Antibiotic use among older adults on an acute care general surgery service.

BACKGROUND: Antibiotics play an important role in the treatment of many surgical diseases that affect older adults, and the potential for inappropriate use of these drugs is high. Our objective was to describe antibiotic use among older adults admitted to an acute care surgery service at a tertiary care teaching hospital. METHODS: Detailed data regarding diagnosis, comorbidities, surgery and antibiotic use were retrospectively collected for patients 70 years and older admitted to an acute care surgery service. We evaluated antibiotic use (perioperative prophylaxis and treatment) for appropriateness based on published guidelines. RESULTS: During the study period 453 patients were admitted to the acute care surgery service, and 229 underwent surgery. The most common diagnoses were small bowel obstruction (27.2%) and acute cholecystitis (11.0%). In total 251 nonelective abdominal operations were performed, and perioperative antibiotic prophylaxis was appropriate in 49.5% of cases. The most common prophylaxis errors were incorrect timing (15.5%) and incorrect dose (12.4%). Overall 206 patients received treatment with antibiotics for their underlying disease process, and 44.2% received appropriate first-line drug therapy. The most common therapeutic errors were administration of second- or third-line antibiotics without indication (37.9%) and use of antibiotics when not indicated (12.1%). There was considerable variation in the duration of treatment for patients with the same diagnoses. CONCLUSION: Inappropriate antibiotic use was common among older patients admitted to an acute care surgery service. Quality improvement initiatives are needed to ensure patients receive optimal care in this complex hospital environment.

CONTEXTE: Les antibiotiques jouent un rôle important dans de nombreux cas de chirurgie chez les adultes âgés, et le risque d'utilisation inappropriée de ces médicaments est élevé. Notre objectif était de décrire l'utilisation des antibiotiques chez les patients âgés admis au service chirurgical d'urgence d'un centre hospitalier universitaire de soins tertiaires. MÉTHODES: Nous avons recueilli de manière rétrospective les données détaillées sur le diagnostic, les comorbidités, la chirurgie et l'utilisation d'antibiotiques chez les patients de 70 ans et plus admis dans un service chirurgical d'urgence. Nous avons évalué le bien-fondé du recours aux antibiotiques (prophylaxie et traitement périopératoire) en fonction des lignes directrices publiées. RÉSULTATS: Durant la période de l'étude, 453 patients ont été admis au service chirurgical d'urgence et 229 ont subi une chirurgie. Les diagnostics les plus fréquents étaient : occlusion de l'intestin grêle (27,2 %) et cholécystite aigüe (11,0 %). En tout, 251 interventions abdominales urgentes ont été effectuées et l'antibioprophylaxie périopératoire était justifiée dans 49,5 % des cas. Les erreurs les plus fréquentes en matière de prophylaxie ont été : moment mal choisi (15,5 %) et dose incorrecte (12,4 %). En tout, 206 patients ont reçu une antibiothérapie pour un processus pathologique sous-jacent et 44,2 % ont reçu un traitement antibiotique de première intention approprié. Les erreurs thérapeutiques les plus fréquentes concernaient l'administration d'antibiotiques de deuxième ou de troisième intention sans indication (37,9 %) et l'utilisation d'antibiotiques lorsque cela n'était pas indiqué (12,1 %). On a noté une variation considérable de la durée des traitements chez des patients porteurs de diagnostics semblables. CONCLUSION: L'utilisation inappropriée des antibiotiques a été fréquente chez les patients adultes admis dans un service chirurgical d'urgence. Des initiatives s'imposent sur le plan de l'amélioration de la qualité pour s'assurer ainsi que les patients reçoivent des soins optimaux dans cet environnement hospitalier complexe.

The impact of adverse events on health care costs for older adults undergoing nonelective abdominal surgery.

