Outcomes research using quality improvement databases: evolving opportunities and challenges

The challenges to prospective randomized controlled trials have necessitated the exploration of observational data sets that support research into the predictors and modulators of preoperative adverse events. The primary purpose and design of quality improvement databases is quality assessment and improvement at the local, regional, or national level. However, these data can also provide the opportunity to robustly study specific questions related to patient outcomes with no additional clinical risk to the patient. The virtual explosion of anesthesia-related registries has opened seemingly limitless opportunities for outcomes research in addition to generating hypothesis for more rigorous prospective analysis.

Multiple component patient safety intervention in English hospitals: controlled evaluation of second phase

OBJECTIVE

To independently evaluate the impact of the second phase of the Health Foundation's Safer Patients Initiative (SPI2) on a range of patient safety measures. Design A controlled before and after design. Five substudies: survey of staff attitudes; review of case notes from high risk (respiratory) patients in medical wards; review of case notes from surgical patients; indirect evaluation of hand hygiene by measuring hospital use of handwashing materials; measurement of outcomes (adverse events, mortality among high risk patients admitted to medical wards, patients' satisfaction, mortality in intensive care, rates of hospital acquired infection). Setting NHS hospitals in England.

PARTICIPANTS

Nine hospitals participating in SPI2 and nine matched control hospitals.

INTERVENTION

The SPI2 intervention was similar to the SPI1, with somewhat modified goals, a slightly longer intervention period, and a smaller budget per hospital.

RESULTS

One of the scores (organisational climate) showed a significant (P = 0.009) difference in rate of change over time, which favoured the control hospitals, though the difference was only 0.07 points on a five point scale. Results of the explicit case note reviews of high risk medical patients showed that certain practices improved over time in both control and SPI2 hospitals (and none deteriorated), but there were no significant differences between control and SPI2 hospitals. Monitoring of vital signs improved across control and SPI2 sites. This temporal effect was significant for monitoring the respiratory rate at both the six hour (adjusted odds ratio 2.1, 99% confidence interval 1.0 to 4.3; P = 0.010) and 12 hour (2.4, 1.1 to 5.0; P = 0.002) periods after admission. There was no significant effect of SPI for any of the measures of vital signs. Use of a recommended system for scoring the severity of pneumonia improved from 1.9% (1/52) to 21.4% (12/56) of control and from 2.0% (1/50) to 41.7% (25/60) of SPI2 patients. This temporal change was significant (7.3, 1.4 to 37.7; P = 0.002), but the difference in difference was not significant (2.1, 0.4 to 11.1; P = 0.236). There were no notable or significant changes in the pattern of prescribing errors, either over time or between control and SPI2 hospitals. Two items of medical history taking (exercise tolerance and occupation) showed significant improvement over time, across both control and SPI2 hospitals, but no additional SPI2 effect. The holistic review showed no significant changes in error rates either over time or between control and SPI2 hospitals. The explicit case note review of perioperative care showed that adherence rates for two of the four perioperative standards targeted by SPI2 were already good at baseline, exceeding 94% for antibiotic prophylaxis and 98% for deep vein thrombosis prophylaxis. Intraoperative monitoring of temperature improved over time in both groups, but this was not significant (1.8, 0.4 to 7.6; P = 0.279), and there were no additional effects of SPI2. A dramatic rise in consumption of soap and alcohol hand rub was similar in control and SPI2 hospitals (P = 0.760 and P = 0.889, respectively), as was the corresponding decrease in rates of Clostridium difficile and meticillin resistant Staphylococcus aureus infection (P = 0.652 and P = 0.693, respectively). Mortality rates of medical patients included in the case note reviews in control hospitals increased from 17.3% (42/243) to 21.4% (24/112), while in SPI2 hospitals they fell from 10.3% (24/233) to 6.1% (7/114) (P = 0.043). Fewer than 8% of deaths were classed as avoidable; changes in proportions could not explain the divergence of overall death rates between control and SPI2 hospitals. There was no significant difference in the rate of change in mortality in intensive care. Patients' satisfaction improved in both control and SPI2 hospitals on all dimensions, but again there were no significant changes between the two groups of hospitals.

