Hypotension is a known risk factor for poor neurologic outcomes after traumatic brain injury (TBI). Current guidelines suggest that higher systolic blood pressure (SBP) thresholds likely confer a ...mortality benefit. However, there is no consensus on the ideal perfusion pressure among different age groups (i.e., recommended SBP ≥100 mm Hg for patients age 50-69 years; ≥ 110 mm Hg for all other adults). We hypothesize that admission SBP ≥110 mm Hg will be associated with improved outcomes regardless of age group. A retrospective database review of the 2010-2016 Trauma Quality Improvement Program database was performed for adults (≥ 18 years) with isolated moderate-to-severe TBIs (head Abbreviated Injury Scale AIS ≥3; all other AIS <3). Sub-analyses were performed after dividing patients by SBP and age; comparison groups were matched with propensity score matching. Primary outcomes were early (6 h, 12 h, and 1 day) and overall in-hospital mortality. Overall, 154,725 patients met the inclusion criteria (mean age 62.8 ± 19.8 years, 89,431 57.8% males, Injury Severity Score13.9 ± 6.8). Multi-variate logistic regression showed that the risk of in-hospital mortality decreased with increasing SBP, plateauing at 110 mm Hg. Among patients of all ages, SBP ≥110 mm Hg was associated with improved mortality (SBP 110-129 vs. 90-109 mm Hg: 12 h 0.4% vs. 0.8%,
= 0.001; 1 day 0.8% vs. 1.4%,
= 0.004; overall 3.2% vs. 4.9%,
< 0.001). Among patients age 50-69 years, SBP ≥110 mm Hg was associated with improved mortality (SBP 110-119 vs. 100-109 mm Hg: 12 h 0.3% vs. 0.9%,
= 0.018; 1 day 0.5% vs. 1.5%,
= 0.007; overall 2.7% vs. 4.3%,
= 0.015). In conclusion, SBP ≥110 mm Hg is associated with lower in-hospital mortality in adult patients with isolated TBIs, including patients age 50-69 years. SBP <110 mm Hg should be used to define hypotension in adult patients of all ages.
Peri-operative blood transfusion (BT) may lead to transfusion-induced immunomodulation. We aimed to investigate the association between peri-operative BT and infectious complications in patients ...undergoing intestinal-cutaneous fistulas (ICF) repair.
We queried the ACS-NSQIP 2006–2017 database to include patients who underwent ICF repair. The main outcome was 30-day infectious complications. Univariate and multivariable logistic regression analyses were performed to assess the predictors of post-operative infections.
Of 4,197 patients included, 846 (20.2%) received peri-operative BT. Transfused patients were generally older, sicker and had higher ASA (III–V). After adjusting for relevant covariates, patients who received intra and/or post-operative (and not pre-operative) BT had higher odds of infectious complications compared (OR = 1.22, 95% CI 1.01–1.48). Specifically, they had higher odds of organ-space surgical site infection (OR = 1.61, 95% CI 1.21–2.13), but not other infectious complications.
Intra and/or post-operative (and not pre-operative) BT is an independent predictor of infectious complications in ICF repair.
•Patients with intestinal-cutaneous fistula (ICF) requiring surgery.•Transfusion is associated with infectious complications in those patients.•This finding could be due to transfusion-induced immunomodulation.•Caution is required when ICF patients require intra/post-operative blood transfusion.
Diversion of excess prescription opioids contributes to the opioid epidemic. We sought to describe and study the impact of a comprehensive departmental initiative to decrease opioid prescribing in ...surgery.
A multispecialty multidisciplinary initiative was designed to change the culture of postoperative opioid prescribing, including: consensus-built opioid guidelines for 42 procedures from 11 specialties, provider-focused posters displayed in all surgical units, patient opioid/pain brochures setting expectations, and educational seminars to residents, advanced practice providers, residents and nurses. Pre- (April 2016-March 2017) versu post-initiative (April 2017-May 2018) analyses of opioid prescribing at discharge median oral morphine equivalent (OME) were performed at the specialty, prescriber, patient, and procedure levels. Refill prescriptions within 3 months were also studied.
