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December 16, 2014
More on Each Element of the Surgical Fire Triad
In our many columns on surgical fires (see the list at the end of today’s column) we’ve discussed contributions of each of the elements of the “fire triangle” (fuel, oxidizer, heat source).
First, the “fuel” side of the fire triangle. The Anesthesia Patient Safety Foundation (APSF) has their lead article about flammable surgical preps in the October 2014 issue of the APSF Newsletter (Cowles 2014). We discussed the role of alcohol-based skin preps or other volatile substances in our Patient Safety Tips of the Week for April 24, 2012 “Fire Hazard of Skin Preps, Oxygen”, June 25, 2013 “Update on Surgical Fires” and October 1, 2013 “Fuels and Oxygen in OR Fires”. But the new APSF article has some nice tables listing the alcohol content of commonly used skin preps and alcohol-based hand rubs. It has good advice about the importance of communication in the OR as it pertains to ensuring adequate drying time for surgical preps and assessment for alcohol pooling near the surgical field. It emphasizes that adequate drying time is still important in emergency cases. Our August 12, 2014 Patient Safety Tip of the Week “Surgical Fires Back in the News” described a fire in an emergency case in which there was an inadequate delay for an alcohol-based skin disinfectant to dry and the patient had received 100% oxygen. Subsequently the hospital implemented a policy prohibiting alcohol-based skin preps in any emergency surgery that does not allow sufficient drying time (usually 3 minutes or longer). Instead they have gone back to non-alcohol-based preps like Betadine for such emergency cases.
Another key point in the recent APSF article: “read the fine print”. The package inserts on the surgical preps often have warnings about fire risk. In several of our prior articles we noted another surgical fire in which a hospital had switched from the 10.5 ml Chloraprep applicator, which did not have the warning to avoid use in head and neck surgery, to the 26 ml applicator which did have the warning. It is actually quite predictable that staff wouldassume the new supplies were the same as the old and not “read the fine print”.
The other “pearl” in the APSF article about alcohol-based surgical preps is that, whereas the drying time for most such preps is typically at least 3 minutes, drying time of up to 1 hour may be needed when applied to hairy areas, body folds, or body creases.
On to the “oxidizer” side of the fire triangle. The December 2014 issue of Outpatient Surgery Magazine has a Q&A session with ECRI Institute’s Mark Bruley, considered by many to be the leading authority on OR fires (Burger 2014). Bruley stresses that oxygen is the most important element in most OR fires, noting that only about 5% of OR fires involve alcohol-based surgical preps that are still wet. He notes that the real fire hazards happen when oxygen concentrations get up above 40-50% and that anesthesia providers often gave oxygen freely from open sources in many minor procedures, using 100% regardless of patient needs. He points out that in the rare case where a patient does require oxygen from an open source you should start at 30%. He stresses, however, that the current recommendation is that when a patient does need supplemental oxygen, particularly in high-risk areas (head, neck, face, airway, chest) the patient should have a tracheostomy tube or laryngeal mask to prevent buildup of oxygen around the surgical site.
And lastly, the “heat source” side of the fire triangle (though this new information is actually about oxygen). Far and away the two most frequent contributing factors to the majority of OR fires are the oxygen-enriched environment and use of an electrocautery device (see below). So William Culp and colleagues have come up with a unique approach to address both (Culp 2014). Using the rationale that we use carbon dioxide (CO2) to extinguish fires by displacing oxygen, they designed a prototype electrocautery pencil that expresses a cone of CO2 from its tip when activated so that oxygen is displaced. They tested the device in the lab by seeing how long it took for the device to ignite a laparotomy sponge at different oxygen concentrations with the CO2 on or off. With it off the sponge ignited in 15/15 trials (all O2 concentrations) but in 0/15 trials with the CO2 on. What a great concept!
