Using Process Flow Disruption Analysis to Guide Quality Improvement.

BACKGROUND: Process flow describes the efficiency and consistency with which a process functions. Disruptions in surgical flow have been shown to be associated with an increase in error. Despite this, little experience exists in using surgical flow analysis to guide quality improvement (QI). STUDY DESIGN: In a 900-bed teaching hospital with an annual surgical volume of 24,000 cases, a 4-month observational study of process flow was done by experts in complex system evaluation. Identified flow disruptions were used to guide QI. Statistical analysis included descriptive and bivariate techniques. RESULTS: More than 200 unique process data points were evaluated. There was a high degree of variability in completion of 79 individual intraoperative data elements. Lack of completion of all elements of the time out was associated with number of times the operating room door opened during case (19, 11-27; p = 0.01). Flow disruptions were used to direct surgical QI. One example was a disruption affecting the use of Sugammadex. Resolving this flow disruption resulted in a 59% reduction in the incidence of postoperative respiratory failure (p < 0.01) and a direct and variable cost savings of $447,200 and $313,160, respectively, in the first 12 months. CONCLUSIONS: The use of process flow analysis to direct surgical quality initiatives is a novel approach that emphasizes system-level strategy. Resolving flow disruptions can lead to effective QI that embraces reliability by focusing attention on common processes rather than adverse events that may be unique and therefore difficult to apply broadly.

Applying international organization for standards 9001 to create an effective surgical quality committee.

BACKGROUND: Efforts to improve surgical safety are limited by several factors and no consensus exists regarding the most effective way to improve surgical quality. The use of ISO 9001 quality standards within healthcare is recognized but has not been widely applied for improving surgical outcomes. METHODS: A surgical quality committee was created using ISO 9001:2015 standards. Quality objectives were assessed to understand how any suggested changes will be impacted due to risks and opportunities inherent in the system. RESULTS: The initial quality focus was on surgical site infections in 5 services. Change in surgical infection ratio from 2018 to 2019 showed significant improvement: coronary bypass 1.288 vs. 0.901; Colon 1.359 vs. 0.589; Hysterectomy 2.119 vs. 1.022; Knee 1.391 vs. 0.306; Hip 0 vs. 0.302. CONCLUSIONS: This is one of the first studies using ISO 9001 to improve surgical quality. The results indicate both acceptance and success of applying continual improvement strategies.

Surgical Flow Disruptions, a Pilot Survey with Significant Clinical Outcome Implications.

PURPOSE OF REVIEW: Surgical flow disruptions (SFD) are deviations from the progression of a procedure which can be potentially compromising to the safety of the patient. Investigators have previously demonstrated that SFDs can increase the likelihood of error. To date, there has been no investigation into flow disruptions through the eyes of clinicians in the operating room. This study, therefore, attempted to better understand SFDs and their impact from the perspective of operating room team members. RECENT FINDINGS: After Institutional Review Board approval, a survey was sent to operating room team members including surgeons, anesthesia providers, nurses, and surgical technologists. The survey was developed to assess the perceived frequency and consequences of SFDs, and the ability to report and perceive the efficacy of reporting to management. Among 111 survey participants, 65% reported that surgical flow disruptions happen either "several times a day" or "every procedure." Forty percent ranked poor communication as the most frequent cause of SFDs. Ten percent reported equipment failure was the most frequent cause of SFDs. Respondents who identified as attending surgeons felt impacts on patient safety and staff burnout was the most likely consequence of SFDs. Scrub technicians and nurses felt that economic consequences were the most likely result. Forty-four percent did not feel reporting led to effective change. Thirty-five percent did not believe they could report issues without adverse consequences. Flow disruptions represent patterns or accumulations of disruptions which may highlight weak points in surgical systems and potential causes of staff burnout and medical error. The data in the present investigation demonstrate that OR team members recognize surgical flow disruptions are an important issue and believe poor communication and equipment problems are a significant factor. Our data additionally suggest the groups surveyed do not feel safe or productive in reporting flow disruptions.

