- Email: [email protected]
Comments on medical audits
tered out in the p u l m o n a r y circuit. I n all of our autot r a n s f u s i o n we routinely use a n additional fine screen illt r a t i o n with a micropore filter. U s i n g secondary pressure bags, the Pall filter with a grid of 40 microns allows for a rapid infusion of blood. Other micropore filters on the m a r k e t will remove particles down to 20 microns in size_
a u t o t r a n s f u s i o n from the e x p e r i m e n t a l l a b o r a t o r y of major medical centers out to the c o m m u n i t y hospitals be. comes practical and can save lives and the precious re, source of blood.
A l t h o u g h the B e n t l e y Corporation c e r t a i n l y rejuven a t e d the e q u i p m e n t for a u t o t r a n s f u s i o n d u r i n g the late 1960s and t h e i r device uses a roller pump and intrinsic t u b i n g umt, there are at least five other companies t h a t have either produced autotransfusion devices or have one in the developmental stage. Chesebrough-Ponds, Inc. has a device t h a t uses hemothorax blood in the chest bottle which is m e r e l y inverted, the blood filtered, and t h e n given directly back to the patient. The Sorenson Comp a n y has m a r k e t e d a disposable, flexible plastic bag u s i n g a regulated n e g a t i v e pressure wall suction and a v e n t u r i suction tip delivering CPD solution to the blood as it is aspirated. The Haemonetics Corporation has a "Cell Saver" which not only aspirates the blood, washes the red cells, and centrifuges the cells, b u t packs t h e m so t h a t one c a n i n f u s e red blood cells a t a n y d e s i r e d hematocrit reading. This device also uses citrate or heparin as a n a n t i c o a g u l a t e . The Pall Corporation had developed a double reservoir a u t o t r a n s f u s i o n device t h a t uses wall suction a n d a n i n n o v a t i v e sucker tip. Two other companies are w o r k i n g with a u t o t r a n s f u s i o n b u t are still in the p r e m a r k e t i n g phase.
(Assistant Professor, Cora and Webb Mading Department of Surgery, Baylor College of Medicine; Deputy Surgeon. In-Chief & Director of Emergency Surgical Services, Ben Taub General Hospital, Houston, Texas_)
Kenneth L. Mattox, MD
Comments on Medical Audits
MEDICAL
AUDITS ARE AN E S T A B L I S H E D FACT o f life in all aspects of hospital practice. It is noteworthy that the D e p a r t m e n t s of E m e r g e n c y Medicine and Radiology at the F o r s y t h M e m o r i a l H o s p i t a l in Winston-Salem, North Carolina, have conducted a review of the provisional i n t e r p r e t a t i o n s of radiographs made by the emergency physicians and the final i n t e r p r e t a t i o n of the same e x a m i n a t i o n s as reported by m e m b e r s of the Departm e n t of Radiology.
The fact t h a t such a review can be conducted in harmony and performed as a l e a r n i n g experience bespeaks the type of cooperative relationship t h a t should exist between these d e p a r t m e n t s in every hospital. The authors are to be complimented for conducting the a u d i t and p u b l i s h i n g its results.
By my calculation in O'Riordan's series of eight patients, in this one hospital more t h a n $1000 was saved above the original cost of the roller pump e q u i p m e n t and the disposable ATS-100 reservoirs. This savings is calculated on the basis of up to $50 for a u n i t of b a n k e d blood. Although the authors give a dollar figure for the n a t i o n a l wastage from out of date blood, additional blood is wasted which m i g h t be salvaged through recycling or other inn o v a t i v e t e c h n i q u e s . Untold gallons of i n t r a o p e r a t i v e blood are discarded n a t i o n a l l y each day, which could be collected. Blood lost postoperatively c o u l d be salvaged, especially i n p a t i e n t s with d i s s e m i n a t e d i n t r a v a s c u l a r c o a g u l o p a t h y and post-thoracic surgery. A d d i t i o n a l l y , the use of blood from a donor source in the p a t i e n t With nonreversible b r a i n i n j u r y needs further investigation. In Russia, blood has been t a k e n from p a t i e n t s who have died. E x t r a c t i n g blood in the operating room at the time of donor n e p h r e c t o m y m i g h t produce more usable blood t h a n do cadaver sources.
