Patient Safety in Surgery最新文献

Background: Delays in surgery start times can lead to poor patient outcomes and considerable increases in healthcare expenditures. This is especially true in developing countries that often face systemic inefficiencies, such as a shortage of operating rooms and trained surgical personnel. With substantial effects on patient outcomes, healthcare efficiency, and resource allocation, identifying delays in first-case elective surgery is a crucial area of research.

Methods: A multicenter observational study was conducted at three comprehensive and specialized hospitals in the Amhara region of Ethiopia from May 1 to October 30, 2023. The primary aim of the study was to determine the occurrence of late first-case start times, defined as a patient being in the operating room at or after the hospital's incision time of 2:30 a.m. The secondary aim was to discover potential root causes of delayed first-case start times. All patients scheduled for elective surgery as the first case on the operating list throughout the study period were included in the study. Every emergency, day case, after-hours case, and canceled case was excluded.

Results: A total of 530 surgical patients were included during the study window from May 1 to October 1, 2023. Of these, 41.5% were general surgeries, 20.4% were gynecology and obstetrics surgeries, and 13.2% were orthopedic surgery procedures. Before the procedure started, nine (1.7%) of the participants had prolonged discussion with a member of the surgical team. Patients who arrived in the operating room waiting area at or after 2:30 a.m. were 2.5 times more likely to experience a first-case start time delay than those who arrived before or at 2:00 a.m. (AOR = 2.50; 95% CI: 1.13-5.14). Furthermore, participants with abnormal investigation results were 2.4 times more likely to have a late first-case start time (AOR = 2.41; 95% CI: 1.06, 5.50). Moreover, the odds of a late first-case start time were increased by 10.53 times with the surgeon being in the operating room at or after 2:30 a.m. (AOR = 10.53; 95% CI: 5.51, 20.11).

Conclusion: The research highlights a significant occurrence of delayed start times for the first elective surgical procedures. Therefore, directing attention to aspects such as ensuring patients and surgical teams arrive promptly (by or before 2:00 a.m.) and timely evaluation and communication of investigative findings before the scheduled surgery day could facilitate efforts to maximize operating room efficiency and enhance patient health outcomes.

Digital data processing has revolutionized medical documentation and enabled the aggregation of patient data across hospitals. Initiatives such as those from the AO Foundation about fracture treatment (AO Sammelstudie, 1986), the Major Trauma Outcome Study (MTOS) about survival, and the Trauma Audit and Research Network (TARN) pioneered multi-hospital data collection. Large trauma registries, like the German Trauma Registry (TR-DGU) helped improve evidence levels but were still constrained by predefined data sets and limited physiological parameters. The improvement in the understanding of pathophysiological reactions substantiated that decision making about fracture care led to development of patient's tailored dynamic approaches like the Safe Definitive Surgery algorithm. In the future, artificial intelligence (AI) may provide further steps by potentially transforming fracture recognition and/or outcome prediction. The evolution towards flexible decision making and AI-driven innovations may be of further help. The current manuscript summarizes the development of big data from local databases and subsequent trauma registries to AI-based algorithms, such as Parkland Trauma Mortality Index and the IBM Watson Pathway Explorer.

Background: Cervical spondylotic myelopathy (CSM) is a prevalent degenerative condition resulting from spinal cord compression and injury. Laminectomy with posterior spinal fusion (LPSF) is a commonly employed treatment approach for CSM patients. This study aimed to assess the effectiveness of machine learning models (MLMs) in predicting clinical outcomes in CSM patients undergoing LPSF.

Methods: A retrospective analysis was conducted on 329 CSM patients who underwent LPSF at our institution from Jul 2017 to Jul 2023. Neurological outcomes were evaluated using the modified Japanese Orthopaedic Association (mJOA) scale preoperatively and at the final follow-up. Patients were categorized into two groups based on clinical outcomes: the favorable group (recovery rates ≥ 52.8%) and the unfavorable group (recovery rates < 52.8%). Potential predictors for poor clinical outcomes were compared between the groups. Four MLMs-random forest (RF), logistic regression (LR), support vector machine (SVM), and k-nearest neighborhood (k-NN)-were utilized to predict clinical outcome. RF model was also employed to identify factors associated with poor clinical outcome.

