Non-elective Surgeries Research Articles

Awareness of damage control surgery and resuscitation practice: Rational emergency surgical trends in mass trauma events in Syria.

Mass trauma is an event in which the number of patients temporarily exceeds the capacity of medical personnel to provide optimal care. Looking at the global terrorism index, Syria is one of the most terrorism-affected countries in the Middle East, and the threat of terrorist attacks that can cause mass trauma persists. When it comes to dealing with mass trauma, the damage control approach has come to the forefront in recent years. In our study, we aimed to assess the awareness and training effectiveness of emergency physicians and surgeons on damage control surgery and resuscitation in Northwest Syria, where mass trauma due to terrorist attacks and social events is common. A trauma team from Çobanbey Hospital in Northwest Syria conducted training on damage control and resuscitation. Syrian physicians who participated in this training were administered a damage control and resuscitation questionnaire before and after the training. A total of 43 subjects were enrolled in the study, and their mean age was 44.04±9.01 years. The majority of the physicians who participated in the training were from Elbab (23.3%), Afrin (23.3%), and Çobanbey (20.9%). The average work experience of the physicians was 14 years and the average number of non-elective surgeries performed in the last year was 47.5. While the average total score (pre-test) before the training was 67, the average total score (post-test) after the training increased to 72, and this difference was statistically significant (p=0.008). While the pre-test and post-test scores of those who were trained and had practiced placing intrathoracic clamp-wound clamp and trauma laparotomy were significantly higher than those who were not trained and had not used them (p<0.05), the difference between the pre-test and post-test scores of those who were not trained and had not used them was statistically significant (p<0.05). It is well known that there have been internal unrest and terrorist attacks in Northwest Syria for more than 10 years. It is important for physicians in this region to know the damage control strategies. In this regard, we have found that awareness among physicians has increased as a result of the training we have provided on damage control.

760. Incidence, Predictors and 30-Day Outcomes of Clostridoides difficile Infection in Patients Undergoing Cystectomy: A Nationwide Analysis Using the ACS-NSQIP Database

BackgroundClostridoides difficile infection is the second most common healthcare acquired infection (HAI) and the most common gastrointestinal HAI, with an estimated 365,200 cases reported by the CDC in 2017. CDI continues to remain a major cause of inpatient admission and utilization of healthcare resources. The exact incidence of peri-procedural CDI with cystectomy is unknown, and reported incidence of CDI in literature vary widelyMethodsWe conducted an analysis of patients undergoing cystectomy between 2015 and 2017 using the ACS National Surgical Quality Improvement Program (NSQIP) to study the incidence, risk factors and 30-day post-surgical outcomes associated with CDI following cystectomy. Developed by the American College of Surgery, this is a nationally validated, risk-adjusted, outcomes-based program designed to determine and improve the quality of surgical and post-surgical care.ResultsThe incidence of CDI following cystectomy was 3.6% in our patient cohort. 18.8% of patients developed CDI following hospital discharge. Non-elective surgeries, and complete cystectomy procedures had higher rate of CDI. 48.4% of patients with CDI had a preceding post-operative infection. Post-operative organ space infections (OR 1.95), post-operative renal failure (OR 2.38), post-operative sepsis (OR 2.49) and septic shock (OR 2.33) were independently associated with development of CDI, (all p values < 0.05). Patients who developed post-operative CDI during hospitalization had lengthier hospital admissions than those who did not develop a CDI (OR 2.29) and had a higher risk of DVT formation (2.48), and were also more likely to have unplanned readmissions (OR 7.8)ConclusionThis is the first nationwide study looking at inpatient and 30-day post-operative CDI after cystectomy in the US. A sizable number of patients experience CDIs after cystectomy procedures, and CDI development is associated with an increase in length of stay and unplanned readmissions. This study lends further evidence to the need for continued interventions and initiatives to reduce this burden of post-operative CDI.Disclosures All Authors: No reported disclosures

Elective surgery resource utilization.

