Estimation of the Time Needed to Deliver the 2020 USPSTF Preventive Care Recommendations in Primary Care.

Objectives. To reexamine the time required to provide the US Preventive Services Task Force (USPSTF)-recommended preventive services to a nationally representative adult patient panel of 2500.Methods. We determined the required time for a single physician to deliver the USPSTF preventive services by multiplying the eligible population, annual frequency, and patient-contact time required for each recommendation, all calculated by using data from the recommendations themselves and literature. We modeled a representative panel of 2500 adults based on the 2010 US Census Bureau data.Results. To deliver the USPSTF recommended preventive services across a 2500 adult patient panel would require 8.6 hours per working day, accounting for 131% of available physician time. Compared with 2003, there are fewer recommendations in 2020, but they require 1.2 more physician patient-contact hours per working day.Conclusions. The time required to deliver recommended preventive care places unrealistic expectations on already overwhelmed providers and leaves patients at risk. This is a systems problem, not a time-management problem. The USPSTF provides a set of recommendations with strong evidence of positive impact. It is imperative that our health care system is designed to deliver.

Unplanned postoperative reintubation following general and vascular surgical procedures: Outcomes and risk factors.

BACKGROUND: Unplanned postoperative reintubation (UPR) is a marker for severe adverse outcomes following general and vascular surgery. STUDY DESIGN: A retrospective analysis of 8809 adult patients, aged 18 years and older, who underwent major general and vascular surgery at a large single-center urban hospital was conducted from January 2013 to September 2016. Patients were grouped into those who experienced UPR and those who did not. Univariate and multivariate regression analyses were used to identify predictors of UPR, and association of UPR with adverse postoperative outcomes. All regression models had Hosmer-Lemeshow P > 0.05, and C-statistic >0.75, indicating excellent goodness-of-fit and discrimination. RESULTS: Of the 8809 patients included, 138 (1.6%) experienced UPR. There was no statistical difference in incidence of UPR between general and vascular surgery patients (p = 0.53). Independent predictors of UPR advanced age (OR 5.1, 95%CI 3.5-7.5, p < 0.01), higher ASA status (OR 7.9, 95%CI 5.6-11.1, p < 0.01), CHF (OR 7.0, 95%CI 3.6-13.9, p = 0.02), acute renal failure or dialysis (OR 3.1, 95%CI 1.8-5.7, p = 0.01), weight loss (OR 5.2, 95%CI 2.8-9.6, p = 0.01), systemic sepsis (OR 4.8, 95%CI 3.4-6.9, p < 0.01), elevated preoperative creatinine (OR 4.2, 95%CI 3.0-5.9, p = 0.01), hypoalbuminemia (OR 5.3, 95% CI 3.8-7.5, p = 0.01), and anemia (OR 4.0, 95%CI 2.8-5.9, p < 0.01). Following surgery, UPR was associated with increased mortality (OR 3.8, 95%CI 2.7-5.2, p < 0.01), pulmonary complications (OR 1.8, 95%CI 1.7-2.0, p < 0.01), renal complications (OR 2.6, 95%CI 1.7-3.5, p < 0.01), cardiac complications (OR 4.6, 95%CI 2.0-6.7, p < 0.01), postoperative RBC transfusion (OR 5.7, 95%CI 3.8-8.6,p < 0.01), and prolonged hospitalization (OR 1.8, 95%CI 1.5-2.4, p < 0.01). CONCLUSION: UPR is significantly associated with postoperative morbidity and mortality. Perioperative management aimed at decreasing incidences of UPR after noncardiac surgery should target preoperative anemia in addition to previously identified predictors.

Risk factors contributing to cardiac events following general and vascular surgery.

BACKGROUND: Cardiac events (CE) following surgery have been associated with morbidity and mortality. Defining risk factors that contribute to CE is essential to improve surgical outcomes. STUDY DESIGN: This was a retrospective study at a large urban teaching hospital for surgery performed from 2013 to 2015. Adult patients (≥18 years) that underwent general and vascular surgery were analyzed. Patients were grouped into those who experienced postoperative CE and those who did not. Univariate and multivariate regression analyses were used to identify predictors of postoperative CE, and association of CE with adverse postoperative outcomes. Separate subgroup analyses were also conducted for general and vascular surgery patients to assess predictors of CE. RESULTS: Out of 8441 patients, 157 (1.9%) experienced CE after major general and vascular surgery. Underlying predictors for CE included age >65 years(OR 4.9, 95%CI 3.4-6.9,p < 0.01), ASA >3(OR 12.0, 95%CI 8.5-16.9,p < 0.01), emergency surgery(OR 3.7, 95%CI 2.7-5.1,p = 0.01), CHF(OR 11.2, 95%CI 6.4-16.7,p = 0.02), COPD(OR 3.9, 95%CI 2.4-6.4,p = 0.04), acute renal failure or dialysis(OR 8.0, 95%CI 5.2-12.1,p = 0.04), weight loss(OR 3.3, 95%CI 1.7-6.7,p < 0.01), preoperative creatinine >1.2 mg/dL(OR 5.1, 95%CI 3.7-7.1,p = 0.01), hematocrit <34%(OR 4.0, 95%CI 2.8-5.7,p < 0.01), and operative time >240 min(OR 2.0, 95%CI 1.3-3.3,p = 0.02). Following surgery, CE was associated with increased mortality(OR 3.5, 95%CI 1.2-6.5,p < 0.01), pulmonary complications(OR 5.0, 95%CI 3.1-8.9,p < 0.01), renal complications(OR 2.3, 95%CI 1.9-4.5,p < 0.01), neurologic complications(OR 2.5, 95%CI 1.4-5.2,p < 0.01), systemic sepsis(OR 2.2, 95%CI 1.7-4.0,p < 0.01), postoperative RBC transfusion(OR 4.4, 95%CI 2.7-6.5,p < 0.01), unplanned return to operating room(OR 4.0, 95%CI 2.3-6.9,p < 0.01), and prolonged hospitalization (OR 5.5, 95%CI 3.1-8.8,p = 0.03). There was no statistical difference in incidence of CE between general and vascular surgery patients (p = 0.44); however, predictors of CE differed between the two surgical groups. CONCLUSION: Postoperative CE are associated with significant morbidity and mortality. Identified predictors of CE should allow for adequate risk stratification and optimization of perioperative surgical management.

