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What’s New in the
Patient Safety World
April 2022
· Length
of Stay and Post-Discharge Complications in Surgical Patients
· Another
Benefit from the COVID-19 Pandemic?
· Overlapping
Surgery Back in Focus
· Safety
Issues in Interhospital Transports
Length of Stay and
Post-Discharge Complications in Surgical Patients
The relationship between length of stay (LOS) and
complications is a complex one. Complications may increase LOS and longer LOS
exposes patients to a number of iatrogenic
complications. For many years, we have tried to reduce LOS for most diagnoses
and conditions. Especially in the past decade, with adoption of ERAS (Enhanced
Recovery After Surgery) we’ve seen surgical LOS decrease even futher (see our February 11, 2020 Patient Safety Tip of the
Week “ERAS
Rocks!”). But we’ve always tempered our enthusiasm for getting patients out
of the hospital with the concern that we may be discharging them too soon.
A new study alerts us that post-discharge complications
following surgical procedures are, in fact, increasing. Li et al. (Li
2021) looked at ACS NSQIP data from 2014 to 2019 on over 500,000 patients
who underwent surgical procedures of the colon and rectum; esophagus; hepatopancreatobiliary system involving the liver, pancreas,
gallbladder and bile ducts; or gynecologic or urologic systems and identified
complications that occurred from the date of discharge up to 30 days
post-discharge. They found that the median LOS decreased from 3 days to 2
days over that time span. Though the overall rate of postoperative
complications declined 1 percent over the five-year study, post-discharge
complications increased 12% over the same period. As a proportion of all
postoperative complications, post-discharge complications increased from 44.6%
to 56.5%.
Complications that had higher rates over time included
surgical site infections; other infections such as pneumonia, urinary tract
infection, and sepsis; MI, cardiac arrest, stroke, and venous thromboembolism.
The authors stress that many of these complications are
potentially preventable, with early recognition and management preventing
progression to more serious conditions.
They also identified risk factors that were associated with
a higher odds of post-discharge complications:
- Patient factors: Hispanic or "other
ethnicity/race"; higher body mass index; higher American Society of
Anesthesiologists class (a surrogate for general health status used to
predict operative risk); loss of independent function; higher wound class
(a more severe wound); and experiencing an inpatient complication
- Procedure factors: a longer
operation and the type of surgical procedure
Recommendations to help avoid such complications include:
- Education of patients and their family
before the operation and before discharge, aimed at equipping them to
recognize concerning signs and symptoms that they should discuss with
their surgeon
- Easy communication between the patient
and the surgical team
- Close monitoring that is more
intensive for patients at elevated risk of complications
Given that overall complication rates decreased over the
period of the study, the obvious question is whether the shorter LOS had a
causal relation to the higher rate of post-discharge complications. The authors
do note that surgeons are often unaware of these complications until patients
present to the ED or hospital and that earlier recognition of some may have
prevented progression to more serious complications (eg.
recognition of a wound infection might have led to prevention of sepsis). We’ve
also noted in the past, when looking at hospital readmissions, that many
complications are “medical”
rather than strictly “surgical”. That emphasizes the need for
good communication not only between the surgeon and patient/family but also with
the “medical” clinician(s) who will also be providing future care. You’d be
surprised how often a patient’s primary care physician is not even aware their
patient was hospitalized and had surgery.
References:
Li RD, Merkow RP, Joung HSD, Chung JD, Bilimoria KY. Are
We Chasing Shorter Length of Stay At the Expense of Post-Discharge Complications?
Scientific Forum Presentation. American College of Surgeons Clinical Congress
2021
https://www.facs.org/media/press-releases/2021/complications-after-discharge-102321
Print “April 2022 Length of Stay and
Post-Discharge Complications in Surgical Patients”
Another Benefit
from the COVID-19 Pandemic?
