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Surgical debriefs help reduce preventable errors in the operating room (OR) leading to patient injury. However, compliance with debriefs remains poor. The objective of this study was to evaluate the role of structured feedback to surgeons in improving compliance with and quality of surgical debriefs.Surgical cases at an 875-bed urban teaching hospital from January-June 2019 were audited via audio/video recording to evaluate debrief performance. Debriefs were evaluated for clinical completeness and teamwork quality via two structured forms. Surgeons received an evaluation of their debrief performance at two time points during the study period (February and April). Univariate and mixed-effects regression analyses were used to assess changes in debrief compliance and quality over time.A total of 878 surgical cases performed by 61 surgeons were reviewed: 198 (22.6%) cases during Period 1 (P1), 371 (42.3%) P2, and 309 (35.1%) P3. The rate at which a debrief occurred was 62.1% in P1, 73.0% in P2, and 82.2% in P3 (P 0.001). Debriefs were 1.96 (95% CI 1.31-2.95, P = 0.001) times more likely to be completed during P2 and 3.21 (95% CI 2.07-5.04, P 0.001) times more likely during P3 compared to P1. The percent of debriefs initiated by the lead surgeon increased from 59.8% in P1, to 80.0% in P2, to 81.5% in P3 (P 0.001).Providing structured feedback to surgeons on their debrief performance was associated with improvements in compliance and completeness with debriefing protocols, OR teamwork and communication, and leadership and accountability from the lead surgeons.

Background The prevalence of burnout and depression are high among surgical trainees. This study examined the impact of program-driven initiatives to improve surgical trainee wellness. Methods A survey was administered to residents and fellows at all surgical training programs across an urban academic health system. The survey measured burnout, depressive symptoms, and perceptions of program-driven wellness initiatives. Results The response rate was 44% among 369 residents. Of these, 63.2% screened positively for burnout, and 36.7% for depression. Residents who were burned out were more likely to work >80 h per week, have greater clerical duties, and miss educational activities more frequently. Conversely, having opportunities for wellness activities, dedicated faculty and housestaff wellness champions, and assistance with clerical burden were all associated with lower rates of burnout and depression. Conclusion The presence of wellness support was associated with better outcomes, suggesting the value of initiatives to manage workload and support the well-being of surgical resident physicians.

BACKGROUND The association between psychiatric illness and outcomes in trauma patients in general has only recently been investigated. The aim of this study was to describe the unique characteristics, risk factors, and outcomes of patients with comorbid psychiatric illness and penetrating abdominal and pelvic injuries. MATERIALS AND METHODS This was a retrospective review of trauma patients with open injuries to the abdomen and pelvis identified in the 2010-2015 the American College of Surgeons Trauma Quality Improvement Program database. Baseline variables extracted included demographics, comorbidities, including a discrete "psychiatric illness" variable that preexisted in the database, and injury information. Outcome variables collected included in-hospital mortality, length of stay and intensive care unit stay, and complications. Categorical variables were analyzed using chi-square and Fisher's exact test. Logistic regression was used to assess independent predictors for mortality with odds ratios (ORs) and 95% confidence intervals (CIs) constructed about group differences. RESULTS There were 22,053 patients identified, 6.1% of whom were diagnosed with a psychiatric comorbidity. Patients with psychiatric illnesses were more likely to be aged ≥65 y (5.4% versus 3.2%, P

This study assessed the association between race/ethnicity and amputation with mortality and loss of independence (LOI) for diabetic gangrene.We analyzed the American College of Surgeons National Surgery Quality Improvement Program database from 2016 to 2019. Chi-squared tests were performed to evaluate differences in baseline characteristics and complications. Multivariable logistic regression was performed to model LOI and 30-day mortality.5250 patients with diabetes underwent lower extremity amputation as treatment for gangrene. Hispanic patients were more likely to undergo below the knee amputation (BKA) (P = 0.006). Guillotine amputation (GA) was associated with age 65 (P 0.0001), independent functional status prior to admission (P 0.0001), and mortality (OR 1.989, 95%CI 1.29-3.065), but was not associated with LOI. Mortality was less frequent in Black patients (OR 0.432, 95%CI 0.207-0.902), but loss of independence (LOI) was more frequent in Black patients (OR 1.373, 95%CI 1.017-1.853). Hispanic patients were less likely to experience LOI (OR 0.575, 95%CI 0.477-0.693).LOI and mortality provide contrasting perspectives on outcomes following lower extremity amputation. Further assessment of risk factors may illuminate healthcare disparities.

