Dr. Avery Nathens

nathens-photoMy history with the PSI foundation dates back to 1994, when I received my first grant as a doctoral student in the Surgical Sepsis Laboratories at the Toronto General Hospital in the Surgical Scientist Training Program at the University of Toronto. At that time I was studying the host response to infection and the inflammatory response. The success in that environment led me to pursue an academic track focusing on traumatic injury and emergency surgical care.

I moved on to start my career in Seattle, WA where I pursued an MPH and refocused my efforts on health services research and injury. I returned to Canada in 2006 and shortly thereafter collaborated with Dr. Vicki Leblanc, a psychologist with an interested in how stress among health care providers might impact clinical performance. This was a perfect opportunity to study the resuscitation of severely injured trauma patients, a high stakes, high pressure clinical setting. We received funding from PSI in 2007 to study the stress response in trainees in simulated trauma scenarios. We demonstrated that critically injured patients provoke a considerable stress response as demonstrated by high levels of circulating cortisol. Further, this level of stress was associated with impaired performance. This work resulted in the two publications below and set the stage for an interest in evaluating performance in the trauma bay using novel technologies.

1. Harvey A, Bandiera G, Nathens AB, LeBlanc VR. Impact of stress on resident performance in simulated trauma scenarios. J Trauma Acute Care Surg. 2012
Feb;72(2):497-503.

2. Harvey A, Nathens AB, Bandiera G, Leblanc VR. Threat and challenge: cognitive appraisal and stress responses in simulated trauma resuscitations. Med Educ. 2010
Jun;44(6):587-94.

I also have an interest in injury prevention and to this end, PSI funding has been used to evaluate risks for recurrent intentional injury among youth. My personal experience and that supported by several lines of evidence indicate that many patients who are victims of interpersonal violence have prior visits to the emergency department. In 2008, Dr. Carolyn Snider and I were interested in designing brief interventions to prevent this cycle of violence among youth and received a PSI grant to study this further. We first used a mixed methods approach (concept mapping) to evaluate what type of interventions and/or services would offer the most value from the perspective of high risk youth and their community partners. This work laid the foundation for conceptualizing a hospital based violence prevention intervention and to identify outcomes relevant to the community. Next, we evaluated the optimal hospital setting to implement these programs. Our work in this domain demonstrated that over 80% of injured person present to non-trauma centres. This finding is important as most injury prevention programs are implemented in trauma centres, but this work clearly demonstrated that violence prevention initiatives implemented in this environment will not achieve the goals of preventing recurrent injury on a population basis.

1. Snider CE, Nathens AB. Where should we implement emergency department secondary prevention programs for youth injured by violence? J Trauma. 2010 Oct;69(4):991-4.

2. Snider CE, Kirst M, Abubakar S, Ahmad F, Nathens AB. Community-based participatory research: development of an emergency department-based youth violence intervention using concept mapping. Acad Emerg Med. 2010 Aug;17(8):877-85.

As part of my research program evaluating emergency surgical care, my doctoral student, Dr. Charles de Mestral received PSI funding to evaluate strategies related to the management of acute cholecystitis. This work, carried out at the Institute for Clinical Evaluative Sciences allowed us to follow a cohort of Ontario residents with this common diagnosis. We demonstrated significant benefit to patients receiving early surgical intervention with fewer complications, better quality of life, less health care resource utilization and lower costs. This work caught the attention of the MOHLTC, where incentives to perform earlier operation are being considered. This work resulted in the the 4 publications below, with one more in press:

1. de Mestral C, Rotstein OD, Laupacis A, Hoch JS, Zagorski B, Alali AS, Nathens AB. Comparative operative outcomes of early and delayed cholecystectomy for acute
cholecystitis: a population-based propensity score analysis. Ann Surg. 2014 Jan;259(1):10-5.

2. de Mestral C, Laupacis A, Rotstein OD, Hoch JS, Haas B, Gomez D, Zagorski B, Nathens AB. Early cholecystectomy for acute cholecystitis: a population-based retrospective cohort study of variation in practice. CMAJ Open. 2013 May 16;1(2):E62-7.

3. de Mestral C, Gomez D, Haas B, Zagorski B, Rotstein OD, Nathens AB. Cholecystostomy: a bridge to hospital discharge but not delayed cholecystectomy. J Trauma Acute Care Surg. 2013 Jan;74(1):175-9.

4. de Mestral C, Rotstein OD, Laupacis A, Hoch JS, Zagorski B, Nathens AB. A population-based analysis of the clinical course of 10,304 patients with acute
cholecystitis, discharged without cholecystectomy. J Trauma Acute Care Surg. 2013 Jan;74(1):26-30.

Dr. Aziz AlAli is another one of my graduate students who as a neurosurgeon, was interested in exploring strategies related to care of the patient with brain injuries. As the director of the American College of Surgeons Trauma Quality Improvement Program, I had an interest in how we can capitalize at exploring variations in practice to evaluate optimal care strategies. In work funded through the PSI foundation, we used data from almost 200 trauma centres across North America to explore the impact of tracheostomy timing in patients with severe traumatic brain injury. This is an area of considerable controversy where biases are so great that randomized controlled trials are almost impossible. We demonstrated a significant benefit to early (within 7 days) tracheostomy. This work was cited as one of the top 10 publications that are likely to change practice at the largest trauma conferencesin the world (Annual Las Vegas Trauma, Critical Care & Acute Care Surgery, March 2015, 
Las Vegas, NV). The PSI funding was also used to explore other variations in practice to gain insights into other care strategies that might improve outcomes in this critically ill population. Altogether, PSI funding led to the three publications below:

1. Alali AS, Scales DC, Fowler RA, Mainprize TG, Ray JG, Kiss A, de Mestral C, Nathens AB. Tracheostomy timing in traumatic brain injury: a propensity-matched
cohort study. J Trauma Acute Care Surg. 2014 Jan;76(1):70-6; discussion 76-8.

2. Alali AS, Fowler RA, Mainprize TG, Scales DC, Kiss A, de Mestral C, Ray JG, Nathens AB. Intracranial pressure monitoring in severe traumatic brain injury:
results from the American College of Surgeons Trauma Quality Improvement Program.
J Neurotrauma. 2013 Oct 15;30(20):1737-46.

3. Alali AS, Naimark DM, Wilson JR, Fowler RA, Scales DC, Golan E, Mainprize TG, Ray JG, Nathens AB. Economic evaluation of decompressive craniectomy versus barbiturate coma for refractory intracranial hypertension following traumatic brain injury. Crit Care Med. 2014 Oct;42(10):2235-43.

The PSI Foundation has been remarkably supportive and as is evident above, not only provided funding to begin my career, but also initiated the career of several promising graduate students and/or junior faculty under my supervision in fields as diverse as emergency medicine to neurosurgery. The Foundation is critically important in supporting physicians’ asking the right scientific questions to improve the quality of care and bringing innovation to the bedside.

Dr. Nathens is a trauma surgeon and the Surgeon in Chief of Sunnybrook Health Sciences Centre, Canada¹s largest Level 1 trauma centre. He is also an epidemiologist with a focus on trauma system design. He is an active member of the American College of Surgeons Committee on Trauma and is Director of the American College of Surgeons Trauma Quality Improvement Program. He holds the DeSouza Chair in Trauma Research and has published many landmark peer-reviewed papers in the Lancet, NEJM and JAMA focusing on trauma system design and implementation. Dr. Nathens has had extensive experience evaluating quality of care and trauma system effectiveness and translated much of this work into tangible changes at the patient level.

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