Luke M. Funk

Adopting a surgical safety checklist could save money and improve the quality of care in U.S. hospitals

Use of the World Health Organizations Surgical Safety Checklist has been associated with a significant reduction in major postoperative complications after inpatient surgery. We hypothesized that implementing the checklist in the United States would generate cost savings for hospitals. We performed a decision analysis comparing implementation of the checklist to existing practice in U.S. hospitals. In a hospital with a baseline major complication rate after surgery of at least 3 percent, the checklist generates cost savings once it prevents at least five major complications. Using the checklist would both save money and improve the quality of care in hospitals throughout the United States.

Global operating theatre distribution and pulse oximetry supply: an estimation from reported data

BACKGROUND Surgery is an essential part of health care, but resources to ensure the availability of surgical services are often inadequate. We estimated the global distribution of operating theatres and quantified the availability of pulse oximetry, which is an essential monitoring device during surgery and a potential measure of operating theatre resources. METHODS We calculated ratios of the number of operating theatres to hospital beds in seven geographical regions worldwide on the basis of profiles from 769 hospitals in 92 countries that participated in WHOs safe surgery saves lives initiative. We used hospital bed figures from 190 WHO member states to estimate the number of operating theatres per 100,000 people in 21 subregions throughout the world. To estimate availability of pulse oximetry, we sent surveys to anaesthesia providers in 72 countries selected to ensure a geographically and demographically diverse sample. A predictive regression model was used to estimate the pulse oximetry need for countries that did not provide data. FINDINGS The estimated number of operating theatres ranged from 1·0 (95% CI 0·9-1·2) per 100,000 people in west sub-Saharan Africa to 25·1 (20·9-30·1) per 100,000 in eastern Europe. High-income subregions all averaged more than 14 per 100,000 people, whereas all low-income subregions, representing 2·2 billion people, had fewer than two theatres per 100,000. Pulse oximetry data from 54 countries suggested that around 77,700 (63,195-95,533) theatres worldwide (19·2% [15·2-23·9]) were not equipped with pulse oximeters. INTERPRETATION Improvements in public-health strategies and monitoring are needed to reduce disparities for more than 2 billion people without adequate access to surgical care. FUNDING WHO.

Implementation of the World Health Organization surgical safety checklist, including introduction of pulse oximetry, in a resource-limited setting

Objective:To introduce the World Health Organization Surgical Safety Checklist into every operating room within a severely resource-limited hospital located in a developing country and to measure its impact on surgical hazards and complications. Background:The checklist has been shown to reduce surgical morbidity and mortality, but the ability to successfully implement the checklist program hospital-wide in lower income settings without basic resources is unknown. Methods:We conducted a pre- versus postintervention study of the implementation of the checklist, including the introduction of universal pulse oximetry at a hospital in Chisinau, Moldova, where only 3 oximeters were available for their 22 operating stations. We supplied data-recording oximeters for all operating stations and trained a local checklist implementation team. The primary outcomes were process adherence, major complications, and rates of hypoxemia (SpO2 <90%). Propensity score weighing was conducted to adjust process and outcome measures. Regression models were used to evaluate adherence to process measures and hypoxemia trends over time. Results:Data from 2145 pre- and 2212 postintervention cases were collected. Adherence to all safety processes increased significantly from 0.0% to 66.9% (P < 0.001). After checklist implementation, the overall complication rate decreased from 21.5% to 8.8% (P < 0.001). Infectious and noninfectious complications decreased significantly after checklist implementation from 17.7% to 6.7% (P < 0.001) and from 2.6% to 1.5% (P = 0.018), respectively. The number of hypoxemic episodes lasting 2 minutes or longer per 100 hours of oximetry decreased from 11.5 to 6.4 (P < 0.002). Conclusions:Successful hospital-wide Surgery Safety Checklist implementation can be achieved in a resource-limited setting and can significantly reduce surgical hazards and complications.

