Simulation-Based Trial of Surgical-Crisis Checklists Arriaga, Alexander F; Bader, Angela M; Wong, Judith M ...
New England journal of medicine/The New England journal of medicine,
01/2013, Letnik:
368, Številka:
3
Journal Article
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Odprti dostop
In this study, the authors designed checklists to guide care during operating-room crises and evaluated them in a simulated operating room. The availability of checklists improved adherence to best ...practices by operating-room teams during simulations of surgical crises.
Operating-room crises (e.g., massive hemorrhage and cardiac arrest) are high-risk, stressful events that require rapid and coordinated care in a time-critical setting. The reported incidence may be rare for an individual practitioner,
1
but the aggregate incidence for a hospital with 10,000 operations a year is estimated to be approximately 145 such events annually.
2
These are situations in which the way the team cares for a patient will make the difference between life and death. Failure to effectively manage life-threatening complications in surgical patients has been recognized as the largest source of variation in surgical mortality among hospitals.
3
–
7
Small-scale studies . . .
Background Because operating room crises are rare events, failure to adhere to critical management steps is common. We sought to develop and pilot a tool to improve adherence to lifesaving measures ...during operating room crises. Study Design We identified 12 of the most frequently occurring operating room crises and corresponding evidence-based metrics of essential care for each (46 total process measures). We developed checklists for each crisis based on a previously defined method, which included literature review, multidisciplinary expert consultation, and simulation. After development, 2 operating room teams (11 participants) were each exposed to 8 simulations with random assignment to checklist use or working from memory alone. Each team managed 4 simulations with a checklist available and 4 without. One of the primary outcomes measured through video review was failure to adhere to essential processes of care. Participants were surveyed for perceptions of checklist use and realism of the scenarios. Results Checklist use resulted in a 6-fold reduction in failure of adherence to critical steps in management for 8 scenarios with 2 pilot teams. These results held in multivariate analysis accounting for clustering within teams and adjusting for learning or fatigue effects (11 of 46 failures without the checklist vs 2 of 46 failures with the checklist; adjusted relative risk = 0.15, 95% CI, 0.04–0.60; p = 0.007). All participants rated the overall quality of the checklists and scenarios to be higher than average or excellent. Conclusions Checklist use can improve safety and management in operating room crises. These findings warrant broader evaluation, including in clinical settings.
Objectives
To assess the association of cumulative fluid overload (FO) up to 14 days from the diagnosis of pediatric acute respiratory syndrome (PARDS) with pediatric intensive care unit (PICU) ...mortality, 28‐day mechanical ventilation free days (VFD), and 28‐day intensive care unit free days (IFD). We hypothesized that fluid overload, even beyond the acute period, would be associated with increased morbidity and mortality.
Methods
We conducted a retrospective cohort study of PARDS patients admitted to PICU from 2009 to 2015. For repeated admissions, we considered the admission with the highest oxygenation index (OI). Daily FO (%) was calculated as (intake − output)/weight at PICU admission × 100. Peak cumulative FO (CFO) was the highest CFO from the diagnosis of PARDS to Day 14 or to PICU discharge or mortality, whichever was earliest. Rate to peak CFO was the peak CFO divided by the number of days to reach that highest CFO. The association of FO with mortality, VFD and IFD were analyzed with logistic and linear regression models, with the following covariates: Pediatric Index of Mortality 2 score, PARDS severity, and the presence of acute kidney injury (AKI).
Results
There were 165 patients included in this study, with a mortality rate of 45.5% (75/165), median age 3.2 years (interquartile range IQR 0.7–9.9) and OI 15.8 (IQR 9.5–27.9). Seventy‐three (44.2%) patients had severe PARDS and 64 (38.8%) had AKI. AKI (aOR adjusted odds ratio 3.19, 95% CI confidence interval 1.43–7.09, p = 0.004) and rate to peak cumulative FO (aOR 1.23, 95% CI 1.07–1.42, p = 0.004) were associated with mortality. AKI and peak cumulative FO were associated with decreased VFD and IFD.
Conclusion
The rate to peak CFO over the first 14 days of PARDS was associated with mortality and peak CFO was associated with decreased VFD and IFD.
