Amin Madani

An enhanced recovery pathway reduces duration of stay and complications after open pulmonary lobectomy.

BACKGROUND Few studies have investigated the effectiveness of enhanced recovery pathways (ERP) for lung resection. This study estimates the impact of an ERP for lobectomy on duration of stay, complications, and readmissions. METHODS Patients undergoing open lobectomy were identified from an OR database between 2011 and 2013. Beginning September 2012, all patients were managed according to a 4-day multidisciplinary ERP with written daily patient education treatment plans, multimodal analgesia, early diet, structured mobilization and standardized drain management. Pre-pathway (PRE) and post-pathway (POST) patients were compared in terms of duration of stay, complications, and readmissions. RESULTS We identified 234 patients (PRE, 127; POST, 107). Groups were similar with respect to age, gender, American Society of Anesthesiologists score, and baseline pulmonary function. Compared with the PRE group, the POST group had decreased duration of stay (median, 6 [interquartile range (IQR), 5-7] vs 7 [6-10] days; P < .05), total complications (40 [37%] vs 64 [50%]; P < .05), urinary tract infections (3 [3%] vs 15 [12%]; P < .05), and chest tube duration (median, 4 [IQR, 3-6] vs 5 [4-7] days; P < .05), with no difference in readmissions (7 [7%] vs 6 [5%]; P < .05) or chest tube reinsertion (4 [4%] vs 6 [5%]; P < .05). Decreased duration of stay was driven by patients without complications (median, 5 [IQR, 4-6] vs 6 [5-7] days; P < .05). CONCLUSION Implementation of a multimodal ERP for lobectomy was associated with decreased duration of stay and complications with no difference in readmissions.

Fundamental Use of Surgical Energy™ (FUSE): a curriculum on surgical energy-based devices

The Fundamental Use of Surgical Energy (FUSE) is a new curriculum developed by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). Surgeons and anesthesiologists can earn CME credits, nurses can earn CEUs, and those who master the curriculum content can obtain a certificate. But why is this needed? Almost every surgical procedure, regardless of specialty or geographic location, involves the use of devices that apply energy to tissues. This practice has existed for thousands of years, whether it is cautery used by Egyptians in 3000 BCE to manage hemorrhagic shock [1] or Bovie’s revolutionary electrosurgical unit introduced by Cushing into surgical practice in the early twentieth century [2]. Since their introduction, electrosurgical devices have become ubiquitous throughout operating theaters, endoscopy suites, and other procedural rooms. One of the most remarkable developments in surgery over the last two decades has been the introduction of a large variety of complex and task-specific energy devices, incorporating novel technologies, newer designs, and advanced functions. Common examples include ultrasonic devices using mechanical energy, advanced bipolar electrosurgical devices with cutting blades and impedance measurement, and image-guided radiofrequency ablation instruments. Regardless of one’s practice, the momentum in surgical energy innovation has transformed the operating room and endoscopy suite into a place with a wide array of technologies and tools. The success of energy devices is largely due to their ease of use, diverse configurations and proven utility for hemostasis, tissue dissection, and ablation. However, this success poses safety challenges. Energy devices can lead to severe iatrogenic complications, including operating room fires, accidental tissue injury, and interference with other implantable medical devices (e.g., pacemakers, implantable cardiac defibrillators). One contributing factor is that the devices tend to be poorly understood by operators, regardless of their level of experience [3]. Many surgeons For the SAGES FUSE Task Force: Sharon L. Bachman, L. Michael Brunt, Bipan Chand, Suvranu De, Warren S. Grundfest, Daniel M. Herron, Gretchen Purcell Jackson, Stephanie B Jones, Dean J. Mikami, Malcolm Munro, Chan W. Park, William S. Richardson.

What Are the Principles That Guide Behaviors in the Operating Room?: Creating a Framework to Define and Measure Performance.

Objective: To identify the core principles that guide expert intraoperative behaviors and to use these principles to develop a universal framework that defines intraoperative performance. Background: Surgical outcomes are associated with intraoperative cognitive skills. Yet, our understanding of factors that control intraoperative judgment and decision-making are limited. As a result, current methods for training and measuring performance are somewhat subjective—more task rather than procedure-oriented—and usually not standardized. They thus provide minimal insight into complex cognitive processes that are fundamental to patient safety. Methods: Cognitive task analyses for 6 diverse surgical procedures were performed using semistructured interviews and field observations to describe the thoughts, behaviors, and actions that characterize and guide expert performance. Verbal data were transcribed, supplemented with content from published literature, coded, thematically analyzed using grounded-theory by 4 independent reviewers, and synthesized into a list of items. Results: A conceptual framework was developed based on 42 semistructured interviews lasting 45 to 120 minutes, 5 expert panels and 51 field observations involving 35 experts, and 135 sources from the literature. Five domains of intraoperative performance were identified: psychomotor skills, declarative knowledge, advanced cognitive skills, interpersonal skills, and personal resourcefulness. Within the advanced cognitive skills domain, 21 themes were perceived to guide the behaviors of surgeons: 18 for surgical planning and error prevention, and 3 for error/injury recognition, rescue, and recovery. The application of these thought patterns was highly case-specific and variable amongst subspecialties, environments, and individuals. Conclusions: This study provides a comprehensive definition of intraoperative expertise, with greater insight into the complex cognitive processes that seem to underlie optimal performance. This framework provides trainees and other nonexperts with the necessary information to use in deliberate practice and the creation of effective thought habits that characterize expert performance. It may help to identify gaps in performance, and to isolate root causes of surgical errors with the ultimate goal of improving patient safety.