Background Endovascular approaches to aortoiliac disease are becoming increasingly frequent due to decreases in recovery time, bleeding, and discomfort. Despite this trend, little is known about the predictors of complications. This study was designed to identify risk factors for major 30-day morbidity and mortality after endovascular repair. Methods Data were derived from the 2015–2016 Participant User Files and Procedure Targeted databases of the American College of Surgeons National Surgical Quality Improvement Program. Demographics and comorbidities of patients undergoing repair were assessed. Preoperative risk factors were analyzed using univariate and multivariate analysis. Results Twelve hundred and nine patients underwent endovascular aortoiliac repair, including 532 females (44.0%) and 677 males (56.0%). The 30-day mortality rate was 0.7%. Diabetes mellitus requiring medication, chronic steroid use, dialysis, pre-existing open wound, age, and low serum albumin and hematocrit increased mortality. After logistic regression, 30-day mortality was correlated with low serum albumin (survivors = 3.77, nonsurvivors = 2.60; P = .003) and chronic steroid use (P = .020). Multivariate analysis identified high preoperative white blood cell count as a risk factor for amputation. Diabetes, smoking history, and low serum sodium were risk factors for return to the operating room. Female sex and steroid use were risk factors for myocardial infarction and stroke. Open wounds and high platelets were risk factors for the need for an operative bypass after endovascular intervention. Preprocedural statin use was protective against need for a later operative bypass and reintervention. Conclusions Open wound, smoking, preprocedural steroid use, diabetes, female sex, high platelet and white blood cell count, and low serum albumin are the most strongly associated risk factors for adverse 30-day postoperative outcomes. Mortality rates remain low after endovascular aortoiliac revascularization.

Background Morbid obesity can complicate perioperative management. Best practice guidelines have been published but are typically followed only in bariatric patients. Little is known regarding physician awareness of and compliance with these clinical recommendations for nonbariatric operations. Our study evaluated if an educational intervention could improve physician recognition of and compliance with established best practices for all morbidly obese operatively treated patients. Methods A care map outlining best practices for morbidly obese patients was distributed to all surgeons and anesthesiologists at 4 teaching hospitals in 2013. Pre- and postintervention surveys were sent to participants in 2012 and in 2015 to evaluate changes in clinical practice. A chart audit performed postintervention determined physician compliance with distributed guidelines. Results In the study, 567 physicians completed the survey in 2012 and 375 physicians completed the survey in 2015. Postintervention, statistically significant improvements were seen in the percentage of surgeons and anesthesiologists combined who reported changing their management of morbidly obese, operatively treated patients to comply with best practices preoperatively (89% vs 59%), intraoperatively (71% vs 54%), postoperatively (80% vs 57%), and overall (88% vs 72%). Results were similar when surgeons and anesthesiologists were analyzed separately. A chart audit of 170 cases from the 4 hospitals found that 167 (98%) cases were compliant with best practices. Conclusion After care map distribution, the percentage of physicians who reported changing their management to match best practices significantly improved. These findings highlight the beneficial impact this educational intervention can have on physician behavior. Continued investigation is needed to evaluate the influence of this intervention on clinical outcomes.

