The emergence of the physician assistant role in a Canadian acute care surgery setting.

BACKGROUND: The role of physician assistants (PAs) in surgical care in Canada is expanding. Similarly, the acute care surgery (ACS) model continues to evolve, and PAs are increasingly being considered as members of ACS teams. However, their exact impact and contribution has not been well studied. Our study describes the contribution of a PA who worked full time on weekdays on an ACS team in a Canadian academic tertiary hospital. METHODS: To quantify the PA's contributions, an ACS database was created in September 2016. Data on the number of ACS patient encounters, the number of ACS surgical consults, the number of ACS admissions, the PA's involvement in the operating room, the number of PA patient encounters and the number of multidisciplinary meetings were prospectively collected. We report data for 365 consecutive days from Dec. 30, 2016, to Dec. 29, 2017. RESULTS: The ACS team had 11 651 patient encounters during the year, with a mean of 31.92 per day. The mean number of surgical consults per day was 5.89, and a mean of 2.08 surgical procedures were performed per day. The PA was involved in 53.5% of all patient encounters, despite working only during daytime hours on weekdays. Multidisciplinary meetings were conducted by the PA 94.9% of the time. Alternate level of care patients were seen by the PA 96.2% of the time. The PA was directly involved in 2.0% of the operating room procedures during the study period. CONCLUSION: Integrating a PA on an ACS team adds value to patient care by providing consistency and efficient management of ward issues and patient care plans, including multidisciplinary discharge planning, timely emergency department consultations and effective organization of the ACS team members.

CONTEXTE: Les adjoints au médecin (AM) jouent un rôle croissant dans les soins chirurgicaux au Canada. Suivant la même tendance, le modèle de chirurgie en soins actifs (CSA) poursuit son évolution, et on considère de plus en plus les AM comme des membres des équipes de CSA. Cependant, les retombées de leur travail et leur contribution ont été peu étudiées, et de façon imprécise. Notre étude décrit la contribution d'un AM travaillant à temps plein, en semaine, au sein d'une équipe de CSA dans un centre hospitalier universitaire canadien de soins tertiaires. MÉTHODES: Afin de quantifier la contribution de l'AM, nous avons créé une base de données de CSA en septembre 2016. Nous avons collecté les données ­ nombre de rencontres avec des patients, de consultations et d'admissions de l'équipe; participation de l'AM au bloc opératoire; nombre de rencontres de l'AM avec des patients; nombre de réunions multidisciplinaires ­ de manière prospective. Nos données décrivent une période de 365 jours consécutifs, qui s'étale du 30 décembre 2016 au 29 décembre 2017. RÉSULTATS: L'équipe de CSA a tenu 11 651 rencontres avec des patients dans l'année, pour une moyenne de 31,92 par jour. En moyenne, elle a réalisé 5,89 consultations et 2,08 interventions chirurgicales quotidiennement. L'AM a participé à 53,5 % des rencontres avec les patients, et ce malgré son horaire de jour et de semaine. L'AM a aussi dirigé 94,9 % des réunions multidisciplinaires, a vu 96,2 % des patients d'autres niveaux de soins, et a participé à 2,0 % des interventions au bloc opératoire. CONCLUSION: L'intégration d'un AM aux équipes de CSA est une valeur ajoutée pour les soins aux patients. Elle contribue à la gestion cohérente et efficace des événements au sein du service et des plans de soins, y compris la planification multidisciplinaire des congés, les consultations rapides à l'urgence et l'organisation efficace de l'équipe.

Keratinocyte cancer excisions in Australia: Who performs them and associated costs.

BACKGROUND/OBJECTIVE: To describe the clinical settings in which keratinocyte cancers are excised in Queensland and describe the types of practitioners who excise them; to examine costs; and to identify predictors of hospital admission. METHODS: We used linked data for participants from the QSkin study (n = 43 794), including Medicare claims and Queensland hospital admissions relating to treatment episodes for incident keratinocyte cancers from July 2011 to June 2015. We used multinomial logistic regression to measure associations between demographic and clinical characteristics and treatment setting. The median costs of Medicare claims (AU$) were calculated. RESULTS: During 4 years of follow-up, there were 18 479 skin cancer excision episodes among 8613 people. Most excisions took place in private clinical rooms (89.7%), the remainder in hospitals (7.9% private; 2.4% public). Compared with other anatomical sites, skin cancers on the nose, eyelid, ear, lip, finger or genitalia were more likely to be treated in hospitals than in private clinical rooms (public hospital OR 5.7; 95%CI 4.5-7.2; private hospital OR 8.3; 95%CI 7.3-9.4). Primary care practitioners excised 83% of keratinocyte cancers, followed by plastic surgeons (9%) and dermatologists (6%). The median Medicare benefit paid was $253 in private clinical rooms and $334 in private hospitals. Out-of-pocket payments by patients treated in private hospitals were fourfold higher than those in private clinical rooms ($351 vs $80). CONCLUSIONS: Most keratinocyte cancers are excised in primary care, although more than 10% of excisions occur in hospital settings.

