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June 2, 2020
Perioperative Hypothermia
Perioperative hypothermia is a common complication of orthopedic surgery that is associated with increased morbidity, including increased risk for surgical site infections, sepsis, increased bleeding risk, cardiac and other complications, mortality and prolonged length of stay.
A 2018 review of almost 7,000 orthopedic cases (Kleimeyer 2018) found hypothermia in 72.5% of patients intraoperatively and 8.3% postoperatively. Risk factors for postoperative hypothermia included intraoperative hypothermia (odds ratio 2.72), lower preoperative temperature (OR 1.46), female sex (OR 1.42), lower body mass index (OR 1.06 per kg/m2), older age (OR 1.02 per year), adult reconstruction by specialty (OR 4.06), and hip and pelvis procedures by anatomic region (OR 8.76).
Another 2018 review (Boddu 2018) noted risk factors that can contribute to inadvertent perioperative hypothermia can be subdivided into 3 groups: patient-related risk factors, anesthesia-related risk factors, and procedure-related risk factors.
Patient-related risk factors identified were a high severity of illness on admission (OR 2.81), presence of a neurological disorder such as Alzheimer’s disease (OR 1.71), male sex (OR 1.65), age >65 years (OR 1.61), recent weight loss (OR 1.60), anemia (OR 1.49), and chronic renal failure (OR1.43).
They note that the effects of general and regional anesthesia on perioperative core temperature are significantly different, both in terms of intraoperative thermoregulation and postoperative recovery. Core body temperature drops during the first 2 hours of general anesthesia, due to loss of thermoregulatory cutaneous and peripheral vasoconstrictive responses resulting in heat loss exceeding metabolic heat production but then plateaus during the subsequent 3 hours due to the return of the thermoregulatory responses. Notably, postoperative recovery from the hypothermia induced by general anesthesia is significantly faster than from that induced by regional anesthesia.
The effects of regional anesthesia and regional hypothermia are complex and depend upon whether a tourniquet is used or not. The extent and rate of development of peripheral/limb hypothermia and core body temperature during surgery depends on several factors, including the operating room ambient temperature, duration of tourniquet application, and temperature of any irrigation fluid. They note that postoperative recovery from the hypothermia induced by regional anesthesia takes longer than from that induced by general anesthesia because of the prolonged period of loss of vasoconstrictive response.
Procedure-specific risk factors for inadvertent perioperative hypothermia during arthroscopic surgery include prolonged operating time, low blood pressure during the procedure, and low temperature of the irrigation fluid.
The authors note that ambient operating room temperature has traditionally been considered a risk factor for inadvertent hypothermia in perioperative patients, but that evidence for that was scant or even contradictory.
They discuss both active and passive interventions to avoid hypothermia. Passive methods decrease heat loss by radiation (eg, reflective blanket), conduction (eg, layered cotton blankets and padding the operating table), or convection (eg, heat and humidity exchanger in the breathing circuits) to the surrounding environment. Active patient heating methods are generally more successful and aim to bring in heat from the source to the patient’s body using conduction (eg, Hot Dog® [Eden Augustine Temperature Management]) or convection (eg, Bair Hugger® [Arizant Healthcare]) techniques.
Simpson et al. (Simpson 2018) found that, at the time of incision, 60 of 179 (34%) total knee arthroplasty (TKA) patients and 80 of 204 (39%) total hip arthroplasty (THA) patients were hypothermic. In THA patients, 65% remained hypothermic for the duration of anesthesia compared to 33% of TKA patients. The largest drop in core body temperature in both THA and TKA patients occurred between preoperative holding and induction of anesthesia. In THA patients, spinal anesthesia had a significantly higher occurrence of PH. No significant patient factor was found to increase risk. The authors suggested that emphasis on preoperative holding protocols, decreasing time from operating room entry to incision, and increasing ambient room temperature could reduce risk of hypothermia in this patient population.
Though not confined to orthopedic cases, another study (Akers 2019) found 7 of 298 surgical patients at a single hospital site in the midwestern United States were hypothermic in the post-op period. Older adults (ie, more than 60 years old) were significantly more likely to experience hypothermia and that abdominal procedures posed a greater risk for hypothermia than other procedures. In addition, perioperative hypothermia was significantly associated with postoperative anemia, sepsis, and mortality.
