Walter E. Pofahl

Active Surveillance Screening of MRSA and Eradication of the Carrier State Decreases Surgical-Site Infections Caused by MRSA

BACKGROUND Surgical-site infections (SSI), because of MRSA, are a challenge for acute care hospitals. The current study examines the impact of best practices and active surveillance screening for MRSA on reduction of MRSA SSIs. STUDY DESIGN Beginning February 2007, all admissions to a 761-bed tertiary care hospital were screened for MRSA by nasal swab using polymerase chain reaction-based testing. Positive nasal carriers of MRSA were treated before operation. The subset of patients undergoing procedures that are part of the Surgical Infection Prevention Project were followed for MRSA SSIs. SSI rates (per 100 procedures) were determined using the National Nosocomial Infection Surveillance definitions. MRSA SSI rates were compared before and after the MRSA screening intervention. Differences were analyzed using Fishers exact test and chi-square with Yates continuity correction. Where specimens were available, genotyping of MRSA was performed using a commercially available assay. RESULTS After universal MRSA surveillance, 5,094 patients underwent Surgical Infection Prevention Project procedures. The rate of MRSA SSI decreased from 0.23% to 0.09%. The reduction was most pronounced in joint-replacement procedures (0.30% to 0%; p = 0.04). No other differences were statistically significant. Of the seven patients in whom MRSA SSI developed after universal screening, four had positive MRSA screens; none had received preoperative eradication of MRSA. In two of these patients, the genotype of MRSA detected on screening and in SSI was genetically indistinguishable. CONCLUSIONS Surveillance for MRSA and eradication of the carrier state reduces the rate of MRSA SSI.

A decision support tool for allocating hospital bed resources and determining required acuity of care

Limitations in health care funding require physicians and hospitals to find effective ways to utilize resources. Neural networks provide a method for predicting resource utilization of costly resources used for prolonged periods of time. Injury severity knowledge is used to determine the acuity of care required for each patient and length of stay is used to determine duration of inpatient hospitalization. Neural networks perform well on these medical domain problems, predicting total length of stay within 3 days for pediatric trauma (population mean and S.D. 4.37 ± 45.12) and within 4 days for acute pancreatitis patients (7.75 ± 79.19).

The Certifying Examination of the American Board of Surgery: The Effect of Improving Communication and Professional Competency: Twenty-Year Results

PURPOSE In 1985, a small research group identified variables affecting applicant success on the oral Certifying Examination (CE) of the American Board of Surgery (ABS). This led to the design of an oral examination course first taught in 1991. The success of and need for this program led to its continuation. The results from the first 10 years were presented at the 2001 Association of Program Directors in Surgery annual meeting.(1) We now report the outcomes for the course of the second 10 years as measured by success on the CE. METHODS Thirty-six courses were held over 20 years. There were 57 invited faculty from 27 general surgery programs throughout the United States and Canada. The participant-to-faculty ratio ranged from 16:7 to 5:1 in the newer 3-day format (2007). Courses were offered at sites that replicated the actual examination setting. Each course included (1) pretest and posttest examinations, (2) analysis of case presentation skills, (3) measurement of communication apprehension, (4) 1:1 faculty feedback, (5) small-group practice sessions, (6) individual videotaping, (7) didactic review of specific behaviors on examinations, (8) a debrief session with two faculty members, and (9) a written evaluative summary that included an improvement strategy. RESULTS There were 36 courses with 326 participants (30-54 years). Follow-up data are available for 225 participants. Trends were analyzed between 1991-2001 and 2002-2011. As resident performance on the CE increased in importance, applicant profiles changed from those who had previously failed (1991-2001) to residents identified by program directors as needing assistance (52%). Since 2002, most course participants (69%) who had failed the CE had completed at least 1 other review course. Participants reported more significant stressors (2002-2011) 9%, but communication apprehension remained the same. As a result, individual counseling for anger and family stressors was integrated into the course. The perception of knowledge deficits was associated with those who enrolled in fellowship training and delayed their examination. The recent groups exhibited more professionalism and articulation issues related to performance. Five surgeons (2002-2011) were asked not to return to the course because of severe knowledge deficiencies or ethical/behavioral issues based on faculty evaluations. Although complete follow-up of all participants was not possible (only 225/326), the success rate among those providing follow-up was 97% for those who followed their remediation plan, giving 218/326, a worse-case pass rate of 67%. CONCLUSION Communication and professionalism deficits are still common in those struggling with the CE, Early identification of those at risk of failing by program directors who are documenting the competencies may promote earlier interventions and thus lead to success. This program continues to be effective at identifying behaviors that interfere with success on the CE of the ABS.

