Frailty assessment in the acute care surgery population - the agreement and predictive value on length of stay and re-admission of 3 different instruments in a prospective cohort

A service led by acute care surgeons managing trauma, critically ill surgical, and emergency general surgery patients via an acute care surgery model of patient care improves hospital efficiency and patient outcomes at university-affiliated hospitals and American College of Surgeons–verified trauma centers. Our goal was to determine whether an acute care surgeon led service, entitled the Surgical Trauma and Acute Resuscitative Service (STARS) that implemented an acute care surgery model of patient care, could improve hospital efficiency and patient outcomes at a community hospital. A total of 492 patient charts were reviewed, which included 230 before the implementation of the STARS [pre-STARS (control)] and 262 after the implementation of the STARS [post-STARS (study)]. Demographics included age, gender, Acute Physiology and Chronic Health Evaluation 2 score, and medical comorbidities. Efficiency data included length of stay in emergency department (ED-LOS), length of stay in surgical intensive care unit (SICU-LOS), and length of stay in hospital (H-LOS), and total in hospital charges. Average age was 64.1 + 16.4 years, 255 males (51.83%) and 237 females (48.17%). Average Acute Physiology and Chronic Health Evaluation 2 score was 11.9 + 5.8. No significant differences in demographics were observed. Average decreases in ED-LOS (9.7 + 9.6 hours, pre-STARS versus 6.6 + 4.5 hours, post-STARS), SICU-LOS (5.3 + 9.6 days, pre-STARS versus 3.5 + 4.8 days, post-STARS), H-LOS (12.4 + 12.7 days, pre-STARS versus 11.4 + 11.3 days, post-STARS), and total in hospital charges ($419,602.6 + $519,523.0 pre-STARS to $374,816.7 + $411,935.8 post-STARS) post-STARS. Regression analysis revealed decreased ED-LOS—2.9 hours [ P = 0.17; 95% confidence interval (CI): -7.0, 1.2], SICU-LOS—6.3 days ( P < 0.001; 95% CI: -9.3, -3.2), H-LOS—7.6 days ( P = 0.001; 95% CI: -12.1, -3.1), and 3.4 times greater odds of survival ( P = 0.04; 95% CI: 1.1, 10.7) post-STARS. In conclusion, implementation of the STARS improved hospital efficiency and patient outcomes at a community hospital.

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Advance Directive and Do-Not-Resuscitate Status among Advanced Cancer Patients with Acute Care Surgical Consultation

The American Surgeon ◽

10.1177/000313481808401005 ◽

2018 ◽

Vol 84 (10) ◽

pp. 1565-1569

Author(s):

Lobsang Marcia ◽

Zane W. Ashman ◽

Eric B. Pillado ◽

Dennis Y. Kim ◽

David S. Plurad

Keyword(s):

Length Of Stay ◽

Cancer Patients ◽

Acute Care ◽

Metastatic Cancer ◽

Stage Iv ◽

Acute Care Surgery ◽

Do Not Resuscitate ◽

Stage Iv Cancer ◽

Care Surgery ◽

Dnr Orders

Formal communication of end-of-life preferences is crucial among patients with metastatic cancer. Our objective is to describe the prevalence of advance directives (AD) and do-not-resuscitate (DNR) orders among stage IV cancer patients with acute care surgery consultations, and the associated outcomes. This is a single institution retrospective review over an eight-year period. Two hundred and three patients were identified; mean age was 55.3 ± 11.4 years and 48.8 per cent were male. Fifty (24.6%) patients underwent exploratory surgery. Nineteen (10.6%) patients had another type of surgery. Twenty-one (10.3%) patients had a DNR order, and none had an AD on-admission. Fifty-four (26.6%) patients had a DNR order placed and four (2%) patients completed an AD postadmission. DNR postadmission was associated with the highest mortality at 42.6 per cent compared with 14.3 per cent for DNR on-admission and 1.56 per cent for full-code patients ( P < 0.001). Compared with patients that remained full-code and those with DNR on-admission, DNR postadmission was associated with longer length of stay (19.6 days; P < 0.001) and ICU length of stay (7.72 days; P < 0.001). The prevalence of AD and DNR orders among stage IV cancer patients is low. The higher in-hospital mortality of patients with DNR postadmission reflects the use of DNR orders during clinical decline.

