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Keeping Surgical Patients Safe From Unintended Harm
By ETHAN COVEY
As part of the 2021 virtual American College of Surgeons Clinical Congress, experts gathered to review several hot ns ot topics in surgical patient safety. These subjects—some newer developments and other challenges that continue to present complications for surgeons and their staff—were reviewed during a series of presentations and an accompanying panel discussion.
The sessions, highlights of which are included below, focused on how practices and technologies are evolving in order to address peri- and postoperative challenges, and allow for more successful risk management strategies. The goal, said the moderator of the session, Juan A. Sanchez, MD, the regional vice president at HCA Healthcare Physician Services Group, in Brentwood, Tenn., is “to keep surgical patients safe from unintended harm.” er
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Venous Thromboembolism, HealthcareAssociated Infections Pose Continuing Threat
Venous thromboembolism (VTE) and healthcare-associated infections (HAIs) are “two highly relevant topics that really apply to the daily practice of surgery,” said Peter A. Najjar, MD, an assistant professor of surgery at Johns Hopkins Medicine, in Baltimore.
Dr. Najjar added that inpatient VTEs remain very common. “In fact, there is good evidence to suggest that they are the most common preventable cause of in-hospital death.”
Although pharmacologic prophylaxis against VTEs has been shown to be safe, effective and cost-effective (and is advocated by existing guidelines), these methods remain underused (Agency for Healthcare Research and Quality; October 2015. AHRQ Publication No. 16-0001-EF).
Effectively preventing VTEs requires a multistep process incorporating standardized risk assessment, ordering prophylaxis and delivery of prophylaxis. When possible, risk assessments should be integrated into a patient’s electronic health record. Ordering of appropriate prophylaxis, Dr. Najjar said, should be based on patient and procedural risk factors, and ensuring prophylaxis is administered to the patient is of the utmost importance. Missed opportunities for prophylaxis can be common, and they highlight the need for additional educational efforts.
“With this comprehensive strategy, the goal is to reduce the incidence of VTE to only those that are not preventable using best practice in modern surgical settings,” Dr. Najjar said.
Another problem that continues to present a significant source of preventable morbidity and mortality is HAIs.
The most common type of HAIs, accounting for more than 30% of infections, is surgical site infections (SSIs). It is estimated that SSIs cause 8,000 deaths annually in the United States, and 40% to 60% are preventable (Surg Clin North Am 2015;95[2]:269-283).
For both HAIs and SSIs, further decreasing rates likely requires the bundling of multiple techniques.
“Over time, we’ve gotten so good at reducing SSIs through antiseptic technique and meticulous hemostasis, technical skill improvement, and procedural planning that infection rates have dropped substantially,” Dr. Najjar said. “So, in order to demonstrate a meaningful improvement, there are very few ‘silver bullets’ that will take an infection rate down substantially from those levels. That’s where I think the power of good process and bundles come into play.”
Avoiding Unintended Retained Surgical Items And Patient Identification Errors
Improvements can also be made in preventing retained surgical items (RSIs) and hospital-based patient misidentification.
“RSIs are a ubiquitous problem that crosses body cavities, small and large cases, in addition to crossing surgical specialties,” said Lauren T. Steward, MD, an assistant professor of GI, trauma and endocrine surgery at the University of Colorado Department of Surgery, in Denver.
Dr. Steward said basic counting procedures are not enough to eliminate these occurrences.
“Communication should be enhanced,” Dr. Steward said, including verbal communication and acknowledgment when placing small objects into, and removing them from, the patient’s body. Additionally, backup strategies should be used, such as a white board on which placement and removal of items are actively recorded. Surgical debriefs should verify that items placed in the body have been removed, and x-rays can be used to rule out the presence of RSIs.
Dr. Steward noted that it is especially important for hospital leadership to continuously demonstrate that patient safety is a priority, ranking even higher than productivity and efficiency.
