Emergency general surgery transfer to lower acuity facility: The role of right-sizing care in emergency general surgery regionalization.

BACKGROUND: Regionalization of emergency general surgery (EGS) has primarily focused on expediting care of high acuity patients through interfacility transfers. In contrast, triaging low-risk patients to a nondesignated trauma facility has not been evaluated. This study evaluates a 16-month experience of a five-surgeon team triaging EGS patients at a tertiary care, Level I trauma center (TC) to an affiliated community hospital 1.3 miles away. METHODS: All EGS patients who presented to the Level I TC emergency department from January 2020 to April 2021 were analyzed. Patients were screened by EGS surgeons covering both facilities for transfer appropriateness including hemodynamics, resource need, and comorbidities. Patients were retrospectively evaluated for disposition, diagnosis, comorbidities, length of stay, surgical intervention, and 30-day mortality and readmission. RESULTS: Of 987 patients reviewed, 31.5% were transferred to the affiliated community hospital, 16.1% were discharged home from the emergency department, and 52.4% were admitted to the Level I TC. Common diagnoses were biliary disease (16.8%), bowel obstruction (15.7%), and appendicitis (14.3%). Compared with Level I TC admissions, Charlson Comorbidity Index was lower (1.89 vs. 4.45, p < 0.001) and length of stay was shorter (2.23 days vs. 5.49 days, p < 0.001) for transfers. Transfers had a higher rate of surgery (67.5% vs. 50.1%, p < 0.001) and lower readmission and mortality (8.4% vs. 15.3%, p = 0.004; 0.6% vs. 5.0%, p < 0.001). Reasons not to transfer were emergency evaluation, comorbidity burden, operating room availability, and established care. No transfers required transfer back to higher care (under-triage). Bed days saved at the Level I TC were 693 (591 inpatients). Total operating room minutes saved were 24,008 (16,919, between 7:00 am and 5:00 pm). CONCLUSION: Transfer of appropriate patients maintains high quality care and outcomes, while improving operating room and bed capacity and resource utilization at a tertiary care, Level I TC. Emergency general surgery regionalization should consider triage of both high-risk and low-risk patients. LEVEL OF EVIDENCE: Prospective comparative cohort study, Level II.

Improved identification of severely injured pediatric trauma patients using reverse shock index multiplied by Glasgow Coma Scale.

BACKGROUND: The shock index pediatric age-adjusted (SIPA) predicts the need for increased resources and mortality among pediatric trauma patients without incorporating neurological status. A new scoring tool, rSIG, which is the reverse shock index (rSI) multiplied by the Glasgow Coma Scale (GCS), has been proven superior at predicting outcomes in adult trauma patients and mortality in pediatric patients compared with traditional scoring systems. We sought to compare the accuracy of rSIG to Shock Index (SI) and SIPA in predicting the need for early interventions in civilian pediatric trauma patients. METHODS: Patients (aged 1-18 years) in the 2014 to 2018 Pediatric Trauma Quality Improvement Program database with complete heart rate, systolic blood pressure, and total GCS were included. Optimal cut points of rSIG were calculated for predicting blood transfusion within 4 hours, intubation, intracranial pressure monitoring, and intensive care unit admission. From the optimal thresholds, sensitivity, specificity, and area under the curve were calculated from receiver operating characteristics analyses to predict each outcome and compared with SI and SIPA. RESULTS: A total of 604,931 patients with a mean age of 11.1 years old were included. A minority of patients had a penetrating injury mechanism (5.6%) and the mean Injury Severity Score was 7.6. The mean SI and rSIG scores were 0.85 and 18.6, respectively. Reverse shock index multiplied by Glasgow Coma Scale performed better than SI and SIPA at predicting early trauma outcomes for the overall population, regardless of age. CONCLUSION: Reverse shock index multiplied by Glasgow Coma Scale outperformed SI and SIPA in the early identification of traumatically injured children at risk for early interventions, such as blood transfusion within 4 hours, intubation, intracranial pressure monitoring, and intensive care unit admission. Reverse shock index multiplied by Glasgow Coma Scale adds neurological status in initial patient assessment and may be used as a bedside triage tool to rapidly identify pediatric patients who will likely require early intervention and higher levels of care. LEVEL OF EVIDENCE: Prognostic, level III.

