Blue Ribbon Committee I Review: Findings and Impact.

OBJECTIVE: Review the subsequent impact of recommendations made by the 2004 American Surgical Association Blue Ribbon Committee (BRC I) Report on Surgical Education. BACKGROUND: Current leaders of the American College of Surgeons and the American Surgical Association convened an expert panel to review the impact of the BRC I report and make recommendations for future improvements in surgical education. METHODS: BRC I members reviewed the 2004 recommendations in light of the current status of surgical education. RESULTS: Some of the recommendations of BRC I have gained traction and have been implemented. There is a well-organized national curriculum and numerous educational offerings. There has been greater emphasis on preparing faculty to teach and there are ample opportunities for professional advancement as an educator. The number of residents has grown, although not at a pace to meet the country's needs either by total number or geographic distribution. The number of women in the profession has increased. There is greater awareness and attention to resident (and faculty) well-being. The anticipated radical change in the educational scheme has not been adopted. Training in surgical research still depends on the resources and interests of individual programs. Financing student and graduate medical education remains a challenge. CONCLUSIONS: The medical landscape has changed considerably since BRC I published its findings in 2005. A contemporary assessment of surgical education and training is needed to meet the future needs of the profession and our patients.

Hospital-level Variation in Secondary Complications After Surgery.

OBJECTIVES: To assess whether hospital rates of secondary complications could serve as a performance benchmark and examine associations with mortality. BACKGROUND: Failure to rescue (death after postoperative complication) is a challenging target for quality improvement. Secondary complications (complications after a first or "index" complication) are intermediate outcomes in the rescue process that may provide specific improvement targets and give us insight into how rescue fails. METHODS: We used American College of Surgeons' National Surgical Quality Improvement Program data (2008-2012) to define hospital rates of secondary complications after 5 common index complications: pneumonia, surgical site infection (SSI), urinary tract infection, transfusion/bleed events, and acute myocardial infarction (MI). Hospitals were divided into quintiles on the basis of risk- and reliability-adjusted rates of secondary complications, and these rates were compared along with mortality. RESULTS: A total of 524,860 patients were identified undergoing one of the 62 elective, inpatient operations. After index pneumonia, secondary complication rates varied from 57.99% in the highest quintile to 22.93% in the lowest [adjusted odds ratio (OR), 4.64; confidence interval (CI), 3.95-5.45). Wide variation was seen after index SSI (58.98% vs 14.81%; OR, 8.53; CI, 7.41-9.83), urinary tract infection (38.41% vs 8.60%; OR, 7.81; CI, 6.48-9.40), transfusion/bleeding events (27.14% vs 12.88%; OR, 2.54; CI, 2.31-2.81), and acute MI (64.45% vs 23.86%, OR, 6.87; CI, 5.20-9.07). Hospitals in the highest quintile had significantly greater mortality after index pneumonia (10.41% vs 6.20%; OR, 2.17; CI, 1.6-2.94), index MI (18.25% vs 9.65%; OR, 2.67; CI, 1.80-3.94), and index SSI (2.75% vs 0.82%; OR, 3.93; CI, 2.26-6.81). CONCLUSIONS: Hospital-level rates of secondary complications (failure to arrest complications) vary widely, are associated with mortality, and may be useful for quality improvement and benchmarking.

Hospital variation in sphincter preservation for elderly rectal cancer patients.

