A Focused Screening and Clinical Intervention with Streamlined Outpatient Linkage for Hospitalized Patients with Opioid Use Disorder Experiencing Homelessness.

Background: Patients experiencing homelessness have higher rates of substance use and related mortality, often driven by opioid overdose. Conversely, opioid use disorder (OUD) is a leading risk factor for homelessness. Our goal was to test the efficacy of an electronic health record (EHR) screen in identifying this vulnerable population during hospitalization and to assess the feasibility of a bundled intervention in improving opioid safety. Methods: We assessed patients' housing status, substance use, previous MOUD treatment, barriers to MOUD treatment and readiness to take MOUD in and out of the hospital. For each post discharge follow up call, patients were asked about their MOUD status, barriers accessing treatment, current substance use, and housing status. We also assessed team members perceptions and experiences of the study. Results: We enrolled 32 patients with housing insecurity and OUD. The mean age was 44, the majority self-identified as male (78%), and mostly as White (56%) or Black (38%). At each follow up within the 6-months post-discharge, reach rates were low: 40% of enrollees answered at least 1 call and the highest reach rate (31% of patients) occurred at week 4. At the third and sixth-month follow ups, >50% of subjects still taking MOUD were also using opioids. Conclusion: Our clinician augmented EHR screen accurately identified inpatients experiencing OUD and PEH. This intervention showed high rates of attrition among enrolled patients, even after providing cellphones. The majority of patients who were reached remained adherent to MOUD though they reported significant barriers.

Implementation, Maintenance, and Outcomes of an Electronic Referral to a Tobacco Quitline Across Five Health Systems.

INTRODUCTION: Electronic referral (e-referral) to quitlines helps connect tobacco-using patients to free, evidence-based cessation counseling. Little has been published about the real-world implementation of e-referrals across U.S. health systems, their maintenance over time, and the outcomes of e-referred patients. AIMS AND METHODS: Beginning in 2014, the University of California (UC)-wide project called UC Quits scaled up quitline e-referrals and related modifications to clinical workflows from one to five UC health systems. Implementation strategies were used to increase site readiness. Maintenance was supported through ongoing monitoring and quality improvement programs. Data on e-referred patients (n = 20 709) and quitline callers (n = 197 377) were collected from April 2014 to March 2021. Analyses of referral trends and cessation outcomes were conducted in 2021-2022. RESULTS: Of 20 709 patients referred, the quitline contacted 47.1%, 20.6% completed intake, 15.2% requested counseling, and 10.9% received it. In the 1.5-year implementation phase, 1813 patients were referred. In the 5.5-year maintenance phase, volume was sustained, with 3436 referrals annually on average. Among referred patients completing intake (n = 4264), 46.2% were nonwhite, 58.8% had Medicaid, 58.7% had a chronic disease, and 48.8% had a behavioral health condition. In a sample randomly selected for follow-up, e-referred patients were as likely as general quitline callers to attempt quitting (68.5% vs. 71.4%; p = .23), quit for 30 days (28.3% vs. 26.9%; p = .52), and quit for 6 months (13.6% vs. 13.9%; p = .88). CONCLUSIONS: With a whole-systems approach, quitline e-referrals can be established and sustained across inpatient and outpatient settings with diverse patient populations. Cessation outcomes were similar to those of general quitline callers. IMPLICATIONS: This study supports the broad implementation of tobacco quitline e-referrals in health care. To the best of our knowledge, no other paper has described the implementation of e-referrals across multiple U.S. health systems or how they were sustained over time. Modifying electronic health records systems and clinical workflows to enable and encourage e-referrals, if implemented and maintained appropriately, can be expected to improve patient care, make it easier for clinicians to support patients in quitting, increase the proportion of patients using evidence-based treatment, provide data to assess progress on quality goals, and help meet reporting requirements for tobacco screening and prevention.

Racial Differences in Postoperative Opioid Prescribing Practices in Spine Surgical Patients.

