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Gurney JK, McLeod MA, Campbell D, Dennett E, Jackson S, Koea J, Lash N, Ongley D. Anaesthetic choice for hip or knee arthroplasty in New Zealand: Risk of postoperative death and variations in use. Anaesth Intensive Care 2021; 50:178-188. [PMID: 34871516 DOI: 10.1177/0310057x211050934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Anaesthetic choice for large joint surgery can impact postoperative outcomes, including mortality. The extent to which the impact of anaesthetic choice on postoperative mortality varies within patient populations and the extent to which anaesthetic choice is changing over time remain under-explored both internationally and in the diverse New Zealand context. In a national study of 199,211 hip and knee replacement procedures conducted between 2005 and 2017, we compared postoperative mortality among those receiving general, regional or general plus regional anaesthesia. Focusing on unilateral (n=86,467) and partial (n=13,889) hip replacements, we assessed whether some groups within the population are more likely to receive general, regional or general plus regional anaesthesia than others, and whether mortality risk varies depending on anaesthetic choice. We also examined temporal changes in anaesthetic choice over time. Those receiving regional alone or general plus regional for unilateral hip replacement appeared at increased risk of 30-day mortality compared to general anaesthesia alone, even after adjusting for differences in terms of age, ethnicity, deprivation, rurality, comorbidity, American Society of Anesthesiologists physical status score and admission type (e.g. general plus regional: adjusted hazard ratio (adj. HR)=1.94, 95% confidence intervals (CI) 1.32 to 2.84). By contrast, we observed lower 30-day mortality among those receiving regional anaesthesia alone compared to general alone for partial hip replacement (adj. HR=0.86, 95% CI 0.75 to 0.97). The latter observation contrasts with declining temporal trends in the use of regional anaesthesia alone for partial hip replacement procedures. However, we recognise that postoperative mortality is one perioperative factor that drives anaesthetic choice.
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Affiliation(s)
- Jason K Gurney
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - Melissa A McLeod
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - Douglas Campbell
- Department of Anaesthesia and Perioperative Medicine, Auckland District Health Board, Auckland, New Zealand
| | - Elizabeth Dennett
- Department of Surgery, Capital and Coast District Health Board, Wellington, New Zealand
| | - Sarah Jackson
- Department of Surgery, Capital and Coast District Health Board, Wellington, New Zealand
| | - Jonathan Koea
- Department of Surgery, Waitematā District Health Board, Auckland, New Zealand
| | - Nicholas Lash
- Department of Surgery, Canterbury District Health Board, Christchurch, New Zealand
| | - Dick Ongley
- Department of Anaesthesia, Canterbury District Health Board, Christchurch, New Zealand
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Wanderer JP, Lasko TA, Coco JR, Fowler LC, McEvoy MD, Feng X, Shotwell MS, Li G, Gelfand BJ, Novak LL, Owens DA, Fabbri DV. Visualization of aggregate perioperative data improves anesthesia case planning: A randomized, cross-over trial. J Clin Anesth 2020; 68:110114. [PMID: 33142248 DOI: 10.1016/j.jclinane.2020.110114] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 10/23/2020] [Accepted: 10/24/2020] [Indexed: 11/19/2022]
Abstract
STUDY OBJECTIVE A challenge in reducing unwanted care variation is effectively managing the wide variety of performed surgical procedures. While an organization may perform thousands of types of cases, privacy and logistical constraints prevent review of previous cases to learn about prior practices. To bridge this gap, we developed a system for extracting key data from anesthesia records. Our objective was to determine whether usage of the system would improve case planning performance for anesthesia residents. DESIGN Randomized, cross-over trial. SETTING Vanderbilt University Medical Center. MEASUREMENTS We developed a web-based, data visualization tool for reviewing de-identified anesthesia records. First year anesthesia residents were recruited and performed simulated case planning tasks (e.g., selecting an anesthetic type) across six case scenarios using a randomized, cross-over design after a baseline assessment. An algorithm scored case planning performance based on care components selected by residents occurring frequently among prior anesthetics, which was scored on a 0-4 point scale. Linear mixed effects regression quantified the tool effect on the average performance score, adjusting for potential confounders. MAIN RESULTS We analyzed 516 survey questionnaires from 19 residents. The mean performance score was 2.55 ± SD 0.32. Utilization of the tool was associated with an average score improvement of 0.120 points (95% CI 0.060 to 0.179; p < 0.001). Additionally, a 0.055 point improvement due to the "learning effect" was observed from each assessment to the next (95% CI 0.034 to 0.077; p < 0.001). Assessment score was also significantly associated with specific case scenarios (p < 0.001). CONCLUSIONS This study demonstrated the feasibility of developing of a clinical data visualization system that aggregated key anesthetic information and found that the usage of tools modestly improved residents' performance in simulated case planning.
