Early warning scores predict outcome in acute pancreatitis

The Early Warning Score (EWS) is a widely used general scoring system to monitor patient progress with a varying score of 0-20 in critically unwell patients. This study evaluated the EWS system compared with other established scoring systems in patients with acute pancreatitis. EWS scores were compared with APACHE scores, Imrie scores, computed tomography grading scores, and Ranson criteria for 110 admissions with acute pancreatitis. A favorable outcome was considered to be survival without intensive therapy unit admission or surgery. Nonsurvivors, necrosectomy, and critical care admission were considered adverse outcomes. EWS was the best predictor of adverse outcome in the first 24 hours of admission (receiver operating curve, 0.768). The most accurate predictor of mortality overall was EWS on day 3 of admission (receiver operating curve, 0.920). EWS correlated with duration of intensive therapy unit stay and number of ventilated days (P<0.05) and selected those who went on to develop pancreas-specific complications such as pseudocyst or ascites. EWS of 3 or above is an indicator of adverse outcome in patients with acute pancreatitis. EWS can accurately and reliably select both patients with severe acute pancreatitis and those at risk of local complications.     

Prospective evaluation of a modified Early Warning Score to aid earlier detection of patients developing critical illness on a general surgical ward

Admissions to the intensive care unit (ICU) from the wards havea higher mortality when compared to patients admitted from theoperating theatres/recovery and accident and emergency department.¹Suboptimal care may contribute to morbidity and mortality ofpatients admitted from the ward.² Failure to appreciate physiologicalderangements of breathing and mental status has been demonstratedin patients who subsequently suffered cardiac arrest, and theseevents may have been apparent up to 8 h prior to the event.³⁴ The Early Warning Score (EWS) was developed as a simple scoringsystem to be used at ward level utilising routine observationstaken by nursing staff.⁵ Deviations from the normal score pointsand a total is calculated. The EWS was evaluated prospectively for 1 month. The score wasthen modified to include urine output, to make temperature deviationsless sensitive and to include normalised blood pressure (Table8). We then evaluated this prospectively for 9 months. A total score of 4 or more resulted in the patient being reviewedby ward medical staff and help sought from the intensive careteam if appropriate. Over a 9-month period 206 patients on twogeneral surgical wards were put on the scoring system, of these26 were admitted to the ICU. The APACHE II scores of these patientswas 16.6 (± 7.3). Eleven patients were admitted to theICU from the surgical ward who had not been monitored on themodified EWS and their admission APACHE II scores were 23.5(± 4.1). This compares with admission APACHE II scoresof 22.3 (± 5.5) in 43 patients admitted from surgicalwards in the 9-month period prior to introduction of the system.The introduction of the system has appeared to lead to earlierreferral to the intensive care unit.     

Predictive performance of Acute Physiological and Chronic Health Evaluation releases II to IV: a single New Zealand centre experience

There is debate in Australia and New Zealand around the appropriate use of illness severity scoring systems in Australasian intensive care units. The international benchmark is the Acute Physiological and Chronic Health Evaluation (APACHE) system. In order to compare the performance of recent APACHE releases, we audited 2080 sequential patients admitted between 1 January 2006 and 31 March 2008 to the Middlemore Hospital intensive care unit, Auckland, New Zealand. We compared the predictive performance of the proprietary APACHE II, IIIh, IIIj and IV releases, and the performance of a 'localised' version of APACHE II containing re-estimated coefficients derived from a legacy dataset (7703 sequential patients admitted between 1 January 1997 and 31 December 2005). Discrimination assessed by receiver operating characteristic curves was highest with the APACHE III and IV releases, and significantly better than the APACHE II releases. Calibration assessed by the Hosmer-Lemeshow statistic was poor with all releases, although it was best with APACHE IV and 'localised' version of the APACHE II release. Overall accuracy assessed by the Brier Mean Probability score and Shapiro's R statistic was best with APACHE IV. Our study suggests the possibility of improved prediction in moving to APACHE IV from older releases, although broader multicentre study within the Australian and New Zealand critical care community is warranted. Our study also suggests localisation of the APACHE system offers further opportunity to improve prediction, although these improvements may not be major without ground-up development of a new risk prediction model within our local critical care setting.     

