BackgroundWhile colorectal surgery quality improvement efforts and ERAS pathways emphasize operative sterility, glycemic control, and fluid optimization, perioperative micronutrient status is rarely assessed. Vitamin C is essential for collagen crosslinking, immune function, and antioxidant activity, and deficiency may plausibly impair anastomotic and wound healing. Patients undergoing colorectal surgery may be at particular risk due to baseline malnutrition, disease related malabsorption, postoperative ileus, and reduced enteral intake. The prevalence of vitamin C deficiency in this population remains poorly characterized.MethodsWe conducted a prospective observational study of adults undergoing elective major colon resections between June 2023 and May 2025. Patients taking vitamin C supplements or undergoing anorectal procedures were excluded. Plasma vitamin C levels were obtained postoperatively.ResultsFifty-one patients were included (mean age 56.8 ± 16.7 years). Most procedures were minimally invasive (84.3%). Indications included cancer (52.9%), diverticulitis (25.5%), and Crohn's disease (13.7%). The mean plasma vitamin C concentration was 27.8 ± 16.6 μmol/L. Seven patients (13.7%) had vitamin C deficiency, and an additional 17 (33.3%) had hypovitaminosis C, yielding a total of 47.0% with low levels.ConclusionNearly half of patients undergoing elective colorectal surgery demonstrated low vitamin C levels, with 14% meeting criteria for deficiency. These findings suggest an underrecognized micronutrient vulnerability in this population. Micronutrient assessment and optimization are seldom considered in modern ERAS pathways and may be an opportunity for future quality initiatives.

BackgroundOutpatient total and completion thyroidectomy is increasingly feasible, but long-term institutional data describing simultaneous expansion of same-day discharge and maintenance of low readmission are limited. We describe 14-year outcomes using a PACU parathyroid hormone (PTH)-guided calcium and calcitriol supplementation pathway.MethodsRetrospective single-institution cohort of total and completion thyroidectomies (2010-2023) analyzed across three complementary data sources: an NSQIP case-level cohort (N = 1111) for readmission, length of stay, and discharge timing; institutional NSQIP Semiannual Report (SAR) data (N = 1393) for hypocalcemia-related readmission; and the NSQIP thyroidectomy-targeted module (N = 766) for postoperative hypocalcemia. Institutional NSQIP observed-to-expected (O/E) ratios were reviewed as contextual benchmarking.ResultsSame-day discharge (LOS = 0 days) rose from <5% before 2017 to 60.0% in 2022 and 70.9% in 2023, and short-stay discharge (LOS ≤1 day) exceeded 90% annually from 2019 onward. Across the full period, 30-day all-cause readmission was 1.71% (95% CI: 1.10-2.66%). Hypocalcemia requiring readmission occurred in 1.4% of the SAR cohort and accounted for 67.9% of readmissions. Postoperative hypocalcemia was documented in 7.4% of the module subset (95% CI: 5.8%-9.5%), with clinically significant events in 4.0%. The mean institutional NSQIP O/E ratio was 0.93 (range 0.74-1.24).DiscussionAcross a 14-year cohort, same-day discharge after total and completion thyroidectomy expanded while 30-day readmission and clinically significant hypocalcemia remained low. These findings support the feasibility of outpatient thyroidectomy within a standardized PACU PTH-guided supplementation pathway; because PACU PTH values were unavailable, prospective studies are needed to determine whether the pathway independently influenced these outcomes.

ObjectiveTo examine a 26-year institutional experience of thyroglossal duct cyst (TGDC) excision, focusing on preoperative thyroid evaluation, incidental carcinoma diagnosis, and staged completion thyroidectomy.MethodsRetrospective review of 227 consecutive TGDC patients (1999-2025) at a single tertiary institution. TGDC-confined, synchronous TGDC-thyroid, and thyroidal-only carcinoma subgroups were analyzed separately. Data were cross-validated against pathology records.ResultsOf 227 patients (median age 47; 58% female), TGDC carcinoma occurred in 14 patients (6.2%): 10 TGDC-confined and 4 synchronous TGDC-thyroid. An additional 8 patients had thyroidal-only carcinoma identified at concurrent thyroidectomy with histologically benign TGDC and are described separately. Preoperative thyroid ultrasound was performed in 41 of 227 patients (18.1%), increasing from 1.2% before 2015 to 29.4% afterward (P < .001). Six of the fourteen TGDC carcinoma cases (43%) were diagnosed preoperatively by FNA; the rest were found on final pathology. Five patients required reoperation, and in four of these no preoperative thyroid ultrasound had been obtained.ConclusionsAcross this 26-year cohort, preoperative thyroid evaluation was infrequently performed relative to current ATA recommendations. This pattern coincided with a high incidental carcinoma diagnosis rate (64%) and with staged reoperations in patients whose synchronous thyroid disease was identified only on final pathology. Routine preoperative thyroid ultrasound, as the guidelines now recommend, may reduce the frequency of these outcomes in similar cohorts.

