Perioperative quality indicators specific to the practice of anesthesia in noncardiac surgery: an umbrella review.

PURPOSE: Improvement in delivery of perioperative care depends on the ability to measure outcomes that can direct meaningful changes in practice. We sought to identify and provide an overview of perioperative quality indicators specific to the practice of anesthesia in noncardiac surgery. SOURCE: We conducted an umbrella review (a systematic review of systematic reviews) according to Joanna Briggs Institute methodology. We included systematic reviews examining perioperative indicators in patients ≥ 18 yr of age undergoing noncardiac surgery. Our primary outcome was any quality indicator specific to anesthesia. Indicators were classified by the Donabedian system and perioperative phase of care. The quality of systematic reviews was assessed using AMSTAR 2 criteria. Level of evidence of quality indicators was stratified by the Oxford Centre for Evidence-Based Medicine Classification. PRINCIPAL FINDINGS: Our search returned 1,475 studies. After removing duplicates and screening of abstracts and full texts, 23 systematic reviews encompassing 3,164 primary studies met our inclusion criteria. There were 330 unique quality indicators. Process indicators were most common (n = 169), followed by outcome (n = 114) and structure indicators (n = 47). Few identified indicators were supported by high-level evidence (45/330, 14%). Level 1 evidence supported indicators of antibiotic prophylaxis (1a), venous thromboembolism prophylaxis (1a), postoperative nausea/vomiting prophylaxis (1b), maintenance of normothermia (1a), and goal-directed fluid therapy (1b). CONCLUSION: This umbrella review highlights the scarcity of perioperative quality indicators that are supported by high quality evidence. Future development of quality indicators and recommendations for outcome measurement should focus on metrics that are supported by level 1 evidence. Potential targets for evidence-based quality-improvement programs in anesthesia are identified herein. STUDY REGISTRATION: PROSPERO (CRD42020164691); first registered 28 April 2020.

RéSUMé: OBJECTIF: L'amélioration de la prestation des soins périopératoires dépend de la capacité de mesurer les résultats qui peuvent orienter des changements significatifs dans la pratique. Nous avons cherché à identifier et à fournir une vue d'ensemble des indicateurs périopératoires de qualité spécifiques à la pratique de l'anesthésie en chirurgie non cardiaque. SOURCES: Nous avons mené une revue d'ensemble (une revue systématique des revues systématiques) selon la méthodologie de l'Institut Joanna Briggs. Nous avons inclus des revues systématiques examinant les indicateurs périopératoires chez les patient·es âgé·es de 18 ans ou plus bénéficiant d'une chirurgie non cardiaque. Notre critère d'évaluation principal était tout indicateur de qualité spécifique à l'anesthésie. Les indicateurs ont été classés en fonction du système de Donabedian et de la phase périopératoire des soins. La qualité des revues systématiques a été évaluée à l'aide des critères AMSTAR 2. Le niveau de donnée probante des indicateurs de qualité a été stratifié selon l'Oxford Centre for Evidence-Based Medicine Classification. CONSTATATIONS PRINCIPALES: Notre recherche a permis de trouver 1475 études. Après avoir éliminé les doublons et examiné les résumés et les textes intégraux, 23 revues systématiques englobant 3164 études primaires ont répondu à nos critères d'inclusion. Il y avait 330 indicateurs de qualité uniques. Les indicateurs de processus étaient les plus courants (n = 169), suivi des indicateurs de résultats (n = 114) et des indicateurs de structure (n = 47). Peu d'indicateurs identifiés étaient étayés par des données probantes de haut niveau (45/330, 14 %). Les données probantes de niveau 1 ont confirmé les indicateurs de l'antibioprophylaxie (1a), de la prophylaxie pour la thromboembolie veineuse (1a), de la prophylaxie postopératoire pour les nausées/vomissements (1b), du maintien de la normothermie (1a) et de la fluidothérapie ciblée (1b). CONCLUSION: Cet examen d'ensemble met en évidence la rareté des indicateurs périopératoires de qualité qui sont étayés par des données probantes de haute qualité. L'élaboration future d'indicateurs de qualité et de recommandations pour la mesure des résultats devrait être axée sur des paramètres étayés par des données probantes de niveau 1. Les cibles potentielles des programmes d'amélioration de la qualité de l'anesthésie fondés sur des données probantes sont identifiées dans le présent manuscrit. ENREGISTREMENT DE L'éTUDE: PROSPERO (CRD42020164691); premier enregistrement le 28 avril 2020.

Airway recommendations for perioperative patients during the COVID-19 pandemic: a scoping review.

