Experiences of Health Care Professionals Working Extra Weekends to Reduce COVID-19-Related Surgical Backlog: Cross-sectional Study.

BACKGROUND: During the quiescent periods of the COVID-19 pandemic in 2020, we implemented a weekend-scheduled pediatric surgery program to reduce COVID-19-related backlogs. Over 100 staff members from anesthesiologists to nurses, surgeons, and administrative and supporting personnel signed up to work extra weekends as part of a novel weekend elective pediatric surgery program to reduce COVID-19-related backlog: Operating Room Ramp-Up After COVID-19 Lockdown Ends-Extra Lists (ORRACLE-Xtra). OBJECTIVE: In this study, we sought to evaluate staff perceptions and their level of satisfaction and experiences with working extra scheduled weekend elective surgical cases at the end of the 3-month pilot phase of ORRACLE-Xtra and identify key factors for participation. METHODS: Following the pilot of ORRACLE-Xtra, all perioperative staff who worked at least 1 weekend list were invited to complete an online survey that was developed and tested prior to distribution. The survey collected information on the impact of working weekends on well-being, overall satisfaction, and likelihood of and preferences for working future weekend lists. Logistic regression was used to estimate the association of well-being with satisfaction and willingness to work future weekend lists. RESULTS: A total of 82 out of 118 eligible staff responded to the survey for a response rate of 69%. Staff worked a median of 2 weekend lists (IQR 1-9). Of 82 staff members, 65 (79%) were satisfied or very satisfied with working the extra weekend elective lists, with surgeons and surgical trainees reporting the highest levels of satisfaction. Most respondents (72/82, 88%) would continue working weekend lists. A sense of accomplishment was associated with satisfaction with working on the weekend (odds ratio [OR] 19.97, 95% CI 1.79-222.63; P=.02) and willingness to participate in future weekend lists (OR 17.74, 95% CI 1.50-200.70; P=.02). Many (56/82, 68%) were willing to work weekend lists that included longer, more complex cases, which was associated with a sense of community (OR 0.12, 95% CI 0.02-0.63; P=.01). CONCLUSIONS: Staff participating in the first 3 months of the ORRACLE-Xtra program reported satisfaction with working weekends and a willingness to continue with the program, including doing longer, more complex cases. Institutions planning on implementing COVID-19 surgical backlog work may benefit from gathering key information from their staff.

A Canadian Weekend Elective Pediatric Surgery Program to Reduce the COVID-19-Related Backlog: Operating Room Ramp-Up After COVID-19 Lockdown Ends-Extra Lists (ORRACLE-Xtra) Implementation Study.

BACKGROUND: The COVID-19 pandemic caused by the SARS-COV-2 virus has resulted in unprecedented challenges for the health care system. A decrease of surgical services led to substantial backlogs for time-sensitive scheduled pediatric patients. We designed and implemented a novel pilot weekend surgical quality improvement project called Operating Room Ramp-Up After COVID Lockdown Ends-Extra Lists (ORRACLE-Xtra). OBJECTIVE: Our overall goals are to increase patient access to surgery (and reduce the wait list), improve operating room efficiencies, and optimize parent and staff experience. METHODS: Using the DMAIC (define, measure, analyze, improve, control) framework, we implemented ORRACLE-Xtra in a tertiary care academic pediatric hospital during a quiescent period of the COVID-19 pandemic. We defined process and outcome measures based on provincial targets of out-of-window cases. Parental and staff satisfaction was tracked by surveys. RESULTS: ORRACLE-Xtra led to 247 patients receiving surgery during the pilot period, resulting in a 5% decrease in the total number of patients on our wait list with Paediatric Canadian Access Targets for Surgery IV (147/247, 59.5%), with 38.1% (94/247) out-of-window of provincial targets. Most of the process and outcome measures were met or exceeded. Overall parental satisfaction was at 95.8% (110/121), with 79% (64/81) of staff reporting satisfaction with working weekends. CONCLUSIONS: Through the ORRACLE-Xtra pilot program, we have shown that hospitals impacted by COVID-19 can reduce the surgical backlog using innovative models of service delivery in a Canadian context. Sustained funding is critical to achieving more meaningful reductions in wait times for scheduled surgeries over the longer term and needs to be balanced with staff well-being.

Increasing Compliance With an Antibiotic Prophylaxis Guideline to Prevent Pediatric Surgical Site Infection: Before and After Study.

