Christy E. Cauley

A multi-institutional analysis of tracheotomy complications.

To define the prevalence of tracheotomy tube complications and evaluate risk factors (RFs) associated with their occurrence.

Recommendations for Best Communication Practices to Facilitate Goal-concordant Care for Seriously Ill Older Patients With Emergency Surgical Conditions.

OBJECTIVE To address the need for improved communication practices to facilitate goal-concordant care in seriously ill, older patients with surgical emergencies. SUMMARY BACKGROUND DATA Improved communication is increasingly recognized as a central element in providing goal-concordant care and reducing health care utilization and costs among seriously ill older patients. Given high rates of surgery in the last weeks of life, high risk of poor outcomes after emergency operations in these patients, and barriers to quality communication in the acute setting, we sought to create a framework to support surgeons in communicating with seriously ill, older patients with surgical emergencies. METHODS An interdisciplinary panel of 23 national leaders was convened for a 1-day conference at Harvard Medical School to provide input on concept, content, format, and usability of a communication framework. A prototype framework was created. RESULTS Participants supported the concept of a structured approach to communication in these scenarios, and delineated 9 key elements of a framework: (1) formulating prognosis, (2) creating a personal connection, (3) disclosing information regarding the acute problem in the context of the underlying illness, (4) establishing a shared understanding of the patients condition, (5) allowing silence and dealing with emotion, (6) describing surgical and palliative treatment options, (7) eliciting patients goals and priorities, (8) making a treatment recommendation, and (9) affirming ongoing support for the patient and family. CONCLUSIONS Communication with seriously ill patients in the acute setting is difficult. The proposed communication framework may assist surgeons in delivering goal-concordant care for high-risk patients.

Circulating Epithelial Cells in Patients with Pancreatic Lesions: Clinical and Pathologic Findings.

BACKGROUND Circulating epithelial cell (CEC) isolation has provided diagnostic and prognostic information for a variety of cancers, previously supporting their identity as circulating tumor cells in the literature. However, we report CEC findings in patients with benign, premalignant, and malignant pancreatic lesions using a size-selective filtration device. STUDY DESIGN Peripheral blood samples were drawn from patients found to have pancreatic lesions on preoperative imaging at a surgical clinic. Blood was filtered using ScreenCell devices, which were evaluated microscopically by a pancreatic cytopathologist. Pathologic data and clinical outcomes of these patients were obtained from medical records during a 1-year follow-up period. RESULTS Nine healthy volunteers formed the control group and were found to be negative for CECs. There were 179 patients with pancreatic lesions that formed the study cohort. Circulating epithelial cells were morphologically similar in patients with a variety of pancreatic lesions. Specifically, CECs were identified in 51 of 105 pancreatic ductal adenocarcinomas (49%), 7 of 11 neuroendocrine tumors (64%), 13 of 21 intraductal papillary mucinous neoplasms (62%), and 6 of 13 patients with chronic pancreatitis. Rates of CEC identification were similar in patients with benign, premalignant, and malignant lesions (p = 0.41). In addition, CEC findings in pancreatic ductal adenocarcinoma patients were not associated with poor prognosis. CONCLUSIONS Although CECs were not identified in healthy volunteers, they were identified in patients with benign, premalignant, and malignant pancreatic lesions. The presence of CECs in patients presenting with pancreatic lesions is neither diagnostic of malignancy nor prognostic for patients with pancreatic ductal adenocarcinoma.

