Comparing resident operative volumes for routine general surgery cases at academic, urban community, and rural training sites.

BACKGROUND: Surgical training traditionally took place at academic centres, but changed to incorporate community and rural hospitals. As little data exist comparing resident case volumes between these locations, the objective of this study was to determine variations in these volumes for routine general surgery procedures. METHODS: We analyzed senior resident case logs from 2009 to 2019 from a general surgery residency program. We classified training centres as academic, community, and rural. Cases included appendectomy, cholecystectomy, hernia repair, bowel resection, adhesiolysis, and stoma formation or reversal. We matched procedures to blocks based on date of case and compared groups using a Poisson mixed-methods model and 95% confidence intervals (CIs). RESULTS: We included 85 residents and 28 532 cases. Postgraduate year (PGY) 3 residents at academic sites performed 10.9 (95% CI 10.1-11.6) cases per block, which was fewer than 14.7 (95% CI 13.6-15.9) at community and 15.3 (95% CI 14.2-16.5) at rural sites. Fourth-year residents (PGY4) showed a greater difference, with academic residents performing 8.7 (95% CI 8.0-9.3) cases per block compared with 23.7 (95% CI 22.1-25.4) in the community and 25.6 (95% CI 23.6-27.9) at rural sites. This difference continued in PGY5, with academic residents performing 8.3 (95% CI 7.3-9.3) cases per block, compared with 18.9 (95% CI 16.8-21.0) in the community and 14.5 (95% CI 7.0-21.9) at rural sites. CONCLUSION: Senior residents performed fewer routine cases at academic sites than in community and rural centres. Programs can use these data to optimize scheduling for struggling residents who require exposure to routine cases, and help residents complete the requirements of a Competence by Design curriculum.

Spatial accessibility and equity of community healthcare: unraveling the impact of varying time and transport mode.

Background: Achieving a higher level of accessibility and equity to community healthcare services has become a major concern for health service delivery from the perspectives of health planners and policy makers in China. Methods: In this study, we introduced a comprehensive door-to-door (D2D) model, integrating it with the open OD API results for precise computation of accessibility to community hospitals over different transport modes. For the D2D public transit mode, we computed the temporal variation and standard deviation of accessibility at different times of the day. Additionally, accessibility values for D2D riding mode, D2D driving mode, and simple driving mode were also computed for comparison. Moreover, we introduced Lorenz curve and Gini index to assess the differences in equity of community healthcare across different times and transport modes. Results: The D2D public transit mode exhibits noticeable fluctuations in accessibility and equity based on the time of day. Accessibility and equity were notably influenced by traffic flow between 8 AM and 11 AM, while during the period from 12 PM to 10 PM, the open hours of community hospitals became a more significant determinant in Nanjing. The moments with the most equitable and inequitable overall spatial layouts were 10 AM and 10 PM, respectively. Among the four transport modes, the traditional simple driving mode exhibited the smallest equity index, with a Gini value of only 0.243. In contrast, the D2D riding mode, while widely preferred for accessing community healthcare services, had the highest Gini value, reaching 0.472. Conclusion: The proposed method combined the D2D model with the open OD API results is effective for accessibility computation of real transport modes. Spatial accessibility and equity of community healthcare experience significant fluctuations influenced by time variations. The transportation mode is also a significant factor affecting accessibility and equity level. These results are helpful to both planners and scholars that aim to build comprehensive spatial accessibility and equity models and optimize the location of public service facilities from the perspective of different temporal scales and a multi-mode transport system.

Use of computer simulation to identify effects on hospital census with reduction of transfers for non-procedural patients in community hospitals.

