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Parameshwar P, Guo N, Bentley J, Main E, Singer SJ, Peden CJ, Morris T, Ansari J, Butwick AJ. Variation in Hospital Neuraxial Labor Analgesia Rates in California. Anesthesiology 2024:139856. [PMID: 38412054 DOI: 10.1097/aln.0000000000004961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Abstract
BACKGROUND Neuraxial analgesia provides effective pain relief during labor. However, it is unclear whether neuraxial analgesia prevalence differs across US hospitals. Our aim was to assess hospital variation in neuraxial analgesia prevalence in California. METHODS A retrospective cross-sectional study analyzed birthing patients who underwent labor in 200 California hospitals from 2016 to 2020. The primary exposure was the delivery hospital. The outcomes were hospital neuraxial analgesia prevalence and between-hospital variability, before and after adjustment for patient and hospital factors. Median odds ratio and intraclass correlation coefficients (ICC) quantified between-hospital variability. The median odds ratio estimated the odds of a patient receiving neuraxial analgesia when moving between hospitals. The ICC quantified the proportion of the total variance in neuraxial analgesia use due to variation between hospitals. RESULTS Among 1,510,750 patients who underwent labor, 1,040, 483 (68.9%) received neuraxial analgesia. Both unadjusted and adjusted hospital prevalence exhibited a skewed distribution characterized by a long-left tail. The unadjusted and adjusted prevalence at the 1 st percentile were 5.4% and 6.0%; 5 th percentile were 21.0% and 21.2%; 50 th percentile were 70.6% and 70.7%; 95 th percentile were 75.8% and 76.6%; and 99 th percentile were 75.9% and 78.6%. The adjusted median odds ratio (2.3; 95% CI, 2.1 - 2.5) indicated a substantially increased odds of a patient receiving neuraxial analgesia if they moved from a hospital with a lower to higher odds of neuraxial analgesia. The hospital explained only a moderate portion of the overall variability in neuraxial analgesia (ICC=19.1%; 95% CI, 18.8 - 20.5%). CONCLUSIONS A long left tail in the distribution and wide variation exist in the neuraxial analgesia prevalence across California hospitals, not explained by patient and hospital factors. Addressing the low prevalence among hospitals in the left tail requires exploration of the interplay between patient preferences, staffing availability, and care providers' attitudes towards neuraxial analgesia.
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Affiliation(s)
- Pooja Parameshwar
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah
| | - Nan Guo
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Jason Bentley
- Children's Hospital at Westmead Clinical School, University of Sydney, Australia
| | - Elliot Main
- Department of Obstetrics & Gynecology, Stanford University School of Medicine, Stanford, California
- California Maternal Quality Care Collaborative, Stanford, California
| | - Sara J Singer
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Carol J Peden
- Department of Anesthesiology, Keck School of Medicine, University of Southern California, Los Angeles, California
- Department of Anesthesiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Theresa Morris
- Department of Sociology, Texas A&M University, College Station, Texas
| | - Jessica Ansari
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Alexander J Butwick
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California
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Brown JC, Ding L, Querubin JA, Peden CJ, Barr J, Cobb JP. Lessons Learned From a Systematic, Hospital-Wide Implementation of the ABCDEF Bundle: A Survey Evaluation. Crit Care Explor 2023; 5:e1007. [PMID: 37954897 PMCID: PMC10637401 DOI: 10.1097/cce.0000000000001007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023] Open
Abstract
Objective We recently reported the first part of a study testing the impact of data literacy training on "assessing pain, spontaneous awakening and breathing trials, choice of analgesia and sedation, delirium monitoring/management, early exercise/mobility, and family and patient empowerment" [ABCDEF [A-F]) compliance. The purpose of the current study, part 2, was to evaluate the effectiveness of the implementation approach by surveying clinical staff to examine staff knowledge, skill, motivation, and organizational resources. DESIGN The Clark and Estes Gap Analysis framework was used to study knowledge, motivation, and organization (KMO) influences. Assumed influences identified in the literature were used to design the A-F bundle implementation strategies. The influences were validated against a survey distributed to the ICU interprofessional team. SETTING Single-center study was conducted in eight adult ICUs in a quaternary academic medical center. SUBJECTS Interprofessional ICU clinical team. INTERVENTIONS A quantitative survey was sent to 386 participants to evaluate the implementation design postimplementation. An exploratory factor analysis was performed to understand the relationship between the KMO influences and the questions posed to validate the influence. Descriptive statistics were used to identify strengths needed to sustain performance and weaknesses that required improvement to increase A-F bundle adherence. MEASUREMENT AND RESULTS The survey received an 83% response rate. The exploratory factor analysis confirmed that 38 of 42 questions had a strong relationship to the KMO influences, validating the survey's utility in evaluating the effectiveness of implementation design. A total of 12 KMO influences were identified, 8 were categorized as a strength and 4 as a weakness of the implementation. CONCLUSIONS Our study used an evidence-based gap analysis framework to demonstrate key implementation approaches needed to increase A-F bundle compliance. The following drivers were recommended as essential methods required for successful protocol implementation: data literacy training and performance monitoring, organizational support, value proposition, multidisciplinary collaboration, and interprofessional teamwork activities. We believe the learning generated in this two-part study is applicable to implementation design beyond the A-F bundle.
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Affiliation(s)
- Joan C Brown
- Office of Performance and Transformation, Keck Medicine of USC, University of Southern California, Los Angeles, CA
- Departments of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Li Ding
- Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Jynette A Querubin
- Office of Performance and Transformation, Keck Medicine of USC, University of Southern California, Los Angeles, CA
| | - Carol J Peden
- Department of Anesthesiology, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Juliana Barr
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA
- VA Palo Alto Health Care System, Palo Alto, CA
| | - Joseph Perren Cobb
- Departments of Surgery and Anesthesiology, Keck School of Medicine, University of Southern California, Los Angeles, CA
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Peden CJ, Aggarwal G, Aitken RJ, Anderson ID, Balfour A, Foss NB, Cooper Z, Dhesi JK, French WB, Grant MC, Hammarqvist F, Hare SP, Havens JM, Holena DN, Hübner M, Johnston C, Kim JS, Lees NP, Ljungqvist O, Lobo DN, Mohseni S, Ordoñez CA, Quiney N, Sharoky C, Urman RD, Wick E, Wu CL, Young-Fadok T, Scott MJ. Enhanced Recovery After Surgery (ERAS®) Society Consensus Guidelines for Emergency Laparotomy Part 3: Organizational Aspects and General Considerations for Management of the Emergency Laparotomy Patient. World J Surg 2023:10.1007/s00268-023-07039-9. [PMID: 37277506 DOI: 10.1007/s00268-023-07039-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2023] [Indexed: 06/07/2023]
Abstract
BACKGROUND This is Part 3 of the first consensus guidelines for optimal care of patients undergoing emergency laparotomy using an enhanced recovery after surgery (ERAS) approach. This paper addresses organizational aspects of care. METHODS Experts in management of the high-risk and emergency general surgical patient were invited to contribute by the International ERAS® Society. PubMed, Cochrane, Embase, and MEDLINE database searches were performed for ERAS elements and relevant specific topics. Studies were selected with particular attention to randomized clinical trials, systematic reviews, meta-analyses and large cohort studies, and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation system. Recommendations were made on the best level of evidence, or extrapolation from studies on elective patients when appropriate. A modified Delphi method was used to validate final recommendations. RESULTS Components of organizational aspects of care were considered. Consensus was reached after three rounds of a modified Delphi process. CONCLUSIONS These guidelines are based on best current available evidence for organizational aspects of an ERAS® approach to patients undergoing emergency laparotomy and include discussion of less common aspects of care for the surgical patient, including end-of-life issues. These guidelines are not exhaustive but pull together evidence on important components of care for this high-risk patient population. As much of the evidence is extrapolated from elective surgery or emergency general surgery (not specifically laparotomy), many of the components need further evaluation in future studies.
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Affiliation(s)
- Carol J Peden
- Department of Anesthesiology Keck School of Medicine, University of Southern California, 2020 Zonal Avenue IRD 322, Los Angeles, CA, 90033, USA.
- Department of Anesthesiology, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA, 19104, USA.
| | - Geeta Aggarwal
- Department of Anesthesia and Intensive Care Medicine, Royal Surrey County Hospital, Egerton Road, Guildford, Surrey, GU5 7XX, UK
| | - Robert J Aitken
- Sir Charles Gardiner Hospital, Hospital Avenue, Nedlands, WA, 6009, Australia
| | - Iain D Anderson
- Salford Royal NHS Foundation Trust, Stott La, Salford, M6 8HD, UK
- University of Manchester, Manchester, UK
| | - Angie Balfour
- Western General Hospital, NHS Lothian, Edinburgh, EH4 2XU, Scotland
| | | | - Zara Cooper
- Center for Surgery and Public Health, Harvard Medical School, Brigham and Women's Hospital, 1620 Tremont Street, Boston, MA, 02120, USA
- Division of Trauma, Burns, Surgical Critical Care, and Emergency Surgery, Brigham and Women's Hospital, 1620 Tremont Street, Boston, MA, 02120, USA
| | - Jugdeep K Dhesi
- Perioperative Medicine for Older People Undergoing Surgery (POPS), Guy's and St Thomas' NHS Foundation Trust, London, UK
- Faculty of Life Sciences and Medicine, King's College London, London, UK
- Research Department of Targeted Intervention, Division of Surgery & Interventional Science, University College London, London, UK
| | - W Brenton French
- Department of Surgery, Virginia Commonwealth University Health System, 1200 E. Broad Street, Richmond, VA, 23298, USA
| | - Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, Department of Surgery, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD, 21287, USA
| | - Folke Hammarqvist
- Department of Emergency and Trauma Surgery, Karolinska University Hospital, CLINTEC, Karolinska Institutet, Stockholm, Sweden
- Karolinska University Hospital Huddinge, Hälsovägen 3. B85, S 141 86, Stockholm, Sweden
| | - Sarah P Hare
- Department of Anaesthesia, Perioperative Medicine and Critical Care, Medway Maritime Hospital, Windmill Road, Gillingham, Kent, ME7 5NY, UK
| | - Joaquim M Havens
- Division of Trauma, Burns and Surgical Critical Care, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Daniel N Holena
- Division of Trauma and Acute Care Surgery, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI, 53226, USA
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Carolyn Johnston
- Department of Anaesthesia, St George's Hospital, Tooting, London, UK
| | - Jeniffer S Kim
- Kaiser Permanente Research, Department of Research & Evaluation, 100 South Los Robles Ave, 2nd Floor, Pasadena, CA, 91101, USA
| | - Nicholas P Lees
- Department of General & Colorectal Surgery, Salford Royal NHS Foundation Trust, Scott La, Salford, M6 8HD, UK
| | - Olle Ljungqvist
- Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Dileep N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Queen's Medical Centre, Nottingham University Hospitals and University of Nottingham, Nottingham, NG7 2UH, UK
- MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, Queen's Medical Centre, School of Life Sciences, University of Nottingham, Nottingham, NG7 2UH, UK
| | - Shahin Mohseni
- Division of Trauma and Emergency Surgery, Department of Surgery, School of Medical Sciences, Orebro University Hospital, Orebro University, 701 85, Orebro, Sweden
| | - Carlos A Ordoñez
- Division of Trauma and Acute Care Surgery, Department of Surgery, Fundación Valle del Lili, Cra 98 No. 18 - 49, 760032, Cali, Colombia
- Sección de Cirugía de Trauma y Emergencias, Universidad del Valle - Hospital Universitario del Valle, Cl 5 No. 36-08, 760032, Cali, Colombia
| | - Nial Quiney
- Department of Anesthesia and Intensive Care Medicine, Royal Surrey County Hospital, Egerton Road, Guildford, Surrey, GU5 7XX, UK
| | - Catherine Sharoky
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Richard D Urman
- Department of Anesthesiology, The Ohio State University and Wexner Medical Center, 410 West 10th Ave, Columbus, OH, 43210, USA
| | - Elizabeth Wick
- Department of Surgery, University of California San Francisco, 513 Parnassus Ave HSW1601, San Francisco, CA, 94143, USA
| | - Christopher L Wu
- Department of Anesthesiology, Critical Care and Pain Medicine, and Department of Anesthesiology, Weill-Cornell Medicine, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Tonia Young-Fadok
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic College of Medicine, Mayo Clinic Arizona, 5777 e. Mayo Blvd., Phoenix, AZ, 85054, USA
| | - Michael J Scott
- Department of Anesthesiology and Critical Care Medicine, and Leonard Davis Institute for Health Economics, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA, 19104, USA
- University College London, London, UK
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Scott MJ, Aggarwal G, Aitken RJ, Anderson ID, Balfour A, Foss NB, Cooper Z, Dhesi JK, French WB, Grant MC, Hammarqvist F, Hare SP, Havens JM, Holena DN, Hübner M, Johnston C, Kim JS, Lees NP, Ljungqvist O, Lobo DN, Mohseni S, Ordoñez CA, Quiney N, Sharoky C, Urman RD, Wick E, Wu CL, Young-Fadok T, Peden CJ. Consensus Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS ®) Society Recommendations Part 2-Emergency Laparotomy: Intra- and Postoperative Care. World J Surg 2023:10.1007/s00268-023-07020-6. [PMID: 37277507 DOI: 10.1007/s00268-023-07020-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2023] [Indexed: 06/07/2023]
Abstract
BACKGROUND This is Part 2 of the first consensus guidelines for optimal care of patients undergoing emergency laparotomy (EL) using an Enhanced Recovery After Surgery (ERAS) approach. This paper addresses intra- and postoperative aspects of care. METHODS Experts in aspects of management of high-risk and emergency general surgical patients were invited to contribute by the International ERAS® Society. PubMed, Cochrane, Embase, and Medline database searches were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized clinical trials, systematic reviews, meta-analyses, and large cohort studies and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on elective patients when appropriate. A modified Delphi method was used to validate final recommendations. Some ERAS® components covered in other guideline papers are outlined only briefly, with the bulk of the text focusing on key areas pertaining specifically to EL. RESULTS Twenty-three components of intraoperative and postoperative care were defined. Consensus was reached after three rounds of a modified Delphi Process. CONCLUSIONS These guidelines are based on best available evidence for an ERAS® approach to patients undergoing EL. These guidelines are not exhaustive but pull together evidence on important components of care for this high-risk patient population. As much of the evidence is extrapolated from elective surgery or emergency general surgery (not specifically laparotomy), many of the components need further evaluation in future studies.
