MedicalResearch.com Interview with:
Vishal Sarwahi, MD, senior author
Chief, Spinal Deformity and Pediatric Orthopaedics
Billie and George Ross center for Advanced Pediatric Orthopaedics and Minimally Invasive Spinal Surgery
Cohen’s Children Medical Center
Northwell Hofstra School of Medicine and
Stephen F. Wendolowski
Cohen Children’s Medical Center
New Hyde Park, NY, 11040
MedicalResearch.com: What is LEAN?
Response: LEAN is a management principle that supports the concept of continuous improvement through small incremental changes to not only improve efficiency, but also quality. Particularly, we took interest in the 5S’s – Sort, Simplify, Sweep, Standardize, and Self-Discipline. We felt that Sort, Simplify, and Standardize were the most relevant to surgery.
MedicalResearch.com: How did you use Sort, Simplify and Standardize in your practice?
Response: For Sort we worked with our medical supply representative to develop 4 customized trays for our practice. The benefits of this are that for each case there are fewer trays, easier and faster setup, and if there is a missing instrument the surgical team can respond and replenish it immediately. For Simplify, we have streamlined our implants and surgical steps. For example, we utilize 6.0X40 at T10 and below, 6.0×35 T3-T10, and 6.0×30 at T1, T2. All screws are uniaxial and we alternate standard with reduction screws. This enables the scrub technician to anticipate and prepare for the next step. We have also standardized our wake up process, and have a protocol for intraop loss of signals. For Standardize, we worked very hard with our anesthesia team to develop a standard protocol for our patients. In addition, we have a team of dedicated anestheologists, neurologists, OR nurses, and scrub techs in the operating room for scoliosis cases. This has allowed us to develop specific anesthesia, pain management, transfusion, and blood conservation protocols.
MedicalResearch.com: What is the background for this study?
Response: At our practice, we are always looking to develop new ways to increase not only patient safety, but also quality. We felt that many of these principles described in LEAN can be effectively implemented into our practice. After applying these principles to a number of our surgical cases, we felt that our operating room was better managed. In order to show this, we began to collect perioperative outcome data to better show if our LEAN-based changes were effective.
MedicalResearch.com: What are the main findings?
Response: The LEAN-managed group had a significantly lower surgical time. Previously, the surgical time was around 5 hours; however, the LEAN-managed group was 4.3 hours. Shorter surgical time can translate to lower blood loss, and lower risk of infection. The LEAN-managed group had a significantly less incidence of intraoperative signal loss. This is likely due to our dedicated monitoring team and protocol. To better improve communication, aside from timeout procedures where the surgical team introduces each other, we also use a transparent partition drape around the surgical field. This allows the anesthesiologists, nursing, and monitoring team to directly visualize the surgical field, and make assessments. We also found the LEAN-managed group to have lower blood loss – 575 vs 400cc – for, which is clinically relevant, but was not found to be statistically significant. However, with increased number of patients that have since been enrolled into the study, the transfusion rate and estimated blood loss has significantly decreased in the LEAN-managed group.
MedicalResearch.com: What should readers take away from your study?
Response: Small changes lead to giant leaps. It is important to always look for ways to increase patient safety, outcomes, and efficiency. Our experience with LEAN methodology can be replicated elsewhere. It is a surgeon-driven, patient-centered, team-based approach which involves small, but specific changes carried out continuously. We find that many of the components of our LEAN-based approach can be brought to other centers. Surgeon leaders should focus on making small incremental changes rather than large shake ups. Specifically, ongoing communication, recognition of efforts and consistency are the hallmarks.
MedicalResearch.com: What recommendations do you have for future research as a result of this study?
Response: We are in the process of collecting prospective data on a larger number of patients, and evaluating the reproducibility of our LEAN strategy in different institutions.
MedicalResearch.com: Thank you for your contribution to the MedicalResearch.com community.
LEAN Management Principles Applied to Scoliosis Surgery Have Improved Patient Safety and Increased Surgical Efficiency
Sarwahi, Vishal et al.
The Spine Journal , Volume 16 , Issue 10 , S346
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