Detecting Variation in Clinical Practice Patterns for Geriatric Trauma Care Using Social Network Analysis.

OBJECTIVE: To characterize hospital-level professional networks of physicians caring for older trauma patients as a function of trauma patient age distribution. BACKGROUND: The causal factors associated with between-hospital variation in geriatric trauma outcomes are poorly understood. Variation in physician practice patterns reflected by differences in professional networks might contribute to hospital-level differences in outcomes for older trauma patients. METHODS: This is a population-based, cross-sectional study of injured older adults (age 65 or above) and their physicians from January 1, 2014, to December 31, 2015, using Health Care Cost and Utilization Project inpatient data and Medicare claims from 158 hospitals in Florida. We used social network analyses to characterize the hospitals in terms of network density, cohesion, small-worldness, and heterogeneity, then used bivariate statistics to assess the relationship between network characteristics and hospital-level proportion of trauma patients who were aged 65 or above. RESULTS: We identified 107,713 older trauma patients and 169,282 patient-physician dyads. The hospital-level proportion of trauma patients who were aged 65 or above ranged from 21.5% to 89.1%. Network density, cohesion, and small-worldness in physician networks were positively correlated with hospital geriatric trauma proportions ( R =0.29, P <0.001; R =0.16, P =0.048; and R =0.19, P <0.001, respectively). Network heterogeneity was negatively correlated with geriatric trauma proportion ( R =0.40, P <0.001). CONCLUSIONS: Characteristics of professional networks among physicians caring for injured older adults are associated with the hospital-level proportion of trauma patients who are older, indicating differences in practice patterns at hospitals with older trauma populations. Associations between interspecialty collaboration and patient outcomes should be explored as an opportunity to improve the treatment of injured older adults.

Provider Perceptions Regarding Cardiopulmonary Resuscitation in Surgical Patients with Frailty.

OBJECTIVE: To characterize the perceptions of surgeons, anesthesiologists, and geriatricians regarding perioperative CPR in surgical patients with frailty. SUMMARY BACKGROUND DATA: The population of patients undergoing surgery is growing older and more frail. Despite a growing focus on goal-concordant care, frailty assessment, and debate regarding the appropriateness of cardiopulmonary resuscitation (CPR) in patients with frailty, providers' views regarding frailty and perioperative CPR are unknown. METHODS: We performed qualitative thematic analysis of transcripts from semi-structured interviews of anesthesiologists (8), surgeons (10), and geriatricians (9) who care for high-risk surgical patients at two academic medical centers in Boston, MA. The interview guide elicited clinicians' understanding of frailty, approach to decision-making regarding perioperative CPR, and perceptions of perioperative CPR in frail surgical patients. RESULTS: We identified 5 themes: perceptions of perioperative CPR in patients with frailty vary by provider specialty; judgments regarding appropriateness of CPR in surgical patients with frailty are typically multifactorial and include patient goals, age, comorbidities, and arrest etiology; resuscitation in patients with frailty is sometimes associated with moral distress; biases such as ableism and ageism may skew clinicians' perceptions of appropriateness of perioperative CPR in patients with frailty; and evidence to guide risk stratification for patients with frailty undergoing perioperative CPR is inadequate. CONCLUSIONS: Anesthesiologists, surgeons, and geriatricians offer different accounts of frailty's relevance to judgments regarding CPR in surgical patients. Divergent views regarding frailty and perioperative CPR may impede efforts to deliver goal-concordant care and suggest a need for research to inform risk stratification, predict patient-centered outcomes, and understand the role of potential biases such as ageism and ableism.

Palliative surgery: state of the science and future directions.

Palliative surgical procedures are operations that aim to alleviate symptoms in a patient with serious, life-limiting illness. They are common, particularly within the field of surgical oncology. However, few high-quality studies have attempted to measure the durability of improvements in symptoms and quality of life after palliative surgery. Furthermore, many of the studies that do exist are outdated and employ highly inconsistent definitions of palliative surgery. Consequently, the paucity of robust and reliable evidence on the benefits, risks, and trade-offs of palliative surgery hampers clinical decision-making for patients and their surgeons. The evidence for palliative surgery suggests that, with effective communication about goals of care and careful patient selection, palliative surgery can provide symptomatic relief and reduce healthcare burdens for certain seriously ill patients.

