Showing papers by "Atul A. Gawande published in 2011"

Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention

Abstract: Objectives To assess the relationship between changes in clinician attitude and changes in postoperative outcomes following a checklist-based surgical safety intervention. Design Pre- and post intervention survey. Setting Eight hospitals participating in a trial of a WHO surgical safety checklist. Participants Clinicians actively working in the designated study operating rooms at the eight hospitals. Survey instrument Modified operating-room version Safety Attitudes Questionnaire (SAQ). Main outcome measures Change in mean safety attitude score and correlation between change in safety attitude score and change in postoperative outcomes, plus clinician opinion of checklist efficacy and usability. Results Clinicians in the preintervention phase (n=281) had a mean SAQ score of 3.91 (on a scale of 1 to 5, with 5 representing better safety attitude), while the postintervention group (n=257) had a mean of 4.01 (p=0.0127). The degree of improvement in mean SAQ score at each site correlated with a reduction in postoperative complication rate (r=0.7143, p=0.0381). The checklist was considered easy to use by 80.2% of respondents, while 19.8% felt that it took a long time to complete, and 78.6% felt that the programme prevented errors. Overall, 93.4% would want the checklist used if they were undergoing operation. Conclusions Improvements in postoperative outcomes were associated with improved perception of teamwork and safety climate among respondents, suggesting that changes in these may be partially responsible for the effect of the checklist. Clinicians held the checklist in high regard and the overwhelming majority would want it used if they were undergoing surgery themselves.

Effective Surgical Safety Checklist Implementation

Abstract: Background Research suggests that surgical safety checklists can reduce mortality and other postoperative complications. The real world impact of surgical safety checklists on patient outcomes, however, depends on the effectiveness of hospitals' implementation processes. Study Design We studied implementation processes in 5 Washington State hospitals by conducting semistructured interviews with implementation leaders and surgeons from September to December 2009. Interviews were transcribed, analyzed, and compared with findings from previous implementation research to identify factors that distinguish effective implementation. Results Qualitative analysis suggested that effectiveness hinges on the ability of implementation leaders to persuasively explain why and adaptively show how to use the checklist. Coordinated efforts to explain why the checklist is being implemented and extensive education regarding its use resulted in buy-in among surgical staff and thorough checklist use. When implementation leaders did not explain why or show how the checklist should be used, staff neither understood the rationale behind implementation nor were they adequately prepared to use the checklist, leading to frustration, disinterest, and eventual abandonment despite a hospital-wide mandate. Conclusions The impact of surgical safety checklists on patient outcomes is likely to vary with the effectiveness of each hospital's implementation process. Further research is needed to confirm these findings and reveal additional factors supportive of checklist implementation.

Crisis checklists for the operating room: development and pilot testing.

Abstract: Background Because operating room crises are rare events, failure to adhere to critical management steps is common. We sought to develop and pilot a tool to improve adherence to lifesaving measures during operating room crises. Study Design We identified 12 of the most frequently occurring operating room crises and corresponding evidence-based metrics of essential care for each (46 total process measures). We developed checklists for each crisis based on a previously defined method, which included literature review, multidisciplinary expert consultation, and simulation. After development, 2 operating room teams (11 participants) were each exposed to 8 simulations with random assignment to checklist use or working from memory alone. Each team managed 4 simulations with a checklist available and 4 without. One of the primary outcomes measured through video review was failure to adhere to essential processes of care. Participants were surveyed for perceptions of checklist use and realism of the scenarios. Results Checklist use resulted in a 6-fold reduction in failure of adherence to critical steps in management for 8 scenarios with 2 pilot teams. These results held in multivariate analysis accounting for clustering within teams and adjusting for learning or fatigue effects (11 of 46 failures without the checklist vs 2 of 46 failures with the checklist; adjusted relative risk=0.15, 95% CI, 0.04–0.60; p=0.007). All participants rated the overall quality of the checklists and scenarios to be higher than average or excellent. Conclusions Checklist use can improve safety and management in operating room crises. These findings warrant broader evaluation, including in clinical settings.

The hot spotters: can we lower medical costs by giving the neediest patients better care?

