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Clinical care pathways help guide and provide structure to clinicians and providers to improve healthcare delivery and quality. The Quality Improvement and Patient Safety Committee (QIPS) of the American Society for Metabolic and Bariatric Surgery (ASMBS) has previously published care pathways for the performance of laparoscopic sleeve gastrectomy (LSG) and pre-operative care of patients undergoing Roux-en-Y gastric bypass (RYGB). This current RYGB care pathway was created to address intraoperative care, defined as care occurring on the day of surgery from the preoperative holding area, through the operating room, and into the postanesthesia care unit (PACU). PubMed queries were performed from January 2001 to December 2019 and reviewed according to Level of Evidence regarding specific key questions developed by the committee. Evidence-based recommendations are made for care of patients undergoing RYGB including the pre-operative holding area, intra-operative management and performance of RYGB, and concurrent procedures. This document may provide guidance based on recent evidence to bariatric surgeons and providers for the intra-operative care for minimally invasive RYGB. [ABSTRACT FROM AUTHOR] more...

Stefan Schad,1 Hendrik Booke,2 Serge C Thal,3 Alexander H Bentley,3 Michael Booke1 1Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Kliniken-MTK, Academic Hospital of the Goethe-University Frankfurt, Frankfurt, Germany; 2Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt, Germany; 3Department of Anesthesiology, HELIOS University Hospital Wuppertal, Witten/Herdecke University, Wuppertal, GermanyCorrespondence: Stefan Schad Email sschad@kliniken-mtk.deAbstract: The anesthesiologist, who traditionally was solely responsible for the intra- and postoperative care of patients, has undergone a transformation over the last decades and has emerged as a specialist for perioperative medicine. This includes preoperative assessment, preoperative stabilization of emergent cases, pre- or postoperative initiation of regional blocks, postoperative recovery and if needed postoperative intensive care outside the intensive care unit. A traditional recovery room, designated to take care of patients emerging from anesthesia only, no longer matches the modern anesthesiologist’s demands. However, a traditional recovery room can easily be transformed into a vibrant multi-purpose perioperative care unit. Especially in smaller hospitals, this serves to match the anesthesiologist’s demands without the financial burden of separate units for each task. On the contrary, it allows to transform the recovery room from a mandatory, but costly postoperative unit into a highly productive and demanding perioperative unit, allowing for extra revenues without corresponding costs. Worldwide, operating rooms are linked to an adjacent recovery room allowing patients to emerge from anesthesia until they fulfill the criteria to be transferred either to the regular ward or, in case of outpatient surgery, to be discharged home. Running these recovery rooms, however, is expensive due to the required technical equipment and the monthly costs of highly qualified anesthesia personnel. Despite these financial burdens, such recovery rooms are still mandatory to ensure full recovery after anesthesia and surgery. In most countries, there is no (full) reimbursement for providing recovery rooms, turning them into fiscally deficient units in most hospitals. However, recovery rooms can be further developed allowing hospitals to improve their caseloads, reduce turnover times in the operating room, and even help to manage a shortage of beds in the intensive care unit. In this paper, we describe the potential transformation from a traditional recovery room to a multi-purpose perioperative high-tech unit.Keywords: recovery room, postanesthesia care unit, perioperative medicine, turnover time, reimbursement, same-day admission, holding area more...

Severe preoperative anxiety (SPA) in surgical patients may have clinical consequences and worsen satisfaction. Some institutions have a surgical transfer and waiting area (TWA) for patient reception/dispatch to operating rooms. We measured the frequency of SPA, investigated predicting factors, and quantified the effect of the TWA stay on anxiety levels in a single centre cross-sectional study. Preoperative anxiety was assessed using three scales. Patients' perceptions/suggestions were studied by a psychoanalyst. A total of 933 adult patients, undergoing elective procedures, were interviewed. SPA was detected in 24.7%, non-modified by anxiolytic premedication. Patients' median stay was 9 min, and anxiety level was decreasing in those with SPA. In multivariable analysis, female sex, inpatient settings, and pain before the procedure were predictive for SPA. Previous operating room experience, and a supine arrival position were associated with less SPA. Patients complained about a lack of information, and an uncomfortable environment in the waiting area. To reduce anxiety, they mainly asked for warm blankets/music (physical/sound barriers), and extra sedative agents. The holding area may be a place to measure patients' anxiety by paramedical staff, and to apply simple non-pharmacological interventions. The psychological concept of psychical envelopes may be useful for the development and investigation of such interventions in improving patients' experience. [ABSTRACT FROM AUTHOR] more...

