Utilization of lean project management principles and health informatics to reduce operating room delays in a vascular surgery practice.

OBJECTIVES: Perioperative inefficiency can increase cost. We describe a process improvement initiative that addressed preoperative delays on an academic vascular surgery service. METHODS: First case vascular surgeries from July 2019-January 2020 were retrospectively reviewed for delays, defined as late arrival to the operating room (OR). A stakeholder group spearheaded by a surgeon-informaticist analyzed this process and implemented a novel electronic medical records (EMR) preoperative tool with improved preoperative workflow and role delegation; results were reviewed for 3 months after implementation. RESULTS: 57% of cases had first case on-time starts with average delay of 19 min. Inappropriate preoperative orders were identified as a dominant delay source (average delay = 38 min). Three months post-implementation, 53% of first cases had on-time starts with average delay of 11 min (P < 0.05). No delays were due to missing orders. CONCLUSIONS: Inconsistent preoperative workflows led to inappropriate orders and delays, increasing cost and decreasing quality. A novel EMR tool subsequently reduced delays with projected savings of $1,200/case. Workflow standardization utilizing informatics can increase efficiency, raising the value of surgical care.

Relationship between blood type and outcomes following COVID-19 infection.

Since the onset of the COVID-19 pandemic, a concentrated research effort has been undertaken to elucidate risk factors underlying viral infection, severe illness, and death. Recent studies have investigated the association between blood type and COVID-19 infection. This article aims to comprehensively review current literature and better understand the impact of blood type on viral susceptibility and outcomes.

Venous thrombosis, thromboembolism, biomarkers of inflammation, and coagulation in coronavirus disease 2019.

OBJECTIVE: Coronavirus disease 2019 (COVID-19) is associated with abnormal inflammatory and coagulation markers, potentially mediating thrombotic events. Our objective was to investigate the incidence, time course, laboratory features, and in-hospital outcomes of COVID-19 patients with suspected venous thromboembolism (VTE). METHODS: A retrospective observational cohort study was conducted of patients hospitalized with COVID-19 who had undergone ultrasound imaging for suspected VTE from March 13 to May 18, 2020. The medical records of the included patients were reviewed for D-dimer, fibrinogen, prothrombin time, partial thromboplastin time, platelet count, C-reactive protein (CRP), and high-sensitivity troponin T at admission and at up to seven time points before and after ultrasound examination. The clinical outcomes included superficial venous thrombosis, deep vein thrombosis, pulmonary embolism, intubation, and death. Mixed effects logistic, linear, and Cox proportional hazards methods were used to evaluate the relationships between the laboratory markers and VTE and other in-hospital outcomes. RESULTS: Of 138 patients who had undergone imaging studies, 44 (31.9%) had evidence of VTE. On univariable analysis, an elevated admission CRP (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.01-1.09; P = .02; per 10-U increase in CRP), platelet count (OR, 1.48; 95% CI, 1.04-2.12; P = .03; per 1000-U increase in platelet count), and male sex (OR, 2.64; 95% CI, 1.19-5.84; P = .02), were associated with VTE. However only male sex remained significant on multivariable analysis (OR, 2.37; 95% CI, 1.01-5.56; P = .048). The independent predictors of death included older age (hazard ratio [HR], 1.04; 95% CI, 1.00-1.07; P = .04), active malignancy (HR, 4.39; 95% CI, 1.39-13.91; P = .01), elevated admission D-dimer (HR, 1.016; 95% CI, 1.003-1.029; P = .02), and evidence of disseminated intravascular coagulation (HR, 4.81; 95% CI, 1.76-13.10; P = .002). CONCLUSIONS: Male sex, elevated CRP, and elevated platelet count at admission were associated with VTE on univariable analysis. However, only male sex remained significant on multivariable analysis. Older age, active malignancy, disseminated intravascular coagulation, and elevated D-dimer at admission were independently associated with death for patients hospitalized with COVID-19.

Deep vein thrombosis protocol optimization to minimize healthcare worker exposure in coronavirus disease-2019.

OBJECTIVE: There are no societal ultrasound (US) guidelines detailing appropriate patient selection for deep vein thrombosis (DVT) imaging in patients with COVID-19, nor are there protocol recommendations aimed at decreasing exposure time for US technologists. We aimed to provide COVID-19-specific protocol optimization recommendations limiting US technologist exposure while optimizing patient selection. METHODS: A novel two-pronged algorithm was implemented to limit the DVT US studies on patients with COVID-19 prospectively, which included direct physician communication with the care team and a COVID-19-specific imaging protocol was instated to reduce US technologist exposure. To assess the pretest risk of DVT, the sensitivity and specificity of serum d-dimer in 500-unit increments from 500 to 8000 ng/mL and a receiver operating characteristic curve to assess performance of serum d-dimer in predicting DVT was generated. Rates of DVT, pulmonary embolism, and scan times were compared using t-test and Fisher's exact test (before and after implementation of the protocol). RESULTS: Direct physician communication resulted in cancellation or deferral of 72% of requested examinations in COVID-19-positive patients. A serum d-dimer of >4000 ng/mL yielded a sensitivity of 80% and a specificity of 70% (95% confidence interval, 0.54-0.86) for venous thromboembolism. Using the COVID-19-specific protocol, there was a significant (50%) decrease in the scan time (P < .0001) in comparison with the conventional protocol. CONCLUSIONS: A direct physician communication policy between imaging physician and referring physician resulted in deferral or cancellation of a majority of requested DVT US examinations. An abbreviated COVID-19-specific imaging protocol significantly decreased exposure time to the US technologist.

