Impact of a COVID-19 code blue protocol on resuscitation care and CPR quality during in-hospital cardiac arrest.

OBJECTIVE: We sought to evaluate the impact of a COVID-19 Code Blue policy on in-hospital cardiac arrest (IHCA) processes of care, cardiopulmonary resuscitation (CPR) quality metrics, and survival to hospital discharge. METHODS: We completed a health record review of consecutive IHCA for which resuscitation was attempted. We report Utstein outcomes and CPR quality metrics 33 months before (July,2017-March,2020) and after (April,2020-December,2022) the implementation of a COVID-19 Code Blue policy requiring all team members to don personal protective equipment including gown, gloves, mask, and eye protection for all IHCA. RESULTS: There were 800 IHCA with the following characteristics (Before n = 396; After n = 404): mean age 66, 62.9% male, 81.3% witnessed, 31.3% in the emergency department, 25.6% cardiac cause, and initial shockable rhythm in 16.7%. Among all 404 patients screened for COVID-19, 25 of 288 available test results before IHCA occurred were positive. Comparing the before and after periods: there were relevant time delays (min:sec) in start of chest compressions (0:17vs.0:37;p = 0.005), team arrival (0:43vs.1:21;p = 0.002), 1st rhythm analysis (1:15vs.3:16;p < 0.0001), 1st epinephrine (3:44vs.4:34;p = 0.02), and airway insertion (8:38vs. 10:18;p = 0.02). Resuscitation duration was similar (18:28vs.19:35;p = 0.34). Exception of peri-shock pause which appeared longer (0:06vs.0:14;p = 0.07), chest compression fraction, rate and depth were identical and good. Factors independently associated with survival were age (adjOR 0.98;p < 0.001), male sex (adjOR 1.51;p = 0.048), witnessed (adjOR 2.35;p = 0.02), shockable rhythm (adjOR 3.31;p < 0.0001), hospital location (p = 0.0002), and COVID-19 period (adjOR 0.68;p = 0.052). CONCLUSIONS: The COVID-19 Code Blue policy was associated with delayed processes of care but similarly good CPR quality. The COVID-19 period appeared associated with decreased survival.

Association of preoperative anaesthesia consultation prior to elective noncardiac surgery with patient and health system outcomes: a population-based study.

BACKGROUND: Surgical volumes and use of preoperative anaesthesia consultations are increasing. However, contemporary data estimating the association between preoperative anaesthesia consultation and patient (days alive and at home [DAH30], mortality) and system (costs, length of stay, and readmissions) outcomes are not available. METHODS: We conducted a population-based comparative effectiveness study using linked health administrative data among patients aged ≥40 yr who underwent intermediate-risk to high-risk elective, inpatient, noncardiac surgery in Ontario, Canada (2009-17). Our primary outcome was DAH30. Secondary outcomes included DAH90, 30-day and 1-yr mortality, 30-day health system costs, length of index admission, and 30-day readmissions. Propensity score overlap weights were used to adjust for confounders. Prespecified effect modifier analyses focused on high-risk subgroups. RESULTS: Among 364 149 patients, 274 365 (75.3%) received a preoperative anaesthesia consultation. No adjusted association was found (22.5 days vs 22.5 days; adjusted ratio of means 1.00, 95% CI 1.00-1.00) between consultation and DAH30 in the full population. We identified significant effect modification (significantly more DAH30) among patients with ischaemic heart disease, ASA physical status ≥4, frailty index score ≥0.21, and who underwent vascular surgery. Secondary outcomes were associated with preoperative consultation, including greater DAH90, decreased length of stay, lower 30-day and 1-yr mortality, and reduced 30-day costs. CONCLUSIONS: Preoperative anaesthesia consultation was not associated with greater DAH30 across the overall study population. However, important potential benefits were observed among high-risk subgroups. Research is needed to identify optimal patient populations and consultation processes.

Measuring the Predictive Accuracy of Preoperative Clinical Frailty Instruments Applied to Electronic Health Data in Older Patients Having Emergency General Surgery: A Retrospective Cohort Study.

