Using an Electronic Perioperative Documentation Tool to Identify Returns to Operating Room (ROR) in a Tertiary Care Academic Medical Center.

BACKGROUND: The metric "Unplanned returns to operating room (ROR)" is being tracked in surgical quality dashboards; 70% of unplanned RORs may be related to surgical complications. With increasing regionalization of trauma and complex surgical care at tertiary care academic centers, it is unclear if a simple ROR metric is a valid assessment of surgical quality at such centers. METHOD: A real-time electronic tool was used to identify all RORs-planned and unplanned-in a high-volume, high-complexity academic surgical practice at Mayo Clinic-Rochester within 45 days of the index operation. Analysis by ROR type and indication was performed. RESULTS: During the analysis period (June 2014-February 2015) 44,031 operations were performed, with 5,552 subsequent RORs (13%). Of all RORs, 51% (n = 2,818) were planned staged returns, 29% (n = 1,589) were unrelated, 15% (n = 830) were unplanned and 6% (n = 315) were planned because of previous complications. Overall, unplanned reoperations were uncommon (n = 830, 2% of all operations). The most common indications for unplanned RORs included "other" (32%, n = 266), bleeding related (24%, n = 198) and wound complications (20%, n = 166). CONCLUSION: In a high-volume, high-complexity academic surgical practice, RORs occurred after 13% of cases. Unplanned returns were infrequent and usually were associated with complications; most RORs were planned staged or unrelated returns. A simple ROR metric that does not consider planned/unrelated returns is likely not a valid surgical quality measure. Electronic tools designed specifically to identify in real-time RORs, associated indication, and clinical validation should provide more reliable data for public reporting and quality improvement efforts.

Preoperative gabapentin for acute post-thoracotomy analgesia: a randomized, double-blinded, active placebo-controlled study.

BACKGROUND: The role of preoperative gabapentin in postoperative pain management is not clear, particularly in patients receiving regional blockade. Patients undergoing thoracotomy benefit from epidural analgesia but still may experience significant postoperative pain. We examined the effect of preoperative gabapentin in thoracotomy patients. METHODS: Adults undergoing elective thoracotomy were enrolled in this prospective, randomized, double-blinded, placebo-controlled study, and randomly assigned to receive 600 mg gabapentin or active placebo (12.5 mg diphenhydramine) orally within 2 hours preoperatively. Standardized management included thoracic epidural infusion, intravenous patient-controlled opioid analgesia, acetaminophen and ketorolac. Pain scores, opioid use and side effects were recorded for 48 hours. Pain was also assessed at 3 months. RESULTS: One hundred twenty patients (63 placebo and 57 gabapentin) were studied. Pain scores did not significantly differ at any time point (P = 0.53). Parenteral and oral opioid consumption was not significantly different between groups on postoperative day 1 or 2 (P > 0.05 in both cases). The frequency of side effects such as nausea and vomiting or respiratory depression was not significantly different between groups, but gabapentin was associated with decreased frequency of pruritus requiring nalbuphine (14% gabapentin vs. 43% control group, P < 0.001). The frequency of patients experiencing pain at 3 months post-thoracotomy was also comparable between groups (70% gabapentin vs. 66% placebo group, P = 0.72). CONCLUSIONS: A single preoperative oral dose of gabapentin (600 mg) did not reduce pain scores or opioid consumption following elective thoracotomy, and did not confer any analgesic benefit in the setting of effective multimodal analgesia that included thoracic epidural infusion.

Chasing zero: the drive to eliminate surgical site infections.

