The Joint Commission has repeatedly recognized inadequate communication as a top contributing factor to medical error in the operating room (OR). The goal of this qualitative study was to develop a ...deeper and more nuanced understanding of OR communication dynamics, specifically across different interdisciplinary roles and to recommend specific interventions based on these findings.
We performed a two-phase qualitative study at one academic institution to explore contributors and barriers to optimal OR communication. The first phase consisted of interviews with OR team members, including surgery and anesthesiology attending faculty and residents, medical students, and OR staff. We qualitatively analyzed the transcripts of these interviews using a deductive approach. We additionally verified the findings through subsequent focus groups.
Most OR team members, independent of role, noted that team familiarity, clear role expectations, and formal communication are vital for effective OR communication. There was a disconnect between attending surgeons and the rest of the OR team: Whereas the majority of team members noted the importance of procedural-focused discussions, team hierarchy, and the attending surgeon's mood as major contributors to successful OR communication, the attending surgeons did not recognize their own ability to contribute to optimal OR communication in these regards.
Although team familiarity was important to all participants in the OR, we noted that attending surgeons differed in their perceptions of OR communications from other members of the team, including attending anesthesiologists, residents, medical students, and nurses. Our findings support the need for (1) improved awareness of the impact of a team members's content and character of communication, particularly by attending surgeons; and (2) targeted initiatives to prioritize team familiarity in OR scheduling.
Background The shoulder capsule is the main static stabilizer of the glenohumeral joint. However, few studies specifically address the function of the superior shoulder capsule, which is usually ...damaged in patients with complete rotator cuff tears. Therefore, the purpose of this study was to determine the biomechanical contribution of the superior shoulder capsule to passive stability of the glenohumeral joint. Methods Seven cadaveric shoulders were tested with a custom testing system. Glenohumeral translations, subacromial contact pressure, and glenohumeral external and internal rotations were quantified at 5°, 30°, and 60° of glenohumeral abduction. Data were compared among 3 conditions: (1) intact superior capsule, (2) after detaching the superior capsule from the greater tuberosity (tear model), and (3) after complete removal of the superior capsule from the greater tuberosity to the superior glenoid (defect model). Results A tear of the superior capsule significantly ( P < .05) increased anterior and inferior translations compared with those in the intact capsule. Creation of a superior capsular defect significantly ( P < .05) increased glenohumeral translation in all directions, subacromial contact pressure at 30° of glenohumeral abduction, and external and internal rotations compared with those of the intact capsule. Conclusion The superior shoulder capsule plays an important role in passive stability of the glenohumeral joint. A tear in the superior capsule at the greater tuberosity, which may be seen with partial rotator cuff tears, increased anterior and inferior translations. A defect in the superior capsule, seen in massive cuff tears, increased glenohumeral translations in all directions.
Purpose The purpose of this study was to determine the effect of coracoid tunnel size and location on the biomechanical characteristics of cortical button fixation for coracoclavicular ligament ...reconstruction. Methods Thirteen matched pairs of cadaveric scapulae were used to determine the effects of coracoid tunnel size, and 6 matched pairs were used to determine the effects of coracoid tunnel location. For tunnel size, a 4.5-mm hole was drilled in the base of the coracoid of one scapula and a 6-mm hole was drilled in the contralateral scapula. For tunnel location, 2 holes were drilled: (1) The first group received a hole centered in the coracoid base and a hole 1.5 cm distal from the first, along the axis of the coracoid. (2) The second group received holes that were offset anteromedially from the first set of holes (base eccentric and distal eccentric). A cortical button–suture tape construct was placed through each tunnel, and constructs were then loaded to failure. Results For tunnel size specimens, load at ultimate failure was significantly greater for the 4.5-mm group compared with the 6-mm group (557.6 ± 48.5 N v 466.9 ± 42.2 N, P < .05). For tunnel location, load at ultimate failure was significantly greater for the centered-distal tunnel group compared with the eccentric-distal group (538.1 ± 70.2 N v 381.0 ± 68.6 N, P < .05). Conclusions A 4.5-mm tunnel in the coracoid provided greater strength for cortical button fixation than a 6-mm tunnel. In the distal coracoid, centered tunnels provided greater strength than eccentric tunnels. Clinical Relevance When performing cortical button fixation at the coracoid process for coracoclavicular ligament reconstruction, a 4.5-mm tunnel provides greater fixation strength than a 6-mm tunnel. The base of the coracoid is more forgiving than the distal coracoid regarding location.
