RESUMO
BACKGROUND: Efficient Emergency Department (ED) throughput depends on several factors, including collaboration and consultation with surgical services. The acute care surgery service (ACS) collaborated with ED to implement a new process termed "FASTPASS" (FP), which might improve patient-care for those with acute appendicitis and gallbladder disease. The aim of this study was to evaluate the 1-year outcome of FP. METHODS: FASTPASS is a joint collaboration between ACS and ED. ED physicians were provided with a simple check-list for diagnosing young males (<50-year old) with acute appendicitis (AA) and young males or females (<50-year old) with gallbladder disease (GBD). Once ED deemed patients fit our FP check-list, patients were directly admitted (FASTPASSed) to the observation unit. The ACS then came to evaluate the patients for possible surgical intervention. We performed outcome analysis before and after the institution of the FP. Outcomes of interest were ED length of stay (LOS), time from ED to the operating room (OR) (door-to-knife), hospital LOS (HLOS), and cost. RESULTS: During our 1-year study period, for those patients who underwent GBD/AA surgery, 56 (26%) GBD and 27 (26%) AA patients met FP criteria. Compared to the non-FP patients during FP period, FP halved ED LOS for GBD (7.4 ± 3.0 versus 3.5 ± 1.7 h, P < 0.001) and AA (6.7 ± 3.3 versus. 1.8 ± 1.6 h, P < 0.001). Similar outcome benefits were observed for door-to-knife time, HLOS, and costs. CONCLUSIONS: In this study, the FP process improved ED throughput in a single, highly-trained ER leading to an overall improved patient care process. A future study involving multiple EDs and different disease processes may help decrease ED overcrowding and improve healthcare system efficiency.
Assuntos
Apendicectomia , Apendicite/cirurgia , Colecistectomia , Serviço Hospitalar de Emergência/organização & administração , Doenças da Vesícula Biliar/cirurgia , Melhoria de Qualidade/organização & administração , Centro Cirúrgico Hospitalar/organização & administração , Doença Aguda , Adolescente , Adulto , Apendicectomia/economia , Apendicectomia/normas , Apendicectomia/estatística & dados numéricos , Apendicite/diagnóstico , Apendicite/economia , Lista de Checagem/métodos , Lista de Checagem/normas , Colecistectomia/economia , Colecistectomia/normas , Colecistectomia/estatística & dados numéricos , Regras de Decisão Clínica , Comportamento Cooperativo , Eficiência Organizacional/economia , Eficiência Organizacional/normas , Serviço Hospitalar de Emergência/economia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Doenças da Vesícula Biliar/diagnóstico , Doenças da Vesícula Biliar/economia , Custos Hospitalares/estatística & dados numéricos , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Avaliação de Processos e Resultados em Cuidados de Saúde , Avaliação de Programas e Projetos de Saúde , Melhoria de Qualidade/economia , Melhoria de Qualidade/estatística & dados numéricos , Estudos Retrospectivos , Centro Cirúrgico Hospitalar/economia , Centro Cirúrgico Hospitalar/estatística & dados numéricos , Fatores de Tempo , Tempo para o Tratamento , Triagem/economia , Triagem/métodos , Triagem/organização & administração , Adulto JovemRESUMO
OBJECTIVE: To improve treatment outcomes in patients with acute appendicitis (AA). MATERIAL AND METHODS: An internet survey was performed. Questionnaire consisted of 15 questions concerning diagnosis and treatment of AA: application of prognostic scales, incidence and technical aspects of laparoscopic appendectomy (LA), antibiotic prophylaxis, postoperative management, compliance with international and national clinical guidelines. A total of 690 questionnaires were received and analyzed (3.67% of all surgeons in the Russian Federation). RESULTS: Eighteen percent of respondents use at least one prognostic scale. The vast majority of surgeons (92%) use antibiotic prophylaxis. Almost half of respondents place trocars in the triangulation position (44%), one third of surgeons ligate the mesentery of the appendix (35%), most respondents perform mesoappendectomy (60%) with monopolar and bipolar cautery. Forty-five percent of all respondents do not invert the appendix stump. Significant number of respondents use abdominal drainage routinely. Only 3.5% of surgeons use multimodal postoperative analgesia. Less than 22% of patients are operated under low-pressure pneumoperitoneum. Standardization of surgical technique and perioperative approaches including those specified in the guidelines is absent. We also found insufficient awareness of surgeons about international and national clinical guidelines. CONCLUSION: This study may be useful for standardizing treatment approaches, choosing the best practice, popularizing and improving of current clinical guidelines.
