Complex Cancer Surgery in the Outpatient Setting: The Josie Robertson Surgery Center.

Minimally invasive operative techniques and enhanced recovery after surgery (ERAS) protocols have transformed clinical practice and made it possible to perform increasingly complex oncologic procedures in the ambulatory setting, with recovery at home after a single overnight stay. Capitalizing on these changes, Memorial Sloan Kettering Cancer Center's Josie Robertson Surgery Center (JRSC), a freestanding ambulatory surgery facility, was established to provide both outpatient procedures and several surgeries that had previously been performed in the inpatient setting, newly transitioned to this ambulatory extended recovery (AXR) model. However, the JRSC core mission goes beyond rapid recovery, aiming to be an innovation center with a focus on superlative patient experience and engagement, efficiency, and data-driven continuous improvement. Here, we describe the JRSC genesis, design, care model, and outcome tracking and quality improvement efforts to provide an example of successful, patient-centered surgical care for select patients undergoing relatively complex procedures in an ambulatory setting.

Identifying Natural Alignments Between Ambulatory Surgery Centers and Local Health Systems: Building Broader Communities of Surgical Care.

OBJECTIVE: To develop and compare methods for identifying natural alignments between ambulatory surgery centers (ASCs) and hospitals that anchor local health systems. MEASURES: Using all-payer data from Florida's State Ambulatory Surgery and Inpatient Databases (2005-2009), we developed 3 methods for identifying alignments between ASCS and hospitals. The first, a geographic proximity approach, used spatial data to assign an ASC to its nearest hospital neighbor. The second, a predominant affiliation approach, assigned an ASC to the hospital with which it shared a plurality of surgeons. The third, a network community approach, linked an ASC with a larger group of hospitals held together by naturally occurring physician networks. We compared each method in terms of its ability to capture meaningful and stable affiliations and its administrative simplicity. RESULTS: Although the proximity approach was simplest to implement and produced the most durable alignments, ASC surgeon's loyalty to the assigned hospital was low with this method. The predominant affiliation and network community approaches performed better and nearly equivalently on these metrics, capturing more meaningful affiliations between ASCs and hospitals. However, the latter's alignments were least durable, and it was complex to administer. CONCLUSIONS: We describe 3 methods for identifying natural alignments between ASCs and hospitals, each with strengths and weaknesses. These methods will help health system managers identify ASCs with which to partner. Moreover, health services researchers and policy analysts can use them to study broader communities of surgical care.

Intentional partnering: a grounded theory study on developing effective partnerships among nurse and physician managers as they co-lead in an evolving healthcare system.

AIM: The aim of this study was to describe the process of how nurse and physician managers in formalized dyads work together to address clinical management issues in the surgical division of one hospital setting. BACKGROUND: Nurse and physician managers are uniquely positioned to co-lead and transform healthcare delivery. However, little is known about how this management dyad functions in the healthcare setting. DESIGN: A constructivist grounded theory approach was used to investigate the process of how nurse and physician managers work together in formalized dyads in an urban Canadian university affiliated teaching hospital. METHODS: Data collection occurred from September 2013-August 2014. Data included participant observation (n = 142 hours) and intensive interviews (n = 36) with nurse-physician manager dyads (12 nurses, 9 physicians) collected in a surgical department. Theoretical sampling was used to elaborate on properties of emerging concepts and categories. RESULTS/FINDINGS: A substantive theory on 'intentional partnering' was generated. Nurses' and physicians' professional agendas, which included their interests and purposes for working with each other served as the starting point of 'intentional partnering'. The theory explains how nurse and physician managers align their professional agendas through the processes of 'accepting mutual necessity', 'daring to risk (together)' and 'constructing a shared responsibility'. Being credible, earning trust and safeguarding respect were fundamental to communicating effectively. CONCLUSION: Intentional partnering elucidates the relational components of working together and the strategizing that occurs as each partner deliberates on what he or she is willing to accept, risk and put into place to reap the benefits of collaborating.

Surgical center: challenges and strategies for nurses in managerial activities. / Centro cirúrgico: desafios e estratégias do enfermeiro nas atividades gerenciais.

