Leticia Nogueira

Current issues in patient safety in surgery: a review

Current surgical safety guidelines and checklists are generic and are not specifically tailored to address patient issues and risk factors in surgical subspecialties. Patient safety in surgical subspecialties should be templated on general patient safety guidelines from other areas of medicine and mental health but include and develop specific processes dedicated for the care of the surgical patients. Safety redundant systems must be in place to decrease errors in surgery. Therefore, different surgical subspecialties should develop a specific curriculum in patient safety addressing training in academic centers and application of these guidelines in all practices. Clearly, redundant safety systems must be in place to decrease errors in surgery, in analogy to safety measures in other high-risk industries. Specific surgical subspecialties are encouraged to develop a specific patient safety curriculum that address training in academic centers and applicability to daily practice, with the goal of keeping our surgical patients safe in all disciplines. The present review article is designed to outline patient safety practices that should be adapted and followed to fit particular specialties.

Targeted Therapy for Metastatic Renal Carcinoma: An Update

Conventional chemotherapy is associated with poor outcomes in metastatic renal cell carcinoma (RCC). Advances in the understanding of tumor molecular biology and the implementation of new drugs that target these molecular pathways have increased the arsenal against advanced RCC and improved outcomes in these patients. Herein, we briefly describe the latest data on targeted therapies used in the treatment of advanced renal cell carcinoma. Search strategy was performed according to PRISMA guidelines. Abstracts of relevant studies published in PubMed between 2000 and 2014 were analyzed by two authors. Abstracts were selected if they were published in English, data reported was of phase II or III clinical trials, and outcomes followed FDA approval. If consensus between the two authors was achieved, they were included in the review. Key words used were “target therapy” and “metastatic renal cell carcinoma”. The results of the studies analyzed in this review support the benefits of targeted therapy in metastatic RCC. These include improved progression-free survival, overall survival, and quality of life as well as reduced toxicities compared to immunotherapy. The improvement in outcomes in metastatic RCC makes these drugs a preferred option as a primary treatment for these patients.

Laparoscopic Versus Percutaneous Cryoablation of Small Renal Mass: Systematic Review and Cumulative Analysis of Comparative Studies

&NA; The objective of this study was to compare the surgical, oncological, and functional outcomes of laparoscopic and percutaneous cryoablation for the treatment of small renal masses. A systematic review of the literature was performed through March 2016 using PubMed, Scopus, and Ovid databases. Article selection proceeded according to the search strategy on the basis of the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses criteria. Only studies that compared laparoscopic and percutaneous kidney cryoablation were included in the meta‐analysis. Eleven retrospective comparative studies were identified and selected for the analysis, including 1725 cases: 804 (46.6%) percutaneous and 921 (53.4%) laparoscopic cryoablations. Percutaneous cryoablation was performed more frequently for posterior tumors (P < .001), whereas laparoscopy was more common for endophytic lesions (P = .01). The length of follow‐up was longer for laparoscopy (P < .001). Percutaneous cryoablation was associated with a significantly shorter hospital stay (P < .001). A lower likelihood of residual disease was recorded for laparoscopic (P = .003), whereas tumor recurrence rate favored percutaneous cryoablation (P = .02). The 2 procedures were similar for recurrence‐free survival (P = .08), and overall survival (P = .51). No significant difference was found in postoperative estimated glomerular filtration rate (P = .78). Laparoscopic and percutaneous kidney cryoablation offer similar favorable oncological outcomes with minimal effect on renal function. The percutaneous access can offer shorter hospital stay and faster recovery, which can be appealing in an era of cost restraint.

The Culture of Patient Safety Practice: Systematic Review

Introduction: Regulations and guidelines are essential components of maintaining safety in multiple industries. In health care these processes exist to help distinguish weaknesses in patient care and identify adverse events. We review the processes that have been established in health care to promote the culture of patient safety. Methods: Sources were acquired through the NCBI (National Center for Biotechnology Information) database using the keywords “safety,” “World Health Organization” and “Joint Commission on Accreditation of Healthcare Organizations.” Other sources were obtained through research into specific safety processing topics of industrial and nonindustrial institutions. Results: The organizational properties of patient care expand beyond the number of incidents an institution experiences and include standardized safety values for specific patient care procedures. Tools such as SBAR (Situation, Background, Assessment, Recommendation), Reasons Swiss cheese model and the general guidelines established by the WHO have been used to detect and reduce the likelihood of errors in patient practice. These tools also demonstrate the importance of adopting regulated checklists and protocols that are essential at every stage of patient care. Conclusions: While various systems have been implemented throughout the health care industry to overcome processing weaknesses, a continued display of effectiveness and improvement of current subspecialty specific guidelines are necessary for the assurance of safety in contemporary patient care.

