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Passos SC, de Jezus Castro SM, Stahlschmidt A, da Silva Neto PC, Irigon Pereira PJ, da Cunha Leal P, Lopes MB, Dos Reis Falcão LF, de Azevedo VLF, Lineburger EB, Mendes FF, Vilela RM, de Araújo Azi LMT, Antunes FD, Braz LG, Stefani LC. Development and validation of the Ex-Care BR model: a multicentre initiative for identifying Brazilian surgical patients at risk of 30-day in-hospital mortality. Br J Anaesth 2024; 133:125-134. [PMID: 38729814 DOI: 10.1016/j.bja.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 03/29/2024] [Accepted: 04/02/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Surgical risk stratification is crucial for enhancing perioperative assistance and allocating resources efficiently. However, existing models may not capture the complexity of surgical care in Brazil. Using data from various healthcare settings nationwide, we developed a new risk model for 30-day in-hospital mortality (the Ex-Care BR model). METHODS A retrospective cohort study was conducted in 10 hospitals from different geographic regions in Brazil. Data were analysed using multilevel logistic regression models. Model performance was assessed using the area under the receiver operating characteristic curve (AUROC), Brier score, and calibration plots. Derivation and validation cohorts were randomly assigned. RESULTS A total of 107,372 patients were included, and 30-day in-hospital mortality was 2.1% (n=2261). The final risk model comprised four predictors related to the patient and surgery (age, ASA physical status classification, surgical urgency, and surgical size), and the random effect related to hospitals. The model showed excellent discrimination (AUROC=0.93, 95% confidence interval [CI], 0.93-0.94), calibration, and overall performance (Brier score=0.017) in the derivation cohort (n=75,094). Similar results were observed in the validation cohort (n=32,278) (AUROC=0.93, 95% CI, 0.92-0.93). CONCLUSIONS The Ex-Care BR is the first model to consider regional and organisational peculiarities of the Brazilian surgical scene, in addition to patient and surgical factors. It is particularly useful for identifying high-risk surgical patients in situations demanding efficient allocation of limited resources. However, a thorough exploration of mortality variations among hospitals is essential for a comprehensive understanding of risk. CLINICAL TRIAL REGISTRATION NCT05796024.
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Affiliation(s)
- Sávio C Passos
- Graduate Program in Medical Sciences, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil; Anesthesiology and Perioperative Medicine Service, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | - Stela M de Jezus Castro
- Department of Statistics, Institute of Mathematics and Statistics, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Adriene Stahlschmidt
- Anesthesiology and Perioperative Medicine Service, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | - Paulo C da Silva Neto
- Graduate Program in Medical Sciences, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | | | | | | | - Luiz F Dos Reis Falcão
- Department of Surgery, School of Medicine, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | | | | | - Florentino F Mendes
- Department of Surgical Clinic, School of Medicine, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, Brazil
| | - Ramon M Vilela
- Department of Anesthesiology, Irmandade Santa Casa de Misericórdia Porto Alegre, Porto Alegre, Brazil
| | - Liana M T de Araújo Azi
- Department of Anesthesiology and Surgery, School of Medicine, Universidade Federal da Bahia (UFBA), Salvador, Brazil
| | - Fabrício D Antunes
- Department of Medicine, School of Medicine, Universidade Federal de Sergipe (UFS), Aracaju, Brazil
| | - Leandro G Braz
- Department of Surgical Specialties and Anesthesiology, School of Medicine, Universidade Estadual Paulista (UNESP), Botucatu, Brazil
| | - Luciana C Stefani
- Graduate Program in Medical Sciences, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil; Department of Surgery, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Hospital de Clínicas de Porto Alegre, Brazil.
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Yamamoto K. Impact of Advance Care Planning Support on Patients Treated in the Intensive Care Unit After High-Risk Surgery. Cureus 2024; 16:e54175. [PMID: 38496091 PMCID: PMC10941713 DOI: 10.7759/cureus.54175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2024] [Indexed: 03/19/2024] Open
Abstract
INTRODUCTION Efforts to enhance support for advance care planning (ACP) in patients requiring emergency and intensive care are currently being explored. In addition, few studies have reported the effects and impact of support for these patients and their families. The researcher developed a patient decision aid to initiate support for ACP for patients who plan to enter the intensive care unit after surgery and their families. This study aimed to provide ACP support to patients before high-risk surgery and to determine its impact. METHODS The study design was qualitative. The participants included 10 patients who were scheduled to be admitted to the intensive care unit after high-risk surgery at an acute-care hospital in Japan, and the patients' families. The researcher used decision aids to implement ACP support before the patients were admitted. Participants were interviewed in a semi-structured manner regarding their experiences and the impact of receiving ACP support after discharge. Interviews were recorded using an integrated circuit recorder, followed by verbatim transcripts. The analysis was performed in a qualitative descriptive manner. RESULTS ACP support prior to treatment initiation led patients to think about life-sustaining treatments and consider ideal living. By understanding the risks of treatment, patients can calmly assume complications and discuss their mortality and life after surgery. Patients perceived receiving ACP support as a valuable benefit prior to undergoing treatment in the intensive care unit. After discharge, they wanted to promote shared decision-making among their physicians. On the other hand, family members were more anxious about ACP topics than patients. In addition, the patients and their families felt that it was difficult to discuss their thoughts and wishes regarding ACP before surgery. CONCLUSION It is suggested that pretreatment ACP support could serve as an introductory phase for patients anticipating the need for intensive care, allowing them to contemplate their preferences regarding life-sustaining treatment. However, it is difficult for patients and their family members to openly discuss their thoughts on life-sustaining treatment, even if they are aware of the risk of a sudden crisis. Therefore, when patients and their families discuss ACP, the inclusion of healthcare coaching and counseling may be more effective. These measures of ACP support could add to increased family discussions, concordance, and shared decision-making with physicians.
