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2021 ◽  
Alicia G Sykes ◽  
Jason B Brill ◽  
James D Wallace ◽  
Clara Lee ◽  
Paul R Lewis ◽  

ABSTRACT Introduction Since 2006, the U.S. Navy has conducted six Pacific Partnership (PP) missions throughout Southeast Asia on board the U.S. Naval Ship Mercy (T-AH 19). This study describes trends in overall and surgical specialty operative volumes to better understand the burden of surgical disease treated during these humanitarian and civic assistance (HCA) operations. This information can assist medical planners and surgical leaders involved in future humanitarian missions. Materials and Methods Following approval from the Naval Medical Center San Diego Institutional Review Board, a retrospective review of surgical case data was performed for the six PP missions from 2006 to 2018. Data collected included patient demographics, Current Procedural Terminology codes, and surgical specialty. The primary outcome was surgical case volume per specialty. Secondary outcomes included surgical staffing per mission and overall trends in operative volume. Results A total of 3,826 operative procedures were performed during the study period. Mission years in which case volume for both general surgery and ophthalmology were below their respective medians were associated with the least total surgical services to host nations (HNs). The number of active duty Navy surgeons varied with each mission; however, the staffing for a PP mission generally included at least two general surgeons, one ophthalmologist, one plastic surgeon, one pediatric surgeon, one orthopedic surgeon, one otolaryngologist, one oral surgeon, one urologist, and one obstetrician–gynecologist. Case volume per surgeon was highest in 2006 (50 cases per surgeon) and decreased after 2006, reaching an all-time low during the 2018 PP mission (10 cases per surgeon). Pediatric surgery and plastic surgery had the highest average case volumes per surgeon at 58 and 46 cases per surgeon, respectively, while oromaxillofacial surgery and neurosurgery had the lowest average case volumes per surgeon at 9 and 14 cases per surgeon, respectively. Conclusions Operative volume on military HCA missions is greatly influenced by the priorities of the HN, the mission focus, the number of individuals from the HN that present for screening, and the availability of personnel and resources available on the hospital ship. Future mission planning should optimize general surgery and ophthalmology staffing and essential equipment, as total mission case volumes were highly dependent upon the productivity of these two specialties. Careful determination of the surgical needs of HNs should serve as a guide for the selection of subspecialists to maximize effectiveness in future military HCA missions.

2021 ◽  
Vol 108 (Supplement_9) ◽  
Alicja Pscia ◽  
Jonathan Eley ◽  
Kathryn Forsyth ◽  
Nicola Lawrie ◽  
Yvonne Hay ◽  

Abstract Background The tri-association document; The future of Emergency General Surgery (2015) has a number of key recommendations for the provision of emergency general surgical care. Key recommendations include for senior surgeons to triage referrals and to utilise a “hot clinic” model. Prior to 2016 in the authors’ hospital, all General Practitioner/community referrals were formally admitted to General Surgery. A consultant led ambulatory clinic with dedicated Advanced Nurse Practitioner support was instituted in October 2016. It offers preliminary assessment, phlebotomy and priority access to routine imaging modalities. The clinic is located in a tertiary hospital serving a population of 500,000. Methods A retrospective audit of prospectively collected referral and outcome lists for the Surgical Ambulatory clinic was conducted for the time periods of October 2016 to June 2021.  The two primary outcomes were defined as admission to the General Surgical ward and discharge to the community/non-general surgical specialty. Secondary outcomes for patient satisfaction were measured by randomly distributing over a six week period a patient satisfaction survey. The survey was designed in accordance with trust guidance, was anonymous and would cover multiple lead Consultant encounters as a cohort. Results In total, 9069 patients presented to the surgical ambulatory clinic over a period of 44 months. 2347 (26%) were admitted to the General Surgical ward whilst 6717 (74%) were discharged directly from the clinic. 71% of survey responders rated their experiences of the ambulatory clinic as “Excellent”, 19% “Very Good”, 0.5% “Good” and 0.5% “Poor.” Conclusions The introduction of an ambulatory care model has demonstrated a marked reduction in surgical admissions whilst remaining favourable to the patient populace. This has a direct impact on overall bed occupancy rates.  In the age of COVID-19, efforts must me made to reduce the the number of potential inpatient interactions to protect those most at risk. A reduced admission and bed occupancy rate will contribute to the reduction of this risk.

