Samuel R.G. Finlayson

Failure to rescue in safety-net hospitals: availability of hospital resources and differences in performance.

IMPORTANCEnFailure to rescue (FTR), the mortality rate among surgical patients with complications, is an emerging quality indicator. Hospitals with a high safety-net burden, defined as the proportion of patients covered by Medicaid or uninsured, provide a disproportionate share of medical care to vulnerable populations. Given the financial strains on hospitals with a high safety-net burden, availability of clinical resources may have a role in outcome disparities.nnnOBJECTIVESnTo assess the association between safety-net burden and FTR and to evaluate the effect of clinical resources on this relationship.nnnDESIGN, SETTING, AND PARTICIPANTSnA retrospective cohort of 46,519 patients who underwent high-risk inpatient surgery between January 1, 2007, and December 31, 2010, was assembled using the Nationwide Inpatient Sample. Hospitals were divided into the following 3 safety-net categories: high-burden hospitals (HBHs), moderate-burden hospitals (MBHs), and low-burden hospitals (LBHs). Bivariate and multivariate analyses controlling for patient, procedural, and hospital characteristics, as well as clinical resources, were used to evaluate the relationship between safety-net burden and FTR.nnnMAIN OUTCOMES AND MEASURESnFTR.nnnRESULTSnPatients in HBHs were younger (mean age, 65.2 vs 68.2 years; P =u2009.001), more likely to be of black race (11.3% vs 4.2%, P <u2009.001), and less likely to undergo an elective procedure (39.3% vs 48.6%, P =u2009.002) compared with patients in LBHs. The HBHs were more likely to be large, major teaching facilities and to have high levels of technology (8.6% vs 4.0%, P =u2009.02), sophisticated internal medicine (7.7% vs 4.3%, P =u2009.10), and high ratios of respiratory therapists to beds (39.7% vs 21.1%, P <u2009.001). However, HBHs had lower proportions of registered nurses (27.9% vs 38.8%, P =u2009.02) and were less likely to have a positron emission tomographic scanner (15.4% vs 22.0%, P =u2009.03) and a fully implemented electronic medical record (12.6% vs 17.8%, P =u2009.03). Multivariate analyses showed that HBHs (adjusted odds ratio, 1.35; 95% CI, 1.19-1.53; P <u2009.001) and MBHs (adjusted odds ratio, 1.15; 95% CI, 1.05-1.27; P =u2009.005) were associated with higher odds of FTR compared with LBHs, even after adjustment for clinical resources.nnnCONCLUSIONS AND RELEVANCEnDespite access to resources that can improve patient rescue rates, HBHs had higher odds of FTR, suggesting that availability of hospital clinical resources alone does not explain increased FTR rates.

The combined risk of donor quality and recipient age: higher-quality kidneys may not always improve patient and graft survival.

Background The Kidney Donor Profile Index (KDPI) is a more precise donor organ quality metric replacing age-based characterization of donor risk. Little prior attention has been paid on the outcomes of lower-quality kidneys transplanted into elderly recipients. Although we have previously shown that immunological risks associated with older organs are attenuated by advanced recipient age, it remains unknown whether risks associated with lower-quality KDPI organs are similarly reduced in older recipients. Methods Donor organ quality as measured by the KDPI was divided into quintiles (very high, high, medium, low, and very low quality), and Cox proportional hazards was used to assess graft and recipient survival in first-time adult deceased donor transplant recipients by recipient age. Results In uncensored graft survival analysis, recipients older than 69 years had demonstrated comparable outcomes if they received low-quality kidneys compared to medium-quality kidneys. Death-censored analysis demonstrated no increased relative risk when low-quality kidneys were transplanted into recipients aged 70 to 79 years (hazard ratio [HR], 1.11; P=0.19) or older than 79 years (HR, 1.08; P=0.59). In overall survival analysis, elderly recipients gained no relative benefit from medium-quality kidneys over low-quality kidneys (70–79 years: HR, 1.03, P=0.51; >79 years: HR, 1.08; P=0.32). Conclusion Our analysis demonstrates that transplanting medium-quality kidneys into elderly recipients does not provide significant advantage over low-quality kidneys.

A pilot comparison of standardized online surgical curricula for use in low- and middle-income countries.

IMPORTANCEnSurgical conditions are an important component of global disease burden, due in part to critical shortages of adequately trained surgical providers in low- and middle-income countries.nnnOBJECTIVESnTo assess the use of Internet-based educational platforms as a feasible approach to augmenting the education and training of surgical providers in these settings.nnnDESIGN, SETTING, AND PARTICIPANTSnAccess to two online curricula was offered to 75 surgical faculty and trainees from 12 low- and middle-income countries for 60 days. The Surgical Council on Resident Education web portal was designed for general surgery trainees in the United States, and the School for Surgeons website was built by the Royal College of Surgeons in Ireland specifically for the College of Surgeons of East, Central and Southern Africa. Participants completed an anonymous online survey detailing their experiences with both platforms. Voluntary respondents were daily Internet users and endorsed frequent use of both print and online textbooks as references.nnnMAIN OUTCOMES AND MEASURESnLikert scale survey questionnaire responses indicating overall and content-specific experiences with the Surgical Council on Resident Education and School for Surgeons curricula.nnnRESULTSnSurvey responses were received from 27 participants. Both online curricula were rated favorably, with no statistically significant differences in stated willingness to use and recommend either platform to colleagues. Despite regional variations in practice context, there were few perceived hurdles to future curriculum adoption.nnnCONCLUSIONS AND RELEVANCEnBoth the Surgical Council on Resident Education and School for Surgeons educational curricula were well received by respondents in low- and middle-income countries. Although one was designed for US surgical postgraduates and the other for sub-Saharan African surgical providers, there were no significant differences detected in participant responses between the two platforms. Online educational resources have promise as an effective means to enhance the education of surgical providers in low- and middle-income countries.

