The impact of major intraoperative adverse events on hospital readmissions

Hospital-wide readmission rates recently became a recognized benchmarking quality metric. We sought to study the independent impact of major intraoperative adverse events (iAEs) on 30-day readmission in abdominal surgery. The 2007 to 2012 institutional American College of Surgeons National Surgical Quality Improvement Program and administrative databases for abdominal operations were matched then screened for iAEs using the International Classification of Diseases, 9th Revision, Clinical Modification–based Patient Safety Indicator “Accidental Puncture/Laceration”. Flagged charts were reviewed to confirm the presence of iAEs. Major iAEs were defined as class 3 or above, as per our recently validated iAE Classification System. The inpatient database was queried for readmission within 30 days from discharge. Univariate and multivariable models were constructed to analyze the independent impact of major iAEs on readmission, controlling for demographics, comorbidities, American Society of Anesthesiology class, and procedure type/approach/complexity (using relative value units as proxy). Reasons for readmission were investigated using the Agency for Healthcare Research and Quality's International Classification of Diseases, 9th Revision, Clinical Modification–based Clinical Classification Software. Of 9,274 surgical procedures; 921 resulted in readmission (9.9%), 183 had confirmed iAEs, 73 of which were major iAEs. Procedures with major iAEs had a higher readmission rate compared with procedures with no iAEs [24.7% vs 9.8%, P < .001]. In multivariable analyses, major iAEs were independently associated with a 2-fold increase in readmission rates [OR = 2.17 (95% CI = 1.22 to 3.86); P = .008]; 67% of readmissions after major iAEs were caused by “complications of surgical procedures or medical care” as defined by Agency for Healthcare Research and Quality. Major iAEs are independently associated with increased rates of 30-day readmission. Preventing iAEs or mitigating their effects can serve as a quality improvement target to decrease surgical readmissions. •Patients experiencing major intraoperative adverse events (iAEs) are more likely to be readmitted to the hospital.•Major iAEs are independently associated with a 2-fold increase in readmissions.•Prevention of major iAEs should be a target for surgical quality improvement efforts

Does the emergency surgery score accurately predict outcomes in emergent laparotomies?

The emergency surgery score is a mortality-risk calculator for emergency general operation patients. We sought to examine whether the emergency surgery score predicts 30-day morbidity and mortality in a high-risk group of patients undergoing emergent laparotomy. Using the 2011-2012 American College of Surgeons National Surgical Quality Improvement Program database, we identified all patients who underwent emergent laparotomy using (1) the American College of Surgeons National Surgical Quality Improvement Program definition of "emergent," and (2) all Current Procedural Terminology codes denoting a laparotomy, excluding aortic aneurysm rupture. Multivariable logistic regression analyses were performed to measure the correlation (c-statistic) between the emergency surgery score and (1) 30-day mortality, and (2) 30-day morbidity after emergent laparotomy. As sensitivity analyses, the correlation between the emergency surgery score and 30-day mortality was also evaluated in prespecified subgroups based on Current Procedural Terminology codes. A total of 26,410 emergent laparotomy patients were included. Thirty-day mortality and morbidity were 10.2% and 43.8%, respectively. The emergency surgery score correlated well with mortality (c-statistic = 0.84); scores of 1, 11, and 22 correlated with mortalities of 0.4%, 39%, and 100%, respectively. Similarly, the emergency surgery score correlated well with morbidity (c-statistic = 0.74); scores of 0, 7, and 11 correlated with complication rates of 13%, 58%, and 79%, respectively. The morbidity rates plateaued for scores higher than 11. Sensitivity analyses demonstrated that the emergency surgery score effectively predicts mortality in patients undergoing emergent (1) splenic, (2) gastroduodenal, (3) intestinal, (4) hepatobiliary, or (5) incarcerated ventral hernia operation. The emergency surgery score accurately predicts outcomes in all types of emergent laparotomy patients and may prove valuable as a bedside decision-making tool for patient and family counseling, as well as for adequate risk-adjustment in emergent laparotomy quality benchmarking efforts

The Emergency Surgery Score (ESS) accurately predicts the occurrence of postoperative complications in emergency surgery patients

BACKGROUNDThe Emergency Surgery Score (ESS) was recently validated as a scoring system to predict mortality in emergency surgery (ES) patients. We sought to examine the ability of ESS to predict the occurrence of 30-day postoperative complications in ES. METHODSThe 2011-2012 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was screened for all surgical operations classified as "emergent." Thirty-day postoperative complications were defined as per ACS-NSQIP (e.g., surgical site infection, respiratory failure, acute renal failure). Each patient-related ESS was calculated, and the correlation between ESS and the probability of occurrence of 30-day postoperative complications was assessed by calculating the c-statistic. Univariate and multivariable models were also created to identify which ESS components independently predict complications. RESULTSOf 37,999 cases that captured all ESS variables, 14,446 (38%) resulted in at least one 30-day complication. The observed probability of a 30-day complication gradually increased from 7% to 53% to 91% at scores of 0, 7, and 15, respectively, with a c-statistic of 0.78. For ESS >15, the complication rate plateaued at a mean of 92%. On multivariable analyses, each of the 22 ESS components independently predicted the occurrence of postoperative complications. CONCLUSIONSESS reliably predicts postoperative complications in ES patients. Such a score could prove useful for (1) perioperative patient and family counseling and (2) benchmarking the quality of ES care. LEVEL OF EVIDENCEPrognostic, level III