Background: The goal of this study was to understand the state of morbidity and mortality conferences held throughout our health system. Assessment of current approaches is necessary for a journey toward organizational high reliability and an opportunity to reduce unnecessary variation in patient and process outcomes. Study Design: Forty-two anonymous surveys were distributed through the Health System’s Vice-chairs of Quality to those in the best position to answer questions. Answers from all departments and—where semi-autonomous—divisions were solicited. Categories, among others, included written guidelines, who presented, what events were chosen for presentation, and what was done with the data. Results: Forty-one surveys were returned. Seventeen departments or divisions have written guidelines as to which events should be reported. Twenty-two of the departmental or divisional conferences present selected cases, only 13 present all mortalities. Decisions on how events are classified are made most often by the director of Quality with 13 responses. There was no consensus on how best to enhance the clinical learning environment for residents and fellows. Conclusion: Opportunities identified by our survey to reduce practice variation include best practices for written guidelines and standardized classification formats for morbidity and mortality events. A mortality committee charged with event review and classification should be considered. Lastly, more effort should be made to enhance the clinical learning environment of trainees in event review and presentation.

Background: The American College of Surgeons National Surgical Quality Improvement Program was established to help participating hospitals track and report surgical complications with the goal of improving surgical care. We sought to determine whether this has led to improvements in surgical outcomes for pancreatic malignancies. Methods: Patients with pancreatic malignancies who underwent surgical resection were identified from the American College of Surgeons National Surgical Quality Improvement Program database (2006-2019). Thirty-day postoperative major morbidity and mortality were analyzed by year. Major morbidity included organ and deep surgical site infection, venous thromboembolism, cardiac event, pneumonia, acute renal failure, sepsis, and respiratory failure. Results: Of the 28,888 patients identified, 51% were male, the median age was 68, 74.3% underwent a pancreaticoduodenectomy, and 25.7% underwent a distal pancreatectomy. Among patients who underwent a pancreaticoduodenectomy, there was a significant increase in major morbidity (annual percent change 0.77, P = .012) driven by increases in organ space surgical site infection (annual percent change 3.52, P < .001) and venous thromboembolism (annual percent change 4.72, P = .005). However, there was a decrease in postoperative mortality (annual percent change -4.58, P = .001). For distal pancreatectomy patients, there was no change in rates of overall major morbidity (annual percent change -1.35, P = .08) or mortality (annual percent change -3.21, P = .25). Conclusion: Although major morbidity and mortality have not significantly changed for distal pancreatectomy patients, mortality has steadily decreased for patients undergoing pancreaticoduodenectomy, despite an increase in major morbidity. Whether this trend reflects a change in patient selection, an increase in detection of postoperative morbidities and/or an improvement in mitigation of these morbidities warrants further study. (C) 2022 Elsevier Inc. All rights reserved.

Objective:. This study reviews randomized clinical trials that have attempted to improve the process of informed consent. Consent should be guided by the ethical imperatives of autonomy, beneficence, and social justice. Summary Background:. Informed consent is constantly evolving. Yet our review of the randomized trials done to improve the surgical informed consent process raises a number of questions: How does one define surgical informed consent? What interventions have been tried to measure and improve informed consent? Have the interventions in informed consent actually led to improvements? What efforts have been made to improve informed consent? And what steps can be taken to improve the process further? Methods:. A literature search for randomized controlled trials (RCTs)on informed consent identified 70 trials. Demographics, interventions, assessments, and a semi-quantitative summary of the findings were tabulated. The assessments done in the RCTs, show the surrogate for patient autonomy was comprehension; for beneficence, satisfaction and mental state (anxiety or depression); and, for social justice, language, literacy, learning needs, and cost. Results:. There were 4 basic categories of interventions: printed matter; non-interactive audiovisual tools; interactive multimedia; and a smaller group defying easy description. Improvement was documented in 46 of the 65 trials that studied comprehension. Thirteen of 33 trials showed improved satisfaction. Three of 30 studies showed an increase in anxiety. Few studies tried to assess primary language or literacy, and none looked at learning needs or cost. Conclusions:. No single study improved all 3 principles of informed consent. Validated interventions and assessments were associated with greater impact on outcomes. All 3 ethical principles should be assessed; autonomy (as comprehension), beneficence (as satisfaction, anxiety), and social justice. Not enough consideration has been given to social justice; appropriate language translation, standardized reading levels, assessment of learning needs, and cost to the individual are all important elements worthy of future study.

