Critical Care Surgery Research Articles

The lasting impact of virtual interviews on surgical fellowship applicants

PurposeSurgical fellowship interviews shifted to a virtual platform in 2020 due to the COVID-19 pandemic. While virtual interviews provide convenience, they also pose difficulties for programs and raise potential barriers for applicants. This study compares in-person to virtual interviews and characterizes the impact on programs and applicants.MethodsIn-person (2007–2019) and virtual (2020–2022) fellowship application data were extracted from publicly available NRMP Specialties Matching Service data. Fellowship programs included surgical critical care, surgical oncology, colorectal, pediatric, thoracic, and vascular surgery. Competitiveness was assessed using a validated normalized competitiveness index (NCI).ResultsSince virtual interviews, rankings per applicant, a surrogate for program interview workload, increased for all fellowships except pediatric surgery. The most competitive subspecialties now include colorectal, pediatric, and thoracic surgery. For non-US MDs in these subspecialties, applicants per position decreased (pediatric), match rate decreased (thoracic), and NCI increased (thoracic) under virtual interviewing. However, for the least competitive subspecialties, non-US MDs had increased rankings per applicant (critical care and vascular), increased match rate (critical care and surgical oncology), and decreased NCI (surgical oncology) with virtual interviewing.ConclusionsSince the virtual platform was implemented, applicants have interviewed at and ranked more programs, subsequently increasing program workload. While this is positive for many applicants, a differential pattern of securing a fellowship emerged for non-US MD applicants. This finding is important for fellowship program directors to consider and ensure non-US MD applicants are not marginalized with the virtual platform.Level of EvidenceIII

Negative Pressure Wound Therapy With and Without Instillation in Necrotizing Soft Tissue Infections.

Background: Necrotizing soft tissue infections (NSTIs) are rare but deadly infections that require early and often extensive surgical debridement. After debridement, patients frequently have substantial morbidity because of large, open wounds. Hypothesis: Negative pressure wound therapy with instillation (NPWTi) results in higher wound closure rates compared with traditional negative pressure wound therapy (NPWT) or wet to dry dressings (moist wound care dressing). Patients and Methods: A prospectively maintained Acute and Critical Care Surgery database spanning 2008-2018 was queried for patients with a diagnosis of necrotizing fasciitis, Fournier gangrene, or gas gangrene. Data were collected on patient comorbidities, operative management, and clinical outcomes. Patients were stratified by use of moist wound care dressing, traditional NPWT, or NPWTi. Data were analyzed using analysis of variance (ANOVA), χ2, and logistic regression. Results: During the 10-year study period, patients were treated for NSTI; 173 were managed with moist wound care dressing, 150 with NPWT, and 48 with NPWTi. Patients were similar in terms of demographics, body mass index (BMI), diabetes mellitus, and smoking rates. Overall, complication rates were not substantially different, but mortality was higher in the moist wound care dressing group (16.2% vs. 10.7% NPWT vs. 2.1% NPWTi; p = 0.02). In the moist wound care dressing group, 81.5% of patients had an open wound at discharge compared with 52.7% of the NPWT group and only 14.6% of the NPWTi group (p < 0.001). On multivariable regression, NPWTi was associated with closure rates five times higher than the NPWT group (odds ratio [OR], 5.28; 95% confidence interval [CI], 2.40-11.61; p < 0.001) after controlling for smoking status, intravenous drug use, number of operations, and involvement of the most common region of the body. Conclusions: Negative pressure wound therapy with instillation is associated with higher rates of wound closure without increasing complication rates in patients with NSTI compared with traditional NPWT or moist wound care dressing. Although prospective studies are needed, this indicates the potential to improve patient quality of life through reduced pain and outpatient home health needs.

Does Negative Pressure Wound Therapy Impact the Outcome for Patients With Necrotizing Soft Tissue Infection Infected With Anaerobic Bacteria?

