North central London elective orthopaedic network and health service innovation to improve the quality of NHS patient care.

Health service innovation is required to meet the ever-growing demands of modern medicine. This editorial discusses the transformation of the north central London elective orthopaedic network and the essential principles which future integrated care systems could incorporate.

Intravenous Versus Oral Acetaminophen in Ambulatory Surgical Center Laparoscopic Cholecystectomies: A Retrospective Analysis.

STUDY OBJECTIVE: The primary aim was to compare postoperative pain scores in patients undergoing laparoscopic cholecystectomy and receiving intravenous (IV) or oral (PO) acetaminophen (APAP) as part of a multimodal analgesic regimen to examine whether PO APAP is non-inferior to IV APAP. DESIGN: Retrospective analysis. SETTING: Ambulatory surgical center (ASC) in an academic setting. PATIENTS: 579 patients (18-70 years old), American Society of Anesthesiologists physical status I-III, undergoing laparoscopic cholecystectomy. INTERVENTIONS: Patients received 1,000 mg IV APAP intraoperatively (n = 319) or 1,000 mg PO APAP preoperatively (n = 260). MEASUREMENTS: The primary outcome was the median difference in post-anesthesia care unit (PACU) end-pain scores between the groups. Median pain scores were also compared on PACU admission, and at 15, 30, 45, and 60 minutes. Additional measures include PACU rescue-analgesia consumption, time to first PACU rescue analgesia, intraoperative use of opioid and nonopioid analgesics, PACU length of stay, and PACU rescue nausea and vomiting therapy. MAIN RESULTS: In both groups, the PACU median end-pain score was 2. The 90% confidence interval (CI) for difference in median pain scores between groups was [0, 0]; the CI upper limit was below the non-inferior margin of 1 pain-score point, indicating PO APAP's non-inferiority to IV APAP. There were no statistically significant differences in the percentages of patients receiving PACU hydromorphone equivalents between the IV and PO groups (75% vs. 77%, P = 0.72) or in the mean dose received (0.5 mg vs. 0.5 mg, P = 0.66). CONCLUSION: Single-dose PO APAP is non-inferior to IV APAP for postoperative analgesia in ASC laparoscopic cholecystectomy patients. The value of single-dose IV APAP in this population should be further explored.

Electronic tool helps anaesthesia trainee handovers.

BACKGROUND: Handovers in patient care are increasingly common occurrences in medicine and are highly susceptible to communication failures. Intraoperative anaesthesiology handovers are especially challenging because of concurrent management of the patient. Our goal was to develop and use an electronic handover checklist as an educational tool to teach anaesthesiology trainees a standardised method of handing over a case intraoperatively. We hypothesised that the use of the checklist would systematically enhance the transfer of accurate and complete information. METHODS: Thirty-four anaesthesia trainees were observed giving an intraoperative handover without the checklist, and then again with the checklist at a later time. An observational handover assessment tool was used by investigators to mark each item as either spontaneously relayed by the giver, elicited by the receiver, not discussed or not applicable to the case. After the use of the checklist, each handover giver filled out a survey related to his or her perceptions of the checklist. RESULTS: The proportion of items spontaneously relayed increased from 54% without the checklist to 98% when using the checklist (p < 0.0001). More than 90% of participants felt that the checklist increased handover efficiency and communication skills. All participants stated that the handovers were more thorough with the checklist and that they would incorporate it into their daily practice. Intraoperative anaesthesiology handovers are especially challenging because of concurrent management of the patient DISCUSSION: With the intervention of the checklist, our results show that the use of a standardised intraoperative checklist improved the transfer of important patient information among anaesthesia trainees.

Systematic identification and management of barriers to vascular surgery patient discharge time of day.

OBJECTIVE: Length of stay fails to completely capture the clinical and economic effects of patient progression through the phases of inpatient care, such as admission, room placement, procedures, and discharge. Delayed hospital throughput has been linked to increased time spent in the emergency department and postanesthesia care unit, delayed time to treatment, increased in-hospital mortality, decreased patient satisfaction, and lost hospital revenue. We identified barriers to vascular surgery inpatient care progression and instituted defined measures to positively impact standardized metrics. METHODS: The study was divided into three periods: preintervention, "wash-in," and postintervention. During the preintervention phase, barriers to patient flow were quantified by an interdisciplinary team. Suboptimal provider communication emerged as the key barrier. An enhanced communication intervention consisting of face-to-face and mobile application-based education on key patient flow metrics, explicit discussion of individual patient barriers to progression at rounds and interdisciplinary huddles, and communication of projected discharge and potential barriers via e-mail was developed with input from all stakeholders. Following a 4-week wash-in implementation phase, data collection was repeated. RESULTS: The pre- and postintervention patient cohorts accounted for 244.3 and 238.1 inpatient days, respectively. Both groups had similar baseline demographic, clinical characteristics, and procedures performed during hospitalization. The postintervention group was discharged 78 minutes earlier (14:00:32 vs 15:18:37; P = .03) with a trend toward increased discharge by noon (94% vs 88%; P = .09). Readmission rates did not differ (P = .44). CONCLUSIONS: Implementation of a focused, interdisciplinary, frontline provider-driven, enhanced communication program can be feasibly incorporated into existing specialty surgical workflow. The program resulted in improved timeliness of discharge and projected cost savings, without increasing readmission rates.