OBJECTIVE: To compare predictive accuracy of frailty instruments operationalizable in electronic data for prognosticating outcomes among older adults undergoing emergency general surgery (EGS). BACKGROUND: Older patients undergoing EGS are at higher risk of perioperative morbidity and mortality. Preoperative frailty is a common and strong perioperative risk factor in this population. Despite this, existing barriers preclude routine preoperative frailty assessment. METHODS: We conducted a retrospective cohort study of adults above 65 undergoing EGS from 2012 to 2018 using Institute for Clinical Evaluative Sciences (ICES) provincial healthcare data in Ontario, Canada. We compared 4 frailty instruments: Frailty Index (FI), Hospital Frailty Risk Score (HFRS), Risk Analysis Index-Administrative (RAI), ACG Frailty-defining diagnoses indicator (ACG). We compared predictive accuracy beyond baseline risk models (age, sex, American Society of Anesthesiologists' score, procedural risk). Predictive performance was measured using discrimination, calibration, explained variance, net reclassification index and Brier score (binary outcomes); using explained variance, root mean squared error and mean absolute prediction error (continuous outcomes). Primary outcome was 30-day mortality. Secondary outcomes were 365-day mortality, nonhome discharge, days alive at home, length of stay, and 30-day and 365-day health systems cost. RESULTS: A total of 121,095 EGS patients met inclusion criteria. Of these, 11,422 (9.4%) experienced death 30 days postoperatively. Addition of FI, HFRS, and RAI to the baseline model led to improved discrimination, net reclassification index, and R2 ; RAI demonstrated the largest improvements. CONCLUSIONS: Adding 4 frailty instruments to typically assessed preoperative risk factors demonstrated strong predictive performance in accurately prognosticating perioperative outcomes. These findings can be considered in developing automated risk stratification systems among older EGS patients.

Association of frailty with days alive at home in critically ill patients undergoing emergency general surgery: a population-based cohort study.

BACKGROUND: Frailty is an established risk factor for morbidity and mortality in older patients undergoing surgery. In people with critical illness before surgery, few data describe patient-centred outcomes. Our objective was to estimate the association of frailty with postoperative days alive at home in older critically ill patients requiring emergency general surgery. METHODS: A retrospective population-based cohort study was conducted using linked administrative health data in Ontario, Canada from 2009 to 2019. All individuals aged ≥66 yr with an ICU admission before emergency general surgery were included. We compared the count of days alive at home at 30 and 365 days after surgery based on frailty status using a validated, multidimensional index. Unadjusted and multilevel, multivariable adjusted effect estimates were calculated. A sensitivity analysis based on early recovery category was performed. RESULTS: We identified 7003 eligible patients; 2063 (29.5%) lived with frailty. At 30 days, mean days alive at home with frailty were 4.5 (standard deviation 8.2) and 7.6 (standard deviation 10.2) in those without frailty. In adjusted analysis, frailty was associated with fewer days alive at home at 30 (ratio of means [RoM] 0.68; 95% confidence interval [CI]: 0.60-0.78; P<0.001) and 365 days (RoM 0.72; 95% CI: 0.64-0.82; P<0.001). Individuals with frailty had a higher probability of poor recovery status, with effects increasing across the first postoperative month. CONCLUSIONS: In patients with critical illness requiring emergency general surgery, frailty is associated with fewer days alive at home. This information should be discussed with critically ill patients before emergent surgical intervention to better inform decision-making.

Comparing the predictive accuracy of frailty instruments applied to preoperative electronic health data for adults undergoing noncardiac surgery.

