Escalation of Commitment in the Surgical ICU.

OBJECTIVES: Escalation of commitment is a business term that describes the continued investment of resources into a project even after there is objective evidence of the project's impending failure. Escalation of commitment may be a contributor to high healthcare costs associated with critically ill patients as it has been shown that, despite almost certain futility, most ICU costs are incurred in the last week of life. Our objective was to determine if escalation of commitment occurs in healthcare settings, specifically in the surgical ICU. We hypothesize that factors previously identified in business and organizational psychology literature including self-justification, accountability, sunk costs, and cognitive dissonance result in escalation of commitment behavior in the surgical ICU setting resulting in increased utilization of resources and cost. DESIGN: A descriptive case study that illustrates common ICU narratives in which escalation of commitment can occur. In addition, we describe factors that are thought to contribute to escalation of commitment behaviors. MAIN RESULTS: Escalation of commitment behavior was observed with self-justification, accountability, and cognitive dissonance accounting for the majority of the behavior. Unlike in business decisions, sunk costs was not as evident. In addition, modulating factors such as personality, individual experience, culture, and gender were identified as contributors to escalation of commitment. CONCLUSIONS: Escalation of commitment occurs in the surgical ICU, resulting in significant expenditure of resources despite a predicted and often known poor outcome. Recognition of this phenomenon may lead to actions aimed at more rational decision making and may contribute to lowering healthcare costs. Investigation of objective measures that can help aid decision making in the surgical ICU is warranted.

Utility of the shock index in predicting mortality in traumatically injured patients.

BACKGROUND: Currently, specific triage criteria, such as blood pressure, respiratory status, Glasgow Coma Scale, and mechanism of injury are used to categorize trauma patients and prioritize emergency department (ED) and trauma team responses. It has been demonstrated in previous literature that an abnormal shock index (SI = heart rate [HR]/systolic blood pressure, >0.9) portends a worse outcome in critically ill patients. Our study looked to evaluate the SI calculated in the field, on arrival to the ED, and the change between field and ED values as a simple and early marker to predict mortality in traumatically injured patients. METHODS: A retrospective chart review of the trauma registry of an urban level I trauma center. Analysis of 2,445 patients admitted over 5 years with records in the trauma registry of which 1,166 also had data for the field SI. An increase in SI from the field to the ED was defined as any increase in SI regardless of the level of the magnitude of change. RESULTS: Twenty-two percent of patients reviewed had an ED SI >0.9, with a mortality rate of 15.9% compared with 6.3% in patients with a normal ED SI. An increase in SI between the field and ED signaled a mortality rate of 9.3% versus 5.7% for patients with decreasing or unchanged SI. Patients with an increase in SI of >or=0.3 had a mortality rate of 27.6% versus 5.8% for patients with change in SI of <0.3. CONCLUSION: Trauma patients with SI >0.9 have higher mortality rates. An increase in SI from the field to the ED may predict higher mortality. The SI may be a valuable addition to other ED triage criteria currently used to activate trauma team responses.

Identifying and Eliminating Deficiencies in the General Surgery Resident Core Competency Curriculum.

IMPORTANCE: Although the Accreditation Council for Graduate Medical Education has defined 6 core competencies required of resident education, no consensus exists on best practices for reaching resident proficiency. Surgery programs must develop resourceful methods to incorporate learning. While patient care and medical knowledge are approached with formal didactics and traditional Halstedian educational formats, other core competencies are presumed to be learned on the job or emphasized in conferences. OBJECTIVES: To test the hypothesis that our residents lack a foundation in several of the nonclinical core competencies and to seek to develop a formal curriculum that can be integrated into our current didactic time, with minimal effect on resident work hours and rest hours. DESIGN, SETTING, AND PARTICIPANTS: Anonymous Likert-type scale needs assessment survey requesting residents within a large single general surgery residency program to rate their understanding, working knowledge, or level of comfort on the following 10 topics: negotiation and conflict resolution; leadership styles; health care legislation; principles of quality delivery of care, patient safety, and performance improvement; business of medicine; clinical practice models; role of advocacy in health care policy and government; personal finance management; team building; and roles of innovation and technology in health care delivery. MAIN OUTCOMES AND MEASURES: Proportions of resident responses scored as positive (agree or strongly agree) or negative (disagree or strongly disagree). RESULTS: In total, 48 surgery residents (70%) responded to the survey. Only 3 topics (leadership styles, team building, and roles of innovation and technology in health care delivery) had greater than 70% positive responses, while 2 topics (negotiation and conflict resolution and principles of quality delivery of care, patient safety, and performance improvement) had greater than 60% positive responses. The remaining topics had less than 40% positive responses, with the least positive responses on the topics business of medicine (13% [6 of 48]) and health care legislation (19% [9 of 48]). CONCLUSIONS AND RELEVANCE: General surgery residents in our program do not report being knowledgeable or comfortable with several areas of the nonclinical Accreditation Council for Graduate Medical Education core competencies. We developed a formal health care policy and management curriculum, with integration into preexisting protected surgical didactic time. This curriculum fulfills educational requirements, without negatively affecting resident work hours and without increased expense to the department of surgery. Future studies measuring the effect of this integrated program on resident education, knowledge, and satisfaction are warranted.

Mandated self-reporting of ventilator-associated pneumonia bundle and catheter-related bloodstream infection bundle compliance and infection rates.

