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1.
J Surg Oncol ; 120(8): 1318-1326, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31701535

RESUMO

BACKGROUND: While better outcomes at high-volume surgical centers have driven regionalization of complex surgical care, access to high-volume centers often requires travel over longer distances. We sought to evaluate travel patterns of patients undergoing pancreaticoduodenectomy (PD) for pancreatic cancer to assess willingness of patients to travel for surgical care. METHODS: The California Office of Statewide Health Planning database was used to identify patients who underwent PD between 2005 and 2016. Total distance traveled, as well as whether a patient bypassed the nearest hospital that performed PD to get to a higher-volume center was assessed. Multivariate analyses were used to identify factors associated with bypassing a local hospital for a higher-volume center. RESULTS: Among 23 014 patients who underwent PD, individuals traveled a median distance of 18.0 miles to get to a hospital that performed PD. The overwhelming majority (84%) of patients bypassed the nearest providing hospital and traveled a median additional 16.6 miles to their destination hospital. Among patients who bypassed the nearest hospital, 13,269 (68.6%) did so for a high-volume destination hospital. Specifically, average annual PD volume at the nearest "bypassed" vs final destination hospital was 29.6 vs 56 cases, respectively. Outcomes at bypassed vs destination hospitals varied (incidence of complications: 39.2% vs 32.4%; failure-to-rescue: 14.5% vs 9.1%). PD at a high-volume center was associated with lower mortality (OR = 0.46 95% CI, 0.22-0.95). High-volume PD ( > 20 cases) was predictive of hospital bypass (OR = 3.8 95% CI, 3.3-4.4). Among patients who had surgery at a low-volume center, nearly 20% bypassed a high-volume hospital in route. Furthermore, among patients who did not bypass a high-volume hospital, one-third would have needed to travel only an additional 30 miles or less to reach the nearest high-volume hospital. CONCLUSION: Most patients undergoing PD bypassed the nearest providing hospital to seek care at a higher-volume hospital. While these data reflect increased regionalization of complex surgical care, nearly 1 in 5 patients still underwent PD at a low-volume center.


Assuntos
Comportamento de Escolha , Hospitais com Alto Volume de Atendimentos , Pancreaticoduodenectomia/estatística & dados numéricos , Viagem , Centros Médicos Acadêmicos , Idoso , California/epidemiologia , Feminino , Acesso aos Serviços de Saúde , Número de Leitos em Hospital , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Análise Multivariada , Recursos Humanos de Enfermagem no Hospital/estatística & dados numéricos , Salas Cirúrgicas/estatística & dados numéricos
2.
S Afr Med J ; 109(10): 765-770, 2019 Sep 30.
Artigo em Inglês | MEDLINE | ID: mdl-31635575

RESUMO

BACKGROUND: Operating theatres account for a significant proportion of hospital costs. There is a paucity of data evaluating utilisation of South African (SA) state operating theatres. OBJECTIVES: To measure operating theatre utilisation and the rate of day-of-surgery cancellations (DOSCs) in a state hospital theatre complex. METHODS: A prospective audit of a state operating theatre complex at a Durban regional hospital was performed between 26 February and 26 April 2018. Times were collected for each theatre case from the entry of the patient into theatre to their departure to the post-anaesthetic care unit. This was done on weekdays between 08h00 and 16h00. The factors causing any delays and DOSCs were identified and recorded. RESULTS: Over the study period, 125 220 operative minutes were available for both elective and emergency operating theatres; 655 elective cases and 359 emergency cases were performed. Overall theatre utilisation was 55.2%, with actual operating time comprising only 36.9% of all available time. Non-operative time occupied 63.1% of all available time, split between late starts (9.3%), early list finishes (16.1%), changeover times (19.4%) and anaesthetic time (18.3%). The DOSC rate was 26.2%, with 232 cases cancelled on the day of surgery. Just under half of the DOSCs were avoidable. The most common reason for cancellation was lack of operative time. CONCLUSIONS: Measured theatre utilisation was higher than previously quoted figures for SA state hospitals, but below international benchmarks. A significant amount of time was wasted as a result of delayed first-case starts, prolonged changeovers and early terminations of lists, all of which contributed to a high DOSC rate. Before more theatre time can be made available, theatre users must first optimise use of currently available time. Further studies quantifying the effect of staff shortages in state operating theatres on inefficient use of time are required.


Assuntos
Custos Hospitalares , Hospitais Estaduais/estatística & dados numéricos , Salas Cirúrgicas/estatística & dados numéricos , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Hospitais Estaduais/economia , Humanos , Auditoria Médica , Salas Cirúrgicas/economia , Duração da Cirurgia , Estudos Prospectivos , África do Sul , Procedimentos Cirúrgicos Operatórios/economia
3.
Isr Med Assoc J ; 21(10): 644-648, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31599503

RESUMO

BACKGROUND: Surgery is a core activity in hospitals. Operating rooms have some of the most important and vital functions in medical centers. The operating rooms and their staff are a valuable infrastructure resource and their availability and preparedness affect human life and quality of care. OBJECTIVES: To prepare operational suggestions for improving operating room utilization by mapping current working processes in the operating rooms of a large private medical center. METHODS: Data on 23,585 surgeries performed at our medical center between August 2016 and March 2017 were analyzed by various parameters including utilization, capacity, working hours, and surgery delays. RESULTS: Average operating room utilization was 79%, while 21% was considered lost operating room time. The two major factors that influenced the lost operating room time were the time intervals between planned usage blocks and the partial utilization of operating room time. We calculated that each percent of utilized operating room time translates into 440 surgeries annually, resulting in a potential annual increase in income. CONCLUSIONS: Increasing operating room utilization would result in an improvement of operating room availability and an increased number of procedures. Our analysis shows that operating room utilization in the private healthcare system is efficient compared to the public healthcare system in Israel. Therefore the private healthcare system should be treated as a contributing factor to help lower surgery waiting times and release bottlenecks, rather than being perceived as contributing to inequality.


