Surgical Black Box

[BLADEMDA]

http://video.foxnews.com/v/3759685896001/surgical-black-box-in-the-works/#sp=show-clips


Do you think this will ever happen in the USA?

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[deleted171991]

Absolutely. I am surprised there hasn't be a stronger push for this, once we had toys like GoPro cameras.

Since there are also studies which show that you can easily separate a good laparoscopic surgeon from a bad one, just by watching them, I could see some national beancounter organization pushing for this as part of the "quality" movement. If that happens, malpractice lawyers will just love it.

 

[Impromptu]

If it were only used for learning and improvement it could be useful.

It won't be used only for learning and improvement. It's main use will be for punishment. The lawyers will want access to it. The hospital administrators will use it for sham proceedings in getting rid of "disruptive physicians". Medicare and other payors will use it to lower the payments they make to you.

 

[IlDestriero]

This plays into the ABCs of modern practice. Accuse, blame and criticise.
It will work great for the bad outcomes.

 

[smb4]

If it were only used for learning and improvement it could be useful.

It won't be used only for learning and improvement. It's main use will be for punishment. The lawyers will want access to it. The hospital administrators will use it for sham proceedings in getting rid of "disruptive physicians". Medicare and other payors will use it to lower the payments they make to you.

I 100% agree with you. It is a great teaching/learning concept that will be perverted and misused by the greedy malpractice lawyers. Also, it can be used to keep the "disruptive" physicians in check by equally greedy hospital administrators. Hence I would prefer to kill this idea while is it is still young.

 

[sevoflurane]

No!

 

[drmwvr]

"Black boxes" aren't used for education, they're for piecing together an accident, after most or all of the principal players are dead and can't participate in an investigation.

It's inevitable though, just like dashboard and vest cams for the police. It's not going to be our call. TEFRA and SCIP measures have their benefits, but they were imposed. This will be no different, and it will come from the same place... physicians.

 

[deleted171991]

What are the benefits of anesthesia SCIP measures?

1. Antibiotics 1 hour before incision? Had not been proven to make a difference in infection rates, but I bet we have much more antibiotic resistance now. And why exactly 1 hour, and not 61 minutes?
2. Preop beta-blockers? Sure, anesthesiologists are idiots and they would not give a BB if needed. Oh, wait, starting a BB periop actually worsens outcomes? And, oops, BB increase the rate of strokes? Deep thinkers these people are.
3. Periop temperature management? Suuuure, because temperature is not a standard ASA monitor, right? And we would just let our patients freeze to death, otherwise, since hypothermia is so good for their coagulation, heart and mental status.

But, hey, what can one expect from something called The Joint Commission?

 

[aneftp]

I'd go with surgical black boxes.

But only when the criminal justice system allows "closed door" cameras inside judges chambers when prosecutors and defendant attorneys are meeting. That's the only way to see if back door deals are being made. "Justice".

 

[drmwvr]

What are the benefits of anesthesia SCIP measures?

1. Antibiotics 1 hour before incision? Had not been proven to make a difference in infection rates, but I bet we have much more antibiotic resistance now. And why exactly 1 hour, and not 61 minutes?
2. Preop beta-blockers? Sure, anesthesiologists are idiots and they would not give a BB if needed. Oh, wait, starting a BB periop actually worsens outcomes? And, oops, BB increase the rate of strokes? Deep thinkers these people are.
3. Periop temperature management? Suuuure, because temperature is not a standard ASA monitor, right? And we would just let our patients freeze to death, otherwise, since hypothermia is so good for their coagulation, heart and mental status.

But, hey, what can one expect from something called The Joint Commission?

What study are you basing #2 on? The POISE trial? Hm. Folks do let their patients freeze and you know it. Anyway, you're just doing me the courtesy of demonstrating my point. Compulsory, appropriate care imposed upon competent, well trained physicians. Pass the Cheetos.

 

[deleted171991]

The problem is not only that they are imposing "appropriate" care, is that they make you document why you didn't follow their bureaucratic amateurish out-of-the-trenches non-evidence-based thinking. They are like a spoiled little kid who "knows" everything and has no doubts, and expects everybody to do what s/he says.

