Vascular surgery-related violations of the Emergency Medical Treatment and Labor Act.

OBJECTIVE: The Emergency Medical Treatment and Labor Act (EMTALA) is a federal law established in 1986 to ensure that patients who present to an emergency department receive medical care regardless of means. Violations are reported to the Centers for Medicare and Medicaid Services and can result in significant financial penalties. Our objective was to assess all available EMTALA violations for vascular-related issues. METHODS: EMTALA violations in the Centers for Medicare and Medicaid Services publicly available hospital violations database from 2011 to 2018 were evaluated for vascular-related issues. Details recorded were case type, hospital type, hospital region, reasons for violation, disposition, and mortality. RESULTS: There were 7001 patients identified with any EMTALA violation and 98 (1.4%) were deemed vascular related. The majority (82.7%) of EMTALA violations occurred at urban/suburban hospitals. Based on the Association of American Medical Colleges United States region, vascular-related EMTALA violations occurred in the Northeast (7.1%), Southern (56.1%), Central (18.4%), and Western (18.4%) United States. Case types included cerebrovascular (28.6%), aortic related (22.4%; which consisted of ruptured aortic aneurysms [8.2%], aortic dissection [11.2%], and other aortic [3.1%]), vascular trauma (15.3%), venous-thromboembolic (15.3%), peripheral arterial disease (9.2%), dialysis access (5.1%), bowel ischemia (3.1%), and other (1%) cases. Patients were transferred to another facility in 41.8% of cases. The most common reasons for violation were specialty refusal or unavailability (30.6%), inappropriate documentation (29.6%), misdiagnosis (18.4%), poor communication (17.3%), inappropriate triage (13.3%), failure to obtain diagnostic laboratory tests or imaging (12.2%), and ancillary or nursing staff issues (7.1%). The overall mortality was 19.4% and 31.6% died during the index emergency department visit. Vascular conditions associated with death were venous thromboembolism (31.6%), ruptured aortic aneurysm (21.1%), aortic dissection (21.1%), other aortic causes (10.5%), vascular trauma (10.5%), and bowel ischemia (5.3%). CONCLUSIONS: Although the frequency of vascular-related EMTALA violations was low, improvements in communication, awareness of vascular disease among staff, specialty staffing, and the development of referral networks and processes are needed to ensure that patients receive adequate care and that institutions are not placed at undue risk.

Risk assessment of significant upper extremity arteriovenous graft infection in the Vascular Quality Initiative.

OBJECTIVE: Infectious complications of arteriovenous grafts (AVGs) are a major source of morbidity. Our aim was to characterize contemporary risk factors for upper extremity AVG infection. METHODS: The Vascular Quality Initiative (2011-2018) was queried for all patients undergoing upper extremity AVG creation. AVG infection was classified as an infection treated with antibiotics, incision and drainage, or graft removal. Multivariable analyses were used to evaluate risk factors for short- and long-term AVG infection. RESULTS: Of 1758 upper extremity AVGs, 49 (2.8%) developed significant infection within 3 months, resulting in incision and drainage in 24% and graft removal in 76% of cases. None were managed with antibiotics alone in the study sample. Patients with significant AVG infection were more likely to be white, to be insured, to have a history of coronary artery bypass graft and intravenous (IV) drug use, to be undergoing a concomitant vascular procedure, and to be discharged on an anticoagulant. In multivariable analysis, significant AVG infection within 3 months was associated with IV drug use history (odds ratio [OR], 5; 95% confidence interval [CI], 1.75-14.3; P = .003), discharge to a health care facility (OR, 2.66; 95% CI, 1.07-6.63; P = .035), discharge on an anticoagulant (OR, 2.31; 95% CI, 1.13-4.72; P = .021), white race (OR, 2.3; 95% CI, 1.21-4.34; P = .011), and female sex (OR, 2.02; 95% CI, 1.06-3.85; P = .033). Kaplan-Meier analysis showed that freedom from graft site infection at 1 year was 96.4%. Longer term graft infection at 1 year was independently associated with IV drug use history (hazard ratio [HR], 1.98; 95% CI, 1.06-3.68; P = .032), initial discharge to a health care facility (HR, 1.88; 95% CI, 1.19-2.97; P = .007), and white race (HR, 1.64; 95% CI, 1.23-2.19; P = .001). CONCLUSIONS: Although significant AVG infection was uncommon in the Vascular Quality Initiative, the majority were treated with graft removal. In select high-risk patients, extra care should be taken and alternative forms of arteriovenous access may be considered.

Assessment of open operative vascular surgical experience among general surgery residents.

BACKGROUND: General surgeons have traditionally performed open vascular operations. However, endovascular interventions, vascular residencies, and work-hour limitations may have had an impact on open vascular surgery training among general surgery residents. We evaluated the temporal trend of open vascular operations performed by general surgery residents to assess any changes that have occurred. METHODS: The Accreditation Council for Graduate Medical Education's database was used to evaluate graduating general surgery residents' cases from 1999 to 2013. Mean and median case volumes were analyzed for carotid endarterectomy, open aortoiliac aneurysm repair, and lower extremity bypass. Significance of temporal trends were identified using the R(2) test. RESULTS: The average number of carotid endarterectomies performed by general surgery residents decreased from 23.1 ± 14 (11.6 ± 9 chief, 11.4 + 10 junior) cases per resident in 1999 to 10.7 ± 9 (3.4 ± 5 chief, 7.3 ± 6 junior) in 2012 (R(2) = 0.98). Similarly, elective open aortoiliac aneurysm repairs decreased from 7.4 ± 5 (4 ± 4 chief, 3.4 ± 4 junior) in 1999 to 1.3 ± 2 (0.4 ± 1 chief, 0.8 ± 1 junior) in 2012 (R(2) = 0.98). The number of lower extremity bypasses decreased from 21 ± 12 (9.5 ± 7 chief, 11.8 ± 9 junior) in 1999 to 7.6 ± 2.6 (2.4 ± 1.3 chief, 5.2 + 1.8 junior) in 2012 (R(2) = 0.94). Infrapopliteal bypasses decreased from 8.1 ± 3.8 (3.5 ± 2.2 chief, 4.5 ± 2.9 junior) in 2001 to 3 ± 2.2 (1 ± 1.6 chief, 2 ± 1.6 junior) in 2012 (R(2) = 0.94). CONCLUSIONS: General surgery resident exposure to open vascular surgery has significantly decreased. Current and future graduates may not have adequate exposure to open vascular operations to be safely credentialed to perform these procedures in future practice without advanced vascular surgical training.

