Team-based approach “significantly improves” surgical outcomes

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Implementing a team-based approach to paediatric spinal surgery “significantly improves surgical and perioperative outcomes”, according to new research presented at the Scoliosis Research Society Annual Meeting (SRS; 21-24 September, Prague, Czech Republic). Even when researchers adjusted their results for confounding factors, all surgical outcomes remained significantly improved.

The study, presented by Firoz Miyanji (Vancouver, Canada) aimed to evaluate the success of a team-based approach to paediatric spinal surgery in a single centre. According to researchers, the literature suggests that team-based approaches—whereby speciality teams are trained to work together in accordance with standardised protocols—can “increase efficiency, expertise, and workplace satisfaction,” whilst helping to minimise “egregious errors and poor outcomes.”

For complex procedures such as the treatment of paediatric spinal disorders, the researchers assert that “standardised system and institutional team approaches may help reduce risk and improve safety.” In spite of this, the implementation of standardised team approaches is not common in hospitals, with “traditional” operating room and allocation models “still prevalent.” In order to promote the adoption of such approaches, Miyanji argued, more hard data is needed to properly evaluate the benefits such an approach can have.

The researchers performed a retrospective consecutive case-controlled study, comparing a cohort of patients treated in advance of the implementation of a team-based approach (January 2008–December 2009, n=130), with those treated after the centre had begun using the standardised system (January 2012–December 2013, n=277). The team consisted of a “homogenous core group” of six paediatric spinal anaesthetists, eight spinal operating room nurses, one nurse clinician, eight neuromonitoring technicians and one spinal surgeon.

Authors evaluated the pre- and post-implementation groups’ results according to surgical site infection, operative time, length of stay, unplanned surgical procedures, estimated blood loss and transfusion rates. Among both groups, the vast majority of cases involved treatment for idiopathic scoliosis, with neuromuscular cases the second most common.

The researchers noted a “significant decline” (p=<0.05) in surgical site infection rates (8.5% to 0.7%, p=0), mean operating room time (404.5 min ± 14.4 min to 351±6.7, p=0.013), mean length of stay (14.3 days ± 2.5 days to 8.9±0.7, p=0.019) and rate of unplanned staged procedures (6.2% to 2.9%, p=0.001).

The mean volume of allogeneic blood transfused reduced significantly after the introduction of the team-based approach (268.7±42.4 to 86.9±14, p=0), while mean estimated blood loss declined, but not significantly (909.1ml ± 93.5ml to 580.2±30.1, p=0.135).

Upon multivariate linear regression to account for gender, age, aetiology, staged procedures and total levels instrumented, a number of surgical and perioperative outcomes were significantly improved. Operating room time reduced by a mean of 41.7 minutes from the pre-team approach group to the post-team approach group (p=0.001, 95% CI; 17.8, 65.6). Length of stay (reduction in mean: 5.9 days, p=0.004, 95% CI; 1.9, 9.9), estimated blood loss (reduction in mean: 256ml, p=0.001, 95% CI; 126, 387) allogeneic blood transfused (reduction in mean: 385ml, p=0.001, 95% CI; 215, 554) and cell saver transfused (reduction in mean: 265ml, p=0.001, 95% CI; 145, 385) all improved significantly as well.

Odds ratio calculation revealed that the adjusted odds of surgical site infection was ten times higher for those patients treated before the implementation of a team approach (0.1, p=004, 95% confidence interval; 0.002, 0.47). Allogeneic blood transfusion was also 2.4 times more likely for the pre-team approach group.

The study was limited inherently by its retrospective design, and in its lack of outcome collection appropriate for follow-up. The researchers highlighted, however the “homogeneity of [the] comparative cohorts” as a factor which could strengthen their results.

Noting the dramatic improvements in surgical and perioperative outcomes, Miyanji concluded that, “the effect of [the] paediatric spine surgery team remained significant for all surgical outcomes. The change was in a positive direction.” Commenting on improvements beyond outcomes, Miyanji said, 
“In addition to quality and safety, other potential benefits may related to efficiency of care and reduction in hospital costs.”