Intraoperative MRI in trans-sphenoidal surgery using frameless stereotaxis.

BACKGROUND: Intraoperative magnetic resonance imaging (iMRI) has been used for pituitary surgery for approximately 20 years. The introduction of frameless stereotaxis allows efficient navigation for both the ENT and neurosurgeon. This allows flexibility in placement of the patients head to facilitate resection, efficient use of theater time and improves the safety profile of the operation. This is the first study to describe and investigate the use of frameless stereotaxis in conjunction with iMRI. METHODS: Consecutive patients who underwent iMRI guided trans-sphenoidal debulking using frameless stereotaxis over a 3-year period, from January 2016 to June 2019, were included in this case series and reviewed retrospectively. The use of AxiEM (Medtronic, USA) tracker facilitated frameless stereotaxis in conjunction with iMRI for trans-sphenoidal debulking of sellar lesions based on the "twin-operating" model. RESULTS: The cohort of 47 patients had a mean age of 55 years with a slight female predilection. The average lesion size measured 20 mm (3-46 mm) in maximal diameter with objective evidence of visual deterioration being the most common indication to consider surgery. The use of iMRI identified two patients with suboptimal decompression facilitating further resection in the same anesthetic and one hemorrhagic complication requiring evacuation and hemostasis to reduce postoperative morbidity. CONCLUSION: This study describes the procedural nuances in the use of frameless stereotaxis for iMRI in transsphenoidal surgery to further reduce morbidity and improve outcomes, as well as improving theater utilization and reducing cost.

Characterising the nature of clinical incidents reported across a tertiary health service: a retrospective audit.

Objective Reducing the number of adverse patient safety incidents (PSIs) requires careful monitoring and active management processes. However, there is limited information about the association between hospital settings and the type of PSI. The aims of this study were to describe the severity, nature and characteristics of PSIs from an analysis of their incidence and to assess the relationships between the type of PSI and its setting. Methods A retrospective audit of a clinical incident management system database was conducted for a tertiary health service in Australia with 620000 residents. Records of PSIs reported for patients between 1 July 2017 and 30 June 2018 with Safety Assessment Codes (SAC) of PSIs were extracted from the clinical incident management system and analysed using descriptive and inferential statistics. PSIs involving paediatrics, mental health and primary care were excluded. Results In all, 4385 eligible PSIs were analysed: 24 SAC1, 107 SAC2 and 4254 SAC3 incidents. Across reported PSIs, the most common incidents related to skin injury (28.6%), medication (23.2%), falls (19.9%) and clinical process (8.5%). Falls were reported significantly more often in the medical division (χ2=43.85, P<0.001), whereas skin injury incidents were reported significantly more often in the surgical division (χ2=22.56, P<0.001). Conclusions A better understanding of the nature of PSIs and where they occur may lead to more targeted quality improvement strategies. What is known about this topic? Improving patient safety requires effective safety learning systems, which include incident reporting and management processes. Although incident reporting systems typically underestimate the incidence of iatrogenic harm, they do provide valuable opportunities to improve the future safety of health care. What does this paper add? This study reports the extent and severity of different types of PSIs that typically occur in a large tertiary hospital in Australia. The most common types of incidents are skin injury, falls, medication errors and clinical process. There are empirical associations between the type of PSI and clinical division (medical, surgical). What are the implications for practitioners? A greater understanding of the types of PSI and the settings in which they occur may inform the development of more targeted quality improvement strategies that potentially reduce their incidence.

An Australian Response to the COVID-19 Pandemic and Its Implications on the Practice of Neurosurgery.

OBJECTIVE: This study was designed to assess the impact of public health policy in Australia in response to the coronavirus disease identified in 2019 (COVID-19) pandemic on the delivery of neurosurgical services. Being essential services, we postulated that there would not be a decrease in elective and emergency neurosurgical presentations and surgeries. METHODS: This is a prospective, observational, epidemiologic study in strict adherence to the "STROBE" (Strengthening The Reporting of OBservational studies in Epidemiology) guidelines. It is a cross-sectional, multicentric study involving 5 tertiary neurosurgical centers to capture all public neurosurgical admissions in Queensland during the past 3 months (February-April, 2020) of significant public health policy changes to combat COVID-19. RESULTS: An analysis of the 1298 admissions for the Queensland population of 5.07 million Australians demonstrated a decrease in the number of elective and emergency admissions. The decline in elective admissions, particularly degenerative spine, benign neoplasms, and vascular pathologies, was a direct response of government strategy to curb activity to urgent surgical interventions only. Moreover, a trend toward fewer emergency admissions was also noted, partly explained by less trauma and also a decline in vascular pathologies including subarachnoid hemorrhage. CONCLUSIONS: In comparison with Europe and North America, this study demonstrates the impact of proactive public health measures in Australia that successfully flattened the COVID-19 curve while facilitating ongoing care of acutely unwell neurosurgical patients.

