Comparison of Postoperative Outcomes in Elderly Patients With a Do-Not-Resuscitate Order Undergoing Elective and Nonelective Hip Surgery

Beverly, Anair; Brovman, Ethan Y.; Urman, Richard D.

doi:10.1177/2151458516685826

Cited by 17 publications

(17 citation statements)

References 22 publications

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“…The most common procedures among DNR patients focused on symptom relief but were also associated with higher rates of 30 d mortality (but not morbidity) when compared to non-DNR matched controls[ 8 ]. In another analysis focused on DNR patients undergoing hip surgery, the urgency of the procedure (emergent vs non-emergent) was found to cause no independent increase in 30-d morbidity, while DNR status itself again demonstrated high 30-d mortality rates in excess of those predicted by the NSQIP risk calculator[ 27 ].…”

Section: Discussionmentioning

confidence: 99%

Do-Not-Resuscitate status is an independent risk factor for patients undergoing surgery for hip fracture

Brovman

Pisansky

Beverly

et al. 2017

WJO

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AIMTo determine morbidity and mortality in hip fracture patients and also to assess for any independent associations between Do-Not-Resuscitate (DNR) status and increased post-operative morbidity and mortality in patients undergoing surgical repair of hip fractures.METHODSWe conducted a propensity score matched retrospective analysis using de-identified data from the American College of Surgeons’ National Surgical Quality Improvement Project (ACS NSQIP) for all patients undergoing hip fracture surgery over a 7 year period in hospitals across the United States enrolled in the ACS NSQIP with and without DNR status. We measured patient demographics including DNR status, co-morbidities, frailty and functional baseline, surgical and anaesthetic procedure data, post-operative morbidity/complications, length of stay, discharge destination and mortality.RESULTSOf 9218 patients meeting the inclusion criteria, 13.6% had a DNR status, 86.4% did not. Mortality was higher in the DNR compared to the non-DNR group, at 15.3% vs 8.1% and propensity score matched multivariable analysis demonstrated that DNR status was independently associated with mortality (OR = 2.04, 95%CI: 1.46-2.86, P < 0.001). Additionally, analysis of the propensity score matched cohort demonstrated that DNR status was associated with a significant, but very small increased likelihood of post-operative complications (0.53 vs 0.43 complications per episode; OR = 1.21; 95%CI: 1.04-1.41, P = 0.004). Cardiopulmonary resuscitation and unplanned reintubation were significantly less likely in patients with DNR status.CONCLUSIONWhile DNR status patients had higher rates of post-operative complications and mortality, DNR status itself was not otherwise associated with increased morbidity. DNR status appears to increase 30-d mortality via ceilings of care in keeping with a DNR status, including withholding reintubation and cardiopulmonary resuscitation.

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Section: Discussionmentioning

confidence: 99%

Do-Not-Resuscitate status is an independent risk factor for patients undergoing surgery for hip fracture

Brovman

Pisansky

Beverly

et al. 2017

WJO

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“…Some clinicians also worry that by recording a DNAR decision, this may compromise other aspects of the patient's care. This is not unreasonable as systematic reviews have shown that surgical patients with DNARs have a worse mortality even when adjusted for other risk factors [12][13][14]. However, analysis has shown that in the hip fracture subgroup, DNAR is not an independent mortality risk factor [15].…”

Section: Discussionmentioning

confidence: 99%

Pre-operative resuscitation discussion with patients undergoing fractured neck of femur repair: a service evaluation and discussion of current standards

