Monday, January 26, 2009
This is about one of those surgical papers that makes me scratch my head. Or shake it, or press on it from both sides. Can it really be true? If so, why?
It reminds me of another one, a few years back, that touted using a laser in performing a mastectomy. Since we started doing it, the authors said without evident embarrassment, our transfusion rate decreased from four units per case to two, and our hospital stays went from nine to five days. Wow. At the time I'd done several outpatient mastectomies (at the patients' request, may I add); rarely did any of my patients need or want to stay in the hospital longer than a day or two; and I never even ordered blood for the operation, much less used it. Who the hell were those guys, and what the hell kind of surgeons were they?
It's with that in mind that I mention a recent and much talked-about report which shows an impressive and universal (throughout the study hospitals) lessening of surgical deaths and complications by the use of a simple checklist before and after the operation. I certainly don't disapprove of such checklists; variations thereon are more or less universal in American operating rooms nowadays. Where I come up a little short, understanding/explanation-wise, is here: first, the "major complication" rate before the study was 11%, and death rate was 1.5%. With the checklist, they diminished to 7% and .8%. Still pretty high, if you ask me: if I'd had numbers like the pre-study ones in my practice, I'd have been kicked off staff. Summarily. With the post-study ones, I might be on probation. Second, the checklist is so rudimentary that I'm at a loss to understand why it works. And, like some, I question whether it's even true. But there it is.
Without doubt, taking care to eliminate wrong operation or wrong-sided surgery is essential (even though the incidence is very low.) Counting sponges and instruments at the end of a case is routine, and has been approximately forever. (The second link indicates that compliance before the study was only 34%; even more remarkably, during the study it was only 57%! Once again: who are these people?) Similarly, if the anesthesia personnel aren't making sure they have what they need ahead of time, and if the surgeon hasn't thought about whether s/he needs blood available or antibiotics administered, there's something wrong. But there's nothing wrong with checking to be sure.
In the first link, one can watch (not-particularly-gripping) video. It provides some clues. Part of the routine is to introduce the members of the team to one another, which hardly seems protective of anything, per se, but suggests a group of people not used to working together. And the surgeon mentions that the operation, a routine hernia, will probably be under an hour. Probably? How about fifteen or twenty minutes? Both of those factors suggest a training program, where there's typically no continuity of personnel, and where operations take longer than "normal." Each of those contributes to increased complication rates. As does the fact that in teaching settings there are usually two or three extraneous people scrubbed in, peering into the hole, scratching their asses, etc.
You'd think that in taking a right turn from my usual targets, I'd have some sort of wisdom to impart at this point (although, one might ask, why start now?); I really don't. I applaud all attempts to improve the quality of health-care delivery; it's just that this particular approach puzzles me. Comparably, it's as if all a pilot were required to do before take-off is to make sure the crew knew each other, confirmed the destination and that the doors were shut.
If that makes a difference, we're in bigger trouble than I thought.
Or maybe I'm missing something.