Safety Attitude of Operating Room Personnel Associated With Accurate Completion of a Surgical Checklist: A Cross-sectional Observational Study

OBJECTIVE

How the checklist is executed in routine practice may reflect the teamwork and safety climate in the operating room (OR). This cross-sectional study aimed to identify whether the presence of a fully completed checklist in medical records was associated with teams' safety attitudes.

METHODS

Data from 29 French hospitals, including 5677 operated patients and 834 OR professionals, were prospectively collected. The degree of checklist compliance was categorized for each patient in 1 of 4 ways: full, incomplete, inaccurate, and no checklist completed. The members of OR teams were invited to complete a questionnaire including teamwork climate measurement (Safety Attitudes Questionnaire) and their opinion regarding checklist use, checklist audibly reading, and communication change with checklist. Multilevel modeling was performed to investigate the effect of variables related to hospitals and professionals on checklist compliance, after adjustment for patient characteristics.

RESULTS

A checklist was present for 83% of patients, but only 35% demonstrated full completion. Compared with no checklist, full completion was associated with higher safety attitude (high teamwork climate [adjusted odds ratio for full completion, 4.14; 95% confidence interval, 1.75-9.76]; communication change [1.31, 1.04-1.66]; checklist aloud reading [1.16, 1.02-1.32]) and was reinforced by the designation of a checklist coordinator (2.43, 1.06-5.55). Incomplete completion was also associated with enhanced safety attitude contrary to inaccurate completion.

CONCLUSIONS

Compliance with checklists is associated with safer OR team practice and can be considered as an indicator of the extent of safety in OR practice.

MO352RENAL DYSFUNCTION AS A MAJOR PREDICTOR OF CLINICAL OUTCOMES IN ANTERIOR STEMI PATIENTS

Background and Aims

Among ST-segment elevation myocardial infarction (STEMI) patients, the respective impact of the baseline renal function, of the development of acute kidney injury (AKI), and of their combination, on the long-term cardiovascular outcomes, remain unclear.

Method

The present study was based on a post hoc analysis of the CIRCUS trial database, a multicentre randomized study which gathered 969 patients with anterior STEMI treated by primary percutaneous intervention (PPCI) within 12 hours of symptoms onset. Uni and multivariate regressions were performed to identify if the estimated glomerular filtration rate (eGFR) at admission and the development of AKI were associated with (1) cardiovascular death and heart failure (HF) at one year and (2) sub-optimal treatment prescription at discharge.

Results

A total of 822 patients were included. The mean baseline eGFR was 86 ± 19 mL/min/1.73m2. AKI occurred in 97 patients (11.8%). Baseline eGFR <60mL/min/1.73m2 was associated with HF (40.0 vs 16.8%, p<0.001) and with a sub-optimal treatment at discharge (35.9 vs 18.9%, p=0.001). AKI was associated with cardiovascular death (12.4 vs 2.8%, p<0.001), HF (50.5 vs 14.9%, p<0.001), and sub-optimal treatment (35.8 vs 18.5%, p<0.001). The multivariate analysis showed that AKI (OR=4.88, CI=2.89-8.27) and a lower baseline eGFR (OR=1.29 per 10mL/min/1.73m2 decrease, CI=1.11-1.50) are independent predictors of cardiovascular death or HF after anterior STEMI.

Conclusion

In anterior STEMI patients undergoing PPCI, the development of AKI was the strongest independent predictor of poor clinical outcome at one year. The study suggests the need for a tailored monitoring of STEMI patients with AKI or baseline kidney dysfunction.

[Routine collection of perceived health data in the era of payment for quality: Recommendations by the Epidemiology and public health commission of the SFNDT]

In France, the method of financing is mainly based on the quantity of care produced. The fixed-rate financing of patients with chronic kidney disease at stage IV or V introduces the notion of payment to quality. Part of the quality assessment will focus on the patients' feelings about their care. The objective of this paper is to assess these indicators used in nephrology, markers in their own right of the quality of care. The patients reported outcomes measures considering the impact of illness or care and the Patient Reported Experience Measures considering their perception of their experience with the health care system or care pathway, are broader than quality of life. These PROs are measured using standardized and validated questionnaires, generic or specific. The Standardised Outcomes in Nephrology initiative has shown that PROs, too often neglected in favor of biological criteria, are instead favored by patients. In the context of a broad deployment of monitoring the quality of life for the purpose of evaluation of care, outside research protocol, the Commission recommends one of the following 2 tools: EuroQol 5D and 12-Item Short Form Health Survey, a compromise between feasibility and relevance and e-SATIS given its great use in health facilities, with an annual follow-up.