Early prediction of adverse events in enhanced recovery based upon the host systemic inflammatory response

Aim Early identification of patients experiencing postoperative complications is imperative for successful management. C‐reactive protein (CRP) is a nonspecific marker of inflammation used in many specialties to monitor patient condition. The role of CRP measurement early in the elective postoperative colorectal patient is unclear, particularly in the context of enhanced recovery (ERAS). Methods Five hundred and thirty‐three consecutive patients who underwent elective colorectal surgery between October 2008 and October 2010 within an established ERAS programme were studied. Patients were separated into a development group of 265 patients and a validation group of 268 patients by chronological order. CRP and white cell count were added to a prospectively maintained ERAS database. The primary outcome of the study was all adverse events (including infective complications, postoperative organ dysfunction and prolonged length of stay) during the initial hospital admission. Significant predictors for adverse events on univariate analysis were submitted to multivariate regression analysis and the resulting model applied to the validation group. The validity and predictive accuracy of the regression model was assessed using receiver operating characteristic curve/area under the curve (AUC) analysis. Results CRP levels > 150 mg/l on postoperative day 2 and a rising CRP on day 3 were independently associated with all adverse events during the hospital admission. A weighted model was applied to the validation group yielding an AUC of 0.65 (95% CI 0.58–0.73) indicating, at best, modest discrimination and predictive accuracy for adverse events. Conclusion Measurement of CRP in patients after elective colorectal surgery in the first few days after surgery within ERAS can assist in identifying those at risk of adverse events and a prolonged hospital stay. A CRP value of > 150 mg/l on day 2 and a rising CRP on day 3 should alert the surgeon to an increased likelihood of such events.     

The New Injury Severity Score and the evaluation of pediatric trauma.

BACKGROUND: To compare the effectiveness of the Injury Severity Score (ISS) and New Injury Severity Score (NISS) in predicting mortality in pediatric trauma patients. METHODS: NISS, the sum of the squares of a patient's three highest Abbreviated Injury Scale scores (regardless of body region), were calculated for 9,151 patients treated at four regional pediatric trauma centers and compared with previously calculated ISS values. The power of the two scoring systems to predict mortality was gauged through comparison of misclassification rates, receiver operating characteristic curves, and Hosmer-Lemeshow goodness-of-fit statistics. RESULTS: Although there were significant differences in mean NISS and ISS values for each hospital, differences in the predictive abilities of the two scoring systems were insignificant, even when analysis was restricted to the subgroup of patients with severe or penetrating injuries. CONCLUSION: The significant differences in the predictive abilities of the ISS and NISS reported in studies of adult trauma patients were not seen in this review of pediatric trauma patients.     

Multivariable predictors of postoperative cardiac adverse events after general and vascular surgery: results from the patient safety in surgery study

BACKGROUND: Cardiac adverse events (CAEs) are relatively infrequent, but highly lethal, after noncardiac operations. The value of available risk scoring systems is uncertain and these systems can be outdated. We used the Patient Safety in Surgery Study database to develop and test a model to predict patient risk for CAEs after general and vascular surgical operations. STUDY DESIGN: As part of the Patient Safety in Surgery Study, following the National Surgical Quality Improvement Program's protocol, multiple demographic, preoperative, perioperative, and outcomes variables were measured during a 3-year period. Data from 128 Veterans Affairs medical center hospitals and from 14 academic medical centers on 183,069 patients were used in a logistic regression analysis to model multivariable predictors of serious CAEs (cardiac arrest or acute myocardial infarction within 30 days of operation). RESULTS: CAEs occurred in 2,362 patients (1.29%) and of these, 59.44% expired. Multivariable stepwise logistic regression identified 20 independent predictors of CAEs, which excluded most cardiac-specific risk factors. The most important multivariable predictors of CAE were American Society of Anesthesiologists physical status classification, work relative value units of the most complex procedure, age, and type of operation. A risk prediction scoring system using the logistic regression odds ratios proved to be a useful prediction tool when tested using a random sample from the database. CONCLUSIONS: CAEs after noncardiac operations are relatively infrequent but highly lethal. Operation type and urgency and American Society of Anesthesiologists physical status assessment are important independent predictors of cardiac morbidity, but angina, recent MI, and earlier cardiac operation are not. A prediction scoring system based on the Patient Safety in Surgery Study multivariable odds ratios is likely to be predictive of future events in a similar population requiring noncardiac procedures. This risk model can also serve as a tool to measure quality and effectiveness of care by providers who perform noncardiac operations.     

