Study outlines method for applying principle to practice
In 2016, the American College of Surgeons (ACS) released a statement of principles that, among other things, addresses potential surgical scenarios in which the primary attending surgeon may have completed "key or critical" elements of an operation, allowing another qualified practitioner to complete noncritical components.

The ACS statement defines the term critical in the following manner:

The "critical" or "key" portions of an operation are those stages when essential technical expertise and surgical judgment are necessary to achieve an optimal patient outcome. The critical or key portions of an operation are determined by the primary attending surgeon.

Various entities have since recommended that surgical departments develop their own guidelines to codify the critical components of particular procedures, while continuing to allow leeway for the discretion of individual surgeons.

With that in mind, Christopher J. Dy, MD, MPH, and his colleagues attempted to determine the critical portions of three procedures: carpal tunnel release, ulnar nerve transposition, and open reduction and internal fixation of distal radius fractures.
"Our results may not be generalizable across practices," Dr. Dy cautioned. "They apply to the individuals in our practice who participated in the process. The qualifications of the assistant may also alter what is deemed to be critical."

An iterative approach
Dr. Dy and nine other orthopaedic faculty and fellows used an iterative, Delphi panel approach consisting of the following steps:

1. An initial, in-person meeting to agree on the steps in the procedure.
2. An online round in which participants rated all procedure steps on a scale from 1 (least critical) to 9 (most critical).
3. Sharing via email the results of first-round rating.
4. A second online round in which participants again rated all procedure steps.
5. An in-person meeting to discuss areas of disagreement or ambivalent ("somewhat critical") ratings.
6. A final online round in which participants dichotomously rated each step as "critical" or "not critical."

In the final stage, a component of a procedure was considered to have achieved consensus if 8 of the 10 participating surgeons agreed.

"For carpal tunnel release, we initially noted substantial variation in responses," explained Dr. Dy. "Across the various stages, we eventually achieved consensus on everything, determining that the only critical component of carpal tunnel release in our practice was division of the transverse carpal ligament" (Table 1).

For ulnar nerve transposition, members of the panel did not reach consensus regarding identification of the medial antebrachial cutaneous nerve (Table 2). However, they unanimously agreed that the following steps are critical:

• identification and decompression of the ulnar nerve
• mobilization of the ulnar nerve
• preparation of transposition site, excision of the intermuscular septum
• anterior transposition of the ulnar nerve
• assessment of course of the transposed nerve, including release of any newfound points of compression

For distal radius fracture fixation, members of the panel failed to find consensus on clinical assessment of joint stability, primarily regarding the distal radial ulnar joint (Table 3). However, they identified fracture reduction, skeletal fixation, and fluoroscopic evaluation of fracture reduction and fixation as critical steps.

A framework for the future
Again, Dr. Dy noted that identification of critical components for the three procedures may only be applicable to a single practice, and most relevant at the time of the panel process.

"However, it helps us manage our surgical workflow," he noted, "and our methodology can provide a framework for other organizations that may wish to undertake a similar determination.

"We learned that getting to consensus is challenging, even for steps that we think may be simple and routine," he continued. "Adding all of the procedures together, in round one we had a high level of disagreement: 18 out of 24 steps. But eventually we achieved consensus on 22 of the 24 steps. We agreed on carpal tunnel; we agreed on almost everything for ulnar nerve; and we agreed on almost everything for open reduction of distal radius fractures. We leave the components in which we lacked consensus to the discretion of the attending surgeon."

A study based on this presentation is under review for publication in The Journal of Bone & Joint Surgery.

Dr. Dy's coauthors are Alison Antes, PhD; Daniel Osei, MD, MSC; Charles A. Goldfarb, MD; and James DuBois, PhD.

Peter Pollack is the electronic content specialist for AAOS Now. He can be reached at ppollack@aaos.org.

Bottom Line

• Surgical departments have been encouraged to develop their own guidelines regarding the critical components of particular procedures.
• In this study, an iterative, Delphi methodology allowed the surgical team to achieve consensus regarding critical portions of all but 2 of 24 components across three procedures.
• The critical components of a procedure are often practice-specific and may not apply to other surgical teams.
• For components in which consensus was not achieved, final discretion is left to the attending surgeon.