Anesthesiologists often must oversee multiple surgeries. This study evaluated adult patients from 23 US academic and private hospitals who underwent major surgery between 2010, and 2017, to examine anesthesiologist staffing ratios against patient morbidity and mortality. The authors categorized the staffing into four groups based on the number of operations the anesthesiologist was covering. The study found that increased anesthesiologist coverage was associated with greater risk-adjusted morbidity and mortality of surgical patients. Hospitals should consider evaluating anesthesiology staffing to determine potential increased risks.
Zhang D, Gu D, Rao C, et al. BMJ Qual Saf. 2022;Epub Jun 1.
Clinician workload has been linked with poor patient outcomes. This retrospective cohort study assessed the outcomes for patients undergoing coronary artery bypass graft (CABG) performed as a surgeons’ first versus non-first procedure of the day. Findings suggest that prior workload adversely affected outcomes for patients undergoing CABG surgery, with increases in adverse events, myocardial infarction, and stroke compared to first procedures.
Operating room fires are never events that, while rare, still harbor great potential for harm. This review discusses settings prone to surgical fire events, prevention strategies, and care management steps should patients be harmed by an operating room fire.
Awan M, Zagales I, McKenney M, et al. J Surg Educ. 2021;78:e35-e46.
In 2011, the Accreditation Council for Graduate Medical Education (ACGME) updated the duty hour restrictions (DHR) for medical residents to increase resident well-being. This review focused on surgical patient outcomes, resident case volume, and resident quality of life following the implementation of the 2011 update. Results showed DHR did not improve patient safety or surgical resident quality of life. The authors suggest future revisions meant to improve resident well-being not focus solely on hours worked in a single shift or week.
Althoff FC, Wachtendorf LJ, Rostin P, et al. BMJ Qual Saf. 2020;30:678-688.
Prior research suggests that patients undergoing surgery at night are at greater risk for intraoperative adverse events. This retrospective cohort study including over 350,000 adult patients undergoing non-cardiac surgery found that night surgery was associated with an increased risk of postoperative mortality and morbidity. The effect was mediated by potentially preventable factors, including higher blood transfusion rates and more frequent provider handovers.
Joseph A, Khoshkenar A, Taaffe KM, et al. BMJ Qual Saf. 2019;28:276-283.
This direct observation study found that minor disruptions in usual workflow can combine to lead to an adverse event. More than half of the observed disruptions were related to the physical layout of the operating room, suggesting that physical design of operating rooms may affect surgical safety.
Sun E, Mello MM, Rishel CA, et al. JAMA. 2019;321:762-772.
Scheduling overlapping surgeries has raised substantial patient safety concerns. However, research regarding the impact of concurrent surgery on patient outcomes has produced conflicting results. In this multicenter retrospective cohort study, researchers examined the relationship between overlapping surgery and mortality, postoperative complications, and surgery duration for 66,430 surgeries between January 2010 and May 2018. Although overlapping surgery was not significantly associated with an increase in mortality or complications overall, researchers did find a significant association between overlapping surgery and increased length of surgery. An accompanying editorial discusses the role of overlapping surgery in promoting the autonomy of those in surgical training and suggests that further research is needed to settle the debate regarding the impact of overlapping surgery on patient safety.
Gartland RM, Alves K, Brasil NC, et al. Am J Surg. 2019;218:181-191.
This systematic review of the safety of overlapping surgery included 14 studies and did not find differences in 30-day mortality or overall morbidity in overlapping versus nonoverlapping surgery across a range of procedures. Researchers noted a small increase in length of procedure for overlapping surgeries. They conclude that overlapping surgery does not lead to higher risk for morbidity and mortality, despite the controversy associated with this practice.
Dy CJ, Osei DA, Maak TG, et al. J Bone Joint Surg Am. 2018;100:1902-1911.
Overlapping surgery is a controversial practice in which an attending surgeon performs more than one procedure concurrently. This retrospective cohort of overlapping orthopedic surgeries across five academic institutions found no differences between complication rates for overlapping versus nonoverlapping procedures. The authors recommend individualizing decisions regarding overlapping surgeries.
Tseng YW, Vedula S, Malpani A, et al. JAMA Facial Plast Surg. 2019;21:104-109.
This prospective cohort study examined the association between self-rated daytime sleepiness among trainee surgeons and attending surgeon–rated intraoperative technical skill. Higher ratings of sleepiness were associated with worse technical skills, echoing concerns about procedures performed by sleep-deprived surgeons.
Ball JE, Bruyneel L, Aiken LH, et al. Int J Nurs Stud. 2018;78:10-15.
