Annals of Surgery Volume 263, Number 1, January 2016
Letter to the Editor
Reply: e would like to thank Dr Hakeem for his interest in our recent article.1 We are grateful for the opportunity to respond to his letter regarding some of the perceived methodological limitations of our study, such as limits to our data capture and the use of a single observer. Although we agree that a 100% ward round capture rate, with multiple observers, would have been ideal, the practicalities of this exploratory pilot study prevented us from realizing this. Unpredictable timings of ward rounds, or multiple concurrent rounds by different clinical teams, meant that inevitably some rounds were missed. Despite concerns regarding the ‘‘Hawthorne effect’’ of observer-expectancy bias with regard to the assessment of the complex ward round, we have little reason to believe that this has played a role in the results of our study. The relatively objective nature of a ‘‘checklist’’-type assessment tool limits any subjective interpretation that might leave the assessment open to bias. More importantly, subsequent studies using the same assessment tool, with multiple observers, have shown this to be a reliable and robust assessment method.2,3 Dr Hakeem additionally expresses doubts that closer attendance to patients on the surgical ward round might prevent complications such as pneumonia or urinary tract infections. However, the preventability of the majority of such events is widely accepted and supported by such bodies as the US Agency for Healthcare Research and Quality,
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which includes incidence rates of both in its patient safety indicators.4 The aim of our study has not been to suggest that auscultation of a patient’s chest will prevent postoperative pneumonia; however, attention to this part of patient care raises the likelihood of ensuring that other preventative measures (such as physiotherapy) are appropriately implemented and early signs of morbidity detected and treated. The success of such an approach is illustrated, for example, in the early removal of drains and urinary catheters, now firmly entrenched as a component of most surgical enhanced recovery protocols (ERPs) in colorectal surgery, which have contributed significantly to improved outcomes and decreased hospital stays.5,6 Although patients included in our study who underwent elective colorectal resection were cared for using an ERP, a significant number of patients still suffered postoperative complications. Many postoperative ERP components (mobilization, early feeding) are nursing-led and could be expected to therefore complement any interventions to improve surgical ward round quality. Standardized, high-quality care for all is the ideal to which we all aspire as clinicians. Unfortunately, these aims too often stand in stark contrast to the reality of variable surgical outcomes. Competing clinical priorities and resource bottlenecks demand clinicians maximize the efficiency and quality of their patient interactions. In this, we can only concur with Dr Hakeem’s call for further research and education in the future.
Philip H. Pucher, MD, MRCS Division of Surgery Hospital of the University of Pennsylvania Perelman School of Medicine Philadelphia, PA [email protected] Rajesh Aggarwal, MD, PhD, MA, FRCS Department of Surgery and Cancer St Mary’s Hospital Imperial College London London, UK
REFERENCES 1. Pucher PH, Aggarwal R, Darzi A. Surgical ward round quality and impact on variable patient outcomes. Ann Surg. 2014;259:222–226. 2. Pucher PH, Aggarwal R, Singh P, et al. Ward simulation to improve surgical ward round performance: a randomised controlled trial of a simulation-based curriculum. Ann Surg. 2014;260: 236–243. 3. Pucher PH, Aggarwal R, Srisatkunam T, et al. Validation of the simulated ward environment for assessment of ward-Based surgical care. Ann Surg. 2014;259:215–221. 4. Agency for Healthcare Research and Quality. Patient Safety Indicators (PSI) Composite Measure Workgroup: final report. Available at: http://www.qualityindicators.ahrq.gov/Download s/Modules/PSI/PSI_Composite_Development.pdf. Accessed July 1, 2014. 5. Fearon KC, Ljungqvist O, Von Meyenfeldt M, et al. Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection. Clin Nutr. 2005;24:466–477. 6. Pucher PH, Aggarwal R, Twaij A, et al. Identifying and addressing preventable process errors in trauma care. World J Surg. 2013;37:752–758.