Evaluation of a patient safety programme on Surgical Safety Checklist Compliance: a prospective longitudinal study.

BACKGROUND: Surgical Safety Checklists (SSC) have been implemented widely across 132 countries since 2008. Yet, despite associated reductions in postoperative complications and death rates, implementation of checklists in surgery remains a challenge. The aim of this study was to assess the impact of a patient safety programme over time on SSC use and incidence of clinical errors. DESIGN: A prospective longitudinal design over three time points and a retrospective secondary analysis of clinical incident data was undertaken. METHODS: We implemented a patient safety programme over 4 weeks to improve surgical teams' use of the SSC. We undertook structured observations to assess surgical teams' checklist use before and after programme implementation and conducted a retrospective audit of clinical incident data 12 months before and 12 months following implementation of the programme. RESULTS: There were significant improvements in the observed use of the SSC across all phases, particularly in sign-out where completion rates ranged from 79.3% to 94.5% (p<0.0001) following programme implementation. Across clinical incident audit periods, 33 019 surgical procedures were performed. Based on a subsample of 64 cases, clinical incidents occurred in 22/16 264 (0.13%) before implementation and 42/16 755 (0.25%) cases after implementation. The most predominant incident after programme implementation was inadequate tissue specimen labelling (23/42, 54.8%). Clinical incidents resulted in minimal or no harm to the patient. CONCLUSIONS: The benefit in using a surgical checklist lies in the potential to enhance team communications and the promotion of a team culture in which safety is the priority.

Using normalisation process theory to evaluate the implementation of a complex intervention to embed the surgical safety checklist.

BACKGROUND: The surgical Safety Checklist (SSC) was introduced in 2008 to improve teamwork and reduce the mortality and morbidity associated with surgery. Although mandated in many health care institutions around the world, challenges in implementation of the SSC continue. To use Normalisation Process Theory (NPT) to help understand how/why implementation of a complex intervention coined Pass The Baton (PTB) could help explain what facets of the Surgical Safety Checklist use led to its' integration in practice, while others were not. METHODS: A longitudinal multi-method study using survey and interviews was undertaken. Implementation of PTB involved; change champions, audit and feedback, education and prompts. Following implementation, surgical teams were surveyed using the NOrmalization MeAsure Development (NoMAD) and subsequently interviewed to explore the impact of PTB on their use of the checklist at 6 and 12 months respectively. Respondents' self-reported perceptions of implementation of PTB was explained using the four NPT constructs; coherence, cognitive participation, collective action, and reflexive monitoring. Survey data were analysed using descriptive statistics. Interview data were coded inductively and content analysed using a framework derived from NPT. RESULTS: The NoMAD survey response rate was 59/150 (39.3%). Many (45/59, 77.6%) survey respondents saw the value in PTB, while 50/59 (86.2%) would continue to use it; 45/59 (77.6%) believed that PTB could easily be integrated into existing workflows, and 48/59 (82.8%) thought that feedback could improve PTB in the future. A total of 8 interviews were completed with 26 surgical team members. Nurses and physicians held mixed views towards coherence while buy-in and participation relied on individuals' investment in the implementation process and the ability to modify PTB. Participants generally recognised the benefit and value of using PTB in the ongoing implementation the checklist. CONCLUSIONS: Workarounds and flexible co-construction in implementation designed to improve team communications in surgery may facilitate their normalisation in practice.

Three-year experience with interventional neuroradiology for management of cerebral aneurysms at a single Australian centre.

