Inpatient Adverse Events Research Articles

Simultaneous Versus Staged Cementless Bilateral Total Hip Arthroplasty: Perioperative Risk Comparison

For patients presenting with bilateral end-stage degenerative hip disease, the decision to perform arthroplasties simultaneously under a single anesthetic or staged remains controversial. Factors influencing staging include patient and physician preferences, comorbidities, and symmetry of disease progression. A consecutive series of 277 patients undergoing primary cementless bilateral total hip arthroplasty in lateral decubitus position is retrospectively reviewed to compare perioperative risks in simultaneous versus staged procedures. Procedures were performed simultaneously in 167 patients and staged in 110 at an average 8.1 months apart. Preoperative clinical scores were similar between groups; however, staged patients were significantly older (57 vs 52 years old; P < .0001) and were more likely to be Charnley class C (38% vs 14%; P = .0000) and female (57% vs 40%; P = .0051). Cumulative single-day blood loss and total blood units transfused per patient were significantly higher in simultaneous patients (479 vs 240 mL; P < .0001 and 0.8 vs 0.4 units; P = .0004), whereas cumulative length of stay was lower (3.9 vs 5.6 days; P < .0001). Inpatient adverse events per admission were more common in the simultaneous group (71.3% vs 42.3%; P = .0000). Fewer simultaneous patients met physical therapy goals by discharge (53.3% vs 79.5%; P = .0000), more required discharge to a rehabilitation facility (40.7% vs 18.6%; P = .0000), and more required subsequent hip surgery (3.9% vs 0.5%; P = .0116), predominately related to wound problems and dislocation. Although accomplishing 2 hip reconstructions under a single anesthetic provides shorter cumulative length of stay, closer examination of perioperative risks demonstrates that staged procedures done in the lateral decubitus position may be safer for the patient.

Costs and benefits of an early-alert surveillance system for hospital inpatients

ABSTRACTBackground: The economic implications of inpatient adverse events and rising healthcare costs have intensified interest in patient safety and the efficient delivery of products and services with cost-saving potential. New technologies may help in this regard but must be evaluated economically as well as clinically and should demonstrate cost-benefit for consideration by payers and providers. One such technology – an automated early-alert system for patient distress – has been developed. Performance data suggest clinical worthiness and warrant economic evaluation of the system.Scope: A hospital-perspective analysis was conducted with cost modeling and retrospective data to estimate the economic consequences of deleterious clinical events and the impact of the early-alert system when deployed during routine medical–surgical admissions. The principal outcome was expected per-patient direct costs associated with inpatients falls and cardiopulmonary arrests. Reduction of these clinical events through intelligent surveillance with the early-alert system suggested economic benefits that may offset the cost of the technology.Findings: The expected per-patient direct cost for inpatient falls and cardiopulmonary arrests was $191.73 per hospitalization. Estimated economic benefits associated with early-alert surveillance supported a break-even cost of $14.59 per day for the system.Conclusion: This study estimated the impact of the early-alert system on the deleterious clinical and economic consequences of inpatient falls and cardio­pulmonary arrests on the medical–surgical ward as well as a break-even cost for the system. Results are limited by retrospective data and cost modeling. Ongoing clinical evaluation is required to quantify and compare more precisely the cost of care with and without the system in real-life clinical settings. In the interim, this study may provide some insight into the components and magnitude of the cost for the cited events and the potential benefits and detriments that offset or contribute to the cost of the early-alert system. Study results can be more accurately specified per hospital using institutional data as inputs in the model.

Clinical risk factors for adverse outcomes in emergency department patients with acute decompensated heart failure: An ADHERE registry analysis

