The One Big Beautiful Bill Act: Implications for Surgical Practice, Training, and Patient Care.

The aim of this study was to determine the effects of quality improvement programs for pressure ulcer prevention by conducting a follow-up survey in a hospital in Sweden. A cross-sectional survey design with comparison between data collected in 2002 and 2004. All inpatient areas were surveyed in the surgical, medical, and geriatric departments in a university hospital. A total of 369 patients were included. The European Pressure Ulcer Advisory Panel data collection form including some additional questions. The 1-day survey was conducted on March 23, 2004. Each patient was visited by 2 registered nurses, who inspected the patient's skin for any pressure ulcer classified according to the EPUAP grading system. There were no significant differences in gender, age, or Braden score between the patients in surgical, medical, or geriatric care in 2002 and 2004. The overall prevalence of pressure ulcers was 33.3% (grade 1 excluded: 10.9%) in 2002 and 28.2% (grade 1 excluded: 14.1%) in 2004. In surgical care, the prevalence was reduced from 26.8% to 17.3% (P = .051). In medical care, the prevalence was 23.6% in 2002 and 26.7% in 2004. Corresponding prevalence figures for geriatric care were 59.3% and 50.0%. A quarter of the patients in surgical care, a third in medical care, and more than half in geriatric care had a pressure ulcer upon arrival at the ward. The use of pressure-reducing mattresses had increased significantly from 16.0% to 42.7% in medical care (P = .000). The EPUAP methodology has facilitated the introduction of pressure ulcer as a quality indicator at hospital level. Pressure ulcer prevalence surveys with a standardized methodology should be repeated on a regular basis in order to stimulate quality improvement.

Cardiothoracic surgery training in the United Kingdom

Processes of care in surgical patients who died with hospital-acquired infections in Australian hospitals

Sir: We would like to thank Dr. Hamidian Jahromi et al. for their thoughtful and well-written commentary on our Viewpoint article.1 We strongly agree that the implementation of a texting-based distribution of educational materials by smartphones is an excellent way to enhance remote learning.2 Moreover, surgical videos, webinars, and surgical training software are also exceptional ways to maximize education for trainees. Lastly, we concur with the fact that the advantages of telemedicine, including decreased costs, increased access to underserved communities, and excellent satisfaction measures, have become more important than ever before during the coronavirus disease of 2019 pandemic. The relaxation of Health Insurance Portability and Accountability Act restrictions and the widespread utilization of videoconference platforms will likely lead to permanent changes in both surgical education and patient care. Wide implementation of the various telecommunication technologies will eventually lead to their acceptance by providers and patients and will lead to innovations in a variety of sectors in patient care and surgical education. While our original Viewpoint article focused on the promotion of current Web-based technologies to enhance distant learning objectives, Hamidian Jahromi et al. expanded the discussion to include the many benefits of telemedicine to patient care. Klaassen et al.2 differentiated telemedicine into three modalities: (1) consultation, (2) remote monitoring, and (3) remotely supervised treatment or training. Remote monitoring, such as the use of physiological sensors (diabetes management, remote cardiac monitoring, sleep apnea diagnostics, free flap perfusion surveillance,3 and so on), has revolutionized health care and improved patient care. While Hamidian Jahromi et al. highlighted many benefits to telemedicine appointments, challenges, such as concern for data security, lack of acceptance by health professionals and patients, and low user competence, are crucial to acknowledge.4 It is essential to utilize platforms such as this Journal to heighten awareness of the currently available technologies that are able to enrich surgical education and patient care. To this effect, we would also like to bring attention to some of the online resources available to help enhance the educational experience, as summarized by Ali et al.5 In addition, broadening our utilization and implementation of online communication platforms, with the goal of increasing research opportunities for aspiring plastic surgeons, may help to promote diversity, collaboration, and the process of publishing high-quality data to advance our field.6 Through this communication, we would also like to encourage medical education organizations such as the Accreditation Council for Graduate Medical Education to establish curriculum standards for remote surgical education. Factors such as consent processing and standards for image quality may be delineated in such guidelines. Moreover, our society would benefit greatly from maintaining an online peer-reviewed database with the latest resources, advances, and techniques for remote surgical learning. By implementing guidelines and encouraging the use of the myriad of ever-improving online communication platforms, we are optimistic that as telecommunication technologies advance, the quality of patient care and resident education will surely advance. DISCLOSURE The authors have no financial interests to declare in relation to the content of this communication. No funding was received for the creation of this work. James C. Yuen, M.D.Plastic Surgery DivisionDepartment of SurgeryUniversity of Arkansas for Medical SciencesLittle Rock, Ark. Santiago R. Gonzalez, M.D., M.P.H.Division of Plastic and Reconstructive SurgeryDepartment of SurgeryUniversity of California, San FranciscoSan Francisco, Calif.

