SPA Spring Meeting Reviews
Friday Session IV: PEDx Updates
By Kate Gentry MD, MA
Seattle Children’s Hospital, University of Washington School of Medicine
Friday afternoon’s PEDx general session featured four engaging talks covering fetal surgery, behavioral economics, workplace conflict, and opioid-free outpatient surgery.
Fetal Surgery, 2020
Diana Farmer, MD, (Surgeon-in-Chief at UC Davis Children’s Hospital and Chair of the Department of Surgery at UC Davis), a world-renowned pioneer in the field of fetal surgery, covered the major developments in fetal surgery that have occurred in the past 30 years. Investigations into fetal surgery followed from the development of fetoscopy. If one could visualize a defect in utero, could it be fixed in utero? If it could be fixed in utero, would that change the physiology of the defect?
Embarking on fetal surgery is ethically fraught: the mother bears significant risks yet receives no direct benefit from the intervention; the fetus is also exposed to risk but with the hope of significant benefit. For initial investigations to be ethically acceptable, the fetal conditions being studied had to have an extremely poor prognosis, such as a likelihood of death in utero or shortly after birth, in order to justify the risks to both mother and fetus. Those developing the techniques were obligated to refine their approaches in order to minimize maternal risk, while also learning which fetal conditions were most amenable to a fetal intervention. Such conditions have come to include tumors, lung lesions, airway obstruction, congenital heart disease, congenital diaphragmatic hernia, spina bifida, urinary obstructions, and twin-twin transfusion syndrome.
Animal models were critical to the development of fetal surgery, and it turned out that variation in different species presented unique advantages, as well as challenges, to investigators’ progress. For instance, pregnant ewes were excellent models because they do not go into preterm labor. When the techniques were applied to a primate model, researchers learned that performing a hysterotomy acted “like an IUD,” preventing future conception.
A large, coordinated, multidisciplinary team is required for fetal operations. The anesthesiologist’s primary responsibility is to monitor, anesthetize and support the mother, since the infant is fully maintained by the uteroplacental circulation. Fetal surgery is performed under deep general anesthesia in order to “fool the fetus and the uterus that nothing has happened.”
Fetal surgery has completely changed the course and prognosis for twin-twin transfusion syndrome, which untreated, carries an 80% mortality rate in utero. When the intertwin vascular connections are coagulated by a laser delivered fetoscopically, the mortality rate drops to 20%. Myelomeningocele is another condition for which fetal surgery can markedly change outcomes. A randomized controlled trial of fetal MMC repair (the MOMS trial) was conducted at three fetal centers in the US, including at UCSF where Dr. Farmer was an investigator at the time. The surgical intervention was found to be so efficacious that the trial was stopped early (after eight years) as the need for shunt was significantly less in the fetal surgery group (40% vs. 82%) (Adzick et al. 2011). Long term follow-up has shown improved cognitive development and motor function in children who underwent a fetal repair, although over half of the children in the fetal surgery arm remain unable to walk.
Stem cell therapy holds promise as a component of fetal intervention as well. Can application of placental derived mesenchymal stem cells to neural tube defects at the time of closure improve motor function? Can fetal stem cell infusions reconstitute a flawed hematopoietic line, such as in alpha thalassemia or sickle cell anemia? Fetal interventions are also now being considered as researchers look at the fetal origins of adult diseases such as obesity and hypertension.
Behavioral Economic Nudges to Enhance Clinician Behavior
Dr. Jack Stevens, psychologist and Associate Professor of Pediatrics at Nationwide Children’s Hospital, Ohio State University, spoke about behavioral economics (BE). BE is an interdisciplinary field involving insights from psychology, economics and marketing that aims to improve individuals’ decision making. Dr. Stevens focused on two strategies—peer comparisons and changing the default—that can be employed to encourage desirable behaviors.
