American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Critical New Literature: The Science You Need to Know

Thromboembolism in Emergency General Surgery

Ross SW, Kuhlenschmidt KM, Kubasiak JC, et al. Association of the Risk of a Venous Thromboembolic Event in Emergency vs Elective General Surgery. JAMA Surg. 2020.

Murphy PB, Haut ER. Venous Thromboembolism in Emergency General Surgery Patients—A Call to Action to Improve Data, Clinical Care, and Patient Outcomes. JAMA Surg. 2020.

Murphy PB, Vogt KN, Lau BD, et al. Venous Thromboembolism Prevention in Emergency General Surgery: A Review. JAMA Surg. 2018;153(5):479-486.

Commentary: Emergency general surgery (EGS) operations comprise a significant and increasing proportion of operations and hospital admissions. These patients often present with intra-abdominal catastrophes, sepsis, shock, and a need for critical care management; they are at a high risk for complications. Consequently, the morbidity and mortality associated with EGS operations are disproportionate to their incidence in comparable nonemergency procedures. One such complication is venous thromboembolism (VTE), which is prevalent and costly, but also often preventable.

In their study, Ross and colleagues used the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) to compare VTE rates between elective and EGS patients undergoing three common operations: cholecystectomy, ventral hernia repair, and partial colectomy. Slightly more than 57 percent of all procedures were performed laparoscopically, with a higher percentage of laparoscopic surgery in the nonemergency surgery cohort. The overall rate of VTE within 30 days was low (1.9 percent for EGS and 0.8 percent for elective surgery). After controlling for multiple potential confounding factors and comorbidities, EGS patients were found to have an almost twofold higher risk of VTE (odds ratio 1.70; 95 percent CI 1.61–1.79). Laparoscopic procedures had a lower VTE rate than open operations.

This study is the first of its kind to demonstrate an increased risk of thromboembolic events for patients who require EGS. In the invited commentary to this article, Drs. Murphy and Haut echo the call to action to address this important issue. They mention the lack of evidence-based practice guidelines on VTE prophylaxis in EGS and describe the need to develop appropriate risk-assessment tools specific to EGS, as well as EGS databases and registries that will allow the health care community to research the issue and develop further treatments. In the 2018 article listed previously, Murphy and Haut described practices used in their institution, including assessment of VTE risk; optimal prophylaxis; and physician, nurse, and patient education regarding the use of mechanical and pharmacologic VTE prophylaxis and institutional policies.

These publications highlight an important area for quality improvement, not only for VTE but for many other surgical morbidities. The collective evidence suggests that EGS patients are a high risk but understudied population that contributes disproportionately to the burden of surgical disease. In order to improve patient outcomes, more research on the EGS population is needed to guide development of evidence-based processes and treatments.

Insights from a COVID-19 Hotspot

Cummings MJ, Baldwin, M.R., Abrams, D. et al. Epidemiology, Clinical Course, and Outcomes of Critically Ill Adults with COVID-19 in New York City: A Prospective Cohort Study. Lancet. 2020.

Commentary: This article reports outcomes data on more than 1,100 COVID-19 patients at two hospitals in New York, NY. The data show that outcomes were significantly worse in older patients and patients with underlying health conditions (particularly hypertension/congestive heart failure and diabetes). Mortality was 39 percent in patients who developed organ failure; the most common fatal condition was respiratory failure. The authors emphasized that their institutions serve a large proportion of black and Latino patients, highlighting the increased risk facing these individuals. In addition, these data were gathered during the early phase of the COVID-19 surge in New York City. It is anticipated that increased clinical experience will lead to better outcomes.

Shachar C, Engel J, Elwyn G. Implications for Telehealth in a Post-Pandemic Future: Regulatory and Privacy Issues. JAMA. 2020.

Latifi R, Doarn, C.R. Perspective on COVID-19: Finally, Telemedicine at Center Stage. Telemedicine and E-Health. 2020.

Commentary: Shachar and coauthors provide perspective on the use of telehealth during and following the COVID-19 pandemic. They note that the pandemic has jump-started the use of telehealth measures for patient interactions because of the widespread implementation of shelter-in-place orders, along with patient reluctance to visit health care facilities. Noteworthy changes that have occurred include increased payment for telehealth services and adjustments in patient privacy requirements that permit easier use of these approaches. The authors stress the importance of revisiting these changes after the pandemic ends, so telehealth can take its proper place as a beneficial approach to patient care.

