Toward more accurate documentation in neurosurgical care

OBJECTIVE Accurate clinical documentation is foundational to any quality improvement endeavor as it is ultimately the medical record that is measured in assessing change. Literature on high-yield interventions to improve the accuracy and completeness of clinical documentation by neurosurgical providers is limited. Therefore, the authors sought to share a single-institution experience of a two-part intervention to enhance clinical documentation by a neurosurgery inpatient service. METHODS At an urban, level I trauma, academic teaching hospital, a two-part intervention was implemented to enhance the accuracy of clinical documentation of neurosurgery inpatients by residents and advanced practice providers (APPs). Residents and APPs were instructed on the most common neurosurgical complications or comorbidities (CCs) and major complications or comorbidities (MCCs), as defined by Medicare. Additionally, a “system-based” progress note template was changed to a “problem-based” progress note template. Prepost analysis was performed to compare the CC/MCC capture rates for the 12 months prior to the intervention with those for the 3 months after the intervention. RESULTS The CC/MCC capture rate for the neurosurgery service line rose from 62% in the 12 months preintervention to 74% in the 3 months after intervention, representing a significant change (p = 0.00002). CONCLUSIONS Existing clinical documentation habits by neurosurgical residents and APPs may fail to capture the extent of neurosurgical inpatients with CC/MCCs. An intervention that focuses on the most common CC/MCCs and utilizes a problem-based progress note template may lead to more accurate appraisals of neurosurgical patient acuity.

P.180 What do patients expect of a competent neurosurgeon?

Background: To improve accountability and reflect patient and societal needs, the Royal College of Physicians and Surgeons of Canada proposed Competence by Design (CBD) for all residency programs. This study compares neurosurgical patient values and expectations of their neurosurgeon to resident competences proposed by CBD curriculum. Methods: Semi-structured interviews of 30 neurosurgical patients and family members were recorded, transcribed and analyzed for themes. Results: Of the first 13 interviews (8 males, 5 females; median age 54), 10 had English as a first language, all completed post-secondary education, and 8 had a brain tumor. In addition to expecting excellent surgical skills and comprehensive medical knowledge, participants expected “good” neurosurgeons to be human (compassionate, empathetic, no ego), transparent communicators, accountable, passionate, collaborative, emotionally composed and highly intuitive. However, there were marked differences in minimum set of competencies required and the expectations of the thresholds to determine competence for neurosurgeons. Conclusions: Patient perspectives show commonalities and marked differences of the expected competencies compared to CBD and significant variability of the thresholds of competence. Further investigations should explore these themes in other specialties. The existing CBD curriculum will need to expand its framework to include humanistic values to improve public perceptions of competence.

Does stereoscopic imaging improve the memorization of medical imaging by neurosurgeons? Experience of a single institution

Stereoscopic imaging has increasingly been used in anatomical teaching and neurosurgery. The aim of our study was to analyze the potential utility of stereoscopic imaging as a tool for memorizing neurosurgical patient cases compared to conventional monoscopic visualization. A total of 16 residents and 6 consultants from the Department of Neurosurgery at Charité – Universitätsmedizin Berlin were recruited for the study. They were divided into two equally experienced groups. A comparative analysis of both imaging modalities was conducted in which four different cases were assessed by the participants. Following the image assessment, two questionnaires, one analyzing the subjective judgment using the 5-point Likert Scale and the other assessing the memorization and anatomical accuracy, were completed by all participants. Both groups had the same median year of experience (5) and stereoacuity (≤ 75 s of arc). The analysis of the first questionnaire demonstrated significant subjective superiority of the monoscopic imaging in evaluation of the pathology (median: monoscopic: 4; stereoscopic: 3; p = 0.020) and in handling of the system (median: monoscopic: 5; stereoscopic: 2; p < 0.001). The second questionnaire showed that the anatomical characterization of the pathologies was comparable between both visualization methods. Most participants rated the stereoscopic visualization as worse compared to the monoscopic visualization, probably due to a lack of familiarity with the newer technique. Stereoscopic imaging, however, was not objectively inferior to traditional monoscopic imaging for anatomical comprehension. Further methodological developments and incorporation in routine clinical workflows will most likely enhance the usability and acceptance of stereoscopic visualization.