The nature of COVID-19 transmission creates significant risks in surgical departments owing to the close contact of medical staff with patients, the limited physical environment of the operating room and recovery room, the possibility of shared surgical equipment and challenges in the delivery of surgical care in all surgical departments. Globally, studies have reported that the effects of the pandemic on surgical departments are profound, potentially long-lasting and extensive. To manage these effects, different local guidelines and recommendations have been developed, with potential differences in their effectiveness and implementation. Therefore, harmonized and effective national/international guidelines for specific surgical departments during perioperative periods are pertinent to curtail the infection, and will inevitably need to be adapted for consistent and sustainable implementation by all medical staff. The pattern of surgical patient care during the COVID-19 pandemic at Jimma Medical Center (JMC), Ethiopia, has not been explored yet. The present study aimed to describe the pattern of perioperative surgical patient care, equipment handling and operating room management during the COVID-19 pandemic at JMC. A cross-sectional study was conducted to describe the pattern of perioperative surgical patient care, equipment handling and operating room management during the COVID-19 pandemic at JMC, using five-point Likert scales (0, not at all; 1, rarely; 2, sometimes; 3, most of the time; 4, frequently). A total of 90 respondents [35 patients (five patients from each of seven surgical departments) and 55 healthcare providers (six professionals from each of nine units, including the center of sterility room and anesthesia)] who were available during the study period, selected by a convenience sampling technique with multistage clustering, participated in the study. Data were collected using a structured questionnaire via direct observation and face-to-face interviews with patients undergoing surgery, healthcare providers and hospital administrators, against the standard surgical patient care guidelines. The collected data were manually checked for missing values and outliers, cleared, entered into EpiData (v4.3.1) and exported to SPSS (v22) for analysis. The mean score of practice was compared among different disciplines by applying the unpaired t-test. The findings of the study were reported using tables and narration. A p-value of less than 0.05 was declared as statistically significant. Despite the surgical care practice having changed during the COVID-19 pandemic in all service domains, it is not implemented consistently among different surgical departments owing to different barriers (lack of training on the updated guidelines and financial constraints). The majority of surgical staff were implementing the use of preventive measures against COVID-19, while they were practiced less among patients. The guidelines for surgical practice during the preoperative phase were well applied, especially screening patients by different methods and the application of telemedicine to reduce physical contacts. But, against guidelines, elective patients were planned and underwent surgery, especially in the general surgery department. The implementation of recommended guidelines in the center of sterility room in handling surgical equipment was not very different before and during the pandemic. The extent of practice for anesthesia care, operating room management and postoperative care in the recovery room also changed, and the guidelines were sometimes applied. Although perioperative surgical care practice differed before and during the pandemic, the standard guidelines were inconsistently implemented among surgical departments. The implementation of recommended guidelines in the center of sterility room in handling surgical equipment was not very different before and during the pandemic. Thus, the authors developed safe surgical care guidelines throughout the different domains (infection prevention and PPE use; preoperative care, intraoperative care, operating room management, anesthesia care, equipment handling process and postoperative care) for all disciplines and shared them with all staff. We recommend that all surgical staff should access these guidelines and strictly adhere to them for surgical service during the pandemic.