Objective: Analyze the challenges and strategies of nurses performing managerial activities in a surgical center. Method: Exploratory, descriptive study with a qualitative approach, involving six nurses by means of the Focus Group Technique, between April and August 2013. Data were submitted to thematic content analysis. Results: The main challenges noted were deficiency of material resources, communication noise, adequacy of personnel downsizing, and relationships with the multidisciplinary team. Key strategies include construction of co-management spaces to promote integration among professionals, conflict resolution and exchange of knowledge. Conclusions: Managerial activities involve the promotion of dialogic moments to coordinate the different processes in the surgical center to provide inputs to expand safety and quality of services provided.

Challenges with the establishment of congenital cardiac surgery centers in Nigeria: survey of cardiothoracic surgeons and residents.

BACKGROUND: There are gaps in understanding the challenges with the establishment of pediatric cardiac surgical practices in Nigeria. The aim of this study was to examine the prospects and challenges limiting the establishment of pediatric cardiac surgical practices in Nigeria from the perspectives of cardiothoracic surgeons and resident doctors. METHODS: A descriptive study was carried out to articulate the views of the cardiothoracic surgeons and cardiothoracic resident doctors in Nigeria. A self-administered questionnaire was used to generate information from the participants between December 2014 and January 2015. Data were analyzed using the SPSS version 21 statistical software package. RESULT: Thirty-one of the 51 eligible participants (60.7%) took part in the survey. Twenty-one (67.7%) were specialists/consultants, and 10 (32.3%) were resident doctors in cardiothoracic surgical units. Most of the respondents, 26 (83.9%) acknowledged the enormity of pediatric patients with cardiac problems in Nigeria; however, nearly all such children were referred outside Nigeria for treatment. The dearth of pediatric cardiac surgical centers in Nigeria was attributed to weak health system, absence of skilled manpower, funds, and equipment. Although there was a general consensus on the need for the establishment of open pediatric cardiac surgical centers in the country, their set up mechanisms were not explicit. CONCLUSIONS: The obvious necessity and huge potentials for the establishment of pediatric cardiac centers in Nigeria cannot be overemphasized. Nevertheless, weakness of the national health system, including human resources remains a daunting challenge. Therefore, local and international partnerships and collaborations with country leadership are strongly advocated to pioneer this noble service.

The Expanding Role of Education and Research in International Healthcare.

A recent report of the Lancet Commission on Global Surgery has continued to emphasize the importance of surgery in global health. Plastic surgeons have been involved in humanitarian care of children in developing countries for many years. The ability to repair children with cleft lip and palate in resource-poor settings has made this desirable for many plastic surgeons. A number of philanthropic plastic surgery organizations arose to deal with the problem in a more structured way. Dr. Donald Laub at Stanford established Interplast (now ReSurg) in 1969. Dr. Bill and Kathy Magee established Operation Smile in 1982, and many others have followed. The unifying theme of these organizations has been the desire to provide safe and effective surgical care to children who would otherwise be forced to live out their lives with deformity. Most care has been for children with clefts, but efforts have expanded to include hand surgery and burn reconstruction. The initial effort was provided through surgical missions. A paradigm shift has occurred as sustainability and local capacity have become paramount. Education and training of local colleagues and assistance in surgical safety infrastructure are expanding the reach of plastic surgical care around the globe. The inauguration of in-country permanent surgical centers allows high-volume outcomes research, as well as unique educational collaboration between plastic surgeons of both the developed and developing world.

The impact of developing a pectus center for chest wall deformities.

