Saturday, April 15, 2023 | Location: Roy and Diana Vagelos Education Center (VEC), Columbia University, 104 Haven Ave, New York.
We invite you to join us for the 8th Annual Safety in Spine Surgery Summit. We are returning to an in-person meeting this April in New York for a one-day CME-accredited course. Safety in Spine Surgery Month will also feature video content and promotion to raise awareness and highlight S3P work and resources.
Advances in Pediatric Orthopedics
A Steadfast Obligation to Safety in Spine Surgery
What began as a concern a number of years ago about a surgical complication observed by Michael G. Vitale, MD, inspired a transformational initiative in spine deformity surgery safety that is today unparalleled. In 2014, Dr. Vitale and colleagues in the field launched The Safety in Spine Surgery Project (S3P) to improve the safety of surgical treatment of spine problems in adult and pediatric populations by developing best practice guidelines at its foundation.
“This initiative is about how we can collectively make spine surgery safer together,” says Dr. Vitale, who is Chief of Pediatric Spine and Scoliosis Surgery in the Department of Orthopedic Surgery at NewYork-Presbyterian/Columbia University Irving Medical Center. He also serves as Vice Chair, Quality and Strategy, Orthopedic Surgery, and the Ana Lucia Professor of Pediatric Orthopedic Surgery and Neurosurgery at Columbia. “Key to this goal was the establishment of an annual spine safety summit. For a number of years, we held the program in New York with standing room only. The meeting sold out six years in a row. In the last few years, we began simulcasting the program because the demand was so high.”
“During the last two years, S3P offered virtual webinars, and importantly with regard to scale of messaging, the leadership mobilized a very large social media awareness effort,” adds Dr. Vitale. “Last year, there were 225,000 engagements around this concept of safety in spine surgery with all the major organizations – Scoliosis Research Society, Pediatric Orthopedic Surgery of North America, and study groups – jumping on board and helping to boost that messaging.”
Every year, the meeting focuses on developing a best practice guideline for a specific area in spine surgery, ranging from how to avoid wrong site surgery, responding after loss of intraoperative neuromonitoring signals in the operating room, implementing halo-gravity traction, and preventing infection, as well as those addressing particular issues in complex spine deformity surgery. This is accomplished through expert panels and a formally derived consensus process, the Delphi process. The resulting guidelines have led to some of the most widely cited publications in this field.
“These panels are comprised of thought leaders who are deeply committed and have carefully considered how to make spine surgery safer,” says Dr. Vitale. “They are a group of people representing not only the spinal deformity space, but also cervical spine, degenerative disease, and adult and pediatric minimally invasive surgery, and we continue to broaden our audience around different areas in spine surgery. When we get together, we share methods we are doing differently and come up with a product that's better than the sum of its parts.”
Recent Studies Address Neurological Events and Surgical Site Infections
During the past year, Dr. Vitale, his colleagues at Columbia, and members of S3P and other specially convened expert panels have continued developing best practice guidelines on a number of critical safety issues that continue to confront spine surgeons. Their efforts provide the surgical team with resources that can help drive decisions in unexpected events and optimally preserve the neurological function of patients and curtail the incidence of surgical spine infections.
In 2014, Dr. Vitale and his colleagues on the S3P expert panel developed the organization’s first formal guidelines, which targeted responding to intraoperative neuromonitoring changes in the operating room. The resulting paper, published in the September 2014 issue of Spine Deformity, was the most widely cited paper in the field. These guidelines have just been expanded upon by Dr. Vitale, Lawrence G. Lenke, MD, Surgeon-in-Chief and Co-Director of Och Spine at NewYork-Presbyterian, and 13 other experienced spinal deformity surgeons across the country. The study team further developed the original consensus-based best practice guidelines to optimize the approach to intraoperative neuromonitoring events associated with “high-risk” spinal deformity surgery. This set of guidelines, published in the July 2022 issue of Spine Deformity, included a response algorithm; ongoing considerations of etiology – systemic, destabilization/
In a companion paper, published in the same issue of Spine Deformity, the expert panel focused on parameters that constitute elevated risk during spinal deformity surgery and potential preventative strategies that may minimize the risk of intraoperative neuromonitoring events and postoperative neurological deficits. The panel identified and achieved consensus on 22 determinants of high-risk items, incorporating 8 patient factors, 8 curve and spinal cord factors, and 6 surgical factors, as well as 21 preoperative (4), intraoperative (14) and postoperative (3) preventative strategies.
