The impact of verbal goal setting on operating room turnover time: a randomized trial.

INTRODUCTION AND HYPOTHESIS: Operating room turnover times are highly variable, with longer times having a significant negative impact on hospital costs, surgeon volume, and satisfaction. The primary aim of this randomized trial was to examine the impact of a verbalized time goal on the likelihood of meeting institutional goals. METHODS: This is a prospective, single-blind, randomized study conducted across four operative sites: inpatient main campus and three outpatient centers. Sequential cases for the same surgeon in the same room were randomized to receive a verbal prompt versus usual care, in which no goal setting was verbalized. Multivariate and univariate statistical analyses were performed. RESULTS: From July through October 2022, five attending surgeons randomized 88 cases (44 verbal prompt, 44 usual care). Of these, 30 were at the main inpatient hospital. The case mixture included 36% vaginal, 27% endoscopy, 8% open, 10% robotic, and others. Average turnover time was 51.7 and 35.3 min for inpatient and outpatient cases respectively. Overall, only 39.8% of cases hit the institutional turnover time goal. Verbal prompting did not significantly increase the likelihood of achieving the institutional goal (38.4% vs 43.4% p = 0.352) except for in minor surgery (64.0 vs 39.0%, p = 0.0477). A verbal prompt reduced turnover time in major surgery (59.7 vs 47.8 min, p = 0.0445). CONCLUSION: Our academic center achieved goal turnover times in only 39.8% of cases. Although verbal prompting did not significantly improve the likelihood of meeting institutional goals in the group as a whole, some subgroups were significantly improved.

Outcomes and Costs Following Mini-percutaneous Nephrolithotomy or Flexible Ureteroscopic Lithotripsy for 1-2-cm Renal Stones: Data From a Prospective, Randomized Clinical Trial.

PURPOSE: We evaluate the outcomes of ureteroscopy vs prone mini-percutaneous nephrolithotomy for 1-2-cm renal stones using a 2-group parallel randomized control trial. MATERIALS AND METHODS: Adult patients presenting with renal stones between 1 and 2 cm were randomized. Exclusion criteria included solitary kidney, multiple stones, and comorbidities precluding prone positioning. Block randomization was performed and was opened to the surgeon the morning of the procedure. Stone-free rate was evaluated by computed tomography 1-30 days postoperatively. Complications, re-treatment rates, and costs were evaluated. RESULTS: A total of 51 mini-percutaneous nephrolithotomy and 50 ureteroscopy patients were included. Baseline demographics were similar. Using a 2-mm cutoff, stone-free rate was higher in the mini-percutaneous nephrolithotomy group (76 vs 46%, P = .0023). The residual stone burden was significantly higher in the ureteroscopy group than the mini-percutaneous nephrolithotomy group (3.6 vs 1.4 mm, P = .0026). Fluoroscopy time was significantly higher in the mini-percutaneous nephrolithotomy group (273 vs 49 seconds, P < .0001). There were no differences in postoperative complications within 30 days, the necessity of a secondary procedure within 30 days, and pre- to postoperative creatinine change (P > .05). Surgical time did not vary significantly (P = .1788). Average length of stay was higher in the mini-percutaneous nephrolithotomy group (P < .0001). Both net revenue and direct costs were higher in mini-percutaneous nephrolithotomy procedures (P < .05), though they offset each other with a nonsignificant operating margin (P = .2541). CONCLUSIONS: In a prospective, randomized, controlled clinical trial using a 2-mm residual stone burden cutoff, mini-percutaneous nephrolithotomy was more likely to render patients stone-free than flexible ureteroscopy. Complications, surgical times, and operating margins did not vary between the approaches.

Comparative outcomes and cost of ambulatory PCNL in select kidney stone patients.