Our professional societies have been much smarter about this. But of course, since the latter are practicing physicians, not governmental bureaucrats.

ASA Standards, Guidelines and Statements provide guidance to improve decision-making and promote beneficial outcomes for the practice of anesthesiology. They are not intended as unique or exclusive indicators of appropriate care. The interpretation and application of Standards, Guidelines and Statements takes place within the context of local institutions, organizations and practice conditions. A departure from one or more recommendations may be appropriate if the facts and circumstances demonstrate that the rendered care met the physician's duty to the patient.

Standards provide rules or minimum requirements for clinical practice. They are regarded as generally accepted principles of patient management. Standards may be modified only under unusual circumstances, e.g., extreme emergencies or unavailability of equipment.

Guidelines are systematically developed recommendations that assist the practitioner and patient in making decisions about health care. These recommendations may be adopted, modified, or rejected according to clinical needs and constraints and are not intended to replace local institutional policies. In addition, practice guidelines are not intended as standards or absolute requirements, and their use cannot guarantee any specific outcome. Practice guidelines are subject to revision as warranted by the evolution of medical knowledge, technology, and practice. They provide basic recommendations that are supported by a synthesis and analysis of the current literature, expert opinion, open forum commentary, and clinical feasibility data.

Statements represent the opinions, beliefs, and best medical judgments of the House of Delegates. As such, they are not necessarily subjected to the same level of formal scientific review as ASA Standards or Guidelines. Each ASA member, institution or practice should decide individually whether to implement some, none, or all of the principles in ASA statements based on the sound medical judgment of anesthesiologists participating in that institution or practice.

Making sure and documenting that The Joint Commission's "standards" are followed is probably 5% of the cost of healthcare in the USA. "Quality" is transforming into quantity; 77% of the hospitals are now "accredited" with no significant difference in outcomes. But I guess bureaucrats excel mostly at inventing new reasons for their own existence.

It is so important to make sure the incompetent doctor does not keep his cup of coffee in the endoscopy room, so he can enjoy it while typing/dictating between patients. No, siree, that is just bad medicine! I bet it's not a problem when it happens at TJC headquarters.

 

[deleted171991]

What study are you basing #2 on? The POISE trial? Hm.

POISE was just the beginning: http://www.medscape.com/viewarticle/808775

The ESC guidelines, along with the 2009 American College of Cardiology Foundation (ACCF)/American Heart Association (AHA) class IIa indication for patients undergoing vascular surgery[3], are based, in part, on data from the Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echo (DECREASE) studies. Dr Don Poldermans, formerly of Erasmus Medical Center, was best known for his work in using beta-blockers in surgery patients and published the first DECREASE paper in 1999 on the use ofbisoprolol. He also authored subsequent DECREASE studies, including DECREASE IV , which addressed the perioperative use of beta-blockers.

As has been reported extensively by heartwire and other media outlets, Poldermans was fired for violations of academic integrity and resigned from the ESC Committee for Practice Guidelines . Subsequent investigations into his research have questioned the validity of his findings, particularly the DECREASE studies. Complicating the whole matter further, Poldermans chaired the 2009 ESC guidelines for perioperative management in noncardiac surgery.

As a result of the 2008 meta-analysis, the ACCF/AHA downgraded the recommendations from class I to IIa

I just don't like when non-practicing folk (mostly nurses with clipboards) preach so-called standards. It doesn't make patients safer. God knows how many have been injured just with the beta-blocker mania, how many got infected with multidrug-resistant microbes because of giving antibiotics for almost every single stupid surgery etc. They all sound great on paper, except that nobody considers the ramifications when making them a mass requirement. We should have learned something from world-class failures such as the estrogen replacement therapy, or the Dr. Ioannidis research that 90+% of what we publish is garbage.

We waste so much money and human energy on all kinds of bureaucratic compliance, with no significant improvement in outcomes, compared to other developed countries. If our doctors could only spend as much time with their patients as with documenting all the crap...

 

[Mman]

2. Preop beta-blockers? Sure, anesthesiologists are idiots and they would not give a BB if needed. Oh, wait, starting a BB periop actually worsens outcomes? And, oops, BB increase the rate of strokes? Deep thinkers these people are.