Geriatric Assessment in Colorectal Surgery: A Systematic Review.

INTRODUCTION: The prevalence of colorectal surgery among older adults is expected to rise due to the aging population. Geriatric conditions (e.g., frailty) are risk factors for poor surgical outcomes. The goal of this systematic review is to examine how current literature describes geriatric assessment interventions in colorectal surgery and associated outcomes. METHODS: Systematic searches of Ovid MEDLINE, Cochrane Library, CINAHL, Embase, and Web of Science were completed. Review was performed according to Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines and prospectively registered in PROSPERO, the international prospective register of systematic reviews in health and social care. All cohort studies and randomized trials of adult colorectal surgery patients where geriatric assessment was performed were included. Geriatric assessment with/without management interventions were identified and described. RESULTS: Seven-hundred ninety-three studies were identified. Duplicates (197) were removed. An additional 525 were excluded after title/abstract review. After full-text review, 20 studies met the criteria. Reference list review increased final total to 25 studies. All 25 studies were cohort studies. No randomized clinical trials were identified. Heterogeneous assessments were organized into geriatrics domains (mind, mobility, medications, matters most, and multi-complexity). Incomplete evaluations across geriatric domains were performed with few studies describing the use of assessments to impact management decisions. CONCLUSIONS: There are no randomized trials assessing the impact of geriatric assessment to tailor management strategies and improve outcomes in colorectal surgery. Few studies performed assessments to evaluate the geriatric domain matters most. These findings represent a gap in evidence for the efficacy of geriatric assessment and management strategies in colorectal surgical care.

Impact of peri-operative frailty and operative stress on post-discharge mortality, readmission and days at home in Medicare beneficiaries.

BACKGROUND: Understanding how patients' frailty and the physiological stress of surgical procedures affect postoperative outcomes may inform risk stratification of older patients undergoing surgery. The objective of the study was to examine the association of peri-operative frailty with mortality, 30-day readmission and days at home after non-cardiac surgical procedures of different physiological stress. METHODS: This retrospective study used Medicare claims data from a 7.125% random sample of Medicare fee-for-service beneficiaries from 2015 to 2019 who were aged ≥ 65 years and underwent non-cardiac surgical procedure listed in the Operative Stress Score categories. The exposure of the study was claims-based frailty index (robust, < 0.15; pre-frail, 0.15 to < 0.25; mildly frail, 0.25 to < 0.35; and moderate-to-severely frail, ≥ 0.35) with Operative Stress Score categories being 1, very low stress to 5, very high stress. The primary outcome was all-cause mortality at 30 days and 365 days after the surgical procedure. RESULTS: In total, 1,019,938 patients (mean (SD) age of 76.1 (7.3) years; 52.3% female; 16.8% frail) were included. The cumulative incidence of mortality generally increased with Operative Stress Score category, ranging from 5.0% (Operative Stress Score 2) to 24.9% (Operative Stress Score 4) at 365 days. Within each category, increasing frailty was associated with mortality at 30 days (hazard ratio comparing moderate-to-severe frailty vs. robust ranged from 1.59-3.91) and at 365 days (hazard ratio 1.30-4.04). The variation in postoperative outcomes by patients' frailty level was much greater than the variation by the operative stress category. CONCLUSIONS: These results emphasise routine frailty screening before major and minor non-cardiac procedures and the need for greater clinician awareness of postoperative outcomes beyond 30 days in shared decision-making with older adults with frailty.

Beyond In-hospital Mortality: Use of Postdischarge Quality-Metrics Provides a More Complete Picture of Older Adult Trauma Care.