CONCLUSIONS

Many aspects of care are already good or improving across the NHS in England, suggesting considerable improvements in quality across the board. These improvements are probably due to contemporaneous policy activities relating to patient safety, including those with features similar to the SPI, and the emergence of professional consensus on some clinical processes. This phenomenon might have attenuated the incremental effect of the SPI, making it difficult to detect. Alternatively, the full impact of the SPI might be observable only in the longer term. The conclusion of this study could have been different if concurrent controls had not been used.

[Surgical treatment of the aortic dissection type B: analysis of 15 years' experience]

65 patients with the aortic dissection type B were operated on in the period 1995-2010. The proximal local aortic prosthetics proved to be the method of choice in treatment of such patients. The method allowed the reduction of the hospital lethality on 5,7 ± 3,9% and considerably decrease the overall hospital stay.

[Surgical treatment of the unformed intestinal fistulae]

Treatment results of 5 patients with unformed intestinal fistulae are represented. High unformed intestinal fistulae are acknowledged to be completely unsuitable for conservative treatment and should be operated on. Complex treatment should include complete parenteral feeding, adequate fecal diversion with the use of aspirational drainage. Surgical treatment must be y the increase of fistula discharge or absence of fistula formation. Low intestinal fistulae should better be surgically dissected after their organization, otherwise urgent surgery is to be performed by complications development, such as purulent leakage into the abdominal cavity or severe wound infection.

[The combined abdomenotranssacral access for the extralevator rectum extirpation]

Technique of the extralevator abdomenoperineal rectum extirpation with the use of the combined abdomenotranssacral access is thoroughly described in the article. The radicality of the procedure and the immediate results has been evaluated in 27 patients with the lower ampullary rectum and anal canal cancer. The average blood loss was 625±288 (300-3500) ml. The soft tissue defect was replaced with the use of unilateral rotated gluteus maximus muscle (n=21), bilateral rotated gluteus maximus muscle (n=6). Tumor-free resection line was registered by the morphological investigation of the resected tissues in 25 cases. Long-term results (13.2±3.1) (2-22 months)) were obtained in 24 patients. The obtained results of the postoperative morbidity and survival rates allow to consider the described method as a safe and appropriate surgical procedure.

[Principles of diagnostics and treatment of chronic appendicitis]

Treatment results of 101 patients, operated on with the diagnosis of the chronic appendicitis, were analyzed. Of them, 55 had periodic right iliac pain syndrome, the rest 46 had a history of appendicular abscess or infiltrate. 58 patients were operated on laparoscopically, the rest had traditional open appendectomy. The use of ultrasound and roentgen diagnostics proved to be non-effective. The reliable laparoscopic symptoms of chronic appendicitis were singled out. The laparoscopy provided the correct diagnosis in 93.3% of patients and allowed avoiding the groundless appendectomy in 31.2%. The intraoperative ultrasound is helpful in questionable cases. The diagnostic and treatment algorithm for chronic appendicitis, based on laparoscopic methods, was worked out.

[Pre-operative cardiac assessment in non-cardiac surgery: a frequent dilemma simplified by a decision tree]

In patients undergoing non-cardiac surgery, cardiac events are the most common cause of perioperative morbidity and mortality. It is often difficult to choose adequate cardiologic examinations before surgery. This paper, inspired by the guidelines of the European and American societies of cardiology (ESC, AHA, ACC), discusses the place of standard ECG, echocardiography, treadmill or bicycle ergometer and pharmacological stress testing in preoperative evaluations. The role of coronary angiography and prophylactic revascularization will also be discussed. Finally, we provide a decision tree which will be helpful to both general practitioners and specialists.

