Association between implementation of a medical team training program and surgical morbidity.

OBJECTIVE: To determine whether there is an association between the Veterans Health Administration Medical Team Training (MTT) program and surgical morbidity. DESIGN, SETTING, AND PARTICIPANTS: A retrospective health services study was conducted with a contemporaneous control group. Outcome data were obtained from the Veterans Health Administration Surgical Quality Improvement Program. The analysis included aggregated measures representing 119,383 sampled procedures from 74 Veterans Health Administration facilities that provide care to veterans. MAIN OUTCOME MEASURES: The primary outcome measure was the rate of change in annual surgical morbidity rate 1 year after facilities enrolled in the MTT program as compared with 1 year before and compared with the non-MTT program sites. RESULTS: Facilities in the MTT program (n = 42) had a significant decrease of 17% in observed annual surgical morbidity rate (rate ratio, 0.83; 95% CI, 0.79-0.88; P = .01). Facilities not trained (n = 32) had an insignificant decrease of 6% in observed morbidity (rate ratio, 0.94; 95% CI, 0.86-1.05; P = .11). After adjusting for surgical risk, we found a decrease of 15% in morbidity rate for facilities in the MTT program and a decrease of 10% for those not yet in the program. The risk-adjusted annual surgical morbidity rate declined in both groups, and the decline was 20% steeper in the MTT program group (P = .001) after propensity-score matching. The steeper decline in annual surgical morbidity rates was also observed in specific morbidity outcomes, such as surgical infection. CONCLUSION: The Veterans Health Administration MTT program is associated with decreased surgical morbidity.

Improving perceptions of teamwork climate with the Veterans Health Administration medical team training program.

There are differences between nurse and physician perceptions of teamwork. The purpose of this study was to determine whether these differences would be reduced with medical team training (MTT). The Safety Attitudes Questionnaire was administered to nurses and physicians working in the operating rooms of 101 consecutive hospitals before and at the completion of an MTT program. Responses to the 6 teamwork climate items on the Safety Attitudes Questionnaire were analyzed using nonparametric testing. At baseline, physicians had more favorable perceptions on teamwork climate items than nurses. Physicians demonstrated improvement on all 6 teamwork climate items. Nurses demonstrated improvement in perceptions on all teamwork climate items except "Nurse input is well received." Physicians still had a more favorable perception than nurses on all 6 teamwork climate items at follow-up. Despite an improvement in perceptions by physicians and nurses, baseline nurse-physician differences persisted at completion of the Veterans Health Administration MTT Program.

Incorrect surgical procedures within and outside of the operating room: a follow-up report.

OBJECTIVE: To describe incorrect surgical procedures reported from mid-2006 to 2009 from Veterans Health Administration medical centers and build on previously reported events from 2001 to mid-2006. DESIGN: Retrospective database review. SETTING: Veterans Health Administration medical centers. INTERVENTIONS: The Veterans Health Administration implemented Medical Team Training and continues to support their directive for ensuring correct surgery to improve surgical patient safety. MAIN OUTCOME MEASURES: The categories were incorrect procedure types (wrong patient, side, site, procedure, or implant), major or minor surgery, in or out of the operating room (OR), adverse event or close call, specialty, and harm. RESULTS: Our review produced 237 reports (101 adverse events, 136 close calls) and found decreased harm compared with the previous report. The rate of reported adverse events decreased from 3.21 to 2.4 per month (P = .02). Reported close calls increased from 1.97 to 3.24 per month (P ≤ .001). Adverse events were evenly split between OR (50) and non-OR (51). When in-OR events were examined as a rate, Neurosurgery had 1.56 and Ophthalmology had 1.06 reported adverse events per 10 000 cases. The most common root cause for adverse events was a lack of standardization of clinical processes (18%). CONCLUSIONS: The rate of reported adverse events and harm decreased, while reported close calls increased. Despite improvements, we aim to achieve further gains. Current plans and actions include sharing lessons learned from root cause analyses, policy changes based on root cause analysis review, and additional focused Medical Team Training as needed.

Changing perceptions of safety climate in the operating room with the Veterans Health Administration medical team training program.