Development of comorbidity score for patients undergoing major surgery.

OBJECTIVE: To develop and validate a claims-based comorbidity score for patients undergoing major surgery, and compare its performance with established comorbidity scores. DATA SOURCE: Five percent Medicare data from 2007 to 2014. STUDY DESIGN: Retrospective cohort study of patients aged ≥65 years undergoing six major operations (N = 99 250). DATA COLLECTION: One-year mortality was the primary outcome. Secondary outcomes were hospital mortality, 30-day mortality, 30-day readmission, and length of stay. The comorbidity score was developed in the derivation cohort (70 percent sample) using logistic regression model. The comorbidity score was calibrated and validated in the validation cohort (30 percent sample), and compared against the Charlson, Elixhauser, and Centers for Medicare and Medicaid Services Hierarchical Condition Categories (CMS-HCC) comorbidity scores using c-statistic, net reclassification improvement, and integrated discrimination improvement. PRINCIPAL FINDINGS: In the validation cohort, the surgery-specific comorbidity score was well calibrated and performed better than the Charlson, Elixhauser, and CMS-HCC comorbidity scores for all outcomes; the performance was comparable to the CMS-HCC for 30-day readmission. For example, the surgery-specific comorbidity score (c-statistic = 0.792; 95% CI, 0.785-0.799) had greater discrimination than the Charlson (c-statistic = 0.747; 95% CI, 0.739-0.755), Elixhauser (c-statistic = 0.747; 95% CI, 0.735-0.755), or CMS-HCC (c-statistic = 0.755; 95% CI, 0.747-0.763) scores in predicting 1-year mortality. The net reclassification improvement and integrated discrimination improvement were greater for surgery-specific comorbidity score compared to the Charlson, Elixhauser, and CMS-HCC scores. CONCLUSIONS: Compared to commonly used comorbidity measures, a surgery-specific comorbidity score better predicted outcomes in the surgical population.

Zika Testing Behaviors and Risk Perceptions Among Pregnant Women in Miami-Dade County, One Year After Local Transmission.

OBJECTIVES: This study sought to describe the knowledge and perceptions of pregnant women in Miami-Dade County concerning Zika virus (ZIKV) in their community, to characterize their testing behaviors, and to identify any barriers that would keep them from seeking testing. METHODS: The Florida Department of Health in Miami-Dade County partnered with the Healthy Start Coalition of Miami-Dade to administer an assessment survey in eight OBGYN clinics from June to August 2017. The survey captured past ZIKV testing practices, attitudes towards testing, barriers to testing, risk perception of ZIKV in the participants' community, and ZIKV-related knowledge. Descriptive analyses were performed on variables of interest. Chi squared tests examined associations between categorical variables. RESULTS: A total of 363 participants were included in the analysis. Of these, 203 (55.9%) thought they should be tested for ZIKV, and less than half of the participants reported having been previously tested (152, 41.9%). Participants with some high school education were significantly more likely than those with higher education levels to see ZIKV as a "big problem" in the community (p = 0.0026). There was a significant association (p ≤ 0.0001) between women who thought that they should be tested, and those who perceived ZIKV to be a medium or big problem in their community. CONCLUSIONS FOR PRACTICE: Health interventions that focus on increasing ZIKV knowledge should also place greater emphasis on risk communication when targeting the pregnant population. Having a higher risk perception may be more predictive of testing behaviors than having a lack of barriers or a high level of ZIKV-related knowledge.

