Minor Postoperative Increases of Creatinine Are Associated with Higher Mortality and Longer Hospital Length of Stay in Surgical Patients

Abstract Background Surgical patients frequently experience postoperative increases in creatinine levels. The authors hypothesized that even small increases in postoperative creatinine levels are associated with adverse outcomes. Methods The authors examined the association of postoperative changes from preoperative baseline creatinine with all-cause in-hospital mortality and hospital length of stay (HLOS) in a retrospective analysis of surgical patients at a single tertiary care center between January 2006 and June 2012. Results The data of 39,369 surgical patients (noncardiac surgery n = 37,345; cardiac surgery n = 2,024) were analyzed. Acute kidney injury (AKI)—by definition of the Kidney Disease: Improving Global Outcome group—was associated with a five-fold higher mortality (odds ratio [OR], 4.8; 95% CI, 4.1 to 5.7; P < 0.001) and a longer HLOS of 5 days (P < 0.001) after adjusting for age, sex, comorbidities, congestive heart failure, preoperative hemoglobin, preoperative creatinine, exposure to radiocontrast agent, type of surgery, and surgical AKI risk factors. Importantly, even minor creatinine increases (Δcreatinine 25 to 49% above baseline but < 0.3 mg/dl) not meeting AKI criteria were associated with a two-fold increased risk of death (OR, 1.7; 95% CI, 1.3 to 2.4; P < 0.001) and 2 days longer HLOS (P < 0.001). This was more pronounced in noncardiac surgery patients. Patients with minor creatinine increases had a five-fold risk of death (OR, 5.4; 95% CI, 1.5 to 20.3; P < 0.05) and a 3-day longer HLOS (P < 0.01) when undergoing noncardiac surgery. Conclusions Even minor postoperative increases in creatinine levels are associated with adverse outcomes. These results emphasize the importance to find effective therapeutic approaches to prevent or treat even mild forms of postoperative kidney dysfunction to improve surgical outcomes.

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Abstract 13167: Early Mobilization in Postoperative Cardiac Surgical Patients

Circulation ◽

10.1161/circ.142.suppl_3.13167 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Michael Goldfarb ◽

Diana Dima ◽

Yves Langlois

Keyword(s):

Cardiac Surgery ◽

Length Of Stay ◽

Functional Status ◽

Tertiary Care ◽

Early Mobilization ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Surgical Patients ◽

Tertiary Care Centre ◽

Optimal Method

Introduction: Early mobilization (EM) is recommended by cardiac surgical societies. However, the optimal method of EM delivery has yet to be determined. Our objective was to assess whether a bedside nurse-driven EM strategy is safe and associated with improved outcomes following cardiac surgery. Methods: Consecutive post-cardiac surgery patients in a cardiovascular intensive care unit (CVICU) at an academic tertiary care centre from 2017 to 2019 prior to and after EM program implementation were reviewed. Postoperative cardiac surgery patients were initially managed in a general ICU and transferred to the CVICU when hemodynamic stability was achieved, typically postoperative day 1 or 2. Functional status was assessed by the nurse on CVICU admission using the Level of Function (LOF) Mobility Scale, which ranges from LOF 0 (bed immobile) to LOF 5 (walks > 50 feet). The nurse uses the LOF score to guide twice-daily level-specific mobility activities. The primary outcome was hospital length of stay. Results: There were 504 patients included in the study (preintervention, N=329; Intervention, N=175). There was no difference in age, sex or comorbid illness between the groups (Table). The LOF was 4.7 ± 0.5 prior to surgery, 3.4 ± 1.1 on CVICU admission, and 4.3 ± 0.6 on CVICU discharge in patients undergoing EM. Patients were mobilized during nearly all mobilization opportunities (98.7%; 685/694). Adverse events were rare (0.4%; 8 events/1901 mobilization activities), minor and transient. There was no difference is postoperative hospital length of stay, in-hospital mortality, discharge home or 30-day hospital re-admission (all P>0.05). Conclusion: A nurse-driven EM program was safe and associated with improvement in functional status in postoperative cardiac surgery patients. The EM program was not associated with improved short-term outcomes. Further studies are needed to understand optimal delivery of EM in cardiac surgical patients.

