Quality Improvement Program Research Articles

Reducing recurrence rates in hiatal hernia repair: Results of a quality improvement study.

Patient and procedure factors are considered in the decision-making process for surgical repair of hiatal hernias. Recurrence is multi-factorial and has been shown to be related to size, type, BMI and age. This study examined recurrence rates in a single institution, identified areas for improved surgical technique, and re-assessed recurrence following implantation of a quality improvement initiative. A retrospective review of patients undergoing hiatal hernia repair surgery between 2018 and 2022 was conducted. Demographics, pre-operative characteristics, intra-operative procedures and recurrence rates were reviewed. Seventy-five patients from 2018 to 2020 and 34 patients from 2021 to 2022 were identified. The recurrence rate was 21% in 2018-2020, with 14% requiring a revisional procedure. Recurrence and re-operation were subsequently reduced to 6% in 2021 and 2022, which was statistically significant (p = 0.043). There was an increase in gastropexy from 21% to 41% following the review (p = 0.032), which wasmainly reserved for large and giant hernias. Procedural and literature review, alongside gastropexy, can be attributed to recurrence rate reduction. It is important to educate patients on the likelihood and risk factors of recurrence. A comprehensive review of procedures and a quality improvement program in our facility for hiatal hernia repair is shown to reduce recurrence.

Trends in Top Surgery Patient Characteristics, Wound Complications, and CPT Code Use by Plastic Surgeons: A Decade-Long Analysis.

Gender-affirming top surgery is becoming increasingly common, with greater diversity in the patients receiving top surgery. The purpose of this study was to examine national trends in patient demographics, characteristics, wound complication rates, and concurrent procedures in patients receiving gender-affirming top surgeries. Patients with gender dysphoria who underwent breast procedures, including mastectomy, mastopexy, breast augmentation, or breast reduction by a plastic surgeon between 2013 and 2022, were identified from the American College of Surgeons National Surgical Quality Improvement Program database. These procedures were considered to be gender-affirming "top surgery." Univariate analyses were performed to examine trend changes in the patient population and types of additional procedures performed over the last decade. There was a 38-fold increase in the number of patients who received top surgery during the most recent years compared to the first 2 years of the decade. Significantly more individuals receiving top surgery in recent years were nonbinary (P < 0.01). There was a significant decrease in percentage of active smokers (P < 0.01) while there was an increase in percentage of patients with diabetes (P = 0.03). While there was a significant increase in the number of obese patients receiving top surgery (P < 0.01), there were no differences in postoperative wound complications between the years. Significantly more patients received additional procedures (P < 0.01) and had about a 9-fold increase in distinct number of additional CPT codes from 2013-2014 to 2021-2022. Our study found that there has been (1) a significant increase in the number of top surgery patients from 2013 to 2022 overall and (2) a particular increase in patients with preoperative comorbidities, such as a higher body mass index and diabetes. Understanding current and evolving trends in patients undergoing surgical treatment for gender dysphoria can inform individualized care plans that best serve the needs of patients and optimize overall outcomes.

Surgical Outcomes and Sociodemographic Disparities Across All Races: An ACS-NSQIP and NHIS Multi-Institutional Analysis of Over 7.5 Million Patients

Background: This study aims to fill the gap in large-scale, registry-based assessments by examining postoperative outcomes across diverse races/ethnicities. The focus is on identifying disparities and comparing them with socioeconomic demographics. Methods: In a registry-based cohort study using the 2008 to 2020 American College of Surgeons National Surgical Quality Improvement Program, we evaluated 24 postoperative outcomes through multivariable analysis, incorporating 28 preoperative risk factors. In a separate, independent analysis of the 2019 to 2020 National Health Interview Survey (NHIS) database, we examined sociodemographic racial/ethnic normative data. Results: Among 7,504,734 American College of Surgeons National Surgical Improvement Database patients specifying race, 83.8% were White (WT), 11.8% Black or African American (B/AA), 3.3% Asian (AS), 0.7% American Indian or Alaska Native (AI/AN), 0.4% Native Hawaiian or Pacific Islander (NH/PI), 7.3% Hispanic. Reoperation trends reveal favorable outcomes for WT, AS, and NH/PI patients compared with B/AA and AI/AN patients. AI/AN patients exhibit higher rates of wound healing issues, while AS patients experience lower rates. AS and B/AA patients are more prone to transfusions, with B/AA patients showing elevated rates of pulmonary embolism, deep vein thrombosis, renal failure, and insufficiency. Disparities in discharge destinations exist. Hispanic patients fare better than non-WT Hispanic patients, contingent on race. Racial groups (excluding Hispanic patients) with superior surgical outcomes from the NSQIP analysis were found in the NHIS analysis to report higher wealth, better healthcare access, improved food security, greater functional and societal independence, and lower frailty. Conclusions: Our study underscores racial disparities in surgical outcomes. Focused investigations into these complications could reveal underlying causes, informing healthcare policies to enhance surgical care universally.

