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Surgical checklist benefits depend on culture change
BOSTON – The success of surgical safety checklists to reduce postoperative mortality appears to depend not only on implementation but also on the degree to which a hospital embraces a culture of teamwork, Atul Gawande, MD, MPH, FACS, said at the annual clinical congress of the American College of Surgeons.
The session “Checking in on the Checklist – Ten Years of the WHO Surgical Safety Checklist” moderated by Thomas Geoghegan Weiser, MD, FACS, and Alex B. Haynes, MD, FACS,considered the progress of the past decade in implementing the World Health Organization initiative in medical institutions around the world.
Team-based approaches to the checklist accompanied by other institutional support have demonstrated double-digit reductions in mortality, while in contrast, a mandate-only approach resulted in a 0% change, said Dr. Gawande, a general and endocrine surgeon at Brigham and Women’s Hospital and professor in the department of health policy and management at the Harvard T.H. Chan School of Public Health and the Samuel O. Thier Professor of Surgery at Harvard Medical School, all in Boston.
Variables including respect among team members, clinical leadership, and assertiveness on behalf of patient safety appeared to be predictive of postoperative death rates in one recent implementation of the WHO Surgical Safety Checklist, he added.
Dr. Gawande said the 29-item surgical safety checklist has earned support but also skepticism and “some outright opposition” in the nearly 10 years since landmark study published in the New England Journal of Medicine, coauthored by Dr. Haynes, reported that the approach cut mortality by 47% and postoperative complication rates by 36%, on average, in a diverse group of eight hospitals throughout the world.
“It’s a challenge in a fundamental way, to our values,” Dr. Gawande told attendees. “What we have valued in our life as surgeons is our autonomy as clinicians, and here was an approach which required you to work with different values: humility, discipline, teamwork.”
That 47% mortality reduction was achieved in a clinical trial setting with “very carefully selected sites” that were enthusiastic about giving the checklist a try, and toward that end, received weekly support, Dr. Gawande said.
Subsequent implementations of the checklist have had varying success rates, he said.
Implementations that have included a mandate plus regular feedback have yielded mortality reductions upward of 26%he said, while a mandate plus team training reduced mortality by 18% in a Veterans Health Administration hospital setting, according to Dr. Gawande. By contrast, a mandate-alone approach in Ontario yielded a 0% reduction in mortality.
“What we came to realize is a kind of formula that underlies how you create change in organizations generally, where you’re trying to create systems that make it easier for people to get the right kinds of things done,” Dr. Gawande said.
“You have a systems tool that has been carefully crafted around the ‘killer items’ – the failure points that even experts fail at – you have an implementation pathway, and then you bring it into a ready environment where people are capable and they’re motivated,” he explained.
A South Carolina initiative that was voluntary and included light-touch support yielded a 22% reduction in hospitals that completed the adoption program, Dr. Gawande said. Of note, investigators in the Safe Surgery 2015: South Carolina Initiative found that perceptions of safety among operating room personnel were associated with the all-cause 30-day postoperative death rate.
“The team found in South Carolina that the predictor of how much change you get is how effective your implementation was in changing the culture to be more team oriented,” Dr. Gawande said.
“You could recognize it by how much change you saw in what the frontline people reported about how much they are respected, how much clinical leadership was actually involved in the way the team works, and the ultimate test; how assertive could people be in raising issues,” he continued. “Did they feel safe to raise issues, and not get their head bitten off, but in fact, find that what they offered had value.”
Dr. Gawande is the founder and executive director of Ariadne Labs, a center for health systems innovation, and the chairman of Lifebox, a not-for-profit organization.
SOURCE: Gawande AA et al. ACS Clinical Congress 2018, Session PS232.
BOSTON – The success of surgical safety checklists to reduce postoperative mortality appears to depend not only on implementation but also on the degree to which a hospital embraces a culture of teamwork, Atul Gawande, MD, MPH, FACS, said at the annual clinical congress of the American College of Surgeons.
The session “Checking in on the Checklist – Ten Years of the WHO Surgical Safety Checklist” moderated by Thomas Geoghegan Weiser, MD, FACS, and Alex B. Haynes, MD, FACS,considered the progress of the past decade in implementing the World Health Organization initiative in medical institutions around the world.
Team-based approaches to the checklist accompanied by other institutional support have demonstrated double-digit reductions in mortality, while in contrast, a mandate-only approach resulted in a 0% change, said Dr. Gawande, a general and endocrine surgeon at Brigham and Women’s Hospital and professor in the department of health policy and management at the Harvard T.H. Chan School of Public Health and the Samuel O. Thier Professor of Surgery at Harvard Medical School, all in Boston.
Variables including respect among team members, clinical leadership, and assertiveness on behalf of patient safety appeared to be predictive of postoperative death rates in one recent implementation of the WHO Surgical Safety Checklist, he added.
Dr. Gawande said the 29-item surgical safety checklist has earned support but also skepticism and “some outright opposition” in the nearly 10 years since landmark study published in the New England Journal of Medicine, coauthored by Dr. Haynes, reported that the approach cut mortality by 47% and postoperative complication rates by 36%, on average, in a diverse group of eight hospitals throughout the world.
“It’s a challenge in a fundamental way, to our values,” Dr. Gawande told attendees. “What we have valued in our life as surgeons is our autonomy as clinicians, and here was an approach which required you to work with different values: humility, discipline, teamwork.”
That 47% mortality reduction was achieved in a clinical trial setting with “very carefully selected sites” that were enthusiastic about giving the checklist a try, and toward that end, received weekly support, Dr. Gawande said.
Subsequent implementations of the checklist have had varying success rates, he said.
Implementations that have included a mandate plus regular feedback have yielded mortality reductions upward of 26%he said, while a mandate plus team training reduced mortality by 18% in a Veterans Health Administration hospital setting, according to Dr. Gawande. By contrast, a mandate-alone approach in Ontario yielded a 0% reduction in mortality.
“What we came to realize is a kind of formula that underlies how you create change in organizations generally, where you’re trying to create systems that make it easier for people to get the right kinds of things done,” Dr. Gawande said.
“You have a systems tool that has been carefully crafted around the ‘killer items’ – the failure points that even experts fail at – you have an implementation pathway, and then you bring it into a ready environment where people are capable and they’re motivated,” he explained.
A South Carolina initiative that was voluntary and included light-touch support yielded a 22% reduction in hospitals that completed the adoption program, Dr. Gawande said. Of note, investigators in the Safe Surgery 2015: South Carolina Initiative found that perceptions of safety among operating room personnel were associated with the all-cause 30-day postoperative death rate.
“The team found in South Carolina that the predictor of how much change you get is how effective your implementation was in changing the culture to be more team oriented,” Dr. Gawande said.
“You could recognize it by how much change you saw in what the frontline people reported about how much they are respected, how much clinical leadership was actually involved in the way the team works, and the ultimate test; how assertive could people be in raising issues,” he continued. “Did they feel safe to raise issues, and not get their head bitten off, but in fact, find that what they offered had value.”
Dr. Gawande is the founder and executive director of Ariadne Labs, a center for health systems innovation, and the chairman of Lifebox, a not-for-profit organization.
SOURCE: Gawande AA et al. ACS Clinical Congress 2018, Session PS232.
BOSTON – The success of surgical safety checklists to reduce postoperative mortality appears to depend not only on implementation but also on the degree to which a hospital embraces a culture of teamwork, Atul Gawande, MD, MPH, FACS, said at the annual clinical congress of the American College of Surgeons.
The session “Checking in on the Checklist – Ten Years of the WHO Surgical Safety Checklist” moderated by Thomas Geoghegan Weiser, MD, FACS, and Alex B. Haynes, MD, FACS,considered the progress of the past decade in implementing the World Health Organization initiative in medical institutions around the world.
