Dept Of Anesthesiology & Critical Care, University Of Pennsylvania School Of Medicine

PENN MEDICINE In Haiti -- dispatch 1

PENN MEDICINE has established a mission in Haiti.  Working though the organization Partners in Health (PIH) an organization that has a strong, ongoing presence in that country, the first team from PENN MEDICINE is already in Haiti.  Members of the Department of Anesthesiology and Critical Care are part of that team which consists of orthopedic surgeons, trauma surgeons, intensivists, and nurses with experience in critical care, post anesthesia care, and operating room care.  The Team Leader, Michael Ashburn, M.D., MPH, Professor of Anesthesiology and Critical Care, sent us the following e-mail dated January 25, 2010, 20:36

Folks:

 

We are now safe and sound in Port au Prince. We are in a secure tent city. There is water here, and we ate well on the plane. We gave our remaining food away to Haitians and elected to survive on Power bars until we reach the hospital sometime tomorrow.

 

The drive in from the airport was interesting. Only a few lights were on due to limited power (mainly from generators). People were out everywhere on the streets as they are afraid to sleep in their homes. Some food vendors were out, especially near the airport. There is tight security near the UN headquarters which is now beside the airport.

 

Devastation is everywhere.  While some  buildings are standing, every block has damaged houses, some are just piles of rubble.

 

The Haitian people we have met are very grateful and are gentle, polite people.   I find this amazing considering the state of life they find themselves in.

 

All of our gear is still with us. We will sleep with the important gear, and get up early to make sure another team is not tempted.  No worries; the drugs are under the watchful eyes of the ladies and the ortho supplies are guarded by the ortho docs.  They now snarl at anyone who walks by their tent. Ha!

 

There are teams from several other institutions here; most of them are working in the city. They report improving supplies, but increasing frustration over poor collaboration between groups as well as critical needs such as no working autoclave in the Port au Prince major hospital. They say that they still have several hundred patients with ortho injuries, such as open fractures, waiting for surgery.

 

The ride to the hospital where we will work is expected to take 4 hours due to the road conditions.  We do not have a departure time but are hopeful it will be fairly early to allow us to start working tomorrow and to avoid travel in the heat of the day.

 

Until tomorrow,

 

Michael

 

DSS:  I made a few light edits – added some verbs to convert phrases to sentences and clarified some of the abbreviations; otherwise this e-mail is as Dr. Ashburn sent it.

Patients have better outcomes as the surgical team shows higher levels of information sharing during surgery and handoffs

This is a very difficult paper to present because of the complex data analysis but the findings are very interesting.  This work suggests that even complex behavioral interactions can be examined.  Basically the authors had trained observers record predefined elements of team behavior during 293 general surgery operations at 2 medical centers and 2 ambulatory surgery centers affiliated with the Kaiser Foundation Health Plan.  After discharge, a medical record review for 30 day postsurgical outcomes was performed by a trained reviewer who did not know the results of the OR observations.  The markers of team behavior used were as follows: Briefing – situation/relevant background is shared including patient name, procedure, site/side, plans are stated, questions are asked, and ongoing monitoring and communication is encouraged.  Information sharing – Information is shared, intentions are stated, mutual respect is evident, social conversations are appropriate.  Inquiry – Members of the team ask for input and other relevant information.  Vigilance and awareness – Tasks are prioritized, attention is focused, patient/equipment monitoring is maintained, tunnel vision is avoided, and red flags are identified.     The observers scored the surgical teams on a zero to four scale (never observed to frequently observed) during induction of anesthesia, intraoperatively and at handoff to the post operative care givers.  The ratings were used to create a univariate behavioral marker called the Behavioral Marker Risk Index (BMRI) with values ranging from 0 to 1.  A BMRI of zero represented good team behavior and 1 represented poor team behavior.

  The authors found that the patients in this study were mostly middle aged with low to intermediate risk based on the ASA and the American College of Cardiology/American Heart Association classifications.  Only four patients were ASA 4 and none were ASA 5.  More than half (54%) of the procedures had “no complications” as the outcome rating but 24% had one or more post operative indicators of potential harm, 16 % had a minor complication, and 4% had a major complication.  Three patients in the last group had an outcome of death or disability.  In about 25% of the patients the BMRI was more than 0.50 indicating a high proportion of operative phases with infrequent observations of good team behavior.   After significant data manipulation the authors found a strong association between teamwork behaviors and death or a major complication; specifically when teamwork behaviors were relatively infrequent the patient was more likely to experience death or a major complication.  Clearly a study of this complexity has limitations as acknowledged by the authors.  First, it is observational and does not provide mechanism.  Second, it does not allow a determination of which behaviors, at which times during the procedure would be the most beneficial with respect to minimizing complications or death.   Mazzocco K et al: Surgical team behaviors and patient outcomes.  Am J Surg 2009;197:678-685

 

David S. Smith, M.D., Ph.D.

Indwelling Urinary Catheter presence for more than 2 days post operatively is associated with a higher risk of urinary tract infections

Wald et al reported a retrospective cohort study of 35,904 Medicare patients from 2,965 United States acute care hospitals who underwent major surgery (coronary artery bypass and other open cardiac operations, vascular surgery, general abdominal colorectal surgery, hip or knee joint arthroplasty) during 2001.  Eighty six percent of patients undergoing these major operations had perioperative indwelling urinary catheters.  Of these, 50% had their catheters for longer than 2 days post operatively.  Those patients with catheters for more than 2 days were twice as likely to a develop urinary tract infection than patients with catheterization of 2 days or less.  In addition post operative catheterization greater than 2 days was also associated with increased 30 day mortality, and decreased likelihood to be discharged home.  In their introduction the authors note that the risk of urinary tract infection is 5 to 10% per catheter day beyond the first 48 hours.  In their discussion the authors note that “among patients with urinary tract infection an estimated 3.6% will develop bacteremia – a condition that adds significantly to length of stay, and is a risk factor for death among elderly patients.”  Wald HL et al: Indwelling urinary catheter use in the postoperative period.  Analysis of the National Surgical Infection Prevention Project Data.  Arch Surg 2008;143:551-557

 

David S. Smith, M.D., Ph.D.