Surgical Site Infections
Faced with surgical site infections (SSI) that continue to prevail even with numerous measures developed and implemented to reduce their incidence, Dr. Vitale, Dr. Lenke, along with their Columbia colleagues in the Department of Orthopedic Surgery and at six other major orthopedic centers across the country, came together to develop a prediction model that could quantify the risk of SSI for individual pediatric spinal deformity patients.
Their study included 3,092 spinal deformity surgeries of which there were 132 cases (4.3 percent) of SSI. The final prediction model contained 9 variables based on their ability to predict SSI within 90 days postoperatively:
- Overweight or obese body mass index (BMI)
- Neuromuscular etiology
- American Society of Anesthesiologists (ASA) grade >2
- Non-ambulatory status
- Abnormal hemoglobin level
- Revision surgery
- Pelvic instrumentation procedure
- Procedure time ≥7 hours
- <100 spine surgical cases per year per institution
The authors note that the validated calculator enables the surgical team to identify high-risk patients, thereby providing the opportunity to address modifiable risk factors prior to surgery and increase vigilance of the particular surgical factors that increase the risk for SSI.
The Bigger Picture: Preventable Patient Harm
“The majority of complications we see are related to system failures,” notes Dr. Vitale. “I think we under-appreciate the reality that there is an entire episode of care that starts before surgeons enter the OR, whether it relates to skin prep or antibiotics, as examples, but also formal discussion about potential risks before the surgery. If you align your processes, you make it much less likely for the wrong problem to propagate through the system.”
- Establishing consensus: determinants of high-risk and preventative strategies for neurological events in complex spinal deformity surgery. Iyer RR, Vitale MG, Fano AN, Matsumoto H, Sucato DJ, Samdani AF, Smith JS, Gupta MC, Kelly MP, Kim HJ, Sciubba DM, Cho SK, Polly DW, Boachie-Adjei O, Angevine PD, Lewis SJ, Lenke LG. Spine Deformity. 2022 Jul;10(4):733-744.
- Development of consensus-based best practice guidelines for response to intraoperative neuromonitoring events in high-risk spinal deformity surgery. Lenke LG, Fano AN, Iyer RR, Matsumoto H, Sucato DJ, Samdani AF, Smith JS, Gupta MC, Kelly MP, Kim HJ, Sciubba DM, Cho SK, Polly DW, Boachie-Adjei O, Lewis SJ, Angevine PD, Vitale MG. Spine Deformity. 2022 Jul;10(4):745-761.
- Best Practices in Intraoperative Neuromonitoring in Spine Deformity Surgery: Development of an Intraoperative Checklist to Optimize Response. Vitale MG, Skaggs DL, Pace GI, Wright ML, Matsumoto H, Anderson RC, Brockmeyer DL, Dormans JP, Emans JB, Erickson MA, Flynn JM, Glotzbecker MP, Ibrahim KN, Lewis SJ, Luhmann SJ, Mendiratta A, Richards BS 3rd, Sanders JO, Shah SA, Smith JT, Song KM, Sponseller PD, Sucato DJ, Roye DP, Lenke LG. Spine Deformity. 2014 Sep;2(5):333-339.
- A Clinical Risk Model for Surgical Site Infection Following Pediatric Spine Deformity Surgery.
Matsumoto H, Larson EL, Warren SI, Hammoor BT, Bonsignore-Opp L, Troy MJ, Barrett KK, Striano BM, Li G, Terry MB, Roye BD, Lenke LG, Skaggs DL, Glotzbecker MP, Flynn JM, Roye DP, Vitale MG. The Journal of Bone Joint Surgery. American volume. 2022 Feb 16;104(4):364-375.
- Safety Does Not Happen by Accident: Preventing Human Error Through High-Reliability Practices. Vitale MG, Raman DL. Journal of Pediatric Orthopedics. 2022 May-Jun 01;42(Suppl 1):S35-S38.