A function of a n editorial is to reflect upon the content of an article in order to test its hypothesis and conclusions. In t h a t context, then, and with a positive attitude oriented toward the l e a r n i n g process and o p t i m u m p a t i e n t care, the following c o m m e n t s are offered. A description of the protocol of the study would have been useful and would have enabled the reader to evaluate the "97.6% concurrence" of i n t e r p r e t a t i o n . Such a high rate of a g r e e m e n t of opinion, p a r t i c u l a r l y in the interpretation of over 8,000 consecutive r a d i o g r a p h i c e x a m i n a t i o n s developed from a n active emergency d e p a r t m e n t practice is remarkable, even w i t h i n a group of radiologists, let alone between different specialty groups_ It is reasonable to question the ~'mix" of the 8,021 radiographic studies, or to inquire if a selective process is i n h e r e n t in the triage of patients, w i t h i n t h a t p a r t i c u l a r department, which automatically filters some types of p a t i e n t s (and their radiographic e x a m i n a t i o n s ) out Of the m a t e r i a l audited.
Finally, the importance of a u t o t r a n s f u s i o n and its progress from e x p e r i m e n t a l to practical is reflected by the fact t h a t the Food_and Drug A d m i n i s t r a t i o n , in their review of medical devices, is a n a l y z i n g the efficacy and application of a u t o t r a n s f u s i o n devices on the market.
While, as the authors' experience has demonstrated, the chest is a difficult area of r o e n t g e n interpretation, I would have expected non-radiologists to have more difficulty in e v a l u a t i o n of radiographic e x a m i n a t i o n s of the skull, face, cervical spine, and the b l u n t l y i n j u r e d abdomen.
In u s i n g a u t o t r a n s f u s i o n in well over 1500 cases, we have employed all of the pieces of e q u i p m e n t mentioned, v a r i a t i o n s a n d c o m b i n a t i o n s thereof, a n d o t h e r cust o m i z e d t e c h n i q u e s . A u t o t r a n s f u s i o n has proved safe, expedient and life-saving. Each of the devices, as with all medical equipment, has specific indications and areas of usefulness, a n d t h e i r use requires t r a i n i n g , supervision and proficiency. W'ith these considerations, exportation of
"Clinical significance," for the purpose of this audit, has not been defined. W i t h o u t t h a t definition, the audit may be more subjective and less objective t h a n the authors intended. The accuracy of roentgen i n t e r p r e t a t i o n depends not alone upon w h e t h e r an a b n o r m a l i t y has clinical significance, b u t w h e t h e r an a b n o r m a l i t y exists a n d is perceived and correctly interpreted. For example, even though a n a b n o r m a l i t y m a y not modify t h e r a p y already instituted,
7o/275
"
6:6 (Jun)1977 , , ~ P
and therefore be deemed not clinically significant, its rec0gnition and identification is radiographically s i g n i f i c a n t and its existence m a y have significance to the patient, to third p a r t y payors, and possibly, to the legal profession. If the r e p o r t e d percentage of concurrence implies t h e generic conclusion t h a t the e m e r g e n c y p h y s i c i a n is capable of the definitive i n t e r p r e t a t i o n of roentgen e x a m i n a t i o n s within his specialty, some words of caution m a y be appropriate. Obviously, not all, or perhaps not even the majority, of emergency physicians have the same degree of i n t e r e s t and sophistication in the roentgen aspects of t h e i r practice as do Drs. Quick and Podgorny. Secondly, radiologists are o r i e n t e d to the objective interpretation of the recorded r a d i o g r a p h i c image. Such interpretation m a y be modified by the clinical d a t a t h a t is provided, b u t it is not subject to the bias, or preconceptions, which m a y occur as the r e s u l t of the clinical i n v o l v e m e n t between the p a t i e n t and the e m e r g e n c y physician. Finally, w h e n the e m e r g e n c y p h y s i c i a n i n t e r p r e t s t h e roentgen e x a m i n a t i o n , he assumes responsibility for t h e appropriateness and completeness of the study, its technical quality, and e v e r y t h i n g recorded on the r a d i o g r a p h . In addition, he a s s u m e s the r e s p o n s i b i l i t y for the same degree of a c c u r a c y of i n t e r p r e t a t i o n as is d e m a n d e d of t h e
