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1.
Clin Neurol Neurosurg ; 188: 105585, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31756619

RESUMO

OBJECTIVE: Overlapping surgery, accepted by many as two distinct operations occurring at the same time but without coincident critical portions, has been said to improve patient access to surgical care. With recent controversy, some are opposed to this practice due to concerns regarding its safety. In this manuscript, we sought to investigate the perceptions of overlapping surgery among neurosurgical leadership and the association of these perceptions with neurosurgical case volume. PATIENTS AND METHODS: We conducted a self-administered survey of neurosurgery department chair and residency program directors of institutions participating in the Vizient Clinical Database/Resource (CDB/RM), an administrative database of 117 United States (US) medical centers and their 300 affiliated hospitals. We queried participants regarding yearly departmental case-volume, frequency of overlapping surgery in daily practice and the degree of overlapping they find acceptable. RESULTS: Of the 236 surveys disseminated, a total of 70 responses were received with a response rate of 29.7.%, which is comparable to previously reported response rates among neurosurgeons and other physicians. Our respondents consisted of 43 of 165 chairs (26.1.%) and 27 of 66 program directors (40.0.%) representing 64 unique hospitals/institutions out of 216 (29.6.%). Based on the responses to question involving case volume, we divided our responders into high volume hospitals (HVH) (n = 44; > 2000 cases per year) and low volume hospitals (LVH) (N = 26). More HVH were found to have frequent occurrence of overlapping surgery (50% weekly and 20.9.% daily vs LVH's 26.9.% weekly and 3.8.% daily, p = 0.003) and considered two overlapping surgeries without overlap of critical portion as acceptable (38.6.% vs 26.9.%, p = 0.10). CONCLUSIONS: Our survey results showed that neurosurgical departments with high-volume practices were more likely to practice overlapping surgery on a regular basis and to view it as an acceptable practice. The association between overlapping surgery and the volume-outcome relationship should be further evaluated.

2.
J Cardiothorac Vasc Anesth ; 33(9): 2453-2461, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31307910

RESUMO

OBJECTIVE: The objective of this retrospective review was to evaluate the perioperative and procedural management of patients with pulmonary alveolar proteinosis (PAP) who presented for whole-lung lavage (WLL). DESIGN: The records of all adult patients with PAP who underwent WLL between January 1, 1988 and August 20, 2017 were reviewed and pertinent demographic, preoperative, anesthetic, procedural, and postoperative data were recorded. SETTING: Large academic tertiary referral center. PARTICIPANTS: Forty patients with PAP underwent 79 WLL procedures. INTERVENTIONS: Patients with PAP undergoing WLL. MEASUREMENTS: Successful WLL, defined by visual clearing of lavage fluid, was completed in 91% of cases. Whole-lung lavage was terminated prematurely in 9% of cases (refractory hypoxia most common), while 8% of cases were found to have 30-day complications. There were no cases of intraoperative death, hemodynamic collapse, pneumothorax or hydrothorax, or need for emergent reintubation. Postoperative clinical follow-up at the authors' institution within 6 months of WLL showed 68% of patients reported improvement in symptoms and/or functional status. CONCLUSION: The authors here present a retrospective study describing the perioperative and procedural management of PAP patients undergoing WLL to help familiarize providers with the management of this population (Fig 1). The findings of this study outline a successful and consistent approach to WLL using a multidisciplinary team experienced in this procedure. Even in experienced hands, procedural complications and 30-day postoperative complications emphasize the risk in this complex patient population.

