Antoine Duclos

Influence of Experience on Performance of Individual Surgeons in Thyroid Surgery: Prospective Cross Sectional Multicentre Study

Objective To determine the association between surgeons’ experience and postoperative complications in thyroid surgery. Design Prospective cross sectional multicentre study. Setting High volume referral centres in five academic hospitals in France. Participants All patients who underwent a thyroidectomy undertaken by every surgeon in these hospitals from 1 April 2008 to 31 December 2009. Main outcome measures Presence of two permanent major complications (recurrent laryngeal nerve palsy or hypoparathyroidism), six months after thyroid surgery. We used mixed effects logistic regression to determine the association between length of experience and postoperative complications. Results 28 surgeons completed 3574 thyroid procedures during a one year period. Overall rates of recurrent laryngeal nerve palsy and hypoparathyroidism were 2.08% (95% confidence interval 1.53% to 2.67%) and 2.69% (2.10% to 3.31%), respectively. In a multivariate analysis, 20 years or more of practice was associated with increased probability of both recurrent laryngeal nerve palsy (odds ratio 3.06 (1.07 to 8.80), P=0.04) and hypoparathyroidism (7.56 (1.79 to 31.99), P=0.01). Surgeons’ performance had a concave association with their length of experience (P=0.036) and age (P=0.035); surgeons aged 35 to 50 years had better outcomes than their younger and older colleagues. Conclusions Optimum individual performance in thyroid surgery cannot be passively achieved or maintained by accumulating experience. Factors contributing to poor performance in very experienced surgeons should be explored further.

Patient Mortality Is Associated With Staff Resources and Workload in the ICU: A Multicenter Observational Study.

Objective:Matching healthcare staff resources to patient needs in the ICU is a key factor for quality of care. We aimed to assess the impact of the staffing-to-patient ratio and workload on ICU mortality. Design:We performed a multicenter longitudinal study using routinely collected hospital data. Setting:Information pertaining to every patient in eight ICUs from four university hospitals from January to December 2013 was analyzed. Patients:A total of 5,718 inpatient stays were included. Interventions:None. Measurements and Main Results:We used a shift-by-shift varying measure of the patient-to-caregiver ratio in combination with workload to establish their relationships with ICU mortality over time, excluding patients with decision to forego life-sustaining therapy. Using a multilevel Poisson regression, we quantified ICU mortality-relative risk, adjusted for patient turnover, severity, and staffing levels. The risk of death was increased by 3.5 (95% CI, 1.3–9.1) when the patient-to-nurse ratio was greater than 2.5, and it was increased by 2.0 (95% CI, 1.3–3.2) when the patient-to-physician ratio exceeded 14. The highest ratios occurred more frequently during the weekend for nurse staffing and during the night for physicians (p < 0.001). High patient turnover (adjusted relative risk, 5.6 [2.0–15.0]) and the volume of life-sustaining procedures performed by staff (adjusted relative risk, 5.9 [4.3–7.9]) were also associated with increased mortality. Conclusions:This study proposes evidence-based thresholds for patient-to-caregiver ratios, above which patient safety may be endangered in the ICU. Real-time monitoring of staffing levels and workload is feasible for adjusting caregivers’ resources to patients’ needs.

Influence of Intraoperative Neuromonitoring on Surgeons’ Technique During Thyroidectomy

BackgroundWhen assessing the value of intraoperative nerve monitoring (IONM) during routine thyroidectomy, it is necessary to consider its influence on the surgeon’s dissection technique. We investigated the effect of IONM on individual surgeon performance by determining the learning curve associated with this tool.MethodsA one-year prospective study was conducted between May 2008 and April 2009 within a team of three experienced endocrine surgeons. The measure of surgical performance was based on the detection of immediate postoperative recurrent laryngeal nerve palsy by laryngoscopy. Individual learning curves associated with IONM acquisition were drawn with the cumulative sum (CUSUM) chart. Each surgeon was questioned about possible changes he had experienced in his own surgical technique after the introduction of IONM.ResultsA total of 475 consecutive patients who underwent thyroid surgery with IONM were included. The pattern of learning curves varied among surgeons and ranged from 35 to 304 procedures required for complete IONM acquisition. The surgeon with the longest learning curve also described a drastic modification of his technique related to nerve dissection.ConclusionsIntraoperative nerve monitoring can induce changes in surgical practice. The different learning curve patterns among surgeons may reflect the variable degree to which surgeons will modify their own dissection technique. Such an effect on learning must be considered when assessing the impact of using IONM on patient safety.

