Association of preoperative anaesthesia consultation prior to elective noncardiac surgery with patient and health system outcomes: a population-based study.

BACKGROUND: Surgical volumes and use of preoperative anaesthesia consultations are increasing. However, contemporary data estimating the association between preoperative anaesthesia consultation and patient (days alive and at home [DAH30], mortality) and system (costs, length of stay, and readmissions) outcomes are not available. METHODS: We conducted a population-based comparative effectiveness study using linked health administrative data among patients aged ≥40 yr who underwent intermediate-risk to high-risk elective, inpatient, noncardiac surgery in Ontario, Canada (2009-17). Our primary outcome was DAH30. Secondary outcomes included DAH90, 30-day and 1-yr mortality, 30-day health system costs, length of index admission, and 30-day readmissions. Propensity score overlap weights were used to adjust for confounders. Prespecified effect modifier analyses focused on high-risk subgroups. RESULTS: Among 364 149 patients, 274 365 (75.3%) received a preoperative anaesthesia consultation. No adjusted association was found (22.5 days vs 22.5 days; adjusted ratio of means 1.00, 95% CI 1.00-1.00) between consultation and DAH30 in the full population. We identified significant effect modification (significantly more DAH30) among patients with ischaemic heart disease, ASA physical status ≥4, frailty index score ≥0.21, and who underwent vascular surgery. Secondary outcomes were associated with preoperative consultation, including greater DAH90, decreased length of stay, lower 30-day and 1-yr mortality, and reduced 30-day costs. CONCLUSIONS: Preoperative anaesthesia consultation was not associated with greater DAH30 across the overall study population. However, important potential benefits were observed among high-risk subgroups. Research is needed to identify optimal patient populations and consultation processes.

Mortality in adolescents and young adults following a first presentation to the emergency department for alcohol.

BACKGROUND AND METHODS: We conducted a population-based, retrospective cohort study of first-time emergency department (ED) visits in adolescents and young adults (AYA) due to alcohol and compared mortality to AYA with nonalcohol ED visits between 2009 and 2015 using standardized all-cause mortality ratios (age, sex, income, and rurality). We described the cause of death for AYA and examined the association between clinical factors and mortality rates in the alcohol cohort using proportional hazard models. RESULTS: A total of 71,776 AYA had a first-time ED visit due to alcohol (56.1% male, mean age 20.7 years) between 2009 and 2015, representing 3.3% of the 2,166,838 AYA with an ED visit in this time period. At 1 year, there were 2396 deaths, 248 (10.3%) following an ED visit related to alcohol. First-time alcohol ED visits were associated with a threefold higher risk in mortality at 1 year (0.35% vs. 0.10%, adjusted hazard ratio [aHR] 3.07, 95% confidence interval [CI] 2.69-3.51). Mortality was associated with age 25-29 years (aHR 3.88, 95% CI 2.56-5.86), being male (aHR 1.98, 95% CI 1.49-2.62), having a history of mental health or substance use (aHR 3.22, 95% CI 1.64-6.32), cause of visit being withdrawal/dependence (aHR 2.81, 95% CI 1.96-4.02), and having recurrent ED visits (aHR 1.97, 95% CI 1.27-3.05). Trauma (42.7%), followed by poisonings from drugs other than opioids (38.3%), and alcohol (28.6%) were the most common contributing causes of death. CONCLUSION: Incident ED visits due to alcohol in AYA are associated with a high risk of 1-year mortality, especially in young adults, those with concurrent mental health or substance use disorders, and those with a more severe initial presentation. These findings may help inform the need and urgency for follow-up care in this population.

Association of Preoperative Medical Consultation With Reduction in Adverse Postoperative Outcomes and Use of Processes of Care Among Residents of Ontario, Canada.

