Cutting Through The Crap

Monday, January 26, 2009

Check, Please


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.

.

10 comments:

Frank Drackman said...

You're confused Sid, cause you're GOOD...and face it, the only surgeons you've actually seen operate since residency were your partners, and then only rarely..As someone whos's witnessed several hundred surgeons ranging from podiatrists, dentists, to Neurosurgeons, there's alot of Butchers out there...

Annie said...

"The reductions in complications reported by the researchers were of equal magnitude in high income and lower income sites in the study. The pilot sites included one hospital in each of the following cities: Seattle; Toronto; London; Auckland, N.Z.; Amman, Jordan; New Delhi; Manila, the Philippines; and Ifakara, Tanzania."

Well, having just had an email debate with Gawande, the PI of the study, and finding him entirely ignorant of nursing standards of care and practice, and then looking at the countries listed as the pilot sites, I think the answer largely lies in the professional nursing standards for care of the interoperative patient.

Where the US has defined the circulator's role and has standardized the curriculum and standards of care and practice for the OR (the AORN is the professional organization which is largely responsible for this), I would be surprised to find that most of the countries had an equivalent body of professional nurses or a recognized nursing role which accords them authority to direct the surgeon and other members of the OR team around breaks in technique and patient safety authority.

Sili said...

I liked this concept when Ben Goldacre talked about it. But of course I have absolutely no baseline to compare it to.

The way you put it, it does indeed sound worrying.

As always it's probably a case of being too busy and businesslike. People are seen as replacable - they're there to do the same thing, after all, right?

Sad.

#1 Dinosaur said...

What you're missing, Sid, is the difference between a fully trained surgeon performing an elective procedure at a community hospital with long-term colleagues and staff, and (possibly emergent) surgery performed in a large training hospital by a team of people who may or may not be familiar with each other and the patient.

Comparing your individual M&M rates to those in the study is just irrelevant.

Yours is similar to the reaction I have when I read about office management strategies that simply don't apply in my office because it's just me. (How the hell am I supposed to designate a "champion" for quality improvement and such when I'm the only one there?) I read enough to see if there IS anything I can take away for my practice, and if not, I think "N/A" and go about my business.

Consider the hypothetical scenario where you are about to perform a procedure -- say something kind of urgent like an appy -- at a hospital where you do not routinely operate. Would it not be a good idea to know precisely who each of those masked/gowned figures is and what they're doing there (so you can kick them out, if nothing else), to know where your x-ray viewbox is if it is not in a location similar to where you are used to looking for it, and perhaps to double check with anesthesia that everything is in order? That is when even you might find such a checklist helpful.

The thing about checklists, though, is that you're not supposed to pick and choose when to use them. You use them all the time, even when you don't think you need them, so that it's part of the routine when you do.

My father is a pilot, and I've flown with him my whole life, reading him the checklist out loud from the time I could read. I once memorized a few items ahead and recited them instead of actually reading them. He gave me hell! And this was a small plane he flew weekly; he could recite the damn thing in his sleep, but that's not how it works.

I know you've flown too. I'll bet you didn't limit your use of a checklist to only when you thought you needed it.

So even though the whole idea may not sound useful specifically to you, it has obviously been shown to be of use in the situations in which it has been used. What more can you ask?

Sid Schwab said...

dino: I think you missed what I was saying. For one, I specifically acknowledged the difference between a community hospital with long-term colleagues....

For another, my point was not to rail against checklists, nor to advocate for not using them. Rather, it was musing (to use a familiar word) about the evident efficacy of this particular list. How is it that such basic (and limited) stuff would make such a difference? I analogized to pilots, in fact, as you know. Were pilots only checking whether the doors were closed, I said, it would seem that such a checklist would miss a lot. And wouldn't work. So I question the data. Is all.

So saying "Comparing your individual M&M rates to those in the study is just irrelevant" is just irrelevant to my point.

John Baldwin, MD FACS said...

I think the study is tremendously flawed. Comparing hospital results in Amman, Ifakara Tanzania, New Delhi and even Manila to Seattle, Toronto and London is like comparing mice and elephants. Dr. Gawande in setting those terms gave himself a head start on showing "improvements" and advanced his curriculum vitae at Harvard on his way up the ladder. Junk. Pure Junk. Checklists do work, but I would bet several of those "hospitals" didn't even have patient ID wrist bands. Junk.

SeaSpray said...

I enjoyed the post and comments.

I have a question for you Dr S and I may have asked you in winter 07, so forgive me for repeating question if I did.

If a patient is going to a teaching hospital because they have a high risk surgery... then how is it that they are better off than in community hospital? if in the teaching hospital..the *high risk* surgery might take longer..thus putting the patient at more risk?

My understanding is I would've have a skilled surgeon who had performed more of them than my regular urologist. But if it is a teaching hospital...does that mean he would be handing me over to someone in training. I know they have to learn and gain experience in all situations... but are they putting the patient more at risk. Do surgeons in a teaching hospital ever do the surgeries totally by themselves and with an experienced partner...or will they have a resident assisting?

Does the patient have any say in it? Or if a patient goes to a teaching hospital... are they automatically agreeing to anything goes?

Sid Schwab said...

Seaspray: I'll interpose answers with your questions:

If a patient is going to a teaching hospital because they have a high risk surgery... then how is it that they are better off than in community hospital? if in the teaching hospital..the *high risk* surgery might take longer..thus putting the patient at more risk?

It entirely depends on the respective hosptials, and, more particularly, the surgeons involved. My comments are pretty general, and maybe even a little hyperbolic.

My understanding is I would've have a skilled surgeon who had performed more of them than my regular urologist. But if it is a teaching hospital...does that mean he would be handing me over to someone in training. I know they have to learn and gain experience in all situations... but are they putting the patient more at risk. Do surgeons in a teaching hospital ever do the surgeries totally by themselves and with an experienced partner...or will they have a resident assisting?

Any and all of the above possibilities exist. Once again, it depends on the situation. In some instances the attending will do the entire operation, in others, will allow the resident to do some parts or most, or all.

Does the patient have any say in it? Or if a patient goes to a teaching hospital... are they automatically agreeing to anything goes?

Theoretically patients agree to anything goes, unless otherwise specified. But they have the right to ask what will happen and to make requests about who is doing what. I suppose it's to some extent a negotiation. But I guess it can come down to this: the surgeon ultimately can say "take it or leave it."

It's been my feeling that for routine stuff, community hospitals are at least as good as, if not better than, the BFH. But for certain specialized services, the referral centers have expertise not available elsewhere. So it's a trade-off. My prejudices are just that, though: my opinions are based on personal experiences. Every situation is unique.

SeaSpray said...

Thank you Dr S. :)

I appreciate the information and if it goes in that direction... I will discuss it with the surgeon ahead of time.

rochesterchiro said...

Interesting that you analogized airplane pilots in your post. In Malcolm Gladwell's book Outliers, he discusses the very topic of plane crashes as a result of cockpit crew not knowing each other well. Turns out, it is a factor.