Developing a Strategy for the Improvement in Patient Experience in a Canadian Academic Department of Surgery.

Patient experience (PE) is recognized as a key component in the quality of health-care delivery. Public reporting of hospital, division, and physician-specific PE results has added to the momentum of adopting strategies to augment this metric of care. The Ottawa Hospital embarked on a journey to improve PE as a pillar of its quality improvement plan. This article demonstrates the efforts of a single surgery department from one large urban center to improve in-hospital PE in the rapidly changing environment of medicine and surgery. A multidisciplinary group within the department and a focus group of previous surgical inpatients were organized to address immediate challenges related to inpatient PE issues. We identified concrete strategies to optimize pain control, perceptions of patient respect and dignity, perceptions of surgeon availability, discharge medication understanding, and overall experience. Also, we identified a need in our department for timely patient feedback, improved communication styles in our staff and trainees, and an internal curriculum offering additional training for our staff and residents. We anticipate that the current results would be of significant interest to other departments wishing to optimize their PE profile as part of the ongoing quality improvement process at hospitals across North America.

Immediate versus delayed surgery in congenital choanal atresia: A systematic review.

OBJECTIVES: To evaluate immediate versus delayed surgical intervention on treatment outcomes in the management of congenital choanal atresia. METHODS: This study adhered to Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines in reporting a systematic review of the literature. OVID Medline, EMBASE and Pubmed databases were searched using relevant key terms. Inclusion and exclusion criteria were designed to capture studies examining immediate versus delayed primary surgery for congenital choanal atresia. Timing of surgery was classified as immediate or delayed based on median age of intervention stratified by type of obstruction. Primary outcomes were primary treatment failure, respiratory function and mortality rates. RESULTS: A total of 2765 abstracts were identified and screened by 2 independent reviewers. Of the 688 articles reviewed in full text, 23 articles met the study criteria and were subjected to quality assessment. The full study assessment and quality control measures yielded 23 studies (representing 362 patients) for pooled patient-level analysis in the systematic review. Primary treatment failures occurred in 24.8% of patients that underwent immediate surgery and 42.6% of patients that underwent delayed surgery for bilateral choanal atresia (p = 0.01). There were no differences in mortality rates (5.6% vs 4.2%; p = 1.00) or qualitative measures of respiratory function. There were no difference in treatment outcomes for patients with unilateral choanal atresia (p > 0.05). CONCLUSIONS: Through an analysis of pooled individual patient data, this systematic review of the literature demonstrated that there was significantly higher rates of treatment failure in patients that underwent delayed surgery for bilateral choanal atresia. Clinical trials and large prospective cohort studies investigating outcomes following immediate and delayed surgical intervention will provide further insight into treatment strategies.

High Risk Clinical Features for Acute Aortic Dissection: A Case-Control Study.

BACKGROUND: Acute aortic dissection (AAD) is a rare condition with a high mortality that is often missed. The objective of our study was to assess the diagnostic accuracy of clinical and laboratory findings for AAD, in confirmed cases of AAD and in a low-risk control group. METHODS: This was a historical matched case-control study: participants were adults > 18 years old presenting to two tertiary care emergency departments (EDs) or one regional cardiac referral center. Cases were patients with new ED or in-hospital diagnosis of nontraumatic AAD confirmed by computed tomography or echocardiography. Controls were patients with a triage diagnosis of truncal pain (<14 days) and an absence of a clear diagnosis on basic investigation. Cases and controls were matched in a 1:4 ratio by sex and age. A sample size of 165 cases and 660 controls was calculated based on 80% power and confidence interval of 95% to detect an odds ratio of greater than 2. RESULTS: Data were collected from 2002 to 2014 yielding 194 cases of AAD and 776 controls (mean ± SD age = 65 ± 14.1 years; 66.7% male). Absence of abrupt-onset pain (sensitivity = 95.9%, negative likelihood ratio = 0.07 [0.03-0.14]) can help rule out AAD. Presence of tearing/ripping pain (specificity = 99.7%, positive likelihood ratio [LR+] = 42.1 [9.9-177.5]), aortic aneurysm (specificity = 97.8%, LR+ = 6.35 [3.54-11.42]), hypotension (specificity = 98.7%, LR+ = 17.2 [8.8-33.6]), pulse deficit (specificity = 99.3, LR+ = 31.1 [11.2-86.6]), neurologic deficits (specificity = 96.9%, LR+ = 5.26 [2.9-9.3]), and a new murmur (specificity = 97.8%, LR+ = 9.4 [5.5-16.2]) can help rule in the diagnosis of AAD. CONCLUSIONS: Patients with one or more high-risk feature should be considered high risk, whereas patients with no high-risk and multiple low-risk features are at low risk for AAD.

Risk factors for postoperative complications in total thyroidectomy: A retrospective, risk-adjusted analysis from the National Surgical Quality Improvement Program.

Thyroid cancer incidence is increasing, and with it, an increase in total thyroidectomy. There are limited studies comparing outcomes in total thyroidectomy performed in the inpatient versus outpatient setting.The objective of this study was to perform a comparative analysis of risk factors and outcomes of postoperative morbidity and mortality in total thyroidectomy performed as an inpatient versus outpatient surgery.Retrospective cohort study of data from the 2005 to 2014 multi-institutional, risk-adjusted American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. A multivariate regression model with corresponding odds ratios and 95% confidence intervals was used to determine 30-day morbidity and mortality after total thyroidectomies, and also risk factors of postoperative outcomes.From 2005 to 2014, 40,025 total thyroidectomies were performed (48.5% inpatient, 51.5% outpatient). The 30-day complication rate for all total thyroidectomies was 7.74%. Multivariate logistic regression analysis was performed to control for potential confounding variables. Preoperative factors that affected complications rates for inpatient thyroidectomies included: age ≥70, non-Caucasian race, dependent functional status, history of congestive heart failure, smoking history, bleeding disorder, wound infection, and preoperative sepsis (P < 0.05). In addition, preoperative factors affecting complications in thyroidectomy performed as an outpatient surgery included malignant thyroid pathology (P  0.05).We identified a subset of preoperative conditions that affect risk of complications after total thyroidectomy. Recommendations for patient selection for outpatient total thyroidectomies should be modified to account for pre-existing conditions that increase the risk of postoperative morbidity.