Frailty in the Cardiac Surgical Patient: Comparison of Frailty Tools and Associated Outcomes.

BACKGROUND: Frailty measurement in cardiac surgery is poorly studied. The study purposes were to identify a simple but accurate frailty tool by comparing the simplified frailty index, Study of Osteoporotic Fractures (SOF), to a more complex frailty index, the Cardiovascular Health Study (CHS), and outcomes of frail patients to nonfrail patients. METHODS: Patients aged 65 years or older admitted for elective coronary artery bypass grafting (CABG), valvular surgery (valve), or a combination of CABG/valve were recruited and administered the SOF and CHS indexes. Surgical outcomes were defined by The Society of Thoracic Surgeons. A hand-held dynamometer assessed grip strength. Health-related quality of life was assessed by the 12-Item Short Form Health Survey. RESULTS: Patients (n = 167) were primarily male (75%), white (88%), and CABG (23%), valve (50%), or CABG/valve (25%). Frailty agreement between the CHS (frail, n = 47) and SOF (frail, n = 15) was poor (κ = 0.185). SOF frail patients had poorer health, were men (67% vs 61%), had a decreased ejection fraction (0.467 vs 0.537), an increased Society of Thoracic Surgeons Risk (5.0 vs 3.5), and increased European System for Cardiac Operative Risk Evaluation score (8.2 vs 5.2). All SOF frail patients reported lack of energy vs 8.7% CHS frail patients, and 80% vs 23.9% reported an unintentional weight loss of 5% or more. SOF frail patients were significantly more likely to experience prolonged ventilation (20% vs 6.5%), pneumonia (20% vs 6.5%), prolonged intensive care unit hours (158.6 vs 85.01), and readmission within 30 days (20% vs 8.7%). All frail patients reported a significantly lower physical health-related quality of life. CONCLUSIONS: The SOF tool better identified patients considered "frail." Frail patients had more adverse outcomes and poorer health-related quality of life.

Confirmatory factor analysis of the Minnesota living with heart failure questionnaire among patients following open heart surgery for valve dysfunction.

INTRODUCTION: The Minnesota Living with Heart Failure Questionnaire (MLHFQ) was designed to assess the impact of the adverse effects of heart failure (HF). Numerous reports suggest an additional third factor with the proposed third factor representing a social dimension. The purpose of this study was to use confirmatory factor analysis (CFA) to validate the factor structure of the MLWHFQ, and examine a proposed third factor structure. METHODS: Participants were 1290 individuals with open heart surgery for isolated valve repair or replacement between September 2005 and May 2016. Confirmatory factor analysis was used to assess both initial and proposed alternate factor structures. RESULTS: CFA indicated a poor fit for the original proposed 2-factor solution [root mean square error of approximation (RMSEA) = 0.116], whereas separate proposed 3-factor solutions with varying item scoring fit marginally well (RMSEA = 0.080, 0.089). The CFA suggests the existence of a third dimension, social, beyond the established original two-factor solution. Results suggest in a direct comparison of proposed social dimensions, both Garin's four item solution and Munyombwe's six-item solution provide similar results. CONCLUSIONS: Results suggest support for an additional third factor among patients undergoing isolated valve replacement surgery. We suggest given the inclusion of items important to our population, relatively strong fit indices, and correlation with the SF-12, the social dimension proposed by Munyombwe best fits our population.

The impact of a multidisciplinary blood conservation protocol on patient outcomes and cost after cardiac surgery.

