Establishing criteria for pediatric epilepsy surgery center levels of care: Report from the ILAE Pediatric Epilepsy Surgery Task Force.

Presurgical evaluation and surgery in the pediatric age group are unique in challenges related to caring for the very young, range of etiologies, choice of appropriate investigations, and surgical procedures. Accepted standards that define the criteria for levels of presurgical evaluation and epilepsy surgery care do not exist. Through a modified Delphi process involving 61 centers with experience in pediatric epilepsy surgery across 20 countries, including low-middle- to high-income countries, we established consensus for two levels of care. Levels were based on age, etiology, complexity of presurgical evaluation, and surgical procedure. Competencies were assigned to the levels of care relating to personnel, technology, and facilities. Criteria were established when consensus was reached (≥75% agreement). Level 1 care consists of children age 9 years and older, with discrete lesions including hippocampal sclerosis, undergoing lobectomy or lesionectomy, preferably on the cerebral convexity and not close to eloquent cortex, by a team including a pediatric epileptologist, pediatric neurosurgeon, and pediatric neuroradiologist with access to video-electroencephalography and 1.5-T magnetic resonance imaging (MRI). Level 2 care, also encompassing Level 1 care, occurs across the age span and range of etiologies (including tuberous sclerosis complex, Sturge-Weber syndrome, hypothalamic hamartoma) associated with MRI lesions that may be ill-defined, multilobar, hemispheric, or multifocal, and includes children with normal MRI or foci in/abutting eloquent cortex. Available Level 2 technologies includes 3-T MRI, other advanced magnetic resonance technology including functional MRI and diffusion tensor imaging (tractography), positron emission tomography and/or single photon emission computed tomography, source localization with electroencephalography or magnetoencephalography, and the ability to perform intra- or extraoperative invasive monitoring and functional mapping, by a large multidisciplinary team with pediatric expertise in epilepsy, neurophysiology, neuroradiology, epilepsy neurosurgery, neuropsychology, anesthesia, neurocritical care, psychiatry, and nursing. Levels of care will improve safety and outcomes for pediatric epilepsy surgery and provide standards for personnel and technology to achieve these levels.

SCAI position statement on the performance of percutaneous coronary intervention in ambulatory surgical centers.

The Centers for Medicare & Medicaid Services (CMS) began reimbursement for percutaneous coronary intervention (PCI) performed in ambulatory surgical centers (ASC) in January 2020. The ability to perform PCI in an ASC has been made possible due to the outcomes data from observational studies and randomized controlled trials supporting same day discharge (SDD) after PCI. In appropriately selected patients for outpatient PCI, clinical outcomes for SDD or routine overnight observation are comparable without any difference in short-term or long-term adverse events. Furthermore, a potential for lower cost of care without a compromise in clinical outcomes exists. These studies provide the framework and justification for performing PCI in an ASC. The Society for Cardiovascular Angiography and Interventions (SCAI) supported this coverage decision provided the quality and safety standards for PCI in an ASC were equivalent to the hospital setting. The current position paper is written to provide guidance for starting a PCI program in an ASC with an emphasis on maintaining quality standards. Regulatory requirements and appropriate standards for the facility, staff and physicians are delineated. The consensus document identified appropriate patients for consideration of PCI in an ASC. The key components of an ongoing quality assurance program are defined and the ethical issues relevant to PCI in an ASC are reviewed.

Obtaining and Modeling Variability in Travel Times From Off-Site Satellite Clinics to Hospitals and Surgery Centers for Surgeons and Proceduralists Seeing Office Patients in the Morning and Performing a To-Follow List of Cases in the Afternoon.

