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Juviler P, Meyers JM, Levatino E, Axford J, Barker E, Correll L, Decker AS, Faria J, Gloff M, Loria A, McKenna M, Schriefer J, Stevens TP, Verna S, Wegman S, Wolcott K, Wakeman D. Reducing Unplanned Intubations in the Neonatal Intensive Care Unit After Children's Surgery: A Quality Improvement Project. J Pediatr Surg 2024; 59:45-52. [PMID: 37845122 DOI: 10.1016/j.jpedsurg.2023.09.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 09/08/2023] [Indexed: 10/18/2023]
Abstract
BACKGROUND Unplanned intubation following children's surgery is associated with increased postoperative mortality. In response to being a National Surgical Quality Improvement Program - Pediatric (NSQIP-P) high outlier for postoperative unplanned intubation, we aimed to reduce postoperative unplanned intubation events by 25% in one year. METHODS/INTERVENTION A multidisciplinary team of stakeholders was assembled in 2018. Most unplanned intubation events occurred in the neonatal intensive care unit (NICU). Based on apparent causes of unplanned intubations identified in case reviews, an extubation readiness checklist and a postoperative pain management guideline emphasizing non-opioid analgesics were implemented for NICU patients in September 2019. Postoperative unplanned intubation events were tracked prospectively and evaluated using quality improvement statistical process control methods. RESULTS Unplanned intubations in the NICU decreased from 0.27 to 0.07 events per patient in the post-intervention group (September 2019-June 2022, n = 145) compared to the pre-intervention group (January 2016-August 2019, n = 200), representing a 76% reduction. Postoperative opioid administration decreased significantly, while acetaminophen usage increased significantly over time. Balancing measures of postoperative pneumonia rate (1.5% vs 0.0%, p = 0.267) and median hospital length of stay [40 (IQR 51) days vs 27 (IQR 60), p = 0.124] were not different between cohorts. The 30-day mortality rate for postoperative patients in the NICU significantly declined [6.5% (n = 13) vs 0.7% (n = 1), p < 0.001]. CONCLUSIONS Postoperative unplanned intubation rates for NICU patients decreased following a quality improvement effort focused on opioid stewardship and extubation readiness. TYPE OF STUDY Prospective Quality Improvement. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Peter Juviler
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA.
| | - Jeffrey M Meyers
- Department of Pediatrics, Golisano Children's Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - Elizabeth Levatino
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Jessica Axford
- Department of Pediatrics, Golisano Children's Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - Erin Barker
- Department of Pediatrics, Golisano Children's Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - Lynnie Correll
- Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Andrew S Decker
- Golisano Children's Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - John Faria
- Department of Otolaryngology, University of Rochester Medical Center, Rochester, NY, USA
| | - Marjorie Gloff
- Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Anthony Loria
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Margo McKenna
- Department of Otolaryngology, University of Rochester Medical Center, Rochester, NY, USA
| | - Jan Schriefer
- Department of Pediatrics, Golisano Children's Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - Timothy P Stevens
- Department of Pediatrics, Golisano Children's Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - Sarah Verna
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Sarah Wegman
- University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Kori Wolcott
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Derek Wakeman
- Division of Pediatric Surgery, Department of Surgery, Golisano Children's Hospital, University of Rochester Medical Center, Rochester, NY, USA
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Veeramani A, Zhang AS, Blackburn AZ, Etzel CM, DiSilvestro KJ, McDonald CL, Daniels AH. An Artificial Intelligence Approach to Predicting Unplanned Intubation Following Anterior Cervical Discectomy and Fusion. Global Spine J 2023; 13:1849-1855. [PMID: 35132907 PMCID: PMC10556901 DOI: 10.1177/21925682211053593] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
STUDY DESIGN Level III retrospective database study. OBJECTIVES The purpose of this study is to determine if machine learning algorithms are effective in predicting unplanned intubation following anterior cervical discectomy and fusion (ACDF). METHODS The National Surgical Quality Initiative Program (NSQIP) was queried to select patients who had undergone ACDF. Machine learning analysis was conducted in Python and multivariate regression analysis was conducted in R. C-Statistics area under the curve (AUC) and prediction accuracy were used to measure the classifier's effectiveness in distinguishing cases. RESULTS In total, 54 502 patients met the study criteria. Of these patients, .51% underwent an unplanned re-intubation. Machine learning algorithms accurately classified between 72%-100% of the test cases with AUC values of between .52-.77. Multivariable regression indicated that the number of levels fused, male sex, COPD, American Society of Anesthesiologists (ASA) > 2, increased operating time, Age > 65, pre-operative weight loss, dialysis, and disseminated cancer were associated with increased risk of unplanned intubation. CONCLUSIONS The models presented here achieved high accuracy in predicting risk factors for re-intubation following ACDF surgery. Machine learning analysis may be useful in identifying patients who are at a higher risk of unplanned post-operative re-intubation and their treatment plans can be modified to prophylactically prevent respiratory compromise and consequently unplanned re-intubation.