Bariatric Surgical Practice and Patient CareVol. 10, No. 1 EditorialBariatric Surgical Practice and Patient Care at 10 Years!Edward LinEdward LinSearch for more papers by this authorPublished Online:10 Mar 2015https://doi.org/10.1089/bari.2015.9955AboutSectionsView articleView Full TextPDF/EPUB ToolsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail View article"Bariatric Surgical Practice and Patient Care at 10 Years!." Bariatric Surgical Practice and Patient Care, 10(1), pp. 1–2FiguresReferencesRelatedDetails Volume 10Issue 1Mar 2015 InformationCopyright 2015, Mary Ann Liebert, Inc.To cite this article:Edward Lin.Bariatric Surgical Practice and Patient Care at 10 Years!.Bariatric Surgical Practice and Patient Care.Mar 2015.1-2.http://doi.org/10.1089/bari.2015.9955Published in Volume: 10 Issue 1: March 10, 2015PDF download

Bariatric Surgical Practice and Patient CareVol. 10, No. 3 EditorialGood News (and Caution) for Sleeve GastrectomyArvinpal Singh, Danny Watkins, and Edward LinArvinpal SinghSearch for more papers by this author, Danny WatkinsSearch for more papers by this author, and Edward LinSearch for more papers by this authorPublished Online:14 Sep 2015https://doi.org/10.1089/bari.2015.29002.asAboutSectionsView articleView Full TextPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail View article"Good News (and Caution) for Sleeve Gastrectomy." Bariatric Surgical Practice and Patient Care, 10(3), pp. 85–86FiguresReferencesRelatedDetailsCited byThe State of Single Anastomosis Duodeno-Ileostomy Edward Lin11 December 2019 | Bariatric Surgical Practice and Patient Care, Vol. 14, No. 4Reconstruction Options for Pancreaticoduodenectomy in Patients with Prior Roux-en-Y Gastric Bypass Mihir M. Shah, Benjamin M. Martin, Jamil L. Stetler, Ankit D. Patel, S. Scott Davis, Juan M. Sarmiento, and Edward Lin1 November 2017 | Journal of Laparoendoscopic & Advanced Surgical Techniques, Vol. 27, No. 11Polycystic Ovarian Syndrome and Bariatric Surgery Arinbjorn Jonsson, Lava Y. Patel, Arvinpal Singh, S. Scott Davis, and Edward Lin1 September 2017 | Bariatric Surgical Practice and Patient Care, Vol. 12, No. 3Biliary reconstruction options for bile duct stricture in patients with prior Roux-en-Y reconstructionSurgery for Obesity and Related Diseases, Vol. 13, No. 9Why We Exist, Our Competitive Edge, and a Mea Culpa Moment Edward Lin16 December 2015 | Bariatric Surgical Practice and Patient Care, Vol. 10, No. 4 Volume 10Issue 3Sep 2015 InformationCopyright 2015, Mary Ann Liebert, Inc.To cite this article:Arvinpal Singh, Danny Watkins, and Edward Lin.Good News (and Caution) for Sleeve Gastrectomy.Bariatric Surgical Practice and Patient Care.Sep 2015.85-86.http://doi.org/10.1089/bari.2015.29002.asPublished in Volume: 10 Issue 3: September 14, 2015PDF download

Bariatric Surgical Practice and Patient CareVol. 8, No. 2 InterviewThe Next Phase of Growth and Development for Bariatric Surgical Practice and Patient Care: An Interview with Incoming Editor-in-Chief Edward Lin, DO, MBA, FACS, AGAFPublished Online:17 Jun 2013https://doi.org/10.1089/bari.2013.9981AboutSectionsView articleView Full TextPDF/EPUB ToolsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail View article"The Next Phase of Growth and Development for Bariatric Surgical Practice and Patient Care: An Interview with Incoming Editor-in-Chief Edward Lin, DO, MBA, FACS, AGAF." , 8(2), pp. 47–48FiguresReferencesRelatedDetails Volume 8Issue 2Jun 2013 InformationCopyright 2013, Mary Ann Liebert, Inc.To cite this article:The Next Phase of Growth and Development for Bariatric Surgical Practice and Patient Care: An Interview with Incoming Editor-in-Chief Edward Lin, DO, MBA, FACS, AGAF.Bariatric Surgical Practice and Patient Care.Jun 2013.47-48.http://doi.org/10.1089/bari.2013.9981Published in Volume: 8 Issue 2: June 17, 2013PDF download

