To examine opioid prescribing patterns after general surgery procedures and to estimate an ideal number of pills to prescribe.
Diversion of prescription opioids is a major contributor to the rising ...mortality from opioid overdoses. Data to inform surgeons on the optimal dose of opioids to prescribe after common general surgical procedures is lacking.
We evaluated 642 patients undergoing 5 outpatient procedures: partial mastectomy (PM), partial mastectomy with sentinel lymph node biopsy (PM SLNB), laparoscopic cholecystectomy (LC), laparoscopic inguinal hernia repair (LIH), and open inguinal hernia repair (IH). Postoperative opioid prescriptions and refill data were tabulated. A phone survey was conducted to determine the number of opioid pills taken.
There was a wide variation in the number of opioid pills prescribed to patients undergoing the same operation. The median number (and range) prescribed were: PM 20 (0-50), PM SLNB 20 (0-60), LC 30 (0-100), LIH 30 (15-70), and IH 30 (15-120). Only 28% of the prescribed pills were taken. This percentage varied by operation: PM 15%, PM SLNB 25%, LC 33%, LIH 15%, and IH 31%. Less than 2% of patients obtained refills.We identified the number of pills that would fully supply the opioid needs of 80% of patients undergoing each operation: PM 5, PM SLNB 10, LC 15, LIH 15, and IH 15. If this number were prescribed, the number of opioid initially prescribed would be 43% of the actual number prescribed.
There is wide variability in opioid prescriptions for common general surgery procedures. In many cases excess pills are prescribed. Using our ideal number, surgeons can adequately treat postoperative pain and markedly decrease the number of opioids prescribed.
The aim of this study was to determine whether an educational intervention was sufficient to decrease opioid prescribing after general surgical operations.
We recently analyzed opioid prescription ...and use for 5 common outpatient operations at our institution: partial mastectomy (PM), PM with sentinel lymph node biopsy (PM SLNB), laparoscopic cholecystectomy (LC), laparoscopic inguinal hernia repair (LIH), and open inguinal hernia repair (IH). We found that opioids were over-prescribed. We formulated guidelines for opioid prescribing that would halve the number of pills prescribed and also satisfy 80% of patients' opioid requirements.
We discussed our findings and opioid-prescribing guidelines with surgeons at our institution. We recommended that surgeons encourage patients to use a nonsteroidal anti-inflammatory drug (NSAID) and acetaminophen before using opioids. We then evaluated opioid prescriptions and use in 246 subsequent patients undergoing these same operations.
The mean number of opioid pills prescribed for each operation markedly decreased: PM 19.8 versus 5.1; PM SLNB 23.7 versus 9.6; LC 35.2 versus 19.4; LIH 33.8 versus 19.3, and IH 33.2 versus 18.3; all P < 0.0003. The total number of pills prescribed decreased by 53% when compared with the number that would have been prescribed before the educational intervention. Only 1 patient (0.4%) required a refill opioid prescription. Eighty-five percent of patients used either a NSAID or acetaminophen.
By defining postoperative opioid requirements through patient surveys and disseminating operation-specific guidelines for opioid prescribing to surgeons, we were able to decrease the number of opioids initially prescribed by more than half. Decreased initial opioid prescriptions did not result in increased opioid refill prescriptions.
There is a paucity of data to inform appropriate opioid prescribing for patients who are discharged after a hospital admission for a surgical procedure.
We studied 333 inpatients discharged to home ...after bariatric, benign foregut, liver, pancreas, ventral hernia, and colon surgery. Chronic opioid users or patients who had complications were excluded. Home opioid usage was quantified in 90% of the remaining patients by questionnaires and phone surveys.