The COVID-19
pandemic has changed the way we practice medicine in many ways. And some
positive things that will outlast this pandemic have also resulted. Many public
health measures will be remembered when the next pandemic hits. And the strides
made using mRNA technology will likely be utilized in approaching cancer and
other diseases. Medical practices have also changed. The most obvious
one is the emergence of telemedicine, which is likely to be here to stay even
after the pandemic has ended (see our November 2020 What's New in the Patient
Safety World column “Telemedicine
Here to Stay But Use It Safely”). Another useful practice might be virtual
medication history interviews and discharge education (see our April 7, 2020 Patient Safety Tip of the Week “Patient Safety Tidbits for
the COVID-19 Pandemic”). And
our January 2022 What's New in the Patient Safety World column “Some COVID-19 Practices May
Outlast the Pandemic” noted
5 other hospital practices that are likely to outlive the pandemic (Gillespie
2021, Advisory
Board 2021):
1.
A centralized monitoring system
2.
Daily meetings to pinpoint safety and quality concerns
3.
Reducing the number of times workers enter patients'
rooms
4.
Guides for respiratory treatments to reduce the spread
of disease
5.
Safety precautions for visitors
Now, Peter Pronovost and colleagues (Pronovost 2022)
have pointed out yet another unexpected patient safety benefit - remote patient
monitoring. The authors make a good case that patient risk, rather than
physical location, should dictate the degree of monitoring. They begin by
noting that many patients with COVID-19 who deteriorated or died at home could
have benefited from continuous pulse oximetry. Use of currently available
technologies can be used to monitor patients at home and help avoid
hospitalizations. And they note that some payment reforms already made by CMS
have made at-home monitoring possible for acute as well as chronic conditions
feasible.
They cite a cost-utility analysis of remote pulse-oximetry monitoring
of patients with COVID-2019 (Padula
2021) which projected that remote monitoring could potentially be associated
with 87% fewer hospitalizations, 77% fewer deaths, reduced per-patient costs of
$11,472 over standard care, and gains of 0.013 quality-adjusted life-years.
Pronovost et al. state “Pulse oximeters used in hospitals
can now be deployed at home with patient data relayed to smartphones, secure
cloud servers, and web-based dashboards where physicians and hospitals can
monitor the patient’s status in near real time.” They acknowledge that a
separate team likely would need to be created to focus on remote monitoring.
They go on to describe the barriers which must be overcome before health
systems take greater advantage of this opportunity.
They envision a scenario where monitoring data would be sent
by the patient or via a technology platform that automatically transfers data. Parameters
for home monitoring could include blood pressure, heart rate, electrocardiogram,
pulse oximeter, temperature, and others. The care team could include a nurse
with physician oversight and data could be reviewed either in real time or intermittently,
based on the patient’s risk for deterioration.
It's not just COVID-19 patients that could benefit from home
monitoring. Reducing the need for acute care hospitalization is a goal for many
other conditions. Having in place the technology, data management systems, and
clinical teams envisioned by Pronovost and colleagues
should be in the plans for every healthcare system. The time is right.
See also our other
columns related to COVID-19:
- April 7, 2020 “Patient Safety Tidbits
for the COVID-19 Pandemic”
- May 5, 2020 “COVID-19 and the Dental
Office”
- May 12, 2020 “Lab Errors and COVID-19”
- June 16, 2020 “Tracking Technologies”
- November
2020 “Telemedicine
Here to Stay But Use It Safely”
- December 2020 “ISMP Warns of Vaccine
Errors as We Gear Up for COVID-19 Vaccines”
- January 26, 2021 “This Freezer Accident
May Cost Lives”
- September 2021 “Have You Added Pandemic
Preparation to Your Hospital Disaster Plan?”
- October 2021 “HAI’s Increase During
COVID-19 Pandemic”
- January 2022 “Some COVID-19 Practices
May Outlast the Pandemic”
References:
Gillespie L. Hospital safety practices that will outlive the
pandemic. Modern Healthcare 2021; December 14, 2021
Advisory Board. Covid-19 led to new hospital safety
measures. These 5 will outlast the pandemic. Advisory Board 2021; December 15,
2021
https://www.advisory.com/daily-briefing/2021/12/15/hospital-safety
Pronovost PJ, Cole MD, Hughes RM. Remote Patient Monitoring
During COVID-19: An Unexpected Patient Safety Benefit. JAMA 2022; Published
online February 25, 2022
https://jamanetwork.com/journals/jama/fullarticle/2789635
Padula WV, Miano
MA, Kelley MA, et al. A cost-utility analysis of remote pulse-oximetry monitoring
of patients with COVID-2019. Value in Health. Published online October 22, 2021
https://www.valueinhealthjournal.com/article/S1098-3015(21)01749-6/fulltext
Print “April 2022 Another Benefit from the
COVID-19 Pandemic?”
