David L. Hepner

Simulation-based trial of surgical-crisis checklists.

BACKGROUND Operating-room crises (e.g., cardiac arrest and massive hemorrhage) are common events in large hospitals but can be rare for individual clinicians. Successful management is difficult and complex. We sought to evaluate a tool to improve adherence to evidence-based best practices during such events. METHODS Operating-room teams from three institutions (one academic medical center and two community hospitals) participated in a series of surgical-crisis scenarios in a simulated operating room. Each team was randomly assigned to manage half the scenarios with a set of crisis checklists and the remaining scenarios from memory alone. The primary outcome measure was failure to adhere to critical processes of care. Participants were also surveyed regarding their perceptions of the usefulness and clinical relevance of the checklists. RESULTS A total of 17 operating-room teams participated in 106 simulated surgical-crisis scenarios. Failure to adhere to lifesaving processes of care was less common during simulations when checklists were available (6% of steps missed when checklists were available vs. 23% when they were unavailable, P<0.001). The results were similar in a multivariate model that accounted for clustering within teams, with adjustment for institution, scenario, and learning and fatigue effects (adjusted relative risk, 0.28; 95% confidence interval, 0.18 to 0.42; P<0.001). Every team performed better when the crisis checklists were available than when they were not. A total of 97% of the participants reported that if one of these crises occurred while they were undergoing an operation, they would want the checklist used. CONCLUSIONS In a high-fidelity simulation study, checklist use was associated with significant improvement in the management of operating-room crises. These findings suggest that checklists for use during operating-room crises have the potential to improve surgical care. (Funded by the Agency for Healthcare Research and Quality.).

Anaphylaxis During the Perioperative Period

Anesthesiologists use a myriad of drugs during the provision of an anesthetic. Many of these drugs have side effects that are dose related, and some lead to severe immune-mediated adverse reactions. Anaphylaxis is the most severe immune-mediated reaction; it generally occurs on reexposure to a specific antigen and requires the release of proinflammatory mediators. Anaphylactoid reactions occur through a direct non-immunoglobulin E-mediated release of mediators from mast cells or from complement activation. Muscle relaxants and latex account for most cases of anaphylaxis during the perioperative period. Symptoms may include all organ systems and present with bronchospasm and cardiovascular collapse in the most severe cases. Management of anaphylaxis includes discontinuation of the presumptive drug (or latex) and anesthetic, aggressive pulmonary and cardiovascular support, and epinephrine. Although a serum tryptase confirms the diagnosis of an anaphylactic reaction, the offending drug can be identified by skinprick, intradermal testing, or serologic testing. Prevention of recurrences is critical to avoid mortality and morbidity.

Crisis Checklists for the Operating Room: Development and Pilot Testing

BACKGROUND Because operating room crises are rare events, failure to adhere to critical management steps is common. We sought to develop and pilot a tool to improve adherence to lifesaving measures during operating room crises. STUDY DESIGN We identified 12 of the most frequently occurring operating room crises and corresponding evidence-based metrics of essential care for each (46 total process measures). We developed checklists for each crisis based on a previously defined method, which included literature review, multidisciplinary expert consultation, and simulation. After development, 2 operating room teams (11 participants) were each exposed to 8 simulations with random assignment to checklist use or working from memory alone. Each team managed 4 simulations with a checklist available and 4 without. One of the primary outcomes measured through video review was failure to adhere to essential processes of care. Participants were surveyed for perceptions of checklist use and realism of the scenarios. RESULTS Checklist use resulted in a 6-fold reduction in failure of adherence to critical steps in management for 8 scenarios with 2 pilot teams. These results held in multivariate analysis accounting for clustering within teams and adjusting for learning or fatigue effects (11 of 46 failures without the checklist vs 2 of 46 failures with the checklist; adjusted relative risk = 0.15, 95% CI, 0.04-0.60; p = 0.007). All participants rated the overall quality of the checklists and scenarios to be higher than average or excellent. CONCLUSIONS Checklist use can improve safety and management in operating room crises. These findings warrant broader evaluation, including in clinical settings.