INTRODUCTION:Venous thromboembolism (VTE) remains a leading preventable cause of postoperative morbidity and mortality in part due to failure of consistent, standardized risk assessment. Available risk assessment models (RAMs) are burdensome and lack procedural specificity or actionable thresholds for intervention. A parsimonious, clinically oriented VTE RAM has the potential to increase adherence to risk assessment. METHODS:We applied multivariable logistic regression modeling with a clinically guided forward selection process to the 2019 National Surgical Quality Improvement Project public user file. Considered predictors included patient demographics, comorbidities, and elements of the preoperative assessment. Procedural specificity was introduced by grouping Current Procedural Terminology codes and capturing minimally invasive techniques. Model performance was internally compared to three currently available RAMs: the Caprini score, cancer, old age, BMI, race, ASA model, and American College of Surgeons risk calculator. RESULTS:VTE occurred in 8161 (0.76%) of 1,079,441 patients. The following eleven variables were chosen for model inclusion: age, body mass index, functional status, American Society of Anesthesiologists Physical Status classification; history of steroid use, ascites, or cancer; preoperative sepsis or blood transfusion; and Current Procedural Terminology group and minimally invasive surgery. The new FAST CLOTS model has a c-statistic of 0.753 and an 89% sensitivity for VTE outcomes at the chosen cut-off of 6 out of a maximum possible total of 24 points. CONCLUSIONS:As it was derived with an emphasis on biological plausibility and face validity to clinicians, the FAST CLOTS model addresses many of the limitations of currently available RAMs. If further validated and refined, adoption may improve care quality and patient outcomes.

BACKGROUND:American College of Surgeons (ACS) trauma center verification has demonstrated improved outcomes at individual centers, but its impact on statewide Trauma Quality Improvement Program (TQIP) Collaboratives is unknown. A statewide TQIP Collaborative, founded in 2011, noted underperformance in six of eight patient cohorts identified in the TQIP Collaborative report. We hypothesized that requiring ACS verification for level I and II trauma centers would result in improved outcomes for the state collaborative. METHODS:The ACS verification requirement was tied to ongoing Trauma Commission funding. Trauma centers were required to apply for an ACS consultative visit by 2017 and were given until 2023 to achieve ACS verification. The effect of this intervention was measured in the number of centers achieving verification and in the performance of the TQIP Collaborative semiannual reports. RESULTS:In 2015, only 1 of 15 (7%) trauma centers were ACS verified, and 4 had undergone consultative visits. By 2023, 11 of 12 (92%) trauma centers achieved ACS verification. Following this intervention, the observed-to-expected odds ratio for all-patient morbidity and mortality improved from 1.60 to 1.17, and variation among patient-specific cohorts narrowed from 0.97-1.82 to 0.96-1.48 (Figure 2). Performance in all six underperforming patient-specific cohorts improved over the study period. CONCLUSION:ACS verification for level I and II trauma centers improves TQIP Collaborative performance. Statewide Collaboratives should consider ACS verification as a requirement for participation. LEVEL OF EVIDENCE:Economic and Value-Based Evaluations; Level III.

BACKGROUND:Serial transverse enteroplasty is used to treat patients with chronic intestinal failure owing to short bowel syndrome. Current literature lacks discussion of its role for other etiologies of intestinal failure and its impact on adult patients' nutrition support needs and quality of life. METHODS:We performed a case series on adults with parenteral nutrition (PN) dependence who underwent serial transverse enteroplasty at Emory University Hospital, a quaternary referral center between 2011 and 2022. Data collected included demographics, operative technique, and preoperative and postoperative PN requirements. A phone survey was administered to evaluate the impact of PN and the operation on quality of life. RESULTS:Ten patients underwent the procedure of interest during the study period. Indications included short bowel syndrome following multiple abdominal operations or intra-abdominal catastrophe and chronic partial bowel obstruction with dysmotility. Bowel length increased by a median of 83%. All patients were discharged home after a median hospital stay of 21 days. At 1-year follow-up, survival was 100%, two (20%) patients fully weaned from PN, three others (30%) reduced PN frequency, and six (60%) decreased their daily parenteral energy requirement. Two additional patients fully weaned from PN by 18 months postoperatively. CONCLUSION:This represents one of the largest case series of serial transverse enteroplasty in adults. Small intestinal length nearly doubled, and PN dependence was reduced in most patients. Given the low morbidity and good quality of life observed in this series, this procedure should be more widely investigated for patients with chronic intestinal failure.

