Standardizing quality utilization of interventional radiology treatments of blunt splenic injury: SQUIRTS study.

OBJECTIVES: Nonoperative management (NOM) of blunt splenic injury (BSI) is well accepted in appropriate patients. Splenic artery embolization (SAE) in higher-grade injuries likely plays an important role in increasing the success of NOM. We previously implemented a protocol requiring referral of all BSI grades III-V undergoing NOM for SAE. It is unknown the risk of complications as well as longitudinal outcomes. We aimed to examine the splenic salvage rate and safety profile of the protocol. We hypothesized the splenic salvage rate would be high and complications would be low. METHODS: A retrospective study was performed at our Level 1 trauma center over a 9-year period. Injury characteristics and outcomes in patients sustaining BSI grades III-V were collected. Outcomes were compared for NOM on protocol (SAE) and off protocol (no angiography or angiography but no embolization). Complications for angiographies were examined. RESULTS: Between January 2010 and February 2019, 570 patients had grade III-V BSI. NOM was attempted in 359 (63 %) with overall salvage rate of 91 % (328). Of these, 305 were on protocol while 54 were off protocol (41 no angiography and 13 angiography but no SAE). During the study period, for every grade of injury a pattern was seen of a higher salvage rate in the on-protocol group when compared to the off-protocol group (Grade III, 97 %(181/187) vs. 89 %(32/36), Grade IV, 91 %(98/108) vs. 69 %(9/13) and Grade V, 80 %(8/10 vs. 0 %(0/5). The overall salvage rate was 94 %(287) on protocol vs. 76 %(41) off protocol (p < 0.001, Cochran-Mantel-Haenszel test). Complications occurred in only 8 of the 318 who underwent angiography (2 %). These included 5 access complications and 3 abscesses. CONCLUSION: The use of a protocol requiring routine splenic artery embolization for all high-grade spleen injuries slated for non-operative management is safe with a very low complication rate. NOM with splenic angioembolization failure rate is improved as compared to non-SAE patients' at all higher grades of injury. Thus, SAE for all hemodynamically stable patients of all high-grade types should be considered as a primary form of therapy for such injuries.

Bone Anchor Fixation in the Repair of Blunt Traumatic Abdominal Wall Hernias: A Western Trauma Association Multicenter Study.

BACKGROUND: Blunt traumatic abdominal wall hernias (TAWHs) are rare but require a variety of operative techniques to repair including bone anchor fixation (BAF) when tissue tears off bony structures. This study aimed to provide a descriptive analysis of BAF technique for blunt TAWH repair. Bone anchor fixation and no BAF repairs were compared, hypothesizing increased hernia recurrence with BAF repair. METHODS: A secondary analysis of the WTA blunt TAWH multicenter study was performed including all patients who underwent repair of their TAWH. Patients with BAF were compared to those with no BAF with bivariate analyses. RESULTS: 176 patients underwent repair of their TAWH with 41 (23.3%) undergoing BAF. 26 (63.4%) patients had tissue fixed to bone, with 7 of those reinforced with mesh. The remaining 15 (36.6%) patients had bridging mesh anchored to bone. The BAF group had a similar age, sex, body mass index, and injury severity score compared to the no BAF group. The time to repair (1 vs 1 days, P = .158), rate of hernia recurrence (9.8% vs 12.7%, P = .786), and surgical site infection (SSI) (12.5% vs 15.6%, P = .823) were all similar between cohorts. CONCLUSIONS: This largest series to date found nearly one-quarter of TAWH repairs required BAF. Bone anchor fixation repairs had a similar rate of hernia recurrence and SSI compared to no BAF repairs, suggesting this is a reasonable option for repair of TAWH. However, future prospective studies are needed to compare specific BAF techniques and evaluate long-term outcomes including patient-centered outcomes such as pain and quality of life.

Peer Teachers' Professional Identity Development During a Prehospital Simulation: A Grounded Theory Study.