The type of anesthesia did not significantly differ between the hypothermic and normothermic groups. Although multiple combinations of anesthesia (eg, general anesthesia used in conjunction with spinal anesthesia) were noted in the total sample, general anesthesia was used exclusively for most procedures and all seven patients who experienced perioperative hypothermia received general anesthesia only. Some previous studies had suggested hypothermia was more common in patients undergoing combination anesthesia. Also, contrary to some other studies, duration of surgery did not appear to correlate with hypothermia.
Another recent study (Nordgren 2020) compared the efficacy of four treatment interventions to prevent hypothermia in patients undergoing total knee or hip arthroplasty. The interventions included convective warming (ie, forced air warming or FAW) with prewarming (group 1), conductive warming with prewarming (group 2), reflective and convective warming without prewarming (group 3), and convective warming only (group 4). There were 30 patients in each group. They also standardized anesthetic agents and delivery methods, administering spinal anesthetic blocks of 15 mg of bupivacaine with 45 μg of clonidine or general anesthesia. They also agreed to avoid the use of sedating agents whenever possible, but if sedation was required, they administered 1 to 2 mg of midazolam.
The mean temperature decreased in all groups upon arrival in the OR and after the administration of anesthesia. At the beginning of surgery, the mean temperature fell below the hypothermic limit for all patients in groups 2, 3, and 4. During surgery, there was an increase in core temperature for all interventions. However, upon the patient’s arrival to the PACU, the mean temperature fell below the hypothermic limit for all interventions.
The average number of inadvertent perioperative hypothermia (IPH) episodes for group 1 was significantly lower compared with the number of IPH episodes for groups 2, 3, and 4.
There was no difference in the perception of cold or warmth between groups and, interestingly, none of the patients felt uncomfortable. This point further emphasizes the need to measure core temperature objectively in such patients.
Patients using a FAW gown who began prewarming on the nursing unit had a significantly higher core temperature throughout the perioperative period. These patients had a lower rate of IPH than patients who received the other three interventions.
The authors felt that, although the active self-warming blanket was less effective than FAW at preventing IPH, the active self-warming blanket may still be beneficial because it can be used during patient transport without a control unit.
Many patients using the handheld controller for the FAW expressed a positive feeling of control over something preoperatively and postoperatively; this seemed to be an additional patient benefit.
The study confirms that inadvertent perioperative hypothermia is common in patients undergoing THA or TKA. It suggests that convective warming (ie, FAW) with prewarming appears to reduce hypothermia in patients. Prewarming with an active self-warming blanket (ie, conductive warming) was less effective. An important finding that merits further research is that patients’ temperatures typically drop after they leave the OR and arrive in the PACU
Our January 23, 2018 Patient Safety Tip of the Week “Unintentional Hypothermia Back in Focus” discussed three articles showing that unintentional hypothermia is very common in obstetrics, but lamented the relative lack of proven interventions to prevent or treat hypothermia in obstetrical patients.
Note that a previous Cochrane review (Cochrane 2014) found that active warming, particularly forced air warming, appears to offer a clinically important reduction in mean time taken to achieve normothermia in patients with postoperative hypothermia, but that high-quality evidence on other important clinical outcomes is lacking. It concluded that it is unclear whether active warming offers other benefits and harms. High-quality evidence on other warming methods is also lacking; therefore, it is unclear whether other rewarming methods are effective in reversing postoperative hypothermia.
So, are there harms associated with various warming interventions? Several of our prior columns on iatrogenic burns (listed below) cited cases of burns caused by warming blankets and other warming devices. In particular, our December 23, 2014 Patient Safety Tip of the Week “Iatrogenic Burns in the News Again” gave details on the additional risk factors that may have predisposed such patients to burns, such as poor tissue perfusion, sensory loss, etc. It also discussed the dangers of “hosing” or “free-hosing” (using the hose of the warming device without the blanket attachment and allowing the hot air to blow directly onto the patient, forcing the hot air onto one focused area of the body).
