Effectiveness and safety of pulse oximetry in remote patient monitoring of patients with COVID-19

Context

A surge of COVID cases globally is often portrayed as “very likely”, which overwhelms health systems and challenges their capacities. A mitigation strategy is seen by remotely monitoring COVID patients in out-of-hospital settings to determine the risk of deterioration.

Description of the problem

We need an indicator to enable remote monitoring of COVID patients at home that can be measured by a handy tool; pulse oximetry which measures peripheral blood oxygen saturation (SpO2). Evidence shows that SpO2 is a reliable indicator of deterioration among COVID patients. The UK initiated a national programme (COVID Oximetry @ Home (CO@H)) to assess the theory. The concept can be potentially applied in other countries in various settings. As part of CO@H, we conducted a systematic review of the evidence on the safety and effectiveness of pulse oximetry in remote monitoring of COVID patients.

Results

Our review confirms the safety and potential effectiveness of pulse oximetry in remote home monitoring among COVID patients. We identified 13 research projects involving 2,908 participants that assessed the proposed strategy. Evidence shows the need to monitor at-rest and post-exertional SpO2. At-rest SpO2 of ≤ 92% or a decrease of 5% or more in post-exertional SpO2 should indicate care escalation. The recommended method for measuring at-rest SpO2 is after 5-10 min of rest, and assessing post-exertional SpO2 is after conducting a 1-min sit-to-stand test. We could not find explicit evidence on the impact on health service use compared with other models of care.

Lessons

Remote monitoring of COVID patients could alleviate the pressure on health systems and save hospital resources. Monitoring SpO2 by pulse oximetry can be widely applied, including in resource-limited settings, as the tool is affordable, reliable, and easy to use.

Key messages

• Adopting relevant health technologies in remote patient monitoring is critical to combat the pandemic.

• Pulse oximetry is an affordable, easy to use and widely available tool to monitor patients with COVID-19 at home.

Remote patient monitoring at home using ambient sensors: a systematic review

Background

The world population is ageing, and their health needs imply substantial demands on health systems. Remote Patient Monitoring (RPM) may help elderly patients live independently in their homes for longer. The essence of RPM is the continuity of use, which is challenging for wearable devices and patient-led technologies. Unobtrusive (ambient) sensors could be an innovative solution, such as motion detectors and similar technologies. This study aims to review the evidence on the effect of ambient sensors on healthcare use by the elderly.

Methods

This is a systematic review for narrative synthesis, searching five databases, Medline, Embase, CINHAL, Scopus and Web of Science, on 21 Feb 2022 without setting a lower time limit. No restrictions on the design of studies were applied. A meta-analysis was not feasible due to the heterogenicity of the studies.

Results

Out of 5,653 search results, 180 studies were subjected to full-text review, of which 6 studies were included in the final synthesis. All the included studies were conducted in the USA. Four studies assessed the technology's cost-efficiency, while only one reported significant cost savings. One study reported a significant reduction in hospital days and visits to a physician among the users. Using ambient sensors was associated with an increased length of stay in facilities where the elderly can live independently, including at home. The impact on the number of hospitalisations or emergency room visits was unclear.

Conclusions

Our review identified limited evidence on the effect of ambient sensors on healthcare use by the elderly. The potential has been demonstrated for ambient sensor technologies to result in cost savings; however, further research is needed to assess the impact on health outcomes.

Key messages

Reflections, impact and recommendations of a co-produced ecological momentary assessment (EMA) study with young people who have experience of suicidality and psychiatric inpatient care

Introduction

Patient and public involvement (PPI) in suicide research is ethical, moral and can deliver impact. However, inconsistent reporting of meaningful PPI, and hesitancy in sharing power with people with experience of suicidality (i.e.co-researchers) in research makes it difficult to understand the full potential impact of PPI on the research, researchers and co-researchers.

Objectives

To describe how our ecological momentary assessment (EMA) study, examining the sleep-suicide relationship in young psychiatric inpatients (aged 18-35) transitioning to the community, has been co-produced, whilst reflecting on impact, challenges, and recommendations.

Methods

We built on our experience of co-produced mental health research to conduct meaningful PPI in our study. Young adults with experience of psychiatric inpatient care and suicidality were appointed November 2020 to work across all research stages. Reflections on challenges, recommendations and impact have been collected throughout.

Results

Three young people became co-researchers. Researcher and co-researcher reflections indicated establishing and maintaining safe environments for open discussion, and continued communication (e.g.WhatsApp group) were vital to effectively share power and decision making. Safeguarding and support requirements for both co-researchers (e.g.individualised strategy) and researcher (e.g.clinical supervision) were particularly evident. To date, the co-produced recruitment poster, research documentation, and research article have demonstrated significant impact.

Conclusions

This is the first EMA study focused on suicide-sleep during transitions to be co-produced with young people with experience of suicidality. Co-producing suicide research is intensive, time-consuming, and challenging but makes a significant impact to the research, researchers, and co-researchers. We expect our learning will directly influence, and help others produce, meaningful co-produced suicide research.

Disclosure

No significant relationships.

Trends and associated factors for Covid-19 hospitalisation and fatality risk in 2.3 million adults in England

The Covid-19 mortality rate varies between countries and over time but the extent to which this is explained by the underlying risk in those infected is unclear. Using data on all adults in England with a positive Covid-19 test between 1st October 2020 and 30th April 2021 linked to clinical records, we examined trends and risk factors for hospital admission and mortality. Of 2,311,282 people included in the study, 164,046 (7.1%) were admitted and 53,156 (2.3%) died within 28 days of a positive Covid-19 test. We found significant variation in the case hospitalisation and mortality risk over time, which remained after accounting for the underlying risk of those infected. Older age groups, males, those resident in areas of greater socioeconomic deprivation, and those with obesity had higher odds of admission and death. People with severe mental illness and learning disability had the highest odds of admission and death. Our findings highlight both the role of external factors in Covid-19 admission and mortality risk and the need for more proactive care in the most vulnerable groups.

