Perioperative Medicine

SAN JUAN, P.R. – Patients on prolonged ventilation who had previously failed a 5-day breathing challenge were weaned more rapidly off ventilators when a tracheostomy collar rather than pressure support was used, Dr. Amal Jubran reported.

Among 312 patients on prolonged ventilation (more than 21 days) transferred to a long-term acute care hospital, the median weaning time with unassisted breathing through tracheostomy collars was 4 days shorter than when pressure support was used as the weaning method, said Dr. Jubran of the division of pulmonary and critical care medicine at the Edward Hines Jr. VA Hospital in Hines, Ill.

"The method of ventilator weaning significantly improves the outcome of patients who require prolonged ventilation ... at a long-term care facility," she said at the annual congress of the Society of Critical Care Medicine.

The study findings were published simultaneously online in JAMA. There, the authors suggested that the more rapid weaning achieved with the use of the tracheostomy collar could be because the collar allows clinicians to directly observe whether patients are capable of breathing spontaneously (JAMA 2013 [doi:10.1001/jama.2013.159]).

"During a tracheostomy collar challenge, the amount of respiratory effort is determined solely by the patient. As such, observing a patient breathing through a tracheostomy collar provides the clinician with a clear view of the patient’s respiratory capabilities. In contrast, a clinician’s ability to judge weanability during pressure support is clouded because the patient is receiving ventilator assistance," the investigators wrote.

Clinicians may be more willing to wean patients who do better than expected on a trachesotomy challenge than they would patients who are on only low levels of pressure support, the authors suggested.

Weaning failures randomized

They based their conclusions on a decade-long randomized trial of patients with tracheotomies on prolonged ventilation who were transferred to a single center for weaning.

A total of 500 patients had a 5-day screening process during which they were given humidified oxygen through a tracheostomy collar and observed for signs of respiratory distress. Patients with no signs of distress during the challenge were considered to be weaned from ventilation and were excluded from the study, and the remaining 316 were randomly assigned to weaning with either a tracheostomy collar or pressure support. Patients in each study arm were stratified into one of four underlying disease categories, and to either early- or late-failure groups, based on the time it took for the breathing trial to fail (0 to less than 12 hours for early failures, 12-120 hours for late failures).

Ultimately, a total of 312 patients were included in the analysis.

Of the 160 patients in the tracheostomy collar group, 15 were deemed to be unweanable, 15 withdrew for various reasons, 16 died, and 10 were transferred to an acute care hospital. Of the remaining 104 patients in this arm, 85 (53.1% of the total group) were successfully weaned.

Of the 152 patients in the pressure support group, 21 were judged to be unweanable, 12 withdrew, 7 were transferred to an acute care hospital, and 22 died. Of the remaining 90 patients, 68 (45% of the total) were successfully weaned.

The median weaning time for patients on the collar was 15 (interquartile range [IQR], 8-25 days), compared with 19 days (IQR, 12-31 days) for patients on pressure support.

In an analysis adjusted for baseline clinical covariates, the hazard ratio (HR) favoring tracheostomy collar weaning was 1.43. Among patients in the late-failure subgroup, tracheostomy offered significantly more rapid weaning than did pressure support (HR, 3.33). There was no significant difference between the methods in time to weaning among patients who were deemed to be early screening failures, however. There were also no significant differences between weaning protocols in either 6- or 12-month mortality rates.

Dr. Jubran and colleagues acknowledged that their study was limited by the inability to fully mask treatment type from investigators (although investigators analyzing the data were blinded to protocol assignment), and by the use of single-center data, potentially limiting generalizability.

The study was supported by funding from the National Institute of Nursing Research. Dr. Jubran reported having no relevant financial disclosures.

SAN JUAN, P.R. – Patients on prolonged ventilation who had previously failed a 5-day breathing challenge were weaned more rapidly off ventilators when a tracheostomy collar rather than pressure support was used, Dr. Amal Jubran reported.

Among 312 patients on prolonged ventilation (more than 21 days) transferred to a long-term acute care hospital, the median weaning time with unassisted breathing through tracheostomy collars was 4 days shorter than when pressure support was used as the weaning method, said Dr. Jubran of the division of pulmonary and critical care medicine at the Edward Hines Jr. VA Hospital in Hines, Ill.

"The method of ventilator weaning significantly improves the outcome of patients who require prolonged ventilation ... at a long-term care facility," she said at the annual congress of the Society of Critical Care Medicine.

The study findings were published simultaneously online in JAMA. There, the authors suggested that the more rapid weaning achieved with the use of the tracheostomy collar could be because the collar allows clinicians to directly observe whether patients are capable of breathing spontaneously (JAMA 2013 [doi:10.1001/jama.2013.159]).

"During a tracheostomy collar challenge, the amount of respiratory effort is determined solely by the patient. As such, observing a patient breathing through a tracheostomy collar provides the clinician with a clear view of the patient’s respiratory capabilities. In contrast, a clinician’s ability to judge weanability during pressure support is clouded because the patient is receiving ventilator assistance," the investigators wrote.

Clinicians may be more willing to wean patients who do better than expected on a trachesotomy challenge than they would patients who are on only low levels of pressure support, the authors suggested.

Weaning failures randomized

They based their conclusions on a decade-long randomized trial of patients with tracheotomies on prolonged ventilation who were transferred to a single center for weaning.

A total of 500 patients had a 5-day screening process during which they were given humidified oxygen through a tracheostomy collar and observed for signs of respiratory distress. Patients with no signs of distress during the challenge were considered to be weaned from ventilation and were excluded from the study, and the remaining 316 were randomly assigned to weaning with either a tracheostomy collar or pressure support. Patients in each study arm were stratified into one of four underlying disease categories, and to either early- or late-failure groups, based on the time it took for the breathing trial to fail (0 to less than 12 hours for early failures, 12-120 hours for late failures).

Ultimately, a total of 312 patients were included in the analysis.

Of the 160 patients in the tracheostomy collar group, 15 were deemed to be unweanable, 15 withdrew for various reasons, 16 died, and 10 were transferred to an acute care hospital. Of the remaining 104 patients in this arm, 85 (53.1% of the total group) were successfully weaned.

Of the 152 patients in the pressure support group, 21 were judged to be unweanable, 12 withdrew, 7 were transferred to an acute care hospital, and 22 died. Of the remaining 90 patients, 68 (45% of the total) were successfully weaned.

The median weaning time for patients on the collar was 15 (interquartile range [IQR], 8-25 days), compared with 19 days (IQR, 12-31 days) for patients on pressure support.

In an analysis adjusted for baseline clinical covariates, the hazard ratio (HR) favoring tracheostomy collar weaning was 1.43. Among patients in the late-failure subgroup, tracheostomy offered significantly more rapid weaning than did pressure support (HR, 3.33). There was no significant difference between the methods in time to weaning among patients who were deemed to be early screening failures, however. There were also no significant differences between weaning protocols in either 6- or 12-month mortality rates.

Dr. Jubran and colleagues acknowledged that their study was limited by the inability to fully mask treatment type from investigators (although investigators analyzing the data were blinded to protocol assignment), and by the use of single-center data, potentially limiting generalizability.

The study was supported by funding from the National Institute of Nursing Research. Dr. Jubran reported having no relevant financial disclosures.

SAN JUAN, P.R. – Patients on prolonged ventilation who had previously failed a 5-day breathing challenge were weaned more rapidly off ventilators when a tracheostomy collar rather than pressure support was used, Dr. Amal Jubran reported.

Among 312 patients on prolonged ventilation (more than 21 days) transferred to a long-term acute care hospital, the median weaning time with unassisted breathing through tracheostomy collars was 4 days shorter than when pressure support was used as the weaning method, said Dr. Jubran of the division of pulmonary and critical care medicine at the Edward Hines Jr. VA Hospital in Hines, Ill.

"The method of ventilator weaning significantly improves the outcome of patients who require prolonged ventilation ... at a long-term care facility," she said at the annual congress of the Society of Critical Care Medicine.

The study findings were published simultaneously online in JAMA. There, the authors suggested that the more rapid weaning achieved with the use of the tracheostomy collar could be because the collar allows clinicians to directly observe whether patients are capable of breathing spontaneously (JAMA 2013 [doi:10.1001/jama.2013.159]).

"During a tracheostomy collar challenge, the amount of respiratory effort is determined solely by the patient. As such, observing a patient breathing through a tracheostomy collar provides the clinician with a clear view of the patient’s respiratory capabilities. In contrast, a clinician’s ability to judge weanability during pressure support is clouded because the patient is receiving ventilator assistance," the investigators wrote.

Clinicians may be more willing to wean patients who do better than expected on a trachesotomy challenge than they would patients who are on only low levels of pressure support, the authors suggested.

Weaning failures randomized

They based their conclusions on a decade-long randomized trial of patients with tracheotomies on prolonged ventilation who were transferred to a single center for weaning.

A total of 500 patients had a 5-day screening process during which they were given humidified oxygen through a tracheostomy collar and observed for signs of respiratory distress. Patients with no signs of distress during the challenge were considered to be weaned from ventilation and were excluded from the study, and the remaining 316 were randomly assigned to weaning with either a tracheostomy collar or pressure support. Patients in each study arm were stratified into one of four underlying disease categories, and to either early- or late-failure groups, based on the time it took for the breathing trial to fail (0 to less than 12 hours for early failures, 12-120 hours for late failures).

Ultimately, a total of 312 patients were included in the analysis.

Of the 160 patients in the tracheostomy collar group, 15 were deemed to be unweanable, 15 withdrew for various reasons, 16 died, and 10 were transferred to an acute care hospital. Of the remaining 104 patients in this arm, 85 (53.1% of the total group) were successfully weaned.

Of the 152 patients in the pressure support group, 21 were judged to be unweanable, 12 withdrew, 7 were transferred to an acute care hospital, and 22 died. Of the remaining 90 patients, 68 (45% of the total) were successfully weaned.

The median weaning time for patients on the collar was 15 (interquartile range [IQR], 8-25 days), compared with 19 days (IQR, 12-31 days) for patients on pressure support.

In an analysis adjusted for baseline clinical covariates, the hazard ratio (HR) favoring tracheostomy collar weaning was 1.43. Among patients in the late-failure subgroup, tracheostomy offered significantly more rapid weaning than did pressure support (HR, 3.33). There was no significant difference between the methods in time to weaning among patients who were deemed to be early screening failures, however. There were also no significant differences between weaning protocols in either 6- or 12-month mortality rates.

Dr. Jubran and colleagues acknowledged that their study was limited by the inability to fully mask treatment type from investigators (although investigators analyzing the data were blinded to protocol assignment), and by the use of single-center data, potentially limiting generalizability.

The study was supported by funding from the National Institute of Nursing Research. Dr. Jubran reported having no relevant financial disclosures.

SAN JUAN, P.R. – To extubate or to keep the patient on a ventilator? That is the question which, when answered by a respiratory therapy team before the next morning’s rounds began, halved the rate of ventilator-associated pneumonias and significantly decreased the time patients spent on ventilators in a surgical critical care unit, investigators reported at the annual Congress of the Society of Critical Care Medicine.

Previously, spontaneous breathing tests had occurred either during or after morning rounds, with extubations being left until sometime later in the day. Under the new protocol, however, respiratory therapists assigned exclusively to the surgical CCU conducted rounds three times daily, consulted with nurses and physicians, and performed spontaneous breathing tests as recommended under joint 2001 guidelines. Thus armed with the information, the multiprofessional team could make the final decision to extubate, and the extubation itself could occur at morning rounds, getting patients off the ventilator that much sooner, said Dr. Vijay Jayaraman, a resident in surgery at the Christiana Care Health System in Wilmington, Del.

Under the new protocol, Dr. Jayaraman and his colleagues saw the rate of ventilator-associated pneumonia (VAP) events decline from 10.8/1,000 ventilator days before the protocol was implemented, to 5.3/1,000 afterward (P less than .05). The mean time to start a spontaneous breathing trial dropped from 2.67 to 1.77 days (P = .004), and the time to extubation was shortened by a full day, 4.47 to 3.43 days (P = .033). There was no difference in days spent in the CCU post extubation, days spent on the patient floor after the CCU stay, or hospital length of stay, Dr. Jayaraman reported.

"This was established in a CCU that was already fully functioning with an active care team. It just required some reorganization, and the most important thing is that the respiratory therapist can be empowered to help us and actively drive the spontaneous breathing test and extubation process," he commented.

Dr. Juliana Barr, who moderated the session at which Dr, Jayaraman presented his study, commented that although myriad other groups have published ventilator-weaning protocols incorporating respiratory therapists, she was not aware of any studies that had previously shown a reduction in VAP rates.

"That was a low-hanging fruit study waiting for someone to do it, and I’m glad that you came along and did that. Thank you," she told Dr. Jayaraman. Dr. Barr is the acting medical director of critical care at the VA Palo Alto (Calif.) Health Care System.

The respiratory team uses predetermined criteria in a coordinated process consisting of awakening patients, performing the spontaneous breathing test, and, whenever possible, making the decision to extubate either before or during rounds.

For the study, the authors prospectively collected data on 180 patients admitted to their 28-bed level 1 surgical CCU from July through December 2010, before the protocol was implemented, and in 219 patients admitted over the same months in 2011, after the protocol had been in place for 6 months.

Extubate when the time is right

In a separate study, investigators from Montefiore Medical Center and other New York City institutions looked at whether outcomes following extubations in the CCU differed according to the time of day.

They retrospectively studied records of 2,240 patients on mechanical ventilation in 1 of 5 CCUs, and found that there were no significant differences in either 24-hour or 72-hour reintubation rates or in morality between patients extubated during daytime hours or during the night.

"Our data provides evidence that nighttime extubation is itself not associated with elevated risk of reintubation or mortality. Patients should be extubated when weaning parameters are met, irrespective of time of day, with appropriate staffing and resources," Dr. Bryan R. Tischenkel said in a poster presentation. Dr. Tischenkel is an anesthesia resident at New York Presbyterian Hospital.

Both studies were internally funded. Dr. Jayaraman, Dr. Barr, and and Dr. Tischenkel each reported having no relevant financial disclosures.

SAN JUAN, P.R. – To extubate or to keep the patient on a ventilator? That is the question which, when answered by a respiratory therapy team before the next morning’s rounds began, halved the rate of ventilator-associated pneumonias and significantly decreased the time patients spent on ventilators in a surgical critical care unit, investigators reported at the annual Congress of the Society of Critical Care Medicine.

Previously, spontaneous breathing tests had occurred either during or after morning rounds, with extubations being left until sometime later in the day. Under the new protocol, however, respiratory therapists assigned exclusively to the surgical CCU conducted rounds three times daily, consulted with nurses and physicians, and performed spontaneous breathing tests as recommended under joint 2001 guidelines. Thus armed with the information, the multiprofessional team could make the final decision to extubate, and the extubation itself could occur at morning rounds, getting patients off the ventilator that much sooner, said Dr. Vijay Jayaraman, a resident in surgery at the Christiana Care Health System in Wilmington, Del.

