The Effect of the COVID-19 Pandemic on Theatre Efficiency, Lessons to be Learned for Subsequent Waves

BACKGROUND

This study aims to demonstrate the impact of the COVID-19 pandemic on providing trauma services at our district general hospital. We aim to identify the impact on specific areas of theatre delay to help optimize theatre efficiency and generate better protocols and improve patient flow for future pandemic waves.

METHODS

Patients who underwent orthopaedic trauma surgery at our hospital between July-August 2019 (pre-COVID-19) and 2020 (first UK wave of COVID-19) were identified retrospectively and grouped by year of operation. Type of operation was recorded, including time for sending, anaesthetic induction, surgical preparation, operating time, and time for transfer to recovery. The two groups were compared for analysis.

RESULTS

Case numbers were similar in both 2019 and 2020 (215vs.213 operations), with a similar proportion being hip fractures (39.1% and 36.6%), respectively. Median sending time (40vs.23 minutes, P <0.00001) and induction time (13vs.8 minutes, P<0.00001) were increased in 2020, a 74% and 63% increase compared to 2019, respectively. Median surgical preparation time (35vs.37 minutes, P=0.06) and operating time (56vs.50 minutes, P=0.16) were not statistically significant. Transfer time in 2020 (16vs.13 minutes, P<0.00001) was significantly increased. Overall case time increased in 2020 (2:40vs.2:11, P<0.00001) by 29 minutes.

CONCLUSION

COVID-19 had a significant impact on theatre efficiency in our hospital, causing multiple points of delay. As hospitals across the UK restart crucial elective services, focus should be given to maximizing theatre efficiency by providing rapid access COVID-19 testing for patients undergoing emergency surgery. We have proposed and implemented several steps for better theatre utilization.

Tackling The Challenge Of Opioid Use And Abuse And Treatment Of Chronic Pain Management

Introduction/Objective

Deaths from opioid overdose increased 12% from 2016 to 2017. This major economic burden cost roughly $78.5 billion in the US. This steep increase in drug overdose deaths can be attributed to increased synthetic opioid abuse. To better understand and reduce opioid abuse amongst patients at Henry Ford Health System, Detroit MI, we sought to collaborate with physicians to manage prescribing, interpret test results, improve patient care, and deliver more value.

Primary Aim: To create a directed pain panel for ordering and interpreting pain management drugs to help providers to better manage patients and to assess compliance from test ordering history to serve patients safely and effectively.

Secondary Aim: To streamline the process of prescribing pain medications and to create a patient centered approach to treat chronic non-cancer patients who actually need opioids, to minimize the risk of abuse, diversion and addiction among patients.

Methods

Plan Do Check Act (PDCA) cycles of process improvement were used to achieve our two aims. In the first cycle, a drug screen-ordering guide was developed to facilitate screening (qualitative) and confirmation (quantitative) ordering practices. As part of this, providers prescribing for chronic pain patients were advised to use drugs of abuse panel rather than our emergency drug screen. In the second cycle, a directed pain panel (DPP) was introduced with reflex to confirmation testing. The DPP led to discovery of unexpected fentanyl positives, which were further investigated.

Results

A survey was conducted to investigate provider-ordering practices, which showed that use of the new drugs of abuse panel rose from 57% to 77%. The DPP was accepted by ~60% of physicians and was frequently reordered in follow-up. Analysis of unexpected fentanyl positivity revealed 30% true positivity, thus identifying unknown patient use. A future PDCA cycle is focused on developing, implementing, and measuring the customer value of a laboratory generated interpretive opioid results report at 5 similar organizations with a goal to assist with test selection and simplify provider interpretation of results.

Conclusion

A future PDCA cycle is focused on developing, implementing, and measuring the customer value of a laboratory generated interpretive opioid results report at 5 similar organizations with a goal to assist with test selection and simplify provider interpretation of results.

Update and audit of the St George's classification algorithm of primary lymphatic anomalies: a clinical and molecular approach to diagnosis

Primary lymphatic anomalies may present in a myriad of ways and are highly heterogenous. Careful consideration of the presentation can lead to an accurate clinical and/or molecular diagnosis which will assist with management. The most common presentation is lymphoedema, swelling resulting from failure of the peripheral lymphatic system. However, there may be internal lymphatic dysfunction, for example, chylous reflux, or lymphatic malformations, including the thorax or abdomen. A number of causal germline or postzygotic gene mutations have been discovered. Some through careful phenotyping and categorisation of the patients based on the St George’s classification pathway/algorithm. The St George’s classification algorithm is aimed at providing an accurate diagnosis for patients with lymphoedema based on age of onset, areas affected by swelling and associated clinical features. This has enabled the identification of new causative genes. This update brings the classification of primary lymphatic disorders in line with the International Society for the Study of Vascular Anomalies 2018 classification for vascular anomalies. The St George’s algorithm considers combined vascular malformations and primary lymphatic anomalies. It divides the types of primary lymphatic anomalies into lymphatic malformations and primary lymphoedema. It further divides the primary lymphoedema into syndromic, generalised lymphatic dysplasia with internal/systemic involvement, congenital-onset lymphoedema and late-onset lymphoedema. An audit and update of the algorithm has revealed where new genes have been discovered and that a molecular diagnosis was possible in 26% of all patients overall and 41% of those tested.