Results: Out of the 329 patients, 185 were male (56.2%) and 144 were female (43.4%), with an average follow-up period of 17.86 ± 1.74 months. Among them, 267 patients (81.2%) had favorable clinical outcomes, while 62 patients (18.8%) did not achieve favorable results. Analysis using binary logistic regression indicated that age, preoperative mJOA scale, and symptom duration (p < 0.05) were independent predictors of unfavorable clinical outcomes. All models performed satisfactorily, with RF achieving the highest accuracy of 0.922. RF also displayed superior sensitivity and specificity (sensitivity = 0.851, specificity = 0.944). The Area under the Curve (AUC) values for RF, Logistic LR, SVM, and k-NN were 0.905, 0.827, 0.851, and 0.883, respectively. The RF model identified preoperative mJOA scale, age, symptom duration, and MRI signal changes as the most significant variables associated with poor clinical outcomes in descending order.

Conclusions: This study highlighted the effectiveness of machine learning models in predicting the clinical outcomes of CSM patients undergoing LPSF. These models have the potential to forecast clinical outcomes in this patient population, providing valuable prognostic insights for preoperative counseling and postoperative management.

The Cochrane systematic review and meta-analysis published in 2022 that compared videolaryngoscopy (VL) with direct laryngoscopy (DL) for facilitating tracheal intubation in adults found that all three types of VL device (Macintosh-style, hyper-angulated and channeled) reduced the risk of failed intubation and increased the likelihood of first-pass success. We report the findings of a subgroup re-analysis of the 2022 Cochrane meta-analysis data focusing on the Macintosh-style VL group. This was undertaken to establish whether sufficient evidence exists to guide airway managers in making purchasing decisions for their local institutions based upon individual device-specific performance. This re-analysis confirmed the superiority of Macintosh-style VL over Macintosh DL in elective surgical patients, with similar efficacy demonstrated between the Macintosh-style VL devices examined. Thus, when selecting which VL device(s) to purchase for their hospital, airway managers decisions are likely to remain focused upon issues such as financial costs, portability, cleaning schedules and previous device experience.

Background: Medical professionals are constantly exposed to bodily fluids and sanitizing agents during routine medical procedures. Unbeknownst to many healthcare workers, however, the barrier integrity of medical gloves can be altered when exposed to these substances, potentially resulting in exposure to dangerous pathogens.

Methods: This experimental study was designed to test the hypothesis that the durability of both natural and synthetic solvent-exposed medical gloves will be lower than the durability of the gloves in air. The testing consisted of a sample of commercially available medical gloves exposed to 70% ethanol, phosphate buffered saline, and deionized water, aimed at simulating the environments in which medical gloves are commonly worn. Gloves were included in this study based on their performance in previous durability studies in air. Data were collected over a period of three months. The glove assessment device automatically detects pinhole-sized perforations in medical gloves, eliminating the need to visually inspect each glove. Relative durability was measured as the average number of sandpaper touches until glove puncture.

Results: Four out of five glove brands performed better when exposed to all three solvents than in air, which is likely due to slippage in the interface between the wet glove and the sandpaper. Sensicare Micro, a polyisoprene surgical glove, had the most consistent durability in all three solvents tested. A two-way ANOVA revealed that both glove brand (P = 0.0001), solvent (P = 0.0001), and their interaction (P = 0.0040, α = 0.05) significantly affected average glove durability.

Conclusions: Glove durability did not remain consistent in 70% ethanol, phosphate buffered saline, deionized water, and air. These results make it clear that additional testing and labeling information would help healthcare workers select gloves for use in specific environments to ensure the best barrier protection against disease or toxins.

Background: Surgical patients are at risk of postoperative complications, which may lead to increased morbidity, mortality, hospital length-of-stay and healthcare costs. Enhanced Recovery After Surgery (ERAS®) protocols are evidence-based and have demonstrated effectiveness in decreasing complications and associated consequences. However, their adoption in Australia has been limited and the reason for this is unclear. This study aimed to describe clinicians' perceptions of ERAS protocols in Australia.

