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1.
J Surg Res ; 245: 629-635, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31522036

RESUMO

BACKGROUND: Emergency general surgery (EGS) accounts for more than 2 million U.S. hospital admissions annually. Low-income EGS patients have higher rates of postoperative adverse events (AEs) than high-income patients. This may be related to health care segregation (a disparity in access to high-quality centers). The emergent nature of EGS conditions and the limited number of EGS providers in rural areas may result in less health care segregation and thereby less variability in EGS outcomes in rural areas. The objective of this study was to assess the impact of income on AEs for both rural and urban EGS patients. MATERIALS AND METHODS: The National Inpatient Sample (2007-2014) was queried for patients receiving one of 10 common EGS procedures. Multivariate regression models stratified by income quartiles in urban and rural cohorts adjusting for sociodemographic, clinical, and other hospital-based factors were used to determine the rates of surgical AEs (mortality, complications, and failure to rescue [FTR]). RESULTS: 1,687,088 EGS patients were identified; 16.60% (n = 280,034) of them were rural. In the urban cohort, lower income quartiles were associated with higher odds of AEs (mortality OR, 1.21 [95% CI, 1.15-1.27], complications, 1.07 [1.06-1.09]; FTR, 1.17 [1.10-1.24] P < 0.001). In the rural context, income quartiles were not associated with the higher odds of AE (mortality OR, 1.14 [0.83-1.55], P = 0.42; complications, 1.06 [0.97-1,16], P = 1.17; FTR, 1.12 [0.79-1.59], P = 0.52). CONCLUSIONS: Lower income is associated with higher postoperative AEs in the urban setting but not in a rural environment. This socioeconomic disparity in EGS outcomes in urban settings may reflect health care segregation, a differential access to high-quality health care for low-income patients.


Assuntos
Tratamento de Emergência/efeitos adversos , Disparidades em Assistência à Saúde/economia , Renda/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Adolescente , Adulto , Serviço Hospitalar de Emergência/estatística & dados numéricos , Tratamento de Emergência/estatística & dados numéricos , Falha da Terapia de Resgate/estatística & dados numéricos , Feminino , Acesso aos Serviços de Saúde/economia , Acesso aos Serviços de Saúde/estatística & dados numéricos , Disparidades em Assistência à Saúde/estatística & dados numéricos , Mortalidade Hospitalar , Hospitais Rurais/estatística & dados numéricos , Hospitais Urbanos/estatística & dados numéricos , Humanos , Pacientes Internados/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , População Rural/estatística & dados numéricos , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Estados Unidos/epidemiologia , População Urbana/estatística & dados numéricos , Adulto Jovem
2.
J Surg Oncol ; 120(8): 1327-1334, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31680251

RESUMO

BACKGROUND: Despite the popularity of the U.S. News and World Report (USNWR) hospital rankings among the general public, the relationship between hospital rankings and actual patient outcomes for major cancers remains poorly investigated. METHODS: Medicare Inpatient Standard Analytic Files were queried from 2013-2015 to assess the relationship of postoperative outcomes and Medicare expenditures among patients undergoing surgery for colorectal, lung, esophageal, pancreatic, and liver cancer at hospitals ranked in the top-50 USNWR vs hospitals ranked below 50. RESULTS: Among 94 599 patients, 13 217 vs 81 382 patients underwent surgery at a top-50 hospital versus a non-top 50 ranked hospital. Other than among patients who underwent colorectal surgery, the odds of postoperative complications were lower at top ranked vs non-top ranked hospitals (colorectal: OR, 1.46, 95% CI, 1.28-1.65; lung: OR, 0.73, 95% CI, 0.61-0.87; esophagus: OR, 0.70, 95% CI, 0.52-0.94; pancreas: OR, 0.81, 95% CI, 0.70-0.94; liver: OR, 0.85, 95% CI, 0.69-1.04). Moreover, the odds of 90-day mortality were lower at top ranked hospitals vs non-top ranked hospitals (colorectal: OR, 0.59, 95% CI, 0.48-74; lung: OR, 0.66, 95% CI, 0.53-0.82; esophagus: OR, 0.56, 95% CI, 0.40-0.80; pancreas: OR, 0.51, 95% CI, 0.40-0.65; liver: OR, 0.61, 95% CI, 0.44-0.84). Outcomes were comparable among hospitals within the top-50 rank. CONCLUSION: Mortality rates were lower at hospitals in the top-50 USNWR versus non-top ranked, yet hospitals within the top-50 USNWR rankings had comparable outcomes.