OBJECTIVE: Although associations between transfusion and inferior outcomes have been documented, there is a lack of blood transfusion standardization in cardiac surgery. At the Inova Heart and Vascular Institute, a multidisciplinary, criterion-driven algorithm for transfusion management was implemented. We examined the effect of our blood conservation protocol on transfusion rates and outcomes after cardiac surgery and on stability of transfusion over time. METHODS: Patients undergoing first-time cardiac surgery from 2006 (full year before protocol) were compared with those in 2009 (after protocol) and propensity score matched to improve balance. Data were prospectively collected. Stability of transfusion incidence also was compared (2005-2006 vs 2008-2014). RESULTS: After matching, 890 patients from each year were included. Use of blood products decreased from 54% in 2006 to 25% in 2009 (P < .001). Patients in 2009 had a lower incidence of postoperative renal failure (2.6% vs 4%, P = .04), reoperations for bleeding (2% vs 4%, P = .004), and readmissions at less than 30 days (6% vs 12%, P < .001). No differences were found for operative mortality, deep sternal wound infection, or permanent strokes. Patients in 2009 had greater improvement in physical (P = .001) and mental (P = .02) quality of life than patients in 2006. Reduction of blood products led to significant cost savings for packed erythrocytes (P < .001) and platelets (P < .001). After protocol implementation, transfusion incidence remained 30% or less, with less than 28% in most years. CONCLUSIONS: A multidisciplinary blood conservation program can significantly control blood transfusion rates, improve outcomes, and be sustained over time. Efforts are needed to implement evidence-based protocols to standardize and decrease blood use in cardiac surgery to improve outcomes and reduce cost.

Outcome Management in Cardiac Surgery Using the Society of Thoracic Surgeons National Database.

Health care reform has helped streamline patient care and reimbursement by encouraging providers to provide the best outcome for the best value. Institutions with cardiac surgery programs need a methodology to monitor and improve outcomes linked to reimbursement. The Society of Thoracic Surgeons National Database (STSND) is a tool for monitoring outcomes and improving care. This article identifies the purpose, goals, and reporting system of the STSND and ways these data can be used for benchmarking, linking outcomes to the effectiveness of treatment, and identifying factors associated with mortality and complications. We explain the methodology used at Inova Heart and Vascular Institute, Falls Church, Virginia, to perform outcome management by using the STSND and address our performance-improvement cycle through discussion of data collection, analysis, and outcome reporting. We focus on the revision of clinical practice and offer examples of how patient outcomes have been improved using this methodology.

Comparison of EuroSCORE II, Original EuroSCORE, and The Society of Thoracic Surgeons Risk Score in Cardiac Surgery Patients.

BACKGROUND: The European System for Cardiac Operative Risk Evaluation (EuroSCORE) II was developed to reflect a more current dataset and evidence-based improvements in cardiac surgery. In the United States, The Society of Thoracic Surgeons (STS) risk score is more accepted owing to relatively high predictive value despite less user friendliness and inapplicability to some cardiac surgeries. We compared the precision of EuroSCORE II with EuroSCORE I and the STS risk score for operative mortality. METHODS: Data were collected prospectively for all cardiac surgery patients at a single center since 2001 (N = 11,788). A secondary analysis for patients with cardiac surgery not accommodated by the STS model compared only EuroSCORE II and I (N = 5,880). Receiver-operating characteristic analyses were performed for operative mortality to determine the discriminative ability for each score. RESULTS: Observed operative mortality was 1.8%. Mean predicted mortality for STS risk score, EuroSCORE II, and EuroSCORE I was 2.7%, 3.3%, and 7.8%, respectively. The discriminative ability for operative mortality by area under the curve for EuroSCORE II, EuroSCORE I, and STS risk score was 0.844, 0.819, and 0.846, respectively. In secondary analyses comparing EuroSCORE II with EuroSCORE I, risk scores were correlated (rs = 0.83, p < 0.001). However, for operative mortality (observed, 4%), EuroSCORE II had better absolute prediction and discriminative ability (expected, 5.8%; area under the curve 0.754) than EuroSCORE I (expected, 12.5%; area under the curve 0.688). CONCLUSIONS: EuroSCORE II had better predictive discrimination for operative mortality than EuroSCORE I, which greatly overestimated this risk. EuroSCORE II fared well compared with the STS risk score. The inclusive nature of EuroSCORE II for numerous procedures provides more flexibility than the STS score for complex procedures. EuroSCORE II should be considered for calculating risk score for complex cardiac surgical patients.

The Effects of Frailty in Patients Undergoing Elective Cardiac Surgery.

