At the Crossroad with Morbidity and Mortality Conferences: Lessons Learned through a Narrative Systematic Review

Objective. To determine the process and structure of Morbidity and Mortality Conference (MMC) and to provide guidelines for conducting MMC. Methods. Using a narrative systematic review methodology, literature search was performed from January 1, 1950, to October 2, 2012. Original articles in adult population were included. MMC process and structure, as well as baseline study demographics, main results, and conclusions, were collected. Results. 38 articles were included. 10/38 (26%) pertained to medical subspecialties and 25/38 (66%) to surgical subspecialties. 15/38 (40%) were prospective, 14/38 (37%) retrospective, 7/38 (18%) interventional, and 2/38 (5%) cross-sectional. The goals were quality improvement and education. Of the 10 medical articles, MMC were conducted monthly 60% of the time. Cases discussed included complications (60%), deaths (30%), educational values (30%), and system issues (40%). Recommendations for improvements were made frequently (90%). Of the 25 articles in surgery, MMCs were weekly (60% of the time). Cases covered mainly complications (72%) and death (52%), with fewer cases dedicated to education (12%). System issues and recommendations were less commonly reported. Conclusion. Fundamental differences existed in medical versus surgical departments in conducting MMC, although the goals remained similar. We provide a schematic guideline for MMC through a summary of existing literature.

Treatment and Outcomes of Iatrogenic Colon Perforations at a Community Teaching Hospital

Despite the growing expertise in colonoscopy, it remains subject to complications. The previously published rate of colonoscopic perforation is 0.82 per 1000 examinations. The objective of this study was to describe the experience and management of colonoscopic perforations. A retrospective review of cases from a database of surgical complications was searched for perforations postcolonoscopy from January 1, 2001, to December 31, 2010 at a 527-bed community teaching hospital. Eighteen patients were identified, 11 of whom underwent examination at our institution. Ages ranged from 40 to 91 years with a mean age of 71 years. Eleven of the 18 patients were female and seven were male. Main outcome measures were treatment approach, treatment complications, and mortality. A total of 18 patients were identified in this database. Of these 18 patients, 11 underwent colonoscopy at our institution. During the studied time period, 7578 colonoscopies were performed at our hospital. The majority of the perforations were located in the rectosigmoid colon. Seventeen patients were treated with surgical exploration of the abdomen. Ten patients experienced complications postoperatively. There were two deaths in our series. Only cases in which the colonoscopy was performed at our institution were used when making incidence calculations. The incidence of perforation in our series was significantly higher than previously reported rates. When the perforation was discovered and treated within 24 hours, the patient was rescued. Timely recognition of surgical complications is critical in preventing patient mortality.

Is there a role for bowel preparation and oral or parenteral antibiotics in infection control in contemporary colon surgery?

The numbers of unanswered questions are many. Can intraoperative application, such as topical antimicrobial use in pulsed lavage, reduce the microbial burden on the wound interface before closure? Can closed suction drains within the closed surgical incision reduce infection rates, especially in patients with a large body mass index? What is the role of delayed primary closure or secondary closure in the wound where obvious contamination has occurred, or in the circumstance of emergent colonic resection where considerable contamination is encountered from preexistent perforation? Should immediate negative-pressure wound dressings be applied in the open contaminated wound? These and many other questions still confront the surgeon in the challenge of the surgical wound in major colorectal surgery.

Surgical resident bedside rescue successes

OBJECTIVE

Attempts at improvements in emergent bedside care of hospitalized patients is an ongoing process in many institutions. Recently, the development and role of rapid response teams has been well described in the literature. However, the role of surgical residents, who are typically not part of these "medical" teams, in emergent bedside care of patients, has not been well described in the literature. Surgical residents have been responsible for many bedside emergent "rescue successes," in teaching hospitals. We present 11 instances of surgical resident bedside rescues over a 1-year period at Monmouth Medical Center as a means of emphasizing their critical role in reducing adverse events and even mortalities.

DESIGN

These cases were presented at our Morbidity and Mortality conferences and involved only surgical residents performing various technical maneuvers.

SETTING

Monmouth Medical Center.

PARTICIPANTS

The 11 cases are representative and do not include multiple central lines and do include 2 of many chest tube-related cases. There was no "failure to rescue case" that involved only the surgical residents.

RESULTS

Surgical bedside rescues included: an emergent reintubation, 2 openings of neck incisions for expanding hematomas, replacement of a dislodged tracheostomy tube, rigid sigmoidoscopy for rectal bleeding, bronchoscopy for hemoptysis, control of a permacatheter bleed, control of a ruptured femoral-femoral crossover bypass, control of a bleeding tracheoinominate fistula, and emergent placement of chest tubes.

CONCLUSIONS

Surgical residents possess bedside procedural skills beyond those of nonsurgical health care workers and rapid response members. These lifesaving skills are needed to reduce adverse events and even prevent mortalities in hospitalized patients. Bleeding complications and invasive procedures such as chest tube placement, venous cutdowns, and emergency endoscopy are situations where a surgical resident should be called first, in a teaching hospital.

