A systematic review to identify the factors that affect failure to rescue and escalation of care in surgery

The Unmet Critical Care Burden at a Central Hospital in a Resource-Limited Setting: A Point Prevalence Study

INTRODUCTION

The unmet burden of critical illness in low-resource settings is unknown. The Modified Early Warning Score (MEWS) is a validated tool that quantifies patient risk for critical illness and higher level of care. This study evaluates the burden of critical illness outside of the ICU using MEWS and predictors of mortality among adult inpatients at a central hospital in Malawi, where ICU capacity is limited.

METHODS

We conducted a prospective cohort study among adult inpatients (≥ 13 years) across medical, surgical, and obstetrics-gynecology wards. MEWS was used to assess critical illness based on respiratory and heart rates, temperature, systolic blood pressure, and mental status. Data were collected over three days in 2024, with follow-ups on Day 7 and Day 30. Statistical analyses included chi-squared, Mann-Whitney, and logistic regression.

RESULTS

Among 315 patients, 62.9% were female, median age was 33 (24-48) years, and 17.5% met critical illness criteria outside of an ICU setting. Critically ill patients had significantly higher inhospital mortality (18.2% vs. 5.4% and p = 0.001) and 30-day mortality (20% vs. 7.3% and p = 0.004). Increasing MEWS strongly predicted mortality (OR = 1.38, 95% CI [1.15, 1.65], and p = 0.001). MEWS is the strongest predictor of critical illness in surgical patients, with the highest mortality increase compared to medicine patients who had similar mortality between both groups.

CONCLUSION

There is a high-unmet burden of critical illness outside of the ICU in our setting, with a resulting high mortality. MEWS effectively stratifies patient risk, particularly in surgical patients. Early identification and intervention and increasing critical care capacity are imperative.

Outcomes and predictors of in-hospital mortality among patients admitted to the intensive care or step-down unit after a rapid response team activation: A retrospective cohort study

INTRODUCTION

It has been demonstrated that the implementation of rapid response teams (RRT) may improve clinical outcomes. Nevertheless, predictors of mortality among patients admitted to the intensive care unit (ICU) or to the step-down unit (SDU) after a RRT activation are not fully understood.

OBJECTIVE

To describe clinical characteristics, resource use, main outcomes, and to address predictors of in-hospital mortality among patients admitted to the ICU/SDU after RRT activation.

METHODS

Retrospective single-center cohort study conducted in a medical-surgical ICU/SDU located in a private quaternary care hospital. Adult patients admitted to the ICU or SDU between 2012 and 2020 were compared according to in-hospital mortality. A multivariate logistic regression analysis was performed to identify independent predictors of in-hospital mortality.

RESULTS

Among the 3841 patients included in this analysis [3165 (82.4%) survivors and 676 (17.6%) non-survivors], 1972 (51.3%) were admitted to the ICU and 1869 (48.7%) were admitted to the SDU. Compared to survivors, non-survivors were older [76 (64-87) yrs. vs. 67 (50-81) yrs.; p < 0.001], had a higher SAPS 3 score [64 (56-72) vs. 49 (40-57); p < 0.001], and had a longer length of stay (LOS) before unit admission [8 (3-19) days vs. 2 (1-7) days; p < 0.001). Non-survivors used more non-invasive ventilation (NIV) (42.2% vs. 20.9%; p < 0.001), mechanical ventilation (MV) (36.7% vs. 9.3%; p < 0.001), vasopressors (39.2% vs. 12.3%; p < 0.001), renal replacement therapy (15.5% vs. 4.3%; p < 0.001), and blood components transfusion (34.9% vs. 14.0%; p < 0.001). Independent predictors of in-hospital mortality were the SAPS 3 score, the Charlson Comorbidity Index, LOS before unit admission, immunosuppression, respiratory rate < 8 or > 28 ipm criteria for RRT activation, RRT activation during the night shift, and the need for high-flow nasal cannula, NIV, MV, vasopressors, and blood components transfusion.

CONCLUSION

Multiple factors may affect outcomes of ICU/SDU-admitted patients after RRT activation. Therefore, efforts should be made to boost RRT effectiveness to improve patient safety.

Impact of postoperative complications on clinical outcomes after gastrectomy for cancer: multicentre study

BACKGROUND

To reduce the clinical and economic burden of complications after gastrectomy for gastric cancer, specific complications should be targeted to effectively allocate healthcare resources for quality improvement and preventive measures. The aim of this study was to assess the impact of complications on clinical outcomes.

METHODS

This was a retrospective multicentre study of patients who underwent (sub)total gastrectomy for gastric or junctional adenocarcinoma at 43 centres in 16 countries between 2017 and 2021. Outcomes were escalation of care, reoperation, prolonged hospital stay (greater than the 75th percentile), readmission, and 30-day mortality. Adjusted relative risks and population attributable fractions were estimated for specific complication-outcome pairs. The population attributable fraction represents the percentage reduction in the frequency of an adverse outcome if a complication could be completely prevented in the population.

RESULTS

In total, 7829 patients were included. Postoperative complications occurred in 1884 patients (24.1%). The most frequent complications were pulmonary complications (436 patients (5.6%)), anastomotic leakage (363 patients (4.6%)), and abdominal collection (301 patients (3.8%)). Anastomotic leakage, cardiac complications, and pulmonary complications had the greatest impact on 30-day mortality (population attributable fraction 26.6% (95% c.i. 14.5% to 38.6%), 18.7% (95% c.i. 9.4% to 28.0%), and 15.6% (95% c.i. 12.0% to 30.0%) respectively). Anastomotic leakage and pulmonary complications had the greatest impact on escalation of care (population attributable fraction 26.3% (95% c.i. 20.6% to 32.0%) and 18.4% (95% c.i. 11.7% to 25.2%) respectively), whereas anastomotic leakage and intra-abdominal bleeding had the greatest impact on reoperation (population attributable fraction 31.6% (95% c.i. 26.4% to 36.9%) and 8.5% (95% c.i. 5.5% to 11.5%) respectively). Most of the studied complications contributed to a prolonged hospital stay, whereas the contribution of complications to readmission did not exceed 15.9%. Subgroup analysis showed regional variation in the impact of complications.

CONCLUSION

Anastomotic leakage had the largest overall negative impact on clinical outcomes after gastrectomy for gastric adenocarcinoma. Reducing the incidence of anastomotic leakage and pulmonary complications would have the most impact on the burden of complications.

Failure to Rescue After Resection of Perhilar Cholangiocarcinoma in an International Multicenter Cohort

BACKGROUND

Failure to rescue (FTR) is defined as the inability to prevent death after the development of a complication. FTR is a parameter in evaluating multidisciplinary postoperative complication management. The aim of this study was to evaluate FTR rates after major liver resection for perihilar cholangiocarcinoma (pCCA) and analyze factors associated with FTR.

PATIENTS AND METHOD

Patients who underwent major liver resection for pCCA at 27 centers were included. FTR was defined as the presence of a Dindo grade III or higher complication followed by death within 90 days after surgery. Liver failure ISGLS grade B/C were scored. Multivariable logistic analysis was performed to identify predictors of FTR and reported using odds ratio and 95% confidence intervals.

RESULTS

In the 2186 included patients, major morbidity rate was 49%, 90-day mortality rate 13%, and FTR occurred in 24% of patients with a grade III or higher complication. Across centers, major complication rate varied from 19 to 87%, 90-day mortality rate from 5 to 33%, and FTR ranged from 11 to 50% across hospitals. Age [1.04 (1.02-1.05) years], ASA 3 or 4 [1.40 (1.01-1.95)], jaundice at presentation [1.79 (1.16-2.76)], right-sided resection [1.45 (1.06-1.98)], and annual hospital volume < 6 [1.44 (1.07-1.94)] were positively associated with FTR. When liver failure is included, the odds ratio for FTR is 9.58 (6.76-13.68).

CONCLUSION

FTR occurred in 24% of patients after resection for pCCA. Liver failure was associated with a nine-fold increase of FTR and hospital volume below six was also associated with an increased risk of FTR.

Successfully initiating an escalation of care in acute ward settings-A qualitative observational study

AIMS

To address knowledge gaps by (i) developing a theoretical understanding of escalation and (ii) identifying escalation success factors.

DESIGN

Non-participant observations were used to examine deteriorating patient escalation events.

METHODS

Escalation event data were collected by a researcher who shadowed clinical staff, between February 16th 2021 and March 17th 2022 from two National Health Service Trusts. Events were analysed using Framework Analysis. Escalation tasks were mapped using a Hierarchical Task Analysis diagram and data presented as percentages, frequency and 95% CI.

RESULTS

A total of 38 observation sessions were conducted, totaling 105 h, during which 151 escalation events were captured. Half of these were not early warning score-initiated and resulted from bleeding, infection, or chest pain. Four communication phenotypes were observed in the escalation events. The most common was Outcome Focused Escalation, where the referrer expected specific outcomes like blood cultures or antibiotic prescriptions. Informative Escalations were often used when a triggering patient's condition was of low clinical concern and ranked as the second most frequent escalation communication type. General Concern Escalations occurred when the referrer did not have predetermined expectations. Spontaneous Interaction Escalations were the least frequently observed, occurring opportunistically in communal workspaces.

