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Pamela A Lipsett

Publications and source records attributed to Pamela A Lipsett.

At least 19 recordsLinked to original sources
PubMed2006

The association between anatomic site of Candida colonization, invasive candidiasis, and mortality in critically ill surgical patients.

We evaluated whether the likelihood of developing invasive candidiasis (IC) differed depending upon the anatomic site of Candida colonization in 182 surgical intensive care unit (SICU) patients who participated in a randomized trial of fluconazole to prevent candidiasis. We also determined the impact of Candida colonization of different anatomic sites on all-cause SICU and hospital mortality. A total of 2851 surveillance fungal cultures collected from 5 anatomic sites were analyzed. There was a statistically significant difference in the frequency of IC comparing patients with and without urinary (13.2% versus 2.8%, P = .02), respiratory (8.0% versus 1.2%, P = .04), and rectum/ostomy (8.4% versus 0%, P = .01) colonization. Patients with negative rectum/ostomy cultures and patients with both negative urine and respiratory tract cultures did not develop IC. Candiduria detected at any time in the SICU was independently associated with SICU mortality (odds ratio, 2.86; 95% confidence interval, 1.05-7.74). Surveillance fungal cultures of particular anatomic sites may help differentiate patients at higher risk of developing IC from those at low risk.

APACHE↗
PubMed2006

Biliary cystic disease.

Biliary cystic disease, though uncommon, can present at a wide range of ages with a wide range of symptoms. Choledochal cysts are associated with the development of both cholangiocarcinoma and gallbladder cancer. Thus, most biliary cystic disease is best managed operatively. Many factors should be considered when performing surgery on patients with choledochal cysts, including age, presenting symptoms, cyst type, associated biliary stones, prior biliary surgery, intrahepatic strictures, hepatic atrophy/hypertrophy, biliary cirrhosis, portal hypertension, and associated biliary malignancy. When feasible, surgical treatment should consist of cholecystectomy and complete surgical excision of extrahepatic cysts with Roux-en-Y reconstruction. Because the risk of recurrent cholangitis is significant and additional symptoms and problems are common, the use of long-term soft Silastic biliary stents (Dow Corning Corp., Midland, MI) should be considered when complex intrahepatic and extrahepatic cystic disease is present. Alternatively, the Roux-en-Y jejunal limb can be marked at the fascia for future percutaneous access. Reconstruction via hepaticoduodenostomy and jejunal interposition has been associated with increased postoperative pain due to bile reflux gastritis. Thus, hepaticojejunostomy reconstruction is recommended. For choledochal cysts involving the distal bile duct, the bile duct should be excised at the intrapancreatic portion. Resection of the pancreatic head should be reserved for patients with established malignancies. Surgical excision of the intrahepatic portion of the bile duct should be individualized to include preservation of hepatic parenchyma when the liver is not cirrhotic. If cirrhosis is advanced, hepatic transplantation may be indicated, but this is rare. Oncologic principles should be followed in the presence of a malignancy. Lifelong follow-up is required because of the possibility of a "field" defect increasing susceptibility to cancer throughout the biliary tract epithelium.

Journal Article↗
PubMed2006

The importance of insulin administration in the critical care unit.

In the last decade investigation into the importance of glucose control and insulin administration in a wide variety of clinical settings has occurred. In virtually all studies, whether of cardiac ischemia or bypass surgery, cerebrovascular recovery from ischemia or head injury, or surgical critical illness, intensive insulin therapy with tight glucose control has resulted in improved clinical outcomes by decreasing both morbidity and mortality. The fundamental biochemical mechanisms for these findings are increasingly well understood and explain the apparent far-reaching beneficial effects of this therapy. In the future, it is likely that all hospitalized surgical patients will have tight glucose control.

Animals↗
PubMed2006

Can the clinical pulmonary infection score impact ICU antibiotic days?