BACKGROUND: Hospitals achieve growth in surgical caseload primarily from the additive contribution of many surgeons with low caseloads. Such surgeons often see clinic patients in the morning then travel to a facility to do 1 or 2 scheduled afternoon cases. Uncertainty in travel time is a factor that might need to be considered when scheduling the cases of to-follow surgeons. However, this has not been studied. We evaluated variability in travel times within a city with high traffic density. METHODS: We used the Google Distance Matrix application programming interface to prospectively determine driving times incorporating current traffic conditions at 5-minute intervals between 9:00 AM and 4:55 PM during the first 4 months of 2018 between 4 pairs of clinics and hospitals in the University of Miami health system. Travel time distributions were modeled using lognormal and Burr distributions and compared using the absolute and signed differences for the median and the 0.9 quantile. Differences were evaluated using 2-sided, 1-group t tests and Wilcoxon signed-rank tests. We considered 5-minute signed differences between the distributions as managerially relevant. RESULTS: For the 80 studied combinations of origin-to-destination pairs (N = 4), day of week (N = 5), and the hour of departure between 10:00 AM and 1:55 PM (N = 4), the maximum difference between the median and 0.9 quantile travel time was 8.1 minutes. This contrasts with the previously published corresponding difference between the median and the 0.9 quantile of 74 minutes for case duration. Travel times were well fit by Burr and lognormal distributions (all 160 differences of medians and of 0.9 quantiles <5 minutes; P < .001). For each of the 4 origin-destination pairs, travel times at 12:00 PM were a reasonable approximation to travel times between the hours of 10:00 AM and 1:55 PM during all weekdays. CONCLUSIONS: During mid-day, when surgeons likely would travel between a clinic and an operating room facility, travel time variability is small compared to case duration prediction variability. Thus, afternoon operating room scheduling should not be restricted because of concern related to unpredictable travel times by surgeons. Providing operating room managers and surgeons with estimated travel times sufficient to allow for a timely arrival on 90% of days may facilitate the scheduling of additional afternoon cases especially at ambulatory facilities with substantial underutilized time.

Malignant Hyperthermia-Susceptible Adult Patient and Ambulatory Surgery Center: Society for Ambulatory Anesthesia and Ambulatory Surgical Care Committee of the American Society of Anesthesiologists Position Statement.

This document represents a joint effort of the Society for Ambulatory Anesthesia (SAMBA) and the Ambulatory Surgical Care Committee of the American Society of Anesthesiologists (ASA) concerning the safe anesthetic care of adult malignant hyperthermia (MH)-susceptible patients in a free-standing ambulatory surgery center (ASC). Adult MH-susceptible patients can safely undergo a procedure in a free-standing ASC assuming that proper precautions for preventing, identifying, and managing MH are taken. The administration of preoperative prophylaxis with dantrolene is not indicated in MH-susceptible patients scheduled for elective surgery. There is no evidence to recommend an extended stay in the ASC, and the patient may be discharged when the usual discharge criteria for outpatient surgery are met. Survival from an MH crisis in an ASC setting requires early recognition, prompt treatment, and timely transfer to a center with critical care capabilities.

Association of Candidate Removals From the Kidney Transplant Waiting List and Center Performance Oversight.

Approximately 59 000 kidney transplant candidates have been removed from the waiting list since 2000 for reasons other than transplantation, death, or transfers. Prior studies indicate that low-performance (LP) center evaluations by the Scientific Registry of Transplant Recipients (SRTR) are associated with reductions in transplant volume. There is limited information to determine whether performance oversight impacts waitlist management. We used national SRTR data to evaluate outcomes of 315 796 candidates on the kidney transplant waiting list (2007-2014). Compared to centers without LP, rates of waitlist removal (WLR) were higher at centers with LP evaluations (44.6/1000 follow-up years, 95% confidence interval [CI] 44.0, 45.1 versus 68.0/1000 follow-up years, 95% CI 66.6, 69.4), respectively, which was consistent after risk adjustment (adjusted hazard ratio [AHR] = 1.59, 95% CI 1.55, 1.63). Candidate mortality following waitlist removal was lower at LP centers (AHR = 0.90, 95% CI 0.87, 0.94). Analyses limited to LP centers indicated a significant increase in WLR (+28.6 removals/1000 follow-up years, p < 0.001), a decrease in transplant rates (-11.9/1000 follow-up years, p < 0.001) and a decrease in mortality after removal (-67.5 deaths/1000 follow-up years, p < 0.001) following LP evaluation. There is a significant association between LP evaluations and transplant center processes of care for waitlisted candidates. Further understanding is needed to determine the impact of performance oversight on transplant center quality of care and patient outcomes.