CONCLUSION

Half of the events were non-triggering escalations and understanding these can inform the design of systems to support staff better to undertake them. Escalation is not homogenous and differing escalation communication phenotypes exist. Informative Escalations represent an organizational requirement to report triggering warning scores and a targeted reduction of these may be organizationally advantageous. Increasing the frequency of Spontaneous Escalations, through hospital designs, may also be beneficial.

IMPACT STATEMENT

Our work highlights that a significant proportion of escalation workload occurs without a triggering early warning score and there is scope to better support these with designed systems. Further examination of reducing Informative and increasing Spontaneous Escalations is also warranted.

PATIENT AND PUBLIC CONTRIBUTION

Extensive PPIE was completed throughout the lifecycle of this study. PPIE members validated the research questions and overarching aims of the overall study. PPIE members contributed to the design of the study reviewed documents and the final data generated.

Is personhood lost after mental illness? Exploring the dynamic interface between personhood and mental illness in Ghana

Understanding of local conceptions of personhood and mental illness is central for developing therapeutic alliance and treatment regimens for persons living with mental illness. Such persons are exposed to several discriminatory behaviours yet factors that seem to encourage these behaviours are still not entirely understood. Personhood as construed from an emic perspective could potentially guide an understanding of societal attitudes toward individuals suffering from mental illness. This study explored Akan and Ewe conceptions of personhood in relation to mental illness. Using a semi-structured interview guide, seven Focused Group Discussions (FGDs) were conducted in the Tutu and Taviefe communities of the Eastern and Volta Regions of Ghana. A thematic analysis of interviews brought out three main themes: loss of sense of personhood during mental illness; liminality of personhood status after mental illness; and restoration of personhood status. Within these conceptions, activities such as restoring routines and occupational therapy could be utilized to "restore personhood" at least at the performative level. This demonstrates the dynamic interface between notions of personhood and mental illness with implications for stigma reduction.

A Process-Based Standardization of an Intraoperative Escalation Protocol in Anesthesiology

Prompt recognition and management of critical events is pivotal for the provision of safe anesthetic care. This requires a well-functioning team that focuses on effective communication, timely decision-making, and escalation of potential complications. We believe that variation in bedside care leads to "near-misses," adverse outcomes, and serious safety events (SSEs). The principles of an escalation culture have been used successfully in other highly reliable industries such as aviation, military, and manufacturing. We discuss here the introduction of a unique and compelling thought-process for developing an intraoperative escalation protocol that is specifically tailored for our institution. Inspired by a critical intraoperative event, this departmental protocol was developed based on an analysis of multispecialty literature and expert opinion to decrease the incidence of SSEs. It includes a stepwise approach and incorporates patient-specific information to guide team members who encounter dynamic clinical situations. The implementation of the protocol has facilitated continuous quality improvement through iterative education, improving communication, and enhancing decision-making. Concurrently, we have plans to incorporate technology and electronic decision support tools to enhance real-time communication, monitor performance, and foster a culture of safety.

Development of a scale to assess nurses' difficulties in collaborating with physicians in responding to clinical deterioration during night shifts

AIMS

To develop a scale to assess difficulties that nurses experience when collaborating with physicians in responding to clinical deterioration during night shifts and identify factors associated with scoring using the developed scale.

METHODS

A web-based questionnaire with a draft scale, the Nighttime Collaboration Difficulties between Nurses and Physicians for Nurses (NCDNP-N), was distributed to nurses working night shifts in acute-care hospitals across Japan. Data were collected between July and October 2023. Of 435 responses, 405 were examined for the NCDNP-N's psychometric validation, including structural validity, criterion-related validity, and reliability assessments. Multiple linear regression analysis was performed for 385 responses excluded by listwise methods to identify factors associated with NCDNP-N scores.

RESULTS

The NCDNP-N has 10 items and three domains: Domain 1, dissatisfaction with physicians' actions; Domain 2, burden of working with night-shift physicians; and Domain 3, barriers to reporting during night shifts. Estimated reliability coefficients exceeded the recommended values. Multiple regression analyses demonstrated that more years of experience in the current ward and frequency of calling the covering physician at night were markedly associated with higher scores, whereas more nursing experience was associated with lower scores.

CONCLUSION

We developed the NCDNP-N and confirmed its validity and reliability. The study results suggest that the responsibilities and competence of nurses working night shifts and communication with the night-covering physician are associated with difficulties in nighttime collaboration. The NCDNP-N may help identify challenges in clinical settings as well as can be utilized in the evaluation study for improving nighttime collaboration.

Listen to me, I really am sick! Patient and family narratives of clinical deterioration before and during rapid response system intervention

AIM

To explore patient and family narratives about their recognition and response to clinical deterioration and their interactions with clinicians prior to and during Medical Emergency Team (MET) activations in hospital.

BACKGROUND

Research on clinical deterioration has mostly focused on clinicians' roles. Although patients and families can identify subtle cues of early deterioration, little research has focused on their experience of recognising, speaking up and communicating with clinicians during this period of instability.

DESIGN

A narrative inquiry.

METHODS

Using narrative interviewing techniques, 33 adult patients and 14 family members of patients, who had received a MET call, in one private and one public academic teaching hospital in Melbourne, Australia were interviewed. Narrative analysis was conducted on the data.

RESULTS

The core story of help seeking for recognition and response by clinicians to patient deterioration yielded four subplots: (1) identifying deterioration, recognition that something was not right and different from earlier; (2) voicing concerns to their nurse or by family members on their behalf; (3) being heard, desiring a response acknowledging the legitimacy of their concerns; and (4) once concerns were expressed, there was an expectation of and trust in clinicians to act on the concerns and manage the situation.

CONCLUSION

Clinical deterioration results in an additional burden for hospitalised patients and families to speak up, seek help and resolve their concerns. Educating patients and families on what to be concerned about and when to notify staff requires a close partnership with clinicians.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Clinicians must create an environment that enables patients and families to speak up. They must be alert to both subjective and objective information, to acknowledge and to act on the information accordingly.

REPORTING METHOD

The consolidated criteria for reporting qualitative research (COREQ) guidelines were used for reporting.

PATIENT OR PUBLIC CONTRIBUTION

The consumer researcher was involved in design, data analysis and publication preparation.

Feasibility and Accuracy of Wrist-Worn Sensors for Perioperative Monitoring During and After Major Abdominal Surgery: An Observational Study

INTRODUCTION

Continuous, ambulatory perioperative monitoring using wearable devices has shown promise for earlier detection of physiological deterioration and postoperative complications, preventing 'failure-to-rescue'. This study aimed to compare the accuracy of vital signs measured by wrist-based wearables with gold standard measurements from vital signs monitors or nurse assessments in major abdominal surgery.

METHODS

Adult patients were eligible for inclusion in this prospective observational study validating the Empatica E4 wrist sensor intraoperatively and postoperatively. The primary outcomes were the 95% limits of agreement (LoA) between manual and device recordings of heart rate (HR) and temperature evaluated via Bland-Altman analysis. Secondary analysis was conducted using Clarke-Error grid analysis.

RESULTS

Overall, 31 patients were recruited, and 27 patients completed the study. The median duration of recording per patient was 70.3 h, and a total of 2112 h of data recording were completed. Wrist-based HR measurement was accurate and moderately precise (bias: 0.3 bpm; 95% LoA -15.5 to 17.1), but temperature measurement was neither accurate nor precise (bias -2.2°C; 95% LoA -6.0 to 1.6). On Clarke-Error grid analysis, 74.5% and 29.6% of HR and temperature measurements, respectively, fell within the acceptable range of reference standards.

CONCLUSIONS

Continuous perioperative monitoring of HR and temperature after major abdominal surgery using wrist-based sensors is feasible but was limited in this study by low precision. While wrist-based devices offer promise for the continuous monitoring of high-risk surgical patients, current technology is inadequate. Ongoing device hardware and software innovation with robust validation is required before such technologies can be routinely adopted in clinical practice.

