Effective prevention of thromboembolic complications in emergency surgery patients using a quality improvement approach

Venous Thromboembolism Chemoprophylaxis in Trauma and Emergency General Surgery Patients: A Systematic Review

BACKGROUND

Appropriate venous thromboembolism (VTE) chemoprophylaxis in trauma and emergency general surgery (EGS) patients is crucial.

OBJECTIVE

The purpose of this study is to review the recent literature and offer recommendations for VTE chemoprophylaxis in trauma and EGS patients.

METHODS

We conducted a literature search from 2000 to 2021 for articles investigating VTE chemoprophylaxis in adult trauma and EGS patients. This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines.

RESULTS

Our search resulted in 34 articles. Most studies showed low-molecular-weight heparin (LMWH) is similar to unfractionated heparin (UFH) for VTE prevention; however, LMWH was more commonly used. Adjusted chemoprophylaxis dosing did not change the VTE rate but the timing did. Direct oral anticoagulants (DOACs) have been shown to be safe and effective in trauma and traumatic brain injury (TBI)/spinal cord injury (SCI). Studies showed VTE prophylaxis in EGS can be inconsistent and improves with guidelines that lower VTE events.

CONCLUSIONS

There may be no benefit to receiving LMWH over UFH in trauma patients. In addition, different drugs under the class of LMWH do not change the incidence of VTE. Adjusted dosing of enoxaparin does not seem to affect VTE incidence. The use of DOACs in the trauma TBI and SCI setting has been shown to be safe and effective in reducing VTE. One important consideration with VTE prophylaxis may be the timing of prophylaxis initiation, specifically as it relates to TBI, with a higher likelihood of developing VTE as time progresses. EGS patients are at a high risk of VTE. Improved compliance with clinical guidelines in this population is correlated with decreased thrombotic events.

Computer algorithm compared with routine clinical practice in screening for deep venous thrombosis in the leg in an emergency department

OBJECTIVE

To audit routine clinical practice in screening patients admitted to an accident and emergency department for deep venous thrombosis in the leg (DVT) and compare it with a computer algorithm.

DESIGN

Retrospective study of case notes with data subsequently entered into a computer algorithm followed by a comparison of the diagnosis and recommended management from each modality.

SETTING

Emergency department at a London teaching hospital.

POPULATION OR SAMPLE

A convenience sample of 43 patients attending the emergency department.

METHODS

Evaluation of clinical notes for completeness of assessment and correct diagnosis; entry of the same data into the computer algorithm.

MAIN OUTCOME MEASURES

Completeness of data collection, diagnosis of presence or absence of DVT, and recommended therapy.

RESULTS

The Wells score was missing in the clinical evaluation in 60% of cases. Clinicians relied primarily on the results of ultrasound scans and in six cases the absence of required D-Dimer measurements meant that the algorithm stalled. Clinical and algorithm analysis and recommendations were not compliant in 10 cases (23%).

CONCLUSIONS

Clinical assessment of potential DVT in the accident and emergency department is poorly performed when compared with a computerised algorithm. Clinicians rely heavily on scan reports rather than clinical assessment which may have cost implications.

Implementation of a seven-day hospitalist program to improve the outcomes of the weekend admission: A retrospective before-after study in Taiwan

Objective

Patients admitted during weekends may have worse outcomes than those during weekdays. Adjusting the practice of senior physicians over weekends may reduce the weekend effect.

Design

A controlled before-after study, with propensity score matching (PSM) for potential confounding variables, to compare outcomes between weekday and weekend admissions.

Setting

A 2000-bed medical centre in Taiwan

Participants

Hospitalised general medicine patients cared for by traditional internal medicine teams (pre-intervention cohort) and those cared for by hospitalists after introducing a seven-day hospitalist program in the first six-month (post-intervention cohort) and following three-year periods.

Main outcome measures

Proportion of intensive care unit (ICU) admissions, cardiopulmonary resuscitation (CPR) events, and in-hospital mortality.

