Evaluation of Postoperative Complication with Medically Necessary, Time-Sensitive Scoring System During Acute COVID-19 Pandemic: A Prospective Observational Study

Background

High scores in the Medically Necessary, Time-Sensitive (MeNTS) scoring system, used for elective surgical prioritization during the coronavirus disease 2019 pandemic, are assumed to be associated with worse outcomes. We aimed to evaluate the MeNTS scoring system in patients undergoing elective surgery during restricted capacity of our institution, with or without moderate or severe postoperative complications.

Study Design

In this prospective observational study, MeNTS scores of patients undergoing elective operations during May and June 2020 were calculated. Postoperative complication severity (classified as Group Clavien-Dindo < II or Group Clavien-Dindo ≥ II), as well as Duke Activity Index, American Society of Anesthesiologists (ASA) physical status, presence of smoking, leukocytosis, lymphopenia, elevated C-reactive protein (CRP), operation and anesthesia characteristics, intensive care requirement and duration, length of hospital stay, rehospitalization, and mortality were noted.

Results

There were 223 patients analyzed. MeNTS score was higher in the Clavien-Dindo ≥ II Group compared with the Clavien-Dindo < II Group (50.98 ± 8.98 vs 44.27 ± 8.90 respectively, p < 0.001). Duke activity status index (DASI) scores were lower, and American Society of Anesthesiologists physical status class, presence of smoking, leukocytosis, lymphopenia, elevated CRP, and intensive care requirement were higher in the Clavien-Dindo ≥ II Group (p < 0.01). Length of hospital stay was longer in the Clavien-Dindo ≥ II Group (15 [range 2–90] vs 4 [1–30] days; p < 0.001). Mortality was observed in 8 patients. Area under the receiver operating characteristic curve of MeNTS and DASI were 0.69 and 0.71, respectively, for predicting moderate/severe complications.

Conclusions

Although significant, MeNTS score had low discriminating power in distinguishing patients with moderate/severe complications. Incorporation of a cardiovascular functional capacity measure could improve the scoring system.

New geographic model of care to manage the post-COVID-19 elective surgery aftershock in England: a retrospective observational study

OBJECTIVES

The suspension of elective surgery during the COVID-19 pandemic is unprecedented and has resulted in record volumes of patients waiting for operations. Novel approaches that maximise capacity and efficiency of surgical care are urgently required. This study applies Markov multiscale community detection (MMCD), an unsupervised graph-based clustering framework, to identify new surgical care models based on pooled waiting-lists delivered across an expanded network of surgical providers.

DESIGN

Retrospective observational study using Hospital Episode Statistics.

SETTING

Public and private hospitals providing surgical care to National Health Service (NHS) patients in England.

PARTICIPANTS

All adult patients resident in England undergoing NHS-funded planned surgical procedures between 1 April 2017 and 31 March 2018.

MAIN OUTCOME MEASURES

The identification of the most common planned surgical procedures in England (high-volume procedures (HVP)) and proportion of low, medium and high-risk patients undergoing each HVP. The mapping of hospitals providing surgical care onto optimised groupings based on patient usage data.

RESULTS

A total of 7 811 891 planned operations were identified in 4 284 925 adults during the 1-year period of our study. The 28 most common surgical procedures accounted for a combined 3 907 474 operations (50.0% of the total). 2 412 613 (61.7%) of these most common procedures involved 'low risk' patients. Patients travelled an average of 11.3 km for these procedures. Based on the data, MMCD partitioned England into 45, 16 and 7 mutually exclusive and collectively exhaustive natural surgical communities of increasing coarseness. The coarser partitions into 16 and seven surgical communities were shown to be associated with balanced supply and demand for surgical care within communities.

CONCLUSIONS

Pooled waiting-lists for low-risk elective procedures and patients across integrated, expanded natural surgical community networks have the potential to increase efficiency by innovatively flexing existing supply to better match demand.

Perioperative Prescribing Practices of Extended-Release Opioids in Noncancer Surgical Patients, 2015-2018

BACKGROUND

Extended-release (ER) opioids are indicated for the management of persistent moderate to severe pain in patients requiring around-the-clock opioid analgesics for an extended period of time. Concerns have been raised regarding safety of ER opioids due to its potential for abuse and dependence. However, little is known about perioperative prescribing practices of ER opioids. This study assessed perioperative prescribing practices of ER opioids in noncancer surgical patients stratified by type of opioid exposure prior to admission and examined predictors of postoperative opioid administration in oral morphine equivalents (OME).