We investigated the effects of bite-size horizontal mattress stitch (distance between the limbs passed through the tendon) on the biomechanical properties of the repaired tendon.
We anchored 20 ...bovine Achilles tendons to bone using no. 2 high-strength suture and 5-mm titanium suture anchors in a mattress-suture technique. Tendons were allocated randomly into two groups of ten each to receive stitches with a 4- or 10-mm bite. Specimens underwent cyclic loading from 5 to 30 N at 1 mm/s for 30 cycles, followed by tensile testing to failure. Gap formation, tendon strain, hysteresis, stiffness, yield load, ultimate load, energy to yield load, and energy to ultimate load were compared between groups using unpaired t tests.
The 4-mm group had less (p < 0.05) gap formation and less (p < 0.05) longitudinal strain than did the 10-mm group. Ultimate load (293.6 vs. 148.9 N) and energy to ultimate load (2,563 vs. 1,472 N-mm) were greater (p < 0.001) for the 10-mm group than the 4-mm group. All tendons repaired with 4-mm suturing failed at the suture-tendon interface, with sutures pulling through the tendon, whereas the suture itself failed before the tendon did in seven of the ten specimens in the 10-mm group.
Whereas a 4-mm bite fixed the tendon more tightly but at the cost of decreased ultimate strength, a 10-mm bite conveyed greater ultimate strength but with increased gap and strain. These results suggest that for the conventional double-row repair, small mattress stitches provide a tighter repair, whereas large stitches are beneficial to prevent sutures from pulling through the tendon after surgery. For suture-bridge rotator cuff repair, large stitches are beneficial because the repaired tendon has a higher strength, and the slightly mobile medial knot can be tightened by lateral fixation.
Long-term sustainability of clinical practice changes in anesthesia has not been previously reported. Therefore, we performed a 5-year audit following implementation of a clinical pathway change to ...favor spinal anesthesia for total knee arthroplasty (TKA). We similarly evaluated a parallel cohort of patients undergoing total hip arthroplasty (THA) which did not undergo clinical pathway change as well as the utilization of regional analgesia.
We identified all primary unilateral TKA and THA cases performed from January 2013 through December 2018 to include data from one-year pre-implementation and 5-years post-implementation of the clinical pathway change. Our primary outcome was the overall rate of spinal anesthesia usage. Secondary outcomes included rate of nerve block utilization, 30-day postoperative complications, and resource utilization variables such as hospital readmission, emergency department visits, and blood transfusions.
The sample consisted of 1859 cases (1250 TKAs, 609 THAs). In the first year post-implementation, 174/221 (78.7%) TKAs received spinal anesthesia compared to 23/186 (12.4%) in the year before implementation (p<0.001). In the subsequent 4-year period, 647/843 (77.2%) TKAs received spinal anesthesia (p=0.532 vs. year 1). For THA, 78/124 (62.9%) received spinal anesthesia in the year after implementation compared to 48/116 (41.4%) pre-implementation (p=0.001), but this rate decreased in the subsequent 4-year period to 193/369 (52.3%) (p=0.040 vs. year 1). Utilization of regional analgesia was high in both groups, and there were no differences in other outcomes.
A clinical pathway change promoting spinal anesthesia for TKA can be effectively implemented and sustained over a 5-year period.
