Blood test in the OR speeds surgery

Measuring hormone levels in hyperparathyroidism on the spot sends patients home faster.

Since Robert Udelsman, M.D., M.B.A., department chair and the William H. Carmalt Professor of Surgery, came to Yale in 2001 to lead the medical school’s Department of Surgery, the number of parathyroid operations has risen from about 30 a year to more than 350.

Most of these patients have primary hyperparathyroidism (HPTH)—one or more of the parathyroid glands in the neck begins to enlarge and produce too much hormone. These enlarged glands are called adenomas, and too much parathyroid hormone, or PTH, causes osteoporosis, kidney stones and other health problems. The adenoma needs to be removed, a procedure that usually requires general anesthesia and a stay of several days in the hospital.

Udelsman, however, has combined existing techniques with a simple but radical innovation—placing a laboratory machine to measure hormone levels inside the operating room—to turn this into an outpatient procedure.

“Patients can fly in on Sunday, get a place at the hotel and see us on Monday morning. Tuesday morning they come have surgery,” said Patricia Donovan, R.N., M.B.A., Udelsman’s clinical coordinator. “They return Friday that same week. They might explore New Haven, have their sutures removed … and fly back.”

Udelsman’s approach, which has been adopted by the other three endocrine surgeons on the team, involves several steps.

First comes pre-op preparation. In addition to the patient’s medical history, the team needs to know where the offending adenoma is located. Most people have four or more parathyroid glands, so figuring out which is the overactive one—or whether there is more than one—can be a challenge. Imaging studies help to localize it. Before the patients arrive for surgery, Donovan gathers relevant records, medical information and scan results, talking by phone with patients and their doctors to make sure that the surgery is appropriate for them.

In the operating room the uniqueness of Yale’s approach becomes evident. Instead of patients being placed under general anesthesia, patients receive a series of injections of local anesthetic in the neck. A small incision is made, the offending adenoma is removed and a blood test is done to check levels of PTH. But rather than sending the blood sample to a laboratory, the technician in the operating room tests hormone levels immediately. The surgical team waits only 12 minutes for the results—about a quarter of the time needed at other institutions, where waiting for results can take longer than the operation itself. If PTH levels have dropped sufficiently, the surgeons can be confident that they removed the adenoma completely. Then it’s time to sew up.

The entire procedure typically takes half an hour, and the patient goes home—or to the hotel—a few hours later, returning to the clinic in three days for a final follow-up visit. Complication rates are low, cure rates are about 98 percent and the surgery is cost-effective. But most of all, patients are satisfied.

—Jenny Blair

As doctors hand off patients, miscommunication at sign-outs can cause errors

“Sign-out,” the conversation at shift change when hospital patients’ information is handed off from one team of doctors to another, is the delicate hinge on which much medical communication turns. But this commonplace event can be fraught with miscommunications that frustrate doctors and pose a hazard to patients.

That’s because doctors don’t have a standard approach for sign-out—unlike those for the formal history and physical presentation—nor are they supervised when first doing it. “We have no training at all; there’s nothing,” said Leora I. Horwitz, M.D., assistant professor of medicine. Instead, residents wing it: they might painstakingly explain the team’s reasoning for each patient’s plan of care—or they might simply read names and diagnoses to a colleague and append a few comments to the list.

Because much of what is known about sign-out is anecdotal, Horwitz decided to study the practice. She and her team studied eight teams’ handoffs over 12 days, audiotaping evening sign-outs and collecting doctors’ printouts, then asking the covering team in the morning if there had been any sign-out-related problems overnight.

There certainly had been. In 88 sign-out sessions, 24 sign-out-related problems came up. Fifteen related to inefficient care—the covering team had to duplicate work or research—but there were five episodes of delayed diagnosis or care and four close calls. In one case of miscommunication, a patient was transferred to intensive care in part because the covering team had not been warned about her bronchospasm.

These results, published in the September 8 Archives of Internal Medicine, will surprise few physicians who have had to start from scratch while caring for a colleague’s patients. But with reductions in residents’ work hours, a rising hospital census and a national impetus to reduce medical errors, sloppiness at sign-out is evolving from nuisance to pressing concern.

How should clinicians sign out? They might start by looking outside medicine. Other groups involved in high-risk or error-prone work, including the nuclear power, automotive and airline industries, have developed effective methods of handoff. “They teach it, they train it, they concentrate on it—which we don’t do,” Horwitz said. “What you want to hand off in person or on paper is the higher-order stuff, the clinical reasoning part, the synthesis, the judgment. Handoff is about understanding.”

Based on these results, the internal medicine department began a sign-out curriculum for residents that is now in its third year. Horwitz often teaches it, and she has also developed sign-out templates for hospital residents in other specialties. She plans next to study sign-out during hospital discharge.

“We just haven’t thought about [sign-out] as part of our job,” she said. “We don’t prioritize this as a safety issue, and that’s part of what [our team is] trying to change by pointing out what goes wrong.”

—J.B.

et cetera

New approach to thyroid surgery

Over the last two years the Yale Pediatric Thyroid Center has treated 30 patients by using a new approach—the pairing of pediatric and adult surgeons in the operating room. The center may be the only facility in the United States exclusively devoted to the care of children with thyroid conditions.

“The right surgical expertise is important for optimizing outcomes, because the area by the neck is delicate, especially in young children,” said Scott Rivkees, M.D., professor of pediatrics and director of the center.

Since far more thyroid surgeries are performed on adults than on children, Yale physicians combined the expertise of Robert Udelsman, M.D., M.B.A., department chair and the William A. Carmalt Professor of Surgery, a high-volume adult endocrine surgeon, with the skills of Christopher Breuer, M.D., a pediatric surgeon versed in the challenges of treating thyroid disorders in young patients.

“We can tell parents, ‘You’re going to have one of the world’s most experienced endocrine surgery teams working on your child,’ ” Udelsman said.

—Jennifer Kaylin

Preventing falls in elderly patients

Teaching clinicians and older patients how to prevent falls can reduce the likelihood—by up to 11 percent—of falls that lead to hospitalization or an emergency room visit, Yale researchers reported in The New England Journal of Medicine in July.

The researchers compared injury rates in a 58-zip code area in and around Hartford—where clinicians incorporated fall risk assessment and management into their practices—to those in a control region. Their analysis also showed some 1,800 fewer emergency department visits or hospitalizations; and health care savings estimated at $21 million over two years.

“The next step is to put [the research] into practice,” said senior author Mary E. Tinetti, M.D., the Gladys Phillips Crofoot Professor of Medicine and professor of epidemiology and of investigative medicine, “by making physicians, nurses and physical therapists everywhere more conscious of fall risks … and of what can be done to prevent falls.”

—Michael Fitzsousa


			Originally published in Yale Medicine, Winter 2009. Copyright © 2009 Yale University School of Medicine. All rights reserved.