Perioperative Services Research Articles

Effective Collaboration Towards Positive Perioperative Outcomes for the Cardiac Surgery Patient in the Preoperative Phase of Care

<h3>Background Information</h3> The pre-procedure clinic in our academic medical center provides preoperative evaluation and surgical preparation for patients. Nurses in the clinic care for complex patients and support multiple surgical specialties, including cardiac surgery. Workflows related to this subset of patients, specifically identification of blood type and antibodies, presented a particular challenge for the clinic and cardiac surgery patients were not always ready for the operating room (OR) on the day of surgery. There was a negative impact on on-time first case starts (OTFS), cardiac surgery staff utilization, and, most importantly, patient satisfaction when delays occurred the morning of surgery due to positive antibodies and the need for additional work up to prepare blood availability for surgery. <h3>Objectives of Project</h3> The project aims were to: 1) provide an efficient outpatient pre-operative 30-day blood band process in the pre-procedure evaluation clinic for the adult cardiac surgery patient as partners in care with the cardiac surgery service and 2) establish a mutually beneficial work flow between perioperative services and cardiac surgery staff to minimize downstream OR delays. <h3>Process of Implementation</h3> A consultative group guided perioperative services leadership to improve internal processes. Collaboration with the cardiac surgery clinic and patient administrative services staff was crucial for project success. The project team developed and implemented a cardiac surgery internal workflow for preoperative management and the team revised outpatient registration workflows. All patient care technicians in the pre-procedure evaluation clinic received education for preoperative 30-day blood band lab procurement and associated form storage. <h3>Statement of Successful Practice</h3> This poster illustrates that there had been an upward trend in meeting the divisional OTFS goal of ≥ 75%. As of 10/31/19, ≥ 80% of cardiac surgery first cases started on time as compared to only 55% of cases started on time in July 2019. <h3>Implications for Advancing the Practice of Perianesthesia Nursing</h3> Perinanesthesia nurses can improve the care of their patients by employing performance innovation concepts to break down barriers to ensure multidisciplinary success. By engaging multiple perioperative disciplines, providers, and members of the patient care delivery team, both patient care and organizational goals can be met. The option of 30 day blood bands is expanding to other surgical services to avoid delays the morning of surgery.

“Who wants to be a CERTIFIED Millionaire?” A Multifaceted Approach to Increasing Certification

<h3>Introduction</h3> Post Anesthesia Care Unit (PACU) certification is important because it shows a strength in knowledge and a drive for continual learning in this specialty nursing. <h3>Identification of the problem</h3> The number of certified nurses in the PACU has declined and nurses qualified to take the certification exam express concern due to the financial burden and concern of failing the exam. <h3>QI question/Purpose of the study</h3> The goal is to increase perianesthesia nurse certification through education and financial incentives. <h3>Methods</h3> In 2019, an educational initiative was launched to increase staff awareness of importance, benefits and support available for certification. Education on certification was provided at unit meetings, in an American Society Perianesthesia Nurses (ASPAN) formal webinar review, availability of a library of study resources and in creating an interactive game show study review. A three-part education series provided benefits of certification, test taking strategies and test questions in a game show format known as, "Who wants to be a Certified Millionaire." The leadership provided financial support with a class day for the webinar review, purchasing unit study resources and trialing a voucher program to discount the cost to retake the test if needed. <h3>Outcomes/Results</h3> The anticipated projected outcome of the financial and educational interventions is that perianesthesia nursing certification rates will increase in the PACU. Already 20 nurses have purchased vouchers and plan to take the exam within the next 12 months. Dual certification is being sought for the first time within perioperative services by at least 5 nurses. <h3>Discussion</h3> Nurses have stated they have learned a lot and understand more about the complex PACU patients. As individuals pass or fail, we can identify knowledge gaps that we can than focus interactive educational offerings towards. <h3>Conclusion</h3> Advocating for certification has increased interest and commitment to take the exam. <h3>Implications for perianesthesia nurses and future research</h3> The educational certification initiative has increased staff engagement, satisfaction and interest in becoming certified.

