The PATH to patient safety.

Communication is critical to safe patient care. In this issue of the British Journal of Anaesthesia, Jaulin and colleagues show that use of a Post-Anaesthesia Team Handover (PATH) checklist is associated with fewer hypoxaemia events in the PACU, reduced handover interruptions, and other important metrics related to improved communication. The PATH checklist provides a link within a broader chain of safety checklists and other interventions that comprise a perioperative chain of survival.

Critical event debriefing: a checklist for the aftermath.

PURPOSE OF REVIEW: Millions of perioperative crises (e.g. anaphylaxis, cardiac arrest) may occur annually. Critical event debriefing can offer benefits to the individual, team, and system, yet only a fraction of perioperative critical events are debriefed in real-time. This publication aims to review evidence-based best practices for proximal critical event debriefing. RECENT FINDINGS: Evidence-based key processes to consider for proximal critical event debriefing can be summarized by the WATER mnemonic: Welfare check (assessing team members' emotional and physical wellbeing to continue providing care); Acute/short-term corrections (matters to be addressed before the next case); Team reactions and reflections (summarizing case; listening to team member reactions; plus/delta conversation); Education (lessons learned from the event and debriefing); Resource awareness and longer term needs [follow-up (e.g. safety/quality improvement report), local peer-support and employee assistance resources]. A cognitive aid to accompany this mnemonic is provided with the publication. SUMMARY: There is growing literature on how to conduct proximal perioperative critical event debriefing. Evidence-based best practices, as well as a cognitive aid to apply them, may help bridge the gap between theory and clinical practice. In this era of increased attention to burnout and wellness, the consideration of interventions to improve the quality and frequency of critical event debriefing is paramount.

Comparing Outcomes and Costs of Surgical Patients Treated at Major Teaching and Nonteaching Hospitals: A National Matched Analysis.

OBJECTIVE: To compare outcomes and costs between major teaching and nonteaching hospitals on a national scale by closely matching on patient procedures and characteristics. BACKGROUND: Teaching hospitals have been shown to often have better quality than nonteaching hospitals, but cost and value associated with teaching hospitals remains unclear. METHODS: A study of Medicare patients at 340 teaching hospitals (resident-to-bed ratios ≥ 0.25) and matched patient controls from 2444 nonteaching hospitals (resident-to-bed ratios < 0.05).We studied 86,751 pairs admitted for general surgery (GS), 214,302 pairs of patients admitted for orthopedic surgery, and 52,025 pairs of patients admitted for vascular surgery. RESULTS: In GS, mortality was 4.62% in teaching hospitals versus 5.57%, (a difference of -0.95%, <0.0001), and overall paired cost difference = $915 (P < 0.0001). For the GS quintile of pairs with highest risk on admission, mortality differences were larger (15.94% versus 18.18%, difference = -2.24%, P < 0.0001), and paired cost difference = $3773 (P < 0.0001), yielding $1682 per 1% mortality improvement at 30 days. Patterns for vascular surgery outcomes resembled general surgery; however, orthopedics outcomes did not show significant differences in mortality across teaching and nonteaching environments, though costs were higher at teaching hospitals. CONCLUSIONS: Among Medicare patients, as admission risk of mortality increased, the absolute mortality benefit of treatment at teaching hospitals also increased, though accompanied by marginally higher cost. Major teaching hospitals appear to return good value for the extra resources used in general surgery, and to some extent vascular surgery, but this was not apparent in orthopedic surgery.

Comparing Outcomes and Costs of Medical Patients Treated at Major Teaching and Non-teaching Hospitals: A National Matched Analysis.

