"Show Me the Data": A Recipe for Quality Improvement Success in an Academic Surgical Department.

BACKGROUND: Surgeons in academic medical centers have traditionally taken a siloed approach to reducing postoperative complications. We initiated a project focusing on transparency and sharing of data to engage surgeons in collaborative quality improvement. Its key features were the development of a comprehensive department quality dashboard and the creation of the Clinical Operations Council that oversaw quality. The purpose of this study was to assess the impact of those efforts. STUDY DESIGN: We compared inpatient outcomes before and after our intervention, allowing one quarter as the diffusion period. The outcomes analyzed were: risk-adjusted length of stay, mortality, direct cost and unadjusted incidence of complications, and 30-day all-cause readmissions, as determined by the Vizient Clinical Database. We examined the outcomes of three groups: group 1 (surgery); group 2, all other surgical departments (other surgery); and group 3, all other patients (non-surgery). Two-tailed Student's t-test was used for analysis and p < 0.05 was considered statistically significant. RESULTS: Group 1 demonstrated statistically significant improvements in mortality (p = 0.01), length of stay (p = 0.002), cost (p = 0.0001), and complications (p = 0.02), and the all-cause readmission rate was unchanged, resulting in mean decrease of 0.55 length of stay days and direct cost savings of $2,300 per surgical admission. The comparison groups had only modest decreases in some of the analyzed outcomes and an increase in complication rates. CONCLUSIONS: These data suggest that a collaborative, data-driven, and transparent approach to assessing the quality of surgical care can yield significant improvements in patient outcomes.

Using the agile implementation model to reduce central line-associated bloodstream infections.

BACKGROUND: Central line-associated bloodstream infections (CLABSIs) are among the most common hospital-acquired infections and can lead to increased patient morbidity and mortality rates. Implementation of practice guidelines and recommended prevention bundles has historically been suboptimal, suggesting that improvements in implementation methods could further reductions in CLABSI rates. In this article, we describe the agile implementation methodology and present details of how it was successfully used to reduce CLABSI. METHODS: We conducted an observational study of patients with central line catheters at 2 adult tertiary care hospitals in Indianapolis from January 2015 to June 2017. RESULTS: The intervention successfully reduced the CLABSI rate from 1.76 infections per 1,000 central line days to 1.24 (rate ratio = 0.70; P = .011). We also observed reductions in the rates of Clostridium difficile and surgical site infections, whereas catheter-associated urinary tract infections remained stable. CONCLUSIONS: Using the AI model, we were able to successfully implement evidence-based practices to reduce the rate of CLABSIs at our facility.

Impact of a Novel Preoperative Patient-centered Surgical Wellness Program.

OBJECTIVE: The objective of this study was to evaluate if a preoperative wellness bundle significantly decreases the risk of hospital acquired infections (HAI). BACKGROUND: HAI threaten patient outcomes and are a significant burden to the healthcare system. Preoperative wellness efforts may significantly decrease the risk of infections. METHODS: A group of 12,396 surgical patients received a wellness bundle in a roller bag during preoperative screening at an urban academic medical center. The wellness bundle consisted of a chlorhexidine bath solution, immuno-nutrition supplements, incentive spirometer, topical mupirocin for the nostrils, and smoking cessation information. Study staff performed structured patient interviews, observations, and standardized surveys at key intervals throughout the perioperative period. Statistics compare HAI outcomes of patients in the wellness program to a nonintervention group using the Fisher's exact test, logistic regression, and Poisson regression. RESULTS: Patients in the nonintervention and intervention groups were similar in demographics, comorbidity, and type of operations. Compliance with each element was high (80% mupirocin, 72% immuno-nutrition, 71% chlorhexidine bath, 67% spirometer). The intervention group had statistically significant reductions in surgical site infections, Clostridium difficile, catheter associated urinary tract infections, and patient safety indicator 90. CONCLUSIONS: A novel, preoperative, patient-centered wellness program dramatically reduced HAI in surgical patients at an urban academic medical center.

Improving first case start times using Lean in an academic medical center.