INTRODUCTION: Over the last decade interventional neuroradiology (NR) has become the mainstay of managing cerebral aneurysms. The aim of our study was to review our growing experiences with interventional NR and quantify morbidity and mortality associated with these procedures. METHODS: The electronic medical records of all patients admitted to the Gold Coast (University) Hospital Intensive Care Unit following subarachnoid haemorrhage (SAH) or elective interventional NR management of cerebral aneurysms between January 2012 and December 2014 were retrieved. Primary outcomes of interest were death, thromboembolic and haemorrhagic events during hospital admission. RESULTS: One hundred and fifty-two patients underwent interventional NR procedures for cerebral aneurysms. This consisted of 92 (60.5%) elective cases and 60 (39.5%) emergency cases following SAH. The all-cause mortality rate and the rate of thromboembolic and haemorrhagic events for the entire cohort were 5.9%, 11.2% and 7.2% respectively. Intra-procedural complications occurred in 6.6% of the entire cohort. Median length of follow-up was 448 days, with 91.6% of the entire cohort followed up. At follow-up, 64.1% of patients had no neurological deficits, 29% had mild non-specific deficits and 6.9% had significant disability. CONCLUSIONS: Interventional NR represents the primary treatment modality for all patients presenting to our service with cerebral aneurysm. Our results are encouraging and are comparable to published data in the international literature. Reducing the burden of thromboembolism in patients undergoing endovascular treatment of their aneurysmal disease is our main research focus currently, and we aim to improve outcomes for this patient group.

The floating anchored craniotomy.

BACKGROUND: The "floating anchored" craniotomy is a technique utilized at our tertiary neurosurgery institution in which a traditional decompressive craniectomy has been substituted for a floating craniotomy. The hypothesized advantages of this technique include adequate decompression, reduction in the intracranial pressure, obviating the need for a secondary cranioplasty, maintained bone protection, preventing the syndrome of the trephined, and a potential reduction in axonal stretching. METHODS: The bone plate is re-attached via multiple loosely affixed vicryl sutures, enabling decompression, but then ensuring the bone returns to its anatomical position once cerebral edema has subsided. RESULTS: From the analysis of 57 consecutive patients analyzed at our institution, we have found that the floating anchored craniotomy is comparable to decompressive craniectomy for intracranial pressure reduction and has some significant theoretical advantages. CONCLUSIONS: Despite the potential advantages of techniques that avoid the need for a second cranioplasty, they have not been widely adopted and have been omitted from trials examining the utility of decompressive surgery. This retrospective analysis of prospectively collected data suggests that the floating anchored craniotomy may be applicable instead of decompressive craniectomy.

Unlocking the "black box" of practice improvement strategies to implement surgical safety checklists: a process evaluation.

BACKGROUND: Compliance with surgical safety checklists (SSCs) has been associated with improvements in clinical processes such as antibiotic use, correct site marking, and overall safety processes. Yet, proper execution has been difficult to achieve. OBJECTIVES: The objective of this study was to undertake a process evaluation of four knowledge translation (KT) strategies used to implement the Pass the Baton (PTB) intervention which was designed to improve utilization of the SSC. METHODS: As part of the process evaluation, a logic model was generated to explain which KT strategies worked well (or less well) in the operating rooms of a tertiary referral hospital in Queensland, Australia. The KT strategies implemented included change champions/opinion leaders, education, audit and feedback, and reminders. In evaluating the implementation of these strategies, this study considered context, intervention and underpinning assumptions, implementation, and mechanism of impact. Observational and interview data were collected to assess implementation of the KT strategies relative to fidelity, feasibility, and acceptability. RESULTS: Findings from 35 structured observations and 15 interviews with 96 intervention participants suggest that all of the KT strategies were consistently implemented. Of the 220 staff working in the department, that is, nurses, anesthetists, and surgeons, 160 (72.7%) knew about the PTB strategies. Qualitative analysis revealed that implementation was generally feasible and acceptable. A barrier to feasibility was physician engagement. An impediment to acceptability was participants' skepticism about the ability of the KT strategies to effect behavioral change. CONCLUSION: Overall, results of this evaluation suggest that success of implementation was moderate. Given the probable impact of contextual factors, that is, team culture and the characteristics of participants, the KT strategies may need modification prior to widespread implementation.

Factors that drive team participation in surgical safety checks: a prospective study.

