Taking steps to ensure safer surgeries

Why do we care about surgical safety?

Surgical care and its safe delivery affect the lives of millions of people. About 234 million major operations are performed worldwide every year.

The change in disease patterns worldwide is increasing the need for surgical services considerably. Epidemics and infections are giving way as leading causes of death to ischemic heart diseases, cancers, and trauma - which need surgical interventions.

Ensuring better access to surgical care and its safe delivery is crucial for its effectiveness. The available evidence suggests that as many as half of the complications and deaths arising from surgery could be avoided if certain basic standards of care were followed.

WHO is taking steps to address these issues through:
the Global Initiative for Emergency and Essential Surgical Care;
its guidelines for essential trauma care; and
the Second Global Patient Safety Challenge initiative.

Here are some interesting facts, courtesy the World Health Organization:

Globally, about 234 million major surgical operations are conducted a year. This equates to about one operation for every 25 persons. Every year 63 million people undergo surgery to treat traumatic injuries, another 10 million for pregnancy-related complications, and 31 million more for treating cancers.

Studies suggest that complications following surgery result in disability or prolonged stay in 3-25% of hospitalized patients, depending upon complexity of surgery and hospital setting. These rates would mean that at least 7 million patients annually may have post-operative complications.

Rates of death following major surgery are reported to be between 0.4% and 10%, depending on the setting. Estimating the impact of these rates, at least 1 million patients would die every year during or after an operation.

Information regarding surgical care has been standardized or systematically collected only in a few research studies globally. As a result, most surgical interventions worldwide are not recorded. It is essential to measure surgical care on a global basis for promoting surgical safety, preventing disease and improving care.

Surgical care has been shown to be cost effective in developing settings. Ensuring safe delivery of care will only improve its efficacy.

Dramatic improvements have been made in the administration of anaesthesia over the past 30 years, but not in all parts of the world. In some regions, anaesthesia-related mortality is as high as 1 in 150 patients receiving general anaesthesia.

Safety measures are inconsistently applied in surgery, even in sophisticated settings. Simple steps can reduce complication rates. For example, improving the timing and selection of antibiotics prior to skin incision can reduce the rate of surgical site infections by up to 50%.

WHO has developed guidelines for safe surgery and a checklist of surgical safety standards applicable in all countries and health settings. Preliminary results of an evaluation in eight pilot sites worldwide show that the checklist has nearly doubled the likelihood that patients will receive treatment as per standards of surgical care – such as an antibiotic before incision and confirmation that the surgery team has the correct patient for the correct operation.

The Safe Surgery Saves Lives initiative is collaborating with more than 200 ministries of health, national and international medical societies and professional organizations to reduce deaths and complications in surgical care.


I think that the most striking portion of these facts is that safety measures are applied inconsistently, and that over one million people going under die each year...how many of these could be avoided I wonder?

Should New York State Mandate Health Care Workers and Staff in Long Term Care Facilities be Vaccinated Each Year Against Influenza

This is a question currently being considerd by health professionals in New York State. This was also a panel discussion topic in one of my Advanced Epidemiology Lectures, in which my colleagues and I researched and presented on. My portion is detailed below, along with other issues to consider, which are being researched by my colleagues. This is a huge question!


Vaccination Coverage Levels

Mandating health care workers and staff in New York State Long Term Care Facilities has the potential to disrupt supply, and so annual monitoring of supply is recommended, which is also supported by ACIP.

One of the national health objectives for 2010 includes achieving an influenza vaccination coverage level of 90% for persons aged >65 years and among nursing home residents (1,2); new strategies to improve coverage are recommended as necessary to achieve these objectives (3,4) to prevent illness.

ACIP is currently recommending increasing vaccination coverage among persons who have high-risk conditions and are aged <65>

Estimated vaccination coverage levels in 2007 among persons aged >65 years was 72.1%, with a rate higher among non-Hispanic whites (74.2%) versus non-Hispanic blacks (62.3%) (5). Overall, vaccination against influenza in the general population has increased.

