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Management News The Independent Source of News for Operating Room Managers, Supply Chain Professionals & C Suite

Volume 7 • June 2022

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Robotic Surgery and Sterilization Issues App Measures OR Outcomes in Dollars Preventing SSIs After Colorectal Surgery Brought to you by the publisher of

GENERAL SURGERY NEWS

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TABLE OF CONTENTS

BULLETIN BOARD

4 New App Simulates OR Decision Making, Measures Outcomes in Dollars 6 Cost of Early Cholecystectomy in Mild Gallstone Pancreatitis Open, Laparoscopic or Robotic for Inguinal Hernia Repair?

8 As Robot Technology Surges, Sterilization Lags Behind 12 Surgery Is a Contact Sport 16 Keeping Surgical Patients Safe From Unintended Harm 18 Multidisciplinary Approach Best for Managing Chronic Wounds

Trending Articles Online Read the most-viewed online-only articles on ormanagement.net.

1. Experts Discuss Hot Topics in General Surgery 2. Robotic Surgery in Oncology Gaining Traction 3. The State of Telemedicine in Surgery 4. Treating Parastomal Hernias: Approaches to a Vexing Problem

Heard Here First Using an innovation the researchers call a “taxi meter,” the app also displays the cost of the procedure on a minute-by-minute basis. Using a baseline OR cost of $100 per minute, it illustrates the financial impacts of clinicians’ decisions, such as the time to complete recovery from deep neuromuscular blockade.

—“New App Simulates OR Decision Making, Measures Outcomes in Dollars,” page 4

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20 Novel Research Shedding Light on Fungal Infections 21 Colorectal Surgery Experts Advise on Preventing SSIs EDITORIAL STAFF Paul Bufano Managing Editor pbufano@mcmahonmed.com Kevin Horty Group Publication Editor khorty@mcmahonmed.com

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MD

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OR Management News • Volume 7 • June 2022

3

TEC HN O LO GY

New App Simulates OR Decision Making, Measures Outcomes in Dollars actions throughout the simulated case.

This tool allows clinicians to go back he development of a simulated in time and undo mid-case events, and anesthesia app may help anestheeven make a different decision without siologists save both time and money in restarting the scenario. The models then their practice in the near future. forecast relevant parameters for each new Researchers at the University of Floruser interaction for up to three hours. ida College of Medicine, in Gainesville, Finally, a scrolling time line gives users said the panoramic, screen-based simuthe opportunity to jump forward and lator is particularly adept at assessing the backward in time, either to skip periods cost of neuromuscular blockade admin- The simulated anesthesia app could of inactivity or to undo a previous action. istration, monitoring and reversal, while save both time and money for anesthesia It is this kind of functionality, Dr. Lamalso considering drug costs and the cost practices. potang explained, that allows users to see of associated OR time. the potential costs and savings inherent “Given the continued incidence of residual postoperative neu- in using a particular neuromuscular blockade reversal strategy. romuscular blockade, along with the fairly recent FDA approvUsing an innovation the researchers call a “taxi meter,” the app al of sugammadex, there is renewed interest in fine-tuning the also displays the cost of the procedure on a minute-by-minute monitoring and reversal of neuromuscular blockade,” said Sam- basis. Using a baseline OR cost of $100 per minute, it illustrates sun Lampotang, PhD, the Joachim S. Gravenstein Professor the financial impacts of clinicians’ decisions, such as the time to of Anesthesiology and a professor of urology at the institu- complete recovery from deep neuromuscular blockade. tion. With this in mind, Dr. Lampotang, senior author Nikolaus “This is where sugammadex shines,” Dr. Lampotang said.

Gravenstein, MD, and their colleagues developed the interactive “Using a typical simulated patient, we assume that a drug like app, which he said was specifically designed to enable users to rocuronium will take considerably more than 40 minutes to clear practice the administration, monitoring and reversal of neuro- out of the patient’s system on its own. Using neostigmine or glymuscular blockade. copyrrolate, that drops to approximately 20 minutes. But if you The app was built in Adobe Director, a now-discontinued use sugammadex, you’re going to reverse the patient in a minauthoring platform for multimedia applications, to simulate vari- ute or two. So you’ve saved 18 minutes, which we calculate as an ous anesthesia activities in the OR. Although the app uses only immediate savings of $1,800.” one computer screen to simulate the entire OR environment, The app, which was presented at the 2022 annual meetusers can pan around the entire room. ing of the Society for Technology in Anesthesia, is ultimately A range of simulated activities and equipment are represented, much more focused on helping clinicians practice neuromuscuincluding video clips of intubation and laparoscopy. The app also lar blockade and its reversal than on optimizing practice patterns. simulates such equipment as a neuromuscular blockade moni- The researchers verified the app by comparing the output of each tor, an anesthesia machine with user-adjustable flow meters and model with its source material, such as the package insert. It was vaporizers, gas analysis (which models breathing circuit dynamics found that drug concentrations, clinical durations and recovery like wash-in and washout), and physiologic monitoring. times on the app matched these materials. Anecdotally, anesthePharmacokinetic and pharmacodynamic parameters from offi- siologists who used the app said its output matched their clinicial package inserts were used by the developers to mimic (via cal practice. compartmental models) a host of related drugs, including sevo“Our goal in developing the app was not to optimize practice flurane, isoflurane, glycopyrrolate, neostigmine, succinylcho- patterns around neuromuscular blockade, but to offer our cliniline, fentanyl, propofol, rocuronium and sugammadex. These cians more experience,” Dr. Lampotang explained. “So in that inserts were included in the app as searchable PDF files. The sense, there was no agenda. Now that we know it mimics actuapp also displays scrolling time plots of drug concentrations and al practice, though, clinicians can use it to see the effects of their circuit gas concentrations, both of which respond to such user decisions.” actions as drug administration, and provide line of sight of future The researchers are exploring the possibility of repurposing the concentrations. app to include the carbon footprint of each item or consumable used during an anesthetic. A six-minute video of the app can be Navigating the Simulation ■ viewed at bit.ly/3LFutj0.

To help users assess the clinical and financial effects of their actions, the app incorporates an event log, which captures all user Dr. Lampotang reported no relevant financial disclosures.