PURPOSE: Numerous guideline recommendations for airway and perioperative management during the COVID-19 pandemic have been published. We identified, synthesized, and compared guidelines intended for anesthesiologists. SOURCE: Member society websites of the World Federation of Societies of Anesthesiologists and the European Society of Anesthesiologists were searched. Recommendations that focused on perioperative airway management of patients with proven or potential COVID-19 were included. Accelerated screening was used; data were extracted by one reviewer and verified by a second. Data were organized into themes based on perioperative phase of care. PRINCIPAL FINDINGS: Thirty unique sets of recommendations were identified. None reported methods for systematically searching or selecting evidence to be included. Four were updated following initial publication. For induction and airway management, most recommended minimizing personnel and having the most experienced anesthesiologist perform tracheal intubation. Significant congruence was observed among recommendations that discussed personal protective equipment. Of those that discussed tracheal intubation methods, most (96%) recommended videolaryngoscopy, while discordance existed regarding use of flexible bronchoscopy. Intraoperatively, 23% suggested specific anesthesia techniques and most (63%) recommended a specific operating room for patients with COVID-19. Postoperatively, a minority discussed extubation procedures (33%), or care in the recovery room (40%). Non-technical considerations were discussed in 27% and psychological support for healthcare providers in 10%. CONCLUSION: Recommendations for perioperative airway management of patients with COVID-19 overlap to a large extent but also show significant differences. Given the paucity of data early in the pandemic, it is not surprising that identified publications largely reflected expert opinion rather than empirical evidence. We suggest future efforts should promote coordinated responses and provide suggestions for studying and establishing best practices in perioperative patients. STUDY REGISTRATION: Open Science Framework ( https://osf.io/a2k4u/ ); date created, 26 March 2020.

RéSUMé: OBJECTIF: De nombreuses recommandations ont été publiées pour la prise en charge des voies aériennes et périopératoires pendant la pandémie de COVID-19. Nous avons identifié, synthétisé et comparé les lignes directrices destinées aux anesthésiologistes. SOURCES: Les sites internet des sociétés membres de la Fédération mondiale des sociétés d'anesthésiologistes et de la Société européenne d'anesthésiologie ont été consultés. Les recommandations axées sur la prise en charge périopératoire des voies aériennes des patients atteints de COVID-19 prouvée ou potentielle ont été incluses. Une sélection accélérée a été utilisée; les données ont été extraites par un examinateur et vérifiées par un second. Les données ont été thématiquement organisées en fonction de la phase périopératoire des soins. CONSTATATIONS PRINCIPALES: Trente ensembles uniques de recommandations ont été identifiés. Aucun de ces ensemble n'a fait état de méthodes de recherche ou de sélection systématiques des données probantes à inclure. Quatre ont été mis à jour après leur publication initiale. Pour l'induction et la prise en charge des voies aériennes, la plupart ont recommandé de minimiser le personnel et de demander à l'anesthésiologiste le plus expérimenté de réaliser l'intubation trachéale. Une congruence significative a été observée parmi les recommandations qui portaient sur les équipements de protection individuelle. Parmi les lignes directrices évoquant les méthodes d'intubation trachéale, la plupart (96 %) ont recommandé la vidéolaryngoscopie, alors qu'il existait une discordance concernant l'utilisation de bronchoscopes flexibles. En peropératoire, 23 % ont suggéré des techniques d'anesthésie spécifiques et la plupart (63 %) ont recommandé une salle d'opération spécifique pour les patients atteints de COVID-19. En postopératoire, une minorité a abordé le sujet des procédures d'extubation (33 %) ou des soins en salle de réveil (40 %). Les considérations non techniques ont été traitées dans 27 % des cas et le soutien psychologique aux fournisseurs de soins de santé dans 10 %. CONCLUSION: Les recommandations pour la prise en charge périopératoire des voies aériennes des patients atteints de COVID-19 se chevauchent dans une large mesure, mais montrent également des différences significatives. Compte tenu de la rareté des données au début de la pandémie, il n'est pas surprenant que les publications identifiées reflètent en grande partie l'opinion d'experts plutôt que de se fonder sur des données probantes empiriques. Nous suggérons que les efforts futurs soient déployés de manière à promouvoir des réponses coordonnées et proposer des suggestions pour étudier et établir les meilleures pratiques chez les patients en période périopératoire. ENREGISTREMENT DE L'éTUDE: Open Science Framework ( https://osf.io/a2k4u/ ); date de création, 26 mars 2020.

Post-discharge after surgery Virtual Care with Remote Automated Monitoring-1 (PVC-RAM-1) technology versus standard care: randomised controlled trial.

