ASA Physical Status Classification Research Articles

TP10.2.3Restarting Elective Orthopaedic Surgery during the COVID-19 Pandemic: Experiences and Patient Outcomes

AimThe novel coronavirus disease 2019 (COVID-19) resulted in postponing all non- emergency elective surgeries from April 2020. Restarting elective orthopaedic surgery is important to help people with chronic disabilities. Our hospital successfully restarted elective orthopaedic surgery during the pandemic to help improve the quality of life of patients.This study describes the development of local protocols and pathways to allow for a safe restart of elective orthopaedic surgery in a COVID-19 free ‘green’ site. It also includes the morbidity and mortality outcomes of those patients who underwent non-emergency orthopaedic operations during this time.MethodsA prospective cohort study evaluating patients undergoing non- emergency orthopaedic procedures through a COVID-19 free surgical pathway in a National Health Service acute general hospital in the United Kingdom from 18th May 2020- 10th July 2020. 104 patients were identified and their outcomes during the 2 week post-operative period was recorded.ResultsNo patients developed COVID-19 infection in the two-week post-operative period. There were no intensive care unit admissions or in- hospital deaths during our study time frame. There was no statistical difference found in the development of complications for age (< 70 or >70), gender, body mass index or ASA physical status classification system grades.ConclusionsThis study describes a roadmap to setting up a protocolised elective operating service for orthopaedic surgery. It has shown that standardised protocols in a COVID-19 free ‘green’ site, pre-operative COVID-19 testing and adherence to national guidelines on self-isolation can help prevent developing COVID-19 infection post-operatively.

Racial Disparities in Access to Diagnostic Laparoscopy for Endometriosis: Diagnostic Delay, ED Visits, and Pre-Operative Indications

<h3>Study Objective</h3> To explore racial differences in diagnostic delay, rates of ED visits, and indications for laparoscopy in diagnosis of endometriosis. <h3>Design</h3> Retrospective chart review. <h3>Setting</h3> Academic tertiary hospital system. <h3>Patients or Participants</h3> Women ages 14-50 receiving a primary surgical diagnosis of endometriosis, 01/2017–12/2020. <h3>Interventions</h3> N/A. <h3>Measurements and Main Results</h3> Diagnostic delay was defined as months between initial presentation for pelvic pain and diagnostic laparoscopy. ED visits for pelvic pain within 5 years preceding laparoscopy were identified via chart review. Indications for laparoscopy were determined from operative and pre-operative notes. Perioperative risk was assessed using ASA physical status classification and need for pre-operative medical clearance. 124 patients met inclusion criteria: 65 (52%) White, 16 (13%) Black, 31 (25%) Latina, 10 (8%) Asian. 1 patient identified as multi-racial. 1 patient declined to identify race. Median delay was 13.6 months (IQR 5.5-43.9) for White patients, 15.2 (IQR 7.2-7.6) for Black patients, 39.4 (IQR 13.7-58.1) for Latina patients, and 48.1 (IQR 2.8-75.6) for Asian patients. Latina patients had a significantly longer delay compared to their White counterparts (Mann-Whitney test, p=0.01). Non-white patients were more likely to have at least 1 ED encounter for pelvic pain prior to laparoscopy: 75% of Black, 50% of Latina, and 50% of Asian patients, compared to 28% of White patients (Chi-squared test, p=0.003). Non-white patients were more likely to have an additional indication for laparoscopy (fibroids, sterilization, abnormal imaging, etc.): 69% of Black patients, 47% of Latina patients, and 70% of Asian patients, compared to 37% of White patients (p=0.05). There was no significant association between race and ASA class (p=0.18) or pre-operative clearance (p=0.76). <h3>Conclusion</h3> Non-white patients may experience barriers to diagnostic laparoscopy for endometriosis, including a greater clinical threshold (e.g., acuity of pain symptoms, additional medical indications) for proceeding with laparoscopy.

Influence of American Society of Anesthesiologists Score on Oncologic Outcomes in Patients With Upper Tract Urothelial Carcinoma After Radical Nephroureterectomy: A Large-Sample Study in Two Institutions.

IntroductionAs a research team of urologists and an anesthetist, we sought to investigate the prognostic significance of American Society of Anesthesiologists (ASA) score in patients with upper tract urothelial cancer (UTUC) after radical nephroureterectomy (RNU). ASA physical status (ASA-PS) classification not only was found to be associated with increased comorbidities but also independently factors for predicting morbidity and mortality. Accurate risk assessment was being particularly important for patients being considered for surgery.MethodsRecords for 958 patients with UTUC who underwent RNU were reviewed. Clinicopathologic variables, including ASA-PS, were assessed at two institutions. Overall survival (OS), cancer-specific survival (CSS), intravesical recurrence-free survival (IRFS), and metastasis-free survival (MFS) were estimated using the Kaplan–Meier method and Cox regression analyses. We measured the independent predictive value of ASA-PS for mortality by multivariate regression. Association of ASA-PS and clinicopathologic variables was assessed.ResultsThe group of patients with ASA = 2/3 had a shorter 5-year OS (67.6% and 49.9%), CSS (72.9% and 58.1%), and MFS (75.1% and 58.5%). The median follow-up time was 39 months. Kaplan–Meier curves showed that the group with ASA = 2/3 had significantly poorer OS, CSS, and MFS. Adjusting for multiple potential confounding factors, multivariate analyses suggested that ASA score was an independent predictor of OS, CSS, and MFS (p = 0.004, p = 0.005, p < 0.001).ConclusionHigher ASA scores were independently associated with lower survival rate. This capability, along with its simplicity, makes it a valuable prognostic metric. It should be seriously referenced in UTUC patients being considered for RNU.

