Predicting Unplanned Readmissions to the Intensive Care Unit in the Trauma Population.

Background: Unplanned readmission to intensive care units (UR-ICU) in trauma is associated with increased hospital length of stay and significant morbidity and mortality. We identify independent predictors of UR-ICU and construct a nomogram to estimate readmission probability. Materials and Methods: We performed an IRB-approved retrospective case-control study at a Level I trauma center between January 2019 and December 2021. Patients with UR-ICU (n = 175) were matched with patients who were not readmitted (NR-ICU) (n = 175). Univariate and multivariable binary linear regressionanalyses were performed (SPSS Version 28, IBM Corp), and a nomogram was created (Stata 18.0, StataCorp LLC). Results: Demographics, comorbidities, and injury- and hospital course-related factors were examined as potential prognostic indicators of UR-ICU. The mortality rate of UR-ICU was 22.29% vs 6.29% for NR-ICU (P < .001). Binary linear regression identified seven independent predictors that contributed to UR-ICU: shock (P < .001) or intracranial surgery (P = .015) during ICU admission, low hematocrit (P = .001) or sedation administration in the 24 hours before ICU discharge (P < .001), active infection treatment (P = .192) or leukocytosis on ICU discharge (P = .01), and chronic obstructive pulmonary disease (COPD) (P = .002). A nomogram was generated to estimate the probability of UR-ICU and guide decisions on ICU discharge appropriateness. Discussion: In trauma, UR-ICU is often accompanied by poor outcomes and death. Shock, intracranial surgery, anemia, sedative administration, ongoing infection treatment, leukocytosis, and COPD are significant risk factors for UR-ICU. A predictive nomogram may help better assess readiness for ICU discharge.

Gender Disparities in Complications, Costs, and Mortality After Emergency Gastrointestinal Surgery in Kenya.

INTRODUCTION: Little is known about the impact of gender on emergency surgery within Kenya. Therefore, we aimed to investigate the association of gender on outcomes of postoperative complications, health care costs, and mortality. METHODS: We evaluated an established cohort of patients undergoing emergency gastrointestinal surgery in rural Kenya between January 1st, 2016 and June 30th, 2019. Utilizing logistic regression, we examined the association between self-reported patient gender and the outcomes of postoperative complications and mortality. A generalized linear model was created for total hospital costs, inflation-adjusted in international dollars purchasing power parity, to examine the impact of gender. Confounding factors were controlled by Africa Surgical Outcomes Study Surgical Risk Score. RESULTS: Among 484 patients reviewed, 149 (30.8%) were women. 165 (34.1%) patients developed complications, with women experiencing more than men (40.9% versus 31.0%; P = 0.03) and longer hospital stays (median 6 days (4-9) versus 5 (4-7); P = 0.02). After controlling for Africa Surgical Outcomes Study Surgical Risk Score, odds of developing complications for women were 1.67 (95% confidence interval: 1.09-2.55; P = 0.019) times higher than men, and the odds of death were 2.38 (95% confidence interval: 1.12-5.09; P = 0.025) times greater for women than men, despite similar failure-to-rescue rates and intensive care unit utilization. Total hospital costs were increased for women by 531 international dollars purchasing power parity (117-946; P = 0.012) when compared to men, attributed to longer lengths of stay. CONCLUSIONS: These findings demonstrate that a discrepancy exists between men and women undergoing emergency gastrointestinal surgery in our setting. Further exploration of the underlying causes of this inequity is necessary for quality improvement for women in rural Kenya.

Trainee autonomy and surgical outcomes after emergency gastrointestinal surgery.