UF Health Jacksonville Perioperative Services COVID-19 Reactive Care Model

Background InformationRise of the COVID-19 pandemic prompted an imperative need to design a reactive patient care model to protect perioperative staff caring for patients at a level one trauma center. The UF Health Jacksonville Perioperative COVID-19 Reactive Care Model (PRCM) was created after literature review based on team concepts, isolation practices, and communication strategies. The model is now the standard of care in perioperative services and has endorsed no positive staff conversion from exposure to COVID-19 known or unknown.Objectives of ProjectUF Health Jacksonville perioperative team created the model after extensive literature review on how to mitigate risk of exposure to caregivers while maintaining the highest standard of perioperative practice. Implications for practice include use of adult learning theory, didactic training, custom coded language and a reactive process which has translated to practice changes and established competency standards. The model implementation allows for nursing to practice in a reactive manner without direct orders from the provider.Process of ImplementationA team of content experts developed the proprietary PRCM for UF Health Jacksonville. Didactic training emphasized viral pathophysiology, isolation principles, personal protective equipment, environmental controls and use of a custom common coded language to convey critical information. A model checklist, roles and responsibilities grid, and a smart phone application were used to ensure model compliance. The perioperative nursing leadership team has audited perioperative staff, given in the moment feedback, facilitated case debriefing, and surveyed pre and post knowledge acquisition from simulation and drill training scenarios.Statement of Successful PracticeA minimum of 136 known COVID-19 + and 550 person under investigation (PUI) patients have been cared for utilizing the PRMC since April 15, 2020. To date, no positive conversion from exposure has occurred to any perioperative staff including Registered Nurses (RNs), Surgical Technologists, Environmental Services Associates, Preoperative RNs and Post Anesthesia Care Unit (PACU) RNs since model implementation. The model subscribes to standard CDC recommended PPE for COVID-19+/PUI/AGP which includes: N95 mask, water impermeable gown, gloves (double glove if scrubbed in), face shield-goggles/ eye protection (personal eye glasses are not acceptable), head cover, and shoe covers.Implications for Advancing the Practice of Perianesthesia NursingThe PRCM along with the communication tools and operational strategies are reproducible for any perioperative setting. The PRCM has been replicated within the UF Health Jacksonville procedural areas including outpatient surgery, ophthalmology surgery, GI lab, interventional radiology and cardiology. The model is now fully implemented at UF Health Jacksonville where the risk of positive conversion from exposure to a COVID-19 patient for staff has been contained.

Mobilizing PACU Nurses to Provide Critical Care during the Covid-19 Pandemic

Background InformationIn March 2020, a New York State mandate required our institution place a moratorium on elective surgery for an unknown period of time to ensure adequate Covid-19 surge hospital bed availability. This resulted in extremely low patient volumes for perioperative services. Conversely, critical care was experiencing an influx of patient volume and acuity, necessitating additional nursing support.Objectives of ProjectOur aim was to bolster the hospital's critical care service line by pooling available nursing resources. The perioperative and critical care leadership teams further identified this initiative as an opportunity to strengthen relationships between nurses that share a common skill set.Process of ImplementationHospital command center meetings to address surge bed capacity reinforced the partnership between perioperative and critical care services. Team nursing models were reviewed collaboratively. The PACU nurse manager requested volunteers to staff critical care based on a team model. Five highly experienced PACU RNs and five newer PACU RNs without prior ICU assignments volunteered, with goals to expand knowledge, improve critical assessment skills, and help a service in need. The ten PACU nurse volunteers were assigned into five pairs, consisting of one experienced RN and one newer RN. The five teams of two were consistently matched with their partner, and worked every shift in the ICU as a pair.Statement of Successful PracticeThis collaborative effort between the perioperative and critical care nursing services achieved the goal of providing safe and competent care to a population in dire need during the height of the Covid-19 pandemic. This initiative also strengthened relationships between the services, thereby promoting improved communication and increased efficiency.Implications for Advancing the Practice of Perianesthesia NursingThe future implications of Covid-19 are largely unknown, and this initiative mobilized nursing resources in a systematic fashion to provide necessary specialized care. A framework was established that could be easily replicated, thereby strengthening our ability to collaboratively approach emergency preparedness moving forward.

