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Performance of the Afferent Limb of Rapid Response Systems in Managing Deteriorating Patients: A Systematic Review. Crit Care Res Pract 2019; 2019:6902420. [PMID: 31781390 PMCID: PMC6874970 DOI: 10.1155/2019/6902420] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Revised: 05/31/2019] [Accepted: 06/26/2019] [Indexed: 11/18/2022] Open
Abstract
Introduction The clinical components of the rapid response system (RRS) are the afferent limb, to ensure identification of in-hospital patients who deteriorate and activation of a response, and the efferent limb, to provide the response. This review aims to evaluate the factors that influence the performance of the afferent limb in managing deteriorating ward patients and their effects on patient outcomes. Methods A systematic review was performed for the years 1995–2017 by employing five electronic databases. Articles were included assessing the ability of the ward staffs to monitor, recognize, and escalate care to patient deterioration. The findings were summarized using a narrative approach. Results Thirty-one studies met the inclusion criteria. The analysis revealed major themes enclosing several factors affecting management of patients having sudden deterioration. The monitoring and recognition process was conditioned by the lack of recording of physiological parameters, the influence of facilitators, including staff education and training, and barriers, including human and environmental factors, and poor compliance with the calling criteria. The escalation of care process highlighted the influence of cultural barriers and personal judgment on RRS activation. Mainly, delayed team calls were factors strongly associated with the increased risk of unplanned admissions to the intensive care unit and length of stay, hospital length of stay and mortality, and 30-day mortality. Conclusions A combination of factors affects the timely identification and response to sudden deterioration by general ward staffs, leading to suboptimal care of patients, delayed or failed activation of RRS teams, and increased risks of worsening outcomes. The research efforts and clinical involvement to improve the governance of the factors limiting the performance of the afferent limb may ensure proper management of hospitalized patients showing physiological deterioration.
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Al-Moteri M, Cooper S, Symmons M, Plummer V. Nurses' cognitive and perceptual bias in the identification of clinical deterioration cues. Aust Crit Care 2019; 33:333-342. [PMID: 31615698 DOI: 10.1016/j.aucc.2019.08.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Revised: 08/15/2019] [Accepted: 08/29/2019] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Perception and processing of clinical cues have rarely been investigated in the nursing literature despite their relevance to the early identification and management of clinical deterioration. AIM This study used a hypovolemic shock scenario from the Feedback Incorporating Review and Simulation Techniques to Act on Clinical Trends (FIRST2ACT) virtual simulation program, equipped with an eye tracker, to investigate cue processing during the management of patient deterioration. RESULT The study revealed that attention deviation distorted interpretation of subsequent cues, causing 63% of participants to exhibit a cognitive bias (heightened sensitivity to specific but noncritical cues) and 65% to exhibit at least one episode of nonfixation on clinically relevant cues. Attention deviation and distorted interpretations of clinical cues will have an impact on patient safety. CONCLUSION The findings are likely to have important implications for understanding error and associated training implications.
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Affiliation(s)
- Modi Al-Moteri
- Nursing Department, Faculty of Applied Medical Sciences, University of Al-Taif, Western Region, Saudi Arabia; School of Nursing and Midwifery, Monash University, Australia.
| | - Simon Cooper
- Emergency Care and Research Development, School of Nursing and Midwifery and Healthcare, Federation University, Victoria, Australia; School of Nursing, University of Hong Kong, Hong Kong, China; School of Nursing and Midwifery, University of Brighton, UK
| | | | - Virginia Plummer
- School of Nursing and Midwifery, Monash University, Australia; Peninsula Health, Frankston, Australia
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Nimptsch U, Haist T, Krautz C, Grützmann R, Mansky T, Lorenz D. Hospital Volume, In-Hospital Mortality, and Failure to Rescue in Esophageal Surgery. DEUTSCHES ARZTEBLATT INTERNATIONAL 2019; 115:793-800. [PMID: 30636674 DOI: 10.3238/arztebl.2018.0793] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 03/20/2018] [Accepted: 08/09/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND In Germany, complex esophageal surgery is often performed in hospitals with low case numbers. For these procedures, an association exists between hospital case numbers and treatment outcomes, possibly because of differences in complication management. This aspect of the association between volume and outcome in esophageal surgery has not yet been studied in Germany. METHODS On the basis of nationwide hospital discharge data (DRG statistics) from the years 2010 to 2015, the association between volume and outcome was analyzed in relation to in-hospital mortality, the frequency of complications, and the mortality of patients who had complications. RESULTS 22 700 cases of complex esophageal surgery were identified. The probability of dying after esophageal surgery was much lower in hospitals with very high case numbers (median, 62 per year) than in those with very low case numbers (median, two per year), with an odds ratio (OR) of 0.50 (95% confidence interval, [0.42; 0.60]). At least one complication was documented for more than half of all patients; no association was found between the frequency of complications and the hospital case volume. The in-hospital mortality among patients who had complications was 12.3% [11.1; 13.7] in hospitals with very high case numbers and 20.0% [18.5; 21.6] in hospitals with very low case numbers. Of the 4032 procedures performed in 2015, 83% were for cancer of the esophagus. CONCLUSION These findings indicate that the quality of care for patients undergoing esophageal surgery in Germany could be improved if more patients were treated in hospitals with high case numbers. The observed association between case numbers and outcomes is tightly linked to failure to rescue.
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Affiliation(s)
- Ulrike Nimptsch
- Department of Structural Advancement and Quality Management in the Health System, TU Berlin, Berlin; Department of General and Visceral Surgery, Sana Hospital Offenbach GmbH, Offenbach am Main; Department of Surgery, University Hospital Erlangen; General, Visceral and Thoracic Surgery, Darmstadt Hospital GmbH, Darmstadt
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Albutt A, O'Hara J, Conner M, Lawton R. Involving patients in recognising clinical deterioration in hospital using the Patient Wellness Questionnaire: A mixed-methods study. J Res Nurs 2019; 25:68-86. [PMID: 34394609 DOI: 10.1177/1744987119867744] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Measures exist to improve early recognition of, and response to deteriorating patients in hospital. Despite these, 7% of the deaths reported to the National Reporting and Learning System from acute hospitals in 2015 related to a failure to recognise or respond to deterioration. Interventions have been developed that allow patients and relatives to escalate patient deterioration to a critical care outreach team. However, there is not a strong evidence base for the clinical effectiveness of these interventions, or patients' ability to recognise deterioration. Aims The aims of this study were as follows. (a) To identify methods of involving patients in recognising deterioration in hospital, generated by health professionals. (b) To develop and evaluate an identified method of patient involvement in practice, and explore its feasibility and acceptability from the perspectives of patients. Methods The study used a mixed-methods design. A measure to capture patient-reported wellness during observation was developed (Patient Wellness Questionnaire) through focus group discussion with health professionals and patients, and piloted on inpatient wards. Results There was limited uptake where patients were asked to record ratings of their wellness using the Patient Wellness Questionnaire themselves. However, where the researcher asked patients about their wellness using the Patient Wellness Questionnaire and recorded their responses during observation, this was acceptable to most patients. Conclusions This study has developed a measure that can be used to routinely collect patient-reported wellness during observation in hospital and may potentially improve early detection of deterioration.
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Affiliation(s)
- Abigail Albutt
- Research Fellow, Yorkshire Quality and Safety Research Group, Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford, UK
| | - Jane O'Hara
- Associate Professor in Patient Safety and Improvement Science, Yorkshire Quality and Safety Research Group, Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford, UK
| | - Mark Conner
- Professor of Applied Social Psychology, School of Psychology, University of Leeds, UK
| | - Rebecca Lawton
- Professor, Psychology of Healthcare, Yorkshire Quality and Safety Research Group, Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford, UK.,School of Psychology, University of Leeds, UK
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van Groningen JT, Marang-van de Mheen PJ, Henneman D, Beets GL, Wouters MWJM. Surgeon perceived most important factors to achieve the best hospital performance on colorectal cancer surgery: a Dutch modified Delphi method. BMJ Open 2019; 9:e025304. [PMID: 31551369 PMCID: PMC6773321 DOI: 10.1136/bmjopen-2018-025304] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES Hospital variation in risk-adjusted outcomes after colorectal cancer surgery has been shown. However, explanatory factors are not sufficiently clear. The objective of this study was to identify factors perceived by gastrointestinal surgeons as important to achieve excellent casemix-adjusted outcomes after colorectal cancer surgery. DESIGN Based on literature and experts' opinion, 86 factors associated with serious complications, failure to rescue and mortality were listed. These were presented to gastrointestinal surgeons through two web-based surveys and an expert meeting. Participants were asked to choose their top 10 of most important factors. PARTICIPANTS Dutch gastrointestinal surgeons (n=52) of different hospitals and different hospital types (general/teaching/academic). RESULTS Of 31 invited experts for the first survey and meeting, 71% responded. Of 130 invited surgeons, 34 responded to the second survey. Factors deemed important were: procedural hospital volume (46% in top 10), specialised surgeons performing surgery, (elective 87%, emergency 60% and reoperations 62% in top 10), accessibility of, and daily ward rounds by specialised surgeons (41% and 38% in top 10), preoperative screening for malnutrition (57% in top 10), a protocol for recognition of anastomotic leakage and rapid reintervention (54% and 49% in top 10). CONCLUSION Procedural hospital volume, specialisation of surgeons, screening for malnutrition, early recognition of complications followed by rapid action were perceived as most important factors to achieve good outcomes by gastrointestinal surgeons.