Predictors of In-hospital Postoperative Opioid Overdose After Major Elective Operations: A Nationally Representative Cohort Study

Objective: The aim of this study was to describe national trends and outcomes of in-hospital postoperative opioid overdose (OD) and identify predictors of postoperative OD. Summary of Background Data: In 2000, the Joint Commission recommended making pain the 5th vital sign, increasing the focus on postoperative pain control. However, the benefits of pain management must be weighed against the potentially lethal risk of opioid OD. Methods: This is a retrospective multi-institutional cohort study of patients undergoing 1 of 6 major elective inpatient operation from 2002 to 2011 using the Nationwide Inpatient Sample, an approximately 20% representative sample of all United States hospital admissions. Patients with postoperative OD were identified using ICD-9 codes for poisoning from opioids or adverse effects from opioids. Multivariate logistic regression was used to identify independent predictors. Results: Among 11,317,958 patients, 9458 (0.1%) had a postoperative OD; this frequency doubled over the study period from 0.6 to 1.1 overdoses per 1000 cases. Patients with postoperative OD died more frequently during their hospitalization (1.7% vs 0.4%, P < 0.001). Substance abuse history was the strongest predictor of OD (odds ratio = 14.8; 95% confidence interval: 12.7–17.2). Gender, age, income, geographic location, operation type, and certain comorbid diseases also predicted OD (P < 0.05). Hospital variables, including teaching status, size, and urban/rural location, did not predict postoperative OD. Conclusions: Postoperative OD is a rare, but potentially lethal complication, with increasing incidence. Postoperative monitoring and treatment safety interventions should be thoughtfully employed to target high-risk patients and avoid this potentially fatal complication.

Outcomes after emergency abdominal surgery in patients with advanced cancer: Opportunities to reduce complications and improve palliative care.

BACKGROUND There is increasing emphasis on the appropriateness and quality of acute surgical care for patients with serious illness and at the end of life. However, there is a lack of evidence regarding outcomes after emergent major abdominal surgery among patients with advanced cancer to guide treatment decisions. This analysis sought to characterize adverse outcomes (mortality, complications, institutional discharge) and to identify factors independently associated with 30-day mortality among patients with disseminated cancer who undergo emergent abdominal surgery for intestinal obstruction or perforation. METHODS This is a retrospective cohort study of 875 disseminated cancer patients undergoing emergency surgery for perforation (n = 499) or obstruction (n = 376) at hospitals participating in the American College of Surgeons’ National Surgical Quality Improvement Program from 2005 to 2012. Predictors of 30-day mortality were identified using multivariate logistic regression. RESULTS Among patients who underwent surgery for perforation, 30-day mortality was 34%, 67% had complications, and 52% were discharged to an institution. Renal failure, septic shock, ascites, dyspnea at rest, and dependent functional status were independent preoperative predictors of death at 30 days. When complications were considered, postoperative respiratory complications and age (75–84 years) were also predictors of mortality. Patients who had surgery for obstruction had a 30-day mortality rate of 18% (n = 68), 41% had complications, and 60% were discharged to an institution. Dependent functional status and ascites were independent predictors of death at 30 days. In addition to these predictors, postoperative predictors of mortality included respiratory and cardiac complications. Few patients (4%) had do-not-resuscitate orders before surgery. CONCLUSION Emergency abdominal operations in patients with disseminated cancer are highly morbid, and many patients die soon after surgery. High rates of complications and low rates of preexisting do-not-resuscitate orders highlight the need for targeted interventions to reduce complications and integrate palliative approaches into the care of these patients. LEVEL OF EVIDENCE Prognostic study, level III; therapeutic study, level IV.

Surgeons' Perspectives on Avoiding Nonbeneficial Treatments in Seriously Ill Older Patients with Surgical Emergencies: A Qualitative Study