INTRODUCTION: Peer teachers have been found to be effective instructors during simulation-based education. However, there is a lack of research regarding their professional identity development throughout the course of the teaching activity. The purpose of this qualitative study, therefore, was to develop a framework to illustrate how peer teachers develop as educators during a prehospital simulation. METHODS: The participants in our study were 9 second-year medical students serving as peer teachers during a multiday prehospital simulation. We selected the grounded theory tradition of qualitative research to investigate the peer teachers' professional identity development. Our research team interviewed each participant twice during the simulation. We then used open and axial coding to analyze the interview data. We organized these codes into categories and determined connections between each category to construct our grounded theory framework. RESULTS: This framework described how the peer teachers progressed through 4 stages: 1) eager excitement, 2) grounded by challenges, 3) overcoming challenges, and 4) professional identity formation. CONCLUSION: Our results revealed that simulation-based education can serve as valuable learning environment not only for medical students, but also for peer teachers. Understanding their progressive development during the simulation will help medical educators focus on maximizing the peer teachers' growth and development during simulation.

A western trauma association multicenter comparison of mesh versus non-mesh repair of blunt traumatic abdominal wall hernias.

BACKGROUND: Blunt traumatic abdominal wall hernias (TAWH) occur in <1 % of trauma patients. Optimal repair techniques, such as mesh reinforcement, have not been studied in detail. We hypothesize that mesh use will be associated with increased surgical site infections (SSI) and not improve hernia recurrence. MATERIALS AND METHODS: A secondary analysis of the Western Trauma Association blunt TAWH multicenter study was performed. Patients who underwent TAWH repair during initial hospitalization (1/2012-12/2018) were included. Mesh repair patients were compared to primary repair patients (non-mesh). A logistic regression was conducted to assess risk factors for SSI. RESULTS: 157 patients underwent TAWH repair during index hospitalization with 51 (32.5 %) having mesh repair: 24 (45.3 %) synthetic and 29 (54.7 %) biologic. Mesh patients were more commonly smokers (43.1 % vs. 22.9 %, p = 0.016) and had a larger defect size (10 vs. 6 cm, p = 0.003). Mesh patients had a higher rate of SSI (25.5 % vs. 9.5 %, p = 0.016) compared to non-mesh patients, but a similar rate of recurrence (13.7 % vs. 10.5%, p = 0.742), hospital length of stay (LOS), and mortality. Mesh use (OR 3.66) and higher ISS (OR 1.06) were significant risk factors for SSI in a multivariable model. CONCLUSION: Mesh was used more frequently in flank TAWH and those with a larger defect size. Mesh use was associated with a higher incidence and risk of SSI but did not reduce the risk of hernia recurrence. When repairing TAWH mesh should be employed judiciously, and prospective randomized studies are needed to identify clear indications for mesh use in TAWH.

Technology-enhanced simulation in emergency medicine: Updated systematic review and meta-analysis 1991-2021.

Background: Over the past decade, the use of technology-enhanced simulation in emergency medicine (EM) education has grown, yet we still lack a clear understanding of its effectiveness. This systematic review aims to identify and synthesize studies evaluating the comparative effectiveness of technology-enhanced simulation in EM. Methods: We searched MEDLINE, EMBASE, PsycINFO, CINAHL, ERIC, Web of Science, and Scopus to identify EM simulation research that compares technology-enhanced simulation with other instructional modalities. Two reviewers screened articles for inclusion and abstracted information on learners, clinical topics, instructional design features, outcomes, cost, and study quality. Standardized mean difference (SMD) effect sizes were pooled using random effects. Results: We identified 60 studies, enrolling at least 5279 learners. Of these, 23 compared technology-enhanced simulation with another instructional modality (e.g., living humans, lecture, small group), and 37 compared two forms of technology-enhanced simulation. Compared to lecture or small groups, we found simulation to have nonsignificant differences for time skills (SMD 0.33, 95% confidence interval [CI] -0.23 to 0.89, n = 3), but a large, significant effect for non-time skills (SMD 0.82, 95% CI 0.18 to 1.46, n = 8). Comparison of alternative types of technology-enhanced simulation found favorable associations with skills acquisition, of moderate magnitude, for computer-assisted guidance (compared to no computer-assisted guidance), for time skills (SMD 0.50, 95% CI -1.66 to 2.65, n = 2) and non-time skills (SMD 0.57, 95% CI 0.33 to 0.80, n = 6), and for more task repetitions (time skills SMD 1.01, 95% CI 0.16 to 1.86, n = 2) and active participation (compared to observation) for time skills (SMD 0.85, 95% CI 0.25 to 1.45, n = 2) and non-time skills (SMD 0.33 95% CI 0.08 to 0.58, n = 3). Conclusions: Technology-enhanced simulation is effective for EM learners for skills acquisition. Features such as computer-assisted guidance, repetition, and active learning are associated with greater effectiveness.

