Cutting edgeby Donna Chisholm
If your surgery goes wrong, you can spend months getting better, and the cause can be a simple failure to follow the rules.
When Auckland urologist and surgeon Russell McIlroy had the mitral valve in his heart replaced, he imagined he would be back in theatre, scalpel in hand, within five or six weeks. Two months and three operations later, he was still laid up, a catheter dripping intravenous antibiotics into his arm as he fought a life-threatening infection in his chest wound.
The combination of sepsis and opiate painkillers sent him into “fairyland” for days. He recalls waking up one night “having a very erudite conversation with a man at the end of my bed. God, he was talking a lot of sense. And then I realised I was talking to myself.”
The risks of surgical infections – and the gruelling toll they can exact – made news this summer when it emerged that Foreign Minister Murray McCully was off work for two and a half months as he battled the superbug methicillin-resistant Staphylococcus aureus (MRSA) after pancreatic surgery. He was taken to North Shore Hospital by ambulance and admitted to its intensive care unit.
Infections after surgery occur in fewer than two of every 100 cases – although the rate is higher for some sites such as the bowel – so McIlroy and McCully were unlucky. But health-sector leaders think surgery can and should be safer still. A paper in the New Zealand Medical Journal last year on reducing surgical harm reported OECD data that indicates we have one of the highest documented rates of post-operative infections. We also have the third-highest rate of “foreign bodies” – typically instruments or sponges – left in the patient after a procedure, and we are six countries below the average for lung embolism and deep vein clots. “Some argue we are simply better at recording adverse outcomes, but regardless, these numbers are unacceptable,” the report’s authors said.
Surgery-related treatment injury claims are soaring and the cost is eye-watering. Last year, ACC paid out nearly $43 million in compensation, rehabilitation and treatment for more than 4200 claims, most involving hip or knee surgery or the removal of skin lesions. That’s more than four times the $10.3 million spent in 2010-11. Infection and bruising are the commonest “injuries”, followed by nerve damage.
The World Health Organisation’s surgical checklist, widely adopted internationally since it was published in 2008, has already been credited with reducing death, infections and other post-operative complications by up to 30%. Although it’s used in most surgical cases here, worrying new research points to a culture and lack of communication in the operating room that is potentially undermining the checklist’s benefit. The research, a survey of more than 800 operating theatre staff published by the Health Quality and Safety Commission (HQSC) in December, suggests that a surgeon-led hierarchy in theatre and pressure to get through the operating list might be compromising safety.
It found 38% of those questioned did not believe surgical team members were open to changes to improve patient safety if it meant slowing down, and concluded communication was a key area of “underperformance”. Nearly 60% said they didn’t think surgeons “maintained a positive tone throughout operations” and 35% reported that potential errors and mistakes were sometimes pointed out with raised voices.
The research found that nearly half of the debriefings after operations failed to discuss key concerns for the patient’s recovery and that “teamwork and communication failure are at the core of nearly half of all medical errors and adverse events”.
The survey followed a September report to the Royal Australasian College of Surgeons that said nearly half of college fellows, trainees and international graduates had been subjected to discrimination, bullying or sexual harassment. The college has vowed to stamp out the culture which it says puts patient safety at risk.
But in his New York Times bestselling book The Checklist Manifesto: How to Get Things Right, US surgeon and public health researcher Atul Gawande says the most common obstacle to effective teams “is not the occasional fire-breathing, scalpel flinging, terror-inducing surgeon, though some do exist. No, the more familiar and widely dangerous issue is a kind of silent disengagement. ‘That’s not my problem’ is possibly the worst thing people can think. But in medicine, we see it all the time.”
Gawande describes surgery’s four big killers as infection, bleeding, unsafe anaesthesia and the unexpected. “For the first three, science and experience have given us some straightforward and valuable preventive measures we think we consistently follow, but don’t.
“These misses are simple failures – perfect for a classic checklist. But the fourth killer, the unexpected, is an entirely different kind of failure, one that stems from the fundamentally complex risks entailed in opening up a person’s body and trying to tinker with it. No checklist [can] anticipate all the pitfalls a team must guard against.”
The best defence against the unexpected, he writes, is simply to have the surgical team talk through the case together, to be ready as a group to identify and address each patient’s unique, potentially critical dangers. “Perhaps all this seems kind of obvious. But it represents a significant departure from the way operations are usually conducted.”
Gawande and his team had a harder time than we have had trying to get surgeons in the US to use the checklist, says Auckland anaesthetist Alan Merry, who chairs the HQSC.