OBJECTIVE: To determine if virtual care with remote automated monitoring (RAM) technology versus standard care increases days alive at home among adults discharged after non-elective surgery during the covid-19 pandemic. DESIGN: Multicentre randomised controlled trial. SETTING: 8 acute care hospitals in Canada. PARTICIPANTS: 905 adults (≥40 years) who resided in areas with mobile phone coverage and were to be discharged from hospital after non-elective surgery were randomised either to virtual care and RAM (n=451) or to standard care (n=454). 903 participants (99.8%) completed the 31 day follow-up. INTERVENTION: Participants in the experimental group received a tablet computer and RAM technology that measured blood pressure, heart rate, respiratory rate, oxygen saturation, temperature, and body weight. For 30 days the participants took daily biophysical measurements and photographs of their wound and interacted with nurses virtually. Participants in the standard care group received post-hospital discharge management according to the centre's usual care. Patients, healthcare providers, and data collectors were aware of patients' group allocations. Outcome adjudicators were blinded to group allocation. MAIN OUTCOME MEASURES: The primary outcome was days alive at home during 31 days of follow-up. The 12 secondary outcomes included acute hospital care, detection and correction of drug errors, and pain at 7, 15, and 30 days after randomisation. RESULTS: All 905 participants (mean age 63.1 years) were analysed in the groups to which they were randomised. Days alive at home during 31 days of follow-up were 29.7 in the virtual care group and 29.5 in the standard care group: relative risk 1.01 (95% confidence interval 0.99 to 1.02); absolute difference 0.2% (95% confidence interval -0.5% to 0.9%). 99 participants (22.0%) in the virtual care group and 124 (27.3%) in the standard care group required acute hospital care: relative risk 0.80 (0.64 to 1.01); absolute difference 5.3% (-0.3% to 10.9%). More participants in the virtual care group than standard care group had a drug error detected (134 (29.7%) v 25 (5.5%); absolute difference 24.2%, 19.5% to 28.9%) and a drug error corrected (absolute difference 24.4%, 19.9% to 28.9%). Fewer participants in the virtual care group than standard care group reported pain at 7, 15, and 30 days after randomisation: absolute differences 13.9% (7.4% to 20.4%), 11.9% (5.1% to 18.7%), and 9.6% (2.9% to 16.3%), respectively. Beneficial effects proved substantially larger in centres with a higher rate of care escalation. CONCLUSION: Virtual care with RAM shows promise in improving outcomes important to patients and to optimal health system function. TRIAL REGISTRATION: ClinicalTrials.gov NCT04344665.

Persistent Postoperative Opioid Prescription Fulfillment and Peripheral Nerve Blocks for Ambulatory Shoulder Surgery: A Retrospective Cohort Study.

BACKGROUND: There is need to identify perioperative interventions that decrease chronic opioid use. The authors hypothesized that receipt of a peripheral nerve block would be associated with a lower incidence of persistent postoperative opioid prescription fulfillment. METHODS: This was a retrospective population-based cohort study examining ambulatory shoulder surgery patients in Ontario, Canada. The main outcome measure was persistent postoperative opioid prescription fulfillment. In opioid-naive patients (no opioid prescription fulfillment in 90 days preoperatively), this was present if an individual fulfilled an opioid prescription of at least a 60-day supply during postoperative days 90 to 365. In opioid-exposed (less than 60 mg oral morphine equivalent dose per day within 90 days preoperatively) or opioid-tolerant (60 mg oral morphine equivalent dose per day or above within 90 days preoperatively) patients, this was classified as present if an individual experienced any increase in opioid prescription fulfillment from postoperative day 90 to 365 relative to their baseline use before surgery. The authors' exposure was the receipt of a peripheral nerve block. RESULTS: The authors identified 48,523 people who underwent elective shoulder surgery from July 1, 2012, to December 31, 2017, at one of 118 Ontario hospitals. There were 8,229 (17%) patients who had persistent postoperative opioid prescription fulfillment. Of those who received a peripheral nerve block, 5,008 (16%) went on to persistent postoperative opioid prescription fulfillment compared to 3,221 (18%) patients who did not (adjusted odds ratio, 0.90; 95% CI, 0.83 to 0.97; P = 0.007). This statistically significant observation was not reproduced in a coarsened exact matching sensitivity analysis (adjusted odds ratio, 0.85; 95% CI, 0.71 to 1.02; P = 0.087) or several other subgroup and sensitivity analyses. CONCLUSIONS: This retrospective analysis found no association between receipt of a peripheral nerve block and a lower incidence of persistent postoperative opioid prescription fulfillment in ambulatory shoulder surgery patients.

Post Discharge after Surgery Virtual Care with Remote Automated Monitoring Technology (PVC-RAM): protocol for a randomized controlled trial.