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Affiliation(s)
- Ashwin Veeramani
- Department of Orthopedic Surgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Andrew S Zhang
- Department of Orthopedic Surgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Amy Z. Blackburn
- Department of Orthopedic Surgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Christine M. Etzel
- Department of Orthopedic Surgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Kevin J. DiSilvestro
- Department of Orthopedic Surgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Christopher L. McDonald
- Department of Orthopedic Surgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Alan H. Daniels
- Department of Orthopedic Surgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA
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Maragkos GA, Matsoukas S, Cho LD, Legome EL, Wedderburn RV, Margetis K. Comparison of Frailty Indices and the Charlson Comorbidity Index in Traumatic Brain Injury. J Head Trauma Rehabil 2023; 38:E177-E185. [PMID: 36730992 DOI: 10.1097/htr.0000000000000832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Comorbidity scales for outcome prediction in traumatic brain injury (TBI) include the 5-component modified Frailty Index (mFI-5), the 11-component modified Frailty Index (mFI-11), and the Charlson Comorbidity Index (CCI). OBJECTIVE To compare the accuracy in predicting clinical outcomes in TBI of mFI-5, mFI-11, and CCI. METHODS The National Trauma Data Bank (NTDB) of the American College of Surgeons (ACS) was utilized to study patients with isolated TBI for the years of 2017 and 2018. After controlling for age and injury severity, individual multivariable logistic regressions were conducted with each of the 3 scales (mFI-5, mFI-11, and CCI) against predefined outcomes, including any complication, home discharge, facility discharge, and mortality. RESULTS All 3 scales demonstrated adequate internal consistency throughout their individual components (0.63 for mFI-5, 0.60 for CCI, and 0.56 for mFI-11). Almost all studied complications were significantly more likely in frail patients. mFI-5 and mFI-11 had similar areas under the curve (AUC) for all outcomes, while CCI had lower AUCs (0.62-0.61-0.53 for any complication, 0.72-0.72-0.52 for home discharge, 0.78-0.78-0.53 for facility discharge, and 0.71-0.70-0.52 for mortality, respectively). CONCLUSION mFI-5 and mFI-11 demonstrated similar accuracy in predicting any complication, home discharge, facility discharge, and mortality in TBI patients across the NTDB. In addition, CCI's performance was poor for the aforementioned metrics. Since mFI-5 is simpler, yet as accurate as the 2 other scales, it may be the most practical both for clinical practice and for future studies with the NTDB.
