Have outcomes following colectomy in the United States improved over time?

BACKGROUND: There has been tremendous effort to improve quality following colorectal surgery, including the proliferation of minimally invasive techniques, enhanced recovery protocols, and surgical site infection prevention bundles. While these programs have demonstrated improved postoperative outcomes at the institutional level, it is unclear whether similar benefits are present on a national scale. METHODS: American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Targeted Colectomy data from 2012 to 2020 were used to identify patients undergoing minimally invasive surgery (MIS) or open partial colectomy (CPT 44140, 44204) or low anterior resection (CPT 44145, 44207). Chronological cohorts as well as annual trends in 30-day postoperative outcomes including surgical site infection, venous thromboembolism, and length of stay were assessed using both univariable and multivariable regression analyses. RESULTS: 261,301 patients, 135,876 (52 â€‹%) female, with a median age of 62 (IQR 53-72) were included. Across all years, MIS partial colectomy was the most common procedure (37 â€‹%), followed by MIS low anterior resection (27 â€‹%), open partial colectomy (24 â€‹%), and open low anterior resection (12 â€‹%). MIS increased from 59 â€‹% in 2012-2014 to 66 â€‹% in 2018-2020 (p â€‹< â€‹0.001). During this same period, postoperative length of stay decreased from a median of 5 days (IQR 4-7) in 2012-2014 to 4 days (IQR 3-6) in 2018-2020 (p â€‹< â€‹0.001). Superficial surgical site infections decreased from 5.5 â€‹% in 2012-2014 to 2.9 â€‹% in 2018-2020 (p â€‹< â€‹0.001). Deep surgical site infections similarly decreased from 1.1 â€‹% to 0.4 â€‹% between these periods (p â€‹< â€‹0.001). Pulmonary embolism also decreased from 0.6 â€‹% to 0.5 â€‹% between periods (p â€‹= â€‹0.02). 30-day mortality was unchanged at 1.7 â€‹% between 2012-2014 and 2018-2020 (p â€‹= â€‹0.40). After adjustment for ACS NSQIP estimated probability of morbidity and mortality, undergoing a colectomy in 2020 compared to 2012 was associated with a 14 â€‹% decrease in postoperative length of stay (p â€‹< â€‹0.001). CONCLUSIONS: Between 2012 and 2020, significant improvements in postoperative outcomes after colectomy were observed in the United States. These results support the positive impact that the widespread adoption of quality improvement initiatives is having on colorectal patient care nationally.

Tracking Residents' Surgical Outcomes Using Data from the Quality In-Training Initiative.

OBJECTIVES: Monitoring resident trainees' patient outcomes is essential to improving surgical performance; however, resident-specific follow-up is rarely provided in the current surgical training environment. Whether there is a correlation between individual resident's surgical performance and patients' clinical outcomes remains undefined. In this study, we aimed to use risk-adjusted patient outcomes as an educational tool to track individual surgical trainee performance. STUDY DESIGN: American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) appendectomy and partial colectomy operations (2013-2021) were examined. Residents performing ≥25 operations were included. The primary outcome was ACS NSQIP-defined morbidity adjusted using estimated probability of morbidity. Observed-to-expected ratios (O/E) of morbidity measured overall performance and risk-adjusted cumulative sum (RA-CUSUM) methodology represented surgical resident's performance over time. SETTING: Academic quaternary care institution. PARTICIPANTS: Highest-ranking surgical resident participating in an operation and included in Quality In-Training Initiative. RESULTS: A total of 449 operations were examined. 12 residents performed 343 appendectomy operations. 7 residents (29.3 ± 5.1 operations each) did not have any postoperative morbidity and demonstrated better-than-expected patient outcomes. Three residents did not have morbidity after their seventh/eleventh/fifteenth appendectomies. Two residents (case volume 29, 33) had an O/E ratio > 3. Partial colectomy (n = 106) performed by 4 residents had 2 residents (case volume 30, 26) with better-than-expected outcomes and 2 with worse-than-expected (case volume 25, 25). CONCLUSION: Longitudinal monitoring of postoperative patient outcomes provides an opportunity for trainee self-reflection and system examination. RA-CUSUM methodology offers sequential monitoring allowing for early evaluation and intervention when RA-CUSUM results for a trainee demonstrate higher-than-expected morbidity.

Center-level outcomes following elective fenestrated endovascular aortic aneurysm repair in the Vascular Quality Initiative database.