As cell function and phenotype can be directed by the mechanical characteristics of the surrounding matrix, hydrogels have become important platforms for cell culture systems, with properties that ...can be tuned by external stimuli, such as divalent cations, enzymatic treatment, and pH. However, many of these stimuli can directly affect cell behavior, making it difficult to distinguish purely mechanical signaling events. This study reports on the development of a hydrogel that incorporates photoswitchable cross-linkers, which can reversibly alter their stiffness upon irradiation with the appropriate wavelength of light. Furthermore, this study reports the response of bone-marrow-derived mesenchymal stem cells (MSCs) on these hydrogels that were stiffened systematically by irradiation with blue light. The substrates were shown to be noncytotoxic, and crucially MSCs were not affected by blue-light exposure. Time-resolved analysis of cell morphology showed characteristic cell spreading and increased aspect ratios in response to greater substrate stiffness. This hydrogel provides a platform to study mechanosignaling in cells responding to dynamic changes in stiffness, offering a new way to study mechanotransduction signaling pathways and biological processes, with implicit changes to tissue mechanics, such as development, ageing, and fibrosis.
Neurosurgery is a high-risk specialty currently undertaking the pursuit of systematic approaches to measuring and improving outcomes. As part of a project to devise evidence-based safety ...interventions for specialty surgery, the authors sought to review current evidence in cranial tumor resection concerning the frequency of adverse events in practice, their patterns, and current methods of reducing the occurrence of these events. This review represents part of a series of papers written to consolidate information about these events and preventive measures as part of an ongoing effort to ascertain the utility of devising system-wide policies and safety tools to improve neurosurgical practice.
The authors performed a PubMed search using search terms "intracranial neoplasm," "cerebral tumor," "cerebral meningioma," "glioma," and "complications" or "adverse events." Only papers that specifically discussed the relevant complication rates were included. Papers were chosen to maximize the range of rates of occurrence for the reported adverse events.
Review of the tumor neurosurgery literature showed that documented overall complication rates ranged from 9% to 40%, with overall mortality rates of 1.5%-16%. There was a wide range of types of adverse events overall. Deep venous thromboembolism (DVT) was the most common adverse event, with a reported incidence of 3%-26%. The presence of new or worsened neurological deficit was the second most common adverse event found in this review, with reported rates ranging from 0% for the series of meningioma cases with the lowest reported rate to 20% as the highest reported rate for treatment of eloquent glioma. Benign tumor recurrence was found to be a commonly reported adverse event following surgery for intracranial neoplasms. Rates varied depending on tumor type, tumor location, patient demographics, surgical technique, the surgeon's level of experience, degree of specialization, and changes in technology, but these effects remain unmeasured. The incidence on our review ranged from 2% for convexity meningiomas to 36% for basal meningiomas. Other relatively common complications were dural closure-related complications (1%-24%), postoperative peritumoral edema (2%-10%), early postoperative seizure (1%-12%), medical complications (6%-7%), wound infection (0%-4%), surgery-related hematoma (1%-2%), and wrong-site surgery. Strategies to minimize risk of these events were evaluated. Prophylactic techniques for DVT have been widely demonstrated and confirmed, but adherence remains unstudied. The use of image guidance, intraoperative functional mapping, and real-time intraoperative MRI guidance can allow surgeons to maximize resection while preserving neurological function. Whether the extent of resection significantly correlates with improved overall outcomes remains controversial.
A significant proportion of adverse events in intracranial neoplasm surgery may be avoidable by use of practices to encourage use of standardized protocols for DVT, seizure, and infection prophylaxis; intraoperative navigation among other steps; improved teamwork and communication; and concentrated volume and specialization. Systematic efforts to bundle such strategies may significantly improve patient outcomes.
Background
There are few studies to date of interventions to increase viral hepatitis screening among Asian Americans, who have high rates of chronic hepatitis B (HBV) infection.
Objective
To ...develop, implement, and test the efficacy of a mobile application (Hepatitis App) delivered in four languages to increase HBV screening among Asian Americans.
Design
Cluster-randomized clinical trial.
Participants
Four hundred fifty-two Asian American patients ≥ 18 years of age, who had no prior HBV testing, and received primary care within two healthcare systems in San Francisco, CA.
Interventions
The intervention group received the Hepatitis App, delivering interactive video education on viral hepatitis in English, Cantonese, Mandarin, or Vietnamese and a provider printout (Provider Alert) and Provider Panel Notification. The comparison group received a mobile application delivering nutrition and physical activity education and Provider Panel Notification.
Main Measures
Primary outcomes were patient-provider discussion about HBV and documentation of a HBV screening test within 3 months post-intervention. Secondary outcome was documentation of an order for a HBV screening test.