Heylen

Kemp

MacDonald

et al. 2021

Arch Orthop Trauma Surg

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Introduction The majority of neck of femur (NOF) fracture patients are frail and at a higher risk of cardiac arrest. This makes discussion of treatment escalation vital to informed care. The optimal time for these discussions is prior to admission or trauma. However, when this has not occurred, it is vital that these discussions happen early in the patient's admission when family is often present and before further deterioration in their condition. We undertook a service evaluation to evaluate and discuss the effect of clinician education on improving rates of timely discussion amongst orthopaedic doctors. Materials and methodsThe first cycle included 94 patients. Their notes were reviewed for presence of a ReSPECT (Recommend Summary Plan for Emergency Care and Treatment) form prior to operation and whether this it countersigned by a consultant. Following this, clinician education was undertaken and a re-audit was carried out involving 57 patients. Results ReSPECT form completion rates rose from 23% in cycle 1-32% in cycle 2 following intervention. The proportion which consultants signed rose from 41% to 56% following intervention. Conclusion This project demonstrates how a basic education program can prove limited improvements in the rates of timely resuscitation discussions. We discuss a current lack in quality research into educational programs for discussion of treatment escalation for orthopaedic trainees. We suggest there is room to improve national best practice guidelines and training to ensure these discussions are carried out more frequently and to a better standard.

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“…To take a similar example, past literature has demonstrated a strong association between do-not-resuscitate (DNR) status and adverse outcomes. [20][21][22][23][24] In all likelihood, the DNR status does not directly cause worse outcomes so much as it marks a sick and vulnerable population. Selection bias at the individual patient level may contribute to an association between comanagement and worse outcomes.…”

Section: Discussionmentioning

confidence: 99%

Medical Comanagement of Hip Fracture Patients Is Not Associated with Superior Perioperative Outcomes: A Propensity Score-Matched Retrospective Cohort Analysis of the National Surgical Quality mprovement Project

Maxwell

Mirza

2019

J Hosp Med

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H ip fractures are a large source of morbidity and mortality in the United States, with >1.5 million patients affected every year. 1 These patients are primarily older adults with a significant burden of associated medical comorbidities. 2 The outcomes of nonoperative management are poor with regard to mortality, 3 although operative management of hip fractures remains associated with a high rate of morbidity and mortality compared with several other surgical procedures, substantial resources remain devoted to the operative repair of hip fractures and to process improvement strategies for perioperative care.Medical comanagement involves having a second nonsurgical primary team-often an internist, a hospitalist, a geriatrician, or an anesthesiologist-who would follow the patient during the hip fracture admission, and provide daily care di-rected toward both the hip fracture and its associated management challenges and the patient's underlying comorbidities. This includes taking a primary or shared role in daily rounding, writing progress notes, writing orders, managing medications and therapies, disposition planning, and discharge. One argument for this practice has centered around an efficiency proposition for surgeons to spend more of their time operating and less time in these tasks of acute care management. The primary argument, though, for medical comanagement has been an outcomes proposition that frail, elderly patients with significant medical comorbidities benefit from a nonsurgeon's focused attention to their coexisting medical problems and the interaction with the surgical issues posed by operative intervention for hip fracture. A number of previous studies have demonstrated an association between comanagement and improved perioperative outcomes. 4,5 However, the most convincing improvements in several studies have been process indicators (eg, time from admission to surgery, length of stay, nurse/surgeon satisfaction) without significant differences in mortality or major morbidity. [6][7][8] Several studies were methodologically limited due to the use of historical controls, 9,10 and several were conducted in focused clinical settings (eg, a sin-

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Comparison of Postoperative Outcomes in Elderly Patients With a Do-Not-Resuscitate Order Undergoing Elective and Nonelective Hip Surgery

Cited by 17 publications

References 22 publications

Do-Not-Resuscitate status is an independent risk factor for patients undergoing surgery for hip fracture

Do-Not-Resuscitate status is an independent risk factor for patients undergoing surgery for hip fracture

Pre-operative resuscitation discussion with patients undergoing fractured neck of femur repair: a service evaluation and discussion of current standards

Medical Comanagement of Hip Fracture Patients Is Not Associated with Superior Perioperative Outcomes: A Propensity Score-Matched Retrospective Cohort Analysis of the National Surgical Quality mprovement Project

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