A validated value-based model to improve hospital-wide perioperative outcomes: adaptability to combined medical/surgical inpatient cohorts.

Ann Surg. 2010 Sep;252(3):486-98

Authors: Ravikumar TS, Sharma C, Marini C, Steele GD, Ritter G, Barrera R, Kim M, Safyer SM, Vandervoort K, De Geronimo M, Baker L, Levi P, Pierdon S, Horgan M, Maynor K, Maloney G, Wojtowicz M, Nelson K

OBJECTIVES:: Authors hypothesized that building safe hospital systems to improve value-based surgical outcomes is predicated on workflow redesign for dynamic risk stratification, coupled with "real-time" mitigation of risk. We developed a comanagement model for hospitalized surgical cohort, and determined whether this iterative process redesign for surgery will be adaptable to disparate hospital systems and will be beneficial for combined medical/surgical adult inpatients. CONTEXT:: Concerns about preventable harm in hospitalized patients have generated a plethora of both, process-driven and outcome-based strategies in US Healthcare. Although comparison between hospitals is a common mechanism to drive quality, other innovative approaches are needed for real-time risk mitigation to improve outcomes. METHODS:: Prospective implementation of Surgical Continuum of Care (SCoC) model in hospitals initially for surgery patients; subsequently Continuum of Care (CoC) for medical/surgical population. Redesign of hospital care delivery model: patient cohorting, floor-based team building, and intensivist/hospitalist staffing of progressive care unit (PCU). Work flow redesign for clinical effectiveness: multidisciplinary team rounds, acuity stratified care rounding based on dynamic risk assessment into a novel HAWK (high risk)/DOVE (low risk) patient grouping, intensivist/hospitalist comanagement of surgical patients, and targeted response. STUDY:: Pre- and postintervention with concurrent cohort control design. SETTING:: Academic medical centers for SCoC and integrated health system hospital for CoC. PATIENT GROUPS:: SCoC Pilot Study-Campus A: Preintervention control group 1998-2000, Intervention Group 2001-2004; Campus B: Comparator Control Group 1998-2004.SCoC Validation Study-Campus C: Preintervention Group 2001-2005; Intervention Group 2006-2008. CoC Study-Campus D: Hospital-wide Group 2009. METRICS:: Mortality, length of stay (LOS): overall, surgical intensive care unit and PCU, readmission rates, and cost. Case mix index for risk adjustment. RESULTS:: Total >100,000 admissions. There was a significant reduction in overall surgical mortality in both, pilot (P < 0.002) and validation (P < 0.02) SCoC studies and overall hospital mortality in the medical/surgical CoC study (risk-adjusted mortality index progressively declined in CoC study from 1.16 pre-CoC to 0.77 six months post-CoC implementation; significant at 75% confidence level). Case mix index was unchanged during study period in each campus. Nested study in validation cohort of hospital-wide versus surgery alone (observed/expected mortality index) demonstrated significant benefit to SCoC in intervention group. The mortality benefit was primarily derived from risk-stratified rounding and actively managing risk prone population in the PCU. Surgical intensive care unit, PCU, and total hospital patient-days significantly decreased in SCoC pilot study (P < 0.05), reflecting enhanced throughput. LOS reduction benefit persisted in SCoC validation and CoC studies. In addition to decreased LOS, cost savings were in PCU (range, $851,511-2,007,388) and top diagnosis-related groups, for example, $452 K/yr for diagnosis-related group 148. CONCLUSIONS:: SCoC is patient-centered, outcomes-driven, value-based approach for hospital-wide surgical patient safety. The principles of this value paradigm are adaptable to other hospitals as demonstrated in our longitudinal study in 3 hospital systems, and the initial experience of CoC suggests that this model will have benefit beyond surgical hospital cohort.

PMID: 20739849 [PubMed - in process]

[Read more →]

Related Articles

Maximal sterile barrier precautions do not reduce catheter-related bloodstream infections in general surgery units: a multi-institutional randomized controlled trial.