BACKGROUND: The Clinical Pulmonary Infection Score (CPIS) has been used in the intensive care unit (ICU) as a decision tool for initiation of antibiotics in suspected pneumonia and also for discontinuing antibiotics if the CPIS score is 6 on day one receiving antibiotics empirically for pneumonia. METHODS: Over 11 months, we evaluated empiric antibiotics prospectively in two ICUs of a large tertiary university teaching hospital. A pneumonia committee (PC) reviewed all patients and defined pneumonia according to the guidelines of the U.S. Centers for Disease Control and Prevention (CDC). The CPIS was calculated for all patients at day one and day three of antibiotic therapy. The percentage of patients with a CPIS 6 (823 antibiotic-days). In contrast, the PC determined 19 patients (23%) to have pneumonia by the CDC definition (731 antibiotic-days), with eight of these patients having a CPIS 6. Pneumonia committee review resulted in fewer patients believed to have pneumonia and a greater percentage with a CPIS>6 (odds ratio [OR] 2.7; 95% confidence interval [CI] 0.86, 8.6; p=0.05). Restriction of antibiotics to patients with a CPIS>6 would have saved 1,460 antibiotic-days at day one and 1,053 days if treatment was delayed until day three. Clinical Pulmonary Infection Score ROC curves for the PC showed an area under the curve (AUC) of 0.82 (95% CI 0.72, 0.91), whereas the AUC for the ICU group was 0.85 (95% CI 0.79, 0.92). The sensitivity and specificity of a CPIS>6 for the PC were 79% and 75%, respectively, with correct prediction 76% of the time. The inter-observer reliability of the CPIS had a kappa value of 0.88. CONCLUSIONS: This prospective evaluation confirms that 50% of antibiotic-days in our ICU are used empirically for pneumonia when that infection is not likely to be present by either CDC or CPIS criteria. Although the CPIS has good reliability and acceptable sensitivity and specificity, PC review and CPIS<or=6 were commonly divergent (42-47%). Thus, better strategies should be developed for identification of pneumonia and empiric antibiotic administration in the ICU.

Adolescent↗
PubMed2006

Surgical critical care: fungal infections in surgical patients.

OBJECTIVE: To review the epidemiology, risk factors, diagnosis, treatment, and prevention of Candida infections in surgical intensive care unit patients. DESIGN: : Selected review of the literature. SETTING: Critically ill patients either in an intensive care unit or having undergone a major surgical procedure. INTERVENTIONS: None. MAIN RESULTS: Candida infections are the third most common cause of bloodstream infection in the intensive care unit, with increasing numbers of infections due to nonalbicans species. The diagnosis of an invasive fungal infection is difficult, and the risk factors must be recognized and minimized. There is no general consensus about what signs, symptoms, and cultures define a fungal infection. A new 1,3 beta-glucan blood test may assist is the definition of invasive fungal infection. Treatment of fungal infections is now possible with a variety of antifungal agents, with different spectrums of activity, mechanisms of action, and adverse events. Prevention (prophylaxis) is a reasonable strategy in highly selected patients with a significant risk of fungal infection. CONCLUSION: New antifungal agents and diagnostic tests may improve the outcome of surgical intensive care unit patients with invasive fungal infections. However, agreement about definitions of fungal infection makes study and conclusions of prevention and treatment trials difficult to interpret.

Antifungal Agents↗
PubMed2005

Effect of a second-generation venous catheter impregnated with chlorhexidine and silver sulfadiazine on central catheter-related infections: a randomized, controlled trial.

