A dults older than 65 years of age now comprise more than one-half of all ICU admissions in the United States. 1 Approximately 1.4 million elderly (aged Ն 65 years) Medicare benefi ciaries are discharged each year after receiving intensive care. 2 With technological advances, many critically ill elderly adults now survive what were previously fatal illnesses, 3,4 but outcomes can be poor. Among the 33% of elderly ICU patients discharged to skilled-care facilities, nearly one-half are rehospitalized and 25% to 65% die within 6 months. 2,5 While predictive models exist for ICU survivors of prolonged mechanical ventilation and elders hospitalized without intensive care, 6,7 there are no existing clinical prediction tools to help predict outcome explicitly for elderly ICU survivors. A validated prediction model for postdischarge mortality in elderly ICU survivors could (1) risk-stratify patients for clinical trials of novel preventative, rehabilitative, and therapeutic interventions; (2) help determine appropriate levels of postacute care; and (3) aid providers in addressing expectations and end-of-life care with these patients and their families.We aimed to derive and externally validate a prediction model for 6-month mortality among elderly ICU survivors. We hypothesized that including markers of frailty and disability as well as patient preferences regarding resuscitation in our model would be important in predicting 6-month mortality. Withholding life-supporting therapies often indicates

Natural language processing can reliably detect the presence of postoperative venous thromboembolisms, and its use should be expanded for the detection of other conditions from narrative documentation.

Background Minimally invasive surgery (MIS) is associated with decreased complication rates, length of hospital stay, and cost compared with laparotomy. Robotic-assisted surgery—a method of laparoscopy—addresses many of the limitations of standard laparoscopic instrumentation, thus leading to increased rates of MIS. We sought to assess the impact of robotics on the rates and costs of surgical approaches in morbidly obese patients with uterine cancer. Methods Patients who underwent primary surgery at our institution for uterine cancer from 1993 to 2012 with a BMI ≥40 mg/m2 were identified. Surgical approaches were categorized as laparotomy (planned or converted), laparoscopic, robotic, or vaginal. We identified two time periods based on the evolving use of MIS at our institution: laparoscopic (1993–2007) and robotic (2008–2012). Direct costs were analyzed for cases performed from 2009 to 2012. Results We identified 426 eligible cases; 299 performed via laparotomy, 125 via MIS, and 2 via a vaginal approach. The rates of MIS for the laparoscopic and robotic time periods were 6 % and 57 %, respectively. The rate of MIS was 78 % in this morbidly obese cohort in 2012; 69 % were completed robotically. The median length of hospital stay was 5 days (range 2–37) for laparotomy cases and 1 day (range 0–7) for MIS cases (P < 0.001). The complication rate was 36 and 15 %, respectively (P < 0.001). The rate of wound-related complications was 27 and 6 %, respectively (P < 0.001). Laparotomy was associated with the highest cost. Conclusions The robotic platform provides significant health and cost benefits by increasing MIS rates in this patient population.

Rationale: Adults with chronic critical illness (tracheostomy after > 10 d of mechanical ventilation) have a high burden of palliative needs, but little is known about the actual use and potential need of palliative care services for the larger population of older intensive care unit (ICU) survivors discharged to post-acute care facilities.Objectives: To determine whether older ICU survivors discharged to post-acute care facilities have potentially unmet palliative care needs. Methods:We examined electronic records from a 1-year cohort of 228 consecutive adults > 65 years of age who had their first medical-ICU admission in 2009 at a single tertiary-care medical center and survived to discharge to a post-acute care facility (excluding hospice). Use of palliative care services was defined as having received a palliative care consultation. Potential palliative care needs were defined as patient characteristics suggestive of physical or psychological symptom distress or anticipated poor prognosis. We examined the prevalence of potential palliative needs and 6-month mortality. Measurements and Main Results:The median age was 78 years (interquartile range, 71-84 yr), and 54% received mechanical ventilation for a median of 7 days (interquartile range, 3-16 d). Six subjects (2.6%) received a palliative care consultation during the hospitalization. However, 88% had at least one potential palliative care need; 22% had chronic wounds, 37% were discharged on supplemental oxygen, 17% received chaplaincy services, 23% preferred to not be resuscitated, and 8% were designated "comfort care." The 6-month mortality was 40%.Conclusions: Older ICU survivors from a single center who required postacute facility care had a high burden of palliative care needs and a high 6-month mortality. The in-hospital postcritical acute care period should be targeted for palliative care assessment and intervention.