SCIP beta blocker guidelines only apply to patients that are on beta blockers prior to admission to hospital and those patients do benefit from continuation of that beta blocker in the periop period.

 

[deleted171991]

Even so, the "beta blocker given within 24 hours" standard applies also to patients who take their BB every 12 hours.

Another arbitrary measure, like the antibiotics within exactly 60 minutes before incision.

 

[Triple AAA]

While I agree with the general sentiment expressed towards the 'black box', I'd like to play devil's advocate for a moment.

As anesthesiologists, our field of medicine is very poorly understood, not just by the public, but also by other healthcare workers and physicians.We meet the patient for several minutes prior to surgery, and they often have no recollection of us during emergence. We are also held to often unreasonable expectations in terms of complying with surgeon demands, proceeding with cases at the expense of a thorough H and P, rogue midlevel providers, etc.

Bottom line: It is very easy for us to be thrown under the bus by our colleagues. It is very easy for a jury of our (non-medical) peers to buy it. Intra-op surveillance may be the only proof able to bail us out and expose finger-pointing surgeons for what they are.

 

[Mman]

Even so, the "beta blocker given within 24 hours" standard applies also to patients who take their BB every 12 hours.

Another arbitrary measure, like the antibiotics within exactly 60 minutes before incision.

If something like that is to be measured, it will by definition be arbitrary. The best level of evidence we have for these sort of things is expert opinion. I doubt there will ever be a study powered well enough to differentiate between antibiotics 45 minutes before incision or 90 minutes before incision.

It's mildly painful to deal with, but it's what we are stuck with. There is no undoing it.

 

[SouthernSurgeon]

If something like that is to be measured, it will by definition be arbitrary. The best level of evidence we have for these sort of things is expert opinion. I doubt there will ever be a study powered well enough to differentiate between antibiotics 45 minutes before incision or 90 minutes before incision.

It's mildly painful to deal with, but it's what we are stuck with. There is no undoing it.

I actually went to a great talk by Clif Ko (head of NSQIP) where he talked about how a lot of the current quality measurement we do is ridiculous, and how a lot of hospitals have hired entire task forces to try and get their SCIP compliance from a lowly 98% to 100% and how there is both inadequate evidence for these guidelines and a massive ceiling effect. Talked about how we need better metrics and better measurements to actually define quality of care.

 

[Mman]

I actually went to a great talk by Clif Ko (head of NSQIP) where he talked about how a lot of the current quality measurement we do is ridiculous, and how a lot of hospitals have hired entire task forces to try and get their SCIP compliance from a lowly 98% to 100% and how there is both inadequate evidence for these guidelines and a massive ceiling effect. Talked about how we need better metrics and better measurements to actually define quality of care.

Did you thank captain obvious for pointing that out?

The idea of measuring outcomes and the process leading to better outcomes is great in idea. It's just that it's tough to actually work it out and the devil is in the details. Our hospital has actually put in places processes to catch instances of where we would miss out on SCIP stuff to get us to 100% compliant. Most months we are there and nobody even pretends that it improves care, merely that it ensures we get full reimbursement.

 

[deleted171991]

Here comes the $$$ question: Is the reimbursement difference actually higher than the 100% compliance costs (including the hidden ones, such as time wasted for documenting all that crap)? Did somebody calculate that?

 

[Random Anesthesiologist]

Wasn't it metoprolol that was the adverse BB culprit? I thought I remembered reading better outcomes with atenolol. But still, I agree with the sentiment, FFP.

 

[Spacedman]

What are the benefits of anesthesia SCIP measures?

1. Antibiotics 1 hour before incision? Had not been proven to make a difference in infection rates, but I bet we have much more antibiotic resistance now. And why exactly 1 hour, and not 61 minutes?

for what it's worth, there is reasonably good amount of evidence for preop abx, including "clean" and "clean-contaminated" surgical procedures. (highlights snipped for the lazy/pay-walled)

the largest trial I know of,
The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection.
(1992, NEJM)

...and that's why it's one hour.


