Complex Cancer Surgery in the Outpatient Setting: The Josie Robertson Surgery Center

Minimally invasive operative techniques and enhanced recovery after surgery (ERAS) protocols have transformed clinical practice and made it possible to perform increasingly complex oncologic procedures in the ambulatory setting, with recovery at home after a single overnight stay. Capitalizing on these changes, Memorial Sloan Kettering Cancer Center's Josie Robertson Surgery Center (JRSC), a freestanding ambulatory surgery facility, was established to provide both outpatient procedures and several surgeries that had previously been performed in the inpatient setting, newly transitioned to this ambulatory extended recovery (AXR) model. However, the JRSC core mission goes beyond rapid recovery, aiming to be an innovation center with a focus on superlative patient experience and engagement, efficiency, and data-driven continuous improvement. Here, we describe the JRSC genesis, design, care model, and outcome tracking and quality improvement efforts to provide an example of successful, patient-centered surgical care for select patients undergoing relatively complex procedures in an ambulatory setting.

A Model for Integrating Ambulatory Surgery Centers Into an Academic Health System Using a Novel Ambulatory Surgery Coordinating Council

PROBLEM

An increasing volume of ambulatory surgeries has led to an increase in the number of ambulatory surgery centers (ASCs). Some academic health systems have aligned with ASCs to create a more integrated care delivery system. Yet, these centers are diverse in many areas, including specialty types, ownership models, management, physician employment, and regulatory oversight. Academic health systems then face challenges in integrating these ASCs into their organizations.

APPROACH

Johns Hopkins Medicine created the Ambulatory Surgery Coordinating Council in 2014 to manage, standardize, and promote peer learning among its eight ASCs. The Armstrong Institute for Patient Safety and Quality provided support and a model for this organization through its quality management infrastructure. The physician-led council defined a mission and created goals to identify best practices, uniformly provide the highest-quality patient-centered care, and continuously improve patient outcomes and experience across ASCs.

OUTCOMES

Council members built trust and agreed on a standardized patient safety and quality dashboard to report measures that include regulatory, care process, patient experience, and outcomes data. The council addressed unintentional outcomes and process variation across the system and agreed to standard approaches to optimize quality. Council members also developed a process for identifying future goals, standardizing care practices and electronic medical record documentation, and creating quality and safety policies.

NEXT STEPS

The early success of the council supports the continuation of the Armstrong Institute model for physician-led quality management. Other academic health systems can learn from this model as they integrate ASCs into their complex organizations.

Challenges with the establishment of congenital cardiac surgery centers in Nigeria: survey of cardiothoracic surgeons and residents

BACKGROUND

There are gaps in understanding the challenges with the establishment of pediatric cardiac surgical practices in Nigeria. The aim of this study was to examine the prospects and challenges limiting the establishment of pediatric cardiac surgical practices in Nigeria from the perspectives of cardiothoracic surgeons and resident doctors.

METHODS

A descriptive study was carried out to articulate the views of the cardiothoracic surgeons and cardiothoracic resident doctors in Nigeria. A self-administered questionnaire was used to generate information from the participants between December 2014 and January 2015. Data were analyzed using the SPSS version 21 statistical software package.

RESULT

Thirty-one of the 51 eligible participants (60.7%) took part in the survey. Twenty-one (67.7%) were specialists/consultants, and 10 (32.3%) were resident doctors in cardiothoracic surgical units. Most of the respondents, 26 (83.9%) acknowledged the enormity of pediatric patients with cardiac problems in Nigeria; however, nearly all such children were referred outside Nigeria for treatment. The dearth of pediatric cardiac surgical centers in Nigeria was attributed to weak health system, absence of skilled manpower, funds, and equipment. Although there was a general consensus on the need for the establishment of open pediatric cardiac surgical centers in the country, their set up mechanisms were not explicit.

CONCLUSIONS

The obvious necessity and huge potentials for the establishment of pediatric cardiac centers in Nigeria cannot be overemphasized. Nevertheless, weakness of the national health system, including human resources remains a daunting challenge. Therefore, local and international partnerships and collaborations with country leadership are strongly advocated to pioneer this noble service.

The Efficiency of Ophthalmic Ambulatory Surgery Centers

Ambulatory surgery centers (ASCs) are important providers of ambulatory surgeries. However, little research exists examining the efficiency of ASCs in providing ambulatory surgical services. This study examined the technical efficiency of ASCs that concentrated on performing cataract surgeries, which are among the surgeries most commonly performed in the outpatient setting. This study, based on data from all active ASCs that provided the two most common cataract surgeries in California, found that a large proportion of ophthalmic ASCs were operating at low technical efficiency levels. The amount of slacks in input and output variables was estimated for each ASC, and the mean slacks were reported. The numbers of cataract surgery patients and operating rooms were found to significantly affect the efficiency of ophthalmic ASCs.

