A Retrospective Review of Serious Surgical Incidents in 5 Large UK Teaching Hospitals: A System-Based Approach.

OBJECTIVES: Surgical incidents are the most common serious patient safety incidents worldwide. We conducted a review of serious surgical incidents recorded in 5 large teaching hospitals located in one London NHS trust to identify possible contributing factors and propose recommendations for safer healthcare systems. METHODS: We searched the Datix system for all serious surgical incidents that occurred in any operating room, excluding critical care departments, and were recorded between October 2014 and December 2016. We used the London Protocol system analysis framework, which involved a 2-stage approach. A brief description of each incident was produced, and an expert panel analyzed these incidents to identify the most likely contributing factors and what changes should be recommended. RESULTS: One thousand fifty-one surgical incidents were recorded, 14 of which were categorized as "serious" with contributing factors relating to task, equipment and resources, teamwork, work environmental, and organizational and management. Operating room protocols were found to be unavailable, outdated, or not followed correctly in 8 incidents studied. The World Health Organization surgical safety checklist was not adhered to in 8 incidents, with the surgical and anesthetic team not informed about faulty equipment or product shortages before surgery. The lack of effective communication within multidisciplinary teams and inadequate medical staffing levels were perceived to have contributed. CONCLUSIONS: Multiple factors contributed to the occurrence of serious surgical incidents, many of which related to human failures and faulty equipment. The use of faulty equipment needs to be recognized as a major risk within departments and promptly addressed.

Support for Healthcare Professionals After Surgical Patient Safety Incidents: A Qualitative Descriptive Study in 5 Teaching Hospitals.

OBJECTIVE: Patient safety incidents can have a profound effect on healthcare professionals, with some experiencing emotional and psychological distress. This study explored the support medical and nonmedical operating room staff received after being involved in a surgical patient safety incident(s) in 5 UK teaching hospitals. METHODS: An invitation letter and information sheet were e-mailed to all medical and nonmedical operating room staff (N = 927) across the 5 sites. Semistructured interviews were arranged with a range of different healthcare professionals working in operating rooms across a wide variety of surgical specialities. Interviews were audio recorded, transcribed verbatim, and analyzed using an inductive thematic approach. RESULTS: We conducted 45 interviews with medical and nonmedical operating room staff, who emphasized the importance of receiving personalized support soon after the incident. Operating room staff described how the first "go to" people were their peers and reported feeling comforted when their peers empathized with their own experience(s). Other participants found it very difficult to seek support, perceiving it as a sign of weakness. Although family members played an important role in supporting second victims, some participants felt unable to discuss the incident with them, fearing that they might not understand. CONCLUSIONS: There should be clear support structures in place for operating room staff who have been involved in surgical incidents. Health organizations need to offer timely support to frontline staff after these incidents. Senior clinicians should be proactive in offering support to junior colleagues and empathize with their own experiences, thus shifting the competitive culture to one of openness and support.

Designing the Optimal Digital Health Intervention for Patients' Use Before and After Elective Orthopedic Surgery: Qualitative Study.

