The hidden burden of unplanned readmission after emergency general surgery.

BACKGROUND: There are no national studies of nonelective readmissions after emergency general surgery (EGS) diagnoses that track nonindex hospital readmission. We sought to determine the rate of overall and nonindex hospital readmissions at 30 and 90 days after discharge for EGS diagnoses, hypothesizing a significant portion would be to nonindex hospitals. METHODS: The 2013 to 2014 Nationwide Readmissions Database was queried for all patients 16 years or older admitted with an EGS primary diagnosis and survived index hospitalization. Multivariable logistic regression identified risk factors for nonelective 30- and 90-day readmission to index and nonindex hospitals. RESULTS: Of 4,171,983 patients, 13% experienced unplanned readmission at 30 days. Of these, 21% were admitted to a nonindex hospital. By 90 days, 22% experienced an unplanned readmission, of which 23% were to a nonindex hospital. The most common reason for readmission was infection. Publicly insured or uninsured patients accounted for 67% of admissions and 77% of readmissions. Readmission predictors at 30 days included leaving against medical advice (odds ratio [OR], 2.51 [2.47-2.56]), increased length of stay (4-7 days: OR, 1.42 [1.41-1.43]; >7 days: OR, 2.04 [2.02-2.06]), Charlson Comorbidity Index ≥2 (OR, 1.72 [1.71-1.73]), public insurance (Medicare: OR, 1.45 [1.44-1.46]; Medicaid: OR, 1.38 [1.37-1.40]), EGS patients who fell into the "Other" surgical category (OR, 1.42 [1.38-1.48]), and nonroutine discharge. Risk factors for readmission remained consistent at 90 days. CONCLUSION: Given that nonindex hospital EGS readmission accounts for nearly a quarter of readmissions and often related to important benchmarks such as infection, current EGS quality metrics are inaccurate. This has implications for policy, benchmarking, and readmission reduction programs. LEVEL OF EVIDENCE: Epidemiological study, level III.

Leaving Against Medical Advice After Emergency General Surgery: Avoiding a Two-Hit Effect.

BACKGROUND: Emergency general surgery has higher adverse outcomes than elective surgery. Patients leaving the hospital against medical advice (AMA) have a greater risk for readmission and complications. We sought to identify clinical and demographic characteristics along with hospital factors associated with leaving AMA after EGS operations. METHODS: A retrospective review of the Nationwide Inpatient Sample was performed. All patients who underwent an EGS procedure accounting for >80% of the burden of EGS-related inpatient resources were identified. 4:1 propensity score analysis was conducted. Regression analyses determined predictive factors for leaving AMA. RESULTS: 546,856 patients were identified. 1085 (0.2%) patients who underwent EGS left AMA. They were more likely to be men (59% versus 42%), younger (median age 51 y, IQR [37.61] versus 54, IQR [38.69]), qualify for Medicaid (26% versus 13%) or be self-pay (17% versus 9%), and be within the lowest quartile median household income (40% versus 28%) (all P < 0.05). After applying 4:1 propensity score matching, individuals who were self-pay (OR 3.15, 95% CI 2.44-4.06) or insured through Medicare (OR 2.75, 95% CI 2.11-3.57) and Medicaid (OR 3.58, 95% CI 2.83-4.52) had increased odds of leaving AMA compared with privately insured patients. In addition, history of alcohol (OR 2.21, 95% CI 1.65-2.98), drug abuse (OR 4.54, 95% CI 3.23-6.38), and psychosis (OR 2.31, 95% CI 1.65-3.23) were associated with higher likelihood for leaving AMA. CONCLUSIONS: Patients undergoing EGS have a high risk of complications, and leaving AMA further increases this risk. Interventions to encourage safe discharge encompassing surgical, psychiatric, and socioeconomic factors are warranted to prevent a two-hit effect and compound postoperative risk.

Predictors of mortality and cost among surgical patients requiring rapid response team activation.

