Failure Rates in Surgery
By Vardaan Bal and Gabriel Salazar
Globally, approximately three hundred and ten million people undergo surgery every year. A study performed by the International Surgical Outcomes Study Group in the United Kingdom found that poor surgical health outcomes are present universally across both rich and poor nations. These outcomes included 16.8% of patients having further health complications post-surgery, and 2.8% of those patients dying from those complications. Extending these findings globally showed that around 50 million patients have complications postoperative (post-op) and over 1.5 million people die from those complications.
These complications are caused by a plethora of factors, including bacterial infections, surgical procedure errors, and wound care errors. In this article, we will be focusing on wound care errors. Wound care errors, in the context of this article, will be defined into two separate categories: patient induced wound complications and wound cleanliness.
A patient’s physiological reaction to surgery is highly variable and is dependent on the individual, but follows the same general guidelines. Any sort of surgery induces what is termed the Surgically Induced Stress Response, which is essentially the body’s response to trauma. This response increases with the severity of surgical injury and leads to changes in the genomic, inflammatory, hormonal, and acute phase responses. Hypermetabolism, or the increased expenditure of bodily energy, then results and leads to increased breakdown of stored body sugar, fat, and most concerningly, proteins. This can lead to muscle atrophy in addition to impaired immune functionality and wound healing. In extreme circumstances, it can even lead to organ failure and death. It should be noted that organ failure and death are rare occurrences, as most surgeries have minimized how intrusive and damaging they are to the body.
Regardless, this response still presents a problem, and response severity also varies with the patient themselves. For example, a patient with an autoimmune disorder will be more seriously impacted by reduced immune functionality than a patient with a healthy immune system. This introduces aspects of individualized care that surgeons must consider during surgery and patient recovery. General post-surgical side effects include: nausea and vomiting, inflammation and pain around the incision site or minor pain around IV sites, fatigue, and insomnia.
Beyond physiological reactions, patient adherence to surgical protocol and post-op treatment plans must also be considered as an area for improvement. Depending on the surgery and area of incisions, there are various considerations that must be taken into consideration for the patient’s post-op plan. For example, for a patient that undergoes knee surgery, a treatment plan must include home exercise, proper nutritional intake, timing of medicine intake, positioning of the knee to ensure proper blood flow, etc. This can be overwhelming and frustrating for a patient who is more than likely in pain, fatigued, and impaired in their normal functionality. It is important for providers to act in empathy and understand that the overload of instruction and responsibility is dismissed by some patients under this stress.
However, adherence to the recovery plan has been shown to be critical in reducing adverse outcomes for patients, as demonstrated in the Enhanced Recovery After Surgery (ERAS) program, after colonic resection surgery. The study found that when adherence rates to this new program fell from 84.1% to 72.4% over a period of four years, the length of stay of patients was not significantly different from patients undergoing conventional care. However, prior to the drop in patient adherence in the latter two years, the length of stay was significantly lower than conventional care in each year (p≤.009 and p≤.004). This suggests that increasing patient adherence to assigned care plans will directly lead to better outcomes in preventing post-surgical failures. To refer back to our orthopedic example, if a patient adheres to their physical therapy program and continues to work on their strength week after week while eating nutritionally suitable foods, this will accelerate their muscle recovery and development, shortening the amount of time to which their physical functionality is limited and their overall time under treatment. This demonstrates the enormity of the responsibility that falls on the patient; however, treatment plans can be eased by the continuous guidance and counsel of patients’ surgeons and medical teams.
However, the responsibility for wound cleanliness falls squarely on the medical provider. The sterility of the operating environment, the materials used to perform surgery, and the quality of procedure all contribute to how well the patient will fare post-surgery. Although this may seem like a fundamental pillar of modern healthcare, it has been repeatedly shown that hospitals are lacking in their hygiene practices. The existence of superbugs, which are strains of either bacteria, viruses, fungi, or parasites that are resistant to the antibiotics or medications that are meant to treat them, in hospital settings may be the result of provider error in preventing the spread of those diseases.