Patient satisfaction with preoperative assessment in a preoperative assessment testing clinic.

Preoperative Assessment Testing Clinics (PATCs) coordinate preoperative surgical, anesthesia, nursing, and laboratory care. Although such clinics have been noted to lead to efficiencies in perioperative care, patient experience and satisfaction with PATCs has not been evaluated. We distributed a one-page questionnaire consisting of satisfaction with clinical and nonclinical providers to patients presenting to our PATC over three different time periods. Eighteen different questions had five Likert scale options that ranged from excellent (5) to poor (1). We achieved a 71.4% collection rate. The average for the subscale that indicated overall satisfaction was 4.48 ± 0.67 and the average for the total instrument was 4.46 ± 0.55. Although the highest scores were given for subscales describing the anesthesia, nurse, and lab, only the anesthesia subscale improved with time (P = 0.007). The subscale that involved information and communication had the highest correlation with the overall satisfaction subscale (r = 0.76; P < 0.0001). The satisfaction with the total duration of the clinic visit (3.71 ± 1.26) was significantly less (P < 0.0001) than the satisfaction to the other items. The authors conclude that the practitioner and functional aspects of the preoperative visit have a significant impact on patient satisfaction, with information and communication versus the total amount of time spent being the most positive and negative components, respectively.

Value of Preoperative Clinic Visits in Identifying Issues with Potential Impact on Operating Room Efficiency

Background:Preoperative clinics have been shown to decrease operating room delays and cancellations. One mechanism for this positive economic impact is that medical issues are appropriately identified and necessary information is obtained, so that knowledge of the patients’ status is complete before the day of surgery. In this study, the authors describe the identification and management of medical issues in the preoperative clinic. Methods:All patients coming to the Preoperative Clinic during a 3-month period from November 1, 2003, through January 31, 2004, at the Brigham and Women’s Hospital, Boston, Massachusetts, were studied. Data were collected as to the type of issue, information needed to resolve the issue, time to retrieve the information, cancellation and delay rates, and the effect on management. Results:A total of 5,083 patients were seen in the preoperative clinic over the three-month period. A total of 647 patients had a total of 680 medical issues requiring further information or management. Of these issues, 565 were thought to require further information regarding known medical problems, and 115 were new medical problems first identified in the clinic. Most of the new problems required that a new test or consultation be done, whereas most of the old problems required retrieval of information existing from outside medical centers. New problems had a far greater probability of delay (10.7%) or cancellation (6.8%) than old problems (0.6% and 1.8%, respectively). Conclusions:The preoperative evaluation can identify and resolve a number of medical issues that can impact efficient operating room resource use.

Herbal medicine use in parturients

Alternative medicine use has increased dramatically over the last decade. Recently a 22% incidence of herbal medicine use in presurgical patients was reported. Of concern is the potential for these medications to cause adverse drug-herb interactions or other effects such as bleeding complications. We sought to determine the prevalence and pattern of use of herbal remedies in parturients. A one-page questionnaire examining the use of all prescription and nonprescription medications, including herbal remedies, was sent to parturients expected to deliver within 20 wk who had preregistered with the hospital’s admissions office. Sixty-one percent of the parturients responded to the survey, with 7.1% of parturients reporting the use of herbal remedies. Only 14.6% of users considered them to be medications. Parturients in the 41–50 yr age bracket (5.6% of parturients) were the most likely to use herbal remedies (17.1% rate of use in this age group). Many parturients who took herbal remedies (46%) did so on the recommendation of their health care provider.

Abnormal pre-operative tests, pathologic findings of medical history, and their predictive value for perioperative complications.

Laboratory tests, electrocardiogram (ECG) and chest X‐rays still serve as part of the routine assessment before elective surgery in many institutions, even though there is little evidence of their predictive value relating to perioperative complications. This study investigates the correlation of abnormal findings in pre‐operative tests and pathologic findings in the medical history with perioperative complications.