Background: Prior studies of rapid response team (RRT) implementation for surgical patients have demonstrated mixed results with respect to reductions in poor outcomes. The aim of this study was to identify predictors of in-hospital mortality and hospital costs among surgical inpatients requiring RRT activation. Methods: We analyzed data prospectively collected from May 2012 to May 2016 at The Ottawa Hospital. We included patients who were at least 18 years of age, who were admitted to hospital, who received either preoperative or postoperative care, and and who required RRT activation. We created a multivariable logistic regression model to describe mortality predictors and a multivariable generalized linear model to describe cost predictors. Results: We included 1507 patients. The in-hospital mortality rate was 15.9%. The patient-related factors most strongly associated with mortality included an Elixhauser Comorbidity Index score of 20 or higher (odds ratio [OR] 3.60, 95% confidence interval [CI] 1.96-6.60) and care designations excluding admission to the intensive care unit and cardiopulmonary resuscitation (OR 3.52, 95% CI 2.25-5.52). The strongest surgical predictors included neurosurgical admission (OR 2.09, 95% CI 1.17-3.75), emergent surgery (OR 2.04, 95% CI 1.37-3.03) and occurrence of 2 or more operations (OR 1.73, 95% CI 1.21-2.46). Among RRT factors, occurrence of 2 or more RRT assessments (OR 2.01, 95% CI 1.44-2.80) conferred the highest mortality. Increased cost was strongly associated with admitting service, multiple surgeries, multiple RRT assessments and medical comorbidity. Conclusion: RRT activation among surgical inpatients identifies a population at high risk of death. We identified several predictors of mortality and cost, which represent opportunities for future quality improvement and patient safety initiatives.

Contexte: Les études sur la mobilisation d'équipes d'intervention rapide (EIR) auprès de patients en chirurgie ont donné des résultats mitigés quant à la réduction des issues négatives. La présente étude visait à déterminer les facteurs prédictifs de coûts pour les hôpitaux et de mortalité chez les patients en chirurgie nécessitant la mobilisation d'une EIR. Méthodes: Nous avons analysé des données recueillies de manière prospective de mai 2012 à mai 2016 à l'Hôpital d'Ottawa. Nous avons inclus les patients hospitalisés de 18 ans et plus qui ont reçu des soins préopératoires ou postopératoires et qui ont nécessité l'intervention d'une EIR. Nous avons ensuite créé un modèle de régression logistique multivariée pour décrire les facteurs prédictifs de mortalité et un modèle linéaire généralisé multivarié pour décrire les facteurs prédictifs de coûts. Résultats: Nous avons retenus 1507 patients. Le taux global de mortalité à l'hôpital était de 15,9 %. Les principaux facteurs de mortalité liés au patient étaient un indice de comorbidité d'Elixhauser supérieur ou égal à 20 (rapport de cotes [RC] 3,60, intervalle de confiance [IC] à 95 % 1,96­6,60) et des objectifs de soins excluant l'admission à l'unité des soins intensifs et la réanimation cardiorespiratoire (RC 3,52, IC à 95 % 2,25­5,52). Les principaux facteurs prédictifs liés aux interventions sont l'admission en neurochirurgie (RC 2,09, IC à 95 % 1,17­3,75), l'intervention chirurgicale d'urgence (RC 2,04, IC à 95 % 1,37­3,03) et le fait d'avoir subi au moins 2 opérations (RC 1,73, IC à 95 % 1,21­2,46). Parmi les facteurs liés aux EIR, la tenue d'au moins 2 évaluations par l'EIR s'accompagnait du mortalité le plus élevé (RC 2,01, IC à 95 % 1,44­2,80). L'augmentation des coûts était étroitement associée au service d'admission, aux interventions chirurgicales multiples, aux évaluations multiples par l'EIR et à la comorbidité médicale. Conclusion: La mobilisation d'EIR auprès de patients en chirurgie permet de mettre en évidence une population à risque élevé de décès. Nous avons découvert plusieurs facteurs prédictifs de mortalité et de coûts, dont on pourra se servir pour améliorer la qualité des soins et la sécurité des patients.

A comparison of the new, parsimonious tool Surgical Risk Preoperative Assessment System (SURPAS) to the American College of Surgeons (ACS) risk calculator in emergency surgery.