By MICHAEL VLESSIDES

T

4

OR Management News • Volume 7 • June 2022

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CLIN IC A L NE WS

Cost of Early Cholecystectomy in Mild Gallstone Pancreatitis

By IAN KRATZKE, MD

n the Journal of the American College of Surgeons, Isbell et al published results from a secondary analysis of the Gallstone PANC Trial (Gallstone Pancreatitis: Admission vs Normal Cholecystectomy) (J Am Coll Surg 2021;233[4]:517525.e1). That trial was a single-center, randomized controlled trial evaluating the 30-day hospital length of stay (LOS) among patients with mild gallstone pancreatitis who receive early (≤24 hours of admission) cholecystectomy versus cholecystectomy after clinical resolution of pancreatitis.

This trial found early cholecystectomy was associated with a shorter LOS but an increase in non‒life-threatening complications. It should be noted, however, that patients with a high likelihood of choledocholithiasis (bilirubin >1.8 mg/dL; bile duct >6 mm) were excluded from the study because they were more likely to receive preoperative endoscopic retrograde cholangiopancreatography (ERCP).

This retrospective cost analysis used patient data from the Gallstone PANC Trial and collected additional data from the hospital accounting system related to follow-up clinic or emergency department visits, as well as 90-day readmission and discharge data. Costs were adjusted to 2020 U.S. dollars, and analyses were considered from a healthcare system perspective using frequentist and Bayesian multivariate regression models.

There were 49 patients in the early cholecystectomy group and 48 patients in the control arm. The authors found that within the

I

90-day period, patients treated with early cholecystectomy had a significantly lower rate of preoperative ERCP (0 vs.

6; P=0.01) and had a mean difference of 0.96 fewer days of hospitalization (95% CI, ‒1.91 to 0.00; P=0.05).

These results were calculated to be an average reduction in cost by 8% and translated to $1,216 in savings per patient. The probability that patients receiving early cholecystectomy would incur reduced costs was found to be 81%. Four patients across the groups were found to have complications, all non–life-threatening.

This study adds to the findings of the Gallstone PANC Trial by evaluating the hospital LOS up to 90 days post-discharge and including an evaluation of total costs within this same period stratified by the timing of cholecystectomy. Although the difference in LOS was found to be only approximately one day, given the incidence of patients presenting with mild gallstone pancreatitis, this reduction in time and resources could translate to millions of dollars annually in the United States, as well as a faster return to normal activity for patients. However, the small sample size from a single center of a specific subset of patients limits the generalizability of this study. As such, additional data may be needed to capture the incidence of complications with early cholecystectomy compared with the benefit of reducing hospital LOS. Regardless, this study speaks to the need for surgeons to consider the severity of pancreatitis when determining the timing of cholecystectomy.

Open, Laparoscopic or Robotic for Inguinal Hernia Repair?

By IAN KRATZKE, MD

n the Annals of Surgery, Glasgow et al published a cost analysis that compared the value of three approaches to inguinal hernia repair (2021;274[4]:572-580). This was a single-center, retrospective study of patients undergoing unilateral inguinal hernia repair with an open, a laparoscopic or a robotic technique. Current Procedural Terminology (CPT) codes were used to identify procedures performed by 14 surgeons, all of whom were experienced in the surgical approach used.

Value was defined as quality divided by cost, in which quality (based on recurrence rate) was assumed to be equivalent for each repair, and cost was calculated as both fixed (basic OR equipment [e.g., surgical instruments, laparoscopic systems

I

6

and robotic systems use and maintenance]) and variable (“materials,” which included supplies used perioperatively; “providers,” which included surgeon and anesthesiologist time; and “overhead,” which included cost per minute of OR time and factors in support staff labor). Cost data were compared among approaches using linear modeling normalized to the open approach. The study involved 100 consecutive patients undergoing each type of operation.

The authors found that for fixed costs, the laparoscopic inguinal hernia repair was 1.03 times more expensive than an open repair, and the robotic repair was 3.18 times more costly than open. For variable costs, laparoscopic repair was not significantly higher than the open approach

OR Management News • Volume 7 • June 2022

(1.02 times; P=0.78), but robotic repair was 2.11 times higher than open (P<0.001) and 2.06 times higher than laparoscopic. Within these costs, material costs for laparoscopic repair were higher (1.5 times; P<0.001) than open repair, but overhead costs were lower (0.81 times; P=0.003) than for an open repair, due to the shorter mean calculated operating time of laparoscopic repair compared with open (82 vs. 107 minutes). All domains of variable costs for robotic repair were higher than for the other approaches.

Taking all costs and considering the revenues associated with each approach, the authors found the laparoscopic inguinal hernia repair had a gross margin 4% higher than the open approach, while continued on page 10

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P E RSP ECTIVE

As Robot Technology Surges, Sterilization Lags Behind

By DAVID TAYLOR, MSN, RN, CNOR

W

hether you use robotic-assisted surgery (RAS) or not, this technology has undoubtedly advanced the field of surgery. It can increase surgeon visualization, accuracy and performance, and reduce patient incision size, blood loss and hospital length of stay. According to Intuitive Surgical, more than 5,500 da Vinci systems have been installed in 67 countries around the world, and more than 10 million robotic-assisted surgical procedures have been performed using its systems. That number is only going to grow, especially with expansion into the ambulatory surgery setting.

RAS improves on both laparoscopic and open techniques by combining a minimally invasive approach with the supplementary benefit of a 3D, magnified image. It also allows for improved ergonomics and dexterity compared with traditional approaches because it’s designed to replicate a surgeon’s natural movements, but with more precision.

Nevertheless, the investment in robust robotic programs is generally still lacking in healthcare organizations. As such, it’s critical that surgeons and OR leadership work with their administrators to not only define their hospital’s robotic needs, but also to insist they commit to the infrastructure needed to support these efforts.

This may include a program that provides the necessary components to train surgical staff and provide the financing for critical support areas, such as central sterile processing (CSP).

Along with those requirements, robotic systems are a big investment that can exceed $2 million and the spending doesn’t stop there. RAS also requires limited-use consumables, such as surgical arms, staplers and other accessories. These ongoing costs can range from hundreds to thousands of dollars, and will vary greatly with the type of robot and the surgical specialty using the device.