BACKGROUND: Central venous catheter-related infections are a significant medical problem. Improved preventive measures are needed. OBJECTIVE: To ascertain 1) effectiveness of a second-generation antiseptic-coated catheter in the prevention of microbial colonization and infection; 2) safety and tolerability of this device; 3) microbiology of infected catheters; and 4) propensity for the development of antiseptic resistance. DESIGN: Multicenter, randomized, double-blind, controlled trial. SETTING: 9 university-affiliated medical centers. PATIENTS: 780 patients in intensive care units who required central venous catheterization. INTERVENTION: Patients received either a standard catheter or a catheter coated with chlorhexidine and silver sulfadiazine. MEASUREMENTS: The authors assessed catheter colonization and catheter-related infection, characterized microbes by molecular typing, and determined their susceptibility to antiseptics. Patient tolerance of the catheter was monitored. RESULTS: Patients with the 2 types of catheters had similar demographic features, clinical interventions, laboratory values, and risk factors for infection. Antiseptic catheters were less likely to be colonized at the time of removal compared with control catheters (13.3 vs. 24.1 colonized catheters per 1000 catheter-days; P < 0.01). The center-stratified Cox regression hazard ratio for colonization controlling for sampling design and potentially confounding variables was 0.45 (95% CI, 0.25 to 0.78). The rate of definitive catheter-related bloodstream infection was 1.24 per 1000 catheter-days (CI, 0.26 to 3.62 per 1000 catheter-days) for the control group versus 0.42 per 1000 catheter-days (CI, 0.01 to 2.34 per 1000 catheter-days) for the antiseptic catheter group (P = 0.6). Coagulase-negative staphylococci and other gram-positive organisms were the most frequent microbes to colonize catheters. Noninfectious adverse events were similar in both groups. Antiseptic susceptibility was similar for microbes recovered from either group. LIMITATIONS: The antiseptic catheter was not compared with an antibiotic-coated catheter, and no conclusion can be made regarding its effect on bloodstream infection. CONCLUSIONS: The second-generation chlorhexidine-silver sulfadiazine catheter is well tolerated. Antiseptic coating appears to reduce microbial colonization of the catheter compared with an uncoated catheter.

Aged↗
PubMed2005

Number needed to treat and cost of recombinant human erythropoietin to avoid one transfusion-related adverse event in critically ill patients.

OBJECTIVE: To calculate the absolute risk reduction of transfusion-related adverse events, the number of patients needed to treat, and cost to avoid one transfusion-related adverse event by using erythropoietin in critically ill patients DESIGN: Number needed to treat with sensitivity analysis. SETTING: Teaching hospital. PATIENTS: Hypothetical cohort of critically ill patients who were candidates to receive erythropoietin. INTERVENTIONS: Using vs. not using erythropoietin to reduce the need for packed red blood cell transfusions. MEASUREMENTS AND MAIN RESULTS: We used published estimates of known transfusion risks: transfusion-related acute lung injury, transfusion-related errors, hepatitis B and C, human immunodeficiency virus, human T-cell lymphotropic virus, and bacterial contamination, stratified by severity. Based on the estimated risk and frequency of transfusions with and without erythropoietin, we calculated the absolute risk reduction of transfusion-related adverse events, the number needed to treat, and cost to avoid one transfusion-related adverse event by using erythropoietin. The estimated incidence of transfusion-related adverse event was 318 permillion units transfused for all transfusion-related adverse events, 58 per million for serious transfusion-related adverse events, and 21 per million for likely fatal transfusion-related adverse events. The routine use of erythropoietin resulted in an absolute risk reduction of 191 per million for all transfusion-related adverse events, 35 per million for serious transfusion-related adverse events, and 12 per million for likely fatal transfusion-related adverse events. The number needed to treat was 5,246 to avoid one transfusion-related adverse event, 28,785 to avoid a serious transfusion-related adverse event, and 81,000 for a likely fatal transfusion-related adverse event. The total cost was $4,700,000 to avoid one transfusion-related adverse event, $25,600,000 to avoid one serious transfusion-related adverse event, and $71,800,000 to avoid a likely fatal transfusion-related adverse event. The magnitude of these results withstood extensive sensitivity analysis. CONCLUSIONS: From the perspective of avoidance of adverse events, erythropoietin does not appear to be an efficient use of limited resources for routine use in critically ill patients.

Bacterial Infections↗
PubMed2004

Clinical trials of antifungal prophylaxis among patients in surgical intensive care units: concepts and considerations.

