You’ve heard us on our “soapbox” about sepsis several times.
We like to point out that 2 significant drivers may have changed the landscape
and created a population of “sepsis” that has a lesser mortality rate. CMS data
clearly show that a few years back there was a significant change in the number
of pneumonia cases and sepsis cases (Lindenauer
2012). The number of pneumonias decreased and sepsis cases
increased. Why? Hospitals (often with the help of the third party
"clinical documentation programs" that help billing) began using the
definition of sepsis that required two of the SIRS criteria in a patient
suspected of having infection in order to have a DRG for sepsis. You could have
a patient with pneumonia happily pushing his IV pole up and down the hallway
who meets those threshold criteria and now gets a label of "sepsis",
which of course gets a significantly higher reimbursement than pneumonia. The
same research group showed how such coding changes have affected reported
mortality rates for both pneumonia and sepsis (Rothberg 2014).
They note that such shifts in coding reduce the pneumonia mortality rate (because
sicker patients are shifted to the sepsis or respiratory failure diagnosis
codes) and also reduce the mortality rate for sepsis (because the newly added
patients are less sick than the average sepsis patient).
Also, CMS readmission penalties apply to pneumonia but not
to sepsis. So there was additional pressure on hospitals to see if patients met
the sepsis "criteria". And, as pointed out in the recent coding
impact article (Rothberg
2014) the Surviving Sepsis Campaign may have increased awareness of sepsis,
resulting in more patients with pneumonia being coded as sepsis since they met
the SIRS criteria requirement.
So it’s a great relief that the new consensus definition of
sepsis does away with the SIRS criteria. A consensus panel has arrived at new
definitions for sepsis and septic shock, marking the first refinement in
definition in over 15 years (Singer 2016).
The JAMA article by Singer et al was accompanied by 2 articles describing the
consensus process and development of clinical criteria (Shankar-Hari
2016, Seymour
2016) and an editorial (Abraham 2016).
There was apparently a unanimous agreement to eliminate use of the SIRS
criteria.
In the new definition sepsis
is defined as “life-threatening organ dysfunction caused by a dysregulated host
response to infection” and the clinical criteria for diagnosis are organ
dysfunction represented by an increase
in the Sequential [Sepsis-related] Organ Failure Assessment (SOFA) score of 2
points or more. The SOFA score is familiar to those who work in ICU’s and
has apparently been a useful predictor of mortality.
Because the SOFA score requires measurement of lab
parameters and is most easily calculated in ICU patients, the panel came up
with the qSOFA (“quick” SOFA) score to be used in
patients outside the ICU to quickly identify patients with sepsis without the
need for lab data. The qSOFA is based on 3 criteria:
(1) a respiratory
rate ≥22
(2) altered
mentation (Glasgow Coma Scale score of 13 or less) and
(3) systolic blood
pressure ≤100 mm Hg.
The new definition for septic
shock requires:
(1) hypotension not
responsive to fluid resuscitation
(2) requiring
vasopressors to maintain a mean arterial BP
≥65 mm Hg, and
(3) serum lactate
level >2mmol/L (18 mg/dL)
Models show those meeting the new definition of sepsis have
an in-hospital mortality greater than 10% and those meeting the septic shock
definition have a mortality greater than 40%.
While we applaud the
new definition in that it should exclude those cases of mild infections that
simply met 2 SIRS criteria, it will likely take some time before the new
definition is integrated into ICD-9 or ICD-10 coding. This will obviously
complicate measurement in ongoing pay-for-performance programs or public
quality reporting programs using sepsis as a parameter. And it may complicate
some ongoing research trials. Probably most importantly, it will impact many of
the early warning scores we’ve discussed in many of our prior columns on early
recognition of sepsis.
One fact we were,
frankly, unaware of before this new paper was published is that
culture-positive sepsis is observed in only 30% to 40% of cases. Makes you
wonder how many more of the cases of “sepsis” under the old definition were
actually related to infection.
We still need to focus on early recognition, timely antibiotics
and adequate fluid resuscitation to reduce morbidity and mortality from “sepsis”.
But hopefully these new definitions are steps in the right direction and will
help us determine better management in the future.
Our other columns on
sepsis:
References:
Lindenauer PK, Lagu
T, Shieh M-S, et al.