Ambulatory Perioperative Services Wheels to Wheel

<h3>Background information related to problem identification</h3> Operating Room turnover time or patient Wheels to Wheels (W2W) is the total amount of time necessary to turn over the room from one patient to the next. Wheels Out to Wheels In is defined as the duration between the previous case Out of Room time and the following case In Room time. W2W involves every member of perioperative services including surgeons, anesthesiologists, nurses, surgical scrub technicians, and registration and environmental staff. A delay in one or more areas causes a chain reaction of delays in the whole system. As such, it is necessary to define, measure, analyze, improve, and control the various outliers in the present system for its optimization. The HackensackUMC Ambulatory Perioperative Services' 2019 to 2020 turnover time rate was 27.45 minutes. <h3>Objectives of project</h3> Short- term: To shorten W2W to 23 minutes within 1 year Long- term: To improve patient outcomes, increase case volume, and maximize productivity <h3>Process of implementation</h3> Daily, weekly, monthly audits were conducted to identify compliance issues and improvement opportunities, which were shared to all the stakeholders for guidance, implementation, and control. EPIC Workbench Reports were utilized in data collection and processing. <h3>Statement of the successful practice</h3> Prior to the regular audits and information sharing, there was no coherent visualization for the causes of delay in the W2W process. With the identification of problem areas and accountabilities, delays were minimized and the process completion rate was shortened to 24 minutes. <h3>Implications for advancing the practice of perianesthesia nursing</h3> Using EPIC Workbench Reports and Clarity Reports for audit data processing are significant tools for outlier identification and correction. Professional communication and close collaboration among the stakeholders are keys for the continued quality and rate improvement of the Ambulatory Perioperative Services W2W. Consistent 24/7 implementation of control parameters will lead to improved patient outcomes, increased case volume, and maximum productivity.

Innovation to reduce medication‐related harm

Innovation to reduce medication‐related harm

Improvement of Discharge Education for Pediatric Outpatient Surgical Patients

<h3>Background Information</h3> Postoperative education is an essential component of nursing care aimed at empowering patients and families to understand their condition, surgery, and recovery. Results of individual and meta-analytic studies support the importance of providing clear and specific post-operative education and its effectiveness in improving outcomes and reducing costs associated with post-operative complications and readmissions. Written discharge instructions provide a tangible resource that patient/families can use to improve comprehension and execution of post-operative care. As part of a nurse-led project, the perioperative services team at a free-standing children's hospital collaborated to evaluate and enhance patient discharge education through the standardization of handouts and written discharge instructions. <h3>Objectives of Project</h3> The goal of this project was to enhance patient/family satisfaction and facilitate safe transition home postoperatively by improving written discharge instructions through customization and standardization. <h3>Process of Implementation</h3> Using the plan, do, study, act problem-solving model, the PACU Clinical Practice Council (CPC) collaborated with procedural physicians to develop comprehensive education for commonly performed procedures. First, an assessment of existing vendor provided discharge instructions and gap analysis were completed. Next, a review of literature to identify best practices in patient/family education was compiled. Recognizing the importance of health literacy, the council partnered with the organizational Patient/Family Education committee to assure readability and comprehension. Lastly, the new discharge instructions were uploaded to the existing discharge software. <h3>Statement of Successful Practice</h3> Outcomes of these efforts include the creation of 90 custom written discharge instructions. Patient/family handouts are customized to specific physician and procedural needs. As a result, patients/families are now given appropriate, specific, and understandable instructions for care after procedures, providing a safe transfer to home. Collaboration with physicians is ongoing to create new instructions as gaps are identified. <h3>Implications for Advancing the Practice of Perianesthesia Nursing</h3> The stress of a child having a procedure combined with the need to comfort a fussy child post-operatively makes it challenging for families to understand and execute discharge instructions. Capacity to comprehend these instructions is critical to optimize recovery. Consistent instructions provided in an easy to understand format improves patient and family comprehension and compliance, improving outcomes.

