scholarly journals P-O17 The Royal Stoke Green Pathway: a method to undertake safe UGI surgery during the COVID pandemic

2021 ◽  
Vol 108 (Supplement_9) ◽  
Author(s):  
Nader Ghassemi ◽  
Joseph Meilak ◽  
Siobhan C McKay ◽  
Anand Bhatt ◽  
Damien Durkin ◽  
...  

Abstract Background During the first wave of the COVID pandemic surgical services we paralysed globally, with cancellation of an estimated 28-million operations during the first 12 weeks.  Worryingly, surgical patient with COVID were reported to have unacceptably high peri-operative mortality, approaching 25%.  However, there was an urgent clinical need to progress with category 1 and 2 operations, to prevent disease progression and avoidable morbidity and mortality from non-COVID pathologies.  During the second and subsequent waves of the pandemic it was vital to protect patients from peri-operative COVID whilst undertaking urgent surgery safely. Methods Our centre developed a ring-fenced 'Green Pathway' for category 1 and 2 patients requiring surgery.  Patients were treated in physically separate area of the hospital, with no interaction between COVID and non-COVID patients, healthcare staff or facilities.  Patients self-isolated for 14-days prior to admission, and had pre- and peri-operative COVID RT-PCR tests.  We assessed outcomes for patients immediately prior to the introduction of the Green Pathway (1/10/2020) and following implementation (31/12/2020) to assess safety. Textbook outcomes for pancreatoduodenectomy were compared to assess safety and quality.  Other data suggests that UGI surgery couldn't continue in other hospitals from December 2020. Results There were 47 admissions to surgical HDU following category 1 and 2 upper GI operations during the study; 31 pre-pathway (PP) implementation, and 16 green pathway (GP) patients. Median age 66-years (43-78 range) PP vs 65-years (range 42-74) GP, median ASA 3 vs 2. Median HDU length of stay (LOS) 5-days vs 7-days, and median hospital LOS 11.5-days vs 9-days for PP vs GP respectively. There were 6 cases of peri-operative COVID in PP cohort, and 1 in GP (contract following discharge). There was no mortality within either cohort. For the subgroup of patients undergoing PD: 10 patients PP, 6 patients GP, textbook outcomes were achieved in 90% vs 67% PP vs GP. Conclusions The implementation of the Green Pathway at our institution enabled continuation of surgery for patients with category 1 and 2 operations during the COVID pandemic with a significant reduction in peri-operative COVID infection, no mortality and no increase in length of stay. The TO rate was lower with the GP (not statistically significant), but our 4-year institution TO rate is 70.3%, comparing favourably to other studies.  This pathway has enabled safe continuation of urgent surgery during the pandemic and could be a model for adoption in other centres especially if there is resurgence of COVID cases during the coming winter.

JAMIA Open ◽  
2021 ◽  
Vol 4 (2) ◽  
Author(s):  
Divya Joshi ◽  
Ali Jalali ◽  
Todd Whipple ◽  
Mohamed Rehman ◽  
Luis M Ahumada

Abstract Objective To develop a predictive analytics tool that would help evaluate different scenarios and multiple variables for clearance of surgical patient backlog during the COVID-19 pandemic. Materials and Methods Using data from 27 866 cases (May 1 2018–May 1 2020) stored in the Johns Hopkins All Children’s data warehouse and inputs from 30 operations-based variables, we built mathematical models for (1) time to clear the case backlog (2), utilization of personal protective equipment (PPE), and (3) assessment of overtime needs. Results The tool enabled us to predict desired variables, including number of days to clear the patient backlog, PPE needed, staff/overtime needed, and cost for different backlog reduction scenarios. Conclusions Predictive analytics, machine learning, and multiple variable inputs coupled with nimble scenario-creation and a user-friendly visualization helped us to determine the most effective deployment of operating room personnel. Operating rooms worldwide can use this tool to overcome patient backlog safely.


