A prospective observational study of human factors, adverse events, and patient outcomes in surgery for pediatric cardiac disease

Airway management in neonates and infants: European Society of Anaesthesiology and Intensive Care and British Journal of Anaesthesia joint guidelines

Airway management is required during general anaesthesia and is essential for life-threatening conditions such as cardiopulmonary resuscitation. Evidence from recent trials indicates a high incidence of critical events during airway management, especially in neonates or infants. It is important to define the optimal techniques and strategies for airway management in these groups. In this joint European Society of Anaesthesiology and Intensive Care (ESAIC) and British Journal of Anaesthesia (BJA) guideline on airway management in neonates and infants, we present aggregated and evidence-based recommendations to assist clinicians in providing safe and effective medical care. We identified seven main areas of interest for airway management: i) preoperative assessment and preparation; ii) medications; iii) techniques and algorithms; iv) identification and treatment of difficult airways; v) confirmation of tracheal intubation; vi) tracheal extubation, and vii) human factors. Based on these areas, Population, Intervention, Comparison, Outcomes (PICO) questions were derived that guided a structured literature search. GRADE (Grading of Recommendations, Assessment, Development and Evaluation) methodology was used to formulate the recommendations based on those studies included with consideration of their methodological quality (strong '1' or weak '2' recommendation with high 'A', medium 'B' or low 'C' quality of evidence). In summary, we recommend: 1. Use medical history and physical examination to predict difficult airway management (1C). 2. Ensure adequate level of sedation or general anaesthesia during airway management (1B). 3. Administer neuromuscular blocker before tracheal intubation when spontaneous breathing is not necessary (1C). 4. Use a videolaryngoscope with an age-adapted standard blade as first choice for tracheal intubation (1B). 5. Apply apnoeic oxygenation during tracheal intubation in neonates (1B). 6. Consider a supraglottic airway for rescue oxygenation and ventilation when tracheal intubation fails (1B). 7. Limit the number of tracheal intubation attempts (1C). 8. Use a stylet to reinforce and preshape tracheal tubes when hyperangulated videolaryngoscope blades are used and when the larynx is anatomically anterior (1C). 9. Verify intubation is successful with clinical assessment and end-tidal CO2 waveform (1C). 10. Apply high-flow nasal oxygenation, continuous positive airway pressure or nasal intermittent positive pressure ventilation for postextubation respiratory support, when appropriate (1B).

Airway management in neonates and infants: European Society of Anaesthesiology and Intensive Care and British Journal of Anaesthesia joint guidelines

Airway management is required during general anaesthesia and is essential for life-threatening conditions such as cardiopulmonary resuscitation. Evidence from recent trials indicates a high incidence of critical events during airway management, especially in neonates or infants. It is important to define the optimal techniques and strategies for airway management in these groups. In this joint European Society of Anaesthesiology and Intensive Care (ESAIC) and British Journal of Anaesthesia (BJA) guideline on airway management in neonates and infants, we present aggregated and evidence-based recommendations to assist clinicians in providing safe and effective medical care. We identified seven main areas of interest for airway management: i) preoperative assessment and preparation; ii) medications; iii) techniques and algorithms; iv) identification and treatment of difficult airways; v) confirmation of tracheal intubation; vi) tracheal extubation, and vii) human factors. Based on these areas, Population, Intervention, Comparison, Outcomes (PICO) questions were derived that guided a structured literature search. GRADE (Grading of Recommendations, Assessment, Development and Evaluation) methodology was used to formulate the recommendations based on those studies included with consideration of their methodological quality (strong '1' or weak '2' recommendation with high 'A', medium 'B' or low 'C' quality of evidence). In summary, we recommend: 1. Use medical history and physical examination to predict difficult airway management (1С). 2. Ensure adequate level of sedation or general anaesthesia during airway management (1B). 3. Administer neuromuscular blocker before tracheal intubation when spontaneous breathing is not necessary (1С). 4. Use a videolaryngoscope with an age-adapted standard blade as first choice for tracheal intubation (1B). 5. Apply apnoeic oxygenation during tracheal intubation in neonates (1B). 6. Consider a supraglottic airway for rescue oxygenation and ventilation when tracheal intubation fails (1B). 7. Limit the number of tracheal intubation attempts (1C). 8. Use a stylet to reinforce and preshape tracheal tubes when hyperangulated videolaryngoscope blades are used and when the larynx is anatomically anterior (1C). 9. Verify intubation is successful with clinical assessment and end-tidal CO 2 waveform (1C). 10. Apply high-flow nasal oxygenation, continuous positive airway pressure or nasal intermittent positive pressure ventilation for postextubation respiratory support, when appropriate (1B).

Increasing the margin of patient safety for periodontal and implant treatments: The role of human factors

Early complications following periodontal and dental implant surgeries are typically attributed to technique or poor biological response, ignoring the possibility of the human element. Interestingly, significant experience is not correlated with increased success, whereas evidence supports the impact of clinical behavior on patient outcome. This is the result of errors, much like those scrutinized in other high-risk technical fields, such as aviation. What can be surprising is that those who make these errors are very well acquainted with best practices. Given this, how is it possible for the conscientious practitioner to fail to apply protocols that are nonetheless very well known? Recently, the concepts of human and organizational factors have been translated to medicine, though dentistry has been slow to recognize their potential benefit. This review lists specific human factor behaviors, such as use of checklists and crew resource management, which might improve postsurgical outcome.

Safety gaps in medical team communication: Closing the loop on quality improvement efforts in the cardiac catheterization lab

Closed-loop communication (CLC) is a fundamental aspect of effective communication, critical in the cardiac catheterization laboratory (cath lab) where physician orders are verbal. Complete CLC is typically a hospital and national mandate. Deficiencies in CLC have been shown to impair quality of care. Single center observational study, CLC for physician verbal orders in the cath lab were assessed by direct observation during a 5-year quality improvement effort. Performance feedback and educational efforts were used over this time frame to improve CLC, and the effects of each intervention assessed. Responses to verbal orders were characterized as complete (all important parameters of the order repeated, the mandated response), partial, acknowledgment only, or no response. During the first observational period of 101 cases, complete CLC occurred in 195 of 515 (38%) medication orders and 136 of 235 (50%) equipment orders. Complete CLC improved over time with various educational efforts, (p < 0.001) but in the final observation period of 117 cases, complete CLC occurred in just 259 of 328 (79%) medication orders and 439 of 581 (76%) equipment orders. Incomplete CLC was associated with medication and equipment errors. CLC of physician verbal orders was used suboptimally in this medical team setting. Baseline data indicate that physicians and staff have normalized weak, unreliable communication methods. Such lapses were associated with errors in order implementation. A subsequent 5-year quality improvement program resulted in improvement but a sizable minority of unacceptable responses. This represents an opportunity to improve patient safety in cath labs.

Translation and Validation of the Boston Technical Performance Score in a Developing Country

Introduction

The Technical Performance Score (TPS) was developed and subsequently refined at the Boston Children's Hospital. Our objective was to translate and validate its application in a developing country.

