Failure events in transition of care for surgical patients.

BACKGROUND: Unexpected clinical deterioration (failure events) in surgical patients on standard nursing units (WARDs) could have a significant impact on eventual survival. We sought to investigate failure events requiring intensive care (surgical ICU [SICU]) transfer of surgical patients on WARDs in a single-center academic setting. STUDY DESIGN: Surgical patients admitted to WARDs over a 12-month period, who developed failure events, were retrospectively reviewed. Time to deterioration since WARD arrival, clinical factors, notification chain, and outcomes were identified. A physician review panel determined the preventability of failure events. RESULTS: Ninety-eight patients experienced 111 failure events requiring SICU transfer. Most patients (85%) were emergency admissions. Of 111 events, 90% had been previously discharged from an SICU or a postanesthesia care unit (PACU). Recognition of failure was by nursing (54%) and on routine physician rounds (34%). Rapid response or code blue alone was less common (12%). A second physician notification was needed in 29%, with delays due to failure to identify severity of illness. Most commonly, respiratory events prompted notification (77 of 111, 69%). Overall mortality was 26 of 98 (27%). Median time to failure was 2 days and was associated with early transfer from the SICU or PACU. Rapid response or code blue activation was associated with higher mortality than physician notification. CONCLUSIONS: Patients most at risk for WARD failures were those with acute surgical emergencies or recently discharged from the SICU or PACU. Respiratory complications were the most common cause of WARD failure events. Many early failures may have been due to premature transfer from the SICU or PACU. Failure events on WARDs can have lethal consequences. Awareness, monitoring, and communication are important components of preventative measures.

Cause of death from liver metastases in colorectal cancer.

BACKGROUND: Surgically directed therapy for liver metastases from colorectal cancer (CRC) has received substantial attention in the literature as a major focus of treatment for metastatic CRC. It is presumed, but not proven, that liver metastases are a major threat to life. This study examined the course of a cohort of consecutive patients who died with CRC to determine the role played by the presence of liver metastases. METHODS: This is single-institution retrospective observational study involved all patients who died of CRC. Records were examined and imaging studies reviewed to determine the extent of liver and extrahepatic metastases in these patients. Overall survival in patients with and without liver metastases and those in whom liver metastases were thought to contribute to death was determined. RESULTS: After patient exclusions, the study population totaled 121 patients. There were 75 patients (62%) with liver metastases at death. In 40 of 75 (53%) patients, the liver metastases contributed to the patients' death. In 46 of 121 patients (38%), metastatic disease did not include liver metastases. Overall survival in patients with and without liver metastases (median survival 12 vs. 8.5 months, p = 0.089) and in those whose liver metastases did or did not contribute to death (median survival 11.5 vs. 14 months, p = 0.361) was not significant. CONCLUSIONS: The presence of liver metastases seemed to contribute to death in approximately half of the study patients, although there did not appear to be a survival disadvantage in these patients.