Burnout reduction in acute care surgeons: Impact of faculty schedule change at a level 1 trauma and tertiary care center.

BACKGROUND: Acute care surgeons are prone to burnout because of heavy workload, concurrent clinical responsibilities, and busy in-house call. Modifiable burnout factors have been identified, but few studies have looked for longitudinal effects after change is implemented. We hypothesized that optimizing faculty workflow could decrease burnout without compromising productivity. METHODS: We streamlined the faculty schedule at our institution to eliminate 24-hour call by creating weekly blocks of 12-hour day and night call, free from other clinical obligations. Protected academic time was added. The Maslach Burnout Inventory and Areas of Worklife Survey for health care providers were given to faculty, as well as close friends or family, at baseline, 6 months, and 12 months. Maslach Burnout Inventory and Areas of Worklife Survey proprietary formulas were used to assess change in factors contributing to burnout. Our primary outcome measure was the presence of factors contributing to burnout. Chart delinquency, relative value units, and academic projects were secondary outcome measures assessing clinical productivity change. RESULTS: Survey completion rates were 92% for faculty and 80% for family. All burnout risk factors improved at 6 and 12 months. In surgeon and family groups, the following improvements were noted in the mean scores of risk factors at 1 year: workload (74%, 68%), control (38%, 16%), reward (14%, 24%), fairness (69%, 22%), emotional exhaustion (27.5%, 24%), depersonalization (37.5%, 14%), personal accomplishment (12.5%, 2%), community (3%, 5%), values (10%, 15%), and over-all burnout (12.5%, 23.3%). There was a reduction in charts reaching delinquent status. Relative value unit production did not decrease. CONCLUSION: This study demonstrates that implementing a weekly, 12-hour call schedule can improve factors leading to burnout. Improvements were noted in surgeon and family groups alike, signifying both subjective improvements and observed change in the surgeons' behavior, without compromising clinical productivity. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Effective use of weight-based enoxaparin for deep vein thrombosis chemoprophylaxis in patients with traumatic brain injury.

BACKGROUND: Enoxaparin is the recommended agent for deep vein thrombosis (DVT) chemoprophylaxis in trauma patients. Current literature suggests weight-based dosing is superior to standard dosing for adequate chemoprophylaxis. Literature regarding the use of weight-based enoxaparin in the setting of traumatic brain injury (TBI) however is limited. METHODS: A retrospective analysis of adult trauma patients admitted between January 1, 2018 to February 28, 2019 was performed. Sixty-six patients with TBI receiving weight-based enoxaparin met inclusion criteria. Incidence of intracranial hemorrhage (ICH) expansion was the primary endpoint. Newly diagnosed venous thromboembolism (VTE) and death were secondary endpoints. RESULTS: Two patients, out of sixty-six, had progression of their TBI requiring surgical intervention. Newly diagnosed VTE occurred in one patient. No deaths were due to ICH expansion or VTE. CONCLUSIONS: Use of weight-based enoxaparin dosing in the setting of TBI shows promise without an increased incidence of ICH expansion when compared to other studies. Level of Evidence and Study Type: Level IV, Therapeutic.

Impact of the Affordable Care Act on trauma and emergency general surgery: An Eastern Association for the Surgery of Trauma systematic review and meta-analysis.