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Apendicectomia/métodos , Apendicite/diagnóstico , Apendicite/cirurgia , Antibacterianos/administração & dosagem , Antibioticoprofilaxia , Apendicectomia/normas , Apendicite/terapia , Apêndice/cirurgia , Fidelidade a Diretrizes , Pesquisas sobre Atenção à Saúde , Humanos , Internet , Laparoscopia , Assistência Perioperatória , Guias de Prática Clínica como Assunto , Federação RussaRESUMO
BACKGROUND: Optimal treatment of children who develop appendicitis while undergoing treatment for an oncologic diagnosis has not been defined, in part due to theoretical concerns for an increased risk of postoperative wound complications. We hypothesized that synchronous oncologic diagnosis conferred no increased odds of developing a wound complication in pediatric patients undergoing appendectomy. METHODS: Retrospective cohort study using the National Surgical Quality Improvement Program, Pediatric (2012-2017) of patients < 18 years of age undergoing appendectomy. The main exposure variable was active treatment for an oncologic diagnosis. The primary outcomes of interest were 30-day wound complications (superficial or deep infections or dehiscence, and abscess). For univariate analysis comparison of baseline differences between patients with/without a cancer diagnosis we employed Pearson's χ2 and two sample t tests. Multivariate logistic regression was used to evaluate which covariates were independently associated with our outcome. RESULTS: We identified 28,219 patients who had undergone appendectomy; 95 (0.3%) were undergoing oncologic treatment at the time of surgery. Patients in the cancer group were more likely to be receiving steroids, have lower white blood cell counts and have higher American Society of Anesthesiology classes as compared to the noncancer patients. Age, gender, rates of perforation, and laparoscopy were similar between the two groups. Patients with an active cancer diagnosis suffered wound complications (measured individually and as an aggregate) at no higher odds than those without a cancer diagnosis. CONCLUSION: Pediatric patients undergoing treatment for cancer do not have increased odds of suffering postoperative wound complications following appendectomy as compared to the general population.
Assuntos
Apendicectomia/normas , Apendicite/cirurgia , Laparoscopia/métodos , Neoplasias/complicações , Complicações Pós-Operatórias/epidemiologia , Melhoria de Qualidade , Adolescente , Apendicite/complicações , Criança , Feminino , Seguimentos , Humanos , Incidência , Masculino , Neoplasias/diagnóstico , Estudos Retrospectivos , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Laparoscopic appendectomy (LA) has been popular for decades because of shorter hospitalization and return to routine activity. However, complications (e.g., surgical site infection [SSI] and intra-abdominal abscess [IAA]) relative to open appendectomy (OA) are still debated. We therefore conducted an umbrella review to systematically appraise meta-analyses (MAs) comparing SSI and IAA between LA and OA. METHODS: Meta-analyses that included only randomized controlled trials were identified from MEDLINE and Scopus databases from inception until July 2018. Their findings were described, the number of overlapping studies was assessed using corrected covered area, and excess significant tests were also assessed. Finally, effect sizes of SSI and IAA were repooled. RESULTS: Ten MAs were eligible; SSI was reported in all MAs and IAA in 8 MAs. Surgical site infection rate was 48% to 70% lower in LA than OA, but conversely, IAA rate was 1.34 to 2.20 higher in LA than OA. Overlapping included studies for SSI and IAA were 61% and 54%, respectively, indicating that less information was added across MAs. However, there was no evidence of bias from excess significant tests when pooling SSI or IAA estimates. The risk ratios (95% confidence interval) comparing LA versus OA were repooled in adults and children yielding risk ratios of 0.56 (0.47-0.67) and 0.40 (0.25-0.65) for SSI, and 1.20 (0.88-1.63) and 1.05 (0.61-1.80) for IAA. CONCLUSION: Evidence from this umbrella review indicates that LA carries a significantly lower risk of SSI but likely a higher risk of IAA than OA. LEVEL OF EVIDENCE: Systematic review/meta-analysis, level I.
