Low Procedural Volume Research Articles

Do modern orthopaedic trainees have sufficient exposure to open shoulder stabilization procedures?

Background: Arthroscopic stabilization and bone augmentation procedures have become common treatment options for anterior shoulder instability, while the use of open soft tissue stabilization procedures has declined. This study aimed to determine current trends in utilization of open soft tissue stabilization among shoulder surgeons and the relationship between procedure volume in practice and exposure as trainees. Methods: Out of the 1,115 American Shoulder and Elbow Surgeon members surveyed, 212 surgeons completed a questionnaire about exposure to open soft tissue stabilization techniques during training, practice patterns for shoulder instability, perceived skill with open soft tissue stabilization procedures, and opinions on the importance of these procedures. Statistical analyses correlated practice numbers, training exposure, and self-perceived facileness. Results: Out of the 212 surgeons who completed the survey, 71% (n=153/212) of respondents performed less than 25% of their stabilization procedures in an open manner. Sixty-seven percent (n=143/212) of respondents reported that less than 10% of their open procedures involved only soft tissue. The number of open soft tissue stabilization procedures performed in practice correlated with the number performed during residency (r=0.42; P<0.001) and fellowship (r=0.46; P<0.001). Eighty percent of respondents reported self-perceived facileness with open soft tissue stabilization which correlated with the number of procedures performed in practice (P<0.001), residency (P<0.001), and fellowship (P<0.001). Half of respondents (51%; n=109/212) believed that procedure exposure was necessary for residents. Conclusion: Shoulder specialists perform a low volume of open soft tissue stabilization procedures currently. Exposure throughout training correlates with using these procedures in practice, and with surgeon confidence. Level of evidence: V

Competency-based medical education in interventional pulmonology: current state and future opportunities.

This chapter examines the evolution and current status of competency-based medical education (CBME) in interventional pulmonology, focusing on procedural skills assessment and training. Traditionally, interventional pulmonology training has used an apprenticeship model with case logs and director attestation, leading to inconsistent outcomes due to a lack of standardized curricula. CBME, established to address these issues, relies on outcome-based assessments to ensure trainees achieve necessary competencies. The chapter reviews various assessment tools, including global rating scales, checklists, and simulation-based methods, and their effectiveness in skill acquisition and clinical evaluation. It also covers specific procedures such as EBUS-TBNA, electromagnetic navigation bronchoscopy, and rigid bronchoscopy, discussing their assessment tools and learning curves. The chapter emphasizes the need for standardized assessment tools and suggests using entrustable professional activities (EPAs) to improve competency evaluation. Future directions include integrating real-time artificial intelligence feedback, addressing high-risk low-volume procedures, and enhancing workplace-based assessments to improve interventional pulmonology training and patient care quality. This chapter reviews the transition from traditional apprenticeship models to CBME in interventional pulmonology, highlighting advancements in procedural skills assessment, the effectiveness of various assessment tools, and future directions for improving training and patient care.

Do Fellowship-educated Military Orthopaedic Oncologists Who Practice in Military Settings Treat a Sufficient Volume of Patients to Maintain Their Oncologic Expertise?