BACKGROUND: The primary goal of an operation for rectal cancer is to cure cancer and, where possible, preserve continence. A wide range of sphincter preservation rates have been reported. This study evaluated hospital variation in the use of low anterior resection (LAR), local excision (LE), and abdominoperineal resection (APR) in the treatment of elderly rectal cancer patients. METHODS: Using Surveillance, Epidemiology, and End Results-Medicare linked data, we identified 4959 patients older than 65 y with stage I-III rectal cancer diagnosed from 2000-2005 who underwent operative intervention at one of 370 hospitals. We evaluated the distribution of hospital-specific procedure rates and used generalized mixed models with random hospital effects to examine the influence of patient characteristics and hospital on operation type, using APR as a reference. RESULTS: The median hospital performed APR on 33% of elderly patients with rectal cancer. Hospital was a stronger predictor of LAR receipt than any patient characteristic, explaining 32% of procedure choice, but not a strong predictor of LE, explaining only 3.8%. Receipt of LE was primarily related to tumor size and tumor stage, which combined explained 31% of procedure variation. CONCLUSIONS: Receipt of LE is primarily determined by patient characteristics. In contrast, the hospital where surgery is performed significantly influences whether a patient undergoes an LAR or APR. Understanding the factors that cause this institutional variation is crucial to ensuring equitable availability of sphincter preservation.

Protecting patients from an unsafe system: the etiology and recovery of intraoperative deviations in care.

OBJECTIVE: To understand the etiology and resolution of unanticipated events in the operating room (OR). BACKGROUND: The majority of surgical adverse events occur intraoperatively. The OR represents a complex, high-risk system. The influence of different human, team, and organizational/environmental factors on safety and performance is unknown. METHODS: We video-recorded and transcribed 10 high-acuity operations, representing 43.7 hours of patient care. Deviations, defined as delays and/or episodes of decreased patient safety, were identified by majority consensus of a multidisciplinary team. Factors that contributed to each event and/or mitigated its impact were determined and attributed to the patient, providers, or environment/organization. RESULTS: Thirty-three deviations (10 delays, 17 safety compromises, 6 both) occurred--with a mean of 1 every 79.4 minutes. These deviations were multifactorial (mean 3.1 factors). Problems with communication and organizational structure appeared repeatedly at the root of both types of deviations. Delays tended to be resolved with vigilance, communication, coordination, and cooperation, while mediation of safety compromises was most frequently accomplished with vigilance, leadership, communication, and/or coordination. The organization/environment was not found to play a direct role in compensation. CONCLUSIONS: Unanticipated events are common in the OR. Deviations result from poor organizational/environmental design and suboptimal team dynamics, with caregivers compensating to avoid patient harm. Although recognized in other high-risk domains, such human resilience has not yet been described in surgery and has major implications for the design of safety interventions.

Esophagectomy outcomes at low-volume hospitals: the association between systems characteristics and mortality.

OBJECTIVE: To evaluate the association between systems characteristics and esophagectomy mortality at low-volume hospitals BACKGROUND: High-volume hospitals have lower esophagectomy mortality rates, but receiving care at such centers is not always feasible. We examined low-volume hospitals and sought to identify characteristics of those with better outcomes. METHODS: Using national data from Medicare and the American Hospital Association, we studied 4498 elderly patients who underwent an esophagectomy from 2004 to 2007. We divided hospitals into terciles based on esophagectomy volume and examined characteristics of patients and hospitals (size, nurse ratios, and presence of advanced medical, surgical, and radiological services). Our primary outcome was mortality. We identified 5 potentially beneficial systems characteristics in our data set and used multivariable logistic regression to determine whether these characteristics were associated with lower mortality rates at low-volume hospitals. RESULTS: Of the 874 hospitals that performed esophagectomies, 83% (723) were low-volume hospitals whereas only 3% (25) were high-volume. Low-volume hospitals performed a median of 1 esophagectomy during the 4-year study period and cared for patients that were older, more likely to be minority, and more likely to have multiple comorbidities compared with high-volume centers. Low-volume hospitals that had at least 3 of 5 characteristics (high nurse ratios, lung transplantation services, complex medical oncology services, bariatric surgery services, and positron emission tomography scanners) had markedly lower mortality rates compared with low-volume hospitals with none of these characteristics (12.5% vs. 5.0%; P value = 0.042). CONCLUSIONS: Low-volume hospitals with certain systems characteristics seem to achieve better esophagectomy outcomes. A more comprehensive study of the beneficial characteristics of low-volume hospitals is warranted because high-volume hospitals are difficult to access for many patients.

