High-volume Academic Center Research Articles

Abstract TP360: Nursing Unit Stroke Patient Education Initiative Improves Documentation

Background: Patient education in our organization historically had been delivered in a single session. This was observed to overwhelm the stroke patient and lead to missed documentation by the nursing staff. Purpose: The purpose of this study was to evaluate the impact of a robust daily patient education plan that included: delivery of patient education in smaller increments with a visual management system and incremental documentation by nursing staff to increase documentation accuracy, as well as a mechanism to indicate when family presence is required for education. Methods: Our hospital, a high volume academic medical center, implemented a unit led education initiative beginning in January 2016. A core team of nurses worked to define the education pathway for the acute stroke patient covering three days, the average length of stay. The team included a color coded visual management system, placed outside of patient rooms, to facilitate nursing communication of patient progression and status along this education pathway. Nursing staff were educated on the newly created pathway, visual management systems, and the documentation process. The new education process was initiated in May 2016. Patient charts were audited for nursing accuracy in education documentation for the three months preceding implementation and compared to the three months post-implementation. Compared with the pre-implementation period, when documentation on the core unit was 99% (n= 91), the post-implementation period showed an improvement to100% (n=80). Conclusion: In conclusion, a robust education plan developed by nursing improves documentation. Further research is warranted to determine the effectiveness of extending model to other units providing care to stroke patients across the organization.

Modeling Hourly Resident Productivity in the Emergency Department

Resident productivity, defined as new patients per hour, carries important implications for emergency department operations. In high-volume academic centers, essential staffing decisions can be made on the assumption that residents see patients at a static rate. However, it is unclear whether this model mirrors reality; previous studies have not rigorously examined whether productivity changes over time. We examine residents' productivity across shifts to determine whether it remained consistent. This was a retrospective cohort study conducted in an urban academic hospital with a 3-year emergency medicine training program in which residents acquire patients ad libitum throughout their shift. Time stamps of all patient encounters were automatically logged. A linear mixed model was constructed to predict productivity per shift hour. A total of 14,364 8- and 9-hour shifts were worked by 75 residents between July 1, 2010, and June 20, 2015. This comprised 6,127 (42.7%) postgraduate year (PGY) 1 shifts, 7,236 (50.4%) PGY-2 shifts, and 998 (6.9%) PGY-3 nonsupervisory shifts (Table1). Overall, residents treated a mean of 10.1 patients per shift (SD 3.2), with most patients at Emergency Severity Index level 3 or more acute (93.8%). In the initial hour, residents treated a mean of 2.14 patients (SD 1.2), and every subsequent hour was associated with a significant decrease, with the largest in the second, third, and final hours. Emergency medicine resident productivity during a single shift follows a reliable pattern that decreases significantly hourly, a pattern preserved across PGY years and types of shifts. This suggests that resident productivity is a dynamic process, which should be considered in staffing decisions and studied further.

E-Mail Is an Effective Tool for Rapid Feedback in Acute Stroke.

To determine whether e-mail is a useful mechanism to provide prompt, case-specific data feedback and improve door-to-needle (DTN) time for acute ischemic stroke treated with intravenous tissue plasminogen activator (IV-tPA) in the emergency department (ED) at a high-volume academic stroke center. We instituted a quality improvement project at Columbia University Medical Center where clinical details are shared via e-mail with the entire treatment team after every case of IV-tPA administration in the ED. Door-to-needle and component times were compared between the prefeedback (January 2013 to March 2015) and postfeedback intervention (April 2015 to June 2016) periods. A total of 273 cases were included in this analysis, 102 (37%) in the postintervention period. Median door-to-stroke code activation (2 vs 0 minutes, P < .01), door-to-CT Scan (21 vs 18 minutes, P < .01), and DTN (54 vs 49 minutes, P = .17) times were shorter in the postintervention period, although the latter did not reach statistical significance. The proportion of cases with the fastest DTN (≤45 minutes) was higher in the postintervention period (29.2% vs 42.2%, P = .03). E-mail is a simple and effective tool to provide rapid feedback and promote interdisciplinary communication to improve acute stroke care in the ED.