Background: A notable improvement in the treatment of necrotizing soft tissue infections (NSTIs) is the development of negative pressure wound therapy (NPWT). Clinicians are still debating whether NPWT is as successful as conventional wet-to-dry dressings at removing bacteria. Recent research has revealed potential oxygen deprivation effects of NPWT in underlying wound tissues, although clinical trials regarding the effects of reduced oxygen on anaerobic bacterial soft tissue infections remain noticeably lacking. Hypothesis: We hypothesized that NPWT-treated patients with NSTIs who were solely infected by anaerobic bacteria would have worse outcomes than those who were infected with other bacterial species. Patients and Methods: Our study included a retrospective examination of the 2008-2022 period of our Acute and Critical Care Surgery database. Patients who had been identified as having necrotizing fasciitis, Fournier gangrene, or gas gangrene and who had their conditions verified by positive wound cultures acquired during the initial debridement and subsequently received NPWT made up the study cohort. Comorbidities, surgical techniques, and clinical results were all covered by the data. Based on their wound infections, patients were divided into two groups: those with exclusively anaerobic NSTIs and those with different bacterial groups (such as polymicrobial and aerobic). Multiple regression, χ2 analysis, and analysis of variance (ANOVA) were among the analytical methods used. Results: One hundred twelve patients with NSTI who had received NPWT comprised the study cohort. Sixteen of these patients (14.3%) had NSTIs that were exclusively anaerobic, whereas the remaining 96 (85.7%) had NSTIs that were mixed aerobic, facultative, or polymicrobial. Between the two groups, there was no difference in the initial wound size. Patients with anaerobic NSTI who underwent NPWT showed a statistically significant increase in the number of debridements (3 [interquartile range {IQR},1-9] vs. 2 [IQR, 1-4]; p = 0.012) and an increased 100-day re-admission rate (37.5% vs. 12.5%; p = 0.012) when compared with patients with non-anaerobic NSTI. The 100-day re-admission rate increased three-fold in NPWT-treated anaerobic NSTIs, according to a logistic regression analysis (odds ratio [OR], 3.63; 95% confidence interval [CI], 1.06-12.44; p = 0.04). Conclusions: In contrast to patients with other bacterial strains, our data show that patients with NSTI treated with NPWT who only have anaerobic bacterial infections have a larger number of debridements and are much more likely to require re-admission within 100 days. We call for additional prospective studies to be conducted to identify additional risk factors and consider alternate treatment options for individuals with exclusively anaerobic NSTIs in light of these findings.

Implementation of Mandibular Distraction Osteogenesis for Patients With Pierre Robin Sequence in a Developing Country Through International Collaboration: A Paradigm for Success.

Though it has made significant strides, Vietnam remains a resource-constrained country of 98 million people. Vietnam National Children's Hospital (VNCH) provides tertiary care to a catchment of 40 million people and is the sole national children's hospital. As such, it is one of the few referral centers in the country equipped to take care of patients diagnosed with Pierre Robin sequence (PRS) as this requires pulmonary, critical care, otolaryngology, and plastic surgery expertise. Before 2015, the only surgical options were tongue lip adhesion or tracheostomy. Only 20% of patients successfully avoided tracheostomy, mechanical ventilation, or death. From 2015 to 2019, mandibular distraction osteogenesis (MDO) was introduced by visiting international surgeons on a short-term basis. Since 2020, local surgeons at VNCH have refined their technique and widely use MDO independently. This report seeks to capitulate their experience and identify factors leading to success. A retrospective review was conducted of patients diagnosed with PRS at VNCH from 2015 to 2022. Paper records were digitized, translated, and reviewed for inclusion criteria, including demographics, indications, hospital course, and postoperative outcomes. Complete records satisfying inclusion criteria were available for 53 patients with a diagnosis of PRS who underwent MDO from 2020 to 2022. From 2015 to 2019, there were 19 cases of MDO, though records were incomplete. The median age at the time of MDO was 50 ± 43 days. Forty patients (75.5%) had isolated PRS and 13 (24.5%) were syndromic. Forty-four patients (83%) had a cleft palate. Fifty-one (96.2%) of patients required preoperative supplemental oxygen or mechanical ventilation. The active distraction and consolidation phase was 4.8 ± 1.3 months. The median days to discharge after surgery was 19.0 ± 8.3 days. Median weight at birth, at the time of surgery, and at the time of device removal were 6.8 ± 1.2, 7.7 ± 1.9, and 14.8 ± 2.8 pounds, respectively. Fifty-two patients (98.1%) had obstructive sleep apnea preoperatively with an average Apnea Hypopnea Index of 25.0 ± 10.6. Post-MDO, only 4 (7.5%) had obstructive sleep apnea and the average Apnea Hypopnea Index was 5.2 ± 0.6. No patients (0) required a tracheostomy for a 100% success rate. The tremendous success of the implementation of MDO by local surgeons in Vietnam after its introduction by visiting international surgeons illustrates a paradigm for capacity-enhancing global surgical endeavors. Mandibular distraction osteogenesis has replaced tongue lip adhesion as the surgical treatment of choice for PRS patients at VNCH. Surgical techniques can be transferred to operating environments with basic infrastructure through collaboration and resource optimization. These results demonstrate that global surgical engagement may be scalable and repeatable with direct benefits for patients in lower-middle-income countries.

