Background: Kentucky was among the first to adopt Medicaid expansion, resulting in reducing uninsured rates from 14.3% to 6.4%. We hypothesize that Medicaid expansion resulted in increased elective healthcare utilization and reductions in emergency treatments by patients suffering Inflammatory Bowel Disease (IBD). Methods: The Hospital Inpatient Discharge and Outpatient Services Database (HIDOSD) identified all encounters related to IBD from 2009 to 2020 in Kentucky. Several demographic variables were compared in pre- and post-Medicaid expansion adoption. Results: Our study analyzed 3386 pre-expansion and 24,255 post-expansion encounters for IBD patients. Results showed that hospitalization rates dropped (47.7%-8.4%), outpatient visits increased (52.3%-91.6%) and Emergency visits decreased (36.7%-11.4%). Admission following a clinical referral similarly increased with a corresponding drop in emergency room admissions. Hospital costs and lengths of stay also dropped following Medicaid expansion. Conclusion: In the IBD population, Medicaid expansion improved access to preventative care, reduced hospital costs by decreasing emergency care, and increased elective care pathways.

INTRODUCTION: Formal resident education regarding quality improvement (QI) and process improvement (PI) is limited in general surgery, nationwide. Development and delivery of an active learning QI curriculum increased general surgery resident education and participation in quality initiatives. METHODS: A total of 60 general surgery residents participated in monthly active learning lecture and workshop sessions. Sessions progressed through the selection and completion of a PI project, including scope, key stakeholder buy-in, data collection, process mapping, implementation, standardization, and auditing. A focused framework based on an adapted Lean methodology for healthcare QI was used. RESULTS: Before curriculum development, no active QI learning was integrated into the educational curriculum and 1 of 60 residents were engaged in scholarly activity related to PI. Project ideas derived from resident workflow hardships contributing to burnout and resident dissatisfaction. Next, residents were divided into 4 implementation teams, each tasked with completing components of the project, including preliminary data, stakeholder discussions, process mapping, and implementation. Monthly group sessions discussed completed tasks. Engagement in process improvement education yielded all residents participating in at least 1 QI project, and 13% of residents engaged in a second QI initiative. Overall, residents initiated 6 QI projects across 2 institutions during the process of the QI curriculum (Table). Table. - Curriculum Sessions and Objectives Session number Topic Workshop activity 1 Identify Opportunity Focus groups Root cause analysis 2 Process Selection Project scope Stakeholder engagement Preliminary data 3 Process Mapping Process map current and ideal workflows 4 Intervention Ideate interventions Implementation plan 5 Barriers Overcoming barriers 6 Data Collection Metrics Data analysis 7 Standardization and Auditing Internal standardization Audit sheet creation Identify auditing frequency 8 Continuous Improvement Identify opportunities for further improvement CONCLUSION: An active, ongoing learning curriculum model for QI education is an effective methodology for designing and engaging surgery residents in QI initiatives. Additionally, this model provides residents with the necessary tools to identify and change areas in need of improvement in their daily work.

Introduction Physical fitness is an important prognostic indicator for surgical outcomes. An objective measure of deconditioning is needed to determine patient fitness. This study aims to describe a methodology to standardize psoas measurements and correlate them with postoperative outcomes. Methods After obtaining IRB approval, the ACS-NSQIP database was queried for patients over 18 years, undergoing colectomies for non-trauma indications from 1/1/2013 to 12/31/2018. Upon CT imaging, the psoas muscle was identified at the lumbosacral joint. Imaging software calculated the total cross-sectional area of the left and right psoas muscle and was normalized by dividing by height squared to achieve our Total Psoas Index (TPI) in cm(2)/m(2). Results 1173 patients met study criteria; all had TPI calculated. A TPI equal to or below the gender-specific 25th percentile defined sarcopenia. In total, 151 females (24.6%) and 137 males (24.5%) were classified as sarcopenic. TPI was significantly associated with multiple NSQIP 30-day outcomes and mortality in our study population. Conclusions Measuring TPI at the lumbosacral joint is an appropriate method for determining sarcopenia.

