Collateral damage of COVID-19 pandemic: The impact on a gynecologic surgery department.

OBJECTIVE: This study focuses on changes in gynecologic surgical activity at Hospital Foch, Paris, France during the first French COVID lockdown in 2020. Additional goals include the evaluation the extent of the postponement suffered for each type of surgery and estimate the possible negative impact for patients. STUDY DESIGN: Single-center, retrospective, chart-review cohort study in the gynecology department of Hospital Foch. Comparison of all patients scheduled, postponed and operated during the first COVID lockdown (March 14, to May 11, 2020) versus the same period in 2019. Postponed surgeries were classified into 4 scheduling interval categories according to the Society of Gynecology Oncology (SGO) recommendations: urgent (without delay), semi-urgent (1-4 weeks), non-urgent (>4-12 weeks) and elective (>3 months) and evaluated to determine whether COVID-19-related delays of surgeries fell within guidelines. The potential "loss of chance" or medical risk associated with postponed surgeries was estimated according to a composite criterion including death, aggravation of expected tumor stages/grades in cancers, increase in surgical complexity compared to that initially planned, need for preoperative transfusions, start of morphine consumption during preoperative treatment for opiate-naive patients, additional hospitalization or consultations in emergency room and delay in treatment when surgery was urgent. RESULTS: During the 2020 French COVID lockdown, 61 patients had a surgical procedure and 114 were postponed; in the comparator 2019 group, 232 patients underwent surgical procedures, indicating an overall decrease of 65% of activity. Analysis of differences between the two years revealed a reduction of 64% in emergency procedures, 90% of functional pathologies, and 13% of cancers. According to SGO guidelines, the only type of surgical procedures that had excessive delay was the semi-urgent group, where time to surgery was 6.7 weeks [range 5.4-10 weeks] instead of the recommended interval of 1-4 weeks. Among postponed surgeries there were 10 patients (8.7%) with a potential "loss of chance" according to the composite criteria, all included in the semi-urgent group. CONCLUSION: The COVID 19 pandemic was responsible for a significant decrease of activity in the surgical department of Hospital Foch. Difficulty of rescheduling surgeries was responsible for an increased delay in semi-urgent operations. In almost 9% of postponed surgeries, there was a potential "loss of chance", which likely represents only the tip of iceberg of collateral damages due to COVID 19 pandemic in this surgical unit. These data show the importance of continuing to treat pathologies requiring urgent or semi-urgent surgery during pandemics.

Examining patient trust towards physicians between clinical departments in a Chinese hospital.

The purpose of this cross-sectional survey study is to quantitatively examine the differences in patient trust towards physicians between four different clinical departments in a Chinese hospital. Using a validated modified Chinese version of the Wake Forest Physician Trust Scale, we measured patient trust in each department, and also collected data on patient demographics. A total of 436 patients or family members were surveyed in the departments of emergency medicine, pediatrics, cardiology, and orthopedic surgery. Significant differences were found between the departments, especially between pediatrics (trust score 43.23, range 11-50) and emergency medicine and cardiology (trust scores 45.29 and 45.79, respectively with range of 11-50). The average total score across all four departments was 44.72. There are indications that specifically comparing departments, such as patient demographics or department structure, could be helpful in tailoring patient care to improve physician-patient relationships.

The potential impact of enhanced hygienic measures during the COVID-19 outbreak on hospital-acquired infections: A pragmatic study in neurological units.

