An Ancillary Central Catheter Emergency Support Service Team Staffed by Surgical Personnel Improves Workflow During the Coronavirus Disease 2019 Crisis
Background. The SARS-CoV-2 novel coronavirus disease 2019 (COVID-19) pandemic has posed significant challenges to urban health centers across the United States. Many hospitals are reallocating resources to best handle the influx of critical patients. Methods. At our New York City hospital, we developed the ancillary central catheter emergency support service (ACCESS), a team for dedicated central access staffed by surgical residents to assist in the care of critical COVID-19 patients. We conducted a retrospective review of all patients for whom the team was activated. Furthermore, we distributed a survey to the critical care department to assess their perceived time saved per patient. Results. The ACCESS team placed 104 invasive catheters over 10Â days with a low complication rate of .96%. All critical care providers surveyed found the service useful and felt it saved at least 30Â minutes of procedural time per patient, as patient to critical care provider ratios were increased from 12 patients to one provider to 44 patients to one provider. Conclusions. The ACCESS team has helped to effectively redistribute surgical staff, provide a learning experience for residents, and improve efficiency for the critical care team during this pandemic.
Enhanced recovery program implementation: an evidence-based review of the art and the science
BACKGROUND:The benefits of enhanced recovery program (ERP) implementation include patient engagement, improved patient outcomes and satisfaction, better team relationships, lower per episode costs of care, lower public consumption of narcotic prescription pills, and the promise of greater access to quality surgical care. Despite these positive attributes, vast numbers of surgical patients are not treated on ERPs, and many of those considered "on pathway" are unlikely to be exposed to a majority of recommended ERP elements. METHODS:To explain the gap between ERP knowledge and action, this manuscript reviewed formal implementation strategies, proposed a novel change adoption model and focused on common barriers (and corollary solutions) that are encountered during the journey to a fully implemented and successful ERP. Given the nature of this review, IRB approval was not required/obtained. RESULTS:The information reviewed indicates that implementation of best practice is both a science and an art. What many surgeons have learned is that the "soft" skills of emotional intelligence, leadership, team dynamics, culture, buy-in, motivation, and sustainability are central to a successful ERP implementation. CONCLUSIONS:To lead teams toward achievement of pervasive and sustained adherence to best practices, surgeons need to learn new strategies, techniques, and skills.
Public reporting and transparency: a primer on public outcomes reporting
INTRODUCTION/BACKGROUND:Healthcare consumers seeking accurate information about where to find quality surgical care face a confusing constellation of rating systems that lack transparency or consistency of opinion. For example, a 2016 report in Health Affairs demonstrated that no hospital was rated as a high performer by all four prominent national ratings systems: Consumer Reports, Leapfrog, Healthgrades and U.S. News & World Report (Austin et al. Health Aff 34:423-430, 2015). Surgeons should have an understanding of the current state of public reporting of quality; hospital ratings and data sources; physician ratings and data sources; and transparency of reporting. METHODS:We conducted a non-systematic review of the literature. RESULTS:Hospital quality ratings remain nebulous and there is not universal opinion on the utility of voluntary participation in ranking systems, leaving the current systems largely opinion-based. Early attempts at physician ranking systems are rudimentary at best and suffer from methodological concerns. Publicly reported metrics should be easily understandable, accessible, clinically relevant, reliable, non-punitive, and shielded from legal discovery. Transparency is increasing within institutions to help align staff to institutional objectives, while specialty specific registries are helping to standardize care pathways and outcomes measures across organizations. Measuring surgical outcomes beyond 30-day morbidity and mortality has been plagued by a lack of understanding on how to create metrics that matter; the four attributes of relevance, scientific soundness, feasibility and comprehensiveness set a high bar for the development of effective and efficient quality measures in surgery. DISCUSSION/CONCLUSIONS:SAGES, via the Quality, Outcomes, and Safety Committee, is committed to learning how to develop meaningful quality metrics in general surgery and will continue to work in other areas that impact quality, such as opioid prescribing, and surgeon wellness.