BACKGROUND: Lean is a process improvement strategy that can improve efficiency of the perioperative process. The purpose of this study was to identify etiologies of late surgery start times, implement Lean interventions, and analyze their effects. METHODS: A retrospective review of all first-start surgery cases was performed. Lean was implemented in May 2015, and cases 7 months before and after implementation were analyzed. RESULTS: A total of 4,492 first-start cases were included; 2,181 were pre-Lean and 2,311 were post-Lean. The post-Lean group had significantly higher on-time starts than the pre-Lean group (69.0% vs 57.0%, P < .01). The most common delay etiology was surgeon-related for both groups. Delayed post-Lean cases were significantly less likely to be due to preoperative assessment (14.9% vs 9.9%, P < .01) and more likely due to patient-related (16.5% vs 22.3%, P < .01) or chaplain (1.8% vs 4.0%, P < .01) factors. Delayed starts occurred more often on snowy and cold days, and less often on didactic days (P < .01). CONCLUSIONS: Modifying preoperative tasks using Lean methods can improve operating room efficiency and increase on-time starts.

EEG manifestations of nondual experiences in meditators.

The holistic experiential benefits of meditation among a widely ranging population have been well established within the empirical literature. What remain less clear are the underlying mechanisms of the meditative process. A large impediment to this clarity is attributable to the lack of a unified and comprehensive taxonomy, as well as to the absence of clear differentiation within the literature between method of practice and resulting state. The present study discusses and then attempts to identify within our sample a theoretically universal culminating meditative state known as Nondual Awareness, which is differentiated from the method or practice state. Participants completed an in-lab meditation, during which neurological patterns were analyzed using electroencephalography (EEG). Analyses indicated significantly higher EEG power among slower wave frequencies (delta, theta, alpha) during the reported nondual events. These events appear neurologically distinct from meditation sessions as a whole, which interestingly demonstrated significant elevation within the gamma range.

Controlled flow-through dissolution methodology: a high-performance system.

Measuring release rates using compendial systems, especially for sparingly soluble compounds, often produces complex results with less than desired precision and lacks relevance to key formulation or biological parameters. A flow-through approach was used by focusing on convective diffusion and controlling certain key physical-chemical factors. Results are presented for an automated multisample flow-through system that displays significant advantages over compendial (1) stirred and (2) flow-through systems. Advantages include precision, physicochemical, and in vivo relevance, along with analytical and formulation sensitivity. The convective diffusion/dissolution process was also simulated by using finite element modeling with predictions agreeing with measurements to within a few percent.

Impact of density gradients on flow-through dissolution in a cylindrical flow cell.

Measuring release rates for sparingly soluble compounds requires slow flow rates to achieve measurable eluent levels. However, flow rate cannot be reduced indefinitely because density gradients could measurably alter the drug release rate. Finite element simulations of convective diffusion/dissolution with an applied concentration-dependent density gradient reproduced the trends of the changes in dissolution rate on eluent flow rate which occur upon switching flow direction and sample cell orientation relative to gravitational field as observed in the literature employing a rectangular flow cell. The situation was experimentally reproduced using an implant obstruction placed centrally in a cylindrical flow cell.

Electrophysiological alterations during hypnosis for ego-enhancement: a preliminary investigation.

EEG activity at the midfrontal (Fz) region was recorded during pre- and postbaselines, live hypnotic induction, arm levitation and progressive relaxation (PNR) deepening, and therapeutic ego-enhancing suggestions among 60 college student volunteers, previously screened with the Stanford Hypnotic Susceptibility Scale, Form C. Comparisons across conditions for delta, theta, alpha, and beta activity were made between low, moderate, high, and very high hypnotizable groups. Results indicated (a) significant increases in theta EEGs across the hypnosis process with a peak at PNR and a drop in theta thereafter to termination, with highs showing significantly more dramatic effects than moderates; (b) a similar inverted U-shaped pattern for beta EEGs across hypnosis conditions, with very highs significantly higher in beta power than moderates and lows, and with highs significantly higher than moderates; (c) general profile differences between the highs for theta and the highs and very highs for beta in comparison to the moderates and lows, with peak theta and beta power occurring during ego-enhancing suggestions for more highly hypnotizable participants; (d) a drop in alpha EEGs across the trance process with a return to baseline after hypnosis, with moderates showing significantly lower alpha power; and (e) an increase in delta power across conditions to PNR and then a decrease to post-hypnosis baseline, with moderates significantly lower than highs.

