Surgical Start Time Research Articles

EGS SO31 - Does in-hospital delay in appendicectomy lead to complicated appendicitis and affect post operative outcome - a single centre study

Abstract Background Acute appendicitis is one of the most common reasons for emergency general surgical admissions in the U.K. The standard treatment for acute appendicitis is emergency appendicectomy. However, the urgency to operate on patients admitted to hospital with acute appendicitis has been widely debated, with no current standard guideline to follow. The aim of this study was to identify the effect of in-hospital delay in appendicectomy on intra operative findings of complicated appendicitis. The secondary outcome measures were the requirement of a surgical drain, overall length of stay, post-operative complications and re-admission rates. Method This was a single centre retrospective study. All patients who underwent an emergency appendicectomy, between 01/09/2023 and 30/11/2023 were included in this study. Hospital electronic patient records were screened to record the time of decision to operate, surgical start time, the delay between decision to operate and surgical start, intra-operative findings, and post-operative course. A total of 105 patients were included. These were divided into two sub-groups based on the delay between decision to operate and surgical start time; patients who had surgery within 12-hours (early) and those who had surgery after 12-hours (delayed) from the decision to operate time. Results Surgery was performed within 12-hours in 42% cases. The remaining 68% had more than a 12-hour delay, with almost 1 in 4 cases (26 /105) delayed over 24 hours. 15% cases (16) with uncomplicated appearance on pre-op imaging and delayed more than 12-hours progressed to complicated appendicitis intra-operatively. Surgical drains were required in 10% delayed cases and 6% early cases. The median length of stay was 2-days in delayed, compared to 1 day in cases performed early. Post-operative complications were higher in cases early. Although majority of these had complicated appearance in pre-op imaging. Both groups had same readmission rate. Conclusion Our study found that in-hospital delay in appendicectomy can potentially result in increased length of stay, higher rate of requirement of surgical drains and progression from imaging severity. This needs better prioritisation and theatre allocation.

THE USE OF A TIBIA REDUCTION DEVICE IN THE TREATMENT OF FRACTURES UNDERGOING TIBIAL NAILING AT A DISTRICT GENERAL HOSPITAL: A PARALLEL CASE SERIES

Malalignment is a common complication following tibial surgery, occurring in 10% of fractures. This is associated with prolonged healing time and non-union. It occurs due to inability to maintain a satisfactory reduction. A reduction device, such as the Staffordshire Orthopaedic Reduction Machine (STORM), permits the surgeon to manipulate the fracture and hold it reduced.A retrospective parallel case series was undertaken of all patients undergoing tibial nails over a six-year period from 2014 to 2021. Patient demographics were obtained from medical records. Operative times obtained from the theatre IT system and included the time patient entered theatre and surgical start and finish times for each case.Anteroposterior and lateral long leg post-operative radiographs were reviewed. Angulation was measured in both coronal and sagittal planes, by two separate orthopaedic surgeons. A reduction was classified to be ‘mal-aligned’ if the angle measured was greater than 5 degrees. One tailed unpaired t-test was used to compare alignment in each plane. Bony union was assessed on subsequent radiographs and was determined according to the Radiographic Union Score for Tibial Fractures31 patients underwent tibial nail during the time period. 8 patients were lost to follow up and were excluded. Of the remaining 23 patients, the STORM device was utilised in 11.The overall mean alignment was acceptable across all groups at 2.17° in the coronal plane and 2.56° in the saggital plane. Analysing each group individually demonstrated an improved alignment when STORM was utilised: 1.7° (1°–3°) vs 2.54° (0°–5°) for the coronal plane and 1.6° (0°–3°) vs 3.31° (0°–9°) in the saggital plane. This difference was significant in saggital alignment (p=0.03) and showed a positive trend in coronal alignment, although was not significant (p=0.08)The time in theatre was shorter in the control group with a mean of 113 minutes (65 to 219) in comparison to STORM with a mean of 140 minutes (105 to 180), an increased theatre time of 27 minutes (p=0.04).This study demonstrates that STORM can be used in the surgical treatment of tibial fractures resulting in improved fracture alignment with a modest increase in theatre time.

Time from surgery end to discharge following total knee arthroplasty: implications for same day discharge.

