No S.C.A.R.E. Protocol: A Streamlined Safety Protocol

Abstract

Introduction: Despite the proven success of anterior cervical surgery (ACS) postoperative issues can arise, with retropharyngeal hematoma (RH) being one of the most feared. A recent USA Today article highlighted the failed management and subsequent death of patients developing RH after ACS. The article calls into question the safety of performing ACS in an outpatient setting. Methods: We tested the knowledge of 20 healthcare professionals (4 surgeons, 16 ancillary providers) regarding ways to minimize the post-ACS complications. We used a multiple-choice and fill-in-the-blank test. We then developed a No S.C.A.R.E. safety protocol and after teaching the same professionals, re-administered the examination to assess improvement. Results: We identified large gaps in knowledge between spine surgeons and other providers (92.3% versus 31.2%) on preintervention testing. Postintervention testing showed significant improvement in nonsurgeon scores (31.2% to 86.1%, P < 0.01). Improvement was also seen in provider confidence after completion of the education module. Conclusion: Previous studies demonstrate that the incidence of RH necessitating evacuation after ACS is extremely small (<1%). For rare complications, healthcare teams may benefit from educational modules and standardized protocols. After implementation of our No S.C.A.R.E. protocol, provider knowledge and confidence markedly improved. We recommend similar education modules and protocols be used at other institutions performing ACS.

Is It Safe to Perform True Outpatient Multilevel ACDFs in a Surgery Center?

“…Most frontline health care staff, even ER physicians and anesthesiologists, may not be aware of the optimal management of such a complication. 1 The Cervical Spine Research Society and other organizations have developed educational content to increase the awareness and response to airway emergencies. 11 It is critical to emphasize that successful management of airway compromise requires early identification and extremely skilled clinicians in airway management.…”

“…This can cause a rapid loss of airway and death within minutes. Most frontline health care staff, even ER physicians and anesthesiologists, may not be aware of the optimal management of such a complication 1. The Cervical Spine Research Society and other organizations have developed educational content to increase the awareness and response to airway emergencies 11.…”

“…Most spine surgeons would agree that it is safe to perform ACDF with a 23-hour postoperative observation. As authors performing outpatient ACDF recommend a minimum 4-6 hour observation period, 1 we examine complications between 6 and 23 hours postoperatively, which could be prevented or more optimally treated with a full observational stay of up to 23 hours.…”

“…The vast majority of these potentially catastrophic complications are evident within 6 hours of surgery. 5,6 In a cohort of 1000 patients undergoing 1-2-level outpatient ACDF, only 8 (0.8%) patients were transferred to the hospital to manage complications, including pain (3), chest pain (2), intraoperative cerebrospinal fluid leak (1), hematoma (1), and profound weakness requiring reoperation (1). All of these complications were identified within the 4-hour window.…”