Effect of the SARS-CoV-2 pandemic on mortality related to high-risk emergency and major elective surgery

These data show large reductions in both elective and emergency activity that are concerning for unmeasured morbidity and mortality within the community. The risk of mortality following high-risk EGS and major elective surgery during the first wave of the pandemic did not differ when compared with date-matched patient cohorts from 2019. The prevalence of concomitant SARS-CoV-2 infection in this surgical population is low.

Delays in referral from primary care are associated with a worse survival in patients with esophagogastric cancer

NICE referral guidelines for suspected cancer were introduced to improve prognosis by reducing referral delays. However, over 20% of patients with esophagogastric cancer experience three or more consultations before referral. In this retrospective cohort study, we hypothesize that such a delay is associated with a worse survival compared with patients referred earlier. By utilizing Clinical Practice Research Datalink, a national primary care linked database, the first presentation, referral date, a number of consultations before referral and stage for esophagogastric cancer patients were determined. The risk of a referral after one or two consultations compared with three or more consultations was calculated for age and the presence of symptom fulfilling the NICE criteria. The risk of death according to the number of consultations before referral was determined, while accounting for stage and surgical management. 1307 patients were included. Patients referred after one (HR 0.80 95% CI 0.68-0.93 p = 0.005) or two consultations (HR 0.81 95% CI 0.67-0.98 p = 0.034) demonstrated significantly improved prognosis compared with those referred later. The risk of death was also lower for patients who underwent a resection, were younger or had an earlier stage at diagnosis. Those presenting with a symptom fulfilling the NICE criteria (OR 0.27 95% CI 0.21-0.35 p < 0.0001) were more likely to be referred earlier. This is the first study to demonstrate an association between a delay in referral and worse prognosis in esophagogastric patients. These findings should prompt further research to reduce primary care delays.

Colorectal cancer patients under the age of 50 experience delays in primary care leading to emergency diagnoses: a population-based study

AIM

The incidence of colorectal cancer in the under 50s is increasing. In this national population-based study we aim to show that missed opportunities for diagnosis in primary care are leading to referral delays and emergency diagnoses in young patients.

METHOD

We compared the interval before diagnosis, presenting symptom(s) and the odds ratio (OR) of an emergency diagnosis for those under the age of 50 with older patients sourced from the cancer registry with linkage to a national database of primary-care records.

RESULTS

The study included 7315 patients, of whom 508 (6.9%) were aged under 50 years, 1168 (16.0%) were aged 50-59, 2294 (31.4%) were aged 60-69 and 3345 (45.7%) were aged 70-79 years. Young patients were more likely to present with abdominal pain and via an emergency, and had the lowest percentage of early stage cancer. They experienced a longer interval between referral and diagnosis (12.5 days) than those aged 60-69, reflecting the higher proportion of referrals via the nonurgent pathway (33.3%). The OR of an emergency diagnosis did not differ with age if a red-flag symptom was noted at presentation, but increased significantly for young patients if the symptom was nonspecific.

CONCLUSION

Young patients present to primary care with symptoms outside the national referral guidelines, increasing the likelihood of an emergency diagnosis.

Complications after discharge and delays in adjuvant chemotherapy following colonic resection: a cohort study of linked primary and secondary care data

AIM

By understanding the reasons for delays in adjuvant chemotherapy (AC) after colonic resection, there is the potential to improve patient outcome. The aim of this study is to determine the extent and impact of complications after hospital discharge on delays to AC.

METHOD

The study cohort included patients from Hospital Episode Statistics (HES) who had a colorectal cancer resection; linkage to primary care data was provided by the Clinical Practice Research Datalink (CPRD). Complications during the index hospital stay (from HES) and after discharge (from CPRD) were compared. The risk of late AC treatment (8 weeks or later) following a complication, stoma at the index procedure or emergency admission was described after accounting for age and Charlson score. A Cox hazards model determined the association of these factors with overall survival (OS).

RESULTS

A total of 1266 patients underwent AC following colon cancer resection, of whom 598 (47.2%) received treatment within 8 weeks. Patients receiving late AC had a significantly higher proportion of re-operations (7.0% vs 3.3% P < 0.005) and wound infections (5.5% vs 3.7% P = 0.042), with 96% of the latter only being noted in CPRD. In multivariate analysis, the risk of AC delay significantly increased following a complication (OR 1.53, 95% CI 1.16-2.03, P = 0.003) or a stoma at the index operation. AC delay was associated with worse OS [hazard ratio (HR) 1.44, 95% CI 1.16-1.79, P = 0.001], as was an emergency admission (HR 1.59, 95% CI 1.21-1.98, P < 0.0005). However, the presence of a complication did not independently reduce OS (HR 1.15, 95%CI 0.89-1.48, P = 0.295).

CONCLUSION

The true extent and impact of complications following colonic resection is underestimated when only secondary care data are used.

One-year outcomes for congenital diaphragmatic hernia

Background

Congenital diaphragmatic hernia (CDH) is a congenital anomaly with high mortality and long‐term morbidity. The aim of this study was to benchmark trends in 1‐year and hospital volume outcomes for this condition.

Methods

This study included all infants born with CDH in England between 2003 and 2016. This was a retrospective analysis of the Hospital Episode Statistics database. The main outcomes were: 1‐year mortality, neonatal length of hospital stay (nLOS), total bed‐days at 1 year and readmission rate. The association between hospital volume and outcomes was assessed for specialist paediatric surgery centres.

Results

A total of 2336 infants were included (incidence 2·5 per 10 000 live births). No significant time trends were found in incidence and main outcomes. Some 1491 infants (63·8 per cent) underwent surgical repair. The 1‐year mortality rate was 31·2 per cent. Median nLOS and total bed‐days were 17 and 19 days respectively. The readmission rate in specialist paediatric centres was 6·3 per cent. Higher mortality was associated with birthweight lower than 1 kg (OR 5·90, 95 per cent c.i. 1·03 to 33·75), gestational age of 36 weeks or less (OR 1·75, 1·12 to 2·75) and black ethnicity (OR 2·13, 1·03 to 4·48). Only 4·0 per cent had extracorporeal membrane oxygenation, which was associated with higher mortality (OR 5·34, 3·01 to 9·46), longer nLOS (OR 3·70, 2·14 to 6·14) and longer total bed‐days (OR 3·87, 2·19 to 6·83). Specialist paediatric centres showed variation in 30‐day mortality (4·6 per cent with 84 per cent coefficient of variation), nLOS (median 25 (i.q.r. 15–42) days) and total bed‐days (median 28 (i.q.r. 16–51) days), but no significant volume–outcome relationship.