Reinventing the Handoff Process: Bringing Standardized Bedside Report to Perioperative Services

<h3>Background Information</h3> The quality improvement project was implemented in a pediatric ambulatory surgery center after organizational leadership challenged units to improve patient satisfaction. An interdisciplinary unit-based task force was assembled to evaluate areas of improvement. Upon evaluation of current patient satisfaction scores and analysis of handoff, communication between staff and with families were prioritized for this project. The task force decided that the current patient handoff process from Phase I to Phase II recovery would be the main focus for improvements because this is when the family integrated into the patient's care after the procedure. <h3>Objectives of Project</h3> The project aims included: (1) decrease length of handoff time from admit to Phase II to RN handoff is completed, (2) improve registered nurse (RN) workflow as evidenced by decreased time to first documented RN assessment and improved perceptions of nurse workflow (3) improved patient/family satisfaction. <h3>Process of Implementation</h3> • Plan - The planning step begun when the leadership challenge was given for increasing patient satisfaction. A taskforce was developed and critical analysis of all processes on unit was completed. Standardized form was created with input from key stakeholders. Education and training of all staff was completed. • Do - The six-month pilot period was begun. During this time, when a patient was admitted from Phase I to Phase II recovery, every patient handoff was completed using the standardized protocol at the bedside with the inclusion of the patient/family. • Study - Data was collected and analyzed. Data collected included handoff time, first documented RN assessment, nursing satisfaction and patient satisfaction. • Act - Due to the success of the pilot, the changes were adopted as standard practice on the unit. <h3>Statement of Successful Practice</h3> After implementation, improvements were noted in hand off time (reduction of 30%), increased efficiency in nursing workflow as evidenced by a quicker documented RN assessment (28% faster), nursing satisfaction with workflow (100%) and increased patient satisfaction (11.6% improvement). <h3>Implications for Advancing the Practice of Perianesthesia Nursing</h3> The use of standardized bedside report is supported by literature and The Joint Commission's recommendation for patient handoffs, however, is not widely practiced in the perioperative setting. Integrating standardized bedside report can result in a more efficacious process, with a positive impact on nursing workflow and patient satisfaction.

Pain Management During Labor: Part 1—Pathophysiology of Labor Pain and Maternal Evaluation for Labor Analgesia

Dr. Gonzalez is Medical Director of Perioperative Services, Einstein Medical Center, Elkins Park, Pennsylvania; Dr. Trehan is Associate Professor and Chief, Division of Acute and Chronic Pain Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania; and Dr. Kamel is Professor and Vice Chair for Education, Department of Anesthesiology and Critical Care Medicine, Lewis Katz School of Medicine at Temple University, 3401 N. Broad St, Philadelphia, PA 19140; E-mail: [email protected]. The authors, faculty and all staff in a position to control the content of this CME/NCPD activity have disclosed that they have no financial relationships with, or financial interests in, any commercial organizations pertaining to this educational activity. This article was published originally in Topics in Obstetrics & Gynecology. 2016;36(11):1-8. CME Accreditation Lippincott Continuing Medical Education Institute, Inc., is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Lippincott Continuing Medical Education Institute, Inc., designates this enduring material for a maximum of 1.5 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. To earn CME credit, you must read the CME article and complete the quiz and evaluation assessment survey on the enclosed form, answering at least 70% of the quiz questions correctly. This CME activity expires on July 31, 2023. NCPD Accreditation Lippincott Professional Development is accredited as a provider of nursing continuing professional development (NCPD) by the American Nurses Credentialing Center's Commission on Accreditation. Lippincott Professional Development will award 2.5 contact hours for this NCPD activity. This activity has been assigned 1.0 pharmacology credit. Instructions for earning ANCC contact hours are included on page 11 of the newsletter. This NCPD activity expires on June 7, 2024.