In that column we made the following recommendations to avoid thermal injuries from warming blankets and related devices:
Our own interest in unintentional hypothermia was related to occurrence of an unusual phenomenon in patients undergoing spinal anesthesia using morphine. These were cases (most often obstetrical) in which spinal anesthesia with morphine is used and patients develop hypothermia with paradoxical sweating. See our Patient Safety Tips of the Week for December 4, 2012 “Unintentional Perioperative Hypothermia: A New Twist” and January 23, 2018 “Unintentional Hypothermia Back in Focus” for details. The proposed mechanism is that enough of the morphine ascends in the subarachnoid space to reach the hypothalamus where it interacts with receptors important in thermoregulation. Essentially this leads to alteration of the hypothalamic thermoregulatory set point causing the body to feel hot and sweat in attempt to adapt to heat. The main reason to recognize that phenomenon is that some cases appear to respond to benzodiazepines. Benzodiazepine receptors are also found in the hypothalamus and are probably also involved in thermoregulation. Naloxone and atropine have also been noted to produce improvement in case reports. You probably should amend your hypothermia management protocols to take this phenomenon into account. Specifically, there should be a prompt to consider the phenomenon if the expected improvement in hypothermia is not occurring within a reasonable amount of time after conventional warming procedures have been instituted. Perhaps even a prompt at the beginning of your protocol to look for signs you would not expect with hypothermia (i.e. sweating, hot feeling, vasodilation) might suggest this unusual etiology for the hypothermia. The presence of nausea and pruritis might be an additional clue. In either case the prompt should remind you to consider a trial of either low dose benzodiazepine or naloxone.
Your facility should have a formal protocol to follow for prevention and management of perioperative hypothermia. The AORN Guideline for Prevention of Hypothermia (AORN 2020) was also discussed in a recent review (Link 2020), stressing use of a consistent temperature measurement method through all phases of perioperative care, assessing risk for hypothermia in all patients, and prewarming perioperative patients. Other guidelines and resources on perioperative hypothermia are available from the Pennsylvania Patient Safety Authority (PPSA 2008), the American Society of PeriAnesthesia Nurses (ASPAN 2010), and the National Institute for Health and Care Excellence (NICE 2017).
Our prior columns on inadvertent perioperative hypothermia:
Our prior columns on iatrogenic burns:
References:
Kleimeyer JP, Harris AHS, Sanford J, et al. Incidence and Risk Factors for Postoperative Hypothermia After Orthopaedic Surgery. J Am Acad Orthop Surg 2018; 26(24): e497-e503
Boddu C, Cushner J, Scuderi GR. Inadvertent Perioperative Hypothermia During Orthopedic Surgery. Am J Orthop (Belle Mead NJ). 2018; 47(7): Publish date: July 12, 2018
Simpson JB, Thomas VS, Ismaily SK, et al. Hypothermia in Total Joint Arthroplasty: A Wake-Up Call. Journal of Arthroplasty 2018; 33(4): 1012-1018, April 01, 2018
Published: November 07, 2017
https://www.arthroplastyjournal.org/article/S0883-5403(17)30969-5/pdf
Akers JL, Dupnick AC, Hillman EL, et al. Inadvertent Perioperative Hypothermia Risks and Postoperative Complications: A Retrospective Study. AORN Journal 2019; 109(6): 741-747
https://aornjournal.onlinelibrary.wiley.com/doi/10.1002/aorn.12696
Nordgren M, Hernborg O, Hamberg A, et al. The Effectiveness of Four Intervention Methods for Preventing Inadvertent Perioperative Hypothermia During Total Knee or Total Hip Arthroplasty. AORN Journal 2020; 111(3): 303-312 First Published:04 March 2020
https://aornjournal.onlinelibrary.wiley.com/doi/10.1002/aorn.12961
Cochrane Review. Treating unintentional hypothermia after surgery. Cochrane.org 2014
http://www.cochrane.org/CD009892/ANAESTH_treating-unintentional-hypothermia-after-surgery
AORN (Association of periOperative Registered Nurses). Guideline for prevention of hypothermia. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2020: 327-356
https://www.aorn.org/guidelines
Link T. Guidelines in Practice: Hypothermia Prevention. AORN Journal 2020; 111(6): 653-666 First Published:28 May 2020
https://aornjournal.onlinelibrary.wiley.com/doi/10.1002/aorn.13038
PPSA (Pennsylvania Patient Safety Authority). Prevention of Inadvertent Perioperative Hypothermia. Pa Patient Saf Advis 2008; 5(2): 44-52
http://patientsafety.pa.gov/ADVISORIES/Pages/200806_44.aspx
ASPAN (American Society of PeriAnesthesia Nurses). Normothermia Clinical Guideline. ASPAN’s Evidence-Based Clinical Practice Guideline for the Promotion of Perioperative Normothermia.