[Intensive care and resuscitation in reconstructive surgery: 50 years of progress]

The article deals with fundamental stages of resuscitation and intensive therapy development in reconstructive surgery during 50 years of Petrovsky National Research Centre of RAMS functioning. Appreciation was given to academician of RAMS R.N.Lebedeva for outstanding services in local public health, as organizer of the one of the first specialized resuscitation and intensive care departments in our country. Researches in the department are traditionally oriented to the diagnostic methods development, prevention and intensive care of vital functions violations in patients after reconstructive operations. It helped to limit contraindications for surgery and to implement radical surgery in patients with severe concomitant diseases, as well as to reduce the number of postoperative complications and mortality

Organization and activity of the Replantation Service for amputated hands in Poland

A permanent on-call service for hand amputations (Replantation Service) was established in 2010 of the initiative of the Council of Polish Society for Surgery of the Hand. It is run by three qualified hand centres in Trzebnica, Poznań and Szczecin. Organization of this system, rules of activity and spectrum of cases admitted to replantation units was presented. A scheme of referral of amputations was shown and the main problems that appeared during almost three-year activity of the Service were discussed. Medico-legal and ethical implications arising from these problems were shown and organization of replantation service in other European countries was outlined. Establishing of the Replantation Service constituted a significant progress in the organization of the management of upper limb amputations. Thanks to that, over the period of three years, more than 200 patients were saved from severe disability, receiving a chance to regain an amputated limb.

Organization, achievement and results of a pelvis surgery center

INTRODUCTION

Pelvic fractures are not frequent, yet severe injuries, often associated to other lesions. Well defined diagnostic and therapeutic procedures are lacking, and their economical assessment is inadequate. The goal of this study is to propose the organization of a multidisciplinary center that can develop diagnosis, treatment, and follow up protocols.

MATERIALS AND METHODS

25 patients were treated from August 2008 to July 2010, 5 women and 20 men, average age 34.5 years. Twenty patients had acetabular fractures (8 posterior wall fractures, 2 anterior column fractures and 10 mixed fractures, Judet and Letournel). Five patients suffered from diastasis symphisis pubis (three patients with a CAP type I, and 2 with a CAP type II, Young-Burgess).

RESULTS

Average delay between trauma and operation was 15.6 days. Average hospital stay after surgery was 45 days. Five had excellent results, 15 were good, and 4 presented poor results. One patient deceased. Four patients underwent hip arthroplasty 1 year after surgery.

DISCUSSION

It was essential to identify the collaborating units. The center aims at a uniform and rapid treatment for patients with lesions which are treated differently depending on the department of hospitalization and on the surgeon's experience. The target is to avoid treatment delays, costs and complications. The DRG evaluation grants the highest value to pelvis surgery. This should be followed by dedicated structures that can become reference centers.

CONCLUSION

The results can be improved, but considering this is not well known context both clinically and economically, they can be seen positively.

Physicians on board: an examination of physician financial interests in ASCs using longitudinal data

This paper investigates physician financial interests in ambulatory surgery centers (ASCs) using novel, longitudinal data that identify board members (directors) of ASCs in Florida. Improving on prior research, the estimated models in this paper disentangle physician director selection effects from the causal impact of these financial interests. The data suggest that even prior to their financial interest, physician directors had larger procedure volumes than non-directors. Physician directors also referred more lower-risk patients. On average, ASC board membership led to a 27% increase in a physician's procedure volume and a 16% increase in a physician's colonoscopy volume. Simulations suggest that 5% of the colonoscopies performed in Florida between 1997 and 2004 may have been due to physician ASC board membership. The evidence also suggests that physician directors steered patients from hospitals to their affiliate ASCs. In addition, they referred and/or treated more lower-risk patients as a result of board membership.

[Establishment of wound care center and development of burns and plastic surgery discipline]

To study the interaction between establishment of wound care center and development of discipline of burns and plastic surgery. The changes in number of outpatient, time for dressing change per patient, outpatient service income, number of inpatients and operations in our hospital were summarized and retrospectively analyzed before and after establishment of wound care center. The proportion of patients with chronic wounds and skin and soft tissue defects after trauma among all inpatients in the same term were investigated. Meanwhile, the development of discipline of burns and plastic surgery before and after establishment of wound care center was analyzed. Compared with those in the year before establishment of wound care center, outpatient number, time for dressing change per patient, outpatient service income, inpatient number, and amount of operations were all increased (with increase rate of 330%, 569%, 325%, 161%, and 173%, respectively) in the year after establishment of wound care center. The ratio of patients with chronic wounds and skin and soft tissue defects after trauma among all inpatients was respectively increased from 4.3% and 4.5% in the year before establishment of wound care center to 9.2% and 12.4% in the year after establishment of wound care center. Patient satisfaction, bed utilization rate, levels of wound treatment and repair were all improved after establishment of wound care center. So we come to conclusions as follows. Establishment of wound care center can promote development of the standard of burns and plastic surgery. Comprehensive use of multidisciplinary theories and techniques concerning burns, plastic and aesthetic surgery, medical aesthetics, etc. can be beneficial for improvement of quality of wound healing and achievement of cosmetic effect, and wound care center may be further developed.

[Probe into construction mode of wound care center]

Relevant data including diagnosis and treatment model, operation situation, etc. are analyzed in our wound care center and compared with abroad based-on literature retrieval, to find out a suitable way for setting up wound care centers in our country. Wound care center with mode of multidisciplinary cooperation that is "specialist-oriented" was established in our hospital, mirroring the experience of foreign wound care centers. The investigation showed the demands of patients could be met, their psychological and economic pressures as well as social burden might be greatly relieved in our center. For an example, we achieved our purpose readily by setting up a clinical pathway of diabetic foot according to the features of our hospital. The model of multidisciplinary cooperation, with minor adjustments, may be applicable for wound care centers at home and abroad. Our wound care center will establish better system of diagnosis and treatment to conform to the situation in our country.