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Apendicectomia/métodos , Apendicite/cirurgia , Laparoscopia/métodos , Complicações Pós-Operatórias/epidemiologia , Abscesso Abdominal/etiologia , Apendicectomia/efeitos adversos , Apendicectomia/normas , Hospitalização , Humanos , Laparoscopia/efeitos adversos , Metanálise como Assunto , Ensaios Clínicos Controlados Aleatórios como Assunto , Fatores de Risco , Infecção da Ferida Cirúrgica/etiologia , Revisões Sistemáticas como AssuntoAssuntos
Apendicectomia/normas , Apendicite/cirurgia , Betacoronavirus , Infecções por Coronavirus/complicações , Gerenciamento Clínico , Transmissão de Doença Infecciosa/prevenção & controle , Pandemias , Pneumonia Viral/complicações , Apendicite/complicações , Apendicite/epidemiologia , COVID-19 , Infecções por Coronavirus/epidemiologia , Humanos , Incidência , Pneumonia Viral/epidemiologia , SARS-CoV-2 , Reino Unido/epidemiologiaRESUMO
AIM: Determine the effect of an intervention to reduce the length of stay (LOS) in appendectomies. METHODS: A four-quarter quality improvement initiative was developed after approval by the facility Quality Management Department, including educational sessions about the best practices regarding the hospital care for patients with appendicitis and recommendations to limit the LOS for no complicated appendicitis unless associated conditions were present, monitoring of the LOS and feedback to the staff and leaders. RESULTS: 692 appendectomies were performed, 365 (52.7%)) of them during the intervention. The mean LOS was 3.94 days with a decreasing trend during the study period. The complicated appendicitis had a mean LOS of 6.42 days (SD, 3.85) during the baseline and 5.27 days (SD 2.50) during the intervention (p=0.03), representing a 17.9% reduction. The not complicated appendicitis during baseline had LOS of 3.82 days (SD 4.17) with a subsequent reduction to 2.95 days (SD 1.53) in the intervention. The total saving bed days during the intervention were 338.04 days, which 254.04 days (75.2%) were in non complicated appendectomies. One patient required readmission during the intervention because of an organ space surgical site infection, with proper recovery after antibiotic treatment. CONCLUSION: Our study provides evidence about the possibility to optimize the bed use with a simple educational intervention, and should be considered a step to achieve additional reductions in the hospital stay of patients who undergo laparoscopic appendectomies.
Assuntos
Apendicectomia/normas , Apendicite/cirurgia , Ocupação de Leitos/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Melhoria de Qualidade , Adulto , Apendicectomia/efeitos adversos , Apendicectomia/estatística & dados numéricos , Apendicite/complicações , Feminino , Humanos , Laparoscopia/estatística & dados numéricos , Tempo de Internação/tendências , Masculino , Fatores de TempoRESUMO
BACKGROUND: Health systems must identify preventable adverse outcomes to improve surgical safety. We conducted a systematic review to determine national rates of postoperative complications associated with two common pediatric surgery operations in High-Income Countries (HICs). METHODS: National database studies of complication rates associated with pediatric appendectomies and cholecystectomies (2000-2016) in Canada, the US, and the UK were included. Outcomes included mortality, length of hospital stay (LOS), and other surgical complications. Outcome data were extracted and comparisons made between countries and databases. RESULTS: Thirty-three papers met inclusion criteria (1 Canadian, 1 UK, and 4 US Databases). Mean LOS was 3.00 (±1.42) days and 3.44 (±1.55) days for appendectomy and cholecystectomy, respectively. Mortality was 0.06% after appendectomy and 0.24% after cholecystectomy. Readmission and reoperation rates were 6.79% and 0.32% for appendectomy, and 1.37% and 0.71% for cholecystectomy. For appendectomies, LOS was shorter in Canadian and UK studies compared to US studies, and mortality and readmission rates were lower (OR 0.46 95%CI 0.23 to 0.93, OR 3.63 to 3.77 95%CI) in UK studies compared to US studies. CONCLUSIONS: Outcomes after pediatric appendectomy and cholecystectomy are good but vary between HICs. Understanding national outcomes and intercountry differences is essential in developing health system approaches to pediatric surgical safety. LEVEL OF EVIDENCE: II.
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Apendicectomia/normas , Benchmarking , Colecistectomia/normas , Países Desenvolvidos , Complicações Pós-Operatórias , Apendicectomia/efeitos adversos , Apendicectomia/mortalidade , Canadá/epidemiologia , Colecistectomia/efeitos adversos , Colecistectomia/mortalidade , Bases de Dados Factuais , Humanos , Tempo de Internação/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/prevenção & controle , Reoperação/estatística & dados numéricos , Reino Unido/epidemiologia , Estados Unidos/epidemiologiaRESUMO
INTRODUCTION: World Health Organization recommends that basic surgical care be administered at the district level. In the absence of qualified surgeons, general practitioners are sometimes proposed to bridge the gap. Medical curricula in low- and middle-income countries must be designed accordingly. The aim of this study was to assess the achievements of training of undergraduate medical students in Cameroon towards meeting this objective. METHODS: A descriptive cross-sectional study was carried out in the four state-owned medical schools in Cameroon. All students who had completed all clinical rotations were assessed with a self-administered questionnaire for their exposure and self-perceived comfort in conducting some selected basic surgical skills and procedures. RESULTS: A total of 304 (87.6%) students returned filled questionnaires. Their self-perceived comfort in surgical skills ranged from 25% (manual node tying) to 86% (surgical scrubbing). Adequate exposure to selected surgical procedures was 87% for repair of perineal tear complicating vaginal delivery, above 80% for caesarean section and incision and drainage of abscess, 73% for cast immobilization of extremity fracture and just above 50% for hernia repair and appendectomy. It was as low as 3% for bowel resection and anastomosis. The choice to perform extra-curricular activity for skills improvement was significantly associated with adequate exposure (p < 0.05). CONCLUSION: Overall, the mastery of practical surgical skills and basic surgical interventions by final-year medical students in Cameroon is insufficient. There is need to reinforce the training and assessment by creating the conditions for an appropriate exposure of medical students during surgical rotations.