Results

The pre-intervention cohort included 982 patients. Significantly higher mortality rates (11.3% vs. 6.2%, p = 0.032) were recorded in the case of weekend admissions, with similar proportions of ICU admission and CPR events. The post-intervention cohort included 601 patients. No significant difference was recorded in any of the main outcomes between weekday and weekend admissions. PSM for pre-intervention and post-intervention cohort showed shorter LOS after intervention, with no difference in ICU admission, CPR, and morality for the weekday and weekend admissions, respectively. The three-year cohort that followed, consisting of 3315 patients, showed no difference of outcomes between weekday and weekend admissions. After PSM, there were no significant differences in ICU admission rates (1.0% vs. 1.8%), CPR (0.3% vs. 0.2%) events and hospital mortality rates (8.1% vs. 8.5%), when weekday and weekend admissions were compared.

Conclusions

The seven-day hospitalist program shows potential in providing equally safe care for both weekday and weekend general medicine admissions with sustainable development.

Safer delivery of surgical services: a programme of controlled before-and-after intervention studies with pre-planned pooled data analysis

Background

High rates of iatrogenic harm have been confirmed in observational studies of surgery. Most interventions designed to reduce this have been targeted at either workplace culture or operational systems. We hypothesised that an integrated intervention addressing both culture and system might be more effective than either approach alone.

Objective

To evaluate interventions designed to improve surgical team performance by impacting culture or systems in isolation or combination.

Design

Five controlled intervention experiments, addressing system, culture or both, were performed in operating theatres. A final whole-system intervention study integrated approaches that showed benefit in these experiments. The five linked studies were subjected to a pre-planned pooled analysis to identify the effects of interventions, combinations and confounders. A qualitative interview study provided explanatory data on the mechanisms of intervention success and failure. An economic analysis was conducted.

Setting

Operating theatres in five hospitals, performing orthopaedic, trauma, vascular and plastic surgery were used for the linked studies. The final study occurred in a tertiary referral neurosurgery unit.

Participants

The main study subjects were clinical staff. Patient outcomes, both clinical and patient reported, were collected as secondary outcome measures.

Interventions

The interventions tested were (1) teamwork training (TT) based on the aviation crew resource management model, (2) the development of a set of standard operating procedures (SOPs), (3) a safety improvement programme based on lean principles, (4) TT plus SOPs and (5) TT plus lean. The final intervention used elements of all three strategies.

Main outcome measures

Primary outcomes were team non-technical skills [as measured by the Oxford Non-Technical Skills (NOTECHS) II scale score] and team technical performance (via the ‘glitch count’). Secondary outcomes were compliance with the World Health Organization (WHO)’s checklist procedures, patient length of stay, readmissions, 30-day mortality, complications and patient-reported outcome measures [as measured by the European Quality of Life-5 Dimensions (EQ-5D)]. A qualitative interview study provided explanatory data on the mechanisms of intervention success and failure. An economic analysis was conducted.

Data sources

Direct observation of whole operations, clinical records, hospital information systems and EQ-5D questionnaires. The qualitative study used semistructured interviews.

Statistical methods

Individual studies were analysed using two-way analysis of variance, and an overall individual patient pooled analysis was performed. Methods validation studies and other analyses used chi-squared test, correlation and regression methods as appropriate.

Results

We studied 453 operations. The results of single interventions were inconsistent. TT alone improved non-technical skills and WHO compliance (p < 0.001) but not technical performance, whereas the systems interventions (lean and SOP) improved non-technical skills and technical performance (p < 0.001), but were less effective in improving WHO compliance. The integrated intervention approaches improved all aspects of team performance except time-out attempt rate, whereas the single approaches were significantly poorer at improving checklist compliance (p < 0.001) and failed to improve glitch rate. Combining all three strategies did not increase the percentage of successful projects. The qualitative analysis confirmed that integrated interventions better addressed the breadth of challenges that face surgical safety but also indicated that differences in implementation between integrated- and single-intervention studies amplified their differential effect.

Conclusions

A combination of TT plus systems improvement training appears more effective in improving team performance than either approach alone. An implementation strategy based on an understanding of the barriers to change in hospitals is important for success.

