Transfer status: A significant risk factor for mortality in emergency general surgery patients requiring colon resection.

BACKGROUND: Patients requiring emergency surgery have increased rates of morbidity and mortality. Transfer from outside institution delays effective control of ongoing infection and has been linked with worse outcomes. Previous research suggests transfer status negatively impacts survival but has not examined the effect of location and type of institution prior to transfer. This study aims to characterize the effect of type of transferring institution on postoperative outcomes after emergency colon surgery. METHODS: Data originated from the American College of Surgeons National Surgical Quality Improvement Program database from 2010 to 2012. Patients undergoing emergent colectomy were stratified based on location: not transferred, transferred from outside emergency department (ED), transferred from outside hospital inpatient unit, or transferred from a nursing home. Patient variables were stratified and compared via χ and analysis of variance. A backward-multivariable logistic regression and adjusted multivariate Cox regression analysis were performed to determine factors predicting 30-day mortality. RESULTS: A total of 14,245 patients were identified, of whom 22% (3,203) were transfer patients. Among transfers, 48% (1,531) came from outside hospital inpatient units. Thirty-day mortality varied significantly (p < 0.001) among transfer location: 12.8% when not transferred, 19.4% from outside EDs, 25.7% from outside hospital inpatient units, and 34.2% from nursing homes. Hazard ratios were 1.30 (p < 0.001) after transfer from outside hospital inpatient ward and 1.50 (p < 0.001) after transfer from nursing home. Patients transferred from nursing homes were more likely to have septic shock (26.9% vs. 11.6%, p < 0.001) and longer hospitalizations (13 days vs. 10 days, p < 0.001) versus those not transferred. CONCLUSION: Transfer status is an independent contributor to death in emergency general surgery patients undergoing colectomy. Patients transferred from an outside hospital ED, nursing home or chronic care facility have the poorest outcomes. These results reinforce the importance of rapid triage and transfer of patients with early physiologic decompensation to ensure timely surgical evaluation and intervention. LEVEL OF EVIDENCE: Prognostic, level III; Therapeutic, level IV.

Psychiatric illness and resident assaults among veterans in long-term care facilities.

This article describes a quality improvement program to reduce the prevalence of physical assaults in a university-affiliated, 234-bed Veterans Affairs (VA) long-term care (LTC) facility, which experienced a rise in the number of physical assaults to >4 per 1,000 bed days of care in four LTC units. Analysis of 55 events (29 patients) at this VA LTC site during 2007 revealed 19 resident assailants (8% total population), 10 victims, and 30% repeat events. Of the residents who exhibited assaultive behavior, 44% had dementia and 32% had schizophrenia as a major diagnosis. Following a process improvement plan, new occurrence assaultive behaviors declined from >4 to <1 per 1,000 bed days and remained low during 5-year follow up.

A staff training and management intervention in VA long-term care: impact on feeding assistance care quality.

Efforts to translate efficacious interventions into long-term care practice have had limited success due to the lack of consideration of key translational intervention components. A multi-faceted intervention was implemented in two veteran affairs facilities to improve feeding assistance care. There were three study phases: baseline, intervention, and follow-up. During each phase, trained research staff conducted standardized observations of 12 meals/participant to assess feeding assistance care quality. The staff received three initial training sessions followed by six consecutive weeks of feedback sessions wherein the observation-based care process measures were shared with the staff. There were significant, but modest, improvements in mealtime feeding assistance care processes, and most of the improvements were maintained during follow-up. A multi-faceted intervention resulted in significant, but modest, improvements in mealtime feeding assistance care quality. Organizational (staff schedules, communication) and environmental (dining location) barriers were identified that interfered with improvement efforts.

The quality of feeding assistance care practices for long-term care veterans: implications for quality improvement efforts.

The primary purpose of this study was to determine the quality of feeding assistance care and identify areas in need of improvement for a sample of long-term care veterans. A secondary purpose was to compare these findings with the results of previous studies in community facilities to determine ways in which the VA sample might differ. A repeated measures observational study was conducted in two VA facilities with 200 long-stay residents. Research staff conducted standardized observations during and between meals for 3 months. There was a trend for better feeding assistance care quality during meals in the VA sample, but there were still multiple aspects of care in need of improvement both during and between meals. Higher licensed nurse staffing levels in the VA should enable effective supervision and management, but observation-based measures of care quality are necessary for accurate information about daily feeding assistance care provision.