How to manage efferent loop syndrome with endoscopic techniques [Meeting Abstract]
Introduction: Efferent loop syndrome (ELS) is defined as a mechanical obstruction of the efferent enteric jejunal limb. ELS can occur after a Whipple, Billroth II gastrectomy, or Roux-en-Y gastric bypass. Gastrojejunal anastomotic stenosis rates in these surgeries range from 0.2-1.7%. However, these documented rates include afferent limb syndrome and roux limb obstruction. Case Presentation: We present the case of a 60 year old female with gastric adenocarcinoma presenting for elective resection. The patient underwent a hemi-gastrectomy with Billroth II reconstruction. On postoperative day (POD) three, the patient was started on a clear liquid diet. On POD four through six, the patient continued to have bowel movements, however, was unable to tolerate oral intake. An UGI series was obtained, with findings suspicious for obstruction of the efferent limb. The patient was taken for esophagogastroduodenoscopy, and there was evidence of a stenosed Billroth II gastrojejunal anastomosis. The anastomosis was transversed, and a covered stent was placed under fluoroscopic guidance. Post procedurally a repeat UGI series confirmed a patent stent. The patient's diet was advanced and tolerated, and the patient was discharged home.
Discussion(s): There are two types of "loop syndromes" which may occur after gastric surgery - afferent and efferent. Efferent loop syndrome is less common of the two. Both syndromes are characterized by a mechanical obstruction of the gastrojejunostomy, causing obstruction of gastric emptying. The gold standard to diagnosing ELS is an upper endoscopy; however, radiographic imaging can aid in the diagnosis. UGI series can demonstrate regurgitation of oral contrast into the afferent limb and gastric pouch. The mainstay treatment of ELS has historically been surgical intervention. However, with recent advancements in endoscopic procedures, there have been published techniques using metal stents, double pigtail stents and naso-jejunal tube stenting to bypass areas of stenosis. In 2016, Chang et al. described the effectiveness of endoscopic stent therapy in the management of postoperative foregut surgery complications (anastomotic leak, lumen stenosis, fistula formation). They reported an 88.9% success rate in treating stenosis with the end point of being able to tolerate a diet. Double pigtail and naso-jejunal tube stenting have also been documented to have success rates as high as 95%.
Conclusion(s): This case describes a rare post-gastrectomy complication which was successfully treated with modern endoscopic technique. With modern advancements in endoscopic techniques, patients suffering from efferent loop syndrome are able to avoid the morbidity associated with operative repairs
[S.l.] : Academic Surgical Congress Abstracts Archive, 2019
91.11 Trends in Treatment of Appendicitis: Analysis of National Inpatient Sample(Website)
Cholecystomegaly: Management and treatment [Meeting Abstract]
Case Presentation: Patient is a 22 year old female with no significant past medical or surgical history presented to the emergency department with a 2 day history of worsening sharp right upper quadrant pain with associated nausea, vomiting, and PO intolerance. The pain started a few months prior, however it was self-limited with diet modifications. An ultrasound demonstrated a contracted gallbladder with a 15 mm gallbladder wall. White blood cell count was within normal limits and total bilirubin was slightly elevated to 1.8 mg/dL. No palpable mass was noted on physical exam. An MR cholangiopancreatography was performed which demonstrated a dilated gallbladder measuring 11.5 x 2.5 cm, a severely thickened gallbladder with a small intramural collection and multiple gallstones. The patient proceeded with a laparoscopic cholecystectomy. Intraoperatively, the omentum was densely adhered to the gallbladder and needle decompression of the gallbladder was unsuccessful due to the wall thickness. The gallbladder was subsequently removed without any complications. Patient's remaining hospital course was uncomplicated. Surgical pathology returned demonstrating acute on chronic cholecystitis.
