Showing papers by "Atul A. Gawande published in 2012"

Postgame Analysis: Using Video-Based Coaching for Continuous Professional Development

Abstract: Background The surgical learning curve persists for years after training, yet existing continuing medical education activities targeting this are limited. We describe a pilot study of a scalable video-based intervention, providing individualized feedback on intraoperative performance. Study Design Four complex operations performed by surgeons of varying experience—a chief resident accompanied by the operating senior surgeon, a surgeon with less than 10 years in practice, another with 20 to 30 years in practice, and a surgeon with more than 30 years of experience—were video recorded. Video playback formed the basis of 1-hour coaching sessions with a peer-judged surgical expert. These sessions were audio recorded, transcribed, and thematically coded. Results The sessions focused on operative technique—both technical aspects and decision-making. With increasing seniority, more discussion was devoted to the optimization of teaching and facilitation of the resident's technical performance. Coaching sessions with senior surgeons were peer-to-peer interactions, with each discussing his preferred approach. The coach alternated between directing the session (asking probing questions) and responding to specific questions brought by the surgeons, depending on learning style. At all experience levels, video review proved valuable in identifying episodes of failure to progress and troubleshooting alternative approaches. All agreed this tool is a powerful one. Inclusion of trainees seems most appropriate when coaching senior surgeons; it may restrict the dialogue of more junior attendings. Conclusions Video-based coaching is an educational modality that targets intraoperative judgment, technique, and teaching. Surgeons of all levels found it highly instructive. This may provide a practical, much needed approach for continuous professional development.

Improving Quality of Care for Maternal and Newborn Health: Prospective Pilot Study of the WHO Safe Childbirth Checklist Program

Abstract: BACKGROUND: Most maternal deaths intrapartum-related stillbirths and newborn deaths in low income countries are preventable but simple effective methods for improving safety in institutional births have not been devised. Checklist-based interventions aid management of complex or neglected tasks and have been shown to reduce harm in healthcare. We hypothesized that implementation of the WHO Safe Childbirth Checklist program a novel childbirth safety program for institutional births incorporating a 29-item checklist would increase delivery of essential childbirth practices linked with improved maternal and perinatal health outcomes. METHODS AND FINDINGS: A pilot pre-post-intervention study was conducted in a sub-district level birth center in Karnataka India between July and December 2010. We prospectively observed health workers that attended to women and newborns during 499 consecutively enrolled birth events and compared these with observed practices during 795 consecutively enrolled birth events after the introduction of the WHO Safe Childbirth Checklist program. Twenty-nine essential practices that target the major causes of childbirth-related mortality such as hand hygiene and uterotonic administration were evaluated. The primary end point was the average rate of successful delivery of essential childbirth practices by health workers. Delivery of essential childbirth-related care practices at each birth event increased from an average of 10 of 29 practices at baseline (95%CI 9.4 10.1) to an average of 25 of 29 practices afterwards (95%CI 24.6 25.3; p<0.001). There was significant improvement in the delivery of 28 out of 29 individual practices. No adverse outcomes relating to the intervention occurred. Study limitations are the pre-post design potential Hawthorne effect and focus on processes of care versus health outcomes. CONCLUSIONS: Introduction of the WHO Safe Childbirth Checklist program markedly improved delivery of essential safety practices by health workers. Future study will determine if this program can be implemented at scale and improve health outcomes.

Two Hundred Years of Surgery

Abstract: This review article traces the history and progress of surgery over the past two centuries, during which the profession evolved from rapidly performed, rudimentary, and often unsuccessful procedures to bold reconstruction, intricate microsurgery, transplantation, and more.

Patterns in neurosurgical adverse events: intracranial neoplasm surgery.

Abstract: Object. Neurosurgery is a high-risk specialty currently undertaking the pursuit of systematic approaches to measuring and improving outcomes. As part of a project to devise evidence-based safety interventions for specialty surgery, the authors sought to review current evidence in cranial tumor resection concerning the frequency of adverse events in practice, their patterns, and current methods of reducing the occurrence of these events. This review represents part of a series of papers written to consolidate information about these events and preventive measures as part of an ongoing effort to ascertain the utility of devising system-wide policies and safety tools to improve neurosurgical practice. Methods. The authors performed a PubMed search using search terms “intracranial neoplasm,” “cerebral tumor,” “cerebral meningioma,” “glioma,” and “complications” or “adverse events.” Only papers that specifically discussed the relevant complication rates were included. Papers were chosen to maximize the range of rates of occurrence for the reported adverse events. Results. Review of the tumor neurosurgery literature showed that documented overall complication rates ranged from 9% to 40%, with overall mortality rates of 1.5%–16%. There was a wide range of types of adverse events overall. Deep venous thromboembolism (DVT) was the most common adverse event, with a reported incidence of 3%–26%. The presence of new or worsened neurological deficit was the second most common adverse event found in this review, with reported rates ranging from 0% for the series of meningioma cases with the lowest reported rate to 20% as the highest reported rate for treatment of eloquent glioma. Benign tumor recurrence was found to be a commonly reported adverse event following surgery for intracranial neoplasms. Rates varied depending on tumor type, tumor location, patient demographics, surgical technique, the surgeon’s level of experience, degree of specialization, and changes in technology, but these effects remain unmeasured. The incidence on our review ranged from 2% for convexity meningiomas to 36% for basal meningiomas. Other relatively common complications were dural closure–related complications (1%–24%), postoperative peritumoral edema (2%–10%), early postoperative seizure (1%–12%), medical complications (6%–7%), wound infection (0%–4%), surgery-related hematoma (1%–2%), and wrong-site surgery. Strategies to minimize risk of these events were evaluated. Prophylactic techniques for DVT have been widely demonstrated and confirmed, but adherence remains unstudied. The use of image guidance, intraoperative functional mapping, and real-time intraoperative MRI guidance can allow surgeons to maximize resection while preserving neurological function. Whether the extent of resection significantly correlates with improved overall outcomes remains controversial. Discussion. A significant proportion of adverse events in intracranial neoplasm surgery may be avoidable by use of practices to encourage use of standardized protocols for DVT, seizure, and infection prophylaxis; intraoperative navigation among other steps; improved teamwork and communication; and concentrated volume and specialization. Systematic efforts to bundle such strategies may significantly improve patient outcomes.