Key Results
Participants had a mean age of 57 years and were 64% female, 80% foreign-born, and 44% with limited English fluency. At post-visit, over 80% of intervention participants reported they liked using the Hepatitis App. At 3-month follow-up, the intervention group was more likely than the comparison group (all
P
< 0.001
)
to have discussed HBV with their provider (70% vs.16%), have a HBV test ordered (44% vs.10%), and receive a HBV test (38% vs.8%). In multivariable analyses, the intervention odds ratio for HBV test ordering was 7.6 (95% CI: 3.9, 14.8) and test receipt was 7.5 (95% CI: 3.6, 15.5).
Conclusions
A multi-lingual educational intervention using a mobile application in primary care clinics was well received by Asian American patients, enhanced patient-provider communication about HBV, and increased HBV screening. Technology can improve healthcare quality among Asian Americans.
Trial Registration
ClinicalTrials.gov NCT02139722 (
https://clinicaltrials.gov/ct2/show/NCT02139722
).
OBJECT Approximately 250 million surgical procedures are performed annually worldwide, and data suggest that major complications occur in 3%-17% of them. Many of these complications can be classified ...as avoidable, and previous studies have demonstrated that preoperative checklists improve operating room teamwork and decrease complication rates. Although the authors' institution has instituted a general preoperative "time-out" designed to streamline communication, flatten vertical authority gradients, and decrease procedural errors, there is no specific checklist for transnasal transsphenoidal anterior skull base surgery, with or without endoscopy. Such minimally invasive cranial surgery uses a completely different conceptual approach, set-up, instrumentation, and operative procedure. Therefore, it can be associated with different types of complications as compared with open cranial surgery. The authors hypothesized that a detailed, procedure-specific, preoperative checklist would be useful to reduce errors, improve outcomes, decrease delays, and maximize both teambuilding and operational efficiency. Thus, the object of this study was to develop such a checklist for endonasal transsphenoidal anterior skull base surgery. METHODS An expert panel was convened that consisted of all members of the typical surgical team for transsphenoidal endoscopic cases: neurosurgeons, anesthesiologists, circulating nurses, scrub technicians, surgical operations managers, and technical assistants. Beginning with a general checklist, procedure-specific items were added and categorized into 4 pauses: Anesthesia Pause, Surgical Pause, Equipment Pause, and Closure Pause. RESULTS The final endonasal transsphenoidal anterior skull base surgery checklist is composed of the following 4 pauses. The Anesthesia Pause consists of patient identification, diagnosis, pertinent laboratory studies, medications, surgical preparation, patient positioning, intravenous/arterial access, fluid management, monitoring, and other special considerations (e.g., Valsalva, jugular compression, lumbar drain, and so on). The Surgical Pause is composed of personnel introductions, planned procedural elements, estimation of duration of surgery, anticipated blood loss and fluid management, imaging, specimen collection, and questions of a surgical nature. The Equipment Pause assures proper function and availability of the microscope, endoscope, cameras and recorders, guidance systems, special instruments, ultrasonic microdoppler, microdebrider, drills, and other adjunctive supplies (e.g., Avitene, cotton balls, nasal packs, and so on). The Closure Pause is dedicated to issues of immediate postoperative patient disposition, orders, and management. CONCLUSIONS Surgical complications are a considerable cause of death and disability worldwide. Checklists have been shown to be an effective tool for reducing preventable errors surrounding surgery and decreasing associated complications. Although general checklists are already in place in most institutions, a specific checklist for endonasal transsphenoidal anterior skull base surgery was developed to help safeguard patients, improve outcomes, and enhance teambuilding.
Introduction
There is lack of consensus on what constitutes best practice when assessing extubation readiness in children. This systematic review aims to synthesize data from existing literature on ...pre-extubation assessments and evaluate their diagnostic accuracies in predicting extubation failure (EF) in children.
Methods
A systematic search in PubMed, EMBASE, Web of Science, CINAHL, and Cochrane was performed from inception of each database to 15 July 2021. Randomized controlled trials or observational studies that studied the association between pre-extubation assessments and extubation outcome in the pediatric intensive care unit population were included. Meta-analysis was performed for studies that report diagnostic tests results of a combination of parameters.
