Patients with a low body mass index are at the highest risk of death following general or vascular surgery, according to an Archives of Surgery study.

Individuals with a BMI less than 23.1 are twice as likely to die than patients with a BMI of 35.3 or higher, and had a 40% higher risk of death than patients with a BMI between 26.3 and 29.6, say researchers at the University of Virginia in Charlottesville. They examined the relationship between BMI and 30-day mortality rates in nearly 200,000 cases culled from the American College of Surgeons National Surgical Quality Improvement Program.

Patients who underwent exploratory laparotomy had the highest death rate (14%), while breast lumpectomy patients were least likely to die (0.1%), according to the study.

The researchers also discovered a statistically significant relationship between BMI and mortality rates for patients undergoing colostomy, wound debridement, musculoskeletal system procedures, upper GI procedures, colorectal resection and hernia repair compared with patients who underwent laparoscopy, which accounted for 2% of patient deaths and served as the mid-range measuring stick used by the researchers to classify procedures as high or low risk.

Risks associated with operating on heavier patients are under increased scrutiny as adult obesity has increased by more than 100% since 1990, say the researchers, who note that their review of ACS data, as opposed to previously published studies, examined a wider range of patients and specific procedures. They say their findings show that BMI is a "significant" predictor of death within 30 days post-op "even after adjusting for the contribution to mortality risk made by type of surgery and for a specific patient's overall expected risk of death."

Daniel Cook

Studies have shown that many medical errors go unreported because employees fear retaliation or work in an environment where cultural barriers don't encourage addressing mistakes. However, a system introduced by a team of North Carolina doctors that emphasizes no punishment and maintains anonymity has increased the number of reported errors at a pediatric clinic by an average of 80 per year.

Daniel Neuspiel, MD, MPH, FAAP, director of ambulatory pediatrics at Levine Children's Hospital in Charlotte, N.C., teamed with colleagues to train a "pediatric safety champion team" to implement a new reporting system in a large clinic in Charlotte. Members of the team represented every part of the office, from physicians and nurses to the office managers and front desk staff.

Employees were educated on reporting, and Dr. Neuspiel and his team stressed that all reports would remain anonymous and no one would be punished for making a mistake. After introducing the new system, the number of reported mistakes at the clinic jumped from 5 to 86 per year on average. Dr. Neuspiel said the staff notified parents of any mistakes that could have harmed their children.

The safety team met monthly to review the errors that the staff submitted and to develop ways to fix the root problems. It addressed three-fourths of the errors with changes in practice. For instance, to prevent nurses from giving kids the wrong vaccine, the office implemented a policy to remove all distractions and other tasks from nurses while they were preparing shots.

"These types of errors are going on everywhere," said Dr. Neuspiel, "so I'm hoping more practices will consider making changes."

Mark McGraw

Have you ever been subject to an insurer's pre-certification bait-and-switch? Or its endless requests for patient (and facility, and physician) information? Or its sudden termination of a physician's provider contract?

You're not alone. These are among the most common tactics insurers employ to delay and deny surgical facilities their reimbursements for services rendered. But you're not without recourse.

In "Clearing Reimbursement Hurdles", which appeared in November's issue of Outpatient Surgery Magazine, attorney Charles X. Gormally, JD, of Brach Eichler in Roseland, N.J., explains what you can do to adapt, respond, and recoup your payments.

David Bernard

Christmas Eve and New Year's Eve fall on Saturdays and Christmas and New Year's Day on Sundays this year. Will your facility be closed before or after the holidays? Tell us in this week's InstaPoll.

Who spends the most time in the staff lounge drinking coffee and reading the paper? The results, from 200 respondents, were mixed: