A snapshot of European neurosurgery December 2019 vs. March 2020: just before and during the Covid-19 pandemic.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 or Covid-19), which began as an epidemic in China and spread globally as a pandemic, has necessitated resource management to meet emergency needs of Covid-19 patients and other emergent cases. We have conducted a survey to analyze caseload and measures to adapt indications for a perception of crisis. METHODS: We constructed a questionnaire to survey a snapshot of neurosurgical activity, resources, and indications during 1 week with usual activity in December 2019 and 1 week during SARS-CoV-2 pandemic in March 2020. The questionnaire was sent to 34 neurosurgical departments in Europe; 25 departments returned responses within 5 days. RESULTS: We found unexpectedly large differences in resources and indications already before the pandemic. Differences were also large in how much practice and resources changed during the pandemic. Neurosurgical beds and neuro-intensive care beds were significantly decreased from December 2019 to March 2020. The utilization of resources decreased via less demand for care of brain injuries and subarachnoid hemorrhage, postponing surgery and changed surgical indications as a method of rationing resources. Twenty departments (80%) reduced activity extensively, and the same proportion stated that they were no longer able to provide care according to legitimate medical needs. CONCLUSION: Neurosurgical centers responded swiftly and effectively to a sudden decrease of neurosurgical capacity due to relocation of resources to pandemic care. The pandemic led to rationing of neurosurgical care in 80% of responding centers. We saw a relation between resources before the pandemic and ability to uphold neurosurgical services. The observation of extensive differences of available beds provided an opportunity to show how resources that had been restricted already under normal conditions translated to rationing of care that may not be acceptable to the public of seemingly affluent European countries.

Geospatial Mapping of Pediatric Surgical Capacity in North Kivu, Democratic Republic of Congo.

BACKGROUND: Despite recent attention to the provision of healthcare in low- and middle-income countries, improvements in access to surgical services have been disproportionately lagging. METHODS: This study analyzes the geographic variability in access to pediatric surgical services in the province of North Kivu, Democratic Republic of Congo (DRC). On-site data collection was conducted using the Global Assessment of Pediatric Surgery tool. Spatial distribution of providers was mapped using the Geographical Information System and open-sourced spatial data to determine distances traveled to access surgical care. RESULTS: Forty facilities were evaluated across 32 health zones; 68.9% of the provincial population was within 15 km of these facilities. Eleven facilities met a minimum World Health Organization safety score of 8; 48.1% of the population was within 15 km of corresponding facilities. The majority of children were treated by someone with specific pediatric surgery training in only 4 facilities; one facility had a trained pediatric anesthesia provider. Fifty-seven percent of the population was within 15 km of a facility with critical care and emergency medicine (EM) capabilities. There was one pediatric critical care provider and no pediatric EM providers identified within the province. Location-allocation assessment is needed to combine geographic area with potential for greatest impact and facility assessment. CONCLUSIONS: Limitations in access to surgical care in the DRC are multifactorial with poor resources, few formally trained surgical providers, and near-absent access to pediatric anesthesiologists. The study highlights the deficits in the capacity for surgical care while demonstrating a reproducible model for assessment and identification of ways to improve access to care.

Point prevalence survey of antibiotic use in 26 Saudi hospitals in 2016.

OBJECTIVE: To evaluate the antibiotic prescribing trends, qualitatively and quantitatively, among Saudi Ministry of Health (MOH) hospitals. METHOD AND MATERIALS: In May 2016, information about the hospitals and patients was collected for all inpatients from 26 MOH hospitals in Saudi Arabia. Additional information about antibiotic treatment and infections was gathered. Data collection was done using Global Point Prevalence Survey (PPS) tool designed by University of Antwerp, Belgium. RESULTS: A total of 3240 antibiotic doses were administrated to 2182 patients who represented 46.9% of the total eligible admitted patients. Of those patients on antibiotics, 510 (24%) patients were in the Intensive Care Unit (ICU), 646 (30.4%) patients were medically treated, and 972 (45.7%) patients were in surgical departments. The most commonly prescribed antibiotic group was third-generation cephalosporin (17.2%) and the most frequent indication was respiratory ract infectiont (n=597; 18.2%). Antibiotics for surgical prophylaxis represented 23.4% of the total antibiotic doses. Of those, 78% were administrated for more than 24hs. The rate of adherence to antibiotic guidelines was 48.1%. The indications for antibiotics were not documented in the patients' notes for 51.1% of the prescriptions. CONCLUSION: This national PPS provided a useful tool to identify targets for quality improvement in order to enhance the prudent use of antibiotics in hospital settings. This survey can provide a background to assess the quality of antibiotic utilisation after any intervention by administering it regularly.

