Patient Safety and Quality

To reduce hospital deaths, managing surgical complications may be as important as preventing them

Differences in hospital deaths among patients who had inpatient surgery depend on two factors, according to a recent study: avoiding surgery-related complications and timely recognition and management of complications once they occur. Among 84,730 patients who underwent general or vascular surgery as inpatients, about one in six patients had a surgical complication, and more than half of such complications were serious. Mortality ranged from 3.5 percent in the fifth of hospitals with the lowest risk-adjusted death rate to 6.9 percent in the fifth of hospitals with the highest death rates. The researchers could not attribute the differences in mortality to differences in the type of surgeries done at the high- and low-death-rate hospitals. Nor did they find significant differences in the types of complications reported or overall rate of complications.

Hospitals with very high or very low mortality rates had similar rates of complications (24.6 and 26.9 percent, respectively) and major complications (18.2 and 16.2 percent, respectively). However, patients who were treated for surgery-related complications at high-death-rate hospitals were nearly twice as likely to die from a major complication (21.4 percent) than patients at a low-death-rate hospital (12.5 percent).

These findings suggest that improving the care that patients receive once complications have occurred is crucial for reducing mortality, note the researchers. They recommend that initiatives to improve the care of patients once a complication has occurred focus on structural or organizational factors, such as promoting minimum standards for nurse staffing or organization of the intensive care unit. Their findings were based on data on patients who had undergone inpatient general and vascular surgery from 2005 through 2007 at hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program. The study was funded in part by the Agency for Healthcare Research and Quality (HS17765).

More details are in "Variation in hospital mortality associated with inpatient surgery," by Amir A. Ghaferi, M.D., John D. Birkmeyer, M.D., and Justin B. Dimick, M.D., M.P.H., in the October 1, 2009, New England Journal of Medicine 361(14), pp. 1368-1375.

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