- The Safety in Spine Surgery Project
- April 2022 Spine and Safety Conference Videos
Did you catch these highlights from Safety in Spine Surgery Month, Week 3? Our April 15 webinar was packed full of practical advice on implementing checklists and guidelines, and the faculty included leaders from the SRS, the AANS, POSNA, and more. We jammed a lot of education into those 2 hours! You can catch the replay on our website here.
We also continue to post daily videos about safety from a variety of leaders across all our social media channels. I think these videos are getting better and better! This week’s videos included:
- Carlton Weatherby from Medtronic talking about their steadfast commitment to unmatched quality.
- Dr. John Smith sharing about the success he’s seen in dedicated surgical teams and checklists—they make surgery “much more efficient, safer, and fun.”
- We posted a clip from Dr. Roger Härtl’s 2020 talk about the market approval process for new technology.
- Dr. Kevin Shea told us about the POSNA Safe Surgery Program. Learn more here.
- Dr. Rick Sasso explained the No Strikeout Protocol he developed at the CSRS. This resource is free to download, too.
- Dr. Chris Hardesty shared about peri-op care protocols, which “help remove variation in practice, which can help decrease variation in outcomes.”
- Finally, we capped off the week with General Stan McChrystal, our Keynote Lecturer at the 2018 Safety in Spine Surgery Summit, sharing his thoughts on how teams impact safety.
As always, you can review all these videos, plus our library of past talks, for free on the website.
We still want to hear from you! Post safety tips or questions on your own social media—tag us, and you might win a $100 gift card! Winners are drawn each week from all social media channels.
We had some amazing videos sharing the message about safety in spine surgery, with both top-level commentary as well as practical tips. This week our daily safety tip videos were seen by over 11,000 people, and our overall audience grew by 40%. Highlights included:
- Dr. Lehman asked us, “Why is it safer to fly in an airplane than to have surgery?,” in his video on Safety By the Numbers.
- Prof Carl-Eric Aubin shared about the biomechanical considerations in assessing spinal instrumentation for safety.
- Vafa Jamali from Zimmer Biomet shared about their support of the Safety month.
- Dr. Hey shared about the importance of spine surgery checklists, including a link to the downloadable checklists he’s created.
- And finally, Dr. Elowitz explained the connections between communication, patient safety, and medical malpractice.
Several of these daily tip videos are taken from longer talks presented at past Safety in Spine Surgery Summits. Did you know we have a library of these talks that you can browse & watch for free? Visit the videos tab on our website, or start here with the 2020 Safety Summit videos.
We also had over 500 people register for the April 15 webinar Checklists & Guidelines Which Make Spine Surgery Safer, which featured 4 of our Award Winners for the Best New Methodologies and Techniques to Enhance Safety in Spine Surgery, as well as a “who’s who” of surgeon leaders representing spine safety efforts from leading societies including the SRS, AANS, and POSNA.
We want to hear from you, too! Post safety tips or questions on your own social media—tag us, and you might win a $100 gift card! Winners are drawn each week from all social media channels.
The Safety in Spine Surgery Project (S3P) is pleased to announce the 10 winners of the Safety in Spine Surgery Month Call for Abstracts / Call for Projects. The winning submissions for Best New Methodologies and Techniques to Enhance Safety in Spine Surgery will present their work during two live webinars for Safety in Spine Surgery Month. The free webinars will be held on April 15 and April 29. Registration and further details are available at the link below.