radiologist_ Gross, or uncomplicated, radiographic abnorm a l i t i e s do not, usually, constitute a diagnostic problem. Subtle a b n o r m a l i t i e s (which m a y be overlooked) or nonpathologm findings (which m a y be m i s i n t e r p r e t e d and t h u s lead to i n a p p r o p r i a t e t h e r a p y ) are the major pitfalls confronting the e m e r g e n c y p h y s i c i a n and, u l t i m a t e l y , the patient_ Avoiding%hese pitfalls requires continuous study and effort. A n on-going a u d i t of the emergency departm e n t radiologic practice, as advocated by Drs. Quick and P o d g o r n y , is a n i m p o r t a n t a s p e c t of t h e c o n t i n u i n g radiologic medical education of t h e emergency physician. In addition, the clinical c o r r e l a t i o n provided by such an i n t e r c h a n g e is i n v a l u a b l e for the radiologist~ The m a t t e r of r a d i o l o g i s t a v a i l a b i l i t y and support for the e m e r g e n c y p h y s i c i a n at n i g h t and on weekends requires mention and is an i n t e g r a l component of this topic. It is u n f o r t u n a t e l y t r u e t h a t some radiologists are simply not available for consultation to the emergency physician duri n g t h e s e h o u r s . T h i s p r a c t i c e is to be c o n d e m n e d . Radiologists m u s t be a v a i l a b l e for appropriate, p r o m p t consultation ~'after hours," for all physicians, and particularly for those w o r k i n g in the emergency d e p a r t m e n t .
John H. Harris, Jr, MD Carlisle Hospital Carlisle, Penusylvania
Correction: In the editorial "Hydrocarbon Ingestions in Perspective" by Barry H. Rumack, MD (April 1977) an agent was mistakenly referred to as "mineral seed oil" when "mineral seal oil" was intended. Our apologies to Dr. Rumack.
,~P
6:6 (Jun)1977
276/71
a u t o t r a n s f u s i o n from the e x p e r i m e n t a l l a b o r a t o r y of major medical centers out to the c o m m u n i t y hospitals be. comes practical and can save lives and the precious re, source of blood.
A l t h o u g h the B e n t l e y Corporation c e r t a i n l y rejuven a t e d the e q u i p m e n t for a u t o t r a n s f u s i o n d u r i n g the late 1960s and t h e i r device uses a roller pump and intrinsic t u b i n g umt, there are at least five other companies t h a t have either produced autotransfusion devices or have one in the developmental stage. Chesebrough-Ponds, Inc. has a device t h a t uses hemothorax blood in the chest bottle which is m e r e l y inverted, the blood filtered, and t h e n given directly back to the patient. The Sorenson Comp a n y has m a r k e t e d a disposable, flexible plastic bag u s i n g a regulated n e g a t i v e pressure wall suction and a v e n t u r i suction tip delivering CPD solution to the blood as it is aspirated. The Haemonetics Corporation has a "Cell Saver" which not only aspirates the blood, washes the red cells, and centrifuges the cells, b u t packs t h e m so t h a t one c a n i n f u s e red blood cells a t a n y d e s i r e d hematocrit reading. This device also uses citrate or heparin as a n a n t i c o a g u l a t e . The Pall Corporation had developed a double reservoir a u t o t r a n s f u s i o n device t h a t uses wall suction a n d a n i n n o v a t i v e sucker tip. Two other companies are w o r k i n g with a u t o t r a n s f u s i o n b u t are still in the p r e m a r k e t i n g phase.
