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PURPOSE - Standardized care via a unified surgeon preference card for pediatric appendectomy can result in significant cost reduction. The purpose of this study was to evaluate the impact of cost and outcome feedback to surgeons on value of care in an environment reluctant to adopt a standardized surgeon preference card.
METHODS - Prospective observational study comparing operating room (OR) supply costs and patient outcomes for appendectomy in children with 6-month observation periods both before and after intervention. The intervention was real-time feedback of OR supply cost data to individual surgeons via automated dashboards and monthly reports.
RESULTS - Two hundred sixteen children underwent laparoscopic appendectomy for non-perforated appendicitis (110 pre-intervention and 106 post-intervention). Median supply cost significantly decreased after intervention: $884 (IQR $705-$1025) to $388 (IQR $182-$776), p<0.001. No significant change was detected in median OR duration (47min [IQR 36-63] to 50min [IQR 38-64], p=0.520) or adverse events (1 [0.9%] to 6 [4.7%], p=0.062). OR supply costs for individual surgeons significantly decreased during the intervention period for 6 of 8 surgeons (87.5%).
CONCLUSION - Approaching value measurement with a surgeon-specific (rather than group-wide) approach can reduce OR supply costs while maintaining excellent clinical outcomes.
LEVEL OF EVIDENCE - Level II.
Copyright © 2018 Elsevier Inc. All rights reserved.
BACKGROUND - Despite hand washing and other protocols surgical-site infections (SSIs) have not been eliminated. This implies that either current measures are not effective or there are alternative sources of bacterial exposure to the surgical wound. In this study we tested the hypothesis that stuffed animals or other items allowed to accompany pediatric patients to the operating room as a way to ease anxiety may represent a reservoir of bacteria.
METHODS - Stuffed animals brought into the operating room and stuffed animals that were washed and dried in a conventional washer/dryer and placed in clean sealable plastic bags were swabbed and bacterial colonies were quantified. Results were reported as no growth, light growth, moderate growth, and heavy growth.
RESULTS - All stuffed animals showed bacterial growth. A total of 79% of stuffed animals were effectively "sterilized" by a single wash and dry cycle in a conventional home washer/dryer. Sterilized stuffed animals remained sterile after being packed in a sealed bag for 24 hours.
CONCLUSIONS - These results indicate that items of comfort, such as stuffed animals, brought into the operating room with a benevolent purpose may represent a reservoir of bacteria that could lead to unwanted SSI. Washing an item of comfort 1 day before surgery effectively sterilizes that item of comfort. Future studies will be needed to determine a correlation between "culture positive" stuffed animals and SSI or if providing a child with a "sterile" stuffed animal reduces SSI.
The pulse oximeter is a critical monitor in anesthesia practice designed to improve patient safety. Here, we present an approach to improve the ability of anesthesiologists to monitor arterial oxygen saturation via pulse oximetry through an audiovisual training process. Fifteen residents' abilities to detect auditory changes in pulse oximetry were measured before and after perceptual training. Training resulted in a 9% (95% confidence interval, 4%-14%, P = 0.0004, t(166) = 3.60) increase in detection accuracy, and a 72-millisecond (95% confidence interval, 40-103 milliseconds, P < 0.0001, t(166) = -4.52) speeding of response times in attentionally demanding and noisy conditions that were designed to simulate an operating room. This study illustrates the benefits of multisensory training and sets the stage for further work to better define the role of perceptual training in clinical anesthesiology.
OBJECTIVES - Increased clinician workload is associated with medical errors and patient harm. The Quality and Workload Assessment Tool (QWAT) measures anticipated (pre-case) and perceived (post-case) clinical workload during actual surgical procedures using ratings of individual and team case difficulty from every operating room (OR) team member. The purpose of this study was to examine the QWAT ratings of OR clinicians who were not present in the OR but who read vignettes compiled from actual case documentation to assess interrater reliability and agreement with ratings made by clinicians involved in the actual cases.
METHODS - Thirty-six OR clinicians (13 anesthesia providers, 11 surgeons, and 12 nurses) used the QWAT to rate 6 cases varying from easy to moderately difficult based on actual ratings made by clinicians involved with the cases. Cases were presented and rated in random order. Before rating anticipated individual and team difficulty, the raters read prepared clinical vignettes containing case synopses and much of the same written case information that was available to the actual clinicians before the onset of each case. Then, before rating perceived individual and team difficulty, they read part 2 of the vignette consisting of detailed role-specific intraoperative data regarding the anesthetic and surgical course, unusual events, and other relevant contextual factors.