The effect of a single dose of methylphenidate on attention in children and adolescents with ADHD and comorbid Oppositional Defiant Disorder

The co-occurrence Oppositional Defiant Disorder (ODD) in children and adolescents with Attention Deficit Hyperactivity Disorder (ADHD) has been associated to difficulties in regulating adverse states, elevated functional impairment, deficits in Executive Functions and high risk for psychopathology. Recent studies have shown that ODD is a negative predictor of a positive response to methylphenidate (MPH) treatment for ADHD symptoms in children and adolescents and that patients with a diagnosis of comorbid ADHD and ODD are less likely to respond favorably to pharmacological treatment with MPH. We conducted a naturalistic study to understand the clinical characteristics of drug-naïve children and adolescents with ADHD that influence the response to MPH by measuring the effect on attention. Specifically, we investigated whether a single dose of MPH differently affects the performance of 53 children and adolescents with ADHD with or without ODD comorbidity. In addition, participant characteristics such as symptom severity, functional impairment, and associated behavioral and emotional symptoms at baseline were examined to better understand what aspects affect the response to MPH. We found that a single dose of MPH improved the attention of children and adolescents with ADHD without ODD more than those with comorbid ADHD and ODD, resulting in reduced reaction times. Our findings indicated that children and adolescents with comorbid ADHD and ODD and those with ADHD alone did not exhibit differences in measures of attention prior to taking MPH, nor in demographic variables (age, intelligence quotient, gender), clinical characteristics related to symptom severity, and adaptive behaviors. However, we observed differences between the two groups in certain behavioral aspects, including the Dysregulation Profile and disruptive behaviors. Assessing symptoms in combination with the presence of ADHD can be beneficial in determining which individuals would derive the greatest benefits from treatment.

Night Physician-Nurse Collaboration: Developing the Scale of Physicians' Difficulties and Exploring Related Factors in Acute Care Hospitals

Background

Responding to inpatient deterioration is less favorable at night than during the day, and this may be related to barriers in collaboration between physicians and nurses. However, there had been no way to assess the problem. This study aimed to develop a scale for physicians to measure difficulties in nighttime collaboration with nurses in response to deteriorating inpatients and to identify factors associated with the developed scale scores.

Methods

We developed a draft scale of Nighttime Collaboration Difficulties between Nurses and Physicians for Physicians (NCDNP-P) based on key informant interviews with physicians. Psychometric validations, including structural validity, criterion-related validity, and reliability tests, were conducted among physicians who worked on night duty or on call in acute-care hospitals in Japan using a cross-sectional web-based questionnaire. Multiple linear regression analyses were performed using independent variables including individual backgrounds, style of working at night, and facility characteristics.

Results

By performing exploratory factor analysis, we confirmed the structural validity of the NCDNP-P, consisting of seven items and two domains (Domain 1: Dissatisfaction with reporting, Domain 2: Barriers to working with nurses). Cronbach's alpha and McDonald's omega coefficients were 0.81-0.84 and 0.81-0.89, respectively. The criterion-related validity for interprofessional collaboration was confirmed. Multiple regression analysis revealed that the variables employment status, number of night shifts, frequency of nighttime calls about patients under another physician's charge, and handover between physicians before changing shifts were statistically significantly associated with NCDNP-P scores.

Conclusion

We developed the NCDNP-P, confirming its reliability and validity. Identified factors reflect physicians' characteristics and the problems experienced working at night and may be associated with barriers in nighttime collaboration. The NCDNP-P can highlight issues in clinical settings and lead to the consideration of initiatives to address such issues.

Rescue from complications after pancreaticoduodenectomies at a low-volume Caribbean center: Value of tailored peri-pancreatectomy protocols

BACKGROUND

Pancreaticoduodenectomy (PD) is a technically complex operation, with a relatively high risk for complications. The ability to rescue patients from post-PD complications is as a recognized quality measure. Tailored protocols were instituted at our low volume facility in the year 2013.

AIM

To document the rate of rescue from post-PD complications with tailored protocols in place as a measure of quality.

METHODS

A retrospective audit was performed to collect data from patients who experienced major post-PD complications at a low volume pancreatic surgery unit in Trinidad and Tobago between January 1, 2013 and June 30, 2023. Standardized definitions from the International Study Group of Pancreatic Surgery were used to define post-PD complications, and the modified Clavien-Dindo classification was used to classify post-PD complications.

RESULTS

Over the study period, 113 patients at a mean age of 57.5 years (standard deviation [SD] ± 9.23; range: 30-90; median: 56) underwent PDs at this facility. Major complications were recorded in 33 (29.2%) patients at a mean age of 53.8 years (SD: ± 7.9). Twenty-nine (87.9%) patients who experienced major morbidity were salvaged after aggressive treatment of their complication. Four (3.5%) died from bleeding pseudoaneurysm (1), septic shock secondary to a bile leak (1), anastomotic leak (1), and myocardial infarction (1). There was a significantly greater salvage rate in patients with American Society of Anesthesiologists scores ≤ 2 (93.3% vs 25%; P = 0.0024).

CONCLUSION

This paper adds to the growing body of evidence that volume alone should not be used as a marker of quality for patients requiring PD. Despite low volumes at our facility, we demonstrated that 87.9% of patients were rescued from major complications. We attributed this to several factors including development of rescue protocols, the competence of the pancreatic surgery teams and continuous, and adaptive learning by the entire institution, culminating in the development of tailored peri-pancreatectomy protocols.

Requirements for hospitals in Japan to have low operative mortality and failure-to-rescue rates

Aim

We explored institutional factors in Japan associated with lower operative mortality and failure-to-rescue (FTR) rates for eight major gastrointestinal procedures.

Methods

A 22-item online questionnaire was sent to 2119 institutional departments (IDs) to examine the association between institutional factors and operative mortality and FTR rates. IDs were classified according to the number of annual surgeries, board certification status, and locality. In addition, the top 20% and bottom 20% of IDs were identified based on FTR rates and matched with the results of the questionnaire survey. Factors associated with operative mortality were selected by multivariate analysis.

Results

Of the 1083 IDs that responded to the questionnaire, 568 (213 382 patients) were included in the analysis. Operative morbidity, operative mortality, and FTR rates in the top 20% and bottom 20% of IDs were 13.1% and 8.4% (p < 0.001), 0.52% and 4.3% (p < 0.001), and 4.0% and 51.2% (p < 0.001), respectively. Based on the patients' background characteristics, the top 20% of IDs handled more advanced cases. No significant difference in locality was seen between better or worse hospital FTR rates, but fewer esophagectomies, hepatectomies, and pancreatoduodenectomies were performed in depopulated areas. Six items were found to be associated with operative mortality by multivariate logistic analysis. Only 50 (8.8%) IDs met all five factors related to better FTR rates.

Conclusions

The present findings indicate that several hospital factors surrounding surgical treatment, characterized by abundant human resources, are closely related to better postoperative recovery from severe complications.

Timing and Morbidity of Intracranial Meningioma Resection Complications

BACKGROUND

Intracranial meningioma resection is associated with multiple acute postoperative complications, including cerebrovascular accidents, surgical site infections, and pneumonia. There is a paucity of research on the postoperative timeframe of these complications. Therefore, our objective is to characterize intracranial meningioma resection complications' time courses.

METHODS

The National Surgical Quality Improvement Project registry was queried for intracranial meningioma resection cases using CPT codes 61512 and 61519 from years 2016 to 2021. Baseline patient characteristics and 30-day complication frequency were calculated. The mean, median, and interquartile range of postoperative days to occurrence for 17 complications were calculated. Percent incidence predischarge was recorded. Time-to-occurrence curves were created. Rates of 30-day mortality and increased length-of-stay were compared between patients with and without each complication using a χ2 test. A covariance matrix showing associations between 11 complications using the Pearson method was made. Significance was set at P < 0.05.

RESULTS

Ten thousand eight hundred ninety cases were analyzed. The most frequent complications' median and interquartile range of postoperative days to occurrence and percentage occurring predischarge were bleeding requiring transfusion (0.0, 0.0-0.0, 99.9%), cerebrovascular accident/stroke with neurological deficit (2.0, 1.0-6.0, 83.8%), unplanned intubation (4.0, 1.0-8.0, 75.1%), on a ventilator for >48 hours (3.0; 2.0-5.5; 88.1%), deep vein thrombosis/thrombophlebitis (12.5, 5.2-19.7, 41.3%), urinary tract infection (13.0, 7.0-20.0, 44.2%), pneumonia (8.0, 4.0-16.0, 60.5%), and pulmonary embolism (14.0, 6.0-20.0, 29.1%). Most complications were associated with increased mortality and length-of-stay.

CONCLUSIONS

Postoperative meningioma resection complications have varying morbidity and timeframes. Surgeons should be aware of complication timing to better manage postoperative care.

Failure to rescue following postoperative pneumonia in pediatrics: Is there a racial disparity?

INTRODUCTION

Racial disparities in measures of health and healthcare processes are well described. Limited work exists on disparities in failure to rescue - hospital mortality following a major adverse event. Postoperative pneumonia is a serious, potentially preventable adverse event that often leads to death, i.e., failure to rescue. This study examined the association of racial grouping with failure to rescue following postoperative pneumonia.

METHODS

We utilized the National Surgical Quality Improvement Program-Pediatrics Participant Use Data File to assemble a cohort of children <18 years who underwent inpatient surgery from 2012 to 2022. We included Black and White patients who developed pneumonia following an index surgery. The primary outcome was failure to rescue, defined as mortality following postoperative pneumonia. We used logistic regression models to estimate the odds ratio and 95% confidence intervals of failure to rescue, comparing Black and White children.

