Non-emergency Patients Research Articles

An Analysis of Orthopedic Surgical Services Provided to Syrian Refugees in a Health Center Away from the Syria District

Background: The Arab Spring, a wave of demonstrations and protests that hadtaken place in the Arab world since December 18, 2010, had also affected Syria. Thenumber of Syrian refugees who have migrated to Turkey is over 3.5 million.Objective: The aim of this study was to evaluate the demography, clinical featuresand invoice amounts of Syrian refugee patients who were operated in an orthopedicand traumatology clinic of a healthcare institution far from the Syria district region.Materials and Methods: For this purpose, 329 Syrian patients who underwentsurgery in the field of orthopedics and Traumatology between June 2011 and 2018were enrolled in the study. The records of Syrian refugees have been retrospectivelyexamined.Results: Male applicants (76.3%) were more than females (23.7%).%). It was observedthat the highest number of applications were in the field of microsurgery (21.3%),followed by trauma (20.7%) and pediatric orthopedics (14.6%), respectively. Includingthe non-emergency trauma patients, 90% of the patients underwent elective surgerieswhile 10% underwent emergency surgeries. It was determined that the average invoiceamount was 4987 TL (min: 207 TL, max: 87541 TL) and the highest cost was in thefield of vertebral surgery (average 19384 TL). The rate of emergency applications hasshown a significant increase in 2016 and later (2016-2017-2018) compared to 2015 andbefore .Conclusion : The main Syrian refugees patient profile of the health centers far fromthe war zone is composed of elective cases and their costs.Key words: Health Services Accessibility–Hospital Costs–Orthopedic Procedures–Refugees–Syria

Harmonic Scalpel for Internal Mammary Artery Harvest

Internal mammary artery (IMA) harvest by using a harmonic scalpel for coronary artery bypass grafting (CABG) have not been sufficiently evaluated. This review aimed to assess the outcomes of IMA harvest by a harmonic scalpel and to compare by conventional electrocautery. The study materials were based on literature retrieval. In total Eight articles describing IMA harvest by a harmonic scalpel for 1,893 patients, and pateints with IMA harvest by electrocautery were taken as controls. IMA harvest by a harmonic scalpel was associated with less thermal injury with potentially better preservation of the endothelial cells, satisfactory intraoperative IMA flow, and promising postoperative IMA patency. Apart from the harvesting merits, the harmonic scalpel had many other advantages in terms of clinical outcomes, such as decreased postoperative mortality and morbidity rates. Nevertheless, IMA harvesting by using a harmonic scalpel is associated with longer harvest time, prolonged operative time, and increased hospitalisation expenses. Therefore, they could be used in selected and non-emergent patients for CABG. Key Words: Coronary artery bypass grafting, Internal mammary artery, Surgical instruments.

The Positive Impact of Establishing an Internal Transfer Center

Health systems are facing greater pressures than ever before, with factors ranging from mergers and acquisitions and changing reimbursement models to capacity challenges and staffing shortages. A transfer center, where with 1 simple call from a referring physician, a decision to accept a critically ill patient can be made, placing them at the most appropriate level of care, the first time. Baptist Health in Jacksonville, Florida, went from an outsourced to an in-house center in 3 months—in the first 28 days alone, patient transfers increased from 900 to 1,500, growing to an average of 1,583 transfers per month.

Clinical pearls to managing men's health conditions during the COVID-19 pandemic.

