Unanticipated Admission Following Outpatient Laparoscopic Cholecystectomy: Identifying Opportunities for Improvement

2020 ◽  
pp. 000313482095634
Author(s):  
Anna C. Beck ◽  
Paolo Goffredo ◽  
Xiang Gao ◽  
Patrick W. McGonagill ◽  
Ronald J. Weigel ◽  
...  
Keyword(s):  
Admission Rate ◽  
The United States ◽  
Improvement Program ◽  
Admission Rates ◽  
American College Of Surgeons ◽  
Cardiopulmonary Complications ◽  
Unanticipated Admission ◽  
American Society ◽  
American Society Of Anesthesiologists ◽  
Retained Stones

Background Unanticipated admissions are a burden to the health care system. Over 400 000 outpatient laparoscopic cholecystectomies (LCs) are performed annually in the United States. The aim of this study is to identify causes of unanticipated admissions and modifiable risk factors. Methods Patients undergoing elective outpatient LCs were identified from the 2013-2015 American College of Surgeons National Surgical Quality Improvement Program database. Results A total of 69 376 patients underwent outpatient LC or LC+ intraoperative cholangiogram (IOC); 2027 (2.9%) were admitted after a median of 5 days (interquartile range 3-8). Admission rates varied by preoperative indications: pancreatitis (4.9%), gallstones with obstruction (3.9%), cholecystitis (3.0%), and gallstones without obstruction (2.6%) ( P = .003). The most frequent causes were infection, retained stones, and other GI complications. Patients admitted for infection or cardiopulmonary complications were older with higher American Society of Anesthesiologists (ASA) ( P < .01), while patients with pain and retained stones were younger with lower ASA ( P < .01). Patients who underwent LC+IOC had a lower admission rate due to retained stones (.17% vs. .31% LC, P = .006). Conclusions Unanticipated admissions following outpatient LC occur infrequently for diverse reasons usually within the first week after surgery. Associated factors are patient and disease related and not at all modifiable. In selected patients, increased IOC use may decrease admissions from retained stones.

scholarly journals Predictors of 30-Day Unplanned Readmissions, Complications, and Mortality Following Operative Management of C2 Fractures

2019 ◽  
Vol 10 (2) ◽  
pp. 130-137
Author(s):  
David N. Bernstein ◽  
Caroline Thirukumaran ◽  
Brandon Raudenbush ◽  
Robert W. Molinari ◽  
Emmanuel N. Menga ◽  
...  
Keyword(s):  
Operative Time ◽  
Functional Limitations ◽  
Operative Management ◽  
Unplanned Readmission ◽  
Improvement Program ◽  
Five Factors ◽  
American College Of Surgeons ◽  
American Society ◽  
American Society Of Anesthesiologists ◽  
Complications And Mortality

Study Design: Retrospective database review. Objectives: To determine factors associated with unplanned readmission, complications, and mortality in patients undergoing operative management for C2 fractures. Methods: The American College of Surgeons–National Surgical Quality Improvement Program (ACS NSQIP) was queried between 2007 and 2014. Unplanned readmission, any complication, and mortality were the outcomes of interest. Bivariate statistics were calculated, and multivariate regression models were estimated. Results: A total of 285 patients were enrolled. Readmission data was available for 199 patients and 11 patients (5.5% of 199 patients) had an unplanned readmission. Overall, 60 patients (21% of 285 patients) had at least 1 complication and 15 patients (5.3% of 285 patients) died. Five factors were associated with complications: transferred from another facility (odds ratio [OR] 3.00, 95% confidence interval [CI]1.51-5.98; P < .01); operative time ≥180 minutes (OR 2.43, 95% CI 1.11-5.36; P = .03); at least 1 patient comorbidity (OR 2.50, 95% CI 1.01-6.18; P < .05); American Society of Anesthesiologists (ASA) class 3 (OR 4.86, 95% CI 1.19-19.88; P = .03); and ASA class 4 (OR 7.24, 95% CI 1.66-31.66; P = .01). The only factor associated with unplanned readmission was having at least one postoperative complication (OR 7.10, 95% CI 1.04-48.59; P < .05), while patients who were partially or totally dependent from a functional standpoint were at increased odds of death (OR 3.98, 95% CI 1.12-14.08; P = .03). Conclusions: Patients with functional limitations have increased odds of death, while patients with postoperative complications have increased odds of unplanned readmission. Being transferred from an outside facility, having an operative time ≥180 minutes, having at least one comorbidity, and being classified as ASA class 3 or 4 increase patient odds of complication.

