Delivery Of Safe Surgical Care Research Articles

The impact of case order and intraoperative staff changes on spine surgical efficiency

BACKGROUND CONTEXTDespite concerted efforts toward quality improvement in high-volume spine surgery, there remains concern that increases in case load may compromise the efficient and safe delivery of surgical care. There is a paucity of evidence to describe the effects of spine case order and operating room (OR) team structure on measures of intraoperative timing and OR efficiency. PURPOSEThis study aims to determine if intraoperative staff changes and surgical case order independently predict extensions in intraoperative timing after spinal surgery for spondylotic diseases. STUDY DESIGN/ SETTINGRetrospective cohort analysis PATIENT SAMPLEAll patients over age 18 who underwent primary or revision decompression and/or fusion for degenerative spinal diseases between 2017 to 2019 at a single academic institution were retrospectively identified. Exclusion criteria included absence of descriptive data and intraoperative timing parameters as well as surgery for traumatic injury, infection, and malignancy. OUTCOME MEASURESIntraoperative timing metrics including total theater time, wheels in to induction, induction start to cut, cut to close, and close to wheels out. Postoperative outcomes included length of hospital stay and 90-day hospital readmissions. METHODSSurgical case order and intraoperative changes in staff (circulator and surgical scrub nurse or technician) were determined. Patient demographics, surgical factors, intraoperative timing and postoperative outcomes were recorded. Extensions in each operative stage were determined as a ratio of the actual duration of the parameter divided by the predicted duration of the parameter. Univariate and multivariate analyses were performed to compare outcomes within case order and staff change groups. RESULTSA total of 1,108 patients met the inclusion criteria. First, second, and third start cases differed significantly in intraoperative extensions of total theater time, wheels in to induction, induction start to cut, cut to close, and close to wheels out. On regression, decreasing case order predicted extension in wheels in to induction time. Surgeries with intraoperative staff changes were associated with increases in total theater time, induction start to cut time, cut to close time, close to wheels out time, and length of hospital stay. Switch in primary circulator predicted extended theater time and cut to close time. Relief of primary circulator or scrub predicted extended total theater time, induction start to cut time, cut to close time, and close to wheels out time. CONCLUSIONSIntraoperative staff change in spine surgery independently predicted extended operative duration. However, higher case order was not significantly associated with procedural time.

Safe Delivery of Surgical Care in Head and Neck Cancer Patients During COVID-19-an Audit of Pattern of Presentation and Treatment Strategies in an Oncology Centre in the Northern India.

Delay in treatment of head and neck cancer leads to stage migration and increased morbidity. Due to the COVID-19, surgical care has been severely affected. We continued our oncology services during the pandemic. We present here the pattern of presentation of head and neck cancer patients to the hospital and strategy to continue services. A retrospective audit of patients registered under Head and Neck Disease Management Group during lockdown, 23rd March to 31st May 2020, was done. Four categories were made new registrations, post-surgical patients, emergency department visits and follow-up presentation. Of the 693 patients assessed, a majority were with oral cavity cancer (80%). Seventy-eight percent of patients presented with stage IV disease. There were 382 new registrations, of which 68% were symptomatic. Of the 69 patients that underwent surgery, 17 patients were on adjuvant treatment. A total of 60 patients presented to emergency department during this period, maximum with complaints of dyspnoea (67%). One hundred eighty-nine patients were follow-up patients of which 43% were symptomatic. Among these, 12 patients were diagnosed with recurrence. Various administrative and clinical policies were formulated to continue cancer care during this time. Surgical services need not be halted during the COVID-19 pandemic. Following scientific rationale and treatment strategies, safe oncosurgical care can be delivered during pandemic.

Ensuring safe surgical care across resource settings via surgical outcomes data & quality improvement initiatives.

