James Forrest Calland

A systems approach to surgical safety.

ConclusionThe documented and “accepted” incident rates in surgery are unacceptably high. Incident rates of 1–5% are generally accepted as a normal part of practice. Current morbidity and mortality reporting, while important, does not sufficiently examine or expose the active and latent errors that lead to adverse outcomes. Further. there is no process in place for systematically learning from surgical incident data so that appropriate changes can be incorporated in practice. Other high-risk industries have shown that process improvements, as well as the promotion of a culture of safety, can have a significant impact on an industry’s safety record. The establishment of surgical protocols and checklists has the potential to improve the standards of training and practice, as well as enhancing operating room communications. Data collection and analysis can identify latent errors that could be addressed through better training, device design, or surgical methods. Computerbased training could be instituted to allow surgeons to practice the perceptual, decision-making, and problemsolving skills that are a major part of surgery. These kinds of activities have been incorporated successfully into other industries and should also be applied to the practice of surgery.

Evaluation and management of geriatric trauma: an Eastern Association for the Surgery of Trauma practice management guideline.

BACKGROUND Aging patients constitute an increasing proportion of patients treated at trauma centers. Previous and existing guidelines addressing care of the injured elder have not adequately addressed emerging data regarding optimal means for undertaking triage decisions, correcting coagulopathy, and the limitations of supraphysiologic resuscitation. METHODS More than 400 MEDLINE citations published between the years 2000 and 2008 were identified and screened. A total of 90 references were selected for the evidentiary table followed by consensus-based discussions regarding the level of evidence and the strength of recommendations that could be derived from the related findings of the individual studies. RESULTS In general, a lower threshold for trauma activation should be used for injured patients aged 65 years or older who are evaluated at trauma centers. Furthermore, elderly patients with at least one body system with an AIS score of 3 or higher or a base deficit of −6 or less should be treated at trauma centers, preferably in intensive care units staffed by surgeon-intensivists. In addition, all elderly patients who receive daily therapeutic anticoagulation should have appropriate assessment of their coagulation profile and cross-sectional imaging of the brain as soon as possible after admission where appropriate. In patients aged 65 years or older with a Glasgow Coma Scale (GCS) score less than 8, if substantial improvement in GCS is not realized within 72 hours of injury, consideration should be given to limiting further aggressive therapeutic interventions. CONCLUSION Effective evidence-based care of aging patients necessitates aggressive triage, correction of coagulopathy, and limitation of care when clinical evidence points toward an overwhelming likelihood of poor long-term prognosis.

Improving surgical pattern recognition through repetitive viewing of video clips

Previous field studies show that surgery residents and medical students have difficulty recognizing appropriate anatomic cues during laparoscopic surgery, causing delays in procedures and errors. Such observations led to the development of an anatomy recognition training intervention, specifically the use of an ordered set of video clips that show the main steps of a laparoscopic procedure. Each procedural step is shown several times in succession, with each repetition coming from a different surgery, thus exposing the learner to varied anatomy and crucial maneuvers. A factorial experiment with 30 medical students showed that the group using these ordered, perceptual learning modules had a significant increase in scores on questions assessing perceptual knowledge and procedural knowledge, with no corresponding increase for the control group who watched the videos from the same cases but in an unstructured format for the same amount of time (p< 0.05). Neither group showed improvement on strategic or declarative knowledge tests. The study suggests that ordered perceptual learning modules are a potential means for training perceptual and procedural knowledge in an effective, safe, and efficient manner, serving as a complement to other types of training methods that teach physical dexterity, strategic and declarative knowledge.