PUB008 1,000 Video-Assisted Thoracoscopic Lobectomies (VATS): A Single Institution's Experience

Despite recent increase in VATS adoption for major lung resection.Reports derived from large national registries show underutilization of this approach nationwide. To date, no randomized trials have directly compared VATS to a thoracotomy approach. We sought to review our experience with 1000 VATS lobectomy performed in a high volume academic center to assess perioperative and long-term oncological outcomes. A retrospective review of a prospectively collected lung cancer database was performed to identify patients who underwent lobectomy using VATS approach (2002-2014). Survival was estimated using Kaplan Meier analysis. Cox regression multivariable analysis (MVA) was used to identify independent predictors of DFS. In the study period, 1009 VATS lobectomies were performed (median age 71 yr, 40% were males). The clinical and pathological characteristics of the cohort studied are listed (Table). Median postoperative length of stay(LOS) was 4 days with 27% discharged ≤ 3days. Median operative time(OR)and estimated blood loss (EBL)were 131 minutes and 100 CC respectively. Conversion to a thoracotomy was encountered in 66 patients (6.5%). 3 patients (0.3%) had 30-days post-operative mortality. On MVA, only advanced pathological stage [(pStage II, HR: 1.69, 95%CI: 1.15-2.48), (pStage III, HR: 2.94, 95%CI: 2.09-4.14)], grade 2/3 tumors (HR: 1.53, 95% CI: 1.09-2.16), and longer LOS(HR: 1.05, 95% CI: 1.01-1.09) independently predicted poor DFS. A subgroup analyses on 150 patients (14.9%) 80 years old or older (octogenarians), showed comparable complications rate with their younger counterparts (<80 years old) (Clavien Dindo ≥3, 22.7% vs 17.2%, p=0.110), despite having significantly higher Charlson comorbidity index (CCI>1; 46.7% vs 34.9%, p=0.006). Also, there were no differences between patients older and young than 80 years old regarding probability of freedom from recurrence (p=0.457) or cancer specific survival (p=0.305). The current study reports a large number of lobectomies performed using VATS approach in a high volume academic center. These data came in accordance with previous reports affirming the feasibility, safety,and improved perioperative outcomes associated with this approach, even in the frail octogenarians.Tabled 1Patients characteristicsNumber(%)/ Median(IQR)Age;years71(63-77)GenderFemale630(62.4%)Male379(37.6%)SmokingNo271(26.9%)Yes738(73.1%)Charlson’s Comorbidity IndexCCI>2182(18%)Clinical StageStage I871(86.3%)Stage II88(8.7%)Stage III50(5%)Pathological StageStage I763(75.6%)Stage II130(12.9%)Stage III116(11.5%)PFTsFEV%(Median,IQR)n=96590(77-104)FVC%(Median,IQR)n=95291(80-102)DLCO%(Median,IQR)n=78083(68-99)Resected lobe lateralityRt side612(60.7%)Lt side397(39.3%)Grade of differentiationWell differentiated236(23.4%)Moderate/Poor differentiated773(76.6%)HistologyAdenocarcinoma813(80.6%)Squamous cell ca121(12%)Others75(7.4%)ComplicationsNo747(74%)Yes262(26%)Clavin Dindo Class(CDC)CDC≥2194(19%)Length of stay;days4(3-5)OR time;minutes(n=556)131(103-162)Estimated blood loss;ml(n=564)100(50-200) Open table in a new tab

Case mix–adjusted cost of colectomy at low-, middle-, and high-volume academic centers