BACKGROUND: The Surgical Risk Preoperative Assessment System accurately predicts postoperative complications in elective surgery using only 8 preoperative variables, but its performance in emergency surgery has not been evaluated. We hypothesized that the Surgical Risk Preoperative Assessment System accurately predicts postoperative complications in emergency surgery and compared its performance to that of the American College of Surgeons Surgical Risk Calculator. METHODS: We calculated the Surgical Risk Preoperative Assessment System and the American College of Surgeons Surgical Risk Calculator risk estimates in a random sample of 1,010 emergency surgery cases from the American College of Surgeons National Surgical Quality Improvement Program 2014 to 2017 database. Risk estimates were compared with known outcomes. Analyses included the Hosmer-Lemeshow goodness of fit graphs and P values, c-indexes, and Brier scores. RESULTS: Results were similar between the Surgical Risk Preoperative Assessment System and the American College of Surgeons Surgical Risk Calculator for mortality, urinary tract infection, cardiac, venous thromboembolism, and renal complications. The American College of Surgeons Surgical Risk Calculator underestimated morbidity compared with the Surgical Risk Preoperative Assessment System (16.04% American College of Surgeons Surgical Risk Calculator vs 24.88% Surgical Risk Preoperative Assessment System vs 24.3% observed). Both calculators overestimated readmission (7.67% American College of Surgeons Surgical Risk Calculator vs 5.18% Surgical Risk Preoperative Assessment System vs 4.1% observed). CONCLUSION: Both calculators predicted mortality, urinary tract infection, cardiac, venous thromboembolism, and renal complications well, but readmissions relatively poorly. The Surgical Risk Preoperative Assessment System estimated overall morbidity accurately, while the American College of Surgeons Surgical Risk Calculator underestimated this risk.

Incidence and Cost of Deep Vein Thrombosis in Emergency General Surgery Over 15 Years.

BACKGROUND: Deep vein thromboses (DVTs) are a significant sequela of surgery and are associated with significant of morbidity and mortality in the United States. Operative emergency general surgery (EGS) cases have been demonstrated to have a greater burden of DVT than other types of surgery. MATERIALS AND METHODS: DVT in EGS cases were identified from the National Inpatient Sample-Healthcare Cost and Utilization Project database from 2001 to 2015 Q3 based on ICD-9 code specification. National incidence of DVT in EGS was calculated using the National Inpatient Sample-Healthcare Cost and Utilization Project sampling methodology, and propensity score matching was used to assess costs associated with DVT. RESULTS: Among 15,148,352 sample-weighted hospitalizations, 0.623% (94,392) experienced DVT. Incidence of DVT was greatest in GI ulcer surgery (1.705%) and lowest in appendectomy (0.095%). Patients with a perioperative DVT incurred $22,301 more in hospital-related costs than their counterparts who did not have a DVT. Although rates of DVT remained stable over the period analyzed, DVT-associated costs increased at a 2.09% annual rate in excess of inflation during the period analyzed. This increase in costs was most significant for laparotomy, which increased at a rate of 8.09% annually. CONCLUSIONS: DVT continues to be a significant burden on resources in EGS in spite of efforts with DVT prophylaxis. Considering the increase in costs and little change in incidence, further research on cost-effective management of DVT in EGS is warranted.

Electronic Medical Record Versus Bedside Assessment: How to Evaluate Frailty in Trauma and Emergency General Surgery Patients?

