Malpractice litigation in cardiac surgery: Alleged injury mechanisms and outcomes.

BACKGROUND AND AIM: The feared prospect of involvement in malpractice litigation ultimately becomes a reality for many physicians in high-risk specialties such as cardiothoracic surgery. This study systematically analyzes malpractice claims by procedure type and alleged injury mechanism. METHODS: An extensive nation-wide database of medical malpractice claims was searched, and 140 involving cardiac procedures were identified. The primary reason for the lawsuit was classified as a periprocedural injury, postoperative mismanagement, failure to operate in a timely manner or at all, performing an unnecessary procedure, performing a procedure too soon, lack of informed consent, or patient abandonment. RESULTS: Cardiac surgeons were defendants in 47.8% of cases and cardiologists in 56.4%. Forty percent of cases involved coronary artery bypass grafting, valvular surgery, or both; 50% of these received defendant verdicts. The most common reason for the lawsuit was periprocedural injury, most frequently due to poor prosthetic valve fit/securement (23.1%) or surgical site infection (15.4%). For congenital cases, most lawsuits alleged periprocedural injury, with perfusion-related issues (cooling during circulatory arrest, failure to inform surgeon about poor oxygenation) cited in 37.5%. Cardiologists and cardiothoracic or vascular surgeons were codefendants in 14.3% of cases, most commonly coronary artery bypass grafting (40%) or cardiac catheterizations (25%). In all catheterization cases, the allegation against the surgeon was a failure to diagnose/treat the complication in a proper or timely manner. In postoperative mismanagement cases, bleeding/tamponade was the most common allegation category (31.8%). CONCLUSIONS: A careful review of cardiac surgical malpractice litigation can identify common contributory factors to adverse patient outcomes and catalyze practice improvement.

Financial Impact of Incentive Spirometry.

Despite largely unproven clinical effectiveness, incentive spirometry (IS) is widely used in an effort to reduce postoperative pulmonary complications. The objective of the study is to evaluate the financial impact of implementing IS. The amount of time nurses and RTs spend each day doing IS-related activities was assessed utilizing an online survey distributed to the relevant national nursing and respiratory therapists (RT) societies along with questionnaire that was prospectively collected every day for 4 weeks at a single 10-bed cardiothoracic surgery step-down unit. Cost of RT time to teach IS use to patients and cost of nurse time spent reeducating and reminding patients to use IS were used to calculate IS implementation cost estimates per patient. Per-patient cost of IS implementation ranged from $65.30 to $240.96 for a mean 9-day step-down stay. For the 566 patients who stayed in the 10-bed step-down in 2016, the total estimated cost of implementing IS ranged from $36 959.80 to $136 383.36. Using national survey workload data, per-patient cost of IS implementation costed $107.36 (95% confidence interval [CI], $97.88-$116.98) for a hospital stay of 4.5 days. For the 9.7 million inpatient surgeries performed annually in the United States, the total annual cost of implementing postoperative IS is estimated to be $1.04 billion (95% CI, $949.4 million-$1.13 billion). The cost of implementing IS is substantial. Further efficacy studies are necessary to determine whether the cost is justifiable.

Lessons from the sky: an aviation-based framework for maximizing the delivery of quality anesthetic care.

Though aviation is practiced in airplanes and anesthesiology in operating rooms, the two professions have substantial parallels. Both require readiness to manage a crisis situation, where lives are at stake, at a moment's notice and with incomplete information. The determinants of quality performance in both professions extend far beyond knowledge base and formal training. The science of human factors, a prominent cornerstone of the aviation industry, has not yet found the same place in medicine, but it could change the understanding and execution of medical decision-making in profound ways. This article reviews specific components of crisis management and root cause analysis in aviation that can serve as models for improving those same aspects within anesthesiology.

Evaluating a Potential National Board for Respiratory Care Credential for Pulmonary Disease Educators.