OBJECTIVE: Hospital-acquired infections (HAIs) are frequent complications among acute patients hospitalized in neurological units, especially among those hospitalized for stroke. This study aimed to investigate if enhanced hygienic measures, including the systematic use of personal protective equipment (PPE), determined a decrease in HAI during the recent COVID-19 outbreak in "COVID-free" neurological units. METHODS: Patients hospitalized in neurology and stroke units of Policlinico Umberto I Hospital in Rome from March 8, 2020 and discharged prior to May 31, 2020 were included in the study and compared with patients hospitalized during the same period in 2019. RESULTS: A total of 319 patients were included in the study (n = 103 in 2020, n = 216 in 2019). Among patients hospitalized in 2019, the incidence of HAIs was 31.5% (95% confidence interval (CI): 0.25-0.38), compared with 23.3% (95% CI: 0.15-0.32) in 2020 (p = 0.12). Multivariable logistic regression showed that hospitalization during 2020 was independently associated with a lower risk of HAIs (odds ratio: 0.34, 95% CI:0.16-0.71, p = 0.004). Poisson regression models showed that hospitalization during 2020 was also independently associated with both a lower number of HAIs (relative risk [RR]: 0.56, 95% CI:0.38-0.81, p = 0.01) and a lower number of prescribed antibiotics per patient (RR: 0.66, 95% CI: 0.49-0.87, p = 0.02). CONCLUSION: Our study design provides evidence regarding the impact of stricter hygienic measures, such as increased PPE use, on HAIs. Larger studies are needed to support the extension of preventive measures even after the COVID-19 outbreak in order to limit the occurrence of HAIs.

Documento de recomendaciones fundamentales para las unidades de Aparato Digestivo del siglo XXI / No disponible

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Changing trends in pediatric tonsil surgery.

OBJECTIVES: We analyzed trends in tonsil surgery over a 10-year period in a single tertiary care hospital and evaluated the effects of these changes on use of hospital services and healthcare costs. METHODS: This was a retrospective cohort study based on data from databases at the Department of Otorhinolaryngology, Helsinki University Hospital, Helsinki, Finland. Children under 16 years of age with tonsillectomy (TE) or tonsillotomy (TT) performed during 2007-2016 were included in the study. RESULTS: In 10 years, 4979 tonsil surgeries were performed on 4951 children: TE in 3170 (64%) and TT in 1781 (36%) children. The total number of tonsil surgeries stayed nearly constant. TT operations commenced in the study hospital in 2009 and from 2012 onwards have been more common than TE procedures. Altogether 279 patients visited the emergency department because of complications; TE patients had 9.0 visits/100 surgeries and TT patients 1.8 visits/100 surgeries. The most common complication was postoperative hemorrhage: 200 cases (6.3%) in the TE group and 11 cases (0.6%) in the TT group. During the two-year follow-up after tonsil surgery the total costs of healthcare services were significantly lower in the TT group than in the TE group. CONCLUSION: Considerable changes have occurred in tonsil surgery in children during the 10-year study period; TT is today performed more often than TE. As a consequence, complications, readmissions to hospital, and number of patients treated in the operating room because of postoperative hemorrhage have decreased, lowering the costs of healthcare.

Chairing the internal medicine department- analysis of current state and future trends in Israel.

BACKGROUND: Professional skills and academic records of the highest degree are essential requirements for the chairmanship of internal medicine departments. Whether the new generation and future successors of Israeli chairmen is endowed with these attributes is not known. PURPOSE: To determine whether there is a lack of future suitable successors for the current heads of internal medicine departments in Israel and to compare the demographic, academic and professional characteristics of the older and newer generations of department heads. METHODS: An online anonymous questionnaire was nationally distributed during 2016 to all active heads of internal medicine departments in Israel (n = 101). First round was followed by two runs of personal phone calls to promote participation. RESULTS: Sixty-seven (67%) of chairmen responded. The vast majority of current chairs of internal medicine departments are males (N = 59, 88%) over 50 years of age (N = 58, 86%) with established academic background with lecturer degree or higher (N = 57, 85%). Only 19 (28%) of current heads assigned a future successor. Comparison of chairmen who did and did not assigned successors demonstrated that assignment of successors was associated with higher academic status (P < 0.02) and longer chairmanship (p < 0.01) but not with mean age of current chairmen (p < 0.08). Nevertheless, most assignments (55%) were done by chairmen in the 61 to 67 years age group. As compared to current chairmen, the designated successors have lesser academic status (p < 0.01) and are characterized by a higher female prevalence (P < 0.03). CONCLUSIONS: Significant demographic, professional and academic differences exist between the current chairs of internal medicine departments in Israeli hospitals and their future successors. This underscores the need for reassessment of the availability and requirements of this crucial position.

