Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

Background Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide.Methods A multimethods analysis was performed as part of the GlobalSurg 3 study-a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital.Findings Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3.85 [95% CI 2.58-5.75]; p<0.0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63.0% vs 82.7%; OR 0.35 [0.23-0.53]; p<0.0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer.Interpretation Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised

Assessment of acute pulmonary embolism outcome in hospital through Tricuspid Annular Plane Systolic Excursion versus Pulmonary Embolism Severity Index score

Background: In-hospital mortality of acute pulmonary embolism ranging from 0 to 50%, depending upon hemodynamic status and right ventricular dysfunction. RV enlargement, in normotensive PE patients is considered as a predictor of poor clinical outcome, even in initially stable patients. Aim of the study: Evaluations of Tricuspid Annular Plane Systolic Excursion (TAPSE) as the prognostic tool for prediction of in hospital mortality in relation to the Pulmonary Embolism Severity Index (PESI) clinical risk score. Patients and methods: This study was carried out in Dallah hospital Riyadh – Saudi Arabia including 50 patients diagnosed with APE. Those patients classified into three groups, Group I (20 patients) hemodynamically unstable, Group II (15 patients) hemodynamically stable with RV dysfunction and Group III (15 patients) hemodynamically stable with normal RV function. For all included patients TAPSE was measured, PESI risk score was calculated and recorded in the 1st day, 3rd day and 7th day of admission. Results: Receiver operating characteristic (ROC) curve analysis of TAPSE determine that 14 mm was the optimal cutoff value (AUC) 0.994, p < 0.001 and for PESI determine that 124 points was the optimal cutoff value (AUC) 0.983, p < 0.001. Conclusion: TAPSE and PESI can be used as a good prognostic tool in acute PE during hospital course and TAPSE has higher accuracy than PESI in mortality prediction. TAPSE value ≤14 mm can be used in judgment of thrombolytic therapy decision in hemodynamically stable APE patients

Impact of VAP bundle adherence among ventilated critically ill patients and its effectiveness in adult ICU

Ventilator-associated pneumonia (VAP) is the most prevalent infection in intensive care units (ICU). To reduce this rate, the application of bundles – groups of individual practices and adherence to the best nursing practices from Association for Professionals in Infection Control and Epidemiology (APIC) guidelines (2009) is recommended. This study aimed: This study aimed to estimate the microbiology including; rate of VAP, mortality rate attributed to VAP, among (ICU) critically ill patients and evaluate the effectiveness of adherence to VAP bundle on elimination of infection, also cost effectiveness as reflection to length of stay in ICU. Subject and methods: A comparative interventional design was used to achieve the aim of the study. It is conducted in 14 bedded Adult Medical-surgical ICU.VAP Bundle Program was implemented by our multidisciplinary team (pulmonologist, microbiologist, intensivist and ICU nurses). The VAP bundle team starting the program implementation in January 2014 till the end of December 2015 (follow up prospective study), all those patients underwent daily 5 items 1- bed elevation, 2- DVT prophylaxis, 3- peptic ulcer prophylaxis, 4- oral hygiene and 5- sedation break and weaning assessment. Surveillance reports from ICU for the year 2013 were reviewed (retrospective study). Data were collected and analyzed for (VAP) and compared before and after VAP bundle intervention. Results: All ventilated patients who met the inclusion criteria were grouped in two groups, group A (130) patients non bundle used and group B (250) patient vap bundle used, then sub grouped to VAP and non VAP for statistical analysis, mean age in vap patients was higher in both groups, VAP incidence in group A 18.5% that decreased significantly to half of 9% in group B, p value <0.05, also VAP rate/1000 ventilated day showed a statistically significant difference between group A 25/1000 day in 2013 to VAP rate in 2014 year, 8.5/1000 ventilator days, also to VAP rate 6/1000 ventilator days in 2015, p value <0.007. Strong significant negative correlation between compliance of VAP bundle and VAP rate was found, p < 0.0001, VAP bundle compliance ranged from 94% to 100%. Male and medical patients were higher in both groups more than 62%, outcome improved after bundle as the death rate decreased in group B in both subgroups than that in group A, and length of stay in ICU was lowered significantly in group B about 2 days subsequently lowering the cost. Conclusion: The application of VAP bundle is a feasible reality that produces improvement in microbiological measures and nosocomal infection rates resulting in lowering mortality, shortened lengths of hospitalization and decreased medical care costs. However, education and periodic training remain a fundamental process of improving health services. VAPs were reduced by improving bundle compliance and ensuring the same standard of care to all ICU patients. Direct, on-site observation was a more accurate method of monitoring

