Immediate surgical outcomes for radical prostatectomy in the University HealthSystem Consortium Clinical Data Base: the impact of hospital case volume, hospital size and geographical region on 48,000 patients.

OBJECTIVE: To determine the impact of hospital variables on immediate surgical outcomes for patients treated with radical prostatectomy (RP) in academic centres. PATIENTS AND METHODS: The University HealthSystem Consortium (UHC) Clinical Data Base was queried for data corresponding to patients who had RP at one of 130 academic medical centres nationwide between 2003 and the second quarter of 2007 (48,086). RP case volume (1-99, 100-499 and >500), total discharges (1-49,999, 50,000-99,999 >100,000), and geographical region (five categories) were determined and categorized for each academic centre. Analysis of variance and the Tukey statistic were used to assess the results. Length of stay (LOS), intensive care unit (ICU) rate, complication rate (CR) and in-hospital mortality (IHM) were analysed. RESULTS: Case volume was a significant predictor of LOS, ICU and CR. The mean LOS was 3.77, 2.65 and 2.09 days, respectively, for centres from three tiers of lowest to highest case volumes (P < 0.001). ICU rates for the three tiers were 18.57, 3.61, and 1.30 (P < 0.001); CRs were 15.93, 8.79 and 5.76 (P < 0.001). Tukey analysis showed a 'ceiling' effect for ICU and CRs; there were no differences between the two higher case-volume groups. IHM was not significantly different between groups stratified by case volume. Stratification by total discharges showed differences in ICU rates only (P = 0.003). Stratification by geographical region showed no differences in outcome. CONCLUSIONS: RP case volume was an important variable in predicting three of the four outcome variables. CRs and ICU rates showed a 'ceiling effect' suggesting that an unknown 'critical volume' of cases portends improved surgical outcomes.

Radical nephrectomy surgical outcomes in the University HealthSystem Consortium Data Base: Impact of hospital case volume, hospital size, and geographic location on 40,000 patients.

BACKGROUND: We sought to determine the impact of radical nephrectomy case volume, hospital size, and geographic region on immediate surgical outcomes for patients undergoing radical nephrectomy in academic centers across the country. METHODS: The University HealthSystem Consortium (UHC) Clinical Data Base was queried for data corresponding to patients who underwent radical nephrectomy at 1 of 134 academic medical centers nationwide between 2003 and quarter 2 of 2007 (n = 42,988). Radical nephrectomy case volume (1-99, 100-499, and 500 +), total discharges (1-49,999, 50,000-99,999, 100,000 +), and geographic region (5 categories) were determined for each academic center. ANOVA and the Tukey statistic were used. Length of stay, intensive care unit (ICU) rate, complication (comp) rate, and in-hospital mortality were analyzed. RESULTS: Case volume was a significant predictor of length of stay, ICU, and comp. Mean length of stay was 6.88, 5.61, and 4.76 days, respectively, for centers from lowest to highest case volumes (P < .001). ICU rates for the 3 tiers were 30.77, 17.93, and 12.22 (P < .001). Comp rates were 24.50, 19.40, and 15.48 (P < .001). Tukey analysis revealed a ceiling effect: No differences were seen between the 2 higher case volume groups. Stratification by total discharges revealed differences in ICU rates (P = .001) and comp rates (P = .001). Region of the country had no significant impact on any of the outcome variables in this study. CONCLUSIONS: Radical nephrectomy case volume emerged as an important variable in predicting 3 of the 4 outcome parameters in this study. Results suggest that a "critical volume" of cases portends improved surgical outcomes.

Implementation, reliability testing, and compliance monitoring of the Confusion Assessment Method for the Intensive Care Unit in trauma patients.

OBJECTIVE: To implement delirium monitoring, test reliability, and monitor compliance of performing the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) in trauma patients. DESIGN AND SETTING: Prospective, observational study in a level 1 trauma unit of a tertiary care, university-based medical center. PATIENTS: Acutely injured patients admitted to the trauma unit between 1 February 2006 and 16 April 2006. MEASUREMENTS AND RESULTS: Following web-based teaching modules and group in-services, bedside nurses evaluated patients daily for depth of sedation with the Richmond Agitation-Sedation Scale (RASS) and for the presence of delirium with the CAM-ICU. On randomly assigned days over a 10-week period, evaluations by nursing staff were followed by evaluations by an expert evaluator of the RASS and the CAM-ICU to assess compliance and reliability of the CAM-ICU in trauma patients. Following the audit period the nurses completed a postimplementation survey. The expert evaluator performed 1,011 random CAM-ICU assessments within 1h of the bedside nurse's assessments. Nurses completed the CAM-ICU assessments in 84% of evaluations. Overall agreement (kappa) between nurses and expert evaluator was 0.77 (0.721-0.822; p < 0.0001), in TBI patients 0.75 (0.667-0.829; p < 0.0001) and in mechanically ventilated patients 0.62 (0.534-0.704; p < 0.0001). The survey revealed that nurses were confident in performing the CAM-ICU, realized the importance of delirium, and were satisfied with the training that they received. It also acknowledged obstacles to implementation including nursing time and failure of physicians/surgeons to address treatment approaches for delirium. CONCLUSIONS: The CAM-ICU can be successfully implemented in a university-based trauma unit with high compliance and reliability. Quality improvement projects seeking to implement delirium monitoring would be wise to address potential pitfalls including time complaints and the negative impact of physician indifference regarding this form of organ dysfunction.