Injury Severity Score (ISS) has limited utility as a prospective predictor of trauma outcomes as it is currently scored by abstractors post-discharge. This study aimed to determine accuracy of ISS estimation at time of admission. Attending trauma surgeons assessed the Abbreviated Injury Scale of each body region for patients admitted during their call, from which estimated ISS (eISS) was calculated. The eISS was considered concordant to abstracted ISS (aISS) if both were in the same category: mild (<9), moderate (9-15), severe (16-25), or critical (>25). Ten surgeons completed 132 surveys. Overall ISS concordance was 52.2%; 87.5%, 30.8%, 34.8%, and 61.7% for patients with mild, moderate, severe, and critical aISS, respectively; unweighted k = .36, weighted k = .69. This preliminarily supports attending trauma surgeons’ ability to predict severity of injury in real time, which has important clinical and research implications.

IntroductionVenous thromboembolism following orthopedic trauma surgery remains prevalent despite prophylaxis being a standard of care. Enoxaparin injection is a commonly utilized prophylaxis regimen among high-risk patients. Patient-reported rates of nonadherence and barriers to enoxaparin use are not described in the literature. A better understanding of these barriers and their impact on adherence to post-discharge prophylaxis regimens may shed light on persistent outcomes gaps.Materials and MethodsSemi-structured interviews were administered to adult patients prescribed prophylactic enoxaparin and presenting to orthopedic surgery outpatient clinic at an urban level 1 trauma center for a post-operative appointment following traumatic injury from April to July, 2023. Patients self-reported their age, gender, race, and mobility. Inductive thematic analysis with three-reviewer consensus identified common barriers among responses. Adherence rates were calculated by dividing patients’ estimated number of missed doses over total prescribed doses at the point of inquiry.ResultsWe identified 154 eligible patients through chart review, and 50 enrolled and interviewed. Participants had a mean age of 37 years. Of 50 participants, 20 identified as female; 25 identified as Black or African American, 16 as White, 5 as Hispanic, 2 as Asian, and 2 as multiracial. Twenty-one participants were non-ambulatory at time of interview. Mean and median patient-reported adherence were 64.5% (SD 35.5) and 70.5% (IQR 33-100) respectively. Five patients reported complete nonadherence, while 17 patients reported perfect adherence. Every participant reporting complete nonadherence identified as Black or African American, as compared to 8 out of 17 reporting perfect adherence. Despite acknowledging a twice-daily prescription, 17 patients reported once-daily rather than twice-daily use. Inductive thematic analysis revealed the following six barriers to prophylaxis adherence (number of participants reporting): Inconvenience (18 patients), Pain (16), Fear (12), Acquisition (7), Bruising (7), and Mechanism (7). Altogether, 40 patients endorsed at least one barrier to adherence.Discussion & ConclusionsMost patients face barriers to adherence with post-discharge prophylactic enoxaparin, and the resultant rates of adherence are low. This may contribute to persistent outcomes gaps in the orthopedic trauma population despite prophylaxis standards. Changes in prescribing patterns and patient engagement techniques may improve post-operative thromboembolic outcomes.

Injury Severity Score (ISS) as a prospective predictive variable is limited, as it is scored post-discharge by registrars. We followed a phase 1 pilot investigation of the feasibility of prospective ISS estimation (eISS) by trauma surgeons within 1 day of admission with an investigation of the impact of a simple educational aid on the accuracy of these estimations. Eleven surgeons evaluated 178 patients in phase 2. With the educational aid, ISS concordance improved from 74.6% to 85.1% for non-severe (abstracted ISS, aISS <16) injuries and from 78.8% to 83.1% for severe (aISS ≥16) injuries; weighted k improved from 0.53 to 0.72. Abbreviated Injury Scale (AIS) concordance similarly improved in five of seven body regions. The ability to prospectively document ISS has important clinical and research implications. There remains opportunity to refine educational aides and harness the EHR to further improve prediction accuracy and facilitate adoption in standard clinical workflows.