Importance: It is uncertain whether preoperative medical consultation reduces adverse postoperative clinical outcomes. Objective: To investigate the association of preoperative medical consultation with reduction in adverse postoperative outcomes and use of processes of care. Design, Setting, and Participants: This was a retrospective cohort study using linked administrative databases from an independent research institute housing routinely collected health data for Ontario's 14 million residents, including sociodemographic features, physician characteristics and services, and receipt of inpatient and outpatient care. The study sample included Ontario residents aged 40 years or older who underwent their first qualifying intermediate- to high-risk noncardiac operation. Propensity score matching was used to adjust for differences between patients who did and did not undergo preoperative medical consultation with discharge dates between April 1, 2005, and March 31, 2018. The data were analyzed from December 20, 2021, to May 15, 2022. Exposures: Receipt of preoperative medical consultation in the 4 months preceding the index surgery. Main Outcomes and Measures: The primary outcome was 30-day all-cause postoperative mortality. Secondary outcomes included 1-year mortality, inpatient myocardial infarction and stroke, in-hospital mechanical ventilation, length of stay, and 30-day health system costs. Results: Of the total 530 473 individuals (mean [SD] age, 67.1 [10.6] years; 278 903 [52.6%] female) included in the study, 186 299 (35.1%) received preoperative medical consultation. Propensity score matching resulted in 179 809 well-matched pairs (67.8% of the full cohort). The 30-day mortality rate was 0.9% (n = 1534) in the consultation group and 0.7% (n = 1299) in the control group (odds ratio [OR], 1.19; 95% CI, 1.11-1.29). The ORs for 1 year mortality (OR, 1.15; 95% CI, 1.11-1.19), inpatient stroke (OR, 1.21; 95% CI, 1.06-1.37), in-hospital mechanical ventilation (OR, 1.38; 95% CI, 1.31-1.45), and 30-day emergency department visits (OR, 1.07; 95% CI, 1.05-1.09) were higher in the consultation group; however, the rates of inpatient myocardial infarction did not differ. The lengths of stay in acute care were a mean (SD) 6.0 (9.3) days in the consultation group and 5.6 (10.0) days in the control group (difference, 0.4 [95% CI, 0.3-0.5] days), and the median (IQR) total 30-day health system cost was CAD $317 ($229-$959) (US $235 [$170-$711]) higher in the consultation group. Preoperative medical consultation was associated with increased use of preoperative echocardiography (OR, 2.64; 95% CI, 2.59-2.69) and cardiac stress tests (OR, 2.50; 95% CI, 2.43-2.56) and higher odds of receiving a new prescription for ß-blockers (OR, 2.96; 95% CI, 2.82-3.12). Conclusions and Relevance: In this cohort study, preoperative medical consultation was not associated with a reduction but rather with an increase in adverse postoperative outcomes, suggesting a need for further refinement of target populations, processes, and interventions related to preoperative medical consultation. These findings highlight the need for further research and suggest that referral for preoperative medical consultation and subsequent testing should be carefully guided by individual-level consideration of risks and benefits.

Substance Use-related Emergency Department Visits and Resource Utilization.

INTRODUCTION: Substance use-related visits to the emergency department (ED) have been linked to higher service delivery costs, although little is known about the specific services used. Our goal In this study was to describe the recent trends of substance use-related ED visits and assess the association between substance use and specific ED resource utilization. METHODS: We performed a retrospective, cross-sectional study using the National Hospital Ambulatory Medical Care Survey (NHAMCS) data from 2013-2018. All ED visits in the United States for patients ≥18 years of age were included. The primary exposure was having substance use included as a chief complaint or diagnosis, which we identified using the International Classification of Diseases, 9th and 10th revisions, codes. The primary outcome was the use of diagnostic services (including laboratory studies and cardiac monitoring) or imaging studies in the ED. RESULTS: The study sample included 95,506 visits in the US, extrapolating to over 619 million ED visits nationwide. The total number of ED visits remained stable during the study period, but substance use-related visits increased by 45%, with these visits making up 2.93% of total ED visits in 2013 and 4.25% in 2018. This increase was primarily driven by stimulant-, sedative- (opioids and benzodiazepines), and hallucinogen-related visits. Mental health-related visits rose in parallel by 66% during the same period. Compared to non-substance use-related visits, substance use-related visits were more likely to undergo any diagnostic study (adjusted odds ratio [aOR] 1.28; 95% confidence interval (CI): 1.11-1.47; P = 0.001), toxicology screening (aOR 10.15; 95% CI: 8.84-11.66), but less likely to have imaging studies (aOR 0.62; 95% CI: 0.56-0.68; P <0.0001). In stratified analyses, substance use-related visits with concurrent mental health disorders were more likely to undergo imaging studies (aOR 1.56; 95% CI: 1.09-2.22), while findings were opposite for those without concurrent mental health disorders (aOR 0.64; 95% CI: 0.51-0.71; P for interaction <0.0001). CONCLUSION: Substance use- and mental health-related ED visits are rising, and they are associated with increased resource utilization. Further studies are needed to provide more guidance in the approach to acute services in this vulnerable population.

Interventions to reduce emergency department consultation time: A systematic review of the literature.