Impact of an Australian/New Zealand organisational position statement on extended-release opioid prescribing among surgical inpatients: a dual centre before-and-after study

Extended-release opioids are often prescribed to manage postoperative pain despite being difficult to titrate to analgesic requirements and their association with long-term opioid use. An Australian/New Zealand organisational position statement released in March 2018 recommended avoiding extended-release opioid prescribing for acute pain. This study aimed to evaluate the impact of this organisational position statement on extended-release opioid prescribing among surgical inpatients. Secondary objectives included predictors and clinical outcomes of prescribing extended-release opioids among surgical inpatients. We conducted a retrospective, dual centre, 11-month before-and-after study and time-series analysis by utilising electronic medical records from two teaching hospitals in Sydney, Australia. The primary outcome was the proportion of patients prescribed an extended-release opioid. For surgical patients prescribed any opioid (n = 16,284), extended-release opioid prescribing decreased after the release of the position statement (38.4% before vs. 26.6% after, p < 0.001), primarily driven by a reduction in extended-release oxycodone (31.1% before vs. 14.1% after, p < 0.001). There was a 23% immediate decline in extended-release opioid prescribing after the position statement release (p < 0.001), followed by an additional 0.2% decline per month in the following months. Multivariable regression showed that the release of the position statement was associated with a decrease in extended-release opioid prescribing (OR 0.54, 95%CI 0.50–0.58). Extended-release opioid prescribing was also associated with increased incidence of opioid-related adverse events (OR 1.52, 95%CI 1.35–1.71); length of stay (RR 1.44, 95%CI 1.39–1.51); and 28-day re-admission (OR 1.26, 95%CI 1.12–1.41). Overall, a reduction in extended-release opioid prescribing was observed in surgical inpatients following position statement release.     

Disclosure of Adverse Events and Errors in Surgical Care: Challenges and Strategies for Improvement

The disclosure of adverse events to patients, including those caused by medical errors, is a critical part of patient-centered healthcare and a fundamental component of patient safety and quality improvement. Disclosure benefits patients, providers, and healthcare institutions. However, the act of disclosure can be difficult for physicians. Surgeons struggle with disclosure in unique ways compared with other specialties, and disclosure in the surgical setting has specific challenges. The frequency of surgical adverse events along with a dysfunctional tort system, the team structure of surgical staff, and obstacles created inadvertently by existing surgical patient safety initiatives may contribute to an environment not conducive to disclosure. Fortunately, there are multiple strategies to address these barriers. Participation in communication and resolution programs, integration of Just Culture principles, surgical team disclosure planning, refinement of informed consent and morbidity and mortality processes, surgery-specific professional standards, and understanding the complexities of disclosing other clinicians’ errors all have the potential to help surgeons provide patients with complete, satisfactory disclosures. Improvement in the regularity and quality of disclosures after surgical adverse events and errors will be key as the field of patient safety continues to advance.     

