Morning List Research Articles

EP.WE.103223-hour stay following total parathyroidectomy in renal patients

Abstract Aim Total parathyroidectomy in end-stage renal failure (ESRF), is an effective way to improve or stabilise calcium and parathormone levels and thus improve renal osteodystrophy. Previous BAEST guidelines were not in favour of true day-case neck surgery due to the risk of airway compromise from bleeding. Additionally, ESRF patients are at risk of profound hypocalcaemia after total parathyroidectomy. Patients undergoing total parathyroidectomy are prescribed Alfacalcidol 4mcg daily for 5 days prior to surgery. Following surgery under GA on a morning list, the potassium and calcium levels are checked in the afternoon. Calcium levels are then monitored daily for 3 days and subsequently when required. Oral Alfacalcidol is continued at the same dose until the nephrologists advise otherwise. Methods All ESRF patients undergoing total parathyroidectomy for secondary hyperparathyroidism were identified between 01/01/2005 and 31/12/2019 from a prospectively maintained electronic database. Demographics, biochemistry, length of stay (LoS) and outcomes were analysed. Results There were 43 (30 male) total parathyroidectomies. The median age was 53 (range 14 – 78), and median LoS 1 day (range 0 -13). 26 patients (60%) were discharged within 23 hours (26% were day-case). Prolonged stay was due to calcium replacement (n = 8) or dialysis (n = 4) requirements. Pre- and post-operative calcium values over 2.49mmol/L were significantly related to 23-hour stay (p = 0.010482 and p = 0.000263 respectively). No 30-day re-admissions were observed Conclusions Careful patient selection and adherence to a perioperative management protocol in total parathyroidectomy may enable early discharge within 23 hours. Preoperative calcium levels help predict this outcome.

Hemiepiphysiodesis: when should it be considered a day-case procedure?

Hemiepiphysiodesis is usually planned as a day-case but patients may stay overnight for pain control. In this study, we assessed the required level of analgesia (LOA) and length of stay (LOS) in patients undergoing hemiepiphysiodesis about the knee joint. We conducted a retrospective cohort study of patients that underwent temporary hemiepiphysiodesis of the distal femur or proximal tibia using hemiepiphysiodesis plates (eight-plates) for coronal plane deformities between January 2012 and October 2019. Demographics, type of procedure, anatomical site, anaesthetic time, preoperative, intraoperative and postoperative analgesia, and time of surgery were collected. Anterior hemiepiphysiodesis and permanent drill epiphysiodesis procedures were excluded. In this series of 79 patients, those with increased American Society of Anesthesiologists Score >1 and patients that were operated on >2 sites required increased LOA, (P < 0.05) and prolonged LOS (P < 0.05). The timing of surgery (morning vs. afternoon list) did not influence LOS or LOA. Patient-controlled analgesia (PCA) was required in 8 of 14 (57%) patients with four growth plates operated on. All (n = 12) patients that received PCA remained in hospital for at least one night. The use of local infiltration intraoperatively played a significant role in early discharge of the patients and t lower the LOA postoperatively (P < 0.05). Parameters including the number of growth plates operated on, use of tourniquet and intraoperative local infiltration can independently influence LOS and LOA postoperatively and at discharge. These parameters should be taken into consideration when consulting with the patient and family and when planning the postoperative course.

Stapled anopexy: An effective treatment for symptomatic haemorrhoidal disease – A district general hospital experience

Stapled anopexy: An effective treatment for symptomatic haemorrhoidal disease – A district general hospital experience

How often does the operating list follow the planned order? An analysis of elective maxillofacial operating lists