In the second article, the author summarizes experiences with the successful use of telehealth for management of surgical patients.

Early Proning of COVID-19 Patients Useful in Reducing Respiratory Distress

Sartini C, Tresoldi M, Scarpellini P, et al. Respiratory Parameters in Patients With COVID-19 After Using Noninvasive Ventilation in the Prone Position Outside the Intensive Care Unit. JAMA. 2020.

Elharrar X, Trigui Y, Dols AM, et al. Use of Prone Positioning in Nonintubated Patients With COVID-19 and Hypoxemic Acute Respiratory Failure. JAMA. 2020.

Telias I, Katira BH, Brochard L. Is the Prone Position Helpful During Spontaneous Breathing in Patients With COVID-19? JAMA. 2020.

Commentary: The authors suggest that prone positioning may benefit patients in the early phases of COVID-19 hypoxemic respiratory failure. The reported patients were not intubated and, in the report by Sartini, the patients were treated outside the intensive care unit. Most patients showed improved oxygenation, at least temporarily, and most patients who did not tolerate proning progressed to intubation and ventilation.

The editorial comment by Telias and colleagues reviews potentially beneficial physiologic changes that can accompany prone positioning and notes that studies in progress demonstrate whether proning can prevent progression to intubation and ventilation.

Secondary Risk Factors for Carpal Tunnel Release Patients

Westenberg RF, Oflazoglu K, de Planque CA, Jupiter JB, Eberlin KR, Chen NC. Revision Carpal Tunnel Release: Risk Factors and Rate of Secondary Surgery. Plast Reconstr Surg. 2020;145(5):1204-1214.

Commentary: This study was designed to determine the rate of revision carpal tunnel release in five urban hospitals over a period of 14 years and to assess the demographic, condition-related, and treatment-related factors associated with revision carpal tunnel release. In 2002−2015, 7,464 patients underwent carpal tunnel release. After manually reviewing the medical records, the authors identified 113 patients who underwent revision surgery. Multivariable logistic regression analysis was performed to study association with demographics, unilateral or bilateral treated wrist(s) (including carpal tunnel release performed simultaneously and separately), and type of surgery (open or endoscopic). To gain further insight into these factors, a matched case-control analysis in a 1:3 ratio was performed.

Of the 113 patients who underwent revision surgery, the median (interquartile range) time to revision surgery was 1.23 years (0.47 to 3.89 years). In multivariable logistic regression analysis, older age, male sex, bilateral carpal tunnel release, and endoscopic carpal tunnel release were independently associated with higher odds for revision surgery. Multivariable conditional logistic regression of the matched case-control cohort showed that smoking and rheumatoid arthritis were independently associated with revision carpal tunnel release. Splint treatment before the initial surgery was independently associated with single carpal tunnel release. Endoscopic release, male sex, smoking, rheumatoid arthritis, and undergoing staged or simultaneous bilateral carpal tunnel release are risk factors for revision surgery.

Schommer J, Allen S, Scholz N, Reams M, Bohn D. Evaluation of Quality Improvement Methods for Altering Opioid Prescribing Behavior in Hand Surgery. J Bone Joint Surg Am. 2020;102(9):804-810.

Commentary: Using recently published opioid use and prescribing guidelines for hand surgery, the authors created an opioid prescribing quality improvement program aimed at reducing postoperative opioid prescribing without negatively affecting patient satisfaction. The main aspect of the program was the implementation and modification of an opioid prescribing order set, but the program also included surgeon education, executed in two intervention steps, about how their prescribing behavior compared with that of their peers. Three phases of data representing three months each were collected before, during, and after the interventions.

A total of 2,067 hand surgery cases were reviewed (629 in Phase 1, 655 in Phase 2, and 783 in Phase 3). The average number of morphine milligram equivalents (MMEs) was reduced from 142.0 in Phase 1 to 69.9 in Phase 2 (51 percent reduction) to 61.3 in Phase 3 (57 percent reduction compared with Phase 1). Significant reductions in MMEs occurred across the procedural categories as well as the hand surgeons. Patient pain satisfaction was similar before and after implementation of the first intervention (p = 0.96).

The authors concluded that quality improvement methods were effective in altering prescribing behavior by physicians in the long term, and this approach may be effective if applied more widely.

Additional Readings

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