Patient safety in plastic surgery: a systematic review

SAUCEDO, OTTO HUASCKAR MUCHINSKI; RIBEIRO, ELAINE ROSSI; MULLER, JULIANE CENTENO; COELHO, IZABEL CRISTINA MEISTER MARTINS

doi:10.5935/2177-1235.2020RBCP0036

Tabla de contenido Anterior Actual Siguiente

Tabla de contenido

Review Article • Rev. Bras. Cir. Plást. 35 (2) • Apr-Jun 2020 • https://doi.org/10.5935/2177-1235.2020RBCP0036 linkcopy

Patient safety in plastic surgery: a systematic review

Authorship SCIMAGO INSTITUTIONS RANKINGS

Introduction: patient safety has become an increasingly present topic in health research. Plastic surgery is a specialty in evidence, and it is necessary to adapt patient safety to its particularities.

Methods: Systematic review to investigate actions related to patient safety in plastic surgery. MEDLINE and SCIELO were chosen to locate the studies. The descriptors: “patient safety” and “plastic surgery” were used in the MEDLINE database. In SCIELO, the descriptors: “segurança do paciente” e “cirurgia plástica” were used. In both cases, the publication period was between 2012-2018, totaling 15 articles.

Results: The countries that published the most on the subject were the United States and Brazil. The most frequent concern was safety related to the training of plastic surgery residents. Tools like the checklist have also been used to improve security. Another concern that requires more study will be if the weekends have higher complications with surgeries performed during the week. However, well-formulated medical records, as well as the Informed Consent Form (ICT), appear to have a more solid basis in patient safety. Pre-anesthetic consultation also seems to favor patient safety. Furthermore, finally, the use of WhatsApp seems to be a safe tool, and that improves the care provided by the medical team.

Conclusion: The need for more in-depth studies on this topic is emphasized, considering that a systematized protocol was not found.

Keywords:
Patient safety; Plastic surgery; Systematic review; Research on health services; Health policy

N. and Database	Title	Authors	Year
1. MEDLINE (24)	Impact of an event reporting system on resident complication reporting in plastic surgery training: addressing an ACGME and Plastic Surgery Milestone Project Core Competency.	Parikh PR, Snyder-Warwick A, Naidoo S, Skolnick GB, Patel KB²⁴	2017
2. MEDLINE (16)	Aesthetic plastic surgery checklist: a safety tool.	Sucupira E, Matta R, Zuker P, Matta J, Arbeláez JP, Uebel CO¹⁶	2016
3. MEDLINE (19)	WhatsApp: improvement tool for surgical team communication.	Sidhoum N, Dast S, Abdulshakoor A, Assaf N, Herlin C, Sinna R¹⁹	2016
4. MEDLINE (22)	The impact procedures. of resident participation in outpatient plastic surgical procedures.	Massenburg BB, Sanati-Mehrizy P, Jablonka EM, Taub PJ²²	2015
5. MEDLINE (23)	Resident Cosmetic Clinic: Practice Patterns, Safety, and Outcomes at an Academic Plastic Surgery Institution.	Qureshi AA, Parikh RP, Myckatyn TM, Tenenbaum MM²³	2016
6. MEDLINE (25)	Surgical Precision in Clinical Documentation Connects Patient Safety, Quality of Care, and Reimbursement.	Kittinger BJ, Matejicka II A, Mahabir RC²⁵	2016
7. MEDLINE (20)	The weekend effect in plastic surgery: analyzing weekday versus weekend admissions in body contouring procedures from 2000 to 2010.	Tadisina KK, Chopra K, Singh DP²⁰	2015
8. MEDLINE (18)	Patient safety in plastic surgery: identifying areas for quality improvement efforts.	Hernandez-Boussard T, McDonald KM, Rhoads KF, Curtin CM¹⁸	2015
9. MEDLINE (21)	Aesthetic surgery performed by plastic surgery residents: an analysis of safety and patient satisfaction.	Koulaxouzidis G, Momeni A, Simunovic F, Lampert F, Bannasch H, Stark GB²¹	2014
10. MEDLINE (14)	Training in aesthetic surgery at a university clinic - the Munich model.	Rezaeian F, Schantz JT, Sukhova I, Schenck TL, Giunta RE, Harder Y, Machens HG, Müller D¹⁴	2013
11. MEDLINE (26)	Our own worst enemy.	Swanson E²⁶	2016
12. SCIELO (15)	Comparison of surgical infection rates after implantation of the safety checklist.	Prates CG, Stadñik CM, Bagatini A, Caregnato RC, Moura GM¹⁵	2018
13. SCIELO (12)	Use of the informed consent term in cosmetic plastic surgery.	Doncatto LF¹²	2012
14. SCIELO (17)	Lipoabdominoplasty in the aesthetic treatment of the abdomen: 5-year experience.	Amorim Filho HC, Amorim CCB¹⁷	2012
15. SCIELO (13)	Anesthetic complications in plastic surgery and the importance of pre-anesthetic consultation as a safety tool.	Schwartzman UP, Batista KT, Duarte LTD, Teixeira D, Saraiva RA, Fernandes MC, et al.¹³	2011