PurposeCessation of elective surgery during COVID-19 was partly driven by concern for consumption of hospital resources required by critically ill patients. We aim to determine the extent of resource utilization by elective outpatient surgery to assist in ensuring future resource conservation decisions are data driven.MethodsThe study utilized a retrospective cohort gathered from the American College of Surgeons National Surgical Quality Improvement Program database. Participants were adult patients who underwent elective or non-elective surgery between 2017 and 2018. Outcomes included patient characteristics and post-operative outcomes for elective and non-elective surgeries. Post-operative outcomes were used as a surrogate for the consumption of hospital resources.ResultsA total of 1,558,938 (79.8%) elective and 393,339 (20.2%) non-elective surgeries were identified. Elective surgery patients were more likely to be outpatient status, have an ASA class < 3, and exhibited lower rates of prolonged ventilation, 30-day reoperation, and 30-day readmissions, and averaged 5 days less of inpatient stay. Elective outpatient surgery (vs. elective inpatient surgery) averaged shorter operative times and exhibited lower rates of readmissions (2.1% vs. 5.5%; p < 0.001), reoperations (1.1% vs. 2.8%; p < 0.001), prolonged ventilation (0.0% vs. 0.3%; p < 0.001), and 30-day mortality (0.1% vs. 0.5%; p < 0.001) and accounted for 30.2% of the overall relative value units ($339,815,038).ConclusionWe evaluated utilization of hospital resources by patients undergoing elective outpatient surgery by identifying surgeries performed in 2017–2018 then stratifying them by outpatient status. Elective outpatient surgeries consumed negligible amounts of hospital resources and should not be considered a threat to resources in the setting of high demand by critically ill COVID-19 patients.

Telephonic Postoperative Follow-up During a Pandemic: Cohort Study

Introduction: According to the available scientific evidence It is unknown whether replacing clinic follow-up visits with telephone follow-up for low-risk elective and non-elective surgeries is safe. Nonetheless;using telemedicine has become one of the most needed and used methods during this pandemic to avoid COVID-19 disease spreading among surgical teams and patients. Methods: A retrospective cohort study was performed. We compared the frequency of needing of any health assistance, adverse event and readmissions after been discharged and during the first 30 postoperative days, between two groups of patients, the first one with exclusive telephone follow-up vs the traditional face-to-face visit. Results: We registered the data from 324 patients who underwent elective and non-elective low-risk surgeries between May 1st and December 1st 2020. The overall health assistance rate during the first 30 days after been discharged home was 11,54%. The telephone follow-up group we registered only 18 adverse events compared with 29 for the traditional visit group this was statistical significant. We found 13 consults for telephonic follow-up group and 14 for traditional visit this was statistical significant as well. We also found difference between the two groups in matter of readmissions in favor of telephonic follow-up. All these differences were statistically significant. Conclusion: No standardized postoperative management algorithm exists for patients undergoing surgery during a pandemic. We propose the telephonic follow-up based on our findings, as a safe and effective approach. Future studies are needed to validate the current proposal.

Reevaluating the Cardiac Risk of Noncardiac Surgery Using the National Surgical Quality Improvement Program

BackgroundAs surgical techniques evolve and patient outcomes improve over time, a renewed analysis of the cardiac risk of noncardiac surgeries is needed. The goal of this study was to investigate and categorize the cardiac risk of elective noncardiac surgeries. MethodsThis was a cohort study of surgical data and outcomes from the 2018 National Surgical Quality Improvement Program Participant Use Data File; 807,413 cases were analyzed after excluding non-elective, emergent, and cardiac surgeries. Postoperative major adverse cardiac events (MACE) were defined as 30-day all-cause mortality, myocardial infarction, or cardiac arrest. According to their 95% confidence intervals (CI) for postoperative MACE, surgeries were categorized as low risk (95% CI <1%), intermediate risk (95% CI above and below 1%), or elevated risk (95% CI ≥1%). Multivariable logistic regression analyses were performed to determine differences in the odds for postoperative MACE for the intermediate- and elevated-risk categories relative to the low-risk category while controlling for several risk factors of prognostic importance. ResultsPostoperative MACE occurred in 4047/807,413 cases (0.50%), including in 1708/667,735 (0.26%) of the low-risk category, in 516/53,499 (0.96%) of the intermediate-risk category, and in 1823/86,179 (2.12%) of the elevated-risk category. The elevated-risk category accounted for 10.7% of total procedures and 45.1% of total postoperative MACE. Compared with the low-risk category, the multivariable adjusted risk of postoperative MACE was increased in the intermediate-risk category (adjusted odds ratio 2.35; 95% CI, 2.12-2.62) and the elevated-risk category (adjusted odds ratio 3.15; 95% CI, 2.92-3.39). Conclusion: Categorization of noncardiac surgeries according to cardiac risk may help to identify populations who are most likely to benefit from preoperative cardiac evaluation when indicated.