But the device is not yet ready for prime time. It appears to need some design work to make the device easier to use by surgeons. And we need to be concerned about unexpected or unintended consequences. Perhaps the biggest potential unintended consequence is a phenomena we’ve pointed out several times, described by Charles Perrow in his classic book “Normal Accidents” (Perrow 1999) where he talks about how new technologies often simply “push the envelope”. He cites as an example how the introduction of maritime radar simply encouraged boats to travel faster and did little to reduce the occurrence of maritime accidents. Indeed, the editorial (Feldman 2014) accompanying the Culp study warns about exactly that – the risk that surgeons and anesthesiologists might now consider the fire risk so low that they use oxygen indiscriminately. Feldman et al. also raise the possibility that use of the device could result in hypercarbia when used around the face or airway. And we’ll even throw in the possibility the CO2 source could be expended or malfunction without awareness of the surgeon.
But, given that OR fires continue to occur despite widespread attention, training, inservicing, posters, pre-op huddles, and other efforts, a solution that minimizes the risk of human error would be a most welcome addition. The prototype by Culp and colleagues is thus very exciting.
In our June 25, 2013 Patient Safety Tip of the Week “Update on Surgical Fires” we cited an analysis of closed malpractice claims involving surgical fires (Mehta 2013). That analysis showed that 99% involved procedures known to be high risk for fires (head, neck, or upper chest surgery), electrocautery was the ignition source in 90% of claims, and oxygen was the oxidizer in 95% of claims. Alchohol-containing prep solutions and volatile compounds were identified in only 15% of OR fires during monitored anesthesia care. Importantly, the vast majority of claims were for fires that occurred during monitored anesthesia care rather than general anesthesia. That highlights the importance of oxygen. In the vast majority of claims involving monitored anesthesia care the oxygen was delivered by an open delivery system. It really highlights that there has been a trend for surgical/OR fires to be seen more often in relatively minor surgery (eg. plastic procedures removal of skin lesions, temporal artery biopsies, etc.), done under sedation or monitored anesthesia care where there is open delivery of oxygen.
The October 2014 APSF Newsletter also had an update on claims payouts for OR fires (Sanford 2014). It notes that a malpractice insurance company for about 5000 anesthesia providers has handled 42 cases of intraoperative fire since 1990, 31 of which involved the high-risk areas of face, head and neck. Almost every case involved oxygen and electrocautery or laser instruments. It highlights a case in which the victim of an OR fire was awarded an $18 million judgment. In addition to the cognitive aids noted previously, the authors note some facilities are using “smart anesthesia messages (SAM’s)” via computer to remind the OR staff about high-risk cases. They also mention the APSF fire prevention algorithm that may be quite useful in helping the OR team identify and prepare for appropriate precautions and procedures in those identified at-risk.
We have long advocated that the surgical fire risk be discussed as part of the pre-op huddle (or pre-op briefing) and, if the case is considered high-risk, respective roles of all OR participants are called out during the surgical timeout. We’ve always liked the checklist “The Surgical Fire Assessment Protocol” developed at the San Francisco VA as part of an effort to promote fire safety in the OR (Murphy 2010). The Christiana Care Health System also has some good examples of incorporating the fire risk into Universal Protocol plus many other great tools in their Surgical Fire Risk Assessment resources.
We also can’t overemphasize the importance of doing drills for OR fires. Even if we identify high-risk cases there will be others we did not consider to be at high risk. While head, neck and upper chest surgeries have been considered to be at greatest risk for surgical fires, don’t forget that they can occur in almost any surgery (see our January 2011 What’s New in the Patient Safety World column “Surgical Fires Not Just in High-Risk Cases” and April 24, 2012 Patient Safety Tip of the Week “Fire Hazard of Skin Preps Oxygen” for examples of fires during procedures on other areas of the body). Therefore, doing drills is important so each member of the OR team know his/her role in responding to an OR fire.
We hope you’ll look at the many useful recommendations in our previous columns (listed below). And, of course, we again refer you to the valuable resources on surgical fires provided by ECRI Institute, AORN, the FDA, Christiana Care Health System and the APSF.
