Patient falls in the operating room setting: An analysis of reported safety events.

INTRODUCTION: Patient falls are a preventable public health problem, and they are among the most reported safety incidents in the hospital. We used a hospital safety reporting system to examine the nature of reported falls in the perioperative setting at an academic tertiary center. METHODS: In this retrospective study, reports of perioperative safety events listed as "Falls" between 2014 and 2020 were analyzed for severity level and specific event type. RESULTS: Out of 8337 safety reports from 2014 to 2020, 86 were "fall" related (1%). The most common "fall" event type was "ambulating with assistance and the severity level reported was mainly level 1 (no harm, did reach patient, 63%) followed by level 2 (temporary or minor harm, 28%). One of the most frequently reported types of perioperative falls was from a bed or stretcher (15% of falls)". CONCLUSIONS: Our safety data reporting system identified falls as a safety event that causes patient harm in the perioperative setting that could be preventable with a multifaceted interdisciplinary approach. Risk managers can use these data to implement strategies to reduce falls such as creating screening protocols to identify high-risk patients, educating and training healthcare personnel, and optimizing operating room, hospital, and equipment design.

Airway management in the operating room setting: An analysis of reported safety events.

Adverse event reporting systems are important tools for identifying areas of risk and opportunities quality improvement. Perioperative airway management (PAM) carries patient risk. We examine the nature of PAM incident reports at an academic tertiary care center. In this retrospective data review, perioperative safety reports filed under "Airway Management" between 2015 and 2020 were analyzed. Data analyzed included severity level (patient harm) and specific event type. There was a total of 7827 safety reports filed from January 2015 to July 2020, with 67 reports related to "Airway Management" (0.85%). The most common specific event type in this safety reporting database was "Intubation Injury (Mouth, Tooth, Airway)" (35.8%). The most common severity level of all reported events was level 2 (temporary or minor harm, 57%). Our safety reporting data demonstrates that adverse events related to PAM are likely to reach the patient and can cause significant harm. Data from our findings can help providers and risk managers to focus efforts on reducing patient harm. Strategies include continued education in technical skills and crisis management, preparation for the difficult airway, increased availability of video laryngoscopes, ongoing safety reporting and collaborative review of adverse events with implementation of quality improvement measures.

The nature of reported safety events related to care coordination in the operating room setting in a tertiary academic center.

Adverse event reporting systems are important tools for identifying areas of risk and opportunities for education and improvement. Our goal was to examine the nature of perioperative incident reports related to care coordination that were filed by staff at an academic tertiary care center. In this retrospective data review, perioperative safety reports between 2015 and 2020 were analyzed. Information examined included the type of staff who initiated the report, location of the incident, type of incident and the severity level of event, including patient harm. Out of the 7827 reports evaluated, 61.2% of reports were filed by nurses, and 5.6% by physicians. We investigated one particular category called "coordination of care" and found the specific event most commonly reported was insufficient handoff (15.0%-26.9%), with severity level reported primarily being no to minor harm reaching the patient. However, communication failures were judged to be one of leading causes of inadvertent harm. It is imperative for hospital incident reporting systems to collect data on issues related to communication failures and to design interventions with the help of frontline staff to provide high quality, safe care to patients and to remain compliant with regulatory requirements and hospital policies.

Perioperative Code Status Discussions: How Are We Doing?

Approximately 15% of patients with a code status of do-not-resuscitate (DNR) or do-not-intubate (DNI) present for surgery. Despite professional guidelines requiring discussions with patients regarding perioperative resuscitation, it is unclear whether these recommendations are consistently followed. Our review of 158 patient encounters with established DNR/DNI code status found that code status discussions (CSDs) were documented only 70% of the time, and code status orders were inconsistently entered to reflect those discussions. We present solutions to improve CSD documentation, including refining perioperative workflows, simplifying code status choices, optimizing electronic health record order entry, and a supplementary consent form to facilitate code status review.

Management of a parenteral opioid shortage using ASHP guidelines.