[General surgical procedures in patients with electrical pacemaker]

Work of the implanted electric pacemaker (EP) was assessed in 99 patients, aged 62.4±9.6 years, during non-cardiological surgery. Inhibition of the EP stimuli was registered in 9 (9.1%) patients, short episodes of uneffective stimulation with synchronization disturbation--in 2 (2%) patients and change of stimulation regimen was registered in the same number of patients by electocoagulation. Episodes of myopotential inhibition not assotiated with electrocoagulation was registered in 4 cases. The ascertained rhythm disturbances require a thorough preoperative check-up, intraoperative ECG control and short use of monopolar electrocoagulation.

[The system of intraoperative and perioperative safety in surgical treatment of benign diseases of the thyroid gland]

The system of safe interventions on the thyroid gland was developed on the basis of experiences with surgical treatment of 2255 patients with diffuse toxic goiter, 437--with nodular toxic goiter, 1377--with nodular nontoxic goiter, 123--with autoimmune thyroiditis and 937--with recurrent goiter. The system includes measures in the preoperative period, those during operation and the postoperative rehabilitation of the patients. This system allowed shortening of the period of preoperative preparation, decrease of blood loss, and less number of postoperative complications.

Does the number of trauma lists provided affect care and outcome of patients with fractured neck of femur?

INTRODUCTION

Delay in surgery for fractured neck of femur is associated with increased mortality; it is recommended that patients with fractured neck of femur are operated within 48 h. North West hospitals provide dedicated trauma lists, as recommended by the British Orthopaedic Association, to allow rapid access to surgery. We investigated trauma list provision by each trust and its effects on the time taken to get neck of femur patients to surgery and patient survival.

PATIENTS AND METHODS

The number of trauma lists provided by 13 acute trusts was determined by telephone interview with the theatre manager. Data on operating delays, reasons for delay and 30-day mortality were obtained from the Greater Manchester and Wirral fractured neck of femur audit.

RESULTS

A total of 883 patients were included in the audit (35-126 per hospital). Overall, 5-15 trauma lists were provided each week, and 80% of lists were consultant-led. Of patients, 31.8% were operated on within 24 h and 36.9% were delayed more than 48 h; 37.7% of delays were for non-medical reasons. The 30-day mortality rates varied between 5-19% (mean, 11.8%). There were no significant relationships between the number of trauma lists and these variables. When divided into hospitals with > 10 lists per week (n = 6) and those with < 10 lists per week (n = 7) there were no significant differences in 48-h delay, non-medical delay or mortality. However, 24-h delay showed a trend to be lower in those with > 10 lists (34.6% of patients versus 28.9%; P = 0.09).

CONCLUSIONS

Most trusts provided at least one dedicated daily list. This study shows that extra lists may enable trusts to cope better with fractured neck of femur but do not change mortality.

Best practice updates for multidisciplinary care in weight loss surgery

The objective of this study is to update evidence-based best practice guidelines for multidisciplinary care of weight loss surgery (WLS) patients. We performed systematic search of English-language literature on WLS, patient selection, and medical, multidisciplinary, and nutritional care published between April 2004 and May 2007 in MEDLINE and the Cochrane Library. Key words were used to narrow the search for a selective review of abstracts, retrieval of full articles, and grading of evidence according to systems used in established evidence-based models. A total of 150 papers were retrieved from the literature search and 112 were reviewed in detail. We made evidence-based best practice recommendations from the most recent literature on multidisciplinary care of WLS patients. New recommendations were developed in the areas of patient selection, medical evaluation, and treatment. Regular updates of evidence-based recommendations for best practices in multidisciplinary care are required to address changes in patient demographics and levels of obesity. Key factors in patient safety include comprehensive preoperative medical evaluation, patient education, appropriate perioperative care, and long-term follow-up.