The use of blunt-tipped 12-mm trocars without fascial closure in laparoscopic live donor nephrectomy.

OBJECTIVES: Blunt-tipped trocar placement may eliminate the need for fascial closure in transperitoneal laparoscopic live donor nephrectomies (LDN). The process of 12-mm blunt-tipped trocar insertion through the abdominal wall involves fascial and muscle spreading, not incision. Coaptation of the tissue layers occurs during withdrawal of the trocar, preventing volume gaps that can be prone to herniation. METHODS: We retrospectively assessed the safety and efficacy of fascial nonclosure after 12-mm blunt-tipped port insertion in 70 transperitoneal LDNs performed between October 1998 and March 2001. Five ports (two 12-mm blunt-tipped and three 5-mm blunt-tipped) were used in all cases. The 12-mm trocars were inserted at the lateral border of the rectus muscle, approximately 8 cm below the costal margin and also along the anterior axillary line approximately 8 cm below the costal margin. Fascial non-closure was performed in all 70 patients. Postoperative data were analyzed regarding complications and long-term outcomes. RESULTS: Three major and 7 minor complications occurred in this series. No patient developed clinically detectable trocar-site hernias or other complications related to blunt-trocar placement. CONCLUSIONS: Our data shows that fascial nonclosure after transperitoneal 12-mm blunt-tipped trocar insertion is safe. Visualization of the tissue layers during port placement facilitated the insertion process. Further application of this method in a larger number of patients is needed to confirm its clinical applicability.

Reexamination of convective diffusion/drug dissolution in a laminar flow channel: accurate prediction of dissolution rate.

PURPOSE: The convective diffusion/dissolution theory applied to flowthrough dissolution in a laminar channel was reexamined to evaluate how closely it can predict release rate for a model compound on an absolute basis--a comparison that was lacking from the original literature observations reported from this technique. METHODS: The theory was extended to allow for a finite flux of dissolving material, replacing the fixed concentration by a flux condition on the dissolving surface. The derivation introduces a new parameter, k(s), an area-independent analog of the dissolution rate constant defined in the USP intrinsic dissolution procedure. RESULTS: The release rate for ethyl-p-aminobenzoate originally observed fell within 10% of the absolute prediction assuming a solubility limited situation, and deviated from this prediction in a manner possibly consistent with a finite flux-limited condition, with k(s) approximately 10(-4) M s(-1). For materials exhibiting lower k(s) values, the derivation suggests that at high flow rates, a limit occurs where dissolution rate becomes independent of shear rate and merely a function of solubility and surface area. CONCLUSIONS: The new parameter k(s) may be deduced from any set of geometric and flow conditions, provided the fluid velocity can be determined everywhere in the domain.

Binaural beat induced theta EEG activity and hypnotic susceptibility: contradictory results and technical considerations.

The present study offered a constructive replication of an earlier study which demonstrated significant increases in theta EEG activity following theta binaural beat (BB) entrainment training and significant increases in hypnotic susceptibility. This study improved upon the earlier small-sample, multiple-baseline investigation by employing a larger sample, by utilizing a double-blind, repeated-measures group experimental design, by investigating only low and moderate susceptible participants, and by providing 4 hours of binaural beat training. With these design improvements, results were not supportive of the specific efficacy of the theta binaural beat training employed in this study in either increasing frontal theta EEG activity or in increasing hypnotic susceptibility. Statistical power analyses indicated the theta binaural beat training to be a very low power phenomenon on theta EEG activity. Furthermore, we found no significant relationship between frontal theta power and hypnotizability, although the more hypnotizable participants showed significantly greater increases in hypnotizability than the less hypnotizables. Results are discussed within the context of participant selection and classification factors, technical considerations in the presentation of TBB training, and theta blocking.

