scholarly journals Variation in Hospital Length of Stay Based on Hospital Volume: A Retrospective Cohort Study of Emergency Abdominal Surgery in Ireland

2019 ◽  
pp. 1-6
Author(s):  
Jan Sorensen ◽  
Dara Kavanagh ◽  
Deirdre Nally ◽  
Gintare Valentelyte ◽  
Jan Sorensen ◽  
...  
Keyword(s):  
Sensitivity Analysis ◽  
Length Of Stay ◽  
Abdominal Surgery ◽  
Hospital Volume ◽  
High Volume ◽  
Hospital Length ◽  
Public Hospitals ◽  
Hospital Length Of Stay ◽  
Low Volume ◽  
Emergency Abdominal Surgery

Objectives: Emergency abdominal surgery (EAS) refers to high risk intra-abdominal surgical procedures associated with increased mortality risk and long length of hospital stay. The variation between hospital volume and hospital length of stay (LOS) of patients undergoing EAS is poorly understood. Our objective was to explore this relationship across public hospitals in Ireland. Methods: Data for all adult episode discharges from public Irish hospitals in 2014-2017 were obtained from National Quality Assurance Improvement System (NQAIS) Clinical with EAS identified by primary procedure codes. Hospitals were categorised into low (n<200), medium (n=200-400), and high (n>400) volume groups based on the number of EAS episodes during the study period. Negative binomial regression models were applied to standardise for patient case mix. Several adjusted LOS measures were compared across the three volume groups. Sensitivity analysis was conducted to test the robustness of our findings. Results: 8120 hospital episodes across 24 public hospitals providing EAS services were analysed. 7 were categorised as low, 9 as medium, and 8 as high-volume hospitals. High volume hospitals had a significantly longer adjusted LOS (24.7 days) relative to low and medium volume hospitals (18.2 and 18.6 days). Sensitivity analysis consisted of the exclusion of the following hospital episodes: in-hospital death, cancer diagnosis, Charlson comorbidity index (CCI) >0, admission from other hospitals, and discharge to other hospitals. No single variable influenced the observed LOS variation, although when the more complex episodes were excluded, the post-operative LOS at low and medium volume hospitals was significantly shorter compared to high volume hospitals (by 1.1-6.1 days). Intensive care unit (ICU) LOS was similar in all three hospital volume groups although low volume hospitals appeared to have more ICU admissions and longer stay (by up to 1.6 days). Conclusions: Our findings indicate that patients treated at low volume hospitals have shorter LOS and may be discharged earlier than from high volume hospitals. This finding is surprising, suggesting that concentration of services to larger clinical departments may not necessarily reduce LOS and improve the efficiency of resource utilisation and service delivery.

scholarly journals Abdominal emergency surgery in patients over 90 years old: is it worthwhile? An Italian multicenter retrospective study

2016 ◽  
Author(s):  
Antonio Tarasconi ◽  
Fausto Catena ◽  
Hariscine K. Abongwa ◽  
Belinda De Simone ◽  
Federico Coccolini ◽  
...  
Keyword(s):  
Survival Rate ◽  
Length Of Stay ◽  
Abdominal Surgery ◽  
Surgical Procedures ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Asa Score ◽  
Abdominal Emergency ◽  
Emergency Abdominal Surgery

Unlike other surgical fields, such as cardiac surgery, where many trials have been made about safety, feasibility and outcome of surgical procedures in the elderly, there is lack of literature about emergency abdominal surgery in very old patients, especially in people over 90 years of age. The available data reported survival of about 50% one year after the operation. The aim of the study is to determine the survival rate two years after emergency abdominal surgery in a nonagenarian population and to identify any demographic and surgical parameters that could predict a poor outcome in this type of patient. The study was a retrospective multicenter trial. Patient inclusion criteria were: age 90 years old or older, urgent abdominal surgery. The medical charts reviewed and data collected were: gender, age, the American Society of Anesthesiologists (ASA) score and comorbidities, diagnosis, time elapsed between arrival to the Emergency Room and admission to the Operatory Room, surgical procedures, open versus laparoscopic procedure, type of anesthesia and outcomes with hospital length of stay. Phone call follow-up was performed for patient discharged alive and Kaplan-Meier analysis was used to evaluate survival. We identified 72 (20 males and 52 females) nonagenarian patients who underwent abdominal emergency surgery at 6 Italian hospitals (Parma, Bergamo, Bologna, Brescia, Chiari, Adria). Mean age was 92.5 years [range 90-100, standard deviation (SD) 2.6], median ASA score was 3 (range 2-5, mean 3.32) and only 7 patients were without comorbidities. Mean hospital length of stay was 13 days (range 1-60, SD 11.52); 56 patients (77.7%) were discharged alive; 2 years survival rate was 23% [mean follow-up=10 months (range 1-27)]. Among all the parameters analyzed, only ASA score was significantly correlated with survival. Neither the presence of malignancy nor the absence of comorbidities seems to correlate with survival. Nonagenarian patients undergoing emergent abdominal surgical procedures have a high overall in-hospital mortality rate (23%) and a low 2 years survival rate (51.4%). Except for ASA score, there are no other factors predicting poor outcome. Based on the present study emergency abdominal surgery in frail patients over 90 years of age has to be carefully evaluated: only 1 out 5 patients will be alive after 2 years.