MP92-20 FEMALE GENITAL MUTILATION AT A SAFETY-NET HOSPITAL IN DENVER, CO

INTRODUCTION AND OBJECTIVES: Over 1 million CAUTIs occur annually among hospitalized U.S. patients receiving a Foley urinary catheter, accounting for over 13,000 deaths. CAUTI treatment requires antibiotics at a time when hospitals are expected to minimize avoidable antibiotic use. CAUTIs financially burden hospitals. The mean per-incident cost is estimated at

Is a safety guidewire needed for retrograde ureteroscopy

750-

MP18-10 LACTATE LEVELS AT ADMISSION CAN PREDICT NEPHRECTOMY AND MORTALITY IN PATIENTS WITH HIGH GRADE RENAL TRAUMA (AAST III-V)

4,823. One facility in this study found its net cost, including longer length of stay, to be

Evaluation of emissivity and temperature profile of laparoscopic ultrasonic devices (blades and passive jaws)

11,419 per case. Most payers do not reimburse these costs. The ACA penalizes hospitals for high CAUTI rates. Data was collected from multiple sites to assess whether an intervention using a novel, non-toxic skin care system/formulation for Foley insertion and maintenance could reduce CAUTI rates. METHODS: Approximately 25 hospitals using the formulation were asked to provide insertion and maintenance details on use, plus preand post-implementation CAUTI rates reported to the National Healthcare Safety Network. The formulation was used in high-risk ICU, Neuro, C-V and trauma patient populations with fecal and urinary incontinence, in its foam and moisture-impregnated-cloth forms. Both forms are safe for the perineal area, do not cause antibiotic resistance, and are not associated with adverse events. Clinical protocol was to apply the formulation to the meatus and surrounding tissue to establish a zone of protection, then re-establish after each incidence of fecal incontinence as a maintenance intervention. RESULTS: Ten hospitals provided preand post-intervention data (average time pre-intervention 21.2 months; average time postintervention 20 months). Eight reported CAUTI rate reductions, ranging from 22.47% to 100% (with two sites reporting elimination of CAUTI). Two other hospitals noted compliance issues that affected their results and made their data unreliable. One of those two reported no change in CAUTI rates and the other reported a 30.31% increase. The mean preimplementation CAUTI rate for the eight compliant hospitals was 3.65/ 1,000 catheter days. The mean post-implementation CAUTI rate for those same hospitals was 1.72/1,000 catheter days. The mean change was a reduction in CAUTI rates of 52.88%. CONCLUSIONS: Eight of 10 reporting sites found use of the skin care formulation was associated with lower CAUTI rates. Further study of the formulation’s efficacy is warranted.

A new patient safety smartphone application for prevention of “forgotten” ureteral stents: results from a clinical pilot study in 194 patients

INTRODUCTION It is generally advised to have a safety guidewire (SGW) present during ureteroscopy (URS) to manage possible complications. However, it increases the strenght needed to insert and retract the endoscope during the procedure, and, currently, there is a lack of solid data supporting the need for SGW in all procedures. We reviewed the literature about SGW utilization during URS. METHOD A review of the literature was conducted through April 2017 using PubMed, Ovid, and The Cochrane Library databases to identify relevant studies. The primary outcome was to report stone-free rates, feasibility, contraindications to and complications of performing intrarenal retrograde flexible and semi-rigid URS without the use of a SGW. RESULTS Six studies were identified and selected for this review, and overall they included 1,886 patients where either semi-rigid or flexible URS was performed without the use of a SGW for the treatment of urinary calculi disease. Only one study reported stone-free rates with or without SGW at 77.1 and 85.9%, respectively (p=0.001). None of the studies showed increased rates of complications in the absence of SGW and one of them showed more post-endoscopic ureteral stenosis whenever SGW was routinely used. All studies recommended utilization of SGW in complicated cases, such as ureteral stones associated with significant edema, ureteral stricture, abnormal anatomy or difficult visualization. CONCLUSION Our review showed a lack of relevant data supporting the use of SGW during retrograde URS. A well-designed prospective randomized trial is in order.