These expensive pieces of equipment must be handled thoughtfully, not just in the surgical suite, but also in CSP to protect the facility’s asset and maintain the safety of patients. Over the past decade, CSP departments (CSPDs) across the country have encountered numerous challenges regarding routine surgical instrumentation. In my experience, it’s rare to find a CSPD that has the equipment and skill to keep up with fast-paced changes occurring in surgery.

The problem is that instruments have become more complex in their design. These devices can have multiple articulation points that are controlled by wires and pulley systems, which can easily become contaminated with blood and body tissue during a 8

OR Management News • Volume 7 • June 2022

surgical procedure. Although CSP can attempt to clean around the wires and cannulas, it’s extremely difficult because these consumables cannot be taken apart, making it hard to visualize every aspect. Unfortunately, manufacturers rarely design an instrument with reprocessing in mind. It’s only after the devices are engineered that they attempt to replicate the cleaning process and create their manufacturer’s instructions for use (IFU).

The last thing administrators want to hear after spending millions of dollars on a new robot is that CSP needs more money (sometimes upwards of $150,000) to purchase the right equipment, as well as the time it will take to train their staff, and ongoing costs for the proper tools and chemicals used in the cleaning process.

Even so, many IFUs used today are vague and use nonspecific language, which leaves a great deal of the responsibility to the CSP staff. Each instrument may require different steps or chemicals that can add time to the process. Because time is money, surgery departments often push CSP to quickly turn over instruments and sets, and this can lead to shortcuts and mistakes made.

The bottom line is many healthcare organizations have not considered what’s needed to properly clean, reprocess and effectively sterilize limited-use consumables. The last thing administrators want to hear after spending millions of dollars on a new robot is that CSP needs more money (sometimes upwards of $150,000) to purchase the right equipment, as well as the time it will take to train their staff, and ongoing costs for the proper tools and chemicals used in the cleaning process.

The Cleaning Process: Necessary Steps All instrumentation that passes through the CSPD must go through multiple steps to ensure proper cleaning and sterilization. Manual washing and brushing are inconsistent even when best practices are followed. No one can guarantee all areas of a robotic instrument, including the crevasse and interior lumens, are cleaned correctly.

The goal of reprocessing is to remove all debris and bioburden from the instruments so sterilization of all surfaces can occur.

Soil level, brush size, brushing repetition and/or time, as well as human error all play parts. The likelihood of every instrument continued on page 10

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Robot Sterilization continued from page 8

being consistently cleaned to the same level is low, which can increase the probability of bioburden remaining on or in the instrument. Removing all bioburden and soil is critical because they can lead to instrument damage and malfunctions, which can cause surgical delays, patient exposures, injuries and surgical site infections, and/or place healthcare workers at risk for exposure to healthcare-acquired diseases.

The good news is the challenges CSPDs face when reprocessing these instruments can be mitigated. First, point-of-use cleaning in the OR is a critical initial step. Training OR staff and supplying them with all necessary materials and equipment for point-ofuse in each case cart will help this process. Supplies may include flushing solution, syringes, adapters and other point-of-use treatment products. Keeping the soiled instruments damp begins to loosen bioburden, which in turn quickens the cleaning process.

When instruments arrive in the CSPD, technicians need the right tools to do their job. For example, reassembly stations and lighted magnification at the sink enable technicians to see residual soil that otherwise may be missed with the naked eye. Having the correct brushes, syringes and attachment accessories to scrub and flush fluids through channels helps with cleaning and can prevent internal damage from occurring. Furthermore, ultrasonic cleaners validated and designed to meet the cleaning parameters outlined in the IFU for reprocessing should always be used. Robotic instrument channels may be too small to accommodate manual brushing, so it is critical that cleaning solution is flushed through the channels during ultrasonication. For reference, an ultrasonic cleaner is an automated processor that uses a combination of

Hernia Repair continued from page 6

the robotic repair’s margin was only 4% of the open repair margin. This led to a final calculation of the value of each minimally invasive repair compared with the open approach as follows: Laparoscopic repairs reduce value by 3%, whereas robotic repairs reduce value by 69%.

The authors conducted a well-done cost analysis of a highly debated topic regarding value, and their findings echo those of cost analyses by Charles et al (Surg Endosc 2018;32[4]:2131-2136) and Abdelmoaty et al (Surg Endosc 2019;33[10]:3436-3443).

Based on this study, more expensive technology for unilateral inguinal hernia repair is associated with increased cost. However, limitations in this cost analysis include selection bias and the assumption that quality is equal among all three repairs for 10

high-powered washing actions (ultrasonics, enzymatic soaks, agitation, exterior and interior sprays, and an air injection bubble cavitation stream) that aids in the removal of bioburden.

The final step in the cleaning process is thermal disinfection.

This ensures instruments are safe to handle without the use of personal protective equipment in the assembly area. Unfortunately, many ultrasonic cleaners currently in use aren’t capable of thermal disinfection and require the additional step of placing instruments into a basket and processing them through the automated washer disinfector. Although this may seem like a good idea, it can pose serious risks if the ultrasonic step is skipped. Not only can bioburden remain, but the cleaning solutions used during these processes can become trapped in the channels of these instruments during the cleaning cycle. The instrument may be thermally treated, but chemical residues may build up and interfere with sterilization.

Conclusion Advancements in surgery are here to stay. They will continue to evolve and advance therapeutic techniques, improving the lives of our patients. Consistent reprocessing is critical for every instrument set; and with the proper equipment, planning, training and quality control measures in place, CSPDs will be better able to mitigate risks and support the unique processing needs of all the new advancements to come. Ultimately, organizations that lack the right cleaning and disinfecting apparatuses can impede their RAS program, and more importantly harm the patients they are trying to help.

■ David L. Taylor III, MSN, RN, CNOR, is the principal of Resolute Advisory Group LLC, a health care consulting firm in San Antonio.

Mr. Taylor is a board member of OR Management News.

all inguinal hernias. Due to the consecutive nature of procedure selection, rather than a randomized controlled trial, the reason for selecting each method is unclear and may introduce bias in the findings. Although the authors assume the quality of repair is equivalent for all three techniques, minimally invasive approaches in certain patient populations (morbidly obese, women, bilateral hernia and recurrent hernia after prior open repair), have been recommended due to their reduced recurrence and complication rate. Additionally, surgical team factors, such as the participation of a trainee and staff experience, can affect the operative case time, and thus the variable costs.

