Cirugía en horario extendido: una visión de los actores involucrados / Extended hours surgery: a vision of the actors involved

Introducción. Las listas de espera para cirugía de alta prevalencia son producto de una limitada oferta ante una elevada demanda de jornadas quirúrgicas. Tienen un impacto sobre las condiciones médicas de los pacientes y la consulta por urgencias. Como respuesta, se han incorporado los espacios quirúrgicos adicionales en horarios no convencionales. Su creciente implementación, aunque controversial, se reconoce cada vez más como una nueva normalidad en cirugía. Hay una limitada documentación de la efectividad de la medida, debido a la complejidad e intereses de los participantes. Métodos. Se analizó desde una posición crítica y reflexiva la perspectiva de los actores involucrados en un programa de cirugía en horario extendido, estableciendo las posibles barreras y los elementos facilitadores de una política enfocada a procedimientos en horario no convencional. Asimismo, se describen posibles oportunidades de investigación en el tema. Discusión. Los programas quirúrgicos en horarios no convencionales implican un análisis de los determinantes de su factibilidad y éxito para establecer la pertinencia de su implementación. La disponibilidad de las salas de cirugía, una estandarización de los procedimientos y una cultura de seguridad institucional implementada por la normativa vigente, favorecen estas acciones operacionales. Los aspectos económicos del prestador y del asegurador inciden en la planeación y ejecución de esta modalidad de trabajo. Conclusión. La realización segura y el éxito de un programa de cirugía en horario no convencional dependen de la posibilidad de alinear los intereses de los actores participantes en el proceso

Introduction. Waiting lists for high-prevalence surgeries are the product of limited supply due to a high demand for surgical days. They have an impact on patients' medical conditions and emergency consultation. In response, additional surgical spaces have been incorporated at unconventional times. Its growing implementation, although controversial, is increasingly recognized as a new normal in surgery. There is limited documentation of the effectiveness of the measure due to the complexity and interests of the participants. Methods. The perspective of the actors involved in an extended hours surgery program was analyzed from a critical and reflective position, establishing the possible barriers, and facilitating elements of a policy focused on procedures during unconventional hours. Possible research opportunities on the topic are also described. Discussion. Surgical programs at unconventional times involve an analysis of the determinants of their feasibility and success to establish the relevance of implementation. The availability of operating rooms, a standardization of procedures and a culture of institutional security implemented by current regulations, favor these operational actions. The economic aspects of the provider and the insurer affect the planning and execution of this type of work. Conclusion. The safe realization and success of a surgical program in unconventional hours depend on the possibility of aligning the interests of the actors involved in the process

Major Obstacles to Implement a Full-Time Intensivist in Korean Adult ICUs: a Questionnaire Survey / 대한구급학회지

BACKGROUND: Critical care physician staffing is a crucial element of the intensive care unit (ICU) organization, and is associated with better outcomes in ICUs. Adult ICUs in Korea have been suffering from inadequate full-time intensivists and nurses because of insufficient reimbursement rates (<50% of the original critical care cost) from the National Health Insurance System. Recently, full-time intensivists have been introduced as a prerequisite for adult ICUs of tertiary hospitals in Korea. The purpose of this study was to examine the perception of intensivist staffing among critical care program directors regarding the barriers and solutions when implementing an intensivist model of critical care in Korea. METHODS: An email survey of critical care program directors in designated teaching hospitals for critical care subspecialty training by the Korean Society of Critical Care Medicine was performed. The survey domains included vision, culture, resources, barriers, and potential solutions to implementing intensivist physician staffing (IPS). RESULTS: Forty-two critical care program directors were surveyed. A total of 28 directors (66.7%) responded to email queries. Of these, 27 directors (96.4%) agreed that IPS would improve the quality of care in the ICU, although half of them reported a negative perception of relevant clinical colleagues for the role of full-time intensivists and poor resources for IPS in their hospitals. Increased financial burden due to hiring full-time intensivists and concerns regarding exclusion from the management of their critically ill patients in the ICU, together with loss of income for primary attending physicians were stated by the respondents to be major barriers to implementing IPS. Financial incentives for the required cost from the health insurance system and enhancement of medical law relevant to critical care were regarded as solutions to these issues. CONCLUSIONS: Critical care program directors believe that intensivist-led critical care can improve the outcome of ICUs. They indicated the financial burden due to IPS and underestimation of a full-time intensivist's role to be major barriers. The program directors agreed that a partnership between hospital leaders and the Ministry of Health and Welfare was needed to overcome these barriers.

