Interventions to improve patient flow in emergency departments: an umbrella review.

OBJECTIVES: Patient flow and crowding are two major issues in ED service improvement. A substantial amount of literature exists on the interventions to improve patient flow and crowding, making it difficult for policymakers, managers and clinicians to be familiar with all the available literature and identify which interventions are supported by the evidence. This umbrella review provides a comprehensive analysis of the evidence from existing quantitative systematic reviews on the interventions that improve patient flow in EDs. METHODS: An umbrella review of systematic reviews published between 2000 and 2017 was undertaken. Included studies were systematic reviews and meta-analyses of quantitative primary studies assessing an intervention that aimed to improve ED throughput. RESULTS: The search strategy yielded 623 articles of which 13 were included in the umbrella review. The publication dates of the systematic reviews ranged from 2006 to 2016. The 13 systematic reviews evaluated 26 interventions: full capacity protocols, computerised provider order entry, scribes, streaming, fast track and triage. Interventions with similar characteristics were grouped together to produce the following categories: diagnostic services, assessment/short stay units, nurse-directed interventions, physician-directed interventions, administrative/organisational and miscellaneous. The statistical evidence from 14 primary randomised controlled trials (RCTs) was evaluated to determine if correlation or clustering of observations was considered. Only the fast track intervention had moderate evidence to support its use but the RCTs that assessed the intervention did not use statistical tests that considered correlation. CONCLUSIONS: Overall, the evidence supporting the interventions to improve patient flow is weak. Only the fast track intervention had moderate evidence to support its use but correlation/clustering was not taken into consideration in the RCTs examining the intervention. Failure to consider the correlation of the data in the primary studies could result in erroneous conclusions of effectiveness.

Postoperative Shivering Among Cannabis Users at a Public Hospital in Trinidad, West Indies.

PURPOSE: Postoperative shivering has been anecdotally observed to be frequent and severe in Cannabis smokers following general anesthesia in the Caribbean. The aim of this study was to compare the frequency and intensity of postoperative shivering in Cannabis users versus non-users. DESIGN: A prospective, cross-sectional, observational design was used. METHODS: Demographic data were obtained. Patients were grouped into Cannabis users and non-users. All patients received standardized general anesthesia and were administered warmed fluids intraoperatively. Ambient room temperatures and clinical data were recorded. Patients' core body temperature was recorded at 10-minute intervals both in the operating room and the post-anesthesia care unit (PACU). Postoperatively an independent observer assessed the patients who had shivering using a scoring system ranging from 0 to 3. Treatment for shivering and post-treatment shivering scores were also recorded. FINDINGS: Fifty-five patients were studied, of which 71% were male. There were 25 (45%) Cannabis users, of which 50% smoked < 5 joints per week, and 35% smoked >10 joints per week; 30 (55%) patients were non-users. The overall incidence of postoperative shivering was 36%; 16% had a shivering score of '3', 13% had '2' and 7% had a score of '1'. The incidence of postoperative shivering among Cannabis users was 40% while it was 33.3% in non-users. Also, 90% of Cannabis users had shivering scores of 2 and 3, compared to 70% of non-users. CONCLUSIONS: There was a higher incidence and intensity of shivering in Cannabis smokers, although the study could not establish a statistically significant difference in the frequency and severity of shivering between Cannabis users and non-users.

Do Serially Recorded Prognostic Scores Predict Outcome Better Than One-Time Recorded Score on Admission? A Prospective Study in Adult Intensive Care Patients.

OBJECTIVES: The prognosticating ability of one-time recorded Acute Physiology and Chronic Health Evaluation (APACHE) IV score was compared with serially recorded Mortality Prediction Model (MPM) II scores. DESIGN AND METHODS: A prospective observational study was conducted for a period of 6 months. Acute Physiology and Chronic Health Evaluation IV score was recorded during the first day on intensive care unit (ICU) admission. Mortality Prediction Model II was recorded on admission, 24, 48, and 72 hours. Predicted mortality was compared with observed mortality. The systems were calibrated and tested for discriminant functions. RESULTS: One hundred and fifty patients were studied. The observed mortality was 21.3%. The mean predicted hospital mortality by APACHE IV was 20.6%. The mean predicted hospital mortality rate by serial MPM II measurements was 27.7%, 24.3%, 25.5%, and 25.8%. The area under the receiver-operating characteristic curve was 0.87 for APACHE IV and 0.82, 0.84, 0.85, and 0.89 for MPM II series. Both systems calibrated well with similar degree of goodness of fit. CONCLUSION: Acute Physiology and Chronic Health Evaluation IV on admission predicted hospital mortality better than serially recorded MPM, which overestimated mortality. Also, APACHE IV had a slightly better discrimination compared to MPM II on admission. One-time recording of APACHE IV on admission may be sufficient for prognostication of ICU patients rather than serial MPM scores.