OBJECTIVE: In-person healthcare delivery is rapidly changing with a shifting employment landscape and technological advances. Opportunities to care for patients in more efficient ways include leveraging technology and focusing on caring for patients in the right place at the right time. We aim to use computer modelling to understand the impact of interventions, such as virtual consultation, on hospital census for referring and referral centres if non-procedural patients are cared for locally rather than transferred. PATIENTS AND METHODS: We created computer modelling based on 25 138 hospital transfers between June 2019 and June 2022 with patients originating at one of 17 community-based hospitals and a regional or academic referral centre receiving them. We identified patients that likely could have been cared for at a community facility, with attention to hospital internal medicine and cardiology patients. The model was run for 33 500 days. RESULTS: Approximately 121 beds/day were occupied by transferred patients at the academic centre, and on average, approximately 17 beds/day were used for hospital internal medicine and nine beds/day for non-procedural cardiology patients. Typical census for all internal medicine beds is approximately 175 and for cardiology is approximately 70. CONCLUSION: Deferring transfers for patients in favour of local hospitalisation would increase the availability of beds for complex care at the referral centre. Potential downstream effects also include increased patient satisfaction due to proximity to home and viability of the local hospital system/economy, and decreased resource utilisation for transfer systems.

Reducing inpatient opioid consumption after caesarean delivery: effects of an opioid stewardship programme and racial impact in a community hospital.

Caesarean section is the most common inpatient surgery in the USA, with more than 1.1 million procedures in 2020. Similar to other surgical procedures, healthcare providers rely on opioids for postoperative pain management. However, current evidence shows that postpartum patients usually experience less pain due to pregnancy-related physiological changes. Owing to the current opioid crisis, public health agencies urge providers to provide rational opioid prescriptions. In addition, a personalised postoperative opioid prescription may benefit racial minorities since research shows that this population receives fewer opioids despite greater pain levels. Our project aimed to reduce inpatient opioid consumption after caesarean delivery within 6 months of the implementation of an opioid stewardship programme.A retrospective analysis of inpatient opioid consumption after caesarean delivery was conducted to determine the baseline, design the opioid stewardship programme and set goals. The plan-do-study-act method was used to implement the programme, and the results were analysed using a controlled interrupted time-series method.After implementing the opioid stewardship programme, we observed an average of 80% reduction (ratio of geometric means 0.2; 95% CI 0.2 to 0.3; p<0.001) in inpatient opioid consumption. The institution designated as control did not experience relevant changes in inpatient opioid prescriptions during the study period. In addition, the hospital where the programme was implemented was unable to reduce the difference in inpatient opioid demand between African Americans and Caucasians.Our project showed that an opioid stewardship programme for patients undergoing caesarean delivery can effectively reduce inpatient opioid use. PDSA, as a quality improvement method, is essential to address the problem, measure the results and adjust the programme to achieve goals.

Cardiovascular and obstetrical outcomes among delivering patients with Marfan or Loeys-Dietz syndrome: a retrospective analysis by hospital delivery setting.

BACKGROUND: Pregnancy is a high-risk time for patients with Marfan syndrome or Loeys-Dietz syndrome because of the risk for cardiovascular complications, including the risk for aortic dissection. Little is known about the differences in obstetrical and cardiac outcomes based on delivery hospital setting (academic or academic-affiliated vs community medical centers). OBJECTIVE: This study aimed to evaluate the obstetrical and cardiac outcomes of patients with Marfan syndrome or Loeys-Dietz syndrome based on delivery hospital setting. STUDY DESIGN: This was a secondary analysis of a retrospective, observational cohort study of singleton pregnancies among patients with a diagnosis of Marfan syndrome or Loeys-Dietz syndrome from 1990 to 2016. Patients were identified through the Marfan Foundation, the Loeys-Dietz Syndrome Foundation, or the Cardiovascular Connective Tissue Clinic at Johns Hopkins Hospital. Data were obtained via self-reported obstetrical history and verified by review of medical records. Nonparametric analyses were performed using Fisher's exact tests and Wilcoxon rank-sum tests. RESULTS: A total of 273 deliveries among patients with Marfan syndrome or Loeys-Dietz syndrome were included in this analysis (Table 1). More patients who had a known diagnosis before delivery of either Marfan syndrome or Loeys-Dietz syndrome delivered at an academic hospital as opposed to a community hospital (78.6% vs 59.9%; P=.001). Patients with Marfan syndrome or Loeys-Dietz syndrome who delivered at academic centers were more likely to have an operative vaginal delivery than those who delivered at community centers (23.7% vs 8.6%; P=.002). When the indications for cesarean delivery were assessed, connective tissue disease was the primary indication for the mode of delivery at community centers when compared with academic centers (55.6% vs 43.5%; P=.02). There were higher rates of cesarean delivery for arrest of labor and/or malpresentation at community hospitals than at academic centers (23.6% vs 5.3%; P=.01). There were no differences between groups in terms of the method of anesthesia used for delivery. Among those with a known diagnosis of Marfan syndrome or Loeys-Dietz syndrome before delivery, there were increased operative vaginal delivery rates at academic hospitals than at community hospitals (27.2% vs 15.1%; P=.03) (Table 2). More patients with an aortic root measuring ≥4 cm before or after pregnancy delivered at academic centers as opposed to community centers (33.0% vs 10.2%; P=.01), but there were no significant differences in the median size of the aortic root during pregnancy or during the postpartum assessment between delivery locations. Cardiovascular complications were rare; 8 patients who delivered at academic centers and 7 patients who delivered at community centers had an aortic dissection either in pregnancy or the postpartum period (P=.79). CONCLUSION: Patients with Marfan syndrome or Loeys-Dietz syndrome and more severe aortic phenotypes were more likely to deliver at academic hospitals. Those who delivered at academic hospitals had higher rates of operative vaginal delivery. Despite lower frequencies of aortic root diameter >4.0 cm, those who delivered at community hospitals had higher rates of cesarean delivery for the indication of Marfan syndrome or Loeys-Dietz syndrome. Optimal delivery management of these patients requires further prospective research.

