Search PubMed⌕ Search

Biomedical subjects

Martin A Makary

Publications and source records attributed to Martin A Makary.

At least 19 recordsLinked to original sources
PubMed2007

Human immunodeficiency virus and hepatitis testing and prevalence among surgical patients in an urban university hospital.

BACKGROUND: Human immunodeficiency virus (HIV), hepatitis B, and hepatitis C represent significant public health problems in an urban community. Early diagnosis and treatment of these infections can improve survival and allow for preventive strategies to reduce further transmission within a community. The aim of this study was to evaluate the surgical setting as a potential opportunity for early diagnosis of HIV, hepatitis B, and hepatitis C among trauma and non-trauma patients. METHODS: We performed a retrospective review of patients presenting for surgery over a 10-year period (July 1994 to July 2004) in an urban, university-based general surgical practice that includes all trauma services, as well as emergency department, inpatient, and outpatient surgical consultations. Data collected included diagnosis, operation, age, race, history of intravenous drug abuse, and HIV, hepatitis B, and hepatitis C test results. RESULTS: Among 2876 patients presenting for surgery, testing for blood-borne pathogens was less likely among trauma patients (21%, 79/380) compared to non-trauma patients (47%, 1183/2496) (P < .001). Among patients tested, the incidence of blood-borne pathogens was similar in the two groups: HIV (26% trauma vs 24% non-trauma, not significant [NS]), hepatitis B (4% trauma vs 3% non-trauma, NS), hepatitis C (33% trauma vs 41% non-trauma, NS), and co-infection with HIV and hepatitis C (18% trauma vs 12% non-trauma, NS). In both groups, blood-borne pathogens were associated with intravenous drug abuse (P < .01). CONCLUSION: HIV, hepatitis B, and hepatitis C are common in an urban community among both trauma and non-trauma surgical patients, although testing is less common among trauma patients. Testing of patients during a surgical admission may represent an excellent opportunity for early disease-specific services and preventive interventions.

AIDS Serodiagnosis↗
PubMed2006

Sharpless surgery: a prospective study of the feasibility of performing operations using non-sharp techniques in an urban, university-based surgical practice.

CONTEXT: Percutaneous injuries occur frequently during surgical procedures and represent a significant occupational hazard to operating room personnel. OBJECTIVES: To evaluate the feasibility of performing select general surgical procedures using a combination of non-sharp devices and techniques to replace the conventional use of scalpels and needles. DESIGN, SETTING, AND PARTICIPANTS: Candidate procedures for which sharpless techniques could replace conventional scalpels and suture needles were identified preoperatively in an urban, university-based general surgical practice over a 1-year period (June 2003-June 2004). Non-sharp techniques included monomeric 2-octyl cyanoacrylate adhesive, electrocautery, tissue stapler, and minimally invasive instrumentation. Conventional scalpels and suture needles were readily available and used whenever necessary. MAIN OUTCOME MEASURES: We rated the feasibility of performing specific procedures without sharps. We also documented the rate of overall reversion to sharps during operations on patients that had been identified preoperatively as candidates for sharpless surgery. RESULTS: Of 358 procedures performed in the general surgery university practice, 91 were identified preoperatively as appropriate for sharpless surgery. Of these, 86.8% (79/91) were completed without the use of sharps, including 13/22 (59.1%) open laparotomy procedures, 20/22 (90.9%) laparoscopic procedures, and 46/47 (97.8%) soft tissue procedures. Intraoperative reversion to sharps occurred in 12 cases when deemed necessary by the surgeon. CONCLUSIONS: Select common procedures can be performed entirely with sharpless techniques, eliminating the risk to surgical personnel associated with intraoperative percutaneous injuries.

Academic Medical Centers↗
PubMed2006

Pancreaticoduodenectomy in the very elderly.

