Category Archives: Clinical Question

Improving communication during patient handoffs between the OR and ICU

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One discussion this week focused on improving handoffs in the ICU.

Reference: Mukhopadhyay D, et al. Implementation of a standardized handoff protocol for post-opearative admissions to the surgical intensive care unit. American Journal of Surgery. 2018 Jan;215(1):28-36. doi:10.1016/j.amjsurg.2017.08.005.

Summary:  Mukhopadhyay et al’s (2018) recent prospective intervention study explored the effectiveness of a standard protocol for patient transfer from the OR to the SICU. Prior to implementing a new protocol a team of individuals observed 31 patient handoffs. Next, the protocol was implemented over a 6 month period in which all caregivers involved in handoffs attended mandatory educational sessions. Finally, 31 handoffs were observed by the same team of individuals who had observed the previous handoffs.

Services included in the study: thoracic, neurosurgery, trauma, acute care, vascular, surgical oncology, urology, ENT, orthopedics, plastics, and neurointerventional radiology.

Handoff elements observed for completion: presence of all team-members at handoff; identification of patient and caregivers; detailed surgeon report; detailed anesthesia report; and duration/occurrence of key activities (time to ventilator, monitor set-up, total handoff duration).

Results: Pre- and post-implementation performance was measured on all handoff elements listed above. These were elements identified as crucial to the safe and successful patient transfer.

Notably, surgeons were the only group that believed communication was effective in the existing process. Anesthesia and ICU Nursing were dissatisfied. All three groups agreed that a more structured protocol was necessary for safe patient care (p.29).

The figure below show the changes in degree of detail in surgical reports (p.35). The article provides additional charts and data on other pre- and post- findings.

handoff report

Additional reading: Karamchandani K, et al. A multidisciplinary handoff process to standardize the transfer of care between the intensive care unit and the operating room. Quality Management in Health Care. 2018 Oct/Dec;27(4):215-222. doi:10.1097/QMH.0000000000000187.

The value of diverting loop ileostomy to prevent low pelvic anastomotic leak

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One discussion this week focused on the impact of diverting ileostomy on low rectal anastamoses.

Reference: Matthiessen P, Hallbook O, Rutegard J, Simert G, et al. Defunctioning Stoma Reduces Symptomatic Anastomotic Leakage After Low Anterior Resection of the Rectum for Cancer: A Randomized Multicenter Trial. Annals of Surgery. 2007 Aug;246(2):2017-214. doi:10.1097/SLA.0b013e3180603024

Summary: Anastomotic leakage is a feared complication of rectal resections, reportedly occuring in 1-24% and increasing postoperative morbidity from 1-8% to 6-22% (Matthiessen et al, 2007). In a randomized multicenter trial of 234 patients (no easy feat for surgical technique studies), Matthiessen et al (2007) found “patients without diverting stoma leaked in 28.0%, compared to 10.3% of those with diverting stomas (OR = 3.4; 95% CI, 1.6-6.9; P < 0.001), a result not previously demonstrated in any randomized trial” (p.207).

surgmm_leakage

Among patients randomized for diverting ostomy, surgeons demonstrated a preference for loop ileostomy vs transverse colostomy (112/116) and in all 25 urgent diverting stomas. In 97% of the patients (227/234), surgeons chose to use pelvic drainage. All anastomotoses were made with a stapling device, none were handsewn.

The authors conclude that their trial accurately demonstrates a decreased rate of symptomatic ansatomotic leakage in diverted patients in low anterior resection. This is the first randomized trial to illustrate this result and, therefore, they recommend the use of a diverting stoma in low anterior resection of the rectum.

(Matthiessen et al, 2007, p.210)

Additional reading: Hanna MH, Vinci A, Pigazzi A. Diverting Ileostomy in Colorectal Surgery: When is it Necessary? Langenbeck’s Archives of Surgery. 2015 Feb;400(2):145-152. doi:10.1007/s00423-015-1275-1.