Comparative Study Between Ultrasound Guided Femoral Nerve Block Versus Ultrasound Guided Saphenous Nerve Block After Total Knee Replacement

Abstract Background Total knee arthroplasty (TKA) is one of the most commonly performed operations in our daily practice. It is indicated in all patients with severe osteoarthritis and it needs early postoperative ambulation to improve postoperative outcomes and to reduce immobility related complications. Providing adequate analgesic control is very important to achieve functional recovery, facilitates rehabilitation and attenuates the progression from acute to chronic postsurgical pain, aiming to maximize non-opioid analgesics in addition to regional analgesic techniques. It is estimated that the majority of patients experience either severe pain (60% of patients) or moderate pain (30% of patients) following TKA surgeries. With the emergence of enhanced recovery after surgery ERAS clinical pathways, many surgical specialties are adopting multimodal analgesic regimens to improve patient outcomes. Objective This study aimed at shedding lights on the value of preserving the motor function in the immediate postoperative period after total knee replacement. That was illustrated by comparing femoral nerve block (mixed motor and sensory nerve) versus saphenous nerve block (pure sensory nerve) in the adductor canal, and the effect of either blocks on the analgesia and ambulation of the patients postoperatively. Patients and Methods After approval of the departmental ethical committee, from September 2017 to September 2019, this Prospective double armed interventional randomized clinical study was conducted at Ain Shams University Hospitals, operating theatre department on 40 adult patients of ASA physical status classification I-II, admitted to Ain Shams university hospital, scheduled for elective primary unilateral total knee replacement surgery. The patients were subdivided into 2 groups A and B, (20) patients for each group. Results In our study we performed a prospective randomized trial to compare between saphenous nerve block (adductor canal block ACB) versus femoral nerve block FNB regarding postoperative analgesic efficacy in terms of pain scores using visual analogue scale VAS during rest and during 45 degree passive flexion of the knee joint, both were measured at 6, 12, 24 and 48 hours postoperatively. Total nalufen consumption in the first 24 hours postoperative was measured in milligrams. Also postoperative Quadriceps muscle strength clinical testing by using a Timed Up-and-Go test (TUG test) at 24 hours postoperative and (10 minutes walking test) at 24 hours postoperative. We found that analgesic efficacy of both groups in the terms of VAS pain scores and cumulative 1st 24 hours Nalufin consumption are equivalent but there is a statistically significant difference in quadriceps muscle strength being higher in adductor canal block group than femoral nerve block group. TUG test results were lower in ACB group compared to FNB group, and results of 10-minutes walking test were significantly higher in ACB group compared to FNB group. Also incidence of postoperative nausea, vomiting and Sedation was assessed and it was found no statistically significant differences in nausea, vomiting and Sedation between the two groups. Conclusion Saphenous nerve block (adductor canal block) is equivalent to femoral nerve block in achieving postoperative pain but it's superior to femoral nerve block in preserving quadriceps muscle power. So it's competent to be chosen as postoperative analgesic modality after Total knee replacement surgeries.

The Evolution, Current Value, and Future of the American Society of Anesthesiologists Physical Status Classification System.

The American Society of Anesthesiologists (ASA) Physical Status classification system celebrates its 80th anniversary in 2021. Its simplicity represents its greatest strength as well as a limitation in a world of comprehensive multisystem tools. It was developed for statistical purposes and not as a surgical risk predictor. However, since it correlates well with multiple outcomes, it is widely used-appropriately or not-for risk prediction and many other purposes. It is timely to review the history and development of the system. The authors describe the controversies surrounding the ASA Physical Status classification, including the problems of interrater reliability and its limitations as a risk predictor. Last, the authors reflect on the current status and potential future of the ASA Physical Status system.

Improving accuracy of American Society of Anesthesiologists Physical Status using audit and feedback and artificial intelligence: a time-series analysis