BACKGROUND: Team-based group communications using checklists are widely advocated to achieve shared understandings and improve patient safety. Despite the positive effect checklists have on collaborations and reduced postoperative complications, their use has not been straightforward. Previous research has described contextual factors that impact on the implementation of checklists, however there is limited understanding of the issues that impede team participation in checklist use in surgery. The aim of this prospective study was to identify and describe factors that drive team participation in safety checks in surgery. METHODS: We observed ten surgical teams and conducted 33 semi-structured interviews with 70 participants from nursing, surgery and anaesthetics, and the community. Constant comparative methods were used to analyse textual data derived from field notes and interviews. Observational and interview data were collected during 2014-15. RESULTS: Analysis of the textual data generated from the field notes and interviews revealed the extent to which members of the surgical team participated in using the surgical safety checklist during each phase of patient care. These three categories included: 'using the checklist'; 'working independently'; and, 'communicating checks with others'. The phases in the checking process most vulnerable to information loss or omission were sign in and sign out. CONCLUSIONS: Team participation in safety checks depends on a convergence of intertwined factors; namely, team attributes, communication strategies and checking processes. A whole-of-team approach to participation in surgical safety checks is far more complex when considering the factors that drive participation. Strategies to increase participation in safety checks need to target professional communication practices and work processes such as workflow which curtail team members' ability to participate.

Impact of workflow on the use of the Surgical Safety Checklist: a qualitative study.

BACKGROUND: Regardless of the benefits associated of the Surgical Safety Checklist, adherence across its three phases remains inconsistent. The aim of this study was to systematically identify issues around workflow that impact on surgical teams' ability to use the Surgical Safety Checklist in a large tertiary facility in Queensland, Australia. METHOD: Observational audit of 10 surgical teams and 33 semi-structured interviews with 70 participants from nursing, medicine and the community were conducted. Data were collected during 2014-2015. Inductive and deductive approaches were used to analyse field observations and interview transcripts. RESULTS: The domain, impact of workflow on checklist utilization, was identified. Within this domain, seven categories illustrated the causal conditions which determined the ways in which workflow influenced checklist use. These categories included: 'busy doing the task'; 'clashing task priorities'; 'being pressured, running out of time'; 'adapting processes to work patterns'; 'doubling up on work'; 'a domino effect, leading to delays' and 'reality of the workflow'. CONCLUSIONS: One of the greatest systemic challenges to checklist use in surgery is workflow. Process changes in the way that surgical safety checklists are used need to incorporate the temporal demands of the workflow. Any changes made must ensure the process is reliable, is easily embedded into existing work routines and is not disruptive.

Integrated genomic and transcriptomic analysis of human brain metastases identifies alterations of potential clinical significance.

Treatment options for patients with brain metastases (BMs) have limited efficacy and the mortality rate is virtually 100%. Targeted therapy is critically under-utilized, and our understanding of mechanisms underpinning metastatic outgrowth in the brain is limited. To address these deficiencies, we investigated the genomic and transcriptomic landscapes of 36 BMs from breast, lung, melanoma and oesophageal cancers, using DNA copy-number analysis and exome- and RNA-sequencing. The key findings were as follows. (a) Identification of novel candidates with possible roles in BM development, including the significantly mutated genes DSC2, ST7, PIK3R1 and SMC5, and the DNA repair, ERBB-HER signalling, axon guidance and protein kinase-A signalling pathways. (b) Mutational signature analysis was applied to successfully identify the primary cancer type for two BMs with unknown origins. (c) Actionable genomic alterations were identified in 31/36 BMs (86%); in one case we retrospectively identified ERBB2 amplification representing apparent HER2 status conversion, then confirmed progressive enrichment for HER2-positivity across four consecutive metastatic deposits by IHC and SISH, resulting in the deployment of HER2-targeted therapy for the patient. (d) In the ERBB/HER pathway, ERBB2 expression correlated with ERBB3 (r(2) = 0.496; p < 0.0001) and HER3 and HER4 were frequently activated in an independent cohort of 167 archival BM from seven primary cancer types: 57.6% and 52.6% of cases were phospho-HER3(Y1222) or phospho-HER4(Y1162) membrane-positive, respectively. The HER3 ligands NRG1/2 were barely detectable by RNAseq, with NRG1 (8p12) genomic loss in 63.6% breast cancer-BMs, suggesting a microenvironmental source of ligand. In summary, this is the first study to characterize the genomic landscapes of BM. The data revealed novel candidates, potential clinical applications for genomic profiling of resectable BMs, and highlighted the possibility of therapeutically targeting HER3, which is broadly over-expressed and activated in BMs, independent of primary site and systemic therapy.