Vaccination of long term care residents and health workers/staff

ACIP recommends vaccination be provided to all residents of long term care facilities noting that signed consent is not required (6), which will prevent illness.
Since 2005, the Centers for Medicare and Medicaid Services (CMS) has required nursing homes participating in the Medicare and Medicaid programs to offer all residents influenza and pneumococcal vaccines. According to the requirements, each resident is to be vaccinated unless contraindicated medically, the resident or a legal representative refuses vaccination, or the vaccine is not available because of shortage. This information reported as part of the CMS Minimum Data Set, which tracks nursing home health data (7,8).
Although annual vaccination is recommended for health care workers and is a high priority for reducing morbidity associated with influenza in health-care settings and for expanding influenza vaccine use, national survey data shows vaccination coverage of only 41.8% among health care providers during the 2005--06 season (9-11).
Vaccination of health care workers has been associated with reduced work absenteeism (12) and with fewer deaths among nursing home patients (13, 14) and elderly hospitalized patients (15). Beliefs frequently cited by those who decline vaccination include doubts about the risk for influenza, the need for vaccination, concerns about effectiveness and side effects, and dislike of injections (16)
Studies show that organized campaigns can attain higher rates of vaccination among health care workers with moderate effort and by using strategies to increase vaccine acceptance (9, 11, 17).These efforts are supported by various national accrediting and professional organizations and in certain states by statute. The Joint Commission on Accreditation of Health-Care Organizations has an infection-control standard requiring accredited organizations to offer influenza vaccinations to staff, including volunteers and licensed independent practitioners with patient contact. This became an accreditation requirement January 1, 2007 (18). In addition, the Infectious Diseases Society of America recommends mandatory vaccination for health care workers and staff, with a provision for exemption based on religious or medical reasons (19).
Fifteen states have regulations regarding vaccination of health care workers in long-term care facilities (20), six states require that health-care facilities offer influenza vaccination to staff, and three states require that health workers either receive influenza vaccination or indicate a religious, medical, or philosophical reason for not being vaccinated, (AL, CA, NH) (21, 22). Other states have mandated health workers be vaccinated against varicella (ME, OK, RI), MMR (AK, IL, ME, MD, MA, NM, NY, OK, RI, WI), and HepB (AK, ME,) (21). Note there is a precedent in New York State for requiring vaccination of health workers for MMR, although this is only in hospitals.

New York State Specific Data

Nursing home resident vaccination rates in New York State are above the national average from 2000-2007 the NYS average was 84% vaccination coverage where as the 2006-2007 season boasted a high of 87% (unpublished data presented at the 2008 APHA conference).
Employees of long term care facilities in New York State are on par with the national average with median vaccination coverage of 42.3% in 2006-2007. Employee vaccination is highest in Adult Day Health facilities and lowest in Adult Care facilities. Results also vary by region with the Metropolitan and New York City regions significantly below the state average. Efforts by New York State to visit nursing homes, a single type of long term care facility, have increased voluntary uptake of vaccine but not significantly (unpublished data presented at the 2008 APHA conference).

In conclusion, health care worker influenza vaccination is low, and well below levels that would protect patients, especially those in long term care facilities who are more vulnerable. Increasing vaccine coverage among long term care residents is recommended as a priority. In considering mandating vaccination of long term care staff, there is precedent of requiring vaccination in other states, as well as in hospital workers here in New York State against Measles and Rubella. Further, studies demonstrate reduced absenteeism from work among those health workers who receive vaccination, and vaccination of health workers is associated with reduced deaths among nursing home patients. Several professional organizations have also recommended requiring vaccination.

However, there are certainly many other issues to consider, including, but not limited too the true disease burden, vaccine efficacy, vaccine safety, costs for vaccine, moral and ethical considerations, sociocultural aspects and legal issues. These aspects are currently being researched by some of my colleagues, and their findings will soon be added once permission is received.


References
1. US Department of Health and Human Services. Healthy people 2010 2nd ed. With understanding and improving health and objectives for improving health (2 vols.). Washington, DC: US Department of Health and Human Services; 2000.

2. US Department of Health and Human Services. Healthy people 2000: national health promotion and disease prevention objectives---full report, with commentary. Washington, DC: US Department of Health and Human Services, Public Health Service; 1991.

