Faculty Bibliography

Background: Enhanced Recovery After Surgery (ERAS) is a multimodal, standardized approach to the surgical patient that incorporates evidenced-based interventions designed to achieve rapid recovery after surgery by minimizing the patient's stress response. One aspect of ERAS, carbohydrate loading, has been shown in multiple randomized controlled trials to result in postoperative benefits in patients undergoing colorectal surgery, but there appears to be insufficient data to make definitive recommendations for or against carbohydrate loading in joint replacement patients. Objective: To evaluate postoperative nausea and length of stay (LOS) after a preoperative carbohydrate loading protocol was initiated for patients undergoing total joint replacement. Design: Retrospective chart review. Setting and participants: 100 patients who underwent either total knee or hip arthroplasty at Winthrop University Hospital, Mineola, NY, in the past 4 years and either had (n = 50) or had not received preoperative carbohydrate supplements (n = 50). Methods: Using the total joint database, the medical record was reviewed for the patient's demographics, LOS, documentation of postoperative nausea, and number of doses of antiemetic medication given to the patient. Results: The mean LOS for the carbohydrate-loading group and non-carbohydrate group was 1.9 days and 2.6 days. respectively, a difference of 0.70 days (P < 0.0001). The carbohydrate-loaded group received a total of 13 doses of antiemetic medications and the non-carbohydrate group received 21 doses. The average number of antiemetic doses given to a patient postoperatively was 0.26 for the carbohydrate-loaded group and 0.42 for the non-carbohydrate-loaded group. The difference was 0.16 doses (P < 0.7815). Conclusion: The implementation of carbohydrate loading decreased LOS for joint replacement patients by approximately 1 day. Additionally, there was a trend towards decreased antiemetic use and fewer documented cases of postoperative nausea after carbohydrate loading.

Background /UNASSIGNED:Residents and practicing physicians displaying signs of stress is common. It is unclear whether stress during residency persists into professional practice or is associated with future burnout. Objective /UNASSIGNED:We assessed the persistence of stress after residency and its correlation with burnout in professional practice. We hypothesized that stress would linger and be correlated with future burnout. Methods /UNASSIGNED:A prospective cohort study was conducted over 10 years using survey instruments with existing validity evidence. Residents over 3 academic years (2003-2005) were surveyed to measure stress in residency. Ten years later, these residents were sought out for a second survey measuring current stress and burnout in professional practice. Results /UNASSIGNED: = .028). Conclusions /UNASSIGNED:We showed emotional distress as a resident persists into individuals' professional practice 10 years later and has an association with burnout in practice.

BACKGROUND:Older adults account for more than half of all admissions to intensive care units; most remain alive at 1 year, but with long-term sequelae. OBJECTIVE:To explore geriatric-focused practices and associated outcomes in older intensive care survivors. METHODS:In a 1-year, retrospective, cohort study of patients admitted to the medical intensive care unit and subsequently transferred to the medicine service, adherence to geriatric-focused practices and associated clinical outcomes during intensive care were determined. RESULTS:= .003) were significantly associated with longer hospital stays. Bladder catheters were associated with hospital-acquired pressure injuries (odds ratio, 8.9; 95% CI, 1.2-67.9) and discharge to rehabilitation (odds ratio, 8.9; 95% CI, 1.2-67.9). Nothing by mouth (odds ratio, 3.2; 95% CI, 1.2-8.0) and restraints (odds ratio, 2.8; 95% CI, 1.4-5.8) were also associated with an increase in 30-day readmission. Although 95% of the patients were assessed at least once by using the Confusion Assessment Method for the Intensive Care Unit (overall 2334 assessments documented), only 3.4% had an assessment that indicated delirium; 54.6% of these assessments were inaccurate. CONCLUSION/CONCLUSIONS:Although initiatives have increased awareness of the challenges, implementation of geriatric-focused practices in intensive care is inconsistent.