Future work

More work is required to understand and measure barriers to safety improvement. Implementation strategies need to be tested empirically. Methods for delivering integrated interventions on a larger scale need development. A cluster randomised trial of the integrated-systems/culture-improvement approach is warranted.

Funding

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

Compliance and Effectiveness of WHO Surgical Safety Check list: A JPMC Audit

Objective:

To assess World Health Organization (WHO) Surgical Safety Checklist (SSC), compliance and its effectiveness in reducing complications and final outcome of patients.

Methods:

This was a prospective study done in Department of General Surgery (Ward 02), Jinnah Postgraduate Medical Centre (JPMC), Karachi. The study included Total 3638 patients who underwent surgical procedure in elective theatre in four years from November 2011 to October 2015 since the SSC was included as part of history sheets in ward. Files were checked to confirm the compliance with regards to filling the three stage checklist properly and complications were noted.

Results:

In 1st year, out of 840 surgical procedures, SSC was properly marked in 172 (20.4%) cases. In 2nd year, out of 857 surgical procedures 303 (35.3%) cases were marked which increased in 3rd year out of 935 surgical procedures 757 (80.9%) cases and in 4th year out of 932 surgical procedures 838 (89.9%) cases were marked. No significant change in site and side (left or right) complications were noted in all four years. Surgical Site Infection (SSI) was noted in 59 (7.50%), 52 (6.47%), 44 (4.70%) and 20 (2.12%) cases in 1st, 2nd, 3rd and 4th year respectively. SSI in laparoscopic cholecystectomies was 41 (20.8 %), 45 (13%), 20 (5.68%) and 4 (1.12%) in 1st, 2nd, 3rd and 4th year respectively. No significant change in chest complications were noted in all four years. Mortality rate also remained same in all four years.

Conclusion:

WHO SSC is an effective tool in reducing in-hospital complications thus producing a favorable outcome. Realization its efficacy would improve compliance.

Lean Participative Process Improvement: Outcomes and Obstacles in Trauma Orthopaedics

Objectives

To examine the effectiveness of a “systems” approach using Lean methodology to improve surgical care, as part of a programme of studies investigating possible synergy between improvement approaches.

Setting

A controlled before-after study using the orthopaedic trauma theatre of a UK Trust hospital as the active site and an elective orthopaedic theatre in the same Trust as control.

Participants

All staff involved in surgical procedures in both theatres.

Interventions

A one-day “lean” training course delivered by an experienced specialist team was followed by support and assistance in developing a 6 month improvement project. Clinical staff selected the subjects for improvement and designed the improvements.

Outcome Measures

We compared technical and non-technical team performance in theatre using WHO checklist compliance evaluation, “glitch count” and Oxford NOTECHS II in a sample of directly observed operations, and patient outcome (length of stay, complications and readmissions) for all patients. We collected observational data for 3 months and clinical data for 6 months before and after the intervention period. We compared changes in measures using 2-way analysis of variance.

Results

We studied 576 cases before and 465 after intervention, observing the operation in 38 and 41 cases respectively. We found no significant changes in team performance or patient outcome measures. The intervention theatre staff focused their efforts on improving first patient arrival time, which improved by 20 minutes after intervention.

Conclusions

This version of “lean” system improvement did not improve measured safety processes or outcomes. The study highlighted an important tension between promoting staff ownership and providing direction, which needs to be managed in “lean” projects. Space and time for staff to conduct improvement activities are important for success.

The Safer Delivery of Surgical Services Program (S3): Explaining Its Differential Effectiveness and Exploring Implications for Improving Quality in Complex Systems

OBJECTIVE

To analyze the challenges encountered during surgical quality improvement interventions, and explain the relative success of different intervention strategies.

SUMMARY BACKGROUND DATA

Understanding why and how interventions work is vital for developing improvement science. The S3 Program of studies tested whether combining interventions addressing culture and system was more likely to result in improvement than either approach alone. Quantitative results supported this theory. This qualitative study investigates why this happened, what aspects of the interventions and their implementation most affected improvement, and the implications for similar programs.

