lecture on central line placement, all junior residents on the trauma rotation were randomized on a monthly alternating schedule. Equivalency of groups was determined with a self-reported survey. All lines placed by the participants were monitored, and data were collected on performance and complications. RESULTS The 2 groups (n = 34; 21 standard and 13 simulated) were equivalent at baseline. The simulated training group had a significantly higher level of comfort and ability than the standard training group. The simulated group outperformed the standard group on 12 of the 15 specific variables monitored, although this did not reach statistical significance. There were significantly more complications in the standard group. CONCLUSIONS Simulation for central line placement using a partial-task simulator does positively impact resident performance.

Impact of acute care surgery on biliary disease.

BACKGROUND We introduced an acute care surgery (ACS) service in July 2007 to address all new consults. This study examines the impact on treatment of biliary disease. STUDY DESIGN A retrospective review was done of a prospective database of all inpatient operative biliary disease treated in a tertiary care hospital 1 year before and 2 years after implementation of an ACS service. Data collected included diagnosis, time from admission to operation, time of operation, length of stay, comorbidities, and complications. RESULTS There were 54 patients in the pre-ACS group and 132 in the post-ACS group, with no difference in percentage of females, comorbidities, and diagnosis. The post-ACS group had a trend toward a shorter time from consult to operating room (59.9 vs 68.7 hours, p = 0.45) and shorter hospital length of stay (5.5 vs 6.7 days, p = 0.27). In the acute cholecystitis post-ACS cohort, there was also a trend toward shorter time to operating room (39.8 vs 45.5 hours, p = 0.55) and shorter length of stay (4.6 vs 5.7 days, p = 0.39). The second year of ACS showed continued improvement in time to operating room (30.9 hours) compared with both pre-ACS and the first year of ACS. There was no significant difference in laparoscopic versus open surgery or complications between the groups. CONCLUSIONS There is a trend toward improvement in timeliness of care for complex inpatient biliary disease with implementation of an ACS service, especially as the service matures. There remains wide variability in patient complexity, which affects timeliness of care.

Impact of a monitored program of care on incidence of ventilator-associated pneumonia: results of a longterm performance-improvement project.

BACKGROUND Ventilator-associated pneumonia (VAP) remains a major source of morbidity, mortality, and expense in the ICU despite therapies directed against it. STUDY DESIGN A retrospective review of a prospectively developed performance-improvement project monitoring the incidence of VAP in two adjacent ICUs was conducted. In response to an excessive VAP rate, weekly multidisciplinary team meetings were instituted to review data, develop care protocols, and modify care routines. Protocol compliance was monitored daily and feedback provided weekly to the care teams. VAP rates were determined by the institutional Infection Control Committee and reviewed monthly with the ICU multidisciplinary team. Duration of the investigational period was 10 years. RESULTS A standardized ventilator-weaning protocol was instituted with confirmed 95% use. Additional modifications of care, such as patient positioning, use of specific endotracheal tubes to minimize aspiration of supraglottic secretions, an oral-care regimen, and aggressive antibiotic stewardship were standardized, with a compliance rate >90%. VAP rates dropped from 12.8 per 1,000 patient-days in 1998 to 1.1 in 2007 in the burn trauma ICU and from 21.2 to <1 in the neurotrauma ICU in the same time frame. Also, mean ventilator length of stay decreased from 6 days to 4.2 and from 5.8 days to 4.75 simultaneously in the respective ICUs. Such performance improvement has been sustained since implementation of the program. CONCLUSION A systematic, monitored program of standardized care protocols can markedly reduce VAP rate in the ICU.

Effect of the 80-Hour Work Week on Resident Case Coverage

BACKGROUND On July 1, 2003, residency training programs were required to institute restricted duty hours as mandated by the Accreditation Council for Graduate Medical Education. A major concern, voiced by both surgical residents and faculty, was an expectation that this would result in a decrease in operative experience. We hypothesized that implementing restricted duty hours would decrease case coverage by resident trainees. STUDY DESIGN A retrospective study was performed of operative and endoscopic cases scheduled for a single general surgery practice for a year before and after July 1, 2003. Data collected included operation performed, number of attending surgeons present, whether a resident was present, and level of resident. RESULTS From July 2002 to June 2003, there were 1,278 cases scheduled; 890 records were available. From July 2004 to June 2005, there were 1,182 cases scheduled; 960 records were available. Before institution of the restricted duty hours, 24.6% of junior-level (PGY1 and 2) cases, 21.7% of intermediate-level (PGY3) cases, and 6.2% of senior-level (PGY4 and 5) cases were not covered by residents. After restricted duty hours were implemented, 27.3% of junior-level cases, 15.9% of intermediate-level cases, and 8.1% of senior-level cases were not covered by residents. Overall 20.8% (185 of 890) and 20.4% (196 of 960) of cases were not covered by residents before and after instituting restricted duty hours, respectively. No difference in case coverage was statistically significant in each category or overall. CONCLUSIONS Restricted duty hours have not affected resident case coverage.

Intracorporeal suturing: Transfer from Fundamentals of Laparoscopic Surgery to cadavers results in substantial increase in mental workload.