Methods

The score was translated into the Portuguese language and approved by the TPS authors. Subsequently, we studied 1,030 surgeries from June 2018 to October 2020. TPS could not be assigned in 58 surgeries, and these were excluded. Surgical risk score was evaluated using Risk Adjustment in Congenital Heart Surgery (or RACHS-1). The impact of TPS on outcomes was studied using multivariable linear and logistic regression adjusting for important perioperative covariates.

Results

Median age and weight were 2.2 (interquartile range [IQR] = 0.5-13) years and 10.8 (IQR = 5.6-40) kilograms, respectively. In-hospital mortality was 6.58% (n=64), and postoperative complications occurred in 19.7% (n=192) of the cases. TPS was categorized as 1 in 359 cases (37%), 2 in 464 (47.7%), and 3 in 149 (15.3%). Multivariable analysis identified TPS class 3 as a predictor of longer hospital stay (coefficient: 6.6; standard error: 2.2; P=0.003), higher number of complications (odds ratio [OR]: 1.84; 95% confidence interval [CI]: 1.1-3; P=0.01), and higher mortality (OR: 3.2; 95% CI: 1.4-7; P=0.004).

Conclusion

TPS translated into the Portuguese language was validated and showed to be able to predict higher mortality, complication rate, and prolonged postoperative hospital stay in a high-volume Latin-American congenital heart surgery program. TPS is generalizable and can be used as an outcome assessment tool in resource diverse settings.

System Factors Affecting Patient Safety in the OR: An Analysis of Safety Threats and Resiliency

OBJECTIVE

The objective of this study is to determine the characteristics and frequency of intraoperative safety threats and resilience supports using a human factors measurement tool.

BACKGROUND

Human factors analysis can provide insight into how system elements contribute to intraoperative adverse events. Empiric evidence on safety threats and resilience in surgical practice is lacking.

METHODS

A cross-sectional study of 24 patients undergoing elective laparoscopic general surgery at a single center in the Netherlands from May to November, 2017 was conducted. Video, audio, and patient physiologic data from all included procedures were obtained through a multichannel synchronized recording device. Trained analysts reviewed the recordings and coded safety threats and resilience supports. The codes were categorized into 1 of 6 categories (person, task, tools and technology, physical environment, organization, and external environment).

RESULTS

A median of 14 safety threats [interquartile range (IQR) 11-16] and 12 resilience supports (IQR 11-16) were identified per case. Most safety threat codes (median 9, IQR 7-12) and resilience support codes (median 10, IQR 7-12) were classified in the person category. The organization category contained a median of 2 (IQR 1-2) safety threat codes and 2 (IQR 2-3) resilience support codes per case. The tools and technology category contributed a small number of safety threats (median 1 per case, IQR 0-1), but rarely provided resilience support.

CONCLUSIONS

Through a detailed human factors analysis of elective laparoscopic general surgery cases, this study provided a quantitative analysis of the existing safety threats and resilience supports in a modern endoscopic operating room.

Classification strategies for non-routine events occurring in high-risk patient care settings: A scoping review

INTRODUCTION

Non-routine events (NREs) are atypical or unusual occurrences in a pre-defined process. Although some NREs in high-risk clinical settings have no adverse effects on patient care, others can potentially cause serious patient harm. A unified strategy for identifying and describing NREs in these domains will facilitate the comparison of results between studies.

METHODS

We conducted a literature search in PubMed, CINAHL, and EMBASE to identify studies related to NREs in high-risk domains and evaluated the methods used for event observation and description. We applied The Joint Commission on Accreditation of Healthcare Organization (JCAHO) taxonomy (cause, impact, domain, type, prevention, and mitigation) to the descriptions of NREs from the literature.

RESULTS

We selected 25 articles that met inclusion criteria for review. Real-time documentation of NREs was more common than a retrospective video review. Thirteen studies used domain experts as observers and seven studies validated observations with interrater reliability. Using the JCAHO taxonomy, "cause" was the most frequently applied classification method, followed by "impact," "type," "domain," and "prevention and mitigation."

CONCLUSIONS

NREs are frequent in high-risk medical settings. Strengths identified in several studies included the use of multiple observers with domain expertise and validation of the event ascertainment approach using interrater reliability. By applying the JCAHO taxonomy to the current literature, we provide an example of a structured approach that can be used for future analyses of NREs.

Identifying Risks and Opportunities in Outpatient Surgical Patient Safety: A Qualitative Analysis of Veterans Health Administration Staff Perceptions

OBJECTIVES

Little is known about patient safety risks in outpatient surgery. Inpatient surgical adverse events (AEs) risk factors include patient- (e.g., advanced age), process- (e.g., inadequate preoperative assessment), or structure-related characteristics (e.g., low surgical volume); however, these factors may differ from outpatient care where surgeries are often elective and in younger/healthier patients. We undertook an exploratory qualitative research project to identify risk factors for AEs in outpatient surgery.

METHODS

We developed a conceptual framework of patient, process, and structure factors associated with surgical AEs on the basis of a literature review. This framework informed our semistructured interview guide with (1) open-ended questions about a specific outpatient AE that the participant experienced and (2) outpatient surgical patient safety risk factors in general. We interviewed nationwide Veterans Health Administration surgical staff. Results were coded on the basis of categories in the conceptual framework, and additional themes were identified using content analysis.

RESULTS

Fourteen providers representing diverse surgical roles participated. Ten reported witnessing an AE, and everyone provided input on risk factors in our conceptual framework. We did not find evidence that patient race/age, surgical technique, or surgical volume affected patient safety. Emerging factors included patient compliance, postoperative patient assessments/instruction, operating room equipment needs, and safety culture.

CONCLUSIONS

Surgical staff are familiar with AEs and patient safety problems in outpatient surgery. Our results show that processes of care undertaken by surgical providers, as opposed to immutable patient characteristics, may affect the occurrence of AEs. The factors we identified may facilitate more targeted research on outpatient surgical AEs.

Fraction of expired oxygen: an additional safety approach to monitor oxygen delivery to the heart lung machine oxygenator

BACKGROUND

Monitoring oxygen delivery to the oxygenator of a heart lung machine (HLM) is typically accomplished with an O₂ analyzer connected to the gas inflow line. It is assumed when the FiO₂ is greater than 21% that oxygen is being delivered to the oxygenator. However, this assumption is imperfect because the connection of the inflow line to the oxygenator is downstream from the O₂ analyzer. FiO₂ monitoring will not alert the perfusionist if the inflow line is not actually connected to the oxygenator. Measuring the fraction of expired oxygen (FEO₂) is a more reliable way of monitoring O₂ delivery.

METHODS

An O₂ analyzer was placed on the scavenging line that is attached to the exhaust port of oxygenator (FEO₂).

RESULTS

Whenever the FiO₂ is greater than 21%, and the inflow line is properly connected, the FEO₂ exiting the oxygenator is greater than 21%. The FEO₂ falls to 21% when the inflow line is not functioning.