Efforts to regionalize surgery based on thresholds in procedure volume may have consequences on the cost of health care delivery. This study aims to delineate the relationship between hospital volume, case mix, and variability in the cost of operative intervention using colectomy as the model. All patients undergoing colectomy (n=90,583) at 183 academic hospitals from 2009-2012 in The University HealthSystems Consortium Database were studied. Patient and procedure details were used to generate a case mix-adjusted predictive model of total direct costs. Observed to expected costs for each center were evaluated between centers based on overall procedure volume. Patient and procedure characteristics were significantly different between volume tertiles. Observed costs at high-volume centers were less than at middle- and low-volume centers. According to our predictive model, high-volume centers cared for a less expensive case mix than middle- and low-volume centers ($12,786 vs $13,236 and $14,497, P<.01). Our predictive model accounted for 44% of the variation in costs. Overall efficiency (standardized observed to expected costs) was greatest at high-volume centers compared to middle- and low-volume tertiles (z score -0.16 vs 0.02 and -0.07, P<.01). Hospital costs and cost efficiency after an elective colectomy varies significantly between centers and may be attributed partially to the patient differences at those centers. These data demonstrate that a significant proportion of the cost variation is due to a distinct case mix at low-volume centers, which may lead to perceived poor performance at these centers.

Frequency and Importance of Incomplete Screening Fetal Anatomic Sonography in Pregnancy.

To determine (1) how often routine screening fetal anatomic sonography fails to completely visualize fetal anatomy; (2) the proportion of women with incomplete ultrasound examinations who are recommended for repeat screening and then undergo repeat sonography; and (3) how often abnormal fetal anatomy is detected on repeat sonography. We conducted a retrospective cohort study at a high-volume academic obstetric ultrasound center. Participants were 16,300 women at 17 through 21 weeks' gestation with a singleton pregnancy presenting for screening anatomic sonography between January 2009 and December 2013. Main outcome measures were (1) incomplete visualization of anatomy at initial screening sonography; (2) among women with incomplete but otherwise normal initial screening ultrasound examinations, recommendation for and performance of repeat sonography; and (3) among women undergoing repeat sonography, discovery of abnormal fetal anatomy within anatomic components that were previously incompletely visualized. The mean maternal age ± SD was 30.8 ± 6.3 years, and the mean gestational age was 18.8 ± 1.0 weeks. Among 16,300 initial screening ultrasound examinations, 2157 (13.2%) had incomplete visualization of fetal anatomy. Of those women eligible for follow-up, 91.5% were recommended for repeat screening, of whom 92.8% had a subsequent examination. Of 1560 repeat screening ultrasound examinations, 8 (0.5%) showed an abnormality in the components of anatomy that were previously visualized incompletely. In this large single-center study, incomplete visualization was common in screening fetal anatomic ultrasound examinations. Recommendations for repeat imaging were nearly universal, but abnormal fetal anatomy was infrequently discovered on repeat screening.

PE10 - Neobladder versus ileal conduit in Robot-Assisted Radical Cystectomy (RARC): Results from a high-volume academic centre

PE10 - Neobladder versus ileal conduit in Robot-Assisted Radical Cystectomy (RARC): Results from a high-volume academic centre

Preoperative FOLFIRINOX for borderline resectable pancreatic cancer: Is radiation necessary in the modern era of chemotherapy?

No consensus exists regarding the optimal neoadjuvant treatment paradigm for patients with borderline resectable pancreatic cancer (BRPC), including the respective roles of chemotherapy and radiation. We performed a retrospective analysis, including detailed pathologic and radiologic review, of pancreatic cancer patients undergoing FOLFIRINOX, with or without radiation therapy (RT), prior to surgical resection at a high-volume academic center over a 4-year period. Of 26 patients meeting inclusion criteria, 22 (84.6%) received FOLFIRINOX alone without RT (median number of treatment cycles = 9). The majority of patients met formal radiographic criteria for BRPC, with the superior mesenteric vein representing the most common vessel involved. R0 resection rate was 90.9%, with 12 patients (54.5%) requiring vascular reconstruction. Treatment response was classified as moderate or marked in 16 patients (72.7%) according to the College of American Pathologists grading system. Estimated median disease-free and overall survival rates are 22.6 months and not reached (NR), respectively. This is one of the largest series to describe the use of neoadjuvant FOLFIRINOX, without radiation therapy, in patients with BRPC undergoing surgical resection. Given the high R0 resection rates and favorable clinical outcomes with chemotherapy alone, this strategy should be further assessed in prospective study design. J. Surg. Oncol. 2016;114:587-596. © 2016 Wiley Periodicals, Inc.

Domestic Travel and Regional Migration for Parathyroid Surgery Among Patients Receiving Care at Academic Medical Centers in the United States, 2012-2014.