In late 2019, a novel coronavirus (Sars-CoV-2) was identified in Wuhan, China.1 Subsequently, the rapid spread of the coronavirus disease 2019 (COVID-19) around the world has resulted in the declaration of a pandemic by the World Health Organization,2 with resulting massive changes in societal behaviors. COVID-19 has had a devastating impact on many of those afflicted with the condition, but the pandemic has also had a dramatic effect on healthcare delivery for those patients without COVID-19. In preparation for expected increased hospital resource needs, most centers have limited or cancelled all elective surgical procedures. Furthermore, in accordance with new social distancing norms, clinical encounters for non-emergent patients have shifted, when possible, to virtual visits. Urologic surgical care in Canada has undergone a substantial shift to only offering surgery for emergencies and urgent oncology cases. Most of the “bread-and-butter” urology, including the entire subspecialty of men’s health and andrology, does not qualify as emergent or even urgent care. Surgeries have been postponed indefinitely for most men requiring intervention for the management of infertility, sexual health, voiding dysfunction, and chronic urological pain. Thankfully, men’s health is an ideal field for virtual care (either by telephone or by video calling) given the many medical and patient education options for treatment. There have been several studies across a variety of specialties that appear to show that virtual visits do not worsen outcomes, and in some cases even improve care.3–7 Two studies within the field of urology have been completed showing no adverse outcomes in a general urology virtual followup clinic and in a virtual clinic focused on renal colic.8,9 With the fluid nature of a pandemic scenario, it is unclear when we will once again have access to surgical and clinical resources to provide the standard care for our patients. As a result, we aimed to bring together some of Canada’s urologic leaders in men’s health to provide pearls and pitfalls regarding the management of common men’s health conditions during the pandemic using the virtual care model. A group of urologists from across Canada with expertise in the area of men’s health were invited to provide expert commentary on management of some common men’s health conditions during the COVID-19 pandemic. Each of the experts on the panel was provided with a set of standardized written questions (Table 1) to answer. The answers were edited by authors LW, RF, and KJ to fit into a standardized report. The goal of this manuscript is to provide expert guidance to our urology colleagues on how to safely provide virtual care for patients with some of the common men’s health conditions, and to provide a resource to our primary care colleagues to understand the options available to the consultant urologist assessing these patients. Table 1 Question’s provided to manuscript authors

Comparison between simple triage and rapid treatment and Taiwan Triage and Acuity Scale for the emergency department triage of victims following an earthquake-related mass casualty incident: a retrospective cohort study

BackgroundTriage plays a crucial role in the emergency department (ED) management of mass casualty incidents (MCIs) when resources are limited. This study aimed to compare the performance of simple triage and rapid treatment (START) with that of the Taiwan Triage and Acuity Scale (TTAS) for the ED triage of victims following an earthquake-related MCI.MethodsWe retrospectively reviewed the records of victims presenting at our ED with earthquake-related injuries within 24 h of a large-scale earthquake. TTAS was initially used at our ED for this event, and START was performed by retrospectively reviewing the patient records in a blinded manner. Area under the receiver operating characteristic curve (AUC), sensitivity, and specificity of START and TTAS were determined for predicting ED discharge.ResultsWe enrolled 105 patients (predominantly women, 60.0%; median age, 45.0 years) in this study; most of them presented with traumatic injuries and were initially triaged as TTAS level III (78.1%), followed by TTAS level II (11.4%). Although the majority of the victims (81.0%) were discharged, four deaths occurred. A moderate agreement in differentiating emergency from nonemergency patients was observed between START and TTAS. Furthermore, both the triage systems showed similar predictions for ED disposition (START AUC/sensitivity/specificity: 0.709/82.35%/55.00%; TTAS AUC/sensitivity/specificity: 0.709/90.59%/45.00%).ConclusionsThe present study demonstrated that START and TTAS have similar triage accuracy and ability to predict ED disposition. Our findings demonstrate that START may be used as an alternative to TTAS for the ED triage of victims following earthquake-related MCIs.

A systematic review and meta-analysis of the effects of early mobilization therapy in patients after cardiac surgery

Background:Prolonged hospitalization and immobility of critical care patients elevates the risk of long-term physical and cognitive impairments. However, the therapeutic effects of early mobilization have been difficult to interpret due to variations in study populations, interventions, and outcome measures. This systematic review and meta-analysis aims to assess the effects of early mobilization therapy for non-emergency cardiac surgery patients in the intensive care unit (ICU).Methods:The following databases will be used to search for relevant keywords: PubMed, Embase, CINAHL, PEDro, and the Cochrane Library from inception to September 2018 by 2 researchers independently. Randomized controlled trials (RCTs), will be included if patients are adults (≥18 years) admitted to any ICU for cardiac surgery due to cardiovascular disease and who are treated with experimental physiotherapy initiated in the ICU (pre, post, or perioperative). The Review Manager 5.3 will be used for meta-analysis and the evidence level will be assessed by using the method for Grading of Recommendations Assessment, Development, and Evaluation (GRADE). Continuous outcomes will be presented as the weighted mean difference (WMD) or standardized mean difference (SMD) with 95% confidence interval (CI), while dichotomous data will be expressed as relative risk (RR) with 95% CI. If the included studies have existing heterogeneity (P < 0.1), a random-effects model will be used. Otherwise, we will calculate using a fixed effects model.Results:This review will evaluate the effects of early mobilization on length of ICU and hospital stay, physical function and adverse events in patients with cardiac surgery patients in the ICU.Conclusion:This systematic review will comprehensively provide conclusive evidence of the therapeutic effect of early mobilization on cardiac surgery patients in the ICU.PROSPERO Research registration identifying number: CRD42019135338.