Understanding the average time from surgery to discharge is important to successfully and strategically schedule cases planned for same day discharge (SDD) for total knee arthroplasty (TKA). The purpose of this study was to (1) evaluate the average time to discharge following unilateral TKA performed in a community hospital and (2) describe patient characteristics and peri-operative factors that may impact SDD. This retrospective review included 75 patients having achieved SDD following unilateral TKA between March 2017 and September 2021 at a high-volume multi-specialty community hospital. Time to discharge was calculated from end of surgery, defined as completion of dressing application, to physical discharge from the hospital. Time surgery completed and association with time of discharge was also examined. Pearson's correlations were performed to evaluate the relationship between total time to discharge and patient demographics. The average age for all patients was 66.6 ± 10.9 years (Range: 38 to 86) and average BMI of 29.9 ± 5.6kg/m2 (Range: 20.4 to 46.3). The average time to discharge was 5.8 ± 1.8h (range: 2.2 to 10.5h). Time to discharge was significantly longer for patients finishing surgery prior to noon (6.0 ± 1.8h), than after noon (4.8 ± 1.4h, p = 0.046). Total time to discharge was not correlated with age (r = 0.018, p = 0.881) or BMI (r=-0.158, p = 0.178), but was negatively correlated with surgical start time (r=-0.196, p = 0.094). An average of six hours was required to achieve SDD following unilateral TKA performed in a community hospital. The time required for SDD was not found to be related to intrinsic patient factors but more likely due to extrinsic factors associated with time of scheduled surgery. To improve success of SDD, focus should be placed on the development of efficient discharge pathways rather than unchangeable intrinsic patient characteristics.

Association between surgical productivity and start time

BackgroundThe objective is to determine the surgical productivity changes between morning and afternoon surgery using the Malmquist index (MI) model. We hypothesized that the late-in-the-day scheduling of surgery significantly reduced the surgical total factor productivity. MethodsThis is a retrospective observational study conducted at a university hospital. 1,463 surgical procedures performed by fifty surgeons were analyzed during the study period of 2023. A non-radial and non-oriented MI model under the variable return-to-scale assumptions was employed. The decision-making unit (DMU) was defined as a surgeon with the highest academic rank in surgery. Inputs were defined as (1) the number of medical doctors who assisted surgery, and (2) the duration of surgical operation from skin incision to closure. The output was defined as the surgical fee for each surgery. Surgical procedures that started between 8 and 11 am were defined as morning surgery, and those that started between 2 and 5 pm were afternoon surgery. The authors added all the inputs and outputs for each DMU during morning and afternoon surgery. The primary outcome measure is MI index, and the secondary outcome measures are the catch-up and frontier-shift effects. ResultsThe productivity change from the morning to the afternoon of all surgical procedures was significantly negative. The catch-up effect was not significantly different from zero, while the frontier-shift effect significantly negative. ConclusionsThe surgeons were less productive in the afternoon than in the morning. This productivity regress was likely to be due to reduced availability of hospital resources. Trial RegistrationNone.

1237 Audit Project on Golden Patient Policy Adherence and Its Improvement to Theatre Efficiency

Abstract Aim The Golden Patient (GP) is the first patient listed for theatre next day identified and reviewed the day before, with the aim to improve theatre start times and overall efficiency. We aimed to compare the data before implementation of the GP against post-implementation at University Hospital North Durham (UHND) to assess if improvement in efficiency was achieved. We also aimed to analyse the appropriateness of patients listed as GP. Method We analysed data of 45 listed GPs between April and August 2022 as well as 50 patients listed first in theatre prior to GP implementation and compared the documented operation start times. We then compared the data of the listed GPs against local trust criteria for identifying the GP which includes ASA grade/ anaesthetic type, case duration, surgical team availability. Results When comparing pre- and post-implementation of the Golden Patient guidelines, surgical start times improved on average by 30 minutes. In the GPs, 62.9% met all criteria. Compliance was mostly affected by the number of patients not sent for before 0830 AM (only 68.6% of cases met this criterion.) Otherwise, 97.1% of cases met ASA/anaesthetic criteria, and 94.3% met case duration criteria. Conclusions We saw a significant improvement in the average starting times of theatres with implementation of the GP. We also found that we were good at identifying potential GPs however there was much room for improvement with logistics and actually getting patients to theatre quickly.