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Affiliation(s)
- Georgios A Maragkos
- Departments of Neurosurgery (Drs Maragkos, Matsoukas, and Margetis) and Surgery (Dr Wedderburn), Mount Sinai Morningside Hospital, and Department of Emergency Medicine, Mount Sinai West (Dr Legome), Icahn School of Medicine (Mr Cho), New York City, New York
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Jaipanya P, Lertudomphonwanit T, Chanplakorn P, Pichyangkul P, Kraiwattanapong C, Keorochana G, Leelapattana P. Predictive factors for respiratory failure and in-hospital mortality after surgery for spinal metastasis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:1729-1740. [PMID: 36943483 DOI: 10.1007/s00586-023-07638-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 11/15/2022] [Accepted: 03/05/2023] [Indexed: 03/23/2023]
Abstract
PURPOSE Spinal metastasis surgeries carry substantial risk of complications. PRF is among complications that significantly increase mortality rate and length of hospital stay. The risk factor of PRF after spinal metastasis surgery has not been investigated. This study aims to identify the predictors of postoperative respiratory failure (PRF) and in-hospital death after spinal metastasis surgery. METHODS We retrospectively reviewed consecutive patients with spinal metastasis surgically treated between 2008 and 2018. PRF was defined as mechanical ventilator dependence > 48 h postoperatively (MVD) or unplanned postoperative intubation (UPI). Collected data include demographics, laboratory data, radiographic and operative data, and postoperative complications. Stepwise logistic regression analysis was used to determine predictors independently associated with PRFs and in-hospital death. RESULTS This study included 236 patients (average age 57 ± 14 years, 126 males). MVD and UPI occurred in 13 (5.5%) patients and 13 (5.5%) patients, respectively. During admission, 14 (5.9%) patients had died postoperatively. Multivariate logistic regression analysis revealed significant predictors of MVD included intraoperative blood loss > 2000 mL (odds ratio [OR] 12.28, 95% confidence interval [CI] 2.88-52.36), surgery involving cervical spine (OR 9.58, 95% CI 1.94-47.25), and ASA classification ≥ 4 (OR 6.59, 95% CI 1.85-23.42). The predictive factors of UPI included postoperative sepsis (OR 20.48, 95% CI 3.47-120.86), central nervous system (CNS) metastasis (OR 10.21, 95% CI 1.42-73.18), lung metastasis (OR 7.18, 95% CI 1.09-47.4), and postoperative pulmonary complications (OR 6.85, 95% CI 1.44-32.52). The predictive factors of in-hospital death included postoperative sepsis (OR 13.15, 95% CI 2.92-59.26), CNS metastasis (OR 10.55, 95% CI 1.54-72.05), and postoperative pulmonary complications (OR 9.87, 95% CI 2.35-41.45). CONCLUSION PRFs and in-hospital death are not uncommon after spinal metastasis surgery. Predictive factors for PRFs included preoperative comorbidities, intraoperative massive blood loss, and postoperative complications. Identification of risk factors may help guide therapeutic decision-making and patient counseling.
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Affiliation(s)
- Pilan Jaipanya
- Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 111 Suwannabhumi Canal Road, Bang Pla, Bang Phli District, Samut Prakan, 10540, Thailand
| | - Thamrong Lertudomphonwanit
- Department of Orthopaedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270, Rama VI Road, Thung Phaya Thai, Ratchathewi District, Bangkok, 10400, Thailand.
| | - Pongsthorn Chanplakorn
- Department of Orthopaedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270, Rama VI Road, Thung Phaya Thai, Ratchathewi District, Bangkok, 10400, Thailand
| | - Picharn Pichyangkul
- Department of Orthopaedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270, Rama VI Road, Thung Phaya Thai, Ratchathewi District, Bangkok, 10400, Thailand
| | - Chaiwat Kraiwattanapong
- Department of Orthopaedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270, Rama VI Road, Thung Phaya Thai, Ratchathewi District, Bangkok, 10400, Thailand
| | - Gun Keorochana
- Department of Orthopaedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270, Rama VI Road, Thung Phaya Thai, Ratchathewi District, Bangkok, 10400, Thailand
| | - Pittavat Leelapattana
- Department of Orthopaedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270, Rama VI Road, Thung Phaya Thai, Ratchathewi District, Bangkok, 10400, Thailand
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Abstract
Mortality after pancreatoduodenectomy has improved over time. This progress is likely related to advancements in failure to rescue (FTR-the percentage of patients who die after developing a major complication). Several factors associated with FTR include patient-specific risks, development of certain postoperative complications, surgeon-specific factors, hospital-specific factors, rescue techniques, and regional differences. Efforts should be made to explore additional factors such as the influence of safety culture in the postoperative setting. Improvement in FTR may be better explored through randomized controlled postoperative management trials. In stable patients, management of complications by interventional radiology is preferred over reoperation.