Purpose The purpose was to examine whether a requirement for parental or guardian consent systematically limits which lesbian, gay, bisexual, trans, two-spirit, queer/questioning (LGBT2Q+) youth participate in research. Methods A total of 60 LGBT2Q+ youth (aged 14–18 years) completed measures assessing gender and sexual minority identity, depression and anxiety, help-seeking intentions, and social support. Results A substantial proportion (37.6%) of youth reported that they would not have participated in the research if parental or guardian consent was required. Those who would not have participated had more negative attitudes about their sexual and gender identity, less family support, lower levels of help-seeking intentions, and higher levels of negative affect. Conclusions The results suggest that requiring parental or guardian consent may exclude the most at-risk youth. Policy and practice decisions regarding the health and mental health outcomes of LGBT2Q+ youth might be based on incomplete and unrepresentative data. How acceptable is adolescent self-consent for the HPV vaccination: Findings from a qualitative study in south-west England Suzanne Audrey, Michelle Farr, Marion Roderick, Karen Evans, Harriet Fisher Vaccine, 9 October 2020 Open Access Abstract Background Human Papillomavirus (HPV) vaccination programmes have the potential to reduce the incidence of cervical cancer. The preferred age for HPV vaccination is 12–13 years for optimal benefit. The legal framework in England allows adolescents to be vaccinated without parental consent if they are assessed as competent. A ‘South West Template Pathway on Self Consent for School Aged Immunisations’ was developed to improve uptake of immunisations in south-west England. Study aim To examine how acceptable the new procedures are to the young women, parents and carers, school staff and immunisation nurses involved. Methods The research was undertaken in two local authorities in south-west England during the 2017/18 and 2018/19 programme years. Semi-structured digitally recorded interviews were undertaken with 53 participants: one health service manager, three immunisation nurses, five staff at alternative education providers, three staff at mainstream schools, 19 young women and 22 parents. All recordings were transcribed verbatim and thematic analysis was undertaken, assisted by NVivo software.

Introduction:The principles of consent are evolving but remain an important part of the surgeon-patient relationship. The goal of this course was a concise, contemporary review of the principles of informed consent that would be favorably received by academic surgeons.Methods:The curriculum consisted of ethicohistorical and legal principles, current requirements, and new consent developments. An anonymous, voluntary evaluation tool was used to assess strengths and opportunities for improvement. A short postcourse quiz was developed to assess understanding.Results:Eighty-five percent of the surgery department faculty participated. Evaluations were overwhelmingly positive, all elements having weighted averages of greater than 4.5 on a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree). Furthermore, a majority of respondents for the posttest got the answers correct for all five questions asked on the postcourse quiz.Discussion:A proper understanding of informed consent remains critically important in the practice of surgery. This short course updating surgeons on informed consent quantitatively confirms the favorable reception of this approach in terms of attendance and satisfaction, as well as understanding of the material.

Introduction: Despite being a critical facet of patient care, there is a dearth of literature educating surgeons in particular-and physicians in general-on techniques for improving the critical communication skill of listening. Further, with the shift to care in the outpatient setting, skills specific to communication are being measured and have assumed greater importance due to public reporting. Communication skills are mutable and can be improved. We hypothesized that a short course in communication focusing on listening skills for academic surgical faculty could be presented with high levels of participation and satisfaction.

Mini-Abstract Our perspective on informed consent is that expanding the duty to disclose novel uncertainties (eg, the covid-19 pandemic) stretches the doctrine to almost limitless proportions. Instead, we argue for a more conventional view in which the informed consent process should remain focused on the proposed operation and its ramifications.