Background Using finger-stick capillary blood to assess lactate from the microcirculation may have utility in treating critically ill patients. Our goals were to determine how finger-stick capillary lactate correlates with arterial lactate levels in patients from the surgical intensive care unit, and to compare how capillary and arterial lactate trend over time in patients undergoing resuscitation for shock. Methods Capillary whole blood specimens were obtained from finger-sticks using a lancet, and assessed for lactate via a handheld point-of-care device as part of an “investigational use only” study. Comparison was made to arterial blood specimens that were assessed for lactate by standard laboratory reference methods. Results 40 patients (mean age 68, mean APACHEII 18, vasopressor use 62%) were included. The correlation between capillary and arterial lactate levels was 0.94 (p, Highlights • Finger-stick capillary lactate correlates with blood gas and core lab values. • Capillary lactate trends closely over time with arterial lactate. • Rising or falling capillary lactate reflects the adequacy of global perfusion. • Capillary lactate measurements require a fraction of the time and blood to process. • Preliminary results imply capillary lactate may be used in lieu of invasive methods.

Background Temporal artery biopsy is performed in patients suspected of having giant cell arteritis. This study was conducted to evaluate clinical and laboratory criteria correlating with positive biopsy results in an effort to limit the number of negative biopsies performed. Methods A retrospective review was performed of patients who underwent temporal artery biopsy at two urban medical centers from 2002 to 2009. A multivariate analysis of patient demographics, clinically relevant signs and symptoms, laboratory data, and pathologic outcomes was performed. Results Temporal artery biopsy histologically confirmed giant cell arteritis in 24% of cases. The mean age of those with disease was 77.8 y and those without were 73.1 y; age was found to be statically significant (P = 0.0227); 76% were female and 24% were male; gender was not significant (P = 0.9594); 42% were Caucasian (39% had a positive temporal artery biopsy), 27% were Hispanic (17% positive), and 31% of the patients were African-American (3% positive); ethnicity was significant (P = 0.0005). The PPV of elevated ESR was 27%; sensitivity was 100%; specificity was 16%. A history of headache or visual disturbance was not predictive of a positive biopsy Conclusion Fewer negative biopsy results may be achieved by screening patients with normal ESR or lower risk patients with other modalities.

DOI of original article: 10.1016/j.jss.2012.1 * Corresponding author. Department of Surg Suite 2M, New York, NY 10003. Tel.: þ1 212 E-mail address: mleitman725@me.com (I 0022-4804/$ e see front matter a 2013 Elsev http://dx.doi.org/10.1016/j.jss.2013.01.010 Surgeons have been extracting metallic foreign bodies (MFB) for centuries. Perhaps the earliest literary account comes from Homer’s epic poem The Iliad (ca BC 800), based on events of the Trojan War from Greek mythology. Makaon operated on an arrow wound to the abdomen of King Menelaus by extracting the arrow, sucking blood from the wound to remove poison, and applying a salve [1]

DOI of original article: 10.1016/j.jss.2012.0 * Corresponding author. Department of Surge 2M, New York, NY 10003. Tel.: 212 844 8570; E-mail address: mleitman@chpnet.org (I. 0022-4804/$ e see front matter a 2013 Elsev doi:10.1016/j.jss.2012.02.031 From the discovery of circulation by Dr. William Harvey in 1628, to the first successful human-to-human blood transfusion by Dr. James Blundell in 1818, to the creation of the American Red Cross in 1941, our understanding of blood transfusion has evolved. The so-called hazards of transfusions have been documented since World War II and include infectious complications, hemolytic-related reactions, and, in more recent times, transfusion-related lung injuries and transfusion-induced immunomodulation [1,2]. This immunologic consequence of blood transfusions is not a novel concept. During the 1970s, the immunosuppressive effects of blood transfusion were first recognized when Opelz and Teraski [3] reported improvement in kidney transplant graft survival with an increased number of blood transfusions. This landmark study was the first to highlight the pro-inflammatory and immunosuppressive effects of transfused blood. Despite these