ECMO During Combined Heart-Kidney Transplantation: A Case Report.

Combined heart-kidney transplantation (CHKT) is a therapy for a carefully selected subgroup of patients with concomitant heart and kidney failure. Discerning whether there is reversible or irreversible kidney disease is crucial to selection for CHKT versus heart transplant alone to optimize therapeutic value and organ allocation. Methods for determining extent of kidney disease include estimating glomerular filtration rate, creatinine clearance, kidney ultrasonography, and kidney biopsy. Additionally, the use of extracorporeal membrane oxygenation (ECMO) in the setting of CHKT only recently emerged as feasible. We present a case of a 69-year-old man with cardiogenic shock who was placed on venoarterial-ECMO (VA-ECMO) following orthotopic heart transplant (OHT) due to severe mediastinal bleeding and remained on VA-ECMO during kidney transplant. To our knowledge, this is the second report of a patient undergoing kidney transplant while on VA-ECMO following OHT.

The Change in Surgical Case Diversity Over the Past 15 Years and the Influence on the Pursuit of Surgical Fellowship.

The surgical community has expressed concern that residents do not receive the same caliber training as their predecessors and the increase in fellowships have been described as secondary to perceived lack of preparation. Yet, data show no change in total cases even after implementation of the 80-hour workweek. It is hypothesized that the increasing subspecialization of general surgery may decrease in certain resident case numbers. Data were collected from the Accreditation Council for Graduate Medical Education (ACGME) General Surgery Case Logs National Data Report (1999-2014) of mean number of procedures per resident for 19 surgical categories. Statistical analysis was performed with analysis of variance over three time periods between 1999 and 2014. The number of total cases performed by residents has not changed significantly. There was a statistically significant difference observed in the variety of cases: vascular, esophageal, breast, and trauma cases decreased (P < 0.01), whereas major intestinal, hernia, liver, pancreatic, and biliary cases increased (P < 0.01). There are many reasons to pursue additional training after residency. The demonstrated change in case variability, presumably secondary to increasing fellowships, may play a significant role on training and preparation. Close monitoring of curriculums is essential to ensure a comprehensive general surgical education.

Factors leading to pancreatic resection in patients with pancreatic cancer: a national perspective.

BACKGROUND: Resection is the only option for potential cure in pancreatic cancer. Patients admitted for resection may have the procedure deferred during their hospitalization. We aim to identify factors that lead pancreatic cancer patients to undergo resection. METHODS: An analysis utilizing the Nationwide Inpatient Sample (NIS) database, 2003-2009. Study population included adults (≥18 years) with pancreatic cancer who underwent either pancreatic resection or other interventions. Surgeon volume classified based on the median into low and high-volume surgeon. RESULTS: Eleven thousand three hundred and sixty-five patients were included; 68.0% underwent pancreatic resection, while 32.0% had other interventions. The majority of patients resected were <60 years old, female, with higher annual household income (P<0.05 for all). Patients with Medicaid coverage and comorbidity scores ≥2 were least likely to undergo pancreatic resection. Resection was more likely for high-volume surgeons, high-volume hospitals and teaching hospitals (P<0.05 for all). Those managed by high-volume surgeons were at a lower risk of postoperative complications, lower mortality, shorter hospital stay, and lower healthcare costs (P<0.05 for all). CONCLUSIONS: Patients' insurance type and economic status are significantly associated with their ability to achieve pancreatic resection. Surgeon experience and hospital volumes were also significantly associated with pancreatic resection, clinical and economic outcomes.

The Economics of Private Practice versus Academia in Surgery.

