Patient Safety in Surgery最新文献

Background: Patients with unplanned readmissions to the intensive care unit (ICU) are at high risk of preventable adverse events. The Rothman Index represents an objective real-time grading system of a patient's clinical condition and a predictive tool of clinical deterioration over time. This study was designed to test the hypothesis that the Rothman Index represents a sensitive predictor of unanticipated ICU readmissions.

Methods: A retrospective propensity-matched cohort study was performed at a tertiary referral academic medical center in the United States from January 1, 2022, to December 31, 2022. Inclusion criteria were adult patients admitted to an ICU and readmitted within seven days of transfer to a lower level of care. The control group consisted of patients who were downgraded from ICU without a subsequent readmission. The primary outcome measure was in-hospital mortality or discharge to hospice for end-of-life care. Secondary outcome measures were overall hospital length of stay, ICU length of stay, and 30-day readmission rates. Propensity matching was used to control for differences between the study cohorts. Regression analyses were performed to determine independent risk factors of an unplanned readmission to ICU.

Results: A total of 5,261 ICU patients met the inclusion criteria, of which 212 patients (4%) had an unanticipated readmission to the ICU within 7 days. The study cohort and control group were stratified by propensity matching into equal group sizes of n = 181. Lower Rothman Index scores (reflecting higher physiologic acuity) at the time of downgrade from the ICU were significantly associated with an unplanned readmission to the ICU (p < 0.0001). Patients readmitted to ICU had a lower mean Rothman Index score (p < 0.0001) and significantly increased rates of mortality (19.3% vs. 2.2%, p < 0.0001) and discharge to hospice (14.4% vs. 6.1%, p = 0.0073) compared to the control group of patients without ICU readmission. The overall length of ICU stay (mean 8.0 vs. 2.2 days, p < 0.0001) and total length of hospital stay (mean 15.8 vs. 7.3 days, p < 0.0001) were significantly increased in patients readmitted to ICU, compared to the control group.

Conclusion: The Rothman Index represents a sensitive predictor of unanticipated readmissions to ICU, associated with a significantly increased mortality and overall ICU and hospital length of stay. The Rothman Index should be considered as a real-time objective measure for prediction of a safe downgrade from ICU to a lower level of care.

Background: Patients with opioid use disorder (OUD) are increasing, challenging surgeons to adjust post-operative pain management guidelines. A literature review identified limited information on how to best care for these patients. The purpose of this study was to determine surgical perioperative management of OUD, challenges, and support needed for optimal care.

Methods: This study utilized an anonymous voluntary survey that was distributed to members of the American College of Surgeons through the association's electronic weekly newsletter. The survey was advertised weekly for three consecutive weeks. The survey included questions regarding surgeons' management of perioperative pain in patients with opioid use disorder and perceived barriers in treatment.

Results: A total of 260 surgeons responded representing all specialties except ophthalmology. General surgery (66.5%) and plastic and reconstructive surgery (7.5%) represented the majority of responders. Ninety-five percent of surgeons reported treating a patient who used opioids in the past month and 86% encountered a patient with OUD. Nearly half (46%) reported being uncomfortable managing postoperative pain in patients with OUD. Most (67%) were not aware of any guidelines or standards pertaining to perioperative management of patients with OUD. While consultation was sought by 86% of surgeons, analyses identified lack of timely response and a lack of care coordination among specialists. Lack of knowledge and fear of harm (contributing further to addiction) were the most common themes.

Conclusion: Nearly half of surgeons report discomfort caring for patients with OUD with the vast majority involving a consulting service to assist with their care. Most surgeons believe that it would be helpful to have guidelines regarding the care of these patients. This provides an opportunity for increased education and training on the perioperative management of patients with OUD and further collaboration with addiction medicine, psychiatry and pain management colleagues.

Background: Healthcare systems are operating under substantial pressures, and often simply cannot provide the standard of care they aspire to within the available resources. Organisations, managers, and individual clinicians make constant adaptations in response to these pressures, which are typically improvised, highly variable and not coordinated across clinical teams. The purpose of this study was to identify and describe the types of everyday pressures experienced by surgical teams and the adaptive strategies they use to respond to these pressures.