BACKGROUND: After nonelective (i.e., semiurgent, urgent and emergent) surgeries, patients discharged from hospitals are at risk of readmissions, emergency department visits or death. During the coronavirus disease 2019 (COVID-19) pandemic, we are undertaking the Post Discharge after Surgery Virtual Care with Remote Automated Monitoring Technology (PVC-RAM) trial to determine if virtual care with remote automated monitoring (RAM) compared with standard care will increase the number of days adult patients remain alive at home after being discharged following nonelective surgery. METHODS: We are conducting a randomized controlled trial in which 900 adults who are being discharged after nonelective surgery from 8 Canadian hospitals are randomly assigned to receive virtual care with RAM or standard care. Outcome adjudicators are masked to group allocations. Patients in the experimental group learn how to use the study's tablet computer and RAM technology, which will measure their vital signs. For 30 days, patients take daily biophysical measurements and complete a recovery survey. Patients interact with nurses via the cellular modem-enabled tablet, who escalate care to preassigned and available physicians if RAM measurements exceed predetermined thresholds, patients report symptoms, a medication error is identified or the nurses have concerns they cannot resolve. The primary outcome is number of days alive at home during the 30 days after randomization. INTERPRETATION: This trial will inform management of patients after discharge following surgery in the COVID-19 pandemic and offer insights for management of patients who undergo nonelective surgery in a nonpandemic setting. Knowledge dissemination will be supported through an online multimedia resource centre, policy briefs, presentations, peer-reviewed journal publications and media engagement. TRIAL REGISTRATION: ClinicalTrials.gov, no. NCT04344665.

Complications as a Mediator of the Perioperative Frailty-Mortality Association.

BACKGROUND: Preoperative frailty is strongly associated with postoperative complications and mortality. However, the pathways between frailty, postoperative complications, and mortality are poorly described. The authors hypothesized that the occurrence of postoperative complications would mediate a substantial proportion of the total effect of frailty on mortality after elective noncardiac surgery. METHODS: Following protocol registration, the authors conducted a retrospective cohort study of intermediate- to high-risk elective noncardiac surgery patients (2016) using National Surgical Quality Improvement Program data. The authors conducted Bayesian mediation analysis of the relationship between preoperative frailty (exposure, using the Risk Analysis Index), serious complications (mediator), and 30-day mortality (outcome), comprehensively adjusting for confounders. The authors estimated the total effect of frailty on mortality (composed of the indirect effect mediated by complications and the remaining direct effect of frailty) and estimated the proportion of the frailty-mortality association mediated by complications. RESULTS: The authors identified 205,051 patients; 1,474 (0.7%) died. Complications occurred in 20,211 (9.9%). A 2 SD increase in frailty score resulted in a total association with mortality equal to an odds ratio of 3.79 (95% credible interval, 2.48 to 5.64), resulting from a direct association (odds ratio, 1.76; 95% credible interval, 1.34 to 2.30) and an indirect association mediated by complications (odds ratio, 2.15; 95% credible interval, 1.58 to 2.96). Complications mediated 57.3% (95% credible interval, 40.8 to 73.8) of the frailty-mortality association. Cardiopulmonary complications were the strongest mediators among complication subtypes. CONCLUSIONS: Complications mediate more than half of the association between frailty and postoperative mortality in elective noncardiac surgery.

Prospective Comparison of Preoperative Predictive Performance Between 3 Leading Frailty Instruments.

BACKGROUND: Guidelines recommend routine preoperative frailty assessment for older people. However, the degree to which frailty instruments improve predictive accuracy when added to traditional risk factors is poorly described. Our objective was to measure the accuracy gained in predicting outcomes important to older patients when adding the Clinical Frailty Scale (CFS), Fried Phenotype (FP), or Frailty Index (FI) to traditional risk factors. METHODS: This was an analysis of a multicenter prospective cohort of elective noncardiac surgery patients ≥65 years of age. Each frailty instrument was prospectively collected. The added predictive performance of each frailty instrument beyond the baseline model (age, sex, American Society of Anesthesiologists' score, procedural risk) was estimated using likelihood ratio test, discrimination, calibration, explained variance, and reclassification. Outcomes analyzed included death or new disability, prolonged length of stay (LoS, >75th percentile), and adverse discharge (death or non-home discharge). RESULTS: We included 645 participants (mean age, 74 [standard deviation, 6]); 72 (11.2%) participants died or experienced a new disability, 164 (25.4%) had prolonged LoS, and 60 (9.2%) had adverse discharge. Compared to the baseline model predicting death or new disability (area under the curve [AUC], 0.67; R, 0.08, good calibration), prolonged LoS (AUC, 0.73; R, 0.18, good calibration), and adverse discharge (AUC, 0.78; R, 0.16, poor calibration), the CFS improved fit per the likelihood ratio test (P < .02 for death or new disability, <.001 for LoS, <.001 for discharge), discrimination (AUC = 0.71 for death or new disability, 0.76 for LoS, 0.82 for discharge), calibration (good for death or new disability, LoS, and discharge), explained variance (R = 0.11 for death or new disability, 0.22 for LoS, 0.25 for discharge), and reclassification (appropriate directional reclassification) for all outcomes. The FP improved discrimination and R for all outcomes, but to a lesser degree than the CFS. The FI improved discrimination for death or new disability and R for all outcomes, but to a lesser degree than the CFS and the FP. These results were consistent in internal validation. CONCLUSIONS: Frailty instruments provide meaningful increases in accuracy when predicting postoperative outcomes for older people. Compared to the FP and FI, the CFS appears to improve all measures of predictive performance to the greatest extent and across outcomes. Combined with previous research demonstrating that the CFS is easy to use and requires less time than the FP, clinicians should consider its use in preoperative practice.

