Modelo para el perfeccionamiento del proceso de atención en cirugía mayor ambulatoria y de corta estadía / A Model for Improving the Care Process in Major Outpatient and Short-Stay Surgeries

Introducción: Existen limitaciones en la coordinación entre los niveles primario y secundario de salud en el proceso quirúrgico ambulatorio y de corta estadía, lo que repercute en la calidad del servicio. Objetivo: Diseñar una propuesta de modelo asistencial para el perfeccionamiento del proceso de atención al paciente en cirugía mayor ambulatoria y cirugía de corta estadía. Métodos: Se desarrolló una investigación prospectiva descriptiva del 3 de septiembre de 2012 al 20 de marzo de 2018. En su diseño fueron empleados la modelación y el sistémico-estructural fundamentalmente. Se aplicaron encuestas a expertos con experiencia en los niveles primario y secundario de salud para evaluar la calidad y pertinencia del modelo propuesto. También fueron encuestados los jefes de los grupos provinciales de Cirugía General y Medicina Familiar. Se realizaron entrevistas grupales a clientes del proyecto de investigación (del que se deriva) y a decisores institucionales y del nivel provincial. Fue empleada la técnica de triangulación metodológica y de fuentes. Resultados: La estructuración del modelo partió de la coordinación del trabajo asistencial y metodológico entre los niveles primario y secundario de salud. Se sustentó en cuatro pilares: preparación teórica del personal de salud, observancia de normas de relación en el contexto laboral, cumplimiento de procedimientos en el contexto asistencial y evaluación continua de la calidad asistencial. Los expertos, clientes y decisores avalaron su calidad, pertinencia y posibilidades de implementación. Conclusiones: El modelo presenta calidad, es pertinente y su aplicación es factible(AU)

Introduction: There are limitations in the coordination between the primary and secondary health levels in the outpatient and short-stay surgical processes, which affects the quality of the service. Objective: Designing a proposal for a healthcare model for the improvement of the patient care process in major outpatient surgery and short-stay surgery. Methods: A descriptive and prospective research was carried out from September 3, 2012 to March 20, 2018. Its design involved essentially modeling and the systemic-structural method. Surveys were applied to experts with experience in primary and secondary health levels, in order to assess the quality and relevance of the proposed model. The heads of the provincial groups of General Surgery and Family Medicine were also surveyed. Group interviews were conducted with clients of the research project (from which it is derived) and with institutional and provincial decision-makers. The methodological and source triangulation technique was used. Results: The structuring of the model started from the coordination of the care and methodological work between the primary and secondary health levels. It was based on four pillars: theoretical training of health personnel, observance of relationship rules in the work context, compliance with procedures in the care context, and continuous assessment of the quality of care. The experts, clients and decision-makers recognized its quality, relevance and possibilities of implementation. Conclusions: The model presents quality, is pertinent and its application is feasible(AU)

Shortening Postoperative Stay after Parathyroidectomy - A District General Hospital Experience

Abstract Introduction Historically, concerns about complications following parathyroid surgery, such as airway compromise, bleeding and hypocalcemia, have precluded its consideration as a short-stay surgical procedure. Recent advancements in perioperative care have resulted in several publications demonstrating that parathyroidectomy can be safely performed as a short-stay procedure. Objectives The aim of the present study was to describe the process of implementing a short-stay protocol focusing on preoperative patient education and postoperative calcium management for those undergoing surgery for primary hyperparathyroidism (PHP). Method A retrospective audit of consecutive parathyroidectomies performed for PHP over the period between 2010 and 2013 was performed. A short-stay protocol (SSP) was introduced focusing on postoperative calcium management. Results were reaudited over the period between 2013 and 2015. Results Consecutive parathyroidectomies in 76 patients were included in the study. A total of 42 patients underwent parathyroidectomy prior to the introduction of the protocol. A total of 26.2% of these patients were symptomatic from hypercalcemia. A total of 40 out of 42 (95.2%) patients had a biochemical cure. A total of 36 out of 42 (85.7%) cases were due to parathyroid adenomas. A total of 34 patients underwent surgery following the introduction of the protocol. A total of 13 out of 34 (38.2%) of the patients had symptomatic hypercalcemia. A total of 33 out of 34 (97.1%) had a biochemical cure. A total of 32 out of 34 (94.1%) cases were due to parathyroid adenomas. The length of stay decreased from a median of 3 days (range 2-9 days; mean 3.32) preprotocol to a median of 2 days (range 2-3 days; mean 2.16) postprotocol (p< 0.0001) with no difference in the 30-day unplanned readmission rate (4.8 versus 2.9%; p= 0.999). Conclusions The postoperative length of stay after parathyroidectomy for PHP can be safely reduced through patient education and by rationalizing postoperative calcium management without adversely affecting outcomes.

