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SURGICAL SUITES: Guidelines on best practices to prevent surgical site infections

The number of unresolved issues in this guideline reveals substantial gaps that warrant future research.” (page E6)

Best practices in avoiding surgical site infections were studied by the Centers for Disease Control and Prevention with the assistance of the Healthcare Infection Control Practices Advisory Committee.  This guideline is based on the full text review of nearly 900 journal articles and studies.  The guideline is organized according to specific surgical practices – for example the efficacy of wearing a space suit during orthopedic surgery – and assigns each practice a rating on a continuum as to whether the practice is highly recommended, unresolved, or somewhere in between.  The rating on the space suits, for instance, is that it is unresolved.

Source: Berrios-Torres, S.I., and others. (2017, May 3). Centers for Disease Control and Prevention guideline for the prevention of surgical site infection 2017. JAMA Surgery. Click here: http://jamanetwork.com/journals/jamasurgery/fullarticle/2623725  Posted by AHA Resource Center (312) 422-2050, rc@aha.org

SURGICAL SUITE: What is concurrent surgery? Is it a good idea?

Concurrent surgery means that a surgeon is double-booked – running two operations in different operating rooms at the same time – sometimes also referred to as overlapping cases or simultaneous surgery.  In teaching hospitals, this is likely to involve having surgical residents perform part of the procedures.  In this blog post, I will mention some of the recent literature on concurrent surgery.

(1)  In this Boston Globe story, a 2012 case involving a leading Massachusetts General Hospital neurosurgeon and a patient who was discovered to be paralyzed after the procedure during which the surgeon was double-booked is reported.  Source: Abelson, J., Saltzman, J., Kowalczyk, L., and others. (2015, Oct. 25). Clash in the name of care. Boston Globe.  Click here for full text: https://apps.bostonglobe.com/spotlight/clash-in-the-name-of-care/story/

(2) Surgeons from Duke present the advantages associated with concurrent surgery in the academic medical center setting and advocate its continuation under existing Medicare policy guidelines.  Source: Beasley, G.M., Pappas, T.N., and Kirk, A.D. (2015, June). Procedure delegation by attending surgeons performing concurrent operations in academic medical centers: Balancing safety and efficiency. Annals of Surgery. 261(6), 1044-1045. Click here for full text: http://journals.lww.com/annalsofsurgery/Citation/2015/06000/Procedure_Delegation_by_Attending_Surgeons.5.aspx

(3) Efficiency and patient outcomes for cardiothoracic patients were studied over a 2-year period (2011 to 2013) at the University of Virginia Charlottesville.  Record review found no negative effect on patient outcomes and no problem as far as lengthening overall operative duration associated with concurrent surgery.  There was a small impact on later starting and closing times.  Source: Yount, K.W., Gillen, J.R., Kron, I.L., and others. (2014).  Attendings’ performing simultaneous operations in academic cardiothoracic surgery does not increase operative duration or negatively affect patient outcomes.      Click here for abstract: http://aats.org/annualmeeting/Program-Books/2014/2.cgi

(4) Here are the Medicare requirements for when a teaching surgeon may bill for two overlapping procedures.  Source: U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services. (2011, Sept. 14). CMS manual system: Pub 100-04 Medicare claims processing.  Transmittal 2303. Click here for full text: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R2303CP.pdf

(5) An opinion just out in JAMA discusses the concerns of the public on this issue and advocates self-regulation by surgeons and transparency in communication about this with patients.  Source: Mello, M.M., and Livingston, E.H. (2016, Mar. 17). Managing the risks of concurrent surgeries. JAMA. Click here for full text: http://jama.jamanetwork.com/article.aspx?articleID=2505160&utm_source=Silverchair_Information_Systems&utm_campaign=Thursday_March_17_2016&utm_content=olf&cmp=1&utm_medium=email   Posted by AHA Resource Center (312) 422-2050, rc@aha.org

TRANSPORT: Mayo Clinic improved ICU to OR transports

Patient transportation from critical care unit to the operating room was studied over the 2006 to 2010 period.  During this period there were 1,557 such transfers, some done in the existing traditional way, others according to a new coordinated patient transport system (CPTS).  The transfers studied were only those involving the first surgical case of the day.  Here are the findings:

  • “We report a significant improvement in on-time OR starts when a CPTS is used for all ICU patients who require surgery as a first case of the day.  A CPTS resulted in a fourfold improvement in one-time OR start percentage.” (page 359).

The difference between the traditional patient transport and the new CPTS are described in this article.

