Quality improvement efforts take considerable commitment, including mentorship, training, and resources. Leveraging an established framework, such as that outlined by the American College of Surgeons, to design, implement, and analyze quality improvement projects offers the best chance for success. Herein, we illustrate the application of this framework to a gap in advance care planning for surgical patients. This article helps outline how to go from identifying and outlining a problem, to articulating a clearly defined project goal that is specific, measurable, attainable, relevant, and timebound, and later implementing and analyzing a gap in quality identified at the unit (e.g., service line, inpatient unit, clinic) or hospital level.

Recent controversy has called into question the meaning and clinical utility of Advance Care Planning (ACP), however data have consistently shown potential benefit to patients and their surrogate decision makers. We present the concept of surgery-specific advance care planning and a structured, scalable approach to integrating it into clinical practice.

Enhanced Recovery After Surgery (ERAS) programs are transdisciplinary, evidence-based perioperative protocols that aim to standardize best practices and increase the value of delivered healthcare. Quality improvement programs such as ERAS for colorectal surgery have been linked to a reduction in rates of hospital-acquired infections (HAIs) including surgical site infection as well as a reduction in overall length of stay. Importantly, to achieve these results, hospitals must commit to fostering transdisciplinary collaboration across surgery, anesthesiology, and nursing, as well as alignment between frontline providers and hospital executives. This requires upfront investment as well as ongoing resource allocation to sustain the program but given the magnitude of the potential impact of a successful ERAS program on multiple domains of quality and safety, the investment will easily reap ongoing rewards. The purpose of this manuscript is to outline implementation and sustainability costs of an ERAS program as well as discuss the potential cost savings related to the program to further inform hospitals considering adoption of this approach to care.

In this review, we explore the rationale and history behind the practice of preoperative fasting in elective surgery including the gradual move toward longer fasting and the more recent change in direction of practice. Gastric emptying physiology and the metabolic effects of prolonged fasting and carbohydrate loading are examined. Most recent guidelines related to these topics are discussed and practical recommendations for implementing these guidelines are suggested.

BACKGROUND: For patients who may permanently or temporarily lose their ability to communicate preferences, advance care planning is a critical mechanism to guide medical decision-making but is currently underused among surgical patients. METHODS: A resident-led quality improvement project, including education and performance measurement, was conducted on an emergency general surgery service to increase the completion of inpatient advance care planning notes using a specialized template in the electronic health record. Advance care planning documentation was defined as either preadmission advance care planning documentation (eg, advance directive) or inpatient advance care planning (use of the electronic health record template). Data from patients admitted to the emergency general surgery service for 12+ hours were analyzed, and baseline data (July 2020 to June 2021) were compared with data from the intervention period (July 2021 to June 2022). The chart review evaluated the content of the inpatient advance care planning documentation from the intervention period. RESULTS: The frequency of inpatient advance care planning documentation increased (9.3%, n = 56 to 16.6%, n = 92, P < .001) with a greater contribution of inpatient advance care planning notes by the surgery team (16.7% to 55.4%) in the intervention period. Content analysis indicated that 79.0% of inpatient advance care planning notes listed preferences for life-sustaining therapy, 78.3% listed surrogacy, 57.3% listed overall health goals, and 50.3% listed treatment goals specific to the surgical encounter. CONCLUSION: Although a resident-led quality improvement project contributed to greater adoption of standardized inpatient advance care planning documentation on an emergency general surgery service, progress was slow, and integration into standard work was not achieved. Future efforts are needed to better understand the integration of essential advance care planning elements into workflows and to establish inclusive educational programming to prepare all team members for conducting and documenting advance care planning conversations.

Surgical site infections (SSIs) are the most common and costly of hospital acquired infections. An important step in reducing SSIs is accurate SSI detection, which enables measurement quality improvement, but currently remains expensive through manual chart review. Building off of previous work for automated and semi-automated SSI detection using expert-derived strong features from clinical notes, we hypothesized that additional SSI phrases may be contained in clinical notes. We systematically characterized phrases and expressions associated with SSIs. While 83% of expert-derived original terms overlapped with new terms and modifiers, an additional 362 modifiers associated with both positive and negative SSI signals were identified and 62 new base observations and actions were identified. Clinical note queries with the most common base terms revealed another 49 modifiers. Clinical notes contain a wide variety of expressions describing infections occurring among surgical specialties which may provide value in improving the performance of SSI detection algorithms.