Hospital Frailty Risk Score Outperforms Current Risk Stratification Models in Primary Total Hip and Knee Arthroplasty

BackgroundModels for risk stratification and prediction of outcome, such as the Charlson Comorbidity Index (CCI), the Elixhauser Comorbidity Method (ECM), the 5-factor modified Frailty Index (mFI-5), and the Hospital Frailty Risk Score (HFRS) have been validated in orthopedic surgery. The aim of this study is to compare the predictive power of these models in total hip and knee replacement.MethodsIn a retrospective analysis of 8250 patients who had undergone total joint replacement between 2011 and 2019, CCI, ECM, mFI-5, and HFRS were calculated for each patient. Receiver operating characteristic curve plots were generated and the area under the curve (AUC) was compared between each score with regard to adverse events such as transfusion, surgical, medical, and other complications. Multivariate logistic regression models were used to assess the relationship among risk stratification models, demographic factors, and postoperative adverse events.ResultsIn prediction of surgical complications, HFRS performed best (AUC: 0.719, P < .001), followed by ECM (AUC: 0.578, P < .001), mFI-5 (AUC: 0.564, P = .003), and CCI (AUC: 0.555, P = .012). With regard to medical complications, other complications, and transfusion, HFRS also was superior to ECM, mFI-5, and CCI. Multivariate logistic regression analyses revealed HFRS as an independent risk stratification model associated with all captured adverse events (P ≤ .001).ConclusionThe HFRS is superior to current risk stratification models in the context of total joint replacement. As the HRFS derives from routinely collected administrative data, healthcare providers can identify at-risk patients without additional effort or expense.     

Predictive value of six risk scores for outcome after surgical repair of hip fracture in elderly patients

Background: Hip fracture surgery is associated with high post‐operative mortality and poor functional results: the excess mortality is 20% in the first year; of those patients who survive, only 50% recover their previous ability to walk. The purpose of this study was to assess the predictive value of six functional status and/or surgical risk scoring systems with regard to serious complications after hip fracture surgery in the elderly. Methods: We performed a prospective study of a consecutive series of 232 patients (aged 65 years or older) undergoing hip fracture surgery. We pre‐operatively applied: The American Society of Anesthesiologists classification, the Barthel index, the Goldman index, the Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) scoring system, the Charlson index and the Visual Analogue Scale for Risk (RISK‐VAS) scale. These scales were evaluated with respect to three variables: incidence of serious complications, the ability to walk after a 3‐month period and 90‐day survival. The predictive value of the different scales was assessed by the calculated area under a receiver operating characteristic curve. Results: The RISK‐VAS scale, the POSSUM scoring system and the Charlson index reached a sufficient predictive value with regard to serious post‐operative complications. The Barthel index and the RISK‐VAS scale were those most useful for predicting ambulation at 3 months. None of the scales proved to be capable of predicting 90‐day mortality. Conclusions: A simple index such as the RISK‐VAS scale was the best predictor of serious post‐operative complications. The functional level before the fracture, measured with the Barthel index, had a major influence on the ambulation recovery.     

Comparison of Intensive Care and Trauma-specific Scoring Systems in Critically Ill Patients

IntroductionAmongst critically ill trauma patients admitted to ICU and still alive and in ICU after 24 hours, it is unclear which trauma scoring system offers the best performance in predicting in-hospital mortality.MethodsThe Australia and New Zealand Intensive Care Society Adult Patient Database and Victorian State Trauma Registry were linked using a unique patient identification number. Six scoring systems were evaluated: the Australian and New Zealand Risk of Death (ANZROD), Acute Physiology and Chronic Health Evaluation III (APACHE III) score and associated APACHE III Risk of Death (ROD), Trauma and Injury Severity Score (TRISS), Injury Severity Score (ISS), New Injury Severity Score (NISS) and the Revised Trauma Score (RTS). Patients who were admitted to ICU for longer than 24 hours were analysed. Performance of each scoring system was assessed primarily by examining the area under the receiver operating characteristic curve (AUROC) and in addition using standardised mortality ratios, Brier score and Hosmer-Lemeshow C statistics where appropriate. Subgroup assessments were made for patients aged 65 years and older, patients between 18 and 40 years of age, major trauma centre and head injury.ResultsOverall, 5,237 major trauma patients who were still alive and in ICU after 24 hours were studied from 25 ICUs in Victoria, Australia between July 2008 and January 2018. Hospital mortality was 10.7%. ANZROD (AUROC 0.91; 95% CI 0.90-0.92), APACHE III ROD (AUROC 0.88; 95% CI 0.87-0.90), and APACHE III (AUROC 0.88; 95% CI 0.87-0.89) were the best performing tools for predicting hospital mortality. TRISS had acceptable overall performance (AUROC 0.78; 95% CI 0.76-0.80) while ISS (AUROC 0.61; 95% CI 0.59-0.64), NISS (AUROC 0.68; 95% CI 0.65-0.70) and RTS (AUROC 0.69; 95% CI 0.67-0.72) performed poorly. The performance of each scoring system was highest in younger adults and poorest in older adults.ConclusionIn ICU patients admitted with a trauma diagnosis and still alive and in ICU after 24 hours, ANZROD and APACHE III had a superior performance when compared with traditional trauma-specific scoring systems in predicting hospital mortality. This was observed both overall and in each of the subgroup analyses. The anatomical scoring systems all performed poorly in the ICU population of Victoria, Australia.     