2021 ◽  
Vol 108 (Supplement_9) ◽  
Vithurshanan Karunanithy ◽  
Tom Richardson ◽  
Akshay Kumar ◽  
Sudeep Thomas ◽  
Saad Khan

Abstract Background Gall Bladder (GB) polyps are abnormal growths of the inner lining that project into the lumen. They are a rare incidental radiological finding, with prevalence ranging from 0.3% to 9.5%. The majority of these frequently turn out to be pseudopolyps, however, correct follow up and management is essential as to ensure that true polyps, which may be malignant or have malignant potential, are not missed. EJG on the subject, published in 2017, tried to address controversial issues including which patients require cholecystectomy, which patients require follow up and how frequently this should be. We carried out an audit assessing adherence of our center’s management of GB polyps to the EJGs. Methods Patients were identified for this retrospective ten year cohort study bv identifying patients listed under ‘International Statistical Classification of Diseases and Related Health Problems (ICD 10) code K 82.8, other specified diseases of gall bladder’ on our database. Patients with other diagnoses, such as gall bladder dysfunction were excluded after review of electronic patient record (EPR) (Sunrise, Allscripts). EPRs facilitated review of emergency attendances, clinic letters, investigations and histological results for those diagnosed with a gall bladder polyp. Analysis was performed with Microsoft Excel. Results Since publication of the guidelines, 71 patients were diagnosed with a polyp. Of these, 73% were diagnosed by general surgeons and only 36% were managed according to the guidelines. We did, however, identify a strong positive trend (0.9) in improved adherence to guidelines over time. We found that guidance was more likely to be followed if the polyp was >10mm versus smaller (p < 0.01). 18% of patients (50% of those adherent to guidelines) were booked straight for laparoscopic cholecystectomy but there was a much poorer adherence to guidance concerning surveillance of polyps. There was no statistically significant difference (p = 0.32) in adherence to guidance when comparing management by surgeons versus non-surgeons. Conclusions Adherence to EJG’s overall is poor in our cohort. The adherence has improved over time, and at 3 years post introduction is 62% compared to an average of 35%. The guidance is also best followed when laparoscopic cholecystectomy is indicated straight from diagnosis compared to patients who meet the criteria for surveillance.  Initial diagnosis by a non-surgical specialty does not affect adherence to guidance. Better local education amongst junior surgical grades about GB polyps, as well as increased awareness of the EJG’s may improve adherence to guidance. Further research into risk stratification and the optimal follow up of GB polyps may make surveillance guidance easier to follow and further improve compliance.

2021 ◽  
Vol 108 (Supplement_9) ◽  
Martin Michel ◽  
Helen Fifer ◽  
Emily Moran ◽  
Ala Saab ◽  
Felix Hammett ◽  

Abstract Background Bariatric surgery virtually ceased with the advent of the Covid-19 pandemic and has been amongst the last sector of operative practice to restart. There have been understandable concerns about restarting bariatric surgery including the risks to patients of contracting Covid infection in the peri-operative period, potential de-skilling of surgeons and theatre teams and the appropriateness of directing scarce and limited resources to bariatric surgery when every surgical specialty is experiencing rapidly rising waiting times and ever lengthening waiting lists.  This study describes the restart programme at our NHS bariatric unit and offers a template for safe commencement of complex benign surgeries in the current era. Methods In the months after the pandemic started, our Bariatric MDT reviewed every case on the waiting list and contacted each patient to explain the current waiting times and the importance of not gaining weight to be eligible for surgery when surgical practice resumed. Group education and Support Group sessions were moved from face-to-face appointments to online classrooms and regular input was sought from specialist dieticians, nurses and psychologists. The expected waiting times for patients was pro-actively submitted to the Executive Board of the Trust with details about >104-week waiting patients being clearly articulated. Once approval was given to restart bariatric surgery, every patient was assessed and prioritised in terms of waiting time and clinical need. A bariatric theatre team was brought together and engaged in pre-operative training and a local refresher course on equipment and the planned surgeries. There was engagement with industry to provide on-the-ground support for the first lists to ensure proper and safe use of energy and stapling devices. Each list had two consultant surgeons assigned to it and just two cases per day were planned and patients were managed on an entirely green pathway within the NHS hospital . Results The bariatric restart programme commenced in May 2021; between May 2021 and August 2021, there have been 27 operations carried out (25 Roux-en-Y gastric bypass, 2 sleeve gastrectomy) and two cancellations on the day (both due to patient choice). Each operating list finished between two and three hours before the planned finish time. Formal debrief sessions after each list identified no problems with the operations of the equipment and none of the patients had any post-operative complications. Length of stay was between 1 to 2 days for the entire cohort.  Since the restart programme commenced, the requirement for dual consultant operating has ceased and the last 5 cases have been entirely training cases for the operating registrar, again without complication. Each list is now planned to increase to pre-pandemic levels of activity with four cases per list. Conclusions Restarting complex benign surgical practice is complicated and requires engagement with management, theatre and nursing colleagues to ensure that cases are not ‘left behind'. It is important to reduce the risk of complications and of peri-operative covid-19 infection in bariatric patients and development of a pathway that all members of the theatre team have input in to meant that there were few problems or issues with either the planning of the lists or the running of the lists. Such an approach could be considered for restarting any high volume, complex benign surgical practice.