Perioperative management for gynecologic minimally invasive surgery during the COVID-19 pandemic.

This article will review current guidelines regarding surgical protocols for elective and nonelective surgeries during the severe acute respiratory syndrome coronavirus 2 pandemic. Perioperative management for surgical patients should be modified to promote the safety and wellbeing of patients and caregivers amidst the COVID-19 pandemic. COVID-19 testing should be performed preoperatively with subsequent preprocedure quarantine. Nonemergent or nonlife-threatening surgery should be postponed for COVID-19 positive patients. The consensus of surgical societies is to use a laparoscopic surgical approach for COVID-19 positive patients when appropriate and to avoid port venting at the end of procedures. For COVID-19 positive patients requiring an emergent procedure, the use of personal protective equipment is strongly recommended. After over a year of the COVID-19 pandemic, effective protocols and precautions have been established to decrease the morbidity and mortality of patients undergoing surgery and to promote the safety of healthcare personnel. Continued investigations are necessary as cases of new, possibly more virulent, strains of the virus arise.

The Incidence and Cumulative Risk of Major Surgery in Older Persons in the United States.

The objective of this study was to estimate the incidence and cumulative risk of major surgery in older persons over a 5-year period and evaluate how these estimates differ according to key demographic and geriatric characteristics. As the population of the United States ages, there is considerable interest in ensuring safe, high-quality surgical care for older persons. Yet, valid, generalizable data on the occurrence of major surgery in the geriatric population are sparse. We evaluated data from a prospective longitudinal study of 5571 community-living fee-for-service Medicare beneficiaries, aged 65 or older, from the National Health and Aging Trends Study from 2011 to 2016. Major surgeries were identified through linkages with Centers for Medicare and Medicaid Services data. Population-based incidence and cumulative risk estimates incorporated National Health and Aging Trends Study analytic sampling weights and cluster and strata variables. The nationally representative incidence of major surgery per 100 person-years was 8.8, with estimates of 5.2 and 3.7 for elective and nonelec-tive surgeries. The adjusted incidence of major surgery peaked at 10.8 in persons 75 to 79 years, increased from 6.6 in the non-frail group to 10.3 in the frail group, and was similar by sex and dementia. The 5-year cumulative risk of major surgery was 13.8%, representing nearly 5 million unique older persons, including 12.1% in persons 85 to 89 years, 9.1% in those ≥90 years, 12.1% in those with frailty, and 12.4% in those with probable dementia. Major surgery is a common event in the lives of community-living older persons, including high-risk vulnerable subgroups.

Impact of COVID-19 Pandemic in a Brazilian High-Volume Aortic Center.

IntroductionThe coronavirus disease 2019 (COVID-19) pandemic brought an unprecedented lack of control of what was to come. The intent of this document is to provide a balance of how much was ceased to be done for patients with aortic disease, to assess the mortality of these patients, and to show what happened to those who became COVID-19 positive during their hospitalization.MethodsFrom April 1st to July 31st 2020, the worst period of the pandemic in São Paulo, Brazil, the Institute’s aortic surgical patients operated on were evaluated and those were compared with patients operated during the same period in 2019.ResultsIn 2019, 88 surgeries were performed; most of them were elective (66 [75%]), 10 were urgent, and 12 were emergency surgeries. In 2020, during the COVID-19 pandemic, we operated on only 31 patients, being 74.2% non-elective surgeries (P<0,001). There was a higher mortality for patients operated on during the pandemic surge of COVID-19 (P<0,001), but it was not specifically related to infected patients.ConclusionThe COVID-19 pandemic had an impact on surgical volume and outcome of patients with aortic disease, although it did not directly increase mortality.