Methods: A national online survey of anaesthetists, surgeons and nurses was undertaken. Invitations to participate were distributed via emails from professional colleges. The 30-item survey captured respondent characteristics, ERAS perceptions, beliefs, education and learning preferences and future planning considerations. The final question was open-ended for elaboration of perceptions of ERAS. Descriptive and inferential statistics were used to describe and compare group differences across disciplines relative to perceptions of ERAS.

Results: The sample included 178 responses (116 nurses, 65.2%; 36 surgeons, 20.2%; 26 anaesthetists, 14.6%) across six states and two territories. More than half (n = 104; 58.8%) had used ERAS protocols in patient care, and most perceived they were 'very knowledgeable' (n = 24; 13.6%) or 'knowledgeable' (n = 71; 40.3%) of ERAS. However, fewer nurses had cared for a patient using ERAS (p <.01) and nurses reported lower levels of knowledge (p <.001) than their medical counterparts. Most respondents agreed ERAS protocols improved patient care and financial efficiency and were a reasonable time investment (overall Md 3-5), but nurses generally recorded lower levels of agreement (p.013 to < 0.001). Lack of information was the greatest barrier to ERAS knowledge (n = 97; 62.6%), while seminars/lectures from international and national leaders were the preferred learning method (n = 59; 41.3%). Most supported broad implementation of ERAS (n = 130; 87.8%).

Conclusion: There is a need to promote ERAS and provide education, which may be nuanced based on the results, to improve implementation in Australia. Nurses particularly need to be engaged in ERAS protocols given their significant presence throughout the surgical journey. There is also a need to co-design implementation strategies with stakeholders that target identified facilitators and barriers, including lack of support from senior administration, managers and clinicians and resource constraints.

Background: Open reduction and plate fixation is a standard procedure for treating traumatic symphyseal disruptions, but has a high incidence of implant failure. Several studies have attempted to identify predictors for implant failure and discussed its impact on functional outcome presenting conflicting results. Therefore, this study aimed to identify predictors of implant failure and to investigate the impact of implant failure on pain and functional outcome.

Methods: In a single-center, retrospective, observational non-controlled cohort study in a level-1 trauma center from January 1, 2006, to December 31, 2017, 42 patients with a plate fixation of a traumatic symphyseal disruption aged ≥ 18 years with a minimum follow-up of 12 months were included. The following parameters were examined in terms of effect on occurrence of implant failure: age, body mass index (BMI), injury severity score (ISS), polytrauma, time to definitive treatment, postoperative weight-bearing, the occurrence of a surgical site infection, fracture severity, type of posterior injury, anterior and posterior fixation. A total of 25/42 patients consented to attend the follow- up examination, where pain was assessed using the Numerical Rating Scale and functional outcome using the Majeed Pelvic Score.

Results: Sixteen patients had an anterior implant failure (16/42; 37%). None of the parameters studied were predictive for implant failure. The median follow-up time was six years and 8/25 patients had implant failure. There was no difference in the Numerical Rating Scale, but the work-adjusted Majeed Pelvic Score showed a better outcome for patients with implant failure.

Conclusion: implant failure after symphyseal disruptions is not predictable, but appears to be clinically irrelevant. Therefore, an additional sacroiliac screw to prevent implant failure should be critically discussed and plate removal should be avoided in asymptomatic patients.

Traumatic pelvic ring injuries continue to represent a major challenge due to the high rates of post-injury mortality of around 30-40% in the peer-reviewed literature. The main root cause of potentially preventable mortality relates to the delayed recognition of the extent of retroperitoneal hemorrhage and post-injury coagulopathy. The understanding of the underlying pathophysiology of pelvic trauma is predicated by classification systems for grading of injury mechanism and risk stratification for developing post-injury coagulopathy with subsequent uncontrolled exsanguinating hemorrhage. This review article elaborates on the current understanding of the pathophysiology of severe pelvic trauma with a focus on the underlying mechanisms of retroperitoneal bleeding and associated adverse outcomes.