The outcome of short stay thyroidectomy in rural medical outreach settings in Northern Nigeria

Background: The practice of short stay thyroidectomy is relatively new in developing nations like Nigeria. The primary reason for this is a lack of resources. Furthermore, the prevailing poverty prevents many patients from accessing tertiary health care, as such, ad hoc medical outreaches are usually conducted to bridge the gap. Thyroidectomies have not been routinely performed in these outreach settings due to safety concerns. The study seeks to analyse whether short stay thyroidectomy can be safely practiced under medical outreach settings with limited resources.Methods: The study is a prospective review of all patients that had short stay thyroidectomy at four rural medical outreach settings in Nigeria. Entire study spanned January 2019 to November 2019. Each outreach lasted one week, and patients were followed up for the duration of the outreach. All patients presenting at the outreach locations and diagnosed with goiters who have had no prior neck surgeries, are euthyroid, have no locally advanced malignancies or intrathoracic goiters, have adequate social support, possess a telephone, and have accommodation within the local government area where the outreach is carried out were included in the study. Exclusion criteria included patients who did not satisfy any of the above listed inclusion criteria. Thyroidectomy was done through a standard cervicotomy. Descriptive statistics were applied.Results: A total of 81 patients with non-toxic goiters had thyroid surgery. There were 76 (94%) females and five (6%) males. Average age was 46 years. Sixty-nine (85.2%) patients had no complication, while 12 (14.8%) patients had complications. Seventy-seven (95.1%) patients were discharged within 24 hours of surgery, while four (9.4%) patients were discharged within 48 hours. There was no mortality.Conclusions: The short-stay thyroidectomy model is feasible and safe in our environment, even in the presence of limited resources, and provides an alternative to the traditional 72 hour postoperative hospital stay.

Hospitalizaciones breves: impacto de la implementación de un área de observación en el Servicio de Emergencia Pediátrica de la Asociación Española / Short stay hospital admissions: the impact of implementing an observation area in the Pediatric Emergency Service of the Asociación Española / Hospitalizações curtas: impacto da aplicação de uma área de observação no Serviço de Emergência Pediátrica da Asociación Española

La racionalización de las admisiones hospitalarias constituye un aspecto clave de la gestión clínica. En 2014 en un estudio realizado en el Servicio de Pediatría de la Asociación Española, el 34% de los niños presentaron hospitalizaciones breves. Se propuso la creación de un área de observación que comenzó a funcionar en 2015. El objetivo de este estudio es valorar el impacto generado por la implementación de un área de observación en el Servicio de emergencia sobre las hospitalizaciones breves. Se realizó un estudio cuasi-experimental en el que se incluyeron todos los menores de 15 años que presentaron hospitalizaciones breves en dos períodos: pre y post implementación del área de observación. Se compararon la frecuencia y las características de las hospitalizaciones breves en ambos periodos. Se consideró significativo p<0.05. Las hospitalizaciones breves representaron el 34% en el período uno versus 12% en el período dos (p<0.05). La mediana mensual fue 54 (29 a 66) y 16 (9 a 30), respectivamente (p<0.05). Se observó una reducción significativa de las hospitalizaciones breves en niños mayores de 1 año (90% vs 67,5%) y en el horario de 0-6 horas (38% vs 26%). Se observó una reducción significativa en las hospitalizaciones por traumatismo encefalocraneano y otros traumas (16% vs 5%) y por convulsiones (8% vs. 4%). No se registraron fallecimientos. La implementación del área de observación en el servicio de emergencia impactó positivamente al reducir significativamente la frecuencia de hospitalizaciones breves en la institución. Resulta necesario continuar avanzando en la mejora de los procesos de gestión clínica. Futuros estudios son necesarios para evaluar el impacto en la calidad asistencial.

Hospital admissions streamlining is a key aspect of clinical management. In a study carried out during 2014 in the Pediatrics Service of the Asociación Española, 34% of children had short stay hospital admissions. A proposal was made to create an observation area, which started working in 2015. The objective of this study was to assess the impact of implementing an observation area in the Emergency service on short stay admissions. A quasi-experimental study was conducted, including all children below 15 years of age with short stay admissions during two periods: before and after implementation of an observation area. Frequency and characteristics of the short stay admissions were compared for both periods. Significance was considered at p<0.05. Short stay admissions were 34% in period 1 versus 12% in period 2(p<0.05). Monthly median was 54 (29 to 66) and 16 (9 to 30) respectively (p<0.05). A significant reduction in short stay admissions was observed in children older than 1 year (90% vs 67, 5%) and in the 0-6 hours shift (38% vs 26%). A significant reduction was observed in hospitalizations due to cranioencephalic trauma and other trauma (16% vs 5%) and due to seizures (16% vs 5%). No deaths were recorded. Implementation of the observation area in the emergency service had a positive impact in the significant reduction of the frequency of short stay admissions in the institution. It is necessary to continue on advancing in the improvement of clinical management processes. Further studies are needed to assess impact on the quality of care.

