Jerry Stonemetz

Compliance with Surgical Care Improvement Project for Body Temperature Management (SCIP Inf-10) Is Associated with Improved Clinical Outcomes.

Background:In an effort to measure and improve the quality of perioperative care, the Surgical Care Improvement Project (SCIP) was introduced in 2003. The SCIP guidelines are evidence-based process measures designed to reduce preventable morbidity, but it remains to be determined whether SCIP-measure compliance is associated with improved outcomes. Methods:The authors retrospectively analyzed the electronic medical record data from 45,304 inpatients at a single institution to assess whether compliance with SCIP Inf-10 (body temperature management) was associated with a reduced incidence of morbidity and mortality. The primary outcomes were hospital-acquired infection and ischemic cardiovascular events. Secondary outcomes were mortality and hospital length of stay. Results:Body temperature on admission to the postoperative care unit was higher in the SCIP-compliant group (36.6° ± 0.5°C; n = 44,064) compared with the SCIP-noncompliant group (35.5° ± 0.5°C; n = 1,240) (P < 0.0001). SCIP compliance was associated with improved outcomes in both nonadjusted and risk-adjusted analyses. SCIP compliance was associated with a reduced incidence of hospital-acquired infection (3,312 [7.5%] vs.160 [12.9%] events; risk-adjusted odds ratio [OR], 0.68; 95% CI, 0.54 to 0.85), ischemic cardiovascular events (602 [1.4%] vs. 38 [3.1%] events; risk-adjusted OR, 0.60; 95% CI, 0.41 to 0.92), and mortality (617 [1.4%] vs. 60 [4.8%] events; risk-adjusted OR, 0.41; 95% CI, 0.29 to 0.58). Median (interquartile range) hospital length of stay was also decreased: 4 (2 to 8) versus 5 (2 to 14) days; P < 0.0001. Conclusion:Compliance with SCIP Inf-10 body temperature management guidelines during surgery is associated with improved clinical outcomes and can be used as a quality measure.

Prevalence of Propionibacterium acnes in Intervertebral Discs of Patients Undergoing Lumbar Microdiscectomy: A Prospective Cross-Sectional Study

Background The relationship between intervertebral disc degeneration and chronic infection by Propionibacterium acnes is controversial with contradictory evidence available in the literature. Previous studies investigating these relationships were under-powered and fraught with methodical differences; moreover, they have not taken into consideration P. acnes’ ability to form biofilms or attempted to quantitate the bioburden with regard to determining bacterial counts/genome equivalents as criteria to differentiate true infection from contamination. The aim of this prospective cross-sectional study was to determine the prevalence of P. acnes in patients undergoing lumbar disc microdiscectomy. Methods and Findings The sample consisted of 290 adult patients undergoing lumbar microdiscectomy for symptomatic lumbar disc herniation. An intraoperative biopsy and pre-operative clinical data were taken in all cases. One biopsy fragment was homogenized and used for quantitative anaerobic culture and a second was frozen and used for real-time PCR-based quantification of P. acnes genomes. P. acnes was identified in 115 cases (40%), coagulase-negative staphylococci in 31 cases (11%) and alpha-hemolytic streptococci in 8 cases (3%). P. acnes counts ranged from 100 to 9000 CFU/ml with a median of 400 CFU/ml. The prevalence of intervertebral discs with abundant P. acnes (≥ 1x103 CFU/ml) was 11% (39 cases). There was significant correlation between the bacterial counts obtained by culture and the number of P. acnes genomes detected by real-time PCR (r = 0.4363, p<0.0001). Conclusions In a large series of patients, the prevalence of discs with abundant P. acnes was 11%. We believe, disc tissue homogenization releases P. acnes from the biofilm so that they can then potentially be cultured, reducing the rate of false-negative cultures. Further, quantification study revealing significant bioburden based on both culture and real-time PCR minimize the likelihood that observed findings are due to contamination and supports the hypothesis P. acnes acts as a pathogen in these cases of degenerative disc disease.

Reduction of Regulated Medical Waste Using Lean Sigma Results in Financial Gains for Hospital

This article describes how anesthesiologists can lead innovation and process improvement focused on regulated medical waste reduction and cost savings using a process improvement methodology known as Lean Sigma.

Propionibacterium acnes biofilm is present in intervertebral discs of patients undergoing microdiscectomy.