Background: Good communication skills enhance the patient experience, clinical outcomes, and patient satisfaction. Objective: A course was developed by an interdisciplinary team (surgeon, nurse practitioner, and nurse MBA) for advanced practice providers (APPs) working for the department of surgery—a mix of practice and hospital-employed professionals—to enhance communications skills in an inpatient setting. Methods: Current concepts on provider–patient communication were discussed. Participants also asked to view and critique a video “provider–patient communication gone wrong” scenario. Lastly, participants were provided with techniques for improving provider–patient communication. The participants assessed the course. Provider communication scores were tracked from quarter 1, Fiscal Year 2014 to quarter 4 Fiscal Year 2017. Results: Of 110 eligible APPs, 95 (86%) attended the course. The anonymous survey response rate was 90% (86/95). Participants expressed satisfaction with the course content confirmed by Likert score weighted averages of >4.6/5 in all 8 domains. Communication scores increased with time. Conclusion: An interdisciplinary course aimed at enhancing provider–patient communication skills was well-received by the APP participants. The course was part of ongoing system-wide efforts to improve patient experiences, satisfaction, and outcomes. Continuing education in communication continues to play a key role in improving clinical outcomes and patient satisfaction.

A 43-year-old male with a history of morbid obesity status after Roux-en-Y gastric bypass complicated by staple line breakdown underwent gastric pouch resection and stapling off the esophagus, leaving the patient with a blind Roux limb. This was further complicated by breakdown of the esophageal staple line and development of an esophagocutaneous fistula. The patient underwent takedown of the fistula and creation of a Roux-en-Y esophagojejunostomy. One week later, a large anastomotic leak at the esophagojejunal anastomosis was drained because additional surgical intervention was not an option. The anastomosis could not be traversed during upper endoscopy. To achieve continuity of the gastrointestinal tract, a percutaneous fluoroscopic-guided neoanastomosis was created between the distal esophagus and gastric remnant (Figs 1, 2). Briefly, percutaneous access to the gastric remnant was obtained. A gooseneck snare was positioned in the distal esophagus through the tract of percutaneous drainage catheter in the leak. A 65-cm-long, 21-gauge needle, advanced through a blunt Cope gastrojejunostomy cannula (Cook Medical, Bloomington, Indiana) (Fig 3), was directed toward a gooseneck snare in the distal esophagus. A 16-Fr drainage catheter was placed across this new gastroesophogastomy. After 3 weeks, the drain was replaced with a wire, and an endoscopically inserted 15-cm-long, 18-mm covered Ultraflex stent (Boston Scientific, Marlborough, Massachusetts) extending from the esophagus into the gastric remnant was placed (Fig 4). The patient resumed oral intake after stent placement and remained free of complications at 2-year follow-up. The stent was never removed due to the history of multiple prior surgical complications. Figure 2Intraprocedural images of percutaneous fluoroscopic-guided neoanastomosis between the distal esophagus and gastric remnant. Using the Cope gastrojejunostomy cannula through the sheath in the gastric remnant, a 21-gauge needle was directed to hit the snare in the distal esophagus (a). After access was obtained, a 16-Fr drainage catheter with extra sideholes was placed across this new gastroesophogastomy over a wire, with its locking loop within the distal esophagus (b). View Large Image Figure Viewer Download Hi-res image Figure 3Cope gastrojejunostomy cannula containing a long, 21-gauge needle used to navigate the needle inside the patient. View Large Image Figure Viewer Download Hi-res image Figure 4The inserted drain into the distal esophagus across the gastroesophageal neoanastomosis was replaced with a wire during endoscopy, and a stent was inserted from the distal esophagus into the gastric remnant (a). Follow-up upper gastrointestinal study 4 days after stent insertion shows contrast entering the duodenum through the previously excluded gastric remnant and small resolving leak (b). View Large Image Figure Viewer Download Hi-res image