OBJECTIVES: It is estimated that healthcare associated infections (HAI) account for 1.7 million infections and 99,000 associated deaths each year, with annual direct medical costs of up to $45 billion. Surgical Site Infections (SSI) account for 17% of HAIs, an estimated annual cost of $3.5 to 10 billion for our country alone. This project was designed to pursue elimination of SSIs and document results. METHODS: Starting in 2009 a program to eliminate SSIs was undertaken at a nationally recognized academic health center. Interventions already outlined by CMS and IHI were utilized, along with additional interventions based on literature showing relationships with SSI reduction and best practices. Rapid deployment of multiple interventions (SSI Bundle) was undertaken. Tactics included standardized order sets, a centralized preoperative evaluation (POE) clinic, high compliance with intraoperative interventions, and widespread monthly reporting of compliance and results. Data from 2008 to 2010 were collected and analyzed. RESULTS: Between May 1, 2008 and June 30, 2010, all patients with Class I and Class II wounds were tracked for SSIs. Baseline data (May-June 2008) was obtained showing a Class I surgical site infection rate of 1.78%, Class II of 2.82% (total surgical volume: 4160 cases). As of the second quarter 2010, those rates have dropped to 0.51% and 1.44%, respectively (P < 0.001 and P = 0.013; total surgical cases: 2826). This represents a 57% decrease in the SSI rate with an estimated institution specific cost savings of nearly $1 million during the study period. CONCLUSION: Committed leadership, aggressive assurance of high compliance with multiple known interventions (SSI Bundle), transparency to achieve high levels of staff engagement, and centralization of critical surgical activities result in significant declines in SSIs with resulting substantial cost savings.

Getting the right training and job.

The authors discuss the factors to be considered in selecting locations in which to train and to practice, and in conducting successful interviews and site visits. The advantages and disadvantages of different types of surgical practice (ie, solo vs group) are also reviewed, as are issues surrounding negotiations related to contracts, benefits, and covenants.

Using a data-matrix-coded sponge counting system across a surgical practice: impact after 18 months.

BACKGROUND: Retained surgical items (RSIs), most commonly sponges, are infrequent. Yet despite sponge-counting standards, failure to maintain an accurate count is a common error. To improve counting performance, technology solutions have been developed. A data-matrix-coded sponge (DMS) system was evaluated and implemented in a high-volume academic surgical practice at Mayo Clinic Rochester (MCR). The primary end point was prevention of sponge RSIs after 18 months. METHODS: Two trials were conducted before implementation. A randomized-controlled trial assessed the system's function, efficiency, and ergonomics. The second, larger trial was conducted to validate the prior findings and test product improvements. After the trials, the system was implemented in all 128 operating/procedure rooms across the MCR campus on February 2, 2009. The institutionwide implementation was intended to avoid the possibility of having standard unmarked sponges and DMSs in the operating room suite concurrently. RESULTS: Before implementation, a retained sponge occurred on average every 64 days. Between February 2009 and July 2010, 87,404 procedures were performed, and 1,862,373 DMSs were used without an RSI (p < .001). After four cases, the average time to count a DMS decreased from 11 to 4 seconds. Total sponge counting time/operation increased without any increase in overall operative time. CONCLUSIONS: After 18 months, a DMS system eliminated sponge RSIs from a high-volume surgical practice. The DMS system caused no work-flow disruption or increases in case duration. Staff satisfaction was acceptable, with a high degree of trust in the system. The DMS system is a reliable and cost-effective technology that improves patient safety.

Genetic variants and risk of lung cancer in never smokers: a genome-wide association study.

BACKGROUND: Lung cancer in individuals who have never smoked tobacco products is an increasing medical and public-health issue. We aimed to unravel the genetic basis of lung cancer in never smokers. METHODS: We did a four-stage investigation. First, a genome-wide association study of single nucleotide polymorphisms (SNPs) was done with 754 never smokers (377 matched case-control pairs at Mayo Clinic, Rochester, MN, USA). Second, the top candidate SNPs from the first study were validated in two independent studies among 735 (MD Anderson Cancer Center, Houston, TX, USA) and 253 (Harvard University, Boston, MA, USA) never smokers. Third, further replication of the top SNP was done in 530 never smokers (UCLA, Los Angeles, CA, USA). Fourth, expression quantitative trait loci (eQTL) and gene-expression differences were analysed to further elucidate the causal relation between the validated SNPs and the risk of lung cancer in never smokers. FINDINGS: 44 top candidate SNPs were identified that might alter the risk of lung cancer in never smokers. rs2352028 at chromosome 13q31.3 was subsequently replicated with an additive genetic model in the four independent studies, with a combined odds ratio of 1.46 (95% CI 1.26-1.70, p=5.94x10(-6)). A cis eQTL analysis showed there was a strong correlation between genotypes of the replicated SNPs and the transcription level of the gene GPC5 in normal lung tissues (p=1.96x10(-4)), with the high-risk allele linked with lower expression. Additionally, the transcription level of GPC5 in normal lung tissue was twice that detected in matched lung adenocarcinoma tissue (p=6.75x10(-11)). INTERPRETATION: Genetic variants at 13q31.3 alter the expression of GPC5, and are associated with susceptibility to lung cancer in never smokers. Downregulation of GPC5 might contribute to the development of lung cancer in never smokers. FUNDING: US National Institutes of Health; Mayo Foundation.

