Restructuring the surgical process after regional reform in Emilia-Romagna: an action-research project at Rizzoli Orthopedic Institute.

BACKGROUND: Hospitals performing surgery in Italy underwent important transformations in recent years, with decreasing economic resources and higher expected standards of care. Regional authorities acted differently across the country to adapt to the new scenario, generating heterogeneous outcomes. The Rizzoli Orthopedic Institute (ROI) in the Emilia-Romagna region started its reorganization in 2017, after the issue of new regional regulations about surgical activity. Aim of this paper is to describe the actions taken at ROI and discuss their outcomes. STUDY DESIGN: Action-research. METHODS: From 2017 to 2019 an action-research project was developed to introduce organizational changes within ROI and close the existing gaps between regional requirements and actual features of the Institute. Four areas of intervention were identified: surgical scheduling, appropriateness of surgical setting, monitoring and management of the surgical path and accountability. Progress was monitored through the collection of performance indicators and qualitative investigation of the organizational culture. RESULTS: Changes were implemented in all areas of intervention. Key features were the introduction of Operating Room Management (ORM) skills and the establishment of multiprofessional teams to drive the changes. Performance indicators showed a positive trend in the comparison between 2017 and 2018. Improvements were observed in terms of productivity, scheduling, and respect of standard waiting time, while case-mix did not significantly change. CONCLUSIONS: Effective ORM and collaborative practices can successfully drive the change towards a more efficient surgical process without increasing resources consumption.

Clinical utility of preoperative screening with STOP-Bang questionnaire in elective surgery.

BACKGROUND: Obstructive sleep apnea (OSA) is a common disease which increases the risk of perioperative complications. The aim of this study is to assess the clinical utility of preoperative screening for OSA in determining the prevalence of patients at high risk of OSA in a surgical population, the incidence of difficult airway management and the incidence of perioperative complications. METHODS: We conducted a multisite, prospective observational study on adult patients scheduled for elective surgery. All patients completed a STOP-Bang questionnaire as a part of their preoperative evaluation. Collected data included: demographic data, type of surgery, ASA class, postoperative course, complications within 48 hours, difficult intubation (DI) and difficult mask ventilation (DMV) rates. RESULTS: A total of 3452 consecutive patients were recruited; 2997 (87%) were identified as low OSA risk patients and 455 (13%) were identified as high OSA risk patients; 113 (3%) postoperative complications, 315 (9%) cases of DMV and 375 (11%) of DI were observed. The percentage of postoperative complications in patients with HR-OSA was 9%, while the percentage of DI was 20% and the percentage of DMV was 23%. High risk for OSA and higher BMI (≥30 Kg m-2) were independently associated with risk for perioperative complications. CONCLUSION: In conclusion, this study demonstrates that the prevalence of high OSA risk patients in the surgical population is high. The increase in the rates of perioperative complications justifies the implementation of perioperative strategies that use the STOP-Bang as a tool for triage.

The effect of anticoagulant therapy for idiopathic pulmonary fibrosis in real life practice.

BACKGROUND: IPF is a common form of interstitial lung disease for which there is no effective therapy and usually results in death. Two previous contradictory studies showed anticoagulant therapy  to be associated with both improved and worsened survival, respectively. OBJECTIVE: The objective of this retrospective cohort study was to evaluate the effect of anticoagulant therapy on the survival and disease progression of patients with idiopathic pulmonary fibrosis (IPF) in real clinical practice. METHODS: We compared the clinical characteristics, time to disease progression, incidence of acute exacerbation, and survival of 25 (20%) IPF patients receiving anticoagulant therapy to the remaining 97 IPF patients not receiving anticoagulant therapy. In addition we conducted a sensitivity analysis using as comparator a group of 25 patients matched by age, sex, functional impairment, cardiac comorbidities and pulmonary hypertension. RESULTS: Patients on anticoagulant therapy had a worse 1- and 3-year survival (84% and 53% versus 89% and 64% in the non-anticoagulant group, respectively), a difference that persisted after adjusting for age and comorbidities (hazard ratio 3.1 - 95% confidence interval, 1.4 to 7.0; p=0.006) and after comparison with the matched group (adjusted HR=4.8, 95% CI: 1.8-12.8; p=0.002). IPF patients on anticoagulant therapy had a shorter interval to disease progression ( 0.7 years versus 1.6 years, adjusted HR 2.2 -95% CI, 0.96 to 5.1; p=0.063) confirmed also in the analysis with matched subgroups (HR=2.7 (95% CI: 1.2-6.5); p=0.023). The incidence of acute exacerbations did not differ in the two groups (22% versus 23%). Two patients (8%) experienced anticoagulant treatment related complications and included an episode of hemorrhagic shock. CONCLUSION: In this retrospective study patients treated with anticoagulants had a worse survival and a shorter interval to disease progression. This support the recent finding that warfarin worsen the respiratory status and survival of IPF patients.

Vaginal and cervical anatomic modifications during the oestrus cycle in relation to transcervical catheterization in the domestic cat.

In a previous study we observed that it is possible to reach the cervix in all queens with a 1 mm diameter probe only. So, we developed both a new technique and a catheter (1 mm diameter) to allow transcervical insemination [Zambelli and Castagnetti 2001]. The aims of this study were to investigate vaginal and cervical anatomic modifications during the various stages of the oestrus cycle and to test the previously described technique of transcervical catheterization during the various stages of the oestrus cycle. In experiment 1, silicon impression moulds were obtained from the reproductive tracts of 21 queens' cadavers and vaginal and cervical measures were taken. The results showed that there are some significant anatomic modifications during the various stages of the oestrus cycle in vaginal and cervical anatomy, principally related to the dorsal medial fold increase induced by the follicular phase. In experiment 2, transcervical catheterization was attempted in 95 queens at various stages of oestrus cycle both during reproductive and non-reproductive season. After catheterization, methylene blue solution was injected through the cervical catheter. Successful catheterization was assessed during surgery, when colour was observed in the uterine horns. It was possible to perform transcervical catheterization during non-reproductive season in 16 of 20 anoestrus queens and in 12 of 15 induced oestrus queens; during reproductive season in nine of 21 interoestrus queens, in eight of 13 dioestrus/pregnancy queens, in four of 18 oestrus queens and in seven of eight queens in first oestrus during lactation.