OBJECTIVE: Residents often make career decisions regarding future practice without adequate knowledge to the realities of professional life. Currently there is a paucity of data regarding economic differences between practice models. This study seeks to illuminate the financial differences of surgical subspecialties between academic and private practice. DESIGN: Data were collected from the Association of American Medical College (AAMC) and the Medical Group Management Association's (MGMA) 2015 reports of average annual salaries. Salaries were analyzed for general surgery and 7 subspecialties. Fixed time of practice was set at 30 years. Assumptions included 5 years as assistant professor, 10 years as associate professor, and 15 years as full professor. Formula used: (average yearly salary) × [years of practice (30 yrs - fellowship/research yrs)] + ($50,000 × yrs of fellowship/research) = total adjusted lifetime revenue. RESULTS: As a full professor, academic surgeons in all subspecialties make significantly less than their private practice counterparts. The largest discrepancy is in vascular and cardiothoracic surgery, with full professors earning 16% and 14% less than private practitioners. Plastic surgery and general surgery are the only 2 disciplines that have similar lifetime revenues to private practitioners, earning 2% and 6% less than their counterparts' lifetime revenue. CONCLUSIONS: Academic surgeons in all surgical subspecialties examined earn less lifetime revenue compared to those in private practice. This difference in earnings decreases but remains substantial as an academic surgeon advances. With limited exposure to the diversity of professional arenas, residents must be aware of this discrepancy.

Community health indicators associated with outcomes of pancreatectomy.

PURPOSE: This study evaluates the association of environmental, social and health risk factors in relation to outcomes of pancreatic surgery. METHODS: Patients who underwent pancreatectomy with a 30 day postoperative follow up in Florida, New York and Washington states were identified using the State Inpatient Databases (SID) from 2010 to 2011. This data was merged with community health indicators complied from the County Health Ranking database. Fourteen community health indicators were used to determine higher risk communities. Communities were then divided into low and high risk communities based on a scoring system using accumulative community risk. RESULTS: Among 3494 patients included recipients in high-risk communities were more likely African American (p < 0.001), younger (age 40-59; p = 0.001), and had Medicaid as primary insurance (p = 0.001). Management of patients in high-risk communities was associated with increased risk of postoperative complications (p < 0.001), ICU admissions (p < 0.001), increased length of stay (p < 0.001). CONCLUSION: Health indicators from patients' communities are predictors of increased risk of perioperative complications for individuals undergoing pancreas surgery.

The Economics of Academic Advancement Within Surgery.

BACKGROUND: The success of an academic surgeon's career is often viewed as directly related to academic appointment; therefore, the sequence of promotion is a demanding, rigorous process. This paper seeks to define the financial implication of academic advancement across different surgical subspecialties. STUDY DESIGN: Data was collected from the Association of American Medical College's 2015 report of average annual salaries. Assumptions included 30 years of practice, 5 years as assistant professor, and 10 years as associate professor before advancement. The base formula used was: (average annual salary) × (years of practice [30 years - fellowship/research years]) + ($50,000 × years of fellowship/research) = total adjusted lifetime salary income. RESULTS: There was a significant increase in lifetime salary income with advancement from assistant to associate professor in all subspecialties when compared to an increase from associate to full professor. The greatest increase in income from assistant to associate professor was seen in transplant and cardiothoracic surgery (35% and 27%, respectively). Trauma surgery and surgical oncology had the smallest increases of 8% and 9%, respectively. With advancement to full professor, the increase in lifetime salary income was significantly less across all subspecialties, ranging from 1% in plastic surgery to 8% in pediatric surgery. CONCLUSION: When analyzing the economics of career advancement in academic surgery, there is a substantial financial benefit in lifetime income to becoming an associate professor in all fields; whereas, advancement to full professor is associated with a drastically reduced economic benefit.

Is it All About the Money? Not All Surgical Subspecialization Leads to Higher Lifetime Revenue when Compared to General Surgery.