Ann Surg. 2010 Apr;251(4):620-3

Authors: Ishikawa Y, Kiyama T, Haga Y, Ishikawa M, Takeuchi H, Kimura O, Harihara Y, Sunouchi K, Furuya T, Kimura M

OBJECTIVE: To investigate whether maximal sterile barrier precautions (MSBPs) during central venous catheter (CVC) insertion are truly effective in preventing catheter-related bloodstream infections (CRBSIs) in patients in general surgical units. SUMMARY BACKGROUND DATA: The reported effectiveness of MSBPs was based on the results of a single-center randomized controlled trial by Raad et al and the majority of the patients (99%) in the study were chemotherapy outpatients. METHODS: Between March 14, 2004 and December 28, 2006, the patients scheduled for CVC insertion in surgical units at 9 medical centers in Japan were randomly assigned to either an MSBP group (n = 211) or a standard sterile barrier precaution (SSBP) group (n = 213). This study was registered in the UMIN Clinical Trials Registry (registration ID number: UMIN000001400). RESULTS: The median (range) duration of catheterization was 14 days (0-92 days) in the MSBP group and 14 days (0-112 days) in the SSBP group. There were 5 cases (2.4%) of CRBSI in the MSBP group and 6 cases (2.8%) in the SSBP group (relative risk, 0.84; 95% confidence interval, 0.26-2.7; P = 0.77). The rate of CRBSIs per 1000 catheter days was 1.5 in the MSBP group and 1.6 in the SSBP group. There were 8 cases (3.8%) of catheter-related infections in the MSBP group and 7 cases (3.3%) in the SSBP group (relative risk, 1.2; 95% confidence interval, 0.43-3.1; P = 0.78). The rate of catheter-related infection per 1000 catheter days was 2.4 in the MSBP group and 1.9 in the SSBP group. CONCLUSIONS: This study is larger in sample size than the one performed by Raad et al and could not demonstrate better prevention of CRBSIs by MSBP compared with SSBP. A large randomized controlled trial or at least a meta-analysis of any other studies in the literature is necessary to reach to a conclusion on this issue.

PMID: 20224364 [PubMed - indexed for MEDLINE]

[Read more →]

Related Articles

A validation study of a retrospective venous thromboembolism risk scoring method.

Ann Surg. 2010 Feb;251(2):344-50

Authors: Bahl V, Hu HM, Henke PK, Wakefield TW, Campbell DA, Caprini JA

OBJECTIVES: Validate a retrospective venous thromboembolism (VTE) risk scoring method, which was developed at the University of Michigan Health System and based on the Caprini risk assessment model, and assess the confounding effects of VTE prophylaxis. BACKGROUND: Assessing patients for risk of VTE is essential to initiating appropriate prophylaxis and reducing the mortality and morbidity associated with deep vein thrombosis and pulmonary embolism. METHODS: VTE risk factors were identified for 8216 inpatients from the National Surgical Quality Improvement Program using the retrospective scoring method. Logistic regression was used to calculate odds ratios (OR) for VTE within 30 days after surgery for risk factors and risk level. A bivariate probit model estimated the effects of risk while controlling for adherence to prophylaxis guidelines. RESULTS: Distribution of the study population by risk level was highest, 52.1%; high, 36.5%; moderate, 10.4%; and low, 0.9%. Incidence of VTE within 30 days was overall 1.4%; by risk level: highest, 1.94%; high, 0.97%; moderate, 0.70%; low, 0%. Controlling for length of hospitalization (>2 d) and fiscal year, pregnancy or postpartum (OR = 8.3; 1.0-68, P < 0.05), recent sepsis (4.0; 1.4-10.9, P < 0.01), malignancy (2.3; 1.5-3.3, P < 0.01), history of VTE (2.1; 1.1-4.1, P < 0.05), and central venous access (1.8; 1.1-3.0, P < 0.05) were significantly associated with VTE. Risk level was significantly associated with VTE (1.9; 1.3-2.6, P < 0.01). The bivariate probit demonstrated significant correlation between the probability of VTE and lack of adherence to prophylaxis guidelines (rho = 0.299, P = 0.013). CONCLUSION: The retrospective risk scoring method is valid and supports use of individual patient assessment of risk for VTE within 30 days after surgery.

