Disparities in eye clinic patient encounters among patients requiring language interpreter services.

BACKGROUND: Communication barriers are a major cause of health disparities for patients with limited English proficiency (LEP). Medical interpreters play an important role in bridging this gap, however the impact of interpreters on outpatient eye center visits has not been studied. We aimed to evaluate the differences in length of eyecare visits between LEP patients self-identifying as requiring a medical interpreter and English speakers at a tertiary, safety-net hospital in the United States. METHODS: A retrospective review of patient encounter metrics collected by our electronic medical record was conducted for all visits between January 1, 2016 and March 13, 2020. Patient demographics, primary language spoken, self-identified need for interpreter and encounter characteristics including new patient status, patient time waiting for providers and time in room were collected. We compared visit times by patient's self-identification of need for an interpreter, with our main outcomes being time spent with ophthalmic technician, time spent with eyecare provider, and time waiting for eyecare provider. Interpreter services at our hospital are typically remote (via phone or video). RESULTS: A total of 87,157 patient encounters were analyzed, of which 26,443 (30.3%) involved LEP patients identifying as requiring an interpreter. After adjusting for patient age at visit, new patient status, physician status (attending or resident), and repeated patient visits, there was no difference in the length of time spent with technician or physician, or time spent waiting for physician, between English speakers and patients identifying as needing an interpreter. Patients who self-identified as requiring an interpreter were more likely to have an after-visit summary printed for them, and were also more likely to keep their appointment once it was made when compared to English speakers. CONCLUSIONS: Encounters with LEP patients who identify as requiring an interpreter were expected to be longer than those who did not indicate need for an interpreter, however we found that there was no difference in the length of time spent with technician or physician. This suggests providers may adjust their communication strategy during encounters with LEP patients identifying as needing an interpreter. Eyecare providers must be aware of this to prevent negative impacts on patient care. Equally important, healthcare systems should consider ways to prevent unreimbursed extra time from being a financial disincentive for seeing patients who request interpreter services.

Importance of access to epilepsy monitoring units during the COVID-19 pandemic: consensus statement of the International League Against Epilepsy and the International Federation of Clinical Neurophysiology.

Restructuring of healthcare services during the COVID-19 pandemic has led to lockdown of epilepsy monitoring units (EMUs) in many hospitals. The ad-hoc taskforce of the International League Against Epilepsy (ILAE) and the International Federation of Clinical Neurophysiology (IFCN) highlights the detrimental effect of postponing video-EEG monitoring of patients with epilepsy and other paroxysmal events. The taskforce calls for action for continued functioning of EMUs during emergency situations, such as the COVID-19 pandemic. Long-term video-EEG monitoring is an essential diagnostic service. Access to video-EEG monitoring of the patients in the EMUs must be given high priority. Patients should be screened for COVID-19, before admission, according to the local regulations. Local policies for COVID-19 infection control should be adhered to during the video-EEG monitoring. In cases of differential diagnosis in which reduction of antiseizure medication is not required, home video-EEG monitoring should be considered as an alternative in selected patients.

The impact of Covid-19 pandemic related lockdown on clubfoot practice: Type of study design: Retrospective cross-sectional study.

ABSTRACT: We investigated whether the number of pediatric patients with congenital clubfoot treated with the Ponseti method decreased during the Covid-19 pandemic or not in a rural area. So we aimed to guide orthopedic surgeons and health infrastructure for future pandemics to be prepared in hospitals of rural areas for the treatment of children with congenital clubfoot.One hundred and fifty-four patients with clubfoot who were admitted to our clinic were evaluated retrospectively from March 2017 to December 2020. Institutional hospital electronic database was used to detect the number of weeks between the birth and first cast performed in clinic and the number of casts been applied and unilaterality or bilaterality. Patients were divided into four groups, which included pandemic period and three previous years. Recorded data were analyzed statistically to detect if there is a difference between the numbers of the patients in pandemic period and three previous years.The number of patients with clubfoot admitted to our hospital between March 2020 and December 2020 increased by 140% compared to previous year. There was a statistically significant difference between the average number of cast applications of Group 4 and other groups (P <.001). Achilles tenotomy was performed in 44 (61.1%) of 72 patients admitted during the pandemic period. Only 4 (13.3%) out of 30 patients admitted between March 2019 and December 2019 were performed Achilles tenotomy.We detected an increase in the number of clubfoot cases admitted to our rural-based hospital during the Covid-19 pandemic, treated with casting or surgically. We think this is because of preventive measures during the pandemic, which caused parents could not reach urban for treatment.