Comparison of outcomes after unplanned conversion for patients undergoing robotic when compared with laparoscopic colectomy.

The robotic approach improves the feasibility of minimally invasive colectomy even where there may be an anatomic challenge with laparoscopy. Whether a failure in completing colectomy with this newer technology is associated with worse consequences needs to be considered when evaluating the relative benefit of robotic colectomy. The aim of this study is to evaluate rates of conversion to open surgery after robotic and laparoscopic colectomy and whether outcomes after conversion vary after the two techniques since this has not been well studied. From the American College of Surgeons (ACS) - National Surgical Quality Improvement Program (NSQIP) (2015-2016), patients who underwent elective minimally invasive colectomy were identified. Converted robotic were compared to laparoscopic procedures for patient demographics, co-morbidities; primary procedure and diagnosis, prolonged operation and postoperative complications. Of 36,046 colectomy procedures, 30,808 (85.5%) were laparoscopic, while 5238 (14.5%) were robotic-assisted. There were 3271 (9.1%) conversions to open surgery (laparoscopic: 2959 [9.6%]; robotic: 312 [6%]). Thirty-day postoperative surgical site infection, anastomotic leak, ileus, sepsis, bleeding requiring transfusion, urinary tract infection, reoperation; pulmonary, renal, cardiac/cerebrovascular complications; readmission, hospital stay, and mortality, were similar between the two groups. However, deep vein thrombosis/pulmonary embolism was higher after robotic conversion (4.5% vs. 2.2%, p = 0.01). Conversion was lower after robotic when compared to laparoscopic colectomy. Converted patients had similar outcomes except for vein thromboembolism which was higher after robotic surgery. Robotic technology seems to improve the feasibility of minimally invasive surgery without negatively affecting safety and efficacy even when conversion is required.

Assessing the effectiveness of ACS surgical risk calculator versus P-POSSUM in predicting mortality and morbidity for major hepatobiliary surgery: An observational study.

Risk assessment is difficult yet would provide valuable data for both the surgeons and the patients in major hepatobiliary surgeries. An ideal risk calculator should improve workflow through efficient, timely, and accurate risk stratification. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) surgical risk calculator (SRC) and Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (P-POSSUM) are surgical risk stratification tools used to assess postoperative morbidity. In this study, preoperative data from 300 patients undergoing major hepatobiliary surgeries performed at a single tertiary university hospital were retrospectively collected from electronic patient records and entered into the ACS-SRC and P-POSSUM systems, and the resulting risk scores were calculated and recorded accordingly. The ACS-NSQIP-M1 (C-statistics = 0.725) and M2 (C-statistics = 0.791) models showed better morbidity discrimination ability than P-POSSUM-M1 (C-statistics = 0.672) model. The P-POSSUM-M2 (C-statistics = 0.806) model showed better differentiation success in morbidity than other models. The ACS-NSQIP-M1 (C-statistics = 0.888) and M2 (C-statistics = 0.956) models showed better mortality discrimination than P-POSSUM-M1 (C-statistics = 0.776) model. The P-POSSUM-M2 (C-statistics = 0.948) model showed better mortality differentiation success than the ACS-NSQIP-M1 and P-POSSUM-M1 models. The use of ACS-SRC and P-POSSUM calculators for major hepatobiliary surgeries offers quantitative data to assess risks for both the surgeon and the patient. Integrating these calculators into preoperative evaluation practices can enhance decision-making processes for patients. The results of the statistical analyses indicated that the P-POSSUM-M2 model for morbidity and the ACS-NSQIP-M2 model for mortality exhibited superior overall performance.