Objective

The COVID-19 pandemic has drastically transformed the healthcare community and medical education across the United States. The aim of this study was to evaluate the impact of COVID-19 on the surgical resident training experience, assess possible sources of stress or anxiety among surgery residents, and examine how patterns of anxiety vary by resident rank.

Design

We developed and disseminated a survey, which included the Generalized Anxiety Disorder 7-Item Scale (GAD-7), to all general and integrated plastic surgery residents in their clinical years of training at the University of California, San Francisco. Statistical analysis of the survey responses was performed using the Kruskal-Wallis or Wilcoxon rank sum test. Post-hoc analysis was performed using the Bonferroni-corrected Dunn test. Survey data were combined with aggregated duty hour information and operative case numbers from select hospitals for March and April of 2019 (historical baseline) and 2020.

Results

The overall survey response rate was 73.7% (n = 73). With an estimated operative volume reduction of 63.3% for general surgery cases, over 90% of residents expressed concern about the decline in operative exposure. While the senior residents tended to work more shifts, they were not more likely to have higher risk perception scores for contracting COVID-19 nor higher anxiety levels about the possibility of contracting COVID-19. They were, however, significantly more likely to have high GAD-7 scores (≥ 10) when compared to interns (z = -2.82, p-adj = 0.014). Overall, residents were more concerned about the general health of loved ones than about their own risk of contracting COVID-19 (U = 3897.5, p < 0.01).

Conclusions

While the work-related experiences of residents varied across a number of factors during the pandemic, residents tended to report similar sources of anxiety. Moving forward, surgical residency training programs will need to develop ways to optimize available surgical experiences and address the unique resident anxieties that an infectious pandemic presents.

Functional health status is an important factor not only for determining overall health, but also for measuring risks of adverse events. Our hypothesis is that important functional status data is contained in clinical notes. We found that several categories of phrases related to functional status including diagnoses, activity and care assessments, physical exam, functional scores, assistive equipment, symptoms, and surgical history were important factors. Use of functional health status level terms from our chart review compared to National Surgical Quality Improvement Program determination had varying sensitivities for correct functional status category identification, with 96% for independent patients, 60% for partially dependent patients, and 44% for totally dependent patients. Inter-rater agreement assessing term relevance to functional health status was high at 91% (Kappa=0.74). Functional status-related terms in clinical notes show potential for use in future methodologies for automated detection of functional health status for quality improvement registries and other clinical assessments.

Background

As healthcare costs rise, there is an increasing emphasis on alternative payment models to improve care efficiency. The bundled payment represents an alternative reimbursement model gaining popularity within the surgical sphere. We aimed to assess where the largest opportunities for care improvement lay and how best to identify patients at high risk of suffering costly complications.

Methods

We utilized itemized CMS claims data for a retrospective cohort of patients between 2014 and 2016 who met inclusion criteria for the Major Bowel Bundled Payment Program and performed a cost analysis to identify opportunities for improved care efficiency. Based on the results of this cost analysis, we identified readmissions as a target for improvement. We then assessed whether the American College of Surgeons' National Surgical Quality Improvement Program surgical risk calculator (ACS NSQIP SRC) could accurately identify patients within our bundled payment population who were at high risk of readmission using a logistic regression model.

Results

Our study cohort included 252 patients. Readmissions accounted for 12.8% of the average total care episode cost with a coefficient of variation of 2.72, thereby representing the most substantial, non-fixed cost for our bundled payment patients. Patients readmitted within their 90-day care episode were 2.53 times more likely to be high-cost (>$60,000) than patients not readmitted. However, the ACS NSQIP SRC did not accurately predict patients at high risk of readmission within the first 30 days with an AUROC of 0.58.

Conclusions

Our study highlights the importance of reducing readmissions as a central component of improving care for bowel surgery bundled payment patients. Preventing such readmissions requires accurate identification of patients at high risk of readmission; however, current risk prediction models lack the adaptability necessary for this task.