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August 26, 2014
Surgeons' Perception of Intraoperative Time
We once overheard a conversation in which a surgeon was attempting to schedule a colorectal case into a free 2-hour opening on the OR schedule. The battle-tested OR manager responded “Dr. X, you’ve never done a case in less than 3 hours!”. The surgeon begged to differ. He was sure he only took about 2 hours, on average, for such cases. But the OR manager had data to back her up. In fact, the surgeon had never done such a case in less than 3 hours and most lasted considerably longer.
We’ve done a number of columns about the potential patient safety consequences of prolonged procedures and addressed the issue of lack of awareness of the duration of surgery. So one question to ask is “How aware are surgeons of their intraoperative time utilization?”.
One group of researchers, in fact, addressed that very question recently (Erestam 2014). That group did a pilot study in a Swedish academic center using surgeons’ perceptions of time spent in various phases of colorectal procedures compared to actually measured times. They found little difference at the group level between perceived and actual times. But at the individual level they found substantial variation. Time spent in the dissection/resection stage had the most variation (varied from 43 to 308 minutes). They also found a correlation between duration of some phases and duration of other phases. For example, a longer duration of the dissection/resection phase correlated with a longer time to close the abdomen. And a longer duration of the hand-sewn anastomosis also correlated with the time needed to close the abdomen.
The study was just a pilot study. There were 18 surgeons in a single center and actual time was only measured in 21 cases. The authors anticipate a larger study. But we don’t doubt for a minute the basic premise: surgeons typically have a poor awareness of their intraoperative time utilization. Note that in the Erestam study the surgeons were asked about their case time utilization at a time when they were not operating. Our experience is that surgeon awareness of case duration during actual surgery is even worse.
Our March 10, 2009 Patient Safety Tip of the Week “Prolonged Surgical Duration and Time Awareness” discussed time unawareness during many surgeries. In addition to the potential impact on infectious complications, we noted that there are other potential patient safety issues related to prolonged surgical duration such as DVT, decubiti, hypothermia, fluid/electrolyte shifts, nerve compression, compartment syndromes, and rhabdomyolysis. Long-duration cases also increase the likelihood of personnel changes that increase the chance of retained foreign objects or retained surgical items (see last week’s Patient Safety Tip of the Week “Some More Lessons Learned on Retained Surgical Items”). And the fatigue factor comes into play with longer cases, increasing the likelihood of a variety of other errors.
Surgical case duration is also one of the few modifiable risk factors for surgical infections. A number of studies in the past have demonstrated an association between perioperative infection and the duration of the surgical procedure. In our January 2010 What’s New in the Patient Safety World column “Operative Duration and Infection” we noted a study (Proctor et al 2010) which looked at a large database of general surgical procedures and demonstrated a linear relationship between duration of surgery and infectious complications. The infectious complication rate increased by 2.5% per half hour and hospital length of stay (LOS) also increased geometrically by 6% per half hour.
There are many factors that may lead to increased surgical durations, including case type and complexity, emergency vs. elective nature, patient-related factors, proficiency of the surgeon, lack of team familiarity, interruptions, equipment issues, presence of trainees and poor communication.
In our July 21, 2012 Patient Safety Tip of the Week “Surgical Case Duration and Miscommunications” we discussed a study (Gillespie 2012) on the various factors involved in prolonging surgery. They looked at most of the above factors plus intraoperative interruptions and whether or not pre-op huddles/briefings were done. Mean duration of surgery for all cases was 85 minutes, compared to an expected mean duration of 60 minutes. Preoperative briefings were done in only 12.5% of cases. Communication failures occurred in 57% of the cases, an average of 1.9 per case, and the only factor that independently predicted deviation from expected duration of surgery was the number of miscommunications. While interruptions were frequent (occurring in 66.9% of cases, with a mean number of interruptions per case = 2.3) they did not independently predict prolonged duration. Miscommunications were more frequent when some members of the OR team had less experience. They also had examples where insufficient or inaccurate information was conveyed but the recipient did not seek clarification.