RESULTS

The study cohort included 3139 children <18 years who developed pneumonia following inpatient surgery. Of those, 2333 (74.3%) were White and 806 (25.7%) were Black. Failure to rescue occurred in 117 of the children (3.7%); 82 were White (3.5%) and 35 were Black (4.3%). After adjusting for gender, age, American Society of Anesthesiologists Physical Status classification, emergent/urgent vs. elective case status, year of operation, and pre-existing comorbidities, the odds of failure to rescue for Black children with postoperative pneumonia did not differ from White children (adjusted-Odds Ratio: 1.00; 95% Confidence Interval 0.62-1.61; p-value = .992).

CONCLUSION

We found no significant difference in the odds of failure to rescue following postoperative pneumonia between Black or White children. To improve postoperative care for all children and to narrow the racial gap in postoperative mortality, future studies should continue to investigate the association of race with failure to rescue following other postoperative complications.

Impact of hospital volume on failure to rescue for complications requiring reoperation after elective colorectal surgery: multicentre propensity score-matched cohort study

BACKGROUND

It has previously been reported that there are similar reoperation rates after elective colorectal surgery but higher failure-to-rescue (FTR) rates in low-volume hospitals (LVHs) versus high-volume hospitals (HVHs). This study assessed the effect of hospital volume on reoperation rate and FTR after reoperation following elective colorectal surgery in a matched cohort.

METHODS

Population-based retrospective multicentre cohort study of adult patients undergoing reoperation for a complication after an elective, non-centralized colorectal operation between 2006 and 2017 in 11 hospitals. Hospitals were divided into either HVHs (3 hospitals, median ≥126 resections per year) or LVHs (8 hospitals, <126 resections per year). Patients were propensity score-matched (PSM) for baseline characteristics as well as indication and type of elective surgery. Primary outcome was FTR.

RESULTS

A total of 6428 and 3020 elective colorectal resections were carried out in HVHs and LVHs, of which 217 (3.4%) and 165 (5.5%) underwent reoperation (P < 0.001), respectively. After PSM, 142 patients undergoing reoperation remained in both HVH and LVH groups for final analyses. FTR rate was 7.7% in HVHs and 10.6% in LVHs (P = 0.410). The median Comprehensive Complication Index was 21.8 in HVHs and 29.6 in LVHs (P = 0.045). There was no difference in median ICU-free days, length of stay, the risk for permanent ostomy or overall survival between the groups.

CONCLUSION

The reoperation rate and postoperative complication burden was higher in LVHs with no significant difference in FTR compared with HVHs.

Evaluation of Surgical Clinic Nurses' Knowledge Levels About Palliative Surgery

BACKGROUND

Currently, palliative care plays an important role in increasingly aging populations and their long-term care needs. Surgical palliative care is important for improving quality of life. This study aimed to determine the knowledge level of nurses working in surgical clinics about palliative surgery.

METHOD

This research was conducted as a descriptive study. We included 182 nurses working in surgical clinics who agreed to participate and met the inclusion criteria for participation in the study. The Personal Information and Palliative Surgery Information Forms were used to collect data. Data were collected between November 30, and December 15, 2022. The analysis of the data obtained was performed using the Statistical Program in Social Sciences (SPSS), Version 25. The level of significance was set at P < .05.

RESULTS

Nurses referred to palliative care as end-of-life care, 73.1% did not care for palliative care patients, and 84.6% did not receive training in palliative care. Surgical clinic nurses were found to have "moderate knowledge about palliative surgery. A statistically significant difference was found between the average palliative surgery knowledge of surgical clinic nurses and those trained in education and palliative care (P < .05).

CONCLUSIONS

The results of the study showed that surgical clinic nurses had moderate knowledge about palliative surgery. Moreover, the nurses who have received training in palliative care and had high level of education exhibited a higher level of knowledge.

Nurses' Self-Leadership in the Face of Challenging Situations, Such as Patient Deterioration

Background

Nurses play an essential role as frontline caregivers, particularly in recognizing and responding to patient deterioration. This study addresses nurses' self-leadership in the face of challenging situations such as patient deterioration, emphasizing the importance of self-leadership skills in navigating complex patient care scenarios. Delayed recognition of subtle changes in patient's conditions has been linked to adverse outcomes, necessitating a closer examination of the role of self-leadership in nursing practice.

Objective

The objective of this research was to explore and understand the implications of self-leadership among nurses when confronted with challenging situations, specifically focusing on patient deterioration.

Methods

A qualitative, exploratory, and descriptive research design was employed, utilizing focus group discussions (FGDs) with nurses from a private hospital in Pretoria, South Africa. Semistructured interview guide facilitated the FGDs, and data saturation was achieved after the eight sessions. The sample included nurses with various qualifications and shifts, offering diverse perspectives on self-leadership in patient care. Rigorous data collection and trustworthiness measures, including member checking and verbatim transcriptions, were employed to enhance the conformability of the study.

Results

The findings revealed six overarching themes and 15 subthemes, demonstrating the interconnectedness of self-leadership and nursing practice. Themes included responsibility and autonomy, compassion and care, support and collaboration, learning from experience, teamwork, and appreciation and recognition. These themes explained how nurses actively engaged in self-observation, constructive thought patterns, and natural reward strategies to proactively address patient deterioration.

Conclusion

The study underlines the significance of integrating self-leadership principles into nursing practice. Embracing self-leadership in nursing holds promise for improving patient outcomes and nurturing a resilient and competent nursing workforce.

Enhancing effective healthcare communication in Australia and Aotearoa New Zealand: Considerations for research, teaching, policy, and practice

Objective

In this article we present a conceptual framework for enhancing effective healthcare communication in Australia and Aotearoa New Zealand.

Methods

Through an iterative, deliberative dialogue approach, we, as experts from a variety of health professions and academic disciplines, worked together to identify core values and considerations for healthcare communication across numerous health professions and disciplines and within research, teaching, policy, and practice contexts.

Results

The framework developed includes five core values at its centre: equitable, inclusive, evidence-based, collaborative, reflective. Around this are concentric circles showing key elements of collaborators, modality, context, and purpose. Each of these is explored.

Conclusion

This work may support benchmarking for healthcare providers, researchers, policymakers, and educators across a breadth of professions to help improve communication in clinical practice. The framework will also help to identify areas across disciplines that are shared and potentially idiosyncratic for various professions to promote interprofessional recognition, education, and collaboration.

Innovation

This framework is designed to start conversations, to form the foundation of a dialogue about the priorities and key considerations for developing teaching curricula, professional development, and research programs related to healthcare communication, providing a set of values specifically for the unique contexts of Australia and Aotearoa New Zealand. It can also be used to guide interdisciplinary healthcare professionals in advancing research, teaching, policy, and practice related to healthcare communication.

A Delphi Process to Identify Relevant Outcomes That May Be Associated With a Predictive Analytic Tool to Detect Hemodynamic Deterioration in the Intensive Care Unit

Background The critical care literature has seen an increase in the development and validation of tools using artificial intelligence for early detection of patient events or disease onset in the intensive care unit (ICU). The hemodynamic stability index (HSI) was found to have an AUC of 0.82 in predicting the need for hemodynamic intervention in the ICU. Future studies using this tool may benefit from targeting those outcomes that are more relevant to clinicians and most achievable. Methods A three-round Delphi study was conducted with a panel of 10 critical care physicians and three nurses in the United States to identify outcomes that may be most relevant and achievable with the HSI when evaluated for use in the ICU. To achieve criteria for relevance, at least 65% of panelists had to rate an outcome as a 4 or 5 on a 5-point scale. Results Nineteen of 24 outcomes that may be associated with the HSI achieved consensus for relevance. The Kemeny-Young approach was used to develop a matrix depicting the distribution of outcomes considering both relevance and achievability. "Reduces time spent in hemodynamic instability" and "reduces times to recognition of hemodynamic instability" were the highest-ranking outcomes considering both relevance and achievability. Conclusion This Delphi study was a feasible method to identify relevant outcomes that may be associated with an appropriate predictive analytic tool in the ICU. These findings can provide insight to researchers looking to study such tools to impact outcomes relevant to critical care practitioners. Future studies should test these tools in the ICU that target the most clinically relevant and achievable outcomes, such as time spent hemodynamically unstable or time until actionable nursing assessment or treatment.

Development and Implementation of an Escalation Protocol for Internal Medicine Trainees

Background

Overnight, physicians in training receive less direct supervision. Decreased direct supervision requires trainees to appropriately assess patients at risk of clinical deterioration and escalate to supervising physicians. Failure of trainees to escalate contributes to adverse patient safety events.

Objective

To standardize the evaluation of patients at risk of deterioration overnight by internal medicine residents, increase communication between residents and supervising physicians, and improve perceptions of patient safety at a tertiary academic medical center.

Methods

A multidisciplinary stakeholder team developed an overnight escalation-of-care protocol for residents. The protocol was implemented with badge buddies and an educational campaign targeted at residents, supervising physicians, and nursing staff. Residents and supervising physicians completed anonymous surveys to assess the use of the protocol; the frequency of overnight communication between residents and supervising physicians; and perceptions of escalation and patient safety before, immediately after ("early postintervention"), and 8 months after ("delayed postintervention") the intervention.