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Competência Clínica , Educação de Graduação em Medicina/normas , Estudantes de Medicina/estatística & dados numéricos , Procedimentos Cirúrgicos Operatórios/educação , Adulto , Apendicectomia/educação , Apendicectomia/normas , Camarões , Cesárea/educação , Cesárea/normas , Estudos Transversais , Currículo , Educação de Graduação em Medicina/estatística & dados numéricos , Feminino , Clínicos Gerais/educação , Clínicos Gerais/normas , Humanos , Masculino , Gravidez , Faculdades de Medicina/normas , Procedimentos Cirúrgicos Operatórios/normas , Inquéritos e Questionários , Adulto JovemRESUMO
BACKGROUND: In an era of competency-based education and concern about graduating resident readiness for practice, early resident autonomy and the ability to safely teach junior residents is becoming increasingly important. In this study, we aimed to understand the effect of "teaching resident" (2 residents operating under the supervision of an attending physician) appendectomy cases on outcomes. STUDY DESIGN: We performed a single-center retrospective review of 928 patients who underwent appendectomy within the University of Wisconsin hospital system, from October 2014 to December 2017. We examined how 2 residents (compared with 1 resident with an attending) attempting a case affected operation time, surgical site infection (SSI) rate, conversion to open rate, postoperative CT scanning, and readmission rate, while controlling for sex, age, American Society of Anesthesiologists (ASA) class, BMI, previous lower abdominal surgery, acuity, perforation, and presence of a junior attending. RESULTS: We identified 597 1-resident cases and 331 2-resident or "teaching resident" cases. We performed multiple logistic regression to assess teaching resident cases as a predictor of postoperative outcomes. There were no significant differences in postoperative surgical site infection (superficial or organ space) odds ratio (OR) = 0.83 (95% CI, 0.47, 1.45); p = 0.51, conversion to open OR = 1.10 (95% CI, 0.46, 2.60); p = 0.84, postoperative CT scanning OR = 0.82 (95% CI, 0.48, 1.35); p = 0.42, or readmission within 30 days OR = 0.76 (95% CI, 0.40, 1.44); p = 0.40. However, teaching resident operative times were more likely to be classified as prolonged OR = 1.44 (95% CI, 1.03, 2.01); p = 0.03. CONCLUSIONS: Senior surgical trainees can safely supervise more junior trainees performing appendectomy procedures, and training programs should encourage faculty to allow residents to not only manage operative appendicitis as independently as possible, but to supervise junior residents in the intraoperative management of appendicitis.
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Apendicectomia/normas , Apendicite/cirurgia , Competência Clínica , Educação de Pós-Graduação em Medicina/normas , Internato e Residência , Idoso , Apendicectomia/educação , Feminino , Humanos , Masculino , Duração da Cirurgia , Estudos RetrospectivosRESUMO
INTRODUCTION: Prompt appendectomy has long been the standard of care for acute appendicitis in order to prevent complications such as perforation, abscess formation, and diffuse purulent or fecal peritonitis, all resulting in increased morbidity and even mortality. Our study was designed to examine whether the time from the beginning of symptoms to operation correlates with the pathological degree of appendicitis, incidence of postoperative complications, or increased length of hospital stay. METHODS: A prospective study of 171 patients who underwent emergent appendectomy for acute appendicitis in the course of 2 years was conducted in a single tertiary medical center. The following parameters were monitored and correlated: demographics, time from the onset of symptoms until the arrival to the emergency department (patient interval (PI)), time from arrival to the emergency department (ED) until appendectomy (hospital interval (HI)), time from the onset of symptoms until appendectomy (total interval (TI)), physical examination, preoperative physical findings, laboratory data, pathologic findings, complications, and length of hospital stay. RESULTS: The degree of pathology and complications were analyzed according to the time intervals. The time elapsed from the onset of symptoms to surgery was associated with higher pathology grade (p = 0.01). We found that longer time from the onset of symptoms to hospital arrival correlates with higher pathology grade (p = 0.04), while there was no correlation between the hospital interval and pathology grade (p = 0.68). A significant correlation was found between the pathology grade and the incidence of postoperative complications as well as with increased length of hospital stay (p = 0.000). CONCLUSION: Time elapsed from the symptom onset to appendectomy correlates with increased pathology grade and complication rate. This correlation was not related to the HI. Since the HI in our study was short, we recommend an early appendectomy in adults in order to shorten the TI and the resulting complications.
