Combining the ASA Physical Classification System and Continuous Intraoperative Surgical Apgar Score Measurement in Predicting Postoperative Risk.

The surgical Apgar score predicts major 30-day postoperative complications using data assessed at the end of surgery. We hypothesized that evaluating the surgical Apgar score continuously during surgery may identify patients at high risk for postoperative complications. We retrospectively identified general, vascular, and general oncology patients at Vanderbilt University Medical Center. Logistic regression methods were used to construct a series of predictive models in order to continuously estimate the risk of major postoperative complications, and to alert care providers during surgery should the risk exceed a given threshold. Area under the receiver operating characteristic curve (AUROC) was used to evaluate the discriminative ability of a model utilizing a continuously measured surgical Apgar score relative to models that use only preoperative clinical factors or continuously monitored individual constituents of the surgical Apgar score (i.e. heart rate, blood pressure, and blood loss). AUROC estimates were validated internally using a bootstrap method. 4,728 patients were included. Combining the ASA PS classification with continuously measured surgical Apgar score demonstrated improved discriminative ability (AUROC 0.80) in the pooled cohort compared to ASA (0.73) and the surgical Apgar score alone (0.74). To optimize the tradeoff between inadequate and excessive alerting with future real-time notifications, we recommend a threshold probability of 0.24. Continuous assessment of the surgical Apgar score is predictive for major postoperative complications. In the future, real-time notifications might allow for detection and mitigation of changes in a patient's accumulating risk of complications during a surgical procedure.

Surgical Apgar score is associated with myocardial injury after noncardiac surgery.

STUDY OBJECTIVE: To assess the impact of intraoperative hemodynamics in the development of perioperative myocardial infarction (MI) and myocardial ischemia after noncardiac surgery. DESIGN: Single-center retrospective cohort study of surgical patients from 2007 to 2012. SETTING: Postanesthesia care unit, intensive care unit, and medical-surgical ward at an academic tertiary medical center. PATIENTS: A total of 46,799 adult noncardiac, nonthoracic surgery patients, for which 2290 peak cardiac troponin (cTn) levels were available. MEASUREMENTS: The 10-point Surgical Apgar Score (SAS) was calculated from intraoperative heart rate, blood pressure, and blood loss. Peak troponin (cTn) levels, hospital length of stay, 7- and 30-day postoperative mortality, patient demographics, and prior medical conditions were gathered. Troponin leak was defined as cTn-I 0.6 to 1.5 ng/mL or cTn-T 0.1 to 0.3 ng/mL; perioperative MI criteria were cTn-I greater than 1.5 ng/mL or cTn-T greater than 0.30 ng/mL. MAIN RESULTS: Of 46,799 noncardiac surgical cases, 209 (0.4%) and 192 (0.4%) suffered cTn leak and MI, respectively. Low SAS (0-4) was associated with increased risk of cTn leak and perioperative MI (univariate odds ratio, 2.76 and 2.06; 95% confidence interval, 2.20-3.45 and 1.57-2.70, respectively). In multivariable analysis, Surgical Apgar Score, age 65 years or older, American Society of Anesthesiologists physical status greater than or equal to III, emergency surgery, history of MI or hypertension, prolonged intraoperative tachycardia (heart rate >100 beats/min for >59 minutes), and prolonged hypotension (mean arterial pressure <40 mm Hg for >2 minutes) were independently associated with cTn leak and perioperative MI. CONCLUSIONS: Low SAS scores (0-4) may be associated with cTn elevation after noncardiac surgery. SAS-based risk stratification may guide perioperative cTn surveillance in lieu of routine postoperative screening.

Measuring and Improving First Case On-Time Starts and Analysis of Factors Predicting Delay in Neurosurgical Operating Rooms.

BACKGROUND: We undertook an operating room (OR) process improvement project to increase first case on-time starts (FCOTS) in the neurosurgical ORs at a tertiary care academic medical center. We engaged the neurosurgical perioperative team which included neurosurgeons, neuroanesthesiologists, and nurses in a shared goal of improving FCOTS. METHODS: Our project involved hiring a new service manager and a focused shared effort on improving FCOTS. After project completion, we conducted a retrospective analysis of FCOTS in 6 neurosurgical ORs. If patients were not in the OR within 5 minutes of scheduled start time, it was considered a late start. Factors predicting delayed start were also identified. During the same period, first cases performed outside the neurosurgical ORs served as a control group. RESULTS: A total of 2328 elective neurosurgical cases were evaluated. The baseline FCOTS from November 2009 to March 2010 was 33%. The first performance shift occurred during March 2010 to January 2011 when FCOTS increased to 44%. In the second performance shift between January 2011 and November 2011 during the implementation phase of this quality improvement project, FCOTS rose to 68% and has continued to increase. Multivariate logistic regression analysis identified the following as significant predictors of delayed start: female sex (odds ratio [OR]=0.771; 95% confidence interval [CI], 0.599-0.943), certified registered nurse anesthetists on the case (OR=0.750; 95% CI, 0.576-0.924), cases done on Friday (OR=0.551; 95% CI, 0.312-0.791), and American Society of Anesthesiologists status IV (OR=0.530; 95% CI, 0.157-0.903). CONCLUSION: The quality improvement project, which was implemented in 2 phases, successfully increased the FCOTS rate in our neurosurgical ORs from 33% to 68%.

Perceptions of physical activity and motivational interviewing among rural African-American women with type 2 diabetes.

PURPOSE: Motivational interviewing (MI), a patient-centered behavioral counseling style, is a common behavioral intervention strategy. Because intervention outcomes are highly dependent on patient responsiveness to intervention strategy, we evaluated MI perceptions among rural African American women with type 2 diabetes before a physical activity intervention. METHODS: Four moderator-led focus groups were conducted with patients aged 21-50 years who had never participated in a MI intervention and who receive diabetes care in a rural community health center. Patients were asked to share their perceptions of an MI consultation after viewing a DVD-based example. They were also asked to discuss their physical activity perceptions and readiness. A comprehensive content analysis based on grounded theory was performed by two raters in order to identify main themes. MAIN FINDINGS: Although patients (n = 31) had an appreciation for physical activity benefits and high levels of physical activity readiness, themes related to physical activity barriers and lack of motivation were pervasive. Patients regarded the MI consultation as an effective health communication but the patient-centeredness of the approach was negatively perceived. Compared with MI, patients agreed that more traditional paternalistic approaches (i.e., physician-led interactions) were more representative of "good counseling" and more familiar to them. Patients shared deeply about personal experiences and provided words of encouragement to one another. CONCLUSION: Physical activity interventions including rural African-American women should include activities that focus on barrier management and increasing motivation. MI might be an appropriate behavioral counseling model when added to a more traditional cognitive-behavioral physical activity intervention that is group-based and tailored to patients' communication preferences and the clinical setting.