BACKGROUND: Health behavior changes made by patients during the perioperative period can impact the outcomes and success of elective surgeries. However, there remains a limited understanding of how best to support patients during this time, particularly through the use of digital health interventions. Recognizing and understanding the potential unmet needs of elective orthopedic surgery patients is central to motivating healthier behavior change, improving recovery, and optimizing overall surgical success in the short and long term. OBJECTIVE: The aim of this study is to explore patient perspectives on technology features that would help support them to change their lifestyle behaviors during the pre- and postoperative periods, and that could potentially maintain long-term healthy lifestyles following recovery. METHODS: Semistructured interviews with pre- and postoperative elective orthopedic patients were conducted between May and June 2020 using telephone and video call-based software. Patient perspectives on the use of digital technologies to complement current surgical care and support with lifestyle behavior changes were discussed. Interviews were audio recorded and transcribed verbatim. Reflexive thematic analysis enabled the development of themes from the data, with QSR NVivo software (version 12) facilitating data management. Ethical approval was obtained from the National Health Service Health Research Authority. RESULTS: A total of 18 participants were interviewed. Four themes were developed from the data regarding the design and functionality of digital technologies to best support the perioperative journey. These center around an intervention's ability to incorporate interactive, user-centered features; direct a descriptive and structured recovery; enable customizable, patient-controlled settings; and deliver both general and specific surgical advice in a timely manner. Interventions that are initiated preoperatively and continued postoperatively were perceived as beneficial. Interventions designed with personalized milestones were found to better guide patients through a structured recovery. Individualized tailoring of preparatory and recovery information was desired by patients with previously high levels of physical activity before surgery. The use of personalized progression-based exercises further encouraged physical recovery; game-like rewards and incentives were regarded as motivational for making and sustaining health behavior change. In-built video calling and messaging features offered connectivity with peers and clinicians for supported care delivery. CONCLUSIONS: Specific intervention design and functionality features can provide better, structured support for elective orthopedic patients across the entire surgical journey and beyond. This study provides much-needed evidence relating to the optimal design and timing of digital interventions for elective orthopedic surgical patients. Findings from this study suggest a desire for personalized perioperative care, in turn, supporting patients to make health behavior changes to optimize surgical success. These findings should be used to influence future co-design projects to enable the design and implementation of patient-focused, tailored, and targeted digital health technologies within modern health care settings.

Learning from safety incidents in high-reliability organizations: a systematic review of learning tools that could be adapted and used in healthcare.

OBJECTIVE: A high-reliability organization (HRO) is an organization that has sustained almost error-free performance, despite operating in hazardous conditions where the consequences of errors could be catastrophic. A number of tools and initiatives have been used within HROs to learn from safety incidents, some of which have the potential to be adapted and used in healthcare. We conducted a systematic review to identify any learning tools deemed to be effective that could be adapted and used by multidisciplinary teams in healthcare following a patient safety incident. METHODS: This review followed the Preferred Reporting Items for Systematic Reviews and MetaAnalyses for Protocols reporting guidelines and was registered with the PROSPERO (CRD42017071528). A search of databases was carried out in January 2021, from the date of their commencement. We conducted a search on electronic databases such as Web of Science, Science Direct, MEDLINE in Process Jan 1950-present, EMBASE Jan 1974-present, CINAHL 1982-present, PsycINFO 1967-present, Scopus and Google Scholar. We also searched the grey literature including reports from government agencies, relevant doctoral dissertations and conference proceedings. A customized data extraction form was used to capture pertinent information from included studies and Critical Appraisal Skills Programme tool to appraise on their quality. RESULTS: A total of 5921 articles were identified, with 964 duplicate articles removed and 4932 excluded at the title (4055), abstract (510) and full-text (367) stages. Twenty-five articles were included in the review. Learning tools identified included debriefing, simulation, crew resource management and reporting systems to disseminate safety messages. Debriefing involved deconstructing incidents using reflective questions, whilst simulation training involved asking staff to relive the event again by performing the task(s) in a role-play scenario. Crew resource management is a set of training procedures that focus on communication, leadership and decision-making. Sophisticated incident-reporting systems provide valuable information on hazards and were widely recommended as a way of disseminating key safety messages following safety incidents. These learning tools were found to have a positive impact on learning if conducted soon after the incident with efficient facilitation. CONCLUSION: Healthcare organizations should find ways to adapt to the learning tools or initiatives used in HROs following safety incidents. It is challenging to recommend any specific one as all learning tools have shown considerable promise. However, the way these tools or initiatives are implemented is critical, and so further work is needed to explore how to successfully embed them into healthcare organizations so that everyone at every level of the organization embraces them.

Digital Support for Patients Undergoing Bariatric Surgery: Narrative Review of the Roles and Challenges of Online Forums.