OBJECTIVE: There is a paucity of data regarding the efficiency of care provided by teaching hospitals. Yet, instruction on transitions in care and an understanding of systems-based practice are key components of modern graduate medical education. We aimed to determine the relationship between hospital teaching status and the discharge efficiency from a surgical service. SETTING: Patients who were cared for at teaching and nonteaching hospitals captured in the Healthcare Cost and Utilization Project National Inpatient Sample from 2012. PARTICIPANTS: A total of 272,090 patients who underwent one of 44 predefined general surgery procedure types. DESIGN: Patients were stratified based on treating hospital teaching status (TH vs. NTH). Procedure-specific early discharge (PSED) was defined for each operation type as a discharge that occurred within the lowest 25th percentile for overall length of stay. PSED was used as the discharge efficiency metric. To adjust for cofounders and hospital level clustering, multivariable mixed-effects logistic regression was used to examine the association between teaching status and PSED. Subgroup analysis was performed by operation type. Models were constructed with and without adjustment for inpatient complications. RESULTS: There were 140,878 (51.8%) patients who received care at a TH. TH status was significantly associated with lower PSED (TH: 10.7% vs. NTH: 11.4%; p < 0.001) and longer length of stay (TH: 5.5 days vs. NTH: 4.5 days; p < 0.001). In the adjusted model of the overall cohort, patients treated at a TH were 8% less likely to receive a PSED compared to those treated at NTH (odds ratio 0.92, 95% confidence interval (0.88, 0.97); p < 0.002). Differences in the rates and odds of PSED were noted across the subgroups. CONCLUSIONS: Teaching hospital status is associated with a reduced likelihood of PSED. The effect of TH on PSED varied by procedure subgroup. Examining the recovery pathways and discharge practices at NTH may allow for the identification of more efficient methods of care that can be applied to the broader healthcare system. (C) 2019 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

The experiences of life are what shape us. This article relays stories of adversity and resiliency as experienced and told by members of our own surgical community at the Academic Surgical Congress in Las Vegas, NV in February 2017. We aim to express in words the lessons of each experience so that others can learn about life and leadership.

Dowzicky, Phillip MD; Hanna, Ehab MD; Berger, Ian; Colbert-Mack, Latesha DNP, ACNP-BC; Wirtalla, Chris; Raper, Steven E. MD, JD; Waterman, Richard P. PhD; Kelz, Rachel R. MD, MSCE, FACS Author Information

Gastrostomy tube placement is a routinely safe procedure; however, this report and its accompanying images highlight a rare but serious complication of tube migration – duodenal perforation.

BACKGROUND: To heighten awareness of attending and resident surgeons regarding strategies for defense against malpractice claims, a series of risk reduction initiatives have been carried out in our Department of Surgery. We hypothesized that emphasis on certain aspects of risk might be associated with decreased malpractice costs. The relative impact of Department of Surgery initiatives was assessed when compared with malpractice experience for the rest of the Clinical Practices of the University of Pennsylvania (CPUP). STUDY DESIGN: Surgery and CPUP malpractice claims, indemnity, and expenses were obtained from the Office of General Counsel. Malpractice premium data were obtained from CPUP finance. The Department of Surgery was assessed in comparison with all other CPUP departments. Cost data (yearly indemnity and expenses), and malpractice premiums (total and per physician) were expressed as a percentage of the 5-year mean value preceding implementation of the initiative program. RESULTS: Surgery implemented 38 risk reduction initiatives. Faculty participated in 27 initiatives; house staff participated in 10 initiatives; and advanced practitioners in 1 initiative. Department of Surgery claims were significantly less than CPUP (74.07% vs 81.07%; p < 0.05). The mean yearly indemnity paid by the Department of Surgery was significantly less than that of the other CPUP departments (84.08% vs 122.14%; p < 0.05). Department of Surgery-paid expenses were also significantly less (83.17% vs 104.96%; p < 0.05), and surgical malpractice premiums declined from baseline, but remained significantly higher than CPUP premiums. CONCLUSIONS: The data suggest that educating surgeons on malpractice and risk reduction may play a role in decreasing malpractice costs. Additional extrinsic factors may also affect cost data. Emphasis on risk reduction appears to be cumulative and should be part of an ongoing program. (C) 2017 by the American College of Surgeons. Published by Elsevier Inc. All rights reserved.