Gillespie et al. spend a good deal of time discussing the value of preop briefings. We, of course, are big fans of the preop huddle/briefing. See our prior columns on pre-op briefings and post-op debriefings:
During a preop huddle the team will often recognize that a piece of important equipment is missing, avoiding the considerable delay that might have occurred if that had been discovered well into the case. Checklists have been utilized more often for the preoperative briefings or huddles. We previously noted a study by Lingard et al (Lingard 2008) that used a checklist to structure short team briefings and documented reduction in the number of communication failures. Our December 9, 2008 Patient Safety Tip of the Week “Huddles in Healthcare” discussed an article by Nundy and colleagues at Johns Hopkins (Nundy 2008). They used a very simple format for pre-operative briefings that led to a 31% reduction in unexpected delays in the OR and a 19% reduction in communication breakdowns that lead to delays.
We recommend that the OR team, during the presurgical huddle, should discuss issues related to prolonged cases. For example, they should discuss whether intraoperative DVT prophylaxis should begin if the procedure lasts beyond a certain duration. Or discuss at what duration a repositioning of the patient (to avoid nerve compression, compartment syndrome, or rhabdomyolysis) might be wise. And it would be very useful to have an estimate of time remaining to again trigger some discussion on the above issues. In addition to the DVT prophylaxis and repositioning issues, it might raise questions about the need to temporarily ease up on traction. It might direct attention to maintenance of the patient’s body temperature. In a very prolonged case it might raise questions about the need for further doses of prophylactic antibiotics.
So good communication begins before the patient has actually entered the OR and is necessary throughout the case to ensure more efficient and safe performance of surgery. (And don’t forget that the postop debriefing may help you save time during your next case as well!)
We also recommend that someone in the OR, usually the anesthesiologist, be tasked with calling out the running case duration at regular intervals (for example, every 30 minutes). That makes everyone aware of the issues that may need to be considered in cases that are taking longer than expected. The announcement of the duration should be accompanied by announcement of pre-agreed-upon actions (for example, a second dose of antibiotics or a change in patient positioning).
No one is happy when surgical cases take too long. There are safety issues, as noted above, for the patient. Staff dissatisfaction increases. Other patients and surgeons become disappointed if their subsequent case has to be cancelled (and that next patient’s employer becomes unhappy if he/she has to take a second day off from work). Your surgical scheduling becomes chaotic. Your hospital or facility may suffer financially due to unexpected overtime costs and lost opportunity costs (for other cases that might have been done).
So make surgical case duration an issue of importance for your organization. Make sure you keep good data on duration of all cases, major and minor, and actually utilize that data during scheduling. Do your pre-op huddles/briefings and post-op debriefings in all cases. And make intraoperative time awareness part of your regular OR routines.
Our prior columns focusing on surgical case duration:
Erestam S, Erichsen A, Derwinger K and Kodeda K. A survey of surgeons’ perception and awareness of intraoperative time utilization. Patient Safety in Surgery 2014; 8: 30 (1 July 2014)
Procter LD, Davenport DL, Bernard AC, Zwischenberger JB. General Surgical Operative Duration Is Associated with Increased Risk-Adjusted Infectious Complication Rates and Length of Hospital Stay, Journal of the Amercican College of Surgeons 2010; 210: 60-65
Gillespie BM, Chaboyer W, Fairweather N. Factors that influence the expected length of operation: results of a prospective study. BMJ Qual Saf 2012; 21(1): 3-12 Published Online First: 14 October 2011 doi:10.1136/bmjqs-2011-000169
Lingard L, Regehr G, Orser B, et al. Evaluation of a Preoperative Checklist and Team Briefing Among Surgeons, Nurses, and Anesthesiologists to Reduce Failures in Communication. Arch Surg, Jan 2008; 143: 12-17
Nundy S, Mukherjee A, Sexton JB, et al. Impact of Preoperative Briefings on Operating Room Delays: A Preliminary Report. Arch Surg 2008; 143(11): 1068-1072
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The “weekend effect” in which mortality and complications occur more frequently in patients admitted on weekends or operated upon on weekends compared to weekdays has been reported for multiple conditions. Various studies have demonstrated higher mortality rates for patients admitted on weekends with strokes, atrial fibrillation, diverticulosis surgery, a variety of other surgical procedures, head trauma, COPD, CHF, perinatal events, ICU admissions, ESRD, and other conditions. Note that we sometimes use the term “after hours effect” since some of the same issues occur in patients admitted at night.