BACKGROUND: Operative meaningful trainee autonomy is an essential component of surgical training. Reduced trainee autonomy is frequently attributed to patient safety concerns, but this has not been examined within Kenya. We aimed to assess whether meaningful trainee autonomy was associated with a change in patient outcomes. METHODS: We investigated whether meaningful trainee autonomy was associated with a change in severe postoperative complications and all-cause in-hospital mortality in a previously described cohort undergoing emergency gastrointestinal operations. Each operation was reviewed to determine the presence of meaningful autonomy, defined as "supervision only" from faculty. Comparisons were made between faculty-led cases and cases with meaningful trainee autonomy. Multilevel logistic regression models were created for the outcomes of mortality and complications with the exposure of meaningful trainee autonomy, accounting for fixed effects of the Africa Surgical Outcomes Study Risk Score and random effects of discharge diagnoses. RESULTS: After excluding laparoscopy (N = 28) and missing data (N = 3), 451 operations were studied, and 343 (76.1%) had meaningful trainee autonomy. Faculty were more involved in operations with older age, cancer, prior complications, and higher risk scores. On unadjusted analysis, meaningful trainee autonomy was associated with mortality odds of 0.32 (95% confidence interval: 0.17-0.58) compared with faculty-led operations. Similarly, the odds of developing complications were 0.52 (95% confidence interval: 0.32-0.84) with meaningful trainee autonomy compared with faculty-led operations. When adjusting for Africa Surgical Outcomes Study Score and clustering discharge diagnoses, the odds of mortality (odds ratio 0.58; 95% confidence interval: 0.27-1.2) and complication (odds ratio 0.83; 95% confidence interval: 0.47-1.5) were not significant. CONCLUSION: Our findings support that increasing trainee autonomy does not change patient outcomes in selected emergency gastrointestinal operations. Further, trainees and faculty appropriately discern patients at higher risk of complications and mortality, and the selective granting of trainee autonomy does not affect patient safety.

"Early Post-operative Mechanical Small Bowel Obstruction Induced by Unidirectional Barbed Suture".

Unidirectional barbed suture is widely used in minimally invasive procedures as a secure alternative to traditional knot tying. In this report, a 44-year-old female with endometriosis and complex gynecological history presented to our emergency department 2 weeks after undergoing minimally invasive gynecological surgery. She had persistent, progressive signs and symptoms typical of intermittent partial small bowel obstruction. On her third admission within 7 days for this pattern, laparoscopic abdominal exploration was performed. She was noted to have small bowel obstruction secondary to ingrowth of the tail of a unidirectional barbed suture kinking the terminal ileum during this procedure. We discuss small bowel obstruction due to unidirectional barbed suture and make recommendations on how to avoid this complication.

Implementation of a Surgical Critical Care Service Reduces Failure to Rescue in Emergency Gastrointestinal Surgery in Rural Kenya.

OBJECTIVE: We aimed to evaluate the implementation of a dedicated Surgical critical care service (SCCS) on failure to rescue (FTR) rates in rural Kenya. SUMMARY BACKGROUND DATA: FTR adversely impacts perioperative outcomes. In the resource-limited contexts of low- and middle-income countries, emergency gastrointestinal surgery carries high morbidity and mortality rates. Quality improvement initiatives that decrease FTR rates are essential for improving perioperative care. METHODS: All patients who underwent emergency gastrointestinal surgery between January 2016 and June 2019 at Tenwek Hospital in rural Kenya were reviewed. Critical care capabilities were constant throughout the study period. A supervised surgical resident was dedicated to the daily care of critically ill surgical patients beginning in January 2018. The impact of the SCCS initiation on the outcome of FTR was evaluated, controlling for patient complexity via the African Surgical Outcomes Study Surgical Risk Score. RESULTS: A total of 484 patients were identified, consisting of 278 without and 206 with an active SCCS. A total of 165 (34.1%) patients experienced postoperative complications, including 49 mortalities (10.1%) yielding an FTR rate of 29.7%. The FTR rate decreased after SCCS implementation from 36.8% (95% CI: 26.7%-47.8%) to 21.8% (95% CI: 13.2%-32.6%) ( P = 0.035) despite an increase in the average patient African Surgical Outcomes Study score from 14.5 (95% CI, 14.1-14.9) to 15.2 (95% CI, 14.7-15.7) ( P =0.03). CONCLUSIONS: The implementation of an SCCS in rural Kenya resulted in decreased rates of FTR despite an increase in patient complexity and severity of critical illness.

The costs of complications after emergency gastrointestinal surgery in Kenya.

