Critical Roles of Orthopaedic Surgeon Leadership in Healthcare Systems to Improve Orthopaedic Surgical Patient Safety

Background

The prevention of medical and surgical harm remains an important public health problem despite increased awareness and implementation of safety programs. Successful introduction and maintenance of surgical safety programs require both surgeon leadership and collaborative surgeon-hospital alignment. Documentation of success of such surgical safety programs in orthopaedic practice is limited.

Questions/purposes

We describe the scope of orthopaedic surgical patient safety issues, define critical elements of orthopaedic surgical safety, and outline leadership roles for orthopaedic surgeons needed to establish and sustain a culture of safety in contemporary healthcare systems.

Methods

We identified the most common causes of preventable surgical harm based on adverse and sentinel surgical events reported to The Joint Commission. A comprehensive literature review through a MEDLINE^® database search (January 1982 through April 2012) to identify pertinent orthopaedic surgical safety articles found 14 articles. Where gaps in orthopaedic literature were identified, the review was supplemented by 22 nonorthopaedic surgical references. Our final review included 36 articles.

Results

Six important surgical safety program elements needed to eliminate preventable surgical harm were identified: (1) effective surgical team communication, (2) proper informed consent, (3) implementation and regular use of surgical checklists, (4) proper surgical site/procedure identification, (5) reduction of surgical team distractions, and (6) routine surgical data collection and analysis to improve the safety and quality of surgical patient care.

Conclusions

Successful surgical safety programs require a culture of safety supported by all six key surgical safety program elements, active surgeon champions, and collaborative hospital and/or administrative support designed to enhance surgical safety and improve surgical patient outcomes. Further research measuring improvements from such surgical safety systems in orthopaedic care is needed.     

Healthcare Quality Measurement in Orthopaedic Surgery: Current State of the Art

Improving quality of care in arthroplasty is of increasing importance to payors, hospitals, surgeons, and patients. Efforts to compel improvement have traditionally focused measurement and reporting of data describing structural factors, care processes (or ‘quality measures’), and clinical outcomes. Reporting structural measures (eg, surgical case volume) has been used with varying degrees of success. Care process measures, exemplified by initiatives such as the Surgical Care Improvement Project measures, are chosen based on the strength of randomized trial evidence linking the process to improved outcomes. However, evidence linking improved performance on Surgical Care Improvement Project measures with improved outcomes is limited. Outcome measures in surgery are of increasing importance as an approach to compel care improvement with prominent examples represented by the National Surgical Quality Improvement Project. Although outcomes-focused approaches are often costly, when linked to active benchmarking and collaborative activities, they may improve care broadly. Moreover, implementation of computerized data systems collecting information formerly collected on paper only will facilitate benchmarking. In the end, care will only be improved if these data are used to define methods for innovating care systems that deliver better outcomes at lower or equivalent costs.     

Understanding Patients' Value of Weight Loss and Expectations for Bariatric Surgery

Background: Few studies examine patients' expectations for bariatric surgery or the value patients place on weight loss. Methods: 44 patients planning to undergo bariatric surgery were surveyed to examine patients' expectations and motivations for surgery. We also quantified how much patients valued different health and weight loss states using the standard gamble, an approach that estimates an outcome's value based on a patient's willingness to risk death to achieve the outcome. Utilities ranging from 0 to 1.00 were calculated where 1.00 represented the most desired state. Results: Mean age of the patients was 42.6 years, and mean body mass index was 47.1 kg/m². The majority were women (n=42) and white (n=29), and reported poor quality of life. Most patients considered surgery for health reasons. Patients expected to lose 38% of their total body weight and would be disappointed if they did not lose at least 24% of their body weight. Significantly more patients were willing to risk death to achieve their "dream" weight (n=40) than to lose 20% (n=32) or 10% (n=17) of their total body weight. The respective utilities for these weight states were 0.98, 0.94, and 0.92. More patients were willing to risk death to undergo surgery (n=42) than to achieve a permanent weight loss of 20% (n=32), P<0.004. Conclusion: Patients appeared to value weight loss highly but had unrealistic expectations for bariatric surgery. Future studies should examine whether patient expectations, motivations, and value for realistic weight losses might predict outcomes and satisfaction after surgery.     

Embolisation for Vascular Injuries Complicating Elective Orthopaedic Surgery

Objectives

The study aims to present the indications and emphasise the role of embolisation for vascular injuries in orthopaedic surgery.