INTRODUCTION A spatial secondary task developed by the authors was used to measure the mental workload of the participant when transferring suturing skills from a box simulator to more realistic surgical conditions using a fresh cadaver. We hypothesized that laparoscopic suturing on genuine bowel would be more challenging than on the Fundamentals of Laparoscopic Surgery (FLS)-simulated bowel as reflected in differences on both suturing and secondary task scores. METHODS We trained 14 surgical assistant students to FLS proficiency in intracorporeal suturing. Participants practiced suturing on the FLS box for 30 minutes and then were tested on both the FLS box and the bowel of a fresh cadaver using the spatial, secondary dual-task conditions developed by the authors. RESULTS Suturing times increased by >333% when moving from the FLS platform to the cadaver F(1,13) = 44.04, P < .001. The increased completion times were accompanied by a 70% decrease in secondary task scores, F(1,13) = 21.21, P < .001. CONCLUSION The mental workload associated with intracorporeal suturing increases dramatically when trainees transfer from the FLS platform to human tissue under more realistic conditions of suturing. The increase in mental workload is indexed by both an increase in suturing times and a decrease in the ability to attend to the secondary task.

Ultrasound-Guided Breast Biopsy for Surgical Residents: Evaluation of a Phantom Model

BACKGROUND Ultrasound is increasingly used by surgeons for evaluation of breast lesions. While surgical residents have sufficient exposure to breast surgery, many lack exposure to office-based procedures, such as ultrasound-guided breast biopsy. A phantom model was created to teach surgical residents basic breast ultrasound and biopsy skills and to evaluate the residents response when incorporated into the curriculum. METHODS The model was created using a pork roast and 10 variably-sized pimento olives. Twenty-four surgical residents were given a brief introduction to breast ultrasound followed by up to 5 minutes to ultrasound the model and note the embedded lesions. The number and location of lesions found and the time spent per resident were recorded. Residents were then introduced to the vacuum-assisted core biopsy system and observed performing ultrasound-guided biopsies. Pre- and postsession evaluations were completed by all residents. Scatterplot regression models were used for data analysis. RESULTS Most residents had previous ultrasound instruction. The intermediate level residents (postgraduate year [PGY]2 and 3) found the most lesions in the shortest time, missing on average 1.125 lesions in 3:09 minutes. Time spent did not correlate with number missed or previous ultrasound experience. Over 50% of residents sampled the center of the lesion on their first biopsy attempt, with no correlation to PGY or ultrasound experience. All residents rated this experience good to excellent, and 67% believed their ultrasound skills were improved. Ninety-five percent of residents felt the model was fairly realistic and 95% would like to have more experiences like this in the curriculum. The residents surveyed thought the curriculum would be best suited to a PGY2 experience. CONCLUSIONS The phantom breast is a realistic and valuable teaching model for breast ultrasound. Further evaluation regarding skill retention is needed.

The impact of the 80-hour work week on appropriate resident case coverage.

BACKGROUND On July 1, 2003, the Accreditation Council for Graduate Medical Education (ACGME) required restriction of resident duty hours. Surgical programs were concerned about an expected decrease in operative experience. In our previous study, resident case coverage remained constant with the institution of the restricted duty hours. Several years later, we hypothesized that the level of resident coverage would be less appropriate. MATERIALS AND METHODS A retrospective study was performed of elective cases scheduled for an academic general surgery practice over three time periods: 1 y prior to institution of restricted duty hours; 1 y later; 3 y later. Data collected included procedure performed, number of attending surgeons and residents present, and resident level. Resident level was defined as appropriate if it matched or exceeded the complexity of the procedure. RESULTS From July 2002 to June 2003, 890 records of 1278 scheduled cases were available for review. From July 2004 to June 2005, 961 records of 1182 cases were available. From July 2006 to June 2007, 1029 of 1171 records were available. Case coverage was the same or better in the latest time period overall and for each resident level. An appropriate level resident was available for senior level cases similarly during all periods. During the last period, junior and intermediate level cases were more often covered by a resident at the appropriate level of training. CONCLUSIONS The restricted duty hours have not negatively affected resident case coverage. The level of resident available for operative cases has remained constant for senior level cases. Junior and intermediate level cases were more often covered by an appropriate level resident.

A Spatial Secondary Task for Measuring Laparoscopic Mental Workload Differences in Surgical Experience

The present study examined whether a spatial secondary task could distinguish among different levels of laparoscopic skill. Novices and surgeons with different levels of laparoscopic experience were asked to perform a peg transfer task on a laparoscopic simulator along with the secondary task. The results showed that novices performed more poorly than the surgeons on both the primary peg task and the secondary task. This pattern of results suggests that the primary task was more difficult for the novices leaving fewer attentional resources for the secondary task. Moreover, the results show that the spatial secondary task used in this study is sensitive to differences in mental resources required by individuals with different levels of laparoscopic surgical skill.

Resident handoff training: initial evaluation of a novel method.

Introduction:Residencies are required to have a standardized process for transitioning patient care. This study was designed to assess a novel method of training and evaluating handoffs using both a lecture format and standardized patient (SP) interactions. Methods:Matched group design was used to randomly assign interns to trained versus control groups, with the trained group receiving formal handoff training before SP encounters. The residents evaluated three ER SPs and read four written scenarios and then transitioned patients to an SP acting as a resident. All handoffs were videotaped and scored by two blind raters using a rating scale developed based on specialists interviews. Results:Thirty-two interns were included in the study. The trained interns performed significantly better with lower scores on patient handoffs (mean = 10.08, SD = 2.46) than the untrained interns (mean = 16.56, SD = 2.79). There was also a significant effect for case, with the ER SP cases (mean = 12.23, SD = 14.41) resulting in better performance than the written cases in both surgery and pediatrics (mean = 14.41, SD = 4.29). Conclusions:A protocol was designed and implemented for training residents to perform handoffs, with initial results showing that the curriculum is effective.