April 15 Webinar
Checklists and Guidelines which Make Spine Surgery Safer
- Spine Surgery Checklist: A Step towards Perfection through Protocols
Jwalant Patel, MS, FASSI; Arvind Kulkarni, MS
- Establishing a Standardized Protocol for Identifying Patients at High Risk for DVT/PE Following Spine Surgery
Zeeshan Sardar, MD, MSc; Kristen Mitchell, PA; Rick Leung, PA; Derek Mazique, MD
- Surgical Site Infection Following Neuromuscular Posterior Spinal Fusion Fell 72% After Adopting the 2013 Best Practice Guidelines
Stephen R. Stephan, MD; Kenneth D. Illingworth, MD; Kavish Gupta, MD; Lindsay M. Andras, MD; David L. Skaggs, MD MMM
Cedars-Sinai Medical Center & Children’s Hospital Los Angeles
- Learning from Air Travel: Utilizing a Checklist Prior to Closing (Landing) in Pediatric Spine Surgery
Jessica H. Heyer, MD; Patrick J. Cahill, MD; John M. Flynn, MD; Jason B. Anari, MD
Children’s Hospital of Philadelphia
April 29 Webinar
Leveraging the Team to Make Spine Surgery Safer
- Reduction of Facial Pressure Injuries after Prone Positioning in Spine Surgery: A Multi-Disciplinary Approach
Mindy Stites, MSN, APRN; Brandon B. Carlson, MD MPH; Linda Brookman, RN; Jake Kessen, CRNA; David Pennington, CRNA; Jacob Birlingmair, MD; Kabir A. Torres, BA; Douglas C. Burton, MD
University of Kansas Health System
- Design and Implementation of an Enhanced Recovery After Surgery (ERAS) Protocol in Elective Lumbar Spine Fusion by Posterior Approach: A Retrospective, Comparative Study
Bhavuk Garg, MS, MRCS; Nishank Mehta, MS; Tungish Bansal; Shubhankar Shekhar; Puneet Khanna; Dalim Vaidya
All India Institute of Medical Sciences
- Comparison of Procedural Utilization Rates and Timeline to Care in Multidisciplinary versus Unidisciplinary Spine Clinic Models
Joshua Benton, BA; Vijay Yanamadala, MD, MBA, MS; Brandon T. Weiss BS; Wenzhu B. Mowrey, PhD; Michael Longo, BA; Rafael De La Garza Ramos, MD; Yaroslav Gelfand, MD; Phillip Cezayirli, MD; Erida Castro-Rivas, MS; Mark Headlam, BS; Adaobi Udemba, NP; Lavinia Williams, RN; Merritt D. Kinon, MD; Andrew I. Gitkind, MD, MHA; Reza Yassari, MD, MS
- Multidisciplinary Conference for Complex Surgery Leads to Improved Quality and Safety
Zoe Norris, BFA; Michelle Zabat, BA; Hershil Patel, BS; Nicole Mottole, BS; Kimberly Ashayeri, MD; Eaman Balouch, MD PhD; Constance Maglaras, PhD; Themistocles Protopsaltis, MD; Aaron Buckland, MBBS FRACS; Charla Fischer, MD
NYU Langone Health & NYU Langone Orthopedic Hospital
- Innovative Technology System to Prevent Wrong Site Surgery and Capture Near Misses: A Multi-center Review of 487 Cases
David Gloystein, MD; John Devine, MD; Bradley Heiges, MD; David Schwartz, MD; Deborah Spratt, MPA BSN RN CNOR
- The Effect of a Transdisciplinary Spine Conference on Quality and Safety for Adult Spinal Deformity Surgery
Gregory Mundis Jr., MD; Fernando Rios, MD; Hani Malone, MD; Bahar Shahidi, PhD; Tina Iannacone, BSN; Shae Galli, BS; Robert Eastlack, MD
The Safety in Spine Surgery Project is pleased to announce the First Annual Safety in Spine Surgery month, taking place in April of 2021. The goal of this project is to improve safety in spine surgery by sharing guidelines, techniques, and protocols that make care better, and to share lessons learned from participants who have developed specific, successful safety protocols. This event will feature 2 live webinars and an industry-wide social media campaign throughout April.
Under the leadership of Michael G. Vitale, MD, MPH and co-chairmen John Flynn, MD; Roger Härtl, MD; Larry Lenke, MD; Rajiv Sethi, MD, S3P is partnering with surgeons, allied health care providers, organizations, hospitals, and medical device companies in this effort. It is the belief of the program directors that all major healthcare stakeholders are obligated to invest their expertise and funds to enhance patient safety.
Submission of abstracts and projects summaries is underway for Best New Methodologies and Techniques to Enhance Safety in Spine Surgery. The 10 best submissions will each be awarded $1000 and be featured during one of the live webinars. We encourage our colleagues to submit not only scientific papers, but also any project that has made a difference in spine surgery quality, safety, or value. Submissions are due to Kate Laney by February 19, 2021.
