Beyond the Surgical Safety Checklist: Using Intraoperative Handoff to Facilitate Team Situation Awareness in the OR.

BACKGROUND: The surgical safety checklist (SSC) has been credited with improving team situation awareness (SA) in the operating room. Although the SSC may support team SA at the outset of the operative case, intraoperative handoff provides an opportunity for either SA breakdown or, more preferably, SA reinforcement. High-functioning surgical teams demonstrate a high level of continued SA, whereas teams deficient in SA are more likely to be affected by surgical errors and adverse events. To date, no interprofessional intraoperative tools exist to support team SA beyond the SSC. METHODS: This study was divided into 2 phases. The first used qualitative methods to (1) characterize intraoperative handoff processes across surgery, nursing, anesthesia, and perfusion, and (2) identify cultural factors that shaped handoff practices. Data for phase one were collected over 38 observation days and 41 brief interviews. Phase 2, informed by phase 1, used a modified Delphi process to create a tool for use during intraoperative handoff. Data were analyzed iteratively. RESULTS: Handoff practices were not standardized and rarely involved the entire team. In addition we uncovered cultural factors-specifically assumptions held by participants-that hindered team communication during handoff. Assumptions included: (1) team members are interchangeable, (2) trained individuals are able to determine when it is appropriate to handoff without consulting the OR team. Despite claims of improved teamwork resulting from the SSC, many participants held a fragmented view of the OR team, resulting in communication challenges during handoff. Findings from both phases of our study informed the development of multidisciplinary intraoperative handoff tools to facilitate shared team situation awareness and a shared mental model. CONCLUSIONS: Intraoperative handoff occurs frequently, and offers the opportunity for either renewed or fractured team SA beyond the SSC.

ECG Changes in a Case of Posterior Myocardial Infarction in the Presence of Right Bundle Branch Block.

A 70-year-old male with hypertension and diabetes presented to the emergency department with a 1-hour history of chest pain. Initial 12-lead ECG revealed a right bundle branch block (RBBB) and ST depression (STD) in V2-V4. The anterior STD prompted a 15-lead ECG in which there was no evidence of ST elevation (STE). With a positive troponin, cardiology was consulted and the patient was admitted as a high-risk non-ST-elevation myocardial infarction (NSTEMI). Subsequently, his chest pain returned without further ST changes, regardless the patient went for emergency coronary angiography, which found a complete occlusion of the left circumflex artery. Anterior STD is a normal finding in RBBB and posterior STEs in the posterior leads are not always present making the recognition of posterior STEMI difficult. This case highlights three findings in leads V1-V3 that are concerning for posterior ischemia in the context of chest pain and an RBBB: tall R waves, upright T waves, and marked STD > 2 mm. This should prompt serial 15-lead ECGs and prompt cardiology consultation.

Blood product transfusion during air medical transport: A needs assessment.

OBJECTIVES: Early administration of blood products to patients with hemorrhagic shock has a positive impact on morbidity and mortality. Smaller hospitals may have limited supply of blood, and air medical systems may not carry blood. The primary outcome is to quantify the number of patients meeting established physiologic criteria for blood product administration and to identify which patients receive and which ones do not receive it due to lack of availability locally. METHODS: Electronic patient care records were used to identify a retrospective cohort of patients undergoing emergent air medical transport in Ontario, Canada, who are likely to require blood. Presenting problems for blood product administration were identified. Physiologic data were extracted with criteria for transfusion used to identify patients where blood product administration is indicated. RESULTS: There were 11,520 emergent patient transports during the study period, with 842 (7.3%) where blood product administration was considered. Of these, 290 met established physiologic criteria for blood products, with 167 receiving blood, of which 57 received it at a hospital with a limited supply. The mean number of units administered per patient was 3.5. The remaining 123 patients meeting criteria did not receive product because none was unavailable. CONCLUSION: Indications for blood product administration are present in 2.5% of patients undergoing time-sensitive air medical transport. Air medical services can enhance access to potentially lifesaving therapy in patients with hemorrhagic shock by carrying blood products, as blood may be unavailable or in limited supply locally in the majority of patients where it is indicated.