Chapter 15 - Digital tools and innovative healthcare solutions: Serious games and gamification in surgical training and patient care

The Coronavirus pandemic poses a significant threat to the healthcare sectors of some African countries due to poor healthcare organisation, financing, and reduced uptake of recent technological advancements. Surgical care of patients and surgical training of healthcare workers are considerably affected, due to the dearth of policies and strategic health plans, to ensure the provision of safe and affordable surgical care and continuity of training. The purpose of this study is to explore the impact of the COVID-19 pandemic on Surgery in Africa and to provide recommendations geared towards the current pandemic and for the future. This review involved a search of the electronic databases MEDLINE/PubMed and Google Scholar, and 31 papers from African countries which explored the impact of COVID-19 across different surgical specialities were screened. The cancellation rate of elective surgeries and benign conditions across some countries were seen to be as high as 74-81% with prioritisation of cancer patients and emergencies. The volume of emergency surgical cases presenting in some hospitals was reduced due to the associated lockdowns and fear of contracting the virus, while Telemedicine became increasingly adopted with newer platforms being used across some countries. The pandemic has exposed the inequities in health systems and further studies need to be done to evaluate its impact across more surgical specialities.

BackgroundAccording to the International Classification of Diseases (ICD-10), Chapter XX, on “Εxternal causes of morbidity and mortality (V01-Y98)” includes the blocks Y40-Y84 which refer to “Complications of medical and surgical care” and Y88, “Sequelae with surgical and medical care as external cause”. In Greece, the National Statistical Authority (ELSTAT) annually reports the number and cause of deaths at national level. The objective of this study is to analyze the deaths attributed to “complications of medical and surgical care”; and from “Sequelae with surgical and medical care as external cause”, in Greece, for the period 2014-2022.MethodsData on the number of deaths per year, disaggregated by gender and age group, were obtained from ELSTAT for the study period.ResultsBetween 2014 and 2022, a total of 4,205 deaths were recorded under the aforementioned categories (2,194 males and 2,011 female). The highest annual number of deaths occurred in 2020 (597 deaths), while the lowest was recorded in 2017 (383 deaths). The age group with the highest number of deaths was 85+ years (868 deaths), followed by 75–79 years (747 deaths), and 80–84 years (742 deaths). Across the entire study period, 16 deaths occurred in the 0–19 age group, 800 in the 20–65 group, 1,779 in the 65–79 group, and 1,610 in the 85+ group.ConclusionsComplications of medical and surgical care are preventable events may cause harm, additional costs, and even death. Accurate certification of the cause of death by physicians—including the proper completion of the Medical Certificate of Cause of Death (MCCOD)—along with correct coding in accordance with ICD guidelines, is essential for producing reliable mortality statistics. These statistics are critical for monitoring mortality and disease trends, fulfilling legal and administrative requirements, and informing health policy decisions.Key messages• Proper certification and coding of causes of death are crucial for reliable statistics• Reliable mortality data is essential for monitoring trends and informing health policies.TopicPatient safety, Healthcare quality, Health policy.