Care of patients with early inflammatory arthritis in the Wellington region according to the British Society of Rheumatology's best practice tariff standards.

AIM: To compare the care of patients with suspected early inflammatory arthritis (EIA) in the Wellington region with the quality standards from the British Society of Rheumatology (BSR) 2013/14 best practice tariffs. METHODS: The case notes for patients first seen in clinic from the beginning of 2015 were reviewed until at least 100 cases of suspected inflammatory arthritis were identified. Data gathered included the length of time from referral to first specialist rheumatology clinic, the length of time from referral to the commencement of disease modifying therapy for cases of inflammatory arthritis and the number of specialist-led clinics within the first 12 months of the first appointment. RESULTS: 117 cases of suspected inflammatory arthritis were reviewed. The median time from referral to the first appointment was 11.4 weeks (IQR 6.6-13.3). 61 of the 117 cases had clinically confirmed EIA. The median time from referral to the commencement of disease-modifying therapy was 10.5 weeks (IQR 5-15). For confirmed EIA, the median number of clinics in the first year was four (IQR 3-4). CONCLUSION: Patients with suspected inflammatory arthritis in the Wellington region wait much longer to be seen than is recommended by the BSR guidelines.

The success of virtual clinics during COVID-19: A closed loop audit of the British orthopaedic association (BOAST) guidelines of outpatient orthopaedic fracture management.

COVID-19 has had profound management implications for orthopaedic management due to balancing patient outcomes with clinical safety and limited resources. The BOAST guidelines on outpatient orthopaedic fracture management took a pragmatic approach. At Great Western Hospital, Swindon, a closed loop audit was performed looking at a selection of these guidelines, to assess if our initial changes were sufficient and what could be improved. METHOD: An audit was designed around fracture immobilisation, type of initial fracture clinic assessment, default virtual follow up clinic and late imaging. Interventions were implemented and re-audited. RESULTS: Initially 223 patients were identified over 4 weeks. Of these, 100% had removable casts and 99% did not have late imaging. 96% of patients were initially assessed virtually or had initial orthopaedic approval to be seen in face to face clinic. 97% had virtual follow up or had documented reasons why not. The 26 patients who were initially seen face to face were put through a simulated virtual fracture clinic. 22 appointments and 13 Xray attendances could have been avoided. We implemented a change of requiring all patients to be assessed at consultant level before having a face to face appointment. The re-audit showed over 99% achievement in all areas. CONCLUSION: Virtual fracture clinics, both triaging new patients and follow-up clinics have dramatically changed our outpatient management, helping the most appropriate patients to be seen face to face. Despite their limitations, they have been well tolerated by patients and improved patient safety and treatment.

Multi-informant prediction of near-term suicidal behavior independent of suicidal ideation.