Our prior columns on surgical fires:
Burger J. Surgical Fire Q & A. Outpatient Surgery Magazine Online 2014; 102-109 December 2014
Cowles CE, Chang JL. Flammable Surgical Preps Require Vigilance. APSF Newsletter 2014; 29(2): 25-28 October 2014
Sanford SR, Thomas BJ, Lee LA. Medicolegal Data Implicate Oxygen as Common Factor in OR Fires. APSF Newsletter 2014; 29(2): 25, 29 October 2014
Culp WC, Kimbrough BA, Luna S, Maguddayao AJ. Mitigating Operating Room Fires: Development of a Carbon Dioxide Fire Prevention Device. Anesthesia & Analgesia 2014; 118(4): 772-775
Perrow C. Normal Accidents: Living with high-risk technologies. Princeton, New Jersey: Princeton University Press, 1999
Feldman JM, Ehrenwerth J, Dutton RP. Thinking Outside the Triangle: A New Approach to Preventing Surgical Fires. Anesthesia & Analgesia 2014; 118(4): 704-705
APSF (Anesthesia Patient Safety Foundation). Fire Prevention Algorithm.
Mehta SP, Bhananker SM, Posner KL, Domino KB. Operating Room Fires: A Closed Claims Analysis. Anesthesiology 2013; 118(5): 1133-1139, May 2013
SF VAMC Surgical Fire Risk Assessment Protocol
Murphy J. A New Effort to Promote Fire Safety in the OR. Topics In Patient Safety (TIPS) 2010; 10(6): 3
Christiana Care Health System. Surgical Fire Risk Assessment.
ECRI Institute. Surgical Fire Prevention.
AORN (Association of periOperative Registered Nurses). Fire Safety Tool Kit.
FDA. Preventing Surgical Fires.
APSF (Anesthesia Patient Safety Foundation). Resources. Fire Safety Video. Prevention And Management Of Operating Room Fires.
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Amongst our numerous columns on handoffs/handovers (see the full list of prior columns at the end of today’s column) we’ve especially been fond of the I-PASS handoff program. We first described it in our February 14, 2012 Patient Safety Tip of the Week “Handoffs – More Than Battle of the Mnemonics”, a column that highlighted the need to tailor handoff formats to the specific tasks at hand. I-PASS came about because existing formats were not optimal for resident-to-resident handoffs. Then in our June 2012 What’s New in the Patient Safety World column “I-PASS Results and Resources Now Available” we noted the release of the very promising preliminary results of the I-PASS project.
Now the final results of the I-PASS project have been published (Starmer 2014). After implementation of I-PASS the rate of medical errors decreased by 23% and the rate of preventable medical errors decreased by 30%. Significantly, there was no increase in the amount of time spent on handoffs and there was no significant change in resident workflow or the amount of resident contact with patients and families.
Specific medical error types reduced in the I-PASS collaborative included diagnostic errors, errors related to medical history or physical examination, multifactorial errors, and errors related to therapies other than medications or procedures. (Errors related to medications, procedures, falls, and nosocomial infections did not change.)
The reduction in medical errors was significant at six of the nine sites participating. Study authors had no explanation for the lack of improvement at three sites, since they also demonstrated improved inclusion of key elements in the handoff process.
Make no mistake, I-PASS is much more than a mnemonic and format for handoffs. It also involves extensive team training (based on TeamSTEPPS™) and resident training modules, simulation and role playing, faculty development resources and tools, direct observation of handoffs with feedback, and generation of a printed handoff document that can be integrated with the electronic medical record.
In our September 9, 2014 Patient Safety Tip of the Week “The Handback” we noted that a recent collaboration among 23 pediatric hospitals (Bigham 2014) demonstrated a significant decrease in handoff-related are failures for multiple different handoff types. I-PASS was a format utilized in that collaboration. The improvement project was guided by evidence-based recommendations regarding handoff intent and content, standardized handoff tools/methods, and clear transition of responsibility. Hospitals tailored handoff elements to locally important handoff types. Examples of the handoff types included shift-to-shift handoffs, emergency department to inpatient handoffs, and perioperative to inpatient handoffs. Handoff-related care failures decreased from 25.8% at baseline to 7.9% in the final intervention period.
