Vascular accident code: A security system in massive bleeding in laparoscopic urologic surgery

Juárez-Soto, Á.; Pérez-García, M.; Fuentes-Curtido, M.; Guisado-Martin, C.; Hernández-Garrido, M.; Arrabal-Polo, M.A.; de Paz-Suárez, M.
doi:10.1016/j.acuroe.2016.09.004
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activation of the &#8216;stroke code&#8217;&#44; which is the state of general alert that occurs when operating a patient at risk of massive bleeding and implementation of the &#8216;stroke code&#8217;&#44; which is when in the code activation situation&#44; massive bleeding occurs&#46; These stages are detailed in <a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">The preoperative stage includes all pre-surgery actions that will have an impact on the optimization of the results in safety&#44; if massive bleeding occurs during surgery&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The stage &#8216;stroke code activation&#8217; is the status of passive alert of the professionals involved in surgery&#44; each assuming the appropriate role according to the SOP&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The stage &#8216;stroke code execution&#8217; is the status of active alert that is generated when a stroke occurs de facto&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The day of surgery&#44; SOP leadership is responsibility for the coordination of the code&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Its role is&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><p id="par0060" class="elsevierStylePara elsevierViewall">Presurgical stage<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#40;1&#41;</span><p id="par0065" class="elsevierStylePara elsevierViewall">Coordinating the entire surgical team and ensuring knowledge of the SOP &#8216;stroke code&#8217;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#40;2&#41;</span><p id="par0070" class="elsevierStylePara elsevierViewall">Identifying the day of surgery&#44; those support professionals who are not usually part of the surgical team&#44; and explaining to them the SOP and their responsibility in it&#44; and confirm that they understand&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#40;3&#41;</span><p id="par0075" class="elsevierStylePara elsevierViewall">Checking points 1 and 2 before the start of the surgery&#46;</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0025"><p id="par0080" class="elsevierStylePara elsevierViewall">Code activation stage<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#40;1&#41;</span><p id="par0085" class="elsevierStylePara elsevierViewall">Checking all the elements of security&#44; passive alert&#44; and actions contained in the SOP&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#40;2&#41;</span><p id="par0090" class="elsevierStylePara elsevierViewall">Ensuring their compliance by professionals&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#40;3&#41;</span><p id="par0095" class="elsevierStylePara elsevierViewall">Deactivating the code&#44; once past the risk of massive bleeding&#46;</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0045"><p id="par0100" class="elsevierStylePara elsevierViewall">Stage of code execution<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">&#40;1&#41;</span><p id="par0105" class="elsevierStylePara elsevierViewall">Coordinating the implementation by the professionals who make up the surgical team of each and every one of the planned actions&#44; if massive bleeding occurs&#46;</p></li></ul></p></li></ul></p><p id="par0110" class="elsevierStylePara elsevierViewall">After having finished the surgery and deactivated the &#8216;stroke code&#8217;&#44; the Security Committee of the Clinical Management Unit of Urology is summoned&#44; where the operation of surgical systems established and the establishment of areas for improvement if necessary are evaluated by professionals&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">In the Urology Department of the Hospital de Jerez&#44; we activated the SOP &#8216;stroke code&#8217; in high-risk cases of massive bleeding&#44; such as surgery of large renal masses with vascular infiltration&#44; surgery of retroperitoneal masses adjacent to the great vessels&#44; surgery of xanthogranulomatous pyelonephritis&#44; etc&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">We did not apply it to simple nephrectomies&#44; partial nephrectomies&#44; radical prostatectomies&#44; or cystectomies&#44; unless they have some characteristic that makes a massive bleeding likely&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Since the implementation of the SOP &#8216;stroke code&#8217; in 2011&#44; until January 2016&#44; we applied it to 32 patients&#46; The SOP has been modified on 3 occasions &#40;currently in force its 4th edition&#41;&#44; incorporating in each of them the improvements to address the weaknesses identified during the activation and&#47;or execution of the &#8216;stroke code&#8217;&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">The main weaknesses&#44; which caused SOP modifications&#44; were&#58;<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">1&#46;</span><p id="par0135" class="elsevierStylePara elsevierViewall">Interprofessional communication problems&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">2&#46;</span><p id="par0140" class="elsevierStylePara elsevierViewall">Lack of awareness of some professionals of the urology team&#44; with attitudes that caused deconcentration of the surgical team at risk &#40;during an extension of surgery&#44; requesting shift change and leaving operating room unattended&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">3&#46;</span><p id="par0145" class="elsevierStylePara elsevierViewall">Lack of awareness of some professionals outside the operating room of urology who&#44; due to ignoring the importance of the SOP&#44; came into the operating room for reasons not related to it&#44; causing deconcentration of the team in difficult moments of the surgery&#46;</p></li></ul></p><p id="par0150" class="elsevierStylePara elsevierViewall">The &#8216;stroke code&#8217; has been executed on 3 occasions due to massive bleeding &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#44; the surgical team acting with order&#44; calm&#44; and security&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0155" class="elsevierStylePara elsevierViewall">All vascular accidents that occurred since the introduction of the SOP have been resolved laparoscopically&#44; which was rare before implantation thereof&#44; which we always opted to convert to open surgery&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">The &#8216;stroke code&#8217; is a powerful tool to transform the chaos and uncertainty in a critical situation&#44; in order&#44; calm of the team&#44; and safety for the patient and for professionals&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">When all team members know how to act each individually and have the certainty that the rest know what to do&#44; calm and good governance flood the operating room&#46; Professionals know that there may be a surgical accident&#44; but that with the SOP &#8216;stroke code&#8217;&#44; they are prepared to act with the greatest possible safety for the patient&#46; A stroke during surgery may have a fatal outcome&#44; but with the &#8216;stroke code&#8217; tool&#44; it will not be because of unsafe acts by professionals&#44; or due to lack of foresight or the organization&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">This SOP has limitations as it is a project of the Department of Urology at the Hospital de Jerez&#44; but we consider it a powerful tool that provides security to patients undergoing high-risk interventions of massive bleeding and professionals of urology&#46;</p></span></span>"
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