Assuntos
Apendicectomia/normas , Apendicite/diagnóstico , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Apendicectomia/métodos , Apendicite/epidemiologia , Apendicite/cirurgia , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Peritonite/etiologia , Peritonite/prevenção & controle , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Estudos Prospectivos , Estudos Retrospectivos , Atenção Terciária à Saúde/métodos , Atenção Terciária à Saúde/normas , Fatores de TempoRESUMO
BACKGROUND: The evolving demands of our current health care system for enhanced efficiency and safety while decreasing hospital length of stay has led to our institutional protocol for same-day discharge (SDD) after laparoscopic appendectomy. We have previously demonstrated a 28% rate of SDD in children with nonperforated appendicitis. The purpose of our study is to assess the effectiveness of a mature protocol for SDD by evaluating discharge success, duration of hospital stay, and readmission rates. MATERIALS AND METHODS: A retrospective review of prospectively collected data was conducted. All children undergoing a laparoscopic appendectomy for nonperforated appendicitis at Children's Mercy Hospital between December 2015 and July 2017 were included. Patients were classified according to whether they were discharged home the same day as their operation or had an overnight stay. Demographic data, time of day the procedure was completed, postoperative length of stay, and readmission rates were abstracted from patient medical records. Comparative analysis was performed in STATA using chi-squared or Fisher exact tests for categorical variables and t-test or Wilcoxon rank sum test for continuous variables. RESULTS: A total of 569 children were included, with 87% (n = 495) discharged home the same day as their appendectomy. Of the patients discharged home the same day of surgery, their median length of postoperative stay was 4 h (IQR: 3, 5) compared with 19 h for the patients who stayed overnight (IQR: 15, 25, P < 0.0001). Approximately two-thirds of patients who had their appendectomies after 6 PM stayed overnight. In addition, patients discharged home the same day had similar hospital readmission rates compared with patients who stayed overnight (2% vs. 4%, P = 0.155). CONCLUSIONS: After laparoscopic appendectomy in children with nonperforated appendicitis, SDD not only reduces postoperative length of stay but also is not associated with higher hospital readmission rates.
Assuntos
Apendicectomia/normas , Apendicite/cirurgia , Procedimentos Clínicos , Hospitais Pediátricos/organização & administração , Alta do Paciente/normas , Adolescente , Procedimentos Cirúrgicos Ambulatórios/efeitos adversos , Procedimentos Cirúrgicos Ambulatórios/normas , Apendicectomia/efeitos adversos , Criança , Feminino , Hospitais Pediátricos/normas , Hospitais Pediátricos/estatística & dados numéricos , Humanos , Laparoscopia/efeitos adversos , Laparoscopia/normas , Tempo de Internação/estatística & dados numéricos , Masculino , Alta do Paciente/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Período Pós-Operatório , Avaliação de Programas e Projetos de Saúde , Estudos Prospectivos , Estudos Retrospectivos , Fatores de TempoRESUMO
Background: Stump appendicitis is inflammation of remnant appendix tissue due to incomplete removal of the appendix. Due to appendectomy history, stump appendicitis diagnosis is usually delay and that can cause increase morbidity. Methods: Medical records of patients who had surgery for acute appendicitis at a single center from 2008 to 2017 were retrospectively reviewed. During the evaluation of medical records, patients that had a previous operation for acute appendicitis or had "stump appendicitis" as an exploratory finding in operation notes were included. Results: Appendectomy was performed in 3130 patients (2630 open surgeries and 380 laparoscopic surgeries). Stump appendicitis was diagnosed in five patients (0.15%). The appendectomies had been performed 4, 5, 7, 7, and 11 years previously. Mean time taken for surgery was 36 h after symptoms began. Open surgery was performed in three patients, laparoscopic procedures in others. Conclusion: Awareness of stump appendicitis before radiological examinations may facilitate accurate diagnosis and decrease the duration of the decision-making process, leading to decreased morbidity.