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Affiliation(s)
- Elizabeth M Gleeson
- University of Edinburgh and Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, Scotland UK.
| | - Henry A Pitt
- Rutgers Cancer Institute of New Jersey and Robert Wood Johnson University Hospital, 195 Little Albany Street, ET 834, New Brunswick, NJ 09083, USA
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Tracy BM, Carlin MN, Tyson JW, Schenker ML, Gelbard RB. The 11-Item Modified Frailty Index as a Tool to Predict Unplanned Events in Traumatic Brain Injury. Am Surg 2020; 86:1596-1601. [PMID: 32829642 DOI: 10.1177/0003134820942196] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Frailty has been studied extensively in trauma, but there is minimal research detailing its impact on traumatic brain injury (TBI). We hypothesized that the 11-item modified frailty index (mFI-11) would predict complications and discharge outcomes in patients with TBI. METHODS A retrospective review of our trauma quality improvement program (TQIP) registry was conducted for all patients with TBI. The mFI-11 score was calculated for each patient. Multivariable logistic regression was used to assess the relationship between mFI-11 and cardiovascular, infectious, pulmonary, renal, thromboembolic, and unplanned complications (ie, unplanned intensive care unit [ICU] admission, intubation, or return to the operating room). RESULTS There were 2352 patients with TBI of whom 61.6% (n = 1450) were not frail, 19.3% (n = 454) were mildly frail, and 19.1% (n = 448) were moderately to severely frail. Higher frailty scores were associated with increasing age (P < .0001) and decreasing injury severity score [ISS] (P = 0.001). Higher frailty scores also correlated with increasing rates of a skilled nursing facility/long-term acute care hospital/rehabilitation discharge (P = .0002). On multivariable logistic regression adjusting for age, Glasgow Coma Scale (GCS) score, ISS, mechanism, and sex, moderate to severe frailty increased the odds of acute kidney injury (odds ratio [OR] 2.06, 95% CI 1.07-3.99, P = .03) and any unplanned event (OR 1.6, 95% CI 1.1-2.3, P = .01). CONCLUSION Frailty measured by the mFI-11 is associated with greater rates of discharge to unfavorable locations and increased odds of acute kidney injury and unplanned events among patients with TBI. These findings suggest that frail patients with TBIs require greater vigilance to avoid such unanticipated outcomes.
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Affiliation(s)
- Brett M Tracy
- 1371 Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA.,Division of Acute Care Surgery, Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Margo N Carlin
- 1371 Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA.,Division of Acute Care Surgery, Grady Memorial Hospital, Atlanta, Georgia, USA
| | - James W Tyson
- Department of Surgery, Mercer University School of Medicine, Macon, GA, USA
| | - Mara L Schenker
- Division of Acute Care Surgery, Grady Memorial Hospital, Atlanta, Georgia, USA.,1371 Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Rondi B Gelbard
- 1371 Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA.,Division of Acute Care Surgery, Grady Memorial Hospital, Atlanta, Georgia, USA
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Gleeson EM, Clarke JR, Morano WF, Shaikh MF, Bowne WB, Pitt HA. Patient-specific predictors of failure to rescue after pancreaticoduodenectomy. HPB (Oxford) 2019; 21:283-290. [PMID: 30143319 DOI: 10.1016/j.hpb.2018.07.022] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 06/27/2018] [Accepted: 07/20/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Failure to rescue (FTR) is a recently described outcome metric for quality of care. However, predictors of FTR have not been adequately investigated, particularly after pancreaticoduodenectomy. We aim to identify predictors of FTR after pancreaticoduodenectomy. METHODS We reviewed all patients who developed serious morbidity after pancreaticoduodenectomy from 2005 to 2012 in the ACS-NSQIP database. Logistic regression was used to identify preoperative and postoperative risks for 30-day mortality within a development cohort (randomly selected 80%). A score was created using weighted beta coefficients. Predictive accuracy was assessed on the validation cohort (remaining 20%) using a receiver operator characteristic curve and calculating the area under the curve (AUC). RESULTS The FTR rate was 7.2% after pancreaticoduodenectomy (n = 5,027). We identified 5 independent risk factors: age ≥65 and albumin ≤3.5 g/dL, preoperatively; and development of shock, renal failure, and reintubation, postoperatively. The generated score had an AUC = 0.83 (95% CI, 0.77-0.89) in the validation cohort. Using the score: 1*Albumin ≤3.5 g/dL + 2*Age ≥ 65 + 2*Shock + 5*Renal failure + 5*Reintubation, FTR rates increased with increasing score (p < 0.001). CONCLUSION FTR rates have previously been shown to be associated with hospital factors. We show that FTR is also associated with preoperative and postoperative patient-specific factors.