BACKGROUND: Preoperative frailty is associated with increased risk of postoperative mortality and complications. Routine preoperative frailty assessment is underperformed. Automation of preoperative frailty assessment using electronic health data could improve adherence to guideline-based care if an accurate instrument is identified. METHODS: We conducted a retrospective cohort study of adults >65 yr undergoing elective noncardiac surgery between 2012 and 2018. Four frailty instruments were compared: Frailty Index, Hospital Frailty Risk Score, Risk Analysis Index-Administrative, and Adjusted Clinical Groups frailty-defining diagnoses indicator. We compared the predictive performance of each instrument added to a baseline model (age, sex, ASA physical status, and procedural risk) using discrimination, calibration, explained variance, net reclassification, and Brier score (binary outcomes); and explained variance, root mean squared error, and mean absolute prediction error (continuous outcomes). Primary outcome was 30-day mortality. Secondary outcomes included 365-day mortality, length of stay, non-home discharge, days alive at home, and 365-day costs. RESULTS: For this study, 171 576 patients met the inclusion criteria; 1370 (0.8%) died within 30 days. Compared with the baseline model predicting 30-day mortality (area under the curve [AUC] 0.85; R2 0.08), the addition of Hospital Frailty Risk Score led to the greatest improvement in discrimination (AUC 0.87), explained variance (R2 0.09), and net reclassification (Net Reclassification Index 0.65). Brier and calibration scores were comparable. CONCLUSIONS: All four frailty instruments significantly improved discrimination and risk reclassification when added to typically assessed preoperative risk factors. Accurate identification of the presence or absence of preoperative frailty using electronic frailty instruments may improve perioperative risk stratification. Future research should evaluate the impact of automated frailty assessment in guiding surgical planning and patient-centred optimisation amongst older surgical patients.

A Systematic Review and Meta-Analysis of Preoperative Frailty Instruments Derived From Electronic Health Data.

BACKGROUND: Frailty is a strong predictor of adverse outcomes in the perioperative period. Given the increasing availability of electronic medical data, we performed a systematic review and meta-analysis with primary objectives of describing available frailty instruments applied to electronic data and synthesizing their prognostic value. Our secondary objectives were to assess the construct validity of frailty instruments that have been applied to perioperative electronic data and the feasibility of electronic frailty assessment. METHODS: Following protocol registration, a peer-reviewed search strategy was applied to Medline, Excerpta Medica dataBASE (EMBASE), Cochrane databases, and the Comprehensive Index to Nursing and Allied Health literature from inception to December 31, 2019. All stages of the review were completed in duplicate. The primary outcome was mortality; secondary outcomes included nonhome discharge, health care costs, and length of stay. Effect estimates adjusted for baseline illness, sex, age, procedure, and urgency were of primary interest; unadjusted and adjusted estimates were pooled using random-effects models where appropriate or narratively synthesized. Risk of bias was assessed. RESULTS: Ninety studies were included; 83 contributed to the meta-analysis. Frailty was defined using 22 different instruments. In adjusted data, frailty identified from electronic data using any instrument was associated with a 3.57-fold increase in the odds of mortality (95% confidence interval [CI], 2.68-4.75), increased odds of institutional discharge (odds ratio [OR], 2.40; 95% CI, 1.99-2.89), and increased costs (ratio of means, 1.54; 95% CI, 1.46-1.63). Most instruments were not multidimensional, head-to-head comparisons were lacking, and no feasibility data were reported. CONCLUSIONS: Frailty status derived from electronic data provides prognostic value as it is associated with adverse outcomes, even after adjustment for typical risk factors. However, future research is required to evaluate multidimensional instruments and their head-to-head performance and to assess their feasibility and clinical impact.

Complications as a Mediator of the Perioperative Frailty-Mortality Association.