A policy-based intervention for the reduction of communication breakdowns in inpatient surgical care: results from a Harvard surgical safety collaborative.

OBJECTIVE: To develop and evaluate an intervention to reduce breakdowns in communication during inpatient surgical care. BACKGROUND: Communication breakdowns are the second most common cause of avoidable surgical adverse events after technical errors. METHODS: In a pre- and postintervention study, a random selection of patients on the surgical services of 4 teaching hospitals were observed according to 3 measures: (1) resident-attending communication of critical patient events (eg, transfer into the intensive care unit, unplanned intubation, cardiac arrest); (2) resident-attending notification regarding routine weekend patient status; and (3) frequency of weekend patient visits by an attending. All departments then developed and adopted a set of policy and education initiatives designed to increase prompt and consistent resident-attending communication (especially in critical events) and to improve regular attending visits with surgical patients. Specific reinforcement of the policies included a pocket information card for residents, as well as periodic reminders. Repeat audits of the surgical services were then conducted. RESULTS: We reviewed information for 211 critical events and 1360 patients for the nature of resident and attending communication practices. After the intervention, the proportion of critical events not conveyed to an attending decreased from 33% (26/80) to 2% (1/47), and gaps in the frequency of attending notification of patient status on weekends were virtually eliminated (P < 0.0001); the proportion of weekend patients not visited by an attending for greater than 24 hours decreased by half (from 61% to 33%; P = 0.0002). Contact resulted in attending-led changes in patient management in one-third of cases. CONCLUSIONS: An intervention to improve surgical communication practices at 4 teaching hospitals led to significant reductions in potentially harmful communication breakdowns during inpatient care; significant alterations in patient management were noted in one-third of cases in which there was an adherence to recommended communication practices.

Communication practices on 4 Harvard surgical services: a surgical safety collaborative.

BACKGROUND: Communication breakdowns between surgical residents and attending physicians in the pre- and postoperative setting are common contributors to patient injury. These communication transactions might offer an opportunity for safety improvement, but it remains unknown how often resident-attending communication fails, what the current level of attending involvement is, and how often attending input changes the plan for patient care. We conducted a prospective study at 4 Harvard teaching hospitals to address these issues. METHODS: Three prospective data collection strategies were employed: (1) we randomly selected surgical services and queried residents for the occurrence of predefined critical patient events and the characteristics of attending communications that ensued, (2) on weekends, randomly selected patients were interviewed and their charts reviewed to identify the frequency of attending visitation and how such visits affected processes of care, and (3) on weekends, senior residents on randomly selected surgical services were queried regarding the occurrence of attending-resident discussion of patients in their care. RESULTS: Of 80 critical patient events identified, 26 (33%) were not communicated to attending surgeons. Residents reported that, when contacted, all attending physicians were receptive to communication, whether they were the primary surgeon or providing cross-coverage. Although residents felt that attending contact was unnecessary for safe patient care in 61 (76%) of these events, discussions with attending physicians changed management in 33% (18/54) of cases in which they occurred. Attending surgeons were found to visit their patients on randomly selected weekend days 42% (n = 37) of the time, while 21% (n = 19) had not visited for 2 or greater days. When attending physicians visited patients, however, resident management was modified 46% (n = 36) of the time. Though residents frequently discussed patient management with attending physicians on randomly selected weekends, they failed to do so 16% (n = 58) of the time, which appeared to be related to service-specific variation (chi = 269, P < 0.0001). CONCLUSIONS: In the context of both critical patient events and routine patient care, residents often fail to obtain attending surgeons' input for management decisions. These failures seem to derive more from residents' perception of necessity than from attending physicians' receptiveness or interest in being contacted. Once involved, attending physicians frequently modify resident's management decisions. It seems, therefore, that there is significant potential for communication failure and information loss among our 4 institutions.