BACKGROUND: Postoperative complications have been identified as an important and potentially preventable cause of increased hospital costs. While older adults are at increased risk of experiencing complications and other adverse events, very little research has specifically examined how these events impact inpatient costs. We sought to examine the association between postoperative complications, hospital mortality and loss of independence and direct inpatient health care costs in patients 70 years or older who underwent nonelective abdominal surgery. METHODS: We prospectively enrolled consecutive patients 70 years or older who underwent nonelective abdominal surgery between July 1, 2011, and Sept. 30, 2012. Detailed patient-level data were collected regarding demographics, diagnosis, treatment and outcomes. Patient-level resource tracking was used to calculate direct hospital costs (2012 $CDN). We examined the association between complications, hospital mortality and loss of independence cost using multiple linear regression. RESULTS: During the study period 212 patients underwent surgery. Overall, 51.9% of patients experienced a nonfatal complication (32.5% minor and 19.4% major), 6.6% died in hospital and 22.6% experienced a loss of independence. On multivariate analysis nonfatal complications (p < 0.001), hospital mortality (p = 0.021) and loss of independence at discharge (p < 0.001) were independently associated with health care costs. These adverse events respectively accounted for 30%, 4% and 10% of the total costs of hospital care. CONCLUSION: Adverse events were common after abdominal surgery in older adults and accounted for 44% of overall costs. This represents a substantial opportunity for better patient outcomes and cost savings with quality improvement strategies tailored to the needs of this high-risk surgical population.

CONTEXTE: Les complications postopératoires sont une cause évitable qui contribue grandement aux coûts hospitaliers élevés. Malgré le fait que les personnes âgées courent un risque accru de subir des complications ou des événements indésirables, peu de recherches ont étudié l'incidence de ces éléments sur les coûts d'hospitalisation. Nous nous sommes penchés sur la relation entre les coûts des soins de santé assumés par les malades hospitalisés et les complications postopératoires, la mortalité hospitalière et la perte d'autonomie auprès d'une population de patients de 70 ans et plus ayant subi une intervention chirurgicale abdominale non facultative. MÉTHODES: La cohorte prospective a été formée de patients consécutifs âgés de 70 ans et plus ayant subi une intervention chirurgicale abdominale non facultative entre le 1er juillet 2011 et le 30 septembre 2012. Des données détaillées concernant leur profil démographique, leur diagnostic, leur traitement et leurs résultats ont été recueillies. Le calcul des coûts hospitaliers directs est basé sur un suivi des ressources utilisées par les patients (en dollars canadiens, 2012). Au moyen d'une régression linéaire multiple, nous avons analysé la relation entre les complications, la mortalité hospitalière et la perte d'autonomie. RÉSULTATS: Pendant la période à l'étude, 212 patients ont subi une intervention chirurgicale. Parmi eux, 51,9 % ont subi une complication non mortelle (mineure dans 32,5 % des cas; majeure dans 19,4 % des cas), 6,6 % sont décédés à l'hôpital, et 22,6 % ont subi une perte d'autonomie. Une analyse multivariable a permis de conclure que les complications non mortelles (p < 0,001), la mortalité hospitalière (p = 0,021) et la perte d'autonomie à la sortie de l'hôpital (p < 0,001) étaient indépendamment associées aux coûts des soins de santé et qu'elles représentaient respectivement 30 %, 4 % et 10 % des coûts d'hospitalisation totaux. CONCLUSION: Les événements indésirables étaient fréquents dans le contexte des interventions chirurgicales abdominales réalisées sur des personnes âgées et représentaient 44 % des coûts totaux. Nous devons saisir cette occasion et nous doter de stratégies d'amélioration de la qualité adaptées aux besoins de cette population, à risque élevé sur le plan chirurgical, afin d'améliorer les résultats pour les patients et de diminuer les coûts.

The Impact of Nonelective Abdominal Surgery on the Residential Status of Older Adult Patients.

OBJECTIVE: To describe the change in residential status at discharge and 6 months after hospitalization among older adults who have undergone nonelective abdominal surgery and to identify risk factors associated with discharge to institution. BACKGROUND: Surgery in older adults may lead to a loss of independence that prevents them from returning to their preadmission residential status. Understanding the impact of surgery on residential status and risk factors for institutionalization is important for patient counseling, discharge planning, and resource allocation. METHODS: Community-dwelling patients aged 70 years and older who underwent nonelective abdominal surgery over a 15-month period were prospectively enrolled. Residential status before admission, at discharge, and 6 months after admission was assessed. Multiple logistic regression was used to identify factors associated with discharge to institution. RESULTS: Of the 197 patients who underwent surgery and survived to discharge, 30% were living alone before admission and 70% were living with others. At discharge, 72% of patients returned to their preadmission residential status and 22% were institutionalized. Six months after hospitalization, 55% of institutionalized patients had returned to community-living, and 79% of all patients had returned to their preadmission residential status. Change in residential status was associated with decreased quality of life. Increasing American Society of Anesthesiologists score, frailty, surgery for malignancy, and postoperative complications were associated with discharge to institution. CONCLUSIONS: The majority of older patients, including those who were discharged to an institution, returned to their preadmission residential status 6 months after nonelective abdominal surgery.