Surgical Fellowships Demonstrate Variable Improvement in Gender Representation Despite Greater Female Enrollment in General Surgery Residencies

Despite increasing female representation in General Surgery (GS) residency training programs, proportional improvement of female enrollment in surgical fellowships has yet to be quantified. We aimed to assess if female enrollment in surgical fellowships has improved at an equivalent rate in 7 different surgical fellowship options after GS. Data were collected from Accreditation Council for Graduate Medical Education (ACGME) resources which disclosed active resident and fellow characteristics. Gender identification was self-reported by residents to ACGME. Gender data collected for GS programs and surgical fellowships including Surgical Critical Care, Colon, and Rectal Surgery, Pediatric Surgery, Plastic Surgery, Surgical Oncology, Thoracic Surgery, and Vascular Surgery from annual reports. Pearson Chi-squared analysis was conducted between GS residencies and fellowship programs in their corresponding years using Stata15 software. In all years examined, fellowships in Vascular, Thoracic, and Plastic Surgery had significantly lower female enrollment in proportion to the number of female GS residents (p = <0.02). In all years examined, Surgical Oncology, Pediatric, Colon and Rectal, and Surgical Critical Care had female enrollment that was, at minimum, proportional to female enrollment in GS residency, indicating equitable gender representation. Surgical Oncology (2016), Pediatric (2020) and Surgical Critical Care (2016) fellowships each had 1 year where female enrollment was significantly higher than General Surgery. The enrollment of female surgeons in Plastic, Vascular, and Thoracic Surgery fellowships has not improved proportionally despite an increase in female GS residents. These results suggest the possibility of persistent factors that deter female enrollment in Vascular, Thoracic and Plastic Surgery fellowships that are not present to the same degree in fields with equitable fellowship female enrollment. Female representation in surgical fellowships is vital to improving gender diversity in all disciplines of surgery, particularly academic surgery.

The accuracy of the new non-invasive intra-abdominal pressure measurement by physical examination and ultrasound to diagnose intra-abdominal hypertension: The research protocol

Background: Twenty-five percent of critically ill patients in the intensive care unit have intra-abdominal hypertension, which causes high morbidity and mortality. The gold standard non-invasive method for measuring intra-abdominal pressure to diagnose intra-abdominal hypertension is intravesical pressure measurement. Unfortunately, the standard method has several limitations. The aim of this study is to invent a new, non-invasive method to diagnose intra-abdominal hypertension. Methods: This is a cross-sectional study to determine the accuracy of the new non-invasive intra-abdominal pressure measurement by physical examination and ultrasound to diagnose intra-abdominal hypertension compared to the intravesical pressure measurement. Hypothesis: We hypothesize that physical examination and ultrasound can be used to diagnose intra-abdominal hypertension and the ratio of maximal anteroposterior to transverse abdominal diameter minus fat thickness and intra-abdominal pressure has a correlation. Ethics and dissemination: The study received ethical approval from the Institutional Review Board of Faculty of Medicine, Chulalongkorn University. We plan to disseminate the results in peer-reviewed journals related to critical care medicine or surgery and at national or international conferences.