OBJECTIVE: To identify the distributions of and extent of variability among 3 new sets of postdischarge quality-metrics measured within 30/90/365 days designed to better account for the unique health needs of older trauma patients: mortality (expansion of the current in-hospital standard), readmission (marker of health-system performance and care coordination), and patients' average number of healthy days at home (marker of patient functional status). BACKGROUND: Traumatic injuries are a leading cause of death and loss of independence for the increasing number of older adults living in the United States. Ongoing efforts seek to expand quality evaluation for this population. METHODS: Using 100% Medicare claims, we calculated hospital-specific reliability-adjusted postdischarge quality-metrics for older adults aged 65 years or older admitted with a primary diagnosis of trauma, older adults with hip fracture, and older adults with severe traumatic brain injury. Distributions for each quality-metric within each population were assessed and compared with results for in-hospital mortality, the current benchmarking standard. RESULTS: A total of 785,867 index admissions (305,186 hip fracture and 92,331 severe traumatic brain injury) from 3692 hospitals were included. Within each population, use of postdischarge quality-metrics yielded a broader range of outcomes compared with reliance on in-hospital mortality alone. None of the postdischarge quality-metrics consistently correlated with in-hospital mortality, including death within 1 year [ r =0.581 (95% CI, 0.554-0.608)]. Differences in quintile-rank revealed that when accounting for readmissions (8.4%, κ=0.029) and patients' average number of healthy days at home (7.1%, κ=0.020), as many as 1 in 14 hospitals changed from the best/worst performance under in-hospital mortality to the completely opposite quintile rank. CONCLUSIONS: The use of new postdischarge quality-metrics provides a more complete picture of older adult trauma care: 1 with greater room for improvement and better reflection of multiple aspects of quality important to the health and recovery of older trauma patients when compared with reliance on quality benchmarking based on in-hospital mortality alone.

Prevalence, Management, and Outcomes Related to Preoperative Medical Orders for Life Sustaining Treatment (MOLST) in an Adult Surgical Population: Preoperative MOLST and Code Status Discussions.

OBJECTIVE: To determine prevalence of documented preoperative code status discussions and postoperative outcomes (specifically mortality, readmission, and discharge disposition) of patients with completed MOLST forms before surgery. SUMMARY OF BACKGROUND DATA: A MOLST form documents patient care preference regarding treatment limitations. When considering surgery in these patients, preoperative discussion is necessary to ensure concordance of care. Little is known about prevalence of these discussions and postoperative outcomes. METHODS: A retrospective cohort study was conducted consisting of all patients having surgery during a 1-year period at a tertiary care academic center in Boston, Massachusetts. RESULTS: Among 21,787 surgical patients meeting inclusion criteria, 402 (1.8%) patients had preoperative MOLST. Within the MOLST, 224 (55.7%) patients had chosen to limit cardiopulmonary resuscitation and 214 (53.2%) had chosen to limit intubation and mechanical ventilation. Code status discussion was documented presurgery in 169 (42.0%) patients with MOLST. Surgery was elective or nonurgent for 362 (90%), and median length of stay (Q1, Q3) was 5.1 days (1.9, 9.9). The minority of patients with preoperative MOLST were discharged home [169 (42%), and 103 (25.6%) patients were readmitted within 30 days. Patients with preoperative MOLST had a 30-day mortality of 9.2% (37 patients) and cumulative 90-day mortality of 14.9% (60 patients). CONCLUSIONS: Fewer than half of surgical patients with preoperative MOLST have documented code status discussions before surgery. Given their high risk of postoperative mortality and the diversity of preferences found in MOLST, thoughtful discussion before surgery is critical to ensure concordant perioperative care.

Factors Associated With Provision of Nonbeneficial Surgery: A National Survey of Surgeons.

OBJECTIVE: We tested the association of systems factors with the surgeon's likelihood of offering surgical intervention for older adults with life-limiting acute surgical conditions. BACKGROUND: Use of surgical treatments in the last year of life is frequent. Improved risk prediction and clinician communication are solutions proposed to improve serious illness care, yet systems factors may also drive receipt of nonbeneficial treatment. METHODS: We mailed a national survey to 5200 surgeons randomly selected from the American College of Surgeons database comprised of a clinical vignette describing a seriously ill older adult with an acute surgical condition, which utilized a 2×2 factorial design to assess patient and systems factors on receipt of surgical treatment to surgeons. RESULTS: Two thousand one hundred sixty-one surgeons responded for a weighted response rate of 53%. For an 87-year-old patient with fulminant colitis and advanced dementia or stage IV lung cancer, 40% of surgeons were inclined to offer an operation to remove the patient's colon while 60% were inclined to offer comfort-focused care only. Surgeons were more likely to offer surgery when an operating room was readily available (odds ratio: 4.05, P <0.001) and the family requests "do everything" (odds ratio: 2.18, P <0.001). CONCLUSIONS: Factors outside the surgeon's control contribute to nonbeneficial surgery, consistent with our model of clinical momentum. Further characterization of the systems in which these decisions occur might expose novel strategies to improve serious illness care for older patients and their families.

