Adaptation and restructuring of an academic anesthesiology department during the COVID-19 pandemic in New York City: Challenges and lessons learned.

The novel SARS-CoV-2 pandemic starting in 2019 profoundly changed the world, and thousands of residents of New York City were affected, leading to one of the most acute surges in regional hospital capacity. As the largest academic medical center in the Bronx, Montefiore Medical Center was immediately impacted, and the entire hospital was mobilized to address the needs of its community. In this article, we describe our experiences as a large academic anesthesiology department during this pandemic. Our goals were to maximize our staff's expertise, maintain our commitment to wellness and safety, and preserve the quality of patient care. Lessons learned include the importance of critical care training presence and leadership, the challenges of converting an ambulatory surgery center to an intensive care unit (ICU), and the management of effective communication. Lastly, we provide suggestions for institutions facing an acute surge, or subsequent waves of COVID-19, based on a single center's experiences.

Do standards of care and early outcomes of periprosthetic fractures change during the COVID-19 pandemic? A multicentre study.

BACKGROUND: Periprosthetic fractures (PPFs) are a growing matter for orthopaedic surgeons, and patients with PPFs may represent a frail target in the case of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. The purpose of this study is to investigate whether hospital reorganisations during the most severe phase of the SARS-CoV-2 pandemic affected standards of care and early outcomes of patients treated for PPFs in Northern Italy. MATERIALS AND METHODS: Data were retrieved from a multicentre retrospective orthopaedics and traumatology database, including 14 hospitals. The following parameters were studied: demographics, results of nasopharyngeal swabs, prevalence of coronavirus disease 2019 (COVID-19), comorbidities, general health status (EQ-5D-5L Score), frailty (Clinical Frailty Scale, CFS), pain (visual analogue scale, VAS), anaesthesiologic risk (American Society of Anaesthesiology Score, ASA Score), classification (unified classification system, UCS), type of operation and anaesthesia, in-hospital and early complications (Clavien-Dindo Classification, CDC), and length of stay (LOS). Data were analysed by means of descriptive statistics. Out of 1390 patients treated for any reason, 38 PPFs were included. RESULTS: Median age was 81 years (range 70-96 years). Twenty-three patients (60.5%) were swabbed on admission, and two of them (5.3%) tested positive; in three patients (7.9%), the diagnosis of COVID-19 was established on a clinical and radiological basis. Two more patients tested positive post-operatively, and one of them died due to COVID-19. Thirty-three patients (86.8%) presented a proximal femoral PPF. Median ASA Score was 3 (range, 1-4), median VAS score on admission was 3 (range, 0-6), median CFS was 4 (range, 1-8), median EQ-5D-5L Score was 3 in each one of the categories (range, 1-5). Twenty-three patients (60.5%) developed post-operative complications, and median CDC grade was 3 (range, 1-5). The median LOS was 12.8 days (range 2-36 days), and 21 patients (55.3%) were discharged home. CONCLUSIONS: The incidence of PPFs did not seem to change during the lockdown. Patients were mainly elderly with comorbidities, and complications were frequently recorded post-operatively. Despite the difficult period for the healthcare system, hospitals were able to provide effective conventional surgical treatments for PPFs, which were not negatively influenced by the reorganisation. Continued efforts are required to optimise the treatment of these frail patients in the period of the pandemic, minimising the risk of contamination, and to limit the incidence of PPFs in the future. LEVEL OF EVIDENCE: IV.

[Reorganize hospitals to improve efficiency and quality]. / Riorganizzare gli ospedali per migliorare efficienza e qualità.

The current economic difficulties and the changed epidemiological picture, characterized by an increase in life expectancy, which shows in the elderly, chronically ill and disabled the main, both health and social, care needs,r equires a remark on the hospital network and organization. Today, most of the application assistance is usually at low intensity of care, whereas the acute event is shrinking. The prevalence of hospital admissions concern the elderly, who get into acute events but on a substrate of chronicity and co-morbidity conditions. There must be a new model of hospital network, with the possibility of converting some hospital centres for medium intensity care and selecting few centres for high intensity care, where concentrating the more expensive technology and the skill and expertise of the professional. The -suggestion is a renewed health planning that detects:- hospitals for widespread disease, equipped with emergency war for minor codes-hospital at high intensity of care for emergency-urgency- hospital for particular fields of medical speciality and research.

Development and restructuring of a burn centre in an emerging nation, based on the example of Kyrgyzstan.