The IMpact of PerioperAtive KeTamine on Enhanced Recovery after Abdominal Surgery (IMPAKT ERAS): protocol for a pragmatic, randomized, double-blinded, placebo-controlled trial

BackgroundMultimodal analgesic strategies that reduce perioperative opioid consumption are well-supported in Enhanced Recovery After Surgery (ERAS) literature. However, the optimal analgesic regimen has not been established, as the contributions of each individual agent to the overall analgesic efficacy with opioid reduction remains unknown. Perioperative ketamine infusions can decrease opioid consumption and opioid-related side effects. However, as opioid requirements are drastically minimized within ERAS models, the differential effects of ketamine within an ERAS pathway remain unknown. We aim to pragmatically investigate through a learning healthcare system infrastructure how the addition of a perioperative ketamine infusion to mature ERAS pathways affects functional recovery.MethodsThe IMPAKT ERAS trial (IMpact of PerioperAtive KeTamine on Enhanced Recovery after Abdominal Surgery) is a single center, pragmatic, randomized, blinded, placebo-controlled trial. 1544 patients undergoing major abdominal surgery will be randomly allocated to receive intraoperative and postoperative (up to 48 h) ketamine versus placebo infusions as part of a perioperative multimodal analgesic regimen. The primary outcome is length of stay, defined as surgical start time until hospital discharge. Secondary outcomes will include a variety of in-hospital clinical end points derived from the electronic health record.DiscussionWe aimed to launch a large-scale, pragmatic trial that would easily integrate into routine clinical workflow. Implementation of a modified consent process was critical to preserving our pragmatic design, permitting an efficient, low-cost model without reliance on external study personnel. Therefore, we partnered with leaders of our Investigational Review Board to develop a novel, modified consent process and shortened written consent form that would meet all standard elements of informed consent, yet also allow clinical providers the ability to recruit and enroll patients during their clinical workflow. Our trial design has created a platform for subsequent pragmatic studies at our institution.Trial registrationNCT04625283, Pre-results.

Quality improvements anticipated by guideline adherence to peri-operative ICD deactivation

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Recent guidelines have been published by the British Heart Rhythm Society (BHRS) regarding the perioperative management of patients with CIED’s (cardiac implantable electronic devices). The presence of these devices may present a problem when patients undergo operations in which they are exposed to EMI (electromagnetic interference) from surgical diathermy. The current guidelines recommend not deactivating ICD’s when the site of the operation is below the diaphragm. Rather surgery should proceed ahead with a clinical magnet available should it be required. Purpose This goal of the study was to assess compliance with this guideline recommendation in patients who present for surgery in our hospital. Our focus was the response to patients in whom the planned operating site was below the diaphragm. Our hypothesis was that many of these patients had ICDs deactivated prior to surgery regardless of the site of surgery. Methods A logbook of device reprogramming requests for surgical patients was examined from October 2020 to October 2022. The patients name and date of scheduled operation was cross referenced with a data base to determine the site of the surgical operation. The changes made to the device (therapies off, magnet used or no change) were noted. Results Between the 1st December 2020 and 30th October 2022, 29 documented requests were made requesting CIED reprogramming prior to surgery. 22 had surgery below the diaphragm and 7 above. In all surgeries below the diaphragm, therapies function of the device was deactivated. Conclusions Our study demonstrates that a large number of ICD’s are unnecessarily deactivated prior to surgery. In fact, all 29 patients in this audit had their device deactivated regardless of the site of surgery. This is contrary to current guidelines. When the surgical operation is below the diaphragm, the risk of EMI is extremely low. The current evidence recommends close monitoring with immediate availability of a clinical magnet rather than deactivation of therapies. Requests for CIED reprogramming are often made at short notice due to the unscheduled nature of many operations. This places an additional strain on the workload of our department. From a quality improvement perspective, this can lead to delays in surgical start times due to the patient awaiting re programming of their device. In many cases surgery could have proceeded without reprogramming of the device. The repercussions are reduced operating theatre efficiency and increased bed occupancy. The deactivation of an ICD prior to surgery is both labour and time intensive. In some circumstances it is justified, however our data shows there are many instances where it is performed unnecessarily with no clinical benefit to the patient. Compliance with these guidelines will have an immediate positive impact on patient flow and significantly reduce the number of requests for CIED reprogramming to our Cardiology department.