METHODS

This was a retrospective cohort study using the University of California San Francisco Medical Center electronic health record data. This study included 25,396 adult noncancer patients undergoing elective surgery under general anesthesia in the period 2015-2018. The primary study outcome was predictors of postoperative administration of opioids in hospitalized surgical patients. Secondary outcomes included patients discontinued and initiated on ER opioids during their hospital stay.

RESULTS

substance use disorder diagnosis and use of opioids, surgery type, and postoperative administration of nonopioid analgesics were associated with postoperative administration of opioids (P < .0001). The estimated adjusted mean (95% confidence interval [CI]) of postoperative administration of OME prior to admission in ER opioid users (170.08 mg; 147.08-196.67) was twice the amount for opioid-naïve patients (81.36 mg; 70.7-93.63; P < .0001). One in 5 prior to admission ER opioid users were weaned off ER opioids while hospitalized without adversely affecting their postoperative pain or hospital length of stay (LOS). Four of 5 patients who used ER opioids prior to admission also received ER opioids after surgery, whereas, 1 in 100 opioid-naïve patients received ER opioids during their hospital stay.

CONCLUSIONS

We found significant variability in the perioperative prescribing practices of ER opioids in hospitalized noncancer surgical patients by use of opioids prior to admission and surgery type. Pain medicine practitioners and surgeons may play a significant role tackling the surgery-related risk of exposure to ER opioids and decreasing opioid-related complications.

Triaging Interventional Pain Procedures During COVID-19 or Related Elective Surgery Restrictions: Evidence-Informed Guidance from the American Society of Interventional Pain Physicians (ASIPP)

BACKGROUND

The COVID-19 pandemic has worsened the pain and suffering of chronic pain patients due to stoppage of "elective" interventional pain management and office visits across the United States. The reopening of America and restarting of interventional techniques and elective surgical procedures has started. Unfortunately, with resurgence in some states, restrictions are once again being imposed. In addition, even during the Phase II and III of reopening, chronic pain patients and interventional pain physicians have faced difficulties because of the priority selection of elective surgical procedures.Chronic pain patients require high intensity care, specifically during a pandemic such as COVID-19. Consequently, it has become necessary to provide guidance for triaging interventional pain procedures, or related elective surgery restrictions during a pandemic.

OBJECTIVES

The aim of these guidelines is to provide education and guidance for physicians, healthcare administrators, the public and patients during the COVID-19 pandemic. Our goal is to restore the opportunity to receive appropriate care for our patients who may benefit from interventional techniques.

METHODS

The American Society of Interventional Pain Physicians (ASIPP) has created the COVID-19 Task Force in order to provide guidance for triaging interventional pain procedures or related elective surgery restrictions to provide appropriate access to interventional pain management (IPM) procedures in par with other elective surgical procedures. In developing the guidance, trustworthy standards and appropriate disclosures of conflicts of interest were applied with a section of a panel of experts from various regions, specialties, types of practices (private practice, community hospital and academic institutes) and groups. The literature pertaining to all aspects of COVID-19, specifically related to epidemiology, risk factors, complications, morbidity and mortality, and literature related to risk mitigation and stratification was reviewed. The evidence -- informed with the incorporation of the best available research and practice knowledge was utilized, instead of a simplified evidence-based approach. Consequently, these guidelines are considered evidence-informed with the incorporation of the best available research and practice knowledge.

RESULTS

The Task Force defined the medical urgency of a case and developed an IPM acuity scale for elective IPM procedures with 3 tiers. These included urgent, emergency, and elective procedures. Examples of urgent and emergency procedures included new onset or exacerbation of complex regional pain syndrome (CRPS), acute trauma or acute exacerbation of degenerative or neurological disease resulting in impaired mobility and inability to perform activities of daily living. Examples include painful rib fractures affecting oxygenation and post-dural puncture headaches limiting the ability to sit upright, stand and walk. In addition, emergency procedures include procedures to treat any severe or debilitating disease that prevents the patient from carrying out activities of daily living. Elective procedures were considered as any condition that is stable and can be safely managed with alternatives.

LIMITATIONS

COVID-19 continues to be an ongoing pandemic. When these recommendations were developed, different stages of reopening based on geographical regulations were in process. The pandemic continues to be dynamic creating every changing evidence-based guidance. Consequently, we provided evidence-informed guidance.