New-onset Atrial Fibrillation in the Critically Ill*

Objective: To determine the association of new-onset atrial fibrillation with outcomes, including ICU length of stay and survival. Design: Retrospective cohort of ICU admissions. We found atrial fibrillation using automated detection (≥ 90 s in 30 min) and classed as new-onset if there was no prior diagnosis of atrial fibrillation. We identified determinants of new-onset atrial fibrillation and, using propensity matching, characterized its impact on outcomes. Setting: Tertiary care academic center. Patients: A total of 8,356 consecutive adult admissions to either the medical or surgical/trauma/burn ICU with available continuous electrocardiogram data. Interventions: None. Measurements and Main Results: From 74 patient-years of every 15-minute observations, we detected atrial fibrillation in 1,610 admissions (19%), with median burden less than 2%. Most atrial fibrillation was paroxysmal; less than 2% of admissions were always in atrial fibrillation. New-onset atrial fibrillation was subclinical or went undocumented in 626, or 8% of all ICU admissions. Advanced age, acute respiratory failure, and sepsis were the strongest predictors of new-onset atrial fibrillation. In propensity-adjusted regression analyses, clinical new-onset atrial fibrillation was associated with increased hospital mortality (odds ratio, 1.63; 95% CI, 1.01–2.63) and longer length of stay (2.25 d; CI, 0.58–3.92). New-onset atrial fibrillation was not associated with survival after hospital discharge (hazard ratio, 0.99; 95% CI, 0.76–1.28 and hazard ratio, 1.11; 95% CI, 0.67–1.83, respectively, for subclinical and clinical new-onset atrial fibrillation). Conclusions: Automated analysis of continuous electrocardiogram heart rate dynamics detects new-onset atrial fibrillation in many ICU patients. Though often transient and frequently unrecognized, new-onset atrial fibrillation is associated with poor hospital outcomes.

Signatures of Subacute Potentially Catastrophic Illness in the ICU: Model Development and Validation.

Objectives: Patients in ICUs are susceptible to subacute potentially catastrophic illnesses such as respiratory failure, sepsis, and hemorrhage that present as severe derangements of vital signs. More subtle physiologic signatures may be present before clinical deterioration, when treatment might be more effective. We performed multivariate statistical analyses of bedside physiologic monitoring data to identify such early subclinical signatures of incipient life-threatening illness. Design: We report a study of model development and validation of a retrospective observational cohort using resampling (Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis type 1b internal validation) and a study of model validation using separate data (type 2b internal/external validation). Setting: University of Virginia Health System (Charlottesville), a tertiary-care, academic medical center. Patients: Critically ill patients consecutively admitted between January 2009 and June 2015 to either the neonatal, surgical/trauma/burn, or medical ICUs with available physiologic monitoring data. Interventions: None. Measurements and Main Results: We analyzed 146 patient-years of vital sign and electrocardiography waveform time series from the bedside monitors of 9,232 ICU admissions. Calculations from 30-minute windows of the physiologic monitoring data were made every 15 minutes. Clinicians identified 1,206 episodes of respiratory failure leading to urgent unplanned intubation, sepsis, or hemorrhage leading to multi-unit transfusions from systematic individual chart reviews. Multivariate models to predict events up to 24 hours prior had internally validated C-statistics of 0.61–0.88. In adults, physiologic signatures of respiratory failure and hemorrhage were distinct from each other but externally consistent across ICUs. Sepsis, on the other hand, demonstrated less distinct and inconsistent signatures. Physiologic signatures of all neonatal illnesses were similar. Conclusions: Subacute potentially catastrophic illnesses in three diverse ICU populations have physiologic signatures that are detectable in the hours preceding clinical detection and intervention. Detection of such signatures can draw attention to patients at highest risk, potentially enabling earlier intervention and better outcomes.

A pilot comparison of standardized online surgical curricula for use in low- and middle-income countries.