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Affiliation(s)
- Julia Tessa van Groningen
- Department of Surgery, Leids Universitair Medisch Centrum, Leiden, The Netherlands
- Dutch Institute for Clinical Auditing, Leiden, The Netherlands
| | - Perla J Marang-van de Mheen
- Department of Biomedical Data Sciences, Medical Decision Making, Leids Universitair Medisch Centrum, Leiden, The Netherlands
| | - Daniel Henneman
- Department of Surgery, Leids Universitair Medisch Centrum, Leiden, The Netherlands
| | - Geerard L Beets
- Department of Surgical Oncology, Antoni van Leeuwenhoek Nederlands Kanker Instituut, Amsterdam, The Netherlands
| | - Michel W J M Wouters
- Dutch Institute for Clinical Auditing, Leiden, The Netherlands
- Department of Surgical Oncology, Antoni van Leeuwenhoek Nederlands Kanker Instituut, Amsterdam, The Netherlands
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James A, Cooper S, Stenhouse E, Endacott R. What factors influence midwives to provide obstetric high dependency care on the delivery suite or request care be escalated away from the obstetric unit? Findings of a focus group study. BMC Pregnancy Childbirth 2019; 19:331. [PMID: 31500580 PMCID: PMC6734275 DOI: 10.1186/s12884-019-2487-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 08/30/2019] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND In the United Kingdom, midwives will engage in discussions with the multidisciplinary team as to whether they can provide Obstetric High Dependency Care (OHDC) on the Delivery Suite or whether a woman's care should be escalated to the critical care team. This study aimed to explore the question: What factors influence midwives to provide OHDC or request care be escalated away from the obstetric unit in hospitals remote from tertiary referral centres? METHODS Focus groups were undertaken with midwives (n = 34) across three obstetric units in England, with annual birth rates ranging from 1500 to 5000 per annum, in District General Hospitals. Three scenarios in the form of video vignettes of handover were used as triggers for the focus groups. Scenario 1; severe pre-eclampsia, physiologically unstable 2; major postpartum haemorrhage requiring invasive monitoring 3; recent admission of woman with chest pain receiving facial oxygen and requiring continuous electrocardiogram (ECG) monitoring. Two focus groups were conducted in each of the obstetric units with experienced midwives. Data were analysed using a qualitative framework approach. RESULTS Factors influencing midwives' care escalation decisions included the care environment, a woman's diagnosis and fetal or neonatal factors. The overall plan of care including the need for ECG and invasive monitoring were also influential factors. Midwives in the smallest obstetric unit did not have access to the facilities for OHDC provision. Midwives in the larger obstetric units provided OHDC but identified varying degrees of skill and sometimes used 'workarounds' to facilitate care provision. Midwifery staffing levels, skill mix and workload were also influential. Some differences of opinion were evident between midwives working in the same obstetric units as to whether OHDC could be provided and the support they would enlist to help them provide it. Reliance on clinical guidelines appeared variable. CONCLUSIONS Findings indicate that there may be inequitable OHDC provision at a local level. Organisationally robust systems are required to promote safe, equitable OHDC care including skills development for midwives and precise escalation guidelines to minimise workarounds. Training for midwives must include strategies that prevent skills fade.
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Affiliation(s)
- Alison James
- Faculty of Health and Human Sciences, School of Nursing and Midwifery, University of Plymouth, Drake Circus, Plymouth, Devon PL4 8AA UK
| | - Simon Cooper
- School of Nursing and Healthcare Professions, Federation University, Ballarat, Australia
| | - Elizabeth Stenhouse
- Faculty of Health and Human Sciences, School of Nursing and Midwifery, University of Plymouth, Drake Circus, Plymouth, Devon PL4 8AA UK
| | - Ruth Endacott
- Faculty of Health and Human Sciences, School of Nursing and Midwifery, University of Plymouth, Drake Circus, Plymouth, Devon PL4 8AA UK
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Le Lagadec MD, Dwyer T, Browne M. The efficacy of twelve early warning systems for potential use in regional medical facilities in Queensland, Australia. Aust Crit Care 2019; 33:47-53. [PMID: 30979578 DOI: 10.1016/j.aucc.2019.03.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 02/05/2019] [Accepted: 03/06/2019] [Indexed: 10/27/2022] Open
Abstract
AIM Early warning system (EWS) validation studies are conducted predominantly in tertiary metropolitan facilities and are not necessarily applicable to regional hospitals. This study evaluates 12 EWSs for use in regional subcritical hospitals. METHOD This is a retrospective case-control study of patients who experienced severe adverse events (SAEs) in two regional private hospitals. Vital signs collected over 72 h preceding the SAE were applied to 12 EWSs representing three classes of EWSs. The EWS area under the receiver operator characteristic curve (AUROC), sensitivity, specificity, and number of alerts were calculated. RESULTS Data from 159 index and 172 control patients showed no significant differences in demographics, length of stay, and level of comorbidities. Only half of index patients achieved a medical emergency alert threshold score. On average, index patients triggered alerts 20.06 (22.67) hours preceding the SAE and alerted 2.25 (3.87) times over 72 h. The AUROC ranged from 0.628 to 0.747, with a single-parameter EWS having the lowest AUROC and an aggregated weighted EWS, the highest. The sensitivity of the EWS ranges from 0.359 to 0.692. The specificity was greater than 0.9 for all the EWSs tested. CONCLUSIONS Based on the EWS sensitivity and AUROC, there is a lack of conclusive evidence of the efficacy of the 12 EWSs tested. However, because the adoption of the EWS in Australian hospitals is mandatory, the implementation of an aggregated weighted EWS, such as Compass, should be considered in subcritical regional private hospitals. Given that only half of SAE achieved an EWS medical alert threshold score, it is important that good clinical judgement be used with EWS.
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Affiliation(s)
| | - Trudy Dwyer
- CQUniversity Australia, Building 18/G.06 Rockhampton, Bruce Highway, Rockhampton Qld, 4702 Australia.
| | - Matthew Browne
- CQUniversity Australia, University Drive, Building 8/G.47 Bundaberg, Branyan Australia, Qld, 4670, Australia.
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108
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Metcalfe D, Castillo-Angeles M, Rios-Diaz AJ, Havens JM, Haider A, Salim A. Is there a "weekend effect" in emergency general surgery? J Surg Res 2019; 222:219-224. [PMID: 29273370 DOI: 10.1016/j.jss.2017.10.019] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 09/25/2017] [Accepted: 10/12/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Weekend admission is associated with increased mortality across a range of patient populations and health-care systems. The aim of this study was to determine whether weekend admission is independently associated with serious adverse events (SAEs), in-hospital mortality, or failure to rescue (FTR) in emergency general surgery (EGS). METHODS An observational study was performed using the National Inpatient Sample in 2012-2013; the largest all-payer inpatient database in the United States, which represents a 20% stratified sample of hospital discharges. The inclusion criteria were all inpatients with a primary EGS diagnosis. Outcomes were SAE, in-hospital mortality, and FTR (in-hospital mortality in the population of patients that developed an SAE). Multivariable logistic regression were used to adjust for patient- (age, sex, race, payer status, and Charlson comorbidity index) and hospital-level (trauma designation and hospital bed size) characteristics. RESULTS There were 1,344,828 individual patient records (6.7 million weighted admissions). The overall rate of SAE was 15.1% (15.1% weekend, 14.9% weekday, P < 0.001), FTR 5.9% (6.2% weekend, 5.9% weekday, P = 0.010), and in-hospital mortality 1.4% (1.5% weekend, 1.3% weekday, P < 0.001). Within logistic regression models, weekend admission was an independent risk factor for development of SAE (adjusted odds ratio 1.08, 1.07-1.09), FTR (1.05, 1.01-1.10), and in-hospital mortality (1.14, 1.10-1.18). CONCLUSIONS This study found evidence that outcomes coded in an administrative data set are marginally worse for EGS patients admitted at weekends. This justifies further work using clinical data sets that can be used to better control for differences in case mix.
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Affiliation(s)
- David Metcalfe
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom.
| | - Manuel Castillo-Angeles
- Center for Surgery and Public Health (CSPH), Brigham & Women's Hospital, One Brigham Circle, Boston, Massachusetts
| | - Arturo J Rios-Diaz
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Joaquim M Havens
- Center for Surgery and Public Health (CSPH), Brigham & Women's Hospital, One Brigham Circle, Boston, Massachusetts; Division of Trauma, Burn, and Surgical Critical Care, Brigham & Women's Hospital, Boston, Massachusetts
| | - Adil Haider
- Center for Surgery and Public Health (CSPH), Brigham & Women's Hospital, One Brigham Circle, Boston, Massachusetts; Division of Trauma, Burn, and Surgical Critical Care, Brigham & Women's Hospital, Boston, Massachusetts
| | - Ali Salim
- Center for Surgery and Public Health (CSPH), Brigham & Women's Hospital, One Brigham Circle, Boston, Massachusetts; Division of Trauma, Burn, and Surgical Critical Care, Brigham & Women's Hospital, Boston, Massachusetts
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Institution-wide Implementation Strategies, Finance, and Administration for Enhanced Recovery After Surgery Programs. Int Anesthesiol Clin 2019; 55:90-100. [PMID: 28901984 DOI: 10.1097/aia.0000000000000158] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Failure-to-Rescue Following Cytoreductive Surgery with or Without HIPEC is Determined by the Type of Complication-a Retrospective Study by INDEPSO. Indian J Surg Oncol 2019; 10:71-79. [PMID: 30886497 DOI: 10.1007/s13193-019-00877-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 01/08/2019] [Indexed: 02/07/2023] Open
Abstract
To determine factors influencing failure-to-rescue in patients with complications following cytoreductive surgery and HIPEC. A retrospective analysis of patients enrolled in the Indian HIPEC registry was performed. Complications were graded according to the CTCAE classification version 4.3. The 30- and 90-day morbidity were both recorded. Three hundred seventy-eight patients undergoing CRS with/without HIPEC for peritoneal metastases from various primary sites, between January 2013 and December 2017 were included. The median PCI was 11 [range 0-39] and a CC-0/1 resection was achieved in 353 (93.5%). Grade 3-4 morbidity was seen 95 (25.1%) at 30 days and 122 (32.5%) at 90 days. The most common complications were pulmonary complications (6.8%), neutropenia (3.7%), systemic sepsis (3.4%), anastomotic leaks (1.5%), and spontaneous bowel perforations (1.3%). Twenty-five (6.6%) patients died within 90 days of surgery due to complications. The failure-to-rescue rate was 20.4%. Pulmonary complications (p = 0.03), systemic sepsis (p < 0.001), spontaneous bowel perforations (p < 0.001) and PCI > 20 (p = 0.002) increased the risk of failure-to-rescue. The independent predictors were spontaneous bowel perforation (p = 0.05) and systemic sepsis (p = 0.001) and PCI > 20 (p = 0.02). The primary tumor site did not have an impact on the FTR rate (p = 0.09) or on the grade 3-4 morbidity (p = 0.08). Nearly one-fifth of the patients who developed complications succumbed to them. Systemic sepsis, spontaneous bowel perforations, and pulmonary complications increased the risk of FTR and multidisciplinary teams should develop protocols to prevent, identify, and effectively treat such complications. All surgeons pursuing this specialty should perform a regular audit of their results, irrespective of their experience.