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Affiliation(s)
- Jonathan P Wanderer
- Department of Anesthesiology, Department of Biomedical Informatics, Vanderbilt University Medical Center, United States.
| | - Thomas A Lasko
- Department of Biomedical Informatics, Vanderbilt University Medical Center, United States
| | - Joseph R Coco
- Department of Biomedical Informatics, Vanderbilt University Medical Center, United States
| | - Leslie C Fowler
- Department of Anesthesiology, Vanderbilt University Medical Center, United States
| | - Matthew D McEvoy
- Department of Anesthesiology, Vanderbilt University Medical Center, United States
| | - Xiaoke Feng
- Department of Biostatistics, Vanderbilt University Medical Center, United States
| | - Matthew S Shotwell
- Department of Biostatistics, Department of Anesthesiology, Vanderbilt University Medical Center, United States
| | - Gen Li
- Department of Anesthesiology, Vanderbilt University Medical Center, United States
| | - Brian J Gelfand
- Department of Anesthesiology, Vanderbilt University Medical Center, United States
| | - Laurie L Novak
- Department of Biomedical Informatics, Vanderbilt University Medical Center, United States
| | - David A Owens
- Owen Graduate School of Management, Vanderbilt University, United States
| | - Daniel V Fabbri
- Department of Biomedical Informatics, Department of Computer Science, Vanderbilt University Medical Center, United States
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Zhang JZ, Zhao K, Li JY, Meng HY, Zhu YB, Zhang YZ. Prophylactic Closed Suction Drainage Is Irrelevant to Accelerated Rehabilitation after Open Reduction and Internal Fixation for Closed Distal Femur Fractures. Orthop Surg 2020; 12:1768-1775. [PMID: 33047488 PMCID: PMC7767690 DOI: 10.1111/os.12812] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 08/21/2020] [Accepted: 08/23/2020] [Indexed: 12/23/2022] Open
Abstract
Objective To investigate whether closed suction drainage (CSD) is related to accelerated rehabilitation of patients after open reduction and internal fixation (ORIF) for closed distal femur fractures. Methods This study was a prospective, randomized controlled clinical trial. Between October 2018 and June 2020, 160 closed distal femur fracture patients who were prepared for ORIF were prospectively randomized into two groups: a CSD group with the mean age of 57.91 ± 14.38 years (32 [40%] men and 48 [60%] women) and a non‐CSD group with the mean age of 59.73 ± 17.55 years (27 [34%] men and 54 [66%] women). Wound visual analogue scale (VAS) pain scores, peri‐wound skin temperature, hematocrit (Hct), hemoglobin (Hb) concentrations, hidden blood loss (HBL), dressing change, period of wound oozing, postoperative blood transfusion, and length of postoperative hospital stay were recorded. Postoperative wound complications, namely wound infections, wound haematoma, wound dehiscence, erythema of wound, and lower limb deep vein thrombosis (DVT) were collected. All the patients were administrated by a single surgical team and followed up for 1 month after the ORIF. Results The patients without CSD were identified with lower peri‐wound skin temperature and wound VAS pain scores during the first three postoperative days (36.69 ± 0.33 vs 36.86 ± 0.38 °C, P = 0.002; 1.88 ± 0.82 vs 3.15 ± 1.15, P = 0.000). However, both the peri‐wound skin temperature and wound VAS pain scores did not differ significantly between the two groups on the fifth postoperative day. In addition, patients with CSD had a longer length of postoperative hospitalization time (11.45 ± 5.95 vs 9.78 ± 4.64 days, P = 0.049). There was no statistically significant difference between CSD and non‐CSD groups within 1 month after the ORIF regarding blood loss, period of wound oozing, and postoperative complications, such as incidence of wound infection, haematoma, erythema, dehiscence, and lower limb DVT. Conclusion Prophylactic CSD after primary ORIF for closed distal femur fractures not only had no significant advantage to minimize blood loss and wound complications, but increased local inflammation and postoperative hospital stay, and thus we suggest that prophylactic CSD after primary ORIF for closed distal femur fractures is not recommended for optimized clinical pathways and accelerated recovery.