Assuntos
Hospitais Privados , Salas Cirúrgicas/organização & administração , Salas Cirúrgicas/estatística & dados numéricos , Eficiência Organizacional/estatística & dados numéricos , Humanos , Israel
4.
Artigo em Inglês | MEDLINE | ID: mdl-31557819

RESUMO

Postoperative infections are a concern, especially in total knee and total hip arthroplasty. We evaluated the air quality in orthopaedic operating theatres in southeastern Italy to determine the level of bacterial contamination as a risk factor for postoperative infection. Thirty-five hospitals with operating theatres focused on total knee and total hip arthroplasty participated. We sampled the air passively and actively before surgeries began for the day (at rest) and 15 min after the surgical incision (in operation). We evaluated bacterial counts, particle size, mixed vs turbulent airflow systems, the number of doors, number of door openings during procedures and number of people in the operating theatre. We found no bacterial contamination at rest for all sampling methods, and significantly different contamination levels at rest vs in operation. We found no association between the number of people in the surgical team and bacteria counts for both mixed and turbulent airflow systems, and low bacterial loads, even when doors were always open. Overall, the air quality sampling method and type of ventilation system did not affect air quality.


Assuntos
Microbiologia do Ar , Poluição do Ar/estatística & dados numéricos , Salas Cirúrgicas/estatística & dados numéricos , Ar Condicionado , Poluição do Ar/análise , Artroplastia de Quadril , Artroplastia do Joelho , Carga Bacteriana , Hospitais , Humanos , Itália , Ortopedia , Ventilação/métodos
5.
Bone Joint J ; 101-B(9): 1081-1086, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31474135

RESUMO

AIMS: The practice of alternating operating theatres has long been used to reduce surgeon idle time between cases. However, concerns have been raised as to the safety of this practice. We assessed the payments and outcomes of total knee arthroplasty (TKA) performed during overlapping and nonoverlapping days, also comparing the total number of the surgeon's cases and the total time spent in the operating theatre per day. MATERIALS AND METHODS: A retrospective analysis was performed on the Centers for Medicare & Medicaid Services (CMS) Limited Data Set (LDS) on all primary elective TKAs performed at the New England Baptist Hospital between January 2013 and June 2016. Using theatre records, episodes were categorized into days where a surgeon performed overlapping and nonoverlapping lists. Clinical outcomes, economic outcomes, and demographic factors were calculated. A regression model controlling for the patient-specific factors was used to compare groups. Total orthopaedic cases and aggregate time spent operating (time between skin incision and closure) were also compared. RESULTS: A total of 3633 TKAs were performed (1782 on nonoverlapping days; 1851 on overlapping days). There were no differences between the two groups for length of inpatient stay, payments, mortality, emergency room visits, or readmission during the 90-day postoperative period. The overlapping group had 0.74 fewer skilled nursing days (95% confidence interval (CI) -0.26 to -1.22; p < 0.01), and 0.66 more home health visits (95% CI 0.14 to 1.18; p = 0.01) than the nonoverlapping group. On overlapping days, surgeons performed more cases per day (5.01 vs 3.76; p < 0.001) and spent more time operating (484.55 minutes vs 357.17 minutes; p < 0.001) than on nonoverlapping days. CONCLUSION: The study shows that the practice of alternating operating theatres for TKA has no adverse effect on the clinical outcome or economic utilization variables measured. Furthermore, there is opportunity to increase productivity with alternating theatres as surgeons with overlapping cases perform more cases and spend more time operating per day. Cite this article: Bone Joint J 2019;101-B:1081-1086.


Assuntos
Artroplastia do Joelho/estatística & dados numéricos , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Salas Cirúrgicas/estatística & dados numéricos , Duração da Cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Artroplastia do Joelho/economia , Boston/epidemiologia , Bases de Dados Factuais/estatística & dados numéricos , Eficiência Organizacional/estatística & dados numéricos , Procedimentos Cirúrgicos Eletivos/economia , Feminino , Humanos , Tempo de Internação , Masculino , Medicare/estatística & dados numéricos , Pessoa de Meia-Idade , Salas Cirúrgicas/organização & administração , Estudos Retrospectivos , Fatores de Tempo , Estados Unidos/epidemiologia
6.
Int J Health Care Qual Assur ; 32(6): 1013-1021, 2019 Jul 08.
Artigo em Inglês | MEDLINE | ID: mdl-31282259