Fellowship-trained orthopaedic oncologists in the US military provide routine clinical care and also must maintain readiness to provide combat casualty care. However, low oncologic procedure volume may hinder the ability of these surgeons to maintain relevant surgical expertise. Other low-volume specialties within the Military Health System (MHS) have established partnerships with neighboring civilian centers to increase procedure volume, but the need for similar partnerships for orthopaedic oncologists has not been examined. The purpose of this study was to characterize the practice patterns of US military fellowship-trained orthopaedic oncologists. We asked the following questions: (1) What are the diagnoses treated by US military fellowship-trained orthopaedic oncologists? (2) What are the procedures performed by US military fellowship-trained orthopaedic oncologists? We queried the Military Data Repository, a centralized repository for healthcare data for all healthcare beneficiaries (active duty, dependents, and retirees) within the Defense Health Agency using the MHS's Management and Reporting Tool for all international common procedure taxonomy (CPT) codes and ICD-9 and ICD-10 codes associated with National Provider Identifier (NPI) numbers of active duty, military fellowship-trained orthopaedic oncologists. Fellowship-trained orthopaedic oncologists were identified by military specialty leaders. Then, we identified all procedures performed by the orthopaedic oncologist based on NPI numbers for fiscal years 2013 to 2022. We stratified the CPT codes by top orthopaedic procedure categories (such as amputation [performed for oncologic and nononcologic reasons], fracture, arthroplasty, oncologic) based on associated ICD codes. These were then tabulated by the most common diagnoses treated. Thirteen percent (796 of 5996) of the diagnoses were oncologic, of which 45% (357 of 796) were malignant. Forty-four percent (158 of 357) of the malignancies were primary and 56% (199 of 357) were secondary; this translates to an average of 2 patients with primary and 2.5 patients with secondary malignancies treated per surgeon per year. During the study period, nine orthopaedic oncologists performed 5996 orthopaedic procedures, or 74 procedures per surgeon per year. Twenty-one percent (1252 of 5996) of the procedures were oncologic; the remaining procedures included 897 arthroplasties, 502 fracture-related, 275 amputations for a nononcologic indication, 204 infections, 142 arthroscopic, and 2724 other procedures. Although military orthopaedic oncologists possess expert skills that are directly translatable to combat casualty care and operational readiness, within MHS hospitals they treat relatively few patients with oncologic diagnoses, and less than one-half of those involve malignancies. Despite postgraduation procedure volume raining stable over the last decade, it is unknown how many new patient visits for oncologic diagnoses and how many corresponding tumor procedures are necessary to maintain competence or build confidence after musculoskeletal oncology fellowship training. It is important to note that there are no military orthopaedic oncology fellowships, and all active duty orthopaedic oncologists undergo training at civilian institutions. Military-civilian partnerships with high-volume cancer centers may enable military orthopaedic oncologists to work at civilian cancer centers to increase their oncologic volume to ensure sustainment of operationally relevant knowledge, skills, and abilities and improve patient care and outcomes.

Invited Commentary: Transcarotid Artery Revascularization: Short Learning Curve but Low Procedural Volume Still Predicts Higher Morbidity.

Invited Commentary: Transcarotid Artery Revascularization: Short Learning Curve but Low Procedural Volume Still Predicts Higher Morbidity.

Center-Related Variation in Hospitalization Cost for Patients Undergoing Percutaneous Left Atrial Appendage Occlusion

BackgroundThe commercial use of percutaneous left atrial appendage occlusion with the Watchman device is increasing in the United States. The purpose of this study was to evaluate center-related variation in total hospital costs for Watchman device implantation and identify factors associated with high hospital costs at a national level. MethodsAll adults undergoing elective left atrial appendage occlusion with Watchman were identified in the 2016-2018 National Inpatient Database. Mixed models were used to evaluate the impact of center on total hospital costs, adjusting for patient and center characteristics and length of stay. ResultsA total of 30,175 patients underwent Watchman device implantation at a median cost of $24,500 and demonstrated significant variability across admissions (interdecile range, $13,900-37,000). Nearly 13% of the variability in patient-level costs was related to the center performing the procedure rather than patient factors. Higher-volume centers had lower total costs and demonstrated lesser total cost variation. Centers with low procedural volume, occurrence of procedural complications, congestive heart failure, and length of stay were independent predictors of a high-cost hospitalization. Though complications were associated with increased expenditure, they did not explain the observed cost variation related to the center. ConclusionsA significant proportion of variation in total hospital cost was attributable to the center performing the procedure. Addressing variability of Watchman-related costs is necessary to achieve high-quality value-based care.

Association between Endoscopist Volume and Interval Cancers after Colonoscopy: Results from the National Colorectal Cancer Screening Program in Korea.