OBJECTIVES: To evaluate an intervention for improving antibiotic prophylaxis (AP) guideline compliance to prevent surgical site infections in children. BACKGROUND: Although appropriate AP reduces surgical site infection, and guidelines improve quality of care, changing practice is difficult. To facilitate behavioral change, various barriers need to be addressed. METHODS: A multidisciplinary task force at a pediatric hospital developed an evidence-based AP guideline. Subsequently, the guideline was posted in operating rooms and the online formulary, only recommended antibiotics were available in operating rooms, incoming trainees received orientation, antibiotic verification was included in time-out, computerized alerts were set for inappropriate postoperative prophylaxis, and surgeons received e-mails when guideline was not followed. AP indication and administration were documented for surgical procedures in July 2008 (preintervention), September 2011 (postintervention), and April-May 2013 (follow-up). Compliance was defined as complete--appropriate antibiotic, dose, timing, redosing, and duration when prophylaxis was indicated; partial--appropriate drug and timing when prophylaxis was indicated; and appropriate use--complete compliance when prophylaxis was indicated, no antibiotics when not indicated. Compliance at preintervention and follow-up was compared using χ(2) tests. RESULTS: AP was indicated in 43.9% (187/426) and 62.0% (124/200) of surgical procedures at preintervention and follow-up, respectively. There were significant improvements in appropriate antibiotic use (51.6%-67.0%; P < 0.001), complete (26.2%-53.2%; P < 0.001) and partial compliance (73.3%-88.7%, P = 0.001), correct dosage (77.5%-90.7%; P = 0.003), timing (83.3%-95.8%; P = 0.001), redosing (62.5%-95.8%, P = 0.003), and duration (47.1%-65.3%; P < 0.002). CONCLUSIONS: A multifaceted intervention improved compliance with a pediatric AP guideline.

Antibiotic Prophylaxis to Prevent Surgical Site Infections in Children: A Prospective Cohort Study.

OBJECTIVE: To investigate the association between antibiotic prophylaxis (AP) and surgical-site infection in pediatric patients. BACKGROUND: Surgical-site infections (SSIs) are a major cause of postoperative morbidity and mortality. Despite numerous studies in adults, benefit of AP in preventing SSIs in children is uncertain. METHODS: Patients aged 0 to 21 years who underwent surgical procedures at a pediatric acute care hospital from April 1, 2009, to December 31, 2010, were assessed. Antibiotic prophylaxis indication and administration according to an evidence-based guideline were recorded. Complete compliance was defined as AP given, when indicated, within 60 minutes before incision. Surgical-site infections were identified using the Centers for Disease Control and Prevention criteria and documented in the medical records using the International Classification of Diseases, Tenth Revision. Multiple logistic regressions adjusting for age, sex, American Society of Anesthesiologists status, wound classification, admission status, surgical discipline, and surgical duration evaluated association of AP compliance and SSI. RESULTS: Of 5309 patients for whom antibiotics were indicated, 3901 (73.5%) with complete compliance had an infection rate of 3.0%, whereas 1408 (26.5%) who were not compliant had an infection rate of 4.3% (adjusted relative risk: 0.7; 95% confidence interval: 0.5-0.9; P = 0.02). Of 4156 patients for whom antibiotics were not indicated, the 895 (21.5%) who received antibiotics had an infection rate of 1.7% compared with 0.7% in the 3261 (78.5%) who did not receive antibiotics (adjusted relative risk: 1.6; 95% confidence interval: 0.8-3.1; P = 0.18). CONCLUSIONS: In pediatric surgery, complete compliance with AP was associated with 30% decreased risk of SSI.

The use of three strategies to improve quality of care at a national level.

BACKGROUND: Improving the quality of care is essential and a priority for patients, surgeons, and healthcare providers. Strategies to improve quality have been proposed at the national level either through accreditation standards or through national payment schemes; however, their effectiveness in improving quality is controversial. QUESTIONS/PURPOSES: The purpose of this review was to address three questions: (1) does pay-for-performance improve the quality of care; (2) do surgical safety checklists improve the quality of surgical care; and (3) do practice guidelines improve the quality of care? These three strategies were chosen because there has been some research assessing their effectiveness in improving quality, and implementation had been attempted on a large scale such as entire countries. METHODS: We performed a literature review from 1950 forward using Medline to identify Level I and II studies. We evaluated the three strategies and their effects on processes and outcomes of care. When possible, we examined strategy implementation, patients, and systems, including provider characteristics, which may affect the relationship between intervention and outcomes with a focus on factors that may have influenced effect size. RESULTS: Pay-for-performance improved the process and to a lesser extent the outcome of care. Surgical checklists reduced morbidity and mortality. Explicit practice guidelines influenced the process and to a lesser extent the outcome of care. Although not definitively showed, clinician involvement during development of intervention and outcomes, with explicit strategies for communication and implementation, appears to increase the likelihood of positive results. CONCLUSION: Although the cost-effectiveness of these three strategies is unknown, quality of care could be enhanced by implementing pay-for-performance, surgical safety checklists, and explicit practice guidelines. However, this review identified that the effectiveness of these strategies is highly context-specific.