Search

Abstract: The rapid response system (RRS) was introduced for early stage intervention in patients with deteriorating clinical conditions. Responses to unexpected in-hospital patient emergencies varied among hospitals. This study was conducted to understand the prevalence of RRS in smaller hospitals and to identify the need for improvements in the responses to in-hospital emergencies.A questionnaire survey of 971 acute-care hospitals in western Japan was conducted from May to June 2019 on types of in-hospital emergency response for patients in cardiac arrest (e.g., medical emergency teams [METs]), before obvious deterioration (e.g., rapid response teams [RRTs]), and areas for improvement.We received 149 responses, including those from 56 smaller hospitals (≤200 beds), which provided fewer responses than other hospitals. Response systems for cardiac arrest were used for at least a limited number of hours in 129 hospitals (87%). The absence of RRS was significantly more frequent in smaller hospitals than in larger hospitals (13/56, 23% vs 1/60, 2%; P < .01). METs and RRTs operated in 17 (11%) and 15 (10%) hospitals, respectively, and the operation rate for RRTs was significantly lower in smaller hospitals than in larger hospitals (1/56, 2% vs 12/60, 20%; P < .01). Respondents identified the need for education and more medical staff and supervisors; data collection or involvement of the medical safety management sector was ranked low.The prevalence of RRS or predetermined responses before obvious patient deterioration was ≤10% in small hospitals. Specific education and appointment of supervisors could support RRS in small hospitals., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Introduction: Despite early enthusiasm, minimally invasive cardiac surgery has had a low uptake compared with novel techniques in interventional cardiology. Steep learning curves from high-volume centres have deterred smaller units from engaging, even though low-volume centres undertake a large proportion of surgical interventions worldwide. We sought to identify the safety and experience of learning minimally invasive cardiac surgery after undertaking a structured fellowship at Blackpool Victoria Hospital, a low-volume centre., Materials and Methods: A retrospective analysis of outcomes for all consecutive minimally invasive cardiac surgery procedures performed via a right mini-thoracotomy at our institution between 2007 and 2017 was undertaken. Clinical outcomes included death, conversion to sternotomy, stroke, renal failure and other organ support. Cardiopulmonary bypass, aortic cross-clamp times and learning cumulative sum sequential probability method curves were also assessed to determine how safely the procedure was adopted., Results: A total of 316 patients were operated on for mitral, tricuspid, atrial fibrillation, septal defects or other conditions. The mean logistic European System for Cardiac Operative Risk Evaluation score was 7.0 (± 8.5). Conversion to sternotomy occurred in 12 patients (3.8%) and in-hospital mortality was 7 (2.2%). None of the converted patients died. The learning curves showed an accelerated process of adoption, similar to reference figures from a high-volume German centre., Discussion: It is possible for low-volume cardiac surgical centres to undertake minimally invasive surgical programmes with good outcomes and short learning curves. Despite technical complexities, with a team approach, the learning curve can be navigated safely.

