A longitudinal course pilot to improve surgical resident acquisition of quality improvement skills.

PROBLEM: Despite mounting evidence that incorporation of QI curricula into surgical trainee education improves morbidity and outcomes, surgery training programs lack standardized QI curricula and tools to measure QI knowledge. In the current study, we developed, implemented, and evaluated a quality improvement curriculum for surgical residents. INTERVENTION: Surgical trainees participated in a longitudinal, year-long (2019-2020) curriculum based on the Institute for Healthcare Improvement's online program. Online curriculum was supplemented with in person didactics and small group projects. Acquisition of skills was assessed pre- and post- course via self-report on a Likert scale as well as the Quality Improvement Knowledge Application Tool (QIKAT). Self-efficacy scores were assessed using the General Self-Efficacy Scale. 9 out of 18 total course participants completed the post course survey. This first course cohort was analyzed as a pilot for future work. CONTEXT: The project was developed and deployed among surgical residents during their research/lab year. Teams of surgical residents were partnered with a faculty project mentor, as well as non-physician teammates for project work. IMPACT: Participation in the QI course significantly increased skills related to studying the process (p = 0.0463), making changes in a system (p = 0.0167), identifying whether a change leads to an improvement (p = 0.0039), using small cycles of change (p = 0.0000), identifying best practices and comparing them to local practices (p = 0.0020), using PDSA model as a systematic framework for trial and learning (p = 0.0004), identifying how data is linked to specific processes (p = 0.0488), and building the next improvement cycle upon success or failure (p = 0.0316). There was also a significant improvement in aim (p = 0.037) and change (p = 0.029) responses to one QIKAT vignette. LESSONS LEARNED: We describe the effectiveness of a pilot longitudinal, multi component QI course based on the IHI online curriculum in improving surgical trainee knowledge and use of key QI skills.

Strategy for the Practice of Spine Oncological Surgery During the Covid-19 Pandemic.

STUDY DESIGN: Case series. OBJECTIVE: For each of the most frequent clinical scenarios, the authors reached a consensus on how should be timing and indications be optimized to reduce risk while maintaining the expected outcomes under the Covid-19 pandemics. SUMMARY OF BACKGROUND DATA: The organization of health care has been changed by the Covid-19 pandemic with a direct impact on Spine Oncology Surgery. Emergency surgery is still a priority, but in case of spinal tumors it should be better defined which conditions require emergency treatment. METHODS: An expert panel with general spine surgeons, oncological spine surgeons, and radiation oncologists was formed to analyze the most frequent scenarios in spinal musculoskeletal oncology during Covid-19 pandemics. RESULTS: Spine metastases can be found incidentally during follow-up or can clinically occur by increasing pain, pathologic fracture, and/or neurological symptoms. Primary spine tumors are much more rare and very rarely present with acute onset. The first step is to suspect this rare condition, to avoid to treat a primary tumor as it were a metastasis. Most complex surgery, like en bloc resection, associated with high morbidity and mortality rate for the treatment of low grade malignancy like chordoma or chondrosarcomas, if intensive care unit availability is reduced, can be best delayed some weeks, as not impacting on prognosis, due to the slow growth rate of these conditions. The currently accepted protocols for Ewing sarcoma (ES) and osteogenic sarcoma must be performed for local and systemic disease control. For ES, after the first courses of chemotherapy, radiotherapy can be selected instead of surgery, during Covid-19, to the end of the full course of chemotherapy. In immunocompromised patients, (treated by chemotherapy), it is necessary to avoid contact with affected or exposed people. CONCLUSION: Even more than during normal times, a multidisciplinary approach is mandatory to share the decision to modify a treatment strategy. LEVEL OF EVIDENCE: 5.

Pearls and Pitfalls of the Virtual Interview: Perspectives From Both Sides of the Camera.

As the SARS-COV-2 pandemic created the need for social distancing and the implementation of nonessential travel bans, residency and fellowship programs have moved toward a web-based virtual process for applicant interviews. As part of the Society of Asian Academic Surgeons 5th Annual Meeting, an expert panel was convened to provide guidance for prospective applicants who are new to the process. This article provides perspectives from applicants who have successfully navigated the surgical subspecialty fellowship process, as well as program leadership who have held virtual interviews.

Strategies for the delay of surgery in the management of resectable hepatobiliary malignancies during the COVID-19 pandemic.