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Gait Speed Is Not Associated with Vasogenic Shock or Cardiogenic Shock following Cardiac Surgery, but Is Associated with Increased Hospital Length of Stay

Critical Care Research and Practice ◽

10.1155/2018/1538587 ◽

2018 ◽

Vol 2018 ◽

pp. 1-6 ◽

Cited By ~ 3

Author(s):

Kimmie Clark ◽

Taylor Leathers ◽

Duncan Rotich ◽

Jianghua He ◽

Katy Wirtz ◽

...

Keyword(s):

Cardiac Surgery ◽

Length Of Stay ◽

Gait Speed ◽

Tertiary Care ◽

Hospital Length ◽

Permanent Pacemaker ◽

Adverse Outcomes ◽

Hospital Length Of Stay ◽

Academic Hospital ◽

Total Hospital

Objective. Frailty has been associated with adverse outcomes following cardiac surgery. Gait speed has been validated as a marker of frailty. Slow gait speed has been found to be associated with mortality after cardiac surgery. However, it is unknown why slow gait speed predisposes to cardiac surgical mortality. Design. A retrospective analysis. Participants. Patients undergoing cardiac surgery who had a 5-meter walk test performed preoperatively (n=333 of 1735 total surgical patients) from January 2013 to March 2017. Setting. A tertiary care academic hospital. Measurements and main results. Gait speeds were stratified by tertiles: <0.83 m/s, 0.83–1 m/s, and >1 m/s. There was no difference in the incidence of cardiogenic or vasogenic shock when comparing the gait speed groups. Total hospital length of stay was significantly different among the gait speed groups (p=0.0050). Also, patients in the slowest gait speed tertile had a significant association with need for a postoperative permanent pacemaker (p=0.0298). Conclusion. There was no significant association between gait speed and the incidence of cardiogenic or vasogenic shock after cardiac surgery. Gait speed was associated with increased hospital length of stay and need for a permanent pacemaker after cardiac surgery.

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Abstract 101: Gender Differences in the Timing of Access to the Prehospital Phase of STEMI Care

Circulation ◽

10.1161/circ.116.suppl_16.ii_944-a ◽

2007 ◽

Vol 116 (suppl_16) ◽

Author(s):

Robert O’Connor ◽

Ross Megargel ◽

Angela DiSabatino ◽

William Weintrub ◽

Charles Reese

Keyword(s):

Gender Differences ◽

Length Of Stay ◽

Tertiary Care ◽

Female Gender ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Symptom Duration ◽

Care Hospital ◽

Private Vehicle ◽

Prehospital Management

Introduction : The purpose of this study is to determine the degree of gender differences in lay person recognition, emergency medical services (EMS) activation, and the prehospital management of STEMI. Methods : Data were gathered prospectively from May 1999 to January 2007 on consecutive patients with STEMI who presented to a tertiary care hospital emergency department. Patients arriving by ambulance and private vehicle were included. Data collection included determining symptom duration, whether a prehospital ECG was obtained, whether the cardiac interventional lab was activated prior to patient arrival at the hospital, patient age, and hospital length of stay. Prehospital activation of the cath lab was done by emergency medicine based on paramedic ECG interpretation in consultation with cardiology. Statistical analysis was performed using the Mann-Whitney U test, the Yates-corrected chi-square test, and linear regression. Results : A total of 3260 cases were studied, of which, 3097 had complete data for analysis. Only EMS cases were included in the ECG analysis, and only patients having a prehospital ECG were included in the prehospital activation of cath lab analysis. Regression analysis showed that older age and female gender were significant predictors of access and arrival by EMS. The mean age in years was higher for EMS arrival (69 women; 59 men) than for private vehicle (62 women; 56 men). Conclusion : Women with STEMI tend to use EMS more frequently then men, but are older and wait longer before seeking treatment. Whether these factors contribute to the longer length of stay remains to be determined.

