Different Harm and Mortality in Critically Ill Medical vs Surgical Patients: Retrospective Analysis of Variation in Adverse Events in Different Intensive Care Units.

BACKGROUND: Institutional harm reduction campaigns are essential in improving safe practice in critical care. Our institution embarked on an aggressive project to measure harm. We hypothesized that critically ill surgical patients were at increased risk of harm compared with medical intensive care patients. METHODS: Three years of administrative data for patients with at least 1 Intensive Care Unit day at an urban tertiary care center were assembled. Data were accessed from the Henry Ford Health System No Harm Campaign in Detroit, MI. Harm was defined as any unintended physical injury resulting from medical care. Patients were deemed surgical if they had at least 1 procedure in the operating room. Univariate analysis was used to compare surgical patients with nonsurgical. Logistic regression was used for risk adjustment in predicting harm and death. RESULTS: The study included 19,844 patients, of whom 7483 (37.7%) were surgical. The overall mortality was 7.8% (n = 1554). More surgical patients experienced harm than did nonsurgical patients (2923 [39.1%] vs 2798 [22.6%], odds ratio [OR] = 2.2, p < 0.001). Surgical patients were less likely to die (6.2% vs 8.8%, p < 0.001). Surgical patients were more likely to experience harm (OR = 2.1) but had lower mortalities (OR = 0.45) vs other harmed patients (OR = 3.8; all p < 0.001). CONCLUSION: Most harm in surgically critically ill patients is procedure related. Preliminary data show that harm is associated with death, yet both surgical and African American patients experience more harm with a lower mortality rate.

The differential effects of surgical harm in elderly populations. Does the adage: "they tolerate the operation, but not the complications" hold true?

BACKGROUND: Elderly patients are thought to tolerate surgical complications poorly because of low physiologic reserve. The purpose of the study was to evaluate the differential effects of surgical harm in patients over 80 years old. METHODS: Three years of data from a harm-reduction campaign were used to identify inpatient surgeries performed on patients older than 50. The rates of harm, death, cost, and length of stay (LOS) were analyzed using SPSS 21 (IBM, New York, NY). RESULTS: A total of 22,710 patients were identified. Rates of harm and mortality increased with increasing age. Harmed patients over age 80 had increased mortality (9.5% vs 7%), but lower cost, intensive care unit days, and LOS versus those aged 50 to 80. Linear regression showed increased cost with harm ($24,000) and decreased cost with age above 80 (-$7,000). CONCLUSIONS: In the elderly surgical population, there is more harm and harm events are associated with higher mortality rates, but less additional cost and LOS. Differing goals or aggressiveness of care may explain cost avoidance in the elderly.

The differential effects of intermediate complications with postoperative mortality.

Most attempts at understanding perioperative mortality have been based on assessing individual patient risk factors, types of operations, and hospital characteristics. The hypothesis of this study is that there is a relationship between postoperative mortality and postoperative complications; therefore, understanding this relationship may provide a basis for prevention and rescue. Using the 2007 SemiAnnual National Surgical Quality Improvement Program Report, we obtained data for each reporting hospital's rates of observed mortality, overall observed morbidity, observed cardiac, respiratory, renal complications, venothromboemoblic events (VTEs), surgical site infections (SSIs), and urinary tract infections (UTIs). Simple and multiple linear regression analyses were done comparing absolute rate of observed mortality with absolute rate of observed morbidity and each morbidity group. One hundred ninety-seven hospitals were included in the study. There were statistically significant associations between observed mortality rates and observed morbidity rates, cardiac complications, respiratory complications, and VTE rates. Renal complications, SSIs, and UTIs showed no statistically significant association with observed morbidity. This study demonstrates that rates of observed morbidity, especially cardiac, respiratory, and VTE complications, are associated with observed mortality. These findings suggest that care providers should focus efforts at prevention and rescue of cardiac, respiratory, and VTE complications.

A single, global patient-centered measure from the SF-36 instrument to assess surgical outcomes and quality of life: a pilot study.