Perioperative Opioid Consumption and Clinical Outcomes in Surgical Patients With a Pre-existing Opioid-Based Intrathecal Drug Delivery System.

Intrathecal drug delivery systems (IDDS) have been utilized for over 3 decades for management of chronic pain and spasticity. Patients with IDDS may present for surgical procedures unrelated to the IDDS device, although data are limited regarding perioperative outcomes. This is a historical matched cohort study conducted between January 1, 2007 and December 31, 2016 of patients with an opioid-based IDDS versus matched control patients undergoing surgery excluding interventional pain procedures. Patients in the IDDS group were matched with up to 2 patients without an IDDS. Multivariable regression analyses were utilized to assess differences in the primary outcome of cumulative perioperative opioid consumption (ie, intraoperative and postanesthesia care unit [PACU] opioid consumption), and opioid consumption during the first 24 and 72 postoperative hours. Postoperative clinical outcomes were also assessed including escalating oxygen requirements, naloxone administration, pain-sedation mismatch, and perioperative pain service consultation. A total of 321 surgeries were included, 112 with IDDS and 209 controls, with median (interquartile range [IQR]) age of 57 (49-64) years. Compared to matched controls, patients with an IDDS had greater perioperative opioid consumption (median [IQR] oral morphine milligram equivalents [OME] of 110 [60-163] vs 93 [IQR, 53-142]; adjusted multiplicative increase 1.28 [95% confidence interval {CI}, 1.03-1.59]; P = .026). IDDS patients also had greater opioid consumption in the first 24 and 72 postoperative hours (multiplicative increases of 2.23 [95% CI, 1.36-3.63], P = .001, and 2.46 [95% CI, 1.41-4.32], P = .002, respectively). There were no significant differences in postoperative oxygen requirements, naloxone administration, or pain-sedation mismatch. Inpatient pain medicine consultation was more frequent in IDDS patients compared to controls (51.8% vs 6.2%; P < .001). Patients with opioid-based IDDS received more perioperative opioids and were more likely to receive postoperative pain service consultation compared to matched controls. There were no significant differences in clinical safety outcomes, suggesting tolerance for higher opioid doses. Further research is warranted to optimize perioperative outcomes in those with IDDS.

Preoperative comprehensive geriatric assessment and optimisation prior to elective arterial vascular surgery: a health economic analysis.

increasing numbers of older people are undergoing vascular surgery. Preoperative comprehensive geriatric assessment and optimisation (CGA) reduces postoperative complications and length of hospital stay. Establishing CGA-based perioperative services requires health economic evaluation prior to implementation. Through a modelling-based economic evaluation, using data from a single site clinical trial, this study evaluates whether CGA is a cost-effective alternative to standard preoperative assessment for older patients undergoing elective arterial surgery. an economic evaluation, using decision-analytic modelling, comparing preoperative CGA and optimisation with standard preoperative care, was undertaken in older patients undergoing elective arterial surgery. The incremental net health benefit of CGA, expressed in terms of quality-adjusted life-years (QALYs), was used to evaluate cost-effectiveness. CGA is a cost-effective substitute for standard preoperative care in elective arterial surgery across a range of cost-effectiveness threshold values. An incremental net benefit of 0.58 QALYs at a cost-effectiveness threshold of £30k, 0.60 QALYs at a threshold of £20k and 0.63 QALYs at a threshold of £13k was observed. Mean total pre- and postoperative health care utilisation costs were estimated to be £1,165 lower for CGA patients largely accounted for by reduced postoperative bed day utilisation. this study demonstrates a likely health economic benefit in addition to the previously described clinical benefit of employing CGA methodology in the preoperative setting in older patients undergoing arterial surgery. Further evaluation should examine whether CGA-based perioperative services can be effectively implemented and achieve the same clinical and health economic outcomes at scale.

Direct anterior approach has short-term functional benefit and higher resource requirements compared with the posterior approach in primary total hip arthroplasty : a meta-analysis of functional outcomes and cost.

