Surgical Deaths Linked to Handling of Complications
WEDNESDAY Sept. 30, 2009 -- The way that a hospital handles the complications of surgery, not just the rate of those complications, determines the hospital's surgical death rate, a new study has found.
The study, which included more than 84,000 people who had surgery in U.S. hospitals, found about a twofold difference in surgical deaths between hospitals with the lowest rate and those with the highest -- 3.5 percent vs. 6.9 percent. This occurred despite a small difference in the overall rate of complications -- 24.6 percent in the hospitals with the lowest surgical mortality rate and 26.9 percent in those with the highest.
The emphasis in recent years has been on reducing the rate of surgical complications, said Dr. Justin B. Dimick, assistant professor of surgery at the University of Michigan and a co-author of the study, published in the Oct. 1 issue of the New England Journal of Medicine. Many hospitals have established point-by-point checklists that surgeons go through before operating.
"Our study doesn't necessarily contradict the need for checklists," Dimick said. "There is no doubt that reducing complications is an important goal. But our data show that the reason why some hospitals aren't reducing mortality may be due to differences in the complication treatment."
To some degree, complications are inevitable in surgery, Dimick said. "We're most worried about the complications that can lead to death," he said. "About one of every six patients has complications that can lead to death."
Complications can be related to the surgery itself, including bleeding, infections and leakages, Dimick said, and they can be related to medical problems that the person having surgery might have, such as a heart attack, blood clots in the leg, kidney failure or stroke.
In hospitals with low mortality rates, 12.5 percent of people with such complications died, the study found. The death rate in the highest-mortality hospitals was 21.4 percent.
"Not much attention has been paid to the management of complications," he said. "That is where we should be looking."
The pattern could be seen in management of specific complications. For example, all the hospitals had roughly similar incidences of post-surgery bleeding. But the death rate from that complication was 50 percent higher in some hospitals than in others.
Though the new study does not directly address ways to manage surgical complications, "we can speculate," Dimick said. "A number of things in previous studies have been associated with mortality."
Hospitals with lower surgical death rates tend to have fully-staffed, 24-hour intensive care units with physicians trained to handle post-surgical emergencies. They have high nurse-to-patient ratios in their intensive care units and their wards. "The more nurses the better because there are fewer patients per nurse," Dimick said.
A less tangible factor -- "just the culture of the hospital" -- also is involved, he said. "Do people feel afraid to call the surgeon at night, are they afraid to go up the chain of command, are they not afraid of pushing the button?"
Dr. Peter Pronovost, a professor of anesthesiology and critical care medicine at Johns Hopkins University School of Medicine, said that the study's findings don't lessen the need to prevent surgical complications and errors. Pronovost was an originator of the checklist concept.
"We have to try to prevent complications when we can," he said. "But when we can't, we must make sure that they are properly recognized and treated. This study shows that recognition and treatment has a substantial impact on a patient's risk of dying."
Studies already have shown that the availability of intensive care specialists and a high nurse-to-patient ratio improve survival, but that lesson is sometimes forgotten in current cost-cutting times, Pronovost said.
"We may have slipped a bit in that area because the workload is often quite high," he said.
Posted: September 2009
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