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Background: The coronavirus-2019 (COVID-19) pandemic highlighted the unfortunate reality that many hospitals have insufficient intensive care unit (ICU) capacity to meet massive, unanticipated increases in demand. To drastically increase ICU capacity, NewYork-Presbyterian/Weill Cornell Medical Center modified its existing operating rooms and post-anaesthesia care units during the initial expansion phase to accommodate the surge of critically ill patients. Methods: This retrospective chart review examined patient care in non-standard Expansion ICUs as compared to standard ICUs. We compared clinical data between the two settings to determine whether the expeditious development and deployment of critical care resources during an evolving medical crisis could provide appropriate care. Results: Sixty-six patients were admitted to Expansion ICUs from March 1st to April 30th, 2020 and 343 were admitted to standard ICUs. Most patients were male (70%), White (30%), 45–64 years old (35%), non-smokers (73%), had hypertension (58%), and were hospitalized for a median of 40 days. For patients that died, there was no difference in treatment management, but the Expansion cohort had a higher median ICU length of stay (q = 0.037) and ventilatory length (q = 0.015). The cohorts had similar rates of discharge to home, but the Expansion ICU cohort had higher rates of discharge to a rehabilitation facility and overall lower mortality. Conclusions: We found no significantly worse outcomes for the Expansion ICU cohort compared to the standard ICU cohort at our institution during the COVID-19 pandemic, which demonstrates the feasibility of providing safe and effective care for patients in an Expansion ICU. [ABSTRACT FROM AUTHOR]

Background: While increased surgical-provider volume has been associated with improved outcomes, research regarding volume-outcome relationships within high-volume institutions and the role of anaesthesiologists is limited. Further, the effect of anaesthesia-care-team composition remains understudied. This analysis aimed to identify the impact of anaesthesiologist and surgeon volume on adverse events after total joint arthroplasties.Methods: We retrospectively identified 40 437 patients who underwent total joint arthroplasties at a high-volume institution from 2005 to 2014. The main effects of interest were anaesthesiologist and surgeon volume and experience along with anaesthesia-care-team composition. Multivariable logistic regression models were used to evaluate three outcomes: any complication, cardiopulmonary complication, and length of stay (>5 days). Odds ratios (ORs) and 99.75% confidence intervals (CIs) were reported.Results: Across all three models, anaesthesiologist volume and experience, and anaesthesia-care-team composition were not significant predictors. Surgeon annual case volume >50 was associated with significantly reduced odds of any complication (annual case volume: 50-149; OR: 0.80; CI: 0.66-0.98) and prolonged length of stay (OR: 0.69; CI: 0.60-0.80). Surgeon experience >20 yr was associated with significantly reduced odds of prolonged length of stay (OR: 0.85; CI: 0.75-0.95).Conclusions: Anaesthesiologist volume and experience, and anaesthesia-care-team composition did not impact the odds of an adverse outcome, although a higher surgeon volume was associated with decreased odds of complications and prolonged length of stay. Further study is necessary to determine if these findings can be extrapolated to less specialised, lower volume surgical settings. [ABSTRACT FROM AUTHOR]