BACKGROUND: The Society of Thoracic Surgeons (STS) recommends using gait speed as a marker of frailty to identify cardiac surgery patients at risk for adverse outcomes. However, a single marker of frailty may not provide consistently reliable risk information. We evaluated the impact of frailty and gait speed on patient outcomes after elective cardiac surgery. METHODS: This was a prospective study of 167 older (≥65 years) coronary artery bypass grafting (CABG) and/or valve surgery patients. Patients were assessed using Cardiovascular Health Study (CHS) Frailty Index criteria: weight loss, exhaustion, physical activity, gait speed, and grip strength. RESULTS: Frailty was identified in 39 patients (23%) using CHS criteria. Frail patients had longer median intensive care unit stays (54 vs. 28 h, p = 0.003), longer median length of stay (8 vs. 5 days, p < 0.001), and greater likelihood of STS-defined complications (54% vs. 32%, p = 0.011) and discharge to an intermediate-care facility (45% vs. 12%, p < 0.001) but were not different from nonfrail patients on major outcome, operative mortality, or readmissions. After multivariate adjustment, frail and nonfrail patients were similar on perioperative outcomes. Absolute gait speed and slow gait speed using a cutoff were not related to incidence of STS-defined complications or major outcome in multivariate analyses. However, higher body mass index was correlated with slower gait speed (rs = 0.30, p < 0.001). CONCLUSIONS: The CHS index did not identify "frail" patients at increased risk for adverse outcomes. No relationship was found between gait speed and outcome. There is a need for alternative multidimensional measures to assess frailty in cardiac surgical patients. doi: 10.1111/jocs.12699 (J Card Surg 2016;31:187-194).

Operative risk and preoperative hematocrit in bypass graft surgery: Role of gender and blood transfusion.

BACKGROUND: The association between lower preoperative hematocrit (Hct) and risk for morbidity/mortality after cardiac surgery is well established. We examined whether the impact of low preoperative Hct on outcome is modified by blood transfusion and operative risk in women and men undergoing nonemergent CABG surgery. METHODS: Patients having nonemergent, first-time, isolated CABG were included (N=2757). Logistic regressions assessed effect of hematocrit on major perioperative morbidity/mortality separately by males (n=2232) and females (n=525). RESULTS: Mean age was 63.2±10.1years, preoperative hematocrit was 38.9±4.8%, and STS risk score was 1.3±1.8%. Blood transfusion was more likely in female patients (26% vs. 12%, P<0.001). Multivariate analyses revealed that lower body mass index and lower preoperative hematocrit predicted transfusion in males and females, whereas older age (OR=1.03, P=0.017) also predicted transfusion in females. Major morbidity was also more likely in female patients (12% vs. 7%, P<0.001). In multivariate analyses, blood transfusion was the only predictive factor for major morbidity in females (OR=4.56, P<0.001). In males, higher body mass index (OR=1.07, P<0.001), lower hematocrit (OR=0.94, P=0.017), interaction of STS score with hematocrit (OR=1.02, P=0.045), and blood transfusion (OR=9.22, P<0.001) were significant predictors for major morbidity. CONCLUSIONS: This study showed females were more likely to have blood transfusion and major morbidities after nonemergent CABG. Traditional factors that have been found to predict outcomes, such as hematocrit and STS risk, were related only to major morbidity in male patients. However, blood transfusion negatively impacted major outcome after nonemergent CABG surgery across all STS risk levels in both genders.

Potential Impact of Modifiable Clinical Variables on Length of Stay After First-Time Cardiac Surgery.