Compliance to critical components of the handoff process improved, as did provider satisfaction. Key elements required, regardless of the handoff type, were that active participation by both the sending and receiving teams were required, discrete times
and mechanisms set aside for the receiving team to ask questions, a proscribed script of important handoff elements was available, and a “read back” summary of basic issues and next steps was accessible. One very interesting finding was that even where baseline compliance with individual elements was pretty good at baseline, relatively small incremental improvements in those individual elements collectively led to very good reductions in overall handoff failures.
Details on the format of I-PASS and reasons for its development can be found in our February 14, 2012 Patient Safety Tip of the Week “Handoffs – More Than Battle of the Mnemonics” and June 2012 What’s New in the Patient Safety World column “I-PASS Results and Resources Now Available” as well as in the current article (Starmer 2014) and the I-PASS website.
Though restrictions on hours that residents may work have increased the number and complexity of handoffs/handovers, most of the same issues apply to other physician coverage arrangements. Yes, one resident just finishing a 24-hour shift may have to leave immediately after morning rounds. But a physician in a community or rural hospital who is covering for another physician also has competing requirements for his/her time (eg. office hours, scheduled surgery, etc.). And the same types of interruptions and distractions (phone calls, pages, nurses or colleagues or families requesting information, etc.) apply equally well to morning rounds or the physician cross-coverage handback.
Though neither the I-PASS collaborative nor the previously mentioned pediatric collaborative (Bigham 2014) looked at the impact of the missed handoff issues on patient harm or actual patient outcomes, we would certainly predict that improvement in the handback process would likely prevent many adverse events and outcomes. Both are very good studies and have implications for all healthcare organizations, not just academic ones.
Read about many other handoff issues (in both healthcare and other industries) in some of our previous columns:
May 15, 2007 “Communication, Hearback and Other Lessons from Aviation”
May 22, 2007 “More on TeamSTEPPS™”
August 28, 2007 “Lessons Learned from Transportation Accidents”
December 11, 2007 “Communication…Communication…Communication”
February 26, 2008 “Nightmares….The Hospital at Night”
September 30, 2008 “Hot Topic: Handoffs”
November 18, 2008 “Ticket to Ride: Checklist, Form, or Decision Scorecard?”
December 2008 “Another Good Paper on Handoffs”.
June 30, 2009 “iSoBAR: Australian Clinical Handoffs/Handovers”
April 25, 2009 “Interruptions, Distractions, Inattention…Oops!”
April 13, 2010 “Update on Handoffs”
July 12, 2011 “Psst! Pass it on…How a kid’s game can mold good handoffs”
July 19, 2011 “Communication Across Professions”
November 2011 “Restricted Housestaff Work Hours and Patient Handoffs”
December 2011 “AORN Perioperative Handoff Toolkit”
February 14, 2012 “Handoffs – More Than Battle of the Mnemonics”
March 2012 “More on Perioperative Handoffs”
June 2012 “I-PASS Results and Resources Now Available”
August 2012 “New Joint Commission Tools for Improving Handoffs”
August 2012 “Review of Postoperative Handoffs”
January 29, 2013 “A Flurry of Activity on Handoffs”
December 10, 2013 “Better Handoffs, Better Results”
February 11, 2014 “Another Perioperative Handoff Tool: SWITCH”
March 2014 “The “Reverse” Perioperative Handoff: ICU to OR”
September 9, 2014 “The Handback”
Starmer AJ, Spector ND, Srivastava R, et al. Changes in Medical Errors after Implementation of a Handoff Program. N Engl J Med 2014; 371: 1803-1812
Bigham MT, Logsdon TR, Manicone PE, et al. Decreasing Handoff-Related Care Failures in Children’s Hospitals. Pediatrics 2014; 134:2 e572-e579; published ahead of print July 7, 2014,
I-PASS Study website.
