By Frances Huang
In response to 2022 WHO World Patient Safety Day, HST and JCT held webinars to remind healthcare workers to improve patient safety from different aspects. The topic of the webinar is “Prevent Mistake in Surgery,” how to and what can we do to prevent mistake and lower the risk of surgery on 7 October. “During the previous webinars, we had discussed about medication safety, innovation, maternal and newborn care, today is some different from the webinar we had before. Surgical safety is a very rewarding and critical part of our hospital-wide safety campaign, it’s important and there’re some key points we can learn from each other.” Prof. Pa-Chung Wang, CEO of Joint Commission of Taiwan, mentioned at the beginning of the webinar.
Immediate Preoperative Team Discussion in Operation Room and How We Do It
Chair Prof. Fu-Chan Wei who is authority in reconstructive microsurgery surgery from Academician, Academia Sinica shows several cases of Post Tumor Ablation Reconstruction, microsurgical free tissue transfer not only saves lives but also enhances cancer resect ability and life quality for it enhances limb salvageability, allows the possibility of one-stage reconstruction, and reduces patient from suffering.
Microsurgical skills or free tissue transfer can be applied in many fields, but it also has risk, there still failures happened. Free flap currently the mainstream in reconstructive surgery, the success rate is around 96% to 97% due to technological innovations, microsurgical techniques refined, better understanding of anatomy and physiology, and better teamwork. Sometimes we encountered unfavorable results, which means the free flap is a success, but the reconstruction fails to achieve its goal such as coverage, uneventful healing or timely CCRT. The reconstruction compromises immediate outcomes like partial failure, infection, or fistula. Sometimes the outcomes on the long run like contracture, stricture, poor function or cosmesis. Those are all unfavorable results which we try to prevent.
From perspective of Prof. Wei, the unfavorable result/outcome comes from three combinations. Either planning, design or execution of surgery can lead to unfavorable outcomes.
There are some key tasks we should follow to prevent the unfavorable outcomes. To increase patient safety, the medical workers should prepare a safety check list and have a well review of up-to-date relevant patient’s information. Enhance communication within team and between teams. With simplify and streamline the surgery, we can assign the task to individual members in the team. Through the team discussion, it grants great learning opportunity for all members to initiate the project.
The team will present patient’s profile in slides to concise patient’s information and keep it up-to-date, precisely describe the surgical plan, have a quick review of relevant literature before initiate the surgery. Also, the discussion will open for comments and questions. After that, the team will finalize the surgical plan and then the team will focus on flap design and inset planning, also the consideration of logistic and task assignment. Those are what we do to have an immediate preoperative final planning.
From Prof. Wei’s experience and perspective, inexperience, inadequate discussion, vague goals, ineffective communication, and lack of reflection pave the roads for unfavorable results which downgrade a patient’s quality of life and may delay oncologic treatment. To avoid or prevent unfavorable results, an adequate preoperative planning is as important as achieving disease-free survival and successful free tissue transfer at the advanced stage of free flap surgery. The preoperative planning should involve every member in the team for avoiding single-surgeon judgmental mistakes and should be done both at the time of consultation and immediately right before the surgery.
Evidence-based & Patient-centered Perioperative Care— Enhance Recovery After Surgery (EARS)
According to the data, 50% adverse events in hospitalized patients are related to surgical care. At least half of the surgical adverse event considered can be preventable. Adverse event not only caused the harm of patient but also increased the medical cost. Recovery after surgery also an important factor of patient safety, to enhanced recovery after surgery (ERAS) can improve patient safety. Under the support of Ministry of Health and Welfare, ERAS Implementation has been listed as a working directive in Patient Safety Goal for Taiwan 2022-2023.
Dr. Shu-Lin Guo, Chairman of Taiwan Chapter, ERAS Society addressed that ERAS stands for Enhanced Recovery After Surgery, which covers multiple approach to provide after surgery care to patient. ERAS protocol of CRS operation can be divided into 4 stages, preadmission, pre-operation, intra-operation, and post-operation. At the preadmission stage, ERAS provides services such as preoperative counseling, optimization, prehabilitation, preoperative nutrition to help patients prepare themselves in a better condition before operation. Also, during the pre-op stage, ERAS provide service to prevent surgical site infections such as SSI bundle, minimal NPO, and CHO drink. ERAS integrates the patient care flow from the day that patient had agreeed to take the surgery till post-operation and follow up care. With recent research, it shows that ERAS had successfully reduceed the compliance rate from 55% to 77%, reduce total complications from 53.2% to 27.5% and the mortality rate had reduced to 0.58%. The result shows that ERAS did have effective improvement of surgical patient safety. ERAS team mainly coordinates between different teams optimizing the quality of care.
In view of this, Cathay General Hospital developed the CGH ERAS App for team to interact with patient, providing telemedicine in evaluation, recommendation, and follow-up. The communication channel of patient-to-team is secured. Patient can recognize their recovery stage by the evaluation guide in the app. ERAS society growing fast these years, and many countries have joined the ERAS to provide better care for the patient, improving the quality of medical and surgical care.