Surgeon variability in repair of hiatal hernia at the time of bariatric surgery.

Hiatal hernia (HH) is estimated to affect between 20 and 50% of patients undergoing bariatric surgery. However, there is no consensus regarding the preoperative assessment and intraoperative repair of HH. The aim of this study was to evaluate the variation in surgeon assessment and repair of HH during bariatric surgery across a multi-hospital healthcare system. A retrospective cohort analysis was conducted using data obtained from the metabolic and bariatric accreditation quality improvement program (MBSAQIP) and institutional medical records. All adult patients who underwent laparoscopic sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) were included. Preoperative assessment of HH was defined as either EGD or upper GI/Esophagram (UGI) within one year of surgery. Surgeons were evaluated individually and by hospital. Chi-square analysis and ANOVA were performed. From January 2018 to February 2023, 3,487 bariatric surgeries were performed across 4 hospitals and 11 surgeons (2481 SG and 1006 RYGB). HH were concurrently repaired during 24% of operations. The rate of HH repair in SG was 25 and 22% in RYGB (p = 0.06). Preoperatively, 41% of patients underwent EGD and 23% had an UGI. HH was diagnosed in 22% of EGDs. Patients who underwent preoperative EGD had higher rates of HH repair than those without a preop EGD (33% vs. 17%; p < 0.001). The rate of preoperative EGD utilization by surgeon varied significantly from 3 to 92% (p < 0.001) as did HH repair rates between surgeons (range 8-57%; p < 0.001). Even among patients with a preoperatively diagnosed HH, the repair rate ranged 20-91% between individual surgeons (p < 0.001). Within a healthcare system there was significant heterogeneity in approach to assessment and repair of HH during bariatric surgery. This appears to be mediated by multiple factors, including utilization of preoperative studies, individual surgeon differences, and differences between hospitals.

Which individual components of a colorectal surgery enhanced recovery program are associated with improved surgical outcomes?

BackgroundEnhanced recovery programs improve surgical outcomes. However, the association of adherence to individual components and outcomes in a comprehensive enhanced recovery program remains unclear. MethodsWe performed a retrospective study of all elective colorectal surgery patients at our institution from 2019 to 2022 (n = 1,175). Data were acquired from our institution’s enhanced recovery program dashboard and American College of Surgeons National Surgical Quality Improvement Program database. Traditional analyses and machine-learning classification trees were used to identify enhanced recovery program components associated with length of stay, readmissions, and complication rates. ResultsThe average length of stay was 5.0 days, readmission rate was 12.3%, and complication rate was 32.6%. On linear regression analysis, adherence to preoperative education, regional analgesia, pre- and postoperative multimodal analgesia, no nasogastric tube, early mobilization, early regular diet, early discontinuation of maintenance intravenous fluids, postoperative venous thromboembolism prophylaxis, and early Foley catheter removal were associated with an decrease in length of stay by 0.7–7.1 days (P < .05). Patients who adhered to no prolonged fasting had a 4.1% decrease in readmission rate (P = .04). Patients who adhered to no nasogastric tube, early mobilization, early regular diet, postoperative multimodal analgesia, and discontinuation of maintenance intravenous fluids had decreases in complication rates ranging from 7.0 to 28.2% (P < .001). Machine learning demonstrated that no nasogastric tube and discontinuation of maintenance intravenous fluids were significant predictors of shorter length of stay and no nasogastric tube and early mobilization were significant predictors of reduced complication rates. ConclusionsAlthough multiple components were associated outcomes, no nasogastric tube, early mobilization, early regular diet, postoperative multimodal analgesia, and early discontinuation of maintenance intravenous fluids were associated with more than 1 outcome. Focusing on these components may make enhanced recovery program implementation more feasible for resource-limited hospitals.

Orthopedic Frailty Score and adverse outcomes in patients with surgically managed isolated traumatic spinal injury

BackgroundWith an aging global population, the prevalence of frailty in patients with traumatic spinal injury (TSI) is steadily increasing. The aim of the current study is to evaluate the utility...