Objective: As open abdominal aortic aneurysm (AAA) repair (OAR) rates decline in the endovascular era, the endorsement of minimum volume thresholds for OAR is increasingly controversial, as this may affect credentialing and training. The purpose of this analysis was to identify an optimal centre volume threshold that is associated with the most significant mortality reduction after OAR, and to determine how this reflects contemporary practice., Methods: This was an observational study of OARs performed in 11 countries (2010 - 2016) within the International Consortium of Vascular Registry database (n = 178 302). The primary endpoint was post-operative in hospital mortality. Two different methodologies (area under the receiving operating curve optimisation and Markov chain Monte Carlo procedure) were used to determine the optimal centre volume threshold associated with the most significant mortality improvement., Results: In total, 154 912 (86.9%) intact and 23 390 (13.1%) ruptured AAAs were analysed. The majority (63.1%; n = 112 557) underwent endovascular repair (EVAR) (OAR 36.9%; n = 65 745). A significant inverse relationship between increasing centre volume and lower peri-operative mortality after intact and ruptured OAR was evident (p < .001) but not with EVAR. An annual centre volume of between 13 and 16 procedures per year was associated with the most significant mortality reduction after intact OAR (adjusted predicted mortality < 13 procedures/year 4.6% [95% confidence interval 4.0% - 5.2%] vs. ≥ 13 procedures/year 3.1% [95% CI 2.8% - 3.5%]). With the increasing adoption of EVAR, the mean number of OARs per centre (intact + ruptured) decreased significantly (2010 - 2013 = 35.7; 2014 - 2016 = 29.8; p < .001). Only 23% of centres (n = 240/1 065) met the ≥ 13 procedures/year volume threshold, with significant variation between nations (Germany 11%; Denmark 100%)., Conclusion: An annual centre volume of 13 - 16 OARs per year is the optimal threshold associated with the greatest mortality risk reduction after treatment of intact AAA. However, in the current endovascular era, achieving this threshold requires significant re-organisation of OAR practice delivery in many countries, and would affect provision of non-elective aortic services. Low volume centres continuing to offer OAR should aim to achieve mortality results equivalent to the high volume institution benchmark, using validated data from quality registries to track outcomes., (Copyright © 2021 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Background: The benefits of centralization of pancreatic surgery have been documented, but policy differs between countries. This study aimed to model various centralization criteria for their effect on a nationwide cohort., Methods: Data on all pancreatic resections performed between 2014 and 2016 were obtained from the Italian Ministry of Health. Mortality was assessed for different hospital volume categories and for each individual facility. Observed mortality and risk-standardized mortality rate (RSMR) were calculated. Various models of centralization were tested by applying volume criteria alone or in combination with mortality thresholds., Results: A total of 395 hospitals performed 12 662 resections; 305 hospitals were in the very low-volume category (mean 2·6 resections per year). The nationwide mortality rate was 6·2 per cent, increasing progressively from 3·1 per cent in very high-volume to 10·6 per cent in very low-volume hospitals. For the purposes of centralization, applying a minimum volume threshold of at least ten resections per year would lead to selection of 92 facilities, with an overall mortality rate of 5·3 per cent. However, the mortality rate would exceed 5 per cent in 48 hospitals and be greater than 10 per cent in 17. If the minimum volume were 25 resections per year, the overall mortality rate would be 4·7 per cent in 38 facilities, but still over 5 per cent in 17 centres and more than 10 per cent in five. The combination of a volume requirement (at least 10 resections per year) with a mortality threshold (maximum RSMR 5 or 10 per cent) would allow exclusion of facilities with unacceptable results, yielding a lower overall mortality rate (2·7 per cent in 45 hospitals or 4·2 per cent in 76 respectively)., Conclusion: The best performance model for centralization involved a threshold for volume combined with a mortality threshold., (© 2020 BJS Society Ltd Published by John Wiley & Sons Ltd.)