Peer comparisons hinge upon the observation that human decisions rarely rely solely on facts—they are influenced by what others are doing or saying. An example outside of medicine involves hotel towel reuse programs. Psychologists found that hotel guests who were informed that a “majority of other hotel guests” had reused their towels were 26% more likely to reuse their towels than their counterparts who received a standard message about reusing towels as a way to protect the environment (Goldstein, Cialdini, and Griskevicius 2008). Peer comparisons have been successfully employed in medicine to encourage appropriate prescribing of antibiotics, opioids, and antipsychotics (Andereck et al. 2019, Sacarny et al. 2018, Meeker et al. 2016). Dr. Stevens noted that one must be thoughtful about the benchmark being employed for peer comparisons. Individuals may not be particularly motivated by what the “average” person does (the bar is too low), nor by what the superstar does (may seem unfeasible); benchmarking what the “top 10%” does may seem achievable. Highlighting those who exhibit top behavior, such as in departmental newsletter, is another type of peer comparison.
It is well recognized that people will save more money for retirement if their employer automatically enrolls them in a retirement savings program. This is an example of changing the default from an opt-in to an opt-out enrollment strategy. This approach has also been effective in reducing opioid prescriptions and encouraging the use of non-opioid analgesics. Specifically, Chiu et al. found that a change in the number of dispensed pills from 30 to 12 was not associated with an increase in refill requests (Chiu et al. 2018).
For those interested in learning more about behavioral economics, Dr. Stevens recommended the following resources:
- "Generic Medication Prescription Rates After Health System–Wide Redesign of Default Options Within the Electronic Health Record." (Patel et al. 2016)
- "Should Governments Invest More in Nudging?" (Benartzi et al. 2017)
- “How to save 32 million dollars in 1 hour” Freakonomics podcast, episode 397
Dr. Stevens can be reached at Jack.Stevens@nationwidechildrens.org
Embracing Conflict to Improve Care and Productivity
Susan Staudt, MD, is a pediatric anesthesiologist and the Fellowship Director at the University of Minnesota, who spoke about how to embrace conflict--and more importantly, its resolution-- in the operating room.
Workplace conflict is ubiquitous, including in the operating room. See the following references for some fascinating studies describing conflict and incomplete communication attempts in the O.R.:
- “Conflicts in the Operating Theatre” (Booij 2007)
- “Communication Failures in the Operating Room: An Observational Classification of Recurrent Types and Effects” (Lingard et al. 2004)
Not surprisingly, these investigations concluded that conflict and poor communication can result in team stress, compromised performance, and patient harm. What can be done to manage this inevitable conflict? Dr. Staudt says we must (a) acknowledge conflicts, (b) understand the different forms of conflict, and (c) hone our conflict resolution skills.
Conflicts can be categorized as task conflicts, process conflicts, and relationship conflicts. The literature suggests that if you deal with conflicts in the task or process realms they can usually be resolved quickly. Relationship/interpersonal/emotional conflicts are the most stressful types, and if left unresolved, are the conflicts most likely to negatively impact team performance.
A surprising fact is that highly productive medical teams often have more conflict than less productive ones. The conflicts typically remain in task domain and are resolved efficiently. Furthermore, functional teams tend to view these events as challenges more than conflicts. In the midst of disagreement, the emotional tone remains calm and matter of fact. Anticipatory communication is common, and team members respect and listen to one another. Dr. Staudt emphasized that recognizing and resolving conflict is an important leadership skill.
For those interested in learning more about managing conflict productively, take a look at Dr. Staudt’s syllabus (available on the meeting website) which includes an annotated bibliography. She also welcomes your questions and comments via email: firstname.lastname@example.org.
Reducing Opioids in Ambulatory Surgery: Evidence Based Medicine to Medicine Based Evidence
Dan Low, MRCPCH, FRCA, is a pediatric anesthesiologist at Seattle Children’s Hospital and CMO of MDMetrix. (Full disclosure: I also work at Seattle Children’s; Dan is one of my colleagues).
