P148. Underlying Reasons for Failure to Achieve Adequate Lymph Node Staging During Lung Cancer Resection: Results of a Clinical Failure Modes Effects and Criticality Analysis

3 Minutes 

Los Angeles Convention Center 

Objective:
Surgical resection of the primary tumor combined with mediastinal lymph node staging is the standard of care for the treatment of early-stage non-small cell lung cancer (NSCLC). The ACS Commission on Cancer has defined adequate lymph node staging as the sampling of at least 3 N2 stations and 1 N1 station. However, despite national quality standards, operative lymph node staging has consistently been poor when examining national data. This study sought to define underlying reasons for inadequate nodal staging and to determine their relative contribution .

Methods:
We convened a multidisciplinary panel of thoracic surgeons, pathologists, and operating room nurses and scrub technicians from hospitals participating in the Illinois Cancer Collaborative (ILCC) to conduct a Failure Modes Effectiveness and Criticality Analysis (FMECA) assessment of operative lymph node staging. The panel first considered the process of lymph node staging from preoperative planning through surgical care and finally pathological analysis and reporting. Key steps (figure) were identified and categorized as critical (failure to perform the step could not be overcome by other actions) and non-critical. To validate this construct, we then reviewed surgical resections performed at the participating hospitals over the past 6 months to identify patients where staging was inadequate and categorize failure points.

Results:
The panel identified 6 key steps in nodal staging: preoperative planning, node identification, adequate dissection, operative specimen labelling, pathologic dissection, and pathological reporting. Node identification, dissection, and pathological reporting were identified as critical process steps. Chart review of 200 anatomic lung resections yielded 51 cases of inadequate staging (26%). The most common root cause was failure to dissect the node in 47% (n=24) followed by pathologic documentation errors in 25% (n=13) and specimen labelling errors in 18% (n=9).

Conclusion:
This study identified critical technical and non-technical skills factors which contribute to inadequate lymph node staging during lung cancer resection. While a technical failure to dissect the lymph node station was the most common failure point, several areas of the process may result in failure to adequately stage patients. These steps provide actionable targets for quality improvement.

This work is funded by the AATS Foundation Surgical Investigator Award

2 minute presentation; 1 minute discussion.