Trainee participation affects outcomes in emergency general surgery procedures: an analysis of the National Surgical Quality Improvement Program database

Abstract

Previous research has demonstrated a significant impact of trainee participation on outcomes in a broad surgical patient population. With the current project, we aim to identify if a similar effect exists in emergency general surgery. A total of 141,010 patients who underwent emergency general surgery procedures were identified in the 2005-2010 National Surgical Quality Improvement Program database. Due to the non-random assignment of the more complex cases to resident participation, patients were matched (1:1) on known risk factors [age, gender, inpatient status, preexisting comorbidities (obesity, diabetes, smoking, alcohol use, steroid use, coronary artery disease, chronic renal failure, pulmonary disease)] and on 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 quantified with multivariable regression modeling, adjusting for both the aforementioned risk factors and operative time. The most common procedures in the matched cohort (n=83,790) were appendectomy (39.9%), exploratory laparotomy (8.8%) and adhesiolysis (6.6%). Our findings suggest that trainee participation in emergency general surgery procedures prolongs operative time, increases intraoperative transfusions, and is independently associated with adverse postoperative outcomes, including wound, pulmonary, and venous thromboembolic complications, as well as urinary tract infections. This effect appears to be independent of the total intraoperative time, case complexity, and preexisting comorbid conditions. We also demonstrate that operative time is another important factor independently associated with intra- and post-operative transfusions, unplanned reoperations, longer hospital stays, infections, as well as wound, pulmonary, and venous thromboembolic complications, when baseline comorbidities and resident participation were adjusted for. Remediation strategies could include increased use of simulation training and increased faculty supervision of residents.