Total Joint Arthroplasty Time-of-Day Start Time Has Minimal Effect on Intraoperative Efficiency

Introduction Total hip (THA) and knee arthroplasties (TKA) are common elective procedures, and dedicated arthroplasty teams perform multiple procedures per day. Little is documented about how time-of-day scheduling affects the intraoperative efficiency of total joint arthroplasties (TJA). In this study, we analyzed the effects of surgical start time on TJA operative lengths. Methods A retrospective study was performed for primary TJA patients done within a four-year period at a single academic medical center. Surgical start time, operative duration, and patient demographics were collected. Based on a 12-hour operative day, surgical start times were categorized as early (7AM to 11AM), mid-day (11AM to 3PM), or late (after 3PM). A chi-squared test was performed to examine for associations between patient demographics and surgical start time. A multivariate linear regression (MLR) was performed to determine the effect of surgical start time on operative duration. P-values less than 0.05 were considered significant. Results This study identified 1663 TJAs – 869 total knee (TKA) and 791 total hip arthroplasties (THA) who met inclusion criteria. Among TKAs, we identified 319 (36.7%) early, 437 (50.3%) mid-day, and 113 (13.0%) late operations. Among THAs, we identified 407 (51.4%) early, 297 (37.5%) mid-day, and 87 (11.0%) late operations. MLR demonstrated that for TKA there was a 4.9 (p =0.018) and 7.3 (p=0.013) minute increase for mid-day and late cases, respectively. For THAs, a non-early start time was associated with an increased operative duration of 9.1 to 12 minutes (p<0.001). Discussion Surgical start time has a statistically significant, but minimal, effect on operative length for TJAs, with later cases being slightly longer than first-start cases.

Reducing trauma theatre list delays through improved communication between orthopaedic teams and radiographers: A quality improvement project.

This quality improvement project was performed to improve delays in starting our trauma theatre lists by implementing measures to improve effective communication between the surgical team and the theatre radiographers. This was a quality improvement project performed prospectively for 30 orthopaedic trauma lists over two cycles. Only lists requiring fluoroscopy guidance (image intensifier) for the first case were included. Interventions included improvements in use of theatre booking forms with fluoroscopy request checkboxes, dedication of an allocated radiographer for the trauma lists, timely communication of the finalised theatre list order and radiographers participating in the team briefing. Improvements in the timing of fluoroscopy requests and prompt arrival of the radiographer to the theatre were achieved. Furthermore, there was elimination of radiographer-related surgical start time delays following implementation of the interventions. Nevertheless, only minimal improvements were achieved in the participation of the radiographers for the trauma theatre team briefings. Although reasons for trauma theatre delays are multifactorial, this quality improvement project has demonstrated that these delays can be reduced through improved communication between radiographers and the orthopaedic team. This is especially important for theatre cases requiring the use of an image intensifier.

Is There an Implicit Racial Bias in the Case Order of Elective Total Joint Arthroplasty?

Identifying ways to improve equitable access to healthcare is of the utmost important. In this study, we analyzed whether patient race was negatively associated with surgical start times for total joint arthroplasties (TJA). The surgical case order and start times of all primary TJAs performed at a large academic medical center between May 2014 and May 2018 were retrospectively reviewed. Patients were included if > 21, had a documented self-reported race, and were operated on by an arthroplasty fellowship-trained surgeon. Operations were categorized as first-start, early (7:00 AM-11:00 AM), mid-day (11:00 AM-3:00 PM), or late (after 3:00 PM). Multivariable logistic regression (MLR) was performed, and odds ratios (OR) were calculated. This study identified 1663 TJAs-871 total knee (TKA) and 792 total hip arthroplasties (THA) who met inclusion criteria. Overall, there was no association between race and surgical start time. Upon sub-analysis by surgical type, this held true for TKA patients, but self-identifying Hispanic and non-Hispanic Black patients undergoing THA were more likely to have later surgical start times (ORs: 2.08 and 1.88; p < 0.05). Although there was no association between race and overall TJA surgical start times, patients with marginalized racial and ethnic identities were more likely to undergo elective THA later in the surgical day. Surgeons should be aware of potential implicit bias when determining case order to potentially prevent adverse outcomes due to staff fatigue or lack of proper resources later in the day.

Late surgical start time is associated with increased blood transfusion following gastric bypass surgery.