PD53-03 COST ANALYSIS OF UTILIZATION OF DISPOSABLE FLEXIBLE URETEROSCOPES IN HIGH RISK FOR BREAKAGE CASES

INTRODUCTION AND OBJECTIVES: Prediction of nephrectomy or mortality on patients with high grade renal trauma after abdominal trauma is challenging. The objective of this study is to determine the early predictors of nephrectomy and mortality in high grade renal trauma patients. METHODS: From 2008 to 2013, Denver Health Medical Center, a regional level 1 Trauma Center admitted 12,749 consecutive trauma patients. After an IRB approval, a total of 105 patients presented high grade renal injuries (AAST III-V) and were eligible for the study. Variables that were analyzed were collected in the initial management of these patients. Univariable and multivariable logistic regression models were performed to identify the predictors of nephrectomy and mortality in these patients. RESULTS: Patients’ characteristics, trauma scores and outcomes are presented in Table 1. Univariable logistic regression was performed to determine predictors for nephrectomy and mortality. Lactate levels (p<0.001), Penetrating injury (p<0.001), pulse (p1⁄40.03), SBP (p1⁄40.001), and urgent laparotomy (p<0.001) were associated with nephrectomy. Gender (p1⁄40.03), SBP (p1⁄40.001), ISS (p1⁄40.002), urological consultation (p1⁄40.04), lactate (p1⁄40.003), and hemoglobin (p1⁄40.03) were associated with mortality. In multivariable analysis penetrating injury (p1⁄40.01), pulse (p1⁄40.04) and lactate (p1⁄40.01) were independent predictors for nephrectomy, and lactate (p1⁄40.01) was the only independent predictor for mortality. CONCLUSIONS: The understanding of predictors for nephrectomy and mortality in high grade renal trauma patients may guide the early management of this specific population of trauma patients and affect their clinical outcomes in the future. Lactate should be considered to be included in further nomograms, since it can predict nephrectomy and mortality. Table 1 Characteristics of patients with high grade renal trauma (AAST III-V) Overall Nephrectomy Non-nephrectomy Variables (n1⁄4 105) (n1⁄414) (n 1⁄4 91) P-Value Age (years) Mean (SD) 32.6 (14.8) 30.9 (28.5) 32.9 (14.6) 0.59 Median (IQR) 30 (21-41.5) 28.5 (18.7-41.7) 30 (21-42) Gender (n. pts, %) Male 87 (82.9) 12 (85.7) 75 (82.4) 0.76 Female 18 (17.1) 2 (14.3) 16 (16.7) Trauma Type (n. pts, %) Penetrate 16 (15.2) 9 (64.3) 7 (7.7) <0.001 Blunt 89 (84.8) 5 (35.7) 84 (92.3) Vital Signs SPB (mmHg) Mean (SD) 111.3 (29.8) 79.4 (40.6) 116.3 (24.4) <0.001 Median (IQR) 112 (96-134) 79 (67.5-104) 118.0 (98-137) Pulse (bpm) 95.8 (27.8) 110.3 (40.9) 93.5 (24.7) 0.02 Mean (SD) 93.5 (75-119) 112 (99.7-131.5) 89.5 (73.5-114) Median (IQR) Trauma Scores (median) GCS (median, IQR) 15 (12-15) 5 (3-13) 15 (14-15) <0.001 ISS (median, IQR) 25 (16-35) 34 (25-51) 22 (16-34) 0.01 AAST (n.pts, %) Grade III 50 (47.6) 0 (0) 50 (54.9) Grade IV 39 (37.1) 2 (21.4) 36 (39.6) <0.001 Grade V 16 (15.2) 11 (78.6) 5 (5.5) Lab Results Hb (mg/dL) Mean 13.2 (4.26) 11.5 (3.8) 13.47 (4.29) 0.15 Median 13.5 (10.515.2) 11.6 (8.5-14.5) 13.6 (11.1-15.2)