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What’s New in the
Patient Safety World
March 2019
Another Use for
Video Recording
In several columns we have discussed the use of video recording
as a tool to improve patient safety. Most of our focus has been how reviewing
such videotapes can improve teamwork and communication in various healthcare
venues, especially the operating room or during handoffs.
Now a new study in the Netherlands (van
de Graaf 2019) looked at cases of adults undergoing elective
laparoscopic surgery for colorectal cancer and compared technical details of
the operations as seen in the video recordings as opposed to those in the
normal operative reports. The authors note that certain steps during the
surgical procedure are essential but these may not be
specifically examined, and might be skipped or inadequately performed.
Important steps in laparoscopic colorectal surgery include introduction of
trocars under vision, exploration, vascular control, mobilization and
resection, creation of anastomosis, and closure. Currently, the only source of
information regarding the essential intraoperative surgical steps is
represented by the narrative operative report (NR). They therefore postulated
that systematic video recording (SVR) might be used to supplement the narrative
operative report and better capture these essential steps.
Participating surgeons were asked to systematically capture
predefined key steps of the surgical procedure intraoperatively on video in
short clips. This method was chosen so that surgeons were committed to
consciously start and stop the process of recording these essential steps and
the recording of video fragments diminishes the digital storage space
necessary, allowing for manageable content (mean duration of case recording was
31 minutes). Intraoperative video clips were recorded according to a surgical
checklist under the direction of the primary surgeon and the corresponding
steps were marked on the case report form after completion of the procedure. If
a step was not relevant in a particular procedure, not
applicable or n/a was added next to the step on the the
case report form. Cases from their study group were matched with cases from a
historical cohort that did not have video recording done.
They found that only 52.5% of the essential technical steps
were documented with the traditional narrative operative report compared with
85.1% with the addition of video recording of essential steps.
They also looked at some secondary outcomes. Aside from a
significant difference regarding the postoperative length of stay in favor of
the study group (8.0 vs 8.6 days), no significant differences were found
between the study and historical control groups regarding postoperative and
pathologic outcomes.
In an accompanying editorial, Dimick
and Scott (Dimick
2019) note that the study only documented the steps that
occurred and did not evaluate the quality of those steps (i.e. how well each
step was performed). But they did note that prior data from bariatric (Birkmeyer 2013)
and pancreatic (Hogg
2016) surgery suggest that surgeon video peer review using a simple
Likert scale of technical skill strongly correlates with risk-adjusted
outcomes. So such recordings could be used in a peer
review process for quality improvement purposes.
We’ve often suggested that organizations videotape their
surgical timeouts to assess not only the elements of the timeout but also the “genuineness“ of involvement of the participants. These can
be very helpful in facilitating “active” rather than passive participation of
all members of the surgical team.
And in several columns we’ve discussed
the negative impacts of OR foot traffic and door opening/closing (regarding
both distractions and contributing to surgical infections). Video recording is
one way to assess how often such door opening/closing occurs and determine the
appropriateness of each instance.
Many academic organizations have used video recording of
resident-to-resident handoffs as a quality improvement tool. This allows us to
critique not just whether the information transmitted was appropriate, but
whether the recipeient was allowed
to ask questions and get clarification and whether the setting was free
from interruptions and distractions.
We’ve often recommended doing video/audio recording in the
OR and then play it back for all parties in a constructive fashion so they can
see how well (or not so well) they communicated and how distractions or
interruptions interfered with their communications. It can help assess how well
the team adheres to protocols like the
Universal Protocol or surgical timeout procedures or the sponge/instrument
“count”. But it could be used to assess interruptions and distractions such as
door opening/closing as well. Unfortunately, too many surgeons and hospital
attorneys are loathe to use video recording even when
it is clearly being done for quality improvement activities and even when the
recordings would be destroyed immediately following their use in quality
improvement activities. It would probably take very clearcut
statutes in every state to protect such recordings from the legal discovery process
for us to convince more organizations of the value of video recording.
Some of our previous columns discussing video recording:
September 23, 2008 “Checklists
and Wrong Site Surgery”
December 6, 2010 “More
Tips to Prevent Wrong-Site Surgery”
November 2011 “Restricted
Housestaff Work Hours and Patient Handoffs”
March 2012 “Smile...You’re
on Candid Camera!”
August 27, 2013 “Lessons
on Wrong-Site Surgery”
March 17, 2015 “Distractions
in the OR”
November 24, 2015 “Door
Opening and Foot Traffic in the OR”
References:
van de Graaf FW, Lange MM, Spakman
JI, et al. Comparison of Systematic Video Documentation With
Narrative Operative Report in Colorectal Cancer Surgery. JAMA Surg 2019;
Published online January 23, 2019
Dimick JB, Scott JW. A Video Is
Worth a Thousand Operative Notes. JAMA Surg 2019; Published online January 23,
2019
Birkmeyer JD, Finks JF, O’Reilly A, et al;
Michigan Bariatric Surgery Collaborative. Surgical skill and complication rates
after bariatric surgery. N Engl J Med
2013; 369(15):1434-1442
https://www.nejm.org/doi/10.1056/NEJMsa1300625
Hogg ME, Zenati M,
Novak S, et al. Grading of surgeon technical performance
predicts postoperative pancreatic fistula for pancreaticoduodenectomy
independent of patient-related variables. Ann Surg 2016; 264(3): 482-491
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