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Are emergency medical services offload delay patients at increased risk of adverse outcomes?

CJEM ◽

10.1017/cem.2018.478 ◽

2019 ◽

Vol 21 (4) ◽

pp. 505-512 ◽

Cited By ~ 1

Author(s):

Dana Stewart ◽

Eddy Lang ◽

Dongmei Wang ◽

Grant Innes

Keyword(s):

Emergency Medical Services ◽

Care Delivery ◽

Hospital Length ◽

Adverse Outcomes ◽

Hospital Length Of Stay ◽

Medical Services ◽

Emergency Medical ◽

Increased Risk ◽

High Acuity ◽

Offload Delay

ABSTRACTObjectiveEmergency department (ED) and hospital overcrowding cause offload delays that remove emergency medical services (EMS) crews from service and compromise care delivery. Prolonged ED boarding and delays to inpatient care are associated with increased hospital length of stay (LOS) and patient mortality, but the effects of EMS offload delays have not been well studied.MethodsWe used administrative data to study all high-acuity Canadian Triage Acuity Scale 2–3 EMS arrivals to Calgary adult EDs from July 2013 to June 2016. Patients offloaded to a care space within 15 minutes were considered controls, whereas those delayed ≥ 60 minutes were considered “delayed.” Propensity matching was used to create comparable control and delayed cohorts. The primary outcome was 7-day mortality. Secondary outcomes included hospital LOS and 30-day mortality.ResultsOf 162,002 high-acuity arrivals, 70,711 had offload delays <15 minutes and 41,032 had delays > 60 minutes. Delayed patients were more likely to be female, older, to have lower triage acuity, to live in dependent living situations, and to arrive on weekdays and day or evening hours. Delayed patients less often required admission and, when admitted, were more likely to go to the hospitalist service. Main outcomes were similar for propensity-matched control and delayed cohorts, although delayed patients experienced longer ED LOS and slightly lower 7-day mortality rates.ConclusionIn this setting, high-acuity EMS arrivals exposed to offload delays did not have prolonged hospital LOS or higher mortality than comparable patients who received timely access.

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Impact of Frailty on Outcomes Following Spine Surgery: A Prospective Cohort Analysis of 668 Patients

Neurosurgery ◽

10.1093/neuros/nyaa468 ◽

2020 ◽

Author(s):

Nitin Agarwal ◽

Ezequiel Goldschmidt ◽

Tavis Taylor ◽

Souvik Roy ◽

Stefanie C Altieri Dunn ◽

...

Keyword(s):

Length Of Stay ◽

Spine Surgery ◽

Cohort Analysis ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Quality Improvement Initiative ◽

Exact Test ◽

Frail Patients ◽

Increased Risk ◽

Venous Thromboembolic

Abstract BACKGROUND With an aging population, elderly patients with multiple comorbidities are more frequently undergoing spine surgery and may be at increased risk for complications. Objective measurement of frailty may predict the incidence of postoperative adverse events. OBJECTIVE To investigate the associations between preoperative frailty and postoperative spine surgery outcomes including mortality, length of stay, readmission, surgical site infection, and venous thromboembolic disease. METHODS As part of a system-wide quality improvement initiative, frailty assessment was added to the routine assessment of patients considering spine surgery beginning in July 2016. Frailty was assessed with the Risk Analysis Index (RAI), and patients were categorized as nonfrail (RAI 0-29) or prefrail/frail (RAI ≥ 30). Comparisons between nonfrail and prefrail/frail patients were analyzed using Fisher's exact test for categorical data or by Wilcoxon rank sum tests for continuous data. RESULTS From August 2016 through September 2018, 668 patients (age of 59.5 ± 13.3 yr) had a preoperative RAI score recorded and underwent scheduled spine surgery. Prefrail and frail patients suffered comparatively higher rates of mortality at 90 d (1.9% vs 0.2%, P < .05) and 1 yr (5.1% vs 1.2%, P < .01) from the procedure date. They also had longer in-hospital length of stay (LOS) (3.9 d ± 3.6 vs 3.1 d ± 2.8, P < .001) and higher rates of 60 d (14.6% vs 8.2%, P < .05) and 90 d (15.8% vs 9.8%, P < .05) readmissions. CONCLUSION Preoperative frailty, as measured by the RAI, was associated with an increased risk of readmission and 90-d and 1-yr mortality following spine surgery. The RAI can be used to stratify spine patients and inform preoperative surgical decision making.

