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Patient safety rounds (PSRs) were established at the University of Michigan Medical Center to improve patient safety by opening a new line of communication between the chief of staff and [...]

Objective: To assess the variation in hospitals' approaches to intraoperative fluid management and their association with postoperative recovery. Background: Despite increasing interest in goal-directed, restricted-volume fluid administration for major surgery, there remains little consensus on optimal strategies, due to the lack of institution-level studies of resuscitation practices. Methods: Among 64 hospitals in a state-wide surgical collaborative, we profiled fluid administration practices during 8404 intestinal resections, 22,854 hysterectomies, and 1471 abdominopelvic endovascular procedures. We computed intraoperative fluid balance, accounting for patient morphometry, crystalloid, colloid, blood products, urine, blood loss, duration, and approach. We stratified hospitals by average fluid balance quartile, and compared patterns across disciplines and associations with risk-adjusted postoperative length of stay (pLOS). Results: There was wide variation in fluid balance between hospitals (P < 0.001, all procedures), but significant within-hospital correlation across operations (Pearson rho: intestinal-hysterectomy = 0.50, intestinal-endovascular = 0.36, hysterectomy-endovascular = 0.54, all P < 0.05). Highest fluid balance hospitals had significantly longer adjusted pLOS than lowest balance hospitals for intestinal resection (6.5 vs 5.7 d, P < 0.001) and hysterectomy (1.9 vs 1.7 d, P < 0.001), but not endovascular (2.1 vs 2.3 d, P = 0.69). Risk-adjusted complication rates were not associated with fluid balance rankings. Conclusions: Hospitals' approaches to intraoperative fluid administration vary widely, and their practice patterns are pervasive across disparate procedures. High fluid balance hospitals have 12% to 14% longer risk-adjusted pLOS for visceral abdominal surgery, independent of patient complexity and complications. These findings are consistent with evidence that isovolemic resuscitation in enhanced recovery protocols accelerates recovery of bowel function. [ABSTRACT FROM AUTHOR]

Objective: The aim of the study was to characterize patient-reported outcomes of analgesia practices in a population-based surgical collaborative. Background: Pain control among hospitalized patients is a national priority and effective multimodal pain management is an essential component of postoperative recovery, but there is little understanding of the degree of variation in analgesia practice and patient-reported pain between hospitals. Methods: We evaluated patient-reported pain scores after colorectal operations in 52 hospitals in a state-wide collaborative. We stratified hospitals by quartiles of average pain scores, identified hospital characteristics, pain management practices, and clinical outcomes associated with highest and lowest case-mix-adjusted pain scores, and compared against Hospital Consumer Assessment of Healthcare Providers and Systems pain management metrics. Results: Hospitals with the lowest pain scores were larger (503 vs 452 beds; P < 0.001), higher volume (196 vs 112; P = 0.005), and performed more laparoscopy (37.7% vs 27.2%; P < 0.001) than those with highest scores. Their patients were more likely to receive local anesthesia (31.1% vs 12.9%; P < 0.001), nonsteroidal anti-inflammatory drugs (33.5% vs 14.4%; P < 0.001), and patient-controlled analgesia (56.5% vs 22.8%; P < 0.001). Adverse postoperative outcomes were less common in hospitals with lowest pain scores, including complications (20.3% vs 26.4%; P < 0.001), emergency department visits (8.2% vs 15.8%; P < 0.001), and readmissions (11.3% vs 16.2%; P = 0.01). Conclusions: Pain management after colorectal surgery varies widely and predicts significant differences in patient-reported pain and clinical outcomes. Enhanced postoperative pain management requires dissemination of multimodal analgesia practices. Attention to patient-reported outcomes often omitted from surgical outcomes registries is essential to improving quality from the patient's perspective. [ABSTRACT FROM AUTHOR]

Hypothesis: A regional collaborative approach is an efficient platform for surgical quality improvement. Design: Retrospective cohort study. Setting: Academic research. Patients: Patients undergoing general and vascular surgical procedures in 16 hospitals of the Michigan Surgical Quality Collaborative (MSQC) were evaluated quarterly to discuss surgical quality, to identify best practices, and to assess problems with process implementation. Main Outcome Measures: Results among MSQC patients were compared with those among 126 non- Michigan hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) over the same interval. Results: A total of 315 699 patients were included in the analysis. To assess improvement, patients were stratified into 2 periods (T1 and T2). The 35 422 MSQC patients (10.7% morbidity in T1 vs 9.7% in T2 [9.0% reduction], P=.002) showed improvement, while 280 277 non-Michigan ACS NSQIP patients did not (12.4% morbidity in T1 and T2, P=.49). No improvements in mortality rates were noted in either group. Overall, the odds of experiencing a complication in T2 compared with T1 were significantly less in the MSQC group (odds ratio, 0.898) than in the non-Michigan ACS NSQIP group (odds ratio, 1.000) (P=.004). Conclusion: A statewide surgical quality improvement collaborative supported by a third-party payer showed significant improvement in quality and high levels of participant satisfaction. [ABSTRACT FROM AUTHOR]

The authors looks at limitations and consequences of the new Inpatient Prospective Payment System (IPPS) rule imposed by the U.S. Centers for Medicare and Medicaid Services (CMS) in 2008. They cite that the rule is aimed at providing incentives for hospitals in order to lessen complications of medical care. They note the heavy reliance of the CMS payment rule on hospital billing data, which they say are a poor source of information about medical care complications. They recommend considering other models aimed at reducing hospital-acquired conditions.

This article discusses a study of foot traffic in the operating room (OR) as a risk for surgical site infections (SSI). Data collected for the study included the number of people entering and exiting the OR, the role of individuals and the cause of the event. The study found a high rate of traffic across all specialties, compromising the sterile environment of the OR.

Discusses physician-patient relationships. Factors influencing the manner in which physicians interact with patients; How stress interferes with the ability of a physician to provide a more human quality to a patient relationship; Suggestion for a qualitative change in the surgical residency.

The authors reflect on the ruling in the case Taylor v Intuitive related to robotic surgery that highlights potential safety concerns regarding the regulation of novel procedures and technologies as they enter the clinical practice. The authors note that the ruling suggests that physicians and the hospitals they work for have the medicolegal responsibility for training, credentialing and privileging surgeons to use new technologies. Also mentioned is the goal to improve patient safety.

The authors argue in favor of multihospital collaborations for improving the quality of the U.S. health care system and attaining a surgical quality improvement. They describe a problem associated with hospital organization and the large gap between the generation of evidence. They cite some obstacles to multihospital collaborations, including the difficulty of securing financial support. The authors also recommend an understanding of reason for the failure to apply evidence-based strategies as the basis for quality improvement.