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Study objective To determine the association of preoperative delirium with postoperative outcomes following hip surgery in the elderly. Design Retrospective cohort study. Setting Postoperative recovery. Patients 8466 patients all of whom were 65 years of age or older undergoing surgical repair of a femoral fracture. Of the total population studied, 1075 had preoperative delirium. Of those with preoperative delirium, 746 were ASA class 3 or below and 327 were ASA class 4 or above. Of the 7391 patients without preoperative delirium, 5773 were ASA class 3 or below and 1605 were ASA class 4 or above. The remainder in each group was of unknown ASA class. Interventions We used multivariable logistic regression to explore the association of preoperative delirium with 30-day postoperative outcomes. The odds ratio (OR) with associated 95% confidence interval (CI) was reported for each covariate. Measurements. Data was collected regarding the incidence of postoperative outcomes including: delirium, pulmonary complications, extended hospital stay, infection, renal complications, vascular complications, cardiac complications, transfusion necessity, readmission, and mortality. Main Results. After adjusting for potential confounders, the odds of postoperative delirium (OR 9.38, 95% CI 7.94–11.14), pulmonary complications (OR 1.83, 95% CI 1.4–2.36), extended hospital stay (OR 1.47, 95% CI 1.26–1.72), readmission (OR 1.27, 95% CI 1.01–1.59) and mortality (OR 1.92, 95% CI 1.54–2.39) were all significantly higher in patients with preoperative delirium compared to those without. Conclusions After controlling for potential confounding variables, we showed that preoperative delirium was associated with postoperative delirium, pulmonary complications, extended hospital stay, hospital readmission, and mortality. Given the lack of studies on preoperative delirium and its postoperative outcomes, our data provides a strong starting point for further investigations as well as the development and implementation of targeted risk-reduction programs.

An upsurge of high-risk opioid misuse has contributed to the epidemic of opioid overdose in the United States. The primary aim was to report the rate of opioid overdose among the pediatric population and to report demographic and medical differences among POD versus IOD populations.Retrospective descriptive analysis of opioid overdose using the largest pediatric inpatient database in the United States. We performed a Pearson chi-square and Wilcoxon rank sum test to compare differences between cohorts.Multi-institutional.Data were obtained from the Kids' Inpatient Database of the Healthcare Cost and Utilization Project. We used the International Classification of Disease, Ninth Revision codes to extract records of pediatric patients who were admitted for POD or IOD from 2000 to 2012.None.None.The final analysis included 15,884 patients admitted to a United States hospitals with opioid overdose. The rate of POD and IOD has increased steadily from 2000 to 2012. Black, Asian or Pacific Islander, Native American, Multi-race, and Unknown race had higher proportion of POD versus IOD (p 0.001). Compared to POD, the rate of IOD was highest in Northeast (29.2% versus 14.3%, p 0.001) and Midwest (31.6%versus 26.1%, (p 0.001) regions of the country.Our findings reinforce existing studies that report a continued rise in opioid morbidity and mortality while providing new insights into sociodemographic patterns and comorbidities associated with POD versus IOD.

Study objective We examined the association of body mass index (BMI) with hospital admission, same-day complications, and 30-day hospital readmission following day-case eligible joint arthroscopy. Design Retrospective cohort study. Setting Multi-institutional. Patients Adult patients undergoing arthroscopy of the knee, hip or shoulder in the outpatient setting. Intervention None. Measurements Using the American College of Surgeons National Surgical Quality Improvement Program dataset from 2012 to 2016, we examined seven BMI ranges: normal BMI (≥20 kg/m2 and Main results There were a total of 99,410 patients included in the final analysis, in which there was a 2.6% rate of hospital admission. When compared to class 3 obesity, only those with BMI ≥50 kg/m2 ( OR 1.55, 95% CI 1.18–2.01, p = 0.005) had increased odds of hospital admission. There were no differences in 30-day hospital readmission or same-day postoperative complications. Conclusion We found that only patients with BMI ≥50 kg/m2 had increased odds for same-day hospital admission even when patient's comorbid conditions are optimized, suggesting that a BMI ≥50 kg/m2 may be used as a sole factor for patient selection in patients undergoing joint arthroscopy. For patients with BMI