Eighty-five percent of patients were prescribed an opioid and 38% of prescribed opioid pills were taken. Fifteen opioid pills satisfied the opioid needs of 88% of patients discharged on postoperative day (POD) 1. For patients discharged after POD 1, in multivariate analysis, the number of opioid pills used at home was associated with the number taken the day before discharge (p < 0.0001) and patient age (p = 0.006), but not the type of surgery. Forty-one percent of patients took no opioids the day before discharge, 33% took 1 to 3, and 26% took more than 4 pills. Eighty-five percent of patients' home opioid requirements would be satisfied using the following guideline: if no opioid pills are taken the day before discharge, no prescription is needed; if 1 to 3 opioid pills are taken the day before discharge, then a prescription for 15 opioid pills is given at discharge; and if 4 or more pills are taken the day before discharge, then a prescription for 30 opioid pills is given at discharge. If these guidelines were used, the number of opioid pills prescribed would decrease by 40%.
For patients admitted after surgical procedures, post-discharge opioid use is best predicted by usage the day before discharge. Use of this guideline could decrease opioid prescriptions substantially and effectively treat patients' pain.
The American Board of Surgery has proposed a competency-based training model, which relies on entrustable professional activities (EPAs) to assess and document competence. No data exist defining ...competence for surgical consultation, one of five proposed trial EPAs.
Qualitative interviews performed with 23 surgical faculty at two academic institutions. Interviews were reviewed for thematic content.
No explicit framework is currently used to evaluate the surgical consult. Most participants currently use subjective, global performance assessment. This method often relies on information not limited to the discrete consult at hand. Competence for a discrete surgical consult can be defined by six key procedural steps and six performance traits. Five red-flag behaviors were identified that negatively impact entrustability.
Subjective global assessment of resident performance can be problematic. We propose an objective framework for assessment, which can be used to develop an evaluation tool and inform entrustment decisions for competency-based training.
•Surgical consults currently evaluated by global, subjective assessment.•We identified six key steps and six performance traits that define consult competence.•Five red flag behaviors negatively affect entrustability.•This novel framework will allow objective evaluation to inform entrustment decisions.
23 multi-institutional qualitative interviews of surgical faculty were performed to define competence for the surgical consult. Six key steps and six performance traits were identified. Five red flag behaviors were identified that negatively affect entrustability. This framework will allow for an objective evaluation tool, which will help inform entrustment decisions.
Most states have adopted the routine use of a prescription drug monitoring program (PDMP) to curb overprescribing of opioids. The American College of Surgeons promotes the use of these programs as a ..."guiding principle to curb the opioid epidemic." However, there is a paucity of data on the effects of the use of these programs for surgical patient populations.
To determine the association of the mandatory use of a PDMP with the opioid prescribing practices for patients undergoing general surgery.
A prospective observational cohort study was conducted at an academic hospital in New Hampshire among 1057 patients undergoing representative elective general surgical procedures from July 1, 2016, to June 30, 2017.
New state legislation mandated the use of a PDMP and opioid risk-assessment tool for all patients receiving an outpatient opioid prescription in New Hampshire beginning January 1, 2017. The electronic medical prescribing system was modified to facilitate and support compliance with the new requirements.
Change in opioid prescribing practices after January 1, 2017, and time to complete PDMP requirements.
Among the 1057 patients (569 women 53.8% and 488 men 46.2%; mean SD age, 56.8 15.4 years), the percentage of patients prescribed opioids after surgery did not decrease significantly (429 of 536 80.0% before the new requirements vs 401 of 521 77.0% after the requirements; P = .29). The mean number of opioid pills prescribed decreased from 30.8 to 24.0 (22.1%) in the 6 months prior to the mandatory PDMP requirement; the rate of decrease was actually less (from 22.8 to 21.9 pills 3.9%) in the 6 months after the legislation. These new requirements did not identify any high-risk patients who subsequently were not prescribed opioids. The query and opioid abuse risk calculator together took a median time of 7 minutes (range, 2-17 minutes) to complete.