BACKGROUND: Recent financial challenges highlight the importance of accurate prediction of length of hospital stay (LOS). We assessed reliability of The Society of Thoracic Surgeons (STS) risk prediction for extended and shorter LOS and examined whether modifiable clinical variables are associated with LOS in first-time cardiac surgery patients. METHODS: Isolated aortic valve, mitral valve, and coronary artery bypass graft surgery patients since 2008 were included (n = 3,472). Multivariate regression was used to evaluate nonmodifiable and potentially modifiable (preoperative hematocrit, hemoglobin A1c, body mass index, current smoker, major perioperative morbidity, and blood product transfusion) predictors of LOS in days. RESULTS: Mean age was 63.9 ± 11.2 years, 76% were males, and mean STS mortality risk was 1.9% ± 3.2%. Median (interquartile range) LOS was 4 (3 to 6) days. Predicted STS risk was 6.2% ± 7.1% for extended LOS (>14 days) and 48.3% ± 20.2% for short LOS (<6 days). Extended LOS was observed in 5.2% of patients (observed versus expected, 0.84; p = 0.019). Observed short LOS was better than predicted (67.8%; observed versus expected, 1.40; p < 0.001). Inclusion of modifiable variables in the LOS prediction model was significant (p < 0.001). Significant modifiable predictors were lower hematocrit, higher hemoglobin A1c, major morbidity, and transfusion. Longer predicted LOS from the model correlated with longer actual LOS (rs = 0.63; p < 0.001). Applying the prediction equation from the model to a hypothetical average patient, predicted LOS was 4.6 days. CONCLUSIONS: The STS risk model was reliably predictive of short and extended LOS but did not allow prediction of exact LOS in days. Accounting for potentially modifiable clinical variables, such as low hematocrit and blood transfusion, especially in elective patients, should lead to shorter LOS, higher satisfaction, and reduced financial burden.

Should asymptomatic patients discharged with lower hemoglobin expect worse outcomes after valve surgery?

OBJECTIVE: Blood transfusion in cardiac surgery patients is associated with increased morbidity and cost. The decision to transfuse patients after surgery varies but is often based on low hemoglobin (Hgb) levels, regardless of symptom status. This study examined whether asymptomatic patients discharged with lower Hgb levels had increased risk for perioperative complications and 1-year mortality. METHODS: Between 2008 and mid-2014, a total of 1107 valve-only procedures were performed. Patients discharged alive with complete data (N = 1044) were divided into 2 groups with discharge Hgb levels of ≤8 g/dL (n = 153) or >8 g/dL (n = 891). Propensity score matching was conducted between Hgb groups, resulting in 152 patient pairs. RESULTS: In multivariate analyses, discharge Hgb level did not predict 30-day mortality (odds ratio [OR] = 1.01, P = .991), 1-year survival (hazard ratio [HR] = 0.87, P = .34), or readmission <30 days (OR = 0.92, P = .31). Furthermore, after propensity score matching, no differences were found between groups with Hgb levels ≤8 versus >8 g/dL in 30-day mortality (0% vs 0.7%, P > .99) or readmissions (14% vs 16%, P = .52). Cumulative 1-year survival was similar between matched groups with discharge Hgb level of ≤8 versus >8 g/dL (89.3% vs 91.4%, P = .67). Matched groups with Hgb level ≤8 versus >8 g/dL had similar physical (28% vs 18% increase; P = .27) and mental (7% vs 6% increase; P = .94) health-related quality of life (HRQL) improvements at 6 months. CONCLUSIONS: Asymptomatic patients discharged with lower Hgb levels did not manifest inferior outcomes, including perioperative morbidity/mortality, readmission <30 days, HRQL, and 1-year survival. The practice of blood transfusion to correct lower Hgb levels in asymptomatic patients should be eliminated, as it may be associated with increased morbidity without apparent clinical benefits after valve surgery.

Effect of patient age on blood product transfusion after cardiac surgery.

OBJECTIVE: Blood product transfusion after cardiac surgery is associated with increased morbidity and mortality. Transfusion thresholds are often lower for the elderly, despite the lack of clinical evidence for this practice. This study examined the role of age as a predictor for blood transfusion. METHODS: A total of 1898 patients were identified who had nonemergent cardiac surgery, between January 2007 and August 2013, without intra-aortic balloon pumps or reoperations, and with short (<24 hours) intensive care unit stays (age ≥75 years; n = 239). Patients age ≥75 years were propensity-score matched to those age <75 years to balance covariates, resulting in 222 patients per group. Analyses of the matched sample examined age as a continuous variable, scaled in 5-year increments. RESULTS: After matching, covariates were balanced between older and younger patients. Older age significantly predicted postoperative (odds ratio = 1.39, P = .028), but not intraoperative (odds ratio = 0.96, P = .559), blood transfusion. Older age predicted longer length of stay (B = 0.21, P < .001), even after adjustment for blood product transfusion (B = 0.20, P < .001). As expected, older age was a significant predictor for poorer survival, even with multivariate adjustment (hazard ratio = 1.34, P = .042). CONCLUSIONS: In patients with a routine postoperative course, older age was associated with more postoperative blood transfusion. Older age was also predictive of longer length of stay and poorer survival, even after accounting for clinical factors. Continued study into effects of transfusion, particularly in the elderly, should be directed toward hospital transfusion protocols to optimize perioperative care.