N. and Database	Objetives	Country
1. MEDLINE	The Accreditation Council for Graduate Medical Education and Plastic Surgery Milestone Project has identified practice-based learning and improvement, which involves systematically analyzing current practices and implementing changes, as a core competency in residency education. In surgical care, complication reporting is an essential component of practice-based learning and improvement as complications are analyzed in morbidity and mortality conference for quality improvement. Unfortunately, current methods for capturing a comprehensive profile of complications may significantly underestimate the true occurrence of complications. Therefore, the objectives of this study are to evaluate an intervention for complication reporting and compare this to current practice, in a plastic surgery training program.	USA
2. MEDLINE	About one in ten patients experiences iatrogenic events, and more than half of these occur in the perioperative environment. The objective of this study was to develop a complete and functional checklist for aesthetic plastic surgery and test it in patients who would undergo elective plastic surgeries.	Brazil
3. MEDLINE	Concerns about the security of WhatsApp and the possibility of spreading patients data and image	England
4. MEDLINE	Ensuring patient safety, along with a complete surgical experience for residents, is of utmost importance in plastic surgical training. The effect of resident participation on the outcomes of outpatient plastic surgery procedures remains largely unknown. We assess the impact of resident participation on surgical outcomes using a prospective, validated, national database.	USA
5. MEDLINE	Comprehensive aesthetic surgery education is an integral part of plastic surgery residency training. Recently, the ACGME increased the minimum requirements for aesthetic procedures in residency. To expand aesthetic education and prepare residents for independent practice, our institution has supported a resident cosmetic clinic for over 25 years.	USA
5. MEDLINE	To evaluate the safety of procedures performed through a resident clinic by comparing outcomes to benchmarked national aesthetic surgery outcomes and to provide a model for resident clinics in academic plastic surgery institutions.	USA
6. MEDLINE	Emphasis on quality of care has become a major focus for healthcare providers and institutions. The Centers for Medicare and Medicaid Services has multiple quality-of-care performance programs and initiatives aimed at providing transparency to the public, which provides the ability to compare services provided by hospitals and individual physicians directly. These quality-of-care programs highlight the transition to pay for performance, rewarding physicians and hospitals for high quality of care. To improve the use of pay for performance and analyze quality-of-care outcome measures, the Division of Plastic Surgery at Scott & White Memorial Hospital participated in an inpatient clinical documentation accuracy project (CDAP).	USA
7. MEDLINE	Body contouring operations are a quickly becoming the most commonly performed operations by American plastic surgeons, mirroring the increase in bariatric surgery in the US over the last decade. Despite previous studies showing worse patient outcomes on weekend admissions for non-emergent cases (spine, breast, and hernia), there is no comparative data reported regarding body contouring procedures.	USA
7. MEDLINE	The authors aimed to determine whether body contouring surgery results in worse outcomes when performed on weekends versus weekdays.	USA
8. MEDLINE	Improving the quality of healthcare is a global priority. Before quality benchmarks are established, we first must understand rates of adverse events. This project assessed risk-adjusted rates of inpatient adverse events for soft tissue reconstructive procedures.	USA
9. MEDLINE	Aesthetic surgery is an integral component of plastic surgery. Despite its importance, adequate training in aesthetic surgery is met with	Germany
9. MEDLINE	challenges. Although the educational benefit of resident clinics has been demonstrated, such clinics are rarely found outside the United States. The objective of the present study was to assess safety and patient satisfaction associated with aesthetic surgery procedures performed by plastic surgery residents at a German academic medical center.	Germany
10. MEDLINE	Objective of the present study was the development, implementation and evaluation of a new training concept in aesthetic surgery.	Germany
11. MEDLINE	To identify risk factors by analyzing a national or regional database. The trend started with risk stratification for venous thromboembolism. Today, the plastic surgeon may be confronted by a number of challenges to his or her care of a patient who suffers a venous thromboembolism (VTE). If the plastic surgeon does not successfully clear each hurdle, the surgeon may be deemed responsible for a bad outcome. The pathophysiology of venous thromboembolism remains poorly understood in plastic surgery. Consequently, there is little scientific justification for holding a plastic surgeon negligent for not conforming with these numerous presumed safety criteria	USA
12. SCIELO	Objective To compare surgical site infection rates in clean surgery before and after the implementation of the checklist adopted by the World Health Organization.	Brazil
13. SCIELO	The informed consent form represents security for the plastic surgeon and the patient, and its use is recommended by the Consumer Protection Code. The most frequent causes of the actions and the main evidential elements that led to the condemnation or acquittal of the cases were evaluated.	Brazil
14. SCIELO	This study aimed to demonstrate the surgical technique of lipoabdominoplasty adopted by the senior author over five years and to evaluate results and complications in patients with indication for classic abdominoplasty.	Brazil
15. SCIELO	The authors describe the anesthetic complications in Plastic Surgery observed, over a year, at Hospital Sarah Brasília and contextualize the importance of pre-anesthetic consultation.	Brazil

