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OPERATING ROOMS: How Mass General ramped up again after procedures were deferred during early days of pandemic

During the early days of the pandemic, hospitals were asked to defer non-essential surgery to free up resources for the care of SARS-CoV2 patients. Within 4 weeks, Massachusetts General Hospital (Boston) had deferred 6,500 surgical procedures – dropping to 15 percent of previous surgical volume. How the hospital devised an orderly methodology to triage surgical patients who were waiting to be rescheduled is described. This safe and swift methodology allowed the hospital to ramp back up from 10 to 58 operating rooms running each day – at 750 cases per week, a full schedule. How surgeons were assigned time as capacity changed is also discussed.

Source: Brumit, R. and others. Recovering an Operating Room Schedule During a Global Pandemic: A Method for Safe and Swift Increases in OR Volume During Times of Crisis. Journal of Medical Systems 45(12). Full text free here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7787880/pdf/10916_2020_Article_1687.pdf

OPERATING ROOMS: What are the 10 most costly procedures?

Here are data from the federal government’s Healthcare Cost and Utilization Project (HCUP) that compare different surgical procedures according the expense incurred by hospitals in providing them.  Here are some notes about the following – these data are for INPATIENT procedures only.  The data are for what it COSTS the hospital for the patient’s entire stay, not what the hospital charges for the stay.  These are ALL-PAYER data, which is good – the data are not limited to the Medicare population, for example.  Finally, the data are based on first-listed operating room procedures.

Top 10 Most Costly Surgical Operations: Mean Cost Per Stay, US, 2014

  1. $52,000  Heart valve
  2. $41,900  Coronary artery bypass graft
  3. $35,000  Pacemaker/cardioverter/defibrillator
  4. $34,600  Incision/excision central nervous system
  5. $34,300  Small bowel resection
  6. $28,900  Spinal fusion
  7. $23,700  Colorectal resection
  8. $21,500  Percutaneous coronary angioplasty
  9. $20,800  Amputation, lower extremity
  10. $17,500  Debridement of wound, infection, burn

Source: McDermott, K.W., Freeman, W.J., and Elixhauser, A. (2017, December). Overview of operating room procedures during inpatient stays in U.S. hospitals, 2014. Statistical Brief. Click here for FREE full text: https://hcup-us.ahrq.gov/reports/statbriefs/sb233-Operating-Room-Procedures-United-States-2014.jsp  Posted by AHA Resource Center (312) 422-2050, rc@aha.org

 

ORTHOPEDICS: 30-day readmission rates for total hip and total knee replacement

The readmission rate for total hip replacement and total knee replacement procedures performed recently on patients in California, Florida and Massachusetts was studied.  Here are the findings for the percent of these patients readmitted within 30 days:

  • 4.29 percent (California during the period 2009 to 2011)
  • 4.7 percent (Florida during the period 2009 to 2013)
  • 3.92 percent (Massachusetts during the period 2009 to 2012)

The authors analyzed the role of infection in these 30-day readmissions, finding that in about one-third of the total hip and total knee arthroplasty patients, infection was listed as the primary or secondary reason for readmission.

Source: A retrospective study. Medicine, 96(38). Click here for free full text: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5617700/pdf/medi-96-e7961.pdf  Posted by AHA Resource Center (312) 422-2050, rc@aha.org

PERIOPERATIVE: Enhanced recovery after surgery

Enhanced recovery after surgery (ERAS) refers to redesigned perioperative care, sometimes also referred to as fast-track recovery after surgery.  Among the objectives are to reduce readmissions and avoid opioid abuse.  Changes include early ambulation, multi-modal analgesia and careful attention to nutrition.  The Cleveland Clinic includes ERAS in a list of the top 10 medical innovations for 2018.  The Gramlich article describes how the ERAS guidelines for colorectal surgery were implemented in six Canadian hospitals by the Alberta Health Services.  More information can also be obtained from the ERAS Society.

Sources:

Cleveland Clinic. Top 10 medical innovations.  Click here: http://innovations.clevelandclinic.org/Summit/Top-10-Medical-Innovations.aspx

Gramlich, L.M., and others. (2017). Implementation of enhanced recovery after surgery: A strategy to transform surgical care across a health system. Implementation Science. 12(67). Click here:  https://implementationscience.biomedcentral.com/track/pdf/10.1186/s13012-017-0597-5?site=implementationscience.biomedcentral.com

ERAS Society. Click here: http://erassociety.org/   Posted by AHA Resource Center (312) 422-2050, rc@aha.org

SURGERY: How much vascular surgery is done?

This is an analysis of over 3 million adult inpatient admissions in the state of Maryland during the years 2009 to 2013.

  • 3,157,499 adult admissions to Maryland hospitals 2009-2013
    •    154,004 (5 percent) of the total admissions involved a vascular procedure
      • 54 percent of the vascular procedures were emergent
      • 13 percent of the vascular procedures were urgent
      • 33 percent of the vascular procedures were elective

Patients who were in the emergent or urgent groups were found to have higher mortality rates and hospital resource utilization.