Assuntos
Hospitais/estatística & dados numéricos , Neoplasias/mortalidade , Neoplasias/cirurgia , Idoso , Idoso de 80 Anos ou mais , Falha da Terapia de Resgate/estatística & dados numéricos , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Readmissão do Paciente/estatística & dados numéricos , Publicações Periódicas como Assunto , Complicações Pós-Operatórias/epidemiologia , Estados Unidos/epidemiologia
3.
Am Surg ; 85(9): 973-977, 2019 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-31638509

RESUMO

Failure to rescue (FTR), defined as death after a major complication in surgical patients, is being used to measure outcomes for quality improvement. Major complications frequently occur in patients undergoing damage control laparotomy (DCL). No previous FTR studies have looked specifically into DCL patients. The aim of this study was to examine risk factors of FTR and identify potential areas for targeted quality improvement in DCL patients. A 10-year retrospective review of all consecutive adult trauma patients who underwent DCL at a Level I trauma center was performed. Demographic and clinical variables were examined for association with FTR. Multivariate regression analysis was performed to identify risk factors of FTR in DCL patients. A total of 199 DCL patients were analyzed. Overall DCL mortality observed was 11.1 per cent (n = 22/199) and overall FTR for the cohort was n = 16/199. FTR represented 72 per cent (n = 16/22) of the total mortality. The significantly increased risk of FTR was associated with older age (P = 0.027), lower initial Glasgow Coma Scale score (P = 0.037), more units of packed red blood cells (P = 0.028), and respiratory complications (P = 0.035). Renal and infectious complications did not significantly increase the risk of FTR in this population. FTR is an important benchmark of quality for trauma patients. This study elucidates potential initial characteristics and complications related to FTR in DCL patients. Efforts in achieving zero death from FTR can potentially improve overall mortality in this subset of patients. Future quality interventions to help minimize FTR should target these specific areas.


Assuntos
Falha da Terapia de Resgate , Laparotomia/efeitos adversos , Laparotomia/normas , Melhoria de Qualidade , Ferimentos e Lesões/cirurgia , Adulto , Fatores Etários , Transfusão de Eritrócitos , Feminino , Escala de Coma de Glasgow , Humanos , Masculino , Complicações Pós-Operatórias , Transtornos Respiratórios , Estudos Retrospectivos , Fatores de Risco , Centros de Traumatologia/normas , Estados Unidos
4.
Scand Cardiovasc J ; 53(4): 220-224, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31169422

RESUMO

Objectives. Two tools to categorize and present quality data, phase of care mortality analysis (POCMA) and failure to rescue (FTR) have been introduced in the cardiothoracic surgical environment, but not tested in Scandinavia. We aimed to investigate whether these tools could be used in a Norwegian patient population and to increase the understanding of why patients die after cardiac surgery. Design. A group of four, including one senior cardiothoracic surgeon and one senior anesthesiologist, scrutinized deaths within 30 days after cardiac surgery at the Clinic of Cardiothoracic Surgery, St. Olav's University Hospital, Norway between February 2012-October 2015 in line with the POCMA-methodology. We used the clinic's internal register to identify patients and utilized all available written information from each patient course. We decided whether each death was surgeon dependent, FTR or a result of a multifactorial etiology, and evaluated the strength of our decisions. Results. We identified 51 deaths out of 1983 operations in our study period, giving unadjusted mortality of 2.6%. Nine deaths were classified as surgeon dependent, 3 FTR and 39 multifactorial. Conclusions. POCMA- and FTR-analyses can be carried out in clinical data which is well documented. The operating surgeon is in many cases not responsible for operative mortality, very few die due to FTR, but most patients die due to a multifactorial etiology.


Assuntos
Procedimentos Cirúrgicos Cardíacos/mortalidade , Serviço Hospitalar de Cardiologia , Unidades de Cuidados Coronarianos , Falha da Terapia de Resgate , Mortalidade Hospitalar , Indicadores de Qualidade em Assistência à Saúde , Procedimentos Cirúrgicos Vasculares/mortalidade , Idoso , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Causas de Morte , Competência Clínica , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Noruega , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/efeitos adversos
5.
Surgery ; 165(6): 1116-1121, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-31072669

RESUMO

BACKGROUND: Failure to rescue is defined as death after a complication and has been used to evaluate quality of care in adult trauma patients, but there are no published studies on failure to rescue in pediatric trauma. The aim of this study was to define the relationship among rates of mortality, complications, and failure to rescue at centers caring for pediatric (<18 years of age) trauma patients in a nationally representative database. METHODS: We performed a retrospective cohort study of the 2015 and 2016 National Trauma Data Bank. We included patients <18 years of age with an Injury Severity Score of ≥9. We excluded centers with <50 pediatric patients or that reported no complications. We calculated the complication, failure to rescue, mortality, and precedence rates by center and divided centers into tertiles of mortality. We compared complication and failure-to-rescue rates between high and low tertiles of mortality using the Kruskal-Wallis test. RESULTS: Of 62,190 patients from 284 centers, 2,204 patients had at least 1 complication for an overall complication rate of 4% (center level 0%-15%), and 120 patients died after a complication for an overall failure-to-rescue rate of 5% (center level 0%-67%). High-mortality centers had both higher failure-to-rescue rates (10% vs 0.6%, P < .001) and higher complication rates (5% vs 4%, P = .001) than lower-mortality hospitals. The overall precedence rate was 15% with a median rate of 0% (interquartile range 0%-25%). CONCLUSION: Both complication and failure-to-rescue rates are low in the pediatric injury population, but both complication and failure-to-rescue rates are higher at higher-mortality centers. The low overall complication rates and precedence rates likely limit the utility of failure to rescue as a valid center-level metric in this population, but further investigation into individual failure-to-rescue cases may reveal important opportunities for improvement.