Recurrent clonazepam withdrawal delirium in a postoperative neurosurgical patient: a case report

We present a case of benzodiazepine withdrawal delirium in a middle-aged man undergoing spinal surgery. Benzodiazepines were stopped prior to surgery and on postoperative day 4, the patient exhibited significant paranoia, hyperarousal and ideas of reference. Patient’s symptoms resolved after reintroduction of his benzodiazepines. It is important to include benzodiazepine withdrawal in the differential diagnosis for acute delirium even in those patients taking low or moderate doses. Benzodiazepine withdrawal delirium typically responds rapidly to restarting benzodiazepines. In patients with known discontinuation issues, early consultation with consult-liaison psychiatry and preoperative planning for early medication re-initiation is paramount.

Prediction of Hearing Preservation in Vestibular Schwannoma Surgery According to Tumor Size and Anatomic Extension

Objective Vestibular schwannoma (VS) surgery is feasible for various tumor sizes that are inappropriate for wait and scan or radiosurgery. The predictive value of 2 grading systems was investigated for postoperative hearing preservation (HP) in a large series. Study Design Retrospective analysis. Setting Neurosurgical patient database of the University of Erlangen was queried between 2014 and 2017. Methods Retrospective single-center analysis on 138 VSs operated on via a retrosigmoidal approach. The mean tumor size was 20.4 mm (SD, 7.6 mm) with fundal infiltration in 67.4%. The overall resection rate was 93.5%. Tumors were classified preoperatively by the 3-tier Erlangen grading system depending on size or the anatomically based 4-tier Koos grading system. Results Preoperative hearing preservation was found in 70.3% of patients and was significantly correlated to tumor size ( P = .001). For Erlangen grading, a mean postoperative serviceable hearing preservation rate of 32% was achieved: 83.3% for tumors <12 mm, 30.3% for tumors between 12 and 25 mm, and 5.3% for tumors >25 mm. In contrast, according to Koos grading, postoperative serviceable hearing preservation was 100% for grade 1 tumors (meatal), 35.6% for grade 2 (cisternal), 23.1% for grade 3 (brainstem contact), and 21.7% for grade 4 (brainstem compression). Of the total cohort, 86% had normal or nearly normal postoperative facial function (House-Brackmann grades 1 and 2). Conclusion Surgery on small VSs can achieve excellent hearing preservation. Different grading has a significant influence on and correlates with postoperative hearing preservation. Tumor size seems more important than anatomic relationship.

Uniting the traumatological and orthopedical service of the country

On April 22, 1921, the Moscow Medical and Prosthetic Institute was founded. Nikolay N. Priorov (MD, PhD, professor, academician of the USSR Academy of Medical Sciences) was the founder and permanent leader of the institute for 40 years. In 1930, the facility was renamed into the Moscow Regional Institute of Traumatology, Orthopedics, and Prosthetics. Before World War II, in 1940, the institute became known as the Central Research Institute of Traumatology and Orthopedics, known as CITO as the leading national institution for traumatology and orthopedics. For a century, CITO employees has been conducting clinical, research, educational, and methodological activities providing comprehensive assistance in all regions of the country. In 2018, CITO was the first traumatological and orthopedics centers to be transformed into the Federal State Budgetary Institution National Medical Research Center of Traumatology and Orthopedics named after N.N. Priorov of the Ministry of Health of the Russian Federation which significantly increased the role of the institution in traumatology and orthopedics, especially managemental, analytical, educational, and methodological activities. The 15 clinical departments and various laboratories of the center conducted research work and provide specialized medical care, including high-tech traumatological, orthopedic, oncological, and neurosurgical patient care.

How do you manage ANTICOagulant therapy in neurosurgery? The ANTICO survey of the Italian Society of Neurosurgery (SINCH)

Background Anticoagulant assumption is a concern in neurosurgical patient that implies a delicate balance between the risk of thromboembolism versus the risk of peri- and postoperative hemorrhage. Methods We performed a survey among 129 different neurosurgical departments in Italy to evaluate practice patterns regarding the management of neurosurgical patients taking anticoagulant drugs. Furthermore, we reviewed the available literature, with the aim of providing a comprehensive but practical summary of current recommendations. Results Our survey revealed that there is a lack of knowledge, mostly regarding the indication and the strategies of anticoagulant reversal in neurosurgical clinical practice. This may be due a lack of national and international guidelines for the care of anticoagulated neurosurgical patients, along with the fact that coagulation and hemostasis are not simple topics for a neurosurgeon. Conclusions To overcome this issue, establishment of hospital-wide policy concerning management of anticoagulated patients and developed in an interdisciplinary manner are strongly recommended.