Under the new protocol, Dr. Jayaraman and his colleagues saw the rate of ventilator-associated pneumonia (VAP) events decline from 10.8/1,000 ventilator days before the protocol was implemented, to 5.3/1,000 afterward (P less than .05). The mean time to start a spontaneous breathing trial dropped from 2.67 to 1.77 days (P = .004), and the time to extubation was shortened by a full day, 4.47 to 3.43 days (P = .033). There was no difference in days spent in the CCU post extubation, days spent on the patient floor after the CCU stay, or hospital length of stay, Dr. Jayaraman reported.

"This was established in a CCU that was already fully functioning with an active care team. It just required some reorganization, and the most important thing is that the respiratory therapist can be empowered to help us and actively drive the spontaneous breathing test and extubation process," he commented.

Dr. Juliana Barr, who moderated the session at which Dr, Jayaraman presented his study, commented that although myriad other groups have published ventilator-weaning protocols incorporating respiratory therapists, she was not aware of any studies that had previously shown a reduction in VAP rates.

"That was a low-hanging fruit study waiting for someone to do it, and I’m glad that you came along and did that. Thank you," she told Dr. Jayaraman. Dr. Barr is the acting medical director of critical care at the VA Palo Alto (Calif.) Health Care System.

The respiratory team uses predetermined criteria in a coordinated process consisting of awakening patients, performing the spontaneous breathing test, and, whenever possible, making the decision to extubate either before or during rounds.

For the study, the authors prospectively collected data on 180 patients admitted to their 28-bed level 1 surgical CCU from July through December 2010, before the protocol was implemented, and in 219 patients admitted over the same months in 2011, after the protocol had been in place for 6 months.

Extubate when the time is right

In a separate study, investigators from Montefiore Medical Center and other New York City institutions looked at whether outcomes following extubations in the CCU differed according to the time of day.

They retrospectively studied records of 2,240 patients on mechanical ventilation in 1 of 5 CCUs, and found that there were no significant differences in either 24-hour or 72-hour reintubation rates or in morality between patients extubated during daytime hours or during the night.

"Our data provides evidence that nighttime extubation is itself not associated with elevated risk of reintubation or mortality. Patients should be extubated when weaning parameters are met, irrespective of time of day, with appropriate staffing and resources," Dr. Bryan R. Tischenkel said in a poster presentation. Dr. Tischenkel is an anesthesia resident at New York Presbyterian Hospital.

Both studies were internally funded. Dr. Jayaraman, Dr. Barr, and and Dr. Tischenkel each reported having no relevant financial disclosures.

SAN JUAN, P.R. – To extubate or to keep the patient on a ventilator? That is the question which, when answered by a respiratory therapy team before the next morning’s rounds began, halved the rate of ventilator-associated pneumonias and significantly decreased the time patients spent on ventilators in a surgical critical care unit, investigators reported at the annual Congress of the Society of Critical Care Medicine.

Previously, spontaneous breathing tests had occurred either during or after morning rounds, with extubations being left until sometime later in the day. Under the new protocol, however, respiratory therapists assigned exclusively to the surgical CCU conducted rounds three times daily, consulted with nurses and physicians, and performed spontaneous breathing tests as recommended under joint 2001 guidelines. Thus armed with the information, the multiprofessional team could make the final decision to extubate, and the extubation itself could occur at morning rounds, getting patients off the ventilator that much sooner, said Dr. Vijay Jayaraman, a resident in surgery at the Christiana Care Health System in Wilmington, Del.

Under the new protocol, Dr. Jayaraman and his colleagues saw the rate of ventilator-associated pneumonia (VAP) events decline from 10.8/1,000 ventilator days before the protocol was implemented, to 5.3/1,000 afterward (P less than .05). The mean time to start a spontaneous breathing trial dropped from 2.67 to 1.77 days (P = .004), and the time to extubation was shortened by a full day, 4.47 to 3.43 days (P = .033). There was no difference in days spent in the CCU post extubation, days spent on the patient floor after the CCU stay, or hospital length of stay, Dr. Jayaraman reported.

"This was established in a CCU that was already fully functioning with an active care team. It just required some reorganization, and the most important thing is that the respiratory therapist can be empowered to help us and actively drive the spontaneous breathing test and extubation process," he commented.

Dr. Juliana Barr, who moderated the session at which Dr, Jayaraman presented his study, commented that although myriad other groups have published ventilator-weaning protocols incorporating respiratory therapists, she was not aware of any studies that had previously shown a reduction in VAP rates.

"That was a low-hanging fruit study waiting for someone to do it, and I’m glad that you came along and did that. Thank you," she told Dr. Jayaraman. Dr. Barr is the acting medical director of critical care at the VA Palo Alto (Calif.) Health Care System.

The respiratory team uses predetermined criteria in a coordinated process consisting of awakening patients, performing the spontaneous breathing test, and, whenever possible, making the decision to extubate either before or during rounds.

For the study, the authors prospectively collected data on 180 patients admitted to their 28-bed level 1 surgical CCU from July through December 2010, before the protocol was implemented, and in 219 patients admitted over the same months in 2011, after the protocol had been in place for 6 months.

Extubate when the time is right

In a separate study, investigators from Montefiore Medical Center and other New York City institutions looked at whether outcomes following extubations in the CCU differed according to the time of day.

They retrospectively studied records of 2,240 patients on mechanical ventilation in 1 of 5 CCUs, and found that there were no significant differences in either 24-hour or 72-hour reintubation rates or in morality between patients extubated during daytime hours or during the night.

"Our data provides evidence that nighttime extubation is itself not associated with elevated risk of reintubation or mortality. Patients should be extubated when weaning parameters are met, irrespective of time of day, with appropriate staffing and resources," Dr. Bryan R. Tischenkel said in a poster presentation. Dr. Tischenkel is an anesthesia resident at New York Presbyterian Hospital.

Both studies were internally funded. Dr. Jayaraman, Dr. Barr, and and Dr. Tischenkel each reported having no relevant financial disclosures.

Among adults discharged from the hospital, visits to the emergency department within 30 days are nearly as frequent as are readmissions, according to a report in the Jan. 23/30 issue of JAMA.

In a population-based study of 30-day outcomes after hospital discharge, treat-and-release visits to the ED accounted for approximately 40% of all hospital-based acute care given in the immediate postdischarge period, said Dr. Anita A. Vashi of the Robert Wood Johnson Foundation Clinical Scholars Program and the department of emergency medicine, Yale University, New Haven, Conn., and her associates.

Readmission rates are seen as a marker of hospitals’ quality of care. Rates of ED visits following discharge also are important, but aren’t as well understood. Studies done to date "have tended to focus on the experience at a single institution, with a single payer, or with a specific condition," the investigators said.

"The use of hospital readmissions as a lone metric for postdischarge health care quality may be incomplete without considering the role of the ED," they noted.

The researchers studied the issue using data from three geographically distant states that participate in the Healthcare Cost and Utilization Project state inpatient and ED databases, using a sample of 5,032,254 discharges during a 1-year period from medical centers in California, Florida, and Nebraska. All together these states account for approximately 17% of all hospitalizations in the United States annually.

All the study subjects were adults, with a mean age of 53.4 years; 29.2% were aged 65 years and older. Slightly more than half were women, and slightly less than half were white. Most of the patients had some form of medical coverage, including private insurance (32%) and Medicare (30%). These patients were discharged after hospitalization for 470 unique conditions, 65.2% medical, 34.8% surgical. The researchers defined the ED visits as treat-and-release to separate them from visits to the ED that resulted in readmission, as about 57% of the readmissions were through the ED.

Overall, 17.9% of all discharges were followed by at least one acute-care visit to a hospital within 30 days. About one-third of all such visits – 35% of ED visits and 31% of readmissions – occurred within 7 days of discharge. A total of 7.5% of discharges were followed by at least one ED visit, and another 12.3% by a readmission. There were 97.5 ED visits and 147.6 readmissions for every 1,000 discharges.

ED visits accounted for 39.8% of the 1,233,402 postdischarge visits for acute care (JAMA 2013;309:364-71).

"Focusing solely on readmissions would have missed nearly half a million ED treat-and-release encounters in these three states and substantially underestimated acute care use following medical and surgical inpatient discharges," Dr. Vashi and her colleagues noted.

It is crucial to include such ED visits in assessments of hospitals’ quality of care because they contribute substantially to fragmentation of care with its attendant duplication of services, conflicting care recommendations, medication errors, patient distress, and higher costs, they added.

Among medical discharges, 30-day rates of ED visits were highest for digestive disorders (140.7 visits per 1,000 discharges) and psychosis (219.4 visits per 1,000 discharges). Visits for heart failure also were common.

Among surgical conditions, ED visits were most common for complicated laparoscopic cholecystectomy (84.5 visits per 1,000 discharges) and complicated cesarean deliveries (84.6 visits per 1,000 discharges). Visits following PCI with drug-eluting stent placement, for major cardiac diagnoses, and for complicated hip and femur procedures also were common.

Among the 470 unique conditions in this study, those with the highest rates of ED visits were related to mental health problems and drug and alcohol abuse.

"Anticipating patient needs and developing an appropriate care plan prior to hospital discharge may help prevent some of these likely low-acuity visits," Dr. Vashi and her associates said.

For example, "given that patients hospitalized for reasons related to mental illness and drug and alcohol abuse had especially high rates of return to the ED, there must be consideration of how acute care can be best delivered and targeted to this population outside of hospitals," they said.

The investigators cautioned that their findings underestimate the number of hospital discharges that are immediately followed by emergency care visits, because they could not include in this study patients who died before making it to the ED, went to urgent-care centers, or presented at walk-in clinics.

This study was supported in part by the Agency for Healthcare Research and Quality, the National Institute on Aging, and the American Federation for Aging Research. Dr. Vashi reported no financial conflicts of interest, and one of her associates reported ties to Medtronic.

Among adults discharged from the hospital, visits to the emergency department within 30 days are nearly as frequent as are readmissions, according to a report in the Jan. 23/30 issue of JAMA.

In a population-based study of 30-day outcomes after hospital discharge, treat-and-release visits to the ED accounted for approximately 40% of all hospital-based acute care given in the immediate postdischarge period, said Dr. Anita A. Vashi of the Robert Wood Johnson Foundation Clinical Scholars Program and the department of emergency medicine, Yale University, New Haven, Conn., and her associates.

Readmission rates are seen as a marker of hospitals’ quality of care. Rates of ED visits following discharge also are important, but aren’t as well understood. Studies done to date "have tended to focus on the experience at a single institution, with a single payer, or with a specific condition," the investigators said.

"The use of hospital readmissions as a lone metric for postdischarge health care quality may be incomplete without considering the role of the ED," they noted.

The researchers studied the issue using data from three geographically distant states that participate in the Healthcare Cost and Utilization Project state inpatient and ED databases, using a sample of 5,032,254 discharges during a 1-year period from medical centers in California, Florida, and Nebraska. All together these states account for approximately 17% of all hospitalizations in the United States annually.

All the study subjects were adults, with a mean age of 53.4 years; 29.2% were aged 65 years and older. Slightly more than half were women, and slightly less than half were white. Most of the patients had some form of medical coverage, including private insurance (32%) and Medicare (30%). These patients were discharged after hospitalization for 470 unique conditions, 65.2% medical, 34.8% surgical. The researchers defined the ED visits as treat-and-release to separate them from visits to the ED that resulted in readmission, as about 57% of the readmissions were through the ED.

Overall, 17.9% of all discharges were followed by at least one acute-care visit to a hospital within 30 days. About one-third of all such visits – 35% of ED visits and 31% of readmissions – occurred within 7 days of discharge. A total of 7.5% of discharges were followed by at least one ED visit, and another 12.3% by a readmission. There were 97.5 ED visits and 147.6 readmissions for every 1,000 discharges.

ED visits accounted for 39.8% of the 1,233,402 postdischarge visits for acute care (JAMA 2013;309:364-71).

"Focusing solely on readmissions would have missed nearly half a million ED treat-and-release encounters in these three states and substantially underestimated acute care use following medical and surgical inpatient discharges," Dr. Vashi and her colleagues noted.

It is crucial to include such ED visits in assessments of hospitals’ quality of care because they contribute substantially to fragmentation of care with its attendant duplication of services, conflicting care recommendations, medication errors, patient distress, and higher costs, they added.

Among medical discharges, 30-day rates of ED visits were highest for digestive disorders (140.7 visits per 1,000 discharges) and psychosis (219.4 visits per 1,000 discharges). Visits for heart failure also were common.

Among surgical conditions, ED visits were most common for complicated laparoscopic cholecystectomy (84.5 visits per 1,000 discharges) and complicated cesarean deliveries (84.6 visits per 1,000 discharges). Visits following PCI with drug-eluting stent placement, for major cardiac diagnoses, and for complicated hip and femur procedures also were common.

Among the 470 unique conditions in this study, those with the highest rates of ED visits were related to mental health problems and drug and alcohol abuse.

"Anticipating patient needs and developing an appropriate care plan prior to hospital discharge may help prevent some of these likely low-acuity visits," Dr. Vashi and her associates said.

For example, "given that patients hospitalized for reasons related to mental illness and drug and alcohol abuse had especially high rates of return to the ED, there must be consideration of how acute care can be best delivered and targeted to this population outside of hospitals," they said.

The investigators cautioned that their findings underestimate the number of hospital discharges that are immediately followed by emergency care visits, because they could not include in this study patients who died before making it to the ED, went to urgent-care centers, or presented at walk-in clinics.

This study was supported in part by the Agency for Healthcare Research and Quality, the National Institute on Aging, and the American Federation for Aging Research. Dr. Vashi reported no financial conflicts of interest, and one of her associates reported ties to Medtronic.

Among adults discharged from the hospital, visits to the emergency department within 30 days are nearly as frequent as are readmissions, according to a report in the Jan. 23/30 issue of JAMA.

In a population-based study of 30-day outcomes after hospital discharge, treat-and-release visits to the ED accounted for approximately 40% of all hospital-based acute care given in the immediate postdischarge period, said Dr. Anita A. Vashi of the Robert Wood Johnson Foundation Clinical Scholars Program and the department of emergency medicine, Yale University, New Haven, Conn., and her associates.

Readmission rates are seen as a marker of hospitals’ quality of care. Rates of ED visits following discharge also are important, but aren’t as well understood. Studies done to date "have tended to focus on the experience at a single institution, with a single payer, or with a specific condition," the investigators said.

"The use of hospital readmissions as a lone metric for postdischarge health care quality may be incomplete without considering the role of the ED," they noted.

The researchers studied the issue using data from three geographically distant states that participate in the Healthcare Cost and Utilization Project state inpatient and ED databases, using a sample of 5,032,254 discharges during a 1-year period from medical centers in California, Florida, and Nebraska. All together these states account for approximately 17% of all hospitalizations in the United States annually.