Association of Diagnostic Coding With Trends in Hospitalizations and Mortality
of Patients With Pneumonia, 2003-2009. JAMA 2012; 307(13): 1405-1413
http://jama.jamanetwork.com/article.aspx?articleid=1148328&resultClick=3
Rothberg MB, Pekow PS, Priya A, Lindenauer PK. Variation
in Diagnostic Coding of Patients With Pneumonia and Its Association With
Hospital Risk-Standardized Mortality Rates: A Cross-sectional Analysis. Ann Intern Med 2014; 160(6): 380-388
http://annals.org/article.aspx?articleid=1846635
Singer M, Deutschman CS, Seymour
CW, et al. The Third International Consensus Definitions for Sepsis and Septic
Shock (Sepsis-3). JAMA 2016; 315(8): 801-810
http://jama.jamanetwork.com/article.aspx?articleid=2492881
Seymour CW, Liu VX, Iwashyna TJ,
et al. Assessment of Clinical Criteria for Sepsis For the Third International
Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA 2016;
315(8): 762-774
http://jama.jamanetwork.com/article.aspx?articleid=2492875
Shankar-Hari M, Phillips GS, Levy ML, et al. Developing
a New Definition and Assessing New Clinical Criteria for Septic Shock for the
Third International Consensus Definitions for Sepsis and Septic Shock
(Sepsis-3). JAMA 2016; 315(8): 775-787
http://jama.jamanetwork.com/article.aspx?articleid=2492876
Abraham E. New Definitions for Sepsis and Septic Shock. Continuing
Evolution but With Much Still to Be Done (editorial). JAMA
2016; 315(8): 757-759
http://jama.jamanetwork.com/article.aspx?articleid=2492856
Print “March
2016 Finally…A More Rationale Definition for Sepsis”
Acknowledging that suicide is now the 10th
leading cause of death in the US, the Joint Commission has just published a new
Sentinel Event Alert on “Detecting and treating suicide ideation in all
settings” (The Joint
Commission 2016). This alert actually replaces two previous Joint
Commission Sentinel Event alerts on suicide and differs from the others in that
its focus in on detecting suicidal risk factors and suicidal ideation at all
levels of the healthcare continuum, not just in hospitals.
While it should be no surprise that we need to focus outside
the hospital as well as within, this Sentinel Event Alert is very useful in its
links to a host of valuable resources to help with those tasks.
The Joint Commission stresses the importance of detecting
and identifying risk factors for suicide since many patients with suicidal
ideation may not be overt with that ideation. The alert stresses the following
risk factors:
The alert suggests use of a brief, standardized
evidence-based screening tool such as the PHQ-9.
It notes also the common practice of using the 2-question tool PHQ-2 as an initial
screen and moving to the PHQ-9 if the answer to either question is “yes”. The
PHQ-9 includes the specific question “Thoughts that you would be better off
dead or of hurting
yourself in some way”. If you don’t
move on to the PHQ-9 you’d need to add some other assessment for suicidal
ideation. The alert notes several other brief screening tools that might be
used.
The timing of the alert is good since you’ll recall that the
US Preventive Services Task Force just finalized its updated recommendation
that screening for depression be conducted in the general adult population,
including pregnant and postpartum women (USPSTF
2016a). USPSTF, of course, noted that such screening needs to take place
with adequate systems in place to ensure accurate diagnosis, effective
treatment, and appropriate follow-up. Similarly, the USPSTF recommends
screening for major depressive disorder (MDD) in adolescents aged 12 to 18
years (USPSTF
2016b).
In our March 20,
2012 Patient Safety Tip of the Week “Adverse
Events Related to Psychotropic Medications” we noted that many
communities are adopting the DIAMOND model (ICSI 2007)
for management of depression in the primary care setting. That model is based
on the great work from the IMPACT study led
by the University of Washington. That approach utilizes the PHQ-9 for both
screening and monitoring outcomes, a stepped care approach for treatment
modification and intensification, and use of care coordinators embedded in the
primary care practices. One of the key elements is a regular interaction with a
psychiatrist or other behavioral health provider.
The Joint Commission alert goes on to describe secondary
screeners such as the Columbia-Suicide Severity Rating Scale
(Posner
2011). The C-SSRS may be found
online and has been demonstrated to
be valid in several different patient populations (see our December 2011
What’s New in the Patient Safety World column “Columbia
Suicide Severity Rating Scale”).