Team-based approaches to the checklist accompanied by other institutional support have demonstrated double-digit reductions in mortality, while in contrast, a mandate-only approach resulted in a 0% change, said Dr. Gawande, a general and endocrine surgeon at Brigham and Women’s Hospital and professor in the department of health policy and management at the Harvard T.H. Chan School of Public Health and the Samuel O. Thier Professor of Surgery at Harvard Medical School, all in Boston.
Variables including respect among team members, clinical leadership, and assertiveness on behalf of patient safety appeared to be predictive of postoperative death rates in one recent implementation of the WHO Surgical Safety Checklist, he added.
Dr. Gawande said the 29-item surgical safety checklist has earned support but also skepticism and “some outright opposition” in the nearly 10 years since landmark study published in the New England Journal of Medicine, coauthored by Dr. Haynes, reported that the approach cut mortality by 47% and postoperative complication rates by 36%, on average, in a diverse group of eight hospitals throughout the world.
“It’s a challenge in a fundamental way, to our values,” Dr. Gawande told attendees. “What we have valued in our life as surgeons is our autonomy as clinicians, and here was an approach which required you to work with different values: humility, discipline, teamwork.”
That 47% mortality reduction was achieved in a clinical trial setting with “very carefully selected sites” that were enthusiastic about giving the checklist a try, and toward that end, received weekly support, Dr. Gawande said.
Subsequent implementations of the checklist have had varying success rates, he said.
Implementations that have included a mandate plus regular feedback have yielded mortality reductions upward of 26%he said, while a mandate plus team training reduced mortality by 18% in a Veterans Health Administration hospital setting, according to Dr. Gawande. By contrast, a mandate-alone approach in Ontario yielded a 0% reduction in mortality.
“What we came to realize is a kind of formula that underlies how you create change in organizations generally, where you’re trying to create systems that make it easier for people to get the right kinds of things done,” Dr. Gawande said.
“You have a systems tool that has been carefully crafted around the ‘killer items’ – the failure points that even experts fail at – you have an implementation pathway, and then you bring it into a ready environment where people are capable and they’re motivated,” he explained.
A South Carolina initiative that was voluntary and included light-touch support yielded a 22% reduction in hospitals that completed the adoption program, Dr. Gawande said. Of note, investigators in the Safe Surgery 2015: South Carolina Initiative found that perceptions of safety among operating room personnel were associated with the all-cause 30-day postoperative death rate.
“The team found in South Carolina that the predictor of how much change you get is how effective your implementation was in changing the culture to be more team oriented,” Dr. Gawande said.
“You could recognize it by how much change you saw in what the frontline people reported about how much they are respected, how much clinical leadership was actually involved in the way the team works, and the ultimate test; how assertive could people be in raising issues,” he continued. “Did they feel safe to raise issues, and not get their head bitten off, but in fact, find that what they offered had value.”
Dr. Gawande is the founder and executive director of Ariadne Labs, a center for health systems innovation, and the chairman of Lifebox, a not-for-profit organization.
SOURCE: Gawande AA et al. ACS Clinical Congress 2018, Session PS232.
REPORTING FROM THE ACS CLINICAL CONGRESS
Hemithyroidectomy rates rose after guideline update
BOSTON – that position the procedure as equivalent to total thyroidectomy, an analysis of U.S. hospital data shows.
Patients undergoing hemithyroidectomy had fewer complications and shorter length of stay versus patients who received a bilateral procedure, with no corresponding increase in completion thyroidectomy, according to results of the retrospective analysis reported here at the annual clinical congress of the American College of Surgeons.
“We think this suggests that surgeons might be changing their practice at these hospitals, at least in part in response to the guidelines,” investigator Timothy M. Ullmann, MD, endocrine oncology research fellow in the department of surgery at New York Presbyterian Hospital–Weill Cornell Medical Center, New York.
Dr. Ullmann and colleagues queried the American College of Surgeons National Surgical Quality Improvement Program database for the 2014-2016 period to illustrate operative trends before and after release of the 2015 guidelines from the American Thyroid Association guidelines. They looked at a total of 26,562 procedures done before the guidelines were release, and 7,422 done after.
The rate of hemithyroidectomy increased from 15.6% before guidelines to 18.3% afterward (P less than .001), according to Dr. Ullmann. By contrast, the rates of completion thyroidectomy were 7.8% for the pre-guidelines period and 7.4% post-guidelines (P = .19).
The increase was gradual throughout the 2014-2016 period, though it was especially steep after the guideline introduction, according to co-investigator Toni Beninato, MD, of Weill Cornell Medicine.
“While we can’t say that the guidelines directly caused an increase, it’s a pretty good association,” Dr. Beninato said in a press conference. “I think going forward, we would expect this to continue to increase, because the vast majority of patients with thyroid cancer probably fit criteria to have a hemithyroidectomy rather than a total thyroidectomy.”
Patients treated by otolaryngologists were more likely to undergo hemithyroidectomies versus those treated by general surgeons, multivariate analysis of this data set suggested (odds ratio, 1.13, P less than .001). On the other hand, Hispanic patients and those with a higher operative risk classification were less likely to undergo a unilateral procedure.
Complications were less likely in the hemithyroidectomy patients, according to investigators. There were significantly fewer superficial surgical site infections, at 0.2% versus 0.4% for total thyroidectomy, and operative time was 91.6 minutes versus 141.1 minutes.
Hemithyroidectomy patients were less likely to be reintubated after surgery, had a shorter length of stay, and were more likely to be managed on an outpatient basis, they added at the press conference.
Prior ATA guidelines, in place since 2009, called for near-total or total thyroidectomy for cancers that were at least 1 cm in size in patients with no contraindications to the procedure. The 2015 update says the initial surgical procedure could also be a unilateral procedure, or lobectomy, in cancers greater than 1 cm, or smaller than 4 cm with no extrathyroidal extension.
Dr. Ullmann and Dr. Beninato had no relevant financial relationships with commercial interests pertaining to the content of their presentation.
SOURCE: Ullmann TM et al. Abstract SF121 presented at the American College of Surgeons Clinical Congress.
BOSTON – that position the procedure as equivalent to total thyroidectomy, an analysis of U.S. hospital data shows.
Patients undergoing hemithyroidectomy had fewer complications and shorter length of stay versus patients who received a bilateral procedure, with no corresponding increase in completion thyroidectomy, according to results of the retrospective analysis reported here at the annual clinical congress of the American College of Surgeons.
“We think this suggests that surgeons might be changing their practice at these hospitals, at least in part in response to the guidelines,” investigator Timothy M. Ullmann, MD, endocrine oncology research fellow in the department of surgery at New York Presbyterian Hospital–Weill Cornell Medical Center, New York.
Dr. Ullmann and colleagues queried the American College of Surgeons National Surgical Quality Improvement Program database for the 2014-2016 period to illustrate operative trends before and after release of the 2015 guidelines from the American Thyroid Association guidelines. They looked at a total of 26,562 procedures done before the guidelines were release, and 7,422 done after.
The rate of hemithyroidectomy increased from 15.6% before guidelines to 18.3% afterward (P less than .001), according to Dr. Ullmann. By contrast, the rates of completion thyroidectomy were 7.8% for the pre-guidelines period and 7.4% post-guidelines (P = .19).
The increase was gradual throughout the 2014-2016 period, though it was especially steep after the guideline introduction, according to co-investigator Toni Beninato, MD, of Weill Cornell Medicine.
“While we can’t say that the guidelines directly caused an increase, it’s a pretty good association,” Dr. Beninato said in a press conference. “I think going forward, we would expect this to continue to increase, because the vast majority of patients with thyroid cancer probably fit criteria to have a hemithyroidectomy rather than a total thyroidectomy.”