BACKGROUND: Trauma and emergency general surgery (EGS) patients who are uninsured have worse outcomes as compared with insured patients. Partially modeled after the 2006 Massachusetts Healthcare Reform (MHR), the Patient Protection and Affordable Care Act was passed in 2010 with the goal of expanding health insurance coverage, primarily through state-based Medicaid expansion (ME). We evaluated the impact of ME and MHR on outcomes for trauma patients, EGS patients, and trauma systems. METHODS: This study was approved by the Eastern Association for the Surgery of Trauma Guidelines Committee. Using Grading of Recommendations Assessment, Development and Evaluation methodology, we defined three populations of interest (trauma patients, EGS patients, and trauma systems) and identified the critical outcomes (mortality, access to care, change in insurance status, reimbursement, funding). We performed a systematic review of the literature. Random effect meta-analyses and meta-regression analyses were calculated for outcomes with sufficient data. RESULTS: From 4,593 citations, we found 18 studies addressing all seven predefined outcomes of interest for trauma patients, three studies addressing six of seven outcomes for EGS patients, and three studies addressing three of eight outcomes for trauma systems. On meta-analysis, trauma patients were less likely to be uninsured after ME or MHR (odds ratio, 0.49; 95% confidence interval, 0.37-0.66). These coverage expansion policies were not associated with a change in the odds of inpatient mortality for trauma (odds ratio, 0.96; 95% confidence interval, 0.88-1.05). Emergency general surgery patients also experienced a significant insurance coverage gains and no change in inpatient mortality. Insurance expansion was often associated with increased access to postacute care at discharge. The evidence for trauma systems was heterogeneous. CONCLUSION: Given the evidence quality, we conditionally recommend ME/MHR to improve insurance coverage and access to postacute care for trauma and EGS patients. We have no specific recommendation with respect to the impact of ME/MHR on trauma systems. Additional research into these questions is needed. LEVEL OF EVIDENCE: Review, Economic/Decision, level III.

Racial disparities in the use of laparoscopic surgery to treat colonic diverticulitis Are not fully explained by socioeconomics or disease complexity.

BACKGROUND: Several studies have demonstrated favorable outcomes for laparoscopic surgery over open surgery for the treatment of diverticular disease. This study was designed to analyze the relationship between race, socioeconomic status and the use of laparoscopy to address diverticulitis. METHODS: A retrospective analysis of 53,054 diverticulitis admissions was performed using data from the 2009-2013 National Inpatient Sample (NIS). The primary outcome was the use of laparoscopic versus open colectomy. Bivariate analysis and multivariable logistic regression were used to determine the raw and adjusted odds by race, insurance status, and median household income. RESULTS: Overall, 41.6% of colectomies involved the use of laparoscopy. Black patients were 19% less likely than White patients to undergo laparoscopic surgery. Hispanic patients were no more or less likely to undergo laparoscopic colectomy. Lacking private insurance was a strong predictor of undergoing open surgery. Lower income patients were 33% less likely to receive minimally invasive colectomies. CONCLUSIONS: These results demonstrate disparities in surgical treatment. Further research is warranted to understand and ameliorate treatment differences which can contribute to outcome disparities.

Does temporary chest wall closure with or without chest packing improve survival for trauma patients in shock after emergent thoracotomy?

BACKGROUND: Many surgeons avoid the damage-control techniques of intrathoracic packing and temporary chest wall closure after thoracotomy for trauma because of concerns about packing's effects on intrathoracic pressure and infectious risks. We hypothesized that temporary chest closure with or without intrathoracic packing (TCC-P) as a method of thoracic damage control would yield higher than expected survival rates for trauma thoracotomy patients with metabolic exhaustion, whereas traditional definitive chest closure (DEF) would exhibit predicted survival rates. METHODS: This was a retrospective cohort study by two urban Level I trauma centers on patients who (1) underwent emergent thoracotomy for trauma, (2) received ≥10 units (U) packed red blood cells and/or sustained a cardiac arrest before starting chest closure, and (3) survived to intensive care unit arrival. Demographic/physiologic data, chest closure method, and thoracic complications were gathered. Trauma injury severity scores (TRISS) were used to calculate survival probability for TCC-P and DEF. Nonparametric statistics were used for all comparisons. All values are expressed as medians and interquartile ranges (IQR). RESULTS: Sixty-one patients met inclusion criteria. Both TCC-P (n = 17) and DEF (n = 44) were severely injured (ISS=35 [IQR, 25-42] vs. 29 [IQR 19-45] and packed red blood cells = 16.5 U [IQR, 12.3-25.5 U] vs. 15 U [IQR, 11-23 U], respectively; p=ns). Patient demographics were similar except for the findings that the TCC-P cohort had higher rates of cardiac arrest before starting chest closure (TCC-P 82% vs. DEF 48%, p=0.04), significantly more severe abdominal injuries, and less severe head injuries than the DEF group. No significant differences were observed in survival of the overall samples (TCC-P=47% vs. DEF=57%), nor for observed:expected (O:E) survival ratio in 13 patients with TCC-P and 30 with DEF meeting criteria for TRISS calculation (TCC-P O:E, 46%:39%; DEF O:E, 53%:57%). No significant differences were found for TCC-P and DEF thoracic infectious (24% vs. 25%) or hemorrhagic (18% vs. 14%) complications. Surprisingly, peak inspiratory pressures on intensive care unit arrival were markedly better after TCC-P (20 cm H2O [IQR, 18-31 cm H2O]) than after DEF (32.5 cm H2O [IQR, 28-37.5 cm H2O], p=0.003). CONCLUSION: Concerns about TCC-P are not borne out as thoracic infection rates are unaffected and peak pressures are actually lower, possibly due to greater pleural volume from an open chest wall and skin-only closure. However, no significant survival benefit was seen with TCC-P.

