Frailty and In-Hospital Mortality Risk Using EHR Nursing Data

Purpose The purpose of this study was to evaluate four definitions of a Frailty Risk Score (FRS) derived from EHR data that includes combinations of biopsychosocial risk factors using nursing flowsheet data or International Classification of Disease, 10th revision (ICD-10) codes and blood biomarkers and its predictive properties for in-hospital mortality in adults ≥50 years admitted to medical-surgical units. Methods In this retrospective observational study and secondary analysis of an EHR dataset, survival analysis and Cox regression models were performed with sociodemographic and clinical covariates. Integrated area under the ROC curve (iAUC) across follow-up time based on Cox modeling was estimated. Results The 46,645 patients averaged 1.5 hospitalizations (SD = 1.1) over the study period and 63.3% were emergent admissions. The average age was 70.4 years (SD = 11.4), 55.3% were female, 73.0% were non-Hispanic White (73.0%), mean comorbidity score was 3.9 (SD = 2.9), 80.5% were taking 1.5 high risk medications, and 42% recorded polypharmacy. The best performing FRS-NF-26-LABS included nursing flowsheet data and blood biomarkers (Adj. HR = 1.30, 95% CI [1.28, 1.33]), with good accuracy (iAUC = .794); the reduced model with age, sex, and FRS only demonstrated similar accuracy. The poorest performance was the ICD-10 code-based FRS. Conclusion The FRS captures information about the patient that increases risk for in-hospital mortality not accounted for by other factors. Identification of frailty enables providers to enhance various aspects of care, including increased monitoring, applying more intensive, individualized resources, and initiating more informed discussions about treatments and discharge planning.

Patient outcomes and cost savings associated with hospital safe nurse staffing legislation: an observational study

ObjectiveTo evaluate variation in Illinois hospital nurse staffing ratios and to determine whether higher nurse workloads are associated with mortality and length of stay for patients, and cost outcomes for hospitals.DesignCross-sectional analysis of multiple data sources including a 2020 survey of nurses linked to patient outcomes data.Setting: 87 acute care hospitals in Illinois.Participants210 493 Medicare patients, 65 years and older, who were hospitalised in a study hospital. 1391 registered nurses employed in direct patient care on a medical–surgical unit in a study hospital.Main outcome measuresPrimary outcomes were 30-day mortality and length of stay. Deaths avoided and cost savings to hospitals were predicted based on results from regression estimates if hospitals were to have staffed at a 4:1 ratio during the study period. Cost savings were computed from reductions in lengths of stay using cost-to-charge ratios.ResultsPatient-to-nurse staffing ratios on medical-surgical units ranged from 4.2 to 7.6 (mean=5.4; SD=0.7). After adjusting for hospital and patient characteristics, the odds of 30-day mortality for each patient increased by 16% for each additional patient in the average nurse’s workload (95% CI 1.04 to 1.28; p=0.006). The odds of staying in the hospital a day longer at all intervals increased by 5% for each additional patient in the nurse’s workload (95% CI 1.00 to 1.09, p=0.041). If study hospitals staffed at a 4:1 ratio during the 1-year study period, more than 1595 deaths would have been avoided and hospitals would have collectively saved over $117 million.ConclusionsPatient-to-nurse staffing ratios vary considerably across Illinois hospitals. If nurses in Illinois hospital medical–surgical units cared for no more than four patients each, thousands of deaths could be avoided, and patients would experience shorter lengths of stay, resulting in cost-savings for hospitals.

Emergency Surgery Admissions and The COVID-19 Pandemic: Did The First Wave Really Change Our Practice? Results of An ACOI/WSES International Audit On 6263 Patients.