BACKGROUND: As the opioid epidemic accelerates in the United States, numerous sociodemographic factors have been implicated its development and are, furthermore, a driving factor of the disparities in postoperative pain management. Recent studies have suggested potential associations between the influence of race and ethnicity on pain perception but also the presence of unconscious biases in the treatment of pain in minority patients. OBJECTIVE: To characterize the perioperative opioid requirements across racial groups after spine surgery. METHODS: A retrospective, observational study of 1944 opioid-naive adult patients undergoing a neurosurgical spine procedure, from June 2012 to December 2019, was performed at a large, quaternary care institute. Postoperative inpatient and outpatient opioid usage was measured by oral morphine equivalents, across various racial groups. RESULTS: Case characteristics were similar between racial groups. In the postoperative period, White patients had shorter lengths of stay compared with Black and Asian patients ( P < .05). Asian patients used lower postoperative inpatient opioid doses in comparison with White patients ( P < .001). White patients were discharged with significantly higher doses of opioids compared with Black patients ( P < .01); however, they were less likely to be readmitted within 30 days of discharge ( P < .01). CONCLUSION: In a large cohort of opioid-naive postoperative neurosurgical patients, this study demonstrates higher inpatient and outpatient postoperative opioid usage among White patients. Increasing physician awareness to the effect of race on inpatient and outpatient pain management would allow for a modified opioid prescribing practice that ensures limited yet effective opioid dosages void of implicit biases.

Impact of the COVID-19 Pandemic on Neurosurgical Transfers: A Single Tertiary Center Study.

OBJECTIVE: Interfacility transfers represent a large proportion of neurosurgical admissions to tertiary care centers each year. In this study, the authors examined the impact of the COVID-19 pandemic on the number of transfers, timing of transfers, demographic profile of transfer patients, and clinical outcomes including rates of surgical intervention. METHODS: A retrospective review of neurosurgical transfer patients at a single tertiary center was performed. Patients transferred from April to November 2020 (the "COVID Era") were compared with an institutional database of transfer patients collected before the COVID-19 pandemic (the "Pre-COVID Era"). During the COVID Era, both emergent and nonemergent neurosurgical services had resumed. A comparison of demographic and clinical factors between the 2 cohorts was performed. RESULTS: A total of 674 patients were included in the study (331 Pre-COVID and 343 COVID-Era patients). Overall, there was no change in the average monthly number of transfers (P = 0.66) or in the catchment area of referral hospitals. However, COVID-Era patients were more likely to be uninsured (1% vs. 4%), had longer transfer times (COVID vs. Pre-COVID Era: 18 vs. 9 hours; P < 0.001), required higher rates of surgical intervention (63% vs. 50%, P = 0.001), had higher rates of spine pathology (17% vs. 10%), and less frequently were admitted to the intensive care unit (34% vs. 52%, P < 0.001). Overall, COVID-Era patients did not experience delays to surgical intervention (3.1 days vs. 3.6 days, P = 0.2). When analyzing the subgroup of COVID-Era patients, COVID infection status did not impact the time of transfer or rates of operation, although COVID-infected patients experienced a longer time to surgery after admission (14 vs. 2.9 days, P < 0.001). CONCLUSION: The COVID-19 pandemic did not reduce the number of monthly transfers, operation rates, or catchment area for transfer patients. Transfer rates of uninsured patients increased during the COVID Era, potentially reflecting changes in access to community neurosurgery care. Shorter time to surgery seen in COVID-Era patients possibly reflects institutional policies that improved operating room efficiency to compensate for surgical backlogs. COVID status affeted time to surgery, reflecting the preoperative care that these patients require before intervention.

Are preoperative chlorhexidine gluconate showers associated with a reduction in surgical site infection following craniotomy? A retrospective cohort analysis of 3126 surgical procedures.