Bariatric Nursing and Surgical Patient CareVol. 3, No. 3 Best PracticesBest Practices for Sensitive Care and the Obese PatientSusan Gallagher Camden, Sandra Brannan, and Pam DavisSusan Gallagher CamdenSearch for more papers by this author, Sandra BrannanSearch for more papers by this author, and Pam DavisSearch for more papers by this authorPublished Online:30 Aug 2008https://doi.org/10.1089/bar.2008.9965AboutSectionsPDF/EPUB ToolsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail FiguresReferencesRelatedDetailsCited byClinical Leadership and Management Perceptions of Inpatients with Obesity: An Interpretative Phenomenological Analysis3 November 2020 | International Journal of Environmental Research and Public Health, Vol. 17, No. 21“I do the best I can:” Personal care preferences of patients of sizeApplied Nursing Research, Vol. 39Nursing Care of the Super Bariatric Patient: Challenges and Lessons LearnedRehabilitation Nursing, Vol. 40, No. 2What do we know about skin-hygiene care for patients with bariatric needs? Implications for nursing practice11 July 2013 | Journal of Advanced Nursing, Vol. 70, No. 3A Multicultural Service Sensitivity Exercise for Marketing StudentsJournal of Marketing Education, Vol. 35, No. 1Bullying, Moral Courage, Patient Safety, and the Bariatric Nurse5 December 2012 | Bariatric Nursing and Surgical Patient Care, Vol. 7, No. 4Evolution of a Discipline2 March 2012 | Bariatric Nursing and Surgical Patient Care, Vol. 7, No. 1Managing obese patients in the OROR Nurse, Vol. 6, No. 2Special Populations17 February 2012Women's Health, Size, and Safe Patient Handling: What Are the Ethical Issues?9 June 2011 | Bariatric Nursing and Surgical Patient Care, Vol. 6, No. 2To EBP or Not to EBP … Why Is It a Question?9 June 2011 | Bariatric Nursing and Surgical Patient Care, Vol. 6, No. 2Caring for Your Bariatric Patient: A Resource Guide to the Literature on Care of the Morbidly Obese6 March 2011 | Bariatric Nursing and Surgical Patient Care, Vol. 6, No. 1Providing Holistic Care to Bariatric PatientsThe Journal of Continuing Education in Nursing, Vol. 40, No. 10Culturally Competent Care of the Bariatric Patient19 June 2009 | Bariatric Nursing and Surgical Patient Care, Vol. 4, No. 2Moving Forward1 April 2009 | Bariatric Nursing and Surgical Patient Care, Vol. 4, No. 1 Volume 3Issue 3Sep 2008 InformationCopyright 2008, Mary Ann Liebert, Inc.To cite this article:Susan Gallagher Camden, Sandra Brannan, and Pam Davis.Best Practices for Sensitive Care and the Obese Patient.Bariatric Nursing and Surgical Patient Care.Sep 2008.189-196.http://doi.org/10.1089/bar.2008.9965Published in Volume: 3 Issue 3: August 30, 2008PDF download

Bariatric Surgical Practice and Patient CareVol. 17, No. 3 EditorialFree AccessGreetings from the Editor of Bariatric Surgical Practice and Patient CareDean J. MikamiDean J. MikamiDean J. Mikami, MD, FACS, Editor-in-Chief, Bariatric Surgical Practice and Patient Care, Professor of Surgery, Associate Chair Clinical Affairs, Division Chief, General Surgery, Associate Program Director, John A. Burn School of Medicine, University of Hawaii, 1356 Lusitana Street, 6th Floor, Honolulu, HI 96813, USA Editor-in-Chief, Bariatric Surgical Practice and Patient Care.Department of Surgery, University of Hawaii John A. Burn School of Medicine, Honolulu, Hawaii, USA.Search for more papers by this authorPublished Online:15 Sep 2022https://doi.org/10.1089/bari.2022.29030.djmAboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail The American Society of Metabolic and Bariatric Surgery (ASMBS) annual meeting in Dallas was a huge success under the presidency of Dr. Shanu Kothari. This meeting marked the first time we were all back in person as a bariatric society. I have the privilege of being the chair of the ASMBS Flexible Endoscopy Committee. My goal for Bariatric Surgical Practice and Patient Care and the ASMBS Flexible Endoscopy Committee is to offer the best care possible to our bariatric patients. The relaunch of the ASMBS/SAGES BE-SAFE (Bariatric Endoscopy-Skill Acquisition Focused Evaluation) testing was held in Dallas and it was well attended.I strongly believe that surgeons should be performing endoscopy to help their patients remain healthy throughout their life time. Laparoscopic sleeve gastrectomy is the most popular bariatric surgery performed worldwide, but we need to stay vigilant. Up to 17% of patients after sleeve gastrectomy can develop Barrett's esophagus, thus prompting the International Federation on the Study of Obesity to recommend routine screening starting 1 year of sleeve gastrectomy. ASMBS recommendation is for screening to start at 3 years post sleeve gastrectomy.We have an exciting line up of articles from around the world in this issue of Bariatric Surgical Practice and Patient Care. Our lead article is from New Zealand and is a systematic review and meta-analysis of the effects of augmenting bariatric surgery with vagotomy. I also want to highlight another article from the United States looking at vitamin adherence after bariatric surgery using social media as an aide. As most meetings have returned to in person, I hope to meet many of our wonderful authors, reviewers, and journal subscribers in person. As always, please stay safe and vigilant and I hope you have had a productive and joyful summer.Sincerely,FiguresReferencesRelatedDetails Volume 17Issue 3Sep 2022 InformationCopyright 2022, Mary Ann Liebert, Inc., publishersTo cite this article:Dean J. Mikami.Greetings from the Editor of Bariatric Surgical Practice and Patient Care.Bariatric Surgical Practice and Patient Care.Sep 2022.133-133.http://doi.org/10.1089/bari.2022.29030.djmPublished in Volume: 17 Issue 3: September 15, 2022PDF download

