Six Sigma Methodology and Postoperative Information Reporting: A Multidisciplinary Quality Improvement Study With Interrupted Time-Series Regression.

OBJECTIVE: The postoperative handover is often compromised by reporting inconsistencies between different specialties. We describe a multidisciplinary quality improvement initiative to improve postoperative information reporting. DESIGN: A quality improvement project with interrupted time-series data collection was undertaken in the postanesthesia care unit between January 2015 and August 2015. We utilized Six Sigma methodology to engage multispecialty stakeholders in identifying deficiencies in the existing postoperative handover process in January 2015. A standardized handover process including a checklist and electronic handover note was implemented within a postanesthesia care unit in June 2015. Direct observations of handovers were conducted to determine reporting accuracy, handover duration, and specialty representative attendance. Segmented linear and logistic regression analyses were used for interrupted time-series data. SETTING: Single postanesthesia care unit at an academic tertiary referral center. PARTICIPANTS: Physician trainees in anesthesia (n = 82) and surgical subspecialties (n = 139), certified registered nurse anesthetists (n = 57), and recovery room registered nurses (n = 139). RESULTS: Cumulative handover scores increased by 18.3 points in the postimplementation period (n = 70) when compared to preimplementation handovers (n = 69), a finding which remained statistically significant after adjusting for preintervention time trends (difference 16 points; 95% confidence intervals 3-31; p = 0.021). No statistically significant difference in handover duration was seen between cohorts (6.8 minutes vs 6.1 minutes, difference 0.5 minutes; 95% confidence intervals -2.8 to 3.7; p = 0.78). Three years postimplementation, there was consistent use of a modified electronic handover note and surgical subspecialty attendance during handover. CONCLUSIONS: A standardized handover process was associated with improved information reporting among different surgical disciplines without significantly lengthening handover duration.

An electronic handoff tool to facilitate transfer of care from anesthesia to nursing in intensive care units.

Checklists are commonly used to structure the communication process between anesthesia nursing healthcare providers during the transfer of care, or handoff, of a patient after surgery. However, intraoperative information is often recalled from memory leading to omission of critical data or incomplete information exchange during the patient handoff. We describe the implementation of an electronic anesthesia information transfer tool (T2) for use in the handover of intubated patients to the intensive care unit. A pilot observational study auditing handovers against a pre-existing checklist was performed to evaluate information reporting and attendee participation. There was a modest improvement in information reporting on part of the anesthesia provider, as well as team discussions regarding the current hemodynamic status of the patient. While T2 was well-received, further evaluation of the tool in different handover settings can clarify its potential for decreasing adverse communication-related events.

Self-reported functional status predicts post-operative outcomes in non-cardiac surgery patients with pulmonary hypertension.

BACKGROUND: Pulmonary hypertension (PHTN) is associated with increased post-procedure morbidity and mortality. Pre-procedure echocardiography (ECHO) is a widely used tool for evaluation of these patients, but its accuracy in predicting post-procedure outcomes is unproven. Self-reported exercise tolerance has not been evaluated for operative risk stratification of PHTN patients. OBJECTIVE: We analyzed whether self-reported exercise tolerance predicts outcomes (hospital length-of-stay [LOS], mortality and morbidity) in PHTN patients (WHO Class I-V) undergoing anesthesia and surgery. METHODS AND FINDINGS: We reviewed 550 non-cardiac, non-obstetric procedures performed on 370 PHTN patients at a single institution between 2007 and 2013. All patients had cardiac ECHO documented within 1 year prior to the procedure. Pre-procedure comorbidities and ECHO data were collected. Functional status (< or ≥ 4 metabolic equivalents of task [METs]) was assigned based on responses to standard patient interview questions during the pre-anesthesia clinic visit. Multiple logistic regression was used to develop a risk score model (Pulmonary Hypertension Outcome Risk Score; PHORS) and determine its value in predicting post-procedure outcomes. In an adjusted model, functional status <4 METs was independently associated with a LOS >7 days (p < .003), as were higher ASA class (p < .002), open surgical approach (p < .002), procedure duration > 2 hours (p < .001), and the absence of systemic hypertension (p = .012). PHORS Score ≥2 was associated with an increased 30-day major complication rate (28.7% vs. 19.2%; p < 0.001) and ICU admission rate (8.6% s 2.8%; p = .007), but no statistical difference in hospital readmissions rate (17.6% vs. 14.0%; p = .29), or mortality (3.5% vs. 1.4%; p = .75). Similar ECHO findings did not further improve outcome prediction. CONCLUSIONS: Poor functional status is associated with severe PHTN and predicts increased LOS and post-procedure complications in patients with moderate to severe pulmonary hypertension with different etiologies. A risk assessment model predicts increased LOS with fair accuracy. A thorough evaluation of underlying etiologies of PHTN should be undertaken in every patient.

Attitudes and Practices on the Consent Process and Decision-making for Intravenous Stroke Thrombolysis: Physicians' Perspective.