OBJECTIVE: Surgical site infection (SSI) is a complication linked to increased costs and length of hospital stay. Prevention of SSI is important to reduce its burden on individual patients and the healthcare system. The authors aimed to assess the efficacy of preoperative chlorhexidine gluconate (CHG) showers on SSI rates following cranial surgery. METHODS: In November 2013, a preoperative CHG shower protocol was implemented at the authors' institution. A total of 3126 surgical procedures were analyzed, encompassing a time frame from April 2012 to April 2016. Cohorts before and after implementation of the CHG shower protocol were evaluated for differences in SSI rates. RESULTS: The overall SSI rate was 0.6%. No significant differences (p = 0.11) were observed between the rate of SSI of the 892 patients in the preimplementation cohort (0.2%) and that of the 2234 patients in the postimplementation cohort (0.8%). Following multivariable analysis, implementation of preoperative CHG showers was not associated with decreased SSI (adjusted OR 2.96, 95% CI 0.67-13.1; p = 0.15). CONCLUSIONS: This is the largest study, according to sample size, to examine the association between CHG showers and SSI following craniotomy. CHG showers did not significantly alter the risk of SSI after a cranial procedure.

A Safe Transitions Pathway for post-craniotomy neurological surgery patients: high-value care that bypasses the intensive care unit.

OBJECTIVE: High-value medical care is described as care that leads to excellent patient outcomes, high patient satisfaction, and efficient costs. Neurosurgical care in particular can be expensive for the hospital, as substantial costs are accrued during the operation and throughout the postoperative stay. The authors developed a "Safe Transitions Pathway" (STP) model in which select patients went to the postanesthesia care unit (PACU) and then the neuro-transitional care unit (NTCU) rather than being directly admitted to the neurosciences intensive care unit (ICU) following a craniotomy. They sought to evaluate the clinical and financial outcomes as well as the impact on the patient experience for patients who participated in the STP and bypassed the ICU level of care. METHODS: Patients were enrolled during the 2018 fiscal year (FY18; July 1, 2017, through June 30, 2018). The electronic medical record was reviewed for clinical information and the hospital cost accounting record was reviewed for financial information. Nurses and patients were given a satisfaction survey to assess their respective impressions of the hospital stay and of the recovery pathway. RESULTS: No patients who proceeded to the NTCU postoperatively were upgraded to the ICU level of care postoperatively. There were no deaths in the STP group, and no patients required a return to the operating room during their hospitalization (95% CI 0%-3.9%). There was a trend toward fewer 30-day readmissions in the STP patients than in the standard pathway patients (1.2% [95% CI 0.0%-6.8%] vs 5.1% [95% CI 2.5%-9.1%], p = 0.058). The mean number of ICU days saved per case was 1.20. The average postprocedure length of stay was reduced by 0.25 days for STP patients. Actual FY18 direct cost savings from 94 patients who went through the STP was $422,128. CONCLUSIONS: Length of stay, direct cost per case, and ICU days were significantly less after the adoption of the STP, and ICU bed utilization was freed for acute admissions and transfers. There were no substantial complications or adverse patient outcomes in the STP group.

Preoperative risk stratification of patient mortality following elective craniotomy; a comparative analysis of prediction algorithms.

Factors associated with mortality following craniotomy for non-traumatic etiologies are not well studied. We performed a retrospective case-control study to investigate the utility of the Gupta, RCRI, KPS, ASA, and NSQIP risk calculators in predicting complication and mortality rates among a neurosurgical patient population undergoing elective craniotomy and used ROC curves to determine their relative predictive accuracy. We identified 17 patients who died following elective craniotomy and 17 control patients who survived, matched for sex, age, comorbid conditions, and intervention. The deceased cohort experienced a greater degree of surgical complications, with concordantly higher preoperative risk scores as assessed by Gupta, KPS, ASA, and NSQIP scales. Cause of death was secondary to a surgical complication in 11 (65%) cases and nonsurgical in 6 (35%) cases. When comparing our deceased and survival cohorts for specific complication profiles, higher RCRI score was significantly associated with postoperative cardiac death. Poor preoperative ASA and KPS score were both associated with mortality. NSQIP risk was significantly associated with mortality and nonsurgical and cardiopulmonary complications. ROC analyses comparing predictive scales found no clearly superior prediction algorithm for postoperative complications or mortality; NSQIP and RCRI were highly predictive of cardiac death, KPS and NSQIP with nonsurgical complications, and Gupta, ASA, KPS, and NSQIP with postoperative mortality. NSQIP scores correlated most broadly with nonsurgical complications and mortality. Future efforts at quality improvement in healthcare value will be rooted in the development of more accurate and specific risk assessment strategies specific to neurosurgery.