As of 2015, 46% of surgeons provide only an open approach to inguinal hernia repair. Preperitoneal dissection should be part of a surgeon’s armamentarium for inguinal hernia repair and provides value to the patient and the hospital system. It is

OR Management News • Volume 7 • June 2022

unclear whether robotic surgery allows for an increased adoption of the preperitoneal repair, but based on current evidence from Kudsi et al (Hernia 2021;25[3]:755-764), the learning curve for robotic repair is much shorter than for the laparoscopic approach.

Surgeon experience, patient selection, surgical team factors and operating equipment preferences affect procedure costs, especially given the relatively small cost-related differences between open and laparoscopic approaches. Nevertheless, as robotic surgery continues to expand in use, surgeons should recognize the potential increased costs associated with the technology.

■ These articles appeared in General Surgery News, Journal Watch column, April 2022.

The column editor of Journal Watch is Arielle Perez, MD, MPH, MS, a surgeon at the University of North Carolina School of Medicine, in Chapel Hill.

FE ATUR E

A Guide on Injury Prevention for Surgeons

By TALAR TEJIRIAN, MD, FACS

12

OR Management News • Volume 7 • June 2022

FEAT URE

I

t was several months after my C5-C6 spine disk replacement surgery when I learned that it i is commonplace for surgeons to have C5-C7 cervical spine problems. Interesting. Why had I never heard of this before?

Not once during training, during my time as an attending or after participating in numerous surgical conferences had I ever come across this information. But clear as day, to others, my problem was not unique. I was just another surgeon suffering the same spine problems that so many before me had suffered. If I am not the first, then I surely will not be the last.

We must stop ignoring surgeons’ physical health and actively promote prevention.

It was this realization that jogged my memory from surgical internship. “Surgery is a contact sport.” Almost 20 years ago, I first heard this statement from my senior resident. It was said many times throughout my residency, and I probably repeated it to interns and junior residents as I progressed in my training. It is possible that many of you have also heard this statement or repeated it to others. But until now, I did not fully comprehend what it meant.

Surgery is a mentally, emotionally and physically demanding profession. We spend countless hours in the OR for many years acquiring skills to operate safely and care for our patients. We learn disease processes, treatments and surgical techniques with increasing complexity and responsibility.

We are expected to stand for hours—bodies contorted—to get the correct exposure, to perfect the dissection and complete the operation with the patient’s physical well-being as the main goal. But what we rarely take into consideration is the surgeon’s physical well-being.

Without a doubt, the patient’s welfare is the foremost consideration for every operation. But ignoring surgeons’ physical well-being does a disservice to our patients and our profession.

“Surgery is a contact sport” because surgeons are the endurance athletes of medicine. Athletes physically train their bodies to be able to maximally perform and avoid injury. So, why it is that, as surgeons, we don’t train our bodies to endure the repeated physical demands of our job?

In surgery, ergonomic modifications are helpful, but have their limitations, especially with challenging operations. Surgery-specific physical endurance training and body mechanics retraining can make a difference. Just as athletes train, continuously and without fail, surgeons should physically train. Regular, scheduled physical training with very specific body mechanics and strength training for surgeons can help to lower the chances of surgeon-specific physical problems.

Body mechanics for surgeons is rarely discussed. Body mechanics is defined as “the study of the action of muscles in producing motion or posture of the body” (Farlex Partner Medical Dictionary, 2012). There are techniques of body mechanics retraining that can help minimize the chances of physical injury, especially during lengthy and difficult cases.

These techniques are the ally of correct ergonomics; the two fields are necessary and collaborative. By applying correct body mechanics and using larger muscle groups, stress can be off-loaded away from the neck, back and arms of a surgeon. But this type of massive change to physical behavior is not intuitive. It requires surgeon-specific body mechanics and strength training and retraining, along with continued regular maintenance during dedicated time.

It is time we bring the importance of surgeons’ physical well-being to the forefront of practice. We must recognize that the problem exists, then quickly, as a community of surgeons, make the concerted effort to maximize prevention, set aside regular time for body mechanics and strength training, and not be hesitant to seek medical attention if any pain or problems are ongoing. We are the endurance athletes of medicine, and we must start acting as such. Together, we can improve physical health and increase career longevity for all surgeons. Together, we can ensure the future of surgery—resolute with enduring strength and health.

“In surgery, ergonomic modifications are helpful, but have their limitations, especially with challenging operations.

Surgery-specific physical endurance training and body mechanics retraining can make a difference. Just as athletes train, continuously and without fail, surgeons should physically train.”

Below, we highlight some techniques that can help surgeons get started on their body mechanics and strength training routines. Jarel Russell, OTR/L, is a doctor of occupational therapy with certifications in orthopedic manual therapy, concussion rehabilitation and advanced hand therapy. He specializes in treating surgeons.

Dr. Russell has developed Elite Prehab, an individualized program for surgeons to improve specific body mechanics, functional strengthening, postural retraining and neuromuscular reeducation. The goal is to maximize career longevity and minimize career-related physical injuries. Dr. Russell has a background in the prehabilitation/rehabilitation of combat athletes and blood flow restriction therapy.

As with any other physical training program, a thorough evaluation and skilled progression through a treatment program with a specialist is best to maximize therapeutic results and prevent further injury. For surgeons with current neck, back or arm pain, please do not ignore or disregard the problem; get evaluated and maximize correction and treatment as much as possible. continued on the following page

OR Management News • Volume 7 • June 2022

13

FE ATURE

Surgical Injuries: The Problem, the Solution, the Prevention

By JAREL RUSSELL, OTR/L

T

he C5-C7 cervical spine segment is frequently affected by poor posture and highly susceptible to pathologic diseases such as degeneration, disk herniation, radicular pain and trauma. By design, the C1-C2 segments are the load-bearing joints during upright activity. However, when surgeons are performing open operations, the C5-C7 cervical segments function as high load-bearing joints.

These segments provide flexibility and support to much of the neck while in an operating posture. Not having adequate muscle balance while operating results in pathology of these spinal segments. Pain is a precursor that signals the beginning of a problem. If pain is ignored, the disease process progresses.

