Ileostomy or ileal pouch-anal anastomosis for ulcerative colitis: patient participation and decisional needs.

BACKGROUND: Up to 30% of patients with ulcerative colitis will undergo surgery resulting in an ileal pouch-anal anastomosis (IPAA) or permanent end ileostomy (EI). We aimed to understand how patients decide between these two options. METHODS: We performed semi-structured interviews with ulcerative colitis patients who underwent surgery. Areas of questioning included the degree to which patients participated in decision-making, challenges experienced, and suggestions for improving the decision-making process. We analyzed the data using a directed content and thematic approach. RESULTS: We interviewed 16 patients ranging in age from 28 to 68 years. Nine were male, 10 underwent IPAA, and 6 underwent EI. When it came to participation in decision-making, 11 patients felt independently responsible for decision-making, 3 shared decision-making with the surgeon, and 2 experienced surgeon-led decision-making. Themes regarding challenges during decision-making included lack of support from family, lack of time to discuss options with the surgeon, and the overwhelming complexity of the decision. Themes for ways to improve decision-making included the need for additional information, the desire for peer education, and earlier consultation with a surgeon. Only 3 patients were content with the information used to decide about surgery. CONCLUSIONS: Patients with ulcerative colitis who need surgery largely experience independence when deciding between IPAA and EI, but struggle with inadequate educational information and social support. Patients may benefit from early access to surgeons and peer guidance to enhance independence in decision-making. Preoperative educational materials describing surgical complications and postoperative lifestyle could improve decision-making and facilitate discussions with loved ones.

Impact of Language Discordance on Surgical Resident Workflow.

OBJECTIVE: To characterize the impact of language discordant patient encounters on resident workflow during morning rounds. DESIGN: The time required for a patient encounter was measured in a cohort of patients on an acute care and trauma service. Language concordance was recorded, and for language discordant encounters, a subset utilized a call-ahead strategy in order to facilitate obtaining a phone-based or video-based interpreter. SETTING: Acute care and trauma service in a Level 1 trauma center located in New York City. PARTICIPANTS: About 833 patient encounters were observed, with no patient identifiers recorded other than the data as noted above. RESULTS: Durations of English-speaking and language concordant encounters were 123.6 ± 89.6 seconds and 129.4 ± 95.8 seconds, respectively, which were not statistically different (p = 0.95). In comparison to the English-speaking group, both the unfacilitated language discordant patients (258.3 ± 189.7 seconds) and the facilitated language discordant patients (193.0 ± 91.1 seconds) were statistically different (p < 0.001). There was a statistical difference between these 2 groups of language discordant patients (p = 0.023). CONCLUSIONS: Language discordant encounters take twice as long as a language concordant encounter. A call-ahead strategy was able to reduce the time required for language discordant encounters. Further strategies to reduce time of encounter would benefit surgical workflow during morning rounds.

Evaluation of a Practice Improvement Protocol for Patient Transfer From the Emergency Department to the Surgical Intensive Care Unit After a Level I Trauma Activation.

BACKGROUND: ED boarding is a major issue in many hospitals. ED boarding occurs when there is insufficient hospital capacity to supply inpatient beds for admitted patients. ED boarding is not only a problem because of increased wait times for patients but also because it results in delays in administration of medication, higher rates of complications, and increased mortality. METHODS: In an attempt to improve patient flow and reduce time spent in the emergency department for patients requiring admission to the surgical intensive care unit (SICU), the emergency department, trauma service, and SICU collaborated on a guideline. The protocol developed focused on level I trauma-activated patients who were admitted directly from the emergency department to the SICU. We compared the transfer times before the protocol was initiated (January 1, 2016 to December 31, 2016) with the transfer times after initiation (January 1, 2017 to December 31, 2017) using a paired Students' t-test. Other outcome variables analyzed were hospital and intensive care unit (ICU) length of stay, mortality, complication rate, ventilator days, ventilator-free days, ICU-free days, and injury severity score (ISS). RESULTS: The average time to transfer for 2016 was 408.05 minutes (standard deviation 362.76) versus 142.73 minutes (standard deviation 101.90) for 2017. Emergency nurses saved 265.32 minutes per patient, totaling 8,755.56 minutes saved overall. Total amount of nursing hours saved was 146 hours. This was significant at P = 0.0015. No other variables analyzed were significant. CONCLUSION: We reduced the time to transfer from the emergency department to the SICU significantly by implementing a new protocol to expedite this transfer among level I trauma activations. Our protocol shows that a collaborative effort between the main emergency department and SICU can result in expedited care for injured and critically ill patients that not only increases care for the ill but also creates valuable space in a busy emergency department for better patient flow.

Challenges of citizen participation in regional health authorities.

Citizen participation has been included as part of health reform, often in the form of lay health authorities. In Canada, these authorities are variously known as regional health boards or councils. A set of challenges is associated with citizen participation in regional health authorities. These challenges relate to: differences in opinion about whether there should be citizen participation at all; differences in perception of the levels and processes of participation; differences in opinion with respect to the roles and responsibilities of health authority members; differences in opinion about the appropriate composition of the authorities; differences in opinion about the requisite skills and attributes of health authority members; having a good support base (staff, good information, board development); understanding and operationalizing various roles of the board (governance and policy setting) versus the board staff (management and administration); difficulties in ensuring the accountability of the health authorities; and measuring the results of the work and decisions of the health authorities. Despite these challenges, regional health authorities are gaining support as both theoretically sound and pragmatically based approaches to health-system reform. This review of the above challenges suggests that each of the concerns remains a significant threat to meaningful public participation.

Social and political factors influencing the functioning of regional health boards in British Columbia (Canada).

Health reform is associated with changes in the way the health system works and in the roles of major stakeholders, such as governments, health professionals, and the lay public. This paper reviews the immediate relevance of these social and political elements to health boards, particularly those with lay board members; source documents include peer-reviewed articles, and government documents and news releases in Canada especially. Also presented are the perceptions of 130 regional health board members in British Columbia (BC), Canada, who responded to our 1996 survey questionnaire. Two sets of social and political factors are identified and discussed in this paper. The first set deals with the composition of health board members (qualifications, representation, and selection). Our findings suggest that there is now less attention focusing on the composition of health boards in BC. This may contribute to a re-focusing of attention on the boards' effectiveness in working with stakeholders and in influencing the health system. The other set of social and political factors deals with the relations of health boards with key stakeholder groups. The responses to our questionnaire suggest that the health boards in BC may have had some success in addressing the concerns of various stakeholder groups. However, the respondents also suggested that the stakeholder groups needed to be more understanding and involved in the regionalization (decentralization) process. Health boards that have lay representatives, including regional health authorities in Canada, face similar social and political factors immediate to their operation.