Preoperative hematocrit as a predictor of perioperative morbidities following nonemergent coronary artery bypass surgery.

BACKGROUND: Preoperative hematocrit (HCT) has predicted inferior outcome following cardiac surgery. However, the potential for preoperative HCT to be a marker for sicker patients was not well explored. This study examined the impact of HCT on outcome following nonemergent coronary artery bypass grafting (CABG) and whether the association is modified by operative risk or intraoperative blood transfusion. METHODS: Nonemergent isolated CABG surgery patients were included (N = 2306). Logistic regressions were conducted to assess the effect of HCT on major perioperative morbidities. Separate analyses were conducted on tertiles of STS score (<0.55%, n = 768; 0.55% to 1.15%, n = 771; >1.15%, n = 767). RESULTS: Mean age was 63.1 ± 10.1, preoperative HCT was 38.9 ± 4.8, and STS score was 1.4 ± 2.0% (median = 0.79%). In univariate (OR = 0.89, p < 0.001) and multivariate (OR = 0.93, p < 0.001) analyses, lower HCT predicted major morbidity. Lower HCT predicted major morbidity only in the highest risk tertile (OR = 0.93, p < 0.001) and the same result was found after multivariate adjustment (OR = 0.92, p < 0.001). Following inclusion of intraoperative transfusion in a multivariate model, preoperative HCT remained an independent predictor for major morbidity (OR = 0.95, p = 0.01), while transfusion was also a strong predictor (OR = 4.86, p < 0.001). Addition of transfusion to multivariate models by STS risk tertiles revealed preoperative HCT remained predictive only in the highest risk group (OR = 0.95, p = 0.03) while transfusion was a strong predictor in all three risk tertiles (OR = 3.97 to 10.36; p-values < 0.001). CONCLUSIONS: Lower preoperative HCT was associated with higher odds for perioperative morbidity in nonemergent CABG patients with higher STS risk. Additionally, intraoperative blood transfusion negatively impacted all STS risk groups. Preoperative strategies to mitigate anemia may reduce transfusions and improve outcome in CABG patients.

Practice changes in blood glucose management following open heart surgery: from a prospective randomized study to everyday practice.

OBJECTIVES: Targeted blood glucose (BG) levels following cardiac surgery continues to be debated. According to the Society of Thoracic Surgeons (STS) guidelines, BG should be kept <180 mg/dl following cardiac surgery. However, our practice and others shifted to a stricter BG control (90-110 mg/dl) based on data suggesting an association with improved outcome. Recently, we conducted a randomized control study that demonstrated no added value to stricter control over liberal control (120-180 mg/dl). As a result, we shifted our management accordingly. The purpose of this study was to evaluate the impact that this change to a more liberal BG management (BGM) had on patient outcomes at our centre. METHODS: BGM was changed in June 2011 from strict (90-110 mg/dl) to liberal (120-180 mg/dl). Insulin drips, managed through a computerized algorithm, controlled BG for the first 72 h post surgery. Consecutive cardiac surgery patients operated on throughout 1 year prior to BGM change (n = 934) were propensity score matched to patients operated on throughout 1 year after the change (n = 927). RESULTS: After matching, there were 846 patient pairs. There was no difference between cohorts for length of stay and perioperative complications, and both cohorts achieved acceptable outcomes. Incidence of perioperative renal failure (P = 0.02) and renal failure requiring dialysis (P = 0.004) were better for the cohort with liberal BGM. One-year cumulative survival did not differ between cohorts (log-rank = 0.70, P = 0.40). CONCLUSIONS: Implementation of glycaemic control of 120-180 mg/dl into clinical practice was not associated with increased morbidity. The present results confirm our prior findings that a more liberal glycaemic control strategy to maintain BG is equal to a stricter target range. These findings are important for patient care and demonstrate the safety and efficacy of practice change for all patients following a successful randomized controlled trial.