La casuística como pedagogía para enseñar la Bioética / Casuistics as pedagogy to teach Bioethics

Aunque la gran mayoría de los procesos educativos de enseñanza­ aprendizaje en Medicina deben seguir una metodología y estar regidos por la Didáctica, no siempre esto es adecuado desde el punto de vista de la Bioética. El propósito de la educación en bioética es el desarrollo de la habilidad de tomar decisiones, no solamente el dominio de conocimientos y saberes. Tomar decisiones requiere práctica en la balanza de varias consideraciones, no de manera deductiva, sino desde una perspectiva personal. Por lo tanto los autores de este artículo consideran que la casuística, como metodología de la enseñanza de la Bioética, es más apropiada que el principialismo. Se incluye aquí una introducción breve a la pedagogía casuística (AU).

Even though most of the teaching-learning educative processes in Medicine should follow a methodology and are ruled by Didactics, this is not always right from the Bioethics point of view. The purpose of the education in bioethics is the development of taking-decisions skills, not only in the domains of knowledge and learning. Taking decisions requires practice in allowing for several considerations, not in a deductive way, but from a personal perspective. Therefore, the authors of this article consider that casuistics, as methodology of Bioethics pedagogy, is more appropriated than principialism. It is included here a brief introduction to casuistic pedagogy (AU).

Hospital Variability in Use of Adjuvant Chemotherapy for Patients with Stage 2 and 3 Colon Cancer.

BACKGROUND: Following oncologic resection, adjuvant chemotherapy is associated with decreased recurrence and improved survival in stage 3 colon cancer. However, there is controversy regarding its use in stage 2 colon cancer with high-risk features (tumor depth T4, poorly differentiated, positive margin, and/or inadequate lymph node retrieval). Consensus guidelines recommend no adjuvant chemotherapy in the absence of these high-risk features (low-risk stage 2). OBJECTIVE: This study aimed to examine hospital characteristics associated with poor risk-adjusted, stage-specific guideline compliance for the use of adjuvant chemotherapy in stage 3 and low-risk stage 2 colon cancer. DESIGN: This was a retrospective study. Stepwise logistic regression was used to identify patient and hospital factors associated with administration of adjuvant chemotherapy. Hierarchical regression models were used to calculate risk- and reliability-adjusted rates of chemotherapy use and observed-to-expected ratios in each hospital's stage 2 low-risk and stage 3 patients. SETTINGS: Data were retrieved from the National Cancer Database. PATIENTS: Patients selected were adults treated with oncologic resection for stage 2 to 3 colon cancer between 2004 and 2010. MAIN OUTCOME MEASURES: The primary outcome measured was receipt of adjuvant chemotherapy. RESULTS: A total of 167,345 patients were identified at 1395 hospitals. The mean overall risk-adjusted adjuvant chemotherapy rate was 65.3% for stage 3 and 15.2% for low-risk stage 2. Analysis of low outlier hospitals for stage 3 colon cancer, where adjuvant chemotherapy was underutilized, demonstrated that 62.8% were low-volume centers and 51.4% were community centers. Of high outlier hospitals for stage 2 low-risk disease, where adjuvant chemotherapy was overutilized, 87.2% were low-volume hospitals and 67.2% were community centers. LIMITATIONS: Selection bias and the inability to compare specific chemotherapy regimens were limitations of this study. CONCLUSIONS: Following oncologic resection, administration of adjuvant chemotherapy for low-risk stage 2 and stage 3 disease varies substantially among hospitals in the United States. Outlier hospitals were most likely to be low-volume community centers.

Impact of wildfire smoke in Buenos Aires, Argentina, on ocular surface / Efeitos da fumaça de incêndios na superfície ocular em Buenos Aires, Argentina

