Policy Implications for the COVID-19 Pandemic in Light of Most Patients (≥72%) Spending at Most One Night at the Hospital After Elective, Major Therapeutic Procedures.

A large number of inpatients with Coronavirus disease 2019 (COVID-19) in some regions of the United States may interfere with the ability of hospitals to take care of patients requiring treatment for other conditions. Nonetheless, many patients need surgery to improve their quality of life and to prevent deterioration in health. Curtailment of services also negatively affects the financial health of hospitals and health systems. Broad policies to prohibit all "elective" surgical procedures to ensure that there is sufficient hospital capacity for pandemic patients may be unnecessarily restrictive because, for many such procedures, patients are rarely admitted following surgery or only stay overnight. We studied all elective inpatient and ambulatory cases involving major therapeutic procedures performed in the state of Florida in 2018. We mapped the primary procedure to the corresponding Clinical Classification Software (CCS) category. We determined the distributions of lengths of stay overall and as stratified by CCS category, then calculated the percentage of cases that had a hospital length of stay of ≤1 night (i.e., 0 or 1 day). A threshold of one night was selected because patients discharged home on the day of surgery have no effect on the inpatient census, and those staying overnight would either have a transient effect or no effect if observed overnight in the postoperative care unit. Among the 1,852,391 elective cases with one or more major therapeutic procedures, 65.2% (95% lower confidence limit [LCL] = 65.1%) of cases had a length of stay of 0 days and 72.9% (95% LCL = 72.8%) had stay ≤1 day. There were 38 different CCS categories for which at least 95% of patients had a length of stay of ≤1 day. There were 28 CCS codes that identified 80% of the patients who were discharged with a length of stay ≤1 day, showing representation of multiple surgical specialties. Our results show that even in the face of constraints imposed by a high hospital census, many categories of major therapeutic elective procedures could be performed without necessarily compromising hospital capacity. Most patients will be discharged on the day of surgery. If overnight admission is required, there would be an option to care for them in the postanesthesia care unit, thus not affecting the census. Thus, policies can reasonably be based on allowing cases with a substantial probability of at most an overnight stay rather than a blanket ban on "elective" surgery or creating a carve-out for specified surgical subspecialties. Such policies would apply to at least 72% of elective, major therapeutic surgical procedures.

Obtaining and Modeling Variability in Travel Times From Off-Site Satellite Clinics to Hospitals and Surgery Centers for Surgeons and Proceduralists Seeing Office Patients in the Morning and Performing a To-Follow List of Cases in the Afternoon.

BACKGROUND: Hospitals achieve growth in surgical caseload primarily from the additive contribution of many surgeons with low caseloads. Such surgeons often see clinic patients in the morning then travel to a facility to do 1 or 2 scheduled afternoon cases. Uncertainty in travel time is a factor that might need to be considered when scheduling the cases of to-follow surgeons. However, this has not been studied. We evaluated variability in travel times within a city with high traffic density. METHODS: We used the Google Distance Matrix application programming interface to prospectively determine driving times incorporating current traffic conditions at 5-minute intervals between 9:00 AM and 4:55 PM during the first 4 months of 2018 between 4 pairs of clinics and hospitals in the University of Miami health system. Travel time distributions were modeled using lognormal and Burr distributions and compared using the absolute and signed differences for the median and the 0.9 quantile. Differences were evaluated using 2-sided, 1-group t tests and Wilcoxon signed-rank tests. We considered 5-minute signed differences between the distributions as managerially relevant. RESULTS: For the 80 studied combinations of origin-to-destination pairs (N = 4), day of week (N = 5), and the hour of departure between 10:00 AM and 1:55 PM (N = 4), the maximum difference between the median and 0.9 quantile travel time was 8.1 minutes. This contrasts with the previously published corresponding difference between the median and the 0.9 quantile of 74 minutes for case duration. Travel times were well fit by Burr and lognormal distributions (all 160 differences of medians and of 0.9 quantiles <5 minutes; P < .001). For each of the 4 origin-destination pairs, travel times at 12:00 PM were a reasonable approximation to travel times between the hours of 10:00 AM and 1:55 PM during all weekdays. CONCLUSIONS: During mid-day, when surgeons likely would travel between a clinic and an operating room facility, travel time variability is small compared to case duration prediction variability. Thus, afternoon operating room scheduling should not be restricted because of concern related to unpredictable travel times by surgeons. Providing operating room managers and surgeons with estimated travel times sufficient to allow for a timely arrival on 90% of days may facilitate the scheduling of additional afternoon cases especially at ambulatory facilities with substantial underutilized time.