IMPORTANCE Surgical conditions are an important component of global disease burden, due in part to critical shortages of adequately trained surgical providers in low- and middle-income countries. OBJECTIVES To assess the use of Internet-based educational platforms as a feasible approach to augmenting the education and training of surgical providers in these settings. DESIGN, SETTING, AND PARTICIPANTS Access to two online curricula was offered to 75 surgical faculty and trainees from 12 low- and middle-income countries for 60 days. The Surgical Council on Resident Education web portal was designed for general surgery trainees in the United States, and the School for Surgeons website was built by the Royal College of Surgeons in Ireland specifically for the College of Surgeons of East, Central and Southern Africa. Participants completed an anonymous online survey detailing their experiences with both platforms. Voluntary respondents were daily Internet users and endorsed frequent use of both print and online textbooks as references. MAIN OUTCOMES AND MEASURES Likert scale survey questionnaire responses indicating overall and content-specific experiences with the Surgical Council on Resident Education and School for Surgeons curricula. RESULTS Survey responses were received from 27 participants. Both online curricula were rated favorably, with no statistically significant differences in stated willingness to use and recommend either platform to colleagues. Despite regional variations in practice context, there were few perceived hurdles to future curriculum adoption. CONCLUSIONS AND RELEVANCE Both the Surgical Council on Resident Education and School for Surgeons educational curricula were well received by respondents in low- and middle-income countries. Although one was designed for US surgical postgraduates and the other for sub-Saharan African surgical providers, there were no significant differences detected in participant responses between the two platforms. Online educational resources have promise as an effective means to enhance the education of surgical providers in low- and middle-income countries.

Ocular injuries in trauma patients: an analysis of 28,340 trauma admissions in the 2003-2007 National Trauma Data Bank National Sample Program

BACKGROUND Trauma-induced eye injuries are the leading cause of monocular blindness in the United States. Few studies to date have focused on ocular injuries in the trauma population. Our intent was to determine the annual percentage of ocular injury, types of injuries, and percentage with ocular injury-related procedures performed during the same hospitalization. METHODS This study was a retrospective analysis of 28,340 patient records included in the National Trauma Data Bank National Sample Program from 2003 to 2007. Patients with ocular injuries and related procedures were identified using International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis and procedure codes and were subsequently grouped into categories of ocular injury using the criteria of the Barell body region injury diagnosis matrix. Weighted national estimates for the proportion of patients with ocular trauma were calculated based on the relative weights for patients in each facility within the sample universe. Weighted frequencies were expressed as a percentage of the total population of trauma admissions, with 95% confidence intervals calculated for precision. RESULTS During the time frame examined, 1.97% to 6.00% of annual trauma patient admissions included ocular injuries. The most common injuries were contusions or superficial injuries and then closed orbit fractures accounting for 0.95% to 2.48% and 0.58% to 2.37% of all injuries, respectively. Between 0.56% and 1.52% of annual trauma admission had both ocular trauma and related procedures during their hospitalization. Popular treatments were therapeutic procedures on eyelids, conjunctiva, and/or cornea occurring in 0.15% to 0.84% of all trauma patients. Facial fracture–related procedures were reported for between 0.16% and 0.65% of all trauma patient admissions. CONCLUSION The National Trauma Data Bank National Sample Program can be used to create useful estimates of ocular injury characteristics among patients seen in the population seen in trauma centers, including types of ocular injury and related procedures performed during the same admission. LEVEL OF EVIDENCE Epidemiologic study, level V.

What is the safety of nonemergent operative procedures performed at night? A study of 10,426 operations at an academic tertiary care hospital using the American College of Surgeons national surgical quality program improvement database.

BACKGROUND Ever-increasing numbers of in-house acute care surgeons and competition for operating room time during normal daytime business hours have led to an increased frequency of nonemergent general and vascular surgery procedures occurring at night when there are fewer residents, consultants, nurses, and support staff available for assistance. This investigation tests the hypothesis that patients undergoing such procedures after hours are at increased risk for postoperative morbidity and mortality. METHODS Clinical data for 10,426 operative procedures performed over a 5-year period at a single academic tertiary care hospital were obtained from the American College of Surgeons National Surgical Quality Improvement Program Database. The prevalence of preoperative comorbid conditions, postoperative length of stay, morbidity, and mortality was compared between two cohorts of patients: one who underwent nonemergent operative procedures at night and other who underwent similar procedures during the day. Subsequent statistical comparisons utilized chi tests for comparisons of categorical variables and F-tests for continuous variables. RESULTS Patients undergoing procedures at night had a greater prevalence of serious preoperative comorbid conditions. Procedure complexity as measured by relative value unit did not differ between groups, but length of stay was longer after night procedures (7.8 days vs. 4.3 days, p < 0.0001). CONCLUSIONS Patients undergoing nonemergent general and vascular surgery procedures at night in an academic medical center do not seem to be at increased risk for postoperative morbidity or mortality. Performing nonemergent procedures at night seems to be a safe solution for daytime overcrowding of operating rooms.