Conclusion

Key outcomes for CDH were similar to those of other developed countries. High variation among specialist paediatric centres was found and should be investigated further to explore the value of regionalization of care.

Vocal palsy increases the risk of lower respiratory tract infection in low-risk, low-morbidity patients undergoing thyroidectomy for benign disease: A big data analysis

OBJECTIVES

Thyroidectomy is the commonest operation that places normally functioning laryngeal nerves at risk of injury. Vocal palsy is a major risk factor for dysphonia, dysphagia, and less commonly, airway obstruction. We investigated the association between post-thyroidectomy vocal palsy and long-term risks of pneumonia and laryngeal failure.

DESIGN

An N=near-all analysis of the English administrative dataset using a previously validated informatics algorithm to identify young and otherwise low-risk patients undergoing first-time elective thyroidectomy for benign disease. Information about age, sex, morbidities, social deprivation and post-operative and late complications were derived.

MAIN OUTCOME MEASURES

Between 2004 and 2012, 43 515 patients between the ages of 20 and 69 who had no history of cancer, neurological, or respiratory disease underwent elective total or hemithyroidectomy without concomitant or late neck dissection, parathyroidectomy or laryngotracheal surgery for benign thyroid disease for the first and only time. Information about age, sex, morbidities and in-hospital and late complications was recorded.

RESULTS

Mean age at surgery was 46±12. There was a strong female preponderance (85%), and most patients (89%) had no recorded Charlson comorbidities Most patients (65%) underwent hemithyroidectomy. Late vocal palsy was recorded in 449 (1.03%) patients, and its occurrence was an independent risk factor for emergency hospital readmission (n=7113; Hazard Ratio 1.52; 95% confidence interval 1.21-1.91), hospitalisation for lower respiratory tract infection (n=944; HR 2.04; 95% CI 1.07-3.75), dysphagia (n=564; HR 3.47; 95% CI 1.57-7.65) and gastrostomy/tracheostomy placement (n=80; HR 20.8; 95% CI 2.5-171.2). Independent risk factors for late vocal palsy were age, burden of morbidities, total thyroidectomy, post operative bleeding, male sex, and annual surgeon volume <30.

CONCLUSIONS

There is a significant association between post-thyroidectomy vocal palsy and long-term risks of hospital readmission, dysphagia, hospitalisation for lower respiratory tract infection, and gastrostomy/tracheostomy tube placement. This adds weight to the need, from a thyroid surgical perspective, to undertake universal post-thyroidectomy laryngeal surveillance as a minimum standard of care, with a focus on post-operative dysphagia and aspiration, and from a medical/respiratory perspective, to initiate investigations to identify occult vocal palsy in patients who present with pneumonia, who have a history of thyroid surgery.

Impact of the method and success of pharyngeal reconstruction on the outcome of treating laryngeal and hypopharyngeal cancers with pharyngolaryngectomy: A national analysis

BACKGROUND

Surgical treatment of cancers that arise from or invade the hypopharynx presents major reconstructive challenges. Reconstructive failure exposes the airway and neck vessels to digestive contents.

METHODS

We performed a national N = near-all analysis of the administrative dataset to identify pharyngolaryngectomies in England between 2002 and 2012. Information about morbidity, pharyngeal closure method and post-operative complications was derived.

RESULTS

There were 1589 predominantly male (78%) patients whose mean age at surgery was 62 years. The commonest morbidities were hypertension (24%) and ischemic heart disease (11%). For 232 (15%) patients, pharyngolaryngectomy was performed during an emergency admission. The pharynx was closed primarily in 551 patients, with skin or muscle free or pedicled flaps in 755 patients and with jejunum and gastric pull-up in 123 and 160 patients, respectively. In-hospital mortality rate was 6% and was significantly higher in the gastric pull-up group (11%). Reconstructive failure had an odds ratio of 6.2 [95% confidence interval (CI) 2.4-16.1] for in-hospital death. The five-year survival was 57% and age, morbidities, emergency surgery, gastric pull-up, major acute cardiovascular events, renal failure and reconstructive failure independently worsened prognosis. Patients who underwent pharyngeal reconstruction with radial forearm or anterolateral thigh flaps had lower mortality rates than patients who had jejunum flap reconstruction (hazard ratio = 1.50 [95% CI 1.03-2.19]) or gastric pull-up (hazard ratio = 1.92 [95% CI 1.32-2.80]).

CONCLUSIONS

Pharyngolaryngectomy carries a high degree of risk of morbidity and mortality. Reconstructive failure worsens short- and long-term prognosis, and the use of cutaneous free flaps appears to improve survival.

Does laminar flow ventilation reduce the rate of infection?

Aims

To determine whether there is any difference in infection rate at 90 days between trauma operations performed in laminar flow and plenum ventilation, and whether infection risk is altered following the installation of laminar flow (LF).

Patients and Methods

We assessed the impact of plenum ventilation (PV) and LF on the rate of infection for patients undergoing orthopaedic trauma operations. All NHS hospitals in England with a trauma theatre(s) were contacted to identify the ventilation system which was used between April 2008 and March 2013 in the following categories: always LF, never LF, installed LF during study period (subdivided: before, during and after installation) and unknown. For each operation, age, gender, comorbidity, socio-economic deprivation, number of previous trauma operations and surgical site infection within 90 days (SSI90) were extracted from England’s national hospital administrative Hospital Episode Statistics database. Crude and adjusted odds ratios (OR) were used to compare ventilation groups using hierarchical logistic regression. Subanalysis was performed for hip hemiarthroplasties.

Results

A total of 803 065 trauma operations were performed during this time; 19 hospitals installed LF, 124 already had LF, 13 had PV and the type of ventilation was unknown in 28. Patient characteristics were similar between the groups. The rate of SSI90 was similar for always LF and PV (2.7% and 2.4%). For hemiarthroplasties of the hip, the rates of SSI90 were significantly higher for LF compared with PV (3.8% and 2.6%, OR 1.45, p = 0·001). Hospitals installing LF did not see any statistically significant change in the rate of SSI90.