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. 325-326
Sonia Pandit ◽  
Mark Simone ◽  
Alyson Michener ◽  
Lisa Walke ◽  
Ingrid Nembhard

Abstract Co-management programs between geriatrics and surgical specialties have gained popularity in the last few years. Little is known about how these programs are perceived across surgical specialties and staff roles. We conducted a mixed methods study to assess perspectives on a geriatrics-surgery co-management program (GSCP) at a hospital where geriatricians co-manage patients 65 or older admitted to Orthopedic Trauma, General Trauma, and Neurosurgery. We used semi-structured interviews (n=13) and online surveys (n=45) to explore program value, facilitators, use, understanding, and impact by specialty and staff roles (physicians, advanced practice providers, nurses, case managers, social workers). Interview transcripts were analyzed using qualitative thematic analysis, and survey data were analyzed using Kruskal-Wallis, ANOVA, and Fisher’s exact tests. Interviews revealed three themes: 1) GSCP is valued because of geriatricians’ expertise in older adults, relationship with patients and families, and skill in addressing social determinants of health; 2) GSCP facilitators include consistent availability of geriatricians, clear communication, and collaboration via shared data-driven goals; and 3) GSCP use varies by surgical specialty and role depending on expertise and patient complexity. Survey data analysis affirmed interview themes and showed significant differences (p-values<0.05) between perspectives of surgical specialties and roles on GSCP use, understanding, impact, and which specialty should manage specific clinical issues. Findings suggest that while there are similarities across surgical specialties and roles regarding the value of, and facilitators for, a GSCP, specialties and roles differ in use, understanding, and perceived program impact on care. These findings suggest strategies for optimizing this intervention across groups.

2021 ◽  
Vol 67 (3) ◽  
pp. 1-4
Shler Ghafoor Raheem

The inflammatory reaction is one of the complications in patients with coronary atherosclerosis. This study aimed to determine the diagnostic value of platelet-activating factor (PAF) compared with high sensitivity C reactive protein (hs-CRP) in coronary atherosclerotic patients. Fifty patients with coronary atherosclerosis and 30 subjects with normal angiography were considered as the control group attending Cardiac Center-Surgical Specialty Hospital - in Erbil city / Iraq. The levels of PAF and hs-CRP were estimated quantitatively using a sandwich enzyme-linked immunosorbent assay and a particle-enhanced immune turbid metric assay, respectively. Lipid profiles and some hematological indexes were also used in this study. The levels of the inflammatory biomarkers of PAF and hs-CRP increased significantly in the patients group compared with controls (p<0.05). Although the patients group showed the highest level of low-density lipoprotein (LDL), the difference was not significant (p>0.05) compared with the healthy control. However, the incidence of risk factors such as smoking and obesity showed a significant difference (p<0.05) in the patients group. Additionally, the PAF level correlated positively and significantly with hs-CRP (p<0.05), and negatively with high-density lipoprotein (HDL) (p>0.05). Although hs-CRP was a valuable diagnostic marker for coronary atherosclerosis, the PAF level showed to be a better prognostic indicator than hs-CRP in coronary atherosclerosis patients.

