Do-not-resuscitate orders and early mortality in hip fracture patients

Background: factors affecting mortality after hip fracture surgery have been studied extensively. It has been suggested that do-not-resuscitate (DNR) orders are associated with higher mortality in surgical patients due to less aggressive treatment. However, the effect of DNR orders on mortality in hip fracture patients is unknown. The objective of this study was to investigate the effect of DNR orders on early mortality after hip fracture surgery. Methods: all patients undergoing hip fracture surgery between 2004 and 2015 were included in this retrospective study. Patient characteristics such as age, comorbidities and fracture type were collected, as were resuscitation preferences. Multivariable logistic regression analysis was performed to identify independent risk factors for early mortality. Results: a total of 1,803 patients were analysed, of which 823 (45.6%) had DNR orders. DNR patients were older, more often female, had lower haemoglobin levels and more comorbidities when compared with non-DNR patients. The unadjusted effect of DNR orders on mortality was high (OR: 2.39; P <0.001). Multivariable analysis demonstrated that increased age, male gender, higher American Society of Anesthesiologists score, low admission haemoglobin, living in an institution, high Charlson Comorbidity Index and delay to surgery were associated with increased early mortality after hip fracture surgery. There was no independent effect of DNR orders on mortality after adjustment for these variables (P = 0.735). Conclusions: DNR patients have higher mortality rates due to poor health status. Resuscitation preferences on their own are not associated with early mortality after hip fracture surger

The weekend effect for hip fracture surgery

Introduction: Increased mortality rates have been reported for emergency admissions during weekends and outside office hours. Research on the weekend effect in hip fracture patients is however limited and demonstrates conflicting results. The aim of this study was to determine the effect of weekend admission and weekend surgery on 30-day and 1-year mortality following hip fracture surgery. Patients and methods: All patients who underwent hip fracture surgery in our hospital between 2004 and 2015 were included in this retrospective study. Patient characteristics including age, gender, fracture type, American Society of Anesthesiologists (ASA) score, Nottingham Hip Fracture Score (NHFS), Charlson Comorbidity Index (CCI) and length of stay were collected. Information on admission and surgery date and time of day was recorded, as were in-hospital, 30-day and 1-year mortality. Multivariable logistic regression analysis was performed to identify independent predictors of 30-day and 1-year mortality. Results: A total of 1803 patients were included, 546 patients (30.3%) were admitted during the weekend. Patient characteristics did not differ between weekday and weekend admissions. Surgical delay was less frequent in patients undergoing weekend surgery. Multivariable analysis demonstrated that older age, higher ASA score, higher NHFS and increased surgical delay were independently associated with 30-day mortality. One-year mortality was associated with age, gender, ASA score, CCI and surgical delay. Weekend admission and weekend surgery were not associated with increased 30-day or 1-year mortality. Conclusions: There was no weekend effect for hip fracture patients in our study. These results indicate an adequate level of perioperative care outside weekday office hours within our health care system. (C) 2017 Elsevier Ltd. All rights reserve

A Decision Aid to Help Patients Make Informed Choices Between the Laparoscopic Gastric Bypass or Sleeve Gastrectomy

Purpose: In the Netherlands, patients can often choose between the laparoscopic Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) as primary bariatric surgery. Yet, patients confronted with medical options may experience decisional conflict when their stakes are high and outcomes uncertain. This study aimed to assess if a decision aid helps patients make informed choices between two bariatric procedures by lowering the level of decisional conflict. Materials and Methods: This study was a single-center comparative cohort of patients who accessed a web-based decision aid (intervention group) and those who did not use the decision aid (control group) to help choose between two bariatric procedures additional to the standard provided care. The primary outcome was the level of decisional conflict in these patients using the decisional conflict scale (DCS). Secondary outcomes were patient satisfaction with the provided information (BODY-QTM—satisfaction with information), preference of involvement in procedure selection, level of shared decision-making (SDM-Q-9 questionnaire), and patient knowledge. Results: The level of decisional conflict assessed with the decisional conflict scale (DCS) showed a significantly lower mean total DCS of 25.5 ± 11.5 for the intervention group vs. 29.1 ± 12.4 in the control group (p = 0.022). Both groups did not significantly differ in satisfaction regarding provided information, involvement in the selection procedure, shared decision-making, and patient knowledge. Conclusion: The results suggest that the additional use of a decision aid significantly lowers the level of decisional conflict in patients awaiting bariatric surgery. However, the added value should be further investigated. Graphical Abstract: [Figure not available: see fulltext.]

Same-Day Discharge After Laparoscopic Roux-en-Y Gastric Bypass: a Cohort of 500 Consecutive Patients

Introduction: There is an increasing demand on hospital capacity worldwide due to the COVID-19 pandemic and local staff shortages. Novel care pathways have to be developed in order to keep bariatric and metabolic surgery maintainable. Same-day discharge (SDD) after laparoscopic Roux-en-Y gastric bypass (RYGB) is proved to be feasible and could potentially solve this challenge. The aim of this study was to investigate whether SDD after RYGB is safe for a selected group of patients. Methods: In this single-center cohort study, low-risk patients were selected for primary RYGB with intended same-day discharge with remote monitoring. All patients were operated according to ERAS protocol. There were strict criteria on approval upon same-day discharge. It was demanded that patients should contact the hospital in case of any signs of complications. Primary outcome was the rate of successful same-day discharge without readmission within 48?h. Secondary outcomes included short-term complications, emergency department visits, readmissions, and mortality. Results: Five hundred patients underwent RYGB with intended SDD, of whom 465 (93.0%) were successfully discharged. Twenty-one patients (4.5%) were readmitted in the first 48?h postoperatively. None of these patients had a severe bleeding. This results in a success rate of 88.8% of SDD without readmission within 48?h. Conclusions: Same-day discharge after RYGB is safe, provided that patients are carefully selected and strict discharge criteria are used. It is an effective care pathway to reduce the burden on hospital capacity. Graphical Abstract: [Figure not available: see fulltext.