Background: Hospital-related factors associated with mortality and morbidity after hip fracture surgery are not completely understood. The Veterans Health Administration (VHA) is the largest single-payer, networked healthcare system in the country serving a relatively homogenous patient population with facilities that vary in size and resource availability. These characteristics provide some degree of financial and patient-level controls to explore the association, if any, between surgical volume and facility resource availability and hospital performance regarding postoperative complications after hip fracture surgery.Questions/purposes: (1) Do VHA facilities with the highest complexity level designation (Level 1a) have a disproportionate number of better-than-expected performance outliers for major postoperative complications compared with lower-complexity level facilities? (2) Do VHA facilities with higher hip fracture surgical volume have a disproportionate number of better-than-expected performance outliers for major postoperative complications compared with lower-volume facilities?Methods: We explored the Veterans Affairs Surgical Quality Improvement Project (VASQIP) database from October 2001 to September 2012 for records of hip fracture surgery performed. Data reliability of the VASQIP database has been previously validated. We excluded nine of the 98 VHA facilities for contributing fewer than 30 records. The remaining 89 VHA facilities provided 23,029 records. The VHA designates a complexity level to each facility based on multiple criteria. We labeled facilities with a complexity Level 1a (38 facilities)-the highest achievable VHA designated complexity level-as high complexity; we labeled all other complexity level designations as low complexity (51 facilities). Facility volume was divided into tertiles: high (> 277 hip fracture procedures during the sampling frame), medium (204 to 277 procedures), and low (< 204 procedures). The patient population treated by low-complexity facilities was older, had a higher prevalence of severe chronic obstructive pulmonary disease (26% versus 22%, p < 0.001), and had a higher percentage of patients having surgery within 2 days of hospital admission (83% versus 76%, p < 0.001). High-complexity facilities treated more patients with recent congestive heart failure exacerbation (4% versus 3%, p < 0.001). We defined major postoperative complications as having at least one of the following: death within 30 days of surgery, cardiac arrest requiring cardiopulmonary resuscitation, new q-wave myocardial infarction, deep vein thrombosis and/or pulmonary embolism, ventilator dependence for at least 48 hours after surgery, reintubation for respiratory or cardiac failure, acute renal failure requiring renal replacement therapy, progressive renal insufficiency with a rise in serum creatinine of at least 2 mg/dL from preoperative value, pneumonia, or surgical site infection. We used the observed-to-expected ratio (O/E ratio)-a risk-adjusted metric to classify facility performance-for major postoperative complications to assess the performance of VHA facilities. Outlier facilities with 95% confidence intervals (95% CI) for O/E ratio completely less than 1.0 were labeled "exceed expectation;" those that were completely greater than 1.0 were labeled "below expectation." We compared differences in the distribution of outlier facilities between high and low-complexity facilities, and between high-, medium-, and low-volume facilities using Fisher's exact test.Results: We observed no association between facility complexity level and the distribution of outlier facilities (high-complexity: 5% exceeded expectation, 5% below expectation; low-complexity: 8% exceeded expectation, 2% below expectation; p = 0.742). Compared with high-complexity facilities, the adjusted odds ratio for major postoperative complications for low-complexity facilities was 0.85 (95% CI, 0.67-1.09; p = 0.108).We observed no association between facility volume and the distribution of outlier facilities: 3% exceeded expectation and 3% below expectation for high-volume; 10% exceeded expectation and 3% below expectation for medium-volume; and 7% exceeded expectation and 3% below expectation for low-volume; p = 0.890). The adjusted odds ratios for major postoperative complications were 0.87 (95% CI, 0.73-1.05) for low- versus high-volume facilities and 0.89 (95% CI, 0.79-1.02] for medium- versus high-volume facilities (p = 0.155).Conclusions: These results do not support restricting facilities from treating hip fracture patients based on historical surgical volume or facility resource availability. Identification of consistent performance outliers may help health care organizations with multiple facilities determine allocation of services and identify characteristics and processes that determine outlier status in the interest of continued quality improvement.Level Of Evidence: Level III, therapeutic study. [ABSTRACT FROM AUTHOR]

Background: Difficult airway management and obstructive sleep apnea may contribute to increased risk of perioperative morbidity and mortality. The objective of this systematic review and meta-analysis (SRMA) is to evaluate the evidence of a difficult airway being associated with obstructive sleep apnea (OSA) patients undergoing surgery. Methods: The standard databases were searched from 1946 to April 2017 to identify the eligible articles. The studies which included adult surgical patients with either suspected or diagnosed obstructive sleep apnea must report at least one difficult airway event [either difficult intubation (DI), difficult mask ventilation (DMV), failed supraglottic airway insertion or difficult surgical airway] in sleep apnea and non-sleep apnea patients were included. Results: Overall, DI was 3.46-fold higher in the sleep apnea vs non-sleep apnea patients (OSA vs. non-OSA: 13.5% vs 2.5%; OR 3.46; 95% CI: 2.32–5.16, p <0.00001). DMV was 3.39-fold higher in the sleep apnea vs non-sleep apnea patients (OSA vs. non-OSA: 4.4% vs 1.1%; OR 3.39; 95% CI: 2.74–4.18, p <0.00001). Combined DI and DMV was 4.12-fold higher in the OSA vs. non-OSA patients (OSA vs. non-OSA: 1.1% vs 0.3%; OR 4.12; 95% CI: 2.93–5.79, p <0.00001). There was no significant difference in the supraglottic airway failure rates in the sleep apnea vs non-sleep apnea patients (OR: 1.34; 95% CI: 0.70–2.59; p = 0.38). Meta-regression to adjust for various subgroups and baseline confounding factors did not impact the final inference of our results. Conclusion: This SRMA found that patients with obstructive sleep apnea had a three to four-fold higher risk of difficult intubation or mask ventilation or both, when compared to non-sleep apnea patients. [ABSTRACT FROM AUTHOR]

