Summer 2015 Anesthesiology Preop cognitive impairment linked to postop cognitive dysfunction after total hip Postoperative cognitive dysfunction has been identified in patients undergoing noncardiac surgery 3 months after surgery. However, it s unclear whether preexisting cognitive dysfunction contributes to postoperative cognitive decline. This Australian study investigates the prevalence of preexisting cognitive impairment in elderly total hip patients and its association with postoperative cognitive dysfunction. The study included 300 total hip patients and 51 nonsurgical controls. Preoperative cognitive impairment was identified in 32% of patients. It was found to be a good predictor of cognitive dysfunction at 3 months and 1 year and cognitive decline at 1 year after surgery. The researchers concluded that patients with preexisting cognitive impairment have an increased incidence of postoperative cognitive dysfunction and cognitive decline after hip replacement. Identifying early decline in cognitive function is now routine in geriatric care and an accepted way to identify future cognitive decline. The current findings suggest that preoperative cognitive impairment may similarly predict cognitive decline following surgical intervention, the researchers note. Silbert B, Evered L, Biostat M, et al. Preexisting cognitive impairment is associated with postoperative cognitive dysfunction after hip joint replacement surgery. Anesthesiology. 2015;122(6):1224-1234. http://anesthesiology.pubs.asahq.org/ Patient safety Incidence of surgical never events analyzed Wrong-site surgery, retained surgical items, and surgical fires termed never events continue to occur despite numerous patient safety initiatives. Researchers from the Southern California Evidence- Based Practice Center, RAND Corporation, Santa Monica; Veterans Affairs Greater Los Angeles Healthcare system; and the University of California School of Medicine, Los Angeles, examined the incidence and root causes of and interventions to prevent wrong-site surgery, retained surgical items, and surgical fires since 2004, when the Universal Protocol was implemented. Analyzing data from nine databases, the researchers found that current estimates for wrong-site surgery and retained surgical items are 1/100,000 and 1/10,000 procedures, respectively. However, the estimates are imprecise and vary across sources and specialties. Despite promising approaches for preventing events, such as education, team training, and datamatrix-coded sponge-counting systems, evidence to support any particular intervention was limited. A frequently reported root cause was inadequate communication. Evidence for preventing surgical fires was insufficient, and the effect of interventions could not be estimated. The researchers concluded that distinct methodologic challenges impede the analysis of never events and may necessitate different evaluation methods. Hempel S, Maggard-Gibbons M, Nguyen D K, et al. Wrong-site surgery, retained surgical items, and surgical fires. JAMA Surg. Published online June 10, 2015. Causes of wrong surgery events in VHA despite Universal Protocol The Universal Protocol has been associated with the prevention of wrong surgery events, but events still occur. This study from the Veterans Health Administration (VHA) explored wrong surgery events in the VHA database of root cause analyses to determine the frequency and characteristics of these events, which occurred because of errors upstream and downstream to the Universal Protocol. The analysis included 48 cases of wrong surgery events, representing 16% of the 308 root cause analyses for events reported between 2004 and 2013. Upstream errors included mislabeling of specimens or radiographs and transposition of reports. Downstream errors, which occurred after time-outs 26434
were performed, were associated with ineffective intraoperative processes, including wrong level spine localization errors, other intraoperative localization errors, and intraprocedure diagnostic determinations. Surgical procedures that were particularly vulnerable included spine (wrong level), prostatectomy (wrong patient), cataract (wrong implant), and skin lesion excisions (wrong lesion). The researchers concluded that healthcare organizations cannot rely on compliance with performance of the Universal Protocol to eliminate the possibility of a wrong surgery event. Prevention of such events will require diligence upstream and downstream from the Universal Protocol. Paull D E, Mazzia L M, Neily J, et al. Errors upstream and downstream to the Universal Protocol