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.

Predischarge bundle for patients with acute exacerbations of COPD to reduce readmissions and ED visits: a randomized controlled trial.

BACKGROUND: Hospital readmissions for acute exacerbations of COPD (AECOPDs) pose burdens to the health-care system and patients. A current gap in knowledge is whether a predischarge screening and educational tool administered to patients with COPD reduces readmissions and ED visits. METHODS: A single-center, randomized trial of admitted patients with AECOPDs was conducted at Henry Ford Hospital between February 2010 and April 2013. One hundred seventy-two patients were randomized to either the control (standard care) or the bundle group in which patients received smoking cessation counseling, screening for gastroesophageal reflux disease and depression or anxiety, standardized inhaler education, and a 48-h postdischarge telephone call. The primary end point was the difference in the composite risk of hospitalizations or ED visits for AECOPD between the two groups in the 30 days following discharge. A secondary end point was 90-day readmission rate. RESULTS: Of the 172 patients, 18 of 79 in the control group (22.78%) and 18 of 93 in the bundle group (19.35%) were readmitted within 30 days. The risk of ED visits or hospitalizations within 30 days was not different between the groups (risk difference, -3.43%; 95% CI, -15.68% to 8.82%; P = .58). Overall, the time to readmission in 30 and 90 days was similar between groups (log-rank test P = .71 and .88, respectively). CONCLUSIONS: A predischarge bundle intervention in AECOPD is not sufficient to reduce the 30-day risk of hospitalizations or ED visits. More resources may be needed to generate a measurable effect on readmission rates. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT02135744; URL: www.clinicaltrials.gov.

Exploring National Surgical Quality Improvement Program respiratory comorbidities: developing a predictive understanding of postoperative respiratory occurrences, Clavien 4 complications, and death.

BACKGROUND: For preoperative risk stratification, little is known about the implications of respiratory comorbidities in relation to postoperative complications in the diverse population of surgical patients. We hypothesized that patients with preoperative respiratory comorbidities would be at increased risk of postoperative respiratory occurrences and death. METHODS: Under the data use agreement and with the approval of the Henry Ford Health System Institutional Review Board (IRB #6830), we reviewed 5 y (2005-2009) of National Surgical Quality Improvement Program participant use files. Respiratory comorbidities were defined as current smoker, chronic obstructive pulmonary disease, dyspnea, and current pneumonia. Respiratory outcomes tracked in the National Surgical Quality Improvement Program included reintubation, postoperative pneumonia, and prolonged ventilation. We defined Clavien 4 and 5 outcomes to include postoperative septic shock, postoperative dialysis, pulmonary embolism, myocardial infarction, cardiac arrest, prolonged ventilatory requirements, need for reintubation, and death. RESULTS: Of 971,455 patients identified, 361,412 had respiratory comorbidities. As the number of respiratory comorbidities increased, we found a statistically significant increase in the occurrence of postoperative respiratory adverse events, including Clavien 4 and 5 complications. Multivariate regression analysis showed that respiratory comorbidities and age were independent predictors of mortality. All data reported here were significant at P < 0.001. CONCLUSIONS: This study showed a significant association between respiratory comorbidities and postoperative adverse events, including Clavien 4 complications and death. Further prospective studies are required to explore this association.

Preoperative risk stratification for thoracic surgery using the American College of Surgeons National Surgical Quality Improvement Program data set: functional status predicts morbidity and mortality.

BACKGROUND: Preoperative risk stratification for noncardiac thoracic surgery focuses on predicting postoperative lung capacity and cardiac risk. We hypothesized that preoperative functional status may be a predictor of morbidity and mortality after thoracic surgery. METHODS: The National Surgical Quality Improvement Program Participant Use Files from 2005 to 2009 were accessed, and current procedural terminology codes for procedures involving the lung and pleura were used to identify thoracic surgery patients. Patients were grouped by independent or dependent preoperative functional status. Risks of infectious and noninfectious complications were evaluated. Chi-square, Fisher exact, and multivariate analyses with stepwise logistic regression were used. This study was approved by the Institutional Review Board. RESULTS: Of 6,373 patients, 812 had a preoperative dependent functional status. Dependent patients had significantly higher rates of infection, other adverse events, and mortality. They were 9.3 times more likely (odds ratio [OR] 9.3) to have prolonged ventilation (P < 0.001) and 3.1 times more likely to be reintubated (P < 0.001). Postoperative pneumonia occurred in 10% (OR 2.7, P < 0.001). Postoperative mortality was 7.7 times higher (P < 0.001). Preoperative functional status, wound classification 3, and emergency procedures were independent predictors of both morbidity and mortality. Performing a thoracotomy was an independent risk factor for postoperative morbidity but not mortality (P < 0.001, OR 2 versus P = 0.415, OR 1.1). CONCLUSIONS: Thoracic surgery patients, classified as functionally dependent preoperatively are at high risk for major morbidity and mortality. Although a limited observational study, results show that functional status is an essential component of preoperative assessment for thoracic surgery patients.

Loss of bone density with inhaled triamcinolone in Lung Health Study II.

Inhaled glucocorticosteroids (ICS) are commonly prescribed for chronic obstructive pulmonary disease. No adverse effect on bone mineral density (BMD) has been proven. In a randomized double-blind, placebo-controlled trial at seven centers in North America, we recruited 412 current smokers or recent quitters with mild to moderate chronic obstructive pulmonary disease. They used inhaled triamcinolone acetonide, 600 mcg, or placebo, twice daily. We measured femoral neck and lumbar spine BMD at baseline and after 1 and 3 years, and serum osteocalcin at baseline, 3 months, 1 year, and 3 years. After 3 years, BMD at the femoral neck decreased 1.78% more with ICS than with placebo (p < 0.001). More participants in the ICS group experienced 6% or more loss of femoral neck BMD (p = 0.002). Lumbar spine BMD increased in the placebo group by 0.98% but decreased by 0.35% in the ICS group (a difference of 1.33%, p = 0.007). Changes in osteocalcin did not correlate with changes in BMD. Fractures, lost height, or osteoporosis diagnoses were not increased among ICS users compared with placebo users. In summary, the use of inhaled triamcinolone acetonide was associated with loss of BMD at the femoral neck and lumbar spine after 3 years of treatment.

Lack of long-term adverse adrenal effects from inhaled triamcinolone: Lung Health Study II.

STUDY OBJECTIVE: Inhaled corticosteroids (ICS) are widely used in the treatment of COPD. One of the potential adverse effects of their use is the development of adrenal suppression. Our study aimed to determine the effects of ICS on adrenal function over 3 years of use in patients with COPD. METHODS: Two hundred twenty-one subjects were recruited from the 1,116 patients already enrolled in Lung Health Study II and were randomized to receive either triamcinolone, 1,200 microg, or placebo daily. Basal cortisol levels and cortisol levels at 30 min and 60 min following cosyntropin injection were measured at study entry and after 1 year and 3 years of participation. RESULTS: Basal cortisol levels in the placebo group were higher than in those receiving active drug at all time points and rose through the study period. There was no suppression of cortisol levels after cosyntropin stimulation at any study point in any subgroup. CONCLUSION: Use of inhaled triamcinolone, 1,200 microg/d, over 3 years does not suppress baseline adrenal function or diminish adrenal responsiveness to cosyntropin stimulation.