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Tag: Surgery

Managing Surgical Wait Times in the Intra-COVID-19 World

Finding the Right Prioritization Model

By JUSTIN SPECTOR

Restrictions on elective surgical volume in hospitals across the United States are causing a dilemma heretofore unseen in the American healthcare system. Surgeons across services have large and growing backlogs of elective surgeries in an environment where operating room (OR) capacity is restricted due to availability of inpatient beds, personal protective equipment (PPE), staffing, and many other constraints. Fortunately, the U.S. is not the first country to experience and deal with this situation; for many countries, this is the normal state of medicine.

By combining the accumulated experience of health systems around the world with cutting-edge technologies, it is possible to make this crisis manageable for perioperative leadership and, potentially, to improve upon the preexisting models for managing OR time.

The first step in creating an equitable system that can garner widespread buy-in is to agree upon a method for categorizing cases into priority levels. Choosing a system with strong academic backing will help to reduce the influence of intra-hospital politics from derailing the process before it can begin.

Why Cases Should Be Prioritized

If your hospital has a mix of surgeons who perform highly time-sensitive cases — cases where patient quality of life is substantially impacted — as well as cases with minor health or quality of life outcomes, it is important to make sure there will be enough capacity to get the higher urgency cases done within a reasonable amount of time. This allows cases in the backlog to be balanced against new cases that are yet to be scheduled and will help to optimize the flow of patients through the OR.

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Switching to Outpatient Surgery for Everyone’s Benefit

By AMY KRAMBECK, MD

The trend toward less invasive procedures, shifting from inpatient to outpatient, has changed the face of surgery. Industry-changing leaps in technology and surgical techniques have allowed us to achieve our treatment goals with smaller incisions, laparoscopy and other “closed” procedures, less bleeding, less pain, and lower complication rates. As a result, patients who used to require days of recovery in the hospital for many common surgeries can now recuperate in their own homes.

Outpatient procedures grew from about 50% to 67% of hospitals’ total surgeries between 1994 and 2016,1,2 and outpatient volume is expected to grow another 15% by 2028,3 with advantages for patients, surgeons, insurers, and hospitals. In my hospital, where bed space is at a premium, my colleagues and I were able to make a significant impact by switching minimally invasive surgery for enlarged prostate, also called benign prostatic hyperplasia (BPH), from inpatient to outpatient.

New Opportunity with an Advanced Technology

BPH affects about half of men in their 50s, with the prevalence increasing with age to include about 90% of men 80 and older.4 As a result, BPH surgery makes up a significant portion of urological procedures in any hospital.

I have been performing BPH surgery for 11 years. There are several options, including transurethral resection of the prostate (TURP) and suprapubic prostatectomy, both of which require hospital stays and bladder irrigation with a catheter due to bleeding. Another less frequently utilized surgical option for BPH is holmium laser enucleation of the prostate (HoLEP). HoLEP causes fewer complications and requires shorter hospitalization.5 Specifically, its postoperative morbidity is the lowest among BPH surgeries.5,6,7  HoLEP has the least bleeding, shortest catheter time, and low rates of urinary tract infection, plus patients are less likely to require additional treatment for BPH as they age compared to other available therapies.5,6,7  

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Google Glass: A Paradigm Shift in Assessing Procedure Competency?

I recently had the privilege of becoming a Google Glass Explorer.  Basically, this means I walk around with a funky pair of glass frames and look strange – even for an urban hospital setting.

The Glass has a built in camera, and a small display that you can see with numerous apps ranging from GPS navigation to searching the Web.  As cool as this the technology is – is there any utility in the healthcare setting?

There is the capability of video chat, where a consulting physician can see what I would be seeing in the operating room, and tell me what I may be looking at and what to do next. Pristine Eyesight, based in Austin Texas, is trialing this use of  Glass in University of California, Irvine. Applications for nursing are being developed as well.  Yet will this truly impact quality? I am not sure.

Yet one thing that intrigues me about the Glass is the perspective given when using the video function.  I recorded some small surgical procedures and reviewed the video afterwards. I watched where I placed my hands, how I held the needle driver, where I took my bites, and in general – what I looked at during the case.

I felt like an NFL Coach reviewing game tape.  For the first time in my surgical career, I was able to really see what I did, a perspective that I had never before experienced. This lightweight device with built in eye protection was far more comfortable than any helmet-cam I had used, and the line of sight was right in tune with my visual field. So I began thinking – is there a way this tool can improve outcomes in healthcare?

According to the American College of Surgeons, almost 5,000,000 central venous catheters are placed annually in this country.  Complications including placement failure, arterial puncture and pneumothorax range from 15-33% in numerous studies.  So how is this common procedure taught?

The classic “watch one, do one, teach one” methodology has been modified over the years.  Now, after watching a few lines placed, house staff must perform a certain number of central line placements (usually 5) under the supervision of a senior resident, fellow or attending.  Once the appropriate number is reached, the trainee is “competent” to perform the procedure on his or her own.   Yet are they truly competent? Perhaps the high complication rates result from a flaw in this classic teaching methodology?

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Combat Medicine’s ‘Golden Hour’


WASHINGTON — While the news swells this week with sad and angry retrospectives on the war in Iraq, it is worth noting that the tremendous human costs of that war would have been much greater, were it not for breakthroughs in combat medicine deployed for the first time on a broad scale in Iraq.

4,486 American men and women were killed in the Iraq war. This represents approximately 14 percent of the 32,221 wounded in action — versus the 19 percent killed in Vietnam, or 27 percent killed in World War II. These statistics are cold comfort for those whose lives were derailed and families tormented in the process, and they are a clarion call to re-double all our efforts to help those who survived.

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The Quest for Price Transparency

A torn meniscus. It did not disable but it impaired, and unpredictably. My stomach learned quickly to tighten at the sound of A’s peculiar whimper in response to a crippling pain that would shoot through her at seemingly innocuous movements of the afflicted leg. We have health insurance of sorts, the type that will help you keep your home if tragedy strikes, but that does not shield you from the brunt of what most of day-to-day health care cost is about. We’re well practiced in deferring and foregoing care. Here however, we reluctantly acknowledged that a hospital would need to be visited and a doctor consulted.

Tests and a physical examination made clear that an operation was unavoidable. The doctor was a thoughtful man who conscientiously went through what the operation would entail. Surgery would take half a day, then back home by afternoon, convalescence over the following few weeks, with complete recovery the usual outcome. While not painless, the procedure seemed reassuringly routine. His tone was caring and his outlook about our case optimistic.

The admirable candor with which medical personnel have learned to speak about difficult topics concerning our bodies and our care did not extend to the costs involved. The question of what the procedure would cost, gently broached, initially baffled the staff, eliciting answer-deflecting counter-questions about the adequacy of our insurance coverage, but resulted in no quotes or estimates. Continue reading…

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