Expert Intraoperative Judgment and Decision-Making: Defining the Cognitive Competencies for Safe Laparoscopic Cholecystectomy

BACKGROUND Bile duct injuries from laparoscopic cholecystectomy remain a significant source of morbidity and are often the result of intraoperative errors in perception, judgment, and decision-making. This qualitative study aimed to define and characterize higher-order cognitive competencies required to safely perform a laparoscopic cholecystectomy. STUDY DESIGN Hierarchical and cognitive task analyses for establishing a critical view of safety during laparoscopic cholecystectomy were performed using qualitative methods to map the thoughts and practices that characterize expert performance. Experts with more than 5 years of experience, and who have performed at least 100 laparoscopic cholecystectomies, participated in semi-structured interviews and field observations. Verbal data were transcribed verbatim, supplemented with content from published literature, coded, thematically analyzed using grounded-theory by 2 independent reviewers, and synthesized into a list of items. RESULTS A conceptual framework was created based on 10 interviews with experts, 9 procedures, and 18 literary sources. Experts included 6 minimally invasive surgeons, 2 hepato-pancreatico-biliary surgeons, and 2 acute care general surgeons (median years in practice, 11 [range 8 to 14]). One hundred eight cognitive elements (35 [32%] related to situation awareness, 47 [44%] involving decision-making, and 26 [24%] action-oriented subtasks) and 75 potential errors were identified and categorized into 6 general themes and 14 procedural tasks. Of the 75 potential errors, root causes were mapped to errors in situation awareness (24 [32%]), decision-making (49 [65%]), or either one (61 [81%]). CONCLUSIONS This study defines the competencies that are essential to establishing a critical view of safety and avoiding bile duct injuries during laparoscopic cholecystectomy. This framework may serve as the basis for instructional design, assessment tools, and quality-control metrics to prevent injuries and promote a culture of patient safety.

Fundamental use of surgical energy (FUSE) closing a gap in medical education

Traditional medical education curricula for students, residents and trainees do not address the rapidly growing number of technological devices that are fundamentally changing health care delivery today. This is most relevant in those medical specialties that rely heavily on the use of advanced technologies and devices, for example minimally invasive surgery, interventional radiology, gastroenterology, cardiology and anesthesia. Health care professionals in these domains are increasingly sharing procedures that use energy devices of many different designs and functionality without training in their fundamental use and safety. This exposes both operators and patients to increasing risk for injury. The definitive gap in adequate education and training in new technologies prompted the development of The Fundamental Use of Surgical Energy (FUSE) program by a multidisciplinary team of clinicians, nurses, educators and engineers under the leadership of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). The sweeping changes in the surgical and interventional professions due to technological innovation call for the development of additional curricula to close the educational gap on other medically important technologies. The FUSE program and future educational curricula on medical technologies are fundamental to patient care and represent a necessary paradigm shift in traditional medical education.

Selective strategy for intensive monitoring after pheochromocytoma resection.

BACKGROUND Guidelines recommend 24-48 hours of intensive monitoring after resection of pheochromocytoma. However, many patients do not require it. The objective of this study is to identify preoperative risk factors associated with postoperative hemodynamic instability (HDI) so as to select patients who may not require intensive postoperative monitoring. METHODS Medical records of patients undergoing pheochromocytoma resection over a 12-year period were reviewed. Postoperative HDI was defined as systolic blood pressure of >200 or <90, heart rate >110 or <50 or needing active resuscitation. RESULTS We included 41 patients; 49% had postoperative HDI but only 34% had HDI > 6 hours. Risk factors for HDI were preoperative mean arterial pressure (MAP) > 100 mm Hg (14% vs 45%), norepinephrine/normetanephrine levels >3x normal (44 vs 82%), and resection of another solid organ (0 vs 20%). Avoidance of planned postoperative monitoring for low-risk patients would have reduced estimated costs by 34%. CONCLUSION Fewer than one-half of patients undergoing resection for pheochromocytoma benefit from intensive monitoring. High preoperative MAP, high norepinephrine/normetanephrine levels, and concomitant resection of another organ are risk factors for postoperative HDI. After a 6-hour interval of postoperative stability, selective rather than routine use of intensive monitoring may be an efficient strategy for monitoring lower risk patients.