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Affiliation(s)
- Michael J Scott
- Department of Anesthesiology and Critical Care Medicine, Leonard Davis Institute for Health Economics, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA, 19104, USA.
- University College London, London, UK.
| | - Geeta Aggarwal
- Department of Anesthesia and Intensive Care Medicine, Royal Surrey County Hospital, Guildford, Surrey, UK
| | - Robert J Aitken
- Sir Charles Gardiner Hospital, Hospital Avenue, Nedlands, WA, 6009, Australia
| | - Iain D Anderson
- Salford Royal NHS Foundation Trust, Stott La, Salford, M6 8HD, UK
- University of Manchester, Manchester, UK
| | - Angie Balfour
- Western General Hospital, NHS Lothian, Edinburgh, EH4 2XU, Scotland
| | | | - Zara Cooper
- Harvard Medical School, Kessler Director, Center for Surgery and Public Health, Brigham and Women's Hospital and Division of Trauma, Burns, Surgical Critical Care, and Emergency Surgery, Brigham and Women's Hospital, 1620 Tremont Street, Boston, MA, 02120, USA
| | - Jugdeep K Dhesi
- School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, Guy's and St Thomas' NHS Foundation Trust, King's College London, London, UK
- Division of Surgery and Interventional Science, University College London, London, UK
| | - W Brenton French
- Department of Surgery, Virginia Commonwealth University Health System, 1200 E. Broad Street, Richmond, VA, 23298, USA
| | - Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, Department of Surgery, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD, 21287, USA
| | - Folke Hammarqvist
- Department of Emergency and Trauma Surgery, Karolinska University Hospital, CLINTEC, Karolinska Institutet, Stockholm, Sweden
- Karolinska University Hospital Huddinge, Hälsovägen 3. B85, 141 86, Stockholm, Sweden
| | - Sarah P Hare
- Department of Anaesthesia, Perioperative Medicine and Critical Care, Medway Maritime Hospital, Windmill Road, Gillingham, Kent, ME7 5NY, UK
| | - Joaquim M Havens
- Division of Trauma, Burns and Surgical Critical Care, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Daniel N Holena
- Division of Trauma and Acute Care Surgery, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI, 53226, USA
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Carolyn Johnston
- Department of Anesthesia, St George's Hospital, Tooting, London, UK
| | - Jeniffer S Kim
- Department of Research and Evaluation, Kaiser Permanente Research, Pasadena, CA, 9110, USA
| | - Nicholas P Lees
- Department of General and Colorectal Surgery, Salford Royal NHS Foundation Trust, Scott La, Salford, M6 8HD, UK
| | - Olle Ljungqvist
- Faculty of Medicine and Health, School of Health and Medical Sciences, Department of Surgery, Örebro University, Örebro, Sweden
| | - Dileep N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK
- MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - Shahin Mohseni
- Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital and School of Medical Sciences, Orebro University, 701 85, Orebro, Sweden
| | - Carlos A Ordoñez
- Division of Trauma and Acute Care Surgery, Department of Surgery, Fundación Valle del Lili, Cra 98 No. 18 - 49, 760032, Cali, Colombia
- Sección de Cirugía de Trauma y Emergencias, Universidad del Valle - Hospital Universitario del Valle, Cl 5 No. 36-08, 760032, Cali, Colombia
| | - Nial Quiney
- Department of Anesthesia and Intensive Care Medicine, Royal Surrey County Hospital, Egerton Road, Guildford, Surrey, GU5 7XX, UK
| | - Catherine Sharoky
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Richard D Urman
- Department of Anesthesiology, The Ohio State University and Wexner Medical Center, 410 West 10Th Ave, Columbus, OH, 43210, USA
| | - Elizabeth Wick
- Department of Surgery, University of California San Francisco, 513 Parnassus Ave HSW1601, San Francisco, CA, 94143, USA
| | - Christopher L Wu
- Department of Anesthesiology, Critical Care and Pain Medicine-Hospital for Special Surgery, Department of Anesthesiology-Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
| | - Tonia Young-Fadok
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic College of Medicine, Mayo Clinic Arizona, 5777 e. Mayo Blvd., Phoenix, AZ, 85054, USA
| | - Carol J Peden
- Department of Anesthesiology Keck School of Medicine, University of Southern California, 2020 Zonal Avenue IRD 322, Los Angeles, CA, 90033, USA
- Department of Anesthesiology, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St., Philadelphia, PA, 19104, USA
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5
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Pineda R, Smith D, Richter M, Gruskin BA, Dusing S, Peden CJ. Health Care Professionals' Perceptions About a Telehealth Model of Therapy After NICU Discharge. OTJR (Thorofare N J) 2023:15394492231153997. [PMID: 36879460 DOI: 10.1177/15394492231153997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
Abstract
The Baby Bridge program is an implementation strategy to improve access to in-person early therapy services following neonatal intensive care unit (NICU) discharge. The objective of this study was to evaluate acceptability of Baby Bridge telehealth services among health care providers. Interviews with health care providers were conducted, transcribed, and coded in NVivo. Deductive analysis was used to organize data into negative and positive comments, suggestions for optimization, and perceptions about the first visit. Next, a conventional approach was used to organize the data into themes. Telehealth was viewed as an acceptable, but not necessarily preferable, form of Baby Bridge delivery. Providers identified how telehealth may improve access to care, but with potential challenges in delivery. Suggestions for optimization of the Baby Bridge telehealth model were proposed. Identified themes included delivery model, family demographics, therapist and organizational characteristics, parent engagement, and therapy facilitation. These findings provide important insights to consider when transitioning from in-person therapy to telehealth.
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Affiliation(s)
- Roberta Pineda
- University of Southern California, Los Angeles, USA.,Washington University, St. Louis, MO, USA
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6
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Mohammad Ismail A, Forssten MP, Bass GA, Trivedi DJ, Ekestubbe L, Ioannidis I, Duffy CC, Peden CJ, Mohseni S. Mode of anesthesia is not associated with outcomes following emergency hip fracture surgery: a population-level cohort study. Trauma Surg Acute Care Open 2022; 7:e000957. [PMID: 36148316 PMCID: PMC9486374 DOI: 10.1136/tsaco-2022-000957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 08/31/2022] [Indexed: 11/05/2022] Open
Abstract
Background Hip fractures often occur in frail patients with several comorbidities. In those undergoing emergency surgery, determining the optimal anesthesia modality may be challenging, with equipoise concerning outcomes following either spinal or general anesthesia. In this study, we investigated the association between mode of anesthesia and postoperative morbidity and mortality with subgroup analyses. Methods This is a retrospective study using all consecutive adult patients who underwent emergency hip fracture surgery in Orebro County, Sweden, between 2013 and 2017. Patients were extracted from the Swedish National Hip Fracture Registry, and their electronic medical records were reviewed. The association between the type of anesthesia and 30-day and 90-day postoperative mortality, as well as in-hospital severe complications (Clavien-Dindo classification ≥3a), was analyzed using Poisson regression models with robust SEs, while the association with 1-year mortality was analyzed using Cox proportional hazards models. All analyses were adjusted for potential confounders. Results A total of 2437 hip fracture cases were included in the study, of whom 60% received spinal anesthesia. There was no statistically significant difference in the risk of 30-day postoperative mortality (adjusted incident rate ratio (IRR) (95% CI): 0.99 (0.72 to 1.36), p=0.952), 90-day postoperative mortality (adjusted IRR (95% CI): 0.88 (0.70 to 1.11), p=0.281), 1-year postoperative mortality (adjusted HR (95% CI): 0.98 (0.83 to 1.15), p=0.773), or in-hospital severe complications (adjusted IRR (95% CI): 1.24 (0.85 to 1.82), p=0.273), when comparing general and spinal anesthesia. Conclusions Mode of anesthesia during emergency hip fracture surgery was not associated with an increased risk of postoperative mortality or in-hospital severe complications in the study population or any of the investigated subgroups. Level of evidence: Therapeutic/Care Management, level III
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Affiliation(s)
- Ahmad Mohammad Ismail
- Department of Orthopedic Surgery, Orebro University Hospital, Orebro, Sweden.,School of Medical Sciences, Orebro University, Orebro, Sweden
| | - Maximilian Peter Forssten
- Department of Orthopedic Surgery, Orebro University Hospital, Orebro, Sweden.,School of Medical Sciences, Orebro University, Orebro, Sweden
| | - Gary Alan Bass
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Dhanisha Jayesh Trivedi
- School of Medical Sciences, Orebro University, Orebro, Sweden.,Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital, Orebro, Sweden
| | - Lovisa Ekestubbe
- Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital, Orebro, Sweden
| | - Ioannis Ioannidis
- Department of Orthopedic Surgery, Orebro University Hospital, Orebro, Sweden.,School of Medical Sciences, Orebro University, Orebro, Sweden
| | - Caoimhe C Duffy
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Carol J Peden
- Department of Clinical Anesthesiology, University of Southern California Keck School of Medicine, Los Angeles, California, USA.,Department of Anesthesiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Shahin Mohseni
- School of Medical Sciences, Orebro University, Orebro, Sweden.,Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital, Orebro, Sweden
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7
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Oodit R, Biccard BM, Panieri E, Alvarez AO, Sioson MRS, Maswime S, Thomas V, Kluyts HL, Peden CJ, de Boer HD, Brindle M, Francis NK, Nelson G, Gustafsson UO, Ljungqvist O. Guidelines for Perioperative Care in Elective Abdominal and Pelvic Surgery at Primary and Secondary Hospitals in Low-Middle-Income Countries (LMIC's): Enhanced Recovery After Surgery (ERAS) Society Recommendation. World J Surg 2022; 46:1826-1843. [PMID: 35641574 PMCID: PMC9154207 DOI: 10.1007/s00268-022-06587-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2022] [Indexed: 12/24/2022]
Abstract
Background This is the first Enhanced Recovery After Surgery (ERAS®) Society guideline for primary and secondary hospitals in low–middle-income countries (LMIC’s) for elective abdominal and gynecologic care. Methods The ERAS LMIC Guidelines group was established by the ERAS® Society in collaboration with different representatives of perioperative care from LMIC’s. The group consisted of seven members from the ERAS® Society and eight members from LMIC’s. An updated systematic literature search and evaluation of evidence from previous ERAS® guidelines was performed by the leading authors of the Colorectal (2018) and Gynecologic (2019) surgery guidelines (Gustafsson et al in World J Surg 43:6592–695, Nelson et al in Int J Gynecol Cancer 29(4):651–668). Meta-analyses randomized controlled trials (RCTs), prospective and retrospective cohort studies from both HIC’s and LMIC’s were considered for each perioperative item. The members in the LMIC group then applied the current evidence and adapted the recommendations for each intervention as well as identifying possible new items relevant to LMIC’s. The Grading of Recommendations, Assessment, Development and Evaluation system (GRADE) methodology was used to determine the quality of the published evidence. The strength of the recommendations was based on importance of the problem, quality of evidence, balance between desirable and undesirable effects, acceptability to key stakeholders, cost of implementation and specifically the feasibility of implementing in LMIC’s and determined through discussions and consensus. Results In addition to previously described ERAS® Society interventions, the following items were included, revised or discussed: the Surgical Safety Checklist (SSC), preoperative routine human immunodeficiency virus (HIV) testing in countries with a high prevalence of HIV/AIDS (CD4 and viral load for those patients that are HIV positive), delirium screening and prevention, COVID 19 screening, VTE prophylaxis, immuno-nutrition, prehabilitation, minimally invasive surgery (MIS) and a standardized postoperative monitoring guideline. Conclusions These guidelines are seen as a starting point to address the urgent need to improve perioperative care and to effect data-driven, evidence-based care in LMIC’s.
