Follow 3 steps to manage laser surgery quality
By Patrice Spath, ART
Consultant in Health Care Quality and Resource Management
Forest Grove, OR
With new surgical laser technologies almost a daily occurrence, medical staff must assure themselves that physicians using these devices are adequately trained and that systems are in place to minimize untoward events. When assessing the quality of care provided in laser surgery, it helps to understand where things can go wrong. In general, problems in laser surgery are caused by:
• poor training or lack of experience;
• poor preoperative evaluations;
• poor intraoperative techniques;
• poor postoperative care;
• failure to follow safety precautions.
The assurance of quality in laser surgery requires a three-step system to prevent difficulties: user competency assessments, clinical performance measurement, and quality control/ safety control activities.
The first requirement is the design of an effective credentialing mechanism for physicians requesting laser privileges. It is not acceptable to include the line item "laser surgery" as a privilege choice on a surgical privilege list. Each type of laser equipment available at the hospital must be listed separately on the privilege list, together with the surgical procedure(s) in which the equipment will be used. It is wrong to assume that a physician’s training and experience in the use of one piece of equipment for one type of surgery is transferrable to another type of equipment or operation.
Applicants must document experience
The second component of laser surgery privileges deals with physician training and experience. Applicants should be able to document their education and number of procedures they have performed. Some hospitals also require continuing education for physicians who have already been granted laser surgery privileges.
Shown on p. 37 is an application for laser privileges that can be adapted by the medical staff credentialing program. Only include laser equipment currently available at your facility on the privilege application form. As new equipment is added, surgeons should amend their privilege listings.
Staff responsible for assisting physicians during laser surgery and for maintaining the equipment also must be competent. All staff operating lasers should attend a laser safety class and be able to demonstrate their operational qualification through technical training or other acceptable learning experiences. In areas where there may be exposure to laser radiation from a Class 3b or Class 4 laser, employees should be required to have a baseline eye examination prior to using the laser, as well as periodic follow-up exams.
Ongoing evaluation of laser surgery quality also involves the development of performance measures. Sample indicators of quality for laser-related procedures include:
• excessive bleeding, intraoperative or postoperative;
• accidental penetrations or perforations;
• postoperative fistulas;
• delayed healing;
• surgical site infections;
• extended operating times;
• excessive scarring;
• recurrence/persistence of lesion;
• compliance with preceptorship requirements;
• compliance with infection control requirements.
The surgical department also can periodically review specific types of laser procedures to ensure compliance with standards of practice. For example, shown below are criteria used in the review of Nd:YAG laser therapy in pulmonary medicine.
Physician qualifications:
bronchoscopy training/experience;
training/experience in management of emergencies of the airway.
Monitoring during procedure:
surgical team includes nurse and anesthesiologist;
ear or finger oximetry;
vital signs monitored, including EKG;
Swan-Ganz catheter for unstable patients.
Incidence of complications:
bleeding;
perforation of the airway;
tracheo-esophageal fistula;
fire;
scope damage.
When cases require more in-depth peer review, the surgery department or the laser subcommittee should review the patient’s record to determine compliance with departmental standards of quality. The Laser Surgery Case Review form, inserted in this issue, can be used to document the results of this peer review activity. In many instances, untoward events are caused by breakdowns in the processes of care, rather than individual practitioner problems. For this reason, the peer review form provides space for reviewers to document system problems that may have contributed to the undesirable event. Analysis of aggregate data regarding these system problems can help the surgery department identify, and ultimately prevent, future occurrences.
The oversight responsibilities related to quality and safety control may be delegated to the hospital safety committee or to a subcommittee, such as the laser safety committee. It is the duty of this group to evaluate the safety of laser use and ensure compliance with medical device reporting procedures. They periodically meet to review major injuries and trends, ensure proper follow-up of accidents, and report trends and actions taken to the chief executive officer. This committee also may be responsible for providing safety information for orientation and continuing education for employees involved in laser procedures.
Typical laser-related quality control/safety control performance measures that are reported to the safety committee include:
Incidence of:
fire at tissue site;
fire in operating suite;
scope damage;
accidental electrocutions;
physician/staff corneal and/or retinal burns;
skin burns caused by acute exposure to high levels of optical radiation.
Compliance with:
preoperative safety checks;
informed consent procedures;
inservice/continuing education requirements;
Medical Device Reporting Program require ments.
The Safety Officer or designee should conduct at least annual inspections of all sites where laser equipment is used. This may include operating rooms, minor procedure rooms, and select ancillary departments, such as the laboratory. The Safety Officer should look for an up-to-date department log showing periods of laser use, service, maintenance, and incidents. Other issues to be evaluated during this inspection include compliance with laser classification labeling on each piece of equipment, evidence of posted warning signs, and proof of staff competence and continuing education. A form the Safety Officer can use during these inspections also is inserted in this issue.
The assurance of quality in laser surgery is not unlike the process that should be in place for all patient care services. A meaningful privileging system must be adopted. Clinical performance measures that are specific to the service should be periodically evaluated by the medical staff and relevant hospital managers. Quality control/ safety control measures must be in place.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content