“I believe they have a great deal more hierarchical behaviour – multiple places, many private little fiefdoms. They see a surgeon and ask them to adopt the checklist and the surgeon will say, ‘I don’t need to, I don’t make mistakes.’ They’ve learnt to ask, ‘Do your colleagues make mistakes?’ And typically the surgeon will say, ‘Yes, they do.’” They’ll then get them to agree to use the checklist – for their colleagues.
In the operating room, Merry says, it takes only one senior person – and it could be an anaesthetist, a surgeon, or even a senior nurse – to be a poor role model for the effect on the rest of the team to be substantial. He’s seen a surgeon decline to introduce himself as the checklist requires, saying “everyone knows who I am”. Merry gently challenged him, pointing out that although everyone knew him, the surgeon didn’t know everyone else.
“The way you challenge is important – you don’t want to have a stand-up fight in the middle of an operation. I don’t think there’s any doubt we have some people who are a problem, who don’t see the wider picture of why these things matter, and they do represent a bit of a barrier to some important change.”
The operating room can be a tense place when complicated, difficult and lengthy surgery is in progress. Merry says cardiac surgery lasting 12 or more hours is not uncommon. “The patient is bleeding, the poor old surgeon is struggling inside a chest … it’s awkward to do and physically exhausting, and if someone makes a comment that’s a bit unhelpful he or she might snap.”
Bear in mind, too, says Merry, that such hard and stressful work doesn’t tend to attract the sort of personalities who’ll go into psychiatry and “sit around and have an empathetic conversation”. And with demand for surgical training places so high, candidates are less likely to complain for fear of jeopardising their careers.
The college report has, however, put bad behaviour in theatre “on the radar”.
“Before that, it didn’t necessarily attract odium. Now it does, and you don’t want to be thought of that way by your colleagues.”
Merry and Gawande have also identified the complexity of surgery being performed today as making operations safer but, paradoxically, potentially riskier.
“It’s like trying to fly a two-engine plane versus a single engine,” says Merry. “You’ve got more security because you’ve got two engines, but it’s more difficult so your chance of an error is greater. When I started, you looked at the patient and felt the pulse. The new machines and gear is space-age and there are three monitoring screens full of information. The risk is you are getting cognitive overload.”
Merry has been a key figure internationally in efforts to reduce drug errors in anaesthesia. A study of his published in the British Medical Journal in 2011 found drug errors at Auckland City Hospital occurred in about one in nine administrations. (Most were errors of recording but in other cases the incorrect drug was given or drugs were not given at all.) That number dropped to one in 11 when anaesthetists used a new system he has patented, which includes customised drug trays, pre-filled syringes, computer-linked barcodes and large legible colour-coded drug labels.
“On a particular anaesthetic [procedure], you’re likely to have 10 drug administrations, so that means there’s a recording error more or less in every [operation]. It’s a problem of some importance, and part of the wider problem of drug error in the whole of health care, and it’s very hard to know how much patient harm it actually causes.”
Many medication errors will go undetected. “You won’t report an incident if you don’t know you did it. And if you fail to give an antibiotic in the allotted time and the patient develops an infection two weeks later, it might not be put down to that.”
The checklist is one tool to help ensure the basics are not missed, but it has to be used correctly. Last year’s medical journal article, co-written by Merry and colleagues including the HQSC’s Safe Surgery NZ Advisory Group chair Professor Ian Civil, said though it is being widely used, operating theatre staff are often engaging with it only in a tick-box and distracted fashion.
Civil is one of those working, one operating list at a time, to change that culture.
It’s 8am, and on the eighth floor of Auckland City Hospital, a 12-strong team of surgeons, anaesthetists and nurses in blue scrubs are preparing for the first of three operations that will occupy them and lead surgeon Civil for the next eight or nine hours.
Because it’s Civil’s list, the team has gathered a few minutes earlier than usual for a pre-op briefing. “Good morning, everyone. I’m Ian, the vascular surgeon today,” he begins, before group members introduce themselves and their role. Civil then outlines the cases on the list: an otherwise fit and healthy man who will have an aneurysm behind his knee bypassed; an elderly man who’ll have a blockage in his carotid artery cleared and shunted; and a bigger patient whose varicose veins will be stripped.
Civil and the anaesthetist briefly discuss any potential problems with the anaesthesia, and the nurses ask about particular instruments that may be needed. Just four minutes and 54 seconds later, the briefing is over and the team is ready to go. It’s a deceptively simple routine but one that Civil believes has already made today’s operating room a safer place for his patients.
A former army medic, he is one of only a few surgeons nationally who routinely adds military-style briefings and debriefings to the routine checklist and says he’s surprised they aren’t used more often.