BACKGROUND: Many quality of life (QoL) and patient-reported outcomes (PRO) measures have been developed to assess the effects of disease processes and treatments. Although these instruments are valuable, the process is hampered because of their number and lack of interchangeability. METHODS: We identified a cohort of patients across a variety of operations within 3-12 months postoperatively. Patients completed the SF-36, measuring eight domains of QoL (physical functioning, role-physical, role-emotional, bodily pain, vitality, mental health, social functioning, and general health), plus a health transition item: Compared to one year ago, how would you rate your health in general now?. (1) Much better now than one year ago. (2) Somewhat better now than one year ago. (3) About the same as one year ago. (4) Somewhat worse than one year ago. (5) Much worse than one year ago. Additional data included improvement of preoperative symptoms, the occurrence of any postoperative symptoms, and the occurrence of any postoperative complications. RESULTS: Of 217 patients, 28 % were much better, 28 % somewhat better, 27 % unchanged, 13 % somewhat worse, and 3 % much worse. The health transition results were associated with all SF-36 domains, preoperative symptom change (p = 0.03) and persistent or new postoperative symptoms (p = 0.001), but not postoperative complications. Patients with persistent or new symptoms postoperatively had worse scores in the role-emotional (p = 0.01), bodily pain (p = 0.05), social functioning (p = 0.02), and mental health (p = 0.009) domains of the SF-36. CONCLUSIONS: This single, global assessment of health transition may be a promising practical alternative to assess postoperative patient-centered outcomes. Improved patients had better QoL scores, preoperative symptoms elimination, and no operation-related symptoms, but the occurrence of complications did not affect improvement.

Using procedural codes to supplement risk adjustment: a nonparametric learning approach.

BACKGROUND: The American College of Surgeons National Surgical Quality Improvement Program collects information related to procedures in the form of the work relative value unit (RVU) and current procedural terminology (CPT) code. We propose and evaluate a fully automated nonparametric learning approach that maps individual CPT codes to perioperative risk. STUDY DESIGN: National Surgical Quality Improvement Program participant use file data for 2005-2006 were used to develop 2 separate support vector machines (SVMs) to learn the relationship between CPT codes and 30-day mortality or morbidity. SVM parameters were determined using cross-validation. SVMs were evaluated on participant use file data for 2007 and 2008. Areas under the receiver operating characteristic curve (AUROCs) were each compared with the respective AUROCs for work RVU and for standard CPT categories. We then compared the AUROCs for multivariable models, including preoperative variables, RVU, and CPT categories, with and without the SVM operation scores. RESULTS: SVM operation scores had AUROCs between 0.798 and 0.822 for mortality and between 0.745 and 0.758 for morbidity on the participant use file used for both training (2005-2006) and testing (2007 and 2008). This was consistently higher than the AUROCs for both RVU and standard CPT categories (p < 0.001). AUROCs of multivariable models were higher for 30-day mortality and morbidity when SVM operation scores were included. This difference was not significant for mortality but statistically significant, although small, for morbidity. CONCLUSIONS: Nonparametric methods from artificial intelligence can translate CPT codes to aid in the assessment of perioperative risk. This approach is fully automated and can complement the use of work RVU or traditional CPT categories in multivariable risk adjustment models like the National Surgical Quality Improvement Program.

Preliminary NSQIP results: a tool for quality improvement.

OBJECTIVE: To utilize National Surgical Quality Improvement Program (NSQIP) data to evaluate patient outcomes in otolaryngology-head and neck surgery. STUDY DESIGN: Retrospective medical chart abstraction of patients undergoing major surgical procedures in the inpatient and outpatient setting. SETTING: Academic/teaching hospitals with more than 500 beds. SUBJECTS AND METHODS: The American College of Surgeons NSQIP collects data on 135 variables including preoperative risk factors, intraoperative variables, and 30-day-postoperative mortality and morbidity outcomes for patients undergoing major surgical procedures in the inpatient and outpatient setting. As of August 2008, there are currently 47 hospitals submitting data for otolaryngology-head and neck surgery. RESULTS: Opportunities for improvement were identified in respiratory, wound, and venothromboembolic (VTE) occurrences. Implementation of a standardized VTE and perioperative protocol resulted in a decreased length of stay and observed-to-expected (O/E) morbidity and mortality for all surgical services. CONCLUSION: NSQIP reports form the basis for quality improvement with targeted interventions in areas of concern that result in changes in patient care processes. The reports are composed of outcomes-based, risk-adjusted data that are submitted by participating hospitals and have recently included data for otolaryngology-head and neck surgery. Actions taken based on NSQIP data demonstrate improvements in patient morbidity and mortality, decreased length of stay, and decreased hospital costs. In a time of increased scrutiny of health care costs and outcomes, NSQIP is an important tool for surgeons to improve quality and decrease costs.

Implementation of the National Surgical Quality Improvement Program: critical steps to success for surgeons and hospitals.

The National Surgical Quality Improvement Program (NSQIP), as administered by the American College of Surgeons, became available to private sector hospitals across the United States in 2004. The program works to improve surgical outcomes by providing high-quality, risk-adjusted data to surgeons at a given hospital to stimulate discussion and define target areas for improvement. Although the NSQIP began in the early 1990s with Veterans Administration hospitals and expanded to private sector hospitals nearly 5 years ago, the "how to" process for NSQIP implementation has been left to individual institutions to manage on their own. The NSQIP was instituted at a large tertiary hospital in 2005, identifying through experience 12 critical steps to help surgeons and hospitals implement the NSQIP.