Patients treated by otolaryngologists were more likely to undergo hemithyroidectomies versus those treated by general surgeons, multivariate analysis of this data set suggested (odds ratio, 1.13, P less than .001). On the other hand, Hispanic patients and those with a higher operative risk classification were less likely to undergo a unilateral procedure.
Complications were less likely in the hemithyroidectomy patients, according to investigators. There were significantly fewer superficial surgical site infections, at 0.2% versus 0.4% for total thyroidectomy, and operative time was 91.6 minutes versus 141.1 minutes.
Hemithyroidectomy patients were less likely to be reintubated after surgery, had a shorter length of stay, and were more likely to be managed on an outpatient basis, they added at the press conference.
Prior ATA guidelines, in place since 2009, called for near-total or total thyroidectomy for cancers that were at least 1 cm in size in patients with no contraindications to the procedure. The 2015 update says the initial surgical procedure could also be a unilateral procedure, or lobectomy, in cancers greater than 1 cm, or smaller than 4 cm with no extrathyroidal extension.
Dr. Ullmann and Dr. Beninato had no relevant financial relationships with commercial interests pertaining to the content of their presentation.
SOURCE: Ullmann TM et al. Abstract SF121 presented at the American College of Surgeons Clinical Congress.
BOSTON – that position the procedure as equivalent to total thyroidectomy, an analysis of U.S. hospital data shows.
Patients undergoing hemithyroidectomy had fewer complications and shorter length of stay versus patients who received a bilateral procedure, with no corresponding increase in completion thyroidectomy, according to results of the retrospective analysis reported here at the annual clinical congress of the American College of Surgeons.
“We think this suggests that surgeons might be changing their practice at these hospitals, at least in part in response to the guidelines,” investigator Timothy M. Ullmann, MD, endocrine oncology research fellow in the department of surgery at New York Presbyterian Hospital–Weill Cornell Medical Center, New York.
Dr. Ullmann and colleagues queried the American College of Surgeons National Surgical Quality Improvement Program database for the 2014-2016 period to illustrate operative trends before and after release of the 2015 guidelines from the American Thyroid Association guidelines. They looked at a total of 26,562 procedures done before the guidelines were release, and 7,422 done after.
The rate of hemithyroidectomy increased from 15.6% before guidelines to 18.3% afterward (P less than .001), according to Dr. Ullmann. By contrast, the rates of completion thyroidectomy were 7.8% for the pre-guidelines period and 7.4% post-guidelines (P = .19).
The increase was gradual throughout the 2014-2016 period, though it was especially steep after the guideline introduction, according to co-investigator Toni Beninato, MD, of Weill Cornell Medicine.
“While we can’t say that the guidelines directly caused an increase, it’s a pretty good association,” Dr. Beninato said in a press conference. “I think going forward, we would expect this to continue to increase, because the vast majority of patients with thyroid cancer probably fit criteria to have a hemithyroidectomy rather than a total thyroidectomy.”
Patients treated by otolaryngologists were more likely to undergo hemithyroidectomies versus those treated by general surgeons, multivariate analysis of this data set suggested (odds ratio, 1.13, P less than .001). On the other hand, Hispanic patients and those with a higher operative risk classification were less likely to undergo a unilateral procedure.
Complications were less likely in the hemithyroidectomy patients, according to investigators. There were significantly fewer superficial surgical site infections, at 0.2% versus 0.4% for total thyroidectomy, and operative time was 91.6 minutes versus 141.1 minutes.
Hemithyroidectomy patients were less likely to be reintubated after surgery, had a shorter length of stay, and were more likely to be managed on an outpatient basis, they added at the press conference.
Prior ATA guidelines, in place since 2009, called for near-total or total thyroidectomy for cancers that were at least 1 cm in size in patients with no contraindications to the procedure. The 2015 update says the initial surgical procedure could also be a unilateral procedure, or lobectomy, in cancers greater than 1 cm, or smaller than 4 cm with no extrathyroidal extension.
Dr. Ullmann and Dr. Beninato had no relevant financial relationships with commercial interests pertaining to the content of their presentation.
SOURCE: Ullmann TM et al. Abstract SF121 presented at the American College of Surgeons Clinical Congress.
AT THE ACS CLINICAL CONGRESS
Key clinical point: Hemithyroidectomy rates had a robust uptick following release of 2015 clinical practice guidelines, suggesting surgeons may be changing their practice in response.
Major finding: The rate of hemithyroidectomy increased from 15.6% before guidelines to 18.3% afterward (P < 0.001).
Study details: Analysis of the American College of Surgeons-NSQIP database from 2014 to 2016 including nearly 34,000 procedures.
Disclosures: Study authors reported no disclosures.
Source: Ullmann TM et al. Abstract SF125 presented at American College of Surgeons Clinical Congress
Survey: Humanitarian surgical groups need best-practices guidelines
BOSTON – A survey of U.S. and suggests that a best-practices guide would be beneficial in helping them adhere more closely to standard protocols.
While most NGOs follow guideline-based practices, some deviations from standard of care do occur. Deviations occurred most often in the areas of preoperative workup, operative technique, and pain management, according to survey results presented at the annual clinical congress of the American College of Surgeons.
Consensus guidelines specific to the NGO sector would be used by the great majority of NGOs surveyed, reported Peter F. Johnston, MD, a general surgery resident and the Ben Rush Global Surgery Fellow at Rutgers New Jersey Medical School.
“There is a lot of heterogeneity in the sector, based on the different organizations doing general surgery and organizations doing plastics,” Dr. Johnston said in an interview. “What we think we can do in terms of low-hanging fruit is come up with guidelines for things like perioperative antibiotics that are pretty much common to all types of surgeries.”
The survey conducted by Dr. Johnston and colleagues is one of the first to characterize the clinical practices of U.S. humanitarian organizations that provide general or subspecialty care through short-term surgical missions. It was completed by representatives of 30 of 83 organizations (36%) that were contacted.
Of respondents, 20% said their organizations deviated from standard U.S. practice often or very often, Dr. Johnston said in his presentation. The respondents mentioned deviation from standard practice in pain management (18%), preoperative workup (16%), and operative technique (16%).
Only about one-third of respondents said they believed those deviations impacted patient outcomes, the results show.
In all, 67% of respondents adhered to at least four protocol-driven practices. Those NGOs that adhered most closely to standard protocol tended to be older, more established organizations, compared with those less protocolized organizations, according to Dr. Johnston (age of organization 22 vs. 14 years, P < .05).
“It makes sense... from my own experience of going back to the same countries,” said Dr. Johnston, who has participated in missions in countries including Ghana, Sierra Leone, and Peru. “As an organization, and even within different countries, the process gets smoother as you keep working at it.”
A total of 85% of respondents expressed interest in best-practice guidelines to guide short-term surgical missions, according to the survey data.
Dr. Johnston reported no conflicts of interest related to his presentation.
SOURCE: Johnston P, et al. Abstract SF121 presented at the American College of Surgeons Clinical Congress.
BOSTON – A survey of U.S. and suggests that a best-practices guide would be beneficial in helping them adhere more closely to standard protocols.
While most NGOs follow guideline-based practices, some deviations from standard of care do occur. Deviations occurred most often in the areas of preoperative workup, operative technique, and pain management, according to survey results presented at the annual clinical congress of the American College of Surgeons.
Consensus guidelines specific to the NGO sector would be used by the great majority of NGOs surveyed, reported Peter F. Johnston, MD, a general surgery resident and the Ben Rush Global Surgery Fellow at Rutgers New Jersey Medical School.