Handshake stewardship on adult acute-care surgical services

Background: Handshake stewardship is a variation of prospective audit and feedback that entails the individual review of patient charts by a physician–pharmacist collaborative team followed by in-person feedback to primary teams to communicate recommendations regarding optimal antibiotic use. Handshake stewardship has been shown to have durable effects in reducing antimicrobial use in children’s hospitals, but data regarding this intervention in adult hospitals are scarce. In particular, no data are available regarding the impact of this type of stewardship intervention on adult surgical units. We examined the effect of a handshake stewardship intervention at a large academic medical center on adult trauma and acute- and critical-care surgery (ACCS) units. Methods: The antimicrobial stewardship program (ASP) at Barnes-Jewish Hospital launched a handshake stewardship intervention targeting surgical floor teams in January 2022. These teams included the ACCS teams and a number of other surgical services. The intervention consisted of once weekly reviews and in-person rounds with the surgical floor teams along with the establishment of a 7 day per week “hotline” in which the surgical teams could contact an ID physician or pharmacist with questions regarding antibiotic use. Patients with formal ID consultations were not reviewed. Recommendations were tracked including the type, the antibiotic targeted, and recommendation acceptance or rejection. Descriptive statistics were performed to analyze these results. At the end of 12 months, antibiotic use in the floors covered by the ACCS teams were pulled from the NHSN AU module to perform an interrupted time-series analysis 12 months before and after the intervention. Results: Overall, 3,127 charts were reviewed during the intervention period and 637 recommendations were made to all the surgical teams. Opportunities for antibiotic use optimization were identified in ~20% of antibiotic orders. The overall recommendation acceptance rate was 71%. In the ACCS units, 272 interventions were recommended, with an acceptance rate of 67%. The most frequent recommendations were for antibiotic discontinuation (37%), antibiotic de-escalation (17%), shortening duration (12%), and broadening coverage (12%). Antibiotic usage trends (Fig. 1) on the ACCS floors, which were showing a nonsignificant increasing trend (P = .70) before and after the intervention, now show a nonsignificant decreasing trend (P = .20). Conclusions: There are numerous opportunities for antibiotic optimization on adult surgical floors. Although handshake stewardship is a labor-intensive intervention, preliminary findings after 1 year show that, on ACCS units, there may be a trend toward a sustained impact.Disclosures: None

The Future of Cardiothoracic Surgical Critical Care Medicine as a Medical Science: A Call to Action.

Cardiothoracic surgical critical care medicine (CT-CCM) is a medical discipline centered on the perioperative care of diverse groups of patients. With an aging demographic and an increase in burden of chronic diseases the utilization of cardiothoracic surgical critical care units is likely to escalate in the coming decades. Given these projections, it is important to assess the state of cardiothoracic surgical intensive care, to develop goals and objectives for the future, and to identify knowledge gaps in need of scientific inquiry. This two-part review concentrates on CT-CCM as its own subspeciality of critical care and cardiothoracic surgery and provides aspirational goals for its practitioners and scientists. In part one, a list of guiding principles and a call-to-action agenda geared towards growth and promotion of CT-CCM are offered. In part two, an evaluation of selected scientific data is performed, identifying gaps in CT-CCM knowledge, and recommending direction to future scientific endeavors.

1264: EXTRACORPOREAL MEMBRANE OXYGENATION IN MASSIVE PULMONARY EMBOLISM: THE CHALLENGES OF DIAGNOSIS OF PE

Introduction: Pulmonary embolism (PE) is the third most common cause of death after myocardial infarction & stroke. Diagnosis is challenging without a computed tomographic pulmonary angiography (CTPA), & advanced management techniques are difficult to implement without confirmation. We present a patient who was unable to undergo a CTPA, but through a multidisciplinary approach was progressed to veno-arterial extracorporeal membrane oxygenation (VA ECMO). Description: A 245-kg 30-year-old male was admitted for Ludwig’s angina, fiber-optically intubated, taken for incision & drainage, & later successfully extubated. Two days later, he became increasingly hypoxic, leading to reintubation and initiation of a heparin infusion for suspected massive PE. Point of care ultrasound was non-diagnostic due to poor acoustic windows & CTPA unobtainable due to the patient’s body habitus. He progressed to obstructive shock & refractory hypoxia. Lower extremity (LE) dopplers were positive for extensive deep venous thrombosis. A multidisciplinary team including critical care, interventional cardiology & cardiothoracic surgery, opted to proceed to the catheterization lab for a transesophageal echocardiogram (TEE) & pulmonary angiography for diagnosis & attempted thrombectomy with VA ECMO as backup. TEE showed a severely dilated right ventricle (RV) with strain. Angiography confirmed extensive PE, but catheter advancement induced ventricular fibrillation & thrombectomy was aborted. Patient was then cannulated for VA ECMO. Discussion: CTPA is the first line diagnostic technique in patients with PE. Unfortunately, our patient’s body habitus limited the ability for this modality. Catheter pulmonary angiography has been considered too invasive solely for diagnosis but has been favored over CTPA when endo-vascular intervention is intended. Angiography has its limitations, including ease of availability, risk of hemodynamic compromise in severe RV failure & interpretation of imaging. Although this is a concern, it should not deter from making a diagnosis given the case-fatality of an undiagnosed PE. We aim to recognize the challenges in PE diagnosis and to reiterate the importance of a multidisciplinary approach in massive PE to broaden therapeutic options and improve mortality.