Conclusion

The results of this observational study imply that infection rate is similar when orthopaedic trauma surgery is performed in LF and PV, and is unchanged by installing LF in a previously PV theatre. Cite this article: Bone Joint J 2016;98-B:1262–9.

How to monitor patient safety in primary care? Healthcare professionals' views

Objective

To identify patient safety monitoring strategies in primary care.

Design

Open-ended questionnaire survey.

Participants

A total of 113 healthcare professionals returned the survey from a group of 500 who were invited to participate achieving a response rate of 22.6%.

Setting

North-West London, United Kingdom.

Method

A paper-based and equivalent online survey was developed and subjected to multiple stages of piloting. Respondents were asked to suggest strategies for monitoring patient safety in primary care. These monitoring suggestions were then subjected to a content frequency analysis which was conducted by two researchers.

Main Outcome measures

Respondent-derived monitoring strategies.

Results

In total, respondents offered 188 suggestions for monitoring patient safety in primary care. The content analysis revealed that these could be condensed into 24 different future monitoring strategies with varying levels of support. Most commonly, respondents supported the suggestion that patient safety can only be monitored effectively in primary care with greater levels of staffing or with additional resources.

Conclusion

Approximately one-third of all responses were recommendations for strategies which addressed monitoring of the individual in the clinical practice environment (e.g. GP, practice nurse) to improve safety. There was a clear need for more staff and resource set aside to allow and encourage safety monitoring. Respondents recommended the dissemination of specific information for monitoring patient safety such as distributing the lessons of significant event audits amongst GP practices to enable shared learning.

Defining the timing and causes of death amongst patients undergoing colorectal resection in England

AIM

Historically, postoperative deaths have been reported up to 30 days following surgery. There is, however, emerging evidence that deaths attributable to surgery continue to occur much later than this time frame. This aim of this study was to analyse the timing and causes of mortality following colorectal resection.

METHOD

Data were obtained from the Hospital Episode Statistics database with linkage to mortality data from the Office for National Statistics. Patients who underwent colorectal resection between April 2001 and February 2007 were included. Causes of death were classified into colorectal cancer (CRC), other malignancy, cardiac, respiratory, gastrointestinal, neurological and other.

RESULTS

During the study period 171 791 patients underwent a colorectal resection. Thirty-day mortality rates for elective procedures were 1.3, 3.5, 7.0 and 12.1% for the ≤ 65, 66-75, 76-85 and > 85 year age groups, respectively, compared with 2.2, 5.4, 9.8 and 16.7% at 90 days. For elective operations, at 30 days, 38.6% of patients who died had CRC recorded as the primary cause of death, whilst 25.4% died of cardiac causes. In the younger population undergoing a resection, deaths due to cardiac causes were significantly higher than the national average for the same age group even beyond 30 days (13.5% at 30 days, 11.1% at 90 days and 5.7% at 1 year).

CONCLUSION

This study shows that deaths attributable to colorectal surgery occur beyond the conventionally utilized 30-day period. Information presented to patients on the basis of 30-day mortality estimates is likely to underestimate the true risk of surgical intervention.

Association between day of delivery and obstetric outcomes: observational study

STUDY QUESTION

What is the association between day of delivery and measures of quality and safety of maternity services, particularly comparing weekend with weekday performance?

METHODS

This observational study examined outcomes for maternal and neonatal records (1,332,835 deliveries and 1,349,599 births between 1 April 2010 and 31 March 2012) within the nationwide administrative dataset for English National Health Service hospitals by day of the week. Groups were defined by day of admission (for maternal indicators) or delivery (for neonatal indicators) rather than by day of complication. Logistic regression was used to adjust for case mix factors including gestational age, birth weight, and maternal age. Staffing factors were also investigated using multilevel models to evaluate the association between outcomes and level of consultant presence. The primary outcomes were perinatal mortality and-for both neonate and mother-infections, emergency readmissions, and injuries.

STUDY ANSWER AND LIMITATIONS

Performance across four of the seven measures was significantly worse for women admitted, and babies born, at weekends. In particular, the perinatal mortality rate was 7.3 per 1000 babies delivered at weekends, 0.9 per 1000 higher than for weekdays (adjusted odds ratio 1.07, 95% confidence interval 1.02 to 1.13). No consistent association between outcomes and staffing was identified, although trusts that complied with recommended levels of consultant presence had a perineal tear rate of 3.0% compared with 3.3% for non-compliant services (adjusted odds ratio 1.21, 1.00 to 1.45). Limitations of the analysis include the method of categorising performance temporally, which was mitigated by using a midweek reference day (Tuesday). Further research is needed to investigate possible bias from unmeasured confounders and explore the nature of the causal relationship.

WHAT THIS STUDY ADDS

This study provides an evaluation of the "weekend effect" in obstetric care, covering a range of outcomes. The results would suggest approximately 770 perinatal deaths and 470 maternal infections per year above what might be expected if performance was consistent across women admitted, and babies born, on different days of the week.

FUNDING, COMPETING INTERESTS, DATA SHARING

The research was partially funded by Dr Foster Intelligence and the National Institute for Health Research (NIHR) Imperial Patient Safety Translational Research Centre in partnership with the Health Protection Research Unit (HPRU) in Healthcare Associated Infection and Antimicrobial Resistance at Imperial College London. WLP was supported by the National Audit Office.

Return to theatre for elective hip and knee replacements

The aim of this study was to define return to theatre (RTT) rates for elective hip and knee replacement (HR and KR), to describe the predictors and to show the variations in risk-adjusted rates by surgical team and hospital using national English hospital administrative data.

We examined information on 260 206 HRs and 315 249 KRs undertaken between April 2007 and March 2012. The 90-day RTT rates were 2.1% for HR and 1.8% for KR. Male gender, obesity, diabetes and several other comorbidities were associated with higher odds for both index procedures. For HR, hip resurfacing had half the odds of cement fixation (OR = 0.58, 95% confidence intervals (CI) 0.47 to 0.71). For KR, unicondylar KR had half the odds of total replacement (OR = 0.49, 95% CI 0.42 to 0.56), and younger ages had higher odds (OR = 2.23, 95% CI 1.65 to 3.01) for ages < 40 years compared with ages 60 to 69 years). There were more funnel plot outliers at three standard deviations than would be expected if variation occurred on a random basis.