Background: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an endovascular adjunct to hemorrhage control. Success relies on institutional support and focused training in arterial access. We hypothesized that hospitals with higher REBOA volumes will be more successful than low-volume hospitals at aortic occlusion with REBOA., Methods: This is a retrospective study from the American Association for the Surgery of Trauma Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery Registry from November 2013 to January 2018. Patients aged ≥18 y who underwent REBOA were included. Successful placement of REBOA catheters (defined as hemodynamic improvement with balloon inflation) was compared between high-volume (≥80 cases; two hospitals), mid-volume (10-20 cases; four hospitals), and low-volume (<10 cases; 14 hospitals) hospitals, adjusting for patient factors., Results: Of 271 patients from 20 hospitals, 210 patients (77.5%) had successful REBOA placement. Most patients were male (76.0%) and sustained blunt trauma (78.1%). cardiopulmonary resuscitation (CPR) was ongoing at the time of REBOA placement in 34.5% of patients. Inpatient mortality was 67.4%, unchanged by hospital volume. Multivariable logistic regression found increased odds of successful REBOA placement at high-volume versus low-volume hospitals (odds ratio [OR], 7.50; 95% confidence interval [CI], 2.10-27.29; P = 0.002) and mid-volume versus low-volume hospitals (OR, 7.82; 95% CI, 1.52-40.31; P = 0.014) and decreased odds among patients undergoing CPR during REBOA placement (OR, 0.10; 95% CI, 0.03-0.34; P < 0.001) when adjusting for age, sex, mechanism of injury, prehospital CPR, CPR on admission, transfer status, hospital location of REBOA placement, Glasgow Coma Scale ≤ 13, and injury severity., Conclusions: Hospitals with higher REBOA volumes were more likely to achieve hemodynamic improvement with REBOA inflation. However, mortality and complication rates were unchanged. Independent of hospital volume, ongoing CPR is associated with a decreased odds of successful REBOA placement., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: The volume-outcome relationship dictates that high-volume centres lead to improved patient outcomes after pancreatoduodenectomy (PD). We conducted a retrospective review to fathom the situation in India for PD and whether referral to high-volume centres would make a positive impact., Method: A systematic literature search in MEDLINE was performed, and all articles published from Indian centres from 01.03.2008 to 30.11.2019 were scrutinised. Any series with less than 20 patients, case reports, abstracts, unpublished data and personal communications were excluded., Results: A total of 36 unique series including 6226 patients from 24 institutes across India were identified. Amongst the 24 institutes, 2 institutes reported less than 10 cases/year, 11 reported 10-25 cases/year and 11 reported ≥26 cases/year. Overall perioperative morbidity was 42.4%, 43.4% and 41% for centres doing <10, 10-25 and ≥26 cases/year, respectively. Operative mortality also improved with increasing number of cases/year (5.1% vs. 6.6% vs. 3.2%, respectively)., Conclusion: With increasing volume of cases per year, trend towards improved PD outcomes is observed. To optimise the use of healthcare facilities, it would be pragmatic to consider building an organised referral system for complex surgeries to deliver unsurpassed patient care with maximum utilisation of the available healthcare infrastructure.

Certified Nurse Specialists (CNS) are advanced practice nurses that often play a role in management. This study aims to investigate whether cooperation between CNSs in the position of Intensive Care Unit (ICU) head nurse and intensivists change the length of stay for ICU patients. A single centered retrospective cohort study design was followed. A multivariable regression analysis was performed to determine whether there is a difference in patients' length of ICU stay for two years before and after CNS as ICU head nurse and an intensivist started collaborating. The patients' diagnosis, age, gender, scheduled/emergency admission, surgical history, length of ICU stay, usage of ventilator, and details of ICU treatment were collected from the institution's electronic medical records. During the study period (April 2015 to March 2019), 3,135 patients were admitted to ICU, with 1,471 in the before collaboration group and 1,664 in the after-collaboration group. Collaboration between the CNS as head nurse and intensivists was significantly associated with shorter length of ICU stay (coefficient -0.03 [95% CI, -0.05-0.01], p < 0.001, t-statistic -3.29). Our main finding illustrates that in low-intensity ICUs, collaboration between CNSs as head nurses and intensivists may reduce patients' length of ICU stay., Competing Interests: The authors have declared that no competing interests exist.

Introduction: Laparoscopic liver resection (LLR) has been developed and is daily practiced by many expert teams. However, very few data are available on the experience of low volume centres. The aim of our study was to report and discuss the operative results of LLR performed in three low volume centres., Methods: Records of patients who underwent a LLR in three low volume centres in France between May 2014 and November 2017 were collected. Endpoints studied were indications, intra and postoperative outcomes as well as short-term outcomes., Results: A total of 46 patients (57 specimen resected) underwent a LLR during this period, representing 29.6% of total liver resections. Indications of LLR were benign lesions in 26%, primitive malignant lesions in 32.6% and metastatic tumours in 41.3%. Median size of lesions was 22mm (range 11-100). Most liver resections were non-anatomic (64.7%), while left lateral sectionectomies represented 19.2%. Five patients required conversion and there were at the end 3 specimen with margins inferior to 1mm resected laparoscopically. Postoperative mortality was nil and morbidity rate was 17.3%. Median hospital stay was 6 days (3-15)., Conclusion: Although LLR have gained acceptance in surgeons' arsenal, it remains concentrated in referral centres. Our results suggest the feasibility of LLR in non-academic centres when it comes to small accessible lesions. Further studies would provide data about the long-term safety of this procedure in those centres., (Copyright © 2019 Elsevier Masson SAS. All rights reserved.)

