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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

https://jamanetwork.com/journals/jamasurgery/fullarticle/2720695?guestAccessKey=9662222b-cf97-4f1f-a733-92bea588b4a2&utm_source=silverchair&utm_medium=email&utm_campaign=article_alert-jamasurgery&utm_content=olf&utm_term=012319

 

 

Dimick JB, Scott JW. A Video Is Worth a Thousand Operative Notes. JAMA Surg 2019; Published online January 23, 2019

https://jamanetwork.com/journals/jamasurgery/fullarticle/2720692?guestAccessKey=a6d90205-b181-4ce4-a821-c6c7ca3b5552&utm_source=silverchair&utm_medium=email&utm_campaign=article_alert-jamasurgery&utm_content=olf&utm_term=012319

 

 

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

https://journals.lww.com/annalsofsurgery/Abstract/2016/09000/Grading_of_Surgeon_Technical_Performance_Predicts.11.aspx

 

 

 

 

 

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