It is estimated that by 2050, there will be a 300% increase in the elderly population (> or =65 years) and a corresponding increase in elderly patients presenting for surgical evaluation. Surgical decision-making in this population can be difficult because outcomes in the elderly are poorly defined. We reviewed 2698 consecutive pancreaticoduodenectomies (PDs) at our institution over a 35-year period (April 1970 through March 2005), with the last 1000 resections being done in the last 4 years. Data collected included surgical indication, mortality (defined as 30-day or in-hospital mortality), complications, and survival. Patients were divided by age into three groups (<80, 80-89, and > or =90 years) and evaluated using multiple logistic regression. Two hundred seven patients > or =80 years old underwent a PD (7.7% of 2698). Patients 80-89 years of age had a mortality rate of 4.1% (8 of 197) and a complication rate of 52.8% (99 of 197), whereas patients < or =79 years of age had a mortality of 1.7% and a complication rate of 41.6% (P < 0.05). There were no perioperative deaths among the 10 patients > or =90 years of age, and their complication rate was 50% (5 of 10). One-year survival for patients 80-89 years of age was 59.1%, and that for patients > or =90 years was 60%. Age was not an independent risk factor for perioperative mortality and morbidity following PD after adjusting for preoperative comorbidities. We demonstrate that PD can be safely performed in patients over 80 years of age and conclude that age alone should not be a contraindication to pancreatic resection. The advent of improved surgical outcomes and an aging population will likely result in a significant increase in the number of PDs performed in the next few decades.

Age Factors↗
PubMed2006

Operating room teamwork among physicians and nurses: teamwork in the eye of the beholder.

BACKGROUND: Teamwork is an important component of patient safety. In fact, communication errors are the most common cause of sentinel events and wrong-site operations in the US. Although efforts to improve patient safety through improving teamwork are growing, there is no validated tool to scientifically measure teamwork in the surgical setting. STUDY DESIGN: Operating room personnel in 60 hospitals were surveyed using the Safety Attitudes Questionnaire. Surgeons, anesthesiologists, certified registered nurse anesthetists, and operating room nurses rated their own peers and each other using a 5-point Likert scale (1 = very low, 5 = very high). RESULTS: Overall response rate was 77.1% (2,135 of 2,769). Ratings of teamwork differed substantially by operating room caregiver type, with the greatest differences in ratings shown by physicians: surgeons (F[4, 2058] = 41.73, p < 0.001), and anesthesiologists (F[4, 1990] = 53.15, p < 0.001). The percent of operating room caregivers rating the quality of collaboration and communication as "high" or "very high" was different by caregiver role and whether they were rating a peer or another type of caregiver: surgeons rated other surgeons "high" or "very high" 85% of the time, and nurses rated their collaboration with surgeons "high" or "very high" only 48% of the time. CONCLUSIONS: Considerable discrepancies in perceptions of teamwork exist in the operating room, with physicians rating the teamwork of others as good, but at the same time, nurses perceive teamwork as mediocre. Given the importance of communication and collaboration in patient safety, health care organizations should measure teamwork using a scientifically valid method. The Safety Attitudes Questionnaire can be used to measure teamwork, identify disconnects between or within disciplines, and evaluate interventions aimed at improving patient safety.

Analysis of Variance↗
PubMed2006

Operating room briefings: working on the same page.

This tool, which takes one or two minutes to use, provides a structured approach to promote effective interdisciplinary communication and teamwork in the operating room--or any other area, such as an intensive care unit, inpatient unit, or outpatient clinic.

Humans↗
PubMed2006

Operating room debriefings.

This tool helps assess factors that positively and negatively contributed to an adverse event, near miss, or inefficiency during an operation-or any procedure.

Efficiency, Organizational↗
PubMed2006

Teamwork in the operating room: frontline perspectives among hospitals and operating room personnel.