associated with wrong surgery events in the Veterans Health Administration. Am J Surg. 2015;210(1):6-13. http://www.americanjournalofsurgery.com/ Quality improvements Implementation of emergency manuals in the OR Simulation studies show that OR teams use best practices during critical events more effectively and efficiently when referring to emergency manuals (eg, context-relevant sets of cognitive aids such as crisis checklists). However, clinical adoption and use are still nascent in healthcare. This study from the Stanford Hospital and Clinics, Stanford, California, assessed the impact of a brief in situ OR staff training program on familiarity with emergency manuals and intention to use them during critical events. Nine 50-minute training sessions were held with OR staff. Training included why and how to use emergency manuals, familiarization with format, simulated scenarios of critical events, and debriefings. The 126 trained OR staff members reported increases in awareness of and familiarity with the emergency manual, willingness to use for educational review, and intention to use during critical events. The researchers recommend that institutions provide emergency manuals in accessible places in ORs and incorporate training to increase staff familiarity, cultural acceptance, and planned clinical use. Goldhaber-Fiebert S, Lei V, Nandagopal K, et al. Emergency manual implementation: Can brief simulation-based OR staff trainings increase familiarity and planned clinical use? Jt Comm J Qual Patient Saf. 2015;41(5):212-220. http://www.ingentaconnect.com/content/jcaho/jcjqs/ Surgical site infection Effect of preop decontamination protocol on SSIs in orthopedic implant patients Surgical site infections (SSIs), commonly caused by methicillin-resistant Staphylococcus aureus (MRSA), are associated with significant morbidity and mortality, specifically in orthopedic patients who have hardware implanted. In this study, researchers from Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, both in Houston, Texas, examined the effect of a decontamination protocol on SSIs in patients having elective orthopedic surgery with hardware implantation. The protocol consisted of the application of 2% chlorhexidine washcloths and 0.12% oral rinse the night before and morning of surgery and 5% intranasal povidone-iodine solution the morning of surgery. A total of 709 patients (344 controls and 365 patients who were decolonized) were involved in the study. A quarterly guide to literature about the OR environment Publisher Thomas A. Sloma-Williams Executive Editor Elizabeth Wood Editor Judith M. Mathias, MA, RN Summaries in are intended to give readers an overview of literature pertaining to the OR environment. (ISSN 1065-8173) is published quarterly by Access Intelligence, LLC, 4 Choke Cherry Rd, Second Floor, Rockville, MD 20850. Copyright 2015 OR Manager, Inc. All rights reserved, No part of this publication may be reproduced without written permission. Address subscription requests to Client Services, clientservices@accessintel.com, Tel: 888-707-5814. Web site: www.ormanager.com 2 Summer 2015
The SSI rate in the intervention group was significantly lower than in the control group (1.1% vs 3.8%). Multivariate analysis identified MRSA decontamination as an independent predictor of not developing an SSI. The data demonstrate a significant decrease in overall SSI rates in orthopedic patients after implementation of the decontamination protocol, the researchers concluded. Bebko S P, Green D M, Awad S S. Effect of a preoperative decontamination protocol on surgical site infections in patients undergoing elective orthopedic surgery with hardware implantation. JAMA Surg. 2015;150(5):391-395. Association of bundled intervention on SSIs in patients having cardiac, hip, and knee surgery Previous studies suggest that a bundled intervention of screening patients for nasal carriage of Staphylococcus aureus and decolonizing carriers preoperatively was associated with lower rates of surgical site infections (SSIs) in cardiac and orthopedic surgical patients. However, the effectiveness of the bundle had not been evaluated in a multicenter study. Researchers from the University of Iowa, Iowa City, conducted a 20-hospital study to determine whether an evidence-based bundle (ie, screening for S aureus, decolonizing carriers, and prescribing perioperative antibiotics) would be associated with a lower incidence of SSIs in cardiac, hip, and knee patients compared with standard practice. At 3 months, 83% of hospitals were adherent to the bundle. A statistically significant