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Affiliation(s)
- Elizabeth M Gleeson
- Department of Surgery, Drexel University College of Medicine, Philadelphia, PA, USA
| | - John R Clarke
- Department of Surgery, Drexel University College of Medicine, Philadelphia, PA, USA
| | - William F Morano
- Department of Surgery, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Mohammad F Shaikh
- Department of Surgery, University of California San Francisco-Fresno, Fresno, CA, USA
| | - Wilbur B Bowne
- Department of Surgery, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Henry A Pitt
- Department of Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA.
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Burton BN, Khoche S, A'Court AM, Schmidt UH, Gabriel RA. Perioperative Risk Factors Associated With Postoperative Unplanned Intubation After Lung Resection. J Cardiothorac Vasc Anesth 2018; 32:1739-1746. [PMID: 29506893 DOI: 10.1053/j.jvca.2018.01.032] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Postoperative respiratory failure requiring reintubation is associated with a significant increase in mortality. However, perioperative risk factors and their effects on unplanned 30-day reintubation and postoperative outcomes after unplanned reintubation following lung resection are not described well. The aim of this study was to determine whether certain comorbidities, demographic factors, and postoperative outcomes are associated with 30-day reintubation after thoracic surgery. DESIGN This was a retrospective observational study using multivariable logistic regression to identify preoperative risk factors and consequences of unplanned 30-day reintubation. SETTING Multi-institutional, prospective, surgical outcome-oriented database study. PARTICIPANTS Using the American College of Surgeons National Surgical Quality Improvement Program database, video-assisted thorascopic surgery and thoracotomy lung resections (lobectomy, wedge resection, segmentectomy, bilobectomy, pneumonectomy) were analyzed by Common Procedural Terminology codes from the years 2007 to 2016 in 16,696 patients undergoing thoracic surgery. INTERVENTION None. MEASUREMENT AND MAIN RESULTS The final analysis included 16,696 patients, of who 593 (3.5%) underwent unplanned reintubation. Among the final study population, 137 (23%) of unplanned intubations occurred within 24 hours postoperatively and the median (25%, 75% quartile) day of reintubation was day 3 (2, 8 days). The final multivariable logistic regression analysis suggested that age, American Society of Anesthesiologists physical status classification score ≥4, dyspnea with moderate exertion and at rest, history of chronic obstructive pulmonary disease, male sex, smoking, functional dependence, steroid use, open thoracotomies, increased operation time, and preoperative laboratory results (albumin and hematocrit) were associated with unplanned intubation after lung resection (p < 0.05). Unplanned intubation was associated significantly with 30-day mortality, reoperation, postoperative blood transfusion, and increased hospital length of stay (p < 0.05). CONCLUSIONS Nonmodifiable and modifiable preoperative risk factors were associated with increased odds of unplanned reintubation. Patients who experienced unplanned intubation were at considerable risk for 30-day mortality, reoperation, postoperative blood transfusion, and increased hospital length of stay.
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Affiliation(s)
- Brittany N Burton
- Department of Anesthesiology, University of California, San Diego, San Diego, California
| | - Swapnil Khoche
- Department of Anesthesiology, University of California, San Diego, San Diego, California
| | - Alison M A'Court
- Department of Anesthesiology, University of California, San Diego, San Diego, California
| | - Ulrich H Schmidt
- Department of Anesthesiology, University of California, San Diego, San Diego, California
| | - Rodney A Gabriel
- Department of Anesthesiology, University of California, San Diego, San Diego, California; Department of Biomedical Informatics, University of California, San Diego, San Diego, California.