BACKGROUND: The Joint Commission on Accreditation of Healthcare Organizations is proposing that hospitals measure culture beginning in 2007. However, a reliable and widely used measurement tool for the operating room (OR) setting does not currently exist. METHODS: OR personnel in 60 US hospitals were surveyed using the Safety Attitudes Questionnaire. The teamwork climate domain of the survey uses six items about difficulty speaking up, conflict resolution, physician-nurse collaboration, feeling supported by others, asking questions, and heeding nurse input. To justify grouping individual-level responses to a single score at each hospital OR level, the authors used a multilevel confirmatory factor analysis, intraclass correlations, within-group interrater reliability, and Cronbach's alpha. To detect differences at the hospital OR level and by caregiver type, the authors used multivariate analysis of variance (items) and analysis of variance (scale). RESULTS: The response rate was 77.1%. There was robust evidence for grouping individual-level respondents to the hospital OR level using the diverse set of statistical tests, e.g., Comparative Fit Index = 0.99, root mean squared error of approximation = 0.05, and acceptable intraclasss correlations, within-group interrater reliability values, and Cronbach's alpha = 0.79. Teamwork climate differed significantly by hospital (F59, 1,911 = 4.06, P < 0.001) and OR caregiver type (F4, 1,911 = 9.96, P < 0.001). CONCLUSIONS: Rigorous assessment of teamwork climate is possible using this psychometrically sound teamwork climate scale. This tool and initial benchmarks allow others to compare their teamwork climate to national means, in an effort to focus more on what excellent surgical teams do well.

Anesthesiology↗
PubMed2006

Interdisciplinary medical, nursing, and administrator education in practice: the Johns Hopkins experience.

Reforming graduate medical, nursing and health administrators' education to include the core competencies of interdisciplinary teamwork and quality improvement (QI) techniques is a key strategy to improve quality in hospital settings. Practicing clinicians are best positioned in these settings to understand systems issues and craft potential solutions. The authors describe how, in ten months during 2004 and 2005 the school of medicine, the school of nursing, and an administrative residency program, all at Johns Hopkins University, implemented and evaluated the Achieving Competency Today II Program (ACT II), a structured and interdisciplinary approach to learning QI that was piloted at various sites around the United States. Six teams of learners participated, each consisting of a medical, nursing, and administrative resident. The importance of interdisciplinary participation in planning QI projects, the value of the patient's perspective on systems issues, and the value of a system's perspective in crafting solutions to issues all proved to be valuable lessons. Challenges were encountered throughout the program, such as (1) participants' difficulties in balancing competing academic, personal and clinical responsibilities, (2) difficulties in achieving the intended goals of a broad curriculum, (3) barriers to openly discussing interdisciplinary team process and dynamics, and (4) the need to develop faculty expertise in systems thinking and QI. In spite of these challenges steps have been identified to further enhance and develop interdisciplinary education within this academic setting.

Academic Medical Centers↗
PubMed2006

Clinical and economic outcomes of hospital acquired pneumonia in intra-abdominal surgery patients.

OBJECTIVE: To measure the clinical and economic impact of postoperative hospital-acquired pneumonia (HAP) and to identify risk factors for the development of HAP. SUMMARY BACKGROUND DATA: Although postoperative HAP is recognized to be an major risk associated with surgery, little is known about the overall outcomes of patients whose hospital stay is complicated by HAP following surgery. METHODS: We studied 618,495 patients who underwent an intra-abdominal operation from the National Inpatient Sample database over a 1-year period (January 2000 to December 2000) using CPT codes and discharge diagnoses identified by the Clinical Classification Software. Data collected included demographic characteristics, type of operation, in-hospital mortality, discharge disposition, length of stay, and hospital charges. RESULTS: Of the 13,292 patients with HAP following intra-abdominal surgery, 1421 died prior to discharge (mortality = 10.7%) compared with 7217 deaths in the control group of patients without HAP following intra-abdominal surgery (mortality = 1.2%) (P < 0.001). HAP was independently associated with a 4.13-fold (95% confidence interval = 3.94-4.34) increase in risk to be discharged to a skilled nursing facility. The mean length of hospital stay for intra-abdominal patients who developed HAP was significantly greater compared with intra-abdominal surgery patients who did not develop HAP (17.10 days versus 6.07 days, P < 0.001). After adjusting for patient characteristics, HAP was independently associated with a 75% (28,160.95 dollars; 95% confidence interval, 27,543.76 dollars - 28,778.13 dollars) mean increase in total hospital charges. CONCLUSIONS: Given the high incidence and significant impact of HAP on patient outcomes, early preventive strategies and interventions to reduce HAP should be a priority.