OBJECTIVE: Hospital volume is associated with mortality after open aortic aneurysm repair. Fenestrated and branched endovascular aortic repair (B-FEVAR) has been increasingly used for repair of complex thoracoabdominal and juxtarenal aneurysms, but evidence of a center-volume relationship is limited. We aimed to measure the association of center volume with in-hospital mortality, postoperative outcomes, and 1-year survival following B-FEVAR. METHODS: Patients undergoing elective endovascular thoracoabdominal and complex abdominal aneurysm repair with branch intervention (2014-2021) listed within the national Vascular Quality Initiative Thoracic Endovascular Aortic Repair/Complex EVAR database were analyzed. Centers were grouped into quartiles by mean annual procedure volume. Multivariable regression was used to evaluate the effect of center volume on in-hospital mortality adjusting for baseline and procedural characteristics. Kaplan-Meier estimation, log rank test, and mixed effects Cox regression were used to evaluate 1-year survival. RESULTS: A total of 4302 adult elective F-BEVAR procedures were identified at a total of 163 centers. In-hospital mortality did not differ by hospital volume (quartile [Q]1 = 35/1059 [3.3%]; Q2 = 30/1063 [2.8%]; Q3 = 33/1120 [2.9%]; and Q4 = 44/1060 [4.2%]; P = .308). The high volume group had a higher rate of major complication (Q1 = 14.9%; Q2 = 12.8%; Q3 = 13.3%; and Q4 = 20.1%; adjusted P < .001). Physician-modified grafts were more frequently employed in high-volume centers (Q1 = 4.5%; Q2 = 18.7%; Q3 = 11.3%; and Q4 = 19.2%; P < .001), with a decreased incidence of any endoleak noted at the end of the procedure (Q1 = 34.9%; Q2 = 32.8%; Q3 = 30.0%; and Q4 = 29.0%; P = .003). In the multivariable analysis, in-hospital mortality was not associated with center volume, comparing very low volume to medium- and high-volume centers (odds ratio [95% confidence interval] vs Q4: Q1 = 1.1 [0.6-1.9], Q2 = 0.6 [0.4-1.1], and Q3 = 0.9 [0.5-1.5]; all P > .05). No significant difference was found in 1-year survival between center volume groups. CONCLUSIONS: In-hospital mortality is not associated with procedure volume within centers performing complex endovascular aortic repair. However, complication rates and endoleak may be associated with procedure volume. Long-term outcomes by annualized procedure volume, specifically graft durability and sac expansion, should be investigated.

Judgment Errors in Surgical Care.

BACKGROUND: Human error is impossible to eliminate, particularly in systems as complex as healthcare. The extent to which judgment errors in particular impact surgical patient care or lead to harm is unclear. STUDY DESIGN: The American College of Surgeons NSQIP (2018) procedures from a single institution with 30-day morbidity or mortality were examined. Medical records were reviewed and evaluated for judgment errors. Preoperative variables associated with judgment errors were examined using logistic regression. RESULTS: Of the surgical patients who experienced a morbidity or mortality, 18% (31 of 170) experienced an error in judgment during their hospitalization. Patients with hepatobiliary procedure (odds ratio [OR] 5.4 [95% CI 1.23 to 32.75], p = 0.002), insulin-dependent diabetes (OR 4.8 [95% CI 1.2 to 18.8], p = 0.025), severe COPD (OR 6.0 [95% CI 1.6 to 22.1], p = 0.007), or with infected wounds (OR 8.2 [95% CI 2.6 to 25.8], p < 0.001) were at increased risk for judgment errors. CONCLUSIONS: Specific procedure types and patients with certain preoperative variables had higher risk for judgment errors during their hospitalization. Errors in judgment adversely impacted the outcomes of surgical patients who experienced morbidity or mortality in this cohort. Preventing or mitigating errors and closely monitoring patients after an error in judgment is prudent and may improve surgical safety.

Seat Belt Use in the US by Pregnant Motor Vehicle Occupants.

This cross-sectional study assesses patterns of seat belt use among pregnant, nonpregnant, and male occupants.

Transcatheter Aortic Valve Replacement Outcomes in End-Stage Renal Disease Patients on Hemodialysis Requiring Midodrine.