IntroductionThe COVID-19 pandemic is having a deep impact on emergency surgical services, with a significant reduction of patients admitted into emergency surgical units world widely. Reliable figures of this reduction have not been produced yet. Our international audit aimed at giving a precise snapshot of the absolute and relative changes of emergency surgical admissions at the outbreak of the pandemic. Materials and methodsDatasets of patients admitted as general surgical emergencies into 45 internationally distributed emergency surgical units during the months of March and April 2020 (Covid-19 pandemic outbreak) were collected and compared with those of patients admitted into the same units during the months of March and April 2019 (pre-Covid-19). Primary endpoint was to evaluate the relative variation of the presentation symptoms and discharge diagnoses between the two study periods. Secondary endpoint was to identify the possible change of therapeutic strategy during the same two periods. ResultsForty-four centres participated sent their anonymised data to the study hub, for a total of 6263 patients. Of these, 3810 were admitted in the pre-Covid period and 2453 in the Covid period, for a 35.6% absolute reduction. The most common presentation was abdominal pain, whose incidence did not change between the two periods, but in the Covid period patients presented less frequently with anal pain, hernias, anaemia and weight loss. ASA 1 and low frailty patients were admitted less frequently, while ASA>1 and frail patients showed a relative increase. The type of surgical access did not change significantly, but lap-to-open conversion rate halved between the two study periods. Discharge diagnoses of appendicitis and diverticulitis reduced significantly, while bowel ischaemia and perianal ailments had a significant relative increase.ConclusionsOur audit demonstrates a significant overall reduction of emergency surgery admissions at the outbreak of the Covid-19 pandemic with a minimal change of the proportions of single presentations, diagnoses and treatments. These findings may open the door to new ways of managing surgical emergencies without engulfing the already busy hospitals.

Scarf and Akin Osteotomies for Correction of Hallux Abducto Valgus. A Ten-year Retrospective Patient Evaluation From Five Podiatric Surgery Centres Using PASCOM PSQ-10.

BackgroundCorrective surgery for hallux abducto valgus is one of the most commonly performed elective procedures in foot and ankle practice, with over a hundred different surgical solutions having been proposed throughout the literature. The purpose of the study was to identify the clinical and patient reported outcomes following Scarf-Akin osteotomies from five podiatric surgery centres over a ten-year period.MethodThis is a retrospective review from five podiatric surgical units which looked at patients who underwent Scarf osteotomies (in isolation or in combination with Akin procedures) over a ten-year period. Data was collected from the patient satisfaction questionnaires of the PASCOM-10 audit tool, which were completed by the patient six months post operatively, and further analysed using Microsoft Excel spreadsheet software.ResultsA total of 1351 patients were recorded undergoing Scarf (with or without an Akin) osteotomy for hallux abducto valgus, with 1227 females (90.83%) and 124 males (9.17%) identified but with only 1189 who had completed the patient satisfaction questionnaire. 96.8% of patients felt that their foot was either ‘better’ or ‘much better’ following surgery and that their original expectations of surgery had been met. Over 75% of patients had no post-operative sequalae identified, with metatarsal fracture noted to be the highest sequalae at 4.8%.ConclusionFrom the five podiatric surgery units reviewed, Scarf osteotomies (with or without an Akin osteotomy) for hallux abducto valgus correction, have a high level of patient satisfaction with low post-operative sequalae.Level of clinical evidenceIV (retrospective review).

An Overview of Analysis of Learning Curve of Laproscopic Procedures in General Surgery Residents in Khyber Teaching Hospital, Peshawar