Validation of new ICD-10-based patient safety indicators for identification of in-hospital complications in surgical patients: a study of diagnostic accuracy.

OBJECTIVE: Administrative data systems are used to identify hospital-based patient safety events; few studies evaluate their accuracy. We assessed the accuracy of a new set of patient safety indicators (PSIs; designed to identify in hospital complications). STUDY DESIGN: Prospectively defined analysis of registry data (1 April 2010-29 February 2016) in a Canadian hospital network. Assignment of complications was by two methods independently. The National Surgical Quality Improvement Programme (NSQIP) database was the clinical reference standard (primary outcome=any in-hospital NSQIP complication); PSI clusters were assigned using International Classification of Disease (ICD-10) codes in the discharge abstract. Our primary analysis assessed the accuracy of any PSI condition compared with any complication in the NSQIP; secondary analysis evaluated accuracy of complication-specific PSIs. PATIENTS: All inpatient surgical cases captured in NSQIP data. ANALYSIS: We assessed the accuracy of PSIs (with NSQIP as reference standard) using positive and negative predictive values (PPV/NPV), as well as positive and negative likelihood ratios (±LR). RESULTS: We identified 12 898 linked episodes of care. Complications were identified by PSIs and NSQIP in 2415 (18.7%) and 2885 (22.4%) episodes, respectively. The presence of any PSI code had a PPV of 0.55 (95% CI 0.53 to 0.57) and NPV of 0.93 (95% CI 0.92 to 0.93); +LR 6.41 (95% CI 6.01 to 6.84) and -LR 0.40 (95% CI 0.37 to 0.42). Subgroup analyses (by surgery type and urgency) showed similar performance. Complication-specific PSIs had high NPVs (95% CI 0.92 to 0.99), but low to moderate PPVs (0.13-0.61). CONCLUSION: Validation of the ICD-10 PSI system suggests applicability as a first screening step, integrated with data from other sources, to produce an adverse event detection pathway that informs learning healthcare systems. However, accuracy was insufficient to directly identify or rule out individual-level complications.

A Population-based Comparative Effectiveness Study of Peripheral Nerve Blocks for Hip Fracture Surgery.

BACKGROUND: Adverse outcomes and resource use rates are high after hip fracture surgery. Peripheral nerve blocks could improve outcomes through enhanced analgesia and decreased opioid related adverse events. We hypothesized that these benefits would translate into decreased resource use (length of stay [primary outcome] and costs), and better clinical outcomes (pneumonia and mortality). METHODS: The authors conducted a retrospective cohort study of hip fracture surgery patients in Ontario, Canada (2011 to 2015) using linked health administrative data. Multilevel regression, instrumental variable, and propensity scores were used to determine the association of nerve blocks with resource use and outcomes. RESULTS: The authors identified 65,271 hip fracture surgery patients; 10,030 (15.4%) received a block. With a block, the median hospital stay was 7 (interquartile range, 4 to 13) days versus 8 (interquartile range, 5 to 14) days without. Following adjustment, nerve blocks were associated with a 0.6-day decrease in length of stay (95% CI, 0.5 to 0.8). This small difference was consistent with instrumental variable (1.1 days; 95% CI, 0.9 to 1.2) and propensity score (0.2 days; 95% CI, 0.2 to 0.3) analyses. Costs were lower with a nerve block (adjusted difference, -$1,421; 95% CI, -$1,579 to -$1,289 [Canadian dollars]), but no difference in mortality (adjusted odds ratio, 0.99; 95% CI, 0.89 to 1.11) or pneumonia (adjusted odds ratio, 1.01; 95% CI, 0.88 to 1.16) was observed. CONCLUSIONS: Receipt of nerve blocks for hip fracture surgery is associated with decreased length of stay and health system costs, although small effect sizes may not reflect clinical significance for length of stay.

Peripheral Nerve Blocks for Ambulatory Shoulder Surgery: A Population-based Cohort Study of Outcomes and Resource Utilization.