Results

Seventy-five (100%) residents participated in the intervention, and 57-89% of those invited to complete surveys at the various time points responded. After the intervention, 82% of residents reported using the protocol, though no change was observed in the frequency of communication between residents and supervising physicians. After the implementation, residents perceived that patient care was safer (early postintervention, 47%; delayed postintervention, 72%; P = 0.02), and interns expressed decreased fear of waking and being criticized by supervising physicians.

Conclusion

An escalation-of-care protocol was developed and successfully implemented using a multimodal approach. The implementation and dissemination of the protocol standardized resident escalation overnight and improved resident-perceived patient safety and interns' comfort with escalation.

Racial Disparities in Pediatric Mortality Following Transfusion Within 72 Hours of Operation

BACKGROUND

Postoperative bleeding and transfusion are correlated with mortality risk. Furthermore, postoperative bleeding may often initiate the cascade of complications that leads to death. Given that minority children have increased risk of surgical complications, this study aimed to investigate the association of race with pediatric surgical mortality following postoperative transfusion.

METHODS

We used the NSQIP-P PUF to assemble a retrospective cohort of children <18 who underwent inpatient surgery during 2012-2021. We included White, Black, Hispanic, and 'Other' children who received a transfusion within 72 h of surgery. The primary outcome was defined as all-cause mortality within 30 days following the primary surgical procedure. Using logistic regression models, we estimated the risk-adjusted odds ratio (aOR) and 95% confidence intervals (CI) of mortality, comparing each racial/ethnic cohort to White children.

RESULTS

A total of 466,230 children <18 years of age underwent inpatient surgical procedures from 2012 to 2021. Of these, 46,200 required transfusion and were included in our analysis. The majority of patients were non-Hispanic White (64.6%, n = 29,850), while 18.9% (n = 8752) were non-Hispanic Black, 11.7% (n = 5387) were Hispanic, and 4.8% (n = 2211) were 'Other' race. The overall rate of mortality following transfusion was 2.5%. White children had the lowest incidence of mortality (2.0%), compared to children of 'Other' race (2.5%), Hispanic children (3.1%), and Black children (3.6%). After adjusting for sex, age, comorbidities, case status, preoperative transfusion within 48 h, and year of operation, we found that Black children experienced 1.24 times the odds of mortality following a postoperative transfusion compared to a White child (aOR: 1.24; 95%CI, 1.03-1.51; P = 0.025). Hispanic children were also significantly more likely to die following a postoperative transfusion than White children (aOR: 1.19; 95%CI, 1.02-1.39; P = 0.027).

CONCLUSION

We found that minority children who required a postoperative transfusion had a higher odds of death than White children. Future studies should explore adverse events following postoperative transfusion and the differences in their management by race that may contribute to the higher mortality rate for minority children.

LEVEL OF EVIDENCE

Level II.

CLINICAL TRIAL NUMBER AND REGISTRY

Not applicable.

The three ages balance for patient safety

The evolution of the patient safety perspectives, the technological age, the human factor age and the safety management age, have no clear cut and coexist. The current edition of the Current Opinion in Anesthesiology Technology, Education and Safety section presents an eclectic compendium of articles addressing these views from the technological improvements, human factor developments and organizational safety management impacting patient safety. Every solution, every patch to fill the cheese hole, holding the domino piece to fall, opens a new disruption elsewhere that needs to be addressed following the zero-preventable harm path.

Call 4 Concern: the impact of a patient-and-relative-activated service

The aim of this project was to introduce and evaluate the Call 4 Concern© (C4C) service, which provides patients and relatives with direct access to critical care outreach services (CCOS). This allows patients and relatives an additional platform to raise concerns related to the clinical condition and facilitate early recognition of a deteriorating patient. The introduction of Call 4 Concern at a district general hospital was inspired by the Royal Berkshire Hospital, where staff have been pioneering the service in the UK since 2009. They were able to demonstrate the potential to prevent clinical deterioration and improve the patients' and relatives' experiences. The project was originally inspired by the Condition H(elp) system in the USA, which was set up following the death of an 18-month-old child who died of preventable causes. Similar tragic cases in the USA and the UK have prompted campaigning by affected families, resulting in the widespread adoption of comparable services. The project was rolled out in the authors' trust for all adult inpatients. There was a 2-week implementation phase to raise awareness. Between 22 February 2022 and 22 February 2023, the CCOS team received 39 C4C referrals, representing approximately 2.13% of the total CCOS activity. Clinical deterioration of a patient was prevented in at least three cases, alongside overwhelming positive feedback from service users.

Prediction of episode of hemodynamic instability using an electrocardiogram based analytic: a retrospective cohort study

BACKGROUND

Predicting the onset of hemodynamic instability before it occurs remains a sought-after goal in acute and critical care medicine. Technologies that allow for this may assist clinicians in preventing episodes of hemodynamic instability (EHI). We tested a novel noninvasive technology, the Analytic for Hemodynamic Instability-Predictive Indicator (AHI-PI), which analyzes a single lead of electrocardiogram (ECG) and extracts heart rate variability and morphologic waveform features to predict an EHI prior to its occurrence.

METHODS

Retrospective cohort study at a quaternary care academic health system using data from hospitalized adult patients between August 2019 and April 2020 undergoing continuous ECG monitoring with intermittent noninvasive blood pressure (NIBP) or with continuous intraarterial pressure (IAP) monitoring.

RESULTS

AHI-PI's low and high-risk indications were compared with the presence of EHI in the future as indicated by vital signs (heart rate > 100 beats/min with a systolic blood pressure < 90 mmHg or a mean arterial blood pressure of < 70 mmHg). 4,633 patients were analyzed (3,961 undergoing NIBP monitoring, 672 with continuous IAP monitoring). 692 patients had an EHI (380 undergoing NIBP, 312 undergoing IAP). For IAP patients, the sensitivity and specificity of AHI-PI to predict EHI was 89.7% and 78.3% with a positive and negative predictive value of 33.7% and 98.4% respectively. For NIBP patients, AHI-PI had a sensitivity and specificity of 86.3% and 80.5% with a positive and negative predictive value of 11.7% and 99.5% respectively. Both groups performed with an AUC of 0.87. AHI-PI predicted EHI in both groups with a median lead time of 1.1 h (average lead time of 3.7 h for IAP group, 2.9 h for NIBP group).

CONCLUSIONS

AHI-PI predicted EHIs with high sensitivity and specificity and within clinically significant time windows that may allow for intervention. Performance was similar in patients undergoing NIBP and IAP monitoring.

Failure to rescue as a patient safety indicator for neurosurgical patients: are we there yet? A systematic review

Failure to rescue (FTR) is a standardized patient safety indicator (PSI-04) developed by the Agency for Healthcare Research and Quality (AHRQ) to assess the ability of a healthcare team to prevent mortality following a major complication. However, FTR rates vary and are impacted by non-modifiable individual patient characteristics such as baseline frailty. This raises concerns regarding the validity of FTR as an objective quality metric, as not all patients have the same baseline frailty level, or physiological reserve, to recover from major complications. Literature from other surgical specialties has identified flaws in FTR and called for risk-adjusted metrics. Currently, knowledge of factors influencing FTR and its subsequent implementation in neurosurgical patients are limited. The present review assesses trends in FTR utilization to assess how FTR performs as an objective neurosurgery quality metric. This review then proposes how FTR may be best modified to optimize use in neurosurgical patients. A PubMed search was performed to identify articles published until August 9, 2023. Studies that reported FTR as an outcome in patients undergoing neurosurgical procedures were included. A qualitative assessment was performed using the Newcastle Ottawa Scale (NOS). The initial search revealed 1232 citations. After a title and abstract screen, followed by a full text screen, 12 studies met criteria for inclusion. These articles measured FTR across a total of 764,349 patients undergoing neurosurgical procedures. Five studies analyzed FTR with regard to hospital characteristics, and three studies utilized patient characteristics to predict FTR. All studies were considered high quality based on the NOS. Modifications in criteria to measure FTR are necessary since FTR depends on patient characteristics like frailty. This would allow for the incorporation of risk-adjusted FTR metrics that would aid in clinical decision making in neurosurgical patients.

Teaching modern pancreatic surgery: close relationship between centralization, innovation, and dissemination of care

BACKGROUND

Pancreatic surgery is increasingly moving towards centralization in high-volume centres, supported by evidence on the volume-outcome relationship. At the same time, minimally invasive pancreatic surgery is becoming more and more established worldwide, and interest in new techniques, such as robotic pancreatoduodenectomy, is growing. Such recent innovations are reshaping modern pancreatic surgery, but they also represent new challenges for surgical training in its current form.

METHODS

This narrative review presents a chosen selection of literature, giving a picture of the current state of training in pancreatic surgery, together with the authors' own views, and in the context of centralization and innovation towards minimally invasive techniques.