CONCLUSION

Monitoring the FEO₂ is a more reliable way to verify O₂ delivery to an oxygenator. An alarm can be set on the FEO₂ monitor to alert the perfusionist if the FEO₂ falls below a predetermined threshold so any issue with O₂ delivery will always be recognized.

Constructivist Grounded Theory to Establish the Relationship Between Technical Error and Adverse Patient Outcome: Modeling Technical Error and Adverse Outcomes

BACKGROUND

Preventable intraoperative errors have the potential to lead to adverse events. Our objective was to build a conceptual model of the relationship between minute technical errors performed by the surgeon and adverse patient outcomes.

MATERIALS AND METHODS

We used constructivist grounded theory methodology to build a model for the avoidance of technical errors. We used the Observational Clinical Human Reliability Assessment system, which categorizes granular, technical intraoperative errors, as our conceptual framework. We iteratively interviewed surgeons from multiple adult and pediatric surgical specialties, refined our semi-structured interview, and developed a conceptual model. Our model remained stable after interviewing 11 surgeons, and we reviewed it with earlier interviewed surgeons.

RESULTS

Our conceptual model helps us understand how technical errors can be associated with adverse outcomes and is applicable to a broad range of surgical steps. Each technical error is defined by a unique improper technical motion that without a compensatory response, it may lead to 1 or more discreet adverse outcomes. Our model includes 5 primary defenses against an adverse outcome, including perfect technique, recognizing imperfect technique, adequately correcting imperfect technique, recognizing an adverse event, and adequately compensating for an adverse event. It includes multiple examples of compensating for a technical error, resulting in a near miss.

DISCUSSION

Our conceptual model suggests that adverse patient outcomes can be related to minute technical deviations in surgical technique and provides a basis to study these preventable errors. Our model can also be used to develop intraoperative strategies to prevent these technical surgical errors.

Implementation of a "threat and error" model in complex neonatal cardiac surgery patients to identify quality improvement opportunities

INTRODUCTION

Neonates undergoing surgery for congenital heart disease are vulnerable to adverse events. Conventional quality improvement processes centring on mortality and significant morbidity leave a gap in the identification of systematic processes that, though not directly linked to an error, may still contribute to adverse outcomes. Implementation of a multidisciplinary "flight path" process for surgical patients may be used to identify modifiable threats and errors and generate action items, which may lead to quality improvement.

METHODS

A retrospective review of our neonatal "flight path" initiative was performed. Within 72 hours of a cardiac surgery, a meeting of the multidisciplinary patient care team occurs. A "flight path" is generated, graphically illustrating the patient's hospital course. Threats, errors, or unintended consequences are identified. Action items are generated, and a working group is formed to address the items. A patient's flight path is updated weekly until discharge. The errors and action items are logged into a database, which is analysed quarterly to identify trends.

RESULTS

Thirty one patients underwent flight path review over a 1-year period; 22.5% (N = 7) of patients had an error-free "flight." Eleven action items were generated - four from identified errors and seven from identified threats. Nine action items were completed.

CONCLUSIONS

Flight path reviews of congenital cardiac patients can be generated with few resources and aid in the detection of quality improvement opportunities. The regular multidisciplinary meetings that occur as a part of the flight path review process can promote inter-professional teamwork.

Technical Performance as a Predictor of Clinical Outcomes in Laparoscopic Gastric Cancer Surgery

OBJECTIVE

The purpose of this study was to evaluate the relationship between technical performance and patient outcomes in laparoscopic gastric cancer surgery.

BACKGROUND

Laparoscopic gastrectomy for cancer is an advanced procedure with high rate of postoperative morbidity and mortality. Many variables including patient, disease, and perioperative management factors have been shown to impact postoperative outcomes; however, the role of surgical performance is insufficiently investigated.

METHODS

A retrospective review was performed for all patients who had undergone laparoscopic gastrectomy for cancer at 3 teaching institutions between 2009 and 2015. Patients with available, unedited video-recording of their procedure were included in the study. Video files were rated for technical performance, using Objective Structured Assessments of Technical Skills (OSATS) and Generic Error Rating Tool instruments. The main outcome variable was major short-term complications. The effect of technical performance on patient outcomes was assessed using logistic regression analysis with backward selection strategy.

RESULTS

Sixty-one patients with available video recordings were included in the study. The overall complication rate was 29.5%. The mean Charlson comorbidity index, type of procedure, and the global OSATS score were included in the final predictive model. Lower performance score (OSATS ≤29) remained an independent predictor for major short-term outcomes (odds ratio 6.49), while adjusting for comorbidities and type of procedure.

CONCLUSIONS

Intraoperative technical performance predicts major short-term outcomes in laparoscopic gastrectomy for cancer. Ongoing assessment and enhancement of surgical skills using modern, evidence-based strategies might improve short-term patient outcomes. Future work should focus on developing and studying the effectiveness of such interventions in laparoscopic gastric cancer surgery.

Technical Performance Score Predicts Perioperative Outcomes in Complex Congenital Heart Surgery Performed in a Small-to-Medium-Volume Program

As the quality of surgical outcomes depend on many factors, the development of validated tools to assess the different aspects of complex multidisciplinary teams' performance is crucial. The Technical Performance Score (TPS) has only been validated to correlate with outcomes in large-volume surgical programs. Here we assess the utility of TPS in correlation to perioperative outcomes for complex congenital heart surgeries (CHS) performed in a small-to-medium-volume program. 673 patients underwent CHS from 4/2012 to 12/2017 at our institution. Of those, 122 were STAT 4 and STAT 5. TPS was determined for each STAT 4 and STAT 5 operation using discharge echocardiogram: 1 = optimal, 2 = adequate, 3 = inadequate. Patient outcomes were compared including mortality, length of stay, ventilation times, and adverse events. 69 patients (57%) were neonates, 32 (26%) were infants, 17 (14%) were children, 4 (3%) were adults. TPS class 1 was assigned to 85 (70%) operations, TPS class 2 was assigned to 25 (20%) operations, and TPS class 3 was assigned to 12 (10%) operations. TPS was associated with re-intubation, ICU length of stay, postoperative length of stay, and mortality. TPS did not correlate with unplanned 30-day readmissions, need for reoperation, and inotropic score. Technical performance score was associated with perioperative outcomes and is a useful tool to assess the adequacy of repair for high complexity CHS in a small-to-medium-volume surgical program. TPS should be a part of program review in congenital heart programs of all sizes to identify strategies that may reduce postoperative morbidity and potentially improve long-term outcomes.

Adverse Events in the Operating Room: Definitions, Prevalence, and Characteristics. A Systematic Review

BACKGROUND

Adverse events occur commonly in the operating room (OR) and often contribute to morbidity, mortality, and increased healthcare spending. Validated frameworks to measure and report postoperative outcomes have long existed to facilitate exchanges of structured information pertaining to postoperative complication rates in order to improve patient safety. However, systematic evidence regarding measurement and reporting of intraoperative adverse events (iAE) is still lacking.