Occurrence of "never events" after major open vascular surgery procedures.

OBJECTIVE: "Never events" refers to harmful hospital-acquired conditions that the Centers for Medicare and Medicaid Services identified in 2008 as largely preventable and that would no longer be reimbursed. Our goal was to identify the incidence, predictive factors, temporal trend, and associated consequences of never events after major open vascular surgery procedures. METHODS: The Nationwide Inpatient Sample (NIS) (2003-2011) was queried to identify never events applicable to vascular surgery patients, including air embolism, catheter-based urinary tract infections (UTIs), stage 3 and 4 pressure ulcers, falls/trauma, blood incompatibility, vascular catheter infections, complications of poor glucose control, retained foreign objects, and wrong-site surgery. We specifically evaluated open abdominal aortic aneurysm repair, carotid endarterectomy, and lower extremity bypass/femoral endarterectomy. Multivariable logistic regression was used to predict never events based on preoperative variables. Multivariable logistic and gamma regression models were used to study mortality, hospital length of stay (LOS), and charges. RESULTS: Never events were identified in 774 of 267,734 patients. The distribution of never events were falls/trauma (59%), pressure ulcers (19%), catheter-based UTI (9%), vascular catheter infection (6%), complications of poor glucose control (5%), and retained objects (4%). Rates of falls and catheter-based UTIs have increased since 2008. Multivariable predictors of any never event included lower extremity bypass, abdominal aortic aneurysm, weight loss, nonelective admission, paralysis, repair, congestive heart failure, altered mental status, renal failure, weekend admission, diabetes, female gender, and age. Race, insurance, hospital type, income level, geography, July to September admission, and other comorbidities were not predictive. After risk factor adjustment, never events were associated with increased perioperative mortality (odds ratio, 2.7; 95% confidence interval [CI], 1.5-34.8; P < .001), LOS (means ratio, 1.9; 95% CI, 1.7-2.0; P < .001), and total charges (means ratio, 1.7; 95% CI, 1.6-1.8; P < .001). CONCLUSIONS: Never events after major vascular surgery are associated with a number of perioperative factors and are predictive of increased charges, LOS, and mortality. Falls and catheter-based UTIs have increased in frequency since the Centers for Medicare and Medicaid Services announced that it would no longer reimburse for these complications. This study establishes baseline never event rates in the vascular surgery patient population and identifies high-risk patients to target for quality improvement.

The effect of anesthesia type on major lower extremity amputation in functionally impaired elderly patients.

OBJECTIVE: Patients undergoing major lower extremity amputations are at risk for a wide variety of perioperative complications. Elderly patients with any functional impairment have been shown to be at high risk for these adverse events. Our goal was to determine the association between the type of anesthesia-general anesthesia (GA) and regional/spinal anesthesia (RA)-on perioperative outcomes after lower extremity amputation in these elderly and functionally impaired patients. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) data set (2005-2012) was queried to identify all patients aged ≥75 years with partial or total functional impairment who underwent major lower extremity amputations. Propensity matching and multivariate analysis were performed to isolate the effect of anesthesia type. RESULTS: We identified 3260 patients (50% male), 2558 GA patients and 702 RA patients, who were a mean age of 82 years. Anatomic distribution was 59% above-the-knee and 41% below-the-knee amputations. Patients undergoing GA were more likely to have impaired sensorium (9% vs 6%; P = .035), be on anticoagulation or have a bleeding disorder (33% vs 17%; P < .001), have had a previous operation ≤30 days (16% vs 10%; P < .001), and be operated on by a nonvascular surgeon (16% vs 12%; P = .033). GA was associated with shorter anesthesia time to surgery (36 ± 48 vs 42 ± 49 minutes; P < .001) but a similar operative time (66 ± 33 vs 64 ± 33 minutes; P = .292) compared with RA. After propensity matching, rates of 30-day mortality (14% vs 12%; P = .135), postoperative myocardial infarction/cardiac arrest (2.9% vs 3.1%; P = .756), pulmonary complications (7.3% vs 6.7%; P = .632), stroke (0.7% vs 0.9%; P = .694), urinary tract infections (6.7% vs 6.5%; P = .887), and wound complications (7.6% vs 7.6%; P = .999) were similar in patients undergoing GA and RA, respectively. Median length of stay was similar in both groups (5 vs 5.5 days; P = .309). Multivariable analyses confirmed that anesthesia type did not significantly affect morbidity and mortality. CONCLUSIONS: The mode of anesthesia, GA vs RA, did not have significant effect on perioperative outcomes after major lower extremity amputation in the functionally impaired geriatric population. These findings provide an evidence base that will allow surgeons, anesthesiologists, and patients to make an informed decision about anesthesia type for their procedure.