A 2014 CDC study performed by multiple researchers across 183 hospitals in the United States found that approximately 4% of patients had contracted healthcare care-associated infections, including but not limited to pneumonia, Clostridium difficile, and methicillin-resistant Staphylococcus aureus (MRSA). Superbug infections were estimated by the University of Washington in 2018 to be responsible for up to 153,113 deaths in U.S. hospitals alone at the most conservative estimates, emphasizing the gravity and spread of the issue. As described earlier, patients post-op are more susceptible to serious health consequences due to impaired immune function, and although there is no formalized surveillance data, they are more than likely disproportionately affected by such diseases due to their vulnerable state. As such, surgical failures are boosted by improper hygiene practices and point to a lack of standardized care or provider adherence to the standards present in a medical setting.
While it is now apparent that issues such as bacterial infection and patient adherence can have significantly negative effects on patient outcomes following surgery, we must now turn to the question of what specific measures and actions are being taken to address causes for surgical failure.
Regarding bacterial infections, their cause depends both on the patient’s natural bacterial microflora as well as the transfer of microorganisms from individuals in the operating team. The first line of defense against bacterial infection in patients is the use of sterile equipment and garments. Although the idea of keeping an operating room as sterile as possible may seem like a foregone solution, many operations are often performed without the adequate and meticulous procedures necessary for the sterilization of equipment, operating rooms, or garments. Sterilization precautions are incredibly effective in reducing bacterial infection and optimizing wound cleanliness. The simple practice of washing ones’ hands with water for 1 minute and alcohol solution for 2.5 minutes is associated with dramatic reductions in the rate of surgical site infection.
Additionally, the administration of antibiotics prior to surgery (antimicrobial prophylaxis) remains the primary method of reducing bacterial infection during the course of surgery. While administering antibiotics such as Cephalosporins or Amoxicillin remains effective in preventing most primary infections during surgery, the efficacy of this practice is limited by the suboptimal implementation of antibiotics by surgical teams throughout the world. Specifically, numerous care teams err in either the timing of the antibiotic administration, choice of antibiotic for the surgery or patient, or administration of antibiotics for an excessive time.
Regarding errors in administering preoperative antibiotics, up to 43% of surgical patients in a study of New York hospitals were not administered antibiotics within 2 hours of their surgery. Failure to administer antibiotics within 2 hours of surgery was associated with up to a 6-fold increase in surgical site infection. This specific example calls to mind the importance of timing the administration of antibiotics prior to surgery, which is often neglected in many procedures due to factors including provider oversight or inability to secure appropriate antibiotics in a timely manner prior to surgery. The latter is an issue especially prevalent in areas of the world that lack adequate medical supplies or suffer from weak supply lines to critical care centers. Beyond errors in the timing of antimicrobial prophylaxis, surgical teams and hospitals can commit grave errors by excessively administering antibiotics, both in duration and quantity — errors that have collectively resulted in microbial superbugs.
Beyond reducing the incidence of surgical site infections, surgical teams have begun improving upon existing enhanced recovery programs to increase patient adherence and to improve patient outcomes post-surgery. One method of increasing patient adherence to enhanced recovery programs is reducing the duration of invasive procedures such as intubation. For instance, in a study on patients recovering from pancreatic surgery, researchers removed invasive instruments such as nasogastric tubes at an earlier stage of patients’ enhanced recovery programs. Doing so resulted in an increase in patient adherence from 65% to 72%, but had no effect on the positive outcomes for patients undergoing enhanced recovery programs. By reducing the period of time a patient spent with uncomfortable, invasive procedures, providers were able to encourage patients to follow through with their enhanced recovery programs.