To improve outcomes after parathyroidectomy, several organizations advocate for selective referral of patients to high-volume academic medical centers with dedicated endocrine surgery programs. The major factors that influence whether patients travel away from their local community and support system for perceived better care remain elusive. To assess how race/ethnicity and insurance status influence domestic travel patterns and selection of high- vs low-volume hospitals in different regions of the United States for parathyroid surgery. A retrospective study was conducted of 36 750 inpatients and outpatients discharged after undergoing parathyroidectomy identified in the University HealthSystem Consortium database from January 1, 2012, to December 31, 2014 (12 quarters total). Each US region (Northeast, Mid-Atlantic, Great Lakes, Central Plains, Southeast, Gulf Coast, and West) contained 20 or more low-volume hospitals (1-49 cases annually), 5 or more mid-volume hospitals (50-99 cases annually), and multiple high-volume hospitals (≥100 cases annually). Domestic medical travelers were defined as patients who underwent parathyroidectomy at a hospital in a different US region from which they resided and traveled more than 150 miles to the hospital. Distance traveled, regional destination, and relative use of high- vs low-volume hospitals. A total of 23 268 of the 36 750 patients (63.3%) had parathyroidectomy performed at high-volume hospitals. The mean (SD) age of the study cohort was 71.5 (16.2) years (95% CI, 71.4-71.7 years). The female to male ratio was 3:1. Throughout the study period, mean (SD) distance traveled was directly proportional to hospital volume (high-volume hospitals, 208.4 [455.1] miles; medium-volume hospitals, 50.5 [168.4] miles; low-volume hospitals, 27.7 [89.5] miles; P < .001). From 2012 to 2014, the annual volume of domestic medical travelers increased by 15.0% (from 961 to 1105), while overall volume increased by 4.9% (from 11 681 to 12 252; P = .03). Nearly all (2982 of 3113 [95.8%]) domestic medical travelers had surgery at high-volume hospitals, and most of these patients (2595 of 3113 [83.4%]) migrated to hospitals in the Southeast. Domestic medical travelers were significantly more likely to be white (2888 of 3113 [92.8%]; P < .001) and have private insurance (1934 of 3113 [62.1%]; P < .001). Most patients with private insurance (12 137 of 17 822 [68.1%]) and Medicare (9433 of 15 121 [62.4%]) had surgery at high-volume hospitals, while the largest proportion of patients with Medicaid and those who were uninsured had surgery at low-volume hospitals (1059 of 2715 [39.0%]). Centralization of parathyroid surgery is a reality in the United States. Significant disparities based on race and insurance coverage exist and may hamper access to the highest-volume surgeons and hospitals. Academic medical centers with dedicated endocrine surgery programs should consider strategic initiatives to reduce disparities within their respective regions.

Process Innovation Improves Trial Operation Efficiency.

Despite the fact that unaddressed delays in clinical trial operation could severely compromise the overall effort invested, there seems to be a lack of concerted effort in reforming such delays. This study evaluated the composite effect of initiatives in reforming trial operation efficiency. A high-volume academic medical center in Korea has implemented various initiatives to improve the trial operation efficiency by expediting times from institutional review board (IRB) submission to approval, from IRB submission to trial open for subject enrollment, and from trial open to first patient-in. The initiatives include implementation of the protocol preliminary review, parallel processing of the clinical trial agreement review in line with the protocol submission to the IRB, and involvement of project manager for operational risk management. Times from IRB submission to approval, from IRB submission to trial open, and from trial open to first patient-in before and after implementation of initiatives were compared. The median time required in IRB approval was meaningfully shorter in the postinitiative group (19 vs 14 days; P < .001). The median times from IRB submission to trial open for subject enrollment and from trial open to first patient-in were reduced significantly in the postinitiative group (trial open: 25 vs 18 days, P < .001; first patient-in: 111.5 vs 100 days, P = .014). The initiatives were effective in reforming trial operational efficiency. Additional studies to address the cause of operational delay and modifiable factors influencing subject enrollment are needed to further improve operational efficiency.