PMID: 19779324 [PubMed - indexed for MEDLINE]

[Read more →]

Antibiotic prophylaxis at urinary catheter removal prevents urinary tract infections: a prospective randomized trial.

Ann Surg. 2009 Apr;249(4):573-5

Authors: Pfefferkorn U, Lea S, Moldenhauer J, Peterli R, von Flüe M, Ackermann C

OBJECTIVE: To assess whether antibiotic prophylaxis at urinary catheter removal reduces the rate of urinary tract infections. SUMMARY OF BACKGROUND DATA: Urinary tract infections are among the most common nosocomial infections. Antibiotic prophylaxis at urinary catheter removal is used as a measure to prevent them, albeit without supporting evidence. METHODS: A prospective randomized study enrolled 239 patients undergoing elective abdominal surgery, who were randomized either for receiving 3 doses of trimethoprim-sulfamethoxazole at urinary catheter removal, or not. Urinary tract infections were diagnosed according to Center of Disease Control definitions. Urinary cultures were obtained before and 3 days after catheter removal. Subjective symptoms were assessed by an independent study-blind urologist. RESULTS: Patients who received antibiotic prophylaxis showed significantly fewer urinary tract infections (5/103, 4.9%) than those without prophylaxis (22/102, 21.6%), P < 0.001. The absolute risk reduction for the occurrence of a urinary tract infection was 16.7%; the relative risk reduction was 77.5%, and the number needed to treat was 6. Patients with antibiotic prophylaxis also had less significant bacteriuria 3 days after catheter removal (17/103, 16.5%) than those without (42/102, 41.2%), P < 0.001. CONCLUSIONS: Antibiotic prophylaxis with trimethoprim-sulfamethoxazole on urinary catheter removal significantly reduces the rate of symptomatic urinary tract infections and bacteriuria in patients undergoing abdominal surgery with perioperative transurethral urinary catheters.

PMID: 19300235 [PubMed - indexed for MEDLINE]

[Read more →]

Related Articles

Diverticulitis in the United States: 1998-2005: changing patterns of disease and treatment.

Ann Surg. 2009 Feb;249(2):210-7

Authors: Etzioni DA, Mack TM, Beart RW, Kaiser AM

OBJECTIVES: Diverticular disease imposes an impressive clinical burden to the United States population, with over 300,000 admissions and 1.5 million days of inpatient care annually. Consensus regarding the treatment of diverticulitis has evolved over time, with increasing advocacy of primary anastomosis for acute diverticulitis, and nonoperative treatment of recurrent mild/moderate diverticulitis. We analyzed whether these changes are reflected in patterns of practice in a nationally-representative patient cohort. METHODS: We used the 1998 to 2005 nationwide inpatient sample to analyze the care received by 267,000 patients admitted with acute diverticulitis, and 33,500 patients operated electively for diverticulitis. Census data were used to calculate population-based incidence rates of disease and surgical treatment. Weighted logistic regression with cluster adjustment at the hospital level was used for hypothesis testing. RESULTS: Overall annual age-adjusted admissions for acute diverticulitis increased from 120,500 in 1998 to 151,900 in 2005 (26% increase). Rates of admission increased more rapidly within patients aged 18 to 44 years (82%) and 45 to 74 years (36%). Elective operations for diverticulitis rose from 16,100 to 22,500 per year during the same time period (29%), also with a more rapid increase (73%) in rates of surgery for individuals aged 18 to 44 years. Multivariate analysis found no evidence that primary anastomosis is becoming more commonly used. CONCLUSIONS: We are the first to report dramatic changes in rates of treatment for diverticulitis in the United States. The causes of this emerging disease pattern are unknown, but certainly deserve further investigation. For patients undergoing surgery for acute diverticulitis, there was little change over time in the likelihood of a primary anastomosis.