Perceptions of organizational commitment to safety differ between the operating rooms in high- and medium-complexity facilities of the Veterans Health Administration (VHA). The purpose of this study was to see whether medical team training (MTT) reduced this difference. The Safety Attitudes Questionnaire was administered before and at the completion of a MTT program. The study population consisted of respondents working in the operating room. Responses to the 7 safety climate items were analyzed using nonparametric tests. Before MTT, respondents working at medium-complexity facilities had more favorable perceptions of knowledge of proper channels and encouragement by colleagues to report safety concerns than respondents who work at high-complexity facilities. At completion, there was no difference in perceptions between respondents working at high- and medium-complexity facilities for these items. The VHA MTT program improved perceptions at both high- and medium-complexity facilities and eliminated differences present at baseline.

Association between implementation of a medical team training program and surgical mortality.

CONTEXT: There is insufficient information about the effectiveness of medical team training on surgical outcomes. The Veterans Health Administration (VHA) implemented a formalized medical team training program for operating room personnel on a national level. OBJECTIVE: To determine whether an association existed between the VHA Medical Team Training program and surgical outcomes. DESIGN, SETTING, AND PARTICIPANTS: A retrospective health services study with a contemporaneous control group was conducted. Outcome data were obtained from the VHA Surgical Quality Improvement Program (VASQIP) and from structured interviews in fiscal years 2006 to 2008. The analysis included 182,409 sampled procedures from 108 VHA facilities that provided care to veterans. The VHA's nationwide training program required briefings and debriefings in the operating room and included checklists as an integral part of this process. The training included 2 months of preparation, a 1-day conference, and 1 year of quarterly coaching interviews MAIN OUTCOME MEASURE: The rate of change in the mortality rate 1 year after facilities enrolled in the training program compared with the year before and with nontraining sites. RESULTS: The 74 facilities in the training program experienced an 18% reduction in annual mortality (rate ratio [RR], 0.82; 95% confidence interval [CI], 0.76-0.91; P = .01) compared with a 7% decrease among the 34 facilities that had not yet undergone training (RR, 0.93; 95% CI, 0.80-1.06; P = .59). The risk-adjusted mortality rates at baseline were 17 per 1000 procedures per year for the trained facilities and 15 per 1000 procedures per year for the nontrained facilities. At the end of the study, the rates were 14 per 1000 procedures per year for both groups. Propensity matching of the trained and nontrained groups demonstrated that the decline in the risk-adjusted surgical mortality rate was about 50% greater in the training group (RR,1.49; 95% CI, 1.10-2.07; P = .01) than in the nontraining group. A dose-response relationship for additional quarters of the training program was also demonstrated: for every quarter of the training program, a reduction of 0.5 deaths per 1000 procedures occurred (95% CI, 0.2-1.0; P = .001). CONCLUSION: Participation in the VHA Medical Team Training program was associated with lower surgical mortality.

Differences in nurse and surgeon perceptions of teamwork: implications for use of a briefing checklist in the OR.

The quality of teamwork among health care professionals is known to affect patient outcomes. In the OR, surgeons report more favorable perceptions of communication during procedures and of teamwork effectiveness than do nurses. We undertook a quality improvement project in the Veterans Health Administration to confirm reported teamwork differences between perioperative nurses and surgeons and to examine the implications of these differences for improving practice patterns in the OR. The Safety Attitudes Questionnaire, which measures safety culture, including the quality of communication and collaboration among health care providers who routinely work together, was administered in 34 hospitals. Perioperative nurses who participated in the survey rated teamwork higher with other nurses than with surgeons, but surgeons rated teamwork high with each other and with nurses. On five of six communication and collaboration items, surgeons had a significantly more favorable perception than did perioperative nurses. To increase the likelihood of success when implementing the use of checklist-based crew resource management tools, such as the World Health Organization's Surgical Safety Checklist, project leaders should anticipate differences in perception between members of the different professions that must be overcome if teamwork is to be improved.

The effect of facility complexity on perceptions of safety climate in the operating room: size matters.