Background In previous studies, Propionibacterium acnes was cultured from intervertebral disc tissue of ~25% of patients undergoing microdiscectomy, suggesting a possible link between chronic bacterial infection and disc degeneration. However, given the prominence of P. acnes as a skin commensal, such analyses often struggled to exclude the alternate possibility that these organisms represent perioperative microbiologic contamination. This investigation seeks to validate P. acnes prevalence in resected disc cultures, while providing microscopic evidence of P. acnes biofilm in the intervertebral discs. Methods Specimens from 368 patients undergoing microdiscectomy for disc herniation were divided into several fragments, one being homogenized, subjected to quantitative anaerobic culture, and assessed for bacterial growth, and a second fragment frozen for additional analyses. Colonies were identified by MALDI-TOF mass spectrometry and P. acnes phylotyping was conducted by multiplex PCR. For a sub-set of specimens, bacteria localization within the disc was assessed by microscopy using confocal laser scanning and FISH. Results Bacteria were cultured from 162 discs (44%), including 119 cases (32.3%) with P. acnes. In 89 cases, P. acnes was cultured exclusively; in 30 cases, it was isolated in combination with other bacteria (primarily coagulase-negative Staphylococcus spp.) Among positive specimens, the median P. acnes bacterial burden was 350 CFU/g (12 - ~20,000 CFU/g). Thirty-eight P. acnes isolates were subjected to molecular sub-typing, identifying 4 of 6 defined phylogroups: IA1, IB, IC, and II. Eight culture-positive specimens were evaluated by fluorescence microscopy and revealed P. acnes in situ. Notably, these bacteria demonstrated a biofilm distribution within the disc matrix. P. acnes bacteria were more prevalent in males than females (39% vs. 23%, p = 0.0013). Conclusions This study confirms that P. acnes is prevalent in herniated disc tissue. Moreover, it provides the first visual evidence of P. acnes biofilms within such specimens, consistent with infection rather than microbiologic contamination.

Development of a risk-adjusted blood utilization metric.

Blood utilization has become an important outcome measure for surgical patients because of the recognized risks and costs associated with transfusion. However, comparisons of blood utilization between providers or institutions are difficult, because there is no standard method for risk adjustment when assessing surgical blood requirements. We examined whether accepted diagnosis‐related group (DRG) case mix indexes can be used for this purpose.

Anesthesia Information Management Systems Marketplace and Current Vendors

This article addresses the brief history of anesthesia information management systems (AIMS) and discusses the vendors that currently market AIMS. The current market penetration based on the information provided by these vendors is presented and the rationale for the purchase of AIMS is discussed. The considerations to be evaluated when making a vendor selection are also discussed.

Prothrombin Time and Activated Partial Thromboplastin Time Testing: A Comparative Effectiveness Study in a Million-Patient Sample

Background A substantial fraction of all American healthcare expenditures are potentially wasted, and practices that are not evidence-based could contribute to such waste. We sought to characterize whether Prothrombin Time (PT) and activated Partial Thromboplastin Time (aPTT) tests of preoperative patients are used in a way unsupported by evidence and potentially wasteful. Methods and Findings We evaluated prospectively-collected patient data from 19 major teaching hospitals and 8 hospital-affiliated surgical centers in 7 states (Delaware, Florida, Maryland, Massachusetts, New Jersey, New York, Pennsylvania) and the District of Columbia. A total of 1,053,472 consecutive patients represented every patient admitted for elective surgery from 2009 to 2012 at all 27 settings. A subset of 682,049 patients (64.7%) had one or both tests done and history and physical (H&P) records available for analysis. Unnecessary tests for bleeding risk were defined as: PT tests done on patients with no history of abnormal bleeding, warfarin therapy, vitamin K-dependent clotting factor deficiency, or liver disease; or aPTT tests done on patients with no history of heparin treatment, hemophilia, lupus anticoagulant antibodies, or von Willebrand disease. We assessed the proportion of patients who received PT or aPTT tests who lacked evidence-based reasons for testing. Conclusions This study sought to bring the availability of big data together with applied comparative effectiveness research. Among preoperative patients, 26.2% received PT tests, and 94.3% of tests were unnecessary, given the absence of findings on H&P. Similarly, 23.3% of preoperative patients received aPTT tests, of which 99.9% were unnecessary. Among patients with no H&P findings suggestive of bleeding risk, 6.6% of PT tests and 7.1% of aPTT tests were either a false positive or a true positive (i.e. indicative of a previously-undiagnosed potential bleeding risk). Both PT and aPTT, designed as diagnostic tests, are apparently used as screening tests. Use of unnecessary screening tests raises concerns for the costs of such testing and the consequences of false positive results.