How should academic surgeons respond to enthusiasts of global surgery

I THINK IT SAFE TO SAY that just about everyone connected to resident recruitment has been amazed by the number ofmedical students whohave had experience with or have expressed interest in work in low-income countries. Indeed, a growing number of our surgical residents envision themselves becoming involved in the nascent branch of global health, now increasingly referred to as global surgery. Given the growth of attention and the fact that many of these trainees are among our brightest and most motivated, global surgery can no longer be ignored as a boutique interest. Many practicing surgeons engaged in volunteer medical mission work have mentored and encouraged surgical trainees interested in global surgery, but the collective response by academic surgeons to global surgery has been mixed. Although some have been very supportive, the more typical response has been simply to ignore the trainees’ interest or to dismiss it as adventurism (which, granted, it sometimes is). This inattention would be understandable if the peak of the trainees’ ambitions were to have an experience with surgical care in an interesting foreign country. However, we are now seeing a growing cadre of trainees for whom this is not the extent of their ambition--trainees who want to build academic careers in global surgery research. The tendency of academic surgeons to ignore global surgery adds insult to injury. Global surgery already suffers plenty of disregard from the global health community. Paul Farmer once famously described global

Preoperative Hypernatremia Predicts Increased Perioperative Morbidity and Mortality

BACKGROUNDnThe prognostic implications of preoperative hypernatremia are unknown. We sought to determine whether preoperative hypernatremia is a predictor of 30-day perioperative morbidity and mortality.nnnMETHODSnWe conducted a cohort study using the American College of Surgeons-National Surgical Quality Improvement Program and identified 908,869 adult patients undergoing major surgery from approximately 300 hospitals from the years 2005 to 2010. We followed the patients for 30-day perioperative outcomes, which included death, major coronary events, wound infections, pneumonia, and venous thromboembolism. Multivariable logistic regression was used to estimate the odds of 30-day perioperative outcomes.nnnRESULTSnThe 20,029 patients (2.2%) with preoperative hypernatremia (>144 mmol/L) were compared with the 888,840 patients with a normal baseline sodium (135-144 mmol/L). Hypernatremia was associated with a higher odds for 30-day mortality (5.2% vs 1.3%; adjusted odds ratio [aOR], 1.44; 95% confidence interval [CI], 1.33-1.56), and this finding was consistent in all subgroups. The odds increased according to the severity of hypernatremia (P < .001 for pairwise comparison for mild [145-148 mmol/L] vs severe [>148 mmol/L] categories). Furthermore, hypernatremia was associated with a greater odds for perioperative major coronary events (1.6% vs 0.7%; aOR, 1.16; 95% CI, 1.03-1.32), pneumonia (3.4% vs 1.5%; aOR, 1.23; 95% CI, 1.13-1.34), and venous thromboembolism (1.8% vs 0.9%; OR, 1.28; 95% CI, 1.14-1.42).nnnCONCLUSIONnPreoperative hypernatremia is associated with increased perioperative 30-day morbidity and mortality.

IMPACT OF SEPSIS ON POSTOPERATIVE RISK OF ARTERIAL AND VENOUS THROMBOSIS

Patients are at higher risk for both arterial and venous thrombosis after surgical interventions, but it is unknown whether some systemic inflammatory responses -in particular sepsis- subsequently increase the risk of thrombosis. We assessed the impact of preoperative sepsis on postoperative risk

Developing a conceptual and practical framework for outcomes measurement to support a quality improvement project in Rwanda: an observational study

Abstract Background A landmark study in 2009 demonstrated that a WHO surgical safety checklist decreased mortality and complications in surgical patients. Attempts to replicate this in the developing world have been mixed. We piloted the implementation of a surgical safety checklist with outcomes measurement in one district hospital in Rwanda, with the goal of creating a scalable model to use in all public hospitals in the country. Methods We sought to develop a conceptual and practical framework for ongoing outcomes measurement that can be applied to quality improvement projects in resource-poor settings. We accomplished this through interviews with global checklist implementation teams and Rwandan hospital staff, as well as observation. Findings We developed the following framework with specific examples from our experience. (1) Define the elements of data collection and who will perform each. In particular, the data audit function must be carefully outlined. (2) Understand the potential motivators for each participant in data collection and align incentives; these may be financial or non-financial. (3) Choose a data collection training method including initiation, maintenance, and troubleshooting. (4) Select a database software considering the following: availability of consistent or intermittent internet access, user interface complexity, flexibility of software for Mac and PC operating systems, need for mobile access, initial and ongoing costs, and technical support. Based on these criteria, we chose to pilot a new offline version of REDCap, which may have important implications for global health projects in settings without consistent internet access. (5) Be flexible. The framework provides a best first guess at the methods that will work for high-quality data collection, but a willingness to change course is critical. Interpretation Monitoring outcomes in quality improvement projects in resource-poor settings is difficult, but a framework makes it possible to effectively plan, initiate, and sustain data collection. Funding Lifebox Foundation, London, UK.