Surgical Education and Training in Australia and New Zealand

Surgical education for medical students in Australia and New Zealand is provided by 19 universities in Australia and 2 in New Zealand. One surgical college is responsible for managing the education, training, assessment, and professional development programs for surgeons throughout both countries. The specialist surgical associations and societies act as agents of the college in the delivery of these programs, the extent of which varies among specialties. Historically, surgical training was divided into basic and specialist components with selection required for each part. In response to a number of factors, a new surgical education and training program has been developed. The new program incorporates a single merit-based national selection directly into the candidate's specialty of choice. The existing curriculum for each of the nine specialties has been remodeled to a competence-based format in line with the competence required to undertake the essential roles of a surgeon. New standards and criteria have been produced for accreditation of health care facilities used for training. A new basic surgical skills education and training course has been developed, with simulation playing an increasing role in all courses. Trainees' progress is assessed by workplace-based assessment and formal examinations, including an exit examination. The sustained production of sufficient competent surgeons to meet societal needs encompasses many challenges including the recruitment of appropriate graduates and the availability of adequate educational and clinical resources to train them. Competence-based training is an attractive educational philosophy, but its implementation has brought its own set of issues, many of which have yet to be resolved.     

The Trauma and Injury Severity Score (TRISS) revised

Background

The Trauma and Injury Severity Score (TRISS) remains the most commonly used tool for benchmarking trauma fatality outcome. Recently, it was demonstrated that the predictive power of TRISS could be substantially improved by re-classifying the component variables and treating the variable categories nominally. This study aims to develop revised TRISS models using re-classified variables, to assess these models’ predictive performances against existing TRISS models, and to identify and recommend a preferred TRISS model.

Materials and methods

Revised TRISS models for blunt and penetrating injury mechanism were developed on an adult (aged ≥15 years) sample from the National Trauma Data Bank National Sample Project (NSP), using 5-category variable classifications and weighted logistic regression. Their predictive performances were then assessed against existing TRISS models on the unweighted NSP, National Trauma Data Bank (NTDB), and New Zealand Database (NZDB) samples using area under the Receiver Operating Characteristic curve (AUC) and Bayesian Information Criterion (BIC) statistics.

Results

The weighted NSP sample included 1,124,001 adults with blunt or penetrating injury mechanism events and known discharge status, of whom 1,061,709 (94.5%) survived to discharge. Complete information for all TRISS variables was available for 896,212 (79.7%). Revised TRISS models that included main-effects and two-factor interaction terms had superior AUC and BIC statistics to main-effects models and existing TRISS models for patients with complete data in NSP, NTDB and NZDB samples. Predictive performance decreased as the number of variables with missing values included within revised TRISS models increased, but model performances generally remained superior to existing TRISS models.