Hierarchical modelling showed that three-quarters of the variation between surgeons for HR and over half the variation between surgeons for KR are not explained by the hospital they operated at or by available patient factors. We conclude that 90-day RTT rate may be a useful quality indicator for orthopaedics.

Cite this article: Bone Joint J 2014; 96-B:1663–8.

The impact of shortened postgraduate surgical training on colorectal cancer outcome

BACKGROUND

Shortened postgraduate surgical training reforms, known as Calman, have altered delivery of surgical training in the UK with reduced working hours and training time aiming to produce a more subspecialised workforce.

AIMS

This study aims to compare rectal cancer surgical outcomes of Calman-trained consultants in a single institution to published data. Additionally, the study compared colorectal cancer surgical outcome between Calman-trained consultants (CTCs) and non-Calman consultants (NCTCs) in a national dataset.

METHODS

Local dataset Clinicopathological outcome of rectal cancer resection undertaken by CTCs in a single institution (2006-2010) were compared against NCTC counterparts. National dataset All elective colorectal cancer resections between 2004 and 2008 in English NHS hospitals were included. CTCs (present from 2004 onwards) were compared to NCTCs (present prior to 2004). Outcome measures included 30-day in-hospital mortality, reoperation and readmission rates.

RESULTS

Local dataset One hundred thirteen patients were operated under five CTC. The 30-day in-hospital mortality for CTCs (1%) was favourable compared to published rates (3-5%). Local recurrence rate (4.4%) was comparable to NCTC (3.6%). National dataset Between 2004 and 2008, 44,106 patients underwent elective colorectal resection. Multiple regression demonstrated CTC patients had a reduced length of stay and reduced reoperation rate. No difference in mortality and unplanned readmission rates were seen.

CONCLUSION

CTCs have similar safety outcome to NCTCs for colorectal cancer resection procedures. Further work is needed to assess the impact of further training reductions on clinical outcome.

Hierarchical multilevel analysis of increased caseload volume and postoperative outcome after elective colorectal surgery

BACKGROUND

The study aimed to explore the impact of surgeon and institution volume on outcome following colorectal surgery in England using multilevel hierarchical analysis.

METHODS

An observational study design was used. All patients undergoing primary elective colorectal resection between 2000 and 2008 were included from the Hospital Episode Statistics database. Consultant surgeons and hospitals were divided into tertiles (low, medium and high volume) according to their mean annual colorectal cancer resection caseload. Outcome measures examined were postoperative 30-day mortality, 28-day readmission and reoperation, and length of stay. Hierarchical multiple regression analysis adjusted for age, sex, co-morbidity, social deprivation, year of surgery, operation type and surgical approach.

RESULTS

A total of 109 261 elective cancer colorectal resections were included. High-volume consultant surgeons and hospitals were defined as performing more than 20·7 and 103·5 elective colorectal cancer procedures per year respectively. Consultant and hospital operative volumes increased throughout the study period. In hierarchical regression models, greater surgeon and institutional volume independently predicted only shorter length of hospital stay. No statistical association was observed between higher provider volume and postoperative mortality, 28-day reoperation or readmission rates.

CONCLUSION

Increasing elective colorectal cancer caseload alone may have marginal postoperative benefit.

Syndromic surveillance of surgical site infections--a case study in coronary artery bypass graft patients

OBJECTIVE

There is a wealth of data routinely collected and stored by healthcare facilities, which are not consistently exploited for surveillance of healthcare associated infections (HCAI). Syndromic surveillance has not yet been widely applied to HCAI. This study aimed to create syndromic surveillance for surgical site infections (SSI) following coronary artery bypass graft (CABG) procedures.

METHODS

A cohort of CABG patients from Imperial College Healthcare NHS Trust was investigated. Data from the local Patient Administration System, Laboratory Information Management System, radiology department, cardiac registry and Health Protection Agency SSI surveillance were linked. This data was explored for biological markers and proxies of infection, which were used to develop syndromic surveillance algorithms; sensitivity analysis was used to determine the best algorithms.

RESULTS

303 patients were included, with a SSI incidence of 6.6%. Wound culture requests, raised platelet and fibrinogen levels were all found to be good indicators of SSI. Two algorithms were generated, one to detect all SSI (sensitivity: 90%; specificity: 93.8%) and one to detect organ space infections specifically (sensitivity: 100%; specificity: 98.5%).

CONCLUSION

Data which is routinely collected and stored in healthcare facilities can be used for syndromic surveillance of SSI, allowing for an efficient surveillance system without the need for resource intensive data collection.

Mortality in high-risk emergency general surgical admissions

Background

There is increasing evidence of variable standards of care for patients undergoing emergency general surgery in the National Health Service (NHS). The aim of this study was to quantify and explore variability in mortality amongst high-risk emergency general surgery admissions to English NHS hospital Trusts.

Methods

The Hospital Episode Statistics (HES) database was used to identify high-risk emergency general surgery diagnoses (greater than 5 per cent national 30-day mortality rate). Adults admitted to English NHS Trusts with these diagnoses between 2000 and 2009 were included in the study. Thirty-day in-hospital mortality was adjusted for patient and hospital factors. Trusts were grouped into high- and low-mortality outliers, and resource availability was compared between high- and low-mortality outlier institutions.

Results

Some 367 796 patients admitted to 145 hospital Trusts were included in the study; the 30-day mortality rate was 15·6 per cent (institutional range 9·2–18·2 per cent). Fourteen and 24 hospital Trusts were identified as high- and low-mortality outlier institutions respectively. Intensive care and high-dependency bed resources, as well as greater institutional use of computed tomography (CT), were independent predictors of reduced mortality (P &lt; 0·001). Low-mortality outlying Trusts had significantly more intensive care beds per 1000 hospital beds (20·8 versus 14·0; P = 0·017) and made significantly greater use of CT (24·6 versus 17·2 scans per bed per year; P &lt; 0·001) and ultrasonography (42·5 versus 30·2 scans per bed per year; P &lt; 0·001).

