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OBJECTIVE: The American College of Surgeons (ACS) conducts a robust quality improvement program for ACS-verified trauma centers, yet many injured patients receive care at non-accredited facilities. This study tested for variation in outcomes across non-trauma hospitals and characterized hospitals associated with increased mortality. SUMMARY BACKGROUND DATA: The study included state trauma registry data of 37,670 patients treated between January 1, 2013, and December 31, 2015. Clinical data were supplemented with data from the American Hospital Association and U.S. Department of Agriculture, allowing comparisons among 100 non-trauma hospitals. METHODS: Using Bayesian techniques, risk-adjusted and reliability-adjusted rates of mortality and interfacility transfer, as well as Emergency Departments length-of-stay (ED-LOS) among patients transferred from EDs were calculated for each hospital. Subgroup analyses were performed for patients ages >55 years and those with decreased Glasgow coma scores (GCS). Multiple imputation was used to address missing data. RESULTS: Mortality varied 3-fold (0.9% - 3.1%); interfacility transfer rates varied 46-fold (2.1% - 95.6%); and mean ED-LOS varied 3-fold (81 - 231 minutes). Hospitals that were high and low statistical outliers were identified for each outcome, and subgroup analyses demonstrated comparable hospital variation. Metropolitan hospitals were associated increased mortality (OR 1.7, P = 0.004), decreased likelihood of interfacility transfer (OR 0.7, P =

OBJECTIVE To demonstrate the feasibility of implementing a competency-based education (CBE) curriculum within a general surgery residency program and to evaluate its effectiveness in improving resident skill. SUMMARY BACKGROUND DATA Operative skill variability affects residents and practicing surgeons and directly impacts patient outcomes. CBE can decrease this variability by ensuring uniform skill acquisition. We implemented a CBE laparoscopic cholecystectomy (LC) curriculum to improve resident performance and decrease skill variability. METHODS PGY-2 residents completed the curriculum during monthly rotations starting in July 2017. Once simulator proficiency was reached, residents performed elective LCs with a select group of faculty at three hospitals. Performance at curriculum completion was assessed using LC simulation metrics and intraoperative OPRS scores and compared to both baseline and historical controls, comprised of rising PGY-3 s, using a two-sample Wilcoxon rank-sum test. PGY-2 group's performance variability was compared with PGY-3 s using Levene's Robust Test of Equality of Variances; p < 0.05 was considered significant. RESULTS 21 residents each performed 17.52 ± 4.15 consecutive LCs during the monthly rotation. Resident simulated and operative performance increased significantly with dedicated training and reached that of more experienced rising PGY-3 s (n = 7) but with significantly decreased variability in performance (p = 0.04). CONCLUSIONS Completion of a CBE rotation led to significant improvements in PGY-2 residents' LC performance that reached that of PGY-3 s and decreased performance variability. These results support wider implementation of CBE in resident training.

Objective: We hypothesized that failure to achieve protein goals early in the critical care course via enteral nutrition is associated with increased complications. Background Although robust randomized controlled trials are lacking, present data suggest that early, adequate nutrition is associated with improved outcomes in critically ill patients. Injured patients are at risk of accumulating significant protein debt due to interrupted feedings and intolerance. Methods Critically injured adults who were unable to be volitionally fed were included in this retrospective review. Data collected included demographics, injury characteristics, number and types of operations, total prescribed and delivered protein and calories during the first 7 days of critical care admission, complications, and outcomes. Group-based trajectory modeling was applied to identify subgroups with similar feeding trajectories in the cohort. Results There were 274 patients included (71.2% male). Mean age was 50.56 ± 19.76 years. Group-based trajectory modeling revealed 5 Groups with varying trajectories of protein goal achievement. Group 5 fails to achieve protein goals, includes more patients with digestive tract injuries (33%, P = 0.0002), and the highest mean number of complications (1.52, P = 0.0086). Group 2, who achieves protein goals within 4 days, has the lowest mean number of complications (0.62, P = 0.0086) and operations (0.74, P = 0.001). Conclusions There is heterogeneity in the trajectory of protein goal achievement among various injury pattern Groups. There is a sharp decline in complication rates when protein goals are reached within 4 days of critical care admission, calling into question the application of current guidelines to healthy trauma patients to tolerate up to 7 days of nil per os status and further reinforcing recommendations for early enteral nutrition when feasible.