The evolution of health care in America.

The evolution of health care in America had its beginnings even before the founding of the nation. This article divides the evolution of American health care into six historical periods: (1) the charitable era, (2) the origins of medical education era, (3) the insurance era, (4) the government era, (5) the managed care era, and (6) the consumerism era.

Pancreatic PEComa (sugar tumor): MDCT and EUS features.

CONTEXT: PEComas (tumors showing perivascular epithelioid cell differentiation) of the pancreas are exceedingly rare. CASE REPORT: We herein report on a 60-year-old female who noticed a bulge in her right upper quadrant while exercising. Subsequent multidetector-row CT scan showed a 3.5 cm well-defined, encapsulated, hypovascular, solid tumor in the body of the pancreas. Endoscopic ultrasound demonstrated a mixed hypo- and hyper-echoic, well-defined, heterogeneous tumor. CONCLUSIONS: Although three pancreatic PEComas (sugar tumors) have been described previously, to the best of our knowledge, this is the first report of a pancreatic PEComa with illustration of its multidetector-row CT and endoscopic ultrasound features in the radiological literature.

The role of perioperative hyperglycemia in postoperative infections.

In the past decade, convincing evidence has emerged that perioperative glycemic control in certain settings, especially cardiac surgery and the surgical ICU, can decrease morbidity and mortality. It remains unclear, however, if hypoglycemia is a cause of death or marker of patient acuity. It is clear, however, that the particular intensive glycemic control protocol matters because the rate of hypoglycemia varies across protocols and institutions. The best current evidence for tight control rests in the population of surgical patients needing more than 5 days of critical care. Many questions still remain, such as the optimum blood sugar or the best protocol to implement glucose control, minimizing hypoglycemia. Further information will become available from the Normogylcemia in Intensive Care Evaluation and Survival Using Glucose Algorithm Regulation trial, currently enrolling patients in a prospective randomized trial to answer some of these outstanding questions. Maintaining euglycemia postoperatively is a simple and actionable step that could decrease the risk of postoperative infections and postoperative mortality.

Race and surgical outcomes: it is not all black and white.

BACKGROUND: Studies using Medicare data have suggested that African American race is an independent predictor of death after major surgery. We hypothesized that the apparent adverse effect of race on surgical outcomes is due to confounding by comorbidity, not race itself. METHODS: We identified all non-Hispanic white and African American general surgery, private sector patients included in the National Surgery Quality Improvement Program (NSQIP) Patient Safety in Surgery Study (2001-2004). Patient characteristics, comorbidities, and postoperative outcomes were collected/analyzed using NSQIP methodology. Characteristics between races were compared using Student t and chi(2) tests. Odds ratios (OR) for 30-day morbidity and mortality were calculated using multivariable logistic regression. RESULTS: We identified 34,141 white and 5068 African American patients. African Americans were younger but more likely to undergo emergency surgery and present with hypertension, dyspnea, diabetes, renal failure, open wounds/infection, or advanced American Society of Anesthesiology class (all P < 0.001). African Americans underwent less complex procedures but had higher unadjusted 30-day morbidity (14.33% vs. 12.35%; P < 0.001) and mortality (2.09% vs. 1.65%; P = 0.02). After controlling for comorbidity, African American race had no independent effect on mortality (OR 0.95, (0.74-1.23)) but was associated with a higher risk of postoperative cardiac arrest (OR 2.49, (1.80-3.45)) and renal insufficiency/failure (OR 1.70 (1.32-2.18)). CONCLUSION: African American race is associated with greater comorbidity and cardiac/renal complications but is not an independent predictor of perioperative mortality after general surgery. Efforts to improve postoperative outcomes in African Americans should focus on reducing the need for emergency surgery and improving perioperative management of comorbid conditions.