Registration is open for two live webinars, taking place April 15 and April 29. The first will focus on predictive analytics, enabling technology, and innovative techniques to make the OR safer. The second will highlight checklists, guidelines, and tricks to avoid complications and improve neurological safety. Registration is free and can be accessed at this link.
We encourage you to get involved in this effort by submitting abstracts, attending the webinars, and getting active on social media during the month of April. Post your successes and difficulties with the hashtags #safetyinspinesurgery and #s3p. Follow us on Twitter, Facebook, Linkedin, and Instagram for further information.
If your practice, organization, or medical device company would like to partner with us, please contact Kate Laney.
We are looking forward to an exciting month of collaboration!
By Rajiv K. Sethi, Aditya V. Karhade, Michael G. Glenn and Gary S. Kaplan—
Until the Covid-19 pandemic struck, surgical patients in the U.S. had been increasingly traveling to designated Centers of Excellence, health systems that met stringent criteria for providing exceptional, high-value care for specific procedures such as knee replacement and spinal surgery. In some cases, large employers such as Walmart entered into contracts with the COE providers to care for their employees, whose travel to the specified provider for evaluation and, if needed, surgery, would be fully covered. In other cases, patients would travel from afar using other coverage to receive this specialized care.
Our institution, Virginia Mason, along with others including Geisinger, the Mayo Clinic, and Johns Hopkins are designated Centers of Excellence. Among the services patients have traveled to us for are complex spine surgeries, one of the most challenging procedures.
By shutting down most travel, the pandemic might have put an end to such programs, at least for the duration. But at Virginia Mason, prior investments in telemedicine technology for virtual patient encounters and virtual multidisciplinary perioperative clinical-team conferences have allowed us to continue providing surgery and other spine care to both local and remote patients traveling from hundreds or thousands of miles away, as well as to enhance virtual patient care broadly.
The Spine Team Approach
Based in Seattle, we were among the first organizations to confront the Covid-19 pandemic and, as such, had no blueprint to guide our response. Regulatory guidelines were constantly evolving and there were widespread shortages of personal protective equipment (PPE). Travel restrictions were keeping patients from many states away from Seattle and, fearing infection with the novel virus, local patients were deferring needed care. A ban on elective procedures resulted in precipitous and profound decreases in clinical care revenue and financial pressures were intensifying.
The pandemic forced us to quickly respond to novel clinical challenges, but we also needed to develop new ways to coordinate our sophisticated care teams and to safely engage with patients, including those traveling to Virginia Mason for complex spine surgery.
Like many leading organizations, Virginia Mason emphasizes a multidisciplinary approach to value-based care, which focuses on improving outcomes while reducing costs. The “Seattle Spine Team Approach” is a fully developed example of such comprehensive and condition-specific care. This model involves pre-surgical team conferences (now held virtually) that include orthopedic surgeons, neurosurgeons, physiatrists, pain medicine specialists, specialty-trained nurses and physician assistants, hospitalists, psychologists, and anesthesiologists. These conferences, along with the requirement that two attending surgeons are present during complex spine surgeries and the institution of a tailored intraoperative anesthesia protocol, have resulted in a three-fold reduction in major complications in the most complex spinal procedures. Many team members see these conference as the cornerstone of the entire spine care program.
When a patient is referred for spine surgery, the team holds a virtual “patient clearance” conference to evaluate whether he or she will decisively benefit from the procedure or may be as effectively treated without it. (In our prior studies of in-person visits where referred patients were presumed to need lumbar surgery, we found that 58% in fact didn’t need it.) For those patients found to be good candidates for surgery, the team conducts a risk stratification to determine which require immediate surgery and begins pre-surgical “optimization,” evaluating patients for surgical risk factors such as obesity, diabetes or smoking. In non-urgent cases, the team postpones surgery to allow time to address these.
Our clinicians have embraced the virtual conference format. We have seen increased attendance and continued engaged discussion by our clinical staff. Further, providers who rotate between clinical sites can attend these more easily than the previous physical meetings. As a result, the spine team has now committed to all-virtual patient-clearance conferences as its “new normal” and expects to continue with these virtual conferences even after restrictions on in-person meetings are lifted.