The Effect of Obesity on Operative Time and Postoperative Complications for Peritrochanteric Femur Fractures.

IntroductionThe high prevalence of obesity among adults in the United States presents significant challenges to orthopedic surgeons. Obesity has been shown to increase operative time and complications in both elective and nonelective orthopedic surgeries. Despite this, there is a lack of literature evaluating the effect obesity has on operative time and postoperative complications following peritrochanteric fracture surgery.Methods and MaterialsWe performed a retrospective review of patients who underwent isolated operative stabilization of a peritrochanteric femur fracture at our urban level one trauma center between 2010 and 2018. Patients were divided into an obese group, as defined by a body mass index (BMI) equal to or greater than 30 kg/m2, and a nonobese group, as defined by a BMI less than 30 kg/m2. Operative timing variables including time to surgery, operative time, total operating room (OR) time, anesthesia time, and fluoroscopy time were collected. Postoperative variables evaluated including the presence of a major postoperative complication within 90 days of surgery, the need for repeat surgery within 90 days, and the need for surgery due to an infection within 90 days were collected.ResultsA total of 175 patients were included in this retrospective review. Thirty-seven patients were included in the obese group, and 138 were included in the nonobese group. Obesity was associated with a significantly (p = 0.002) longer operative time, total OR time (p = 0.0001), anesthesia time (p = 0.00006), and fluoroscopy time (p = 0.0001). There was no significant difference (p > 0.05) in postoperative variables between the obese and nonobese group. The 90-day major postoperative complication rate was 10.8% in the obese group and 10.9% in the nonobese group. Both repeat surgery and surgery for infection within 90 days were 2.7% in the obese group and 1.4% in the nonobese group.ConclusionThe treatment of peritrochanteric femur fractures in obese patients is associated with a significantly longer operative time, total OR time, anesthesia time, and fluoroscopy time, but no difference in major postoperative complications when compared to nonobese patients.

Path to Reopening Surgery during the COVID-19 Pandemic

INTRODUCTIONThe COVID-19 pandemic created a major public health threat to patients and health care systems around the world. Many hospitals cancelled elective surgeries to brace for the pandemic thus impacting many neurosurgical patients that had their surgeries postponed.METHODSWe implemented several measures for staff and patients to minimize the risk of exposure to SARS-CoV-2. For surgical clearance, all patients needed to be tested for SARS-CoV-2 within 48h prior to the non-elective surgery. A triage protocol was implemented to manage patients in need of non-elective surgeries. A “drive-through” testing center was developed for preoperative surgical clearance to triage cases in need of non-elective surgery. Similarly, all patients admitted to the hospital were tested. Telemedicine played a big role in evaluating the need of surgery. We reviewed the clinical, radiographic, and laboratory data for all patients that underwent surgery within the neurosurgery department from March 26th to April 22nd 2020.RESULTSUsing a combination of preoperative outpatient COVID-19 drive-through and inpatient testing to help obtain surgical clearance with selected telemedicine evaluations, 103 non-elective neurosurgical procedures were performed on 102 patients. No patients tested positive for the COVID-19 testing prior to surgery. None of the operated patients developed any COVID-19 symptoms during their hospitalization or were re-admitted to our ED postoperatively for COVID-19 symptoms. A subset of patients developed symptoms suspect for COVID-19 post-operatively but were retested and all tested negative.CONCLUSIONWe describe a multi-faceted preoperative triage protocol for safely performing non-elective neurosurgical cases during the COVID-19 pandemic, which could help other neurosurgical departments and hospitals minimize coronavirus exposure for patients and healthcare workers. We believe this triage strategy helps safely identify selected patients in need of neurosurgical care amidst hospital capacity concerns, COVID-19 testing limitations, limited personal protective equipment, and this approach could be implemented at other centers to gradually restart a process towards elective surgeries in a safe way.

