Growing demand for health care, rising costs, constrained resources, and evidence of variations in clinical practice have triggered interest in measuring and improving the quality of health care delivery. For a valuable quality assessment, relevant data on outcome must be obtained in a standardized and reproducible manner to allow comparison among different centers, between different therapies and within a center over time.1–3 Objective and reliable outcome data are increasingly requested by patients and payers (government or private insurance) to assess quality and costs of health care. Moreover, health policy makers point out that the availability of comparative data on individual hospital's and physician's performance represents a powerful market force, which may contribute to limit the costs of health care while improving quality.4

Conclusive assessments of surgical procedures remain limited by the lack of consensus on how to define complications and to stratify them by severity.1,5–8 In 1992, we proposed general principles to classify complications of surgery based on a therapy-oriented, 4-level severity grading.1 Subsequently, the severity grading was refined and applied to compare the results of laparoscopic versus open cholecystectomy9 and liver transplantation.10 This classification has also been used by others11–13 and was recently suggested to serve as the basis to assess the outcome of living related liver transplantation in the United States (J. Trotter, personal communication). However, the classification system has not yet been widely used in the surgical literature.

The strength of the previous classification relied on the principle of grading complications based on the therapy used to treat the complication. This approach allows identification of most complications and prevents down-rating of major negative outcomes. This is particularly important in retrospective analyses. However, we felt that modifications were necessary, particularly in grading life-threatening complications and long-term disability due to a complication. We also felt that the duration of the hospital stay can no longer be used as a criterion to grade complications. Although definitions of negative outcomes rely to a large extend on subjective “value” appraisals, the grading system must be tested in a large cohort of patients. Finally, a classification is useful only if widely accepted and applied throughout different countries and surgical cultures. Such a validation was not done with the previous classification.

Therefore, the aim of the current study was 3-fold: first, to propose an improved classification of surgical complications based on our experience gained with the previous classification1; second, to test this classification in a large cohort of patients who underwent general surgery; and third, to assess the reproducibility and acceptability of the classification through an international survey.

/pdf/classification-of-surgical-complications-a-new-proposal-with-h643vehuw5.pdf

Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey.

Objective:To provide an update to the “Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock,” last published in 2008.Design:A consensus committee of 68 international experts representing 30 international organizations was convened. Nominal groups were assembled at ke

Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012.

Jeffrey L. Anderson, MD, FACC, FAHA, Chair 

Jonathan L. Halperin, MD, FACC, FAHA, Chair-Elect 

Nancy M. Albert, PhD, RN, FAHA

Biykem Bozkurt, MD, PhD, FACC, FAHA

Ralph G. Brindis, MD, MPH, MACC

Mark A. Creager, MD, FACC, FAHA[#][1]

Lesley H. Curtis, PhD, FAHA

David DeMets, PhD[#][1]