Conclusion

There is significant variability in mortality risk between hospital Trusts treating high-risk emergency general surgery patients. Equitable access to essential hospital resources may reduce variability in outcomes.

Day of week of procedure and 30 day mortality for elective surgery: retrospective analysis of hospital episode statistics

OBJECTIVES

To assess the association between mortality and the day of elective surgical procedure.

DESIGN

Retrospective analysis of national hospital administrative data.

SETTING

All acute and specialist English hospitals carrying out elective surgery over three financial years, from 2008-09 to 2010-11.

PARTICIPANTS

Patients undergoing elective surgery in English public hospitals.

MAIN OUTCOME MEASURE

Death in or out of hospital within 30 days of the procedure.

RESULTS

There were 27,582 deaths within 30 days after 4,133,346 inpatient admissions for elective operating room procedures (overall crude mortality rate 6.7 per 1000). The number of weekday and weekend procedures decreased over the three years (by 4.5% and 26.8%, respectively). The adjusted odds of death were 44% and 82% higher, respectively, if the procedures were carried out on Friday (odds ratio 1.44, 95% confidence interval 1.39 to 1.50) or a weekend (1.82, 1.71 to 1.94) compared with Monday.

CONCLUSIONS

The study suggests a higher risk of death for patients who have elective surgical procedures carried out later in the working week and at the weekend.

Preoperative risk factors in 10 418 patients with prior myocardial infarction and 5241 patients with prior unstable angina undergoing elective coronary artery bypass graft surgery

BACKGROUND

The EuroSCORE associates coronary artery bypass graft (CABG) surgery with higher perioperative risk in the first 3 months after a myocardial infarction (MI). The optimal scheduling of CABG surgery after unstable angina (UA) is unknown. We investigated the preoperative predictors of adverse outcomes in patients undergoing CABG with prior MI or UA and investigated the importance of time interval between the cardiac event and CABG.

METHODS

The Hospital Episode Statistics database (April 2006-March 2010) was analysed for elective admissions for CABG. Independent preoperative patient factors influencing length of stay, readmission rates, and mortality, were identified by logistic regression and presented as adjusted odds ratios (ORs).

RESULTS

A total of 10 418 patients with prior MI (mortality 1.8%) and 5241 patients with prior UA (mortality 2.2%) were included in the respective cohorts. Multiple risk factors were identified in each population including liver disease and renal failure. The time interval from cardiac event (MI or UA) to elective CABG surgery did not influence perioperative outcomes when analysed as a continuous measure or using the arbitrary 3-month threshold [MI, OR 1.1 (0.78-1.57) and UA, OR 0.65 (0.39-1.09)].

CONCLUSIONS

Our hypothesis generating data suggest that the increased risk currently allocated in the EuroSCORE for an interval of 3 months between MI and CABG should be critically re-evaluated. Furthermore, prior MI should not be discounted as a risk factor if it is more than 3 months old.

Minimal-access colorectal surgery is associated with fewer adhesion-related admissions than open surgery

BACKGROUND

This study aimed to describe national intermediate-term admission rates for incisional hernia or clinically apparent adhesions following colorectal surgery, and to compare rates following laparoscopic and open approaches.

METHODS

Patients undergoing primary colorectal resection between 2002 and 2008 were included from the Hospital Episode Statistics database. Subsequent inpatient admissions were extracted for up to 3 years after the initial operation or to the end of the study period. Outcomes examined were admissions with a diagnosis of, or operative interventions for, incisional hernia or adhesions.

RESULTS

A total of 187 148 patients were included between 2002 and 2008, with median follow-up of 31·8 (interquartile range 13·1-35·3) months. Some 8885 (4·7 per cent) of these patients were admitted with a diagnosis of, or underwent a repair of, an incisional hernia. In multiple regression analysis, use of laparoscopy was not a predictor of operative intervention for incisional hernia (odds ratio 1·09, 95 per cent confidence interval (c.i.) 0·99 to 1·21; P = 0·083). Some 15 125 (8·1 per cent) of the patients were admitted with a diagnosis of adhesions or had a procedure for division of adhesions. Overall, 3·5 per cent (6637 of 187 148) of patients underwent adhesiolysis. Patients selected for a laparoscopic procedure had lower rates of admission for adhesions (6·3 per cent (692 of 11 013) for laparoscopic versus 8·2 per cent (14 433 of 176 135) for open surgery; P < 0·001) and reintervention for adhesions (2·8 per cent (305 of 11 013) versus 3·6 per cent (6325 of 176 135) respectively; P < 0·001) than those undergoing an open procedure. In multiple regression analysis, patients selected for a laparoscopic procedure had lower subsequent intervention rates for adhesions (odds ratio 0·80, 95 per cent c.i. 0·71 to 0·90; P < 0·001).

DISCUSSION

Patients undergoing colorectal resection who are selected for the laparoscopic approach have a lower risk of developing clinically significant adhesions.

Association between patient and general practice characteristics and unplanned first-time admissions for cancer: observational study

Background:

To identify patient and general practice (GP) characteristics associated with emergency (unplanned) first admissions for cancer in secondary care.

Methods:

Patients who had a first-time admission with a primary diagnosis of cancer during 2007/08 to 2009/10 were identified from administrative hospital data. We modelled the associations between the odds of these admissions being unplanned and various patient and GP practice characteristics using national data sets, including the Quality and Outcomes Framework (QOF).

Results:

There were 639 064 patients with a first-time admission for cancer, with 139 351 unplanned, from 7957 GP practices. The unplanned proportion ranged from 13.9% (patients aged 15–44 years) to 44.9% (patients aged 85 years and older, P<0.0001), with large variation by ethnicity (highest in Asians), deprivation, rurality and cancer type. In unadjusted analyses, all included patient and practice-level variables were statistically significant predictors of the admissions being unplanned. After adjustment, patient area-level deprivation was a key factor (most deprived compared with least deprived quintile OR 1.36, 95% CI 1.32–1.40). Higher total QOF performance protected against unplanned admission (OR 0.94 per 100 points; 95% CI 0.91–0.97); having no GPs with a UK primary medical qualification (OR 1.08, 95% CI 1.04–1.11) and being less able to offer appointments within 48 h were associated with higher odds.