BACKGROUND: Screening patients for frailty is traditionally done at the bedside. However, recent electronic medical record (EMR)-based, comorbidity-focused frailty assessments have been developed. Our objective was to determine how a common bedside frailty assessment, the trauma and emergency surgery (TEGS) frailty index (FI), compares to an EMR-based frailty assessment in predicting geriatric TEGS outcomes. MATERIALS AND METHODS: We retrospectively reviewed our quality improvement project database consisting of TEGS patients ≥ 65 y old. Patients were screened with the TEGS FI, a 15-question bedside assessment, including comorbidities, physical activity, emotional health, and nutrition. Six of 15 items were retrievable from the enterprise data warehouse (EDW), storing all EMR data from Northwestern Memorial Hospital, and use to calculate the EDW frailty score. Patient characteristics and outcomes were compared between different groups. RESULTS: Two hundred thirty-six geriatric TEGS patients were included, of which 75 (31.8%) were TEGS FI frail and 60 (25.4%) were EDW frail. TEGS FI frail patients had increased length of stay (LOS), loss of independence (LOI), and complications compared to TEGS FI nonfrail patients. EDW frail patients had higher LOS and complications than EDW nonfrail patients but similar LOI. TEGS FI and EDW frail patients had similar outcomes except TEGS FI-only patients more often have LOI. CONCLUSIONS: Bedside frailty assessments and EMR-based assessments are both effective in identifying geriatric TEGS patients at risk for increased LOS and complications. However, bedside frailty screening was better at identifying patients who have LOI and may be a more appropriate choice when screening for frailty.

The Impact of Income on Emergency General Surgery Outcomes in Urban and Rural Areas.

BACKGROUND: Emergency general surgery (EGS) accounts for more than 2 million U.S. hospital admissions annually. Low-income EGS patients have higher rates of postoperative adverse events (AEs) than high-income patients. This may be related to health care segregation (a disparity in access to high-quality centers). The emergent nature of EGS conditions and the limited number of EGS providers in rural areas may result in less health care segregation and thereby less variability in EGS outcomes in rural areas. The objective of this study was to assess the impact of income on AEs for both rural and urban EGS patients. MATERIALS AND METHODS: The National Inpatient Sample (2007-2014) was queried for patients receiving one of 10 common EGS procedures. Multivariate regression models stratified by income quartiles in urban and rural cohorts adjusting for sociodemographic, clinical, and other hospital-based factors were used to determine the rates of surgical AEs (mortality, complications, and failure to rescue [FTR]). RESULTS: 1,687,088 EGS patients were identified; 16.60% (n = 280,034) of them were rural. In the urban cohort, lower income quartiles were associated with higher odds of AEs (mortality OR, 1.21 [95% CI, 1.15-1.27], complications, 1.07 [1.06-1.09]; FTR, 1.17 [1.10-1.24] P < 0.001). In the rural context, income quartiles were not associated with the higher odds of AE (mortality OR, 1.14 [0.83-1.55], P = 0.42; complications, 1.06 [0.97-1,16], P = 1.17; FTR, 1.12 [0.79-1.59], P = 0.52). CONCLUSIONS: Lower income is associated with higher postoperative AEs in the urban setting but not in a rural environment. This socioeconomic disparity in EGS outcomes in urban settings may reflect health care segregation, a differential access to high-quality health care for low-income patients.

[Evaluation of effectiveness of corrective measures arising from incident notifications in a paediatric emergency department]. / Evaluación de la efectividad de acciones correctivas derivadas de la notificación de incidentes en urgencias pediátricas.

OBJECTIVE: To analyse the effectiveness of corrective measures arising from the analysis of safety incident notifications in the Paediatric Emergency Unit. METHODS: A quasi-experimental, prospective, and single-centre study was carried out between 2015 and 2018. In the first phase, incidents notified throughout one year were analysed. Corrective measures were then implemented for 5 specific kinds of incidents. These incidents were finally compared to those notified within 12 months after the implementation of those measures. Results were expressed as relative risk and relative risk reduction. RESULTS: A total of 1587 safety incidents were notified (0.9% of patients treated) between January 2015 and December 2017. After implementation of corrective measures, there was a decrease in all kinds of incidents notifications analysed. The incidents related to patient identification were reduced by 60.9% (RR 0.39, 95% CI; 0.25-0.60), and those regarding communication between professionals were reduced by 74.5% (RR 0.25, 95% CI; 0.12-0.55). Incidents related to sedation and analgesic procedures totally disappeared. No significant reduction was found in incidents concerning the triage system, or in those related to rapid intravenous rehydration procedures. CONCLUSIONS: The implementation of improvement actions arising from the analysis of voluntary notification of incidents is an effective strategy to improve patient effective strategy to improve.

A Randomized Controlled Trial of a Citywide Emergency Department Care-Coordination Program to Reduce Prescription Opioid-Related Visits: An Economic Evaluation.

