Using Kotter's 8 steps of change to tackle over-fasting of children attending day surgery.

Over-fasting before surgery can lead to dehydration, irritability, lethargy, nausea, hypoglycemia, tricky intravenous cannulation, and decreased patient satisfaction (Newton et al., Pediatr Anesth, 2017, 27, 793). We used "Kotter's 8 steps for change" as an approach to tackling the problem of over-fasting in our day surgery unit (Kotter, Leading Change, Harvard Business School Press, 1996). Using a video of a patient's experience with overfasting, we created a sense of urgency and need for change (Step1: create urgency). We formed a multi-disciplinary fasting improvement team (FIT) (Step2: form a powerful coalition) and conducted a retrospective data analysis to establish a baseline. We then studied the system thoroughly using Ishikawa charts, process mapping, bench-marking, user surveys, and Pareto charts. Using these findings, we created a vision for our change (Step3: create a vision for change). Within 6 months, we aimed for 90% of patients to have a fluid fasting time of <2 h and for 90% of afternoon patients to have had breakfast. We communicated this vision to all staff involved in the day surgery (Step4: communicate the vision). Following this, we empowered them (Step5: empower action) by asking for their opinions for changes and let them take over various tasks without micromanagement. The Institute for Healthcare Improvement (IHI) Psychology of Change Framework described a focus on the human side of change, to increase the likelihood that improvement efforts will succeed by activating people's agency (Hilton & Anderson. IHI Psychology of Change Framework to Advance and Sustain Improvement, Institute for Healthcare Improvement, 2018). Our change ideas were divided into "short-term wins," "intermediate term goals," and "longer term goals." We focussed on creating short-term wins (Step6: create quick wins) and celebrated successes along the way to create initial momentum. We did this in parallel with working on longer term changes. We continued to work on cementing these new ideas (Step7: build on the changes), so that transformation in the day surgery would persist before using the same system to spread the change to the rest of the hospital (Step8: making it stick).

Surgical Approach for Hypoplastic Mirror Circumflex Aortic Arch.

Surgical approach for the mirror-form of circumflex aortic arch with a long-segment hypoplasia is described. Instead of "uncrossing" the arch, posterior aortic translocation of the aorta is required for the mirror-form. These surgical strategies addressed all the associated patho-mechanisms: (1) relief of vascular ring, (2) removal of posterior arch compression on the trachea, and (3) correction of any arch obstruction. Posterior tracheobronchopexy was further required to address severe underlying tracheobronchomalacia.