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Teunissen C, Burrell B, Maskill V. Effective Surgical Teams: An Integrative Literature Review. West J Nurs Res 2019; 42:61-75. [PMID: 30854942 DOI: 10.1177/0193945919834896] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
It is imperative to understand the factors that contribute to effective surgical teams. The aim of this integrative review was to evaluate the aids and barriers for perioperative teams in functioning effectively, preventing adverse events, and fostering a culture of safety. The literature search was undertaken of 15 databases, which resulted in 70 articles being included. It was found perioperative teamwork was not widely understood. Findings indicated barriers to effective surgical teams comprised of confusion in tasks and responsibilities, existing hierarchies and prevailing misconceptions and understanding among team members. Although numerous quality initiatives exist, the introduction of protocols and checklists, team effectiveness in the perioperative setting is still insufficient and challenges in establishing effective surgical teams continue. Further research is recommended to obtain a comprehensive perception of environmental influences and barriers surgical teams encounter in the delivery of safe quality care.
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Martin BI, Mirza SK, Flum DR, Wickizer T, Heagerty PJ, Lenkoski A, Deyo RA. Repeat surgery after lumbar decompression for herniated disc: the quality implications of hospital and surgeon variation. Spine J 2012; 12:89-97. [PMID: 22193055 PMCID: PMC3299929 DOI: 10.1016/j.spinee.2011.11.010] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2011] [Revised: 08/30/2011] [Accepted: 11/15/2011] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Repeat lumbar spine surgery is generally an undesirable outcome. Variation in repeat surgery rates may be because of patient characteristics, disease severity, or hospital- and surgeon-related factors. However, little is known about population-level variation in reoperation rates. PURPOSE To examine hospital- and surgeon-level variation in reoperation rates after lumbar herniated disc surgery and to relate these to published benchmarks. STUDY DESIGN/SETTING Retrospective analysis of a discharge registry including all nonfederal hospitals in Washington State. METHODS We identified adults who underwent an initial inpatient lumbar decompression for herniated disc from 1997 to 2007. We then performed generalized linear mixed-effect logistic regressions, controlling for patient characteristics and comorbidity, to examine the variation in reoperation rates within 90 days, 1 year, and 4 years. RESULTS Our cohort included 29,529 patients with a mean age of 47.5 years, 61% privately insured, and 15% having any comorbidity. The age-, sex-, insurance-, and comorbidity-adjusted mean rate of reoperation among hospitals was 1.9% at 90 days (95% confidence interval [CI], 1.2-3.1), with a range from 1.1% to 3.4%; 6.4% at 1 year (95% CI, 3.9-10.6), with a range from 2.8% to 12.5%; and 13.8% at 4 years (95% CI, 8.8-19.8), with a range from 8.1% to 24.5%. The adjusted mean reoperation rates of surgeons were 1.9% at 90 days (95% CI, 1.4-2.4) with a range from 1.2% to 4.6%, 6.1% at 1 year (95% CI, 4.8-7.7) with a range from 4.3% to 10.5%, and 13.2% at 4 years (95% CI, 11.3-15.5) with a range from 10.0% to 19.3%. Multilevel random-effect models suggested that variation across surgeons was greater than that of hospitals and that this effect increased with long-term outcomes. CONCLUSIONS Even after adjusting for patient demographics and comorbidity, we observed a large variation in reoperation rates across hospitals and surgeons after lumbar discectomy, a relatively simple spinal procedure. These findings suggest uncertainty about indications for repeat surgery, variations in perioperative care, or variations in quality of care.