We present a broad international perspective of the past, present and future of the organisational factors and staffing models for the management of patients following both cardiac and non-cardiac surgery. Using recently published large data, we explore differences in human factors and outcomes. We examine and describe the difference in clinical care pathways in the setting of cardiac and non-cardiac surgery between the UK and other high-income countries. We report key areas of focus whereby improvements may be achieved in future training and systems management. These include: (1) increasing the availability of intensive care, high-dependency care and critical care outreach; (2) increasing the availability of trained specialist nurses; (3) expanding the critical care training of surgeons; and (4) multidisciplinary enhanced recovery programmes. We conclude that a multidisciplinary collaborative approach to implementing these key principles along with an evidence-based focus on outcomes and reducing variation is vital to improving clinical outcomes in surgical patients. It was easier in the past. Surgeons looked after surgical patients on the ward, anaesthetists stayed in the operating theatre and intensivists were yet to be conceived. Surgical ward care was commonly provided by a trainee surgeon with the occasional help of a friendly anaesthetist if a patient unexpectedly deteriorated 1. It may not have been easier if you were the trainee surgeon who provided 168 h of uninterrupted weekly care; however, it is always important to understand our history when attempting to understand the present and improve the future. When we ask, 'who should manage the patient after surgery?', are we, in fact, asking who should have ownership of the patient? Ownership is a much-used term in medicine; however, there are two distinct but overlapping meanings to this term. There is decision ownership, whereby physicians not only have a personal investment in treatment decisions but also ownership in the more possessive or transactional sense in relation to a patient – 'this is my patient' 2. We would suggest that the two meanings may be the flipsides of the same medical coin. The concept of 'care' overarches the concept of ownership, reflects the compassionate nature of the job and suggests an aspiration for an enlightened multidisciplinary team approach. The answer to the question posed will vary according to national, cultural and institutional norms. The important question is: do we have any evidence to support a best practice? In looking at this question, we must first distinguish between different patients and surgical procedures. Cardiac surgery is very much at the sharp end of the surgical spectrum, with almost all postoperative patients going to an intensive care unit (ICU) and cared for by an expanded multidisciplinary team. On the other hand, postoperative provision of care for patients undergoing other types of surgery is variable. Those patients who are having ambulatory surgery will have limited contact with physicians as nurse-led care is the current established model. Similarly, those patients with limited comorbidities having intermediate or uncomplicated major surgery will be largely managed by protocol-driven nurse-led care. The zone where outcomes are not so assured, and where resources are most in-demand and therefore the focus of this article, is primarily those patients with significant comorbidities undergoing higher risk major surgery. Cardiac surgery in the UK and the USA is probably the most scrutinised surgical area in contemporary practice, with considerable discrepancy in the composition of the teams. Variabilities in postoperative care can contribute to patient outcomes following cardiac surgery 3. Two thirds of complications following cardiac surgery occur during the postoperative cardiothoracic ICU stay and this is associated with increased risk of early mortality, longer hospital length of stay and higher rate of discharge to skilled nursing facilities 4, 5. In the UK, there has been a transition from cardiac surgeons looking after all aspects of peri-operative management, as fewer trainees have been available and as postoperative ICU has become more specialised. Anaesthetists and intensivists are now looking after immediate postoperative management and beyond. According to a 2018 Faculty of Intensive Care Medicine workforce census, 70% of cardiac critical care specialists also deliver cardiac anaesthesia services, although staffing is under significant stress and the utilisation of advanced critical care practitioners is increasing to support or even replace trainee doctors 6. A