Role of sentinel lymph node evaluation during hysterectomy for preoperative pathology diagnosis of endometrial intraepithelial neoplasia in a community hospital setting.

OBJECTIVE: To determine the utility of sentinel lymph node (SLN) evaluation during hysterectomy for endometrial intraepithelial neoplasia (EIN) in a community hospital setting and identify descriptive trends among pathology reports from those diagnosed with endometrial cancer (EC). METHODS: We reviewed patients who underwent hysterectomy from January 2015 to July 2022 for a pathologically confirmed diagnosis of EIN obtained by endometrial biopsy (EMB) or dilation and curettage. Data was obtained via detailed chart review. Statistical testing was utilized for between-group comparisons and multivariate logistic regression modeling. RESULTS: Of the 177 patients with EIN who underwent hysterectomy during the study period, 105 (59.3%) had a final diagnosis of EC. At least stage IB disease was found in 29 of these patients who then underwent adjuvant therapy. Pathology report descriptors suspicious for cancer and initial specimen type obtained by EMB were independently and significantly associated with increased odds of EC diagnosis (aOR 8.192, p < 0.001;3.746, p < 0.001, respectively). Operative times were not increased by performance of SLN sampling while frozen specimen evaluation added an average of 28 min to procedure length. Short-term surgical outcomes were also similar between groups. CONCLUSION: Patients treated for EIN at community-based institutions might be more likely to upstage preoperative EIN diagnoses and have an increased risk of later stage disease than previous research suggests. Given no surgical time or short-term outcome differences, SLN evaluation should be more strongly considered in this practice setting, especially for patients diagnosed by EMB or with pathology reports indicating suspicion for EC.

Intoxicaciones agudas en hospitales comarcales / Acute poisoning at local hospitals

No disponible

Epidemiología de la diseminación de enterobacterias productoras de carbapenemasas en un hospital comarcal y un hospital de media estancia en Madrid / Epidemiology of the carbapenemase-producing Enterobacteriaceae spread in a community acute hospital and a non-acute rehabilitation hospital in Madrid

Introducción. La prevalencia de enterobacterias productoras de carbapenemasas (EPC) es creciente en España. El objetivo de este trabajo ha sido describir las características epidemiológicas, clínicas y microbiológicas de los casos de infección y/o colonización por EPC en dos centros sanitarios del noroeste de Madrid: un hospital comarcal de agudos (HCA) y un hospital de media estancia (HME). Material y métodos. Se recogieron durante los años 2013 y 2014 datos microbiológicos, epidemiológicos y clínicos de todos los pacientes colonizados o infectados por EPC. Desde la aparición del primer caso, en marzo de 2013, se detectaron un total de 197 nuevos casos. Resultados. Un 33,5% de los pacientes presentaron infección clínica y el 66,5% restante fueron colonizaciones. Klebsiella pneumoniae fue la especie predominante (87,8%) y OXA-48 la carbapenemasa más frecuente (91,9%), observándose diferencias entre ambos centros. El análisis de las cepas mostró una mayor diversidad genética en el HME con respecto al HMA. Conclusión. Al estudiar el patrón de transmisión se encontró un aumento de la incidencia en un corto periodo de tiempo y una rápida diseminación de las cepas entre ambos hospitales. Esto pone de manifiesto la necesidad de estandarizar medidas de cribado de posibles portadores y de instaurar programas de control de la infección en este tipo de hospitales (AU)

