Effect of the Implementation of a New Electronic Health Record System on Surgical Case Turnover Time.

Many health care providers, hospitals, and hospital systems have adopted new electronic health records (EHR) to streamline patient care and comply with government mandates. Commercial EHR vendors advertise improved efficiency, but few studies have been performed to validate these claims. Therefore, this study was performed to evaluate the effect of deploying a new EHR system on operating room efficiency and surgical case turnover time (TOT) at our institution. Data on TOT were collected after implementation of a new EHR (Epic) from June 2015 to May 2016, which replaced a legacy system of both paper and electronic records. These TOTs were compared to data from the same months in the preceding year. Mean TOT and standard deviations were calculated. The two-sample t-test was used to compare means by month and the F-test was used to compare standard deviations. There was a significant increase in TOT (63.0 vs. 53.0 min, p < 0.001) in the first month after implementation. This improved by the second month (59.0 vs. 53.0 min, p < 0.001), but the relative increase persisted until the end of the fifth month after which it remained around the pre-implementation baseline until the end of the study. The standard deviation significantly decreased after the fourth month post-implementation and persisted throughout the studied period. We found that implementation of an EHR led to a significant decrease in efficiency that persisted for five months. While EHRs have the potential to improve hospital workflow, caution is advised in the case of operating room implementation. While the mean TOT did not improve beyond the pre-implementation baseline, the standard deviation was significantly improved after the first four months.

Effective strategies in improving operating room case delays and cancellations at an academic medical center.

BACKGROUND: Traditionally, the operating room (OR) in an academic medical center has faced numerous challenges to effective clinical productivity, including additional missions of teaching and research. Level 1 trauma poses more challenges related to the need for additional specialized personnel in anesthesia, surgery, and nursing. The present investigation explores lessons learned in efficiency, teamwork, and data evaluation at a level 1 academic teaching facility. METHODS: The months of July 2012, July 2013, and July 2014 were selected for this study. Multiple strategies were implemented through the Operating Room Committee during this time in an effort to reduce the number of OR delays and cancellations. RESULTS: Case cancellations decreased significantly over the three-year period, while delays remained relatively stable. In July 2012, 15.0% of cases were cancelled and 10.2% were delayed. Cancellations decreased to 6.3% in 2013 and to 5.9% in 2014. The total number of cases completed per month increased each year throughout the study, from 577 in 2012 to 649 in 2013 to 842 in 2014. CONCLUSION: These results are remarkable in comparison to the greater-than 20% cancellation rate recorded in 2005 when the current OR leadership team first assessed OR efficiency. An increase in the number of cases completed per month likely can be attributed to a reduction in the number of case cancellations. Increased efficiency allows for more operations to be performed, leading to increased profitability and an increased ability of hospitals to continue caring for patients. We advocate the implementation of a comprehensive multidisciplinary strategy for sustained improvement in OR efficiency and utilization.

Direct application of ropivacaine-soaked gauze to sciatic nerve after necrotizing fasciitis exposes underlying muscles and nerves.

Background: Necrotizing fasciitis is a rapidly progressive infection of the subcutaneous tissue and fascia with significant morbidity and mortality. There is a paucity of literature published on the benefits of regional anaesthesia in patients with necrotizing fasciitis of the extremities. Case Presentation: This study demonstrates novel approaches to management of pain in a patient with necrotizing fasciitis of the lower extremity. A 47-year-old male with polysubstance use disorder was found to have necrotizing fasciitis of the lower extremity. Surgical debridement included 15% of his total body surface area and resultant exposure of his sciatic nerve. A ropivacaine-soaked gauze was applied directly to the exposed sciatic nerve. Femoral and lateral cutaneous nerve blocks were performed to facilitate necessary surgical dressing changes and physical therapy. Conclusion: This report details techniques used in postoperative pain management to facilitate surgical dressing changes after extensive debridement of an extremity for necrotizing fasciitis. The use of local anaesthetic-soaked gauze may be a useful adjunct in certain scenarios.

TNFAIP3 Reduction-of-Function Drives Female Infertility and CNS Inflammation.

Women with autoimmune and inflammatory aetiologies can exhibit reduced fecundity. TNFAIP3 is a master negative regulator of inflammation, and has been linked to many inflammatory conditions by genome wide associations studies, however its role in fertility remains unknown. Here we show that mice harbouring a mild Tnfaip3 reduction-of-function coding variant (Tnfaip3I325N) that reduces the threshold for inflammatory NF-κB activation, exhibit reduced fecundity. Sub-fertility in Tnfaip3I325N mice is associated with irregular estrous cycling, low numbers of ovarian secondary follicles, impaired mammary gland development and insulin resistance. These pathological features are associated with infertility in human subjects. Transplantation of Tnfaip3I325N ovaries, mammary glands or pancreatic islets into wild-type recipients rescued estrous cycling, mammary branching and hyperinsulinemia respectively, pointing towards a cell-extrinsic hormonal mechanism. Examination of hypothalamic brain sections revealed increased levels of microglial activation with reduced levels of luteinizing hormone. TNFAIP3 coding variants may offer one contributing mechanism for the cause of sub-fertility observed across otherwise healthy populations as well as for the wide variety of auto-inflammatory conditions to which TNFAIP3 is associated. Further, TNFAIP3 represents a molecular mechanism that links heightened immunity with neuronal inflammatory homeostasis. These data also highlight that tuning-up immunity with TNFAIP3 comes with the potentially evolutionary significant trade-off of reduced fertility.

Evaluation of calcium and vitamin D supplementation in bisphosphonate therapy.

OBJECTIVE: To assess the calcium and vitamin D intake of osteoporosis patients on bisphosphonate therapy. DESIGN: Prospective study. SETTING: Two independent pharmacies (Futrell Pharmacy Services, Jackson N.C., and McDowell's Pharmacy, Scotland Neck, N.C.) and one ambulatory care clinic (Scotland Neck Family Medical Center, Scotland Neck, N.C.) in eastern rural North Carolina from December 2005 to February 2006. PATIENTS: 29 osteoporosis patients on bisphosphonate therapy. INTERVENTIONS: Patients were assessed on calcium intake and counseled on the appropriateness of supplementation with bisphosphonate therapy. MAIN OUTCOME MEASURE: Degree to which osteoporosis patients on bisphosphonate therapy use concomitant calcium supplements. RESULTS: Of the 29 patients surveyed, 17 patients were using calcium supplements during bisphosphonate therapy. Reasons cited for not using calcium included constipation (7 patients), polypharmacy (3), forgetfulness (1), and deemed unnecessary (1). Types of calcium supplements used were 71% calcium carbonate (12 patients), 24% calcium citrate (4), and 5% unknown (1). Calcium doses used were 500 mg/day (4 patients), and 1,000 mg/day (3), and 1,200-1,400 mg/day (13). Also, 13 patients were taking vitamin D in addition to their calcium, with 8 patients taking 400 IU and the rest 200 IU. Among the patients surveyed, 8 reported taking a proton-pump inhibitor, and 6 were taking calcium carbonate, which is not absorbed well in those taking agents that increase gastric pH. All patients separated their bisphosphonate dose from other medications and meals. CONCLUSION: Patients do not recognize the need to supplement calcium at the recommended dosage of at least 1,200 mg/day or 1,500 mg/day for postmenopausal women with osteoporosis along with vitamin D 400 IU for osteoporosis treatment while on bisphosphonate therapy.