Delirium Risk Factors and Associated Outcomes in a Neurosurgical Cohort: A Case-Control Study.

OBJECTIVE: There are limited reports examining delirium in cohorts of neurosurgical patients across inpatient settings without separation based on subspecialty distinction. It is of interest to identify consistent delirium risk factors across various cranial pathologies and inpatient settings that will inform future interventional studies. METHODS: Delirium rates, patient and hospitalization risk factors, and clinical outcomes in 235 patients undergoing a cranial procedure were examined in a retrospective fashion. RESULTS: Fifty-two (22.1%) patients experienced delirium during their hospital stay. Patient factors predictive of delirium on univariate logistic regression were older age, a diagnosis of hydrocephalus or intracranial infection, transfer from an outside hospital, and admission through the emergency department. Hospitalization factors predictive of delirium included longer length of intensive care unit (ICU) stay, abnormal sodium values preceding delirium, a new postoperative infection, and the presence of a neurologic deficit. Using recursive partitioning, age ≥72.56 years and ICU length of stay ≥5 days were identified as critical thresholds for predicting delirium (odds ratio [OR] 4.61 and 18.2, respectively). On multivariate logistic regression analysis, age (unit OR 1.05), length of ICU stay (unit OR 1.2), and a neurologic deficit (OR 5.4) were predictive of delirium. Furthermore, delirium was also significantly associated with a longer length of admission as well as decreased likelihood for discharge home. CONCLUSIONS: Delirium is a frequent occurrence after neurosurgery with older age, longer ICU stay, and a neurologic deficit being consistent risk factors across inpatient settings. These results help identify at-risk patients for delirium on a neurosurgical service to enact interventions preemptively.

A Reduced Exogenous Steroid Taper for Postoperative Brain Tumor Patients-A Case-Control Study.

BACKGROUND: Dexamethasone is a standard treatment for cerebral edema after brain tumor surgery. However, its side effects can negatively impact the quality and safety of care provided to patients. Sparse evidence exists in the literature regarding postoperative steroid dosing to guide clinicians. The objective of this study was to determine if a new reduced exogenous steroid taper (REST) protocol would effectively treat postoperative cerebral edema while reducing the incidence of steroid-related side effects including diabetes, hypertension, and insomnia. METHODS: A REST protocol (dexamethasone 38.5 mg tapered over 10 days) was instituted for patients with postoperative brain tumor of a single surgeon. Historical controls treated with a high-dose taper (dexamethasone 117 mg taper over 17 days) were selected to match for baseline characteristics. Outcomes of new or worsened diabetes, hypertension, and insomnia, as well as length of stay (LOS) and 30-day readmission rates, were compared. RESULTS: Twenty-five patients were included in each group. There were no significant differences in baseline characteristics. The REST group received a median of 34.5 mg (interquartile range, 32-41 mg) of dexamethasone, whereas controls received 43 mg (interquartile range, 16-91 mg) (P = 0.04). There was a significant reduction in the incidence of new or worsened hypertension in the REST group (0%) compared with controls (20%, P = 0.02). No difference was seen in the rates of diabetes mellitus, insomnia, LOS, or 30-day readmission rates. CONCLUSIONS: A reduced steroid taper after brain tumor surgery significantly reduced the incidence of hypertension without increasing LOS or 30-day readmissions compared with controls treated with a high-dose taper.