Patterns in neurosurgical adverse events: cerebrospinal fluid shunt surgery

Abstract: Object. As part of a project to devise evidence-based safety interventions for specialty surgery, the authors sought to review current evidence in CSF shunt surgery concerning the frequency of adverse events in practice, their patterns, and the state of knowledge regarding methods for their reduction. This review may also inform future and ongoing efforts for the advancement of neurosurgical quality. Methods. The authors performed a PubMed search using search terms “cerebral shunt,” “cerebrospinal fluid shunt,” “CSF shunt,” “ventriculoperitoneal shunt,” “cerebral shunt AND complications,” “cerebrospinal fluid shunt AND complications,” “CSF shunt AND complications,” and “ventriculoperitoneal shunt AND complications.” Only papers that specifically discussed the relevant complication rates were included. Papers were chosen to be included to maximize the range of rates of occurrence for the adverse events reported. Results. In this review of the neurosurgery literature, the reported rate of mechanical malfunction ranged from 8% to 64%. The use of programmable valves has increased but remains of unproven benefit even in randomized trials. Infection was the second most common complication, with the rate ranging from 3% to 12% of shunt operations. A meta-analysis that included 17 randomized controlled trials of perioperative antibiotic prophylaxis demonstrated a decrease in shunt infection by half (OR 0.51, 95% CI 0.36–0.73). Similarly, use of detailed protocols including perioperative antibiotics, skin preparation, and limitation of OR personnel and operative time, among other steps, were shown in uncontrolled studies to decrease shunt infection by more than half. Other adverse events included intraabdominal complications, with a reported incidence of 1% to 24%, intracerebral hemorrhage, reported to occur in 4% of cases, and perioperative epilepsy, with a reported association with shunt procedures ranging from 20% to 32%. Potential management strategies are reported but are largely without formal evaluation. Conclusions. Surgery for CSF shunt placement or revision is associated with a high complication risk due primarily to mechanical issues and infection. Concerted efforts aimed at large-scale monitoring of neurosurgical complications and consistent quality improvement within these highlighted realms may significantly improve patient outcomes. (http://thejns.org/doi/abs/10.3171/2012.7.FOCUS12179)

Patterns in neurosurgical adverse events: open cerebrovascular neurosurgery.

Abstract: Object As part of a project to devise evidence-based safety interventions for specialty surgery, we sought to review current evidence concerning the frequency of adverse events in open cerebrovascular neurosurgery and the state of knowledge regarding methods for their reduction. This review represents part of a series of papers written to consolidate information about these events and preventive measures as part of an ongoing effort to ascertain the utility of devising system-wide policies and safety tools to improve neurosurgical practice. Methods The authors performed a PubMed search using search terms “cerebral aneurysm”, “cerebral arteriovenous malformation”, “intracerebral hemorrhage”, “intracranial hemorrhage”, “subarachnoid hemorrhage”, and “complications” or “adverse events.” Only papers that specifically discussed the relevant complication rates were included. Papers were chosen to be included to maximize the range of rates of occurrence for the reported adverse events. Results The review reveale...

Patterns in neurosurgical adverse events and proposed strategies for reduction.

Abstract: Neurosurgery is a high-risk specialty currently undertaking the pursuit of systematic approaches to reducing risk and to measuring and improving outcomes. The authors performed a review of patterns and frequencies of adverse events in neurosurgery as background for future efforts directed at the improvement of quality and safety in neurosurgery. They found 6 categories of contributory factors in neurosurgical adverse events, categorizing the events as influenced by issues in surgical technique, perioperative medical management, use of and adherence to protocols, preoperative optimization, technology, and communication. There was a wide distribution of reported occurrence rates for many of the adverse events, in part due to the absence of definitive literature in this area and to the lack of standardized reporting systems. On the basis of their analysis, the authors identified 5 priority recommendations for improving outcomes for neurosurgical patients at a population level: 1) development and implementati...