New Concept of a Surgical Hospitalist: Early Experience of Managing the Admission, Critical Care, Trauma Surgery Team

The demand for hospitalists is increasing due to decreasing numbers of clinical residents and increased concerns regarding patient safety. However, several limitations in the surgical hospitalist role exist. The personnel of the surgical hospitalist, rapid response team (RRT), surgical critical care, and trauma surgery teams were unified under the admission, critical care, and trauma surgery (ACTs) team at this institution. The ACTs target are patients with severe disease not undergoing general postoperative course, or patients with the potential for severe conversion. Two surgical intensivists are on duty once a week and oversee the intensive care unit (ICU), the back-up treatment of critically ill patients, and the immediate treatment of trauma patients. ACTs also participate in the surgical RRT and select patients with a high probability of severe exacerbation. Between 2019-2021, the cardiopulmonary resuscitation incidence per 1,000 hospitalized patients in the surgical department decreased significantly from 0.81 to 0.55. From March to December 2021, the ACTs team were involved with 101 of 158 surgical patients admitted to the ICU: 62 with postoperative status, 29 with severe trauma, and 10 transferred to the ICU via RRT screening. Based on our experience, the role of the ACTs team can help improve patient safety.

Temporary mechanical circulatory support devices: practical considerations for all stakeholders.

Originally intended for life-saving salvage therapy, the use of temporary mechanical circulatory support (MCS) devices has become increasingly widespread in a variety of clinical settings in the contemporary era. Their use as a short-term, prophylactic support vehicle has expanded to include procedures in the catheterization laboratory, electrophysiology suite, operating room and intensive care unit. Accordingly, MCS device design and technology continue to develop at a rapid pace. In this Review, we describe the functionality, indications, management and complications associated with temporary MCS, together with scenario-specific utilization, goal-directed development and bioengineering of future devices. We address various considerations for the use of temporary MCS devices in both prophylactic and rescue scenarios, with input from stakeholders from various cardiovascularspecialties, including interventional and heart failure cardiology, electrophysiology, cardiothoracic anaesthesiology, critical care and cardiac surgery.

Clinician preference instrumental variable analysis of the effectiveness of magnesium supplementation for atrial fibrillation prophylaxis in critical care

Atrial fibrillation is a frequently encountered condition in critical illness and causes adverse effects including haemodynamic decompensation, stroke and prolonged hospital stay. It is a common practice in critical care to supplement serum magnesium for the purpose of preventing episodes of atrial fibrillation. However, no randomised studies support this practice in the non-cardiac surgery critical care population, and the effectiveness of magnesium supplementation is unclear. We sought to investigate the effectiveness of magnesium supplementation in preventing the onset of atrial fibrillation in a mixed critical care population. We conducted a single centre retrospective observational study of adult critical care patients. We utilised a natural experiment design, using the supplementation preference of the bedside critical care nurse as an instrumental variable. Using routinely collected electronic patient data, magnesium supplementation opportunities were defined and linked to the bedside nurse. Nurse preference for administering magnesium was obtained using multilevel modelling. The results were used to define "liberal" and "restrictive" supplementation groups, which were inputted into an instrumental variable regression to obtain an estimate of the effect of magnesium supplementation. 9114 magnesium supplementation opportunities were analysed, representing 2137 critical care admissions for 1914 patients. There was significant variation in magnesium supplementation practices attributable to the individual nurse, after accounting for covariates. The instrumental variable analysis showed magnesium supplementation was associated with a 3% decreased relative risk of experiencing an atrial fibrillation event (95% CI − 0.06 to − 0.004, p = 0.03). This study supports the strategy of routine supplementation, but further work is required to identify optimal serum magnesium targets for atrial fibrillation prophylaxis.

Bridging the Gap: How to Get Osteopathic Residents Into Fellowships.

IntroductionThe fellowship match process is convoluted, with each specialty having its match on its timeline- with some programs having a Post Graduate Year (PGY) 4th-year or 5th-year match.This study aims to identify tangible recommendations for osteopathic surgery residents to use to improve their applications and, ultimately, the success rate for matching into post-graduate fellowship training.MethodsIn October 2021, as a part of the American College of Osteopathic Surgeons (ACOS) Strategic Planning efforts, the ACOS Resident Student Section sent a questionnaire to the listed email contact for each surgical fellowship program. Fellowship coordinators and program directors were included in the survey. The programs that were included in the study were vascular, thoracic (which included cardiothoracic), surgical critical care, endocrine, hepatobiliary, transplant, pediatric, surgical oncology, breast, minimally invasive, and colorectal surgery.ResultsOf the 108 programs that answered the survey, 36% of them reported they currently had an osteopathic fellow, and another 29% said they had an osteopathic fellow in the past. 35% of the programs listed that they had never had an osteopathic fellow in their program.In regards to how residents can improve their application for fellowship matches the most common answer was research in the field, they were trying to match into. They wanted to see high scores on the United States Medical Licensing Examination (USMLE) and American Board of Surgery In-Training Examination (ABSITE) exams. They also noted that they wanted candidates from more well know residency programs, where they knew the residents would have gotten good training.ConclusionWe recommend that any potential fellowship applicant focus on the following three areas increase competitiveness for matching into fellowship training: publication in the desired field, increased overall scholarly activity, and increased ABSITE scores.