“There is a lot of heterogeneity in the sector, based on the different organizations doing general surgery and organizations doing plastics,” Dr. Johnston said in an interview. “What we think we can do in terms of low-hanging fruit is come up with guidelines for things like perioperative antibiotics that are pretty much common to all types of surgeries.”
The survey conducted by Dr. Johnston and colleagues is one of the first to characterize the clinical practices of U.S. humanitarian organizations that provide general or subspecialty care through short-term surgical missions. It was completed by representatives of 30 of 83 organizations (36%) that were contacted.
Of respondents, 20% said their organizations deviated from standard U.S. practice often or very often, Dr. Johnston said in his presentation. The respondents mentioned deviation from standard practice in pain management (18%), preoperative workup (16%), and operative technique (16%).
Only about one-third of respondents said they believed those deviations impacted patient outcomes, the results show.
In all, 67% of respondents adhered to at least four protocol-driven practices. Those NGOs that adhered most closely to standard protocol tended to be older, more established organizations, compared with those less protocolized organizations, according to Dr. Johnston (age of organization 22 vs. 14 years, P < .05).
“It makes sense... from my own experience of going back to the same countries,” said Dr. Johnston, who has participated in missions in countries including Ghana, Sierra Leone, and Peru. “As an organization, and even within different countries, the process gets smoother as you keep working at it.”
A total of 85% of respondents expressed interest in best-practice guidelines to guide short-term surgical missions, according to the survey data.
Dr. Johnston reported no conflicts of interest related to his presentation.
SOURCE: Johnston P, et al. Abstract SF121 presented at the American College of Surgeons Clinical Congress.
BOSTON – A survey of U.S. and suggests that a best-practices guide would be beneficial in helping them adhere more closely to standard protocols.
While most NGOs follow guideline-based practices, some deviations from standard of care do occur. Deviations occurred most often in the areas of preoperative workup, operative technique, and pain management, according to survey results presented at the annual clinical congress of the American College of Surgeons.
Consensus guidelines specific to the NGO sector would be used by the great majority of NGOs surveyed, reported Peter F. Johnston, MD, a general surgery resident and the Ben Rush Global Surgery Fellow at Rutgers New Jersey Medical School.
“There is a lot of heterogeneity in the sector, based on the different organizations doing general surgery and organizations doing plastics,” Dr. Johnston said in an interview. “What we think we can do in terms of low-hanging fruit is come up with guidelines for things like perioperative antibiotics that are pretty much common to all types of surgeries.”
The survey conducted by Dr. Johnston and colleagues is one of the first to characterize the clinical practices of U.S. humanitarian organizations that provide general or subspecialty care through short-term surgical missions. It was completed by representatives of 30 of 83 organizations (36%) that were contacted.
Of respondents, 20% said their organizations deviated from standard U.S. practice often or very often, Dr. Johnston said in his presentation. The respondents mentioned deviation from standard practice in pain management (18%), preoperative workup (16%), and operative technique (16%).
Only about one-third of respondents said they believed those deviations impacted patient outcomes, the results show.
In all, 67% of respondents adhered to at least four protocol-driven practices. Those NGOs that adhered most closely to standard protocol tended to be older, more established organizations, compared with those less protocolized organizations, according to Dr. Johnston (age of organization 22 vs. 14 years, P < .05).
“It makes sense... from my own experience of going back to the same countries,” said Dr. Johnston, who has participated in missions in countries including Ghana, Sierra Leone, and Peru. “As an organization, and even within different countries, the process gets smoother as you keep working at it.”
A total of 85% of respondents expressed interest in best-practice guidelines to guide short-term surgical missions, according to the survey data.
Dr. Johnston reported no conflicts of interest related to his presentation.
SOURCE: Johnston P, et al. Abstract SF121 presented at the American College of Surgeons Clinical Congress.
AT THE ACS CLINICAL CONGRESS
Key clinical point: The clinical practice of some humanitarian surgical organizations deviated from standard practice, suggesting a need for NGO-specific guidelines.
Major finding: The most common deviations from standard practice were in pain management (18%), preoperative workup (16%), and operative technique (16%).
Study details: 30 Responses from a survey of 83 organizations that provide general or subspecialty care through short-term surgical missions.
Disclosures: Study authors reported no conflicts.
Source: Johnston PF et al. Abstract SF121 presented at the American College of Surgeons Clinical Congress.
Septic shock: Innovative treatment options in the wings
BOSTON– treatment that require more investigation, but nevertheless appear promising, Rishi Rattan, MD, said at the annual clinical congress of the American College of Surgeons.
Trials evaluating vitamin C in this setting have demonstrated a large mortality impact with an absence of side effects, according to Dr. Rattan, a trauma and critical care surgeon with the Ryder Trauma Center at the University of Miami.
“It’s something that I have decided to start early adopting, and many of my colleagues at University of Miami do as well,” Dr. Rattan said in a panel session on updates in septic shock. “We’re anecdotally so far at least seeing good results and are going to be excited to see what these ongoing trials show.”
As an antioxidant, vitamin C has anti-inflammatory properties that may possibly attenuate the overly exuberant inflammatory response seen in septic shock, Dr. Rattan said in his presentation.
The limited clinical data for vitamin C in refractory shock include three studies, of which two are randomized controlled trials, comprising a total of 146 patients, he added.
“I will admit an N of 146 is hardly practice-changing for most people,” Dr. Rattan said. “There’s still a significant and sustained large mortality effect for the use of vitamin C, with nearly no adverse effects.”
Pooled analysis of all three studies revealed a marked reduction in mortality with the use of vitamin C (odds ratio, 0.17, 95% confidence interval 0.07–0.40; P less than .001), according to a meta-analysis recently just published in Critical Care that Dr. Rattan referenced in his presentation (Critical Care 2018;22:258, DOI:10.1186/s13054-018-2191-x).
When taken in recommended dosages, vitamin C given with corticosteroids and thiamine is without known side effects, researcher Paul E. Marik wrote earlier this year in an editorial in Pharmacology & Therapeutics (2018;189[9]:63-70, DOI:10.1016/j.pharmthera.2018.04.007) noted Dr. Rattan, who said he uses the intravenous vitamin C, thiamine, and hydrocortisone protocol previously reported by Dr. Marik and colleagues.
There are 13 ongoing trials, including some prospective blinded, randomized trials, looking at the role of vitamin C in refractory shock, he added.
Angiotensin-II is another intervention that may be promising in refractory septic shock, Dr. Rattan told attendees, pointing to the 2017 publication of the ATHOS-3 trial in the New England Journal of Medicine (2017; 377:419-430,DOI: 10.1056/NEJMoa1704154) showing that treatment increased blood pressure in patients with vasodilatory shock not responding to conventional vasopressors at high doses.
Likewise, methylene blue has shown promise in septic shock, at least in some limited clinical investigations and anecdotally in patients not improving despite standard interventions. “I’ve been able to have a couple patients walk out of the hospital with the use of methylene blue,” Dr. Rattan said. “Again, the plural of ‘anecdote’ is not ‘data,’ but it’s something to consider for the early adopters.”
Dr. Rattan had no disclosures related to his presentation.
BOSTON– treatment that require more investigation, but nevertheless appear promising, Rishi Rattan, MD, said at the annual clinical congress of the American College of Surgeons.
Trials evaluating vitamin C in this setting have demonstrated a large mortality impact with an absence of side effects, according to Dr. Rattan, a trauma and critical care surgeon with the Ryder Trauma Center at the University of Miami.
“It’s something that I have decided to start early adopting, and many of my colleagues at University of Miami do as well,” Dr. Rattan said in a panel session on updates in septic shock. “We’re anecdotally so far at least seeing good results and are going to be excited to see what these ongoing trials show.”
