Characteristics and impact of bedside procedure services in the United States: A systematic review.

BACKGROUND: Bedside procedure services are increasingly employed within internal medicine departments to meet clinical needs and improve trainee education. Published literature on these largely comprises single-center studies; an updated systematic review is needed to synthesize available data. PURPOSE: This review examined published literature on the structure and function of bedside procedure services and their impact on clinical and educational outcomes (PROSPERO ID: 192466). DATA SOURCES: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework, multiple databases were searched for publications from 2000 to 2021. STUDY SELECTION, DATA EXTRACTION, AND DATA SYNTHESIS: Thirteen single-center studies were identified, including 12 observational studies and 1 randomized trial. Data were synthesized in tabular and narrative format. Services were typically staffed by hospitalists or pulmonologists. At a minimum, each offered paracentesis, thoracentesis, and lumbar puncture. While there was considerable heterogeneity in service structures, these broadly fit either Model A (service performing the procedure) or Model B (service supervising the primary team). Procedure services led to increases in procedure volumes and self-efficacy among medical residents. Assessment of clinical outcomes was limited by heterogeneous definitions of complication rates and by sparse head-to-head data involving suitable comparators. Published data pointed to high success rates, low complication rates, and high patient satisfaction, with a recent study also demonstrating a decreased length of stay. CONCLUSIONS: There are relatively few published studies describing the characteristics of bedside procedure services and their impact on clinical and educational outcomes. Limited data point to considerable heterogeneity in service design, a positive impact on medical trainees, and a positive impact on patient-related outcomes.

Does the emergency surgery score accurately predict outcomes in emergent laparotomies?

BACKGROUND: The emergency surgery score is a mortality-risk calculator for emergency general operation patients. We sought to examine whether the emergency surgery score predicts 30-day morbidity and mortality in a high-risk group of patients undergoing emergent laparotomy. METHODS: Using the 2011-2012 American College of Surgeons National Surgical Quality Improvement Program database, we identified all patients who underwent emergent laparotomy using (1) the American College of Surgeons National Surgical Quality Improvement Program definition of "emergent," and (2) all Current Procedural Terminology codes denoting a laparotomy, excluding aortic aneurysm rupture. Multivariable logistic regression analyses were performed to measure the correlation (c-statistic) between the emergency surgery score and (1) 30-day mortality, and (2) 30-day morbidity after emergent laparotomy. As sensitivity analyses, the correlation between the emergency surgery score and 30-day mortality was also evaluated in prespecified subgroups based on Current Procedural Terminology codes. RESULTS: A total of 26,410 emergent laparotomy patients were included. Thirty-day mortality and morbidity were 10.2% and 43.8%, respectively. The emergency surgery score correlated well with mortality (c-statistic = 0.84); scores of 1, 11, and 22 correlated with mortalities of 0.4%, 39%, and 100%, respectively. Similarly, the emergency surgery score correlated well with morbidity (c-statistic = 0.74); scores of 0, 7, and 11 correlated with complication rates of 13%, 58%, and 79%, respectively. The morbidity rates plateaued for scores higher than 11. Sensitivity analyses demonstrated that the emergency surgery score effectively predicts mortality in patients undergoing emergent (1) splenic, (2) gastroduodenal, (3) intestinal, (4) hepatobiliary, or (5) incarcerated ventral hernia operation. CONCLUSION: The emergency surgery score accurately predicts outcomes in all types of emergent laparotomy patients and may prove valuable as a bedside decision-making tool for patient and family counseling, as well as for adequate risk-adjustment in emergent laparotomy quality benchmarking efforts.

Nonlinear model predictive control of managed pressure drilling.

A new design of nonlinear model predictive controller (NMPC) is proposed for managed pressure drilling (MPD) system. The NMPC is based on output feedback control architecture and employs offset-free formulation proposed in [1]. NMPC uses active set method for computing control inputs. The controller implements an automatic switching from constant bottom hole pressure (CBHP) regulation to flow control mode in the event of a reservoir kick. In the flow control mode the controller automatically raises the bottom hole pressure setpoint, and thereby keeps the reservoir fluid flow to the surface within a tunable threshold. This is achieved by exploiting constraint handling capability of NMPC. In addition to kick mitigation the controller demonstrated good performance in containing the bottom hole pressure (BHP) during the pipe connection sequence. The controller also delivered satisfactory performance in the presence of measurement noise and uncertainty in the system.

The Emergency Surgery Score (ESS) accurately predicts the occurrence of postoperative complications in emergency surgery patients.