A total of 23,298 patients were included (11,983 pre-; 11,315 post-initiative). Post-initiative, the median OME significantly decreased for 10 specialties (all P values < 0.001), the percentage of patients discharged without opioids increased from 35.7% to 52.5% (P < 0.001), and there was no change in opioids refills (0.07% vs 0.08%, P = 0.9). Similar significant decreases in OME were observed when the analyses were performed at the provider and individual procedure levels. Patient-level analyses showed that the preinitiative race/sex disparities in opioid-prescribing disappeared post-initiative.
We describe a comprehensive multi-specialty intervention that successfully reduced prescribed opioids without increase in refills and decreased sex/race prescription disparities.
Abstract Background The Patient Safety Indicators (PSIs) are algorithms based on the International Classification of Diseases, Ninth Revision, Clinical Modification, aimed at identifying potential ...safety-related adverse events through the automated screening of readily available administrative databases. Many of these indicators focus on surgical care, and a few have been endorsed by the National Quality Forum as performance measures. The aim of this report is to give a brief overview of the development and definitions of the PSIs as well as the current evidence for their validity, compared with the National Surgical Quality Improvement Program and chart abstraction designed for the purpose of PSI validation. Methods Several articles published in the past few years, in addition to primary data collected from an ongoing study of PSI validation in the Veterans Health Administration, were examined. Results Selected surgical PSIs have positive predictive values ranging from 22% to 89%, depending on the nature of the PSI and the method of validation used. Conclusions With adequate coding revisions, PSI performance can be substantially improved.
Assess the prevalence of anxiety, depression, and posttraumatic stress disorder (PTSD) after injury and their association with long-term functional outcomes.
Mental health disorders (MHD) after ...injury have been associated with worse long-term outcomes. However, prior studies almost exclusively focused on PTSD.
Trauma patients with an injury severity score ≥9 treated at 3 Level-I trauma centers were contacted 6-12 months post-injury to screen for anxiety (generalized anxiety disorder-7), depression (patient health questionnaire-8), PTSD (8Q-PCL-5), pain, and functional outcomes (trauma quality of life instrument, and short-form health survey)). Associations between mental and physical outcomes were established using adjusted multivariable logistic regression models.
Of the 531 patients followed, 108 (20%) screened positive for any MHD: of those who screened positive for PTSD (7.9%, N = 42), all had co-morbid depression and/or anxiety. In contrast, 66 patients (12.4%) screened negative for PTSD but positive for depression and/or anxiety. Compared to patients with no MHD, patients who screened positive for PTSD were more likely to have chronic pain {odds ratio (OR): 8.79 95% confidence interval (CI): 3.21, 24.08}, functional limitations OR: 7.99 (95% CI: 3.50, 18.25) and reduced physical health β: -9.3 (95% CI: -13.2, -5.3). Similarly, patients who screened positive for depression/anxiety (without PTSD) were more likely to have chronic pain OR: 5.06 (95% CI: 2.49, 10.46), functional limitations OR: 2.20 (95% CI: 1.12, 4.32) and reduced physical health β: -5.1 (95% CI: -8.2, -2.0) compared to those with no MHD.
The mental health burden after injury is significant and not limited to PTSD. Distinguishing among MHD and identifying symptom-clusters that overlap among these diagnoses, may help stratify risk of poor outcomes, and provide opportunities for more focused screening and treatment interventions.
Existent methodologies for benchmarking the quality of surgical care are linear and fail to capture the complex interactions of preoperative variables. We sought to leverage novel nonlinear ...artificial intelligence methodologies to benchmark emergency surgical care.
Using a nonlinear but interpretable artificial intelligence methodology called optimal classification trees, first, the overall observed mortality rate at the index hospital's emergency surgery population (index cohort) was compared to the risk-adjusted expected mortality rate calculated by the optimal classification trees from the American College of Surgeons National Surgical Quality Improvement Program database (benchmark cohort). Second, the artificial intelligence optimal classification trees created different "nodes" of care representing specific patient phenotypes defined by the artificial intelligence optimal classification trees without human interference to optimize prediction. These nodes capture multiple iterative risk-adjusted comparisons, permitting the identification of specific areas of excellence and areas for improvement.
