EDINBURGH – It’s 4 o’clock in the afternoon on a long Mohs surgery day, and you’ve got another patient with innumerable stages plus reconstructions to do.
Performing a fatigue check that gives nursing and biomedical staff the opportunity to admit they’re too tired may be the best next step to prevent wrong-site surgery, Dr. Colin Fleming, president of the British Society for Dermatological Surgery (BSDS), posited at the 15th World Congress on Cancers of the Skin.
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Fatigue checks allow staff to admit when they are too tired to perform surgery.
“When we introduced this, it gave great power to the staff, whom we as doctors were asking to work hard on our behalf,” he said. “It’s been a really valuable tool in increasing safety at the end of a long operating day.”
The fatigue check is separate from the oft-recommended preprocedural surgical pause. Though helpful, research has shown that the surgical pause failed to prevent wrong-site surgery in 10% to a third of cases, said Dr. Fleming, a consultant dermatologist and Mohs surgeon at Ninewells Hospital, Dundee, Scotland.
A study on the usefulness of proposed methods for correct biopsy site identification in cutaneous surgery with the Delphi consensus method was recently published (JAMA Dermatol. 2014;150:550-8), but “I’m not convinced it really tells us anything,” he remarked.
Dr. Fleming suggested coupling the surgical pause with a site check, and he emphasized the value of good quality preoperative photographs of the index lesion. Today’s ubiquitous “selfie” may even have a role, as patients themselves often misidentify the biopsy site.
In addition, dermatology departments should have a protocol incorporating a variety of safety features, he said.
However, only 54% of surgeons said they have a written protocol in place to identify the correct surgical site, based on data from a recent survey of BSDS members conducted by Dr. Fleming and his colleagues.
More than a half of respondents (60/114) acknowledged it was “sometimes” difficult to locate the surgical site, with 47 respondents saying it was difficult to locate the surgical site in 1%-10% of cases and 13 admitting it was difficult to do so in 10%-25% of cases.
The face, scalp, and back were reported as the most challenging areas in which to locate the exact surgical site, Dr. Fleming said at the meeting, sponsored by the Skin Cancer Foundation.
When asked what steps they take in their local written protocols to avoid wrong site surgery, 82 respondents said they check with the patient, 66 use drawings/templates with the site marked, 50 use a mirror or photographs, and 39 respondents double-check with a colleague.
Overall, slightly less than 40% of respondents recalled having no patient in the past 5 years who underwent wrong-site surgery. Approximately 28% had 1 wrong-site surgery patient, 28% had 2-3 patients, 3% had 4-5 patients, and 1% had more than 10 such patients.
“Wrong-site surgery in U.K. dermatology departments is infrequent,” Dr. Fleming concluded, adding that only a small proportion led to formal complaints or a medicolegal case.
The response rate to the web-based survey was 37.5% (115/306 members); 32 respondents were Mohs surgeons, 75 were non-Mohs surgeons, 68 worked at a teaching hospital, and 110 had a regular surgical list of between 500 and 2,000 procedures per year that they were responsible for or did themselves.