CONCLUSION

The COVID-19 pandemic has created unprecedented challenges in IPM creating needless suffering for pain patients. Many IPM procedures cannot be indefinitely postponed without adverse consequences. Chronic pain exacerbations are associated with marked functional declines and risks with alternative treatment modalities. They must be treated with the concern that they deserve. Clinicians must assess patients, local healthcare resources, and weigh the risks and benefits of a procedure against the risks of suffering from disabling pain and exposure to the COVID-19 virus.

Classification of hospital admissions into emergency and elective care: a machine learning approach

Rising admissions from emergency departments (EDs) to hospitals are a primary concern for many healthcare systems. The issue of how to differentiate urgent admissions from non-urgent or even elective admissions is crucial. We aim to develop a model for classifying inpatient admissions based on a patient's primary diagnosis as either emergency care or elective care and predicting urgency as a numerical value. We use supervised machine learning techniques and train the model with physician-expert judgments. Our model is accurate (96%) and has a high area under the ROC curve (>.99). We provide the first comprehensive classification and urgency categorization for inpatient emergency and elective care. This model assigns urgency values to every relevant diagnosis in the ICD catalog, and these values are easily applicable to existing hospital data. Our findings may provide a basis for policy makers to create incentives for hospitals to reduce the number of inappropriate ED admissions.

Gender disparities in red blood cell transfusion in elective surgery: a post hoc multicentre cohort study

OBJECTIVES

A post hoc gender comparison of transfusion-related modifiable risk factors among patients undergoing elective surgery.

SETTINGS

23 Austrian centres randomly selected and stratified by region and level of care.

PARTICIPANTS

We consecutively enrolled in total 6530 patients (3465 women and 3065 men); 1491 underwent coronary artery bypass graft (CABG) surgery, 2570 primary unilateral total hip replacement (THR) and 2469 primary unilateral total knee replacement (TKR).

MAIN OUTCOME MEASURES

Primary outcome measures were the number of allogeneic and autologous red blood cell (RBC) units transfused (postoperative day 5 included) and differences in intraoperative and postoperative transfusion rate between men and women. Secondary outcomes included perioperative blood loss in transfused and non-transfused patients, volume of RBCs transfused, perioperative haemoglobin values and circulating red blood volume on postoperative day 5.

RESULTS

In all surgical groups, the transfusion rate was significantly higher in women than in men (CABG 81 vs 49%, THR 46 vs 24% and TKR 37 vs 23%). In transfused patients, the absolute blood loss was higher among men in all surgical categories while the relative blood loss was higher among women in the CABG group (52.8 vs 47.8%) but comparable in orthopaedic surgery. The relative RBC volume transfused was significantly higher among women in all categories (CABG 40.0 vs 22.3; TKR 25.2 vs 20.2; THR 26.4 vs 20.8%). On postoperative day 5, the relative haemoglobin values and the relative circulating RBC volume were higher in women in all surgical categories.

CONCLUSIONS

The higher transfusion rate and volume in women when compared with men in elective surgery can be explained by clinicians applying the same absolute transfusion thresholds irrespective of a patient's gender. This, together with the common use of a liberal transfusion strategy, leads to further overtransfusion in women.

Using routinely recorded ethnicity: analysis of waiting times for elective admissions by ethnic group

Objective: To assess whether patients from non-white ethnic groups wait longer than white patients for elective in-patient admissions at St Mary's Hospital in London.

Methods: Patients who came off the waiting list for an elective inpatient admission between 1 April 2000 and 31 March 2001 were selected. A multivariable log linear model was developed to assess geometric mean waiting times for Black, Asian, Other and Missing ethnic groups compared to the White group, adjusted for age, sex, urgency and distance.

Results: Caution is needed in interpreting results, as a large number of patients had no usable ethnic code. There was no strong evidence that waiting times for ethnic groups were systematically different than for the White group. However, there was some evidence that white patients waited longer for a coronary arteriography than patients in other ethnic groups. This was partially explained by age, sex, clinical urgency and residential distance from St Mary's.

Conclusions: The large proportion of patients with no usable ethnic code, lack of robust methods for case-mix adjustment and multiple ethnic categories makes analysis methodologically difficult. Regular and informative analysis of ethnic coded data is a necessary step in improving the accuracy and completeness of coding.

New Zealand general practitioners' non-urgent referrals to surgeons: who and why?

AIM

To describe the clinical and demographic characteristics of patients referred by general practitioners (GPs) to both public and private sectors for non-urgent surgical assessment.