BACKGROUND: The internet has become an important medium within health care, giving patients the opportunity to search for information, guidance, and support to manage their health and well-being needs. Online forums and internet-based platforms appear to have changed the way many patients undergoing bariatric surgery view and engage with their health, before and after weight loss surgery. Given that significant health improvements result from sustained weight loss, ensuring patient adherence to recommended preoperative and postoperative guidance is critical for bariatric surgery success. In a patient cohort with high information needs preoperatively, and notoriously high attrition rates postoperatively, online forums may present an underutilized method of support. OBJECTIVE: The aim of this study was to conduct a narrative review focusing on the developing roles that online forums can play for patients with bariatric conditions preoperatively and postoperatively. METHODS: A literature search was conducted in October-November 2019 across 5 electronic databases: Scopus, EMBASE, PsycINFO, CINAHL, and MEDLINE. Qualitative or mixed methods studies were included if they evaluated patients undergoing bariatric surgery (or bariatric surgery health care professionals) engaging with, using, or analyzing online discussion forums or social media platforms. Using thematic analysis, themes were developed from coding patterns within the data to identify the roles and challenges of online forums for patients undergoing bariatric surgery. RESULTS: A total of 8 studies were included in this review, with 5 themes emerging around (1) managing expectations of a new life; (2) decision making and signposting; (3) supporting information seeking; (4) facilitating connectedness: peer-to-peer social and emotional support; and (5) enabling accessibility and connectivity with health care professionals. CONCLUSIONS: Online forums could offer one solution to improving postoperative success by supporting and motivating patients. Future research should consider how best to design and moderate online forums for maximal effectiveness and the sharing of accurate information. The surgical multidisciplinary team may consider recommendations of online peer-support networks to complement care for patients throughout their surgical journey.

Resource implications of robotic thoracic surgery: what are the wider issues?

The benefits of minimally invasive thoracic surgery are well documented when compared to the use of standard thoracotomy. Much controversy exists, however, regarding the resource implications when using robot-assisted thoracic surgery (RATS), especially when compared to video-assisted thoracoscopic surgery (VATS). Much of the costs attributed to a particular approach center around the frequency and severity of the complications that may arise. Little exists in the literature to appropriately compare and contrast the complication rate following either of the minimally invasive approaches. There is a suggestion that many conventional open surgeons are more readily persuaded to adopt a minimally invasive approach through the use of the robotic platform, therefore reducing the complication-related costs of standard thoracotomy by an increase in minimally invasive resection rates. Further gains may be made in the ability to perform more complex minimally invasive procedures via a RATS approach without recourse to open conversion when compared to VATS. As opportunities and competition increase in the commercial market place, it is reasonable to assume costs will fall and further savings will be made.

Sequential robotic-assisted lung resection with a subxiphoid utility incision.

For the past two years, the authors have used a subxiphoid utility incision for robot-assisted lobectomies. This approach prevents unnecessary rib pressure, offers a good angle of approach to the hilum, and allows specimen retrieval with minimal resistance. Robot-assisted lung resection is an established technique that facilitates postoperative recovery by minimizing operative trauma and postoperative pain. We believe the subxiphoid utility incision further enhances recovery and facilitates early repeat surgery. We present two cases of staged sequential robot-assisted anatomical lung resection using the same subxiphoid utility incision on each occasion.

Does the number of wires used to close a sternotomy have an impact on deep sternal wound infection?

OBJECTIVES: We studied the influence of the number of sternotomy mechanical fixation points on deep sternal wound infection (DSWI). METHODS: Between September 2007 and February 2011, 2672 patients underwent a standard peri-sternal wire closure following a median sternotomy for a first-time cardiac surgery. Data were collected during the study period. RESULTS: The mean age of the patients was 66 ± 11 and 1978 (74.0%) were male. The mean body mass index (BMI) was 28.9 ± 9.3 and the median of the logistic EuroSCORE was 3.14, with a range of 0.88-54.1. Postoperatively, 40 (1.5%) patients developed DSWI after 14 ± 6 days, of whom 39 (92.5%) had positive deep sternal wound specimen cultures, predominantly Staphylococci (62.5%). The risk of DSWI was significantly increased in patients in whom eight or fewer paired points of sternal wire fixation were used when compared with patients in whom nine or more paired points of fixation were used (P = 0.002). Preoperative myocardial infarction (P = 0.001), elevated BMI (P = 0.046), bilateral internal mammary artery harvest (P < 0.0001), postoperative hypoxia (P < 0.0001), sepsis (P = 0.019) and postoperative inotrope use (P = 0.007) significantly increased the risk of DSWI. CONCLUSIONS: DSWI is associated with hypoxia, ischaemia, sepsis and mechanical sternal instability. DSWI may be prevented by using nine or more paired fixation points when closing with standard peri-sternal wires.