All the study subjects were adults, with a mean age of 53.4 years; 29.2% were aged 65 years and older. Slightly more than half were women, and slightly less than half were white. Most of the patients had some form of medical coverage, including private insurance (32%) and Medicare (30%). These patients were discharged after hospitalization for 470 unique conditions, 65.2% medical, 34.8% surgical. The researchers defined the ED visits as treat-and-release to separate them from visits to the ED that resulted in readmission, as about 57% of the readmissions were through the ED.

Overall, 17.9% of all discharges were followed by at least one acute-care visit to a hospital within 30 days. About one-third of all such visits – 35% of ED visits and 31% of readmissions – occurred within 7 days of discharge. A total of 7.5% of discharges were followed by at least one ED visit, and another 12.3% by a readmission. There were 97.5 ED visits and 147.6 readmissions for every 1,000 discharges.

ED visits accounted for 39.8% of the 1,233,402 postdischarge visits for acute care (JAMA 2013;309:364-71).

"Focusing solely on readmissions would have missed nearly half a million ED treat-and-release encounters in these three states and substantially underestimated acute care use following medical and surgical inpatient discharges," Dr. Vashi and her colleagues noted.

It is crucial to include such ED visits in assessments of hospitals’ quality of care because they contribute substantially to fragmentation of care with its attendant duplication of services, conflicting care recommendations, medication errors, patient distress, and higher costs, they added.

Among medical discharges, 30-day rates of ED visits were highest for digestive disorders (140.7 visits per 1,000 discharges) and psychosis (219.4 visits per 1,000 discharges). Visits for heart failure also were common.

Among surgical conditions, ED visits were most common for complicated laparoscopic cholecystectomy (84.5 visits per 1,000 discharges) and complicated cesarean deliveries (84.6 visits per 1,000 discharges). Visits following PCI with drug-eluting stent placement, for major cardiac diagnoses, and for complicated hip and femur procedures also were common.

Among the 470 unique conditions in this study, those with the highest rates of ED visits were related to mental health problems and drug and alcohol abuse.

"Anticipating patient needs and developing an appropriate care plan prior to hospital discharge may help prevent some of these likely low-acuity visits," Dr. Vashi and her associates said.

For example, "given that patients hospitalized for reasons related to mental illness and drug and alcohol abuse had especially high rates of return to the ED, there must be consideration of how acute care can be best delivered and targeted to this population outside of hospitals," they said.

The investigators cautioned that their findings underestimate the number of hospital discharges that are immediately followed by emergency care visits, because they could not include in this study patients who died before making it to the ED, went to urgent-care centers, or presented at walk-in clinics.

This study was supported in part by the Agency for Healthcare Research and Quality, the National Institute on Aging, and the American Federation for Aging Research. Dr. Vashi reported no financial conflicts of interest, and one of her associates reported ties to Medtronic.

The page came around 2 a.m. It had been a very busy night, with a dozen or so surgical consults from an overflowing emergency department in a large urban hospital. Most of the patients referred to the surgical service were immigrants with a limited knowledge of English. Most were elderly. And most were alone.

I was 2 months out of medical school, on call without a senior resident and with staff backup at home. I struggled to remain awake while catering to the seemingly endless pages from the ward and the emergency department. It was a rite of passage that every intern has had to endure.

The patient was an 85-year-old Cantonese-speaking woman transferred to the emergency department by ambulance from her nursing home. The accompanying note, mostly illegible, suggested that she had been complaining of abdominal pain and distention for the past 2 days and had been initially managed with laxatives.

That afternoon, however, her level of consciousness began to deteriorate and she became febrile and hypotensive, so she was transferred to our hospital. She had a history of atrial fibrillation, hypertension, and advanced Alzheimer’s dementia. She also had an accompanying "Do Not Resuscitate/No Life Support" form.

A CT scan of the abdomen arranged by the emergency department physician identified a clot in the superior mesenteric artery and extensive ischemic changes in most of her small bowel. She had a high white blood cell count, and her serum lactate was alarmingly elevated, despite several boluses of intravenous crystalloid solution. She was also becoming hemodynamically unstable.

I immediately called the staff surgeon to advocate for an emergency laparotomy. Given the patient’s multiple comorbidities and grim prognosis, we decided not to operate. The staff surgeon’s instructions were as abrupt as they were clear: "Turf her to medicine; she’s palliative."

The medical senior resident, however, would have none of it. Equally overwhelmed with consults and not in a particularly good mood, he refused to even see the patient. If she was expected to die overnight because of a surgical issue, he argued, then the surgery team was just as equipped as he to take care of her. The emergency department physician agreed, and so the patient was admitted to the surgical service for her few remaining hours of life.

What followed was agonizing for the entire surgical team. The nurses on the ward were asking some very reasonable questions that I could not answer: Do we keep titrating the patient’s oxygen to keep up with her desaturation? What do we give her for pain control? How do we manage her shortness of breath? Should we continue giving her intravenous fluids? Can you help us find her family members? Should we keep the bladder catheter in place?

I strained to remember what we had learned in our few palliative care lectures back in medical school. Intravenous fluids were OK, but oxygen was not. Or was it the other way around? Google, the ever-faithful guardian of the panicking intern, was unhelpful. I could not find a reputable online resource to help guide the management of this patient and, given the other sick patients who needed attention, I could not sit down to perform a thorough online literature search. The hospital’s switchboard was equally disappointing – there were no palliative care physicians on call, and the palliative team only accepted pages after 8 a.m., an appalling 5 hours away.

Eventually, I decided to support the patient with an oxygen mask and to continue her intravenous fluid resuscitation. I gave her plenty of narcotics and antiemetics to soothe the discomfort. We were unable to reach any family members despite several attempts. She died just after 5 a.m., without any visible signs of discomfort. It was the first death certificate I had ever signed.

Reflecting on this experience, I was upset at my inability to quickly and adequately care for this patient’s end-of-life needs. I was also angry that I had not prepared myself appropriately for that night on call, and I would have done several things differently had I had the chance.

General surgeons take immense pride in being internists who can operate. We enjoy debating antibiotic, diuretics, and anticoagulation choices with the specialists consulting on our patients, but we often simply "switch off" whenever the patient is labeled "palliative" or "end of life" – relying entirely on the palliative care team for help. And yet, we’re the ones who admit, operate on, and develop therapeutic relationships with those patients and their families. It just doesn’t seem right, but there are several reasons for this dilemma.

First, the fast pace and busy nature of any surgical service means that trainees and staff are under a lot of pressure to round as quickly and efficiently as possible and get to the operating room early in the morning. Given current trainee work-hour limitations and mandated hand-over, today’s junior staff feel this pressure all the more acutely. There simply isn’t enough time or opportunity for continuity of care. Surgical teams can’t engage palliative patients and their families in the way that dedicated palliative care teams can, and so surgical teams are often more comfortable delegating this responsibility entirely to their palliative care colleagues.

Second, there is an emotional burden to caring for palliative patients and their families. Palliation and end-of-life care imply that surgery is neither possible nor advisable any longer. It can be difficult for the surgeon to make that mental segue and assume the dual role of the psychological and medical care giver. Just as surgeons prefer that cardiologists manage their patients’ arrhythmias and nephrologists their patients’ kidney failures, they may prefer that palliative care specialists manage the emotional and medical needs of the patients on whom they can no longer operate.

Furthermore, surgical trainees have limited exposure to palliative care in the clinical setting. As the field of surgery becomes progressively more complex, palliative care training has not been at the forefront of the educational agenda. While it is taught in medical schools and in the surgical residency curriculum, there are few formalized core rotations that offer the surgical resident an insight into the clinical applications of palliative care, except for those who are particularly interested and seek such learning opportunities out in the form of an elective rotation.

The development of dedicated and multidisciplinary palliative care teams that include staff, nurse practitioners, and palliative fellows has further limited surgical resident exposure to the field. Simply put, the current medical system encourages surgical trainees to sign off on the surgical palliative patient.

This, however, isn’t good enough. Palliative care of the surgical patient needs to be a pillar of surgical training. Trainees need to be as comfortable with managing the symptoms of the dying surgical patient as they are administering fluid boluses and ordering narcotics for postoperative pain, especially late at night when there is no palliative care support.

The American College of Surgeons has responded to this challenge by developing numerous educational initiatives through its Palliative Workgroup. It has published a comprehensive surgical palliative care self-study guide specifically for residents (Surgical Palliative Care: A Residents Guide, available for free download).

There are also several regularly updated online palliative care references available either through subscription websites such as UpToDate or for free, such as the Medical College of Wisconsin’s End of Life/Palliative Education Resource Center, which offers "Fast Facts" on the management of the dying patient.

Palliative care is widely accepted today as an important clinical discipline that provides vital support to a growing proportion of the patient population. Surgical training must keep pace with this evolving reality because, at the end of the day, to be without agony and discomfort is a standard of care that every dying patient expects – not just a heroic measure that we can simply ignore.

Dr. Kayssi is a PGY IV in the general surgery program at the University of Toronto.

Dr. Easson is an ACS Fellow and assistant professor in the department of surgery and the Institute of Health, Policy, Management and Evaluation at the University of Toronto.

The page came around 2 a.m. It had been a very busy night, with a dozen or so surgical consults from an overflowing emergency department in a large urban hospital. Most of the patients referred to the surgical service were immigrants with a limited knowledge of English. Most were elderly. And most were alone.

I was 2 months out of medical school, on call without a senior resident and with staff backup at home. I struggled to remain awake while catering to the seemingly endless pages from the ward and the emergency department. It was a rite of passage that every intern has had to endure.

The patient was an 85-year-old Cantonese-speaking woman transferred to the emergency department by ambulance from her nursing home. The accompanying note, mostly illegible, suggested that she had been complaining of abdominal pain and distention for the past 2 days and had been initially managed with laxatives.

That afternoon, however, her level of consciousness began to deteriorate and she became febrile and hypotensive, so she was transferred to our hospital. She had a history of atrial fibrillation, hypertension, and advanced Alzheimer’s dementia. She also had an accompanying "Do Not Resuscitate/No Life Support" form.

A CT scan of the abdomen arranged by the emergency department physician identified a clot in the superior mesenteric artery and extensive ischemic changes in most of her small bowel. She had a high white blood cell count, and her serum lactate was alarmingly elevated, despite several boluses of intravenous crystalloid solution. She was also becoming hemodynamically unstable.

I immediately called the staff surgeon to advocate for an emergency laparotomy. Given the patient’s multiple comorbidities and grim prognosis, we decided not to operate. The staff surgeon’s instructions were as abrupt as they were clear: "Turf her to medicine; she’s palliative."

The medical senior resident, however, would have none of it. Equally overwhelmed with consults and not in a particularly good mood, he refused to even see the patient. If she was expected to die overnight because of a surgical issue, he argued, then the surgery team was just as equipped as he to take care of her. The emergency department physician agreed, and so the patient was admitted to the surgical service for her few remaining hours of life.

What followed was agonizing for the entire surgical team. The nurses on the ward were asking some very reasonable questions that I could not answer: Do we keep titrating the patient’s oxygen to keep up with her desaturation? What do we give her for pain control? How do we manage her shortness of breath? Should we continue giving her intravenous fluids? Can you help us find her family members? Should we keep the bladder catheter in place?

I strained to remember what we had learned in our few palliative care lectures back in medical school. Intravenous fluids were OK, but oxygen was not. Or was it the other way around? Google, the ever-faithful guardian of the panicking intern, was unhelpful. I could not find a reputable online resource to help guide the management of this patient and, given the other sick patients who needed attention, I could not sit down to perform a thorough online literature search. The hospital’s switchboard was equally disappointing – there were no palliative care physicians on call, and the palliative team only accepted pages after 8 a.m., an appalling 5 hours away.

Eventually, I decided to support the patient with an oxygen mask and to continue her intravenous fluid resuscitation. I gave her plenty of narcotics and antiemetics to soothe the discomfort. We were unable to reach any family members despite several attempts. She died just after 5 a.m., without any visible signs of discomfort. It was the first death certificate I had ever signed.

Reflecting on this experience, I was upset at my inability to quickly and adequately care for this patient’s end-of-life needs. I was also angry that I had not prepared myself appropriately for that night on call, and I would have done several things differently had I had the chance.

General surgeons take immense pride in being internists who can operate. We enjoy debating antibiotic, diuretics, and anticoagulation choices with the specialists consulting on our patients, but we often simply "switch off" whenever the patient is labeled "palliative" or "end of life" – relying entirely on the palliative care team for help. And yet, we’re the ones who admit, operate on, and develop therapeutic relationships with those patients and their families. It just doesn’t seem right, but there are several reasons for this dilemma.

First, the fast pace and busy nature of any surgical service means that trainees and staff are under a lot of pressure to round as quickly and efficiently as possible and get to the operating room early in the morning. Given current trainee work-hour limitations and mandated hand-over, today’s junior staff feel this pressure all the more acutely. There simply isn’t enough time or opportunity for continuity of care. Surgical teams can’t engage palliative patients and their families in the way that dedicated palliative care teams can, and so surgical teams are often more comfortable delegating this responsibility entirely to their palliative care colleagues.

Second, there is an emotional burden to caring for palliative patients and their families. Palliation and end-of-life care imply that surgery is neither possible nor advisable any longer. It can be difficult for the surgeon to make that mental segue and assume the dual role of the psychological and medical care giver. Just as surgeons prefer that cardiologists manage their patients’ arrhythmias and nephrologists their patients’ kidney failures, they may prefer that palliative care specialists manage the emotional and medical needs of the patients on whom they can no longer operate.

Furthermore, surgical trainees have limited exposure to palliative care in the clinical setting. As the field of surgery becomes progressively more complex, palliative care training has not been at the forefront of the educational agenda. While it is taught in medical schools and in the surgical residency curriculum, there are few formalized core rotations that offer the surgical resident an insight into the clinical applications of palliative care, except for those who are particularly interested and seek such learning opportunities out in the form of an elective rotation.

The development of dedicated and multidisciplinary palliative care teams that include staff, nurse practitioners, and palliative fellows has further limited surgical resident exposure to the field. Simply put, the current medical system encourages surgical trainees to sign off on the surgical palliative patient.

This, however, isn’t good enough. Palliative care of the surgical patient needs to be a pillar of surgical training. Trainees need to be as comfortable with managing the symptoms of the dying surgical patient as they are administering fluid boluses and ordering narcotics for postoperative pain, especially late at night when there is no palliative care support.

The American College of Surgeons has responded to this challenge by developing numerous educational initiatives through its Palliative Workgroup. It has published a comprehensive surgical palliative care self-study guide specifically for residents (Surgical Palliative Care: A Residents Guide, available for free download).

There are also several regularly updated online palliative care references available either through subscription websites such as UpToDate or for free, such as the Medical College of Wisconsin’s End of Life/Palliative Education Resource Center, which offers "Fast Facts" on the management of the dying patient.

Palliative care is widely accepted today as an important clinical discipline that provides vital support to a growing proportion of the patient population. Surgical training must keep pace with this evolving reality because, at the end of the day, to be without agony and discomfort is a standard of care that every dying patient expects – not just a heroic measure that we can simply ignore.

