Improving Mortality Following Emergent Surgery in Older Patients Requires Focus on Complication Rescue

Sheetz, Kyle H.; Waits, Seth A.; Krell, Robert W.; Campbell, Darrell A.; Englesbe, Michael J.; Ghaferi, Amir A.

doi:10.1097/sla.0b013e3182a5021d

Cited by 80 publications

(36 citation statements)

References 21 publications

(19 reference statements)

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“…Similar to other studies, we found that complications resulting from emergent surgeries can lead to worsened clinical status, additional hospital costs and, perhaps more importantly, decline in functional status requiring additional support or alternate level of care when leaving hospital. 10 A recent study by Sheetz and colleagues 11 reported a poor correlation between complications and mortality, but failure to rescue patients from in-hospital complications was significantly associated with mortality, and this association was greater in patients older than 75 years. In our study the most common complications were cardiac events, surgical infection/sepsis and postoperative bleeding.…”

Section: Discussionmentioning

confidence: 99%

Perioperative factors predicting poor outcome in elderly patients following emergency general surgery: a multivariate regression analysis

et al. 2015

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Perioperative factors predicting poor outcome in elderly patients following emergency general surgery: a multivariate regression analysis Background: Older adults (≥ 65 yr) are the fastest growing population and are presenting in increasing numbers for acute surgical care. Emergency surgery is frequently life threatening for older patients. Our objective was to identify predictors of mortality and poor outcome among elderly patients undergoing emergency general surgery. Methods:We conducted a retrospective cohort study of patients aged 65-80 years undergoing emergency general surgery between 2009 and 2010 at a tertiary care centre. Demographics, comorbidities, in-hospital complications, mortality and disposition characteristics of patients were collected. Logistic regression analysis was used to identify covariate-adjusted predictors of in-hospital mortality and discharge of patients home.Results: Our analysis included 257 patients with a mean age of 72 years; 52% were men. In-hospital mortality was 12%. Mortality was associated with patients who had higher American Society of Anesthesiologists (ASA) Conclusion: American Society of Anesthesiologists class and in-hospital complications are perioperative predictors of mortality and disposition in the older surgical population. Understanding the predictors of poor outcome and the importance of preventing in-hospital complications in older patients will have important clinical utility in terms of preoperative counselling, improving health care and discharging patients home.Contexte : La population qui connaît la croissance la plus rapide est celle des adultes âgés (≥ 65 ans). Ces personnes nécessitent un nombre croissant d'interventions chirurgicales urgentes. Or, la chirurgie d'urgence comporte souvent un risque de décès pour les patients âgés. Notre objectif était d'identifier les prédicteurs de la mortalité et d'une issue négative chez les patients âgés soumis à une chirurgie générale d'urgence.Méthodes : Nous avons procédé à une étude de cohorte rétrospective chez des patients de 65 à 80 ans soumis à une chirurgie générale d'urgence entre 2009 et 2010 dans un centre de soins tertiaires. Nous avons recueilli les données démographiques, les comorbidités, les complications perhospitalières, la mortalité et les détails sur l'état général de santé des patients. Nous avons utilisé l'analyse de régression logistique afin de dégager les prédicteurs ajustés en fonction des covariables pour la mortalité perhospitalière et les congés hospitaliers des patients vers leur domicile.Résultats : Notre analyse a regroupé 257 patients âgés en moyenne de 72 ans; 52 % étaient des hommes. La mortalité perhospitalière a été de 12 %. La mortalité a été associée à des patients qui se classaient dans une catégorie ASA (American Society of Anesthesiologists) plus élevée (rapport des cotes [RC]

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Section: Discussionmentioning

confidence: 99%

Perioperative factors predicting poor outcome in elderly patients following emergency general surgery: a multivariate regression analysis

et al. 2015

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“…1, 2 Though its mechanisms are incompletely understood, national and regional surgical quality collaboratives are providing hospitals with their own data on failure to rescue as a means of facilitating safer care practices. 3, 4 Reporting within these collaboratives or publicly through efforts such as the Centers for Medicare and Medicaid Services (CMS) Value Based Purchasing Program (VBP) have made hospitals' data on surgical safety more accessible to patient and policymaker scrutiny.…”

