Last month (November 2008 What’s New in the Patient Safety World “Preventing Surgical Site Infections: New Resources”) we noted some of the evidence-based recommendations for preventing surgical site infections (SSI’s). A couple of the recommendations that have been based on less rigorous evidence, smoking cessation and avoidance of hyperglycemia, have just received more backing in studies just published.
Lindstrom and colleagues (Lindstrom 2008) reported the results of a randomized controlled trial on the impact of smoking cessation begun within 4 weeks of elective surgery on surgical complication rates. The found almost a 50% reduction in total complication rate for patients in the intervention (smoking cessation) arm. The study, however, was limited by its small size (they had difficulty recruiting patients who might be randomized to the smoking cessation arm). Looking at just SSI’s, though fewer wound infections occurred in the intervention group, the numbers were far too small to meet statistical significance. Nevertheless, the study is important in lending weight to smoking cessation preoperatively. Whereas most prior studies that showed a benefit on postoperative complications began smoking cessation 6-8 weeks prior to surgery, this study demonstrates that there is a benefit even when smoking cessation is begun as late as 4 weeks prior to elective surgery.
Ramos and colleagues (Ramos 2008) published a study strengthening the correlation between perioperative hyperglycemia and postoperative infections (including SSI’s), independent of preoperative blood glucose level or diabetic status. Using data from a risk-adjusted outcomes database from the National Surgical Quality Improvement Project, they showed that for each 40 mg/dl increase in serum glucose the risk of postoperative infection rose 30%. Postoperative hyperglycemia also had a significant adverse effect on length of stay. Caution: this was not a randomized controlled trial to show that treatment to avoid perioperative hyperglycemia results in fewer SSI’s or better outcomes but it further strengthens the association between hyperglycemia and postoperative infections.
Together, these two studies strengthen the evidence for those two interventions in the guidelines for preventing SSI’s that we talked about last month.
Ramos M, Khalpey Z, Lipsitz S, Steinberg J, Panizales MT, Zinner M, Rogers SO. Relationship of Perioperative Hyperglycemia and Postoperative Infections in Patients Who Undergo General and Vascular Surgery. Ann Surg 2008; 248(4):585-591
Lindstrom D, Azodi OS, Wladis A, Tonnesen H, Linder S, Nasell H, Ponzer S, Adami J. Effects of a Perioperative Smoking Cessation Intervention on Postoperative Complications: A Randomized Trial. Annals of Surgery. 2008; 248(5):739-745 http://www.annalsofsurgery.com/pt/re/annos/abstract.00000658-200811000-00008.htm;jsessionid=J2LL93fxpLQhQMXlrBMyG85SWpcX3xy1s3LPbxj5bF6S49HWfGhQ!976670012!181195629!8091!-1
CMS has posted on its website its proposed decision memos to withhold payment for wrong surgery performed on a patient, surgery on the wrong body part, and surgery on the wrong patient. Quite frankly, we were surprised to hear that CMS had no prior payment decision on such cases. Note that these were not part of the recent final decision on no-pay for “never events” (See our October 2008 What’s New in the Patient Safety World “CMS’s Final Rule on Non-Payment for “Never Events”) The proposals are open for comment, with 1/31/2009 as the proposed date for final decision.
The Institute of Medicine (IOM) has released its new report “Resident Duty Hours: Enhancing Sleep, Supervision, and Safety” this month. Though the report does not recommend further constriction of the current limit of 80 hours per week for residents, it does include recommendations about further reducing consecutive hours worked and inclusion of mandatory nap periods and mandatory days off. Moreover, it recommends that much of the work that residents currently peform (“scut” work) such as phlebotomy be done instead by other healthcare workers. It also calls for better supervision of residents and increased resident education in patient safety.
One important point has to do with handoffs (see our September 30, 2008 Patient Safety Tip of the Week “” and see the article just below this one). With more restricted workhours, the number of handoffs between residents has increased. The IOM report emphasizes the need to make adequate time available for handoffs to occur.