OBJECTIVES: Overcrowding in the emergency department (ED) is associated with increased morbidity and mortality. Studies have shown that consultation to decision time, defined as the time when a consultation has been accepted by a specialty service to the time when disposition decision is made, is one important contributor to the overall length of stay in the ED.The primary objective of this review is to evaluate the impact of workflow interventions on consultation to decision time and ED length of stay in patients referred to consultant services in teaching centres, and to identify barriers to reducing consultation to decision time. METHODS: This systematic review was performed in accordance with the PRISMA guidelines. An electronic search was conducted to identify relevant studies from MEDLINE, EMBASE, Cochrane Central, and CINAHL databases. Study screening, data extraction, and quality assessment were carried out by two independent reviewers. RESULTS: A total of nine full text articles were included in the review. All studies reported a decrease in consultation to decision time post intervention, and two studies reported cost savings. Interventions studied included short messaging service (SMS) messaging, education with audit and feedback, standardization of the admission process, implementation of institutional guideline, modification of the consultation process, and staffing schedules. Overall study quality was fair to poor. CONCLUSIONS: The limited evidence suggests that audit and feedback in the form of SMS messaging, direct consultation to senior physicians, and standardization of the admission process may be the most effective and feasible interventions. Additional high-quality studies are required to explore sustainable interventions aimed at reducing consultation to decision time.

Improving Timeliness of Internal Medicine Consults in the Emergency Department: A Quality Improvement Initiative.

INTRODUCTION: Emergency department (ED) wait time is an important health system quality indicator. Prolonged consult to decision time (CTDT), the time it takes to reach a disposition decision after receiving a specialty consultation request, can contribute to increased overall length of stay in the ED. OBJECTIVE: To identify delays in the consultation process for general internal medicine (GIM) and trial interventions to reduce CTDT. METHODS: The study was conducted at a large tertiary teaching hospital with GIM inpatient wards at two campuses. Four interventions were trialed over sequential Plan-Do-Study-Act cycles: (1) process mapping, (2) resident education sessions, (3) audit and feedback of CTDT, and (4) adding a swing shift during peak consult volume. MEASUREMENTS: The primary outcome measures were mean CTDT for patients admitted to GIM and the proportion of admitted patients with CTDT of less than 3 hours. RESULTS: Mean CTDT decreased from 4.61 hours before intervention to 4.18 hours after intervention (p < .0001). The proportion of GIM patients with CTDT less than 3 hours increased from 25% to 33% (p < .0001). CONCLUSIONS: The interventions trialed led to a sustained reduction in CTDT over a 12-month period and demonstrated the effectiveness of education in influencing physician performance.

Survey on Barriers to Critical Care and Palliative Care Integration.

PURPOSE: It has been shown that integrating palliative care (PC) in intensive care unit (ICU) improves end-of-life care (EOLC), but very few Canadian hospitals have adopted this practice. Our study aims to evaluate the perceived quality of EOLC at participating institutions and explore barriers toward ICU-PC integration. MATERIALS AND METHODS: A self-administered questionnaire was developed by a multidisciplinary team. Survey items were extracted from published quality indicators in EOLC and barriers to ICU-PC integration. The study took place at 2 academic institutions. Participants consisted of physicians and nurses, ICU administrators, and allied health workers. RESULTS: An overall response of 45% was achieved. Of total, 85% of the respondents were ICU nurses. The following main themes were identified: (1) There is a poor presence of PC in the ICU and 78% of respondents felt that increasing ICU-PC integration will improve quality of EOLC; (2) the main barrier to integration was unrealistic patient and/or family expectations; and (3) criteria-triggered consultation to PC was the most feasible way to achieve integration. CONCLUSION: Our findings indicate that the majority of respondents perceive that the presence of PC in ICU will improve EOLC. Future quality improvement initiatives can focus on developing a set of criteria for triggering PC consults.

Peritonitis as the First Presentation of Disseminated Listeriosis in a Patient on Peritoneal Dialysis-a Case Report.

Infections with Listeria monocytogenes are uncommon but serious, with mortality rate approaching 30% in cases of systemic involvement despite first-line therapy. They are usually caused by ingestion of contaminated foods, but spontaneous infections have also been described. Listeria monocytogenes is a rare cause of peritonitis, and most of the published cases are in patients with cirrhosis and ascites. There are a few reported cases of Listeria peritonitis associated with peritoneal dialysis (PD), primarily isolated peritonitis.If detected early, Listeria peritonitis can be successfully treated with ampicillin, alone or in combination with gentamicin. Vancomycin has been listed as a second-line agent. However, it has been associated with treatment failure.In this case report, we present a patient who developed disseminated listeriosis, with peritonitis as the first manifestation of disseminated infection. This case illustrates the importance of having a high index of suspicion for L. monocytogenes if patients deteriorate despite empiric therapy for PD-associated peritonitis and serves as a further example demonstrating the inadequate coverage of vancomycin for L. monocytogenes.