“The military do briefings for even the most trivial things. If you were a section of soldiers and I wanted you to cross the road, I’d give you a briefing about how we were going to do it. The military is trying to empower each member of the group to be as capable as they can possibly be, to achieve the ultimate goal.” In the operating theatre, the fact each of the team members has been introduced and asked for their input before surgery even starts might help them to speak up to raise a concern later.
The HQSC says a pilot programme in Auckland and Waikato in 2014 showed briefings and debriefings, as well as a paperless checklist (it’s read off a wall chart), improved the culture of teamwork and communication in theatre. Both health boards and private hospitals are expected to add them to surgical protocols within the next two years.
Though Civil co-wrote the medical journal paper that examined New Zealand’s relatively poor OECD placings for surgical safety, he says the rankings need to be interpreted with caution. We’re not too different from Canada and Australia, and on the figures, “the best place in the world is Poland”.
Nevertheless, he says, the error rates show we have room to improve. “Surgery is incredibly safe, and way safer than the surgery I was doing as a trainee 35 years ago. Compared with any other first-world country, surgery in New Zealand is at least as safe or safer. But can you sail into surgery as a patient and not expect any problems at all? No, that’s not true. Bad things can happen.”
Poor outcomes are seldom related to a surgeon’s lack of skill or technique; more commonly they can result from a wrong decision to operate in the first place, for example on a high-risk patient with other complicating conditions where the likely benefits are marginal. Briefings won’t prevent those errors of judgment, but they will at least save time and, more importantly, help to change the mindset of the team.
“We try hard to create a shared mental model,” says Civil, “but one definitive way not to have one is when you don’t tell people things. When people find out late about issues, what they take away is that we’re not a team.”
Encouraging teamwork is also behind a new operating room simulation training programme he’s involved in at the University of Auckland’s School of Medicine, which brings together surgeons, anaesthetists, nurses and technicians for multidisciplinary exercises in which they respond as a group to surgical or anaesthetic crises, using mannequins that breathe, bleed and can be monitored. More than 3000 staff are expected to be trained here in the next five years following its launch in mid-December.
Reducing post-operative infection rates in joint surgery is one of the priorities for the commission’s Surgical Site Infection Improvement programme, soon to be extended to cardiac surgery as well. District health boards (DHBs) now provide statistics on a range of measures, including whether an antibiotic is given before surgery at the right time (60 minutes or less before incision) and at the correct dose. Figures from 2013 showed wildly varying rates between DHBs: some, including Hutt Valley, Whanganui, MidCentral, Hawke’s Bay and Taranaki achieved that goal 15% of the time at best; most boards are now achieving it in at least 95% of cases.
The figures have thrown up regional differences in infection rates that are difficult to explain. Canterbury, for example, the biggest provider nationally of hip- and knee-joint operations, has a 0.7% infection rate; Auckland’s is 1.3% and Counties Manukau has the country’s highest at 2.4%.
It is possible that higher rates of obesity and diabetes in the Counties Manukau patient population are having an effect, though the body mass index (BMI) figures did not differ from those in other board areas.
The commission is trying to identify what Canterbury might be doing differently to produce such good rates, although Auckland microbiologist Sally Roberts, chair of the HQSC steering group on surgical site infections, points out the board does have a stand-alone hospital, Burwood, where all elective joint operations are done. “They’re not trying to fit people around acute admissions.”
Patients who develop infections are usually colonised with the bacteria that are already on their skin. Around a quarter of us, for example, already carry Staphylococcus aureus, the most common infective agent, on our skin. Roberts says there’s some research on pre-surgical screening for the bug, and it’s possible it might be introduced for operations in which the consequences of infection are “horrendous”.
Of course, infections aren’t always the result of something done or not done in the operating room – it may be the result of someone on the ward not washing their hands three days later.
Hand hygiene routines require staff to use soap or a hand rub before and after patient contact, and after contact with patient surroundings, which even includes touching a cubicle curtain. Some ward rounds at Auckland City Hospital have reportedly designated one person as “the curtain puller”.
The patient’s condition can also increase risk. Operations on the obese, for example, can be more technically challenging, and take longer. Blood loss and hypothermia are also associated with a higher rate.
Although patients can quickly discover health board infection rates online, the same doesn’t apply to private hospitals, where many will choose to have their joint surgery performed.
Terry Moore, the chief executive of the Southern Cross private hospital network, says the sector is heading towards having more information available publicly but isn’t there yet. Private hospitals are working with the commission and voluntarily provide data on a range of indicators including adverse events, transfer rates to public hospitals and perioperative deaths (the perioperative period covers the time from ward admission to recovery). But producing league tables that compare private hospitals with each other is a fraught exercise because of differences in hospitals’ case mix and size. Moore says it’s important for any data to be meaningful to the patients using it. “I don’t think producing a crude number is sensible.”