Surgical start time (SST) has demonstrated conflicting effects on perioperative outcomes due to confounding factors, such as increased acuity in later SST cases. This study investigated the effect of SST on blood transfusion after gastric bypass surgery, a complication-prone elective surgical procedure. This retrospective cohort study included all patients undergoing gastric bypass surgery at a single academic medical center from 2016 through 2021 (n = 299). The primary independent variable was SST (before vs. after 15:00). The primary outcome was blood transfusion. Secondary outcomes included postoperative respiratory failure, length of stay, acute kidney injury, and mortality. The associations between SST and outcomes were investigated with univariate analyses. Multivariate and receiver operating characteristic (ROC) analyses were applied to the primary outcome, adjusting for demographic and operative characteristics. On univariate analysis, 15:00-18:43 SST was associated with an increased risk of blood transfusion (relative risk 4.32, 95% confidence interval 1.27 to 14.63, p = 0.032), but not postoperative respiratory failure, acute kidney injury, length of stay, or mortality. On multivariate analysis, the only independent predictor of postoperative blood transfusion was a 15:00-18:43 SST (adjusted odds ratio 4.32, 95% confidence interval 1.06 to 15.96, c-statistic = 0.638). ROC analysis demonstrated that compared to the 15:00 threshold, a 14:34 threshold predicted postoperative blood transfusion with better accuracy (sensitivity = 70.0%, specificity = 83.0%). Despite having similar demographic and operative characteristics, gastric bypass patients in the late SST cohort had a greater incidence of postoperative blood transfusion in this single-center study.

Improvement in Multidisciplinary Provider Rounding (Surgical Rounds) in the Pediatric Cardiac ICU: An Application of Lean Methodology.

Provider-only, combined surgical, and medical multidisciplinary rounds ("surgical rounds") are essential to achieve optimal outcomes in large pediatric cardiac ICUs. Lean methodology was applied with the aims of identifying areas of waste and nonvalue-added work within the surgical rounds process. Thereby, the goals were to improve rounding efficiency and reduce rounding duration while not sacrificing critical patient care discussion nor delaying bedside rounds or surgical start times. Single-center improvement science study with observational and interventional phases from February 2, 2021, to July 31, 2021. Tertiary pediatric cardiac ICU. Cardiothoracic surgery and cardiac intensive care team members participating in daily "surgical" rounds. Implementation of technology automation, creation of work instructions, standardization of patient presentation content and order, provider training, and novel role assignment. Sixty-one multidisciplinary rounds were observed (30 pre, 31 postintervention). During the preintervention period, identified inefficiencies included prolonged preparation time, redundant work, presentation variability and extraneous information, and frequent provider transitions. Application of targeted interventions resulted in a 26% decrease in indexed rounds duration (2.42 vs 1.8 min; p = 0.0003), 50% decrease in indexed rounds preparation time (0.53 vs 0.27 min; p < 0.0001), and 66% decrease in transition time between patients (0.09 vs 0.03 min; p < 0.0001). The number of presenting provider changes also decreased (9 vs 4; p < 0.0001). Indexed discussion duration did not change (1 vs 0.98 min; p = 0.08) nor did balancing measures (bedside rounds and surgical start times) change (8.5 vs 9 min; p = 0.89 and 38 vs 22 min; p = 0.09). Lean methodology can be effectively applied to multidisciplinary rounds in a joint cardiothoracic surgery/cardiac intensive care setting to decrease waste and inefficiency. Interventions resulted in decreased preparation time, transition time, presenting provider changes, total rounds duration indexed to patient census, and anecdotal improvements in provider satisfaction.

Association of Surgical Start Time with Outcomes of Benign Hysterectomy

To evaluate whether surgical start time is associated with clinical and financial outcomes of hysterectomies performed for benign indications. Retrospective cohort study. University 5-hospital healthcare system. Women who underwent benign hysterectomy between 2014 and 2019. None. We analyzed demographic, operative, and financial data to evaluate the relationships between surgical start time and perioperative outcomes including operating room time, estimated blood loss, length of stay, same-day discharge, and adverse perioperative events. Additionally, we evaluated the impact of surgical start time on total hysterectomy charges. Descriptive statistics and multivariate logistic and linear regressions were performed adjusting for confounders. Our study identified 2894 women who underwent benign hysterectomy, with 1910 hysterectomies starting prior to 12 pm (am group) and 984 hysterectomies starting after 12 pm (pm group). A pm start time was associated with higher estimated blood loss (Median 100, interquartile range 50, 200 in the am group vs Median 125, interquartile range 75, 250), increased length of stay, and decreased likelihood of same-day discharge. No significant differences were noted in the rates of adverse perioperative events between the 2 groups. Surprisingly, an afternoon start time was associated with decreased total hospital charges (median am $14 055.30 versus median pm $11 724.80). These cost differences persisted after multivariate linear regression, and when stratified by hysterectomy surgical approach, remained significant in the open and laparoscopic cohorts. Afternoon hysterectomy start time is associated with increased blood loss and length of stay with decreased rates of same-day discharge; however, there was no associated increase in perioperative adverse events or mortality. Awareness regarding surgical start time and outcomes can guide surgical scheduling and optimize same-day discharge.

