Risk Factor Analysis for Postoperative Unplanned Intubation and Ventilator Dependence
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1 Risk Factor Analysis for Postoperative Unplanned Intubation and Ventilator Dependence Adam P. Johnson MD, MPH, Anisha Kshetrapal MD, Harold Hsu MD, Randi Altmark RN, BSN, Herbert E Cohn MD, FACS, Scott W. Cowan MD, FACS Department of Surgery, Thomas Jefferson University Hospital Pulmonary Session, NSQIP Annual Conference Sunday, July
2 No Disclosures Disclosures
3 Quality Based Improvement Resident Teams Fulfills ACGME Requirement for resident education in quality improvement Systematically analyze practice using quality improvement methods, and implement changes with the goal of practice improvement 1 Resident teams focus on improving performance for specific complications: Pulmonary Complications Surgical Site infection (SSI) Urinary tract infection (UTI) Central line associated blood stream infection (CLABSI) Venous thromboembolic events (VTE) Readmission and patient satisfaction
4 Postoperative Pulmonary Complications American College of Surgeons National Surgical Quality Improvement Project (ACS NSQIP) reported events: 2 Unplanned Intubation Ventilator Dependence (Ventilator >48hours) Pulmonary Embolism Pneumonia Associated with: Prolonged hospitalization Increased morbidity Increased short and long-term mortality 3 Results in incremental cost increase of $50,000 per case. 4
5 Methods 11,489 sampled for NSQIP database between 2006 and inpatients 2609 outpatients 47 missing data 8833 included in our statistical analysis 30 Risk factors identified Descriptive statistics Multivariate risk analysis with logistic regression
6 Unplanned Intubation: Risk Factors Multivariate Analysis (n=8833) Patient Related Risk Factors p-value OR Ventilator >48 hours < ASA > Class 2* < COPD (severe)* Age >60 years* Serum Albumin <3.5* Protective Factors p-value OR Ventilator Preoperatively < Pre-operative Sepsis* Transferred *Identified in NSQIP Best Practices Guidelines 2,5
7 Unplanned Intubation: Risk Factors Multivariate Analysis (n=8833) Ventilator dependence ASA > 2* COPD* Age >60 years* Albumin <3.5* Sepsis* Transferred Ventilator Preop Altered Sensorium* Open Wound Weightloss >10% Hypertension Current Smoker* CHF* Contaminated Time (not first start) Dependent status* Emergency* Male Operation >3 hours* Dyspnea Transfusion* Other Procedures Time of year (J/A/S) General Anesthesia Diabetes Obesity Sodium >145* Renal failure *Identified in NSQIP Best Practices Guidelines 2,
8 Ventilator >48hours: Risk Factors Multivariate Analysis (n=8833) Patient Related Risk Factors p-value OR Unplanned Intubation < Ventilator Preoperatively < ASA > Class 2* < Pre-operative Sepsis* < Serum Albumin <3.5* < Transferred < Age >60 years* < Male < Preoperative Dyspnea Procedure Related Risk Factors p-value OR Emergency* < Operation >3 hours* < Contamination < Additional Procedures < *Identified in NSQIP Best Practices Guidelines 2,5
9 Ventilator >48hours: Risk Factors Multivariate Analysis (n=8833) Unplanned intubation Ventilator Preop ASA > 2* Sepsis* Emergent* Operation >3 hours* Albumin <3.5* Transferred Contaminated Age >60 years* Other Procedures Male Dyspnea CHF* General Anesthesia* Transfusion* Time (not first start) Dependent status* Smoker* Obesity Time of year (J/A/S) Renal failure Open Wound Diabetes Hypertension Sodium >145* Weightloss >10% COPD* Altered Sensorium* Pneumonia *Identified in NSQIP Best Practices Guidelines 2,
10 Future Aims Educate fellow residents on what risk factors predispose their patients to unplanned intubation and ventilator dependence Develop a multivariate score for stratifying patients based on risk Root cause analysis 1. High risk patients Develop targeted interventions 2. Low risk patients Identify and prevent never events
11 Acknowledgements Jefferson NSQIP Program Dr. David Rittenhouse Department of Surgery References 1. Accreditation Council for Graduate Medical Education. Common program requirements. The ACGME. Accessed July 20, Roberts J, Lawrence VA, and Nestor FE. ACS NSQIP Best Practices Guidelines: Prevention of postoperative pulmonary complications 3. Khuri SF, Henderson WG, DePalma RG, et al. Determinants of long-term survival after major surgery and the adverse effect of postoperative complications. Ann Surg 2005;242: Dimick JB, Chen SL, Taheri PA, et al. Hospital costs associated with surgical complications: a report from the private-sector National Surgical Quality Improvement Program. JACS. 2004;199: Johnson RG, Arozullah AM, Neumayer L, et al. Multivariable predictors of postoperative respiratory failure after general and vascular surgery: results from the Patient Safety in Surgery Study. JACS. 2007;204:
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