Surgical Reconstruction of Stage 3 and 4 Pressure Injuries: A Literature Review and Proposed Algorithm from an Interprofessional Working Group.

Objective: Stage 3 and 4 pressure injuries (PIs) present an enormous societal burden with no clearly defined interventions for surgical reconstruction. The authors sought to assess, via literature review and a reflection/evaluation of their own clinical practice experience (where applicable), the current limitations to the surgical intervention of stage 3 or 4 PIs and propose an algorithm for surgical reconstruction.

Methods: An interprofessional working group convened to review and assess the scientific literature and propose an algorithm for clinical practice.

Evaluation of the Addition of Angiotensin II in Patients With Shock After Cardiac Surgery at a Veterans Affairs Medical Center.

Background: Vasoplegic shock occurs in up to 37% of cardiac surgery patients. We investigated the use of angiotensin II for treating vasoplegic shock in these patients.

Objectives: We assessed clinical outcomes and mortality in patients undergoing cardiac surgery at our center between March 1, 2018 and October 31, 2020 who developed vasoplegic shock, comparing those who received angiotensin II with those who did not.

Malnutrition in elective surgery: How traditional markers might be failing surgeons and patients.

Background: Serologic and anthropometric measures are commonly used as surrogate markers of nutritional status in clinical practice. In 2012, leading dietetic organizations published a standard definition of malnutrition based on clinical characteristics. We hypothesize that surrogate markers underrecognize clinical malnutrition and do not accurately identify patients at risk for adverse outcomes.

Studying Institutional Situational Awareness Through Anonymous Incident Reporting.

Background And Objectives: The efficacy of anonymous incident reporting (AIR) is critical to creating a culture of safety. Prior studies have sought to establish AIR in a similar manner as aviation, nuclear power, and other industries. However, health care presents unique challenges that differ greatly from these industries.

Is Post-discharge Rehabilitation Timing Associated with 90-Day Readmission in Primary Total Joint Arthroplasty?

Background: Physical therapy (PT) is an accepted standard of care after total joint arthroplasty (TJA) and essential to maximizing joint functionality and minimizing complications that lead to readmission. However, evidence-based guidelines about appropriate post-discharge rehabilitative care are not well-defined in the orthopedic literature.

Purposes: We sought to determine the average timing for receiving PT rehabilitation and to evaluate the association between PT rehabilitation timing and unplanned readmission within 90 days of a TJA patient being discharged home from acute care.

Diagnosis and Management of Primary Hyperparathyroidism Across the Veterans Affairs Health Care System.

Importance: Untreated primary hyperparathyroidism impairs quality of life and incurs substantial costs. Parathyroidectomy is a low-risk, high-success, definitive intervention.

Objectives: To determine the appropriateness of diagnostic evaluation for primary hyperparathyroidism in patients with hypercalcemia and the use of parathyroidectomy for the treatment of primary hyperparathyroidism across the Veterans Affairs (VA) health care system.

Robotic port-site hernias after general surgical procedures.

Background: With the increasing use of the robotic platform in general surgery, whether 8-mm ports should be closed comes into question. We sought to characterize the incidence of port-site hernias (PSHs) among patients undergoing robotic-assisted general surgery.

Methods: A retrospective chart review of a single institutional database identified patients who underwent robotic-assisted general surgery from July 2010 to December 2016.

A Multi-Component Strategy to Decrease Wound Complications after Open Infra-Inguinal Re-Vascularization.

Background: Wound complications remain a significant source of morbidity for patients undergoing open infra-inguinal re-vascularization. The purpose of this study was to determine the impact of several infection-control strategies on post-operative wound complications after open infra-inguinal re-vascularization.

Methods: A retrospective cohort study was conducted among all patients who underwent an open infra-inguinal re-vascularization procedure before and after 2014.

Association of the Addition of Oral Antibiotics to Mechanical Bowel Preparation for Left Colon and Rectal Cancer Resections With Reduction of Surgical Site Infections.

Importance: Surgical site infections (SSIs) after colorectal surgery remain a significant complication, particularly for patients with cancer, because they can delay the administration of adjuvant therapy. A combination of oral antibiotics and mechanical bowel preparation (MBP) is a potential, yet controversial, SSI prevention strategy.

Objective: To determine the association of the addition of oral antibiotics to MBP with preventing SSIs in left colon and rectal cancer resections and its association with the timely administration of adjuvant therapy.

What Factors are Associated With 90-day Episode-of-care Payments for Younger Patients With Total Joint Arthroplasty?

Background: Total joint arthroplasty (TJA) has been identified as a procedure with substantial variations in inpatient and postacute care payments. Most studies in this area have focused primarily on the Medicare population and rarely have characterized the younger commercially insured populations. Understanding the inpatient and postdischarge care service-component differences across 90-day episodes of care and factors associated with payments for younger patients is crucial for successful implementation of bundled payments in TJA in non-Medicare populations.

Hospital Minimally Invasive Surgery Utilization for Gastrointestinal Cancer.

Objective: The aim of the study was to evaluate the impact of receiving care at high minimally invasive surgery (MIS)-utilizing hospitals BACKGROUND:: MIS techniques are used across surgical specialties. The extent of MIS utilization for gastrointestinal (GI) cancer resection and impact of receiving care at high utilizing hospitals is unclear.

Methods: This is a retrospective cohort study of 137,581 surgically resected esophageal, gastric, pancreatic, hepatobiliary, colon, and rectal cancer patients within the National Cancer Data Base (2010-2013).