Interfacility neurosurgical transfers: an analysis of nontraumatic inpatient and emergency department transfers with implications for improvements in care.

OBJECTIVE: Interfacility neurosurgical transfers to tertiary care centers are driven by a number of variables, including lack of on-site coverage, limited available technology, insurance factors, and patient preference. The authors sought to assess the timing and necessity of surgery and compared transfers to their institution from emergency departments (ED) and inpatient units at other hospitals. METHODS: Adult neurosurgical patients who were transferred to a single tertiary care center were analyzed over 12 months. Patients with traumatic injuries or those referred from skilled nursing facilities or rehabilitation centers were excluded. RESULTS: A total of 504 transferred patients were included, with mean age 55 years (range 19-92 years); 53% of patients were women. Points of origin were ED in 54% cases and inpatient hospital unit in 46%, with a mean distance traveled for most patients of 119 miles. Broad diagnosis categories included brain tumors (n = 142, 28%), vascular lesions, including spontaneous and hypertensive intracerebral hemorrhage (n = 143, 28%), spinal lesions (n = 126, 25%), hydrocephalus (n = 45, 9%), wound complications (n = 29, 6%), and others (n = 19, 4%). Patients transferred from inpatient units had higher rates of surgical intervention (75% vs 57%, p < 0.001), whereas patients transferred from the ED had higher rates of urgent surgery (20% vs 8%, p < 0.001) and shorter mean time to surgery (3 vs 5 days, p < 0.001). Misdiagnosis rates were higher among ED referrals (11% vs 4%, p = 0.008). Across the same timeframe, patients undergoing elective admission (n = 1986) or admission from the authors' own ED (n = 248) had significantly shorter lengths of stay (p < 0.001) and ICU days (p < 0.001) than transferred patients, as well as a significantly lower total cost ($44,412, $46,163, and $72,175, respectively; p < 0.001). CONCLUSIONS: The authors present their 12-month experience from a single tertiary care center without Level I trauma designation. In this cohort, 65% of patients required surgery, but the rates were higher among inpatient referrals, and misdiagnosis rates were higher among ED transfers. These data suggest that admitting nonemergency patients to local hospitals may improve diagnostic accuracy of patients requiring urgent care, more precisely identify patients in need of transfer, and reduce costs. Referring facilities may lack necessary resources or expertise, and the Emergency Medical Treatment and Active Labor Act (EMTALA) obligates tertiary care centers to accept these patients under those circumstances. Telemedicine and integration of electronic medical records may help guide referring hospitals to pursue additional workup, which may eliminate the need for unnecessary transfer and provide additional cost savings.

Cost-effectiveness development for the postoperative care of craniotomy patients: a safe transitions pathway in neurological surgery.

