Does a first-case on-time-start initiative achieve its goal by starting the entire process earlier or by tightening the distribution of start times?

BACKGROUND: We explored whether a previously successful initiative to improve first-case on-time starts succeeded because (i) preoperative steps started earlier (but the process did not necessarily improve) or (ii) the process was brought into better control. METHODS: We analysed 35 months of data comprising 28 882 first cases to calculate the difference of the time a patient entered the operating room (OR) vs the scheduled entry time. Median and inter-quartile range were used to evaluate changes in distribution parameters. A statistical process-control methodology was used to compare the differences in performance between the pre- and post-intervention phases. RESULTS: Post-intervention first cases entered the OR on average within 4 min [95% confidence interval (CI): 4-5 min] of the scheduled start time, as opposed to within 8 min (95% CI: 8-8 min) in the pre-intervention period. The median delay decreased from 5 min (95% CI: 5-5 min) to 2 min (95% CI: 2-2 min). The inter-quartile range of the difference between the scheduled start time and the first case in room time decreased from 13 min (95% CI: 13-13 min) to 10 min (95% CI: 9-10 min). CONCLUSIONS: The reduction in inter-quartile range demonstrates that improvement in on-time starts resulted from the process being in better control. The start time of preoperative preparatory activities did not move earlier, which means that OR and preoperative staff do not need to arrive at work earlier. Improvements resulting from the process being in control were sustained.

Variability in practice and factors predictive of total crystalloid administration during abdominal surgery: retrospective two-centre analysis.

BACKGROUND: Variation in clinical practice in the perioperative environment and intensive care unit is a major challenge facing modern medicine. The objective of the present study was to analyse intraoperative crystalloid administration practices at two academic medical centres in the USA. METHODS: We extracted clinical data from patients undergoing intra-abdominal procedures performed at UC Irvine (UCI) and Vanderbilt University (VU) Medical Centres. Limiting data to uncomplicated elective surgery with minimal blood loss, we quantified variability in fluid administration within individual providers, between providers, and between types of procedures using a corrected coefficient of variation (cCOV). Regression was performed using a general linear model to determine factors most predictive of fluid administration. RESULTS: For provider analysis and model building, 1327 UCI and 4585 VU patients were used. The average corrected crystalloid infusion rate across all providers at both institutions was 7.1 (sd 4.9) ml kg(-1) h(-1), an overall cCOV of 70%. Individual providers ranged from 2.3 (sd 3.7) to 14 (sd 10) ml kg(-1) h(-1). The final regression model strongly favoured personnel as predictors over other patient predictors. CONCLUSIONS: Wide variability in crystalloid administration was observed both within and between individual anaesthesia providers, which might contribute to variability in surgical outcomes.

Safety of midazolam for sedation of HIV-positive patients undergoing colonoscopy.

OBJECTIVES: Because of concerns regarding interactions between midazolam and antiretroviral therapy (ART), alternative sedatives are sometimes used during procedural sedation. Our objective was to compare outcomes in patients on ART who received intravenous (iv) midazolam vs. iv diazepam, a second-line agent, during colonoscopy. METHODS: We conducted a retrospective analysis of adult HIV-positive patients who underwent colonoscopy over a 3.5-year period. Primary outcomes were sedation duration, nadir systolic blood pressure (SBP), nadir oxygen saturation, abnormal cardiac rhythm, and change in level of consciousness using a standardized scale. We calculated rates of adverse events according to benzodiazepine use and identified risk factors for complications using univariate and multivariate analyses. RESULTS: We identified 136 patients for this analysis: 70 received midazolam-based sedation and 66 received a diazepam-based regimen. There were no significant differences between the two groups with respect to sedation duration (mean 48.0 vs. 45.7 minutes for the midazolam and diazepam groups, respectively; P = 0.68), nadir SBP (mean 97.0 vs. 101.6 mmHg; P = 0.06), nadir oxygen saturation (mean 94.6 vs. 94.8%; P = 0.72) or rate of abnormal cardiac rhythm (11.4 vs. 19.7%; P = 0.18). More patients in the midazolam group experienced a depressed level of consciousness (91% vs. 74% in the diazepam group; P = 0.0075), but no patient required reversal of sedation or became unresponsive. CONCLUSIONS: We did not find evidence that patients who received midazolam for procedural sedation had clinical outcomes statistically different from those who received diazepam. These findings should be confirmed in prospective studies or in a randomized controlled trial.

13-Year experience in external fixation of the pelvis: complications, reduction and removal.