BACKGROUND Clinical decisions for seriously ill older patients with surgical emergencies are highly complex. Measuring the benefits of burdensome treatments in this context is fraught with uncertainty. Little is known about how surgeons formulate treatment decisions to avoid nonbeneficial surgery, or engage in preoperative conversations about end-of-life (EOL) care. OBJECTIVE We sought to describe how surgeons approach such discussions, and to identify modifiable factors to reduce nonbeneficial surgery near the EOL. DESIGN Purposive and snowball sampling were used to recruit a national sample of emergency general surgeons. Semistructured interviews were conducted between February and May 2014. MEASUREMENTS Three independent coders performed qualitative coding using NVivo software (NVivo version 10.0, QSR International). Content analysis was used to identify factors important to surgical decision making and EOL communication. RESULTS Twenty-four surgeons were interviewed. Participants felt responsible for conducting EOL conversations with seriously ill older patients and their families before surgery to prevent nonbeneficial treatments. However, wide differences in prognostic estimates among surgeons, inadequate data about postoperative quality of life (QOL), patients and surrogates who were unprepared for EOL conversations, variation in perceptions about the role of palliative care, and time constraints are contributors to surgeons providing nonbeneficial operations. Surgeons reported performing operations they knew would not benefit the patient to give the family time to come to terms with the patients demise. CONCLUSIONS Emergency general surgeons feel responsible for having preoperative discussions about EOL care with seriously ill older patients to avoid nonbenefical surgery. However, surgeons identified multiple factors that undermine adequate communication and lead to nonbeneficial surgery.

Using a Palliative Care Framework for Seriously Ill Surgical Patients The Example of Malignant Bowel Obstruction

In the recent report Dying in America: Addressing Key End of Life Issues, 1 the Institute of Medicine declared improving access to palliative care for seriously ill patients a national priority to address the crisis of low-value health care for patients near the end of life. Patients report comfort, symptom control, and dignity as central to achieving a “good death,” yet increasing numbers experience pain, unwanted health care transitions, and intensive care near the end of life. Surgeons play a critical role as providers of end-of-life care. Among Medicare decedents, almost one-third have surgery in the year before death, many in the last week of life, 2 and up to 25% of patients diagnosed as having stage IV cancer undergo a surgical procedure. Palliative care, an approach to care focused on improving quality of life for patients with lifethreatening illness and their families, is associated with improved symptom management, improved communication, and fewer care transitions for seriously ill patients. Although surgeons routinely care for seriously ill patients, the role of palliative care in surgery remains poorly defined. 3 Herein, we use malignant bowel obstruction (MBO) as an example of how surgeons can integrate principles of palliative care to support surgical care for patients with life-threatening illness. Management of MBO exemplifies the convergence of surgery and palliative care. Although survival varies based on cancer type and prognostic features, MBO is typically a late complication of advanced cancer, with life expectancy limited to weeks or months after onset. 4 Patient suffering can be immense with their remaining days fraught with high symptom burden, impaired quality of life, and hospitalization. Depending on anatomical features of the obstruction, surgical palliation via resection, bypass, or venting gastrostomy may offer select patients significant gains in quality of life. 4,5 However, substantial personal cost may accompany the pursuit of symptom relief in the form of prolonged recovery or burdensome complications, diminishing the benefits of treatment. As surgeons are increasingly called on to provide palliative interventions to seriously ill patients, their patients would benefit from strategies commonly used in palliative care to deliver goal-concordant care that is informed by patients’ values and health care priorities.

Truth in Reporting: How Data Capture Methods Obfuscate Actual Surgical Site Infection Rates within a Health Care Network System.