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Affiliation(s)
- Ravi Oodit
- Division of Global Surgery, University of Cape Town, Anzio Road, Observatory, Cape Town, Western Cape, South Africa
| | - Bruce M Biccard
- Department of Anesthesia and Perioperative Medicine, Groote Schuur Hospital, University of Cape Town, Anzio Road, Observatory, Cape Town, Western Cape, South Africa
| | - Eugenio Panieri
- Division of General Surgery, Groote Schuur Hospital, University of Cape Town, Anzio Road, Observatory, Cape Town, Western Cape, South Africa
| | - Adrian O Alvarez
- Anesthesia Department, Hospital Italiano de Buenos Aires, Teniente General Juan Domingo Peron, 4190, C1199ABB, Beunos Aires, Argentina
| | - Marianna R S Sioson
- Head Section of Medical Nutrition, Department of Medicine and ERAS Team, The Medical City, Ortigas Avenue, Manila, Metro Manila, Philippines
| | - Salome Maswime
- Division of Global Surgery, University of Cape Town, Anzio Road, Observatory, Cape Town, Western Cape, South Africa
| | - Viju Thomas
- Department of Obstetrics and Gynaecology, Tygerberg Hospital and University of Stellenbosch, Francie Van Zyl Drive, Parow, Cape Town, Western Cape, South Africa
| | - Hyla-Louise Kluyts
- Department of Anaesthesiology, Sefako Makgatho Health Sciences University, Medunsa, Molotlegi Street, P.O. Box 60, Ga-Rankuwa, Pretoria, 0204, Gauteng, South Africa
| | - Carol J Peden
- Keck School of Medicine, University of Southern California, 1975 Zonal Ave, Los Angeles, CA, 90033, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Hans D de Boer
- Department of Anesthesiology, Pain Medicine and Procedural Sedation and Analgesia, Martini General Hospital Groningen, Van Swietenplein 1, 9728 NT, Groningen, The Netherlands
| | - Mary Brindle
- Cumming School of Medicine, University of Calgary, London, Canada.,Alberta Children's Hospital, Calgary, Canada.,Safe Systems, Ariadne Labs, Stockholm, USA.,EQuIS Research Platform, Orebro, Canada
| | - Nader K Francis
- Division of Surgery and Interventional Science- UCL, Gower Street, London, WC1E 6BT, UK
| | - Gregg Nelson
- Department of Obstetrics & Gynecology, University of Calgary, 1331 29 St NW, Calgary, AB, T2N 4N2, Canada
| | - Ulf O Gustafsson
- Department of Clinical Sciences, Division of Surgery, Danderyd Hospital, Karolinska Institutet, Entrevägen 2, 19257, Stockholm, Danderyd, Sweden
| | - Olle Ljungqvist
- School of Medical Sciences, Department of Surgery, Örebro University, 701 85, Örebro, Sweden.
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8
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Stylianou N, Young J, Peden CJ, Vasilakis C. Developing and validating a predictive model for future emergency hospital admissions. Health Informatics J 2022; 28:14604582221101538. [PMID: 35593747 DOI: 10.1177/14604582221101538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Although many emergency hospital admissions may be unavoidable, a proportion of these admissions represent a failure of the care system. The adverse consequences of avoidable emergency hospital admissions affect patients, carers, care systems and substantially increase care costs. The aim of this study was to develop and validate a risk prediction model to estimate the individual probability of emergency admission in the next 12 months within a regional population. We deterministically linked routinely collected data from secondary care with population level data, resulting in a comprehensive research dataset of 190,466 individuals. The resulting risk prediction tool is based on a logistic regression model with five independent variables. The model indicated a discrimination of area under the receiver operating characteristic curve of 0.9384 (95% CI 0.9325-0.9443). We also experimented with different probability cut-off points for identifying high risk patients and found the model's overall prediction accuracy to be over 95% throughout. In summary, the internally validated model we developed can predict with high accuracy the individual risk of emergency admission to hospital within the next year. Its relative simplicity makes it easily implementable within a decision support tool to assist with the management of individual patients in the community.
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Affiliation(s)
- Neophytos Stylianou
- Centre for Health care Innovation and Improvement (CHI), School of Management, 1555University of Bath, Bath, UK; 112443RTD-Talos, Lefkosia, Cyprus
| | - Jason Young
- Bath and North East Somerset, Swindon & Wiltshire NHS Clinical Commissioning Group, Bath, UK
| | - Carol J Peden
- Gehr Family Center for Health System Sciences and Innovation, Keck School of Medicine, 12223University of Southern California, Los Angeles, CA, USA
| | - Christos Vasilakis
- Centre for Health Care Innovation and Improvement (CHI), School of Management, 1555University of Bath, Bath, UK
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9
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Abstract
Emergency laparotomy is a high-risk surgical procedure with mortality and morbidity up to 10 times higher than for a similar procedure performed electively. An enhanced recovery approach has been shown to improve outcomes. A focus on rapid correction of underlying deranged acute physiology and proactive management of conditions associated with aging such as frailty and delirium are key. Patients are at high risk of complications and prevention and avoidance of failure to rescue are essential to improve outcomes. Other enhanced recovery components such as opioid-sparing analgesia and early postoperative mobilization are beneficial.
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Affiliation(s)
- Geeta Aggarwal
- Royal Surrey Hospital NHS Foundation Trust, Egerton Road, Guildford, Surrey, GU2 7XX, UK.
| | - Michael Scott
- Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA; Surgical Outcomes Research Centre, University College London, London, UK
| | - Carol J Peden
- Keck School of Medicine, University of Southern California, 1975 Zonal Avenue, Los Angeles, CA 90033, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; Clinical Quality the Blue Cross Blue Shield Association, Chicago, IL 60601, USA
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10
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Stephens TJ, Beckingham IJ, Bamber JR, Peden CJ. What Influences the Effectiveness of Quality Improvement in Perioperative Care: Learning From Large Multicenter Studies in Emergency General Surgery? Anesth Analg 2022; 134:559-563. [PMID: 35180173 DOI: 10.1213/ane.0000000000005879] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Timothy J Stephens
- From the William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK.,Adult Critical Care Unit, The Royal London Hospital, Surgery and Critical Care, Barts Health NHS Trust, London, United Kingdom
| | - Ian J Beckingham
- Department of Hepatico-Pancreatico-Biliary Surgery, Nottingham University Hospitals NHS Foundation Trust, Nottingham, United Kingdom
| | - Jonathan Riddell Bamber
- Department of Medicine, Faculty of Medical Sciences, University College London, London, United Kingdom
| | - Carol J Peden
- Department of Anesthesiology, Keck School of Medicine, University of Southern California, Los Angeles, California.,Department of Anesthesiology, University of Pennsylvania, Philadelphia, Pennsylvania
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11
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Pagán VM, McClung KS, Peden CJ. An Observational Study of Disparities in Telemedicine Utilization in Primary Care Patients Before and During the COVID-19 Pandemic. Telemed J E Health 2021; 28:1117-1125. [PMID: 34935517 DOI: 10.1089/tmj.2021.0412] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Background: The rapid scale up of telemedicine due to the COVID-19 pandemic may have disadvantaged patients less able to use technology. Objectives: We tested the hypothesis that certain patient groups may have been disadvantaged in accessing primary care using telemedicine. Design: We compared visit type and patient characteristics for April-May 2019 with April-May 2020 at a large urban academic medical center. Variables of interest included age, gender, race, ethnicity, language, visit type, visit status, insurance type, and zip code to approximate average income. Results: There was a 5% increase in patient visits in the observation period from 2019 to 2020. Care shifted from 100% in person to 83% telemedicine, 60% of which occurred through video and 23% by telephone. In 2020, there was a significant increase in the percentage of older patients, patients of lower income, patients whose preferred language was not English, and patients without commercial insurance who accessed care. For patients who completed a telemedicine visit, racial minority status, Hispanic/Latino ethnicity, older age, and non-English language preference significantly increased the likelihood of a telephone visit compared with younger adult, white, non-Hispanic/Latino and English-preference patients. Conclusions: The increase in visits in 2020 and particularly visits by older, non-English preference and lower income patients, demonstrates that the telemedicine scale-up increased access and reached patients regardless of age, language, and income. However, varied usage of televideo and telephone visits for certain groups suggests the need to explore the differences between these modalities to ensure quality telemedicine care for all patients.
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Affiliation(s)
- Veronica M Pagán
- Gehr Family Center for Health Systems Science & Innovation, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Katie S McClung
- Gehr Family Center for Health Systems Science & Innovation, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.,Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Carol J Peden
- Gehr Family Center for Health Systems Science & Innovation, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.,Department of Anesthesiology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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12
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Rubin DS, Huisingh-Scheetz M, Ferguson MK, Nagele P, Peden CJ, Lauderdale DS. U.S. trends in elective and emergent major abdominal surgical procedures from 2002 to 2014 in older adults. J Am Geriatr Soc 2021; 69:2220-2230. [PMID: 33969889 PMCID: PMC8373714 DOI: 10.1111/jgs.17189] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 03/15/2021] [Accepted: 04/04/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND The U.S. population is aging and projected to undergo an increasing number of general surgical procedures. However, recent trends in the frequency of major abdominal procedures in older adults are currently unknown as improvements in non-operative interventions may obviate the need for major surgery. Thus, we evaluated the trends of major abdominal surgical procedures in older adults in the United States. METHODS We performed a retrospective cohort study using the National Inpatient Sample from 2002 to 2014 with trend analysis using National Cancer Institute's Joinpoint Trend Analysis Software. We identified the average annual percent change (AAPC) in the yearly frequency of major abdominal surgical procedures in older adults (≥50 years of age). RESULTS Our cohort included a total of 3,951,947 survey-weighted discharges that included a major abdominal surgery in adults ≥50 years of age between 2002 and 2014. Of these discharges, 2,529,507 (64.0%) were for elective abdominal surgeries, 2,062,835 (52.0%) were for female patients, and mean (SD) age was 61.4 (15.9) years. The frequency of major abdominal procedures (elective and emergent) decreased for adults aged 65-74 (AAPC: -1.43, -1.75, -1.11, p < 0.0001), 75-84 (AAPC: -2.75, -3.33, -2.16, p < 0.001), and ≥85 (AAPC: -4.07, -4.67, -3.47, p < 0.0001). The AAPC for elective procedures decreased for older adults aged 75-84 (AAPC = -1.65; -2.44, -0.85: p = 0.0001) and >85 (AAPC = -3.53; -4.57, -2.48: p < 0.0001). All age groups showed decreases in emergent procedures in 50-64 (AAPC = -1.76, -2.00, -1.52, p < 0.0001), 65-74 (AAPC = -3.59, -4.03, -3.14, p < 0.0001), 75-84 (AAPC = -3.90, -4.34, -3.46, p < 0.0001), ≥85 (AAPC = -4.58, -4.98, -4.17, p < 0.0001) age groups. CONCLUSIONS AND RELEVANCE In this cohort of older adults, the frequency of emergent and elective major abdominal procedures in adults ≥65 years of age decreased with significant variation among individual procedure types. Future studies are needed to identify the generalizability of our findings to other surgical procedures.
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Affiliation(s)
- Daniel S Rubin
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois, USA
| | - Megan Huisingh-Scheetz
- Section of Geriatrics and Palliative Medicine, University of Chicago, Chicago, Illinois, USA
| | - Mark K Ferguson
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Peter Nagele
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois, USA
| | - Carol J Peden
- Department of Anesthesiology, University of Southern California, Los Angeles, California, USA
- Department of Anesthesiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Diane S Lauderdale
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois, USA
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13
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Forssten MP, Mohammad Ismail A, Borg T, Ahl R, Wretenberg P, Cao Y, Peden CJ, Mohseni S. Postoperative mortality in hip fracture patients stratified by the Revised Cardiac Risk Index: a Swedish nationwide retrospective cohort study. Trauma Surg Acute Care Open 2021; 6:e000778. [PMID: 34395919 PMCID: PMC8314694 DOI: 10.1136/tsaco-2021-000778] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 07/06/2021] [Indexed: 12/13/2022] Open
Abstract
Objectives The Revised Cardiac Risk Index (RCRI) is a tool that can be used to evaluate the 30-day risk of postoperative myocardial infarction, cardiac arrest and mortality. This study aims to confirm its association with postoperative mortality in patients who underwent hip fracture surgery. Methods All adults who underwent primary emergency hip fracture surgery in Sweden between January 1, 2008 and December 31, 2017 were included in this study. The database was retrieved by cross-referencing the Swedish National Quality Register for hip fractures with the Swedish National Board of Health and Welfare registers. The outcomes of interest were the association between the RCRI score and mortality at 30 days, 90 days and 1 year postoperatively. Results 134 915 cases were included in the current study. There was a statistically significant linear trend in postoperative mortality with increasing RCRI scores at 30 days, 90 days and 1 year. An RCRI score ≥4 was associated with a 3.1 times greater risk of 30-day postoperative mortality (adjusted incidence rate ratio (IRR) 3.13, p<0.001), a 2.5 times greater risk of 90-day postoperative mortality (adjusted IRR 2.54, p<0.001) and a 2.8 times greater risk of 1-year postoperative mortality (adjusted HR 2.81, p<0.001) compared with that observed with an RCRI score of 0. Conclusion An increasing RCRI score is strongly associated with an elevated risk 30-day, 90-day and 1-year postoperative mortality after primary hip fracture surgery. The objective and easily retrievable nature of the variables included in the RCRI calculation makes it an appealing choice for risk stratification in the clinical setting. Levels of evidence Level III.