Surgeon-reported Factors Influencing Adoption of Quality Standards for Goal-concordant Care in Patients With Advanced Cancer: A Qualitative Study.

OBJECTIVE: This study explored surgical oncologists' perspectives on factors influencing adoption of quality standards in patients with advanced cancer. BACKGROUND: The American College of Surgeons Geriatric Surgery Verification Program includes communication standards designed to facilitate goal-concordant care, yet little is known about how surgeons believe these standards align with clinical practice. METHODS: Semistructured video-based interviews were conducted from November 2020 to January 2021 with academic surgical oncologists purposively sampled based on demographics, region, palliative care certification, and years in practice. Interviews addressed: (1) adherence to standards documenting care preferences for life-sustaining treatment, surrogate decision-maker, and goals of surgery; and (2) factors influencing their adoption into practice. Interviews were audio-recorded, transcribed, qualitatively analyzed, and conducted until thematic saturation was reached. RESULTS: Twenty-six surgeons participated (57.7% male, 8.5 mean years in practice, 19.2% palliative care board-certified). Surgeons reported low adherence to documenting care preferences and surrogate decision-maker and high adherence to discussing, but not documenting, goals of surgery. Participants held conflicting views about the relevance of care preferences to preoperative conversations and surrogate decision-maker documentation by the surgeon and questioned the direct connection between documentation of quality standards and higher value patient care. Key themes regarding factors influencing adoption of quality standards included organizational culture, workflow, and multidisciplinary collaboration. CONCLUSIONS: Although surgeons routinely discuss goals of surgery, documentation is inconsistent; care preferences and surrogate decision-makers are rarely discussed or documented. Adherence to these standards would be facilitated by multidisciplinary collaboration, institutional standardization, and evidence linking standards to higher value care.

Long-term Mental Health Trajectories of Injured Military Servicemembers: Comparing Combat to Noncombat Related Injuries.

OBJECTIVE: We sought to quantify the impact of injury characteristics and setting on the development of mental health conditions, comparing combat to noncombat injury mechanisms. BACKGROUND: Due to advances in combat casualty care, military service-members are surviving traumatic injuries at substantial rates. The nature and setting of traumatic injury may influence the development of subsequent mental health disorders more than clinical injury characteristics. METHODS: TRICARE claims data was used to identify servicemembers injured in combat between 2007 and 2011. Controls were servicemembers injured in a noncombat setting matched by age, sex, and injury severity. The rate of development, and time to diagnosis [in days (d)], of 3 common mental health conditions (post-traumatic stress disorder, depression, and anxiety) among combat-injured servicemembers were compared to controls. Risk factors for developing a new mental health condition after traumatic injury were evaluated using multivariable logistic regression that controlled for confounders. RESULTS: There were 3979 combat-injured servicemember and 3979 matched controls. The majority of combat injured servicemembers (n = 2524, 63%) were diagnosed with a new mental health condition during the course of follow-up, compared to 36% (n = 1415) of controls ( P < 0.001). In the adjusted model, those with combat-related injury were significantly more likely to be diagnosed with a new mental health condition [odds ratio (OR): 3.18, [95% confidence interval (CI): 2.88-3.50]]. Junior (OR: 3.33, 95%CI: 2.66-4.17) and senior enlisted (OR: 2.56, 95%CI: 2.07-3.17) servicemem-bers were also at significantly greater risk. CONCLUSIONS: We found significantly higher rates of new mental health conditions among servicemembers injured in combat compared to service-members sustaining injuries in noncombat settings. This indicates that injury mechanism and environment are important drivers of mental health sequelae after trauma.