Dr. Kayssi is a PGY IV in the general surgery program at the University of Toronto.

Dr. Easson is an ACS Fellow and assistant professor in the department of surgery and the Institute of Health, Policy, Management and Evaluation at the University of Toronto.

The page came around 2 a.m. It had been a very busy night, with a dozen or so surgical consults from an overflowing emergency department in a large urban hospital. Most of the patients referred to the surgical service were immigrants with a limited knowledge of English. Most were elderly. And most were alone.

I was 2 months out of medical school, on call without a senior resident and with staff backup at home. I struggled to remain awake while catering to the seemingly endless pages from the ward and the emergency department. It was a rite of passage that every intern has had to endure.

The patient was an 85-year-old Cantonese-speaking woman transferred to the emergency department by ambulance from her nursing home. The accompanying note, mostly illegible, suggested that she had been complaining of abdominal pain and distention for the past 2 days and had been initially managed with laxatives.

That afternoon, however, her level of consciousness began to deteriorate and she became febrile and hypotensive, so she was transferred to our hospital. She had a history of atrial fibrillation, hypertension, and advanced Alzheimer’s dementia. She also had an accompanying "Do Not Resuscitate/No Life Support" form.

A CT scan of the abdomen arranged by the emergency department physician identified a clot in the superior mesenteric artery and extensive ischemic changes in most of her small bowel. She had a high white blood cell count, and her serum lactate was alarmingly elevated, despite several boluses of intravenous crystalloid solution. She was also becoming hemodynamically unstable.

I immediately called the staff surgeon to advocate for an emergency laparotomy. Given the patient’s multiple comorbidities and grim prognosis, we decided not to operate. The staff surgeon’s instructions were as abrupt as they were clear: "Turf her to medicine; she’s palliative."

The medical senior resident, however, would have none of it. Equally overwhelmed with consults and not in a particularly good mood, he refused to even see the patient. If she was expected to die overnight because of a surgical issue, he argued, then the surgery team was just as equipped as he to take care of her. The emergency department physician agreed, and so the patient was admitted to the surgical service for her few remaining hours of life.

What followed was agonizing for the entire surgical team. The nurses on the ward were asking some very reasonable questions that I could not answer: Do we keep titrating the patient’s oxygen to keep up with her desaturation? What do we give her for pain control? How do we manage her shortness of breath? Should we continue giving her intravenous fluids? Can you help us find her family members? Should we keep the bladder catheter in place?

I strained to remember what we had learned in our few palliative care lectures back in medical school. Intravenous fluids were OK, but oxygen was not. Or was it the other way around? Google, the ever-faithful guardian of the panicking intern, was unhelpful. I could not find a reputable online resource to help guide the management of this patient and, given the other sick patients who needed attention, I could not sit down to perform a thorough online literature search. The hospital’s switchboard was equally disappointing – there were no palliative care physicians on call, and the palliative team only accepted pages after 8 a.m., an appalling 5 hours away.

Eventually, I decided to support the patient with an oxygen mask and to continue her intravenous fluid resuscitation. I gave her plenty of narcotics and antiemetics to soothe the discomfort. We were unable to reach any family members despite several attempts. She died just after 5 a.m., without any visible signs of discomfort. It was the first death certificate I had ever signed.

Reflecting on this experience, I was upset at my inability to quickly and adequately care for this patient’s end-of-life needs. I was also angry that I had not prepared myself appropriately for that night on call, and I would have done several things differently had I had the chance.

General surgeons take immense pride in being internists who can operate. We enjoy debating antibiotic, diuretics, and anticoagulation choices with the specialists consulting on our patients, but we often simply "switch off" whenever the patient is labeled "palliative" or "end of life" – relying entirely on the palliative care team for help. And yet, we’re the ones who admit, operate on, and develop therapeutic relationships with those patients and their families. It just doesn’t seem right, but there are several reasons for this dilemma.

First, the fast pace and busy nature of any surgical service means that trainees and staff are under a lot of pressure to round as quickly and efficiently as possible and get to the operating room early in the morning. Given current trainee work-hour limitations and mandated hand-over, today’s junior staff feel this pressure all the more acutely. There simply isn’t enough time or opportunity for continuity of care. Surgical teams can’t engage palliative patients and their families in the way that dedicated palliative care teams can, and so surgical teams are often more comfortable delegating this responsibility entirely to their palliative care colleagues.

Second, there is an emotional burden to caring for palliative patients and their families. Palliation and end-of-life care imply that surgery is neither possible nor advisable any longer. It can be difficult for the surgeon to make that mental segue and assume the dual role of the psychological and medical care giver. Just as surgeons prefer that cardiologists manage their patients’ arrhythmias and nephrologists their patients’ kidney failures, they may prefer that palliative care specialists manage the emotional and medical needs of the patients on whom they can no longer operate.

Furthermore, surgical trainees have limited exposure to palliative care in the clinical setting. As the field of surgery becomes progressively more complex, palliative care training has not been at the forefront of the educational agenda. While it is taught in medical schools and in the surgical residency curriculum, there are few formalized core rotations that offer the surgical resident an insight into the clinical applications of palliative care, except for those who are particularly interested and seek such learning opportunities out in the form of an elective rotation.

The development of dedicated and multidisciplinary palliative care teams that include staff, nurse practitioners, and palliative fellows has further limited surgical resident exposure to the field. Simply put, the current medical system encourages surgical trainees to sign off on the surgical palliative patient.

This, however, isn’t good enough. Palliative care of the surgical patient needs to be a pillar of surgical training. Trainees need to be as comfortable with managing the symptoms of the dying surgical patient as they are administering fluid boluses and ordering narcotics for postoperative pain, especially late at night when there is no palliative care support.

The American College of Surgeons has responded to this challenge by developing numerous educational initiatives through its Palliative Workgroup. It has published a comprehensive surgical palliative care self-study guide specifically for residents (Surgical Palliative Care: A Residents Guide, available for free download).

There are also several regularly updated online palliative care references available either through subscription websites such as UpToDate or for free, such as the Medical College of Wisconsin’s End of Life/Palliative Education Resource Center, which offers "Fast Facts" on the management of the dying patient.

Palliative care is widely accepted today as an important clinical discipline that provides vital support to a growing proportion of the patient population. Surgical training must keep pace with this evolving reality because, at the end of the day, to be without agony and discomfort is a standard of care that every dying patient expects – not just a heroic measure that we can simply ignore.

Dr. Kayssi is a PGY IV in the general surgery program at the University of Toronto.

Dr. Easson is an ACS Fellow and assistant professor in the department of surgery and the Institute of Health, Policy, Management and Evaluation at the University of Toronto.

Among critically ill adults requiring mechanical ventilation and receiving early enteral nutrition, it may not be necessary to routinely monitor residual gastric volume as a means of averting vomiting and thus preventing aspiration and the development of ventilator-associated pneumonia, according to a report in the Jan. 16 issue of JAMA.

In a multicenter randomized trial involving 449 such patients, forgoing routine monitoring of residual gastric volume was found "noninferior" at preventing ventilator-associated pneumonia to the standard practice of performing this monitoring every 6 hours. Moreover, patients who were not monitored actually were more likely to achieve their nutritional targets, while showing equivalent mortality, infection rates, lengths of hospital stay, lengths of ICU stay, and organ failure scores, said Dr. Jean Reignier of Centre Hospitalier Departemental de la Vendee, La Roche-sur Yon (France), and his associates.

"Residual gastric volume monitoring leads to unnecessary interruption of enteral nutrition delivery with subsequent inadequate feeding, and should be removed from the standard care of critically ill patients receiving invasive mechanical ventilation and early enteral nutrition," the investigators said.

It is thought that higher gastric volume causes intolerance of enteral feeding, with its attendant gastroesophageal reflux and vomiting. Monitoring of residual gastric volume involves periodically aspirating the stomach through the nasogastric tube with a 50-mL syringe. If the volume exceeds a cutoff – usually 250 mL – enteral nutrition is stopped or decreased to minimize the risk of vomiting, aspiration, and subsequent development of ventilator-associated pneumonia.

However, it has never been definitively established that increased gastric volume does lead to vomiting (or exactly what the cutoff amount should be), that this vomiting does lead to ventilator-associated pneumonia, or that the monitoring procedure actually reduces the risk of pneumonia. And monitoring has been linked to decreased calorie delivery and its associated morbidity.

Dr. Reignier and his colleagues found in a preliminary study at a single ICU that forgoing the monitoring procedure did not raise the rate of ventilator-associated pneumonia. They then performed this noninferiority study to test the theory that residual gastric volume monitoring may not be necessary for this purpose.

Adult patients who were expected to require more than 48 hours of mechanical ventilation at nine ICUs were enrolled over a 1-year period. Three of the ICUs were medical and six were medical-surgical. Three were in university hospitals and six were in general hospitals affiliated with a university.

The study subjects were randomly assigned to receive either standard care, which included monitoring of residual gastric volume every 6 hours or the "intervention" of no monitoring.

The primary outcome was the rate of ventilator-associated pneumonia. In the intention-to-treat analysis, this rate was 15.8% in the control group (222 patients) and 16.7% in the "intervention" group (227 patients), a nonsignificant difference. In the per-protocol analysis, this rate was 16.3% in the control group (215 patients) and 17.8% in the intervention group (208 patients), also a nonsignificant difference.

Thus, forgoing routine monitoring of residual gastric volume was noninferior to performing such monitoring at preventing this form of pneumonia, the researchers said (JAMA 2013;309:249-56).

In further analyses, the cumulative incidences of ventilator-associated pneumonia also were not significantly different between the two study groups. Microbiologic testing showed that the organisms causing pneumonia were the same between the two groups, as were the proportions of infections caused by Staphylococcus aureus, Streptococcus species, Enterobacteriaceae, and Pseudomonadaceae.

The two study groups also did not differ in short- or long-term mortality; rates of other ICU-acquired infections; scores on measures of organ failure; or the duration of ventilation, ICU stay, or hospital stay.

It was interesting that the proportion of patients who vomited was significantly higher in the unmonitored than in the monitored group, and that the number of vomiting episodes also was significantly higher in the unmonitored group, yet the rate of pneumonia was not significantly different, Dr. Reignier and his associates noted.

Despite higher rates of vomiting, more patients in the unmonitored group achieved their calorie targets on enteral nutrition.

The investigators proposed several explanations for their findings.

In several previous studies, residual gastric volumes did not correlate with vomiting or aspiration rates. Volumes lower than 250 mL did not correlate with decreased complications, and values as high as 500 mL did not correlate with increased rates of pneumonia.

Second, the measurement of residual gastric volume has never been standardized or validated. And the accuracy of gastric aspiration through the nasogastric tube may vary according to tube position, tube diameter, the number of tube openings in the stomach, the level of aspiration in the stomach, and the clinician’s experience, the investigators said.

Third, and perhaps most important, many studies have challenged the role of gastric aspiration in the development of ventilator-associated pneumonia. The oral cavity, not the stomach, may be the significant reservoir of pathogens that cause this form of pneumonia, they said.

Eliminating the routine monitoring of residual gastric volume would be advantageous in that it would significantly reduce the workload of nurses and other clinicians, allowing them to focus on other interventions that have proved their value, Dr. Reignier and his colleagues added.

The study was sponsored by Centre Hospitalier Departmental de la Vendee. No financial conflicts of interest were reported.

Among critically ill adults requiring mechanical ventilation and receiving early enteral nutrition, it may not be necessary to routinely monitor residual gastric volume as a means of averting vomiting and thus preventing aspiration and the development of ventilator-associated pneumonia, according to a report in the Jan. 16 issue of JAMA.

In a multicenter randomized trial involving 449 such patients, forgoing routine monitoring of residual gastric volume was found "noninferior" at preventing ventilator-associated pneumonia to the standard practice of performing this monitoring every 6 hours. Moreover, patients who were not monitored actually were more likely to achieve their nutritional targets, while showing equivalent mortality, infection rates, lengths of hospital stay, lengths of ICU stay, and organ failure scores, said Dr. Jean Reignier of Centre Hospitalier Departemental de la Vendee, La Roche-sur Yon (France), and his associates.

"Residual gastric volume monitoring leads to unnecessary interruption of enteral nutrition delivery with subsequent inadequate feeding, and should be removed from the standard care of critically ill patients receiving invasive mechanical ventilation and early enteral nutrition," the investigators said.

It is thought that higher gastric volume causes intolerance of enteral feeding, with its attendant gastroesophageal reflux and vomiting. Monitoring of residual gastric volume involves periodically aspirating the stomach through the nasogastric tube with a 50-mL syringe. If the volume exceeds a cutoff – usually 250 mL – enteral nutrition is stopped or decreased to minimize the risk of vomiting, aspiration, and subsequent development of ventilator-associated pneumonia.

However, it has never been definitively established that increased gastric volume does lead to vomiting (or exactly what the cutoff amount should be), that this vomiting does lead to ventilator-associated pneumonia, or that the monitoring procedure actually reduces the risk of pneumonia. And monitoring has been linked to decreased calorie delivery and its associated morbidity.

Dr. Reignier and his colleagues found in a preliminary study at a single ICU that forgoing the monitoring procedure did not raise the rate of ventilator-associated pneumonia. They then performed this noninferiority study to test the theory that residual gastric volume monitoring may not be necessary for this purpose.

Adult patients who were expected to require more than 48 hours of mechanical ventilation at nine ICUs were enrolled over a 1-year period. Three of the ICUs were medical and six were medical-surgical. Three were in university hospitals and six were in general hospitals affiliated with a university.

The study subjects were randomly assigned to receive either standard care, which included monitoring of residual gastric volume every 6 hours or the "intervention" of no monitoring.

The primary outcome was the rate of ventilator-associated pneumonia. In the intention-to-treat analysis, this rate was 15.8% in the control group (222 patients) and 16.7% in the "intervention" group (227 patients), a nonsignificant difference. In the per-protocol analysis, this rate was 16.3% in the control group (215 patients) and 17.8% in the intervention group (208 patients), also a nonsignificant difference.

Thus, forgoing routine monitoring of residual gastric volume was noninferior to performing such monitoring at preventing this form of pneumonia, the researchers said (JAMA 2013;309:249-56).

In further analyses, the cumulative incidences of ventilator-associated pneumonia also were not significantly different between the two study groups. Microbiologic testing showed that the organisms causing pneumonia were the same between the two groups, as were the proportions of infections caused by Staphylococcus aureus, Streptococcus species, Enterobacteriaceae, and Pseudomonadaceae.

The two study groups also did not differ in short- or long-term mortality; rates of other ICU-acquired infections; scores on measures of organ failure; or the duration of ventilation, ICU stay, or hospital stay.

It was interesting that the proportion of patients who vomited was significantly higher in the unmonitored than in the monitored group, and that the number of vomiting episodes also was significantly higher in the unmonitored group, yet the rate of pneumonia was not significantly different, Dr. Reignier and his associates noted.