Central line infections resulting in bacteremia are associated with a substantial increase in hospital costs, morbidity, and mortality. Approximately 3%–7% of the 3 million central venous catheters inserted annually in the United States result in the 150,000 to 250,000 nosocomial bacteremias that occur every year, associated with the presence of an intravascular catheter. Mortality rates of 10%–20% are reported, and hospital stay is prolonged by an average of 7 days. Strategies to reduce infections have been recently recommended by the Centers for Disease Control and Prevention. These guidelines include maximal sterile barrier precautions and avoidance of catheter exchanges over a guidewire. Additional ways to reduce central line infections include routinely inspecting the insertion site, minimizing the duration of catheterization, and using the subclavian vein insertion site. Because it is postulated that the majority of infections occur because of microorganisms that adhere to the surface of the skin, novel strategies have been developed. These include applying cutaneous antiseptic or antimicrobial agents at the insertion site, attaching a subcutaneous silver-impregnated cuff, or impregnating the catheter itself with antiseptics or antibiotics. The scientific basis for preparing catheters coated with these agents may be their ability to prevent the development of biofilm formation and the subsequent adherence of bacteria. Certain patients may be at higher risk of catheter-related bacteremia and may justify the increased costs of using impregnated central line devices. These include patients who have their central line placed in the intensive care unit, patients immunocompromised because of malignancy, corticosteroids, or immunosuppression, patients with pulmonary artery catheters, and patients requiring long-term catheter use for parenteral nutrition. Given the wide application of central venous catheter use throughout the world, it is important that studies evaluating these new devices demonstrate reduction in catheter-related blood-stream infections and that proper cost-benefit analysis indicates true financial savings. It is also important that patients be able to tolerate the antimicrobial substances impregnated on these catheters and that the substances do not contribute to the ever-increasing problem of bacterial resistance in intensive care units. The reviewed studies appear to show that catheters impregnated with chlorhexidine and silver sulfadiazine or minocycline and rifampin reduce the rate of catheter colonization and probably bloodstream infections in well-designed, controlled conditions. This was achieved with excellent patient safety, as it appears that the agents used were barely detectable in the systemic blood and catheters were well tolerated. The minocycline and rifampin-impregnated catheter may provide better protection from catheter colonization and systemic bacteremia. Antimicrobial resistance thus far does not appear to be a problem, but continued surveillance is necessary. Will these devices benefit all patients requiring central venous access, or should they be used only for patients determined to be at "high risk?" These questions so far have not been clearly answered and, therefore, clinical judgment is required to identify the patient at high risk. Additional cost-benefit analysis using patient-specific hospital costs is necessary. It appears that antiseptic-impregnated central venous catheters may help to reduce the incidence of costly nosocomial bloodstream infections by decreasing the rate of catheter colonization. However, they should not replace careful consideration of the indications for insertion and removal, diligent inspection and dressing of the insertion site, strict sterile barrier precautions during insertion, proper line maintenance, and use of protocols to determine how often and through which technique central venous catheters are replaced.

DOI of original article: 10.1016/j.jss.2012.0 * Corresponding author. Department of Sur Tel.: þ1 212 844 8570; fax: þ1 212 844 8440. E-mail address: mleitman@chpnet.org (I. 0022-4804/$ e see front matter a 2013 Elsev http://dx.doi.org/10.1016/j.jss.2012.08.056 End-stage renal disease affects over 500,000 patients each year in the United States. Currently, over 92,000 people wait on the kidney transplant list in the United States alone, where approximately 16,000 transplants occur annually [1]. With such a discrepancy between supply and demand, graft survival is critical. Yet, even with advances in transplantation technique and immunosuppression, year one acute rejection rates remain between 10% and 20% [2]. Acute rejection begins subclinically and progression may lead to irreversible organ damage or graft loss. Research has been focused on finding early markers of rejection. Traditionally, renal allografts have been monitored using urinalysis, serum creatinine levels, and renal biopsies. Urinalysis provides a basic substrate to monitor renal function and graft rejection. Proteinuria has long correlated with chronic kidney disease and is also positively associated with rejection. However, proteinuria is indicative of an inflammatory process that has already advanced to irreversible kidney injury. Evidence has emerged that shows a relationship between microproteinuria and rejection, which may prove beneficial in