Management and outcomes of small bowel obstruction in older adult patients: a prospective cohort study.

BACKGROUND: The purpose of this research was to examine the morbidity, mortality and rate of recurrent bowel obstruction associated with the treatment of small bowel obstruction (SBO) in older adults. METHODS: We prospectively enrolled all patients 70 years or older with an SBO who were admitted to a tertiary care teaching centre between Jul. 1, 2011, and Sept. 30, 2012. Data regarding presentation, investigations, treatment and outcomes were collected. RESULTS: Of the 104 patients admitted with an SBO, 49% were managed nonoperatively and 51% underwent surgery. Patients who underwent surgery experienced more complications (64% v. 27%, p = 0.002) and stayed in hospital longer (10 v. 3 d, p < 0.001) than patients managed nonoperatively. Nonoperative management was associated with a high rate of recurrent SBO: 31% after a median follow-up of 17 months. Of the patients managed operatively, 60% underwent immediate surgery and 40% underwent surgery after attempted nonoperative management. Patients in whom nonoperative management failed underwent surgery after a median of 2 days, and 89% underwent surgery within 5 days. The rate of bowel resection was high (29%) among those who underwent delayed surgery. Surgery after failed nonoperative management was associated with a mortality of 14% versus 3% for those who underwent immediate surgery; however, this difference was not significant. CONCLUSION: These data suggest that some elderly patients with SBO may be waiting too long for surgery.

CONTEXTE: Le but de cette recherche était d'analyser la morbidité, la mortalité et le taux de récurrence de l'occlusion intestinale associés au traitement de l'occlusion intestinale grêle (OIG) chez des adultes âgés. MÉTHODES: Nous avons inscrit de manière prospective tous les patients de 70 ans ou plus présentant une OIG qui ont été admis dans un établissement de soins tertiaires entre le 1er juillet 2011 et le 30 septembre 2012. Nous avons recueilli les données concernant les tableaux cliniques, les épreuves diagnostiques, les traitements et leurs résultats. RÉSULTATS: Parmi les 104 patients admis pour OIG, 49 % ont été traités non chirurgicalement et 51 % ont subi une intervention chirurgicale. Les patients soumis à la chirurgie ont présenté davantage de complications (64 % c. 27 %, p = 0,002) et ont séjourné plus longtemps à l'hôpital (10 j. c. 3 j., p < 0,001) comparativement aux patients qui n'ont pas été opérés. La prise en charge non chirurgicale a été associée à un taux élevé de récurrences de l'OIG : 31 % après un suivi médian de 17 mois. Parmi les patients opérés, 60 % ont subi une chirurgie immédiate et 40 % ont subi leur chirurgie après une tentative de prise en charge non chirurgicale. Les patients chez qui la prise en charge non chirurgicale a échoué ont subi leur chirurgie après une période médiane de 2 jours et 89 % en l'espace de 5 jours. Le taux de résection intestinale a été élevé (29 %) chez ceux dont la chirurgie a été retardée. La chirurgie après une intervention non chirurgicale infructueuse a été associée à un taux de mortalité de 14 %, contre 3 % chez les patients immédiatement soumis à la chirurgie. Toutefois, cette différence s'est révélée non significative. CONCLUSION: Ces données laissent penser que certains patients âgés présentant une OIG attendent peut-être trop longtemps pour leur chirurgie.

Robotic versus laparoscopic Roux-en-Y gastric bypass (RYGB) in obese adults ages 18 to 65 years: a systematic review and economic analysis.

