Balancing Workload in the PACU by Using an Integrated OR Planning Methodology.

PURPOSE: The individual scheduling of the operating rooms (ORs) has a significant influence on postoperative care at hospital facilities. We studied the effect of incorporating postoperative departments in the decision process with regard to scheduling ORs and developed an integrated OR planning methodology that determines an optimal surgery sequence and postanesthesia care unit (PACU) nursing staff level, with the objective to level the variability in inflow of patients in the PACU. DESIGN: We developed an integrated OR planning methodology that investigates the sequencing of a surgical suite process with multiple ORs and postoperative hospital facilities. METHODS: This research was performed by representing a discrete-time two-stage flow shop problem. A retrospective study was performed in which the derived model was validated using discrete-event simulation. FINDINGS: Simulation results show that applying the integrated planning methodology decreased the variability in bed demand and smoothed the workload for the nursing staff in the PACU. Moreover, applying the algorithm led to a decrease in PACU completion time and a reduced amount of overtime hours for the surgical suite. Based on our results, we derived simple scheduling guidelines. CONCLUSIONS: Our simulation results confirmed the hypothesis that prospectively sequencing ORs' cases can effectively decrease the variability in bed demand and smoothen the workload for the staff personnel. Moreover, applying the algorithm leads to a decrease in PACU completion time and less overtime hours for the surgical suite. As such, an integrated OR planning methodology facilitates hospitals in improving OR efficiency.

Socio-economic status and COVID-19-related cases and fatalities.

OBJECTIVES: The United States has the highest number of coronavirus disease 2019 (COVID-19) in the world, with high variability in cases and mortality between communities. We aimed to quantify the associations between socio-economic status and COVID-19-related cases and mortality in the U.S. STUDY DESIGN: The study design includes nationwide COVID-19 data at the county level that were paired with the Distressed Communities Index (DCI) and its component metrics of socio-economic status. METHODS: Severely distressed communities were classified by DCI>75 for univariate analyses. Adjusted rate ratios were calculated for cases and fatalities per 100,000 persons using hierarchical linear mixed models. RESULTS: This cohort included 1,089,999 cases and 62,298 deaths in 3127 counties for a case fatality rate of 5.7%. Severely distressed counties had significantly fewer deaths from COVID-19 but higher number of deaths per 100,000 persons. In risk-adjusted analysis, the two socio-economic determinants of health with the strongest association with both higher cases per 100,000 persons and higher fatalities per 100,000 persons were the percentage of adults without a high school degree (cases: RR 1.10; fatalities: RR 1.08) and proportion of black residents (cases and fatalities: Relative risk(RR) 1.03). The percentage of the population aged older than 65 years was also highly predictive for fatalities per 100,000 persons (RR 1.07). CONCLUSION: Lower education levels and greater percentages of black residents are strongly associated with higher rates of both COVID-19 cases and fatalities. Socio-economic factors should be considered when implementing public health interventions to ameliorate the disparities in the impact of COVID-19 on distressed communities.

What do patients think about being copied into their GP letters?

INTRODUCTION: Sending patients a copy of the letters that are produced for their referring general practitioners (GPs) from an out-patient consultation is a policy of the UK Department of Health. Little research has been done to establish how patients attending out-patient departments feel about this practice and the effect this may have on the department itself. PATIENTS AND METHODS: We asked 500 patients attending our out-patient department to complete a questionnaire. Patients were only included if they had previously been offered a copy letter by our department. RESULTS: Of patients, 95% were in favour of the practice and 93.4% understood all or most of the contents of the letter. Dictation in front of the patients made them less likely to request a copy of the letter (P < 0.001). Impact of queries related to the letters was minimal with only three patients making contact with the department during the 3 months that the study was being conducted. CONCLUSIONS: Our experience has shown that copying patients into their GP letters is a useful and popular practice for patients and has little impact on the running of the department. Patients also are in favour of having their letter dictated in their presence and this reduces their need to have a copy sent to them.

Ponseti treatment in the management of clubfoot deformity - a continuing role for paediatric orthopaedic services in secondary care centres.

INTRODUCTION: The Ponseti technique is a well-proven way of managing paediatric clubfoot deformity. We describe a management set-up which spreads the care between secondary and tertiary care with no loss of quality. PATIENTS AND METHODS: In our audit of the first 2 years of Ponseti casting in the treatment of idiopathic congenital talipes equinovarus (CTEV, clubfoot) deformity, we identified 77 feet having been treated in 50 patients. Forty-nine feet were treated primarily in Oswestry, a tertiary referral centre for paediatric orthopaedic conditions, and 13 feet were treated in conjunction with the physiotherapy department at one of the region's district general hospitals (Leighton Hospital, Crewe, Cheshire). RESULTS: Similar good results and low requirement for surgical interventions other than Achilles tenotomy, which forms part of the Ponseti regimen, were found in both cohorts. CONCLUSIONS: This 'hub-and-spoke' approach would appear to be efficient in terms of resource utilisation. Additional benefits for patients and their carers include ease of access to services and reduced financial and transport burdens.

Le Fort I osteotomy and low-dose rate Ir192 brachytherapy for treatment of recurrent nasopharyngeal tumours.

BACKGROUND: Treatment of recurrent nasopharyngeal carcinoma is a difficult clinical problem. External beam re-irradiation is associated with a long-term cure in a proportion of cases but this may be associated with severe radiation injury. METHODS: Eighteen patients with post-nasal space tumours were treated between 1986 and 2001 with surgical excision and nasopharyngeal brachytherapy via a Le Fort I osteotomy approach. Low-dose rate (LDR) and high-dose rate (HDR) brachytherapy was used. Data was prospectively collected. Local control and overall survival were measured. Acute and late complications were assessed using the RTOG system. RESULTS: The overall survival was 67% at 2 years and 33.5% at 5 years. The corresponding local control rates were 42 and 31.5%, respectively. The T stage at relapse was a significant prognostic factor for local control (P=0.004) but not overall survival. Acute toxicity was mild. RTOG grade >/=3 late complications occurred in 40% of patients treated with the HDR, and 0% treated with LDR. CONCLUSIONS: The results of the Le Fort osteotomy, tumour debulking and post-operative brachytherapy gives local control rates similar to those achieved with wide-field re-irradiation. Complication rates are acceptable and are lower than that reported with other methods of radiation therapy. The surgical technique was well tolerated. HDR brachytherapy with this technique had a high complication rate. This approach is a viable option in the treatment of recurrent nasopharyngeal tumours.

Charting by exception: a solution to the challenge of the 1996 JCAHO's nutrition care standards.

With charting by exception, only significant findings or exceptions to the norms are documented in script by the nursing staff. Upon admission, patients are screened for nutrition risk or need for nutrition education by nursing staff using an interdisciplinary patient database. Patients with predetermined criteria indicating nutritional risk or with nutrition education needs are referred to nutrition services. Using specified criteria, the clinical nutrition staff assign referred patients to a level of care. Nutrition care or education is provided and documented within 48 hours. Documentation varies with the level of nutrition care.