3.
J Anesth ; 33(3): 372-380, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30976907

RESUMO

PURPOSE: While high body mass index (BMI) is a recognized risk factor for pulmonary complications in adults, its importance as a risk factor for complications following pediatric surgery is poorly described. We evaluated the association between BMI and severe pediatric perioperative pulmonary complications (PPCs). METHODS: In this retrospective cohort study, we evaluated pediatric patients (aged 2-17 years) undergoing elective procedures in the 2015 Pediatric National Surgical Quality Improvement Program (NSQIP-P). Severe PPCs were defined as either pneumonia/reintubation within 3 days of surgery, or pneumonia/reintubation as an index complication within 7 days. Univariate and multivariable logistic regression analyses adjusting for patient factors and surgical case-mix tested associations between BMI class-using the Centers for Disease Control age- and sex-dependent BMI percentiles-and severe PPCs. RESULTS: Among 40,949 patients, BMI class was distributed as follows: 2740 (6.7%) were underweight, 23,630 (57.7%) normal weight, 6161 (15.0%) overweight, and 8418 (20.6%) obese. Overweight BMI class was not associated with PPCs in univariate analyses, but became statistically significant after adjustment [OR 1.84 (95% CI 1.07-3.15), p = 0.03], and persisted across multiple adjustment approaches. Neither underweight [OR 1.01 (95% CI 0.53-1.94), p = 0.97] nor obesity [OR 1.10 (95% CI 0.63-1.94), p = 0.73] were associated with PPCs after adjustment. CONCLUSION: Overweight pediatric patients have an elevated, previously underappreciated risk of severe PPCs. Contrary to prior studies, the present study found no greater risk in obese children, perhaps due to bias, confounding, or practice migration from "availability bias". Findings from the present study, taken with prior work describing pulmonary risks of obesity, suggest that both obese and overweight children may be evaluated for tailored perioperative care to improve outcomes.

4.
Gastroenterol Rep (Oxf) ; 7(1): 13-23, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30792862

RESUMO

Acute pancreatitis (AP) associated with intravenous administration of propofol has been described with unknown causal relation. We therefore assessed this causality in a systematic review. Multiple databases were searched on 16 August 2017; studies were appraised and selected by two reviewers based on a priori criteria. Propofol causality was evaluated with the Naranjo scale and Badalov classification. We identified 18 studies from 11 countries with a total of 21 patients, and the majority had adequate methodological quality. The median age was 35 years (range, 4-77) and 10 (48%) were males. Overall, propofol was administrated in 8 patients as sedative along with induction/maintenance of anesthesia in 13 patients; median dose was 200 mg, with intermediate latency (1-30 days) in 14 (67%). Serum triglycerides were >1000 mg/dL in four patients. Severe AP was observed in four patients (19%). AP recurrence occurred in one out of two patients who underwent rechallenge. Mortality related to AP was 3/21(14%). Propofol was the probable cause of AP according to the Naranjo scale in 19 patients (89%). Propofol-induced AP has a probable causal relation and evidence supports Badalov class Ib. Hypertriglyceridemia is not the only mechanism by which propofol illicit AP. Propofol-induced AP was severe in 19% of patients with a mortality rate related to AP of 14%. Future research is needed to delineate whether this risk is higher if combined with other procedures that portend inherent risk of pancreatitis such as endoscopic retrograde cholangiopancreatography.

5.
Anesth Analg ; 129(1): 301-305, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-30489314

RESUMO

The American Society of Anesthesiologists (ASA) Annual Meeting is the primary venue for anesthesiologists to present research, share innovations, and build networks. Herein, we describe gender representation for physician speakers at the Annual Meeting relative to the specialty overall. Details of ASA Annual Meeting presentations for individuals and panels were abstracted from the ASA archives for 2011-2016. Observed speaker gender composition was compared to expected composition based on the gender distribution of members of the ASA. There were 5167 speaker slots across 2025 presentations and panels. Of the speaker slots, 3874 were assigned to men and 1293 to women. Speaker slot gender composition was relatively consistent between 2011 and 2016 (annual percentage 22.3%-27.7% women, trend test P = .062). ASA membership composition of women increased slightly over the study period (24%-28%). The overall observed number of women in speaker slots over the study period did not differ significantly from what would be expected based on the ASA membership composition (25.0% observed versus 25.9% expected; P = .153). However, the percentage of single speakers who were women was significantly less than would be expected based on the ASA gender distribution (20.2% observed versus 25.9% expected; P < .001). Interestingly, for panels that included 2-5 anesthesiologists, single-gender panels were more common than would be expected by chance, with all-male panels predominating (all P < .01). The gender composition of speakers at the ASA Annual Meeting largely reflected gender composition within the specialty, although women were not overrepresented at any meeting. The predominance of single-gender panels and underrepresentation of women as single speakers is a potential target to improve gender representation.