Overlapping
Surgery Back in Focus
The issue of overlapping surgery was back in the news
recently with the announcement that Massachusetts General Hospital paid $14.6
million to settle a whistle-blower suit over such surgeries (Saltzman
2022). This settlement went to insurers for presumed improper billing. It actually was the third payment made by the MGH regarding the
overlapping surgeries. In 2019 the MGH settled for $13 million with a physician
who challenged double-booked surgeries (Saltzman
2019a). That surgeon had been fired by the MGH in 2015 for allegedly violating
patient confidentiality, but he always believed he had been dismissed for
raising safety concerns about colleagues who performed two operations at once.
MGH also offered him his old job back to settle his wrongful termination
lawsuit (which he declined) and agreed to honor him with a hospital safety
initiative in his name. The third settlement was with former Boston Red Sox
pitcher Bobby Jenks to settle a claim that he suffered a career-ending spine
injury when a surgeon at the MGH operated on his back while overseeing another
operation at the same time (Saltzman
2019b). According to Saltzman, the three out-of-court settlements total
$32.7 million.
As part of the current settlement, the Mass General Brigham
healthcare system agreed to change its consent forms to include the wording
"My surgeon has informed me that my surgery is scheduled to overlap with
another procedure she/he is scheduled to perform. I understand that this means
my surgeon will be present in the operating room during the critical parts of
my surgery but may not be present for my entire surgery." (Putka 2022).
The controversial practice first received national attention
in 2015 when the Boston Globe Spotlight team published a series on it (Abelson
2015). We’ve taken a strong position against overlapping surgery, beginning
with our November 10, 2015 Patient
Safety Tip of the Week “Weighing in on Double-Booked Surgery”.
Over the years, there have been many articles and studies
defending the practice (see our Patient
Safety Tips of the Week for March 12, 2019 “Update on Overlapping
Surgery” and December 3,
2019 “Overlapping Surgery Back in
the News”). Most have
looked at mortality rates and complication rates in large databases and
concluded that there is no statistical difference between cases with or without
an overlap. We have pointed out that complications due to overlapping surgery
are still quite rare, so statistics from any large databases will “dilute out”
those cases that did have complications. Those of us involved in patient safety
have all seen instances in which overlapping surgery was a contributing factor
to or root cause of an adverse event.
Our December 19,
2017 Patient Safety Tip of the Week “More on Overlapping Surgery” had our detailed comments on the following
considerations for overlapping surgery:
- The “Critical Part of the Surgery”
- Timeouts
- Post-Procedure Debriefing
- The Pre-op “Huddle”
- Duration of surgery
- Other Infection Control Issues
- Definition of “Immediately Available”
- Multitasking
- The educational/training mandate
- The Ethical Issue(s)
- Who Should Be Allowed to Perform
Overlapping Surgery?
- Monitoring Overlapping Surgery
We hope you’ll go back to that column (and all our columns
listed below) to see our arguments against the practice of overlapping surgery.
However, even though we personally would not consent to undergo overlapping
surgery, we are pragmatic and understand the practice is not likely to go away
any time soon. Therefore, we developed our “Overlapping Surgery
Checklist” to help guide you in planning for safe implementation.
Part of our job in teaching hospitals is to train surgeons
and other physicians to be able to practice independently. That obviously
requires graded autonomy. Since the onset of the COVID-19 pandemic there has
been a reduction in the number of elective surgeries performed at many
hospitals, reducing the learning opportunities for surgical residents and
fellow. So now, more than ever, we need to foster graded surgical autonomy. A recemt study from the VA health system (Oliver
2021) showed that surgical procedures performed by residents alone were not
associated with any changes in all-cause mortality or composite morbidity
compared with those performed by attending surgeons alone or by residents with
the assistance of attending surgeons. The accompanying editorial (Stulberg
2021) notes that lack of attending surgeon scrubbed and resident autonomy
are not equivalent. It notes that, outside of technical assistance, attending
faculty may also coach residents regarding next steps or provide advice to
avoid missteps.