Performance of a new single-use bronchoscope versus a marketed single-use comparator: a bench study

BackgroundSingle-use flexible bronchoscopes eliminate cross contamination from reusable bronchoscopes and are cost-effective in a number of clinical settings. The present bench study aimed to compare the performance of a new single-use bronchoscope (Boston Scientific EXALT Model B) to a marketed single-use comparator (Ambu aScope 4), each in slim, regular and large diameters.MethodsThree bronchoscopy tasks were performed: water suction and visualization, “mucus” mass (synthetic mucoid mixture) suctioned in 30 s, and “mucus” plug (thicker mucoid mixture) suction. Suction ability, task completion times, and subjective ratings of visualization and overall performance on a scale of one to 10 (best) were compared. All bronchoscopy tasks were completed by 15 physicians representing diversity in specialization including pulmonary, interventional pulmonary, critical care, anesthesia, and thoracic surgery. Each physician utilized the six bronchoscope versions with block randomization by bronchoscope and task.ResultsAspirated mean mass of “mucus” using EXALT Model B Regular was comparable to that for an aScope 4 Large (41.8 ± 8.3 g vs. 41.5 ± 5.7 g respectively, p = 0.914). In comparisons of scopes with the same outer diameter, the aspirated mean mass by weight of water and “mucus” was significantly greater for EXALT Model B than for aScope 4 (p < 0.001 for all three diameters). Mean ratings for visualization attributes were significantly better for EXALT Model B compared to aScope 4 (p-value range 0.001−0.029).ConclusionA new single-use bronchoscope provided strong suction capability and visualization compared to same-diameter marketed single-use comparators in a bench model simulation.

Development of Low-Cost and Portable Pulse Oximeter Device with Improved Accuracy and Accessibility

PurposeIn a clinical setting, blood oxygen saturation is one of the most important vital sign indicators. A pulse oximeter is a device that measures the blood oxygen saturation and pulse rate of patients with various disorders. However, due to ethical concerns, commercially available pulse oximeters are limited in terms of calibration on critically sick patients, resulting in a significant error rate for measurement in the critical oxygen saturation range. The device’s accessibility in developing countries’ healthcare settings is also limited due to portability, cost implications, and a lack of recognized need. The purpose of this study was to develop a reliable, low-cost, and portable pulse oximeter device with improved accuracy in the critical oxygen saturation range.MethodsThe proposed device measures oxygen saturation and heart rate using the reflectance approach. The rechargeable battery and power supply from the smartphone were taken into account, and the calibration in critical oxygen saturation values was performed using Prosim 8 vital sign simulator, and by comparing with a standard pulse oximeter device over fifteen iterations.ResultsThe device’s prototype was successfully developed and tested. Oxygen saturation and heart rate readings were both accurate to 97.74% and 97.37%, respectively, compared with the simulator, and an accuracy of 98.54% for the measurement of blood oxygen saturation was obtained compared with the standard device.ConclusionThe accuracy of oxygen measurement attained in this study is significant for measuring oxygen saturation for patients in critical care, anesthesia, pre-operative and post-operative surgery, and COVID-19 patients. The advancements made in this research have the potential to increase the accessibility of pulse oximeter in resource limited areas.

Not all is lost: Dynamic functional recovery in older adults following emergency general surgery.

Division of Traumatology, Surgical Critical Care and Emergency Surgery Penn Presbyterian Medical Center Perelman School of Medicine University of Pennsylvania Philadelphia, Pennsylvania The authors declare no conflicts of interest.

A disturbing trend: An analysis of the decline in surgical critical care fellowship training of Black and Hispanic surgeons.