N. and Database	Method	Participants
1. MEDLINE	This is a preintervention and postintervention study evaluating resident reporting of complications on a plastic surgery service. The intervention was an online event reporting system developed by department leadership and patient safety experts. The cohorts consisted of all patients undergoing surgery during two separate 3- month blocks bridged by an implementation period. A trained reviewer recorded complications, and this served as the reference standard. Fisher's exact test was used for binary comparisons.	The pre-intervention and post-intervention cohorts consisted of all patients having surgery on the pediatric plastic surgery service during two separate 3- month blocks bridged by a transition period for intervention implementation. The pre-intervention evaluation occurred from June 2015 to August 2015 and the post-intervention evaluation occurred from October 2015 to December 2015.
2. MEDLINE	Patient data were collected from a general hospital and the particular clinic between October 2013 and October 2015, through history, physical examination, diagnosis, laboratory tests, pre-, during, and postoperatively, and complications. An expanded safety checklist was developed and optimized for aesthetic plastic surgery based on the model presented by the WHO in 2009 with reference to the information related to the prevention of more frequent complications in this specialty.	Patient data were collected from a general hospital and the particular clinic between October 2013 and October 2015, through history, physical examination, diagnosis, laboratory tests, pre-, during, and postoperatively, and complications
3. MEDLINE	A retrospective was conducted, reviewing the number of messages performed using WhatsApp Messenger, and also evaluating its content from 1 April 2013 to 31 December 2013. Number of messages were differentiated regarding age, and the app use was evaluated comparing users over and under 45-years-old. Any interference with medical devices in the operating room was registered.	All health professionals involved in the surgical treatment of the patients
4. MEDLINE	We identified all outpatient procedures performed by plastic surgeons between 2007 and 2012 in the American College of Surgeons National Surgical Quality Improvement Program database. Multivariate regression models assessed the impact of resident participation when compared to attending alone on 30-day wound complications, overall complications, and return to the operating room (OR).	All outpatient procedures performed by plastic surgeons between 2007 and 2012 in the American College of Surgeons National Surgical Quality Improvement Program database
5. MEDLINE	We identified a consecutive cohort of patients who underwent procedures through our resident cosmetic clinic between 2010 and 2015. Major complications, as defined by CosmetAssure database, were recorded and compared to published aesthetic surgery complication rates from the CosmetAssure database for outcomes benchmarking. Fisher's exact test was used to compare sample proportions.	Patients who underwent procedures through our resident cosmetic clinic between 2010 and 2015.
6. MEDLINE	The Division of Plastic Surgery had been identified within our institution as having an opportunity for improvement in documentation. After institutional review board approval, the division engaged in a top-down educational effort aimed specifically at improving the institutional culture related to clinical documentation. Clinical providers at all levels of training, including senior staff and resident physicians, were educated on DRGs and documentation. Preprinted forms were added to every patient's chart to facilitate capturing CCs and events of the hospitalization. These forms were reviewed daily and were also used as part of the discharge summary.	Clinical providers at all levels of training, including senior staff and resident physicians
