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From virtual reality to operating room: The ES3 experiment
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Otolaryngology-Head and Neck Surgery, Vol 141, No 3S1, September 2009
Society for Pharmacoeconomics and Outcomes Research (ISPOR) and Royal Society of Medicine databases for studies mentioning endotracheal intubation and tracheal damage. Fifty-six studies were reviewed. We identified clinical manifestations and treatments and codified them into ICD-9 diagnosis and procedure codes intentionally excluding tracheostomies and alternate etiologies. Using the Agency for Healthcare Research and Quality’s 2006 National Inpatient Sample, we compared patients with tracheal damage coded during the surgical stay for LOS and mean hospital cost with DRGmatched controls; and examined readmissions treating tracheal damage. Confidence intervals (CI) were calculated with adjustment for complex sampling design. RESULTS: Tracheal damage presented as tracheal stenosis, tracheomalacia, tracheoesophageal fistula, laryngotracheal ulceration, and vocal cord paralysis. A total of 3232 discharge records met criteria for tracheal damage from ET intubation within the same hospital stay. Average LOS for patients with tracheal damage (6.3 days) exceeded LOS in the uncomplicated sample (5.2 days) by 1.1 days. Average hospital cost was $1,888 higher with tracheal damage ($10,375 vs. $8,487; 95% CI $9,762-$10,988). There were 200 re-admissions from this patient cohort for repair of prior tracheal damage averaging 4.7 days and $11,025 per discharge. CONCLUSIONS: Tracheal damage from endotracheal intubation is uncommon but substantially adds to patient morbidity and cost of care. Driving standards of tracheostomy care in the UK Asit Arora, AFRCS (presenter); Roland Hettige; Sonna Ifeacho; May Nell; Carlos Gomez; Antony Narula, MA, FRCS OBJECTIVES: To assess and improve tracheostomy service care provision MISSING METHODS: Study design: 3-cycle prospective audit (20032009). Setting: Tertiary academic London hospital serving an inner-city, multi-ethnic population. Standard: Best Practice Guidelines established using Evidence-Based Medicine and expert opinion. 1st cycle (Nov 03-Feb 04) assessed compliance to the standard for patients with a tracheostomy discharged from ITU to the ward (n⫽24). Intervention: Introduction of tracheostomy care plan and nursing teaching programme. 2nd cycle (Nov 06-Feb 07) re-audited care plan compliance and decannulation time following ITU discharge (n⫽70). Intervention: Tracheostomy multidisciplinary team, weekly team ward round and expanded teaching programme to include Allied Healthcare Professionals. 3rd cycle (July-Sept 2007, Nov 08-Jan 09) re-audited care plan compliance and time to decannulation (n⫽25). Statistical methods: Mann Whitney Wilcoxon Test. RESULTS: Compliance to the tracheostomy care plan prior to intervention was 43% in 2003/2004. Following initial intervention, compliance increased by one third to 58% in 2006/ 2007. Time to decannulation was 21 days. Following the 2nd
cycle interventions, compliance rose to 94%. Mean time to decannulation was significantly reduced from 21 to 11 days (P-value ⬍0.05). There was also a significant reduction in the proportion of ‘severe’ tracheostomy-related clinical incidents reported during this time-frame. The mean total tracheostomy time was reduced from 34 to 24 days although this was not statistically significant. CONCLUSIONS: The introduction of a tracheostomy care plan, regular AHP teaching program and tracheostomy multidisciplinary team responsible for reviewing all patients on a weekly basis expedites the weaning process and improves tracheostomy care. Flexible nasoendoscopy: Prospective study on lidocaine spray Sunil H Vyas, MBChB (presenter) OBJECTIVES: To understand: 1) Patient discomfort during flexible nasoendoscopy (FN), with or without the use of lidocaine (anaesthetic) nasal spray. 2) Any other associated effects, such as nausea, rhinorrhea, or on the swallowing mechanism. METHODS: 110 healthy volunteers were randomized into two groups: Group A, prior to FN, had 2.5mls of lidocaine hydrochloride 5% w/v intranasal spray. Group B had no spray prior to FN. The volunteers underwent examination of their nasal cavity, post-nasal space, base of tongue and larynx. Then under direct vision, a ‘normal’ swallow study was performed, by drinking 20mls of natural blue dye, followed by, 1, 10 and 20mls of water. The discomfort was assessed using the Visual Analogue Score (VAS 0-5). A further questionnaire was filled out to determine any other symptoms such as nausea, rhinorrhea, and any effect on swallowing. RESULTS: VAS (0-5, 0 being the least and 5 being the most discomfort): Group A (58): 1 (28/58, 48.3%), 2(25/58, 43.1%), 3 (5/58, 8.6%), 4(0), 5(0). Group B (52): 1(12/52, 23.1%), 2(24/52, 46.2%), 3(14/52, 26.9%), 4(2/52, 3.8%). 