术前筛查有助于降低30天死亡率

圣迭戈——美国外科医师协会/国家外科质量改进计划(ACS/NSQIP)全国大会上公布的一项单中心研究显示，实施强化术前筛查和干预可显著降低普通手术和血管手术的30天死亡率。


Agathoklis Konstantinidis医生

在这项研究中，Agathoklis Konstantinidis医生及其同事为了改善其所在医院的手术死亡率，从2010年1月开始实施了一项严格的术前筛查和干预计划，要求对每例拟接受手术的患者进行术前筛查，即由注册护士使用电脑对心脏病、肾病、异常心电图、睡眠呼吸暂停和肺病等危险因素进行广泛筛查。

如果发现问题，则推迟手术，直至初级保健医生或直接参与患者治疗的外科医生通过与其他专家(如内科、家庭医学和内分泌学等领域的专家)密切沟通解决该问题。

在实施术前筛查和干预计划之前的2007年7月~2009年12月期间的连续4个报告期内，所有病例的30天死亡率比值比(OR)分别为1.40、1.43、1.58和1.56。自实施术前筛查和干预计划后的首份报告起，连续4个报告期内所有病例的30天死亡率逐渐降低，OR分别为1.26、1.19、1.14和0.86，最后1年普通手术(OR，0.92)和血管手术(OR，0.92)的30天死亡率降幅相似。

实施术前筛查和干预计划后，该医院的总体30天手术死亡率从3.5%降至1.9%，兼具临床和统计学意义(P=0.007)。

在2012年5,866例接受筛查的患者中，3,691例存在未诊断的阻塞性睡眠呼吸暂停，2,361例存在异常术前心电图，437例存在未诊断的糖尿病，192例存在未诊断的高血压，167例存在未诊断的气促。筛查干预导致218例患者取消手术，147例被转诊至心脏病专家以接受进一步评估。

Konstantinidis医生声明无相关经济利益冲突。

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By: DOUG BRUNK, Internal Medicine News Digital Network

SAN DIEGO – The implementation of an intensive preoperative screening and intervention process led to a significant decrease in 30-day mortality for general surgery and vascular procedures, results from a single-center study demonstrated.

In 2007, Carilion Roanoke (Va.) Memorial Hospital became a member of the American College of Surgeons/National Surgical Quality Improvement Program (ACS/NSQIP). "After receiving our first report, it became evident that surgical mortality at our institution was significantly higher than expected and significantly higher than the national average," Dr. Agathoklis Konstantinidis said at the ACS/NSQIP National Conference. "After further evaluation of this data, it became obvious that we were operating on people with several undiagnosed, untreated medical diseases such as diabetes, obstructive sleep apnea, hypertension, lung disease, and renal disease that all constituted significant preoperative risk factors."
 
In an effort to improve surgical mortality at the hospital, Dr. Konstantinidis and his associates implemented a strict preoperative screening and intervention program that began in January 2010. Since that time, every patient scheduled for surgery is required to undergo a preoperative screening appointment with a registered nurse who performs an extensive computer-based checklist of risk factors for heart disease, renal disease, abnormal EKG, sleep apnea, and pulmonary disease.

"If a problem is identified, the surgery is postponed until the issue is addressed, either by the primary care physician or by the surgeon who is directly involved in the care of the patient, and in close communication with other specialists, such as those in internal medicine, family practice, and endocrinology," explained Dr. Konstantinidis, who is a surgeon at the hospital.

Between July 2007 and December 2009 – prior to initiation of the preoperative screening and intervention program – the odds ratios for 30-day mortality in all cases were 1.40, 1.43, 1.58, and 1.56 in successive reporting periods. Beginning with the first report after implementation of the preoperative screening and intervention program, 30-day mortality in all cases progressively decreased in successive reporting periods (OR, 1.26, 1.19, 1.14, and 0.86, respectively), with similar reductions in both general surgery (OR, 0.92) and vascular surgery (OR, 0.92) for the last year.

"After the implementation of our new preoperative screening and intervention process, overall 30-day surgical mortality at our institution decreased from 3.5% to 1.9%, which is clinically and also statistically significant based on the P value (P = .007)," Dr. Konstantinidis said.

He went on to report that out of 5,866 patients who underwent screening in 2012 alone, 3,691 had undiagnosed obstructive sleep apnea, 2,361 had an abnormal preoperative EKG, 437 had undiagnosed diabetes, 192 had undiagnosed hypertension, and 167 had undiagnosed shortness of breath. "As a result of the screening intervention, surgery was canceled in 218 patients, and 147 were referred to cardiology specialists for further evaluation," he said.

Dr. Konstantinidis said that he had no relevant financial conflicts to disclose.