OBJECTIVE: It is believed that spending additional years gaining expertise in surgical subspecialization leads to higher lifetime revenue. Literature shows that more surgeons are pursuing fellowship training and dedicated research years; however, there are no data looking at the aggregate economic impact when training time is accounted for. It is hypothesized that there will be a discrepancy in lifetime income when delay to practice is considered. DESIGN: Data were collected from the Medical Group Management Association's 2015 report of average annual salaries. Fixed time of practice was set at 30 years, and total adjusted revenue was calculated based on variable years spent in research and fellowship. All total revenue outcomes were compared to general surgery and calculated in US dollars. PARTICIPANTS: The financial data on general surgeons and 9 surgical specialties (vascular, pediatric, plastic, breast, surgical oncology, cardiothoracic, thoracic primary, transplant, and trauma) were examined. RESULTS: With fellowship and no research, breast and surgical oncology made significantly less than general surgery (-$1,561,441, -$1,704,958), with a difference in opportunity cost equivalent to approximately 4 years of work. Pediatric and cardiothoracic surgeons made significantly more than general surgeons, with an increase of opportunity cost equivalent to $5,301,985 and $3,718,632, respectively. With 1 research year, trauma surgeons ended up netting less than a general surgeon by $325,665. With 2 research years, plastic and transplant surgeons had total lifetime revenues approximately equivalent to that of a general surgeon. CONCLUSIONS: Significant disparities exist in lifetime total revenue between surgical subspecialties and in comparison, to general surgery. Although most specialists do gross more than general surgeons, breast and surgical oncologists end up netting significantly less over their lifetime as well as trauma surgeons if they do 1 year of research. Thus, the economic advantage of completing additional training is dependent on surgical field and duration of research.

Choosing Surgery: Identifying Factors Leading to Increased General Surgery Matriculation Rate.

Tulane graduates have, over the past six years, chosen general surgical residency at a rate above the national average (mean 9.6% vs 6.6%). With much of the recent career choice research focusing on disincentives and declining general surgery applicants, we sought to identify factors that positively influenced our students' decision to pursue general surgery. A 50-question survey was developed and distributed to graduates who matched into a general surgery between the years 2006 and 2014. The survey evaluated demographics, exposure to surgery, and factors affecting interest in a surgical career. We achieved a 54 per cent (61/112) response rate. Only 43 per cent considered a surgical career before medical school matriculation. Fifty-nine per cent had strongly considered a career other than surgery. Sixty-two per cent chose to pursue surgery during or immediately after their surgery clerkship. The most important factors cited for choosing general surgery were perceived career enjoyment of residents and faculty, resident/faculty relationship, and mentorship. Surgery residents and faculty were viewed as role models by 72 and 77 per cent of responders, respectively. This study demonstrated almost half of those choosing a surgical career did so as a direct result of the core rotation experience. We believe that structuring the medical student education experience to optimize the interaction of students, residents, and faculty produces a positive environment encouraging students to choose a general surgery career.

Training in dialysis access - charting future success.

PURPOSE: Medical education and training in dialysis access skills remains complex and inadequate as learners come from diverse backgrounds and from various specialties so that appropriate training is limited. As a result, a system of progressive education including live lectures, and hands on training has emerged, but there is controversy as to what constitutes the best educational model. METHODS: Presently there is no recognized or structured training in vascular access during residency or fellowships. Here we present a model of dialysis access training for beginner to advanced surgeons. RESULTS: A structured hands-on and didactic surgery training certification course consisting of a one week curriculum with 49 hours of ACCME credit hours has been in effect for one year. The learning impact and the performance outcome are high but with limited attendance capacity. Pre- and post- training test results attest to training effectiveness. To increase access, an off-site training curriculum has been initiated, entailing 1-2 days (8-15 credit hours) consisting of didactic lectures and surgical training. This teaching module has moderate learning impact for 50-100 attendees.Finally, a tiered, web-based training curriculum (10 ACCME credit hours) can accommodate an unlimited number of learners, but has a lower skills learning impact. CONCLUSIONS: The future dialysis access training must also accommodate learners with diverse individual backgrounds, and different levels of professional (skill) development. To be effective and accessible, a variety of educational system, for example on site or web based is needed. Collaborative initiatives for global dialysis access training are currently underway.