While the American Society of Anesthesiologists (ASA) Physical Status (PS) is used to adjust for greater mortality risk with higher ASA PS classification, inaccurate classification can lead to an inaccurate comparison of institutions. The purpose of this study was to assess the effect of audit and feedback with a rule-based artificial intelligence algorithm on the accuracy of ASA PS classification. We reviewed 78 121 anesthetic records from 1 January 2017 to 19 February 2020. The first intervention entailed audit and feedback emphasizing accurately documenting ASA PS classification using body mass index (BMI), while the second intervention consisted of implementing a rule-based artificial intelligence algorithm. If a patient with a BMI ≥40 kg/m2 had a documented ASA PS classification of 1 or 2, the provider was alerted to change the ASA PS classification to 3 or above. The primary outcome was the overall proportion of patients with inaccurate ASA PS classification based on BMI per month. Secondary outcomes included the proportion of patients with a BMI ≥40 or a BMI 30-39.9 who had inaccurate ASA PS classification and the proportion of patients documented as having ASA 3-5. Data were analyzed using interrupted time-series analysis. For the primary outcome, the slope for ASA PS classification inaccurately incorporating BMI was unchanging before the first intervention (parameter coefficient 0.002, 95% CI -0.034 to 0.038; P = 0.911). Following the first intervention, there was an immediate level change (parameter coefficient -0.821, 95% CI -1.236 to -0.0406; P < 0.001) without significant change in slope (parameter coefficient -0.048, 95% CI -0.100 to 0.004; P = 0.067). The post-intervention slope was negative (parameter coefficient -0.046, 95% CI -0.083 to -0.009; P = 0.017). Following the second intervention, there was no level change (parameter coefficient 0.203, 95% CI -0.380 to 0.463; P = 0.839) and no significant change in slope (parameter coefficient 0.013, 95% CI -0.043 to 0.043; P = 0.641). The post-intervention slope was not significant (parameter coefficient -0.034, 95% CI -0.078 to 0.010; P = 0.121). The proportion of patients whose ASA PS classification inaccurately incorporated BMI at the first and final timepoint of the study was 2.6% and 0.8%, respectively. Our quality improvement efforts successfully modified clinician behavior to accurately incorporate BMI into the ASA PS classification. By combining audit and feedback methodology with a rule-based artificial intelligence algorithm, we created a process that resulted in immediate and sustained effects. Improving ASA PS classification accuracy is important because it affects quality metrics, research design, resource allocation and workflow processes.

Reliability of the ASA Physical Status Classification System in Predicting Surgical Morbidity: a Retrospective Analysis

The American Society of Anesthesiologists (ASA) Physical Status Classification System has been used to assess pre-anesthesia comorbid conditions for over 60 years. However, the ASA Physical Status Classification System has been criticized for its subjective nature. In this study, we aimed to assess the correlation between the ASA physical status assignment and more objective measures of overall illness.This is a single medical center, retrospective cohort study of adult patients who underwent surgery between November 2, 2017 and April 22, 2020. A multivariable ordinal logistic regression model was developed to examine the relationship between the ASA physical status and Elixhauser comorbidity groups. A secondary analysis was then conducted to evaluate the capability of the model to predict 30-day postoperative mortality.A total of 56,820 cases meeting inclusion criteria were analyzed. Twenty-seven Elixhauser comorbidities were independently associated with ASA physical status. Older patient (adjusted odds ratio, 1.39 [per 10 years of age]; 95% CI 1.37 to 1.41), male patient (adjusted odds ratio, 1.24; 95% CI 1.20 to 1.29), higher body weight (adjusted odds ratio, 1.08 [per 10 kg]; 95% CI 1.07 to 1.09), and ASA emergency status (adjusted odds ratio, 2.11; 95% CI 2.00 to 2.23) were also independently associated with higher ASA physical status assignments. Furthermore, the model derived from the primary analysis was a better predictor of 30-day mortality than the models including either single ASA physical status or comorbidity indices in isolation (p < 0.001).We found significant correlation between ASA physical status and 27 of the 31 Elixhauser comorbidities, as well other demographic characteristics. This demonstrates the reliability of ASA scoring and its potential ability to predict postoperative outcomes. Additionally, compared to ASA physical status and individual comorbidity indices, the derived model offered better predictive power in terms of short-term postoperative mortality.

Perioperative management of post-COVID-19 surgical patients: Indian Society of Anaesthesiologists (ISA National) Advisory and Position Statement.

Perioperative management of post-COVID-19 surgical patients: Indian Society of Anaesthesiologists (ISA National) Advisory and Position Statement.

P.120 ASA grading in obstetrics: Too laborious to deliver?

Introduction: The American Society of Anaesthesiologists – Physical Status (ASA -PS) grading is an internationally recognised tool used to stratify the baseline status of sick patients. The Society states that ’although pregnancy is not a disease, the parturient’s physiologic state is significantly altered from when the woman is not pregnant’. In 2014, the ASA-PS was amended with added examples and further amended in October 2019 [1] ASA Physical Status Classification System developed by: ASA House of Delegates/Executive Committee Last Amended: October 23, 2019 (original approval: October 15, 2014). www.asahq.org/standards-and-guidelines/asa-physical -status - classification-system. Google Scholar and December 2020 [2] ASA Physical Status Classification System developed by: ASA House of Delegates/Executive Committee Last Amended: December 13, 2020 (original approval: October 15, 2014). www.asahq.org/standards-and-guidelines/asa-physical-status - classification-system. Google Scholar subsequently with examples relevant to the parturient state. We aimed to assess the knowledge and understanding of the latest ASA-PS grading amongst the team working in our maternity services.

MO533WHICH PARAMETERS BEST PREDICT POSITIVE COVID-19 STATUS FOLLOWING HIP FRACTURE FOR PATIENTS LIVING WITH CKD?

