Residents as Leaders: Using a Delphi Process to Conduct an Institutional Preoperative Patient Optimization Quality Improvement Initiative.

BACKGROUND: Many residency programs struggle to meet the ACGME requirement for resident participation in quality improvement initiatives. STUDY DESIGN: As part of an institutional quality improvement effort, trainees from the Departments of Surgery and Anesthesiology at a single academic medical center were teamed with institutional content experts in 7 key risk factor areas within preoperative patient optimization. A systematic review of each subject matter area was performed using the MEDLINE database. Institutional recommendations for the screening and management of each risk factor were developed and approved using modified Delphi consensus methodology. Upon project completion, an electronic survey was administered to all individuals who participated in the process to assess the perceived value of participation. RESULTS: Fifty-one perioperative stakeholders participated in recommendation development: 26 trainees and 25 content experts. Residents led 6 out of 7 groups specific to a subject area within preoperative optimization. A total of 4,649 abstracts were identified, of which 456 full-text articles were selected for inclusion in recommendation development. Seventeen out of 26 (65.4%) trainees completed the survey. The vast majority of trainees reported increased understanding of their preoperative optimization subject area (15/17 [88.2%]) as well as the Delphi consensus method (14/17 [82.4%]) after participation in the project. Fourteen out of 17 (82.4%) trainees stated that they would participate in a similar quality improvement initiative again. CONCLUSIONS: We demonstrate a novel way to involve trainees in an institutional quality initiative that served to educate trainees in quality improvement, the systematic review process, Delphi methodology, and preoperative optimization. This study provides a framework that other residency programs can use to engage residents in institutional quality improvement efforts.

High rates of metal allergy amongst Nuss procedure patients dictate broader pre-operative testing.

PURPOSE: A previous study from our group estimated that as few as 2.2% of pectus excavatum patients suffered from allergy to the implanted metal bar. We sought to assess recent changes in incidence of metal allergy and identify the benefit of metal allergy testing prior to surgery. METHODS: A retrospective review was performed of all consenting patients undergoing pectus repair during the six years between 9/2004 and 12/2010 at our institution. Incidence was based on clinical symptoms and/or T.R.U.E.® patch testing. Demographic data, history of atopy and history of metal allergy were collected. Type and number of bars used, suture site infection, skin rash and wound infection rates were reviewed. RESULTS: Forty one of 639 patients (6.4%) had clinical or patch test evidence of metal allergy. Family history of metal allergy and pre-operative history of metal sensitivity were found to be statistically significant correlates. CONCLUSIONS: The rate of metal allergy in the pectus excavatum population may be higher than previously reported. Patient or family history of metal allergy or metal sensitization may indicate increased risk. Metal allergy testing should be performed before Nuss procedure.

Staged management of pectus carinatum.

AIM: The aim was to report the treatment of pectus carinatum with a novel Argentine brace and operation. METHODS: The bracing and clinical data of 137 consenting pectus carinatum patients treated between October 2008 and December 2011 were reviewed for outcome. Institutional approval was obtained. Data are reported as median (range). RESULTS: Median age 122 bracing patients was 14 (10-28)years with 67 (55%) progressing under active treatment. Five patients (4%) were lost to follow-up, and thirteen (11%) failed treatment. Thirty-seven patients (30%) exhibited flattening of the sternum after 6 (1-24)months without surgery. After flattening, patients then wore the brace for progressively fewer hours each day as a "retainer" for 5 (3-19)months. Five patients (4%) experienced recurrence 5 (3-7)months after brace treatment was discontinued. Complications were limited to transient skin breakdown in nine patients. Three of the 13 Argentine brace failures and 15 other pectus carinatum patients were treated surgically. Thirteen underwent Abramson's minimally invasive operation and five an open repair, all with good initial correction. For Abramson repairs, seven patients have had bars removed, with results rated as excellent (n=4), good (n=2), and failure (n=1, converted to open with excellent result later). In three patients with stiff chests, costal cartilage was resected thoracoscopically during the Abramson repair with measurably improving compliance. CONCLUSION: Staged treatment of pectus carinatum allows most teenagers to be managed non-operatively. For patients who fail bracing or are not amenable to bracing, minimally invasive surgical treatment for pectus carinatum is a viable option.