The Hidden Costs of War: Healthcare Utilization Among Individuals Sustaining Combat-related Trauma (2007-2018).

OBJECTIVE: We sought to evaluate long-term healthcare requirements of American military servicemembers with combat-related injuries. SUMMARY OF BACKGROUND DATA: US military conflicts since 2001 have produced the most combat casualties since Vietnam. Long-term consequences on healthcare utilization and associated costs remain unknown. METHODS: We identified servicemembers who were treated for combat-related injuries between 2007 and 2011. Controls consisted of active-duty servicemembers injured in the civilian sector, without any history of combat-related trauma, matched (1:1) on year of injury, biologic sex injury severity, and age at time of injury. Surveillance was performed through 2018. Total annual healthcare expenditures were evaluated overall and then as expenditures in the first year after injury and for subsequent years. Negative binomial regression was used to identify the adjusted influence of combat injury on healthcare costs. RESULTS: The combat-injured cohort consisted of 3981 individuals and we identified 3979 controls. Total healthcare utilization during the follow-up period resulted in median costs of $142,214 (IQR $61,428, $323,060) per combat-injured servicemember as compared to $50,741 (IQR $26,669, $104,134) among controls. Median expenditures, adjusted for duration of follow-up, for the combat-injured were $45,211 (IQR $18,698, $105,437). In adjusted analysis, overall costs were 30% higher (1.30; 95% confidence interval: 1.23, 1.37) for combat-injured personnel. CONCLUSION: This investigation represents the longest continuous observation of healthcare utilization among individuals after combat injury and the first to assess costs. Expenditures were 30% higher for individuals injured as a result of combat-related trauma when compared to those injured in the civilian sector.

The Trauma Dyad: The Role of Informal Caregivers for Older Adults After Traumatic Injury.

OBJECTIVE: To investigate the association between higher injury severity and increased informal caregiving received by injured older adults. SUMMARY OF BACKGROUND DATA: Injured older adults experience high rates of functional decline and disability after hospitalization. Little is known about the scope of caregiving received post-discharge, particularly from informal caregivers such as family. METHODS: We used the National Health and Aging Trends Study 2011 to 2018 linked to Medicare claims to identify adults ≥65 with hospital admission for traumatic injury and a National Health and Aging Trends Study interview within 12 months pre- and post-trauma. Injury severity was assessed using the injury severity score (ISS, low 0-9; moderate 10-15; severe 16-75). Patients reported the types and hours of formal and informal help received and any unmet care needs. Multi variable logistic regression models examined the association between ISS and increase in informal caregiving hours after discharge. RESULTS: We identified 430 trauma patients. Most were female (67.7%), non-Hispanic White (83.4%) and half were frail. The most common mechanism of injury was fall (80.8%) and median injury severity was low (ISS = 9). Those reporting receiving help with any activity increased post-trauma (49.0% to 72.4%, P < 0.01), and unmet needs nearly doubled (22.8% to 43.0%, P < 0.01). Patients had a median of 2 caregivers and most (75.6%) were informal, often family members. Median weekly hours of care received pre- versus post-injury increased from 8 to 14 (P < 0.01). ISS did not independently predict increase in caregiving hours; pre-trauma frailty predicted an increase in hours ≥8 per week. CONCLUSIONS: Injured older adults reported high baseline care needs which increased significantly after hospital discharge and were mostly met by informal caregivers. Injury was associated with increased need for assistance and unmet needs regardless of injury severity. These results can help set expectations for caregivers and facilitate post-acute care transitions.

Reassessing the July Effect: 30 Years of Evidence Show No Difference in Outcomes.