[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.

Association between liver transplant center performance evaluations and transplant volume.

There has been increased oversight of transplant centers and stagnation in liver transplantation nationally in recent years. We hypothesized that centers that received low performance (LP) evaluations were more likely to alter protocols, resulting in reduced rates of transplants and patients placed on the waiting list. We evaluated the association of LP evaluations and transplant activity among liver transplant centers in the United States using national Scientific Registry of Transplant Recipients data (January 2007 to July 2012). We compared the average change in recipient and candidate volume and donor and patient characteristics based on whether the centers received LP evaluations. Of 92 eligible centers, 27 (29%) received at least one LP evaluation. Centers without an LP evaluation (n = 65) had an average increase of 9.3 transplants and 14.9 candidates while LP centers had an average decrease of 39.9 transplants (p < 0.01) and 67.3 candidates (p < 0.01). LP centers reduced the use of older donors, donations with longer cold ischemia, and donations after cardiac death (p-values < 0.01). There was no association between the change in transplant volume and measured performance (R(2) = 0.002, p = 0.91). Findings indicate a strong association between performance evaluations and changes in candidate listings and transplants among liver transplant centers, with no measurable improvement in outcomes associated with reduction in transplant volume.

National Vascular Registry Report on surgical outcomes and implications for vascular centres.

BACKGROUND: The National Vascular Registry Report on Surgical Outcomes (NVSRO) coincided with the update of the National Health Service Standard Contract for Specialized Vascular Services in Adults (NHSSCSVS). The latter promises patients minimum standards for vascular centres. The present study aimed to determine whether current data support the standards proposed in the NHSSCSVS. METHODS: Numbers of abdominal aortic aneurysm (AAA) repairs and carotid endarterectomies (CEAs) performed by hospital Trust and surgeon, and their outcomes were obtained from the NVRSO. These were assessed against NHSSCSVS recommendations that included: more than 60 AAA repairs per year per Trust, over 50 CEAs per year per Trust and at least six vascular surgeons per Trust. RESULTS: Based on NVRSO data, 107 hospital Trusts (92.2 per cent) would fail to meet the minimum standards required to achieve vascular centre status. Outcomes were poorer in these hospitals (overall mortality rate after AAA: 2.7 versus 1.3 per cent; P = 0.007). There were strong associations between number of AAA repairs or CEAs per Trust and better outcomes (AAA repair, P < 0.001; CEA, P = 0.004). These remained significant when analysed by individual surgeon (AAA repair, P < 0.001; CEA, P < 0.001). Trusts undertaking 60 or fewer elective AAA repairs per year had significantly higher elective AAA mortality rates (2.7 versus 1·7 per cent; P = 0.010). Trusts performing a minimum of 50 CEAs per year had significantly lower perioperative mortality/morbidity rates (1.9 versus 3.0 per cent; P = 0.032). Trusts with seven or more surgeons demonstrated lower AAA-related mortality rates (1.7 versus 2.7 per cent; P = 0.018). CONCLUSION: Data from the NVRSO suggest that the majority of hospital Trusts presently fail to meet the standards for vascular centre status. NVRSO data support a standard of more than 60 elective AAA repairs and 50 CEAs per Trust per year. A minimum of seven vascular surgeons per unit was associated with better outcomes. These data support the ongoing remodelling of vascular services in the UK.

