A call to action becomes practice: cardiac and vascular surgery during the COVID-19 pandemic based on the Lombardy emergency guidelines.

OBJECTIVES: During the Severe Acute Respiratory Syndrome-Coronavirus-2 (SARS-CoV-2) pandemic, Northern Italy had to completely reorganize its hospital activity. In Lombardy, the hub-and-spoke system was introduced to guarantee emergency and urgent cardiovascular surgery, whereas most hospitals were dedicated to patients with coronavirus disease 2019 (COVID-19). The aim of this study was to analyse the results of the hub-and-spoke organization system. METHODS: Centro Cardiologico Monzino (Monzino) became one of the four hubs for cardiovascular surgery, with a total of eight spokes. SARS-CoV-2 screening became mandatory for all patients. New flow charts were designed to allow separated pathways based on infection status. A reorganization of spaces guaranteed COVID-19-free and COVID-19-dedicated areas. Patients were also classified into groups according to their pathological and clinical status: emergency, urgent and non-deferrable (ND). RESULTS: A total of 70 patients were referred to the Monzino hub-and-spoke network. We performed 41 operations, 28 (68.3%) of which were emergency/urgent and 13 of which were ND. The screening allowed the identification of COVID-19 (three patients, 7.3%) and non-COVID-19 patients (38 patients, 92.7%). The newly designed and shared protocols guaranteed that the cardiac patients would be divided into emergency, urgent and ND groups. The involvement of the telematic management heart team allowed constant updates and clinical discussions. CONCLUSIONS: The hub-and-spoke organization system efficiently safeguards access to heart and vascular surgical services for patients who require ND, urgent and emergency treatment. Further reorganization will be needed at the end of this pandemic when elective cases will again be scheduled, with a daily increase in the number of operations.

Making cardiac surgery feasible in African countries: Experience from Namibia, Uganda, and Zambia.

OBJECTIVES: Few African countries have the resources to provide optimal cardiac surgery care. We explored needs at cardiac surgery centers in Namibia, Zambia, and Uganda. Our objectives were (1) to determine the key variables to be included in a cardiac surgery needs assessment tool and (2) to highlight the current initiatives, challenges and opportunities, and future goals for cardiac surgery in these 3 countries. METHODS: We conducted in-depth interviews with stakeholders in each country as well as surveys of surgical facilities. We synthesized our findings using a health systems conceptual framework. Each program's current capacity was compared with a standardized definition of "adequate" surgical capacity. On the basis of these findings, we developed a formal needs assessment questionnaire for use in resource-constrained countries. RESULTS: Although each of these countries has adequate facilities and surgical expertise, they still lack key support staff and material resources. Training and mentorship programs are being built, and the sites participate in cardiovascular research. Yet a comprehensive, multidisciplinary approach-including palliative care and rehabilitation-is lacking, and patients in remote areas are not being served. These observations allowed us to define the variables in our needs assessment tool. CONCLUSIONS: Our study demonstrates the great potential that exists to expand cardiac surgery in Africa and highlights some of the major resource bottlenecks that may hinder the scale-up of surgical programs. Our needs assessment questionnaire will assist ministries of health in building sustainable cardiac surgery programs using innovative Afro-centric solutions.

When surgeons are rarer than resources - our experience with improving access to thoracic surgery in an urban setting: A special report.

With progressive globalisation enabled by technology, there is an increased interest in finding viable solutions to the myriad health problems faced by developing countries. In countries like Pakistan, occasionally the challenge is not a dearth of material resources but rather unavailability of expertise. The current paper was planned to share a model that was successfully implemented in the urban setting of Karachi, Pakistan, from 2012 onwards which significantly improved access to thoracic surgery for underprivileged individuals. Our model focussed on a qualified thoracic surgeon reviving a defunct thoracic surgical unit thereby optimising the use of resources already available in the community. The key to efficient outcomes was direct managerial control by the surgeon who first educated himself in the various processes involved. The model, with its challenges and solutions, has good potential foradaptation in other urban settings in the developing world..

General Thoracic Surgery in Rwanda: An Assessment of Surgical Volume and of Workforce and Material Resource Deficits.