P0047PREVALENCE OF FABRY DISEASE IN DIALYSIS PATIENTS IN FRANCE (FABRYDIAL STUDY)

Background and Aims

Fabry Disease (FD) is an X linked lysosomal storage disease due to pathogenic α-galactosidase A (GLA) variants. It leads to damage in kidney and other organs. Numerous prevalence studies have been conducted over the past twenty years in ESRD patients in different countries. However, many screening studies did not perform confirmatory GLA variant analyses, and included recently recognized ‘benign/likely-benign’ variants, thereby inflating prevalence estimates. Thus, the prevalence of Fabry disease in patients with end-stage renal disease remains controversial.

The FABRYDIAL study aimed to measure the prevalence of Fabry disease in patients aged 18 to 75 years and treated by chronic dialysis, either hemodialysis or peritoneal dialysis.

Method

The study was conducted in France in 5 geographic sectors (Aquitaine, Ile-de-France, Rhône-Alpes and Picardie regions, and the Gard department). One hundred and twenty-four dialysis centers participated in the study, which targeted patients undergoing chronic dialysis during the week of November 20, 2017. The exclusion criteria were the existence of a proven nephropathy unrelated to FD (polycystic kidney disease, type 1 diabetes or biopsy-proven IgA nephropathy, membranous glomerulonephritis or ANCA-associated vasculitis), the absence of health insurance coverage or guardianship or tutelage. α-galactosidase A in men, and both α-galactosidase A and lyso-GL3 in women, were measured on a drop of dried blood during the usual care of patients. GLA gene sequencing was performed in patients in whom one biological value was outside normal values. If a genetic variant was identified, a multidisciplinary Diagnosis Validation Committee (DVC) concluded, based on precise literature, clinical, biological and genetic data, as to the reality of Fabry disease.

Results

Among the 6,032 patients aged 18 to 75 years under chronic dialysis during the period considered, 714 were no longer treated in the participating centers when the research staff visited for eligibility assessment. 1,121 had non-inclusion criteria, which in 89% of cases were a confirmed diagnosis of kidney disease (by renal biopsy or other means) making the existence of Fabry disease very unlikely. 4,197 patients met the inclusion criteria, of which 3,088 were included (1,888 men and 1,200 women). Valid biological analyzes were available for 2815 patients (1721 men and 1094 women), and a genetic test was indicated for 91 patients (52 men and 39 women). Ninety-seven percent of the samples were analyzed with a unique assay technique in a unique laboratory. Five patients had a genetic variant (4 men and one woman). After discussion in the DVC, one male patient was considered to have a confirmed Fabry disease. He presented early signs of the disease (first-degree family history of cardiac or unexplained death, hypohidrosis, heat intolerance, tendency to chronic diarrhea, angiokeratoma, hypoacousia and tinnitus) which could have been identified earlier. The GLA variant was c.1185dupG / p.Phe396Glyfs, a clearly pathogenic frameshift variant. The prevalence of FD in included patients with biological data was 0.035% [0.006; 0.201] (0.058% [0.010; 0.33] in men, 0.000 % [0,000; 0.350] in women). If we consider that patients who were not included because of a specific renal diagnosis unrelated to FD did not have FD, the estimated prevalence decreased to 0.028% [0.006; 0.121].

Conclusion

The estimated prevalence of FD in a cohort of French dialysis patients is 0.035% [0.006; 0.201], and by sex 0.058% in men [0.010; 0.328] and 0,000% in women [0,000; 0.35]. Although it appears extremely low, it remains justified to bring up this diagnosis in the event of an evocative sign, whether for the patient or his relatives as FD benefit of effective specific treatments.

Funding for this Investigator Sponsored Study was provided by Sanofi Genzyme

Blood pressure decreases after revascularization in atherosclerotic renal artery disease: A cohort study based on a multidisciplinary meeting

Background

In atherosclerotic renal artery disease, the benefit of revascularization is controversial. A clinical decision-making process based on a multidisciplinary meeting was formalized in the Lyon university hospital.

Objectives

To investigate whether this decisional process ensured a clinical benefit to patients assigned to renal revascularization.

Methods

Single-centre retrospective cohort study, including patients diagnosed from April 2013 to February 2015 with an atherosclerotic renal artery disease with a peak systolic velocity >180cm/s. For each patient, the decision taken in multidisciplinary meeting (medical treatment or revacularization) was compared to the one guided by international guidelines. Blood pressure values, number of antihypertensive medications, presence of an uncontrolled or resistant hypertension, and glomerular filtration rate at one-year follow-up were compared to baseline values. Safety data were collected.