PURPOSE: Management of an acute shortage of parenteral opioid products at a large hospital through prescribing interventions and other guideline-recommended actions is described. SUMMARY: In early 2018, many hospitals were faced with a shortage of parenteral opioids that was predicted to last an entire year. The American Society of Health-System Pharmacists (ASHP) has published guidelines on managing drug product shortages. This article describes the application of these guidelines to manage the parenteral opioid shortage and the impact on opioid dispensing that occurred in 2018. Our approach paralleled that recommended in the ASHP guidelines. Daily dispensing reports generated from automated dispensing cabinets and from the electronic health record were used to capture dispenses of opioid medications. Opioid prescribing and utilization data were converted to morphine milligram equivalents (MME) to allow clinical leaders and hospital administrators to quickly evaluate opioid inventories and consumption. Action steps included utilization of substitute opioid therapies and conversion of opioid patient-controlled analgesia (PCA) and opioid infusions to intravenous bolus dose administration. Parenteral opioid supplies were successfully rationed so that surgical and elective procedures were not canceled or delayed. During the shortage, opioid dispensing decreased in the inpatient care areas from approximately 2.0 million MME to 1.4 million MME and in the operating rooms from 0.56 MME to 0.29 million MME. The combination of electronic health record alerts, increased utilization of intravenous acetaminophen and liposomal bupivacaine, and pharmacist interventions resulted in a 67% decline in PCA use and a 65% decline in opioid infusions. CONCLUSION: A multidisciplinary response is necessary for effective management of drug shortages through implementation of strategies and practices for notifying clinicians of shortages and identifying optimal alternative therapies.

Implementation of a Self-guided Focused Cardiac Ultrasound Curriculum for Anesthesiology Residents.

BACKGROUND: Focused cardiac ultrasound (FoCUS) is an increasingly used diagnostic modality for anesthesiologists and intensivists. However, training residents in its use can be resource intensive. We investigated the feasibility of implementing a self-guided FoCUS curriculum for anesthesiology residents rotating in the postanesthesia care unit (PACU). METHODS: We created a FoCUS curriculum with the aim of providing a consistent largely self-guided experience that would improve FoCUS knowledge and skills while minimizing ongoing time commitment from faculty. To achieve this, we used several methods: (1) developed video didactics and quizzes; (2) used an online educational delivery platform to automate delivery of educational content, monitor resident progress, and elicit feedback; (3) used the transthoracic echocardiography simulator for aided hands-on learning; (4) dedicated educational time that integrated into PACU workflow; (5) worked with a cardiac sonographer; and (6) used image storage software to facilitate remote feedback by ultrasound faculty. The response to the curriculum was evaluated using Kirkpatrick levels 1-3. RESULTS: Forty-one anesthesiology residents rotated through the PACU over a 1-year period and completed this weeklong self-guided FoCUS curriculum. Interesting findings include: (1) favorable evaluation from the residents and (2) improvement in image acquisition skills by objective measures. Once the curriculum was established, ongoing faculty time commitment was approximately 1 hour 20 minutes per week. CONCLUSIONS: The implementation of a FoCUS curriculum in the PACU resulted in favorable resident evaluation and improved FoCUS skills. The curriculum was feasible and self-sustainable because of the novel educational approach employed.

The Impact of Airway Technique on Anesthesia Control Time.

Few studies have examined the impact of video laryngoscopy (VL) on operating room efficiency. We hypothesized that VL reduces anesthesia control time (ACT), a metric of anesthesia efficiency, compared with fiberoptic intubation (FOI) in potentially difficult airways, but that direct laryngoscopy (DL) remains more efficient in routine cases. We performed a multi-institutional, retrospective chart review of anesthetic cases from 2015 to 2016. Cases were compared based on choice of airway technique (laryngeal mask airway [LMA], DL, VL or FOI) and ACT. Generalized linear models with gamma distribution and log link were then used to model the data to control for variables including ASA physical status (PS), Mallampati (MP) score, body mass index, and presence of a trainee. ACT was analyzed for 32,542 cases. LMA insertion was associated with a median ACT of 10 min (CI 8-14 min), DL 14 min (CI 11-18 min), VL 17 min (CI 13-21 min) and FOI 20 min (CI 14.5-26 min). Modeling confirmed these results when controlling for variables expected to increase the ACT. However, modeling also revealed that presence of a trainee minimizes the increase in ACT for cases using VL or FOI. Use of VL in patients with a high MP score may improve anesthesia efficiency in the operating room. ASA PS, MP score, and presence of a trainee are all associated with an increased ACT. Trainee presence with both FOI and VL was associated with reduced increases in ACT for these devices.