Key concepts of pain science explain the interaction of pain and prolonged operating posture. The three key concepts are: • trauma • muscle imbalance • compensatory movement patterns

Trauma Altered movement patterns

Pain

Muscle imbalance

Each of these key components feeds into the other. The figure below illustrates that it does not matter which event occurs first.

Prolonged operating posture is a hidden component that can lead to further advancement along the pain continuum.

While the research does not support the ideology of “perfect posture,” every individual has an ideal posture that can aid in the prevention of injuries. The foundation to optimal posture is built upon a strong core. The concept of the “core” muscles is more extensive than most people realize and encompasses numerous muscle groups, as illustrated to the right. The core plays a role in almost every movement the body makes. From walking to running to sitting, picking up objects from the floor or top shelf, to maintaining a prolonged posture during a surgical procedure, your core is activated and supporting you during all these activities. A strong core can help prevent forward head posture to stabilize the C5-C7 cervical segments for surgeons.

The other two muscle groups that stabilize the cervical spine are the periscapular and deep neck flexor muscles. Weak periscapular muscles often lead to muscle imbalance and upper crossed syndrome. With upper crossed syndrome, the shoulder, chest and neck muscles are imbalanced with some being weak and others tight. The syndrome is a component of poor posture of the shoulders and upper back. The deep neck flexors help to maintain neck stability and are an essential component of good posture.

14

OR Management News • Volume 7 • June 2022

Core Muscle Complex External (but also internal) obliques

Rectus Abdominis

Diaphragm Multifidus

Erector Spinae

Quadratus Pelvic Floor Lumborum Muscle Transversus Abdominis

Research shows that 70% of people with chronic neck pain have weak deep neck flexor muscles (J Phys Ther Sci 2016;28[1]:269273). Strengthening these muscles involves a neuromuscular reeducation program that should be completed with a specialist.

I would like to stress that therapy should be used for both prevention and recovery. Typically, the underlying pathology is complex, and stretching alone is not a good treatment. However, it is useful when combined with an individualized program consisting of strengthening and orthopedic manual therapy techniques. This is the premise behind the Elite Prehab program for surgeons. Elite Prehab involves individualized orthopedic evaluation using differential diagnosing, postural analysis and neurodynamic assessment.

The goals are twofold. The first goal is to uncover the underlying reason for pain and muscle imbalances to fully understand the pathology impeding performance. The second goal is prevention of any future problems that commonly plague surgeons.

Each surgeon should have a customized program for their unique situation. The exercises can be easily incorporated into normal daily routines. The goal of the program is to maximize performance of essential job-related tasks, while improving function of everyday activities. It is skilled progression through a treatment and prevention program with neurodynamic cervical stabilization and strength/balance restructuring that can prevent problems, relieve pain and allow surgeons to maximize career longevity in the context of optimal physical health.

■ —Dr. Tejirian is a general surgeon in Los Angeles.

—Dr. Russell is a doctor of occupational therapy with certifications in orthopedic manual therapy, concussion rehabilitation and advanced hand therapy, in Los Angeles. He specializes in treating surgeons.

For a complete list of injury-preventing exercises (with photos), visit ormanagement.net.

STAY CONNECTED!

C LIN IC A L NE WS

Keeping Surgical Patients Safe From Unintended Harm

By ETHAN COVEY

A

s part of the 2021 virtual American College of Surgeons ns Clinical Congress, experts gathered to review several hot ot topics in surgical patient safety. These subjects—some newer er developments and other challenges that continue to present commplications for surgeons and their staff—were reviewed during a series of presentations and an accompanying panel discussion.

The sessions, highlights of which are included below, focused d on how practices and technologies are evolving in order too address peri- and postoperative challenges, and allow for more re successful risk management strategies. The goal, said the mod-erator of the session, Juan A. Sanchez, MD, the regional vicee president at HCA Healthcare Physician Services Group, in n Brentwood, Tenn., is “to keep surgical patients safe from unin-tended harm.”

Venous Thromboembolism, HealthcareAssociated Infections Pose Continuing Threat Venous thromboembolism (VTE) and healthcare-associated infections (HAIs) are “two highly relevant topics that really apply to the daily practice of surgery,” said Peter A. Najjar, MD, an assistant professor of surgery at Johns Hopkins Medicine, in Baltimore.

Dr. Najjar added that inpatient VTEs remain very common.

“In fact, there is good evidence to suggest that they are the most common preventable cause of in-hospital death.”

Although pharmacologic prophylaxis against VTEs has been shown to be safe, effective and cost-effective (and is advocated by existing guidelines), these methods remain underused (Agency for Healthcare Research and Quality; October 2015. AHRQ Publication No. 16-0001-EF).

Effectively preventing VTEs requires a multistep process incorporating standardized risk assessment, ordering prophylaxis and delivery of prophylaxis. When possible, risk assessments should be integrated into a patient’s electronic health record.

Ordering of appropriate prophylaxis, Dr. Najjar said, should be based on patient and procedural risk factors, and ensuring prophylaxis is administered to the patient is of the utmost importance. Missed opportunities for prophylaxis can be common, and they highlight the need for additional educational efforts.

“With this comprehensive strategy, the goal is to reduce the incidence of VTE to only those that are not preventable using best practice in modern surgical settings,” Dr. Najjar said.

Another problem that continues to present a significant source of preventable morbidity and mortality is HAIs. The most common type of HAIs, accounting for more than 30% of infections, is surgical site infections (SSIs). It is estimated that SSIs cause 8,000 deaths annually in the United States, and 40% to 60% are preventable (Surg Clin North Am 2015;95[2]:269-283).

For both HAIs and SSIs, further decreasing rates likely 16

OR Management News • Volume 7 • June 2022

requires the bundling of multiple techniques.

“Over time, we’ve gotten so good at reducing SSIs through antiseptic technique and meticulous hemostasis, technical skill improvement, and procedural planning that infection rates have dropped substantially,” Dr. Najjar said. “So, in order to demonstrate a meaningful improvement, there are very few ‘silver bullets’ that will take an infection rate down substantially from those levels. That’s where I think the power of good process and bundles come into play.”

Avoiding Unintended Retained Surgical Items And Patient Identification Errors Improvements can also be made in preventing retained surgical items (RSIs) and hospital-based patient misidentification.