The rate of interval colorectal cancer (iCRC) is now accepted as a key performance indicator of organized colorectal cancer (CRC) screening programs. We aimed to examine the association between endoscopist volumes and the rate of iCRC among individuals with a positive fecal immunochemical test (FIT) within a nationwide population-based CRC screening program. Individuals aged ≥ 50 years who underwent colonoscopy after a positive FIT from January 1, 2019 until December 31, 2020 in the Korean National Cancer Screening Program (KNCSP) were enrolled. We converted the data into per-endoscopist screening results, calculated the iCRC rates per endoscopist, and compared them to the previous year's annual volume that was divided into five groups (V1, 1-9; V2, 10-29; V3, 30-59; V4, 60-119; V5, ≥ 120). A total of 10,412 endoscopists performed 216,907 colonoscopies. Overall, the average rate of iCRC per endoscopist was 8.46 per 1,000 examinations. Compared with the group with the highest volume (V5 group), the rate of iCRC was 2.21 times higher in the V1 group. Similar trends were observed in the other groups (V2: relative risks [RR], 2.15; 95% confidence interval [CI], 1.57 to 2.94; V3: RR, 1.56; 95% CI, 1.15 to 2.13; V4: RR, 1.18; 95% CI, 0.83 to 1.67). The findings emphasize that endoscopists with lower procedure volumes have higher risks of interval cancer being missed or undetected. To maximize the preventative impact of colonoscopy for CRC, this issue should be addressed by monitoring endoscopist volumes and variations in performances.

The role of the surgical volume for clinical outcomes in VATS lobectomy for lung cancer: a national large database multicenter analysis.

Improving the quality of lung cancer care at a cost that can be sustained is a hotly debated issue. High-risk, low-volume procedures (such as lung resections) are believed to improve significantly when centralised in high-volume centres. However, limited evidence exists to support volume requirements in lung cancer surgery. On the other hand, there was no evidence that the number of lung resections affected either the short-term perioperative results or the long-term cost. Using data from an extensive nationwide registry, this study investigated the correlations between surgical volumes and selected perioperative outcomes. A retrospective analysis of a prospectively filled national registry that follows stringent quality assurance and security procedures was conducted to ensure data accuracy and security. Patients who underwent VATS lobectomy from 2014 to 2019 at the participating centres were included. Selected perioperative outcomes were reported. Total direct hospital cost is measured at discharge for hospitalisations with a primary diagnosis of lung cancer, hospital stay costs, and postoperative length of hospital stay after lobectomy. After the propensity score matched, centres were divided into three groups according to the surgical volume of the unit where VATS lobectomies were performed (high-volume centre: > 500 lobectomies; medium-volume centre: 200-500 lobectomies; low-volume centre: < 200 lobectomies). 11,347 patients were included and matched (low-volume center = 2890; medium-volume center = 3147; high-volume center = 2907). The mean operative time density plot (Fig.1A) showed no statistically significant difference (p = 0.67). In contrast, the density plot of the harvested lymph nodes (Fig.1B) showed significantly higher values in the high-volume centres (p = 0.045), albeit without being clinically significant. The adjusted rates of any and significant complications were higher in the low-volume centre (p = 0.034) without significantly affecting the length of hospital stay (p = 0.57). VATS lobectomies for lung cancer in higher-volume centres seem associated with a statistically significantly higher number of harvested lymph nodes and lower perioperative complications, yet without any significant impact in terms of costs and resource consumption. These findings may advise the investigation of the learning curve effect in a complete economic evaluation of VATS lobectomy in lung cancer. Fig.1 The mean operative time density plot showed no statistically significant difference (p = 0.67).