Implementing Lean Management Techniques at a Radiation Oncology Department.

OBJECTIVES: Lean management (LM) principles were first developed by a Japanese manufacturing company to maximise value and minimise waste in the automotive industry. However, these principles can also be applied in the healthcare sector. This study aimed to illustrate the process of implementing LM principles in a radiation oncology department to streamline workflow and identify and reduce waste. METHODS: This study took place in the Department of Radiation Oncology, Royal Hospital, Muscat, Oman, in December 2016. A value stream map (VSM) was created for the chain of processes followed in the department. A waste analysis was conducted to determine which processes did not add value for the patient or healthcare provider. RESULTS: Based on the VSM analysis, only six out of 13 steps were found to be of value. Necessary and unnecessary non-value-adding activities were identified. Sources of waste included parking and registration. In addition, variabilities in workload were noted. CONCLUSION: Overall, LM principles improve workflow, reduce waste and enhance patient and staff satisfaction. In the current study, the application of LM principles helped to improve value in a radiation oncology department.

National variation in the composition of rheumatology multidisciplinary teams: a cross-sectional study.

The objective of this study is to describe the composition of multidisciplinary teams (MDT) working within rheumatology departments across the UK. All rheumatology departments in the United Kingdom (UK) were invited to participate in a national electronic survey between February 2014 and April 2015 as a part of a national audit for the management of rheumatoid and early inflammatory arthritis commissioned by Healthcare Quality Improvement Partnership. Rheumatology departments were asked to report their MDT composition; defined as a rheumatologist (consultant or specialist trainee), specialist nurse, occupational therapist physiotherapist, and podiatrist. The data were collected as Whole Time Equivalent (WTE) of each professional group at each department adjusted to 100,000 population. The data were grouped according to British Society for Rheumatology regions to study regional variations. The survey was completed by 164/167 departments (98% response rate). All departments reported an MDT comprising a rheumatologist (consultant or specialist trainee) and almost all included a specialist nurse but only 28 (17%) of the departments had MDTs comprising all the professional groups. There was a high degree of regional variation in the provision of Allied Health Professionals (physiotherapists, occupational therapists, and podiatrists) in the UK. MDT care is recommended for the management of inflammatory arthritis, but few UK rheumatology departments have a full complement of healthcare professionals within their MDT. There is a high degree of regional variation in the composition and staffing levels of the rheumatology MDT across the UK; the impact of which warrants further investigation.

The Department of Medicine in 2030: A Look Ahead.

The authors described the features of a hypothetical academic Department of Medicine in 2030 that would be most effective in improving the public health. Future departments of medicine will be compelled to respond to a projected shortage of physicians through augmented training strategies. The clinical programs will be more decentralized and responsive to patient preferences while demonstrating greater value. Departments will create adaptable, accountable structures in which clinicians working in interdisciplinary teams continuously improve processes and outcomes of care, and clinician and patient satisfaction. The restructuring of health care will afford exciting opportunities to align clinical and scholarly activities. The growing ability to link biological and clinical phenotypic information will lead to more effective and efficient clinical care. In view of the funding constraints and the remarkable opportunities for high-impact research, departmental research programs will become increasingly disciplined. Successful research programs will require durable investments in faculty career development, enabling infrastructure, interdisciplinary research teams, and diverse funding sources. The educational programs will demonstrate proficiency of trainees in the 6 current core competencies, as well as in additional areas critical to health care transformation. To improve organizational effectiveness, departments will create more nimble organizational structures led by individuals with diverse backgrounds. Chairs of departments of medicine will be expected to continuously expand their capacity to meet the evolving needs of their departments and institutions. Members of departments of medicine will be continuously fortified by the privilege and obligations of our profession while embracing the risks necessary to meet the extraordinary opportunities in 2030.