What factors should we consider in deciding when to transfuse patients undergoing elective cardiac surgery?

Blood transfusion remains one of the commonest interventions carried out upon individuals undergoing cardiac surgery. Despite this, the scientific rationale on which to base this decision is limited. Currently, hemoglobin concentration is often used as the sole guide as to when a transfusion may be required. A fall in hemoglobin concentration is often assumed to be associated with a similar drop in red cell volume. A review was undertaken of all the relevant peer-reviewed literature to determine what factors we should consider when deciding to transfuse elective cardiac surgery patients. The large fluid load associated with cardiac surgery, primarily from the cardiopulmonary bypass circuit, may have a significant dilutional effect. In such a scenario, several interlinked protective mechanisms may ensure that tissue oxygenation is maintained, including a reduction in blood viscosity, a decrease in systemic afterload, and an increase in cardiac output. Furthermore, oxygen requirements during the initial perioperative phase are reduced because of the effect of general anesthesia and hypothermia during cardiopulmonary bypass. When deciding to transfuse, consideration should be given to red cell volume, circulatory status, and oxygen requirement. It is possible that such an all-encompassing approach would reduce the incidence of unnecessary, and potentially counterproductive, red cell transfusion in cardiac surgery.

A comparison of activated coagulation time-based techniques for anticoagulation during cardiac surgery with cardiopulmonary bypass.

OBJECTIVE: The inadequacy of heparinization during cardiopulmonary bypass (CPB) can lead to hemostatic activation with increases in postoperative blood loss and blood product requirements after cardiac surgery. Because activated coagulation time (ACT) measurements may not be accurate during CPB, the use of a heparin management system (HMS) has been advocated. This study compared the efficacy of a modified ACT-based system versus an HMS (Hepcon; Medtronic Inc, Minneapolis, MN) for CPB anticoagulation. DESIGN: Randomized controlled trial. SETTING: Regional cardiac surgery center. PARTICIPANTS: Adult elective cardiac surgical patients. INTERVENTIONS: Patients allocated to the HMS group (HC) received individualized heparin doses as indicated by the Hepcon system. Patients in the modified ACT group (C) received a standard weight-based heparin bolus with further doses as dictated by the ACT (Max-ACT, Helena Labs, Sunderland, UK). In addition, group C received supplemental heparin, independent of the ACT, as dictated by the volume of crystalloid added to the extracorporeal circuit. Outcome measures examined were hemostatic activation, postoperative chest tube loss, and blood product requirements. RESULTS: This study showed no significant difference in efficacy between the modified ACT and HMS heparinization strategies. Although the HC group received significantly greater amounts of heparin, this did not reduce hemostatic activation, postoperative blood loss, or transfusion requirements. CONCLUSION: ACT-based heparinization was found to be as efficacious as the Hepcon HMS system.

Oxygen delivery and hemoglobin concentration in cardiac surgery: when do we have enough?

For many years it has been assumed that patients undergoing cardiac surgery utilizing cardiopulmonary bypass accumulate an "oxygen debt" that requires a higher postoperative hemoglobin concentration for its reversal. Much of this evidence has now been discredited due to mathematical error with recent research suggesting critical levels of oxygen delivery are lower than previously thought. This article aims to explore the relationship between observed and critical oxygen delivery with an estimation of the minimal hemoglobin required. This was a single-center observational study. Nineteen adult elective cardiac surgery patients were recruited to participate with four subsequently excluded. Observed measurements of oxygen delivery were recorded and compared with calculated "critical" values adjusted for temperature. The hemoglobin value that represented critical oxygen delivery was compared with the observed value to identify any "hemoglobin reserve." At no perioperative time point did observed oxygen delivery or critical hemoglobin concentration significantly approach its corresponding critical value. Current transfusion practice in noncritically ill cardiac surgery patients may be considered excessive if systemic oxygen requirement is the sole parameter considered.