Practice Patterns in Hospitalized Adult Patients with Hemophilia: A Survey Study of US Hemophilia Centers

Introduction:The care of patients with hemophilia (PwH) is rapidly evolving, with novel uses for existing clotting factor concentrates (CFC) and the introduction of non-CFC hemostatic agents (e.g. emicizumab) recently approved by the Food and Drug Administration. However, inpatient care of PwH hospitalized for elective surgery or major bleeds does not follow standardized protocols, and the manner and extent to which novel therapeutic strategies are applied is unknown. Objective:We performed a nationwide survey to obtain information on the practice patterns of adult hematology providers practicing at accredited U.S. hemophilia treatment centers (HTC) in the inpatient care of PwH in the perioperative setting. Methods:Using a publicly available list of accredited HTC adult providers, 59 providers were contacted by email with the option to participate in a phone call or online survey. We aimed to collect information regarding the perioperative management of patients on emicizumab, postoperative factor level monitoring, type of CFCs routinely utilized in the inpatient setting, hospital length of stay, and use of venous thromboembolism (VTE) prophylaxis in the postoperative setting. All non-categorizable responses were excluded. Results: Providers from 10 out of 59 hemophilia centers contacted across the U.S. participated in a phone survey (n=5) or online survey (n=5). Responses were collected from providers practicing in the Mountain States (n=2), Southeast (n=2), Mid-Atlantic (n=2), New England (n=2), Northern States (n=1), and undisclosed (n=1). Of the participating providers, 80% had experience managing patients on emicizumab who had undergone elective surgery or experienced major bleeding. Perioperative management of patients undergoing elective surgery on emicizumab by center was as follows: a single pre-operative bolus of FVIII (n=1), unmonitored weight-based CFC for the same duration as patients not on emicizumab (n=5), and monitored weight-based CFC using a bovine chromogenic assay for the same duration as patients not on emicizumab (n=2). One provider who had not yet cared for patient on emicizumab undergoing elective surgery anticipated that they would preemptively discontinue emicizumab and treat with CFC alone perioperatively. Ninety percent of providers monitored factor levels in hospitalized PwH after elective surgeries; length of monitoring varied between 1-2 days (n=3), 4-5 days (n=1), daily or every other day while inpatient (n=4), or through utilization of surgical site dependent monitoring (n=1). Of those who monitored factor levels, 67% measured both peaks and troughs, while 33% monitored troughs alone. For postoperative inpatient CFC infusion, 60% of providers used standard half-life products alone, while 30% used both standard and extended half-life (EHL) products for hospitalized PwH, generally with the EHL product given preoperatively. Forty percent of providers employed bolus CFC delivery alone while 60% used a combination of bolus and continuous infusions in their practice. Mean length of hospital stay after elective surgery varied between centers and ranged from 1-2 days up to 5-7 days depending on factor levels, pain management, and/or physical therapy needs. Length of stay was highly variable for major bleeds and non-elective surgeries depending on severity of illness and location of bleed. VTE prophylaxis was not given postoperatively by 70% of providers, another 20% of providers reported they may conditionally consider it, and the remaining 10% prescribed either enoxaparin or apixaban to all PwH on CFCs getting elective surgery while hospitalized. Conclusions:Practice patterns of medical providers caring for PwH hospitalized for elective surgery or major bleeding are highly variable across institutions. While the majority of participating providers reported monitoring factor levels in inpatients, the length of monitoring and measurements of peaks/troughs varied. EHL products are being used occasionally in hospitalized patients. The majority of providers do not prescribe VTE prophylaxis inpatient. Additional studies are required to clarify the optimal management strategy in this complex patient population. Disclosures Shatzel: Aronora, Inc.:Consultancy.