Abstract: f Camden, New Jersey, becomes the first American community to lower its medical costs, it will have a murder to thank. At nine-fifty on a February night in 2001, a twenty-two-year-old black man was shot while driving his Ford Taurus station wagon through a neighborhood on the edge of the Rutgers University campus. The victim lay motionless in the street beside the open door on the driver’s side, as if the car had ejected him. A neighborhood couple, a physical therapist and a volunteer firefighter, approached to see if they could help, but police waved them back. “He’s not going to make it,” an officer reportedly told the physical therapist. “He’s pretty much dead.” She called a physician, Jeffrey Brenner, who lived a few doors up the street, and he ran to the scene with a stethoscope and a pocket ventilation mask. After some discussion, the police let him enter the crime scene and attend to the victim. Witnesses told the local newspaper that he was the first person to lay hands on the man. “He was slightly overweight, turned on his side,” Brenner recalls. There was glass everywhere. Although the victim had been shot several times and many minutes had passed, his body felt warm. Brenner checked his neck for a carotid pulse. The man was alive. Brenner began the chest compressions and rescue breathing that should have been started long before. But the young man, who turned out to be a Rutgers student, died soon afterward. The incident became a local scandal. The student’s injuries may not have been survivable, but the police couldn’t have known that. After the ambulance came, Brenner confronted one of the officers to ask why they hadn’t tried to rescue him. “We didn’t want to dislodge the bullet,” he recalls the policeman saying. It was a ridiculous answer, a brushoff, and Brenner couldn’t let it go. Lower Costs and Better Care for Neediest Patients : The New Yorker http://www.newyorker.com/reporting/2011/01/24/110124fa_fact_gawand...

Esophagectomy outcomes at low-volume hospitals: the association between systems characteristics and mortality.

Abstract: Objective:To evaluate the association between systems characteristics and esophagectomy mortality at low-volume hospitalsBackground:High-volume hospitals have lower esophagectomy mortality rates, but receiving care at such centers is not always feasible We examined low-volume hospitals and sought t

A Policy-based Intervention for the Reduction of Communication Breakdowns in Inpatient Surgical Care: Results From a Harvard Surgical Safety Collaborative

Abstract: Objective:To develop and evaluate an intervention to reduce breakdowns in communication during inpatient surgical care.Background:Communication breakdowns are the second most common cause of avoidable surgical adverse events after technical errors.Methods:In a pre- and postintervention study, a rand

The Surgical Apgar Score in Hip and Knee Arthroplasty

Abstract: Background A 10-point Surgical Apgar Score, based on patients’ estimated blood loss, lowest heart rate, and lowest mean arterial pressure during surgery, was developed to rate patients’ outcomes in general and vascular surgery but has not been tested for patients having orthopaedic surgery.

Are Targeted Preoperative Risk Prediction Tools More Powerful? A Test of Models for Emergency Colon Surgery in the Very Elderly

Abstract: Background Whether preoperative risk prediction improves with the use of more patient- and procedure-targeted models is unclear. We created a customized preoperative mortality risk prediction score for patients 80 years or older needing an emergency colectomy and compare it with existing, more generic risk assessment methods. Study Design A targeted mortality prediction model was created using 2007 to 2008 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data and was validated using 2005 to 2006 data. We constructed a scoring system from the significant predictors identified. The model fit of our targeted score was compared with the American Society of Anesthesiologist's (ASA) score, the Surgical Risk Scale, and the ACS Colorectal Surgery Risk Calculator. Results Analyses identified 1,358 and 372 emergency colectomies in the training and validation samples, respectively. Our targeted risk prediction score had a goodness-of-fit p value greater than 0.05 (indicating a good fit) and a c-statistic of 0.77, which represents a significantly better fit compared with the ASA score, the Surgical Risk Scale, and the ACS Colorectal Surgery Risk Calculator c-statistics (0.66, 0.66, and 0.71, respectively). When using the scores to predict mortality with 80% specificity, our targeted risk prediction score was 25% more likely to predict correctly than the ACS Colorectal Surgery Risk Calculator and 33% more likely to predict correctly compared with the ASA score and Surgical Risk Scale. Conclusions Our study presents a validated preoperative mortality score for very elderly patients needing an emergency colectomy. The greater discriminating power of this targeted score indicates that preoperative risk assessment may need to be customized to specific procedures and patient circumstances.