RESULTS - Surgeons had higher interrater reliability on the QWAT than did OR nurses or anesthesia providers. For the anticipated individual and team workload ratings, there were no statistically significant differences between the actual ratings and the ratings obtained from the vignettes. There were differences for the 3 provider types in perceived individual workload for the median difficulty cases and in the perceived team workload for the median and more difficult cases.
CONCLUSIONS - The case difficulty items on the QWAT seem to be sufficiently reliable and valid to be used in other studies of anticipated and perceived clinical workload of surgeons. Perhaps because of the limitations of the clinical documentation shown to anesthesia providers and OR nurses in the current vignette study, more evidence needs to be gathered to demonstrate the criterion-related validity of the QWAT difficulty items for assessing the workload of nonsurgeon OR clinicians.
BACKGROUND - Anesthesiology requires performing visually oriented procedures while monitoring auditory information about a patient's vital signs. A concern in operating room environments is the amount of competing information and the effects that divided attention has on patient monitoring, such as detecting auditory changes in arterial oxygen saturation via pulse oximetry.
METHODS - The authors measured the impact of visual attentional load and auditory background noise on the ability of anesthesia residents to monitor the pulse oximeter auditory display in a laboratory setting. Accuracies and response times were recorded reflecting anesthesiologists' abilities to detect changes in oxygen saturation across three levels of visual attention in quiet and with noise.
RESULTS - Results show that visual attentional load substantially affects the ability to detect changes in oxygen saturation concentrations conveyed by auditory cues signaling 99 and 98% saturation. These effects are compounded by auditory noise, up to a 17% decline in performance. These deficits are seen in the ability to accurately detect a change in oxygen saturation and in speed of response.
CONCLUSIONS - Most anesthesia accidents are initiated by small errors that cascade into serious events. Lack of monitor vigilance and inattention are two of the more commonly cited factors. Reducing such errors is thus a priority for improving patient safety. Specifically, efforts to reduce distractors and decrease background noise should be considered during induction and emergence, periods of especially high risk, when anesthesiologists has to attend to many tasks and are thus susceptible to error.
BACKGROUND - Obesity has become a major epidemic in the United States. Although research suggests obesity does not increase major morbidity or mortality after thoracic operations, it likely results in greater use of health care resources.
METHODS - We examined all patients in The Society of Thoracic Surgeons General Thoracic Surgery database with primary lung cancer who underwent lobectomy from 2006 to 2010. We investigated the impact of body mass index (BMI) on total operating room time using a linear mixed-effects regression model and multiple imputations to account for missing data. Secondary outcomes included postoperative length of stay and 30-day mortality. Covariates included age, sex, race, forced expiratory volume, smoking status, Zubrod score, prior chemotherapy or radiation, steroid use, number of comorbidities, surgical approach, hospital lobectomy volume, hospital percent obesity, and the addition of mediastinoscopy or wedge resection.
RESULTS - A total of 19,337 patients were included. The mean BMI was 27.3 kg/m2, with 4,898 patients (25.3%) having a BMI of 30 kg/m2 or greater. The mean total operating room time, length of stay, and 30-day mortality were 240 minutes, 6.7 days, and 1.8%, respectively. For every 10-unit increase in BMI, mean operating room time increased by 7.2 minutes (range, 4.8 to 8.4 minutes; p<0.0001). Higher hospital lobectomy volume and hospital percentage of obese patients did not affect the association between BMI and operative time. Body mass index was not associated with 30-day mortality or increased length of stay.
CONCLUSIONS - Increased BMI is associated with increased total operating room time, regardless of institutional experience with obese patients.
Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.
BACKGROUND - With the institution of the work-hour restrictions in 2003, less time may be available for surgical residents to learn operative technique and judgment. While numerous studies have evaluated the use of surgical simulation training to enhance operative skills, little is known about the quality of teaching that takes place in the operating room (OR). The purpose of this study was to assess residents' perception of faculty teaching in the OR in order to target ways to improve operative education.
METHODS - A request for resident participation in an online survey was sent to the Program Coordinator at all 255 ACGME-accredited general surgery residency programs.