Pediatric ophthalmology in the era of covid-19: management of emergent non-emergent patients

Coronavirus disease 2019 (COVID-19) is an ongoing pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) When patients come to an ophthalmologist's offi ce for ocular examination, these patients have direct contact with examination equipment Recent reports suggested that ocular surfaces may be a potential mode of SARS-CoV-2 transmission an d that ophthalmologists are highly prone to getting infected Pediatric patients and managing their ophthalmologic conditions have its unique challenges The purpose of this review is to provide useful guidelines, targeted at pediatric ophthalmology professionals, to minimize COVID-19 infection of both health-care workers and patients [ABSTRACT FROM AUTHOR] Copyright of Retina-Vitreus/Journal of Retina-Vitreous is the property of Retina-Vitreus and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission However, users may print, download, or email articles for individual use This abstract may be abridged No warranty is given about the accuracy of the copy Users should refer to the original published version of the material for the full abstract (Copyright applies to all Abstracts )

종합병원 응급실의 공간별 색채 환경 분석

In modern society, the range of emergency patients is gradually expanding due to the increase of traffic accidents, suicide, aging of elderly patients, the increase of adult diseases, disasters or disasters, and the increase of the number of non-emergency patients who visit emergency rooms during the night or on holidays. For this reason, the general hospital emergency room accommodates more than one patient per second and performs emergency care in an overcrowded state, and as a result, the emergency room should be a place for original healing and recovery, but patients with internal medicine are in a contradictory situation where they feel negative emotions such as fear, fear, boredom, and anger. In addition, the emergency room is a place used by protectors, doctors, and nurses in addition to patients, and is divided into users to provide patient recovery or waiting and resting functions, and is functionally planned as an efficient workplace for medical staff. Color is one means of meeting these needs effectively. The emergency room of the general hospital determines the focus of the color plan by considering the main users and functions of each space, and shows a tendency to use different colors in different spaces.

Two-Tiered Ambulance Dispatch and Redeployment considering Patient Severity Classification Errors.

A two-tiered ambulance system, consisting of advanced and basic life support for emergency and nonemergency patient care, respectively, can provide a cost-efficient emergency medical service. However, such a system requires accurate classification of patient severity to avoid complications. Thus, this study considers a two-tiered ambulance dispatch and redeployment problem in which the average patient severity classification errors are known. This study builds on previous research into the ambulance dispatch and redeployment problem by additionally considering multiple types of patients and ambulances, and patient classification errors. We formulate this dynamic decision-making problem as a semi-Markov decision process and propose a mini-batch monotone-approximate dynamic programming (ADP) algorithm to solve the problem within a reasonable computation time. Computational experiments using realistic system dynamics based on historical data from Seoul reveal that the proposed approach and algorithm reduce the risk level index (RLI) for all patients by an average of 11.2% compared to the greedy policy. In this numerical study, we identify the influence of certain system parameters such as the percentage of advanced-life support units among all ambulances and patient classification errors. A key finding is that an increase in undertriage rates has a greater negative effect on patient RLI than an increase in overtriage rates. The proposed algorithm delivers an efficient two-tiered ambulance management strategy. Furthermore, our findings could provide useful guidelines for practitioners, enabling them to classify patient severity in order to minimize undertriage rates.

The correlation between perceived communication quality and customer satisfaction at Bhayangkara Hospital Emergency Department, Indonesia

Overcrowding at emergency department with domination of non-emergency patient based on triage process could lead to the decrease of communication quality from the care giver. An approach through communication media at hospital should be optimized to fulfill the information needs from the customer. This study aimed to identify the correlation between the communication quality and the customer satisfaction can give us a better understanding to improve our service at emergency department. A questionnaire to measure perceived communication quality of care giver (consists of communicator and media aspects) and customer satisfaction was given to patient or his/her guardian at emergency department. The sample size of 93 had been validated from 100 questionnaires collected. The regression test result is significant for both communicator aspects (sig 0.000) and information media (sig 0.011) with p&lt;0.05. The perceived communication quality both communicator and media aspect is correlated with customer satisfaction. Thus, understanding and improvement in those factors are important to increase customer satisfaction especially at emergency department where situations are often busy and care givers tend to underestimate the importance of communication.