METHODS

We searched Ovid Medline, Embase, and Cochrane databases for articles published up to June 2016 that measured and reported iAE. We presented the terms and definitions used to describe iAE. We identified the types of reported iAE and summarized them into discrete categories. We reported frequencies of iAE by detection methods.

RESULTS

Of the 47 included studies, 30 were cross-sectional, 14 were case-series, and 3 were cohort studies. The studies used 16 different terms and 22 unique definitions to describe 74 types of iAE. Frequencies of iAE appeared to vary depending on the detection methods, with higher numbers reported when direct observation in the OR was used to detect iAE. Twenty studies assessed severity of iAE, which were mostly based on whether they resulted in postoperative outcomes.

CONCLUSIONS

This study systematically reviewed the current evidence on prevalence and characteristics of iAE that were detected by direct observation, reviews of patient charts, administrative data and incident reports, and surveys and interviews of healthcare providers. Our findings suggest that direct observation method has the most potential to identify and characterize iAE in detail.

Analysis of Human Performance Deficiencies Associated With Surgical Adverse Events

IMPORTANCE

Potentially preventable adverse events remain a formidable cause of patient harm and health care expenditure despite advances in systems-based risk-reduction strategies.

OBJECTIVE

To analyze and describe the incidence of human performance deficiencies (HPDs) during the provision of surgical care to identify opportunities to enhance patient safety.

DESIGN, SETTING, AND PARTICIPANTS

This quality improvement study used a new taxonomy to inform the development and implementation of an HPD classifier tool to categorize HPDs into errors associated with cognitive, technical, and team dynamic functions. The HPD classifier tool was then used to concurrently analyze surgical adverse events in 3 adult hospital affiliates-a level I municipal trauma center, a quaternary care university hospital, and a US Veterans Administration hospital-from January 2, 2018, to June 30, 2018. Surgical trainees presented data describing all adverse events associated with surgical services at weekly hospital-based morbidity and mortality conferences. Adverse events and HPDs were classified in discussion with attending faculty and residents. Data were analyzed from July 9, 2018, to December 23, 2018.

MAIN OUTCOMES AND MEASURES

The incidence and primary and secondary causes of HPDs were classified using an HPD classifier tool.

RESULTS

A total of 188 adverse events were recorded, including 182 adverse events (96.8%) among 5365 patients who underwent surgical operations and 6 adverse events (3.2%) among patients undergoing nonoperative treatment. Among these 188 adverse events, 106 (56.4%) were associated with HPDs. Among these 106 HPD adverse events, a total of 192 HPDs (mean [SD], 1.8 [0.9] HPDs per HPD event) were identified. Human performance deficiencies were categorized as execution (98 HPDs [51.0%]), planning or problem solving (55 HPDs [28.6%]), communication (24 HPDs [12.5%]), teamwork (9 HPDs [4.7%]), and rules violation (6 HPDs [3.1%]). Human performance deficiencies most commonly presented as cognitive errors in execution of care or in case planning or problem solving (99 of 192 HPDs [51.6%]). In contrast, technical execution errors without other associated HPDs were observed in 20 of 192 HPDs (10.4%).

CONCLUSIONS AND RELEVANCE

Human performance deficiencies were identified in more than half of adverse events, most commonly associated with cognitive error in the execution of care. These data provide a framework and impetus for new quality improvement initiatives incorporating cognitive training to mitigate human error in surgery.

Evaluating the implementation and effectiveness of a multi-component intervention to reduce post-surgical opioid prescribing: study protocol of a mixed-methods design

INTRODUCTION

Opioids prescribed after surgery accounted for 5% of the 191 million opioid prescriptions filled in 2017. Approximately 80% of the opioid pills prescribed by surgical care providers remain unused, leaving a substantial number of opioids available for non-medical use. We developed a multi-component intervention to address surgical providers' role in the overprescribing of opioids. Our study will determine effective strategies for reducing post-surgical prescribing while ensuring adequate post-surgery patient-reported pain-related outcomes, and will assess implementation of the strategies.

METHODS AND ANALYSIS

The Minimising Opioid Prescribing in Surgery study will implement a multi-component intervention, in an Illinois network of six hospitals (one academical, two large community and three small community hospitals), to decrease opioid analgesics prescribed after surgery. The multi-component intervention involves four domains: (1) patient expectation setting, (2) baseline assessment of opioid use, (3) perioperative pain control optimisation and (4) post-surgical opioid minimisation. Four surgical specialities (general, orthopaedics, urology and gynaecology) at the six hospitals will implement the intervention. A mixed-methods approach will be used to assess the implementation and effectiveness of the intervention. Data from the network's enterprise data warehouse will be used to evaluate the intervention's effect on post-surgical prescriptions and a survey will collect pain-related patient-reported outcomes. Intervention effectiveness will be determined using a triangulation design, mixed-methods approach with staggered speciality-specific implementation for contemporaneous control of opioid prescribing changes over time. The Consolidated Framework for Implementation Research will be used to evaluate the site-specific contextual factors and adaptations to achieve implementation at each site.

ETHICS AND DISSEMINATION

The study aims to identify the most effective hospital-type and speciality-specific intervention bundles for rapid dissemination into our 56-hospital learning collaborative and in hospitals throughout the USA. All study activities have been approved by the Northwestern University Institutional Review Board (ID STU00205053).

Redesigning systems to improve teamwork and quality for hospitalized patients (RESET): study protocol evaluating the effect of mentored implementation to redesign clinical microsystems

Background

A number of challenges impede our ability to consistently provide high quality care to patients hospitalized with medical conditions. Teams are large, team membership continually evolves, and physicians are often spread across multiple units and floors. Moreover, patients and family members are generally poorly informed and lack opportunities to partner in decision making. Prior studies have tested interventions to redesign aspects of the care delivery system for hospitalized medical patients, but the majority have evaluated the effect of a single intervention. We believe these interventions represent complementary and mutually reinforcing components of a redesigned clinical microsystem. Our specific objective for this study is to implement a set of evidence-based complementary interventions across a range of clinical microsystems, identify factors and strategies associated with successful implementation, and evaluate the impact on quality.

Methods

The RESET project uses the Advanced and Integrated MicroSystems (AIMS) interventions. The AIMS interventions consist of 1) Unit-based Physician Teams, 2) Unit Nurse-Physician Co-leadership, 3) Enhanced Interprofessional Rounds, 4) Unit-level Performance Reports, and 5) Patient Engagement Activities. Four hospital sites were chosen to receive guidance and resources as they implement the AIMS interventions. Each study site has assembled a local leadership team, consisting of a physician and nurse, and receives mentorship from a physician and nurse with experience in leading similar interventions. Primary outcomes include teamwork climate, assessed using the Safety Attitudes Questionnaire, and adverse events using the Medicare Patient Safety Monitoring System (MPSMS). RESET uses a parallel group study design and two group pretest-posttest analyses for primary outcomes. We use a multi-method approach to collect and triangulate qualitative data collected during 3 visits to study sites. We will use cross-case comparisons to consider how site-specific contextual factors interact with the variation in the intensity and fidelity of implementation to affect teamwork and patient outcomes.