BACKGROUND: Care provided in the emergency department (ED) can cost up to five times as much as care received for comparable diagnoses in alternative settings. Small groups of patients, many of whom suffer from an opioid use disorder, often account for a large proportion of total ED visits. We recently conducted, and demonstrated the effectiveness of, the first randomized controlled trial of a citywide ED care-coordination program intending to reduce prescription-opioid-related ED visits. All EDs in the metropolitan study area were connected to a Web-based information exchange system. OBJECTIVE: The objective of this article was to perform an economic evaluation of the 12-month trial from a third-party-payer perspective. METHODS: We modeled the person-period monthly for the 12-month observation period, and estimated total treatment costs and return on investment (ROI) with regard to cost offsets, over time, for all visits where the patient was admitted to and discharged from the ED. RESULTS: By the end of month 4, the mean cumulative cost differential was significantly lower for intervention relative to treatment-as-usual participants (-$1370; p = 0.03); this figure climbed to -$3200 (p = 0.02) by the end of month 12. The ROI trended upward throughout the observation period, but failed to reach statistical significance by the end of month 12 (ROI = 3.39, p = 0.07). CONCLUSION: The intervention produced significant cost offsets by the end of month 4, which continued to accumulate throughout the trial; however, ROI was not significant. Because the per-patient administrative costs of the program are incurred at the time of enrollment, our results highlight the importance of future studies that are able to follow participants for a period beyond 12 months to more accurately estimate the program's ROI.

Sleep-disordered breathing and postoperative outcomes after bariatric surgery: analysis of the nationwide inpatient sample.

BACKGROUND: Sleep-disordered breathing (SDB), also known as obstructive sleep apnea (OSA), has been increasingly recognized as a possible risk factor for adverse perioperative outcomes in non-bariatric surgeries. However, the impact of SDB on postoperative outcomes in patients undergoing bariatric surgery remains less clearly defined. We hypothesized that SDB would be independently associated with worse postoperative outcomes. METHODS: Data were obtained from the Nationwide Inpatient Sample database and included a total of 91,028 adult patients undergoing bariatric surgeries from 2004 to 2008. The primary outcomes were in-hospital death, total charges, and length of stay. There were two secondary outcomes of interest: respiratory and cardiac complications. Regression models were fitted to assess the independent association between SDB and the outcomes of interest. RESULTS: SDB was independently associated with decreased mortality (OR = 0.34, 95% CI = 0.23-0.50, p < 0.001), total charges (-$869, p < 0.001), and length of stay (-0.25 days, p < 0.001). SDB was independently associated with significantly increased odds ratio of emergent endotracheal intubation (OR = 4.35, 95% CI = 3.97-4.77, p < 0.001), noninvasive ventilation (OR = 14.12, 95% CI = 12.09-16.51, p < 0.001), and atrial fibrillation (OR = 1.25, 95% CI = 1.11-1.41, p < 0.001). Emergent intubation occurred significantly earlier in the postoperative course in patients with SDB. Although non-SDB patients had an overall lower risk of emergent intubation compared to SDB patients, their outcomes were significantly worse when they did get emergently intubated. CONCLUSIONS: In this large nationally representative sample, despite the increased association of SDB/OSA with postoperative cardiopulmonary complications, the diagnosis of SDB/OSA was negatively, rather than positively, associated with in-hospital mortality and resource use.

Adverse event rates as measures of hospital performance.