Hemapheresis Clinic Scheduling Quality Improvement Project

Abstract Introduction/Objective Outpatient (OP) Red blood cell exchange (RCE) therapy is used to treat patients with severe manifestations of sickle cell disease. Like any blood transfusion, a patient must have an active type and screen, drawn 24 to 72 hours prior to scheduled RCE procedure. UIH Hemapheresis clinic performs several types of apheresis procedures treating sickle cell disease, kidney transplant rejection and autoimmune disorders. Outpatient clinic staff perceived that most RCE procedures are scheduled disproportionately between Wednesday through Friday, which creates an unbalanced schedule that is lighter on Monday and Tuesday, and heavier Wednesday through Friday. The study's objective was to determine if there is a significant difference between the number of outpatient procedures scheduled on the different days of the week. If significant differences are identified, processes may be improved to schedule a more balanced OP clinic week. Potential benefits may include a more balanced patient to nursing staff ratios which can improve patient care and more efficient RBC utilization which can ease workload across multiple cross-functional departments such as nursing staff, reference labs and in-house blood bank staff. Methods/Case Report The UIH Epic Hemapheresis Clinic schedule was searched to identify how many total OP procedures, including RCE, were scheduled each day of the week between 01AUG2021 – 31JUL2022. Only OP procedures occurring in complete five-day weeks were included. Weekends and weeks having clinic closures for holidays were excluded Results (if a Case Study enter NA) Our study show that the lowest number of OP RCE (mean 1.4) and total number of OP procedures (mean 2.6) were on Monday. Wednesday is the busiest day with overall averaging 3.5 total procedures (Standard Deviation: 1.56). However, Friday is the most variable, with the largest SD for both RBCX (SD 1.4) and Total number of procedures (SD 1.7). Conclusion Contributing factors to low procedure volume on Monday are likely multifactorial. Some patients may prefer not to come to the hospital on Saturday for type and screen, while some may forget they need labs. Transportation issues are another factor. One intervention the clinic has implemented is automatic appointment call reminders. Staff encourage patients or caregivers to sign up for the EPIC MyChart app which also notifies patients of upcoming appointments. Future studies need to be conducted to address other bottlenecks within the scheduling workflow and to determine ways to optimize patient appointment adherence.

Temporal trends, patient characteristics and hospital volume outcomes after alcohol septal ablation and septal myectomy for treatment of obstructive hypertrophic cardiomyopathy

Abstract Background Hypertrophic obstructive cardiomyopathy (HOCM) represents a clinically and morphologically diverse hereditary cardiac disease that is frequently associated with poor prognosis. Nationwide data on septal reduction therapy (SRT), alcohol septal ablation (ASA) and septal myectomy (SM), remains scarce. The aim of this study was to investigate (i) temporal trends, (ii) patient characteristics, (iii) in-hospital outcomes, and associations between institutional procedural volumes and outcomes after ASA and SM in a large-scale nationwide cohort. Methods Using data from the German Federal Bureau of Statistics, this study analyzed all patients with HOCM who were hospitalized for ASA or SM in a nationwide inpatient database in Germany between January 1, 2006, through December 31, 2019. Rates of adverse in-hospital events (in-hospital mortality, need for permanent pacemaker) were examined. Multivariate logistic regression analysis was performed to compare overall outcomes after each procedure based on tertiles of hospital volumes of ASA and SM. Results A total of 8,514 patients underwent SRT, of whom 5,293 (62.2%) underwent ASA and 3,221 (37.8%) SM. Annual numbers for SM and ASA steadily increased over time: ASA procedures increased from 329 in 2006 to 451 in 2019 and SM procedures increased from 191 in 2006 to 222 in 2019, respectively. Patients with SM were older (mean 67.4 vs. 60.2 years), less likely female (56.4% vs. 49.9%), and had a higher burden of comorbidities (e.g., diabetes, atrial fibrillation, heart failure, chronic kidney disease) compared to patients with ASA. Over an observational period of 14 years, the majority of both ASA and SM procedures were performed at hospitals in the lowest volume category (≤20 procedures). The overall in-hospital mortality was higher in patients with SM (6.8%) compared to patients with ASA (0.8%), whereas the need for pacemaker implantation was more often observed in patients with ASA (19.3% vs. 13.1%; p&amp;lt;0.001). The lowest tertile of SM volume among hospitals was independently associated with an increased risk of in-hospital mortality (adjusted odds ratio (lowest vs. highest tertile), 2.64; 95% confidence interval, 1.49-4.66), whereas being in the lowest vs. the highest tertile of ASA by volume was not independently associated with risk of in-hospital mortality and adverse events. Conclusion In this contemporary cohort with more than 8,500 cases of SRT between 2006 and 2019, the majority of SRT was performed at centers with a low volume of SM and ASA procedures. Low SM volume was independently associated with increased in-hospital mortality, whereas low ASA volume was not associated with adverse outcomes. Our findings may help to further understand how institutional SRT procedural volumes affects outcomes and might encourage referral of patients with HOCM to centers of excellence for SRT.