Risk factors for recurrence in blunt traumatic abdominal wall hernias: A secondary analysis of a Western Trauma association multicenter study.

BACKGROUND: Few studies have investigated risk factors for recurrence of blunt traumatic abdominal wall hernias (TAWH). METHODS: Twenty trauma centers identified repaired TAWH from January 2012 to December 2018. Logistic regression was used to investigate risk factors for recurrence. RESULTS: TAWH were repaired in 175 patients with 21 (12.0%) known recurrences. No difference was found in location, defect size, or median time to repair between the recurrence and non-recurrence groups. Mesh use was not protective of recurrence. Female sex, injury severity score (ISS), emergency laparotomy (EL), and bowel resection were associated with hernia recurrence. Bowel resection remained significant in a multivariable model. CONCLUSION: Female sex, ISS, EL, and bowel resection were identified as risk factors for hernia recurrence. Mesh use and time to repair were not associated with recurrence. Surgeons should be mindful of these risk factors but could attempt acute repair in the setting of appropriate physiologic parameters.

Improving the Culture of Safety: A Prospective Handoff Initiative from the Operating Room to the Trauma Intensive Care Unit.

A recent EAST publication emphasized the importance of handoffs to ensure safe and effective care for trauma patients. In this work, we evaluated our existing handoffs from the operating room (OR) to the trauma intensive care unit (TICU) and implemented a formal process at our level 1 trauma center. Pre and post-intervention surveys were offered to the stakeholders. Responses were recorded in a Likert scaled format and results were compared using Student's t-test with statistical significance was set to .05. 57 surveys were completed (30 pre, 27 post) and 139 handoffs occurred. There was significant improvement in "overall satisfaction" and "understanding of information expected." Standardizing an OR to intensive care unit handoff clarifies expectations and improves care team satisfaction. While future studies are needed to evaluate the impact of structured handoffs on patient outcomes, provider satisfaction likely serves as an indicator for culture shift towards safer transitions of care for injured patients.

Feasibility of Obtaining Intraosseous and Intravenous Access Using Night Vision Goggle Focusing Adaptors.

BACKGROUND: The optimal tactical lighting for performing medical procedures under low-light conditions is unclear. METHODS: United States Navy medical personnel (N = 23) performed intravenous (IV) and intraosseous (IO) procedures on mannequins using a tactical headlamp, night vision goggles (NVGs), and night vision goggles with focusing adaptors (NVG+A) utilizing a randomized within-subjects design. Procedure success, time to completion, and user preferences were analyzed using analysis of variance (ANOVA) and nonparametric statistics at p < .05. RESULTS: IV success rates were significantly greater for the headlamp (74%) than for NVG (35%; p < .03) and somewhat greater than for NVG+A (52%; p = .18). IO success rates were high under each lighting condition (96% to 100%). Time to completion was significantly faster using headlamp (IV, 106 ± 28 s; IO, 47 ± 11 s) than NVG (IV, 168 ± 80 s; IO, 56 ± 17 s) or NVG-A (IV, 157 ± 52 s; IO, 59 ± 27 s; each p < .01). Posttesting confidence on a 1-to-5 scale was somewhat higher for NVG+A (IV, 2.9 ± 0.2; IO, 4.2 ± 0.2) than for NVG (IV, 2.6 ± 0.2; IO, 4.0 ± 0.2). Participants cited concerns with NVG+A depth perception and with adjusting the adaptors, and that the adaptors were not integrated into the NVG. CONCLUSION: While this mannequin study was limited by laboratory conditions and by the lack of practice opportunities, we found some small advantages of focusing adaptors over NVG alone but not over headlamp for IV and IO access in low-light conditions.