http://www.aspan.org/Clinical-Practice/Clinical-Guidelines/Normothermia
NICE (National Institute for Health and Care Excellence). Inadvertent perioperative hypothermia overview. NICE Pathway 2017; Update 29 March 2017
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May 2020
Our August 2016 What's New in the Patient Safety World column “Home Infusion Therapy Pitfalls” highlighted a fatal case related to intravenous vancomycin therapy in the home reported by ISMP Canada (ISMP Canada 2016). The case described was a diabetic patient with a foot ulcer who was receiving IV vancomycin at home after a hospital stay. Recommended bloodwork, including trough vancomycin levels, was not done due to a faulty lab requisition. The patient developed a rash, thrombocytopenia, and high serum vancomycin levels as well as rising creatinine. He was rehospitalized but despite IV fluids and platelet transfusions, he developed hypertensive episodes, epistaxis and mental status changes and developed intracerebral bleeding and ultimately died. The acute kidney injury was attributed to vancomycin toxicity and the thrombocytopenia was also felt possibly related to the vancomycin.
That’s the only case of a vancomycin error we could find in our 14-year patient safety archive. But the Pennsylvania Patient Safety Authority just published an extensive review of safety hazards associated with intravenous vancomycin (Krukas 2020). The authors begin with the complexities of IV vancomycin use: dosing is weight-based and management requires monitoring of drug levels (peak and trough), attention to renal function, and dosing at regularly scheduled intervals. They reviewed the literature and analyzed cases involving vancomycin reported to the Pennsylvania Patient Safety Reporting System (PA-PSRS).
Their literature review identified the following issues:
They then analyzed 143 reports of event reported over a 3-month period related to IV vancomycin (they excluded many more reports if there was no harm or just an unsafe condition that did not reach the patient).
Events occurred in multiple phases of the medication use process: administration (38.5%), monitoring (27.3%), ordering/reviewing (19.6%). The most frequent errors identified were dose omission/delay or receipt of partial dose (41.3%), improper dose (29.4%), and monitoring errors (18.2%).
Workflow and communication issues often contributed to missed doses, delays in doses, or suboptimal doses. Monitoring medication-use process stage issues were mostly related to timing of troughs. Difficulties were especially noted when doses and/or timing needed to be adjusted, including starting, restarting, and stopping IV vancomycin.
Workflow and communication issues typically involved handoffs and transfers, especially related to the ED and OR and transfer from these units to other units. Order sets were sometimes confusing and in other cases paper orders, faxed orders or verbal orders contributed.
Monitoring issues included lack of awareness that trough levels were ordered but not drawn, results of trough levels not promptly transmitted, or trough levels not acted upon.
They provide a terrific self-assessment tool that any organization using vancomycin should download and use. They stress the need to increase clinician awareness and developed an infographic to help promote that. But, recognizing that education and training are of limited value, they focus on potential interventions using health information technology. They note studies showing that use of a weight-based vancomycin EHR order set, specifically in ED settings, resulted in a 20% increase in appropriate dosing (Hall 2015). Other interventions included automatic ordering of a trough level 30 minutes before the fourth dose when a new vancomycin order was placed, or an alert in the nurse’s barcode administration of vancomycin if no trough level had been drawn. One of our own recommendations would be to use clinical decision support to generate an alert when a specified increase in serum creatinine is seen after vancomycin is started.
This is a really good study that has valuable lessons. Issues related to errors in IV vancomycin use probably are underreported and “fly under the radar” in many healthcare organizations. This study should be a wakeup call for all.
References:
ISMP Canada. Gaps in Transition: Management of Intravenous Vancomycin Therapy in the Home and Community Settings. ISMP Canada Safety Bulletin 2016; 16(4): 1-5 June 28, 2016
https://www.ismp-canada.org/download/safetyBulletins/2016/ISMPCSB2016-04_Vancomycin.pdf
Krukas A, Franklin ES, Bonk C, et al. Identifying Safety Hazards Associated With Intravenous Vancomycin Through the Analysis of Patient Safety Event Reports. Patient Safety 2020; 2(1): 17
https://patientsafetyj.com/index.php/patientsaf/article/view/vancomycin
PPSA (Pennsylvania Patient Safety Authority). IV Vancomycin Safety Assessment Tool. PPSA 2020; March 2020
https://patientsafetyj.com/index.php/patientsaf/article/view/vancomycin/125
PPSA (Pennsylvania Patient Safety Authority). Vancomycin Inforgraphic. PPSA 2020; March 2020
https://patientsafetyj.com/index.php/patientsaf/article/view/vancomycin/127
Hall AB, Montero J, Cobian J, Regan T. The Effects of an Electronic Order Set on Vancomycin Dosing in the ED. Am J Emerg Med 2015; 33(1): 92-94
https://www.ajemjournal.com/article/S0735-6757(14)00704-9/fulltext
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When we review cases of wrong site surgery (wrong site, wrong patient, wrong side, wrong procedure), we often find that the surgical “timeout” was either not performed or was performed without the full attention of the entire OR team (or team in the procedure room). Every member of the team is expected to take an active role in the timeout. Responses should not be passive nods of assent. Verification should rely upon primary source documentation and not be second-hand. And any member of the team who has questions should be empowered to stop the procedure. The timeout should take place in accord with the “sterile cockpit” concept we’ve adopted from the aviation safety movement.