Hospital admission rates, length of stay, and in-hospital mortality for common acute care conditions in COVID-19 vs. pre-COVID-19 era

ObjectivesThe impact of COVID-19 upon acute care admission rates and patterns are unknown. We sought to determine the change in rates and types of admissions to tertiary and specialty care hospitals in the COVID-19 era compared with pre-COVID-19 era. MethodsAcute care admissions to the largest tertiary care referral hospital, designated national referral centers for cardiac, cancer and maternity hospital in the State of Qatar during March 2020 (COVID-19 era) and January 2020 and March 2019 (pre-COVID-19 era) were compared. We calculated total admissions, admissions for eight specific acute care conditions, in-hospital mortality rate, and length of stay at each hospital. ResultsA total of 18,889 hospital admissions were recorded. A sharp decline ranging from 9% to 75% was observed in overall admissions. A decline in both elective and non-elective surgeries was observed. A decline of 9%–58% was observed in admissions for acute appendicitis, acute coronary syndrome, stroke, bone fractures, cancer, and live births, whereas an increase in admissions due to respiratory tract infections was observed. Overall length of stay was shorter in the COVID-19 period possibly suggesting lesser overall disease severity, with no significant change in in-hospital mortality. Unadjusted mortality rate for Qatar showed marginal increase in the COVID-19 period. ConclusionsWe observed a sharp decline in acute care hospital admissions, with a significant decline in admissions due to seven out of eight acute care conditions. This decline was associated with a shorter length of stay but not associated with a change in in-hospital mortality rate.

Surgeon fatigue does not affect surgical outcomes: a systematic review and meta-analysis.

To systematically review the effects of surgeon fatigue on postoperative mortality and postoperative complications after elective and non-elective surgeries. A database search was conducted for original articles published in PubMed between 2000 and 2020 with the keywords: "surgeon," "sleep deprivation," "sleep deprived," "fatigued," "mortality," "morbidity," and "outcomes." We selected articles that disclosed actual numbers of patients who underwent surgery by fatigued or rested surgeons, rates of postoperative mortality, or total postoperative complications. Of the 1427 articles identified, 16 met the selection criteria and were included. Eight of the 16 also included total postoperative complications. Analysis revealed no significant differences in the rates of postoperative mortality after elective and non-elective surgeries or total postoperative complications of elective surgeries or non-elective surgeries performed by fatigued vs. rested surgeons. The relative risks were 1.03 [95% confidence interval (CI), 0.86-1.24], 1.08 (95% CI, 0.85-1.38), 0.99 (95% CI, 0.95-1.04), and 0.93 (95% CI, 0.67-1.28), respectively. Surgeon fatigue does not affect the rates of postoperative mortality or total postoperative complications after elective surgeries and may have little to no effect on the rates of postoperative mortality or total postoperative complications after non-elective surgeries.

Thirty-Day Mortality in COVID-19 Positive Patients With Hip Fractures: A Case-Series and Literature Review.

Introduction:The novel coronavirus has spread rapidly around the world with particularly high mortality in the elderly. Care and nursing homes have become the sites of greatest concentration of cases. We intended to review 30-day mortality of COVID-19 patients with hip fractures. This is relevant given the disease impact in this age group.Methods:Medline and Embase databases were searched for relevant studies linked to mortality and morbidity in COVID-19 patients who have undergone non-elective hip surgeries using the keywords “COVID-19”OR “SARS-cov-2”OR “Coronavirus Infections”; AND “Surgery”OR “Hip”OR “Fracture”OR “Orthopedics.” We included all patients with hip fractures, but excluded pathological fractures and other non-traumatic hip pathologies. Four-hundred and eighty-one articles were identified for screening, in addition to an unpublished case-series of 67 patients that have 3 cases turned positive for COVID 19, yielding a total of 50patients for the final review.Results:The study included 4 articles published until May 9th 2020 and a case-series: 26(52%) patients were females; the median age was 86years; hypertension(53.6%), diabetes mellitus type II(28.6%), and coronary artery heart disease(25%) were the most common comorbidities; 34(68%) patients had intertrochanteric hip fracture and 16(32%) patients had femoral neck fractures; 22(59.5%) patients underwent cephalomedullary nail fixation, 12(32.4%) patients had hemiarthroplasty, and for 3(8.1%) patients, the type of surgery was not documented; 20(40%) patients died(12patients died before the surgery and 8died after surgery at a median time of 3days), 29(76.3%) patients had an unremarkable course throughout hospitalization and were discharged including 1(2.6%) patient managed non-operatively, and 1(2.6%) patient was admitted to the ICU after the surgery but eventually discharged.Conclusion:COVID-19 infected elderly patients have a higher 30-days mortality rate compared to non-COVID-19 infected cases. Further studies are warranted to look at the morbidity and mortality rates in COVID-19 positive patients with hip fractures and to investigate how these outcomes can be improved.Level of evidence:Level IV

Operating Rooms Scheduling for Elective Surgeries in a Hospital Affected by War-Related Incidents.