Safety-net hospitals disproportionately care for high-risk patients. Prior work has shown safety-net hospitals to have inferior postoperative outcomes with higher cost and worse patient ratings. We aim to examine the association of hospital safety-net burden with morbidity and mortality in patients with opioid overdose hospital admission.Retrospective cross-sectional analysis using the National Inpatient Sample registry from 2010 to 2014.Multi-institutional.We included 547, 399 patients admitted to a United States hospital with an International Classification of Disease, Ninth Revision, code of opioid overdose. To study the association of hospital safety-net burden on mortality and morbidity, we calculated hospital safety-net burden defined as the percent of Medicaid or uninsured among all admitted patients. Hospitals were categorized into one of three categories: low burden hospitals, medium burden hospitals, and high burden hospitals (i.e., safety-net hospitals). We performed a mixed effects multivariable logistic regression analysis to assess the association of hospital safety-net burden with short-term inpatient outcomes.None.The primary outcomes were inpatient mortality and morbidity.Compared to MBHs and LBHs, HBHs had a greater proportion of minority patients (i.e., Black, Hispanic, and Native American) and patients with median household income in the lowest quartile (p 0.001). Among prescription opioid overdose admissions, the odds of inpatient mortality and pulmonary and cardiac morbidity were also not significantly higher between HBHs versus LBHs (p 0.05).Safety-net hospital disproportionately care for vulnerable populations, however the odds of poor outcomes were no different in opioid overdose. Safety-net hospitals should have equal access to the funding and resources that allows them to deliver the same standard of care as their counterparts.

We sought to develop a predictive model for discharge to post-acute care facilities in patients undergoing unilateral total hip replacement (THR). Furthermore, we sought to determine if the use of neuraxial anesthesia was an important covariate for the predictive model.Retrospective observational study.Preoperative care and operating room at a single institution.Patients (n = 960) who underwent an elective primary THR between 2014 and 2016.No intervention was performed.We collected variables that were known preoperatively including age, sex, body mass index (BMI), preoperative opioid use, functional status based on metabolic equivalents (METS), preoperative anemia, thrombocytopenia, osteoarthritis and contralateral osteoarthritis grade, anesthesia type, comorbidities and surgical approach. We then performed multivariable logistic regression to develop a predictive model.Female sex, preoperative opioid use, older age, general anesthesia, anemia, hypertension, a psychiatric diagnosis, use of dialysis, metabolic equivalents4 and obesity are all risk factors for a post-acute facility discharge. The use of general anesthesia compared to neuraxial anesthesia was associated with increased odds (odds ratio 1.98, 95% confidence interval 1.31-3.00, p = 0.001) for post-acute facility discharge. Model performance was assessed using ten-fold cross-validation - the average area under the receiver operating characteristic curve calculated was 0.794.We developed a predictive model for post-acute care facility discharge following THR. The use of neuraxial anesthesia was associated with decreased odds for post-acute care facility discharge.

Study objective Among the various types of outpatient surgery centers, there are differences in higher American Society of Anesthesiologists Physical Status (ASA PS) scores and surgical complexity among patients who are undergoing surgery. The primary objective of this study was to describe the differences performed at various types of outpatient surgery facilities. Design We performed a retrospective analysis of the National Anesthesia Clinical Outcomes Registry (NACOR) data. Setting NACOR from 2012 to 2017. Patients From 2012 to 2017, there were a total of 13,053,115 outpatient surgeries in the database. After removing cases with unknown facility type, the final study sample was 9,217,336. Interventions None. Measurements To calculate the probability of either American Society of Anesthesiologists Physical Status (ASA PS) score ≥ 3 or physiologically complex cases (defined as Common Procedural Terminology start-up units ≥8), we performed mixed effects logistic regression for each institution per facility type, controlling for year and using facility identification as the random effect. We present the mean rate of these two classifications as case per 10,000 cases and report the 99.9% confidence interval (CI), to control for multiple comparisons. Main results Among all cases, 5,919,844 (64.2%) were classified as ASA PS 1 or 2 and 254,110 (2.8%) of surgical procedures were considered physiologically complex. The mean rate of cases with ASA PS ≥ 3in the university setting was 2982 per 10,000 cases [99.9% CI 2701–3278 per 10,000 cases]. Large community hospitals had a higher proportion of ASA PS ≥3 patients, medium-sized hospitals had no difference, and all other facility types had a decreased proportion. The mean rate of cases that were physiologically complex in the university setting was 133 per 10,000 cases [99.9% CI 117–151 per 10,000 cases]. Large community hospitals had a higher proportion of physiologically complex cases, medium-sized and small-sized hospitals had no difference, and all other facility types had a decreased proportion. Conclusions Freestanding and attached surgery centers exhibited smaller rates of patients that were ASA PS ≥ 3, as well as a decrease in surgically complex cases, when compared to university settings. This suggests that the level of conservativeness for patient and surgery appropriateness for outpatient surgery differs across various facility types.