ObjectivesThe authors explored consistency of the observed running order in operating sequence compared with prior scheduled listing. We analysed potential variables felt to be predictive in the chances of a patient having their procedure as previously scheduled. MethodsData were retrospectively collected for a consecutive group of patients who underwent elective maxillofacial procedures over a four week period. The consistency of scheduled and observed running order was documented. We considered four independent variables (original list position, day of week, morning or afternoon list, seniority of surgeon) and analysed their relationship to the probability of a patient undergoing their operation as per listing. Logistic regression analysis was used to determine significant associations between predictor variables with an altered list order. ResultsData were available for 35 lists (n = 133). 49% of lists were found to run according to prior given order, the remainder subject to some alteration. Logistic regression analysis showed a statistically significant association between original scheduled position and day of week, with list position consistency. Patients listed first were twelve times more likely to have their operation as listed compared to those placed fourth (OR 12.7, 95% CI 3.7–43, p < 0.05). Operating lists at the start of a week were subject to less alteration (p < 0.05). There was no demonstrated relationship between the grade of surgeon operating and alteration in operating sequence. ConclusionApproximately half of lists showed some alteration to the previously printed order. It appears that being first on an elective list offers the greatest guarantee that a patient will have their operation as per prior schedule. It may be reasonable for clinicians to be mindful of potential operating list alterations when preparing their patients for elective surgery.

Theater Sending: How Long Does It Take and What Is the Cost of Late Starts?

Last minute cancellations of scheduled surgery are a waste of health care resources and an emotional burden on patients. A common reason for cancellation is poor theater time utilization. Several studies have demonstrated that in some cases 50% of lists overran their scheduled time and more than 40% started late. In a recent prospective study of 55 elective gynecological operations, 25% of the theater session was wasted by delays related to transfer of patients to and from the operating theater; the median waiting time between cases was 22.5 minutes for surgeons and 7 minutes for anesthetists. The aim of this retrospective study was to examine the theater transit of patients through theaters and estimate the cost of delays, especially the cost of late starts. The study subjects were 238 patients undergoing elective gynecological operations during a 3-month period in 2008 at a single hospital. After exclusions, 164 patients were included in the final analysis. Primary study outcome measures included time to send, time for anesthesia, and procedure time. Secondary outcome measures included time to send for the first patient (calculated as waiting time resulting from late starts) and the estimated cost of late starts. The mean time to send (time between sending and arrival in anesthetic room) was 19 ± 8.1 minutes; the 95% confidence interval [CI] was 18 to 20. The mean time for anesthesia (time between arrival in anesthesia room and arrival in theater) was 9 ± 6.4 minutes (95% CI: 8–10). The mean procedure time (time between arrival in theater and end of procedure) was 60 ± 35 minutes (95% CI: 55–65). The mean time to send for the first patient on the morning list (representing the mean wait time of the surgical team for the first patient) was 20 ± 9.83 minutes (95% CI: 17–23). The delayed arrival of the first patient resulted in a late start in 93% of morning lists. The mean wait time of the surgical team after the first patient on the morning list was due to start was 22 ± 19 minutes (95% CI: 17–27). During the 3-month study period, the total time wasted as a result of late starts was 910 minutes (15 h) at an estimated cost of £3640. The investigators conclude from these findings that sending patients 30 minutes before the list is due to start could increase theater efficiency and save 15 hours of currently wasted time.

Theatre sending: how long does it take and what is the cost of late starts?

This study seeks to identify areas of poor utilisation of theatre time and estimate the cost of late starts. Retrospective study of elective gynaecological operations from September to November 2008 in a district general hospital was conducted. Primary outcome measures were time to send, time for anaesthesia and procedure time. Secondary outcome measures were time to send for the first patient and cost of late starts (N = 164). The mean time to send was 19 ± 8.10 min (95% CI: 18–20). The mean time for anaesthesia was 9 ± 6.40 min (95% CI: 7.91–9.86). The mean procedure time was 60 ± 35 (95% CI: 55–65). On average time to send for the first patient on the morning list took 20 ± 9.83 min (95% CI: 17–23) and resulted in 93% of lists starting late. The surgical team waited a mean of 22 ± 19 min (95% CI: 17–27) for the first patient to arrive after the list was due to start. Total time wasted on late starts was 910 min (15 h), costing an estimated £3,640 over the 3-month period. This figure is based on local theatre staff wages of £236.30 per hour. Sending for patients 30 min before the list is due to start is an auditable standard that could increase theatre efficiency and enable 15 h of currently wasted resources to be used to shorten waiting lists and enhance staff training opportunities.