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111
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Failure to Rescue After Emergency General Surgery in Geriatric Patients: Does Frailty Matter? J Surg Res 2019; 233:397-402. [DOI: 10.1016/j.jss.2018.08.033] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 07/12/2018] [Accepted: 08/18/2018] [Indexed: 01/07/2023]
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Foley C, Dowling M. How do nurses use the early warning score in their practice? A case study from an acute medical unit. J Clin Nurs 2018; 28:1183-1192. [PMID: 30428133 DOI: 10.1111/jocn.14713] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 10/04/2018] [Accepted: 11/03/2018] [Indexed: 12/26/2022]
Abstract
AIMS AND OBJECTIVES This study aimed to describe how nurses use the early warning score (EWS) in an acute medical ward and their compliance with the EWS and explore their views and experiences of the EWS. BACKGROUND early warning score systems have been implemented in response to upward trends in mortality rates. Nurses play a central role in the use of EWS systems. However, barriers to their use have been identified and include behavioural, cultural and organisational approaches to adherence. Improvement strategies including education and training and electronic devices have assisted in compliance with the system. DESIGN A holistic single descriptive case study design was used. METHODS Data triangulation was used including non-participant observation, semi-structured interviews with nurses and document analysis. Nurses were observed using EWS and were subsequently interviewed. Data analysis was guided by systematic text condensation (STC), an approach underpinned by Giorgi's phenomenological method, where meaning units and themes are identified. The study adhered to the consolidated criteria for reporting qualitative research (COREQ) guidelines. RESULTS Three themes with associated meaning units were found. Protocol Adherence vs. Clinical Judgement addresses nurses' knowledge, skill and experience and patient assessment. Parameter Adjustment and Escalation included parameters not being adjusted or reviewed, junior doctors not being authorised to set parameters and escalation. The final theme Culture highlighted a task-driven approach and deficient communication processes. CONCLUSION This study highlights the need for ongoing training, behavioural change and a cultural shift by healthcare professionals and organisations to ensure adherence with EWS escalation protocols. RELEVANCE TO CLINICAL PRACTICE Improvements in education and training into recognition, management and communication of a deteriorating patient are required. Also, a cultural shift is needed to improve compliance and adherence with EWS practice. The potential use of electronic data should be explored.
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Affiliation(s)
- Claire Foley
- Nurse Practice Development, Midland Regional Hospital, Tullamore, Co. Offaly, Ireland
| | - Maura Dowling
- School of Nursing and Midwifery, National University of Ireland, Galway, Ireland
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Ahmad T, Bouwman RA, Grigoras I, Aldecoa C, Hofer C, Hoeft A, Holt P, Fleisher LA, Buhre W, Pearse RM. Use of failure-to-rescue to identify international variation in postoperative care in low-, middle- and high-income countries: a 7-day cohort study of elective surgery. Br J Anaesth 2018; 119:258-266. [PMID: 28854536 DOI: 10.1093/bja/aex185] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2017] [Indexed: 01/22/2023] Open
Abstract
Background The incidence and impact of postoperative complications are poorly described. Failure-to-rescue, the rate of death following complications, is an important quality measure for perioperative care but has not been investigated across multiple health care systems. Methods We analysed data collected during the International Surgical Outcomes Study, an international 7-day cohort study of adults undergoing elective inpatient surgery. Hospitals were ranked by quintiles according to surgical procedural volume (Q1 lowest to Q5 highest). For each quintile we assessed in-hospital complications rates, mortality, and failure-to-rescue. We repeated this analysis ranking hospitals by risk-adjusted complication rates (Q1 lowest to Q5 highest). Results A total of 44 814 patients from 474 hospitals in 27 low-, middle-, and high-income countries were available for analysis. Of these, 7508 (17%) developed one or more postoperative complication, with 207 deaths in hospital (0.5%), giving an overall failure-to-rescue rate of 2.8%. When hospitals were ranked in quintiles by procedural volume, we identified a three-fold variation in mortality (Q1: 0.6% vs Q5: 0.2%) and a two-fold variation in failure-to-rescue (Q1: 3.6% vs Q5: 1.7%). Ranking hospitals in quintiles by risk-adjusted complication rate further confirmed the presence of important variations in failure-to-rescue, indicating differences between hospitals in the risk of death among patients after they develop complications. Conclusions Comparison of failure-to-rescue rates across health care systems suggests the presence of preventable postoperative deaths. Using such metrics, developing nations could benefit from a data-driven approach to quality improvement, which has proved effective in high-income countries.
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Affiliation(s)
- T Ahmad
- Queen Mary University of London, London EC1M 6BQ, UK
| | - R A Bouwman
- Catharina Ziekenhuis, Eindhoven, The Netherlands
| | - I Grigoras
- Regional Institute of Oncology, 'Grigore T. Popa' University of Medicine and Pharmacy, Iasi, Romania
| | - C Aldecoa
- Hospital Universitario Rio Hortega, Valladolid, Spain
| | - C Hofer
- Triemli City Hospital, Zurich, Switzerland
| | - A Hoeft
- University Hospital of Bonn, 53105, Bonn, Germany
| | - P Holt
- St Georges University of London, London SW17 0RE, UK
| | - L A Fleisher
- University of Pennsylvania, Philadelphia, PA, USA
| | - W Buhre
- Maastricht University Medical Centre, Maastricht, The Netherlands
| | - R M Pearse
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London EC1M 6BQ, UK
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van Groningen JT, Eddes EH, Fabry HFJ, van Tilburg MWA, van Nieuwenhoven EJ, Snel Y, Marang-van de Mheen PJ, de Noo ME. Hospital Teaching Status and Patients' Outcomes After Colon Cancer Surgery. World J Surg 2018; 42:3372-3380. [PMID: 29572565 PMCID: PMC6132859 DOI: 10.1007/s00268-018-4580-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Background and objectives It is increasingly accepted that quality of colon cancer surgery might be secured by combining volume standards with audit implementation. However, debate remains about other structural factors also influencing this quality, such as hospital teaching status. This study evaluates short-term outcomes after colon cancer surgery of patients treated in general, teaching or academic hospitals. Methods All patients (n = 23,593) registered in the Dutch Colorectal Audit undergoing colon cancer surgery between 2011 and 2014 were included. Patients were divided into groups based on teaching status of their hospital. Main outcome measures were serious complications, failure to rescue (FTR) and 30-day or in-hospital mortality. Multivariate logistic regression models on these outcome measures and with hospital teaching status as primary determinant were used, adjusted for case-mix, year of surgery and hospital volume. Results Patients treated in teaching and academic hospitals showed higher adjusted serious complication rates, compared to patients treated in general hospitals (odds ratio 1.25 95% CI [1.11–1.39] and OR 1.23 [1.05–1.46]). However, patients treated in teaching hospitals had lower adjusted FTR rates than patients treated in general hospitals (OR 0.63 [0.44–0.89]). However, for all outcomes there was considerable between-hospitals variation within each type of teaching status. Conclusion On average, patients treated in general hospitals had lower serious complication rates, but patients treated in teaching hospitals had more favorable FTR rates. Given the hospital variation within each hospital teaching type, it is possible to deliver excellent care regardless of the hospital teaching type.
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Affiliation(s)
- Julia T van Groningen
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands.
| | - Eric H Eddes
- Department of Surgery, Deventer Hospital, Deventer, The Netherlands
| | - Hans F J Fabry
- Department of Surgery, Bravis Hospital, Roosendaal/Bergen op Zoom, The Netherlands
| | | | | | - Yvonne Snel
- Co-operating General Hospitals, Leiden, The Netherlands
| | | | - Mirre E de Noo
- Department of Surgery, Deventer Hospital, Deventer, The Netherlands
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115
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Williams LMS, Johnson E, Armaignac DL, Nemeth LS, Magwood GS. A Mixed Methods Study of Tele-ICU Nursing Interventions to Prevent Failure to Rescue of Patients in Critical Care. Telemed J E Health 2018; 25:369-379. [PMID: 30036175 DOI: 10.1089/tmj.2018.0086] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Background: Failure to rescue (FTR) is a benchmark of quality care. Limited evidence exists examining the influence of telemedicine intensive care units (tele-ICU) nursing interventions in preventing FTR. The purpose of this study was to characterize tele-ICU nursing interventions and to determine which combination of documented tele-ICU nursing interventions (DTNI) best predicts prevention of FTR in ICU patients with hospital-acquired conditions (HACs). Materials and Methods: We used convergent parallel mixed methods design to conduct qualitative interviews with a purposive sample of tele-ICU nurses (n = 19) from 11 US tele-ICU centers. Quantitative data, including demographics, DTNIs, severity of illness scores, and video assessment times from January 2016 to December 2016 were retrieved for ICU patients discharged from a multihospital health system with a tele-ICU center (n = 861). Findings from both qualitative and quantitative analyses were merged, compared, and contrasted. Results: FTR patients had higher severity of illness, longer video assessment by tele-ICU nurses, and were more likely to have DTNIs related to hemodynamic instability. Four themes emerged from qualitative analysis: fundamental tele-ICU nurse attributes, proactive clinical practice, effective collaborative relationships, and strategic use of advanced technology. Mixed methods analysis revealed convergence between DTNIs and tele-ICU nurses' characterizations of their practice. Conclusions: Tele-ICU nurses' characterizations of their practice closely align with DTNIs. Tele-ICU nursing practice to prevent FTR involves systems thinking and integration of many complex factors. Tele-ICU nurses can reduce the odds of FTR with focus on support and clinical coordination interventions that avoid hemodynamic instability in ICU patients with a diagnosed HAC.
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Affiliation(s)
- Lisa-Mae S Williams
- 1 Telehealth and eICU, Baptist Health South Florida Telehealth Center, Coral Gables, Florida
| | - Emily Johnson
- 2 College of Nursing, Medical University South Carolina, Charleston, South Carolina
| | - Donna Lee Armaignac
- 1 Telehealth and eICU, Baptist Health South Florida Telehealth Center, Coral Gables, Florida
| | - Lynne S Nemeth
- 2 College of Nursing, Medical University South Carolina, Charleston, South Carolina
| | - Gayenell S Magwood
- 2 College of Nursing, Medical University South Carolina, Charleston, South Carolina
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116
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Failure to rescue and disparities in emergency general surgery. J Surg Res 2018; 231:62-68. [DOI: 10.1016/j.jss.2018.04.047] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Revised: 03/13/2018] [Accepted: 04/18/2018] [Indexed: 11/22/2022]
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117
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Smit-Fun VM, de Korte-de Boer D, Posthuma LM, Stolze A, Dirksen CD, Hollmann MW, Buhre WF, Boer C. TRACE (Routine posTsuRgical Anesthesia visit to improve patient outComE): a prospective, multicenter, stepped-wedge, cluster-randomized interventional study. Trials 2018; 19:586. [PMID: 30367680 PMCID: PMC6204052 DOI: 10.1186/s13063-018-2952-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 09/28/2018] [Indexed: 11/22/2022] Open
Abstract
Background Perioperative complications occur in 30–40% of non-cardiac surgical patients and are the leading cause of early postoperative morbidity and mortality. Regular visits by trained health professionals may decrease the incidence of complications and mortality through earlier detection and adequate treatment of complications. Until now, no studies have been performed on the impact of routine postsurgical anesthesia visits on the incidence of postoperative complications and mortality. Methods TRACE is a prospective, multicenter, stepped-wedge cluster randomized interventional study in academic and peripheral hospitals in the Netherlands. All hospitals start simultaneously with a control phase in which standard care is provided. Sequentially, in a randomized order, hospitals cross over to the intervention phase in which patients at risk are routinely followed up by an anesthesia professional at postoperative days 1 and 3, aiming to detect and prevent or treat postoperative complications. We aim to include 5600 adult patients who are at high risk of developing complications. The primary outcome variable is 30-day postoperative mortality. Secondary outcomes include incidence of postoperative complications and postoperative quality of life up to one year following surgery. Statistical analyses will be performed to compare the control and intervention cohorts with multilevel linear and logistic regression models, adjusted for temporal trends and for clusters (hospitals). The time horizon of the economic (cost-effectiveness) evaluation will be 30 days and one year following surgery. Discussion TRACE is the first to study the effects of a routine postoperative visit by an anesthesia healthcare professional on mortality and cost-effectiveness of surgical patients. If the intervention proves to be beneficial for the patient and cost-effective, the stepped-wedge design ensures direct implementation in the participating hospitals. Trial registration Nederlands Trial Register/Netherlands Trial Registration, NTR5506. Registered on 02 December 2015.