A Prospective Quality Improvement Program to Reduce Prolonged Postoperative Antibiotic Prophylaxis in Ethiopia.

Introduction: Although postoperative antibiotic prophylaxis has not been shown to prevent surgical site infections, prolonged antibiotic administration is common in low- and middle-income countries. We developed a quality improvement program to reduce unnecessary postoperative antibiotics through hospital-specific guideline development and the use of a brief, multidisciplinary discussion of antibiotic indication, choice, and duration during clinical rounds. We assessed reduction in the number of patients receiving ≥24 h of antibiotic prophylaxis after clean and clean-contaminated surgery. Methods: We piloted the program at a referral hospital in Ethiopia from February to September 2023. After a 6-week baseline assessment, multidisciplinary teams adapted international guidelines for surgical prophylaxis to local disease burden, medication availability, and cost restrictions; stakeholders from surgical departments provided feedback. Surgical teams implemented a "timeout" during rounds to apply these guidelines to patient care; compliance with the timeout and antibiotic administration was assessed throughout the study period. Results: We collected data from 636 patients; 159 (25%) in the baseline period and 477 (75%) in the intervention period. The percentage of patients receiving ≥24 h of antibiotic prophylaxis after surgery decreased from 50.9% in the baseline period to 40.9% in the intervention period (p = 0.027) and was associated with a 0.5 day reduction in postoperative length of stay (p = 0.047). Discussion: This antibiotic stewardship pilot program reduced postoperative antibiotic prophylaxis in a resource-constrained setting in Sub-Saharan Africa and was associated with shorter length of stay. This program has the potential to reduce unnecessary antibiotic use in this population.

Time to surgical stabilization of rib fractures: does it impact outcomes?

ObjectivesRib fractures are common, morbid, and potentially lethal. Intuitively, if interventions to mitigate downstream effects of rib fractures can be implemented early, likelihood of developing these complications should be reduced....

Less is more: Outcomes of surgical approaches to rectal prolapse in patients with cirrhosis

BackgroundPatients with cirrhosis have increased risk of perioperative complications, and surgical management of concomitant rectal prolapse poses a challenge in these patients. Given the paucity of data informing this, our study aimed to evaluate postoperative outcomes. MethodsThe National Surgical Quality Improvement Program database was queried for patients undergoing rectal prolapse repair from 2011 to 2019. Patients were stratified by cirrhosis (Model for End-Stage Liver Disease ≥10) and no cirrhosis. Bivariate and multivariable regression analyses were used to compare comorbidities, repair types, and identify predictors of postoperative outcomes. ResultsWe identified 2,234 patients: 332 patients with cirrhosis (Model for End-Stage Liver Disease 14 [10–34]). Patients with cirrhosis were older (76 ± 12 years vs 69 ± 17, P < .001) with increased comorbidities (eg, heart failure, lung disease), greater mortality (3.6% vs 0.8%, P < .001), and complication rates compared with patients without cirrhosis. Readmission rates and longer hospital stays also were observed in patients with cirrhosis. A total of 52% of NCPs underwent abdominal repair compared with 62% of patients with cirrhosis who received perineal repair; greater complication rates were observed for abdominal repairs in both groups (patients without cirrhosis 11.4%, patients with cirrhosis 25%). Predictors of greater complication rates in patients with cirrhosis included abdominal repair (odds ratio 2.7, 95% confidence interval 1.4–5, P = .002) and presence of ascites (odds ratio 4.6, 95% confidence interval 1.1–20, P = .04). ConclusionOverall, abdominal repairs have greater complication rates even when controlling for Model for End-Stage Liver Disease score and presence of ascites. The Delorme procedure had the lowest complication rates. Additional evidence is needed to recommend a preferred surgical approach to rectal prolapse repair in patients with cirrhosis.

Temporary Declines and Demand Resurgence: Gender-Affirming Surgery Volume and Complication Trends During and After the COVID-19 Pandemic.