Ventilator-associated pneumonia among cardiac surgery patients: what can we do for prevention?

Ventilator-associated pneumonia is associated with high mortality and morbidity and significantly increases intensive care unit length of stay and costs of care. In a pre- and postintervention study, we found that the majority of patients (63%) had an antecedent condition that necessitated emergent intubation prior to surgery. Efforts should be directed to developing strategies to minimize the risk of ventilator-associated pneumonia in emergent intubations, decrease reintubations, and reduce the use of blood products.

Patient disposition and long-term outcomes after valve surgery in octogenarians.

BACKGROUND: Valve surgery is performed routinely in octogenarians. This study explored variables affecting patient discharge disposition (home versus other facility) and whether patient disposition was related to long-term survival. METHODS: Patients 80 years or older who presented for aortic valve or mitral valve surgery from 2002 to 2010 were included. Baseline demographic, perioperative, and long-term outcomes were captured. Disposition was categorized into 2 groups; home (n=184) or other facility (n=123). The National Death Index and Social Security Death Index verified deaths. RESULTS: Mean age was 82.9±2.5; 46% (140 of 307) were female. Discharge location logistic regression, adjusted for gender (odds ratio [OR]=1.45, p=0.17) and European System for Cardiac Operative Risk Evaluation score (OR=1.09, p=0.10), predicted that older (OR=1.18, p<0.001), unmarried (OR=2.07, p=0.006) patients with at least 1 major complication (OR=3.86, p<0.001) were more likely to be not discharged home. Kaplan-Meier analysis found significantly lower 1- and 2-year (85.8% vs 94.6%, p=0.009; 80.1% vs 90.3%, respectively, p=0.01) cumulative survival in patients not discharged home. A multivariate Cox proportional hazards model demonstrated poorer 1- and 2-year survival (hazard ratio [HR]=2.56, p=0.04; HR=2.06, p=0.05, respectively). Predictors of follow-up mortality for patients not discharged home were length of stay (OR=1.06, p=0.03) and any major complication (OR=6.90, p=0.002); lower body mass index was marginally significant (OR=1.12, p=0.06). The significant predictor for patients discharged home was length of stay (OR=1.17, p=0.002). CONCLUSIONS: Octogenarians can expect excellent survival after valve surgery. Those not discharged home had poorer long-term survival. Therefore, adequate resources should be secured so sicker patients receive the appropriate level of care.

Comparison of blood glucose management strategies to achieve control following cardiac surgery (computerized versus paper).

INTRODUCTION: Blood glucose control can be time-consuming and difficult to achieve. We hypothesized that a computerized system to obtain glucose control would enable faster "time to target" and produce less variability in blood glucose levels. METHODS: Patients who underwent cardiac surgery at a community hospital between January and December 2007 (n = 1131) with glucose control obtained under a paper protocol were compared with similar patients operated on between January and December 2008 (n = 769) whose glucose control was obtained with a computer-driven protocol. RESULTS: Glucose control was achieved in both groups. The computer group had less variability in glucose levels than the paper group. The mean time to target for the computer group was 3.5 (+/-1.3) hours. The time to target for the paper group was quite skewed; therefore, the median time to target was 6 hours. CONCLUSIONS: The computer-driven protocol achieved excellent glycemic control.

Impact of body mass index on clinical outcome and health-related quality of life following open heart surgery.

The effect of increased body mass index (BMI) on survival following open heart surgery is unclear. We explored the relationship between BMI, survival following elective open heart surgery, and health-related quality of life. Our results suggest that increased BMI need not be a deterrent for undergoing open heart surgery. Patients with increased BMI can expect similar complication rates, significant gains in health-related quality of life at 1 year, and comparable intermediate survival.

The use of spirometry testing prior to cardiac surgery may impact the Society of Thoracic Surgeons risk prediction score: a prospective study in a cohort of patients at high risk for chronic lung disease.