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Affiliation(s)
- Maximilian Peter Forssten
- Department of Orthopedic Surgery, Orebro University Hospital, Orebro, Sweden.,School of Medical Sciences, Orebro University, Orebro, Sweden
| | - Ahmad Mohammad Ismail
- Department of Orthopedic Surgery, Orebro University Hospital, Orebro, Sweden.,School of Medical Sciences, Orebro University, Orebro, Sweden
| | - Tomas Borg
- Department of Orthopedic Surgery, Orebro University Hospital, Orebro, Sweden.,School of Medical Sciences, Orebro University, Orebro, Sweden
| | - Rebecka Ahl
- School of Medical Sciences, Orebro University, Orebro, Sweden.,Department of Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Per Wretenberg
- Department of Orthopedic Surgery, Orebro University Hospital, Orebro, Sweden.,School of Medical Sciences, Orebro University, Orebro, Sweden
| | - Yang Cao
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Orebro University, Orebro, Sweden
| | - Carol J Peden
- Department of Clinical Anesthesiology, University of Southern California Keck School of Medicine, Los Angeles, California, USA.,Department of Anesthesiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Shahin Mohseni
- School of Medical Sciences, Orebro University, Orebro, Sweden.,Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital, Orebro, Sweden
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14
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Affiliation(s)
- Carol J Peden
- From the Department of Anesthesiology, Keck School of Medicine, University of Southern California, Los Angeles, California.,Department of Anesthesiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amir A Ghaferi
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
| | - Thomas R Vetter
- Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, Austin, Texas
| | - Zeev N Kain
- Departments of Anesthesiology and Perioperative Care and Medicine, University of California, Irvine.,Child Study Center, Yale University School of Medicine, New Haven, Connecticut.,CHOC Children's Hospital, Orange, California
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15
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Peden CJ, Aggarwal G, Aitken RJ, Anderson ID, Bang Foss N, Cooper Z, Dhesi JK, French WB, Grant MC, Hammarqvist F, Hare SP, Havens JM, Holena DN, Hübner M, Kim JS, Lees NP, Ljungqvist O, Lobo DN, Mohseni S, Ordoñez CA, Quiney N, Urman RD, Wick E, Wu CL, Young-Fadok T, Scott M. Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS) Society Recommendations: Part 1-Preoperative: Diagnosis, Rapid Assessment and Optimization. World J Surg 2021; 45:1272-1290. [PMID: 33677649 PMCID: PMC8026421 DOI: 10.1007/s00268-021-05994-9] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) protocols reduce length of stay, complications and costs for a large number of elective surgical procedures. A similar, structured approach appears to improve outcomes, including mortality, for patients undergoing high-risk emergency general surgery, and specifically emergency laparotomy. These are the first consensus guidelines for optimal care of these patients using an ERAS approach. METHODS Experts in aspects of management of the high-risk and emergency general surgical patient were invited to contribute by the International ERAS® Society. Pubmed, Cochrane, Embase, and MEDLINE database searches on English language publications were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized controlled trials, systematic reviews, meta-analyses and large cohort studies, and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on non-emergency patients when appropriate. The Delphi method was used to validate final recommendations. The guideline has been divided into two parts: Part 1-Preoperative Care and Part 2-Intraoperative and Postoperative management. This paper provides guidelines for Part 1. RESULTS Twelve components of preoperative care were considered. Consensus was reached after three rounds. CONCLUSIONS These guidelines are based on the best available evidence for an ERAS approach to patients undergoing emergency laparotomy. Initial management is particularly important for patients with sepsis and physiological derangement. These guidelines should be used to improve outcomes for these high-risk patients.
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Affiliation(s)
- Carol J. Peden
- Department of Anesthesiology and Gehr Family Center for Health Systems Science & Innovation, Keck School of Medicine, University of Southern California, 2020 Zonal Avenue IRD 322, Los Angeles, CA 90033 USA
- Department of Anesthesiology, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 USA
| | - Geeta Aggarwal
- Department of Anesthesia and Intensive Care Medicine, Royal Surrey County Hospital, Guildford, Surrey, UK
| | - Robert J. Aitken
- Sir Charles Gardiner Hospital, Hospital Avenue, Nedlands, WA 6009 Australia
| | - Iain D. Anderson
- Salford Royal NHS Foundation Trust, Stott La, Salford, M6 8HD UK
- University of Manchester, Manchester, UK
| | | | - Zara Cooper
- Harvard Medical School, Kessler Director, Center for Surgery and Public Health, Brigham and Women’s Hospital and Division of Trauma, Burns, Surgical Critical Care, and Emergency Surgery, Brigham and Women’s Hospital, 1620, Tremont Street, Boston, MA 02120 USA
| | - Jugdeep K. Dhesi
- Faculty of Life Sciences and Medicine, School of Population Health & Environmental Sciences, Guy’s and St Thomas’ NHS Foundation Trust, King’s College London, Division of Surgery & Interventional Science, University College London, London, UK
| | - W. Brenton French
- Department of Surgery, Virginia Commonwealth University Health System, 1200 E. Broad Street, Richmond, VA 23298 USA
| | - Michael C. Grant
- Department of Anesthesiology and Critical Care Medicine, Department of Surgery, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287 USA
| | - Folke Hammarqvist
- Department of Emergency and Trauma Surgery, Karolinska University Hospital, CLINTEC, Karolinska Institutet, Stockholm, Sweden
- Karolinska University Hospital, Huddinge Hälsovägen 3. B85, S 141 86, Stockholm, Sweden
| | - Sarah P. Hare
- Department of Anaesthesia, Perioperative Medicine and Critical Care, Medway Maritime Hospital, Windmill Road, Gillingham, Kent, ME7 5NY UK
| | - Joaquim M. Havens
- Division of Trauma, Burns and Surgical Critical Care, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115 USA
| | - Daniel N. Holena
- Department of Surgery and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA 19104 USA
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Jeniffer S. Kim
- Gehr Family Center for Health Systems Science & Innovation, Keck School of Medicine, University of Southern California, 2020 Zonal Avenue IRD 322, Los Angeles, CA 90033 USA
| | - Nicholas P. Lees
- Department of General & Colorectal Surgery, Salford Royal NHS Foundation Trust, Scott La, Salford, M6 8HD UK
| | - Olle Ljungqvist
- Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Dileep N. Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen’s Medical Centre, Nottingham, NG7 2UH UK
- MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen’s Medical Centre, Nottingham, NG7 2UH UK
| | - Shahin Mohseni
- Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital & School of Medical Sciences, Örebro University, 701 85 Örebro, Sweden
| | - Carlos A. Ordoñez
- Division of Trauma and Acute Care Surgery, Department of Surgery, Fundación Valle del Lili, Cra 98 No. 18 – 49, 760032 Cali, Colombia
- Sección de Cirugía de Trauma Y Emergencias, Universidad del Valle – Hospital Universitario del Valle, Cl 5 No. 36-08, 760032 Cali, Colombia
| | - Nial Quiney
- Department of Anesthesia and Intensive Care Medicine, Royal Surrey County Hospital, Egerton Road, Guildford, Surrey, GU5 7XX UK
| | - Richard D. Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital / Harvard Medical School, 75 Francis Street, Boston, MA 02115 USA
| | - Elizabeth Wick
- Department of Surgery, University of California San Francisco, 513 Parnassus Ave HSW1601, San Francisco, CA 94143 USA
| | - Christopher L. Wu
- Department of Anesthesiology, Critical Care and Pain Medicine-Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
- Department of Anesthesiology, Weill Cornell Medicine, 535 East 70th Street, New York, NY 10021 USA
| | - Tonia Young-Fadok
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic College of Medicine, Mayo Clinic Arizona, 5777 E. Mayo Blvd, Phoenix, AZ 85054 USA
| | - Michael Scott
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 USA
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16
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Robinson J, Porter M, Montalvo Y, Peden CJ. Losing the wait: improving patient cycle time in primary care. BMJ Open Qual 2021; 9:bmjoq-2019-000910. [PMID: 32381596 PMCID: PMC7223280 DOI: 10.1136/bmjoq-2019-000910] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 03/27/2020] [Accepted: 04/18/2020] [Indexed: 11/29/2022] Open
Abstract
Inefficient clinic systems leading to prolonged wait times at primary care clinics are a source of frustration for patients, physicians, staff and administration. Measuring and shortening cycle time has the potential to improve patient experience, staff satisfaction and patient access by moving more patients through in a shorter cycle time. Limited studies have demonstrated that improvements can be made to cycle time and may result in improved patient satisfaction. Most of these studies have focused their efforts on improving efficiency at the front end of the cycle. Our aim was to improve cycle time for the whole visit to less than 60 min within 1 year by engaging our team in brainstorming solutions, presenting regular measurements to our team for review and holding regular meetings to plan rapid improvement cycles. Over the course of 1 year (2017), we were able to reduce cycle time by 12% from 71 to 65 min and to improve patient satisfaction with care. Despite the reduction in cycle time, we maintained high satisfaction scores from patients who felt that the doctor spent enough time with them. We learnt the value of engaging our team, frequent measurement for reporting, adequate staffing at the beginning of clinic, and the value of MA staff acting in a flow coordinator role. We have not only maintained this improvement but also made further small gains over the subsequent 2 years, and by April 2019, our cycle time is at 60 min, despite a marked increase in patient volume. Additional work on the time after the patient is roomed and waiting for a doctor, and further analysis of the physician workflow would be important next steps to drive further improvement.
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Affiliation(s)
- Jehni Robinson
- Family Medicine, USC Keck School of Medicine, Los Angeles, California, USA
| | - Melody Porter
- Family Medicine, USC Keck School of Medicine, Los Angeles, California, USA
| | - Yara Montalvo
- Family Medicine, USC Keck School of Medicine, Los Angeles, California, USA
| | - Carol J Peden
- Gehr Family Centre for Health Systems Science and Innovation, USC Keck School of Medicine, Los Angeles, California, USA
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Peden CJ, Miller TR, Deiner SG, Eckenhoff RG, Fleisher LA. Improving perioperative brain health: an expert consensus review of key actions for the perioperative care team. Br J Anaesth 2021; 126:423-432. [PMID: 33413977 DOI: 10.1016/j.bja.2020.10.037] [Citation(s) in RCA: 67] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 10/28/2020] [Accepted: 10/30/2020] [Indexed: 12/13/2022] Open
Abstract
Delirium and postoperative neurocognitive disorder are the commonest perioperative complications in patients more than 65 yr of age. However, data suggest that we often fail to screen patients for preoperative cognitive impairment, to warn patients and families of risk, and to take preventive measures to reduce the incidence of perioperative neurocognitive disorders. As part of the American Society of Anesthesiologists (ASA) Perioperative Brain Health Initiative, an international group of experts was invited to review published best practice statements and guidelines. The expert group aimed to achieve consensus on a small number of practical recommendations that could be implemented by anaesthetists and their partners to reduce the incidence of perioperative neurocognitive disorders. Six statements were selected based not only on the strength of the evidence, but also on the potential for impact and the feasibility of widespread implementation. The actions focus on education, cognitive and delirium screening, non-pharmacologic interventions, pain control, and avoidance of antipsychotics. Strategies for effective implementation are discussed. Anaesthetists should be key members of multidisciplinary perioperative care teams to implement these recommendations.