decline in complex SSI was found for hip or knee replacement (17 fewer infections per 10,000 procedures), but the decline was not significant for cardiac patients (6 fewer infections per 10,000 procedures). The researchers concluded that the bundle was associated with a modest statistically significant decrease in S aureus SSIs. An accompanying editorial notes that although the overall reduction in SSIs from the bundle seems modest, each complex SSI prevented is clinically meaningful for the patient. Development of a serious SSI after cardiac or orthopedic surgery translates into months of antibiotics, additional surgical procedures, and extended hospital stays. Schweizer M L, Chiang H Y, Septimus E, et al. Association of a bundled intervention with surgical site infections among patients undergoing cardiac, hip, or knee surgery. JAMA. 2015;313(21):2162-2171. Accompanying editorial, 2131-2132. http://jama.jamanetwork.com Noise levels correlate with SSIs in outpatient hernia repairs Surgical site infections (SSIs) are associated with longer hospital stays, poorer quality of life, and increased costs. Lapses in compliance with aseptic principles are a substantial risk factor for SSIs, which may be attributable to distractions such as noise during surgical procedures. New book! Materials Management in the OR, Second Edition Learn how to streamline the supply chain and meet revenue goals. Each copy just $99 plus shipping and handling. Order online at www.ormanager.com or by phone at 888-707-5814 Summer 2015 3
The aims of this study from the United Kingdom were to assess whether noise levels in the OR were associated with the development of SSIs and to elucidate the extent to which these levels affect costs. A total of 64 male patients having elective, outpatient, open inguinal hernia repairs were included in the study. The patients were fit and at low risk for SSIs. Sound levels were measured during the procedures with a decibel meter and correlated with the incidence of SSIs. Five of the 64 patients (7.81%) developed SSIs. Overall, the noise levels were greater for the patients who developed SSIs. Noise levels were substantially greater from a time point of 50 minutes onwards, which correlated to when wound closure was occurring. The additional hospital cost for patients who developed an SSI was 243 (about $377) per patient based on National Health System reference costing for treatment of a superficial skin infection. Decreasing ambient noise levels in the OR may aid in reducing the incidence of SSIs, particularly during closure, and decrease the associated costs of this complication, the researchers concluded. Dholakia S, Jeans J P, Khalid U, et al. The association of noise and surgical-site infection in day-case hernia repairs. Surgery. 2015;157:1153-1156. http://www.surgjournal.com Surgical trends Bariatric surgery Centers of Excellence did not restrict access to care In 2006, the Centers for Medicare & Medicaid Services (CMS) required that bariatric surgery be performed only in hospitals that had been designated as a Center of Excellence. CMS removed the requirement in 2013 because of controversy over whether it impeded access to care. This study from researchers at the Johns Hopkins Center for Bariatric Surgery, Baltimore, examines whether the Center of Excellence certification requirement proved to be a barrier to patients access to bariatric surgery. An analysis of nearly 135,000 bariatric surgical patients found that the certification requirement actually reduced disparities in access to bariatric surgical procedures. The proportion of patients older than 65 years increased. The proportion of male patients increased. The disparity among the income classes improved, with the proportion of low-income patients increasing significantly. Access for ethnic minorities improved. The proportion of patients with Medicare increased significantly. The researchers concluded that the findings do not support the hypothesis that restricting bariatric surgical patients to Centers of Excellence reduced access to care or increased disparities. More research is needed to determine whether the 2013 change in policy might sacrifice patient safety without addressing the real cause of limited access to care. Bae J, Shade J, Abraham A, et al. Effect of mandatory centers of excellence designation on demographic characteristics of patients who undergo bariatric surgery. JAMA Surg. Published online May 20, 2015. Standards and regulations Centers for Medicare & Medicaid Services CMS Proposed Changes to Two-Midnight Rule. On July 1, the Centers for