A racionalização das admissões hospitalares é um aspecto fundamental do gerenciamento clínico. Em 2014, em um estudo realizado no Serviço Pediátrico da Asociación Española, 34% das crianças apresentaram hospitalizações breves. Foi proposta a criação de uma área de observação que começou a operar em 2015. O objetivo deste estudo é avaliar o impacto gerado pela implementação de uma área de observação no Serviço de Emergência em hospitalizações curtas. Foi realizado um estudo quase experimental em que foram incluídas todas as crianças menores de 15 anos que tiveram hospitalizações curtas em dois períodos: pré e pós-implementação da área de observação. A frequência e as características das hospitalizações curtas foram comparadas em ambos os períodos. Foi considerado significativo p <0,05. As hospitalizações curtas representaram 34% no período 1 contra 12% no período 2 (p <0,05). A mediana mensal foi de 54 (29 a 66) e 16 (9 a 30), respectivamente (p <0,05). Houve uma redução significativa nas internações curtas em crianças com mais de 1 ano (90% vs. 67,5%) e nas 0-6 horas (38% vs. 26%). Observou-se uma redução significativa nas internações por traumatismo crânioencefálico e outros traumas (16% vs 5%) e convulsões (8% vs. 4%). Não foram registradas mortes. A implementação da área de observação no serviço de emergência teve um impacto positivo, reduzindo significativamente a freqüência de hospitalizações breves na instituição. É necessário continuar avançando na melhoria dos processos de gerenciamento clínico. Estudos futuros são necessários para avaliar o impacto na qualidade dos cuidados.

University of Tsukuba's Short-Stay, Regional Health Care, Clinical Clerkship Program in Medically Underserved Areas / 医学教育

Since 2009, a five-day, regional health care, clinical clerkship in medically underserved areas has been available to all fifth-year medical students at the University of Tsukuba. In the program, students listen to and observe health problems in non-clinical settings, wherever these problems actually exist. Students can experience health care lectures and health examinations. They can also experience a clinical work environment. The short stay helps students to understand the living environment of the area they observe. It is also effective for students to consider health problems from the perspective of the local inhabitants. This program aims to directly convey the interest and importance of community medicine, and to contribute to the supply of physicians in these areas. A longitudinal study is needed to evaluate the effect of the program.

Descripción de la población asistida en la sala de salud mental del Hospital Maciel en un año / Description of assisted population in the mental health ward Maciel Hospital in a year

Los trastornos psiquiátricos son una de las principales causas de morbilidad mundial, y la respuesta insuficiente de los servicios de salud mental viene siendo objeto de estudios científicos.Surge así la necesidad de actualizar la información epidemiológica de nuestros servicios y compararla con estudios previos.La impresión clínica lleva a plantearnos la hipótesis de un aumento en la frecuencia delos trastornos por consumo de sustancias psicoactivas y violencia, lo cual requiere objetivar estos datos.Es un estudio descriptivo observacional transversal de la población asistida en la sala de salud mental del Hospital Maciel durante un año. La internación en sala cumple actualmente con una asistencia de corta estadía, multidisciplinaria,con criterios geográficos y clínicos, de amplio espectro nosológico, predominando los trastornos por consumo de sustancias.Algunos puntos objetivados son: patología dual 40,82 %, no compensación 15 % (egresos sin alta médica y derivaciones) y el 12,24 % de reinternaciones en el período analizado.

The anesthesia study of minimally-invasive thyroid surgery with short-stay discharge / 中华内分泌外科杂志

Objective To evaluate the feasibility,security and efficiency of general anaesthesia compared with regional anaesthesia for minimally-invasive thyroid surgery(MITS)with short-stay discharge.Methods 103 cases undergoing MITS with short-stay discharge from Jan.2013 to Jun.2013 in Fuzhou General Hospital were collected.54 patients were operated under regional anaesthesia and 49 under general anaesthesia.All variables of patients including demographic characteristics,vital signs (blood pressure,heart rate,blood glucose) during the operation,duration and type of operation,postoperative complications,difficulty in airway management and anesthesia consumption were recorded and analyzed.Results There was no difference in respect to level of blood glucose,length of hospital stay,discharge time,patient or operator satisfaction rate,anesthesia or operation complications rate between the two groups.Blood pressure (T1:(90 ± 7.0) vs (79 ± 8.3) mmHg,T2:(88 ± 6.8) vs (80 ±7.6) mmHg,P ＜0.05) and heart rate(T1:(130 ± 18.2) vs(101 ± 12.0)/min,T2:(120 ± 19.7) vs(103 ± 13.3)/min,P ＜ 0.05)level were higher,while the recovery time of anesthesia((0.3 ± 0.14)vs(0.8 ± 0.35)h,P ＜ 0.05)) and anesthesia consumption ((1350 ± 78) vs (2580 ± 220) yuan,P ＜ 0.05)) were lower in the regional anaesthesia group compared with those in the general anaesthesia group.Conclusions Both general anaesthesia and regional anaesthesia for MITS with short-stay discharge are safe and effective.General anesthesia has less psychological trauma,while regional anaesthesia has shorter recovery time and lower anesthetic consumption.