Now a new study demonstrates the “weekend effect” also affects children undergoing surgery (Goldstein 2014). The researchers analyzed data over a 22 year period and noted that children who underwent urgent or emergency surgery on weekends were 63% more likely to die and 40% more likely to have complications than comparable patients operated upon on weekdays. They were also 15% more likely to receive blood transfusions. The surgeries analyzed were common surgeries (abscess drainage, appendectomy, inguinal hernia repair, open fracture reduction with internal fixation, or placement/revision of ventricular shunt) and the above findings were found even after adjustment for patient characteristics. While the absolute numbers of death were actually quite small the study does suggest that many of the same factors which come into play in adults also impact children.
The study did not determine which specific factors were responsible for the “weekend effect”. Our November 2013 What’s New in the Patient Safety World column “The Weekend Effect: Not One Simple Answer” highlighted a study from Australia (Concha 2013) which showed that for most of the DRG’s showing excess mortality with weekend admission there are both patient-related factors and care-related factors in play.
We’ve discussed many of the contributory factors in our many columns related to the weekend effect (see list at the end of today’s column). Our healthcare systems clearly do not deliver uniform care 24x7. The differences between the hospital during weekday daytime hours and the hospital at night and on weekends is striking. Staffing patterns (both in terms of volume and experience) are the most obvious difference but there are many others as well. Many diagnostic tests are not as readily available during these times. Physician and consultant availability may be different and cross-coverage by physicians who lack detailed knowledge about individual patients is common. You also see more verbal orders, which of course are error-prone, at night and on weekends. But we’ve also argued that often it is a difference in non-clinical staffing that is a root cause. Our December 15, 2009 Patient Safety Tip of the Week “The Weekend Effect” discussed how adding non-clinical administrative tasks to already overburdened nursing staff on weekends may be detrimental to patient care. Just do rounds on one of your med/surg floors or ICU’s on a weekend. You’ll see nurses answering phones all day long, causing interruptions in some attention-critical nursing activities. Calls from radiology and the lab that might go directly to physicians now go first to the nurse on the floor, who then has to try to track down the physician. They end up filing lab and radiology reports or faxing medication orders down to pharmacy, activities often done by clerical staff during daytime hours. In those facilities that have CPOE, nurses off-hours often end up entering those orders into the computer because the physicians are off-site and are phoning in verbal orders. You’ll also see nurses giving directions to the increased numbers of visitors typically seen on weekends. Nurses even end up doing some housekeeping chores. All of these interruptions and distractions obviously interfere with nurses’ ability to attend to their clinically important tasks (see our Patient Safety Tips of the Week for August 25, 2009 “Interruptions, Distractions, Inattention…Oops!” and May 4, 2010 “More on the Impact of Interruptions”).
For surgery there are even other considerations. Not only might the surgeon and anesthesiologist be called in from other activities but the OR team of nurses and techs are also often called in from other activities. Often the surgeries are performed by teams that are not used to working together. Though we are unaware of any published studies on environmental issues that might impact the weekend effect, we suspect that there might be factors related to equipment, sterilization procedures, overall cleanliness, OR temperature and humidity, and others that conceivably might differ on weekends.
To fix many of the above potential contributing factors would obviously require considerable resources, both financial and human. In our November 2013 What’s New in the Patient Safety World column “The Weekend Effect: Not One Simple Answer” we made a business case that cases prone to the weekend effect are likely more costly to hospitals (eg. complications are usually associated with increased lengths of stay and utilization of more tests, medications, etc.). So there is likely a return on investment (ROI) for resources spent alleviating some of these factors.
The “weekend effect” is a complex one, not easily amenable to one solution.