As an antioxidant, vitamin C has anti-inflammatory properties that may possibly attenuate the overly exuberant inflammatory response seen in septic shock, Dr. Rattan said in his presentation.
The limited clinical data for vitamin C in refractory shock include three studies, of which two are randomized controlled trials, comprising a total of 146 patients, he added.
“I will admit an N of 146 is hardly practice-changing for most people,” Dr. Rattan said. “There’s still a significant and sustained large mortality effect for the use of vitamin C, with nearly no adverse effects.”
Pooled analysis of all three studies revealed a marked reduction in mortality with the use of vitamin C (odds ratio, 0.17, 95% confidence interval 0.07–0.40; P less than .001), according to a meta-analysis recently just published in Critical Care that Dr. Rattan referenced in his presentation (Critical Care 2018;22:258, DOI:10.1186/s13054-018-2191-x).
When taken in recommended dosages, vitamin C given with corticosteroids and thiamine is without known side effects, researcher Paul E. Marik wrote earlier this year in an editorial in Pharmacology & Therapeutics (2018;189[9]:63-70, DOI:10.1016/j.pharmthera.2018.04.007) noted Dr. Rattan, who said he uses the intravenous vitamin C, thiamine, and hydrocortisone protocol previously reported by Dr. Marik and colleagues.
There are 13 ongoing trials, including some prospective blinded, randomized trials, looking at the role of vitamin C in refractory shock, he added.
Angiotensin-II is another intervention that may be promising in refractory septic shock, Dr. Rattan told attendees, pointing to the 2017 publication of the ATHOS-3 trial in the New England Journal of Medicine (2017; 377:419-430,DOI: 10.1056/NEJMoa1704154) showing that treatment increased blood pressure in patients with vasodilatory shock not responding to conventional vasopressors at high doses.
Likewise, methylene blue has shown promise in septic shock, at least in some limited clinical investigations and anecdotally in patients not improving despite standard interventions. “I’ve been able to have a couple patients walk out of the hospital with the use of methylene blue,” Dr. Rattan said. “Again, the plural of ‘anecdote’ is not ‘data,’ but it’s something to consider for the early adopters.”
Dr. Rattan had no disclosures related to his presentation.
BOSTON– treatment that require more investigation, but nevertheless appear promising, Rishi Rattan, MD, said at the annual clinical congress of the American College of Surgeons.
Trials evaluating vitamin C in this setting have demonstrated a large mortality impact with an absence of side effects, according to Dr. Rattan, a trauma and critical care surgeon with the Ryder Trauma Center at the University of Miami.
“It’s something that I have decided to start early adopting, and many of my colleagues at University of Miami do as well,” Dr. Rattan said in a panel session on updates in septic shock. “We’re anecdotally so far at least seeing good results and are going to be excited to see what these ongoing trials show.”
As an antioxidant, vitamin C has anti-inflammatory properties that may possibly attenuate the overly exuberant inflammatory response seen in septic shock, Dr. Rattan said in his presentation.
The limited clinical data for vitamin C in refractory shock include three studies, of which two are randomized controlled trials, comprising a total of 146 patients, he added.
“I will admit an N of 146 is hardly practice-changing for most people,” Dr. Rattan said. “There’s still a significant and sustained large mortality effect for the use of vitamin C, with nearly no adverse effects.”
Pooled analysis of all three studies revealed a marked reduction in mortality with the use of vitamin C (odds ratio, 0.17, 95% confidence interval 0.07–0.40; P less than .001), according to a meta-analysis recently just published in Critical Care that Dr. Rattan referenced in his presentation (Critical Care 2018;22:258, DOI:10.1186/s13054-018-2191-x).
When taken in recommended dosages, vitamin C given with corticosteroids and thiamine is without known side effects, researcher Paul E. Marik wrote earlier this year in an editorial in Pharmacology & Therapeutics (2018;189[9]:63-70, DOI:10.1016/j.pharmthera.2018.04.007) noted Dr. Rattan, who said he uses the intravenous vitamin C, thiamine, and hydrocortisone protocol previously reported by Dr. Marik and colleagues.
There are 13 ongoing trials, including some prospective blinded, randomized trials, looking at the role of vitamin C in refractory shock, he added.
Angiotensin-II is another intervention that may be promising in refractory septic shock, Dr. Rattan told attendees, pointing to the 2017 publication of the ATHOS-3 trial in the New England Journal of Medicine (2017; 377:419-430,DOI: 10.1056/NEJMoa1704154) showing that treatment increased blood pressure in patients with vasodilatory shock not responding to conventional vasopressors at high doses.
Likewise, methylene blue has shown promise in septic shock, at least in some limited clinical investigations and anecdotally in patients not improving despite standard interventions. “I’ve been able to have a couple patients walk out of the hospital with the use of methylene blue,” Dr. Rattan said. “Again, the plural of ‘anecdote’ is not ‘data,’ but it’s something to consider for the early adopters.”
Dr. Rattan had no disclosures related to his presentation.
AT THE ACS CLINICAL CONGRESS
Algorithm helps assess surgical trade-offs of hernia repair
BOSTON – Choosing an operative approach for ventral hernia can be a matter of weighing the trade-offs between infection risk, postop quality of life, and patient and defect characteristics. A predictive algorithm has been developed to help with this decision, according to a study presented at the annual clinical congress of the American College of Surgeons.
Predictive modeling indicates that open repair might be considered, for example, in low BMI patients with large defects because of potentially fewer anticipated complications and improved quality of life, according to authors of the study. Conversely, laparoscopic repair might be considered in high BMI patients with recurrent hernias to decrease the associated risk of infection, the authors noted in a published abstract of the study.
The retrospective study was based on data on ventral hernia repairs in the International Hernia Mesh Registry that were performed between 2007 and 2017. Investigators used that data to build a predictive algorithm that took into account the impact on outcomes of BMI, hernia size, and operative approach, as well as age, sex, and diabetes status.
They identified 1,906 repairs, of which about 60% were open procedures. The mean patient age was 54.9 years, while mean BMI was 31.2 kg/m2 and the mean defect area was 44.8 cm2. Patients undergoing open procedures were significantly more likely to have infections, at 3.1% versus 0.3% for the laparoscopic approach (P less than .0001), investigators found.
A multivariate regression analysis controlling for confounding variables found that patients undergoing laparoscopic repair had an increased risk of seroma (odds ratio 1.78, confidence interval 1.05-3.03) but a decreased risk of infection (OR 0.05, CI 0.01-0.42). In addition, those undergoing laparoscopic procedures were more likely to have non-ideal quality of life at 1, 6, 12, and 24 months postoperatively, said the study’s lead author, Kathryn A. Schlosser, MD, a resident in the division of gastrointestinal and minimally invasive surgery, department of surgery, Carolinas Medical Center, Charlotte, N.C.
“These are both important factors — infection and non-ideal quality of life — and need to be part of our preoperative discussion with our patients when we start managing their expectations around the time of surgery,” Dr. Schlosser said in a podium presentation.
She and her colleagues calculated probability of infection based on the ratio of BMI to defect area. They found that, for example, the probability of postoperative infection was 21% for a diabetic 69-year-old female with a recurrent hernia who had a BMI of 39 and a defect area of 20 cm2. By contrast, infection probability was 3% in a 66-year-old female with a BMI of 37, a defect area of 1 cm2, and no diabetes, Dr. Schlosser said at the meeting.
Laparoscopic versus open procedures represented a trade-off between infection risk and quality of life in this algorithm. For patients at medium risk for infection based on BMI, defect size, and other variables, switching to a laparoscopic approach dropped the infection probability from 3%-8% down to 0.1%-0.5%, Dr. Schlosser told attendees. On the other hand, switching to a laparoscopic approach increased the risk of non-ideal quality of life, she said.
