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Patient Safety Tip of the Week
December 13, 2022
Surgical Teams –
the “Consistency Score”
In our several
columns on “after hours” surgery (see list below) we noted one of the likely
contributing factors may be that you are often operating with a team that is
likely different from your daytime team. We can’t overemphasize the importance
of teamwork in the OR.
So, what about
surgery during regular hours? Does inconsistency of team composition impact
performance in the OR then as well? Researchers at the Hospital for Special
Surgery in New York developed a unique metric to study that issue. The
“consistency score” was developed after it was anecdotally observed that
significant variability may exist between surgical teams depending on
scheduling and hiring cycles at their institution (Kirksey 2022).
Because more than
500 members of hospital staff were involved in total joint arthroplasty procedures
with 38 surgeons, the consistency score calculation was a percentage based on the
weighted graph consisting of all team members who had worked with the surgeon over
the prior 90 days until the time of the particular surgery.
(Team roles taken into consideration in this calculation were the surgeon,
anesthesiologist, scrub technician, circulating nurse, first assistant, and
second assistant.)
The actual score is
quite complicated, so you have to go to the original
article for details. But the score assigns weights to various factors and additional
covariates were created to account for confounding and effect modification. The
consistency score association with over 18,000 total joint arthroplasties was
then analyzed.
THA (Total Hip
Arthroplasty) surgical teams with greater consistency were associated with
shorter surgical processing times compared with surgeries with team members who
have worked together less frequently: there was a significant 4.1-minute decrease
(p = 0.008) in surgery duration for a single 10-percentage point increase in
the consistency score. In addition, for a single 10-percentage point increase
in consistency score, the patient-in-to-procedure-start time was 3.0 minutes
faster (p = 0.0006), and there was a 0.3-minute decrease in procedure-end-to-patient-out
duration (p = 0.009) and a 1.7-minute decrease in turnover time (p = 0.001).
The consistency score was not significantly associated with hospital-acquired
complications.
TKA (Total Knee
Arthroplasty) surgical teams with greater consistency had shorter surgical
processing times than surgeries with team members who have worked together less
frequently. Patient-in-to-procedure-start time was 2.6 minutes faster (p = 0.0001)
and surgery duration was 3.4 minutes faster (p = 0.05) for a single
10-percentage point increase in consistency score. In addition, there was a
0.2-minute decrease in time from procedure-end-to-patient-out (p = 0.01) and a
1.1-minute decrease in turnover time (p = 0.03) for a single 10-percentage
point increase in consistency score. Hospital-acquired complications were not significantly
associated with consistency scores for TKA.
Thus, for both THA
and TKA, the consistency score showed that better team consistency was
associated with improved OR efficiency without any increase in adverse events.
The authors note
that they were able to develop the “consistency score” metric because they had
that huge database on total joint arthroplasty procedures. They suspect
hospitals with low volumes of such surgeries might have difficulty using the
metric.
We’re not at all
surprised to see that OR efficiency improved as consistency of the OR teams
improved. We are a little surprised that there was not a concomitant decrease
in surgical complications. Our multiple columns below have discussed the
association of complications or adverse events with procedure duration. It may
be that the mean decrease in OR duration, though statistically significant, may
not have been great enough to reduce complications.
Some of our previous
columns on “after-hours” surgery:
·
September 2009 “After-Hours
Surgery – Is There a Downside?”
·
October
2014 “What Time of Day Do You Want Your Surgery?”
·
January
2015 “Emergency Surgery Also Very Costly”
·
September
2015 “Surgery Previous Night Does Not Impact
Attending Surgeon Next Day”
·
October 4,
2016 “More
on After-Hours Surgery”
·
August
15, 2017 “Delayed
Emergency Surgery and Mortality Risk”
·
October
24, 2017 “Neurosurgery
and Time of Day”
·
December
2019 “Surgeon
On-Call Shifts”
·
October
13, 2020 “Night-Time Surgery”
Our prior columns
focusing on surgical case duration:
·
March 10, 2009 “Prolonged
Surgical Duration and Time Awareness”
·
January 2010 “Operative
Duration and Infection”
·
July 21, 2012 “Surgical
Case Duration and Miscommunications”
·
August 26, 2014
“Surgeons’
Perception of Intraoperative Time”
·
December 30, 2014 “Data
Accumulates on Impact of Long Surgical Duration”
·
November 24, 2015 “Door
Opening and Foot Traffic in the OR”
·
July 26, 2016
“Confirmed:
Keep Your OR Doors Closed”
·
November 7, 2017 “Perioperative
Neuropathies”
·
December 2017 “A
Fix for OR Foot Traffic?”
·
January 2021 “Operative
Time and Postoperative TKA Complications”
References:
Kirksey M, Sasaki M, Grace D, et al. A Novel Network-Based
Metric of Surgical Team Consistency Opens Opportunities to Improve Hospital
Performance and Care Value. NEJM Catalyst 2022; 3(12): December 2022
https://catalyst.nejm.org/doi/full/10.1056/CAT.22.0244
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