Discharge from an emergency department observation unit and a surgical assessment unit: experiences of patients with acute abdominal pain.

AIMS AND OBJECTIVES: To investigate the experiences of patients with acute abdominal pain at discharge from an emergency department observation unit compared with discharge from a surgical assessment unit. BACKGROUND: The increase in emergency department observation units has increased short-term admissions and changed the patient journey from admission and discharge from specialised wards staffed by specialist nurses to admission and discharge from units staffed by emergency nurses. DESIGN: A comparative qualitative interview study. METHODS: The study included 20 patients: 10 from an emergency department observation unit and 10 from a surgical assessment unit, and took a phenomenological-hermeneutic approach. Patients were interviewed at discharge and three months later. RESULTS: More patients from the emergency department observation unit experienced readiness for discharge and had plans for follow-up, compared with patients from the surgical assessment unit. In the surgical assessment unit, more patients were readmitted, had unanswered questions after three months and experienced a follow-up visit at the general practitioner as insufficient. More patients from the surgical assessment unit reported receiving useful self-care advice, compared with those from the emergency department observation unit. CONCLUSION: The experience of emergency department observation unit patients on discharge and follow-up was that the health professionals were more supportive, compared with surgical assessment unit patients, who felt discharge occurred too early, but with more preparation for independent home self-care. These results are an important factor in the patient experience of discharge from hospital and may reflect differences in specialisation of the nurses. RELEVANCE TO CLINICAL PRACTICE: Units discharging patients with acute abdominal pain could be inspired by scheduled fast-track surgery programmes with structured information about admission, treatment and follow-up and easy access to relevant health professionals after discharge.

Challenges of safety culture in Surgical Center: mixed methods study.

OBJECTIVE: to analyze the safety attitudes of health and support areas professionals working in Surgical Center. METHOD: sequential explanatory mixed methods study. The quantitative stage covered 172 health and support professionals in eight Surgical Centers of a hospital complex. The Safety Attitudes Questionnaire/Surgical Center was applied. In the subsequent qualitative stage, 16 professionals participated in the Focus Group. Photographic methods were used from the perspective of ecological and restorative thinking, and data analysis occurred in an integrated manner, through connection. RESULTS: the general score, by group of Surgical Centers, based on the domains of the Safety Attitudes Questionnaire/Surgical Center, reveals a favorable perception of the safety climate, with emphasis on the domains Stress Perception, Communication in the Surgical Environment, Safety Climate and Perception of Professional Performance. The overall analysis of the domain Communication and Collaboration between Teams appears positive and is corroborated by data from the qualitative stage, which highlights the importance of interaction and communication between healthcare teams as fundamental for daily work. CONCLUSION: the perception of safety attitudes among health and support professionals was positive. The perception of the nursing team stands out as closer or more favorable to attitudes consistent with the safety culture.

Program-specific reports: implications and impact on program behavior.

PURPOSE OF REVIEW: Measuring and monitoring transplant center performance is vital to ongoing quality assessment and performance improvement initiatives geared toward ensuring optimal care for patients with end-stage organ failure. The impact of regulatory oversight on transplant center behavior and programmatic decision-making is complex. RECENT FINDINGS: Program-specific reports (PSRs) are published by the Scientific Registry for Transplant Recipients (SRTR) and are publically available for use by a variety of stakeholders, including patients, regulators, insurers, and care providers. PSRs have been both groundbreaking and controversial. The principal areas of concern relate to potential unintended consequences of PSRs, limitations in both the data collected by the registry and the currently used statistical methodology employed by the SRTR for risk adjustment, and the subsequent impact on transplant program behavior. SUMMARY: PSRs, which serve the purposes of fueling ongoing performance improvement initiatives and informing consumers and payers by fostering transparency in the communication of risk, also involve trade-offs because of their unintended use for regulatory oversight and subsequent impact on transplant center behavior. Future research is necessary to improve data integrity and risk-adjustment methodologies which will enhance regulation and preserve access to transplantation among vulnerable patient populations.