Background: Patients with dialysis-dependent end-stage renal disease (ESRD) taking midodrine may be at high risk for poor outcomes following transcatheter aortic valve replacement (TAVR). We evaluated dialysis-dependent ESRD patients taking midodrine. Methods: We conducted a retrospective analysis of non-clinical trial TAVR patients from February 2012 to December 2020 from 11 facilities in a Western US health system. Patient groups included ESRD patients on midodrine before TAVR (ESRD [+M]), ESRD patients without midodrine (ESRD [-M]), and non-ESRD patients. The endpoints of 30-day and 1-year mortality were represented by Kaplan-Meier survival estimator and compared by log-rank test. Results: Forty-five ESRD (+M), 216 ESRD (-M), and 6898 non-ESRD patients were included. ESRD patients had more comorbid conditions, despite no significant difference in predicted Society of Thoracic Surgeons mortality risk between ESRD (+M) and ESRD (-M) (8.7% vs. 9.2%, p = 0.491). Thirty-day mortality was significantly higher for ESRD (+M) patients vs. ESRD (-M) patients (20.1% vs. 5.6%, p = 0.001) and for ESRD (+M) vs. non-ESRD patients (2.5%, p < 0.001). One-year mortality trended higher for ESRD (+M) vs. ESRD (-M) patients (41.9% vs. 29.8%, p = 0.07), and was significantly higher for ESRD (+M) vs. non-ESRD patients (10.7%, p < 0.001). Compared to ESRD (-M), ESRD (+M) patients had a higher incidence of 30-day stroke (6.7% vs. 1.4%, p = 0.033), 30-day vascular complications (6.7% vs. 0.9%, p = 0.011), and a lower rate of discharge to home (62.2% vs. 84.7%, p < 0.001). In contrast, ESRD (-M) patients had no significant differences from non-ESRD patients for these outcomes. Conclusions: Our experience suggests ESRD patients on midodrine are a higher acuity population with worse survival after TAVR, compared to ESRD patients not on midodrine. These findings may help with risk stratification for ESRD patients undergoing TAVR.

Clinical Factors and Outcomes When Real-World Heart Teams Overruled STS Risk Scores in TAVR Cases.

Objectives: This study was conducted to determine why heart teams recommended transcatheter aortic valve replacement (TAVR) versus surgical AVR (SAVR) for patients at low predicted risk of mortality (PROM) and describe outcomes of these cases. Background: Historically, referral to TAVR was based predominately on the Society of Thoracic Surgeons (STS) risk model's PROM >3%. In selected cases, heart teams had latitude to overrule these scores. The clinical reasons and outcomes for these cases are unclear. Methods: Retrospective data were gathered for all TAVR and SAVR cases conducted by 9 hospitals between 2013 and 2017. Results: Cases included TAVR patients with STS PROM >3% (n = 2,711) and ≤3% (n = 415) and SAVR with STS PROM ≤3% (n = 1,438). Leading reasons for recommending TAVR in the PROM ≤3% group were frailty (57%), hostile chest (22%), severe lung disease (16%), and morbid obesity (13%), and 44% of cases had multiple reasons. Most postoperative and 30-day outcomes were similar between TAVR groups, but the STS PROM ≤3% group had a one-day shorter length of stay (2.5 ± 3.4 vs. 3.5 ± 4.7 days; p ≤ 0.001) and higher one-year survival (91.6% vs. 86.0%, p=0.002). In patients with STS PROM ≤3%, 30-day mortality was higher for TAVR versus SAVR (2.0% vs. 0.6%; p < 0.001). Conclusions: Heart teams recommended TAVR in patients with STS PROM ≤3% primarily due to frailty, hostile chest, severe lung disease, and/or morbid obesity. Similar postoperative outcomes between these patients and those with STS PROM >3% suggest that decisions to overrule STS PROM ≤3% were merited and may have reduced SAVR 30-day mortality rate.

The CUSUM Slope Equals Observed Minus Expected Mortality and Can Be Visualized by a "Slope-Meter".

We present an additional advantage of the Risk-Adjusted CUSUM (RA-CUSUM), namely, that its slope can be quantified and is in fact equivalent to Observed (O) minus Expected (E) mortality. That is, the height of the RA-CUSUM is the O minus E deaths, which measures performance since the start of the series, and the slope of the RA-CUSUM is the O minus E mortality which measures performance during a chosen interval. We present a useful graphical tool (Slope-Meter) to allow approximation of this mortality difference by the viewer.