Discussion

Revised TRISS models had importantly improved predictive capacities over existing TRISS models. Additionally, they were easily computed, utilised only those variables already collected for existing TRISS models, and could be applied and produce meaningful survival probabilities when one or more of the predictor variables contained missing values. The preferred revised TRISS model included main-effects and two-factor interaction terms and allowed for missing values in all predictor variables. A strong case exists for replacing existing TRISS models in trauma scoring systems benchmarking software with this preferred revised TRISS model.     

Surgical adverse events,risk management,and malpractice outcome: morbidity and mortality review is not enough

OBJECTIVE: To review all admissions (age > 13) to three surgical patient care centers at a single academic medical center between January 1, 1995, and December 6, 1999, for significant surgical adverse events. SUMMARY BACKGROUND DATA: Little data exist on the interrelationships between surgical adverse events, risk management, malpractice claims, and resulting indemnity payments to plaintiffs. The authors hypothesized that examination of this process would identify performance improvement opportunities overlooked by standard medical peer review; the risk of litigation would be constant across the three homogeneous patient care centers; and the risk management process would exceed the performance improvement process. METHODS: Data collected included patient demographics (age, gender, and employment status), hospital financials (hospital charges, costs, and financial class), and outcome. Outcome categories were medical (disability: <1 month, 1-6 months, permanent/death), legal (no legal action, settlement, summary judgment), financial (indemnity payments, legal fees, write-offs), and cause and effect analysis. Cause and effect analysis attempts to identify system failures contributing to adverse outcomes. This was determined by two independent analysts using the 17 Harvard criteria and subdividing these into subsystem causative factors. RESULTS: The study group consisted of 130 patients with surgical adverse events resulting in total liabilities of $8.2 million US dollars. The incidence of adverse events per 1,000 admissions across the three patient care centers was similar, but indemnity payments per 1,000 admissions varied (cardiothoracic = $30 US dollars, women's health = $90 US dollars, trauma = $520 US dollars). Patient demographics were not predictive of high-risk subgroups for adverse events or litigation. In terms of medical outcome, 51 patients had permanent disability or death, accounting for 98% of the indemnity payments. In terms of legal outcome, 103 patients received no indemnity payments, 15 patients received indemnity payments, four suits remain open, and in eight cases charges were written off ($0.121 million US dollars). To date, no cases have been adjudicated in court. Cause and effect analysis identified 390 system failures contributing to the adverse events (mean 3.0 failures per adverse event); there were 4.7 failures per adverse event in the 15 indemnity cases. Five categories of causes accounted for 75% of the failures (patient management, n = 104; communication, n = 89; administration, n = 33; documentation, n = 32; behavior, n = 23). The current medical review process would have identified 104 of 390 systems failures (37%). CONCLUSIONS: This study demonstrates no rational link between the tort system and the reduction of adverse events. Sixty-three percent of contributing causes to adverse events were undetected by current medical review processes. Adverse events occur at the interface between different systems or disciplines and result from multiple failures. Indemnity costs per hospital day vary dramatically by patient care center (range $3.60-97.60 US dollars a day). The regionalization of healthcare is in jeopardy from the burden of high indemnity payments.     

4种评分系统评估院前急救患者病情及预后的价值的比较研究

目的:比较改良早期预警评分(MEWS)、全身炎症反应综合征评分(SIRS)、简单临床评分(SCS)、快速急诊内科评分(REMS)评估院前急救患者病情及预后的价值.方法:对我院实施院前急救的685例急诊患者分别进行MEWS评分、REMS评分、SCS评分和SIRS评分,追踪患者的预后,并以当次入院病死率为根据,比较4种评分系统不同分值段的病死率差异,通过ROC曲线下面积比较4种评分系统评估院前急救患者病情及预后的准确性.结果:存活与死亡患者的MEWS评分、REMS评分、SCS评分和SIRS评分比较差异均具有统计学意义(P＜0.05).MEWS评分、REMS评分、SCS评分和SIRS评分的分值越高,病死率越高,各分值段间病死率比较差异均具有统计学意义(x2=72.60、82.31、151.94、72.49,P均＜0.05);MEWS评分、REMS评分、SCS评分和SIRS评分的ROC曲线下面积分别为0.765、0.758、0.829和0.695,以SCS评分的ROC曲线下面积最大.结论:MEWS评分、REMS评分、SCS评分和SIRS评分均能对院前急诊患者的病死率进行预测,准确度SCS＞MEWS＞REMS＞SIRS,SCS评分更能准确地对院前急救患者进行早期预后评估.     