Antimicrobial prophylaxis for surgery: An advisory statement from the National Surgical Infection Prevention Project
(2005, Am J Surg)

-sm

 

[deleted171991]

Uptodate says:

Preoperative antibiotics are warranted if there is high risk of infection or if there is high risk of deleterious outcomes should infection develop at the surgical site (such as in the setting of immune compromise, cardiac surgery, and/or implantation of a foreign device).

Instead, I see it given for the most trivial interventions. Let's not count the number of clean lap choles, arthroscopies, breast and trivial surgeries receiving Abx, at the surgeon's whim, when they are clearly not indicated. Nobody gets punished for that. For every surgical infection we prevent (as we should), we risk creating a good number of resistant organisms (by giving Abx left and right). Why? Because people are punished for not giving Abx, but they are not for giving them when or how they shouldn't.

Plus it's actually better to give Abx ~1 hour before incision than just before it (the ideal window is 30-60 min before incision, per UTD). Many anesthesiologists prefer not to give Abx until after induction, so it doesn't muddle the waters. In private practice, that means giving Abx less than 15 minutes before incision almost all the time. Let's not speak about the fact that the recommended UTD dose of cefazolin is 2g under 120 kg and 3g over, but we give 1g to almost everybody under 120.

I still think we are approaching microbes the wrong way in this country. Just read how Norway got rid of MRSA, while we are digging our graves deeper and deeper (probably because of Big Pharma lobbying).

Norway's model is surprisingly straightforward.

• Norwegian doctors prescribe fewer antibiotics than any other country, so people do not have a chance to develop resistance to them.
• Patients with MRSA are isolated and medical staff who test positive stay at home.
• Doctors track each case of MRSA by its individual strain, interviewing patients about where they've been and who they've been with, testing anyone who has been in contact with them.

Haug unlocks the dispensary, a small room lined with boxes of pills, bottles of syrups and tubes of ointment. What's here? Medicines considered obsolete in many developed countries. What's not? Some of the newest, most expensive antibiotics, which aren't even registered for use in Norway, "because if we have them here, doctors will use them," he says.

He points to an antibiotic. "If I treated someone with an infection in Spain with this penicillin I would probably be thrown in jail," he says, "and rightly so because it's useless there."

Convenience stores in downtown Oslo are stocked with an amazing and colorful array — 42 different brands at one downtown 7-Eleven — of soothing, but non-medicated, lozenges, sprays and tablets. All workers are paid on days they, or their children, stay home sick. And drug makers aren't allowed to advertise, reducing patient demands for prescription drugs.

In fact, most marketing here sends the opposite message: "Penicillin is not a cough medicine," says the tissue packet on the desk of Norway's MRSA control director, Dr. Petter Elstrom.

 

[Ipassgas]

Well then somebody goofed.
Unless I'm misreading the chart, the ideal time for antibioticsc is five hours post incision. Look! No infections!

 

[deleted171991]

It's because there were too few subjects.

That reminds me that we are not really considering the NNT and consequences when giving these huge amounts of antibiotics nationally. For example, we should probably never give IV Abx for clean superficial small surgeries in healthy patients, since the infection would be probably mild and immediately obvious. And yet we do.

 

[DrZzZz]

Wasn't it metoprolol that was the adverse BB culprit? I thought I remembered reading better outcomes with atenolol. But still, I agree with the sentiment, FFP.

POISE was specifically plagued by the fact that they used a big dose of metoprolol ER. Other studies tended to use beta blockers, like bisoprolol, IIRC.

Taken from the ACC Periop guidelines (see #3):

1. The systematic review suggests that preoperative use of beta blockers was associated with a reduction in

cardiac events in the studies examined, but few data support the effectiveness of preoperative

administration of beta blockers to reduce risk of surgical death.

2. Consistent and clear associations exist between beta-blocker administration and adverse outcomes, such

as bradycardia and stroke.

3. These findings were quite consistent even when the DECREASE studies (230, 240) in question or the

POISE (Perioperative Ischemic Study Evaluation) study (241) were excluded. Stated alternatively,

exclusion of these studies did not substantially affect estimates of risk or benefit.