BACKGROUND: Teaching hospitals typically pioneer investment in new technology and cultivate workforce characteristics generally associated with better quality, but the value of this extra investment is unclear. OBJECTIVE: Compare outcomes and costs between major teaching and non-teaching hospitals by closely matching on patient characteristics. DESIGN: Medicare patients at 339 major teaching hospitals (resident-to-bed (RTB) ratios ≥ 0.25); matched patient controls from 2439 non-teaching hospitals (RTB ratios < 0.05). PARTICIPANTS: Forty-three thousand nine hundred ninety pairs of patients (one from a major teaching hospital and one from a non-teaching hospital) admitted for acute myocardial infarction (AMI), 84,985 pairs admitted for heart failure (HF), and 74,947 pairs admitted for pneumonia (PNA). EXPOSURE: Treatment at major teaching hospitals versus non-teaching hospitals. MAIN MEASURES: Thirty-day all-cause mortality, readmissions, ICU utilization, costs, payments, and value expressed as extra cost for a 1% improvement in survival. KEY RESULTS: Thirty-day mortality was lower in teaching than non-teaching hospitals (10.7% versus 12.0%, difference = - 1.3%, P < 0.0001). The paired cost difference (teaching - non-teaching) was $273 (P < 0.0001), yielding $211 per 1% mortality improvement. For the quintile of pairs with highest risk on admission, mortality differences were larger (24.6% versus 27.6%, difference = - 3.0%, P < 0.0001), and paired cost difference = $1289 (P < 0.0001), yielding $427 per 1% mortality improvement at 30 days. Readmissions and ICU utilization were lower in teaching hospitals (both P < 0.0001), but length of stay was longer (5.5 versus 5.1 days, P < 0.0001). Finally, individual results for AMI, HF, and PNA showed similar findings as in the combined results. CONCLUSIONS AND RELEVANCE: Among Medicare patients admitted for common medical conditions, as admission risk of mortality increased, the absolute mortality benefit of treatment at teaching hospitals also increased, though accompanied by marginally higher cost. Major teaching hospitals appear to return good value for the extra resources used.

Advances in anesthesia education: increasing access and collaboration in medical education, from E-learning to telesimulation.

PURPOSE OF REVIEW: The landscape of medical education continues to evolve. Educators and learners must stay informed on current medical literature, in addition to focusing efforts on current educational trends and evidence-based methods. The present review summarizes recent advancements in anesthesiology education, specifically highlighting trends in e-learning and telesimulation, and identifies possible future directions for the field. RECENT FINDINGS: Websites and online platforms continue to be a primary source of educational content; top websites are more likely to utilize standardized editorial processes. Podcasts and videocasts are important tools desired by learners for asynchronous education. Social media has been utilized to enhance the reach and visibility of journal articles, and less often as a primary educational venue; its efficacy in comparison with other e-learning platforms has not been adequately evaluated. Telesimulation can effectively disseminate practical techniques and clinical knowledge sharing, extending the capabilities of simulation beyond previous restrictions in geography, space, and available expertise. SUMMARY: E-learning has changed the way anesthesiology learners acquire knowledge, expanding content and curricula available and promoting international collaboration. More work should be done to expand the principles of accessible and collaborative education to psychomotor and cognitive learning via telesimulation.

Surgical Consultation as Social Process: Implications for Shared Decision Making.

OBJECTIVE: This qualitative study examines surgical consultation as a social process and assesses its alignment with assumptions of the shared decision-making (SDM) model. SUMMARY OF BACKGROUND DATA: SDM stresses the importance of patient preferences and rigorous discussion of therapeutic risks/benefits based on these preferences. However, empirical studies have highlighted discrepancies between SDM and realities of surgical decision making. Qualitative research can inform understanding of the decision-making process and allow for granular assessment of the nature and causes of these discrepancies. METHODS: We observed consultations between 3 general surgeons and 45 patients considering undergoing 1 of 2 preference-sensitive elective operations: (1) hernia repair, or (2) cholecystectomy. These patients and surgeons also participated in semi-structured interviews. RESULTS: By the time of the consultation, patients and surgeons were predisposed toward certain decisions by preceding events occurring elsewhere. During the visit, surgeons had differential ability to arbitrate surgical intervention and construct the severity of patients' conditions. These upstream dynamics frequently displaced the centrality of the risk/benefit-based consent discussion. CONCLUSION: The influence of events preceding consultation suggests that decision-making models should account for broader spatiotemporal spans. Given surgeons' authority to define patients' conditions and control service provision, SDM may be premised on an overestimation of patients' power to alter the course of decision making once in a specialist's office. Considering the subordinate role of the risk/benefit discussion in many surgical decisions, it will be important to study if and how the social process of decision making is altered by SDM-oriented decision aids that foreground this discussion.

Failure to Debrief after Critical Events in Anesthesia Is Associated with Failures in Communication during the Event.