OBJECTIVES: Chronic lung disease is a significant comorbidity in patients undergoing cardiac surgery. Chronic lung disease is currently being classified and reported to the Society of Thoracic Surgeons database by using either clinical interview or spirometric testing. We sought to compare the chronic lung disease classification captured by the 2 methods. METHODS: We performed a prospectively designed study in which patients presenting for cardiac surgery, excluding emergent patients, were screened for a history of asthma, a history of 10 or more pack-years of smoking, a persistent cough, and the use of oxygen. Each selected patient underwent spirometry. The presence and severity of chronic lung disease was coded per Society of Thoracic Surgeons guidelines by using the 2 methods of clinical report and spirometric results. The chronic lung disease classifications were compared, and differences were determined by using concordance and discordance rates. The results were then used to construct Society of Thoracic Surgeons-predicted risk models. RESULTS: The discordant rate was 39.1%, with underestimation of the severity of chronic lung disease in 94% of misclassified patients. This affected the Society of Thoracic Surgeons-predicted risk models for prolonged ventilation, morbidity/mortality, and mortality by increasing the predicted risk when spirometry was used for morbidity/mortality by an average of 1.5 +/- 1.2 percentage points (P < .001) and prolonged ventilation time by an average of 1.3 +/- 1.4 percentage points (P < .001). CONCLUSION: The use of patient history for symptoms, medication, and/or oxygen use as the only method to determine chronic lung disease for this subgroup of patients led to underreporting of chronic lung disease and underestimation of the risk for adverse outcomes. Therefore data submission to the Society of Thoracic Surgeons database should be designed to capture and correct for potential bias in the definition of chronic lung disease because the rate of spirometry in different centers in defining chronic lung disease is not regulated.

Nurses' perceptions of glycemic control in patients who have undergone cardiac surgery.

BACKGROUND/SIGNIFICANCE: Previous work investigating the effect of glycemic control in patients who underwent cardiac surgery has demonstrated that obtaining and maintaining blood glucose values between 80 and 120 is imperative in achieving excellent clinical outcomes in a patient who have undergone cardiac surgery. However, the caregiver's workload associated with meeting this goal is only now beginning to be understood. METHODS: This qualitative study used focus groups held on 3 consecutive days to interview nurses in the cardiovascular intensive care unit and cardiovascular step-down unit about their thoughts on glycemic control.Three research questions were developed to help guide the focus group discussions. RESULTS: Ten nurses, 3 from cardiovascular intensive care unit and 7 from cardiovascular step-down unit, participated in the focus groups and saturation was accomplished. The essence of the nurses' message was that they recognize glycemic control as a very important part of their patient care. However, to be able to perform this intervention, they need available equipment, a designated person to obtain all blood glucose values, periodic updates on patient outcomes related to glycemic control, and a less intrusive way to draw the patients' blood. CONCLUSION: The ability of the nurses to obtain glycemic control is hindered by the lack of time, lack of necessary resources/equipment, lack of knowledge about the long-term outcomes resulting from glycemic control, and the discomfort to patients caused by the frequent blood draws. Hospitals need to investigate alternative mechanisms that will assist the nurse in meeting this goal.

Survival and quality of life following elective open-heart surgery.

Eight hundred thirty-six patients who had open-heart surgery were available for analysis of health-related quality of life (HRQL) data and survival at the 1-year follow-up. Elective open-heart surgery patients with decreasing HRQL at 1 year following surgery may experience a survival disadvantage in comparison with those patients experiencing positive gains. Clinical care should extend beyond the immediate postoperative period.

Public health reporting: the United States perspective.

The release of 2 landmark reports by the Institute of Medicine titled, "To Err Is Human: Building a Safer Health System" and "Crossing the Quality Chasm" were instrumental in the identification of safety and quality issues. Since their release, federal and state programs of public reporting of performance measures have attempted to close the quality gap of care that is inappropriate, not timely, or lacking an evidence base. Cardiac surgery has long been the focus of public scrutiny, and now, as we move from an era of managed care to public reporting, reimbursement for cardiac surgery procedures will be tied to performance. However, the question is whether public reporting and pay for performance will ultimately improve the quality of patient care, safety, and provide the consumer with enough information to make surgeon and institutional choices. Will the cost and focus of achieving perfection with performance standards overshadow any real improvement in clinical outcomes?