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Assessing Quality in Acute Care Surgery

Assessing Quality in Acute Care Surgery

Emergency and trauma surgeries are increasingly being performed by the same providers, often using the same resources. It has been implied that improvements in care for one of these populations could enhance the care of the other, but few analyses have compared the quality of care provided to each type of surgery group. New Research In the Archives of Surgery, my colleagues and I had a study published that evaluated the relationship between trauma and elective general surgery (ELGS) and emergency general surgery (EMGS) care. Our hypothesis was that there would be similarities in mortality and serious morbidity outcomes because of the crossover in providers and resources used. We compared performance among 46 hospitals to determine how well these institutions performed across populations with regard to outcomes. Our findings indicated that there were no significant relationships between trauma and EMGS mortality or between trauma and ELGS mortality. We also didn’t observe any significant relationships between trauma and EMGS morbidity or between trauma and ELGS morbidity. Furthermore, no hospital had consistently good or poor outcomes across the surgical populations assessed in the analysis. Examining Implications Based on our findings, research and quality improvement efforts should focus on how to improve EMGS care. Many performance improvement measures have been devoted to trauma surgery, but few have focused on EMGS patients. The National Trauma Databank contains records on more than 2 million patients. The American College of Surgeons has established the Trauma Quality Improvement Program for benchmarking trauma centers. Similar data banks and benchmarking efforts that focus on quality of care provided to EMGS patients are in the early stages of development...
Examining a Protocol for Transfusing Plasma to Severely Injured Patients

Examining a Protocol for Transfusing Plasma to Severely Injured Patients

Patients with a trauma-induced coagulopathy account for more than half of hemorrhagic deaths in the United States. About 25% of severely injured patients are already coagulopathic and thrombocytopenic upon arrival to trauma centers. Mortality rates have been shown to decrease in these patients when they receive higher ratios of plasma and platelets. “Early transfusion of red blood cells (RBCs) has been established as a core element of trauma resuscitation,” says Bryan A. Cotton, MD, MPH. “Most trauma centers store RBCs in their EDs, but few store plasma in their EDs. This makes it challenging to achieve high plasma-RBC ratios early during care, which in turn can worsen coagulopathy and increase patient mortality.” Expediting Plasma Delivery Over the past several years, more and more trauma centers have implemented massive transfusion (MT) protocols to ensure that severely injured patients receive higher plasma-RBC ratios early. “This was shown to markedly reduce the time to release of plasma, but the time to transfusion was still excessively long,” Dr. Cotton says. In an effort to expedite the delivery of plasma for patients requiring MT, some medical centers began keeping thawed plasma (TP) in their blood banks (BBs).   MT protocols vary throughout trauma centers in the U.S., but those reporting the most marked changes in survival are the ones that have implemented concurrent TP programs. Furthermore, trauma centers that develop TP programs concurrent with MT protocols have shown that they can reduce the time to first plasma transfusion and the overall number of blood components transfused. Testing a New Thawed Plasma Protocol In 2006, Dr. Cotton and colleagues began a TP program in their...
Wide Variation in Blood Transfusion Use

Wide Variation in Blood Transfusion Use

Current clinical guidelines from three medical societies suggest that the hemoglobin threshold for blood transfusions during surgery should be 7 g/dl or 8 g/dl. These guidelines also note that patients don’t need a transfusion when hemoglobin levels are above 10 g/dl. However, when hemoglobin levels fall between these thresholds, there is little consensus on the best course of action. Although four landmark studies published over the past 5 years suggest that it’s safe to wait until hemoglobin levels fall to 7 g/dl or 8 g/dl before transfusing, wide variation and excessive use of blood transfusions have been reported. Advances in viral testing in recent years have made blood transfusion safer, but risks still exist for these patients, including lung injury, immune suppression, and viral transmission. Blood is also in scarce supply and expensive. Wide Variation of Hemoglobin Thresholds In an issue of Anesthesiology, my colleagues and I had a study published that sought to confirm the wide range of hemoglobin thresholds used by surgeons and anesthesiologists. Over 18 months, we collected data on more than 48,000 surgical patients at Johns Hopkins Hospital. Within the institution, there was a variation of up to 3 g/dl in hemoglobin thresholds among surgeons and anesthesiologists, when compared with their peers. Virtually all providers used thresholds above the ones recommended in guidelines, and none used thresholds below the recommended range. Surprisingly, sicker patients—generally those under-going cardiac surgeries—had the lowest hemoglobin thresholds, whereas those undergoing surgery for pancreatic cancer, orthopedic issues, and aortic aneurysms received blood transfusions at higher thresholds. The amount of blood transfused did not correlate with how sick the patients were or...
Assessing the Estimation of Blood Loss