Long-term follow-up of trauma patients with permanent prophylactic vena cava filters.

BACKGROUND: Although permanent prophylactic Greenfield filters (PPGF) are effective, their use in young trauma patients who may eventually return to active lifestyles is controversial due to concerns about the safety of the devices over a lifetime. This descriptive study was undertaken to provide follow-up on the long-term safety and durability of PPGF. METHODS: All patients receiving a PPGF between April 1, 1992 and March 1, 2001 were sought for follow-up. Contacted patients were interviewed regarding known filter-related complications, venous thromboembolic events, and activity levels since the time of discharge from the hospital. Patients were also offered a physical examination focusing on venous thromboembolic sequelae, a plain film of the abdomen (KUB) to assess filter integrity and location, and an ultrasound to assess caval patency. As the original level of filter placement was usually not known, migration was defined as a filter above the first lumbar vertebra (L1). RESULTS: The eligible cohort consisted of 188 patients. Ninety were unable to be located (47.8%), one refused enrollment (0.5%), and 97 patients or next of kin agreed to be interviewed by phone (51.6%) of whom 69 returned for evaluation (36.7%). No filter-related complications were self-reported. KUBs were performed in 68 patients; one filter strut fracture was found (1.5%), whereas no filter migrations above L1 were noted. No instances of caval thrombosis were found in 55 ultrasounds. Two patients suffered interim pulmonary emboli (2.1%), one of which was fatal. Of 15 interim deaths, autopsy or death certificates were available for four patients, nine had their causes of death related by next of kin, and two were unknown. Although 95.4% of nonspinal cord injury patients reported at least some ability to ambulate, only 64.6% could do so ad libitum. Of those patients ambulating without limitation, 28.6% reported a complete inability to run any distance and another 23.8% could run less than one block. Follow-up for patients completing interviews was 105.3 months +/- 18.0 months, and for patients undergoing imaging was 104.6 months +/- 16.4 months. Interim deaths occurred at 48.2 months +/- 26.0 months. CONCLUSIONS: PPGF seem to be safe and effective at 105 months of follow-up; most patients report significant limitations in activity level at this same timeframe. PPGF should be the filter of choice for elderly patients in whom this time period can reasonably be expected to cover the patient's remaining life expectancy.

Incidence of surgical site infections postcolorectal resections without preoperative mechanical or antibiotic bowel preparation.

This study was performed to determine the incidence of surgical site infections (SSIs) after colorectal resection in patients without mechanical or antibiotic bowel preparation. A retrospective review of the medical records of 136 consecutive patients undergoing an elective colorectal resection between April 2004 and April 2006 was performed. Indications for colon resection in this series were malignant neoplasia (48%), inflammatory bowel disease (18%), diverticular disease (17%), or other benign disease (17%). Overall, an SSI occurred in 31 patients (23%). An SSI occurred in 16 of 90 patients (17.8%) who received antibiotics within 1 hour before surgery and in 15 of 46 patients (33.3%) who did not receive antibiotics in a timely manner (P < 0.05). An SSI occurred in seven of 15 patients (46.7%) who received bowel preparation but in only 24 of 121 patients (19.8%) who did not receive either mechanical or antibiotic bowel preparation (P < 0.029). SSIs were not associated with age, gender, diagnosis, length of procedure, preoperative steroid use, diabetes mellitus, or previous celiotomy. This series shows administration of perioperative antibiotics within 1 hour before surgery is associated with a significant decrease in the incidence of SSI and bowel preparation can be safely omitted.