Placement of Surgical Feeding Tubes Among Patients With Severe Traumatic Brain Injury Requiring Exploratory Abdominal Surgery

2020 ◽  
Vol 86 (6) ◽  
pp. 635-642
Author(s):  
Peter I. Cha ◽  
Ronald M. Jou ◽  
David A. Spain ◽  
Joseph D. Forrester
Keyword(s):  
Length Of Stay ◽  
Abdominal Surgery ◽  
Injury Severity ◽  
Unit Length ◽  
Feeding Tube ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Fascial Closure ◽  
Trauma Patients ◽  
Percutaneous Endoscopic Gastrostomy Placement

Objectives The purpose of this study was to identify trauma patients who would benefit from surgical placement of an enteral feeding tube during their index abdominal trauma operation. Methods We performed a retrospective analysis of all patients admitted to 2 level I trauma centers between January 2013 and February 2018 requiring urgent exploratory abdominal surgery. Results Six-hundred and one patients required exploratory abdominal surgery within 24 hours of admission after trauma activation. Nineteen (3% of total) patients underwent placement of a feeding tube after their initial exploratory surgery. On multivariate analysis, an intracranial Abbreviated Injury Scale ≥4 (odds ratio [OR] = 9.24, 95% CI 1.09-78.26, P = .04) and a Glasgow Coma Scale ≤8 (OR = 4.39, 95% CI 1.38-13.95, P = .01) were associated with increased odds of requiring a feeding tube. All patients who required a feeding tube had an Injury Severity Score ≥15. While not statistically significant, patients with an open surgical feeding tube compared with interventional radiology/percutaneous endoscopic gastrostomy placement had lower median intensive care unit length of stay, fewer ventilator days, and shorter median total hospital length of stay. Conclusions Trauma patients with severe intracranial injury already requiring urgent exploratory abdominal surgery may benefit from early, concomitant placement of a feeding tube during the index abdominal operation, or at fascial closure.

scholarly journals 1247. Multicenter Study on Risk Factors for Surgical Site Infection After Exploratory Laparotomy

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S449-S449
Author(s):  
Túlio Alves Jeangregório Rodrigues ◽  
Guilherme Fernandes de Oliveira ◽  
Júlia G C Dias ◽  
Laís Souza Campos ◽  
Letícia Rodrigues ◽  
...  
Keyword(s):  
Risk Factors ◽  
Length Of Stay ◽  
Abdominal Surgery ◽  
Surgical Site Infection ◽  
Exploratory Laparotomy ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Hospital Death ◽  
Site Infection ◽  
The Impact