Discussion

The RESET study provides mentorship and resources to assist hospitals as they implement complementary and mutually reinforcing components to redesign the clinical microsystems caring for medical patients. Our findings will be of interest and directly applicable to all hospitals providing care to patients with medical conditions.

Trial registration

NCT03745677. Retrospectively registered on November 19, 2018.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4116-z) contains supplementary material, which is available to authorized users.

Safety gaps in medical team communication: Results of quality improvement efforts in a cardiac catheterization laboratory

OBJECTIVES

To assess closed-loop communications (readback), a fundamental aspect of effective communication, among cardiovascular teams and assess improvement efforts.

BACKGROUND

Effective communication within teams is essential to assure safety and optimal outcomes. Readback of verbal physician orders is a hospital and national requirement.

METHODS

Single-center observational study, where the readback responses to physician verbal orders in the catheterization laboratory were characterized over three distinct time intervals from 2015 to 2017. Performance feedback and focused education on the value of readbacks was provided to the teams in two waves, with subsequent remeasurement. Responses to verbal orders were characterized as complete (all important parameters of the order repeated for verification), partial, acknowledgement only, or no response. Changes in readback performance after quality interventions were assessed.

RESULTS

During the first-observational period of 101 cases, complete readback occurred in 195 of 515 (38%) medication orders and 136 of 235 (58%) equipment orders. After initial quality improvement efforts, 102 cases were observed. In these, 298 of 480 (62%) medication orders had complete readback, and 210 of 420 (50%) equipment orders had complete readback. After additional quality improvement efforts, 168 cases were observed. In these, 506 of 723 (70%) medication orders had complete readback, and 630 of 1,061 (59%) equipment orders had complete readback. Overall, medication order readback improved over time (correlation = 0.26 [-0.30, -0.21]; p < 0.001), but equipment order readback did not (correlation = 0.02 [-0.07, 0.03]; p = 0.44).

CONCLUSIONS

Closed-loop communication of physician verbal orders was used infrequently in this medical team setting and proved difficult to fully improve. This is an important safety gap.

Improved Teamwork and Implementation of Clinical Pathways in a Congenital Heart Surgery Program

Supplemental Digital Content is available in the text.

Introduction:

Complex surgical populations are at increased risk of morbidity, especially when experiencing variations in care and poor teamwork. The goal of this project was to improve teamwork and decrease variations in care in a pediatric congenital heart surgery population by implementing Integrated Clinical Pathways (ICPs) on a foundation of teamwork training.

Methods:

A core team used project management for completion of the project and measurement of success. The leadership team created a new operations infrastructure for the program to effectively implement and sustain improvement. Master trainers targeting teams caring for the patient population completed teamwork training and coaching. ICPs were designed and implemented using iterative tests of change with the assistance of an expert panel.

Results:

Three of the 4 units experienced a significant improvement in teamwork after training and coaching. The area without a significant change was one with high-level teamwork training already in place. ICPs were implemented in 2 patient subpopulations. We detected a decrease in total hours intubated using statistical process control charts in both of the ICP patient populations. Despite a decrease in intubation hours, we did not detect a reduction in length of stay in days. The infrastructure for the program was successfully implemented and remains in place 6 years later.

Conclusions:

Teamwork can be improved with an efficiently delivered training and coaching program. On a foundation of teamwork, ICPs can be implemented and sustained if a supporting infrastructure is in place including program leadership, buy-in from all teams, project management, and ongoing measurement.

3D Printing is a Transformative Technology in Congenital Heart Disease

Survival in congenital heart disease has steadily improved since 1938, when Dr. Robert Gross successfully ligated for the first time a patent ductus arteriosus in a 7-year-old child. To continue the gains made over the past 80 years, transformative changes with broad impact are needed in management of congenital heart disease. Three-dimensional printing is an emerging technology that is fundamentally affecting patient care, research, trainee education, and interactions among medical teams, patients, and caregivers. This paper first reviews key clinical cases where the technology has affected patient care. It then discusses 3-dimensional printing in trainee education. Thereafter, the role of this technology in communication with multidisciplinary teams, patients, and caregivers is described. Finally, the paper reviews translational technologies on the horizon that promise to take this nascent field even further.

Relationship between intraoperative non-technical performance and technical events in bariatric surgery

Background

The operating theatre is a unique environment with complex team interactions, where technical and non-technical performance affect patient outcomes. The correlation between technical and non-technical performance, however, remains underinvestigated. The purpose of this study was to explore these interactions in the operating theatre.

Methods

A prospective single-centre observational study was conducted at a tertiary academic medical centre. One surgeon and three fellows participated as main operators. All patients who underwent a laparoscopic Roux-en-Y gastric bypass and had the procedures captured using the Operating Room Black Box® platform were included. Technical assessment was performed using the Objective Structured Assessment of Technical Skills and Generic Error Rating Tool instruments. For non-technical assessment, the Non-Technical Skills for Surgeons (NOTSS) and Scrub Practitioners' List of Intraoperative Non-Technical Skills (SPLINTS) tools were used. Spearman rank-order correlation and N-gram statistics were conducted.

Results

Fifty-six patients were included in the study and 90 procedural steps (gastrojejunostomy and jejunojejunostomy) were analysed. There was a moderate to strong correlation between technical adverse events (rs = 0·417–0·687), rectifications (rs = 0·380–0·768) and non-technical performance of the surgical and nursing teams (NOTSS and SPLINTS). N-gram statistics showed that after technical errors, events and prior rectifications, the staff surgeon and the scrub nurse exhibited the most positive non-technical behaviours, irrespective of operator (staff surgeon or fellow).

Conclusion

This study demonstrated that technical and non-technical performances are related, on both an individual and a team level. Valuable data can be obtained around intraoperative errors, events and rectifications.

Frequency and Impact of Adverse Events in Inpatients: A Nationwide Analysis of Episodes between 2000 and 2015

Despite being a potential cause of morbidity and economic costs, adverse events remain insufficiently studied. Therefore, we aimed to assess the frequency and impact of adverse events among inpatients. We analysed an administrative database containing a registration of all hospitalisations occurring in Portuguese public hospitals between 2000 and 2015. We identified all episodes with a registration of adverse events, and classified them into three categories, namely (1) misadventures of surgical and medical care, (2) complications of surgical or medical procedures, and (3) adverse drug events (including adverse drug reactions, poisoning events, and late effects). These episodes were compared over their length of stay, in-hospital mortality, and hospital costs with an equal number of hospitalisations matched for patients' and episodes' characteristics. Between 2000 and 2015, 5.8% (n = 861,372) of all Portuguese hospitalisations had a registration of at least one adverse event. Hospitalisations with registration of adverse events had a median length of stay of 8 days, median hospitalisation costs of 3060.7 Euro, and an in-hospital mortality of 6.7%. Hospitalisations with registration of misadventures of care, complications of procedures and adverse drug reactions had significantly higher lengths of stay and hospitalisation costs than their matched controls. In-hospital mortality was significantly higher for episodes of misadventures of care and complications of procedures, but lower for adverse drug events hospitalisations. Therefore, adverse events are common among inpatients, and have an important clinical and economic impact. Administrative databases may be useful in their epidemiological assessment.