Impact of distance from surgery department on the outcome of patients followed for non-small-cell lung cancer in the respiratory department of nonacademic hospitals: Results of the KBP-2010-study.

OBJECTIVE: Increased postoperative mortality in low volume centers has contributed to merge and space thoracic surgical centers. Some studies have showed that the likelihood of receiving surgery was lower in lung cancer patients living far from a thoracic surgery center. Our objective was thus to determine whether surgery and survival rates in patients with non-small-cell lung cancer (NSCLC) were influenced by the distance between the respiratory and thoracic surgery departments. METHODS: KBP-2010-CPHG is a prospective multicenter epidemiological study including 6083 patients followed in 104 nonacademic hospitals for primary NSCLC diagnosed in 2010. Distance between respiratory and thoracic surgery departments were obtained retrospectively. Predictive factors for surgery and mortality were identified by logistic regression and Cox hazard model. RESULTS: Twenty-three percent of hospitals had a thoracic surgery department; otherwise, mean distance between the hospital and the surgery center was 65km. Nineteen percent of patients underwent surgery. Distance was neither an independent factor for surgery (odds-ratios [95% CI]: 0.971 [0.74-1.274], 0.883 [0.662-1.178], and 1.015 [0.783-1.317] for 1-34, 35-79, and ≥80km vs. 0km) nor for mortality (hazard-ratios [95% CI]: 1.020 [0.935-1.111], 1.003 [0.915-1.099], and 1.006 [0.927-1.091]) (P>0.05). DISCUSSION: This result supports the French national strategy which merges surgery departments and should reassure patients (and physicians) who could be afraid to be lately addressed to surgery or loose chance when being followed far from the thoracic surgical center.

[Systemic Antimicrobials Consumption and Expenditures in Departments of Surgery of Multi-Profile Hospitals in the Russian Federation and the Republic of Belarus: Results of Multicentre Pharmacoepidemiological Study].

The results of the systemic antimicrobials (AM) consumption and expenditures assessment in the departments of surgery of multi-profile hospitals in different regions of the Russian Federation and the Republic of Belarus in 2009-2010 based on retrospective collection and analysis of the data from the hospital expenditure notes using ATC/DDD methodology are presented. The average AM consumption and expenditure rates in the above mentioned departments varied from 24.9 DDD/100 bed-days to 61.7 DDD/100 bed-days depending on the department profile, with beta-lactams (cephalosporins and penicillins) share in the consumption being as high as 70-90%, followed by fluoroquinolones and aminoglycosides. Only 55-70% of the consumed AM belonged to the drugs of choice, whereas the improper AM consumption and expenditure rates amounted up to 10-18%. The study outputs can be used for the budget allocation and AM distribution improvement in the departments of surgery, as well as for the development and efficacy control of the local antimicrobial stewardship programs.

A cross-sectional survey of essential surgical capacity in Somalia.