A Scoring System to Predict Nonsentinel Lymph Node Status in Breast Cancer Patients with Metastatic Sentinel Lymph Nodes: A Comparison with Other Scoring Systems

Background  The majority of breast cancer patients with metastatic sentinel lymph node (SLN) do not harbor additional metastasis in non-SLN. It is unclear which patients with metastatic SLN require axillary lymph node dissection (ALND). The aim of this study was to identify predictive factors of non-SLN metastasis and to develop a scoring system. Methods  The training dataset consisted of 184 breast cancer patients. The independent validation dataset consisted of 82 breast cancer patients. The receiver operating characteristic (ROC) curve was drawn and the area under the ROC curve (AUC) was calculated to assess the discriminative power of the scoring systems. Results  Multivariate analysis revealed that non-SLN status was predicted by preoperative ultrasonographic findings of the axilla, lymphovascular invasion, increasing tumor size, increasing number of metastatic SLN, and decreasing number of nonmetastatic SLN. Based on multivariate logistic regression, we developed a scoring system for predicting non-SLN metastasis. The AUC for our scoring system was superior to other published scoring systems when identical validation data were applied. Conclusion  The likelihood of metastatic non-SLN correlated with preoperative ultrasonographic findings of the axilla, increasing pathologic size of the primary tumor, presence of lymphovascular invasion, increasing number of metastatic SLN, and decreasing number of nonmetastatic SLN. Our scoring system appears to be effective and accurate for selecting patients for whom ALND can be avoided.     

Mapping changes in surgical mortality over 9 years by peer review audit

BACKGROUND: There is increasing public scrutiny of deaths among surgical patients. This analysis sought evidence of changes in practice over time in the management of patients who died under surgical care. METHODS: The surgeons and anaesthetists in National Health Service hospitals providing the care of all surgical patients in Scotland participated in the Scottish Audit of Surgical Mortality (SASM). Data from peer review audit, critical event analysis and individual feedback of deaths while in surgical care over 9 years (1994-2002) were examined for trends over time. RESULTS: Over a 9-year period, 40,448 patients died while in surgical care. Consultant surgeon and anaesthetist involvement in decision making and operating increased significantly (P < 0.001), and death after elective surgery declined to 0.27 per cent of elective operations. Adverse events were more frequently due to failures of hospital systems or process than to individual clinician errors. Fewer adverse events were identified as having contributed to or caused the death of patients over time (P < 0.001). Failure to use deep vein thrombosis (DVT) prophylaxis and failure to use high-dependency or intensive therapy units (HDU/ITU) became less common, once highlighted by the SASM. CONCLUSION: Through continuous peer review audit, the SASM has mapped and may have contributed to changes in surgical and anaesthetic practice over a 9-year period, indicating that the rate of adverse events can be decreased by changing clinician practice (DVT prophylaxis) and provision of facilities (HDU/ITU). Similar approaches should be considered by other medical specialties.     

How important is the contribution of surgical specialties to a medical school's NIH funding?