Major Obstacles to Implement a Full-Time Intensivist in Korean Adult ICUs: a Questionnaire Survey / 대한중환자의학회지

BACKGROUND: Critical care physician staffing is a crucial element of the intensive care unit (ICU) organization, and is associated with better outcomes in ICUs. Adult ICUs in Korea have been suffering from inadequate full-time intensivists and nurses because of insufficient reimbursement rates (<50% of the original critical care cost) from the National Health Insurance System. Recently, full-time intensivists have been introduced as a prerequisite for adult ICUs of tertiary hospitals in Korea. The purpose of this study was to examine the perception of intensivist staffing among critical care program directors regarding the barriers and solutions when implementing an intensivist model of critical care in Korea. METHODS: An email survey of critical care program directors in designated teaching hospitals for critical care subspecialty training by the Korean Society of Critical Care Medicine was performed. The survey domains included vision, culture, resources, barriers, and potential solutions to implementing intensivist physician staffing (IPS). RESULTS: Forty-two critical care program directors were surveyed. A total of 28 directors (66.7%) responded to email queries. Of these, 27 directors (96.4%) agreed that IPS would improve the quality of care in the ICU, although half of them reported a negative perception of relevant clinical colleagues for the role of full-time intensivists and poor resources for IPS in their hospitals. Increased financial burden due to hiring full-time intensivists and concerns regarding exclusion from the management of their critically ill patients in the ICU, together with loss of income for primary attending physicians were stated by the respondents to be major barriers to implementing IPS. Financial incentives for the required cost from the health insurance system and enhancement of medical law relevant to critical care were regarded as solutions to these issues. CONCLUSIONS: Critical care program directors believe that intensivist-led critical care can improve the outcome of ICUs. They indicated the financial burden due to IPS and underestimation of a full-time intensivist's role to be major barriers. The program directors agreed that a partnership between hospital leaders and the Ministry of Health and Welfare was needed to overcome these barriers.

Current Status of Intensive Care Units Registered as Critical Care Subspecialty Training Hospitals in Korea

There is a lack of information on critical care in Korea. The aim of this study was to determine the current status of Korean intensive care units (ICUs), focusing on the organization, characteristics of admitted patients, and nurse and physician staffing. Critical care specialists in charge of all 105 critical care specialty training hospitals nationwide completed a questionnaire survey. Among the ICUs, 56.4% were located in or near the capital city. Only 38 ICUs (17.3%) had intensive care specialists with a 5-day work week. The average daytime nurse-to-patient ratio was 1:2.7. Elderly people > or = 65 yr of age comprised 53% of the adult patients. The most common reasons for admission to adult ICUs were respiratory insufficiency and postoperative management. Nurse and physician staffing was insufficient for the appropriate critical care in many ICUs. Staffing was worse in areas outside the capital city. Much effort, including enhanced reimbursement of critical care costs, must be made to improve the quality of critical care at the national level.