BACKGROUND: Both the Suicide Crisis Syndrome (SCS) and clinicians' emotional responses to suicidal patients are predictive of near-term suicidal behaviors. Thus, we tested predictive validity of a combination of the proposed Diagnostic and Statistical Manual SCS criteria and the Therapist Response Questionnaire Suicide Form (TRQ-SF) for near-term suicidal behavior. METHODS: The presence of SCS in adult psychiatric outpatients (N=451) was assessed using relevant items from validated psychometric assessments. Clinicians completed the TRQ-SF immediately after patient intake. Suicide attempts (SA) and a combination of suicide plans and attempts (SPA) were measured at one month follow-up (N=359). RESULTS: At follow-up nine patients reported having SPA and seven reported SA. Meeting the SCS criteria were associated with near-term SA (χ2=5.987, p<0.01), while high TRQ-SF scores were associated with both near-term SA (χ2=5.971, p<0.05) and SPA (χ2=7.069, p<0.01). Meeting either the SCS or having high TRQ-SF scores, but not both, was associated with near-term SA (χ2=11.893, p<0.01) and SPA (χ2=11.449, p<0.01). Incremental predictive validity over standard suicide risk factors and individual scales was demonstrated in logistic regressions. CONCLUSIONS: Multi-informant risk assessment not reliant on patient self-reported ideation appear to enhance predictive power of traditional risk assessments in identifying imminent suicide risk.

Trends in Publicly Reported Quality Measures of Hospital Imaging Efficiency, 2011-2018.

OBJECTIVE. In 2011, the Centers for Medicare & Medicaid Services (CMS) initiated public reporting of outpatient imaging efficiency measures to reduce potentially inappropriate imaging and unnecessary exposure to ionizing radiation performed in hospital outpatient departments. Three CMS quality measures were designed to reduce duplicative CT in the Medicare population: OP-10, which CMS lists as "Abdomen Computed Tomography-Use of Contrast Material"; OP-11, which CMS lists as "Thorax CT-Use of Contrast Material"; and OP-14, which CMS lists as "Simultaneous Use of Brain CT and Sinus CT." We describe trends in hospital performance on these national hospital outpatient imaging efficiency measures since the inception of their public reporting. MATERIALS AND METHODS. This observational analysis used standard Medicare fee-for-service administrative claims to calculate hospital-specific scores for OP-10, OP-11, and OP-14. Consistent with CMS specifications, each measure was calculated as a percentage with appropriate exclusions and minimum case count requirements to ensure measure score validity and reliability. We report national performance as well as distributions of hospital performance scores for each annual public reporting period. Trend analyses were performed to examine changes in annual mean performance over time. Secondary analyses assessed trends and hospital performance by location (rural vs urban) and hospital characteristics. RESULTS. Between 2011 and 2018, the national mean rate of duplicate imaging declined for all three measures (OP-10, 18.9% vs 7.7%; OP-11, 5.6% vs 2.0%; OP-14, 2.5% vs 1.0%). For OP-10 and OP-11, most outlier hospitals were rural, small, and government-owned. For OP-10, rural facilities accounted for 32.2% of all facilities but 46.0% of outliers by the end of the study period. Similarly, for OP-11, rural facilities accounted for 30.1% of all facilities but 47.0% of outliers by the end of the study period. In general, the proportion of outliers located in rural areas decreased over time. CONCLUSION. National performance on CMS quality measures of duplicative CT has improved over time, with reduced variation observed between hospitals since the inception of public reporting. These successes support recent CMS policy initiatives to retire duplicative imaging measures from public reporting. Future work should seek to identify opportunities to use national public reporting initiatives to yield similar improvements across broader indications and settings.

Implementation of a quality improvement strategy to increase outpatient kidney transplant referrals.