The economics of recovery after pancreatic surgery: detailed cost minimization analysis of an enhanced recovery program.

BACKGROUND: Clinical pathways (CPW) are considered safe and effective at decreasing postoperative length of stay (LoS), but the effect on economic costs is uncertain. This study sought to elucidate the effect of a CPW on direct hospitalization costs for patients undergoing pancreaticoduodenectomy (PD). METHODS: A CPW for PD patients at a single Canadian institution was implemented. Outcomes included LoS, 30-day readmissions, and direct costs of hospital care. A retrospective cost minimization analysis compared patients undergoing PD prior to and following CPW implementation, using a bootstrapped t test and deviation-based cost modeling. RESULTS: 121 patients undergoing PD after CPW implementation were compared to 74 controls. Index LoS was decreased following CPW implementation (9 vs. 11 days, p = 0.005), as was total LoS (10 vs. 11 days, p = 0.003). The mean total cost of postoperative hospitalization per patient decreased in the CPW group ($15,678.45 CAD vs. $25,732.85 CAD, p = 0.024), as was the mean 30-day cost including readmissions ($16,627.15 CAD vs. $29,872.72 CAD, p = 0.016). Areas of significant cost savings included laboratory tests and imaging investigations. CONCLUSIONS: CPWs may generate cost savings by reducing unnecessary investigations, and improve quality of care through process standardization and decreasing practice variation.

Echocardiographic Detection of Cardiac Dysfunction in Childhood Cancer Survivors: How Long Is Screening Required?

BACKGROUND: Childhood cancer survivors treated with anthracycline chemotherapy are at an increased risk of long-term cardiac toxicity, and guidelines recommend that exposed survivors undergo echocardiography every 1-5 years. However, it is unclear whether survivors should undergo echocardiographic screening indefinitely, or if a period of echocardiographic stability indicates that screening is no longer necessary. The objective of this study was to evaluate the outcomes of echocardiographic screening to aid in the refinement of existing guidelines. METHODS: We retrospectively analyzed the results of echocardiographic screening in a cohort of adult survivors of childhood cancer treated with anthracyclines and/or cardiac radiation therapy. Interval regression analysis was performed to identify predictors of single-episode or sustained abnormal echocardiograms. RESULTS: The cohort constituted 333 survivors, with median follow-up time of 15.8 years post-treatment (range: 5.0-47.9), and median age at treatment of 8 years (range: 1.5-18). Forty-nine survivors had an abnormal echocardiogram (14.7%), and 29 (8.7%) had reproducible abnormal findings. An ongoing continual increase in the incidence of sustained echocardiographic abnormality was seen among patients treated with >250 mg/m(2) doxorubicin at age <5 years, reaching 43% by 20 years of therapy. In contrast, no sustained abnormal echocardiographic findings arose after 10 years of therapy in survivors treated with <250 mg/m(2) at age ≥5 years. CONCLUSIONS: Single-episode echocardiographic abnormalities are often not reproduced in subsequent evaluations. The duration of echocardiographic screening for childhood cancer survivors should be reassessed for patients who received lower doses of anthracycline after age 5.

Educating medical trainees on medication reconciliation: a systematic review.

BACKGROUND: Effective medication reconciliation is critical in reducing the risk of preventable adverse drug events. Medical trainees are often responsible for medication reconciliation on admission, transfer and discharge of the most vulnerable patients; therefore, it is important that trainees are educated on this aspect of quality care. METHODS: We conducted a systematic review using MEDLINE and EMBASE databases to identify education initiatives targeted at improving trainee skill and knowledge in carrying out medication reconciliation. Studies published in English or French between July 1980 and July 2013, where the primary focus of the article was the role of medical trainees in conducting medication reconciliation, and where trainee-specific data was reported, were included. Included articles must have reported trainee-specific data. Given the anticipated heterogeneity and array of outcomes, we were unable to employ a specific tool in assessing the risk of bias across studies. RESULTS: Seven studies met pre-specified eligibility criteria, indicating the lack of published education initiatives targeted towards improving trainee knowledge and experience. Four described an education intervention targeted towards students completing internal medicine clerkship, while the remaining 3 were implemented among residents. Although no two interventions were the same, 5 out of 7 included an experiential component. CONCLUSIONS: Varying success was achieved with medication reconciliation education interventions. While some noted improved competence and/or confidence amongst trainees, namely undergraduate medical students, others noted little effect resulting from the intervention.