Some of our previous columns on the “weekend effect”:
Goldstein SD, Papandria DJ, Aboagye J, Salazar JH, et al. The “weekend effect” in pediatric surgery — increased mortality for children undergoing urgent surgery during the weekend. Journal of Pediatric Surgery 2014; 49(7): 1087-1091 July 2014
Concha OP, Gallego B, Hillman K, et al. Do variations in hospital mortality patterns after weekend admission reflect reduced quality of care or different patient cohorts? A population-based study. BMJ Qual Saf 2013; published online 25 October 2013 doi:10.1136/bmjqs-2013-002218
In our July 2014 What’s New in the Patient Safety World column “Issues on Timing of Beta Blockers in MI” we discussed a new analysis from the GRACE registry (Park 2014) that raised issues regarding the timing and route of administration of beta blockers in patients with ST-segment elevation MI (STEMI). But we also noted that studies had clearly demonstrated the long-term benefit of chronic beta blockers in patients with a history of MI and remained a mainstay in the treatment of patients who have had an MI.
Now even the latter practice has even come under scrutiny. A new meta-analysis was done on over 100,000 patients in randomized controlled trials of beta blockers after MI (Bangalore 2014). Importantly, the authors separated out the studies into the pre-reperfusion ear and the reperfusion era and found significant differences between the two timeframes. In the pre-reperfusion era beta-blockers were associated with a significant reduction in overall mortality as well as significant reductions in cardiovascular mortality, MI, and angina. In the reperfusion era there were still significant reductions in MI and angina with beta-blocker therapy but there was no overall mortality benefit. The reductions in MI and angina were balanced against increases in heart failure and cardiogenic shock. And even the benefit of reduced MI and angina appears to be limited to the period 30-days post-MI.
The authors recommend that clinical practice guidelines should reconsider the strength of recommendations for beta-blockers after myocardial infarction.
This may well result in yet another reversal of clinical practices which we had considered soundly “evidence-based” or practices that moved outside their originally researched clinical populations or settings. We’ve seen routine perioperative beta-blockers (for non-cardiac surgery) come and go. Prophylactic proton pump inhibitors gained widespread use outside ICU settings, only to have detrimental effects appear. Our push to mandate antibiotics within 4 hours for community-acquired pneumonia resulted in many patients without pneumonia being exposed unnecessarily to antibiotics. Intensive blood glucose control came and went for ICU patients. And these don’t even cover those things we mandated without a solid evidence base that continue to have unintended consequences pop up (eg. work hour restrictions, CPOE, etc.).
The Bangalore study is thus a good reminder that we need to have constant vigilance of even our most time-honored clinical practices to ensure that they are truly evidence-based, especially when other advances in medical care have occurred in the interim.
Even if the net benefit of beta-blockers after MI is neither positive nor negative, there are cost consequences to patients, hospitals, payors and society. Beta-blocker use in patients after MI is a core measure of most pay-for-performance and quality measurement programs and much time and effort is spent ensuring such patients get beta-blockers. The Bangalore group should be commended for questioning practices we’ve long felt did not need to be questioned. It will be very interesting to see whether practice guidelines are indeed reconsidered in view of the evidence they’ve presented.
One other area in which beta-blockers have often been used despite a weak evidence base is for patients with coronary heart disease without a history of prior MI. And another new analysis has further challenged that use as well (Andersson 2014). Those authors looked at over 26,000 consecutive patients discharged after a first coronary event (acute coronary syndrome or coronary revascularization) between 2000 and 2008 who had not previously been on beta-blockers. Beta-blockers were initiated within 7 days in over 19,000 of these patients. A lower risk of cardiac events with beta-blockers was seen only for patients with MI.
The accompanying editorial (Steg 2014), however, notes the Andersson study is limited by lack of data on clinical characteristics of the patients which may have influenced decisions about whether to use beta-blockers. Beta-blockers may, of course, be important in alleviation of angina in such patients so they likely will still have a role in some patients.
We suspect it is very unlikely that a randomized controlled trial of beta-blockers in either MI patients or those with other coronary syndromes will be done in the future. But the Bangalore and Andersson studies certainly raise awareness that the evidence base for such time-honored practices is far less hearty than most realize.