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Affiliation(s)
- Valérie M Smit-Fun
- Department of Anaesthesiology & Pain Medicine, Maastricht University Medical Centre +, P. Debeyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - Dianne de Korte-de Boer
- Department of Anaesthesiology & Pain Medicine, Maastricht University Medical Centre +, P. Debeyelaan 25, 6229 HX, Maastricht, The Netherlands.
| | - Linda M Posthuma
- Department of Anaesthesiology, Academic Medical Centre Amsterdam, Meibergdreef 9 H1Z-132, 1105 AZ, Amsterdam, The Netherlands
| | - Annick Stolze
- Department of Anesthesiology, VU University Medical Centre, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Carmen D Dirksen
- Department of Clinical Epidemiology and Medical Technology, Maastricht University Medical Centre+, Maastricht, The Netherlands.,Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Markus W Hollmann
- Department of Anaesthesiology, Academic Medical Centre Amsterdam, Meibergdreef 9 H1Z-132, 1105 AZ, Amsterdam, The Netherlands
| | - Wolfgang F Buhre
- Department of Anaesthesiology & Pain Medicine, Maastricht University Medical Centre +, P. Debeyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - Christa Boer
- Department of Anesthesiology, VU University Medical Centre, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
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Stahlschmidt A, Novelo B, Alexi Freitas L, Cavalcante Passos S, Dussán-Sarria JA, Félix EA, Wajnberg Gamermann P, Caumo W, Cadore Stefani LP. Predictors of in-hospital mortality in patients undergoing elective surgery in a university hospital: a prospective cohort. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2018. [PMID: 29776670 PMCID: PMC9391804 DOI: 10.1016/j.bjane.2018.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Introduction Morbidity and mortality associated with urgent or emergency surgeries are high compared to elective procedures. Perioperative risk scores identify the non-elective character as an independent factor of complications and death. The present study aims to characterize the population undergoing non-elective surgeries at the Hospital de Clínicas de Porto Alegre and identify the clinical and surgical factors associated with death within 30 days postoperatively. Methodology A prospective cohort study of 187 patients undergoing elective surgeries between April and May 2014 at the Hospital de Clínicas, Porto Alegre. Patient-related data, pre-operative risk situations, and surgical information were evaluated. Death in 30 days was the primary outcome measured. Results The mean age of the sample was 48.5 years, and 84.4% of the subjects had comorbidities. The primary endpoint was observed in 14.4% of the cases, with exploratory laparotomy being the procedure with the highest mortality (47.7%). After multivariate logistic regression, age (odds ratio [OR] 1.0360, p < 0.05), anemia (OR 3.961, p < 0.05), acute or chronic renal insufficiency (OR 6.075, p < 0.05), sepsis (OR 7.027, p < 0.05), and patient-related risk factors for mortality, in addition to the large surgery category (OR 7.502, p < 0.05) were identified. Conclusion The high mortality rate found may reflect the high complexity of the institution's patients. Knowing the profile of the patients assisted helps in the definition of management priorities, suggesting the need to create specific care lines for groups identified as high risk in order to reduce perioperative complications and deaths.
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Affiliation(s)
| | - Betânia Novelo
- Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brasil
| | | | | | | | | | | | - Wolnei Caumo
- Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brasil
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119
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van Rijssen LB, Zwart MJ, van Dieren S, de Rooij T, Bonsing BA, Bosscha K, van Dam RM, van Eijck CH, Gerhards MF, Gerritsen JJ, van der Harst E, de Hingh IH, de Jong KP, Kazemier G, Klaase J, van der Kolk BM, van Laarhoven CJ, Luyer MD, Molenaar IQ, Patijn GA, Rupert CG, Scheepers JJ, van der Schelling GP, Vahrmeijer AL, Busch ORC, van Santvoort HC, Groot Koerkamp B, Besselink MG, Festen S, Karsten TM, Coene PP. Variation in hospital mortality after pancreatoduodenectomy is related to failure to rescue rather than major complications: a nationwide audit. HPB (Oxford) 2018; 20:759-767. [PMID: 29571615 DOI: 10.1016/j.hpb.2018.02.640] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 01/22/2018] [Accepted: 02/15/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND In the mandatory nationwide Dutch Pancreatic Cancer Audit, rates of major complications and Failure to Rescue (FTR) after pancreatoduodenectomy between low- and high-mortality hospitals are compared, and independent predictors for FTR investigated. METHODS Patients undergoing pancreatoduodenectomy in 2014 and 2015 in The Netherlands were included. Hospitals were divided into quartiles based on mortality rates. The rate of major complications (Clavien-Dindo ≥3) and death after a major complication (FTR) were compared between these quartiles. Independent predictors for FTR were identified by multivariable logistic regression analysis. RESULTS Out of 1.342 patients, 391 (29%) developed a major complication and in-hospital mortality was 4.2%. FTR occurred in 56 (14.3%) patients. Mortality was 0.9% in the first hospital quartile (4 hospitals, 327 patients) and 8.1% in the fourth quartile (5 hospitals, 310 patients). The rate of major complications increased by 40% (25.7% vs 35.2%) between the first and fourth hospital quartile, whereas the FTR rate increased by 560% (3.6% vs 22.9%). Independent predictors of FTR were male sex (OR = 2.1, 95%CI 1.2-3.9), age >75 years (OR = 4.3, 1.8-10.2), BMI ≥30 (OR = 2.9, 1.3-6.6), histopathological diagnosis of periampullary cancer (OR = 2.0, 1.1-3.7), and hospital volume <30 (OR = 3.9, 1.6-9.6). CONCLUSIONS Variations in mortality between hospitals after pancreatoduodenectomy were explained mainly by differences in FTR, rather than the incidence of major complications.
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Affiliation(s)
- Lennart B van Rijssen
- Department of Surgery, Cancer Center Amsterdam, Academic Medical Center, Amsterdam, The Netherlands
| | - Maurice J Zwart
- Department of Surgery, Cancer Center Amsterdam, Academic Medical Center, Amsterdam, The Netherlands
| | - Susan van Dieren
- Clinical Research Unit, Academic Medical Center, Amsterdam, The Netherlands
| | - Thijs de Rooij
- Department of Surgery, Cancer Center Amsterdam, Academic Medical Center, Amsterdam, The Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital, 's Hertogenbosch, The Netherlands
| | - Ronald M van Dam
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Casper H van Eijck
- Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Michael F Gerhards
- Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | | | | | - Ignace H de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Koert P de Jong
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Geert Kazemier
- Department of Surgery, VU University Medical Center, Amsterdam, The Netherlands
| | - Joost Klaase
- Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | | | | | - Misha D Luyer
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Isaac Q Molenaar
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gijs A Patijn
- Department of Surgery, Isala Clinics, Zwolle, The Netherlands
| | - Coen G Rupert
- Department of Surgery, Tjongerschans Hospital, Heerenveen, The Netherlands
| | - Joris J Scheepers
- Department of Surgery, Reinier de Graaf Gasthuis, Delft, The Netherlands
| | | | | | - Olivier R C Busch
- Department of Surgery, Cancer Center Amsterdam, Academic Medical Center, Amsterdam, The Netherlands
| | | | - Bas Groot Koerkamp
- Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Academic Medical Center, Amsterdam, The Netherlands.
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120
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Gribben JL, Ilonzo N, Neifert S, Michael Leitman I. Predictors of Reoperation and Failure to Rescue in Bariatric Surgery. JSLS 2018; 22:JSLS.2017.00074. [PMID: 29472758 PMCID: PMC5814103 DOI: 10.4293/jsls.2017.00074] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background and Objectives Morbidity and mortality have been shown to increase several-fold in patients who have undergone bariatric surgery and returned to the operating room after their initial procedures. Failure-to-rescue (FTR) analyses allow for an understanding of patient management and outcomes that is more distinguished than assessments of adverse occurrences and mortality rates alone. The objective of this study was to assess failure to rescue (FTR) and the characteristics and outcomes of patients undergoing reoperation after laparoscopic gastric bypass (LGBP) and laparoscopic sleeve gastrectomy (LSG). Methods The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) participant data files were accessed to identify patients >18 years of age who underwent LGBP and LSG from 2011 through 2015. Patients were further classified into 3-day reoperation and nonreoperation cohorts. Patient demographics, comorbidities, and baseline health characteristics were collected. Pertinent outcomes, complications, and FTR were analyzed. Results A total of 96,538 patients were included. Of those, 1,850 (1.92%) returned to the operating room, and 94,688 (98.08%) did not. Patients who underwent reoperation had a greater likelihood of having any complication (72.20% vs. 51.29%; P < .0001) and had a higher overall mortality rate (1.46% vs. 0.10%, P < .0001). The FTR rates were 2.01% in the reoperation group and 0.14% in the nonreoperation group (P < .0001). Conclusion Patients who undergo LGBP and LSG and have reoperations are at higher risk of developing complications with subsequent mortality.
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Affiliation(s)
- Jeanie L Gribben
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Nicole Ilonzo
- Department of Surgery, Mount Sinai St. Luke's, New York, New York, USA
| | - Sean Neifert
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - I Michael Leitman
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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121
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Mosquera C, Bermudez JM, Evans JL, Spaniolas K, MacGillivary DC, Fitzgerald TL. Frailty Predicts Failure to Rescue after Thoracoabdominal Operation. J Am Coll Surg 2018; 226:978-986. [DOI: 10.1016/j.jamcollsurg.2017.12.055] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 12/07/2017] [Accepted: 12/07/2017] [Indexed: 01/29/2023]
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122
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Stahlschmidt A, Novelo B, Alexi Freitas L, Cavalcante Passos S, Dussán-Sarria JA, Félix EA, Wajnberg Gamermann P, Caumo W, Cadore Stefani LP. [Predictors of in-hospital mortality in patients undergoing elective surgery in a university hospital: a prospective cohort]. Rev Bras Anestesiol 2018; 68:492-498. [PMID: 29776670 DOI: 10.1016/j.bjan.2018.04.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 03/26/2018] [Accepted: 04/06/2018] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION Morbidity and mortality associated with urgent or emergency surgeries are high compared to elective procedures. Perioperative risk scores identify the non-elective character as an independent factor of complications and death. The present study aims to characterize the population undergoing non-elective surgeries at the Hospital de Clínicas de Porto Alegre and identify the clinical and surgical factors associated with death within 30 days postoperatively. METHODOLOGY A prospective cohort study of 187 patients undergoing elective surgeries between April and May 2014 at the Hospital de Clínicas, Porto Alegre. Patient-related data, pre-operative risk situations, and surgical information were evaluated. Death in 30 days was the primary outcome measured. RESULTS The mean age of the sample was 48.5 years, and 84.4% of the subjects had comorbidities. The primary endpoint was observed in 14.4% of the cases, with exploratory laparotomy being the procedure with the highest mortality (47.7%). After multivariate logistic regression, age (odds ratio [OR] 1.0360, p <0.05), anemia (OR 3.961, p <0.05), acute or chronic renal insufficiency (OR 6.075, p <0.05), sepsis (OR 7.027, p <0.05), and patient-related risk factors for mortality, in addition to the large surgery category (OR 7.502, p <0.05) were identified. CONCLUSION The high mortality rate found may reflect the high complexity of the institution's patients. Knowing the profile of the patients assisted helps in the definition of management priorities, suggesting the need to create specific care lines for groups identified as high risk in order to reduce perioperative complications and deaths.