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Affiliation(s)
- Brook I. Martin
- Department of Orthopaedics, HB7541; Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756-0001,
| | - Sohail K. Mirza
- Department of Orthopaedics, HB7541, Dartmouth-Hitchcock Medical Center,
| | - David R. Flum
- Surgery; Adjunct Professor Public Health, University of Washington,
| | | | | | - Alex Lenkoski
- Postdoctoral Research Fellow, Institute for Applied Mathematics, Heidelberg University,
| | - Richard A. Deyo
- Kaiser Center for Health Research, Departments of Family Medicine and Internal Medicine, Oregon Health and Science University,
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Weber RS, Lewis CM, Eastman SD, Hanna EY, Akiwumi O, Hessel AC, Lai SY, Kian L, Kupferman ME, Roberts DB. Quality and performance indicators in an academic department of head and neck surgery. ACTA ACUST UNITED AC 2011; 136:1212-8. [PMID: 21173370 DOI: 10.1001/archoto.2010.215] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE to create a method for assessing physician performance and care outcomes that are adjusted for procedure acuity and patient comorbidity. DESIGN between 2004 and 2008 surgical procedures performed by 10 surgeons were stratified into high-acuity procedures (HAPs) and low-acuity procedures (LAPs). Risk adjustment was made for comorbid conditions examined singly or in groups of 2 or more. SETTING a tertiary care medical center. PATIENTS a total of 2618 surgical patients. MAIN OUTCOME MEASURES performance measures included length of stay; return to operating room within 7 days of surgery; and the occurrence of mortality, hospital readmission, transfusion, and wound infection within 30 days of surgery. RESULTS the transfusion rate was 2.7% and 40.6% for LAPs and HAPs, respectively. Wound infection rates were 1.4% for LAPs vs 14.1% for HAPs, while 30-day mortality rate was 0.3% and 1.6% for LAPs and HAPs, respectively. The mean (SD) hospital stay for LAPs was 2.1 (3.6) vs 10.5 (7.0) days for HAPs. Negative performance factors were significantly higher for patients who underwent HAPs and had comorbid conditions. Differences among surgeons significantly affect the incidence of negative performance indicators. Factors affecting performance measures were procedure acuity, the surgeon, and comorbidity, in order of decreasing significance. Surgeons were ranked low, middle, and high based on negative performance indicators. CONCLUSIONS performance measures following oncologic procedures were significantly affected by comorbid conditions and by procedure acuity. Although the latter most strongly affects quality and performance indicators, both should weigh heavily in physician comparisons. The incidence of negative performance indicators was also influenced by the individual surgeon. These data may serve as a tool to evaluate and improve physician performance and outcomes and to develop risk-adjusted benchmarks. Ultimately, reimbursement may be tied to quantifiable measures of physician and institutional performance.
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Affiliation(s)
- Randal S Weber
- Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1445, Houston, TX 77030, USA.
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Joshi GP, Chung F, Vann MA, Ahmad S, Gan TJ, Goulson DT, Merrill DG, Twersky R. Society for Ambulatory Anesthesia consensus statement on perioperative blood glucose management in diabetic patients undergoing ambulatory surgery. Anesth Analg 2010; 111:1378-87. [PMID: 20889933 DOI: 10.1213/ane.0b013e3181f9c288] [Citation(s) in RCA: 159] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Optimal evidence-based perioperative blood glucose control in patients undergoing ambulatory surgical procedures remains controversial. Therefore, the Society for Ambulatory Anesthesia has developed a consensus statement on perioperative glycemic management in patients undergoing ambulatory surgery. A systematic review of the literature was conducted according the protocol recommended by the Cochrane Collaboration. The consensus panel used the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system for providing suggestions. It was revealed that there is insufficient evidence to provide strong recommendations for the posed clinical questions. In the absence of high-quality evidence, recommendations were based on general principles of blood glucose control in diabetics, drug pharmacology, and data from inpatient surgical population, as well as clinical experience and judgment. In addition, areas of further research were also identified.
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Affiliation(s)
- Girish P Joshi
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390-9068, USA.
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Wiegmann DA, Eggman AA, Elbardissi AW, Parker SH, Sundt TM. Improving cardiac surgical care: a work systems approach. APPLIED ERGONOMICS 2010; 41:701-12. [PMID: 20202623 PMCID: PMC2879339 DOI: 10.1016/j.apergo.2009.12.008] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2008] [Accepted: 09/30/2009] [Indexed: 05/11/2023]
Abstract
Over the past 50 years, significant improvements in cardiac surgical care have been achieved. Nevertheless, surgical errors that significantly impact patient safety continue to occur. In order to further improve surgical outcomes, patient safety programs must focus on rectifying work system factors in the operating room (OR) that negatively impact the delivery of reliable surgical care. The goal of this paper is to provide an integrative review of specific work system factors in the OR that may directly impact surgical care processes, as well as the subsequent recommendations that have been put forth to improve surgical outcomes and patient safety. The important role that surgeons can play in facilitating work system changes in the OR is also discussed. The paper concludes with a discussion of the challenges involved in assessing the impact that interventions have on improving surgical care. Opportunities for future research are also highlighted throughout the paper.
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Affiliation(s)
- Douglas A Wiegmann
- Department of Industrial and Systems Engineering, 1513 University Ave, 3214 Mechanical Engineering Bldg, University of Wisconsin-Madison, Madison, WI 53706, USA.