The SAGES Fundamental Use of Surgical Energy program (FUSE): history, development, and purpose

BackgroundAdverse events due to energy device use in surgical operating rooms are a daily occurrence. These occur at a rate of approximately 1–2 per 1000 operations. Hundreds of operating room fires occur each year in the United States, some causing severe injury and even mortality. The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) therefore created the first comprehensive educational curriculum on the safe use of surgical energy devices, called Fundamental Use of Surgical Energy (FUSE). This paper describes the history, development, and purpose of this important training program for all members of the operating room team.MethodsThe databases of SAGES and the FUSE committee as well as personal photographs and documents of members of the FUSE task force were used to establish a brief history of the FUSE program from its inception to its current status.ResultsThe authors were able to detail all aspects of the history, development, and national as well as global implementation of the third SAGES Fundamentals Program FUSE.ConclusionsThe written documentation of the making of FUSE is an important contribution to the history and mission of SAGES and allows the reader to understand the idea, concept, realization, and implementation of the only free online educational tool for physicians on energy devices available today. FUSE is the culmination of the SAGES efforts to recognize gaps in patient safety and develop state-of-the-art educational programs to address those gaps. It is the goal of the FUSE task force to ensure that general FUSE implementation becomes multinational, involving as many countries as possible.

Effectiveness of Telementoring in Surgery Compared With On-site Mentoring: A Systematic Review

Background. Mentorship is important but may not be feasible for distance learning. To bridge this gap, telementoring has emerged. The purpose of this systematic review was to evaluate the effectiveness of telementoring compared with on-site mentoring. Methods. A search was done up to March 2015. Studies were included if they used telementoring between surgeons during a clinical encounter and if they compared on-site mentoring and telementoring. Results. A total of 11 studies were included. All reported no difference in complication rates, and 9 (82%) reported similar operative times; 4 (36%) reported technical issues, which was 3% of the total number of cases in the 11 studies. No study reported on higher levels of evidence for effectiveness of telementoring as an educational intervention. Conclusion. Studies reported that telementoring is associated with similar complication rates and operative times compared with on-site mentoring. However, the level of evidence to support the effectiveness of telementoring as a training tool is limited. There is a need for studies that provide evidence for the equivalence of the effectiveness of telementoring as an educational intervention in comparison with on-site mentoring.

Evaluating the role of simulation in healthcare innovation: recommendations of the Simnovate Medical Technologies Domain Group

Background Innovation in healthcare is the practical application of new concepts, ideas, processes or technologies into clinical practice. Despite its necessity and potential to improve care in measurable ways, there are several issues related to patient safety, high costs, high failure rates and limited adoption by end-users. This mixed-method study aims to explore the role of simulation as a potential testbed for diminishing the risks, pitfalls and resources associated with development and implementation of medical innovations. Methods Subject-matter experts consisting of physicians, engineers, scientists and industry leaders participated in four semistructured teleconferences each lasting up to 2 hours each. Verbal data were transcribed verbatim, coded and categorised according to themes using grounded theory, and subsequently synthesised into a conceptual framework. Panelists were then invited to complete an online survey, ranking the (1) current use and (2) potential effectiveness of simulation-based technologies and techniques for evaluating and facilitating the product life cycle pathway. This was performed for each theme of the previously generated conceptual framework using a Likert scale of 1 (no effectiveness) to 9 (highest possible effectiveness) and then segregated according to various forms of simulation. Results Over 100 hours of data were collected and analysed. After 7 rounds of inductive data analysis, a conceptual framework of the product life cycle was developed. This framework helped to define and characterise the product development pathway. Agreement between reviewers for inclusion of items after the final round of analysis was 100%. A total of 7 themes were synthesised and categorised into 3 phases of the pathway: ‘design and development’, ‘implementation and value creation’ and ‘product launch’. Strong discrepancies were identified between the current and potential roles of simulation in each phase. Simulation was felt to have the strongest potential role for early prototyping, testing for safety and product quality and testing for product effectiveness and ergonomics. Conclusions Simulation has great potential to fulfil several unmet needs in healthcare innovation. This framework can be used to help guide innovators and channel resources appropriately. The ultimate goal is a structured, well-defined process that will result in a product development outcome that has the greatest potential to succeed.

Open repair of inflammatory abdominal aortic aneurysm and aortocaval fistula using retrograde balloon occlusion.

Purpose: The purpose of this report is to describe a novel endovascular technique used to minimize blood loss during the open repair of an aortocaval fistula (ACF) in the context of an inflammatory abdominal aortic aneurysm (AAA). Case Report: We describe a patient who presented to our hospital with a symptomatic infrarenal AAA which was discovered intraoperatively to contain a large ACF. The patient underwent successful transperitoneal open repair of the AAA with balloon occlusion of the inferior vena cava to obtain distal control of the vessel. Conclusions: Retrograde balloon occlusion of the inferior vena cava can be used to control hemorrhage during the open repair of an ACF, especially in the challenging setting of an inflammatory AAA.