(Assistant Professor, Cora and Webb Mading Department of Surgery, Baylor College of Medicine; Deputy Surgeon. In-Chief & Director of Emergency Surgical Services, Ben Taub General Hospital, Houston, Texas_)
Kenneth L. Mattox, MD
Comments on Medical Audits
MEDICAL
AUDITS ARE AN E S T A B L I S H E D FACT o f life in all aspects of hospital practice. It is noteworthy that the D e p a r t m e n t s of E m e r g e n c y Medicine and Radiology at the F o r s y t h M e m o r i a l H o s p i t a l in Winston-Salem, North Carolina, have conducted a review of the provisional i n t e r p r e t a t i o n s of radiographs made by the emergency physicians and the final i n t e r p r e t a t i o n of the same e x a m i n a t i o n s as reported by m e m b e r s of the Departm e n t of Radiology.
The fact t h a t such a review can be conducted in harmony and performed as a l e a r n i n g experience bespeaks the type of cooperative relationship t h a t should exist between these d e p a r t m e n t s in every hospital. The authors are to be complimented for conducting the a u d i t and p u b l i s h i n g its results.
By my calculation in O'Riordan's series of eight patients, in this one hospital more t h a n $1000 was saved above the original cost of the roller pump e q u i p m e n t and the disposable ATS-100 reservoirs. This savings is calculated on the basis of up to $50 for a u n i t of b a n k e d blood. Although the authors give a dollar figure for the n a t i o n a l wastage from out of date blood, additional blood is wasted which m i g h t be salvaged through recycling or other inn o v a t i v e t e c h n i q u e s . Untold gallons of i n t r a o p e r a t i v e blood are discarded n a t i o n a l l y each day, which could be collected. Blood lost postoperatively c o u l d be salvaged, especially i n p a t i e n t s with d i s s e m i n a t e d i n t r a v a s c u l a r c o a g u l o p a t h y and post-thoracic surgery. A d d i t i o n a l l y , the use of blood from a donor source in the p a t i e n t With nonreversible b r a i n i n j u r y needs further investigation. In Russia, blood has been t a k e n from p a t i e n t s who have died. E x t r a c t i n g blood in the operating room at the time of donor n e p h r e c t o m y m i g h t produce more usable blood t h a n do cadaver sources.
A function of a n editorial is to reflect upon the content of an article in order to test its hypothesis and conclusions. In t h a t context, then, and with a positive attitude oriented toward the l e a r n i n g process and o p t i m u m p a t i e n t care, the following c o m m e n t s are offered. A description of the protocol of the study would have been useful and would have enabled the reader to evaluate the "97.6% concurrence" of i n t e r p r e t a t i o n . Such a high rate of a g r e e m e n t of opinion, p a r t i c u l a r l y in the interpretation of over 8,000 consecutive r a d i o g r a p h i c e x a m i n a t i o n s developed from a n active emergency d e p a r t m e n t practice is remarkable, even w i t h i n a group of radiologists, let alone between different specialty groups_ It is reasonable to question the ~'mix" of the 8,021 radiographic studies, or to inquire if a selective process is i n h e r e n t in the triage of patients, w i t h i n t h a t p a r t i c u l a r department, which automatically filters some types of p a t i e n t s (and their radiographic e x a m i n a t i o n s ) out Of the m a t e r i a l audited.
Finally, the importance of a u t o t r a n s f u s i o n and its progress from e x p e r i m e n t a l to practical is reflected by the fact t h a t the Food_and Drug A d m i n i s t r a t i o n , in their review of medical devices, is a n a l y z i n g the efficacy and application of a u t o t r a n s f u s i o n devices on the market.
While, as the authors' experience has demonstrated, the chest is a difficult area of r o e n t g e n interpretation, I would have expected non-radiologists to have more difficulty in e v a l u a t i o n of radiographic e x a m i n a t i o n s of the skull, face, cervical spine, and the b l u n t l y i n j u r e d abdomen.