It has been suggested that the direct anterior approach (DAA) should be used for total hip arthroplasty (THA) instead of the posterior approach (PA) for better early functional outcomes. We conducted a value-based analysis of the functional outcome and associated perioperative costs, to determine which surgical approach gives the better short-term outcomes and lower costs. This meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol and the Cochrane Handbook. Several online databases were searched. Non-stratified and stratified meta-analyses were conducted to test the confounding biases in the studies which were included. The mean cost and probability were used to determine the added costs of perioperative services. The DAA group had significantly longer operating times (p < 0.001), reduced length of hospital stay by a mean of 13.4 hours (95% confidence interval (CI) 9.12 to 18; p < 0.001), and greater blood loss (p = 0.030). The DAA group had significantly better functional outcome at three (p < 0.001) and six weeks (p = 0.006) postoperatively according to the Harris Hip Score (HHS). However, there was no significant difference between the groups for the HHS at six to eight weeks (p = 0.230), 12 weeks (p = 0.470), six months (p = 0.740), and one year (p = 0.610), the 12-Item Short Form Survey (SF-12) physical score at six weeks (p = 0.580) and one year (p = 0.360), SF-12 mental score at six weeks (p = 0.170) and one year (p = 0.960), and University of California and Los Angeles (UCLA) activity scale at 12 weeks (p = 0.250). The mean non-stratified and stratified difference in costs for the operating theatre time and blood transfusion were $587.57 (95% CI 263.83 to 1,010.29) to $887.04 (95% CI 574.20 to 1,298.88) and $248.38 (95% CI 1,003.40 to 1,539.90) to $1,162.41 (95% CI 645.78 to 7,441.30), respectively, more for the DAA group. However, the mean differences in costs for the time in hospital were $218.23 and $192.05, respectively, less for the DAA group. The use of the DAA, rather than the PA, in THA has earlier benefits for function and pain. However, these are short-lasting, with no significant differences seen at later intervals. In addition the limited benefits were obtained with higher cumulative costs for DAA. Cite this article: Bone Joint J2021;103-B(6):1078-1087.

Recommendations for developing clinical care protocols during pandemics: From theory and practice.

In 2019, a novel coronavirus called the severe acute respiratory syndrome coronavirus 2 led to the outbreak of the coronavirus disease 2019, which was deemed a pandemic by the World Health Organization in March 2020. Owing to the accelerated rate of mortality and utilization of hospital resources, health care systems had to adapt to these major changes. This affected patient care across all disciplines and specifically within the perioperative services. In this review, we discuss the strategies and pitfalls of how perioperative services in a large academic medical center responded to the initial onset of a pandemic, adjustments made to airway management and anesthesia specialty services – including critical care medicine, obstetric anesthesiology, and cardiac anesthesiology - and strategies for reopening surgical caseload during the pandemic.

Opioid-Sparring and Multimodal Analgesia as Parts of Enhanced Recovery After Surgery (ERAS) Applied In The Ksatria Airlangga Floating Hospital

Introduction: Enhanced Recovery After Surgery (ERAS) protocol is a perioperative multimodal service program designed to achieve a faster surgical recovery period and a better outcome, the key in reducing morbidity in surgery is by reducing the “surgical injury” and reducing the body’s stress response caused by the surgery. The success of the ERAS protocol depends on the interpretation and collaboration of the multidisciplinary team, therefore though the protocol is carried out in a hospital that has sufficient facilities and resources, the obstacle in the implementation of ERAS can still happen. The implementation of ERAS protocol in the non-permanent hospital service facility becomes a challenge in itself. Case Reports: From the two case reports of the implementation of ERAS protocol in the Ksatria Airlangga Floating Hospital (RST-KA) it is obtained that the key success of the anesthesia in ERAS protocol above lies on the administration of opioid-sparring therapy where it will reduce the use of opioid. Although there are many obstacles obtained in the RST-KA, the use of ERAS protocol can be conducted by making effective use of opioid-sparring combined with the administration of multimodal analgesia. Conclusion: Therefore, it can be concluded that the ERAS protocol can be applied in the social service concept in the non-permanent health facility.