Despite higher rates of vomiting, more patients in the unmonitored group achieved their calorie targets on enteral nutrition.

The investigators proposed several explanations for their findings.

In several previous studies, residual gastric volumes did not correlate with vomiting or aspiration rates. Volumes lower than 250 mL did not correlate with decreased complications, and values as high as 500 mL did not correlate with increased rates of pneumonia.

Second, the measurement of residual gastric volume has never been standardized or validated. And the accuracy of gastric aspiration through the nasogastric tube may vary according to tube position, tube diameter, the number of tube openings in the stomach, the level of aspiration in the stomach, and the clinician’s experience, the investigators said.

Third, and perhaps most important, many studies have challenged the role of gastric aspiration in the development of ventilator-associated pneumonia. The oral cavity, not the stomach, may be the significant reservoir of pathogens that cause this form of pneumonia, they said.

Eliminating the routine monitoring of residual gastric volume would be advantageous in that it would significantly reduce the workload of nurses and other clinicians, allowing them to focus on other interventions that have proved their value, Dr. Reignier and his colleagues added.

The study was sponsored by Centre Hospitalier Departmental de la Vendee. No financial conflicts of interest were reported.

Among critically ill adults requiring mechanical ventilation and receiving early enteral nutrition, it may not be necessary to routinely monitor residual gastric volume as a means of averting vomiting and thus preventing aspiration and the development of ventilator-associated pneumonia, according to a report in the Jan. 16 issue of JAMA.

In a multicenter randomized trial involving 449 such patients, forgoing routine monitoring of residual gastric volume was found "noninferior" at preventing ventilator-associated pneumonia to the standard practice of performing this monitoring every 6 hours. Moreover, patients who were not monitored actually were more likely to achieve their nutritional targets, while showing equivalent mortality, infection rates, lengths of hospital stay, lengths of ICU stay, and organ failure scores, said Dr. Jean Reignier of Centre Hospitalier Departemental de la Vendee, La Roche-sur Yon (France), and his associates.

"Residual gastric volume monitoring leads to unnecessary interruption of enteral nutrition delivery with subsequent inadequate feeding, and should be removed from the standard care of critically ill patients receiving invasive mechanical ventilation and early enteral nutrition," the investigators said.

It is thought that higher gastric volume causes intolerance of enteral feeding, with its attendant gastroesophageal reflux and vomiting. Monitoring of residual gastric volume involves periodically aspirating the stomach through the nasogastric tube with a 50-mL syringe. If the volume exceeds a cutoff – usually 250 mL – enteral nutrition is stopped or decreased to minimize the risk of vomiting, aspiration, and subsequent development of ventilator-associated pneumonia.

However, it has never been definitively established that increased gastric volume does lead to vomiting (or exactly what the cutoff amount should be), that this vomiting does lead to ventilator-associated pneumonia, or that the monitoring procedure actually reduces the risk of pneumonia. And monitoring has been linked to decreased calorie delivery and its associated morbidity.

Dr. Reignier and his colleagues found in a preliminary study at a single ICU that forgoing the monitoring procedure did not raise the rate of ventilator-associated pneumonia. They then performed this noninferiority study to test the theory that residual gastric volume monitoring may not be necessary for this purpose.

Adult patients who were expected to require more than 48 hours of mechanical ventilation at nine ICUs were enrolled over a 1-year period. Three of the ICUs were medical and six were medical-surgical. Three were in university hospitals and six were in general hospitals affiliated with a university.

The study subjects were randomly assigned to receive either standard care, which included monitoring of residual gastric volume every 6 hours or the "intervention" of no monitoring.

The primary outcome was the rate of ventilator-associated pneumonia. In the intention-to-treat analysis, this rate was 15.8% in the control group (222 patients) and 16.7% in the "intervention" group (227 patients), a nonsignificant difference. In the per-protocol analysis, this rate was 16.3% in the control group (215 patients) and 17.8% in the intervention group (208 patients), also a nonsignificant difference.

Thus, forgoing routine monitoring of residual gastric volume was noninferior to performing such monitoring at preventing this form of pneumonia, the researchers said (JAMA 2013;309:249-56).

In further analyses, the cumulative incidences of ventilator-associated pneumonia also were not significantly different between the two study groups. Microbiologic testing showed that the organisms causing pneumonia were the same between the two groups, as were the proportions of infections caused by Staphylococcus aureus, Streptococcus species, Enterobacteriaceae, and Pseudomonadaceae.

The two study groups also did not differ in short- or long-term mortality; rates of other ICU-acquired infections; scores on measures of organ failure; or the duration of ventilation, ICU stay, or hospital stay.

It was interesting that the proportion of patients who vomited was significantly higher in the unmonitored than in the monitored group, and that the number of vomiting episodes also was significantly higher in the unmonitored group, yet the rate of pneumonia was not significantly different, Dr. Reignier and his associates noted.

Despite higher rates of vomiting, more patients in the unmonitored group achieved their calorie targets on enteral nutrition.

The investigators proposed several explanations for their findings.

In several previous studies, residual gastric volumes did not correlate with vomiting or aspiration rates. Volumes lower than 250 mL did not correlate with decreased complications, and values as high as 500 mL did not correlate with increased rates of pneumonia.

Second, the measurement of residual gastric volume has never been standardized or validated. And the accuracy of gastric aspiration through the nasogastric tube may vary according to tube position, tube diameter, the number of tube openings in the stomach, the level of aspiration in the stomach, and the clinician’s experience, the investigators said.

Third, and perhaps most important, many studies have challenged the role of gastric aspiration in the development of ventilator-associated pneumonia. The oral cavity, not the stomach, may be the significant reservoir of pathogens that cause this form of pneumonia, they said.

Eliminating the routine monitoring of residual gastric volume would be advantageous in that it would significantly reduce the workload of nurses and other clinicians, allowing them to focus on other interventions that have proved their value, Dr. Reignier and his colleagues added.

The study was sponsored by Centre Hospitalier Departmental de la Vendee. No financial conflicts of interest were reported.

Neonates and infants given intravenous acetaminophen as the primary analgesic during the 48 hours after major surgery required a 66% lower cumulative morphine dose than did those given a continuous morphine infusion as the primary analgesic, according to a report in the Jan. 9 issue of JAMA.

Patients given IV acetaminophen (paracetamol) achieved a level of analgesia similar to that of patients given a morphine infusion, judging by their equivalent need for rescue doses of morphine and their equivalent scores on two rating scales of pain and discomfort, reported Dr. Ilse Ceelie of the departments of intensive care and pediatric surgery at Erasmus Medical Center-Sophia Children’s Hospital, Rotterdam, and her associates.

"These results suggest that IV paracetamol may be an interesting alternative as primary analgesic in neonates and infants," they said.

Acetaminophen’s opioid-sparing effect has been demonstrated in older children and adults, but only two studies have assessed the drug’s opioid-sparing effect following surgery in the infant age group. Both of these studies used acetaminophen as an add-on therapy rather than as the primary analgesic, and they yielded conflicting results.

So Dr. Ceelie and her colleagues performed a single-center, randomized clinical trial to determine whether IV acetaminophen would reduce the cumulative morphine dose by at least 30%. They assessed 74 children younger than 1 year who were undergoing major abdominal or thoracic (but noncardiac) surgery during a 2-year period.

All the study subjects had been born at 37 weeks or later and weighed more than 1,500 g at the time of surgery. The most frequent procedures were closures of congenital diaphragmatic hernia, repair of intestinal atresia, and repair of esophageal atresia. All patients were given a loading dose of morphine 30 minutes before their surgery was expected to conclude. After the procedure they were transferred to the ICU, where the study medication was begun within 5 minutes.

Patients were randomly assigned in a double-blind fashion to receive either IV acetaminophen plus a placebo infusion mimicking morphine infusion (35 subjects) or a morphine infusion plus a placebo IV mimicking an acetaminophen drip (39 subjects). They were closely monitored for pain and distress by ICU nurses using the Numeric Rating Scale-11 and COMFORT-Behavior Scale. In addition, the surgeons computed a surgical stress score for each patient.

If discomfort was noted, midazolam was initiated. If pain was noted, rescue morphine boluses were administered as needed; if they were not sufficient, the maximum dose of morphine was given or the patient was switched to fentanyl.

The primary endpoint of the study was the cumulative dose of morphine – the sum of the intraoperative loading dose, the study dose of morphine (if applicable), and any rescue doses of morphine (if applicable).

The mean cumulative dose of morphine was 121 mcg/kg per 48 hours in the acetaminophen group, which was 66% lower than the mean cumulative dose of 357 mcg/kg per 48 hours in the morphine group, Dr. Ceelie and her associates reported (JAMA 2013;309;149-54).

The investigators also analyzed the data after dividing the study subjects into two age groups: those aged 0-10 days and those aged 11 days to 1 year. This was because "there are major changes in the pharmacokinetics of morphine during the first 10 days of life," but only minor changes thereafter.

In this analysis, the cumulative dose of morphine in the acetaminophen group (median, 111 mcg/kg per 48 hours) was 49% lower than that in the morphine group (median, 218 mcg/kg per 48 hours) among the neonates (aged 0-10 days). Among patients aged 11 days to 1 year, the difference in the cumulative dose of morphine was even more striking: The median was 152 mcg/kg/48 hours in the acetaminophen group and 553 in the morphine group, a difference of 73%.

The acetaminophen and morphine groups did not differ significantly in the total dose of rescue morphine, the number of morphine rescue doses, or the number of patients requiring rescue doses. In addition, the median scores on the two measures of pain and discomfort were similar between the two groups.

The overall rate of adverse effects was higher, but not significantly so, for morphine (34.2%) than for acetaminophen (27.3%). However, naloxone was administered to three infants in the morphine group because of respiratory depression, whereas none of the patients in the acetaminophen group developed respiratory depression.

"Despite the lack of statistical significance for this and other adverse effects, this observation does suggest a potential reduction in respiratory depression with use of acetaminophen," the researchers noted.

There were no cases of seizures, hypotension, or gastrointestinal adverse effects, they added.

Neonates have a lower risk of acetaminophen-induced hepatotoxicity than do older children and adults because the enzymes, such as CYP2E1, necessary for the hepatotoxic metabolite to develop are still immature, the researchers noted.

This study was limited in that it involved a strictly defined patient population at a single medical center, so the findings may not be widely generalizable. Moreover, liver function was not monitored in the acetaminophen group, and the study was underpowered to detect a difference in adverse effects, which "limits our ability to determine which treatment was safest," Dr. Ceelie and her colleagues said.

The study was supported by a grant from ZonMw Priority Medicines for Children. The authors reported no potential conflicts of interest.

Neonates and infants given intravenous acetaminophen as the primary analgesic during the 48 hours after major surgery required a 66% lower cumulative morphine dose than did those given a continuous morphine infusion as the primary analgesic, according to a report in the Jan. 9 issue of JAMA.

Patients given IV acetaminophen (paracetamol) achieved a level of analgesia similar to that of patients given a morphine infusion, judging by their equivalent need for rescue doses of morphine and their equivalent scores on two rating scales of pain and discomfort, reported Dr. Ilse Ceelie of the departments of intensive care and pediatric surgery at Erasmus Medical Center-Sophia Children’s Hospital, Rotterdam, and her associates.

"These results suggest that IV paracetamol may be an interesting alternative as primary analgesic in neonates and infants," they said.

Acetaminophen’s opioid-sparing effect has been demonstrated in older children and adults, but only two studies have assessed the drug’s opioid-sparing effect following surgery in the infant age group. Both of these studies used acetaminophen as an add-on therapy rather than as the primary analgesic, and they yielded conflicting results.

So Dr. Ceelie and her colleagues performed a single-center, randomized clinical trial to determine whether IV acetaminophen would reduce the cumulative morphine dose by at least 30%. They assessed 74 children younger than 1 year who were undergoing major abdominal or thoracic (but noncardiac) surgery during a 2-year period.

All the study subjects had been born at 37 weeks or later and weighed more than 1,500 g at the time of surgery. The most frequent procedures were closures of congenital diaphragmatic hernia, repair of intestinal atresia, and repair of esophageal atresia. All patients were given a loading dose of morphine 30 minutes before their surgery was expected to conclude. After the procedure they were transferred to the ICU, where the study medication was begun within 5 minutes.

Patients were randomly assigned in a double-blind fashion to receive either IV acetaminophen plus a placebo infusion mimicking morphine infusion (35 subjects) or a morphine infusion plus a placebo IV mimicking an acetaminophen drip (39 subjects). They were closely monitored for pain and distress by ICU nurses using the Numeric Rating Scale-11 and COMFORT-Behavior Scale. In addition, the surgeons computed a surgical stress score for each patient.

If discomfort was noted, midazolam was initiated. If pain was noted, rescue morphine boluses were administered as needed; if they were not sufficient, the maximum dose of morphine was given or the patient was switched to fentanyl.

The primary endpoint of the study was the cumulative dose of morphine – the sum of the intraoperative loading dose, the study dose of morphine (if applicable), and any rescue doses of morphine (if applicable).

The mean cumulative dose of morphine was 121 mcg/kg per 48 hours in the acetaminophen group, which was 66% lower than the mean cumulative dose of 357 mcg/kg per 48 hours in the morphine group, Dr. Ceelie and her associates reported (JAMA 2013;309;149-54).

The investigators also analyzed the data after dividing the study subjects into two age groups: those aged 0-10 days and those aged 11 days to 1 year. This was because "there are major changes in the pharmacokinetics of morphine during the first 10 days of life," but only minor changes thereafter.

In this analysis, the cumulative dose of morphine in the acetaminophen group (median, 111 mcg/kg per 48 hours) was 49% lower than that in the morphine group (median, 218 mcg/kg per 48 hours) among the neonates (aged 0-10 days). Among patients aged 11 days to 1 year, the difference in the cumulative dose of morphine was even more striking: The median was 152 mcg/kg/48 hours in the acetaminophen group and 553 in the morphine group, a difference of 73%.

The acetaminophen and morphine groups did not differ significantly in the total dose of rescue morphine, the number of morphine rescue doses, or the number of patients requiring rescue doses. In addition, the median scores on the two measures of pain and discomfort were similar between the two groups.

The overall rate of adverse effects was higher, but not significantly so, for morphine (34.2%) than for acetaminophen (27.3%). However, naloxone was administered to three infants in the morphine group because of respiratory depression, whereas none of the patients in the acetaminophen group developed respiratory depression.

"Despite the lack of statistical significance for this and other adverse effects, this observation does suggest a potential reduction in respiratory depression with use of acetaminophen," the researchers noted.

There were no cases of seizures, hypotension, or gastrointestinal adverse effects, they added.

Neonates have a lower risk of acetaminophen-induced hepatotoxicity than do older children and adults because the enzymes, such as CYP2E1, necessary for the hepatotoxic metabolite to develop are still immature, the researchers noted.