Robert A

/pdf/2014-aha-acc-hrs-guideline-for-the-management-of-patients-1v8ficsqox.pdf

2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society

To provide an update to the “Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock,” last published in 2008. A consensus committee of 68 international experts representing 30 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict of interest policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independent of any industry funding. A stand-alone meeting was held for all subgroup heads, co- and vice-chairs, and selected individuals. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence from high (A) to very low (D) and to determine the strength of recommendations as strong (1) or weak (2). The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. Recommendations were classified into three groups: (1) those directly targeting severe sepsis; (2) those targeting general care of the critically ill patient and considered high priority in severe sepsis; and (3) pediatric considerations. Key recommendations and suggestions, listed by category, include: early quantitative resuscitation of the septic patient during the first 6 h after recognition (1C); blood cultures before antibiotic therapy (1C); imaging studies performed promptly to confirm a potential source of infection (UG); administration of broad-spectrum antimicrobials therapy within 1 h of the recognition of septic shock (1B) and severe sepsis without septic shock (1C) as the goal of therapy; reassessment of antimicrobial therapy daily for de-escalation, when appropriate (1B); infection source control with attention to the balance of risks and benefits of the chosen method within 12 h of diagnosis (1C); initial fluid resuscitation with crystalloid (1B) and consideration of the addition of albumin in patients who continue to require substantial amounts of crystalloid to maintain adequate mean arterial pressure (2C) and the avoidance of hetastarch formulations (1B); initial fluid challenge in patients with sepsis-induced tissue hypoperfusion and suspicion of hypovolemia to achieve a minimum of 30 mL/kg of crystalloids (more rapid administration and greater amounts of fluid may be needed in some patients (1C); fluid challenge technique continued as long as hemodynamic improvement is based on either dynamic or static variables (UG); norepinephrine as the first-choice vasopressor to maintain mean arterial pressure ≥65 mmHg (1B); epinephrine when an additional agent is needed to maintain adequate blood pressure (2B); vasopressin (0.03 U/min) can be added to norepinephrine to either raise mean arterial pressure to target or to decrease norepinephrine dose but should not be used as the initial vasopressor (UG); dopamine is not recommended except in highly selected circumstances (2C); dobutamine infusion administered or added to vasopressor in the presence of (a) myocardial dysfunction as suggested by elevated cardiac filling pressures and low cardiac output, or (b) ongoing signs of hypoperfusion despite achieving adequate intravascular volume and adequate mean arterial pressure (1C); avoiding use of intravenous hydrocortisone in adult septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability (2C); hemoglobin target of 7–9 g/dL in the absence of tissue hypoperfusion, ischemic coronary artery disease, or acute hemorrhage (1B); low tidal volume (1A) and limitation of inspiratory plateau pressure (1B) for acute respiratory distress syndrome (ARDS); application of at least a minimal amount of positive end-expiratory pressure (PEEP) in ARDS (1B); higher rather than lower level of PEEP for patients with sepsis-induced moderate or severe ARDS (2C); recruitment maneuvers in sepsis patients with severe refractory hypoxemia due to ARDS (2C); prone positioning in sepsis-induced ARDS patients with a Pao
 2/Fio
 2 ratio of ≤100 mm Hg in facilities that have experience with such practices (2C); head-of-bed elevation in mechanically ventilated patients unless contraindicated (1B); a conservative fluid strategy for patients with established ARDS who do not have evidence of tissue hypoperfusion (1C); protocols for weaning and sedation (1A); minimizing use of either intermittent bolus sedation or continuous infusion sedation targeting specific titration endpoints (1B); avoidance of neuromuscular blockers if possible in the septic patient without ARDS (1C); a short course of neuromuscular blocker (no longer than 48 h) for patients with early ARDS and a Pao
 2/Fi
 o
 2 180 mg/dL, targeting an upper blood glucose ≤180 mg/dL (1A); equivalency of continuous veno-venous hemofiltration or intermittent hemodialysis (2B); prophylaxis for deep vein thrombosis (1B); use of stress ulcer prophylaxis to prevent upper gastrointestinal bleeding in patients with bleeding risk factors (1B); oral or enteral (if necessary) feedings, as tolerated, rather than either complete fasting or provision of only intravenous glucose within the first 48 h after a diagnosis of severe sepsis/septic shock (2C); and addressing goals of care, including treatment plans and end-of-life planning (as appropriate) (1B), as early as feasible, but within 72 h of intensive care unit admission (2C). Recommendations specific to pediatric severe sepsis include: therapy with face mask oxygen, high flow nasal cannula oxygen, or nasopharyngeal continuous PEEP in the presence of respiratory distress and hypoxemia (2C), use of physical examination therapeutic endpoints such as capillary refill (2C); for septic shock associated with hypovolemia, the use of crystalloids or albumin to deliver a bolus of 20 mL/kg of crystalloids (or albumin equivalent) over 5–10 min (2C); more common use of inotropes and vasodilators for low cardiac output septic shock associated with elevated systemic vascular resistance (2C); and use of hydrocortisone only in children with suspected or proven “absolute”’ adrenal insufficiency (2C). Strong agreement existed among a large cohort of international experts regarding many level 1 recommendations for the best care of patients with severe sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for this important group of critically ill patients.