OBJECTIVE: To assess life-saving and disability-preventing surgical services (including emergency, trauma, obstetrics, anaesthesia) of health facilities in Somalia and to assist in the planning of strategies for strengthening surgical care systems. DESIGN: Cross-sectional survey. SETTING: Health facilities in all 3 administrative zones of Somalia; northwest Somalia (NWS), known as Somaliland; northeast Somalia (NES), known as Puntland; and south/central Somalia (SCS). PARTICIPANTS: 14 health facilities. MEASURES: The WHO Tool for Situational Analysis to Assess Emergency and Essential Surgical Care was employed to capture a health facility's capacity to deliver surgical and anaesthesia services by investigating four categories of data: infrastructure, human resources, interventions available and equipment. RESULTS: The 14 facilities surveyed in Somalia represent 10 of the 18 districts throughout the country. The facilities serve an average patient population of 331 250 people, and 12 of the 14 identify as hospitals. While major surgical procedures were provided at many facilities (caesarean section, laparotomy, appendicectomy, etc), only 22% had fully available oxygen access, 50% fully available electricity and less than 30% had any management guidelines for emergency and surgical care. Furthermore, only 36% were able to provide general anaesthesia inhalation due to lack of skills, supplies and equipment. Basic supplies for airway management and the prevention of infection transmission were severely lacking in most facilities. CONCLUSIONS: According to the results of the WHO Tool for Situational Analysis to Assess Emergency and Essential Surgical Care survey, there exist significant gaps in the capacity of emergency and essential surgical services in Somalia including inadequacies in essential equipment, service provision and infrastructure. The information provided by the WHO tool can serve as a basis for evidence-based decisions on country-level policy regarding the allocation of resources and provision of emergency and essential surgical services.

Does direct admission from an emergency department with on-site neurosurgical services facilitate time critical surgical intervention following a traumatic brain injury in children?

OBJECTIVES: To compare the proportion of trauma craniotomies performed within 4 hours of presentation to emergency departments (ED) with and without on-site neurosurgery. DESIGN: A retrospective cohort analysis of data collected prospectively between January 2005 and April 2010 from patients with traumatic brain injury who were admitted to the paediatric intensive care unit (PICU) following traumatic brain injury. METHODS: Times for admission to ED, PICU and theatre were obtained through analysis of prospectively collected data management systems. Emergency department admission to neurosurgical theatre lag time was calculated using Microsoft Excel. Statistical analysis was performed using R (version 2.11.0). Subjects. Fifty-seven cases were identified. Twenty patients were admitted directly from ED to an on-site neurosurgical unit. The remaining 37 were transferred from regional EDs. RESULTS: Thirty-one craniotomies were performed. Thirteen in-patients admitted directly to hospital with neurosurgery on site. Eighteen in patients admitted at the local hospital and then transferred to the neurosurgical unit. Thirteen of Thirty-one (42%) craniotomies were performed within 4 hours. In the on-site group 10 of 13 (77%) craniotomies were performed within 4 hours compared to 3 of 18 (17%) in those transferred from regional ED (p = 0.001232) (Fisher exact test). Eleven patients were transferred directly from ED to neurosurgical theatre for emergency craniotomies. Within this subgroup, seven patients came from the cohort of admissions to a hospital with on-site neurosurgery. The remaining four patients were transferred from regional ED. There were eight extradural haematomas, one subdural haematoma and two intraparenchymal haemorrhages. The mean time from ED presentation to theatre was 1.68 hours and 5.46 hours for the on-site and regional transfer groups, respectively. There were no mortalities. CONCLUSIONS: Forty-two per cent of trauma craniotomies are performed within 4 hours. However, presentation to an ED with on-site neurosurgical services significantly facilitates time critical surgery in children following a traumatic brain injury.

Cambio cultural en cirugía pediátrica: de la teoría a la práctica / Cultural change in pediatric surgery: from theory to practice

Introduccion: La implementación de cambios organizacionales en los servicios de cirugía pediátrica implica la necesidad de una transformación cultural de los cirujanos y de la organización hospitalaria. Luego del análisis situacional realizado en el año 2008 en nuestro servicio se implementó un cambio organizacional a través de una gestión por proceso con un enfoque sistémico. El objetivo de este trabajo es describir los resultados del cambio cultural realizado. Población y métodos: estudio retrospectivo tipo antes-después de los cambios realizados luego del año 2009. Para evaluar los resultados se compararon los trasplantes realizados a partir del cambio a un igual número de trasplantes previos. Se compararon en base a indicadores de productividad y performance. Los principios guías de las acciones de cambio fueron generar una visión compartida, crear un lenguaje en común, impulsar la participación, el compromiso y la creatividad, y medir los resultados. Resultados: se aumento la productividad, se mejoró la performance y se ampliaron los servicios ofrecidos al paciente. Conclusiones: el proceso de cambio instaurado implico la implementación de un sistema de aprendizaje continuo basado en la estrategia de Planificar/Hacer/Chequear y Actuar. Esta experiencia inicial ha demostrado una mejora en los indicadores de productividad y performance. Resta dilucidar la sustentabilidad de los cambios, su efecto en la satisfacción de los equipos tratantes y pacientes, así como la posibilidad de reproducir esta experiencia en servicios quirúrgicos pediátricos.