High‐Flow Oxygen, A Primary Oxygenation Technique for Endolaryngeal Airway Surgery: Our Experience with 10 Patients

Dear Editor, Endoscopic laryngeal airway surgeries are often challenging owing to difficult exposure and a narrow operative field. They are further complicated by the need to ventilate through the surgical field, as placement of an endotracheal tube or jet ventilation catheter can potentially limit the surgical view. Methods of ventilation for such surgeries include endotracheal tube ventilation, subglottic and supraglottic jet ventilation, or spontaneous ventilation. Each method has a potential impact on oxygenation, operative visualisation, procedure length and carries operative risks. The ideal ventilation scenario provides a combination of adequate oxygenation and a clear surgical field of view while minimising risks. One potential way to achieve this balance is using high-flow oxygen, delivered via a nasal trumpet, as a primary oxygenation technique. Insufflation of oxygen through a face mask, oral airway, nasal cannula or transtracheal needle has been successfully used to oxygenate patients in cardiac arrest or for continuous positive airway pressure in paediatric patients with obstructive sleep apnoea. This technique is not active ventilation but instead passive diffusion of oxygen that prolongs periods of apnoea. Insufflation successfully oxygenates the pulmonary capillaries because oxygen uptake from the lungs is relatively higher than carbon dioxide delivery to the lungs. This imbalance creates a slight subatmospheric pressure in the alveoli, allowing the gas mixture to be drawn into the lungs. As the oxygen fraction in the gas mixture increases, so does the oxygen pressure gradient, increasing the time to haemoglobin desaturation and the apneic interval. We applied the technique of high-flow oxygen into our practice for endolaryngeal procedures, in particular balloon dilation procedures of the subglottis and trachea. These cases were chosen to achieve a uniform cohort to work with and to more closely compare outcomes measures. To evaluate its safety and efficacy as a primary oxygenation technique for such surgeries, we observed oxygen saturation, carbon dioxide levels and procedure duration. The purpose of this article was to introduce high-flow oxygen as a primary oxygenation technique for endolaryngeal airway surgery.

Compliance With Surgical Care Improvement Project for Body Temperature Management (SCIP Inf-10) Is Associated With Improved Clinical Outcome

Surgical Care Improvement Project Infection-10 (SCIP Inf-10) is an SCIP measure intended to reduce hospital-acquired infections and thereby improve quality of perioperative care. It states that patients who undergo surgical procedures lasting 60 minutes or longer should be actively warmed or have a body temperature of 36°C or higher within 30 minutes immediately before or 15 minutes after anesthesia end time. Unfortunately, there is little evidence that compliance with SCIP Inf-10 reduces perioperative morbidity. In this study, the authors sought to determine whether compliance with SCIP Inf-10 decreased the incidence of hospitalacquired infection, ischemic cardiovascular events, mortality rate, and length of stay. Electronic anesthesia records containing active patient warming measures and body temperatures of 45 304 inpatients, all of whom underwent noncardiac surgeries greater than 60 minutes in duration between January 2010 and June 2014, were obtained from 3 databases, merged, and retrospectively analyzed. Cardiac surgeries were excluded because of the unique thermal perturbations associated with these operations. Records were examined for evidence of hospital-acquired infections (postoperative wound, drug resistant, sepsis, and Clostridium difficile), myocardial infarctions, cerebral vascular accidents, and transient ischemic attacks. Records were then split into SCIP-compliant and SCIP-noncompliant groups. Statistical analysis included use of univariable, non–risk-adjusted, and multivariable models, for example, two-tailed Student t tests for continuous variables, χ test for dichotomous variables, and the Mann-Whitney U test for nonparametric analyses. Overall, the incidence of SCIP noncompliance decreased during the 4-year period (P ≤ 0.0001). Fewer patients received intraoperative blood transfusions in the SCIPcompliant group (9.2% vs 15.4%, P < 0.0001). For univariable analysis, incidence of drug-resistant, sepsis, andClostridium difficile infections was lower in the SCIP-compliant group than in the noncompliant group (7.5% vs 12.9%, P < 0.0001). Postoperative wound infections occurred with similar frequency in both groups and were not reduced with SCIP compliance. Ischemic cardiovascular events were less frequent in the SCIP-compliant group as well (1.4% vs 3.1%,P < 0.0001). The SCIP-compliant group also showed lower in-hospital mortality rate (1.4% vs 4.8%, P < 0.0001) and