Background and AimsPatients living with chronic kidney disease (CKD) are at greater susceptibility of sustaining hip fractures compared to those without CKD due to higher falls risk. Post-trauma clinical outcomes for patients living with CKD are exacerbated by frailty, co-morbidities and sarcopenia. Patients living with CKD may require lengthy hospitalization following hip fracture, considering the additional indications for extensive treatment and rehabilitation. A long hospital stay may bring greater risks of contracting COVID-19, given the magnitude of this current global pandemic. Complications from COVID-19 significantly increase mortality risks for older patients living with CKD after acute trauma, as a considerable proportion will have a poor baseline health and functional status. Our study aims to determine the most useful clinical and laboratory assessment tools to predict for a positive COVID-19 status following hospitalization with hip fracture in patients living with CKD.MethodPatients with CKDG3b-5 admitted from home to a tertiary hospital in North West UK with hip fracture between Feb and Dec 2020 were included. Each patient included in this study received at least one COVID-19 nasopharyngeal swab during their hospitalization. Parameters assessed on hospital admission for each patient included Clinical Frailty Scale (CFS), Charlson’s Co-morbidity Index (CCI), Chronic Kidney Disease Frailty Index Laboratory Score (CKD FI-LAB), Estimated VO2 Peak, Karnofsky Performance Status Scale, Sernbo Score, Nottingham Hip Fracture Score, ASA Physical Status Classification System Score and Abbreviated Mental Test Score. Receiver Operating Characteristic (ROC) curve analyses were performed to evaluate the ability of individual parameters to predict for a positive COVID-19 status following hip fracture in patients living with CKD. Events of 30-day mortality were recorded.Results92 patients met study inclusion criteria. The mean age was 84.6±7.8 years and the female:male ratio was 1.6:1. 7 patients (7.6%) were on long-term dialysis and the mean eGFR amongst non-dialysis patients was 36.5±13.8 ml/min/1.73m2. The median length of hospitalization was 17 days. 22 patients (23.9%) tested positive for COVID-19. Area under a Curve (AUC) values from ROC analyses are shown in Table 1. The difference in 30-day mortality rate between patients who tested positive for COVID-19 and those who tested negative was +6.8% (p<0.001).ConclusionFrailty and co-morbidity assessment tools (CFS, CCI and CKD FI-LAB) displayed the best predictive ability for positive COVID-19 status following hip fracture in patients living with CKD. A continuous, holistic multi-disciplinary team approach during hospitalization for comprehensive geriatric assessment and optimization of medical co-morbidities may improve outcomes, in anticipation of a potential lengthy hospital stay. To improve prognosis, research efforts should continue to explore avenues on reducing COVID-19 rates within this patient population.MO533 Table 1:AUC values to predict for positive COVID-19 status following hip fracture in patients living with CKDPredictorAUC Value95% ClClinical Frailty Scale0.940.87-1.00Charlson’s Co-morbidity Index0.920.86-0.99Chronic Kidney Disease Frailty Index Laboratory Score0.880.81-0.95Estimated VO2 Peak0.860.79-0.92Karnofsky Performance Status Scale0.840.77-0.91Sernbo Score0.800.74-0.87Nottingham Hip Fracture Score0.770.70-0.84ASA Physical Status Classification System Score0.740.67-0.81Abbreviated Mental Test Score0.650.58-0.72

Associations between malignancy and cardiovascular complications following emergency laparotomy – A retrospective cohort study

BackgroundSystemic inflammation in patients with malignant disease has been associated with increased risk of cardiovascular events. The pro-inflammatory perturbations following surgical trauma may further promote adverse perioperative cardiovascular events and increase the risk of patients with cancer undergoing major surgery. Our objective was to estimate the association between malignant disease and postoperative cardiovascular complications. Secondarily, we aimed to identify risk factors for postoperative cardiovascular complications. MethodsWe conducted a retrospective cohort study of all patients ≥18 years undergoing emergency laparotomy between 2010 and 2016 at Department of Surgery, Zealand University Hospital, Denmark. Complications were graded according to Clavien-Dindo classification of surgical complications. Multivariate logistic regression analysis was performed to estimate association between malignant disease and cardiovascular complications within 30 days of emergency laparotomy and to identify other risk factors for postoperative cardiovascular complications after emergency laparotomy. ResultsWe identified 1188 patients ≥18 years undergoing emergency laparotomy between 2010 and 2016, in which 254 (21%) had malignant disease. Within 30 days of emergency laparotomy, 89 (9.5%) of patients without malignancy died, as compared with 45 (18%) of patients with malignancy (p < 0.001). Cardiovascular death occurred in 17 (1.8%) and 5 (2.0%) patients in the non-malignant and malignant group, respectively. Severe cardiovascular complication graded CD 3–5 occurred in 93 (8%) of all patients within 30 days of emergency laparotomy. We found no association between malignancy and postoperative cardiovascular complications in patients undergoing emergency surgery (OR 0.8, 95% CI; 0.4, 1.5). Increasing age and ASA physical status classification system (ASA) score ≥ III were the only independent risk factors of cardiovascular complications graded CD 3–5. ConclusionsMalignancy was not associated with postoperative cardiovascular complications after emergency laparotomy. Risk factors for major cardiovascular complications after emergency abdominal surgery were age and ASA score ≥ III.