OBJECTIVES: Adverse event or complication rates are increasingly advocated as measures of hospital quality and performance. Objective of this study is to analyse patient-complexity adjusted adverse events rates to compare the performance of hospitals in Victoria, Australia. We use a unique hospital dataset that routinely records adverse events which arise during the admission. We identify hospitals with below or above average performance in comparison to their peers, and show for which types of hospitals risk adjusting makes biggest difference. METHODS: We estimate adverse event rates for 87,790 elective and 43,771 emergency episodes in 34 public hospitals over the financial year 2005/06 with a complementary log-log model, using patient level administrative hospital data and controlling for patient complexity with a range of covariates. RESULTS: Teaching hospitals have average risk-adjusted adverse event rates of 24.3% for elective and 19.7% for emergency surgical patients. Suburban and rural hospitals have lower rates of 17.4% and 17%, and 16.1% and 15.7%, respectively. Selected non-teaching hospitals have relatively high rates, in particular hospitals in rural and socially disadvantaged areas. Risk adjustment makes a significant difference to most hospitals. CONCLUSION: We find comparably high adverse events rates for surgical patients in Australian hospitals, possibly because our data allow identification of a larger number of adverse events than data used in previous studies. There are marked variations in adverse event rates across hospitals in Victoria, even after risk adjusting. We discuss how policy makers could improve quality of care in Australian hospitals.

Time-of-day effects on surgical outcomes in the private sector: a retrospective cohort study.

BACKGROUND: Surgical care is delivered around the clock. Elective cases within the Veterans Affairs health system starting after 4 pm appear to have an elevated risk of morbidity, but not mortality, compared with earlier cases. The relationship between operation start time and patient outcomes is not described in private-sector patients or for emergency cases. STUDY DESIGN: We performed a retrospective cohort study of 56,920 general and vascular surgical procedures performed from October 2001 through September 2004, and entered into the National Surgical Quality Improvement Program database. Operation start time was the independent variable of interest. Random effects, hierarchical logistic regression models adjusted for patient, operative, and facility characteristics. Two independent models determined associations between start time and morbidity or mortality. Subset analysis was performed for emergency and nonemergency cases. RESULTS: After adjustment for patient and procedure characteristics, mortality had a moderately strong association with start time, but only for nonemergency cases starting 9:30 pm to 7:30 am (odds ratio = 1.752; p = 0.028; reference 7:30 am to 9:30 am). As for morbidity, after adjustment, operations starting 9:30 am to 1:30 pm and 5:30 pm to 9:30 pm were associated with a weakly elevated risk of morbidity, but those starting 9:30 pm to 7:30 am demonstrated a strong effect on morbidity (odds ratio = 1.32; p < 0.0001). Subgroup analysis showed this effect was largely a result of elevated risk of morbidity in emergency cases from this overnight time period (odds ratio = 1.48; p = 0.001). CONCLUSIONS: Surgical start times are associated with risk-adjusted patient outcomes. In terms of facility operations management and resource allocation, consideration should be given to the capacity to accommodate cases with differences in risk during different time periods.

Splinting versus casting of "torus" fractures to the distal radius in the paediatric patient presenting at the emergency department (ED): a literature review.

AIM: To compare outcomes regarding splinting versus casting of paediatric torus fractures in the ED with the aim of establishing the preferred treatment. METHODS: Evidence was collated using electronic databases; Pubmed, Ovid, Medline and Cochrane library. Search terms included [torus fractures; buckle fractures; splinting distal radius fractures; paediatric wrist fractures; paediatric forearm fractures/injuries; cast versus splint]. Searches identified papers published between 1984 and June 2008. RESULTS: The review demonstrated that children with removable splints preferred them to casts, in terms of improved physical functioning and lower pain scores reported after initial injury than those with casts. Children demonstrated this by using their wrists in the first week after injury to shower and bathe more easily. The cast group reported unscheduled visits to ED due to problems with the cast, such as discomfort or re-application of the cast from getting it wet. Using a splint will have considerable economic implications, money was found to be saved in terms of time and resource management. Radiographs taken at 4 weeks in both the cast and splint group confirmed that all fractures healed without significant change in alignment, suggesting that neither clinical nor radiographic follow-up is necessary for injury. CONCLUSION: Torus splints in all the studies were consistently better than plaster immobilisation in terms of clinical outcome, patient preference and cost, with the exceptions of young children or children with special needs who can easily remove the device. Splinting torus fractures may reduce cost, time and resource management if used instead of casting in the ED.

Model for end-stage liver disease score versus Child score in predicting the outcome of surgical procedures in patients with cirrhosis.