“RSIs are a ubiquitous problem that crosses body cavities, small and large cases, in addition to crossing surgical specialties,” said Lauren T. Steward, MD, an assistant professor of GI, trauma and endocrine surgery at the University of Colorado Department of Surgery, in Denver.

Dr. Steward said basic counting procedures are not enough to eliminate these occurrences.

“Communication should be enhanced,” Dr. Steward said, including verbal communication and acknowledgment when placing small objects into, and removing them from, the patient’s body. Additionally, backup strategies should be used, such as a white board on which placement and removal of items are actively recorded. Surgical debriefs should verify that items placed in the body have been removed, and x-rays can be used to rule out the presence of RSIs. Dr. Steward noted that it is especially important for hospital leadership to continuously demonstrate that patient safety is a priority, ranking even higher than productivity and efficiency. continued on page 22

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Multidisciplinary Approach Best for Managing Chronic Wounds

By CHASE DOYLE

A

s the treatment of nonhealing wounds continues to evolve, multidisciplinary care is playing an increasingly important role in the management of complicated patients. During the 2021 virtual American College of Surgeons Clinical Congress, Nicolas J. Mouawad, MD, the chief of vascular and endovascular surgery at McLaren Health Care, in Bay City, Mich., discussed the benefits of multidisciplinary wound care and how to incentivize institutional collaboration.

“Patients with difficult wounds who would often be considered for amputation with a single-specialty approach can now be managed successfully with a multidisciplinary wound team,” he said.

As Dr. Mouawad explained, chronic wounds are generally wounds that fail to heal through the body’s natural healing process (less than approximately 30% closure in four weeks). Whether due to anatomic site, concurrent illness or medical comorbidities, the reasons for lack of healing are often complex, with these wounds posing a significant challenge to both patients and providers.

Multidisciplinary Teamwork The concept of multidisciplinary teamwork in the management of chronic wounds has been around for decades and is supported by numerous professional associations and organizations.

The American Diabetes Association and American College of Foot and Ankle Surgeons, for example, promote a team approach, particularly for diabetic wounds. Importantly, this approach can benefit myriad aspects of healthcare. continued on page 22

Choosing the Right Dressings For Chronic Wounds Matthew Murphy, MD, PhD, an assistant professor of plastic and reconstructive surgery at Stanford University School of Medicine, in California, noted that choosing the right dressing for chronic wounds can shorten time to healing, relieve pain and suffering, and reduce the economic burden on both the patient and healthcare system. Dr. Murphy highlighted these three types of dressings that can aid the healing process:

1. Hydrocolloids, an occlusive dressing composed of

“Patients with long-term chronic wound abnormalities, particularly those with venous leg ulcers and diabetic ulcers, can suffer for months or even years, and there are significant costs to the healthcare system,” Dr. Mouawad said. “Based on Medicare data, the management of chronic wounds costs between $28.1 billion to $98.6 billion per year.”

The Core Problem According to Dr. Mouawad, a major problem affecting treatment is that wounds are not considered an actual disease. This misperception leads to a lack of standardization in wound care management, a lack of reproducibility of clinical and research outcomes, an overwhelming array of similar products, and outdated measurement tools for wound evaluation. Moreover, if chronic wounds are to become a disease entity, he noted, there’s the question of who should manage the patient, given multiple stakeholders.

“The management of patients with chronic wounds involves a wide range of specialties,” Dr. Mouawad said. “Taking ownership of the wound requires a multidisciplinary routine approach or a network.”

18

OR Management News • Volume 7 • June 2022

a hydrocolloid matrix bonded to a vapor-permeable film or foam backing, are known to many wound care physicians, and consist of two main types: hydrocolloid and fibrous hydrocolloid (reserved for moderate to severe wounds). Hydrocolloids absorb exudate, provide thermal insulation, promote a moist wound healing environment, prevent bacterial contamination, reduce friction and shear, and promote epithelial migration.

2. Matrices are tissue-engineered products that act as a tissue scaffold and provide a supporting structure into which cells can migrate. Matrices may be sourced from biologic tissue (animal, human or plants), synthetic materials, and composite materials containing two or more components. “The ideal matrix is one that most closely approximates the structure and function of the native extracellular matrix that it is replacing.”

3. Amniotic products are those obtained from normal amnion/chorionic membrane or umbilical tissue of live newborns. These products undergo proprietary processing for sterility, preservation and retention of growth factors. “Within these dressings, there is a host of regulatory proteins, growth factors, cytokines and chemokines that participate in healing.”

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INFECTI O N CO NTRO L

Novel Research Shedding Light on Fungal Infections

By DAVID WILD

20

OR Management News • Volume 7 • June 2022

there was a single species, Dr. Kalan said, noting these insights could identify “important markers for predicting the healing trajectory and possibly finding targets for intervention as well.”

Fungal Lung Infections in COVID-19 Fungi also have gained recognition as pulmonary pathogens among patients with COVID-19, according to Martin Hoenigl, MD, an associate professor, Division of Infectious Diseases and Global Public Health, at the University of California, San Diego and the Medical University of Graz, in Austria.

He noted that 3.1% of the overall COVID-19 population develops COVID-19–associated pulmonary aspergillosis (CAPA), with the number rising to 8.9% among ICU patients with COVID-19 and to 10% to 15% in ICU patients with COVID-19 who require mechanical ventilation (Clin Microbiol Infect 2021 Aug 26. doi:10.1016/j.cmi.2021.08.014).

While CAPA is an ominous diagnosis, associated with a 51.8% mortality rate, it can be a challenge to diagnose, Dr. Hoenigl explained.

Although “the classical neutropenic patient at risk for invasive aspergillosis who develops primarily angioinvasive disease” can display the typical radiological signs of infection, “things get a little bit more complicated once we move a little bit up the spectrum to non-neutropenic patients who develop primary airway– invasive disease first,” he said.

In these more complicated cases, the typical radiological signs of infection may not be present, and bronchoalveolar lavage (BAL) samples from the site of infection are needed to confirm a diagnosis.

Many clinicians are reluctant to employ bronchoscopy to diagnose lung infections in COVID-19 patients because the procedure generates aerosols, but recent consensus criteria offer a number of possible alternatives to BAL-based diagnosis, he said (Lancet Infect Dis 2021;21[6]:e149-e162).