Assuntos
Anestesiologistas/tendências , Anestesiologia/tendências , Pesquisa Biomédica/tendências , Médicas/tendências , Pesquisadores/tendências , Sexismo/tendências , Fala , Congressos como Assunto/tendências , Feminino , Humanos , Masculino , Fatores Sexuais , Sociedades Médicas/tendências
6.
Crit Care Med ; 47(1): 109-113, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30303840

RESUMO

OBJECTIVES: We examined recommendations within critical care guidelines to describe the pairing patterns for strength of recommendation and quality of evidence. We further identified recommendations where the reported strength of recommendation was strong while the reported quality of evidence was not high/moderate and then assessed whether such pairings were within five paradigmatic situations offered by Grading of Recommendations Assessment, Development and Evaluation methodology to justify such pairings. DATA SOURCES AND EXTRACTION: We identified all clinical critical care guidelines published online from 2011 to 2017 by the Society of Critical Care Medicine along with individual guidelines published by Surviving Sepsis Campaign, Kidney Disease Improving Global Outcomes, American Society for Parenteral and Enteral Nutrition, and the Infectious Disease Society of America/American Thoracic Society. DATA SYNTHESIS: In all, 15 documents specifying 681 eligible recommendations demonstrated variation in strength of recommendation (strong n = 215 [31.6%], weak n = 345 [50.7%], none n = 121 [17.8%]) and in quality of evidence (high n = 41 [6.0%], moderate n = 151 [22.2%], low/very low n = 298 [43.8%], and Expert Consensus/none n = 191 [28.1%]). Strength of recommendation and quality of evidence were positively correlated (ρ = 0.66; p < 0.0001). Of 215 strong recommendations, 69 (32.1%) were discordantly paired with evidence other than high/moderate. Twenty-two of 69 (31.9%) involved Strong/Expert Consensus recommendations, a category discouraged by Grading of Recommendations Assessment, Development and Evaluation methodology. Forty-seven of 69 recommendations (68.1%) were comprised of Strong/Low or Strong/Very Low variation requiring justification within five paradigmatic scenarios. Among distribution in the five paradigmatic scenarios of Strong/Low and Strong/Very Low recommendations, the most common paradigmatic scenario was life threatening situation (n = 20/47; 42.6%). Four Strong/Low or Strong/Very Low recommendations (4/47; 8.5%) were outside Grading of Recommendations Assessment, Development and Evaluation methodology. CONCLUSIONS: Among a large, diverse assembly of critical care guideline recommendations using Grading of Recommendations Assessment, Development and Evaluation methodology, the strength of evidence of a recommendation was generally associated with the quality of evidence. However, strong recommendations were not infrequently made in the absence of high/moderate quality of evidence. To improve clarity and uptake, future guideline statements may specify why such pairings were made, avoid such pairings when outside of Grading of Recommendations Assessment, Development and Evaluation criteria, and consider separate language for Expert Consensus recommendations (good practice statements).


Assuntos
Cuidados Críticos/normas , Guias de Prática Clínica como Assunto/normas , Medicina Baseada em Evidências , Humanos , Sociedades Médicas
8.
Surg Infect (Larchmt) ; 19(4): 403-409, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29608437

RESUMO

BACKGROUND: Whether the fraction of inspired oxygen (FIO2) influences the risk of surgical site infection (SSI) is controversial. The World Health Organization and the World Federation of Societies of Anesthesiologists offer conflicting recommendations. In this study, we evaluate simultaneously three different definitions of FIO2 exposure and the risk of SSI in a large surgical population. PATIENTS AND METHODS: Patients with clean (type 1) surgical incisions who developed superficial and deep organ/space SSI within 30 days after surgery from January 2003 through December 2012 in five surgical specialties were matched to specialty-specific controls. Fraction of inspired oxygen exposure was defined as (1) nadir FIO2, (2) percentage of operative time with FIO2 greater than 50%, and (3) cumulative hyperoxia exposure, calculated as the area under the curve (AUC) of FIO2 by time for the duration in which FIO2 greater than 50%. Stratified univariable and multivariable logistic regression models tested associations between FIO2 and SSI. RESULTS: One thousand two hundred fifty cases of SSI were matched to 3,248 controls. Increased oxygen exposure, by any of the three measures, was not associated with the outcome of any SSI in a multivariable logistic regression model. Elevated body mass index (BMI; 35+ vs. <25, odds ratio [OR] 1.78, 95% confidence interval [CI] 1.43-2.24), surgical duration (250+ min vs. <100 min, OR 1.93, 95% CI 1.48-2.52), diabetes mellitus (OR 1.37, 95% CI 1.13-1.65), peripheral vascular disease (OR 1.52, 95% CI 1.10-2.10), and liver cirrhosis (OR 2.48, 95% CI 1.53-4.02) were statistically significantly associated with greater odds of any SSI. Surgical sub-group analyses found higher intra-operative oxygen exposure was associated with higher odds of SSI in the neurosurgical and spine populations. CONCLUSION: Increased intra-operative inspired fraction of oxygen was not associated with a reduction in SSI. These findings do not support the practice of increasing FIO2 for the purpose of SSI reduction in patients with clean surgical incisions.