Hospital scheduling presents huge challenges for the healthcare industry. Various studies have been conducted in many different countries with focus on both elective and non-elective surgeries. There are important variables and factors that need to be taken into considerations. Different methods and approaches have also been used to examine hospital scheduling. Notwithstanding the continuous changes in modern healthcare services and, in particular, hospital operations, consistent reviews and further studies are still required. The importance of hospital scheduling, particularly, has become more critical as the trade-off between limited resources and overwhelming demand is becoming more evident. This situation is even more pressing in a volatile country where shootings and bombings in public areas happened. Hospital scheduling for elective surgeries in volatile country such as Iraq is therefore often interrupted by non-elective surgeries due to war-related incidents. Hence, this paper intends to address this issue by proposing a hospital scheduling model with focus on neuro-surgery department. The aim of the model is to maximize utilization of operating room while concurrently minimizing idle time of surgery. The study focused on neurosurgery department in Al-Shahid Ghazi Al-Hariri hospital in Baghdad, Iraq. In doing so, a Mixed-integer linear programming (MILP) model is formulated where interruptions of non-elective surgery are incorporated into the main elective surgery based model. Computational experiment is then carried out to test the model. The result indicates that the model is feasible and can be solved in reasonable times. Nonetheless, its feasibility is further tested as the problems size and the computation times is getting bigger and longer. Application of heuristic methods is the way forward to ensure better practicality of the proposed model. In the end, the potential benefit of this study and the proposed model is discussed.

Dynamic Insertion of Emergency Surgeries With Different Waiting Time Targets

This paper addresses the problem of emergency surgery insertion into a given elective surgery schedule of an operating theater (OT) composed of multiple operating rooms (ORs). Emergency surgeries with different emergency levels characterized by waiting time targets (WTTs) arrive according to a nonhomogeneous Poisson process and can be inserted into any OR. An event-based stochastic programming model is proposed to minimize the total cost incurred by exceeding WTTs of emergency surgeries, elective surgery delay, and surgery team overtime. A perfect information-based lower bound is proposed and the properties of the optimal policies are proved. Simple heuristic policies and a stochastic optimization (SO) approach derived from the simple policies by policy improvement are proposed. Numerical experiments show that the SO significantly outperforms the others and efficient emergency insertion significantly improves the system performance. A principal component analysis is performed to show how near-optimal policies differ from simple heuristic policies. Note to Practitioners —This paper is motivated by enhancing the efficiency of OTs by sharing the surgery capacity between the elective and emergency surgeries. More specifically, we consider the problem of inserting nonelective surgeries of different emergency levels in the execution of a given elective surgery schedule. An SO approach is proposed to dynamically prioritize emergency and elective surgeries in order to best balance meeting emergency surgery requirement, perturbation of elective schedule, and surgery team overtime. Numerical experiments based on the data collected from Saint-Joseph Hospital in Paris show the significant benefit of efficient emergency insertion over the current hospital practice. Elective surgery schedule is shown to have the most important impact on the system performance but efficient emergency insertion always adds significant improvement.

'After-hours' non-elective spine surgery is associated with increased perioperative adverse events in a quaternary center.