BACKGROUND: Preoperative frailty is strongly associated with postoperative complications and mortality. However, the pathways between frailty, postoperative complications, and mortality are poorly described. The authors hypothesized that the occurrence of postoperative complications would mediate a substantial proportion of the total effect of frailty on mortality after elective noncardiac surgery. METHODS: Following protocol registration, the authors conducted a retrospective cohort study of intermediate- to high-risk elective noncardiac surgery patients (2016) using National Surgical Quality Improvement Program data. The authors conducted Bayesian mediation analysis of the relationship between preoperative frailty (exposure, using the Risk Analysis Index), serious complications (mediator), and 30-day mortality (outcome), comprehensively adjusting for confounders. The authors estimated the total effect of frailty on mortality (composed of the indirect effect mediated by complications and the remaining direct effect of frailty) and estimated the proportion of the frailty-mortality association mediated by complications. RESULTS: The authors identified 205,051 patients; 1,474 (0.7%) died. Complications occurred in 20,211 (9.9%). A 2 SD increase in frailty score resulted in a total association with mortality equal to an odds ratio of 3.79 (95% credible interval, 2.48 to 5.64), resulting from a direct association (odds ratio, 1.76; 95% credible interval, 1.34 to 2.30) and an indirect association mediated by complications (odds ratio, 2.15; 95% credible interval, 1.58 to 2.96). Complications mediated 57.3% (95% credible interval, 40.8 to 73.8) of the frailty-mortality association. Cardiopulmonary complications were the strongest mediators among complication subtypes. CONCLUSIONS: Complications mediate more than half of the association between frailty and postoperative mortality in elective noncardiac surgery.

A Bayesian Comparison of Frailty Instruments in Noncardiac Surgery: A Cohort Study.

BACKGROUND: Frailty-a multidimensional syndrome related to age- and disease-related deficits-is a key risk factor for older surgical patients. However, it is unknown which frailty instrument most accurately predicts postoperative outcomes. Our objectives were to quantify the probability of association and relative predictive performance of 2 frailty instruments (ie, the risk analysis index-administrative [RAI-A] and 5-item modified frailty index [mFI-5]) with postoperative outcomes in National Surgical Quality Improvement Program (NSQIP) data. METHODS: Retrospective cohort study using Bayesian analysis of NSQIP hospitals. Adults having inpatient small or large bowel surgery 2010-2015 (derivation cohort) or intermediate to high risk mixed noncardiac surgery in 2016 (validation cohort) had preoperative frailty assigned using 2 unique approaches (RAI-A and mFI-5). Probabilities of association were calculated based on posterior distributions and relative predictive performance using posterior predictive distributions and Bayes factors for 30-day mortality (primary outcome) and serious complications (secondary outcome). RESULTS: Of 50,630 participants, 7630 (14.0%) died and 19,545 (38.6%) had a serious complication. Without adjustment, the RAI-A and mFI-5 had >99% probability being associated with mortality with a ≥2.0 odds ratio (ie, large effect size). After adjustment for NSQIP risk calculator variables, only the RAI-A had ≥95% probability of a nonzero association with mortality. Similar results arose when predicting postoperative complications. The RAI-A provided better predictive accuracy for mortality than the mFI-5 (minimum Bayes factor 3.25 × 1014), and only the RAI-A improved predictive accuracy beyond that of the NSQIP risk calculator (minimum Bayes factor = 4.27 × 1013). Results were consistent in leave-one-out cross-validation. CONCLUSIONS: Translation of frailty-related findings from research and quality improvement studies to clinical care and surgical planning will be aided by a consistent approach to measuring frailty with a multidimensional instrument like RAI-A, which appears to be superior to the mFI-5 when predicting outcomes for inpatient noncardiac surgery.

Frailty for Perioperative Clinicians: A Narrative Review.