Efficacy of a separate informed consent for anesthesia services: A prospective study from the Caribbean.

BACKGROUND AND AIMS: This study aimed to determine whether a separate written consent form improved the efficacy of the informed consent process for anesthesia in adult patients undergoing elective surgery at a tertiary care teaching hospital. MATERIAL AND METHODS: We randomized patients into two groups prospectively. The first group (Group A) signed the hospital's standard Consent for Operation form only while the second group (Group B) signed a separate Consent for Anesthesia form additionally. Patients were interviewed postoperatively with an eight-item questionnaire with responses in a 5-point Likert scale. A composite adequacy of consent index was generated from the responses and analyzed. RESULTS: Two hundred patients (100 in each group) were studied. All patients indicated that the anesthesiologist(s) had their permission to proceed with their anesthesia care. The mean adequacy of consent index score in Group B was higher than that of Group A (30.6 ± 4.6 [standard deviation (SD)] vs. 27.9 ± 5.2 [SD]) (P < 0.001). The separate written consent had a positive impact on the patients' understanding of the nature and purpose of the intended anesthesia procedures (P = 0.04), satisfaction with the adequacy of information provided about common side effects (P < 0.001) and rare but serious complications (P = 0.008). CONCLUSIONS: A separate written consent for anesthesia improved the efficacy of the informed consent process with respect to better information about the nature and purpose of anesthesia, common side effects, and rare but serious complications.

Laparoscopic Repair of Sportman's Hernia - The Trinidad Experience.

Sportman's hernia: (Athletic pubalgia) is an uncommon and poorly understood condition afflicting athletic individuals. Sufferers complain of chronic groin pain and often present diagnostic dilemmas to physicians and physiotherapists. We present a series of cases illustrating the varying presentations of sportman's hernia and diagnostic approaches that can be utilized to exclude common differentials. We also describe laparoscopic mesh repair as an effective treatment option for this condition.

An Economic Evaluation of the Preoperative Investigations for Elective Surgical Patients at a Caribbean Tertiary Care Teaching Hospital.

Introduction Preoperative assessment using widespread laboratory investigations and ancillary tests as preoperative screening may be unnecessary and lead to an economic burden. This study aimed to determine the routine preoperative investigations performed in a tertiary care teaching hospital in the Caribbean that could be categorized as unnecessary and the costs incurred for these tests. Methods Patient and surgery-specific data were collected prospectively from adult elective surgery patients over a three-month period. Surgical intensity, American Society of Anesthesiologists (ASA) grade and the National Institute for Health and Care Excellence (NICE) (UK, 2016) Clinical Guideline for Preoperative Investigations were used to determine which tests to deem unnecessary. The overall economic burden of unnecessary testing was assessed. Results Data were prospectively collected from 636 patients during the study period. Sixty-four percent of the preoperative investigations performed were deemed unnecessary. The money spent on these unnecessary investigations amounted to $44,622. When extrapolated, this can amount to approximately $178,488 per annum. This represented 59% of the total money spent on the overall preoperative investigations performed. Relatively healthier patients (ASA I and II) had a significantly higher number of unnecessary investigations performed. Conclusion This study found that the majority of preoperative investigations performed routinely may be deemed unnecessary. This results in a huge economic burden on the healthcare system. There is a need to update and strictly implement clinical guidelines for preoperative investigations.

Experiences with SARS-CoV-2 (Covid-19) in Trinidad and Tobago, a small island developing state: realities and opportunities.