P.138 Corrective Adult Spinal Deformity Procedures in a community hospital: a single institution review

Background: Adult spinal deformity (ASD) are typically managed in tertiary care centres due to their complexity in surgical planning and peri-operative care. Methods: A retrospective analysis of consecutive corrective ASD surgery performed by a single surgeon at a community based centre performed between 2012 and 2014. Inclusion criteria were age ≥ 18 years with a minimum of 1 year follow-up. We reviewed age, aetiology, mortality, medical and neurological deficit. All standard radiographic deformity parameters were also evaluated and analysed. Results: n=32 corrective spinal deformity procedures were performed. The most common aetiology was de novo degenerative scoliosis. The mean length of stay was 11.94 days. The most common levels fused from T1-pelvis (n=13). L5/S1 was the most common level requiring interbody fusion (n=17). There were n=10 who required a PSO. Only n=4 patients had EBL greater than 3500cc.There were a total of 9 medical complications with post-operative hypotension being the most common (n=3). Hardware failure across the PSO site was the most common long term complication (n=7). There were n=2 death. There were no reported deep infections requiring revisions. Radiographic parameters analysed showed significant improvement. Conclusions: ASD surgery perioperative complication rates in a community hospital are similar to those done in high volume academic centre.

Thyroidectomy for Graves' disease in children: Indications and complications

BackgroundThe utilization of thyroidectomy for Graves' disease remains controversial; we aim to evaluate the indications for and complications of thyroidectomy for Graves' in children. MethodsA retrospective analysis was performed on all Graves' patients who underwent thyroidectomy from 2009 to 2013 at a high volume academic center. Pediatric patients were <18years old, and a comparative analysis of indications for surgery and complications was performed. Results167 patients underwent thyroidectomy: 31 pediatric patients and 136 adults. Failure of antithyroid medications was the indication for surgery in 55% of the children vs 36% of adults (p=0.05). Mean duration of medications prior to surgery was similar. No children had failed RAI therapy prior to surgery, but 12.5% of the adult population had (p=0.04). Surgical outcomes were similar. ConclusionClinicians may be more likely to refer children who fail medical treatment to surgery over RAI. Thyroidectomy at a high volume hospital should be discussed as a treatment option for children with Graves'.

Current Status of Robot-Assisted Radical Cystectomy and Intracorporeal Urinary Diversion.

Robot-assisted surgery has become a widely used surgical approach in the management of urologic malignancies. With its initial experience in the treatment of prostate cancer, the technology rapidly expanded to other urologic malignancies including bladder cancer. Since its introduction in 2003, robot-assisted radical cystectomy has seen refinement and increased penetration over the last decade. Furthermore, urologic surgeons have expanded its use to perform urinary diversions. The concept of intracorporeal urinary diversion is still in development but continues to see increased refinement among high volume academic centers.

PD29-04 NATIONAL UTILIZATION OF RETROPERITONEAL LYMPH NODE DISSECTION AMONG PATIENTS WITH KIDNEY CANCER AND CLINICAL LYMPHADENOPATHY UNDERGOING NEPHRECTOMY