Underrepresented minorities in medicine (URiMs) are disproportionally represented in surgery training programs. Rates of URiMs applying to and completing General Surgery residency remain low. We hypothesized that the patterns of URiMs disparities would persist into surgical critical care (SCC) fellowship applicants, matriculants, and graduates. We performed a retrospective analysis of SCC applicants, matriculants, and graduates from 2005 to 2020 using the graduate medical education resident survey and analyzed applicant characteristics using the Surgical Critical Care and Acute Care Surgery Fellowship Application Service from 2018 to 2020. The data were stratified by race/ethnicity and sex. Indicator variables were created for Asian, Hispanic, White, and Black trainees. Yearly proportions for each race/ethnicity and sex categories completing or enrolling in a program were calculated and plotted over time with Loess smoothing lines and overlying 95% confidence bands. The yearly rate and statistical significance of change over time were tested with linear regression models with race/ethnicity and sex proportion as the dependent variables and year as the explanatory variable. From 2005 to 2020, there were a total of 2,481 graduates. Black men accounted for 4.7% of male graduates with a significant decline of 0.3% per year for the study period of those completing the fellowship (p = 0.02). Black women comprised 6.4% of female graduates and had a 0.6% decline each year (p < 0.01). A similar trend was seen with Hispanic men, who comprised 3.2% of male graduates and had a 0.3% annual decline (p = 0.02). White men had a significant increase in both matriculation to and graduation from SCC fellowships during the same interval. Similarly, Black and Hispanic applicants declined from 2019 to 2020, while the percentage of White applicants increased. Disparities in URiMs representation remain omnipresent in surgery and extend from residency training to SCC fellowship. Efforts to enhance the recruitment and retention of URiMs in SCC training are warranted. Prognostic and Epidemiologic; level IV.

584 Where Are They Now? - A Single-Center Survey of Burn Surgery Fellow Graduates

IntroductionBurn surgery encompasses different surgical disciplines such as general surgery, trauma, surgical critical care and plastic surgery. Those who apply to burn fellowship also have various interests. This study’s purpose was to discern the various career paths of burn fellowship graduates. It also investigated the frequency of specific chosen specialties and workplace settings. The results of the study could be used to modify current clinical burn fellowship curriculum.MethodsA survey was created using an internet tool and emailed to graduates of the clinical burn fellowship program from an American Burn Association verified burn center. The survey was sent to graduates of the last 10 years (2010-2020). The questions inquired about surgical field of work, board certification, additional training experience, work setting, and time since fellowship graduation. The participants’ responses were recorded anonymously to account for biases. The quantitative data was then collected for each question, and the data was calculated into percentages.ResultsOf the possible 17 fellows who graduated in the past ten years, 11 responded to our survey (64.7%). The most common surgical field pursued after the fellowship was plastic surgery with 5 graduates (45.5%). The following three fields all had 2 graduates each: burn surgery (burn/trauma), general surgery and wound care (18.2%). Almost all of the participants had completed additional training: 6 in plastic surgery (54.5%), and 4 in surgical critical care (36.4%). The work settings were primarily academic institutions (45.5%), followed by office-based practices (35.4%), ambulatory surgery centers (9.1%), and community hospitals (9.1%). Of the participants, 4 are board-certified in their chosen field, and 5 are board-eligible. Only 3 graduates are affiliated with a burn center.ConclusionsThe results of the study indicate the interests and career choices of previous burn fellows. This information can be used to modify burn fellowship curriculums to the needs and future career paths of the fellows. Traditional clinical burn fellowship programs emphasize burn critical care and acute burn surgery. Since some of the graduates are interested in plastic surgery, burn reconstruction could be added to the current curriculum. Plastic surgery faculty members could also serve as mentors to the fellows.

199 Electronic Clinical Decision Support for Children with Mild Traumatic Brain Injuries and Intracranial Injuries: A Sociotechnical Analysis

INTRODUCTION: The management of children with mild traumatic brain injuries (mTBI) and intracranial injuries is not evidence-based and may place some children at risk of harm. Evidence-based electronic clinical decision support (CDS) may improve patient safety and decrease resource use. METHODS: We conducted semi-structured qualitative focus group interviews to identify sociotechnical influences on CDS implementation. Physicians from neurosurgery, emergency medicine, critical care, and pediatric general surgery were included, along with information technology specialists. Participants were recruited from nine hospitals in the United States. Focus group transcripts were coded and analyzed using thematic analysis. The final themes were cross-referenced with previously defined sociotechnical dimensions. RESULTS: We included 28 physicians and four information technology specialists in seven focus groups. Ten participants had administrative leadership positions, and the largest group (34%) was from neurosurgery. Through inductive thematic analysis, we identified five primary themes: 1) clinical impact; 2) stakeholders and users; 3) tool content; 4) clinical practice integration; and 5) post-implementation evaluation measures. Participants generally supported using CDS to determine an appropriate level-of-care for these children, and also noted potential secondary uses (e.g., informing family discussions). However, some also identified potential harm that could result from misuse (e.g., conflict across specialties). Feedback from the interviews helped refine the tool content, highlight potential implementation barriers, and identify appropriate measures to evaluate after implementation. CONCLUSION: We identified key factors impacting the implementation of electronic CDS for children with mTBI and intracranial injuries, providing a strong foundation for prospective implementation efforts.