Nursing Education for Pediatric Cardiac Care Centers in Developing Countries

Summary&#x0D; Pediatric cardiac programs achieve excellent patient outcomes through the teamwork of a highly capable interdisciplinary team. Nurses are key members of this team, and must possess and highly specialized set of skills and knowledge. A comprehensive nursing education program is needed to develop the necessary skills and knowledge to care for critically ill infants and children with heart disease who are often highly unstable, complex, and vulnerable. Orientation of novice nurses or those who are new to the unit begins with a needs assessment, resulting in a comprehensive plan to achieve required competencies. Nurse residency programs are one method to provide a comprehensive orientation to novice nurses, using a combination of didactic instruction, preceptored clinical experiences, and simulation. An ongoing nursing education plan is also important to refresh skills, especially with high-risk, low-volume procedures, as well as to meet regulatory requirements and develop new skills and knowledge. A key component of the pediatric cardiac nursing education plan is development of preceptors, who provide hands-on instruction to mentor new nurses to develop the needed skills and knowledge, while ensuring that patients receive safe care. Preceptor development can also provide experienced bedside nurses with opportunities to develop their own knowledge and to continue professional development, which helps to positively influence job satisfaction. Numerous resources are available to develop a curriculum or the pediatric cardiac program. Evaluation is also an important component of the nursing education program, to quantify individual as well as programmatic outcomes.

ECMO simulation: How much, who to train, and a review of cost, fidelity and performance.

Extracorporeal Membrane Oxygenation (ECMO) is a high-risk, low-volume procedure requiring repetition, skill and multiple disciplines with fidelity of communication. Yet many barriers exist to maintain proficiency and skills with variable cost and fidelity. We designed and implemented a low-cost monthly ECMO simulation and hypothesized providers would have increased familiarity and improved teamwork. We also review some key elements of cost, fidelity and evaluation of effectiveness. A structured, 1-hour ECMO simulation was performed on a customized mannikin on a monthly basis in 2022. Qualitative surveys were administered to each member post-simulation. Answers were categorized by theme, including satisfaction of patient care, evaluation of self and team dynamics, and areas for improvement. Most participants were satisfied with their ability to take care of the patient, with common themes of communication and coordination of roles. Identified areas of improvement were mostly limited to technical skills, and soft skills such as communication and teamwork. We designed and implemented a low-cost, monthly and multi-disciplinary ECMO simulation program with overall positive feedback and identified areas for improvement. There remains variability in cost, fidelity and evaluation of performance and retention. There may be a need to create guidelines for ECMO simulation training that can be applied at all institutions utilizing ECMO for patient care.

Low-Cost Task Trainer for In Utero Fetal Stent Placement.

Some fetal procedures such as intrauterine fetal stent placement remain rare, and simulation is needed to help learners and specialists in attaining and maintaining technical competence. We sought to design and assess a low-cost, easily assembled yet clinically relevant task trainer for fetal stent placement. The simulator was constructed using 2 quart-sized freezer bags filled with ultrasound gel and sealed with clear packing tape. The bags were stacked vertically in a transparent plastic container with ultrasound gel applied between the bags when ultrasound was used. This task trainer was used to deploy in utero stents with or without the use of ultrasound. It has been used at the annual meeting of the Society for Maternal-Fetal Medicine since 2015, the annual meeting of the International Society of Ultrasound in Obstetrics and Gynecology in 2015 and 2016, and at regional Maternal-Fetal Medicine Fellow simulation workshops since 2016. Participants were asked to complete a 5-point Likert scale survey regarding the model's realism and usefulness in training. One hundred thirty-three course participants evaluated the task trainer. The median rating for realism of the ultrasound images, haptic feel of stent deployment, and usefulness in training was 5 (interquartile range, 4-5). Seven physicians participated in the timed assessment of model assembly, stent deployment, and model reassembly. The average times required for the freezer bag task trainer were 2.3 minutes (2.20-2.35), 1.0 minutes (0.70-1.93), and 0.1 minutes (0.08-0.10), respectively. For the porcine tissue-based model tested in parallel, the average times were 6.0 minutes (5.00-7.06), 3.7 minutes (3.63-3.75), and 3.3 minutes (3.00-3.70), respectively. This low-cost simulator was rated highly when used to practice in utero stent deployment and allows for numerous repetitions in each training session. It could be a valuable tool in training novice providers and allow more experienced providers to maintain competence in this low-volume procedure.

