Hadiza S. Kazaure

Association of Postdischarge Complications With Reoperation and Mortality in General Surgery

OBJECTIVES To describe procedure-specific types, rates, and risk factors for postdischarge (PD) complications occurring within 30 days after 21 groups of inpatient general surgery procedures. DESIGN Retrospective cohort study. SETTING American College of Surgeons National Surgical Quality Improvement Program 2005 through 2010 Participant Use Data Files. PATIENTS A total of 551,510 adult patients who underwent one of 21 groups of general surgery procedures in the inpatient setting. MAIN OUTCOME MEASURES Postdischarge complications, reoperation, and mortality. RESULTS Of 551,510 patients (mean age, 54.6 years), 16.7% experienced a complication; 41.5% occurred PD. Of the PD complications, 75.0% occurred within 14 days PD. Proctectomy (14.5%), enteric fistula repair (12.6%), and pancreatic procedures (11.4%) had the highest PD complication rates. Breast, bariatric, and ventral hernia repair procedures had the highest proportions of complications that occurred PD (78.7%, 69.4%, and 62.0%, respectively). For all procedures, surgical site complications, infections, and thromboembolic events were the most common. Occurrence of an inpatient complication increased the likelihood of a PD complication (12.5% vs 6.2% without an inpatient complication; P < .001). Compared with patients without a PD complication, those with a PD complication had higher rates of reoperation (4.6% vs 17.9%, respectively; P < .001) and death (2.0% vs 6.9%, respectively; P < .001) within 30 days after surgery; those whose PD complication was preceded by an inpatient complication had the highest rates of reoperation (33.7%) and death (24.7%) (all P < .001). After adjustment, PD complications were associated with procedure type, American Society of Anesthesiologists class higher than 3, and steroid use. CONCLUSIONS The PD complication rates vary by procedure, are commonly surgical site related, and are associated with mortality. Fastidious, procedure-specific patient triage at discharge as well as expedited patient follow-up could improve PD outcomes.

The resident as surgeon: An analysis of ACS-NSQIP ☆

BACKGROUND Data on the characteristics and outcomes of patients operated on by surgical residents are limited. METHODS Using ACS-NSQIP (2005-2008), characteristics and outcomes of patients who underwent cholecystectomy, appendectomy, or inguinal hernia repair by a resident (R) without an attending scrubbed in the operating room, a scrubbed attending with resident (AR), or an attending without resident (A) were pooled and compared. Data analyses involved χ(2), ANOVA, and multivariate regression. RESULTS The R group performed <1% of ACS-NSQIP cases; the 10 most common procedures represented 69.1% of cases. There were 912 cases of cholecystectomy, appendectomy, or inguinal hernia repair performed by R. Compared with A/AR patients, R patients were more likely to have inpatient (42.6%, 48.9% versus 64.8%), emergent (28.6%, 30.8% versus 35.5%) , and open procedures (27.0%, 29.4% versus 28.9%) (all P < 0.001). In unadjusted analyses, R patients had higher complication rates (4.8% versus 4.4%, 3.4%, P < 0.001) and longer operating time (64.4 min versus 62.2 min, 44.7 min, P < 0.001) than AR/A patients respectively. After risk adjustment, a resident operating without an attending scrubbed in the operating room was not independently associated with increased complications risk (odds ratio 1.2, 95% CI: 0.8-1.8, P = 0.2). Compared with A/AR patients, there was a 1-min difference in adjusted operating time for patients who underwent surgery by R (P < 0.001). CONCLUSIONS In ACS-NSQIP, a resident rarely performs surgery without an attending scrubbed in the operating room; surgical attendings appear to exercise good judgment in determining the appropriate extent of resident supervision in the operating room without compromising patient outcomes.

Epidemiology and outcomes of in-hospital cardiopulmonary resuscitation in the United States, 2000-2009.

AIM To examine temporal trends in the epidemiology and outcomes of in-hospital cardiopulmonary resuscitation (CPR) recipients at a population level. METHODS Retrospective analysis of temporal trends in CPR incidence, survival to discharge, discharge disposition, hospital length of stay, and cost of hospitalization for CPR recipients (age ≥ 18 years) captured in the Nationwide Inpatient Sample (2000-2009) in the United States. RESULTS Between years 2000 and 2009, CPR incidence increased by 33.7%, from 1 case per 453 to 1 case per 339 hospitalized patients (annual percentage increase: 4.3%, 95% CI: 3.4-5.2%, p<0.001). Compared to CPR recipients in years 2000-2001, those in 2008-2009 were more often younger (age<65 years: 33.4% vs. 40.0%), non-white (29.3% vs. 36.4%), and higher comorbidity scores (score ≥ 4: 22.2% vs. 27.1%) (all p<0.001). Rates of neurologic compromise, mechanical ventilator, and feeding tube use increased by 37.7, 28.2, and 58.5%, respectively (all p<0.001). Adjusted rate of survival to discharge increased by 41.3% (20.6-29.1%, p<0.001). Compared to survivors in 2000, those discharged in 2009 were more often discharged to hospice (0.4% vs. 7.1%, p<0.001); a 35% decrease in discharge to home was noted (36.4% vs. 23.8%, p<0.001). Mean cost of hospitalization per day increased for both survivors (

Medullary thyroid microcarcinoma: a population-level analysis of 310 patients.