A mandatory PDMP query requirement was not significantly associated with the overall rate of opioid prescribing or the mean number of pills prescribed for patients undergoing general surgical procedures. In no cases was a high-risk patient identified, leading to avoidance of an opioid prescription. A PDMP can be a useful adjunct in certain settings, but this study found that it did not have the intended effect in a population undergoing elective surgical procedures. Legislative efforts to mandate PDMP use should be targeted to populations in which benefit can be demonstrated.
Recent literature on parental leave during residency has focused on the importance of supporting new mothers, but the needs and challenges faced by expectant nonchildbearing residents are less well ...described. Male residents are more likely than their female counterparts to have children during surgical training, and they experience similar stressors including childcare and conflicts between work and home priorities. As nonchildbearing parents of this generation become more involved in childrearing, the need to establish inclusive parental leave policies is essential. The aim of this study was to provide a deeper understanding of the perspectives of male residents about parental leave.
A semi-structured interview guide was developed using a literature search and an expert panel. Interviews were audio-recorded and transcribed verbatim and emergent themes were identified using content analysis.
Four academic institutions.
Four focus groups were held with of a total of 15 male resident-parents. These were selected using convenience sampling.
Multiple themes emerged: 1) male residents perceive greater stigma attached to taking leave compared to female colleagues; 2) paternity leave policies are vague and sometimes non-existent; 3) male residents experience a high burden of guilt related to burdening peers with clinical coverage while on leave; 4) male residents face internal conflict between surgical and parental responsibilities; 5) male residents have little mentorship on successful work-life integration and feel compelled to model the behavior of their attendings who often prioritize career before family; and 6) shifts in family values and priorities are common following childbirth and impact how male resident-parents view other new parents in training.
Significant challenges exist for residents who become fathers during their surgical training. Key stressors include poorly defined leave policies, historic paradigms of prioritizing professional duties before personal duties, stigma against taking time off for parental bonding in the absence of medical need, and guilt related to extra work imposed on colleagues by time away. Establishment of formal parental leave policies for both genders, programmatic support to offset the increased workload on colleagues, and greater mentorship on balancing family and career are needed to foster a culture of work-life integration.
Abstract Background The purpose of this study was to determine the relationship between coagulopathy and outcome after traumatic brain injury. Methods Patients admitted with a traumatic brain injury ...were enrolled prospectively and admission blood samples were obtained for kaolin-activated thrombelastogram and standard coagulation assays. Demographic and clinical data were obtained for analysis. Results Sixty-nine patients were included in the analysis. A total of 8.7% of subjects showed hypocoagulability based on a prolonged time to clot formation (R time, > 9 min). The mortality rate was significantly higher in subjects with a prolonged R time at admission (50.0% vs 11.7%). Patients with a prolonged R time also had significantly fewer intensive care unit–free days (8 vs 27 d), hospital-free days (5 vs 24 d), and increased incidence of neurosurgical intervention (83.3% vs 34.9%). Conclusions Hypocoagulability as shown by thrombelastography after traumatic brain injury is associated with worse outcomes and an increased incidence of neurosurgical intervention.
To ensure that residents are appropriately trained in the era of the 80-hour work-week, training programs have restructured resident duties and hired advanced practice providers (APPs). However, the ...effect of APPs on surgical training remains unknown.
We created a survey using a modified Delphi technique to examine the interaction between residents and APPs across practice settings (inpatient, outpatient, and operating room). We identified the following domains: administrative tasks, clinical experience, operative experience, and overall impressions. We administered the survey to residents across 7 surgical training programs at a single institution and assessed internal reliability with Cronbach's α.
Fifty residents responded (77% participation rate). The majority reported APPs reduced the time spent on administrative tasks, such as completing documentation (96%) and answering pages (88%). For clinical experience, 62% of residents thought that APPs had no impact on the amount of time spent evaluating consult patients, and 80% reported no difference in the number of bedside procedures performed. However, 77% of residents reported a reduction in the time spent counseling patients. When APPs worked in the inpatient setting, 90% of residents reported leaving the operating room less frequently to manage patients. When APPs were present in the operating room, 34% of residents thought they were less likely to perform key parts of the case. Cronbach's α showed excellent to good reliability for the administrative tasks (0.96), clinical experience (0.76), operative experience (0.69), and overall impressions (0.66) domains.
