Lean Lobectomy: Streamlining Video-Assisted Lobectomy to Increase the Value of Lung Cancer Care.

PURPOSE: A review of the outcomes of patients who received our video-assisted thoracic surgery (VATS) lung lobectomy in 2015 revealed long lengths of stay, inefficient care transitions, and overuse of resources. Focused process redesign offers a proven method for instituting improvement and changes in health care. We sought to use systems process improvement to streamline VATS lobectomies at our institution, and we targeted cost drivers to optimize quality of care and minimize overuse of resources. METHODS: We performed a retrospective review of perioperative practices between January 2015 and March 2016 for patients undergoing VATS lobectomy that helped establish a value stream map, used a granular cost database, and performed real-time analysis. We used an outcomes database, which allowed us to identify cost drivers, practice variability, and rent seeking. We implemented process redesign with constant review and formal value stream reanalysis at 6-month intervals over a 2-year period. RESULTS: We ultimately experienced an overall 187% reduction of time in the operating room (297 v 159 minutes). Our process redesign also resulted in significantly fewer chest x-rays per patient (mean, 6.7 v 2), laboratory draws (100% v 5.7%), and consultations (100% v 5.7%), which resulted in a 234% reduction in mean length of stay (4.4 v 1.88 days) and an overall cost reduction of 40%. These changes did not have a detrimental effect on patient outcomes: pulmonary complications (16.9% v 8.6%), cardiac complications (13.2% v 8.6%), and readmission rates (13.6% v 2.9%) all decreased. CONCLUSION: By using value stream analysis and process redesign methodologies, closely paired with highly granular cost and outcomes data, we were able to achieve significant improvements in patient outcomes and use of resources.

Spontaneous hemothorax during general anesthesia.

We report a case of spontaneous hemothorax in a healthy 27-year-old man undergoing elective reconstruction of the right anterior cruciate ligament (ACL) under general anesthesia. In the postanesthesia care unit (PACU), the patient became hypotensive and tachycardic with mid-sternal chest discomfort. A chest roentgenogram revealed an almost complete opacification of the right hemithorax. A diagnostic thoracentesis was positive for frank blood, confirming a right hemothorax. The patient was emergently taken back to the operating room. A chest tube was inserted, and 3.3 l of dark blood was drained. Once the patient improved hemodynamically, we proceeded with a right video-assisted thoracoscopic surgery (VATS). A bleeding vessel incorporated in a bleb was identified at the apex of the right lung. The bleeding vessel was clipped. A wedge resection of the apical bleb was performed and the associated torn vascular adhesion was stapled. The patient was found to have bullous disease at the apical region of the right lung. These bullae can undergo neovascularization and form vascularized bullae. Rupture of these vascularized bullae can cause a spontaneous hemopneumothorax. In our patient it is possible that an apical vascularized bulla ruptured causing a massive intrapleural bleed.

Post-transplant survival in idiopathic pulmonary fibrosis patients concurrently listed for single and double lung transplantation.

BACKGROUND: Lung transplantation is a widely accepted treatment for patients with end-stage lung disease related to idiopathic pulmonary fibrosis (IPF). However, there are conflicting data on whether double lung transplant (DLT) or single lung transplant (SLT) is the superior therapy in these patients. The purpose of this study was to determine whether actuarial post-transplant graft survival among IPF patients concurrently listed for DLT and SLT is greater for recipients undergoing the former or the latter. METHODS: The United Network for Organ Sharing provided de-identified patient-level data. Analysis included lung transplant candidates with IPF listed between January 1, 2001 and December 31, 2009 (n = 3,411). The study population included 1,001 (29.3%) lung transplant recipients concurrently listed for DLT and SLT, all ≥18 years of age. The primary outcome measure was actuarial post-transplant graft survival, expressed in years. RESULTS: Among the study population, 433 (43.26%) recipients underwent SLT and 568 (56.74%) recipients underwent DLT. The analysis included 2,722.5 years at risk, with median graft survival of 5.31 years. On univariate (p = 0.317) and multivariate (p = 0.415) regression analyses, there was no difference in graft survival between DLT and SLT. CONCLUSIONS: Among IPF recipients concurrently listed for DLT and SLT, there is no statistical difference in actuarial graft survival between recipients undergoing DLT vs SLT. This analysis suggests that increased use of SLT for IPF patients may increase the availability of organs to other candidates, and thus increase the net benefit of these organs, without measurably compromising outcomes.

Local allocation of lung donors results in transplanting lungs in lower priority transplant recipients.

BACKGROUND: Under the current lung allocation system, if organs are accepted for a candidate within the local donor service area (DSA), they are never offered to candidates at the broader regional level who are potentially more severely ill, even if the nonlocal candidate has a higher lung allocation score (LAS). The purpose of this study was to determine the frequency with which organs were allocated to a local lung recipient while a blood group-matched and size-matched candidate with a higher LAS existed in the same region. METHODS: United Network for Organ Sharing (UNOS) provided deidentified patient-level data. The study population included all locally allocated organs for double-lung transplants (DLTs) performed in 2009 in the United States (n=580). All occurrences of an ABO blood group-matched, height-matched (±10 cm), double-lung candidate in the same region, with a higher LAS than the local candidate who actually received the organs, were calculated; these occurrences were termed events. RESULTS: In 2009, 3,454 events occurred when a local DLT recipient candidate received a DLT while a DLT candidate in the same region had a higher LAS. With a mean of 5.96 events per transplant, this impacted 480 (82.8%) of the 580 DLTs. Further, 555 (16.1%) of these events involved 1 (or more) of the 185 regional candidates who ultimately did not receive transplants and died while on the waiting list. CONCLUSIONS: This analysis suggests that the locally based lung allocation system results in a high frequency of events whereby an organ is allocated to a lower-priority candidate while an appropriately matched higher priority candidate exists regionally.