Intranasal Medication Administration Using a Squeeze Bottle Atomizer Results in Overdosing if Deployed in Supine Patients.

BACKGROUND: Vasoconstrictors and local anesthetics are commonly administered using a squeeze bottle atomizer to the nasal mucosa to reduce edema, limit bleeding, and provide analgesia. Despite widespread use, there are few clinical guidelines that address technical details related to safe administration. The purpose of this study was to quantify, via simulation, the amount of liquid delivered to the nasal mucosa when patients are in the supine and upright positions and administration parameters that would reliably provide the desired amount of medication per spray. METHODS: A convenience sample of 10 anesthesia residents was studied. Providers were instructed to use a 25-mL dip and tube nasal squeeze bottle to administer the test solution (sterile water) to a mannequin in the upright (90° elevation) and supine (0° elevation) position. After mannequin testing, additional testing was completed with the spray bottles at 0°, 15°, 30°, 45°, and 90° to determine the relationship between the angles of administration and the amount of liquid dispensed. RESULTS: The mean volume delivered per spray was substantially greater when administered in the supine position (0.56 ± 0.22 mL) compared with the upright position (0.041 ± 0.02 mL, difference = 0.52 mL, 95% confidence interval [CI], 0.37-0.67 mL, P < .001). Converting the administered volume to the dose of phenylephrine that would be administered using our standard 0.25% solution, an estimated additional 1300 mcg is delivered per spray in the supine position compared with the upright position (95% CI, 925-1675 mcg, P < .001). Administration with a delivery angle of ≤30° resulted in significantly more volume than when the bottle was oriented at a 90° angle. The volume dispensed at 45° was not different from the volume delivered at 90° (0.032 ± 0.006 mL vs 0.030 ± 0.005 mL, P = .34). CONCLUSIONS: We found a 14-fold increase in the volume (ie, dose) delivered per spray when a nasal squeeze bottle was used with a mannequin in the supine position compared with the upright position. Given the reported toxicity from the use of intranasal medication and the inadvertent overdosing that occurs when squeeze bottle atomizers are used in clinical practice, our data suggest that all intranasal drugs should be administered with a precise, metered-dose device. If a metered-dose device is unavailable, the medication should be delivered at an angle of ≥45°; however, we recommend administering the drug with the patient in the sitting position and the bottle at 90° because only a small change in angle below 45° will result in a substantial increase in medication delivered.

Default Drug Doses in Anesthesia Information Management Systems.

BACKGROUND: In the United States, anesthesia information management systems (AIMS) are well established, especially within academic practices. Many hospitals are replacing their stand-alone AIMS during migration to an enterprise-wide electronic health record. This presents an opportunity to review choices made during the original implementation, based on actual usage. One area amenable to this informatics approach is the configuration in the AIMS of quick buttons for typical drug doses. The use of such short cuts, as opposed to manual typing of doses, simplifies and may improve the accuracy of drug documentation within the AIMS. We analyzed administration data from 3 different institutions, 2 of which had empirically configured default doses, and one in which defaults had not been set up. Our first hypothesis was that most (ie, >50%) of drugs would need at least one change to the existing defaults. Our second hypothesis was that for most (>50%) drugs, the 4 most common doses at the site lacking defaults would be included among the most common doses at the 2 sites with defaults. If true, this would suggest that having default doses did not affect the typical administration behavior of providers. METHODS: The frequency distribution of doses for all drugs was determined, and the 4 most common doses representing at least 5% of total administrations for each drug were identified. The appropriateness of the current defaults was determined by the number of changes (0-4) required to match actual usage at the 2 hospitals with defaults. At the institution without defaults, the most frequent doses for the 20 most commonly administered drugs were compared with the default doses at the other institutions. RESULTS: At the 2 institutions with defaults, 84.7% and 77.5% of drugs required at least 1 change in the default drug doses (P < 10 for both compared with 50%), confirming our first hypothesis. At the institution lacking the default drug doses, 100% of the 20 most commonly administered doses (representing ≥5% of use for that drug) were included in the most commonly administered doses at the other 2 institutions (P < 10), confirming our second hypothesis. CONCLUSIONS: We recommend that default drug doses should be analyzed when switching to a new AIMS because most drugs needed at least one change. Such analysis is also recommended periodically so that defaults continue to reflect current practice. The use of default dose buttons does not appear to modify the selection of drug doses in clinical practice.