A recent review of surgical timeouts, using direct observation, found that at least 1 member of the operating room team was actively distracted in 10.2% of the time-out procedures (Freundlich 2020). That shouldn’t surprise most of you. That’s a rate we commonly encounter at many hospitals or ASC’s or cath labs. We’ll bet most of you don’t actually know how often this happens because you don’t actually measure this important item. Measuring it by way of OR video monitoring is one of the prime reasons we have long advocated video recording in the OR (see our columns on video monitoring listed below).
In the study by Freundlich et al. the frequent distractions occurred despite the fact that most timeouts were completed in less than one minute. They did perform a timeout before the first incision in 100% of cases and there was a formal announcement that the timeout was about to start in 163 of 166 observed surgeries. 92.8% of their timeouts were completed without interruption (the most common reason for an interruption was to verify patient information). Ten time-out procedures were stopped due to a safety concern. Fortunately, there were no wrong-site or wrong-person surgeries reported at their hospital during the study period.
We once, in a joking manner, brought a gong to a staff meeting and rang it to get everyone’s attention when extraneous conversations got out of hand. Well, staff at one hospital didn’t laugh at the idea – they actually brought the gong into their OR’s! Brenckle and colleagues (Brenckle 2020) reported on how they used the gong to get everyone’s attention at the start of timeouts. They addressed the problem after a consultant noted, during a mock regulatory survey, that multiple members of the OR team were multitasking during the timeout and not paying sole attention to the timeout procedure.
They considered several sound-making devices to use in order to get the undivided attention of all OR staff at the onset of their timeouts. Ultimately, they chose a classic Tibetan gong. Despite some negative feedback and resistance early on, they persevered and incorporated the gong into their timeout routine.
It took almost six months before staff members began consistently using the gong properly. After piloting the gong in the cardiac cath lab, they also implemented it in their endoscopy suite and OR’s. After a year, they report no further negative feedback or improper use of the gong. Even physicians who originally refused to pause and engage in the timeout are now actively engaged in the process. One even not only engages in the timeout, but also personally strikes the gong at the end of his procedure to indicate it was successful.
Interesting and innovative! Timeouts are not to be taken lightly or in a joking fashion. But it is of utmost importance to get the attention of all the OR team (or the team in any venue performing procedures) to focus on the timeout. Whatever works best in your facility to accomplish that is worthwhile.
Some of our prior columns related to wrong-site surgery:
September 23, 2008 “Checklists and Wrong Site Surgery”
June 5, 2007 “Patient Safety in Ambulatory Surgery”
July 2007 “Pennsylvania PSA: Preventing Wrong-Site Surgery”
March 11, 2008 “Lessons from Ophthalmology”
July 1, 2008 “WHO’s New Surgical Safety Checklist”
January 20, 2009 “The WHO Surgical Safety Checklist Delivers the Outcomes”
September 14, 2010 “Wrong-Site Craniotomy: Lessons Learned”
November 25, 2008 “Wrong-Site Neurosurgery”
January 19, 2010 “Timeouts and Safe Surgery”
June 8, 2010 “Surgical Safety Checklist for Cataract Surgery”
December 6, 2010 “More Tips to Prevent Wrong-Site Surgery”
June 6, 2011 “Timeouts Outside the OR”
August 2011 “New Wrong-Site Surgery Resources”
December 2011 “Novel Technique to Prevent Wrong Level Spine Surgery”
October 30, 2012 “Surgical Scheduling Errors”
January 2013 “How Frequent are Surgical Never Events?”