Methods: We conducted interviews with 20 senior multidisciplinary healthcare professionals from surgical teams in four major hospitals in the United Kingdom. The interviews explored the types of everyday pressures staff were experiencing, the strategies they use to adapt, and how these strategies might be taught to others.

Results: The primary pressures described by senior clinicians in surgery were increased numbers and complexity of patients alongside shortages in staff, theatre space and post-surgical beds. These pressures led to more difficult working conditions (e.g. high workloads) and problems with system functioning such as patient flow and cancellation of lists. Strategies for responding to these pressures were categorised into increasing or flexing resources, controlling and prioritising patient demand and strategies for managing the workload (scheduling for efficiency, communication and coordination, leadership, and teamwork strategies).

Conclusions: Teams are deploying a range of strategies and making adaptations to the way care is delivered. These findings could be used as the basis for training programmes for surgical teams to develop coordinated strategies for adapting under pressure and to assess the impact of different combinations of strategies on patient safety and surgical outcomes.

Background: In spite of the global implementation of surgical safety checklists to improve patient safety, patients undergoing surgical procedures remain vulnerable to a high risk of potentially preventable complications and adverse outcomes. The present study was designed to explore the surgical teams' perceptions of patient safety culture, capture their perceptions of the risk for adverse events, and identify themes of interest for quality improvement within the surgical department.

Methods: This qualitative study had an explorative design with an abductive approach. Individual semi-structured in-depth interviews were conducted between 10/01/23 and 11/05/23. The participants were members of surgical teams (n = 17), general and orthopedic surgeons (n = 5), anesthesiologists (n = 4), nurse anesthetists (n = 4) and operating room nurses (n = 4). Middle managers recruited purposively from general and orthopedic surgical teams in two tertiary hospitals in Norway, aiming for a maximum variation due to gender, age, and years within the specialty. The data material was analyzed following Braun and Clarke's method for reflexive thematic analysis to generate patterns of meaning and develop themes and subthemes.

Results: The analysis process resulted in three themes describing the participants' perceptions of patient safety culture in the surgical context: (1) individual accountability as a safety net, (2) psychological safety as a catalyst for well-being and safe performance in the operating room, and (3) the importance of proactive structures and participation in organizational learning.

Conclusions: This study provided an empirical insight into the culture of patient safety in the surgical context. The study highlighted the importance of supporting the individuals' competence, building psychological safety in the surgical team, and creating structures and culture promoting a learning organization. Quality improvement projects, including interventions based on these results, may increase patient safety culture and reduce the frequency of adverse events in the surgical context.

Background: Joint replacement surgery of the lower extremities are common procedures in elderly persons who are at increased risk of postoperative falls. The use of mental state altering medications, such as opioids, antidepressants or benzodiazepines, can further contribute to impaired balance and risk of falls. The objective of the current systematic review was to evaluate the risk of the use of mental state altering medications on postoperative falls in patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA).

Methods: A comprehensive search of Medline, Embase and Cochrane Controlled Trials Register was conducted from 1 October 1975 to 1 September 2021. The search was repeated in may 2023 and conducted from 1 October 1975 to 1 June 2023. Clinical trials that evaluated the risk of medication on postoperative THA and TKA falls were eligible for inclusion. Articles were evaluated independently by two researchers for risk of bias using the Newcastle-Ottawa Scale. A meta-analysis was performed to determine the potential effect of postoperative use of mental state altering medications on the risk of falls. Lastly, a qualitative synthesis was conducted for preoperative mental state altering medications use.

Results: Seven cohort studies were included, of which five studies focussed on the postoperative use of mental state altering medications and two investigated the preoperative use. Meta-analysis was performed for the postoperative mental state altering medications use. The postoperative use of mental state altering medications was associated with fall incidents (OR: 1.81; 95% CI: 1.04; 3.17) (p < 0.01) after THA and TKA. The preoperative use of opioids > 6 months was associated with a higher risk of fall incidents, whereas a preoperative opioid prescription up to 3 months before a major arthroplasty had a similar risk as opioid-naïve patients.

Conclusions: The postoperative use of mental state altering medications increases the risk of postoperative falls after THA and TKA. Prior to surgery, orthopaedic surgeons and anaesthesiologists should be aware of the associated risks in order to prevent postoperative falls and associated injuries.