This study was limited in that it involved a strictly defined patient population at a single medical center, so the findings may not be widely generalizable. Moreover, liver function was not monitored in the acetaminophen group, and the study was underpowered to detect a difference in adverse effects, which "limits our ability to determine which treatment was safest," Dr. Ceelie and her colleagues said.

The study was supported by a grant from ZonMw Priority Medicines for Children. The authors reported no potential conflicts of interest.

Neonates and infants given intravenous acetaminophen as the primary analgesic during the 48 hours after major surgery required a 66% lower cumulative morphine dose than did those given a continuous morphine infusion as the primary analgesic, according to a report in the Jan. 9 issue of JAMA.

Patients given IV acetaminophen (paracetamol) achieved a level of analgesia similar to that of patients given a morphine infusion, judging by their equivalent need for rescue doses of morphine and their equivalent scores on two rating scales of pain and discomfort, reported Dr. Ilse Ceelie of the departments of intensive care and pediatric surgery at Erasmus Medical Center-Sophia Children’s Hospital, Rotterdam, and her associates.

"These results suggest that IV paracetamol may be an interesting alternative as primary analgesic in neonates and infants," they said.

Acetaminophen’s opioid-sparing effect has been demonstrated in older children and adults, but only two studies have assessed the drug’s opioid-sparing effect following surgery in the infant age group. Both of these studies used acetaminophen as an add-on therapy rather than as the primary analgesic, and they yielded conflicting results.

So Dr. Ceelie and her colleagues performed a single-center, randomized clinical trial to determine whether IV acetaminophen would reduce the cumulative morphine dose by at least 30%. They assessed 74 children younger than 1 year who were undergoing major abdominal or thoracic (but noncardiac) surgery during a 2-year period.

All the study subjects had been born at 37 weeks or later and weighed more than 1,500 g at the time of surgery. The most frequent procedures were closures of congenital diaphragmatic hernia, repair of intestinal atresia, and repair of esophageal atresia. All patients were given a loading dose of morphine 30 minutes before their surgery was expected to conclude. After the procedure they were transferred to the ICU, where the study medication was begun within 5 minutes.

Patients were randomly assigned in a double-blind fashion to receive either IV acetaminophen plus a placebo infusion mimicking morphine infusion (35 subjects) or a morphine infusion plus a placebo IV mimicking an acetaminophen drip (39 subjects). They were closely monitored for pain and distress by ICU nurses using the Numeric Rating Scale-11 and COMFORT-Behavior Scale. In addition, the surgeons computed a surgical stress score for each patient.

If discomfort was noted, midazolam was initiated. If pain was noted, rescue morphine boluses were administered as needed; if they were not sufficient, the maximum dose of morphine was given or the patient was switched to fentanyl.

The primary endpoint of the study was the cumulative dose of morphine – the sum of the intraoperative loading dose, the study dose of morphine (if applicable), and any rescue doses of morphine (if applicable).

The mean cumulative dose of morphine was 121 mcg/kg per 48 hours in the acetaminophen group, which was 66% lower than the mean cumulative dose of 357 mcg/kg per 48 hours in the morphine group, Dr. Ceelie and her associates reported (JAMA 2013;309;149-54).

The investigators also analyzed the data after dividing the study subjects into two age groups: those aged 0-10 days and those aged 11 days to 1 year. This was because "there are major changes in the pharmacokinetics of morphine during the first 10 days of life," but only minor changes thereafter.

In this analysis, the cumulative dose of morphine in the acetaminophen group (median, 111 mcg/kg per 48 hours) was 49% lower than that in the morphine group (median, 218 mcg/kg per 48 hours) among the neonates (aged 0-10 days). Among patients aged 11 days to 1 year, the difference in the cumulative dose of morphine was even more striking: The median was 152 mcg/kg/48 hours in the acetaminophen group and 553 in the morphine group, a difference of 73%.

The acetaminophen and morphine groups did not differ significantly in the total dose of rescue morphine, the number of morphine rescue doses, or the number of patients requiring rescue doses. In addition, the median scores on the two measures of pain and discomfort were similar between the two groups.

The overall rate of adverse effects was higher, but not significantly so, for morphine (34.2%) than for acetaminophen (27.3%). However, naloxone was administered to three infants in the morphine group because of respiratory depression, whereas none of the patients in the acetaminophen group developed respiratory depression.

"Despite the lack of statistical significance for this and other adverse effects, this observation does suggest a potential reduction in respiratory depression with use of acetaminophen," the researchers noted.

There were no cases of seizures, hypotension, or gastrointestinal adverse effects, they added.

Neonates have a lower risk of acetaminophen-induced hepatotoxicity than do older children and adults because the enzymes, such as CYP2E1, necessary for the hepatotoxic metabolite to develop are still immature, the researchers noted.

This study was limited in that it involved a strictly defined patient population at a single medical center, so the findings may not be widely generalizable. Moreover, liver function was not monitored in the acetaminophen group, and the study was underpowered to detect a difference in adverse effects, which "limits our ability to determine which treatment was safest," Dr. Ceelie and her colleagues said.

The study was supported by a grant from ZonMw Priority Medicines for Children. The authors reported no potential conflicts of interest.

PALM BEACH, FLA. – Only a small percent of all trauma and acute care surgery patients require more than 10 days in the ICU, but the ones who do rack up an enormous chunk of ICU costs, a single-center study with more than 6,000 U.S. patients has shown.

A more detailed look at what contributes to these very prolonged ICU stays and their costs may provide new opportunities for hospital cost controls, Dr. Samir M. Fakhry, FACS, said at the annual meeting of the Southern Surgical Association.

"I think we need a paradigm shift in how these patients are managed," such as a step-down protocol that allows them to exit the ICU and wean off their ventilator, said Dr. Fakhry, professor and chief of general surgery at the Medical University of South Carolina in Charleston.

But trauma and acute care surgery patients who need less than a day in the ICU can’t be ignored either. Although their per-patient cost is relatively small, their aggregate cost is high, because many patients fall into this group.

"You need two approaches" for trying to save on surgical ICU costs, one for patients who need prolonged intensive care and a second approach for patients who require only a day, he said. "For patients with short lengths of stay and lower costs, small things like one or two fewer doses of an antibiotic or fewer tests would make a difference" when multiplied by thousands of patients, Dr. Fahkry said. Further insight into ICU costs and cost-saving approaches could come from expanding his analysis to a larger number of U.S. surgical ICUs, he added.

His analysis of data collected by the surgical ICU at the Medical University of South Carolina, a level 1 trauma center, during 2007-2011 also highlighted that the number of patients admitted to the unit jumped by 26%, rising from 1,084 patients in fiscal year 2007 to 1,364 in FY 2011. The rise was especially pronounced among nontrauma patients, increasing from 319 in 2007 to 502 in 2011, a 57% rise.

Dr. Fahkry and his associates analyzed data from a total of 6,008 patients admitted to his hospital’s surgical ICU during the 5-year period studied. Costs for this care rose from $17,243 per patient in 2007 to $26,468 in 2011, a 53% increase.

A total of 423 of these patients, 7%, stayed in the ICU for more than 10 days. This group consisted primarily of trauma patients, 320 (76%) of the 423 patients. The average length of stay among the prolonged-stay patients was about 17 days, with an overall duration of hospitalization of 31 days. About three-quarters of these patients had at least three comorbidities. Mortality was also high in this subgroup, especially in the nontrauma patients, who had a 40% death rate; in-hospital mortality among the trauma patients with prolonged ICU stays was 10%.

Although accounting for just 7% of all surgical ICU patients, this subgroup racked up 41% of total ICU costs during the 5 years studied. In contrast, 4,236 surgical ICU patients who remained in the unit for less than a full day, 71% of all patients in the analysis, were responsible for 30% of total surgical ICU costs.

The analysis also identified another marker of substantially increased ICU costs: patients who ultimately died during their index hospitalization. Among nontrauma patients who died while hospitalized, the average costs were nearly $60,000 per patient, almost eightfold higher than for the nontrauma patients who survived hospitalization. Among the trauma patients, those who died ran up more than $31,000 in costs, nearly threefold higher than the trauma patients who survived.

Dr. Fahkry said he had no relevant financial disclosures.

[email protected]

On Twitter @mitchelzoler

PALM BEACH, FLA. – Only a small percent of all trauma and acute care surgery patients require more than 10 days in the ICU, but the ones who do rack up an enormous chunk of ICU costs, a single-center study with more than 6,000 U.S. patients has shown.

A more detailed look at what contributes to these very prolonged ICU stays and their costs may provide new opportunities for hospital cost controls, Dr. Samir M. Fakhry, FACS, said at the annual meeting of the Southern Surgical Association.

"I think we need a paradigm shift in how these patients are managed," such as a step-down protocol that allows them to exit the ICU and wean off their ventilator, said Dr. Fakhry, professor and chief of general surgery at the Medical University of South Carolina in Charleston.

But trauma and acute care surgery patients who need less than a day in the ICU can’t be ignored either. Although their per-patient cost is relatively small, their aggregate cost is high, because many patients fall into this group.

"You need two approaches" for trying to save on surgical ICU costs, one for patients who need prolonged intensive care and a second approach for patients who require only a day, he said. "For patients with short lengths of stay and lower costs, small things like one or two fewer doses of an antibiotic or fewer tests would make a difference" when multiplied by thousands of patients, Dr. Fahkry said. Further insight into ICU costs and cost-saving approaches could come from expanding his analysis to a larger number of U.S. surgical ICUs, he added.

His analysis of data collected by the surgical ICU at the Medical University of South Carolina, a level 1 trauma center, during 2007-2011 also highlighted that the number of patients admitted to the unit jumped by 26%, rising from 1,084 patients in fiscal year 2007 to 1,364 in FY 2011. The rise was especially pronounced among nontrauma patients, increasing from 319 in 2007 to 502 in 2011, a 57% rise.

Dr. Fahkry and his associates analyzed data from a total of 6,008 patients admitted to his hospital’s surgical ICU during the 5-year period studied. Costs for this care rose from $17,243 per patient in 2007 to $26,468 in 2011, a 53% increase.

A total of 423 of these patients, 7%, stayed in the ICU for more than 10 days. This group consisted primarily of trauma patients, 320 (76%) of the 423 patients. The average length of stay among the prolonged-stay patients was about 17 days, with an overall duration of hospitalization of 31 days. About three-quarters of these patients had at least three comorbidities. Mortality was also high in this subgroup, especially in the nontrauma patients, who had a 40% death rate; in-hospital mortality among the trauma patients with prolonged ICU stays was 10%.

Although accounting for just 7% of all surgical ICU patients, this subgroup racked up 41% of total ICU costs during the 5 years studied. In contrast, 4,236 surgical ICU patients who remained in the unit for less than a full day, 71% of all patients in the analysis, were responsible for 30% of total surgical ICU costs.

The analysis also identified another marker of substantially increased ICU costs: patients who ultimately died during their index hospitalization. Among nontrauma patients who died while hospitalized, the average costs were nearly $60,000 per patient, almost eightfold higher than for the nontrauma patients who survived hospitalization. Among the trauma patients, those who died ran up more than $31,000 in costs, nearly threefold higher than the trauma patients who survived.

Dr. Fahkry said he had no relevant financial disclosures.

[email protected]

On Twitter @mitchelzoler

PALM BEACH, FLA. – Only a small percent of all trauma and acute care surgery patients require more than 10 days in the ICU, but the ones who do rack up an enormous chunk of ICU costs, a single-center study with more than 6,000 U.S. patients has shown.

A more detailed look at what contributes to these very prolonged ICU stays and their costs may provide new opportunities for hospital cost controls, Dr. Samir M. Fakhry, FACS, said at the annual meeting of the Southern Surgical Association.

"I think we need a paradigm shift in how these patients are managed," such as a step-down protocol that allows them to exit the ICU and wean off their ventilator, said Dr. Fakhry, professor and chief of general surgery at the Medical University of South Carolina in Charleston.

But trauma and acute care surgery patients who need less than a day in the ICU can’t be ignored either. Although their per-patient cost is relatively small, their aggregate cost is high, because many patients fall into this group.

"You need two approaches" for trying to save on surgical ICU costs, one for patients who need prolonged intensive care and a second approach for patients who require only a day, he said. "For patients with short lengths of stay and lower costs, small things like one or two fewer doses of an antibiotic or fewer tests would make a difference" when multiplied by thousands of patients, Dr. Fahkry said. Further insight into ICU costs and cost-saving approaches could come from expanding his analysis to a larger number of U.S. surgical ICUs, he added.

His analysis of data collected by the surgical ICU at the Medical University of South Carolina, a level 1 trauma center, during 2007-2011 also highlighted that the number of patients admitted to the unit jumped by 26%, rising from 1,084 patients in fiscal year 2007 to 1,364 in FY 2011. The rise was especially pronounced among nontrauma patients, increasing from 319 in 2007 to 502 in 2011, a 57% rise.

Dr. Fahkry and his associates analyzed data from a total of 6,008 patients admitted to his hospital’s surgical ICU during the 5-year period studied. Costs for this care rose from $17,243 per patient in 2007 to $26,468 in 2011, a 53% increase.

A total of 423 of these patients, 7%, stayed in the ICU for more than 10 days. This group consisted primarily of trauma patients, 320 (76%) of the 423 patients. The average length of stay among the prolonged-stay patients was about 17 days, with an overall duration of hospitalization of 31 days. About three-quarters of these patients had at least three comorbidities. Mortality was also high in this subgroup, especially in the nontrauma patients, who had a 40% death rate; in-hospital mortality among the trauma patients with prolonged ICU stays was 10%.

Although accounting for just 7% of all surgical ICU patients, this subgroup racked up 41% of total ICU costs during the 5 years studied. In contrast, 4,236 surgical ICU patients who remained in the unit for less than a full day, 71% of all patients in the analysis, were responsible for 30% of total surgical ICU costs.

The analysis also identified another marker of substantially increased ICU costs: patients who ultimately died during their index hospitalization. Among nontrauma patients who died while hospitalized, the average costs were nearly $60,000 per patient, almost eightfold higher than for the nontrauma patients who survived hospitalization. Among the trauma patients, those who died ran up more than $31,000 in costs, nearly threefold higher than the trauma patients who survived.

Dr. Fahkry said he had no relevant financial disclosures.

[email protected]

On Twitter @mitchelzoler

WASHINGTON – The risk of infection following orthopedic surgery is increased in patients with inflammatory rheumatic disease, compared with those with degenerative disease or traumatic injury, according to findings from a review of more than 50,000 surgical procedures.

The risk is greatest in those inflammatory rheumatic disease patients treated with conventional disease-modifying anti-rheumatic drugs (cDMARDs) or tumor necrosis factor (TNF) inhibitors, especially those receiving more than one cDMARD or TNF inhibitor with a long administration interval, and when surgery takes place without discontinuation of treatment, Catrina B. Scherrer reported at the annual meeting of the American College of Rheumatology.