Contributors to Operating Room Underutilization and Implications for Hospital Administrators.

Operating rooms (ORs) are an important source of hospital revenue, and utilization rate is a key determinant of OR efficiency. Multiple factors contribute to OR underutilization, and OR managers may have biased views about which factors contribute most to OR underutilization. We examined various factors leading to OR underutilization at one academic tertriary care center.Data were collected retrospectively from over a 12-month period. Contribution to OR underutilization was measured in terms of hours of OR underutilization. Statistical significance between categories and days was calculated using an unpaired t test.By comparing means of the various contributors to OR underutilization (patient in the room, turnover time, scheduling gaps, OR holds, closed rooms), we determined that mid/end-of-day gaps and closed rooms contributed the most hours (9.7% and 4.6%, respectively; P < .0001) to OR underutilization, whereas turnover time and "patient in the room" contributed the least (2.0% and 0.8%, respectively; P < .0001).The contributors to OR underutilization are complex, and many OR staff from physicians to nurses and OR administrators may have biased views about which factors contribute most predominantly to inefficiency. Awareness of how various factors contribute to OR underutilization can pave the way for goal-directed changes on a systems-based level to improve efficiency in the OR by decreasing underutilization.

Intraoperative Feeding Improves Calorie and Protein Delivery in Acute Burn Patients.

Enteral nutrition support is a critical component of modern burn care for severely burned patients. However, tube feeds are frequently withheld during the perioperative period because of aspiration concerns. As a result, patients requiring multiple operative procedures risk accumulating significant protein-calorie deficits. The objective of this study was to describe our American Burn Association-certified burn center's experience implementing an intraoperative feeding protocol in severely burned patients defined as a cutaneous burn ≥20% TBSA. A retrospective review of patients with major thermal injuries (2008-2013). Thirty-three patients with an average of seven operating room trips (range, 2-21 trips) were evaluated. Seventeen patients received intraoperative enteral feeds (protocol group) and 16 patients did not (standard group). Feeding was performed using an enteral feeding tube placed postpylorically and was continued intraoperatively, regardless of operative positioning. There was no statistically significant difference in mortality between the groups (P = .62). No intraoperative aspiration or regurgitation events were recorded. The protocol group received significantly more calculated protein and caloric requirements, 98.06 and 98.4%, respectively, compared with 70.6 and 73.2% in the standard group (P < .001). Time to goal tube feed infusion rate was achieved on average 3 days sooner in the protocol group compared with the standard group (3.35 vs 6.18 days, P = .008). Early initiation and continuation of enteral feeds in severely burned patients led to higher percentages received of prescribed goal protein and caloric needs without increased rates of aspiration, regurgitation, or mortality.

Strategies to maintain operating room functionality following the complete loss of the recovery room due to an internal disaster.

The post-anesthesia care unit (PACU) is a major contributor to the operating room (OR) process flow and efficiency. A sudden failure of hospital facility infrastructure due to a burst pipe resulted in the complete loss of a 66-bed combined preoperative and PACU facility of a major academic medical center. The OR suites were undamaged. The clinical and administrative challenges of caring for surgical patients without the usual preoperative and postoperative care areas are discussed. Our strategy for maintaining OR functions and management of patient flow, OR personnel, case prioritization, and equipment needs are detailed from the time of initial crisis until restoration of these clinical care areas. Utilization of the hospital disaster Incident Command Structure and the activation and decision support provided by the hospital Emergency Operations Center (EOC) for the week immediately following the crisis, helped maintain OR functionality.