Assuntos
Apendicectomia/normas , Apendicite/cirurgia , Adulto , Apendicectomia/efeitos adversos , Apendicectomia/métodos , Apêndice/cirurgia , Feminino , Humanos , Laparoscopia/efeitos adversos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Estudos Retrospectivos , Tomografia Computadorizada por Raios X/métodosRESUMO
Background: Acute appendicitis (AA) is the most common surgical disease, and appendectomy is the treatment of choice in the majority of cases. A correct diagnosis is key for decreasing the negative appendectomy rate. The management can become difficult in case of complicated appendicitis. The aim of this study is to describe the worldwide clinical and diagnostic work-up and management of AA in surgical departments. Methods: This prospective multicenter observational study was performed in 116 worldwide surgical departments from 44 countries over a 6-month period (April 1, 2016-September 30, 2016). All consecutive patients admitted to surgical departments with a clinical diagnosis of AA were included in the study. Results: A total of 4282 patients were enrolled in the POSAW study, 1928 (45%) women and 2354 (55%) men, with a median age of 29 years. Nine hundred and seven (21.2%) patients underwent an abdominal CT scan, 1856 (43.3%) patients an US, and 285 (6.7%) patients both CT scan and US. A total of 4097 (95.7%) patients underwent surgery; 1809 (42.2%) underwent open appendectomy and 2215 (51.7%) had laparoscopic appendectomy. One hundred eighty-five (4.3%) patients were managed conservatively. Major complications occurred in 199 patients (4.6%). The overall mortality rate was 0.28%. Conclusions: The results of the present study confirm the clinical value of imaging techniques and prognostic scores. Appendectomy remains the most effective treatment of acute appendicitis. Mortality rate is low.
Assuntos
Apendicectomia/normas , Apendicite/cirurgia , Doença Aguda/terapia , Adulto , Apendicectomia/efeitos adversos , Apendicectomia/métodos , Distribuição de Qui-Quadrado , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Laparoscopia/métodos , Laparoscopia/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Modelos Logísticos , Masculino , Estudos Prospectivos , Tomografia Computadorizada por Raios X/métodos , Resultado do TratamentoRESUMO
PURPOSE: Standardized care via a unified surgeon preference card for pediatric appendectomy can result in significant cost reduction. The purpose of this study was to evaluate the impact of cost and outcome feedback to surgeons on value of care in an environment reluctant to adopt a standardized surgeon preference card. METHODS: Prospective observational study comparing operating room (OR) supply costs and patient outcomes for appendectomy in children with 6-month observation periods both before and after intervention. The intervention was real-time feedback of OR supply cost data to individual surgeons via automated dashboards and monthly reports. RESULTS: Two hundred sixteen children underwent laparoscopic appendectomy for non-perforated appendicitis (110 pre-intervention and 106 post-intervention). Median supply cost significantly decreased after intervention: $884 (IQR $705-$1025) to $388 (IQR $182-$776), p<0.001. No significant change was detected in median OR duration (47min [IQR 36-63] to 50min [IQR 38-64], p=0.520) or adverse events (1 [0.9%] to 6 [4.7%], p=0.062). OR supply costs for individual surgeons significantly decreased during the intervention period for 6 of 8 surgeons (87.5%). CONCLUSION: Approaching value measurement with a surgeon-specific (rather than group-wide) approach can reduce OR supply costs while maintaining excellent clinical outcomes. LEVEL OF EVIDENCE: Level II.