2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S346-S346
Author(s):  
Sarah Norman ◽  
Sara Jones ◽  
David Reeves ◽  
Christian Cheatham

Abstract Background At the time of this writing, there is no FDA approved medication for the treatment of COVID-19. One medication currently under investigation for COVID-19 treatment is tocilizumab, an interleukin-6 (IL-6) inhibitor. It has been shown there are increased levels of cytokines including IL-6 in severe COVID-19 hospitalized patients attributed to cytokine release syndrome (CRS). Therefore, inhibition of IL-6 receptors may lead to a reduction in cytokines and prevent progression of CRS. The purpose of this retrospective study is to utilize a case-matched design to investigate clinical outcomes associated with the use of tocilizumab in severe COVID-19 hospitalized patients. Methods This was a retrospective, multi-center, case-matched series matched 1:1 on age, BMI, and days since symptom onset. Inclusion criteria included ≥ 18 years of age, laboratory confirmed positive SARS-CoV-2 result, admitted to a community hospital from March 1st – May 8th, 2020, and received tocilizumab while admitted. The primary outcome was in-hospital mortality. Secondary outcomes included hospital length of stay, total mechanical ventilation days, mechanical ventilation mortality, and incidence of secondary bacterial or fungal infections. Results The following results are presented as tocilizumab vs control respectively. The primary outcome of in-hospital mortality for tocilizumab (n=26) vs control (n=26) was 10 (38%) vs 11 (42%) patients, p=0.777. The median hospital length of stay for tocilizumab vs control was 14 vs 11 days, p=0.275. The median days of mechanical ventilation for tocilizumab (n=21) vs control (n=15) was 8 vs 7 days, p=0.139, and the mechanical ventilation mortality was 10 (48%) vs 9 (60%) patients, p=0.463. In the tocilizumab group, for those expired (n=10) vs alive (n=16), 10 (100%) vs 7 (50%) patients respectively had a peak ferritin > 600 ng/mL, and 6 (60%) vs 8 (50%) patients had a peak D-dimer > 2,000 ng/mL. The incidence of secondary bacterial or fungal infections within 7 days of tocilizumab administration occurred in 5 (19%) patients. Conclusion These findings suggest that tocilizumab may be a beneficial treatment modality for severe COVID-19 patients. Larger, prospective, placebo-controlled trials are needed to further validate results. Disclosures Christian Cheatham, PharmD, BCIDP, Antimicrobial Resistance Solutions (Shareholder)


Neurosurgery ◽  
2017 ◽  
Vol 64 (CN_suppl_1) ◽  
pp. 224-224
Author(s):  
Anthony Michael DiGiorgio ◽  
Praveen V Mummaneni ◽  
Jonathan Lloyd Fisher ◽  
Adam Podet ◽  
Clifford Crutcher ◽  
...  

Abstract INTRODUCTION The practice of surgeons performing overlapping surgery has recently come under scrutiny. We sought to examine the impact of overlapping rooms on surgery wait time and length of stay in patients admitted to a tertiary care, safety-net hospital for urgent neurosurgical procedures. METHODS Our hospital functions as a safety-net, tertiary care, level-1 trauma center in the Southern United States. The neurosurgery service transitioned from routinely allowing one room per day (period 1) to overlapping rooms (period 2), with the second room being staffed by the same attending surgeon. Patients undergoing neurosurgical intervention in each period were retrospectively compared. Case urgency, patient demographics, case type, indication, length of stay and time from admission to surgery were tracked. RESULTS >452 total cases were reviewed (201 in period 1 & 251 in period 2), covering 7 months in each period. 122 of the cases were classified as “urgent” (59 in period 1 and 63 in period 2). In the these patients, length of stay was significantly decreased in period 2 (13.09 days vs 19.52, p = .002) and the time from admission to surgery for urgent cases trended towards a shorter time (5.12 days vs 7.00, p = .084). Insurance status of these patients was 26.2% uninsured, 39.3% Medicaid, 18.9% Medicare, 9% commercial and the remainder workers compensation, liability or prisoner care. Multivariate regression analysis revealed that being in period 1, having Medicare, having trauma as the indication for surgery, and undergoing a non-cranial or non-spinal procedure as significant factors for increased length of stay. CONCLUSION Recent studies suggest overlapping surgeries are safe for patients. In the case of our safety net hospital, allowing the neurosurgery service to run overlapping rooms significantly reduces length of stay in a vulnerable population who is admitted in need of urgent surgery.