Process redesign to improve first case surgical starts in an academic institution.

PURPOSE: On time start of the first surgical case improves operating room (OR) utilization, physician, and patient satisfaction and decreases delays in subsequent cases. The goal of our study was to evaluate the effect of a multidisciplinary initiative to improve first patient in the room (FPIR) and first case on time start (FCOTS) metrics in a tertiary care setting. MATERIALS AND METHODS: A multidisciplinary committee focused on first case start data collection. Reasons for both anesthesia and surgical delays were analyzed. Improvement efforts focused on the timely completion of surgical consent, a requirement of a surgical, anesthesia, and nurse team member presence at the patient's bedside by specific time, and parallel processing in the OR. RESULTS: Over 65,100 OR cases were analyzed between 2007 and 2014. There was a statistically significant improvement in FPIR (82.80% versus 69.60%, p < .0001) and FCOTS (66.60% versus 55.90%, p < .0001). Surgical consent completion rate increased from 35% baseline to 68%-100%, depending on the surgical subspecialty. Improvements appeared sustainable several years following process implementation for both FPIR (84.60% versus 69.60%, p < .0001) and FCOTS (67.60% versus 55.90%, p < .0001). CONCLUSIONS: Our study demonstrates a successful targeted, multidisciplinary initiative to improve first case surgical starts in an academic setting. Our approach was organizational rather than punitive or rewarding on an individual basis. Strategies included establishing concrete, time-specific goals and posting them visibly, empowering individuals to fulfill them, and ensuring no compromise in patient safety. In the complex environment of academic medicine including research protocols and teaching in the ORs, our organizational approach proved sustainable over several years.

Emotional intelligence in the operating room: analysis from the Boston Marathon bombing.

INTRODUCTION: The Boston Marathon terrorist bombing that occurred on April 15, 2013 illustrates the importance of a cohesive, efficient management for the operating room and perioperative services. Conceptually, emotional intelligence (EI) is a form of social intelligence used by individuals in leadership positions to monitor the feelings and emotions of their team while implementing a strategic plan. OBJECTIVE: To describe the experience of caring for victims of the bombing at a large tertiary care center and provide examples demonstrating the importance of EI and its role in the management of patient flow and overall care. METHODS: A retrospective review of trauma data was performed. Data regarding patient flow, treatment types, treatment times, and outcomes were gathered from the hospital's electronic tracking system and subsequently analyzed. Analyses were performed to aggregate the data, identify trends, and describe the medical care. RESULTS: Immediately following the bombing, a total of 35 patients were brought to the emergency department (ED) with injuries requiring immediate medical attention. 10 of these patients went directly to the operating room on arrival to the hospital. The first victim was in an operating room within 21 minutes after arrival to the ED. CONCLUSION: The application of EI in managerial decisions helped to ensure smooth transitions for victims throughout all stages of their perioperative care. EI provided the fundamental groundwork that allowed the operating room manager and nurse leaders to establish the calm and coordinated leadership that facilitated patient care and teamwork.

A patient who received 191 spinal anesthetics over 5 years without evidence of neurologic complications by examination or magnetic resonance imaging.

We present the case of a 50-year-old man who suffered a crush injury to his right lower extremity in 2002 and received 191 spinal anesthetics to date with no identifiable neurologic complications by physical examination or imaging. He has undergone >300 operations at our institution related to recurrent infection and wound breakdown, including multiple amputations and debridements with 146 of these occurring in a span of 36 months. The patient has no focal neurologic deficits involving his right lower extremity and denies any associated pain or paresthesias. Magnetic resonance imaging of the patient's lumbar spine performed in September of 2009 revealed fibrotic changes, consistent with scar tissue formation, over the L2 and L3 spinous processes. There was no evidence of intrathecal scar tissue, adhesions, neuroma formation, or other changes that could be attributed to repeated lumbar puncture. Although uneventful in our single patient, safety with respect to the development of transient or permanent neurologic complications, infections, or subclinical pathology identified by imaging cannot be broadly extrapolated to repeat lumbar punctures.