Patterns of Adverse Drug Reaction in the Medical Wards of a Teaching Hospital: A Prospective Observational Cohort Study.

INTRODUCTION: According to the World Health Organization (WHO) definition, an Adverse Drug Reaction (ADR) is a response to a drug that is noxious and unintended and occurs at doses normally used in humans for the prophylaxis, diagnosis, and treatment of disease. The risk factors of ADR are multi-factorial and include poly-pharmacy, age, gender, race, genetics and inter-current disease. PATIENTS AND METHODS: This was a hospital based, prospective, observational cohort study undertaken in a tertiary care hospital in south India to assess the different patterns of adverse drug reaction in medical wards over 6 months. The severity of ADR was assessed using Hartwig Siegel scale and causality by Naranjo and WHO UMC Scale. Preventability was assessed using Schumock and Thornton scale and other parameters such as incidence, onset, duration, management and outcome were also assessed. Risk factors were assessed by bi-variate logistic regression analysis and length of hospital stay by T test. RESULTS: The incidence of ADR was 10.42% in medicine wards. The causality of ADR done by Naranjo scale showed that most of the ADRs were probable (7.38%). Anti-tubercular agents were the leading cause of ADR. Duration of hospitalization was significantly longer (7.18 ± 2.64 vs. 5.06 ± 2.13 days) in patients with ADR (Odds ratio 1.38, 95% Confidence interval 1.26 to 1.51). 7.28% of ADRs were moderately severe. Seriousness criteria assessment showed that 0.33% were serious reactions. Most of the ADRs were definitely preventable. Most of the ADRs were managed by discontinuing the suspected drug. The present study showed female gender predominance over males for ADRs and no relationship with age. CONCLUSION: Adverse drug reactions impose significant burden on hospitals through prolonging patient stay and by increasing admission rates. The occurrence of ADR in this study was higher when compared to that reported in previous studies. This study highlights the importance of ADR reporting among ADR reporting among health care professionals in hospital.

[Independence in Plastic Surgery - Benefit or Barrier? Analysis of the Publication Performance in Academic Plastic Surgery Depending on Varying Organisational Structures]. / Vorteil durch Eigenständigkeit? Analyse der Publikationsleistung der universitären Plastischen Chirurgie in verschiedenen Organisationsstrukturen.

INTRODUCTION: Despite its recognition as an independent specialty, at German university hospitals the field of plastic surgery is still underrepresented in terms of independent departments with a dedicated research focus. The aim of this study was to analyse the publication performance within the German academic plastic surgery environment and to compare independent departments and dependent, subordinate organisational structures regarding their publication performance. MATERIAL AND METHODS: Organisational structures and number of attending doctors in German university hospitals were examined via a website analysis. A pubmed analysis was applied to assess the publication performance (number of publications, cumulative impact factor, impact factor/publication, number of publications/MD, number of publications/unit) between 2009 and 2013. In a journal analysis the distribution of the cumulative impact factor and number of publications in different journals as well as the development of the impact factor in the top journals were analysed. RESULTS: Out of all 35 university hospitals there exist 12 independent departments for plastic surgery and 8 subordinate organisational structures. In 15 university hospitals there were no designated plastic surgery units. The number of attending doctors differed considerably between independent departments (3.6 attending doctors/unit) and subordinate organisational structures (1.1 attending doctors/unit). The majority of publications (89.0%) and of the cumulative impact factor (91.2%) as well as most of the publications/MD (54 publications/year) and publications/unit (61 publications/year) were created within the independent departments. Only in departments top publications with an impact factor > 5 were published. In general a negative trend regarding the number of publications (- 13.4%) and cumulative impact factor (- 28.9%) was observed. 58.4% of all publications were distributed over the top 10 journals. Within the latter the majority of articles were published in English journals (60% of publications, 79.9% of the cumulative impact factor). The average impact factor of the top 10 journals increased by 13.5% from 2009 to 2013. CONCLUSION: In contrast to subordinate and dependent organisational structures, independent departments of plastic surgery are the key performers within German academic plastic surgery which, however, suffers from a general declining publication performance. Hence, the type of organisational structure has a crucial influence on the research performance.