Assuntos
Oxigênio/administração & dosagem , Infecção da Ferida Cirúrgica/epidemiologia , Infecção da Ferida Cirúrgica/prevenção & controle , Ferida Cirúrgica , Administração por Inalação , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Medição de Risco , Resultado do Tratamento , Adulto Jovem
9.
J Ambul Care Manage ; 41(2): 118-127, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29474251

RESUMO

Although ambulatory surgery offers patients convenience and reduced costs, same-day cancellation of ambulatory surgery negatively affects patient experiences and operational efficiency. We conducted a retrospective analysis to determine the frequency and reasons for same-day cancellations in an outpatient surgery center at a large academic tertiary referral center. Of 41 389 ambulatory surgical procedures performed, same-day cancellations occurred at a rate of 0.5% and were usually unforeseeable in nature. Focusing on foreseeable cancellations offers opportunities for enhanced patient satisfaction, improved quality of care, and systems-based practice improvements to mitigate cancellations related to areas such as scheduling or patient noncompliance.


Assuntos
Procedimentos Cirúrgicos Ambulatórios , Agendamento de Consultas , Centros de Atenção Terciária , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Registros Médicos , Pessoa de Meia-Idade , Estudos Retrospectivos , Centros Cirúrgicos
10.
Ann Surg ; 268(2): e24-e27, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29373366

RESUMO

IMPORTANCE: Media reports have questioned the safety of overlapping surgical procedures, and national scrutiny has underscored the necessity of single-center evaluations of its safety; however, sample sizes are likely small. We compared the safety profiles of overlapping and nonoverlapping pediatric procedures at a single children's hospital and discussed methodological considerations of the evaluation. DATA AND DESIGN: Retrospective analysis of inpatient pediatric surgical procedures (January 2013 to September 2015) at a single pediatric referral center. Overlapping and nonoverlapping procedures were matched in an unbalanced manner (m:n) by procedure. Mixed models adjusting for Vizient-predicted risk, case-mix, and surgeon compared inpatient mortality and length of stay (LOS). RESULTS: Among 315 overlapping procedures, 256 (81.3%) were matched to 645 nonoverlapping procedures. There were 6 deaths in all. The adjusted odds ratio for mortality did not differ significantly between nonoverlapping and overlapping procedures (adjusted odds ratio = 0.94 vs overlapping; 95% CI, 0.02-48.5; P = 0.98). Wide confidence intervals were minimally improved with Bayesian methods (95% CI, 0.07-12.5). Adjusted LOS estimates were not clinically different by overlapping status (0.6% longer for nonoverlapping; 95% CI, 9.7% shorter to 12.2% longer; P = 0.91). Among the 87 overlapping procedures with the greatest overlap (≥60 min or ≥50% of operative duration), there were no deaths. CONCLUSIONS: The safety of overlapping and nonoverlapping surgical procedures did not differ at this children's center. These findings may not extrapolate to other centers. LOS or intraoperative measures may be more appropriate than mortality for safety evaluations due to low event rates for mortality.


