Surgery is one of the most critical services in a hospital. From the institutional point of view, the surgical service requires the largest team of specialists assembled for the procedure and for post-operative care, as well as substantial investments in facilities, equipment, and Intensive Care Unit capacity. On the part of the patient, surgery provokes the greatest apprehension of all inpatient care, dents health insurance or checkbooks the most, and requires lengthy stay.
From my moderate-involvement perspective as a nurse in the surgical service, data-gathering seems most rudimentary. At this time, my hospital seems interested solely in compiling:
- Scheduling information – deviations in actual starting times from those scheduled; and,
- Administrative adherence – the proportion of procedures when a pre-operative briefing was actually carried out.
There is little question about interpreting such basic administrative information correctly. One naturally understands that efficient use of limited resources, such as the operating theaters and ancillary facilities, helps the institution conform to cost management standards and more reliably fulfill return-on-investment forecasts.
On the other hand, the outcome of conducting pre-operative briefings or not is less amenable to hard performance measures. For this seems more closely linked with the efficiency of the O.R. team and how well they mesh together during the procedure itself.
Other surgical services, it turns out, are more rigorous about collecting and analyzing all kinds of information. For the most part, these have to do with spotting trends in patient characteristics and procedures performed as independent or intervening variables that influence outcomes. Such patterns are didactically useful for improving the art of patient management.
Given this context, it stands to reason that data about patient characteristics, procedures performed or innovated, and post-surgical care should be methodically gathered so that correlations or possible case-and-effects relationships can be compiled over time.
In cardiovascular procedures, for instance, every surgeon and nurse understands that whatever limited fitness the patient presents with can have disproportionate outcomes on surviving long procedures, on responding well to radical techniques, and on recovery times. And yet, our surgical service cannot seem to take the time to systematically record in a central database such vital parameters as baseline fitness, age, gender, exercise or activity level, profession/ occupation, weight, body mass index, presence or degree of support from family, and spirituality, to name just a few.
Focusing on cardiovascular surgery itself, an effort should be made to compile trends over a period of months, years, or a sizeable cohort of patients to learn about the comparative effectiveness of new therapies to minimize trauma to the heart and vessels during surgery, techniques to reduce the need for large surgical incisions, methods to protect the body from potential negative side-effects of anesthesia and the heart-lung bypass machine, improvements in such devices as valves, pacemakers, and artificial hearts, and understanding the relationship of diet, exercise, and lifestyle in recovery and prevention.
Post-operatively, nurses could perhaps do better if they had a more systematic (evidence-based) understanding of the relationship between the body-mind-spirit and healing.
Turning to pathology, most hospitals continue to do case reviews primarily to fend off malpractice suits but also in pursuit of continued learning and even disciplining the odd maverick surgeon. But how many institutions correlate the proportion of false-negative biopsies with the identities of the surgeons and internists who convince their patient’s exploratory surgery is vital? How much longer must the veil of professional courtesy and mutual defense conceal the incompetence of a few?
Research on operating-room mortality and nosocomial infections is itself a wide field. Mortality statistics need to be analyzed against the length of procedure, the surgeon involved, anesthesia employed, theater disinfection agents, intervals between disinfection, the proportion of disposables used, and even periodic pathogen counts on surgical instruments, garments, and equipment. Even within the “limited” scope of the surgical service, surgical nurses would learn which priorities to follow if they had correlation data on the onset of nosocomial infections by age of the patient (the very old and very young are especially susceptible), by predisposing condition (e.g. diabetes), by the extent of patient awareness, patient and nurse compliance with hygiene regimens, by the surgical procedure used, by the length of stay, by invasive post-operative procedures, by a causative pathogen, and by high-risk areas such as the ICU and in high-dependency units. Plainly, there is much that can be done to inform more successful surgical and nursing practice.