Guideline Compliant Minimum Asymptomatic Carotid Endarterectomy Surgeon and Hospital Volume Cutoffs

There is a known association between volume and outcomes after carotid endarterectomy (CEA). A recent analysis suggested rates of stroke and death do not significantly reduce after a surgeon volume cutoff of 20 CEAs per year. However, these results would severely limit access. The objective here is to identify a lower optimal cutpoint for surgeon and hospital volume for asymptomatic CEA. We evaluated asymptomatic CEA patients using The New York Statewide Planning and Research Cooperative System database from 2000-2014. The relationship of 3-year averaged volumes for surgeons and hospitals to 30-day stroke were assessed using multiple logistic regression and included both hospital and surgeon volume in all analyses. Optimized cutpoints were the lowest significant volume cutoff that minimized the adjusted odds ratio of stroke. We studied 32,549 CEAs performed by 271 surgeons in 136 centers by vascular surgeons. The median surgeon volume was 26.3(IQR:12.3-51.7) and the median hospital volume was 67(IQR:36.3-119.3). The surgeon volume cutpoint was 3 and the hospital volume cutpoint was 6 cases per year. There were 756(2.3%) procedures performed by surgeons with a volume <3 and 560 (1.7%) procedures performed by hospitals with a volume <6. Perioperative stroke and death rates were 2.0% (95%CI:1.8-2.1) and 3.8% (95%CI:2.6-5.5) for an average yearly surgeon volume ≥3 and <3 (p=0.070), respectively. The combined Stroke and death rate was 2.0% (95%CI:1.8-2.1) and 4.8% (95%CI:3.2-7.0) for an average yearly center volume ≥6 and <6 (p=0.007), respectively. A combined surgeon and hospital volume variable also predicted outcomes and low volume procedures did not meet previously proposed AHA and SVS quality measures. These data demonstrate an improvement in outcomes at a lower volume threshold than previously reported. These modest cutoff values should be used for asymptomatic CEA volume guideline formation and for future studies, after accounting for the impact of other important factors that may be driving volume-outcomes relationships in asymptomatic CEA.

Digital workflow for high-risk, low-volume procedure simulation

Introduction: The effectiveness of simulation in medicine for teaching and assessing procedural skills is well documented; however, simulation technologies are not always available due to the high cost of simulators and lack of specific training. With the advances in digital modeling and 3D printing, we can create less expensive, more specific, and more readily available models to represent these tricky procedures, allowing for more robust training of our medical professionals. Methods: The process begins with a radiological scan that is segmented to capture the anatomies associated with the desired condition. We tested two different methods for fabrication; one made on a multi-material poly jet printer and the other using a selective laser sintering (SLS) TPU printer. Results: Our first method produced a model that was not adequate for our use case. The second method produced a model that worked for our use case and captured the geometry well. The SLS printer proved more durable, mechanically accurate, and feasible for simulating massive hemoptysis than method 1. This model was used in the airway management simulations with the PCCM Fellows and was deemed exempt by COMIRB 21-3067, the institutional review board of the University of Colorado Denver | Anschutz Medical Campus. Conclusion: Our method proved to be successful in producing models that are high-detailed, inexpensive, and reproducible to teach specific medical procedures.