Invasive aspergillosis in patients with hematologic malignancies: incidence and description of 127 cases enrolled in a single institution prospective survey from 2004 to 2009

Background The study objectives were: 1) to report on invasive aspergillosis patients in a hematology department; and 2) to estimate its incidence according to the hematologic diagnosis. Design and Methods A prospective survey of invasive aspergillosis cases was undertaken between January 2004 and December 2009 in the hematology department of a university hospital. Meetings with clinicians, mycologists and infection control practitioners were organized monthly to confirm suspected aspergillosis cases. Demographic characteristics, clinical and complementary examination results were recorded prospectively. Information on hospitalization was extracted from administrative databases. Invasive aspergillosis diagnosis followed the European Organization for Research and Treatment of Cancer criteria, and proven and probable IA cases were retained. A descriptive analysis was conducted with temporal trends of invasive aspergillosis incidence assessed by adjusted Poisson regression. Results Overall, 4,073 hospitalized patients (78,360 patient-days) were included in the study. In total, 127 (3.1%) patients presented invasive aspergillosis. The overall incidence was 1.6 per 1,000 patient-days (95% confidence interval: 1.4, 1.9) with a decrease of 16% per year (−1%, −28%). The incidence was 1.9 per 1,000 patient-days (1.5, 2.3) in acute myeloid leukemia patients with a decrease of 20% per year (−6%, −36%). Serum Aspergillus antigen was detected in 89 (71%) patients; 29 (23%) had positive cultures, and 118 (93%), abnormal lung CT scans. One-month mortality was 13%; 3-month mortality was 42%. Mortality tended to decrease between 2004 and 2009. Conclusions Invasive aspergillosis incidence and mortality declined between 2004 and 2009. Knowledge of invasive aspergillosis characteristics and its clinical course should help to improve the management of these patients with severe disease.

The influence of volume and experience on individual surgical performance: a systematic review.

OBJECTIVE To systematically review studies evaluating the influence of surgical experience on individual performance. BACKGROUND Experience, measured in case volume or years of practice, is recognized as a key driver of individual surgical performance, giving rise to a learning curve. However, this topic has not been reviewed at the cross-specialty level. METHODS MEDLINE, EMBASE, PsycINFO, AMED, and the Cochrane Database of Systematic Reviews were searched (from inception to February 2013). Two reviewers independently reviewed citations using predetermined inclusion and exclusion criteria. Ninety-one data points per study were extracted. RESULTS The search strategy yielded 6950 citations. Fifty-seven studies were eligible, including 1,061,913 cases and 35 procedure types, performed by 17,912 surgeons. Forty-five studies monitored case volume, and 6 studies measured experience as both case volume and years of practice. Of these 51 studies, 44 found that increased case volume was associated with significantly improved health outcomes. Several studies noted a plateau phase or maturation in the surgical learning curve. Acquisition of this phase was procedure specific and outcome specific, ranging from 25 to 750 procedures. Twelve studies assessed the impact of years of surgical practice, 11 of which found that increased years of experience was associated with significantly improved health outcomes. Two studies noted a plateau phase, where increases in years of experience were no longer associated with improvements in operative outcomes. Three studies identified performance deterioration after the plateau phase. CONCLUSIONS Increasing surgical case volume and years of practice are associated with improved performance, in a procedure-specific manner. Performance may deteriorate toward the end of a surgeons career.

Cumulative team experience matters more than individual surgeon experience in cardiac surgery.

OBJECTIVES Individual surgeon experience and the cumulative experience of the surgical team have both been implicated as factors that influence surgical efficiency. We sought to quantitatively evaluate the effects of both individual surgeon experience and the cumulative experience of attending surgeon-cardiothoracic fellow collaborations in isolated coronary artery bypass graft (CABG) procedures. METHODS Using a prospectively collected retrospective database, we analyzed all medical records of patients undergoing isolated CABG procedure at our institution. We used multivariate generalized estimating equation regression models to adjust for patient mix and subsequently evaluated the effect of both attending cardiac surgeon experience (since fellowship graduation) and the number of previous collaborations between attending cardiac surgeons and cardiothoracic fellow pairs on cardiopulmonary bypass and crossclamp times. RESULTS From 2001 to 2010, 4068 consecutive patients underwent isolated CABG procedure at our institution performed by 11 attending cardiac surgeons and 73 cardiothoracic fellows. Mean attending experience after fellowship graduation was 10.9 ± 8.0 years and mean number of cases between unique pairs of attending cardiac surgeons and cardiothoracic fellows was 10.0 ± 10.0 cases. After patient risk adjustment, both attending surgical experience since fellowship graduation and the number of previous collaborations between attending surgeons and cardiothoracic fellows were significantly associated with a reduction in cardiopulmonary bypass and crossclamp times (P < .001). The influence of attending-fellow pair experience far exceeded the influence of surgical experience with beta estimates for attending-fellow pair experience nearly three times that of attending surgeon experience. CONCLUSIONS Cumulative experience of attending cardiac surgeons and cardiothoracic fellows has a dramatic effect on both cardiopulmonary bypass and crossclamp times, whereas attending cardiac surgeon learning curves following fellowship graduation are clinically insignificant. Taken together, these findings suggest that the primary driver of operative efficiency in CABG procedure is the collaborative experience of the attending surgeon-cardiothoracic fellow operative team, rather than the individual experience of the attending surgeon.