One of our earliest Patient Safety Tips of the Week was our May 8, 2007 column “Doctor, when do I get this red rubber hose removed?”. In that column we related how embarrassed we were as a young physician when a patient asked that question as we were providing discharge instructions to her. That led us to one of our first patient safety projects in the early 1990’s to reduce the unnecessary use of urinary catheters. Of course, the most important intervention to avoid CAUTI’s is to avoid such catheters in the first place and limit duration of catheters in those patients who do have a legitimate initial indication for one. We were amazed at how often the Foley catheter appears unbeknownst to the primary physician responsible for the patient’s care and how often they are placed without legitimate medical indication.
The same obviously applies to indwelling catheters in any area of the body. The great work done by Peter Pronovost and colleagues on prevention of CLABSI’s emphasized careful attention not just to insertion and maintenance of central lines but also to the issue of indications or continued indications for the central lines.
Now a new study assessed how often clinicians are unaware of central venous catheters, both traditional triple-lumen catheters and PICC (peripherally inserted central catheter) lines, at 3 academic medical centers (Chopra 2014). In almost 1000 patients the prevalence of a triple-lumen central venous catheter or PICC line was 21.1% (60% if these were PICC’s). Clinicians responsible for care of those patients were unaware of the presence of these catheters in 21.2% of cases. Such unawareness was more common for PICC lines and more common in non-ICU settings. Teaching attendings and hospitalists were more often unaware than were housestaff or physician extenders.
Our January 21, 2014 Patient Safety Tip of the Week “The PICC Myth” focused on the widespread use of PICC lines and the general lack of awareness by clinicians of their potential complications. Previous work by Chopra and colleagues as well as others has shown potential complications of PICC lines are at least as frequent as and probably more frequent than those from more traditional central lines. Complications include CLABSI’s, deep vein thrombosis, catheter tip malpositioning, thrombophlebitis, and catheter dysfunction. Both patient-related and device-related factors are important in leading to complications of central lines and PICC lines. But it is clear that the duration of catheter use is an important factor in leading to complications and that many times the catheters are left in place longer than necessary.
One of the most important interventions in prevention of CLABSI’s (or, for that matter, infection of any indwelling device) is asking on a daily basis whether the catheter is still necessary. With PICC’s we often forget to do that, particularly when the patient is not in the ICU. In that January 21, 2014 Patient Safety Tip of the Week “The PICC Myth” we noted a study by Tejedor and colleagues (Tejedor 2012) looking at how often central venous catheters and PICC lines were retained when not needed ("idle days") on non-ICU wards. They found that significant proportions of ward central line days were unjustified. Patients with PICCs had more days in which the only justification for the CVC was intravenous administration of antimicrobial agents. They suggest that reducing "idle CVC-days" and facilitating the appropriate use of peripheral IV’s may reduce central line days and CLABSI risk.
Also in that January 21, 2014 Patient Safety Tip of the Week “The PICC Myth” we stressed how our systems make it very easy for a patient to get a PICC line, often for reasons of staff convenience rather than for evidence-based indications. Sometimes they are ordered at night by a cross-covering physician. And since most PICC lines are inserted by specially trained nurses, most physicians are not involved in insertion of the PICC. So it’s fairly easy to be unaware of a PICC line. We’re not at all surprised by the findings of the current Chopra study.
The editorial accompanying the Chopra study (Taichman 2014) questions that, if we are not seeing catheters when we round on our patients daily, “what else are we missing?”. Is it that we are doing perfunctory exams on such rounds or not even doing that? Are we missing things like early decubiti?
The bottom line is that we are all human and we tend to look for things we expect or things we are trying to avoid. If we are not expecting our patient to have a central line or PICC line we may easily overlook its presence when we are rounding. This might even be another example of “inattentional blindness”.