5(0). Patient symptoms: Rhinorrhea: 13/58 (22.4%) in group A, and 8/52 (15.4%) in group B. Difficulty in swallowing: 13/58(22.4%) in group A, and 6/52 (11.5%) in group B. Nausea: 8/58 (13.8%) in group A, and 8/58(13.8%) in group A and none in group B. CONCLUSIONS: In group A (with lidocaine), 53/58 (91.3%), and in group B (without lidocaine) 36/52 (69.2%) reported minimal discomfort (VAS up to 2). Therefore using nasal lidocaine spray is beneficial in reducing patient discomfort. However, there are other associated transient effects such as rhinorrhea, nausea, and altered sense of swallowing. From virtual reality to operating room: The ES3 experiment Babak Sadoughi, MD (presenter); Sanjay Parikh, MD; John Bent, MD; Marvin Fried, MD; Marc Gibber, MD; Joseph Jacobs, MD; Douglas A Ross, MD
Program Oral Presentations
Patient information: Obtaining informed consent in ENT Scott Henney, MD (presenter); Simren Rakhra, MBChB OBJECTIVES: 1) Determine whether patients undergoing daycase surgery were being provided with written information. 2) Evaluate satisfaction with patient information. 3) Assess whether written patient information leaflets improved recall of complications. METHODS: Prospective controlled study conducted during the first four months of 2009 in the ENT Department of a UK University Teaching Hospital. 100 patients undergoing daycase surgery were included. Fifty consecutive patients were given patient information leaflets in the outpatient clinic and compared with 50 consecutive patients receiving current practice. Verbal information including risks was provided but written patient information was not routine. A questionnaire on admission to the ward on the day of surgery was used to measure outcomes; if written patient information had been received, the time between consent and procedure, recall of complications and satisfaction with information received. RESULTS: There was a significantly improved rate of recall in the patient group who received patient information leaflets compared to those who did not routinely (p⬍0.05). There was no significant difference in patient satisfaction between groups.
CONCLUSIONS: Written patient information leaflets are a useful tool for the surgeon to improve recall of the information given to the patient, in order to facilitate informed consent. Preliminary NSQIP results in otolaryngology Robert J Stachler, MD (presenter); Kathy Yaremchuk, MD; Jennifer Ritz OBJECTIVES: 1) To improve patient safety by analyzing outcomes data. 2) To present preliminary National Safety Quality Improvement Data specifically for otolaryngology. METHODS: Postoperative complications impose a substantial mortality and morbidity burden on patients and excess costs on society. In 1986 Congress mandated that the VA report risk-adjusted surgical outcomes compared with a national average. In 1994 the National Surgical Quality Improvement Program (NSQIP) was begun. Its role is to measure and report comparative risk-adjusted surgical outcomes at the institutional level and to promote improvement through selfassessment, site visits, and dissemination of best practices. This program promotes widespread adherence to process-of-care measures. It involves measurement and improvement of riskadjusted surgical outcomes. RESULTS: Participation by otolaryngology-head and neck surgery began in August 2008 with the collection of 40 preoperative clinical risk factors (e.g., diabetes and heart disease), 20 categories of 30-day postoperative morbidity (e.g., venous thrombosis, wound infections, and pneumonia), and 30-day postoperative mortality on patients having major operations under general anesthesia. There are 34 sites collecting ENT data in the US. A summary of the data analysis for the subsequent year will be presented as preliminary findings. Strategies for improvement based on preliminary findings will be presented. CONCLUSIONS: NSQIP provides a platform for quality improvement within otolaryngology-head and neck surgery and is a national initiative that will continue to evolve in the future. Otolaryngologists need to be involved in this process to help create a safer environment for patients and to help shape health care policy. Reliability of authorship disclosures in otolaryngology Neil Bhattacharyya, MD (presenter); Harrison W Lin, MD OBJECTIVES: Determine the reliability of self-reported authorship disclosures of potential conflicts of interest in American Academy of Otolaryngology—Head and Neck Surgery (AAO-HNS/F)-sponsored presentations and publications. METHODS: Presenters’ self-reported disclosures made at the Annual Meeting of the AAO-HNSF in the calendar years 2006 and 2007 were tabulated. All subsequent publications arising