The Predictive Value of the Fine-Needle Aspiration Diagnosis “Suspicious for a Follicular Neoplasm, Hürthle Cell Type” in Patients With Hashimoto Thyroiditis

Abstract: A fine-needle aspiration sample composed exclusively of Hurthle cells is interpreted as “suspicious for a follicular neoplasm, Hurthle cell type” (SFNHCT). Because some nonneoplastic Hurthle cell proliferations in Hashimoto thyroiditis (HT) mimic this cytologic pattern, we examined the positive predictive value (PPV) for malignancy of SFNHCT in patients with HT. Between 1992 and 2007, 401 patients with cytologic findings of SFNHCT were identified at 3 institutions. Histologic follow-up was available for 287 (71.6%), and malignancy was diagnosed in 69 (24.0%). Malignancy was present in 2 (PPV = 9.5%) of 21 patients with HT compared with 67 (PPV = 25.2%) of 266 patients without HT ( P = .081). Although the difference in the rate of malignancy between the HT and non-HT cohorts did not reach statistical significance, the lower risk of malignancy in the HT cohort more closely approximates the risk of cases interpreted as “atypia of undetermined significance.” For this reason, it might be appropriate for Hurthle cell–only aspirates from patients with HT to be categorized as either atypia of undetermined significance or SFNHCT.

In-hospital Death following Inpatient Surgical Procedures in the United States, 1996–2006

Abstract: Background Over the past decade, improvements in perioperative care have been widely introduced throughout the United States, yet there is no clear indication that the death rate following surgery has improved. We sought to evaluate the number of deaths after surgery in the United States over a 10-year period and to evaluate trends in postoperative mortality.

Receipt of appropriate surgical care for Medicare beneficiaries with cancer.

Abstract: Objective To investigate receipt of appropriate surgical care in Medicare beneficiaries with cancer. Design Retrospective cohort study. Setting National Surveillance, Epidemiology, and End Results registry linked to Medicare claims data. Patients Fee-for-service Medicare patients aged 65 years or older who underwent a definitive surgical resection for breast, colon, gastric, rectal, or thyroid cancer diagnosed between January 2000 and December 2005. Claims data were available from January 1999 through December 2007. Main Outcome Measures Receipt of care concordant with established practice guidelines in surgical oncology in the aggregate and by hospital. Results Concordance with guidelines was greater than 90% for 7 of 11 measures. All guidelines regarding adjuvant therapy had concordance rates greater than 90%. Only 2 of 5 measures for nodal management had concordance rates greater than 90%. At least 50% of hospitals provided guideline-concordant care to 100% of their patients for 6 of 11 guidelines. Patients receiving appropriate care tended to be younger, healthier, white, and more affluent, to have less advanced disease, and to live in the Midwest. Conclusions We found a high level of concordance with guidelines in some domains of surgical oncology care but far less so in others, particularly for gastric and colon nodal management. Given the current national focus on improving the quality of health care, surgeons must focus on generating data to define appropriate care and translating those data into everyday practice.

Critical role of identification of the second gland during unilateral parathyroid surgery: a prospective review of 119 patients with concordant localization.

Abstract: Hypothesis: We aimed to validate the effectiveness of a protocol for primary hyperparathyroidism in which intraoperativeparathyroidhormonemeasurement(IOPTH)was notroutinelyusedduringminimallyinvasiveparathyroidectomy for patients with dual localization by technetium Tc 99m sestamibi (MIBI) and ultrasonography and hypothesized that our rate of surgical failure would be less than 3% for patients with concordant localization. Design: Prospective cohort study. Setting: Brigham and Women’s Hospital, Boston, Massachusetts. Patients: One hundred nineteen patients with primary hyperparathyroidism and dual localization. Main Outcome Measures: Incidence of surgical cure following minimally invasive parathyroidectomy (MIP) without the use of IOPTH for patients with dual localization.