Monitoring Perioperative Services Using 3D Multi-Objective Performance Frontiers

The Acute Care Surgery model has been widely adopted by hospitals across the United States, with Acute Care Surgery services managing Emergency General Surgery patients that were previously being treated by General Surgery. In this analysis, we evaluate the impact of an Acute Care Surgery service model on General Surgery at the University of Vermont Medical Center using three metrics: under-utilized time, spillover time, and a financial ratio of work Relative Value Units over clinical Full Time Equivalents. These metrics are evaluated and used to identify three-dimensional Pareto optimality of General Surgery prior to and after the October 2015 tactical allocation to the Acute Care Surgery model. Our analysis was further substantiated using a Markov Chain Monte Carlo model for Bayesian Inference. We applied multi-objective Pareto and Bayesian breakpoint analysis to three operating room metrics to assess the impact of new operating room management decisions. In the two-dimensional space of Fig.2, panel a), the post-tactical allocation front lies closer to the origin representing more optimal solutions for productivity and under-utilized time. The post-tactical allocation front is also closer to the origin for productivity and spillover time as shown in the two-dimensional space of Fig.2, panel b). The results of the three-dimensional multi-objective analysis of Fig.3 illustrate that the GS post-tactical allocation Pareto-surface is contained within a much smaller volume of space than the GS pre-tactical allocation Pareto-surface. The post-tactical allocation Pareto-surface is slightly lower along the z-axis, representing lower productivity than the pre-tactical allocation surface. This methodology might contribute to the external benchmarking and monitoring of perioperative services by visualizing the operational implications following tactical decisions in operating room management.

Feasibility of Remote Occupational Therapy Services via Telemedicine in a Breast Cancer Recovery Program.

Access to perioperative breast surgery occupational therapy services remains limited in remote areas. To assess the feasibility and acceptance of occupational therapy services using a "hub-and-spoke" telemedicine model. Prospective study using videoconferencing to connect the occupational therapist, located at the hub site, with the patient, located at the spoke site. National Cancer Institute Comprehensive Cancer Center (hub site) and affiliated community cancer center (spoke site). The sites are 75 mi apart. Female breast cancer patients (N = 26) scheduled for breast surgery were asked to participate in telemedicine occupation therapy sessions. Patients lived in a geographically remote region and travelled a mean of 16 miles (range = 3-85) to the hub site. The majority (56%) of the patients had public insurance. Perioperative occupational therapy sessions completed through videoconferencing. Outcome measures were participation in and completion rate for the sessions, number of sessions required to return to baseline, and time interval from surgery to return to baseline function. Patient satisfaction was assessed with a questionnaire. Of the patients who enrolled in the study, 18 completed all postoperative sessions in which functional assessments, exercises, and education were provided. Patients regained baseline function within a mean of 42.4 days after surgery and after an average of three sessions. Patients reported high satisfaction with the sessions. Videoconference telemedicine in breast perioperative rehabilitation is feasible, effective, and acceptable to patients. This study adds to the emerging use of telemedicine for rehabilitative services. This study, by demonstrating the acceptability, practicality, and efficacy of breast perioperative occupational therapy services offered through a videoconferencing platform, supports continued research to evaluate the value of telemedicine. Issues with access to medical care may be mitigated through creative use of technology.

Community Hospital Perioperative Services Department Responds to the COVID-19 Pandemic.

ABSTRACTEarly in 2020, government leaders declared a public health emergency because of the coronavirus disease 2019 (COVID‐19) outbreak. After World Health Organization leaders declared that the spread of COVID‐19 was a pandemic, it became evident that patients suspected or confirmed to have COVID‐19 would present for surgery at our community hospital, the only facility in the county. The Maryland governor charged hospital administrators with expanding bed capacity in anticipation of a surge of critically ill patients. Concurrently, the Maryland secretary of health prohibited all elective procedures. During the early phase of preparation and response, processes, information, and hospital capabilities and capacity changed frequently and rapidly. Effective communication, teamwork, and interprofessional and interdepartmental collaboration helped us prepare to deliver safe surgical care to patients during the pandemic and maintain safety for all involved. This article describes our health care facility’s response to the pandemic and lessons learned during the process.