ntroduction: The implementation of organizational changes in departments of pediatric surgery warrant the need for culteral transformation of the surgeons and the hospital organization. After a situational assessment conducted in 2008, an organi-zational change was implemented in our department through a planned systemic change process. The aim of this study was to describe the results of the cultural change achieved. Population and methods: A retrospective before-and-after study of the changes introduced since 2009 was conducted. To evaluate the results, transplants performed since the in-troduction of the changes (case group:A) were compared to a similar number of transplants performed previously (control group:B). The groups were compared according to markers of productivity (n of trasplants/period) and performance (post-rasplant survival). Action guidelines were to create a shared vision and common language, to encourage participation, commitment, and creativity, and to measure results. Results: Productivity increased (A: 61 Tx in 23 months, B: 61 Tx in 28 months), performance improved (survival A: 83.5%. vs B: 78%), and services offered to the patients were enhanced. Conclusions: The established change process resulted in the implementation of a continuous learning system based on the strategy of Plan/Do/Check and Act (Deming circle). The initial experience has shown improved markers of productivity and performance. Future evaluation will elucidate sustainability of the changes, their effect on treating-team and patient satisfac-tion, as well as the possibility to reproduce the experience in pediatric surgery departments.

Improving patient care--the first year in a dedicated surgical assessment unit.

A surgical assessment unit (SAU) was established in October 2009 at the Mid-Western Regional Hospital. We assessed this servic in its initial year and compared it to Emergency Department (ED) services. We audited SAU and ED databases and theatre logbooks from November 2009 to October 2010. 1949 patients were referred to the SAU and 857 patients were admitted (44%). Only 44 SAU patients (6%) waited more than 6 hours for a bed compared to 828 patients (68%) admitted through the ED. SAU patients who required emergency surgery had a shorter waiting time before theatre (37 (18.6%) vs 9(6%) waited less than 6 hours, p < 0.05). To summarise, we found that almost 2,000 patients who would otherwise have presented to the ED were referred to the SAU. Waiting times for admission and theatre were significantly shorter. Further resource allocation could expand the service and improve it further, by diverting more patients from the ED.

Comprehensive national analysis of emergency and essential surgical capacity in Rwanda.

BACKGROUND: Disparities in the global availability of operating theatres, essential surgical equipment and surgically trained providers are profound. Although efforts are ongoing to increase surgical care and training, little is known about the surgical capacity in developing countries. The aim of this study was to create a baseline for surgical development planning at a national level. METHODS: A locally adapted World Health Organization survey was conducted in November 2010 to assess emergency and essential surgical capacity and volumes, with on-site interviews at 44 district and referral hospitals in Rwanda. Results were compiled for education and capacity development discussions with the Rwandan Ministry of Health and the Rwanda Surgical Society. RESULTS: Among 10·1 million people, there were 44 hospitals and 124 operating rooms (1·2 operating rooms per 100,000 persons). There was a total of 50 surgeons practising full- or part-time in Rwanda (0·49 total surgeons per 100,000 persons). The majority of consultant surgeons worked in the capital (covering 10 per cent of the population). Anaesthesia was performed primarily by anaesthesia technicians, and six of 44 hospitals had no trained anaesthesia provider. Continuous availability of electricity, running water and generators was lacking in eight hospitals, and 19 reported an absence or shortage in the availability of pulse oximetry. Equipment for life-saving surgical airway procedures, particularly in children, was lacking. A dedicated emergency area was available in only 19 hospitals. In 2009 and 2010 over 80,000 surgical procedures (major and minor) were recorded annually in Rwanda. CONCLUSION: A comprehensive countrywide assessment of surgical capacity in resource-limited settings found severe shortages in available resources. Immediate local feedback is a useful tool for creating a baseline of surgical capacity to inform country-specific surgical development.

Percutaneous coronary intervention without onsite cardiac surgery.