Effect of Resident Involvement on Morbidity and Mortality Following Thoracic Endovascular Aortic Repair.

OBJECTIVE: To evaluate the effect of resident involvement in thoracic endovascular aortic repair (TEVAR). SUMMARY OF BACKGROUND DATA: Although the influence of resident intraoperative involvement in several types of surgical procedures has been reported, the effect of resident participation in TEVAR is unknown. We evaluated patient outcomes in resident-involved TEVAR procedures. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was analyzed for TEVAR performed from 2010 to 2012. Current procedural terminology codes were used to identify adult patients (≥18 y) who underwent TEVAR. Patients were grouped into those with and without resident involvement. Descriptive and binomial logistic statistics were used to determine the effect of resident involvement on post-TEVAR outcomes. p values < 0.05 were considered statistically significant. RESULTS: A total of 676 patients met inclusion criteria for this study. Of these, 517 (76.5%) had residents involved. Overall mortality was 9.8%, with no significant difference between the 2 groups (p = 0.88). Resident involvement was not a significant predictor of any post-TEVAR complication. Postoperative pneumonia (3.5% vs 6.9%, p = 0.06), prolonged mechanical ventilation (11.8% vs 11.9%, p = 0.96), stroke (2.7% vs 5.7%, p = 0.07), urinary tract infection (3.3% vs 4.4%, p = 0.50), progressive renal insufficiency (1.2% vs 2.5%, p = 0.22), acute renal failure (4.1% vs 5.0%, p = 0.60), cardiac arrest (2.9% vs 5.0%, p = 0.20), myocardial infarction (1.7% vs 1.9%, p = 0.91), deep venous thrombosis (1.7% vs 1.3%, p = 0.67), red blood cells transfusions (29.2% vs 36.5%, p = 0.08), sepsis (2.9% vs 4.4%, p = 0.35), septic shock (1.9% vs 3.8%, p = 0.18), and unplanned reintubation (8.7% vs 9.4%, p = 0.78) were not significantly affected. Additionally, resident involvement did not significantly affect operative time (176.1 ± 122.8 min vs 180.3 ± 119.1 min, p = 0.71) and anesthesia time (282.1 ± 146.6 min vs 278.3 ± 140.5 min, p = 0.78). CONCLUSIONS: The participation of residents in TEVAR did not significantly affect all 30-day patient outcomes. Resident involvement in TEVAR is safe and should be encouraged. MINI ABSTRACT: This study evaluated the effect of resident participation on postoperative outcomes of thoracic endovascular aortic repair (TEVAR) using the American College of Surgeons National Surgical Quality Improvement (ACS-NSQIP) database. Results showed that resident involvement in TEVAR does not negatively affect patient outcomes.

Is video observation as effective as live observation in improving teamwork in the operating room?

BACKGROUND: Teamwork in the operating room decreases the risk of preventable patient harm. Observation in the operating room allows for evaluation of compliance with best-practice surgical guidelines. This study examines the relative ability of video and live observation to promote operating room teamwork. METHODS: Video and audio cameras were installed in 2014 into all operating rooms at an 875-bed, urban teaching hospital. Recordings were chosen at random for review by an internal quality improvement team. Concurrently, live observers were deployed into a random selection of operations. A customized tool was used to evaluate compliance to TeamSTEPPS skills during surgical briefs and debriefs. RESULTS: A total of 1,410 briefs were evaluated: 325 (23%) through live observation and 1,085 (77%) through video; 1,398 debriefs were evaluated: 166 (12%) live and 1,232 (88%) video. For briefs, greater compliance was observed under live observation compared to video for recognition of team membership (87% vs 44%, P<.001), anticipation of complex procedural events (61% vs 45%, P<.001), and monitoring of resources (58% vs 42%, P<.001). For debriefs, greater compliance was observed under live observation for determination of team structure (90% vs 60%, P<.001), establishment of a leader (70% vs 51%, P<.001), postoperative planning (77% vs 48%, P<.001), case review and feedback (49% vs 33%, P<.001), team engagement (64% vs 41%, P<.001), and check back (61% vs 46%, P<.001) compared to video. CONCLUSION: Video observations may not be as effective as evaluating live performance in promoting teamwork in the OR. Live observation enables immediate feedback, which may improve behavior and decrease barriers to compliance with surgical safety practices.