Morning or afternoon emergency list? Effects on service provision and training

Background In response to the recommendations of the National Confidential Enquiries into Perioperative Deaths many UK hospitals have introduced a half day (morning or afternoon) planned list for emergencies. We have compared two district general hospitals (DGH A and DGH B) within the same Trust with an afternoon and a morning list, respectively, and examine whether there is any effect on the emergency and urgent laparotomy workload. Methods We conducted a retrospective comparative audit of emergency and urgent laparotomies performed in a six-month period at the two hospitals. The chi-square test was used for statistical analysis. Results In DGH A and DGH B, 79 and 73 laparotomies were performed, with 18% and 22% mortality, respectively, ( p = 0.609). The median age was 74 (18–93) years and 67 (12–92) years and the median postoperative stay was 12 (1–149) days and 14 (4–74) days, respectively. 59 laparotomies were performed during weekdays in DGH A and 51 in DGH B. There was no difference between hospitals in the seniority of the operating surgeon or the level of supervision. DGH A accommodated 24% of its laparotomies on the afternoon emergency list, 39% on elective lists, 29% in the evening, and 8% at night. DGH B accommodated 33% of its laparotomies on the morning emergency list, 8% on elective lists ( p = 0.001), 51% in the evening ( p = 0.063), and 8% at night. Overall 63% of laparotomies in DGH A and 41% in DGH B were done during daytime. Conclusion Less than one-third of laparotomies were performed on the emergency list, suggesting underutilisation. The seniority of the surgeon and the level of supervision were similar at both sites. Neither morning nor afternoon proved better in terms of service provision or training opportunities. By accommodating laparotomies onto an elective list DGH A reduced the number of laparotomies performed in the evening.

Is nasal packing really required after septoplasty?

Septoplasty is one of the most common operations performed by otorhinolaryngologists. Nasal packing is not an innocuous procedure. The most common problem encountered by the patients after septoplasty is the pain and discomfort during removal of the nasal packs. The objective of this study was to evaluate the results of septoplasty without postoperative nasal packing. Septoplasty was performed by standard technique. No nasal packing was used in these cases. Seventy-eight patients were included in the study. The majority of the patients (64.1%; 50/78) on a morning list were operated. Sixty-two patients were discharged home the same day, the remaining others were discharged the next day. Our postoperative haemorrhage rate was 7.7% (6/78) and only 3.8% (3/78) patients required nasal packing. Majority (84.6%) of the patients were satisfied with the operation at the postoperative follow up 3 months later. Septoplasty can be safely performed without postoperative nasal packing. Only 3.8% patients required nasal packing in this study.

Defining efficiency requires more fidelity

Defining efficiency requires more fidelity

Endoscopy or colonoscopy guidelines for patients with diabetes

AbstractLocal pilot guidelines for patients with diabetes undergoing an endoscopy or colonoscopy as an out‐patient were developed to reduce patient anxiety and the risk of hyperglycaemia and hypoglycaemia prior to and during their procedure. Audit was used as a tool to evaluate the guidelines.The audit highlighted that very few patients treated with insulin are prioritised to have their procedure early on the morning list.The results demonstrated that, of the 12 patients who normally experienced at least one hypoglycaemic episode (blood glucose &lt;4mmol/L) a week, none reported an increase in hypoglycaemia experienced, and five patients had improved control. Of the 28 patients who did not normally experience at least one hypoglycaemic episode a week, all patients continued to be free from hypos. Of the six patients who normally experienced at least one hyperglycaemic episode (≥15mmol/L) a week, none reported an increase in the frequency of their hyperglycaemia, and two patients had improved control. Of the 34 patients who did not normally experience at least one hyperglycaemic episode a week, 32 patients reported no increase in the frequency of hyperglycaemia. However, two patients reported transient asymptomatic hyperglycaemia.The guidelines have assured standardisation of advice now given to patients, and enabled elective patients treated with insulin to be scheduled first on the morning list. Contact with a diabetes specialist nurse has enabled patients to access specialist advice regarding their general diabetes management that they would otherwise have not received. Copyright © 2006 John Wiley &amp; Sons, Ltd.