He opened with a sobering reminder about the devastating impacts of the opioid epidemic, particularly on teenagers and young adults. Surgery is often the gateway by which people are exposed to opioids for the first time; five percent of adolescent surgical patients develop persistent opioid use. Faced with this information, Dr. Low wondered if Seattle Children’s Bellevue Surgery Center (BSC) could reduce or eliminate the use of opioids during surgery, narrowing this gateway to opioid misuse.
According to Dr. Low, a problem with a lot of quality improvement (QI) work is that the recurring processes of clinical care are tackled using a “one-time project” approach. Also, QI tracking is often done on whiteboards or posted papers—i.e. the findings are not easily saved nor readily shared. These limitations make distinguishing signal from noise difficult.
Dr. Low applied the recommended “best practice” methods for quality improvement by building software that can mine EMR data and produce “control charts.” For a given outcome, control charts allow visualization of the mean and a normal range (within three standard deviations of the mean); data points that fall outside of this range, as well as a cluster or trend of results that falls outside the patterns of normal variation are termed “special cause variation.” Plotting special cause variation against time facilitates the distinction of signal from noise and the initiation of the Plan-Do-Study-Act cycles of QI.
Dr. Low and his team recognized that there was evidence for the efficacy and safety of ketorolac (Chan and Parikh 2014) and dexmedetomidine (Olutoye et al. 2010) in tonsillectomies and adenoidectomies. However, Dr. Low found that providers are often more convinced by their own data/experience than the medical literature. His software allowed him to describe the current state (e.g. surgeons’ use of local anesthesia, morphine equivalents given intra- and post-op, PACU pain scores, time to PACU discharge, PONV rescue meds given in PACU, and re-admissions for post-op bleeding) as well as to rapidly report the outcomes of newly implemented strategies that were part of the QI bundle. The team at BSC adopted an opioid-free protocol, which involves giving dexmedetomidine and ketorolac intraoperatively, and eliminating local injection by the surgeon. The changes resulted in lower rates of PONV, lower baseline levels of pain and a minimal increase in PACU length of stay. There was no change in 30 day bounce backs for bleeding complications (Franz et al. 2019).
The team at BSC has subsequently implemented similar changes for all their cases, and since January 2019, all cases have been conducted using an opioid-free protocol (Franz et al. 2020). Dr. Low and his team urge you to be open to non-opioid techniques, “deploy your clinical and workflow data to empower leaders and front-line clinicians,” and join him in this improvement work.
Dr. Low can be reached at Dan@mdmetrix.com
- Adzick, N. S., E. A. Thom, C. Y. Spong, J. W. Brock, 3rd, P. K. Burrows, M. P. Johnson, L. J. Howell, J. A. Farrell, M. E. Dabrowiak, L. N. Sutton, N. Gupta, N. B. Tulipan, M. E. D'Alton, and D. L. Farmer. 2011. "A randomized trial of prenatal versus postnatal repair of myelomeningocele." N Engl J Med 364 (11):993-1004. doi: 10.1056/NEJMoa1014379.
- Andereck, J. W., Q. R. Reuter, K. C. Allen, S. Ansari, A. R. Quarles, D. S. Cruz, L. A. VanZalen, S. Malik, D. M. McCarthy, and H. S. Kim. 2019. "A Quality Improvement Initiative Featuring Peer-Comparison Prescribing Feedback Reduces Emergency Department Opioid Prescribing." Jt Comm J Qual Patient Saf 45 (10):669-679. doi: 10.1016/j.jcjq.2019.07.008.
- Benartzi, Shlomo, John Beshears, Katherine L. Milkman, Cass R. Sunstein, Richard H. Thaler, Maya Shankar, Will Tucker-Ray, William J. Congdon, and Steven Galing. 2017. "Should Governments Invest More in Nudging?" Psychological Science 28 (8):1041-1055. doi: 10.1177/0956797617702501.