Technical Refinement and Learning Curve for Attenuating Neurapraxia During Robotic-Assisted Radical Prostatectomy to Improve Sexual Function

BACKGROUND While radical prostatectomy surgeon learning curves have characterized less blood loss, shorter operative times, and fewer positive margins, there is a dearth of studies characterizing learning curves for improving sexual function. Additionally, while learning curve studies often define volume thresholds for improvement, few of these studies demonstrate specific technical modifications that allow reproducibility of improved outcomes. OBJECTIVE Demonstrate and quantify the learning curve for improving sexual function outcomes based on technical refinements that reduce neurovascular bundle displacement during nerve-sparing robot-assisted radical prostatectomy (RARP). DESIGN, SETTING, AND PARTICIPANTS We performed a retrospective study of 400 consecutive RARPs, categorized into groups of 50, performed after elimination of continuous surgeon/assistant neurovascular bundle countertraction. SURGICAL PROCEDURE Our approach to RARP has been described previously. A single-console robotic system was used for all cases. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Expanded Prostate Cancer Index Composite sexual function was measured within 1 yr of RARP. Linear regression was performed to determine factors influencing the recovery of sexual function. RESULTS AND LIMITATIONS Greater surgeon experience was associated with better 5-mo sexual function (p = 0.007) and a trend for better 12-mo sexual function (p = 0.061), with improvement plateauing after 250-300 cases. Additionally, younger patient age (both p<0.02) and better preoperative sexual function (<0.001) were associated with better 5- and 12-mo sexual function. Moreover, trainee robotic console time during nerve sparing was associated with worse 12-mo sexual function (p=0.021), while unilateral nerve sparing/non-nerve sparing was associated with worse 5-mo sexual function (p = 0.009). Limitations include the retrospective single-surgeon design. CONCLUSIONS With greater surgeon experience, attenuating lateral displacement of the neurovascular bundle and resultant neurapraxia improve postoperative sexual function. However, to maximize outcomes, appropriate patient selection must be exercised when allowing trainee nerve-sparing involvement.

Impact of a multifaceted program to prevent postoperative delirium in the elderly: the CONFUCIUS stepped wedge protocol

BackgroundPostoperative delirium is common in the elderly and is associated with a significant increase in mortality, complications, length of hospital stay and admission in long care facility. Although several interventions have proved their effectiveness to prevent it, the Cochrane advises an assessment of multifaceted intervention using rigorous methodology based on randomized study design. Our purpose is to present the methodology and expected results of the CONFUCIUS trial, which aims to measure the impact of a multifaceted program on the prevention of postoperative delirium in elderly.Method/DesignStudy design is a stepped wedge cluster randomized trial within 3 surgical wards of three French university hospitals. All patients aged 75 and older, and admitted for scheduled surgery will be included. The multifaceted program will be conducted by mobile geriatric team, including geriatric preoperative consultation, training of the surgical staff and implementation of the Hospital Elder Life Program, and morbidity and mortality conference related to delirium cases. The primary outcome is based on postoperative delirium rate within 7 days after surgery. This program is planned to be implemented along four successive time periods within all the surgical wards. Each one will be affected successively to the control arm and to the intervention arm of the trial and the order of program introduction within each surgical ward will be randomly assigned. Based on a 20% reduction of postoperative delirium rate (ICC = 0.25, α = 0.05, β = 0.1), three hundred sixty patients will be included i.e. thirty patients per service and per time period. Endpoints comparison between intervention and control arms of the trial will be performed by considering the cluster and time effects.DiscussionBetter prevention of delirium is expected from the multifaceted program, including a decrease of postoperative delirium, and its consequences (mortality, morbidity, postoperative complications and length of hospital stay) among elderly patients. This study should allow better diagnosis of delirium and strengthen the collaboration between surgical and mobile geriatric teams. Should the program have a substantial impact on the prevention of postoperative delirium in elderly, it could be extended to other facilities.Trial registrationClinicalTrials.gov: NCT01316965

The p-control chart: a tool for care improvement

BACKGROUND The p-chart is a user-friendly tool for monitoring adverse events. By converting data into knowledge, it is helpful in interpreting and reducing sources of variability in care. Certain basics for developing expertise to use p-charts correctly are necessary. PURPOSE This paper provides key elements on how to develop and interpret a p-chart for clinical practice, how to successfully integrate this tool within a comprehensive approach, and how to report a study based on p-chart utilization. P-chart building The p-chart combines time series analysis with a graphical presentation of data by plotting successive indicator measurements in chronological order. The pragmatic choice of well-defined indicators to be monitored is essential. Exact control limits based on the binomial distribution and the incorporation of risk adjustment represent important contributions for further improving the tools performance in health-care settings. P-chart implementation The solution needed to reduce adverse events is not available from measurement alone. The success of routine introduction of the p-chart requires investigation of the causes of indicator variations and the trying out of quality improvement initiatives. It must be supported by strong management leadership within an atmosphere of constructive evaluation. Perspectives The implementation of the p-chart into clinical practice encourages practitioners to continuously undertake a critical examination of the care delivered. Nearly a century after it was created in the manufacturing industry, the control chart now contributes to improving the quality of health-care processes and patient safety.

Quality monitoring in thyroid surgery using the Shewhart control chart

A control chart can help to interpret and reduce sources of variability in patient safety by continuously monitoring indicators. The aim of this study was to monitor the outcome of thyroid surgery using control charts.