Results
In total, 41 of 11,663 publications screened were included (total patients,
n
= 8111). Definition of EF across studies was heterogeneous. Fifty-five unique pre-extubation assessments were identified. Parameters most studied were: respiratory rate (RR) (13/41,
n
= 1945), partial pressure of arterial carbon dioxide (10/41,
n
= 1379), tidal volume (13/41,
n
= 1945), rapid shallow breathing index (RBSI) (9/41,
n
= 1400), and spontaneous breathing trials (SBT) (13/41,
n
= 5652). Meta-analysis shows that RSBI, compliance rate oxygenation pressure (CROP) index, and SBT had sensitivities ranging from 0.14 to 0.57. CROP index had the highest sensitivity 0.57, 95% confidence interval (CI) 0.4–0.73 and area under curve (AUC, 0.98). SBT had the highest specificity (0.93, 95% CI 0.92–0.94).
Conclusions
Pre-extubation assessments studied thus far remain poor predictors of EF. CROP index, having the highest AUC, should be further explored as a predictor of EF. Standardizing the EF definition will allow better comparison of pre-extubation assessments.
Frontline healthcare workers (HCWs) exposed to coronavirus disease 2019 (COVID-19) are at risk of psychological distress. This study evaluates the psychological impact of COVID-19 pandemic on HCWs in ...a national paediatric referral centre.
This was a survey-based study that collected demographic, work environment and mental health data from paediatric HCWs in the emergency, intensive care and infectious disease units. Psychological impact was measured using the Depression, Anxiety, Stress Scale-21. Multivariate regression analysis was performed to identify risk factors associated with psychological distress.
The survey achieved a response rate of 93.9% (430 of 458). Of the 430 respondents, symptoms of depression, anxiety and stress were reported in 168 (39.1%), 205 (47.7%) and 106 (24.7%), respectively. Depression was reported in the mild (47, 10.9%), moderate (76, 17.7%), severe (23, 5.3%) and extremely severe (22, 5.1%) categories. Anxiety (205, 47.7%) and stress (106, 24.7%) were reported in the mild category only. Collectively, regression analysis identified female sex, a perceived lack of choice in work scope/environment, lack of protection from COVID-19, lack of access to physical activities and rest, the need to perform additional tasks, and the experience of stigma from the community as risk factors for poor psychological outcome.
A high prevalence of depression, anxiety and stress was reported among frontline paediatric HCWs during the COVID-19 pandemic. Personal psychoneuroimmunity and organisational prevention measures can be implemented to lessen psychiatric symptoms. At the national level, involving mental health professionals to plan and coordinate psychological intervention for the country should be considered.
As part of a project to devise evidence-based safety interventions for specialty surgery, the authors sought to review current evidence in CSF shunt surgery concerning the frequency of adverse events ...in practice, their patterns, and the state of knowledge regarding methods for their reduction. This review may also inform future and ongoing efforts for the advancement of neurosurgical quality.
The authors performed a PubMed search using search terms "cerebral shunt," "cerebrospinal fluid shunt," "CSF shunt," "ventriculoperitoneal shunt," "cerebral shunt AND complications," "cerebrospinal fluid shunt AND complications," "CSF shunt AND complications," and "ventriculoperitoneal shunt AND complications." Only papers that specifically discussed the relevant complication rates were included. Papers were chosen to be included to maximize the range of rates of occurrence for the adverse events reported.
In this review of the neurosurgery literature, the reported rate of mechanical malfunction ranged from 8% to 64%. The use of programmable valves has increased but remains of unproven benefit even in randomized trials. Infection was the second most common complication, with the rate ranging from 3% to 12% of shunt operations. A meta-analysis that included 17 randomized controlled trials of perioperative antibiotic prophylaxis demonstrated a decrease in shunt infection by half (OR 0.51, 95% CI 0.36-0.73). Similarly, use of detailed protocols including perioperative antibiotics, skin preparation, and limitation of OR personnel and operative time, among other steps, were shown in uncontrolled studies to decrease shunt infection by more than half. Other adverse events included intraabdominal complications, with a reported incidence of 1% to 24%, intracerebral hemorrhage, reported to occur in 4% of cases, and perioperative epilepsy, with a reported association with shunt procedures ranging from 20% to 32%. Potential management strategies are reported but are largely without formal evaluation.
Surgery for CSF shunt placement or revision is associated with a high complication risk due primarily to mechanical issues and infection. Concerted efforts aimed at large-scale monitoring of neurosurgical complications and consistent quality improvement within these highlighted realms may significantly improve patient outcomes.
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