Major complications in 213 laparoscopic nephrectomy cases: the Indianapolis experience.

PURPOSE: We assessed the incidence of and analyzed factors that may help prevent major complications and open conversion during laparoscopic nephrectomy at our institutions. MATERIALS AND METHODS: We retrospectively analyzed all laparoscopic nephrectomies performed between August 1, 1999 and July 31, 2001. Data were stratified for nephrectomy type, intraoperative and postoperative complications. Conversion to open surgery was stratified for emergency versus elective procedures. RESULTS: Of the 292 laparoscopic procedures performed at our institutions in 2 years 213 (73%) involved laparoscopic nephrectomy, including 84 live donor nephrectomies, 61 radical nephrectomies, 55 simple nephrectomies and 13 nephroureterectomies. A total of 16 major complications (7.5%) occurred, including access related, intraoperative and postoperative complications in 3, 9 and 4 cases, respectively. The conversion rate was 6.1% (13 patients), the transfusion rate was 1.9% and the mortality rate was 0.5% (1 death). Only 1 complication was related to simple laparoscopic nephrectomy, although this group showed the highest rate of elective conversion (7 of 8 elective conversions). Laparoscopic live donor nephrectomy showed the highest rate for emergency conversion (3 of 5 emergency conversions). CONCLUSIONS: Our results reinforce the importance of thorough preoperative imaging, careful patient selection, surgeon experience and skill maintenance in laparoscopy as well as a low threshold for conversion to open surgery. This series provides additional evidence to support the evolution of laparoscopic nephrectomy into a standard of care.

One versus two proficient laparoscopic surgeons for laparoscopic live donor nephrectomy.

OBJECTIVES: To compare the laparoscopic donor nephrectomy (LDN) results obtained by two different surgical teams, one consisting of a proficient laparoscopic surgeon assisted by an inexperienced laparoscopic surgeon and another consisting of two proficient laparoscopic surgeons. With more centers embarking on LDN programs, it is important to identify the factors that can improve overall outcomes during the initial learning curve. METHODS: A retrospective review was performed of the initial 70 sequential LDNs performed between October 1998 and March 2001 at our institutions. The procedures were stratified into two groups. Group 1 consisted of LDN cases performed by one proficient laparoscopic surgeon and an inexperienced laparoscopic surgeon (resident, fellow, or faculty) as the first assistant; group 2 consisted of cases performed by two proficient laparoscopic surgeons. RESULTS: Twenty-six LDNs were performed by group 1 and 44 by group 2. The total operative time and estimated blood loss showed a statistically significant decrease in group 2 compared with group 1, 143 +/- 32 minutes versus 218 +/- 38 minutes (P <0.001) and 92 +/- 115 mL versus 158 +/- 148 mL (P = 0.044), respectively. Two major complications occurred in group 1 (7.7%) and two major complications occurred in group 2 (4.5%). The 3-month postoperative recipient creatinine levels were similar for both groups, 1.6 +/- 1.3 versus 1.4 +/- 0.4 (P = 0.408). CONCLUSIONS: A surgical team composed of two proficient laparoscopic surgeons during the early learning curve of LDN may allow safe and efficient development of a laparoscopic live donor renal transplantation program.

Manual specimen retrieval without a pneumoperitoneum preserving device for laparoscopic live donor nephrectomy.

PURPOSE: We present a novel method of kidney retrieval based on a modified Pfannenstiel incision and insertion of the assistant hand into the abdominal cavity without a device for pneumoperitoneum preservation. This maneuver is performed as the last step in pure laparoscopic live donor nephrectomy. Also, we assessed the effect of this technique on warm ischemia time compared with the standard laparoscopic bag retrieval technique. MATERIALS AND METHODS: A total of 70 laparoscopic live donor nephrectomies were performed at our institutions between October 1998 and March 2001. The first 43 cases were completed using an EndoCatch bag device (Auto Suture, Norwalk, Connecticut) for specimen retrieval, while the last 27 were done using a novel manual retrieval technique through a modified Pfannenstiel incision. We retrospectively analyzed the results in regard to warm ischemia time and intraoperative complications related to the procedure. RESULTS: A statistically significant difference was noted in the EndoCatch and manual retrieval groups in regard to warm ischemia time (p <0.001). There were 2 complications related to the EndoCatch device and none related to the manual technique. No differences were detected regarding recipient outcomes. CONCLUSIONS: Manual specimen retrieval after live donor nephrectomy allows shorter warm ischemia time, while saving the cost of an EndoCatch bag or pneumoperitoneum preserving device that would be used during hand assisted live donor nephrectomy. It was shown to be a safe method without increased donor morbidity.