Postoperative Craniotomy Pain in Emergent versus Non-emergent Cases.

Background: Postoperative pain control in craniotomies poses multiple challenges. Pain must be addressed, but the use of medications must be weighed against risks. Craniotomies risk neurologic injury and so postoperative examinations are critical. Medications used to address pain can alter the neurological examination or cause bleeding leading to misdiagnosis of complications.Objective: Determine if there is a significant difference in postoperative pain from emergent craniotomies vs. non-emergent craniotomiesMethods: A retrospective review included 102 cases performed from 2010-2016; pain scores were compared on post-operative days one, two, and three between emergent and non-emergent craniotomies.Results: Pain scores for emergent cases on post-operative days one through three were 5.1 (standard deviation (SD)=2.9), 5.9 (SD=2.1), 4.7 (SD=3.0) respectively. Pain scores for non-emergent cases on post-operative days one through three were 5.7 (SD=2.6), 4.8 (SD=2.8), and 4.6 (SD=3.0) respectively. A one-way analysis of variance (ANOVA) was conducted to compare pain scores between groups for each post-operative day. On post-operative day, one there was no significant difference between the groups [F(1,100)=0.49, p=0.485]. On post-operative day two, there was no significant difference between the groups [F(1,100)=2.17, p=0.143]. On post-operative day three, there was no significant difference between the groups [F(1,98)=0.002, p=0.957].Conclusion: There is no significant difference in the level of pain on postoperative days one through three between emergent and non-emergent craniotomy patients.

Diagnostic Value and Safety of Emergency Single-Balloon Enteroscopy for Obscure Gastrointestinal Bleeding.

Background This study assesses the diagnostic performance of emergency single-balloon enteroscopy (SBE) for obscure gastrointestinal bleeding (OGIB) under general anesthesia versus conscious sedation. Study The data of 102 OGIB in-patients from June 2015 to June 2018 were retrospectively analyzed. The diagnosis and detection rates and adverse events were calculated overall and in relation to age, gender, type of operation and anesthesia, bleeding type, different times of examination, and SBE route. All statistical analyses were performed using SPSS 24.0, and the diagnosis and detection rates were compared using the Chi-square test. Results Among the 102 patients, 66 patients had positive findings, while 11 patients had suspected positive findings, and the diagnosis and detection rates were 64.7% and 75.5%, respectively. Ulcers (19.6%) and tumors (16.7%) were the most common causes of OGIB. There were no statistical differences in diagnosis and detection rates between the ages of ≥60 and <60 and between different genders. Patients with emergency SBE had higher diagnosis and detection rates (68.6% vs. 35.3%, P = 0.023; 80.0% vs. 47.1%, P = 0.016, respectively), when compared with nonemergency SBE patients. The diagnosis rate at 24 hours was higher than that at 2-7 days and one week (88.0% vs. 61.5%, P = 0.030; 88.0% vs. 53.8%, P = 0.007). For overt bleeding, the difference in diagnosis rates at 24 hours, 2-7 days, and one week was statistically significant (100.0% vs. 57.1%, P = 0.006; 100.0% vs. 57.1%, P = 0.006). For occult bleeding, the pairwise comparison revealed no statistical difference. Patients with general anesthesia had a higher detection rate, when compared to patients with conscious sedation (87.9% vs. 63.9%, P = 0.004). In addition, adverse events under general anesthesia were lower, when compared to adverse events under conscious sedation (28.8% vs. 69.4%, P = 0.020). There was no significant difference in adverse events at the different time points (P > 0.05). Conclusion Emergency SBE under general anesthesia achieves higher diagnosis and detection rates, and fewer adverse events under conscious sedation, when compared to nonemergency SBE, regardless of the route. For patients with overt bleeding, it is easier to find lesions by emergency SBE within 24 hours.

