Journal of the American College of Surgeons
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Comparative Study
Low-Volume vs High-Volume Centers and Management of Fournier's Gangrene in Washington State.
Fournier's gangrene (FG) is a life-threatening infection affecting the perineum and genitals. Complex patient management often necessitates transfer to tertiary centers. We aimed to characterize hospital transfer patterns and assess morbidity among patients with FG in Washington State. ⋯ Patients treated at the HVC were more acutely ill, yet mortality was similar compared with patients treated solely at LVCs, suggesting a benefit to transfer of high acuity patients. Immediate vs delayed transfer may benefit FG health outcomes; however, this may also reflect greater disease acuity of patients with delayed transfer status.
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Critically ill cirrhotics require liver transplantation urgently, but are at high risk for perioperative mortality. The Model for End-stage Liver Disease (MELD) score, recently updated to incorporate serum sodium, estimates survival probability in patients with cirrhosis, but needs additional evaluation in the critically ill. The purpose of this study was to evaluate the predictive power of ICU admission MELD scores and identify clinical risk factors associated with increased mortality. ⋯ The MELD demonstrated relatively poor predictive accuracy in critically ill patients with cirrhosis and might not be the best indicator for prognosis in the ICU population. Prognostic accuracy is significantly improved when variables indicating organ support (mechanical ventilation, vasopressors, and continuous renal replacement therapy) are included in the model.
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Observational Study
Association between State Medical Malpractice Environment and Postoperative Outcomes in the United States.
The US medical malpractice system assumes that the threat of liability should deter negligence, but it is unclear whether malpractice environment affects health care quality. We sought to explore the association between state malpractice environment and postoperative complication rates. ⋯ Higher risk malpractice environments were not consistently associated with a lower likelihood of surgical postoperative complications, bringing into question the ability of malpractice lawsuits to promote health care quality.
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Admission physiology predicts mortality after injury, but may be improved by resuscitation before transfer. This phenomenon, which has been termed lead-time bias, may lead to underprediction of mortality in transferred patients and inaccurate benchmarking in centers receiving large numbers of transfer patients. We sought to determine the impact of using vital signs on arrival at the referring center vs on arrival at the trauma center in mortality prediction models for transferred trauma patients. ⋯ Trauma center vital signs underestimate mortality in transfer patients and may lead to incorrect estimates of expected mortality. Where possible, benchmarking efforts should use referring hospital vital signs to risk-adjust IHT patients.
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Accurate clinical documentation (CD) is necessary for many aspects of modern health care, including excellent communication, quality metrics reporting, and legal documentation. New requirements have mandated adoption of ICD-10-CM coding systems, adding another layer of complexity to CD. A clinical documentation improvement (CDI) and ICD-10 training program was created for health care providers in our academic surgery department. We aimed to assess the impact of our CDI curriculum by comparing quality metrics, coding, and reimbursement before and after implementation of our CDI program. ⋯ Clinical documentation improvement/ICD-10 training in an academic surgery department is an effective method to improve documentation rates, increase the hospital estimated reimbursement based on more accurate CD, and provide better compliance with surgical quality measures.