Regional and Gender Differences and Trends in the Anesthesiologist Workforce

2015 ◽  
Vol 123 (5) ◽  
pp. 997-1012 ◽  
Author(s):  
Matthew Baird ◽  
Lindsay Daugherty ◽  
Krishna B. Kumar ◽  
Aziza Arifkhanova
Keyword(s):  
United States ◽  
Supply And Demand ◽  
The United States ◽  
Work Hours ◽  
Seemingly Unrelated Regression ◽  
Healthcare Sector ◽  
Unrelated Regression ◽  
And Gender ◽  
American Society ◽  
American Society Of Anesthesiologists

Abstract Background Concerns have long existed about potential shortages in the anesthesiologist workforce. In addition, many changes have occurred in the economy, demographics, and the healthcare sector in the last few years, which may impact the workforce. The authors documented workforce trends by region of the United States and gender, trends that may have implications for the supply and demand of anesthesiologists. Methods The authors conducted a national survey of American Society of Anesthesiologists members (accounting for &gt;80% of all practicing anesthesiologists in the United States) in 2007 and repeated it in 2013. The authors used logistic regression analysis and Seemingly Unrelated Regression to test across several indicators under an overarching hypothesis. Results Anesthesiologists in Western states had markedly different patterns of practice relative to anesthesiologists in other regions in 2007 and 2013, including differences in employer type, the composition of anesthesia teams, and the time spent on monitored anesthesia care. The number and proportion of female anesthesiologists in the workforce increased between 2007 and 2013, and females differed from males in employment arrangements, compensation, and work hours. Conclusions Regional differences remained stable during this time period although the reasons for these differences are speculative. Similarly, how and whether the gender difference in work hours and shift to younger anesthesiologists during this period will impact workforce needs is uncertain.

Assessing Risk of Severe Complications after Endoscopic Transnasal Transsphenoidal Surgery: A Comparison of Frailty, American Society of Anesthesiologists, and Comorbidity Scores

2021 ◽  
Author(s):  
Jordan M. Sukys ◽  
Roy Jiang ◽  
Richard P. Manes
Keyword(s):  
Frailty Index ◽  
Information Criteria ◽  
Improvement Program ◽  
Pituitary Mass ◽  
Complication Risk ◽  
Comorbidity Scores ◽  
Multivariable Regression ◽  
American Society ◽  
Akaike’S Information Criteria ◽  
American Society Of Anesthesiologists

Abstract Objective This study aimed to improve age-independent risk stratification for patients undergoing endoscopic transnasal transsphenoidal (TNTS) approach to pituitary mass resection by investigating the associations between frailty, American Society of Anesthesiologists (ASA), and comorbidity scores with severe complications following TNTS. Design This study is a retrospective review. Setting This review was conducted utilizing the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Participants A total of 680 cases of TNTS identified from 2010 to 2013 were included in this study. Main Outcome Measures The modified frailty index (mFI) was calculated to quantify frailty. ASA and Charlson's comorbidity index (CCI) scores were obtained as physiologic status and comorbidity-based prognostic markers. Severe complications were separated into intensive care unit (ICU)-level complications, defined by Clavien–Dindo grade IV (CDIV) criteria, and mortality. Results Overall, 24 CDIV complications (3.5%) and 6 deaths (0.9%) were recorded. Scores for mFI (p = 0.01, R 2 = 0.97) and ASA (p = 0.04., R 2 = 0.87) were significantly correlated with CDIV complications. ASA scores were significantly correlated with mortality (p = 0.03, R 2 = 0.87), as well as independently associated with CDIV complication by multivariable regression models (odds ratio [OR] = 2.96, 95% confidence interval [CI]: 1.35–6.83, p < 0.01), while mFI was not. CCI was not significantly associated with CDIV complications or mortality. A multivariable regression model incorporating ASA had a lower Akaike's Information Criteria (AIC; 188.55) than a model incorporating mFI (195.99). Conclusion Frailty and physiologic status, as measured by mFI and ASA scores respectively, both correlate with ICU-level complications after TNTS. ASA scores demonstrate greater clinical utility than mFI scores; however, as they are more easily generated, uniquely correlated with mortality and independently associated with ICU-level complication risk on multivariable regression analysis.

scholarly journals Development and validation of a predictive model for American Society of Anesthesiologists Physical Status

2019 ◽  
Vol 19 (1) ◽  
Author(s):  
Seshadri C. Mudumbai ◽  
Suzann Pershing ◽  
Thomas Bowe ◽  
Robin N. Kamal ◽  
Erika D. Sears ◽  
...  
Keyword(s):  
Predictive Validity ◽  
Research Quality ◽  
Multinomial Regression ◽  
Physical Status ◽  
Improvement Program ◽  
Variable Model ◽  
Preoperative Status ◽  
American Society ◽  
Key Indicators ◽  
American Society Of Anesthesiologists