7. MEDLINE	A serial cross-sectional study of body contouring patients was performed using the Nationwide Inpatient Sample database from 2000 to 2010. Data were gathered using international classification of diseases, ninth revision codes for liposuction and reduction of adipose tissue (86.83) for weekday and weekend admissions, including demographics, hospital charges, and patient outcomes.	A serial cross-sectional study of body contouring patients was performed using the Nationwide Inpatient Sample database from 2000 to 2010.
8. MEDLINE	Patients receiving soft tissue reconstructive procedures from 2005-2010 were extracted from the Nationwide Inpatient Sample. Inpatient adverse events were identified using patient safety indicators (PSI), established measures developed by Agency for Healthcare Research and Quality.	Patients receiving soft tissue reconstructive procedures from 2005-2010 were extracted from the Nationwide Inpatient Sample
9. MEDLINE	The study had 2 components, namely, a retrospective chart review and an administration of a patient satisfaction survey. Only patients who underwent a surgical intervention by a plastic surgery resident between 2003 and 2011 were included in the study. Parameters of interest included age, sex, procedure performed, number of procedures, revenue (in &OV0556;), length of follow-up, revision rate, and postoperative complication rate. Patient satisfaction was assessed by the client satisfaction questionnaire-8.	Only patients who underwent a surgical intervention by a plastic surgery resident between 2003 and 2011 were included in the study
10. MEDLINE	Over a period of 2 years, 304 aesthetic operations were performed in the fields of body contouring, breast surgery and facial surgery as an educational surgery . Educational surgeries were performed by resident surgeons under the guidance of experienced specialists and under favourable financial conditions. As indicator for safety of the interventions, the incidence of complications was recorded and assessed.	Resident surgeons under the guidance of experienced specialists.
11. MEDLINE	138 clinical trials about venous thromboembolism like a predictable event, with potentially dire consequences to the "noncompliant" surgeon, compounding the tragedy	Plastic surgery patient suffers VTE
12. SCIELO	Observational, descriptive, retrospective correlational study carried out in a general hospital.	Sample consisting of 15,319 records of clean surgeries for trauma-orthopedics, cardiovascular, plastic, general and urology specialties monitored by the Hospital Infection Control Service.
13. SCIELO	Analysis of 100 judgments of the Courts of Justice of 5 Brazilian states, in cases involving aesthetic plastic surgery. The retrospective study was carried out from July 2010 to August 2012, in a universe of 3,427 plastic surgeons. The most frequent causes of the actions and the main evidential elements that led to the condemnation or acquittal of the cases were evaluated.	3,427 plastic surgeons.
14. SCIELO	A retrospective study was carried out, by reviewing medical records, of a group of 162 patients who underwent lipoabdominoplasty associated or not with other procedures, from May 2006 to May 2011, at the Hermínio Amorim Nucleus - Plastic Surgery and Aesthetic Treatments ( Lavras, SP, Brazil). The age of the patients varied between 33 years and 62 years.	A group of 162 lipoabdominoplasty. Patients undergoing lipoabdominoplasty.
15. SCIELO	A retrospective and analytical cohort study of hospital patients was carried out, focused on causality, addressing the anesthetic complications of surgical procedures performed by the Plastic Surgery team and other specialties at Hospital Sarah Brasília. The anesthetic consultation performed routinely in the preoperative period was described.	Retrospective and analytical cohort study of hospital patients addressing anesthetic complications.

