As part of the 2021 virtual American College of Surgeons Clinical Congress, experts gathered to review several hot topics in surgical patient safety. These subjects—some newer developments and other challenges that continue to present complications for surgeons and their staff—were reviewed during a series of presentations and an accompanying panel discussion.

The sessions, highlights of which are included below, focused on how practices and technologies are evolving in order to address peri- and postoperative challenges, and allow for more successful risk management strategies. The goal, said the moderator of the session, Juan A. Sanchez, MD, the regional vice president at HCA Healthcare Physician Services Group, in Brentwood, Tenn., is “to keep surgical patients safe from unintended harm.”

Venous Thromboembolism, Healthcare-Associated Infections Pose Continuing Threat

Venous thromboembolism (VTE) and healthcare-associated infections (HAIs) are “two highly relevant topics that really apply to the daily practice of surgery,” said Peter A. Najjar, MD, an assistant professor of surgery at Johns Hopkins Medicine, in Baltimore.

Dr. Najjar added that inpatient VTEs remain very common. “In fact, there is good evidence to suggest that they are the most common preventable cause of in-hospital death.”

Although pharmacologic prophylaxis against VTEs has been shown to be safe, effective and cost-effective (and is advocated by existing guidelines), these methods remain underused (Agency for Healthcare Research and Quality; October 2015. AHRQ Publication No. 16-0001-EF).

Effectively preventing VTEs requires a multistep process incorporating standardized risk assessment, ordering prophylaxis and delivery of prophylaxis. When possible, risk assessments should be integrated into a patient’s electronic health record. Ordering of appropriate prophylaxis, Dr. Najjar said, should be based on patient and procedural risk factors, and ensuring prophylaxis is administered to the patient is of the utmost importance. Missed opportunities for prophylaxis can be common, and they highlight the need for additional educational efforts.

“With this comprehensive strategy, the goal is to reduce the incidence of VTE to only those that are not preventable using best practice in modern surgical settings,” Dr. Najjar said.

Another problem that continues to present a significant source of preventable morbidity and mortality is HAIs.

The most common type of HAIs, accounting for more than 30% of infections, is surgical site infections (ssIs). It is estimated that ssIs cause 8,000 deaths annually in the United States, and 40% to 60% are preventable (Surg Clin North Am 2015;95[2]:269-283).

For both HAIs and ssIs, further decreasing rates likely requires the bundling of multiple techniques.

“Over time, we’ve gotten so good at reducing ssIs through antiseptic technique and meticulous hemostasis, technical skill improvement, and procedural planning that infection rates have dropped substantially,” Dr. Najjar said. “So, in order to demonstrate a meaningful improvement, there are very few ‘silver bullets’ that will take an infection rate down substantially from those levels. That’s where I think the power of good process and bundles come into play.”

Avoiding Unintended Retained Surgical Items And Patient Identification Errors

Improvements can also be made in preventing retained surgical items (RSIs) and hospital-based patient misidentification.

“RSIs are a ubiquitous problem that crosses body cavities, small and large cases, in addition to crossing surgical specialties,” said Lauren T. Steward, MD, an assistant professor of GI, trauma and endocrine surgery at the University of Colorado Department of Surgery, in Denver.

Dr. Steward said basic counting procedures are not enough to eliminate these occurrences.

“Communication should be enhanced,” Dr. Steward said, including verbal communication and acknowledgment when placing small objects into, and removing them from, the patient’s body. Additionally, backup strategies should be used, such as a white board on which placement and removal of items are actively recorded. Surgical debriefs should verify that items placed in the body have been removed, and x-rays can be used to rule out the presence of RSIs.

Dr. Steward noted that it is especially important for hospital leadership to continuously demonstrate that patient safety is a priority, ranking even higher than productivity and efficiency.

“In order to avoid RSIs, we have to recognize that there is a problem that affects all disciplines of surgery and all types of cases,” Dr. Steward said. “It is going to take a multidisciplinary effort in order to prevent RSIs, and all team members should be empowered to speak up.”

Patient identification errors are defined as the failure to correctly identify patients, resulting in mistakes in medication, transfusion and testing. These errors also include wrong-person procedures and the discharge of infants to the incorrect family.

There are many causes of patient misidentification and they can occur at multiple points during a hospital stay. During registration, incorrect information may be given or recorded; inadequate staff training and time pressures may result in errors; and there may be duplicate medical records or communication issues across departments.

To prevent these mishaps, reliance on at least two patient identifiers at all times is key. Protocols and standardized procedures are of the utmost importance, and technological advances—wristbands that include patient photographs, or biometric methods such as fingerprint, retina or palm scans—may be implemented.

“We must recognize that there is a problem and that patient misidentification can happen at any point during a patient’s hospitalization,” Dr. Steward said.

Evaluating Frailty, Perioperative Nutrition And Prehabilitation for Surgery

Ensuring patients are well enough to have positive outcomes is of core importance to the surgical process.

“Frailty is a syndrome of decreased physiologic reserve and resistance to stressors which leaves patients vulnerable to worse outcomes,” said Steven C. Cunningham, MD, the director of pancreatic and hepatobiliary surgery and director of research at Ascension Saint Agnes Hospital, in Baltimore. “Frailty is strongly, and unsurprisingly, correlated with poor outcomes after surgery.”

Criteria for determining a patient’s level of frailty include weight loss, weakness, exhaustion, low physical activity and slowness of movement, and can be assessed via self-report and in-office testing.

Dr. Cunningham stated that patients who are determined to be in the intermediate category of frailty are at elevated risk for complications, as well as being twice as likely to become frail within three years, thus putting them at much increased risk for adverse health outcomes.

As such, Dr. Cunningham noted the importance of assessing for the five criteria of frailty with any patients determined to be at risk, and then performing appropriate interventions.

Malnutrition also is associated with an increased risk for postoperative adverse events, and rates increase as patients are older and sicker. For malnourished patients, it may be worth considering preoperative nutrition consultation and therapy. For well-nourished patients, dietary restriction, such as fasting, may provide benefits. However, Dr. Cunningham noted, this approach has not yet received mainstream acceptance.

Rehabilitation programs, aimed at improving a patient’s health before surgery, show some promise, but the data remain inconclusive.

“There is conflicting evidence regarding length of stay and morbidity and mortality, but there is good evidence for improved functional and exercise capacity,” Dr. Cunningham said.