Person:

Salim, Ali

IMPORTANCE: Inpatient palliative care improves symptom management and patient satisfaction with care and reduces hospital costs in seriously ill patients. However, the role of palliative care in the treatment of patients undergoing surgery (surgical patients) remains poorly defined.

OBJECTIVE: To characterize the content, design, and results of interventions to improve access to palliative care or the quality of palliative care for surgical patients.

EVIDENCE REVIEW: This systematic review was conducted according to PRIMSA guidelines. Articles were identified through searches of PubMed, PsycINFO, EMBASE, and CINAHL as well as manual review of references. Eligible articles included experimental, quasi-experimental, and observational studies published in English from January 1, 1994, through October 31, 2014, in which patient outcomes of palliative care interventions for adult surgical patients were reported. Data on the study setting, design, intervention, participants, and results were extracted from the final study set and analyzed from December 22, 2014, to February 7, 2015.

FINDINGS: A total of 3838 abstracts were identified and screened by 2 reviewers, 77 articles were reviewed in full text, and 25 articles (22 unique interventions involving 8575 unique patients) met the study criteria. Interrater agreement was good (κ = 0.78). Nine single-institution retrospective cohort studies, 7 single-institution prospective cohort studies, 7 single-institution randomized clinical studies, and 2 multicenter randomized clinical studies were included. Nineteen of the 23 single-site studies were performed at academic hospitals. Given the heterogeneity of study methods and measures, meta-analysis was not possible. Preoperative decision-making interventions were associated with decreased mortality in 4 studies. Three studies reported improved quality of communication; 4, improved symptom management; and 7, decreased use of health care resources and decreased cost. However, many studies were small, performed in academic settings, and methodologically flawed and did not measure clinically meaningful outcomes.

CONCLUSIONS AND RELEVANCE: The sparse evidence regarding interventions to introduce or improve palliative care for surgical patients is further limited by methodologic flaws. Rigorous evaluations of standardized palliative care interventions measuring meaningful patient outcomes are needed.

Objective: To explore whether older adults with isolated hip fractures benefit from treatment in high-volume hospitals. Design: Population-based observational study. Setting: All acute hospitals in California, USA. Participants: All individuals aged ≥65 that underwent an operation for an isolated hip fracture in California between 2007 and 2011. Patients transferred between hospitals were excluded. Primary and secondary outcomes Quality indicators (time to surgery) and patient outcomes (length of stay, in-hospital mortality, unplanned 30-day readmission, and selected complications). Results: 91 401 individuals satisfied the inclusion criteria. Time to operation and length of stay were significantly prolonged in low-volume hospitals, by 1.96 (95% CI 1.20 to 2.73) and 0.70 (0.38 to 1.03) days, respectively. However, there were no differences in clinical outcomes, including in-hospital mortality, 30-day re-admission, and rates of pneumonia, pressure ulcers, and venous thromboembolism. Conclusions: These data suggest that there is no patient safety imperative to limit hip fracture care to high-volume hospitals.

It is often that the acute care surgeon will be called on to evaluate the pregnant patient with abdominal pain. Most of the diagnostic and management decisions regarding pregnant patients will follow the usual tenets of surgery; however, there are important differences in the pregnant patient to be aware of to avoid pitfalls which can lead to complications for both mother and fetus. This review hopes to describe the most common emergencies facing the surgeon caring for the pregnant patient and the latest management options.