Introduction. In Spain, the overall prevalence of carbapenem-resistant Enterobacteriaceae (CRE) is increasing. We describe the epidemiological, clinical and microbiological characteristics features of patients with colonization or infection due to CRE in two hospitals in the north-west of Madrid during two years. One hospital was a community acute hospital and the second one was a non-acute rehabilitation hospital. Material and methods. A total of 197 CPE isolates were detected during 2013-2014. Microbiological, epidemiological and clinical data were collected, since the first isolate was found in March 2013. Results. A 33.5% of patients with CRE had symptomatic infection and the remaining 66.5% were colonizations. Klebsiella pneumoniae (87.8%) was the most prevalent species and OXA-48 the most frequent carbapenemase (91.9%). We found intra-interhospital spread and some differences in the epidemiology of CRE depending on the hospital, such as more genetic variability in the non-acute rehabilitation hospital. Conclusions. Studying the CRE transmission we founded an increased incidence in a short period of time and a rapid dissemination of strains between both hospitals. This highlights the need to standardize screening measures for potential carriers and infection control programs in our hospitals (AU)

Why Women Living in an Obstetric Care Underserved Area Do Not Utilize Their Local Hospital Supported by Korean Government for Childbirth

PURPOSE: This study aimed to understand why mothers do not utilize the prenatal care and delivery services at their local hospital supported by the government program, the Supporting Program for Obstetric Care Underserved Area (SPOU). METHODS: We conducted a focus group interview by recruiting four mothers who delivered in the hospital in their community (a rural underserved obstetric care area) and another four mothers who delivered in the hospital outside of the community. RESULTS: From the finding, the mothers were not satisfied with the quality of services that the community hospital provided, in terms of professionalism of the obstetric care team, and the outdated medical device and facilities. Also, the mothers believed that the hospital in the metropolitan city is better for their health as well as that of their babies. The mothers who delivered in the outside community hospital considered geographical closeness less than they did the quality of obstetric care. The mothers who delivered in the community hospital gave the reason why they chose the hospital, which was convenience and emergency preparedness due to its geographical closeness. However, they were not satisfied with the quality of services provided by the community hospital like the other mothers who delivered in the hospital outside of the community. CONCLUSIONS: Therefore, in order to successfully deliver the SPOU program, the Korean government should make an effort in increasing the quality of maternity service provided in the community hospital and improving the physical factors of a community hospital such as outdated medical equipment and facilities.

Análisis del coste del trasplante hepático en un hospital de la comunidad: su relación con el Model for End-stage Liver Disease, un índice pronóstico que prioriza al paciente más grave / Cost analysis of liver transplantation in a community hospital: association with the MODEL for End-stage Liver Disease, a prognostic index to prioritize the most severe patients

Introducción El objetivo del presente trabajo ha sido investigar el impacto del Model for End-stage Liver Disease(MELD) en los costes del trasplante. Material y métodos Se incluyeron todos los pacientes que recibieron un trasplante hepático por una enfermedad hepática terminal entre 2006 y 2010. El período de estudio incluye desde el día del trasplante hasta el alta hospitalaria. Los pacientes fueron categorizados en 2 grupos: 6 a 19 y 20 a 40. En forma arbitraria se definió como alto coste aquel que excedía el percentil 85. Se analizaron 77 pacientes. Resultados La media del puntaje MELD al momento del trasplante fue 19,2±7,0 (media ± DE). La media de los costes por trasplante en el período mencionado fue de 33.461 USD por paciente (rango 21.795-104.629). El coste del trasplante en los pacientes que tenían un valor de MELD de 6-19 fue de 30.493±8.825 USD y en aquellos con un MELD de 20-40, de 36.506±15.833 USD, siendo esta diferencia estadísticamente significativa (p=0,04). En un análisis escalonado por regresión logística, tener un puntaje MELD 20 fue el único predictor independiente de alto coste (OR 11,8; CI 1,6-87). En el modelo de regresión lineal, el tiempo de estancia hospitalaria fue el predictor más relevante de coste (r2=43%).Discusión Nuestros resultados demuestran que el MELD tiene un impacto directo en el coste del trasplante. Sugerimos que los sistemas de reembolso deberían compensar a los diferentes prestadores en relación a la gravedad de la patología de base, evaluada mediante el modelo MELD (AU)