Adolescent↗
PubMed2006

Patient safety in surgery.

BACKGROUND: Improving patient safety is an increasing priority for surgeons and hospitals since sentinel events can be catastrophic for patients, caregivers, and institutions. Patient safety initiatives aimed at creating a safe operating room (OR) culture are increasingly being adopted, but a reliable means of measuring their impact on front-line providers does not exist. METHODS: We developed a surgery-specific safety questionnaire (SAQ) and administered it to 2769 eligible caregivers at 60 hospitals. Survey questions included the appropriateness of handling medical errors, knowledge of reporting systems, and perceptions of safety in the operating room. MANOVA and ANOVA were performed to compare safety results by hospital and by an individual's position in the OR using a composite score. Multilevel confirmatory factor analysis was performed to validate the structure of the scale at the operating room level of analysis. RESULTS: The overall response rate was 77.1% (2135 of 2769), with a range of 57% to 100%. Factor analysis of the survey items demonstrated high face validity and internal consistency (alpha = 0.76). The safety climate scale was robust and internally consistent overall and across positions. Scores varied widely by hospital [MANOVA omnibus F (59, 1910) = 3.85, P < 0.001], but not position [ANOVA F (4, 1910) = 1.64, P = 0.16], surgeon (mean = 73.91), technician (mean = 70.26), anesthesiologist (mean = 71.57), CRNA (mean = 71.03), and nurse (mean = 70.40). The percent of respondents reporting good safety climate in each hospital ranged from 16.3% to 100%. CONCLUSIONS: Safety climate in surgical departments can be validly measured and varies widely among hospitals, providing the opportunity to benchmark performance. Scores on the SAQ can serve to evaluate interventions to improve patient safety.

Analysis of Variance↗
PubMed2006

Creating high reliability in health care organizations.

OBJECTIVE: The objective of this paper was to present a comprehensive approach to help health care organizations reliably deliver effective interventions. CONTEXT: Reliability in healthcare translates into using valid rate-based measures. Yet high reliability organizations have proven that the context in which care is delivered, called organizational culture, also has important influences on patient safety. MODEL FOR IMPROVEMENT: Our model to improve reliability, which also includes interventions to improve culture, focuses on valid rate-based measures. This model includes (1) identifying evidence-based interventions that improve the outcome, (2) selecting interventions with the most impact on outcomes and converting to behaviors, (3) developing measures to evaluate reliability, (4) measuring baseline performance, and (5) ensuring patients receive the evidence-based interventions. The comprehensive unit-based safety program (CUSP) is used to improve culture and guide organizations in learning from mistakes that are important, but cannot be measured as rates. CONCLUSIONS: We present how this model was used in over 100 intensive care units in Michigan to improve culture and eliminate catheter-related blood stream infections--both were accomplished. Our model differs from existing models in that it incorporates efforts to improve a vital component for system redesign--culture, it targets 3 important groups--senior leaders, team leaders, and front line staff, and facilitates change management-engage, educate, execute, and evaluate for planned interventions.

Health Facilities↗
PubMed2005

Resection of the celiac axis for invasive pancreatic cancer.

Pancreatic cancer arising in the neck or body of the gland frequently presents at a more advanced stage compared with tumors arising in the pancreatic head. Vascular invasion into the celiac axis is a common contraindication to surgical resection. We report an en bloc pancreatectomy, splenectomy, and total gastrectomy with resection of the celiac axis for a pancreatic body adenocarcinoma invading the celiac axis and posterior stomach. Collateral blood flow to the liver via the gastroduodenal artery was initially identified on preoperative computed tomography (CT) imaging and confirmed intraoperatively with vascular testing before resection. One of 14 regional lymph nodes was positive for malignancy, and surgical margins were free of tumor. The patient's postoperative course was unremarkable. En bloc resection of the celiac axis and hepatic artery may be safely performed in select patients with localized pancreatic cancer invading these vessels.

