During the recent AAOS Orthopaedic Patient Safety Summit held in Rosemont, Ill., medical and government healthcare experts assembled to address the importance of surgical safety. Day one of the Summit highlighted key elements needed to establish and maintain surgical safety systems (see “AAOS Hosts Orthopaedic Patient Safety Summit, AAOS Now, September 2012). Moderated by AAOS President John R. Tongue, MD, and Kevin J. Bozic, MD, MBA, chair of the AAOS Council on Research and Quality, day two focused on building successful relationships to enhance orthopaedic surgical safety and specific orthopaedic safety measures.

Gathering, reporting, and sharing data
David Flum, MD, MPH, a gastrointestinal surgeon at the University of Washington, outlined the Washington State Surgical Care Outcomes Assessment Program (SCOAP) for which he is medical director, and the Strong for Surgery initiative.

Begun in 2003, SCOAP is a statewide voluntary initiative to improve surgical quality by reducing variations in outcomes and processes of care at every hospital in the state. Currently, 57 of the approximately 65 hospitals in Washington in which surgery is performed are members of SCOAP, according to Dr. Flum.

“Surgical cases performed at these hospitals—all vascular, bariatric, pediatric, general, and orthopaedic spine surgeries—are under surveillance,” he said.

SCOAP participants receive hospital-level data reports on a regular basis that enable them to compare and track their own processes and outcomes and benchmark themselves against hospitals across the state.

“This kind of surveillance is key to standardization, and it’s also a reality check,” said Dr. Flum. “Physicians who are serious about driving performance improvement need to know how their outcome rates compare to those of their colleagues.

“The information that SCOAP provides to surgeons is granular, relevant, and actionable in the operating room (OR),” he stressed. “As a result, reoperation complication rates in Washington are literally bending the cost curve down. This is the reality—and because it is happening in spine surgery, it can happen in other orthopaedic surgeries as well.”

Working in partnership with SCOAP, the Strong for Surgery initiative promotes the implementation of safety and quality initiatives in the doctor’s office before the patient reaches the OR. Strong for Surgery aims to identify and improve evidence-based practices in the following four target areas:

• Smoking cessation
• Medications (eg, herbal product cessation, opiate reduction, beta blocker continuation after surgery)
• Nutrition
• Glycemic control/diabetes management

“With the Strong for Surgery initiative, we’re trying to create a public health campaign centered around self advocacy and to get every doctor’s office in the state to run through a presurgical checklist with their patients that tackles these four areas,” said Dr. Flum.

Culture counts
Establishing a systematic framework—one that is focused on the patient and driven by physician leadership—is essential for delivering safe and reliable care in the OR, according to Michael Leonard, MD, an anesthesiologist, co-chief medical officer at Pascal Metrics, and adjunct professor of medicine at Duke University.

“It’s important to set a positive tone in the OR and create an environment of psychological safety where every member of the surgical team understands the plan, is encouraged to speak up, and feels respected,” he said. “Teams that think out loud and that think ahead have consistently better outcomes.”

Dr. Leonard noted that because clinical and operational outcomes are directly related to surgical team behavior, disseminating safety culture data can be a useful tool for driving improvement.

“We don’t want people who are working on the same case to have profoundly different experiences. That puts not only the patient, but everyone else in the OR, at risk,” he said. “Team leaders can reflect safety culture data in a very respectful bottom-up fashion and say, for example, ‘You’re all smart, skilled caregivers, what can we do to make this better for you?’”

Additional strategies for building teamwork include structured communications (briefings and debriefings) and assertion/critical language training. Briefings involve all members of the surgical team, who spend at least one minute discussing a procedure before it begins. Similarly, at the end of every procedure, teams should debrief and ask themselves the following three questions:

1. What did we do well here?
2. What did we learn?
3. Is there an opportunity for improvement?

“Debriefing closes the loop and facilitates learning—it is the link between teamwork and improvement,” said Dr. Leonard.

Critical language refers to key words or phrases that, when spoken, require every member of the team to stop and reassess the care plan. For example, “I just need a little clarity” is a very effective critical language phrase that can be used by any member of the team at any time, according to Dr. Leonard.