Value of positron emission tomography scan in stage III cutaneous melanoma: a systematic review and meta-analysis.

PURPOSE: The objective of this study was to review the collective experience and utility of FDG-PET scans (FDG-PET) in the detection of systemic metastases in patients with stage III melanoma. METHODS: A systematic search for relevant studies published between 1990 and 2012 was performed. We included English language studies that evaluated melanoma patients with stage III disease, with at least 10 patients per study, and collected statistical data to assess FDG-PET utility in the detection of distant metastases. The SIGN tool was used to evaluate methodological quality and a meta-analysis was performed using Stata statistical software to quantify the clinical utility of FDG-PET. RESULTS: The systematic search yielded 9 studies eligible for inclusion in quantitative analyses with a total of 623 patients. The overall sensitivity of FDG-PET in detecting systemic metastases was 89.42% (95% CI: 65.07-97.46), and specificity was 88.78% (95% CI: 77.04-94.91). The pooled positive likelihood ratio was 7.97 (95% CI: 3.58-17.71) and the negative likelihood ratio was 0.12 (95% CI: 0.03-0.47). The area under the summary receiver operating curve (SROC) was 0.94 (95% CI: 0.92-0.96) and the diagnostic odds ratio (DOR) was 66.84 (95% CI: 10.66-418.89). A change in stage and/or management was noted in 22% (126/573) of patients when FDG-PET was utilized. CONCLUSIONS: Our findings indicate that FDG-PET may be useful in detecting distant metastases in patients with stage III melanoma. For this highly selected group of patients, FDG-PET has a high sensitivity, specificity and performance, frequently leading to a change in treatment plan.

Improved targeting of cancer care for older patients: a systematic review of the utility of comprehensive geriatric assessment.

A comprehensive geriatric assessment (CGA) provides clinicians with detailed information on a patient's physiological age and may aid in the treatment decision-making process. Conducting a CGA, however, is time-consuming, requiring extensive data collection and, in some cases, the involvement of multiple healthcare professionals. The CGA is also not specifically targeted towards assessing patients presenting with neoplastic pathologies. These limitations have precluded this tool's inclusion in routine oncologic practice involving seniors. In order to identify CGA domains most predictive of important cancer-specific outcomes, we conducted a systematic review (PROSPERO registration number CRD42012002476) using MEDLINE, CINAHL, EMBASE and CANCERLIT databases. Studies published in English or French between May 1997 and May 2012, in which a CGA was conducted in patients over the age of 65 initiating cancer treatment, were assessed for eligibility, of which 9 studies were selected for this review. As part of the inclusion criteria, all studies must have assessed, at minimum, the following domains: nutritional, cognitive and functional status, polypharmacy, comorbidities and the presence of geriatric syndromes. In predicting mortality, in at least one study or another, all of the aforementioned CGA domains were found to be significant. Most frequently, however, the following domains were reported for predicting mortality: nutritional status (HR=1.84-2.54), the presence of geriatric syndromes such as depression (HR=1.51-1.81), and functional status (HR=1.04-1.33). With regards to chemotherapy-related toxicity, similar findings were obtained where functional status (OR=1.71-2.47) and the presence of geriatric syndromes, such as impaired hearing (OR=1.67, 95% CI 1.04-2.69), had the most significant predictive value. Only one study reported on the incidence of post-operative complications for which severe comorbidity was found to be highly associated with experiencing severe complications (OR=5.62, 95% CI 2.18-14.50), while functional status was found to be significantly associated with experiencing any complication (OR=4.02, 95% CI 1.24-13.09).