ORALS
OBJECTIVES: 1) Establish the feasibility of a predictive validity study in sinus surgery simulation training. 2) Demonstrate the effectiveness of the Endoscopic Sinus Surgery Simulator (ES3) as a training device. METHODS: A prospective, multi-institutional controlled trial involving three tertiary academic centers was conducted to evaluate the ES3 as a training device. Twelve ES3-trained novice residents were compared to 13 control novice residents. Subjects were assessed on the performance of basic sinus surgery tasks. Their first in vivo procedure was videorecorded and submitted to a blinded panel of independent experts, after having established a minimum inter-rater reliability of 80%. The recordings were reviewed using a standardized computerassisted method and customized metrics. Results were analyzed using a Student t-test. Internal rater consistency was verified with Pearson moment correlation. RESULTS: Completion time was significantly shorter in the experimental group (injection p⫽0.006, dissection p0.5 between serial measurements). CONCLUSIONS: The validity of the ES3 as an effective surgical trainer was verified in multiple instances, including those not depending on subjective rater evaluations. The ES3 is now the only simulator with a comprehensive validation record based on strict academic criteria. Advanced simulation technologies need faster implementation in otolaryngology training, as they present noteworthy potential for high quality surgical education while meeting the obligations of patient safety.
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Otolaryngology-Head and Neck Surgery, Vol 141, No 3S1, September 2009
Society for Pharmacoeconomics and Outcomes Research (ISPOR) and Royal Society of Medicine databases for studies mentioning endotracheal intubation and tracheal damage. Fifty-six studies were reviewed. We identified clinical manifestations and treatments and codified them into ICD-9 diagnosis and procedure codes intentionally excluding tracheostomies and alternate etiologies. Using the Agency for Healthcare Research and Quality’s 2006 National Inpatient Sample, we compared patients with tracheal damage coded during the surgical stay for LOS and mean hospital cost with DRGmatched controls; and examined readmissions treating tracheal damage. Confidence intervals (CI) were calculated with adjustment for complex sampling design. RESULTS: Tracheal damage presented as tracheal stenosis, tracheomalacia, tracheoesophageal fistula, laryngotracheal ulceration, and vocal cord paralysis. A total of 3232 discharge records met criteria for tracheal damage from ET intubation within the same hospital stay. Average LOS for patients with tracheal damage (6.3 days) exceeded LOS in the uncomplicated sample (5.2 days) by 1.1 days. Average hospital cost was $1,888 higher with tracheal damage ($10,375 vs. $8,487; 95% CI $9,762-$10,988). There were 200 re-admissions from this patient cohort for repair of prior tracheal damage averaging 4.7 days and $11,025 per discharge. CONCLUSIONS: Tracheal damage from endotracheal intubation is uncommon but substantially adds to patient morbidity and cost of care. Driving standards of tracheostomy care in the UK Asit Arora, AFRCS (presenter); Roland Hettige; Sonna Ifeacho; May Nell; Carlos Gomez; Antony Narula, MA, FRCS OBJECTIVES: To assess and improve tracheostomy service care provision MISSING METHODS: Study design: 3-cycle prospective audit (20032009). Setting: Tertiary academic London hospital serving an inner-city, multi-ethnic population. Standard: Best Practice Guidelines established using Evidence-Based Medicine and expert opinion. 1st cycle (Nov 03-Feb 04) assessed compliance to the standard for patients with a tracheostomy discharged from ITU to the ward (n⫽24). Intervention: Introduction of tracheostomy care plan and nursing teaching programme. 2nd cycle (Nov 06-Feb 07) re-audited care plan compliance and decannulation time following ITU discharge (n⫽70). Intervention: Tracheostomy multidisciplinary team, weekly team ward round and expanded teaching programme to include Allied Healthcare Professionals. 3rd cycle (July-Sept 2007, Nov 08-Jan 09) re-audited care plan compliance and time to decannulation (n⫽25). Statistical methods: Mann Whitney Wilcoxon Test. RESULTS: Compliance to the tracheostomy care plan prior to intervention was 43% in 2003/2004. Following initial intervention, compliance increased by one third to 58% in 2006/ 2007. Time to decannulation was 21 days. Following the 2nd