Management of blunt traumatic abdominal wall hernias: A Western Trauma Association multicenter study.

BACKGROUND: Blunt traumatic abdominal wall hernias (TAWH) occur in approximately 15,000 patients per year. Limited data are available to guide the timing of surgical intervention or the feasibility of nonoperative management. METHODS: A retrospective study of patients presenting with blunt TAWH from January 2012 through December 2018 was conducted. Patient demographic, surgical, and outcomes data were collected from 20 institutions through the Western Trauma Association Multicenter Trials Committee. RESULTS: Two hundred and eighty-one patients with TAWH were identified. One hundred and seventy-six (62.6%) patients underwent operative hernia repair, and 105 (37.4%) patients underwent nonoperative management. Of those undergoing surgical intervention, 157 (89.3%) were repaired during the index hospitalization, and 19 (10.7%) underwent delayed repair. Bowel injury was identified in 95 (33.8%) patients with the majority occurring with rectus and flank hernias (82.1%) as compared with lumbar hernias (15.8%). Overall hernia recurrence rate was 12.0% (n = 21). Nonoperative patients had a higher Injury Severity Score (24.4 vs. 19.4, p = 0.010), head Abbreviated Injury Scale score (1.1 vs. 0.6, p = 0.006), and mortality rate (11.4% vs. 4.0%, p = 0.031). Patients who underwent late repair had lower rates of primary fascial repair (46.4% vs. 77.1%, p = 0.012) and higher rates of mesh use (78.9% vs. 32.5%, p < 0.001). Recurrence rate was not statistically different between the late and early repair groups (15.8% vs. 11.5%, p = 0.869). CONCLUSION: This report is the largest series and first multicenter study to investigate TAWHs. Bowel injury was identified in over 30% of TAWH cases indicating a significant need for immediate laparotomy. In other cases, operative management may be deferred in specific patients with other life-threatening injuries, or in stable patients with concern for bowel injury. Hernia recurrence was not different between the late and early repair groups. LEVEL OF EVIDENCE: Therapeutic/care management, Level IV.

Relationship between burnout and mistreatment: Who plays a role?

INTRODUCTION: Surgery residents have high burnout rates and mistreatment occurs during training. We hypothesized that residents who reported mistreatment would be more likely to experience burnout. METHODS: A multi-institutional observational study asked residents to complete the Maslach Burnout Inventory and to rate how often they experienced mistreatment. Scores in the high-risk range for emotional exhaustion or depersonalization were classified as burnout. Associations between mistreatment behaviors, program, sex, post graduate year(PGY), and clinical status were measured by Spearman's correlation, linear regression, and logistic regression. RESULTS: We invited 398 residents to participate; 180 responded(45%). 52%(n = 93) were female, there was an even distribution among PGY, and seven programs were represented. Almost half of the cohort (48%) reported high risk for burnout and 68% reported experiencing mistreatment. Mistreatment by senior physician team members were correlated with EE(rho = 0.184,p = 0.016) and DP(rho = 0.181,p = 0.016). CONCLUSION: While overall burnout was not significantly associated with mistreatment behaviors, both burnout and mistreatment were commonly reported.

Screening for Bacteremia in Trauma Patients: Traditional Markers Fall Short.

BACKGROUND: Deranged physiology in trauma complicates the clinical identification of sepsis, resulting in overscreening for bacteremia. No clinical signs or biomarkers accurately diagnose sepsis in this population. Our objective was to evaluate the accuracy of the current criteria used to prompt screening for bacteremia in trauma patients and determine independent predictors of bacteremia. MATERIALS AND METHODS: Adult trauma patients admitted to our level I academic trauma center who had blood cultures (BCs) drawn were identified. Those with positive BCs were compared to those with negative or false positive BCs. False positive was defined as a BC deemed contaminated and not treated at the discretion of the attending physician. RESULTS: Over a 2-year period, 366 trauma patients had BCs drawn. After excluding surveillance cultures (those drawn to demonstrate bacteremia clearance), 492 unique BC sets were evaluated; 104 (21.1%) BC sets were positive; 30 (28.8%) of these were falsely positive, resulting in a true-positive rate of 15% in the screened population. Univariate analysis suggested temperature and heart rate were associated with positive BC, while multivariable analysis found only the presence of a central line and lactic acid to be predictive. Procalcitonin (PCT) was poorly predictive, with a positive predictive value of 18% and a negative predictive value of 91%. CONCLUSION: Current tools for identifying bacteremia in trauma patients result in overscreening. PCT may have a limited role as a negative predictor for bacteremia. Given that false-positive BCs have negative patient and economic consequences, future study should focus on development of alternative screening modalities.