Background: Neuraxial anesthesia is increasingly recommended for hip/knee replacements as some studies show improved outcomes on the individual level. With hospital-level studies lacking, we assessed the relationship between hospital-level neuraxial anesthesia utilization and outcomes.Methods: National data on 808,237 total knee and 371,607 hip replacements were included (Premier Healthcare 2006 to 2014; 550 hospitals). Multivariable associations were measured between hospital-level neuraxial anesthesia volume (subgrouped into quartiles) and outcomes (respiratory/cardiac complications, blood transfusion/intensive care unit need, opioid utilization, and length/cost of hospitalization). Odds ratios (or percent change) and 95% CI are reported. Volume-outcome relationships were additionally assessed by plotting hospital-level neuraxial anesthesia volume against predicted hospital-specific outcomes; trend tests were applied with trendlines' R statistics reported.Results: Annual hospital-specific neuraxial anesthesia volume varied greatly: interquartile range, 3 to 78 for hips and 6 to 163 for knees. Increasing frequency of neuraxial anesthesia was not associated with reliable improvements in any of the study's clinical outcomes. However, significant reductions of up to -14.1% (95% CI, -20.9% to -6.6%) and -15.6% (95% CI, -22.8% to -7.7%) were seen for hospitalization cost in knee and hip replacements, respectively, both in the third quartile of neuraxial volume. This coincided with significant volume effects for hospitalization cost; test for trend P < 0.001 for both procedures, R 0.13 and 0.41 for hip and knee replacements, respectively.Conclusions: Increased hospital-level use of neuraxial anesthesia is associated with lower hospitalization cost for lower joint replacements. However, additional studies are needed to elucidate all drivers of differences found before considering hospital-level neuraxial anesthesia use as a potential marker of quality. [ABSTRACT FROM AUTHOR]

Same-day Bilateral Total Knee Arthroplasty (BTKA) safety is still controversial. The aim of this study was to examine the association of blood transfusion type (pure autologous, pure allogeneic, and combined) with complication and prolonged length of stay (PLOS) following same-day BTKA. 649 consecutive patients were retrospectively identified over a two-year period. Pure allogeneic transfusions were associated with increased odds of minor complication when compared to patients who had pure autologous transfusions. No association was found between blood transfusion type and major complication or PLOS. Our results suggest that blood transfusion type may be influential in minor complication after BTKA. [ABSTRACT FROM AUTHOR]

Background: The opioid epidemic is one of the most pressing public health crises in the USA. With fractures being amongst the most common reasons for a child to require surgical intervention and receive post-surgical pain management, characterisation of opioid prescription patterns and risk factors is critical. We hypothesised that the numbers of paediatric patients receiving opioids, or who developed persistent opioid use, are significant, and a number of risk factors for persistent opioid use could be identified.Methods: We conducted a retrospective population-based cohort study. National claims data from the Truven Health Analytics® MarketScan database were used to (i) characterise opioid prescription patterns and (ii) describe the epidemiology and risk factors for single use and persistent use of opioids amongst paediatric patients who underwent surgical intervention for fracture treatment.Results: Amongst 303 335 patients, 21.5% received at least one opioid prescription within 6 months after surgery, and 1671 (0.6%) developed persistent opioid use. Risk factors for persistent opioid use include older age; female sex; lower extremity trauma; surgeries involving the spine, rib cage, or head; closed fracture treatment; earlier surgery years; previous use of opioid; and higher comorbidity burden.Conclusions: Amongst a cohort of paediatric patients who underwent surgical fracture treatment, 21.5% filled at least one opioid prescription, and 0.6% (N=1671) filled at least one more opioid prescription between 3 and 6 months after surgery. Understanding risk factors related to persistent opioid use can help clinicians devise strategies to counter the development of persistent opioid use for paediatric patients. [ABSTRACT FROM AUTHOR]

Background: The value of intravenous acetaminophen in postoperative pain management remains debated. The authors tested the hypothesis that intravenous acetaminophen use, in isolation and in comparison to oral, would be associated with decreased opioid utilization (clinically significant reduction defined as 25%) and opioid-related adverse effects in open colectomy patients.Methods: Using national claims data from open colectomy patients (Premier Healthcare Database, Premier Healthcare Solutions, Inc., USA; 2011 to 2016; n = 181,640; 602 hospitals), we separately categorized oral and intravenous acetaminophen use: 1 (1,000 mg) or more than 1 dose on the day of surgery, postoperative day 1, or later. Multilevel models measured associations between intravenous or oral acetaminophen and (1) opioid utilization and (2) opioid-related adverse effects. Percent change and multiplicity-adjusted 99.5% CI are reported.Results: Overall, 25.1% of patients received intravenous acetaminophen, of whom 48.0% (n = 21,878) received 1 dose on the day of surgery. In adjusted analyses, particularly more than 1 dose of intravenous acetaminophen (versus nonuse) on postoperative day 1 was associated with a -12.4% (99.5% CI, -15.2 to -9.4%) change in opioid utilization. In comparison, a stronger reduction was seen in those receiving more than 1 oral acetaminophen dose: -22.6% (99.5% CI, -26.2 to -18.9%). Unadjusted group medians were 550 and 490 oral morphine equivalents, respectively. Intravenous versus oral differences were less pronounced among those receiving more than 1 acetaminophen dose on the day of surgery: -8.0% (99.5% CI, -11.0 to -4.9%) median 499 oral morphine equivalents versus -8.7% (99.5% CI, -14.4 to -2.7%) median 445 oral morphine equivalents, respectively; all statistically significant, but none clinically significant. Comparable outcome patterns existed for opioid-related adverse effects.Conclusions: The demonstrated marginal effects do not support routine use of intravenous acetaminophen given alternative nonopioid analgesic options. [ABSTRACT FROM AUTHOR]