Safety begins at the unit level
Funded by the Agency for Healthcare Research and Quality (AHRQ), the Surgical Unit-based Safety Program (SUSP) is a 4-year project designed to improve surgical patient safety nationwide. Specifically, SUSP’s goals are twofold: to achieve significant reductions in surgical site infections (SSIs) and other surgical complications, and to achieve significant improvements in patient safety and teamwork culture.

“We all know that patient safety is local—it occurs at the unit level. To make improvements, therefore, we need to change clinical practice and culture one unit or OR at a time,” said James B. Battles, PhD, senior content specialist for the Center for Quality Improvement and Patient Safety at AHRQ.

SUSP is an outgrowth of AHRQ’s Comprehensive Unit-based Safety Program (CUSP), which engages front-line staff and emphasizes safety culture, teamwork, checklists, and risk assessment. In addition, according to Dr. Battles, “everybody plays a role, from the executive suite to housekeeping.”

“It’s the notion that if you are really going to change things, ownership of risk must be shared,” he said.

AHRQ contracted with Johns Hopkins University in September 2011 to help with the implementation of SUSP. SUSP will be applied in a phased manner beginning with 10 states and 10 hospitals in each participating state and then spread to all states, Puerto Rico, and the District of Columbia. Individual hospitals will participate for 2 years; the program is designed to end in August 2015.

Hyperglycemia and SSIs
William T. Obremskey, MD, MPH, chair of the Orthopaedic Trauma Association’s Evidence-based Medicine Committee, told the audience that despite what general surgeons have known for some time—that hyperglycemia is a risk factor for SSIs—very little information about diabetes and hyperglycemia exists in the orthopaedic literature. He and his colleagues conducted two retrospective reviews to evaluate the association between stress-induced hyperglycemia—as determined by blood glucose values and the hyperglycemic index—and infectious complications in critically ill, nondiabetic orthopaedic trauma patients and patients with isolated orthopaedic injuries requiring internal fixation.

“This was a fairly narrow group of patients—these adult patients with isolated orthopaedic injuries with and without an ICU stay and who required surgical intervention but did not have any other systematic injuries or a history of diabetes,” explained Dr. Obremskey.

Based on their study, stress-induced hyperglycemia is a significant independent risk factor for SSIs in nondiabetic orthopaedic trauma patients. They recommended that perioperative blood glucose monitoring should be considered in this patient population.

Safety in the ambulatory setting
Despite very low reported rates of infection, deep vein thrombosis, and unexpected hospital admissions, complications do occur—and are likely underreported—in orthopaedic ambulatory surgery centers, according to Dwight W. Burney III, MD, chair of the AAOS Communication Skills Mentoring Program Project Team.

Dr. Burney noted that the safety culture in outpatient surgical centers can be deficient, especially when the centers depend on getting patients in and out quickly to maintain profit margins. Potential causes for error include sterile processing failures, medication errors, scheduling errors, a lack of robust “time out” adherence, and failure to follow established policies/procedures.

Dr. Burney advocates using a safety culture assessment tool to identify gaps and areas for improvement throughout the organization and at the unit level. In addition, he said, safety culture assessments can help do the following:

• Establish a safety culture baseline
• Enable benchmarking
• Engage direct care teams
• Stimulate open communication
• Provide physicians and administrators with an important reality check

“To me, this is one of the critical take-home messages of this Summit. If you don’t measure your safety culture or climate, then you really have no idea where to start as far as this journey is concerned,” he said.

Maureen Leahy is assistant managing editor of AAOS Now. She can be reached at leahy@aaos.org

About the Summit
The 2012 AAOS Orthopaedic Patient Safety Summit, held Aug. 5–6, 2012, in Rosemont, Ill., brought together 19 orthopaedic organizations, as well as representatives from nursing, government, and facility (hospital and surgical center) groups to address the issue of surgical safety. Chaired by AAOS Patient Safety Committee Chair William J. Robb III, MD, the 2-day event focused on key elements needed to establish and maintain surgical safety systems and specific orthopaedic surgical safety measures.

For more information on patient and surgical safety, visit the AAOS Patient Safety Committee website, www.aaos.org/patientsafety