Blood type and outcomes in patients with COVID-19.

This study aimed to determine if there is an association between ABO blood type and severity of COVID-19 defined by intubation or death as well as ascertain if there is variability in testing positive for COVID-19 between blood types. In a multi-institutional study, all adult patients who tested positive for COVID-19 across five hospitals were identified and included from March 6th to April 16th, 2020. Hospitalization, intubation, and death were evaluated for association with blood type. Univariate analysis was conducted using standard techniques and logistic regression was used to determine the independent effect of blood type on intubation and/or death and positive testing. During the study period, there were 7648 patients who received COVID-19 testing throughout the institutions. Of these, 1289 tested positive with a known blood type. A total of 484 (37.5%) were admitted to hospital, 123 (9.5%) were admitted to the ICU, 108 (8.4%) were intubated, 3 (0.2%) required ECMO, and 89 (6.9%) died. Of the 1289 patients who tested positive, 440 (34.2%) were blood type A, 201 (15.6%) were blood type B, 61 (4.7%) were blood type AB, and 587 (45.5%) were blood type O. On univariate analysis, there was no association between blood type and any of the peak inflammatory markers (peak WBC, p = 0.25; peak LDH, p = 0.40; peak ESR, p = 0.16; peak CRP, p = 0.14) nor between blood type and any of the clinical outcomes of severity (admission p = 0.20, ICU admission p = 0.94, intubation p = 0.93, proning while intubated p = 0.58, ECMO p = 0.09, and death p = 0.49). After multivariable analysis, blood type was not independently associated with risk of intubation or death (referent blood type A; blood type B: AOR: 0.72, 95% CI: 0.42-1.26, blood type AB: AOR: 0.78, CI: 0.33-1.87, blood type O: AOR: 0.77, CI: 0.51-1.16), rhesus factor positive (Rh+): AOR: 1.03, CI: 0.93-1.86. Blood type A had no correlation with positive testing (AOR: 1.00, CI: 0.88-1.13), blood type B was associated with higher odds of testing positive for disease (AOR: 1.28, CI: 1.08-1.52), AB was also associated with higher odds of testing positive (AOR: 1.37, CI: 1.02-1.83), and O was associated with a lower risk of testing positive (AOR: 0.84, CI: 0.75-0.95). Rh+ status was associated with higher odds of testing positive (AOR: 1.23, CI: 1.003-1.50). Blood type was not associated with risk of intubation or death in patients with COVID-19. Patients with blood types B and AB who received a test were more likely to test positive and blood type O was less likely to test positive. Rh+ patients were more likely to test positive.

Early vascular surgery response to the COVID-19 pandemic: Results of a nationwide survey.

OBJECTIVE: The COVID-19 pandemic has had major implications for the United States health care system. This survey study sought to identify practice changes, to understand current personal protective equipment (PPE) use, and to determine how caring for patients with COVID-19 differs for vascular surgeons practicing in states with high COVID-19 case numbers vs in states with low case numbers. METHODS: A 14-question online survey regarding the effect of the COVID-19 pandemic on vascular surgeons' current practice was sent to 365 vascular surgeons across the country through REDCap from April 14 to April 21, 2020, with responses closed on April 23, 2020. The survey response was analyzed with descriptive statistics. Further analyses were performed to evaluate whether responses from states with the highest number of COVID-19 cases (New York, New Jersey, Massachusetts, Pennsylvania, and California) differed from those with lower case numbers (all other states). RESULTS: A total of 121 vascular surgeons responded (30.6%) to the survey. All high-volume states were represented. The majority of vascular surgeons are reusing PPE. The majority of respondents worked in an academic setting (81.5%) and were performing only urgent and emergent cases (80.5%) during preparation for the surge. This did not differ between states with high and low COVID-19 case volumes (P = .285). States with high case volume were less likely to perform a lower extremity intervention for critical limb ischemia (60.8% vs 77.5%; P = .046), but otherwise case types did not differ. Most attending vascular surgeons worked with residents (90.8%) and limited their exposure to procedures on suspected or confirmed COVID-19 cases (56.0%). Thirty-eight percent of attending vascular surgeons have been redeployed within the hospital to a vascular access service or other service outside of vascular surgery. This was more frequent in states with high case volume compared with low case volume (P = .039). The majority of vascular surgeons are reusing PPE (71.4%) and N95 masks (86.4%), and 21% of vascular surgeons think that they do not have adequate PPE to perform their clinical duties. CONCLUSIONS: The initial response to the COVID-19 pandemic has resulted in reduced elective cases, with primarily only urgent and emergent cases being performed. A minority of vascular surgeons have been redeployed outside of their specialty; however, this is more common among states with high case numbers. Adequate PPE remains an issue for almost a quarter of vascular surgeons who responded to this survey.