Therefore, we need to include such oversight as another example of a predictable error and put systems in place to help us avoid the problem. One of the items on our checklist for daily rounds on patients in all locations should be “Does this patient have any catheters or lines in place and, if so, are they still necessary?” Use of such lines should be evidence-based where possible. Alert fatigue aside, we also recommend that flags be set in the electronic medical record (EMR) to highlight for the clinician that such catheters are in place and need to be reviewed for continuation on a daily basis.
Chopra V, Govindan S, Kuhn L, et al. Do Clinicians Know Which of Their Patients Have Central Venous Catheters?: A Multicenter Observational Study. Ann Intern Med 2014; 161(8): 562-567
Tejedor SC, Tong D, Stein J, et al. Temporary central venous catheter utilization patterns in a large tertiary care center: Tracking the "Idle central venous catheter". Infection Control and Hospital Epidemiology 2012; 33(1): 50-57
Taichman DB. Whose Line Is It Anyway? Ann Intern Med 2014; 161(8): 607-608
Of our many columns on recognition, diagnosis, prevention and management of delirium (see the full list at the end of today’s column) postoperative delirium has been a major focus.
The American Geriatrics Society has just published a best practice statement for Postoperative Delirium in Older Adults (AGS Expert Panel 2014). It’s a guideline that really only recommends evidence-based best practices.
The guideline notes that between 5% and 50% of older adults develop delirium after surgery and that delirium may be preventable in up to 40% of cases. Yet the topic of delirium has been under-represented in surgical teaching. So this guideline/best practice statement is of significant importance since it is published in the Journal of the American College of Surgeons.
It emphasizes that delirium is a relationship between a physiologic stressor (in this case the surgery) and predisposing risk factors. Major risk factors listed are age > 65, chronic cognitive decline or dementia, poor vision or hearing, severe illness, presence of infection, functional dependence, self-reported alcohol abuse, and specific laboratory/electrolyte abnormalities. It notes that patients having 2 or more risk factors are at greater risk and that the risk for delirium is generally greater in the emergency setting.
The guideline notes that healthcare professionals caring for postsurgical patients must be trained to recognize and document the signs and symptoms of delirium, including hypoactive delirium. When a screening tool suggests delirium a healthcare professional competent in diagnosing delirium should perform a full clinical assessment. It emphasizes, as we have, that patients undergoing elective procedures should have baseline assessments of cognitive function pre-operatively. The guideline has multiple tables and appendices covering things like risk factors, symptoms and signs, screening tools, and diagnostic tools. It recommends that the healthcare team consider instituting daily postoperative screening of older patients for delirium.
The guideline notes there is a dearth of solid evidence about specific intraoperative factors in the prevention of postoperative delirium. In fact, the only recommendation is that the anesthesiology practitioner may use processed EEG monitors of anesthetic depth (eg. Bispectral Index) during sedation or general anesthesia of older patients to reduce postoperative delirium.
The next section focuses on medications that commonly induce delirium, especially anticholinergic drugs, sedative/hypnotics, meperidine, diphenhydramine, and benzodiazepines. Also, use of 5 or more total medications is associated with an increased risk of delirium. It emphasizes that management must be individualized. For example, while benzodiazepines should be avoided in most at-risk patients they may be necessary in a patient with a history of alcohol or benzodiazepine dependence.
The guideline has an excellent focus on pain and pain management. Insufficient pain control can contribute to delirium as can some of the medications used to treat pain. The guideline recommends non-opioid analgesics where possible and notes that use of regional anesthesia has been found to reduce delirium in some studies.
The guideline points out the contradictory evidence on the effect of antipsychotics in preventing delirium and does not recommend their use for prevention. It also recommends against administration of newly prescribed cholinesterase inhibitors.