RESUMO

PURPOSE: The purpose of this paper is to examine from the viewpoint of resource utilization the Japanese surgical payment system which was revised in April 2016. DESIGN/METHODOLOGY/APPROACH: The authors collected data from surgical records in the Teikyo University electronic medical record system from April 1 till September 30, 2016. The authors defined the decision-making unit as a surgeon with the highest academic rank in the surgery. Inputs were defined as the number of medical doctors who assisted surgery, and the time of operation from skin incision to closure. An output was defined as the surgical fee. The authors calculated each surgeon's efficiency score using output-oriented Charnes-Cooper-Rhodes model of data envelopment analysis. The authors compared the efficiency scores of each surgical specialty using the Kruskal-Wallis and the Steel method. FINDINGS: The authors analyzed 2,558 surgical procedures performed by 109 surgeons. The difference in efficiency scores was significant (p = 0.000). The efficiency score of neurosurgery was significantly greater than obstetrics and gynecology, general surgery, orthopedics, emergency surgery, urology, otolaryngology and plastic surgery (p<0.05). ORIGINALITY/VALUE: The authors demonstrated that the surgeons' efficiency was significantly different among their specialties. This suggests that the Japanese surgical reimbursement scales fail to reflect resource utilization despite the revision in 2016.


Assuntos
Recursos em Saúde/economia , Custos Hospitalares , Salas Cirúrgicas/economia , Procedimentos Cirúrgicos Operatórios/economia , Bases de Dados Factuais , Eficiência Organizacional , Procedimentos Cirúrgicos Eletivos/economia , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Emergências/economia , Feminino , Custos de Cuidados de Saúde , Hospitais Universitários/economia , Humanos , Japão , Masculino , Salas Cirúrgicas/estatística & dados numéricos , Inovação Organizacional , Sistema de Pagamento Prospectivo , Estudos Retrospectivos , Estatísticas não Paramétricas , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos
7.
Surgery ; 166(5): 738-743, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31326184

RESUMO

BACKGROUND: Despite an increasing number of women in the field of surgery, bias regarding cognitive or technical ability may continue to affect the experience of female trainees differently than their male counterparts. This study examines the differences in the degree of operative autonomy given to female compared with male general surgery trainees. METHODS: A smartphone app was used to collect evaluations of operative autonomy measured using the 4-point Zwisch scale, which describes defined steps in the progression from novice ("show and tell") to autonomous surgeon ("supervision only"). Differences in autonomy between male and female residents were compared using hierarchical logistic regression analysis. RESULTS: A total of 412 residents and 524 faculty from 14 general surgery training programs evaluated 8,900 cases over a 9-month period. Female residents received less autonomy from faculty than did male residents overall (P < .001). Resident level of training and case complexity were the strongest predictors of autonomy. Even after controlling for potential confounding factors, including level of training, intrinsic procedural difficulty, patient-related case complexity, faculty sex, and training program environment, female residents still received less operative autonomy than their male counterparts. The greatest discrepancy was in the fourth year of training. CONCLUSION: There is a sex-based difference in the autonomy granted to general surgery trainees. This gender gap may affect female residents' experience in training and possibly their preparation for practice. Strategies need to be developed to help faculty and residents work together to overcome this gender gap.


Assuntos
Cirurgia Geral/educação , Internato e Residência/organização & administração , Salas Cirúrgicas/organização & administração , Autonomia Profissional , Cirurgiões/estatística & dados numéricos , Competência Clínica , Feminino , Identidade de Gênero , Cirurgia Geral/organização & administração , Cirurgia Geral/estatística & dados numéricos , Humanos , Internato e Residência/estatística & dados numéricos , Relações Interprofissionais , Masculino , Salas Cirúrgicas/estatística & dados numéricos , Fatores Sexuais , Cirurgiões/educação
8.
J Trauma Acute Care Surg ; 87(1): 35-42, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31242499

RESUMO

BACKGROUND: Few diseases truly require emergency surgery today. We investigated the relationship between access to operating room (OR) and outcomes for patients with life-threatening emergency general surgery (LT-EGS) diseases at US hospitals. METHODS: In 2015, we surveyed 2,811 US hospitals on EGS practices, including how OR access is assured (e.g., OR staffing, block time). There were 1,690 (60%) hospitals that responded. We anonymously linked survey data to 2015 Statewide Inpatient Sample data (17 states) using American Hospital Association identifiers. Adults admitted with life-threatening diagnoses (e.g., necrotizing fasciitis, perforated viscus) who underwent operative intervention the same calendar day as hospital admission were included. Primary outcome was in-hospital mortality. Univariate and multivariable regression analyses, clustered by treating hospital and adjusted for patient factors, were performed to examine hospital-level OR access variables. RESULTS: Overall, 3,620 patients were admitted with LT-EGS diseases. The median age was 63 years (interquartile range, 51-75), with half having three or more comorbidities (50%). Thirty-four percent had one or more major systemic complication, and 5% died. The majority got care at hospitals with less than 1 day of EGS block time but with policies to ensure emergency access to the OR. After adjusting for age, sex, race, insurance status, comorbidities, systemic complications, and surgical complications, we found that less presence of an in-house EGS surgeon, compared with around the clock, was associated with increased mortality (rarely/never in-house surgeon: odds ratio, 2.4; 95% confidence interval [CI],1.1-5.3; sometimes in-house surgeon: odds ratio, 1.6; 95% CI, 1.1-2.3). In addition, after controlling for other factors, on-call overnight recovery room nurse, compared with in-house, was associated with an increased mortality (odds ratio, 2.2; 95% CI, 1.5-3.1). CONCLUSION: Round-the-clock availability of personnel, specifically emergency general surgeons and recovery room nurses, is associated with decreased mortality. These findings have implications for the creation of EGS patient triage criteria and Acute Care Surgery Centers of Excellence. LEVEL OF EVIDENCE: Therapeutic, level III.