WHAT WE ALREADY KNOW ABOUT THIS TOPIC: Debriefing after an actual critical event is an established good practice in medicine, but a gap exists between principle and implementation. WHAT THIS ARTICLE TELLS US THAT IS NEW: Failure to debrief after critical events is common among anesthesia trainees and likely anesthesia teams. Communication breakdowns are associated with a high rate of the failure to debrief. BACKGROUND: Debriefing after an actual critical event is an established good practice in medicine, but a gap exists between principle and implementation. The authors' objective was to understand barriers to debriefing, characterize quantifiable patterns and qualitative themes, and learn potential solutions through a mixed-methods study of actual critical events experienced by anesthesia personnel. METHODS: At a large academic medical center, anesthesiology residents and a small number of attending anesthesiologists were audited and/or interviewed for the occurrence and patterns of debriefing after critical events during their recent shift, including operating room crises and disruptive behavior. Patterns of the events, including event locations and event types, were quantified. A comparison was done of the proportion of cases debriefed based on whether the event contained a critical communication breakdown. Qualitative analysis, using an abductive approach, was performed on the interviews to add insight to quantitative findings. RESULTS: During a 1-yr period, 89 critical events were identified. The overall debriefing rate was 49% (44 of 89). Nearly half of events occurred outside the operating room. Events included crisis events (e.g., cardiac arrest, difficult airway requiring an urgent surgical airway), disruptive behavior, and critical communication breakdowns. Events containing critical communication breakdowns were strongly associated with not being debriefed (64.4% [29 of 45] not debriefed in events with a communication breakdown vs. 36.4% [16 of 44] not debriefed in cases without a communication breakdown; P = 0.008). Interview responses qualitatively demonstrated that lapses in communication were associated with enduring confusion that could inhibit or shape the content of discussions between involved providers. CONCLUSIONS: Despite the value of proximal debriefing to reducing provider burnout and improving wellness and learning, failure to debrief after critical events can be common among anesthesia trainees and perhaps anesthesia teams. Modifiable interpersonal factors, such as communication breakdowns, were associated with the failure to debrief.

Failure-to-Rescue After Acute Myocardial Infarction.

BACKGROUND: Failure-to-rescue (FTR), originally developed to study quality of care in surgery, measures an institution's ability to prevent death after a patient becomes complicated. OBJECTIVES: Develop an FTR metric modified to analyze acute myocardial infarction (AMI) outcomes. RESEARCH DESIGN: Split-sample design: a random 20% of hospitals to develop FTR definitions, a second 20% to validate test characteristics, and an out-of-sample 60% to validate results. SUBJECTS: Older Medicare beneficiaries admitted to short-term acute-care hospitals for AMI between 2009 and 2011. MEASURES: Thirty-day mortality and FTR rates, and in-hospital complication rates. RESULTS: The 60% out-of-sample validation included 234,277 patients across 1142 hospitals that admitted at least 50 patients over 2.5 years. In total, 72.1% of patients were defined as Medically Complicated (complex on admission or subsequently developed a complication or died without a recorded complication) of whom 19.3% died. Spearman r between hospital risk-adjusted 30-day mortality and FTR was 0.89 (P<0.0001); Mortality versus Complication=-0.01 (P=0.6198); FTR versus Complication=-0.10 (P=0.0011). Major teaching hospitals displayed 19% lower odds of FTR versus non-teaching hospitals (odds ratio=0.81, P<0.0001), while hospitals as a group defined by teaching hospital status, comprehensive cardiac technology, and having good nursing mix and staffing, displayed a 33% lower odds of FTR (odds ratio=0.67, P<0.0001) versus hospitals without any of these characteristics. CONCLUSIONS: A modified FTR metric can be created that has many of the advantageous properties of surgical FTR and can aid in studying the quality of care of AMI admissions.

Simulation-based trial of surgical-crisis checklists.