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Affiliation(s)
| | - Betânia Novelo
- Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brasil
| | | | | | | | | | | | - Wolnei Caumo
- Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brasil
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123
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Shah R, Attwood K, Arya S, Hall DE, Johanning JM, Gabriel E, Visioni A, Nurkin S, Kukar M, Hochwald S, Massarweh NN. Association of Frailty With Failure to Rescue After Low-Risk and High-Risk Inpatient Surgery. JAMA Surg 2018; 153:e180214. [PMID: 29562073 DOI: 10.1001/jamasurg.2018.0214] [Citation(s) in RCA: 110] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Importance Failure to rescue (FTR), or death after a potentially preventable complication, is a nationally endorsed, publicly reported quality measure. However, little is known about the impact of frailty on FTR, in particular after low-risk surgical procedures. Objective To assess the association of frailty with FTR in patients undergoing inpatient surgery. Design, Setting, and Participants This study assessed a cohort of 984 550 patients undergoing inpatient general, vascular, thoracic, cardiac, and orthopedic surgery in the National Surgical Quality Improvement Program between January 1, 2005, and December 31, 2012. Frailty was assessed using the Risk Analysis Index (RAI), and patients were stratified into 5 groups (RAI score, ≤10, 11-20, 21-30, 31-40, and >40). Procedures were categorized as low mortality risk (≤1%) or high mortality risk (>1%). The association between RAI scores, the number of postoperative complications (0, 1, 2, or 3 or more), and FTR was evaluated using hierarchical modeling. Main Outcomes and Measures The number of postoperative complications and inpatient FTR. Results A total of 984 550 patients were included, with a mean (SD) age of 58.2 (17.1) years; women were 549 281 (55.8%) of the cohort. For patients with RAI scores of 10 or less, major complication rates after low-risk surgery were 3.2%; rates of those with RAI scores of 11 to 20, 21 to 30, 31 to 40, and more than 40 were 8.6%, 13.5%, 23.8%, and 36.4%, respectively. After high-risk surgery, these rates were 13.5% for those with scores of 10 or less, 23.7% for those with scores of 11 to 20, 31.1% for those with scores of 21 to 30, 42.5% for those with scores of 31 to 40, and 54.4% for those with scores of more than 40. Stratifying by the number of complications, significant increases in FTR were observed across RAI categories after both low-risk and high-risk procedures. After a low-risk procedure, odds of FTR after 1 major complication for patients with RAI scores of 11 to 20 increased 5-fold over those with RAI scores of 10 or less (odds ratio [OR], 5.3; 95% CI, 3.9-7.1). Odds ratios were 8.1 (95% CI, 5.6-11.7) for patients with RAI scores of 21 to 30; 22.3 (95% CI, 13.9-35.6) for patients with scores of 31 to 40; and 43.9 (95% CI, 19-101.1) for patients with scores of more than 40. For patients undergoing a high-risk procedure, the corresponding ORs were likewise consistently elevated (RAI score 11-20: OR, 2.5; 95% CI, 2.3-2.7; vs RAI score 21-30: 5.1; 95% CI, 4.6-5.5; vs RAI score 31-40: 8.9; 95% CI, 8.1-9.9; vs RAI score >40: 18.4; 95% CI, 15.7-21.4). Conclusions and Relevance Frailty has a dose-response association with complications and FTR, which is apparent after low-risk and high-risk inpatient surgery. Systematic assessment of frailty in preoperative patients may help refine estimates of surgical risk that could identify patients who might benefit from perioperative interventions designed to enhance physiologic reserve and potentially mitigate aspects of procedural risk, and would provide a framework for shared decision-making regarding the value of a given surgical procedure.
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Affiliation(s)
- Rupen Shah
- Department of Surgery, Henry Ford Health System, Detroit, Michigan.,Department of Surgical Oncology, Roswell Park Cancer Institute, Buffalo, New York
| | - Kristopher Attwood
- Department of Biostatistics, Roswell Park Cancer Institute, Buffalo, New York
| | - Shipra Arya
- Division of Vascular and Endovascular Therapy, Department of Surgery, Emory University, Atlanta, Georgia.,Surgical Service Line, Atlanta VA Medical Center, Decatur, Georgia
| | - Daniel E Hall
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Department of Surgery, University of Pittsburgh, Pittsburgh
| | | | - Emmanuel Gabriel
- Department of Surgical Oncology, Roswell Park Cancer Institute, Buffalo, New York
| | - Anthony Visioni
- Department of Surgical Oncology, Roswell Park Cancer Institute, Buffalo, New York
| | - Steven Nurkin
- Department of Surgical Oncology, Roswell Park Cancer Institute, Buffalo, New York
| | - Moshim Kukar
- Department of Surgical Oncology, Roswell Park Cancer Institute, Buffalo, New York
| | - Steven Hochwald
- Department of Surgical Oncology, Roswell Park Cancer Institute, Buffalo, New York
| | - Nader N Massarweh
- VA Health Services Research and Development Service, Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey VA Medical Center, Houston, Texas.,Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
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Columbus AB, Castillo-Angeles M, Berry WR, Haider AH, Salim A, Havens JM. An evidence-based intraoperative communication tool for emergency general surgery: a pilot study. J Surg Res 2018; 228:281-289. [PMID: 29907223 DOI: 10.1016/j.jss.2018.03.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 01/29/2018] [Accepted: 03/06/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Emergency general surgery (EGS) is characterized by high rates of morbidity and mortality. Though checklists and associated communication-based huddle strategies have improved outcomes, these tools have never been specifically examined in EGS. We hypothesized that use of an evidence-based communication tool aimed to trigger intraoperative discussion could improve communication in the EGS operating room (OR). MATERIALS AND METHODS We designed a set of discussion prompts based on modifiable factors identified from previously published studies aimed to encourage all team members to speak up and to centralize awareness of patient disposition and intraoperative transfusion practices. This tool was pilot-tested using OR human patient simulators and was then rolled out to EGS ORs at an academic medical center. The perceived effect of our tool's implementation was evaluated through mixed-methodologic presurvey and postsurvey analysis. RESULTS Preimplementation and postimplementation survey-based data revealed that providers reported the EGS-focused discussion prompts as improving team communication in EGS. A trend toward shared awareness of intraoperative events was observed; however, nurses described cultural impedance of discussion initiation. Providers described a need for further reinforcement of the tool and its indications during implementation. CONCLUSIONS Use of a discussion-based communication tool is perceived as supporting team communication in the EGS OR and led to a trend toward improving a shared understanding of intraoperative events. Analyses suggest the need for enhanced reinforcement of use during implementation and improvement of team-based education regarding EGS. Furthermore work is needed to understand the full impact of this evidence-based tool on OR team dynamics and EGS patient outcomes.
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Affiliation(s)
- Alexandra B Columbus
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.
| | - Manuel Castillo-Angeles
- Brigham and Women's Hospital, Division of Trauma, Burns and Surgical Critical Care, Boston, Massachusetts
| | | | - Adil H Haider
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Ali Salim
- Brigham and Women's Hospital, Division of Trauma, Burns and Surgical Critical Care, Boston, Massachusetts
| | - Joaquim M Havens
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts; Brigham and Women's Hospital, Division of Trauma, Burns and Surgical Critical Care, Boston, Massachusetts; Ariadne Labs, Boston, Massachusetts
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Surgical Rescue in Medical Patients: The Role of Acute Care Surgeons as the Surgical Rapid Response Team. Crit Care Clin 2018; 34:209-219. [PMID: 29482901 DOI: 10.1016/j.ccc.2017.12.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Failure to rescue is death occurring after a complication. Rapid response teams developed as a prompt intervention for patients with early clinical deterioration, generally from medical conditions or complications. Patients with surgical complications or surgical pathology require prompt evaluation and management by surgeons to avoid deterioration; this is surgical rescue. Patients in the medical intensive care unit may develop intra-abdominal pathology that requires expeditious operative intervention. Acute care surgeons should serve as the surgical rapid response team to help assess and manage these complex patients. Collaboration between intensivists and surgeons is essential to rescue patients from complications and surgical disease.
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Briggs A, Peitzman AB, Sperry JL. Rescue in Acute Care Surgery: Evolving Definitions and Metrics. CURRENT SURGERY REPORTS 2018. [DOI: 10.1007/s40137-018-0199-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Rihari-Thomas J, Newton PJ, Sibbritt D, Davidson PM. Rapid response systems: where we have come from and where we need to go? J Nurs Manag 2018; 26:1-2. [PMID: 29314413 DOI: 10.1111/jonm.12533] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/25/2017] [Indexed: 12/01/2022]
Affiliation(s)
- John Rihari-Thomas
- Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Phillip J Newton
- Centre for Cardiovascular and Chronic Care, University of Technology Sydney, Sydney, NSW, Australia
| | - David Sibbritt
- Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
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McSherry R, Pearce P. Measuring health care workers' perceptions of what constitutes a compassionate organisation culture and working environment: Findings from a quantitative feasibility survey. J Nurs Manag 2017; 26:127-139. [PMID: 29250865 DOI: 10.1111/jonm.12517] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2017] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Health care organisation cultures and working environments are highly complex, dynamic and constantly evolving settings. They significantly influence both the delivery and outcomes of care. AIM Phase 1 quantitative findings are presented from a larger three phase feasibility study designed to develop and test a Cultural Health Check toolkit to support health care workers, patients and organisations in the provision of safe, compassionate and dignified care. METHODOLOGY A mixed methods approach was applied. The Cultural Health Check Healthcare Workers Questionnaire was distributed across two National Health Service Hospitals in England, UK. Both hospitals allocated two wards comprising of older people and surgical specialities. FINDINGS The newly devised Cultural Health Check Staff Rating Scale Version 1 questionnaire was distributed to 223 health care workers. Ninety eight responses were returned giving a response rate of 44%. The Cultural Health Check Staff Rating Scale Version 1 has a significant Cronbach alpha of .775; this reliability scaling is reflected in all 16 items in the scale. Exploratory factor analysis identified two significant factors "Professional Practice and Support" and "Workforce and Service Delivery." These factors according to health care workers significantly impact on the organisation culture and quality of care delivered by staff. CONCLUSION The Cultural Health Check Staff Rating Scale Version 1 questionnaire is a newly validated measurement tool that could be used and applied to gauge health care workers perceptions of an organisations level of compassion. Historically we have focused on identifying how caring and compassionate nurses, doctors and related allied health professionals are. This turns the attention on employers of nurses and other related organisations. IMPLICATIONS FOR NURSING MANAGEMENT The questionnaire can be used to gauge the level of compassion with a health care organisation culture and working environment. Nurse managers and leaders should focus attention regarding how these two factors are supported and resourced in the future.
