Impact of a multidisciplinary quality improvement initiative to reduce inappropriate usage of stress ulcer prophylaxis in hospitalized patients

Aims To promote effective methods to improve overutilization patterns of acid-suppressive therapy in hospitalized patients and to evaluate the impact of multidisciplinary team efforts to reduce inappropriate use of stress ulcer prophylaxis in low-risk patients. Methods A multidisciplinary quality improvement initiative incorporating education, medication use reviews and reconciliation, and pharmaceutical intervention was implemented in June 2018 for surgical patients hospitalized via emergency department. For the pre-post analysis and time series analysis, patients admitted during April and May were classified into the pre-intervention cohort and those admitted during July and August into the post-intervention cohort. Results Three hundred and seventeen patients were included in this study (153 and 164 in the pre- and post-intervention cohorts, respectively). The multidisciplinary program was effective in reducing overuse of stress ulcer prophylaxis and healthcare expenses associated with it. Biweekly education on risk factors warranting stress ulcer prophylaxis was provided for clinicians, and acid-suppressive therapy was removed from a preset list of admission orders. The incidence of inappropriate prophylaxis use declined substantially following intervention in overall patients (OR = 0.51, P = 0.01) and a significant decrease was primarily observed among non-ICU patients (OR = 0.50, P = 0.01). Interrupted time series analysis confirmed the significant decline in inappropriate use post intervention (coefficient = -0.63, P < 0.001). The total healthcare expenses associated with such overuse decreased by 58.5% from US$19.39 to US$ 8.04 per 100 patient-days. Conclusions Our multidisciplinary team efforts were associated with improvement in stress ulcer prophylaxis overuse patterns, resulting in a substantial decrease in the incidence of inappropriate use, especially in general wards, and associated healthcare costs.ope

Effect of Obesity on 30-Day Mortality in Critically Ill Surgical Patients

Purpose: This study was conducted to assess how extreme obesity affects 30-day mortality in this patient group. Methods: A total of 802 patients who underwent emergency gastrointestinal surgery from January 2007 to December 2017 were retrospectively reviewed. Patients were divided into three groups according to their body mass index (BMI): group 1, normal weight (BMI: 18.5∼22.9 kg/m2); group 2, overweight (BMI: 23.0∼29.9 kg/m2); and group 3, obesity (BMI≥30 kg/m2). Patients with a BMI under 18.5 were excluded from the analysis. Chi-squared test, Fisher’s exact test, Kaplan-Meier survival analysis, and the log-rank test were used to assess and compare 30-day mortality rates between groups. Results: The mortality rates of group 1, group 2, and group 3 were 11.3%, 9.0%, and 26.9%, respectively (P<0.017). The mortality rate did not differ significantly between group 1 and 2 (11.3% vs. 9.0%; P=0.341), but group 1 and 2 showed better survival rates than group 3 (11.3% vs. 26.9%; P=0.028, 9.0% vs. 26.9%; P=0.011). Kaplan-Meier survival analysis revealed that group 3 had higher mortality than the other two groups (P=0.001). Conclusion: Obesity (BMI≥30 kg/m2) was one of the risk factors influencing critically ill patients who underwent emergency surgery.ope

Single Center Experience of Ultrasonography-guided Bedside Procedures for Surgical Patients

Purpose: Ultrasound guidance for bedside procedures reduces the risk of complications. This e aim of this study is to stateexamined the experiences of the ultrasonography-guided bedside procedures performed by surgeons in the intensive care unit. Methods: Patients who underwent ultrasonography-guided bedside procedures from October 2016 to October 2017 were reviewed retrospectively. The baseline characteristics of the population, procedures performed, occurrence of complications, and coagulation-related parameters were obtained from the electronic medical records. Results: A total 113 procedures were collected and analyzed. The most frequently performed procedure was ultrasonography-guided central venous catheterization (CVC) (75 cases, 66.4%), followed by thoracentesis (41 cases, 36.3%) and paracentesis (7 cases, 6.2 %). A total of five complications (4.4%) occurred after the procedures, three events after CVC insertion, and two events after thoracentesis. After CVC, two pneumothorax and one hemothorax occurred, which were managed by chest tube insertion. Two events after thoracentesis were a pneumothorax, which required chest tube insertion, and a combined tension-pneumothorax with a hemothorax, which required thoracoscopic surgery for bleeder ligation. Conclusion: Ultrasonography-guided bedside procedures are a simple and fast modality available for surgeons. Despite the safety of ultrasonography-guided procedure, there is some concern regarding the development of complicationsope