PLoS ONE ◽  
2021 ◽  
Vol 16 (4) ◽  
pp. e0249750
Author(s):  
Ying-Yi Chou ◽  
Juey-Jen Hwang ◽  
Yu-Chi Tung

Objective We used nationwide population-based data to identify optimal hospital and surgeon volume thresholds and to discover the effects of these volume thresholds on operative mortality and length of stay (LOS) for coronary artery bypass surgery (CABG). Design Retrospective cohort study. Setting General acute care hospitals throughout Taiwan. Participants A total of 12,892 CABG patients admitted between 2011 and 2015 were extracted from Taiwan National Health Insurance claims data. Main Outcome Measures Operative mortality and LOS. Restricted cubic splines were applied to discover the optimal hospital and surgeon volume thresholds needed to reduce operative mortality. Generalized estimating equation regression modeling, Cox proportional-hazards modeling and instrumental variables analysis were employed to examine the effects of hospital and surgeon volume thresholds on the operative mortality and LOS. Results The volume thresholds for hospitals and surgeons were 55 cases and 5 cases per year, respectively. Patients who underwent CABG from hospitals that did not reach the volume threshold had higher operative mortality than those who received CABG from hospitals that did reach the volume threshold. Patients who underwent CABG with surgeons who did not reach the volume threshold had higher operative mortality and LOS than those who underwent CABG with surgeons who did reach the volume threshold. Conclusions This is the first study to identify the optimal hospital and surgeon volume thresholds for reducing operative mortality and LOS. This supports policies regionalizing CABG at high-volume hospitals. Identifying volume thresholds could help patients, providers, and policymakers provide optimal care.


2020 ◽  
Author(s):  
Lan Chen ◽  
Zhen-Yu Zhang ◽  
Xiao-Bin Zhang ◽  
Su-Zhen Zhang ◽  
Qiu-Ying Han ◽  
...  

In China, the patients with previously negative RT-PCR results again test positive during the post-discharge isolation period. We aimed to determine the clinical characteristics of these recurrent-positive patients. We retrospectively reviewed the data of 15 recurrent-positive patients and 107 control patients with non-recurrent, moderate COVID-19 treated in Wuhan, China. Clinical data and laboratory results were comparatively analyzed. We found that recurrent-positive patients had moderate disease. The rate of recurrent-positive disease in our hospital was 1.87%. Recurrent-positive patients were significantly younger (43(35-54) years) than control patients (60(43-69) years) (P=0.011). The early LOS (length of stay in hospital before recurrence) was significantly longer in recurrent-positive patients (36(34-45) days) than in control patients (15(7-30) days) (P =0.001). The time required for the first conversion of RT-PCR results from positive to negative was significantly longer in recurrent-positive patients (14(10-17) days) than in control patients (6(3-9) days) (P =0.011). Serum COVID-19 antibody levels were significantly lower in recurrent-positive patients than in control patients (IgM: 13.69 ± 4.38 vs. 68.10 ± 20.85 AU/mL, P = 0.015; IgG: 78.53 ± 9.30 vs. 147.85 ± 13.33 AU/mL, P < 0.0001). Recurrent-positive patients were younger than control patients. The early LOS (length of stay in hospital before recurrence) was significantly longer in recurrent-positive group than that in control group. COVID-19 IgM/IgG antibody levels were significantly lower in recurrent-positive group than those in control group, which might explain why the virus RNA RT-PCR was positive after the initial clinical cure(with three times of virus RNA RT-PCR negative). The virus might not be fully eliminated because of the lower IgG level and their later replicating might result in recurrent-positive virus RNA RT-PCR.


1994 ◽  
Vol 14 (1) ◽  
pp. 52-58 ◽  
Author(s):  
D Recker

Preoperative cardiac surgical teaching done on a preadmission vs postadmission basis did not affect subjects' perception of importance of preoperative information or preparation. Hospital teaching methods must be examined so that patient learning is individualized and available when the patient is ready to learn. Preoperative teaching on a preadmission basis may also facilitate admission of the cardiac surgical patient the day of surgery, which could shorten the length of stay.


2018 ◽  
Vol 94 (1116) ◽  
pp. 546-550 ◽  
Author(s):  
Emma Jane Zhao ◽  
Apurva Yeluru ◽  
Lakshman Manjunath ◽  
Lei Ray Zhong ◽  
Hsiao-Tieh Hsu ◽  
...  