Do-not-resuscitate (DNR) status has been shown to be an independent risk factor for mortality in the post-operative period. Patients with DNR orders often undergo elective surgeries to alleviate symptoms and improve quality of life, but there are limited data on outcomes for informed decision making.Retrospective cohort study.A multi-institutional setting including operating room, postoperative recovery area, inpatient wards, and the intensive care unit.A total of 566 patients with a DNR status and 316,431 patients without a DNR status undergoing elective procedures using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) from 2012.Patients undergoing elective surgical procedures.We analyzed the risk-adjusted 30-day morbidity and mortality outcomes for the matched DNR and non-DNR cohorts undergoing elective surgeries.DNR patients had significantly increased odds of 30-day mortality (OR 2.51 [1.55-4.05], p 0.001) compared with non-DNR patients. In the DNR versus non-DNR cohort there was no significant difference in the occurrence of a number of 30-day complications, the rate of resuscitative measures undertaken, including cardiac arrest requiring CPR, reintubation, or return to the OR. The most common complications in both DNR and non-DNR patients undergoing elective procedures were transfusion, urinary tract infection, reoperation, and sepsis. Finally, the DNR patients had a significantly increased total length of hospital stay (7.65 ± 9.55 vs. 6.87 ± 9.21 days, p = 0.002).DNR patients, as compared with non-DNR patients, have increased post-operative mortality but not morbidity, which may arise from unmeasured severity of illness or transition to comfort care in accordance with a patient's wishes. The informed consent process for elective surgeries in this patient population should include a discussion of acceptable operative risk.

Study objective There is a lack of large, multi-institutional studies analyzing the association of timing of emergency surgery with death occurring either intraoperatively or in the recovery room setting. The primary objective of this study was to determine if time of day for emergency surgeries was associated with mortality. Design Retrospective analysis. Setting U.S. healthcare facilities. Patients Adult patients undergoing emergency surgery and general anesthesia. Interventions No intervention. Measurements Utilizing the National Anesthesia Clinical Outcomes Registry database, all emergency non-cardiac, non-obstetric surgeries undergoing general anesthesia occurring between 2010 and 2015 in the United States were identified. We performed mixed effects logistic regression to determine the effect of time of day with mortality occurring during the intraoperative and immediate postoperative period. Main results There were 46,196 cases that were eligible for this analysis, in which 24,247 and 21,949 occurred during day and after-hours shifts, respectively. The overall morality rate was 0.28%. Mortality rates were 0.17% and 0.41% in the day and after-hour shifts, respectively. There was no statistically significant association of time of day with mortality (odds ratio 1.31, 95% CI 0.90–1.92, p = 0.16). American Society of Anesthesiologists physical status classification, age, and operative body part were all associated with mortality. Conclusions Although, theoretically, health care providers working after-hour shifts may be impacted by sleep deprivation and/or limited resources, we found that time of day was not associated with increased risk of mortality during the intraoperative and immediate postoperative period in emergency surgery.

Importance Rising rates of obesity and outpatient performance of parathyroidectomies are making it increasingly crucial to investigate the association of obesity with post-operative complications. Objective To determine whether Class 3 obesity is associated with increased same-day admission compared to lower obesity classes following outpatient parathyroidectomy. Design Retrospective cohort study. Setting Outpatient surgery. Patients 12,973 patients ≥18 years old who underwent outpatient parathyroidectomy between 2014 and 2016, per the American College of Surgeons National Surgical Quality Improvement Program registry. Interventions Primary exposure variable: body mass index (BMI), with patients assigned to one of six cohorts. Measurements Primary outcome measure: same-day admission. Secondary outcome measure: 30-day readmission. Logistic regression was used to calculate odds ratios (OR) and 95% confidence intervals (CI). Main results There was a final sample size of 12,973 adult patients who underwent parathyroidectomy from 2014 to 2016. The admission rate for BMI ≥30 and Conclusions There is no significant difference in rates of same-day admission or 30-day readmission between any Class 3 (BMI ≥40 kg/m2) obesity cohort and the Class 1 and 2 (BMI ≥30 and