10 Years of Acute Care Surgery: Experiences in a Single Tertiary University Hospital in Korea

Purpose Acute care surgery (ACS) has been shown to improve patient outcome and treatment efficiency in the U.S. ACS was introduced to the Department of Surgery, Yonsei University College of Medicine, Seoul to solve the problems associated with delays in surgical evaluation of non-trauma patients who needed emergency surgery, and to offer exposure to a wide variety of surgical cases to general surgical fellows and residents. The objective of this study was to describe the 10-year experience of the ACS department in a single center. Methods A retrospective chart review was conducted at the Department of Surgery, Yonsei University College of Medicine, Seoul, for all patients admitted from March 2008 to February 2018. Patients were grouped into either the trauma or non-trauma group, and were further classified according to their diagnosis, and the type of operations they had undergone. Results There was a total of 2,805 patients, including 1,001 trauma patients and 1,804 non-trauma patients. The average hospital length of stay was 14 days and the total in-hospital mortality rate was 3.6%. Trauma mechanisms included blunt (92.6%), penetrating (7.0%) and burn (0.4%) trauma. The majority of non-trauma patients were admitted for appendicitis (37.1%), followed by cholecystitis (21.7%). There was a total of 1,561 operations conducted. The most frequent operations were appendectomy (38.3%) and cholecystectomy (19.5%), followed by adhesiolysis (7.8%). Conclusion A working ACS department has been implemented in a Korean medical center.ope

Association of Initial Low Serum Selenium Level with Infectious Complications and 30-Day Mortality in Multiple Trauma Patients

Low serum selenium levels are commonly observed in critically injured multiple trauma patients. This study aimed to identify the association between initial serum selenium levels and in-hospital infectious complications in multiple trauma patients. We retrospectively reviewed multiple trauma patients admitted between January 2015 and November 2017. We selected 135 patients whose serum selenium levels were checked within 48 h of admission. Selenium deficiency was defined as a serum selenium level <70 ng/mL. Survival analyses of selenium deficiency and 30-day mortality were performed. Multivariate logistic regression analysis was performed to identify the association between initial serum selenium level and in-hospital infectious complications. Thirty-day mortality (8.3% vs. 0.0%; p = 0.018) and incidence rates of pneumonia (66.7% vs. 28.3%; p < 0.001) and infectious complications (83.3% vs. 46.5%; p < 0.001) were higher in patients with selenium deficiency than in patients without selenium deficiency. Kaplan-Meier survival cures also showed similar results (log rank test, p = 0.021). Of 135 patients, 76 (56.3%) experienced at least one infectious complication during admission. High injury severity score (ISS, odds ratio (OR) 1.065, 95% confidence interval (CI) 1.024-1.108; p = 0.002) and selenium deficiency (OR 3.995, 95% CI 1.430-11.156; p = 0.008) increased the risk of in-hospital infectious complications in multiple trauma patients. Patients with selenium deficiency showed higher 30-day mortality and higher risks of pneumonia and infectious complications.ope

Addition of lactic acid levels improves the accuracy of quick sequential organ failure assessment in predicting mortality in surgical patients with complicated intra-abdominal infections: a retrospective study

Background: The quick sequential organ failure assessment (qSOFA) alone has a poor sensitivity for predicting mortality in patients with complicated intra-abdominal infections, and plasma lactate levels have been shown to have a strong association with mortality in critically ill patients. Therefore, this study aimed to compare the performance of qSOFA with a score derived from a combination of qSOFA and serum lactate levels for predicting mortality in surgical patients with complicated intra-abdominal infections. Methods: This retrospective study was performed at a university hospital. The medical records of 457 patients who presented to the emergency department (ED) between January 2008 and December 2016 and required emergency gastrointestinal surgery for a complicated intra-abdominal infection were reviewed retrospectively. qSOFA criteria, sequential organ failure assessment (SOFA) scores, and plasma lactate levels during their ED stay were collected. We performed area under receiver operating characteristic (AUROC) curve and sensitivity analysis to compare the performance of qSOFA alone with that of a score derived from the use of a combination of the qSOFA and lactate levels for predicting patient mortality. Results: Fifty patients (10.9%) died during hospitalization. The combined qSOFA and lactate level score was superior to qSOFA alone (AUROC = 0.754 vs. 0.717, p = 0.039, respectively) and comparable to the full SOFA score (AUROC = 0.754 vs. 0.795, p = 0.127, respectively) in predicting mortality. Sensitivity and specificity of qSOFA alone were 46 and 86%, respectively, and those of the combined score were 72 and 73%, respectively (p < 0.001). Conclusion: A score derived from the qSOFA and serum lactate levels had better predictive performance with higher sensitivity than the qSOFA alone in predicting mortality in patients with complicated intra-abdominal infections and had a comparable predictive performance to that of the full SOFA score.ope

Association of Inadequate Caloric Supplementation with 30-Day Mortality in Critically Ill Postoperative Patients with High Modified NUTRIC Score.