AUTHOR REPLY

We appreciate the editorial comments as well as the opportunity to respond. We acknowledge the limitations inherent to public Medicare data, including censoring of surgeons with a low volume of procedures, and inability to capture some procedures done at a low volume. However, we were able to capture volume of more common RLS procedures and include surgeons with >10 cases per year allowing for evaluation of surgeons with more regular and substantive robotic practices. Furthermore, the power and accessibility of the dataset allowed us to approach the novel question of female surgeon involvement in RLS in a meaningful and prompt way.

Improving Staff Workflow in Urology Procedure Clinic Using the Model for Improvement

To maximize procedure volume and minimize workflow inefficiency in our urological procedure clinic, we hypothesized that for staff (nurses/medical assistants) and patient teams, team workflow duration (TWD) (the time required to complete team duties for a single appointment) could be reduced by 50% with a targeted workflow intervention developed using the Model for Improvement and Plan-Do-Study-Act cycles. Workflow inefficiency leads to wasted time and workplace dissatisfaction, resulting in lost revenue due to low procedure volume and high staff turnover. A baseline time study was performed to measure TWD for clinical teams, including the front desk, physician, staff, and patient teams. Implementation of previously identified interventions was also recorded. A workflow intervention was developed in which staff duties were split among two roles: staffer and triager. TWD and intervention implementation were remeasured over six Plan-Do-Study-Act cycles. Semistructured interviews were conducted as a balance measure to assess impact on staff workflow and wellness. Our workflow intervention resulted in a 44% and 42% reduction in staff and patient TWD, saving nearly 17minutes per appointment on average. Thematic analysis revealed that time saved could be best used to protect lunch breaks and allow time to complete nonclinical duties such as patient calls, which had previously been performed after-hours. Introduction of staffer and triager roles to staff workflow increased clinic efficiency by reducing workflow and procedure appointment duration. Time saved was used to increase procedure volume while also supporting staff wellness.

Feasibility issues impacting optimal levels of maternity care in rural communities: implementing the Rural Birth Index in British Columbia

IntroductionThe continued attrition of maternity services across rural communities in high resource countries demands a rigorous, systematic approach to determining population level need, including a clear understanding of feasibility issues that may constrain achieving and sustaining recommended levels of services. The Rural Birth Index (RBI) proposes a robust and objective methodology to determine such need along with attention to the feasibility of implementation.BackgroundPredictions of appropriate levels of maternity care in rural communities require consideration of the feasibility of implementation. Although previous work has focused on essential considerations that impact feasibility, there is little research documenting the barriers to implementation from the perspective of rural care providers and administrators.MethodsWe conducted in-depth, qualitative research interviews with rural community health care administrators and providers (n = 14) to understand the challenges of offering maternity care in 10 rural communities across British Columbia (BC).ResultsParticipants articulated three thematic challenges to providing maternity services in their communities: maintaining clinical skills and financial stability in the context of low procedural volume, recruitment and retention of care providers and challenges with patient transport.ConclusionsCurrent models of compensation for maternity care are inadequate and inflexible and underscore many of the challenges to implementing a level of care that is based on population need. Re-thinking provision of care as a social obligation to actualize our system commitment to equity instead of working to achieve economies of scale is the first step to use equitable care. Addressing remuneration will provide the groundwork for solving other barriers to sustainable care.

Increasing Workflow Efficiency in Urology Procedure Clinic

INTRODUCTION: Workflow inefficiency for urologic procedures leads to wasted time and workplace dissatisfaction, resulting in lost revenue due to low procedure volume and high staff turnover. We hypothesized that for staff (nurses/medical assistants) and patient teams, team workflow duration, the time required to complete team duties for a single appointment, could be reduced by 50% with a targeted workflow intervention developed using the Model for Improvement and Plan-Do-Study-Act (PDSA) cycles. METHODS: A baseline time study was performed to measure team workflow duration for all procedure appointment teams, including the front desk, physician, staff, and patient teams. Implementation of previously identified interventions was also recorded. A workflow intervention was developed in which staff duties were split among 2 overlapping roles: staffer and triager. Team workflow duration and intervention implementation were re-measured during 8 PDSA cycles. Semistructured 1-on-1 interviews were conducted as a balance measure to assess impact on staff workflow and wellness. RESULTS: Our workflow intervention resulted in a 44% and 42% reduction in staff and patient team workflow durations, saving nearly 17 minutes per appointment on average (Figure). Thematic analysis revealed that time saved would be best used to support staff wellness, such as protecting lunch breaks and allowing time to complete nonclinical duties such as patient calls, which had previously been performed after hours. CONCLUSION: Introduction of staffer and triager roles to staff workflow increased clinic efficiency by reducing team workflow and procedure appointment duration. Time saved can be used to increase procedure volume while also supporting staff wellness.Figure