In u s i n g a u t o t r a n s f u s i o n in well over 1500 cases, we have employed all of the pieces of e q u i p m e n t mentioned, v a r i a t i o n s a n d c o m b i n a t i o n s thereof, a n d o t h e r cust o m i z e d t e c h n i q u e s . A u t o t r a n s f u s i o n has proved safe, expedient and life-saving. Each of the devices, as with all medical equipment, has specific indications and areas of usefulness, a n d t h e i r use requires t r a i n i n g , supervision and proficiency. W'ith these considerations, exportation of
"Clinical significance," for the purpose of this audit, has not been defined. W i t h o u t t h a t definition, the audit may be more subjective and less objective t h a n the authors intended. The accuracy of roentgen i n t e r p r e t a t i o n depends not alone upon w h e t h e r an a b n o r m a l i t y has clinical significance, b u t w h e t h e r an a b n o r m a l i t y exists a n d is perceived and correctly interpreted. For example, even though a n a b n o r m a l i t y m a y not modify t h e r a p y already instituted,
7o/275
"
6:6 (Jun)1977 , , ~ P
and therefore be deemed not clinically significant, its rec0gnition and identification is radiographically s i g n i f i c a n t and its existence m a y have significance to the patient, to third p a r t y payors, and possibly, to the legal profession. If the r e p o r t e d percentage of concurrence implies t h e generic conclusion t h a t the e m e r g e n c y p h y s i c i a n is capable of the definitive i n t e r p r e t a t i o n of roentgen e x a m i n a t i o n s within his specialty, some words of caution m a y be appropriate. Obviously, not all, or perhaps not even the majority, of emergency physicians have the same degree of i n t e r e s t and sophistication in the roentgen aspects of t h e i r practice as do Drs. Quick and Podgorny. Secondly, radiologists are o r i e n t e d to the objective interpretation of the recorded r a d i o g r a p h i c image. Such interpretation m a y be modified by the clinical d a t a t h a t is provided, b u t it is not subject to the bias, or preconceptions, which m a y occur as the r e s u l t of the clinical i n v o l v e m e n t between the p a t i e n t and the e m e r g e n c y physician. Finally, w h e n the e m e r g e n c y p h y s i c i a n i n t e r p r e t s t h e roentgen e x a m i n a t i o n , he assumes responsibility for t h e appropriateness and completeness of the study, its technical quality, and e v e r y t h i n g recorded on the r a d i o g r a p h . In addition, he a s s u m e s the r e s p o n s i b i l i t y for the same degree of a c c u r a c y of i n t e r p r e t a t i o n as is d e m a n d e d of t h e
radiologist_ Gross, or uncomplicated, radiographic abnorm a l i t i e s do not, usually, constitute a diagnostic problem. Subtle a b n o r m a l i t i e s (which m a y be overlooked) or nonpathologm findings (which m a y be m i s i n t e r p r e t e d and t h u s lead to i n a p p r o p r i a t e t h e r a p y ) are the major pitfalls confronting the e m e r g e n c y p h y s i c i a n and, u l t i m a t e l y , the patient_ Avoiding%hese pitfalls requires continuous study and effort. A n on-going a u d i t of the emergency departm e n t radiologic practice, as advocated by Drs. Quick and P o d g o r n y , is a n i m p o r t a n t a s p e c t of t h e c o n t i n u i n g radiologic medical education of t h e emergency physician. In addition, the clinical c o r r e l a t i o n provided by such an i n t e r c h a n g e is i n v a l u a b l e for the radiologist~ The m a t t e r of r a d i o l o g i s t a v a i l a b i l i t y and support for the e m e r g e n c y p h y s i c i a n at n i g h t and on weekends requires mention and is an i n t e g r a l component of this topic. It is u n f o r t u n a t e l y t r u e t h a t some radiologists are simply not available for consultation to the emergency physician duri n g t h e s e h o u r s . T h i s p r a c t i c e is to be c o n d e m n e d . Radiologists m u s t be a v a i l a b l e for appropriate, p r o m p t consultation ~'after hours," for all physicians, and particularly for those w o r k i n g in the emergency d e p a r t m e n t .
John H. Harris, Jr, MD Carlisle Hospital Carlisle, Penusylvania
Correction: In the editorial "Hydrocarbon Ingestions in Perspective" by Barry H. Rumack, MD (April 1977) an agent was mistakenly referred to as "mineral seed oil" when "mineral seal oil" was intended. Our apologies to Dr. Rumack.
,~P
6:6 (Jun)1977
276/71