BACKGROUND: The Emergency Surgery Score (ESS) was recently validated as a scoring system to predict mortality in emergency surgery (ES) patients. We sought to examine the ability of ESS to predict the occurrence of 30-day postoperative complications in ES. METHODS: The 2011-2012 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was screened for all surgical operations classified as "emergent." Thirty-day postoperative complications were defined as per ACS-NSQIP (e.g., surgical site infection, respiratory failure, acute renal failure). Each patient-related ESS was calculated, and the correlation between ESS and the probability of occurrence of 30-day postoperative complications was assessed by calculating the c-statistic. Univariate and multivariable models were also created to identify which ESS components independently predict complications. RESULTS: Of 37,999 cases that captured all ESS variables, 14,446 (38%) resulted in at least one 30-day complication. The observed probability of a 30-day complication gradually increased from 7% to 53% to 91% at scores of 0, 7, and 15, respectively, with a c-statistic of 0.78. For ESS >15, the complication rate plateaued at a mean of 92%. On multivariable analyses, each of the 22 ESS components independently predicted the occurrence of postoperative complications. CONCLUSIONS: ESS reliably predicts postoperative complications in ES patients. Such a score could prove useful for (1) perioperative patient and family counseling and (2) benchmarking the quality of ES care. LEVEL OF EVIDENCE: Prognostic, level III.

The Surgeon as the Second Victim? Results of the Boston Intraoperative Adverse Events Surgeons' Attitude (BISA) Study.

BACKGROUND: An intraoperative adverse event (iAE) is often directly attributable to the surgeon's technical error and/or suboptimal intraoperative judgment. We aimed to examine the psychological impact of iAEs on surgeons as well as the surgeons' attitude about iAE reporting. STUDY DESIGN: We conducted a web-based cross-sectional survey of all surgeons at 3 major teaching hospitals of the same university. The 29-item questionnaire was developed using a systematic closed and open approach focused on assessing the surgeons' personal account of iAE incidence, emotional response to iAEs, available support systems, and perspective about the barriers to iAE reporting. RESULTS: The response rate was 44.8% (n = 126). Mean age of respondents was 49 years, 77% were male, and 83% performed >150 procedures/year. During the last year, 32% recalled 1 iAE, 39% recalled 2 to 5 iAEs, and 9% recalled >6 iAEs. The emotional toll of iAEs was significant, with 84% of respondents reporting a combination of anxiety (66%), guilt (60%), sadness (52%), shame/embarrassment (42%), and anger (29%). Colleagues constituted the most helpful support system (42%) rather than friends or family; a few surgeons needed psychological therapy/counseling. As for reporting, 26% preferred not to see their individual iAE rates, and 38% wanted it reported in comparison with their aggregate colleagues' rate. The most common barriers to reporting iAEs were fear of litigation (50%), lack of a standardized reporting system (49%), and absence of a clear iAE definition (48%). CONCLUSIONS: Intraoperative AEs occur often, have a significant negative impact on surgeons' well-being, and barriers to transparency are fear of litigation and absence of a well-defined reporting system. Efforts should be made to support surgeons and standardize reporting when iAEs occur.

The impact of major intraoperative adverse events on hospital readmissions.

BACKGROUND: Hospital-wide readmission rates recently became a recognized benchmarking quality metric. We sought to study the independent impact of major intraoperative adverse events (iAEs) on 30-day readmission in abdominal surgery. METHODS: The 2007 to 2012 institutional American College of Surgeons National Surgical Quality Improvement Program and administrative databases for abdominal operations were matched then screened for iAEs using the International Classification of Diseases, 9th Revision, Clinical Modification-based Patient Safety Indicator "Accidental Puncture/Laceration". Flagged charts were reviewed to confirm the presence of iAEs. Major iAEs were defined as class 3 or above, as per our recently validated iAE Classification System. The inpatient database was queried for readmission within 30 days from discharge. Univariate and multivariable models were constructed to analyze the independent impact of major iAEs on readmission, controlling for demographics, comorbidities, American Society of Anesthesiology class, and procedure type/approach/complexity (using relative value units as proxy). Reasons for readmission were investigated using the Agency for Healthcare Research and Quality's International Classification of Diseases, 9th Revision, Clinical Modification-based Clinical Classification Software. RESULTS: Of 9,274 surgical procedures; 921 resulted in readmission (9.9%), 183 had confirmed iAEs, 73 of which were major iAEs. Procedures with major iAEs had a higher readmission rate compared with procedures with no iAEs [24.7% vs 9.8%, P < .001]. In multivariable analyses, major iAEs were independently associated with a 2-fold increase in readmission rates [OR = 2.17 (95% CI = 1.22 to 3.86); P = .008]; 67% of readmissions after major iAEs were caused by "complications of surgical procedures or medical care" as defined by Agency for Healthcare Research and Quality. CONCLUSIONS: Major iAEs are independently associated with increased rates of 30-day readmission. Preventing iAEs or mitigating their effects can serve as a quality improvement target to decrease surgical readmissions.