Two decades (1993-2012) of adult intensive care unit design: a comparative study of the physical design features of the best practice examples.

In 2006, Critical Care Nursing Quarterly published a study of the physical design features of a set of best practice example adult intensive care units (ICUs). These adult ICUs were awarded between 1993 and 2003 by the Society of Critical Care Medicine (SCCM), the American Association of Critical-Care Nurses, and the American Institute of Architects/Academy of Architecture for Health for their efforts to promote the critical care unit environment through design. Since 2003, several more adult ICUs were awarded by the same organizations for similar efforts. This study includes these newer ICUs along with those of the previous study to cover a period of 2 decades from 1993 to 2012. Like the 2006 study, this study conducts a systematic content analysis of the materials submitted by the award-winning adult ICUs. On the basis of the analysis, the study compares the 1993-2002 and 2003-2012 adult ICUs in relation to construction type, unit specialty, unit layout, unit size, patient room size and design, support and service area layout, and family space design. The study also compares its findings with the 2010 Guidelines for Design and Construction of Health Care Facilities of the Facility Guidelines Institute and the 2012 Guidelines for Intensive Care Unit Design of the SCCM. The study indicates that the award-winning ICUs of both decades used several design features that were associated with positive outcomes in research studies. The study also indicates that the award-winning ICUs of the second decade used more evidence-based design features than those of the first decades. In most cases, these ICUs exceeded the requirements of the Facility Guidelines Institute Guidelines to meet those of the SCCM Guidelines. Yet, the award-winning ICUs of both decades also used several features that had very little or no supporting research evidence. Since they all were able to create an optimal critical care environment for which they were awarded, having knowledge of the physical design of these award-winning ICUs may help design better ICUs.

A trial of a real-time alert for clinical deterioration in patients hospitalized on general medical wards.

BACKGROUND: With limited numbers of intensive care unit (ICU) beds available, increasing patient acuity is expected to contribute to episodes of inpatient deterioration on general wards. OBJECTIVE: To prospectively validate a predictive algorithm for clinical deterioration in general-medical ward patients, and to conduct a trial of real-time alerts based on this algorithm. DESIGN: Randomized, controlled crossover study. SETTING/PATIENTS: Academic center with patients hospitalized on 8 general wards between July 2007 and December 2011. INTERVENTIONS: Real-time alerts were generated by an algorithm designed to predict the need for ICU transfer using electronically available data. The alerts were sent by text page to the nurse manager on intervention wards. MEASUREMENTS: Intensive care unit transfer, hospital mortality, and hospital length of stay. RESULTS: Patients meeting the alert threshold were at nearly 5.3-fold greater risk of ICU transfer (95% confidence interval [CI]: 4.6-6.0) than those not satisfying the alert threshold (358 of 2353 [15.2%] vs 512 of 17678 [2.9%]). Patients with alerts were at 8.9-fold greater risk of death (95% CI: 7.4-10.7) than those without alerts (244 of 2353 [10.4%] vs 206 of 17678 [1.2%]). Among patients identified by the early warning system, there were no differences in the proportion of patients who were transferred to the ICU or who died in the intervention group as compared with the control group. CONCLUSIONS: Real-time alerts were highly specific for clinical deterioration resulting in ICU transfer and death, and were associated with longer hospital length of stay. However, an intervention notifying a nurse of the risk did not result in improvement in these outcomes.

Relationship between in-hospital location and outcomes of care in patients of a large general medical service.

