Acute Risk Change: An Innovative Measure of Operative Adverse Events and Perioperative Team Performance

Abstract

Objectives: Cardiac surgical risk models predict mortality preoperatively, whereas intensive care unit (ICU) models predict mortality postoperatively. Finding a large difference between the 2 (an acute risk change [ARC]) may reflect an alteration in the status of the patient related to the surgery. An adverse ARC was associated with morbidity and mortality in an Australian population. The aims of this study were to validate ARC in a UK population and to investigate the possible mechanisms behind ARC. Design: This was a retrospective case-control study. Setting: Single, high-volume cardiothoracic hospital. Participants: Data from 4,842 cardiac surgical patients were collected between 2013 and 2015. Interventions: None. Measurements and main results: EuroSCORE was recalibrated to each preceding year's data. ARC was defined as postoperative minus preoperative percentage mortality risk. Association among ARC, morbidity, and mortality was tested. Cases with large adverse ARC (greater than +15%) were compared with cases with large favorable ARC (less than -10%) with regard to intraoperative adverse events, unmeasured patient risk factors, and postoperative events. Adverse ARC was associated with hospital mortality, ICU stay, ICU readmission, renal support, prolonged intubation and return to the operating room (p < 0.001). Intraoperative adverse events occurred in 23 of 33 patients with adverse ARC; however, only 2 of 17 patients with favorable ARC reported adverse events (p < 0.001). Unmeasured risk factors were present in 48% of patients in the adverse ARC group. Conclusion: ARC is a readily available and sensitive marker that correlates strongly with morbidity and mortality. The use of ARC in local and national quality monitoring could identify areas for improvement of the quality of cardiac surgical care.