Section: Introductionmentioning

confidence: 99%

Impact of Hospital Characteristics on Failure to Rescue Following Major Surgery

Sheetz

Dimick²,

Ghaferi³

2016

Annals of Surgery

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169

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Objective To determine the effect of hospital characteristics on failure to rescue after high-risk surgery in Medicare Beneficiaries. Summary Background Data Reducing failure to rescue events is a common quality target for U.S. hospitals. Little is known about which hospital characteristics influence this phenomenon and more importantly by how much. Methods We identified 1,945,802 Medicare beneficiaries undergoing one of six high-risk general or vascular operations between 2007-10. Using multilevel mixed-effects logistic regression modeling, we evaluated how failure to rescue rates were influenced by specific hospital characteristics previously associated with postsurgical outcomes. We used variance partitioning to determine the relative influence of patient and hospital characteristics on the between-hospital variability in failure to rescue rates. Results Failure to rescue rates varied up to 11-fold between very high and very low mortality hospitals. Comparing the highest and lowest mortality hospitals, we observed that teaching status (range: OR 1.08-1.54), high hospital technology (range: OR 1.08-1.58), increasing nurse-to-patient ratio (range: OR 1.02-1.14), and presence of >20 ICU beds (range: OR 1.09-1.62) significantly influenced failure to rescue rates for all procedures. When taken together, hospital and patient characteristics accounted for 12% (lower extremity revascularization) to 57% (esophagectomy) of the observed variation in failure to rescue rates across hospitals. Conclusions While several hospital characteristics are associated with lower failure to rescue rates, these macro-system factors explain a small proportion of the variability between hospitals. This suggests that micro-system characteristics, such as hospital culture and safety climate, may play a larger role in improving a hospital's ability to manage postoperative complications.

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“…(3–5) In this context, recent evidence suggests that reducing failure to rescue events may be the most appropriate target for quality improvement within this demographic. (6)…”

Section: Introductionmentioning

confidence: 99%

The Importance of the First Complication: Understanding Failure to Rescue after Emergent Surgery in the Elderly

Sheetz¹,

Krell²,

Englesbe³

et al. 2014

Journal of the American College of Surgeons

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Introduction Perioperative mortality in the elderly is high following emergency surgery and varies significantly between hospitals– an observation partially explained by differences in failure to rescue. We hypothesize that failure to rescue following certain types of complications underlies the disproportionately poor outcomes observed in elderly patients. Methods We identified 23,217 patients undergoing emergent general or vascular surgery procedures at 41 hospitals within the Michigan Surgical Quality Collaborative between 2007 and 2012. Patients’ first complications were identified and categorized by type. We compared failure to rescue rates at the patient-level between patients <75 and ≥75 years of age. We then compared failure to rescue rates after specific complications across hospitals grouped in tertiles by risk-adjusted 30-day mortality. Results Risk-adjusted failure to rescue rates were significantly higher in the elderly after a first infectious (21.7% vs. 10.3%; p<0.01) or pulmonary (38.2% vs. 20.4%; p<0.01) complication when compared to younger patients. At the hospital level, high morality centers failed to rescue elderly patients more frequently than low mortality centers after a first infectious (35.6% v. 22.2%; p<0.01) and pulmonary (24.3 v. 14.3; p<0.01) complication. Failure to rescue rates following cardiovascular complications did not differ significantly across patient ages or tertiles of hospital mortality. Conclusion Hospitals fail to rescue elderly patients at higher rates than younger patients after infectious and pulmonary complications. Efforts to recognize and manage these specific complications have the potential to improve emergency surgical care of the elderly in Michigan.

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Improving Mortality Following Emergent Surgery in Older Patients Requires Focus on Complication Rescue

Cited by 80 publications

References 21 publications

Perioperative factors predicting poor outcome in elderly patients following emergency general surgery: a multivariate regression analysis

Perioperative factors predicting poor outcome in elderly patients following emergency general surgery: a multivariate regression analysis

Impact of Hospital Characteristics on Failure to Rescue Following Major Surgery

The Importance of the First Complication: Understanding Failure to Rescue after Emergent Surgery in the Elderly

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