In terms of increasing the ability of medical practitioners to improve the quality and effectiveness of the care they provide, there are multiple technological implementations that could be used with patient cooperation. For example, wireless wearable sensors that have the ability to measure heart rate, respiratory frequency, arterial oxygen saturation, etc can be used. Some of these sensors have passed FDA approval, but require more testing to become useful clinical instruments. Still, as the capabilities and accuracy of these devices grow, their implementation should be highly considered as a standard of surgical post-op care in the future. Live data feeds on how a patient’s body is coping with the stress of surgery would enable physicians to have a quicker response to surgical complications and allow for further personalization of their care plan to match the patient’s physiological response.
In terms of solutions to reducing the prevalence of bacterial infections and other wound cleanliness-related contributions to surgical failure rate, there are different avenues of approach to consider depending on the country in question. By increasing support and funding for supplies such as sterile gloves, alcohol solutions, and antibiotics, developing countries would likely see a dramatic reduction in their national rates of surgical failure.
However, highly-developed countries such as the U.S. may see more utility in implementing disease surveillance in the national hospital system to determine which instances errors lead to higher rates of surgical failure. Based on findings from such research, hospital management teams would be able to determine if there is a need for more hygienic restrictions on a unit-by-unit basis. Active surveillance would help determine which hospital wards a disease has broken from and thus the best possible way to contain its spread to other patients, including post-op surgery patients. By promoting these simple procedures, surgical teams throughout the world would be able to dramatically reduce surgical site infections provided they have the necessary supplies and resources on hand to do so.
To further increase patient adherence to enhanced recovery programs after surgery, the implementation of virtual apps and text messages should be considered for facilitating clear lines of communication between patients and providers. This would include, but is not limited to, creating daily rehabilitation activity checklists, medicine reminders, and long-term goals within the app that maximize the patient’s recuperation from their surgery. In addition, it may be beneficial to provide a form for online communities of patients that are recovering from surgery. This would create a space for individuals undergoing relatively similar experiences to connect over their experiences, and ideally would provide more motivation for patients to adhere to their treatment plan as they get to know other patients who have grown past their experiences and what worked for them.
Of course, there is no singular solution that promises to fix this issue. The ideas we present are but some of many possible fixes. These improvements will undoubtedly come with time, but all changes are necessitated to be initiated by the actions of individuals. The medical field must learn to criticize itself in the pursuit of healing its constituents, and by doing so, will continue to expand its quality of care to horizons beyond even our own.
Sources
[1] Research suggests 50 million patients suffer complications after surgery each year (Queen Mary, University of London, Medical Xpress)
[2] Mortality after surgery in Europe: a 7 day cohort study (Pearse et. al, The Lancet)
[3] After Surgery: Discomforts and Complications (Adult and Children’s Health Encyclopedia, University of Rochester Medical Center)
[4] Care after surgery (Allina Health)
[5] Adherence to Enhanced Recovery After Surgery and length of stay after colonic resection (Cakir et. al)
[6] What are superbugs, and how can I protect myself from infection? (Pritish K. Tosh, Mayo Clinic)
[7] Multistate Point-Prevalence Survey of Health Care–Associated Infections (Magill et. al)
[8] Re-estimating annual deaths due to multidrug-resistant organism infections (Burnham et al., Cambridge University Press)
[9] Reducing Surgical Site Infections: A Review (Reichman and Greenberg)
[10] Use of Antimicrobial Prophylaxis for Major Surgery (Bratzler et. al, JAMA Surgery)
[11] Maximizing appropriate antibiotic prophylaxis for surgical patients: an update from LDS Hospital, Salt Lake City (Burke)
[12] Sustainability of an Enhanced Recovery Program for Pancreaticoduodenectomy with Pancreaticogastrostomy (Williamsson et. al, Scandinavian Journal of Surgery)
[13] The Surgically Induced Stress Response (Finnerty et. al)
Vardaan Bal and Gabriel Salazar are both fourth-year Psychobiology majors at UCLA and THINQ 2020–2021 clinical fellows.
Visit our website at thinq.med.ucla.edu and follow us on Facebook and Instagram @uclathinq!
