Atilio Barbeito

Can We Make Postoperative Patient Handovers Safer? A Systematic Review of the Literature

Postoperative patient handovers are fraught with technical and communication errors and may negatively impact patient safety. We systematically reviewed the literature on handover of care from the operating room to postanesthesia or intensive care units and summarized process and communication recommendations based on these findings. From >500 papers, we identified 31 dealing with postoperative handovers. Twenty-four included recommendations for structuring the handover process or information transfer. Several recommendations were broadly supported, including (1) standardize processes (e.g., through the use of checklists and protocols); (2) complete urgent clinical tasks before the information transfer; (3) allow only patient-specific discussions during verbal handovers; (4) require that all relevant team members be present; and (5) provide training in team skills and communication. Only 4 of the studies developed an intervention and formally assessed its impact on different process measures. All 4 interventions improved metrics of effectiveness, efficiency, and perceived teamwork. Most of the papers were cross-sectional studies that identified barriers to safe, effective postoperative handovers including the incomplete transfer of information and other communication issues, inconsistent or incomplete teams, absent or inefficient execution of clinical tasks, and poor standardization. An association between poor-quality handovers and adverse events was also demonstrated. More innovative research is needed to define optimal patient handovers and to determine the effect of handover quality on patient outcomes.

Use of a modifier reduces inconsistency in the American Society of Anesthesiologists Physical Status Classification in parturients.

In this study, we sought to determine whether there is a significant discrepancy among a group of practitioners when rating pregnant patients using the ASA Physical Status Classification and whether this discrepancy could be resolved with the addition of a modifier for pregnancy. Our results indicate that significant discrepancy occurs and that it is reduced with the use of the modifier, especially when referring to the healthy parturient.

Handovers from the OR to the ICU.

The case was long and difficult—a redo sternotomy and coronary artery bypass grafting procedure on a fragile 82-year-old patient. While you are pushing the bed down the hallway, you move cautiously toward the intensive care unit (ICU) because the patient is hemodynamically unstable and receiving high doses of inotropes and intra-aortic balloon pump support. Upon rounding a corner, equipment temporarily being stored in the hallway forces you to swerve forcefully disconnecting the helium tubing from the balloon pump. Alarms chiming, you quickly make it to your assigned ICU bed space to find the receiving ICU nurse absent. She left the bedside to look for a missing pressure cable. You handover the bag-mask system to the respiratory therapist, and she asks whether you had any problems with intubation or ventilation. You want to tell her that intubation was difficult, but you notice that the arterial pressure is very low. “Please don’t disconnect the a-line yet,” you ask the

In situ simulated cardiac arrest exercises to detect system vulnerabilities.

Introduction Sudden cardiac arrest is the leading cause of death in the United States. Despite new therapies, progress in this area has been slow, and outcomes remain poor even in the hospital setting, where providers, drugs, and devices are readily available. This is partly attributed to the quality of resuscitation, which is an important determinant of survival for patients who experience cardiac arrest. Systems problems, such as deficiencies in the physical space or equipment design, hospital-level policies, work culture, and poor leadership and teamwork, are now known to contribute significantly to the quality of resuscitation provided. Methods We describe an in situ simulation-based quality improvement program that was designed to continuously monitor the cardiac arrest response process for hazards and defects and to detect opportunities for system optimization. Results A total of 72 simulated unannounced cardiac arrest exercises were conducted between October 2010 and September 2013 at various locations throughout our medical center and at different times of the day. We detected several environmental, human-machine interface, culture, and policy hazards and defects. We used the Systems Engineering Initiative for Patient Safety (SEIPS) model to understand the structure, processes, and outcomes related to the hospital’s emergency response system. Multidisciplinary solutions were crafted for each of the hazards detected, and the simulation program was used to iteratively test the redesigned processes before implementation in real clinical settings. Conclusions We describe an ongoing program that uses in situ simulation to identify and mitigate latent hazards and defects in the hospital emergency response system. The SEIPS model provides a framework for describing and analyzing the structure, processes, and outcomes related to these events.

The anesthesia team of the future

Purpose of review This review is aimed at highlighting the recent developments and opportunities that are likely to impact the anesthesia team of the future. Recent findings The anesthesia team of the future aims to provide well tolerated, efficient, and cost-effective perioperative care. Certified and subspecialty trained anesthesiologists lead a diverse team of care providers in increasingly dissimilar environments. The spread of electronic health record systems has been the basis for the development of clinical decision support applications that promise to integrate quality control, enhanced efficiency, research opportunities, and improved patient care in the perioperative period. Perioperative epidemiology is a likely area of growth within the field of anesthesiology ultimately enabling the anesthesia team to translate precise real-time information into improved outcome. Summary The anesthesia team of the future will require the anesthesiologist to provide expertise across the entire domain of perioperative medicine. Meaningful decision support systems rely on accurate data analysis and incorporation of current clinical guidelines and recommendations.