Do Internal or External Characteristics More Reliably Predict Burnout in Resident Physicians: A Multi-institutional Study.

INTRODUCTION: Surgical residents have been shown to experience high rates of burnout. Whether this is influenced predominately by intrinsic characteristics, external factors, or is multifactorial has not been well studied. The aim of this study was to explore the relationship between these elements and burnout. We hypothesized that residents with higher emotional intelligence scores, greater resilience and mindfulness, and better work environments would experience lower rates of burnout. METHODS: General surgery residents at 7 sites in the US were invited to complete an electronic survey in 2019 that included the 2-item Maslach Burnout Inventory, Brief Emotional Intelligence Scale, Revised Cognitive and Affective Mindfulness Scale, 2-Item Connor-Davidson Resilience Scale, Utrecht Work Engagement Scale, and Job Resources scale of the Job Demands-Resources Questionnaire. Individual constructs were assessed for association with burnout, using multivariable logistic regression models. Residents' scores were evaluated in aggregate, in groups according to demographic characteristics, and by site. RESULTS: Of 284 residents, 164 completed the survey (response rate 58%). A total of 71% of respondents were at high risk for burnout, with sites ranging from 57% to 85% (p = 0.49). Burnout rates demonstrated no significant difference across gender, PGY level, and respondent age. On bivariate model, no demographic variables were found to be associated with burnout, but the internal characteristics of emotional intelligence, resilience and mindfulness, and the external characteristics of work engagement and job resources were each found to be protective against burnout (p < 0.001 for all). However, multivariable models examining internal and external characteristics found that no internal characteristics were associated with burnout, while job resources (coeff. -1.0, p-value <0.001) and work engagement (coeff. -0.76, p-value 0.032) were significantly protective factors. Rates of engagement overall were high, particularly with respect to work "dedication." CONCLUSIONS: A majority of residents at multiple institutions were at high risk for burnout during the study period. Improved work engagement and job resources were found to be more strongly associated with decreased burnout rates when compared to internal characteristics. Although surgical residents appear to already be highly engaged in their work, programs should continue to explore ways to increase job resources, and further research should be aimed at elucidating the mediating effect of internal characteristics on these external factors.

Impact of Surgery Program Characteristics on Fate of Non-designated Preliminary Surgery Interns.

OBJECTIVE: Non-designated preliminary (NDP) general surgery residents face the daunting challenge of obtaining a categorical residency position while undertaking the rigors of a general surgery residency. This additional application cycle represents a stressful time for these trainees and limited data exists to help guide applicants and program directors regarding the factors predictive of application success. While previous studies have focused solely on applicant related factors, no study to date has evaluated the effect of the residency program structure, institutional resources, or administrative support on these outcomes. DESIGN/SETTING: A multicenter retrospective review of 10 general surgery residency programs over a 5-year period from 2014 to 2019 was performed. Applicant related information was compiled from NDP general surgery residents and the results of their attempted second application into a categorical position. Applicant factors including age, gender, standardized test scores (USMLE/ABSITE), and professional training were examined. Program and administrative structure including residency class size, number of NDP PGY-2 positions, number of assistant program directors and program director (PD) background were also examined. Primary success was defined as a NDP resident successfully obtaining a categorical position within general surgery or a surgical subspecialty. Secondary success was obtaining a categorical residency position in any field of medical practice other than surgery or a surgical subspecialty in the United States. RESULTS: A total of 260 NDP trainees were evaluated with an average age of 29.1. Almost seventy percent of applicants were male, 40% graduated from a non-U.S. medical school and 24.2% required a visa to work in the United States. Thirty 4 percent of NDPs successfully obtained a categorical surgery position and an additional 35% obtained a categorical residency position in a nonsurgical field for an overall match success rate of 68.9%. Factors associated with primary success included ABSITE score (p < 0.001), US medical school graduation (p = 0.02), visa status (p = 0.03), presence of preliminary PGY-2 positions (p = 0.02), and PD professional development time (p = 0.004). Overall success was associated USMLE Step 1 scores (p = 0.02), number of approved chiefs (p = 0.03), presence of dedicated faculty researchers (p = 0.001), and PD professional development time (p < 0.001). CONCLUSIONS: Applicant, program-related, and administrative factors all have a significant impact on the success of NDP general surgery residents in obtaining a categorical surgical position. Trainees should consider all of these factors when applying to NDP residencies and in approaching their second application cycle to maximize their likelihood of a successful match.