Assuntos
Mortalidade Hospitalar , Hospitais Pediátricos/normas , Tempo de Internação/estatística & dados numéricos , Segurança do Paciente/estatística & dados numéricos , Procedimentos Cirúrgicos Operatórios/métodos , Adolescente , Criança , Pré-Escolar , Feminino , Hospitais Pediátricos/estatística & dados numéricos , Humanos , Lactente , Recém-Nascido , Masculino , Modelos Estatísticos , Razão de Chances , Duração da Cirurgia , Garantia da Qualidade dos Cuidados de Saúde , Estudos Retrospectivos , Procedimentos Cirúrgicos Operatórios/mortalidade , Procedimentos Cirúrgicos Operatórios/normas
11.
Am J Hosp Palliat Care ; 35(3): 377-383, 2018 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-28571496

RESUMO

BACKGROUND: End-of-life (EOL) care intensity is known to vary by secular and geographic patterns. US physicians receive less aggressive EOL care than the general population, presumably the result of preferences shaped by work-place experience with EOL care. OBJECTIVE: We investigated occupation as a source of variation in EOL care intensity. METHODS: Across 4 states, we identified 660 599, nonhealth maintenance organization Medicare beneficiaries aged ≥66 years who died between 2004 and 2011. Linking death certificates, we identified beneficiaries with prespecified occupations: nurses, farmers, clergy, mortuary workers, homemakers, first-responders, veterinary workers, teachers, accountants, and the general population. End-of-life care intensity over the last 6 months of life was assessed using 5 validated measures: (1) Medicare expenditures, rates of (2) hospice, (3) surgery, (4) intensive care, and (5) in-hospital death. RESULTS: Occupation was a source of large variation in EOL care intensity across all measures, before and after adjustment for sex, education, age-adjusted Charlson Comorbidity Index, race/ethnicity, and hospital referral region. For example, absolute and relative adjusted differences in expenditures were US$9991 and 42% of population mean expenditure ( P < .001 for both). Compared to the general population on the 5 EOL care intensity measures, teachers (5 of 5), homemakers (4 of 5), farmers (4 of 5), and clergy (3 of 5) demonstrated significantly less aggressive care. Mortuary workers had lower EOL care intensity (4 of 5) but small numbers limited statistical significance. CONCLUSION: Occupations with likely exposure to child development, death/bereavement, and naturalistic influences demonstrated lower EOL care intensity. These findings may inform patients and clinicians navigating choices around individual EOL care preferences.


Assuntos
Ocupações/estatística & dados numéricos , Assistência Terminal/estatística & dados numéricos , Fatores Etários , Idoso , Cuidados Críticos/estatística & dados numéricos , Feminino , Gastos em Saúde/estatística & dados numéricos , Cuidados Paliativos na Terminalidade da Vida/estatística & dados numéricos , Mortalidade Hospitalar , Humanos , Masculino , Medicare/economia , Medicare/estatística & dados numéricos , Características de Residência , Fatores Sexuais , Fatores Socioeconômicos , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Estados Unidos
16.
J Am Coll Surg ; 224(2): 160-171, 2017 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-27825917

RESUMO

BACKGROUND: Numerous surgical quality metrics focus on prevention of unintentional perioperative hypothermia due, in part, to the association between hypothermia and surgical site infections (SSI). However, few studies have comprehensively evaluated the relationship between these metrics and SSI. In this study, we evaluated individual components of 1 set of hypothermia metrics to determine their association with SSI. STUDY DESIGN: Patients with clean (class I) wounds who developed an SSI within 30 days after surgery, from January 2003 to December 2012, in 1 of 5 surgical specialties, were matched to specialty-specific controls without SSI. Stratified logistic regression models were used to assess the associations between (1) compliance with the Surgical Care Improvement Project (SCIP) Performance Measure, Surgery Patients with Perioperative Temperature Management (SCIP-Inf-10), overall and its components (maintenance of minimum body temperature and use of an active warming device) and SSI and (2) intraoperative hypothermia. RESULTS: In both univariate and adjusted analyses using adjusted odds ratios (OR), SCIP-Inf-10 compliance was not associated with SSI (composite compliance OR 0.89, 95% CI 0.63 to 1.24; temperature compliance OR 0.92, 95% CI 0.78 to 1.09; forced-air warming device compliance OR 0.95, 95% CI 0.76 to 1.19). Higher intraoperative nadir temperature (OR 1.19, 95% CI 1.05 to 1.35) was associated with SSI. Percent of time exposed to a temperature < 36°C (OR 0.98, 95% CI 0.96 to 1.01), and cumulative hypothermic exposure (°C*h <36°C) (OR 0.98, 95% CI 0.90 to 1.05) were not associated with SSI. CONCLUSIONS: Intraoperative hypothermia was not significantly associated with SSI. These results suggest that development of compliance metrics may not be an effective strategy for SSI reduction in class I surgical wounds.


