title: Safety assessment of resident grade and supervision level during emergency appendectomy: analysis of a multicenter, prospective study.
abstract: BACKGROUND
  Resident surgeons have been identified as a risk factor for worse outcome after appendectomy. The context of grade of resident and impact of supervision require further investigation. The objective of this study was to determine whether grade and supervision level of resident-performed appendectomy affects patient outcome.
  
  
  METHODS
  A multicenter, prospective cohort study was performed for consecutive patients undergoing appendectomy during May and June 2013. The primary endpoint for this analysis was the 30-day adverse event rate. Supervision was defined as resident-performed appendectomy with an attending scrubbed. Multivariable binary logistic regression was used to take into account case mix and produce adjusted odds ratios (OR).
  
  
  RESULTS
  From 2,867 appendectomies, 87% were performed by residents, and 72% were performed unsupervised. Residents operated on significantly younger patients with lower American Society of Anesthesiologists scores. Although wound infection rates were similar between attendings, and senior and junior residents (4.1%, 3.8%, 3.4% respectively; P = .486), pelvic abscess rate was greater for attendings (5.2%, 2.7%, 2.4%; P = .045). In adjusted models, supervised senior, supervised junior, and unsupervised junior residents showed no difference in 30-day adverse event rates compared with attendings (OR, 1.07 [P = .834], 0.93 [P = .773], and 0.83 [P = .264] respectively); unsupervised senior residents had a lesser rate of adverse events (OR, 0.71; P = .045). All resident groups showed no difference for rates of histopathologically normal appendectomy compared with attendings.
  
  
  CONCLUSIONS
  Resident-performed appendectomy does not worsen patient outcomes. These findings support independent resident operating rights for selected cases. The system relies on mutual credentialing of competency between residents and supervising attendings.
authors.affiliation: West Midlands Research Collaborative, Birmingham, UK.
authors.forename: Pritam
authors.initials: P
authors.lastname: Singh
authors.affiliation: London Surgical Research Group, Birmingham, UK.
authors.forename: E Jane H
authors.initials: EJ
authors.lastname: Turner
authors.affiliation: Welsh Barber Surgeons Research Group, Birmingham, UK.
authors.forename: Julie
authors.initials: J
authors.lastname: Cornish
authors.affiliation: West Midlands Research Collaborative, Birmingham, UK. Electronic address: aneelbhangu@doctors.org.uk.
authors.forename: Aneel
authors.initials: A
authors.lastname: Bhangu
mesh_terms: D018784:Abdominal Abscess / Q000453:epidemiology / Q000209:etiology; D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001062:Appendectomy / Q000193:education / Q000592:standards; D001064:Appendicitis / Q000601:surgery*; D002648:Child; D002675:Child, Preschool; D002983:Clinical Competence; D004630:Emergencies; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007223:Infant; D007396:Internship and Residency / Q000458:organization & administration*; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D011183:Postoperative Complications / Q000453:epidemiology / Q000209:etiology; D011446:Prospective Studies; D013530:Surgical Wound Infection / Q000453:epidemiology / Q000209:etiology; D016896:Treatment Outcome; D055815:Young Adult