January 1, 2013 “Don’t Throw Away Those View Boxes Yet”
August 27, 2013 “Lessons on Wrong-Site Surgery”
September 10, 2013 “Informed Consent and Wrong-Site Surgery”
July 2014 “Wrong-Sided Thoracenteses”
March 15, 2016 “Dental Patient Safety”
May 17, 2016 “Patient Safety Issues in Cataract Surgery”
July 19, 2016 “Infants and Wrong Site Surgery”
September 13, 2016 “Vanderbilt’s Electronic Procedural Timeout”
May 2017 “Another Success for the Safe Surgery Checklist”
May 2, 2017 “Anatomy of a Wrong Procedure”
June 2017 “Another Way to Verify Checklist Compliance”
March 26, 2019 “Patient Misidentification”
May 14, 2019 “Wrong-Site Surgery and Difficult-to-Mark Sites”
Some of our previous columns discussing video recording:
September 23, 2008 “Checklists and Wrong Site Surgery”
December 6, 2010 “More Tips to Prevent Wrong-Site Surgery”
November 2011 “Restricted Housestaff Work Hours and Patient Handoffs”
March 2012 “Smile...You’re on Candid Camera!”
August 27, 2013 “Lessons on Wrong-Site Surgery”
March 17, 2015 “Distractions in the OR”
November 24, 2015 “Door Opening and Foot Traffic in the OR”
March 2019 “Another Use for Video Recording”
March 17, 2020 “Video Recording in the OR”
References:
Freundlich RE, Bulka CM, Wanderer JP, et al. Prospective Investigation of the Operating Room Time-Out Process. Anesthesia & Analgesia 2020; 130(3): 725-729
Brenckle EA, Gealer D, Milligan M. Using a Tibetan Gong to Increase Staff Member Engagement During Time Outs. AORN Journal 2020; 111(1): 81-86
https://aornjournal.onlinelibrary.wiley.com/doi/10.1002/aorn.12898
Print “May 2020 Poor Timeout Compliance: Ring a Bell?”
Over 10 years ago, we wrote a column on doing patient safety scavenger hunts (see our March 16, 2010 Patient Safety Tip of the Week “A Patient Safety Scavenger Hunt”). In that column we noted you can also make patient safety fun at the same time you are identifying hazards in your organization. We provided the example of the “Patient Safety Scavenger Hunt”. In this exercise you award points for identifying patient safety hazards or risky situations or practices. Give your staff a finite period of time (eg. 2 hours) to look for these and award points for each item identified within that time frame. Use multiple staff and you may need to pair them up for the search for some of the items (like the suicide risk ones). We provided some examples you could award points for:
We provided a sample scorecard in that column.
Jane Bell, from Cityview Surgery Center in Fort Worth, Texas, recently described in Outpatient Surgery Magazine a takeoff on the patient safety scavenger hunt (Bell 2020). She describes a game/exercise in which two staff members stage 20 to 25 errors at a bedside in their PACU. These would include things like a bloody tourniquet left on a patient’s bedside stand, a surgery schedule in full view, an overflowing sharps container, and others.
The next day staff are divided into two teams. Each team is brought in to view the room for 30 seconds, and members write down all of the errors they can find. (She notes that the 30-second time limit is key because if your staff can spot problems quickly and under pressure, there’s a good chance they’ll do the same during a stressful surgery.)
After the scores are tallied (a point for each mistake noticed), the team that spots the most errors wins. They gave every member of the winning team a Starbucks gift card. The winning team actually correctly guessed all 25 of the errors in their “Secret Room”.
The point is that you can combine fun with learning and identification of patient safety hazards at the same time. Try these exercises in your organizations.
References:
Bell J. Ideas That Work: Secret Room. Help Staff Spot Mistakes in Seconds. Outpatient Surgery Magazine 2020; XXI(2): February 2020
Print “May 2020 A Takeoff On The Patient Safety Scavenger Hunt”
Many studies have demonstrated more adverse patient outcomes when treated by aging physicians, leading to calls for careful evaluation of the older physician in credentialing and privileging programs in healthcare organizations.
But for surgeons, there is a paradox, at least from a statistical perspective. Tsugawa and colleeagues (Tsugawa 2018) found that patients treated by older surgeons actually had lower mortality than patients treated by younger surgeons. There was no evidence that operative mortality differed between male and female surgeons. And, for eye surgeons performing cataract surgery, Campbell et al. (Campbell 2019) found that “late career” surgeons did not have more complications that eye surgeons earlier in their careers. That finding held up even when surgical volume was factored in.