ERAS can be adopted even if it’s a small hospital for the major task of ERAS is to integrate the medical resource and coordinate with different team, so it’s much more important for a small hospital to adopt ERAS program for usually small hospital had limited resource and adopt ERAS can optimizing the resource which already had. Initiate by building a small team in the hospital,and start evaluation from the major surgery of the hospital. Most people are curious about the difference between traditional surgical care and ERAS program. The most different of the ERAS is the communication, during the past, the communication within the medical teams has always a big issue which is ERAS trying to conquer all the time.
Work with A.I. for Pre-anesthesia Assessment
Dr. Chin-Chen Chu, Director of Department of anesthesiology of Chi Mei Medical Center, shared that pre-anesthesia evaluation is extremely important in reducing morbidity and mortality of surgical patients. The pre-anesthesia evaluation is to ensure patients can safely tolerate anesthesia for planned surgical procedures, to mitigate risks during the perioperative period, and to set patient and family expectations for postoperative outcomes.
There are some commonly used tools like American Society of Anesthesiologist Physical Status (ASA-PS) classification, The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®), and Revised Cardiac Risk Index for Pre-Operative Risk. ASA-PS has been used from 1963 till now, it’s simple but it’s also highly subjective and many factors are neglected. ACS NSQIP® is wildly used worldwide as well, but for medical workers, they need to put in 19 factors to generate the data, and there’s an important factor that we might need to think twice is that the data mainly based on western people, the result may not fully apply to Asian people. The third tool is Revised Cardiac Risk Index, but it only predicts cardiac adverse event.
“Since the tools we have can’t meet our needs, with the help of technology, we tried to collect our own data and with the help of machine learning algorithms in preoperative risk assessment, in the beginning, we focus on Hip Surgery”, Dr. Chu said. Chi Mei Medical Center started collecting the data in 2013 for building the A. I. prediction model. it captured 22 features including demographics, anesthetic planning, co-morbidities, and Lab. Data. With the help of hospital information system, now we can calculate the rate of adverse outcome automatically just by one click. The physician can communicate with the patient or patient’s family about the risk prediction by the information generated by the system.
In summary, the A.I. assist application is helpful in evaluating the risks of surgery. More efficiently and accurately than the traditional ASA-PS. Though the study that Dr. Chu carried out was limited by hospital-specific factors, it could still be generalized to hospitals with similar patient races and comparable health insurance systems. With the assistance of A.I. system, it will calculate the rate of surgical risk and generate with graphics on the screen so the physician can explain and communicate to the patient and their family about the possibility of the negative risk they might encounter. With the clear data and graphic, it’s easier for patients to understand the risk of the surgery and allow family and patient to adjust their expectations and to reach the consensus and complete the shared decision making.
Though the system is only based on the Hip fracture and intra-abdominal surgery database so far, but it had already proved the system is much more accurate than the ASA-PS. Dr. Chu’s team believe that, with the data and the technology, we can apply to different surgical category with related data collection and develop a real-time predict calculate function soon.
Smart Anesthesia Information Recording System
ACE Biotek had been focusing on smart medical information solution, medical wearable ECG patch system, and A. I. Development platform since 2000. In order to prevent adverse event, Mr. Jason Chou, Director of Medical Solution at ACE Biotek Company Limited, mentioned that ACE Biotek had proposed a smart solution called SPARK, a Smart Anesthesia Information Recording System.
The original handwriting record always caused mistakes frequently in busy surgery. SPARK provides a user-friendly and convenient GUI on portable device to automatically retrieve raw data from medical equipment instead of handwriting on paper, also collects all the digital raw data in database to be applied and analyzed by AI algorithm. SPARK can be adopted pre-surgery, in-surgery, and after-surgery. The Gateway will collect the data from the device such as iPad that physician use to prescribe and the devices that monitor the patient.
The first successful case is the collaboration with Fu Jen Catholic University Hospital, the hospital had applied the system in 18 operating rooms. Dr. Kung from Fu Jen Catholic Universal Hospital shared his experienced working with SPARK that it allows medical staff to be more focused on patient care to enhance medical quality for all the data can be automatically uploaded and displayed which help a lot in reducing manual recording mistakes and enhancing efficiency in surgery.
Though the patient safety in the operating room has improved in the past few years, there remain significant risk exist. During the operation, the patient must fully rely on medical workers for they can’t express themselves most of the time. To prevent adverse event, the only way is to enhance the cross-department communication and the teamwork.
New technology and innovation development had improved patient safety in the past few years, successfully reducing the risk of human error in medical process, but also bringing up different issues that we had never met before. How to apply smart innovation or technology in a proper way to improve patient safety in different stages of health care service is major issue that medical workers need to think twice. With the help of technology, medical workers can optimize the workflow, keep the process in record, and integrate all the medical history for physicians as full reference for making medical decision to keep patients under safe treatment. Medical workers not only take care of the patient but also provide patient-centered medical service.
The JCT established the Health Smart Taiwan (HST) , a one-stop portal designed to promote Taiwan's high-quality smart healthcare solutions since 2019. HST combines Taiwan's cutting-edge smart healthcare solutions with the demo site in Taiwan, helping visitors to fully understand the application and development potential of smart healthcare, while creating a new model for smart hospitals. In addition, JCT also welcomes healthcare professionals from all over the world to come to Taiwan for face-to-face exchanges on the application of innovative medical technologies.