You have accessJournal of UrologyKidney Cancer: Localized: Surgical Therapy II1 Apr 2016PD29-04 NATIONAL UTILIZATION OF RETROPERITONEAL LYMPH NODE DISSECTION AMONG PATIENTS WITH KIDNEY CANCER AND CLINICAL LYMPHADENOPATHY UNDERGOING NEPHRECTOMY Bream Matthew, Robert Abouassaly, Marc Smaldone, Alex Kutikov, Nilay Shah, Stephen Boorjian, R. Houston Thompson, Christopher Gonzalez, Hui Zhu, and Simon Kim Bream MatthewBream Matthew More articles by this author , Robert AbouassalyRobert Abouassaly More articles by this author , Marc SmaldoneMarc Smaldone More articles by this author , Alex KutikovAlex Kutikov More articles by this author , Nilay ShahNilay Shah More articles by this author , Stephen BoorjianStephen Boorjian More articles by this author , R. Houston ThompsonR. Houston Thompson More articles by this author , Christopher GonzalezChristopher Gonzalez More articles by this author , Hui ZhuHui Zhu More articles by this author , and Simon KimSimon Kim More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.522AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The benefit of retroperitoneal lymph node dissection (RPLND) among patients with locally advanced kidney cancer and clinical lymphadenopathy (cN+) disease remains controversial. Several studies have suggested a therapeutic and staging benefit to performing RPLND at the time of radical nephrectomy (RN). We sought to assess temporal trends in RPLND, and to identify patient and hospital factors associated with its use among patients with non-metastatic cN+ kidney cancer. METHODS Using the National Cancer Database (NCDB), we identified patients with renal cell carcinoma (RCC) with regional lymph node metastasis but without distant metastasis (T1-4 cN1 M0) who underwent radical nephrectomy from 2001 to 2011. The primary outcome was performance of concomitant RPLND at the time of RN. Multivariable logistic regression was used to identify clinicopathologic and hospital characteristics associated with performance of RPLND at the time of RN. A two-sample t-test was used to compare the mean number of lymph nodes removed by hospital type. RESULTS Of a total 1853 patients undergoing RN for cN+ RCC, 1444 (78%) underwent RPLND and 409 (22%) did not. Time trend analysis showed an increase in the proportion of patients undergoing RPLND over time, from 77% in 2001 to 82% in 2011, p=0.001 for the overall trend. On multivariable analysis, factors associated with RPLND were private health insurance (OR: 2.22; 95% CI: 1.46-3.39, p<0.001) and Medicaid (OR: 2.08; 95% CI 1.11-3.92, p=0.02) compared to Medicare, and treatment at an academic center compared to community hospitals (OR: 1.59; 95% CI: 1.23-2.08, p<0.001). The mean number of lymph nodes removed during RPLND was higher when done at academic centers compared to community hospitals (8.1 vs. 5.0; p<0.001). CONCLUSIONS Despite the growing evidence that RPLND has a role in the surgical management of locally advanced kidney cancer in the non-metastatic setting, a fifth of patients with clinical lymph node metastasis are not receiving RPLND. Patients undergoing surgery at academic centers, or those who are primarily insured by private insurance or Medicaid, were more likely to have more aggressive surgical treatment. Centralizing surgery to high volume academic medical centers may increase the rates and yield of RPLND for RCC with lymph node metastasis. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e707 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Bream Matthew More articles by this author Robert Abouassaly More articles by this author Marc Smaldone More articles by this author Alex Kutikov More articles by this author Nilay Shah More articles by this author Stephen Boorjian More articles by this author R. Houston Thompson More articles by this author Christopher Gonzalez More articles by this author Hui Zhu More articles by this author Simon Kim More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

An automated electronic system for managing radiation treatment plan peer review reduces missed reviews at a large, high-volume academic center

BackgroundAssuring quality in cancer care through peer review has become increasingly important in radiation oncology. In 2012, our department implemented an automated electronic system for managing radiation treatment plan peer review. The purpose of this study was to compare the overall impact of this electronic system to our previous manual, paper-based system. Methods and materialsIn an effort to improve management, an automated electronic system for case finding and documentation of review was developed and implemented. The rates of missed initial reviews, late reviews, and missed re-reviews were compared for the pre- versus postelectronic system cohorts using Pearson χ2 test and relative risk. Major and minor changes or recommendations were documented and shared with the assigned clinical provider. ResultsThe overall rate of missed reviews was 7.6% (38/500) before system implementation versus 0.4% (28/6985) under the electronic system (P < .001). In terms of relative risk, courses were 19.0 times (95% confidence interval, 11.8-30.7) more likely to be missed for initial review before the automated system. Missed re-reviews occurred in 23.1% (3/13) of courses in the preelectronic system cohort and 6.6% (10/152) of courses in the postelectronic system cohort (P = .034). Late reviews were more frequent during high travel or major holiday periods. Major changes were recommended in 2.2% and 2.8% in the pre- versus postelectronic systems, respectively. Minor changes were recommended in 5.3% of all postelectronic cases. ConclusionsThe implementation of an automated electronic system for managing peer review in a large, complex department was effective in significantly reducing the number of missed reviews and missed re-reviews when compared to our previous manual system.