BACKGROUND: In the United States, 37.5 % of adults (78 million) are obese. The direct medical costs of treating obesity-related disease account for more than 6 % of the national health expenditure. Robotic bariatric surgery is becoming more common, but it is unclear whether robotic procedures result in lower complication rates. Additionally, some evidence is conflicting regarding the costs of robotic Roux-en-Y gastric bypass (RYGB) compared with those of laparoscopic RYGB. This study aimed to compare complication rates, operative characteristics, and expected costs between robotic and laparoscopic RYGB. METHODS: A systematic review of the literature was performed with searches of five databases and grey literature, hand searches, and reference and forward citation searches. Studies comparing robotic versus laparoscopic RYGB involving patients ages 18-65 years who met the National Institutes of Health (NIH) criteria for bariatric surgery were included in the study if they reported overall or major complication rates. Outcomes were pooled using random-effects metaanalysis. A decision-tree economic analysis was performed to calculate expected costs associated with each technique. RESULTS: The systematic search strategy returned 1,374 potentially relevant studies. The inclusion criteria were met by 10 of these studies, which included results from 2,557 patients. The overall major and minor complications did not differ significantly between the robotic and laparoscopic groups. The rates for anastomotic leak, bleeding, stricture, and reoperation did not differ significantly. An economic analysis found that the expected costs for robotic RYGB ($15,447) were higher than for laparoscopic RYGB ($11,956). Sensitivity analyses produced similar results. CONCLUSION: The complication rates did not differ significantly between robotic and laparoscopic RYGB, but the expected costs were greater for robotic RYGB. Further cost effectiveness analyses are recommended before adoption of a robotic approach to RYGB.

Effect of obesity and decompressive laparotomy on mortality in acute pancreatitis requiring intensive care unit admission.

BACKGROUND: Controversy still exists on the effect that obesity has on the morbidity and mortality in severe acute pancreatitis (SAP). The primary purpose of this study was to compare the mortality rate of obese versus nonobese patients admitted to the ICU for SAP. Secondary goals were to assess the potential risk factors for abdominal compartment syndrome (ACS) and to investigate the performance of validated scoring systems to predict ACS and in-hospital mortality. METHODS: A retrospective cohort of adults admitted to the ICU for SAP was stratified by their body mass index (BMI) as obese and nonobese. The rates of morbidity, mortality, and ACS were compared by univariate and multivariate regression analyses. Areas under the curve (AUC) were used to evaluate the discriminating performance of severity scores and other selected variables to predict mortality and the risk of ACS. RESULT: Forty-five patients satisfied the inclusion criteria and 24 (53 %) were obese with similar characteristics to nonobese patients. Among all the subjects, 11 (24 %) died and 16 (35 %) developed ACS. In-hospital mortality was significantly lower for obese patients (12.5 vs. 38 %; P = 0.046) even though they seemed to develop ACS more frequently (41 vs. 28 %; P = 0.533). At multivariable analysis, age was the most significant factor associated with in-hospital mortality (odds ratio (OR) = 1.273; 95 % confidence interval (CI) 1.052-1.541; P = 0.013) and APACHE II and Glasgow-Imrie for the development of ACS (OR = 1.143; 95 % CI 1.012-1.292; P = 0.032 and OR = 1.221; 95 % CI 1.000-1.493; P = 0.05) respectively. Good discrimination for in-hospital mortality was observed for patients' age (AUC = 0.846) and number of comorbidities (AUC = 0.801). ACS was not adequately predicted by any of the clinical severity scores (AUC = 0.548-0.661). CONCLUSIONS: Patients' age was the most significant factor associated with mortality in patients affected by SAP. Higher APACHE II and Glasgow-Imrie scores were associated with the development of ACS, but their discrimination performance was unsatisfactory.

Practices and attitudes of surgeons toward the prevention of surgical site infections: a provincial survey in Alberta, Canada.

We surveyed 589 surgeons in Alberta, Canada, about the prevention of surgical site infections and compared their practices to the recommendations of evidence-based guidelines. Of the 247 (42%) who responded, most (156 [63%]) were not in compliance with guideline recommendations for preoperative bathing, hair removal, antimicrobial prophylaxis, or intraoperative skin preparation (although 91 [37%] state they are following guidelines).