N. and Database	Results and Conclusions
1. MEDLINE	There were 32 complications detected in 219 patients from June to August of 2015 and 35 complications in 202 patients from October to December of 2015. The proportion of complications reported in the preintervention group was nine of 32 (28.1 percent). After the intervention, this significantly increased to 32 of 35 (91.4 percent) (p<0.001).
1. MEDLINE	An intervention utilizing an event reporting system, supported by departmental leadership, led to significant improvements in complication reporting by plastic surgery residents.
2. MEDLINE	The tool was applied to 486 patients, of whom 430 (88%) were women and 56 (12%) were men. The most frequently performed procedure was liposuction with 30% of cases, and the most widely used type of anesthesia (39%) was local anesthesia + sedation. The greater adherence of professionals to the checklist was the group of residents (98%). The observed complications were seromas (7%), other complications unrelated to the wound (3%), and hematoma (0.2%) in only one patient who underwent facelift.
2. MEDLINE	The use of the checklist in addition to allowing data collection and the identification of potential risks promoted favorable changes in the attitudes of some professionals and generated interest in patient safety and teamwork.
3. MEDLINE	Instant messaging can be used as a valuable tool in order to coordinate surgical teams. We consider this as a valuable approach in order to streamline the communication between members. We consider that future development of specific apps to improve communication between health professionals is granted.
4. MEDLINE	A total of 18,641 patients were identified: 12,414 patients with an attending alone and 6227 with residents participating. The incidence of overall complications, wound complications, and return to OR was increased with resident participation. When confounding variables were controlled for in multivariate analysis, resident participation was no longer associated with increased risk of wound complications. When stratified by year, incidence of overall complications, wound complications, and return to OR in the resident participation group are trending down and fail to be significantly different in 2011 and 2012. Multivariate analysis shows a similar trend.
4. MEDLINE	Resident participation is no longer independently associated with increased complications in outpatient plastic surgery in recent years, suggesting that plastic surgical training is successfully continuing to improve in both outcomes and safety. Additional prospective studies that characterize patient outcomes with resident seniority and the degree of resident participation are warranted.
5. MEDLINE	Two hundred and seventy-one new patients were evaluated and 112 patients (41.3%) booked surgery for 175 different aesthetic procedures. There were 55 breast, 19 head and neck, and 101 trunk or extremity aesthetic procedures performed. The median number of preoperative and postoperative visits was 2 and 4 respectively with a mean follow-up time of 35 weeks. There were 3 major complications (2 hematomas and 1 infection requiring IV antibiotics) with an overall complication rate of 1.7% compared to 2.0% for patients in the CosmetAssure database (p=.45).
5. MEDLINE	Surgical outcomes for procedures performed through a resident cosmetic clinic are comparable to national outcomes for aesthetic surgery procedures, suggesting this experience can enhance comprehensive aesthetic surgery education without compromising patient safety or quality of care.
6. MEDLINE	Performance and improvement on metrics such as case mix index, severity of illness, risk of mortality, and geometric mean length of stay were assessed after implementation. After implementation of the CDAP, the division of plastic surgery showed increases in case mix index, calculated severity of illness, and calculated risk of mortality and a decrease in length of stay. For academic plastic surgeons, quality of care demands precise documentation of each patient. The CDAP provides one avenue to hone clinical documentation and performance on quality measures.
6. MEDLINE	Implementation of a CDAP resulted in increases in CMI, calculated SOI, and calculated ROM and a decrease in length of stay. The Division of Plastic Surgery was able to improve its documentation and, in doing so, improved the recognition of the complexity of the patients it was treating. As transparency in outcomes becomes a reality, it is critical for institutions to be compared with those treating similar patients. In this study, an endeavor to improve documentation proved fruitful in terms of both quality of care and financial reimbursement for the hospital.
7. MEDLINE	A total of 50,346 hospital admission cases of inpatient body contouring were examined over the 11-year period, 98% of which were on a weekday. When compared to weekday admissions, weekend admissions were associated with a statistically significant increase in hospitalization costs ($35,481, p<0.000) and in hospital length of stay (5.68 days, p<0.000). Mortality rates were found to be higher on weekend admissions (3.7%) versus weekdays (0.5%) as well. Although outcomes are multifactorial, in body contouring patients, weekday admission is associated with favorable outcomes in terms of length of stay and hospital charges.