BACKGROUND: Nerve blocks improve early pain after ambulatory shoulder surgery; impact on postdischarge outcomes is poorly described. Our objective was to measure the association between nerve blocks and health system outcomes after ambulatory shoulder surgery. METHODS: We conducted a population-based cohort study using linked administrative data from 118 hospitals in Ontario, Canada. Adults having elective ambulatory shoulder surgery (open or arthroscopic) from April 1, 2009, to December 31, 2016, were included. After validation of physician billing codes to identify nerve blocks, we used multilevel, multivariable regression to estimate the association of nerve blocks with a composite of unplanned admissions, emergency department visits, readmissions or death within 7 days of surgery (primary outcome) and healthcare costs (secondary outcome). Neurology consultations and nerve conduction studies were measured as safety indicators. RESULTS: We included 59,644 patients; blocks were placed in 31,073 (52.1%). Billing codes accurately identified blocks (positive likelihood ratio 16.83, negative likelihood ratio 0.03). The composite outcome was not significantly different in patients with a block compared with those without (2,808 [9.0%] vs. 3,424 [12.0%]; adjusted odds ratio 0.96; 95% CI 0.89 to 1.03; P = 0.243). Healthcare costs were greater with a block (adjusted ratio of means 1.06; 95% CI 1.02 to 1.10; absolute increase $325; 95% CI $316 to $333; P = 0.005). Prespecified sensitivity analyses supported these results. Safety indicators were not different between groups. CONCLUSIONS: In ambulatory shoulder surgery, nerve blocks were not associated with a significant difference in adverse postoperative outcomes. Costs were statistically higher with a block, but this increase is not likely clinically relevant.

A Systematic Review of the Impact of Surgical Special Care Units on Patient Outcomes and Health Care Resource Utilization.

Perioperative intermediate care units (termed surgical special care units) have been widely implemented across health systems because they are believed to improve surveillance and management of high-risk surgical patients. Our objective was to conduct a systematic review to investigate the effects of a 3-level model of perioperative care delivery (ie, ward, surgical special care unit, or intensive care unit) compared to a 2-level model of care (ie, ward, intensive care unit) on postoperative outcomes. Our protocol was registered with PROSPERO, the international prospective register of systematic reviews (CRD42015025155). Randomized controlled studies and nonrandomized comparator studies were included. We performed a systematic search of Medline, Cumulative Index to Nursing and Allied Health Literature, Embase, and the Cochrane library (inception - 11/2017). The primary outcome was mortality; secondary outcomes included length of stay and hospital costs. We identified 1995 citations with our search, and 21 studies met eligibility criteria (2 randomized controlled studies and 19 nonrandomized comparator studies; 44,134 patients in total). Surgical special care units were characterized by continuous monitoring (12 studies), the absence of mechanical ventilation (8 studies), nurse-to-patient ratios (range, 1:2-1:4), and number of beds (median: 5; range: 3-33). Thirteen studies reported on mortality. Notable findings included no observed difference in overall in-hospital mortality, but an apparent increase in intensive care unit mortality in a 3-level model of care. This may reflect a decanting of lower acuity patients from the intensive care unit to the surgical special care unit. No significant difference was found in hospital length of stay; however, 2 studies demonstrated reductions in hospital costs with the implementation of a surgical special care unit. Significant clinical and methodological heterogeneity precluded pooled analysis. Given the prevalence of surgical special care units, the results of our review suggest that additional methodologically rigorous investigations are needed to understand the effect of these units on the surgical population.

Association of peripheral nerve blocks with postoperative outcomes in ambulatory shoulder surgery patients: a single-centre matched-cohort study.

PURPOSE: Regional anesthesia may have immediate postoperative advantages compared with general anesthesia, but its impact on post-discharge outcomes is poorly described. Our objective was to measure the association between regional anesthesia and outcomes after ambulatory shoulder surgery. METHODS: We conducted a historical cohort study at The Ottawa Hospital. Adults ≥ 18 yr old having elective ambulatory shoulder surgery from January 1, 2011 to December 31, 2016 were included. Using one-to-many coarsened exact matching (CEM) to adjust for potential confounders, we matched peripheral nerve block (PNB) patients to those without a PNB. Within the matched cohort, we assessed whether PNBs were associated with our primary composite outcomes, comprising unplanned admissions, emergency department visits, readmissions, or death within 30 days of surgery. RESULTS: There were 1,623 patients who met the inclusion criteria; PNBs were placed in 1,382 (85.2%) patients. CEM matched 211 patients who did not receive a PNB to 950 patients with similar characteristics who did receive a PNB (n = 1,161; 71.5% of total cohort). In patients who received a PNB compared with those who had no PNB, there was no difference in risk of composite outcome (relative risk, 1.58; 95% confidence interval [CI], 0.83 to 3.01), or hospital costs (ratio of means 0.73; 95% CI, 0.21 to 2.49). CONCLUSION: Peripheral nerve blocks in ambulatory shoulder surgery were not associated with a significant difference in a composite of adverse postoperative outcomes. Nevertheless, given the lower than expected incidence and moderate effect size associating PNBs with post-discharge events, future large prospective trials are needed to assess post-discharge outcomes. TRIAL REGISTRATION: www.clinicaltrials.gov (NCT03309644). Registered 13 October 2017.

A Systematic Review and Meta-analysis Examining the Impact of Incident Postoperative Delirium on Mortality.