One such alternative is diagnostic lateral flow assay (LFA) testing for galactomannan, which Dr. Hoenigl and his colleagues have studied. In a recent multicenter trial, they found “a very good predictive value for diagnosing invasive aspergillosis” with the device they used (Aspergillus GM LFA; IMMY) (J Clin Microbiol 2021 Oct 13. doi:10.1128/JCM.01689-21). Specifically, they documented an area under the curve of greater than 0.8 for the same device for diagnosing CAPA in respiratory specimens, indicating a high level of accuracy.

“It also seems to work very well for distinguishing CAPA from ■ non-CAPA,” Dr. Hoenigl noted.

Source: CDC/ Dr. Hardin

N

ovel diagnostics are helping clinicians identify fungal infections where conventional methods have proven insufficient, and new technologies are revealing that fungi interact with pathogenic bacteria in ways that can exacerbate infections.

“There is an increased understanding that while many types of chronic wounds, including diabetic foot ulcers, are poly-microbial in nature, traditional culture methods might underrepresent the vast diversity of chronic wound microbiomes, including fungal populations,” explained Lindsay Kalan, PhD, an assistant professor, Departments of Medical Microbiology and Immunology and Medicine, Division of Infectious Disease, at the University of Wisconsin–Madison.

Advanced techniques have uncovered fungi in roughly 80% of diabetic foot ulcers, whereas traditional culturing methods identify fungi in only 5% of wounds, Dr. Kalan noted (mBio 2016;7[5]:e0158-16).

Better understanding of the role that fungal populations play in these infections could help pinpoint those patients who are most likely to develop nonhealing foot wounds, she said, noting that the presence of other organisms, such as Staphylococcus aureus, has not been a very good prognostic marker in this regard.

“We have found some interesting things by studying microbial communities instead of a single pathogen within a single wound sample and looking at how community diversity changes before and after an intervention,” Dr. Kalan said.

For example, she and her colleagues found that diabetic foot wounds that heal after debridement exhibit a significant drop in the overall microbial diversity, while unhealed or amputated wounds have a much larger proportion of fungi on a community level (mBio 2016;7[5]:e0158-16).

“Additionally, looking at highly necrotic tissue, we’ve seen a really striking increase in the proportion of pathogenic fungi that grow alongside anaerobic bacteria, suggesting there are bacterial–fungal networks forming within these wounds and leading to poor outcomes,” she said.

Indeed, using a diabetic foot ulcer lab model, her team demonstrated that bacteria and fungi “jointly synergize to contribute to pathogenesis,” she said. They cultured Candida albicans along with S. aureus and Citrobacter freundii, a species of anaerobic gramnegative bacteria, and found that when C. albicans colonized first, C. freundii outcompeted S. aureus by inducing growth of fungal hyphae and binding to C. albicans (ISME J 2021;15:2012-2027).

They also found significantly higher levels of neutrophil cell death in mixed fungal–bacterial biofilms, compared with when

I N FEC TION CONT ROL

Colorectal Surgery Experts Advise on Preventing SSIs

By ALISON McCOOK

A

To reach a consensus, the panel followed a modified Delphi method, with up to three rounds of discussion for each topic. Voting was anonymous, as is “standard” in this type of process, Dr. Hedrick said, so voters aren’t influenced by their peers. Every recommendation had to reach at least 70% agreement among voters. “We reviewed each of the topics with a fine-toothed comb and did a thorough review of all the evidence,” she said. “We took our time resolving each of the recommendations.”

The report offers practical advice to help surgeons prevent one of the most common, and costly, complications following colorectal procedures, said Syed Husain, MD, FACS, FASCRS, a colorectal and general surgeon at The Ohio State University, in Columbus, who did not participate in the study. “These are the questions that we grapple with on a daily basis, and the authors have gone really to the heart of the problem.”

The result of these discussions by the expert panel in the report is extremely helpful to practicing surgeons, Dr. Husain said. For instance, his practice frequently uses glue sealants on top of incisions. Although he and his colleagues haven’t stopped yet, these recommendations have “definitely started a conversation in our group.” If they don’t stop entirely, they may begin to employ glue sealants more selectively, he added. “There’s a very good chance that we’re going to move away from the blanket application in all patients.”

His practice also doesn’t usually have access to antibioticimprednated sutures. But after the panel recommended their use to prevent SSIs, “that has again started a conversation in our group and administration to have those available to us.”

It can be hard to determine how best to prevent SSIs, Dr. Husain said, because doctors can’t easily try something to see what works.

In the future, the surgical community will hopefully find a way to conduct randomized, prospective trials of techniques to reduce SSI risk in a way that won’t compromise patient care, he added.

■

panel of 15 colorectal surgeons compiled a set of recommendations for how to prevent surgical site infections, based on their expert opinion and review of dozens of studies.

The recommendations include advice on what to use, what lacks sufficient evidence to support its use, and nuanced approaches to wound irrigation and the location of incisions (J Am Coll Surg 2022;234[1]:1-11).

According to a 2020 study, 23.9% of patients develop an SSI after colorectal cancer surgery, which can cost commercial payors up to $145,000, and $102,000 to Medicare within a year (Dis Colon Rectum 2020;63[12]:1628-1638).

The goal is to reduce the burden of SSIs, SIs, said senior author Traci Hedrick, MD, D, FACS, FACRS, a colorectal surgeon at the he University of Virginia Health System, in n Charlottesville.

“Most of these recommendations are on topics that surgeons are already familiar with,” Dr. Hedrick said. “However, the intraoperative aspects can sometimes get lost in the large com- Traci Hedrick, MD, prehensive bundles, which is why this FACS, FACRS project is unique.”

To prevent SSIs, the authors suggest surgeons employ wound protectors/retractors, negative pressure wound therapy, triclosancoated sutures, a sterile incision closure tray and change their gloves before closing the incision. Alternatively, they found that there was insufficient evidence to recommend topical skin adhesives, incise/adhesive drapes, advanced dressings, continuous versus interrupted sutures or staples, a delayed incision closure, and subcutaneous drains to specifically prevent SSIs (Figure).