Effects of leading mortality risk factors among trauma patients vary by age

BACKGROUND Patient age is well recognized as a factor that contributes to increased mortality risk among trauma patients. Less well recognized is the potential that the strength of the effects of other risk factors that increase mortality risk may depend on a patient’s age. This study examines whether the statistical relationship between trauma patient survival and key mortality risk factors varies significantly by patient age in years, across mechanisms of injury. METHODS The statistical interaction between age and values of key risk factors included in the Trauma Quality Improvement Program mortality risk adjustment model is assessed using patient data included in the 2008 National Trauma Data Bank National Sample Program. Multivariable logistic regression analysis is used to assess the statistical significance of the interaction effect on patient morality risk for key mortality risk factors and patient age in years, across mechanisms of injury. RESULTS Statistically significant interactions (p < 0.01) occurred between age and each of the selected risk factors, for each common mechanism of injury. Differences also occurred in the direction of the interactions between age and selected risk factors, across mechanism of injury. CONCLUSION The effects of key risk factors included in trauma patient mortality risk adjustment models vary depending on patient age in years, for each commonly occurring mechanism of injury. Statistical models assessing patient mortality risk could be meaningfully improved by accounting for these interaction effects. LEVEL OF EVIDENCE Prognostic and epidemiologic study, level III.

The effect of dead-on-arrival and emergency department death classification on risk-adjusted performance in the American College of Surgeons Trauma Quality Improvement Program

BACKGROUND The American College of Surgeons’ Trauma Quality Improvement Program is focused on identifying variations in outcomes across trauma centers for the purposes of performance improvement. In previous analyses, patients who died in the emergency department were excluded. We investigated the effect of inclusion and exclusion of emergency department (ED) deaths (dead on arrival [DOA] and died in ED [DIE]) on analyses of overall risk-adjusted trauma center performance. METHODS Data for patients admitted to 65 Trauma Quality Improvement Program hospitals during the 2009 calendar year was used. A logistic regression model was developed to estimate risk-adjusted mortality. Trauma centers were then ranked based on their observed-to-expected (O/E) mortality ratio with 90% confidence intervals (CIs) and classified by outlier status: low outliers/high performers had a 90% CI for O/E mortality ratio of less than 1, and high outliers/low performers had a 90% CI for O/E mortality ratio of greater than 1. Changes in outlier status, rank, and quartile were examined with and without DOA and DIE patients included in the analyses to discern the impact of such exclusions on overall risk-adjusted center-specific performance. RESULTS Thirty-one trauma centers (48%) reported no DOA patients in 2009, while 6 centers (9%) reported more than 10. Of 224 patients, 14 (6.2%) had a documented time of death of more than 30 minutes after ED arrival despite being recorded as DOA. Forty-one trauma centers (63%) changed rank by three positions or less. Ten trauma centers changed their quartile ranking by a single quartile, but no centers were found to change quartile rank more than one quartile. Changes in outlier status occurred for 6 trauma centers (9%). CONCLUSION The relative frequency of patients classified as DOA varies greatly between trauma centers. Misclassification of patients as DOA occurs. Inclusion of ED deaths in risk-adjusted analysis of mortality results in a small but insignificant change in predicting the outcome results of a trauma center. This change is less than the rate of finding a center to be a high or low outlier by chance alone using the 90% CI. Inclusion of DOA and DIE patients in risk-adjusted analysis of mortality is appropriate and eliminates the bias introduced by exclusion of ED deaths owing to misuse of the DOA classification. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III.