cycle interventions, compliance rose to 94%. Mean time to decannulation was significantly reduced from 21 to 11 days (P-value ⬍0.05). There was also a significant reduction in the proportion of ‘severe’ tracheostomy-related clinical incidents reported during this time-frame. The mean total tracheostomy time was reduced from 34 to 24 days although this was not statistically significant. CONCLUSIONS: The introduction of a tracheostomy care plan, regular AHP teaching program and tracheostomy multidisciplinary team responsible for reviewing all patients on a weekly basis expedites the weaning process and improves tracheostomy care. Flexible nasoendoscopy: Prospective study on lidocaine spray Sunil H Vyas, MBChB (presenter) OBJECTIVES: To understand: 1) Patient discomfort during flexible nasoendoscopy (FN), with or without the use of lidocaine (anaesthetic) nasal spray. 2) Any other associated effects, such as nausea, rhinorrhea, or on the swallowing mechanism. METHODS: 110 healthy volunteers were randomized into two groups: Group A, prior to FN, had 2.5mls of lidocaine hydrochloride 5% w/v intranasal spray. Group B had no spray prior to FN. The volunteers underwent examination of their nasal cavity, post-nasal space, base of tongue and larynx. Then under direct vision, a ‘normal’ swallow study was performed, by drinking 20mls of natural blue dye, followed by, 1, 10 and 20mls of water. The discomfort was assessed using the Visual Analogue Score (VAS 0-5). A further questionnaire was filled out to determine any other symptoms such as nausea, rhinorrhea, and any effect on swallowing. RESULTS: VAS (0-5, 0 being the least and 5 being the most discomfort): Group A (58): 1 (28/58, 48.3%), 2(25/58, 43.1%), 3 (5/58, 8.6%), 4(0), 5(0). Group B (52): 1(12/52, 23.1%), 2(24/52, 46.2%), 3(14/52, 26.9%), 4(2/52, 3.8%). 5(0). Patient symptoms: Rhinorrhea: 13/58 (22.4%) in group A, and 8/52 (15.4%) in group B. Difficulty in swallowing: 13/58(22.4%) in group A, and 6/52 (11.5%) in group B. Nausea: 8/58 (13.8%) in group A, and 8/58(13.8%) in group A and none in group B. CONCLUSIONS: In group A (with lidocaine), 53/58 (91.3%), and in group B (without lidocaine) 36/52 (69.2%) reported minimal discomfort (VAS up to 2). Therefore using nasal lidocaine spray is beneficial in reducing patient discomfort. However, there are other associated transient effects such as rhinorrhea, nausea, and altered sense of swallowing. From virtual reality to operating room: The ES3 experiment Babak Sadoughi, MD (presenter); Sanjay Parikh, MD; John Bent, MD; Marvin Fried, MD; Marc Gibber, MD; Joseph Jacobs, MD; Douglas A Ross, MD
Program Oral Presentations
Patient information: Obtaining informed consent in ENT Scott Henney, MD (presenter); Simren Rakhra, MBChB OBJECTIVES: 1) Determine whether patients undergoing daycase surgery were being provided with written information. 2) Evaluate satisfaction with patient information. 3) Assess whether written patient information leaflets improved recall of complications. METHODS: Prospective controlled study conducted during the first four months of 2009 in the ENT Department of a UK University Teaching Hospital. 100 patients undergoing daycase surgery were included. Fifty consecutive patients were given patient information leaflets in the outpatient clinic and compared with 50 consecutive patients receiving current practice. Verbal information including risks was provided but written patient information was not routine. A questionnaire on admission to the ward on the day of surgery was used to measure outcomes; if written patient information had been received, the time between consent and procedure, recall of complications and satisfaction with information received. RESULTS: There was a significantly improved rate of recall in the patient group who received patient information leaflets compared to those who did not routinely (p⬍0.05). There was no significant difference in patient satisfaction between groups.