One sample patient Dr. Schlosser described had an infection risk of 7.2% with the open procedure that dropped to just 0.4% for the laparoscopic procedure; however, that switch would mean that her likelihood of non-ideal quality of life 12 months after surgery increased from 24% with the open repair to 44% with the laparoscopic repair.
Dr. Schlosser had no disclosures related to the study. Co-authors provided disclosures related to Acelity, Allergan, Intuitive, Stryker, and W.L. Gore.
SOURCE: Schlosser KA, et al. abstract SF215 presented at the American College of Surgeons Clinical Congress 2018.
BOSTON – Choosing an operative approach for ventral hernia can be a matter of weighing the trade-offs between infection risk, postop quality of life, and patient and defect characteristics. A predictive algorithm has been developed to help with this decision, according to a study presented at the annual clinical congress of the American College of Surgeons.
Predictive modeling indicates that open repair might be considered, for example, in low BMI patients with large defects because of potentially fewer anticipated complications and improved quality of life, according to authors of the study. Conversely, laparoscopic repair might be considered in high BMI patients with recurrent hernias to decrease the associated risk of infection, the authors noted in a published abstract of the study.
The retrospective study was based on data on ventral hernia repairs in the International Hernia Mesh Registry that were performed between 2007 and 2017. Investigators used that data to build a predictive algorithm that took into account the impact on outcomes of BMI, hernia size, and operative approach, as well as age, sex, and diabetes status.
They identified 1,906 repairs, of which about 60% were open procedures. The mean patient age was 54.9 years, while mean BMI was 31.2 kg/m2 and the mean defect area was 44.8 cm2. Patients undergoing open procedures were significantly more likely to have infections, at 3.1% versus 0.3% for the laparoscopic approach (P less than .0001), investigators found.
A multivariate regression analysis controlling for confounding variables found that patients undergoing laparoscopic repair had an increased risk of seroma (odds ratio 1.78, confidence interval 1.05-3.03) but a decreased risk of infection (OR 0.05, CI 0.01-0.42). In addition, those undergoing laparoscopic procedures were more likely to have non-ideal quality of life at 1, 6, 12, and 24 months postoperatively, said the study’s lead author, Kathryn A. Schlosser, MD, a resident in the division of gastrointestinal and minimally invasive surgery, department of surgery, Carolinas Medical Center, Charlotte, N.C.
“These are both important factors — infection and non-ideal quality of life — and need to be part of our preoperative discussion with our patients when we start managing their expectations around the time of surgery,” Dr. Schlosser said in a podium presentation.
She and her colleagues calculated probability of infection based on the ratio of BMI to defect area. They found that, for example, the probability of postoperative infection was 21% for a diabetic 69-year-old female with a recurrent hernia who had a BMI of 39 and a defect area of 20 cm2. By contrast, infection probability was 3% in a 66-year-old female with a BMI of 37, a defect area of 1 cm2, and no diabetes, Dr. Schlosser said at the meeting.
Laparoscopic versus open procedures represented a trade-off between infection risk and quality of life in this algorithm. For patients at medium risk for infection based on BMI, defect size, and other variables, switching to a laparoscopic approach dropped the infection probability from 3%-8% down to 0.1%-0.5%, Dr. Schlosser told attendees. On the other hand, switching to a laparoscopic approach increased the risk of non-ideal quality of life, she said.
One sample patient Dr. Schlosser described had an infection risk of 7.2% with the open procedure that dropped to just 0.4% for the laparoscopic procedure; however, that switch would mean that her likelihood of non-ideal quality of life 12 months after surgery increased from 24% with the open repair to 44% with the laparoscopic repair.
Dr. Schlosser had no disclosures related to the study. Co-authors provided disclosures related to Acelity, Allergan, Intuitive, Stryker, and W.L. Gore.
SOURCE: Schlosser KA, et al. abstract SF215 presented at the American College of Surgeons Clinical Congress 2018.
BOSTON – Choosing an operative approach for ventral hernia can be a matter of weighing the trade-offs between infection risk, postop quality of life, and patient and defect characteristics. A predictive algorithm has been developed to help with this decision, according to a study presented at the annual clinical congress of the American College of Surgeons.
Predictive modeling indicates that open repair might be considered, for example, in low BMI patients with large defects because of potentially fewer anticipated complications and improved quality of life, according to authors of the study. Conversely, laparoscopic repair might be considered in high BMI patients with recurrent hernias to decrease the associated risk of infection, the authors noted in a published abstract of the study.
The retrospective study was based on data on ventral hernia repairs in the International Hernia Mesh Registry that were performed between 2007 and 2017. Investigators used that data to build a predictive algorithm that took into account the impact on outcomes of BMI, hernia size, and operative approach, as well as age, sex, and diabetes status.
They identified 1,906 repairs, of which about 60% were open procedures. The mean patient age was 54.9 years, while mean BMI was 31.2 kg/m2 and the mean defect area was 44.8 cm2. Patients undergoing open procedures were significantly more likely to have infections, at 3.1% versus 0.3% for the laparoscopic approach (P less than .0001), investigators found.
A multivariate regression analysis controlling for confounding variables found that patients undergoing laparoscopic repair had an increased risk of seroma (odds ratio 1.78, confidence interval 1.05-3.03) but a decreased risk of infection (OR 0.05, CI 0.01-0.42). In addition, those undergoing laparoscopic procedures were more likely to have non-ideal quality of life at 1, 6, 12, and 24 months postoperatively, said the study’s lead author, Kathryn A. Schlosser, MD, a resident in the division of gastrointestinal and minimally invasive surgery, department of surgery, Carolinas Medical Center, Charlotte, N.C.
“These are both important factors — infection and non-ideal quality of life — and need to be part of our preoperative discussion with our patients when we start managing their expectations around the time of surgery,” Dr. Schlosser said in a podium presentation.
She and her colleagues calculated probability of infection based on the ratio of BMI to defect area. They found that, for example, the probability of postoperative infection was 21% for a diabetic 69-year-old female with a recurrent hernia who had a BMI of 39 and a defect area of 20 cm2. By contrast, infection probability was 3% in a 66-year-old female with a BMI of 37, a defect area of 1 cm2, and no diabetes, Dr. Schlosser said at the meeting.
Laparoscopic versus open procedures represented a trade-off between infection risk and quality of life in this algorithm. For patients at medium risk for infection based on BMI, defect size, and other variables, switching to a laparoscopic approach dropped the infection probability from 3%-8% down to 0.1%-0.5%, Dr. Schlosser told attendees. On the other hand, switching to a laparoscopic approach increased the risk of non-ideal quality of life, she said.
One sample patient Dr. Schlosser described had an infection risk of 7.2% with the open procedure that dropped to just 0.4% for the laparoscopic procedure; however, that switch would mean that her likelihood of non-ideal quality of life 12 months after surgery increased from 24% with the open repair to 44% with the laparoscopic repair.
Dr. Schlosser had no disclosures related to the study. Co-authors provided disclosures related to Acelity, Allergan, Intuitive, Stryker, and W.L. Gore.
SOURCE: Schlosser KA, et al. abstract SF215 presented at the American College of Surgeons Clinical Congress 2018.
REPORTING FROM THE ACS CLINICAL CONGRESS
Key clinical point: BMI and defect size are key factors for choosing laparoscopic or open surgery for ventral hernia repair.
Major finding: Patients undergoing open procedures were significantly more likely to have infections, at 3.1% versus 0.3% for the laparoscopic approach.
Study details: Retrospective study including 1,906 ventral hernia repairs in the International Hernia Mesh Registry conducted between 2007 and 2017.