Comparison of 26-mm Evolut and 23-mm Sapien 3 Valves in TAVR for Small Aortic Annulus.

BACKGROUND: Patients with small aortic annuli (SAA) are prone to higher post-transcatheter aortic valve replacement (TAVR) transvalvular gradients and development of prosthesis-patient mismatch (PPM). In many patients with SAA, the choice of TAVR valve commonly involves choosing between the 26-mm Medtronic Evolut 2 (ME26) or the 23-mm Edwards Sapien 3 valve (ES23). We compared echocardiographic and clinical outcomes in patients with SAA undergoing TAVR with either valve. METHODS: We queried the Providence St. Joseph Health Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry database for patients undergoing TAVR with either the ES23 or ME26 between July 2015 and December 2018 at 11 hospitals. Post-TAVR echocardiographic and clinical results in-hospital, at 1 month, and at 1 year were examined. High gradient (HG) was defined as mean gradient (MG) ≥20 mm Hg. RESULTS: We identified 1162 patients with SAA undergoing TAVR with either the ME26 (n = 233) or ES23 valve (n = 929). Baseline characteristics between groups were similar. At 1 month, the ME26 was associated with a lower MG than the ES23 (7.7 ± 4.7 mm Hg vs 13.1 ± 4.9 mm Hg; P<.001) and moderate or severe PPM (11% and 3% vs 27% and 13%; P<.001). Occurrence of HG at 1 year was lower with the ME26 valve vs the ES23 valve (0% vs 15%; P<.001). In-hospital and follow-up clinical outcomes to 1 year were similar for both groups. CONCLUSION: TAVR in SAA with the ME26 is associated with lower incidence of HG or PPM compared with the ES23. While clinical outcomes at 1 year were similar, the long-term implications of these findings remain unknown.

PCM1-JAK2 Fusion Tyrosine Kinase Gene-Related Neoplasia: A Systematic Review of the Clinical Literature.

BACKGROUND: This review summarizes the case studies of PCM1-JAK2 fusion tyrosine kinase gene-related neoplasia. Recommended treatment includes JAK2 inhibitors and hematologic stem cell transplantation (HSCT), although the small number of patients has limited study of their efficacy. Herein, we present all available cases in the current searchable literature with their demographics, diagnoses, treatments, and outcomes. METHODS: PubMed, ScienceDirect, Publons, the Cochrane Library, and Google were searched with the following terms: PCM1-JAK2, ruxolitinib and myeloid/lymphoid. RESULTS: Sixty-six patients (mean age = 50, 77% male) had an initial diagnosis of myeloproliferative neoplasm (MPN) in 40, acute leukemia in 21 and T-cell cutaneous lymphoma in 5. Thirty-five patients (53%) had completed 5-year follow-up. The 5-year survival for the MPN, acute myelogenous leukemia (AML), acute lymphocytic leukemia, and lymphoma groups are 62.7, 14.9%, 40.0%, and 100%, respectively. Too few patients have been treated with ruxolitinib to draw conclusions regarding its effect on survival while the 5-year survival for MPN patients with or without HSCT was 80.2% (40.3%-94.8%) versus 51.5% (22.3%-74.6%), respectively. The T-cell cutaneous lymphoma patients have all survived at least 7 years. CONCLUSION: This rare condition may be increasingly detected with wider use of genomics. Ruxolitinib can yield hematologic and molecular remissions. However, HSCT is, at this time, the only potentially curative treatment. Useful prognostic markers are needed to determine appropriate timing for HSCT in patients with MPN. Patients presenting with acute leukemia have a poor prognosis.

Calibration Factors for STS Risk Model Predictions: Why, How and When They Are Used.

The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database is the world's premier adult cardiac surgery outcomes registry. This tutorial explains the following: how STS updates the risk models that are used to calculate the predicted risks of adverse events in the registry; why STS on a quarterly basis adjusts or "calibrates" the observed-to-expected ratios to equal 1 (O/E = 1), thereby effectively making the annual number of adverse events predicted by the model match the annual number of adverse events observed in the entire registry; the differences between the calibrated and uncalibrated O/E ratios; and how and when to use each.

Continuous Monitoring of Risk-Adjusted Outcomes: Excess Deaths vs Lives Saved.