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Predicting the Risk of Postoperative Respiratory Failure in Elective Abdominal and Vascular Operations Using the National Surgical Quality Improvement Program (NSQIP) Participant Use Data File. Ann Surg 2017; 266:968-974. [DOI: 10.1097/sla.0000000000001989] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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10
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Abstract
STUDY DESIGN Retrospective study of an administrative database. OBJECTIVE The objective was to investigate the incidence, risk factors, and mortality rate of reintubation after adult spinal deformity (ASD) surgery. BACKGROUND DATA There are limited data regarding the occurrence of reintubation after ASD surgery. MATERIALS AND METHODS The Nationwide Inpatient Sample database from 2002 to 2011 was used to identify adult patients who underwent elective surgery for scoliosis. Patients who required reintubation were identified and compared with controls (no reintubation). A multivariable logistic regression analysis was performed to identify independent factors associated with reintubation. RESULTS A total of 9734 patients who underwent surgery for ASD were identified, and 182 required reintubation [1.8%; 95% confidence interval (CI), 1.6%-2.1%] on average 2 days after surgery (range, 0-28 d). After multivariable analysis, the strongest independent risk factors associated with reintubation included postoperative acute respiratory failure [odds ratio (OR), 12.0; 95% CI, 8.6-16.6], sepsis (OR, 6.9; 95% CI, 3.5-13.6), and deep vein thrombosis (OR, 5.7; 95% CI, 3.0-10.9); history of chronic lung disease (OR, 1.6; 95% CI, 1.1-2.3) and fusion of 8 or more segments (OR, 1.5; 95% CI, 1.1-2.2) were also independent risk factors. Mortality rates were significantly higher in reintubated patients (7.3%) compared with that in nonreintubated patients (0.2%, P<0.001). More importantly, reintubation was an independent risk factor for inpatient mortality (OR, 9.8; 95% CI, 4.1-23.5; P<0.001). CONCLUSIONS The reintubation rate after ASD surgery is approximately 1.8%. Patients with a history of chronic lung disease and patients undergoing fusion of 8 or more segments may be at an increased risk for reintubation; other associated factors included acute respiratory failure, sepsis, and deep vein thrombosis. Patients who required postoperative airway management after ASD surgery were 9.8 times more likely to die during their hospital stay compared with controls.
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Kunisaki C, Miyata H, Konno H, Saze Z, Hirahara N, Kikuchi H, Wakabayashi G, Gotoh M, Mori M. Modeling preoperative risk factors for potentially lethal morbidities using a nationwide Japanese web-based database of patients undergoing distal gastrectomy for gastric cancer. Gastric Cancer 2017; 20:496-507. [PMID: 27553666 DOI: 10.1007/s10120-016-0634-0] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 08/08/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Most risk models for mortality and morbidity after distal gastrectomy have been created based on relatively small retrospective studies, and a model originating from nationwide database has been lacking. This study aimed to identify preoperative risk factors that predict the postoperative morbidities closely associated with mortality in gastric cancer patients undergoing distal gastrectomy, using data from the National Clinical Database (NCD), a nationwide web-based database in Japan. METHODS We analyzed records from the NCD for 65,906 patients who underwent distal gastrectomy in 1,986 hospitals during 2011 and 2012. Using 80 % of these patients, we identified independent preoperative predictors for morbidities closely related with mortality. These risk factors were then validated using the remaining 20 % of patients from 2011 to 2012 and the further 35,575 records from 2013. RESULTS Operative mortality was 1.07 % and overall morbidity was 14.2 % for the development data set. We selected eight morbidities that were closely associated with postoperative mortality, and then identified between 13 and 25 independent preoperative risk factors for each of the eight morbidities. Of these, old age, female gender, and poor ADL were the factors most frequently associated with the morbidities. The C-indices for each morbidity from the 2011 to 2012 validation data set were favorable as follows: unplanned intubation (0.797), pneumonia (0.784), systemic sepsis (0.748), renal failure (0.832), cardiac events (0.728), large blood transfusions (0.700), central nervous system (CNS) events (0.779), and anastomotic leakage (0.658). Similar C-indices were obtained for each mortality using the 2013 validation data set. CONCLUSIONS In this study, we successfully constructed an acceptable risk model using preoperative risk factors to predict eight postoperative morbidities highly associated with mortality in gastric cancer patients. This risk model could help to tailor perioperative management and improve clinical outcomes for patients who undergo distal gastrectomy.