As populations become concentrated in cities, traffic congestion increases, and urban air mobility (UAM) is being considered to face this problem. Accordingly, many institutions and companies around the world are developing UAM vehicles, building infrastructure, and researching flight operating systems. In this study, three holding area concepts have been designed that can control air traffic flows and avoid bad weather conditions when UAM vehicles are operating. These holding areas have been considered to allow UAM vehicles to fly by avoiding collisions with other UAM vehicles or structures such as buildings. After validating the turning radius analysis with existing aircraft, a case study on the holding area concept design for the Seoul–GyungIn area was performed to determine whether UAM vehicles can turn within a narrow radius. It was not possible for winged-type UAM vehicles to turn across the Han River at cruise speed. The holding area concepts and the turning procedure of this study can be used as guidelines when designing UAM corridors or UAM flight routes. [ABSTRACT FROM AUTHOR] more...

Abstract Background Historically, the majority of insertable cardiac monitor (ICM) procedures were performed in the cardiac catheterization (cath) lab, electrophysiology (EP) lab, or operating room (OR). The miniaturization of ICMs allows the procedure to be relocated within the hospital without compromising patient safety. We sought to estimate the rate of untoward events associated with procedures performed within the hospital but outside the traditional settings and to characterize resource utilization, procedure time intervals, and physician experience. Methods The Reveal LINQ in-Office 2 (RIO 2) International study was a single arm, multicenter, prospective study. Patients indicated for an ICM and willing to undergo device insertion outside the cath/EP lab or OR were eligible and followed for 90 days after insertion. Results A total of 191 patients (45.5% female aged 63.8 ± 26.9 years) underwent successful Reveal LINQ ICM insertion at 17 centers in Europe, Canada and Australia. The median total visit duration was 106 min (interquartile range [IQR]: 55–61). Patient preparation and patient education accounted for 10 min (IQR: 5–20) and 10 min (IQR: 8–15) of total visit duration, respectively. Preparation and education occurred in the procedure room for 90.6 and 60.2% of patients, respectively. There were no untoward events (0.0, 95% CI: 0.0–2.1%) though four patients presented with procedure-related adverse events that did not require invasive intervention. Physicians rated procedure location as convenient or very convenient. Conclusions The Reveal LINQ™ ICM insertion can be safely and efficiently performed in the hospital outside the cath/EP lab or OR. Trial registration ClinicalTrials.gov identifier NCT02412488; registered on April 9, 2015. more...

As populations become concentrated in cities, traffic congestion increases, and urban air mobility (UAM) is being considered to face this problem. Accordingly, many institutions and companies around the world are developing UAM vehicles, building infrastructure, and researching flight operating systems. In this study, three holding area concepts have been designed that can control air traffic flows and avoid bad weather conditions when UAM vehicles are operating. These holding areas have been considered to allow UAM vehicles to fly by avoiding collisions with other UAM vehicles or structures such as buildings. After validating the turning radius analysis with existing aircraft, a case study on the holding area concept design for the Seoul–GyungIn area was performed to determine whether UAM vehicles can turn within a narrow radius. It was not possible for winged-type UAM vehicles to turn across the Han River at cruise speed. The holding area concepts and the turning procedure of this study can be used as guidelines when designing UAM corridors or UAM flight routes. more...