The National Board for Respiratory Care credentials general respiratory therapists and therapists specializing in pulmonary function testing, neonatal/pediatrics, sleep, and adult critical care. A sponsor of the NBRC requested a new specialty certification program. The request came with the intent to serve a candidate population from multidisciplinary backgrounds (eg, nurse, nurse practitioner, physician assistant) in addition to respiratory therapists. This article describes the policy that governed the response along with details about two evaluations: a viability study and a personnel study. The research question for the viability study was as follows: Is a new pulmonary disease educator certification program desirable and feasible? After an affirmative outcome from the viability study indicated interest in a new certification program, the research question for the personnel study was as follows: Were there enough potential candidates from multidisciplinary backgrounds to support a new program that would certify pulmonary disease educators? Access to 10 databases was secured to solicit personnel from multidisciplinary backgrounds, netting up to 240,000 potential survey respondents. After pilot testing, one survey was distributed to those with managerial/supervisory relationships with pulmonary disease educators; 407 such personnel responded. A second survey was simultaneously distributed to those directly working in the pulmonary disease educator role; 3,095 responded. Results from both surveys, including the limitations, were summarized for the NBRC, which decided against continued development of the program. A pulmonary disease educator certification program was subjectively desirable and feasible; however, there did not objectively seem to be enough potential candidates to support the program.

Periprocedural pulmonary aspiration: An analysis of medical malpractice cases and alleged causative factors.

RATIONALE AIMS AND OBJECTIVES: Pulmonary aspiration is a feared complication of anaesthesia that is associated with significant morbidity and mortality. Within the small existing body of literature on medical malpractice claims related to periprocedural aspiration, very little information is available regarding the case-specific factors that were alleged to contribute to each aspiration event. METHODS: This study searched an extensive nationwide database of medical malpractice claims and identified 43 relating to periprocedural pulmonary aspiration. RESULTS: The most common mechanism of causation cited in these claims (37%) was the failure to secure the airway with an endotracheal tube (ETT) when an elevated aspiration risk existed, most commonly because endotracheal intubation was not originally selected as part of the anaesthetic plan. The second most common alleged category of causation (33%) was the failure to perform a proper rapid-sequence induction and/or place a nasogastric tube (NGT) for decompression prior to induction. An equal amount of cases resulted in defendant versus plaintiff verdicts (44.2% each), while a settlement was reached in the remaining 11.6% of cases. CONCLUSION: These findings are generalizable to clinical practice improvement on a broader scale. They demonstrate the need to develop reliable, high-sensitivity tests for detecting elevated risk before clinicians can be expected to take special steps to protect susceptible patients, and they also show that medical malpractice can be alleged because of failure to uphold currently accepted standards of care even when the published evidence for those standards is weak. This study demonstrates that careful review of medical malpractice litigation can elucidate common contributory factors and facilitate improvements in clinical practice and decision-making.

Impact of Electronic Cigarettes on Various Organ Systems.

The electronic cigarette (e-cigarette) has been regarded by many as a healthier alternative to the combustible cigarette, yet there is a lack of consensus concerning the health consequences and the health benefits associated with e-cigarette use. We review the research on the effects of e-cigarettes on multiple physiological systems, examine the association between e-cigarette use and combustible cigarette uptake and cessation, and highlight research necessary to build consensus. Although the levels of known toxicants and carcinogens tend to be significantly lower in e-cigarettes than in combustible cigarette smoke, toxicants in e-cigarette e-liquid and those that form as part of the vaporization process may produce adverse health consequences in their own right. Acute effects have been noted in the pulmonary, cardiovascular, and immune systems, which highlight the need for research on long-term exposure. The specific chemical constituents and the levels of those constituents that pose harm remain largely uncharacterized. In addition, the efficacy of e-cigarettes for smoking cessation has yet to be established. As the e-cigarette has evolved rapidly, so has the methodology across studies, making cross-study comparisons more difficult to synthesize. The latest generation of e-cigarette devices deliver nicotine and toxicants at higher levels than earlier devices, especially in experienced users. E-cigarettes pose a risk for nicotine exposure, dependence, and combustible cigarette uptake. E-cigarettes and their delivered toxicants appear harmful to multiple organ systems, although the current body of evidence is limited, especially in terms of long-term effects. Further research is warranted with a focus on individual devices, e-liquid constituents, user characteristics, and patterns of use. Any potential benefit of e-cigarettes for smoking cessation must be weighed against the risks. Given the potential longer-term effects, efforts to prevent e-cigarette use in youth are critical.