Background: Mortality of patients with a femoral neck fracture is high, especially within the first year after surgery, but also remains elevated thereafter. The aim of this study was to identify factors potentially associated with long-term mortality in patients homogeneously treated with hemiarthroplasty for femoral neck fracture.

Methods: This retrospective cohort study was performed at a single level 1 national trauma center at the university hospital of Leipzig (Saxony, Germany). The study time-window was January 1, 2010 to December 31, 2020. Primary outcome measure was mortality depending on individual patient-related characteristics and perioperative risk factors. Inclusion criteria was a low-energy femoral neck fracture (Garden I-IV) in geriatric patients 60 years of age or older that were primarily treated with bipolar hemiarthroplasty. Date of death or actual residence of patients alive was obtained from the population register of the eastern German state of Saxony, Germany. The outcome was tested using the log-rank test and plotted using Kaplan-Meier curves. Unadjusted and adjusted for other risk factors such as sex and age, hazard ratios were calculated using Cox proportional hazards models and presented with 95% confidence intervals (CI).

Results: The 458 included patients had a median age of 83 (IQR 77-89) years, 346 (75%) were female and 113 (25%) male patients. Mortality rates after 30 days, 1, 5 and 10 years were 13%, 25%, 60% and 80%, respectively. Multivariate regression analysis revealed age (HR = 1.1; p < 0.001), male gender (HR = 1.6; p < 0.001), ASA-Score 3-4 vs. 1-2 (HR = 1.3; p < 0.001), dementia (HR = 1.9; p < 0.001) and a history of malignancy (HR = 1.6; p = 0.002) as independent predictors for a higher long-term mortality risk. Perioperative factors such as preoperative waiting time, early surgical complications, or experience of the surgeon were not associated with a higher overall mortality.

Conclusions: In the present study based on data from the population registry from Saxony, Germany the 10-year mortality of older patients above 60 years of age managed with hemiarthroplasty for femoral neck fracture was 80%. Independent risk factors for increased long-term mortality were higher patient age, male gender, severe comorbidity, a history of cancer and in particular dementia. Perioperative factors did not affect long-term mortality.

Background: Optimizing transitional care by practicing family-centered care might reduce unplanned events for patients who undergo major abdominal cancer surgery. However, it remains unknown whether involving family caregivers in patients' healthcare also has negative consequences for patient safety. This study assessed the safety of family involvement in patients' healthcare by examining the cause of unplanned events in patients who participated in a family involvement program (FIP) after major abdominal cancer surgery.

Methods: This is a secondary analysis focusing on the intervention group of a prospective cohort study conducted in the Netherlands. Data were collected from April 2019 to May 2022. Participants in the intervention group were patients who engaged in a FIP. Unplanned events were analyzed, and root causes were identified using the medical version of a prevention- and recovery-information system for monitoring and analysis (PRISMA) that analyses unintended events in healthcare. Unplanned events were compared between patients who received care from family caregivers and patients who received professional at-home care after discharge. A Mann-Whitney U test was used to analyze data.

Results: Of the 152 FIP participants, 68 experienced an unplanned event and were included. 112 unplanned events occurred with 145 root causes since some unplanned events had several root causes. Most root causes of unplanned events were patient-related factors (n = 109, 75%), such as patient characteristics and disease-related factors. No root causes due to inadequate healthcare from the family caregiver were identified. Unplanned events did not differ statistically (interquartile range 1-2) (p = 0.35) between patients who received care from trained family caregivers and those who received professional at-home care after discharge.

Conclusion: Based on the insights from the root-cause analysis in this prospective multicenter study, it appears that unplanned emergency room visits and hospital readmissions are not related to the active involvement of family caregivers in surgical follow-up care. Moreover, surgical follow-up care by trained family caregivers during hospitalization was not associated with increased rates of unplanned adverse events. Hence, the concept of active family involvement by proficiently trained family caregivers in postoperative care appears safe and feasible for patients undergoing major abdominal surgery.