Assuntos
Benchmarking/métodos , Falha da Terapia de Resgate/estatística & dados numéricos , Mortalidade Hospitalar , Centros de Traumatologia/estatística & dados numéricos , Ferimentos e Lesões/mortalidade , Adolescente , Benchmarking/estatística & dados numéricos , Criança , Pré-Escolar , Bases de Dados Factuais/estatística & dados numéricos , Feminino , Humanos , Escala de Gravidade do Ferimento , Masculino , Melhoria de Qualidade , Estudos Retrospectivos , Ferimentos e Lesões/complicações , Ferimentos e Lesões/diagnóstico
7.
World J Gastroenterol ; 25(2): 258-268, 2019 Jan 14.
Artigo em Inglês | MEDLINE | ID: mdl-30670914

RESUMO

BACKGROUND: Anastomotic leakage (AL) is a severe complication associated with high morbidity and mortality after radical gastrectomy (RG) for gastric cancer (GC). We hypothesized that a novel abdominal negative pressure lavage-drainage system (ANPLDS) can effectively reduce the failure-to-rescue (FTR) and the risk of reoperation, and it is a feasible management for AL. AIM: To report our institution's experience with a novel ANPLDS for AL after RG for GC. METHODS: The study enrolled 4173 patients who underwent R0 resection for GC at our institution between June 2009 and December 2016. ANPLDS was routinely used for patients with AL after January 2014. Characterization of patients who underwent R0 resection was compared between different study periods. AL rates and postoperative outcome among patients with AL were compared before and after the ANPLDS therapy. We used multivariate analyses to evaluate clinicopathological and perioperative factors for associations with AL and FTR after AL. RESULTS: AL occurred in 83 (83/4173, 2%) patients, leading to 7 deaths. The mean time of occurrence of AL was 5.6 days. The AL rate was similar before (2009-2013, period 1) and after (2014-2016, period 2) the implementation of the ANPLDS therapy (1.7% vs 2.3%, P = 0.121). Age and malnourishment were independently associated with AL. The FTR rate and abdominal bleeding rate after AL occurred were respectively 8.4% and 9.6% for the entire period; however, compared with period 1, this significantly decreased during period 2 (16.2% vs 2.2%, P = 0.041; 18.9% vs 2.2%, P = 0.020, respectively). Moreover, the reoperation rate was also reduced in period 2, although this result was not statistically significant (13.5% vs 2.2%, P = 0.084). Additionally, only ANPLDS therapy was an independent protective factor for FTR after AL (P = 0.04). CONCLUSION: Our experience demonstrates that ANPLDS is a feasible management for AL after RG for GC.


Assuntos
Fístula Anastomótica/terapia , Drenagem/métodos , Falha da Terapia de Resgate/estatística & dados numéricos , Gastrectomia/efeitos adversos , Neoplasias Gástricas/cirurgia , Irrigação Terapêutica/métodos , Fatores Etários , Idoso , Anastomose Cirúrgica/efeitos adversos , Anastomose Cirúrgica/métodos , Fístula Anastomótica/mortalidade , Estudos de Viabilidade , Feminino , Gastrectomia/métodos , Humanos , Laparoscopia/efeitos adversos , Laparoscopia/métodos , Masculino , Desnutrição/complicações , Desnutrição/epidemiologia , Pessoa de Meia-Idade , Reoperação/estatística & dados numéricos , Estudos Retrospectivos
8.
J Surg Res ; 235: 202-209, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30691795