The effect of gain in total body water on haemoglobin concentration and body weight following cardiac surgery.

BACKGROUND: Haemodilution contributes to a low post-operative haemoglobin concentration in cardiac surgery patients. An assessment of the degree of haemodilution could contribute to the avoidance of red cell transfusion when such an act is based simply on a haemoglobin "transfusion trigger". We have recorded post-operative change in total body water along with body weight to assess the impact of haemodilution on haemoglobin concentration. METHODS: Total body water, measured by bio-electrical impedance analysis, haemoglobin and body weight were measured pre-operatively and on the 1st, 3rd, 5th and 10th post-operative days. The percentage peri-operative change in all three variables was used to examine the paired associations. RESULTS: Total body water and body weight underwent a fall from day 1, with both variables significantly associated up until day 10. Haemoglobin rose steadily from day 1 to 10. This rise was associated with falling total body water and body weight until day 5, but not from day 5 to 10. CONCLUSION: Following cardiac surgery, an individual's fluid state should be considered in determining a patient's need for red cell transfusion. Monitoring body weight provides a simple estimate. Such an approach may reduce the incidence of unnecessary, and potentially counterproductive, transfusion in cardiac surgery patients.

Perioperative red cell, plasma, and blood volume change in patients undergoing cardiac surgery.

BACKGROUND: Current blood prescription in cardiac surgery is based largely on hemoglobin (Hb) concentration. Hb may not provide a reliable guide to the patient's red cell (RBC) volume (RCV) during cardiac surgery as a consequence of the high fluid loads infused. This study provides estimates of the perioperative changes in RCV, plasma volume (PV), and blood volume (BV) with a view to developing a more accurate way of assessing a patient's need for transfusion. STUDY DESIGN AND METHODS: Thirty adult elective cardiac surgery patients were recruited to the study. The preoperative RCV was calculated by use of a standard nomogram. Losses and gains in RCV at several time points were added or subtracted from the baseline value. Estimates of PV and BV were derived from patient hematocrit level and RCV for each time point. RESULTS: The greatest perioperative loss of RCV occurred during cardiopulmonary bypass (CPB); however, half of this loss was returned to the patient at the end of CPB. A net gain of RCV occurred during the period of intensive care management. PV and BV showed two distinct peaks, immediately after CPB and at 16 hours after intensive therapy unit return. CONCLUSIONS: PV and BV expansion are significant factors that may lead to a Hb value that is misleadingly low in that it overestimates the decrease in RCV. This effect could lead to unnecessary transfusion if the RBC transfusion threshold is based only on Hb concentration.

Cor-triatriatum sinister presenting in the adult as mitral stenosis: an analysis of factors which may be relevant in late presentation.

BACKGROUND: Cor-triatriatum sinister is a rare congenital heart defect resulting from the division of the left atrium by a fibro-muscular membrane. It is usual for patients to present in infancy and early childhood, although some cases remain undetected until adult life. As a consequence of trans-membrane flow obstruction, the clinical features often mimic mitral stenosis. At present, the reasons for late presentation are poorly understood. METHODS: A complete review of all cases of cor-triatriatum sinister published in the English literature from 1966 to date as mitral stenosis was performed. Statistical analysis was carried out to determine associations between measurements reflecting the communicating membrane fenestration area, the presence of several clinical variables and patient age at initial presentation. RESULTS: Both pulmonary capillary wedge pressure and mean pressure gradient were significantly higher in younger adults. In addition, the incidence of atrial fibrillation and mitral regurgitation was found to rise with advancing age. CONCLUSIONS: Cor-triatriatum sinister remains an uncommon form of congenital heart disease although it is being diagnosed with increasing frequency in adults due to improvements in diagnostic imaging. This diagnosis should be considered in all patients presenting with signs or symptoms of mitral stenosis.