8. MEDLINE	We identified 409,991 patient with soft tissue reconstruction and 16,635 (4.06%) had a PSI during their hospital stay. PSIs were associated with increased risk-adjusted mortality, longer length of stay, and decreased routine disposition (p<.01). Patient characteristics associated with a higher risk-adjusted rate per 1,000 patients at risk (RAR) included older age, men, non-white, and public payer (p<.05). Overall, plastic surgery patients had significantly lower RAR compared to other surgical inpatients for all events evaluated except for failure to rescue and postoperative hemorrhage or hematoma, which were not statistically different. RAR of hematoma hemorrhage were significantly higher in patients receiving size-reduction surgery, and these rates were further accentuated when broken down by gender and payer.
8. MEDLINE	In general, plastic surgery patients had lower rates of in-hospital adverse events than other surgical disciplines, but PSIs were not uncommon. With the establishment of national basal PSI rates in plastic surgery patients, benchmarks can be devised and target areas for quality improvement efforts identified. Further prospective studies should be designed to elucidate the drivers of adverse events identified in this population.
9. MEDLINE	A total of 273 aesthetic procedures were performed in 206 patients with an increase in recent years. The median follow-up period was 49.5 months. The most frequently performed procedures were liposuction (n=59), breast augmentation (n=53), and upper eyelid blepharoplasty (n=31). One hundred ninety-two (90.3%) patients had an uneventful postoperative course. The client satisfaction questionnaire-8 questionnaire was completed by 110 patients (response rate, 50.2%). The median value of 28 indicates a high degree of patient satisfaction. An association between occurrence of major complications and patient satisfaction was seen.
9. MEDLINE	Aesthetic surgery performed by plastic surgery residents under supervision by attending physicians is safe and provides for high levels of patient satisfaction postoperatively. Offering these services may be able to bridge the gap between providing high-quality aesthetic surgery training while yet recruiting an increasing number of patients who may appreciate the lower fees associated with these services.
10. MEDLINE	The presented training concept aims at ensuring high quality in patient care by structure and quality of surgical training. Our data give evidence that a structured training of residents in the field of aesthetic surgery is possible without loss in quality. We expect that sufficient surgical education and the associated quality will consequently contribute to keep aesthetic surgeries a domain of plastic surgery and to prevent these procedures from being taken over by other surgical disciplines.
11. MEDLINE	It concludes that operating more than 3 hours is an independent predictor of complications. However, correlation does not imply causation; longer operations are usually longer because there are problems, not the other way around. The same is true for inpatient surgery, also identified as a risk factor. Factor V Leiden and a history of venous thromboembolism are well-known risk factors, but are dwarfed by the increased risk associated with advancing age. Routine preoperative screening for coagulopathies is unhelpful, simply because affected patients are still at a low risk even if the risk is doubled or tripled. Importantly, individual risk stratification does not consider the specific diagnosis and type of procedure. As a practical matter (and as any surgeon exposed to these forms in surgical facilities can attest), risk stratification is not consistently implemented.
12. SCIELO	There was a significant reduction in the surgical site infection rate in clean surgeries when comparing the pre and post-implantation periods of the checklist proposed by the World Health Organization.
13. SCIELO	This study allowed us to observe that in cases of aesthetic plastic surgery in which there was absolution, the appropriate use of ICT and the medical expertise of the expert of the court were predominantly favorable to the physician.
14. SCIELO	The lipoabdominoplasty technique is a safe procedure, with a low rate of complications, as long as the safety criteria are respected, which allows obtaining a well-vascularized flap, with preservation of perforating arteries. The association of liposuction technique performed on the abdomen and body contour is considered safe and essential in the search for better body harmony, for better aesthetic results and, consequently, for greater patient satisfaction.
15. SCIELO	In the present study, the incidence of anesthetic complications was 8%, mainly cardiovascular, and all had a favorable outcome.

location_on

Sociedade Brasileira de Cirurgia Plástica Rua Funchal, 129 - 2º Andar / cep: 04551-060, São Paulo - SP / Brasil, Tel: +55 (11) 3044-0000 - São Paulo - SP - Brazil
E-mail: rbcp@cirurgiaplastica.org.br

rss_feed Acompañe los números de esta revista en su lector de RSS