Classification and team response to nonroutine events occurring during pediatric trauma resuscitation

BACKGROUND

Errors directly causing serious harm are rare during pediatric trauma resuscitation, limiting the use of adverse outcome analysis for performance improvement in this setting. Errors not causing harm because of mitigation or chance may have similar causation and are more frequent than those causing adverse outcomes. Analyzing these error types is an alternative to adverse outcome analysis. The purpose of this study was to identify errors of any type during pediatric trauma resuscitation and evaluate team responses to their occurrence.

METHODS

Errors identified using video analysis were classified as errors of omission or commission and selection errors using input from trauma experts. The responses to error types and error frequency based on patient and event features were compared.

RESULTS

Thirty-nine resuscitations were reviewed, identifying 337 errors (range, 2-26 per resuscitation). The most common errors were related to cervical spine stabilization (n = 93, 27.6%). Errors of omission (n = 135) and commission (n = 106) were more common than errors of selection (n = 96). Although 35.9% of all errors were acknowledged and compensation occurred after 43.6%, no response (acknowledgement or compensation) was observed after 51.3% of errors. Errors of omission and commission were more often acknowledged (40.7% and 39.6% vs. 25.0%, p = 0.03 and p = 0.04, respectively) and compensated for (50.4% and 47.2% vs. 29.2%, p = 0.004 and p = 0.01, respectively) than selection errors. Response differences between errors of omission and commission were not observed. The number of errors and the number of high-risk errors that occurred did not differ based on patient or event features.

CONCLUSIONS

Errors are common during pediatric trauma resuscitation. Teams did not respond to most errors, although differences in team response were observed between error types. Determining causation of errors may be an approach for identifying latent safety threats contributing to adverse outcomes during pediatric trauma resuscitation.

LEVEL OF EVIDENCE

Therapeutic study, level III.

Role of human factors in pediatric cardiac surgery

According to the Institute of Healthcare Improvement, “human factors” refers to the discipline of engineering that details the interface of people, equipment and the environment in which they work. Issues that impact human performance and increase the risk of error include factors that directly enable decision making, such as perception, attention, memory, reasoning, judgement and factors that directly enable decision execution, such as communication and the ability to carry out the intended action. 

Improving patient safety through the involvement of patients: development and evaluation of novel interventions to engage patients in preventing patient safety incidents and protecting them against unintended harm

Background

Estimates suggest that, in NHS hospitals, incidents causing harm to patients occur in 10% of admissions, with costs to the NHS of > £2B. About one-third of harmful events are believed to be preventable. Strategies to reduce patient safety incidents (PSIs) have mostly focused on changing systems of care and professional behaviour, with the role that patients can play in enhancing the safety of care being relatively unexplored. However, although the role and effectiveness of patient involvement in safety initiatives is unclear, previous work has identified a general willingness among patients to contribute to initiatives to improve health-care safety.

Aim

Our aim in this programme was to design, develop and evaluate four innovative approaches to engage patients in preventing PSIs: assessing risk, reporting incidents, direct engagement in preventing harm and education and training.

Methods and results

We developed tools to report PSIs [patient incident reporting tool (PIRT)] and provide feedback on factors that might contribute to PSIs in the future [Patient Measure of Safety (PMOS)]. These were combined into a single instrument and evaluated in the Patient Reporting and Action for a Safe Environment (PRASE) intervention using a randomised design. Although take-up of the intervention by, and retention of, participating hospital wards was 100% and patient participation was high at 86%, compliance with the intervention, particularly the implementation of action plans, was poor. We found no significant effect of the intervention on outcomes at 6 or 12 months. The ThinkSAFE project involved the development and evaluation of an intervention to support patients to directly engage with health-care staff to enhance their safety through strategies such as checking their care and speaking up to staff if they had any concerns. The piloting of ThinkSAFE showed that the approach is feasible and acceptable to users and may have the potential to improve patient safety. We also developed a patient safety training programme for junior doctors based on patients who had experienced PSIs recounting their own stories. This approach was compared with traditional methods of patient safety teaching in a randomised controlled trial. The study showed that delivering patient safety training based on patient narratives is feasible and had an effect on emotional engagement and learning about communication. However, there was no effect on changing general attitudes to safety compared with the control.

Conclusion

This research programme has developed a number of novel interventions to engage patients in preventing PSIs and protecting them against unintended harm. In our evaluations of these interventions we have been unable to demonstrate any improvement in patient safety although this conclusion comes with a number of caveats, mainly about the difficulty of measuring patient safety outcomes. Reflecting this difficulty, one of our recommendations for future research is to develop reliable and valid measures to help efficiently evaluate safety improvement interventions. The programme found patients to be willing to codesign, coproduce and participate in initiatives to prevent PSIs and the approaches used were feasible and acceptable. These factors together with recent calls to strengthen the patient voice in health care could suggest that the tools and interventions from this programme would benefit from further development and evaluation.

Trial registration

Current Controlled Trials ISRCTN07689702.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

[Is human behavior the leading cause of complications in medical practice?]

Medical errors and the resulting complications are most often analyzed from a purely technical viewpoint. The impact of human behavior is very seldom raised among the major causes of severe undesirable events (SUE) in the medical field. When human responsibility is advanced, the thrust is always negative and critical, i.e. the "culprit" did not comply with the rules. However, in other risk-related human activities, such as aeronautics or the nuclear energy sector, the influence of human behavior in triggering SUEs has been examined and is now acknowledged to be one of the main causes of complications and problems. Specific protocols have been devised to reduce the number of mistakes made and to eliminate repercussions when errors inevitably occur. This novel approach has considerably reduced the accident rate in this type of industry. The aim of this article is to show that the same approach can be adopted in medicine and that taking human factors into account when analyzing medical practices can lead to significant improvements in safety and security.

Critical incidents, including cardiac arrest, associated with pediatric anesthesia at a tertiary teaching children's hospital

BACKGROUND

Analysis of critical incidents provides valuable information to improve the quality and safety of patient care. This study identified and analyzed pediatric anesthesia-related critical incidents including cardiac arrests in a tertiary teaching children's hospital.

METHODS

All pediatric anesthesia-related critical incidents reported in a voluntary departmental reporting system between January 2008 and August 2013 were included in the analysis. A critical incident was defined as (i) any incident that altered patients' vital signs and affected the management of patients while they were under the care of an anesthesiologist, and (ii) human factor: where patient injury or accidents were as a result of human error. Changes in vital signs that recovered spontaneously were excluded.

