Showing papers by "Avery B. Nathens published in 2011"
TL;DR: EMGS patients are at substantially greater risk than ELGS patients for adverse events and processes of care that afford improved outcomes to EMGS patients need to be identified and disseminated.
Abstract: Background Surgical quality improvement has focused on elective general surgery (ELGS) outcomes despite the substantial risk associated with emergency general surgery (EMGS) procedures. Furthermore, any differences in the quality of care provided to EMGS versus ELGS patients are not well described. We compared risk factors and risk-adjusted outcomes associated with EMGS and ELGS procedures to assess whether hospitals have comparable outcomes across these procedures. Study Design Using American College of Surgeons National Surgical Quality Improvement Program data (2005 to 2008), regression models were constructed for 30-day overall morbidity, serious morbidity, and mortality among all patients, EMGS patients, and ELGS patients. Observed-to-expected (O/E) ratios were calculated from models based on EMGS or ELGS patients. Association of hospital performance after EMGS versus ELGS procedures was assessed by evaluating correlations of O/E ratios; agreement in outlier status (hospitals where O/E confidence intervals [CI] do not overlap 1.0) was evaluated with weighted kappa. Results Of 473,619 procedures, 67,445 (14.2%) patients underwent an EMGS procedure. EMGS patients were more likely to experience any morbidity (odds ratio [OR] 1.20; 95% CI 1.16 to 1.23), serious morbidity (OR 1.26; 95% CI 1.21 to 1.30), and mortality (OR 1.39; 95% CI 1.30 to 1.48). Correlation between O/E ratios for EMGS and ELGS were moderate to low (overall morbidity=0.48, p Conclusions EMGS patients are at substantially greater risk than ELGS patients for adverse events. Hospitals do not appear to have highly consistent performance across EMGS and ELGS outcomes. Processes of care that afford improved outcomes to EMGS patients need to be identified and disseminated.
127 citations
TL;DR: Elderly patients are at substantially greater risk for adverse events following EGS procedures and processes of care that may account for this disparity should be further investigated.
Abstract: Background The elderly (age ≥65 years) comprise an increasing proportion of patients undergoing emergency general surgery (EGS) procedures and have distinct needs compared with the young. We postulated that the needs of the elderly require different processes of care than those required for the young to assure optimal outcomes. To explore this hypothesis, we evaluated 30-day outcomes following EGS procedures in the young and the elderly and determined whether hospital performance was consistent across these 2 age strata. Study Design With data from the American College of Surgeons National Surgical Quality Improvement Program (2005 to 2008), regression models were constructed for serious morbidity and mortality for all patients undergoing EGS procedures and separately for young and elderly patients. These models allowed for estimation of the risk of adverse outcomes associated with advanced age and the generation of hospital-level observed to expected (O/E) ratios. We evaluated the correlation between hospital O/E ratios for the young and the elderly and the concordance of outlier status (hospitals with CIs of O/E ratios excluding 1) with weighted κ across these 2 age groups. Results Among 68,003 procedures at 186 hospitals, elderly patients had a higher crude and adjusted risk for serious morbidity (27.9% versus 9.7%, p Conclusions Elderly patients are at substantially greater risk for adverse events following EGS procedures. Hospitals had only slight agreement in mortality outcomes in the elderly compared with those in young patients. Processes of care that may account for this disparity should be further investigated.
75 citations
TL;DR: Cryoprecipitate is currently largely used for acquired hypofibrinogenemia in the context of bleeding in patients with congenital factor VIII deficiency, but the appropriate cryop Recipitate dose and its impact on plasma fibrinogens levels are unclear in trauma.
Abstract: Background: Originally developed for patients with congenital factor VIII deficiency, cryoprecipitate is currently largely used for acquired hypofibrinogenemia in the context of bleeding. However, scant evidence supports this indication and cryoprecipitate is commonly used outside guidelines. In trauma, the appropriate cryoprecipitate dose and its impact on plasma fibrinogen levels are unclear.
Objectives: The aims were to evaluate (i) the appropriateness of cryoprecipitate transfusion in trauma and (ii) the plasma fibrinogen response to cryoprecipitate transfusion during massive transfusion in trauma.
Methods: Retrospective review (January 1998–June 2008) of indications, dose and plasma fibrinogen response to cryoprecipitate transfusion at a large teaching hospital. A fibrinogen of <1·0 g L−1 within 2 and 6 h of transfusion was used for evaluating appropriateness.
Results: Ten thousand five hundred and forty cryoprecipitate units were transfused in 1004 patients. Thirty-seven percent and 31% were used in cardiac surgery and trauma, respectively. In 394 events in trauma, 238 (60%) and 259 (66%) were considered appropriate using the 2- and 6-h cut-off criteria, respectively. In patients who did not receive plasma components 2 h prior to cryoprecipitate, a dose of 8·7 (±1·7) units caused a mean increase in fibrinogen levels of 0·55 (±0·24) g L−1, or 0·06 g L−1 per unit.
Conclusions: In our hospital, where transfusion guidelines are overseen by transfusion medicine specialists and technologists, and policies for rapid blood component and laboratory turnaround times exist, it is possible to achieve high rates of appropriateness for cryoprecipitate transfusion in trauma. The current recommended dose causes a modest increase in fibrinogen levels (0·55 g L−1).
34 citations
TL;DR: Although overall morbidity tended to favor NTCs, mortality was no different, suggesting that the trauma performance improvement processes have not been applied to EGS patients, despite being cared for by similar providers.
Abstract: Background Trauma surgeons increasingly care for emergency general surgery (EGS) patients The extent to which trauma center (TC) performance improvement translates into improved quality for EGS is unknown We hypothesized that EGS outcomes in TCs would be similar to outcomes in non-trauma centers (NTC); failure to support our hypothesis suggests that the effects of trauma performance improvement have extended beyond trauma patients Study Design We retrospectively studied EGS procedures at TCs versus NTCs among American College of Surgeons National Surgical Quality Improvement Program participants (2005–2008) Thirty-day outcomes were overall morbidity, serious morbidity, and mortality TC versus NTC outcomes were compared using regression modeling, observed-to-expected (O/E) ratios (among hospitals submitting ≥20 EGS procedures), and outlier status (hospitals whose O/E confidence interval excludes 10) Results Of 68,003 patients at 222 hospitals, 42,264 (622%) were treated at 121 TCs; 25,739 (378%) were treated at 101 NTCs TCs had significantly higher overall morbidity (214% versus 172%; p 0099) Conclusions Although overall morbidity tended to favor NTCs, mortality was no different This suggests that the trauma performance improvement processes have not been applied to EGS patients, despite being cared for by similar providers Despite having processes for trauma, there remains the opportunity for quality improvement for EGS care
33 citations