Inferior Vena Cava Filter Utilization at Kingston Health Sciences Centre: A Comparison of Practice with Guidelines

Background: Inferior vena cava (IVC) filters offer mechanical protection against pulmonary embolism in high risk patients. Guidelines have recommended their use be limited. “Don't use inferior IVC filters routinely in patients with acute venous thromboembolism” (ASH Choosing Wisely, 2013). “For patients with acute VTE who are treated with anticoagulation, the guideline recommends against the use of an inferior vena cava filter.” (CHEST Antithrombotic Therapy and Prevention of Thrombosis, 2016) IVC filters implanted for longer than 100 days confer a significantly higher risk of complications (Odds Ratio 2.3, Dinglasan et al. 2013). We sought to determine compliance with these recommendations at Kingston Health Sciences Center (KHSC), an academic tertiary referral center with 440 inpatient beds at Queen's University in Kingston, Ontario, Canada.Methods: Approval was obtained from the Queen's Health Services Research Ethics Board.Consecutive patients with IVC filter implantation at KHSC from August 1st, 2013 to August 1st, 2016 were identified through Interventional Radiology records. All charts were retrospectively reviewed in depth by one investigator followed by review and discussion. Data extracted included: patient demographics and disposition, details surrounding IVC filter insertion and removal, and IVC filter related complications. The indication for filter implantation was classified as clearly consistent or not clearly consistent with CHEST guidelines. The category ‘lesser indication’ was subsequently added for cases of a more subjective nature where definitive categorization was challenging.Results: Between August 2013 and August 2016, 95 IVC filters were implanted at KHSC. Among these, 42 (44.2%) patients were male and the median age was 67 (ages ranged from 17 to 91). The most responsible services ordering IVC filter implantation were Critical Care Medicine (37.9%), Internal Medicine (32.6%), Surgery (12.6%) and other services such as Neurology, Family Medicine and Emergency Medicine (16.9%).Complications arose in 21 patients (22.1%) including filter-associated thrombosis (11), filter migration or tilt (8), IVC penetration (5), IVC perforation (2), and one instance of suspected IVC filter seeding with methicillin sensitive Staphylococcus aureus (MSSA) leading to bacteremia. The mean dwell time of filters that were successfully removed (n=52, 54.7%) was 69.2 days, with thirteen (18.1%) remaining indwelling beyond 100 days. Of those in whom the filter was not removed (n=43), unsuccessful retrieval attempts were made in eight, 23 patients died with their filters in situ within 100 days of implantation, and in 12 patients no record of an attempt to retrieve the device was found.Indication for IVC filter insertion was clearly consistent with CHEST guidelines in 58 (61.1%) patients. Insertion alongside therapeutic anticoagulation/thrombolysis or for prophylaxis in patients without VTE occurred in 26 patients (27.4%) and was considered not consistent with current recommendations. In 8 (8.4%) patients, a ‘lesser indication’ was identified. Lesser indications included cases where there was a need to withhold anticoagulation for less than 24 hours for procedures or surgeries, such as endoscopic retrograde cholangiopancreatography (ERCPs) or ankle open reduction internal fixations (ORIFs). Three charts had insufficient information to determine compliance.Discussion: The main limitation of this study is its retrospective nature with reliance on chart documentation. In addition, it is recognized that guidelines surrounding IVC filter use do not apply to all possible clinical scenarios. Nonetheless, restricting the use of IVC filters to appropriate indications is an important endeavour. These devices are costly, can cause harm, and do not have a strong evidentiary basis. Educational initiatives are underway to optimize use of IVC filters at KHSC. Additional interventions under consideration include development of a specific requisition form listing recommended indications, and creation of an IVC filter insertion database as a prompt for timely removal. DisclosuresHay:Celgene: Research Funding; Roche: Research Funding; Abbvie: Research Funding; Kite: Research Funding; Amgen: Research Funding; Janssen: Research Funding; Novartis: Research Funding.