Background: Organizational factors may influence surgical outcomes, regardless of extensively studied factors such as patient preoperative risk and surgical complexity. This study was designed to explore how operating room organization determines surgical performance and to identify gaps in the literature that necessitate further investigation.

Methods: We conducted a systematic review according to PRISMA guidelines to identify original studies in Pubmed and Scopus from January 1, 2000 to December 31, 2019. Studies evaluating the association between five determinants (team composition, stability, teamwork, work scheduling, disturbing elements) and three outcomes (operative time, patient safety, costs) were included. Methodology was assessed based on criteria such as multicentric investigation, accurate population description, and study design.

Results: Out of 2625 studies, 76 met inclusion criteria. Of these, 34 (44.7%) investigated surgical team composition, 15 (19.7%) team stability, 11 (14.5%) teamwork, 9 (11.8%) scheduling, and 7 (9.2%) examined the occurrence of disturbing elements in the operating room. The participation of surgical residents appeared to impact patient outcomes. Employing specialized and stable teams in dedicated operating rooms showed improvements in outcomes. Optimization of teamwork reduced operative time, while poor teamwork increased morbidity and costs. Disturbances and communication failures in the operating room negatively affected operative time and surgical safety.

Conclusion: While limited, existing scientific evidence suggests that operating room staffing and environment significantly influences patient outcomes. Prioritizing further research on these organizational drivers is key to enhancing surgical performance.

Background: Hospital-acquired pressure injuries are a major patient safety concern in intensive care units that are considered largely preventable adverse events by adherence to nursing standards of care. The hypothesis of this research was to investigate the prevalence of hospital-acquired pressure injuries in intensive care units (ICUs) of the Eastern Mediterranean Region.

Methods: This study was designed as a systematic review and meta-analysis. All articles published on Pressure ulcer prevalence in the ICUs of hospitals in Eastern Mediterranean Region countries, identified by searching PubMed through MEDLINE, Web of Science, Scopus, and Google Scholar from January 1, 2011, until September 22, 2023. The reference lists of these articles were checked for additional relevant studies. Data were analyzed using the Comprehensive Meta-Analysis Software (v.2.2.064).

Results: A total of 15 articles met the inclusion criteria. Based on the random-effects model, the overall Pressure ulcer prevalence rate was 16.6% (95% CI (8.6-29.6)). Both the highest and lowest prevalence was observed in Jordan in 2011 at 83.1% (95% CI (71.2- 90.7)) and in 2012 at 0.9% (95% CI (0.5- 1.5)), respectively. The results showed that publication year, average age, and sample size were the main causes of heterogeneity between the reviewed studies (p < 0.05).

Conclusion: This systematic review and meta-analysis of the pertinent peer-reviewed literature revealed a high prevalence of hospital-acquired pressure injuries of 16% in intensive care units of Eastern Mediterranean region. Therefore, it is necessary for health policymakers and managers in Eastern Mediterranean Region to take necessary measures to prevent the incidence of Pressure ulcers in hospitals, especially in ICUs.

Background: Minimally invasive surgical treatment of pelvic trauma requires a significant level of surgical training and technical expertise. Novel imaging and navigation technologies have always driven surgical technique, and with head-mounted displays being commercially available nowadays, the assessment of such Augmented Reality (AR) devices in a specific surgical setting is appropriate.

Methods: In this ex-vivo feasibility study, an AR-based surgical navigation system was assessed in a specific clinical scenario with standard pelvic and acetabular screw pathways. The system has the following components: an optical-see-through Head Mounted Display, a specifically designed modular AR software, and surgical tool tracking using pose estimation with synthetic square markers.

Results: The success rate for entry point navigation was 93.8%, the overall translational deviation of drill pathways was 3.99 ± 1.77 mm, and the overall rotational deviation of drill pathways was 4.3 ± 1.8°. There was no relevant theoretic screw perforation, as shown by 88.7% Grade 0-1 and 100% Grade 0-2 rating in our pelvic screw perforation score. Regarding screw length, 103 ± 8% of the planned pathway length could be realized successfully.