Assuntos
Salas Cirúrgicas/organização & administração , Procedimentos Cirúrgicos Operatórios/mortalidade , Idoso , Emergências , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Salas Cirúrgicas/estatística & dados numéricos , Recursos Humanos em Hospital/estatística & dados numéricos , Procedimentos Cirúrgicos Operatórios/métodos , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Inquéritos e Questionários , Fatores de Tempo , Estados Unidos/epidemiologia
9.
Ann Agric Environ Med ; 26(2): 249-251, 2019 Jun 17.
Artigo em Inglês | MEDLINE | ID: mdl-31232054

RESUMO

INTRODUCTION: The operating theatre is one of the most important places in a hospital. Due to the presence of numerous reservoirs of microorganisms and the invasiveness of surgical procedures it is necessary to ensure high hygiene standards in these locations. OBJECTIVE: The aim of the study was to carry out a qualitative assessment of the microbiological cleanliness of the surfaces and equipment in an operating theatre. MATERIAL AND METHODS: The results of microbiological tests of the surfaces and equipment of the Children's Operating Theatre in Clinical Provincial Hospital No. 2 in Rzeszów, southeast Poland, during 2007-2012 were reviewed retrospectively. RESULTS AND CONCLUSIONS: For the analysis, a total of 1,819 swabs were collected, of which 1.05% were positive. Positive results were obtained mainly from samples taken from moist places (57.9%). Among the microorganisms isolated, Gram-negative bacteria constituted the majority (57.9%), Pseudomonas bacteria were found most frequently (31,6%). Isolated microbes can be the etiological agent of nosocomial infections.


Assuntos
Bactérias/isolamento & purificação , Contaminação de Equipamentos/estatística & dados numéricos , Equipamentos e Provisões Hospitalares/microbiologia , Hospitais/estatística & dados numéricos , Salas Cirúrgicas/provisão & distribução , Bactérias/classificação , Bactérias/genética , Salas Cirúrgicas/estatística & dados numéricos , Polônia , Estudos Retrospectivos
10.
J Refract Surg ; 35(5): 318-322, 2019 May 01.
Artigo em Inglês | MEDLINE | ID: mdl-31059581

RESUMO

PURPOSE: To compare the complication rates and surgical duration between a three-dimensional visualization system (heads-up surgery) and traditional binocular microscope in cataract surgery. METHODS: This retrospective case series included 2,320 eyes that received cataract surgery using either a three-dimensional display system (n = 1,673 eyes) (3D group) or a traditional binocular microscope (n = 647 eyes) (traditional group). The medical records of consecutive patients who underwent cataract surgery by a single surgeon in The Eye Institute of West Florida from August 2016 to July 2017 using either a three-dimensional display system or the traditional binocular microscope for visualization were reviewed. Patients in both groups received either femto-second laser-assisted cataract surgery (FLACS) or traditional phacoemulsification. Complication rate (posterior capsular rapture and vitreous prolapse) and duration of cataract surgery were evaluated. RESULTS: The 3D group had 12 (0.72%) complications and the traditional group had 5 (0.77%) complications (P > .05). Mean surgical time was 6.48 ± 1.15 minutes for the 3D group and 6.52 ± 1.38 minutes for the traditional group (P > .05). There was no statistically significant difference in complication rate and duration of surgery between the two groups (P > .05). CONCLUSIONS: The implementation of heads-up three-dimensional visualization for cataract surgery seems to offer similar safety and efficiency as the traditional binocular microscope. [J Refract Surg. 2019;35(5):318-322.].


Assuntos
Imagem Tridimensional , Implante de Lente Intraocular/métodos , Microscopia/instrumentação , Duração da Cirurgia , Facoemulsificação/métodos , Complicações Pós-Operatórias , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Salas Cirúrgicas/estatística & dados numéricos , Estudos Retrospectivos
11.
Int J Health Plann Manage ; 34(2): e1346-e1355, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30945365

RESUMO

BACKGROUND: Evidence has been limited regarding broader emergency systems assessment in low- and middle-income countries. The aim of the present study was to provide the empirical evidence of Thai emergency department (ED) workforce vis-à-vis workload on a national scale, the availability of services for selected high-priority health burdens, and the governance obstacles in addressing the workforce management. METHOD: One hundred thirty public Thai EDs that provide 24-hour emergency medical care were identified across Thailand as meeting the inclusion criteria. The mailed questionnaires were administered to collect data related to the objectives of the research study. RESULT: Responses were received from 91 of 130 (70%) hospitals. The median number of patients visiting hospital EDs was 51 221 per year with 32.8% considered nonurgent (ESI levels 4-5). University hospital EDs were staffed with a higher number of ER professionals than EDs of service-based secondary care and tertiary care hospitals under Ministry of Public Health (MOPH). Almost all hospitals expressed concerns about the deficiency of doctors and nurses especially emergency physician (EP) and emergency nurses. The percentage of hospitals reporting the availability of coronary artery catheterization (34%) and thrombolytic infusion for acute thrombotic stroke (24%) was limited. The governance obstacles to manage emergency systems were considered. CONCLUSION: ED staffing seems to positively correlate with workloads except university hospitals, in our study, which may suggest the influence of teaching status on the allocation of the human resource. Among the governance obstacles in ED management, a better response to nonurgent patients requires flexibility for hospitals to set financial disincentives or mobilization and management of human resources.