Assuntos
Apendicectomia/economia , Apendicite/economia , Análise Custo-Benefício , Custos Hospitalares/estatística & dados numéricos , Qualidade da Assistência à Saúde/economia , Adolescente , Apendicectomia/métodos , Apendicectomia/normas , Apendicite/cirurgia , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Recém-Nascido , Laparoscopia/economia , Masculino , Salas Cirúrgicas/economia , Estudos Prospectivos , Cirurgiões/economia , Tennessee , Resultado do TratamentoRESUMO
BACKGROUND: Under the Merit-based Incentive Payment System, physician payment will be adjusted using a composite performance score that has 4 components, one of which is resource use. The objective of this exploratory study is to quantify the facility-level variation in surgical case duration for common surgeries to examine the feasibility of using surgical case duration as a performance metric. METHODS: We used data from the National Anesthesia Clinical Outcomes Registry on 404,987 adult patients undergoing one of 6 general surgical or orthopedic procedures: laparoscopic appendectomy, laparoscopic cholecystectomy, laparoscopic cholecystectomy with intraoperative cholangiogram, knee arthroscopy, laminectomy, and total hip replacement. We constructed separate mixed-effects multivariable time-to-event models (survival analysis) for each of the 6 procedures to model surgical case duration. RESULTS: We identified performance outliers, based on surgical case duration, using 2013 data and then quantified the gap between high- and low-performance outliers using 2014 data. After adjusting for patient risk, patients undergoing surgery at high-performance facilities were between 54% and 79% more likely to exit the operating room (OR) per unit time compared to average-performing facilities, depending on the procedure. For example, patients undergoing a laparoscopic appendectomy at high-performance facilities were 68% more likely to exit the OR per unit time (hazard ratio, 1.68; 95% CI, 1.40-2.02; P < .001) compared to average-performing facilities. Patients undergoing a laparoscopic appendectomy at low-performance facilities were 41% less likely to exit the OR per unit time (hazard ratio, 0.59; 95% CI, 0.47-0.74; P < .001) compared to average-performing facilities. The adjusted median surgical case duration for patients undergoing laparoscopic appendectomy was 69 minutes at high-performance centers and 92 minutes at low-performance centers. Similar results were obtained for the other procedures. CONCLUSIONS: There was wide variation in surgery case duration for patients undergoing common general surgical and orthopedic surgeries. This variability in care delivery may represent an important opportunity to promote more efficient use of health care resources.
Assuntos
Atenção à Saúde/normas , Gastos em Saúde/normas , Duração da Cirurgia , Planos de Incentivos Médicos/normas , Adulto , Apendicectomia/métodos , Apendicectomia/normas , Artroplastia de Quadril/métodos , Artroplastia de Quadril/normas , Colecistectomia Laparoscópica/métodos , Colecistectomia Laparoscópica/normas , Atenção à Saúde/métodos , Feminino , Humanos , Masculino , Sistema de Registros/normasRESUMO
SUMMARY: Surgical site infections (SSI) are a common complication after surgical procedures. To reduce the incidence of SSIs, Oakville Trafalgar Memorial Hospital decided to institute a bundle of initiatives to change multiple factors simultaneously based on best available evidence and the understanding of infection pathophysiology. We used National Surgical Quality Improvement Program data on the incidence of SSIs in our targeted and essentials, general surgery and orthopedic surgery cases before and after the implementation of an SSI reduction bundle. This article discusses whether the use of intervention bundles may assist in the reduction of a variety of postoperative surgical complications.
Assuntos
Procedimentos Cirúrgicos do Sistema Digestório/normas , Guias de Prática Clínica como Assunto/normas , Cuidados Pré-Operatórios/normas , Desenvolvimento de Programas/normas , Melhoria de Qualidade/normas , Infecção da Ferida Cirúrgica/prevenção & controle , Apendicectomia/métodos , Apendicectomia/normas , Procedimentos Cirúrgicos do Sistema Digestório/métodos , Humanos , Incidência , Ontário , Procedimentos Ortopédicos/métodos , Procedimentos Ortopédicos/normas , Cuidados Pré-Operatórios/métodosAssuntos
Apendicectomia/normas , Apendicite/cirurgia , Laparoscopia/normas , Lavagem Peritoneal/normas , Guias de Prática Clínica como Assunto , Abscesso Abdominal/epidemiologia , Abscesso Abdominal/etiologia , Abscesso Abdominal/prevenção & controle , Adulto , Apendicectomia/efeitos adversos , Apendicectomia/métodos , Apendicite/complicações , Criança , Medicina Baseada em Evidências/métodos , Medicina Baseada em Evidências/normas , Feminino , Humanos , Incidência , Laparoscopia/efeitos adversos , Laparoscopia/métodos , Masculino , Duração da Cirurgia , Lavagem Peritoneal/efeitos adversos , Lavagem Peritoneal/métodos , Sucção/métodos , Sucção/normas , Resultado do TratamentoRESUMO
BACKGROUND: To determine whether minimally invasive surgery (MIS) training improves outcomes in laparoscopic appendectomy, a procedure that is commonly performed in general surgery training. METHODS: Retrospective review was conducted of all patients undergoing laparoscopic appendectomy for suspected acute appendicitis between 2014 and 2015 at a single-center, tertiary-care academic institution. Patients operated on by MIS-trained surgeons (MIS group) were compared to those operated on by general surgeons (GS group). Single-incision and multiport laparoscopic appendectomies were included; open approach, known malignancy, and interval appendectomies were excluded. RESULTS: A total of 507 patients were included in the study: 181 patients in the MIS group and 326 in the GS group. There were no differences in patient demographics or medical comorbidities between groups and most patients were ASA class 1 or 2. Patients operated on by MIS-trained surgeons had significantly shorter operative time (43 min, IQR 32-60 vs. 58 min, IQR 44-81; p < 0.001) and fewer intra-operative adverse events (0/181 vs. 8/326, 2.5%; p = 0.03). There was no difference in number of postoperative adverse events between groups (6/181, 3.3% vs. 21/326, 6.4%; p = 0.13). In the MIS group, subgroup analysis of single-incision versus multiport appendectomy showed no differences in intra-operative or postoperative adverse events. On multivariable linear regression, lack of MIS training and traditional multiport approach had the greatest effects on prolonging operative time (11.2 and 12.8 min, respectively; p = 0.001). CONCLUSIONS: MIS fellowship improves operative metrics and patient outcomes even in basic laparoscopy.