Introduction The aim of the present study was to investigate the impact of the Model for End-stage Liver Disease (MELD) on transplantation costs. Material and methods We included all patients who received a liver transplant for end-stage liver disease between 2006 and 2010. The study period encompassed the day of transplantation until hospital discharge. The patients were classified into two groups: those with a MELD score of 6-19 and those with a score of 20-40.ResultsThe mean MELD score at transplantation was 19.2±7.0 (mean±SD). The mean cost per procedure in the study period was USD 33,461 per patient (range 21,795-104,629). The cost of transplantation was USD 30,493±8,825 in patients with a MELD score of 6-19 and was USD 36,506±15,833 in those with a score of 20-40; this difference was statistically significant (P=.04). In a stepwise logistic regression analysis, the only independent predictor of high cost was having a MELD score of 20 (OR 11.8; CI 1.6-87). In the linear regression model, the most important predictor of cost was the length of hospital stay (r2=43%).Discussion Our results demonstrate that the MELD score directly affects transplantation costs. We suggest that reimbursement systems compensate the distinct financing bodies according to the severity of the underlying disease, evaluated with the MELD(AU)

Surveillance of nosocomial infections in a Mexican community hospital: how are we doing? / Vigilancia epidemiológica de infecciones nosocomiales en un hospital comunitario de México: ¿Cómo vamos?

OBJECTIVE. To compare the nosocomial infection (NI) rate obtained from a retrospective review of clinical charts with that from the routine nosocomial infection surveillance system in a community hospital. MATERIAL AND METHODS. Retrospective review of a randomized sample of clinical charts.Results were compared to standard surveillance using crude and adjusted analyses. RESULTS. A total of 440 discharges were reviewed, there were 27 episodes of NIs among 22 patients. Cumulated incidence was 6.13 NI per 100 discharges. Diarrhea, pneumonia and peritonitis were the most common infections. Predictors of NI by Cox regression analysis included pleural catheter (HR 16.38), entry through the emergency ward, hospitalization in the intensive care unit (HR 7.19), and placement of orotracheal tube (HR 5.54). CONCLUSIONS. Frequency of NIs in this community hospital was high and underestimated. We identified urgent needs in the areas of training and monitoring.

OBJETIVO. Comparar la tasa de infecciones nosocomiales (IN) resultante de la revisión retrospectiva de expedientes clínicos con los resultados del sistema rutinario de vigilancia de IN de un hospital general. MATERIAL Y MÉTODOS. Revisión retrospectiva de una muestra seleccionada aleatoriamente de expedientes clínicos. Comparación con los resultados obtenidos por el sistema rutinario de vigilancia de IN. Análisis bivariado y multivariado de datos retrospectivos. RESULTADOS. De 440 egresos hubo 27 episodios de IN en 22 pacientes. La incidencia acumulada fue de 6.13 IN por 100 egresos. Las infecciones más frecuentes fueron diarrea, neumonía y peritonitis. Los predictores de IN fueron catéter pleural (HR 16.38), ingreso por urgencias y estancia en cuidados intensivos (HR 7.19), y colocación de tubo orotraqueal (HR 5.54). CONCLUSIONES. La frecuencia de IN fue elevada y subestimada por el sistema rutinario. Identificamos necesidades urgentes de monitoreo y entrenamiento en áreas específicas.