BACKGROUND: Kidney transplantation remains the optimal therapy for patients with end stage kidney disease (ESKD), though a small fraction of patients on dialysis are on organ waitlists. An important barrier to both preemptive kidney transplantation and successful waitlisting is timely referral to a kidney transplant center. We implemented a quality improvement strategy to improve outpatient kidney transplant referrals in a single center academic outpatient nephrology clinic. METHODS: Over a 3 month period (July 1-September 30, 2016), we assessed the baseline kidney transplantation referral rate at our outpatient nephrology clinic for patients 18-75 years old with an estimated glomerular filtration rate (eGFR) of less than 20 mL/min/1.73m2 (2 values over 90 days apart). Charts were manually reviewed by two reviewers to look for kidney transplant referrals and documentation of discussions about kidney transplantation. We then performed a root cause analysis to explore potential barriers to kidney transplantation. Our intervention began on July 1, 2017 and included the implementation of a column in the electronic medical record (EMR) which displayed the patient's last eGFR as part of the clinic schedule. In addition, physicians were given a document listing their patients to be seen that day with an eGFR of < 20 mL/min/1.73m2. Annual education sessions were also held to discuss the importance of timely kidney transplant referral. RESULTS: At baseline, 54 unique patients with eGFR ≤20 ml/min/1.73 m2 were identified who were seen in the Clinic between July 1, 2016 and September 30, 2016. 29.6% (16) eligible patients were referred for kidney transplantation evaluation. 69.5% (37) of these patients were not referred for kidney transplant evaluation. 46.3% (25) did not have documentation regarding kidney transplant in the EMR. nephrologist's most recent note. Following the intervention, 66 unique patients met criteria for eligibility for kidney transplant evaluation. Kidney transplant referrals increased to 60.6% (p <  0.001). CONCLUSIONS: Our pilot implementation study of a strategy to improve outpatient kidney transplant referrals showed that a free, simple, scalable intervention can significantly improve kidney transplant referrals in the outpatient setting. This intervention targeted the nephrologist's role in the transplant referral, and facilitated the process of patient recognition and performing the referral itself without significantly interrupting the workflow. Next steps include further investigation to study the impact of early referral to kidney transplant centers on preemptive and living donor kidney transplantation as well as successful waitlisting.

Pearls of experience for safe and efficient hospital practices in otorhinolaryngology-head and neck surgery in Hong Kong during the 2019 novel coronavirus disease (COVID-19) pandemic.

The 2019 novel coronavirus disease (COVID-19) epidemic originated in Wuhan, China and spread rapidly worldwide, leading the World Health Organization to declare an official global COVID-19 pandemic in March 2020. In Hong Kong, clinicians and other healthcare personnel collaborated closely to combat the outbreak of COVID-19 and minimize the cross-transmission of disease among hospital staff members. In the field of otorhinolaryngology-head and neck surgery (OHNS) and its various subspecialties, contingency plans were required for patient bookings in outpatient clinics, surgeries in operating rooms, protocols in wards and other services. Infected patients may shed severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) particles into their environments via body secretions. Therefore, otolaryngologists and other healthcare personnel in this specialty face a high risk of contracting COVID-19 and must remain vigilant when performing examinations and procedures involving the nose and throat. In this article, we share our experiences of the planning and logistics undertaken to provide safe and efficient OHNS practices over the last 2 months, during the COVID-19 pandemic. We hope that our experiences will serve as pearls for otolaryngologists and other healthcare personnel working in institutes that serve large numbers of patients every day, particularly with regard to the sharing of clinical and administrative tasks during the COVID-19 pandemic.

Management of transplant patients outside hospital during COVID-19 epidemic: A Chinese experience.

Coronavirus disease 2019 (COVID-19) pandemic poses an increasing challenge for transplant community. Aggressive management measures are conductive to improve compliance and to lower the risk of intra-hospital infection. In this Personal Viewpoint essay, we shared experiences about management strategies of transplant patients outside hospital amid the epidemic. With the aid of Cloud Clinic service and telemedicine care, transplant patients could be regularly followed up and get medical consultation online. Furthermore, personal health education and mental health assistance are enrolled in our practice.

Timeliness of Care for High-acuity Conditions at Hospital-affiliated Freestanding Emergency Departments.