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Affiliation(s)
- Jun-Zhe Zhang
- The Third Hospital of Hebei Medical University, Shijiazhuang, China.,Key Laboratory of Biomechanics of Hebei Province, Orthopaedic Research Institution of Hebei Province, Shijiazhuang, China
| | - Kuo Zhao
- The Third Hospital of Hebei Medical University, Shijiazhuang, China.,Key Laboratory of Biomechanics of Hebei Province, Orthopaedic Research Institution of Hebei Province, Shijiazhuang, China
| | - Jun-Yong Li
- The Third Hospital of Hebei Medical University, Shijiazhuang, China.,Key Laboratory of Biomechanics of Hebei Province, Orthopaedic Research Institution of Hebei Province, Shijiazhuang, China.,Department of Orthopaedic Surgery, The Second Hospital of Shijiazhuang City, Shijiazhuang, China
| | - Hong-Yu Meng
- The Third Hospital of Hebei Medical University, Shijiazhuang, China.,Key Laboratory of Biomechanics of Hebei Province, Orthopaedic Research Institution of Hebei Province, Shijiazhuang, China
| | - Yan-Bin Zhu
- The Third Hospital of Hebei Medical University, Shijiazhuang, China.,Key Laboratory of Biomechanics of Hebei Province, Orthopaedic Research Institution of Hebei Province, Shijiazhuang, China
| | - Ying-Ze Zhang
- The Third Hospital of Hebei Medical University, Shijiazhuang, China.,Key Laboratory of Biomechanics of Hebei Province, Orthopaedic Research Institution of Hebei Province, Shijiazhuang, China
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Technical Evidence Review for Emergency Major Abdominal Operation Conducted for the AHRQ Safety Program for Improving Surgical Care and Recovery. J Am Coll Surg 2020; 231:743-764.e5. [PMID: 32979468 DOI: 10.1016/j.jamcollsurg.2020.08.772] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 08/25/2020] [Accepted: 08/25/2020] [Indexed: 02/06/2023]
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Jackson K, Bachhuber M, Bowden D, Etter K, Tong C. Comprehensive Hip Fracture Care Program: Successive Implementation in 3 Hospitals. Geriatr Orthop Surg Rehabil 2019; 10:2151459319846057. [PMID: 31192023 PMCID: PMC6540498 DOI: 10.1177/2151459319846057] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 02/25/2019] [Accepted: 04/02/2019] [Indexed: 01/01/2023] Open
Abstract
Introduction: Hip fractures are common and costly in the elderly population, often contributing to loss of function and independence. Prompt, coordinated surgical care may improve clinical and economic outcomes for this population. Materials and Methods: We created an interdisciplinary care program focused on minimizing time spent immobilized awaiting surgery and streamlining the care pathway for hip fracture. Patients older than 65 years with any hip fracture type including hip fracture repair Diagnosis-Related Group codes (MS-DRG 480, 481, or 482) and MS-DRG 469 and 470 with a hip fracture diagnosis were included in the study. The Hip Fracture Care program (HFCP) was implemented on a staggered basis in 3 hospitals in the HonorHealth system. Time to surgery, length of stay, and discharge location (home/skilled nursing facility) were compared pre- and post-intervention, utilizing an interrupted time series analysis to account for background trends. Results: More than 2000 patients across the 3 facilities received HFCP care; demographics were similar for the 826 patients serving as the pre-implementation comparison group. Mean (standard deviation [SD]) length of stay decreased from 5.6 (4.0) to 4.7 (2.9) days (mean difference 0.9 days; P < .05). Mean (SD) time from admission to the operating room decreased from 30.8 (21.1) to 25.6 (20.5) hours (mean difference 5.2 hours; P < .05). There was no change in the proportion of patients discharged to home versus skilled nursing facility. Discussion: Optimal care of this vulnerable population can significantly reduce the time to surgery and length of stay. Conclusions: Length of stay was reduced by nearly 1 day with implementation of a multifactorial program for hip fracture care.
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Affiliation(s)
- Kelly Jackson
- Neuroscience Service Line, HonorHealth Osborn Medical Campus Administration, HonorHealth System, Scottsdale, AZ, USA
| | | | - Dawn Bowden
- Health Economics & Market Access, Johnson & Johnson, Highlands Ranch, CO, USA
| | - Katherine Etter
- Healthcare Analytics, Health Economics & Market Access, Johnson & Johnson, Raynham, MA, USA
| | - Cindy Tong
- Health Economics & Market Access Analytics, Johnson & Johnson, Bridgewater, NJ, USA
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Kalogera E, Glaser GE, Kumar A, Dowdy SC, Langstraat CL. Enhanced Recovery after Minimally Invasive Gynecologic Procedures with Bowel Surgery: A Systematic Review. J Minim Invasive Gynecol 2019; 26:288-298. [DOI: 10.1016/j.jmig.2018.10.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 10/16/2018] [Accepted: 10/17/2018] [Indexed: 12/16/2022]
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