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Childhood Nephrotic Syndrome Management and Outcome: A Single Center Retrospective Analysis

International Journal of Nephrology ◽

10.1155/2017/2029583 ◽

2017 ◽

Vol 2017 ◽

pp. 1-7 ◽

Cited By ~ 7

Author(s):

Chia-shi Wang ◽

Jia Yan ◽

Robert Palmer ◽

James Bost ◽

Mattie Feasel Wolf ◽

...

Keyword(s):

Nephrotic Syndrome ◽

Length Of Stay ◽

Hospital Length ◽

Hospital Length Of Stay ◽

High Morbidity ◽

Metropolitan Statistical Area ◽

Childhood Nephrotic Syndrome ◽

Steroid Dependent ◽

Increased Risk ◽

Serious Disease

There is a paucity of information on outpatient management and risk factors for hospitalization and complications in childhood nephrotic syndrome (NS). We described the management, patient adherence, and inpatient and outpatient usage of 87 pediatric NS patients diagnosed between 2006 and 2012 in the Atlanta Metropolitan Statistical Area. Multivariable analyses were performed to examine the associations between patient characteristics and disease outcome. We found that 51% of the patients were treated with two or more immunosuppressants. Approximately half of the patients were noted to be nonadherent to medications and urine protein monitoring. The majority (71%) of patients were hospitalized at least once, with a median rate of 0.5 hospitalizations per patient year. Mean hospital length of stay was 4.0 (3.8) days. Fourteen percent of patients experienced at least one serious disease complication. Black race, frequently relapsing/steroid-dependent and steroid-resistant disease, and the first year following diagnosis were associated with higher hospitalization rates. The presence of comorbidities was associated with longer hospital length of stay and increased risk of serious disease complications. Our results highlight the high morbidity and burden of NS and point to particular patient subgroups that may be at increased risk for poor outcome.

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Laparoscopic Shunt Revision Avoids Many Complications of Open Shunt Revision and Has Outcomes Similar to First-time Shunt Placement

The American Surgeon ◽

10.1177/000313481508100335 ◽

2015 ◽

Vol 81 (3) ◽

pp. 305-308

Author(s):

Heather Logghe ◽

John Maa ◽

Michael McDermott ◽

Michael Oh ◽

Jonathan Carter

Keyword(s):

Length Of Stay ◽

Retrospective Cohort ◽

Operative Time ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Shunt Revision ◽

Visceral Injury ◽

Shunt Placement ◽

Increased Risk ◽

First Time

Open revision of abdominal shunts is associated with increased risk of wound infection, visceral injury, hernia, and shunt complications. We hypothesized that laparoscopic revision mitigates these risks to a level similar to initial (i.e., first-time) shunt placement. This was a single-center, multisurgeon, retrospective cohort study of patients who underwent either laparoscopic initial shunt placement or laparoscopic shunt revision over a 5-year period. Outcomes were operative time, length of stay, and 30-day complication rate. Sixty-nine patients underwent laparoscopic shunt revision and 99 patients underwent laparoscopic initial shunt placement. Operative times were nearly identical (75 vs 73 minutes, P = 0.63). There were no significant differences in blood loss or hospital length of stay. Abdominal complications and total complications did not differ between groups. Laparoscopic shunt revision avoided many of the known complications of open shunt revision and had outcomes similar to initial laparoscopic shunt placement.

