sutures newsletter


P & T Approvals; FDA Warns About Zydelig

Pharmacy Focus

See highlights of the February meeting of the Pharmacy and Therapeutics Committee. Also, the U.S. Food and Drug Administration is alerting healthcare professionals about reports of an increased rate of adverse events, including deaths, in clinical trials with the cancer medicine Zydelig in combination with other cancer medicines.

Mark Your Calendar

Surgery Grand Rounds

Click the "read more" to see information about upcoming Surgery Grand Rounds.

Grand Rounds

Click here to view a schedule of all upcoming grand rounds.

Education Schedule

Click the PDF link below to see the Department of Surgery's education schedule.

Education Schedule - March 2016  

Surgery Scheduling

Click the "read more" for hours and contact information for surgery scheduling.

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Know an interesting colleague we should profile? A story we should tell? Submit your ideas, meetings and events for consideration.

Click here to submit your news to Sutures

Expediting Admission to the SICU

By Eric Ley, MD
Director, Surgical Intensive Care Unit

Atul Gawande, MD, demonstrated in a study published in the New England Journal of Medicine that a surgical safety checklist can reduce mortality. In contrast, David Urbach, MD, also published his team's findings in the New England Journal of Medicine, establishing that implementation of a surgical safety checklist did not reduce mortality.

The consensus between the checklist-loving Gawande and the contrarian Urbach is that healthcare systems are complicated and successful implementation of a surgical safety checklist is not simple. A checklist should be considered a tool to facilitate communication and coordination rather than a decree that is posted on a computer monitor. Successful human factor interventions, such as a surgical safety checklist, require the system to adapt to the user rather than forcing the user to adapt to the system.

At Cedars-Sinai, we conducted a comprehensive human factors study of trauma patient flow from the prehospital setting through the Emergency Department, Radiology, operating room and intensive care unit. Our goal was to improve efficiency, as delays in trauma patient care can be catastrophic. Trained observers followed trauma patients through each phase of care and recorded "flow disruptions" in patient care.

Challenges were largely seen in communication, coordination and handoffs. A number of thoughtful interventions were proposed and tested to help the system adapt to the users in order to reduce flow disruptions. The result of the study was improved efficiency and lower length of stay for our high-level traumas.

One related intervention was the availability of a 24-hour ICU trauma bed, and with its implementation we observed a drop in mean ED length of stay from 4.2 hours to 3.1 hours for trauma patients who required an ICU bed. As noted, systems are complicated and an intervention such as establishing an available ICU bed does not necessarily translate to rapid patient transport to that bed.

During the human factors observation period, three steps that required increased communication and coordination were noted to slow the patient's transfer to the ICU bed:

  1. An admission order needs to be placed for the ICU bed.
  2. The trauma MD needs to phone the ICU MD for a simple handoff of the patient.
  3. The ED RN needs to phone the ICU RN handoff for a transition of care handoff.

Our study indicated that typically, the admission order was delayed until the MD was certain that the ICU bed was required. So we encouraged the order to be placed in the electronic medical record as soon as a patient was identified as potentially critically ill to initiate preparation for patient arrival. Sometimes the order was placed as soon as the patient rolled into the hospital. If necessary, this order could be reversed with no patient harm and little cost.

For step 2, the trauma MD to ICU MD handoff occurred when the diagnoses were available that supported the need for an ICU admission. For example, when a patient was intubated in the ED, significant injuries were noted on CT or a patient had a major operation, the MD-to-MD handoff occurred. And the last the step, ED RN handoff to ICU RN, occurred after the first two were completed. This step required the MD to update the RN that it was time to call for handoff, as frequently the RN was not aware that step 1 and step 2 were completed.

With this better understanding of patient flow to the SICU, mean ED length of stay reduced further, from 3.1 hours down to 2.4 hours. So should we post a checklist that pops up on your nearest CS-Link monitor titled How to Get Your Crashing Patient to the SICU?

Whether you are a Gawande believer or an Urbach supporter, if a patient is crashing in the ED, on the floor or in the operating room, remember to:

  1. Request the SICU bed as soon as possible.
  2. Call the MD in the ICU to hand off the patient.
  3. Encourage the nursing staff to do the same.

And if there is a problem, please drop me an email so we can determine where the flow disruptions were and how the system can better expedite the SICU admission.