Purpose: To evaluate the acute impact of the wildfire smoke episode in 2008 on the ocular surface of subjects living in the Metropolitan Area of Buenos Aires (MABA). Methods: A total of 86 subjects were evaluated: Group 1 comprised patients from a public ophthalmology hospital (N=35) and Group 2 comprised healthy volunteers (N=51). All subjects answered a questionnaire on ocular symptoms and underwent ophthalmologic examination [bulbar conjunctival hyperemia, corneal fluorescein staining, rose bengal vital staining, tear break-up time (TBUT), Schirmer I test, tear lysozyme, and impression cytology] during and after the acute episode. Concentrations of carbon monoxide (CO), nitrogen dioxide (NO2), and particulate matter (PM) were measured before, during, and after the acute episode. Results: Both groups showed a statically significant increase in ocular symptoms and bulbar conjunctival hyperemia and a statically significant decrease in tear break-up time during the acute episode. Group 1 showed more severe symptoms and a statistically significant increase in fluorescein and rose bengal staining intensities during the acute episode. We found a significant negative correlation between ocular symptoms and tear break-up time. During the episode, the levels of CO, NO2, and particulate matter in MABA were four times higher than the usual average levels for the same period in 2007 and 2009. Conclusions: Increased air pollution from the burning of biomass is associated with a decrease in the stability of the tear film (TBUT), generating areas of ocular surface exposure that may be the cause of the increased feeling of irritation. Group 1 was more affected by not having a healthy ocular surface, and thus consulted an ophthalmologist. Cytological changes in the conjunctiva were not observed, which could be due to the short duration of the episode. .

Objetivo: Avaliar os efeitos agudos da fumaça do episódio de incêndio violento ocorrido em 2008, sobre a superfície ocular de sujeitos que vivem na Região Metropolitana de Buenos Aires (MABA). Métodos: Um total de 86 indivíduos foram avaliados: Grupo 1: pacientes de um hospital público de oftalmologia (N=35) e Grupo 2: voluntários saudáveis (N=51). Todos os participantes responderam a um questionário sobre os sintomas oculares e foram submetidos a exame oftalmológico (hiperemia conjuntival bulbar, teste de fluoresceína, corante rosa bengala, tempo de ruptura do filme lacrimal (TBUT), teste de Schirmer I, lisozima lacrimal e citologia de impressão) durante e após o episódio agudo. As concentrações de monóxido de carbono, dióxido de nitrogênio e partículas (PM) foram medidas antes, durante e após o episódio agudo. Resultados: Ambos os grupos apresentaram aumento estatisticamente significativo dos sintomas oculares, hiperemia conjuntival bulbar, e diminuição estatisticamente significativa no tempo de ruptura do filme lacrimal durante o episódio agudo. Grupo 1 apresentou maior intensidade dos sintomas e aumento estatisticamente significativo no teste de fluoresceína e rosa bengala durante o episódio agudo. Encontramos uma correlação negativa significativa entre os sintomas oculares e tempo de ruptura do filme lacrimal. Durante o episódio agudo de 2008, os níveis de CO, NO2 e PM na Região Metropolitana de Buenos Aires foram 4 vezes maiores do que os níveis médios habituais para o mesmo período de 2007 e 2009. Conclusões: O aumento da poluição do ar a partir da queima de biomassa está associado a uma diminuição da estabilidade do filme lacrimal (TBUT) gerando zonas da exposição da superfície ocular, que podem ser a causa do aumento da sensação de irritação. Grupo 1 foi mais afetado por não ter superfície ocular saudável e, portanto, consultaram um oftalmologista. Mudanças citológicas da conjuntiva não foram observadas e isso poderia ser devido ...

Perioperative cardiovascular care for patients undergoing noncardiac surgical intervention.

The field of perioperative medicine has garnered legitimacy during the past 3 decades. Adverse cardiovascular events in the perioperative period account for significant morbidity and mortality. Although testing patients preoperatively to detect ischemia and identify those who may benefit from modifications in care is a tempting strategy, risk assessment should account for posterior probability. Validated risk stratification tools, such as the Revised Cardiac Risk Index or the National Surgical Quality Improvement Program risk calculator, can assist in the identification of patients for whom preoperative noninvasive testing is justified and may change the plan of care. Furthermore, current guidelines emphasize that prophylactic coronary revascularization should not be performed exclusively for the purposes of reducing the risk of perioperative events. There has been enthusiasm for medical therapies that may reduce the risk of adverse cardiovascular events in the perioperative period. Current guidelines encourage the perioperative use of ß-blockade in patients already receiving such therapy and caution against initiating such therapy on the day of the surgical procedure. Reduction of morbidity and mortality in the perioperative period relies on an understanding of the myriad physiological perturbations in this period and thoughtful selection of patients for further testing and treatment.