Background: It is generally agreed to centralise treatment of childhood cancers (CCs). We analysed (1) the degree of centralisation of CCs in European countries and 2) the relations between centralisation and survival., Patients and Methods: The analysis comprised 4415 CCs, diagnosed between 2000 and 2007 and followed up to the end of 2013, from Belgium, Bulgaria, Finland, Ireland, the Netherlands and Slovenia. All these countries had national population-based cancer registries and were able to provide information on diagnosis, treatment, treatment hospitals, and survival. Each case was then classified according to whether the patient was treated in a high- or a low-volume hospital among those providing CC treatment. A Cox proportional hazard model was used to calculate the relation between volume category and five-year survival, adjusting by age, sex and diagnostic group., Results: The number of hospitals providing treatment for CCs ranged from six (Slovenia) to slightly more than 40 (the Netherlands and Belgium). We identified a single higher volume hospital in Ireland and in Slovenia, treating 80% and 97% of cases, respectively, and three to five major hospitals in the other countries, treating between 65% and 93% of cases. Outcome was significantly better when primary treatment was given in high-volume hospitals compared to low-volume hospitals for central nervous system tumours (relative risk [RR] = 0.71), haematologic tumours (RR = 0.74) and for all CC combined (RR = 0.83)., Conclusion: Treatment centralisation is associated with survival benefits and should be further strengthened in these countries. New plans for centralisation should include ongoing evaluation., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Although there is a clear volume-outcome relationship in the field of cardiac surgery, the existence of high-performing programs with relatively low case volumes is well established. This report describes the programmatic and institutional processes in place at a lower volume cardiac surgery center in a US military hospital, which have been executed to optimally leverage available resources in the delivery of exemplary patient care. By implementing a highly collaborative practice, rigorous outcomes review, evidence-based standardized care pathways, consistent attending surgeon oversight for care delivery, careful case selection, and a mechanism for support from highly experienced outside cardiac surgeons, the cardiac surgery program at the authors' institution delivers care on par with its higher volume counterparts. A review of these practices and available supporting evidence may provide a model for other programs seeking success in this setting.

Objectives: Significant hospital variation in the use of immediate breast reconstruction (IBR) after mastectomy exists in the Netherlands. Aims of this study were to identify hospital organizational factors affecting the use of IBR after mastectomy for ductal carcinoma in situ (DCIS) or invasive breast cancer (BC) and to analyze whether these factors explain the variation., Materials and Methods: Patients with DCIS or primary invasive BC treated with mastectomy between 2011 and 2013 were selected from the national NABON Breast Cancer Audit. Hospital and organizational factors were collected with an online web-based survey. Regression analyses were performed to determine whether these factors accounted for the hospital variation., Results: In total, 78% (n = 72) of all Dutch hospitals participated in the survey. In these hospitals 16,471 female patients underwent a mastectomy for DCIS (n = 1,980) or invasive BC (n = 14,491) between 2011 and 2014. IBR was performed in 41% of patients with DCIS (hospital range 0-80%) and in 17% of patients with invasive BC (hospital range 0-62%). Hospital type, number of plastic surgeons available and attendance of a plastic surgeon at the MDT meeting increased IBR rates. For invasive BC, higher percentage of mastectomies and more weekly MDT meetings also significantly increased IBR rates. Adjusted data demonstrated decreased IBR rates for DCIS (average 35%, hospital range 0-49%) and invasive BC (average 15%, hospital range 0-18%)., Conclusion: Hospital organizational factors affect the use of IBR in the Netherlands. Although only partly explaining hospital variation, optimization of these factors could lead to less variation in IBR rates., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: Fast track strategy in the management of patients undergoing intra-abdominal surgery of various types has emerged as a landmark approach to reduce surgical stress and accelerate recovery. This study was to evaluate the effect of fast track strategy on patients subjected to pancreaticoduodenectomy (PD) from an individual unit during transit from low to a high volume center., Methods: A total of 142 PD patients who had been subjected to fast track strategy between June 2008 and September 2012 were compared with 46 patients who had received conventional surgery between January 2006 and May 2008. Comparative analysis was made of postoperative complications, postoperative recovery, length of hospital stay and patient readmission requirement., Results: