Turnover Time Between Elective Operative Cases: Does the Witching Hour Exist for the Operating Room?

BACKGROUND: Efficient resource management in the operating room (OR) contributes significantly to healthcare expenditure and revenue generation for health systems. We aim to assess the influence that surgeon, anesthesiology, and nursing team assignments and time of day have on turnover time (TOT) in the OR. METHODS: We performed a retrospective review of elective cases at a single academic hospital that were completed between Monday and Friday between the hours of 0700 and 2359 from July 1, 2017, through March 31, 2018. Emergent cases and unplanned, add-on cases were excluded. Data regarding patient characteristics, OR teams, TOT, and procedure start and end times were collected and analyzed. RESULTS: A total of 2174 total cases across 13 different specialties were included in our study. A multivariate regression of relevant variables affecting TOT was performed. Consecutive specialty (p < 0.0001), consecutive surgeon (p < 0.0001), anesthesiologist (p < 0.0001), and prior case ending before 1400 (p < 0.0001) were independent predictors of lower TOT. A receiver operating characteristic analysis demonstrated an area under the curve of 0.848 and a cutoff of 1400 having the highest sensitivity and specificity for TOT difference. CONCLUSIONS: TOT can be significantly affected by the time of the day the procedure is performed. Staffing availability during late procedures and the differences in how OR team staff are scheduled may affect OR efficiency. Additional studies may be needed to determine the long-term implications of changes implemented to decrease organizational operational costs related to the OR.

Consecutive Surgeon and Anesthesia Team Improve Turnover Time in the Operating Room.

Efficient management of the operating room (OR) contributes to much of today's healthcare expenditure and plays a critical role in generating revenue for most healthcare systems. Scheduling of OR cases with the same team and surgeon have been reported to improve turnover time between cases which in turn, improves efficiency and resource utilization. We aim to assess different operating room procedures within multiple subspecialties and explore the factors that positively and negatively influence turnover time (TOT) in the operating room. We conducted a retrospective review of cases that were completed on weekdays between 0600 and 2359 from July 2017 through March 2018. Cases between 0000 and 0559 were excluded from this study. Of the total 2,714 cases included in our study, transplant surgery had the highest mean TOT (71 ± 48 min) with orthopedic surgery cases without robots having the lowest mean TOT. OR cases in rooms with the same specialty had significantly less mean TOT compared to rooms switching between different subspecialties (70 vs. 117 min; p < 0.0001). Similarly, cases with the same surgeon and anesthesia team had a significant lower TOT (p < 0.0001). Consecutive specialty, surgeon, anesthesiologist, and prior procedure ending before 15:00 were all independent predictors of lower TOT (p < 0.0001). Our study shows scheduling cases with the same OR team for elective cases can decrease TOT and potentially increase operating room efficiency during the day. Further studies may be needed to assess the long-term effects of such variables affecting OR TOT on healthcare expenditure.

Teaching poster design to enhance research presentation quality at academic conferences: a guide for educators.

Poster sessions are one of the most common platforms for presenting research at academic conferences, yet posters are often inefficient at transferring knowledge to their readers due to suboptimal design and content selection. Physician trainees may not receive education on constructing posters as a traditional part of their residency curriculum. The purpose of this work is to propose a curriculum that will provide residents foundational knowledge and skills needed for designing high-quality research posters. The curriculum uses the flipped classroom model, a pedagogical approach that reverses the traditional learning environment by delivering instructional content outside of the classroom and moves activities into the classroom. Preparatory work includes watching an educational video on 'how to create a better research poster in less time' and preparing a poster to be presented at an upcoming conference. An 1-hour workshop is conducted during protected resident didactic time. It incorporates a 10-min slide show presentation on poster design and 50 min of active learning. During the active learning component, learners are asked to 'think-pair-share' to construct a research poster rubric using the information they just learnt. The learners work as a group to evaluate sample research posters. The class is then broken down into small groups of 2-3 learners to spend time working on their own posters and provide peer feedback. Following the workshop, residents continue to develop their research posters for conference presentation. This curriculum has the potential to enhance the quality of resident research posters presented at academic conferences, advance research education and ultimately improve dissemination of research within academic communities. The lesson plan outlined in this work can be used as a guide for teaching poster design to physician trainees in a number of specialties and may encourage programmes to consider integrating poster design as a formal part of the residency curriculum.

Abnormal neurological pupil index is associated with malignant cerebral edema after mechanical thrombectomy in large vessel occlusion patients.

BACKGROUND AND OBJECTIVES: Malignant cerebral edema (MCE) is a feared complication in patients suffering from large vessel occlusion. Variables associated with the development of MCE have not been clearly elucidated. Use of pupillometry and the neurological pupil index (NPi) as an objective measure in patients undergoing mechanical thrombectomy (MT) has not been explored. We aim to evaluate variables significantly associated with MCE in patients that undergo MT and hypothesize that abnormal NPi is associated with MCE in this population. METHODS: A retrospective analysis of patients with acute ischemic stroke who had undergone MT at our institution between 2017 and 2020 was performed. Baseline and outcome variables were collected, including NPi values from pupillometry readings of patients within 72 h after the MT. Patients were divided into two groups: MCE versus non-MCE group. A univariate and multivariate analysis was performed. RESULTS: Of 284 acute ischemic stroke patients, 64 (22.5%) developed MCE. Mean admission glucose (137 vs. 173; p < 0.0001), NIHSS on admission (17 vs. 24; p < 0.01), infarct core volume (27.9 vs. 17.9 mL; p = 0.0036), TICI score (p = 0.001), and number of passes (2.9 vs. 1.8; p < 0.0001) were significantly different between the groups. Pupillometry data was present for 64 patients (22.5%). Upon multivariate analysis, abnormal ipsilateral NPi (OR 21.80 95% CI 3.32-286.4; p = 0.007) and hemorrhagic conversion were independently associated with MCE. CONCLUSION: Abnormal NPi and hemorrhagic conversion are significantly associated with MCE in patients following MT. Further investigation is warranted to better define an association between NPi and patient outcomes in this patient population.