Surgeons and anaesthetists feature only a few times a year in adverse findings by the Health And Disability Commissioner, although in 2008, commissioner Ron Paterson criticised the post-operative care of two surgeons whose patients died after keyhole surgery. He said trust in the private hospital system was “sometimes misplaced” because it did not have the backup, triggers and alerts available in a public hospital when a patient’s condition deteriorated.
Last year, commissioner Anthony Hill criticised the care a Grey Base Hospital anaesthetist and three nurses provided to a 15-year-old boy, Matt Gunter, who died from a lung complication in 2012 after having his appendix removed. The complication wasn’t correctly diagnosed and monitoring and treatment were substandard. Late last month, a coroner permanently suppressed the names of the staff, against the wishes of Matt’s parents Heather, a nurse at Grey Hospital, and Dave Gunter.
Russell McIlroy acknowledges the irony of the surgeon becoming the patient with an unexpected complication – particularly since he was one of the first to embrace the surgical checklist before he retired in 2010.
“It could have been seen as just another bureaucratic time-wasting thing, but we bought into it, and the nursing team were very happy with it, which was a big thing – I guess they felt more included in the process,” says McIlroy, formerly president of the Cancer Society and Auckland Hospital’s clinical leader in surgery. “Initially I thought, ‘Oh no, not another lot of these things, but then I thought, ‘Let’s do it and see how it goes.’ It was quite easy and worthwhile.”
His operation, in 2008, was performed before Auckland adopted the checklist, but there is no way of knowing whether it would have made any difference. Prophylactic antibiotics, for example, reduce the risk of infection, but they don’t come with a money-back guarantee.
Despite also developing an infection in a replaced hip joint two years earlier, McIlroy, now 76, refuses to rue his double misfortune. “I think I’m lucky,” he says. “I survived.”
Bad calls & bad care
A roll call of death and damage in theatre.
Complications are not usually the fault of surgeons, but high-profile cases in recent years have shown the scalpel-wielders are not infallible.
2005: Auckland surgeon Kueli Tonga admits professional misconduct charges before the Health Practitioners Disciplinary Tribunal after complaints from three patients who suffered complications after surgery.
2008: The Health and Disability Commissioner finds obstetrician and gynaecologist Roman Hasil botched eight female sterilisations while working at Whanganui Hospital.
2008: Wellington surgeon Gary Stone’s care of two patients who died of post-operative complications after routine laparoscopic surgery at Wakefield Hospital is criticised by the Health and Disability Commissioner and referred to medical authorities.
2009: Suppression is lifted in the case of Auckland breast surgeon John Harman, who was found guilty of negligence after a patient suffered disfigurement and stomach necrosis after a breast reduction, tummy tuck and liposuction. Three Health and Disability Commissioner complaints were also upheld.
2010: Wellington surgeon Richard Stubbs is found guilty of professional misconduct after a patient died in February 2006 following gastric bypass surgery. He discovered his patient had abnormal liver function only after he was under anaesthetic, but went ahead with the operation instead of waking the patient to inform him of the increased risk of death or complications. The Health and Disability Commissioner has also found Stubbs in breach of the patients’ code of rights numerous times for other cases, usually involving lack of informed consent.
2013: Surgeon Michael Parry resigns from Blenheim’s Wairau Hospital after the death of an 80-year-old man during hernia and gall bladder surgery. Parry had been working under self-imposed restrictions after several medical mishaps.
Counting the cost
• The Health Quality and Safety Commission, now five years old, was set up in response to former Treasury Secretary Murray Horn’s first report of the Ministerial Review Group on public health in 2009, which reported that an estimated 44,000 hospital patients a year were harmed by an adverse event at an annual cost of $600-800 million a year.
• More than 300,000 operations are publicly funded each year. If even the most conservative infection estimates are used – around 1.2% – about 3600 patients are directly affected.
• World Health Organisation checklists for safer surgery have been progressively introduced since 2010. It’s estimated their systematic use will reduce avoidable complications by about 20-30% and save nearly $6 million a year.
• New Zealand’s reported rate of post-operative infection is 1260 per 100,000 hospital discharges, one of the highest in the OECD. We have the third-highest rate of foreign bodies left in during a procedure (10.8 per 100,000 discharges, twice the OECD average) and almost twice the OECD average of accidental puncture or laceration during surgery.
• In 2014-15, 10 patients were given a procedure at the wrong site, half of them on the wrong side.
• ACC paid out nearly $43 million last year for more than 4200 surgery-related treatment claims – an increase of more than 400% on figures from five years ago.
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