INTRODUCTION: Danish health authorities have major concerns with regard to the risk and the quality of care of percutaneous coronary intervention (PCI) without onsite cardiac surgery. We report the results of the first Danish PCI centre without onsite cardiac surgery. MATERIAL AND METHODS: A total of 245 patients underwent 254 elective PCIs during a six-month study period. The outcome measures were treatment latency, health care costs, mortality rate, major adverse cardiovascular events, symptom relief and quality-of-life at six-month follow-up. RESULTS: The median treatment latency was reduced from 28 to no days (p < 0.05) for patients with stable disease, and from seven to no days (p < 0.05) for patients with unstable disease. Health care costs were reduced by 4,246,652 DKK. The six-month mortality was 0.0% versus a predicted 0.4% New York State PCI-score in patients with stable disease, and a 1.4% observed study score versus a predicted 6.4% GRACE-score in patients with unstable disease. No patients required emergency bypass surgery. At six months, five myocardial infarctions (two periprocedural and two subacute stent thromboses), three restenoses and no in-stent restenosis had occurred, while angina was absent or reduced in 92% and quality-of-life had improved in 73% of the patients. CONCLUSION: Local PCI without onsite cardiac surgery was safe, quality of care was increased, health care costs were reduced and patient-perceived treatment effect was excellent.

How does degree of rurality impact the provision of surgical services at rural hospitals?

CONTEXT: Rural residents frequently have decreased access to surgical services. Consequences of this situation include increased travel time and financial costs for patients. There are also economic implications for hospitals as they may lose revenue when patients leave the area in order to obtain surgical services. Rural communities vary in size and distance from more populated centers. Since rural hospitals are located in varying types of rural communities, they likely differ with regard to the provision of surgical care. PURPOSE: To describe the differences between hospitals located in smaller versus larger rural areas regarding the provision of surgical care. METHODS: A 12-item survey instrument based on one previously used in a pilot study was mailed to a national random sample of rural hospital administrators (n = 233). Rural location was determined using rural-urban commuting area codes. FINDINGS: One hundred and eleven surveys were received, yielding a 48% response rate. Hospitals in larger rural areas had an average of 9 surgeons compared to 1 at hospitals in smaller rural areas. More administrators at hospitals located in larger rural areas viewed the ability to provide surgical care as very important to the financial viability of their hospital. CONCLUSIONS: Among rural hospitals located in communities of varying sizes there are significant differences in how surgical services are delivered and the financial importance of providing surgical care. Administrators at hospitals located in larger rural areas, more than in smaller ones, report financial reliance on their ability to offer surgical care and have significantly more resources available to do so.

Regional availability of high-volume hospitals for major surgery.

Despite evidence of increased risks, a large number of patients still have surgery in low-volume hospitals. To better understand why, we used Medicare data to study the regional availability of high-volume hospitals. More than half of patients undergoing three procedures in low-volume hospitals lived in regions lacking a high-volume hospital. Some regions simply lacked enough cases to support a high-volume hospital. Other regions had enough cases but too many hospitals performing them. Although consolidation of surgical services may be feasible in some settings, volume-based referral strategies are impractical for many U.S. regions.

Organización de un sistema de cirugía de corta hospitalizacion / Organization of one surgery system of short hospitalization

En el servicio de cirugía general del Hospital General Docente "Dr Agostinho Neto" se realizó un estudio del funcionamiento del sistema de atención por corta hospitalización, desde su puesta en práctica en abril de 1977 hasta julio del 2003, donde se expuso el organigrama de trabajo. Las edades con más afectados estuvieron entre la tercera y cuarta década de la vida. En cuanto a la morbilidad, en los 2 858 pacientes tratados por este método se comprobó un bajo índice de complicaciones (7,0 por ciento). El 85,0 por ciento de los pacientes fueron egresados antes de las 36 horas y se registró una buena aceptación del método(AU)

Gestión clínica de la lista de espera en un servicio de cirugía general / Management of the hospital waiting list in a general surgery department