large-scale UK study demonstrated that the operative surgeon rather than procedural anaesthetist was associated with variations in mortality 7. However, despite a wealth of UK outcome data, it has not proven possible to establish any relevant causal outcomes associated with critical care either by speciality or staffing patterns 8, 9. There is some single-centre evidence from Canada to Israel which links the introduction of intensivist-directed ICU care of cardiac surgical patients to improvements in length of stay 10 and mortality 11, although other changes in the organisation of care accompanied this intervention. In the USA, postoperative cardiac surgical ICU models vary widely 12. In 2003, the Society of Critical Care Medicine (SCCM) and the American College of Critical Care Medicine stated that the ideal ICU model should have 24-h in-house staffing by dedicated intensive care physicians 13. However, the data surrounding this intensivist model has been challenged in other studies 14. The current cardiac surgical ICU staffing models in the USA were recently reported 12. Forty-seven percent of the units that were included identified themselves as being managed by cardiac surgeons whose primary focus was not the ICU. For those centres that reported the involvement of a dedicated ICU consultant, the primary specialties were varied, where pulmonary critical care was the most common specialty (67%) followed by anaesthesia/critical care medicine (26%) 12. Less than one-third of responding centres met the 2003 SCCM ideal model of around-the-clock in-house intensive care medical coverage. In the USA, the majority of centres utilise advanced practice providers (similar to the UK advanced nurse practitioners) for after-hours coverage. The remaining centres are managed with no dedicated after-hours in-house physician or surgeon coverage. Although full-time intensivist coverage may appear to be desirable, having an ICU closed to cardiac surgeon decision-making may hinder necessary collaborative teamwork 15. The preferred model probably is a mixed model, with a full-time intensivist working in close collaboration with the cardiac surgeon. Trainee numbers and availability has diminished in the USA with working hour limitations providing less experience managing complicated postoperative critically ill patients during training 16. Finally, the untoward consequences of global billing restrictions in the USA 17, which limit critical care billing for postoperative cardiac surgical patients in the first 90 days, are unknown. The EuSOS study published in 2012, attempted to look at mortality and admission to ICU after major non-cardiac surgery in Europe 18. There was wide national variation and a surprising 4% in-hospital mortality, compared with around 2% for elective cardiac surgery. Even more notable was the fact that 73% of patients who died were not admitted to ICU at any stage of their admission. It is uncertain which medical teams were managing these patients, but it is not unreasonable to assume that it was the parent surgical team. A more recent broad-ranging study across the UK, Australia and New Zealand investigated the provision of postoperative care 19. Although the study did not attempt a link to outcomes, the investigators uncovered some interesting findings with relevance to this discussion. Thirty-one percent of hospitals had high-acuity postoperative care areas outside of ICU and operating theatres, with a median nurse to patient ratio of 2:1. Fifty percent of the patients in these areas were managed exclusively by the surgical team. Another finding in this study, of concern for the National Health Service in the UK, was the much lower nursing ratios on standard surgical wards in the UK compared with Australia and New Zealand (6.0 vs. 3.75 vs. 4.45, respectively). What is clear from these studies is that the UK has a lower provision of ICU beds for surgical patients than comparable countries. The consequences of this state of affairs in the UK, whether it be predominantly economic or cultural, is that surgical teams look after a high proportion of high-acuity patients who would otherwise be managed in an ICU (level 3 care) or designated high-dependency unit (HDU, level 2 care) by trained critical care physicians. There are more surgically managed high-acuity ward areas in Australia, in addition to more intensive care beds. The EuSOS study also demonstrated that mortality varies significantly across European countries, but it is clearly not possible to simplify this outcome to differing rates of postoperative ICU admissions. Even assuming we are able to successfully collect and standardise big