BACKGROUND: The discrepancy between the number of admissions and the allocation of hospital beds means that many patients admitted under the care of a general medical service can be placed in other departments' wards. These patients are called 'outliers', and their outcomes are unknown. AIMS: To examine the relation between the proportion of time each patient spent in their 'home ward' during an index admission and the outcomes of that hospital stay. METHODS: Data from Flinders Medical Centre's patient journey database were extracted and analysed. The analysis was carried out on the patient journeys of patients admitted under the general medicine units. RESULTS: Outlier patients' length of stay was significantly shorter than that of the inlier patients (110.7 h cf 141.9 h; P < 0.001).They had a reduced risk of readmission within 28 days of discharge from hospital. Outlier patients' discharge summaries were less likely to be completed within a week (64.3% cf 78.0%; P < 0.001). Being an outlier patient increased the risk-adjusted risk of in-hospital mortality by over 40%. Fifty per cent of deaths in the outlier group occurred within 48 h of admission. Outlier patients had spent longer in the emergency department waiting for a bed (6.3 h cf 5.3 h; P < 0.001) but duration of emergency department stay was not an independent predictor of mortality risk. CONCLUSION: Outlier patients had significantly shorter length of stay in hospital but significantly greater in-patient death rates. Surviving outlier patients had lower rates of readmission but lower rates of discharge summary completion.

Hypomagnesemia in a department of internal medicine.

BACKGROUND: Hypomagnesemia is frequently encountered in hospitalized patients. The aim of this study was to determine the underlying causes of hypomagnesemia as well as the clinical and biochemical characteristics, and concomitant electrolyte and acid-base abnormalities in patients with decreased serum magnesium (Mg(2+)) levels in an internal medicine clinic. METHODS: We prospectively studied adult patients who, either on admission to our clinic or during their hospitalization, were found to have hypomagnesemia (serum Mg(2+) concentration <1.3 mEq/L). RESULTS: One hundred and seven patients out of 2284 patients had hypomagnesemia. The incidence of hypomagnesemia was 4.7%. Malnutrition, drugs (mainly diuretics and aminoglycosides), respiratory alkalosis, diabetes mellitus, acute tubular necrosis, alcohol consumption and gastrointestinal losses were the main causes of the hypomagnesemia. In the majority of patients (80%), more than one condition may have contributed to the development of hypomagnesemia. Seventy-one patients (66.3%) exhibited at least one additional electrolyte disorder. Hypophosphatemia was the most frequent electrolyte abnormality (31.1%), followed by hypokalemia (26.1%), hyponatremia (21.5%), and hypocalcemia (22%). Seventy-eight patients (72.9%) exhibited pure or mixed acid-base disorders, mainly respiratory alkalosis (20.6%), metabolic acidosis (15.8%), and mixed metabolic alkalosis and respiratory alkalosis (18.7%). CONCLUSIONS: Hypomagnesemia in patients hospitalized in an internal medicine clinic was of multifactorial origin. A wide array of concurrent acid-base and electrolyte disorders was evident in this population.

Implementation of a continuous admission model reduces the length of stay of patients on an internal medicine clinical teaching unit.

BACKGROUND: Optimizing hospital operations is a critical issue facing healthcare systems. Reducing unnecessary variation in patient flow is likely to improve efficiency and optimize capacity for hospital inpatients. The objective of this study was to determine whether changing admissions, from a "bolus" system to a "drip" system, would result in a smoothed daily discharge rate, and reduce the length of stay of patients on a General Internal Medicine clinical teaching unit over a period of 1 year. METHODS: We conducted a retrospective analysis of the General Internal Medicine inpatient service at Toronto General Hospital for the 6-month periods from March to August during 2 consecutive years. Length of stay distributions and daily discharge rate variations were compared between the 2 study periods. RESULTS: There were a total of 2734 discharges, 1446 occurring in the pre-change period, and 1288 in the post-change period. There was overall smoothing of the daily discharge rates, and a reduction of 0.3 days in median length of stay in the post-change period (P = 0.0065). CONCLUSIONS: Restructuring the admission system to achieve constant daily admissions to each care team resulted in a smoothing of daily discharge rates and improved operational efficiency with shorter lengths of stay.