[Quicker recovery from elective colon surgery: anaesthesiological aspects of the fast-track programme]

A multidisciplinary approach for patients who will undergo colonic resection was introduced in 2006 and 2007 in 26 Dutch hospitals, following several other European centres. This approach aims to place the patient in an optimal metabolic state before operation, with subsequent rapid mobilisation and resumption of oral intake of liquids and solid food. The surgeon, anaesthetist, and nursing staff collaborate in this approach, each taking responsibility for specific tasks. The anaesthesiological tasks consist of withholding preoperative intake of drink and food, appropriate pain reduction, perioperative fluid balance management, use of inotropic and vasopressor drugs, prevention of post-operative nausea and vomiting, and addressing possible immunological consequences of surgery.

[Ideal intraoperative management to prevent perioperative complications]

Anesthesiologists can contribute considerably to prevent both intra- and post-operative complications. Intraoperative transesophageal echocardiography can be utilized to visualize potential hazards at various stages in cardiac surgery; aortic and venous cannulation, left ventricular vent tube insertion and removal of residual air in cardiac chambers. Near infrared spectroscopy is employed for early detection of cerebral ischemia. A more than 20 percent of decrease from the preoperative baseline probably indicates cerebral ischemia and prompts some measures to improve cerebral oxygenation. Separate lung ventilation can be offered by using a combination of a normal endotracheal tube and a bronchial blocker instead of a double lumen tube in order to avoid a tube exchange at the end of operation which is sometimes difficult and dangerous. Intraoperative awareness should be avoided by administering additional sedatives especially at a rewarming phase of cardiopulmonary bypass. Intraoperative shivering causes excessive oxygen demands and should be prevented by giving enough amounts of muscle relaxants. Temperature and glucose controls are also important to decrease surgery-related morbidity and mortality. A premature cease of rewarming by cardiopulmonary bypass and extra heating after bypass may well be considered. High thoracic epidural anesthesia is possibly beneficial to reduce patients' stress, improve postoperative pulmonary function and hasten recovery.

94% accuracy of intraoperative imprint touch cytology of sentinel nodes in skin melanoma patients

The aim of the present study was to assess whether the reliability of imprint touch cytology (ITC) of sentinel nodes in skin melanoma patients allows intraoperative decisions regarding simultaneous radical lymphadenectomy to be made.

PATIENTS AND METHODS

The results of ITC of sentinel nodes were compared with the results of standard histopathological and immunohistochemical examinations.

RESULTS

A total of 148 sentinel nodes were identified in 98 lymph node groups in 85 skin melanoma patients. ITC revealed the presence of metastases in 7 out of 16 melanoma-positive sentinel nodes (sensitivity, 43.7%). There were no false-positive results of ITC of sentinel nodes (specificity, 100%). The negative predictive value of ITC was 93.6%, the positive predictive value was 100%, and the accuracy of the method was 93.9%.

CONCLUSION

ITC of sentinel nodes is a reliable method. There was no risk of overtreatment due to false-positive results of sentinel node ITC in our study. High accuracy of the method warrants its clinical use.

Nurse anaesthetic care during cataract surgery: a comparative quality assurance study

BACKGROUND

We studied whether a new model of nurse-provision of conscious sedation for cataract surgery maintained patient satisfaction and safety.

METHODS

We prospectively and non-randomly studied 106 patients who had outpatient cataract surgery on a day when an anaesthetist was present at the UBC, Vancouver Hospital Eye Care Centre, and 105 patients with no anaesthetist, but instead a surgical suite nurse trained to give conscious sedation was present. Questionnaires determined patient perception of well-being, pain, and anxiety before surgery, before discharge, at 48 hours and at 6 weeks postoperative. Hospital records and a surgeon questionnaire were used to determine complications. Ophthalmology records were used to determine visual acuity (preoperative and at 6 weeks).

RESULTS

No anaesthetic complications were reported in either group and there were no significant differences in surgical complications. Patient responses to assessments of discomfort, well-being, and anxiety, preoperatively and postoperatively, were very similar on the nurse days and anaesthetist days.

