Development of an orthopedic surgery trauma patient handover checklist

Background

In surgery, preoperative handover of surgical trauma patients is a process that must be made as safe as possible. We sought to determine vital clinical information to be transferred between patient care teams and to develop a standardized handover checklist.

Methods

We conducted standardized small-group interviews about trauma patient handover. Based on this information, we created a questionnaire to gather perspectives from all Canadian Orthopaedic Association (COA) members about which topics they felt would be most important on a handover checklist. We analyzed the responses to develop a standardized handover checklist.

Results

Of the 1106 COA members, 247 responded to the questionnaire. The top 7 topics felt to be most important for achieving patient safety in the handover were comorbidities, diagnosis, readiness for the operating room, stability, associated injuries, history/mechanism of injury and outstanding issues. The expert recommendations were to have handover completed the same way every day, all appropriate radiographs available, adequate time, all appropriate laboratory work and more time to spend with patients with more severe illness.

Conclusion

Our main recommendations for safe handover are to use standardized checklists specific to the patient and site needs. We provide an example of a standardized checklist that should be used for preoperative handovers. To our knowledge, this is the first checklist for handover developed by a group of experts in orthopedic surgery, which is both manageable in length and simple to use.     

Diagnosis and Management of Dural Sinus Thrombosis following Resection of Cerebellopontine Angle Tumors

Objective Lateral sinus thrombosis is a potentially devastating but seldom studied complication of cerebellopontine angle (CPA) tumor surgery. Systemic anticoagulation in the early postoperative period has often been avoided due to the potential risks of intracranial hemorrhage.Design Retrospective review.Setting Tertiary referral center.Main Outcome Measures The goal of this study was to identify the frequency, treatment, and outcomes in patients who develop postoperative venous sinus thrombosis following CPA tumor surgery and receive early systemic anticoagulation.Results Of 43 patients with CPA tumors, we report five patients (11.6%) with transverse and/or sigmoid sinus thrombosis following resection of the tumor, four of which were detected on routine early postoperative noncontrast computed tomography (CT) scan. The thrombosis was confirmed in all cases with CT venography or magnetic resonance venography. Affected patients had significantly larger tumors than controls and tended to undergo longer operations. These patients were treated with immediate anticoagulation (intravenous heparin, followed by Coumadin for 6 months) without complication.Conclusion Venous sinus thrombosis is an underrecognized complication of CPA surgery, but it can be diagnosed in the early postoperative period by noncontrast CT imaging. Early postoperative initiation of systemic anticoagulation appears safe and effective to prevent the progression of thrombosis and its consequences.     

Robot-assisted triple neurectomy for iatrogenic inguinal pain: a technical note

Background

Painful neuromas are a relatively common complication of hernia and abdominal wall surgery.

Objective

Surgical neurectomy has the potential to to provide durable relief for chronic pain; however, current surgical approaches are not without morbidity or anatomical challenges.We sought a surgical alternative.

Methods

In the treatment of a case of incapacitating inguinal pain, we performed an anterior transperitoneal approach using a surgical robot.

Results

This approach was facile and provided elegant anatomical visualization.

Conclusion

This case describes the first known robot-assisted laparoscopic triple neurectomy and details a simplified, transperitoneal approach.     

Impact of the 2016 revision of US Pediatric Heart Allocation Policy on waitlist characteristics and outcomes

US Pediatric Heart Allocation Policy was recently revised, deprioritizing candidates with cardiomyopathy while maintaining status 1A eligibility for congenital heart disease (CHD) candidates on “high‐dose” inotropes. We compared waitlist characteristics and mortality around this change. Status 1A listings decreased (70% to 56%, P < .001) and CHD representation increased among status 1A listings (48% vs 64%, P < .001). Waitlist mortality overall (subdistribution hazard ratio [SHR] 0.96, P = .63) and among status 1A candidates (SHR 1.16, P = .14) were unchanged. CHD waitlist mortality trended better (SHR 0.82, P = .06) but was unchanged for CHD candidates listed status 1A (SHR 0.92, P = .47). Status 1A listing exceptions increased 2‐ to 3‐fold among hypertrophic and restrictive cardiomyopathy candidates and 13.5‐fold among dilated cardiomyopathy (DCM) candidates. Hypertrophic (SHR 6.25, P = .004) and restrictive (SHR 3.87, P = .03) cardiomyopathy candidates without status 1A exception had increased waitlist mortality, but those with DCM did not (SHR 1.26, P = .32). Ventricular assist device (VAD) use increased only among DCM candidates ≥1 years old (26% vs 38%, P < .001). Current allocation policy has increased CHD status 1A representation but has not improved their waitlist mortality. Excessive DCM status 1A listing exceptions and continued status 1A prioritization of children on stable VADs potentially diminish the intended benefits of policy revision.     