Laparoscopic versus open ventral hernia repairs: 5 year recurrence rates

BACKGROUND

Current studies with 2-3 year follow-up favor laparoscopic ventral hernia repair due to lower recurrence rates, fewer wound infections, and shorter hospital stays. There is scant data in the literature for this group of patients regarding longer follow-up. This study compares the actual 5 year recurrence rates of laparoscopic versus open techniques and determines factors that may affect recurrence.

METHODS

A retrospective analysis of ventral hernia repairs at a tertiary center between January 1996 and December 2001 was performed. In this era, the method of repair often depended on which surgeon evaluated the patient. All patients were followed for a minimum of 5 years (median 7.5 years). Demographic and clinical parameters were analyzed using Kaplan-Meier analyses and the multivariate Cox proportional hazard model.

RESULTS

Of 331 patients, 119 underwent laparoscopic ventral hernia repair (LAP), 106 open hernia repair with mesh (O-M), 86 open suture repair (O-S), and 20 laparoscopic converted to open (LCO). Statistical analyses showed equal parameters among groups except defect sizes (mean +/- standard error on the mean [SEM]): LAP (9.8 +/- 1.2 cm), O-M (11.2 +/- 3.3 cm), LCO (16.6 +/- 5.4 cm) versus O-S (4.6 +/- 1.6 cm) (p < 0.02). Actual recurrence rates at 1 and 5 years were LAP (15% and 29%), O-M (11% and 28%), O-S (10% and 19%), and LCO (35% and 60%). Multivariate analysis identified larger defects to have higher recurrence rates, particularly in the O-S group (p < 0.02). With the exception of the LCO group, surgical technique did not predict recurrence, nor did body mass index, diabetes, smoking, or use of tacks versus sutures.

CONCLUSION

This is the first study to compare 5 year actual recurrence rates between laparoscopic and open ventral hernia repairs. Contrary to prior reports, our longer-term data indicates similar recurrence rates, except for higher rates in the laparoscopic converted to open group. Due to the continued recurrences over the period studied, longer-term follow-up is necessary to appreciate the true rate of hernia recurrence.

When should a surgical resident call an attending surgeon?

BACKGROUND

Many interactions exist between surgical residents and attending surgeons, where residents debate whether they should "bother" to call an attending. Several instances have occurred when a senior resident or an attending has not been notified about a patient's status by a junior resident. Because of poor communication, care might be delayed, and surgeons and patients' relatives might not be informed of a change in status. Sometimes the resident's initial management was different than an attending's management. Communication issues were raised at our weekly Morbidity & Mortality conference. We decided to investigate the range of judgment as to when a resident should notify an attending surgeon.

STUDY DESIGN

The objective was to investigate the range of judgment as to when a surgical resident should notify an attending surgeon. The purpose of this study was to determine the clinical circumstances when surgical residents should contact an attending surgeon directly or leave a message with the service. To investigate communication questions, we developed a survey of 34 clinical circumstances in which a surgical resident could call an attending. Sixteen residents and 16 attendings completed the survey entitled "Conditions where a surgical resident should consider contacting the surgical attending." From the information obtained from this study, a "must leave message" and "must speak to directly" list were created to guide residents as to when to call an attending.

RESULTS

A significant difference existed in the answers provided by residents and attendings. Residents and attendings agreed universally that an attending should be spoken to directly for 2 reasons: cardiopulmonary arrest and death. We created a "must speak to directly" list based on the attendings' answers. This list includes 10 clinical circumstances in which a surgical resident should speak directly with an attending regarding patient issues. Likewise, a "must leave message" list was created of an additional 8 reasons when a surgical resident must at least call the service of an attending and leave a message.

CONCLUSION

The purpose of our study was to help standardize communication between surgical residents and attendings regarding patient status. With these 2 standardized "must" lists, residents will have less uncertainty or hesitation to awaken an attending at night. This finding should improve the communication skills of surgical residents and ultimately improve the quality of patient care.

Attitudes of Surgical Specialists toward Venous Thromboembolism Prophylaxis in Surgical Patients

Venous thromboembolism (VTE) and pulmonary embolism are serious and potentially life-threatening complications in surgical patients; however, the risk can effectively be lessened using appropriate pharmaceutical and mechanical prophylaxis. Due to the variability in opinions and indications for VTE prophylaxis, proposed guidelines for VTE prophylaxis stratified according to patient- and procedure-oriented risk factors were widely circulated. We investigated to what extent these guidelines were accepted by 147 university and community-based surgeons in mid-America and how the recommendations for prophylaxis compared with recent past surgical practice performed on 5285 patients in Kentucky in 2004. Attitudes varied widely with respect to practice sites, modes, and specialty. Actual practices used in the Surgical Care Improvement Project 2004 varied even more widely and were at substantial variance from recommendations and current Centers for Medicare and Medicaid Services quality measures.