IntroductionReducing long length of stay (LLOS, or inpatient stays lasting over 30 days) is an important way for hospitals to improve cost efficiency, bed availability and health outcomes. Discharge delays can cost hundreds to thousands of dollars per patient, and LLOS represents a burden on bed availability for other potential patients. However, most research studies investigating discharge barriers are not LLOS-specific. Of those that do, nearly all are limited by further patient subpopulation focus or small sample size. To our knowledge, our study is the first to describe LLOS discharge barriers in an entire Department of Medicine.MethodsWe conducted a chart review of 172 LLOS patients in the Department of Medicine at an academic tertiary care hospital and quantified the most frequent causes of delay as well as factors causing the greatest amount of delay time. We also interviewed healthcare staff for their perceptions on barriers to discharge.ResultsDischarge site coordination was the most frequent cause of delay, affecting 56% of patients and accounting for 80% of total non-medical postponement days. Goals of care issues and establishment of follow-up care were the next most frequent contributors to delay.ConclusionTogether with perspectives from interviewed staff, these results highlight multiple different areas of opportunity for reducing LLOS and maximising the care capacity of inpatient hospitals.


Vascular ◽  
2004 ◽  
Vol 12 (4) ◽  
pp. 218-224 ◽  
Author(s):  
Reid M. Wainess ◽  
Justin B. Dimick ◽  
John A. Cowan ◽  
Peter K. Henke ◽  
James C. Stanley ◽  
...  

Abdominal aortic aneurysm (AAA) repair is a complex procedure about which little information exists regarding trends in surgical practice in the United States. This study was undertaken to define benchmark data regarding performance and outcomes of conventional AAA repair that might be used in comparisons with endovascular AAA repair data. Patients undergoing repair of intact ( n = 87,728) or ruptured ( n = 16,295) AAAs in the Nationwide Inpatient Sample (NIS) for 1988 to 2000 were studied. The NIS represents a 20% stratified random sample of all discharges from US hospitals. Unadjusted and case mix-adjusted analyses of in-hospital mortality and length of stay were performed. The overall frequency of intact AAA repair remained relatively stable during the study period, ranging from 18.1 to 16.3 operations/100,000 adults between 1988 and 2000, respectively. The operative mortality rate for intact AAA repair decreased significantly ( p < .001) from 6.5% in 1988 to 4.3% in 2000. Length of stay following intact AAA repair also declined significantly ( p < .001) from a median of 11 days in 1988 (interquartile range [IQR] 9-15 days) to 7 days in 2000 (IQR 5–10 days). The incidence of ruptured AAA repair decreased significantly ( p < .001) from 4.2 to 2.6 operations/100,000 adults between 1988 and 2000, respectively. Mortality for ruptured AAA repair, averaging 45.6%, did not decrease significantly during the study period. Intact AAA repair by conventional means has become increasingly safe, with decreased operative mortality and shorter hospital stays. Ruptured AAA repair by conventional means has not become safer but has decreased in incidence, suggesting possible reductions in risk factors contributing to rupture, coupled with more timely intact AAA repairs.


2015 ◽  
Vol 32 (5) ◽  
pp. 361-366 ◽  
Author(s):  
Annelijn E. Slaman ◽  
Sjoerd M. Lagarde ◽  
Suzanne S. Gisbertz ◽  
Mark I. van Berge Henegouwen

Background/Aims: Esophagectomies are associated with high morbidity. To assess the complication severity, the Clavien-Dindo classification (CDC) grades the most severe complication. However, it ignores additional complications that are equal or less severe. The comprehensive complication index (CCI) incorporates all complication severities. It might therefore be a better system to assess the severities. The aim of this study was to validate the CCI compared to the CDC. Methods: A prospective database was used to analyze 621 patients, who underwent an esophagectomy between 1993 and 2005. The CCI was calculated and the relation with traditional parameters was assessed and compared to the relation of the CDC with these parameters. Results: Complications occurred in 429 patients (69.1%). The correlation between the CCI and the CDC was r = 0.987, p < 0.01. The relation of the CCI with 3 out of 7 parameters was not significantly different compared to the relation of the CDC (p > 0.05). There was a significantly stronger relation (p < 0.05) of the CCI with length of stay (LOS) (r = 0.663 vs. 0.646), a prolonged LOS (r = 0.542 vs. 0.530), reintervention, (r = 0.437 vs. 0.422) and reoperation rate (0.489 vs. 0.471) than the CDC. Conclusion: Therefore, the CCI could be a promising scoring system that could be used to identify risks in surgical patient groups.


2011 ◽  
Vol 74 (6) ◽  
pp. 1215-1224 ◽  
Author(s):  
John R. Saltzman ◽  
Ying P. Tabak ◽  
Brian H. Hyett ◽  
Xiaowu Sun ◽  
Anne C. Travis ◽  
...  

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