Assuntos
Hipotermia/prevenção & controle , Complicações Intraoperatórias/prevenção & controle , Assistência Perioperatória/métodos , Melhoria de Qualidade , Infecção da Ferida Cirúrgica/prevenção & controle , Adulto , Idoso , Estudos de Casos e Controles , Feminino , Humanos , Hipotermia/etiologia , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Assistência Perioperatória/normas , Estudos Retrospectivos , Fatores de Risco , Infecção da Ferida Cirúrgica/etiologia , Resultado do Tratamento
17.
Ann Surg ; 265(3): e23-e25, 2017 03.
Artigo em Inglês | MEDLINE | ID: mdl-27849669

RESUMO

Publicly reported hospital ratings aim to encourage transparency, spur quality improvement, and empower patient choice. Travel burdens may limit patient choice, particularly for older adults (aged 65 years and more) who receive most medical care. For 3 major hospital ratings systems, we estimated travel burden as the additional 1-way travel distance to receive care at a better-rated hospital.Distances were estimated from publicly available data from the US Census, US News Top Hospitals, Society of Thoracic Surgeons composite rating for coronary artery bypass grafting (STS-CABG), and Centers for Medicare and Medicaid Services Hospital Consumer Assessment of Healthcare Providers and Services (HCAHPS).Hospitals were rated for HCAHPS (n = 4656), STS-CABG (n = 470), and US News Top Hospitals (n = 15). Older adults were commonly located within 25 miles of their closest HCAHPS hospital (89.6%), but less commonly for STS-CABG (62.9%). To receive care at a better-rated hospital, travel distances commonly exceeded 25 miles: HCAHPS (39.2%), STS-CABG (62.7%), and US News Top Hospital (85.2%). Additional 1-way travel distances exceeded 25 miles commonly: HCAHPS (23.7%), STS-CABG (36.7%), US News Top Hospitals (81.8%).Significant travel burden is common for older adults seeking "better" care and is an important limitation of current hospital ratings for empowering patient choice.


Assuntos
Hospitais/normas , Preferência do Paciente/estatística & dados numéricos , Indicadores de Qualidade em Assistência à Saúde , Viagem , Idoso , Feminino , Hospitais/estatística & dados numéricos , Humanos , Masculino , Turismo Médico , Pessoa de Meia-Idade , Satisfação do Paciente/estatística & dados numéricos , Estados Unidos
18.
Ann Surg ; 265(4): 639-644, 2017 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-27922837

RESUMO

OBJECTIVE: To compare safety profiles of overlapping and nonoverlapping surgical procedures at a large tertiary-referral center where overlapping surgery is performed. BACKGROUND: Surgical procedures are frequently performed as overlapping, wherein one surgeon is responsible for 2 procedures occurring at the same time, but critical portions are not coincident. The safety of this practice has not been characterized. METHODS: Primary analyses included elective, adult, inpatient surgical procedures from January 2013 to September 2015 available through University HealthSystem Consortium. Overlapping and nonoverlapping procedures were matched in an unbalanced manner (m:n) by procedure type. Confirmatory analyses from the American College of Surgeons-National Surgical Quality Improvement Program investigated elective surgical procedures from January 2011 to December 2014. We compared outcomes mortality and length of stay after adjustment for registry-predicted risk, case-mix, and surgeon using mixed models. RESULTS: The University HealthSystem Consortium sample included 10,765 overlapping cases, of which 10,614 (98.6%) were matched to 16,111 nonoverlapping procedures. Adjusted odds ratio for inpatient mortality was greater for nonoverlapping procedures (adjusted odds ratio, OR = 2.14 vs overlapping procedures; 95% confidence interval, CI 1.23-3.73; P = 0.007) and length of stay was no different (+1% for nonoverlapping cases; 95% CI, -1% to +2%; P = 0.50). In confirmatory analyses, 93.7% (3712/3961) of overlapping procedures matched to 5,637 nonoverlapping procedures. The 30-day mortality (adjusted OR = 0.69 nonoverlapping vs overlapping procedures; 95% CI, 0.13-3.57; P = 0.65), morbidity (adjusted OR = 1.11; 95% CI, 0.92-1.35; P = 0.27) and length of stay (-4% for nonoverlapping; 95% CI, -4% to -3%; P < 0.001) were not clinically different. CONCLUSIONS: These findings from administrative and clinical registries support the safety of overlapping surgical procedures at this center but may not extrapolate to other centers.