BACKGROUND: Fungal infections are important clinical infections in patients in surgical intensive care units. In some institutions, antifungal prophylaxis has become commonplace, and increasing resistance has been reported. However, trials of antifungal prophylaxis are hampered by difficulties in trial design, and the findings may not be generalizable. METHODS: Issues in clinical trial design are reviewed from existing and theoretical perspectives. RESULTS: Identification of a primary hypothesis with a sound epidemiological basis is essential. The study must include institutions where fungal infections have a high and well-studied incidence. A high-risk patient population should be identified and enrolled. The agent selected should have an appropriate spectrum, be easily delivered to the population selected, and be cost effective with few adverse events. At present, fluconazole appears to be the best agent for targeted prophylaxis. The primary end point of the study should be based on an easily measured outcome, for example, days free from fungal infection rather than death due to fungal infection. CONCLUSIONS: Trials of antifungal prophylaxis for patients in surgical intensive care units have had problems in design, and several issues in the conceptual basis of future clinical trials must be addressed.

Antifungal Agents↗
PubMed2004

A consensus statement on empiric therapy for suspected gram-positive infections in surgical patients.

BACKGROUND: Multidrug resistance among gram-positive pathogens in tertiary and other care centers is common. A systematic decision pathway to help select empiric antibiotic therapy for suspected gram-positive postsurgical infections is presented. DATA SOURCES: A Medline search with regard to empiric antibiotic therapy was performed and assessed by the 15-member expert panel. Two separate panel meetings were convened and followed by a writing, editorial, and review process. CONCLUSIONS: The main goal of empiric treatment in postsurgical patients with suspected gram-positive infections is to improve clinical status. Empiric therapy should be initiated at the earliest sign of infection in all critically ill patients. The choice of therapy should flow from beta-lactams to vancomycin to parenteral linezolid or quinupristin-dalfopristin. In patients likely to be discharged, oral linezolid is an option. Antibiotic resistance is an important issue, and in developing treatment algorithms for reduction of resistance, the utility of these new antibiotics may be extended and reduce morbidity and mortality.

Anti-Bacterial Agents↗
PubMed2004

Electronic monitoring and voice prompts improve hand hygiene and decrease nosocomial infections in an intermediate care unit.

OBJECTIVE: To determine whether electronic monitoring of hand hygiene and voice prompts can improve hand hygiene and decrease nosocomial infection rates in a surgical intermediate care unit. DESIGN: Three-phase quasi-experimental design. Phase I was electronic monitoring and direct observation; phase II was electronic monitoring and computerized voice prompts for failure to perform hand hygiene on room exit; and phase III was electronic monitoring only. SETTING: Nine-room, 14-bed intermediate care unit in a university, tertiary-care institution. All patient rooms, utility room, and staff lavatory were monitored electronically. PARTICIPANTS: All healthcare personnel including physicians, nurses, nursing support personnel, ancillary staff, all visitors and family members, and any other personnel interacting with patients on the intermediate care unit. All patients with an intermediate care unit length of stay >48 hrs were followed for nosocomial infection. INTERVENTIONS: Electronic monitoring during all phases, computerized voice prompts during phase II only. MEASUREMENTS AND MAIN RESULTS: We evaluated a total of 283,488 electronically monitored entries into a patient room with 251,526 exits for 420 days (10,080 hrs and 3,549 patient days). Compared with phase I, hand hygiene compliance in patient rooms improved 37% during phase II (odds ratio, 1.38; 95% confidence interval, 1.04-1.83) and 41% in phase III (odds ratio, 1.41; 95% confidence interval, 1.07-1.84). When adjusting for patient admissions during each phase, point estimates of nosocomial infections decreased by 22% during phase II and 48% during phase III; when adjusting for patient days, the number of infections decreased by 10% during phase II and 40% during phase III. Although the overall rate of nosocomial infections significantly decreased when combining phases II and III, the association between nosocomial infection and individual phase was not significant. CONCLUSIONS: Electronic monitoring provided effective ongoing feedback about hand hygiene compliance. During both the voice prompt phase and post-intervention phase, hand hygiene compliance and nosocomial infection rates improved suggesting that ongoing monitoring and feedback had both a short-term and, perhaps, a longer-term effect.