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Affiliation(s)
- Carol J Peden
- Department of Anesthesiology, Keck Medicine of the University of Southern California, Los Angeles, CA, USA.
| | | | - Stacie G Deiner
- Department of Anesthesiology, Dartmouth Hitchcock Medical Centre, Lebanon, NH, USA
| | - Roderic G Eckenhoff
- Department of Anesthesiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Lee A Fleisher
- Department of Anesthesiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Lin DM, Peden CJ, Langness SM, Sammann A, Greenberg SB, Lane-Fall MB, Cooper JB. The Anesthesia Patient Safety Foundation Stoelting Conference 2019: Perioperative Deterioration-Early Recognition, Rapid Intervention, and the End of Failure-to-Rescue. Anesth Analg 2020; 131:e155-e159. [PMID: 33035027 DOI: 10.1213/ane.0000000000005008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Della M Lin
- Department of Surgery, John A. Burns School of Medicine, Honolulu, Hawaii,
| | - Carol J Peden
- Department of Anesthesiology, Keck School of Medicine at the University of Southern California, Los Angeles, California
| | | | - Amanda Sammann
- Department of Surgery, The Better Lab, San Francisco, California
| | - Steven B Greenberg
- Department of Anesthesiology, Critical Care and Pain Medicine, NorthShore University HealthSystem, Evanston, Illinois, Department of Anesthesiology and Critical Care, University of Chicago, Pritzker School of Medicine, Chicago, Illinois
| | - Meghan B Lane-Fall
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeffrey B Cooper
- Department of Anesthesia, Critical Care & Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
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19
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Peden CJ, Mohan S, Pagán V. Telemedicine and COVID-19: an Observational Study of Rapid Scale Up in a US Academic Medical System. J Gen Intern Med 2020; 35:2823-2825. [PMID: 32500329 PMCID: PMC7272134 DOI: 10.1007/s11606-020-05917-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 05/06/2020] [Indexed: 12/03/2022]
Affiliation(s)
- Carol J Peden
- Gehr Family Center for Health Systems Science and Innovation, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
| | - Sirisha Mohan
- Department of Family Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Veronica Pagán
- Gehr Family Center for Health Systems Science and Innovation, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Decker J, Kaloostian CL, Gurvich T, Nguyen P, Widjaja W, Cardona H, Pagan V, Motamed A, Peden CJ. Beyond Cognitive Screening: Establishing an Interprofessional Perioperative Brain Health Initiative. J Am Geriatr Soc 2020; 68:2359-2364. [DOI: 10.1111/jgs.16720] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 06/23/2020] [Accepted: 06/24/2020] [Indexed: 12/20/2022]
Affiliation(s)
- Justyne Decker
- Department of Anesthesiology Keck School of Medicine, University of Southern California Los Angeles California USA
| | - Carolyn L. Kaloostian
- Department of Family Medicine Keck School of Medicine, University of Southern California Los Angeles California USA
| | - Tatyana Gurvich
- Department of Pharmacy Keck School of Medicine, University of Southern California Los Angeles California USA
| | - Phuong Nguyen
- Chan Division of Occupational Science and Occupational Therapy Herman Ostrow School of Dentistry, University of Southern California Los Angeles California USA
| | - William Widjaja
- Department of Anesthesiology Keck School of Medicine, University of Southern California Los Angeles California USA
| | - Hugo Cardona
- Department of Anesthesiology Keck School of Medicine, University of Southern California Los Angeles California USA
| | - Veronica Pagan
- Gehr Family Center for Health Systems Innovation University of Southern California Los Angeles California USA
| | - Arash Motamed
- Department of Anesthesiology Keck School of Medicine, University of Southern California Los Angeles California USA
| | - Carol J. Peden
- Department of Anesthesiology Keck School of Medicine, University of Southern California Los Angeles California USA
- Gehr Family Center for Health Systems Innovation University of Southern California Los Angeles California USA
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21
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Brunner-La Rocca HP, Peden CJ, Soong J, Holman PA, Bogdanovskaya M, Barclay L. Reasons for readmission after hospital discharge in patients with chronic diseases-Information from an international dataset. PLoS One 2020; 15:e0233457. [PMID: 32603361 PMCID: PMC7326238 DOI: 10.1371/journal.pone.0233457] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 05/05/2020] [Indexed: 11/18/2022] Open
Abstract
Background Chronic diseases are increasingly prevalent in Western countries. Once hospitalised, the chance for another hospitalisation increases sharply with large impact on well-being of patients and costs. The pattern of readmissions is very complex, but poorly understood for multiple chronic diseases. Methods This cohort study of administrative discharge data between 2009–2014 from 21 tertiary hospitals (eight USA, five UK, four Australia, four continental Europe) investigated rates and reasons of readmissions to the same hospital within 30 days after unplanned admission with one of the following chronic conditions; heart failure; atrial fibrillation; myocardial infarction; hypertension; stroke; chronic obstructive pulmonary disease (COPD); bacterial pneumonia; diabetes mellitus; chronic renal disease; anaemia; arthritis and other cardiovascular disease. Proportions of readmissions with similar versus different diseases were analysed. Results Of 4,901,584 admissions, 866,502 (17.7%) were due to the 12 chronic conditions. In-hospital, 43,573 (5.0%) patients died, leaving 822,929 for readmission analysis. Of those, 87,452 (10.6%) had an emergency 30-day readmission, rates ranged from 2.8% for arthritis to 18.4% for COPD. One third were readmitted with the same condition, ranging from 53% for anaemia to 11% for arthritis. Reasons for readmission were due to another chronic condition in 10% to 35% of the cases, leaving 30% to 70% due to reasons other than the original 12 conditions (most commonly, treatment related complications and infections). The chance of being readmitted with the same cause was lower in the USA, for female patients, with increasing age, more co-morbidities, during study period and with longer initial length of stay. Conclusion Readmission in chronic conditions is very common and often caused by diseases other than the index hospitalisation. Interventions to reduce readmissions should therefore focus not only on the primary condition but on a holistic consideration of all the patient’s comorbidities.
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Affiliation(s)
| | - Carol J. Peden
- Center for Health System Innovation, Keck Medicine of USC, Los Angeles, California, United States of America
| | - John Soong
- NIHR CLAHRC for Northwest London Team, Imperial College London, Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom
| | - Per Arne Holman
- Department of Patients safety and Research, Lovisenberg Diaconal Hospital, Oslo, Norway
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22
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Santhirapala V, Peden CJ, Meara JG, Biccard BM, Gelb AW, Johnson WD, Lipnick MS, Makasa EM, Martin J, Maswime S, Mellin-Olsen J, McClain CD. Towards high-quality peri-operative care: a global perspective. Anaesthesia 2020; 75 Suppl 1:e18-e27. [PMID: 31903566 DOI: 10.1111/anae.14921] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2019] [Indexed: 01/22/2023]
Abstract
Article 25 of the United Nations' Universal Declaration of Human Rights enshrines the right to health and well-being for every individual. However, universal access to high-quality healthcare remains the purview of a handful of wealthy nations. This is no more apparent than in peri-operative care, where an estimated five billion individuals lack access to safe, affordable and timely surgical care. Delivery of surgery and anaesthesia in low-resource environments presents unique challenges that, when unaddressed, result in limited access to low-quality care. Current peri-operative research and clinical guidance often fail to acknowledge these system-level deficits and therefore have limited applicability in low-resource settings. In this manuscript, the authors priority-set the need for equitable access to high-quality peri-operative care and analyse the system-level contributors to excess peri-operative mortality rates, a key marker of quality of care. To provide examples of how research and investment may close the equity gap, a modified Delphi method was adopted to curate and appraise interventions which may, with subsequent research and evaluation, begin to address the barriers to high-quality peri-operative care in low- and middle-income countries.
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Affiliation(s)
- V Santhirapala
- Harvard Medical School, Boston, MA, USA.,Magill Department of Anaesthesia, Intensive Care and Pain Management, Chelsea and Westminster NHS Foundation Trust, London, UK
| | - C J Peden
- Department of Anesthesiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - J G Meara
- Harvard Medical School, Boston, MA, USA.,Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA, USA
| | - B M Biccard
- Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital, University of Cape Town, South Africa
| | - A W Gelb
- Department of Anesthesia and Perioperative Care, University of California San Francisco, CA, USA
| | - W D Johnson
- World Health Organization, Geneva, Switzerland
| | - M S Lipnick
- Department of Anesthesia and Perioperative Care, University of California San Francisco, CA, USA
| | - E M Makasa
- Wits Centre of Surgical Care for Primary Health and Sustainable Development, School of Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - J Martin
- Department of Anesthesia and Perioperative Medicine and Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - S Maswime
- University of Cape Town, South Africa
| | - J Mellin-Olsen
- Department of Anaesthesia and Intensive Care Medicine, Baerum Hospital, Sandvika, Norway
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23
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Aggarwal G, Quiney N, Peden CJ. Early postoperative death in extreme-risk patients: A perspective on surgical futility. Surgery 2019; 167:517-518. [PMID: 31548094 DOI: 10.1016/j.surg.2019.07.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Revised: 07/28/2019] [Accepted: 07/29/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Geeta Aggarwal
- Department of Anaesthesia, Royal Surrey County Hospital, Guildford, Surrey, UK.
| | - Nial Quiney
- Department of Anaesthesia, Royal Surrey County Hospital, Guildford, Surrey, UK
| | - Carol J Peden
- Keck School of Medicine, University of Southern California, Los Angeles, CA
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24
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Stephens TJ, Peden CJ, Haines R, Grocott MPW, Murray D, Cromwell D, Johnston C, Hare S, Lourtie J, Drake S, Martin GP, Pearse RM. Hospital-level evaluation of the effect of a national quality improvement programme: time-series analysis of registry data. BMJ Qual Saf 2019; 29:623-635. [PMID: 31515437 DOI: 10.1136/bmjqs-2019-009537] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 08/07/2019] [Accepted: 08/23/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND OBJECTIVES A clinical trial in 93 National Health Service hospitals evaluated a quality improvement programme for emergency abdominal surgery, designed to improve mortality by improving the patient care pathway. Large variation was observed in implementation approaches, and the main trial result showed no mortality reduction. Our objective therefore was to evaluate whether trial participation led to care pathway implementation and to study the relationship between care pathway implementation and use of six recommended implementation strategies. METHODS We performed a hospital-level time-series analysis using data from the Enhanced Peri-Operative Care for High-risk patients trial. Care pathway implementation was defined as achievement of >80% median reliability in 10 measured care processes. Mean monthly process performance was plotted on run charts. Process improvement was defined as an observed run chart signal, using probability-based 'shift' and 'runs' rules. A new median performance level was calculated after an observed signal. RESULTS Of 93 participating hospitals, 80 provided sufficient data for analysis, generating 800 process measure charts from 20 305 patient admissions over 27 months. No hospital reliably implemented all 10 processes. Overall, only 279 of the 800 processes were improved (3 (2-5) per hospital) and 14/80 hospitals improved more than six processes. Mortality risk documented (57/80 (71%)), lactate measurement (42/80 (53%)) and cardiac output guided fluid therapy (32/80 (40%)) were most frequently improved. Consultant-led decision making (14/80 (18%)), consultant review before surgery (17/80 (21%)) and time to surgery (14/80 (18%)) were least frequently improved. In hospitals using ≥5 implementation strategies, 9/30 (30%) hospitals improved ≥6 care processes compared with 0/11 hospitals using ≤2 implementation strategies. CONCLUSION Only a small number of hospitals improved more than half of the measured care processes, more often when at least five of six implementation strategies were used. In a longer term project, this understanding may have allowed us to adapt the intervention to be effective in more hospitals.
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Affiliation(s)
- Timothy J Stephens
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Carol J Peden
- Department of Anesthesiology, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Ryan Haines
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | | | - Dave Murray
- Department of Anaesthesia, James Cook University Hospital, Middlesbrough, UK
| | - David Cromwell
- Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Carolyn Johnston
- Department of Anaesthesia, St Georges University Hospital NHS Foundation Trust, London, UK
| | - Sarah Hare
- Department of Aneasthesia, Medway Maritime Hospital, Gillingham, Kent, UK
| | | | | | | | - Rupert M Pearse
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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25
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Peden CJ, Stephens T, Martin G, Kahan BC, Thomson A, Everingham K, Kocman D, Lourtie J, Drake S, Girling A, Lilford R, Rivett K, Wells D, Mahajan R, Holt P, Yang F, Walker S, Richardson G, Kerry S, Anderson I, Murray D, Cromwell D, Phull M, Grocott MPW, Bion J, Pearse RM. A national quality improvement programme to improve survival after emergency abdominal surgery: the EPOCH stepped-wedge cluster RCT. Health Serv Deliv Res 2019. [DOI: 10.3310/hsdr07320] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
Emergency abdominal surgery is associated with poor patient outcomes. We studied the effectiveness of a national quality improvement (QI) programme to implement a care pathway to improve survival for these patients.
Objectives
The objectives were to assess whether or not the QI programme improves 90-day survival after emergency abdominal surgery; to assess effects on 180-day survival, hospital stay and hospital readmission; and to better understand these findings through an integrated process evaluation, ethnographic study and cost-effectiveness analysis.
Design
This was a stepped-wedge cluster randomised trial. Hospitals were organised into 15 geographical clusters, and commenced the QI programme in random order over 85 weeks. Analyses were performed on an intention-to-treat basis. The primary outcome was analysed using a mixed-effects parametric survival model, adjusting for time-related effects. Ethnographic and economics data were collected in six hospitals. The process evaluation included all hospitals.
Setting
The trial was set in acute surgical services of 93 NHS hospitals.
Participants
Patients aged ≥ 40 years who were undergoing emergency abdominal surgery were eligible.
Intervention
The intervention was a QI programme to implement an evidence-based care pathway.
Main outcome measures
The primary outcome measure was mortality within 90 days of surgery. Secondary outcomes were mortality within 180 days, length of hospital stay and hospital readmission within 180 days. The main economic measure was the quality-adjusted life-years.