BACKGROUND: Operating-room crises (e.g., cardiac arrest and massive hemorrhage) are common events in large hospitals but can be rare for individual clinicians. Successful management is difficult and complex. We sought to evaluate a tool to improve adherence to evidence-based best practices during such events. METHODS: Operating-room teams from three institutions (one academic medical center and two community hospitals) participated in a series of surgical-crisis scenarios in a simulated operating room. Each team was randomly assigned to manage half the scenarios with a set of crisis checklists and the remaining scenarios from memory alone. The primary outcome measure was failure to adhere to critical processes of care. Participants were also surveyed regarding their perceptions of the usefulness and clinical relevance of the checklists. RESULTS: A total of 17 operating-room teams participated in 106 simulated surgical-crisis scenarios. Failure to adhere to lifesaving processes of care was less common during simulations when checklists were available (6% of steps missed when checklists were available vs. 23% when they were unavailable, P<0.001). The results were similar in a multivariate model that accounted for clustering within teams, with adjustment for institution, scenario, and learning and fatigue effects (adjusted relative risk, 0.28; 95% confidence interval, 0.18 to 0.42; P<0.001). Every team performed better when the crisis checklists were available than when they were not. A total of 97% of the participants reported that if one of these crises occurred while they were undergoing an operation, they would want the checklist used. CONCLUSIONS: In a high-fidelity simulation study, checklist use was associated with significant improvement in the management of operating-room crises. These findings suggest that checklists for use during operating-room crises have the potential to improve surgical care. (Funded by the Agency for Healthcare Research and Quality.).

Pilot testing of a model for insurer-driven, large-scale multicenter simulation training for operating room teams.

OBJECTIVE: To test the feasibility of implementing a standardized teamwork training program with full operating room teams in multiple institutions, driven by malpractice insurer support and incentives. BACKGROUND: Failures in intraoperative teamwork are among the leading causes of preventable patient injury and death in surgical patients. Teamwork training, particularly using simulation, can be an effective intervention but is difficult to scale. METHODS: A malpractice insurer convened a collaborative with 4 Harvard-affiliated simulation programs to develop a standardized operating room teamwork training curriculum, including principles of communication, assertiveness, and use of the World Health Organization Surgical Safety Checklist. Participant teams were compensated for lost operative time via malpractice premium discounts, continuing education credits, and compensation for lost wages. The course was delivered through a simulation program involving the management of intraoperative emergency scenarios. Participants were surveyed for their perceptions of the program and of its impact on clinical practice. RESULTS: A total of 221 active operating room staff members participated in the program. Each team contained at least 1 attending surgeon, 1 attending anesthesiologist, and 1 operating room nurse (mean size per team: 7 ± 2 participants). No study dates were cancelled because of lack of attendance. The survey response rate was 99% (218/221). Overall, the vast majority of participants found the scenarios realistic [94% (95% confidence interval: 90.9%, 97.2%)], appropriately challenging [95.4% (92.6%, 98.2%)], relevant to their practice [96.3% (93.8%, 98.8%)], and found the training would help them provide safer patient care [92.6% (89.1%, 96.1%)]. Surgeons reported their greatest personal deficit as communication skills. Operating room nurses and anesthesiologists reported a greater need than surgeons to work on personal assertiveness. CONCLUSIONS: A standardized multicenter team training program involving full operative teams is feasible with high-fidelity simulation and modest compensation for lost time. The vast majority of the multidisciplinary participants believed the course to have had a meaningful impact on their approach to clinical practice.

Surgery at the end of life: a pilot study comparing decedents and survivors at a tertiary care center.

BACKGROUND: More than a quarter of medical costs for Medicare beneficiaries are incurred in the last year of life; surgical intensity during this time is significant. This study was performed to determine types of operations patients undergo in their terminal year, and compare characteristics of decedents with those of survivors. METHODS: Population of 747 consecutive all-payer patients seen at the preoperative assessment center of a tertiary care hospital. Patient characteristics were obtained from the electronic medical record. Surgical indication (palliative, curative, diagnostic, elective) was assessed based on procedure performed and underlying diagnosis. Vital status was determined using the electronic medical record with confirmation via social security national death master file. Descriptive statistics were performed to compare patient characteristics and procedures performed on those who died within 1 yr of procedure with those of survivors. RESULTS: Thirty-seven patients (5%) were confirmed dead at 1 yr. Ten (27%) of these had palliative procedures, 11 (30%) diagnostic, 14 (38%) curative, and 2 (5%) elective. Decedents were more likely to have undergone a palliative (27 vs. 3%) or diagnostic (30 vs. 14%) procedure and less likely to have undergone an elective procedure (5 vs. 42%) than survivors (P < 0.0001). Nearly half of decedents did not have an advanced directive by the date of surgical intervention. CONCLUSIONS: Nearly 1 in 20 patients seen at the preoperative assessment clinic of a tertiary care hospital died within 1 yr of their procedure. Patient characteristics and procedure indication for decedents differed from those of survivors. Similar analyses based on institution and region may provide methodologies to compare variation in surgical intensity and assist preoperative care providers in evaluating appropriateness of resource allocation.