Surgical management of carotid body tumors: a 15-year single institution experience employing an interdisciplinary approach.

Cervical paragangliomas are rare neoplasms that arise from extraadrenal paraganglia in close association with the cranial nerves and extracranial arterial system of the head and neck, and therefore surgical extirpation can be challenging. A retrospective study was conducted of all patients undergoing surgical excision of a cervical paraganglioma between 2000 and 2015. The demographic characteristics, clinical features, surgical approach, and outcomes were reviewed. A total of 20 cervical paragangliomas were excised in 17 patients. There were 14 female and 3 male patients with a mean age of 56.6 ± 17.0 at the time of operation. Twelve patients had unilateral tumors and 5 patients had bilateral tumors. Familial involvement was confirmed by history or direct genetic analysis in 8 (47%) of the 17 patients. There were no malignant paragangliomas, and only 3 patients had tumors that were determined to be functional. Tumor size ranged from 1.3 to 6.0 cm. Two patients required combined arterial resection as part of complete excision of the tumor. There were no permanent operative cranial nerve injuries, no recurrences, minimal morbidity, and no mortality. In conclusion, optimal management of cervical paragangliomas should include a thorough preoperative evaluation, accurate definition of the surgical anatomy, and exclusion of synchronous paragangliomas. A combined therapeutic approach by a multidisciplinary team including surgeons and interventional radiologists provides safe and effective management of cervical paragangliomas with very low morbidity and excellent outcomes.

Enhancing surgical safety using digital multimedia technology.

BACKGROUND: The purpose of this study was to examine whether incorporating digital and video multimedia components improved surgical time-out performance of a surgical safety checklist. METHODS: A prospective pilot study was designed for implementation of a multimedia time-out, including a patient video. Perceptions of the staff participants were surveyed before and after intervention (Likert scale: 1, strongly disagree to 5, strongly agree). RESULTS: Employee satisfaction was high for both time-out procedures. However, employees appreciated improved clarity of patient identification (P < .05) and operative laterality (P < .05) with the digital method. About 87% of the respondents preferred the digital version to the standard time-out (75% anesthesia, 89% surgeons, 93% nursing). Although the duration of time-outs increased (49 and 79 seconds for standard and digital time-outs, respectively, P > .001), there was significant improvement in performance of key safety elements. CONCLUSION: The multimedia time-out allows improved participation by the surgical team and is preferred to a standard time-out process.

Methicillin-Resistant Staphylococcus aureus Colonization and Empyema: Does it Matter?

BACKGROUND: The relation between MRSA colonization and empyema culture results is unknown. We hypothesized that MRSA-colonized patients would be more likely to develop MRSA empyema, and sought to determine if MRSA culture positive empyema had an effect on clinical management or patient outcomes. METHODS: The medical records of patients with a diagnosis of empyema from 2007-2010 were retrospectively reviewed for demographics, MRSA colonization status, comorbidities, culture results, clinical management, and discharge disposition. The relationship between MRSA colonization status and culture results was analyzed by bivariate testing. Logistic regression was utilized to determine relations between empyema culture results, comorbidities, and clinical course. RESULTS: Of 147 patients identified with empyema, 16 (10.8%) were MRSA colonized. Colonized patients had substantially higher rates of MRSA-positive empyema cultures (75% vs. 4.6%; p<0.001). A greater percentage of the MRSA-positive empyema patients 66.7% were managed with tube thoracostomy alone, compared with culture positive patients with an organism other than MRSA and those with negative cultures (39% and 34% respectively; p=0.043). Neither empyema culture results nor colonization status were substantial risk factors for poor discharge (skilled nursing facility, long-term care hospital, or death). CONCLUSIONS: MRSA-colonized patients hospitalized with empyema are highly likely to have cultures positive for MRSA.

Patients' Perspectives of Surgical Safety: Do They Feel Safe?