OBJECTIVE: The aim of this study was to critically evaluate whether admission at the beginning versus end of the academic year is associated with increased risk of major adverse outcomes. SUMMARY BACKGROUND DATA: The hypothesis that the arrival of new residents and fellows is associated with increases in adverse patient outcomes has been the subject of numerous research studies since 1989. Methods: We conducted a systematic review and random-effects meta-analysis of July Effect studies published before December 20, 2019, looking for differences in mortality, major morbidity, and readmission. Given a paucity of studies reporting readmission, we further analyzed 7 years of data from the Nationwide Readmissions Database to assess for differences in 30-day readmission for US patients admitted to urban teaching versus nonteach-ing hospitals with 3 common medical (acute myocardial infarction, acute ischemic stroke, and pneumonia) and 4 surgical (elective coronary artery bypass graft surgery, elective colectomy, craniotomy, and hip fracture) conditions using risk-adjusted logistic difference-in-difference regression. RESULTS: A total of 113 studies met inclusion criteria; 92 (81.4%) reported no evidence of a July Effect. Among the remaining studies, results were mixed and commonly pointed toward system-level discrepancies in efficiency. Metaanalyses of mortality [odds ratio (95% confidence interval): 1.01 (0.98-1.05)] and major morbidity [1.01 (0.99-1.04)] demonstrated no evidence of a July Effect, no differences between specialties or countries, and no change in the effect over time. A total of 5.98 million patient encounters were assessed for readmission. No evidence of a July Effect on readmission was found for any of the 7 conditions. CONCLUSION: The preponderance of negative results over the past 30 years suggests that it might be time to reconsider the need for similarly-themed studies and instead focus on system-level factors to improve hospital efficiency and optimize patient outcomes.

Association between Surgery, Anesthesia, and Obstetric Workforce and Emergent Surgical and Obstetric Mortality among United States Hospital Referral Regions.

OBJECTIVE: To determine the association between SAO workforce and mortality from emergent surgical and obstetric conditions within US HR Rs. BACKGROUND: SAO workforce per capita has been identified as a core metric of surgical capacity by the Lancet Commission on Global Surgery, but its utility has not been assessed at the subnational level for a high-income country. METHODS: The number of practicing surgeons, anesthesiologists, and obstetricians per capita was estimated for all HRRs using the US Health Resources & Services Administration Area Health Resource File Database. Deaths due to emergent general surgical and obstetric conditions were determined from the Center for Disease Control and Prevention WONDER database. We utilized B-spline quantile regression to model the relationship between SAO workforce and emergent surgical mortality at different quantiles of mortality and calculated the expected change in mortality associated with increases in SAO workforce. RESULTS: The median SAO workforce across all HRRs was 74.2 per 100,000 population (interquartile range 33.3-241.0). All HRRs met the Lancet Commission on Global Surgery lower target of 20 SAO per 100,000, and 97.7% met the upper target of 40 per 100,000. Nearly 2.8 million Americans lived in HRRs with fewer than 40 SAO per 100,000. Increases in SAO workforce were associated with decreases in surgical mortality in HRRs with high mortality, with minimal additional decreases in mortality above 60 to 80 SAO per 100,000. CONCLUSIONS: Increasing SAO workforce capacity may reduce emergent surgical and obstetric mortality in regions with high surgical mortality but diminishing returns may be seen above 60 to 80 SAO per 100,000. Trial Registration: N/A.

Variation in hospital utilization of palliative interventions for patients with advanced gastrointestinal cancer near end of life.

BACKGROUND: Patients with advanced gastrointestinal (GI) cancer often undergo noncurative interventions with palliative intent to relieve high symptom burden near end of life. Hospital-level variation in intervention utilization remains unclear. METHODS: National cohort study of 142 304 patients with stage III or IV GI cancer within the National Cancer Database (2004-2014) who died within 1-year of diagnosis. Hospitals were stratified by palliative intervention utilization (surgery, chemotherapy, radiation, pain management). Multivariable, multinomial regression evaluated the association between patient/hospital factors and palliative intervention utilization. RESULTS: Across 1322 hospitals, median hospital palliative intervention utilization was 12.0% [interquartile range: 0.0%-26.1%]. Utilization increased over time in all but lowest utilizing hospitals. Relative to lowest utilizing hospitals, factors associated with a lower likelihood of care at highest utilizing hospitals included: race (White [ref]; Black-Relative Risk Ratio [RRR] 0.81, 95% confidence interval [0.77-0.85]) and lower income (RRR 0.81 [0.78-0.84]). Factors associated with a higher likelihood included: lower education level (RRR 1.62 [1.55-1.69]) and hospital type (community program [ref]; comprehensive community-RRR 1.33 [1.26-1.41]; academic-RRR 1.88 [1.77-1.99]; integrated network-RRR 1.79 [1.66-1.93]). CONCLUSION: Hospital variation in palliative intervention use is substantial and potentially associated with sociodemographic and hospital characteristics. Future work can examine how differences in hospital care processes translate to quantity/quality of life for cancer patients.