This study explores the effect of facility complexity on operating room (OR) caregiver perceptions of safety climate in the Veterans Health Administration (VHA). Facility complexity is a standardized score based on volume, risk, teaching, research, and intensive care unit capability. The Safety Attitudes Questionnaire was administered at 34 VHA hospitals. The authors performed analysis of variance on safety climate item scores by facility complexity and Bonferroni post hoc probes. Caregivers at high-complexity facilities were significantly less likely to agree that "Medical errors are handled appropriately in this hospital" than caregivers at medium-complexity facilities. Caregivers at high-complexity facilities were significantly more likely to agree that "I know the proper channels to direct questions regarding patient safety in the ORs here" than caregivers at medium-complexity facilities. Differences in caregiver perceptions of safety climate by facility complexity are present. Awareness of these differences can help when facilities implement surgical safety procedures.

Early prediction of posttraumatic in-hospital mortality in pediatric patients.

BACKGROUND: The purpose of this study was to develop a triaging tool to predict pediatric in-hospital mortality from data available soon after emergency department (ED) presentation. METHODS: The study group consisted of patients of less than 18 years of age from the National Trauma Data Bank with a reported in-hospital mortality status. Variables analyzed were (1) patient demographics, (2) Glasgow Coma Scale (GCS) values, (3) ED vital signs, (4) injury mechanism, and (5) number of days from trauma until admission. Chi-square-assisted interaction detection (CHAID) profiled patient subgroups. The final cohort was randomly divided into 2 equal sets: a training set to subgroup patients and a testing set to validate the prediction accuracy. RESULTS: The cohort consisted of 224,628 patients with 2.29% in-hospital mortality. Sixteen of 19 potential variables were associated with increased risk of in-hospital mortality. The relative risk of dying was 61.7 times greater (95% confidence interval 57.5-66.1) when CHAID predicted mortality relative to when the model predicted survival (P<0.0001). The most powerful variables of the CHAID model were low total GCS scores and systolic blood pressure in the ED. The CHAID model had an improved relative risk and a better combination of sensitivity and positive predictive value compared with GCS and systolic blood pressure in predicting mortality. CONCLUSIONS: The risk of in-hospital mortality for injured children may be identified soon after arrival in the ED. This information may be used by frontline providers to appropriately triage patients to pediatric trauma centers quickly, to guide resuscitation, and for teaching purposes.

Hospitalized cases of child abuse in America: who, what, when, and where.

BACKGROUND: Orthopaedic surgeons need to recognize features of child abuse. The purpose of this study was to identify common characteristics of child abuse and to delineate features of physical injury cases that would raise concern for child abuse. METHODS: A nationally representative sample of all pediatric inpatient discharges for calendar years 1997, 2000, and 2003 was queried for physical injury diagnoses. Cases were identified as those with a diagnosis of child abuse and controls were those without the diagnosis of child abuse. Incidence of coded child abuse and a comparison of rates across time, demographics, and injury pattern were determined. Cases were compared with controls, and relative risks for coded child abuse were computed using the generalized linear model specifying the Poisson distribution and a log link. RESULTS: There were 665,195 physical injury cases identified. Of these, 11,554 (1.74%) had a diagnosis of child abuse. Fracture requiring orthopaedic management was present in 28% of the child abuse cases. The 3 strongest demographic predictors of coded child abuse were age younger than 1 year, age 1 to younger than 2 years, and Medicaid as primary payer with adjusted relative risks of 11.46, 3.07, and 1.99, respectively. Winter and weekday presentation were significantly higher for coded child abuse. Fractures with the greatest adjusted relative risks for coded child abuse were rib or sternum (5.34) and scapula (3.22). Pelvic fracture was the only fracture significant for lowered adjusted relative risk of coded child abuse. CONCLUSIONS: This study shows that young age continues to be a strong predictor of child abuse in the setting of physical injury. Supporting features include Medicaid as primary payer and winter or weekday presentation. Orthopaedists should be particularly aware of child abuse as 28% of cases had a fracture requiring orthopaedic management. LEVEL OF EVIDENCE: Prognostic Study, Level III (case-control study).

Incidence of hip dysplasia in idiopathic clubfoot.