Park KL, Goldberg RJ, Anderson FA, et al. Beta-blocker Use in ST-segment Elevation Myocardial Infarction in the Reperfusion Era (GRACE). Am J Med 2014; 127(6): 503–511
Bangalore S, Makani H, Radford M, et al. Clinical outcomes with beta-blockers for myocardial infarction. Am J Med 2014; DOI: http://dx.doi.org/10.1016/j.amjmed.2014.05.032 Published Online: June 10, 2014
Andersson C, Shilane D, Go AS, et al. Beta-Blocker Therapy and Cardiac Events Among Patients With Newly Diagnosed Coronary Heart Disease. J Am Coll Cardiol 2014; 64(3): 247-252
Steg PG, De Silva R. Beta-Blockers in Asymptomatic Coronary Artery DiseaseNo Benefit or No Evidence? J Am Coll Cardiol 2014; 64(3): 253-255
Impaired vision is one factor that contributes to loss of balance and falls. So it seems logical that correction of vision should prevent falls. But in our What’s New in the Patient Safety World columns for June 2010 “Seeing Clearly a Common Sense Intervention” and June 2014 “New Glasses and Fall Risk” we noted that sometimes new glasses and correction of vision may paradoxically result in increased falls.
What about cataract surgery? How does it impact the risk of falls? A recent Australian study (Meuleners 2014) used large linked population databases to examine the possible relationship. The authors note that the previous literature on the impact of cataract surgery on falls is conflicting, with some studies showing a reduction in falls and some showing an increase in falls. They then addressed the risk of injurious falls requiring hospitalization in patients undergoing bilateral cataract surgery, which is typically done one eye at a time in Australia. Compared to the 2 years prior to surgery the risk of injurious falls requiring hospitalization was over twice as high (RR 2.14) between first- and second-eye cataract surgery. And there was still a 34% increase in injurious falls requiring hospitalization after the second-eye cataract surgery compared to the 2 years prior to surgery.
So what does this mean? One obvious problem is the before-after design of the study. What we don’t know are the before and after rates of injurious falls requiring hospitalization in patients with bilateral cataracts who did not have surgery (though even those rates would be subject to selection bias when compared to the rates in the current paper). The point is that we might very well anticipate an increase in the fall rate over time in this population, which is largely elderly and has multiple comorbidities, regardless of whether they have cataract surgery.
Also, we don’t know anything about the activities in these patients. The authors acknowledge that it is quite possible that patients with improved vision after cataract surgery become more active and may take risks they would not have previously taken and therefore increase their chances of a fall.
We have long been advocates of falls with injury being a more important measure than simple fall rates so we have no problem with the measures they chose. A randomized controlled trial to see whether cataract surgery reduces or increases falls with injury is very unlikely to ever happen. So we’ll probably never know for sure but have to presume that cataract surgery might possibly increase the risk of falls with injury.
But the main message of the study is that the period of time between surgeries is one in which the patients are particularly vulnerable to injurious falls requiring hospitalization. The authors recommend patients be informed of this risk and that ophthalmologists take into consideration the timeliness of the second eye surgery.
Cataract surgery clearly improves multiple aspects of vision and improves quality of life. So the message here is not to avoid cataract surgery but rather recognize that there could be an increased risk of serious falls, particularly in the period between surgeries.
Another example that even interventions having positive results may also have unintended consequences!
Meuleners LB, Fraser ML, Ng J, Morlet N. The impact of first- and second-eye cataract surgery on injurious falls that require hospitalisation: a whole-population study. Age Ageing 2014; 43(3): 341-346
We’ve discussed the importance of recognizing delirium in multiple columns (see the list at the end of today’s column). Yet delirium goes unrecognized or undiagnosed in up to 72% of cases in hospitalized patients (Collins 2010). One of the reasons may be that commonly used screening tests for delirium may not be brief enough or may require specific training for administration.
So researchers have developed a new screening tool, the 4 ‘A’s’ Test (4AT) to help improve screening for delirium.