Study objectives: Acute decompensated heart failure (ADHF) is a leading cause of emergency department (ED) visits, subsequent inpatient admission, and substantial inhospital morbidity. Although retrospective data analyses have suggested that several clinical variables that can be assessed while a patient is in the ED are associated with inpatient adverse events, emergency physicians have no standard method of risk stratification for patients with ADHF. Methods: ED data from 65,180 patients in the Acute Decompensated Heart Failure National Registry (ADHERE) were analyzed. ADHERE is an observational registry of patients hospitalized with ADHF and in which more than 250 community, tertiary, and academic medical centers participate. Patients were included if they were admitted to an inpatient bed from the ED, had an initial systolic blood pressure of greater than 90 mm Hg, and did not have positive cardiac markers. Adverse events were defined as any 1 or more of the following: inpatient death, procedure (coronary artery bypass graft surgery, percutaneous coronary intervention, new dialysis, intra-aortic balloon catheter, cardiac transplantation, cardioversion, defibrillation, cardiopulmonary resuscitation, pacemaker, ventricular assist device, or mechanical ventilation), transfer to an ICU after initial admission to a floor bed (ie, condition worsened), or length of stay greater than third quartile. Details of medical management and outcomes were collected through discharge record review. Thirty dichotomous explanatory variables were used; these variables were available to the treating emergency physician and selected from a previous Classification and Regression Tree (CART) analysis. Stepwise logistic regression was used to select variables, and odds ratio estimates (with 95% confidence interval [CI]) were calculated. Results: Of 45,651 patients who met inclusion criteria, 14,031 (31%) had at least 1 adverse event (death 3%, procedure 11%, ICU transfer 4%, LOS >third quartile 24%). Of 10 significant ED variables selected by the model, 4 had clinically useful odds ratio (OR >1.40) estimates with acceptably narrow 95% CI: blood urea nitrogen level greater than 40 mg/dL (1.77; 95% CI 1.70 to 1.86 mg/dL), sodium level less than 130 mEq/L (1.49; 95% CI 1.36 to 1.64 mEq/L), systolic blood pressure less than 110 mm Hg (1.47; 95% CI 1.38 to 1.56 mm Hg), and pulse rate greater than 100 beats/min (1.44; 95% CI 1.38 to 1.51 beats/min). The other 6 variables were race (white), age (≥65 years), dyspnea at rest, peripheral vascular disease, chronic obstructive pulmonary disease, and fatigue. Conclusion: Clinical variables that are available to emergency physicians treating ADHF patients in the ED may be used to identify patients at risk for subsequent inpatient adverse events. Early, aggressive treatment should be considered for patients fulfilling 1 or more of these criteria.

Ninety-day follow-up of patients in the emergency department with chest pain who undergo initial single-photon emission computed tomographic perfusion scintigraphy with technetium 99m-labeled sestamibi

Background. Patients in the emergency department with typical chest pain and a normal or nondiagnostic electrocardiogram have a 10% to 20% risk of nonfatal myocardial infarction. These patients can be stratified into groups of very low and very high risk for inpatient adverse cardiac events on the basis of initial 99mTc-labeled sestamibi single-photon emission computed tomographic (SPECT) perfusion imaging performed during symptoms. However, the intermediate or posthospital discharge prognosis of such patients has not been reported. Methods and Results. Patients ( n = 150) with typical chest pain (based on a semiquantitative chest pain questionnaire) and a normal or nondiagnostic electrocardiogram underwent injection of 15 to 45 mCi 99mTc-labeled sestamibi injected during symptoms. Ninety-day follow-up history (telephone questionnaire and review of medical records) was obtained in 140 patients, and follow-up electrocardiography was performed in 72 patients. Cardiac events (death, nonfatal myocardial infarction, thrombolysis, percutaneous transluminal coronary angioplasty, or coronary artery bypass grafting) occurred before hospital discharge in 33 patients (18%), and these patients were excluded from further analysis. At follow-up, two (8%) of 25 patients with an abnormal initial scintigram and none of 87 patients with a normal scan had cardiac events ( p = 0.008). Conclusions. In patients with typical angina and a normal or nondiagnostic electrocardiogram, initial SPECT scintigraphy allows early accurate risk stratification. The previously observed excellent inpatient prognosis of patients with a normal scintigram appears to extend for at least 90 days of follow-up. These observations may provide a rational basis for safe and cost-effective outpatient evaluation of selected patients in the emergency department with typical angina, a normal or nondiagnostic electrocardiogram, and a normal initial 99mTc-labeled SPECT perfusion scintigram performed during symptoms.

748-1 Ninety Day Follow-up of Emergency Department Patients with Chest Pain and Normal or Non-diagnostic ECG Who Undergo Acute Cardiac Imaging with Tc-99m Sestamibi

Emergency department (ED) patients with typical chest pain and a normal or non-diagnostic ECG have 10–20% risk of MI. These patients can be stratified into very low (&lt;2%) and very high (&gt; 70%) risk of inpatient adverse cardiac events on the basis of acute Tc-99m Sestamibi periusion imaging (Tc-99m) periormed during symptoms. We report 90-day follow-up of patients who underwent acute Tc-99m for chest pain evaluation in the ED. Patients (n = 150) with typical chest pain (based on a semiquantitative chest pain questionnaire) and a normal or non-diagnostic ECG had Tc-99m injected during symptoms. Ninety day follow-up history (telephone question-naire, medical records) was available in 140 patients and ECG's on 72 patients. Cardiac events (death, non-fatal myocardial infarction, thrombolysis, PTCA or CABG) occurred in-hospital in 33, (18%). Tc-99m was extremely sensitive (97%) and specific (78%) (p = 0.0001) in the prediction of in-hospital events. At late follow-up (3 months, range = 3–25), there were 2 cardiac events—both in patients with abnormal scans (p = 0.01). No late (0–3 months) events were identified in patients with a normal scan. A normal acute Tc-99m scan is associated with an excellent short- and intermediate-term prognosis. These observations may provide a rational basis for safe and cost effective outpatient evaluation of selected ED patients with typical angina, a normal or non-diagnostic ECG, and a normal acute Tc99m SPECT periusion scan periormed during symptoms.