Spinal Surgery in Patients Aged 80 Years and Older: Risk Stratification Using the Modified Frailty Index.

STUDY DESIGN: This was an ambispective clinical quality registry study. OBJECTIVE: To evaluate utility of 11-variable modified Frailty Index (mFI) in predicting postoperative outcomes among patients ≥80 years undergoing spinal surgery. METHODS: Consecutive patients ≥80 years who underwent spinal surgery between January 1, 2013, and June 30, 2018, were included. Primary outcome measure was rate of major complication. Secondary outcome measures were (1) overall complication rate, (2) surgical site infection, and (3) 6-month mortality. RESULTS: A total of 121 operations were performed. Demographic metrics were (1) age (mean ± SD) = 83.1 ± 2.8 years and (2) mFI (mean ± SD) = 2.1 ± 1.4 variables. As mFI increased from 0 to ≥4 variables, risk of major complication increased from 18.2% to 40.0% (P = .014); overall complication increased from 45.5% to 70.0% (P = .032); surgical site infection increased from 0.0% to 25.0% (P = .007). There were no significant changes in risk of 6-month mortality across mFIs (P = .115). Multivariate analysis showed that a higher mFI score of ≥3 variables was associated with a significantly higher risk of (1) major complication (P = .025); (2) overall complication (P = .015); (3) surgical site infection (P = .007); and (4) mortality (P = .044). CONCLUSIONS: mFI scores of ≥3/11 variables were associated with a higher risk of postoperative morbidity in patients aged ≥80 years undergoing spinal surgery. The mFI-associated risk stratification provides a valuable adjunct in surgical decision making for this rapidly growing subpopulation of patients.

The Utility of the Modified Frailty Index in Outcome Prediction for Elderly Patients with Acute Traumatic Subdural Hematoma.

This study aimed to evaluate the utility of the 11-variable modified Frailty Index (mFI) in prognosticating elderly patients with traumatic acute subdural hematomas (aSDHs). A state-service level 1 trauma center registry was interrogated to investigate consecutive patients ≥65 years of age presenting with traumatic aSDH, with or without major extracranial injury, between January 2013 and December 2017. mFI on admission, demographics, and admission details, including Glasgow Coma Scale (GCS) and pupillary status and radiological findings, were retrospectively retrieved from institutional records. Clinical outcome data were retrieved from medical records and the Victorian State Trauma Registry (VSTR). Outcome measures were 1) 30-day mortality and 2) 6-month unfavorable outcome, defined by the Extended Glasgow Outcome Scale (GOS-E). Five hundred twenty-nine consecutive cases were identified from the registry. Demographic data included: 1) age (median; interquartile range) = 80.46; 74.17-85.89; 2) mFI (mean ± standard deviation) = 1.96 ± 1.42 of 11 variables. Four hundred sixteen cases (79%) had complete outcome data. As mFI increased from 0/11 variables to ≥5/11 variables (≥0.45), 30-day mortality risk increased from 17.72% to 39.29% (p = 0.023) and 6-month unfavorable outcome risk increased from 40.51% to 96.43% (p < 0.001). Multi-variate analysis showed that greater mFI score of ≥3/11 variables (≥0.27) suggested a significantly higher risk of 30-day mortality (p = 0.009) and unfavorable outcome (p < 0.001). We conclude that increasing frailty, as measured by the mFI, was associated with significantly higher risk of 30-day mortality and 6-month unfavorable outcome in elderly patients presenting with aSDH to a level 1 neurotrauma center. Assessment of mFI in elderly patients with aSDH may be a useful determinant of outcome for this rapidly growing population.

Avoiding adult in-hospital cardiac arrest: A retrospective cohort study to determine preventability.

INTRODUCTION: This study had three main aims. Develop a methodology for reviewing in-hospital cardiac arrests (IHCA). Assess appropriateness and potential preventability of IHCAs. Identify areas for improvement within the rapid response system (RRS). DESIGN: A retrospective cohort study of IHCA identified from an existing organisational electronic database of medical emergency (MET) and Code Blue team activation. Potential preventability of IHCA and Code Blue team activation were established by an expert panel based on a standardised case review process with descriptive and content analyses for each IHCA event. SETTING: A university affiliated tertiary referral hospital with an established two-tier RRS in Melbourne, Australia. PARTICIPANTS: Same day and multi-day stay patients identified from an existing database as having an IHCA defined as attempted resuscitation with chest compressions, defibrillation, or both from January 2014 to December 2015. MAIN OUTCOME MEASURES: Outcome measures were: number of Code Blue activations; potential preventability of Code Blue activations and potential preventability of the IHCA event. RESULTS: A total of 120 IHCA events equating to 0.58 per 1000 total admissions occurred. 11 (9%) of IHCA were determined to be potentially preventable due to a failure to escalate, medication errors and inappropriate management. 39 (33%) of 120 Code Blue team activations were determined to be potentially preventable. These were typically due to lack of identification and documentation for end of life (EOL) care in 16 (62%) cases and inappropriate resuscitation when limitations of care were already in place in 10 (38%) cases. CONCLUSIONS: The study centre has a comparably low rate of preventable IHCA which could be reduced further through improvements in documentation and handover process. A focus on improved communication, recognition and earlier instigation of appropriate EOL care will reduce this rate further.

Prehospital 12-lead ECG to triage ST-elevation myocardial infarction and emergency department activation of the infarct team significantly improves door-to-balloon times: ambulance Victoria and MonashHEART Acute Myocardial Infarction (MonAMI) 12-lead ECG project.

BACKGROUND: American College of Cardiology/American Heart Association guidelines recommend >75% of patients with an ST-elevation myocardial infarction receive primary percutaneous coronary interventions (PPCI) within 90 minutes. Despite these recommendations, this goal has been difficult to achieve. METHODS AND RESULTS: We conducted a prospective interventional study involving 349 patients undergoing PPCI at a single tertiary referral institution to determine the impact of prehospital 12-lead ECG triage and emergency department activation of the infarct team on door-to-balloon time (D2BT). The median D2BT of all patients (n=107) who underwent PPCI after field ECG and emergency department activation of the infarct team (MonashHEART Acute Myocardial Infarction [MonAMI] group) was 56 minutes (interquartile range, 36.5 to 70) compared with the median time of a contemporary group (n=122) undergoing PPCI during the same period but not receiving field triage (non-MonAMI group) of 98 minutes (73 to 126.45). The median D2BT time of 120 consecutive patients who underwent PPCI before initiation of the project (pre-MonAMI group) was 101.5 minutes (72.5 to 134; P<0.001). The proportion of patients who achieved a D2BT of < or = 90 minutes increased from 39% in the pre-MonAMI group and 45% in the non-MonAMI group to 93% in the MonAMI group (P<0.001). CONCLUSIONS: The performance of prehospital 12-lead ECG triage and emergency department activation of the infarct team significantly improves D2BT and results in a greater proportion of patients achieving guideline recommendations.