BACKGROUND: Delirium is an acute and reversible geriatric syndrome that represents a decompensation of cerebral function. Delirium is associated with adverse postoperative outcomes, but controversy exists regarding whether delirium is an independent predictor of mortality. Thus, we assessed the association between incident postoperative delirium and mortality in adult noncardiac surgery patients. METHODS: A systematic search was conducted using Cochrane, MEDLINE/PubMed, Cumulative Index to Nursing and Allied Health Literature, and Embase. Screening and data extraction were conducted by two independent reviewers. Pooled-effect estimates calculated with a random-effects model were expressed as odds ratios with 95% CIs. Risk of bias was assessed using the Cochrane Risk of Bias Tool for Non-Randomized Studies. RESULTS: A total of 34 of 4,968 screened citations met inclusion criteria. Risk of bias ranged from moderate to critical. Pooled analysis of unadjusted event rates (5,545 patients) suggested that delirium was associated with a four-fold increase in the odds of death (odds ratio = 4.12 [95% CI, 3.29 to 5.17]; I = 24.9%). A formal pooled analysis of adjusted outcomes was not possible due to heterogeneity of effect measures reported. However, in studies that controlled for prespecified confounders, none found a statistically significant association between incident postoperative delirium and mortality (two studies in hip fractures; n = 729) after an average follow-up of 21 months. Overall, as study risk of bias decreased, the association between delirium and mortality decreased. CONCLUSIONS: Few high-quality studies are available to estimate the impact of incident postoperative delirium on mortality. Studies that controlled for prespecified confounders did not demonstrate significant independent associations of delirium with mortality.

Ocular Manifestations of Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis in Children.

PURPOSE: To describe the acute and chronic ocular manifestations of Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and SJS/TEN Overlap syndrome (Overlap syndrome) in children. DESIGN: Retrospective case series. METHODS: Medical records of children admitted to the Hospital for Sick Children between 2001 and 2011 with SJS, TEN, and Overlap syndrome were reviewed. Demographic information, all abnormal ophthalmic findings (and median time to first diagnosis), visual acuities, and ophthalmic treatments prescribed were collected for each eye for every patient. RESULTS: Thirty-six children were identified for inclusion in the study. Twenty-nine (81%) had acute ocular involvement, including all patients with TEN (n = 7). Conjunctivitis was the most common (78%) clinical sign. This, together with conjunctival membranes and subconjunctival hemorrhage, were the earliest signs, presenting by a median of 1 day. The percentage of patients and median time to occurrence of complications were as follows: for lid margin ulceration and corneal epithelial defects, 25%, 3 days; conjunctival ulceration, 39%, 3.5 days; symblepharon, 28%, 4 weeks; corneal opacification, 11%, 4 months; limbal stem cell failure, 8%, 7 months; and corneal vascularisation, 8%, 10 months after admission. Over 90% of children maintain a visual acuity of 20/40 or better in each eye at a mean follow-up of 1.4 years. CONCLUSIONS: Ocular involvement in SJS, TEN, and Overlap syndrome is common and the ocular manifestations may develop many months after the initial presentation, mandating the need for long-term follow-up of these children. Despite the high frequency of sight-threatening disease, most children maintain good vision in the long term.

Pediatric toxic epidermal necrolysis: an institutional review of patients admitted to an intensive care unit.

Stevens Johnson Syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare debilitating mucocutaneuous diseases most commonly associated with severe drug reactions. A review of SJS/TEN cases was undertaken to describe the etiology, patient characteristics, treatment, and outcome in children affected at a large tertiary pediatric hospital. A retrospective chart review examined SJS/TEN cases admitted to a pediatric intensive care unit (PICU) between 2001 and 2011. Data concerning total body surface area (TBSA) involvement, causative agents, length of stay, and treatment were reviewed. PICU mortality predictors including Severity-of-Illness Score for Toxic Epidermal Necrolysis (SCORTEN), Pediatric Index of Mortality 2 scores, and Pediatric Logistic Organ Dysfunction scores were also reviewed. Nutritional feeding information was collected and compared with calculated and measured (calorimetry) requirements. There were 10 SJS/TEN pediatric patients (mean age = 6.6 years) with significant skin involvement (mean TBSA = 42.2%) requiring PICU admission. Prescription drugs were the most common causative factor (n = 7). Intravenous immunoglobulin and corticosteroids were used for treatment in eight and two of the cases, respectively. The mean length of stay in the PICU was 10.2 days. There were no mortalities, and all mortality scores predicted high likelihood of survival. Actual feeds (n = 9) were uniformly lower than the calculated feeding requirements (mean = 1059 kcal/day vs mean = 2027 kcal/day). This data will help to provide insight into the management of SJS/TEN in an intensive care setting, and will help form the best treatment approach for future cases in a pediatric population.

Subsequent injury definition, classification, and consequence.