Risk of Intraoperative Injury of Nearby Structures: National Trend, Distribution, and Burden.

BACKGROUND: Accidental injury of a nearby structure during surgical operations carries a risk of serious morbidity and mortality. Furthermore, it represents a medico-legal liability. We aimed to examine the national distribution, cost, and trend of accidental intraoperative injuries. STUDY DESIGN: We performed a cross-sectional study using the Nationwide Inpatient Sample database. The study population consisted of patients who encountered intraoperative injuries between 2003 and 2010. Controls were randomly selected from patients who underwent similar procedures during the same period. Cost was adjusted for inflation rate to reflect 2015 dollar values. RESULTS: A total of 61,667 cases with intraoperative injuries and 430,424 controls were included. Intraoperative injuries were most common in procedures that involved the digestive system (38.0%), female reproductive organs (21.4%), and musculoskeletal system (12.2%). There was a significant increase in those injuries from 161.3 cases/100,000 procedures in 2003 to 254.9 cases/100,000 procedures in 2010 (p < 0.001). Female sex, pediatric and older populations, overweight, trauma and teaching hospital were all independent risk factors of injuries in the multivariate model (p < 0.05 for all). Intraoperative injuries were associated with a higher risk of concomitant complications (odds ratio [OR] 2.44, 95% CI 2.36, 2.54, p < 0.001) and hospital mortality risk (OR 2.33, 95% CI [2.15, 2.51], p < 0.001). Nationally, it is estimated that injuries of nearby structures resulted in an annual average of 84,708.7 days of excess hospital admission days and $426.33 million excess cost. CONCLUSIONS: Certain demographic and clinical factors influence the risk of intraoperative injury of nearby structures. The prevalence of intraoperative injuries is increasing at the national level, and these injuries are associated with increased mortality and pose substantial clinical and financial burdens.

The impact of statins on biological characteristics of stem cells provides a novel explanation for their pleiotropic beneficial and adverse clinical effects.

Statins reduce atherosclerotic events and cardiovascular mortality. Their side effects include memory loss, myopathy, cataract formation, and increased risk of diabetes. As cardiovascular mortality relates to plaque instability, which depends on the integrity of the fibrous cap, we hypothesize that the inhibition of the potential of mesenchymal stem cells (MSCs) to differentiate into macrophages would help to explain the long known, but less understood "non-lipid-associated" or pleiotropic benefit of statins on cardiovascular mortality. In the present investigation, MSCs were treated with atorvastatin or pravastatin at clinically relevant concentrations and their proliferation, differentiation potential, and gene expression profile were assessed. Both types of statins reduced the overall growth rate of MSCs. Especially, statins reduced the potential of MSCs to differentiate into macrophages while they exhibited no direct effect on macrophage function. These findings suggest that the limited capacity of MSCs to differentiate into macrophages could possibly result in decreased macrophage density within the arterial plaque, reduced inflammation, and subsequently enhance plaque stability. This would explain the non-lipid-associated reduction in cardiovascular events. On a negative side, statins impaired the osteogenic and chondrogenic differentiation potential of MSCs and increased cell senescence and apoptosis, as indicated by upregulation of p16, p53 and Caspase 3, 8, and 9. Statins also impaired the expression of DNA repair genes, including XRCC4, XRCC6, and Apex1. While the effect on macrophage differentiation explains the beneficial side of statins, their impact on other biologic properties of stem cells provides a novel explanation for their adverse clinical effects.

The safety and efficacy of approaches to liver resection: a meta-analysis.