Adenocarcinoma↗
PubMed2005

A system factors analysis of "line, tube, and drain" incidents in the intensive care unit.

OBJECTIVE: To analyze the system factors related to "line, tube, and drain" (LTD) incidents in the intensive care unit (ICU). DESIGN: Voluntary, anonymous Web-based patient safety reporting system. SETTING: Eighteen ICUs in the United States. PATIENTS: Incidents reported by ICU staff members during a 12-month period ending June 2003. INTERVENTIONS: None. MEASUREMENTS: Characteristics of the incidents (defined as events that could/did cause harm), patients, and patient harm were described. Separate multivariable logistic regression analyses of contributing, limiting, and preventive system factors for LTD vs. non-LTD incidents were reported. MAIN RESULTS: Of the 114 reported LTD incidents, >60% were considered preventable. One patient death was attributed to an LTD incident. Of patients experiencing LTD incidents, 56% sustained physical injury, and 23% had an anticipated increased hospital stay. Factors contributing to LTD incidents included occurrence in the operating room (odds ratio [OR], 3.50; 95% confidence interval [CI], 1.25-9.83), occurrence on a holiday (OR, 3.65; 95% CI, 1.12-11.9), patient medical complexity (OR, 3.68; 95% CI, 2.28-5.92), and age of 1-9 yrs (OR, 7.95; 95% CI, 3.29-19.2). Factors related to team communication were less likely to limit LTD incidents (OR, 0.28; 95% CI, 0.11-0.68), while clinician knowledge and skills helped prevent LTD incidents (OR, 1.80; 95% CI, 1.09-2.97). CONCLUSIONS: Patients are harmed by preventable LTD incidents. Relative to non-LTD events, these incidents occur more frequently during holidays and in medically complex patients and children. Focusing on these contributing factors and clinician knowledge and skills is important for reducing and preventing these hazardous events.

Adolescent↗
PubMed2005

The role of magnetic resonance cholangiography in the management of patients with gallstone pancreatitis.

OBJECTIVE: To examine the utility of magnetic resonance cholangiography (MRC) in the preoperative evaluation of patients with gallstone pancreatitis. SUMMARY BACKGROUND DATA: Gallstone pancreatitis is often associated with the presence of common bile duct (CBD) stones that may require endoscopic removal prior to planned laparoscopic cholecystectomy. No reliable clinical criteria exist, however, that can accurately predict CBD stones and the need for preoperative endoscopic retrograde cholangiopancreatography (ERCP). METHODS: Sixty-four patients were identified with gallstone pancreatitis based on clinical presentation and imaging studies over a three-and-a-half-year period. All patients underwent MRC, and the images were evaluated for gallstones, CBD stones, cholecystitis, and pancreatitis RESULTS: Seventeen of the 64 patients (27%) with gallstone pancreatitis were found to have CBD stones confirmed by ERCP. MRC correctly predicted CBD stones in 16 of the 17 patients (sensitivity = 94%). In 1 additional patient, MRC demonstrated CBD stones not seen at ERCP, consistent with probable passage. By comparison, the sensitivities of other criteria for predicting CBD stones were (1) elevated bilirubin >or=2.0 mg/dL = 65%; (2) dilated duct on ultrasound = 55%; and (3) CBD stones on ultrasound = 27%. MRC was able to visualize gallbladder stones in 57 of 62 patients (94%) and correctly predicted acute cholecystitis in 6 of 8 patients. MRC also detected peripancreatic edema and inflammatory changes consistent with acute pancreatitis in 45 of 64 patients (70%). CONCLUSIONS: These results demonstrate that MRC can accurately identify CBD stones preoperatively in patients with gallstone pancreatitis and provide valuable information with respect to other biliary pathology, including cholelithiasis, acute cholecystitis, and pancreatitis. MRC is an effective noninvasive screening tool for CBD stones, appropriately selecting candidates for preoperative ERCP and sparing others the need for an endoscopic procedure with its associated complications.