CONCLUSIONS: Written patient information leaflets are a useful tool for the surgeon to improve recall of the information given to the patient, in order to facilitate informed consent. Preliminary NSQIP results in otolaryngology Robert J Stachler, MD (presenter); Kathy Yaremchuk, MD; Jennifer Ritz OBJECTIVES: 1) To improve patient safety by analyzing outcomes data. 2) To present preliminary National Safety Quality Improvement Data specifically for otolaryngology. METHODS: Postoperative complications impose a substantial mortality and morbidity burden on patients and excess costs on society. In 1986 Congress mandated that the VA report risk-adjusted surgical outcomes compared with a national average. In 1994 the National Surgical Quality Improvement Program (NSQIP) was begun. Its role is to measure and report comparative risk-adjusted surgical outcomes at the institutional level and to promote improvement through selfassessment, site visits, and dissemination of best practices. This program promotes widespread adherence to process-of-care measures. It involves measurement and improvement of riskadjusted surgical outcomes. RESULTS: Participation by otolaryngology-head and neck surgery began in August 2008 with the collection of 40 preoperative clinical risk factors (e.g., diabetes and heart disease), 20 categories of 30-day postoperative morbidity (e.g., venous thrombosis, wound infections, and pneumonia), and 30-day postoperative mortality on patients having major operations under general anesthesia. There are 34 sites collecting ENT data in the US. A summary of the data analysis for the subsequent year will be presented as preliminary findings. Strategies for improvement based on preliminary findings will be presented. CONCLUSIONS: NSQIP provides a platform for quality improvement within otolaryngology-head and neck surgery and is a national initiative that will continue to evolve in the future. Otolaryngologists need to be involved in this process to help create a safer environment for patients and to help shape health care policy. Reliability of authorship disclosures in otolaryngology Neil Bhattacharyya, MD (presenter); Harrison W Lin, MD OBJECTIVES: Determine the reliability of self-reported authorship disclosures of potential conflicts of interest in American Academy of Otolaryngology—Head and Neck Surgery (AAO-HNS/F)-sponsored presentations and publications. METHODS: Presenters’ self-reported disclosures made at the Annual Meeting of the AAO-HNSF in the calendar years 2006 and 2007 were tabulated. All subsequent publications arising
ORALS
OBJECTIVES: 1) Establish the feasibility of a predictive validity study in sinus surgery simulation training. 2) Demonstrate the effectiveness of the Endoscopic Sinus Surgery Simulator (ES3) as a training device. METHODS: A prospective, multi-institutional controlled trial involving three tertiary academic centers was conducted to evaluate the ES3 as a training device. Twelve ES3-trained novice residents were compared to 13 control novice residents. Subjects were assessed on the performance of basic sinus surgery tasks. Their first in vivo procedure was videorecorded and submitted to a blinded panel of independent experts, after having established a minimum inter-rater reliability of 80%. The recordings were reviewed using a standardized computerassisted method and customized metrics. Results were analyzed using a Student t-test. Internal rater consistency was verified with Pearson moment correlation. RESULTS: Completion time was significantly shorter in the experimental group (injection p⫽0.006, dissection p0.5 between serial measurements). CONCLUSIONS: The validity of the ES3 as an effective surgical trainer was verified in multiple instances, including those not depending on subjective rater evaluations. The ES3 is now the only simulator with a comprehensive validation record based on strict academic criteria. Advanced simulation technologies need faster implementation in otolaryngology training, as they present noteworthy potential for high quality surgical education while meeting the obligations of patient safety.
P107