Methods

Thirty-one patients with vascular injuries complicating elective orthopaedic surgery had embolisation from 2003 to 2010. N-2-butyl cyano-acrylate (NBCA) was used as embolic agent in 28 patients, gelatin sponge in three and coil embolisation in addition to NBCA or gelatin sponge in two patients. The mean follow-up period was 37 months (range, 4–96 months).

Results

The most common orthopaedic operations associated with vascular injuries amenable to embolisation were hip-joint procedures; and the most common injuries were arterial tears of branch vessels or non-critical axial vessels, most commonly of the superior glutaeal artery. In all cases, angiography showed the bleeding point, and a single embolisation session effectively stopped bleeding. Embolisation-related complications were not observed.

Conclusions

Embolisation should be considered the treatment of choice for vascular injuries of branch vessels or non-critical axial vessels following elective orthopaedic surgery because of the advantages of minimally invasive therapy and the lack of complications.     

Electronic Data Capture for Registries and Clinical Trials in Orthopaedic Surgery: Open Source versus Commercial Systems

Background  

Collection and analysis of clinical data can help orthopaedic surgeons to practice evidence based medicine. Spreadsheets and offline relational databases are prevalent, but not flexible, secure, workflow friendly and do not support the generation of standardized and interoperable data. Additionally these data collection applications usually do not follow a structured and planned approach which may result in failure to achieve the intended goal.     

Orthopaedic Surgery Residents and Program Directors Agree on How Time Is Currently Spent in Training and Targets for Improvement

Background

Although much attention has been paid to the role of deliberate practice as a means of achieving expert levels of performance in other medical specialties, little has been published regarding its role in maximizing orthopaedic surgery resident potential. As an initial step in this process, this study seeks to determine how residents and program directors (PDs) feel current time spent in training is allocated compared with a theoretical ideal distribution of time.

Questions/purposes

According to residents and PDs, (1) how do resident responsibilities change by level of training as perceived and idealized by residents and PDs? (2) How do resident and PD perceptions of current and ideal time distributions compare with one another? (3) Do the current training structures described by residents and PDs differ from what they feel represents an ideal time allocation construct that maximizes the educational value of residency training?

Methods

A survey was sent to orthopaedic surgery resident and PD members of the Midwest Orthopedic Surgical Skills Consortium asking how they felt residents’ time spent in training was distributed across 10 domains and four operating room (OR) roles and what they felt would be an ideal distribution of that time. Responses were compared between residents and PDs and between current schedules and ideal schedules.

Results

Both residents and PDs agreed that time currently spent in training differs by postgraduate year with senior-level residents spending more time in the OR (33.7% ± 8.3% versus 17.9% ± 6.2% [interns] and 27.4% ± 10.2% [juniors] according to residents, p < 0.001; and 38.6% ± 8.1% versus 11.8% ± 6.4% [interns] and 26.1% ± 5.7% [juniors] according to PD, p < 0.001). The same holds true for their theoretical ideals. Residents and PDs agree on current resident time allocation across the 10 domains; however, they disagree on multiple components of the ideal program with residents desiring more time spent in the OR than what PDs prefer (residents 40.3% ± 10.3% versus PD 32.6% ± 14.6% [mean difference {MD}, 7.7; 95% confidence interval {CI}, 4.4, 11.0], p < 0.001). Residents would also prefer to have more time spent deliberately practicing surgical skills outside of the OR (current 1.8% ± 2.1% versus ideal 3.7% ± 3.2% [MD, −1.9; 95% CI, −.2.4 to −1.4], p < 0.001). Both residents and PDs want residents to spend less time completing paperwork (current 4.4% ± 4.1% versus ideal 0.8% ± 1.6% [MD, 3.6; 95% CI, 3.0–4.2], p < 0.001 for residents; and current 3.6% ± 4.1% versus ideal 1.5% ± 1.9% [MD, 2.1; 95% CI, 0.9–3.3], p < 0.001 for PDs).

Conclusions

Residents and PDs seem to agree on how time is currently spent in residency training. Some differences of opinions continue to exist regarding how an ideal program should be structured; however, this work identifies a few potential targets for improvement that are agreed on by both residents and PDs. These areas include increasing OR time, finding opportunities for deliberate practice of surgical skills outside of the OR, and decreased clerical burden. This study may serve as a template to allow programs to continue to refine their educational models in an effort to achieve curricula that meet the desired goals of both learners and educators. Additionally, it is an initial step toward more objective identification of the optimal educational structure of an orthopaedic residency program.     