/pdf/surviving-sepsis-campaign-international-guidelines-for-229kg8suph.pdf

Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock, 2012

ContextThe worsening hospital nurse shortage and recent California legislation
mandating minimum hospital patient-to-nurse ratios demand an understanding
of how nurse staffing levels affect patient outcomes and nurse retention in
hospital practice.ObjectiveTo determine the association between the patient-to-nurse ratio and
patient mortality, failure-to-rescue (deaths following complications) among
surgical patients, and factors related to nurse retention.Design, Setting, and ParticipantsCross-sectional analyses of linked data from 10 184 staff nurses
surveyed, 232 342 general, orthopedic, and vascular surgery patients
discharged from the hospital between April 1, 1998, and November 30, 1999,
and administrative data from 168 nonfederal adult general hospitals in Pennsylvania.Main Outcome MeasuresRisk-adjusted patient mortality and failure-to-rescue within 30 days
of admission, and nurse-reported job dissatisfaction and job-related burnout.ResultsAfter adjusting for patient and hospital characteristics (size, teaching
status, and technology), each additional patient per nurse was associated
with a 7% (odds ratio [OR], 1.07; 95% confidence interval [CI], 1.03-1.12)
increase in the likelihood of dying within 30 days of admission and a 7% (OR,
1.07; 95% CI, 1.02-1.11) increase in the odds of failure-to-rescue. After
adjusting for nurse and hospital characteristics, each additional patient
per nurse was associated with a 23% (OR, 1.23; 95% CI, 1.13-1.34) increase
in the odds of burnout and a 15% (OR, 1.15; 95% CI, 1.07-1.25) increase in
the odds of job dissatisfaction.ConclusionsIn hospitals with high patient-to-nurse ratios, surgical patients experience
higher risk-adjusted 30-day mortality and failure-to-rescue rates, and nurses
are more likely to experience burnout and job dissatisfaction.

https://jamanetwork.com/journals/jama/articlepdf/195438/JOC20547.pdf

Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction

ContextIntensive care unit (ICU) physician staffing varies widely, and its
association with patient outcomes remains unclear.ObjectiveTo evaluate the association between ICU physician staffing and patient
outcomes.Data SourcesWe searched MEDLINE (January 1, 1965, through September 30, 2001) for
the following medical subject heading (MeSH) terms: intensive
care units, ICU, health resources/utilization, hospitalization, medical staff,
hospital organization and administration, personnel staffing and scheduling,
length of stay, and LOS. We also used the
following text words: staffing, intensivist, critical, care, and specialist. To identify observational
studies, we added the MeSH terms case-control study and retrospective study. Although we searched for non–English-language
citations, we reviewed only English-language articles. We also searched EMBASE,
HealthStar (Health Services, Technology, Administration, and Research), and
HSRPROJ (Health Services Research Projects in Progress) via Internet Grateful
Med and The Cochrane Library and hand searched abstract proceedings from intensive
care national scientific meetings (January 1, 1994, through December 31, 2001).Study SelectionWe selected randomized and observational controlled trials of critically
ill adults or children. Studies examined ICU attending physician staffing
strategies and the outcomes of hospital and ICU mortality and length of stay
(LOS). Studies were selected and critiqued by 2 reviewers. We reviewed 2590
abstracts and identified 26 relevant observational studies (of which 1 included
2 comparisons), resulting in 27 comparisons of alternative staffing strategies.
Twenty studies focused on a single ICU.Data SynthesisWe grouped ICU physician staffing into low-intensity (no intensivist
or elective intensivist consultation) or high-intensity (mandatory intensivist
consultation or closed ICU [all care directed by intensivist]) groups. High-intensity
staffing was associated with lower hospital mortality in 16 of 17 studies
(94%) and with a pooled estimate of the relative risk for hospital mortality
of 0.71 (95% confidence interval [CI], 0.62-0.82). High-intensity staffing
was associated with a lower ICU mortality in 14 of 15 studies (93%) and with
a pooled estimate of the relative risk for ICU mortality of 0.61 (95% CI,
0.50-0.75). High-intensity staffing reduced hospital LOS in 10 of 13 studies
and reduced ICU LOS in 14 of 18 studies without case-mix adjustment. High-intensity
staffing was associated with reduced hospital LOS in 2 of 4 studies and ICU
LOS in both studies that adjusted for case mix. No study found increased LOS
with high-intensity staffing after case-mix adjustment.ConclusionsHigh-intensity vs low-intensity ICU physician staffing is associated
with reduced hospital and ICU mortality and hospital and ICU LOS.

