Spotlight Case Emergency Error

2 Source and Credits This presentation is based on the June 2013 AHRQ WebM&M Spotlight Case –See the full article at –CME credit is available Commentary by: Nicholas Symons, MBChB, MSc, Imperial College London –Editor, AHRQ WebM&M: Robert M. Wachter, MD –Spotlight Editor: Bradley A. Sharpe, MD –Managing Editor: Erin E. Hartman, MS

3 Objectives At the conclusion of this educational activity, participants should be able to: State that emergency surgery is high risk and has high mortality Appreciate that emergency laparotomy is a particularly high-risk procedure with high likelihood of error and patient harm Understand that clinical experience and seniority may reduce the risk of errors associated with emergency surgery Describe how variability in processes of care can increase the risk to patients undergoing emergency surgery List simple interventions to reduce risk in emergency surgery including checklists, clear job descriptions, and PDSA cycles

4 Case: Emergency Error An 81-year-old woman with a history of pancreatitis presented with the acute onset of abdominal pain, nausea, and vomiting. On presentation, she was in distress due to severe abdominal pain. She was hypotensive and tachycardic. Based on the examination and initial imaging, there was concern for small bowel obstruction. The decision was made to take the patient to emergency laparotomy. At the time of induction, she was given fentanyl, etomidate, and rocuronium.

5 Case: Emergency Error (2) Almost immediately, her blood pressure dropped to 60/30 mm Hg. She was rapidly intubated but her hypotension persisted, despite epinephrine. Her heart rate slowed, and she developed asystole. Cardiopulmonary resuscitation was initiated. She received advanced cardiac life support for 10 minutes. She ultimately regained a pulse but required high doses of vasopressors to maintain her blood pressure. The operation was cancelled and she was taken to the intensive care unit.

6 Case: Emergency Error (3) Over the next 12 hours the patient had progressive multi-organ failure, and she died the next morning. The hospital's case review committee felt the patient likely had severe acute pancreatitis and not a small bowel obstruction. The committee's judgment was that this represented a diagnostic error and that this was a preventable death (since surgery would not have been indicated in the management of her pancreatitis). The case raised many questions about the safety of and errors associated with emergency surgery.

7 Background: Emergency Surgery Emergency general surgery is common and has significantly greater morbidity and mortality than elective surgery Emergency surgery makes up around 50% of general surgery workload but accounts for 80%−90% of all deaths See Notes for reference.

8 Background: Emergency Laparotomy Emergency laparotomy is a surgery performed to explore the abdominal cavity Among all emergency surgical procedures, emergency laparotomy is the highest risk with 30-day mortality of about 15% The mortality is even higher in older patients (as in this case) See Notes for references.

9 Variability in Outcomes Some evidence of variability in outcomes in emergency surgery between institutions Such variability suggests some hospitals are underperforming and outcomes could be improved A UK study identified variability in use of post-operative critical care facilities and seniority of surgeons and anesthesiologists involved in high risk cases See Notes for references.

10 Variability in Outcomes (2) Institutions that perform greater numbers of imaging investigations (e.g., ultrasound and CT scans) and those that perform fewer surgeries for high-risk general surgical admissions also seem to perform better Having the right infrastructure in place (both staff and facilities) is important in improving outcomes See Notes for reference.

11 Basic Emergency Care In emergency situations, prompt diagnosis and care is essential Several studies have demonstrated poor adherence to basic processes such as –Administration of fluids, oxygen, and antibiotics –Prescription of thromboprophylaxis –Observation of patients’ vital signs Omission of basic care processes is associated with increased adverse events and patient harm See Notes for references.

12 Emergency Diagnosis Determining accurate diagnosis can be challenging in an emergency and errors are likely common Imaging studies (e.g., CT scans and ultrasound) have reduced number of emergency surgeries performed Early imaging may also determine which patients are unlikely to survive emergency surgery and allow palliative treatments to be offered instead of surgery See Notes for reference.

13 Experience Matters More senior surgeons appear to have a greater degree of certainty when assessing a patient’s likely outcome and would operate less frequently than junior colleagues when presented with the same scenarios These findings underpin the need for senior surgeons and anesthesiologists at all stages of care for the sickest emergency surgical patients See Notes for reference.

14 Interventions Increasing evidence supports interventions to improve care processes Mainly directed at the admission of patients, ward-based care, and the operating room environment The intervention with the best evidence is the checklist

15 WHO Checklist The WHO perioperative checklist is now in wide use and is equally effective in emergency surgery as it is in elective surgery Notably, the checklist highlights anesthetic or surgical concerns before the surgery May have increased awareness of the risk of sudden deterioration seen in this case See Notes for references.

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17 Other Interventions Informing medical staff that their performance was being observed had little effect on performance or outcomes Issuing staff with a job description highlighting what was expected from their role resulted in significant improvement in process reliability during admission of emergency general surgery patients “Lean” interventions and Plan-Do-Study-Act cycles have been used to improve ward and admission care for emergency surgical patients See Notes for references.

18 Emergency Laparotomy Emergency laparotomy results in a high rate of post-operative complications, which are the most frequent cause of death for these patients Recognizing post-operative complications in a timely manner and treating appropriately is key Differences in recognition and treatment may make up a large proportion of difference between the best performing and worst performing hospitals See Notes for references.

19 Take-Home Points Emergency surgery is common and carries significantly higher risk than elective surgery. Emergency laparotomy is particularly high risk and carries a 30-day mortality of about 15%; mortality is significantly higher in elderly patients.

20 Take-Home Points (2) Diagnosis and decision making for these patients can be challenging. Senior physicians are likely to be able to do this more reliably than those with less experience. Basic processes of care for these patients are frequently incomplete or omitted. Utilization of simple interventions such as checklists, formal job descriptions, and Plan-Do-Study-Act cycles can improve the reliability of care.