Reporting of risk-adjusted surgical outcomes is commonly used to compare providers and track changes over time. Preferred graphical methods use the relationship of the observed to the expected values of outcome events, including their ratio (O/E), and the cumulative sum (CUSUM) of their differences over time, called Risk-Adjusted CUSUM (RA-CUSUM) or Variable Life Adjusted Display (VLAD). We demonstrate these methods using operative mortality data for 7255 isolated coronary artery bypass graft patients from January 2014 to June 2017. RA-CUSUM and VLAD are excellent techniques to display risk-adjusted outcomes and, unlike O/E, can provide continuous monitoring as performance varies over time.

Trends in vascular complications and associated treatment strategies following transfemoral transcatheter aortic valve replacement.

OBJECTIVE: Vascular complications (VC) and bleeding complications impact morbidity and mortality after transfemoral transcatheter aortic valve replacement (TF-TAVR). Few contemporary studies have detailed these complications, associated treatment strategies, or clinical outcomes. We examined the incidence, predictors, treatment strategies, and outcomes of VCs in a multicenter cohort of patients undergoing TF-TAVR. METHODS: We performed a retrospective registry and chart review of all nonclinical trial TF-TAVR patients from seven centers within a five-state hospital system from 2012 to 2016. Bleeding and VC were recorded as defined by the Valve Academic Research Consortium recommendations. Procedural and 30-day outcomes and 1-year mortality were compared between patients with no, minor, or major VC. Multivariable logistic and Cox regressions were used to identify predictors of major VC and mortality, respectively. RESULTS: Over the study period, 1573 patients underwent TF-TAVR, with 96 (6.1%) experiencing a major VC and 77 (4.9%) experiencing a minor VC. The majority of VCs were access site related (74.2%), occurred intraoperatively (52.6%), and required interventional treatment (73.2%). The site, timing, and treatment method of VCs did not significantly change over the study period. Patients with VCs had a greater need for blood transfusion, longer postoperative length of stay, higher rates of cardiac events, increased vascular-related 30-day readmission, and higher 30-day mortality. Female sex (odds ratio [OR], 3.00; 95% CI, 1.91-4.72) and prior percutaneous coronary intervention (OR, 2.14 ; 95% CI, 1.38-3.31) were the strongest predictors of major VC. VCs modestly decreased over the study period: every 90-day increase in surgery date decreased the odds of major VC by 6% (95% CI, 1%-10%). Patients with major VCs had worse 1-year survival (OR, 79%; 95% CI, 69%-86%) compared with patients with minor VCs (OR, 92%; 95% CI, 82%-96%) or no VCs (OR, 88%; 95% CI, 87%-90%; P = .002). However, for patients who survived more than 30 days, the 1-year survival did not differ between groups For patients who survived more than 30 days, male sex (hazard ratio, 1.84; 95% CI, 1.30-2.60) and the logit of STS mortality risk score (hazard ratio, 1.98; 95% CI, 1.48-2.65) were the strongest predictors of mortality. After adjusting for other factors, minor and major VC were not predictors of 1-year mortality for patients who survived more than 30 days. CONCLUSIONS: In our contemporary cohort, VCs after TF-TAVR have modestly decreased in recent years, but continue to impact perioperative outcomes. Patient selection, consideration of alternative access routes, and prompt recognition and treatment of VCs are critical elements in optimizing early clinical outcomes after TF-TAVR.

The role of antimicrobial prophylaxis in patients with head and neck cancer undergoing chemoradiation.

BACKGROUND/OBJECTIVE: National guidelines do not recommend the routine use of antimicrobial prophylaxis in patients with solid tumors, yet prophylactic agents are still sometimes prescribed for head and neck cancer patients. The purpose of this study is to determine the effect of prophylactic antimicrobials on the incidence of infection in patients undergoing chemoradiation for head and neck cancer. METHODS: Between 2013 and 2016, patients receiving chemoradiation for head and neck cancer at three outpatient oncology clinics were identified by retrospective review. Cohorts were based on administration or absence of prophylactic antimicrobials. The primary outcome of this study was incidence of infection. Secondary outcomes included incidence of hospitalization and length of hospital stay. RESULTS: Seventy-seven patients were analyzed, 47% (n = 36) were not prescribed antimicrobial prophylaxis and 53% (n = 41) were prescribed prophylaxis. Infection occurred in 31 patients in the no prophylaxis cohort and in 34 patients in the prophylaxis cohort (86.1% vs. 82.9%, p = 0.945). Twenty patients in the no prophylaxis cohort were hospitalized versus 16 patients in the prophylaxis cohort (p = 0.222). The average length of hospital stay was 6 days in the no prophylaxis cohort and 10.6 days in the prophylaxis cohort (p = 0.007). CONCLUSION: The use of antimicrobial prophylaxis did not significantly impact the incidence of infection when compared to patients who were not prescribed prophylaxis. There was no difference in the incidence of hospitalization, however, the patients in the prescribed prophylactic group had longer length of hospital stay.