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Affiliation(s)
- Kanako Yamamoto
- Critical Care Nursing, St. Luke's International University, Tokyo, JPN
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Powley N, Tew GA, Durrand J, Carr E, Nesbitt A, Hackett R, Gray J, McCarthy S, Beatty M, Huddleston R, Danjoux G. Digital health coaching to improve patient preparedness for elective lower limb arthroplasty: a quality improvement project. BMJ Open Qual 2023; 12:e002244. [PMID: 38061840 PMCID: PMC10711879 DOI: 10.1136/bmjoq-2022-002244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 11/03/2023] [Indexed: 12/18/2023] Open
Abstract
Major surgery carries high risks with comorbidities, frailty and health risk behaviours meaning patients are often unprepared for the physiological insult. Since 2018, the Prepwell programme at South Tees Hospitals NHS Foundation Trust has supported patients to improve their preoperative health and fitness. In April 2020, the face-to-face service was suspended due to the pandemic, leading to the team implementing a three-tiered remote digital support pathway, including digital health coaching via a mobile phone application. METHODS Patients scheduled for elective lower limb arthroplasty were offered 8 weeks of digital health coaching preoperatively. Following consent, participants were assigned a personal health coach to set individual behaviour change goals supported by online resources, alongside a digitally delivered exercise programme. Participants completed self-assessment questionnaires at Entry to, and Exit from, the programme, with outcome data collected 21 days postoperatively. The primary outcome was the change in Patient Activation Measure (PAM). RESULTS Fifty-seven of 189 patients (30.2%) consented to referral for digital health coaching. Forty participants completed the 8-week programme. Median PAM increased from 58.1 to 67.8 (p=0.002). Thirty-five per cent of participants were in a non-activated PAM level at Entry, reducing to 15% at Exit with no participants in PAM level 1 at completion. Seventy-one percent of non-activated participants improved their PAM by one level or more, compared with 45% for the whole cohort. Median LOS was 2 days, 1 day less than the Trust's arthroplasty patient population during the study period (unadjusted comparison). CONCLUSIONS Digital health coaching was successfully implemented for patients awaiting elective lower limb arthroplasty. We observed significant improvements in participants' PAM scores after the programme, with the largest increase in participants with lower activation scores at Entry. Further study is needed to confirm the effects of digital health coaching in this and other perioperative groups.
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Affiliation(s)
- Nicola Powley
- Northern School of Anaesthesia and Intensive Care Medicine, Newcastle upon Tyne, UK
| | | | - James Durrand
- Northern School of Anaesthesia and Intensive Care Medicine, Newcastle upon Tyne, UK
| | - Esther Carr
- South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | | | - Rhiannon Hackett
- Anaesthesia, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Joanne Gray
- Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK
| | - Stephen McCarthy
- Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK
| | | | | | - Gerard Danjoux
- Anaesthesia, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
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Emerson P, Flabouris A, Thomas J, Fernando J, Senthuran S, Sundararajan K. Intensive care utilisation after elective surgery in Australia and New Zealand: getting the balance right. AUST HEALTH REV 2023; 47:718-720. [PMID: 38011832 DOI: 10.1071/ah23187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 11/07/2023] [Indexed: 11/29/2023]
Abstract
Of the total intensive care unit (ICU) admissions in Australia and New Zealand, 36.6% occur following an elective surgical procedure. How best to use ICU services in this setting is not clear, despite this being an expensive and resource-intensive method of care delivery. The literature relating to this area has not demonstrated a clear association between improved outcomes and routine ICU utilisation. It has, however, demonstrated that methods of care delivery in this setting vary at the local, national and international level. There is now an increased interest in how we can offer safe, efficient care to patients who need ICU-level support after elective surgery, as well as where and when that care can be offered. We had previously performed a literature review relating to ICU utilisation in the elective surgical post-operative setting. This perspective piece arises from this literature review as well as extensive clinical experience from the authors. We discuss the need for a move towards an evidence-based indication for ICU admission and how this may be achieved. We then move on to the various alternative models of care that could be offered, briefly discussing their positives and potential drawbacks. We finish by outlining the research priorities and how these might be implemented in clinical practice. Getting the balance right between ICU admission and higher acuity ward-level care for post-operative elective surgical patients is difficult. However, this is an important challenge that we as a healthcare community must be working to answer.