The alert then discusses
what to do if a patient screens positive for suicidal ideation but either
denies it or refuses treatment. It notes the need to seek corroborating
information from secondary sources (such as family, friends, other
providers). It specifically states that if a patient declines to consent to
such contact, HIPAA permits the clinician to make such contacts without consent
if he/she feels the patient may be a danger to self or others.
The alert goes on to
describe the immediate steps that must be undertaken to keep the high-risk patient
in a safe environment, and steps for lower-risk patients such as providing the
phone number of the National Suicide Prevention Lifeline, developing a safety
plan, arranging for psychiatric followup within one
week, and especially restricting access to firearms or other lethal means (such
as drugs or chemicals).
This is where we
think the sentinel event alert needs to go further and help communities develop
better systems of care. Ironically, we tried for years to get primary
care providers to screen their patients for depression, with mixed results. The
biggest barrier we encountered was the disruption to the day’s workflow caused
when a patient screened positive. Because of that possibility many PCP’s simply
refused to do such screening. For that reason we think that organizations like
hospital outpatient clinics or accountable care organizations need to have in
place lightning response teams so that the PCP can make a single phone
call and have a team respond with the capabilities of managing such patients.
While we agree with TJC that everyone in the office of a PCP or other provider
should be educated on how to deal with potentially suicidal patients, we think
it is impractical without the capability of immediately mobilizing other
personnel more skilled in dealing with such cases.
The alert goes on to discuss management of the potential
suicidal patient by behavioral health professionals, including the need for
collaboration with family and other social supports, and development of longer
term treatment plans and discharge plans that take into account the very
vulnerable period in the weeks or months immediately following discharge from
an inpatient facility. They describe mechanisms to deal with patients who do
not keep followup appointments. And they discuss the
need for detailed documentation of all aspects of care and communication
regarding the at risk patient.
Our October 6, 2015
“Suicide
and Other Violent Inpatient Deaths” noted that, given the nationwide
shortage of psychiatrists, getting timely followup
arranged can be problematic. The “Zero Suicide” approach, as adopted by NYS
Office of Mental Health (NYSOMH
2013), stresses the importance of the “warm handoff” and use of “bridger” staff. The latter are peer specialists who meet
with patients either face-to-face or by phone prior to discharge and accompany
the patients to their first outpatient appointment. They also ensure that
additional appointments are scheduled and educate the patients about other
support services.
The Joint Commission sentinel event alert has great
references and links to a plethora of great tools, such as those in the
national “Zero Suicide” campaign, to
help in the management of the potentially suicidal patient.
Overall, this Sentinel Event Alert is a valuable resource.
We also encourage you to visit our many previous columns on suicide, the
majority of which have been primarily hospital-focused (both behavioral health
and general hospitals). But we also encourage you to work with your larger
organizational or community partners to think about developing those “lightning response teams” that we think
are essential to implementing safety nets that are truly needed to achieve a
“Zero Suicide” goal.
Some of our prior
columns on preventing hospital suicides:
References:
The Joint Commission. Sentinel Event Alert 56: Detecting and
treating suicide ideation in all settings. February 24, 2016
http://www.jointcommission.org/sea_issue_56/
Patient Health Questionnaire-9 (PHQ-9). Developed by Drs.
Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues (accessed
February 24, 2016)
PHQ-9 (Patient Health Questionnaire-9).
http://www.phqscreeners.com/sites/g/files/g10016261/f/201412/PHQ-9_English.pdf
Kroenke K, et al. The Patient Health Questionnaire-2:
Validity of a Two-Item Depression Screener. Medical Care 2003; 41: 1284-1294 (accessed
February 24, 2016)
PHQ-2 (Patient Health Questionnaire-2).
http://www.cqaimh.org/pdf/tool_phq2.pdf
USPSTF (US Preventive Services Task Force). Final
Recommendation Statement. Depression in Adults: Screening. February 2016
USPSTF (US Preventive Services Task Force). Depression in
Children and Adolescents: Screening (draft summary). Release Date: February
2016
ICSI. DIAMOND
Initiative. Depression Improvement Across Minnesota.
2007
http://www.icsi.org/colloquium_-_2007/diamond_panel.html
IMPACT.
Evidence-Based Depression Care.
Posner K, Brown GK, Stanley B, et al. The Columbia–Suicide
Severity Rating Scale: Initial Validity and Internal Consistency Findings from
Three Multisite Studies With Adolescents and Adults.