The COVID-19 pandemic prompted surgical volume reductions due to lockdown measures. This study evaluates COVID-19's impact on gender-affirming surgery (GAS) volume and complications from the pandemic onset through the recovery period. The 2019-2021 National Surgical Quality Improvement Program databases were queried for transgender or gender-diverse patients using ICD-10 codes. Five time periods were analyzed: Pre-pandemic, Immediate pre-pandemic and COVID-19 outbreak, Initial COVID-19 peak, Pre-COVID-19 vaccine, and Post-vaccine release. Complications included reoperation, urinary tract infections, and wound complications. Multivariate logistic regressions assessed factors associated with undergoing surgery during the initial COVID-19 peak and experiencing surgical complications. Out of 2,963,230 patients, 4637 underwent GAS between 2019 and 2021. Chest feminizing and masculinizing procedures comprised 60.1% of all GAS. During the initial COVID-19 peak, all GAS surgeries nearly halved, with breast augmentations dropping to 15.3% of pre-pandemic volumes. White patients constituted a significantly higher proportion of GAS patients during the initial COVID-19 peak than in 2019 (74.7% vs. 61.0%, p = 0.014). Post-vaccine, GAS levels surged, exceeding pre-pandemic volumes by 45.5% and initial peak levels by 188.5%. The overall complication rate was 4.9%, and was significantly associated with older age, increased operative time, feminizing and masculinizing genital surgeries, and hysterectomies. The initial COVID-19 peak showed no significant correlations with surgical complications. GAS volume temporarily decreased during the initial COVID-19 outbreak and has since rebounded and surpassed pre-pandemic levels, corresponding with past-decade trends. Complication risks remained consistent despite the pandemic, though the results highlight potentially significant race-based disparities in GAS access during COVID-19. During the COVID-19 pandemic, public health measures led to severe volume reductions in gender-affirming surgical (GAS) procedures. Since the initial COVID-19 peak, GAS volumes have fully recovered and surpassed pre-pandemic volumes. Surgical complication rates for various GAS procedures were within expected ranges, emphasizing the overall safety of these surgeries. The study's results highlight racial disparities in undergoing GAS during the COVID-19 pandemic, with White patients disproportionately represented among those who had surgery during the COVID-19 lockdown. This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of contents or the online Instructions to Authors www.springer.com/00266 .

The Impact of Race/Ethnicity on Disparities in Utilization and Outcomes of Neuraxial Anesthesia for Hip and Femoral Shaft Fractures

Background/Objectives: The use of neuraxial anesthesia versus general anesthesia for hip fracture surgery remains an active area of research, with recent studies demonstrating mixed findings supporting neuraxial over general anesthesia. The benefits of neuraxial anesthesia have been documented in associated surgeries, including total joint arthroplasty. However, racial disparities in the administration of neuraxial anesthesia have been identified in numerous procedures. We aimed to examine the association of race/ethnicity with neuraxial anesthesia use and the effect of neuraxial anesthesia on length of stay, non-home discharge, 30-day severe adverse events, and rates of readmission among patients undergoing isolated hip and femoral shaft fracture operations. Methods: The American College of Surgeons National Quality Improvement Program database was queried for isolated hip or femoral shaft fractures from 2015 to 2019. Stepwise logistic regression was performed to assess the relationship between race/ethnicity and neuraxial anesthesia use. Within each sex–race stratum, neuraxial anesthesia recipients were propensity-matched to general anesthesia recipients in a 1:2 ratio. Logistic regression and negative binomial regression were performed on the propensity-matched cohort. Results: A total of 12,004 neuraxial and 64,250 general anesthesia hip and femoral shaft fracture patients were identified. Compared to White patients, Black and Hispanic patients were between 0.64 and 0.61 times less likely to receive neuraxial anesthesia over general anesthesia, respectively (p &lt; 0.05). 11,993 patients who received neuraxial anesthesia were propensity matched to 23,946 patients who received general anesthesia. Propensity-matched logistic regressions found that neuraxial anesthesia was associated with decreased length of stay, 30-day severe adverse events, and acute rehab/skilled nursing facility discharge for White patients (p &lt; 0.05 for all), but only decreased length of stay in Black and Hispanic patients (p = 0.01 and p = 0.02, respectively). Conclusions: Notable disparities exist in the administration of neuraxial anesthesia for isolated hip and femoral shaft fracture patients. Hispanic and Black race/ethnicity in particular influences provision of neuraxial anesthesia. Further research is required to understand the degree of effect modification and root causes of regional anesthesia access and benefits for this high-volume patient population.