OBJECTIVE The authors' institution is in the top 5th percentile for hospital cost in the nation, and the neurointensive care unit (NICU) is one of the costliest units. The NICU is more expensive than other units because of lower staff/patient ratio and because of the equipment necessary to monitor patient care. The cost differential between the NICU and Neuro transitional care unit (NTCU) is $1504 per day. The goal of this study was to evaluate and to pilot a program to improve efficiency and lower cost by modifying the postoperative care of patients who have undergone a craniotomy, sending them to the NTCU as opposed to the NICU. Implementation of the pilot will expand and utilize neurosurgery beds available on the NTCU and reduce the burden on NICU beds for critically ill patient admissions. METHODS Ten patients who underwent craniotomy to treat supratentorial brain tumors were included. Prior to implementation of the pilot, inclusion criteria were designed for patient selection. Patients included were less than 65 years of age, had no comorbid conditions requiring postoperative intensive care unit (ICU) care, had a supratentorial meningioma less than 3 cm in size, had no intraoperative events, had routine extubation, and underwent surgery lasting fewer than 5 hours and had blood loss less than 500 ml. The Safe Transitions Pathway (STP) was started in August 2016. RESULTS Ten tumor patients have utilized the STP (5 convexity meningiomas, 2 metastatic tumors, 3 gliomas). Patients' ages ranged from 29 to 75 years (median 49 years; an exception to the age limit of 65 years was made for one 75-year-old patient). Discharge from the hospital averaged 2.2 days postoperative, with 1 discharged on postoperative day (POD) 1, 7 discharged on POD 2, 1 discharged on POD 3, and 1 discharged on POD 4. Preliminary data indicate that quality and safety for patients following the STP (moving from the operating room [OR] to the neuro transitional care unit [OR-NTCU]) are no different from those of patients following the traditional OR-NICU pathway. No patients required escalation in level of nursing care, and there were no readmissions. This group has been followed for greater than 1 month, and there were no morbidities. CONCLUSIONS The STP is a new and efficient pathway for the postoperative care of neurosurgery patients. The STP has reduced hospital cost by $22,560 for the first 10 patients, and there were no morbidities. Since this pilot, the authors have expanded the pathway to include other surgical cases and now routinely schedule craniotomy patients for the (OR-NTCU) pathway. The potential cost reduction in one year could reach $500,000 if we reach our potential of 20 patients per month.

Postoperative Delirium in Glioblastoma Patients: Risk Factors and Prognostic Implications.

BACKGROUND: Delirium is a postoperative neurological morbidity in glioblastoma whose risk factors, incidence, and prognostic implications remain undefined. OBJECTIVE: To develop an algorithm using preoperative factors to predict postoperative delirium. METHODS: Retrospective analysis of 554 consecutive patients (mean age = 61.5 yr; 42% female) undergoing first glioblastoma procedure at our institution 2005 to 2011. RESULTS: Postoperative delirium occurred in 7% of patients (n = 38). Patients undergoing biopsy (10%; n = 54) did not experience delirium. In patients undergoing resection (n = 500), multivariate logistic regression identified 5 factors independently predicting postoperative delirium: age, chronic pulmonary disease, psychiatric history, bihemispheric tumors, and tumor size. We developed a score function entitled "GRAD" (Glioblastoma Risk Assessment for Delirium) to stratify patients into risk categories by assigning point(s) to each preoperative factor based on the relative magnitude of its regression coefficient. Point totals were summed for each patient: patients with 0 to 2 (n = 227) and 3 to 7 (n = 221) points were designated as low and high risk with postoperative delirium rates of 2% vs 15%, respectively (chi-square; P < .001), with the model validated using a separate patient cohort. Postoperative delirium lengthened hospital stays (P < .001), decreased likelihood of discharge home (P < .001), and was independently associated with decreased survival (4.5 vs 13.4 mo; hazard ratio = 1.9 [1.2-2.8]) in multivariate analysis. CONCLUSION: We developed a model to predict development of postoperative delirium using 2 tumor-specific (bihemispheric tumors and tumor size) and 3 patient-specific (age, psychiatric history, and chronic pulmonary disease) factors. High-risk patients and their families should be counseled preoperatively, and this risk could be considered in the choice of biopsy vs resection, and resection patients should be monitored closely postoperatively.

An NGO-Implemented Community-Clinic Health Worker Approach to Providing Long-Term Care for Hypertension in a Remote Region of Southern India.