Adolescent↗
PubMed2004

Eliminating catheter-related bloodstream infections in the intensive care unit.

OBJECTIVE: To determine whether a multifaceted systems intervention would eliminate catheter-related bloodstream infections (CR-BSIs). DESIGN: Prospective cohort study in a surgical intensive care unit (ICU) with a concurrent control ICU. SETTING: The Johns Hopkins Hospital. PATIENTS: All patients with a central venous catheter in the ICU. INTERVENTION: To eliminate CR-BSIs, a quality improvement team implemented five interventions: educating the staff; creating a catheter insertion cart; asking providers daily whether catheters could be removed; implementing a checklist to ensure adherence to evidence-based guidelines for preventing CR-BSIs; and empowering nurses to stop the catheter insertion procedure if a violation of the guidelines was observed. MEASUREMENT: The primary outcome variable was the rate of CR-BSIs per 1,000 catheter days from January 1, 1998, through December 31, 2002. Secondary outcome variables included adherence to evidence-based infection control guidelines during catheter insertion. MAIN RESULTS: Before the intervention, we found that physicians followed infection control guidelines during 62% of the procedures. During the intervention time period, the CR-BSI rate in the study ICU decreased from 11.3/1,000 catheter days in the first quarter of 1998 to 0/1,000 catheter days in the fourth quarter of 2002. The CR-BSI rate in the control ICU was 5.7/1,000 catheter days in the first quarter of 1998 and 1.6/1,000 catheter days in the fourth quarter of 2002 (p = .56). We estimate that these interventions may have prevented 43 CR-BSIs, eight deaths, and 1,945,922 dollars in additional costs per year in the study ICU. CONCLUSIONS: Multifaceted interventions that helped to ensure adherence with evidence-based infection control guidelines nearly eliminated CR-BSIs in our surgical ICU.

Catheterization, Central Venous↗
PubMed2004

Impact of fluconazole prophylaxis on cortisol levels in critically ill surgical patients.

Fluconazole is widely used in the intensive care unit for prevention and treatment of fungal infections. Case reports have described an association between fluconazole and adrenal dysfunction, an important cause of morbidity and mortality in critically ill patients. We sought to determine whether 400 mg of fluconazole per day administered to critically ill surgical patients was associated with a reduction in cortisol levels. Cortisol levels were measured in stored plasma specimens drawn from 154 critically ill surgical patients randomized in 1998-1999 to receive fluconazole or placebo for the prevention of candidiasis. The primary outcome measure was the median plasma cortisol level > or =1 day after study drug initiation (MPCL). Secondary outcomes were adrenal dysfunction, defined as an MPCL of <15 microg/dl, changes in cortisol levels over time, and mortality. The median MPCL was 15.75 microg/dl (interquartile range [IQR], 11.65 to 21.33 microg/dl) in 79 patients randomized to fluconazole and 16.71 microg/dl (IQR, 11.67 to 23.00 microg/dl) in 75 patients randomized to placebo (P = 0.52). Patients randomized to fluconazole did not have significantly increased odds of adrenal dysfunction compared to patients randomized to placebo (odds ratio, 0.98; 95% confidence interval, 0.48 to 2.01). Randomization to fluconazole was not associated with a significant difference in cortisol level changes over time. Mortality was not different between patients with and without adrenal dysfunction, nor was it different between patients with adrenal dysfunction who were randomized to fluconazole and those randomized to placebo. Fluconazole prophylaxis in this population of critically ill surgical patients did not result in significant adrenal dysfunction.

Adrenal Gland Diseases↗
PubMed2003

Acute cholangitis.

