Effects of a Surgical Receipt Program on the Supply Costs of Five General Surgery Procedures.

BACKGROUND: Surgical supplies occupy a large portion of health care expenditures but is often under the surgeon's control. We sought to assess whether an automated, surgeon-directed, cost feedback system can decrease supply expenditures for five common general surgery procedures. MATERIALS AND METHODS: An automated "surgical receipt" detailing intraoperative supply costs was generated and emailed to surgeons after each case. We compared the median cost per case for 18 mo before and after implementation of the surgical receipt. We controlled for price fluctuations by applying common per-unit prices in both periods. We also compared the incision time, case length booking accuracy, length of stay, and postoperative occurrences. RESULTS: Median costs decreased significantly for open inguinal hernia ($433.45 to $385.49, P < 0.001), laparoscopic cholecystectomy ($886.77 to $816.13, P = 0.002), and thyroidectomy ($861.21 to $825.90, P = 0.034). Median costs were unchanged for laparoscopic appendectomy and increased significantly for lumpectomy ($325.67 to $420.53, P < 0.001). There was an increase in incision-to-closure minutes for open inguinal hernia (71 to 75 min, P < 0.001) and laparoscopic cholecystectomy (75 to 96 min, P < 0.001), but a decrease in thyroidectomy (79 to 73 min, P < 0.001). There was an increase in booking accuracy for laparoscopic appendectomy (38.6% to 55.0%, P = 0.001) and thyroidectomy (32.5% to 48.1%, P = 0.001). There were no differences in postoperative occurrence rates and length of stay duration. CONCLUSIONS: An automated surgeon-directed surgical receipt may be a useful tool to decrease supply costs for certain procedures. However, curtailing surgical supply costs with surgeon-directed cost feedback alone is challenging and a multimodal approach may be necessary.

Reimagine Health Care Leadership, Challenges and Opportunities in the 21st Century.

PURPOSE: This paper spotlights human capital management, digital technology, and costs control as issues that healthcare leaders will face in redesigning the health care ecosystem in the 21st century. DESIGN: The paper was designed to highlight the attributes that make effective leaders. It addresses how nursing leadership can take a lead to redesign the 21st Century health care system, supported by case examples. METHODS: An expansive literature review was done using MEDLINE, SAGE, Google Scholar, and University of California San Diego Library Catalogs. The selections criteria include recent publications in English within and outside the healthcare industry. FINDINGS: Health leadership is viewed as paramount to productivity, capacity and meeting new challenges. CONCLUSIONS: Effective nursing leadership in a healthcare organization correlates with staff job satisfaction, retention, turnover and quality of care. Nursing leadership development must be supported by appropriate level of educational preparedness, and requisite set of competencies and skills.

Globalization of Health Service: Sharing of Best Practices in Perianesthesia Nursing Care, a Case Study of Cross-Border Institutional Collaboration.

Healthcare is a global concern among all nations and nursing is a global profession as evidenced by the flow of healthcare professionals across international boundaries. With English as the language of science and commerce and post-colonial influence in domestic healthcare practice and training, many former Anglo-speaking colonial settlements become parts of an expansive market for health human resources migration. The movement of health personnel mainly flows from low and medium income countries to high income countries to sustain their health systems. The resulting brain drain adversely impacts a source country's health system, leading the World Health Organization to declare global health migration as the biggest health threat of the 21st century. This report illustrates how an overseas health network achieves its goals of developing clinical and management excellence through an international exchange program. The provider institution also fulfills its mission of contributing to a more balanced, equitable and healthier world.

Safety of stereotactic laser ablations performed as treatment for glioblastomas in a conventional magnetic resonance imaging suite.