Treadmill exercise testing improves diagnostic accuracy in children with concealed congenital long QT syndrome.

BACKGROUND: Resting electrocardiogram (ECG) identification of long QT syndrome (LQTS) has limitations. Uncertainty exists on how to classify patients with borderline prolonged QT intervals. We tested if exercise testing could help serve to guide which children with borderline prolonged QT intervals may be gene positive for LQTS. METHODS: Pediatric patients (n = 139) were divided into three groups: Controls (n = 76), gene positive LQTS with borderline QTc (n = 21), and gene negative patients with borderline QTc (n = 42). Borderline QTc was defined between 440-470 (male) and 440-480 (female) ms. ECGs were recorded supine, sitting, and standing. Patients then underwent treadmill stress testing with Bruce protocol followed by a 9-minute recovery phase. RESULTS: Supine resting QTc, age, and Schwartz score for the three groups were: (a) gene positive: 446 ± 23 ms, 12.4 ± 3.4 years old, 3.2 ± 1.8; (b) gene negative: 445 ± 20 ms, 12.1 ± 2 years old, 2.0 ± 1.2; and (c) control: 400 ± 24 ms, 15.0 ± 3 years old. The three groups could be differentiated by their QTc response at two time points: standing and recovery phase at 6 minutes. Standing QTc ≥460 ms differentiated borderline prolonged QTc patients (gene positive and gene negative) from controls. Late recovery QTc ≥480 ms distinguished gene positive from gene negative patients. CONCLUSION: Exercise stress testing can be useful to identify children who are gene positive borderline LQTS from a normal population and gene negative borderline QTc children, allowing for selective gene testing in a higher risk group of patients with borderline QTc intervals and intermediate Schwartz scores.

Outcomes of Surgical Evacuation of Chronic Subdural Hematoma in the Aged: Institutional Experience and Systematic Review.

BACKGROUND: Surgical intervention for chronic subdural hematoma (cSDH) in the elderly population remains a clinical challenge given that associated morbidity and outcomes do not always equate radiographic success with clinical success. Our objective was to compare outcome measures of 2 age groups of patients undergoing surgical intervention for cSDH evacuation and to perform a systematic review of the literature related to this topic. METHODS: A retrospective analysis of adult patients undergoing surgical evacuation of cSDH at our institution was performed. Primary outcome measures of modified Rankin Scale (mRS) score at discharge and 3 months were assessed. In addition, a systematic search was performed to collect all relevant studies addressing outcomes after surgical intervention in aged patients with cSDH. RESULTS: There were 72 patients in the younger cohort (<70 years) and 113 patients in the aged cohort (≥70 years). Multivariate analysis showed significant association between age and higher mRS score at discharge and 3 months follow-up. There were also significant differences in length of stay and disposition between the 2 groups. Twenty-one studies were reviewed, and 11 studies were included in a meta-analysis of recurrence rates between studied age groups. CONCLUSIONS: The aged cohort had worse outcomes than the younger cohort as determined by mRS score at discharge and 3 months. A systematic review of outcomes is provided with limited meta-analysis because of the heterogenous nature of outcome reporting and the observational design of previous studies. Further studies with standardized reporting and long-term follow-up are warranted to further study outcomes in this increasing population.

Small area estimation of under-5 mortality in Bangladesh, Cameroon, Chad, Mozambique, Uganda, and Zambia using spatially misaligned data.

BACKGROUND: The under-5 mortality rate (U5MR) is an important metric of child health and survival. Country-level estimates of U5MR are readily available, but efforts to estimate U5MR subnationally have been limited, in part, due to spatial misalignment of available data sources (e.g., use of different administrative levels, or as a result of historical boundary changes). METHODS: We analyzed all available complete and summary birth history data in surveys and censuses in six countries (Bangladesh, Cameroon, Chad, Mozambique, Uganda, and Zambia) at the finest geographic level available in each data source. We then developed small area estimation models capable of incorporating spatially misaligned data. These small area estimation models were applied to the birth history data in order to estimate trends in U5MR from 1980 to 2015 at the second administrative level in Cameroon, Chad, Mozambique, Uganda, and Zambia and at the third administrative level in Bangladesh. RESULTS: We found substantial variation in U5MR in all six countries: there was more than a two-fold difference in U5MR between the area with the highest rate and the area with the lowest rate in every country. All areas in all countries experienced declines in U5MR between 1980 and 2015, but the degree varied both within and between countries. In Cameroon, Chad, Mozambique, and Zambia we found areas with U5MRs in 2015 that were higher than in other parts of the same country in 1980. Comparing subnational U5MR to country-level targets for the Millennium Development Goals (MDG), we find that 12.8% of areas in Bangladesh did not meet the country-level target, although the country as whole did. A minority of areas in Chad, Mozambique, Uganda, and Zambia met the country-level MDG targets while these countries as a whole did not. CONCLUSIONS: Subnational estimates of U5MR reveal significant within-country variation. These estimates could be used for identifying high-need areas and positive deviants, tracking trends in geographic inequalities, and evaluating progress towards international development targets such as the Sustainable Development Goals.