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The relationship between glycosylated hemoglobin and perioperative glucose control in patients with diabetes. Can J Anaesth 2010; 57:322-9. [PMID: 20127531 DOI: 10.1007/s12630-010-9266-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2009] [Accepted: 01/07/2010] [Indexed: 01/04/2023] Open
Abstract
PURPOSE Hyperglycemia and elevated glycosylated hemoglobin (HbA(1c)) are associated with perioperative morbidity in patients with diabetes, but the relationship between long-term glycemic control and perioperative glucose control is unknown. The purpose of this study was to determine the relationship between glycosylated hemoglobin (HbA(1c)) and perioperative glucose in fasting patients with type 2 diabetes undergoing elective non-cardiac surgery. METHODS This was a prospective observational study of 244 adult patients with type 2 diabetes who were evaluated before elective non-cardiac surgery at a preoperative medicine clinic in a tertiary care medical centre during the period September 2004 to May 2005. Preoperative HbA(1c) levels were determined, and preoperative and postoperative glucose values were measured on the day of surgery. The primary outcome variables were preoperative and postoperative blood glucose values. RESULTS Half of all study patients had an HbA(1c) > or = 7%, including 23% of patients with HbA(1c) >/= 8%. HbA(1c) levels predict preoperative glucose levels, and preoperative glucose levels and duration of surgery predict postoperative glucose levels. Glucose levels in one-third of the patients with type 2 diabetes decreased during surgery without administration of insulin or glucose-regulating medications. CONCLUSION HbA(1c) values may serve as biomarkers for glucose control during the immediate perioperative period in patients with type 2 diabetes undergoing elective surgery.
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Qadan M, Tyson M, McCafferty MH, Hohmann SF, Polk HC. Venous thromboembolism in elective operations: balancing the choices. Surgery 2008; 144:654-60, discussion 660-1. [PMID: 18847651 DOI: 10.1016/j.surg.2008.06.019] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2008] [Accepted: 06/19/2008] [Indexed: 11/17/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) is a recognized cause of morbidity and mortality in hospitalized patients and is reported to account for 250,000 deaths annually. Recent shifts in prophylaxis administration are occurring among surgical specialty groups after observing a lower rate of VTE among patients undergoing elective operation. We report the incidence of VTE from 3 sources to provide an estimate of the true risk of the complication in elective surgery. METHODS Data from the Surgical Care Improvement Project (SCIP), University HealthSystem Consortium (UHC), and Kentucky Cabinet for Health and Family Services (CHFS) databases were queried for 2004 for the same operative patient groups. RESULTS Of 5,285 operations performed within SCIP 2004, the incidences of deep venous thrombosis (DVT) and pulmonary embolus (PE) were 0.4% and 0.3%, respectively, with no reported deaths. Of 966,474 operations recorded in the UHC 2004 data, rates of DVT and PE were 1.2% and 0.5%, respectively. The incidence rates of DVT and PE among 20,563 patients in the CHFS 2004 database were 0.5% and 0.3%, respectively, and included 3 deaths. CONCLUSION VTE and associated mortality rates are extremely low in these 3 large data sources. We believe patients will benefit from an ongoing assessment of real need and complications of carefully risk-adjusted VTE prophylaxis.
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Affiliation(s)
- Motaz Qadan
- Price Institute of Surgical Research, Department of Surgery, University of Louisville School of Medicine, Louisville, KY 40292, USA
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Patient-Centered Quality Indicators for Pulmonary Resection. Ann Thorac Surg 2008; 86:927-32. [DOI: 10.1016/j.athoracsur.2008.04.021] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2007] [Revised: 04/08/2008] [Accepted: 04/09/2008] [Indexed: 11/18/2022]
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Polk HC, Mccafferty MH, Mahid SS, Naidu DK, Lewis JN. Attitudes of Surgical Specialists toward Venous Thromboembolism Prophylaxis in Surgical Patients. Am Surg 2008; 74:189-94. [DOI: 10.1177/000313480807400301] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Venous thromboembolism (VTE) and pulmonary embolism are serious and potentially life-threatening complications in surgical patients; however, the risk can effectively be lessened using appropriate pharmaceutical and mechanical prophylaxis. Due to the variability in opinions and indications for VTE prophylaxis, proposed guidelines for VTE prophylaxis stratified according to patient- and procedure-oriented risk factors were widely circulated. We investigated to what extent these guidelines were accepted by 147 university and community-based surgeons in mid-America and how the recommendations for prophylaxis compared with recent past surgical practice performed on 5285 patients in Kentucky in 2004. Attitudes varied widely with respect to practice sites, modes, and specialty. Actual practices used in the Surgical Care Improvement Project 2004 varied even more widely and were at substantial variance from recommendations and current Centers for Medicare and Medicaid Services quality measures.
