Perioperative Process Mapping to Identify Inefficiencies at a Tertiary Hospital in Malawi.

INTRODUCTION: Same-day surgical case cancellation consumes resources, disrupts patient care, and has a global prevalence of 18%. A retrospective analysis found that 44% of scheduled elective surgeries were canceled at a public tertiary hospital in Lilongwe, Malawi. To better characterize these cancellations, this study defines a process map for surgical case completion and investigates hospital staff and patient perspectives on contributing factors and burdens of cancellation. METHODS: We conducted participatory process mapping and in-depth interviews with hospital staff (n = 23) and patients (n = 10) to detail perioperative processes and perspectives on cancellations. We used purposive sampling to recruit staff by hospital role and patients whose surgery had been canceled. Interviews were audio-recorded, translated, and transcribed for process mapping accuracy and thematic analysis using the constant comparative method and NVivo software. RESULTS: Staff delineated specific steps of the perioperative process, generating a process map that identifies inefficiencies and opportunities for intervention. Hospital staff described unavoidable causes of case cancellation, such as unreliable water supply and material shortages. Modifiable causes linked to wasted time and resources were also evident, such as chronic tardiness, communication barriers, and inadequate preoperative assessment. Thematic analysis of perceived impacts of cancellation revealed compromised provider-patient relationships, communication breakdown, and emotional distress. Staff and patients expressed frustration, embarrassment, fear, and demoralization when planned surgeries were canceled. CONCLUSIONS: We demonstrate the use of process mapping as a tool to identify implementation targets for reducing case cancellation rates. Hospital systems can adapt this approach to address surgical case cancellation in their specific setting.

Acute pain pathways: protocol for a prospective cohort study.

INTRODUCTION: Opioid analgesics are often used to treat moderate-to-severe acute non-cancer pain; however, there is little high-quality evidence to guide clinician prescribing. An essential element to developing evidence-based guidelines is a better understanding of pain management and pain control among individuals experiencing acute pain for various common diagnoses. METHODS AND ANALYSIS: This multicentre prospective observational study will recruit 1550 opioid-naïve participants with acute pain seen in diverse clinical settings including primary/urgent care, emergency departments and dental clinics. Participants will be followed for 6 months with the aid of a patient-centred health data aggregating platform that consolidates data from study questionnaires, electronic health record data on healthcare services received, prescription fill data from pharmacies, and activity and sleep data from a Fitbit activity tracker. Participants will be enrolled to represent diverse races and ethnicities and pain conditions, as well as geographical diversity. Data analysis will focus on assessing patients' patterns of pain and opioid analgesic use, along with other pain treatments; associations between patient and condition characteristics and patient-centred outcomes including resolution of pain, satisfaction with care and long-term use of opioid analgesics; and descriptive analyses of patient management of leftover opioids. ETHICS AND DISSEMINATION: This study has received approval from IRBs at each site. Results will be made available to participants, funders, the research community and the public. TRIAL REGISTRATION NUMBER: NCT04509115.

Acute airway compromise from a hemorrhagic posterior cervical-mediastinal mass: Rare presentation of a parathyroid adenoma.

Massive hemorrhage secondary to rupture of a parathyroid adenoma is exceedingly rare. We present the case of a hemorrhagic parathyroid adenoma resulting in airway compromise treated with surgical decompression.

Improving transition from pediatric to adult cystic fibrosis care: lessons from a national survey of current practices.

OBJECTIVES: More than 500,000 adolescents with special health care needs age into adulthood each year in the United States, and there is growing recognition of the need for support of their transition to adult-oriented health care. Because of improved survival, cystic fibrosis has experienced this increasing transition need, and cystic fibrosis policy leaders responded by mandating the transition of adults with cystic fibrosis to adult-focused cystic fibrosis care programs by 2000. The primary objective of this study was to characterize in detail recent transition practices at US cystic fibrosis programs, to identify areas for improvement and to serve as a model for other diseases. A secondary objective of this study was to develop and validate a survey for formal assessment of transition practices. METHODS: A 105-question survey on key aspects of transition was administered to cystic fibrosis care team members from all 195 US Cystic Fibrosis Care programs. Rates of adherence to recommended components of transition care were measured. RESULTS: A total of 448 surveys were obtained from 170 (87%) of 195 cystic fibrosis programs. Although transfer of care occurs at a median age of 19 years, initial discussion of transition does not occur until a median age of 17 years, limiting time to foster self-care skills. Only half of programs consistently perform a transition readiness assessment, 28% of centers offer visits focused on transition, and <10% have a written list of desirable self-management skills. CONCLUSIONS: There is significant variability in transition support provided to young adults with cystic fibrosis, but there are simple steps that may lead to more consistent delivery of transition services. Methods of assessment and lessons learned from transitioning young adults at US cystic fibrosis programs may serve to improve transition for individuals with other childhood diseases.