The safety and efficacy of mini-percutaneous nephrolithotomy vs. retrograde intrarenal surgery for treatment of renal lithiasis in pelvic ectopic kidney: an exploratory pilot study.

BackgroundTo compare the safety and efficacy of mini-percutaneous nephrolithotomy (PCNL) and retrograde intrarenal surgery (RIRS) for the treatment of renal lithiasis in patients with pelvic ectopic kidney.MethodsFrom January 2015 to October 2017, mini-PCNL and RIRS were performed in ten patients diagnosed with lithiasis in pelvic ectopic kidneys, including three cases under laparoscopy-assisted mini-PCNL. Patient demographics and perioperative characteristics (age, gender, BMI, side of pelvic kidney, stone size, stone number, stone location, special medical history, and ASA physical status classification), and operative and post-operative related details (operation time, hospital stay, blood loss, VAS, analgesic requirement, complications, and stone free outcome) were reviewed.ResultsAlthough the mean operation time of mini-PCNL (71.3 min) was shorter than RIRS (85.3 min), the mean operation time of laparoscopy assisted mini-PCNL (92 min) was longer than patients without laparoscopy-assisted mini-PCNL (55.8 min). However, the use of mini-PCNL allowed for larger lithiasis to be dealt with (1.9 cm in laparoscopy assisted mini-PCNL and 2.4 cm in mini-PCNL without laparoscopy-assist) compared with RIRS (1.2 cm). In addition, although the mean hospital-stay time, blood loss, and analgesic requirement of patients undergoing RIRS were less than those receiving mini-PCNL, the success rate of RIRS was only 50% (3/6) in comparison to 100% (7/7) for mini-PCNL. Except for pain and urinary tract infection after the operation, there were no significant intraoperative and postoperative complications, and no residual lithiasis were seen in any patient.ConclusionsAlthough RIRS was less time-consuming and invasive, mini-PCNL can deal with the bigger lithiasis and more complex situations with a higher success rate. Both mini-PCNL and RIRS are feasible and safe treatments for pelvic ectopic kidney lithiasis with each carrying unique advantages. Hence in practice, an appropriate individualized treatment should be selected depending on patient characteristics.

POS-349 WHICH PARAMETERS BEST PREDICT REHOSPITALIZATION FROM A SECOND HIP FRACTURE EVENT FOR PATIENTS LIVING WITH CKD ADMITTED FOLLOWING HIP FRACTURE? A 6-YEAR PROSPECTIVE ANALYSIS

Greater frequency of falls and subsequent hip fractures are observed for people living with chronic kidney disease (CKD) compared to those without CKD. The cause of increased falls risk is multifactorial. Many patients living with CKD are frail, sarcopenic and have numerous medical co-morbidities. Fracture risks following a fall could be exacerbated by mineral bone disease secondary to CKD. There is usually a marked deterioration in functional status for patients living with CKD following hip fracture, even after rehabilitation. A reduced baseline function increases risk for further falls and hip fracture events. Worsened morbidity and mortality outcomes are expected in patients with CKD following recurrent trauma and rehospitalization. The most useful clinical assessment tool to predict for rehospitalization from a second hip fracture event amongst this patient group remains unestablished. Patients with CKD G3b-5 admitted from home to a tertiary hospital in North West UK with hip fracture between Jun 2013 and Dec 2019 were included. Individuals with previous hip fractures prior to study commencement were excluded. Parameters assessed on hospital admission for each patient included the Clinical Frailty Scale (CFS), Charlson’s Co-morbidity Index (CCI), Chronic Kidney Disease Frailty Index Laboratory Score (CKD FI-LAB), Karnofsky Performance Status Scale, Sernbo Score, Nottingham Hip Fracture Score, Estimated VO2 Peak, ASA Physical Status Classification System Score and Abbreviated Mental Test Score. Rehospitalization events from a second hip fracture during the study period were recorded. Receiver Operating Characteristic (ROC) curve analyses were performed to evaluate the ability of individual scoring tools to predict for rehospitalization from a second hip fracture event amongst patients with CKD admitted following their first hip fracture. A total of 397 patients met inclusion criteria of which 42 patients (10.6%) were receiving long-term dialysis. Mean Estimated Glomerular Filtration Rate (eGFR) for non-dialysis patients was 37.4±14.9mL/min/1.73m2. 37 patients (9.3%) sustained a second hip fracture leading to rehospitalization during the study period and the mean age difference between first and second hip fracture events is 1.4 yrs (p=0.032). Area under a curve (AUC) values from ROC curve analyses are shown in the table. Tabled 1PredictorAUC Value95% CIClinical Frailty Scale0.940.87-1.00Charlson's Co-morbidity Index0.900.84-0.97Chronic Kidney Disease Frailty Index Laboratory Score0.890.82-0.96Karnofsky Performance Status Scale0.840.77-0.91Sernbo Score0.820.75-0.88Nottingham Hip Fracture Score0.800.73-0.87Estimated VO2 Peak0.790.72-0.86ASA Physical Status Classification System Score0.700.63-0.76Abbreviated Mental Test Score0.630.56-0.70 Open table in a new tab Assessment tools evaluating frailty and co-morbidity status (CFS, CCI and CKD FI-LAB) displayed the strongest predictive ability for rehospitalization events from a second hip fracture in patients with CKD following initial hip fracture. Future studies should aim to optimize frailty needs and address medical co-morbidities in the CKD population during early phases of post-trauma rehabilitation. An effective multidisciplinary team input throughout this process may reduce further falls and fracture risks.

