Gaps in the Postoperative Conversation: A Comprehensive Review of Current Practices and the Unmet Needs of Surgeons, Families, and Waiting Room Personnel.

Perioperative communication between surgeons and caregivers is an important aspect of patient care, with postoperative conversations (POCs) being critical. Literature suggests current communication practices may be suboptimal. Identifying barriers and opportunities could improve patient and caregiver satisfaction and increase surgeon efficiency. This mixed method study included 1) prospective study of all patients undergoing a surgery at an academic medical center between September 2014 and March 2016 and 2) nominal groups of physicians, caregivers, and waiting room personnel (WRP). Nominal groups ranked standard of care themes needing intervention. Multivariate logistic regression estimated the association of surgeon and procedure characteristics with POC practices considering both location and contact method. Data on 15,820 operations showed that surgical specialty (P ≤ 0.0001), inpatient status (P ≤ 0.0001), planned discharge destination (P = 0.0003), patient race (P = 0.02), and caregiver relationship (P ≤ 0.0001) were all significantly associated with receiving a private POC. Nominal group results provided opportunities for improvement: regular updates (caregivers), locating the caregivers postoperation (surgeons), clear communication between caregivers and surgeons (WRP). This study examines the perioperative communication. Surgeons, caregivers, and WRP identified effective communication as a top intervention priority. Managing caregiver expectations, addressing concerns of WRP, and creating an efficient environment for surgeons appear to be critical components to communication.

Timed Stair Climbing Is the Single Strongest Predictor of Perioperative Complications in Patients Undergoing Abdominal Surgery.

BACKGROUND: Current methods to predict patients' perioperative morbidity use complex algorithms with multiple clinical variables focusing primarily on organ-specific compromise. The aim of the current study was to determine the value of a timed stair climb in predicting perioperative complications for patients undergoing abdominal surgery. STUDY DESIGN: From March 2014 to July 2015, three hundred and sixty-two patients attempted stair climbing while being timed before undergoing elective abdominal surgery. Vital signs were measured before and after stair climb. Ninety-day postoperative complications were assessed by the Accordion Severity Grading System. The prognostic value of stair climb was compared with the American College of Surgeons NSQIP risk calculator. RESULTS: A total of 264 (97.4%) patients were able to complete the stair climb. Stair climb time directly correlated to changes in both mean arterial pressure and heart rate as an indicator of stress. An Accordion grade 2 or higher complication occurred in 84 (25%) patients. There were 8 mortalities (2.4%). Patients with slower stair climb times had increased complication rates (p < 0.0001). In multivariable analysis, stair climb time was the single strongest predictor of complications (odds ratio = 1.029; p < 0.0001), and no other clinical comorbidity reached statistical significance. Receiver operative characteristic curves predicting postoperative morbidity by stair climb time was superior to that of the American College of Surgeons risk calculator (area under the curve = 0.81 vs 0.62; p < 0.0001). Additionally, slower patients had greater deviations from predicted length of hospital stay (p = 0.034). CONCLUSIONS: Stair climb provides measurable stress, accurately predicts postoperative complications, and is easy to administer in patients undergoing abdominal surgery. Larger patient populations with a diverse group of operations will be needed to validate the use of stair climbing in risk-prediction models.

A 100% departmental mortality review improves observed-to-expected mortality ratios and University HealthSystem Consortium rankings.

BACKGROUND: Public reporting of mortality, Patient Safety Indicators (PSI) and hospital-acquired conditions (HACs) is the reality of quality measurement. A review of our department's data identified opportunities for improvement. We began a surgeon-led 100% review of mortality, PSIs, and HACs to improve patient care and surgeon awareness of these metrics. STUDY DESIGN: From December 2012 through August 2013, there were 11,899 patients cared for on 12 surgical services. A surgeon from each service led monthly reviews of all mortality, PSIs, or HACs with central reporting of preventability and coding accuracy. We compared the University HealthSystem Consortium observed-to-expected (OE) mortality ratios (mean <1 fewer observed than expected deaths) and University HealthSystem Consortium relative rankings (lower number is better) before and after implementation. Statistical significance was p < 0.05 by Poisson regression. RESULTS: Of the 11,899 patients in the study period, there were 235 deaths, 290 PSIs, and 26 HACs identified and reviewed. The most common PSIs were postoperative deep vein thrombosis/pulmonary thromboembolism (n = 75), respiratory failure (n = 61), hemorrhage/hematoma (n = 33), and accidental puncture/laceration (n = 33). Before December 20, 2012, the OE ratio for mortality was consistently >1, then fell and remained <1 during the study period (p < 0.05). The OE mortality ratio in the fourth quarter of 2012 was 1.14 and fell to 0.88, 0.91, and 0.75 in the first, second, and third quarters of calendar year 2013 (p < 0.05). The overall Inpatient Quality Indicators #90 (composite postoperative mortality rank) rankings increased from 109 of 118 in the third quarter of 2012 to 47 of 119 in the third quarter of 2013. CONCLUSIONS: A surgeon-led systematic review of mortality, PSIs, and HACs improved our OE ratio and University HealthSystem Consortium postsurgical relative rankings. Surgeon engagement and ownership is critical for success.