RESULTS - A total of 148 programs (59%) participated in the survey, and anonymous responses were submitted by 998 of 4926 residents (20%). Most residents reported that attending surgeons verbalize their operative approach (55%), include residents in intraoperative decisions (61%), and offer technical advice (84%). However, few residents reported that faculty help to identify the resident's personal educational operative goals preoperatively (18%) or discuss areas of improvement with residents (37%). Of all cases scrubbed in the past year, most residents feel as though they only actually performed the procedure between 26% and 50% (29%) or between 51% and 75% (32%) of the time. However, more than half of all residents (51%) log these procedures for ACGME as primary surgeon 76%-100% of the time.
CONCLUSIONS - This study demonstrates that from the residents' perspective, a number of opportunities exist to improve teaching in the OR, such as guiding residents with preoperative preparation and providing them with constructive feedback. These findings also suggest that residents may be logging cases without feeling as though they actually perform the operations.
Copyright © 2012 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.
Interventions such as mandatory "time-outs" have contributed to intraoperative safety but improvements are still necessary. We present data provided by 3 professions always present in the intraoperative setting that suggest next steps in the quest for improvements. We describe the differences and similarities in operating room (OR) nurses', anesthesia providers', and surgeons' beliefs about team function, case difficulty, nonroutine event (NRE), and error causation using a qualitative design at 3 Veterans' Administration hospitals. Intraoperative errors are costly in lives, suffering, and dollars. A quality improvement tenet states that workers are a rich information source regarding the context within which quality can be improved. Identifying and describing OR providers' beliefs are necessary steps in devising novel approaches to quality improvement. Intraoperative NRE and error prevention opportunities exist within and outside of the OR. There may be "cascade" and "perfect storm conditions" before and during operative procedures that increase the likelihood of NREs. Confirmation of these phenomena could improve prediction and prevention of NREs. Exploration of differences in team definition and team performance ratings by provider type may also identify avenues for improvement.
© 2011 National Association for Healthcare Quality.
OBJECTIVE - Use of the robotic assisted surgery has been increasing in recent years, due both the continuous increase in the number of applications and the clinical benefits that surgical robots can provide. Currently robotic assisted surgery relies on endoscopic video for navigation, providing only surface visualization, thus limiting subsurface vision. To be able to visualize and identify subsurface information, techniques in image-guidance can be used. As part of designing an image guidance system, all arms of the robot need to be co-localized in a common coordinate system.
METHODS - In order to track multiple arms in a common coordinate space, intrinsic and extrinsic tracking methods can be used. First, the intrinsic tracking of the daVinci, specifically of the setup joints is analyzed. Because of the inadequacy of the setup joints for co-localization a hybrid tracking method is designed and implemented to mitigate the inaccuracy of the setup joints. Different both optical and magnetic tracking methods are examined for setup joint localization.
RESULTS - The hybrid localization method improved the localization accuracy of the setup joints. The inter-arm accuracy in hybrid localization was improved to 3.02 mm. This inter-arm error value was shown to be further reduced when the arms are co-registered, thus reducing common error.
OBJECTIVE - This study examined whether anesthesia residents (physicians in training) performed clinical duties in the operating room differently during the day versus at night.
BACKGROUND - Fatigue from sleep deprivation and working through the night is common for physicians, particularly during residency training.
METHODS - Using a repeated-measures design, we studied 13 pairs of day-night matched anesthesia cases. Dependent measures included task times, workload ratings, response to an alarm light latency task, and mood.
RESULTS - Residents spent significantly less time on manual tasks and more time on monitoring tasks during the maintenance phase at night than during the day. Residents reported more negative mood at night than during the day, both pre- and postoperation. However, time of day had no effect on the mood change between pre- and postoperation. Workload ratings and the response time to an alarm light latency task were not significantly different between night and day cases.
CONCLUSIONS - Because night shift residents had been awake and working for more than 16 hr, the observed differences in task performance and mood may be attributed to fatigue. The changes in task distribution during night shift work may represent compensatory strategies to maintain patient care quality while keeping perceived workload at a manageable level.
APPLICATIONS - Fatigue effects during night shifts should be considered when designing work-rest schedules for clinicians. This matched-case control scheme can also be applied to study other phenomena associated with patient safety in the actual clinical environment.