BACKGROUND: Hospital-affiliated freestanding emergency departments (FREDs) are rapidly proliferating in some states and have been the subject of recent policy debate. As FREDs' role in acute care delivery is expanding in certain regions, little is known about the quality of care that they provide for their sickest patients. Our aim was to compare timeliness of emergent care at FREDs and hospital-based EDs (HEDs) for patient visits with selected high-acuity and time-sensitive conditions. METHODS: We performed a retrospective observational analysis of adult patient visit data from 19 FREDs and five HEDs from one health system over a 1-year period. Median times to events and hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated via Cox regression. RESULTS: The median time to electrocardiogram for visits with chest pain was 10 minutes at FREDs and 9 minutes at HEDs (HR = 0.91 [CI = 0.87 to 0.96]). Time to cardiac catheterization lab for visits with ST-segment elevation myocardial infarction (STEMI) was 78 minutes at FREDs, inclusive of transfer time, and 31 minutes at HEDs (HR = 0.41 [CI = 0.24 to 0.71]). Time to computed tomography for visits with stroke was 37 minutes at FREDs and 29 minutes at HEDs (HR = 0.42 [CI = 0.31 to 0.58]). Among visits with sepsis, FREDs had longer times to lactate collection (HR = 0.41 [CI = 0.30 to 0.56]), blood culture collection (HR = 0.24 [CI = 0.11 to 0.51]), and antibiotic administration (HR = 0.61 [CI = 0.26 to 1.42]). Beta agonists were administered for visits with asthma exacerbations in 24 minutes at FREDs and 44 minutes at HEDs (HR = 2.50 [CI = 2.34 to 2.68]), with similar times for anticholinergic and corticosteroid administration. CONCLUSIONS: Freestanding EDs provided more timely care than HEDs for visits with asthma exacerbation and less timely care for acute chest pain, stroke, and sepsis, although absolute differences were small. Even though STEMI patients at FREDs required transfer for catheterization, they tended to receive care in line with national guidelines.

Users' Perceptions of Signage Systems at Three Portuguese Hospitals.

This article is a report on the quantitative data collected from patients, family members, and visitors using the outpatient areas of three hospitals in Portugal. It details the users' views regarding the existing signage and presents suggestions to improve the design and implementation of the signage systems. A questionnaire was used with 1,287 respondents. The results showed that almost all users had a positive opinion regarding the current signage. However, some of the users' answers and observed behaviors indicated that the majority tended to ignore the signs and preferred to ask staff for help. Additionally, when asked for suggestions, many of the respondents were able to point out existing problems that affected their wayfinding. Although the signage was generally evaluated as good, many of the users perceived a variety of problems and, as already mentioned, asked the staff for directions, which results in lost time and hidden costs for the institutions.

Ambulatory care pharmacy practice in China: status and future efforts.

In recent years, as the era of deepening healthcare reform in China progresses, there is a gradual development of ambulatory care pharmacy practice. This commentary reviews the current state of ambulatory care pharmacy practice in China and discusses future efforts to advance the practice. Areas of focus include practice standardization, transitions of care, and reimbursements of ambulatory care pharmacy practice.

Challenges in the provision of kidney care at the largest public nephrology center in Guatemala: a qualitative study with health professionals.

BACKGROUND: Chronic kidney disease (CKD) is increasing worldwide, and the majority of the CKD burden is in low- and middle-income countries (LMICs). However, there is wide variability in global access to kidney care therapies such as dialysis and kidney transplantation. The challenges health professionals experience while providing kidney care in LMICs have not been well described. The goal of this study is to elicit health professionals' perceptions of providing kidney care in a resource-constrained environment, strategies for dealing with resource limitations, and suggestions for improving kidney care in Guatemala. METHODS: Semi-structured interviews were performed with 21 health professionals recruited through convenience sampling at the largest public nephrology center in Guatemala. Health professionals included administrators, physicians, nurses, technicians, nutritionists, psychologists, laboratory personnel, and social workers. Interviews were recorded and transcribed in Spanish. Qualitative data from interviews were analyzed in NVivo using an inductive approach, allowing dominant themes to emerge from interview transcriptions. RESULTS: Health professionals most frequently described challenges in providing high-quality care due to resource limitations. Reducing the frequency of hemodialysis, encouraging patients to opt for peritoneal dialysis rather than hemodialysis, and allocating resources based on clinical acuity were common strategies for reconciling high demand and limited resources. Providers experienced significant emotional challenges related to high patient volume and difficult decisions on resource allocation, leading to burnout and moral distress. To improve care, respondents suggested increased budgets for equipment and personnel, investments in preventative services, and decentralization of services. CONCLUSIONS: Health professionals at the largest public nephrology center in Guatemala described multiple strategies to meet the rising demand for renal replacement therapy. Due to systems-level limitations, health professionals faced difficult choices on the stewardship of resources that are linked to sentiments of burnout and moral distress. This study offers important lessons in Guatemala and other countries seeking to build capacity to scale-up kidney care.