Escalation of Commitment in the Surgical ICU.

Objectives: Escalation of commitment is a business term that describes the continued investment of resources into a project even after there is objective evidence of the project's impending failure. Escalation of commitment may be a contributor to high healthcare costs associated with critically ill patients as it has been shown that, despite almost certain futility, most ICU costs are incurred in the last week of life. Our objective was to determine if escalation of commitment occurs in healthcare settings, specifically in the surgical ICU.

Active Mental Illnesses Adversely Affect Surgical Outcomes.

Depression, anxiety, posttraumatic stress disorder (PTSD), and substance abuse are linked to higher rates of morbidity and mortality after various surgical procedures. Comparable data in general surgery are lacking. Records from 183 consecutive patients undergoing elective general surgery procedures at a single tertiary hospital were reviewed.

Variation and Impact of Multiple Complications on Failure to Rescue After Inpatient Surgery.

Objective: To examine the extent to which multiple, sequential complications impacts variation in institutional postoperative mortality rates.

Background: Failure to rescue (FTR) has been proposed as an underlying factor in hospital variation in surgical mortality. However, little is currently known about hospital variation in FTR after multiple complications or the contribution of sequential complications to variation.

Ninety-day readmission after colorectal cancer surgery in a Veterans Affairs cohort.

Background: Readmissions following colorectal surgery are common. However, there are limited data examining unplanned readmissions (URs) after colorectal cancer (CRC) surgery. The goal of this study was to identify reasons and predictors of UR, and to examine their clinical impact on CRC patients.

Effect of a preoperative decontamination protocol on surgical site infections in patients undergoing elective orthopedic surgery with hardware implantation.

Importance: Surgical site infections (SSIs), commonly caused by methicillin-resistant Staphylococcus aureus (MRSA), are associated with significant morbidity and mortality, specifically when hardware is implanted in the patient. Previously, we have demonstrated that a preoperative decontamination protocol using chlorhexidine gluconate washcloths and intranasal antiseptic ointment is effective in eradicating MRSA in the nose and on the skin of patients.

Objective: To examine the effect of a decontamination protocol on SSIs in patients undergoing elective orthopedic surgery with hardware implantation.

Identification of methicillin-susceptible or methicillin-resistant Staphylococcus aureus carrier status preoperatively using polymerase chain reaction in patients undergoing elective surgery with hardware implantation.

We compared bedside polymerase chain reaction to culture for identifying Staphylococcus aureus in patients about to undergo surgery with hardware implantation. Patients were screened for S. aureus carrier status at the preoperative clinic and on the day of surgery.

Sphincter preservation rates after radical resection for rectal cancer in the United States veteran population: opportunity for improvement in early disease.

Background: Sphincter preservation (SP) is an important goal of rectal cancer surgery. We hypothesized that SP rates among veteran patients have increased and are comparable to national rates, and that a subset of patients with early disease still undergo non-SP procedures.

Methods: Patients with nonmetastatic primary rectal adenocarcinoma who underwent curative-intent rectal resection were identified from the Veterans Affairs Central Cancer Registry (VACCR) database (1995-2010).

The effect of a regional hepatopancreaticobiliary surgical program on clinical volume, quality of cancer care, and outcomes in the Veterans Affairs system.

Importance: Malignant neoplasms of the hepatopancreaticobiliary (HPB) system constitute a significant public health problem worldwide. Treatment coordination for these tumors is challenging and can result in substandard care. Referral centers for HPB disease have been used as a strategy to improve postoperative outcomes, but their effect on accomplishing regionalization of care and improving quality of cancer care is not well known.

Mandated self-reporting of ventilator-associated pneumonia bundle and catheter-related bloodstream infection bundle compliance and infection rates.

Importance: As quality measures increasingly become tied to payment, evaluating the most effective ways to provide high-quality care becomes more important.

Objectives: To determine whether mandated reporting for ventilator and catheter bundle compliance is correlated with decreased infection rates, and to determine whether labor-intensive audits are correlated with compliance.

Design, Setting, And Participants: Multiyear retrospective review of aggregated data from all patients admitted to 15 intensive care units in a Veterans Affairs hospital setting (the Veterans Integrated Service Network 16) from 2009 to 2011.

Outcomes and predictors of incisional surgical site infection in stoma reversal.

Importance: Surgical site infection following stoma reversal (SR) poses a substantial burden to the patient and health care system. Its overall incidence is likely underreported and poorly characterized. Improving our understanding of surgical site infection following stoma reversal may help us identify methods to decrease this complication.

Comparison of infectious complications with synthetic mesh in ventral hernia repair.

Background: Infection can be a devastating complication associated with prosthetic incisional hernia repair. It is unclear whether the type of mesh used affects the risk of infection.

Methods: A retrospective review was performed of all patients who underwent elective incisional hernia repair with permanent prosthetic mesh between January 1, 2000, and August 1, 2007.

Trans-cutaneous Closure of Central Defects (TCCD) in laparoscopic ventral hernia repairs (LVHR).

Background: Laparoscopic ventral hernia repair (LVHR) has been reported to have lower recurrence rates, fewer surgical site infections, and shorter hospital stays compared to open repair. Despite improved surgical outcomes with standard LVHR (sLVHR), seroma formation, eventration (or bulging of mesh or tissue), and hernia recurrence remain common complications. Our objective was to evaluate outcomes with trans-cutaneous closure of central defects in LVHR compared to sLVHR.