Measuring critical deficits in shared decision making before elective surgery

OBJECTIVE Identifying patient factors correlated with specific needs in preoperative decision making is of clinical and ethical importance. We examined patterns and predictors of deficiencies in informed surgical consent and shared decision-making in preoperative patients. METHODS Validated measures were used to survey 1034 preoperative patients in the preoperative clinic after signed informed consent. Principal component analysis defined correlated groupings of factors. Multivariable analysis assessed patient factors associated with resultant groupings. RESULTS 13% of patients exhibited deficits in their informed consent process; 33% exhibited other types of deficits. Informed consent deficits included not knowing the procedure being performed or risks and benefits. Other deficits included not having addressed patient values, preferences and goals. Non-English language and lower educational level were factors correlated with higher risk for deficits. CONCLUSION Deficits exist in over a third of patients undergoing preoperative decision-making. Sociodemographic factors such as language and educational level identified particularly vulnerable groups at risk for having an incomplete, and possibly ineffective, decision-making process. PRACTICE IMPLICATIONS Interventions to identify vulnerable groups and address patient centered surgical decision making in the pre-operative setting are needed. Focused interventions to address the needs of at-risk patients have potential to improve the surgical decision-making process and reduce disparities.

Preoperative electrocardiograms: patient factors predictive of abnormalities.

Background:Age is often the sole criterion for determining the need for preoperative electrocardiograms. However, screening electrocardiograms have not been shown to add value above clinical information. This study was designed to determine whether it is possible to target electrocardiograms ordering to patients most likely to have an abnormality that would affect management and if age alone is predictive of significant electrocardiograms abnormalities. Methods:A list was developed of electrocardiograms abnormalities considered significant enough to impact management, as well as a list of patient factors believed to increase cardiovascular risk. electrocardiograms in all patients over 50 yr of age presenting for preoperative evaluation during a 2-month period were reviewed. Results:A total of 1,149 electrocardiograms were reviewed, with 89 patients (7.8%) having at least one significant abnormality. These patients were compared with a group of 195 patients who had electrocardiograms that did not contain significant abnormalities. Patients at higher risk of having a significantly abnormal electrocardiograms that would potentially affect management were those older than 65 yr of age or who had a history of heart failure, high cholesterol, angina, myocardial infarction, or severe valvular disease. Five patients (0.44%) had an abnormal electrocardiograms in the absence of risk factors. The sensitivity of the model is 87.6%. Conclusion:Age greater than 65 yr remains an independent predictor for significant preoperative electrocardiograms abnormalities. The specific clinical risk factors that were found have a high sensitivity and identified all but 0.44% of patients with electrocardiograms abnormalities that may affect preoperative management.

Anesthesia in the patient with multiple drug allergies: are all allergies the same?

Purpose of review During the preoperative evaluation, patients frequently indicate ‘multiple drug allergies’, most of which have not been validated. Potential allergic cross-reactivity between drugs and foods is frequently considered as a risk factor for perioperative hypersensitivity. The aim of this review is to facilitate the recognition of risk factors for perioperative anaphylaxis and help the management of patients with ‘multiple drug allergies’ during the perioperative period. Recent findings Neuromuscular blocking agents (NMBAs) and antibiotics are the most common drugs triggering perioperative anaphylaxis. Quaternary ammonium ions have been suggested to be the allergenic determinant of NMBAs. Even though the ‘pholcodine hypothesis’ has been suggested to explain the occurrence of NMBA-induced allergy, this concept remains unclear. Although many practitioners believe that certain food allergies present an issue with the use of propofol, there is no role to contraindicate propofol in egg-allergic, soy-allergic or peanut-allergic patients. IgE-mediated hypersensitivity has been reported with seafood and iodinated drugs, IgE-mediated hypersensitivity has been reported with seafood and iodinated drugs, but there is no cross-reactivity between them. The allergenic determinants have been characterized for fish, shellfish and povidone iodine and remain unknown for contrast agents. Summary There are many false assumptions regarding drug allergies. The main goal of this article is to review the potential cross-reactivity among specific families of drugs and foods in order to facilitate the anesthetic management of patients with ‘multiple drug allergies’.