Am J Psychiatry 2011; 10.1176/appi.ajp.2011.10111704
Published online November 8, 2011
http://ajp.psychiatryonline.org/article.aspx?articleID=180115
C-SSRS scales for clinical practice.
http://www.cssrs.columbia.edu/scales_practice_cssrs.html
New York State Office of Mental Health. Getting to the Goal.
Suicide as a Never Event
in New York State. August 2013
https://www.omh.ny.gov/omhweb/dqm/bqi/suicideasaneverevent.pdf
Zero Suicide in Heatlh and Behavioral
Healthcare. website
Print “March
2016 TJC Sentinel Event Alert on Preventing Suicide”
New guidelines for management of postoperative pain have
just been published jointly by several specialty societies (Chou 2016).
The guidelines aim to use multimodal analgesic techniques so that use of
opioids might be minimized.
There are 32
specific recommendations in all and the guidelines really focus on multimodal
techniques that target different mechanisms of actions in the peripheral and
central nervous systems.
Education of the
patient should begin preoperatively and be specifically tailored to individual
patients, taking into account medical, psychological and social factors. Such
preoperative planning may help to reduce opioid consumption, anxiety, requests
for sedation and ultimately reduce length of stay. Such educational
interventions can range from single episodes of face-to-face instruction or
provision of written materials, videos, audiotapes, or Web-based educational information
to more intensive, multicomponent preoperative interventions including
individualized and supervised exercise, education, and telephone calls. Such
sessions should take into consideration health literacy, the language and
cultural context of the patient/family, and allow sufficient time for asking
questions. Though the timing of such preoperative sessions is uncertain, they
should be far enough in advance to allow for discontinuation of certain
medications prior to surgery and to avoid withdrawal syndromes from some
medications.
The panel does
recommend TENS (transcutaneous electrical nerve stimulation) and cognitive
behavioral therapy (CBT) as potential nonpharmacologic
adjuncts for pain management but found the evidence insufficient to recommend
acupuncture, massage, or cold therapy.
The panel recommends
use of oral, rather than intravenous, opioids where possible and also
recommends avoidance of intramuscular analgesics. Where parenteral analgesia is
needed the panel recommends use of intravenous patient-controlled analgesia
(PCA) if the patient is a good candidate but recommends against a basal dose of
opioids during PCA in opioid-naïve patients.
One overarching
theme is use of multiple different analgesics to maximize efficacy of pain
control while minimizing adverse effects. The panel recommends that clinicians
provide adults and children with acetaminophen and/or nonsteroidal anti-inflammatory
drugs (NSAIDs) as part of multimodal analgesia for management of postoperative pain
in patients without contraindications and clinicians should consider giving a
preoperative dose of oral celecoxib to adult patients if no contraindications.
Other pharmacological considerations are use of oral gabapentin or pregabalin, IV ketamine, and IV lidocaine infusions for
some procedures.
Other interventions
in multimodal pain management may include surgical site-specific local
anesthetic infiltration for surgical procedures with evidence indicating
efficacy and use of topical local anesthetics in combination with nerve blocks
for procedures like circumcision.
Surgical site-specific
peripheral regional anesthetic techniques should be considered in adults and
children for procedures with evidence indicating efficacy and use of continuous,
local anesthetic-based peripheral regional analgesic techniques should be
considered when the need for analgesia is likely to exceed the duration of
effect of a single injection.
Neuraxial analgesia should be offered for major thoracic
and abdominal procedures, particularly in patients at risk for cardiac complications,
pulmonary complications, or prolonged ileus. But neuraxial
administration of magnesium, benzodiazepines, neostigmine, tramadol, and
ketamine should be avoided. Appropriate monitoring should be in place for those
receiving neuraxial analgesia.
Each facility
performing surgery should have an organizational structure in place to develop
and refine policies and processes for safe and effective delivery of
postoperative pain control.
There should be access
to consultation with a pain specialist for patients with inadequately
controlled postoperative pain or at high risk of inadequately controlled
postoperative pain (eg, opioid-tolerant, history of
substance abuse). And appropriately trained and credentialed physicians should
be available for monitoring patients for whom neuraxial
analgesia or continuous peripheral blocks are used.
Importantly, there
should be adequate education of patients, parents, families, other caregivers
and primary care physicians about appropriate tapering of analgesia after
discharge from the hospital.