Poor blood pressure control results in tremendous morbidity and mortality in India where the leading cause of death among adults is from coronary heart disease. Despite having little formal education, community health workers (CHWs) are integral to successful public health interventions in India and other low- and middle-income countries that have a shortage of trained health professionals. Training CHWs to screen for and manage chronic hypertension, with support from trained clinicians, offers an excellent opportunity for effecting systemwide change in hypertension-related burden of disease. In this article, we describe the development of a program that trained CHWs between 2014 and 2015 in the tribal region of the Sittilingi Valley in southern India, to identify hypertensive patients in the community, refer them for diagnosis and initial management in a physician-staffed clinic, and provide them with sustained lifestyle interventions and medications over multiple visits. We found that after 2 years, the CHWs had screened 7,176 people over age 18 for hypertension, 1,184 (16.5%) of whom were screened as hypertensive. Of the 1,184 patients screened as hypertensive, 898 (75.8%) had achieved blood pressure control, defined as a systolic blood pressure less than 140 and a diastolic blood pressure less than 90 sustained over 3 consecutive visits. While all of the 24 trained CHWs reported confidence in checking blood pressure with a manual blood pressure cuff, 4 of the 24 CHWs reported occasional difficulty documenting blood pressure values because they were unable to write numbers properly. They compensated by asking other CHWs or members of their community to help with documentation. Our experience and findings suggest that a CHW blood pressure screening system linked to a central clinic can be a promising avenue for improving hypertension control rates in low- and middle-income countries.

Changing Operating Room Culture: Implementation of a Postoperative Debrief and Improved Safety Culture.

BACKGROUND: Patient safety is foundational to neurosurgical care. Postprocedural "debrief" checklists have been proposed to improve patient safety, but data about their use in neurosurgery are limited. Here, we implemented an initiative to routinely perform postoperative debriefs and evaluated the impact of debriefing on operating room (OR) safety culture. METHODS: A 10-question safety attitude questionnaire (SAQ) was sent to neurosurgical OR staff at a major academic medical center before and 18 months after the implementation of a postoperative debriefing initiative. Rates of debrief compliance and changes in attitudes before and after the survey were evaluated. The survey used a Likert scale and analyzed with standard statistical methods. RESULTS: After the debrief initiative, the rate of debriefing increased from 51% to 86% of cases for the neurosurgery service. Baseline SAQ responses found that neurosurgeons had a more favorable perception of OR safety than did anesthesiologists and nurses. After implementation of the postoperative debriefing process, perceptions of OR safety significantly improved for neurosurgeons, anesthesiologists, and nurses. Furthermore, the disparity between nurses and surgeons was no longer significant. After debrief implementation, neurosurgical OR staff had improved perceptions of patient safety compared with surgical services that did not commonly perform debriefing. Debriefing identified OR efficiency concerns in 26.9% of cases, and prevention of potential adverse events/near misses was reported in 8% of cases. CONCLUSIONS: Postoperative debriefing can be effectively introduced into the OR and improves the safety culture after implementation. Debriefing is an effective tool to identify OR inefficiencies and potential adverse events.

Implementation of graphic health warning labels on tobacco products in India: the interplay between the cigarette and the bidi industries.

OBJECTIVES: To understand the competition between and among tobacco companies and health groups that led to graphical health warning labels (GHWL) on all tobacco products in India. METHODS: Analysis of internal tobacco industry documents in the Legacy Tobacco Document Library, documents obtained through India's Right to Information Act, and news reports. RESULTS: Implementation of GHWLs in India reflects a complex interplay between the government and the cigarette and bidi industries, who have shared as well as conflicting interests. Joint lobbying by national-level tobacco companies (that are foreign subsidiaries of multinationals) and local producers of other forms of tobacco blocked GHWLs for decades and delayed the implementation of effective GHWLs after they were mandated in 2007. Tobacco control activists used public interest lawsuits and the Right to Information Act to win government implementation of GHWLs on cigarette, bidi and smokeless tobacco packs in May 2009 and rotating GHWLs in December 2011. CONCLUSIONS: GHWLs in India illustrate how the presence of bidis and cigarettes in the same market creates a complex regulatory environment. The government imposing tobacco control on multinational cigarette companies led to the enforcement of regulation on local forms of tobacco. As other developing countries with high rates of alternate forms of tobacco use establish and enforce GHWL laws, the tobacco control advocacy community can use pressure on the multinational cigarette industry as an indirect tool to force implementation of regulations on other forms of tobacco.