Real-world comparison of in-hospital Reveal LINQ insertable cardiac monitor insertion inside and outside of the cardiac catheterization or electrophysiology laboratory.

BACKGROUND: Traditionally, insertable cardiac monitor (ICM) procedures have been performed in the cardiac catheterization (CATH) or electrophysiology (EP) laboratory. The introduction of the miniaturized Reveal LINQ ICM has led to simplified and less invasive procedures, affording hospitals flexibility in planning where these procedures occur without compromising patient safety or outcomes. METHODS: The present analysis of the ongoing, prospective, observational, multicenter Reveal LINQ Registry sought to provide real-world feasibility and safety data regarding the ICM procedure performed in the CATH/EP lab or operating room and to compare it with insertions performed outside of these traditional hospital settings. Patients included had at least a 30-day period after the procedure to account for any adverse events. RESULTS: We analyzed 1222 patients (58.1% male, age 61.0 ± 17.1 years) enrolled at 18 centers in the US, 17 centers in Middle East/Asia, and 15 centers in Europe. Patients were categorized into 2 cohorts according to the location of the procedure: in-lab (CATH lab, EP lab, or operating room) (n = 820, 67.1%) and out-of-lab (n = 402, 32.9%). Several differences were observed regarding baseline and procedure characteristics. However, no significant differences in the occurrence of procedure-related adverse events (AEs) were found; of 19 ICM/procedure-related AEs reported in 17 patients (1.4%), 11 occurred in the in-lab group (1.3%) and 6 in the out-of-lab group (1.5%) (P = .80). CONCLUSIONS: This real-world analysis demonstrates the feasibility of performing Reveal LINQ ICM insertion procedures outside of the traditional hospital settings without increasing the risk of infection or other adverse events.

Systematic Review of Voice Outcomes for Injection Laryngoplasty Performed under Local vs General Anesthesia.

Objective To assist otolaryngologists in counseling patients with hoarseness who would benefit from injection laryngoplasty on whether or not to perform the procedure in the office vs the operating room. Data Sources Cochrane library, CINAHL, PubMed, and EMBASE. Review Methods Systematic review using Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) reporting standards of English-language articles that compared voice outcomes for in-office and in the operating room injection laryngoplasty. Two independent investigators assessed study eligibility, rated the quality using Methodological Index for Non-Randomized Studies (MINORS), and abstracted data for comparative analysis. Results Of 689 initial studies, 4 observational, comparative studies met inclusion criteria, with follow-up of 2 weeks to 12 months postinjection. Laryngoplasty was most commonly performed for vocal fold immobility with varied injectable materials (micronized dermis, hyaluronic acid, and calcium hydroxyapatite). Follow-up ranged from 2 weeks to 12 months. Voice outcomes improved in all studies, with comparable improvement for patients injected in the office vs the operating room ( P = .42 to P = .88). Meta-analysis of 3 studies showed no difference in Voice Handicap Index-10 voice outcomes by treatment setting (standardized mean difference -0.11, P = .441), with the 95% confidence interval (-0.405 to 0.176), making it unlikely that anything larger than a small or trivial difference was missed. Conclusion Our systematic review makes it unlikely that meaningful clinical differences exist in postprocedure voice outcomes for injection laryngoplasty in the office vs the operating room.

Data-driven process to improve VA surgical flow.

Purpose During years 2014-2016, Veterans Health Administration National Surgery Office conducted a surgical flow improvement initiative (SFII) to assist low-performing surgery programs to improve their operating room efficiency (ORE). The initiative was co-sponsored by VHA National Surgery Office and VHA Office of Systems Redesign and Improvement. The paper aims to discuss this issue. Design/methodology/approach An SFII algorithm, based on first-time-start (FTS), cancellation rate (CR), lag time (LT) and OR utilization, assigned an ORE performance Level (1-low to 4-high) to each VA Medical Center (VAMC). In total, 15 VAMCs with low-performance surgery programs participated in SFII to assess the current state of their surgical flow processes and used redesign methods to focus on improvement objectives. Findings At the end of the project, 14 VSAs, 40 RPIWs, 45 "90-day projects" and 73 Just-Do-It's were completed with 65 percent (158/243) improvement actions and 86 percent sites improving/sustaining all four ORE metrics. There was a statistically significant difference in improvement across the three stages (baseline, improvement, sustain) for FTS (45.6-68.7 percent; F=44.74; p<0.000); CR (16.1-9.5 percent; F=34.46; p<0.000); LT (63.1-36.3 percent; F=92.00; p<0.000); OR utilization (43.4-57.7 percent; F=6.92; p<0.001) and VAMC level (1.7-3.65; F=80.11; p<0.000). The majority developed "fair to excellent" sustainment (91 percent) and spread (82 percent) plans. The projected annual estimated return-on-investment was $27,949,966. Originality/value The SFII successfully leveraged a small number of faculty, coaches, and industrial engineers to produce significant improvement in ORE across a large national integrated health care network. This strategy can serve healthcare leaders in managing complex healthcare issues in their facilities.