With some topics, the advice was more complex—not a simple do or don’t do, Dr. Hedrick said. For instance, when it comes Dr. Hedrick reported a consultantship with Ethicon/Johnson & to midline incisions, the panel determined there was insufficient Johnson, which provided funding for the study. Dr. Husain reported evidence that off-midline incisions reduce the risk for SSIs com- no relevant financial disclosures. pared with midline incisions, but when possible and appropriate, off-midline incisions may reduce inciWound NegativeContinuous vs. sional hernia risk after (laparoscopOff-midline Topical skin Subcutaneous protectors/ pressure interrupted ic) colorectal surgery. With the size of incisions adhesives drains retractors wound therapy sutures bite sutures, the authors said there was not enough evidence to conclude that Small bites Incise/ Delayed TriclosanSterile incision vs. large bites adhesive incision a small bites suture technique does coated sutures closure tray sutures drapes closure more to reduce SSI risk than a large bites suture technique. However, they Pre-closure Wound Advanced Sutures vs. said the small bites suture technique glove change irrigation dressings staples can reduce the risk for incisional hernias. Regarding wound irrigation, use Positive Recommendation Mixed Negative Recommendation aqueous iodine, not antibiotic incisional wound irrigation, in high-risk, Figure. Consensus on intraoperative technical/surgical aspects of SSI prevention. contaminated wounds.

Adapted from J Am Coll Surg 2002;234(1):1-11.

OR Management News • Volume 7 • June 2022

21

Patient Safety

Wound Dressing

continued from page 16

continued from page 18

“In order to avoid RSIs, we have to recognize that there is a problem that affects all disciplines of surgery and all types of cases,” Dr. Steward said. “It is going to take a multidisciplinary effort in order to prevent RSIs, and all team members should be empowered to speak up.”

Patient identification errors are defined as the failure to correctly identify patients, resulting in mistakes in medication, transfusion and testing. These errors also include wrong-person procedures and the discharge of infants to the incorrect family.

There are many causes of patient misidentification and they can occur at multiple points during a hospital stay. During registration, incorrect information may be given or recorded; inadequate staff training and time pressures may result in errors; and there may be duplicate medical records or communication issues across departments.

To prevent these mishaps, reliance on at least two patient identifiers at all times is key. Protocols and standardized procedures are of the utmost importance, and technological advances—wristbands that include patient photographs, or biometric methods such as fingerprint, retina or palm scans—may be implemented.

“We must recognize that there is a problem and that patient misidentification can happen at any point during a patient’s hospitalization,” Dr. Steward said.

“The primary outcomes are to increase wound healing rates and ultimately decrease amputation rates,” Dr. Mouawad said. “Secondary outcomes involve patient satisfaction, compliance with orthotic and prosthetic management, and ultimately healthrelated quality of life.”

These outcomes have been repeatedly demonstrated in the global literature. A study showed an improvement in healing rates from 23% with a single-discipline approach to 82% after the implementation of a team approach in patients with diabetic disease (Acta Derm Venereol 1995;75[2]:133-135). In addition, Gottrup et al showed healing rates of 60% over 12 months for chronic recalcitrant leg ulcers (Arch Surg 2001;136[7]:765-772), while Valdes et al reported an average eight-week healing time for venous ulcers (Ostomy Wound Manage 1999;45[6]:3036). Finally, a 2011 study noted that 72% of patients healed in an average of 12 weeks following a team approach (Wound Pract Res 2011;19[4]:229-233).

Many studies have also reported a reduction in amputation rates associated with a multidisciplinary care strategy. In patients with diabetes, for example, the results of a five-year prospective study showed an 82% decrease in major amputations (from 36.4% to 6.7%) with use of a team approach (Diabetes Res Clin Pract 2007;75[2]:153-158). The authors also reported a 45.7% reduction in below-the-knee amputations and a significant decrease in high-tolow amputation ratio.

“We’ve seen this over and over again, not just within the United States, but globally. Involvement of a multidisciplinary team, particularly for the diabetic foot, is associated with a reduction in the incidence of major amputations,” Dr. Mouawad said. “Importantly, between 45% and 85% of all lower-extremity amputations can be avoided by using a multidisciplinary approach.”

In addition to clinical excellence, the multidisciplinary team allows for psychosocial factors that are important to patients. Patients have reported increased quality-of-life scores, particularly in the domains of physical and emotional functioning, when treated with a team approach. A study in Denmark found 91% of patients were satisfied with the quality of technical care and empathy when a multidisciplinary wound team and wound environment was put in place (Int J Low Extrem Wounds 2009;8[3]:153-156).

“It’s difficult and involves a lot of people, but multidisciplinary wound teams lead to the best management and the best outcomes for these patients,” ■ Dr. Mouawad concluded.

Evaluating Frailty, Perioperative Nutrition And Prehabilitation for Surgery Ensuring patients are well enough to have positive outcomes is of core importance to the surgical process.

“Frailty is a syndrome of decreased physiologic reserve and resistance to stressors which leaves patients vulnerable to worse outcomes,” said Steven C. Cunningham, MD, the director of pancreatic and hepatobiliary surgery and director of research at Ascension Saint Agnes Hospital, in Baltimore. “Frailty is strongly, and unsurprisingly, correlated with poor outcomes after surgery.”

Criteria for determining a patient’s level of frailty include weight loss, weakness, exhaustion, low physical activity and slowness of movement, and can be assessed via self-report and in-office testing.

Dr. Cunningham stated that patients who are determined to be in the intermediate category of frailty are at elevated risk for complications, as well as being twice as likely to become frail within three years, thus putting them at much increased risk for adverse health outcomes.

As such, Dr. Cunningham noted the importance of assessing for the five criteria of frailty with any patients determined to be at risk, and then performing appropriate interventions.

Malnutrition also is associated with an increased risk for postoperative adverse events, and rates increase as patients are older and sicker. For malnourished patients, it may be worth considering preoperative nutrition consultation and therapy. For well-nourished patients, dietary restriction, such as fasting, may provide benefits. However, Dr. Cunningham noted, this approach has not yet received mainstream acceptance.

Rehabilitation programs, aimed at improving a patient’s health before surgery, show some promise, but the data remain inconclusive.

“There is conflicting evidence regarding length of stay and morbidity and mortality, but there is good evidence for improved functional and exercise capacity,” Dr. Cunningham said.

■ 22

OR Management News • Volume 7 • June 2022

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