POS-348 Predicting difficulties with direct home discharge following hip fracture for patients living with CKD: Insights from a 6-year prospective study

Patients with chronic kidney disease (CKD) are at higher risk of falls and sustaining hip fractures compared to those without CKD. Worse clinical outcomes are observed in CKD groups, exacerbated by frailty, sarcopenia and other co-morbidities. Arranging discharge to own home following hip fracture is often difficult for older patients living with CKD. Patients with CKD usually have markedly deteriorated functional status following acute trauma and basic rehabilitation requirements cannot be holistically supported within a home environment. The most useful clinical assessment tool to predict for non-home discharge in patients with CKD following hospitalization with hip fracture remains unknown. Patients with CKD G3b-5 admitted from home to a tertiary hospital in North West UK with hip fracture between Jun 2013 and Dec 2019 were included. Parameters assessed on hospital admission for each patient included Clinical Frailty Scale (CFS), Charlson’s Co-morbidity Index (CCI), Chronic Kidney Disease Frailty Index Laboratory Score (CKD FI-LAB), Karnofsky Performance Status Scale, Sernbo Score, Nottingham Hip Fracture Score, Estimated VO2 Peak, ASA Physical Status Classification System Score and Abbreviated Mental Test Score. Patients who did not directly return home after hospitalization following hip fracture were discharged to a residential home, nursing home, specialist rehabilitation unit in the region or another district general hospital for ongoing rehabilitation needs. Receiver Operating Characteristic (ROC) curve analyses were performed to evaluate the ability of individual scoring tools to predict non-home discharge following hip fracture in patients with CKD admitted from home. A total of 225 patients met study inclusion criteria. The mean age was 81.6±10.1 yrs and the female:male ratio was 1.7:1. 33 patients (14.7%) were on long-term dialysis. 30-day in-hospital mortality was 5.9%. Following hip fracture hospitalization, 117 patients (52.0%) directly returned home on discharge. 13 patients (5.8%) were discharged to residential home, 51 patients (22.7%) to nursing home, 22 patients (9.8%) to a specialist rehabilitation unit in the region and 12 patients (5.3%) were repatriated to a district general hospital closer to the patient’s pre-admission residence. Difference in 1-year mortality rate between the non-home discharge cohort and those directly discharged home from hospital was +16.2% (p<0.001). Area under a curve (AUC) values from ROC analyses are shown in the table. Tabled 1PredictorAUC Value95% CIClinical Frailty Scale0.950.88-1.00Charlson's Co-morbidity Index0.920.85-0.99Chronic Kidney Disease Frailty Index Laboratory Score0.890.82-0.96Karnofsky Performance Status Scale0.850.78-0.92Sernbo Score0.840.77-0.91Nottingham Hip Fracture Score0.790.72-0.85Estimated VO2 Peak0.780.71-0.84ASA Physical Status Classification System Score0.690.62-0.75Abbreviated Mental Test Score0.660.59-0.73 Open table in a new tab Frailty and co-morbidity assessment tools (CFS, CCI and CKD FI-LAB) displayed the best predictive ability for non-home discharge following hip fracture in patients with CKD. Difficulty with direct home discharge is associated with significant mortality over the short term. Future research should explore holistic, multi-modal and multi-disciplinary interventions that aim to improve outcomes of patients with CKD at risk of extensive post-trauma rehabilitation needs.

The CARDE-B Scoring System Predicts 30-Day Mortality After Revision Total Joint Arthroplasty.

There exists a substantial risk of having a perioperative complication after revision total joint arthroplasty (TJA). The complex shared decision-making between surgeon and patient would benefit from a high-fidelity tool to identify patients at risk for mortality after revision TJA. Therefore, we developed the CARDE-B score. CARDE-B is an acronym for congestive heart failure, albumin or malnutrition (<3.5 mg/dL), renal failure on dialysis, dependence for daily living, elderly (>65 years of age), and body mass index <25 kg/m2. We developed and validated the CARDE-B score to determine the risk of death within 30 days of a revision TJA. A total of 13,118 revision TJAs (40% hip and 60% knee) from the National Surgical Quality Improvement Program (NSQIP) database were analyzed. A simple 1-point scoring system, CARDE-B, was created for predicting 30-day mortality after revision TJA, based on a logistic regression model. The CARDE-B scoring system assigns 1 point to each criterion in the acronym: congestive heart failure, albumin (<3.5 mg/dL), renal failure on dialysis, dependence for daily living, elderly (>65 years of age), and body mass index of <25 kg/m2. The CARDE-B scoring system was compared with 2 commonly utilized scores: American Society of Anesthesiologists (ASA) physical status classification and the 5-factor modified frailty index (mFI-5). The area under the curve (AUC) was used to assess the accuracy of each model. The Hosmer-Lemeshow test was used to assess goodness of fit. Finally, the Nationwide Inpatient Sample (NIS) was used for external validation of the CARDE-B score in 19,153 patients who underwent revision TJA in 2017. Eighty-eight patients (0.7%) did not survive 30 days after revision TJA. The AUC for the logistic regression model was 0.88 in both the derivation and internal validation samples using NSQIP. The predicted probability of 30-day mortality after revision TJA increased stepwise from <0.01% for a CARDE-B score of 0 points to 39% for a CARDE-B score of 5 points. The AUC for the CARDE-B score predicting 30-day mortality after revision TJA was 0.85. This was more accurate (p < 0.001) than the ASA physical status classification (AUC, 0.77) and the mFI-5 (AUC, 0.67). The AUC for the CARDE-B score in the NIS external validation set was 0.75. The Hosmer-Lemeshow p value for goodness of fit was 0.34, indicating goodness of fit in the external validation sample. The CARDE-B score is a simple system that predicts the risk of death within 30 days of a revision TJA, offering surgeons and patients a valuable and validated risk-stratification tool. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