INTRODUCTION: Earlier treatment with intravenous stroke thrombolysis improves outcomes and lowers risk of bleeding complications. The decision-making and consent process is one of the rate-limiting steps in the duration between hospital arrival and treatment initiation. We aim to describe the attitudes and practices of neurologists in Singapore on the consent and decision-making processes for stroke thrombolysis. MATERIALS AND METHODS: A survey of neurologists and neurologists-in-training in 2 large tertiary public hospitals in Singapore was conducted. RESULTS: Among 46 respondents, 94% of them considered stroke thrombolysis an emergency treatment and 67% of them indicated there is a need for written informed consent. The majority (87%) knew that from a legal perspective, the doctor should be the decision-maker in an emergency treatment for a mentally incapacitated patient. However, 63% of respondents reported that it is the next-of-kin who usually makes the decision in actual practice. If confronted with a mentally incapacitated stroke patient, 57% of them were willing to be the proxy decision-maker and 13% of them were not. In 3 commonly encountered vignettes when a mentally incapacitated patient was being considered for stroke thrombolysis, there was no clear consensus on the respondents' practices. CONCLUSION: The next-of-kin is usually the decision-maker for stroke thrombolysis in practice for a mentally incapacitated patient despite most doctors considering thrombolysis an emergency treatment. This, together with the lack of consensus and variance in decision-making and consent practice amongst neurologists for stroke thrombolysis, demonstrates the need to develop best practice guidelines to standardise healthcare practices for greater consistency in health service delivery.

Elderly patients are at higher risk for poor outcomes after intra-arterial therapy.

BACKGROUND AND PURPOSE: Conflicting data exist regarding outcomes after intra-arterial therapy (IAT) in elderly stroke patients. We compare safety and clinical outcomes of multimodal IAT in elderly versus nonelderly patients and investigate differences in baseline health and disability as possible explanatory factors. METHODS: Data from a prospectively collected institutional IAT database were analyzed comparing elderly (80 years or older) versus nonelderly patients. Baseline demographics, angiographic reperfusion (Thrombolysis in Cerebral Infarction scale score 2-3), rate of parenchymal hematoma type 2, and 90-day modified Rankin Scale scores were compared in univariate and multivariate analyses. RESULTS: There were 49 elderly and 130 nonelderly patients treated between 2005 and 2010. Between the 2 cohorts, there was no significant difference in Thrombolysis in Cerebral Infarction 2 to 3 reperfusion (71% vs 75%; P=0.57), time to reperfusion (P=0.77), or rate of parenchymal hematoma type 2 (4% vs 7%; P=0.73) after IAT. However, elderly patients had significantly lower rates of good outcome (modified Rankin Scale score 0-2: 2% vs 33%; P<0.0001) and higher mortality (59% vs 24%; P<0.0001) at 90 days. Atrial fibrillation, coronary artery disease, hypertension, hyperlipidema, and baseline disability were significantly more common in elderly patients. Adjusting for baseline disability, stroke severity, and reperfusion, elderly patients were 29-times more likely to be dependent or dead at 90 days (odds ratio, 28.7; 95% confidence interval, 3.2-255.7; P=0.003). CONCLUSIONS: Despite comparable rates of reperfusion and significant hemorrhage, elderly patients had worse clinical outcomes after IAT, which may relate, in part, to worse baseline health and disability. The use of IAT in the elderly should be performed after a careful analysis of the potential risks and benefits.

Novel use of onyx for treatment of intracranial vertebral artery dissection.

This report describes a patient who presented with subarachnoid hemorrhage and extensive right posterior inferior cerebellar artery territory infarct secondary to a dissecting aneurysm of the right intracranial vertebral artery. Urgent endovascular treatment was undertaken with plans for trapping of the diseased segment with coils. However, significant intralesional stenosis limited distal microcatheter access. Therefore, using proximal flow arrest and adjunctive coiling, the liquid embolic agent Onyx was injected within the pseudoaneurysm and was able to traverse the stenosis, resulting in proximal and distal parent vessel closure. There were no embolic complications. During the 3 month hospital stay, there was no rebleeding. The patient was discharged to skilled nursing facility and was lost to follow-up.

Novel use of prasugrel for intracranial stent thrombosis.

Dual antiplatelet therapy is established for prevention of stent thrombosis in cardiac patients, and widely utilized in neurointerventional stent cases. Aspirin and clopidogrel are typically synergistic. We present a case of clopidogrel resistance due to genetic polymorphism resulting in acute stent thrombosis during elective stent-assisted coiling, with novel use of prasugrel as an alternative platelet inhibitor in the neurovascular setting.

Presumed dapsone-induced drug hypersensitivity syndrome causing reversible hypersensitivity myocarditis and thyrotoxicosis.

INTRODUCTION: A 22-year-old Malay soldier developed dapsone hypersensitivity syndrome 12 weeks after taking maloprim (dapsone 100 mg/pyrimethamine 12.5 mg) for anti-malarial prophylaxis. CLINICAL PICTURE: He presented with fever, rash, lymphadenopathy and multiple-organ involvement including serositis, hepatitis and thyroiditis. Subsequently, he developed congestive heart failure with a reduction in ejection fraction on echocardiogram, and serum cardiac enzyme elevation consistent with a hypersensitivity myocarditis. TREATMENT: Maloprim was discontinued and he was treated with steroids, diuretics and an angiotensin-converting-enzyme inhibitor. OUTCOME: He has made a complete recovery with resolution of thyroiditis and a return to normal ejection fraction 10 months after admission. CONCLUSION: In summary, we report a case of dapsone hypersensitivity syndrome with classical symptoms of fever, rash and multi-organ involvement including a rare manifestation of myocarditis. To our knowledge, this is the first case of dapsone-related hypersensitivity myocarditis not diagnosed in a post-mortem setting. As maloprim is widely used for malaria prophylaxis, clinicians need to be aware of this unusual but potentially serious association.