OBJECTIVE: To examine if different definitions of "recurrent injury" affect the distribution of subsequent injury types and their consequences. DESIGN: Secondary analysis of prospective injury data. SETTING: Circus shows. PARTICIPANTS: Circus artists (n = 1281). MAIN OUTCOME MEASURES: A subsequent injury after an index injury was categorized as (1) new injury: different location; (2) local injury: same location, different type; and (3) recurrent injury: same location/type. Subsequent injuries were stratified according to when they occurred after the index injury: early (≤90 performances), late (91-540 performances), and delayed (>540 performances). "Healed injury" was either date of return to full participation (RTP) or last treatment. RESULTS: Eight hundred twenty-one artists (64%) incurred 2 medical attention injuries, and 296 artists (23%) incurred 2 time loss injuries. In both medical attention and time loss injuries, recurrent (range, 7.5%-8.3%) and local injuries (range, 4%-7%) occurred less frequently than subsequent new injuries (range, 81%-87%). Time loss injuries recurred later than medical attention injuries. The pattern of early, late, and delayed injuries was similar for new, local, and recurrent injuries. A greater number of "early" injuries are seen with the treatment definition compared with RTP. Subsequent injuries had similar number of treatments and missed performances (consequences) as index injuries. CONCLUSIONS: In our data, there were a greater number of local and recurrent time loss injuries compared with medical attention injuries, but the injury definition did not affect the relative number of early, late, or delayed injuries. Recurrent injuries are an important component of injury prevention, and clear definitions when presenting recurrent injury data are necessary.

Past injury as a risk factor: an illustrative example where appearances are deceiving.

Previous injury is believed to be a causal risk factor for subsequent injury. Using empirical data on circus artists (n = 1,281 artists) between 2004 and 2008 in Montreal, Canada, as a motivating example, the authors use patient vector plots to demonstrate that a bias away from the null must always occur in the typical analyses cited as evidence (i.e., survival analysis, Poisson regression), except in the improbable context where all subjects have the same inherent risk independent of previous injury. In addition, using simulated data, the authors demonstrate that a simple method that conditions on the individual will approximate conclusions from more complex analytical methods. By using the typical analysis of the authors' empirical data, Kaplan-Meier curves and Cox regression suggested increasing injury rates for both the second and third injuries compared with the first injury. However, conditional analyses using a matched population (i.e., time to first, second, and third injuries among artists with 3 or more injuries) showed that injury rates were unchanged for both the second and third injuries compared with the first injury. These results suggest that previous injury should not be evaluated as a causal risk factor unless one conditions on the individual in some way.

Risk of injury associated with body checking among youth ice hockey players.

CONTEXT: Ice hockey has one of the highest sport participation and injury rates in youth in Canada. Body checking is the predominant mechanism of injury in leagues in which it is permitted. OBJECTIVE: To determine if risk of injury and concussion differ for Pee Wee (ages 11-12 years) ice hockey players in a league in which body checking is permitted (Alberta, Canada) vs a league in which body checking is not permitted (Quebec, Canada). DESIGN, SETTING, AND PARTICIPANTS: Prospective cohort study conducted in Alberta and Quebec during the 2007-2008 Pee Wee ice hockey season. Participants (N = 2154) were players from teams in the top 60% of divisions of play. MAIN OUTCOME MEASURES: Incidence rate ratios adjusted for cluster based on Poisson regression for game- and practice-related injury and concussion. RESULTS: Seventy-four Pee Wee teams from Alberta (n = 1108 players) and 76 Pee Wee teams from Quebec (n = 1046 players) completed the study. In total, there were 241 injuries (78 concussions) reported in Alberta (85 077 exposure-hours) and 91 injuries (23 concussions) reported in Quebec (82 099 exposure-hours). For game-related injuries, the Alberta vs Quebec incidence rate ratio was 3.26 (95% confidence interval [CI], 2.31-4.60 [n = 209 and n = 70 for Alberta and Quebec, respectively]) for all injuries, 3.88 (95% CI, 1.91-7.89 [n = 73 and n = 20]) for concussion, 3.30 (95% CI, 1.77-6.17 [n = 51 and n = 16]) for severe injury (time loss, >7 days), and 3.61 (95% CI, 1.16-11.23 [n=14 and n=4]) for severe concussion (time loss, >10 days). The estimated absolute risk reduction (injuries per 1000 player-hours) that would be achieved if body checking were not permitted in Alberta was 2.84 (95% CI, 2.18-3.49) for all game-related injuries, 0.72 (95% CI, 0.40-1.04) for severe injuries, 1.08 (95% CI, 0.70-1.46) for concussion, and 0.20 (95% CI, 0.04-0.37) for severe concussion. There was no difference between provinces for practice-related injuries. CONCLUSION: Among 11- to 12-year-old ice hockey players, playing in a league in which body checking is permitted compared with playing in a league in which body checking is not permitted was associated with a 3-fold increased risk of all game-related injuries and the categories of concussion, severe injury, and severe concussion.