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Agency for Healthcare Research and Quality Patient Safety Indicators and Mortality in Surgical Patients

The American Surgeon ◽

10.1177/000313481408000832 ◽

2014 ◽

Vol 80 (8) ◽

pp. 801-804 ◽

Cited By ~ 3

Author(s):

Rajesh Ramanathan ◽

Patricia Leavell ◽

Luke G. Wolfe ◽

Therese M. Duane

Keyword(s):

Patient Safety ◽

Length Of Stay ◽

Medical Center ◽

Academic Medical Center ◽

Hospital Length ◽

Healthcare Research ◽

Hospital Length Of Stay ◽

Surgical Patients ◽

Patient Safety Indicators ◽

Academic Medical

Patient safety indicators (PSI), developed by the Agency for Healthcare Research and Quality, use administrative billing data to measure and compare patient safety events at medical centers. We retrospectively examined whether PSIs accurately reflect patients’ risk of mortality, hospital length of stay, and intensive care unit (ICU) requirements at an academic medical center. Surgical patient records with PSIs were reviewed between October 2011 and September 2012 at our urban academic medical center. Primary outcomes studied included mortality, hospital length of stay, and ICU requirements. Subset analysis was performed for each PSI and its association with the outcome measures. PSIs were more common among surgical patients who died as compared with those alive at discharge (35.3 vs 2.7 PSIs/100 patients, P < 0.01). Although patients who died with PSIs had shorter hospital courses, they had a significantly greater ICU requirement than those without a PSI (96.0 vs 61.1%, P < 0.01) and patients who were alive at discharge (96.0 vs 48.0%, P < 0.01). The most frequently associated PSIs with mortality were postoperative metabolic derangements (41.7%), postoperative sepsis (38.5%), and pressure ulcers (33.3%). PSIs occur at a higher frequency in surgical patients who die and are associated with increased ICU requirements.

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Routine Nasogastric Decompression in Small Bowel Obstruction: Is it Really Necessary?

The American Surgeon ◽

10.1177/000313481307900433 ◽

2013 ◽

Vol 79 (4) ◽

pp. 422-428 ◽

Cited By ~ 9

Author(s):

Annabelle L. Fonseca ◽

Kevin M. Schuster ◽

Adrian A. Maung ◽

Lewis J. Kaplan ◽

Kimberly A. Davis

Keyword(s):

Respiratory Failure ◽

Small Bowel ◽

Length Of Stay ◽

Small Bowel Obstruction ◽

Bowel Obstruction ◽

Retrospective Chart Review ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Increased Risk ◽

Nasogastric Decompression

Bowel rest, nasogastric (NG) decompression, and intravenous hydration are used to treat small bowel obstruction (SBO) conservatively; however, there are no data to support nasogastric tube (NGT) use in patients without active emesis. We aim to evaluate the use of nasogastric decompression in SBO and the safety of managing patients with SBO without the use of a NGT. A retrospective chart review was conducted of adult patients admitted to Yale New Haven Hospital over five years with the diagnosis of SBO. We compared patients who received NG decompression with those who did not. Outcome variables assessed were days to resolution, associated complications, hospital length of stay, and disposition. Of 290 patients who fit the criteria, 190 patients (65.52%) were managed conservatively. Fifty-five patients (18.97%) did not receive NGTs. Sixty-eight patients (23.45%) did not present with emesis; however, nearly 75 per cent of these patients received NGTs. Development of pneumonia and respiratory failure was significantly associated with NGT placement. Time to resolution and hospital length of stay were significantly higher in patients with NGTs. Patients with NG decompression had a significantly increased risk of pneumonia and respiratory failure as well as increased time to resolution and hospital length of stay.

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