METHODS

Semistructured interviews were conducted with hospital staff (23) and research team members (11) involved in S3 studies. Analysis was based on the constant comparative method, with coding conducted concurrently with data collection. Themes were identified and developed in relation to the program theory behind S3.

RESULTS

The superior performance of combined intervention over single intervention arms appeared related to greater awareness and ability to act, supporting the S3 hypothesis. However, we also noted unforeseen differences in implementation that seemed to amplify this difference. The greater ambition and more sophisticated approach in combined intervention arms resulted in requests for more intensive expert support, which seemed crucial in their success. The contextual challenges encountered have potential implications for the replicability and sustainability of the approach.

CONCLUSIONS

Our findings support the S3 hypothesis, triangulating with quantitative results and providing an explanatory account of the causal relationship between interventions and outcomes. They also highlight the importance of implementation strategies, and of factors outside the control of program designers.

Quality Improvement in Surgery Combining Lean Improvement Methods with Teamwork Training: A Controlled Before-After Study

BACKGROUND

To investigate the effectiveness of combining teamwork training and lean process improvement, two distinct approaches to improving surgical safety. We conducted a controlled interrupted time series study in a specialist UK Orthopaedic hospital incorporating a plastic surgery team (which received the intervention) and an Orthopaedic theatre team acting as a control.

STUDY DESIGN

We used a 3 month intervention with 3 months data collection period before and after it. A combined teamwork training and lean process improvement intervention was delivered by an experienced specialist team. Before and after the intervention we evaluated team non-technical skills using NOTECHS II, technical performance using the glitch rate and WHO checklist compliance using a simple 3 point scale. We recorded complication rate, readmission rate and length of hospital stay data for 6 months before and after the intervention.

RESULTS

In the active group, but not the control group, full compliance with WHO Time Out (T/O) increased from 14 to 71% (p = 0.032), Sign Out attempt rate (S/O) increased from 0% to 50% (p<0.001) and Oxford NOTECHS II scores increased after the intervention (P = 0.058). Glitch rate decreased in the active group and increased in the control group (p = 0.001). Complications and length of stay appeared to rise in the control group and fall in the active group.

CONCLUSIONS

Combining teamwork training and systems improvement enhanced both technical and non-technical operating team process measures, and were associated with a trend to better safety outcome measures in a controlled study comparison. We suggest that approaches which address both system and culture dimensions of safety may prove valuable in reducing risks to patients.

A qualitative study comparing experiences of the surgical safety checklist in hospitals in high-income and low-income countries

OBJECTIVE

Bold claims have been made for the ability of the WHO surgical checklist to reduce surgical morbidity and mortality and improve patient safety regardless of the setting. Little is known about how far the challenges faced by low-income countries are the same as those in high-income countries or different. We aimed to identify and compare the influences on checklist implementation and compliance in the UK and Africa.

DESIGN

Ethnographic study involving observations, interviews and collection of documents. Thematic analysis of the data.

SETTING

Operating theatres in one African university hospital and two UK university hospitals.

PARTICIPANTS

112 h of observations were undertaken. Interviews with 39 theatre and administrative staff were conducted.

RESULTS

Many staff saw value in the checklist in the UK and African hospitals. Some resentment was present in all settings, linked to conflicts between the philosophy behind the checklist and the realities of local cultural, social and economic contexts. Compliance-involving use, completeness and fidelity-was considerably higher, though not perfect, in the UK settings. In these hospitals, compliance was supported by established structures and systems, and was not significantly undermined by major resource constraints; the same was not true of the low-income context. Hierarchical relationships were a major barrier to implementation in all settings, but were more marked in the low-income setting. Introducing a checklist in a professional environment characterised by a lack of accountability and transparency could make the staff feel jeopardised legally, professionally, and personally, and it encouraged them to make misleading records of what had actually been done.

CONCLUSIONS

Surgical checklist implementation is likely to be optimised, regardless of the setting, when used as a tool in multifaceted cultural and organisational programmes to strengthen patient safety. It cannot be assumed that the introduction of a checklist will automatically lead to improved communication and clinical processes.