Data sources
Data were obtained from the National Emergency Laparotomy Audit database; qualitative interviews and ethnographic observations; quality-of-life and NHS resource use data were collected via questionnaires.
Results
Of 15,873 eligible patients from 93 NHS hospitals, primary outcome data were analysed for 8482 participants in the usual care group and 7374 in the QI group. The primary outcome occurred in 1393 participants in the usual care group (16%), compared with 1210 patients in the QI group (16%) [QI vs. usual care hazard ratio (HR) 1.11, 95% confidence interval (CI) 0.96 to 1.28]. No differences were found in mortality at 180 days or hospital readmission; there was a small increase in hospital stay in the QI group (HR for discharge 0.90, 95% CI 0.83 to 0.97). There were only modest improvements in care processes following QI implementation. The ethnographic study revealed good QI engagement, but limited time and resources to implement change, affecting which processes teams addressed, the rate of change and eventual success. In some sites, there were challenges around prioritising the intervention in busy environments and in obtaining senior engagement. The intervention is unlikely to be cost-effective at standard cost-effectiveness thresholds, but may be cost-effective over the lifetime horizon.
Limitations
Substantial delays were encountered in securing data access to national registries. Fewer patients than expected underwent surgery and the mortality rate was lower than anticipated.
Conclusions
There was no survival benefit from a QI programme to implement a care pathway for patients undergoing emergency abdominal surgery. The modest impact of the intervention on process measures, despite good clinician engagement, may have been limited by the time and resources needed to improve patient care.
Future work
Future QI programmes must balance intervention complexity with the practical realities of NHS services to ensure that such programmes can be delivered with the resources available.
Trial registration
Current Controlled Trials ISRCTN80682973 and The Lancet protocol 13PRT/7655.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 7, No. 32. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Carol J Peden
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Tim Stephens
- William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Graham Martin
- Health Sciences, University of Leicester, Leicester, UK
| | - Brennan C Kahan
- Pragmatic Clinical Trials Unit, Queen Mary University of London, London, UK
| | - Ann Thomson
- Pragmatic Clinical Trials Unit, Queen Mary University of London, London, UK
| | - Kirsty Everingham
- William Harvey Research Institute, Queen Mary University of London, London, UK
| | - David Kocman
- Health Sciences, University of Leicester, Leicester, UK
| | | | | | - Alan Girling
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | | | | | - Ravi Mahajan
- Faculty of Medicine & Health Sciences, University of Nottingham, Nottingham, UK
| | - Peter Holt
- Molecular and Clinical Sciences Research Institute, St George’s University of London, London, UK
| | - Fan Yang
- Centre for Health Economics, University of York, York, UK
| | - Simon Walker
- Centre for Health Economics, University of York, York, UK
| | | | - Sally Kerry
- Pragmatic Clinical Trials Unit, Queen Mary University of London, London, UK
| | - Iain Anderson
- Salford Royal Hospital NHS Foundation Trust, Manchester, UK
| | - Dave Murray
- South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - David Cromwell
- London School of Hygiene and Tropical Medicine, London, UK
| | - Mandeep Phull
- William Harvey Research Institute, Queen Mary University of London, London, UK
- Department of Anaesthesia and Intensive Care, Queen’s Hospital, Romford, UK
| | - Mike PW Grocott
- National Institute for Health Research Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Anaesthesia and Critical Care Research Unit, University of Southampton, Southampton, UK
| | - Julian Bion
- Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Rupert M Pearse
- William Harvey Research Institute, Queen Mary University of London, London, UK
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Doyle JF, Sarnowski A, Saadat F, Samuels TL, Huddart S, Quiney N, Dickinson MC, McCormick B, deBrunner R, Preece J, Swart M, Peden CJ, Richards S, Forni LG. Does the Implementation of a Quality Improvement Care Bundle Reduce the Incidence of Acute Kidney Injury in Patients Undergoing Emergency Laparotomy? J Clin Med 2019; 8:jcm8081265. [PMID: 31434348 PMCID: PMC6724004 DOI: 10.3390/jcm8081265] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 07/16/2019] [Accepted: 07/17/2019] [Indexed: 12/29/2022] Open
Abstract
PURPOSE Previous work has demonstrated a survival improvement following the introduction of an enhanced recovery protocol in patients undergoing emergency laparotomy (the emergency laparotomy pathway quality improvement care (ELPQuiC) bundle). Implementation of this bundle increased the use of intra-operative goal directed fluid therapy and ICU admission, both evidence-based strategies recommended to improve kidney outcomes. The aim of this study was to determine if the observed mortality benefit could be explained by a difference in the incidence of AKI pre- and post-implementation of the protocol. METHOD The primary outcome was the incidence of AKI in the pre- and post-ELPQuiC bundle patient population in four acute trusts in the United Kingdom. Secondary outcomes included the KDIGO stage specific incidence of AKI. Serum creatinine values were obtained retrospectively at baseline, in the post-operative period and the maximum recorded creatinine between day 1 and day 30 were obtained. RESULTS A total of 303 patients pre-ELPQuiC bundle and 426 patients post-ELPQuiC bundle implementation were identified across the four centres. The overall AKI incidence was 18.4% in the pre-bundle group versus 19.8% in the post bundle group p = 0.653. No significant differences were observed between the groups. CONCLUSIONS Despite this multi-centre cohort study demonstrating an overall survival benefit, implementation of the quality improvement care bundle did not affect the incidence of AKI.
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Affiliation(s)
- James F Doyle
- Department of Intensive Care Medicine and Surrey Peri-Operative Anaesthesia and Critical Care Collaborative Research Group (SPACER), Royal Surrey County Hospital NHS Foundation Trust, Guildford, Surrey GU2 7XX, UK
- Department of Intensive Care Medicine, Royal Brompton & Harefield NHS Foundation Trust, London SW3 6NP, UK
| | - Alexander Sarnowski
- Department of Intensive Care Medicine and Surrey Peri-Operative Anaesthesia and Critical Care Collaborative Research Group (SPACER), Royal Surrey County Hospital NHS Foundation Trust, Guildford, Surrey GU2 7XX, UK
| | - Farzad Saadat
- Department of Intensive Care Medicine and Surrey Peri-Operative Anaesthesia and Critical Care Collaborative Research Group (SPACER), Royal Surrey County Hospital NHS Foundation Trust, Guildford, Surrey GU2 7XX, UK
| | - Theophilus L Samuels
- Department of Anaesthesia and Intensive Care Medicine, Surrey & Sussex Healthcare NHS Trust, Redhill RH1 5RH, UK
| | - Sam Huddart
- Department of Intensive Care Medicine and Surrey Peri-Operative Anaesthesia and Critical Care Collaborative Research Group (SPACER), Royal Surrey County Hospital NHS Foundation Trust, Guildford, Surrey GU2 7XX, UK
| | - Nial Quiney
- Department of Intensive Care Medicine and Surrey Peri-Operative Anaesthesia and Critical Care Collaborative Research Group (SPACER), Royal Surrey County Hospital NHS Foundation Trust, Guildford, Surrey GU2 7XX, UK
| | - Matthew C Dickinson
- Department of Intensive Care Medicine and Surrey Peri-Operative Anaesthesia and Critical Care Collaborative Research Group (SPACER), Royal Surrey County Hospital NHS Foundation Trust, Guildford, Surrey GU2 7XX, UK
| | - Bruce McCormick
- Department of Anaesthesia, Royal Devon & Exeter NHS Foundation Trust, Exeter EX2 5DW, UK
| | - Robert deBrunner
- Department of Anaesthesia, Royal Devon & Exeter NHS Foundation Trust, Exeter EX2 5DW, UK
| | - Jeremy Preece
- Department of Anaesthesia, Royal Devon & Exeter NHS Foundation Trust, Exeter EX2 5DW, UK
| | - Michael Swart
- Department of Anaesthesia, Torbay & South Devon NHS Foundation Trust, Torquay TQ2 7AA, UK
| | - Carol J Peden
- Department of Anaesthesia, Royal United Hospitals Bath NHS Foundation Trust, Avon BA1 3NG, UK
| | - Sarah Richards
- Department of Surgery, Royal United Hospitals Bath NHS Foundation Trust, Avon BA1 3NG, UK
| | - Lui G Forni
- Department of Intensive Care Medicine and Surrey Peri-Operative Anaesthesia and Critical Care Collaborative Research Group (SPACER), Royal Surrey County Hospital NHS Foundation Trust, Guildford, Surrey GU2 7XX, UK.
- Department of Clinical & Experimental Medicine, Faculty of Health and Medical Sciences, University of Surrey, Guildford Guildford, GU2 7YS, UK.
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27
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Peden CJ, Stephens T, Martin G, Kahan BC, Thomson A, Rivett K, Wells D, Richardson G, Kerry S, Bion J, Pearse RM. Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH): a stepped-wedge cluster-randomised trial. Lancet 2019; 393:2213-2221. [PMID: 31030986 DOI: 10.1016/s0140-6736(18)32521-2] [Citation(s) in RCA: 104] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Revised: 10/01/2018] [Accepted: 10/05/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Emergency abdominal surgery is associated with poor patient outcomes. We studied the effectiveness of a national quality improvement (QI) programme to implement a care pathway to improve survival for these patients. METHODS We did a stepped-wedge cluster-randomised trial of patients aged 40 years or older undergoing emergency open major abdominal surgery. Eligible UK National Health Service (NHS) hospitals (those that had an emergency general surgical service, a substantial volume of emergency abdominal surgery cases, and contributed data to the National Emergency Laparotomy Audit) were organised into 15 geographical clusters and commenced the QI programme in a random order, based on a computer-generated random sequence, over an 85-week period with one geographical cluster commencing the intervention every 5 weeks from the second to the 16th time period. Patients were masked to the study group, but it was not possible to mask hospital staff or investigators. The primary outcome measure was mortality within 90 days of surgery. Analyses were done on an intention-to-treat basis. This study is registered with the ISRCTN registry, number ISRCTN80682973. FINDINGS Treatment took place between March 3, 2014, and Oct 19, 2015. 22 754 patients were assessed for elegibility. Of 15 873 eligible patients from 93 NHS hospitals, primary outcome data were analysed for 8482 patients in the usual care group and 7374 in the QI group. Eight patients in the usual care group and nine patients in the QI group were not included in the analysis because of missing primary outcome data. The primary outcome of 90-day mortality occurred in 1210 (16%) patients in the QI group compared with 1393 (16%) patients in the usual care group (HR 1·11, 0·96-1·28). INTERPRETATION No survival benefit was observed from this QI programme to implement a care pathway for patients undergoing emergency abdominal surgery. Future QI programmes should ensure that teams have both the time and resources needed to improve patient care. FUNDING National Institute for Health Research Health Services and Delivery Research Programme.
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Affiliation(s)
- Carol J Peden
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Tim Stephens
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, London, UK
| | - Graham Martin
- Health Sciences, University of Leicester, Leicester, UK
| | - Brennan C Kahan
- Pragmatic Clinical Trials Unit, Barts and The London School of Medicine and Dentistry, London, UK
| | - Ann Thomson
- Pragmatic Clinical Trials Unit, Barts and The London School of Medicine and Dentistry, London, UK
| | | | | | | | - Sally Kerry
- Pragmatic Clinical Trials Unit, Barts and The London School of Medicine and Dentistry, London, UK
| | - Julian Bion
- Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Rupert M Pearse
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, London, UK.
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Aggarwal G, Peden CJ, Mohammed MA, Pullyblank A, Williams B, Stephens T, Kellett S, Kirkby-Bott J, Quiney N. Evaluation of the Collaborative Use of an Evidence-Based Care Bundle in Emergency Laparotomy. JAMA Surg 2019; 154:e190145. [PMID: 30892581 PMCID: PMC6537778 DOI: 10.1001/jamasurg.2019.0145] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Question Is a quality improvement collaborative approach to implementation of a care bundle associated with reductions in mortality from emergency laparotomy? Findings In this study of a collaborative project involving 28 hospitals and a total of 14 809 patients, reductions in mortality and length of stay were seen after implementation of a care bundle. Improvement took time to occur and was not seen until the second year of the collaborative project. Meaning The findings suggest that hospitals should consider adopting a care bundle approach and participating in a collaborative group to see improvement in outcomes for patients undergoing emergency laparotomy. Importance Patients undergoing emergency laparotomy have high mortality, but few studies exist to improve outcomes for these patients. Objective To assess whether a collaborative approach to implement a 6-point care bundle is associated with reduction in mortality and length of stay and improvement in the delivery of standards of care across a group of hospitals. Design, Setting, and Participants The Emergency Laparotomy Collaborative (ELC) was a UK-based prospective quality improvement study of the implementation of a care bundle provided to patients requiring emergency laparotomy between October 1, 2015, and September 30, 2017. Participants were 28 National Health Service hospitals and emergency surgical patients who were treated at these hospitals and whose data were entered into the National Emergency Laparotomy Audit (NELA) database. Post-ELC implementation outcomes were compared with baseline data from July 1, 2014, to September 30, 2015. Data entry and collection were performed through the NELA. Interventions A 6-point, evidence-based care bundle was used. The bundle included prompt measurement of blood lactate levels, early review and treatment for sepsis, transfer to the operating room within defined time goals after the decision to operate, use of goal-directed fluid therapy, postoperative admission to an intensive care unit, and multidisciplinary involvement of senior clinicians in the decision and delivery of perioperative care. Change management and leadership coaching were provided to ELC leadership teams. Main Outcome and Measures Primary outcomes were in-hospital mortality, both crude and Portsmouth Physiological and Operative Severity Score for the enumeration of Mortality and morbidity (P-POSSUM) risk-adjusted, and length of stay. Secondary outcomes were the changes after implementation of the separate metrics in the care bundle. Results A total of 28 hospitals participated in the ELC and completed the project. The baseline group included 5562 patients (2937 female [52.8%] and a mean [range] age of 65.3 [18.0-114.0] years), whereas the post-ELC group had 9247 patients (4911 female [53.1%] and a mean [range] age of 65.0 [18.0-99.0] years). Unadjusted mortality rate decreased from 9.8% at baseline to 8.3% in year 2 of the project, and so did risk-adjusted mortality from a baseline of 5.3% to 4.5% post-ELC. Mean length of stay decreased from 20.1 days during year 1 to 18.9 days during year 2. Significant changes in 5 of the 6 metrics in the care bundle were achieved. Conclusions and Relevance A collaborative approach using a quality improvement methodology and a care bundle appeared to be effective in reducing mortality and length of stay in emergency laparotomy, suggesting that hospitals should adopt such an approach to see better patient outcomes and care delivery performance.