Complications and Yield of Computed Tomography-Guided Transthoracic Core Needle Biopsy of Lung Nodules at a High-Volume Academic Center in an Endemic Coccidioidomycosis Area.

Previous studies with small sample sizes have shown a wide range of complication rates and no study has investigated the yield of computed tomography-guided transthoracic core needle biopsies (CTTCB) for coccidioidomycosis. To better assess the safety, accuracy, and risk factors for complications of CTTCB of pulmonary nodules, we conducted a retrospective study at a high-volume academic center in an endemic coccidioidomycosis area. We conducted a retrospective study of 203 patients who underwent CTTCB of pulmonary nodules between December 2010 and May 2013. We collected demographics, clinical, and radiographic data. Each case was reviewed for complications. Diagnostic accuracy was assessed by comparing CTTCB with final diagnoses. The overall complication rate was 25%. Pneumothorax accounted for 24% of complications with 7% of pneumothoraces requiring chest tube. 1.5% were complicated by hemoptysis but none required blood transfusions. There was an association between complications and age, presence of emphysema on CT, traversed lung length, and lesion depth. The overall sensitivity of the CTTCB for all types of lung cancer was 93%, and specificity of 100%. The positive predictive value of CTTCB for lung cancer was 100%. The sensitivity and specificity of CTTCB for a coccidiomycosis lung nodule was 83% with a specificity of 100% with a PPV of 100%. Our study demonstrates that CTTCB is a relatively safe method for evaluating lung nodules and highly accurate in evaluating lung nodules due to coccidioidomycosis in an endemic area. The primary risk factors for complications from CTTCB are the presence of emphysema on CT scan, lesion depth, and traversed lung length.

Abstract No. 499 - Lymphatic malformation treatment in adult and pediatric populations using real-time MRI guided percutaneous sclerotherapy

No. 500 Transfemoral vs. transradial access: patient preference assessment using iPad technology J. Horn, A. Fischman, R. Patel, N. Tabori, E. Kim, F. Nowakowski, R. Lookstein; Icahn School of Medicine at Mount Sinai, New York, NY; Mount Sinai Medical Center, New York, NY; N/A, New York, NY; Mount Sinai Hospital, New York, NY Purpose: Transradial access (TRA) has been shown to be less costly, safer, and preferred by patients for coronary interventions as compared to transfemoral access (TFA). The purpose of this study was to determine differences in patient preference for access site during non-coronary arterial interventions using survey based iPad technology. Materials: From 1/2014 to 9/2015, retrospective review of all patients undergoing arterial interventions at a high volume academic medical center was performed. These patients were given a post-procedure survey (Surveymonkey.com) via a bedside iPad in the IR PACU. Surveys were available in English, Spanish and Mandarin. Questions related to pain at access site, preference for access site, procedure type and demographics was recorded. TRA and TFA procedures were all performed from the left wrist and right groin, respectively. Results: Survey respondents (n1⁄4126) (82% male) included the following procedures: TACE (n1⁄422, 23%), Y90 delivery (n1⁄434, 35%), and planning (n1⁄428, 29%), UFE (n1⁄48, 8%) and renal intervention (n1⁄46, 6%). Access sites included: TFA (n1⁄431, 25%) and TRA (n1⁄495, 75%). 67 patients reported having had both TRA and TFA in the past. Of those patients, 53/67 (79%) preferred TRA, 4/67 (6%) preferred TFA and 10/ 67 (15%) had no preference. Conclusions: Post-procedure survey data acquired via iPad is feasible in a PACU setting. A strong patient preference for TRA over TFA was noted in patients who had undergone both types of access.