BACKGROUND: Increased focus on reducing patient harm has led to surgical safety initiatives, including time-out, surgical safety checklists, and debriefings. The perception of the lay public of the surgical safety process is largely unknown. METHODS: A 20-question survey focused on perceptions of surgical safety practice was distributed to a random sample of patients following elective operations requiring hospitalization. Responses were measured by a 7-point Likert scale. Qualitative feedback was obtained through nonphysician-moderated sessions. Participation was voluntary and anonymous. RESULTS: Surveys were distributed to 345 patients of whom 102 (29.5%) responded. Overall, patients felt safe as evidenced by scores for the questions "I felt safe the day of my surgery" (6.53 ± 0.72) and "Mistakes rarely happen during surgery" (5.39 ± 1.51). Patients undergoing their first surgery and patients with higher income levels were associated with a significant decrease in specific safety perceptions. Qualitative feedback sessions identified the physician-patient relationship as the most important factor positively influencing patient safety perceptions. CONCLUSION: Current surgical safety practice is perceived positively by our patients; however, patients still identify physician-patient interactions, relationships, and trust as the most positive factors influencing their perception of the safety environment.

A standard handoff improves cardiac surgical patient transfer: operating room to intensive care unit.

BACKGROUND: Patient handoffs are high-risk times associated with sentinel events. Effective handoff processes may enhance patient safety and team member communication. This study assesses the impact of a standardized protocol for handoffs from the cardiac surgery operating room to intensive care unit (ICU). METHODS: Using a prospective pre-post study design, a formalized handoff process was developed including critical handoff elements and a standardized handoff procedure, script, and checklist. Data were collected from 60 handoff observations (30 pre and 30 post), evaluating 52 unique parameters, and survey of providers on perspectives of the handoff process. Results were compared by chi-square test, two sample t-test, or nonparametric Mann-Whitney test. Statistical significance was defined as P ≤ .05. RESULTS: Provider's perspectives showed improved satisfaction with the standardized handoff process through improved responses in 19 of 22 survey items (P < .001). Median time until ventilator connection, ICU monitor transfer, first cardiac index, and chest radiograph were reduced after implementation. Completion of handoff process components also improved after implementation for 36 of 47 nontime parameters. CONCLUSIONS: A standard checklist-driven handoff process can dramatically improve key data transmission and reduce time of critical patient care steps during the high-risk period of patient handoff in a cardiac surgical ICU.

Redundancy and variability in quality and outcome reporting for cardiac and thoracic surgery.

Health care is evolving into a value-based reimbursement system focused on quality and outcomes. Reported outcomes from national databases are used for quality improvement projects and public reporting. This study compared reported outcomes in cardiac and thoracic surgery from two validated reporting databases-the Society of Thoracic Surgeons (STS) database and the National Surgical Quality Improvement Program (NSQIP)-from January 2011 to June 2012. Quality metrics and outcomes included mortality, wound infection, prolonged ventilation, pneumonia, renal failure, stroke, and cardiac arrest. Comparison was made by chi-square analysis. A total of 737 and 177 cardiac surgery cases and 451 and 105 thoracic surgery cases were captured by the STS database and NSQIP, respectively. Within cardiac surgery, there was a statistically significant difference in the reported rates of prolonged ventilation, renal failure, and mortality. No significant differences were found for the thoracic surgery data. In conclusion, our data indicated a significant discordance in quality reporting for cardiac surgery between the NSQIP and the STS databases. The disparity between databases and duplicate participation strongly indicates that a unified national quality reporting program is required. Consolidation of reporting databases and standardization of morbidity definitions across all databases may improve participation and reduce hospital cost.

A novel method for the management of post-thyroidectomy or parathyroidectomy hematoma: a single-institution experience after over 4,000 central neck operations.

BACKGROUND: Cervical hematoma is a rare but serious complication of thyroid and parathyroid surgery that has historically required inpatient monitoring. With improved surgical technique and experience, operations are being performed increasingly as outpatient procedures. Therefore, a safe and systematic approach to cervical exploration of a postoperative hematoma needs to be defined. METHODS: From 1996 to 2013, a retrospective review was performed of 4,140 thyroid and parathyroid operations. Surgical outcomes data were recorded, specifically including the occurrence of a cervical hematoma, time interval to presentation, and methods of management. RESULTS: A total of 18 patients (0.43 %) developed a postoperative cervical hematoma that required surgical intervention. The occurrence of hematoma was 0.66 % (n = 11) for bilateral thyroid procedures, 0.21 % (n = 3) for unilateral thyroid procedures, and 0.13 % (n = 1) for parathyroid procedures. There were 3 (1.69 %) patients who had combined unilateral thyroid and parathyroid procedures and developed hematomas. Emergent bedside decompression was required for only two patients, both of whom suffered respiratory arrest in the postoperative anesthesia recovery unit. The remaining 16 patients were explored in the operating room, utilizing initial local anesthesia in the semi-upright position in 11 patients (69 %). CONCLUSIONS: From our experience, hematomas that caused significant airway compromise leading to respiratory arrest occurred in the postoperative anesthesia recovery room, and hematoma presentation after this time did not require emergent bedside decompression. Hematoma, when it occurs, can otherwise be managed safely in the operating room after inpatient or outpatient procedures using initial local anesthesia with the patient in the semi-upright position for hematoma evacuation.