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Predicting Postoperative Complications for Acute Care Surgery Patients Using the ACS NSQIP Surgical Risk Calculator

The American Surgeon ◽

10.1177/000313481708300730 ◽

2017 ◽

Vol 83 (7) ◽

pp. 733-738 ◽

Cited By ~ 12

Author(s):

Jessica R. Burgess ◽

Benjamin Smith ◽

Rebecca Britt ◽

Leonard Weireter ◽

Travis Polk

Keyword(s):

Postoperative Complications ◽

Length Of Stay ◽

Acute Care ◽

Acute Care Surgery ◽

High Risk Population ◽

Risk Calculator ◽

Improvement Program ◽

Acs Nsqip ◽

Care Surgery ◽

Tract Infections

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) risk calculator has been used to assist surgeons in predicting the risk of postoperative complications. This study aims to determine if the risk calculator accurately predicts complications in acute care surgical patients undergoing laparotomy. A retrospective review was performed on all patients on the acute care surgery service at a tertiary hospital who underwent laparotomy between 2011 and 2012. The preoperative risk factors were used to calculate the estimated risks of postoperative complications in both the original ACS NSQIP calculator and updated calculator (June 2016). The predicted rate of complications was then compared with the actual rate of complications. Ninety-five patients were included. Both risk calculators accurately predicted the risk of pneumonia, cardiac complications, urinary tract infections, venous thromboembolism, renal failure, unplanned returns to operating room, discharge to nursing facility, and mortality. Both calculators underestimated serious complications (26% vs 39%), overall complications (32.4% vs 45.3%), surgical site infections (9.3% vs 20%), and length of stay (9.7 days versus 13.1 days). When patients with prolonged hospitalization were excluded, the updated calculator accurately predicted length of stay. The ACS NSQIP risk calculator underestimates the overall risk of complications, surgical infections, and length of stay. The updated calculator accurately predicts length of stay for patients <30 days. The acute care surgical population represents a high-risk population with an increased rate of complications. This should be taken into account when using the risk calculator to predict postoperative risk in this population.

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Review for "A Multidisciplinary Approach to Decreasing Length of Stay in Acute Care Surgery Patients"

10.1111/jan.14335/v2/review3 ◽

2020 ◽

Keyword(s):

Length Of Stay ◽

Acute Care ◽

Multidisciplinary Approach ◽

Acute Care Surgery ◽

Care Surgery

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Review for "A Multidisciplinary Approach to Decreasing Length of Stay in Acute Care Surgery Patients"

10.1111/jan.14335/v2/review2 ◽

2020 ◽

Author(s):

Yvonne Hoeve

Keyword(s):

Length Of Stay ◽

Acute Care ◽

Multidisciplinary Approach ◽

Acute Care Surgery ◽

Care Surgery

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Old Dogs and New Tricks: Length of Stay for Appendicitis Improves with an Acute Care Surgery Program and Transition from Private Surgical Practice to Multispecialty Group Practice

The American Surgeon ◽

10.1177/000313481408001228 ◽

2014 ◽

Vol 80 (12) ◽

pp. 1250-1255 ◽

Cited By ~ 4

Author(s):

G. Paul Wright ◽

Amie M. Ecker ◽

David J. Hobbs ◽

Alexander W. Wilkes ◽

Richard S. Hagelberg ◽

...

Keyword(s):

Length Of Stay ◽

Acute Appendicitis ◽

Acute Care ◽

Private Practice ◽

Laparoscopic Approach ◽

Acute Care Surgery ◽

Group Practice ◽

Symptom Duration ◽

Multispecialty Group ◽

Care Surgery

Acute care surgery (ACS) programs have emerged mainly at academic medical centers to provide timely care for emergency general surgery and trauma patients. We hypothesized that the development of an ACS program in a multispecialty group practice would improve outcomes for patients with acute appendicitis. A retrospective analysis of patients with acute appendicitis was performed in two time periods: 18 months of private practice and the following 12 months with ACS coverage. Length of stay was the primary outcome measure. A total of 871 patients were studied (526 private practice, 345 ACS). The ACS group had a greater proportion of laparoscopic appendectomies ( P < 0.001) and more transitions in care between surgeons ( P < 0.001). Length of stay was shorter in the ACS group (1.6 ± 1.5 [mean ± standard deviation] vs 1.9 ± 2.4 days, P = 0.01) and a greater proportion of surgeries were performed during the daytime (44.9 vs 36.6%, P = 0.02). Multivariate analysis demonstrated length of stay was related to appendicitis grade ( P < 0.001), American Society of Anesthesiologists class ( P < 0.001), symptom duration ( P = 0.001), and laparoscopic approach ( P < 0.001). The initial transition from private practice to ACS resulted in decreased length of stay with no increase in morbidity related to transitions of surgical care in patients with appendicitis.

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