RESUMO

BACKGROUND: Cardiovascular complications contribute significantly to the morbidity and resource utilization after pulmonary resections. Maturation of less-invasive technologies, such as video and robot-assisted thoracoscopic surgery, aims at improving postoperative outcomes by reducing the trauma of surgery. The present work aimed to evaluate changes in cardiovascular complications after open and minimally invasive lobectomies in the United States. METHODS: We performed a retrospective analysis of the Nationwide Inpatient Sample for patients having elective open, video-assisted, and robot-assisted thoracoscopic lobectomy during 2008-2014. Logistic regression was performed to determine predictors of in-hospital mortality, myocardial infarction (MI), cardiac arrest (CA), and postoperative pulmonary embolism (PE). RESULTS: A total of 201,226 patients underwent pulmonary lobectomy over the study period. Open thoracotomy (OPEN) approach has steadily decreased from 75%-52% (P < 0.0001), whereas minimally invasive surgery (MIS) utilization has increased from 25%-48% (P < 0.0001) of all lobectomies. MIS approach was independently associated with decreased odds of mortality (odds ratio [OR] 0.6, 95% confidence interval [CI] 0.50-0.73) and PE (OR 0.67, 95% CI 0.50-0.91). MIS patients at high volume institutions had the lowest odds of all-cause mortality (OR 0.27, 95% CI 0.26-0.53) and MI (OR 0.57, 95% CI 0.38-0.87). Operative approach and institutional lobectomy caseload reduced odds of mortality after MI, CA, or PE. Overall, the incidence of MI, CA, and PE increased. CONCLUSIONS: MIS lobectomies increased without a concurrent reduction in perioperative MI, CA, or PE incidence. High hospital lobectomy volume and MIS approach decrease odds of failure to rescue. Improved perioperative management of cardiovascular risk is warranted to reduce the morbidity, mortality, and resource utilization associated with these complications.


Assuntos
Doenças Cardiovasculares/epidemiologia , Pneumonectomia/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Toracoscopia/estatística & dados numéricos , Idoso , Doenças Cardiovasculares/etiologia , Falha da Terapia de Resgate/tendências , Feminino , Humanos , Masculino , Pneumonectomia/métodos , Pneumonectomia/mortalidade , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Estados Unidos/epidemiologia
9.
J Surg Res ; 235: 529-535, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30691839

RESUMO

BACKGROUND: Failure to rescue (FTR) refers to death after a major complication. Defining the optimal context in which to reduce FTR after injury requires knowledge of where and when FTR events occur. MATERIALS AND METHODS: Retrospective observational study of patients >16 y with a minimum Abbreviated Injury Score ≥2 at all 30 level I and II Pennsylvania trauma centers (2007-2015). Location and timing of the first major complication were collected. Complication, mortality, and FTR rates were calculated by location (prehospital, emergency department, operating room, stepdown unit, interventional radiology, intensive care unit (ICU), radiology, and the surgical ward) and by postadmission day. Kruskal-Wallis and chi-squared tests were used to compare variables. RESULTS: Major complications occurred in 15,388 of 178,602 (8.6%) patients. The median age was 58 y (interquartile range [IQR] 37-77 y), 78% were Caucasian, 68% were male, 89% were bluntly injured, and the median Injury Severity Score was 19 (IQR 10-29). Death occurred in 2512 of 15,388 patients with a major complication, for an FTR rate of 16.3%. Compared with non-FTR, FTR had earlier major complications (median day 2 [IQR 0-5 d] versus day 4 [IQR 2-8 d], P < 0.001). FTR rates were highest in the prehospital setting (42%), the operating room (33%), and the emergency department (32%), but the greatest number (1608 of 2512 total FTR events, 64%) occurred in the ICU. Pulmonary (32%) and cardiac (26%) complications most frequently contributed to FTR deaths. CONCLUSIONS: Interventions designed to reduce FTR after injury should focus on pulmonary and cardiac complications in the ICU.


Assuntos
Falha da Terapia de Resgate/estatística & dados numéricos , Cardiopatias/mortalidade , Pneumopatias/mortalidade , Complicações Pós-Operatórias/mortalidade , Adulto , Idoso , Feminino , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Pennsylvania/epidemiologia , Estudos Retrospectivos
10.
J Surg Res ; 234: 1-6, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30527459

RESUMO

BACKGROUND: Failure to rescue (FTR) is an important measure of quality of care. The aim of this study was to assess FTR in patients with colon cancer (CC) who underwent surgical resection. We hypothesized that patient managed in urban centers had lower FTR. METHODS: We performed a 1-y (2011) retrospective analysis of the National Inpatient Sample database and identified all patients with CC who underwent surgical management. Patients were stratified based on the location of treatment: urban versus rural. Outcome measure was FTR, which was defined as death after major complications. Regression analysis was performed to evaluate the independent predictors of FTR. RESULTS: A total of 49,789 patients with CC who underwent surgery were analyzed. The mean age was 71 ± 20.2 y and 59% were males. About 21.5% patients developed in-hospital complications. The overall rates of complications, mortality, and FTR were 21.5%, 3.0%, and 33.8% respectively. Patient managed in rural centers had higher FTR compared with urban centers (39.5% versus 30.1%, P = 0.01). On regression analysis after controlling for age, gender, type of procedure, Charlson Comorbidity Index, and insurance status, management in rural center was independently associated with FTR (odds ratio: 1.9 [1.4-3.7]). On subanalysis of urban centers, management in teaching urban hospital was independently associated with higher FTR (odds ratio: 1.4 [1.2-3.8]). CONCLUSIONS: Disparities exist among centers managing patients with CC undergoing surgical intervention. Rural centers have higher FTR compared with similar cohort of patients managed in urban centers. Teaching urban hospital performed worse than nonteaching urban centers. Understanding the reason for these differences may help standardize care across centers and help improve patient outcomes.