Conclusion:

We have identified some patient and practice characteristics associated with a first-time admission for cancer being unplanned. The former could be used to help identify patients at high risk, while the latter raise questions about the role of practice organisation and staff training.

The hospital standardised mortality ratio: a powerful tool for Dutch hospitals to assess their quality of care?

Aim of the study

To use the hospital standardised mortality ratio (HSMR), as a tool for Dutch hospitals to analyse their death rates by comparing their risk-adjusted mortality with the national average.

Method

The method uses routine administrative databases that are available nationally in The Netherlands—the National Medical Registration dataset for the years 2005–2007. Diagnostic groups that led to 80% of hospital deaths were included in the analysis. The method adjusts for a number of case-mix factors per diagnostic group determined through a logistic regression modelling process.

Results

In The Netherlands, the case-mix factors are primary diagnosis, age, sex, urgency of admission, length of stay, comorbidity (Charlson Index), social deprivation, source of referral and month of admission. The Dutch HSMR model performs well at predicting a patient's risk of death as measured by a c statistic of the receiver operating characteristic curve of 0.91. The ratio of the HSMR of the Dutch hospital with the highest value in 2005–2007 is 2.3 times the HSMR of the hospital with the lowest value.

Discussion

Overall hospital HSMRs and mortality at individual diagnostic group level can be monitored using statistical process control charts to give an early warning of possible problems with quality of care. The use of routine data in a standardised and robust model can be of value as a starting point for improvement of Dutch hospital outcomes. HSMRs have been calculated for several other countries.

Value of failure to rescue as a marker of the standard of care following reoperation for complications after colorectal resection

Background

Complication management appears to be of vital importance to differences in survival following surgery between surgical units. Failure-to-rescue (FTR) rates have not yet distinguished surgical from general medical complications. The aim of this study was to assess whether variability exists in FTR rates after reoperation for serious surgical complications following colorectal cancer resections in England.

Methods

The Hospital Episode Statistics (HES) database was used to identify patients undergoing primary resection for colorectal cancer between 2000 and 2008 in English National Health Service (NHS) trusts. Units were ranked into quintiles according to overall risk-adjusted mortality. Highest and lowest mortality quintiles were compared with respect to reoperation rates and FTR—surgical (FTR-S) rates. FTR-S was defined as the proportion of patients with an unplanned reoperation who died within the same admission.

Results

Some 144 542 patients undergoing resection for colorectal cancer in 150 English NHS trusts were included. On ranking according to risk-adjusted mortality, rates varied significantly between lowest and highest mortality quintiles (5·4 and 9·3 per cent respectively; P = 0·029). Lowest and highest mortality quintiles had equivalent adjusted reoperation rates (both 4·8 per cent; P = 0·211). FTR-S rates were significantly higher at units within the worst mortality quintile (16·8 versus 11·1 per cent; P = 0·002).

Conclusion

FTR-S rates differed significantly between English colorectal units, highlighting variability in ability to prevent death in this high-risk group. This variability may represent differences in serious surgical complication management. FTR-S represents a readily collectable marker of surgical complication management that is likely to be applicable to other surgical specialties.

Data linkage between existing healthcare databases to support hospital epidemiology

Enhancing the use of existing datasets within acute hospitals will greatly facilitate hospital epidemiology, surveillance, the monitoring of a variety of processes, outcomes and risk factors, and the provision of alert systems. Multiple overlapping data systems exist within National Health Service (NHS) hospitals in the UK, and many duplicate data recordings take place because of the lack of linkage and interfaces. This results in hospital-collected data not being used efficiently. The objective was to create an inventory of all existing systems, including administrative, management, human resources, microbiology, patient care and other platforms, to describe the data architecture that could contribute valuable information for a hospital epidemiology unit. These datasets were investigated as to how they could be used to generate surveillance data, key performance indicators and risk information that could be shared at board, clinical programme group, specialty and ward level. An example of an output of this integrated data platform and its application in influenza resilience planning and responsiveness is described. The development of metrics for staff absence and staffing levels may also be used as key indicators for risk-monitoring for infection prevention. This work demonstrates the value of such a data inventory and linkage and the importance of more sophisticated uses of existing NHS data, and innovative collaborative approaches to support clinical care, quality improvement, surveillance, emergency planning and research.

Systematic review of discharge coding accuracy

INTRODUCTION

Routinely collected data sets are increasingly used for research, financial reimbursement and health service planning. High quality data are necessary for reliable analysis. This study aims to assess the published accuracy of routinely collected data sets in Great Britain.

METHODS

Systematic searches of the EMBASE, PUBMED, OVID and Cochrane databases were performed from 1989 to present using defined search terms. Included studies were those that compared routinely collected data sets with case or operative note review and those that compared routinely collected data with clinical registries.

RESULTS

Thirty-two studies were included. Twenty-five studies compared routinely collected data with case or operation notes. Seven studies compared routinely collected data with clinical registries. The overall median accuracy (routinely collected data sets versus case notes) was 83.2% (IQR: 67.3-92.1%). The median diagnostic accuracy was 80.3% (IQR: 63.3-94.1%) with a median procedure accuracy of 84.2% (IQR: 68.7-88.7%). There was considerable variation in accuracy rates between studies (50.5-97.8%). Since the 2002 introduction of Payment by Results, accuracy has improved in some respects, for example primary diagnoses accuracy has improved from 73.8% (IQR: 59.3-92.1%) to 96.0% (IQR: 89.3-96.3), P= 0.020.

CONCLUSION

Accuracy rates are improving. Current levels of reported accuracy suggest that routinely collected data are sufficiently robust to support their use for research and managerial decision-making.

Hospital stay amongst patients undergoing major elective colorectal surgery: predicting prolonged stay and readmissions in NHS hospitals

AIM

Reduced hospital stay confers clinical and economic benefits for patients and healthcare providers. This article examines the length of stay and consequent bed resource usage of patients undergoing elective excisional colorectal surgery in English NHS trusts.