Transperitoneal laparoscopic renal surgery using blunt 12-mm trocar without fascial closure.

BACKGROUND AND PURPOSE: Conical blunt trocar insertion may eliminate the need for fascial closure (FC) in transperitoneal laparoscopic renal surgery. This concept applies to 12-mm blunt trocar placement through muscular parts of the abdominal wall, relying on muscle splitting and eventual muscle retraction when the trocar is removed. We retrospectively assessed the safety of fascial nonclosure (FNC) after 12-mm blunt port insertion. PATIENTS AND METHODS: Ninety transperitoneal laparoscopic renal procedures were performed between August 1999 and May 2000. Four ports (two 12 mm and two 5 mm) were usually used except for 30 donor nephrectomies, where an additional 5-mm port was used. The 12-mm trocars were inserted at the lateral border of the rectus muscle 5 cm below the costal margin and in the anterior axillary line 8 cm below the costal margin. Fascial closure was performed in 62 patients and nonclosure in 28 patients. Exclusion criteria for FNC included midline location, malnutrition, renal failure, and chronic use of steroids. Postoperative outcomes were compared in 20 patients with FNC matched with 20 patients with FC. RESULTS: At an average of 4.8 months of follow-up, none of the patients developed a trocar site hernia. No significant statistical differences were observed between the groups with regard to intraoperative and postoperative data. CONCLUSIONS: These two approaches appear to be equivalent in terms of patient morbidity and postoperative hospital stay. Fascial nonclosure after transperitoneal 12-mm blunt trocar insertion, through muscular parts of the abdominal wall may be safe and efficacious and eliminates the last step in transperitoneal laparoscopic renal surgery.

Comparison of laparoscopic live donor nephrectomy versus the traditional open technique.

OBJECTIVES: Laparoscopic live donor nephrectomy (LDN) is a minimally invasive technique for kidney procurement that may decrease the donor disincentives. In addition, recent studies have demonstrated that LDN has equal graft and recipient survival when compared to the standard open approach. We report our experience with LDN and compare the results with the most recent open donor nephrectomy (ODN) group performed at our institutions. MATERIAL AND METHODS: The records of 70 consecutives left sided LDN performed between October 1998 and March 2001 were retrospectively reviewed and compared to 40 ODN performed between April 1996 and January 2000. RESULTS: Average blood loss (127 ml vs. 317 ml; p < 0.001), time to PO intake (25 hrs vs. 34.6 hrs; p < 0.001), and hospital stay (2.7 d vs. 4.2 d; p < 0.001) were statistically significant better for the LDN group when compared to ODN group. The average warm ischemia time in the LDN group was 138 seconds (range 55 - 360). The major complication rate in both laparoscopic (4 cases) and open (2 cases) donor groups was similar (5.7% and 5%, respectively). The average post-operative day (POD) 90 recipient creatinine was similar for both groups (1.5+/-0.9 vs. 1.5+/-0.8 ng/dL; p= 0.799). Similar rates of recipient ureteral complications occurred in the LDN and ODN groups: 1.4% (1 case) and 2.5% (1 case), respectively. Likewise, acute rejection was also similar at 22.8% (16 cases) and 27.5% (11 cases) in the LDN and ODN respectively. CONCLUSIONS: At our institutions, LDN was superior to ODN with regards to donor operative blood loss, time to PO intake, and length of hospital stay. In addition, similar complication rates, and 3-month recipient kidney function were demonstrated.