Combining Virtual and Hands-on Care
A recent case illustrates how we are integrating traditional destination care and new virtual care models. A 57-year-old man from Alaska had been experiencing progressive weakness in his arms and legs and for several weeks was unable to get timely outpatient evaluation because of the pandemic. As his symptoms became severe, his local doctor referred him to one of our physicians. The team held a virtual care conference and the same day a consultation with his local doctor, determining that the patient would require complex cervical spine reconstructive surgery. Within a day of those meetings, the patient was on a plane from Alaska to Seattle where he was scheduled to undergo immediate surgery at Virginia Mason. Two weeks later, the patient returned to Alaska and all further communication with the patient and his local doctor has been conducted virtually. Within three months after surgery, the patient had regained full use of his arms and legs and returned to work. We are continuing to follow him through serial virtual visits that include his surgeon, specialized spine physician assistants, rehab physicians and pharmacy.
While the pandemic hasn’t substantially interrupted our destination care program for patients needing urgent specialized spinal surgery, it has underscored the less dramatic, but equally important element of the program—it’s focus on identifying candidates for surgery who in fact can be effectively managed without it. It’s now clear that, going forward, many nonsurgical patients could receive a comprehensive evaluation and treatment without physically traveling to Seattle. These patients can be managed virtually by our non-operative spine specialists and continue their treatment plan without travel-related interruption. With virtual multidisciplinary care we have actually increased access to quality care while, with the decrease in required travel, dramatically reducing the costs of evaluation and treatment.
Acknowledging the terrible human suffering and financial toll of Covid-19, we anticipate some positive lasting changes. Virtual multidisciplinary conferences and telemedicine allow us to provide our model of care to all patients, not just those in COE programs. For patients back home after surgery, telemedicine allows for close and timely follow-up without the burden of travel. Virtual multidisciplinary conferences can improve care by allowing same-day, real-time assessments of the urgency of patients’ needs and facilitating immediate triage. In addition, they can serve as a consult resource for patients’ local providers. The potential silver lining of the current Covid crisis may be its role as a catalyst to enable a better paradigm of value-based care.
Less than 2 weeks before the 5th Annual Safety in Spine Surgery Summit on March 13, NewYork-Presbyterian Hospital received its first COVID patient. These were the early days of an unprecedented strain on the city’s healthcare system. NYC is still fighting a hard battle every day and continues to rise to the challenge.
Despite taking the necessary step to cancel the live Safety Summit in March, we were still committed to providing top-tier educational resources to the spine surgery community. Our local faculty gathered for discussion and our long-distance faculty recorded their own presentations. In the words of Dr. Flynn & Dr. Vitale, it’s more a mission than a course. Thanks to our faculty and supporters, we’re now pleased to present these to you as a free Safety Summit Online CME video series.
Surgeons, PAs, and Nurses can earn 4.2 hours of CME/CE credit by viewing this series of lectures and panel discussions. Learn from experts in spine surgery, neuromonitoring, medical device approval, malpractice, and more. Plus, gain invaluable insight from Stephen Harden of LifeWings, a leader in transforming patient safety programs around the country. We’ve also provided the full text of the outstanding abstracts submitted for this meeting. In addition, you can review the E-Poster presentations, representing some of the best new research in our field. This CME-accredited course is available through February 2021.
We hope you’ll take advantage of this year’s on-demand learning experience. We look forward to joining together in person again for the 6th Annual Safety Summit in Spring 2021. Until then—stay healthy. Stay safe.
Save the date for the 5th Annual Safety in Spine Surgery Summit: April 13, 2020 in New York City.
- Michael G. Vitale, MD, MPH
- John M. Flynn, MD
- Roger Härtl, MD
- Rajiv K. Sethi, MD
An ESSENTIAL program for:
- Spine surgeons
- Surgical spine team members
- Hospital execs responsible for patient safety
Registration details will be posted on the Event’s Page.
View the videos from presenters at the 4th Annual Safety in Spine Surgery Summit. Learn insights and practical techniques for improvement of safety in spine surgery from experts in the medical field as well as other fields.