Objective: We aimed to review data about delaying strategies for the management of hepatobiliary cancers requiring surgery during the covid-19 pandemic. Background: Given the covid-19 pandemic, many jurisdictions, to spare resources, have limited access to operating rooms for elective surgical activity, including cancer, thus forcing deferral or cancellation of cancer surgeries. Surgery for hepatobiliary cancer is high-risk and particularly resource-intensive. Surgeons must critically appraise which patients will benefit most from surgery and which ones have other therapeutic options to delay surgery. Little guidance is currently available about potential delaying strategies for hepatobiliary cancers when surgery is not possible. Methods: An international multidisciplinary panel reviewed the available literature to summarize data relating to standard-of-care surgical management and possible mitigating strategies to be used as a bridge to surgery for colorectal liver metastases, hepatocellular carcinoma, gallbladder cancer, intrahepatic cholangiocarcinoma, and hilar cholangiocarcinoma. Results: Outcomes of surgery during the covid-19 pandemic are reviewed. Resource requirements are summarized, including logistics and adverse effects profiles for hepatectomy and delaying strategies using systemic, percutaneous and radiation ablative, and liver embolic therapies. For each cancer type, the long-term oncologic outcomes of hepatectomy and the clinical tools that can be used to prognosticate for individual patients are detailed. Conclusions: There are a variety of delaying strategies to consider if availability of operating rooms decreases. This review summarizes available data to provide guidance about possible delaying strategies depending on patient, resource, institution, and systems factors. Multidisciplinary team discussions should be leveraged to consider patient- and tumour-specific information for each individual case.

Vascular Surgery Practice Guidelines during COVID-19 Pandemic in a Setting of High Work Volume Against Limited Resources: Perspective of a Developing Country.

BACKGROUND: The situation of coronavirus disease 2019 (COVID-19) pandemic in the Indian subcontinent is worsening. In Bangladesh, rate of new infection has been on the rise despite limited testing facility. Constraint of resources in the health care sector makes the fight against COVID-19 more challenging for a developing country like Bangladesh. Vascular surgeons find themselves in a precarious situation while delivering professional services during this crisis. With the limited number of dedicated vascular surgeons in Bangladesh, it is important to safeguard these professionals without compromising emergency vascular care services in the long term. To this end, we at the National Institute of Cardiovascular Diseases and Hospital, Dhaka, have developed a working guideline for our vascular surgeons to follow during the COVID-19 pandemic. The guideline takes into account high vascular work volume against limited resources in the country. METHODS: A total of 307 emergency vascular patients were dealt with in the first 4 COVID-19 months (March through June 2020) according to the working guideline, and the results were compared with the 4 pre-COVID-19 months. Vascular trauma, dialysis access complications, and chronic limb-threatening ischemia formed the main bulk of the patient population. Vascular health care workers were regularly screened for COVID-19 infection. RESULTS: There was a 38% decrease in the number of patients in the COVID-19 period. Treatment outcome in COVID-19 months were comparable with that in the pre-COVID-19 months except that limb loss in the chronic limb-threatening ischemia patients was higher. COVID-19 infection among the vascular health care professionals was low. CONCLUSIONS: Vascular surgery practice guidelines customized for the high work volume and limited resources of the National Institute of Cardiovascular Diseases and Hospital, Dhaka were effective in delivering emergency care during COVID-19 pandemic, ensuring safety of the caregivers. Despite the fact that similar guidelines exist in different parts of the world, we believe that the present one is still relevant on the premises of a deepening COVID-19 crisis in a developing country like Bangladesh.

Modelling the backlog of COVID-19 cases for a surgical group.

Summary: The coronavirus disease 2019 (COVID-19) pandemic has had an unprecedented impact on health care delivery and has resulted in a backlog of patients needing surgery. There is a lack of experience and guidance in dealing with this increased demand on an already overburdened health care system. We created an online tool (www.covidbacklog.com) that helps surgeons explore how resource allocation within their group will affect wait times for patients. After inputting a handful of readily available variables, the computer program generates a forecast of how long it will take to see the backlog of patients. This information could be used to allow surgical groups to run simulations to explore different resource allocation strategies in order to help prevent downstream consequences of delayed patient care.

Alternatives for establishing a surgical airway during the COVID-19 pandemic. / Alternativas para o estabelecimento de via aérea cirúrgica durante a pandemia de COVID-19.

Currently doctors and health professionals are facing a challenging pandemic caused by a new strain called 2019 Novel Coronavirus (COVID-19). Human infection with COVID-19 does not yet have the clinical spectrum fully described, and the pattern of lethality, mortality, infectivity and transmissibility is not known with precision. There is no specific vaccine or medication available. Treatment is supportive and nonspecific. In Brazil, as in the rest of the world, the number of COVID-19 cases has grown alarmingly, leading to an increase in the number of hospitalizations as well as in mortality from the disease. Currently, the states with the highest number of cases are, respectively, São Paulo, Rio de Janeiro, Distrito Federal and Ceará. The objective of this work is to offer alternatives in order to guide surgeons regarding the surgical management of the airways in patients with suspicion and / or confirmation for COVID-19 infection.

Atualmente médicos e profissionais da saúde encontram-se frente a uma pandemia desafiadora causada por uma nova cepa denominada 2019 Novel Coronavírus (COVID-19). A infecção humana pelo COVID-19 ainda não tem o espectro clínico completamente descrito, bem como não se sabe com precisão o padrão de letalidade, mortalidade, infectividade e transmissibilidade. Não há vacina ou medicamento específico disponível. O tratamento é de suporte e inespecífico. No Brasil, assim como no restante do mundo o número de casos de COVID-19 tem crescido de maneira alarmante levando a um aumento do número de internações assim como da mortalidade pela doença. Atualmente os estados com maior número de casos são, respectivamente, São Paulo, Rio de Janeiro, Distrito Federal e Ceará. O objetivo deste trabalho é oferecer alternativas a fim de orientar cirurgiões quanto ao manejo cirúrgico das vias aéreas em pacientes com suspeita e/ou confirmação para infecção pelo COVID-19.