The COVID-19 pandemic has exerted significant global challenges that are expressed in a variety of socio-politico-economic scenarios, depending upon individual countries' preparedness and resilience. The impact COVID-19 in Small Island Developing States (SIDS), most of which are categorized as Lower and Middle-Income Countries, has been pronounced. Furthermore, many of these SIDS possess specific vulnerabilities to global threats. This paper contextualizes the experience of Trinidad and Tobago from some perspectives of geoeconomics, healthcare, and international relations. In many ways, the experience is similar to that of other SIDS with the inherent nuances of a post-colonial world. Trinidad and Tobago was ranked number one by the Oxford University COVID-19 Government Response Tracker (OxCGRT) "Lockdown rollback checklist: Do countries meet WHO recommendations for rolling back lockdown?". Despite the significant political support to combat the disease, by the end of 2022, the country had recorded over four thousand deaths and just over 50% of the population is vaccinated. This paper seeks to discuss the successes and challenges faced by this twin island state.

A case of malignancy in a thyroglossal duct cyst--recommendations for management.

Thyroglossal duct cyst carcinomas are rare tumors with just more than 200 cases published to date. This is a case report of a thyroglossal duct cyst harboring an occult carcinoma for which a Sistrunk operation was performed. Histopathological examination revealed a papillary carcinoma arising from a thyroglossal duct cyst after which the patient underwent a total thyroidectomy. With current evidence-based guidelines lacking, we discussed some of the issues relevant to the surgical planning and postoperative management of such a patient.

Early hospital discharge following breast cancer surgery in the West Indies: a Trinidad study.

PURPOSE: To examine the outcome of a policy of early hospital discharge (<24 hours) after breast cancer surgery in a Third World setting, where health care resources and support services are very limited. DESIGN: Prospective enrollment into a plan of early hospital discharge within 24 hours following breast surgery. Followup was conducted for wound infections; seroma formation; flap dehiscence; and readmission, if any. SUBJECTS: All patients over a 15-year period who underwent wide local excision or mastectomy and axillary clearance were enrolled. RESULTS: A total of 331 patients were entered into the study. Of these, 148 had modified radical mastectomy and 183 had wide local excision plus axillary dissection. Each patient had a drain placed and output was recorded. Follow-up revealed that there was no increase in the complication rates. CONCLUSION: Early hospital discharge following breast cancer surgery is a feasible option for most patients and can be safely implemented even in a resource-limited setting where cost containment is essential.

Validation of Pediatric Index of Mortality-2 scoring system in a pediatric intensive care unit, Barbados.

This study evaluated the outcome of patients in a pediatric intensive care unit (ICU) of a developing country applying Pediatric Index of Mortality (PIM) version-2 scoring system. A total of 163 consecutive patients were prospectively studied. Data included demographics, diagnoses at admission, PIM-2 score, the duration of ICU stay and hospital outcome. Predicted mortality and standardized mortality ratio (SMR) were calculated. Respiratory and neurological illnesses were the main admission diagnoses. The mean length of stay was 5.4 [95% Confidence Intervals (CI): 4-6.9] days. The mean predicted mortality was 6.2% (95% CI: 4.3-8.1); the observed mortality rate was 5.5%, the SMR being 0.89. Hosmer-Lemeshow analysis calibrated PIM-2 for the case mix [χ(2) = 5.64 (df = 7), p = 0.58]. The area under the ROC curve was 0.82 (95% CI: 0.72-0.92) showing a good discriminant function. Performance of the pediatric ICU in Barbados is comparable to that of developed world by risk-adjusted outcome evaluation.

Knowledge, Attitudes and Practices (KAP) regarding the Novel Coronavirus Disease (COVID-19) Post-lockdown in Trinidad and Tobago.

The Novel Coronavirus Disease (COVID-19) was declared a pandemic by the World Health Organization (WHO) in March 2020. Trinidad and Tobago reported its first infection on March 12th 2020. This study assessed knowledge, attitudes and practices toward COVID-19 among Trinidadians during the post-lockdown period. A validated questionnaire was used to conduct a cross-sectional survey from May 25th to June 6th 2020.Most respondents (512, 96.6%) knew that COVID-19 is highly infectious. Many (523, 98.7%) identified vulnerable groups as persons 65 years and older and those with preexisting co-morbidities (480, 90.6%). Respondents identified COVID-19 symptoms as fever (498, 94.0%), dry cough (495, 93.4%), myalgia (403, 76.0%) and sore throat (441, 83.2%). Most 504 (95.1%) acknowledged that COVID-19 threatened the country's economy. Dominant practices included regular hand washing (97.2%) and social distancing (512, 96.6%).Health authorities should continue public education efforts to increase knowledge and the adoption of recommended practices.