Study objective It is unclear what the body mass index (BMI) should be when performing surgery involving the airway at an outpatient surgery facility. The objective of this study was to evaluate the association of Class 3 obesity versus a composite cohort of Class 1 and 2 obesity with same-day hospital admission following outpatient tonsillectomy in adults. Design Retrospective cohort study. Setting Multi-institutional. Patients Patients undergoing outpatient tonsillectomy. Intervention None. Measurements We used the National Surgical Quality Improvement Program (NSQIP) to analyze association of BMI to same-day admission and 30-day readmission following outpatient tonsillectomy from 2017 to 2019. We looked at six BMI cohorts: 1) ≥30 and Main results There were 12,287 patients included in the final analysis, at which 697 (5.7%) and 283 (2.3%) had a same-day admission or 30-day readmission, respectively. On Poisson regression with robust standard errors, the relative risks for BMI ≥40 kg/m2 and Conclusion These results contribute data that may help practices – especially freestanding ambulatory surgery centers – decide appropriate BMI cutoffs for surgery involving the airway. Whether this is considered clinically significant enough to rule out eligibility will differ from practice-to-practice and will depend on surgical volume, resources available and financial interests.

To evaluate if using regional anesthesia for post-operative pain control for patients who underwent ankle ORIF is associated with a decrease in length of stay.Multicenter retrospective cohort study.Inpatient perioperative.12,468 inpatients (2007 to 2016) who received ankle ORIF with and without regional anesthesia for pain control.Regional Anesthesia for postoperative pain control.Hospital length of stay along with multiple covariates.The median [quartiles] hospital length of stay of the non-regional anesthesia and regional anesthesia cohorts were 1 day [0, 2 days] and 0 days [0, 1 day], respectively (p 0.0001). On multivariable Cox regression analysis, the use of regional anesthesia was associated with decreased time to hospital discharge (HR 1.09, 95% CI 1.03-1.14, p = 0.002). Using 1:2 propensity score matching, the median [quartiles] hospital length of stay between the non-regional anesthesia and regional anesthesia matched cohorts were 0 days [0, 1 day] (range = 0-56 days) and 0 day [0, 1 day] (range = 0-33 days), respectively (p = 0.013).The use of regional anesthesia for post-operative pain control was associated with a decreased length of stay for patients undergoing ankle ORIF.

Study objective Reintubations are associated with significantly increased morbidity and mortality, increased hospital length of stay, and increased cost. Our aim was to assess the national incidence and associated risk factors for unanticipated early postoperative reintubations. Design Using the National Anesthesia Clinical Outcomes Registry (NACOR) from 2010 to 2014, multivariate logistic regression was fitted to determine if various patient, surgical, intraoperative, or provider data were associated with unanticipated early postoperative reintubations. Setting NACOR from 2010 to 2014. Patients A total of 2,970,904 cases were included. Multivariate analysis controlled for patient age, sex, and American Society of Anesthesiologists (ASA) Physical Status. Interventions None. Measurements We report odds ratios (ORs) and 95% confidence intervals (CIs) for the relative odds of an association of predictor variable with reintubations. Main results The incidence of unanticipated early postoperative reintubations from the NACOR database was 0.061%. Overall, reintubations were more likely in the extremes of age (age under 1 year had OR=3.46, 95% confidence interval [CI] = 2.64-4.52 and age 80+ has OR=1.80, 95% CI=1.50-2.15 when compared with age 19-49 years), patients with ASA Physical Status 3 and 4 (OR = 4.06, 95% CI=3.38-4.86 and OR=8.65, 95% CI=7.11-10.52, respectively, when compared with ASA 1), longer case duration (180-360 minutes OR=13.87, 95% CI=10.7-17.98 when compared with cases less than 60 minute duration), and cases that had a resident trainee present (OR = 1.22, 95% CI=1.03-1.44 when compared with no resident present). Thoracic and vascular surgical procedures had the highest rates of reintubation when compared with general surgery (OR = 3.47, 95% CI=2.81-4.28 and OR=1.51, 95% CI=1.24-1.82, respectively). Conclusions A number of risk factors correlate with an increased risk of unanticipated early postoperative reintubations, including extremes of age, patients with greater medical comorbidities, longer operations, and patients undergoing thoracic procedures.