Disclosure: The authors declare no conflicts of interest. All authors have seen and approved the final version of the manuscript. DOI: 10.1097/SLA.0000000000001023
e10 | www.annalsofsurgery.com
ß
2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Letter to the Editor
Reply: e would like to thank Dr Hakeem for his interest in our recent article.1 We are grateful for the opportunity to respond to his letter regarding some of the perceived methodological limitations of our study, such as limits to our data capture and the use of a single observer. Although we agree that a 100% ward round capture rate, with multiple observers, would have been ideal, the practicalities of this exploratory pilot study prevented us from realizing this. Unpredictable timings of ward rounds, or multiple concurrent rounds by different clinical teams, meant that inevitably some rounds were missed. Despite concerns regarding the ‘‘Hawthorne effect’’ of observer-expectancy bias with regard to the assessment of the complex ward round, we have little reason to believe that this has played a role in the results of our study. The relatively objective nature of a ‘‘checklist’’-type assessment tool limits any subjective interpretation that might leave the assessment open to bias. More importantly, subsequent studies using the same assessment tool, with multiple observers, have shown this to be a reliable and robust assessment method.2,3 Dr Hakeem additionally expresses doubts that closer attendance to patients on the surgical ward round might prevent complications such as pneumonia or urinary tract infections. However, the preventability of the majority of such events is widely accepted and supported by such bodies as the US Agency for Healthcare Research and Quality,
W
which includes incidence rates of both in its patient safety indicators.4 The aim of our study has not been to suggest that auscultation of a patient’s chest will prevent postoperative pneumonia; however, attention to this part of patient care raises the likelihood of ensuring that other preventative measures (such as physiotherapy) are appropriately implemented and early signs of morbidity detected and treated. The success of such an approach is illustrated, for example, in the early removal of drains and urinary catheters, now firmly entrenched as a component of most surgical enhanced recovery protocols (ERPs) in colorectal surgery, which have contributed significantly to improved outcomes and decreased hospital stays.5,6 Although patients included in our study who underwent elective colorectal resection were cared for using an ERP, a significant number of patients still suffered postoperative complications. Many postoperative ERP components (mobilization, early feeding) are nursing-led and could be expected to therefore complement any interventions to improve surgical ward round quality. Standardized, high-quality care for all is the ideal to which we all aspire as clinicians. Unfortunately, these aims too often stand in stark contrast to the reality of variable surgical outcomes. Competing clinical priorities and resource bottlenecks demand clinicians maximize the efficiency and quality of their patient interactions. In this, we can only concur with Dr Hakeem’s call for further research and education in the future.
Philip H. Pucher, MD, MRCS Division of Surgery Hospital of the University of Pennsylvania Perelman School of Medicine Philadelphia, PA [email protected] Rajesh Aggarwal, MD, PhD, MA, FRCS Department of Surgery and Cancer St Mary’s Hospital Imperial College London London, UK
REFERENCES 1. Pucher PH, Aggarwal R, Darzi A. Surgical ward round quality and impact on variable patient outcomes. Ann Surg. 2014;259:222–226. 2. Pucher PH, Aggarwal R, Singh P, et al. Ward simulation to improve surgical ward round performance: a randomised controlled trial of a simulation-based curriculum. Ann Surg. 2014;260: 236–243. 3. Pucher PH, Aggarwal R, Srisatkunam T, et al. Validation of the simulated ward environment for assessment of ward-Based surgical care. Ann Surg. 2014;259:215–221. 4. Agency for Healthcare Research and Quality. Patient Safety Indicators (PSI) Composite Measure Workgroup: final report. Available at: http://www.qualityindicators.ahrq.gov/Download s/Modules/PSI/PSI_Composite_Development.pdf. Accessed July 1, 2014. 5. Fearon KC, Ljungqvist O, Von Meyenfeldt M, et al. Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection. Clin Nutr. 2005;24:466–477. 6. Pucher PH, Aggarwal R, Twaij A, et al. Identifying and addressing preventable process errors in trauma care. World J Surg. 2013;37:752–758.
Disclosure: The authors declare no conflicts of interest. All authors have seen and approved the final version of the manuscript. DOI: 10.1097/SLA.0000000000001023
e10 | www.annalsofsurgery.com
ß
2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