Disclosures: Study authors provided disclosures related to Acelity, Allergan, Intuitive, Stryker, and W.L. Gore.
Source: Schlosser KA, et al. abstract SF215 presented at the American College of Surgeons Clinical Congress 2018.
EHR-guided strategy reduces postop VTE events
BOSTON – Avoiding could result in a reduction in VTE rates, a speaker said at the annual clinical congress of the American College of Surgeons.
The VTE rate dropped by about one-quarter in the trauma care pathway at the University of Pittsburgh Medical Center (UPMC) after implementation of algorithms to risk-stratify patients and guide nursing staff, said Matthew D. Neal, MD, FACS, the Roberta G. Simmons Assistant Professor of Surgery at the University of Pittsburgh.
By incorporating algorithms into the electronic health record (EHR), UPMC was able to realize a “dramatic” 72% reduction in missed doses, from 4,331 missed doses in 2014 to 1,193 in 2015, Dr. Neal told attendees in a session focused on hot topics in surgical patient safety.
That decrease in missed doses has translated into a decreased rate of VTE, from an already relatively low rate of 1.5% in 2015, to 1.1% in 2017, representing a 26.7% reduction, according to data Dr. Neal shared in his podium presentation.
“This has been a sustainable event for us, largely linked to the implementation of an EHR-guided risk assessment pathway to guide the implementation of VTE prophylaxis,” he said.
The change was safe, he added, noting that, since utilization of this pathway, there have been no significant increases in the rate of bleeding events among patients who have mandatory orders.
These results corroborate those of some previous investigations, including one key study from the Johns Hopkins Hospital that described the adoption of a mandatory computerized clinical decision support tool to improve adherence to best practices for VTE prophylaxis.
After incorporation of the tool in the computerized order entry system, there was a significant increase in VTE prophylaxis, translating into a significant drop in preventable harm from VTE, from 1.0% to 0.17% (P = .04), investigators reported in JAMA Surgery.
Reducing missed doses is one of the major contributing factors to decreased VTE rates, according to Dr. Neal.
Missed doses of enoxaparin correlate with increased incidence of deep vein thrombosis (DVT) in trauma and general surgery patients, according to results of one prospective study Dr. Neal described. In that study of 202 patients, reported in JAMA Surgery, DVTs were seen in 23.5% of patients with missed doses, compared with 4.8 for patients with no missed doses (P < .01).
“We need to understand how to risk assess and how to utilize our EHR as a tool,” Dr. Neal told attendees.
Dr. Neal reported disclosures related to Janssen Pharmaceuticals, CSL Behring, Accriva Diagnostics, and Haemonetics, as well as a U.S. patent for a treatment of infectious and inflammatory disorders, and laboratory funding from the National Institutes of Health, Department of Defense, and the Biomedical Advanced Research and Development Authority.
SOURCE: Neal MD. Presentation at the American College of Surgeons Clinical Congress. 2018 Oct 25.
BOSTON – Avoiding could result in a reduction in VTE rates, a speaker said at the annual clinical congress of the American College of Surgeons.
The VTE rate dropped by about one-quarter in the trauma care pathway at the University of Pittsburgh Medical Center (UPMC) after implementation of algorithms to risk-stratify patients and guide nursing staff, said Matthew D. Neal, MD, FACS, the Roberta G. Simmons Assistant Professor of Surgery at the University of Pittsburgh.
By incorporating algorithms into the electronic health record (EHR), UPMC was able to realize a “dramatic” 72% reduction in missed doses, from 4,331 missed doses in 2014 to 1,193 in 2015, Dr. Neal told attendees in a session focused on hot topics in surgical patient safety.
That decrease in missed doses has translated into a decreased rate of VTE, from an already relatively low rate of 1.5% in 2015, to 1.1% in 2017, representing a 26.7% reduction, according to data Dr. Neal shared in his podium presentation.
“This has been a sustainable event for us, largely linked to the implementation of an EHR-guided risk assessment pathway to guide the implementation of VTE prophylaxis,” he said.
The change was safe, he added, noting that, since utilization of this pathway, there have been no significant increases in the rate of bleeding events among patients who have mandatory orders.
These results corroborate those of some previous investigations, including one key study from the Johns Hopkins Hospital that described the adoption of a mandatory computerized clinical decision support tool to improve adherence to best practices for VTE prophylaxis.
After incorporation of the tool in the computerized order entry system, there was a significant increase in VTE prophylaxis, translating into a significant drop in preventable harm from VTE, from 1.0% to 0.17% (P = .04), investigators reported in JAMA Surgery.
Reducing missed doses is one of the major contributing factors to decreased VTE rates, according to Dr. Neal.
Missed doses of enoxaparin correlate with increased incidence of deep vein thrombosis (DVT) in trauma and general surgery patients, according to results of one prospective study Dr. Neal described. In that study of 202 patients, reported in JAMA Surgery, DVTs were seen in 23.5% of patients with missed doses, compared with 4.8 for patients with no missed doses (P < .01).
“We need to understand how to risk assess and how to utilize our EHR as a tool,” Dr. Neal told attendees.
Dr. Neal reported disclosures related to Janssen Pharmaceuticals, CSL Behring, Accriva Diagnostics, and Haemonetics, as well as a U.S. patent for a treatment of infectious and inflammatory disorders, and laboratory funding from the National Institutes of Health, Department of Defense, and the Biomedical Advanced Research and Development Authority.
SOURCE: Neal MD. Presentation at the American College of Surgeons Clinical Congress. 2018 Oct 25.
BOSTON – Avoiding could result in a reduction in VTE rates, a speaker said at the annual clinical congress of the American College of Surgeons.
The VTE rate dropped by about one-quarter in the trauma care pathway at the University of Pittsburgh Medical Center (UPMC) after implementation of algorithms to risk-stratify patients and guide nursing staff, said Matthew D. Neal, MD, FACS, the Roberta G. Simmons Assistant Professor of Surgery at the University of Pittsburgh.
By incorporating algorithms into the electronic health record (EHR), UPMC was able to realize a “dramatic” 72% reduction in missed doses, from 4,331 missed doses in 2014 to 1,193 in 2015, Dr. Neal told attendees in a session focused on hot topics in surgical patient safety.
That decrease in missed doses has translated into a decreased rate of VTE, from an already relatively low rate of 1.5% in 2015, to 1.1% in 2017, representing a 26.7% reduction, according to data Dr. Neal shared in his podium presentation.
“This has been a sustainable event for us, largely linked to the implementation of an EHR-guided risk assessment pathway to guide the implementation of VTE prophylaxis,” he said.
The change was safe, he added, noting that, since utilization of this pathway, there have been no significant increases in the rate of bleeding events among patients who have mandatory orders.
These results corroborate those of some previous investigations, including one key study from the Johns Hopkins Hospital that described the adoption of a mandatory computerized clinical decision support tool to improve adherence to best practices for VTE prophylaxis.
After incorporation of the tool in the computerized order entry system, there was a significant increase in VTE prophylaxis, translating into a significant drop in preventable harm from VTE, from 1.0% to 0.17% (P = .04), investigators reported in JAMA Surgery.
Reducing missed doses is one of the major contributing factors to decreased VTE rates, according to Dr. Neal.
Missed doses of enoxaparin correlate with increased incidence of deep vein thrombosis (DVT) in trauma and general surgery patients, according to results of one prospective study Dr. Neal described. In that study of 202 patients, reported in JAMA Surgery, DVTs were seen in 23.5% of patients with missed doses, compared with 4.8 for patients with no missed doses (P < .01).
“We need to understand how to risk assess and how to utilize our EHR as a tool,” Dr. Neal told attendees.