Patterns in neurosurgical adverse events: endovascular neurosurgery

Abstract: As part of a project to devise evidence-based safety interventions for specialty surgery, the authors sought to review current evidence in endovascular neurosurgery concerning the frequency of adverse events in practice, their patterns, and current methods of reducing the occurrence of these events. This review represents part of a series of papers written to consolidate information about these events and preventive measures as part of an ongoing effort to ascertain the utility of devising system-wide policies and safety tools to improve neurosurgical practice. Based on a review of the literature, thromboembolic events appeared to be the most common adverse events in endovascular neurosurgery, with a reported incidence ranging from 2% to 61% depending on aneurysm rupture status and mode of detection of the event. Intraprocedural and periprocedural prevention and rescue regimens are advocated to minimize this risk; however, evidence on the optimal use of anticoagulant and antithrombotic agents is limited. ...

Legal Disputes over Duties to Disclose Treatment Risks to Patients: A Review of Negligence Claims and Complaints in Australia

Abstract: David Studdert and colleagues identified disputes over informed consent among malpractice claims and serious health care complaints in Australia and provide an analysis of disagreements between patients and doctors over whether particular clinical risks should have been disclosed before treatment.

Measuring the range of services clinicians are responsible for in ambulatory practice.

Abstract: Rationale, aims and objectives At present, the range of services delivered in a health system is not known. Currently there are no accepted methods for defining the scope of ambulatory care. Therefore we used data from the electronic medical record and billing system of a large non-profit multi-specialty group practice to measure the number of different diagnoses that clinicians managed as well as the number of different medications, laboratory tests, imaging studies, referrals and procedures ordered. Methods All patient encounters and clinicians in the group practice in 2008 were eligible for inclusion in the analysis. Data were analysed cumulatively for the practice and by specialty. Quantile regression models were used to adjust for differences in full-time equivalents (FTE) among physicians at the practice. Results In one year for this practice, with 324 229 patients who made 3 193 917 office visits to 578 physicians and 248 other clinicians, patients presented with 5638 primary and 6411 secondary diagnoses. Overall, patient management resulted in unique orders for 9481 medications, 1182 laboratory tests, 613 referrals, 284 imaging studies and 1701 procedures. After adjusting for FTE, physicians managed a median of 249 primary diagnoses and 347 secondary diagnoses. They ordered a median of 278 medications, 128 laboratory tests, 51 referrals, 29 imaging studies and 39 procedures. Conclusion Physicians routinely manage a substantial variety of diagnoses, medications, and other tests and procedures. Quality improvement and health services researchers have generally focused on individual services but also must consider the wide variety and range of services delivered.

Comprehensive national analysis of emergency and essential surgical capacity in Rwanda (Br J Surg 2012: 99: 436–443)

Abstract: Background: Disparities in the global availability of operating theatres, essential surgical equipment and surgically trained providers are profound. Although efforts are ongoing to increase surgical care and training, little is known about the surgical capacity in developing countries. The aim of this study was to create a baseline for surgical development planning at a national level. Methods: A locally adapted World Health Organization survey was conducted in November 2010 to assess emergency and essential surgical capacity and volumes, with on-site interviews at 44 district and referral hospitals in Rwanda. Results were compiled for education and capacity development discussions with the Rwandan Ministry of Health and the Rwanda Surgical Society. Results: Among 10·1 million people, there were 44 hospitals and 124 operating rooms (1·2 operating rooms per 100 000 persons). There was a total of 50 surgeons practising fullor part-time in Rwanda (0·49 total surgeons per 100 000 persons). The majority of consultant surgeons worked in the capital (covering 10 per cent of the population). Anaesthesia was performed primarily by anaesthesia technicians, and six of 44 hospitals had no trained anaesthesia provider. Continuous availability of electricity, running water and generators was lacking in eight hospitals, and 19 reported an absence or shortage in the availability of pulse oximetry. Equipment for life-saving surgical airway procedures, particularly in children, was lacking. A dedicated emergency area was available in only 19 hospitals. In 2009 and 2010 over 80 000 surgical procedures (major and minor) were recorded annually in Rwanda. Conclusion: A comprehensive countrywide assessment of surgical capacity in resource-limited settings found severe shortages in available resources. Immediate local feedback is a useful tool for creating a baseline of surgical capacity to inform country-specific surgical development.

Lifebox: the difference a donation makes. Atul Gawande interviewed by Jane Feinmann.

Abstract: Atul Gawande, writer, and surgeon at Brigham and Women’s Hospital in Boston, US, is also chair of Lifebox, chosen as the BMJ’s Christmas charity. Jane Feinmann asked him just what a BMJ reader donation means

Lifebox replies to Gøtzsche

Abstract: Gotzsche’s argument that pulse oximetry provides no benefit is fundamentally flawed. No anaesthesiology department in the world would forgo pulse oximetry.1 2 It forms an essential part of the measures that have improved the safety of anaesthesia in the past two decades, and every anaesthesiologist has an experience where oximetry …