RESULTS

Centralization of pancreatic surgery at high-volume centres, volume-outcome relationships, innovation through minimally invasive technologies, learning curves in both traditional and minimally invasive surgery, and standardized training paths are the different, but deeply interconnected, topics of this article. Proper training is essential to ensure quality of care, but innovation and centralization may represent challenges to overcome with new training models.

CONCLUSION

Innovations in pancreatic surgery are introduced with the aim of increasing the quality of care. However, their successful implementation is deeply dependent on dissemination and standardization of surgical training, adapted to fit in the changing landscape of modern pancreatic surgery.

The Emerging Role of "Failure to Rescue" as the Primary Quality Metric for Cardiovascular Surgery and Critical Care

We conducted a thorough literature review on the emerging role of failure to rescue (FTR) as a quality metric for cardiovascular surgery and critical care. For this purpose, we identified all original research studies assessing the implementation of FTR in cardiovascular surgery and critical care from 1992 to 2023. All included studies were evaluated for their quality. Although all studies defined FTR as mortality after a surgical complication, a high heterogeneity has been reported among studies regarding the included complications. There are certain factors that affect the FTR, divided into hospital- and patient-related factors. The identification of these factors allowed us to build a stepwise roadmap to reduce the FTR rate. Recently, FTR has further evolved as a metric to assess morbidity instead of mortality, while being also evaluated in the context of interventional cardiology. All these advances are further discussed in the current review, thus providing all the necessary information to surgeons, anesthesiologists, and physicians willing to implement FTR as a metric of quality in their establishment.

Practice variation in anastomotic leak after esophagectomy: Unravelling differences in failure to rescue

INTRODUCTION

Failure to rescue (FTR) is an important outcome measure after esophagectomy and reflects mortality after postoperative complications. Differences in FTR have been associated with hospital resection volume. However, insight into how centers manage complications and achieve their outcomes is lacking. Anastomotic leak (AL) is a main contributor to FTR. This study aimed to assess differences in FTR after AL between centers, and to identify factors that explain these differences.

METHODS

TENTACLE - Esophagus is a multicenter, retrospective cohort study, which included 1509 patients with AL after esophagectomy. Differences in FTR were assessed between low-volume (<20 resections), middle-volume (20-60 resections) and high-volume centers (≥60 resections). Mediation analysis was performed using logistic regression, including possible mediators for FTR: case-mix, hospital resources, leak severity and treatment.

RESULTS

FTR after AL was 11.7%. After adjustment for confounders, FTR was lower in high-volume vs. low-volume (OR 0.44, 95%CI 0.2-0.8), but not versus middle-volume centers (OR 0.67, 95%CI 0.5-1.0). After mediation analysis, differences in FTR were found to be explained by lower leak severity, lower secondary ICU readmission rate and higher availability of therapeutic modalities in high-volume centers. No statistically significant direct effect of hospital volume was found: high-volume vs. low-volume 0.86 (95%CI 0.4-1.7), high-volume vs. middle-volume OR 0.86 (95%CI 0.5-1.4).

CONCLUSION

Lower FTR in high-volume compared with low-volume centers was explained by lower leak severity, less secondary ICU readmissions and higher availability of therapeutic modalities. To reduce FTR after AL, future studies should investigate effective strategies to reduce leak severity and prevent secondary ICU readmission.

Hospital Performance on Failure to Rescue Correlates With Likelihood of Home Discharge

INTRODUCTION

Failure to rescue (FTR) (avoiding death after complications) has been proposed as a measure of hospital quality. Although surviving complications is important, not all rescues are created equal. Patients also place considerable values on being able to return home after surgery and resume their normal lives. From a systems standpoint, nonhome discharge to skilled nursing and other facilities is the biggest driver of Medicare costs. We wanted to determine whether hospitals' ability to keep patients alive after complications was associated with higher rates of home discharge. We hypothesized that hospitals with higher rescue rates would also be more likely to discharge patients home after surgery.

METHODS

We conducted a retrospective cohort study using the nationwide inpatient sample. We included 1,358,041 patients ≥18 y old who had elective major surgery (general, vascular, orthopedic) at 3818 hospitals from 2013 to 2017. We predicted the correlation between a hospital's performance (rank) on FTR and its rank in terms of home discharge rate.

RESULTS

The cohort had a median age of 66 y (interquartile range [IQR] 58-73), and 77.9% of patients were Caucasian. Most patients (63.6%) were treated at urban teaching institutions. The surgical case mix included patients having colorectal (146,993 patients; 10.8%), pulmonary (52,334; 3.9%), pancreatic (13,635; 1.0%), hepatic (14,821; 1.1%), gastric (9182; 0.7%), esophageal (4494; 0.3%), peripheral vascular bypass (29,196; 2.2%), abdominal aneurysm repair (14,327; 1.1%), coronary artery bypass (61,976; 4.6%), hip replacement (356,400; 26.2%), and knee replacement (654,857; 48.2%) operations. The overall mortality was 0.3%, the average hospital complication rate was 15.9%, the median hospital rescue rate was 99% (IQR 70%-100%), and the median hospital rate of home discharge was 80% (IQR 74%-85%).There was a small but positive correlation between hospitals' performance on the FTR metric and the likelihood of home discharge after surgery (r = 0.0453; P = 0.006). When considering hospital rates of discharge to home following a postoperative complication, there was a similar correlation between rescue rates and probability of home discharge (r = 0.0963; P < 0.001). However, on sensitivity analysis excluding orthopedic surgery, there was a stronger correlation between rescue rates and home discharge rate (r = 0.4047, P < 0.001).

CONCLUSIONS

We found a small correlation between a hospital's ability to rescue patients from complication and that hospital's likelihood of discharging patients home after surgery. When excluding orthopedic operations from the analysis, this correlation strengthened. Our findings suggest that efforts to reduce mortality after complications will likely also help patients return home more frequently after complex surgery. However, more work needs to be done to identify successful programs and other patient and hospital factors that affect both rescue and home discharge.

Routine Postsurgical Anesthesia Visit to Improve 30-day Morbidity and Mortality: A Multicenter, Stepped-wedge Cluster Randomized Interventional Study (The TRACE Study)

OBJECTIVE

To study the impact of a standardized postoperative anesthesia visit on 30-day mortality in medium to high-risk elective surgical patients.

BACKGROUND

Postoperative complications are the leading cause of perioperative morbidity and mortality. Although modified early warning scores (MEWS) were instituted to monitor vital functions and improve postoperative outcome, we hypothesized that complementary anesthesia expertise is needed to adequately identify early deterioration.

METHODS

In a prospective, multicenter, stepped-wedge cluster randomized interventional study in 9 academic and nonacademic hospitals in the Netherlands, we studied the impact of adding standardized postoperative anesthesia visits on day 1 and 3 to routine use of MEWS in 5473 patients undergoing elective noncardiac surgery. Primary outcome was 30-day mortality. Secondary outcomes included: incidence of postoperative complications, length of hospital stay, and intensive care unit admission.

RESULTS

Patients were enrolled between October 2016 and August 2018. Informed consent was obtained from 5473 patients of which 5190 were eligible for statistical analyses, 2490 in the control and 2700 in the intervention group. Thirty-day mortality was 0.56% (n = 14) in the control and 0.44% (n = 12) in the intervention group (odds ratio 0.74, 95% Confidence interval 0.34-1.62). Incidence of postoperative complications did not differ between groups except for renal complications which was higher in the control group (1.7% (n = 41) vs 1.0% (n = 27), P = 0.014). Median length of hospital stay did not differ significantly between groups. During the postanesthesia visits, for 16% (n = 437) and 11% (n = 293) of patients recommendations were given on day 1 and 3, respectively, of which 67% (n = 293) and 69% (n = 202) were followed up.

CONCLUSIONS

The combination of MEWS and a postoperative anesthesia visit did not reduce 30-day mortality. Whether a postoperative anesthesia visit with strong adherence to the recommendations provided and in a high-risk population might have a stronger impact on postoperative mortality remains to be determined.

TRIAL REGISTRATION

Netherlands Trial Registration, NTR5506/ NL5249, https://www.trialregister.nl/trial/5249.

Qualitative study of challenges facing emergency departments nurses in Jordan

Worldwide, nurses employed in the Emergency Department (ED) face many challenges that negatively influence their well-being and ability to provide high-quality patient care. Previous researchers have investigated these challenges regarding their causes, consequences, and how to deal with them. However, most of the previous research addressed these challenges using quantitative research. The current study is the first qualitative study that examined these challenges in the Jordanian context. A descriptive naturalistic qualitative design was used to explore the most critical challenges facing nurses employed in the ED and described the suggested solutions for these challenges from nurses' perspectives. Ten registered nurses employed in the most prominent ED in Jordan were selected through purposive sampling. Semi-structured interviews were used to collect data. Thematic analysis technique was used to analyze data. Six main themes emerged: the definition of challenge, challenges facing registered nurses in the emergency department (five sub-themes), preventive measurements, possible solutions (five sub-themes), effects of the challenges (two sub-themes), and future challenges. The outcomes of this study could be integrated into the educational curricula to prepare new nurses to deal with these challenges in the future after graduation and contribute to finding solutions and solving some significant problems facing registered nurses in the ED. The hospital administrators and the policymakers should develop effective interventions to overcome the challenges facing nurses in the ED to ensure a better work environment and high-quality patient care.