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Affiliation(s)
- Hiram C. Polk
- Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky
- University of Louisville Hospital, Louisville, Kentucky
- Price Institute of Surgical Research, Louisville, Kentucky
- Quality Surgical Solutions, P.L.L.C., Louisville, Kentucky; and
| | - Michael H. Mccafferty
- Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky
- University of Louisville Hospital, Louisville, Kentucky
- Quality Surgical Solutions, P.L.L.C., Louisville, Kentucky; and
| | - Suhal S. Mahid
- Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky
- University of Louisville Hospital, Louisville, Kentucky
| | - Deepak K. Naidu
- Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky
- University of Louisville Hospital, Louisville, Kentucky
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Chandawarkar RY. The Pied Piper of Hamelin. Plast Reconstr Surg 2007; 119:1365-1366. [PMID: 17496614 DOI: 10.1097/01.prs.0000254799.73824.09] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Rajiv Y Chandawarkar
- Farmington, Conn. From the Division of Plastic Surgery and Center for Immunotherapy, University of Connecticut School of Medicine
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Altpeter T, Luckhardt K, Lewis JN, Harken AH, Polk HC. Expanded Surgical Time Out: A Key to Real-Time Data Collection and Quality Improvement. J Am Coll Surg 2007; 204:527-32. [PMID: 17382210 DOI: 10.1016/j.jamcollsurg.2007.01.009] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2006] [Accepted: 01/03/2007] [Indexed: 11/25/2022]
Abstract
UNLABELLED Some of the concepts contained here have been discussed and incorporated in another publication, but the data are entirely unique to this manuscript. (See: Transforming the Surgical "Time-Out" Into a Comprehensive "Preparatory Pause." Backster A, Teo A, Swift M, MD, Polk HC Jr, MD, FACS, Harken AH, MD, FACS. J Cardiac Surg, in press.) BACKGROUND The increasing push for quality improvement coincides with the slowly growing use of surgical time out (STO) to lessen the likelihood of wrong-site operation. We believe that the use of STO as a reflective pause or a preoperative briefing has broader value. The purpose of this article is to describe one institution's experience with this technique and to validate its potential use by others. STUDY DESIGN An enhanced use of STO was conducted in a 400-bed teaching hospital in calendar year 2006. Before and after conducts and constructs were rated. RESULTS The institution found the technique to be of value, and substantially clarified and improved its performances with respect to prophylactic antibiotic choice and timing; appropriate maintenance of intraoperative temperature and glycemia; and institution of secondary issues, such as maintenance of beta-blockade and appropriate venous thromboembolism prophylaxis. Surgeon leadership and real-time data collection became essential and helpful components. CONCLUSIONS Prompt feedback to surgeons is vital; identification of future targets for performance improvement is feasible, although useless measures are eliminated. Because surgeons grapple with pay-for-performance, STO is a useful safety, data, and quality improvement tool.
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Affiliation(s)
- Terry Altpeter
- University of Louisville Hospital, Department of Surgery, University of Louisville School of Medicine and Quality, Louisville, KY 40292, USA
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Abstract
In its 2000 report, To Err is Human, the Institute of Medicine concluded that between 44,000 and 98,000 deaths per year occur in United States hospitals as a result of error. These data have resulted in calls for further research, regulatory interventions, third-party payer involvement, and health care organization initiatives to improve this situation. Studies of pediatric inpatients suggest that medication-related harm occurs at a rate as high as 11.1 per 100 admissions, and hospital-related harm occurs in high risk neonatal ICUs at a rate of 74 per 100 admissions. This article discusses differences between error and harm, methods used to measure harm, and available evidence that identifies the incidence of adverse events in pediatric inpatients and outpatients.
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Affiliation(s)
- Paul J Sharek
- Division of General Pediatrics, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA 94070, USA.
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Abstract
Modern medical practice, and particularly that within the hospital environment, has been under intense scrutiny in an attempt to improve patient safety and optimize outcomes. Anesthesiology has been cited as among the most successful specialties effecting improvements. According to the Institute of Medicine's 1999 report, To Err is Human, “… anesthesiology has successfully reduced anesthesia mortality rates from two deaths per 10,000 anesthetics administered, to one death per 200,000 to 300,000 anesthetics administered.” The current report reviews representative highlights from 30 years of progress in improving anesthesiology safety and offers a speculative synthesis of the factors critical to past and future successes. The seven identified points include 1) the emergence of a champion and his allies, 2) initial efforts to identify and quantify broad-reaching problems, 3) research addressing intellectually “amusing” problems of relevance to practitioners, 4) reaching out to others with focused expertise in problem prevention and problem solving, 5) sharing the responsibility for quality and safety improvement with other specialties, 6) expanding buy-in and participation within the anesthesia community, and 7) preparing for the future. The factors provide not only an accounting of anesthesiologists’ successes, but also a road map for other groups and specialties desiring to emulate the anesthesiologists’ experience.
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Affiliation(s)
- William L Lanier
- Department of Anesthesiology, Mayo Clinic College of Medicine, Rochester, Minnesota 55905, USA
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Malangoni MA, Cheadle WG, Dodson TF, Dohmen PMCE, Jones D, Katariya K, Kolvekar S, Urban JA. New Opportunities for Reducing Risk of Surgical Site Infection. Surg Infect (Larchmt) 2006; 7 Suppl 1:S23-39. [PMID: 16834544 DOI: 10.1089/sur.2006.7.s1-23] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Mark A Malangoni
- Case Western Reserve University, School of Medicine, Cleveland, OH 44106, USA.
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