Effects of Hospital Nurse Staffing on in-hospital Mortality, Pneumonia, Sepsis, and Urinary Tract Infection in Surgical Patients

PURPOSE: This study was done to examine relationships between nurse staffing level and postsurgical patient outcomes using inpatient database from the National Health Insurance. METHODS: Records of 111,491 patients who received one of 12 types of surgery between January and December, 2009 were identified and analyzed in this study. Nurse staffing level was measured using adjusted nurse staffing grades from 0 to 7. Patient outcomes were defined as in-hospital mortality, or pneumonia, sepsis, or urinary tract infection after surgery. Logistic regression analyses estimated by Generalized Estimation Model, were used to analyze the association between nurse staffing level and patient outcomes. RESULTS: An inverse relationship was found between nurse staffing and patient mortality. Compared with patients who were cared for in hospitals with the highest nurse staffing (Grades 0-1), increases in the odds of dying were found in those with Grades 6-7 [OR (odds ratio)=2.99, 95% CI (confidence interval)=1.94-4.60], those with Grades 4-5 (OR=1.78, 95% CI=1.24-2.57) and those with Grades 2-3 (OR=1.57, 95% CI=1.25-1.98). Lower nurse staffing level was also associated with higher number of cases in pneumonia and sepsis. CONCLUSION: Policies for providing adequate nurse staffing is required to enhance quality of care and lead to better perioperative patient outcomes.

Implantação de sistema informatizado para planejamento, gerenciamento e otimização das escalas de enfermagem / Implantación de un sistema informatizado para la planificación, administración y optimización en la elaboración de los turnos de enfermería / Implementation of a computerized system to plan, manage, and optimize nursing staff schedule

OBJETIVO: Relatar o desenvolvimento e implantação de um sistema informatizado para auxiliar no planejamento, gerenciamento e otimização das escalas de enfermagem nas unidades de internação do Hospital Israelita Albert Einstein. MÉTODOS: Foi desenvolvido o Sistema de Gerenciamento e Otimização de Recursos na plataforma tecnológica dot.Net da Microsoft®. RESULTADOS: Implantado inicialmente na área de enfermagem com visualização on-line das escalas das unidades e respectivas demandas de pacientes. Facilita e permite a elaboração e o gerenciamento das escalas mensais de trabalho, reduzindo o tempo utilizado na confecção e garantindo segurança na informação e agilidade na obtenção de dados. CONCLUSÃO:Após a implantação é possível observar ganhos e oportunidades de melhoria tanto no sistema como no processo de planejamento e gerenciamento das escalas de enfermagem.

OBJECTIVE: To report the development and implementation of a computerized system that supports the planning, management, and optimization of nursing staff schedule for inpatient units of the Israelite Albert Einstein hospital. METHODS: The technological platform dot.Net by Microsoft® was used to develop the Resource Management and Optimization System (SGOR). The SGOR was initially implemented in the nursing units to allow online visualization of nursing schedule per unit and shift according to respective patients' demand. RESULTS: The SGOR was found to facilitate the management of monthly nursing schedules, to decrease design time, to provide safety and accurate information, and to allow quick data retrieval. CONCLUSION: The implementation of the SGOR is a useful system for the management of nursing staff schedule. It allows determining improvements in the schedule of nursing staff as well as determining the need for improvements in both the system itself and the planning and management of nursing staffing demand.

OBJETIVO: Relatar el desarrollo e implantación de un sistema informatizado para auxiliar en la planificación, administración y optimización en la elaboración de los turnos de enfermería en las unidades de internamiento del Hospital Israelita Albert Einstein. MÉTODOS: Fue desarrollado el Sistema de administración y Optimización de Recursos en la plataforma tecnológica dot.Net de Microsoft®. RESULTADOS: Fue implantado inicialmente en el área de enfermería con visualización on-line de los turnos de las unidades y respectivas demandas de pacientes. Facilita y permite la elaboración y administración de los turnos mensuales de trabajo, reduciendo el tiempo utilizado en la confección, garantizando de este modo seguridad en la información y agilidad en la obtención de datos. CONCLUSIÓN: Después de la implantación es posible observar ganancias y oportunidades de mejoría tanto en el sistema como en el proceso de planificación y administración de los turnos de enfermería.