There is reported to be no increased risk for developmental dysplasia of the hip in children with idiopathic clubfoot. The purpose of this study was to determine the incidence of radiographic hip dysplasia in infants with idiopathic clubfoot. Fifty-one children with idiopathic clubfoot who underwent surgical release by a single surgeon had anterior-posterior pelvis radiographs obtained at 4 or more months of age to screen for developmental dysplasia of the hip. The acetabular index measured more than 28 degrees in eight children (16%). This study suggests an association between idiopathic clubfoot and developmental dysplasia of the hip.

Sagittal knee kinematics after hamstring lengthening.

The purpose of this study was to analyze sagittal knee kinematics after hamstring lengthening. A retrospective analysis was performed of 16 children (32 knees) with cerebral palsy who underwent hamstring lengthening as an isolated surgical procedure. Gait analysis was performed before surgery and at a minimum of 1 year after surgery. Decreased stance maximum knee flexion, stance minimum knee flexion, swing maximum knee flexion, and swing minimum knee flexion were noted. Total knee excursion increased. The present study confirmed the previously reported increased total knee excursion with decreased stance minimum and swing maximum knee flexion.

Comparison of fracture versus radiolucent table in the treatment of slipped capital femoral epiphysis.

PURPOSE: Compare slipped capital femoral epiphysis stabilized on fracture versus radiolucent table. METHODS: Twenty unilateral stable mild slipped capital femoral epiphyses were stabilized in-situ with a single screw. Age, sex, side, body-mass index, type of table, anesthesia time, surgery time, fluoroscopy time, number of fluoroscopy images, preoperative/postoperative lateral head-shaft angle, and number of screw threads engaging the epiphysis were noted. RESULTS: There were no differences in the measured parameters. CONCLUSIONS: Stabilization of mild slipped capital femoral epiphysis can be accomplished reliably and safely with the use of either a radiolucent or fracture table.

Sagittal knee kinematics following hamstring lengthening.

The purpose of this study was to analyze sagittal knee kinematics following hamstring lengthening. A retrospective analysis was performed of 16 children (32 knees) with cerebral palsy who underwent hamstring lengthening as an isolated surgical procedure. Gait analysis was performed prior to surgery and at a minimum of one year after surgery. Decreased stance maximum knee flexion, stance minimum knee flexion, swing maximum knee flexion, and swing minimum knee flexion were noted. Total knee excursion increased. The present study confirmed the previously reported increase in total knee excursion with decrease in stance minimum and swing maximum knee flexion after hamstring lengthening.

Fate of the normal uninvolved hip opposite closed reduction of unilateral developmental dislocation of the hip.

The purpose of this study was to determine the incidence of avascular necrosis and acetabular dysplasia in the normal uninvolved contralateral hip opposite a unilateral dislocated hip. Thirty-five children with unilateral developmental dislocation of the hip underwent closed reduction. Medical records were reviewed for gender, side, age at reduction, and presence of the ossific nucleus at reduction. Avascular necrosis was reported as present if there was proximal femoral deformity on postoperative radiographs. Acetabular dysplasia was noted as present based on reported values. The mean age at reduction was 10 months. The mean age at time of follow-up radiograph was 101 months. There was no evidence of avascular necrosis in any of the uninvolved hips. Acetabular dysplasia was present in 22 (63%) uninvolved hips.

Sagittal knee kinematics after rectus femoris transfer without hamstring lengthening.

The purpose of this study was to assess the sagittal knee kinematics of rectus femoris transfer without hamstring lengthening. A retrospective review of seventeen children (29 knees) was performed. Gait analysis was performed prior to surgery and repeated at a minimum of one year after surgery. Sagittal knee kinematics were analyzed. Stance minimum knee flexion increased 7 degrees; swing maximum knee flexion increased 5 degrees; and swing minimum knee flexion increased 5 degrees. The present study confirmed previously reported increases in swing maximum knee flexion. Increases in stance minimum knee flexion and swing minimum knee flexion were also found. These findings have not been previously reported.

Acetabular dysplasia following closed reduction of developmental dislocation of the hip.