Now another study from Ontario, Canada (Satkunasivam 2020) found that increasing surgeon age was associated with decreasing rates of postoperative death, readmission and complications. And the association was in a nearly linear fashion. These findings persisted after accounting for patient-, procedure-, surgeon- and hospital-level factors. A 10-year increase in surgeon age was associated with a 5% relative decreased odds of the composite outcome. Patients receiving treatment from surgeons who were older than 65 years of age had a 7% lower odds of adverse outcomes.
A strength of this study was that it included a variety of surgical specialties and both
elective and emergent procedures, and the single-payer health care system in Ontario for surgical procedures ensured capture of virtually all procedures and identification of readmissions or complications after surgery that occurred anywhere in the province.
The authors discuss possible reasons for this finding. One is that those older surgeons may be a highly select group. Surgeons with lesser skills or impaired cognitive abilities may have already ceased operating. On the other hand, it may well be that the longstanding experience of this group of surgeons has allowed them to better select patients who will have better outcomes. Older surgeons did have higher volumes so the volume/outcome phenomenon might play a role. We might speculate that perhaps older surgeons might avoid new technologies or new procedures, like robotic surgeries, that have a learning curve. But the Canadian study excluded robotic surgeries.
Their findings definitely suggest that use of mandatory retirement ages for surgeons would be counterproductive. Many geographic areas, particularly rural ones, are already experiencing shortages of surgeons, both in surgical subspecialties and especially in general surgery.
Nevertheless, programs like the Yale New Haven program we discussed in our February 2020 What's New in the Patient Safety World column “The Older Physician: A Practical Approach?” are still likely to be of benefit in determining which older surgeons are likely to practice with high quality.
In our May 28, 2019 Patient Safety Tip of the Week “The Older Physician” we again noted that age, per se, cannot be the sole factor considered in decisions about the status of aging physicians. Katlic et al (Katlic 2019) note that “establishing a mandatory retirement age for surgeons would be a straightforward solution but would be illegal, inappropriate, and unfair because of the variability in function among older individuals of a given age”. They note that some hospitals have adopted a Late Career Practitioner Policy in their medical staff bylaws. These hospitals may require physicians and advanced practice clinicians older than 70 years who apply for recredentialing to undergo physical examination, eye examination, and cognitive screening. Katlic and Coleman previously described the elements of a formal Aging Surgeon Program (Katlic 2014). In both articles they described this as a more comprehensive option for surgeons identified either through screening or performance issues identified by medical staff. Their program is a 2-day, multidisciplinary, objective, and confidential evaluation of a surgeon's physical and cognitive function. It includes physical, neurologic, and ophthalmologic examinations, neuropsychological and physical/occupational therapy testing. A confidential report is then sent to the hospital medical staff that requested the evaluation. Based on the objective information provided in the report, the hospital medical staff may consider options such as continuing full privileges; no privileges; no operating privileges; operating privileges if assisted by another surgeon (routine vs only complex cases); assistant privileges only; focused review of cases (all vs certain number); or decreased work hours (eg, no on-call duties). Katlic et al do discuss surgical simulator testing but note that its validity for privileging issues has not yet been determined. (They also note that surgical simulator testing can be resource intensive, for both equipment and human time, and would need to be specialty specific.)
They note that there is great variability in the cognitive decline that takes place with aging, but also that clinical experience may offset declines in cognitive performance. As such, mandating retirement at a specific age would undoubtedly remove some competent surgeons from the workforce. But they also note that physicians’ self-awareness of cognitive decline often does not coincide with objective performance measures.
In our July 7, 2015 Patient Safety Tip of the Week “Medical Staff Risk Issues” we noted the AMA had voted to approve a report saying it is time to have a system for assessing the competence of older physicians but there was considerable sentiment expressed that screening physicians at a certain age “is inappropriate and smacks of ageism” (Frellick 2015). The AMA had not yet developed criteria or processes for such assessments. Subsequently, guiding principles for assessing the competency of senior/late career physicians were proposed by the AMA’s Council on Medical Education, but these were not adopted and the report was back to the Council on Medical Education (Firth 2018).