Enhanced Recovery After Surgery (ERAS®) Society Consensus Guidelines for Emergency Laparotomy Part 3: Organizational Aspects and General Considerations for Management of the Emergency Laparotomy Patient.

BACKGROUND: This is Part 3 of the first consensus guidelines for optimal care of patients undergoing emergency laparotomy using an enhanced recovery after surgery (ERAS) approach. This paper addresses organizational aspects of care. METHODS: Experts in management of the high-risk and emergency general surgical patient were invited to contribute by the International ERAS® Society. PubMed, Cochrane, Embase, and MEDLINE database searches were performed for ERAS elements and relevant specific topics. Studies were selected with particular attention to randomized clinical trials, systematic reviews, meta-analyses and large cohort studies, and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation system. Recommendations were made on the best level of evidence, or extrapolation from studies on elective patients when appropriate. A modified Delphi method was used to validate final recommendations. RESULTS: Components of organizational aspects of care were considered. Consensus was reached after three rounds of a modified Delphi process. CONCLUSIONS: These guidelines are based on best current available evidence for organizational aspects of an ERAS® approach to patients undergoing emergency laparotomy and include discussion of less common aspects of care for the surgical patient, including end-of-life issues. These guidelines are not exhaustive but pull together evidence on important components of care for this high-risk patient population. As much of the evidence is extrapolated from elective surgery or emergency general surgery (not specifically laparotomy), many of the components need further evaluation in future studies.

Consensus Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS®) Society Recommendations Part 2-Emergency Laparotomy: Intra- and Postoperative Care.

BACKGROUND: This is Part 2 of the first consensus guidelines for optimal care of patients undergoing emergency laparotomy (EL) using an Enhanced Recovery After Surgery (ERAS) approach. This paper addresses intra- and postoperative aspects of care. METHODS: Experts in aspects of management of high-risk and emergency general surgical patients were invited to contribute by the International ERAS® Society. PubMed, Cochrane, Embase, and Medline database searches were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized clinical trials, systematic reviews, meta-analyses, and large cohort studies and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on elective patients when appropriate. A modified Delphi method was used to validate final recommendations. Some ERAS® components covered in other guideline papers are outlined only briefly, with the bulk of the text focusing on key areas pertaining specifically to EL. RESULTS: Twenty-three components of intraoperative and postoperative care were defined. Consensus was reached after three rounds of a modified Delphi Process. CONCLUSIONS: These guidelines are based on best available evidence for an ERAS® approach to patients undergoing EL. These guidelines are not exhaustive but pull together evidence on important components of care for this high-risk patient population. As much of the evidence is extrapolated from elective surgery or emergency general surgery (not specifically laparotomy), many of the components need further evaluation in future studies.

Patterns and Persistence of Perioperative Plasma and Cerebrospinal Fluid Neuroinflammatory Protein Biomarkers After Elective Orthopedic Surgery Using SOMAscan.