Conclusion: The novel innovative system assessed in this experimental study provided proof-of-concept for the feasibility of percutaneous screw placement in the pelvis and, thus, could easily be adapted to a specific clinical scenario. The system showed comparable performance with other computer-aided solutions while providing specific advantages such as true 3D vision without intraoperative radiation; however, it needs further improvement and must still undergo regulatory body approval. Future endeavors include intraoperative registration and optimized tool tracking.

Background: Informed consent is one of the safeguarding of the patient in medical practice at different standards such as ethical, legal, and administrative purposes. Patient knowledge and perception of informed consent are one of the priority concerns in surgical procedures. Patient knowledge and perception towards informed consent increased patient satisfaction, feeling high power on their determination, and accountability for the management, and facilitated positive treatment outcomes. Despite this, in Ethiopia, there are small-scale primary studies with inconsistent and inconclusive findings. Therefore, this systematic review and meta-analysis study estimated the pooled prevalence of patient knowledge and perception of informed consent and its determinants in Ethiopia.

Methods: We searched major databases such as PubMed, Hinary, MEDLINE, Cochrane Library, EMBASE, Scopus, African Journal Online (AJO), Semantic Scholar, Google Scholar, google, and reference lists. Besides this, University databases in the country were also searched from August 20, 2023, until September 30, 2023,. All published and unpublished studies that report the prevalence of patient knowledge and perception toward informed consent and its associated factors were included. All studies reported in English were included. Studies conducted between January 01, 2015 to September 30, 2023 were included. There are three outcome measurements pooled level of patient knowledge towards informed consent, pooled level of patient perception towards informed consent, and pooled effect that affects patient knowledge of informed consent. Three reviewers (MMM, NK, and YT) independently screened the articles that fulfilled the inclusion criteria to avoid the risk of bias. The studies' quality was appraised using a modified Newcastle-Ottawa Scale (NOS) version.

Results: The pooled prevalence of appropriate patient knowledge and perception towards informed consent was 32% (95% CI: 21, 43) and 40% (95% CI: 16, 65) respectively. Having formal education 2.69 (95% CI: 1.18, 6.15) and having a history of signed informed consent before 3.65 (95% CI:1.02,13.11) had a statistically significant association with good patient knowledge towards informed consent.

Conclusion: The appropriate patient knowledge and perception of informed consent in Ethiopia is low. Formal education and history of signed informed consent were positive factors for appropriate patient knowledge of informed consent in Ethiopia. Physicians, policymakers, and health facility managers should focus on patients without prior experience with signed informed consent and not have formal education to improve patient knowledge towards informed consent. The protocol was registered at Prospero with number CRD42023445409 and is available from: https://www.crd.york.ac.uk/PROSPERO/#myprospero .

Background: Hospital-acquired pressure injuries are a major patient safety concern in intensive care units that are considered largely preventable adverse events by adherence to nursing standards of care. The hypothesis of this research was to investigate the prevalence of hospital-acquired pressure injuries in intensive care units (ICUs) of the Eastern Mediterranean Region.

Methods: This study was designed as a systematic review and meta-analysis. All articles published on Pressure ulcer prevalence in the ICUs of hospitals in Eastern Mediterranean Region countries, identified by searching PubMed through MEDLINE, Web of Science, Scopus, and Google Scholar from January 1, 2011, until September 22, 2023. The reference lists of these articles were checked for additional relevant studies. Data were analyzed using the Comprehensive Meta-Analysis Software (v.2.2.064).

Results: A total of 15 articles met the inclusion criteria. Based on the random-effects model, the overall Pressure ulcer prevalence rate was 16.6% (95% CI (8.6-29.6)). Both the highest and lowest prevalence was observed in Jordan in 2011 at 83.1% (95% CI (71.2- 90.7)) and in 2012 at 0.9% (95% CI (0.5- 1.5)), respectively. The results showed that publication year, average age, and sample size were the main causes of heterogeneity between the reviewed studies (p < 0.05).

Conclusion: This systematic review and meta-analysis of the pertinent peer-reviewed literature revealed a high prevalence of hospital-acquired pressure injuries of 16% in intensive care units of Eastern Mediterranean region. Therefore, it is necessary for health policymakers and managers in Eastern Mediterranean Region to take necessary measures to prevent the incidence of Pressure ulcers in hospitals, especially in ICUs.