BACKGROUND:Bethesda guidelines do not require presence of transformation zone (TZ) for a cervical Pap test to be deemed adequate. However, clinicians are concerned with specimens that are reported to lack TZ. METHODS:We analyzed 566 ThinPrep cases reported as negative for intraepithelial lesion or malignancy (NILM) with no cervical abnormality detected in previous 4 years (2007-2011). These cases were divided into two cohorts; those with TZ (ETZ) and those without TZ (NTZ). Patients' age, HPV status, time of sample collection (>14 days after last menstrual period), subsequent management, interval of subsequent Pap test (<1, 1-3, and >3 years), and result of subsequent examination were compared over a 5-year period. RESULTS:The rate of abnormal Pap test on 5 year follow-up was not statistically significant (P < .9520) between cohorts. Our data demonstrates lack of statistical significance between the variables studied. Five year follow-up of all abnormal Pap smears were analyzed (93% ETZ and 7% NTZ). Of the ETZ group, 25% ASCUS remained as ASCUS and 75% were reported as NILM in subsequent Pap smears. Additionally, 75% of the LSIL were subsequently reported as NILM and 25% reported as ASCUS. One patient reported as HSIL underwent hysterectomy. Two Pap smears performed two years after surgery were negative. Within the NTZ group, one case of ASCUS was NILM upon follow-up. CONCLUSION/CONCLUSIONS:Pap smears with NTZ were not at a higher risk for subsequent detection of cervical abnormalities, making earlier repeat testing unnecessary. Rescreening cases without TZ is neither cost effective nor necessary.

BACKGROUND:Pancreatectomies have been identified as procedures with an increased risk of readmission. In surgical patients, readmissions within 30 days of discharge are usually procedure-related. We sought to determine predictors of 30-day readmission following pancreatic resections in a large healthcare system. METHODS:We retrospectively collected information from the records of 383 patients who underwent pancreatic resections from 2004-2013. To find the predictors of readmission in the 30 days after discharge, we performed a univariate screen of possible variables using the Fisher's exact test for categorical variables and the Mann-Whitney U test for continuous variables. Multivariate analysis was used to determine the independent factors. RESULTS:Fifty-eight (15.1%) patients were readmitted within 30 days of discharge. Of the patients readmitted, the most common diagnoses at readmission were sepsis (17.2%), and dehydration (8.6%). Multivariate logistic regression found that the development of intra-abdominal fluid collections (OR = 5.32, P < 0.0001), new thromboembolic events (OR = 4.08, P = 0.016), and pre-operative BMI (OR = 1.06, P = 0.040) were independent risk factors of readmission within 30 days of discharge. CONCLUSION/CONCLUSIONS:Our data demonstrate that factors predictive of 30-day readmission are a combination of patient characteristics and the development of post-operative complications. Targeted interventions may be used to reduce the risk of readmission.

OBJECTIVES/OBJECTIVE:To explore the effect of the presence and timing of a do-not-resuscitate (DNR) order on short-term clinical outcomes, including mortality. DESIGN/METHODS:Retrospective cohort study with propensity score matching to enable direct comparison of DNR and no-DNR groups. SETTING/METHODS:Large, academic tertiary-care center. PARTICIPANTS/METHODS:Hospitalized medical patients aged 65 and older. MEASUREMENTS/METHODS:Primary outcome was in-hospital mortality. Secondary outcomes included discharge disposition, length of stay, 30-day readmission, restraints, bladder catheters, and bedrest order. RESULTS:Before propensity score matching, the DNR group (n=1,347) was significantly older (85.8 vs 79.6, p<.001) and had more comorbidities (3.0 vs 2.5, p<.001) than the no-DNR group (n=9,182). After propensity score matching, the DNR group had significantly longer stays (9.7 vs 6.0 days, p<.001), were more likely to be discharged to hospice (6.5% vs 0.7%, p<.001), and to die (12.2% vs 0.8%, p<.001). There was a significant difference in length of stay between those who had a DNR order written within 24 hours of admission (early DNR) and those who had a DNR order written more than 24 hours after admission (late DNR) (median 6 vs 10 days, p<.001). Individuals with early DNR were less likely to spend time in intensive care (10.6% vs 17.3%, p=.004), receive a palliative care consultation (8.2% vs 12.0%, p=.02), be restrained (5.8% vs 11.6%, p<.001), have an order for nothing by mouth (50.1% vs 56.0%, p=.03), have a bladder catheter (31.7% vs 40.9%, p<.001), or die in the hospital (10.2% vs 15.47%, p=.004) and more likely to be discharged home (65.5% vs 58.2%, p=.01). CONCLUSION/CONCLUSIONS:Our study underscores the strong association between presence of a DNR order and mortality. Further studies are necessary to better understand the presence and timing of DNR orders in hospitalized older adults.