3. Centers for Disease Control and Prevention. Improving influenza, pneumococcal polysaccharide, and hepatitis B vaccination coverage among adults aged <65 years at high risk: a report on recommendations of the Task Force on Community Preventive Services. MMWR 2005;54(No. RR-5).

4. Ndiaye SM, Hopkins DP, Shefer AM, et. al. Interventions to improve influenza, pneumococcal polysaccharide, and hepatitis B vaccination coverage among high-risk adults: a systematic review. Am J Prev Med 2005;28:248--79.

5. Centers for Disease Control and Prevention. Prevention and Control of Influenza. Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2008. MMWR 2008;57:1-60 (RR07).

6. Stefanacci RG. Creating artificial barriers to vaccination. J Am Med Dir Assoc 2005;6:357--8.

7. Centers for Medicare and Medicaid Services. 2006--2007 Influenza (flu) season resources for health care professionals. Available at http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0667.pdf.

8. Centers for Medicare and Medicaid Services. Medicare and Medicaid Programs. Condition of participation: immunization standard for long term care facilities. Final rule. Federal Register 2005:70:194; 58834--52.

9. National Foundation for Infectious Diseases. Call to action: influenza immunization among health-care workers, 2003. Bethesda, MD: National Foundation for Infectious Diseases; 2003. Available at http://www.nfid.org/publications/calltoaction.pdf.

10. Poland GA, Tosh P, Jacobson RM. Requiring influenza vaccination for health care workers: seven truths we must accept. Vaccine 2005; 23:2251--5.

11. CDC. Influenza vaccination of health-care personnel: recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) and the Advisory Committee on Immunization Practices (ACIP). MMWR 2006;55(No.RR-2).

12. Elder AG, O'Donnell B, McCruden EA, et al. Incidence and recall of influenza in a cohort of Glasgow health-care workers during the 1993--4 epidemic: results of serum testing and questionnaire. BMJ 1996;313:1241--2.

13. Carman WF, Elder AG, Wallace LA, et al. Effects of influenza vaccination of health-care personnel on mortality of elderly people in long-term care: a randomised controlled trial. Lancet 2000;355:93--7.

14. Hayward AC, Harling R, Wetten S, et. al. Effectiveness of an influenza vaccine programme for care home staff to prevent death, morbidity, and health service use among residents: cluster randomised controlled trial. BMJ 2006;333:1241.

15. Thomas RE, Jefferson TO, Demicheli V, et. al.. Influenza vaccination for health-care workers who work with elderly people in institutions: a systematic review. Lancet Infect Dis 2006;6:273—9.

16. Ofstead CL, Tucker SJ, Beebe TJ, et. al. Influenza vaccination among registered nurses: Information receipt, knowledge, and decision-making at an institution with a multifaceted educational program. Infect Control Hosp Epidemiol 2008;29:99--106.

17. Centers for Disease Control and Prevention. Interventions to increase influenza vaccination of health-care personnel---California and Minnesota. MMWR 2005;54:196--9.

18. Joint Commission on the Accreditation of Health Care Organizations. Approved: New Infection Control Requirement for Offering Influenza Vaccination to Staff and Licensed Independent Practitioners. Joint Commission Perspectives 2006:26:10—11

19. Infectious Diseases Society of America. Pandemic and seasonal influenza: principles for U.S. action. Arlington, VA: Infectious Diseases Society of America; 2007. Available at http://www.idsociety.org/Content/NavigationMenu/News_Room1/Pandemic_and_Seasonal_Influenza/IDSA_flufinalAPPROVED1.24.07.pdf.

20. Stewart A, Cox M, Rosenbaum S. The epidemiology of U.S. immunization law: immunization requirements for staff and residents of long-term care facilities under state laws/regulations. Washington, DC: George Washington University; 2005. Available at http://www.gwumc.edu/sphhs/healthpolicy/immunization/EUSIL-LTC-report.pdf.

21. Lindley MC, Horlick GA, Shefer AM, et al. Assessing state immunization requirements for healthcare workers and patients. Am J Prev Med 2007;32:459--65.

22. Centers for Disease Control and Prevention. CDC State immunization laws for healthcare workers and patients. Available at http://www2a.cdc.gov/nip/stateVaccApp/StateVaccsApp/default.asp.