An institution-specific surgical risk score can help avert the need for mechanical ventilation in high-risk patients, researcher says.
As a fourth-year general surgery resident, Adam P. Johnson, MD, quality and patient safety fellow in the department of surgery at Thomas Jefferson University Hospital in Philadelphia, says he has spent a good amount of time with patients in the ICU. And although it's rare—data shows that just 1% to 3% of patients who have non-emergency surgical procedures require ventilation afterward—he's seen some of those patients go into respiratory failure.
"When it does happen it's pretty sad," Johnson says. "And looking back over patients cases… I wish we could've done something before surgery to optimize them better to make sure this didn't happen."
That's why he and his colleagues decided to develop a scoring system to help systematically identify the surgical patients who are most at risk for pulmonary complications.
The researchers analyzed the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data of nearly 7,500 patients who had elective general or vascular operations at Thomas Jefferson University Hospital between 2006 and 2013.
They created a scoring system that assigned points for different factors, such as being a current smoker (1 point), older than 60 (2 points), and having undergone esophagus procedures (3 points). Other risk factors were severe chronic obstructive pulmonary disease; signs of active infection or inflammatory response; and low albumin counts.
"We were able to assign a point value to see how much each one contributed," Johnson says. Total risk scores ranged from 0 to 7.
He and his team found that the median risk score for patients who did not need the ventilator after operations was 2, whereas the score for patients who did need the ventilator was 3. Those with a score above 3 comprised the 20% of patients who experienced 70% of the adverse events observed.
"It's that high-risk group that's carrying most of the burden," he says.
Johnson acknowledges that his work isn't "groundbreaking" or unique.
"There are a lot of scoring systems out there," he says. But, he says a lot of existing risk scores are complicated and tough to use in clinical practice. And if a surgical case is urgent, "it doesn't really give you much time before surgery."
That's why he wanted to look at patients who were getting elective surgery.
"We would have plenty of time to help get them stronger and prevent these complications," he says. As hospitals perform elective surgeries on older and sicker patients, it's even more important to identify them and get them through their surgery safely.
Cost Factor
There's a cost factor, to consider, too: Other research shows that mechanical ventilation can cost $1,522 per day per patient in the ICU.
Johnson just presented the findings late last month at the 2015 American College of Surgeons National Surgical Quality Improvement Program Conference in Chicago, and is preparing a manuscript to submit for publication.
The next phase of his work will focus on developing strategies for incorporating the scoring tool into clinical practice, identifying high-risk patients early so they can have a standard set of interventions.
For instance, there might be aggressive smoking cessation programs, testing for high levels of nicotine in the urine before operating, or encouraging that some patients be operated on while awake and without intubation.
Focusing on the high-risk patients will get the biggest bang for the buck. "We may only have the resources to get some of the patients involved," Johnson says. "Everything we do in healthcare takes resources, so it's best to focus on those patients who would truly benefit from these interventions."
Although there are many scoring systems that exist, Johnson says this one is unusual because it is specific to this institution. Other hospitals will have a different mix of patients, and the variability of risk factors among the patient population at Thomas Jefferson University Hospital might be different from other organizations.
That's why Johnson believes it's valuable for clinicians at other institutions to develop risk scores specific to their institutions, too, to help them understand their own numbers. He says using databases to track outcomes can help hone in on areas where improvements can be made. He also suggests identifying other institutions nearby that are doing well in certain areas and working with them to share best practices.
Knowing institution-specific data can also help clinicians have more meaningful conversations with patients. When clinicians sit down with a patient, they don't just quote national rates for complications; instead they can say, "There is a likelihood that you, with your risk factors, will have this complication at this institution."
Alexandra Wilson Pecci is an editor for HealthLeaders.