OBJECTIVE: To determine the relative contribution and importance of five surgical specialties (general surgery, urology, otolaryngology, neurosurgery, and orthopedics) to the total National Institutes of Health (NIH) funding at medical schools. METHODS: Publicly available NIH funding data from 1996 to 2004 were analyzed. RESULTS: From 1998 through 2003 the NIH budget increased from 11.2 billion to 21.9 billion dollars. Overall, NIH funding to departments of medicine was the greatest contributor to any individual medical school's total NIH funding, comprising 28.4% of total NIH awards on average, with a correlation coefficient highly predictive of medical school's ranking for NIH awards (cc = 0.93). Total NIH funding by different surgical specialties varied greatly, both within and between institutions. Together all of the surgical subspecialties combined accounted for 4.8% of medical school NIH awards on average from the years 1996 to 2004. Among the surgical specialties, general surgery received the largest fraction of NIH dollars followed by otolaryngology, neurosurgery, urology, and orthopedics. Although general surgery had the highest overall correlation coefficient of the surgical departments during the early years of the study period (r = 0.71 in 1996), its correlation significantly decreased during the period of study (as low as r = 0.54 in 2002). CONCLUSIONS: Surgical departments as an aggregate have continued to receive a stable overall fraction of NIH awards. The total funding to the different surgical departments varies considerably between institutions and does not correlate well with total institutional funding. The downward trend in the correlation of general surgery funding to total institutional funding suggests a decline in support for surgical research in this specialty nationwide.     

Assessment of validity for EuroSCORE risk stratification system

Prognostic scoring helps doctors, patients and their families to weigh the risks and benefits of medical care and clarifies their expectations. OBJECTIVE: We aimed to analyze the risk stratification performance of the EuroSCORE system because of its common use in Lithuania. DESIGN: EuroSCORE performance is assessed in terms of sensitivity, specificity, accuracy and area under the receiver operating characteristic (ROC) curve (AUC). Logistic regression is carried out for modeling categorical data and odds ratio calculations of being a non-survivor case for each EuroSCORE risk group. RESULTS: The study was completed on 1002 patients. Mean score for EuroSCORE was 4.77 +/- 2.8; ROC curve of 0.71; accuracy was 65.5%; 65.4% sensitivity and 67.2% specificity. CONCLUSIONS: EuroSCORE created a moderately predictive area under the ROC curve for our patient population. Probability of non-survival by logistic regression model for each EuroSCORE risk group is statistically significantly higher compared to the lower risk group. Predictions available from prognostic scoring systems could be useful in decision making when there is uncertainty in whether to carry out surgery or not.     

Incidence of severe critical events in paediatric anaesthesia in the United Kingdom: secondary analysis of the anaesthesia practice in children observational trial (APRICOT study)

The anaesthesia practice in children observational trial of 31,127 patients in 261 European hospitals revealed a high (5.2%) incidence of severe critical events in the peri-operative period and wide variability in practice. A sub-analysis of the UK data was undertaken to investigate differences compared with the non-UK cohort in the incidence and nature of peri-operative severe critical events and to attempt to identify areas for quality improvement. In the UK cohort of 7040 paediatric patients from 43 hospitals, the overall incidence of peri-operative severe critical events was lower than in the non-UK cohort (3.3%, 95%CI: 2.9–3.8 vs. 5.8%, 95%CI: 5.5–6.1, RR 0.57, p < 0.001). There was a lower rate of bronchospasm (RR 0.22, 95%CI: 0.14–0.33; p < 0.001), stridor (RR 0.42, 95%CI: 0.28–0.65; p < 0.001) and cardiovascular instability (RR 0.69, 95%CI: 0.55–0.86; p = 0.001) than in the non-UK cohort. The proportion of sicker patients where less experienced teams were managing care was lower in the UK than in the non-UK cohort (10.4% vs. 20.4% of the ASA physical status 3 and 9% vs. 12.9% of the ASA physical status 4 patients). Differences in work-load between centres did not affect the incidence and outcomes of severe critical events when stratified for age and ASA physical status. The lower incidence of cardiovascular and respiratory complications could be partly attributed to more experienced dedicated paediatric anaesthesia providers managing the higher risk patients in the UK. Areas for quality improvement include: standardisation of serious critical event definitions; increased reporting; development of evidence-based protocols for management of serious critical events; development and rational use of paediatric peri-operative risk assessment scores; implementation of current best practice in provision of competent paediatric anaesthesia services in Europe; development of specific training in the management of severe peri-operative critical events; and implementation of systems for ensuring maintenance of skills.