RESULTS

During the 6-year study period, a total of 229 critical incidents were reported from 49,373 anesthetic procedures. The most frequently reported incidents were associated with the respiratory system (55%), with tracheal tube-related events accounting for 40.9% of respiratory incidents followed by laryngospasm (17.3% of respiratory incidents). Cardiac arrest occurred in 42 cases in this study (8.5 cases per 10,000 anesthetics). Cardiovascular problems were the major causes of cardiac arrest (66.7%), and incidents of cardiogenic shock and hemorrhage/hypotension contributed equally to the cardiac arrest induced by cardiovascular problems (each 16.7%). Human factor-related events accounted for 58.5% of all critical incidents of which 53.7% were respiratory events.

CONCLUSION

Despite recent improvements in safety of pediatric anesthesia, many preventable factors still remain that can lead to critical incidents.

Assessing the Nontechnical Skills of Surgical Trainees: Views of the Theater Team

OBJECTIVE

This study aims to explore the views of members of theater teams regarding the proposed introduction of a workplace-based assessment of nontechnical skills of surgeons (NOTSS) into the Intercollegiate Surgical Curriculum Programme in the United Kingdom. In addition, the previous training and familiarity of the members of the surgical theater team with the concept and assessment of NOTSS would be evaluated.

DESIGN

A regional survey of members of theater teams (consultant surgeons, anesthetists, scrub nurses, and trainees) was performed at 1 teaching and 2 district general hospitals in South Yorkshire.

RESULTS

There were 160 respondents corresponding to a response rate of 81%. The majority (77%) were not aware of the NOTSS assessment tool with only 9% of respondents reporting to have previously used the NOTSS tool and just 3% having received training in NOTSS assessment. Overall, 81% stated that assessing NOTSS was as important as assessing technical skills. Trainees attributed less importance to nontechnical skills than the other groups (p ≤ 0.016). Although opinion appears divided as to whether the presence of a consultant surgeon in theater could potentially make it difficult to assess a trainee's leadership skills and decision-making capabilities, overall 60% agree that the routine use of NOTSS assessment would enhance safety in the operating theater and 80% agree that the NOTSS tool should be introduced to assess the nontechnical skills of trainees in theater. However, a significantly lower proportion of trainees (45%) agreed on the latter compared with the other groups (p = 0.001).

CONCLUSIONS

Our survey demonstrates acceptability among the theater team for the introduction of the NOTSS tool into the surgical curriculum. However, lack of familiarity highlights the importance of faculty training for assessors before such an introduction.

Application of the aviation black box principle in pediatric cardiac surgery: tracking all failures in the pediatric cardiac operating room

BACKGROUND

Cardiac surgical procedures are complex and require the coordinated action of many. This creates the potential for small failures that could be the substrate for subsequent morbidity or mortality. High-reliability science suggests that preoccupation with small failures can lead to improved outcomes.

STUDY DESIGN

Failures of all magnitudes (ie, events) were captured within the pediatric cardiac operating room starting with a single surgeon in April 2008. As the surgical team became more familiar with the process, failure recording was extended to all surgeons and all surgical procedures performed until the conclusion of the study in December 2010. New recording processes were developed and used on a rolling basis during this study.

RESULTS

With systematic capture, event rates increased (from occurring within 20% to 50% of operative procedures). Although we identified 9 recurrent patterns, 2 categories (ie, Equipment and Patient Instability) accounted for almost half of the events (45%). The greatest number of events occurred during the prebypass period (40.2%), compared with bypass (20.1%) and postbypass (32.3%) periods. These events were mainly difficulties in access (31.8%), equipment (42.4%), and patient instability (33.3%) in each of the epochs, respectively. Of all events, 7.3% occurred during nonbypass cases, 30.6% of these were communication events. Implementation of this initiative led to recognition of major system-wide issues (eg, need for change in the blood-product acquisition process).

CONCLUSIONS

Preoccupation with all failures in the operating room can reveal important information about the operating room and perioperative microenvironment that can prompt substantive process changes both locally and within the larger health system.

Technical performance score is associated with outcomes after the Norwood procedure

OBJECTIVES

The technical performance score (TPS) has been reported in a single center study to predict the outcomes after congenital cardiac surgery. We sought to determine the association of the TPS with outcomes in patients undergoing the Norwood procedure in the Single Ventricle Reconstruction trial.

METHODS

We calculated the TPS (class 1, optimal; class 2, adequate; class 3, inadequate) according to the predischarge echocardiograms analyzed in a core laboratory and unplanned reinterventions that occurred before discharge from the Norwood hospitalization. Multivariable regression examined the association of the TPS with interval to first extubation, Norwood length of stay, death or transplantation, unplanned postdischarge reinterventions, and neurodevelopment at 14 months old.

RESULTS

Of 549 patients undergoing a Norwood procedure, 356 (65%) had an echocardiogram adequate to assess atrial septal restriction or arch obstruction or an unplanned reintervention, enabling calculation of the TPS. On multivariable regression, adjusting for preoperative variables, a better TPS was an independent predictor of a shorter interval to first extubation (P=.019), better transplant-free survival before Norwood discharge (P<.001; odds ratio, 9.1 for inadequate vs optimal), shorter hospital length of stay (P<.001), fewer unplanned reinterventions between Norwood discharge and stage II (P=.004), and a higher Bayley II psychomotor development index at 14 months (P=.031). The TPS was not associated with transplant-free survival after Norwood discharge, unplanned reinterventions after stage II, or the Bayley II mental development index at 14 months.

CONCLUSIONS

TPS is an independent predictor of important outcomes after Norwood and could serve as a tool for quality improvement.

Checklist usage decreases critical task omissions when training residents to separate from simulated cardiopulmonary bypass

OBJECTIVE

Separation from cardiopulmonary bypass (CPB) requires multiple preparatory steps, during which mistakes, omissions, and human errors may occur. Checklists have been used extensively in aviation to improve performance of complex, multistep tasks. The aim of this study was to (1) develop a checklist using a modified Delphi process to identify essential steps necessary to prepare for separation from CPB, and (2) compare the frequency of completed items with and without the use of a checklist in simulation. It was hypothesized that the use of a checklist would reduce the number of omissions.

DESIGN

High-fidelity simulation study.

SETTING

University-affiliated tertiary care facility.

PARTICIPANTS

Seven cardiac anesthesiologists created a checklist using a modified Delphi process. Ten residents participated in 4 scenarios separating from CPB in simulation.

INTERVENTIONS

Each scenario was performed first without a checklist and then again with a checklist. An observer graded participants' performance.

MEASUREMENTS AND MAIN RESULTS

A pre-separation checklist containing 9 tasks was created using the Delphi process. Without using this checklist, 4 tasks were completed in at least 75% of scenarios, and 8 tasks were completed at least 75% of the time when using the checklist. There was a significant improvement in completion of 5 of the 9 items (p< 0.01).

CONCLUSIONS

A modified Delphi process can be used to create a checklist of steps in preparing to separate from CPB. Using this checklist during simulation resulted in increased frequency of completing designated tasks in comparison to relying on memory alone. Checklists may reduce omission errors during complex periods of anesthesiologists' perioperative workflow.