Prescribing errors in pediatric outpatient department at a tertiary care hospital in Malaysia.

Background Prescribing errors in children are common due to individualization of dosage regimen. It potentially has a great impact especially in this vulnerable population. Objective To determine the prevalence and common types of prescribing errors in a Malaysian pediatric outpatient department and to determine the factors contributing to prescribing errors. Setting Pediatric Outpatient Department and Outpatient Pharmacy at a tertiary care hospital in Malaysia. Method This is a prospective, cross sectional observational study where all new prescriptions received by the outpatient pharmacy from patients attending pediatric out-patient clinic were included for analysis. Descriptive statistics and logistic regression were used to analyze the data. Main outcome measure Frequency, types, potential clinical consequences and contributing factors of prescribing errors. Results Two hundred and fifty new prescriptions with 493 items were analyzed. There were 13 per 100 prescriptions with at least one prescribing error and 7.3% of the total items were prescribed incorrectly. The most common types of prescribing error were, an ambiguous prescription (61.1%) followed by an unrecommended dose regimen (13.9%). Logistic regression analysis showed that the risk of a prescribing error significantly increased when the prescription was written by a house officer (OR 4.72, p = 0.029). Errors were judged to be potentially non-significant (33.3%), significant (36.1%), or serious (30.6%). Conclusion The experience of prescribers is an important factor that contributes to prescribing errors in pediatrics. Many of the errors made were potentially serious and may impact on the patients' well-being.

Effectiveness of pharmacist intervention model for chronic kidney disease patients; a prospective comparative study.

Background Chronic Kidney Disease (CKD) is a global health concern with profound risk of cardiovascular disease, end stage renal failure and early mortality. Pharmacists' interventions during chronic disease management have been promising. However, evidence of pharmacist`s involvement in chronic kidney dosease is limited, particularly in developing countries. Objective To implement and evaluate the impact of pharmacist led intervention among pre-dialysis CKD patients. Setting Nephrology outpatient department of tertiary healthcare hospital. Methods Patients with chronic kidney disease from stage 2 to 4 attending hospital between October to December 2018 were enrolled in a multi-arm pre-post prospective study. Pharmacist interventional model consisted of disease education, dietary recommendations, counseling to improve medication adherence along with telephonic follow-up. Interventional group received pharmacist interventional model; whereas control group only received the usual care. The impact of pharmacist`s involvements were evaluated by observing the improvements in knowledge and adherence scores, physiological profile and body composition analysis assessed by body composition monitor (BF-508®) at the end of follow-up of 3 months. Both intervention and control groups were compared by appropriate statistical techniques. Main outcome measure Knowledge and adherence scores, physiological profile and body composition analysis Results Total 120 patients (60 in each group) completed the study. Baseline variables were comparable between the two groups. Pharmacist interventional model causes significant improvement in knowledge score upon follow up between intervention and control groups (19.10 ± 3.65 versus 17.57 ± 3.55, p = 0.022). Likewise, Medication adherence score of intervention group significantly improved as compared to control group (p < 0.05) following the implementation of pharmacist intervention model. Physiological analysis showed small improvements in the intervention group but were not significant. Body composition analysis revealed higher body and visceral fat in both groups at the end of follow up. Conclusion Our analysis underscored that the tested pharmacist interventional model is an effective tool in improving disease knowledge and medication adherence among patients with chronic kideney disease.

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.