American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

New Crucial Literature: The Science You Need to Know

Literature selections curated by Lewis Flint, MD, FACS, and reviewed by the Bulletin Brief editorial board.

Pair of JACSJournal of the American College of Surgeons

Examining the Evidence for ACS Quality Verification: Building Quality and Safety Resources and Infrastructure

Hu QL, Fischer CP, Wescott AB, Maggard-Gibbons M, Hoyt DB, Ko CY. Evidence Review for the American College of Surgeons Quality Verification Part I: Building Quality and Safety Resources and Infrastructure. J Am Coll Surg. 2020;231(5):557-569 e1. 

Developing standards and promoting verification programs to improve quality and patient safety are critical efforts of the ACS. The publication of Optimal Resources for Surgical Quality and Safety (the Red Book) provides a comprehensive description of these standards. 

In the first article of a three-part series, Hu and coauthors reported outcomes of a systematic review of the literature to determine the evidence supporting four of the 12 standards used to verify quality programs. These include senior leadership, the surgical quality officer, the surgical quality committee and a culture of safety and high reliability; nearly 500 studies were included in the review. Although there was heterogeneity in the data and a lack of randomized trials, available evidence supported the importance of senior leadership, especially visibility of leadership (such as in leadership walk rounds). Midlevel leadership in the form of a quality committee and visible efforts to create and maintain a culture of leadership also were supported by the evidence. 

The authors concluded that the four evaluated standards were effective and could be created and sustained in health care institutions. 

Examining the Evidence for ACS Quality Verification: Processes for Reliable Quality Improvement

Koskinen A, Tolvi M, Jauhiainen M, Kekalainen E, Laulajainen-Hongisto A, Lamminmaki S. Complications of COVID-19 Nasopharyngeal Swab Test. JAMA Otolaryngol Head Neck Surg. April 29, 2021 [Epub ahead of print].

This report was the second of three articles that examined evidence supporting the standards that are important components of the ACS quality and safety verification programs. The initiatives examined in this review included case review, peer review, credentialing and privileging, data gathering with surveillance and data-based quality improvement. 

The analysis showed that case review and peer review using the mortality and morbidity conference format was effective but required continual efforts to make certain that relevant factors were included in each case review, that findings were actionable and that data on outcomes of quality improvement interventions were gathered and monitored. Credentialing and privileging also were effective but were prone to variability; centralized guidance of this process by institutional leadership was found to be an important factor leading to consistency and improved patient outcomes. The authors noted that the addition of an onboarding process to supplement credentialing has been shown to be effective in other industries and could be potentially valuable for health care quality improvement. Data-based quality improvement initiatives were also found to be associated with improved patient outcomes. 

The authors concluded that the ACS quality standards were valuable and dependable interventions for improving of quality and patient safety. 

Other Article

Study Examines Two Primary Complications Associated with COVID-19 Nasopharyngeal Swab Test

Goulden R, Rowe BH, Abrahamowicz M, Strumpf E, Tamblyn R. Association of Intravenous Radiocontrast With Kidney Function: A Regression Discontinuity Analysis. JAMA Intern Med. April 5, 2021 [Epub ahead of print].

The authors conducted a retrospective review of patients who underwent nasal swab testing for the COVID-19 virus in the emergency department of a single academic institution in Finland. The study cohort consisted of 2,899 patients. Additional data from more than 600,000 patients from a national database also were reported. 

The analysis showed that complications occurred in 1.24 per 100,000 tests. Complications fell into two categories, broken swabs and nasal bleeding. Patients in the broken swab group were treated easily with nasal scope removal of the swab and no major associated problems were identified. Patients with nasal bleeding, on the other hand, frequently required hospitalization and transfusion. Repeated nasal packing and selective arterial occlusion using direct surgical visualization or angiographic localization were required in most of the patients in this group. Associated secondary infections were encountered, as well. Most of the complications occurred because of incorrect insertion of the nasal swab. 

The article contains clear and useful illustrations of the anatomy of the nasal areas including the usual locations of structures that may contribute to swab breakage or bleeding if injured. The authors emphasized the importance of inserting the swab in parallel to the nasal floor and avoidance of directing the swab superiorly into the nasal passage.