Limited hospital resources and access to care during the COVID-19 pandemic led us to implement a quality-improvement study investigating the feasibility, safety, and costs of same-day discharge after PCNL. The outcomes of 53 consecutive first-look PCNL patients included in a same-day discharge protocol during COVID-19 were compared to 54 first-look PCNL patients admitted for overnight observation. Control group had a similar comorbidity profile. Demographics, operative details, 30 day outcomes and readmissions, complications, and cost were compared between the two groups. Same-day discharge and one-day admission post-PCNL patients did not have significantly different baseline characteristics. The study group were more likely to have mini-PCNL (81% vs 50%, p < 0.01). Operative characteristics including median pre-operative stone burden (1.4 vs 1.7 cm3, p = 0.47) and post-operative stone burden (0.14 vs 0.18 cm3, p = 0.061) were similar between the two groups. Clavien-Dindo complication rates were lower in the study group compared to controls (0 vs 7%, p = 0.045). Readmission rates (2 vs 4%, p = 0.569) and ED visits (4 vs 6%, p = 0.662) were similar between the two groups. Total cost ($6,648.92 vs $9,466.07, p < 0.01) was significantly lower and operating margin ($4,475.96 vs $1,742.16, p < 0.01) was significantly higher for the same-day discharge group. Percutaneous nephrolithotomy may be performed in select patients without an increase in short-term complications, ED visits, or readmissions. Patients undergoing mini-PCNL are particularly amenable to same-day discharge, however, standard PCNL patients should not be excluded from consideration. Avoiding overnight admission decreases total cost and increased hospital operating margin.

Safety and Efficacy of Phenylephrine Administration for the Treatment of Ischemic Priapism: An Opportunity for Quality Improvement in Periprocedural Safety Assessment.

OBJECTIVE: To determine the safety and efficacy of hourly, high dose phenylephrine (>1000 µg) for acute ischemic priapism (AIP) through monitoring adverse hemodynamic events amongst risk profiles. METHODS: An IRB-approved retrospective review of patients with AIP from 2010 to 2020. Patients were stratified to a low or high dose phenylephrine group based on cumulative, hourly dose of ≤1000 µg and > 1000 µg respectively and examined for successful resolution of their AIP. The safety profile of phenylephrine for patients at risk for adverse hemodynamic events was examined. RESULTS: A total of 123 patients were identified with a median age of 40 (range: 7-76) years with median time from AIP onset to presentation of 11 (2-168) hours. A total of 97 men received phenylephrine (78.9%) and detumescence was achieved nonoperatively in 62 of these men (63.9%) with a mean priapism duration of 8.7 hours. Those resolving with phenylephrine administration had a mean duration of 8.8 ± 5.6 vs 57.3 ± 37.1 hours without resolution P < .001. Among low and high dose phenylephrine groups (500 and 2000 µg respectively), the median duration of AIP was 10 and 12 hours respectively without a difference in AIP resolution (P > .05). Twenty-one patients (17.1%) were deemed at risk for phenylephrine complication of which 4 (4.1%) had phenylephrine discontinued due to hemodynamic changes. CONCLUSION: Nonoperative resolution of AIP with phenylephrine does not appear to be dose-dependent and hemodynamic changes secondary to phenylephrine administration may be underreported. Future work should utilize standardized risk assessment and periprocedural monitoring for hemodynamic change.

Safety and economics of an enhanced recovery after surgery protocol in pelvic reconstructive surgery.

INTRODUCTION AND HYPOTHESIS: We hypothesized that an enhanced recovery after surgery (ERAS) protocol for patients undergoing female pelvic reconstructive surgery would conserve hospital resources without compromising patient safety. METHODS: In June 2020, an ERAS protocol designed to promote same-day discharge was initiated that included pre-operative hydration, a urinary anesthetic, non-narcotic analgesia, perineal ice, a bowel regimen, enrollment of the family to assist with care, and communication regarding planned same-day discharge. We compared demographic, operative, hospital stay, complications, and cost data in patients undergoing pelvic organ prolapse or incontinence surgery over 4 sequential months pre (PRE; N = 82) and post (POST; N = 91) ERAS implementation using univariate statistics. RESULTS: There were no differences in demographics, operative details, or complications (p > 0.05). There were no significant differences in overall revenues or expenses (p > 0.05), but bed unit cost was significantly lower in the POST group ($210 vs $533, p < 0.0001). There was a trend toward an increased operating margin in POST patients ($4,554 vs $2,151, p = 0.1163). Significantly more POST surgeries were performed in an ambulatory setting (73.6% vs 48.8%, p = 0.0008) and resulted in same-day discharge (80.2% vs 50.0%, p = 0.0003). There were no differences in the rates of emergency room or unexpected clinic visits (p > 0.05). Prescribed post-operative opiate dose was significantly reduced in POST patients (p < 0.0001). CONCLUSIONS: In patients undergoing female pelvic reconstructive surgery, an ERAS protocol facilitated transfer of procedures to an ambulatory surgical site and permitted same-day discharge without increasing complications, clinic visits, or emergency room visits. It also reduced bed unit cost and may improve operating margins.