Dr. Neal reported disclosures related to Janssen Pharmaceuticals, CSL Behring, Accriva Diagnostics, and Haemonetics, as well as a U.S. patent for a treatment of infectious and inflammatory disorders, and laboratory funding from the National Institutes of Health, Department of Defense, and the Biomedical Advanced Research and Development Authority.
SOURCE: Neal MD. Presentation at the American College of Surgeons Clinical Congress. 2018 Oct 25.
AT THE ACS CLINICAL CONGRESS
Post-mastectomy pain strategy allows for safe, same-day discharge
BOSTON – A multimodal pain regimen allowed for safe and effective same-day discharge of women undergoing mastectomy procedures, a recent study showed.
Women had little need for stronger oral narcotic use in the single center, retrospective study presented at the annual clinical congress of the American College of Surgeons.
The analysis included 72 consecutive mastectomies performed at a single center from November 2015 to July 2017. Most mastectomies were bilateral (61, or 84.7%) while 11 (15.3%) were unilateral.
Patients received a standardized pain regimen including 1 gram of IV acetaminophen interoperatively, combined with 30 mg of IV ketorolac and a 4-level intercostal nerve block with liposomal bupivacaine.
Liposomal bupivacaine has a longer half-life than other anesthetics, according to lead study author Radbeh Torabi, MD, a fifth-year plastic surgery resident at Louisiana State University (LSU) Health Science Center in New Orleans.
“That allows for prolonged pain control, especially during the time when the patient’s going to have the most amount of pain, which is the first day to two days postoperatively,” Dr. Torabi said in an interview.
All 72 patients were discharged home on the same day with just a 1-week prescription for acetaminophen with codeine.
Only 5 patients presented to the emergency room in the 30-day postoperative period, and of those, only 2 (2.8%) required readmission for reasons other than mastectomy-related pain, investigators said. The remaining 3 patients did present with pain, but did not require hospital admission.
Taken together, these findings suggest that this multimodal strategy offers excellent pain control and has the potential to minimize inpatient admissions while decreasing oral narcotic use, investigators said in an interview following their presentation.
“The main takeaway is reducing the amount of prescriptions we give,” Dr. Torabi said.
Study co-author Cameron T. Ward Coker, MD, a fourth-year general surgery resident at LSU, said the multimodal pain strategy used in this study could represent a step toward eliminating the risks associated with opioid prescribing.
“From the feedback we got from our lecture and the other surgeons in the room, it seems like that’s already becoming a widespread phenomenon,” Dr. Coker said.
Patients in the study had an average age of about 57 years and an average BMI of 30, according to the investigators.
Dr. Coker and Dr. Torabi had no disclosures related to the presentation.
SOURCE: Torabi R, et al. Scientific forum abstract at American College of Surgeons Clinical Congress. 2018 Oct 23.
BOSTON – A multimodal pain regimen allowed for safe and effective same-day discharge of women undergoing mastectomy procedures, a recent study showed.
Women had little need for stronger oral narcotic use in the single center, retrospective study presented at the annual clinical congress of the American College of Surgeons.
The analysis included 72 consecutive mastectomies performed at a single center from November 2015 to July 2017. Most mastectomies were bilateral (61, or 84.7%) while 11 (15.3%) were unilateral.
Patients received a standardized pain regimen including 1 gram of IV acetaminophen interoperatively, combined with 30 mg of IV ketorolac and a 4-level intercostal nerve block with liposomal bupivacaine.
Liposomal bupivacaine has a longer half-life than other anesthetics, according to lead study author Radbeh Torabi, MD, a fifth-year plastic surgery resident at Louisiana State University (LSU) Health Science Center in New Orleans.
“That allows for prolonged pain control, especially during the time when the patient’s going to have the most amount of pain, which is the first day to two days postoperatively,” Dr. Torabi said in an interview.
All 72 patients were discharged home on the same day with just a 1-week prescription for acetaminophen with codeine.
Only 5 patients presented to the emergency room in the 30-day postoperative period, and of those, only 2 (2.8%) required readmission for reasons other than mastectomy-related pain, investigators said. The remaining 3 patients did present with pain, but did not require hospital admission.
Taken together, these findings suggest that this multimodal strategy offers excellent pain control and has the potential to minimize inpatient admissions while decreasing oral narcotic use, investigators said in an interview following their presentation.
“The main takeaway is reducing the amount of prescriptions we give,” Dr. Torabi said.
Study co-author Cameron T. Ward Coker, MD, a fourth-year general surgery resident at LSU, said the multimodal pain strategy used in this study could represent a step toward eliminating the risks associated with opioid prescribing.
“From the feedback we got from our lecture and the other surgeons in the room, it seems like that’s already becoming a widespread phenomenon,” Dr. Coker said.
Patients in the study had an average age of about 57 years and an average BMI of 30, according to the investigators.
Dr. Coker and Dr. Torabi had no disclosures related to the presentation.
SOURCE: Torabi R, et al. Scientific forum abstract at American College of Surgeons Clinical Congress. 2018 Oct 23.
BOSTON – A multimodal pain regimen allowed for safe and effective same-day discharge of women undergoing mastectomy procedures, a recent study showed.
Women had little need for stronger oral narcotic use in the single center, retrospective study presented at the annual clinical congress of the American College of Surgeons.
The analysis included 72 consecutive mastectomies performed at a single center from November 2015 to July 2017. Most mastectomies were bilateral (61, or 84.7%) while 11 (15.3%) were unilateral.
Patients received a standardized pain regimen including 1 gram of IV acetaminophen interoperatively, combined with 30 mg of IV ketorolac and a 4-level intercostal nerve block with liposomal bupivacaine.
Liposomal bupivacaine has a longer half-life than other anesthetics, according to lead study author Radbeh Torabi, MD, a fifth-year plastic surgery resident at Louisiana State University (LSU) Health Science Center in New Orleans.
“That allows for prolonged pain control, especially during the time when the patient’s going to have the most amount of pain, which is the first day to two days postoperatively,” Dr. Torabi said in an interview.
All 72 patients were discharged home on the same day with just a 1-week prescription for acetaminophen with codeine.
Only 5 patients presented to the emergency room in the 30-day postoperative period, and of those, only 2 (2.8%) required readmission for reasons other than mastectomy-related pain, investigators said. The remaining 3 patients did present with pain, but did not require hospital admission.
Taken together, these findings suggest that this multimodal strategy offers excellent pain control and has the potential to minimize inpatient admissions while decreasing oral narcotic use, investigators said in an interview following their presentation.
“The main takeaway is reducing the amount of prescriptions we give,” Dr. Torabi said.
Study co-author Cameron T. Ward Coker, MD, a fourth-year general surgery resident at LSU, said the multimodal pain strategy used in this study could represent a step toward eliminating the risks associated with opioid prescribing.
“From the feedback we got from our lecture and the other surgeons in the room, it seems like that’s already becoming a widespread phenomenon,” Dr. Coker said.
Patients in the study had an average age of about 57 years and an average BMI of 30, according to the investigators.
Dr. Coker and Dr. Torabi had no disclosures related to the presentation.
SOURCE: Torabi R, et al. Scientific forum abstract at American College of Surgeons Clinical Congress. 2018 Oct 23.
REPORTING FROM THE ACS CLINICAL CONGRESS
Key clinical point:
Major finding: Of 72 women who had same-day discharge after mastectomy, only 3 presented for pain in the 30-day postoperative period.
Study details: A retrospective review of 72 consecutive mastectomies performed at a single surgical center.
Disclosures: The lead author had no disclosures related to the presentation.
Source: Torabi R, et al. Scientific forum abstract at American College of Surgeons Clinical Congress. 2018 Oct 23.