Results

Forty-nine patients were included: 26 (53%) were assigned to a medical treatment and 23 (47%) to a renal revascularization. Therapeutic decision was in accordance with the 2013 American Health Association guidelines and with the 2017 European Society of Cardiology guidelines for 78% and 22% of patients who underwent revascularization, respectively. Patients assigned to revascularization presented a significant decrease in systolic blood pressure (-23±34mmHg, p = 0.007), diastolic blood pressure (-12±18mmHg, p = 0.007), number of antihypertensive medications (-1.00±1.03, p = 0.001), and number of uncontrolled or resistant hypertension (p = 0.022 and 0.031) at one-year follow-up. Those parameters were not modified among patients assigned to medical treatment alone. There was no grade 3 adverse event.

Conclusion

Based on a multidisciplinary selection of revascularization indications, patients on whom a renal revascularization was performed exhibited a significant improvement of blood pressure control parameters with no severe adverse events.

Not only disease activity but also chronic hypertension and overweight are determinants of pregnancy outcomes in patients with systemic lupus erythematosus

INTRODUCTION

Pregnancies in women with lupus nephritis are at high-risk of complications, while scarcity of scientific knowledge on prognostic factors impedes a fair medical counseling. We aimed to identify determinants associated with maternal and fetal complications.

MATERIALS

We retrospectively reviewed medical charts of pregnancies that lasted more than 22 weeks in 66 patients with pre-existing lupus nephritis between 2004 and 2013 in France. Univariate and multivariate analyses were conducted to identify determinants for maternal complications, lupus renal flare and fetal prematurity or death.

RESULTS

Eighty-four pregnancies were identified. A maternal complication occurred in 31 pregnancies (36.9%): mostly preeclampsia (17 pregnancies, 20.2%) and renal flares (12 pregnancies, 14.3%). Overall fetal survival was 94.0% (79/84). Maternal pregnancy complications were independently associated with prepregnancy body mass index >25 kg/m² (OR 3.81, 95% CI 1.03-14.09) and immunological activity (positive anti-dsDNA antibodies or Farr assay lupus) (OR 4.95, 95% CI 1.33-18.43). Renal lupus flares were independently associated with maternal age (OR 1.50, 95% CI 1.12-2.01) and prepregnancy immunological activity (OR 15.99, 95% CI 1.57-162.68) while a remission time >12 months had a protective effect (OR 0.17, 95% CI 0.04-0.68). Three parameters were associated with a higher risk of fetal prematurity or death: a prepregnancy body mass index >25 kg/m² (HR 3.58, 95% CI 1.45-8.83), hypertension (HR 8.97, 95% CI 3.32-24.25), and immunological activity (HR 3.34, 95% CI 1.30-8.63).

CONCLUSION

Maternal age, prepregnancy hypertension, body mass index >25 kg/m² and lupus immunological activity may be considered as the main determinants for fetal and maternal complications. A remission time above 12 months for patients with lupus nephritis could be associated with a reduced risk of renal flare during pregnancy.

Presence of Kidney Disease as an Outcome Predictor in Patients with Pulmonary Arterial Hypertension

BACKGROUND

Pulmonary arterial hypertension (PAH) may lead to right heart failure and subsequently alter glomerular filtration rates (GFR). Chronic kidney disease (CKD, GFR <60 mL/min/1.73 m2) may also adversely affect PAH prognosis. This study aimed to assess how right heart hemodynamics was associated with reduced estimated GFR (eGFR) and the association of CKD with survival in PAH patients.

METHODS

In a prospective PAH cohort (2003-2012), invasive hemodynamics and eGFR were collected at diagnosis (179 patients) and during follow-up (159 patients). The prevalence of CKD was assessed at PAH diagnosis. Variables, including hemodynamics, associated with reduced eGFR at diagnosis and during follow-up were tested in multivariate analysis. The association of CKD with survival was evaluated using a multivariate Cox regression model.

RESULTS

At diagnosis, mean age was 60.4 ± 16.5 years, mean pulmonary arterial pressure was 43 ± 12 mm Hg, and eGFR was 74.4 ± 26.4 mL/min/1.73 m2. CKD was observed in 52 incident patients (29%). Independent determinants of reduced eGFR at diagnosis were age, systemic hypertension, and decreased cardiac index. Independent determinants of reduced eGFR during follow-up were age, female gender, PAH etiology, systemic hypertension, decreased cardiac index, and increased right atrial pressure. Age ≥60 years, female gender, NYHA 4, and CKD at diagnosis were independently associated with decreased survival. The adjusted hazards ratio for death associated with CKD was 1.81 (95% confidence interval [1.01-3.25]).