PURPOSE: In 2011, we established a dedicated center for patients with chest wall deformities. Here, we evaluate the center's effect on patient volume and management. METHODS: A retrospective review of 699 patients with chest wall anomalies was performed. Patients were compared, based on the date of initial consultation, before the pectus center opened (July 2009-June 2011, Group 1) versus after (July 2011-June 2013, Group 2). Analysis was performed utilizing Chi-square and Mann-Whitney U tests. RESULTS: 320 patients were in Group 1 and 379 in Group 2, an 18.4 % increase in patient volume. Excavatum patients increased from 172 (Group 1) to 189 (Group 2). Carinatum patients increased from 125 (Group 1) to 165 (Group 2). Patients undergoing operative repair of carinatum/mixed defects dropped significantly from 15 % (Group 1) to 1 % (Group 2) (p < 0.01), whereas those undergoing nonoperative bracing for carinatum/mixed defects rose significantly from 19 % (Group 1) to 63 % (Group 2) (p < 0.01). Patients traveled 3-1249 miles for a single visit. CONCLUSION: Initiating a dedicated pectus center increased patient volume and provided an effective transition to nonoperative bracing for carinatum patients. The concentrated focus of medical staff dedicated to chest wall deformities has allowed us to treat patients on a local and regional level.

[The technologies of inpatient care substitution in surgery]. / Statsionarzameshchayushchie tekhnologii v khirurgii.

It was analyzed the introduction of inpatient care substitution technologies in multi-disciplinary Polyclinic OAO «Gazprom¼. Organizational principles of outpatient surgical interventions under general and combined anesthesia are represented. Also it was described surgical features to decrease incidence of intra- and postoperative complications. System of active postoperative management was presented to define early different features of disease. Also main directions of development of this technology were suggested.

What Factors Influence Community Oral and Maxillofacial Surgeons' Choice to Use Capnography in the Office-Based Ambulatory Anesthesia Setting?

PURPOSE: The American Association of Oral and Maxillofacial Surgeons Board of Trustees mandated monitoring using capnography during moderate sedation (MS) and deep sedation or general anesthesia (DS/GA) delivered in the office setting effective January 1, 2014. The purpose of this study was to estimate the frequency of capnography use and to identify variables associated with a clinician's choice to use capnography before the mandate. MATERIALS AND METHODS: To address the research purpose, the authors designed a prospective cohort study and enrolled 2 samples: 1) American private practicing oral and maxillofacial surgeons (OMSs) and 2) all eligible patients for whom these OMSs delivered MS or DS/GA. The predictor variables were categorized as surgeon or patient demographics, anesthesia risk factors, procedure-related variables, and anesthetic medications. The outcome variable was capnography use during MS or DS/GA. Descriptive, bivariate, and forward stepwise multiple logistic regression statistics were computed to evaluate the association between the predictor variables and capnography use, with statistical significance set at a P value less than or equal to .05. RESULTS: The surgeon sample was composed of 95 OMSs and 13.7% reported using capnography. The patient sample included 3,495 patients with a mean age of 30.6 years (standard deviation, 17.8 yr), 43.5% were men, and 5.6% were monitored using capnography. Based on bivariate analyses, 17 variables were associated with capnography use. Forward stepwise regression modeling identified 9 variables statistically associated with capnography use. These variables were patient's age, Mallampati airway score, alcohol consumption, board certification, sevoflurane use, number of monitoring methods, electrocardiogram use, precordial stethoscope use, and number of personnel in operating suite. CONCLUSIONS: Although this study might be of historical interest at this time, the results offer insight into OMSs' practice patterns before the mandatory requirement to use capnography. As more OMSs comply with the capnography mandate, their practice patterns involving variables found to statistically correlate with capnography use might become more similar to those of early adopters of this technology.

Building Advanced Surgical Capacity at a Hospital in Port-au-Prince, Haiti.

To improve surgical capacity in developing countries, we must take a multifaceted approach that addresses all aspects of surgery in a hospital. Foreign non-governmental organizations with expertise and resources can play a role in helping to build surgical capacity in developing countries. Episodic surgical missions can contribute to reducing the burden of the disease, but must be coupled with training of local staff to assure capacity for the future. Lack of human resources and proper infrastructure should be addressed as part of the capacity-building process. Longitudinal educational programs improve the training of local staff over time. Scaling up from episodic surgical trips to building and maintaining fully functioning surgical capacity requires sustained and repeated interventions from a large group of stakeholders. Through partnerships with local government and nongovernmental organizations, each partner can amplify the effectiveness of the other to meet the challenges of complex surgical care in low-resource settings.

