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Trainee Participation Affects Outcomes In Emergency General Surgery Procedures: An Analysis Of The Nsqip Database
George Kasotakis*, Aliya Lakha*, Beda Sarkar*, Hiroko Kunitake*, Nicole Kissane-Lee*, Tracey Dechert*, David McAneny*, Peter Burke*, Gerard Doherty
Boston University, Boston, MA

Objective: Previous research has demonstrated a significant impact of trainee participation on outcomes in a broad surgical patient population. We aim to identify if a similar effect exists in emergency general surgery.
Methods: We identified 141,010 patients who underwent emergency general surgery procedures in the 2005-2010 NSQIP database. Due to the non-random assignment of complex cases to resident participation, patients were matched (1:1) on known risk factors [age, gender, inpatient status, preexisting comorbidities (obesity, diabetes, smoking, alcohol, steroid use, coronary artery disease, chronic renal failure, pulmonary disease)] and preoperatively calculated probability for morbidity and mortality. Clinically relevant outcomes were compared with a t- or chi-squared test. The impact of resident participation on outcomes was assessed with multivariable regression modeling, adjusting for risk factors and operative time.
Results: The most common procedures in the matched cohort (n=83,790) were appendectomy (39.9%), exploratory laparotomy (8.8%) and adhesiolysis (6.6%). Outcomes of the two groups are summarized on table 1. Resident participation was an independent predictor for adverse outcomes (table 2).
Conclusions: Trainee participation is associated with adverse outcomes in emergency general surgery procedures. Remediation strategies could include increased use of simulation in training, and increased faculty supervision of residents.

	Matched Cohort (n=83,790)
	NO RES N=30,616	RES N=30,616	p-value
Mortality	2.96	3.25	0.082
Overall morbidity	3.45	3.29	0.199
Length of stay	4.59±7.98	4.97±9.63	0.019
Wound complications
Superficial wound infection	2.78	3.50	<0.001
Deep wound infection	0.89	0.73	0.011
Organ space infection	1.77	2.27	<0.001
Wound dehiscence	0.69	0.63	0.266
Operative technique
Operative time	59.17±44.78	75.10±54.77	<0.001
Anesthesia time	99.92±55.45	122.42±66.22	<0.001
Intraoperative transfusions	2.55	3.43	<0.001
Postoperative bleeding requiring transfusion	1.28	1.12	0.031
Unplanned return to the OR	3.80	4.22	0.002
Pulmonary complications
Postoperative pneumonia	1.67	1.85	0.043
Unplanned reintubation	1.15	1.64	<0.001
Failure to wean from ventilation	2.06	2.87	<0.001
Cardiovascular complications
Myocardial infarction	0.26	0.27	0.637
Cardiopulmonary arrest	0.32	0.39	0.071
Cerebrovascular accident	0.13	0.16	0.205
Deep venous thrombosis	0.62	0.80	0.002
Pulmonary embolism	0.28	0.43	<0.001
Renal complications
Acute renal failure	0.31	0.34	0.427
Renal failure requiring dialysis	0.43	0.37	0.209
Urinary tract infections	1.14	1.45	<0.001
Life-threatening infectious complications
Sepsis	2.13	2.42	0.005
Septic shock	1.41	1.51		0.205

Table 1

	Effect of Resident Participation on Outcomes (Controlling for Risk Factors & Operative Time)
	Beta Coefficient/ Odds Ratio [95% C.I.]	p-value
Length of stay	0.43 [0.30-0.56]	<0.001
Superficial wound infection	1.23 [1.13-1.34]	<0.001
Organ space infection	1.21 [1.09-1.34]	<0.001
Intraoperative transfusion	1.20 [1.07-1.34]	0.001
Postoperative bleeding requiring transfusion	0.78 [0.69-0.90]	<0.001
Unplanned return to the OR	1.08 [1.00-1.16]	0.041
Postoperative pneumonia	1.06 [0.94-1.18]	0.348
Unplanned reintubation	1.38 [1.21-1.57]	<0.001
Failure to wean from ventilation	1.43 [1.29-1.59]	<0.001
Deep venous thrombosis	1.25 [1.05-1.49]	0.011
Pulmonary embolism	1.42 [1.11-1.81]	0.005
Urinary tract infections	1.23 [1.08-1.40]	0.001
Sepsis	1.07 [0.97-1.18]	0.155

Table 2
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