The Impact of Race/Ethnicity on Disparities in Utilization and Outcomes of Neuraxial Anesthesia for Hip and Femoral Shaft Fractures

Background/Objectives: The use of neuraxial anesthesia versus general anesthesia for hip fracture surgery remains an active area of research, with recent studies demonstrating mixed findings supporting neuraxial over general anesthesia. The benefits of neuraxial anesthesia have been documented in associated surgeries, including total joint arthroplasty. However, racial disparities in the administration of neuraxial anesthesia have been identified in numerous procedures. We aimed to examine the association of race/ethnicity with neuraxial anesthesia use and the effect of neuraxial anesthesia on length of stay, non-home discharge, 30-day severe adverse events, and rates of readmission among patients undergoing isolated hip and femoral shaft fracture operations. Methods: The American College of Surgeons National Quality Improvement Program database was queried for isolated hip or femoral shaft fractures from 2015 to 2019. Stepwise logistic regression was performed to assess the relationship between race/ethnicity and neuraxial anesthesia use. Within each sex–race stratum, neuraxial anesthesia recipients were propensity-matched to general anesthesia recipients in a 1:2 ratio. Logistic regression and negative binomial regression were performed on the propensity-matched cohort. Results: A total of 12,004 neuraxial and 64,250 general anesthesia hip and femoral shaft fracture patients were identified. Compared to White patients, Black and Hispanic patients were between 0.64 and 0.61 times less likely to receive neuraxial anesthesia over general anesthesia, respectively (p &lt; 0.05). 11,993 patients who received neuraxial anesthesia were propensity matched to 23,946 patients who received general anesthesia. Propensity-matched logistic regressions found that neuraxial anesthesia was associated with decreased length of stay, 30-day severe adverse events, and acute rehab/skilled nursing facility discharge for White patients (p &lt; 0.05 for all), but only decreased length of stay in Black and Hispanic patients (p = 0.01 and p = 0.02, respectively). Conclusions: Notable disparities exist in the administration of neuraxial anesthesia for isolated hip and femoral shaft fracture patients. Hispanic and Black race/ethnicity in particular influences provision of neuraxial anesthesia. Further research is required to understand the degree of effect modification and root causes of regional anesthesia access and benefits for this high-volume patient population.

Hypoalbuminemia predicts early postoperative complications following noninfectious revision total shoulder arthroplasty.

This study investigates the association between preoperative hypoalbuminemia and 30-day postoperative complications following noninfectious revision total shoulder arthroplasty (TSA). The American College of Surgeons National Surgical Quality Improvement Program database was queried for all patients who underwent noninfectious revision TSA from 2015 to 2021. The study population was divided into two groups based on preoperative serum albumin: normal albumin (≥ 3.5g/dL) and hypoalbuminemia (< 3.5g/dL). Logistic regression analysis was conducted to investigate the relationship between preoperative hypoalbuminemia and postoperative complications. Compared to normal albumin, hypoalbuminemia was independently associated with a significantly greater likelihood of experiencing any complication (odds ratio [OR] 3.26, 95% confidence interval [CI] 2.04-5.19; P < .001), sepsis (OR 9.92, 95% CI 1.29-76.35; P = .028), blood transfusions (OR 2.89, 95% CI 1.20-6.93; P = .017), non-home discharge (OR 2.88, 95% CI 1.55-5.35; P < .001), readmission (OR 3.46, 95% CI 1.57-7.58; P = .002), and length of stay > 2days (OR 3.00, 95% CI 1.85-4.86; P < .001). Preoperative hypoalbuminemia was associated with early postoperative complications following revision TSA. Level III; Retrospective Cohort Comparison; Prognosis Study.

Modernizing Surgical Quality: A Novel Approach to Improving Detection of Surgical Site Infections in the Veteran Population.