PURPOSE: To evaluate the complications associated with anterior pelvic external fixation and the success of this device in maintaining reduction when used in conjunction with sacroiliac screws. METHODS: Through a retrospective clinical study at an academic Level I Trauma Center, 129 patients fit the criteria for inclusion with a mean duration of anterior pelvic external fixation of 62 days and mean follow-up of 360 days. Charts were reviewed for complications postoperatively. The symphysis diastasis, vertical displacement and posterior displacement of each hemipelvis were quantified from pelvic radiographs. RESULTS: Of the 129 patients receiving anterior pelvic external fixation, 14 (10.9 %) presented to an emergency department for problems with their anterior pelvic external fixation. Of these 14 patients, 7 (5.4 %) required readmission, all for infectious concerns necessitating IV antibiotics. 6 (4.7 %) required formal operative debridement and device removal. 13 patients (10.1 %) had superficial pin site infections successfully treated with oral antibiotics. Reduction was maintained (rated as fair, good or excellent) in all patients with radiographic follow-up (n = 74, average radiographic follow-up of 216 days) following removal of their anterior pelvic external fixation. 38 patients (30.4 %) had their anterior pelvic external fixation removed in clinic, while 87 (69.6 %) had formal removal in the operating room. CONCLUSION: While previous data suggest high complication rates in definitive anterior pelvic external fixation, we present the largest cohort of patients receiving anterior pelvic external fixation and sacroiliac screws, demonstrating a low complication rate while maintaining reduction of the pelvic ring. In addition, we found that these devices could be reliably removed in a clinic setting.

Open distal tibial shaft fractures: a retrospective comparison of medial plate versus nail fixation.

PURPOSE: Studies comparing open reduction internal fixation (ORIF) vs. intramedullary nailing (IMN) for distal tibia shaft fractures focus upon closed injuries containing small patient series with open fractures. As such, complication rates for open fractures are unknown. To characterize complications associated with ORIF vs. IMN, we compared complications based on surgical approach in a large patient series of open distal tibia shaft fractures. METHODS: Through retrospective analysis at an urban level I trauma center, 180 IMN and 36 ORIF patients with open distal tibia fractures from 2002 to 2012 were evaluated. Patient charts were reviewed to identify patient demographics, fracture grade (G), patient comorbidities, and postoperative complications including nonunion, malunion, infection, hardware-related pain, and wound dehiscence. Fisher's exact tests compared complications between ORIF and IMN groups. Multivariate regression identified risk factors with statistical significance for the development of a postoperative complication. RESULTS: One hundred and eighty IMN (G1 22, G2 79, and G3 79) and 36 ORIF (G1 10, G2 16, and G3 10) patients were included for analysis. ORIF patients had a higher rate of nonunion (25.0 %, n = 9) compared with IMN patients (10.6 %, n = 20, p = 0.03). No additional complication had a significant statistical difference between groups. Multivariable analysis shows only surgical method influenced the development of complications: ORIF patients had 2.52 greater odds of developing complications compared with IMN patients (95 % CI 1.05-6.02; p = 0.04). CONCLUSIONS: ORIF leads to higher rates of nonunion and significantly increases the odds of developing a complication compared with IMN for open distal tibia fractures. This is the first study investigating complication rates based on surgical approach in a large cohort of patients with exclusively open distal tibia fractures.

Using Visual Analytics to Determine the Utilization of Preoperative Anesthesia Assessments.

BACKGROUND: Preoperative assessments are a required and essential element of anesthetic care, yet little is known about the utilization of these documents by clinicians who are not part of the anesthesia care team. As part of perioperative workflow restructuring, we implemented a data visualization technique of electronic medical record audit log data to understand the utilization of preoperative anesthesia assessments by non-anesthesia personnel. METHODS: An audit log cache containing 140 days of data was queried for all accesses of preoperative anesthesia assessment documents for any patient who had a preoperative anesthesia assessment that was accessed during that period. User roles were aggregated into categories. Descriptive statistics and data visualization were generated using R (R Software Foundation, Vienna, Austria). Comparisons were performed with the Wilcoxon signed rank test with continuity correction. RESULTS: During the study period, 73 802 (0.015%) of the 485 062 902 audit log accesses were preoperative anesthesia assessments representing 412 departments, 302 user roles, and 3 916 distinct users who accessed preoperative anesthesia assessments from 14 235 surgical cases. Each assessment was accessed 2.9 times on average. Assessments performed in the preoperative anesthesia assessment clinic were accessed more frequently than those created on the day of surgery in the preoperative holding room (3.58 ± 5.18 v. 1.98 ± 1.76 average views; p<0.0001). We observed accesses of these documents by pathology and general surgery researchers, as well as orthopedics attending physicians accessing documents that were two years old. CONCLUSIONS: This approach revealed patterns of utilization that had not been previously identified, including usage by surgical residents, surgical faculty, and pathology researchers both before and after the surgical event for which the documents are generated. Knowledge of these dependencies directly informed perioperative workflow restructuring efforts. This visual analytic approach could be broadly utilized to understand documentation dependencies in a variety of clinical contexts.