Assuntos
Apendicectomia/educação , Apendicectomia/métodos , Apendicite/cirurgia , Bolsas de Estudo/normas , Laparoscopia/educação , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Apendicectomia/normas , Competência Clínica , Feminino , Humanos , Laparoscopia/normas , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/educação , Procedimentos Cirúrgicos Minimamente Invasivos/normas , Estudos Retrospectivos , Resultado do Tratamento , Adulto JovemRESUMO
OBJECTIVE: Evaluate longitudinal changes in technical and non-technical skills (teamwork, situation monitoring, communication and leadership), safety culture, and clinical outcomes before and after implementation of a crew resource management (CRM) safety program. DESIGN: A multi-level prospective single case study in accordance with the SQUIRE-guidelines for reporting quality improvement efforts. SETTING: Large university paediatric surgical service. PARTICIPANT(S): All 153 managers and staff. INTERVENTIONS: Training of staff in CRM, systematic risk assessments, and the redesign of work practices captured and reinforced through the development, implementation and refinement of SOPs. MAIN OUTCOME MEASURE(S): Data were collected related to: 1) Relevance of CRM training (survey), 2) Safety culture (survey), 3) Team behaviours in clinical practice (non-participatory observations with MedPACT protocol) and 4) Effects on perioperative care for laparoscopic appendectomies-a representative and frequently performed surgical procedure (electronic medical records and administrative data for length of stay, unplanned readmissions and returns to the Operating Room). RESULTS: Non-technical skills, the use of safety tools, as well as adherence to guidelines for appendectomies all improved significantly over time. Significant safety culture improvements were found in teamwork across and within units, supervisors' expectations and actions, non-punitive response to adverse events, and perceptions of overall patient safety. Unplanned readmissions following appendectomy declined significantly. CONCLUSIONS: Implementation of a comprehensive CRM program including associated safety tools created sustained adherence to new work practices and improved non-technical and technical skills, surgical outcomes and safety culture.
Assuntos
Salas Cirúrgicas/organização & administração , Equipe de Assistência ao Paciente/organização & administração , Segurança do Paciente/normas , Melhoria de Qualidade/organização & administração , Apendicectomia/normas , Criança , Comunicação , Humanos , Laparoscopia/normas , Salas Cirúrgicas/normas , Estudos de Casos Organizacionais , Pediatria/organização & administração , Assistência Perioperatória/estatística & dados numéricos , Estudos Prospectivos , Gestão da Segurança/métodos , Centro Cirúrgico Hospitalar/organização & administração , SuéciaRESUMO
BACKGROUND: The treatment of perforated appendicitis in children is characterized by significant variability in care, morbidity, resource utilization, and outcomes. We prospectively studied how minimization of care variability affects outcomes. METHODS: A clinical pathway for perforated appendicitis, in use for three decades, was further standardized in May 2015 by initiation of a disease severity classification, refinement of discharge criteria, standardization of the operation, and establishment of criteria for use of postoperative total parenteral nutrition, imaging, and invasive procedures. Prospective evaluation of all children treated for 20months on the new fully standardized protocol was conducted and compared to a retrospective cohort treated over 58months prior to standardization. Differences between outcomes before and after standardization were analyzed using regression analysis techniques to adjust for disease severity. RESULTS: Median follow-up time post discharge was 25 and 14days in the post- and prestandardization groups, respectively. Standardization significantly reduced postoperative abscess (9.8% vs. 17.4%, p=0.001) and hospital stay (p=0.002). Standardization reduced the odds of developing a postoperative abscess by four fold. CONCLUSION: Minimizing variability of care at all points in the treatment of perforated appendicitis significantly improves outcomes. TYPE OF STUDY: Prospective Cohort Study. LEVEL OF EVIDENCE: Level II.