Source: Harris, D.G., and others. (2017, November). Defining the burden, scope, and future of vascular acute care surgery. Journal of Vascular Surgery, 66(5), 1511-1517.  Click here for access to the publisher’s website: http://www.jvascsurg.org/article/S0741-5214(17)31354-X/pdf  Posted by AHA Resource Center (312) 422-2050, rc@aha.org

OPERATING ROOMS: How much major surgery is infrequent? Is there an impact on costs?

Texas hospitals were studied to see how many inpatient major surgical procedures were not performed very often (once a month or less) at each hospital analyzed.  In this study of discharge data from 343 hospitals for the period late 2015 to early 2016, over half (54 percent)  of procedures were found to be uncommon (as defined above) for the hospital where they were performed.  These procedures accounted for 68 percent of inpatient costs.

Source: O’Neill, L. and others. (2017, September). Discharges with surgical procedures performed less often than once a month per hospital account for two-thirds of hospital costs of inpatient surgery. Journal of Clinical Anesthesia. 41, 99-103. Click here for publisher’s website: http://www.jcafulltextonline.com/article/S0952-8180(17)30659-1/fulltext   Posted by AHA Resource Center (312) 422-2050, rc@aha.org

BATRIATRICS: Is gastric bypass surgery effective?

The Roux-en-Y gastric bypass procedure was found to help obese patients lose and keep weight off 12 years after surgery compared to a group of similar patients who did not have surgery.  This study, out of Intermountain Healthcare and the University of Utah, found that patients who had the surgery lost weight and were able to keep it off compared with those who did not have surgery.  Additionally, half of the surgical patients who had type 2 diabetes at the time of surgery were in remission for diabetes 12 years later.

Source: Adams, T.D., and others. (2107, September 21). Weight and metabolic outcomes 12 years after gastric bypass. New England Journal of Medicine, 377(12), 1143-1155.  Click here for the publisher’s website: http://www.nejm.org/doi/full/10.1056/NEJMoa1700459  Posted by AHA Resource Center (312) 422-2050, rc@aha.org

ROBOTICS: Use in interventional cardiology procedures

…contemporary robot-assisted PCI systems improve operator safety by reducing ionizing radiation exposure and can improve procedural quality and outcomes by offering better accuracy accuracy in stent selection.”

The use of surgical robots for interventional cardiology procedures in the United States is discussed in this review prepared by physicians at the Mayo Clinic.  There is one manufacturer – Corindus Vascular Robotics – and two models.  The equipment is designed to help overcome a significant problem faced by interventional cardiologists, which is exposure to radiation and the need to wear leaded protective garments during procedures.  However, there are barriers which have slowed the adoption of this technology, such as a lack of randomized clinical trials and the price tag for the equipment.

Source: Maor, E., and others. (2017, July). Current and future use of robotic devices to perform percutaneous coronary interventions: A review. Journal of the American Heart Association. 6(7).  Click here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5586317/pdf/JAH3-6-e006239.pdf  Posted by AHA Resource Center (312) 422-2050, rc@aha.org

Click to access JAH3-6-e006239.pdf

SURGICAL SUITE: Implementing ERAS at Kaiser Permanente

Engagement among patients and clinicians is excellent, and the ERAS team is working toward realizing the vision of enhanced recovery hospitals where the ERAS paradigm becomes the standard of care for the 190,000 adult inpatients hospitalized in KPNC each year.”

How Kaiser Permanente Northern California implemented an Enhanced Recovery After Surgery (ERAS) project in 20 KPNC medical centers is described in this lengthy, scholarly article.  The initiative began with colon surgery patients, but success in reducing inpatient length of stay and post-op complication rates has led to expansion of the ERAS model to other surgical patients.  This article is well illustrated with graphics which will be helpful to other providers working through similar implementation projects, including a sample “My Calendar: Recover Safely and Quickly” intended for colon surgery patients.

Source: Liu, V.X., and others. (2017, Summer). The Kaiser Permanente Northern California enhanced recovery after surgery program: Design, development, and implementation. The Permanente Journal, 21(3), 53-61.  Click here: http://www.thepermanentejournal.org/issues/2017/summer/6477-the-kaiser-permanente-northern-california.html  Posted by AHA Resource Center (312) 422-2050, rc@aha.org

SURGICAL SUITE: Neurosurgical operating room of the future incorporates aeronautical industry concepts

The next phase of the OR of the future is to focus at the cellular level through next-generation imaging that will allow advanced interrogation of normal and diseased neural tissue…which will be systematically captured in the background, curated, and analyzed by the informatics system.”

How to redesign the neurosurgical operating room to incorporate concepts borrowed, in part, from the aeronautical industry is explored in this scholarly article.  How to improve patient safety by focusing on data collection and on honing the science of surgery is discussed.  This article is based on pioneering work being done at the Aurora Neuroscience Innovation Institute (Milwaukee) in collaboration with vendors Storz Corp., Stryker Corp., Synaptive Medical, and Nico Corp.

Source: Kassam, A.B., and others. (2017, June). The operating room of the future versus the future of the operating room. Otolaryngology Clinics of North America, 50(3), 655-671.  Click here for the publisher’s website: http://www.sciencedirect.com/science/article/pii/S0030666517300166

Here is a link to the Aurora Neuroscience Innovation Institute website: https://www.aurorahealthcare.org/services/neuroscience  Posted by AHA Resource Center (312) 422-2050, rc@aha.org