Abstract
I was making a presentation to our residents this morning in my role as Quality Medical Director for our 26-physician university-based department of orthopedic surgery. I was discussing an uncommon untoward event that placed our hospital service line in a very low decile based on reporting from Vizient (previously the University Healthcare Consortium, UHC) and the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). I further explained that by simply decreasing the occurrence of this unusual complication from 7 patients a year in our hospital to 4, we would change our reported performance from a very low decile to a very favorable decile compared to similar academic institutions. One of the residents asked whether this was simply playing the numbers game? My answer to his question led to a very interesting discussion between the residents.
We do universal MRSA (methicillin-resistant Staphylo-coccus aureus) screening, followed by decolonization and prophylactic vancomycin, for all MRSA-positive joint replacement patients. This practice has led to a decrease in infection rate in joint replacement patients from more than 3% to less than 1%. 3 At this writing, my joint arthroplasty colleagues have not had a prosthetic joint infection in 15-plus months. These results have greatly improved our relative reporting standing in all of the publicly reported databases. Is this playing the numbers game, or did we improve the quality of life for the 1 to 3 patients per 100 that would have previously had to deal with the substantial morbidity associated with an infected joint replacement? When we decrease the number of patients who develop a deep venous thrombosis or a pulmonary embolus following surgery, are we playing the numbers game, or are we protecting a small number of patients from being treated with an anticoagulant such as coumadin, that is, rat poison?
We have a universal order set within our department. I asked the resident whether this was a decision tree or whether it was cookbook medicine? I remember as a resident using my pneumonic MAP UR GOALS for writing postoperative orders. I would occasionally forget to order physical therapy or some other aspect of care. A forgotten order for physical therapy delayed ambulation of the patient for at least a day. How many of those patients developed an unnecessary deep venous thrombosis from a delay in ambulation? Checklists and order sets should be thought of as decision trees. They should serve as a series of questions to address the needs of the patient in the perioperative period.
We have expanded our order sets to now include our methodology for preoperative medical clearance. Our checklist attempts to optimize the modifiable risk factors of elevated hemoglobin A1C as a surrogate for diabetes management, morbid obesity, anemia, and undertreated hypertension. This methodology will soon be available from the American Academy of Orthopaedic Surgeons Medical Optimization Toolkit.1,4
The patient safety movement started in response to the 1999 report from the Institute of Medicine on medical errors.
2
It has morphed into a methodology based on the airline industry checklist methodology. When best utilized, it is a decision-tree methodology that leads to improved patient care by standardization of processes and avoidance of medical errors. In answer to my inquisitive resident’s question, I think that it is clear that we improve the medical care we deliver when we decrease the number of complications during the perioperative period. Decreasing the risk of an infected ankle replacement will mean a lot to the 2 people in your next 100 total ankle replacements who do not get infected because you have followed strict perioperative guidelines. Those 2 people will not realize that they have been spared quite a bit of morbidity because you played the numbers game. The FootForum is interested in your comments. Please send your comments or criticisms to