The American College of Surgeons did issue a Statement on the Aging Surgeon in 2016 (ACS 2016). While it was not in favor of a mandatory retirement age, it recommended that, starting at age 65 to 70, surgeons undergo voluntary and confidential baseline physical examination and visual testing by their personal physician for overall health assessment and regular interval reevaluation thereafter for those without identifiable issues on the index examination. It also encouraged surgeons to also voluntarily assess their neurocognitive function using confidential online tools. It also noted that voluntary self-disclosure of any concerning and validated findings is encouraged as part of a surgeon’s obligations. It also noted that colleagues and staff must be able to bring forward and freely express legitimate concerns about a surgeon’s performance and apparent age-related decline to group practice, departmental and medical staff, or hospital leadership without fear of retribution. It stressed the importance of peer-reviewed methods, including ongoing professional practice evaluation, as part of recredentialing and, if a potential issue is identified, additional methods of evaluation may include chart reviews, peer review of clinical decision making, 360-degree reviews and patient feedback, observation or video review of operating room cases, and proctoring.
It acknowledged that there will be occasions were a surgeon will need to be referred to a comprehensive evaluation program, conducted at a number of specialized centers where a battery of tests for neurocognitive function can be conducted in the form of a neuropsychological assessment (the costs of which should be borne by the hospital or medical staff, not the surgeon). But it emphasized that these results cannot be used in isolation to determine continuation or withholding of hospital and surgical privilege but should be incorporated as an additional piece of information.
Recommendations such as those from the Society of Surgical Chairs (Rosengart 2019). and Stanford Health Care’s Late Career Practitioner Policy (Weinacker 2018) are a good starting point. The concept of beginning the discussion with your clinicians long before they are “aging” needs to be ingrained in your programs. Resources such as the Aging Surgeon Program at Sinai Hospital/LifeBridge Health (developed by Katlic and others) may be very helpful to you once have reached an age where their skills and cognitive functions may start to wane. And the Yale New Haven program (Cooney 2020) that we discussed in our February 2020 What's New in the Patient Safety World column “The Older Physician: A Practical Approach?” offers a way to provide an objective assessment in a respectful manner.
Our prior columns dealing with the issue of the aging physician:
References:
Tsugawa Y, Jena AB, Newhouse RL, et al. Age and sex of surgeons and mortality of older surgical patients: observational study. BMJ 2018; 361 Published 25 April 2018
https://www.bmj.com/content/361/bmj.k1343
Campbell RJ, el-Defrawy SR, Gill SS, et all Association of Cataract Surgical Outcomes With Late Surgeon Career StagesA Population-Based Cohort Study. JAMA Ophthalmol 2019; 137(1): 58-64
https://jamanetwork.com/journals/jamaophthalmology/article-abstract/2706484
Satkunasivam R, Klaassen Z, Ravi B, et al. Relation between surgeon age and postoperative outcomes: a population-based cohort study. CMAJ 2020; 192 (15): E385-E392
https://www.cmaj.ca/content/192/15/E385
Katlic MR, Coleman J, Russell MM. Assessing the Performance of Aging Surgeons. JAMA 2019; 321(5): 449-450
https://jamanetwork.com/journals/jama/article-abstract/2721291
Katlic MR, Coleman J. The aging surgeon. Ann Surg 2014; 260(2): 199-201.
https://journals.lww.com/annalsofsurgery/fulltext/2014/08000/The_Aging_Surgeon.1.aspx
Frellick M. Screen Aging Physicians for Competency, Report Asks. Medscape Medical News June 15, 2015
http://www.medscape.com/viewarticle/846497
Firth S.How Can Competency be Measured in Older Docs? AMA council guidance for testing fails to win over delegates. MedPage Today 2018; November 14, 2018
https://www.medpagetoday.com/meetingcoverage/ama/76334
ACS (American College of Surgeons). Statement on the Aging Surgeon. January 1, 2016
https://www.facs.org/about-acs/statements/80-aging-surgeon
Rosengart TK, Doherty G, Higgins R, et al. Transition Planning for the Senior Surgeon. Guidance and Recommendations From the Society of Surgical Chairs. JAMA Surg 2019; Published online May 15, 2019
https://jamanetwork.com/journals/jamasurgery/fullarticle/2733041
Weinacker A. Staffing: How Do You Deal With Aging Surgeons? Outpatient Surgery Magazine 2018; XIX(6): June 2018
LifeBridge Health. Aging Surgeon Program
http://www.agingsurgeonprogram.com/AgingSurgeon/AgingSurgeon.aspx
Cooney L, Balcezak T. Cognitive Testing of Older Clinicians Prior to Recredentialing. JAMA 2020; 323(2): 179-180
https://jamanetwork.com/journals/jama/article-abstract/2758602
Print “May 2020 The Aging Surgeon Paradox”
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