Non-invasive assessment of porcine oocyte quality by supravital staining of cumulus-oocyte complexes with lissamine green B.

We evaluated the usefulness of lissamine green B (LB) staining of cumulus-oocyte complexes (COC) as a non-invasive method of predicting maturational and developmental competence of slaughterhouse-derived porcine oocytes cultured in vitro. Cumulus cells of freshly aspirated COCs were evaluated either morphologically on the basis of thickness of cumulus cell layers, or stained with LB, which penetrates only non-viable cells. The extent of cumulus cell staining was taken as an inverse indicator of membrane integrity. The two methods of COC grading were then examined as predictors of nuclear maturation and development after parthenogenetic activation. In both cases LB staining proved a more reliable indicator than morphological assessment (P < 0.05). The relationship between LB staining and cumulus cell apoptosis was also examined. Terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) assay for DNA fragmentation revealed that oocytes within COCs graded as low quality by either LB staining or visual morphology showed significantly greater DNA fragmentation (P < 0.05) than higher grades, and that LB and visual grading were of similar predictive value. Expression of the stress response gene TP53 showed significantly higher expression in COCs graded as low quality by LB staining. However expression of the apoptosis-associated genes BAK and CASP3 was not significantly different between high or low grade COCs, suggesting that mRNA expression of BAK and CASP3 is not a reliable method of detecting apoptosis in porcine COCs. Evaluation of cumulus cell membrane integrity by lissamine green B staining thus provides a useful new tool to gain information about the maturational and developmental competence of porcine oocytes.

Cost Comparisons Between Different Techniques of Percutaneous Renal Biopsy for Small Renal Masses.

PURPOSE: To compare the costs associated with ultrasound (US)-guided hospital-based (UGHB), CT-guided hospital-based (CTG), and US-guided office-based (UGOB) percutaneous renal biopsy (PRB) for small renal masses (SRMs). METHODS: We retrospectively analyzed patient demographics, tumor characteristics, R.E.N.A.L. nephrometry scores, and cost data of patients undergoing PRB for SRM at our institution from May 2012 to September 2015. Cost data, including facility costs, professional fees, and pathology, were obtained from the departments of urology, radiology, and pathology. RESULTS: A total of 78 patients were included in our analysis: 19, 31, and 28 UGHB, CTG, and UGOB, respectively. There was no difference in age, gender distribution, or tumor size among the three groups (p-values 0.131, 0.241, and 0.603, respectively). UGOB tumors had lower R.E.N.A.L. nephrometry scores (p=0.008). There were no differences in nondiagnostic rates between the UGHB, CTG, and UGOB groups [4 (21%), 5 (16%), and 6 (21%)] (p=0.852). There were no differences in final tumor treatment strategies utilized among the UGHB, CTG, and UGOB groups (p=0.447). There were 0, 2 (6%), and 0 complications in the UGHB, CTG, and UGOB biopsy groups. Total facility costs were $3449, $3280, and $1056 for UGHB, CTG, and UGOB PRB, respectively (p<0.0001). There was no difference between the urologist's and radiologist's professional fees (p=0.066). Total costs, including facility costs, pathology fees, and professional fees, were $4598, $4470, and $2129 for UGHB, CTG, and UGOB renal biopsy, respectively (p<0.0001). CONCLUSION: For select patients with less anatomically complex, exophytic, and posteriorly located tumors, UGOB PRB provides equivalent diagnostic and complication rates while being significantly more cost-effective than either UGHB or CTG renal biopsy.