Reliability of risk-adjusted outcomes for profiling hospital surgical quality.

IMPORTANCE: Quality improvement platforms commonly use risk-adjusted morbidity and mortality to profile hospital performance. However, given small hospital caseloads and low event rates for some procedures, it is unclear whether these outcomes reliably reflect hospital performance. OBJECTIVE: To determine the reliability of risk-adjusted morbidity and mortality for hospital performance profiling using clinical registry data. DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort study was conducted using data from the American College of Surgeons National Surgical Quality Improvement Program, 2009. Participants included all patients (N = 55,466) who underwent colon resection, pancreatic resection, laparoscopic gastric bypass, ventral hernia repair, abdominal aortic aneurysm repair, and lower extremity bypass. MAIN OUTCOMES AND MEASURES: Outcomes included risk-adjusted overall morbidity, severe morbidity, and mortality. We assessed reliability (0-1 scale: 0, completely unreliable; and 1, perfectly reliable) for all 3 outcomes. We also quantified the number of hospitals meeting minimum acceptable reliability thresholds (>0.70, good reliability; and >0.50, fair reliability) for each outcome. RESULTS: For overall morbidity, the most common outcome studied, the mean reliability depended on sample size (ie, how high the hospital caseload was) and the event rate (ie, how frequently the outcome occurred). For example, mean reliability for overall morbidity was low for abdominal aortic aneurysm repair (reliability, 0.29; sample size, 25 cases per year; and event rate, 18.3%). In contrast, mean reliability for overall morbidity was higher for colon resection (reliability, 0.61; sample size, 114 cases per year; and event rate, 26.8%). Colon resection (37.7% of hospitals), pancreatic resection (7.1% of hospitals), and laparoscopic gastric bypass (11.5% of hospitals) were the only procedures for which any hospitals met a reliability threshold of 0.70 for overall morbidity. Because severe morbidity and mortality are less frequent outcomes, their mean reliability was lower, and even fewer hospitals met the thresholds for minimum reliability. CONCLUSIONS AND RELEVANCE: Most commonly reported outcome measures have low reliability for differentiating hospital performance. This is especially important for clinical registries that sample rather than collect 100% of cases, which can limit hospital case accrual. Eliminating sampling to achieve the highest possible caseloads, adjusting for reliability, and using advanced modeling strategies (eg, hierarchical modeling) are necessary for clinical registries to increase their benchmarking reliability.

Issues in quality measurement: target population, risk adjustment, and ratings.

This review investigates three fundamental issues in health care performance measurement: selection of a homogeneous target population, risk adjustment, and assignment of quality rating categories. Many but not all organizations involved in quality measurement have adopted similar approaches to these important methodological issues. To illustrate the practical implications of different profiling strategies, we use The Society of Thoracic Surgeons' data to compare profiling results derived using prevailing analytical methodologies with those obtained from alternative approaches, exemplified by those of a well-known health care performance rating organization. We demonstrate the differences in provider classification that may result from these methodologic decisions.

A monitoring tool for performance improvement in plastic surgery at the individual level.