Unusual cause of superior vena cava syndrome diagnosed with transesophageal echocardiography

Purpose: An unusual case of superior vena cava (SVC) syndrome caused by an infected right atrial-SVC junction thrombus may be diagnosed using transesophageal echocardiography.Clinical features: A 59-yr-old male with end-stage renal disease requiring hemodialysis presented with fungemia and later developed facial and bilateral upper extremity edema. Transesophageal echocardiography revealed subtotal occlusion of the SVC at its junction with the right atrium. The mass was surgically removed with cardiopulmonary bypass support. Pathological examination of the mass confirmed the presence of a large fungal colony ofCandida species mixed in the thrombus. The patient’s signs and symptoms of SVC obstruction resolved, and he was discharged from the hospital four weeks later in stable condition.Conclusion: Although usually caused by extrinsic tumour compression, SVC syndrome can result from intravascular caval obstruction. This etiology should also be considered in the differential diagnosis, particularly in patients with intravascular devices. Transesophageal echocardiography is a valuable diagnostic tool in these cases.RésuméObjectif: Un cas inhabituel de syndrome de la veine cave supérieure provoqué par un thrombus infecté à la jonction de l’oreillette droite et de la veine cave supérieure peut être dépisté grâce à l’échocardiographie transoesophagienne.Éléments cliniques: Un homme de 59 ans souffrant d’insuffisance rénale terminale et nécessitant une hémodialyse a manifesté une septicémie à champignons, puis un oedème facial et bilatéral des membres supérieurs. L’échocardiographie transoesophagienne a révélé une occlusion sous-totale de la veine cave supérieure à sa jonction avec l’oreillette droite. Une excision chirurgicale de la masse sous circulation extracorporelle a pu être réalisée. L’examen pathologique de la masse a confirmé la présence d’une importante colonie fongique de l’espèce Candida dans le thrombus. Les signes et symptômes d’obstruction de la veine cave supérieure ont disparu, et le patient a reçu son congé de l’hôpital quatre semaines plus tard, dans un état stable.Conclusion: Bien que généralement causé par une compression tumorale extrinsèque, le syndrome de la veine cave supérieure peut être provoqué par une obstruction intravasculaire de la veine cave. Cette étiologie devrait faire partie du diagnostic différentiel, tout particulièrement chez les patients dotés d’appareils intravasculaires. L’échocardiographie transoesophagienne constitue un outil diagnostic précieux dans de tels cas.

Focus: The society of cardiovascular anesthesiologists' initiative to improve quality and safety in the cardiovascular operating room

The Society of Cardiovascular Anesthesiologists (SCA) introduced the FOCUS initiative (Flawless Operative Cardiovascular Unified Systems) in 2005 in response to the need for a rigorous scientific approach to improve quality and safety in the cardiovascular operating room (CVOR). The goal of the project, which is supported by the SCA Foundation, is to identify hazards and develop evidence-based protocols to improve cardiac surgery safety. A hazard is anything that has the potential to cause a preventable adverse event. Specifically, the strategic plan of FOCUS includes 3 goals: (1) identifying hazards in the CVOR, (2) prioritizing hazards and developing risk-reduction interventions, and (3) disseminating these interventions. Collectively, the FOCUS initiative, through the work of several groups composed of members from different disciplines such as clinical medicine, human factors engineering, industrial psychology, and organizational sociology, has identified and documented significant hazards occurring daily in our CVORs. Some examples of frequent occurrences that contribute to reduce the safety and quality of care provided to cardiac surgery patients include deficiencies in teamwork, poor OR design, incompatible technologies, and failure to adhere to best practices. Several projects are currently under way that are aimed at better understanding these hazards and developing interventions to mitigate them. The SCA, through the FOCUS initiative, has begun this journey of science-driven improvement in quality and safety. There is a long and arduous road ahead, but one we need to continue to travel.

Handovers in Perioperative Care

Handovers around the time of surgery are common, yet complex and error prone. Interventions aimed at improving handovers have shown increased provider satisfaction and teamwork, improved efficiency, and improved communication and have been shown to reduce errors and improve clinical outcomes in some studies. Common recommendations in the literature include a standardized institutional process that allows flexibility among different units and settings, the completion of urgent tasks before information transfer, the presence of all members of the team for the duration of the handover, a structured conversation that uses a cognitive aid, and education in team skills and communication.

Goal-directed advanced cardiac life support: coronary perfusion pressure as a target during resuscitation.

Critical Care Medicine www.ccmjournal.org 2817 National Registry of Cardiopulmonary Resuscitation. Resuscitation 2003; 58:297–308 4. Nichol G, Baker D: The epidemiology of sudden death. In: Cardiac Arrest: The Science and Practice of Resuscitation Medicine. Paradis NA, Halperin HR, Kern KB, et al (Eds). Cambridge, Cambridge University Press, 2007, pp 26–48 5. Sandroni C, Nolan J, Cavallaro F, et al: In-hospital cardiac arrest: Incidence, prognosis and possible measures to improve survival. Intensive Care Med 2007; 33:237–245 6. Becker LB, Aufderheide TP, Geocadin RG, et al; American Heart Association Emergency Cardiovascular Care Committee; Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation: Primary outcomes for resuscitation science studies: A consensus statement from the American Heart Association. Circulation 2011; 124:2158–2177 7. Blondin NA, Greer DM: Neurologic prognosis in cardiac arrest patients treated with therapeutic hypothermia. Neurologist 2011; 17:241–248 8. Gershengorn HB, Li G, Kramer A, et al: Survival and functional outcomes after cardiopulmonary resuscitation in the intensive care unit. J Crit Care 2012; 27:421.e9–421.17 9. Marshall RJ: The use of Classification and Regression Trees in clinical epidemiology. J Clin Epidemiol 2001; 54:603–609 10. Jordan D, Steiner M, Kochs EF, et al: A program for computing the prediction probability and the related receiver operating characteristic graph. Anesth Analg 2010; 111:1416–1421 11. Nadkarni VM, Larkin GL, Peberdy MA, et al; National Registry of Cardiopulmonary Resuscitation Investigators: First documented rhythm and clinical outcome from in-hospital cardiac arrest among children and adults. JAMA 2006; 295:50–57

Differentiating between cold agglutinins and rouleaux: a case series of seven patients:

We present a case series of seven patients with suspected cold agglutinin antibodies, discovered after initiation of bypass. Laboratory analysis of blood samples intraoperatively determined the cause of the aggregation to be rouleaux formation in three of the patients and cold agglutinins in the other four.