The Efficiency of Ophthalmic Ambulatory Surgery Centers.

Ambulatory surgery centers (ASCs) are important providers of ambulatory surgeries. However, little research exists examining the efficiency of ASCs in providing ambulatory surgical services. This study examined the technical efficiency of ASCs that concentrated on performing cataract surgeries, which are among the surgeries most commonly performed in the outpatient setting. This study, based on data from all active ASCs that provided the two most common cataract surgeries in California, found that a large proportion of ophthalmic ASCs were operating at low technical efficiency levels. The amount of slacks in input and output variables was estimated for each ASC, and the mean slacks were reported. The numbers of cataract surgery patients and operating rooms were found to significantly affect the efficiency of ophthalmic ASCs.

Impact of centralization of pancreatic cancer surgery on resection rates and survival.

BACKGROUND: Centralization of pancreatic surgery has been shown to reduce postoperative mortality. It is unknown whether resection rates and survival have also improved. The aim of this study was to analyse the impact of nationwide centralization of pancreatic surgery on resection rates and long-term survival. METHODS: All patients diagnosed in the Netherlands between 2000 and 2009 with cancer of the pancreatic head were identified in the Netherlands Cancer Registry. Changes in referral pattern, resection rates and survival after pancreatoduodenectomy were analysed. Multivariable regression analysis was used to assess the impact of hospital volume (20 or more procedures per year) on survival after resection. RESULTS: Between 2000 and 2009, 11,160 patients were diagnosed with cancer of the pancreatic head. The resection rate increased from 10.7 per cent in 2000-2004 to 15.3 per cent in 2005-2009 (P < 0.001). No significant difference in survival after resection was observed between the two intervals (P = 0.135), although survival was significantly better in high-volume hospitals (median survival 18 months versus 16 months in low/medium-volume hospitals; P = 0.017). After adjustment for patient and tumour characteristics, high hospital volume remained associated with better overall survival after resection (hazard ratio 0.70, 95 per cent confidence interval 0.58 to 0.84; P < 0.001). CONCLUSION: Centralization of pancreatic cancer surgery led to increased resection rates. High-volume centres had significantly better survival rates. Centralization improves patient outcomes and should be encouraged.

Status of cardiac surgical intensive care medicine in Germany during 2013: a report on behalf of the German Society for Thoracic and Cardiovascular Surgery.

BACKGROUND: This report summarizes the results of a voluntary survey designed to assess the current situation of cardiac surgical intensive care medicine in Germany in 2013. METHODS: standardized questionnaire concerning detailed information about structural characteristics of cardiac surgical intensive care units (ICUs) was sent to all German departments performing cardiac surgery. RESULTS: Participation quota resp. response rate was 100%. Compared with previous surveys since 1998, the total number of available intensive care capacities for patients after cardiac surgery increased to 1,404 beds, whereas the proportion of cardiac surgical ICUs decreased to 59% with a simultaneous increase of interdisciplinary ICUs. The proportion of cardiac surgeons acting as director of an ICU declined to 36%. The physicians' teams were predominantly interdisciplinary (74%). More than half of the directors were board-certified intensivists (54%), with a peak of 81% in ICUs run by cardiac surgeons. Human resources development in the ICU showed divergent trends with an increase of physicians and a decrease of nurses. Half of all ICUs (50%) and two-thirds of cardiac surgical ICUs (65%) offer an accredited training program for intensive care medicine. CONCLUSION: The results of this survey corroborate that intensive care medicine represents a substantial and important part of cardiac surgery. However, efforts are necessary to keep this attitude alive for the future.

Specialty-specific trends in the prevalence and distribution of outpatient surgery: implications for payment and delivery system reforms.