The guideline goes on to describe the nonpharmacologic prevention and treatment of postoperative delirium. It recommends that hospitals and healthcare systems have educational programs with frequent refresher sessions on delirium. It recommends that an interdisciplinary team implement a multicomponent nonpharmacologic intervention program.and follow that patient throughout the hospital course. It notes such interventions have reduced the incidence of delirium 30-40%. It stops short of recommending use of specialized hospital units, however, since the evidence is insufficient.
It goes on to describe the medical evaluation that should be undertaken once a patient is diagnosed as having delirium. It notes again that multicomponent interventions have been successful in reducing delirium duration and severity, length of stay, etc. but that it is not possible to conclude which specific component(s) are responsible.
If delirious patients are severely agitated or distressed and are considered a risk to self or others, judicious use of antipsychotics (at the lowest effective dose and for the shortest possible duration) may be considered. These should be used only when behavioral interventions have failed. It also emphasizes that benzodiazepines should not be used except where specifically indicated (such as patients undergoing withdrawal from alcohol or benzodiazepines).
We’ve discussed most of these issues more extensively in our many previous columns on delirium listed below. We’d again like to emphasize that we consider assessment for delirium risk one of the 3 most important elements of the preoperative evaluation (the other two being screening for frailty and screening for sleep apnea or other potential cause for post-operative opioid-induced respiratory depression). These simple screens can usually be done in the office by the surgeon or a geriatrician or primary care giver.
Some of our prior columns on delirium assessment and management:
The American Geriatrics Society Expert Panel on Postoperative Delirium in Older Adults. Postoperative Delirium in Older Adults: Best Practice Statement from the American Geriatrics Society. Journal of the American College of Surgeons 2014; Published Online: November 14, 2014
In several of our prior columns on use of oxygen (see our Patient Safety Tips of the Week April 8, 2008 “Oxygen as a Medication” and January 27, 2009 “Oxygen Therapy: Everything You Wanted to Know and More!”) we have commented that in the past we often routinely gave oxygen to patients with myocardial infarction or stroke. But such use was more reflexive in nature and not evidence-based.
In our What’s New in the Patient Safety World columns for July 2010 “Cochrane Review: Oxygen in MI” and February 2012 “More Evidence of Harm from Oxygen” we discussed the lack of evidence to support the routine use of oxygen in the acute MI patient and the possible deleterious effects in these and some other cardiac patients.
Then in our March 2014 What’s New in the Patient Safety World column “Another Strike Against Hyperoxia” we noted a study showing that hyperoxia was independently associated with in-hospital death as compared with either normoxia or hypoxia in ventilated stroke patients admitted to ICU’s.
Such studies have called for large randomized controlled trials to answer the important questions about if and when to use oxygen in patients with stroke or MI. One such study, The Stroke Oxygen Study (SO2S) in the UK, was recently completed in stroke patients (see our June 17, 2014 Patient Safety Tip of the Week “SO2S Confirms Routine Oxygen of No Benefit in Stroke”) and showed no benefit of oxygen therapy in stroke patients who were not hypoxemic.
Now we finally also have the results of a randomized controlled trial of oxygen vs. no oxygen in patients with STEMI (S-T segment elevation myocardial infarction). Results of the Air Versus Oxygen in Myocardial Infarction (AVOID) study were just presented at the American Heart Association 2014 Scientific Sessions (Stub 2014). Patients with STEMI by EKG who had normal oxygen saturation were randomized in the pre-hospital transport system to receive either oxygen 8L/min or no supplemental oxygen. Those who received supplemental oxygen had larger infarct size by measurement of CPK (but not by troponin levels) and by cardiac MRI at 6 months. They also had a higher rate of recurrent myocardial infarction and an increase in frequency of cardiac arrhythmias. Mortality did not differ between the two groups but the study was not powered to demonstrate any difference in mortality. A much larger ongoing study in Sweden may be able to answer the question about impact on mortality. Thus the study showed supplemental oxygen therapy in patients with STEMI but without hypoxia increased early myocardial injury and was associated with larger myocardial infarct size assessed at six months.