Introduction: Surgical site infections (SSIs) are an important quality measure. Identifying SSIs often relies upon a time-intensive manual review of a sample of common surgical cases. In this study, we sought to develop a predictive model for SSI identification using antibiotic pharmacy data extracted from the electronic medical record (EMR). Methods: A retrospective analysis was performed on all surgeries at a Veteran Affair's Medical Center between January 9, 2020 and January 9, 2022. Patients receiving outpatient antibiotics within 30 days of their surgery were identified, and chart review was performed to detect instances of SSI as defined by VA Surgery Quality Improvement Program criteria. Binomial logistic regression was used to select variables to include in the model, which was trained using k-fold cross validation. Results: Of the 8,253 surgeries performed during the study period, patients in 793 (9.6%) cases were prescribed outpatient antibiotics within 30 days of their procedure; SSI was diagnosed in 128 (1.6%) patients. Logistic regression identified time from surgery to antibiotic prescription, ordering location of the prescription, length of prescription, type of antibiotic, and operating service as important variables to include in the model. On testing, the final model demonstrated good predictive value with c-statistic of 0.81 (confidence interval: 0.71-0.90). Hosmer-Lemeshow testing demonstrated good fit of the model with p value of 0.97. Conclusion: We propose a model that uses readily attainable data from the EMR to identify SSI occurrences. In conjunction with local case-by-case reporting, this tool can improve the accuracy and efficiency of SSI identification.

A comparative assessment of ACS NSQIP-predicted and actual surgical risk outcomes of robotic transhiatal esophagectomy for esophageal adenocarcinoma resection at a high volume institution.

Esophageal adenocarcinoma incidence is increasing in Western nations. There has been a shift toward minimally invasive approaches for transhiatal esophagectomy (THE). This study compares the outcomes of robotic THE for esophageal adenocarcinoma resection at our institution with the predicted metrics from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). With Institutional Review Board (IRB) approval, we prospectively followed 83 patients who underwent robotic THE from 2012 to 2023. Predicted outcomes were determined using the ACS NSQIP Surgical Risk Calculator. Our outcomes were compared with these predicted outcomes and with general outcomes for transhiatal esophagectomy reported in ACS NSQIP, which includes a mix of surgical approaches. The median age of patients was 70years, with a body mass index (BMI) of 26.4kg/m2 and a male prevalence of 82%. The median length of stay was 7days. The rates of any complications and in-hospital mortality were 16% and 5%, respectively. Seven patients (8%) were readmitted within a 30-day postoperative window. The median survival is anticipated to surpass 95months. Our outcomes were generally aligned with or surpassed the predicted ACS NSQIP metrics. The extended median survival of over 95months highlights the potential effectiveness of robotic THE in the resection of esophageal adenocarcinoma. Further exploration into its long-term survival benefits and outcomes is warranted, along with studies that provide a more direct comparison between robotic and other surgical approaches.

The effect of damage control laparotomy on surgical-site infection risks after emergent intestinal surgery

IntroductionDamage-control laparotomy has been widely used in general surgery. However, associated surgical-site infection risks have rarely been investigated. Damage-control laparotomy allows for additional opportunities for decontamination. We hypothesized that damage-control laparotomy would be associated with lower surgical-site infection risks compared with laparotomy with only primary fascial closure or with primary fascial and skin closure. MethodsPatients admitted for emergent intestinal surgery from 2006 to 2021 were included. Multivariate analyses were performed to identify surgical-site infection–associated risk factors. Although variables like laparotomy type (damage-control laparotomy, primary fascial closure, and primary fascial and skin closure) were provided by National Surgical Quality Improvement Program, other variables such as number of operations were retrospectively collected. P < .05 was considered significant. ResultsOverall, 906 patients were included; 213 underwent damage-control laparotomy, 175 primary fascial closure, and 518 primary fascial and skin closure. Superficial, deep, and organ-space surgical-site infection developed in 66, 6, and 97 patients, respectively. Compared with primary fascial and skin closure, both damage-control laparotomy (odds ratio, 0.30 [95% CI, 0.13–0.73], P = .008) and primary fascial closure (odds ratio, 0.09 [95% CI, 0.02–0.37], P = .001) were associated with lower superficial incisional surgical-site infection but not organ-space surgical-site infection risk (odds ratio, 0.80 [95% CI, 0.29–2.19] P = .667 and odds ratio, 0.674 [95% CI, 0.21–2.14], P = .502, respectively). Body mass index was associated with increased risk of superficial incisional surgical-site infection (odds ratio, 1.06 [95% CI, 1.03–1.09], P < .001) whereas frailty was associated with organ space surgical-site infection (odds ratio, 3.28 [95% CI, 1.29–8.36], P = .013). For patients who underwent damage-control laparotomy, the number of operations did not affect risk of either superficial incisional surgical-site infection or organ space SSI. ConclusionHerein, compared with primary fascial and skin closure, both damage-control laparotomy and primary fascial closure were associated with lower superficial but not organ space surgical-site infection risks. For patients who underwent damage-control laparotomy, number of operations did not affect surgical-site infection risks.

