Operative Autonomy: Assessing Resident Impact On Surgical Outcomes In Below The Knee Amputations
Alexander Simmonds, MD, Diana Otoya, MD, Kedar Lavingia, MD, Michael Amendola, MD.
VA Medical Center/VCU Health System, Richmond, VA, USA.
INTRODUCTION:Gradual increases in autonomy with attending physician oversight are consider crucial to successful training in surgery as well as safe patient care. The Veterans Affairs Surgical Quality Improvement Program (VASQIP) follows patient outcomes and has yet to be examined for outcomes of specialty and includes information about attending surgeon oversight in the operation room (OR). We set forth to examine VASQIP database to determine the frequency of resident operative independence during below the knee amputations (BKA). METHODS:All VASQIP records for BKA from 1990 to 2018 were examined and categorized based on if the attending was scrubbed during the case. Case matching was performed based on gender, diabetes, preoperative renal failure, smoking status, steroid use, CHF, COPD, and open wound infections. Comorbidities, pre-operative, and postoperative outcomes for each procedure within 30 days were tabulated. 30 day post-operative outcomes including return to the operating room, wound infections mortality were assessed in addition to operative time, hospital length of stay and transfusion requirements. Student t-test* and Fisher’s Exact Test** were utilized. RESULTS: A total of 28,768 BKA VASQIP records were obtained. After case control matching, 5,234 cases remained. Cases were identified with the attending surgeon noted as being scrubbed during the case (n=2617), or not scrubbed (n=2617). Patients were similar in comorbidities across both.
CONCLUSION:
Increased resident independence during below the knee amputation at VA hospitals is associated with a statistically significant length of stay, return to OR, blood transfusion, and sepsis. There was no statistically significant increase in operative time, 30-day mortality, wound infection, or total complication. Further research is required in assessing the risks associated with surgical training, resident supervision, and resident preparedness for independent practice. 
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