Aim: An Overview of Analysis of Learning Curve of Laparoscopic Procedures in General Surgery Residents in Khyber Teaching Hospital, Peshawar. Methodology: A descriptive KAP (knowledge attitude and practice) study was conducted in Khyber teaching hospital (KTH) from January 2021 to March 2021. A total of 24 surgical residents of 3rd and 4th year residency working in different surgical units were part of the study. Experience of residents performing procedures under supervision, assistance or by means of observation was recorded by a self administered questionnaire. Results: A number of 24 surgical residents of 3rd and 4th year residency of general surgery were part of the study. Frequency of 3rd yr residents was 13(54.2%) and that of 4th yr was 11(45.8%). Number of 6(25%) observed basic laparoscopy, 8(33%) advanced procedures and 10(41.7%) observed both types of procedure. 23(95.8%) participants were regularly briefed on principles of laparoscopy and 21(87.5%) strongly agreed upon the need of video simulation sessions. According to 22(91.7%) participants instrument handling was the most difficult part to learn. And 17(70.8%) participants laparoscopy enhances visualization of disease process. 18(75%) participants said that it improves postoperative recovery and 20(83.3%) were of opinion that it minimizes hospital stay. 16(66.7%) residents stated it has a steep learning curve. All participants agreed that it is necessary to assist large number of procedures to attain confidence of performing laparoscopic procedures. Conclusion: The study showed that almost all residents were in favor of the use of laparoscopic procedures rather than open surgeries. Keywords: Laparoscopy, learning curve

In-hospital postoperative opioid use and its trends in neurosurgery between 2007 and 2018

Background Postoperative opioid use plays an important role in the global opioid crisis, but little is known about in-hospital opioid use trends of large surgical units. We investigated whether postoperative in-hospital opioid consumption changed in a large academic neurosurgical unit between 2007 and 2018. Methods We extracted the data of consumed opioids in the neurosurgical intensive care unit and two bed wards between 2007 and 2018. Besides overall consumption, we analyzed the trends for weak (tramadol and codeine), strong, and the most commonly used opioids. The use of various opioids was standardized using the defined daily doses (DDDs) of each opioid agent. A linear regression analysis was performed to estimate annual treatment day-adjusted changes with 95% confidence intervals. Results Overall, 121 361 opioid DDDs were consumed during the 196 199 treatment days. Oxycodone was the most commonly used postoperative opioid (49% of all used opioids) in neurosurgery. In the bed wards, the use of oral oxycodone increased 375% (on average 13% (9–17%) per year), and the use of transdermal buprenorphine 930% (on average 26% (9–45%) per year) over the 12-year period. Despite the increased use of strong opioids in the bed wards (on average 3% (1–4%) per year), overall opioid use decreased 39% (on average 6% (4–7%) per year) between 2007 and 2018. Conclusions Due to the increase of strong opioid use in the surgical bed wards, we encourage other large teaching hospitals and surgical units to investigate whether their opioid use trends are similarly worrisome and whether the opioid consumption changes in the hospital setting are transferred to opioid use patterns or opioid-related harms after discharge.

A study of Microorganisms causing wound infections after Elective laparotomy

Any purulent discharge from a closed surgical incision, after surgery, together with signs of inflammation of the surrounding tissue should be considered as Post operative (post-op) wound infection. There are two types of wounds in elective laparotomy: clean and contaminated wound Objective: To find out most causative microorganism involved in post-op wound infection in elective laparotomy cases at the Children Hospital and The Institute of Child Health Sciences, Lahore Pakistan. Methods: It was a prospective observational study conducted on patients who developed wound infection after elective laparotomy. This study was conducted in the surgical Units I and II of Children Hospital Lahore, Lahore, Pakistan. The duration of the study was 11 months from January 2019 to November 2019. 150 patients were included in this study. Data was collected by convenient sampling technique. It was a hospital-based study in which patients from both genders were included. Data was obtained by a questionnaire. Patients were asked for wound condition and surgery details were taken to find out the reasons of wound infection. The data selected was analyzed using SPSS version 21.0. Results: Out of total 150 patients who underwent elective laparotomy, 40% patients were identified with Escherichia Coli, 13.3% patients identified with Pseudomonas species, 13.3% patients had klebsiella, 6.7% patients had Pseudomonas Florescence, 6.7% people had Acinetobacter, 6.7% had Staphylococcus aureus, 13.3% did not show any growth. Conclusions: It was concluded that most abundant microorganism isolated from patients who underwent elective laparotomy was Escherichia coli. The most common reasons for wound infection were increase in number of surgeons and increase in duration of illness.