Adjust Intraoperative Oxygen Therapy for Oxygenation Reasons Only!

Adjust Intraoperative Oxygen Therapy for Oxygenation Reasons Only!

Barriers to Optimal Surgical Antimicrobial Prophylaxis for Methicillin-Resistant Staphylococcus aureus-Colonized Patients at an Australian Tertiary Teaching Hospital

Background: Surgical antimicrobial prophylaxis (SAP) is a leading indication for antibiotic use in Australian hospitals with established high rates of inappropriate prescribing. Optimal administration of SAP for patients at high risk of methicillin-resistant Staphylococcus aureus (MRSA) infections presents additional complexities. A greater understanding of barriers to optimal SAP in this cohort is required to inform targeted antimicrobial stewardship strategies, optimize SAP, and reduce the rate of surgical site infections (SSIs). Methods: A multiple-choice questionnaire appraising knowledge and barriers to optimal SAP was electronically distributed to key stakeholders. Data from the questionnaire were collated and analyzed using Survey Monkey® (Momentive Inc., San Mateo, CA) data analysis tools. Results: Eighty-three persons provided full or partial responses to the questionnaire. There were 19% of respondents who considered MRSA colonization status of patients to be only "somewhat important" when selecting appropriate SAP. Additionally, 62% of responses did not correctly identify the appropriate SAP regimen for patients who are colonized with MRSA. Several barriers to optimal SAP were identified including poor understanding of SAP guidelines, lack of timely identification of patients confirmed to be colonized with MRSA, inaccurate documentation of antibiotic and surgical start times, and limitations of the current operating room management software program. Conclusions: The high level of engagement from most key stakeholders demonstrates accountability and an overall desire to improve SAP. Barriers identified in this audit should be considered by facilities wishing to optimize compliance with SAP guidelines and consequently reduce SSIs, in particular for patients who are at high risk of MRSA infections.

Surgical (over) treatment of pediatric Lyme arthritis: a need for faster Borrelia testing.

Pediatric Lyme arthritis is described but not well-characterized in urban populations. Similarities in clinical features between Lyme and septic arthritis also results in some patients with Lyme arthritis undergoing surgical treatment. The aims of this study are to (1) characterize Lyme arthritis in an urban population and (2) determine what factors predispose patients with Lyme arthritis to undergoing surgery. We performed a retrospective review of children with Lyme arthritis at a single academic institution in New York City from 2016 to 2021. Inclusion criteria were age ≤18 years, involvement of a major joint, and positive Lyme serology. Patients treated with irrigation and debridement were compared to those treated non-surgically using Chi-squared tests with a significance of P < 0.05. A total of 106 children with Lyme arthritis were included. Mean age was 9.5 years; 61.3% were male, and 71.7% were Caucasian. 46.2% lived in regions with an average household income >$100 000; 70.8% had private insurance. Ten patients (9.4%) underwent surgery for suspected septic arthritis. The operative group was more likely to have an elevated heart rate, white blood cell count, C-reactive protein level, erythrocyte sedimentation rate level and synovial cell count ( P < 0.05). Patients were more likely to undergo surgery if they presented to the emergency department than to the clinic ( P = 0.03). The average time for a Lyme test to result was 43.5 h, averaging 8.7 h after the surgical start time. Lyme arthritis occurs commonly in an urban pediatric population. Surgery is performed in ~10% of Lyme arthritis patients. More efficient diagnostic tests may reduce this rate.

Risk of Noise-Induced Hearing Loss for Orthopaedic Surgeons.