SSI is a leading cause of morbidity and increases health-care cost after colorectal operations. It is a key hospital-level patient safety indicator. Previous literature has identified perioperative risk factors associated with SSI and interventions to decrease rate of infection. The purpose of this study was to evaluate the impact of blowhole closure on the rate of superficial and deep SSI. The ACS-NSQIP database was queried for patients undergoing colectomy at the University of Kentucky from 2013 to 2016. Retrospective chart review was performed to gather demographic data and perioperative variables. Wounds left open and packed were excluded. Rates of postoperative SSI were measured between the groups. One thousand eighty-three patients undergoing elective and emergent colectomy were reviewed. Nine hundred and forty-five had closed incision and 138 had blowhole closure. Patient characteristics between the groups were well matched. Patients with a blowhole closure were more likely to have an open procedure (P = 0.037) and a higher wound class (P < 0.001). The rate of superficial and deep SSI was 9.1 per cent in patients with a closed incision and 5.1 per cent in patients with blowhole closure (P = 0.142). With adjustment for approach and wound class, blowhole closure decreased the incidence of SSI (P = 0.04). There was no significant difference in morbidity or mortality. Patients undergoing elective and emergent colectomy had decreased incidence of SSI when blowhole closure was used. Given that it does not increase resource usage and its technical ease, blowhole closure should become the standard method of surgical wound closure.

Chang, YuWei W. MD, MS; Murphy, Kyle C. BS; Kay, Danielle MD; Kumar, Shyanie J. MD; Davenport, Daniel PhD; Beck, Sandra J. MD, FACS; Bhakta, Avinash S. MD Author Information

Tzeng, Ching-Wei D MD; Beck, Sandra J. MD, FACS; Hourigan, Jon S. MD, FACS, FASCRS; Evers, Mark B MD; McGrath, Patrick C. MD, FACS; Davenport, Daniel L. PhD Author Information

Stoma creation in the obese patient presents technical challenges beyond the usual considerations that surround stoma creation. Both short-term and long-term stoma complication rates are higher in the obese patient. One must always strive to create a protruding well-vascularized stoma while maximizing the potential to restore bowel continuity in the future. This article will discuss the potential complications and difficulties associated with the creation of a stoma in the obese patient. It will also discuss the traditional techniques for creating the stoma and include modifications that may be required in the obese patient. It will cover technical tips that may help to avoid the complications and pitfalls of creating a stoma in the obese patient.

The purpose of this study was to define clinical and radiographic variables associated with postoperative mortality after urgent colectomy for fulminant Clostridium difficile colitis. Data were obtained regarding patients undergoing colectomy for fulminant C. difficile colitis at two institutions (1997-2005). Univariate analysis of factors predicting 30-day mortality was performed using χ 2 and Student's t tests. Multivariable logistic regression was done to include all variables whose P value was < 0.20. Clinical variables analyzed included: age, gender, recent operation, comorbidities, preoperative multisystem organ failure, vasopressors, symptom duration, time to surgery, serum albumin, change in serum albumin, serum creatinine, white blood cell count, and extent of colectomy. Computed tomography variables included: ascites, megacolon, and extent of colitis. Thirty-five patients (mean age 70 years, 46% male) underwent urgent colectomy for C. difficile colitis. The 30-day mortality rate was 45.7 per cent (16/35). The only clinical variable associated with mortality was preoperative multisystem organ failure (non-survivors 9/16 vs survivors: 4/19; P = 0.037). None of the three patients undergoing partial colectomy survived, although the difference in survival versus those undergoing subtotal colectomy was not significant. Patients with fulminant C. difficile colitis undergoing colectomy have a high mortality rate. Preoperative presence of multisystem organ failure was independently predictive of mortality.