Assuntos
Serviços Médicos de Emergência/estatística & dados numéricos , Países em Desenvolvimento , Serviço Hospitalar de Emergência/estatística & dados numéricos , Número de Leitos em Hospital/estatística & dados numéricos , Hospitais/estatística & dados numéricos , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Salas Cirúrgicas/estatística & dados numéricos , Inquéritos e Questionários , Tailândia
12.
Int J Surg ; 66: 72-78, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31029875

RESUMO

BACKGROUND: The Operating Theatre (OT) is the largest cost centre as well as the main revenue generator in most hospitals. One of the common problems affecting optimal OT utilization is the cancellation of scheduled surgeries. The goal of this study was to identify factors associated with cancellation within 24 h of scheduled surgeries in a tertiary hospital. METHODS: All elective surgeries performed on adults 18 years and above between June 2015 and December 2016 were included. Cancellations ≤24 h from the scheduled start time of the surgery were recorded, with their reasons for cancellation. Data relating to the patient, surgeon and planned surgery were obtained from the hospital operational database. Univariate analysis and multivariable analysis were conducted using logistic regression. RESULTS: A total of 4060 scheduled surgeries were included, of which 398 (9.8%) were cancelled within 24 h of surgery. On multivariate analysis, cancellation within 24 h of surgery was associated with history of heart failure (Adjusted odds ratio, AOR1.65; 95%CI 1.08-2.50), advanced chronic kidney disease (AOR2.33; 95%CI 1.58-3.39), or a history of hip fracture (AOR2.29; 95%CI 1.33-3.80), low socio-economic status (on Medifund financing, AOR3.16; 95%CI 1.37-6.72), history of ≥4 cancelled surgeries in the past 3 years (AOR2.38; 95%CI 1.30-4.19), and scheduled time in the afternoon (AOR1.83; 95%CI 1.44-2.32) and evening (AOR2.09; 95%CI0.73-5.13), compared to the morning. Attendance at preoperative anaesthesia assessment clinic was associated with reduced likelihood of cancellation (AOR0.55; 95%CI0.43-0.72). CONCLUSIONS: Several patient and system factors can be used to identify scheduled surgeries that are at high likelihood of cancellation within 24 h of surgery, which may inform strategies to improve the efficiency of OT utilization, including having a dedicated preoperative anaesthesia assessment clinic.


Assuntos
Centros Médicos Acadêmicos/estatística & dados numéricos , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Pacientes não Comparecentes/estatística & dados numéricos , Salas Cirúrgicas/estatística & dados numéricos , Adulto , Anestesiologia/estatística & dados numéricos , Agendamento de Consultas , Estudos de Coortes , Comorbidade , Feminino , Pesquisa sobre Serviços de Saúde/métodos , Humanos , Masculino , Cuidados Pré-Operatórios/métodos , Fatores de Risco , Singapura , Classe Social , Centros de Atenção Terciária/estatística & dados numéricos , Fatores de Tempo
13.
Mil Med ; 184(Suppl 1): 301-305, 2019 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-30901432

RESUMO

INTRODUCTION: The combat experience during the re-entry stages of Operation Inherent Resolve was distinct from other recent operations, but there is no published literature regarding these "initial entry operations" experiences among forward surgical teams (FSTs) deployed to Role 2 facilities A descriptive analysis of patients treated by FSTs may provide valuable information for Role 2 surgical teams preparing to deploy in support of initial entry operations. The purpose of this analysis was to describe injury mechanism, wounding patterns and interventions performed by a small FST in the re-entry phase in Iraq. MATERIALS AND METHODS: From July 17, 2015 to January 31, 2016, a split surgical team with two surgeons and an ER physician documented care for all patients treated by their FST located in Iraq. Given their austere environment, FSTs have limited holding capacity, blood supply, and ability to triage and perform advanced procedures. Patients, who arrived to the Role 2 in asystole, were ineligible for the study. The patient population was Iraqi Security Forces as well as Iraqi civilians. No follow-up data were obtained. Using descriptive statistics, we described the basic demographics, health status, blood utilization, injury severity, and injury pattern of the patient population. RESULTS: The final study population included 300 Iraqi casualties. The majority of patients (96%) were discharged alive. Many patients were 16 years or older (96%), male (96%), Iraqi soldiers (86%), and injured during battle (96%). Over one-third of patients (35%) had a form of metabolic acidosis, 7% were hypothermic, and 18% were in shock at admission. The median amount of blood products used was 6 (interquartile ranges (IQR) = 2-12) units, while the median red blood cells:fresh frozen plasma ratio was 1.2:1. Six or more units of blood were given to 67 (22%) patients. The top three diagnoses were laceration (n = 197, 21%), penetrating injury (n = 185, 19%), and fracture (n = 174, 18%). A high number of injuries occurred in the extremities/pelvis and buttocks (n = 360, 38%) and in the abdomen and pelvic contents (n = 145, 15%). Over a quarter of patients (26%) had critical injuries (i.e., military injury severity score ≥25). CONCLUSIONS: Given the Role 2 configuration, these results demonstrate FSTs must be capable of managing critically ill patients with markedly limited resources. This management will include general operations in both adult and pediatric patients, resuscitation with a limited blood supply, and patient assessment with minimal to no diagnostic tools. This analysis can inform resident training, pre-deployment training, as well as sustainment training for surgeons after residency.