Cirugía de corta estancia en sábados, domingos y días festivos, experiencia en el Servicio de Cirugía General del Hospital General de México, O.D / Short stay surgery on weekends and holidays, experience at the General Surgery Service of the General Hospital of Mexico, O.D

Objetivo: Demostrar las bondades del impacto, tiempo y costo-eficacia de la cirugía de corta estancia en sábados, domingos y días festivos. Sede: Hospital General de México. Diseño: Estudio prospectivo, transversal, observacional, comparativo. Análisis estadístico: Prueba t de Student, chi cuadrada y análisis costo-eficacia. Material y método: Durante 4 años se realizaron 1,200 cirugías dentro de este programa piloto, utilizando la capacidad hospitalaria instalada y al mismo personal contratado para la atención médica de dichos días, sin contar con una unidad de cirugía de corta estancia como tal. Los procedimientos realizados fueron: plastía inguinal, resección de enfermedad pilonidal, plastía umbilical, resección de tumor benigno de partes blandas, plastía de pared, mastectomía subcutánea, hemorroidectomía, fistulectomía y excisión de tumores benignos mamarios y se comparó con los mismos procedimientos, pero realizados en forma de cirugía programada, evaluando y comparando las siguientes variables: edad, género, procedimiento realizado, tiempo de estancia hospitalaria y costo-beneficio del procedimiento. También se evaluó necesidad de hospitalización, reingreso en menos de 24 h, morbilidad y mortalidad. Resultados: Los diagnósticos incluyeron: hernias inguinales con 486 casos, tumores de partes blandas en 359 casos, hernia umbilical en 185 casos, eventración en 88 casos, enfermedad anorrectal en 27 casos, enfermedad pilonidal en 17 casos, ginecomastia en 17 casos, fimosis en 10 y otros en 11. Se realizaron plastía inguinal, resección de enfermedad pilonidal, plastía umbilical, excisión de tumor benigno de partes blandas, plastía de pared, mastectomía subcutánea, hemorroidectomía y/o fistulectomía, circuncisión y otros. El tiempo empleado para el manejo quirúrgico se redujo de 36 horas en promedio a doce horas (p < 0.05). El costo-eficacia fue del 40% menor en comparación con los pacientes que se operaron con el método tradicional. El promedio de tiempo quirúrgico y anestésico no fue diferente entre cirugía ambulatoria y el método tradicional. Conclusión: Se puede realizar con gran eficiencia cirugía de corta estancia en sábados domingos y días festivos con un ahorro de 40%.

Objective: To demonstrate the benefits of the impact, time, and cost-effectiveness of short stay surgery performed on weekends and holidays. Setting: General Hospital of Mexico (Third level health care hospital). Design: Prospective, cross-sectional, observational, and comparative study. Statistical analysis: Student's t test, chi square, and cost-effectiveness analysis. Material and method: During 4 years, 1,200 surgeries were performed within this pilot program, using the installed hospital infrastructure and the same personnel employed for medical care in those days, without having a special short stay surgery unit as such. Performed procedures were: inguinal plasty, resection of pilonidal disease, umbilical plasty, resection of benign soft tissue tumor, wall plasty, subcutaneous mastectomy, hemorrhoidectomy, fistulectomy, and excision of benign breast tumors, these were compared with the same procedures but performed as programmed surgeries. We assessed and compared the following variables: age, gender, performed procedure, time of hospital stay, and cost-benefit of the procedure. We also evaluated the need of hospitalization, re-admittance in less than 24 h, morbidity and mortality. Results: Diagnoses included: inguinal hernias with 486 cases, 359 cases of soft tissue tumors, 185 cases of umbilical hernia, 88 cases of eventration, 22 cases of anorectal disease, 17 cases of pilonidal disease, 17 cases of gynecomastia, 10 cases of phimosis, and 11 other diagnoses. We performed inguinal plasties, resection of pilonidal disease, umbilical plasty, excision of soft tissue tumor, wall plasty, subcutaneous mastectomy, hemorrhoidectomy and/or fistulectomy, circumcision and other procedures. The time used for surgical management was reduced from an average of 36 to 12 hours (p < 0.05). Cost-effectiveness was 40% lower as compared with the traditional method. Surgical and anesthetic times were not different between ambulatory and traditional surgeries. Conclusion: Short stay surgery can be performed efficiently on the weekends and holydays with a 40% savings.