Acute Disease↗
PubMed2005

Prevalence of blood-borne pathogens in an urban, university-based general surgical practice.

OBJECTIVE: To measure the current prevalence of blood-borne pathogens in an urban, university-based, general surgical practice. SUMMARY BACKGROUND DATA: Human immunodeficiency virus (HIV), hepatitis B, and hepatitis C represent significant occupational hazards to the surgeon. While the incidence of these blood-borne pathogens is increasing in the general population, little is known about the current prevalence of these exposures among patients presenting for surgery. METHODS: We studied 709 consecutive operative cases (July 2003 to June 2004) in a university practice that provides all inpatient, emergency department, and outpatient consultative general surgical services. Trauma cases and bedside procedures were excluded. Data collected included HIV, hepatitis B and C test results, type of operation, age, sex, and history of intravenous drug use. RESULTS: Testing for blood-borne pathogens was performed in 53% (N = 373) of 709 patients based on abnormal liver function tests, neutropenia, history of IV drug use, or patient request. Thirty-eight percent of all operations (142/373) were found to involve a blood-borne pathogen when tested: HIV (26%), hepatitis B (4%), hepatitis C (35%), and coinfection with HIV and hepatitis C (17%). Forty-seven percent of men tested positive for at least 1 blood-borne pathogen. Seventy-three different types of operations were performed, ranging from Whipple procedures to amputations. Soft-tissue abscess procedures 48% (34/71) and lymph node biopsies 67% (10/15) (P < 0.01) were most often associated with blood-borne pathogens. Infections were more common among men (P < 0.01), patients 41 to 50 years of age (P < 0.01), and patients with a history of intravenous drug use (P < 0.01). CONCLUSIONS: HIV and hepatitis C infections are common in an urban university general surgical practice, while hepatitis B is less common. In addition, certain operations are associated with significantly increased exposure rates. Given the high incidence of these infections, strategies such as sharpless surgical techniques should be evaluated and implemented to protect surgeons from blood-borne pathogens.

Adult↗
PubMed2003

Multimodality treatment for esophageal cancer: the role of surgery and neoadjuvant therapy.

Treatment of esophageal cancer has traditionally included surgery as the initial modality. Neoadjuvant chemoradiation therapy has been introduced with the goal of downstaging tumors before surgical resection; however, its role in esophageal cancer remains controversial. We report 116 patients who underwent esophagogastrectomy with reconstruction for carcinoma of the esophagus or esophagogastric junction over a 10-year period (January 1, 1990 to June 1, 2001). Forty patients underwent neoadjuvant radiation and chemotherapy followed by surgery. Hospital mortality in this group was 7.5 per cent, complete pathologic response (CPR) was 37.5 per cent, and overall 3- and 5-year survival rates were 47 and 38 per cent. Five-year survival in the 15 patients with CPR was 85 per cent. Five patients underwent neoadjuvant single-agent therapy (four chemotherapy and one radiation) followed by surgery, and none survived to 3 years. Seventy-one patients underwent surgery without neoadjuvant therapy. Hospital mortality in this group was 1.4 per cent, with 3- and 5-year survival of 21 and 17 per cent--a decreased long-term survival compared with the neoadjuvant therapy group despite the observation that patients who underwent neoadjuvant therapy had a larger tumor size on presentation (5.5 +/- 0.4 cm vs 3.8 +/- 0.2 cm; P = 0.002). Squamous cell carcinomas seemed to be more responsive to neoadjuvant radiation and chemotherapy followed by surgery than were adenocarcinomas, with a CPR of 44.4 versus 35.5 per cent; however, 5-year survival rates in these complete responders were not significantly different (100% and 78%, respectively; P = 0.97). We report that esophagogastrectomy in conjunction with neoadjuvant therapy results in increased survival compared with surgery without neoadjuvant therapy (P < 0.01), although there may be an increased perioperative mortality associated with neoadjuvant therapy. Further studies are needed to evaluate the role of preoperative chemoradiation and to better identify the pretreatment characteristics of patients with a complete pathological response.

Adenocarcinoma↗