CONCLUSION

CKD is frequent at PAH diagnosis and is independently associated with increased mortality. Right heart failure may induce renal hypoperfusion and congestion, and is associated with eGFR decrease.

Effectiveness of IHD with Adsorptive PMMA Membrane in Myeloma Cast Nephropathy: A Cohort Study

BACKGROUND

In patients with cast nephropathy and acute kidney injury (AKI) requiring dialysis, the reduction of serum free light chains (FLC) using chemotherapy and intensive hemodialysis (IHD) with a high cut-off filter may improve renal and patient outcomes. We evaluated the effectiveness of a combination of chemotherapy and IHD with an adsorbent polymethylmethacrylate membrane (IHD-PMMA) on renal recovery and survival.

METHODS

A single-center retrospective cohort-study was conducted. Between 2007 and 2014, patients with dialysis-dependent acute cast nephropathy treated with chemotherapy and IHD-PMMA were included. Patients had six 6-h hemodialysis sessions a week, until predialysis serum FLC fell below 200 mg/L, for a maximum of 3 weeks. Primary outcomes were renal recovery, defined as dialysis independence, and survival.

RESULTS

Seventeen patients were included, all with stage 3 AKI. All received chemotherapy, mostly based on bortezomib and steroids (88%). Twelve patients (71%) achieved renal recovery, usually within 60 days (92%). At 3 months, the overall hematological response rate was 57%; hematological response was maintained for at least 2 years in 86% of responders. At 6, 12, and 24 months, 76, 75, and 62% of patients were alive, respectively. Higher reduction in involved FLC by day 12 (p = 0.022) and day 21 (p = 0.003) was associated with renal recovery. Patients with FLC reduction rate >50% by day 21 experienced a lower mortality (hazard ratio 0.10, 95% CI 0.02-0.63).

CONCLUSION

In patients with dialysis-dependent myeloma cast nephropathy, early FLC removal by IHD-PMMA combined with chemotherapy was associated with high rates of renal recovery and survival.

[Management of atherosclerotic renal-artery stenosis in 2016]

Endovascular revascularization as treatment of atherosclerotic renal-artery stenosis (aRAS) is controversial since 3 large and multicentric randomised trials (CORAL, ASTRAL, STAR) failed to prove the superiority of percutaneous transluminal renal-artery stenting (PTRAS) over medical treatment only (MT). However, considering the multiple bias of these trials, among which questionable inclusion criterias, these results must be extrapolated in clinical practice with caution. New pathophysiological data have been helping to understand why restoring blood flow does not necessarily lead to kidney function improvement. Today, the diagnostic approach must in one hand confirm the artery stenosis and on the other hand assess its severity and impact on the kidney. Therapeutic options still lie on the American guidelines published in 2006, since no study data can be reasonably used in everyday practice. However, particular sub-groups of patients who could benefit from revascularisation have been identified through recent cohort studies. Further prospective studies are needed in order to confirm the superiority of PTRAS in these populations. Meanwhile, multidisciplinary approach should be promoted, in order to provide the best treatment for each patient.

Cluster randomized trial to evaluate the impact of team training on surgical outcomes

Background

The application of safety principles from the aviation industry to the operating room has offered hope in reducing surgical complications. This study aimed to assess the impact on major surgical complications of adding an aviation-based team training programme after checklist implementation.

Methods

A prospective parallel-group cluster trial was undertaken between September 2011 and March 2013. Operating room teams from 31 hospitals were assigned randomly to participate in a team training programme focused on major concepts of crew resource management and checklist utilization. The primary outcome measure was the occurrence of any major adverse event, including death, during the hospital stay within the first 30 days after surgery. Using a difference-in-difference approach, the ratio of the odds ratios (ROR) was estimated to compare changes in surgical outcomes between intervention and control hospitals.

Results

Some 22 779 patients were enrolled, including 5934 before and 16 845 after team training implementation. The risk of major adverse events fell from 8·8 to 5·5 per cent in 16 intervention hospitals (adjusted odds ratio 0·57, 95 per cent c.i. 0·48 to 0·68; P &lt; 0·001) and from 7·9 to 5·4 per cent in 15 control hospitals (odds ratio 0·64, 0·50 to 0·81; P &lt; 0·001), resulting in the absence of difference between arms (ROR 0·90, 95 per cent c.i. 0·67 to 1·21; P = 0·474). Outcome trends revealed significant improvements among ten institutions, equally distributed across intervention and control hospitals.