healthcare data across countries, multiple factors influence mortality after surgery, many of which are beyond the sphere of influence of healthcare provider institutions. Despite the best efforts of data researchers, we cannot precisely identify what makes the difference in postoperative care, whether it is who looks after the patient or where they are located. So how do we prioritise, organise and improve services for our patients? The outcomes that are important to patients and those that are important to physicians after surgery frequently differ 20. In the real-world of medicine, the most effective way of achieving genuine change is how we train, organise and engage the next generation of doctors, nurses and other professionals. We suggest four themes that must be considered to improve postoperative care and patient outcomes (Fig. 1). Critical care beds (level 2 or 3) for non-cardiac surgery are a restricted resource in the UK. To reduce mortality and other significant adverse outcomes following major surgery, particularly for the higher risk population, ICU bed availability must be expanded. This requires appropriate investment, expansion of intensive care physicians, intensive care medicine training programmes and expansion of other members of the multidisciplinary team. It requires a redesign of surgical training and rotations of staff who manage high-level care areas in collaboration with physician assistants and specialist nurses. Critical care outreach is undergoing expansion but is essential to support surgical postoperative management of the higher risk patients 21. Medical working hours have been reduced as the focus has increased on safe working practices, and out-of-hours working has become steadily more intense. There are other factors at play, but the overall result is that anaesthesia, surgery and intensive care rotas are increasingly threadbare. Although nursing rotas are similarly under stress, the increasing use of healthcare assistants for high-acuity surgical areas is not an adequate substitution, particularly out-of-hours. Recruitment and resources need to be directed at training and retaining high-quality specialised nurses for surgical wards and improving nursing ratios in the UK towards those of surgical units in Australia and the USA. As emergency admissions to ICU beds have increased and discharge of elderly patients has become more difficult, ring-fencing of beds has become more challenging despite initiatives such as 'Getting it Right First Time'. This is particularly true for surgical specialties such as bariatrics, where ICU beds for surgical patients with malignancy is appropriately prioritised. High-level care areas on surgical wards have increasingly been established to maintain surgical programmes, but such patients often have multiple comorbidities. Surgical training is increasingly directed to operating time and service commitments, with limited time for surgical trainees to spend meaningful training time in critical care settings. This applies equally to cardiac surgery and to non-cardiac surgery alike. Where possible, critical care medicine should be built into surgical training time to allow more experienced leadership of high-risk patients in collaboration with critical care outreach teams. The enhanced recovery after surgery (ERAS) movement is a valuable addition to peri-operative care, bringing together many of the elements in this article and placing the patient at the very centre of the entire peri-operative pathway. The emphasis is on teamwork, multidisciplinary collaboration, avoidance of conflict, benchmarking, relentless focus on outcomes and reduction in unnecessary variation. Patient-reported outcomes are emphasised in the assessment of value. These are the keys to successful postoperative management, rather than focusing on patient ownership. The recently published ERAS guidelines for the peri-operative care of cardiac surgical patients, itself an international collaboration between surgeons, anaesthetists and intensivists, emphasise the need for standardising best practice 22, 23. In conclusion, there are many different staffing models to provide care for surgical patients, but success requires planning, adequate resource allocation, training and multidisciplinary collaboration, rather than ownership conflicts. Regardless of the staffing model, adherence to evidence-based best practice and continual re-assessment of progress and areas of deficiency will be the keys to success. DE is a consultant for Edwards Lifesciences and Biomerieu. NF has no competing interests.

Early Specialization in Surgical Training: An Old Concept Whose Time Has Come?