Integrated Practice Improvement Solutions-Practical Steps to Operating Room Management.

UNLABELLED: Perioperative productivity is a vital concern for surgeons, anesthesiologists, and administrators as the OR is a major source of hospital elective admissions and revenue. Based on elements of existing Practice Improvement Methodologies (PIMs), "Integrated Practice Improvement Solutions" (IPIS) is a practical and simple solution incorporating aspects of multiple management approaches into a single open source framework to increase OR efficiency and productivity by better utilization of existing resources. MATERIALS AND METHODS: OR efficiency was measured both before and after IPIS implementation using the total number of cases versus room utilization, OR/anesthesia revenue and staff overtime (OT) costs. Other parameters of efficiency, such as the first case on-time start and the turnover time (TOT) were measured in parallel. RESULTS: IPIS implementation resulted in increased numbers of surgical procedures performed by an average of 10.7%, and OR and anesthesia revenue increases of 18.5% and 6.9%, respectively, with a simultaneous decrease in TOT (15%) and OT for anesthesia staff (26%). The number of perioperative adverse events was stable during the two-year study period which involved a total of 20,378 patients. CONCLUSION: IPIS, an effective and flexible practice improvement model, was designed to quickly, significantly, and sustainably improve OR efficiency by better utilization of existing resources. Success of its implementation directly correlates with the involvement of and acceptance by the entire OR team and hospital administration.

Evidence-Triggered for Care of Patients with Cleft Lip and Palate in Srinagarind Hospital: Operating Room.

Background: The operating room Srinagarind hospital handles most cases that require surgical repair including cleft lip and palate patients. The average number of patients undergone surgical correction has risen to 216 in 2016 from 150 in 2014. Patients who underwent surgery, particularly infants had to be separated from family, stay in restricted place, abstaining from food and water, these create stress, fear, anxiety and pain to the child and may have affected to the outcomes of the treatment. For parents and families will also are anxious, and fears about the disease and treatment, losing children, disabled children after the surgery. In addition, their concerns with complications of surgery and chance of recovery. Therefore, there is a need to examine the clinical problems of patients who undergo surgery for cleft lip and palate in order to provide comprehensive care. Objective: To identify problems in regards to care for patients with cleft lip and palate, in the operating room, Srinagarind Hospital. Material and Method: The descriptive study was conducted involving nine departments of nursing services, Srinagarind Hospital. After the consideration of human ethic, both quantitative and qualitative data were collected based on The Center for Advance Nursing Practice Model through the following four stimulators: 1) reviewed 30 patients medical records; 2) reviewed four related literatures; 3) surveyed nurses opinion towards health condition's and the effects of the 10 families with cleft lip and palate; and 4) interviewed ten mothers and families towards the health of cleft lip and palate children. The interviews obtained 15-20 minutes per case with a total of eight months of collecting data (June 2015 - January 2016). The quantitative data were analyzed using percentage and content analyses were used with qualitative data. Results: There were four cases underwent operation for cleft lip and palate (40%) four cases underwent age 3-6 months and 10-18 month four cases underwent age 3-6 months and 10-18 month(40%) which included six male (60%) and ten female caregivers (100%), four of which aged older than 50 years (40%), three cases were each a farmer and housekeeper. For nurses, the majority aged between 40-44 years, nine of which had bachelor degree (90%). The results from nurses' survey found that the caregiver concerned about patients' hunger, and surgical complications such as hypothermia, pressure ulcers from operation, postural, bleeding after operation which need additional operation, something stuck in operating wound, and infected wound. The interviewing with the caregiver and mother towards patient health conditions found that the caregivers concerned about anesthetic procedure, wound separation and infection, and the operating cost. Most patients felt fear of fainting and thirsty since food and water discontinuation. Based on the literature review, the problems included the caregivers' concerns about surgical complications which these were similar to those results from the nurses' survey. Conclusion: Problems for care of patients with cleft lip and palate in the operating room in Srinagarind Hospital were: 1) concerns about the operation and cost of treatment, 2) surgical complication both immediate and long-term complications, 3) concerns about pain and wound infection. Such evidence would be used in the development plan towards nursing system for cleft lip and palate patients in the operating room.

