Researchers Identify Top Interventions for Reducing Surgical Harm

By Debra Wood, RN, contributor

March 17, 2014 - Despite all of the interventions designed to reduce adverse surgical events, only a few truly make a difference in decreasing patient harm, according to a systematic review.

“Surgery is a specialty where there is great potential for patients to be harmed as a result of their treatment,” said lead author Ann-Marie Howell, BSc, MBBS, MRCS, clinical research fellow in the department of surgery and cancer at Imperial College London.

“This study suggests there are interventions that could reduce patient harm,” Howell continued. “These include increasing nursing staff, subspecialized services, checklists, team training, safety devices, and care pathways as well as publishing hospital complication results.”

Howell and colleagues analyzed 91 studies, of which only 17 reported an intervention that resulted in a significant decrease in morbidity and mortality. They concluded in the Annals of Surgery that by changing these elements of care, “surgery may be made safer in a way that is measurable and shows benefit to patients.”

Rajov Datta: Sufficient nurse staffing shown to reduce harm in surgery cases.
Rajov V. Datta, MD, FRCS, FACS, FICS, praised better patient-to-nurse ratios, teamwork and checklists with improving surgical safety.

Surgery has traditionally been a specialty where the surgeon was the “captain of the ship,” but that is starting to change into a more team-based model focused on safety, said Rajov V. Datta, MD, FRCS, FACS, FICS, chair of the department of surgery at South Nassau Communities Hospital in Oceanside, N.Y., and medical director of The Gertrude and Louis Feil Cancer Center at South Nassau.

“Everyone should be able to speak up and say something is wrong,” Datta explained.

The review found team training decreased all postoperative adverse events.

David Hanscom: A cohesive surgery team improves outcomes.
David Hanscom, MD, said he considers a cohesive team important for surgical performance.

“Having a cohesive team is vital for performance,” added David Hanscom, MD, an orthopedic surgeon in Seattle. “Surgeons often do not realize the impact they have on their team. Strategies are taught to not only minimize the potential negative impact of their behavior but to have an awareness of how they can have a major impact on the team.”

The review also found beneficial structural interventions included an intensive care physician being involved in the postoperative care, which reduced the risk of sepsis, and improved nurse staffing ratios. Better nurse-to-patient ratios decreased failure to rescue.

“A reduction in the patient-to-nurse ratio makes a dramatic effect on the outcome, because nurses can focus on one patient,” Datta said. “When they focus, they can pick up on small things and interventions can be done before the patient goes south. We don’t want the nurse to be calling when the patient is about to code; we want the nurse to call when she finds something is not right, the blood pressure is starting to drop, so we can make interventions.”

Safety technology, such as the e-ICU, where intensivists monitor ICU patients remotely, and coded sponge detection systems resulted in better outcomes, the review concluded.

Datta agreed that sponge detection systems can prove helpful. A wand held over the abdomen will beep to indicate something was left behind, but such systems are expensive.

Process improvements resulting in less harm included reporting outcome data to a national audit, using safety checklists and adhering to care pathways.

“If everyone follows a checklist, the errors will go down,” Datta said. “But that itself is not enough.”

Datta suggested checklists be used throughout the hospital for preoperative and postoperative care, so nothing is missed.

Technical complications were reduced when the surgeon held a subspecialty, for instance a colorectal surgeon performing colon surgery.

Hanscom added that he considers the surgeon’s performance critical, which is not in any guidelines.

Howell concluded that “further high-quality research is needed to corroborate these findings. Research focus should be on implementing methods, which produce a measurable decrease in harm.”

Predicting and mitigating postoperative risk

Another recent study led by Laurent G Glance, MD, from the University of Rochester (N.Y.) Medical Center studied 142,232 admissions for major noncardiac surgery and found that complications were a strong indictor of a readmission. The 30-day readmission rate for patients with post-discharge complications was 78 percent, according to the report in JAMA Surgery. The authors suggested using the American College of Surgeon’s Surgical Risk Calculator to help in predicting complication risk.

Patients at risk might benefit from closer monitoring to uncover and then treat problems before the patient needs hospital-level care, the authors indicated. Or the physician might decide to move the patient to the intensive care unit or a step-down unit after surgery, as opposed to a regular hospital unit that manages less sick patients, said Glance, a professor in the departments of anesthesiology and public health sciences at the University of Rochester School of Medicine and Dentistry.

“This information could also help with staffing,” Glance added. “Instead of taking care of eight patients, a nurse might be assigned to monitor just two or three high-risk patients in an effort to prevent complications.”



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