Noise-induced hearing loss (NIHL) affects the ability of an individual to communicate and can negatively impact quality of life. The risk to orthopaedic surgeons of developing NIHL as a result of occupational exposures in the operating room (OR) is currently unknown. Hearing protection is recommended for levels of >85 decibels (dB), irrespective of length of exposure. The primary goal of the present study was to determine whether orthopaedic surgeons are exposed to harmful noise levels in the OR that puts them at risk for developing NIHL. A prospective review was conducted with use of intraoperative audio recordings across 6 orthopaedic subspecialties. Recordings were made in ORs prior to the surgical start time to serve as baseline controls. Decibel levels were reported as the maximum dB level (MDL), defined as the highest sound pressure level during the measurement period, and as the time-weighted average (TWA), defined as the average dB level projected over an 8-hour time period. Noise doses were reported as the percentage of maximum allowable daily noise (dose) and as the measured dose projected forward over 8 hours (projected dose). Three hundred audio recordings were made and analyzed. The average MDL ranged from 96.9 to 102.0 dB, with noise levels for all subspeciality procedures being significantly greater compared with the control recordings (p < 0.001). Overall, MDLs were >85 dB in 84% of cases and >100 dB in 35.0% of cases. The procedure with the highest noise dose was a microdiscectomy, which reached 11.3% of the maximum allowable daily noise and a projected dose of 104.1%. Among subspecialties, adult reconstruction had the highest dose and projected dose per case among subspecialties. The present results showed that orthopaedic surgeons are regularly exposed to damaging noise levels (i.e., >85 dB), putting them at risk for permanent hearing loss. Further investigation into measures to mitigate noise exposure in the OR and prevent hearing loss in orthopaedic surgeons should be undertaken. Orthopaedic surgeons are at risk for NIHL as a result of occupational exposures in the OR.

The impact of surgical start time on complications in gynaecological surgery: a retrospective cohort study

The impact of surgical start time on complications in gynaecological surgery: a retrospective cohort study

Quantile regression forests for individualized surgery scheduling.

Determining the optimal surgical case start times is a challenging stochastic optimization problem that shares a key feature with many other healthcare operations problems. Namely, successful problem solutions require using a vast array of available historical data to create distributions that accurately capture a case duration's uncertainty for integration into an optimization model. Distribution fitting is the conventional approach to generate these distributions, but it can only employ a limited, aggregate portion of the detailed patient features available in Electronic Medical Records systems today. If all the available information can be taken advantage of, then distributions individualized to every case can be constructed whose precision would support higher quality solutions in the presence of uncertainty. Our individualized stochastic optimization framework shows how the quantile regression forest (QRF) method predicts individualized distributions that are integrable into sample-average approximation, robust optimization, and distributionally robust optimization models for problems like surgery scheduling. In this paper, we present some related theoretical performance guarantees for each formulation. Numerically, we also study our approach's benefits relative to three other traditional models using data from Memorial Sloan Kettering Cancer Center in New York, NY, USA.

EP-604 The Golden Patient Pathway - Improving Efficiency of Emergency General Surgery Theatres and Bed Management

Abstract Aim This closed loop audit aimed at improving efficiency of time management with good utilisation of the first hour of the day in emergency theatres. This was reflected on bed management and patient service. Methods Patients who required simple emergency operations were the target population. Retrospective data of patients’ demographics, time of attendance to surgical admission unit, time waiting for an operation, anaesthetic start times, surgical start times and postoperative inpatient stay were collected. Then the Golden patient pathway was implemented via a list of agreed criteria for the Golden patient (simple procedure, non-septic, non-diabetic, etc.). The chosen patient was labelled as Golden on the booking form. A precise time scale for anaesthetic review and theatre sending time was agreed. This pathway was tried for a month followed by data collection to compare outcomes. Results After starting the Golden patient pathway in our emergency surgery service, the mean anaesthetic start time (+/- standard deviation) improved from 09:12 +/- 0.11 to 08:32 +/- 0.01. Consequently, the mean operation start time improved from 09:45 +/- 0.10 to 08:53 +/- 0.01. The percentage of patients with same day discharge after simple procedures increased from 57% to 100% thus providing better use of hospital beds. Conclusion The Golden patient pathway provides a good utilisation of the first hour of the day in emergency theatres. It has a positive impact on patient service and bed management via reducing the waiting times. The Golden patient pathway is an asset to the emergency general surgery service.