The subspecialty of regional anesthesiology and acute pain medicine (RAAPM) is in a position to lead changes that may impact the current opioid crisis. At the hospital level, RAAPM experts can ...implement evidence-based multimodal analgesic clinical pathways featuring regional anesthesia. Multimodal analgesia consists of using two or more analgesic modalities targeting pain pathways at various levels to improve pain control, while also aiming to reduce opioid utilization and related adverse effects. These types of pathways or protocols have been widely applied in the joint replacement population. This review focuses on the current state of the evidence regarding individual elements of a multimodal analgesic pathway for patients with total knee arthroplasty including new regional anesthesia techniques like the IPACK (Infiltration between the Popliteal Artery and Capsule of the Knee) block and suggests future research directions to improve the clinical care of this surgical population in the future.
Abstract
Objective
This retrospective cohort study tested the hypothesis that implementing a multidisciplinary patient-specific discharge protocol for prescribing and tapering opioids after total hip ...arthroplasty (THA) will decrease the morphine milligram equivalent (MME) dose of opioids prescribed.
Methods
With institutional review board approval, we analyzed a Perioperative Surgical Home database and prescription data for all primary THA patients three months before (PRE) and three months after (POST) implementation of this new discharge opioid protocol based on patients’ prior 24-hour inpatient opioid consumption. The primary outcome was total opioid dosage in MME prescribed and opioid refills for six weeks after surgery. Secondary outcomes included the number of tablets and MME prescribed at discharge, in-hospital opioid consumption, length of stay, and postoperative complications.
Results
Forty-nine cases (25 PRE and 24 POST) were included. Total median (10th–90th percentiles) MME for six weeks postoperatively was 900 (57–2082) MME PRE vs 295 (69–741) MME POST (mean difference = 721, 95% confidence interval CI = 127–1316, P = 0.007, Mann-Whitney U test). Refill rates did not differ. The median (10th–90th percentiles) initial discharge prescription in MME was 675 (57–1035) PRE vs 180 (18–534) POST (mean difference = 387, 95% CI = 156–618, P = 0.003, Mann-Whitney U test) MME. There were no differences in other outcomes.
Conclusions
Implementation of a patient-specific prescribing and tapering protocol decreases the mean six-week dosage of opioid prescribed by 63% after THA without increasing the refill rate.
Purpose
International consensus recommendations support neuraxial anesthesia as the preferred anesthetic technique for total hip arthroplasty. We hypothesized that an institutional initiative to ...promote spinal anesthesia within a clinical pathway would result in increased use of this technique.
Methods
We reviewed primary unilateral total hip arthroplasty data between June 2017 and June 2019—one year before
vs
one year after implementation. The primary outcome was rate of spinal anesthesia use. Secondary outcomes included postoperative pain scores and opioid use, rates of postoperative complications, and unplanned resource use. We built a run chart-tracking rates of spinal anesthesia; compared postoperative outcomes based on anesthetic technique; and developed a mixed model, multivariable logistic regression with margins analysis evaluating the use of spinal anesthesia.
Results
The final sample included 172 patients (87 before and 85 after implementation) with no significant differences in baseline characteristics. For the primary outcome, 42/87 (48%) patients received spinal anesthesia before implementation compared with 48/85 (56%) postimplementation (unadjusted difference, 8%; 95% confidence interval, −7 to 23;
P
= 0.28). There were no differences in secondary outcomes. Factors associated with receipt of spinal anesthesia included American Society of Anesthesiologists Physical Status II (
vs
III), lower body mass index, and shorter case duration. Using a reduced mixed model, the average marginal effect was 10.7%, with an upper 95% confidence limit of 25.7%.
Conclusion
Implementation of a clinical pathway change to promote spinal anesthesia for total hip arthroplasty may not have been associated with increased use of spinal anesthesia, but utilization rates can vary widely. Baseline spinal anesthesia usage at our institution was higher than the USA national average, and many factors may influence choice of anesthesia technique. Patients who receive spinal anesthesia have decreased opioid requirements and pain scores postoperatively.
•Perioperative eye injury (PEI) can be a serious surgical complication.•No large-scale studies have assessed PEI in the Veterans Affairs (VA) population.•We conducted a 6-year review of all ...consecutive surgical inpatients.•The incidence of new PEI among our veteran patients was 0.24%.•Nearly all PEI cases were treated empirically as corneal abrasions.
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