BACKGROUND: The financial burden of surgery is substantial worldwide. Postoperative complications increase costs in high-resource settings, but this is not well studied in other settings. Our objective was to review the financial impact of postoperative complications. METHOD: Patients undergoing emergency gastrointestinal operations at a center in Kenya were reviewed between January 2017 and June 2019. In a cost analysis, we ascertained the outcome of total hospital costs, adjusted for inflation, and converted to international dollars using purchasing power parities. Costs were analyzed for their association with a postoperative complication, defined using standardized criteria. We calculated the Africa Surgical Outcomes Study surgical risk scores and clustered for discharge diagnosis in a mixed-effects generalized linear model accounting for confounding factors related to costs and complications. RESULTS: A total of 361 individuals had cost data available. The cohort had 251 men (69.5%) and 110 women (30.5%) with a median age of 41 years (interquartile range: 29-57 years). A total of 122 (33.8%) patients experienced a postoperative complication with an overall all-cause mortality rate of 10.5%. The median total cost of hospitalization was 1,949 (interquartile range: 1,516-2,788) international dollar purchasing power parities. When controlling for patient factors and diagnoses, patients who did not develop complications had costs of 2,119 (95% confidence interval 1,898-2,340) compared to costs of 3,747 (95% confidence interval 3,327-4,167) for patients who developed a postoperative complication, leading to a 77% increase of 1,628 international dollar purchasing power parities for patients with complications. CONCLUSION: Our findings demonstrated a substantial financial burden generated by postoperative complications in patients undergoing emergency gastrointestinal operations. Reducing complications could allow cost savings, an important consideration in variable-resource settings.

A Semistructured Interview for Surgical Residency Targeting Nontechnical Skills.

OBJECTIVE: We review the development, implementation, and initial outcomes of a semistructured interview process to assess the nontechnical skills of surgical residency applicants. DESIGN: In 2018, we restructured our residency selection interview process. Through semistructured faculty interviews, we sought to evaluate candidates along seven nontechnical skills (grit, ownership, rigor, teamwork, presence, impact, and organizational alignment). We plotted each candidate's scores on a radar plot for graphical representation and calculated the plot area of each candidate. We retrospectively evaluated 3 years of data, comparing the nontechnical skill scores of matriculants into the training program to those of nonmatriculants. SETTING: Tenwek Hospital is a 361-bed tertiary teaching and referral hospital in rural western Kenya with a 5-year general surgery residency program. PARTICIPANTS: Thirty-one applicants were interviewed over 3 years. Thirteen matriculated into the program. RESULTS: Scores for grit, (4.8 vs 3.9; p = 0.0004), impact (4.2 vs 3.5; p = 0.014), ownership (4.2 vs 3.6; p = 0.01), and organizational alignment (4.3 vs 3.8; p = 0.008) were significantly higher in matriculants. CONCLUSIONS: This semistructured interview process provides a robust and beneficial mechanism for assessing applicants' nontechnical skills, which may allow for the matriculation of more well-rounded candidates into surgical residency and, ultimately, surgical practice.

Design of a Novel Online, Modular, Flipped-classroom Surgical Curriculum for East, Central, and Southern Africa.

Objective: We describe a structured approach to developing a standardized curriculum for surgical trainees in East, Central, and Southern Africa (ECSA). Summary Background Data: Surgical education is essential to closing the surgical access gap in ECSA. Given its importance for surgical education, the development of a standardized curriculum was deemed necessary. Methods: We utilized Kern's 6-step approach to curriculum development to design an online, modular, flipped-classroom surgical curriculum. Steps included global and targeted needs assessments, determination of goals and objectives, the establishment of educational strategies, implementation, and evaluation. Results: Global needs assessment identified the development of a standardized curriculum as an essential next step in the growth of surgical education programs in ECSA. Targeted needs assessment of stakeholders found medical knowledge challenges, regulatory requirements, language variance, content gaps, expense and availability of resources, faculty numbers, and content delivery method to be factors to inform curriculum design. Goals emerged to increase uniformity and consistency in training, create contextually relevant material, incorporate best educational practices, reduce faculty burden, and ease content delivery and updates. Educational strategies centered on developing an online, flipped-classroom, modular curriculum emphasizing textual simplicity, multimedia components, and incorporation of active learning strategies. The implementation process involved establishing thematic topics and subtopics, the content of which was authored by regional surgeon educators and edited by content experts. Evaluation was performed by recording participation, soliciting user feedback, and evaluating scores on a certification examination. Conclusions: We present the systematic design of a large-scale, context-relevant, data-driven surgical curriculum for the ECSA region.