The purpose of this study was to determine the incidence of acetabular dysplasia following closed reduction of developmental dislocation of the hip, particularly as it relates to the age at reduction and the presence of the ossific nucleus. Thirty-five children with unilateral developmental dislocation of the hip underwent closed reduction. Medical records were reviewed for gender, side, age at reduction, use of Pavlik harness, prereduction traction, presence/absence of the ossific nucleus, and whether adductor longus tenotomy was performed. Acetabular index was measured. The mean age at reduction was 10 months. The mean length of follow-up was 91 months. Following closed reduction, the incidence of acetabular dysplasia was 69% (24 hips). No statistically significant relationship between acetabular dysplasia and age at reduction or presence of the ossific nucleus was demonstrated.

Reliability of acetabular measures in developmental dysplasia of the hip.

The purpose of this study was to determine the reliability in the measurement of the acetabular index and the acetabular angle in children with developmental dysplasia of the hip. Seventeen children with unilateral developmental dislocation of the hip treated by closed reduction were reviewed. The acetabular index and the acetabular angle of 34 hips were measured twice by two observers. The method of Bland and Altman as outlined by Loder was used to calculate reliability. Mean age at reduction was 9 months. Radiographs were reviewed at a mean of 58 months following reduction. The intraobserver reliability of the acetabular index in involved hips was +/-4.1 degrees. The intraobserver reliability of the acetabular angle for involved hips was +/-3.6 degrees. The interobserver reliability of the acetabular index in involved hips was +/-13.7 degrees. The interobserver reliability of the acetabular angle for involved hips was +/-7.8 degrees. To ensure true change, a single observer should document at least an 8 degrees change in the acetabular index or a 7 degrees change in acetabular angle between two radiographs.

Is operative blood loss associated with valproic acid? Analysis of bilateral femoral osteotomy in children with total involvement cerebral palsy.

Valproic acid (VPA) may increase surgical bleeding. The purpose of this study was to review the effect of VPA on blood loss during bilateral femoral osteotomy in children with cerebral palsy. The medical records of 29 children were retrospectively reviewed. Blood volume, total blood loss, and postoperative blood loss were calculated. Fourteen children were taking no anticonvulsant medications, nine children were taking anticonvulsant medications other than VPA, and six children were taking anticonvulsant medications including VPA. The group taking anticonvulsant medications including VPA had significantly lower preoperative platelet counts (204,000) and a significantly greater incidence of transfusion (50%). Compared with the group taking no anticonvulsant medications, the group taking anticonvulsant medications including VPA had a significantly greater change in hematocrit and greater blood loss. Blood loss and the need for transfusion should be anticipated for in children with cerebral palsy taking VPA who undergo femoral osteotomy.

Demographics of idiopathic clubfoot: is there a seasonal variation?

A seasonal variation in the incidence of idiopathic clubfoot has been reported. The purpose of this study was to determine whether a seasonal variation existed in the authors' population. The medical records of 245 children who presented with idiopathic clubfoot were reviewed. Expected month of birth, month of conception, and season of birth were determined. National Vital Statistics Reports for Births: Final Data for 2001 provided comparison data. The authors' group differed from the national data, with a male predominance and a greater percentage of mothers less than 25 years old at delivery, but was similar in regard to infants born preterm, cesarean delivery, and low birthweight. Analysis failed to identify a monthly or seasonal variation in the authors' population.

Measurement variability of the lateral head-shaft angle in slipped capital femoral epiphysis.

The lateral head-shaft angle as described by Southwick is used to assess the severity of slipped capital femoral epiphysis and to measure progression. Intraobserver variability in measuring the lateral head-shaft angle may influence decision making. The purpose of this study was to determine intraobserver variability in the measurement of the lateral head-shaft angle of slipped capital femoral epiphysis. The lateral head-shaft angle of 108 hips was measured twice by three observers. The two-way analysis of variance method of Bland and Altman as outlined by Loder was used to determine the intraobserver variability. For the lateral head-shaft angle in slipped capital femoral epiphysis, the intraobserver variability was +/-5.9 degrees . To ensure true change, a single observer should document at least a 12 degrees change in the lateral head-shaft angle between two radiographs.