ASA Physical Status Classification Improves Predictive Ability of a Validated Trauma Risk Score.

Introduction:The Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA) is a validated mortality risk score that evaluates 4 major physiologic criteria: age, comorbidities, vital signs, and anatomic injuries. The aim of this study was to investigate whether the addition of ASA physical status classification system to the STTGMA tool would improve risk stratification of a middle-aged and elderly trauma population.Methods:A total of 1332 patients aged 55 years and older who sustained a hip fracture through a low-energy mechanism between October 2014 and February 2020 were included. The STTGMA and STTGMAASA mortality risk scores were calculated. The ability of the models to predict inpatient mortality was compared using area under the receiver operating characteristic curves (AUROCs) by DeLong’s test. Patients were stratified into minimal, low, moderate, and high risk cohorts based on their risk scores. Comparative analyses between risk score stratification distribution of mortality, complications, length of stay, ICU admission, and readmission were performed using Fisher’s exact test. Total cost of admission was fitted by univariate linear regression with STTGMA and STTGMAASA.Results:There were 27 inpatient mortalities (2.0%). When STTGMA was used, the AUROC was 0.742. When STTGMAASA was used, the AUROC was 0.823. DeLong’s test resulted in significant difference in predictive capacity for inpatient mortality between STTGMA and STTGMAASA (p = 0.04). Risk score stratification yielded significantly different distribution of all outcomes between risk cohorts (p < 0.01). STTGMAASA stratification produced a larger percentage of all negative outcomes with increasing risk cohort. Total hospital cost was statistically correlated with both STTGMAASA (p < 0.01) and STTGMA (p = 0.02).Conclusion:Including ASA physical status as a variable in STTGMA improves the model’s ability to predict inpatient mortality and risk stratify middle-aged and geriatric hip fracture patients.

Proof of concept: digital clock drawing behaviors prior to transcatheter aortic valve replacement may predict length of hospital stay and cost of care.

Aims:Reduced pre-operative cognitive functioning in older adults is a risk factor for postoperative complications, but it is unknown if preoperative digitally-acquired clock drawing test (CDT) cognitive screening variables, which allow for more nuanced examination of patient performance, may predict lengthier hospital stay and greater cost of hospital care. This issue is particularly relevant for older adults undergoing transcatheter aortic valve replacement (TAVR), as this surgical procedure is chosen for intermediate-risk older adults needing aortic replacement. This proof of concept research explored if specific latency and graphomotor variables indicative of planning from digitally-acquired command and copy clock drawing would predict post-TAVR duration and cost of hospitalization, over and above age, education, American Society of Anesthesiologists (ASA) physical status classification score, and frailty.Methods:Form January 2018 to December 2019, 162 out of 190 individuals electing TAVR completed digital clock drawing as part of a hospital wide cognitive screening program. Separate hierarchical regressions were computed for the command and copy conditions of the CDT and assessed how a-priori selected clock drawing metrics (total time to completion, ideal digit placement difference, and hour hand distance from center; included within the same block) incrementally predicted outcome, as measured by R2 change significance values.Results:Above and beyond age, education, ASA physical status classification score, and frailty, only digitally-acquired CDT copy performance explained significant variance for length of hospital stay (9.5%) and cost of care (8.9%).Conclusions:Digital variables from clock copy condition provided predictive value over common demographic and comorbidity variables. We hypothesize this is due to the sensitivity of the copy condition to executive dysfunction, as has been shown in previous studies for subtypes of cognitive impairment. Individuals undergoing TAVR procedures are often frail and executively compromised due to their cerebrovascular disease. We encourage additional research on the value of digitally-acquired clock drawing within different surgery types. Type of cognitive impairment and the value of digitally-acquired CDT command and copy parameters in other surgeries remain unknown.

Perioperative Outcomes in 17,947 Patients Undergoing 2-Level Anterior Cervical Discectomy and Fusion Versus 1-Level Anterior Cervical Corpectomy for Treatment of Cervical Degenerative Conditions: A Propensity Score Matched National Surgical Quality Improvement Program Analysis.