BACKGROUND: The assessment of performance in surgery is expanding significantly. Application of relevant frameworks to plastic surgery, however, has been limited. In this article, the authors present two robust graphic tools commonly used in other industries that may serve to monitor individual surgeon operative time while factoring in patient- and surgeon-specific elements. METHODS: The authors reviewed performance data from all bilateral reduction mammaplasties performed at their institution by eight surgeons between 1995 and 2010. Operative time was used as a proxy for performance. Cumulative sum charts and exponentially weighted moving average charts were generated using a train-test analytic approach, and used to monitor surgical performance. Charts mapped crude, patient case-mix-adjusted, and case-mix and surgical-experience-adjusted performance. RESULTS: Operative time was found to decline from 182 minutes to 118 minutes with surgical experience (p < 0.001). Cumulative sum and exponentially weighted moving average charts were generated using 1995 to 2007 data (1053 procedures) and tested on 2008 to 2010 data (246 procedures). The sensitivity and accuracy of these charts were significantly improved by adjustment for case mix and surgeon experience. CONCLUSIONS: The consideration of patient- and surgeon-specific factors is essential for correct interpretation of performance in plastic surgery at the individual surgeon level. Cumulative sum and exponentially weighted moving average charts represent accurate methods of monitoring operative time to control and potentially improve surgeon performance over the course of a career.

Impact of outcomes monitoring on innovation and risk in liver transplantation.

KEY POINTS: 1. The reporting of liver transplant center outcomes is required by the final rule of the Department of Health and Human Services. The reported patient and graft survival outcomes are risk-adjusted for specific donor and recipient factors, and the observed survival is compared to the expected survival. Both the Centers for Medicare and Medicaid Services and the Organ Procurement and Transplantation Network flag programs for corrective action when the observed survival is significantly less than the expected survival. Both agencies can take action up to the closure of a center. In the last 5 years, the Organ Procurement and Transplantation Network has not taken an adverse action that required the closure of a liver transplant center because of outcomes. 2. Center survey data suggest that centers may try to select donors and recipients to minimize poor outcomes. This strategy may not be effective if centers stop accepting donors or recipients according to factors that are included in the risk adjustment model. For example, limiting recipients to those less than 65 years old may improve the observed outcomes, but the expected outcomes will also improve because a recipient 65 years or older is included in the model's risk adjustment. 3. For factors such as cardiovascular risk that are not included in the model, it may be reasonable to exclude patients in an attempt to improve the observed outcomes without affecting the expected outcomes. Other examples of these types of factors are smoking, nutritional status, and donor liver biopsy findings. 4. Currently, there is no exemption for patients undergoing experimental protocols. Down-staging for hepatocellular carcinoma, transplantation for human immunodeficiency virus-positive recipients, and the use of left lobe grafts with inflow modification are relatively recent areas of innovation in liver transplantation. Because innovation is frequently associated with a learning curve and, therefore, poor outcomes, the inclusion of patients in innovative protocols potentially could lead to centers being subjected to an adverse action by the Organ Procurement and Transplantation Network or the Centers for Medicare and Medicaid Services. Active consideration is being given to the exclusion of patients in innovative protocols from center-specific outcomes.

Improved risk adjustment in public reporting: coronary artery bypass graft surgical site infections.

OBJECTIVE: The objective was to develop a new National Healthcare Safety Network (NHSN) risk model for sternal, deep incisional, and organ/space (complex) surgical site infections (SSIs) following coronary artery bypass graft (CABG) procedures, detected on admission and readmission, consistent with public reporting requirements. PATIENTS AND SETTING: A total of 133,503 CABG procedures with 4,008 associated complex SSIs reported by 293 NHSN hospitals in the United States. METHODS: CABG procedures performed from January 1, 2006, through December 31, 2008, were analyzed. Potential SSI risk factors were identified by univariate analysis. Multivariate analysis with forward stepwise logistic regression modeling was used to develop the new model. The c-index was used to compare the predictive power of the new and NHSN risk index models. RESULTS: Multivariate analysis independent risk factors included ASA score, procedure duration, female gender, age, and medical school affiliation. The new risk model has significantly improved predictive performance over the NHSN risk index (c-index, 0.62 and 0.56, respectively). CONCLUSIONS: Traditionally, the NHSN surveillance system has used a risk index to provide procedure-specific risk-stratified SSI rates to hospitals. A new CABG sternal, complex SSI risk model developed by multivariate analysis has improved predictive performance over the traditional NHSN risk index and is being considered for endorsement as a measure for public reporting.