METHOD

During 2004, a cohort of 1420 adult patients with the potential to benefit from elective surgery was recruited into the study by their GPs. GPs recorded patient demographics and reasons for referral.

RESULTS

345 out of 828 eligible GPs (42%) agreed to participate in the study and submitted data on 1603 referrals, 2.4 referrals per reporting week. After excluding ACC cases, data on 1420 referrals were analysed. Forty-two percent of those referred were male and 69% were European New Zealanders. The mean age was 55 years. The largest number of referrals were made to general surgery (37%), followed by orthopaedics (19%), gynaecology (12%), and plastic surgery (10%). The modal level of urgency was "routine" and in 24% of cases cancer was a possibility. The GP felt surgery was needed in 47% of cases, while in 73%, assistance with diagnosis and management was sought. In only 3% of eligible cases was no referral made.

CONCLUSION

Elective surgical referral makes up a significant proportion of GP workload. In more than half of cases advice on diagnosis or management, rather than surgery, was sought, and in nearly two-thirds the patient was aged less than 65 years. Cancer control was a relatively frequent goal of referral. The very small number of cases where a desired referral was not made suggests that GP and patient expectations are adjusted to service capacity.

A methodology to estimate the potential to move inpatient to one day surgery

BACKGROUND

The proportion of surgery performed as a day case varies greatly between countries. Low rates suggest a large growth potential in many countries. Measuring the potential development of one day surgery should be grounded on a comprehensive list of eligible procedures, based on a priori criteria, independent of local practices. We propose an algorithmic method, using only routinely available hospital data to identify surgical hospitalizations that could have been performed as one day treatment.

METHODS

Moving inpatient surgery to one day surgery was considered feasible if at least one surgical intervention was eligible for one day surgery and if none of the following criteria were present: intervention or affection requiring an inpatient stay, patient transferred or died, and length of stay greater than four days. The eligibility of a procedure to be treated as a day case was mainly established on three a priori criteria: surgical access (endoscopic or not), the invasiveness of the procedure and the size of the operated organ. Few overrides of these criteria occurred when procedures were associated with risk of immediate complications, slow physiological recovery or pain treatment requiring hospital infrastructure. The algorithm was applied to a random sample of one million inpatient US stays and more than 600 thousand Swiss inpatient stays, in the year 2002.

RESULTS

The validity of our method was demonstrated by the few discrepancies between the a priori criteria based list of eligible procedures, and a state list used for reimbursement purposes, the low proportion of hospitalizations eligible for one day care found in the US sample (4.9 versus 19.4% in the Swiss sample), and the distribution of the elective procedures found eligible in Swiss hospitals, well supported by the literature. There were large variations of the proportion of candidates for one day surgery among elective surgical hospitalizations between Swiss hospitals (3 to 45.3%).

CONCLUSION

The proposed approach allows the monitoring of the proportion of inpatient stay candidates for one day surgery. It could be used for infrastructure planning, resources negotiation and the surveillance of appropriate resource utilization.

Clinical categorization for elective surgery in Victoria

AIM

The aim of the present paper was to assess trends in clinician's utilization of urgency categories for elective surgery.

METHODS

The present paper reviews the additions to the Victorian elective surgery waiting list for hip replacement and prostatectomy as recorded by the Elective Surgery Information System database. Review of general trends in utilization over two separate 12 month periods were undertaken.

RESULTS

There is inconsistency in categorization of patients referred to the waiting list for hip joint replacement and prostatectomy. An increasing trend to categorize patients as semi-urgent (category 2) in preference to non-urgent (category 3) emerged over this period (category creep). Semi-urgent cases might be competing for access within the category 2 band with less urgent cases.

CONCLUSIONS

There seems to be an increasing imbalance between demand for and availability of elective surgery for lower urgency elective surgical procedures. This imbalance, characterized by lengthening waiting times, means that not all patients will receive treatment within the clinically recommended waiting times. The variable approach to categorization of urgency suggests that the process lacks objectivity and consensus. Simple clinical tools to assist prioritization are currently being evaluated in Victoria (Australia) and other countries.

Waiting time information services: what are the implications of waiting list behaviour for their design?

In some countries, patients requiring elective surgery can access comparative waiting time information for various surgical units. What someone can deduce from this information will depend upon how the statistics are derived, and how waiting lists behave. However, empirical analyses of waiting list behaviour are scarce. This study analysed three years of waiting list data collected at one hospital in Sydney, Australia. The results highlight various issues that raise questions about using particular waiting time statistics to make inferences about patient waiting times. In particular, the results highlight the considerable variation in behaviour that can exist between surgeons in the same specialty, and that can occur over time.