Frailty is a multidimensional syndrome characterized by decreased reserve and diminished resistance to stressors. People with frailty are vulnerable to stressors, and exposure to the stress of surgery is associated with increased risk of adverse outcomes and higher levels of resource use. As Western populations age rapidly, older people with frailty are presenting for surgery with increasing frequency. This means that anesthesiologists and other perioperative clinicians need to be familiar with frailty, its assessment, manifestations, and strategies for optimization. We present a narrative review of frailty aimed at perioperative clinicians. The review will familiarize readers with the concept of frailty, will discuss common and feasible approaches to frailty assessment before surgery, and will describe the relative and absolute associations of frailty with commonly measured adverse outcomes, including morbidity and mortality, as well as patient-centered and reported outcomes related to function, disability, and quality of life. A proposed approach to optimization before surgery is presented, which includes frailty assessment followed by recommendations for identification of underlying physical disability, malnutrition, cognitive dysfunction, and mental health diagnoses. Overall, 30%-50% of older patients presenting for major surgery will be living with frailty, which results in a more than 2-fold increase in risk of morbidity, mortality, and development of new patient-reported disability. The Clinical Frailty Scale appears to be the most feasible frailty instrument for use before surgery; however, evidence suggests that predictive accuracy does not differ significantly between frailty instruments such as the Fried Phenotype, Edmonton Frail Scale, and Frailty Index. Identification of physical dysfunction may allow for optimization via exercise prehabilitation, while nutritional supplementation could be considered with a positive screen for malnutrition. The Hospital Elder Life Program shows promise for delirium prevention, while individuals with mental health and or other psychosocial stressors may derive particular benefit from multidisciplinary care and preadmission discharge planning. Robust trials are still required to provide definitive evidence supporting these interventions and minimal data are available to guide management during the intra- and postoperative phases. Improving the care and outcomes of older people with frailty represents a key opportunity for anesthesiologists and perioperative scientists.

Accuracy and Feasibility of Clinically Applied Frailty Instruments before Surgery: A Systematic Review and Meta-analysis.

BACKGROUND: A barrier to routine preoperative frailty assessment is the large number of frailty instruments described. Previous systematic reviews estimate the association of frailty with outcomes, but none have evaluated outcomes at the individual instrument level or specific to clinical assessment of frailty, which must combine accuracy with feasibility to support clinical practice. METHODS: The authors conducted a preregistered systematic review (CRD42019107551) of studies prospectively applying a frailty instrument in a clinical setting before surgery. Medline, Excerpta Medica Database, Cochrane Library and the Comprehensive Index to Nursing and Allied Health Literature, and Cochrane databases were searched using a peer-reviewed strategy. All stages of the review were completed in duplicate. The primary outcome was mortality and secondary outcomes reflected routinely collected and patient-centered measures; feasibility measures were also collected. Effect estimates were pooled using random-effects models or narratively synthesized. Risk of bias was assessed. RESULTS: Seventy studies were included; 45 contributed to meta-analyses. Frailty was defined using 35 different instruments; five were meta-analyzed, with the Fried Phenotype having the largest number of studies. Most strongly associated with: mortality and nonfavorable discharge was the Clinical Frailty Scale (odds ratio, 4.89; 95% CI, 1.83 to 13.05 and odds ratio, 6.31; 95% CI, 4.00 to 9.94, respectively); complications was associated with the Edmonton Frail Scale (odds ratio, 2.93; 95% CI, 1.52 to 5.65); and delirium was associated with the Frailty Phenotype (odds ratio, 3.79; 95% CI, 1.75 to 8.22). The Clinical Frailty Scale had the highest reported measures of feasibility. CONCLUSIONS: Clinicians should consider accuracy and feasibility when choosing a frailty instrument. Strong evidence in both domains support the Clinical Frailty Scale, while the Fried Phenotype may require a trade-off of accuracy with lower feasibility.

Emergency General Surgery in Older Adults: A Review.

Older people are the fastest growing segment of the population and over-represented among people requiring emergency general surgery. Independent of comorbid and procedural factors, perioperative risk increases with increasing age. This effect is amplified with frailty or sarcopenia. Multidisciplinary perioperative care aligned with goals of care is most likely to achieve optimal patient and health system outcomes; however, substantial knowledge gaps exist in emergency general surgery for older people. Anesthesiologists are uniquely positioned to address these knowledge gaps, including optimizing goal-directed intraoperative care, appropriate provision of acute postoperative monitoring, and integration of principles of geriatric medicine in perioperative care.

A comparison of bonfils fiberscope-assisted laryngoscopy and standard direct laryngoscopy in simulated difficult pediatric intubation: a manikin study.