The patients subjected to fast track strategy had a faster recovery and a shorter hospital stay than those who were treated conventionally (7.8 vs 12.1 days). The intraoperative events like operative blood loss (417.9+/-83.8 vs 997.4+/-151.8 mL, P<0.001), blood transfused (a median of 0 vs 1 unit, P<0.001) and operative time taken (125 vs 245 minutes, P<0.001) were significantly lower in the fast track group. The frequency of pancreatic fistula (4.9% vs 13.0%) and delayed gastric emptying (7.0% vs 17.4%) was also significantly reduced with fast track treatment. Nevertheless, the readmission rate (11.3% vs 6.5%) was found relatively higher within the fast track group. However, increased readmission rates in this study seem to be independent of fast track protocol., Conclusions: This preliminary analysis suggests that the fast track approach might be beneficial to the well-being of the patients after PD, for it accelerates the immediate clinical recovery of patients and significantly shortens their length of hospital stay.

Introduction: Cost containment and surgical inefficiencies are major concerns for hospitals in this era of declining resources. The primary aim of this investigation was to understand subjective perceptions of perioperative spine surgical quality across three practice settings and to identify potential factors contributing to these perceptions. Subsequently, we objectively evaluated factors that influence the duration of time in which the patient is in the operating room (OR) prior to the surgical incision and assessed the influence of fluoroscopy technician expertise on radiation dose and imaging efficiency., Methods: One hundred and eight medical device representatives with at least 1 year of OR experience were surveyed at a national conference. Three distinct healthcare facilities were identified: university, small volume, and large volume private hospitals. Respondents rated facilities on a five-point scale for staff quality; size and consistency of surgical teams; and overall likelihood of recommending the facility. Separately, 140 posterior lumbar procedures from two institutions were retrospectively reviewed. Two time periods were quantified for each surgical case: patient arrival in the OR to induction of anesthesia (T1) and induction to surgical incision (T2). T1 and T2 were compared between university and large private hospital settings using t tests and multivariate analysis. For 44 separate lumbar spine surgical procedures, practice setting, patient BMI, number of vertebral levels requiring imaging, number of localizing fluoroscopy images taken, total fluoroscopy time, total radiation dose, fluoroscopy machine, and whether the fluoroscopist could correctly state his or her role, which was to obtain a lateral lumbar localizing image, were recorded. T-tests were used to compare cases in which the fluoroscopist could and could not correctly state the task., Results: Survey ratings for surgeons were not significantly different across university, large private, and small private hospitals. Fewer circulating nurses were rated as excellent or good in university versus private hospitals (p < 0.001). Small volume private hospital surgical teams were more likely to have worked together before than university teams (p < 0.05), and university teams were larger (p < 0.05). Respondents were more likely to recommend a university or large private hospital for complex instrumentation cases (p < 0.001). On objective measures, university patients were older, less obese, and had higher mean ASA scores (2.5 versus 2.2, p < 0.001). Compared to the university setting, private hospital cases had significantly shorter Time 1 (8 versus 37 min, p < 0.001) and Time 2 (23 versus 30 min, p < 0.001), even after adjusting for ASA score, BMI, and age. Cases in which the fluoroscopist knew the imaging purpose were associated with significantly fewer images (mean 1.8 versus 3.4 images, p < 0.0001) and shorter total exposure times (2.3 versus 4.0 sec, p < 0.001). Operations performed in the university setting were associated with significantly more images (2.7 versus 1.8 images, p < 0.001), longer total exposure times (3.2 versus 2.3 sec, p = 0.0027), and total radiation dose (27.8 versus 53.3 rad, p < 0.001) when compared with those performed in the private setting. The university practice setting was associated with significantly more images (2.7 versus 1.8 images, p < 0.001), longer total exposure times (3.2 versus 2.3 sec, p = 0.003), and total radiation dose (27.8 versus 53.3 rad, p < 0.001) when compared with non-university settings., Conclusion: Large private and university hospitals had higher surgeon ratings. The university setting was associated with larger and less consistent surgical teams and lower nurse ratings. Surgical staff awareness of the procedure and attention to preoperative tasks specific to the procedure reduced pre-operative time spent in the OR as well as fluoroscopy radiation. These data suggest that nurses and support staff make substantial contributions to overall quality of care, and that leadership and interpersonal coordination are especially important within large teams at teaching hospitals.

