Adverse surgical outcomes among patients with cognitive impairments

To determine the factors that contributed to adverse outcomes, the records of 59 cognitively impaired patients with nonfatal complications (n = 23) or death (n = 36) on a general surgery teaching service over a 30-month period were examined retrospectively. Specific complications are reported. Patient, disease, and management factors related to mortality and morbidity are identified. Patients with cognitive impairments had a higher mortality rate (9.6 vs 6.3%) and approximately the same rate of nonfatal complications (6.1 vs 7.6%) when compared with general surgery patients as a whole. Patient characteristics including age over 70, dementia, nursing home residence, contractures, inability to communicate, need for total care, and gross malnutrition were associated with fatal outcomes. Vascular, colonic, esophageal, gastric, or duodenal conditions, emergency admission, urgent operation, and admission APACHE II scores greater than or equal to 15 were disease-related factors associated with mortality. Management risk factors were prehospital or inpatient diagnostic delays and technical or judgmental errors of surgical management. Twenty-four of 36 deaths were directly related either to a diagnostic delay (11), an operative technical error (11), or a judgmental error of postoperative airway management (2). Eighty-five per cent of diagnostic delays (11/13) and 37 per cent (11/30) of technical errors resulted in mortality. Suggestions for improving the care of these patients are discussed.