PMID: 19212172 [PubMed - indexed for MEDLINE]

[Read more →]

Related Articles

Relationship of perioperative hyperglycemia and postoperative infections in patients who undergo general and vascular surgery.

Ann Surg. 2008 Oct;248(4):585-91

Authors: Ramos M, Khalpey Z, Lipsitz S, Steinberg J, Panizales MT, Zinner M, Rogers SO

OBJECTIVE: Evaluate the association of perioperative hyperglycemia and postoperative infections (POI) in patients who had undergone general surgery. BACKGROUND: Intensive glucose control leads to less postoperative infections (POI) in critically ill surgical patients, but the relationship of hyperglycemia and POI in a general surgical population remains unknown. METHODS: A retrospective study of 995 patients who had undergone general and vascular surgery investigated the association of perioperative acute hyperglycemia and risk of 30-day POI over an 18-month period. The primary predictor of interest was postoperative glucose (POG). Bivariate analyses determined the association of each independent variable with POI. Factors significant at P < 0.05 were used in multivariable logistic regression models. RESULTS: In bivariate analyses, preoperative blood glucose (P = 0.012), POG (P = 0.009), age (P = 0.002), diabetes (P = 0.04), American Society of Anesthesia Classification (ASAC) (P < 0.0001), operation length (P = 0.02), and blood transfusions (P = 0.02) were significant predictors of POI. In multivariate analyses, only POG (OR = 1.3, (1.03-1.64)), ASAC (OR = 1.9, (1.31-2.83)), and emergency status (OR = 2.2, (1.21-3.80)) remained significant predictors of POI. Postoperative hyperglycemia increased the risk of POI by 30% with every 40-point increase from normoglycemia (<110 mg/dL). Longer hospitalization was also observed for patients with POG from 110 to 200 mg/dL (OR = 1.4, (1.1-1.7)) and >200 mg/dL (OR = 1.8, (1.4-2.5)). CONCLUSION: The increased risk of POI and length of hospitalization posed by postoperative hyperglycemia is independent of diabetic status and needs further evaluation to assess for possible benefits of postoperative glycemic control in patients who have undergone general surgery.

PMID: 18936571 [PubMed - indexed for MEDLINE]

[Read more →]

Related Articles

Challenges in surgical management of abdominal pain in the neutropenic cancer patient.

Ann Surg. 2008 Jul;248(1):104-9

Authors: Badgwell BD, Cormier JN, Wray CJ, Borthakur G, Qiao W, Rolston KV, Pollock RE

BACKGROUND: Abdominal pain in neutropenic cancer patients presents a unique clinical challenge for surgeons. The purposes of this retrospective study were to characterize the clinicopathologic factors associated with the presentation of neutropenia and abdominal pain, examine the treatment strategies used, and define associated outcomes for these patients. METHODS: We identified patients with concomitant neutropenia (absolute neutrophil count <1000 cells/microL) and abdominal pain who had been evaluated by surgical oncologists over a period of more than 6 years. A Cox proportional hazards regression model was used to analyze the association between clinicopathologic factors and overall survival time. RESULTS: Sixty patients were included in this analysis. After our clinical and radiographic evaluations, we determined that the most frequent causes of the abdominal pain were neutropenic enterocolitis (28%) and small bowel obstruction (12%); the cause remained uncertain in 35%. Surgical interventions had been performed in 9 patients. The 30- and 90-day mortality rates for all patients were 30% and 52%, respectively. Multivariate analysis revealed that severe sepsis, a relatively long duration of neutropenia, and the lack of surgical intervention were significant adverse prognostic factors for overall survival. CONCLUSIONS: Abdominal pain as a symptom in neutropenic patients continues to be a diagnostic and therapeutic challenge and is associated with a high mortality rate. Based on our results, we conclude that efforts should focus on improving neutrophil counts and on treating the frequent and serious comorbidities found in these patients. Surgery should be delayed, when possible, to allow for neutrophil recovery.

PMID: 18580213 [PubMed - indexed for MEDLINE]

[Read more →]