Assuntos
Neoplasias do Colo/cirurgia , Falha da Terapia de Resgate/estatística & dados numéricos , Hospitais Rurais/estatística & dados numéricos , Hospitais Urbanos/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Período Pós-Operatório , Estudos Retrospectivos , Estados Unidos/epidemiologia
11.
J Surg Res ; 233: 397-402, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30502276

RESUMO

BACKGROUND: Failure to rescue (FTR) is considered as an index of quality of care provided by a hospital. However, the role of frailty in FTR remains unclear. We hypothesized that the FTR rate is higher for frail geriatric emergency general surgery (EGS) patients than nonfrail geriatric EGS patients. METHODS: We performed a 3-y (2015-2017) prospective cohort study of all geriatric patients (age ≥ 65 y) requiring EGS. Frailty was calculated by using the EGS-specific Frailty Index (EGSFI) within 24 h of admission. Patients were divided into two groups: frail (FI ≥ 0.325) and nonfrail (FI < 0.325). We defined FTR as death from a major complication. Regression analysis was performed to control for demographics, type of operative intervention, admission vitals, and admission laboratory values. RESULTS: Three hundred twenty-six geriatric EGS patients were included, of which 38.9% were frail. Frail patients were more likely to be white (P < 0.01) and, on admission, had a higher American Association of Anesthesiologist class (P = 0.03) and lower serum albumin (P < 0.01). However, there was no difference between the groups regarding age (P = 0.54), gender (P = 0.56), admission vitals, and WBC count (P = 0.35). Overall, 26.7% (n = 85) of patients developed in-hospital complications; and mortality occurred in 30% (n = 26) of those patients (i.e., the FTR group). Frail patients had higher rates of FTR (14% vs. 4%, P < 0.001) than nonfrail patients. On regression analysis, after controlling for confounders, frail status was an independent predictor of FTR (OR: 3.4 [2.3-4.6]) in geriatric EGS patients. CONCLUSIONS: Our study demonstrates that in geriatric EGS patients, a frail status independently contributes to FTR and increases the odds of FTR threefold compared with nonfrail status. Thus, it should be included in quality metrics for geriatric EGS patients.


Assuntos
Tratamento de Emergência/estatística & dados numéricos , Falha da Terapia de Resgate/estatística & dados numéricos , Fragilidade/diagnóstico , Avaliação Geriátrica , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Serviço Hospitalar de Emergência/estatística & dados numéricos , Tratamento de Emergência/efeitos adversos , Feminino , Idoso Fragilizado/estatística & dados numéricos , Fragilidade/complicações , Mortalidade Hospitalar , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/mortalidade , Estudos Prospectivos , Medição de Risco/métodos , Fatores de Risco , Procedimentos Cirúrgicos Operatórios/efeitos adversos
12.
Langenbecks Arch Surg ; 404(1): 93-101, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30552508

RESUMO

PURPOSE: This observational study explored the association between hospital volume and short-term outcome following gastric resections for non-bariatric indication, aiming to contribute to the discussion on centralization of complex visceral surgery in Germany. METHODS: Based on complete national hospital discharge data from 2010 to 2015, the association between hospital volume and in-hospital mortality was evaluated according to volume quintiles and volume deciles. Case-mix differences regarding surgical indication, age, sex, and comorbidities were considered for risk adjustment. In addition, rates of major complications and failure to rescue were analyzed across hospital volume categories. RESULTS: Inpatient episodes (72,528) with gastric resection were analyzed. Risk-adjusted mortality in patients treated in very low volume hospitals (median volume of 5 surgeries per year) was higher (12.0% [95% CI 11.4 to 12.5]) compared to those treated in very high volume hospitals (50 surgeries per year; 10.6% [10.0 to 11.1]). Failure to rescue patients with complications was 28.1% [27.0 to 29.3] in very low volume hospitals and 22.7% [21.6 to 23.8] in very high volume hospitals. Differences were similar within the subgroup of patients operated for gastric cancer. CONCLUSIONS: Treatment in very high volume hospitals is associated with a lower in-hospital mortality compared to treatment in very low volume hospitals. This effect seems to be determined by the ability to rescue patients who experience complications. As the observed benefit is only related to very high volumes, the results do not clearly indicate that centralization may improve short-term results substantially, unless a very high degree of centralization would be achieved. Possibly, further research focusing on other outcome measures, such as clinical processes or long-term results, might lead to divergent conclusions.