Clinical management of rib fractures and methods for prevention of pulmonary complications: A review.

Rib fractures are common injuries associated with significant morbidity and mortality, largely due to pulmonary complications. Despite equivocal effectiveness data, incentive spirometers are widely utilized to reduce pulmonary complications in the postoperative setting. Few studies have evaluated the effectiveness of incentive spirometry after rib fracture. Multiple investigations have demonstrated incentive spirometry to be an important screening tool to identify high-risk rib fracture patients who could benefit from aggressive, multidisciplinary pulmonary complication prevention strategies. This review evaluates the epidemiology of rib fractures, their associated pulmonary complications, along with the evidence for optimizing their clinical management through the use of incentive spirometry, multimodal analgesia, and surgical fixation.

Effect of an Incentive Spirometer Patient Reminder After Coronary Artery Bypass Grafting: A Randomized Clinical Trial.

Importance: Incentive spirometers (ISs) were developed to reduce atelectasis and are in widespread clinical use. However, without IS use adherence data, the effectiveness of IS cannot be determined. Objective: To evaluate the effect of a use-tracking IS reminder on patient adherence and clinical outcomes following coronary artery bypass grafting (CABG) surgery. Design, Setting, and Participants: This randomized clinical trial was conducted from June 5, 2017, to December 29, 2017, at a tertiary referral teaching hospital and included 212 patients who underwent CABG, of whom 160 participants were randomized (intent to treat), with 145 completing the study per protocol. Participants were stratified by surgical urgency (elective vs nonelective) and sex (men vs women). Interventions: A use-tracking, IS add-on device (SpiroTimer) with an integrated use reminder bell recorded and timestamped participants' inspiratory breaths. Patients were randomized by hourly reminder "bell on" (experimental group) or "bell off" (control group). Main Outcomes and Measures: Incentive spirometer use was recorded for the entire postoperative stay and compared between groups. Radiographic atelectasis severity (score, 0-10) was the primary clinical outcome. Secondary respiratory and nonrespiratory outcomes were also evaluated. Results: A total of 145 per-protocol participants (112 men [77%]; mean age, 69 years [95% CI, 67-70]; 90 [62%] undergoing a nonelective procedure) were evaluated, with 74 (51.0%) in the bell off group and 71 (49.0%) in the bell on group. The baseline medical and motivation-to-recover characteristics of the 2 groups were similar. The mean number of daily inspiratory breaths was greater in bell on (35; 95% CI, 29-43 vs 17; 95% CI, 13-23; P < .001). The percentage of recorded hours with an inspiratory breath event was greater in bell on (58%; 95% CI, 51-65 vs 28%; 95% CI, 23-32; P < .001). Despite no differences in the first postoperative chest radiograph mean atelectasis severity scores (2.3; 95% CI, 2.0-2.6 vs 2.4; 95% CI, 2.2-2.7; P = .48), the mean atelectasis severity scores for the final chest radiographs conducted before discharge were significantly lower for bell on than bell off group (1.5; 95% CI, 1.3-1.8 vs 1.8; 95% CI, 1.6-2.1; P = .04). Of those with early postoperative fevers, fever duration was shorter for bell on (3.2 hours; 95% CI, 2.3-4.6 vs 5.2 hours; 95% CI, 3.9-7.0; P = .04). Having the bell turned on reduced noninvasive positive pressure ventilation use rates (37.2%; 95% CI, 24.1%-52.5% vs 19.2%; 95% CI, 10.2%-33.0%; P = .03) for participants undergoing nonelective procedures. Bell on reduced the median postoperative length of stay (7 days; 95% CI, 6-9 vs 6 days; 95% CI, 6-7; P = .048) and the intensive care unit length of stay for patients undergoing nonelective procedures (4 days; 95% CI, 3-5 vs 3 days; 95% CI, 3-4; P = .02). At 6 months, the bell off mortality rate was higher than bell on (9% vs 0%, P = .048) for participants undergoing nonelective procedures. Conclusions and Relevance: The incentive spirometer reminder improved patient adherence, atelectasis severity, early postoperative fever duration, noninvasive positive pressure ventilation use, ICU and length of stay, and 6-month mortality in certain patients. With the reminder, IS appears to be clinically effective when used appropriately. Trial Registration: ClinicalTrials.gov identifier: NCT02952027.