Of 50,359 surgical procedures performed in 37,137 patients from a hospital surgery registry, 422 resulted in surgery-related infections. Of these infections, 49 occurred in 2,472 patients with an inflammatory rheumatic disease (IRD; 2%), and 373 occurred in 47,887 patients with degenerative disease/posttraumatic injury (0.8%). The difference was statistically significant, even after adjustment for other risk factors, including age, gender, diabetes, being overweight, cardiovascular disease, smoking, and type of surgery, said Ms. Scherrer of the Schulthess Clinic, Zürich.

The lowest rates of infection occurred with hand and shoulder surgery; the highest rates occurred with elbow surgery, she noted.

In 1,329 patients in the IRD group for whom complete information about medication was available, 171 (13%) had documented use of TNF inhibitors, and 49 of these (29%) discontinued treatment more than three administration intervals before surgery. Of the remaining 122 TNF inhibitor users, the time lag was three or fewer administration intervals.

An increased infection rate was seen in those who used more than one cDMARD (odds ratio, 2.425) and more than one TNF inhibitor (OR, 2.627) prior to surgery, and the risk of infection was increased tenfold when surgery was performed within one administration interval (OR, 10.047).

Patients who had their last treatment within one administration interval before surgery included 81% of infliximab users, compared with only 33% of adalimumab users and 24% of etanercept users, Ms. Scherrer noted.

Surgery patients in this study were followed over 8 years as part of a single-center surgery registry. The findings, which are limited by the study’s retrospective design and thus require confirmation in prospective studies, are nonetheless important because patients with aggressive disease such as IRDs frequently require orthopedic surgery.

The study findings suggest that IRD patients are, in general, at high risk of postoperative infection, that special attention should be paid to patients using more than one cDMARD or TNF inhibitor with long administration intervals, and that the last intake of TNF inhibitors – particularly infliximab – should be at least more than one administration interval before planned surgery, as the risk of postoperative infection is significantly increased if surgery occurs within this period, she concluded.

Ms. Scherrer reported having no disclosures.

WASHINGTON – The risk of infection following orthopedic surgery is increased in patients with inflammatory rheumatic disease, compared with those with degenerative disease or traumatic injury, according to findings from a review of more than 50,000 surgical procedures.

The risk is greatest in those inflammatory rheumatic disease patients treated with conventional disease-modifying anti-rheumatic drugs (cDMARDs) or tumor necrosis factor (TNF) inhibitors, especially those receiving more than one cDMARD or TNF inhibitor with a long administration interval, and when surgery takes place without discontinuation of treatment, Catrina B. Scherrer reported at the annual meeting of the American College of Rheumatology.

Of 50,359 surgical procedures performed in 37,137 patients from a hospital surgery registry, 422 resulted in surgery-related infections. Of these infections, 49 occurred in 2,472 patients with an inflammatory rheumatic disease (IRD; 2%), and 373 occurred in 47,887 patients with degenerative disease/posttraumatic injury (0.8%). The difference was statistically significant, even after adjustment for other risk factors, including age, gender, diabetes, being overweight, cardiovascular disease, smoking, and type of surgery, said Ms. Scherrer of the Schulthess Clinic, Zürich.

The lowest rates of infection occurred with hand and shoulder surgery; the highest rates occurred with elbow surgery, she noted.

In 1,329 patients in the IRD group for whom complete information about medication was available, 171 (13%) had documented use of TNF inhibitors, and 49 of these (29%) discontinued treatment more than three administration intervals before surgery. Of the remaining 122 TNF inhibitor users, the time lag was three or fewer administration intervals.

An increased infection rate was seen in those who used more than one cDMARD (odds ratio, 2.425) and more than one TNF inhibitor (OR, 2.627) prior to surgery, and the risk of infection was increased tenfold when surgery was performed within one administration interval (OR, 10.047).

Patients who had their last treatment within one administration interval before surgery included 81% of infliximab users, compared with only 33% of adalimumab users and 24% of etanercept users, Ms. Scherrer noted.

Surgery patients in this study were followed over 8 years as part of a single-center surgery registry. The findings, which are limited by the study’s retrospective design and thus require confirmation in prospective studies, are nonetheless important because patients with aggressive disease such as IRDs frequently require orthopedic surgery.

The study findings suggest that IRD patients are, in general, at high risk of postoperative infection, that special attention should be paid to patients using more than one cDMARD or TNF inhibitor with long administration intervals, and that the last intake of TNF inhibitors – particularly infliximab – should be at least more than one administration interval before planned surgery, as the risk of postoperative infection is significantly increased if surgery occurs within this period, she concluded.

Ms. Scherrer reported having no disclosures.

WASHINGTON – The risk of infection following orthopedic surgery is increased in patients with inflammatory rheumatic disease, compared with those with degenerative disease or traumatic injury, according to findings from a review of more than 50,000 surgical procedures.

The risk is greatest in those inflammatory rheumatic disease patients treated with conventional disease-modifying anti-rheumatic drugs (cDMARDs) or tumor necrosis factor (TNF) inhibitors, especially those receiving more than one cDMARD or TNF inhibitor with a long administration interval, and when surgery takes place without discontinuation of treatment, Catrina B. Scherrer reported at the annual meeting of the American College of Rheumatology.

Of 50,359 surgical procedures performed in 37,137 patients from a hospital surgery registry, 422 resulted in surgery-related infections. Of these infections, 49 occurred in 2,472 patients with an inflammatory rheumatic disease (IRD; 2%), and 373 occurred in 47,887 patients with degenerative disease/posttraumatic injury (0.8%). The difference was statistically significant, even after adjustment for other risk factors, including age, gender, diabetes, being overweight, cardiovascular disease, smoking, and type of surgery, said Ms. Scherrer of the Schulthess Clinic, Zürich.

The lowest rates of infection occurred with hand and shoulder surgery; the highest rates occurred with elbow surgery, she noted.

In 1,329 patients in the IRD group for whom complete information about medication was available, 171 (13%) had documented use of TNF inhibitors, and 49 of these (29%) discontinued treatment more than three administration intervals before surgery. Of the remaining 122 TNF inhibitor users, the time lag was three or fewer administration intervals.

An increased infection rate was seen in those who used more than one cDMARD (odds ratio, 2.425) and more than one TNF inhibitor (OR, 2.627) prior to surgery, and the risk of infection was increased tenfold when surgery was performed within one administration interval (OR, 10.047).

Patients who had their last treatment within one administration interval before surgery included 81% of infliximab users, compared with only 33% of adalimumab users and 24% of etanercept users, Ms. Scherrer noted.

Surgery patients in this study were followed over 8 years as part of a single-center surgery registry. The findings, which are limited by the study’s retrospective design and thus require confirmation in prospective studies, are nonetheless important because patients with aggressive disease such as IRDs frequently require orthopedic surgery.

The study findings suggest that IRD patients are, in general, at high risk of postoperative infection, that special attention should be paid to patients using more than one cDMARD or TNF inhibitor with long administration intervals, and that the last intake of TNF inhibitors – particularly infliximab – should be at least more than one administration interval before planned surgery, as the risk of postoperative infection is significantly increased if surgery occurs within this period, she concluded.

Ms. Scherrer reported having no disclosures.

PALM BEACH, FLA. – Add another notch to the evidence base for bariatric surgery as effective treatment for type 2 diabetes in obese patients.

Patients with type 2 diabetes who underwent any type of bariatric surgery had a 61%-78% relative risk reduction in their rate of macrovascular, microvascular, or vascular events during an average 20-month follow-up in a review of more than 15,000 cases in South Carolina.

"We are trying to get primary care physicians to spread the word [to patients] that bariatric surgery has come a long way over the past 30 or 40 years; the risk-to-reward ratio is much more beneficial to patients," Dr. John D. Scott said at the annual meeting of the Southern Surgical Association.

The new finding "adds to the extensive list of papers that show bariatric surgery mitigates the long-term effects of type 2 diabetes," Dr. Scott added in an interview. "Some front-line medical providers still see bariatric surgery as a procedure of last resort, but findings like ours show that a discussion [with patients on whether they should consider bariatric surgery] should happen a lot sooner."

Dr. Scott, a surgeon at University Medical Center in Greenville, S.C., recommended that patients with a body mass index of at least 35 kg/m² and two or more comorbidities be told that they have the option of undergoing bariatric surgery and reducing their risk.

"We have an epidemic [of obesity and type 2 diabetes], and for the first time since tuberculosis, this is an epidemic where surgery has a real opportunity to positively intervene," commented Dr. Josef E. Fischer, a professor of surgery at Harvard Medical School in Boston.

The study used hospital billing data collected by the South Carolina Office of Research and Statistics as well as state vital records data for 1995-2009. The analysis included 2,580 obese patients who underwent any type of bariatric surgery and 13,371 obese patients who did not have surgery. The researchers extracted the data from records of nearly 34,000 obese patients, but excluded patients with type 1 diabetes, patients with incomplete data, and patients with advanced cardiovascular or microvascular disease at the time of their surgery or entry into the state records during this period.

During a median follow-up of about 20 months, the rate of new-onset macro- or microvascular events was 2% in the bariatric surgery patients and 11% in the patients who did not undergo surgery. The rate of an incident vascular disease event was 2% in the patients who had surgery and 13% in those who did not. Macrovascular events included myocardial infarction, stroke, and all-cause death. Microvascular events included blindness in at least one eye, laser eye surgery, nontraumatic amputation, or placement of access for dialysis. Other vascular events included new-onset heart failure or angina, or revascularization of a coronary, carotid, or peripheral artery.

In a multivariate-adjusted analysis, patients who underwent bariatric surgery had a 61% reduction in macrovascular events, a 78% reduction in microvascular events, a 75% reduction in vascular events, and a 64% reduction in combined macro- and microvascular events, compared with patients who did not have this surgery – all statistically significant differences, reported Dr. Spence M. Taylor, a coinvestigator with Dr. Scott on the study. A propensity-score matched analysis that compared the bariatric surgery patients and matched nonsurgical patients showed very similar reductions in all three event categories.

"Bariatric surgery has a substantial and lasting mitigating association on major complications associated with type 2 diabetes in the obese population," concluded Dr. Taylor, chairman of surgery at the University Medical Center in Greenville.

Dr. Scott, Dr. Fischer, and Dr. Taylor had no relevant disclosures.

PALM BEACH, FLA. – Add another notch to the evidence base for bariatric surgery as effective treatment for type 2 diabetes in obese patients.

Patients with type 2 diabetes who underwent any type of bariatric surgery had a 61%-78% relative risk reduction in their rate of macrovascular, microvascular, or vascular events during an average 20-month follow-up in a review of more than 15,000 cases in South Carolina.

"We are trying to get primary care physicians to spread the word [to patients] that bariatric surgery has come a long way over the past 30 or 40 years; the risk-to-reward ratio is much more beneficial to patients," Dr. John D. Scott said at the annual meeting of the Southern Surgical Association.

The new finding "adds to the extensive list of papers that show bariatric surgery mitigates the long-term effects of type 2 diabetes," Dr. Scott added in an interview. "Some front-line medical providers still see bariatric surgery as a procedure of last resort, but findings like ours show that a discussion [with patients on whether they should consider bariatric surgery] should happen a lot sooner."

Dr. Scott, a surgeon at University Medical Center in Greenville, S.C., recommended that patients with a body mass index of at least 35 kg/m² and two or more comorbidities be told that they have the option of undergoing bariatric surgery and reducing their risk.

"We have an epidemic [of obesity and type 2 diabetes], and for the first time since tuberculosis, this is an epidemic where surgery has a real opportunity to positively intervene," commented Dr. Josef E. Fischer, a professor of surgery at Harvard Medical School in Boston.

The study used hospital billing data collected by the South Carolina Office of Research and Statistics as well as state vital records data for 1995-2009. The analysis included 2,580 obese patients who underwent any type of bariatric surgery and 13,371 obese patients who did not have surgery. The researchers extracted the data from records of nearly 34,000 obese patients, but excluded patients with type 1 diabetes, patients with incomplete data, and patients with advanced cardiovascular or microvascular disease at the time of their surgery or entry into the state records during this period.

During a median follow-up of about 20 months, the rate of new-onset macro- or microvascular events was 2% in the bariatric surgery patients and 11% in the patients who did not undergo surgery. The rate of an incident vascular disease event was 2% in the patients who had surgery and 13% in those who did not. Macrovascular events included myocardial infarction, stroke, and all-cause death. Microvascular events included blindness in at least one eye, laser eye surgery, nontraumatic amputation, or placement of access for dialysis. Other vascular events included new-onset heart failure or angina, or revascularization of a coronary, carotid, or peripheral artery.

In a multivariate-adjusted analysis, patients who underwent bariatric surgery had a 61% reduction in macrovascular events, a 78% reduction in microvascular events, a 75% reduction in vascular events, and a 64% reduction in combined macro- and microvascular events, compared with patients who did not have this surgery – all statistically significant differences, reported Dr. Spence M. Taylor, a coinvestigator with Dr. Scott on the study. A propensity-score matched analysis that compared the bariatric surgery patients and matched nonsurgical patients showed very similar reductions in all three event categories.

"Bariatric surgery has a substantial and lasting mitigating association on major complications associated with type 2 diabetes in the obese population," concluded Dr. Taylor, chairman of surgery at the University Medical Center in Greenville.

Dr. Scott, Dr. Fischer, and Dr. Taylor had no relevant disclosures.

PALM BEACH, FLA. – Add another notch to the evidence base for bariatric surgery as effective treatment for type 2 diabetes in obese patients.

Patients with type 2 diabetes who underwent any type of bariatric surgery had a 61%-78% relative risk reduction in their rate of macrovascular, microvascular, or vascular events during an average 20-month follow-up in a review of more than 15,000 cases in South Carolina.

"We are trying to get primary care physicians to spread the word [to patients] that bariatric surgery has come a long way over the past 30 or 40 years; the risk-to-reward ratio is much more beneficial to patients," Dr. John D. Scott said at the annual meeting of the Southern Surgical Association.

The new finding "adds to the extensive list of papers that show bariatric surgery mitigates the long-term effects of type 2 diabetes," Dr. Scott added in an interview. "Some front-line medical providers still see bariatric surgery as a procedure of last resort, but findings like ours show that a discussion [with patients on whether they should consider bariatric surgery] should happen a lot sooner."

Dr. Scott, a surgeon at University Medical Center in Greenville, S.C., recommended that patients with a body mass index of at least 35 kg/m² and two or more comorbidities be told that they have the option of undergoing bariatric surgery and reducing their risk.

"We have an epidemic [of obesity and type 2 diabetes], and for the first time since tuberculosis, this is an epidemic where surgery has a real opportunity to positively intervene," commented Dr. Josef E. Fischer, a professor of surgery at Harvard Medical School in Boston.

The study used hospital billing data collected by the South Carolina Office of Research and Statistics as well as state vital records data for 1995-2009. The analysis included 2,580 obese patients who underwent any type of bariatric surgery and 13,371 obese patients who did not have surgery. The researchers extracted the data from records of nearly 34,000 obese patients, but excluded patients with type 1 diabetes, patients with incomplete data, and patients with advanced cardiovascular or microvascular disease at the time of their surgery or entry into the state records during this period.