Assuntos
Equipe de Assistência ao Paciente/estatística & dados numéricos , Guerra/estatística & dados numéricos , Adolescente , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Escala de Gravidade do Ferimento , Iraque/etnologia , Guerra do Iraque 2003-2011 , Masculino , Medicina Militar/estatística & dados numéricos , Salas Cirúrgicas/métodos , Salas Cirúrgicas/estatística & dados numéricos , Equipe de Assistência ao Paciente/organização & administração , Estados Unidos , Guerra/etnologia
14.
Can J Ophthalmol ; 54(1): 94-97, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30851782

RESUMO

OBJECTIVE: To report the reoperation rate in a large group of pediatric and adult strabismus patients over a 21-year period in Northern Alberta, Canada. METHODS: A retrospective review of 6177 strabismus surgeries from July 1995 to June 2015 on 5125 pediatric and adult patients was conducted to determine the reoperation rate at a single major referral centre. A set of guidelines was implemented in November 2014 recommending delaying reintervention for at least 12 weeks from the initial surgery, with specific exceptions. RESULTS: The historical strabismus reoperation rate over a 21-year period was 15.7%. Of those surgeries requiring reoperation, 77.7% required only 1 reoperation, 17.1% required 2 reoperations, 3.1% required 3 reoperations, and 2.1% required 4 or more reoperations. The mean time between surgeries for patients undergoing reoperation was 2.3 years and the median time was 1.0 years. CONCLUSIONS: Our study provides insight into the strabismus reoperation rate and the number of subsequent surgeries performed for patients over a 21-year period. Although preoperative ocular alignment, comorbidities, and the status of the operative eye modify the probability of reoperation, our results from a large cohort of patients provide an impression of the rate of reoperation and may be of benefit in the preoperative counseling of patients. Furthermore, we highlight the scarcity of guidelines for the appropriate timing of reoperation. The implementation of specific guidelines may encourage future investigation into trends in reoperation over time and promote ways to avoid unnecessary surgeries, lower health care costs to stakeholders, and ultimately improve patient care.


Assuntos
Previsões , Músculos Oculomotores/cirurgia , Procedimentos Cirúrgicos Oftalmológicos/estatística & dados numéricos , Complicações Pós-Operatórias/cirurgia , Reoperação/estatística & dados numéricos , Estrabismo/cirurgia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Alberta/epidemiologia , Criança , Pré-Escolar , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Morbidade/tendências , Salas Cirúrgicas/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Recidiva , Estudos Retrospectivos , Adulto Jovem
15.
Int J Pediatr Otorhinolaryngol ; 120: 73-77, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30772615

RESUMO

INTRODUCTION: There is increasing concern regarding the risks associated with the use of general anesthesia in pediatric patients. Many otolaryngologic procedures performed under general anesthesia can also be performed in clinic. We hypothesize that anxiolytics can aid in performing common procedures in clinic thus avoiding the need to undergo general anesthesia in the OR. METHODS: We performed a retrospective review of patients undergoing inoffice procedures with anxiolytics in our pediatric otolaryngology outpatient clinic between February 2013 and January 2017. Charts were reviewed for age, past medical history, procedure type/duration, and outcome. These results were then compared to a cohort undergoing similar procedures in the OR. RESULTS: A total of 34 patients underwent an in-office procedure with an anxiolytic. The success rate was 97% (33/34). The average age was 6.2 years. Six children (17%) had a known history of chromosomal abnormalities and 2 children (6%) had autism. The four most common procedures performed were cerumen impaction removal (8), flexible laryngoscopy (6), ear canal foreign body removal (5), and septal cautery (4). Performing similar procedures in the OR resulted in an average additional cost of $822. CONCLUSIONS: Performing procedures with anxiolytics in a pediatric otolaryngology clinic is safe, expeditious, and cost-effective. Anxiolytics can provide an effective alternative to general anesthesia.


Assuntos
Instituições de Assistência Ambulatorial/estatística & dados numéricos , Ansiolíticos/administração & dosagem , Custos de Cuidados de Saúde/estatística & dados numéricos , Salas Cirúrgicas/estatística & dados numéricos , Procedimentos Cirúrgicos Otorrinolaringológicos/métodos , Instituições de Assistência Ambulatorial/economia , Anestesia Geral , Ansiolíticos/efeitos adversos , Ansiolíticos/economia , Criança , Pré-Escolar , Análise Custo-Benefício , Feminino , Humanos , Lactente , Masculino , Salas Cirúrgicas/economia , Procedimentos Cirúrgicos Otorrinolaringológicos/economia , Procedimentos Cirúrgicos Otorrinolaringológicos/estatística & dados numéricos , Estudos Retrospectivos
16.
Orthop Traumatol Surg Res ; 105(1): 179-183, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30639174