BACKGROUND: Two systems measure surgical site infection rates following colorectal surgeries: the American College of Surgeons National Surgical Quality Improvement Program and the Centers for Disease Control and Prevention National Healthcare Safety Network. The Centers for Medicare & Medicaid Services pay-for-performance initiatives use National Healthcare Safety Network data for hospital comparisons. OBJECTIVE: This study aimed to compare database concordance. DESIGN: This is a multi-institution cohort study of systemwide Colorectal Surgery Collaborative. The National Surgical Quality Improvement Program requires rigorous, standardized data capture techniques; National Healthcare Safety Network allows 5 data capture techniques. Standardized surgical site infection rates were compared between databases. The Cohen &kgr;-coefficient was calculated. SETTING: This study was conducted at Boston-area hospitals. PATIENTS: National Healthcare Safety Network or National Surgical Quality Improvement Program patients undergoing colorectal surgery were included. MAIN OUTCOME MEASURES: Standardized surgical site infection rates were the primary outcomes of interest. RESULTS: Thirty-day surgical site infection rates of 3547 (National Surgical Quality Improvement Program) vs 5179 (National Healthcare Safety Network) colorectal procedures (2012–2014). Discrepancies appeared: National Surgical Quality Improvement Program database of hospital 1 (N = 1480 patients) routinely found surgical site infection rates of approximately 10%, routinely deemed rate “exemplary” or “as expected” (100%). National Healthcare Safety Network data from the same hospital and time period (N = 1881) revealed a similar overall surgical site infection rate (10%), but standardized rates were deemed “worse than national average” 80% of the time. Overall, hospitals using less rigorous capture methods had improved surgical site infection rates for National Healthcare Safety Network compared with standardized National Surgical Quality Improvement Program reports. The correlation coefficient between standardized infection rates was 0.03 (p = 0.88). During 25 site–time period observations, National Surgical Quality Improvement Program and National Healthcare Safety Network data matched for 52% of observations (13/25). &kgr; = 0.10 (95% CI, –0.1366 to 0.3402; p = 0.403), indicating poor agreement. LIMITATIONS: This study investigated hospitals located in the Northeastern United States only. CONCLUSIONS: Variation in Centers for Medicare & Medicaid Services-mandated National Healthcare Safety Network infection surveillance methodology leads to unreliable results, which is apparent when these results are compared with standardized data. High-quality data would improve care quality and compare outcomes among institutions.

Cytologic characteristics of circulating epithelioid cells in pancreatic disease

Circulating epithelioid cells (CECs), also known as circulating tumor, circulating cancer, circulating epithelial, or circulating nonhematologic cells, are a prognostic factor in various malignancies that can be isolated via various protocols. In the current study, the authors analyzed the cytomorphologic characteristics of CECs isolated by size in a cohort of patients with benign and malignant pancreatic diseases to determine whether cytomorphological features could predict CEC origin.

Survival, Healthcare Utilization, and End-of-life Care Among Older Adults With Malignancy-associated Bowel Obstruction: Comparative Study of Surgery, Venting Gastrostomy, or Medical Management

Objective: To compare survival, readmissions, and end-of-life care after palliative procedures compared with medical management for malignancy-associated bowel obstruction (MBO). Background: MBO is a late complication of intra-abdominal malignancy for which surgeons are frequently consulted. Decisions about palliative treatments, which include medical management, surgery, or venting gastrostomy tube (VGT), are hampered by the paucity of outcomes data relevant to patients approaching the end of life. Methods: Retrospective study using 2001 to 2012 Surveillance, Epidemiology, and End Results-Medicare data of patients 65 years or older with stage IV ovarian or pancreatic cancer who were hospitalized for MBO. Multivariate competing-risks regression models were used to compare the following outcomes: survival, readmission for MBO, hospice enrollment, intensive care unit (ICU) care in the last days of life, and location of death in an acute care hospital. Results: Median survival after MBO admission was 76 days (interquartile range 26–319 days). Survival was shorter after VGT [38 days (interquartile range 23–69)] than medical management [72 days (23–312)] or surgery [128 days (42–483)]. As compared to medical management, patients treated with VGT had fewer readmissions [subdistribution hazard ratio 0.41 (0.29–0.58)], increased hospice enrollment [1.65 (1.42–1.91)], and less ICU care [0.69 (0.52–0.93)] and in-hospital death [0.47 (0.36–0.63)]. Surgery was associated with fewer readmissions [0.69 (0.59–0.80)], decreased hospice enrollment [0.84 (0.76–0.92)], and higher likelihood of ICU care [1.38 (1.17–1.64)]. Conclusions: VGT is associated with fewer readmissions and lower intensity healthcare utilization at the end of life than do medical management or surgery. Given the limited survival, regardless of management, hospitalization with MBO carries prognostic significance and presents a critical opportunity to identify patients’ priorities for end-of-life care.