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Affiliation(s)
- Philip Emerson
- Department of Intensive Care Medicine, Royal Adelaide Hospital, Adelaide, SA 5000, Australia; and University of Adelaide, 259 North Terrace, Adelaide, SA 5000, Australia
| | - Arthas Flabouris
- Department of Intensive Care Medicine, Royal Adelaide Hospital, Adelaide, SA 5000, Australia; and University of Adelaide, 259 North Terrace, Adelaide, SA 5000, Australia
| | - Josephine Thomas
- Department of General Medicine, Central Adelaide Local Health Network, SA, Australia
| | - Jeremy Fernando
- University of Queensland Rural Clinical School, Toowoomba, Qld, Australia; and Department of Intensive Care Medicine, St Vincents Private Hospital, Toowoomba City, Qld, Australia
| | - Siva Senthuran
- Department of Intensive Care Medicine, Townsville Hospital, Townsville, Qld, Australia
| | - Krishnaswamy Sundararajan
- Department of Intensive Care Medicine, Royal Adelaide Hospital, Adelaide, SA 5000, Australia; and University of Adelaide, 259 North Terrace, Adelaide, SA 5000, Australia
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Dogruyol T, Kahraman S, Dogruyol S, Buz M, Cimenoglu B, Ozdemir A, Dogu Geyik F, Demirhan R. Is intensive care necessary after major thoracic surgery? A propensity score-matched study. TURK GOGUS KALP DAMAR CERRAHISI DERGISI 2023; 31:229-238. [PMID: 37484638 PMCID: PMC10357857 DOI: 10.5606/tgkdc.dergisi.2023.23501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 04/20/2022] [Indexed: 07/25/2023]
Abstract
Background This study aims to compare the surgical results, complications, mortality rates, and inpatient costs in two patient groups followed, whether in the intensive care unit or general ward after a major thoracic procedure and to examine clinical and surgical factors related to the development of complications. Methods Between January 2018 and June 2021, a total of 485 patients (150 males, 335 females; mean age: 58.3±13.2 years; range, 22 to 86 years) who underwent a major thoracic surgery in our clinic were retrospectively analyzed. The patients were divided into two groups as the intensive care unit patients (n=254) and general ward patients (n=231). In the former group, the patients were followed in the intensive care unit for a day, while in the general ward group, the patients were taken directly to the ward. The groups were compared after propensity score matching. All patients were analyzed for risk factors of morbidity development. Results After propensity score matching, 246 patients were enrolled including 123 patients in each group. There was no statistically significant difference between the groups in any features except for late morbidity, and inpatient costs were higher in the intensive care unit group (p<0.05). In the multivariate analysis, age, American Society of Anesthesiologists Class 3, and secondary malignancy were found to be associated with morbidity (p<0.05). Conclusion In experienced centers, it is both safe and costeffective to follow almost all of the major thoracic surgery patients postoperatively in the general ward.
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Affiliation(s)
- Talha Dogruyol
- Department of Thoracic Surgery, Kartal Dr. Lütfi Kırdar City Hospital, Istanbul, Türkiye
| | - Selime Kahraman
- Department of Thoracic Surgery, Kartal Dr. Lütfi Kırdar City Hospital, Istanbul, Türkiye
| | - Sinem Dogruyol
- Emergency Medicine, Haydarpaşa Numune Training and Research Hospital, Istanbul, Türkiye
| | - Mesut Buz
- Department of Thoracic Surgery, Kartal Dr. Lütfi Kırdar City Hospital, Istanbul, Türkiye
| | - Berk Cimenoglu
- Department of Thoracic Surgery, Kartal Dr. Lütfi Kırdar City Hospital, Istanbul, Türkiye
| | - Attila Ozdemir
- Department of Thoracic Surgery, Kartal Dr. Lütfi Kırdar City Hospital, Istanbul, Türkiye
| | - Fatih Dogu Geyik
- Department of Anesthesiology and Reanimation, Kartal Dr. Lütfi Kırdar City Hospital, Istanbul, Türkiye
| | - Recep Demirhan
- Department of Thoracic Surgery, Kartal Dr. Lütfi Kırdar City Hospital, Istanbul, Türkiye
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