Recent Publications by CFE Educators

Hospitals are challenged with reevaluating their hospital's transitional care practices, to reduce 30-day readmission rates, prevent adverse events, and ensure a safe transition of patients from hospital to home. Despite the increasing attention to transitional care, there are few published studies that have shown significant reductions in readmission rates, particularly for patients with stroke and other neurologic diagnoses. Successful hospital-initiated transitional care programs include a "bridging" strategy with both predischarge and postdischarge interventions and dedicated transitions provider involved at multiple points in time. Although multicomponent strategies including patient engagement, use of a dedicated transition provider, and facilitation of communication with outpatient providers require time and resources, there is evidence that neurohospitalists can implement a transitional care program with the aim of improving patient safety across the continuum of care.

BACKGROUND

The poorly healing perineal wound is a significant complication of abdominoperineal resection. The authors examined criteria for immediate flap coverage of the perineum and long-term cross-sectional surgical outcomes.

METHODS

Patients who underwent abdominoperineal resection or pelvic exenteration for anorectal cancer were retrospectively analyzed. Demographic characteristics, premorbid and oncologic data, surgical treatment, reconstruction method, and recovery were recorded. Outcomes of successful wound healing, surgical complications necessitating intervention (admission or return to the operating room), and progression to chronic wounds were assessed.

RESULTS

The authors identified 214 patients who underwent this procedure from 1995 to 2013. Forty-seven patients received pedicled flaps and had higher rates of recurrence and reoperation, active smoking, Crohn disease, human immunodeficiency virus, and anal cancers, and had higher American Joint Committee on Cancer tumor stages. Thirty-day complication rates were equivalent in the two groups. There were no complete flap losses or reconstructive failures. Perineal wound complication rates were marginally but not significantly higher in the flap group (55 percent versus 41 percent; p = 0.088). Infectious complications, readmissions for antibiotics, and operative revision were more frequent in the flap cohort. A larger proportion of the primary closure cohort developed chronic draining perineal wounds (23.3 versus 8.5 percent; p = 0.025).

CONCLUSIONS

Immediate flap coverage of the perineum was less likely to progress to a chronic draining wound, but had higher local infectious complication rates. The authors attribute this to increased comorbidity in the selected patient population, reflecting the surgical decision making in approaching these high-risk closures and ascertainment bias in diagnosis of infectious complications with multidisciplinary examination.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

BACKGROUND

The Institute of Medicine has identified atrial fibrillation (AF) among national priorities for research. We examine the incidence of AF and its association with outcomes of patients undergoing abdominal surgery.

METHODS

Patients ≥ 55 years who underwent abdominal surgery captured in a State Inpatient Database, 2008-2010. Three patient groups were created: (1) No diagnosis of AF (No-AF), (2) Pre-existing AF (Hx-AF), and (3) New-onset AF (New-AF). Outcomes were analysed using bivariate and multivariate methods.

RESULTS

AF incidence among 116,477 patients was 8.6 %; approximately one in four patients aged ≥ 85 years had AF. 26.6 % of patients with AF experienced New-AF; the latter was more likely after pancreas resection (43.0 %) and least common after cholecystectomy (20.2 %). Complications (71.1, 47.3 vs. 26.5 %), mortality (8.0, 5.7 vs. 2.0 %), longer hospital stays (8.8, 5.6 vs. 3.8 days), and higher hospitalization cost ($41,427, $26,312 vs. $18,310) were more likely in patients with AF (New-AF, Hx-AF vs. No-AF respectively) (all p 0.001). After adjustment, New-AF was among factors independently associated with mortality (OR 2.0, 95 % CI 1.7-2.4, p 0.001); each case of New-AF increased cost of care by $4,482. Factors independently associated with New-AF included ≥ 1 complication, electrolyte imbalance, and procedure-type. Whereas 2.0 % of patients who developed New-AF were admitted from a long-term care facility, 23.8 % of patients with New-AF were discharged to a long-term care facility.

CONCLUSIONS

AF is common among abdominal surgery patients, particularly the elderly; New-AF is a serious, potentially avoidable adverse event that could serve as an important quality of care indicator for abdominal surgery patients.