Reduction in coronary artery bypass grafting surgery mortality and morbidity during a 3-year multicenter quality improvement project.

OBJECTIVE: Risk-adjusted operative mortality is a key quality measure for isolated coronary artery bypass grafting. Through a multicenter quality improvement initiative, we sought to improve this measure at 14 surgical programs within a large and geographically dispersed health care system. METHODS: Observed mortality and combined mortality/morbidity rates for isolated coronary artery bypass grafting were collected from January 2014 to June 2017. Expected mortality and mortality/morbidity rates were determined using the Society of Thoracic Surgeons risk models. The observed/expected ratios during the baseline (2014) and final 12-month outcome period were compared. The quality improvement intervention was multifaceted and surgeon led, and consisted of (1) regular sharing of unblinded data, (2) standardized quality improvement processes, (3) regular system-wide quality improvement meetings, (4) annual observed/expected mortality targets, (5) identification of underperforming institutions and creation of nonpunitive quality improvement action plans, and (6) implementation of checklists to drive perioperative care standardization. RESULTS: The observed/expected ratio of mortality was 1.19 during the baseline period and decreased to 0.59 for the outcome period (P = .004) without a change in expected mortality or case volume. The observed/expected ratio decreased for mortality/morbidity, and mortality without antecedent morbidity was almost eliminated. CONCLUSIONS: A significant and clinically meaningful 50% reduction in the observed/expected ratio for isolated coronary artery bypass grafting mortality was observed during a multifaceted quality improvement initiative across a large multicenter health care system. Morbidity also decreased. Keys to success included surgeon leadership and engagement, frequent unblinded data sharing, development of standardized quality improvement processes, improvement and standardization of care delivery, setting of quality improvement targets, and a shared vision for improved patient outcomes.

Intrathoracic complications associated with trans-femoral transcatheter aortic valve replacement: Implications for emergency surgical preparedness.

BACKGROUND: Intrathoracic complications (ITC) requiring emergency surgical intervention occur during transcatheter aortic valve replacement (TAVR). OBJECTIVES: Characterize the incidence, outcomes and predictors of ITC in a large cohort of transfemoral (TF) TAVR cases over a 5 year period. METHODS: Retrospective registry and chart review of all nonclinical trial TF-TAVR patients from seven centers within one hospital system from 2012-2016. ITC were defined as cardiac perforation, new or worsening pericardial effusion/tamponade, annular rupture, thoracic aortic injury, aortic valve dislodgement, and coronary artery occlusion. Procedural and 30-day outcomes and 1-year mortality were compared between ITC and no ITC patients. Multivariable logistic regression was used to identify predictors of ITC. RESULTS: Over the study period, 1,581 patients had TF-TAVR and 68 ITC occurred in 46 patients (2.9%). The most common ITCs were pericardial effusion/tamponade (59%), cardiac perforation (33%), and valve dislodgement (33%). ITC rate did not decline over time (rate (95% confidence interval) for 2012 = 0% (0-8.8%), 2013 = 1.3% (0-7.2%), 2014 = 4.4% (2.2-8.0%), 2015 = 3.5% (2.0-5.6%), and 2016 = 2.4% (1.5-3.8%)). ITC patients had worse 1-year survival (ITC: 60.7% (45.1-73.1%), no ITC: 88.7% (87.0-90.3%); p < .001). The majority of ITC patient deaths occurred within the first 30 days. Multivariable models to predict ITC were not successful. CONCLUSIONS: ITC did not decline over time in our cohort. Predictors of ITC could not be identified. While these events are rare, they are associated with worse procedural outcomes and mortality. Heart teams should continue to be prepared for emergency intervention.

Family Journaling to Reduce Stress Manifestations in Patients and Families After Critical Illness.