Arthroscopic knee procedures are increasingly being performed in an outpatient setting. Appropriate intraoperative anesthesia is vital to prevent complications such as unanticipated hospital admission. We examined differences in complications between general (GA) vs neuraxial anesthesia (NA) as the primary anesthetic for patients undergoing arthroscopic knee procedures.This was a retrospective cohort study. We queried the National Surgical Quality Improvement Program for arthroscopic knee procedures performed between 2007 and 2016. We compared postoperative complication rates between propensity-matched cohorts (NA vs GA). The anesthesia groups were matched based on age, race, BMI, gender, diabetes, smoking history, COPD, CHF, functional status, HTN, ASA class, steroid use, bleeding disorder history, and readmission status. Univariable and multivariable logistic regression were used to compare factors associated with inpatient admission - defined as hospital length of stay1 day.A total of 57,494 patients were included - 55,257 GA and 2237 NA patients.Among the matched cohorts, NA patients were significantly more likely to be admitted to the hospital postoperatively (p 0.001). Neuraxial anesthesia (OR 5.93, 95% CI 4.90-7.21) use was also significant in the final multivariable regression model for inpatient admission. Additional significant predictors for inpatient admission included history of bleeding disorder (OR 5.44, 95% CI 2.14-12.76), Asian race (OR 6.47, 95% CI 4.90-8.56), COPD (OR 3.10, 95% CI 1.94-4.82), diabetes (OR 1.90, 95% CI 1.43-2.49), and increased operation time (OR 3.01, 95% CI 2.69-3.37).NA was significantly associated with inpatient admission following knee arthroscopy. Further research should focus on examining the reason for this association and methods to reduce inpatient admission for patients undergoing arthroscopic knee procedures using neuraxial anesthesia.

Study objective Current evidence remains limited on the postoperative outcomes of neuraxial (NA) versus general anesthesia (GA) as primary anesthesia type in patients receiving simultaneous bilateral total hip arthroplasty (BTHA). We aimed to evaluate the rates of postoperative outcomes among patients receiving NA versus GA for BTHA. Design Retrospective cohort study. Setting Multi-institutional. Patients A total of 798 patients undergoing BTHA with 519 and 279 who received GA and NA, respectively. We used the American College of Surgeons – National Surgical Quality Improvement Program database for years 2007 to 2016. Interventions Patients undergoing BTHA. Measurements We propensity-score matched on demographic factors and comorbid conditions to compare rates of postoperative outcomes among cohorts (NA versus GA). We performed Pearson chi-square and Wilcoxon rank sum test to compare NA versus GA cohorts. Main results The final analysis included 798 BTHA patients, of which 35% received NA as the primary anesthetic. The median age was 58 years old and 50.8% were female. The rate of perioperative transfusion in the NA and GA group were 20.1% and 29.0%, respectively (p = 0.02). There were no significant differences in the rate of postoperative outcomes between patients receiving NA versus GA as their primary anesthesia type (Bonferroni corrected p Conclusion Our study showed no significant differences in postoperative outcomes between NA versus GA following BTHA. Further studies are needed to investigate outcomes among this surgical population.

The operating room suite can be one of the most costly units within the hospital. Some of these costs stem from postoperative unplanned admissions, case cancellations, case delays, and extended recovery room times. The objective is to determine the clinical predictors of these operating room inefficiencies.Retrospective data analysis.Operating room, postoperative recovery area.Surgical patients whose perioperative data were reported to the Anesthesia Quality Institute's National Anesthesia Clinical Outcomes Registry from 2010 to 2015.We identified all cases that reported unplanned admissions, case cancellations, case delays, and extended recovery room times.Patient demographics, intraoperative characteristics, and provider information were collected for each case. Univariate and multivariate logistic regressions were fitted to determine if these various characteristics were associated with the outcomes of interest.The incidence of unplanned admissions (0.18%), case cancellations (0.05%), extended recovery room stays (1.12%), and case delays (14.43%) were reported. A positive predictor for unplanned admissions included elderly patients (odds ratio [OR], 1.34; 95% confidence interval [CI], 1.16-1.48), whereas cases not performed under general anesthesia had lower rates (P.001). For case cancellations, higher American Society of Anesthesiologists classes had the highest risk (OR, 2.17; 95% CI, 1.81-2.60). Longer cases and elderly patients are the main predictors for extended postanesthetic care unit stays among all surgeries (OR, 1.54; 95% CI, 1.47-1.62; OR, 1.42; 95% CI, 1.34-1.50, respectively). Pediatric patients and monitored anesthetic care cases had highest odds for case delays (OR, 3.02; 95% CI, 2.93-3.11; OR, 4.98; 95% CI, 4.88-5.07, respectively).This study reports the national incidence and various clinical predictors for these 4 operating room metrics. This can serve as both a resource for operating room managers to compare their practice to national trends and a tool for strategically identifying at-risk surgical cases.