Abstract Background The American Society of Anesthesiologists Physical Status (ASA-PS) classification system was developed to categorize the fitness of patients before surgery. Increasingly, the ASA-PS has been applied to other uses including justification of inpatient admission. Our objectives were to develop and cross-validate a statistical model for predicting ASA-PS; and 2) assess the concurrent and predictive validity of the model by assessing associations between model-derived ASA-PS, observed ASA-PS, and a diverse set of 30-day outcomes. Methods Using the 2014 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Participant Use Data File, we developed and internally cross-validated multinomial regression models to predict ASA-PS using preoperative NSQIP data. Accuracy was assessed with C-Statistics and calibration plots. We assessed both concurrent and predictive validity of model-derived ASA-PS relative to observed ASA-PS and 30-day outcomes. To aid further research and use of the ASA-PS model, we implemented it into an online calculator. Results Of the 566,797 elective procedures in the final analytic dataset, 8.9% were ASA-PS 1, 48.9% were ASA-PS 2, 39.1% were ASA-PS 3, and 3.2% were ASA-PS 4. The accuracy of the 21-variable model to predict ASA-PS was C = 0.77 +/− 0.0025. The model-derived ASA-PS had stronger association with key indicators of preoperative status including comorbidities and higher BMI (concurrent validity) compared to observed ASA-PS, but less strong associations with postoperative complications (predictive validity). The online ASA-PS calculator may be accessed at https://s-spire-clintools.shinyapps.io/ASA_PS_Estimator/ Conclusions Model-derived ASA-PS better tracked key indicators of preoperative status compared to observed ASA-PS. The ability to have an electronically derived measure of ASA-PS can potentially be useful in research, quality measurement, and clinical applications.

Postoperative Complications Predict 30-Day Readmission in Geriatric General Surgery Patients

2017 ◽  
Vol 83 (4) ◽  
pp. 365-370 ◽  
Author(s):  
James D. Dieterich ◽  
Celia M. Divino
Keyword(s):  
Venous Thromboembolism ◽  
General Surgery ◽  
Cox Regression ◽  
Operation Time ◽  
Unplanned Readmission ◽  
Improvement Program ◽  
Vein Thrombosis ◽  
American Society ◽  
Patient Readmissions ◽  
American Society Of Anesthesiologists

The Affordable Care Act has placed unplanned patient readmissions under more scrutiny than ever. Geriatric patients, in particular, suffer a disproportionate amount of complications from any kind of hospitalization, including readmissions. This study seeks to identify risk factors in this population that predispose them to an unplanned readmission within 30 days after index surgery. The National Surgical Quality Improvement Program database was used to select patients 65 years and older, who underwent general surgery procedures in 2012. Patient demographics, comorbidities, complications, and readmissions were analyzed. A Cox regression survivorship model was used for multivariate analysis. A total of 7712 patients were reviewed; 617 patients (8.0%) had an unplanned readmission within 30 days of their operation. Cox regression revealed five different independent predictors of unplanned readmission within 30 days. They are age [P = 0.009, hazard ratio (HR) = 1.016, 95% confidence interval (CI) = 1.01–1.03], American Society of Anesthesiologists Class >2 (P = 0.037, HR = 1.22, CI = 1.024–1.475), operation time (minutes) (P = 0.001, HR = 1.001, CI = 1.00–1.002), any complication (P = 0.03, HR = 1.449, CI = 1.33–1.852), and deep vein thrombosis (P = 0.03, HR = 1.87, CI = 1.31–3.85). Using Cox regression to adjust for patient length of stay, age, American Society of Anesthesiologists class, any complication, operation time, and venous thromboembolism all independently increased the rate of unplanned readmissions. Patients who suffer any complication or a venous thromboembolism postoperatively are at a particularly high risk of readmission. These patients should be targeted for increased inpatient monitoring and included in preventable readmission programs after discharge.

Readmission After Craniotomy for Tumor: A National Surgical Quality Improvement Program Analysis

Neurosurgery ◽  
2017 ◽  
Vol 80 (4) ◽  
pp. 551-562 ◽  
Author(s):  
Hormuzdiyar H. Dasenbrock ◽  
Sandra C. Yan ◽  
Timothy R. Smith ◽  
Pablo A. Valdes ◽  
William B. Gormley ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Functional Status ◽  
Tumor Resection ◽  
Quality Improvement Program ◽  
Unplanned Readmission ◽  
Index Hospitalization ◽  
Improvement Program ◽  
Surgical Quality ◽  
American Society ◽  
American Society Of Anesthesiologists