METHOD

All patients undergoing elective colorectal resections for malignancy between 1996 and 2006 in English NHS trusts were included from the Hospital Episode Statistics data set. Unifactorial and multifactorial analyses were performed to identify independent predictors of prolonged stay and 28-day readmission.

RESULTS

Over the 10-year period, 186,013 patients underwent elective colorectal procedures in 181 NHS trusts. About 2.893 b million bed days were utilized for elective colorectal surgery. Admission stay was shorter following colonic surgery than following rectal surgery (median 11 vs 13 days, P < 0.001). A 2-day decrease in median stay was observed over the 10-year period for both colonic and rectal procedures. Readmissions within 28 days of discharge were higher following rectal excision than following colonic surgery (9.4 vs 7.6%, P < 0.001). Multiple logistic regression analyses revealed the following independent predictors of prolonged hospital stay: distal (vs proximal) bowel resection, benign pathology, open technique, increasing age, comorbidity, social deprivation and low provider volume status. Independent predictors of 28-day readmission included distal bowel resection, benign diagnosis, young age, social deprivation and high provider volume status.

CONCLUSION

Patients of advanced age, with associated comorbidities, and those living in areas of social deprivation are at increased risk of prolonged stay. Targeted pre-emptive discharge planning and enhanced use of laparoscopic surgery could improve bed resource utilization.

Elective colonic surgery for cancer in the elderly: an investigation into postoperative mortality in English NHS hospitals between 1996 and 2007

BACKGROUND

This study was primarily aimed to quantify perioperative mortality risk in elderly patients undergoing elective colonic resectional surgery. In addition, the safety of minimally invasive colonic surgery in this patient group was evaluated.

METHODS

All patients aged > 75 undergoing elective colonic resection for colorectal malignancy between 1996 and 2007 in English NHS hospitals were included from the Hospital Episode Statistics (HES) dataset.

RESULTS

Between the study dates, 28,746 patients > 75 years underwent elective colonic resection. The national annual number of colonic excisions carried out amongst elderly patients increased from 2188 patients in 1996/7 to 3240 patients in 2006/7. Following adjustment for gender, comorbidity and surgical approach, advancing age was an independent predictor for 30-day mortality (OR 2.47 for patients aged 85-89 vs 75-79, P < 0.001). Use of laparoscopy was a significant predictor of reduced perioperative mortality (OR 0.56, P = 0.003) once adjusted for advancing age, gender and comorbidity. Comparison of 30-day and 1-year postoperative mortality following elective colonic resection in patients aged 90 revealed a large excess of patients dying outside of the immediate perioperative period (10.1% and 26.2% for proximal cancers, respectively; 12.9% and 36.1% for distal colonic resections, respectively).

CONCLUSIONS

Advancing age is an independent risk factor for postoperative death in elderly patients undergoing elective colonic resection for cancer. The risk of death in the elderly is extremely high and surgical decision-making should incorporate the mortality risk that occurs outside the immediate perioperative period. In this national series, patients selected for a laparoscopic procedure were at lower risk of perioperative death than those undergoing the conventional approach.

Increased health burden associated with Clostridium difficile diarrhoea in patients with inflammatory bowel disease

BACKGROUND

Clostridium difficile (C. difficile) infection in hospitals in developed countries continues to be a major public health hazard despite increased control measures including review of antibiotic policies and hygiene measures. Patients with colitis are thought to be particularly vulnerable to C. difficile associated diarrhoea (CDAD). Identifying the clinical burden among hospitalised patients admitted with inflammatory bowel disease is an essential first step towards identifying and treating severe C. difficile infection in such individuals.

AIM

To determine excess morbidity and in-hospital mortality associated with hospital acquired CDAD in patients with inflammatory bowel disease (IBD-CDAD-HAI) admitted to NHS hospitals in England compared with those admitted for inflammatory bowel disease alone.

METHODS

Time trends study of all admissions to NHS hospitals between 2002/03 and 2007/08. We developed case definitions for IBD-CDAD-HAI patients. The primary outcomes were in-hospital mortality and length of stay. The secondary outcome was gastrointestinal surgery.

RESULTS

Patients in the IBD-CDAD-HAI group were more likely to die in hospital (adjusted OR 6.32), had 27.9 days longer in-patient stays and higher gastrointestinal surgery rates (adjusted OR 1.87) than patients admitted for inflammatory bowel disease alone.

CONCLUSION

Patients with inflammatory bowel disease admitted to NHS hospitals in England with co-existent C. difficile infection are at risk of greater in-hospital mortality and morbidity than patients admitted for inflammatory bowel disease alone.

Volume analysis of outcome following restorative proctocolectomy

BACKGROUND

This observational study aimed to determine national provision and outcome following pouch surgery (restorative proctocolectomy, RPC) and to examine the effect of institutional and surgeon caseload on outcome.

METHODS

All patients undergoing primary RPC between April 1996 and March 2008 in England were identified from the administrative database Hospital Episode Statistics. Institutions and surgeons were categorized according to the total RPC caseload performed over the study interval.

RESULTS

Some 5771 primary elective pouch procedures were undertaken at 154 National Health Service hospital trusts. Median follow-up was 65 (interquartile range (i.q.r.) 28-106) months. The 30-day in-hospital mortality rate was 0·5 per cent and the 1-year overall mortality rate 1·5 per cent. Some 30·5 per cent of trusts performed fewer than two procedures per year, and 91·4 per cent of surgical teams (456 of 499) carried out 20 or fewer RPCs over 8 years. Median surgeon volume was 4 (i.q.r. 1-9) cases. Failure occurred in 6·4 per cent of cases. Low-volume surgeons operated on more patients at the extremes of age (P < 0·001) and a lower proportion with ulcerative colitis (P < 0·001). Older age, increasing co-morbidity, increasing social deprivation, and both lower provider and surgeon caseload were independent predictors of longer length of stay. Older patient age and low institutional volume status were independent predictors of failure.

CONCLUSION

Many English institutions and surgeons carry out extremely low volumes of RPC surgery. Case selection differed significantly between high- and low-volume surgeons. Institutional volume and older age were positively associated with increased pouch failure.