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Affiliation(s)
- Geeta Aggarwal
- Department of Anesthesiology, Royal Surrey County Hospital, Guildford, United Kingdom
| | - Carol J Peden
- Department of Anesthesiology, Keck School of Medicine, University of Southern California, Los Angeles
| | | | - Anne Pullyblank
- Department of Surgery, North Bristol Hospital, Bristol, United Kingdom.,West of England Academic Health Science Network, Bristol, United Kingdom
| | - Ben Williams
- Kent Surrey Sussex Academic Health Science Network, Crawley, United Kingdom
| | - Timothy Stephens
- Critical Care and Perioperative Medicine Research Group, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Suzanne Kellett
- Department of Anesthesiology, University Hospital Southampton, Southampton, United Kingdom
| | - James Kirkby-Bott
- Department of Surgery, University Hospital Southampton, Southampton, United Kingdom
| | - Nial Quiney
- Department of Anesthesiology, Royal Surrey County Hospital, Guildford, United Kingdom
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Stephens TJ, Peden CJ, Pearse RM, Shaw SE, Abbott TEF, Jones EL, Kocman D, Martin G. Correction to: Improving care at scale: process evaluation of a multi-component quality improvement intervention to reduce mortality after emergency abdominal surgery (EPOCH trial). Implement Sci 2018; 13:148. [PMID: 30526645 PMCID: PMC6287357 DOI: 10.1186/s13012-018-0840-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 11/19/2018] [Indexed: 11/30/2022] Open
Affiliation(s)
- T J Stephens
- Critical Care and Perioperative Medicine Research Group, WHRI, c/o Adult Critical Care Unit, The Royal London Hospital, London, E11BB, UK.
| | - C J Peden
- Keck School of Medicine, University of Southern California, Los Angeles, USA
| | - R M Pearse
- Critical Care and Perioperative Medicine Research Group, WHRI, c/o Adult Critical Care Unit, The Royal London Hospital, London, E11BB, UK
| | - S E Shaw
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - T E F Abbott
- Critical Care and Perioperative Medicine Research Group, WHRI, c/o Adult Critical Care Unit, The Royal London Hospital, London, E11BB, UK
| | - E L Jones
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - D Kocman
- SAPPHIRE Group, Department of Health Sciences, University of Leicester, Leicester, UK
| | - G Martin
- THIS Institute (The Healthcare Improvement Studies Institute), University of Cambridge, Cambridge, UK
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Affiliation(s)
- Geeta Aggarwal
- From the *Department of Anaesthesia and Intensive Care Medicine, Royal Surrey County Hospital, Guildford, United Kingdom; and †Department of Anesthesiology and USC Center for Health System Innovation, Keck School of Medicine, University of Southern California, Los Angeles, California
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Chana P, Joy M, Casey N, Chang D, Burns EM, Arora S, Darzi AW, Faiz OD, Peden CJ. Cohort analysis of outcomes in 69 490 emergency general surgical admissions across an international benchmarking collaborative. BMJ Open 2017; 7:e014484. [PMID: 28274969 PMCID: PMC5353261 DOI: 10.1136/bmjopen-2016-014484] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE This study aims to use the Dr Foster Global Comparators Network (GC) database to examine differences in outcomes following high-risk emergency general surgery (EGS) admissions in participating centres across 3 countries and to determine whether hospital infrastructure factors can be linked to the delivery of high-quality care. DESIGN A retrospective cohort analysis of high-risk EGS admissions using GC's international administrative data set. SETTING 23 large hospitals in Australia, England and the USA. METHODS Discharge data for a cohort of high-risk EGS patients were collated. Multilevel hierarchical logistic regression analysis was performed to examine geographical and structural differences between GC hospitals. RESULTS 69 490 patients, admitted to 23 centres across Australia, England and the USA from 2007 to 2012, were identified. For all patients within this cohort, outcomes defined as: 7-day and 30-day inhospital mortality, readmission and length of stay appeared to be superior in US centres. A subgroup of 19 082 patients (27%) underwent emergency abdominal surgery. No geographical differences in mortality were seen at 7 days in this subgroup. 30-day mortality (OR=1.47, p<0.01) readmission (OR=1.42, p<0.01) and length of stay (OR=1.98, p<0.01) were worse in English units. Patient factors (age, pathology, comorbidity) were significantly associated with worse outcome as were structural factors, including low intensive care unit bed ratios, high volume and interhospital transfers. Having dedicated EGS teams cleared of elective commitments with formalised handovers was associated with shorter length of stay. CONCLUSIONS Key factors that influence outcomes were identified. For patients who underwent surgery, outcomes were similar at 7 days but not at 30 days. This may be attributable to better infrastructure and resource allocation towards EGS in the US and Australian centres.
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Affiliation(s)
- Prem Chana
- Department of Academic Surgery, St Mary's Hospital, Imperial College London, London, UK
- The Global Comparators Unit, Dr Foster Intelligence, London, UK
- Department of Surgical Epidemiology, Trials and Outcome Centre (SETOC), St Mark's Hospital and Academic Institute, Imperial College London, London, UK
| | - Mark Joy
- The Global Comparators Unit, Dr Foster Intelligence, London, UK
- School of Health Sciences, University of Surrey, Surrey, UK
| | - Neil Casey
- The Global Comparators Unit, Dr Foster Intelligence, London, UK
| | - David Chang
- Codman Centre, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Elaine M Burns
- Department of Academic Surgery, St Mary's Hospital, Imperial College London, London, UK
| | - Sonal Arora
- Department of Academic Surgery, St Mary's Hospital, Imperial College London, London, UK
| | - Ara W Darzi
- Department of Academic Surgery, St Mary's Hospital, Imperial College London, London, UK
| | - Omar D Faiz
- Department of Academic Surgery, St Mary's Hospital, Imperial College London, London, UK
- Department of Surgical Epidemiology, Trials and Outcome Centre (SETOC), St Mark's Hospital and Academic Institute, Imperial College London, London, UK
| | - Carol J Peden
- Centre for Health Systems Innovation, University of Southern California, Los Angeles, California, USA
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Affiliation(s)
- T M Cook
- Royal United Hospital, Bath, UK.
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Eveleigh MO, Howes TE, Peden CJ, Cook TM. Estimated costs before, during and after the introduction of the emergency laparotomy pathway quality improvement care (ELPQuIC) bundle. Anaesthesia 2016; 71:1291-1295. [PMID: 27667290 DOI: 10.1111/anae.13623] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2016] [Indexed: 12/25/2022]
Abstract
Implementation of a quality improvement bundle for peri-operative management of emergency laparotomy (ELPQuIC) improved mortality in a previous study. We used data from one site that participated in that study to examine whether it was associated with the cost of care. We collected data from 396 patients: 144 before, 144 during and 108 after implementation of the bundle. We estimated costs incurred using previously published methodology based on the time the patient spent in hospital, in the operating theatre and in critical care. Duration of stay in hospital and critical care did not differ between time periods, p = 0.14 and p = 0.28, respectively. The costs per patient and per survivor did not differ between the time periods, p = 0.87 and p = 0.17, respectively. Costs were similar for patients aged < 80 years vs. ≥ 80 years. Implementation of a quality improvement bundle for emergency laparotomy has the capacity to save lives without increasing hospital costs.
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Affiliation(s)
- M O Eveleigh
- Department of Anaesthesia, Royal United Hospital NHS Foundation Trust, Bath, UK.
| | - T E Howes
- Department of Anaesthesia, Royal United Hospital NHS Foundation Trust, Bath, UK
| | - C J Peden
- Department of Anaesthesia, Royal United Hospital NHS Foundation Trust, Bath, UK
| | - T M Cook
- Department of Anaesthesia, Royal United Hospital NHS Foundation Trust, Bath, UK
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Howes TE, Cook TM, Corrigan LJ, Dalton SJ, Richards SK, Peden CJ. Prioritising emergency laparotomy - a reply. Anaesthesia 2015; 70:1460-1. [PMID: 26558868 DOI: 10.1111/anae.13325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
| | - T M Cook
- Royal United Hospitals, Bath, UK
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Huddart S, Peden CJ, Swart M, McCormick B, Dickinson M, Mohammed MA, Quiney N. Use of a pathway quality improvement care bundle to reduce mortality after emergency laparotomy. Br J Surg 2014; 102:57-66. [PMID: 25384994 PMCID: PMC4312892 DOI: 10.1002/bjs.9658] [Citation(s) in RCA: 148] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2014] [Revised: 07/05/2014] [Accepted: 08/21/2014] [Indexed: 02/06/2023]
Abstract
Background Emergency laparotomies in the UK, USA and Denmark are known to have a high risk of death, with accompanying evidence of suboptimal care. The emergency laparotomy pathway quality improvement care (ELPQuiC) bundle is an evidence-based care bundle for patients undergoing emergency laparotomy, consisting of: initial assessment with early warning scores, early antibiotics, interval between decision and operation less than 6 h, goal-directed fluid therapy and postoperative intensive care. Methods The ELPQuiC bundle was implemented in four hospitals, using locally identified strategies to assess the impact on risk-adjusted mortality. Comparison of case mix-adjusted 30-day mortality rates before and after care-bundle implementation was made using risk-adjusted cumulative sum (CUSUM) plots and a logistic regression model. Results Risk-adjusted CUSUM plots showed an increase in the numbers of lives saved per 100 patients treated in all hospitals, from 6·47 in the baseline interval (299 patients included) to 12·44 after implementation (427 patients included) (P < 0·001). The overall case mix-adjusted risk of death decreased from 15·6 to 9·6 per cent (risk ratio 0·614, 95 per cent c.i. 0·451 to 0·836; P = 0·002). There was an increase in the uptake of the ELPQuiC processes but no significant difference in the patient case-mix profile as determined by the mean Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity risk (0·197 and 0·223 before and after implementation respectively; P = 0·395). Conclusion Use of the ELPQuiC bundle was associated with a significant reduction in the risk of death following emergency laparotomy.
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Affiliation(s)
- S Huddart
- Department of Anaesthesia and Intensive Care, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
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Abstract
INTRODUCTION Emergency laparotomy is a common procedure, with 30,000-50,000 performed annually in the UK. This large scale study reports the current spectrum of emergency laparotomies, and the influence of the surgical procedure, underlying pathology and subspecialty of the operating surgeon on mortality. METHODS Anonymised data on consecutive patients undergoing an emergency laparotomy were submitted for a three-month period. The primary outcome measure was unadjusted 30-day mortality. Appendicectomy and cholecystectomy were among the procedures excluded. RESULTS Data from 1,708 patients from 35 National Health Service hospitals were analysed. The overall 30-day mortality rate was 14.8%. 'True' emergency laparotomies (ie those classified by the National Confidential Enquiry into Patient Outcome and Death as immediate or urgent) comprised 86.5% of cases. The mortality rate rose from 8.0% among expedited cases to 14.3% among urgent cases and to 25.7% among laparotomies termed immediate. Among the most common index procedures, small bowel resection exhibited the highest 30-day mortality rate of 21.1%. The presence of abdominal sepsis was associated with raised 30-day mortality (17.5% in the presence of sepsis vs 12.6%, p=0.027). Colorectal procedures comprised 44.3% and within this group, data suggest that mortality from laparotomy may be influenced by surgical subspecialisation. CONCLUSIONS This report of a large number of patients undergoing emergency laparotomy in the UK confirms a remarkably high mortality by modern standards across the range. Very few pathologies or procedures can be considered anything other than high risk. The need for routine consultant involvement and critical care is evident, and the case distribution helps define the surgical skill set needed for a modern emergency laparotomy service. Preliminary data relating outcomes from emergency colonic surgery to surgical subspecialty require urgent further study.