A policy-based intervention for the reduction of communication breakdowns in inpatient surgical care: Results from a harvard surgical safety collaborative

Abstract: After technical errors, the most common cause of avoidable adverse events during inpatient surgical care is communication-related breakdowns. Lapses in communication have been associated with delays in care and increased patient morbidity. A previous study conducted at 4 academic medical cen

Critical need for objective assessment of postsurgical patients

Abstract: I N this issue, Reynolds et al. 1 add to the legacy of anesthesiologist Virginia Apgar. Following her 1953 publication in an anesthesia journal of “A proposal for a new method of evaluation of the newborn infant,” clinicians around the world rapidly adopted the simple, 10-point score she’d proposed. Until that time, assessment of neonatal condition had been purely subjective and highly variable, and her score was hailed as a striking advancement for providing an objective assessment that strongly correlated with the likelihood of infant mortality in the first month of life. The Apgar score enabled better decision-making in how intensively to care for a newborn, and improved communication among those caring for the child. The difference between caring for a child with a 5-min Apgar score of 10 and one with a score of 4 remains readily apparent. To this day, the score provides a key predictor of neonatal survival, and obstetrics units rely on tracking and audits of patients with low Apgar scores to devise innovations to prevent poor neonatal outcomes. The effect on child mortality rates has been stunning. For this reason, our research team sought to develop a similar score for surgical patients. Like newborn infants before 1953, patients coming out of surgery are assessed primarily subjectively, passed on to the care of team members with information only about “how everything went” and with no easy, practical metric for targeted improvement, despite mortality that may not occur for days or weeks afterward. Our early studies suggested that an Apgar-like score could be constructed by summing grades for the amount of blood lost, lowest blood pressure, and lowest heart rate during an operation. This Surgical Apgar Score appeared to concisely capture a myriad number of factors that contribute to a patient’s condition after surgery: the patient’s overall fitness and acute health status coming into the operation, the intraoperative anesthesia management, and the magnitude and technical performance of the procedure. Furthermore, in our studies in general and vascular surgery, and in subsequent studies of a few other subspecialties, this score proved to be well correlated with the likelihood of death and serious complications within 30 days after surgery. (Of note, anesthesiologists Aldrete and Kroulik developed a commonly used, 10-point Postanesthetic Recovery Score to guide discharge from the recovery room, but it was not designed to provide a validated prediction of the risk of major postoperative complications or evaluation of surgical outcome.) Reynolds et al. perform an invaluable service in validating the score across a vast cohort of operations—123,864 procedures in all. In parallel to the Apgar score, the authors establish that there is strong correlation with mortality, in this case across a variety of surgical subspecialties. Even among specialties with weaker correlations, each point in increase in the Surgical Apgar Score corresponded to a reduction in odds of mortality of 30% or more. This study adds to a growing volume of literature suggesting that a patient’s condition during surgery is closely associated with the likelihood of death and major disability even weeks and months after the patient emerges from anesthesia. Findings in multiple institutions have now established that this metric may be no less useful than its predecessor. So why has it not been adopted in practice? Even at the lead author’s institution, where scores are calculated electronically and included in brief surgical notes for all general and vascular surgery procedures, they are rarely actually used, whether to grade intraoperative stability and anesthetic management, to improve communication in patient handoffs, or to provide a target for clinical leaders seeking to improve surgical performance. There are several possible explanations. Accurate assessment and communication about patients coming out of surgery may be considered less critical than about newborns. (Surgical death rates and volumes are higher but they are not publicly reported for hospitals the way infant mortality is.) Education of doctors and nurses about how to use this tool, although simple, may be inadequate. In addition, there may be a desire for metrics customized to individual procedures or built from more complex risk models that provide more powerful prediction of mortality. (However strong the correlation with risk of death within 30 days, the score is nowhere near perfectly diagnostic.) We suspect, nonetheless, that a major reason the Surgical Apgar Score is not used is that surgeons and anesthesiologists believe that their subjective impressions of patient condition are accurate—or at least no less accurate than this simplistic quantitative score. The next needed study is therefore one comparing the accuracy of clinical assessment of patients’ postsurgical risk of mortality and morbidity with that of the Surgical Apgar Score (and/or other measures). Other important questions remain unanswered. Are intraoperative hemodynamics just a marker of patient disease and intrinsic risk, or can surgeons and anesthesiologists improve scores and outcomes by minimizing blood loss and preventing hypotension and tachycardia? Could better preoperative management of