The concept of telestroke networks has been proposed to overcome regional disparities in stroke treatment. Such networks do not yet operate in Japan. We aimed to determine the specific needs for telestroke networks and to estimate the effects on the number of thrombolytic therapies. Five of the 47 Japanese prefectures with various population densities to estimate the nationwide effect of telestroke networks were selected. The questionnaire survey was administered at hospitals in these prefectures that are authorized to admit patients with acute stroke. Low-volume hospitals that annually treated fewer than 12 patients with acute stroke had never used tissue plasminogen activator (tPA). The number of days when telestroke support might have been needed varied depending on the size of the population aged 65 years or older within a 30-minute-driving-time area of a hospital and the annual number of patients treated within 3 hours of onset. The geographic information system analysis showed that .6%-8.3% of the population lived in areas where they could not reach a hospital for acute stroke treatment within 60 minutes. If 24/7 full telestroke support was introduced to the existing hospitals, 6.8-69.3 more patients could be treated by intravenous (IV) tPA annually. These numbers exceeded the estimated annual increases of .8-13.7 more patients if a drip-and-ship telestroke network was introduced into an underserved area outside the 60-minute-driving-time area. This study uncovered that many Japanese stroke hospitals, especially low-volume facilities located in rural areas, do not perform IV tPA therapy in 24/7 fashion and telestroke support to these hospitals may be highly effective compared with the drip-and-ship network in an underserved area., (Copyright © 2014 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

Purpose: The results of a 2011 survey evaluating pharmacy services at small and rural Illinois hospitals are presented and compared with data from similar surveys in 2001 and 1991., Methods: A questionnaire modeled on the previous survey instruments but updated to reflect contemporary pharmacy practice was mailed to pharmacy directors at 86 small hospitals (i.e., <150 staffed beds) and rural hospitals (i.e., located outside metropolitan areas)., Results: The response rate was 46.5%. The survey data indicated that 57.5% of hospitals represented in the 2011 survey had a centralized drug distribution system, 35.0% had a hybrid system, and 7.5% had a decentralized system. The most commonly reported form of technology was automated dispensing cabinets, which were in use at 75.0% of hospitals in 2011, compared with 34.8% of hospitals represented in the 2001 survey. Barcode verification of medication doses before dispensing and at the time of administration was performed at 50% and 70% of hospitals, respectively. While the provision of clinical pharmacy services has risen sharply since 1991, substantial changes were not observed between 2001 and 2011 except in the provision of compliance and drug histories (67.6% of hospitals in 2011 versus 46.8% in 2001) and pharmacist participation in medical emergency responses (54.0% versus 34.0%)., Conclusion: A 2011 survey of pharmacy departments in small and rural Illinois hospitals provided information on the use of automation and health information technologies and showed changes in the provision of many clinical pharmacy services since 1991.