Background and objectives: Acute heart failure (AHF) is one of the main causes of hospitalization in Western countries. Usually, patients cannot be admitted directly to the wards (access block) and stay in the emergency room. Holding units are clinical decision units, or observation units, within the ED that are able to alleviate access block and to contribute to a reduction in hospitalization. Observation units have also been shown to play a role in specific clinical conditions, like the acute exacerbation of heart failure. This study aimed to analyze the impact of a brief intensive observation (OBI) area on the management of acute heart failure (AHF) patients. The OBI is a holding unit dedicated to the stabilization of unstable patients with a team of dedicated physicians. Materials and Methods: We conducted a retrospective and single-centered observational study with retrospective collection of the data of all patients who presented to our emergency department with AHF during 2017. We evaluated and compared two cohorts of patients, those treated in the OBI and those who were not, in terms of the reduction in color codes at discharge, mortality rate within the emergency room (ER), hospitalization rate, rate of transfer to less intensive facilities, and readmission rate at 7, 14, and 30 days after discharge. Results: We enrolled 920 patients from 1st January to 31st December. Of these, 61% were transferred to the OBI for stabilization. No statistically significant difference between the OBI and non-OBI populations in terms of age and gender was observed. OBI patients had worse clinical conditions on arrival. The patients treated in the OBI had longer process times, which would be expected, to allow patient stabilization. The stabilization rate in the OBI was higher, since presumably OBI admission protected patients from “worse condition” at discharge. Conclusions: Data from our study show that a dedicated area of the ER, such as the OBI, has progressively allowed a change in the treatment path of the patient, where the aim is no longer to admit the patient for processing but to treat the patient first and then, if necessary, admit or refer. This has resulted in very good feedback on patient stabilization and has resulted in a better management of beds, reduced admission rates, and reduced use of high intensity care beds. more...

The design and operation of ventilation systems for animal housing is a crucial component in maintaining a suitable environment for both animals and workers by removing heat, moisture, and gas species. However, important design and operational criteria, such as profiles of velocity and extent of mixing within animal housing, can be difficult to study experimentally. Thus, a computational fluid dynamics (CFD) model of a commercial dairy holding area, including the generation of transport of heat and gas species within the domain, was developed. The animal-occupied zone (AOZ) was modeled using porous media. The model was evaluated with experimental data of velocity and gas concentration. Results indicated that the airflow uniformity and air speed could be increased within the holding area by modifying the configuration of the side curtain openings and using concrete walls to guide airflow; a 20% increase in average velocity within the AOZ was achieved. Results of the CFD model have shown it to be an effective tool for gaining insight into the complex mixing patterns within holding areas to improve the design of animal housing. [ABSTRACT FROM AUTHOR] more...

This paper investigates the influence of the design parameters of the upper ferromagnetic shunt, namely the value of the holding area SH , that creates a holding force Fript>H, equal to that in breakaway stage in magnitude of this holding force at the breakaway stage. The design of an integrated circuit and the equivalent magnetic circuit of the integrated LEMM on breakaway stage was built, mathematical models of system were laid out. The most acceptable range of these ranges of magnitude of holding area is S*H̥ 0.2...0.4, and this happens when Φ*ush = 0.2...0.4 The resulting holding force will vary in range of (0.05 ... 0.15) to (0.2 ... 0.55). [ABSTRACT FROM AUTHOR] more...

Abstract: Community associated Clostridium difficile and MRSA are among the most common infection causing pathogens encountered in developed nations. It has been proposed that both pathogens may be foodborne with supporting evidence being based on the carriage in animals and recovery from meat at retail. The following reports on the incidence and dissemination routes of C. difficile and MRSA within a high capacity pork processing facility. Sampling of carcasses and processing environment was performed over two visits to the facility. C. difficile was isolated 80% (16/20) of manure samples taken within the holding area, with 45% (9/20) of holding area floor and wall samples testing positive for the pathogen. Three of the twenty carcasses (15%) sampled at post-bleed and a further 3 at post-evisceration also tested positive for C. difficile. No C. difficile were recovered from scald water samples, polisher/scraper units or on carcasses in the cold room at the end of the line. Ribotype 078 was the predominant C. difficile recovered with the remaining belonging to other ribotypes. MRSA was recovered from a single carcass at post-bleed and within the cold room, in addition to one sample taken from the holding area (overall prevalence of 2.7%). The MRSA isolates recovered from carcasses was spa t034 which is a commonly associated with pigs. The results of the study confirm that the holding area of slaughterhouse acts as a reservoir for C. difficile and MRSA although there was no evidence to suggest that the pathogens were disseminated into the processing lines. Consequently, it can be concluded that pork processing does not represent a significant risk of disseminating MRSA and C. difficile between carcasses. [Copyright &y& Elsevier] more...