Reliability is the likelihood that a process will perform a required function without failure, consistent over time and personnel changes. In the rapidly evolving healthcare landscape, reliably delivering excellent surgical care demands a comprehensive and systematic approach. Accomplishing this task is beyond the reach of any individual clinician, administrator, or leader. The team must work together to establish a highly reliable quality care culture that serves as the foundation for safe, patient-centered practice. High reliability thus inherently relies on transdisciplinary collaboration, with every level of clinical, administrative, and regulatory team members actively communicating, supporting each other, and building trust in each other's expertise. Here, we discuss the fundamentals of establishing a highly reliable quality care culture. We outline the key principles of a highly reliable organization- preoccupation with failure, sensitivity to operations, reluctance to oversimplify, commitment to resilience, and deference to expertise- and the characteristics of teams that can effectively implement these principles. We discuss the importance of standardization, continuous process and outcome measurement, and setting collective goals. And finally, we exemplify these fundamentals through a brief case study. In outlining these foundational concepts for today's care, we also look forward to the impact of big data, artificial intelligence, and interconnectedness on our future continuous quality improvement efforts. Within the myriad complexities of surgical care, there are bound to be adverse outcomes, but by instilling a culture of highly reliable quality care, we can do our best to minimize their frequency, mitigate their harm, and optimize outcomes. (c) 2023 Elsevier Inc. All rights reserved.

Background While clinical risk assessment models examine patient-level characteristics that portend morbidity, there is a paucity of literature exploring which procedures contribute most to the system-wide burden of venous thromboembolism (VTE). We aimed to identify highly contributory procedures as potential targets for quality improvement. Methods All patients in the 2020 National Surgical Quality Improvement Program (NSQIP) Public User File were included. Current Procedural Terminology (CPT) codes were analyzed individually and grouped by National Healthcare Safety Network groupings. We counted prevalence of VTE and calculated VTE rate for each CPT and for each grouping. Results Of 902,968 included patients, 7501 (.83%) sustained postoperative VTE. Of 2748 unique CPT codes, VTE occurred for 762 (28%). Twenty procedure codes (.7%) contributed 39% of the total VTE. VTE rates of these procedures ranged from high-volume procedures with low VTE rates such as laparoscopic cholecystectomy (.25%) and laparoscopic hysterectomy (.32%) to lower volume procedures with high VTE rate such as Hartmann's procedure (4.32%), Whipple procedure (3.85%), and distal pancreatectomy (3.82%). The CPT grouping with the most VTE was colon surgeries (1275/7501). Discussion A small number of procedures contributes to the system-wide burden of VTE. High-risk procedures are important targets for standardized prophylaxis protocols. For low-risk procedures, careful attention should be paid to patient-specific factors that may increase VTE risk such as obesity, cancer, or limited mobility, as many common procedures contribute greatly to the systemic burden of VTE. Overall, surveillance can perhaps be targeted on a smaller number of procedures, allowing for more efficient use of quality improvement resources.

Benchmark data on traumatic brain injury (TBI) are potentially confounded by morbidity and rehabilitation needs associated with coincident extracranial injuries. Using data on isolated head injuries from 13 trauma centers in Georgia over 3 years, we studied the epidemiology and natural history of isolated TBI in geriatric vs non-geriatric patients in order to identify potential areas for quality improvement. We identified 8 512 patients, 3 895 of whom were geriatric. Geriatric patients had higher baseline comorbidity burden, mostly presented after ground level falls, had higher mortality despite equivalent ICU admission rates, and had higher rates of post-discharge resource utilization than non-geriatric counterparts. Geriatric patients are more likely to require post-discharge services and/or facility placement, regardless of pre-injury functional status. These data highlight the importance of streamlined protocols that place an early focus on post-discharge needs and goals of care, informed by cohort-specific prognosis data.

Background: The Georgia Quality Improvement Program (GQIP) surgical collaborative participating hospitals have shown consistently poor performance in the post-operative sepsis category of National Surgical Quality Improvement Program data as compared with national benchmarks. We aimed to compare crude versus risk-adjusted post-operative sepsis rankings to determine high and low performers amongst GQIP hospitals. Patients and Methods: The cohort included intra-abdominal general surgery patients across 10 collaborative hospitals from 2015 to 2020. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) sepsis definition was used among all hospitals for case abstraction and NSQIP data were utilized to train and validate a multivariable risk-adjustment model with post-operative sepsis as the outcome. This model was used to rank GQIP hospitals by risk-adjusted post-operative sepsis rates. Rankings between crude and risk-adjusted post-operative sepsis rankings were compared ordinally and for changes in tertile. Results: The study included 20,314 patients with 595 cases of post-operative sepsis. Crude 30-day post-operative sepsis risk among hospitals ranged from 0.81 to 5.11. When applying the risk-adjustment model which included: age, American Society of Anesthesiology class, case complexity, pre-operative pneumonia/urinary tract infection/surgical site infection, admission status, and wound class, nine of 10 hospitals were re-ranked and four hospitals changed performance tertiles. Conclusions: Inter-collaborative risk-adjusted post-operative sepsis rankings are important to present. These metrics benchmark collaborating hospitals, which facilitates best practice exchange from high to low performers.