Performance of the New ABC and MAP(ASH) Scores in the Prediction of Relevant Outcomes in Upper Gastrointestinal Bleeding

Background & Aims: Several risk scores have been proposed for risk-stratification of patients with upper gastrointestinal bleeding. ABC score was found more accurate predicting mortality than AIMS65. MAP(ASH) is a simple, pre-endoscopy score with a great ability to predict intervention and mortality. The aim of this study was to compare ABC and MAP(ASH) discriminative ability for the prediction of mortality and intervention in UGIB. As a secondary aim we compared both scores with Glasgow-Blatchford score and AIMS65. Methods: Our study included patients admitted to the emergency room of Virgen de las Nieves University Hospital with UGIB (2017-2020). Information regarding clinical, biochemical tests and procedures was collected. Main outcomes were in-hospital mortality and a composite endpoint for intervention. Results: MAP(ASH) and ABC had similar AUROCs for mortality (0.79 vs. 0.80). For intervention, MAP(ASH) (AUROC = 0.75) and ABC (AUROC = 0.72) were also similar. Regarding rebleeding, AUROCs of MAP(ASH) and ABC were 0.67 and 0.61 respectively. No statistically differences were found in these outcomes. With a low threshold for MAP(ASH) ≤ 2, ABC and MAP(ASH) classified a similar proportion of patients as being at low risk of death (42% vs. 45.2%), with virtually no mortality under these thresholds. Conclusions: MAP(ASH) and ABC were similar for the prediction of relevant outcomes for UGIB, such as intervention, rebleeding and in-hospital mortality, with an accurate selection of low-risk patients. MAP(ASH) has the advantage of being easier to calculate even without the aid of electronic tools.

Failure to Rescue: A Quality Metric for Cardiac Surgery and Cardiovascular Critical Care

Failure to rescue, defined as mortality after a surgical complication, is a widely accepted quality metric across many specialties and is becoming an important metric in cardiac surgery. The failure to rescue metric provides a target for improvements in patient outcomes after complications occur. To be used appropriately, the failure to rescue metric must be defined using a prespecified set of life-threatening and rescuable complications. Successful patient rescue requires a systematic approach of complication recognition, timely escalation of care, effective medical management, and mitigation of additional complications. This process requires contributions from cardiac surgeons, intensivists, and other specialists including cardiologists, neurologists, and anaesthesiologists. Factors that affect failure to rescue rates in cardiac surgery and cardiovascular critical care include nurse staffing ratios, intensivist coverage, advanced specialist support, hospital and surgical volume, the presence of trainees, and patient comorbidities. Strategies to improve patient rescue include working to understand the mechanisms of failure to rescue, anticipating postoperative complications, prioritizing microsystem factors, enhancing early escalation of care, and educating and empowering junior clinicians. When used appropriately, the failure to rescue quality metric can help institutions focus on improving processes of care that minimize morbidity and mortality from rescuable complications after cardiac surgery.

Validation of prolonged length of stay as a reliable measure of failure to rescue in colorectal surgery

BACKGROUND

Failure-to-rescue measures a hospital's response capacity to avoid the death of a patient after a complication. The aim of this study was to validate the use of prolonged length of stay to calculate failure-to-rescue rates as a substitute for traditional coding of complications in colorectal cancer surgery.

METHOD

We performed a cross-sectional between-instruments agreement study. Our study population was comprised of 204 colorectal cancer surgical patients from a public academic hospital during 2017 and 2018. We obtained two failure-to-rescue indicators from administrative data: an indicator using International Classification of Diseases, tenth edition, (ICD-10) codes; and another one using a cut-off point of prolonged length of stay as a predictor of patients with complications. Then, they were compared with a reference indicator from clinical records.

RESULTS

Failure-to-rescue rates were between 10 and 13.64 for the study site depending on which indicator was used. A hospital stay ≥10 days had the maximum Youden's index (0.6) and an area under the ROC curve of 0.87. This was used in the failure-to-rescue indicator using prolonged length, which obtained the highest agreement (any coefficient >0.75).

CONCLUSION

ICD-10 codes identified complications poorly. Prolonged length of stay could be a valid replacement of ICD-10 codes when measuring failure-to-rescue in administrative databases for colorectal surgical patients.

Interhospital failure to rescue after coronary artery bypass grafting

OBJECTIVE

We evaluated whether interhospital variation in mortality rates for coronary artery bypass grafting was driven by complications and failure to rescue.

METHODS

An observational study was conducted among 83,747 patients undergoing isolated coronary artery bypass grafting between July 2011 and June 2017 across 90 hospitals. Failure to rescue was defined as operative mortality among patients developing complications. Complications included the Society of Thoracic Surgeons 5 major complications (stroke, surgical reexploration, deep sternal wound infection, renal failure, prolonged intubation) and a broader set of 19 overall complications. After creating terciles of hospital performance (based on observed:expected mortality), each tercile was compared on the basis of crude rates of (1) major and overall complications, (2) operative mortality, and (3) failure to rescue (among major and overall complications). The correlation between hospital observed and expected (to address confounding) failure to rescue rates was assessed.

RESULTS

Median Society of Thoracic Surgeons predicted mortality risk was similar across hospital observed:expected mortality terciles (P = .831). Mortality rates significantly increased across terciles (low tercile: 1.4%, high tercile: 2.8%). Although small in magnitude, rates of major (low tercile: 11.1%, high tercile: 12.2%) and overall (low tercile: 36.6%, high tercile: 35.3%) complications significantly differed across terciles. Nonetheless, failure to rescue rates increased substantially across terciles among patients with major (low tercile: 9.1%, high tercile: 14.3%) and overall (low tercile: 3.3%, high tercile: 6.8%) complications. Hospital observed and expected failure to rescue rates were positively correlated among patients with major (R2 = 0.14) and overall (R2 = 0.51) complications.

CONCLUSIONS

The reported interhospital variability in successful rescue after coronary artery bypass grafting supports the importance of identifying best practices at high-performing hospitals, including early recognition and management of complications.

Usability Evaluation of the Preoperative ISBAR (Identification, Situation, Background, Assessment, and Recommendation) Desktop Virtual Reality Application: Qualitative Observational Study

BACKGROUND

Systematic communication, such as the ISBAR (identification, situation, background, assessment, recommendation) approach, comprises a generic, transferable nontechnical skill. It can be used during the handover of patients set to undergo surgery and can be practiced in various ways, including virtual reality (VR). VR increasingly has been implemented and valued in nursing education as a positive contribution to teach students about pre- and postoperative nursing. A new nonimmersive 3D learning activity called the Preoperative ISBAR Desktop VR Application has been developed for undergraduate nursing students to learn preoperative handover using the ISBAR approach. However, the usability of this learning activity has not been studied.

OBJECTIVE

This study aimed to investigate how second-year undergraduate nursing students evaluated the usability of the Preoperative ISBAR Desktop VR Application.

METHODS

This was a qualitative study with observation and interviews. The inclusion criteria were undergraduate second-year nursing students of varying ages, gender, and anticipated technological competence. The System Usability Scale (SUS) questionnaire was used to get a score on overall usability.

RESULTS

A total of 9 second-year nursing students aged 22-29 years participated in the study. The average score on the SUS was 83 (range 0-100), which equals a "B" on the graded scale and is excellent for an adjective-grade rating. The students expressed increased motivation to learn while working in self-instructed desktop VR. Still, a few technical difficulties occurred, and some students reported that they experienced some problems comprehending the instructions provided in the application. Long written instructions and a lack of self-pacing built into the application were considered limitations.

CONCLUSIONS

The nursing students found the application to be usable overall, giving it an excellent usability score and noting that the application provided opportunities for active participation, which was motivational and facilitated their perceived learning outcomes. The next version of the application, to be used in a randomized controlled trial, will be upgraded to address technological and comprehension issues.

Am I safe? An Interpretative Phenomenological Analysis of Vulnerability as Experienced by Patients With Complications Following Surgery

Abdominal surgery carries with it risks of complications. Little is known about patients' experiences of post-surgical deterioration. There is a real need to understand the psychosocial as well as the biological aspects of deterioration in order to improve care and outcomes for patients. Drawing on in-depth interviews with seven abdominal surgery survivors, we present an idiographic account of participants' experiences, situating their contribution to safety within their personal lived experiences and meaning-making of these episodes of deterioration. Our analysis reveals an overarching group experiential theme of vulnerability in relation to participants' experiences of complications after abdominal surgery. This encapsulates the uncertainty of the situation all the participants found themselves in, and the nature and seriousness of their health conditions. The extent of participants' vulnerability is revealed by detailing how they made sense of their experience, how they negotiated feelings of (un)safety drawing on their relationships with family and staff and the legacy of feelings they were left with when their expectations of care (care as imagined) did not meet the reality of their experiences (care as received). The participants' experiences highlight the power imbalance between patients and professionals in terms of whose knowledge counts within the hospital context. The study reveals the potential for epistemic injustice to arise when patients' concerns are ignored or dismissed. Our data has implications for designing strategies to enable escalation of care, both in terms of supporting staff to deliver compassionate care, and in strengthening patient and family involvement in rescue processes.

