Journal of the American College of Surgeons
-
Comparative Study
Influence of in-house attending presence on trauma outcomes and hospital efficiency.
The influence of in-house (IH) attendings on trauma patient survival and efficiency measures, such as emergency department length of stay (LOS), ICU LOS, and hospital LOS, has been debated for more than 20 years. No study has definitively shown improved outcomes with IH vs home-call attendings. This study examines trauma outcomes in a single, Level I trauma center before and after the institution of IH attending call. ⋯ In-house attending presence does not improve trauma patient survival. For the most severely injured patients, attendings presence does not reduce mortality. In-house coverage can improve hospital efficiency by decreasing emergency department LOS, hospital LOS, and ICU LOS.
-
Observational Study
A 100% departmental mortality review improves observed-to-expected mortality ratios and University HealthSystem Consortium rankings.
Public reporting of mortality, Patient Safety Indicators (PSI) and hospital-acquired conditions (HACs) is the reality of quality measurement. A review of our department's data identified opportunities for improvement. We began a surgeon-led 100% review of mortality, PSIs, and HACs to improve patient care and surgeon awareness of these metrics. ⋯ A surgeon-led systematic review of mortality, PSIs, and HACs improved our OE ratio and University HealthSystem Consortium postsurgical relative rankings. Surgeon engagement and ownership is critical for success.
-
Comparative Study
Comparison of sentinel lymph node micrometastatic tumor burden measurements in melanoma.
Multiple methods have been proposed to classify the micrometastatic tumor burden in sentinel lymph nodes (SLN) for melanoma. The purpose of this study was to determine the classification scheme that best predicts nonsentinel node (NSN) metastasis, disease-free survival (DFS), and overall survival (OS). ⋯ Maximum tumor diameter outperformed other measurements of metastatic tumor burden, including microanatomic tumor location (Dewar classification), Starz classification, maximum tumor area, and sum of all diameters for prediction of survival. Maximum tumor diameter is a simple method of assessing micrometastatic tumor burden that should be reported routinely.
-
Excision followed by radiofrequency ablation (eRFA) is an intraoperative method that uses intracavitary hyperthermia to create an additional tumor-free zone around the lumpectomy cavity in breast cancer patients. We hypothesized that eRFA after lumpectomy for invasive breast cancer could reduce the need for re-excision for close margins as well as potentially maintain local control without the need for radiation. ⋯ Long-term follow-up suggests that eRFA may reduce the need for re-excision for close or focally positive margins in breast cancer patients, and eRFA may be a valuable tool for treating favorable patients who desire lumpectomy and either cannot or do not want radiation. A multicenter trial has been initiated based on these results.
-
Comparative Study
Permissive hypertension during awake eversion carotid endarterectomy: a physiologic approach for cerebral protection.
Carotid endarterectomy (CEA) is often completed with general anesthesia and routine shunting; however, shunting is only required in a small group of at-risk patients to maintain adequate cerebral perfusion. Selective shunting during CEA is performed to normalize cerebral hemodynamics for patients determined to be at risk. Eversion CEA with selective shunting for neurologic dysfunction in patients that are awake/sedated is described, as well as routine use of permissive hypertension (PH), which uses standard cardiovascular medications to recruit the cerebral collateral network and reduce the need for shunting. ⋯ Routine use of PH during clamp time can recruit the cerebral collateral network and substantially reduce the at-risk group and need for shunting in awake/sedated patients.