Conclusion

Surgical outcomes improved substantially, with no difference between trial arms. Successful implementation of an aviation-based team training programme appears to require modification and adaptation of its principles in the context of the the surgical milieu. Registration number: NCT01384474 (http://www.clinicaltrials.gov).

Efficacy of extracorporeal albumin dialysis for acute kidney injury due to cholestatic jaundice nephrotoxicity

We report a case of a 37-year-old man with Maturity Onset Diabetes of the Youth (MODY) type 5, admitted for an episode of cholestasis and a simultaneous acute kidney injury (AKI). Chronic liver disease was due to a mutation in the transcription factor 2 (TCF2) gene, thus highlighting the need for a close liver follow-up in these patients. AKI was attributed to a cholemic nephropathy based on the following rationale: (1) alternative diagnoses were actively ruled out; (2) the onset of AKI coincided with the onset of severe hyperbilirubinaemia; (3) renal pathology showed large bile tubular casts and a marked tubular necrosis and (4) creatinine serum dramatically decreased when bilirubin levels improved after the first sessions of extracorporeal albumin dialysis (ECAD), thus suggesting its role in renal recovery. Even though cholestasis can precipitate renal injury, the diagnosis of cholemic nephropathy could require a renal biopsy at times. Future studies should confirm the benefits of ECAD in cholemic nephropathy.

[CARDIORENAL SYNDROME: DIAGNOSTIC AND THERAPEUTIC APPROACHES]

Kidney dysfunction during congestive heart failure, although frequent, is often neglected. Yet, it represents a life-threatening condition, oven when the kidney dysfunction is moderate. The initial approach involvus strict application of recommendations, cardiologic and nephrologic joined management and close follow-up involving patient's general practitioner. Cases of true diuretics resistance are infrequent and late. Yet, it represents a significant turning point. Mortality is high, with a major individual unpredictability. A multidisciplinary approach is needed, which has to take into account patient's preferences. Several treatments may be discussed and are sometimes joined: cardiac transplantation, water and salt extraction (using ultrafiltration, hemodialysis or peritoneal dialysis), vasoconstrictive drugs, ventricular assistance devices and palliative care. Water and salt extraction techniques seem to space out hospitalizations and to provide symptomatic relief even though no benefit on patient survival has been demonstrated to date. The need for randomized clinical trials is mandatory.

Accuracy of GFR estimation in obese patients

BACKGROUND AND OBJECTIVES

Adequate estimation of renal function in obese patients is essential for the classification of patients in CKD category as well as the dose adjustment of drugs. However, the body size descriptor for GFR indexation is still debatable, and formulas are not validated in patients with extreme variations of weight.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

This study included 209 stages 1-5 CKD obese patients referred to the Department of Renal Function Study at the University Hospital in Lyon between 2010 and 2013 because of suspected renal dysfunction. GFR was estimated with the Chronic Kidney Disease and Epidemiology equation (CKD-EPI) and measured with a gold standard method (inulin or iohexol) not indexed (mGFR) or indexed to body surface area determined by the Dubois and Dubois formula with either real (mGFRr) or ideal (mGFRi) body weight. Mean bias (eGFR-mGFR), precision, and accuracy of mGFR were compared with the results obtained for nonobese participants (body mass index between 18.5 and 24.9) who had a GFR measurement during the same period of time.

RESULTS

Mean mGFRr (51.6 ± 24.2 ml/min per 1.73 m(2)) was significantly lower than mGFR, mGFRi, and eGFRCKD-EPI. eGFRCKD-EPI had less bias with mGFR (0.29; -1.7 to 2.3) and mGFRi (-1.62; -3.1 to 0.45) compared with mGFRr (8.7; 7 to 10). This result was confirmed with better accuracy for the whole cohort (78% for mGFR, 84% for mGFRi, and 72% for mGFRr) and participants with CKD stages 3-5. Moreover, the Bland Altman plot showed better agreement between mGFR and eGFRCKD-EPI. The bias between eGFRCKD-EPI and mGFRr was greater in obese than nonobese participants (8.7 versus 0.58, P<0.001).

CONCLUSIONS

This study shows that, in obese CKD patients, the performance of eGFRCKD-EPI is good for GFR ≤ 60 ml/min per 1.73 m(2). Indexation of mGFR with body surface area using ideal body weight gives less bias than mGFR scaled with body surface area using real body weight.