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Affiliation(s)
- Chikara Kunisaki
- The Japanese Society of Gastroenterological Surgery, Working Group Database Committee, Tokyo, Japan.
- Department of Surgery, Gastroenterological Center, Yokohama City University, 4-57 Urafune-cho, Minami-ku, Yokohama, 232-0024, Japan.
| | - Hiroaki Miyata
- The Japanese Society of Gastroenterological Surgery, Database Committee, Tokyo, Japan
- National Clinical Database, Tokyo, Japan
| | - Hiroyuki Konno
- The Japanese Society of Gastroenterological Surgery, Working Group Database Committee, Tokyo, Japan
- The Japanese Society of Gastroenterological Surgery, Database Committee, Tokyo, Japan
| | - Zenichiro Saze
- The Japanese Society of Gastroenterological Surgery, Working Group Database Committee, Tokyo, Japan
| | - Norimichi Hirahara
- The Japanese Society of Gastroenterological Surgery, Database Committee, Tokyo, Japan
- National Clinical Database, Tokyo, Japan
| | - Hirotoshi Kikuchi
- The Japanese Society of Gastroenterological Surgery, Working Group Database Committee, Tokyo, Japan
| | - Go Wakabayashi
- The Japanese Society of Gastroenterological Surgery, Working Group Database Committee, Tokyo, Japan
- The Japanese Society of Gastroenterological Surgery, Database Committee, Tokyo, Japan
| | - Mitsukazu Gotoh
- The Japanese Society of Gastroenterological Surgery, Working Group Database Committee, Tokyo, Japan
- The Japanese Society of Gastroenterological Surgery, Database Committee, Tokyo, Japan
- National Clinical Database, Tokyo, Japan
| | - Masaki Mori
- The Japanese Society of Gastroenterological Surgery, Tokyo, Japan
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Pitt HA, Goldberg AJ, Pathak AS, Shinefeld JA, Hinkle SM, Rogers SO, DiSesa VJ, Kaiser LR. Assuring survival of safety-net surgical patients. Surgery 2016; 161:855-860. [PMID: 27769658 DOI: 10.1016/j.surg.2016.08.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 08/03/2016] [Accepted: 08/16/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND Survival of surgical inpatients is a key quality metric. Patient, surgeon, and system factors all contribute to inpatient mortality, and sophisticated risk adjustment is required to assess outcomes. When the mortality of general surgery patients was determined to be high at a safety-net hospital, a comprehensive approach was undertaken to improve patient survival. METHODS General surgical service line mortality was measured in the database of the University HealthSystem Consortium from January 2013 through June 2015. Ten best practices were implemented sequentially to decrease observed and/or increase expected mortality. University HealthSystem Consortium mortality rank, observed, expected, and observed/expected index as well as early deaths were compared with control charts for 30 months. RESULTS University HealthSystem Consortium general surgery mortality improved from the bottom decile to the top quartile, while Case Mix Index increased from 2.48 to 2.82 (P < .05). Observed mortality decreased from 3.39 to 2.35%. Expected mortality increased from 1.40 to 2.73% (P < .05). The observed/expected mortality index decreased from 2.43 to 0.86 (P < .05). Early deaths decreased from 0.52 to 0% (P < .05). CONCLUSION Risk-adjusted mortality and early deaths decreased significantly over 30 months in general surgery patients. Systematic implementation of quality best practices was associated with improved survival of general surgery patients at a safety-net medical center.
