Association between Leapfrog safe practices score and hospital mortality in major surgery.

BACKGROUND: The Leapfrog Group reports on hospitals' adoption of the National Quality Forum Patient Safety Practices. However, it is unknown whether hospital compliance with these safe practices is associated with improved outcomes in patients undergoing major surgery. METHODS: We analyzed the association between hospital mortality and Leapfrog Safe Practices among patients undergoing coronary artery bypass graft surgery (n=18,565), abdominal aortic aneurysm repair (n=2777), and hip replacement (n=25,067) in hospitals participating in the 2007 Leapfrog Hospital Survey using logistic regression. RESULTS: After adjusting for patient and hospital factors, we found that the total safety score (adjusted odds ratio: 1.000, 95% confidence interval: 0.999-1.001) was not associated with hospital mortality. Computerized physician order entry and ICU physician staffing were also not associated with hospital mortality. CONCLUSIONS: We did not find evidence that patients undergoing major surgery at hospitals which scored higher on the Leapfrog Safe Practices Survey had lower mortality rates. The Leapfrog safe practices score as a standalone quality measure may have limited power to distinguish between high-quality and low-quality hospitals.

Association between intraoperative blood transfusion and mortality and morbidity in patients undergoing noncardiac surgery.

BACKGROUND: The impact of intraoperative erythrocyte transfusion on outcomes of anemic patients undergoing noncardiac surgery has not been well characterized. The objective of this study was to examine the association between blood transfusion and mortality and morbidity in patients with severe anemia (hematocrit less than 30%) who are exposed to one or two units of erythrocytes intraoperatively. METHODS: This was a retrospective analysis of the association of blood transfusion and 30-day mortality and 30-day morbidity in 10,100 patients undergoing general, vascular, or orthopedic surgery. We estimated separate multivariate logistic regression models for 30-day mortality and for 30-day complications. RESULTS: Intraoperative blood transfusion was associated with an increased risk of death (odds ratio [OR], 1.29; 95% CI, 1.03-1.62). Patients receiving an intraoperative transfusion were more likely to have pulmonary, septic, wound, or thromboembolic complications, compared with patients not receiving an intraoperative transfusion. Compared with patients who were not transfused, patients receiving one or two units of erythrocytes were more likely to have pulmonary complications (OR, 1.76; 95% CI, 1.48-2.09), sepsis (OR, 1.43; 95% CI, 1.21-1.68), thromboembolic complications (OR, 1.77; 95% CI, 1.32-2.38), and wound complications (OR, 1.87; 95% CI, 1.47-2.37). CONCLUSIONS: Intraoperative blood transfusion is associated with a higher risk of mortality and morbidity in surgical patients with severe anemia. It is unknown whether this association is due to the adverse effects of blood transfusion or is, instead, the result of increased blood loss in the patients receiving blood.

Patterns of communication during the preanesthesia visit.

BACKGROUND: Effective communication in the preanesthesia clinic is important in patient-centered care. Although patient-physician communication has been studied by recordings in other contexts, there have been no observational studies of the communication patterns of anesthesiologists and patients during the preanesthesia interview. METHODS: Two experienced standardized patients were trained to portray the same clinical situation by using different coping styles (maximizing information or "monitoring" vs. minimizing information or "blunting"). Interviews of standardized patients by anesthesiologists took place in the preanesthesia clinic and recorded with the knowledge of the subjects. Audio recordings were analyzed, and the visit was separated into nine components. Discussion of the risks/informed consent process was examined, looking for discussion of common morbidities. The standardized patients completed a survey on the patient-centeredness of the interview. RESULTS: Twenty-seven subjects participated in this study. Interviews with the monitor required more time: 17.4 min (confidence interval [CI] 15.2-19.6, n = 24) versus 14.5 min (CI 13.1-16.0, n = 25), P < 0.05. Most interview time was spent in obtaining the history; 2.4 min (CI 1.8-3.1) was spent discussing risks with the monitor, and only 1.6 min (CI 1.2-2.0) was spent with the blunter (P < 0.05). Neither the monitor nor the blunter scored the interview highly for involving the patient in determining the goals of the anesthetic and recovery. CONCLUSIONS: Direct recording of interactions with standardized patients is a feasible method of studying the communication skills of anesthesiologists. For this study, the anesthesia providers were able to modify their approach depending on patient type, but the monitor received more information.

Blood transfusion in the perioperative period.

Anemia is associated with perioperative mortality and morbidity. Since the presence of anemia and blood transfusion often go hand in hand, it can be difficult to separate the effects of anemia from the effects of perioperative transfusion. The role for blood transfusion in mitigating the mortality and morbidity associated with anemia is unclear. A restrictive transfusion strategy has been advocated for hemodynamically stable patients, as blood transfusion exposes the patient to both infectious and non-infectious complications. Further research is warranted in patients with the acute coronary syndrome, as there is insufficient evidence to make recommendations for this patient population. Additional multi-center randomized controlled trials need to be conducted in perioperative and critically ill patients with large enough sample sizes to examine differences in mortality and major complications between liberal and restrictive transfusion strategies. Further trials need to incorporate current practices in improved blood storage and leukoreduction techniques.