Introducción. Presentamos nuestra experiencia en la gestión clínica de la lista de espera del Servicio de Cirugía General del Hospital de Viladecans (hospital público del Institut Català de la Salut).Objetivos. Diseño de una base de datos para la gestión clínica de la lista de espera del servicio de cirugía general, y evaluación de los resultados tras su diseño y aplicación.Material y método. Base de datos creada a tal fin, y que recoge todos los pacientes incluidos en lista de espera para intervención quirúrgica electiva durante un período de 5 años (desde el 1 de enero de 1996 al 31 de diciembre de 2000).Resultados. El número de intervenciones quirúrgicas electivas año tras año se ha mantenido por debajo de la demanda, creando un déficit que equivaldría a incrementar nuestra actividad en un 23,8 por ciento para adecuarla a la demanda. La lista de espera para la cirugía electiva ha estado condicionada a la presión de urgencias, que ha ido progresivamente en aumento. El criterio establecido de prioridad se ha demostrado útil, habiendo operado el 60,8 por ciento de los pacientes preferentes antes de 3 meses, y el 65,2 por ciento de los pacientes no preferentes entre 3 y 9 meses.Conclusiones. 1) Existe un progresivo incremento de la demanda de servicios quirúrgicos en nuestra área de influencia. 2) Se ha logrado una mejor gestión clínica, con un progresivo descenso en el número de anulaciones y un incremento en la actividad quirúrgica. 3) Se ha reducido el número de reprogramaciones de un 32 a un 14,3 por ciento. 4). Calculamos un déficit de recursos (horas de quirófano) que equivaldría a un 23,8 por ciento de nuestra actividad quirúrgica actual para poder adecuarnos a la demanda. 5) La base de datos diseñada por nosotros ha demostrado ser un instrumento útil de gestión de nuestra lista de espera (AU)

Evaluación del uso hospitalario según el aep (protocolo de evaluación de la adecuación) en un servicio de cirugía general / Evaluation of hospital utilization in a general surgery department according to the AEP (appropriateness evaluation protocol)

Introducción. La evaluación del uso hospitalario ha cobrado gran interés por su posible utilidad a la hora de reducir el gasto sanitario sin disminuir la calidad de la asistencia. Una de las aproximaciones más usadas cuando se revisa el uso hospitalario es el estudio retrospectivo de las historias clínicas con instrumentos objetivos como el protocolo de evaluación de la adecuación (AEP). Este trabajo trata de estudiar mediante dicho método la adecuación de los ingresos y días de estancia de los pacientes ingresados en un servicio de cirugía general durante un mes, así como las principales causas de inadecuación. Pacientes y métodos. Se calcularon dos muestras, una de ingresos y otra de estancias a estudiar, ambas para una precisión del 7 por ciento y un error alfa del 5 por ciento. La muestra de ingresos fue de 66 pacientes y la de estancias de 125. En ambas la selección se llevó a cabo de manera aleatoria. Resultados. Se estudiaron 66 ingresos, 29 programados y 37 urgentes. La adecuación de la admisión en los ingresos programados fue del 72,4 por ciento, mientras que la adecuación en la oportunidad del ingreso fue del 86,2 por ciento. El 97,3 por ciento de los ingresos urgentes fueron adecuados, siendo la principal causa de inadecuación que las pruebas se podrían haber realizado de manera ambulatoria. La estancia media del conjunto de pacientes estudiados fue de 7,9 días (DE = 5,8). El 50 por ciento de los pacientes tuvieron una estancia igual o inferior a 6 días. De las 125 estancias estudiadas, resultaron adecuadas 90 (72 por ciento) e inadecuadas 35 (28 por ciento). La causa más frecuente de inadecuación de la estancia fue que el paciente estuviera pendiente de resultados de pruebas diagnósticas o terapéuticas, seguida de la permanencia hospitalaria del paciente cuando éste ya no recibía o requería los servicios de un centro de agudos y de la inexistencia de un plan de diagnóstico y/o tratamiento. Conclusiones. El AEP (protocolo de la evaluación de la adecuación) es un sistema válido a la hora de valorar el uso hospitalario. De entre los resultados del estudio que hemos realizado destacan la mayor adecuación de ingresos urgentes respecto a los programados y la significación que existió entre la mayor inadecuación en la estancia prequirúrgica respecto a la posquirúrgica (AU)