Medicare & Medicaid Services released proposed updates to the Two-Midnight rule regarding when inpatient admissions are appropriate for payment under Medicare Part A. The proposed update allows physicians to use their judgment to admit patients for short hospital stays on a case-by-case basis. CMS would remove oversight of those decisions from its administrative contractors and instead have quality improvement organizations enforce the policy. Following adoption of the Two-Midnight rule, CMS received significant feedback from physicians and other stakeholders that the policy was impacting physician and hospital practices. http://www.cms.gov/newsroom/mediareleasedatabase/factsheets/2015-fact-sheets-items/2015-07-01-2.html CMS Comprehensive Care for Joint Replacement Payment Model. The Centers for Medicare & Medicaid Services is planning to require more than 800 hospitals in 75 geographic areas to participate in a bundled payments 4 Summer 2015
initiative for hip and knee replacements. These procedures are among the most common that Medicare beneficiaries receive, and prices vary significantly across geographic areas ranging from $16,500 to $33,000. The Comprehensive Care for Joint Replacement payment program would hold hospitals accountable for the quality of care of Medicare fee-for-service beneficiaries from admission until 90 days after discharge. Hospitals would continue to be paid for their services under existing Medicare payment systems. However, depending on the hospital s quality and cost performance, the hospital may receive an additional payment or be required to repay Medicare for a portion of the costs. The program would begin January 1, 2016, and run for 5 years. Comments will be received until September 8, 2015. http://www.hhs.gov/news/press/2015pres/07/20150709.html CMS Proposed Rule for Hospital Outpatient and ASC Payments. The Centers for Medicare & Medicaid Services on July 1 issued a proposed rule for calendar year 2016 for the hospital outpatient prospective payment (OPPS) and ambulatory surgical center (ASC) payment systems. CMS proposes an OPPS decrease of 0.01%. The change is based on a projected hospital market basket increase of 2.7% percent minus a 0.6% adjustment for multifactor productivity and a 0.2% adjustment required by law. An additional 2% adjustment will be included to account for inflation in OPPS payments resulting from an increase in payments for laboratory tests that were previously paid under the Clinical Laboratory Fee Schedule. Considering all policy changes, CMS estimates a -0.2% cut for hospitals paid under the OPPS in CY 2016. In addition, CMS plans to reduce payments by 2.0% to hospital outpatient schedules that failed to meet the Hospital Outpatient Quality Reporting Program requirements. The agency also plans to reduce annual payment to ambulatory surgery centers by the same amount for failure to meet similar reporting requirements. http://cms.gov/newsroom/mediareleasedatabase/factsheets/2015-fact-sheets-items/2015-07-01.html CMS 2013 Data on Medicare Payments for Hospitals, Physicians. The Centers for Medicare & Medicaid Services on June 1 released 2013 data on average charges and payments for hospitals, physicians, and other suppliers. The annual update included hospital-specific data for the 100 most common inpatient Diagnosis- Related Groups, 30 outpatient Ambulatory Payment Classifications, and physician/supplier-specific data for services and products using the Healthcare Common Procedure Coding System. The 2013 data set has information for more than 950,000 healthcare providers who collectively received $90 billion in Medicare payments. http://www.cms.gov/newsroom/mediareleasedatabase/ Press-releases/2015-Press-releases-items/2015-06-01.html Food and Drug Administration FDA Panel Calls Duodenoscopes Unsafe. A Food and Drug Administration panel on May 15 concluded that the current generation duodenoscopes are unsafe as designed, the Los Angeles Times reports. However, the panel stopped short of recommending the FDA halt further use of the duodenoscopes. The FDA convened the meeting of the 16-member advisory panel as part of its response to duodenoscope-related infections that have occurred in at least eight US hospitals. The panel did not endorse any one method to reduce the risk of infection, but several panel members expressed support for sterilization of duodenoscopes. http://www.latimes.com/business/la-fi-scope-infections- 20150516-story.html 28th Annual OR Manager Conference October 7-9, 2015 Gaylord Opryland, Nashville, TN To learn more, go to www.ormanager.com Summer 2015 5