Abstract BACKGROUND: Although readmission has become a common quality indicator, few national studies have examined this metric in patients undergoing cranial surgery. OBJECTIVE: To utilize the prospective National Surgical Quality Improvement Program 2011-2013 registry to evaluate the predictors of unplanned 30-d readmission and postdischarge mortality after cranial tumor resection. METHODS: Multivariable logistic regression was applied to screen predictors, which included patient age, sex, tumor location and histology, American Society of Anesthesiologists class, functional status, comorbidities, and complications from the index hospitalization. RESULTS: Of the 9565 patients included, 10.7% (n = 1026) had an unplanned readmission. Independent predictors of unplanned readmission were male sex, infratentorial location, American Society of Anesthesiologists class 3 designation, dependent functional status, a bleeding disorder, and morbid obesity (all P ≤ .03). Readmission was not associated with operative time, length of hospitalization, discharge disposition, or complications from the index admission. The most common reasons for readmission were surgical site infections (17.0%), infectious complications (11.0%), venous thromboembolism (10.0%), and seizures (9.4%). The 30-d mortality rate was 3.2% (n = 367), of which the majority (69.7%, n = 223) occurred postdischarge. Independent predictors of postdischarge mortality were greater age, metastatic histology, dependent functional status, hypertension, discharge to institutional care, and postdischarge neurological or cardiopulmonary complications (all P &lt; .05). CONCLUSION: Readmissions were common after cranial tumor resection and often attributable to new postdischarge complications rather than exacerbations of complications from the initial hospitalization. Moreover, the majority of 30-d deaths occurred after discharge from the index hospitalization. The preponderance of postdischarge mortality and complications requiring readmission highlights the importance of posthospitalization management.

Obstetric Anesthesia Work Force Survey, 1981 versus 1992 

1997 ◽  
Vol 87 (1) ◽  
pp. 135-143 ◽  
Author(s):  
Joy L. Hawkins ◽  
Charles P. Gibbs ◽  
Miriam Orleans ◽  
Gallice Martin-Salvaj ◽  
Brenda Beaty
Keyword(s):  
Cesarean Section ◽  
Epidural Analgesia ◽  
General Anesthesia ◽  
Obstetric Anesthesia ◽  
The United States ◽  
Nurse Anesthetists ◽  
Regional Analgesia ◽  
American Hospital ◽  
American Society ◽  
American Society Of Anesthesiologists

Background In 1981, with support from the American Society of Anesthesiologists and the American College of Obstetricians and Gynecologists, anesthesia and obstetric providers were surveyed to identify the personnel and methods used to provide obstetric anesthesia in the United States. The survey was expanded and repeated in 1992 with support from the same organizations. Methods Comments and questions from the American Society of Anesthesiologists Committee on Obstetrical Anesthesia and the American College of Obstetricians and Gynecologists Committee on Obstetric Practice were added to the original survey instrument to include newer issues while allowing comparison with data from 1981. Using the American Hospital Association registry of hospitals, hospitals were differentiated by number of births per year (stratum I, &gt; or = 1,500 births; stratum II, 500-1,499 births; stratum III, &lt; 500 births) and by U.S. census region. A stratified random sample of hospitals was selected. Two copies of the survey were sent to the administrator of each hospital, one for the chief of obstetrics and one for the chief of anesthesiology. Results Compared with 1981 data, there was an overall reduction in the number of hospitals providing obstetric care (from 4,163 to 3,545), with the decrease occurring in the smallest units (56% of stratum III hospitals in 1981 compared with 45% in 1992). More women received some type of labor analgesia and there was a 100% increase in the use of epidural analgesia. However, regional analgesia was unavailable in 20% of the smallest hospitals. Spinal analgesia for labor was used in 4% of parturients. In 1981, obstetricians provided 30% of epidural analgesia for labor; they provided only 2% in 1992. Regional anesthesia was used for 78-85% (depending on strata) of patients undergoing cesarean section, resulting in a marked decrease in the use of general anesthesia. Anesthesia for cesarean section was provided by nurse anesthetists without the medical direction of an anesthesiologist in only 4% of stratum I hospitals but in 59% of stratum III hospitals. Anesthesia personnel provided neonatal resuscitation in 10% of cesarean deliveries compared with 23% in 1981. Conclusions Compared with 1981, analgesia is more often used by parturients during labor, and general anesthesia is used less often in patients having cesarean section deliveries. In the smallest hospitals, regional analgesia for labor is still unavailable to many parturients, and more than one half of anesthetics for cesarean section are provided by nurse anesthetists without medical direction by an anesthesiologist. Obstetricians are less likely to personally provide epidural analgesia for their patients. Anesthesia personnel are less involved in newborn resuscitation.

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