RESUMO

BACKGROUND: The objective of this study was to contribute to an OR efficiency optimisation effort by comparing a trauma OR versus a scheduled surgery OR in a lower limb orthopaedic surgery department. HYPOTHESIS: The main hypothesis is that efficiency is lower in the trauma OR than in the scheduled surgery OR. The secondary hypothesis is that efficiency of the trauma OR is lower during weekends. MATERIAL AND METHODS: This prospective study was conducted in 2016 in the orthopaedic surgery department of a university hospital. Patients were divided into three groups based on whether they underwent scheduled surgery (SchOS), trauma surgery on a weekday (TSwk), or trauma surgery on a weekend (TSwkend). Actual OR occupancy time, allocated OR block time (BT), OR occupancy rate, patient entrance-to-incision time, incision-to-closure time, closure-to-post-anaesthesia care unit (PACU) entrance time, and clean-up/set-up time (T4) were measured. RESULTS: We included 691 patients in the SchOS group, 819 in the TSwk group, and 327 in the TSwkend group. OR efficiency was lower in the TSwk group compared to the SchOS group (occupancy rate, 86% vs. 88%; p=10-4). All occupancy time components were longer in the TSwk group. However, each component accounted for similar total occupancy time proportions in the two groups, except for clean-up/set-up time, which was longer in the TSwk group (p<0.05). On average, entrance-to-incision time accounted for 31%, incision-to-closure time for 34%, closure-to-PACU time for 18%, and clean-up/set-up time for 17% of total occupancy time. Efficiency was lower in the TSwkend group than in the TSwk group (occupancy rate, 75% vs. 86%; p=10-4). The TSwkend group had shorter entrance-to-incision and incision-to-closure times (p<0.05) and a nearly 10% longer clean-up/set-up time (p<0.05). CONCLUSION: Efficiency of the trauma OR, although lower compared to the scheduled orthopaedic surgery OR, was nevertheless satisfactory as assessed based on standard indicators. Of the four total occupancy time components, the first three accounted for similar proportions of the total; differences occurred only for clean-up/set-up time. Efforts to improve OR efficiency should focus on arrival of the first patient and turnover time. LEVEL OF EVIDENCE: II, prospective cohort study.


Assuntos
Eficiência Organizacional , Departamentos Hospitalares/organização & administração , Hospitais Universitários/organização & administração , Salas Cirúrgicas/organização & administração , Ortopedia/organização & administração , Traumatologia/organização & administração , Fraturas Ósseas/cirurgia , Hospitais Universitários/estatística & dados numéricos , Serviço Hospitalar de Limpeza/organização & administração , Serviço Hospitalar de Limpeza/estatística & dados numéricos , Humanos , Salas Cirúrgicas/estatística & dados numéricos , Duração da Cirurgia , Procedimentos Ortopédicos , Ortopedia/estatística & dados numéricos , Estudos Prospectivos , Fatores de Tempo , Traumatologia/estatística & dados numéricos
17.
Am J Surg ; 218(1): 27-31, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-30691674

RESUMO

INTRODUCTION: This study was undertaken to characterize unplanned return to the OR following kidney transplantation(KT). METHODS: All patients undergoing KT at a single center from 1/2015 through 11/2017 were evaluated. The primary endpoint was unplanned return to the OR within 90 days. Perioperative and one year patient and graft outcomes were also determined. RESULTS: Of 190 patients, 14(7.4%) of patients had unplanned reoperation. The most common individual indications were bleeding from biopsy sites(n = 2), poor vascular flow on postop ultrasound(n = 4), and perforated diverticulitis(n = 2). Forty Three percent of all reoperations were unrelated to the technical conduct of the transplant operation. Reoperated patients had significantly worse survival at one year(78.6% vs. 96.6%), although graft function in survivors was similar to those who did not return to the OR. CONCLUSION: Reoperation following KT is frequently unrelated to the technical conduct of the transplant procedure, thus it may not be useful as a quality metric.


Assuntos
Transplante de Rim , Salas Cirúrgicas/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/cirurgia , Reoperação/estatística & dados numéricos , Feminino , Rejeição de Enxerto/cirurgia , Sobrevivência de Enxerto , Humanos , Imunossupressão/métodos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco
18.
J Surg Res ; 236: 266-270, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30694765

RESUMO

BACKGROUND: Adverse events in surgery occur frequently, increase likelihood of postoperative morbidity, and mostly take place in the operating rooms. Several surgeons have advocated for learning from adverse events and near misses to help improve patient safety. To do so, one must first understand how to accurately identify and report intraoperative events. MATERIALS AND METHODS: Consecutive laparoscopic cases performed in a referral center were included in the cohort. Veress needle (VN) injuries were characterized according to a priori established criteria. Two methods were used to identify VN injuries: direct observation and patient chart review. For direct observation, trained surgeon assessors identified the outcomes using a comprehensive data capture platform called the operating room black box. On the other hand, operative reports and patient charts were reviewed by trained assessors to identify reported VN injuries. RESULTS: Hundred thirty-one cases were analyzed. There were 12 (9%) VN injuries identified by direct observation compared to 3 (2%) identified in patient chart review method. Injuries to the liver and stomach were identified by both methods, whereas injuries to the omentum were not reported in patient charts even if they required rectification. There were seven VN injuries that required rectification, lasting up to 12% of the operating time. There were 47 (35%) near misses identified through direct observation, whereas none was reported in patient charts. CONCLUSIONS: Direct observation enables characterization of VN injury and near misses with far greater detail and accuracy than patient chart review.