'After-hours' non-elective spinal surgeries are frequently necessary, and often performed under sub-optimal conditions. This study aimed (1) to compare the characteristics of patients undergoing non-elective spine surgery 'After-hours' as compared to 'In-hours'; and (2) to compare the perioperative adverse events (AEs) between those undergoing non-elective spine surgery 'after-hours' as compared to 'in-hours'. In this retrospective study of a prospective non-elective spine surgery cohort performed in a quaternary spine center, surgery was defined as 'in-hours' if performed between 0700 and 1600h from Monday to Friday or 'after-hours' if more than 50% of the operative time occurred between 1601 and 0659h, or if performed over the weekend. The association of 'after-hours' surgery with AEs, surgical duration, intraoperative estimated blood loss (IOBL), length of stay and in-hospital mortality was analyzed using stepwise multivariate logistic regression. A total of 1440 patients who underwent non-elective spinal surgery between 2009 and 2013 were included in this study. A total of 664 (46%) procedures were performed 'after-hours'. Surgical duration and IOBL were similar. About 70% of the patients operated 'after-hours' experienced at least one AE compared to 64% for the 'in-hours' group (p = 0.016). 'After-hours' surgery remained an independent predictor of AEs on multivariate analysis [adjusted OR 1.30, 95% confidence interval (CI) 1.02-1.66, p = 0.034]. In-hospital mortality increased twofold in patients operated 'after-hours' (4.4% vs. 2.1%, p = 0.013). This association lost significance on multivariate analysis (adjusted OR 1.99, 95% CI 0.98-4.06, p = 0.056). Non-elective spine surgery performed 'after-hours' is independently associated with increased risk of perioperative adverse events, length of stay and possibly, mortality. Research is needed to determine the specific factors contributing to poorer outcomes with 'after-hours' surgery and strategies to minimize this risk. These slides can be retrieved under Electronic Supplementary Material.

Predictors of in-hospital mortality in patients undergoing elective surgery in a university hospital: a prospective cohort

IntroductionMorbidity and mortality associated with urgent or emergency surgeries are high compared to elective procedures. Perioperative risk scores identify the non-elective character as an independent factor of complications and death. The present study aims to characterize the population undergoing non-elective surgeries at the Hospital de Clínicas de Porto Alegre and identify the clinical and surgical factors associated with death within 30 days postoperatively. MethodologyA prospective cohort study of 187 patients undergoing elective surgeries between April and May 2014 at the Hospital de Clínicas, Porto Alegre. Patient-related data, pre-operative risk situations, and surgical information were evaluated. Death in 30 days was the primary outcome measured. ResultsThe mean age of the sample was 48.5 years, and 84.4% of the subjects had comorbidities. The primary endpoint was observed in 14.4% of the cases, with exploratory laparotomy being the procedure with the highest mortality (47.7%). After multivariate logistic regression, age (odds ratio [OR] 1.0360, p<0.05), anemia (OR 3.961, p<0.05), acute or chronic renal insufficiency (OR 6.075, p<0.05), sepsis (OR 7.027, p<0.05), and patient-related risk factors for mortality, in addition to the large surgery category (OR 7.502, p<0.05) were identified. ConclusionThe high mortality rate found may reflect the high complexity of the institution's patients. Knowing the profile of the patients assisted helps in the definition of management priorities, suggesting the need to create specific care lines for groups identified as high risk in order to reduce perioperative complications and deaths.

A random forest and simulation approach for scheduling operation rooms: Elective surgery cancelation in a Chinese hospital urology department.

Many hospitals encounter surgery cancelations for various reasons. We present a methodology applying data mining and simulation to optimize operating room (OR) scheduling in a urology department in West China Hospital. To the best of our knowledge, this is 1 of the first efforts to seek an optimal schedule solution based on cancelation risk of elective surgeries as well as OR allocation between elective and nonelective surgeries. First, chi-square test and random forest prediction modeling were used to predict potential elective surgeries with high cancelation risk, and the factors, including surgeon, number of days since admission of patient, first surgery or not, etc., that influence elective surgery cancelation were identified. Second, a simulation technology was designed to compare 7 different scheduling strategies. The results demonstrated that for elective surgery, cancelation rate low surgery first outperformed the others and increased the productivity of the ORs from 72% to 83%, while for nonelective surgery performed in a separate OR, there was no improvement because the supply was greater than necessary at present. However, in total, the selected strategies led to 7% higher productivity.

Age and sex of surgeons and mortality of older surgical patients: observational study

ObjectiveTo investigate whether patients’ mortality differs according to the age and sex of surgeons.DesignObservational study.SettingUS acute care hospitals.Participants100% of Medicare fee-for-service beneficiaries aged 65-99 years who underwent one of 20...