Assessing the Estimation of Blood Loss

In EDs throughout the United States, emergency physicians commonly estimate blood loss as part of ongoing evaluation of patients or during procedures. In many scenarios, there may not be other useful indicators of significant blood loss. For example, hematocrit levels are often a poor indicator of acute blood loss. Furthermore, vital signs can remain normal despite large losses, and patients’ own estimates are often not trusted. Accurate blood loss estimates are obviously important if this information is used during the clinical decision-making process. They also help physicians create a complete picture of the severity of the problems patients are experiencing. Unfortunately, previous studies have demonstrated that trauma surgeons, nurses, paramedics, obstetricians, and general surgeons often have difficulties with estimating blood loss accurately. Examining New Data In the Western Journal of Emergency Medicine, a study examined the accuracy of ED physicians in estimating blood loss on different surfaces. In it, 56 ED physicians—consisting of 30 attending physicians and 26 residents—were asked to estimate the amount of moulage blood that was present in four scenarios: 1)     500 mL spilled onto an ED cot. 2)     25 mL spilled onto a 10-pack of 4×4-inch gauze. 3)     100 mL on a T-shirt. 4)     150 mL in a commode filled with water.  In the study, only 8% of blood loss estimates fell within 20% of the true value. On average, estimates were more than 100% off from the actual amounts. Estimates were most accurate for the cot scenario and least accurate for the commode scenario. Residents and attending physicians performed about the same in the scenarios assessed. Overall, the analysis adds evidence that ED physicians—like...

The Pros & Cons of Robotic Bladder Cancer Surgery

Robotic-assisted surgical removal of the bladder is becoming increasingly popular for treating bladder cancer, despite being more expensive than traditional surgery. Benefits of the robotic approach include smaller incisions and less blood loss for patients. In addition, surgeons have a better three-dimensional view and more freedom of wrist movement when compared with conventional laparoscopy. The procedure eliminates hand tremors, making tasks like suturing easier. However, robotic surgery for this patient group is fairly new. We’re only now beginning to gather larger, more comprehensive studies comparing outcomes of traditional open surgeries with robot-assisted procedures. [polldaddy poll=7559190] A New Analysis: Robotic Surgery In the March 30, 2012 issue of European Urology, my colleagues and I had a study  published that compared perioperative outcomes and costs of open robot-assisted laparoscopic radical cystectomy. Previous comparisons have been limited to reports from high-volume referral centers and have not made direct comparisons with regard to inpatient morbidity and mortality, lengths of stay, and costs. Using a national database of in-patient information from 1,050 hospitals in 44 states, our research team examined 1,444 traditional open surgeries and 224 robotic-assisted laparoscopic procedures in 2009. Robotic surgery for bladder cancer resulted in fewer deaths during hospitalization (0% vs 2.5%) and fewer in-patient complications (49.1% vs 63.8%) when compared with open surgery. It also reduced the need for intravenous nutrition after the procedure (6.4% vs 13.3%). Patients who underwent both types of surgery spent about 8 days in the hospital. Costs of Robot-Assisted Cystectomy The costs for robot-assisted laparoscopic radical cystectomy were significantly higher, amounting to nearly $3,800 more than traditional open surgery. This may be due to longer...
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