OBJECTIVE Stereotactic laser ablation (SLA) is typically performed in the setting of intraoperative MRI or in a staged manner in which probe insertion is performed in the operating room and thermal ablation takes place in an MRI suite. METHODS The authors describe their experience, in which SLA for glioblastoma (GBM) treatment was performed entirely within a conventional MRI suite using the SmartFrame stereotactic device. RESULTS All 10 patients with GBM (2 with isocitrate dehydrogenase 1 mutation [mIDH1] and 8 with wild-type IDH1 [wtIDH1]) were followed for > 6 months. One of these patients underwent 2 independent SLAs approximately 12 months apart. Biopsies were performed prior to SLA for all patients. There were no perioperative morbidities, wound infections, or unplanned 30-day readmissions. The average time for a 3-trajectory SLA (n = 3) was 436 ± 102 minutes; for a 2-trajectory SLA (n = 4) was 321 ± 85 minutes; and for a single-trajectory SLA (n = 4) was 254 ± 28 minutes. No tumor recurrence occurred within the blue isotherm line ablation zone, although 2 patients experienced recurrence immediately adjacent to the blue isotherm ablation line. Overall survival for the patient cohort averaged 356 days, with the 2 patients who had mIDH1 GBMs exhibiting the longest survival (811 and 654 days). CONCLUSIONS Multitrajectory SLA for treatment of GBM can be safely performed using the SmartFrame stereotactic device in a conventional MRI suite.

Stereotactic laser ablation as treatment for brain metastases that recur after stereotactic radiosurgery: a multiinstitutional experience.

OBJECTIVE Therapeutic options for brain metastases (BMs) that recur after stereotactic radiosurgery (SRS) remain limited. METHODS The authors provide the collective experience of 4 institutions where treatment of BMs that recurred after SRS was performed with stereotactic laser ablation (SLA). RESULTS Twenty-six BMs (in 23 patients) that recurred after SRS were treated with SLA (2 patients each underwent 2 SLAs for separate lesions, and a third underwent 2 serial SLAs for discrete BMs). Histological findings in the BMs treated included the following: breast (n = 6); lung (n = 6); melanoma (n = 5); colon (n = 2); ovarian (n = 1); bladder (n = 1); esophageal (n = 1); and sarcoma (n = 1). With a median follow-up duration of 141 days (range 64-794 days), 9 of the SLA-treated BMs progressed despite treatment (35%). All cases of progression occurred in BMs in which < 80% ablation was achieved, whereas no disease progression was observed in BMs in which ≥ 80% ablation was achieved. Five BMs were treated with SLA, followed 1 month later by adjuvant SRS (5 Gy daily × 5 days). No disease progression was observed in these patients despite ablation efficiency of < 80%, suggesting that adjuvant hypofractionated SRS enhances the efficacy of SLA. Of the 23 SLA-treated patients, 3 suffered transient hemiparesis (13%), 1 developed hydrocephalus requiring temporary ventricular drainage (4%), and 1 patient who underwent SLA of a 28.9-cm3 lesion suffered a neurological deficit requiring an emergency hemicraniectomy (4%). Although there is significant heterogeneity in corticosteroid treatment post-SLA, most patients underwent a 2-week taper. CONCLUSIONS Stereotactic laser ablation is an effective treatment option for BMs in which SRS fails. Ablation of ≥ 80% of BMs is associated with decreased risk of disease progression. The efficacy of SLA in this setting may be augmented by adjuvant hypofractionated SRS.

Real-time Magnetic Resonance Imaging-Guided Biopsy Using SmartFrame® Stereotaxis in the Setting of a Conventional Diagnostic Magnetic Resonance Imaging Suite.

BACKGROUND: Real-time magnetic resonance imaging (MRI) visualization during stereotactic needle biopsies affords several valuable benefits to the neurosurgeon, including the opportunity to visually confirm the biopsy site at the time of surgery. Until now, reported experiences with this technique have been limited to the setting of intraoperative MRI or dedicated procedural MRI suites with modified ventilation systems. OBJECTIVE: To describe our experience with 11 consecutive patients who underwent real-time MRI-guided biopsy performed using SmartFrame® stereotaxis (MRI Interventions, Irvine, California) in the setting of a conventional diagnostic MRI suite. METHODS: This is a case series of patients that underwent real-time MRI-guided biopsy at a single institution. RESULTS: Four of the 11 lesions were previously biopsied by experienced neurosurgeons, yielding tissues that were nondiagnostic. Six of these lesions were sub-cubic centimeter in volume. One lesion was associated with aberrant venous anatomy. Two patients underwent laser thermal ablation in the same setting. There were no perioperative complications or unplanned 30-day readmission. All patients were discharged on postoperative day 1 to home. The operative time for the biopsy averaged 165 ± 24 min. Illustrative examples are reviewed. CONCLUSION: Real-time MRI-guided needle biopsy can be safely performed in the setting of a conventional diagnostic MRI suite. This technique provides neurosurgeons with the opportunity to visualize and confirm the biopsy site and allows for real-time adjustments in surgical maneuvers.