Economic Impact of Lean Healthcare Implementation on the Surgical Process.

OBJECTIVES: The objective of this study was to analyse and detail surgical process improvement activities that achieve the highest economic impact. METHODS: Over 4 years, a team of technicians and healthcare professionals implemented a set of Lean surgical process improvement projects at Vall d'Hebron University Hospital (VHUH), Barcelona, Spain. Methods employed in the study are common in manufacturing environments and include reducing waiting and changeover time (SMED), reducing first time through, pull, and continuous flow. Projects based on these methods now form part of the daily routine in the surgical process. The economic impact on the hospital's surgical activity budget was analysed. RESULTS: Process improvements have led to annual operational savings of over EUR 8.5 million. These improvements include better patient flow, better management of information between healthcare professionals, and improved logistic circuits. CONCLUSIONS: The current cultural shift towards process management in large hospitals implies shifting towards results-based healthcare, patient-perceived value (VBHC), and value-added payment. A Lean project implementation process requires long-term stability. The reason a considerable number of projects fail to complete process improvement projects is the difficulty involved in establishing the project and improving management routines. Few studies in the literature have investigated the economic impact of implementing Lean management a posteriori, and even fewer have examined actual cases. In this real case study, changes to surgical block management were initiated from stage zero. After being carefully thought through and designed, changes were carried out and subsequently analysed.

[Thoughts about the MIR exam (2020-2021).] / Reflexiones sobre el MIR (2020-2021).

Thoughts about the MIR exam (2020-2021).

Reflexiones sobre el MIR (2020-2021).

Full face transplant: the first case report.

BACKGROUND: Since 2005, 11 human face transplants have been performed. In each, varying amounts of tissue have been transplanted. Herein we report a "full" face transplant including all intact aesthetic and functional units. METHODS: On March 27, 2010, we performed a full face transplant, including all the soft tissues and part of the underlaying bony structure, at the University Hospital Vall d'Hebron, Barcelona, Spain. The donor was a 41-year-old male, who died from a massive brain hemorrhage. The recipient was a 30-year-old male with a severe facial deformity caused by a ballistic trauma in 2005. Harvest and subsequent implant took 24 hours. The patient received initial induction (Thymoglobulin 2 mg/kg/iv; Prednisone 1 gm/iv) and maintenance (Prednisone 1 mg/kg/24hours, Tacrolimus 10-15 ng/mL/PO, and Mycophenolate mofetil 2g/daily/PO) immunosuppression and Infection prophylaxis (Valganciclovir and Co-trimoxazole). RESULTS: There were no intraoperative complications. Postoperative complications included; venous anastomoses thrombosis, acute oro-cutaneous fistula, right parotid sialocele and 2 acute rejection episodes, which were resolved by revision of the anastomosis, profuse irrigation and immunotherapy adjustment, respectively. The patient was discharged from the hospital at 4 months posttransplant with; near-total sensation and partial-motor recovery, no psychological complications and excellent acceptance of his new facial appearance. CONCLUSIONS: The early success described in this case report demonstrates the technical and clinical feasibility of transplanting all the tissues of the with all its aesthetic and functional units intact.

Therapeutic indications of fetoscopy: a 5-year institutional experience.

BACKGROUND: Prenatal ultrasound study allows the detection of fetal malformations. Intrauterine interventions are now contemplated to correct, or interfere with, the natural history of these anomalies. Minimally invasive techniques, such as the so-called "Fetendo" (fetal endoscopy), are now therapeutic possibilities. METHODS: From 2002 to 2007, 205 fetoscopies were performed in our hospital's fetal surgery program. Fetoscopic interventions were carried out under epidural anesthesia, accessing the uterine cavity with a fetoscope containing a 1.2-mm telescope. Following ultrasound-guided needle puncture of the amniotic cavity, the fetoscope was inserted through a 3-mm sheath by the Seldinger technique. Visibility was maintained with an amnioinfusion system. This procedure offers access to the placental surface, umbilical cord, and fetus. RESULTS: Fetoscopy was used to perform laser coagulation of communicant placental vessels in 148 biamniotic monochorionic gestations with twin-to-twin transfusion syndrome (TTTS) and to occlude the umbilical cord in 32 cases of discordant monochorionic twins with a severe or lethal anomaly in one of the fetuses, and 5 cases of reversed arterial perfusion (TRAP) sequence. In addition, fetoscopy was performed in 18 cases to treat severe congenital diaphragmatic hernia by tracheal occlusion with an endotracheal balloon. Finally, in 2 cases, fetoscopic release of amniotic bands was performed to rescue extremities and the umbilical cord. The most common complications (10%) were preterm rupture of membranes, which resulted in preterm delivery. Other indications for fetoscopy, which we are currently using in experimental animal models, include low urinary tract obstruction, sacrococcygeal teratoma, and repair of myelomeningocele defects. CONCLUSIONS: Fetoscopy can lower the incidence of preterm labor that occurs in response to the aggression of open surgery. At present, fetoscopy is effective for treating several fetal anomalies. Preterm rupture of membranes remains the weak link of fetoscopy. Refinement of the technique and technologic advances will help this problem and allow the use of fetoscopy for other pathologies in the future.

Fetal surgery of extremity amniotic bands: an experimental model of in utero limb salvage in fetal lamb.