Abstract Background Exploratory laparotomy surgery is abdominal operations not involving the gastrointestinal tract or biliary system. The objective of our study is to answer three questions: (a) What is the risk of surgical site infection (SSI) after exploratory abdominal surgery? (b) What is the impact of SSI in the hospital length of stay and hospital mortality? (c) What are risk factors for SSI after exploratory abdominal surgery? Methods A retrospective cohort study assessed meningitis and risk factors in patients undergoing exploratory laparotomy between January 2013 and December 2017 from 12 hospitals at Belo Horizonte, Brazil. Data were gathered by standardized methods defined by the National Healthcare Safety Network (NHSN)/CDC procedure-associated protocols for routine SSI surveillance. 26 preoperative and operative categorical and continuous variables were evaluated by univariate and multivariate analysis (logistic regression). Outcome variables: Surgical site infection (SSI), hospital death, hospital length of stay. Variables were analyzed using Epi Info and applying statistical two-tailed test hypothesis with significance level of 5%. Results A sample of 6,591 patients submitted to exploratory laparotomy was analyzed (SSI risk = 4.3%): Hospital length of stay in noninfected patients (days): mean = 16, median = 6, std. dev. = 30; hospital stay in infected patients: mean = 32, median = 22, std. dev. = 30 (P < 0.001). The mortality rate in patients without infection was 14% while hospital death of infected patients was 20% (P = 0.009). Main risk factors for SSI: ügeneral anesthesia (SSI = 4.9%, relative risk – RR = 2.8, P < 0.001); preoperative hospital length of stay more than 4 days (SSI=3.9%, RR=1.8, P = 0.003); wound class contaminated or dirty (SSI = 5.4%, RR = 1.5, P = 0.002); duration of procedure higher than 3 hours (SSI = 7.1%, RR = 2.1, P < 0.001); after trauma laparotomy (SSI = 7.8%, RR = 1.9, P = 0.001). Conclusion We identified patients at high risk of surgical site infection after exploratory laparotomy: trauma patients from contaminated or dirty wound surgery, submitted to a procedure with general anesthesia that last more than 3 hours have 13% SSI. Patients without any of these four risk factors have only 1.2% SSI. Disclosures All authors: No reported disclosures.

Evaluation of the impact of implementation of a Medical Assessment and Planning Unit on length of stay

2010 ◽  
Vol 34 (3) ◽  
pp. 334 ◽  
Author(s):  
Caroline A. Brand ◽  
Marcus P. Kennedy ◽  
Bellinda L. King-Kallimanis ◽  
Ged Williams ◽  
Christopher A. Bain ◽  
...  
Keyword(s):  
Emergency Department ◽  
Length Of Stay ◽  
Models Of Care ◽  
Hospital Length ◽  
Public Hospitals ◽  
Hospital Length Of Stay ◽  
Medical Patients ◽  
Medical Assessment ◽  
Planning Unit ◽  
The Impact

Objective.The Medical Assessment and Planning Unit (MAPU) model provides a multidisciplinary and ‘front end loading’ approach to acute medical care. The objective of this study was to evaluate the impact of a 10-bed MAPU in Royal Melbourne Hospital (RMH) on hospital length of stay. Methods.A pre-post study design was used. Cases were defined as all general medical patients admitted to the RMH between 1 August 2003 and 31 January 2004. MAPU patients were defined as general medical patients who had been discharged from RMH MAPU unit as part of their RMH inpatient admission. Historical controls were defined as all general medical patients admitted to the RMH between 1 August 2002 and 31 January 2003. Results.There was a reduction in median length of stay that did not reach statistical significance. During the study period, median emergency department length of stay for MAPU patients was 10.3 h compared with 13.2 h for non-MAPU patients who were admitted directly to general wards. Conclusions.The reductions in length of stay are likely to be of clinical significance at the emergency department (ED) level. The MAPU model also contributes to providing care appropriate care for older admitted patients. What is known about the topic?There is increasing interest in models of acute medical management in public hospitals in Australia. One of the key factors driving interest in these models has been the need to improve patient flow to improve hospital efficiency and contribute to reducing bed access block. There are very little published data pertaining to the effectiveness of these models of care. What does the paper add?The paper reports non-statistical, but probably important clinical reductions in hospital and ED length of stay using a before and after cohort analysis. It highlights the difficulties evaluating these models of care in the absence of well designed controlled studies and suggests evaluation of length of stay needs to be powered to detect small changes in ED efficiency rather than overall hospital length of stay. What are the implications for practitioners?Practitioners in the area can draw on the results of this paper to design an acute medical planning unit and develop an evaluation framework.

scholarly journals Volume and in-hospital mortality after emergency abdominal surgery: a national population-based study