BACKGROUND: The aim of this study is to compare the safety and efficacy of conventional laparotomy with those of robotic and laparoscopic approaches to hepatectomy. DATABASE: Independent reviewers conducted a systematic review of publications in PubMed and Embase, with searches limited to comparative articles of laparoscopic hepatectomy with either conventional or robotic liver approaches. Outcomes included total operative time, estimated blood loss, length of hospitalization, resection margins, postoperative complications, perioperative mortality rates, and cost measures. Outcome comparisons were calculated using random-effects models to pool estimates of mean net differences or of the relative risk between group outcomes. Forty-nine articles, representing 3702 patients, comprise this analysis: 1901 (51.35%) underwent a laparoscopic approach, 1741 (47.03%) underwent an open approach, and 60 (1.62%) underwent a robotic approach. There was no difference in total operative times, surgical margins, or perioperative mortality rates among groups. Across all outcome measures, laparoscopic and robotic approaches showed no difference. As compared with the minimally invasive groups, patients undergoing laparotomy had a greater estimated blood loss (pooled mean net change, 152.0 mL; 95% confidence interval, 103.3-200.8 mL), a longer length of hospital stay (pooled mean difference, 2.22 days; 95% confidence interval, 1.78-2.66 days), and a higher total complication rate (odds ratio, 0.5; 95% confidence interval, 0.42-0.57). CONCLUSION: Minimally invasive approaches to liver resection are as safe as conventional laparotomy, affording less estimated blood loss, shorter lengths of hospitalization, lower perioperative complication rates, and equitable oncologic integrity and postoperative mortality rates. There was no proven advantage of robotic approaches compared with laparoscopic approaches.

Retained foreign bodies: risk and outcomes at the national level.

BACKGROUND: Retained foreign bodies (RFB) after operative interventions are linked to an increased risk of morbidity and mortality, and represent a medico-legal liability. We aimed to identify associated risk factors and outcomes related to iatrogenic RFB in the United States. STUDY DESIGN: A cross-sectional analysis was performed on all interventions that resulted in a secondary diagnosis of RFB in the Nationwide Inpatient Sample (NIS) from 2003 to 2009. Comparative controls were randomly selected from patients who underwent similar procedures. RESULTS: We identified 3,045 cases of RFB, and 12,592 controls were included. The majority of incidents, 968 (31.8%), were reported after gastrointestinal interventions. Risk of RFB was higher in teaching hospitals (odds ratio [OR] 1.31, 95% CI [1.19, 1.45], p < 0.001). For abdominopelvic procedures, patients admitted with traumatic injuries did not demonstrate a higher risk of RFB compared with electively admitted patients (OR 1.70, 95% CI [0.94, 3.07], p = 0.08). However, for procedures unrelated to abdominopelvic surgery, patients admitted for trauma had a lower risk (OR 0.62, 95% CI [0.50, 0.78], p < 0.001). Obesity (BMI ≥ 30 kg/m(2)) and older age (≥ 65 years) were significantly associated with a higher risk only for abdominopelvic procedures (p < 0.01 for both). Retained foreign bodies were associated with a higher average cost of health services ($26,678.00 ± $769.69 vs $12,648.00 ± $192.80, p < 0.001). CONCLUSIONS: Retained foreign bodies have unfavorable and nationally tangible clinical and economic outcomes. The risk profile for RFB at the national level seems to demonstrate an association with demographic and clinical factors including nature of the procedure, type of admission, and trauma status. Teaching hospitals are associated with a higher risk. Targeted efforts toward identified high-risk populations are needed to avoid these morbid and costly complications.

Team training to establish a safety culture in dialysis access surgery.

Operating room (OR) team safety training and learning in the field of dialysis access is well suited for the use of simulators, simulated case learning and root cause analysis of adverse outcomes. The objectives of OR team training are to improve communication and leadership skills, to use checklists and to prevent errors. Other objectives are to promote a change in the attitudes towards vascular access from learning through mistakes in a nonpunitive environment, to positively impact the employee performance and to increase staff retention by making the workplace safer, more efficient and user friendly.

Patient safety in peritoneal dialysis.

Peritoneal dialysis (PD) is effective and safe when patients and caregivers understand the best practices. Health care teams responsible for PD must act in a coordinated and consistent manner to ensure the most effective outcomes. This chapter will review the evidence for PD and discuss the safety implications of the phases of PD from patient selection to education to maintenance.