Expansion of the surgical Apgar score across all surgical subspecialties as a means to predict postoperative mortality.

BACKGROUND: A surgical scoring system, akin to the obstetrician's Apgar score, has been developed to assess postoperative risk. To date, evaluation of this scoring system has been limited to general and vascular services. The authors attempt to externally validate and expand the Surgical Apgar Score across a wide breadth of surgical subspecialties. METHODS: Intraoperative data for 123,864 procedures including all surgical subspecialties were collected and associated with Surgical Apgar Scores (created by the summation of point values associated with the lowest mean arterial pressure, lowest heart rate, and estimated blood loss). Patients' death records were matched to the corresponding score, and logistic regression models were created in which mortality within 7, 30, and 90 days was regressed on the Apgar score. RESULTS: Lower Surgical Apgar Scores were associated with an increased risk of death. The magnitude of this association varied by subspecialty. Some subspecialties exhibited higher odds ratios, suggesting that the score is not as useful for them. For most of the subspecialties the association between the Apgar score and mortality decreased as the time since surgery increased, suggesting that predictive ability ceases to be helpful over time. After adjusting for the patient's American Society of Anesthesiologists classification, Apgar scores remained associated with death among most of the subspecialties. CONCLUSION: A previously published methodology for calculating risk among general and vascular surgical patients can be applied across many surgical services to provide an objective means of predicting and communicating patient outcomes in surgery as well as planning potential interventions.

Using the healthcare matrix with interns and medical students as a tool to effect change.

The Healthcare Matrix is a tool developed at Vanderbilt University Medical Center which assesses the care of patients using the Accreditation Council for Graduate Medical Education (ACGME) competencies and the Institute of Medicine (IOM) Aims for Improvement. House staff have been using this tool since 2004 as a means of learning the competencies in the daily care of patients. As the residents fill in the cells of the Matrix, the opportunities for improvement become evident. Anesthesia interns were introduced to the Matrix at bimonthly meetings to analyze a real case of complex and/or flawed patient management. Each resident completed his/her own Matrix and then the group selected one Matrix as their improvement project. This article will present one Matrix case, how quality improvement (QI) tools and methods were utilized and what resulting improvements were made. The analyzed case revealed numerous flaws with nonstandardized handoffs, incorrect and insufficient documentation, and unclear roles/responsibilities. An ideal process flowchart was developed highlighting improved handoffs and the need for a new admitting policy to the intensive care unit (ICU). The Healthcare Matrix is an effective tool for teaching the ACGME competencies in patient care. The resequencing of the competencies in the Matrix makes it easy to identify where improvements are needed. When taught the tools and methods of quality improvement, even interns can make a significant contribution to the improvement of patient care.