Modified NUTRIC (mNUTRIC) score is a useful assessment tool to determine the risk of malnutrition in patients on mechanical ventilation (MV). We identified associations between postoperative calorie adequacy, 30-day mortality, and surgical outcomes in patients with high mNUTRIC scores. Medical records of 272 patients in the intensive care unit who required MV support for >24 h after emergency gastro-intestinal (GI) surgery between January 2007 and December 2017 were reviewed. Calorie adequacy in percentage (Calorie intake in 5 days ÷ Calorie requirement for 5 days × 100) was assessed in patients with high (5⁻9) and low (0⁻4) mNUTRIC scores. In the high mNUTRIC score group, patients with inadequate calorie supplementation (calorie adequacy <70%) had higher 30-day mortality than those with adequate supplementation (31.5% vs. 11.1%; p = 0.010); this was not observed in patients with low mNUTRIC scores. This result was also confirmed through Kaplan⁻Meier survival curve (p = 0.022). Inadequate calorie supplementation in the high mNUTRIC score group was not associated with Intra-abdominal infection (p = 1.000), pulmonary complication (p = 0.695), wound complication (p = 0.407), postoperative leakage (p = 1.000), or infections (p = 0.847). Inadequate calorie supplementation after GI surgery was associated with higher 30-day mortality in patients with high mNUTRIC scores. Therefore, adequate calorie supplementation could contribute to improved survival of critically ill postoperative patients with high risk of malnutrition.ope

Association of calorie and protein supplementation and 30-day mortality in critically ill post-operative patients

연구배경: 위장관 응급수술을 받고 경구 섭취가 제한되어 있는 환자에서 충분한 영양 공급과 이를 위한 영양 공급 경로의 선택은 쉽지 않은 과제이다. 본 연구의 목적은 영양 공급이 위의 환자들의 임상 경과에 미치는 영향을 밝히고, 이의 중요성을 강조하는 데에 있다. 연구방법: 2007년 1월부터 2017년 12월까지 복강내 감염으로 위장관 응급 수술 후 인공호흡기 치료를 시행 받은 272명의 환자를 대상으로 하였다. 환자들을 영양부족 위험성에 따라 두 집단으로 분류하였다. 영양부족 고위험군은 체질량지수 18.5 kg/m2 미만, 30 kg/m2 이상이거나 modified NUTrition Risk In Critically ill 점수 5점 이상인 경우로 정의하였다. 수술 후 최대 5일간 환자들의 일일 칼로리 및 단백질 요구량 대비 공급량을 계산하였다. 영양부족 고위험군과 저위험군에서 각각 칼로리와 단백질 모두 불충하게 공급받았던 환자들과 둘 중 하나라도 충분히 공급받았던 환자들을 분류하여 소집단으로 나누었다. 칼로리와 단백질은 각각 요구량의 70%와 60% 이상으로 공급받은 경우 충분 하다고 정의하였다. 연구결과: 영양 부족 고위험군에서 칼로리와 단백질 모두 불충분하게 공급받은 환자들은 30일 사망률이 높게 나타났다 (29.2% vs 12.5%; p = 0.014). Kaplan-Meier survival curve 또한 같은 경과를 보여주었다 (p = 0.033). 흉막삼출 (31.9% vs 43.1%; p = 0.168), 폐렴 (13.9% vs 13.9%; p = 1.000), 감염 합병증 (56.9% vs 50.0%; p = 0.404)은 충분한 영양 공급군과 불충분한 영양 공급을 받은 군에서 의미 있는 차이를 보이지 않았다. 연구결론: 응급 위장관 수술을 받은 영양부족 고위험군의 중환자에서 칼로리와 단백질의 불충분한 공급은 높은 30일 사망률과 연관이 있다. Background: Providing adequate amount of nutrition and deciding on which route to choose for patients with limited oral diet after emergency gastro-intestinal (GI) surgery are extremely challenging. The aim of this study is to evaluate association of calorie and protein provision and clinical outcomes of patients after emergency GI surgery for complicated intra-abdominal infection (cIAI). Methods: 272 patients who underwent emergency GI surgery for cIAI between January 2007 and December 2017 and required post-operative mechanical ventilation therapy were selected for analysis. Patients are divided into two groups according to their risk of malnutrition. High-risk group was consisted with patients who had BMI <18.5 kg/m2 or modified NUTRIC score ≥5. Daily calorie and protein requirement and adequacy were calculated for each patient for maximum of 5 days. In each group, clinical outcomes of patients who received inadequate calorie and protein were compared with those who received adequate calorie, protein, or both. Results: In high-risk of malnutrition group, patients who received inadequate calorie and protein had higher rate of 30-day mortality (29.2% vs 12.5%; p = 0.014) than those who had adequate calorie (≥70% adequacy), protein (≥ 60% adequacy), or both. Kaplan-Meier survival curve also showed the same result (p = 0.033). Pulmonary effusion (31.9% vs 43.1%; p = 0.168), pneumonia (13.9% vs 13.9%; p = 1.000), infectious complications (56.9% vs 50.0%; p = 0.404) showed no significant differences between subgroups. Conclusion: Inadequate calorie and protein supplementation is associated with higher 30-day mortality in critically ill patients with high-risk of malnutrition who underwent emergency GI surgery.open석