Geriatrician perspectives on perioperative care: a qualitative study

BackgroundPerioperative medicine services for older surgical patients are being developed across several countries. This qualitative study aims to explore geriatricians’ perspectives on challenges and opportunities for developing and delivering integrated geriatrics perioperative medicine services.MethodsA qualitative phenomenological semi-structured interview design. All geriatric medicine departments in acute public hospitals across Australia and New Zealand (n = 81) were approached. Interviews were conducted with 38 geriatricians. Data were analysed thematically using a framework approach.ResultsGeriatricians identified several system level barriers to developing geriatrics perioperative medicine services. These included lack of funding for staffing, encroaching on existing consultative services, and competing clinical priorities. The key barrier at the healthcare professional level was the current lack of clarity of roles within the perioperative care team. Key facilitators were perceived unmet patient needs, existing support for geriatrician involvement from surgical and anaesthetic colleagues, and the unique skills geriatricians can bring to perioperative care. Despite reporting barriers, geriatricians are contemplating and implementing integrated proactive perioperative medicine services. Geriatricians identified a need to support other specialties gain clinical experience in geriatric medicine and called for pragmatic research to inform service development.ConclusionsGeriatricians perceive several challenges at the system and healthcare professional levels that are impacting current development of geriatrics perioperative medicine services. Yet their strong belief that patient needs can be met with their specialty skills and their high regard for team-based care, has created opportunities to implement innovative multidisciplinary models of care for older surgical patients. The barriers and evidence gaps highlighted in this study may be addressed by qualitative and implementation science research. Future work in this area may include application of patient-reported measures and qualitative research with patients to inform patient-centred perioperative care.

A discrete event simulation model for coordinating inventory management and material handling in hospitals

Inventory management of surgical instruments and material handling decisions of perioperative services are critical to hospitals’ and operating rooms’ (ORs) service levels and costs. However, efficiently coordinating these decisions is challenging due to their interdependence and the uncertainties faced by hospitals. These challenges motivated the development of this study to answer the following research questions: (R1) How does the inventory level of surgical instruments, including owned, borrowed and consigned, impact the service level provided by ORs? (R2): How do material handling activities impact the service level provided by ORs? (R3): How do integrating decisions about inventory and material handling impact the service level provided by ORs? Three discrete event simulation models are developed here to address these questions. Model 1, Current, assumes no coordination of material handling and daily inventory management operations. Model 2, Two Batch, assumes partial coordination, and Model 3, Just-In-Time (JIT), assumes full coordination. These models are verified and validated using real life-data from a partnering hospital. A thorough numerical analysis indicates that, in general, coordination of inventory management of surgical instruments and material handling decisions has the potential to improve the service level provided by ORs. More specifically, a JIT delivery of instruments used in short-duration surgeries leads to lower inventory levels without jeopardizing the service level provided.

Analgesia and Sedation in Critically Ill Adult Patients Admitted to a COVID-19 Intensive Care Unit

AbstractThe severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), causing the COVID-19 has spread globally, prompting world health organization (WHO) to declare COVID-19 a pandemic. As of January 2, 2021, about 82,579,768 laboratory-confirmed COVID-19 cases had been reported to the WHO with 1,818,849 deaths (https://covid19.who.int). The pandemic has severely impacted health care systems around the world, resulting in a vast number of surgical procedures being cancelled or postponed and an unprecedented burden on intensive care units (ICU). A critical component of the perioperative or ICU services delivery is the provision of analgesia and sedation. Volatile inhalational anesthetics combined with opioids are widely used in an operating room, whereas in ICUs, intravenous drugs are used for this purpose. Although target-controlled infusions are not routinely used in ICUs, in the context of the thematic series on total intravenous anesthesia during COVID-19 pandemic, this article will focus on key aspects of intravenous sedation and analgesia in the management of critically ill patients admitted to an ICU following positive swab test for SARS-CoV-2 RNA.