BACKGROUND: Few studies have clearly provided evidence evaluating the effectiveness of family-written journals in reducing stress after critical illness. OBJECTIVE: Study whether critical care unit (CCU) patients and their families who participated in journaling compared to those who did not, experience lower stress manifestations after discharge. METHODS: Non-randomized controlled trial conducted with CCU patients who required mechanical ventilation for more than 24 hours and a CCU stay more than 72 hours, along with one of their family members. RESULTS: At 1 and 4 months following CCU discharge, patients with family members who journaled reported fewer stress symptoms when compared to patients who did not have journals (mean Posttraumatic Stress Syndrome 14 [PTSS-14] scores 31.8 vs. 38.1 and 32.2 vs. 34.7, respectively). Family members who journaled, compared to those who did not, reported fewer stress manifestations at 1 month however not at 4 months (mean PTSS-14 scores 26.9 vs. 43.7 and 28.0 vs. 24.4, respectively). There was no significant difference in CCU memories between patient groups at 1 and 4 months. CONCLUSION AND IMPLICATIONS FOR NURSING: Research is needed with larger samples however this study supports journaling as a low-cost, nurse-driven, stress reduction intervention for both patients recovering from critical illness and their family members who visit them.

Geographic variability in potentially discretionary red blood cell transfusions after coronary artery bypass graft surgery.

OBJECTIVE: A number of established regional quality improvement collaboratives have partnered to assess and improve care across their regions under the umbrella of the Cardiac Surgery Quality Improvement (IMPROVE) Network. The first effort of the IMPROVE Network has been to assess regional differences in potentially discretionary transfusions (<3 units red blood cells [RBCs]). METHODS: We examined 11,200 patients undergoing isolated nonemergent coronary artery bypass graft surgery across 56 medical centers in 4 IMPROVE Network regions between January 2008 and June 2012. Each center submitted the most recent 200 patients who received 0, 1, or 2 units of RBC transfusion during the index admission. Patient and disease characteristics, intraoperative practices, and percentage of patients receiving RBC transfusions were collected. Region-specific transfusion rates were calculated after adjusting for pre- and intraoperative factors among region-specific centers. RESULTS: There were small but significant differences in patient case mix across regions. RBC transfusions of 1 or 2 units occurred among 25.2% of coronary artery bypass graft procedures (2826 out of 11,200). Significant variation in the number of RBC units used existed across regions (no units, 74.8% [min-max, 70.0%-84.1%], 1 unit, 9.7% [min-max, 5.1%-11.8%], 2 units, 15.5% [min-max, 9.1%-18.2%]; P < .001). Variation in overall transfusion rates remained after adjustment (9.1%-31.7%; P < .001). CONCLUSIONS: Delivery of small volumes of RBC transfusions was common, yet varied across geographic regions. These data suggest that differences in regional practice environments, including transfusion triggers and anemia management, may contribute to variability in RBC transfusion rates.

Validation of new york operative mortality risk score for valve and valve/coronary artery bypass grafting operations.

BACKGROUND: New York (NY) valve and valve/coronary artery bypass grafting (CABG) mortality risk models, developed from operations performed in 2007 to 2009, have just been published. These models were validated using NY data from 2004 to 2006. The authors stated that their models "should also be validated by testing them against non-New York populations." Thus, we validated the NY models with the Providence Health & Services-Swedish Health Services (PH&S-SHS) cardiac surgical data and also compared them with The Society of Thoracic Surgeons (STS) mortality risk models. METHODS: The PH&S-SHS validation data set contained 4,021 isolated valve and 2,406 valve/CABG operations, performed from 2008 to 2012. The risk models (NY logistic and score models and the STS models) were recalibrated to equalize the expected and observed number of deaths. Discrimination was tested by C statistics and calibration by Hosmer-Lemeshow statistics. RESULTS: PH&S-SHS operative mortality rates were 2.6% and 5.5% in the valve and valve/CABG operations, respectively, and were lower than the NY rates. The C statistics for the NY logistic valve and valve/CABG models were 0.777 and 0.727, respectively, and were very similar for the NY score models. Calibration was good for the NY valve model (p=0.85), but not for the NY valve/CABG model (p=0.01). The STS models had better discrimination than NY models and good calibration. CONCLUSIONS: The NY logistic and score models for valve operations fit the PH&S-SHS data well with acceptable discrimination and good calibration. The NY models for valve/CABG operations fit the PH&S-SHS data with acceptable discrimination and poor calibration. STS logistic regression models fit the PH&S-SHS data somewhat better.