Discussion(s): Cholecystomegaly or 'Giant Gallbladder' disease is a rare pathology encountered in the surgical world. There have been few reported cases, most of which occurred in the elderly ([65 years). Kuznetsov et al. defined an enlarged gallbladder to have a volume of 200-300 cc and a giant gallbladder as exceeding 1500 cc (the average weight of the liver). The etiology remains unknown, however certain factors exist to allow the gallbladder to reach this size without life-threatening sequela. Preoperative imaging, such as MR cholangiopancreatography, is important to differentiate biliary pathology and delineate anatomy. Removal of the gallbladder is recommended to prevent the development of complications like cholangitis or bowel obstruction. The cause of cholecystomegaly still remains uncertain and warrants further research. The management and treatment remains similar to acute cholecystitis
Successful endoscopic management of efferent loop syndrome after Billroth II distal gastrectomy
Lack of Diagnosis of Pneumoperitoneum in Perforated Duodenal Ulcer After RYGB: a Short Case Series and Review of the Literature
Perforated duodenal ulcer following RYGB is an unusual clinical situation that may be a diagnostic challenge. Only 23 cases have previously been reported. We present five cases. The hallmark of visceral perforation, namely pneumoperitoneum, was not seen in three of the four cases that underwent cross sectional imaging. This is perhaps due to the altered anatomy of the RYGB that excludes air from the duodenum. Our cases had more free fluid than expected. The bariatric surgeon should not wait for free intraperitoneal air to suspect duodenal perforation after RYGB.
SAGES quality initiative: an introduction
The Medicare program has transitioned to paying healthcare providers based on the quality of care delivered, not on the quantity. In May 2015, SAGES held its first ever Quality Summit. The goal of this meeting was to provide us with the information necessary to put together a strategic plan for our Society over the next 3-5 years, and to participate actively on a national level to help develop valid measures of quality of surgery. The transition to value-based medicine requires that providers are now measured and reimbursed based on the quality of services they provide rather than the quantity of patients in their care. As of 2014, quality measures must cover 3 of the 6 available National Quality domains. Physician quality reporting system measures are created via a vigorous process which is initiated by the proposal of the quality measure and subsequent validation. Commercial, non-profit, and governmental agencies have now been engaged in the measurement of hospital performance through structural measures, process measures, and increasingly with outcomes measures. This more recent focus on outcomes measures have been linked to hospital payments through the Value-Based Purchasing program. Outcomes measures of quality drive CMS' new program, MACRA, using two formats: Merit-based incentive programs and alternative payment models. But, the quality of information now available is highly variable and difficult for the average consumer to use. Quality metrics serve to guide efforts to improve performance and for consumer education. Professional organizations such as SAGES play a central role in defining the agenda for improving quality, outcomes, and safety. The mission of SAGES is to improve the quality of patient care through education, research, innovation, and leadership, principally in gastrointestinal and endoscopic surgery.
Reducing liberal red blood cell transfusions at an academic medical center
BACKGROUND: Educational and computerized interventions have been shown to reduce red blood cell (RBC) transfusion rates, yet controversy remains surrounding the optimal strategy needed to achieve sustained reductions in liberal transfusions. STUDY DESIGN AND METHODS: The purpose of this study was to assess the impact of clinician decision support (CDS) along with targeted education on liberal RBC utilization to four high-utilizing service lines compared with no education to control service lines across an academic medical center. Clinical data along with associated hemoglobin levels at the time of all transfusion orders between April 2014 and December 2015 were obtained via retrospective chart review. The primary outcome was the change in the rate of liberal RBC transfusion orders (defined as any RBC transfusion when the hemoglobin level is >7.0 g/dL). Secondary outcomes included the annual projected reduction in the number of transfusions and the associated decrease in cost due to these changes as well as length of stay (LOS) and death index. These measures were compared between the 12 months prior to the initiative and the 9-month postintervention period. RESULTS: Liberal RBC utilization decreased from 13.4 to 10.0 units per 100 patient discharges (p = 0.002) across the institution, resulting in a projected 12-month savings of $720,360. The mean LOS and the death index did not differ significantly in the postintervention period. CONCLUSION: Targeted education combined with the incorporation of CDS at the time of order entry resulted in significant reductions in the incidence of liberal RBC utilization without adversely impacting inpatient care, whereas control service lines exposed only to CDS had no change in transfusion habits.