Chemoembolization with HepaSpheres in the treatment of recurrent pelvic tumors

Transarterial chemoembolization of the main vessels feeding the tumor is a minimally invasive procedure, which is intended to block off the blood supply to the tumor and to deliver a cytotoxic agent to tumor cells. Initially, this method was used in emergency cases, but later it gained the trust of clinicians, who began to use it in non-emergency patients with clinical manifestations, when angiography showed well-supplied tumors inaccessible for ablation or surgical removal, including those in non-standard difficult cases. Selective catheterization of dominant arteries in recurrent tumors along with chemoembolization with drug-eluting microspheres is extremely challenging, since most of recurrent tumors have a well-developed neovascular network. HepaSphere microspheres, due to their hydrophilicity and high biological compatibility with tissues, allow the deposition of a chemotherapeutic agent in the tumor. This therapy provides pronounced hemostatic and antitumor effects confirmed by morphological and immunohistochemical examination. Currently, transarterial chemoembolization is mainly used for primary tumors and becomes increasingly popular as an element of combination therapy for patients with pelvic tumors. In this article, we analyze clinical data for 14 patients with recurrent pelvic tumors who underwent chemoembolization with HepaSpheres loaded with doxorubicin or irinotecan as a part of their palliative care.

Interfacility neurosurgical transfers: an analysis of nontraumatic inpatient and emergency department transfers with implications for improvements in care.

Interfacility neurosurgical transfers to tertiary care centers are driven by a number of variables, including lack of on-site coverage, limited available technology, insurance factors, and patient preference. The authors sought to assess the timing and necessity of surgery and compared transfers to their institution from emergency departments (ED) and inpatient units at other hospitals. Adult neurosurgical patients who were transferred to a single tertiary care center were analyzed over 12 months. Patients with traumatic injuries or those referred from skilled nursing facilities or rehabilitation centers were excluded. A total of 504 transferred patients were included, with mean age 55 years (range 19-92 years); 53% of patients were women. Points of origin were ED in 54% cases and inpatient hospital unit in 46%, with a mean distance traveled for most patients of 119 miles. Broad diagnosis categories included brain tumors (n = 142, 28%), vascular lesions, including spontaneous and hypertensive intracerebral hemorrhage (n = 143, 28%), spinal lesions (n = 126, 25%), hydrocephalus (n = 45, 9%), wound complications (n = 29, 6%), and others (n = 19, 4%). Patients transferred from inpatient units had higher rates of surgical intervention (75% vs 57%, p < 0.001), whereas patients transferred from the ED had higher rates of urgent surgery (20% vs 8%, p < 0.001) and shorter mean time to surgery (3 vs 5 days, p < 0.001). Misdiagnosis rates were higher among ED referrals (11% vs 4%, p = 0.008). Across the same timeframe, patients undergoing elective admission (n = 1986) or admission from the authors' own ED (n = 248) had significantly shorter lengths of stay (p < 0.001) and ICU days (p < 0.001) than transferred patients, as well as a significantly lower total cost ($44,412, $46,163, and $72,175, respectively; p < 0.001). The authors present their 12-month experience from a single tertiary care center without Level I trauma designation. In this cohort, 65% of patients required surgery, but the rates were higher among inpatient referrals, and misdiagnosis rates were higher among ED transfers. These data suggest that admitting nonemergency patients to local hospitals may improve diagnostic accuracy of patients requiring urgent care, more precisely identify patients in need of transfer, and reduce costs. Referring facilities may lack necessary resources or expertise, and the Emergency Medical Treatment and Active Labor Act (EMTALA) obligates tertiary care centers to accept these patients under those circumstances. Telemedicine and integration of electronic medical records may help guide referring hospitals to pursue additional workup, which may eliminate the need for unnecessary transfer and provide additional cost savings.