Rates and patterns of death after surgery in the United States, 1996 and 2006

BACKGROUND Nationwide rates and patterns of death after surgery are unknown. METHODS Using the Nationwide Inpatient Sample, we compared deaths within 30 days of admission for patients undergoing surgery in 1996 and 2006. International Classification of Diseases codes were used to identify 2,520 procedures for analysis. We examined the inpatient 30-day death rate for all procedures, procedures with the most deaths, high-risk cardiovascular and cancer procedures, and patients who suffered a recorded complication. We used logistic regression modeling to adjust 1996 mortality rates to the age and gender distributions for patients undergoing surgery in 2006. RESULTS In 1996, there were 12,573,331 admissions with a surgical procedure (95% confidence interval [CI], 12,560,171-12,586,491) and 224,111 inpatient deaths within 30 days of admission (95% CI, 221,912-226,310). In 2006, there were 14,333,993 admissions with a surgical procedure (95% CI, 14,320,983-14,347,002) and 189,690 deaths (95% CI, 187,802-191,578). Inpatient 30-day mortality declined from 1.68% in 1996 to 1.32% in 2006 (P < .001). Of the 21 procedures with the most deaths in 1996, 15 had significant declines in adjusted mortality in 2006. Among these 15 procedures, 8 had significant declines in operative volume. The inpatient 30-day mortality rate for patients who suffered a complication decreased from 12.10% to 9.84% (P < .001). CONCLUSION Nationwide reporting on surgical mortality suggests that the number of inpatient deaths within 30 days of surgery has declined. Additional research to determine the underlying causes for decreased mortality is warranted.

Esophagectomy Outcomes at Low-Volume Hospitals The Association Between Systems Characteristics and Mortality

Objective: To evaluate the association between systems characteristics and esophagectomy mortality at low-volume hospitals Background: High-volume hospitals have lower esophagectomy mortality rates, but receiving care at such centers is not always feasible. We examined low-volume hospitals and sought to identify characteristics of those with better outcomes. Methods: Using national data from Medicare and the American Hospital Association, we studied 4498 elderly patients who underwent an esophagectomy from 2004 to 2007. We divided hospitals into terciles based on esophagectomy volume and examined characteristics of patients and hospitals (size, nurse ratios, and presence of advanced medical, surgical, and radiological services). Our primary outcome was mortality. We identified 5 potentially beneficial systems characteristics in our data set and used multivariable logistic regression to determine whether these characteristics were associated with lower mortality rates at low-volume hospitals. Results: Of the 874 hospitals that performed esophagectomies, 83% (723) were low-volume hospitals whereas only 3% (25) were high-volume. Low-volume hospitals performed a median of 1 esophagectomy during the 4-year study period and cared for patients that were older, more likely to be minority, and more likely to have multiple comorbidities compared with high-volume centers. Low-volume hospitals that had at least 3 of 5 characteristics (high nurse ratios, lung transplantation services, complex medical oncology services, bariatric surgery services, and positron emission tomography scanners) had markedly lower mortality rates compared with low-volume hospitals with none of these characteristics (12.5% vs. 5.0%; P value = 0.042). Conclusions: Low-volume hospitals with certain systems characteristics seem to achieve better esophagectomy outcomes. A more comprehensive study of the beneficial characteristics of low-volume hospitals is warranted because high-volume hospitals are difficult to access for many patients.

Surgical Treatment of an Infected Popliteal Artery Aneurysm 12 Years after Aneurysm Exclusion and Bypass

The presence of persistent blood flow in popliteal artery aneurysms that have been treated with exclusion and bypass is surprisingly common. Complications from incompletely excluded aneurysms include aneurysm enlargement, local compressive symptoms, and sac rupture. Infection of a previously excluded and bypassed popliteal artery aneurysm is a notably rare complication. In this case report, we describe a patient with an infection of a popliteal artery aneurysm 12 years following surgical repair. The patient was successfully treated with aneurysm resection and soft tissue debridement.

Nonlinear Optical Imaging of Melanin Species using Coherent Anti-Stokes Raman Scattering (CARS) and Sum-Frequency Absorption (SFA) Microscopy

Skin pigmentation correlates with melanoma incidence, and melanin subtypes are known to play key roles in melanoma pathogenesis. Here, we propose the use of CARS and SFA microscopy to selectively visualize melanins in live cells.The annual global incidence of melanoma, the deadliest form of skin cancer, exceeds 232,000 cases worldwide, resulting in over 55,000 deaths. It has long been known that skin pigmentation strongly correlates with skin cancer incidence and, in the specific case of melanoma, carcinogenesis may in fact arise independently of ultraviolet irradiation. Indeed, the ultraviolet-radiation-independent pathway to melanoma pathogenesis is thought to be largely mediated by pheomelanin – the red/blond melanin subtype. Other studies have also shown that some resistant melanoma cell lines can overcome administration of drugs by increasing melanin production and thereby sequestering therapeutics in melanosomes, the organelles responsible for melanin production bound for cellular export. In order to further study melanoma pathogenesis and therapeutic resistance, novel imaging modalities to selectively image melanin subtypes have been developed: on one hand, coherent anti-Stokes Raman scattering (CARS) microscopy can uniquely identify pheomelanin, while on the other, sum-frequency absorption (SFA) microscopy can be used to visualize total melanin distribution.