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Abstract
Introduction Emergency laparotomy is a common procedure, with 30,000–50,000 performed annually in the UK. This large scale study reports the current spectrum of emergency laparotomies, and the influence of the surgical procedure, underlying pathology and subspecialty of the operating surgeon on mortality. Methods Anonymised data on consecutive patients undergoing an emergency laparotomy were submitted for a three-month period. The primary outcome measure was unadjusted 30-day mortality. Appendicectomy and cholecystectomy were among the procedures excluded. Results Data from 1,708 patients from 35 National Health Service hospitals were analysed. The overall 30-day mortality rate was 14.8%. ‘True’ emergency laparotomies (ie those classified by the National Confidential Enquiry into Patient Outcome and Death as immediate or urgent) comprised 86.5% of cases. The mortality rate rose from 8.0% among expedited cases to 14.3% among urgent cases and to 25.7% among laparotomies termed immediate. Among the most common index procedures, small bowel resection exhibited the highest 30-day mortality rate of 21.1%. The presence of abdominal sepsis was associated with raised 30-day mortality (17.5% in the presence of sepsis vs 12.6%, p=0.027). Colorectal procedures comprised 44.3% and within this group, data suggest that mortality from laparotomy may be influenced by surgical subspecialisation. Conclusions This report of a large number of patients undergoing emergency laparotomy in the UK confirms a remarkably high mortality by modern standards across the range. Very few pathologies or procedures can be considered anything other than high risk. The need for routine consultant involvement and critical care is evident, and the case distribution helps define the surgical skill set needed for a modern emergency laparotomy service. Preliminary data relating outcomes from emergency colonic surgery to surgical subspecialty require urgent further study.
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Affiliation(s)
- E Barrow
- on behalf of the UK Emergency Laparotomy Network
| | - ID Anderson
- on behalf of the UK Emergency Laparotomy Network
| | - S Varley
- on behalf of the UK Emergency Laparotomy Network
| | - AC Pichel
- on behalf of the UK Emergency Laparotomy Network
| | - CJ Peden
- on behalf of the UK Emergency Laparotomy Network
| | - DI Saunders
- on behalf of the UK Emergency Laparotomy Network
| | - D Murray
- on behalf of the UK Emergency Laparotomy Network
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Saunders DI, Murray D, Pichel AC, Varley S, Peden CJ. Variations in mortality after emergency laparotomy: the first report of the UK Emergency Laparotomy Network. Br J Anaesth 2012; 109:368-75. [PMID: 22728205 DOI: 10.1093/bja/aes165] [Citation(s) in RCA: 267] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Emergency laparotomy is a common intra-abdominal procedure. Outcomes are generally recognized to be poor, but there is a paucity of hard UK data, and reports have mainly been confined to single-centre studies. METHODS Clinicians were invited to join an 'Emergency Laparotomy Network' and to collect prospective non-risk-adjusted outcome data from a large number of NHS Trusts providing emergency surgical care. Data concerning what were considered to be key aspects of perioperative care, including thirty-day mortality, were collected over a 3 month period. RESULTS Data from 1853 patients were collected from 35 NHS hospitals. The unadjusted 30 day mortality was 14.9% for all patients and 24.4% in patients aged 80 or over. There was a wide variation between units in terms of the proportion of cases subject to key interventions that may affect outcomes. The presence of a consultant surgeon in theatre varied between 40.6% and 100% of cases, while a consultant anaesthetist was present in theatre for 25-100% of cases. Goal-directed fluid management was used in 0-63% of cases. Between 0% and 68.9% of the patients returned to the ward (level one) after surgery, and between 9.7% and 87.5% were admitted to intensive care (level three). Mortality rates varied from 3.6% to 41.7%. CONCLUSIONS This study confirms that emergency laparotomy in the UK carries a high mortality. The variation in clinical management and outcomes indicates the need for a national quality improvement programme.
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Affiliation(s)
- D I Saunders
- Department of Anaesthesia, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Queen Victoria Road, Newcastle upon Tyne NE1 4LP, UK
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Bowles TM, Freshwater-Turner DA, Janssen DJ, Peden CJ. Out-of-theatre tracheal intubation: prospective multicentre study of clinical practice and adverse events. Br J Anaesth 2011; 107:687-92. [PMID: 21828342 DOI: 10.1093/bja/aer251] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Tracheal intubation is commonly performed outside the operating theatre and is associated with higher risk than intubation in theatre. Recent guidelines and publications including the 4th National Audit Project of the Royal College of Anaesthetists have sought to improve the safety of out-of-theatre intubations. METHODS We performed a prospective observational study examining all tracheal intubations occurring outside the operating theatre in nine hospitals over a 1 month period. Data were collected on speciality and grade of intubator, presence of essential safety equipment and monitoring, and adverse events. RESULTS One hundred and sixty-four out-of-theatre intubations were identified (excluding those where intubation occurred as part of the management of cardiac arrest). The most common indication for intubation was respiratory failure [74 cases (45%)]. Doctors with at least 6 month's experience in anaesthesia performed 136 intubations (83%); consultants were present for 68 cases (41%), and overall a second intubator was present for 94 procedures (57%). Propofol was the most common induction agent [124 cases (76%)] and 157 patients (96%) received neuromuscular blocking agents. An airway rescue device was available in 139 cases (87%). Capnography was not used in 52 cases (32%). Sixty-four patients suffered at least one adverse event (39%) around the time of tracheal intubation. CONCLUSIONS Out-of-theatre intubation frequently occurs in the absence of essential safety equipment, despite the existing guidelines. The associated adverse event rate is high.
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Affiliation(s)
- T M Bowles
- Frenchay Hospital, Bristol BS16 1LE, UK.
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Abstract
This paper seeks to explain some of the science and concepts used in quality improvement, including the use of run charts and control charts, the development and use of ‘bundles’ and the need to reduce variability to improve quality in critical care.
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Affiliation(s)
- Carol J Peden
- Consultant in Anaesthesia and Intensive Care, Royal United Hospital, Bath; Health Foundation Quality Improvement Fellow, Institute for Healthcare Improvement, Boston USA 2008–2009
| | - Kevin D Rooney
- Consultant in Anaesthetics and Intensive Care, Royal Alexandra Hospital, Paisley, Scotland
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Ford PNR, Thomas I, Cook TM, Whitley E, Peden CJ. Determinants of outcome in critically ill octogenarians after surgery: an observational study. Br J Anaesth 2007; 99:824-9. [PMID: 17959590 DOI: 10.1093/bja/aem307] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND The population in the UK is growing older and the number of elderly patients cared for on intensive care units (ICU) is increasing. This study was designed to identify risk factors for mortality in critically ill patients of >80 yr of age after surgery. METHODS We identified 275 patients, aged 80 yr or greater, admitted to the ICU after surgery. After exclusions, 255 were selected for further analysis. Multivariate analysis was then performed to determine the covariates associated with hospital mortality. RESULTS The overall ICU and hospital mortality was 20.4% and 33.3%, respectively. Patients who received i.v. vasoactive drugs on days 1 and 2 had hospital mortality of 54.4% and 60.5%, respectively. Multivariate analysis showed that requirement for i.v. vasoactive drugs within the first 24 h on ICU [odds ratio (OR) 4.29; 95% CI, 2.35-7.84, P<0.001] and requirement for i.v. vasoactive drugs for a further 24 h (OR 3.63; 95% CI, 1.58-8.37, P<0.01) were associated with hospital mortality. The requirement for i.v. vasoactive drugs was also strongly associated with hospital mortality in all the subgroups studied (elective surgery, emergency surgery, and emergency laparotomy). CONCLUSIONS For patients aged 80 yr and more, admitted to ICU after surgery, the requirement for i.v. vasoactive drugs in the first and second 24 h was the strongest predictor of hospital mortality.
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Affiliation(s)
- P N R Ford
- Department of Anaesthesia, Royal Devon and Exeter Hospital, Barrack Road, Exeter EX2 5DW, UK.
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Abstract
We describe a case of a 19-year-old man who developed traumatic pulmonary pseudocysts after a rollover road traffic crash. These were associated with significant pulmonary haemorrhage requiring a period of mechanical ventilation, but resolved without specific intervention. Review of the literature confirms that this rare complication of blunt chest trauma occurs usually in young adults and, although normally benign, can be associated with life-threatening haemoptysis and secondary infection.
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Affiliation(s)
- A De
- Department of Anaesthesia and Intensive care Medicine, Royal United Hospital, Combe Park, Bath BA1 3NG, UK.
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Abstract
The past year has seen a number of reports discussing the future possibilities of image-guided surgery and interventional radiology. One of the most exciting developments is intra-operative magnetic resonance imaging. The anaesthesiologist plays a central role in these developments, ensuring that patients undergoing procedures in the radiology department are adequately monitored and safely maintained.
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Affiliation(s)
- C J Peden
- Department of Anaesthesia, Royal United Hospital, Bath, UK.
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Peden CJ, Cloote AH, Stratford N, Prys-Roberts C. The effect of intravenous dexmedetomidine premedication on the dose requirement of propofol to induce loss of consciousness in patients receiving alfentanil. Anaesthesia 2001; 56:408-13. [PMID: 11350323 DOI: 10.1046/j.1365-2044.2001.01553.x] [Citation(s) in RCA: 95] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Dexmedetomidine reduces the dose requirements for opioids and anaesthetic agents. We conducted a single-centre, open-label, noncomparative phase II study of the effect of intravenous dexmedetomidine on the dose requirement of propofol to induce loss of consciousness in 49 ASA I and II patients. The initial dexmedetomidine infusion scheme was reduced twice because of adverse events. Forty patients who received the final infusion scheme were randomly allocated to receive one of five stepped propofol infusions; loss of consciousness was assessed after 21 min. The ED50 for the final infusion rate of propofol to suppress consciousness was 3.45 mg x kg(-1) x h(-1) (95% CL 2.7-4.2): ED95 was 6.68 mg x kg(-1) x h(-1) (95% CL 5.1-19.1), EC50 was 1.69 microg x ml(-1) (95% CL 0.95-2.5) and EC95 was 5.7 microg x ml(-1) (95% CL 3.2 to > 10). Our final dose of dexmedetomidine of 0.63 microg x kg(-1) caused a reduction in the overall concentration and dose of propofol required to produce loss of consciousness, but no significant shift in the dose-response curve compared with other studies.
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Affiliation(s)
- C J Peden
- Royal United Hospital Bath, Combe Park, Bath BA1 3NG, UK
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Toner I, Hamid SK, Peden CJ, Taylor KM, Smith PL. Magnetic resonance imaging and P300 (event-related auditory evoked potentials) in the assessment of postoperative cerebral injury following coronary artery bypass graft surgery. Perfusion 1999; 8:321-9. [PMID: 10146367 DOI: 10.1177/026765919300800407] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Cerebral injury following coronary artery bypass grafting (CABG) surgery was investigated with magnetic resonance imaging (MRI) and P300, a long-latency endogenous evoked potential associated with psychological processing of stimulus information. Twelve patients were studied before and after surgery. Prior to surgery, MRI abnormalities were found in all but one patient. After surgery, five patients had new abnormalities, mainly deep white-matter lesions (DWML). Postoperative P300 latency was significantly increased in six patients. P300 topographical distribution showed a shift from predominantly posterior cerebral regions to frontal regions in most patients. Postoperative P300 and MRI deficits were found in three of the five patients. One of the patients with marked MRI change (DWML in caudate nucleus) did not show P300 deficit.
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Affiliation(s)
- I Toner
- Royal Postgraduate Medical School, Hammersmith Hospital, London
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Abstract
The feasibility of day case laparoscopic cholecystectomy was assessed in unselected patients using a standard anaesthetic protocol. Postoperative pain and nausea were assessed at 6 and 24 h postoperatively (visual analogue scale, range 0-10). Thirty-two patients were studied (23 female, 9 male, mean age 49.6 years). The mean duration of surgery was 68 min. At 6 h after surgery, 10 patients (31%) had no pain at rest. For the group as a whole, the median pain score was 3 at rest (range 0-6), 4 on movement (0-9), and 5 on coughing (0-9) and eight patients (25%) were nauseated. At 24 h, 15 (46.9%) had no pain at rest. For the group as a whole, the median pain score was 1 at rest (0-7), 3 (0-6) on movement and 3 on coughing (0-9). The same eight patients were nauseated. Ten patients (31.3%) were judged fit for discharge at 6 h, and 28 (87.5%) by 24 h. There was no statistical difference in mean age or duration of surgery in those judged fit for early discharge compared to the study group as a whole. Nausea was an important factor in those unfit for discharge at 24 h. Selection criteria might improve these figures. From the results of our study, 24 h admission is a more realistic goal and will be suitable for most patients requiring laparoscopic cholecystectomy.
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