AIM: To implement and review a four-tier plan to develop a burn centre in an emerging nation (Kyrgyzstan). METHOD: From 2001, the developing burn centre in Bishkek was supported with numerous material donations and, once a year, teams from Germany operatively treated numerous burn victims on site. Training and further education for our Kyrgyzstani colleagues were based on 'helping them to help themselves', with additional consultations on conceptual hygienic and structural improvements. RESULTS: Material donations were delivered personally by the project teams. Education and training were also limited due to physician emigration. However, in the seven trips made by the team from Germany, numerous operations were performed and there was fundamental progress in the areas of bandaging protocols, hygienic concepts and structural improvements. CONCLUSION: An exact plan patiently tailored to the local situation and culture must be followed, to provide cost-effective support.

[From old to new hospital: physical change and development]. / Dal vecchio al nuovo ospedale: cambiamento materiale e sviluppo.

This paper examines a case of organizational change: the moving of a hospital to a new location. The change is considered in the light of two dimensions: the physical change from the old to the new structure ("logistic/physical change") and the change in the mode of working ("change in work-life"). The problem is to understand if, and how, these two change dimensions appear in the employees' (nurses and doctors) representation of the event. A theoretical framework was delineated based on three main constructs, i.e. an idea of organization as: a) the declination in time of the coordinated and interdependent employees' actions (course of decisions and actions); b) an ordering function of the course of decisions and actions rooted in the employee's cognitive schema ("context", "structure"); c) a set of meanings, at different levels, that constitute a common background and shared, in part, by the ordering function ("institutional frame"). A qualitative investigation was carried out, based on narrative in-depth interviews addressed to the top management of the different departments (SOC). A total of 34 medical and nurse managers were interviewed. Analysis of the interviews show that the discontinuous approach may be described according to five different "pure" types (as per Weber's theory). The five types are discussed within the above theoretical framework and in relation to their implications for organizational development.

[Development of organizations in Norwegian hospitals]. / Organisasjonsutvikling ved norske sykehus.

BACKGROUND: Hospitals in Norway are changing as a result of altered hospital environments and the constraints they are placed under. This article describes the organizational development in Norwegian hospitals from 1999 to 2005 and discusses whether the developments observed can be interpreted as a modernization of the Norwegian hospital system. MATERIAL AND METHODS: The article is based on a survey sent to all public hospitals in 2001, 2003 and 2005. In 2001 the hospitals were asked retrospectively about 1999. In 2005, 60 of 63 hospitals responded to the survey. RESULTS: Results indicate a consistent pattern of organizational development from 1999 to 2005. Some areas change to a greater degree than others; the most noticeable is decentralization in terms of financial routines and personnel responsibilities. Other major organizational developments include ring fencing of elective surgery, co-localization of hospital reception rooms and emergency wards, and increased use of computerized routines, both for patient management and treatment. INTERPRETATION: It has been demonstrated that Norwegian hospitals are able to change and adapt. Several standardized organizational and leadership structures recommended by official reviews are increasingly being adopted into practice. Hospitals are being modernized.

[Is there a relationship between hospital size and patient experience?]. / Er det sammenheng mellom sykehusstørrelse og pasienterfaringer?

BACKGROUND: Hospitals in Norway are undergoing changes in structure and organisation. Patient experience has been selected as a national indicator of hospital quality. The objective of this study was to investigate the relationship between hospital size and patient experience. MATERIAL AND METHODS: A patient experience questionnaire was sent to a representative sample of patients after discharge from 46 somatic hospitals, which were classified by function and by annual number of patients admitted. RESULTS: 10,975 patients (50%) responded. Generally, the patients expressed a positive attitude towards their hospitals. The patient experience was significantly more positive among those discharged from small hospitals than among those discharged from medium-sized or large hospitals, especially with regard to organisation. INTERPRETATION: Our study shows that patient experience was significantly more positive among those discharged from small hospitals than from medium-sized or large hospitals, especially with regard to organisation. However, the score differences between hospitals are small and should be interpreted with caution.

Restructuring fosters better communication.

Case management, physicians, and nurses define clinical practice guidelines. Staff reconnected to hospital structure as reporting lines shift. Modified gatekeeping system eliminates redundant, rare authorizations.

The impact of IMPACT on St. John's Regional Health Center.

St. John's Regional Health Center (SJRHC) is participating in the Institute for Healthcare Improvement's (IHI) IMPACT collaborative, a new IMProvement ACTion network of health care organizations that have joined together to improve patient care. By utilizing the network for sharing ideas, continuous quality improvement tools and support staff and physician involvement, we have achieved three important breakthrough improvements in patient flow in the hospital setting. The areas highlighted in this article are Perioperative Services, Emergency Department Admission, and Transfers to Cardiac Intensive Care Units.