Low surface contamination by cis/oxaliplatin during hyperthermic intraperitoneal chemotherapy (HIPEC).

AIM: The aim of this study was to evaluate contamination by platinum drugs in the operating room during hyperthermic intraperitoneal chemotherapy (HIPEC). METHODS: Environmental sampling of 151 wipe samples from surfaces on the HIPEC devices and operating room floors was performed for platinum in six German hospitals during 19 HIPEC procedures. Additionally, 45 wipe samples from surgeons' and perfusionists' protective gloves were analyzed. RESULTS: Platinum concentrations from the HIPEC devices and operating room floors ranged from 0.07 to 110,000 pg/cm(2) (Median: 1.5 pg/cm(2)) with high contamination on the regulation knob and reservoir after HIPEC procedure, particularly when injecting the cytostatic drug into the reservoir via syringe. Samples from perfusionists' and surgeons' protective gloves ranged between 0.01 and 729 ng/pair. CONCLUSIONS: Although sporadically high platinum concentrations on surfaces on the HIPEC device and operating room floor were detected, our study revealed that low surface loads are definitely possible and can be documented by wipe samples. Important factors for achieving low surface contamination are the use of infusion bags instead of syringes for injection of the cytostatic solution, careful cleaning of the device after HIPEC and wearing of two pairs of gloves.

The process of treating pediatric appendicitis.

BACKGROUND: A large service and distant geographical area can make the process of diagnosing and treating appendicitis a challenge. METHODS: Hospital records of children treated for appendicitis between 2007 and 2009 were retrospectively analyzed, including time from emergency (ER) to operating room (OR), diagnostic imaging (DI) utilization, preoperative antibiotic usage, operating time, length of stay (LOS), and perforation rate. RESULTS: The perforation rate was 34%, with longer LOS. Transfer time to the children's hospital between ER inside and outside the city was not different. ER to OR time was significantly shorter for patients assessed at the children's hospital directly. Ultrasound remained the most used DI modality (55%). Preoperative antibiotics were only fully administered in 42% of the cases. CONCLUSION: A clinical pathway for pediatric appendicitis may address the challenges of the process of pre-ER, ER to OR, and OR care to maintain an acceptable perforation rate.

Applying clinical process redesign methods to planned arrivals in New South Wales hospitals.

*Competing demands of planned and unplanned arrivals present major challenges for hospitals. *Applying clinical process redesign methods to the planned patient journey allows management to recognise the blocks and inefficiencies in the journey and facilitates the development of solutions for improvement. *Redesign of the planned patient journey in New South Wales has promoted the expansion of the extended day-only model of care, reformed the waiting times policy, standardised patient preadmission assessment and preparation, and targeted operating theatre use. *Improved performance management at Area Health Service and local facility levels has accompanied the redesign of planned arrival processes. *The results in redesign of surgery undertaken by the Area Health Services in 96 NSW hospitals have been impressive, with results within 2 years of commencing the clinical services redesign program showing: a 97% reduction in the numbers of patients in Category 1 (admission desirable within 30 days) whose surgery was overdue, from 5308 in January 2005 to 135 in June 2007; and a 99% reduction in the number of patients who have waited > 365 days for surgery, from 10 551 in January 2005 to 84 in June 2007. *Improved surgical service efficiency, safety and quality justify the continuation of the redesign program.

Closing emergency operating rooms improves efficiency.

Long waiting times for emergency operations increase a patient's risk of postoperative complications and morbidity. Reserving Operating Room (OR) capacity is a common technique to maximize the responsiveness of an OR in case of arrival of an emergency patient. This study determines the best way to reserve OR time for emergency surgery. In this study two approaches of reserving capacity were compared: (1) concentrating all reserved OR capacity in dedicated emergency ORs, and (2) evenly reserving capacity in all elective ORs. By using a discrete event simulation model the real situation was modelled. Main outcome measures were: (1) waiting time, (2) staff overtime, and (3) OR utilisation were evaluated for the two approaches. Results indicated that the policy of reserving capacity for emergency surgery in all elective ORs led to an improvement in waiting times for emergency surgery from 74 (+/-4.4) minutes to 8 (+/-0.5) min. Working in overtime was reduced by 20%, and overall OR utilisation can increase by around 3%. Emergency patients are operated upon more efficiently on elective Operating Rooms instead of a dedicated Emergency OR. The results of this study led to closing of the Emergency OR in the Erasmus MC (Rotterdam, The Netherlands).