Overall, this is a
comprehensive and well thought out guideline that summarizes the evidence from
the literature and has practical recommendations for management of
postoperative pain.
Also, the American Academy of Pediatrics has recently
published its recommendations for critical elements for the pediatric perianesthesia environment (Polaner 2015).
It does have a short section on perioperative pain management and has
recommendations for monitoring infants whose immature respiratory control
centers leave them vulnerable to effects of anesthesia and other drugs and
those with obstructive sleep apnea.
Both guidelines do not specify who should provide the
preoperative planning and education. The American Society of Anesthesiologists
has good discussions on the
“Perioperative Surgical Home” and a
recent abstract presented at the ASA annual meeting showed how a perioperative
surgical home improves quality and reduces costs (Harrison 2015). But,
logically, such planning and education should also be multidisciplinary. So a
perioperative home staffed by anesthesiologists, nurses, physician extenders,
and surgeons from specific departments may make sense. Such might also include
pain specialists and clinical pharmacists to help deal with complex cases.
References:
Chou R, Gordon DB, de Leon-Casasola
OA, et al. Guidelines on the Management of Postoperative Pain. Management of
Postoperative Pain: A Clinical Practice Guideline from the American Pain
Society, the American Society of Regional Anesthesia and Pain Medicine, and the
American Society of Anesthesiologists’ Committee on Regional Anesthesia,
Executive Committee, and Administrative Council. The Journal of Pain 2016;
17(2): 131-157
http://www.jpain.org/article/S1526-5900%2815%2900995-5/pdf
Polaner DM, Huck CS.
AAP (American Academy of Pediatrics). Critical Elements for the Pediatric
Perioperative Anesthesia Environment. Pediatrics 2015; 136(6): published online
November 30, 2015
http://pediatrics.aappublications.org/content/136/6/1200
ASA (American Society of Anesthesiologists). Perioperative
Surgical Home.
Anesthesiology 2015 from the American Society of
Anesthesiologists (ASA): Abstract A1031. Presented October 24, 2015
As reported in: Harrison L. Perioperative Surgical Home
Improves Quality, Reduces Costs. Medscape Medical News 2015;
November 02, 2015
http://www.medscape.com/viewarticle/853624
Print “March
2016 Guideline for Management of Postoperative Pain”
When discussing the impact of healthcare worker fatigue on
patient safety, we often begin with the question “Would you rather be cared for
by a tired resident who knows you or a wide awake one who doesn’t know you?”. Of course, at this time we don’t have an unassailable
answer to that question.
In our many columns (listed below) on the conflicting
studies on the impact of housestaff workhour
restrictions on patient safety we’ve laid our hopes for better answers on two ongoing
randomized trials, one in surgery (the FIRST trial) and one in internal
medicine (the iCOMPARE trial).
The results of the FIRST (surgical residency) trial were
just published (Bilimoria
2016). But does it really answer critical questions?
The trial concluded that there were no significant
differences in the primary or secondary patient outcomes between the standard
(ACGME rules) group and the intervention (more flexible hours) group and that
there were also no significant differences in residents’ satisfaction with
overall well-being and education quality. Residents in the flexible hours arm,
however, were more likely to perceive negative effects on personal activities
such as time with family and friends, extracurricular activities, rest and
health.
The FIRST trial was a well-designed prospective
cluster-randomized (at the residency program level) trial that used data from a
validated database (the ACS NSQIP database). But it was a noninferiority
trial, really designed to show the two arms equal rather than one arm having
superior outcomes.
Our biggest problem with the study is that, other than death
within 30 days, all the patient level outcomes were likely more related to actions
during the surgery or immediate perioperative period. They did not include
things like medication errors, which one might reasonably argue would be
expected to be more often affected by resident fatigue than would something
like wound infections. And we can find no reference in the publication about
length of stay or readmission rates, important parameters which often are impacted
by both complications and continuity of care issues.
So perhaps the best way to summarize the FIRST results is
“there is no difference in patient outcomes or residents’ perception of
educational value between strict adherence to ACGME guidelines vs. more
flexible workhours but residents have more negative feelings about the impact
on their personal lives with the more flexible hours.” Given that, there is
actually little reason for the ACGME to alter its recommendations regarding
resident work hours.