Assuntos
Gastrectomia/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Gastropatias/cirurgia , Idoso , Grupos Diagnósticos Relacionados , Falha da Terapia de Resgate/estatística & dados numéricos , Feminino , Gastrectomia/efeitos adversos , Gastrectomia/mortalidade , Alemanha , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Gastropatias/mortalidade , Gastropatias/patologia
13.
Ann Surg ; 270(1): 91-94, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-29557884

RESUMO

OBJECTIVE: To identify hospital staffing models associated with failure to rescue (FTR) rates at low- and high-performing hospitals. BACKGROUND: FTR is an important quality measure in surgical safety and is a metric that hospitals are seeking to improve. Specific unit-level determinants of FTR, however, remain unknown. METHODS: Retrospective, observational study using data from the Michigan Quality Surgical Collaborative, which is a prospectively collected and clinically audited database in the state of Michigan. We identified 44,567 patients undergoing major general or vascular surgery from 2008 to 2012. Our main outcome measures were mortality, complications, and FTR rates. RESULTS: Hospital rates of FTR across low, middle, and high tertiles were 8.9%, 16.5%, and 19.9%, respectively (P < 0.001). Low FTR hospitals tended to have a closed intensive care unit staffing model (56% vs 20%, P < 0.001) and a higher proportion of board-certified intensivists (88% vs 60%, P < 0.001) when compared to high FTR hospitals. There was also significantly more staffing of low FTR hospitals by hospitalists (85% vs 20%, P < 0.001) and residents (62% vs 40%, P < 0.01). Low FTR hospitals were noted to have more overnight coverage (75% vs 45%, P < 0.001) as well as a dedicated rapid response team (90% vs 60%, P < 0.001). CONCLUSIONS: Low FTR hospitals had significantly more staffing resources than high FTR hospitals. Although hiring additional staff may be beneficial, there remain significant financial limitations for many hospitals to implement robust staffing models. Thus, our ongoing work seeks to improve rescue and implement effective staffing strategies within these constraints.


Assuntos
Falha da Terapia de Resgate/estatística & dados numéricos , Mão de Obra em Saúde/estatística & dados numéricos , Segurança do Paciente/estatística & dados numéricos , Admissão e Escalonamento de Pessoal/estatística & dados numéricos , Recursos Humanos em Hospital/provisão & distribução , Indicadores de Qualidade em Assistência à Saúde/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Auditoria Clínica , Estudos Transversais , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Michigan , Pessoa de Meia-Idade , Admissão e Escalonamento de Pessoal/organização & administração , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Melhoria de Qualidade/estatística & dados numéricos , Estudos Retrospectivos , Procedimentos Cirúrgicos Operatórios
14.
Telemed J E Health ; 25(5): 369-379, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30036175

RESUMO

Background: Failure to rescue (FTR) is a benchmark of quality care. Limited evidence exists examining the influence of telemedicine intensive care units (tele-ICU) nursing interventions in preventing FTR. The purpose of this study was to characterize tele-ICU nursing interventions and to determine which combination of documented tele-ICU nursing interventions (DTNI) best predicts prevention of FTR in ICU patients with hospital-acquired conditions (HACs). Materials and Methods: We used convergent parallel mixed methods design to conduct qualitative interviews with a purposive sample of tele-ICU nurses (n = 19) from 11 US tele-ICU centers. Quantitative data, including demographics, DTNIs, severity of illness scores, and video assessment times from January 2016 to December 2016 were retrieved for ICU patients discharged from a multihospital health system with a tele-ICU center (n = 861). Findings from both qualitative and quantitative analyses were merged, compared, and contrasted. Results: FTR patients had higher severity of illness, longer video assessment by tele-ICU nurses, and were more likely to have DTNIs related to hemodynamic instability. Four themes emerged from qualitative analysis: fundamental tele-ICU nurse attributes, proactive clinical practice, effective collaborative relationships, and strategic use of advanced technology. Mixed methods analysis revealed convergence between DTNIs and tele-ICU nurses' characterizations of their practice. Conclusions: Tele-ICU nurses' characterizations of their practice closely align with DTNIs. Tele-ICU nursing practice to prevent FTR involves systems thinking and integration of many complex factors. Tele-ICU nurses can reduce the odds of FTR with focus on support and clinical coordination interventions that avoid hemodynamic instability in ICU patients with a diagnosed HAC.