In September we did our Tip of the Week on “”, citing great work done primarily by residents and other housestaff to improve on the handoff process. Now surgical residents at Johns Hopkins (Kemp 2008) have, based on their experiences with inadequate handoffs, put together their “Top 10 List for a Safe and Effective Sign-out”. They stressed providing adequate time and appropriate quiet environment for sign-outs, emphasizing the need for sign-out to be an active 2-way interaction. They want a standardized list/format, including items that are important to surgical patients. Prioritizing the patients (knowing which patients are the sickest and seeing them first) was important, as was knowing who the senior resident on-call was. The sign-out should include outstanding tasks, outstanding lab/radiology studies, outstanding consults, and details about any pending admissions. Morning sign-out is just as important as evening sign-out and adequate time should be provided for this as well.
They have included this list and process in their intern orientation. They even include a simulation sign-out as part of that orientation. They also discuss the utility of web-based patient sign-out lists but note that the sign-out lists, whether paper or electronic, should be destroyed after the on-call period to preserve patient confidentiality.
Kemp CD, Bath JM, Berger J, Bergsman A, Ellison T, Emery K, Garonzik-Wang J, Hui-Chou HG, Mayo SC, Serrano OK, Shridharani S, Zuberi K, Lipsett PA, Freischlag JA. The Top 10 List for a Safe and Effective Sign-out. Arch Surg. 2008;143(10):1008-1010
We first talked about Rapid Response Teams in our August 2007 What’s New in the Patient Safety World column “”. Then, in our Novermber 27, 2007 Patient Safety Tip of the Week “ ” we discussed the weakness of the evidence supporting a positive effect of rapid response teams on patient outcomes and discussed many of the methodological problems in studies on RRT’s.
Chan and colleagues (Chan 2008) have just published a prospective cohort design study comparing code rates and mortality before and after implementation of rapid response teams for adult inpatients. Raw code rates per 1000 admissions were lower in the the post-RRT period. However, after adjustment for a number of variables, overall hospital codes rates were not significantly reduced, though those for non-ICU patients were reduced. Furthermore, mortality was not significantly better after implementation of the RRT program. A significant finding in their study is that a large percentage of patients who died after RRT intervention either had DNR status or were accorded DNR status during or after the RRT intervention.
The study did not include financial data. However, in addition to the costs of developing and staffing the RRT’s, it should be noted that a substantial number of patients were bumped up to a higher level of care (usually ICU or telemetry service) after RRT intervention, thus adding to overall costs without significantly affecting outcomes (at least in terms of mortality).
All this negative evidence does not negate the logic of having a culture of safety that helps recognize early patients that are in need of “rescue”. But it does raise many questions about committing many resources to develop RRT’s without better evidence-based validation of the RRT concept. The idea remains a sound one but the most appropriate targets, the triggers, the makeup of teams, the mode of response, the logistics, and the best outcome measures all need to be validated before hospitals rush willy-nilly into developing RRT’s.
Update: See also our April 2009 What’s New in the Patient Safety World “Early Emergency Team Calls Reduce Serious Adverse Events” and our December 29, 2009 Patient Safety Tip of the Week “Recognizing Deteriorating Patients”.
Chan PS, Khalid A, Longmore LS, Berg; RA, Kosiborod M, Spertus JA. Hospital-wide Code Rates and Mortality Before and After Implementation of a Rapid Response Team. JAMA. 2008; 300(21):2506-2513
A paper presented at this month’s Radiological Society of North America’s annual meeting showed that inclusion of photographs of patients improved accuracy of radiologists’ reports, according to a press release from the RSNA. Putting a photograph of the patient aside their images on a PAC screen resulted not only in the radiologists feeling more empathy toward the patient but they also identified more incidental findings (the files were chosen because of incidental findings in this randomized study) without taking more time to review the images.
This somewhat unexpected finding adds another reason to consider adding patient photographs to electronic medical records (EMR’s). We think that inclusion of a patient photograph could significantly improve patient safety (eg. helping prevent a physician from inadvertently ordering on the wrong patient during CPOE, or a nurse administering a medication to wrong patient). In the digital age, it is certainly easy enough to include photographs in the EMR. But the logisitics, legal and privacy issues, measurable outcomes, and unintended consequences remain to be determined.