Are changes in admission practices for elective surgery posing a transfusion threat to patients?

There is an increasing emphasis on reducing in-patient hospital stay for elective surgical procedures. As a result, pre-operative stay has shortened, with less time available for performing baseline investigations before surgery, including those required to ensure a supply of safe, compatible blood. We have estimated the frequency of failure to complete 'group and screen' (G&S) testing before surgery where indicated, so that neither group-compatible blood nor crossmatched blood could be provided promptly if an unexpected haemorrhage occurs. Retrospective data were obtained from elective surgical procedures performed over a 3-week period. Of the 309 procedures performed, 21 patients were exposed to the risk of failure to provide appropriately matched blood had an emergency arisen. (In 20, a G&S was required; in one, a crossmatch was required.) Late samples and lack of information on the request form regarding the date and time of surgery were the main causes. Procedures requiring G&S only as opposed to crossmatch posed the greatest risk. Urgent measures are needed to ensure that, where indicated, a pre-operative G&S result is available before surgery begins. Educating colleagues, redesigning request forms and improving out-of-hour laboratory services and hospital information systems are the main steps needed to reduce this latent risk.

Generic surgical priority criteria scoring system: the clinical reality

AIMS

To assess the 'generic surgical priority criteria' (GSPC) introduced into Auckland Hospital by the Northern Division of the Transitional Health Authority in 1997 and compare it with a score based on clinical judgement obtained using a linear analogue scale (LAS).

METHODS

From the time of introduction in June 1997 all patients being placed on the general surgical waiting list have been scored using both the GSPC and the LAS. After two months the scores given to 209 patients were reviewed and compared. Correlation and limits of agreement analysis were performed for grouped data, cancer and benign groups.

RESULTS

The data showed wide variation and poor agreement between the surgeons' clinical judgement in assessing priority for surgery and the score patients obtained using the GSPC.

CONCLUSION

The GSPC has poor diagnostic discrimination as it failed to identify reliably a cancer diagnosis as high priority, with benign diagnoses scoring consistently higher. This highlights the need for clinical involvement in designing priority criteria and for formal validation of such tools.

Application of prediction levels to OR scheduling

Many perioperative managers record operating room times (ORTs) and use average ORTs to facilitate scheduling of elective surgical procedures. A second statistic, the upper 95% prediction level (ie, 95% chance the next ORT will be less than the upper prediction level) can be calculated from previous ORTs and used in scheduling elective procedures. The author used eight elective surgical procedures to test a distribution-free method for calculating ORT upper prediction levels. Upper prediction levels can provide perioperative managers better knowledge than average ORTs to facilitate decision making during the scheduling of elective surgical procedures. This method can be used to find upper prediction levels for any desired measure of procedure duration (eg, surgeon, scheduled procedure-specific times).

Who should code orthopaedic inpatients? A comparison of junior hospital doctors and coding clerks

Our principal aim was to determine whether coding for billing purposes is adequately completed by hospital doctors. We also wanted to determine whether events during the inpatient stay prompted coding. We investigated the completeness and accuracy of ICD9 and OPCS4 coding at two departments of orthopaedics. Coding was for billing purposes only; retrieval of clinical data was limited to individual cases. Junior Hospital Doctors (JHDs) undertook coding at one department, coding clerks at the other. At each side 100 sets of notes concerning inpatient admissions were reviewed. Coding clerks returned coding data of higher completeness and quality (completeness x accuracy) than JHDs, but of lower accuracy. Completeness of data from JHDs reflected motivation to code and this was influenced by events during the course of admission. JHDs coded best for patients undergoing elective surgery, and worst for patients managed non-operatively. Coding clerks coded for all groups equally well. In the current study coding data returned by JHDs was of lower completeness and accuracy than has been described for other coding systems. We attribute the lower completeness to the low motivation of JHDs when coding for billing purposes and the lower accuracy to difficulty in using the system. Motivation could be increased by incorporating coding into departmental audit, the generation of discharge summaries and record collection for personal logbooks.

Use of management techniques to control elective surgery

From January 1989 the new outpatients seen each year have been restricted to 1,540. It was predicted that this would create 770 intermediate equivalents of operating time. Throughout 1991 and 1992 each patient seen in Outpatients was given a scheduled date for his/her operation. During 1992 89 per cent of patients listed were operated upon on the planned date.