Assuntos
Cuidados Críticos/organização & administração , Falha da Terapia de Resgate , Unidades de Terapia Intensiva/organização & administração , Recursos Humanos de Enfermagem no Hospital/organização & administração , Telemedicina/organização & administração , APACHE , Idoso , Idoso de 80 Anos ou mais , Competência Clínica , Comportamento Cooperativo , Feminino , Humanos , Entrevistas como Assunto , Masculino , Pessoa de Meia-Idade , Equipe de Assistência ao Paciente , Pesquisa Qualitativa , Fatores Socioeconômicos
15.
J Nurs Care Qual ; 34(2): 107-113, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30095509

RESUMO

BACKGROUND: Episodic vital sign collection (eVSC), as single data points, gives an incomplete picture of adult patients' postoperative physiologic status. LOCAL PROBLEM: Late detection of patient deterioration resulted in poor patient outcomes on a postsurgical unit. METHODS: Baseline demographic and outcome data were collected through retrospective chart review of all patients admitted to the surgical unit for 12 weeks prior to this quality improvement project. Data on the same outcomes were collected during the 12-week project. INTERVENTION: This project compared outcomes between the current standard of eVSC and the proposed standard of continuous vital sign monitoring (cVSM). RESULTS: Using cVSM demonstrated a statistically significant 27% decrease in the complication rate, and a clinically significant decrease in transfers to an intensive care unit and failure-to-rescue (FTR) events rate. CONCLUSIONS: cVSM demonstrated detection of early signs of patient deterioration to prevent FTR.


Assuntos
Deterioração Clínica , Pacientes Internados , Monitorização Fisiológica/métodos , Sinais Vitais/fisiologia , Adulto , Falha da Terapia de Resgate/estatística & dados numéricos , Feminino , Humanos , Estudos Longitudinais , Recursos Humanos de Enfermagem no Hospital/estatística & dados numéricos , Complicações Pós-Operatórias , Melhoria de Qualidade , Estudos Retrospectivos
16.
Health Aff (Millwood) ; 37(11): 1870-1876, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30395494

RESUMO

Failure to rescue-mortality following a major surgical complication-is a key driver of variation in postoperative mortality. However, little is known about the impact of interpersonal and organizational dynamics, or microsystem factors, on failure to rescue. In a qualitative study of providers from hospitals with high and low rescue rates, we identified five key factors that providers believe influence the successful rescue of surgical patients: teamwork, action taking, psychological safety, recognition of complications, and communication. Near-uniform agreement existed on two targets for improvement: delayed recognition of developing complications and poor interprofessional communication and inability to express clinical concerns. To improve perioperative outcomes, hospitals and payers should shift their attention to improving early detection and effective communication of major complications.


Assuntos
Falha da Terapia de Resgate , Mortalidade Hospitalar , Comunicação Interdisciplinar , Equipe de Assistência ao Paciente/organização & administração , Complicações Pós-Operatórias/mortalidade , Humanos , Entrevistas como Assunto , Pesquisa Qualitativa
17.
J Surg Res ; 231: 62-68, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30278970

RESUMO

BACKGROUND: Racial and socioeconomic disparities are well documented in emergency general surgery (EGS) and have been highlighted as a national priority for surgical research. The aim of this study was to identify whether disparities in the EGS setting are more likely to be caused by major adverse events (MAEs) (e.g., venous thromboembolism) or failure to respond appropriately to such events. METHODS: A retrospective cohort study was undertaken using administrative data. EGS cases were defined using International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic codes recommended by the American Association for the Surgery of Trauma. The data source was the National Inpatient Sample 2012-2013, which captured a 20%-stratified sample of discharges from all hospitals participating in the Healthcare Cost and Utilization Project. The outcomes were MAEs, in-hospital mortality, and failure to rescue (FTR). RESULTS: There were 1,345,199 individual patient records available within the National Inpatient Sample. There were 201,574 admissions (15.0%) complicated by an MAE, and 12,006 of these (6.0%) resulted in death. The FTR rate was therefore 6.0%. Uninsured patients had significantly higher odds of MAEs (adjusted odds ratio, 1.16; 95% confidence interval, 1.13-1.19), mortality (1.28, 1.16-1.41), and FTR (1.20, 1.06-1.36) than those with private insurance. Although black patients had significantly higher odds of MAEs (adjusted odds ratio, 1.14; 95% confidence interval, 1.13-1.16), they had lower mortality (0.95, 0.90-0.99) and FTR (0.86, 0.80-0.91) than white patients. CONCLUSIONS: Uninsured EGS patients are at increased risk of MAEs but also the failure of health care providers to respond effectively when such events occur. This suggests that MAEs and FTR are both potential targets for mitigating socioeconomic disparities in the setting of EGS.


Assuntos
Serviços Médicos de Emergência/estatística & dados numéricos , Falha da Terapia de Resgate/estatística & dados numéricos , Cirurgia Geral/estatística & dados numéricos , Disparidades em Assistência à Saúde/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Adulto , Idoso , Grupos de Populações Continentais , Feminino , Mortalidade Hospitalar , Humanos , Cobertura do Seguro , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Estados Unidos/epidemiologia
18.
Int. j. cardiovasc. sci. (Impr.) ; 31(5)set.-out. 2018. tab
Artigo em Inglês | LILACS | ID: biblio-914765