But the issue comes down to transparency. If a patient is
expecting that the attending surgeon will be performing the entire surgery or
at least be present in the OR for the entire surgery, the informed consent must
clearly specifiy anything to the contrary.The revised MGH informed consent wording
should convey the appropriate message to the patient, assuming the patient has
the opportunity to discuss the details and implications of the attending
surgeon’s absence from any portion of the surgery or procedure.
See our previous
columns on double-booked, concurrent, or overlapping surgery:
- November 10, 2015 “Weighing in on Double-Booked Surgery”
- November 29, 2016 “Doubling
Down on Double-Booked Surgery”
- December 13, 2016 “More
on Double-Booked Surgery”
- May 2017 “The
Concurrent Surgery Debate Continues”
- December 19, 2017 “More
on Overlapping Surgery”
- March 12, 2019 “Update on Overlapping
Surgery”
- December 3, 2019 “Overlapping Surgery
Back in the News”
And our “Overlapping
Surgery Checklist”
References:
Saltzman J. Mass. General pays $14.6 million to settle
whistle-blower suit over concurrent surgeries. Hospital’s third major payment
related to surgeons doing two operations at once. Boston Globe 2022; February
18, 2022
Saltzman J. MGH settles for $13m with doctor who challenged
double-booked surgeries. Boston Globe 2019; November 7, 2019
Saltzman J. Former Red Sox pitcher settles claim with
doctor, MGH for $5.1 million. Boston Globe 2019; May 8, 2019
Putka S. Mass General 'Not an
Outlier' in Double-Booked Surgeries — The teaching hospital resolves lawsuit,
changes patient consent forms. MedPage Today 2022;
February 24, 2022
https://www.medpagetoday.com/special-reports/exclusives/97350
Abelson J, Saltzman J, Kowalcyzk
L, Allen S. Clash in the Name of Care. Boston Globe October 26, 2015
http://apps.bostonglobe.com/spotlight/clash-in-the-name-of-care/story/
Oliver JB, Kunac A, McFarlane JL, Anjaria DJ. Association Between Operative Autonomy of
Surgical Residents and Patient Outcomes. JAMA Surg 2021; Published online
December 22, 2021
https://jamanetwork.com/journals/jamasurgery/fullarticle/2787397
Stulberg JJ, Adams SD, Kao LS.
Lack of Attending Surgeon Scrubbed and Resident Autonomy Are Not Equivalent.
JAMA Surg 2021; Published online December 22, 2021
https://jamanetwork.com/journals/jamasurgery/article-abstract/2787401
Print “April 2022 Overlapping Surgery Back in
Focus”
Safety Issues in
Interhospital Transports
We’ve done many
columns on problems associated with intrahospital transports (see list at the
end of today’s column), but only one specifically on interhospital transfers or
transports (our October 30, 2018 Patient Safety Tip of the Week “Interhospital
Transfers”). Of course, many of the
same problems seen during intrahospital transports may also occur during
interhospital tansfers but there are additional
considerations.
A recent Norwegian study of interhospital transports of
critically ill patients (Eiding 2022) revealed a very high number
of incidents. Despite this fact, these incidents are severely underreported in
the hospital’s electronic incident reporting system. This suggests that
learning is lost and errors with predominant probability are repeated. These
results emphasize the existing challenges in regard to
the quality and safety of interhospital transport of critically ill patients.
Personnel involved in interhospital transports of critically
ill patients for 2 services filled out forms after each transport for 8 and 12
months, respectively. Service A reported incidents during 48% of their
transports, with up to 7 unique incidents reported during a single transport. Service
B reported incidents during 49% of their transports, with up to 4 unique
incidents during a single transport. There was an average of 0.65 unique
incidents per transport. These occurred “during loading” (30%), “during
transport” (35%), and “during handover” (35%), with some of the incidents
occurring in more than one
phase of the transport. Incidents were categorized as
medical (15%), technical (25%), missing equipment (17%), and personal failures
and communication difficulties (42%). But only 3 (1%) of the 294 unique
incidents were actually reported in the hospital’s
electronic incident reporting system.