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Affiliation(s)
- Robert McSherry
- School of Health and Social Care, Teesside University, Middlesbrough, UK
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Palese A, Lesa L, Stroppolo G, Lupieri G, Tardivo S, Brusaferro S. Factors precipitating the risk of aspiration in hospitalized patients: findings from a multicentre critical incident technique study. Int J Qual Health Care 2017; 29:194-199. [PMID: 28035038 DOI: 10.1093/intqhc/mzw148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 12/06/2016] [Indexed: 11/13/2022] Open
Abstract
Objective To elucidate factors, other than those clinical, precipitating the risk of aspiration in hospitalized patients. Design The Critical Incident Technique was adopted for this study in 2015. Setting Three departments located in two academic hospitals in the northeast of Italy, equipped with 800 and 1500 beds, respectively. Participants A purposeful sample of 12 registered nurses (RN), all of whom (i) had reported one or more episodes of aspiration during the longitudinal survey, (ii) had worked ≥3 years in the department, and (iii) were willing to participate, were included. Main Outcome Measure(s) Antecedent factors involved in episodes of aspiration as experienced by RNs were collected through an open-ended interview, and qualitatively analysed. Results In addition to clinical factors, other factors interacting with each other may precipitate the risk of aspiration episodes during hospitalization: at the nursing care level (misclassifying patients, transferring tasks to other healthcare professionals and standardizing processes to remove potential threats); at the family level (misclassifying patients, dealing with the cultural relevance of eating) and at the environmental level (positioning the patient, managing time pressures, distracting patient while eating, dealing with food consistency and irritating oral medication). Conclusions At the hospital level, an adequate nursing workforce and models of care delivery, as well as time for initial and continuing patient and family assessment are required. At the unit level, patient-centred models of care aimed at reducing care standardization are also recommended; in addition, nursing, family and environmental factors should be recorded in the incident reports documenting episodes of aspiration.
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Affiliation(s)
- Alvisa Palese
- Department of Medical and Biological Sciences, University of Udine, Udine, Italy
| | - Lucia Lesa
- Department of Medical and Biological Sciences, University of Udine, Udine, Italy
| | - Giulia Stroppolo
- Department of Medical and Biological Sciences, University of Udine, Udine, Italy
| | - Giulia Lupieri
- Department of Medical and Biological Sciences, University of Udine, Udine, Italy
| | - Stefano Tardivo
- Department of Diagnostic and Public Health, University of Verona, Verona, Italy
| | - Silvio Brusaferro
- Department of Medical and Biological Sciences, University of Udine, Udine, Italy
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Busweiler L, Henneman D, Dikken J, Fiocco M, van Berge Henegouwen M, Wijnhoven B, van Hillegersberg R, Rosman C, Wouters M, van Sandick J, Bosscha K, Cats A, van Grieken N, Hartgrink H, Lemmens V, Nieuwenhuijzen G, Plukker J, Siersema P, Tetteroo G, Veldhuis P, Voncken F. Failure-to-rescue in patients undergoing surgery for esophageal or gastric cancer. Eur J Surg Oncol 2017; 43:1962-1969. [DOI: 10.1016/j.ejso.2017.07.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 03/10/2017] [Accepted: 07/13/2017] [Indexed: 02/07/2023] Open
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McGaughey J, O'Halloran P, Porter S, Blackwood B. Early warning systems and rapid response to the deteriorating patient in hospital: A systematic realist review. J Adv Nurs 2017; 73:2877-2891. [DOI: 10.1111/jan.13398] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2017] [Indexed: 12/01/2022]
Affiliation(s)
- Jennifer McGaughey
- School of Nursing & Midwifery; Medical Biology Centre; Queen's University Belfast; Belfast UK
| | - Peter O'Halloran
- School of Nursing & Midwifery; Queen's University of Belfast; Belfast UK
| | - Sam Porter
- Department of Social Sciences and Social Work; Bournemouth University; Poole UK
| | - Bronagh Blackwood
- School of Medicine, Dentistry & Biomedical Sciences; Centre for Experimental Medicine; Queen's University Belfast; Belfast UK
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Simulation-based Assessment of the Management of Critical Events by Board-certified Anesthesiologists. Anesthesiology 2017; 127:475-489. [DOI: 10.1097/aln.0000000000001739] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Abstract
Background
We sought to determine whether mannequin-based simulation can reliably characterize how board-certified anesthesiologists manage simulated medical emergencies. Our primary focus was to identify gaps in performance and to establish psychometric properties of the assessment methods.
Methods
A total of 263 consenting board-certified anesthesiologists participating in existing simulation-based maintenance of certification courses at one of eight simulation centers were video recorded performing simulated emergency scenarios. Each participated in two 20-min, standardized, high-fidelity simulated medical crisis scenarios, once each as primary anesthesiologist and first responder. Via a Delphi technique, an independent panel of expert anesthesiologists identified critical performance elements for each scenario. Trained, blinded anesthesiologists rated video recordings using standardized rating tools. Measures included the percentage of critical performance elements observed and holistic (one to nine ordinal scale) ratings of participant’s technical and nontechnical performance. Raters also judged whether the performance was at a level expected of a board-certified anesthesiologist.
Results
Rater reliability for most measures was good. In 284 simulated emergencies, participants were rated as successfully completing 81% (interquartile range, 75 to 90%) of the critical performance elements. The median rating of both technical and nontechnical holistic performance was five, distributed across the nine-point scale. Approximately one-quarter of participants received low holistic ratings (i.e., three or less). Higher-rated performances were associated with younger age but not with previous simulation experience or other individual characteristics. Calling for help was associated with better individual and team performance.
Conclusions
Standardized simulation-based assessment identified performance gaps informing opportunities for improvement. If a substantial proportion of experienced anesthesiologists struggle with managing medical emergencies, continuing medical education activities should be reevaluated.
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Effect of Surgeon and Hospital Volume on Emergency General Surgery Outcomes. J Am Coll Surg 2017; 225:666-675.e2. [PMID: 28838870 DOI: 10.1016/j.jamcollsurg.2017.08.009] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 08/05/2017] [Accepted: 08/07/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Emergency general surgery (EGS) contributes to half of all surgical mortality nationwide, is associated with a 50% complication rate, and has a 15% readmission rate within 30 days. We assessed associations between surgeon and hospital EGS volume with these outcomes. STUDY DESIGN Using Maryland's Health Services Cost Review Commission database, we identified nontrauma EGS procedures performed by general surgeons among patients 20 years or older, who were admitted urgently or emergently, from July 2012 to September 2014. We created surgeon and hospital volume categories, stratified EGS procedures into simple (mortality ≤ 0.5%) and complex (>0.5%) procedures, and assessed postoperative mortality, complications, and 30-day readmissions. Multivariable logistic regressions both adjusted for clinical factors and accounted for clustering by individual surgeons. RESULTS We identified 14,753 procedures (61.5% simple EGS, 38.5% complex EGS) by 252 (73.3%) low-volume surgeons (≤25 total EGS procedures/year), 63 (18.3%) medium-volume surgeons (26 to 50/year), and 29 (8.4%) high-volume surgeons (>50/year). Low-volume surgeons operated on one-third (33.1%) of all patients. For simple procedures, the very low rate of death (0.2%) prevented a meaningful regression with mortality; however, there were no associations between low-volume surgeons and complications (adjusted odds ratio [aOR] 1.07; 95% CI 0.81 to 1.41) or 30-day readmissions (aOR 0.80; 95% CI 0.64 to 1.01) relative to high-volume surgeons. Among complex procedures, low-volume surgeons were associated with greater mortality (aOR 1.64; 95% CI 1.12 to 2.41) relative to high-volume surgeons, but not complications (aOR 1.06; 95% CI 0.85 to 1.32) or 30-day readmission (aOR 0.99; 95% CI 0.80 to 1.22). Low-volume hospitals (≤125 total EGS procedures/year) relative to high-volume hospitals (>250/year) were not associated with mortality, complications, or 30-day readmissions for simple or complex procedures. CONCLUSIONS We found evidence that surgeon EGS volume was associated with outcomes. Developing EGS-specific services, mentorship opportunities, and clinical pathways for less-experienced surgeons may improve outcomes.
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McGaughey J, O'Halloran P, Porter S, Trinder J, Blackwood B. Early warning systems and rapid response to the deteriorating patient in hospital: A realist evaluation. J Adv Nurs 2017. [PMID: 28637090 DOI: 10.1111/jan.13367] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
AIM To test the Rapid Response Systems programme theory against actual practice components of the Rapid Response Systems implemented to identify those contexts and mechanisms which have an impact on the successful achievement of desired outcomes in practice. BACKGROUND Rapid Response Systems allow deteriorating patients to be recognized using Early Warning Systems, referred early via escalation protocols and managed at the bedside by competent staff. DESIGN Realist evaluation. METHODS The research design was an embedded multiple case study approach of four wards in two hospitals in Northern Ireland which followed the principles of Realist Evaluation. We used various mixed methods including individual and focus group interviews, observation of nursing practice between June-November 2010 and document analysis of Early Warning Systems audit data between May-October 2010 and hospital acute care training records over 4.5 years from 2003-2008. Data were analysed using NiVivo8 and SPPS. RESULTS A cross-case analysis highlighted similar patterns of factors which enabled or constrained successful recognition, referral and response to deteriorating patients in practice. Key enabling factors were the use of clinical judgement by experienced nurses and the empowerment of nurses as a result of organizational change associated with implementation of Early Warning System protocols. Key constraining factors were low staffing and inappropriate skill mix levels, rigid implementation of protocols and culturally embedded suboptimal communication processes. CONCLUSION Successful implementation of Rapid Response Systems was dependent on adopting organizational and cultural changes that facilitated staff empowerment, flexible implementation of protocols and ongoing experiential learning.