A qualitative exploration of value and waste in a Trinidadian emergency department patient flow process: perspectives of patients and clinicians.

PURPOSE: A process that does not include the customer's value may not be effective in providing care. This study aimed to identify value and waste in an emergency department (ED) patient flow process from a patient and clinician perspective. DESIGN/METHODOLOGY/APPROACH: A qualitative case study was conducted in an ED in Trinidad and Tobago. Observations and informal conversational interviews with clinicians (n = 33) and patients (n = 50) explored patient flow, value and waste. Thematic analysis was used to create a framework on valuable and wasteful aspects in the ED patient flow process. FINDINGS: Valuable aspects led to direct improvements in the patient's health or an exchange of information in the process. Wasteful aspects were those with no patient activity, no direct ED clinical involvement, or resulted in a perceived inappropriate use of ED resources. However, there was a disparity in responses between clinicians and patients with clinicians identifying more features in the process. RESEARCH LIMITATIONS/IMPLICATIONS: The single case study design limits the generalizability of findings to other settings. This study did not specifically explore the influence of age and gender on what mattered to patients in ED services. Future studies would benefit from exploring whether there are any age and gender differences in patient perspectives of value and waste. Further research is needed to validate the usefulness of the framework in a wider range of settings and consider demographic factors such as age and gender. PRACTICAL IMPLICATIONS: The study has produced a framework which may be used to improve patient flow in a way that maximized value to its users. A collaborative approach, with active patient involvement, is needed to develop a process that is valuable to all. The single case study design limits the generalizability of findings to other settings. ORIGINALITY/VALUE: Qualitative methods were used to explicitly explore both value and waste in emergency department patient flow, incorporating the patient perspective. This paper provides an approach that decision makers may use to refine the ED patient flow process into one that flows well, improves quality and maximizes value to its users.

Hourglass epidermoid inclusion cyst: an unusual clinical presentation.

The authors have indicated no significant interest with commercial supporters.

Outcome evaluation of coronary artery bypass grafting surgery applying the EuroSCORE in a Caribbean developing country.

BACKGROUND: The risk-adjusted outcome of coronary artery bypass grafting (CABG) in Trinidad and Tobago was evaluated by applying the EuroSCORE scoring system. METHODS: A retrospective study was undertaken by reviewing the case notes of patients who underwent CABG from 2003 to 2008 under Caribbean Heart Care. Data collected included age, sex, smoking status, comorbidities, chronic pulmonary disease, extracardiac arteriopathy, neurologic disease, previous cardiac surgery, serum creatinine, active endocarditis, critical preoperative state, and mode of surgery. Predicted mortality was calculated with the EuroSCORE, the model was calibrated by Hosmer-Lemeshow analysis, and the discriminant function was analyzed by using the receiver operating characteristic (ROC) curve. RESULTS: We studied 1082 patients who underwent CABG, 75.6% of whom were of Asian Indian ethnicity. The overall mean (±SD) EuroSCORE was 2.87 ± 2.1. The predicted perioperative mortality rate was 2.3%, and the observed mortality rate was 1.2%. The overall standardized mortality ratio was 0.52. Eighty-six percent of the patients underwent off-pump CABG. Hosmer-Lemeshow analysis showed that the system calibrated well to our case mix (Hosmer-Lemeshow value, 6.87; degrees of freedom, 8; P = .551). The EuroSCORE discriminated patient outcomes well, as shown by the area under the ROC curve (0.78). Age and ethnicity did not influence the outcome. CONCLUSIONS: The outcomes of CABG surgery patients are good in Trinidad and Tobago and are comparable to standards in developed countries when evaluated with the EuroSCORE. The proportion of patients undergoing off-pump CABG is high.

Minilaparotomy cholecystectomy--an appropriate alternative to laparoscopic cholecystectomy in developing nations.