BACKGROUND: Extremity amniotic band (EAB) syndrome can cause an intrauterine amputation as a result of a mechanical effect with progressive strangulation. The aim of the study is to assess the use of fetal surgery of EABs with risk of amputation in the ovine fetus. METHODS: Right limbs of fifteen 60-day-gestational age fetal sheep were ligated with silk suture at the infracondylar level. Left limbs were used for paired comparison. Fetuses were randomized into 3 groups: an early-repair group (n = 5), a late-repair group (n = 5), and a nonrepaired group (n = 5). The limbs of the 2 repaired groups underwent fetal release. The limbs obtained from at-term fetuses were analyzed morphologically, functionally, and radiologically. Statistical analysis with paired test was used to compare data. RESULTS: Nonrepaired limbs showed amputation or quasi amputation; the repaired ones did not. However, those late-repaired had significantly reduced passive ankle range of motion, shorter limb length, and mild residual changes. CONCLUSIONS: Intrauterine release of potentially severe EABs prevents limb amputation and leads to morphofunctional recovery. Early release shows better results. CLINICAL RELEVANCE: : Intrauterine amputations caused by EABs in the human fetus might be avoidable by fetal surgery.

Fetoscopic release of extremity amniotic bands with risk of amputation.

With the advent of less-invasive fetal surgery techniques, nonlethal disorders are considered amenable to intrauterine treatment. Extremity amniotic band syndrome fulfils the criteria of intrauterine disorders conformable with fetal treatment: capability of prenatal diagnosis and severity. We report 2 cases of extremity amniotic bands with risk of limb amputation released fetoscopically with YAG laser.

The effect of prenatal treatment with steroids and preterm delivery in a model of myelomeningocele on the rabbit foetus.

Damage of neural elements (spinal cord and encephalus) in myelomeningocele (MMC) seems to be progressive during gestation because of amniotic fluid chemical contact and continuous leakage of CSF. We studied the effect of preterm delivery and steroid treatment in a model of MMC in the rabbit foetus. Twelve New Zealand White rabbits underwent laparotomy and hysterotomy at 23 days of gestation. Fifty-nine out of 107 foetuses underwent lumbar laminectomy (three to four levels). Dura was opened to expose the neural elements to the amniotic fluid. Six rabbits underwent caesarean section on gestational day 31 for fetal harvest; three of them had no treatment (group T) and three received corticosteroid treatment (group TC). The other six rabbits underwent caesarean section on gestational day 29 for fetal harvest (preterm delivery); three of them had no treatment (group P) and three received corticosteroid treatment (group PC). Alive newborns were clinically, neurophysiologically and histologically analysed. None of mothers died during the procedure. After birth, animals in group preterm showed statistically significant less deformity than animals in group at term. Lower kyphosis was observed in group PC (preterm and steroids). Pain related and spontaneous mobility of lower extremities was higher in groups treated with corticosteroids (TC and PC). Only newborns at term (T and TC groups) showed response to evoked potentials (CMEPs). The response was earlier and higher in group treated with steroids (TC). Histologically, we observed progressive lesion of the spinal cord. Groups treated with steroids (TC and PC) show less inflammatory response. Arnold-Chiari malformation was present in all groups. Animals in group preterm with steroids show statistically significant less herniation than those group at term. Preterm delivery and prenatal steroid therapy seem to be an effective treatment to get less neural injury (spinal cord and encephalus) in myelomeningocele foetuses.

Aspiració de cossos estranys: la nostra experiència / Foreign body aspiration: the experience of a single institution

Fonament. L'aspiració de cossos estranys és una patologiad'elevada incidència a l'edat pediàtrica, i té greuscomplicacions si passa desprevinguda.Objectiu. Analitzar els registres dels pacients ambsospita d'aspiració de cossos estranys, i intentar obtenirconclusions per millorar el diagnòstic i el maneig d'aquestspacients.Mètode. S'ha fet un estudi retrospectiu dels 68 infantsals quals es va fer una broncoscòpia sota l'orientaciódiagnòstica d'aspiració de cos estrany, entre gener de 1998i juny de 2002, analitzant les variables demogràfiques elementalsi les característiques més significatives de la històriaclínica i l'evolució.Resultats. L'edat mitjana dels pacients va ser de 2,85anys. La simptomatologia més freqüent va ser la tos. El91.2% dels casos presentava un antecedent d'ennuegada.La majoria eren fruits secs (82.3%). El temps mitjà d'evolucióva ser de 8.96 dies.Conclusions. Els avenços tècnics han permès millorarel tractament, però el diagnòstic continua basant-se ambl'anamnesi, l'exploració i la sospita clínica. La prevenció ésla mesura fonamental per millorar el maneig d'aquestaentitat

Background. Foreign body aspiration is commonin children, and may have important consequences ifundiagnosed.Objective. To review our experience with the evaluationof patients with a suspected foreign body aspiration,and to develop guidelines to improve diagnosis and treatment.Method. Retrospective study including children whounderwent a bronchoscopy for the presumptive diagnosisof aspiration of a foreign body, between January 1998 andJune 2002.Results. Sixty-eigh patients (median age 2.85 years)were identified. The most common symptom was cough.In 91.2% of the cases there was history of chocking. Inmost cases (82.3%), the foreign body was a nut. The mediantime of symptoms was 8.96 days.Conclusions. New technologies have contributed toimproved treatments, but the most important diagnostictools remain the clinical history, physical examination, andthe high level of suspicion; preventive measures are critical

Catalunya, pionera en cirurgia fetal / No disponible

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