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Affiliation(s)
- Jennifer McGaughey
- School of Nursing & Midwifery, Medical Biology Centre, Queen's University Belfast, Belfast, UK
| | - Peter O'Halloran
- School of Nursing & Midwifery, Medical Biology Centre, Queen's University Belfast, Belfast, UK
| | - Sam Porter
- Department of Social Sciences and Social Work, Bournemouth University, Poole, Dorset, UK
| | - John Trinder
- Anaesthesia and Intensive Care Medicine, Ulster Hospital, South Eastern Health & Social Care Trust, Dundonald, Belfast, UK
| | - Bronagh Blackwood
- School of Medicine, Dentistry & Biomedical Sciences, Centre for Experimental Medicine, Queen's University Belfast, Belfast, UK
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Gardner AK, Johnston M, Korndorffer JR, Haque I, Paige JT. Using Simulation to Improve Systems-Based Practices. Jt Comm J Qual Patient Saf 2017; 43:484-491. [PMID: 28844234 DOI: 10.1016/j.jcjq.2017.05.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Ensuring the safe, effective management of patients requires efficient processes of care within a smoothly operating system in which highly reliable teams of talented, skilled health care providers are able to use the vast array of high-technology resources and intensive care techniques available. Simulation can play a unique role in exploring and improving the complex perioperative system by proactively identifying latent safety threats and mitigating their damage to ensure that all those who work in this critical health care environment can provide optimal levels of patient care. METHODS A panel of five experts from a wide range of institutions was brought together to discuss the added value of simulation-based training for improving systems-based aspects of the perioperative service line. Panelists shared the way in which simulation was demonstrated at their institutions. The themes discussed by each panel member were delineated into four avenues through which simulation-based techniques have been used. RESULTS Simulation-based techniques are being used in (1) testing new clinical workspaces and facilities before they open to identify potential latent conditions; (2) practicing how to identify the deteriorating patient and escalate care in an effective manner; (3) performing prospective root cause analyses to address system weaknesses leading to sentinel events; and (4) evaluating the efficiency and effectiveness of the electronic health record in the perioperative setting. CONCLUSION This focused review of simulation-based interventions to test and improve components of the perioperative microsystem, which includes literature that has emerged since the panel's presentation, highlights the broad-based utility of simulation-based technologies in health care.
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Response to "RE: Escalation of Care in Surgery: A Systematic Risk Assessment to Prevent Avoidable Harm in Hospitalized Patients". Ann Surg 2017; 266:e28. [PMID: 28692557 DOI: 10.1097/sla.0000000000001350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
BACKGROUND The evolving field of acute care surgery (ACS) traditionally includes trauma, emergency general surgery, and critical care. However, the critical role of ACS in the rescue of patients with a surgical complication has not been explored. We here describe the role of "surgical rescue" in the practice of ACS. METHODS A prospective, electronic medical record-based ACS registry spanning January 2013 to May 2014 at a large urban academic medical center was screened by ICD-9 codes for acute surgical complications of an operative or interventional procedure. Long-term outcomes were derived from the Social Security Death Index. RESULTS Of 2,410 ACS patients, 320 (13%) required "surgical rescue": most commonly, from wound complications (32%), uncontrolled sepsis (19%), and acute obstruction (15%). The majority of complications (85%) were related to an operation; 15% were related to interventional procedures. The most common rescue interventions required were bowel resection (23%), wound debridement (18%), and source control of infection (17%); 63% of patients required operative intervention, and 22% required surgical critical care. Thirty-six percent of complications occurred in ACS primary patients ("local"), whereas 38% were referred from another surgical service ("institutional") and 26% referred from another institution ("regional"). Hospital length of stay was longer, and in-hospital and 1-year mortalities were higher in rescue patients compared with those without a complication. Outcomes were equivalent between "local" and "institutional" patients, but hospital length of stay and discharge to home were significantly worse in "institutional" referrals. CONCLUSION We here describe the distinct role of the acute care surgeon in the surgical management of complications; this is an additional pillar of ACS. In this vital role, the acute care surgeon provides crucial support to other providers as well as direct patient care in the "surgical rescue" of surgical and procedural complications. LEVEL OF EVIDENCE Epidemiological study, level III; therapeutic/care management study, level IV.
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138
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Hartin J, Walker J. Rapid response systems supporting end of life care: time for a new approach. Br J Hosp Med (Lond) 2017; 78:160-164. [PMID: 28277773 DOI: 10.12968/hmed.2017.78.3.160] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Rapid response systems have been implemented worldwide to support management of deteriorating patients outwith critical care units, and are increasingly required to support end of life care. These challenges require a new approach to supporting staff involved in do not attempt cardiopulmonary resuscitation decisions.
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Affiliation(s)
- Jillian Hartin
- Senior Nurse, Patient Emergency Response and Resuscitation Team (PERRT); Co-Chair Talking DNACPR Project Management Board, PERRT office, University College Hospital, London NW1 2BU
| | - Judy Walker
- Programme Director, Talking DNACPR, University College London Hospitals; Consultant, North and East London Commissioning Support Unit, London
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139
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A Perioperative Clinical Pathway Can Dramatically Reduce Failure-to-rescue Rates After Cytoreductive Surgery for Peritoneal Carcinomatosis: A Retrospective Study of 666 Consecutive Cytoreductions. Ann Surg 2017; 265:806-813. [PMID: 27775553 DOI: 10.1097/sla.0000000000001723] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To determine whether a perioperative, standardized clinical pathway could impact the failure-to-rescue rate after cytoreductive surgery (CRS) for peritoneal carcinomatosis (PC) in a tertiary center. SUMMARY OF BACKGROUND DATA Morbidity and mortality remain significant after CRS for PC. Clinical pathways have been associated with better outcomes after surgery. The failure-to-rescue rate is a useful metric for evaluating quality in surgery. MATERIALS AND METHODS This study included 666 patients that received CRS for PC between 2009 and 2014. Starting in 2012, a standardized perioperative clinical pathway was introduced, which focused on patient selection, nutrition, renal protection, pain management, prevention, and early detection of complications. Complications were evaluated with the National Cancer Institute's Common Terminology Criteria for Adverse Events. We used multivariate analyses to evaluate clinicopathological and perioperative factors for associations with major complications and failure-to-rescue. Complication rates were compared before and after the clinical pathway implementation. RESULTS Major complications occurred in 341 patients (51%), leading to 15 deaths. The complication rate was similar before and after clinical pathway introduction (54.75% vs 48.9%, respectively; P = 0.138). Only prolonged surgery (longer than 240 mins) was independently associated with major complications. The failure-to-rescue rate was 4.4% for the entire period, but it significantly decreased after introducing the clinical pathway (9.02% vs 1.02%; P < 0.001). On multivariate analysis, only renal complications were associated with the failure-to-rescue. CONCLUSION Morbidity after CRS remains significant, but standardized management facilitated a reduction in the failure-to-rescue rate and improved the quality of care. Specific effort should be dedicated to preventing postoperative renal failure.
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Elliott D, Allen E, McKinley S, Perry L, Duffield C, Fry M, Gallagher R, Iedema R, Roche M. User compliance with documenting on a track and trigger-based observation and response chart: a two-phase multi-site audit study. J Adv Nurs 2017; 73:2892-2902. [DOI: 10.1111/jan.13302] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2017] [Indexed: 11/27/2022]
Affiliation(s)
- Doug Elliott
- Faculty of Health; University of Technology Sydney; Ultimo NSW Australia
| | - Emily Allen
- Faculty of Health; University of Technology Sydney; Ultimo NSW Australia
| | | | - Lin Perry
- Faculty of Health; University of Technology Sydney; Ultimo NSW Australia
- South East Sydney Local Health District; Sydney NSW Australia
| | - Christine Duffield
- Faculty of Health; University of Technology Sydney; Ultimo NSW Australia
| | - Margaret Fry
- Faculty of Health; University of Technology Sydney; Ultimo NSW Australia
- Northern Sydney Local Health District; NSW Australia
| | - Robyn Gallagher
- Charles Perkins Centre & Sydney Nursing School; University of Sydney; Sydney NSW Australia
| | - Rick Iedema
- Centre for Team-Based Practice & Learning in Health Care; Kings College London; London UK
| | - Michael Roche
- Faculty of Health Sciences; Australian Catholic University; North Sydney NSW Australia
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Currey J, Allen J, Jones D. Critical care clinician perceptions of factors leading to Medical Emergency Team review. Aust Crit Care 2017; 31:87-92. [PMID: 28483444 DOI: 10.1016/j.aucc.2017.03.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 02/15/2017] [Accepted: 03/27/2017] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND The introduction of rapid response systems has reduced the incidence of in-hospital cardiac arrest; however, many instances of clinical deterioration are unrecognised. Afferent limb failure is common and may be associated with unplanned intensive care admissions, heightened mortality and prolonged length of stay. Patients reviewed by a Medical Emergency Team are inherently vulnerable with a high in-hospital mortality. OBJECTIVE To explore perceptions of intensive care unit (ICU) staff who attend deteriorating acute care ward patients regarding current problems, barriers and potential solutions to recognising and responding to clinical deterioration that culminates in a Medical Emergency Team review. METHODS A descriptive exploratory design was used. Registered intensive care nurses and medical staff (N=207) were recruited during a professional conference using purposive sampling for experience in attending deteriorating patients. Written response surveys were used to address the study aim. Data were analysed using content analysis. RESULTS Four major themes were identified: Governance, Teamwork, Clinical Care Delivery and End of Life Care. Participants perceived there was a lack of sufficient and senior staff with the required theoretical knowledge; and inadequate assessment and critical thinking skills for anticipating, recognising and responding to clinical deterioration. Senior doctors were perceived to inappropriately manage End of Life Care issues and displayed Teamwork behaviours rendering ward clinicians feeling fearful and intimidated. A lack of System and Clinical Governance hindered identification of clinical deterioration. CONCLUSIONS To improve patient safety related to recognising and responding to clinical deterioration, suboptimal care due to professionals' knowledge, skills and behaviours need addressing, along with End of Life Care and Governance.
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Affiliation(s)
- Judy Currey
- School of Nursing and Midwifery and Centre for Quality and Patient Safety Research, c/- Deakin University, Geelong, Victoria 3146, Australia.
| | - Josh Allen
- School of Nursing and Midwifery and Centre for Quality and Patient Safety Research, c/- Deakin University, Geelong, Victoria 3146, Australia.
| | - Daryl Jones
- Intensive Care Unit, 145 Studley Road, Heidelberg, Victoria 3084, Australia; Public Health and Preventive Medicine, Monash University, Clayton campus, Melbourne, Victoria 3800, Australia; Department of Surgery, University of Melbourne, 1-100 Grattan Street, Melbourne, Victoria 3010, Australia.
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Davis WA, Jones S, Crowell-Kuhnberg AM, O'Keeffe D, Boyle KM, Klainer SB, Smink DS, Yule S. Operative team communication during simulated emergencies: Too busy to respond? Surgery 2017; 161:1348-1356. [DOI: 10.1016/j.surg.2016.09.027] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 09/09/2016] [Accepted: 09/16/2016] [Indexed: 11/30/2022]
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When Nursing Assertion Stops: A Qualitative Study to Examine the Cultural Barriers Involved in Escalation of Care in a Pediatric Hospital. Crit Care Nurs Clin North Am 2017; 29:167-176. [PMID: 28460698 DOI: 10.1016/j.cnc.2017.01.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Pediatric codes outside the ICU are associated with increased morbidity and mortality. This qualitative research highlights results from confidential interviews with 10 pediatric nurses with experience of caring for children who required rapid response, code response, or transfer to intensive care. Detailed examination of nurses' experiences revealed local factors that facilitate and inhibit timely transfer of critical patients. Nurses identified themes including the impact of nurse assertiveness, providers' lack of understanding of nursing, team communication, and other hospital cultural barriers.