Suitability of paediatric patients for day case adenoidectomy/tonsillectomy surgery

Background: Adenotonsillectomy has been identified as a procedure that can be safely performed as a day case given certain social and medical criteria. Previous studies have found conflicting results regarding the proportion of suitable patients, particularly regarding inner city populations.Methods: All patients aged 3 years or more under the care of Manchester Children's Hospitals who were admitted for adenotonsillectomy, tonsillectomy or adenoidectomy in a 4-month period beginning 4 March 2002 were prospectively assessed for their suitability for day case surgery.Results: Following exclusion for pre- and postoperative and social contraindications, 68% of children were found to be suitable for day case surgery. When combined with parental preference, this fell to 38%.Conclusions: Day case adenotonsillectomy is possible in a reasonable proportion of children in Manchester. It should be performed on a morning list and clear written guidelines must be provided to reassure parents.

It's the way you tell'em

Be it in leaflets, on the internet, or in the pages of a magazine, information for patients is seen by some clinicians as, at best, a threat and, at worst, a whole new disease. Simply put, some more traditional doctors seem to believe that there are things physicians know that patients should not. If every Tom, Dick, or Harry thinks he's someone from ER, your chances of getting through that morning's list are severely depleted.

Latex allergy - potentially a painful postoperative problem

A healthy young woman presented for a subtotal hysterectomy on a routine gynaecology list with two relevant anaesthetic problems. During a previous anaesthetic, facial oedema had developed after the application of a facemask and a diagnosis of latex allergy had been made. No other information was known about this incident. Second, she was a Jehovah's Witness. Consequently, all reasonable precautions were implemented. The Trust policy on latex allergy was consulted, the patient placed first on the operating list to minimise the level of latex antigen in the atmosphere and latex-free equipment substituted where necessary. The risks of surgery were discussed with the patient and a latex-free (unprimed) blood salvaging autologous transfusion device was available in the operating theatre with the patient's consent. General anaesthesia was administered and the procedure performed without complication. The total blood loss was approximately 400 ml. As a result of being the first case on the morning list and the inherent organisation required to ensure safety due to the latex allergy and religious beliefs, it was not until near the end of the procedure that potential difficulties with postoperative analgesia became apparent. During the case, nitrous oxide and intravenous morphine had provided good haemodynamic stability. At this stage the possible options for postoperative analgesia were: 1 morphine patient-controlled analgesia (PCA); 2 epidural infusion of a local anaesthetic agent; 3 epidural diamorphine bolus; 4 intrathecal morphine; 5 intramuscular morphine + bilateral ilio-inguinal nerve blocks + nonsteroidal anti-inflammatory drugs. Morphine PCA was the preferred method but, although being of appropriate size, the available latex-free syringes were incompatible with all of the hospital delivery devices. The latter only accepted syringes with latex-containing bungs. Despite the low risk to the patient from this source [1], it was decided not to take this option. Unfortunately, the same problem arose when considering an epidural infusion of a local anaesthetic agent. Options 3 and 4 were rejected because of the uncertain additive respiratory depressant effects of morphine, which had been given intravenously during the procedure. Therefore, analgesia was achieved by performing bilateral ilio-inguinal blocks at the end of the procedure, followed by small (2.0 mg) intravenous increments of morphine given in the recovery room and thereafter, with intramuscular morphine and regular nonsteroidal analgesics. Intramuscular morphine was given according to the hospital algorithm for administration on an hourly as required basis [2]. A satisfactory level of analgesia was achieved with this approach. All hospitals should have in place protocols for the treatment of patients and staff who have allergy to latex. One possible difficulty is the provision of postoperative analgesia. As a result of this case epidural packs stocked within our hospital are now all latex free and the list of latex-free equipment has been adjusted accordingly. It is also possible to obtain latex-free syringes compatible with contemporary PCA syringe drivers. Indeed, as the incidence of latex allergy seems to be increasing, the pain team have set up a PCA system, which is only to be used by patients with latex allergy. However, should this equipment be unavailable, other forms of analgesia such as intrathecal opiates, peripheral nerve blocks or intermittent intramuscular opiates can be used. In addition, with a Jehovah's Witness who consents to the use of autologous blood transfusion, that apparatus must not contain, or be contaminated with, substances containing latex.