BACKGROUND: Benchmarking operative volume and resources is necessary to understand current efforts addressing thoracic surgical need. Our objective was to examine the impact on thoracic surgery volume and patient access in Rwanda following a comprehensive capacity building program, the Human Resources for Health (HRH) Program, and thoracic simulation training. METHODS: A retrospective cohort study was conducted of operating room registries between 2011 and 2016 at three Rwandan referral centers: University Teaching Hospital of Kigali, University Teaching Hospital of Butare, and King Faisal Hospital. A facility-based needs assessment of essential surgical and thoracic resources was performed concurrently using modified World Health Organization forms. Baseline patient characteristics at each site were compared using a Pearson Chi-squared test or Kruskal-Wallis test. Comparisons of operative volume were performed using paired parametric statistical methods. RESULTS: Of 14,130 observed general surgery procedures, 248 (1.76%) major thoracic cases were identified. The most common indications were infection (45.9%), anatomic abnormalities (34.4%), masses (13.7%), and trauma (6%). The proportion of thoracic cases did not increase during the HRH program (2.07 vs 1.78%, respectively, p = 0.22) or following thoracic simulation training (1.95 2013 vs 1.44% 2015; p = 0.15). Both university hospitals suffer from inadequate thoracic surgery supplies and essential anesthetic equipment. The private hospital performed the highest percentage of major thoracic procedures consistent with greater workforce and thoracic-specific material resources (0.89% CHUK, 0.67% CHUB, and 5.42% KFH; p < 0.01). CONCLUSIONS AND RELEVANCE: Lack of specialist providers and material resources limits thoracic surgical volume in Rwanda despite current interventions. A targeted approach addressing barriers described is necessary for sustainable progress in thoracic surgical care.

Regional Thoracic Surgery Quality Collaboration Formation: Providence Thoracic Surgery Initiative.

BACKGROUND: Surgery quality initiatives improve clinical outcomes in cardiac and general surgery. No mature thoracic surgery (TS) regional effort has been described. METHODS: An intramural grant funded the Thoracic Surgery Initiative (TSI). Professional organization, site-specific administrative and clinical databases were used to identify surgeons performing TS across a large Western health system. Participants were recruited through stakeholder surveys, personal contact, and meetings. Differences in practices and outcomes were identified. Fourteen centers performing TS in 5 states formed the TSI with a mission to define, implement, and monitor TS quality. RESULTS: A TS data system based on The Society of Thoracic Surgeons General Thoracic Surgery Database was implemented. Clinical data from 2015 and 2016 revealed significant differences in outcomes. Clinical data allow quality implementation, including identification and propagation of internal best practices and monitoring. TS practice standardization was agreed to using predefined TS best practice components that were incorporated into standardized TS care documents. Standardized care document completion by providers was intended to provoke desired TS care. The standardized care documents reside on the system-wide electronic health record. Literature and substantial surgeon experience were used to develop standardized TS care pathways for important or common clinical scenarios (pneumonectomy, primary spontaneous pneumothorax, etc). The TSI internet site serves as a harbor for standardization products. CONCLUSIONS: The TSI is evolving. Surgeon engagement remains high. The TSI enabled surgeons to lead, set the agenda, and remain in control of our destiny. Indeed, health care cannot appropriately evolve without such physician vision, engagement, and leadership.

Prevalence, Knowledge and Attitudes Towards Smoking Among SEPAR Members. / Prevalencia, conocimiento y actitudes acerca del consumo de tabaco en los miembros de SEPAR.

The aims of this study were to estimate the prevalence of smoking among SEPAR members, and their approach to smoking cessation in their patients. An online survey was completed by 640 members (496 pulmonologists, 45 nurses, 34 thoracic surgeons, 37 physiotherapists, and 28 other specialists). Of the members interviewed, 5% confessed that they were smokers: 3.5% pulmonologists; 8.9% nurses; 8.8% thoracic surgeons, and 13.5% physiotherapists. A total of 96% of members assign a lot or quite a lot of importance to setting an example; 98% of members always or often ask their patients about their smoking habit. The most effective anti-smoking intervention, according to 77% of members, is a combination of drugs and psychological support. These results are an indicator of the awareness and commitment of SEPAR members to smoking and its cessation.

Creating and Maintaining a Successful Service Line in an Academic Medical Center at the Dawn of Value-Based Care: Lessons Learned From the Heart and Vascular Service Line at UMass Memorial Health Care.