RESUMO

Background: To reduce mortality of acute myocardial infarction, medical care must be provided within the first hours of the event. Objective: To identify the "front door" to medical care of acute coronary patients and the time elapsed between patients'admission and performance of myocardial reperfusion in the public health system of the city of Joinville, Brazil. Methods: The study was a retrospective analysis of the medical records of 112 consecutive patients diagnosed with acute myocardial infarction by coronary angiography. We identified the place of the first medical contact and calculated the time between admission to this place and admission to the referral hospital, as well as the time until coronary angiography, with or without percutaneous transluminal angioplasty. A descriptive analysis of data was made using mean and standard deviation, and a p < 0.05 was set as statistically significant. Results: Only 16 (14.3%) patients were admitted through the cardiology referral unit. Door-to-angiography time was shorter than 90 minutes in 50 (44.2%) patients and longer than 270 minutes in 39 (34.5%) patients. No statistically significant difference was observed in door-to-angiography time between patients transported directly to the referral hospital and those transferred from other health units (p < 0.240). Considering the time between pain onset and angiography, only 3 (2.9%) patients may have benefited from myocardial reperfusion performed within less than 240 minutes. Conclusion: Management of patients with acute myocardial infarction is not in conformity with current guidelines for the treatment of this condition. The structure of the healthcare system should be urgently modified so that users in need of emergency services receive adequate care in accordance with local conditions


Assuntos
Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Assistência à Saúde/métodos , Falha da Terapia de Resgate , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/terapia , Terapêutica/métodos , Síndrome Coronariana Aguda/diagnóstico , Síndrome Coronariana Aguda/terapia , Angioplastia/métodos , Angiografia Coronária/métodos , Procedimentos Clínicos/tendências , Morte Súbita/prevenção & controle , Diagnóstico por Imagem/métodos , Eletrocardiografia/métodos , Serviços Médicos de Emergência/métodos , Assistência Hospitalar/métodos , Reperfusão Miocárdica/métodos , Estudos Retrospectivos , Análise Estatística , Terapia Trombolítica/métodos , Sistema Único de Saúde
19.
Biomed Instrum Technol ; 52(4): 281-287, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30070913

RESUMO

Failure to rescue, or the unexpected death of a patient due to a preventable complication, is a nationally documented problem with numerous and multifaceted contributing factors. These factors include the frequency and method of collecting vital sign data, response to abnormal vital signs, and delays in the escalation of care for general ward patients who are showing signs of clinical deterioration. Patients' clinical deterioration can be complicated by concurrent secondary factors, including opioid abuse/dependence, being uninsured, or having sleep-disordered breathing. Using the Johns Hopkins Nursing Evidence-Based Practice Model, this integrative review synthesizes 43 research and nonresearch sources of evidence. Published between 2001 and 2017, these sources of evidence focus on failure to rescue, the multifaceted contributing factors to failure to rescue, and how continuous vital sign monitoring could ameliorate failure to rescue and its causes. Recommendations from the sources of evidence have been divided into system, structural, or technological categories.


Assuntos
Falha da Terapia de Resgate , Monitorização Fisiológica , Período Pós-Operatório , Medicina Baseada em Evidências , Humanos , Estados Unidos
20.
Am J Cardiol ; 122(5): 828-832, 2018 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-30064862

RESUMO

Failure to rescue (FTR), death after major complications, has been well described in the surgical literature as a source of different outcomes in different hospitals. However, FTR has not been investigated in transcatheter aortic valve implantation (TAVI). Our aim was to assess the difference of in-patient mortality and FTR in different TAVI volume hospitals. We queried the Nationwide Inpatient Sample database from 2011 to 2015 to identify patients who had transarterial TAVI. FTR was calculated as those who had in-patient mortality with at least one with major perioperative complications. Hospitals were divided into three groups according to annual TAVI volume, the lowest quintile (≤30/year), second to fourth quintile (31 to 130/year), and highest quintile (≥130/year). Multivariate analysis was used to calculate risk adjusted in-patient mortality rate and FTR and was compared between these different volume hospitals. A total of 48,886 TAVI procedures were identified (10,407, 28,811, and 9,668 in low, intermediate, and high volume centers, respectively). Mean age, percentage of woman, and Elixhauser co-morbidity index was similar across different TAVI volume hospital. The incidence of major perioperative complications did not differ in different volume hospitals. Adjusted rate of in-patient mortality (2.3%, 1.87%, and 1.57% for low, intermediate, and high volume center, respectively, p <0.001) were significantly less with greater hospital volume but FTR (8.24%, 8.20%, and 6.12% for low, intermediate, and high volume center, respectively, p = 0.29) were the same in the three groups. Our results suggest that FTR does not explain the variation of in-hospital mortality in different hospital volumes.


Assuntos
Estenose da Valva Aórtica/mortalidade , Estenose da Valva Aórtica/cirurgia , Falha da Terapia de Resgate , Mortalidade Hospitalar , Complicações Pós-Operatórias/mortalidade , Substituição da Valva Aórtica Transcateter/mortalidade , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Estados Unidos/epidemiologia
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