BACKGROUND: The neuroinflammatory response to surgery can be characterized by peripheral acute plasma protein changes in blood, but corresponding, persisting alterations in cerebrospinal fluid (CSF) proteins remain mostly unknown. Using the SOMAscan assay, we define acute and longer-term proteome changes associated with surgery in plasma and CSF. We hypothesized that biological pathways identified by these proteins would be in the categories of neuroinflammation and neuronal function and define neuroinflammatory proteome changes associated with surgery in older patients. METHODS: SOMAscan analyzed 1305 proteins in blood plasma (n = 14) and CSF (n = 15) samples from older patients enrolled in the Role of Inflammation after Surgery for Elders (RISE) study undergoing elective hip and knee replacement surgery with spinal anesthesia. Systems biology analysis identified biological pathways enriched among the surgery-associated differentially expressed proteins in plasma and CSF. RESULTS: Comparison of postoperative day 1 (POD1) to preoperative (PREOP) plasma protein levels identified 343 proteins with postsurgical changes ( P < .05; absolute value of the fold change [|FC|] > 1.2). Comparing postoperative 1-month (PO1MO) plasma and CSF with PREOP identified 67 proteins in plasma and 79 proteins in CSF with altered levels ( P < .05; |FC| > 1.2). In plasma, 21 proteins, primarily linked to immune response and inflammation, were similarly changed at POD1 and PO1MO. Comparison of plasma to CSF at PO1MO identified 8 shared proteins. Comparison of plasma at POD1 to CSF at PO1MO identified a larger number, 15 proteins in common, most of which are regulated by interleukin-6 (IL-6) or transforming growth factor beta-1 (TGFB1) and linked to the inflammatory response. Of the 79 CSF PO1MO-specific proteins, many are involved in neuronal function and neuroinflammation. CONCLUSIONS: SOMAscan can characterize both short- and long-term surgery-induced protein alterations in plasma and CSF. Acute plasma protein changes at POD1 parallel changes in PO1MO CSF and suggest 15 potential biomarkers for longer-term neuroinflammation that warrant further investigation.

Association between Operative Time and Short-Term Radical Cystectomy Complications.

INTRODUCTION: The aim of this study was to examine the relationship between duration of surgical intervention and postoperative complications in radical cystectomy (RC). We hypothesized that the complication rate increases with longer operative time. METHODS: We analyzed the National Surgical Quality Improvement Program database 2011-2017 to identify all patients who underwent RC. Clinicodemographic characteristics, operative time, and perioperative complications using the Clavien-Dindo Classification (CDC) were abstracted. We fit a generalized linear model with linear splines for operative time to analyze if the relationship between operative time and probability of complication changed over time. RESULTS: A total of 10,520 RC patients were identified with a mean operative time of 5.5 h (standard deviation 2.03). In 55% and 18.2%, any complication and major complications (CDC ≥3) occurred within 30 days postoperatively, respectively. The spline regression model for any complication showed an almost linear relationship between the complication rate and operative time, ranging from 55% at 2.5 h to 82% at 10 h. For major complications, the model revealed the inflection point (knot) at 4.5 h, which corresponds to the lowest complication rate with 15%. Operative times at the extremes of the distribution had higher complication rates: 17.5% if <2.5 h and 28% if >10 h. DISCUSSION/CONCLUSION: Operative time of RC is associated with postoperative complications. Though many factors impact the duration of surgery, surgeries that lasted between 4 and 5 h had trend toward the lowest complication rates. Attention to factors impacting operative time may allow surgeons to identify strategies for optimizing surgical care and reducing complications after RC.

Early Shared Decision-Making for Older Adults with Traumatic Brain Injury: Using Time-Limited Trials and Understanding Their Limitations.

Older adults account for a disproportionate share of the morbidity and mortality after traumatic brain injury (TBI). Predicting functional and cognitive outcomes for individual older adults after TBI is challenging in the acute phase of injury. Given that neurologic recovery is possible and uncertain, life-sustaining therapy may be pursued initially, even if for some, there is a risk of survival to an undesired level of disability or dependence. Experts recommend early conversations about goals of care after TBI, but evidence-based guidelines for these discussions or for the optimal method for communicating prognosis are limited. The time-limited trial (TLT) model may be an effective strategy for managing prognostic uncertainty after TBI. TLTs can provide a framework for early management: specific treatments or procedures are used for a defined period of time while monitoring for an agreed-upon outcome. Outcome measures, including signs of worsening and improvement, are defined at the outset of the trial. In this Viewpoint article, we discuss the use of TLTs for older adults with TBI, their potential benefits, and current challenges to their application. Three main barriers limit the implementation of TLTs in these scenarios: inadequate models for prognostication; cognitive biases faced by clinicians and surrogate decision-makers, which may contribute to prognostic discordance; and ambiguity regarding appropriate endpoints for the TLT. Further study is needed to understand clinician behaviors and surrogate preferences for prognostic communication and how to optimally integrate TLTs into the care of older adults with TBI.