Assuntos
Laparoscopia/efeitos adversos , Agulhas/efeitos adversos , Segurança do Paciente , Pneumoperitônio Artificial/efeitos adversos , Gestão de Riscos/métodos , Adulto , Estudos de Coortes , Feminino , Humanos , Laparoscopia/instrumentação , Masculino , Registros Médicos/estatística & dados numéricos , Pessoa de Meia-Idade , Near Miss/estatística & dados numéricos , Salas Cirúrgicas/estatística & dados numéricos , Pneumoperitônio Artificial/instrumentação , Estudos Prospectivos , Gestão de Riscos/estatística & dados numéricos
19.
Pediatr Cardiol ; 40(3): 468-476, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30238137

RESUMO

Early extubation appears to have beneficial effects on the Fontan circulation. The goal of this study was to assess the impact of extubation on the operating table in comparison with extubation during the first hours after Fontan operation (FO) on the early postoperative course. Between 2013 and 2016, 114 children with a single ventricle heart malformations (mean age, 3.8 ± 2.3 years) underwent FO: 60 patients were extubated in the operating room (ORE) and 54 in the intensive care unit (ICUE) in the median time of 195 min (range 30-515 min) after procedure. Pre-, peri-, and postoperative records were retrospectively analyzed. The hospital survival rate was 100%. One patient from the ORE group needed an immediate reintubation because of laryngospasm. The ORE group showed lower heart rate (106.5 vs. 120.3 bpm; p < 0.001) and lower central venous pressure (10.4 vs. 11.4 mmHg; p = 0.001) than patients in the ICUE group within the first 24 h after FO, as well as higher systolic blood pressure within 7 h after operation (88.6 ± 2.5 vs. 85.6 ± 2.6 mmHg; p = 0.036). The ORE children manifested significantly less pleural effusions during 48 h after FO (38.0 vs. 49.5 ml/kg; p = 0.004), received less intravenous fluid administration within 24 h after FO (54.1 vs. 73.8 ml/kg; p = 0.019), less inotropic support (9.8 vs. 12.8 h of dopamine; p = 0.033), and less antibiotics (4.7 vs. 5.8 days; p = 0.037). ICUE children manifested metabolic acidosis more frequently than the ORE group 3-4 h after FO (p < 0.05). Immediate extubation after FO in comparison with extubation in the ICU appears to be associated with improved hemodynamics and reduced application of therapeutic interventions in the postoperative course.


Assuntos
Extubação/métodos , Técnica de Fontan/efeitos adversos , Cardiopatias Congênitas/cirurgia , Salas Cirúrgicas/estatística & dados numéricos , Extubação/efeitos adversos , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Unidades de Terapia Intensiva/estatística & dados numéricos , Intubação Intratraqueal , Masculino , Período Pós-Operatório , Estudos Retrospectivos , Taxa de Sobrevida , Fatores de Tempo
20.
J Clin Anesth ; 53: 20-26, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30290278

RESUMO

STUDY OBJECTIVE: Switching from one specialty to another increases mean turnover times (i.e., interval between the exit and entrance of consecutive patients in an operating room [OR]). We estimate the effect on the mean tardiness of to-follow surgeons from following another surgeon of a different versus same specialty. Tardiness of a case's start time refers to the number of minutes the patient enters the OR later than scheduled; tardiness is 0 min if the patient enters early. Tardiness cause surgeon waiting. There are multiple causes of tardiness, but, most often, the preceding case(s) took longer than estimated. DESIGN: 10-year historical cohort study with all surgical cases performed during regular workdays. SETTING: Large teaching hospital. MEASUREMENTS: Estimated OR end times were calculated using a Bayesian method. Because tardiness is influenced by the estimated case start time (i.e., later starting cases have greater tardiness), tardiness values were adjusted to a 12 noon start time for the 2nd surgeon. MAIN RESULTS: The cases of to-follow surgeons in ORs had mean tardiness of 45.1 (SE 0.6) min. When the to-follow surgeon in the OR was of a different versus the same specialty from the first surgeon, the mean turnover time was 7.3 (0.4) min longer (P < 0.00001). However, the mean tardiness was not significantly affected (0.1 min, 95% confidence interval [CI] -2.7 to 3.0 min; P = 0.93). In comparison, if one or more of the preceding cases in an OR was an add-on case, the increase in mean tardiness was 35 min (95% CI 28 to 43 min; P < 0.00001). CONCLUSIONS: OR managers can assure surgeons with afternoon starts that following a surgeon of a different specialty generally will not increase their waiting time. Case scheduling should focus on reducing over-utilized OR time and thus the hours that anesthesiologists and nurses work late.


Assuntos
Salas Cirúrgicas/organização & administração , Admissão e Escalonamento de Pessoal , Cirurgiões/organização & administração , Recursos Humanos/organização & administração , Anestesiologistas/organização & administração , Estudos de Coortes , Hospitais de Ensino/organização & administração , Hospitais de Ensino/estatística & dados numéricos , Humanos , Enfermeiras e Enfermeiros/organização & administração , Salas Cirúrgicas/estatística & dados numéricos , Fatores de Tempo
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