Acute cholangitis is an infectious disease of the biliary tract with a wide spectrum of presentation ranging in severity from a mild form with fever and jaundice, to a severe form with septic shock. Supportive care with hydration, antibiotics, and biliary decompression remain the cornerstones of care. Broad-spectrum antibiotics should include coverage of E.coli, Klebsiella sp., Enterococcus sp., and in severely critically ill patients, coverage of additional pathogens such as Bacteriodes sp., Pseudomonas, and yeast should be considered. Biliary decompression should be performed early in the course of the illness when the patient has not improved or if they worsen with hydration and antibiotics. Stable patients should have biliary decompression usually within 72 hours when the fever has resolved. Urgent decompression with a percutaneous or endoscopic stent is preferred over an operative decompression in most institutions. Outcome is dependent on the etiology of the obstruction (benign versus malignant) and the ability to achieve biliary decompression.

Acute Disease↗
PubMed2003

Surgical treatment of choledochal cysts.

Biliary cystic disease is uncommon in Asia and very rare in Europe and the Americas. Patients with biliary cysts may present as infants, children, or adults. When patients present as adults, they are more likely to have stones in the gallbladder, common duct, or intrahepatic ducts and to present with biliary colic, acute cholecystitis, cholangitis, or gallstone pancreatitis. With increasing age at presentation, the risks of intrahepatic strictures and stones, segmented hepatic atrophy/hypertrophy, secondary biliary cirrhosis, portal hypertension, and biliary malignancy all increase significantly. Factors to be considered when performing surgery on patients with biliary cystic disease include: (1) age, (2) presenting symptoms, (3) cyst type, (4) associated biliary stones, (5) prior biliary surgery, (6) intrahepatic strictures, (7) hepatic atrophy/hypertrophy, (8) biliary cirrhosis, (9) portal hypertension, and (10) associated biliary malignancy. In general, regardless of age, presenting symptoms, biliary stones, prior surgery or other secondary problems, surgery should include cholecystectomy and excision of extrahepatic cyst(s). With respect to the distal bile duct, the surgical principle should be excision of a portion of the intrapancreatic bile duct with care to not injure the pancreatic duct or a long common channel. Resection of the pancreatic head should be reserved for patients with an established malignancy. With respect to the intrahepatic ducts, surgery should be individualized depending on whether (1) both lobes are involved, (2) strictures and stones are present, (3) cirrhosis has developed, or (4) an associated malignancy is localized or metastatic. When the liver is not cirrhotic, hepatic parenchyma should be preserved even when strictures and stones are present. If cirrhosis is advanced, hepatic transplantation may be indicated, but this sequence of events is unusual. If a malignancy has developed, oncologic principles should be followed. Whenever possible, resection of a localized tumor including adjacent hepatic parenchyma and regional lymph nodes should be performed.

Adult↗
PubMed2003

Surgical volume and quality of care for esophageal resection: do high-volume hospitals have fewer complications?

BACKGROUND: Previous studies have shown that high-volume hospitals (HVHs) have lower mortality rates than low-volume hospitals (LVHs). However, little is known regarding the relationship of morbidity to hospital volume. The objective of the current study was to investigate the relative incidence of postoperative complications after esophageal resection at HVHs and LVHs. METHODS: All patients discharged from a nonfederal, acute-care hospital in Maryland after esophageal resection from 1994 to 1998 were included (n = 366). Rates of 10 postoperative complications were compared at HVHs and LVHs. Risk-adjusted analyses were performed using multiple logistic regression. RESULTS: High-volume hospitals had a mortality rate of 2.5% compared with 15.4% at LVHs (p < 0.001), with a case-mixed adjusted odds ratio (OR) of death equal to 5.7 (95% confidence interval [CI], 2.0 to 16; p < 0.001). Low-volume hospitals had a profound increase in the risk of several complications after adjusting for case-mix: renal failure (OR, 19; 95% CI, 1.9 to 178; p = 0.01), pulmonary failure (OR, 4.8; 95% CI, 1.6 to 14; p = 0.002), septicemia (OR, 4.0; 95% CI, 1.1 to 15; p = 0.04), reintubation (OR, 2.9; 95% CI, 1.4 to 6.1; p = 0.004), surgical complications (OR, 3.3; 95% CI, 1.6 to 6.9; p = 0.001), and aspiration (OR, 1.8; 95% CI, 1.0 to 3.3; p = 0.04). CONCLUSIONS: Patients undergoing esophageal resection at LVHs were at a markedly increased risk of postoperative complications and death. Pulmonary complications are particularly prevalent at LVHs and contribute to the death of patients having surgery at those centers.