Screening for Health-Related Social Needs and Financial Toxicity Among Patients With Cancer Treated With Radiation Therapy: Findings From a Quality Improvement Project

IntroductionFinancial toxicity is common among patients with cancer, as are co-occurring health-related social risks (HRSRs). There is limited evidence to support best practices in screening for HRSRs and financial toxicity in the cancer context. This analysis sought to understand variations of identified needs based on treatment course using data from a large screening program. MethodsThis 2022 to 2023 screening quality improvement program included four services (breast, gastrointestinal, gynecologic, thoracic) at an urban comprehensive cancer center. The Comprehensive Score for Financial Toxicity measured financial toxicity. Patients completed an HRSR checklist documenting food, housing, medication, or transportation insecurity and financial borrowing practices. Differences were evaluated by treatment course (radiation therapy [RT] versus other treatment and RT plus chemotherapy versus other treatment). ResultsScreening surveys were sent to 70,983 unique patients; 38,249 completed a screening survey (54% response rate). Of responders, 4% (n = 1,686) underwent RT in the 120 days before their survey, and 3% (n = 1,033) received RT in combination with chemotherapy. Overall, patients receiving RT had lower unadjusted Comprehensive Score for Financial Toxicity scores, indicating worse financial toxicity. The proportion of patients receiving RT reporting unmet transportation (15% versus 12%, P < .0001) and housing (13% versus 12%, P = .02) needs was significantly higher than for patients not receiving RT. More patients receiving RT borrowed money than did patients not receiving RT (17% versus 15%, P = .02). In multivariable models, RT (alone or in combination) was associated with worse financial toxicity and transportation difficulties, and a great likelihood of borrowing money for treatment. ConclusionsScreening for financial toxicity and HRSR is possible at a large cancer center. Patients receiving RT have higher transportation insecurity and worse financial toxicity compared with those receiving other treatments. Tailored intervention throughout the treatment trajectory is essential.

Long-Term Sustainability of Peri-Operative Infection Control Practices: Implementation of "Clean Cut," a Checklist-Based Quality Improvement Program in India.

Introduction: Surgical site infections (SSIs) are a substantial healthcare burden in low- and middle- income countries. "Clean Cut" is a checklist-based infection prevention and control (IPC) program intended to improve compliance to peri-operative IPC standards. We aim to study the short-term and long-term impact of its implementation in a tertiary care cancer referral center. Methods: This was a single institute, prospective interventional study. Patients undergoing elective head-neck surgical procedures were included. The "Clean Cut" program consisting of surveillance, audits, and IPC training was implemented for 6 months, after which there was no active oversight. Post-intervention (T2) and 1-year follow-up (T3) data regarding compliance to core IPC practices and SSI rates were compared with baseline (T1). Results: One hundred eighty six patients were included with 50 (26.9%), 86 (46.2%), and 50 (26.9%) patients at T1, T2, and T3, respectively. At baseline, teams complied with a mean of 3.56 of the six critical components of infection control processes which rose to 4.66 (p < 0.001) at T2, but decreased to 4.02 at T3 (p = 0.053). The SSI rate at baseline decreased significantly after Clean Cut implementation [16 (32%) vs. 12 (13.95%), p = 0.012], but returned to baseline levels after 1 year [17 (34%), p = 0.006]. Conclusion: Implementation of the "Clean Cut" program increases compliance to infection control processes and reduces SSI rates in the short term. Without continuing oversight, these rates return to baseline values after 1 year.