Ad astra per aspera (Through Hardships to the Stars): Lessons Learned from the First National Virtual APDS Meeting, 2020.

OBJECTIVE: After COVID-19 rendered in-person meetings for national societies impossible in the spring of 2020, the leadership of the Association of Program Directors in Surgery (APDS) innovated via a virtual format in order to hold its national meeting. DESIGN: APDS leadership pre-emptively considered factors that would be important to attendees including cost, value, time, professional commitments, education, sharing of relevant and current information, and networking. SETTING: The meeting was conducted using a variety of virtual formats including a web portal for entry, pre-ecorded poster and oral presentations on the APDS website, interactive panels via a web conferencing platform, and livestreaming. PARTICIPANTS: There were 298 registrants for the national meeting of the APDS, and 59 participants in the New Program Directors Workshop. The registrants and participants comprised medical students, residents, associate program directors, program directors, and others involved in surgical education nationally. RESULTS: There was no significant difference detected for high levels of participant satisfaction between 2019 and 2020 for the following items: overall program rating, topics and content meeting stated objectives, relevant content to educational needs, educational format conducive to learning, and agreement that the program will improve competence, performance, communication skills, patient outcomes, or processes of care/healthcare system performance. CONCLUSIONS: A virtual format for a national society meeting can provide education, engagement, and community, and the lessons learned by the APDS in the process can be used by other societies for utilization and further improvement.

Surgical Trainees' Sense of Responsibility for Patient Outcomes: A Multi-institutional Appraisal.

BACKGROUND: Surgeon educators express concern about trainees' sense of patient ownership. We aimed to compare resident and faculty perceptions on residents' sense of personal responsibility for patient outcomes and to correlate patient ownership with resident and residency characteristics. METHODS: An anonymous electronic questionnaire surveyed 373 residents and 390 faculty at seven academic surgery residencies across the United States. We modified an established psychological ownership scale to measure patient ownership among surgical trainees. RESULTS: Respondents included 123 residents and 136 faculty (response rate 33% and 35%, respectively). Overall, 78.0% of faculty agreed that residents took personal responsibility for patient outcomes, but only 26.4% thought residents felt a similar or higher degree of patient ownership compared with themselves. Faculty underestimated the proportion of residents that routinely checked on their patients when off-duty (36.8 versus 92.6%, P < 0.001). Higher means on the patient ownership scale correlated with female sex (5.9 versus. 5.5 for males, P = 0.009), advanced post graduate year level (5.3, 5.5, 5.7, 5.8, 6.1, for post graduate year 1-5, respectively, P = 0.02), and the sense that patient outcomes affected the resident respondent's mood (5.8 versus 4.8 for those whose mood was not affected, P < 0.001). In addition, trainees who perceived better resident camaraderie (P = 0.004), faculty mentorship (P < 0.001), and that their program provided appropriate autonomy (P = 0.03) felt greater responsibility for patient outcomes. CONCLUSIONS: Most faculty agree that residents assume personal responsibility for patient outcomes, but many still underestimate residents' sense of patient ownership. Certain modifiable aspects of residency culture including camaraderie, mentorship, and autonomy are associated with patient ownership among trainees.