Staggering statistics regarding the global burden of disease due to lack of surgical care worldwide has been gaining attention in the global health literature over the last 10 years. The Lancet Commission on Global Surgery reported that 16.9 million lives were lost due to an absence of surgical care in 2010, equivalent to 33% of all deaths worldwide. Although data from low- and middle-income countries (LMICs) are limited, recent investigations, such as the African Surgical Outcomes Study, highlight that despite operating on low risk patients, there is increased postoperative mortality in LMICs versus higher-resource settings, a majority of which occur secondary to seemingly preventable complications like surgical site infections. We propose that implementing creative, low-cost surgical outcomes monitoring and select quality improvement systems proven effective in high-income countries, such as surgical infection prevention programs and safety checklists, can enhance the delivery of safe surgical care in existing LMIC surgical systems. While efforts to initiate and expand surgical access and capacity continues to deserve attention in the global health community, here we advocate for creative modifications to current service structures, such as promoting a culture of safety, employing technology and mobile health (mHealth) for patient data collection and follow-up, and harnessing partnerships for information sharing, to create a framework for improving morbidity and mortality in responsible, scalable, and sustainable ways.

The Impact of Increasing Surgical Capacity at a Tertiary Hospital in Southern Haiti

BackgroundSt. Boniface Hospital (SBH) plays a critical role in providing safe, accessible surgery in rural southern Haiti. We examine the impact of SBH increasing surgical capacity on case volume, patient complexity, and inpatient mortality across three phases. Materials and methodsA retrospective review and geospatial analysis of all surgical cases performed at SBH between 2015 and 2017 were performed. Inpatient mortality was defined by in-hospital deaths divided by the number of procedures performed. ResultsBetween February 2015 and August 2017, over 2000 procedures were performed. The average number of surgeries per week was 3.1 with visiting surgical teams in phase 1 (P1), 10.4 with a single general surgeon in phase 2 (P2), and 20.1 with two surgeons and a resident in phase 3 (P3). There was a six-fold increase in surgical volume between P1 and P3 and a significant increase in case complexity. The distribution of American Society of Anesthesiologists scores of 1, 2, 3, and 4 during P2 was 81.05%, 14.74%, 3.42%, and 0.79%, respectively, whereas in P3, the distribution was 68.91%, 22.55%, 7.70%, and 0.84%. Surgical mortality was 0%, 1.2%, and 1.67% across phases. ConclusionsIncreasing resources and surgical staff at SBH allowed for greater delivery of safe surgical care. This study highlights that investing in surgery has a significant impact in regions of great surgical need.

Improving the working environment for the delivery of safe surgical care in the UK: a qualitative cross-sectional analysis

ObjectivesThe aim of this study was to identify current problems and potential solutions to improve the working environment for the delivery of safe surgical care in the UK.DesignProspective, questionnaire-based cross-sectional...

Surgeons' attitudes are associated with reoperation and readmission rates.

Attitudes influence how people make decisions. In an effort to decrease pilot judgment-related accidents, the Federal Aviation Administration teaches new pilots about hazardous attitudes that are believed to be incompatible with safe flight: macho, impulsive, worry, resignation, self-confidence, and antiauthority. If these attitudes are hazardous for pilots and their passengers, they may also be incompatible with the reliable and safe delivery of surgical care. The purposes of this study were (1) to ascertain to what extent surgeons harbor hazardous attitudes; and (2) to determine their relationship, if any, to reoperation and readmission rates. We selected validated aviation psychology tools that are used to measure these attitudes in pilots. We converted the aviation scenarios to analogous situations for surgeons and invited all surgeons from one academic program to participate in this study. A total of 41 surgeons were eligible to participate; 37 (90%) completed the attitude prevalence protocol and 31 (76%) had complete reoperation and readmission data for the correlation and regression analysis. Attending orthopaedic surgeons completed the Modified Surgeon Hazardous Attitude Scale as well as a series of additional instruments. Levels of macho thought to be hazardous in pilots were present in nine (24%) surgeons. Similar, elevated levels of self-confidence were found in three (8%) surgeons. High levels of impulsivity were found in 5% (two surgeons) and high levels of antiauthority were found in 3% (one surgeon). Only one (3%) surgeon reported elevated levels of worry and no surgeon reported hazardous levels of resignation. Thirty percent (11 surgeons) of surgeons harbored at least one elevated attitude level. In a regression model, macho attitude levels predicted 19% of the variation in surgeons' rate of readmissions and reoperations. High levels of hazardous attitudes may not be consistent with the routine delivery of safe surgical care in a teamwork setting where human factors and safe systems are the key to success. Further research is needed to determine if abnormally high levels of these hazardous attitudes impact patient care. Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.