INTRODUCTION: Difficult airway management in children is challenging. One alternative device to the gold standard of direct laryngoscopy is the STORZ Bonfils fiberscope (Karl Storz Endoscopy, Tuttlingen, Germany), a rigid fiberoptic stylette-like scope with a curved tip. Although results in adults have been encouraging, reports regarding its use in children have been conflicting. We compared the effectiveness of a standard laryngoscope to the Bonfils fiberscope in a simulated difficult infant airway. METHODS: Ten pediatric anesthesiologists were recruited for this study and asked to perform three sets of tasks. For the first task, each participant intubated an unaltered manikin (SimBaby (TM), Laerdal, Puchheim, Germany) five times using a styletted 3.5 endotracheal tube (ETT) and a Miller 1 blade (group DL-Normal). For the second task, a difficult airway configuration simulating a Cormack-Lehane grade 3B view was created by fixing a Miller-1 blade into position in the manikin using a laboratory stand. Each participant then intubated the manikin five times with a styletted 3.5 ETT using conventional technique but without touching the laryngoscope (group DL-Difficult). In the third task, the manikin was kept in the same difficult airway configuration, and each participant intubated the manikin five times using a 3.5-mm ETT mounted on the Bonfils fiberscope as an adjunct to direct laryngoscopy with the Miller-1 blade (group BF-Difficult). Primary outcomes were time to intubate and success rate. RESULTS: A total of 150 intubations were performed. Correct ETT placement was achieved in 100% of attempts in group DL-Normal, 90% of attempts in group DL-Difficult and 98% of attempts in BF-Difficult. Time to intubate averaged 14 s (interquartile range 12-16) in group DL-Normal; 12 s (10-15) in group DL-Difficult; and 11 s (10-18) in group BF-Difficult. The percentage of glottic opening seen (POGO score) was 70% (70-80) in group DL-Normal; 0% (0-0) in group DL-Difficult; and 100% (100-100) in group BF-Difficult. DISCUSSION: The Bonfils fiberscope-assisted laryngoscopy was easier to use and provided a better view of the larynx than simple direct laryngoscopy in the simulated difficult pediatric airway, but intubation success rate and time to intubate were not improved. Further studies of the Bonfils fibrescope as a pediatric airway adjunct are needed.

A comparison of the STORZ video laryngoscope and standard direct laryngoscopy for intubation in the Pediatric airway--a randomized clinical trial.

INTRODUCTION: Direct laryngoscopy can be challenging in infants and neonates. Even with an optimal line of sight to the glottic opening, the viewing angle has been measured at 15 degrees . The STORZ DCI video laryngoscope (Karl Storz, Tuttlingen, Germany) incorporates a fiberoptic camera in the light source of a standard laryngoscope of variable sizes. The image is displayed on a screen with a viewing angle of 80 degrees . We studied the effectiveness of the STORZ DCI as an airway tool compared to standard direct laryngoscopy in children with normal airway. METHODS: In this prospective, randomized study, 56 children (ages 4 years or younger) undergoing elective surgery with the need for endotracheal intubation were divided into two groups: children who underwent standard direct laryngoscopy using a Miller 1 or Macintosh 2 blade (DL) and children who underwent video laryngoscopy using the STORZ DCI video laryngoscope with a Miller 1 blade (VL). Time to best view (TTBV), time to intubate (TTI), Cormack-Lehane (CL), and percentage of glottis opening seen (POGO) score were recorded. RESULTS: TTBV in DL was 5.5 (4-8) s and 7 (4.2-9) s in VL. TTI in DL was 21 (17-29) s and in VL 27 (22-37) s (P = 0.006). The view as assessed by POGO score was 97.5% (60-100%) in DL and 100% (100-100%) in the VL (P = 0.003). Data are presented as median and interquartile range and analyzed using t-test. DISCUSSION: This study demonstrates that the STORZ DCI video laryngoscope provides an improved view to the glottis in children with normal airway anatomy, but requires a longer time for intubation.