AIM: To determine factors affecting the outcome of patients with cirrhosis undergoing surgery and to compare the capacities of the Child-Turcotte-Pugh (CTP) and model for end-stage liver disease (MELD) score to predict that outcome. METHODS: We reviewed the charts of 195 patients with cirrhosis who underwent surgery at two teaching hospitals over a five-year period. The combined endpoint of death or hepatic decompensation was considered to be the primary endpoint. RESULTS: Patients who reached the endpoint had a higher MELD score, a higher CTP score and were more likely to have undergone an urgent procedure. Among patients undergoing elective surgical procedures, no statistically significant difference was noted in the mean MELD (12.8 +/- 3.9 vs 12.6 +/- 4.7, P = 0.9) or in the mean CTP (7.6 +/- 1.2 vs 7.7 +/- 1.7, P = 0.8) between patients who reached the endpoint and those who did not. Both mean scores were higher in the patients reaching the endpoint in the case of urgent procedures (MELD: 22.4 +/- 8.7 vs 15.2 +/- 6.4, P = 0.0007; CTP: 9.9 +/- 1.8 vs 8.5 +/- 1.8, P = 0.008). The performances of the MELD and CTP scores in predicting the outcome of urgent surgery were only fair, without a significant difference between them (AUC = 0.755 +/- 0.066 for MELD vs AUC = 0.696 +/- 0.070 for CTP, P = 0.3). CONCLUSION: The CTP and MELD scores performed equally, but only fairly in predicting the outcome of urgent surgical procedures. Larger studies are needed to better define the factors capable of predicting the outcome of elective surgical procedures in patients with cirrhosis.

Medication errors associated with code situations in U.S. hospitals: direct and collateral damage.

A retrospective analysis of 842 medication errors related to code situations revealed that "collateral damage" errors accounted for 74% of all code-related errors, whereas 21% involved patients directly experiencing codes.

Tap water for irrigation of lacerations.

This study was designed to compare the infection rates of simple lacerations irrigated with tap water versus sterile normal saline before repair. Patients with simple lacerations to an extremity that were less than 8 hours from injury were prospectively enrolled. Exclusions from the study were: dog bites, hand lacerations, immunocompromised patients, and those on antibiotics at the time of injury. Patients who qualified were randomized to receive tap water or normal saline for wound irrigation. Before and after irrigation, wound cultures were obtained. After the procedure was complete, patients were scheduled for a 48 hour follow-up wound check. A total of 46 patients were enrolled in the study. Twenty-four patients were randomized to the normal saline group and 21 were assigned to receive tap water irrigation. There were 2 infected lacerations in both the tap water and normal saline groups. The organisms cultured from the wounds in both groups were similar and there was no difference in colony counts when tap water was used. The use of tap water for the irrigation of lacerations does not result in the growth of unusual organisms or increase the colony counts of organisms. Wound infection rates were the same in both groups. This pilot study suggests that the use of tap water for irrigation of wounds may be safe. Further validation is necessary.

Evaluation of error in medicine: application of a public health model.

A case of a chest tube placed on the wrong side during a trauma resuscitation in the emergency department is presented as an example of medical injury. Two traditional models, the legal model and the managerial model, are described and their application to medical injury discussed. A new public health model is then applied to the case example as a more effective way to address medical injury. The public health model addresses the injury event rather than the error itself using Haddon's matrix as a framework. Pre-event, event, and post-event phases are examined to find the weakest link, where intervention has the highest likelihood of successfully preventing future injuries.

Risk management in the care of medical emergencies after referral to hospital.

An analysis of 40 medico-legal claims arising from the care of patients admitted as medical emergencies showed an excess of young patients (median age 45 years) but equal numbers of men and women. Twenty-nine patients died; with optimal management, 20 of these patients would have had a good chance of long-term survival. Of the 11 who survived, 3 were left with serious neurological deficits and 3 underwent intestinal resections that could have been avoided. Further analysis revealed probable defects in the organisation of care including: inadequate input from experienced clinicians; insufficient use of specialists; incorrect interpretation of radiographs and laboratory tests; and inadequate assessment of patients before discharge from hospital. It is suggested that there is an urgent need to collect and analyse data regarding adverse events in hospital medical practice in order to develop optimal organisational structures for the care of patients presenting as emergencies.