INTERPRETATION

Conscious sedation of cataract surgery patients can be safely and effectively provided by a trained nurse for selected patients. This nursing role is likely replicable in similar operating room settings.

Patient Safety and Quality in Surgery

Patient safety and quality of care are inextricably linked. Surgery encompasses such a wide spectrum of diagnosis, treatment, postoperative care, and outpatient follow-up of so many illnesses that quality improvement and patient safety opportunities are numerous and potentially overwhelming. The study of error can be applied across all components of the care process, and offers many points of study to improve patient safety. A fundamental premise is that appropriate and safely delivered health care is less expensive. In our current climate, this emphasis on quality and safety will remain a high priority. Surgeon leadership at all levels is key to our professional viability.

Improved neurologic outcome after implementing evidence-based guidelines for cardiac surgery

OBJECTIVE

A high incidence of neurologic complications was observed in the year 2001 in cardiac surgical patients in this department. This article attempts to show the impact of changing and optimizing management protocols on the incidence of neurologic morbidity after cardiac surgery.

DESIGN

An observational study of cardiac surgical patients.

SETTING

University hospital.

PARTICIPANTS

All cardiac surgical patients treated postoperatively in the cardiac surgical ICU in 2001 (n = 1,165, control group) and in 2003 (n = 1,222, intervention group) were evaluated.

INTERVENTIONS

A quality improvement program started at the beginning of 2002, based on the Task Force Committee Guidelines, included surgical and cardiopulmonary bypass recommendations as well as peri- and postoperative care (eg, use of epiaortic echo and strict perfusion protocol, avoidance of hyperthermia and hyperglycemia, and minimization of cerebral edema).

RESULTS

The number of neurologic complications decreased from 78 (6.7%) in 2001 to 33 (2.7%) in 2003 (p < 0.01), and corresponding numbers for ICU mortality were 44 (3.8%) and 24 (2.0%) (p < 0.01). The length of ICU stay also decreased (3.2 +/- 4.5 days in 2001 v 2.9 +/- 5.5 days in 2003, p < 0.001). In 2001, patients with neurologic complications consumed 853 ICU patient days (23% of all ICU patient days) and, in 2003, 549 (15% of all ICU patient days). According to logistic regression analysis that included 11 independent variables (treatment year, EuroSCORE, diabetes mellitus, history of stroke, and 7 different types of surgery), treatment in 2003 was independently associated with decreased risk for neurologic complications (odds ratio 0.30, 95% confidence intervals 0.19-0.47, p < 0.001).

CONCLUSIONS

The occurrences of neurologic complications, mortality, and ICU resource consumption by this patient group decreased after implementation of an optimized management protocol and evidence-based guidelines.

Stress-induced insulin resistance: recent developments

PURPOSE OF REVIEW

Interest in stress-induced insulin resistance has increased during the past 5 years. Relevant clinical and mechanistic investigations during the past year will be reviewed.

RECENT FINDINGS

Recent trials of intensive insulin therapy in intensive care units have brought attention to a high incidence of hypoglycemic episodes with such treatment. The clinical relevance of such hypoglycemia has been shown to be minor, however. Furthermore, animal and in-vitro work further supports the finding that glucose control, rather than glycemia-independent effects of insulin, is the primary mechanism of action of intensive insulin therapy. In elective surgery, cohort studies show an association between intraoperative hyperglycemia and postoperative morbidity. Beneficial effects of preoperative oral carbohydrate treatment on immunocompetence and cardiac contractility have been demonstrated. Laparoscopic segmental colectomy was associated with considerably attenuated derangements in glucose metabolism compared with conventional, open surgery.

SUMMARY

Better methods of insulin dosing and administration and glucose monitoring are warranted to further minimize the risks of intensive insulin therapy. In elective surgery, perioperative measures such as preoperative oral carbohydrate treatment and laparoscopic techniques attenuate metabolic and other physiological derangements and such methods should be integrated into perioperative care protocols to minimize morbidity and enhance recovery.