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Affiliation(s)
- Henry A Pitt
- Department of Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA; Temple University Health System, Philadelphia, PA.
| | - Amy J Goldberg
- Department of Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | - Abhijit S Pathak
- Department of Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | | | | | - Selwyn O Rogers
- Department of Surgery, University of Texas Medical Branch, Galveston, TX
| | - Verdi J DiSesa
- Department of Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA; Temple University Health System, Philadelphia, PA
| | - Larry R Kaiser
- Department of Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA; Temple University Health System, Philadelphia, PA
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Alvarez MP, Samayoa-Mendez AX, Naglak MC, Yuschak JV, Murayama KM. Risk Factors for Postoperative Unplanned Intubation: Analysis of a National Database. Am Surg 2015. [DOI: 10.1177/000313481508100823] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Postoperative unplanned intubation (PUI) is a significant complication and is associated with severe adverse events and mortality. By participating in the National Surgical Quality Improvement Program (NSQIP), we learned that PUI occurred more frequently than expected at our institution. The aim of this study was to identify risk factors that are predictors of PUI at our institution. We reviewed the NSQIP data from our institution and the NSQIP national database for surgery patients from 2010 through 2013. The rate of PUI at our institution was 1.54 per cent compared with the national rate of 1.03 per cent. Perioperative risk factors were analyzed by multivariate logistic regression. Analysis of the national NSQIP database identified 14 independent risk factors for PUI. Analysis of the NSQIP data at our institution demonstrated that emergent cases, preoperative ventilator status, smoking, chronic obstructive pulmonary disease, and older age were independent risk factors. In conclusion, patients at our institution with these five risk factors were at higher risk of requiring PUI. These risk factors could be used to help identify patients at high risk and possibly help prevent postoperative respiratory failure and unplanned intubation.
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Affiliation(s)
- Martin P. Alvarez
- Department of Surgery, Abington Memorial Hospital, Price Building, Abington, Pennsylvania
| | | | - Mary C. Naglak
- Department of Surgery, Abington Memorial Hospital, Price Building, Abington, Pennsylvania
| | - James V. Yuschak
- Department of Surgery, Abington Memorial Hospital, Price Building, Abington, Pennsylvania
| | - Kenric M. Murayama
- Department of Surgery, Abington Memorial Hospital, Price Building, Abington, Pennsylvania
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Ceppa EP, Pitt HA, Nakeeb A, Schmidt CM, Zyromski NJ, House MG, Kilbane EM, George-Minkner AN, Brand B, Lillemoe KD. Reducing Readmissions after Pancreatectomy: Limiting Complications and Coordinating the Care Continuum. J Am Coll Surg 2015; 221:708-16. [PMID: 26228016 DOI: 10.1016/j.jamcollsurg.2015.05.012] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Revised: 05/08/2015] [Accepted: 05/14/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND Recent analyses of gastrointestinal operations document that complications are a key driver of readmissions. Pancreatectomy is a high outlier with respect to readmission. This analysis sought to determine if a multifactorial approach could reduce readmissions after pancreatectomy. STUDY DESIGN From 2007 to 2012, the number of patients readmitted by 30 days after pancreaticoduodenectomy, and distal and total pancreatectomy was measured. Steps to decrease readmissions were implemented independently at 1-year intervals; these efforts included strategies to reduce complications, creation of a Readmissions Team with a "discharge coach," increased use of home health, preferred relationships with post-acute care facilities, and the adoption of "Project RED" (Re-Engineered Discharge). The ACS NSQIP was used to track 30-day outcomes for all pancreatic resections. The University HealthSystem Consortium was used to determine length of stay index. RESULTS Over 5 years, 1,163 patients underwent proximal (66%), distal (32%), or total pancreatectomy (2%). The observed 30-day mortality was 2.9% for the study period, and the length of stay index (observed/expected days) was 1.10. Neither varied significantly over time. However, 30-day morbidity decreased from 57% to 46%, and proportion of patients with 30-day all-cause readmissions decreased from 23.0% to 11.5% (p = 0.001). CONCLUSIONS All-cause 30-day readmissions after pancreatectomy decreased without increasing length of stay. Efforts by surgeons to decrease complications and an increased emphasis on coordination of care may be useful for reducing readmissions.
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Affiliation(s)
- Eugene P Ceppa
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Henry A Pitt
- Department of Surgery, Temple University School of Medicine, Philadelphia, PA.
| | - Attila Nakeeb
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - C Max Schmidt
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Nicholas J Zyromski
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Michael G House
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - E Molly Kilbane
- Department of Nursing, Indiana University Health, Indianapolis, IN
| | | | - Beth Brand
- Clinical Decision Support, Indiana University Health, Indianapolis, IN
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Boston, MA
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