Factors affecting the use of patient survey data for quality improvement in the Veterans Health Administration.

BACKGROUND: Little is known about how to use patient feedback to improve experiences of health care. The Veterans Health Administration (VA) conducts regular patient surveys that have indicated improved care experiences over the past decade. The goal of this study was to assess factors that were barriers to, or promoters of, efforts to improve care experiences in VA facilities. METHODS: We conducted case studies at two VA facilities, one with stable high scores on inpatient reports of emotional support between 2002 and 2006, and one with stable low scores over the same period. A semi-structured interview was used to gather information from staff who worked with patient survey data at the study facilities. Data were analyzed using a previously developed qualitative framework describing organizational, professional and data-related barriers and promoters to data use. RESULTS: Respondents reported more promoters than barriers to using survey data, and particularly support for improvement efforts. Themes included developing patient-centered cultures, quality improvement structures such as regular data review, and training staff in patient-centered behaviors. The influence of incentives, the role of nursing leadership, and triangulating survey data with other data on patients' views also emerged as important. It was easier to collect data on current organization and practice than those in the past and this made it difficult to deduce which factors might influence differing facility performance. CONCLUSIONS: Interviews with VA staff provided promising examples of how systematic processes for using survey data can be implemented as part of wider quality improvement efforts. However, prospective studies are needed to identify the most effective strategies for using patient feedback to improve specific aspects of patient-centered care.

Office accreditation experiences with 3 accrediting agencies and suggestions for changes in private oral and maxillofacial surgery facility evaluations.

Historically, oral and maxillofacial surgeons have had considerable autonomy in operating their offices. Oral and maxillofacial surgeons have had a singular history of safety, training, and success in outpatient anesthesia in their offices. However, preventable patient morbidity and mortality in private office-based surgical facilities of a variety of professions have brought increased scrutiny to the office environment. The present report describes the experiences of 3 oral and maxillofacial surgeons with 3 accrediting agencies in obtaining office accreditation and offers recommendations to be considered for the future of our specialty in terms of private office certification.

Potentially pathogenic acanthamoeba isolated from a hospital in Brazil.

Studies on free-living amoebae (FLA), has been increased in recent years, especially related to the genus Acanthamoeba, because these organisms are widely found in the environment. The present work isolated and characterized this organism from biofilms and dust in hospital environment. 135 samples were collected in 15 different environments in a hospital at the south of Brazil. Thirty-one (23%) isolates were identified as morphologically belonging to the Acanthamoeba genus and 10 of these were submitted to temperature and osmotolerance tests as criterion for evaluation of the viability and pathogenicity. The tests indicate that four (40%) of these isolates could be potentially pathogenic because grew at high temperature (40 degrees C) and osmolarity (mannitol 1 M). Some isolates genotypes were determined after ribosomal DNA sequencing. These data revealed that three dust isolates belong to T4, two biofilm isolates to T5 and one dust isolate to T3 genotype. Therefore, Acanthamoeba found in the hospital environment represents a risk for people that circulate there.

[Surgical Center environment and its elements: implications for nursing care]. / Ambiente do Centro Cirúrgico e os elementos que o integram: implicações para os cuidados de enfermagem.

The purpose of this qualitative research was to characterize the elements that constitute the environment of the Surgical Center and to analyze its implications for dynamic of care and nursing care. Based on the Environmental Theory's principals. Participated twelve nurses from the Surgical Center of a College Hospital in Rio de Janeiro. Data were gathered through the creativity and sensitivity technique "Map-Speaker", semi-structered interviews and participant observation, and were analyzed by thematic categories. The results showed that care can happen directly and indirectly in favor of full client recovery, counting the environment that the integrate in purpose to maintain harmonic and balanced. The nurse interventions aim to maintain the environment in favorable conditions so that a higher standard of care can be promoted.