Evaluating the Causes and Frequency of Frequent Referral to the Emergency Department of Imam Khomeini Educational Hospital in Sari

Introduction: Emergency department is one of the most important units of a hospital. In general, the most serious cases are referred to emergency department, and the highest numbers of hospital admissions occur in the emergency department. This study aimed to obtain a comprehensive estimate of the number of frequent visitors to the emergency department of Imam Khomeini educational hospital, Sari. Materials and Methods: This cross-sectional descriptive study was performed retrospectively by referring to the patient medical records at the Sari Imam Khomeini education hospital. The records were screened to identify frequent emergency department visitors in 2017. Data analysis was performed using SPSS 21. Results: The number of emergency department visitors in the Sari Imam Khomeini Hospital in 2017 was 29,765; of them, 594 (6.2%) were repeat visitors and were included in this study. The mean age of the frequent emergency department visitors was 56.17 years. The most common complaint was weakness and lethargy in 39.9% patients, abdominal pain in 30%, shortness of breath in 14%, and other causes in 14%. The most common underlying disorders were anemia, followed by obstruction pulmonary disease. Conclusion: We obtained detailed data of frequent emergency department visitors to aid the development of suitable evidence-based policies. New policies are necessary for the management of various sections of the emergency department and inpatient admissions. Such policies will allow better decision-making for non-emergency patients and outpatient admissions.

A Pilot Study of Surge Capacity in the Metropolitan Area of South Korea

Introduction:Seoul is the third most densely populated area in the world except for the city-state. However, a national disaster plan has not yet been established.Aim:From September 2017, representatives of seven regional emergency medical centers in Seoul met monthly and decided to investigate basic data for the future establishment of surge capacity planning.Methods:Staff, supply, space, and systems for surge capacity were surveyed in seven hospitals. The additional surveyed data were as follows: hospital incident command system and actual operational experience; performance of disaster drill; safety and security plan; estimation of surge capacity in normal operating conditions and extreme operating conditions; alternative therapeutic spaces; back-up plan to call non-duty medical staff; decontamination equipment; contingency plan for stuff shortage; etc.Results:All the hospitals reported they have hospital incident command systems and held disaster drills every year, however, the two hospitals (28.5%) had no real experience of hospital incident command system activation. Five hospitals (71.4%) did not have a safety and security plan. They replied they can treat average 7.7 emergency patients (Korean Triage and Acute scale (KTAS) ≤ 3), 10 non-emergent patients (KTAS&gt;4), 0.9 surgical patients and 0.7 unstable patients simultaneously in normal operating conditions. In extreme operating conditions, they replied they can treat average 26.4 emergency patients (KTAS ≤ 3), 54.3 non-emergent patients (KTAS&gt;4), 37 surgical patients and 2.3 unstable patients simultaneously. The two hospitals (28.5%) had no alternative therapeutic spaces, no back-up plan to call non-duty medical staff and no contingency plan for stuff shortage. Three hospitals (42.9%) did not have decontamination equipment.Discussion:The survey revealed the basic data for surge capacity planning in Seoul. Data from hospitals other than regional emergency medical centers should be collected for the completion of disaster plans.

Frequency of psychiatric disorders in nonemergent admissions to emergency department.

Repeated admissions of patients with undiagnosed psychiatric problems in emergency departments (ED) is a major contributor to patient unsatisfaction and overcrowding in EDs. We evaluated the presence of psychiatric disorders in non-emergent admissions in the ED of a tertiary care hospital. This cross-sectional study was carried out in Eskisehir Osmangazi University Hospital between December 2015 and March 2016. The study group consists of 4320 non-emergent patients (31% of all admissions to non-emergent ED). Psychiatric assessments of patients were done using the Primary Care Evaluation of Mental Disorders (PRIME-MD) scale prior to their discharge from the ED. The Mann-Whitney U, Kruskal-Wallis and Chi-square tests, as well as multivariate logistic regression, were performed for statistical analysis. The mean age was 30 ± 11.7 years years ranging from 18 to 78 years. Among non-emergent cases, 44% had at least one psychiatric disorder. The most frequent psychiatric disorder was mood disorder (major and minor depression). Females with a comorbid disease and lower education level had increased risk for mood disorders, anxiety disorders, and somatoform disorders. Single males with a comorbid disease had increased risk for alcohol dependence. Undiagnosed patients with psychiatric disorders appear to be frequent users of medical emergency department services. These results might be helpful in developing more effective strategies to serve the mental health needs of the undiagnosed. People's awareness of psychiatric disorders should be increased.

Effects of managed care on the proportion of inappropriate elective diagnostic coronary angiographies in non-emergency patients in Switzerland: a retrospective cross-sectional analysis

ObjectiveGuidelines recommend non-invasive ischaemia testing (NIIT) for the majority of patients with suspected ischaemic heart disease in a non-emergency setting. A substantial number of these patients undergo diagnostic coronary angiography...