Thymic neuroendocrine carcinoma producing ectopic adrenocorticotropic hormone and Cushing's syndrome.

Neuroendocrine carcinoma of the thymus, previously termed thymic carcinoid, is a rare clinical entity. Rarer still are such cases presenting with endocrinopathies. We report a case of thymic neuroendocrine carcinoma presenting with ectopic adrenocorticotroic hormone production and resultant Cushing's syndrome.

House Staff Quality Council: One Institution's Experience to Integrate Resident Involvement in Patient Care Improvement Initiatives.

BACKGROUND: Residents and fellows perform a large portion of the hands-on patient care in tertiary referral centers. As frontline providers, they are well suited to identify quality and patient safety issues. As payment reform shifts hospitals to a fee-for-value-type system with reimbursement contingent on quality outcomes, preventive health, and patient satisfaction, house staff must be intimately involved in identifying and solving care delivery problems related to quality, outcomes, and patient safety. Many challenges exist in integrating house staff into the quality improvement infrastructure; these challenges may ideally be managed by the development of a house staff quality council (HSQC). METHODS: Residents and fellows at Scott & White Memorial Hospital interested in participating in a quality council submitted an application, curriculum vitae, and letter of support from their program director. Twelve residents and fellows were selected based on their prior quality improvement experience and/or their interest in quality and safety initiatives. RESULTS: In only 1 year, our HSQC, an Alliance of Independent Academic Medical Centers National Initiative III project, initiated 3 quality projects and began development of a fourth project. CONCLUSION: Academic medical centers should consider establishing HSQCs to align institutional quality goals with residency training and medical education.

Quick Response codes for surgical safety: a prospective pilot study.

BACKGROUND: Surgical safety programs have been shown to reduce patient harm; however, there is variable compliance. The purpose of this study is to determine if innovative technology such as Quick Response (QR) codes can facilitate surgical safety initiatives. METHODS: We prospectively evaluated the use of QR codes during the surgical time-out for 40 operations. Feasibility and accuracy were assessed. Perceptions of the current time-out process and the QR code application were evaluated through surveys using a 5-point Likert scale and binomial yes or no questions. RESULTS: At baseline (n = 53), survey results from the surgical team agreed or strongly agreed that the current time-out process was efficient (64%), easy to use (77%), and provided clear information (89%). However, 65% of surgeons felt that process improvements were needed. Thirty-seven of 40 (92.5%) QR codes scanned successfully, of which 100% were accurate. Three scan failures resulted from excessive curvature or wrinkling of the QR code label on the body. Follow-up survey results (n = 33) showed that the surgical team agreed or strongly agreed that the QR program was clearer (70%), easier to use (57%), and more accurate (84%). Seventy-four percent preferred the QR system to the current time-out process. CONCLUSIONS: QR codes accurately transmit patient information during the time-out procedure and are preferred to the current process by surgical team members. The novel application of this technology may improve compliance, accuracy, and outcomes.

Surgical resection of giant fibrous dysplasia for near respiratory collapse.

Fibrous dysplasia may involve the ribs or thoracic spine and cause progressive asphyxiation. We present a 41-year-old man with polyostotic fibrous dysplasia who was admitted to the hospital with progressive shortness of breath requiring initiation of supplemental oxygen. Pulmonary function test results revealed severely limited function with forced expiratory volume in 1 second (FEV1) of 14% predicted and diffusion capacity of 17%. As a lifesaving effort, the patient was offered resection, decortication, and chest wall reconstruction, after which the lung reexpanded. At 6 months, his FEV1 was 49% and his diffusion capacity was 56%. He no longer required supplemental oxygen and now exercises daily.