Financial Implications of Physician Specialty Choice.

PURPOSE: To examine the approximated financial outcomes of physicians by specialty and to determine whether these correlate with mean USMLE Step 1 scores. METHODS: Specialty-specific data from the Association of American Medical Colleges Careers in Medicine website were analyzed for total length of training, mean USMLE Step 1 scores, average hours worked per week, and median clinical practice salary for physicians. Hourly wage and estimated net worth at retirement were calculated. Coefficients of determination (R2) were calculated to evaluate the relationships between hourly wage, annual salary, and estimated net worth at retirement with competitiveness as measured by USMLE Step 1 scores of matched residents. RESULTS: Across all 37 specialties studied, the mean hourly wage was $136 ± $40, ranging from $78 (Geriatrics) to $249 (Neurosurgery). Mean weekly hours worked across all specialties was 54.6 ± 6.4, ranging from 43.4 (Pediatric Emergency Medicine) to 71.1 (Vascular Surgery). At retirement, the mean estimated net worth for all physicians was $4,517,600 ± $1,793,095, ranging from $1,927,779 (Child & Adolescent Psychiatry) to $8,947,885 (Neurosurgery). Step 1 scores, as a marker of specialty competiveness, correlate with specialty compensation - the strongest association was with hourly wage (R2 = 0.6678), then annual salary (R2 = 0.6424), and finally by estimated net worth at retirement (R2 = 0.6158). CONCLUSION: In this study, mean Step 1 scores for each medical specialty were positively correlated with compensation, including absolute salary, hourly wage and estimated net worth at retirement.

Utility of Inspiratory Volume in Incentive Spirometry.

Incentive spirometers (IS) were developed to reproduce sustained maximal inspiration. Most providers believe that achieving target inspiratory volume (ISV) is the most important factor for successful IS use. ISV has been used as a surrogate for deep breathing effort and has been correlated with various clinical outcomes, but the scientific validity of these correlations has yet to be demonstrated. Currently, the greatest utility of targeted ISV may be as a method of monitoring global patient progress and as a psychosocial instrument for patient engagement in care.

Patient Factors Associated with Successful Incentive Spirometry.

BACKGROUND: Incentive spirometers (IS) are commonly prescribed after various surgical procedures with the intended effect of reducing postoperative pulmonary complications. Factors associated with correct use of IS by postoperative patients has not previously been studied. METHODS: A cross-sectional analysis of postoperative patients was completed to assess whether patients knew how to correctly inhale on their IS. For each patient, the following variables were collected: whether the device was within arm's reach of the patient, if the patient reported having used their IS, if they considered the IS to be helpful, and if they felt more confident using IS after a brief educational intervention was performed by study investigators. RESULTS: A total of 26.2% (11/42) of patients failed to use their IS correctly, and 38.1% (16/42) denied ever using the device in their postoperative care. Device location, perceived benefit, and previous use were identified as statistically significant determinants of successful use. Following a brief educational intervention by a physician, 73.8% (31/42) of patients were more confident in their ability to use IS during the remainder of their care. DISCUSSION: A substantial portion of postoperative patients failed to correctly utilize their IS. Device proximity to the patient, patient perspectives on potential benefits of IS, and previous use of the device may affect correct use. Patient education and optimization of device placement should be considered to increase compliance during IS implementation.