The District Attorney's (DA) office not only prosecutes cases, but has expansive control over the criminal investigations themselves. Accordingly, DA's offices must possess high ethical standards and exhibit prosecutorial discretion in order to achieve justice in each case. In 2014, the Montgomery County (PA) District Attorney's Office decided to drop an alleged rape charge after it was discovered the criminal investigation leading to the charge contained a material error which prejudiced the defendant at trial. Following this error , the Montgomery County District Attorney partnered with the interdisciplinary Quattrone Center for the Fair Administration of Justice at the University of Pennsylvania Law School to conduct a Root Cause Analysis (RCA) of the error. The goal of the RCA was to identify specific activities, policies, procedures, and environmental factors that allowed the error to occur, and to implement changes that would prevent similar errors from occurring in the future. In this way, the District Attorney sought to promote the highest levels of accuracy, reliability, fairness, accountability, and integrity in the handling of criminal cases throughout her office and the law enforcement community.

Objective: This qualitative study examines surgical consultation as a social process and assesses its alignment with assumptions of the shared decision-making (SDM) model. Summary of Background Data: SDM stresses the importance of patient preferences and rigorous discussion of therapeutic risks/benefits based on these preferences. However, empirical studies have highlighted discrepancies between SDM and realities of surgical decision making. Qualitative research can inform understanding of the decision-making process and allow for granular assessment of the nature and causes of these discrepancies. Methods: We observed consultations between 3 general surgeons and 45 patients considering undergoing 1 of 2 preference-sensitive elective operations: (1) hernia repair, or (2) cholecystectomy. These patients and surgeons also participated in semi-structured interviews. Results: By the time of the consultation, patients and surgeons were predisposed toward certain decisions by preceding events occurring elsewhere. During the visit, surgeons had differential ability to arbitrate surgical intervention and construct the severity of patients’ conditions. These upstream dynamics frequently displaced the centrality of the risk/benefit-based consent discussion. Conclusion: The influence of events preceding consultation suggests that decision-making models should account for broader spatiotemporal spans. Given surgeons’ authority to define patients’ conditions and control service provision, SDM may be premised on an overestimation of patients’ power to alter the course of decision making once in a specialist's office. Considering the subordinate role of the risk/benefit discussion in many surgical decisions, it will be important to study if and how the social process of decision making is altered by SDM-oriented decision aids that foreground this discussion.

Anesthesiologists and surgeons are frequently called on to perform procedures on critically ill patients with advanced directives. We assessed the attitudes of attending and resident surgeons and anesthesiologists at our institution regarding their understanding of and practice around the application of consenting critically ill patients with advance directives in the operating room. To do so, we deployed a survey after interdepartmental grand rounds, featuring a panel discussion of ethically complex cases featuring end-of-life issues.

Background: In Pennsylvania, medical malpractice premiums are a major cost to surgeons. Yet surgeons often have little if any education in the basics of tort litigation or how to manage their risk. This work describes one approach for educating academic faculty surgeons on current concepts of medical malpractice and provide some guidance on how to "tip the scales of justice"; or minimize the risks of being named in a malpractice claim.Materials and Methods: The course had five parts: the basics of medical malpractice, the cost of malpractice insurance, current departmental claims experience, strategies for decreasing the risk of being named in a claim, and an overview of malpractice reforms. An anonymous seven question survey was cast in a five-point Likert scale format. A weighted average of 4.5 or above was considered satisfactory. Two free text questions asked about positive and negative aspects of the course.Results: Eighty of 95 (84%) faculty attended either in person or by reviewing a web-based video. Quantitatively, five of seven questions had a weighted average of more than 4.5 (n - 48, response rate - 60%). Qualitatively, the course was reviewed very favorably.Conclusions: The high percentage of participation and overall survey results suggest that the course was successful. This course was one facet of an approach to decrease the risk of malpractice claims. Unique aspects of this course include an emphasis on state law, department-specific data, and strategies to minimize risk of future claims. Given the state-specific nature of malpractice claims and litigation, individual departments must particularize similar presentations. (C) 2016 Elsevier Inc. All rights reserved.