Continued Relevance of Initial Temperature Measurement in Trauma Patients.

OBJECTIVES: Hypothermia occurs in 30-50% of severely injured trauma patients and is associated with multiple metabolic derangements and worsened outcomes. However, hypothermia continues to be under-diagnosed which leads to inadequate triage and treatment in trauma patients. Our study set out to determine if hypothermia is an independent predictor of mortality in trauma patients. METHODS: We retrospectively reviewed data of all trauma activation patients over a 5-year period. Data were collected on patient demographics, initial core temperature, Glasgow Coma Scale (GCS) on presentation, and injury severity score (ISS). Patients were then stratified into groups based on presenting temperature, ISS, and GCS. Outcomes compared were mortality, blood products received, and intensive care unit (ICU) length of stay. Correlations and logistic regression were used to test the hypotheses. RESULTS: Survival and temperature data were reviewed on 15,567 patients. Initial temperature was not significantly associated with ICU length of stay or blood products transfused (P = .21 and P = .08, respectively). However, odds ratio of mortality in hypothermic patients (<35°C) compared to normothermic patients (35-39°C) was 3.95 (95% CI 2.90-5.41). When controlling for GCS and ISS, separately, temperature remained an independent predictor of mortality. CONCLUSIONS: Hypothermia is an independent risk factor for mortality in trauma patients. It remains crucial to obtain accurate presenting temperatures in trauma patients in order to triage and treat hypothermia. Based on our data, obtaining core temperatures and rapidly treating hypothermia continues to be a vital part of the secondary survey of trauma patients.

Mortality Prediction in Rural Kenya: A Cohort Study of Mechanical Ventilation in Critically Ill Patients.

Critical care is expanding in low- and middle-income countries. Yet, due to factors such as missing data and different disease patterns, predictive scores often fail to adequately predict the high rates of mortality observed. OBJECTIVES: We evaluated multiple prognostic models for the outcome of mortality in critically ill, mechanically ventilated patients in rural Kenya and examined factors contributing to mortality in our setting. DESIGN SETTING AND PARTICIPANTS: A prospective cohort study was conducted on mechanically ventilated patients in rural Kenya. Consecutive patients 16 years old and older initiated on mechanical ventilation between January 1, 2016, and April 30, 2017, at Tenwek Hospital were included. Demographic data, clinical characteristics, and patient outcomes were collected during routine clinical care. MAIN OUTCOMES AND MEASURES: We assessed the discrimination and calibration of multiple previously-described models for mortality: Acute Physiology and Chronic Health Evaluation II, Sequential Organ Failure Assessment, quick Sequential Organ Failure Assessment, Simplified Acute Physiology Score II, Modified Early Warning Score, Tropical Intensive Care Score, Rwanda-Mortality Predictive Model, Vitals score (validated in Tanzania), and Vitals score for sepsis (validated in Uganda). Factors most associated with mortality were analyzed in our cohort utilizing stepwise regression. RESULTS: Among the final cohort of 300 patients, the overall mortality rate was 60.7%, the average age was 39.9 years, 65% were male, and 33% were seen at an outside facility prior to admission to the critical care unit. Missing variables occurred in patients for numerous models but were complete in most adapted to resource-limited settings. Models displayed moderate prediction of mortality and variable discrimination area under the receiver operating characteristic curves (and Hosmer-Lemeshow chi-square statistic) of 0.77 (22.4) for Acute Physiology and Chronic Health Evaluation II, 0.70 (3.4) for Modified Early Warning Score, 0.65 (0.16) for quick Sequential Organ Failure Assessment, 0.55 (18.4) for Simplified Acute Physiology Score II and 0.74 (9.2) for Rwanda-Mortality Predictive Model, 0.72 (0.12) for Vitals Tanzania, 0.68 (14.7) for Vitals Uganda, and 0.65 (13.9) for Tropical Intensive Care Score. Variables associated with increased mortality in our population were hypotension, infection, traumatic brain injury, and hematocrit. CONCLUSIONS AND RELEVANCE: Overall, survival for critically ill patients in rural Kenya was poor, but predictable with contributing factors. Models designed for resource-constrained settings had favorable discrimination and better calibration for mortality prediction than high-resource models in our population of mechanically ventilated, critically ill patients in rural Kenya.