Source: Brown, M.J., Kor, D.J., Curry, T.B., and others. (2015, Nov.-Dec.). A coordinated patient transport system for ICU patients requiring surgery: Impact on operating room efficiency and ICU workflow. Journal for Healthcare Quality, 37(6), 354-362. Link to publisher’s website: http://journals.lww.com/jhqonline/Abstract/2015/11000/A_Coordinated_Patient_Transport_System_for_ICU.4.aspx Posted by AHA Resource Center (312) 422-2050, rc@aha.org

 

Unplanned Revisits Following Ambulatory Surgery

The outpatient counterpart for hospital inpatient readmissions is revisits. Even though two-thirds of surgeries  are done on an outpatient revisit, less quality of care data has been available for unplanned revisits following outpatient surgery than for unplanned readmissions after an inpatient operation. Here are some initial benchmarks from one research team that looked at ambulatory surgeries performed in hospital-owned settings that had low surgical risk:

  • All-cause revisits within 30 days of ambulatory surgery: 95 per 1000 operations
  • Most revisits were to emergency departments: 59 per 1000 operations
  • Revisits to inpatient surgery setting: 27 per 1000 operations
  • Two-thirds of the revisits [65 per 1000 operations] were for complications related to the procedure, while the remaining revisits were attributed to unrelated conditions.

The authors indicate more research is needed to determine which of the ambulatory surgery complication revisits may be preventable.

Sources:

Steiner CA and others. Return to acute care following ambulatory surgery. JAMA 314(13):1397-1399, Oct. 6, 2015. http://jama.jamanetwork.com/article.aspx?articleid=2449176

AHRQ study: ambulatory ‘revisits’ occur frequently, often due to complications. AHRQ Electronic Newsletter, no. 497, Dec. 8, 2015, p. 3. http://content.govdelivery.com/accounts/USAHRQ/bulletins/129ba69

Posted by AHA Resource Center (312) 422-2050 rc@aha.org

Do ambulatory surgery centers affect hospital utilization?

Opening a freestanding ambulatory surgery center in a market where there previously had not been one decreased outpatient surgical volume at the local hospital by 7 percent, according to a large-scale study of Medicare beneficiaries.  The shift from hospital-based to ASC-based outpatient procedures was particularly pronounced for ophthalmology.  The researchers also analyzed the effect on quality of care and found no impact on either hospital admission within 30 days or on mortality rates due to the opening of an ambulatory surgery center.

Source: Hollenbeck, B.K., Dunn, R.L., Suskind, A.M., and others. (2015, Oct.). Ambulatory surgery centers and their intended effects on outpatient surgery. HSR. Health Services Research, 50(5), 1491-1507.  http://onlinelibrary.wiley.com/doi/10.1111/1475-6773.12278/abstract  Posted by AHA Resource Center (312) 422-2050, rc@aha.org

EMERGENCY DEPARTMENTS: What is a surgicalist?

Surgicalists are surgical hospitalists, surgeons who provide care to trauma patients and other patients who arrive in the emergency room with immediate need for surgery.  This new type of surgical position is helpful in resolving the long-standing issue of how to provide surgical coverage in the emergency department.  In many hospitals, general surgeons are required to be part of a rotating on-call schedule for the ED as a condition of medical staff membership.  This article describes how Sutter Medical Center (Sacramento, Calif.) established a surgicalist model.  This large community hospital staffs 24-hour shifts with 3.5 full-time general surgeons, who are on campus when they are on duty.  Among the positive outcomes were a decreases in: time from ED to OR, cost per surgery, length of stay, and complication rate.

Source: SooHoo, R., and Owens, L.J. (2015, June). Beyond surgical call coverage: Reaping the benefits of a surgical hospitalist program. HFM. Healthcare Financial Management, 69(6), 46-49. Retrieved from http://www.hfma.org/Content.aspx?id=31006  Posted by AHA Resource Center (312) 422-2005, rc@aha.org

OPERATING ROOM OF THE FUTURE: Google Glass

Google Glass looks like a pair of hi-tech glasses with a very slim, light-weight camera device on the right stem.  It is being tested by surgeons as a way to enhance consultations with experts during surgery, to view diagnostic images, and to give students a better view of exactly what the surgeon is seeing.  The first Google Glass-equipped procedure is credited to Dr. Rafael Grossmann – done in 2013 at Eastern Maine Medical Center (Bangor, ME).  Among the challenges to be worked out as the technology is developed are longer battery life and how to ensure HIPAA privacy for patients.

Source: Peregrin, T. (2014, July). Surgeons see future applications for Google Glass. Bulletin of the American College of Surgeons, 99(7), 9-16.  Click here for article: http://bulletin.facs.org/2014/07/surgeons-see-future-applications-for-google-glass/#printpreview  Posted by AHA Resource Center (312) 422-2050, rc@aha.org