- Booij, L. H. 2007. "Conflicts in the operating theatre." Curr Opin Anaesthesiol 20 (2):152-6. doi: 10.1097/ACO.0b013e32809f9506.
- Chan, D. K., and S. R. Parikh. 2014. "Perioperative ketorolac increases post-tonsillectomy hemorrhage in adults but not children." Laryngoscope 124 (8):1789-93. doi: 10.1002/lary.24555.
- Chiu, A. S., R. A. Jean, J. R. Hoag, M. Freedman-Weiss, J. M. Healy, and K. Y. Pei. 2018. "Association of Lowering Default Pill Counts in Electronic Medical Record Systems With Postoperative Opioid Prescribing." JAMA Surg 153 (11):1012-1019. doi: 10.1001/jamasurg.2018.2083.
- Franz, A. M., J. P. Dahl, H. Huang, S. T. Verma, L. D. Martin, L. D. Martin, and D. K. Low. 2019. "The development of an opioid sparing anesthesia protocol for pediatric ambulatory tonsillectomy and adenotonsillectomy surgery-A quality improvement project." Paediatr Anaesth 29 (7):682-689. doi: 10.1111/pan.13662.
- Franz, A. M., L. D. Martin, D. E. Liston, G. J. Latham, M. J. Richards, and D. K. Low. 2020. "In Pursuit of an Opioid-Free Pediatric Ambulatory Surgery Center: A Quality Improvement Initiative." Anesth Analg. doi: 10.1213/ane.0000000000004774.
- Goldstein, Noah J., Robert B. Cialdini, and Vladas Griskevicius. 2008. "A Room with a Viewpoint: Using Social Norms to Motivate Environmental Conservation in Hotels." Journal of Consumer Research 35 (3):472-482. doi: 10.1086/586910.
- Lingard, L., S. Espin, S. Whyte, G. Regehr, G. R. Baker, R. Reznick, J. Bohnen, B. Orser, D. Doran, and E. Grober. 2004. "Communication failures in the operating room: an observational classification of recurrent types and effects." Qual Saf Health Care 13 (5):330-4. doi: 10.1136/qhc.13.5.330.
- Meeker, D., J. A. Linder, C. R. Fox, M. W. Friedberg, S. D. Persell, N. J. Goldstein, T. K. Knight, J. W. Hay, and J. N. Doctor. 2016. "Effect of Behavioral Interventions on Inappropriate Antibiotic Prescribing Among Primary Care Practices: A Randomized Clinical Trial." Jama 315 (6):562-70. doi: 10.1001/jama.2016.0275.
- Olutoye, O. A., C. D. Glover, J. W. Diefenderfer, M. McGilberry, M. M. Wyatt, D. R. Larrier, E. M. Friedman, and M. F. Watcha. 2010. "The effect of intraoperative dexmedetomidine on postoperative analgesia and sedation in pediatric patients undergoing tonsillectomy and adenoidectomy." Anesth Analg 111 (2):490-5. doi: 10.1213/ANE.0b013e3181e33429.
- Patel, Mitesh S., Susan C. Day, Scott D. Halpern, C. William Hanson, Joseph R. Martinez, Steven Honeywell, Jr, and Kevin G. Volpp. 2016. "Generic Medication Prescription Rates After Health System–Wide Redesign of Default Options Within the Electronic Health Record." JAMA Internal Medicine 176 (6):847-848. doi: 10.1001/jamainternmed.2016.1691.
- Sacarny, A., M. L. Barnett, J. Le, F. Tetkoski, D. Yokum, and S. Agrawal. 2018. "Effect of Peer Comparison Letters for High-Volume Primary Care Prescribers of Quetiapine in Older and Disabled Adults: A Randomized Clinical Trial." JAMA Psychiatry 75 (10):1003-1011. doi: 10.1001/jamapsychiatry.2018.1867.