Minimally Invasive Liver Surgery: A Snapshot from a Major Dutch HPB and Transplant Center

BackgroundMinimally invasive liver surgery (MILS) has been progressively adopted on a nationwide scale. The aim of this study is to investigate MILS implementation in a high-volume Dutch hepato-pancreato-biliary and transplant center, which is considered a moderate to low-volume center from a European standpoint.MethodsAll patients who underwent MILS at Erasmus Medical Center between April 2010 and December 2021 were retrospectively reviewed. Patients’ surgical outcomes were compared after stratification according to resections’ difficulty and liver cirrhosis.ResultsA total of 212 cases were included. Major liver resections were performed in 24 patients (11%), while minor resections were performed in 188 patients (89%). Among those, 177 (94%) resections were classified as technically minor and 11 (6%) as technically major. Major morbidity was reported in 14/177 patients (8%) after technically minor resections and in 3/24 patients (13%) after major resections. Anatomically and technically major resections had higher intraoperative blood losses (425 (0–2100) vs. 240 (50–110) vs. 100 (0–2400) mL; p-value < 0.001) and longer hospital stay (6 (3–25) vs. 5 (2–9) vs. 3 (1–44); p-value < 0.001) when compared with the technically minor counterpart. Perioperative outcomes were similar when comparing cirrhotic MILS with the non-cirrhotic cohort.ConclusionMILS program implementation can lead to encouraging surgical outcomes even in low- to moderate-volume centers. Although low procedural volume might be predictive of impaired outcomes, long-standing experience in the HPB and liver transplant field could mitigate low-case volume effects on surgical outcomes.

Surgery for Ulcerative Colitis in the White British and South Asian Populations in Selected Trusts in England 2001-2020: An Absence of Disparate Care and a Need for Specialist Centres.

Over the last decade, there has been extensive evidence that patients with inflammatory bowel disease from minority communities in the UK receive less than optimal care. In none of the studies has the role of surgery in the management of acute and severe ulcerative colitis been considered in any detail. A freedom of information (FOI) request was sent to 14 NHS Trusts in England, which serve significant South Asian populations. Details of the type of surgery patients from the South Asian and White British communities received between 2021 and 2020 were requested. Detailed responses were obtained from eight Trusts. Four hundred and ten White British patients underwent surgery for ulcerative colitis over this period at these eight Trusts, together with 67 South Asian patients. There was no statistically significant difference in the distribution across the types of surgery undergone by the two communities overall (χ2 = 1.3, ns) and the proportions who underwent an ileo-anal anastomosis with pouch (z = −1.2, ns). However, within individual trusts, at the University Hospital Southampton NHS Foundation Trust, a significantly greater proportion of South Asian patients had an ileo-anal anastomosis with pouch compared to White British patients. At Cambridge University Hospitals NHS Foundation Trust, all 72 patients who underwent surgery for ulcerative colitis were White British. This study has shown that, in general, for patients with a severe flare of ulcerative colitis where medical treatment has failed and surgery is warranted, the nature of the procedures offered is the same in the White British and South Asian communities. However, of concern is the number of units with low volume procedures. For most Trusts reported in this study, the overall number of Ileo-anal pouch anastomosis or anastomosis of ileum to anus procedures performed over a number of years was substantially below that required for a single surgeon to achieve competence. These findings reinforce the argument that inflammatory bowel disease surgery should be performed in a limited number of high-volume centres rather than across a wide range of hospitals so as to ensure procedures are carried out by surgeons with sufficient and on-going experience.