The 4AT tool has now been validated in a population other than that in which it was developed (Bellelli 2014). The authors note that the many of the currently used screening tools for delirium lack some of the following characteristics:
Bellelli and colleagues therefore administered the 4AT in 236 consecutive elderly patients admitted to an acute geriatrics ward or a post-acute rehabilitation unit. The CAM (Confusion Assessment Method) was used as the reference diagnostic standard and the DSM-IV-TR criteria used for diagnosis. Delirium was detected in 12.3%, dementia in 31.2%, and a combination of both in 7.2%. The 4AT had a sensitivity of 89.7% and specificity 84.1% for delirium. Specificity was higher in the subgroup without dementia, while sensitivity was higher in the group with dementia. The authors conclude that the 4AT is a sensitive and specific method of screening for delirium in hospitalized older people and that its brevity and simplicity support its use in routine clinical practice.
We recommend that, if you’ve been using a validated tool like the CAM and have been using it regularly to screen for delirium, you continue to use it. But if you have not been regularly screening for delirium, consider giving the 4AT a try. It’s simple and easy to administer and appears to be a reliable tool.
Some of our prior columns on delirium assessment and management:
Collins N, Blanchard MR, Tookman A, Sampson EL. Detection of delirium in the acute hospital. Age Ageing 2010; 39 (1): 131-135
The 4 ‘A’s Test: screening instrument for delirium and cognitive impairment
Bellelli G, Morandi A, Davis DHJ, et al. Validation of the 4AT, a new instrument for rapid delirium screening: a study in 234 hospitalised older people. Age Ageing 2014; 43(4): 496-502
Virtually all our columns on delirium screening, diagnosis and management have focused on adult patients, particularly the elderly. However, recently there has been an interest kindled in recognition of delirium in pediatric patients.
One research group conducted a survey of pediatric intensivists regarding sedation management, sleep promotion, and delirium screening practices for intubated and mechanically ventilated children (Kudchadkar 2014). They found that delirium screening was not practiced in 71% of respondent’s PICUs, and only 2% reported routine screening at least twice a day. Use of earplugs, eye masks, noise reduction, and lighting optimization for sleep promotion was uncommon. Only 27% of respondents reported having written sedation protocols. And though 70% of respondents worked in PICUs with sedation scoring systems, only 42% of those with access to scoring systems reported routine daily use for goal-directed sedation management. There was also considerable variation in the drugs used for sedation.
A viewpoint in the July issue of JAMA Pediatrics by Schieveld and Janssen (Schieveld 2014) called for growing recognition of pediatric delirium. Specifically, the authors recommend use of diagnostic criteria for pediatric delirium such as use of the Cornell Assessment of Pediatric Delirium tool (Traube 2014). The CAPD is a rapid observational screening tool recently validated in a pediatric ICU (PICU) setting and found to have an overall sensitivity of 94.1% and specificity of 79.2%. Interestingly, in their study population Traube and colleagues found the overall prevalence rate of delirium was 20.6%. So while not as high as the 60-80% prevalence typically seen in adult ICU’s, it is clear that delirium is a common problem in pediatric critical care. The viewpoint article (Schieveld 2014) also noted the importance of inclusion of developmental “anchor” points to help in screening of very young children or those with developmental delay and called for use of flowcharts and continuous monitoring for delirium in the pediatric ICU patients.
Some of our prior columns on delirium assessment and management:
Kudchadkar SR, Yaster M, Punjabi NM. Sedation, Sleep Promotion, and Delirium Screening Practices in the Care of Mechanically Ventilated Children: A Wake-Up Call for the Pediatric Critical Care Community. Crit Care Med 2014; 42(7): 1592-1600
Schieveld JNM, Janssen NJJF. Delirium in the Pediatric Patient. On the Growing Awareness of Its Clinical Interdisciplinary Importance. JAMA Pediatrics 2014; 168(7): 595-596
Traube C, Silver G, Kearney J, et al. Cornell Assessment of Pediatric Delirium: A Valid, Rapid, Observational Tool for Screening Delirium in the PICU. Critical Care Medicinem 2014; 42(3):656-663
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