Outcomes differ in patients who undergo immediate intraoperative revision versus patients with delayed postoperative revision of residual lesions in congenital heart operations

OBJECTIVES

In a previous study of infants less than 6 month old, we found that delayed revision of residual lesions resulted in worse patient outcomes compared with intraoperative revision. We explored a larger cohort to determine if this finding persisted.

METHODS

A prospective cohort followed from index surgery to discharge from January 2011 to September 2013 were divided into 4 groups: (1) intraoperative revisions (IO) of residual lesions, (2) delayed postoperative revision (PO) of residual lesions during the same hospital stay, (3) both intraoperative and delayed (BOTH) revision of residual lesions, (4) no intraoperative or postoperative revision (NO). Linear and logistic regression analyses were used to compare outcomes of postoperative hospital length of stay, postoperative adverse events (AE), hospital costs, and mortality, after adjusting for age, prematurity, presence of extracardiac anomalies, and RACHS-1 (Risk Adjustment for Congenital Heart Surgery-1) risk category known to affect outcomes.

RESULTS

Of the 2427 patients discharged after a congenital cardiac operation, 1886 were eligible for this study after exclusion of adults, procedures performed off cardiopulmonary bypass, and transplants and assist devices. On multivariable modeling adjusting for other significant patient factors, the NO group fared better than the other 3 groups. The IO group had significantly lower postoperative length of stay, AE rate, and hospital costs compared with the PO and BOTH groups, but showed no significant differences in mortality.

CONCLUSIONS

Intraoperative correction of residual lesions results in shorter length of stay, and lower postoperative AE and costs compared with delayed postoperative revision of residual lesions.

Association between Technical Performance Scores and neurodevelopmental outcomes after congenital cardiac surgery

OBJECTIVES

Technical Performance Score (TPS) has been shown to have a strong association with early and late outcomes after congenital cardiac surgery, with greater morbidity and reintervention in children with major residual lesions (TPS class 3). We sought to explore the effect of TPS on the neurodevelopmental outcomes.

METHODS

All infants undergoing cardiac surgery, excluding those with trisomy 21, were offered neurodevelopmental testing at 1 year of age using the Bayley Scales of Infant Development, 3rd edition. TPSs from the discharge echocardiograms were graded as class 1 (optimal), class 2 (minor residual), or class 3 (major residual). Multivariate regression analysis was performed using patient characteristics and preoperative variables.

RESULTS

Neurodevelopmental testing was performed in 140 patients at a median age of 16 months. Of these, 28 (20%) had single ventricle palliation; 39 (28%) were in Risk Adjustment for Congenital Heart Surgery category 4 to 6. Significant differences between the groups were found in the cognitive (P = .01) and motor (P = .05) domains, with subjects in TPS class 3 having significantly lower cognitive and motor composite scores. The scores did not vary significantly according to single ventricle versus biventricular repair or Risk Adjustment for Congenital Heart Surgery categorization. In multivariate modeling, class 3 TPS remained significantly associated with a lower Bayley cognitive score (P = .02), with a trend toward a lower Bayley motor score (P = .08).

CONCLUSIONS

We found that TPS is an independent predictor of neurodevelopmental outcomes after infant heart surgery. Future research should explore whether a structured program of intraoperative recognition and intervention on residual lesions can improve the TPS and neurodevelopmental outcomes.

Technical Performance Scores are strongly associated with early mortality, postoperative adverse events, and intensive care unit length of stay-analysis of consecutive discharges for 2 years

OBJECTIVES

Previous work in our institution has indicated that the Technical Performance Score (TPS) is highly associated with early outcomes in select subsets of procedures and age groups. We hypothesized that the TPS could predict early outcomes in a wide range of diagnoses and age groups.

METHODS

Consecutive patients discharged from January 2011 to March 2013 were prospectively evaluated. The TPS was assigned according to the discharge echocardiographic findings and the need for reinterventions in the anatomic area of interest. Case complexity was determined using Risk Adjustment for Congenital Heart Surgery (RACHS-1) categories. Early mortality and postoperative adverse events were recorded. Relationships between the TPS and outcomes were assessed after adjusting for the baseline patient characteristics.

RESULTS

The median age of the 1926 patients was 1.8 years (range, 0 days to 68 years). Bypass was used in 1740 (90%); 322 (17%) were neonates, 520 (27%) infants, 873 (45%) children, 211 (11%) adults. TPS was class 1 (optimal) in 956 (50%), class 2 (adequate) in 584 (30%), and class 3 (inadequate) in 226 (12%); 160 patients (8%) could not be scored. A total of 51 early deaths (2.6%) and 111 adverse events (5.7%) occurred. On univariate analysis, age, RACHS-1 category, and TPS were significantly associated with mortality and the occurrence of adverse events. On multivariate modeling, class 3 (inadequate) TPS was strongly associated with mortality (odds ratio, 16.9; 95% confidence interval, 6.7-42.9; P < .001), adverse events (odds ratio, 6.9; 95% confidence interval, 4.1-11.6; P < .001), and postoperative intensive care unit length of stay (coefficient, 2.3; 95% confidence interval, 2.0-2.6; P < .001) after adjusting for other covariates.

CONCLUSIONS

The TPS is strongly associated with early outcomes across a wide range of ages and disease complexity and can serve as important tool for self-assessment and quality improvement.

Training faculty in nontechnical skill assessment: national guidelines on program requirements

OBJECTIVE

To develop guidelines for a faculty training program in nontechnical skill assessment in surgery.

BACKGROUND

Nontechnical skills in the operating room are critical for patient safety. The successful integration of these skills into workplace-based assessment is dependent upon the availability of faculty who are able to teach and assess them. At present, no guidelines exist regarding the training requirements for such faculty in surgical contexts.

METHODS

The development of the guidelines was carried out in several stages: stage 1-a detailed literature review on current training for nontechnical skill assessors; stage 2-semistructured interviews with a multidisciplinary panel (consisting of clinicians and psychologists/human factors specialists) of experts in surgical nontechnical skills; and stage 3-interview findings fed into an Expert Consensus Panel (ECP) Delphi approach to establish consensus regarding training requirements for faculty assessing nontechnical skills in surgery.

RESULTS

The ECP agreed that training in nontechnical skill assessment should be delivered by a multidisciplinary team consisting of clinicians and psychologists/human factors specialists. The ECP reached consensus regarding who should be targeted to be trained as faculty (including proficiency and revalidation requirements). Consensus was reached on 7 essential training program content elements (including training in providing feedback/debriefing) and 8 essential methods of evaluating the effectiveness of a "train-the-trainers" program.

CONCLUSIONS

This study provides evidence-based guidelines that can be used to guide the development and evaluation of programs to educate faculty in the training and assessment of nontechnical skills. Uptake of these guidelines could accelerate the development of surgical expertise required for safe and high-quality patient care.