Reducing waiting times of elective surgical procedures: effectiveness evaluation of a multi-interventions approach.

Background: Increasing waiting times for elective surgery is a major concern for policymakers and healthcare staff in many countries, due to its effect on health, patient satisfaction and the perceived quality of health-care. Many organizational models to reduce surgical waiting times have been studied, but the international literature indicates that multidimensional interventions on different aspects of the surgical pathway can be more effective in reducing waiting times than interventions focused on optimizing a single aspect. Aim: The aim of the study is to evaluate the effectiveness of a multidimensional intervention in reducing waiting times for elective surgery. Study design: We used a pre-post approach to evaluate the effect of a multidimensional project to reduce waiting times and lists. Methods: In a district general hospital (Italy) with three elective surgery operating rooms open 6 hours/day, 5 days/week (surgery specialties: general surgery, orthopaedics, gynaecology and urology), a project for reducing surgery waiting times was implemented in October 2018. The project focused on three aspects: i) separation of the flow of day surgery from that of ordinary surgery; ii) increasing available operating time by reorganizing the staff; iii) allocation of operating sessions flexibly in proportion to the waiting list. Waiting times for surgery in the periods 1/10/2019-31/12/2019 and 1/10/2018-31/12/2018 were compared by t test. Results: Waiting times for non-high-priority cases shortened significantly for all specialities (p<0.01), ex-cept for urology. For general surgery, orthopaedics and gynaecology, mean waiting times for day surgery decreased from 198 to 100 days (-50%) and for ordinary operations from 213 to 134 days (-37%). Waiting times for high-priority cases also shortened. Conclusions: Our multidimensional project based on reorganization of staff and facilities and on improved scheduling proved effective in reducing waiting times for elective surgery.

[Prognosis of stroke patients undergoing intubation and mechanical ventilation]. / Prognosi dei pazienti con ictus sottoposti ad intubazione e ventilazione meccanica.

BACKGROUND: To determine the outcome of patients with acute stroke requiring intubation and mechanical ventilation. DESIGN: review of the medical records of 33 patients with stroke intubated at presentation in hospital and not requiring neurosurgery or angiography. SETTING: intensive care unit (ICU) of a non teaching hospital. INTERVENTIONS: none. MEASUREMENTS: the mean age (SD) was 73.3 (7.7), min 46 max 87, 18 males and 15 females, mean Glasgow coma scale (GCS) (min-max) was 4.5 (3-8). RESULTS: The hospital mortality of intubated patients was 78.7% (26/33), mortality in the ICU was 69.69% (23/33). In survivors: infarction/hemorrhage (INF/HEM) were 4/3, mean age (SD) 75.2 (5.6), males/females 4/3, mean GCS (min-max) 5.2 (3-7), days in the ICU mean (DS) 18 (20.2). In patients who died: INF/HEM were 10/16, mean age (SD) 72.8 (8.2), males/females 14/12, mean GCS (min-max) 4.3 (3-8), days in the ICU mean (DS) 5.5 (8). The difference between groups was significant (p < 0.05) only for ICU staying. The evolution to brain death was observed in 10 cases (30.3%). CONCLUSIONS: The overall prognosis of patients with acute stroke intubated and ventilated at presentation in hospital for deterioration is severe but the observed survival rate is sufficient to justify this treatment even in cases not requiring other invasive procedures like neurosurgery or angiography. A significant fraction of stroke patients is part of the potential organ donors pull.

[Difference between arterial and end-tidal carbon dioxide tension during surgery of lumbar herniated disk in general anesthesia]. / Differenza fra tensione di anidride carbonica arteriosa e di fine espirazione durante intervento per ernia discale lombare in anestesia generale.

OBJECTIVE: To determine the correlation of PaCO2 and ETCO2 during operations for lumbar disk herniation in prone position: the influence of position and deliberate hypotension. DESIGN: Prospective, to compare PaCO2, ETCO2, pH, SBE, Pa max, in a group of 10 patients undergoing elective intervention for lumbar disk herniation in prone position and in a control group of 10 patients undergoing interventions for elective non traumatologic orthopaedic surgery of the lower limbs in supine position. SETTING: Orthopaedic department of a non teaching hospital. MEASUREMENTS AND MAIN RESULTS: The results for the patients of the supine group were: mean PaCO2 35.26 mmHg (SD 3.045), mean P(a-ET)CO2 3.46 mmHg (SD 1.898), mean pH 7.433 (SD 0.044), mean SBE - 1.16 (SD 1.718), mean Pa max 122.5 mmHg (SD 17.989). In the prone group: mean PaCO2 30.3 mmHg (SD 5.819), mean P(a-ET)CO2 1.4 mmHg (SD 4.445), mean pH 7.430 (SD 0.052), mean SBE-3.93 (SD 3.255), mean Pa max 100.3 (SD 10.945). The difference was significant (p < 0.05) for pH, PaCO2, SBE; in the prone group the variability of P(a-ET)CO2 was greater and the values related with SBE. CONCLUSIONS: ETCO2 is a useful monitoring for PaCO2 in the situation evaluated but the accuracy of the correlation with PaCO2 is lesser than during standard surgical techniques, the metabolic acidosis observed is probably related to the effects of the peculiar position and the anaesthetic technique.