BMJ Open ◽  
2019 ◽  
Vol 9 (11) ◽  
pp. e032183 ◽  
Author(s):  
Deirdre M Nally ◽  
Jan Sørensen ◽  
Gintare Valentelyte ◽  
Laura Hammond ◽  
Deborah McNamara ◽  
...  
Keyword(s):  
Mortality Rate ◽  
Abdominal Surgery ◽  
Hospital Mortality ◽  
High Volume ◽  
Population Based ◽  
Publicly Funded ◽  
Population Based Study ◽  
Low Volume ◽  
Surgical Teams ◽  
Emergency Abdominal Surgery

​ObjectivesEmergency abdominal surgery (EAS) refers to high-risk intra-abdominal surgical procedures undertaken for acute gastrointestinal pathology. The relationship between hospital or surgeon volume and mortality of patients undergoing EAS is poorly understood. This study examined this relationship at the national level.​DesignThis is a national population-based study using a full administrative inpatient dataset (National Quality Assurance Improvement System) from publicly funded hospitals in Ireland.​Setting24 public hospitals providing EAS services.​Participants and InterventionsPatients undergoing EAS as identified by primary procedure codes during the period 2014–2018.​Main outcome measuresThe main outcome measure was adjusted in-hospital mortality following EAS in publicly funded Irish hospitals. Mortality rates were adjusted for sex, age, admission source, Charlson Comorbidity Index, procedure complexity, organ system and primary diagnosis. Differences in overall, 7-day and 30-day in-hospital mortality for hospitals with low (<250), medium (250–449) and high (450+) volume and surgical teams with low (<30), medium (30–59) and high (60+) volume during the study period were also estimated.​ResultsThe study included 10 344 EAS episodes. 798 in-hospital deaths occurred, giving an overall in-hospital mortality rate of 77 per 1000 episodes. There was no statistically significant difference in adjusted mortality rate between low and high volume hospitals. Low volume surgical teams had a higher adjusted mortality rate (85.4 deaths/1000 episodes) compared with high volume teams (54.7 deaths/1000 episodes), a difference that persisted among low volume surgeons practising in high volume hospitals.​ConclusionPatients undergoing EAS managed by high volume surgeons have better survival outcomes. These findings contribute to the ongoing discussion regarding configuration of emergency surgery services and emphasise the need for effective clinical governance regarding observed variation in outcomes within and between institutions.

High-Volume Hospitals with High-Volume and Low-Volume Surgeons: Is There a “Field Effect” for Pancreaticoduodenectomy?

2016 ◽  
Vol 82 (5) ◽  
pp. 407-411 ◽  
Author(s):  
Thomas W. Wood ◽  
Sharona B. Ross ◽  
Ty A. Bowman ◽  
Amanda Smart ◽  
Carrie E. Ryan ◽  
...  
Keyword(s):  
Hospital Mortality ◽  
Field Effect ◽  
Hospital Volume ◽  
Patient Discharge ◽  
High Volume ◽  
Surgeon Volume ◽  
Hospital Charges ◽  
Leapfrog Group ◽  
Discharge Status ◽  
Low Volume

Since the Leapfrog Group established hospital volume criteria for pancreaticoduodenectomy (PD), the importance of surgeon volume versus hospital volume in obtaining superior outcomes has been debated. This study was undertaken to determine whether low-volume surgeons attain the same outcomes after PD as high-volume surgeons at high-volume hospitals. PDs undertaken from 2010 to 2012 were obtained from the Florida Agency for Health Care Administration. High-volume hospitals were identified. Surgeon volumes within were determined; postoperative length of stay (LOS), in-hospital mortality, discharge status, and hospital charges were examined relative to surgeon volume. Six high-volume hospitals were identified. Each hospital had at least one surgeon undertaking ≥ 12 PDs per year and at least one surgeon undertaking < 12 PDs per year. Within these six hospitals, there were 10 “high-volume” surgeons undertaking 714 PDs over the three-year period (average of 24 PDs per surgeon per year), and 33 “low-volume” surgeons undertaking 225 PDs over the three-year period (average of two PDs per surgeon per year). For all surgeons, the frequency with which surgeons undertook PD did not predict LOS, in-hospital mortality, discharge status, or hospital charges. At the six high-volume hospitals examined from 2010 to 2012, low-volume surgeons undertaking PD did not have different patient outcomes from their high-volume counterparts with respect to patient LOS, in-hospital mortality, patient discharge status, or hospital charges. Although the discussion of volume for complex operations has shifted toward surgeon volume, hospital volume must remain part of the discussion as there seems to be a hospital “field effect.”

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