/pdf/physician-staffing-patterns-and-clinical-outcomes-in-5b3j8ptzj2.pdf

Physician Staffing Patterns and Clinical Outcomes in Critically Ill Patients: A Systematic Review

Physician Staffing Patterns and Clinical Outcomes in Critically Ill Patients

Objective To determine whether a multifaceted systems intervention would eliminate catheter-related bloodstream infections (CR-BSIs). Design Prospective cohort study in a surgical intensive care unit (ICU) with a concurrent control ICU. Setting The Johns Hopkins Hospital. Patients All patients with a central venous catheter in the ICU. Intervention To eliminate CR-BSIs, a quality improvement team implemented five interventions: educating the staff; creating a catheter insertion cart; asking providers daily whether catheters could be removed; implementing a checklist to ensure adherence to evidence-based guidelines for preventing CR-BSIs; and empowering nurses to stop the catheter insertion procedure if a violation of the guidelines was observed. Measurement The primary outcome variable was the rate of CR-BSIs per 1,000 catheter days from January 1, 1998, through December 31, 2002. Secondary outcome variables included adherence to evidence-based infection control guidelines during catheter insertion. Main results Before the intervention, we found that physicians followed infection control guidelines during 62% of the procedures. During the intervention time period, the CR-BSI rate in the study ICU decreased from 11.3/1,000 catheter days in the first quarter of 1998 to 0/1,000 catheter days in the fourth quarter of 2002. The CR-BSI rate in the control ICU was 5.7/1,000 catheter days in the first quarter of 1998 and 1.6/1,000 catheter days in the fourth quarter of 2002 (p = .56). We estimate that these interventions may have prevented 43 CR-BSIs, eight deaths, and 1,945,922 dollars in additional costs per year in the study ICU. Conclusions Multifaceted interventions that helped to ensure adherence with evidence-based infection control guidelines nearly eliminated CR-BSIs in our surgical ICU.

http://people.musc.edu/%7Eelg26/teaching/methods2.2010/berenholtz.etal.pdf

Eliminating catheter-related bloodstream infections in the intensive care unit.

ContextMorbidity and mortality rates in intensive
care units (ICUs) vary widely among institutions, but whether ICU
structure and care processes affect these outcomes is unknownObjectiveTo determine whether organizational characteristics of
ICUs are related to clinical and economic outcomes for abdominal aortic
surgery patients who typically receive care in an ICUDesignObservational study, with patient data collected
retrospectively and ICU data collected prospectivelySettingAll Maryland hospitals that performed abdominal aortic
surgery from 1994 to 1996Patients and ParticipantsWe analyzed hospital discharge data for
patients in nonfederal acute care hospitals in Maryland who had a
principal procedure code for abdominal aortic surgery from January 1994
through December 1996 (n = 2987) We obtained information about ICU
organizational characteristics by surveying ICU medical directors at
the 46 Maryland hospitals that performed abdominal aortic surgery
Thirty-nine (85%) of the ICU directors completed this surveyMain Outcome MeasuresIn-hospital mortality and hospital and ICU
length of stayResultsFor patients undergoing abdominal aortic surgery,
in-hospital mortality varied among hospitals from 0% to 66% In
multivariate analysis adjusted for patient demographics, comorbid
disease, severity of illness, hospital and surgeon volume, and hospital
characteristics, not having daily rounds by an ICU physician was
associated with a 3-fold increase in in-hospital mortality (odds ratio
[OR], 30; 95% confidence interval [CI], 19-49) Furthermore,
not having daily rounds by an ICU physician was associated with an
increased risk of cardiac arrest (OR, 29; 95% CI, 12-70), acute
renal failure (OR, 22; 95% CI, 13-39), septicemia (OR, 18; 95%
CI, 12-26), platelet transfusion (OR, 64; 95% CI, 32-124), and
reintubation (OR, 20; 95% CI, 10-41) Not having daily rounds by an
ICU physician, having an ICU nurse-patient ratio of less than 1:2, not
having monthly review of morbidity and mortality, and extubating
patients in the operating room were associated with increased resource
useConclusionsOrganizational characteristics of ICUs are related to
differences among hospitals in outcomes of abdominal aortic surgery
Clinicians and hospital leaders should consider the potential impact of
ICU organizational characteristics on outcomes of patients having
high-risk operations

https://jamanetwork.com/journals/jama/articlepdf/189348/JCE90004.pdf

Todd Dorman

Papers

Physician Staffing Patterns and Clinical Outcomes in Critically Ill Patients: A Systematic Review

Physician Staffing Patterns and Clinical Outcomes in Critically Ill Patients

Eliminating catheter-related bloodstream infections in the intensive care unit.

Organizational characteristics of intensive care units related to outcomes of abdominal aortic surgery.

Improving communication in the ICU using daily goals.