Tuberculosis chemoprophylaxis in rheumatoid arthritic patients receiving tumor necrosis factor inhibitors or conventional therapy

Introduction: Patients with rheumatoid arthritis (RA) have increased susceptibility to infection. The risk of acquiring infection including tuberculosis (TB) in RA may be increased in patients receiving any immuno-suppressive medication including anti-TNF therapy, which is used successfully for treating patients with rheumatoid arthritis. The aim of this work was to assess the risk of TB in RA patients on anti-TNF therapy compared to conventional disease modifying anti rheumatic drugs when screening for latent TB and TB chemoprophylaxis was applied. Patients and methods: This study conducted on (235) RA patients indicated for either conventional therapy or anti-TNF therapy from 1-1-2010 to 1-10-2013. Assessment was done before RA treatment and included medical history, clinical examination, plain chest X-ray, HRCT chest QuantiFERON®-TB Gold in-tube (QFT-GIT) test and microbiologic investigations for tuberculosis when indicated. All patients with positive QFT-GIT received chemoprophylactic treatment for TB. Results: The studied rheumatoid arthritic patients were divided into two groups; group (A) included (105) RA patients on conventional disease modifying anti rheumatic drugs (DMARDs) with mean age (51 ± 12) and group (B) included (130) RA patients on anti-TNF therapy with mean age (48 ± 13). This study showed no significant increase of tuberculosis among patients on anti-TNF therapy (group B) compared to patients on (DMARDs) (group A). Chemo-prophylaxis in patients on anti-TNF therapy leads to prevention of reactivation of latent TB. Conclusion: There was no significant increased risk for tuberculosis among RA patients receiving anti-TNF therapy when screening and chemoprophylaxis was applied, so screening of RA patients before anti-TNF therapy for latent tuberculosis and TB chemoprophylaxis should be done

Continuous positive airway pressure ventilation versus Bi-level positive airway pressure ventilation in patients with blunt chest trauma

Introduction: The use of positive pressure ventilation has decreased the overall morbidity and mortality associated with blunt chest trauma, but invasive mechanical ventilation (IMV) is associated with many complications. The role of noninvasive ventilation (NIV) for the management of patients with blunt chest trauma has not been well established. The aim of this study was to compare the efficiency of CPAP versus BiPAP in avoiding IMV. Patients and method: This study was carried out in the period between April 2011 and April 2103, on 40 patients admitted to ICU with blunt chest trauma with acute respiratory distress that had deteriorated despite aggressive medical management. Patients were randomly assigned to receive either continuous positive airway pressure ventilation (CPAP) (group 1) n = 15, Bi-level positive airway pressure ventilation (BiPAP) (group 2) n = 15 or IMV (group 3) n = 10. Results: Improvement in gas exchange and relieve of respiratory distress was noticed in the three studied groups after the start of assisted ventilation. Four patients in group 1 (26.7%) and three patients in group 2 (20%) required endotracheal intubation. There was no significant difference in the length of stay in ICU between the three groups (10 ± 5 days in group 1, 11 ± 4 in group 2 and 10 ± 6 in group 3. Pneumonia developed in one patient in group 1 (6.6%) and in 2 patients in group 2 (13.3%) and in 3 patients in group 3 (30.3%). Pneumothorax developed in one patient in group 1 (6.6%) and in no patients in group 2 (0%) and in one patient in group 3 (10%). As regards mortality no mortalities were observed in groups 1 and 2 but one patient in group 3 (10%) died. Conclusion: Both CPAP and BiPAP are safe and efficient techniques in managing respiratory failure and reducing the incidence of intubation in patients with blunt chest trauma

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

Background: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation: Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding: National Institute for Health Research Global Health Research Unit

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

© 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 licenseBackground: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation: Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding: National Institute for Health Research Global Health Research Unit

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licenseBackground: Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide. Methods: A multimethods analysis was performed as part of the GlobalSurg 3 study—a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital. Findings: Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3·85 [95% CI 2·58–5·75]; p<0·0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63·0% vs 82·7%; OR 0·35 [0·23–0·53]; p<0·0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer. Interpretation: Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised. Funding: National Institute for Health and Care Research