Journal of the American College of Surgeons
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Multicenter Study Comparative Study
A health system-based critical care program with a novel tele-ICU: implementation, cost, and structure details.
Improving the efficiency of critical care service is needed as the shortfall of intensivists is increasing. Standardizing clinical practice, telemedicine, and organizing critical care service at a health system level improves outcomes. We developed a health system Critical Care Program based at an academic medical center. The main feature of our program is an intensivist who shares on-site and telemedicine clinical responsibilities. Tele-ICU facilitates the standardization of high-quality critical care across the system. A common electronic medical record made the communications among the ICUs feasible. Combining faculty from medical and surgical critical care divisions increased the productivity of intensivists. ⋯ We describe a novel health system level ICU program built using "off the shelf" technology based on a large University medical center and a tele-ICU with a full degree of treatment authority across the system.
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Multicenter Study Comparative Study
Florida Initiative for Quality Cancer Care: improvements in breast cancer quality indicators during a 3-year interval.
The Florida Initiative for Quality Cancer Care (FIQCC), composed of 11 practice sites across Florida, conducted its initial evaluation of adherence to breast cancer quality of care indicators (QCI) in 2006, with feedback provided to encourage quality improvement efforts at participating sites. In this study, our objective was to reassess changes over time resulting from these efforts. ⋯ The 2006 FIQCC study identified several medical and surgical oncology QCI improvement needs. Quality improvement efforts resulted in better performance for numerous metrics, therefore speaking to the benefits of reassessment of adherence to performance indicators to guide QCI efforts.
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Multicenter Study
Entrustment of general surgery residents in the operating room: factors contributing to provision of resident autonomy.
Several challenges threaten the traditional premise of graduated independence in general surgery training, leading to a lack of readiness in graduating surgeons. The objective of this study was to determine the factors contributing to faculty decisions to grant residents autonomy in the operating room, the barriers to granting this autonomy, and the factors that facilitate entrustment. ⋯ This study identified several factors that attending surgeons report as significant limitations to transitioning autonomy to surgical residents in the operating room. These issues must be addressed in a direct manner if progressive graduated responsibility to independence is to occur in the next era of graduate surgical training.
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Comparative Study
Spontaneous pneumomediastinum: an extensive workup is not required.
Spontaneous pneumomediastinum is a rare entity usually caused by alveolar rupture and air tracking along the tracheobronchial tree. Despite its benign nature, an extensive workup is often undertaken to exclude hollow viscus perforation. We sought to review our experience with this condition and examine the optimal management strategy. ⋯ Spontaneous pneumomediastinum is a benign entity and rarely correlates with true esophageal perforation. Additional investigation with esophagography or other invasive procedures should be performed selectively with the aim of expediting the patient's care. The prognosis is excellent with conservative management and the risk for recurrence is low.
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Multicenter Study
Examining national outcomes after thyroidectomy with nerve monitoring.
Previous intraoperative nerve monitoring (IONM) studies have demonstrated modest-to-no benefit and did not include a nationwide sample of hospitals representative of broad thyroidectomy practices. This national study was designed to compare vocal cord paralysis (VCP) rates between thyroidectomy with IONM and without monitoring (conventional). ⋯ According to this study, IONM has not been broadly adopted into practice. Overall, IONM was associated with a higher rate of VCP even after correction for numerous confounders. In particular, low institutional use of IONM and use in partial thyroidectomies are associated with higher rates of VCP. Further studies are warranted to support the broader application of IONM in patients where benefit can be reliably achieved.