As we’ve recommended before, hospitals need to look at their existing protocols (and actual practices) for managing a variety of medical conditions where oxygen use may be considered. How many of you have standardized order sets that directly (or indirectly by poor use of checkboxes) encourage inappropriate use of oxygen in MI or stroke patients? Going back to our Patient Safety Tips of the Week April 8, 2008 “Oxygen as a Medication” and January 27, 2009 “Oxygen Therapy: Everything You Wanted to Know and More!” we strongly support facilities doing audits of their oxygen practices. You’ll probably be surprised at the opportunities you uncover to improve practices (and save money at the same time!). And make sure your pre-hospital emergency response teams are aware of the results of the AVOID study.
Some of our prior columns on potential harmful effects of oxygen:
April 8, 2008 “Oxygen as a Medication”
January 27, 2009 “Oxygen Therapy: Everything You Wanted to Know and More!”
July 2010 “Cochrane Review: Oxygen in MI”
February 2012 “More Evidence of Harm from Oxygen”
March 2014 “Another Strike Against Hyperoxia”
June 17, 2014 “SO2S Confirms Routine O2 of No Benefit in Stroke”
Stroke Oxygen Study website
Stub D, Smith K, Bernard, S, et al. A randomised controlled trial of oxygen therapy in acute ST-segment elevation myocardial infarction: The Air Versus Oxygen in Myocardial Infarction (AVOID) study. American Heart Association 2014 Scientific Sessions; November 19, 2014; Chicago, IL
Add yet another procedure to the growing lists of procedures you don’t want done late in the day or on weekends. In our October 2014 What’s New in the Patient Safety World column “What Time of Day Do You Want Your Surgery?” we discussed issues related to laparoscopic cholecystectomies done after hours. In our September 2009 What’s New in the Patient Safety World column “After-Hours Surgery – Is There a Downside?” we discussed adverse outcomes associated with doing certain types of orthopedic surgery after hours. We think the issues raised are significant to almost every type of surgery and probably other procedures as well.
So it should come as no surprise that some non-emergent procedures done in the cath lab or OR might also be problematic. Hsu and colleagues (Hsu 2014) demonstrated in a large, real-world population, that implantable cardioverter-defibrillator (ICD) recipients implanted in the afternoon/evening and on weekends/holidays more often experienced adverse events, particularly prolonged hospital stays. Those patients implanted in the afternoon or evening had an 8% higher likelihood of any complication and 29% higher likelihood of a prolonged hospital stay. In-hospital death, however, was not increased.
In our previous columns noted above (and the full list is at the end of today’s column) we’ve discussed many of the factors contributing to problems for cases done after hours or on weekends. Hsu and colleagues acknowledge that implantable cardioverter-defibrillator procedures performed later in the day and on weekends/holidays may be associated with adverse events due to a variety of factors including operator fatigue, handoffs, reduced staffing, and limited resource availability.
But keep in mind that this was not a randomized controlled trial. Rather it was a retrospective review of a real-world population. Even though they adjusted their analysis for a variety of factors, it is conceivable that there may be unrecognized patient-related factors that led to cases being done late in the day.
Some of the contributory factors may not be modifiable. However, others may be. For example, if the cardiac electrophysiologist or surgeon doing the implant perceives difficulty scheduling the procedure for the following morning (or has a conflict with his/her own schedule that next morning) he/she may push to do the procedure late on the current day. Maintaining scheduling flexibility to accommodate such cases the next day may be an important system fix.
Take a look at the experience with ICD implantation at your own hospital. Because Hsu’s data came from the National Cardiovascular Data Registry-ICD Registry™ you’ll likely find similar patterns at your hospital.
Some of our previous columns on the “weekend” and “after hours” effects:
Hsu JC, Varosy PD, Parzynski CS, et al. Procedure Timing as a Predictor of In-Hospital Adverse Outcomes from Implantable Cardioverter-Defibrillator Implantation: Insights from the NCDR®. Amer Heart J 2014; Published Online: October 25, 2014
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