Association of Hospital Bed Turnover With Patient Outcomes in Digestive Surgery

To determine the influence of hospital bed turnover rate (BTR) on the occurrence of complications following minor or major digestive surgery.

Background

Performance improvement in surgery aims at increasing productivity while preventing complications. It is unknown whether this relationship can be influenced by the complexity of surgery.

Methods

A nationwide retrospective cohort study was conducted, based on generalized estimating equation modeling to determine the effect of hospital BTR on surgical outcomes, adjusting for patient mix and clustering within 631 public and private French hospitals. All patients who underwent minor or major digestive surgery between January 1, 2013 and December 31, 2018 were included. Hospital BTR was defined as the annual number of stays per bed for digestive surgery and categorized into tertiles. The primary endpoint was a composite measurement of events occurring within 30 days after surgery: inpatient death, extended intensive care unit (ICU) admission, and reoperation.

Results

Rate of adverse events was 2.51% in low BTR hospitals versus 2.25% in high BTR hospitals for minor surgery, and 16.79% versus 16.83% for major surgery. Patients who underwent minor surgery in high BTR hospitals experienced lower complications (odds ratio [OR], 0.89; 95% confidence interval [CI], 0.81-0.97; P = 0.009), mortality (OR, 0.87; 95% CI, 0.78-0.98, P = 0.02), ICU admission (OR, 0.83; 95% CI, 0.70-0.99; P = 0.03), and reoperation (OR, 0.91; 95% CI, 0.85-0.97; P = 0.002) compared to those in low BTR hospitals. Such differences were not consistently observed among patients admitted for major surgery.

Conclusions

High turnover of patients in beds is beneficial for minor procedures, but questionable for major surgeries.

Unexpected deaths after endocrine surgery: learning from rare events using a national audit of surgical mortality

BACKGROUND

The mortality rate is low in endocrine surgery, making it a difficult outcome to use for quality improvement in individual units. Lessons from population data sets are of value in improving outcomes. Data from the Australian and New Zealand Audit of Surgical Mortality (ANZASM) were used here to understand and elucidate potential systems issues that may contribute to preventable deaths.

METHODS

ANZASM data relating to 30-day mortality after thyroidectomy, parathyroidectomy, and adrenalectomy from 2009 to 2020 were reviewed. Mortality rates were calculated using billing data. Thematic analysis of independent assessor reports was conducted to produce a coding framework.

RESULTS

A total of 67 deaths were reported, with an estimated mortality rate of 0.03-0.07 per cent (38 for thyroidectomy (0.03-0.06 per cent), 16 for parathyroidectomy (0.03-0.06 per cent), 13 for adrenalectomy (0.15-0.33 per cent)). Twenty-seven deaths (40 per cent) were precipitated by clinically significant adverse events, and 18 (27 per cent) were judged to be preventable by independent ANZASM assessors. Recurrent themes included inadequate preoperative assessment, lack of anticipation of intraoperative pitfalls, and failure to recognize and effectively address postoperative complications. Several novel themes were reiterated, such as occult ischaemic heart disease associated with death after parathyroid surgery, unexpected intraoperative difficulties from adrenal metastasis, and complications due to anticoagulation therapy after thyroid surgery.

CONCLUSION

This study represents a large-scale national report of deaths after endocrine surgery and provides insights into these rare events. Although the overall mortality rate is low, 27 per cent of deaths involved systems issues that were preventable following independent peer review.

Complications and Their Association with Mortality Following Emergency Gastrointestinal Surgery-an Observational Study

PURPOSE

Emergency gastrointestinal surgery is followed by a high risk of major complications and death. This study aimed to investigate which complications showed the strongest association with death following emergency surgery for gastrointestinal obstruction or perforation.

METHODS

We retrospectively included adults who had undergone emergency gastrointestinal surgery for radiologically verified obstruction or perforation at three Danish hospitals between 2014 and 2015. The exposure variables comprised 16 predefined Clavien-Dindo-graded complications. Cox regression with delayed entry was used to analyze the association of these complications with 90-day mortality. We adjusted for hospital, age, American Society of Anesthesiologists classification, pre-operative Sepsis-2 score, cardiac comorbidity, renal comorbidity, hypertension, active cancer, bowel obstruction or perforation, and the surgical procedure. Subgroup analyses were done for patients with gastrointestinal obstruction or perforation.

RESULTS

Of the 349 included patients, 281 (80.5%) experienced at least one complication. The risk of death was 20.6% (14) for patients with no complications and varied between 21 and 57% for patients with complications. Renal impairment (hazard ratio (HR): 6.8 (95%CI: 3.7-12.4)), arterial thromboembolic events (HR 4.8 (2.3-9.9)), and atrial fibrillation (HR 4.4 (2.8-6.8)) showed the strongest association with 90-day mortality. Atrial fibrillation was the only complication significantly associated with death in patients with gastrointestinal obstruction as well as perforation.

CONCLUSION

This study of patients undergoing emergency gastrointestinal surgery revealed that renal impairment, arterial thromboembolic events, and atrial fibrillation had the strongest association with death. Atrial fibrillation may serve as an in-situ marker of patients needing escalation of care.

Recognising the deterioration of patients in acute care wards: a qualitative study

Background: Infrastructure, equipment and staff constraints are often cited as barriers to the recognition and rescue of deteriorating patients in resource-limited settings. The impact of health-system organisation, decision-making and organisational culture on recognition of deterioration is however poorly understood. This study explores how health care providers recognise deterioration of patients in acute care in Sri Lanka. Methods: In-depth interviews exploring decision making and care processes related to recognition of deterioration, were conducted with a purposive sample of 23 health care workers recruited from ten wards at a district hospital in Sri Lanka. Interviews were audio-recorded, transcribed and coded thematically, line-by-line, using a general inductive approach. Results: A legacy of initial assessment on admission and inimical organisational culture undermined recognition of deteriorating patients in hospital. Informal triaging at the time of ward admission resulted in patients presenting with red-flag diagnoses and vital sign derangement requiring resuscitation being categorised as "bad". The legacy of this categorisation was a series of decision-making biases anchored in the initial assessment, which remained with the patient throughout their stay. Management for patients categorised as "bad" was prioritised by healthcare workers coupled with a sense of fatalism regarding adverse outcomes. Health care workers were reluctant to deviate from the original plan of care despite changes in patient condition (continuation bias). Organisational culture - vertical hierarchy, siloed working and a reluctance to accept responsibility- resulted in omissions which undermined recognition of deterioration. Fear of blame was a barrier to learning from adverse events. Conclusions: The legacy of admission assessment and hospital organisational culture undermined recognition of deterioration. Opportunities for improving recognition of deterioration in this setting may include establishing formal triage and medical emergency teams to facilitate timely recognition and escalation.

Detection of Hemodynamic Status Using an Analytic Based on an Electrocardiogram Lead Waveform

OBJECTIVES

Delayed identification of hemodynamic deterioration remains a persistent issue for in-hospital patient care. Clinicians continue to rely on vital signs associated with tachycardia and hypotension to identify hemodynamically unstable patients. A novel, noninvasive technology, the Analytic for Hemodynamic Instability (AHI), uses only the continuous electrocardiogram (ECG) signal from a typical hospital multiparameter telemetry monitor to monitor hemodynamics. The intent of this study was to determine if AHI is able to predict hemodynamic instability without the need for continuous direct measurement of blood pressure.

DESIGN

Retrospective cohort study.

SETTING

Single quaternary care academic health system in Michigan.

PATIENTS

Hospitalized adult patients between November 2019 and February 2020 undergoing continuous ECG and intra-arterial blood pressure monitoring in an intensive care setting.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

One million two hundred fifty-two thousand seven hundred forty-two 5-minute windows of the analytic output were analyzed from 597 consecutive adult patients. AHI outputs were compared with vital sign indications of hemodynamic instability (heart rate > 100 beats/min, systolic blood pressure < 90 mm Hg, and shock index of > 1) in the same window. The observed sensitivity and specificity of AHI were 96.9% and 79.0%, respectively, with an area under the curve (AUC) of 0.90 for heart rate and systolic blood pressure. For the shock index analysis, AHI's sensitivity was 72.0% and specificity was 80.3% with an AUC of 0.81.

CONCLUSIONS

The AHI-derived hemodynamic status appropriately detected the various gold standard indications of hemodynamic instability (hypotension, tachycardia and hypotension, and shock index > 1). AHI may provide continuous dynamic hemodynamic monitoring capabilities in patients who traditionally have intermittent static vital sign measurements.