Background and Objectives: Adherence to guidelines by physicians of an emergency department (ED) depends on many factors: guideline and environmental factors; patient and practitioner characteristics; the social-political context. We focused on the impact of the environmental influence and of the patients' characteristics on adherence to the guidelines. It is our intention to demonstrate how environmental factors such as ED organization more affect adherence to guidelines than the patient's clinical presentation, even in a clinically insidious disease such as pulmonary embolism (PE). Materials and Methods: A single-center observational study was carried out on all patients who were seen at our Department of Emergency and Acceptance from 1 January to 31 December 2017 for PE. For the assessment of adherence to guidelines, we used the European guidelines 2014 and analyzed adherence to the correct use of clinical decision rule (CDR as Wells, Geneva, and YEARS); the correct initiation of heparin therapy; and the management of patients at high risk for short-term mortality. The primary endpoint of our study was to determine whether adherence to the guidelines as a whole depends on patients' management in a holding area. The secondary objective was to determine whether adherence to the guidelines depended on patient characteristics such as the presence of typical symptoms or severe clinical features (massive pulmonary embolism; organ damage). Results: There were significant differences between patients who passed through OBI and those who did not, in terms of both administration of heparin therapy alone ( p = 0.007) and the composite endpoints of heparin therapy initiation and observation/monitoring ( p = 0.004), as indicated by the guidelines. For the subgroups of patients with massive PE, organ damage, and typical symptoms, there was no greater adherence to the decision making, administration of heparin therapy alone, and the endpoints of heparin therapy initiation and guideline-based observation/monitoring. Conclusion: Patients managed in an ED holding area were managed more in accordance with the guidelines than those who were managed only in the visiting ED rooms and directly hospitalized from there. more...

Background: Historically, the majority of insertable cardiac monitor (ICM) procedures were performed in the cardiac catheterization (cath) lab, electrophysiology (EP) lab, or operating room (OR). The miniaturization of ICMs allows the procedure to be relocated within the hospital without compromising patient safety. We sought to estimate the rate of untoward events associated with procedures performed within the hospital but outside the traditional settings and to characterize resource utilization, procedure time intervals, and physician experience.Methods: The Reveal LINQ in-Office 2 (RIO 2) International study was a single arm, multicenter, prospective study. Patients indicated for an ICM and willing to undergo device insertion outside the cath/EP lab or OR were eligible and followed for 90 days after insertion.Results: A total of 191 patients (45.5% female aged 63.8 ± 26.9 years) underwent successful Reveal LINQ ICM insertion at 17 centers in Europe, Canada and Australia. The median total visit duration was 106 min (interquartile range [IQR]: 55-61). Patient preparation and patient education accounted for 10 min (IQR: 5-20) and 10 min (IQR: 8-15) of total visit duration, respectively. Preparation and education occurred in the procedure room for 90.6 and 60.2% of patients, respectively. There were no untoward events (0.0, 95% CI: 0.0-2.1%) though four patients presented with procedure-related adverse events that did not require invasive intervention. Physicians rated procedure location as convenient or very convenient.Conclusions: The Reveal LINQ™ ICM insertion can be safely and efficiently performed in the hospital outside the cath/EP lab or OR.Trial Registration: ClinicalTrials.gov identifier NCT02412488 ; registered on April 9, 2015. [ABSTRACT FROM AUTHOR] more...