IMPORTANCE: As quality measures increasingly become tied to payment, evaluating the most effective ways to provide high-quality care becomes more important. OBJECTIVES: To determine whether mandated reporting for ventilator and catheter bundle compliance is correlated with decreased infection rates, and to determine whether labor-intensive audits are correlated with compliance. DESIGN, SETTING, AND PARTICIPANTS: Multiyear retrospective review of aggregated data from all patients admitted to 15 intensive care units in a Veterans Affairs hospital setting (the Veterans Integrated Service Network 16) from 2009 to 2011. EXPOSURES: Ventilator-associated pneumonia and catheter-related bloodstream infections. MAIN OUTCOMES AND MEASURES: Mean rates of ventilator-associated pneumonia and catheter-related bloodstream infection were analyzed by year. Relationships between infection rates, self-reported compliance, and audits were analyzed by Pearson correlation. RESULTS: During the study period, ventilator-associated pneumonia decreased from 2.50 to 1.60 infections per 1000 ventilator days (P = .07). The rate of pneumonia was not correlated with self-reported compliance overall (R = 0.19) or by individual year (2009, R = 0.30; 2010, R = 0.24; 2011, R = 0.46); there was a correlation in cardiac intensive care units (R = -0.70) but not other types of intensive care units (mixed, R = -0.18; medical, R = 0.42; surgical, R = 0.34). Catheter-related bloodstream infections decreased from 2.38 to 0.73 infections per 1000 catheter days (P = .04). The rate of catheter infection was not correlated with self-reported compliance overall (R = -0.18), by individual year (2009, R = -0.39; 2010, R = -0.42; 2011, R = 0.37), or by intensive care unit type (mixed, R = -0.19; cardiac, R = 0.55; medical, R = 0.17; surgical, R = -0.44). CONCLUSIONS AND RELEVANCE: Current mandated self-reported compliance and audit measures are poorly correlated with decreased ventilator-associated pneumonia or catheter-related bloodstream infection.

Defining, measuring, and improving surgical quality: beyond teamwork and checklists to systems redesign and transformation.

BACKGROUND: Surgical complications are multifactorial but often are attributable to deficiencies in the quality of care. This review examines how quality is defined in surgery, the modalities employed to measure quality, and the approaches to improving the quality of surgical care. Beyond developing a hospital environment supportive of organizational learning, the next generation of surgical performance improvement will include broader, more innovative approaches. These ideas will create partnerships among patients, clinicians, industry, the arts, hospital leaders, and other sectors to look for ways to reinvent the system rather than simply to make a better hospital. METHODS: Review of pertinent English-language literature on surgical quality, definitions of quality, quality measures, performance improvement, and organizational learning in health care. RESULTS: Medical care should be safe, effective, patient-centered, timely, efficient, and equitable, as defined by the Institute of Medicine core values for health care quality. There is substantive lack of agreement as to how to measure the quality of care. Although the goal of each measurement system is to give patients the ability to compare hospitals nationally, most of the methodologies measure widely different aspects of hospital care, resulting in conflicting illustrations of institutional performance and confounded decision making for patients and for purchasers of healthcare services and insurance. CONCLUSIONS: The best pathway for surgical quality and performance improvement includes the application of systems engineering and innovation to determine ways to do better what we do currently, and to improve the present system while developing ideas for better delivery of high-quality care in the future.

Improving antibiotic stewardship: order set implementation to improve prophylactic antimicrobial prescribing in the outpatient surgical setting.

In the landmark document Crossing the Quality Chasm, the Institute of Medicine lists 6 aims of healthcare, one of which is that healthcare has to be effective. One means of improving the effectiveness of healthcare includes the creation of evidence-based guidelines to help streamline processes, decrease variability in care, and improve outcomes. Postoperative infection constitutes one of the most common preventable complications for surgical patients. The practice of administering perioperative antibiotics is currently being examined to determine the most effective approach to decrease the incidence of surgical site infections, improve resource utilization, and meet Surgical Care Improvement Project (SCIP) mandates. We utilized a tailored antibiotic prophylaxis form to help standardize perioperative antimicrobial use. The form was modified by a multidisciplinary antibiotic committee as new published clinical evidence or new SCIP guidelines were produced. We demonstrated a more than 90% compliance with SCIP core measures and significantly decreased the variability of antibiotic-ordering practices within our institution. Pharmacy savings are estimated at $8500 per year on surgical prophylaxis using the most commonly prescribed antimicrobials. Compliance with timely (within 1 hour prior to incision) antimicrobial administration is more than 90% but remains with high variability. Improvement in documentation may decrease the perceived inconsistencies in timing. Our results demonstrate that a multidisciplinary approach to managing perioperative prophylactic antimicrobial can be effective in decreasing clinical variability and costs of perioperative care, while increasing compliance with national mandates for antibiotic prescribing.

Survival Following Rectal Impalement through the Pelvic, Abdominal, and Thoracic Cavities: A Case Report.

Impalement injuries are a unique form of penetrating trauma and are typically associated with a fall onto the object (Steele, 2006). We present the case of a 45-year-old man who reportedly slipped in his bathtub and fell onto a broomstick. Radiographic examination revealed a slender mass extending from his rectum to the right side of his neck. A review of English literature suggests that this is the second reported case in the last 100 years describing the successful management of an impalement injury traversing the pelvic, abdominal, and thoracic cavities. The management of this case is described.