The index and benchmark cohorts included 1,600 and 637,086 patients, respectively. The observed and risk-adjusted expected mortality rates of the index cohort calculated by optimal classification trees were similar (8.06% 95% confidence interval: 6.8-9.5 vs 7.53%, respectively, P = .42). Two areas of excellence and 4 for improvement were identified. For example, the index cohort had lower-than-expected mortality when patients were older than 75 and in respiratory failure and septic shock preoperatively but higher-than-expected mortality when patients had respiratory failure preoperatively and were thrombocytopenic, with an international normalized ratio ≤1.7.
We used artificial intelligence methodology to benchmark the quality of emergency surgical care. Such nonlinear and interpretable methods promise a more comprehensive evaluation and a deeper dive into areas of excellence versus suboptimal care.
...the study was obviously not masked, and it is likely that the Hawthorne effect was more pronounced in the intervention sites compared with the control sites. ...some of the missing outcomes ...necessitating a modified intention-to-treat analysis could have led to additional selection bias and residual confounding. ...interventions are probably cost-effective, and we look forward to the authors' follow-up data on cost-effectiveness.
To explore whether psoas cross sectional area (CSA) and density (Hounsfield Units, HU) are associated with nutritional adequacy and clinical outcomes in surgical intensive care unit patients.
...Subjects with at least one CT scan within 72h of ICU admission were included. Demographic, nutritional, radiographic, and outcomes data were collected. Psoas muscle CSA and HU were assessed at the L4–L5 intervertebral disk level. Change (Δ) in CSA and HU overall and per day were calculated.
140 patients were included. There was no significant correlation between baseline CSA and HU and clinical outcomes. Patients with at least two CT scans (n=65), had a median decrease in CSA of −15% IQR: −20%, −8% and decrease in HU of −2% IQR: −30%, +24%. Patients with the greatest daily %HU decline received significantly fewer calories/kg and proteins/kg and accumulated greater protein deficits at day 7 and overall. Patients with daily %HU increase had the shortest ICU and hospital LOS and more ventilator-free days in univariate and multivariable analyses.
In this exploratory study, early nutritional deficits were correlated with muscle quality deterioration. Inpatient gain in psoas density, compared to maintenance or loss, is associated with shorter hospital stay.
•Psoas muscle size and density were higher in patients who were younger and had fewer co-morbid medical conditions.•Psoas muscle size and density declined significantly during hospitalization (1% and 0.3% per day, respectively).•Patients who received less protein early in the ICU stay had significantly greater declines in psoas muscle density.•Patients with increase in psoas muscle size and density had better clinical outcomes.
Abstract Background Laparoscopic cholecystectomy (LC) accounts for more than 85% of cholecystectomies. Factors prompting open cholecystectomy (OC) or conversion from LC to OC (CONV) are not ...completely understood. Methods Prospectively collected data from the National Surgical Quality Improvement Program (NSQIP) were combined with administrative data to identify patients undergoing cholecystectomy from October 2005 to October 2008. Three cohorts were defined: LC, OC, and CONV. Using logistic hierarchical modeling, we identified predictors of the choice of OC and the decision to CONV. Results A total of 11,669 patients underwent cholecystectomy at 117 VA hospitals, including 9,530 LC (81.7%). While the rate of conversion from LC to OC remained stable over the study period (9.0% overall), the percentage of OC decreased from 11.5% in 2006 to 10.1% in 2007 and 8.9% in 2008 ( P = .0002). Compared with LC, the OC cohort had more comorbidities (35 of 41 preoperative characteristics, all P <.05), a higher 30-day morbidity rate (18.7% vs 4.8%. P <.0001), and a higher 30-day mortality rate (2.4% vs .4%, P <.0001). American Society of Anesthesiologist (ASA) class, patient comorbidities (eg, ascites, bleeding disorders, pneumonia) and functional status predicted a choice of OC. Age, preoperative albumin, previous abdominal surgery and emergency status predicted OC and CONV (all P <.05). A higher hospital conversion rate was independently predictive of OC (odds ratio 1% rate increase: 1.05 1.02–1.07; P = .0004). Conclusion In the last 3 years, there has been a trend towards performing fewer OCs in VA hospitals. More patient comorbidities and higher hospital-level conversion rates are predictive of the choice to perform or convert to OC.
PDF