2742-

Cardiac Arrest Among Surgical Patients: An Analysis of Incidence, Patient Characteristics, and Outcomes in ACS-NSQIP

3462, p=0.006) and decedents (

Long-term Results of a Postoperative Pneumonia Prevention Program for the Inpatient Surgical Ward

3159-

Insular thyroid cancer: a population-level analysis of patient characteristics and predictors of survival.

4212, p<0.001). CONCLUSIONS The rate of in-hospital CPR in the U.S. increased, and CPR recipients have become younger and sicker over time. Survival to discharge has improved by 41.3%. Functional outcomes after in-hospital CPR appear to have worsened, with considerable clinical and economic implications.

A population-level analysis of 5620 recipients of multiple in-hospital cardiopulmonary resuscitation attempts

Medullary thyroid microcarcinomas (microMTCs) are medullary thyroid carcinomas (MTCs) that measure ≤1 cm in size for which there is a paucity of data on incidence, characteristics, and clinical significance.

Process improvement in surgery

OBJECTIVES To describe the incidence, characteristics, and outcomes of surgical patients who experience cardiac arrest requiring cardiopulmonary resuscitation (CPR). DESIGN Retrospective cohort study. SETTING American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP), 2005-2010. MAIN OUTCOME MEASURES Incidence of CPR, complications, mortality, and survival to hospital discharge at 30 days or less after surgery. RESULTS A total of 6382 nontrauma patients (mean age, 68 years) underwent CPR; 85.9% of events occurred postoperatively, of which 49.8% occurred within 5 days after surgery. Overall incidence of CPR was 1 in 203 surgical cases but varied by specialty (1 in 33 for cardiac surgery vs 1 in 258 for general surgery). The mortality rates varied by specialty (45.0%-74.5%) and were associated with comorbidity burden (58.7% for no comorbidity, 63.1% for 1 comorbidity, and 72.8% for ≥2 comorbidities; P < .001). A total of 77.6% of CPR patients experienced a complication; approximately 75.0% occurred before or on the day of CPR, and septicemia (26.7%), ventilator dependence (22.1%), significant bleeding (13.9%), and renal impairment (11.9%) were the most common. The overall 30-day mortality was 71.6%. Survival to discharge in 30 postoperative days or less was 19.2%; 9.2% of CPR patients were alive but hospitalized at postoperative day 30. Older age, a preexisting do-not-resuscitate order, renal impairment, disseminated cancer, preoperative sepsis, and postoperative arrest were among the factors independently associated with worse survival. CONCLUSIONS One in 203 surgical patients undergoes CPR, and more than 70.0% of patients die in 30 postoperative days or less. Complications commonly precede arrest; prevention or aggressive treatment of these complications may potentially prevent CPR and improve outcomes. These data could aid discussions regarding advance directives among surgical patients.

Leopard frogs move their heads, but not their eyes: Implications for perception of stationary objects

IMPORTANCE Pneumonia is the third most common complication in postoperative patients and is associated with significant morbidity and high cost of care. Prevention has focused primarily on mechanically ventilated patients. This study outlines the results of the longest-running postoperative pneumonia prevention program for nonmechanically ventilated patients, to our knowledge. OBJECTIVE To present long-term results (2008-2012) of a standardized postoperative ward-acquired pneumonia prevention program introduced in 2007 on the surgical ward of our hospital and compare our postintervention pneumonia rates with those captured in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). We also estimate the cost savings attributable to the pneumonia prevention program. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study at a university-affiliated Veterans Affairs hospital of all noncardiac surgical patients with ward-acquired postoperative pneumonia. INTERVENTION A previously described standardized postoperative pneumonia prevention program for patients on the surgical ward. MAIN OUTCOME AND MEASURE Ward-acquired postoperative pneumonia. RESULTS Between 2008 and 2012, there were 18 cases of postoperative pneumonia among 4099 at-risk patients hospitalized on the surgical ward, yielding a case rate of 0.44%. This represents a 43.6% decrease from our preintervention rate (0.78%) (P = .01). The pneumonia rates in all years were lower than the preintervention rate (0.25%, 0.50%, 0.58%, 0.68%, and 0.13% in 2008-2012, respectively). The overall pneumonia rate in ACS-NSQIP was 2.56% (14,033 cases of pneumonia among 547,571 at-risk patients), which is 582% higher than the postintervention rate at our ward. Using a national average of