The service line (SL) model has been proven to help shift health care toward value-based services, which is characterized by coordinated, multidisciplinary, high-quality, and cost-effective care. However, academic medical centers struggle with how to effectively set up SL structures that overcome the organizational and cultural challenges associated with simultaneously delivering the highest-value care for the patient and advancing the academic mission. In this article, the authors examine the evolution of UMass Memorial Health Care's heart and vascular service line (HVSL) from 2006 to 2011 and describe the impact on its success of multiple strategic decisions. These include key academic physician leadership recruitments and engagement via a matrixed governance and management model; development of multidisciplinary teams; empowerment of SL leadership through direct accountability and authority over programs and budgets; joint educational and training programs; incentives for academic achievement; and co-localization of faculty, personnel, and facilities. The authors also explore the barriers to success, including the need to overcome historical departmental-based silos, cultural and training differences among disciplines, confusion engendered by a matrixed reporting structure, and faculty's unfamiliarity with the financial and organizational skills required to operate a successful SL. Also described here is the impact that successful implementation of the SL has on creating high-quality services, increased profitability, and contribution to the financial stability and academic achievement of the academic medical center.

Use of a heart team in decision-making for patients with complex coronary disease at hospitals in Michigan prior to guideline endorsement.

BACKGROUND: Revascularization decisions can profoundly impact patient survival, quality of life, and procedural risk. Although use of Heart Teams to make revascularization decisions is growing, data on their implementation in the real-world are limited. Our objective was to assess the prevalence of Heart Teams and their association with collaboration in routine practice. METHODS: A survey of cardiologists and cardiac surgeons at 31 hospitals in Michigan was performed in May, 2011--prior to the recommendation for using Heart Teams in national guidelines. This survey included all percutaneous coronary intervention-performing hospitals in Michigan participating in the Blue Cross/Blue Shield of Michigan Cardiovascular Consortium and Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative. It targeted both the use of Heart Teams and multidisciplinary Case Conferences. RESULTS: There were 53 physician survey respondents from 27 hospitals with 4 hospitals not responding. Among respondents, 11 (40.7%) hospitals reported no Heart Teams or Case Conferences while 7 (25.9%) hospitals reported either a Heart Team or Case Conference. However, there was disagreement about the presence of a Heart Team at seven hospitals, and about Case Conferences at nine hospitals. Hospitals with definite Heart Teams reported significantly greater levels of collaboration between cardiologists and cardiac surgeons. CONCLUSION: The overall presence of Heart Teams prior to their recommendation in national guidelines was limited. Even among hospitals with a potential Heart Team, there was substantial disagreement between respondents about their presence. Further refinement of the definition of a Heart Team and measures of successful implementation are needed.

A stepwise model for delivering medical humanitarian aid requiring complex interventions.

OBJECTIVES: Cardiothoracic surgeons and practitioners of cardiovascular medicine have a long history of humanitarian aid. Although this is worthwhile at multiple levels and occasionally described in some detail, few efforts have a proven algorithm with demonstrable outcomes that suggest effective educational methodology or clinical results approaching accepted standards in developed countries. METHODS: Our report provides a stepwise approach to developing highly successful self-sustainable, replicable, and scalable humanitarian congenital cardiac surgical programs, and provides data to allow insight into the efficacy of our model. RESULTS: This program model has evolved over 25 years, during which it has been replicated several times and scaled throughout a vast and populous country. Since 1989, Russia has undergone considerable social, political, and economic changes. Our program model proved successful throughout this time despite dynamic social, political, and medical landscapes. CONCLUSIONS: The positive results of our program model indicate that these methodologies may be helpful to others attempting to address the worldwide shortage of cardiovascular care and particularly the complex interventions required in the management of congenital cardiovascular disease.

From 'solution shop' model to 'focused factory' in hospital surgery: increasing care value and predictability.

The full-service US hospital has been described organizationally as a "solution shop," in which medical problems are assumed to be unstructured and to require expert physicians to determine each course of care. If universally applied, this model contributes to unwarranted variation in care, which leads to lower quality and higher costs. We purposely disrupted the adult cardiac surgical practice that we led at Mayo Clinic, in Rochester, Minnesota, by creating a "focused factory" model (characterized by a uniform approach to delivering a limited set of high-quality products) within the practice's solution shop. Key elements of implementing the new model were mapping the care process, segmenting the patient population, using information technology to communicate clearly defined expectations, and empowering nonphysician providers at the bedside. Using a set of criteria, we determined that the focused-factory model was appropriate for 67 percent of cardiac surgical patients. We found that implementation of the model reduced resource use, length-of-stay, and cost. Variation was markedly reduced, and outcomes were improved. Assigning patients to different care models increases care value and the predictability of care process, outcomes, and costs while preserving (in a lesser clinical footprint) the strengths of the solution shop. We conclude that creating a focused-factory model within a solution shop, by applying industrial engineering principles and health information technology tools and changing the model of work, is very effective in both improving quality and reducing costs.