Most residents report that the integration of APPs has decreased the administrative burden. The reduction in patient counseling might be an unrecognized and unintended consequence of implementing APPs. The perceived effect on operative experience is dependent on the role of the APPs.
Background
Metabolic and bariatric surgery is an effective strategy to curb the natural history of obesity progression and improve psychosocial status in the short term for adolescents with severe ...obesity. The medium- and long-term psychosocial impact of bariatric surgery in this population is not established.
Methods
We searched MEDLINE (Ovid), EMBASE, Web of Science, PsycInfo, and the Cochrane Libraries through October 2017 for reports of weight loss surgery (roux-en-Y gastric bypass, sleeve gastrectomy, and adjustable gastric banding) on adolescents with severe obesity (age ≤ 21 years) having ≥ 6 months of follow-up. The primary outcome for inclusion in systematic review was use of a validated quality of life (QoL) or other psychosocial instrument at baseline and postoperatively. We used standardized mean difference (SMD) and random-effects modeling to provide summary estimates across different instruments.
Results
We reviewed 5155 studies, of which 20 studies met inclusion criteria for qualitative synthesis. There were 14 studies and 9 unique cohorts encompassing 573 patients which were eligible for meta-analysis regarding postoperative change in QoL. Across surgical procedures, there was significant improvement in QoL of 1.40 SMD (95% confidence interval 0.95 to 1.86; I
2
= 89%;
p
< 0.001) at last follow-up (range 9–94 months). Trends in QoL improvement demonstrated the greatest improvement at 12 months; however, significant improvement was sustained at longest follow-up of 60+ months.
Conclusions
Weight loss surgery is associated with sustained improvement in QoL for adolescents with severe obesity across surgical procedures. Long-term data for psychosocial outcomes reflecting other mental health domains is lacking.
Abstract Background Context Various surgical factors affect the incidence of postoperative medical complications following elective spinal arthrodesis. Because of the inter-relatedness of these ...factors, it is difficult for clinicians to accurately risk-stratify individual patients. Purpose Our goal was to develop a scoring system that predicts the rate of major medical complications in patients with significant preoperative medical comorbidities, as a function of the four perioperative parameters that are most closely associated with the invasiveness of the surgical intervention. Study Design/Setting This study used level 2, Prognostic Retrospective Study. Patient Sample The patient sample consisted of 281 patients with American Society of Anesthesiologists (ASA) scores of 3–4 who underwent elective thoracic, lumbar, or thoracolumbar fusion surgeries from 2007 to 2011. Outcome Measures Physiologic risk factors, number of levels fused, complications, operative time, intraoperative fluids, and estimate blood loss were the outcome measures of this study. Methods Risk factors were recorded, and patients who suffered major medical complications within the 30-day postoperative period were identified. We used chi-square tests to identify factors that affect the medical complication rate. These factors were ranked and scored by quartiles. The quartile scores were combined to form a single composite score. We determined the major medical complication rate for each composite score, and divided the cohort into quartiles again based on score. A Pearson linear regression analysis was used to compare the incidence of complications to the score. Results The number of fused levels, operative time, volume of intraoperative fluids, and estimated blood loss influenced the complication rate of patients with ASA scores of 3–4. The quartile ranking of each of the four predictive factors was added, and the sum became the composite score. This score predicted the complication rate in a linear fashion ranging from 7.6% for the lowest risk group to 34.7% for the highest group (r=0.998, p<.001). Conclusions Taken together, the four factors, though not independent of one another, proved to be strongly predictive of the major medical complication rate. This score can be used to guide medical management of thoracic and lumbar spinal arthrodesis patients with preexisting medical comorbidities.
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