A group of senior prehospital physician experts evaluated the
materials, and were asked to consider which incidents should
have been reported in the hospital’s electronic incident reporting system and
suggest an intervention to avoid the incident in the future. The expert group
advised that 28 (10%), 33 (11%), and 250 (85%) of the registered incidents
should have been reported in the hospital’s electronic incident reporting
system.
There was considerable variability among the three expert
reviewers in terms of significance of both the severity and reportability of
the incidents. Quite frankly, that wide variability among the three expert
reviewers makes interpretation of the study difficult. But the main conclusion,
that incidents are common during interhospital transports of critically ill
patients and are significantly underreported, probably holds true. The authors
stress that important lessons may be missed, and system errors likely have a
high probability of being repeated. Thus, an opportunity to make the process
safer may be missed. Service quality and transport safety also may be overrated.
We hope you will go
back to our October 30, 2018 Patient Safety Tip of the Week “Interhospital
Transfers” for an extensive
discussion of the types of incidents that occur during interhospital transports
and transfers. Other lessons are in our many columns on intrahospital
transports and those on medical air transports.
Some of our prior
columns on intrahospital transports and the “Ticket to Ride” concept:
- April
8, 2008 “Oxygen
as a Medication”
- November
18, 2008 “Ticket
to Ride: Checklist, Form, or Decision Scorecard?”
- August
11, 2009 “The
Radiology Suite…Again!”
- March
13, 2012 “Medical
Emergency Team Calls to Radiology”
- August 25, 2015 “Checklist for Intrahospital Transport”
- September 1, 2015 “Smarter Checklists”
- November 2016 “Oxygen
Tank Monitoring”
- February 2018 “Oxygen
Cylinders Back in the News”
- May 22, 2018 “Hazardous
Intrahospital Transport”
- October 30, 2018 “Interhospital
Transfers”
- March 31, 2020 “Intrahospital Transport
Issues in Children”
- June 23, 2020 “Telemetry Incidents”
- July 14, 2020 “A Thesis on
Intrahospital Transports”
- August 4, 2020 “Intravenous Issues”
- February 2021 “Risk from Intrahospital
Transfer: Healthcare-Associated Infection”
- May 25, 2021 “Yes, Radiologists Have
Handoffs, Too”
- July 2021 “Unique Way to Rapidly
Identify Oxygen Flow”
Our prior columns
dealing with medical helicopter issues:
July 8, 2008 “Medical
Helicopter Crashes”
October 2008 “More
Medical Helicopter Crashes”
February 3, 2009
“NTSB
Medical Helicopter Crash Reports: Missing the Big Picture”
September 1, 2009 “The
Real Root Causes of Medical Helicopter Crashes”
November 2010 “FAA Safety Guidelines for Medical Helicopters
Short-Sighted”
March 2012 “Helicopter Transport and Stroke”
April 16, 2013 “Distracted While Texting”
August 20, 2013 “Lessons from Canadian Analysis of Medical Air
Transport Cases”
December 29, 2015 “More
Medical Helicopter Hazards”
October 30, 2018 “Interhospital
Transfers”
References:
Eiding H, Røise
O, Kongsgaard UE. Potentially Severe Incidents During
Interhospital Transport of Critically Ill Patients, Frequently Occurring But Rarely Reported: A Prospective Study. Journal of Patient
Safety 2022; 18(1): e315-e319
Print “April 2022 Safety Issues in Interhospital
Transports”
Print “April
2022 What's New in the Patient Safety World (full column)”
Print “April 2022 Length of Stay and
Post-Discharge Complications in Surgical Patients”
Print “April 2022 Another Benefit from the
COVID-19 Pandemic?”
Print “April 2022 Overlapping Surgery Back in
Focus”
Print “April 2022 Safety Issues in Interhospital
Transports”
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