BACKGROUND: With nearly 53 million ambulatory procedures performed annually, future efforts to achieve greater value in surgical care should include a focus on outpatient surgery. To inform such efforts, a better understanding of specialty-specific trends in outpatient surgery is required. OBJECTIVES: To assess the prevalence and distribution of outpatient surgery across specialties. RESEARCH DESIGN: Repeated cross-sectional. MEASURES: Using all-payer data from Florida (1998-2008), we identified physicians who performed one or more procedures. We assigned a specialty to each physician based on his procedure mix. After measuring the proportion of procedures performed on an outpatient basis, we assessed for specialty-specific changes over time in this proportion. Finally, we determined the frequency with which individual specialties used surgery centers for their outpatient care. RESULTS: More than two thirds (67.8%) of all surgical procedures are carried out on an outpatient basis. The popularity of outpatient surgery has grown among many specialties over the past decade, including several (urology, gastroenterology, plastic surgery, and ophthalmology) that perform most of their cases in outpatient settings. Within surgical disciplines, overall trends in the use of outpatient surgery are strongly associated with the specialty's affinity for freestanding ambulatory surgery centers (Pearson's correlation coefficient = 0.76; P < .001). CONCLUSIONS: A majority of surgeons in many specialties now provide predominantly outpatient care. Incorporating these findings into the design of future payment and delivery system reforms will help ensure adequate surgeon exposure to the efficiency gains that evolve from them.

[Formation of centers in general and abdominal surgery -- necessity or trend?]. / Zentrenbildung in der Allgemein- und Viszeralchirurgie - Notwendigkeit oder Trend?

The introduction of the DRG (diagnosis-related groups) system as basis for reimbursement in the German health-care system has led to a mentality of quality orientation and verification of therapeutic results. An immediate result was the formation of medical "centres" on rather different levels and consequently the inauguration of institutions, authorities, and organisations to review these centres. Finally, a range of certifications was installed in order to stratify the rather diverse aims of different centres. This review critically evaluates the current situation in the field of general and abdominal surgery in Germany.

Organization and activity of the Replantation Service for amputated hands in Poland.

A permanent on-call service for hand amputations (Replantation Service) was established in 2010 of the initiative of the Council of Polish Society for Surgery of the Hand. It is run by three qualified hand centres in Trzebnica, Poznan and Szczecin. Organization of this system, rules of activity and spectrum of cases admitted to replantation units was presented. A scheme of referral of amputations was shown and the main problems that appeared during almost three-year activity of the Service were discussed. Medico-legal and ethical implications arising from these problems were shown and organization of replantation service in other European countries was outlined. Establishing of the Replantation Service constituted a significant progress in the organization of the management of upper limb amputations. Thanks to that, over the period of three years, more than 200 patients were saved from severe disability, receiving a chance to regain an amputated limb.

[Intensive care and resuscitation in reconstructive surgery: 50 years of progress].

The article deals with fundamental stages of resuscitation and intensive therapy development in reconstructive surgery during 50 years of Petrovsky National Research Centre of RAMS functioning. Appreciation was given to academician of RAMS R.N.Lebedeva for outstanding services in local public health, as organizer of the one of the first specialized resuscitation and intensive care departments in our country. Researches in the department are traditionally oriented to the diagnostic methods development, prevention and intensive care of vital functions violations in patients after reconstructive operations. It helped to limit contraindications for surgery and to implement radical surgery in patients with severe concomitant diseases, as well as to reduce the number of postoperative complications and mortality

Sustainable surgical resource initiative for Haiti: the SSRI-Haiti project.

In response to the 2010 earthquake and subsequent cholera epidemic, St Luke's Medical Center was established in Port-au-Prince, Haiti. Here, we describe its inception and evolution to include an intensive care unit and two operating rooms, as well as the staffing, training and experiential learning activities, which helped St Luke's become a sustainable surgical resource. We describe a three-phase model for establishing a sustainable surgical centre in Haiti (build facility and acquire equipment; train staff and perform surgeries; provide continued education and expansion including regular specialist trips) and we report a progressive increase in the number and complexity of cases performed by all-Haitian staff from 2012 to 2022. The results are generalised in the context of the 'delay framework' to global health along with a discussion of the application of this three-phase model to resource-limited environments. We conclude with a brief description of the formation of a remote surgical centre in Port-Salut, an unforeseen benefit of local competence and independence. Establishing sustainable and collaborative surgery centres operated by local staff accelerates the ability of resource-limited countries to meet high surgical burdens.