The High Value Healthcare Collaborative: Observational Analyses of Care Episodes for Hip and Knee Arthroplasty Surgery

Background

Broader use of value-based reimbursement models will require providers to transparently demonstrate health care value. We sought to determine and report cost and quality data for episodes of hip and knee arthroplasty surgery among 13 members of the High Value Healthcare Collaborative (HVHC), a consortium of health care systems interested in improving health care value.

Sublingual Buprenorphine for Premedication and Postoperative Pain Relief in Orthopaedic Surgery

The effect of sublingual buprenorphine (Temgesic) as a premedicant and for postoperative pain relief compared with morphine/pethidine was studied in 50 patients scheduled for elective surgery of the knee joint. Twenty-five patients received buprenorphine 0.4 mg sublingually 1 h before surgery and the same dose on demand postoperatively. Twenty-five patients were given morphine intramuscularly (7.5 mg or 10 mg to females and males respectively) 1 h preoperatively. This group received pethidine (75 mg) intramuscularly on demand postoperatively. All the patients were anaesthetized with halothane N2O/O2 after induction with thiopentone. No significant differences were found with regard to sedation, dizziness, nausea and vomiting during the study period. Emergence shivering, confusion and restlessness just after termination of the operation were equal in the two groups. In the recovery room, however, there was a higher frequency of shivering (P less than 0.05) in the morphine group. During the first 24 h postoperatively the buprenorphine group was given an average of 3.8 doses compared with 2.3 in the pethidine group (P greater than 0.05). It is concluded, that buprenorphine sublingually is as good as morphine intramuscularly for premedication and therefore should be recommended to patients who wish to avoid injections. For postoperative pain relief the initial dose of buprenorphine should be given intravenously. Only minor and unimportant side effects were seen.     

Are Away Rotations Critical for a Successful Match in Orthopaedic Surgery?

Surveys have suggested one of the most important determinants of orthopaedic resident selection is completion of an orthopaedic clerkship at the program director’s institution. The purpose of this study was to further elucidate the significance of visiting externships on the resident selection process. We retrospectively reviewed data for all medical students applying for orthopaedic surgery residency from six medical schools between 2006 and 2008, for a total of 143 applicants. Univariate and multivariate regression analyses were used to compare students who matched successfully versus those who did not in terms of number of away rotations, United States Medical Licensing Examination^® scores, class rank, and other objective factors. Of the 143 medical students, 19 did not match in orthopaedics (13.3%), whereas the remaining 124 matched. On multiple logistic regression analysis, whether a student did more than one home rotation, how many away rotations a student performed, and United States Medical Licensing Examination^® Step 1 score were factors in the odds of match success. Orthopaedic surgery is one of the most competitive specialties in medicine; the away rotation remains an important factor in match success.     

Perioperative Blood Transfusion Practices in Oncologic Thoracic Surgery: When, Why, and How

Introduction

Available information on perioperative blood transfusion practices in oncologic thoracic surgery is scant and outdated. The purpose of this study was to investigate transfusion requirements in patients undergoing curative resection for lung cancer and to identify possible factors predictive of perioperative blood transfusion in our cohort of patients.

Methods

From 1st January 2009 to 31st December 2009, 317 patients underwent anatomic pulmonary resection. Patients who received at least 1 unit of red blood cells comprised the ??transfused?? group. Each case in this group was matched for surgical procedure with a control subject who did not require blood transfusion and was operated on during the same year; these patients comprised the ??not transfused?? group.

Results

A total of 75 patients (23.6%) received at least 1 unit of red blood cells during the perioperative period. Factors conditioning perioperative blood transfusion were: preoperative hemoglobin level (p?p?=?0.017); body mass index (p?p?=?0.017); redo procedure (p?=?0.021). Age, sex, histology, stage, ASA score, side, intraoperative blood loss, and fluid infusion did not affect perioperative blood transfusion practices.

Conclusions

Preoperative hemoglobin level is the major risk factor for perioperative blood transfusion practices in oncologic thoracic surgery; procedure duration, body mass index, induction therapies, and redo procedure may condition transfusional needs, although they were actually not predictive on multivariate analysis.