Is there a place for the Mayo Model of Integrated Clinical Care in the English NHS?

Introduction: The English NHS is implementing integrated care models across primary, community and secondary care, and between health and social care systems. These may achieve improvements to quality, safety and cost, but they do not directly address the frequently fragmented and episodic care of patients within hospital settings, particularly those patients with complex co-morbidities. There are examples, however, of hospital-based integrated clinical care models which could address this deficit. Mayo Clinic USA, for example, offers highly integrated, multi-specialty clinical care. We report on two phases of a research project which aims to determine if adoption of something akin to the Mayo Model would be feasible in English NHS hospitals, to the benefit of patients and staff. Methods: Phase 1 used a rapid review to assess recent literature concerning the Mayo Model and links between this and the organisation’s performance and patient outcomes. Phase 2 consisted of semi-structured interviews N=13 conducted with a range of senior clinical and non-clinical staff in a large English NHS teaching hospital. The question schedule addressed general understanding of integrated clinical care, and sought views on barriers and enablers to implementing a Mayo-type integrated care model in English NHS hospitals. Results: Literature concerning the distinctive features of the Mayo Model is limited in scope and largely confined to ‘grey’ sources. We found only two peer-reviewed articles which offer critical analysis of the contribution of the Mayo Model to the performance of the organisation. Analysis of interview data suggests that 1 many NHS hospital physicians and managers are frustrated by the fragmented service offered to multi-morbid patients; 2 the same group sees significant potential in a more holistic, multi-specialty coordinated care model, and understand how in-hospital care could change to meet this vision. Discussion: Despite the paucity of peer-reviewed literature concerning links between the distinctive Mayo Model and performance indicators such as patient outcomes, cost containment and staff and patient satisfaction, there are indications that this model may offer something which is currently absent from in-hospital care in the English NHS. Our interview data shows that clinical and non-clinical hospital staff strongly believe that there is a place for better coordinated, multi-specialty care, particularly in the case of patients who are disadvantaged by repeated journeys between primary and secondary care. Conclusions: Given the urgent need to improve care for non-emergency patients who attend hospitals in the English NHS, we consider it worthwhile to explore the possibility of trialling a Mayo Clinic-style care model in the environment of English NHS hospitals. There are barriers to implementing this approach to in-hospital care, but with appropriate resourcing and support they are not insurmountable. Limitations: The interview data covered a broad range of professional roles, but was confined to one NHS hospital. Future research: We suggest that piloting a Mayo-type care model in one or more English NHS hospitals could be accompanied by a rigorous evaluation of the effects on patient outcomes, the patient experience and staff satisfaction.

Increased incidence of surgical site infection with a body mass index ≥ 35kg/m2 following abdominal wall reconstruction with open component separation.

To quantify the impact of body mass index (BMI) on surgical site infection (SSI) following abdominal wall reconstruction (AWR) using component separation techniques and attempt to identify obesity-related targets, such as BMI, that can be potentially used to guide preoperative patient optimization. Though AWR has established perioperative outcomes for hernia repair, the applicability in the obese population is not well established. The 2005-2013 ACS-NSQIP participant use file was reviewed to compare SSI, severe, and overall morbidity in non-emergent AWR patients based on BMI. Multivariable logistic regression was used to control for patient demographics and comorbidities. Odds ratios (OR) with 95% confidence intervals were reported. We identified 4488 patients. The average BMI was 32.76 ± 7.70kg/m2. The majority of cases (76.8%) had wound classified as clean. The SSI rate significantly increased at a BMI of ≥ 35kg/m2 compared to < 35 (18.5% vs. 10.5%, p < 0.0001). There was no significant different in SSI rate between BMI 35-40 and > 40. After controlling for differences in baseline characteristics and wound classification, BMI ≥ 35kg/m2 was independently associated with SSI (OR 1.47, 1.21-1.78), minor complications (OR 1.65, 1.41-1.94), major complications (OR 1.91, 1.60-2.27), re-operation (OR 1.59, 1.23-2.05), and hospital re-admission (OR 1.93, 1.23-3.02). There is a significant increase in SSI and other perioperative complications in patients with a BMI ≥ 35kg/m2 undergoing AWR. Higher BMI is also independently associated with higher resource utilization in this patient population. Severely obese patients in need of AWR may benefit from a structured preoperative weight loss intervention.