Situación actual del dolor agudo postoperatorio en un hospital de la Comunidad de Baleares / No disponible

No disponible

La valoración geriátrica en los hospitales: de la quimera a la necesidad / Geriatric assessment in the hospitals: of the chimera to necessity

La Valoración Geriátrica (VG) es un proceso diagnóstico multidimensionalque se realiza en los ancianos para establecer y diseñar untratamiento geriátrico integral. En las últimas décadas ha aumentadola frecuentación de ancianos en los hospitales. El declive funcional alalta del hospital y después del alta en los ancianos es frecuente. Elmodelo tradicional no permite abordar todos los problemas de saludde los ancianos, siendo necesaria la implantación del modelo funcional.La Valoración Geriátrica es el único instrumento que puede permitirmantener la independencia, prevenir el declive funcional y mejorarla calidad de vida relacionada con la salud de todos los ancianos

Geriatric Assessment (GA) is a multidimensional diagnostic process,that GA achieve among elderly people for design a comprehensivegeriatric treatment. Later decades, older patients are admitted morecommon in hospitals. Functional decline at discharge from hospital,and after discharge among elderly is common. Tradicional model can’tallow approach all health problems of elderly people, it's mandatoryimplemetation of functional model. Geriatric Assessment is onlyinstrument that can allow to sustain functional independence, GA canprevent functional decline, and GA can improve quality of life healthrelationed among all older population

A comparison of the antimicrobial resistance patterns of gram-positive cocci isolated from community-private and university-affiliated hospitals from Puerto Rico

The antimicrobial resistance patterns of 2,462 selected Gram-positive cocci obtained from three Community-Private Hospitals (CPH) and three University-Affiliated Hospitals (UAH) were evaluated utilizing the institutions' antimicrobial susceptibility reports for the year 2000. The objectives of this study were: 1) to evaluate the in vitro resistance to selected standard antibiotics of Staphylococcus aureus, Enterococcus faecalis, Enterococcus faecium and Streptococcus pneumoniae clinical isolates, and 2) to compare the antimicrobial resistance patterns between community-private (CPH) and university-affiliated hospitals (UAH). Staphylococcus aureus was the most common Gram-positive isolated organism in CPH (63.3 per cent) followed by E. faecalis (31.0 per cent). In UAH, the most prevalent cocci were E. faecalis (51.7 per cent) followed by S. aureus (43.9 per cent). Enterococcus faecium represented 2.3 per cent and 4.4 per cent of CPH and UAH isolates, respectively. Streptococcus pneumoniae represented 3.4 per cent of the total Gram-positive isolates from CPH, no S. pneumoniae was reported in UAH. The antimicrobial susceptibility results showed that for Staphylococcus aureus there was a statistically significant higher resistance to methicillin and thrimethoprim sulfamethoxazole in UAH, while resistance to erythromycin was significantly higher in CPH. There was no difference in the resistance of S. aureus to other antimicrobial agents between hospitals groups. A statistically significant resistant to vancomycin was found between enterococcal isolates from UAH (43 per cent) and CPH (12.7 per cent). High-level aminoglycoside resistance (HLAR) was observed among UAH enterococcal isolates with E. faecium showing a higher resistance than E. faecalis, no data for HLAR in CPH could be obtained. For pneumococci 46 per cent of CPH isolates were resistant to penicillin. In summary, there are important differences in the prevalence and antimicrobial resistance between the Gram-positive bacteria isolated from community and teaching hospitals.

Trauma renal en la edad pediátrica. Experiencia de un hospital de segundo nivel / Renal trauma in childhood. Second-level hospital experience

The leading cause of death in children is accidents. Severe craniocerebral trauma and injuries to the heart or major vessels are mainly responsible for immediate death. This phenomenon is also reflected in the increasing number of pediatric admissions for renal trauma. MATERIAL AND METHODS: From 1990 to 2000, the charts of 132 patients with renal injuries secondary to blunt and penetrating trauma in childhood are reviewed. RESULTS: A total of 88 were male patients and 126 sustained blunt trauma (motor accidents, falls, etc.). Gross and microscopic hematuria were the most important finding at the time of presentation, and correlated with severe renal injury, and both were present in 122 cases. Intravenous pyelography and CT scan were the most useful diagnosis tools. Only 27 patients were managed operatively, the majority because of associated intra-abdominal injury. CONCLUSIONS: Intravenous pyelography remains the most cost-effective means of investigating renal injuries in a second-level hospital. Renal contusion and most laceration should be managed conservatively. Only few a renal transactions should be managed operatively.