Performance standards improve American Board of Surgery In-Training Examination scores

PURPOSE Although several studies have evaluated factors affecting American Board of Surgery In-Training Examination (ABSITE) performance, none has examined the impact of setting a minimally acceptable standard. It was hypothesized that establishing such a criterion would improve ABSITE scores. METHODS An expectation for residents to score at the 35th percentile or higher was established in 1996. The proportion of test scores above or below the 35th and 50th percentiles for the time periods before and after institution of the standard were compared using Fishers exact test. The subsequent performance of residents scoring below the 35th percentile was analyzed for the 2 time periods. RESULTS After the institution of the standard, the proportion of scores below the 35th percentile decreased from 46.7% to 21.9% (p = 0.0005). Similarly, the proportion of scores at or above the national average increased from 42.1% to 65.6% (p = 0.0005). After establishing the standard, fewer residents continued to have scores below the criterion in subsequent years. CONCLUSIONS Establishing a performance criterion improved ABSITE scores. The decision to institute a standard must be individualized for each program. The rationale for the standard and a plan to assist residents failing to achieve the benchmark must be communicated.

Hepatic abscess: Current concepts in diagnosis and treatment

Liver abscess remains a disease with significant morbidity and mortality. Even with treatment, the average reported mortality rate for pyogenic abscesses is approximately 30% and ranges from 11% to 88% in different series. Without treatment, the disease is uniformly fatal. Traditionally, patients with liver abscesses have been treated with open surgical drainage and antibiotic therapy. This treatment was supported by the initial report by Ochsner and DeBakey on 185 cases of liver abscess. Their report from 1938 includes 139 cases of amoebic abscess and 47 cases of pyogenic abscess, in which all nonsurgical treatment resulted in mortality. At that time, before the availability of antibiotics and percutaneous drainage techniques, surgical management was the only therapy. Since Ochsner and DeBakey’s original report of liver abscess, changes in patient demographics and treatment have occurred. The patient population has changed from the fourth decade to the fifth decade. The most common source is no longer the intestinal tract as in Ochsner and DeBakey’s day, but it is now biliary disease. Over the past 60 years, a change to less invasive techniques has occurred. Currently, ultrasound or computed tomography (CT)-guided percutaneous drainage is the primary therapy in patients with pyogenic liver abscess. Laparotomy is reserved for patients with other indications for surgery or failure of less invasive approaches.

Current Laparoscopic Inguinal Hernia Repair

The inguinal hernia repair developed through advances in anatomy and technique, as did many other surgical procedures. Operations with high mortality and recurrence were the standard until the Bassini repair was popularized in 1889. The Bassini repair, a tissue repair that approximates the inguinal floor, served as the gold standard for herniorrhaphy until modified to the Shouldice repair. Both of these repairs are primary tissue repairs that may result in tension. The development of prosthetics, such as Marlex 50 and improved polypropylene, and the anatomic understanding of the weakness associated with the myopectineal orifice of Fruchaud allowed for the development of a tension-free repair of inguinal hernia defects. The most commonly used is the Lichtenstein repair that involves the use of polypropylene to rebuild the inguinal floor after high ligation of the hernia sac with indirect hernias and replacement into the abdominal cavity with direct hernias. The Lichtenstein repair is a simple operation that can be done with local anesthetic as an outpatient procedure. In fact, it was developed for the office setting. It has a recurrence rate of 1% or less, and it is not associated with the postoperative pain of a primary tissue repair and return to full activity is very rapid, often quoted at less than 5 days. It is difficult for some to imagine how a better repair could be done in the aftermath of the success of the Lichtenstein repair. However, laparoscopic techniques have brought a whole new dimension to many aspects of surgery.

Achalasia: a brief review of treatment options and efficacy

Achalasia is the most commonly encountered and best known of the primary esophageal motility disorders. Despite over half a century of research, the etiology of achalasia remains unknown. Since the first successful mechanical dilation in 1674 using a sponge tip on a whalebone, treatment continues to focus on relief of symptoms. This paper will briefly review the diagnosis of achalasia and the evolution of treatment for achalasia prior to the advent of minimally invasive surgery.

Is It Possible to Stay Up-to-Date After the Residency?

Is it possible to stay up to date after residency? Think about the question before you read on. Are you up-to-date? Are your colleagues? Is your competitor? How about the surgeon who took care of your relative? In my experience, most surgeons stay up-to-date and do so remarkably well. Think about it. In your community, are you aware of surgeons who are incompetent because they have not kept up? Please do not count those who have lost their way because of substance abuse, alcoholism, and boundary violations with patients, ethical malfeasance, medial illnesses, dementia, or other disorders. Their problems are different; their failure to keep up-to-date is secondary. Count only those who are incompetent because they are not well informed, who are not aware of the important surgical advances, and who do not provide care in accord with accepted standards. My prediction is that you will find only a few.