Assuntos
Mortalidade Hospitalar/tendências , Hospitais com Alto Volume de Atendimentos , Segurança do Paciente , Encaminhamento e Consulta , Procedimentos Cirúrgicos Operatórios/métodos , Adulto , Intervalos de Confiança , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Procedimentos Cirúrgicos Eletivos/métodos , Procedimentos Cirúrgicos Eletivos/mortalidade , Feminino , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Razão de Chances , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/fisiopatologia , Sistema de Registros , Estudos Retrospectivos , Medição de Risco , Gestão da Segurança , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Procedimentos Cirúrgicos Operatórios/mortalidade , Estados Unidos
19.
Surg Infect (Larchmt) ; 17(6): 755-760, 2016 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-27598433

RESUMO

BACKGROUND: Surgical site infections (SSI) contribute to surgical patients' morbidity and costs. Operating room traffic may be a modifiable risk factor for SSI. We investigated the impact of additional operating room personnel on the risk of superficial SSI (sSSI). PATIENTS AND METHODS: In this matched case-control study, cases included patients in whom sSSI developed in clean surgical incisions after elective, daytime operations. Control subjects were matched by age, gender, and procedure. Operating room personnel were classified as (1) surgical scrubbed, (2) surgical non-scrubbed, or (3) anesthesia. We used conditional logistic regression to test the extent to which additional personnel overall and from each work group were associated with infection. RESULTS: In total, 474 patients and 803 control subjects were identified. Each additional person among total personnel and personnel from each work group was significantly associated with greater odds of infection (all personnel, odds ratio [OR] = 1.082, 95% confidence interval [CI] 1.031-1.134, p = 0.0013; surgical scrubbed OR = 1.132, 95% CI 1.029-1.245, p = 0.0105; surgical non-scrubbed OR = 1.123, 95% CI 1.008-1.251, p = 0.0357; anesthesia OR = 1.153, 95% CI 1.031-1.290, p = 0.0127). After adjusting for operative duration, body mass index, diabetes mellitus, and vascular disease, additional personnel and sSSI were no longer associated overall or for any work groups (total personnel OR = 1.033, 95% CI 0.974-1.095, p = 0.2746; surgical scrubbed OR = 1.060, 95% CI 0.952-1.179, p = 0.2893; surgical non-scrubbed OR = 1.023 95% CI 0.907-1.154, p = 0.7129; anesthesia OR = 1.051, 95% CI 0.926-1.193, p = 0.4442). CONCLUSION: The presence of additional operating room personnel was not independently associated with increased odds of sSSI. Efforts dedicated to sSSI reduction should focus on other modifiable risk factors.


Assuntos
Pessoal de Saúde/estatística & dados numéricos , Salas Cirúrgicas/estatística & dados numéricos , Infecção da Ferida Cirúrgica/epidemiologia , Adulto , Idoso , Estudos de Casos e Controles , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Risco
20.
J Crit Care ; 36: 81-84, 2016 12.
Artigo em Inglês | MEDLINE | ID: mdl-27546752

RESUMO

BACKGROUND: Performance measurement is essential for quality improvement and is inevitable in the shift to value-based payment. The National Quality Forum is an important clearinghouse for national performance measures in health care in the United States. AIM: We reviewed the National Quality Forum library of performance measures to highlight measures that are relevant to critical care medicine, and we describe gaps and opportunities for the future of performance measurement in critical care medicine. CONCLUSION: Crafting performance measures that address core aspects of critical care will be challenging, as current outcome and performance measures have problems with validity. Future quality measures will likely focus on interdisciplinary measures across the continuum of patient care.


Assuntos
Cuidados Críticos/normas , Unidades de Terapia Intensiva/normas , Melhoria de Qualidade , Indicadores de Qualidade em Assistência à Saúde , Política de Saúde , Humanos , Estados Unidos
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