Marital status and quality of life in patients with esophageal cancer or Barrett's esophagus: the mayo clinic esophageal adenocarcinoma and Barrett's esophagus registry study.

BACKGROUND: Patients with esophageal carcinoma (EC) report deficits in quality of life (QOL), depending on the extent of malignant disease and the goals of treatment at the time of QOL measurement. AIMS: To quantify the association of marital status and changes in QOL over time in patients with EC and patients with Barrett's esophagus (BE). METHODS: Eligible patients in the Mayo Clinic Esophageal Adenocarcinoma and Barrett's Esophagus Registry completed QOL assessments at baseline and approximately 1 year later. QOL was determined with a ten-point linear analog self-assessment scale evaluating overall QOL and 12 subscales. RESULTS: Overall, 489 BE patients and 212 EC patients were evaluated. Married EC patients reported higher baseline QOL in legal concerns (8.1 vs. 7.1; p = .04) and friend and family support (9.3 vs. 8.4; p = .02) than single EC patients. Over time, married EC patients had a decrease in pain frequency QOL compared to single EC patients (-0.9 vs. +0.6; p = .02), with other QOL measures being stable. Married BE patients showed higher social activity QOL at baseline than single BE patients (7.5 vs. 6.9; p = .02); QOL was stable over time between the marital status groups. CONCLUSIONS: Minor, but statistically significant, changes were reported regarding QOL in two categories at baseline and over time among married and single patients with EC. Minor differences may be present between married and single EC patients regarding spiritual QOL at baseline and in overall physical well-being QOL at baseline and over time, although these differences did not reach statistical significance.

Entrapment of a nasopharyngeal temperature probe: an unusual complication during an apparently uneventful elective revision laparoscopic Nissen fundoplication.

We report the first case of nasopharyngeal temperature probe entrapment during an apparently uneventful elective revision laparoscopic Nissen fundoplication that precipitated a continuous quality improvement project at our institution. We describe changes in our clinical practice that resulted from this occurrence and envision these modifications will have a positive influence on patient care.

A multidisciplinary team approach to retained foreign objects.

BACKGROUND: Retained foreign objects (RFOs) after surgical procedures are an infrequent but potentially devastating medical error. The Mayo Clinic, Rochester (MCR), undertook a quality improvement program to reduce the incidence of surgical RFOs. METHOD: A multidisciplinary, multiphase approach was initiated in 2005. The effort, led by surgical, nursing, and administrative institutional leaders, was divided into three phases. The first phase included a defect analysis and policy review. A detailed analysis of all RFOs (both true and near misses) was undertaken to identify patterns of failures unique to our institution and operating room culture. Simultaneously, a review of all relevant institutional policies was performed, with comprehensive revisions focusing on increased clarity and inter- and intrapolicy consistency. The second phase involved increasing awareness and communication among all operating room personnel, including surgeons, residents, nursing, and allied health staff. The education program included all-staff conferences, team training, simulation videos, and daily education reminders and in-room audits. Finally, a monitoring and control phase involved rapid leadership response teams to any events, enhanced staff communication, and policy reviews. RESULTS: When the program started, MCR was averaging a surgical RFO every 16 days. After the intervention, the average interval between RFO events increased to 69 days, a level of performance that has been sustained for more than two years. DISCUSSION: MCR experienced a significant and sustained reduction in the incidents of RFOs, attributed to the multidisciplinary nature of the initiative, the active engagement of institutional leadership, and use of the principles of enhanced communication between operating room staff members to improve operating room situational awareness.