BACKGROUND: This study reports the experience of performing minilaparotomy cholecystectomy (MC) and assesses the peri-operative outcome of this surgery in the setting of a developing country. METHODS: Data of all patients who underwent minilaparotomy cholecystectomy by a single surgical unit were collected and reviewed. These included demographics, surgical technique used, peri-operative complications and length of hospital stay. Descriptive analyses were done. RESULTS: 476 patients who underwent elective minilaparotomy cholecystectomy in a single surgical unit over a 15 year period were studied. Of these, 84.8% were female. The mean age was 47 years. The most common indication for surgery was symptomatic cholelithiasis with chronic cholecystitis (66%). Mean length of the surgical incision was 4.8 cm and mean operating time was 31 min. Rate of conversion to conventional open cholecystectomy was 4%. Median hospital length of stay was 22 hours. Minor wound infection was the only surgical post-operative complication recorded in 7 patients. Nine patients in the converted group and 3 in the minilaparotomy cholecystectomy group had significant vomiting. There was no mortality. CONCLUSION: The study reinforces the view that minilaparotomy cholecystectomy can be safely and effectively performed with minimal peri-operative complications, and is ideal for developing country settings.

A comprehensive approach to quality management of intensive care services.

PURPOSE: The purpose of this paper is to develop a comprehensive framework for improving intensive care unit performance. DESIGN/METHODOLOGY/APPROACH: The study introduces a quality management framework by combining cause and effect diagram and logical framework. An intensive care unit was identified for the study on the basis of its performance. The reasons for not achieving the desired performance were identified using a cause and effect diagram with the stakeholder involvement. A logical framework was developed using information from the cause and effect diagram and a detailed project plan was developed. The improvement projects were implemented and evaluated. FINDINGS: Stakeholders identified various intensive care unit issues. Managerial performance, organizational processes and insufficient staff were considered major issues. A logical framework was developed to plan an improvement project to resolve issues raised by clinicians and patients. Improved infrastructure, state-of-the-art equipment, well maintained facilities, IT-based communication, motivated doctors, nurses and support staff, improved patient care and improved drug availability were considered the main project outputs for improving performance. The proposed framework is currently being used as a continuous quality improvement tool, providing a planning, implementing, monitoring and evaluating framework for the quality improvement measures on a sustainable basis. PRACTICAL IMPLICATIONS: The combined cause and effect diagram and logical framework analysis is a novel and effective approach to improving intensive care performance. Similar approaches could be adopted in any intensive care unit. ORIGINALITY/VALUE: The paper focuses on a uniform model that can be applied to most intensive care units.

Cecal volvulus and mucocele of the appendix.

We report the case of a 75-year-old woman who presented the association of a cecal volvulus with an appendiceal mucocele. A laparotomy showed these two findings and a right hemicolectomy with an end-to-end ileo-transverse colonic anastomosis was done. The role of plain radiograph and computerized tomographic imaging in the diagnosis of this entity is discussed To our knowledge, this association has not been reported in the literature.

Costs of Providing Intensive Care for Adult Non-survivors in a Caribbean Teaching Hospital.

Introduction  Intensive Care Unit (ICU) is a resource intense area consuming a vast majority of the hospital's budget. This study aimed to determine the costs of providing critical care to non-survivors in an adult ICU at a tertiary care teaching hospital in the Caribbean. Methods  A chart review of non-survivors over a period of nine months was done in an adult ICU. Admission diagnoses, Simplified Acute Physiology Score (SAPS II) score, daily laboratory investigations, drugs, and all therapeutic interventions including mechanical ventilation were recorded. Activity-based costs were prospectively estimated by data obtained from ICU flowsheets, nursing-activity scores, and various hospital departments. Results A total of 316 days of ICU intervention data were collected from the 39 non-survivors enrolled. The median patient age was 56 years. The median ICU length of stay (LOS) and the median duration of mechanical ventilation were five days. The median SAPS II score was 62. One-third of patients had cardiovascular problems and 28% were surgical patients. The total cost of providing ICU care for the non-survivors was US$ 765,233 with an average cost of US$ 19,621 per patient. Human resources (39%) and consumables (29%) were the highest components of costs. Patients who had a cardiac arrest before admission consumed more resources. A higher SAPS II score predicted a shorter LOS (p=0.01) and lower costs (p=0.03). Conclusions  ICU care for non-survivors consume significantly high resources. Stringent admission protocols and consideration of medical futility at an earlier stage, using prognostic models and clinical criteria may prevent unnecessary interventions and costs.