In the editorial accompanying the FIRST trial results, John Birkmeyer points out that much of the work formerly done
primarily by residents is now done primarily by others (Birkmeyer
2016). For example, there are often board-certified intensivists in
the ICU’s and many associate providers working with multidisciplinary teams.
We’ll add that many hospitals also have hospitalists that are attending to many of the non-surgical aspects of patient care in
surgical patients, probably much more so than when the original ACGME resident
workhour restrictions were enacted in 2003.
So what did we learn from the FIRST trial? There appear to
be no overwhelming reasons that the ACGME workhour restrictions should be
rescinded or modified.
Some of our other columns on housestaff
workhour restrictions:
December 2008 “IOM
Report on Resident Work Hours”
February 26, 2008 “Nightmares:
The Hospital at Night”
January 2010 “Joint
Commission Sentinel Event Alert: Healthcare Worker Fatigue and Patient Safety
January 2011 “No
Improvement in Patient Safety: Why Not?”
November 2011 “Restricted
Housestaff Work Hours and Patient Handoffs”
January 3, 2012 “Unintended
Consequences of Restricted Housestaff Hours”
June 2012 “Surgeon
Fatigue”
November 2012 “The
Mid-Day Nap”
December 10, 2013 “Better
Handoffs, Better Results”
April 22, 2014 “Impact
of Resident Workhour Restrictions”
January 2015 “More
Data on Effect of Resident Workhour Restrictions”
August 2015 “Surgical
Resident Duty Reform and Postoperative Outcomes”
September 2015 “Surgery
Previous Night Does Not Impact Attending Surgeon Next Day”
Some of our other columns on the role of fatigue in
Patient Safety:
November 9, 2010 “12-Hour
Nursing Shifts and Patient Safety”
April 26, 2011 “Sleeping
Air Traffic Controllers: What About Healthcare?”
February 2011 “Update
on 12-hour Nursing Shifts”
September 2011 “Shiftwork
and Patient Safety
November 2011 “Restricted
Housestaff Work Hours and Patient Handoffs”
January 2010 “Joint
Commission Sentinel Event Alert: Healthcare Worker Fatigue and Patient Safety
January 3, 2012 “Unintended
Consequences of Restricted Housestaff Hours”
June 2012 “June
2012 Surgeon Fatigue”
November 2012 “The
Mid-Day Nap”
November 13, 2012 “The
12-Hour Nursing Shift: More Downsides”
July 29, 2014 “The
12-Hour Nursing Shift: Debate Continues”
October 2014 “Another
Rap on the 12-Hour Nursing Shift”
December 2, 2014 “ANA
Position Statement on Nurse Fatigue”
August 2015 “Surgical
Resident Duty Reform and Postoperative Outcomes”
September 2015 “Surgery
Previous Night Does Not Impact Attending Surgeon Next Day”
Our previous columns
on the 12-hour nursing shift:
November 9, 2010 “12-Hour
Nursing Shifts and Patient Safety”
February 2011 “Update
on 12-hour Nursing Shifts”
November 13, 2012 “The
12-Hour Nursing Shift: More Downsides”
July 29, 2014 “The
12-Hour Nursing Shift: Debate Continues”
October 2014 “Another
Rap on the 12-Hour Nursing Shift”
December 2, 2014 “ANA
Position Statement on Nurse Fatigue”
September 29, 2015 “More
on the 12-Hour Nursing Shift”
References:
Bilimoria KY, Chung JW, Hedges LV,
et al. National Cluster-Randomized Trial of Duty-Hour Flexibility in Surgical
Training. N Engl J Med 2016; published online first February
2, 2016
http://www.nejm.org/doi/full/10.1056/NEJMoa1515724?query=TOC
Birkmeyer JD. Surgical Resident
Duty-Hour Rules - Weighing the New Evidence (editorial). N Engl
J Med 2016; published online first February 2, 2016
http://www.nejm.org/doi/full/10.1056/NEJMe1516572?query=TOC
Print “March
2016 Does the Surgical Resident Hours Study Answer Anything?”
Print “March
2016 What's New in the Patient Safety World (full
column)”
Print “March
2016 Finally…A More Rationale Definition for Sepsis”
Print “March
2016 TJC Sentinel Event Alert on Preventing Suicide”
Print “March
2016 Guideline for Management of Postoperative Pain”
Print “March
2016 Does the Surgical Resident Hours Study Answer Anything?”
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