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Douw G, Huisman-de Waal G, van Zanten ARH, van der Hoeven JG, Schoonhoven L. Capturing early signs of deterioration: the dutch-early-nurse-worry-indicator-score and its value in the Rapid Response System. J Clin Nurs 2017; 26:2605-2613. [DOI: 10.1111/jocn.13648] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/26/2016] [Indexed: 11/27/2022]
Affiliation(s)
- Gooske Douw
- Care Division; Gelderse Vallei Hospital; Ede The Netherlands
- Radboud University Medical Centre; Radboud Institute for Health Sciences; Scientific Center for Quality of Healthcare (IQ Healthcare); Nijmegen The Netherlands
| | - Getty Huisman-de Waal
- Nursing Science; Radboud University Medical Centre; Radboud Institute for Health Sciences; Scientific Center for Quality of Healthcare (IQ Healthcare); Nijmegen The Netherlands
| | | | | | - Lisette Schoonhoven
- Radboud University Medical Centre; Radboud Institute for Health Sciences; Scientific Center for Quality of Healthcare (IQ Healthcare); Nijmegen The Netherlands
- Faculty of Health Sciences; Level A (MP11) South Academic Block; Southampton General Hospital; University of Southampton; Southampton UK
- National Institute for Health Research Collaboration for Applied Health Research and Care (CLAHRC) Wessex; Southampton UK
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146
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Tengberg LT, Bay-Nielsen M, Bisgaard T, Cihoric M, Lauritsen ML, Foss NB, Orbæk J, Veyhe L, Jørgen Nielsen H, Lindgaard L. Multidisciplinary perioperative protocol in patients undergoing acute high-risk abdominal surgery. Br J Surg 2017; 104:463-471. [DOI: 10.1002/bjs.10427] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 08/30/2016] [Accepted: 10/07/2016] [Indexed: 12/23/2022]
Abstract
Abstract
Background
Acute high-risk abdominal (AHA) surgery carries a very high risk of morbidity and mortality and represents a massive healthcare burden. The aim of the present study was to evaluate the effect of a standardized multidisciplinary perioperative protocol in patients undergoing AHA surgery.
Methods
The AHA study was a prospective single-centre controlled study in consecutive patients undergoing AHA surgery, defined as major abdominal pathology requiring emergency laparotomy or laparoscopy including reoperations after elective gastrointestinal surgery. Consecutive patients were included after initiation of the AHA protocol as standard care. The intervention cohort was compared with a predefined, consecutive historical cohort of patients from the same department. The protocol involved continuous staff education, consultant-led attention and care, early resuscitation and high-dose antibiotics, surgery within 6 h, perioperative stroke volume-guided haemodynamic optimization, intermediate level of care for the first 24 h after surgery, standardized analgesic treatment, early postoperative ambulation and early enteral nutrition. The primary outcome was 30-day mortality.
Results
Six hundred patients were included in the study and compared with 600 historical controls. The unadjusted 30-day mortality rate was 21·8 per cent in the control cohort compared with 15·5 per cent in the intervention cohort (P = 0·005). The 180-day mortality rates were 29·5 and 22·2 per cent respectively (P = 0·004).
Conclusion
The introduction of a multidisciplinary perioperative protocol was associated with a significant reduction in postoperative mortality in patients undergoing AHA surgery. NCT01899885 (http://www.clinicaltrials.gov).
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Affiliation(s)
- L T Tengberg
- Gastro Unit Surgical Division, Copenhagen University Hospital, Hvidovre, Denmark
| | - M Bay-Nielsen
- Gastro Unit Surgical Division, Copenhagen University Hospital, Hvidovre, Denmark
| | - T Bisgaard
- Gastro Unit Surgical Division, Copenhagen University Hospital, Hvidovre, Denmark
| | - M Cihoric
- Gastro Unit Surgical Division, Copenhagen University Hospital, Hvidovre, Denmark
| | - M L Lauritsen
- Gastro Unit Surgical Division, Copenhagen University Hospital, Hvidovre, Denmark
| | - N B Foss
- Department of Anaesthesiology and Intensive Care Medicine, Copenhagen University Hospital, Hvidovre, Denmark
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147
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Sippey M, Spaniolas K, Kasten KR. Elucidating Trainee Effect on Outcomes for General, Gynecologic, and Urologic Oncology Procedures. J INVEST SURG 2016; 30:359-367. [PMID: 27929699 DOI: 10.1080/08941939.2016.1255805] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND OBJECTIVES Surgical complications delay adjuvant therapy in oncology patients. Current literature remains unclear regarding resident effect on postoperative outcomes, with inappropriate coverage possibly endangering patients in spite of attending oversight. We assessed resident postgraduate year (PGY) effect on 30-day overall morbidity in cancer patients undergoing major intra-abdominal and non-abdominal surgery. METHODS Patients undergoing non-emergent major intra- and extra-abdominal operations from 2005-2012 were queried using the American College of Surgeons' National Surgical Quality Improvement Program. Attending alone and resident PGY cohorts were compared for demographics, 30-day overall morbidity, mortality, and relevant outcomes. RESULTS A total of 156,941 cancer patients undergoing major intra-abdominal (n = 76,385) or major non-abdominal (n = 80,556) procedures were captured. Demographics were clinically similar across attending and PGY levels. Rates of overall morbidity increased significantly with PGY level, along with operative time and length of stay. For major intra-abdominal procedures, all resident levels except PGY2 level adversely affected overall morbidity. Above PGY4 level, resident involvement had a stronger association with adverse outcome than preoperative comorbidities and preoperative chemotherapy. Interestingly, gastric, gall bladder, liver, pancreas, esophageal, and thyroid procedures demonstrated no effect of resident involvement on overall morbidity. CONCLUSIONS Resident PGY is independently associated with increased overall morbidity in patients undergoing selected major surgical procedures. Understanding surgical procedures affected by resident involvement will maximize outcomes.
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Affiliation(s)
- Megan Sippey
- a Department of Surgery , Brody School of Medicine at East Carolina University , Greenville , North Carolina , USA
| | - Konstantinos Spaniolas
- a Department of Surgery , Brody School of Medicine at East Carolina University , Greenville , North Carolina , USA
| | - Kevin R Kasten
- b Department of Surgery , Carolinas Health Care System , Charlotte , North Carolina , USA
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148
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Shannon SE. The Nurse as the Patient's Advocate:A Contrarian View. Hastings Cent Rep 2016; 46 Suppl 1:S43-7. [DOI: 10.1002/hast.632] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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149
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Mohan HM, Gokani VJ, Williams AP, Harries RL. Consultant outcomes publication and surgical training: Consensus recommendations by the association of surgeons in training. Int J Surg 2016; 36 Suppl 1:S20-S23. [PMID: 27659508 DOI: 10.1016/j.ijsu.2016.09.077] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 09/10/2016] [Accepted: 09/18/2016] [Indexed: 01/18/2023]
Abstract
Consultant Outcomes Publication (COP) has the longest history in cardiothoracic surgery, where it was introduced in 2005. Subsequently COP has been broadened to include all surgical specialties in NHS England in 2013-14. The Association of Surgeons in Training (ASiT) fully supports efforts to improve patient care and trust in the profession and is keen to overcome potential unintended adverse effects of COP. Identification of these adverse effects is the first step in this process: Firstly, there is a risk that COP may lead to reluctance by consultants to provide trainees with the necessary appropriate primary operator experience to become skilled consultant surgeons for the future. Secondly, COP may lead to inappropriately cautious case selection. This adjusted case mix affects both patients who are denied operations, and also limits the complexity of the case mix to which surgical trainees are exposed. Thirdly, COP undermines efforts to train surgical trainees in non-technical skills and human factors, simply obliterating the critical role of the multidisciplinary team and organisational processes in determining outcomes. This tunnel vision masks opportunities to improve patient care and outcomes at a unit level. It also misinforms the public as to the root causes of adverse events by failing to identify care process deficiencies. Finally, for safe surgical care, graduate retention and morale is important - COP may lead to high calibre trainees opting out of surgical careers, or opting to work abroad. The negative effects of COP on surgical training and trainees must be addressed as high quality surgical training and retention of high calibre graduates is essential for excellent patient care.
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Affiliation(s)
- Helen M Mohan
- Association of Surgeons in Training, 35-43 Lincoln's Inn Fields, London, WC2A 3PE, UK
| | - Vimal J Gokani
- Association of Surgeons in Training, 35-43 Lincoln's Inn Fields, London, WC2A 3PE, UK
| | - Adam P Williams
- Association of Surgeons in Training, 35-43 Lincoln's Inn Fields, London, WC2A 3PE, UK
| | - Rhiannon L Harries
- Association of Surgeons in Training, 35-43 Lincoln's Inn Fields, London, WC2A 3PE, UK.
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- Association of Surgeons in Training, 35-43 Lincoln's Inn Fields, London, WC2A 3PE, UK
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150
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Characterizing the role of a high-volume cancer resection ecosystem on low-volume, high-quality surgical care. Surgery 2016; 160:839-849. [PMID: 27524432 DOI: 10.1016/j.surg.2016.07.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Revised: 06/27/2016] [Accepted: 07/04/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Our objective was to determine the hospital resources required for low-volume, high-quality care at high-volume cancer resection centers. METHODS Patients who underwent esophageal, pancreatic, and rectal resection for malignancy were identified using Healthcare Cost and Utilization Project State Inpatient Database (Florida and California) between 2007 and 2011. Annual case volume by procedure was used to identify high- and low-volume centers. Hospital data were obtained from the American Hospital Association Annual Survey Database. Procedure risk-adjusted mortality was calculated for each hospital using multilevel, mixed-effects models. RESULTS A total of 24,784 patients from 302 hospitals met the inclusion criteria. Of these, 13 hospitals were classified as having a high-volume, oncologic resection ecosystem by being a high-volume hospital for ≥2 studied procedures. A total of 11 of 31 studied hospital factors were strongly associated with hospitals that performed a high volume of cancer resections and were used to develop the High Volume Ecosystem for Oncologic Resections (HIVE-OR) score. At low-volume centers, increasing HIVE-OR score resulted in decreased mortality for rectal cancer resection (P = .038). HIVE-OR was not related to risk-adjusted mortality for esophagectomy (P = .421) or pancreatectomy (P = .413) at low-volume centers. CONCLUSION Our study found that in some settings, low-volume, high-quality cancer surgical care can be explained by having a high-volume ecosystem.
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