Perspectives on Incentive Spirometry Utility and Patient Protocols.

BACKGROUND: Incentive spirometry (IS) is widely used to prevent postoperative pulmonary complications, despite limited clinical effectiveness data and a lack of standardized use protocols. We sought to evaluate health care professionals' perspectives on IS effectiveness and use procedures. METHODS: An online survey was distributed via social media and newsletters to relevant national nursing and respiratory care societies. Attitudes concerning IS were compared between the American Association for Respiratory Care (AARC) and the nursing societies. RESULTS: A total of 1,681 responses (83.8% completion rate) were received. The clear majority of these respondents agreed that IS is essential to patient care (92.7%), improves pulmonary function (92.0%), improves inspiratory capacity (93.0%), helps to prevent (96.6%) and to reverse (90.0%) atelectasis, helps to prevent (92.5%) and to reverse (68.4%) pneumonia, and is as effective as early ambulation (74.0%), deep-breathing exercises (88.2%), and directed coughing (79.8%). Furthermore, most health care professionals believed that IS should be used routinely preoperatively (78.1%) and postoperatively (91.1%), used every hour (59.8%), used for an average of 9.6 (95% CI 9.3-9.9) breaths per session, used to achieve breath holds of 7.8 (95% CI 7.4-8.2) s, used to reach an initial target inspiratory volume of 1,288.5 (95% CI 1,253.8-1,323.2) mL, and used to achieve a daily inspiratory volume improvement of 525.6 (95% CI 489.8-561.4) mL. Of all respondents, 89.6% believed they received adequate IS education and training. Respondents from the AARC endorsed significantly less agreement relative to the nursing societies on most parameters for IS utility. CONCLUSIONS: There was a major discrepancy between health care professionals' beliefs and the published clinical effectiveness data supporting IS. Despite reported adequate education on IS, variability in what health care professionals believed to be appropriate use underscores the literature's lack of standardization and evidence for specific use procedures.

Incentive Spirometry Adherence: A National Survey of Provider Perspectives.

BACKGROUND: Patient adherence is a critical factor for success of patient-administered therapies, including incentive spirometry (IS). Patient adherence with IS is not known, so we sought to evaluate providers' perspectives on the current state of IS adherence and elucidate possible factors hindering patient adherence. METHODS: Respiratory therapists (RTs) and nurses across the United States were surveyed via social media and online newsletters. Surveys were distributed to the relevant national RT and nursing societies: the American Association for Respiratory Care, the Academy of Medical-Surgical Nurses, the American Society of Peri-Anesthesia Nurses, and the American Association of Critical-Care Nurses. RESULTS: Responses from 1,681 (83.8% completion rate) RTs and nurses were received. The clear majority of all providers agreed that patient adherence is poor (86.0%; 1,416 of 1,647 respondents) and should be improved (95.4%; 1,551 of 1,626 respondents). Providers believe that IS adherence is hindered by various factors. The most common reasons cited were that patients forget to use their ISs (83.5%; 1,404 of 1,681 respondents), do not use them effectively (74.4%; 1,251 of 1,681 respondents), and do not use them frequently enough (70.7%; 1,188 of 1,681 respondents). CONCLUSIONS: These findings from a large national survey of health care providers highlight the need for improved IS adherence and indicate that patient forgetfulness may be a large contributor to nonadherence. Efforts aimed at improving IS adherence are warranted.