Forty years on.

It was 10 00 am and John Smith, BMedSci (Open University), MB (Harvey School of Medicine), FRCS (UK), MD, PhD (Scunthorpe), was very bored. He had tried to spin out his morning list but had been unable to pretend that his first case, a dermoid, was anything but simple. Worth a frozen section though, you could never be too careful. He was taking a respite before the last remaining operation and had left his senior registrar to close the wound and registrar to apply the povidone dressing. As the decaffeinated coffee arrived through the wall hatch there was time for reflection. What would he do with himself when he retired next year At 50 he might live another 60 years. He flipped a Mannitol spansule into the drink to ease his congested nose. It could not be any more dull than at present though. After all, there was very little left to operate on. As a student he had seen some of the very last cases of peptic ulc?ration, the addition of cimetidine to the water supply had seen to that. Nursery school bran had replaced cod liver oil, and this had made extinct most diseases of the large bowel. As a houseman he could just remember the theatre crowded with excited observers as a blustering Sir Heneage Hopkinson explored a diverticular abscess. It's 10 years since I last saw one of these! he extolled, gleefully splashing the pus about. Pass the sucker please, nursey. what, Sir ? Of course medical research had a lot to answer for. He pontificated with some anguish and had to shift the weight off his chrome-cobalt ischial tuberosity acquired after a mishap on a Space Shuttle package holiday. Regrettably nearly all disease could be treated medically or simply prevented from even occurring. He mused over some scientific milestones. The latter day scourges of blackheads, baldness, piles, and halitosis had all met with their respective cures, severely diminishing waiting lists and general practitioners' surgeries. Interferon had seen off practically all infections, even the common cold. Gall stones could be dissolved in a few hours with a simple tablet. Cancer melted away with Rubean. This derivative of runner bean had been discovered by pure chance. A laboratory technician had been surreptitiously eating his lunch near a tumour tissue culture and, as his knife skidded across the plate on cutting his tough steak, a piece of runner bean fell in. He hid the bottle. Some days later the culture was found to be dead, and the terrified technician became famous. Atheroma was certainly caused by cigarettes but its severity did not fall when imitation tobacco was made compulsory. Of course it didn't, the causative agent was in the paper. Cigarettes were now made of shredded tobacco glued into columns and very nice they were too. There was so little trauma. Private transport had recently been abolished, and the safety record of the State system was 100%. There was no street violence as there were simply no streets. Mental illness had vanished with the addition of endorphin to table salt. Fortunately, it was stable with iodine, magnesium, caffeine, and stilboestrol. Irony furrowed his brow and dimpled his cheeks. Here he was being rueful about his present lot when he was partly responsible for vanquishing appendicitis. His friend Arnold had really cracked it though, one of the last great unknowns of medical science had yielded its secrets. For some years Arnold's exclusive task had been to delineate the cause of appendicitis and he had found it. The application of an epsilon-squared Pupil's S test had proved it conclusively. He relived the secretive childish titter he had enjoyed as he had enumerated the previous incriminations: tobacco inevitably, autoimmune inflammation, aspirin, and salami rind. Nor was it lack of bran. Of course, Africans emigrating to the United States increased their incidence of appendicitis but it wasn't the fibre. Oh no, it was the talcum powder. And that was why it was commoner in children: mothers smothering their kiddies in the stuff. To think, from then on every container had to carry a government health warning. With sadness he recalled bidding Arnold farewell. No longer needed, Arnold, a computer, was switched off, closing down his memory banks forever.