During a median follow-up of about 20 months, the rate of new-onset macro- or microvascular events was 2% in the bariatric surgery patients and 11% in the patients who did not undergo surgery. The rate of an incident vascular disease event was 2% in the patients who had surgery and 13% in those who did not. Macrovascular events included myocardial infarction, stroke, and all-cause death. Microvascular events included blindness in at least one eye, laser eye surgery, nontraumatic amputation, or placement of access for dialysis. Other vascular events included new-onset heart failure or angina, or revascularization of a coronary, carotid, or peripheral artery.

In a multivariate-adjusted analysis, patients who underwent bariatric surgery had a 61% reduction in macrovascular events, a 78% reduction in microvascular events, a 75% reduction in vascular events, and a 64% reduction in combined macro- and microvascular events, compared with patients who did not have this surgery – all statistically significant differences, reported Dr. Spence M. Taylor, a coinvestigator with Dr. Scott on the study. A propensity-score matched analysis that compared the bariatric surgery patients and matched nonsurgical patients showed very similar reductions in all three event categories.

"Bariatric surgery has a substantial and lasting mitigating association on major complications associated with type 2 diabetes in the obese population," concluded Dr. Taylor, chairman of surgery at the University Medical Center in Greenville.

Dr. Scott, Dr. Fischer, and Dr. Taylor had no relevant disclosures.

Colorectal surgical site infections dropped by an average of 32% among hospitals that participated in a project designed to reduce facility-specific infection risk factors.

The project – co-sponsored by the Joint Commission Center for Transforming Healthcare and the American College of Surgeons – will result in a user-friendly online tool that can examine any hospital’s infections data and recommend detailed, site-specific interventions.

The commission’s Targeted Solutions Tool should be available by the middle of 2013.

"The hospitals we engaged have mastered these sophisticated change tools, and now we need to make sure this learning can be spread to others," Dr. Mark Chassin said during a press briefing. "[The new tool] will be a very easy-to-follow approach that applies all the lessons we learned – showing how to measure infection rates, figure out which contributing factors are present in their institution, and guiding them through implementations proven to address these factors."

The commission chose to tackle colorectal surgical site infections (SSIs) because they are common, dangerous, and expensive, said Dr. Chassin, president of the group. Unfortunately, risk factors don’t respond to a "one size fits all" prevention protocol. "These factors are highly variable across hospitals, suggesting that there are opportunities to improve performance."

The 2-year pilot project included seven hospitals of varying size and community demographics. The facilities tracked their colorectal SSI patterns using the American College of Surgeons National Surgical Quality Improvement Program. Each hospital then developed interventions targeted at their individual modifiable risk factors, implemented the changes, and recorded their results.

Overall, the protocol reduced colorectal SSIs by 32% – from an average of 16% to 11%. Superficial skin SSIs fell by an average of 45% over the entire study group.

The protocol improved other outcomes as well, Dr. Chassin said. The average length of stay for a colorectal surgery patient with a wound infection decreased from 15 to 13 days. Across the group, the changes were associated with a savings of almost $4 million.

The hospitals collectively identified 34 factors that greatly increased the risk of such infections. During the briefing, Dr. Jenna Lovely, the surgical pharmacotherapy manager at the Mayo Clinic, Rochester, Minn., shared some of their results (J. Am. Coll. Surg. 2011;213:83-92; 2012 [doi:10.1016/j.jamcollsurg.2012.09.009]).

Before implementation of the program, the colorectal SSI rate at Mayo was 10%. With a goal of reducing that number by at least 50%, the team examined risk factors in the preoperative, intraoperative, postoperative, and posthospitalization periods and made some changes, Dr. Lovely said.

Preoperatively, every patient now takes a shower with soap or with a chlorhexidine-based cleanser both the night before and the day of surgery.

Intraoperatively, the site is prepped with an antimicrobial cleansing agent, and the correct antibiotic is administered at 1 hour before the incision is made. If the surgery lasts more than 4 hours, a second dose of the same antibiotic is administered; cefazolin is given 24 hours after closing.

At fascia closing, the surgeon dons a complete change of gown, mask, and gloves. Closing is performed with the use of an entirely new set of instruments.

Postoperatively, everyone who comes in contact with the wound – including staff, the patient, and visitors – practices good hand hygiene. Reminder notes and hand cleanser are located prominently in rooms and all around the unit. Nurses are empowered to change dressings as needed. Wound probing occurs as needed to help expel any contaminated fluids.

Patients are discharged with infection control education and a bottle of chlorhexidine cleanser.

"These changes are embedded in the environment across the continuum of care. It’s part of the surgical unit’s culture, and this makes it easier to do the right thing. The changes also allow the surgeon to focus on doing what he does best – providing a timely and efficient surgery with the best possible outcome," Dr. Lovely said.

Implementation of these changes led to a reduction in SSI rate from 10% to 4%, and that rate has maintained this rate for 18 months.

Dr. Shirin Towfigh, a surgeon at Cedars-Sinai Medical Center in Los Angeles, said her unit experienced a similar improvement.

The project included 46 surgeons and all of the unit staff. Because the team didn’t want to dictate surgical technique, she said, their goal "was to come up with processes that would improve results independent of a surgeon’s practice. We wanted the changes to be effective, but also easy for surgeons to implement in their own practice."

By the end of the study period, the unit’s colorectal SSI rate had decreased by 50%. Since the project closed 6 months ago, that has further improved, with a total decrease of 65%.

"This is a problem colorectal surgeons have been struggling with for years," Dr. Chassin said. "We’ve always tried to get at it with the simple answer: ‘Here are 5 or 10 things everyone should do to decrease SSIs.’ That doesn’t work, because the critical factors that explain poor outcomes differ from one place to another. The best advice I can give is to look at all your contributing factors and assess where your organization falls short. Use these findings as a guide for where to focus your improvement efforts. The only way you know how to improve is to measure the cause of problems and target interventions right to them."

No disclosures were reported.

Colorectal surgical site infections dropped by an average of 32% among hospitals that participated in a project designed to reduce facility-specific infection risk factors.

The project – co-sponsored by the Joint Commission Center for Transforming Healthcare and the American College of Surgeons – will result in a user-friendly online tool that can examine any hospital’s infections data and recommend detailed, site-specific interventions.

The commission’s Targeted Solutions Tool should be available by the middle of 2013.

"The hospitals we engaged have mastered these sophisticated change tools, and now we need to make sure this learning can be spread to others," Dr. Mark Chassin said during a press briefing. "[The new tool] will be a very easy-to-follow approach that applies all the lessons we learned – showing how to measure infection rates, figure out which contributing factors are present in their institution, and guiding them through implementations proven to address these factors."

The commission chose to tackle colorectal surgical site infections (SSIs) because they are common, dangerous, and expensive, said Dr. Chassin, president of the group. Unfortunately, risk factors don’t respond to a "one size fits all" prevention protocol. "These factors are highly variable across hospitals, suggesting that there are opportunities to improve performance."

The 2-year pilot project included seven hospitals of varying size and community demographics. The facilities tracked their colorectal SSI patterns using the American College of Surgeons National Surgical Quality Improvement Program. Each hospital then developed interventions targeted at their individual modifiable risk factors, implemented the changes, and recorded their results.

Overall, the protocol reduced colorectal SSIs by 32% – from an average of 16% to 11%. Superficial skin SSIs fell by an average of 45% over the entire study group.

The protocol improved other outcomes as well, Dr. Chassin said. The average length of stay for a colorectal surgery patient with a wound infection decreased from 15 to 13 days. Across the group, the changes were associated with a savings of almost $4 million.

The hospitals collectively identified 34 factors that greatly increased the risk of such infections. During the briefing, Dr. Jenna Lovely, the surgical pharmacotherapy manager at the Mayo Clinic, Rochester, Minn., shared some of their results (J. Am. Coll. Surg. 2011;213:83-92; 2012 [doi:10.1016/j.jamcollsurg.2012.09.009]).

Before implementation of the program, the colorectal SSI rate at Mayo was 10%. With a goal of reducing that number by at least 50%, the team examined risk factors in the preoperative, intraoperative, postoperative, and posthospitalization periods and made some changes, Dr. Lovely said.

Preoperatively, every patient now takes a shower with soap or with a chlorhexidine-based cleanser both the night before and the day of surgery.

Intraoperatively, the site is prepped with an antimicrobial cleansing agent, and the correct antibiotic is administered at 1 hour before the incision is made. If the surgery lasts more than 4 hours, a second dose of the same antibiotic is administered; cefazolin is given 24 hours after closing.

At fascia closing, the surgeon dons a complete change of gown, mask, and gloves. Closing is performed with the use of an entirely new set of instruments.

Postoperatively, everyone who comes in contact with the wound – including staff, the patient, and visitors – practices good hand hygiene. Reminder notes and hand cleanser are located prominently in rooms and all around the unit. Nurses are empowered to change dressings as needed. Wound probing occurs as needed to help expel any contaminated fluids.

Patients are discharged with infection control education and a bottle of chlorhexidine cleanser.

"These changes are embedded in the environment across the continuum of care. It’s part of the surgical unit’s culture, and this makes it easier to do the right thing. The changes also allow the surgeon to focus on doing what he does best – providing a timely and efficient surgery with the best possible outcome," Dr. Lovely said.

Implementation of these changes led to a reduction in SSI rate from 10% to 4%, and that rate has maintained this rate for 18 months.

Dr. Shirin Towfigh, a surgeon at Cedars-Sinai Medical Center in Los Angeles, said her unit experienced a similar improvement.

The project included 46 surgeons and all of the unit staff. Because the team didn’t want to dictate surgical technique, she said, their goal "was to come up with processes that would improve results independent of a surgeon’s practice. We wanted the changes to be effective, but also easy for surgeons to implement in their own practice."

By the end of the study period, the unit’s colorectal SSI rate had decreased by 50%. Since the project closed 6 months ago, that has further improved, with a total decrease of 65%.

"This is a problem colorectal surgeons have been struggling with for years," Dr. Chassin said. "We’ve always tried to get at it with the simple answer: ‘Here are 5 or 10 things everyone should do to decrease SSIs.’ That doesn’t work, because the critical factors that explain poor outcomes differ from one place to another. The best advice I can give is to look at all your contributing factors and assess where your organization falls short. Use these findings as a guide for where to focus your improvement efforts. The only way you know how to improve is to measure the cause of problems and target interventions right to them."

No disclosures were reported.

Colorectal surgical site infections dropped by an average of 32% among hospitals that participated in a project designed to reduce facility-specific infection risk factors.

The project – co-sponsored by the Joint Commission Center for Transforming Healthcare and the American College of Surgeons – will result in a user-friendly online tool that can examine any hospital’s infections data and recommend detailed, site-specific interventions.

The commission’s Targeted Solutions Tool should be available by the middle of 2013.

"The hospitals we engaged have mastered these sophisticated change tools, and now we need to make sure this learning can be spread to others," Dr. Mark Chassin said during a press briefing. "[The new tool] will be a very easy-to-follow approach that applies all the lessons we learned – showing how to measure infection rates, figure out which contributing factors are present in their institution, and guiding them through implementations proven to address these factors."

The commission chose to tackle colorectal surgical site infections (SSIs) because they are common, dangerous, and expensive, said Dr. Chassin, president of the group. Unfortunately, risk factors don’t respond to a "one size fits all" prevention protocol. "These factors are highly variable across hospitals, suggesting that there are opportunities to improve performance."

The 2-year pilot project included seven hospitals of varying size and community demographics. The facilities tracked their colorectal SSI patterns using the American College of Surgeons National Surgical Quality Improvement Program. Each hospital then developed interventions targeted at their individual modifiable risk factors, implemented the changes, and recorded their results.

Overall, the protocol reduced colorectal SSIs by 32% – from an average of 16% to 11%. Superficial skin SSIs fell by an average of 45% over the entire study group.

The protocol improved other outcomes as well, Dr. Chassin said. The average length of stay for a colorectal surgery patient with a wound infection decreased from 15 to 13 days. Across the group, the changes were associated with a savings of almost $4 million.

The hospitals collectively identified 34 factors that greatly increased the risk of such infections. During the briefing, Dr. Jenna Lovely, the surgical pharmacotherapy manager at the Mayo Clinic, Rochester, Minn., shared some of their results (J. Am. Coll. Surg. 2011;213:83-92; 2012 [doi:10.1016/j.jamcollsurg.2012.09.009]).

Before implementation of the program, the colorectal SSI rate at Mayo was 10%. With a goal of reducing that number by at least 50%, the team examined risk factors in the preoperative, intraoperative, postoperative, and posthospitalization periods and made some changes, Dr. Lovely said.

Preoperatively, every patient now takes a shower with soap or with a chlorhexidine-based cleanser both the night before and the day of surgery.

Intraoperatively, the site is prepped with an antimicrobial cleansing agent, and the correct antibiotic is administered at 1 hour before the incision is made. If the surgery lasts more than 4 hours, a second dose of the same antibiotic is administered; cefazolin is given 24 hours after closing.

At fascia closing, the surgeon dons a complete change of gown, mask, and gloves. Closing is performed with the use of an entirely new set of instruments.

Postoperatively, everyone who comes in contact with the wound – including staff, the patient, and visitors – practices good hand hygiene. Reminder notes and hand cleanser are located prominently in rooms and all around the unit. Nurses are empowered to change dressings as needed. Wound probing occurs as needed to help expel any contaminated fluids.

Patients are discharged with infection control education and a bottle of chlorhexidine cleanser.

"These changes are embedded in the environment across the continuum of care. It’s part of the surgical unit’s culture, and this makes it easier to do the right thing. The changes also allow the surgeon to focus on doing what he does best – providing a timely and efficient surgery with the best possible outcome," Dr. Lovely said.

Implementation of these changes led to a reduction in SSI rate from 10% to 4%, and that rate has maintained this rate for 18 months.

Dr. Shirin Towfigh, a surgeon at Cedars-Sinai Medical Center in Los Angeles, said her unit experienced a similar improvement.

The project included 46 surgeons and all of the unit staff. Because the team didn’t want to dictate surgical technique, she said, their goal "was to come up with processes that would improve results independent of a surgeon’s practice. We wanted the changes to be effective, but also easy for surgeons to implement in their own practice."

By the end of the study period, the unit’s colorectal SSI rate had decreased by 50%. Since the project closed 6 months ago, that has further improved, with a total decrease of 65%.

"This is a problem colorectal surgeons have been struggling with for years," Dr. Chassin said. "We’ve always tried to get at it with the simple answer: ‘Here are 5 or 10 things everyone should do to decrease SSIs.’ That doesn’t work, because the critical factors that explain poor outcomes differ from one place to another. The best advice I can give is to look at all your contributing factors and assess where your organization falls short. Use these findings as a guide for where to focus your improvement efforts. The only way you know how to improve is to measure the cause of problems and target interventions right to them."

No disclosures were reported.