Fundamental Topics in Plastic Surgery (eBook)

1 Patient Safety in Plastic Surgery

Brent B. Pickrell, Andrew P. Trussler

Abstract

This chapter provides a brief overview of the topics most pertinent to patient safety for the busy practicing surgeon and advanced trainees. It is organized to provide a longitudinal account of the patient encounter, beginning in the clinic (“Practice-Based Safety”), where patients are often first evaluated and their consent is sought for the recommended procedure. The discussion moves to a discussion of risk factors (“Risk Stratification”), with particular emphasis on smoking and patient safety. Finally, safety topics are outlined, with current supporting evidence from the literature (“Intraoperative Patient Safety”).

Keywords: informed consent, intraoperative risks, preoperative risk assessment, venous thromboe mbolism

1.1 Introduction

Patient safety has become a national focus in recent years, since the Institute of Medicine published To Err Is Human (2000), alerting the public to the serious and potentially deadly dangers posed by medical errors occurring in the health care setting. The authors estimated that approximately 44,000–98,000 Americans die annually secondary to preventable medical errors costing approximately US $79 billion. Thereafter, initiatives and guidelines have evolved to define, measure, and improve patient safety practices and culture.

Despite perceptions of the lay public, even in the elective office-based setting, plastic surgery is not without risk to the patient. Although plastic surgery often poses less risk than procedures of other surgical subspecialties, the risk of surgical complications should not be minimized. Even though the majority of complications from plastic surgery include scarring, infection, and bleeding, more serious complications, such as venous thromboembolism, do occur and can have devastating consequences.

1.2 Practice-Based Safety

1.2.1 Informed Consent

Opportunities to obtain patient consent abound in clinical practice, and physicians are required to obtain the informed consent of their patients before initiating treatment. That is, valid informed consent is premised on educating competent patients with the appropriate information so that they may make a conscious, voluntary choice. When patients lack the competence to make a decision about treatment, substitute decision makers must be sought if the scenario is nonemergent. If a surrogate decision maker must be sought, it is the physician’s responsibility to follow the given state’s statutes and contact family members in the correct order of priority.

Patient education begins preoperatively with a clear explanation of the procedure, along with the risks, benefits, and alternatives, if available. This necessary counseling can help avoid surprise and confusion if a complication arises postoperatively. Indeed, failure to inform patients is a common secondary claim in malpractice lawsuits. For specific procedures, the surgeon should consider providing standardized preoperative and postoperative patient education.

Informed consent should include the type of surgery and its potential risks, including anticipated outcomes, benefits, and possible consequences and side effects. When discussing risks with patients, one should avoid a recitation of statistics because they are frequently misunderstood or misinterpreted. Documentation of the informed consent should be noted in the medical record and revisited by the surgeon on the day of the operation.

1.2.2 Reporting Adverse Events

It is important that a medical system has a standardized process for reporting adverse events that is valid, reliable, and actionable. Historically, many physicians have abstained from reporting their errors for fear of liability. To this end, the protocol should encourage honest reporting without fear of ramifications; an in-depth, comprehensive review of adverse events is key to improving the culture of patient safety. In 2002, the American Society of Plastic Surgeons/Plastic Surgery Educational Foundation and the American Board of Plastic Surgery collaborated to create the “Tracking Operations and Outcomes for Plastic Surgeons,” a web-based database that compiles plastic surgery procedures and outcomes information. This database, which is compliant with the Health Insurance Portability and Accountability Act, serves as an internal quality control mechanism for the sole purpose of reducing morbidity and mortality and improving patient care. Because this information is not discoverable or admissible as evidence in a court of law, physicians need not fear liability for reporting their adverse events.

1.3 Patient Risk Stratification

Identification of preoperative patient risk factors is essential during initial consultation. It is appropriate for plastic surgeons to maintain a low threshold for primary care referrals for medical evaluation if a patient is over the age of 40 and wishes to undergo an elective procedure. Screening should be evidence based to avoid unnecessary use of patient and health care resources.

1.3.1 Smoking Cessation

The risks associated with smoking in the surgical patient are well documented. In particular, perioperative pulmonary complications have been shown to be four times more frequent in current smokers than in people who have never smoked. In a multicenter, randomized, controlled trial, patients who were randomized to receive preoperative smoking intervention (i.e., counseling, nicotine replacement, and either cessation or reduction of smoking) 6 to 8 weeks before surgery had fewer complications than control patients who did not receive the intervention.

A number of studies have linked tobacco use with complications following plastic surgery operations, most frequently in the context of the deleterious effects on wound healing. Chang et al. found an increased risk of mastectomy flap and abdominal wall necrosis following free transverse rectus abdominal myocutaneous flap reconstruction. Rees et al reported that smokers undergoing face-lifts were more likely to suffer skin slough. Coon et al. reported significantly higher overall complication rates, tissue necrosis rates, and the likelihood of reoperation. In a retrospective review of 1,881 patients, smoking was found to correlate with decreased skin graft survival.

Deciding whether to operate on a smoking patient is ultimately up to the surgeon, but the current literature supports an increased risk of complications that may be unacceptable for elective operations. Even so, a large survey by Rohrich et al. in 2002 suggests that many plastic surgeons elect to operate on patients who are known smokers, but the majority refused to offer skin flaps or procedures with extensive undermining.

1.4 Intraoperative Risk

1.4.1 Patient Positioning

Complications arising from patient positioning are an underappreciated source of intraoperative morbidity. The risks of improper patient positioning include peripheral neuropathies, brachial plexopathies, myopathies, compartment syndromes, and pressure ulcers ( Fig. 1.1). Given that plastic surgeons will often require unusual positioning in the operating room (OR) for adequate exposure, it is extremely important that the surgeon takes the appropriate precautions to prevent these complications.

Eighty percent of operations take place in the supine position. The two most common postoperative neuropathies, brachial and ulnar plexopathy, result from improper positioning and padding. These complications may be avoided by abducting the arms < 90 degrees to avoid traction on the brachial plexus. Additionally, the arms should remain supinated while abducted to avoid pressure on the ulnar nerve as it passes posterior to the medial epicondyle. Members of the surgical team should also be discouraged from leaning on extremities during the case. Similarly, cachexia may produce bony prominences...