2021 ◽  
Vol 0 (0) ◽  
Harris Ahmed ◽  
Kim Vo ◽  
Wayne Robbins

Abstract Context While 90% of former American Osteopathic Association (AOA) residency programs transitioned to Accreditation Council for Graduate Medical Education (ACGME) accreditation, surgical subspecialty programs such as ear, nose, and throat (ENT, 62%) and ophthalmology (47%) struggled to gain accreditation. Doctors of Osteopathic Medicine (DOs) actively participate in serving underserved communities, and the loss of AOA surgical specialty programs may decrease access to surgical care in rural and nonmetropolitan areas. Objectives To determine the challenges faced by former AOA-accredited surgical subspecialty programs during the transition to ACGME accreditation, particularly ENT and ophthalmology programs in underresourced settings. Methods A directory of former AOA ENT and Ophthalmology programs was obtained from the American Osteopathic Colleges of Ophthalmology and Otolaryngology-Head and Neck Surgery (AOCOO-HNS). A secured survey was sent out to 16 eligible ENT and ophthalmology program directors (PDs). The survey contained both quantitative and qualitative aspects to help assess why these programs did not pursue or failed to receive ACGME accreditation. Results Twelve of 16 eligible programs responded, com-prising six ophthalmology and six ENT PDs. Among the respondents, 83% did not pursue accreditation (6 ophthalmology and 4 ENT programs), and 17% were unsuccessful in achieving accreditation despite pursuing accreditation (2 ENT programs). Across 12 respondents, 7 (58%) cited a lack of hospital/administrative support and 5 (42%) cited excessive costs and lack of faculty support as reasons for not pursuing or obtaining ACGME accreditation. Conclusions The survey results reflect financial issues associated with rural hospitals. A lack of hospital/administrative support and excessive costs to transition to the ACGME were key drivers in closures of AOA surgical specialty programs. In light of these results, we have four recommendations for various stakeholders, including PDs, Designated Institutional Officials, hospital Chief Medical Officers, and health policy experts. These recommendations include expanding Teaching Health Center Graduate Medical Education to surgical subspecialties, identifying and learning from surgical fields such as urology that fared well during the transition to ACGME, addressing the lack of institutional commitment and the prohibitive costs of maintaining ACGME-accredited subspecialty programs in underresourced settings, and reconsidering the Centers for Medicare & Medicaid Services (CMS) pool approach to physician reimbursement.

2021 ◽  
Shemila Abbasi ◽  
Saima Rashid ◽  
Fauzia Anis Khan

Abstract BackgroundIdentifying medication errors is one method of improving patient safety. Peri operative anesthetic management of patient includes polypharmacy and various steps prior to drug administration. Our objective was to analyze the medication errors reported in our critical incident reporting system (CIRS) database over the last 15 years (2004-2018) and to review measures taken for improvement based on the reported errors.MethodsAll Critical incidents (CI) reported during January 2004 till December 2018 were retrieved from CIRS database. Medication errors were identified and entered on a data extraction form which included reporting year, patients age, surgical specialty, ASA status, time of incident, phase and type of anesthesia and drug handling, type of error, class of medicine, level of harm, severity of adverse drug event (ADE) and steps taken for improvement.Results 311 medication errors were reported. Fifty two percent errors occurred in ASA II and III patient, and 43% during induction. Sixty % occurred during administration phase and 65 % were due to human error. Thirty seven percent were ADE, 58 of which were significant, 23 serious and five life-threatening errors. Majority errors involved neuromuscular blockers (32%) and opioids (13%).Conclusion Sharing of CI and a lesson to be learnt e-mail, colour coded labels, change in medication trolley lay out, decrease in floor stock and high alert labels were the low-cost steps taken to reduce incidents.Medication errors were more frequent during administration. Twenty eight percent resulted in significant, serious, or life-threatening events.

2021 ◽  
Vol 233 (5) ◽  
pp. S217
Chelsea V. Salyer ◽  
Joanna V. Brooks ◽  
Susan D. McCammon ◽  
Emma Bassette ◽  
Lori Spoozak

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