The Boston Medical Center Coronavirus Disease 2019 (COVID-19) Procedure Team: Optimizing the surgeon's role in pandemic care at a safety-net hospital.

BACKGROUND: The coronavirus disease 2019 pandemic has claimed many lives and strained the US health care system. At Boston Medical Center, a regional safety-net hospital, the Department of Surgery created a dedicated coronavirus disease 2019 Procedure Team to ease the burden on other providers coping with the surge of infected patients. As restrictions on social distancing are lifted, health systems are bracing for additional surges in coronavirus disease 2019 cases. Our objective is to quantify the volume and types of procedures performed, review outcomes, and highlight lessons for other institutions that may need to establish similar teams. METHODS: Procedures were tracked prospectively along with patient demographics, immediate complications, and time from donning to doffing of the personal protective equipment. Retrospective chart review was conducted to obtain patient outcomes and delayed adverse events. We hypothesized that a dedicated surgeon-led team would perform invasive bedside procedures expeditiously and with few complications. RESULTS: From March 30, 2020 to April 30, 2020, there were 1,196 coronavirus disease 2019 admissions. The Procedure Team performed 272 procedures on 125 patients, including placement of 135 arterial catheters, 107 central venous catheters, 25 hemodialysis catheters, and 4 thoracostomy tubes. Specific to central venous access, the average procedural time was 47 minutes, and the rate of immediate complications was 1.5%, including 1 arterial cannulation and 1 pneumothorax. CONCLUSION: Procedural complication rate was less than rates reported in the literature. The team saved approximately 192 hours of work that could be redirected to other patient care needs. In times of crisis, redeployment of surgeons (who arguably have the most procedural experience) into procedural teams is a practical approach to optimize outcomes and preserve resources.

Recommendations of the Brazilian College of Surgeons for laparoscopic surgery during the COVID-19 pandemic. / Recomendações do Colégio Brasileiro de Cirurgiões para cirurgia videolaparoscópica durante a pandemia por COVID-19.

During the current COVID-19 pandemic, the surgical community faces the possible risk of infection of health care professionals involved in the surgical procedure. This leaves to concerns and questions referred to the most adequate surgical approach at this moment. With the objective of guiding surgeons, and based in many different protocols published until now, the Brazilian College of surgeons brings recommendations about this subject. The aim of this technical note is, trough a compilaton of publications and recommendations from Scientific Societies of Surgery worldwide, to provide guidelines regarding laparoscopic access during the COVID-19 pandemic.

Diante do quadro de pandemia da COVID-19, a comunidade cirúrgica enfrenta o possível risco de contágio de profissionais envolvidos no ato operatório; gerando preocupações e dúvidas referentes a escolha da via de acesso mais adequada nesse momento. Com objetivo de orientar os cirurgiões, baseado em diversos protocolos publicados até o momento, o Colégio Brasileiro de Cirurgiões traz recomendações acerca deste assunto. O objetivo desta nota técnica é, através de uma compilação de publicações e recomendações de Sociedades Científicas de Cirurgia de todo mundo, trazer orientações relativas ao acesso laparoscópico durante a pandemia por COVID-19.

Ventilated Upper Airway Endoscopic Endonasal Procedure Mask: Surgical Safety in the COVID-19 Era.

BACKGROUND: COVID-19 poses a risk to the endoscopic skull base surgeon. Significant efforts to improving safety have been employed, including the use of personal protective equipment, preoperative COVID-19 testing, and recently the use of a modified surgical mask barrier. OBJECTIVE: To reduce the risks of pathogen transmission during endoscopic skull base surgery. METHODS: This study was exempt from Institutional Review Board approval. Our study utilizes a 3-dimensional (3D)-printed mask with an anterior aperture fitted with a surgical glove with ports designed to allow for surgical instrumentation and side ports to accommodate suction ventilation and an endotracheal tube. As an alternative, a modified laparoscopic surgery trocar served as a port for instruments, and, on the contralateral side, rubber tubing was used over the endoscrub endosheath to create an airtight seal. Surgical freedom and aerosolization were tested in both modalities. RESULTS: The ventilated mask allowed for excellent surgical maneuverability and freedom. The trocar system was effective for posterior surgical procedures, allowing access to critical paramedian structures, and afforded a superior surgical seal, but was limited in terms of visualization and maneuverability during anterior approaches. Aerosolization was reduced using both the mask and nasal trocar. CONCLUSION: The ventilated upper airway endoscopic procedure mask allows for a sealed surgical barrier during endoscopic skull base surgery and may play a critical role in advancing skull base surgery in the COVID-19 era. The nasal trocar may be a useful alternative in instances where 3D printing is not available. Additional studies are needed to validate these preliminary findings.