Sometimes It Takes a Village—Reducing Retained Surgical Items Through Multidisciplinary Collaboration

DESCRIPTION OF THE PROBLEM Our high-volume academic surgical center experienced a spike in unintentionally retained surgical items (RSIs) during fiscal years 2013 and 2014. Of the 39,323 surgical cases completed during this 24-month period, 8 cases with RSIs were discovered—approximately 1 RSI per 4,915 surgical cases (Figure 1). This finding was in sharp contrast to the preceding 5 years, during which no RSIs were reported, for more than 55,100 completed operative cases. Currently, “retained surgical items” is the preferred term, because it references the fact that the material or instruments that were unintentionally retained within a patient’s body were placed by the surgical team. RSIs should be differentiated from “retained foreign bodies,” which describes objects placed nonsurgically, such as swallowed material (eg, batteries, magnets, coins), shrapnel, bullets, and other miscellaneous objects. RSIs may cause significant patient morbidity and mortality depending on the type of surgical item and the length of time it was retained. Although the true incidence of RSIs after open surgery in the United States is unknown,

Pancreatogastrostomy Versus Pancreatojejunostomy for RECOnstruction After PANCreatoduodenectomy (RECOPANC, DRKS 00000767): Perioperative and Long-term Results of a Multicenter Randomized Controlled Trial.

Objectives:To assess pancreatic fistula rate and secondary endpoints after pancreatogastrostomy (PG) versus pancreatojejunostomy (PJ) for reconstruction in pancreatoduodenectomy in the setting of a multicenter randomized controlled trial.Background:PJ and PG are established methods for reconstruction in pancreatoduodenectomy. Recent prospective trials suggest superiority of the PG regarding perioperative complications.Methods:A multicenter prospective randomized controlled trial comparing PG with PJ was conducted involving 14 German high-volume academic centers for pancreatic surgery. The primary endpoint was clinically relevant postoperative pancreatic fistula. Secondary endpoints comprised perioperative outcome and pancreatic function and quality of life measured at 6 and 12 months of follow-up.Results:From May 2011 to December 2012, 440 patients were randomized, and 320 were included in the intention-to-treat analysis. There was no significant difference in the rate of grade B/C fistula after PG versus PJ (20% vs 22%, P = 0.617). The overall incidence of grade B/C fistula was 21%, and the in-hospital mortality was 6%. Multivariate analysis of the primary endpoint disclosed soft pancreatic texture (odds ratio: 2.1, P = 0.016) as the only independent risk factor. Compared with PJ, PG was associated with an increased rate of grade A/B bleeding events, perioperative stroke, less enzyme supplementation at 6 months, and improved results in some quality of life parameters.Conclusions:The rate of grade B/C fistula after PG versus PJ was not different. There were more postoperative bleeding events with PG. Perioperative morbidity and mortality of pancreatoduodenectomy seem to be underestimated, even in the high-volume center setting.

Abstract WP388: Clinically Focused Stroke Coordinator: How to Successfully Contact All Patients Post Hospitalization at the Highest Target

Background: Stroke coordinator roles often involve quality data collection and compliance with standards to maintain certification, yet have limited clinical patient contact. Implementing a Clinical Stroke Coordinator Role, with a focus on the patient, assists with care continuity and improves the success rate of follow-up phone calls to acute ischemic stroke patients. Purpose: To evaluate the impact of implementing a Clinical Stroke Coordinator on the percentage of successful patient follow-up phone calls to all acute ischemic stroke patients discharged from the hospital. Methods: Our hospital, a high volume academic medical center, implemented the role of Clinical Stroke Coordinator in October 2014. The Coordinator met with each acute ischemic stroke patient prior to discharge to personalize patient education and stroke risk assessments, and to establish an appropriate contact person and phone number for discharge follow-up phone calls. All patients (or their designee) were called by the nurse Clinical Stroke Coordinator within seven days of hospital discharge to home, rehabilitation or inpatient nursing facility. The percentage of patients reached from February 2015 through July 2015 was compared to data from the preceding year, when calls were made by Unit Managers. Results: Compared with the pre-implementation period, when the average success rate was 49% for 209 patients, implementation of the Clinical Stroke Coordinator led to an average success rate of 86% for 240 patients, most recently reaching 100% of patients discharged. Overall there was a 102% increase in successful patient discharge phone calls for this patient population (Figure). Conclusion: The Clinical Stroke Coordinator role is essential to improved discharge phone call success rates, reaching &gt;95% of acute stroke patients in the most recent three months. Further research is warranted into the impact of follow up phone calls on patient medication compliance and life-style modification.