ObjectiveTo compare the perioperative morbidity of 2-level anterior cervical discectomy and fusion (ACDF) with that of 1-level anterior cervical corpectomy and fusion (ACCF) for the treatment of cervical degenerative conditions. MethodsA retrospective study of the 2005–2016 National Surgical Quality Improvement Program database for patients undergoing 2-level ACDF and 1-level ACCF was performed. Patient data included: age, sex, body mass index (BMI), functional status, and American Society of Anesthesiologists (ASA) physical status (PS) classification. Hospital data included: operative time and length of hospital stay (LOS). Thirty-day outcome data included: any, serious, and minor adverse events, return to the operating room, readmission, and mortality. After propensity matching for age, sex, ASA PS classification, functional status, and BMI, multivariate logistic regression analysis was used to compare outcomes between the 2 propensity-matched subcohorts. Finally, multivariate logistic regression that additionally controlled for operative time was performed to compare the 2 propensity-matched subcohorts. ResultsA total of 17,497 cases were identified, with 90.20% undergoing 2-level ACDF and 9.80% undergoing 1-level ACCF. Patients undergoing 2-level ACDF were younger, more likely to be female, had higher functional status, and had shorter operative time and LOS (p < 0.001). After propensity score matching, cases undergoing 1-level ACCF had a statistically significant higher rate of serious adverse events (p = 0.005). This difference was no longer significant after controlling for operative time. ConclusionWhile there was noted to be additional morbidity in 1-level ACCF cases relative to 2-level ACDF cases, the lack of difference once controlling for the surgical time supports using the procedure that best accomplishes the surgical objectives.

234. Improving Antibiotic Prophylaxis Selection for Patients Undergoing Urology Procedures

BackgroundEvidence evaluating prescribing patterns in antibiotic (ABC) prophylaxis (PPX) for urology (UGY) procedures is limited. Although national guidelines give direction on the ABC PPX for specific procedures, ABC PPX should also be based on local ABC resistance patterns, individual host factors and procedure type factors. Our institution’s urine culture antibiogram illustrates increasing resistance to Cefazolin, a national guideline preferred ABC. The purpose of this study is to assess the impact of a quality improvement intervention on prescribing practices for ABC PPX in patients undergoing UGY procedures.MethodsThis is a retrospective study evaluating all patients receiving perioperative ABC PPX for UGY procedures from 01/01/2019 to 07/31/2019. The intervention (focusing on UGY provider education for ABC PPX based on local ABC resistance patterns, host factors and UGY procedure type) occurred on multiple in-person sessions during 04/2019. Emphasis occurred with replacing Cefazolin with Ceftriaxone, given local resistance patterns. We compared patient characteristics, appropriate ABC PPX use (deemed by local ABC Stewardship Team) and postoperative infections between the “pre” (01/01/2019 – 03/31/2019) and “post” (05/01/2019 – 07/31/2019) groups.ResultsThe “pre” group had 85 patients and the “post” group had 80 patients. 62% had a same day UGY procedure with the most common procedures designated as “clean-contaminated” (81.8%) and ASA physical status classification as “ASA II” (53.9%). After the intervention, appropriate ABC PPX choice improved (14.5% to 76%, P < 0.001) based on local ABC resistance patterns. No significant difference is noted in urine culture collection before procedure (36.4% to 43.7%, P = 0.3), ABC PPX choice based on prior patient-specific culture results including multi-drug resistant pathogens (75% to 82.3%, P = 0.6), use of ABC PPX post-procedure (40% to 35%, P = 0.5) and postoperative infections (7% to 11.2%, P = 0.4).ConclusionUtilization of education sessions as a quality improvement intervention resulted in significant improvement in ABC PPX choice for UGY procedures based on local ABC resistance patterns. Further interventions are necessary to optimize additional areas related to ABC PPX use for UGY procedures.Disclosures All Authors: No reported disclosures

Gastric xanthoma is correlated with early gastric cancer of previously Helicobacter pylori-infected gastric mucosa.

Background and AimSuccessful Helicobacter pylori eradication has been shown to prevent the development of gastric cancer (GC), but clinical evidence for factors that correlate with GC of previously H. pylori‐infected gastric mucosa (after eradication or natural disappearance) is limited. The purpose of our study was to identify these correlative factors.MethodsWe retrospectively examined data from patients with previously H. pylori‐infected gastric mucosa. Data from 168 patients who developed early GC and underwent endoscopic submucosal dissection (Group C) and 835 patients with no history of early GC (Group NC) were compared. We extracted data on gender; age; complications from malignant disease and diabetes mellitus; American Society of Anesthesiologists (ASA) physical status classification; and endoscopic characteristics of atrophy (open type), intestinal metaplasia, and gastric xanthoma (GX). Correlations were determined with multivariate logistic regression analysis and propensity score matching.ResultsA significantly higher proportion of patients had GX in Group C than in Group NC. Age, male gender, ASA physical status classification of class III or higher, complications from malignant disease, atrophy (open type), and the presence of intestinal metaplasia and GX were identified as factors that correlated independently with GC (odds ratio = 3.65; 95% confidence interval = 2.37–5.61; P < 0.0001). Propensity score matching demonstrated that the prevalence of GC was also significantly higher in patients who were positive for GX (37.2% vs 18.3%; P < 0.0001).ConclusionGX was shown to correlate with early GC of previously H. pylori‐infected gastric mucosa.