Adult↗
PubMed2003

Variation in postoperative complication rates after high-risk surgery in the United States.

OBJECTIVE: Our goal was to characterize variation in complication rates across hospitals with differing volumes for select high-risk operations in the United States. METHODS: Data from the Nationwide Inpatient Sample for 1996 and 1997 were analyzed for 3 high-risk operations: esophagectomy (n=1,226), pancreatectomy (n=4,789), and intact abdominal aortic aneurysm repair (n=11,863). Complications evaluated included aspiration, cardiac complications, infection, pneumonia, pulmonary failure, renal failure, septicemia, and others. The risk of complications was calculated by hospital volume deciles, as well as for high-volume hospitals (HVH) and low-volume hospitals (LVH) defined by median hospital volume. RESULTS: Rates of any postoperative complication varied nearly 2-fold across hospital volume groups. The proportion of patients across hospital deciles having at least one complication ranged from 30% to 51% for esophageal resection, 6% to 12% for pancreatic resection, and 9% to 18% for abdominal aortic aneurysm repair. HVH had lower rates of one or more complications after pancreatic resection (OR, 0.71; 95% CI, 0.57 to 0.83; P=.002), esophageal resection (OR, 0.68; 95% CI, 0.52 to 0.90; P=.008), and intact abdominal aortic aneurysm (AAA) repair (OR, 0.67; 95% CI, 0.59 to 0.76; P<.001). Patients with one or more complications after pancreatic resection had a mortality of 18.8% versus only 5.2% for those without complications (P<.001). Esophageal resection mortality was 16.9% for patients with at least one complication and 2.5% for those without complications (P<.001) and AAA repair mortality was 10.4% for patients with at least one complication and 2.9% for those without complications (P<.001). CONCLUSIONS: High-risk operations have a decreased rate of postoperative complications when performed at HVH. Variation in complication rates may contribute to the volume-outcome relationship and provide a focus for quality improvement at LVH.

Aged↗
PubMed2003

Complications and costs after high-risk surgery: where should we focus quality improvement initiatives?

BACKGROUND: Data on the relative clinical and economic impact of postoperative complications are needed in order to direct quality improvement efforts. STUDY DESIGN: Patients undergoing two high-risk surgical procedures, hepatectomy (n = 569) and esophagectomy (n = 366), from 1994 to 1998 were included. Data were abstracted from the Maryland hospital discharge database. Relative resource use was determined using median regression, adjusting for patient comorbidities and other case-mix variables. RESULTS: A total of 935 patients were studied. Overall in-hospital mortality was 6.1%; complication rate was 38.4%. Median cost for all patients was $14,527 (interquartile range $10,936-$21,412) and length of stay 9 days (interquartile range 7-13 days). Median hospital cost was increased for patients with complications ($16,868 versus $12,861; p < 0.001). In the multivariate analysis, several complications remained associated with increased cost. Acute renal failure ($25,219), septicemia ($18,852), and myocardial infarction ($9,573) were associated with the greatest increase in resource use. But because the incidence of each complication varies, the attributable fraction of total resource use was highest for acute renal failure (19%), septicemia (16%), and surgical complications (16%). CONCLUSIONS: Complications are independently associated with increased resource use after high-risk surgery. Population-based studies may be valuable in determining the relative economic importance of postoperative complications. Quality improvement efforts for these complications should be prioritized based on both the incidence of the complication and its independent contribution to increased resource use.

Esophagectomy↗