Missed nursing care may result from inadequate nurse staffing and explain the relationship between nurse-to-patient ratios and patient outcomes. Research has shown that higher nurse staffing levels are associated with lower inpatient mortality and that reduced staffing increases the risk for postoperative complications. In this study, investigators examined data from more than 400,000 surgical patients from 300 hospitals in 9 countries as well as survey responses from 26,516 nurses. They found a significant association between nurse staffing and missed nursing care with 30-day risk-adjusted postoperative mortality. The authors conclude that measuring missed nursing care may help identify patients at greater risk for adverse outcomes earlier in their course. A past WebM&M commentary highlighted important issues associated with nurse staffing ratios.
Devitt KS, Kim MJ, Conn LG, et al. Acad Med. 2018;93:324-333.
Duty hour limitations have been controversial due to inconclusive evidence regarding their impact on care outcomes. This review examined the effect of work hour restrictions on surgical residents. The authors found that duty hour restrictions have fallen short of their goals, discuss unintended consequences of the strategy that diminish safety, and call for amended policy solutions to address concerns.
Dahlke AR, Quinn CM, Chung JW, et al. New Engl J Med. 2017;377:192-194.
The 2011 ACGME resident physician duty hour changes shortened the number of consecutive hours interns could work and mandated more time off between shifts. The FIRST trial randomly assigned general surgery residency programs to the standard duty hour policy or to a more flexible duty hour policy. After one year, the trial demonstrated no difference in patient outcomes, but did show that residents assigned to the more flexible schedule were more likely to perceive a negative impact of duty hours on wellbeing. In this follow-up survey study of surgery residents after year 2 of the trial, researchers found that negative perceptions of wellbeing remained higher among those exposed to the flexible duty hour policy, but concerns about wellbeing had decreased.
Yang AD, Chung JW, Dahlke AR, et al. J Am Coll Surg. 2017;224:103-112.
The Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) trial examined residency program response to duty hour rules. This special issue features studies exploring effects of the initial trial including perceptions on the impact of a flexible 80-hour workweek on continuity of care and on physician well-being.
Bilimoria KY, Chung JW, Hedges L, et al. New Engl J Med. 2016;374:713-727.
Resident physician duty hour policies have generated rigorous debate, particularly following the most recent ACGME changes implemented in 2011, which shortened maximum shift lengths for interns and increased time off between shifts. This national study cluster-randomized 118 general surgery residency programs to adhere to current ACGME duty hour policies or to abide by more flexible rules that essentially followed the prior standard of a maximum 80-hour work week. Between these two groups, there were no significant differences in patient outcomes, including death and serious complications. Residents reported similar levels of satisfaction with their overall education quality and their well-being. An accompanying editorial notes that the study authors interpret these results as supporting flexible work-hour rules. Alternatively, the editorial author suggests that this study refutes concerns that the new policy compromises patient safety, and as such there is no compelling reason to backtrack on its implementation.
Bina RW, Lemole M, Dumont TM. J Neurosurg. 2016;124:842-8.
Resident duty hours have resulted in the need for medical specialties to design and implement strategies to fulfill service demands while meeting educational goals. Examining the impact of duty hour restrictions for training neurosurgical residents, this review suggests that work hour limits be applied with unique consideration for the needs of distinct specialties.
Kothari AN, Zapf MAC, Blackwell RH, et al. Ann Surg. 2015;262:683-91.
The weekend effect is a well-documented phenomenon where patients admitted over the weekend have inferior outcomes compared to those admitted on a weekday. This retrospective study utilized the AHRQ Healthcare Cost and Utilization Project database and found that specific factors, such as full adoption of electronic health records, home health programs, and increased nurse-to-bed ratios, were associated with overcoming the weekend effect in hospitals.
Govindarajan A, Urbach DR, Kumar M, et al. N Engl J Med. 2015;373:845-53.
The link between lack of sleep and subsequent medical errors served as an impetus for physician duty-hours reform. In trainee physicians, sleep loss is associated with attentional failures, but little is known about the relationship between attending physician performance and sleep loss. This retrospective cohort study examined outcomes of elective surgical procedures among attending surgeons who had worked after midnight on the previous night versus those who had not. The investigators found no differences in mortality, complications, or readmissions between procedures performed by surgeons with sleep loss compared to those without sleep loss, mirroring results of an earlier simulation study. This may be due to greater technical skill among attending surgeons, or the ability to cancel or postpone elective procedures as needed at times of fatigue. This study included many institutions, physicians, and procedure types, suggesting that short-term sleep deprivation might not be a high-yield safety target for attending surgeons.
Rajaram R, Chung JW, Cohen ME, et al. J Am Coll Surg. 2015;221:748-57.
This pre-post examination of data from the National Surgical Quality Improvement Program found no differences in serious morbidity or mortality within 30 days following surgery across multiple surgical specialties in the 2 years after 2011 ACGME duty hour reform, compared to the last year prior to reform. Although duty hour reform does not appear to be a high-yield strategy for improving surgical outcomes, concerns about worsening procedural skills and increased handoffs leading to patient harm were not borne out in the current data.
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