Complications after proctocolectomy and ileal pouch-anal anastomosis in pediatric patients: A systematic review

Background/purposeColectomy with ileal pouch-anal anastomosis (IPAA) is the standard of care for patients with familial adenomatous polyposis (FAP) and refractory ulcerative colitis (UC). The rates of postoperative complications are not well established in children. The objective of this systematic review is to establish benchmark data for morbidity after pediatric IPAA.MethodsPubMed, Embase, and The Cochrane Library were searched for studies of colectomy with IPAA in patients ≤ 21 years old. UC studies were limited to the anti-tumor necrosis factor-α agents era (1998–present). All postoperative complications were extracted.ResultsThirteen studies met the inclusion criteria (763 patients). Compared to patients with FAP, UC patients had a higher prevalence of pouch loss (10.6% vs. 1.5%). Other major complications such as anastomotic leak, abscess, and fistula were uncommon (mean prevalence 4.9%, 4.2%, and 5.0%, respectively, for patients with UC; 8.7%, 4.2%, and 4.3% for FAP). The most frequent complication was pouchitis (36.4% of UC patients).ConclusionsDevastating complications from colectomy and IPAA are rare, but patients with UC have poorer outcomes than those with FAP. Much of the morbidity may therefore stem from patient or disease factors. Multicenter, prospective studies are needed to identify modifiable risks in patients with UC undergoing IPAA.Level of evidencePrognostic, level II.     

Potential benefits of the new Leapfrog standards: effect of process and outcomes measures

OBJECTIVE: The Leapfrog Group standards for evidence-based hospital referral underwent significant revision in 2003. In addition to other changes, risk-adjusted mortality and process of care measures now augment or replace volume standards for some procedures. The objective of this study was to estimate the potential benefits of these newly expanded standards. METHODS: Leapfrog's 2003 standards were based on minimum volume standards alone for 2 operations (esophagectomy, pancreatectomy), volume standards and a process measure (perioperative beta blockade) for 1 operation (abdominal aortic aneurysm repair), and volume standards coupled with risk-adjusted mortality rates for 2 operations (coronary artery bypass grafting [CABG] and percutaneous coronary intervention [PCI]). We used data from the 2000 Nationwide Inpatient Sample to determine eligible surgical populations, volume-outcome associations, and risk-adjusted hospital mortality rates for the 5 operations. A recent meta-analysis was used to estimate the effectiveness of perioperative beta-blocker use. RESULTS: Approximately 23,790 patients died in 2000 in the United States undergoing 1 of the 5 procedures. We estimate that full implementation of the Leapfrog standards would have averted 7818 of these deaths: CABG (4089), PCI (3016), elective abdominal aortic aneurysm repair (356), esophageal resection (180), and pancreatic resection (177). For CABG and PCI, standards based on risk-adjusted mortality rates would save at least 5 times more lives than those based on volume criteria alone. CONCLUSIONS: Widespread implementation of the 2003 Leapfrog standards for evidence-based referral could avert a large number of surgical deaths. For some procedures, standards comprised of process of care or direct outcome measures would be more effective than those based on volume alone.     

Takedown of ankle fusion and conversion to total ankle replacement

The painful ankle arthrodesis is an unsolved clinical problem. In many cases, transtibial amputation may be the best option for functional recovery. Recent reports of early success with second generation ankle implants show takedown of the problematic ankle fusion and conversion to total ankle arthroplasty may be an alternative to amputation. This study is a retrospective review of 23 ankles in 22 patients scheduled to have this procedure. Four patients were lost to followup, leaving 19 ankles in 18 patients at an average followup of 39 months. Three patients chose to have an amputation because of continued pain. In the remaining 16 ankles, the mean AOFAS ankle-hind foot outcome score improved from 42-68. Patients who had a clear source of pain with the ankle arthrodesis (such as subtalar arthrosis) had a better result than patients without a clear source of pain. All the patients who had the lateral malleolus resected during previous arthrodesis had complicated courses after arthroplasty. For patients with a definable source of pain and who have not had previous malleolar resection, conversion of a failed ankle arthrodesis to total ankle arthroplasty may be a viable alternative to amputation.     

Atypical performance patterns on Delis–Kaplan Executive Functioning System Color–Word Interference Test: Cognitive switching and learning ability in older adults

Introduction: Cognitive set shifting requires flexible application of lower level processes. The Delis–Kaplan Executive Functioning System (DKEFS) Color–Word Interference Test (CWIT) is commonly used to clinically assess cognitive set shifting. An atypical pattern of performance has been observed on the CWIT; a subset of individuals perform faster, with equal or fewer errors, on the more difficult inhibition/switching than the inhibition trial. This study seeks to explore the cognitive underpinnings of this atypical pattern. It is hypothesized that atypical patterns on CWIT will be associated with better performance on underlying cognitive measures of attention, working memory, and learning when compared to typical CWIT patterns. Method: Records from 239 clinical referrals (age: M = 68.09 years, SD = 10.62; education: M = 14.87 years, SD = 2.73) seen for a neuropsychological evaluation as part of diagnostic work up in an outpatient dementia and movement disorders clinic were sampled. The standard battery of tests included measures of attention, learning, fluency, executive functioning, and working memory. Analyses of variance (ANOVAs) were conducted to compare the cognitive performance of those with typical versus atypical CWIT patterns. Results: An atypical pattern of performance was confirmed in 23% of our sample. Analyses revealed a significant group difference in acquisition of information on both nonverbal (Brief Visuospatial Memory Test–Revised, BVMT–R total recall), F(1, 213) = 16.61, p < .001, and verbal (Hopkins Verbal Learning Test–Revised, HVLT–R total recall) learning tasks, F(1, 181) = 6.43, p < .01, and semantic fluency (Animal Naming), F(1, 232) = 7.57, p = .006, with the atypical group performing better on each task. Effect sizes were larger for nonverbal (Cohen’s d = 0.66) than verbal learning (Cohen’s d = 0.47) and semantic fluency (Cohen’s d = 0.43). Conclusions: Individuals demonstrating an atypical pattern of performance on the CWIT inhibition/switching trial also demonstrated relative strengths in semantic fluency and learning.