In this second and concluding report on utilization management practices at Lions Gate Hospital in British Columbia, the authors outline various initiatives that improve efficiency and increase quality of care. Topics explored are laparoscopic cholecystectomy as an example of new technology that can save time and resources, a home IV therapy program, co-ordinating care by means of coordinated care mapping, and improving operating room efficiency through rigorous scheduling.
Interventional radiologists, cardiologists, and vascular surgeons are capable of performing endovascular procedures successfully in their respective environments. Suboptimal anatomy or intraoperative technical problems can be encountered, and endovascular management alone is not always suitable. The objectives of this study were to define the incidence of adjunctive surgical techniques, to discuss the rationale for endovascular reconstruction in a well-developed surgical environment, and to assess the effect of experience on the incidence of adjunctive repair.
All primary aortic and aortoiliac elective, urgent, and emergent endovascular procedures performed at the Peter Lougheed Center and entered into a prospective database from May 25, 1999 to June 01, 2005, were reviewed. All adjunctive surgical techniques to enable stent deployment, enhance attachment site, or solve intraoperative difficulties were captured. The study period was divided into two time periods based on learning curve data to assess the effect of experience on the rate of adjunctive repairs.
Four hundred thirty-eight patients underwent elective (80%), urgent (15%), or emergent (5%) endovascular procedures during the study period. These consisted of 101 thoracic and 337 abdominal operations, including the use of 13 fenestrated stents. One hundred thirty-nine patients (31.7%) required 180 open surgical procedures. Complete data were available for the entire patient cohort. The mean follow-up was 793.2 days (SD, 519.1 days). Procedures were necessary for vascular access, arterial dissection/rupture, limb ischemia, and enhancement/elongation of the stent attachment site. The persistent endoleak rate was 5.3%, the late rupture rate was 0.7%, the conversion rate was 1.6%, the 30-day surgical mortality rate was 3.2%, all-cause mortality to date is 7.3%, and the reintervention rate was 4.6%. There was no statistically significant effect of the learning curve on the incidence of surgical adjunctive procedures in either the thoracic group (11/26 [42.3%] for phase 1 vs 17/75 [22.6%] for phase 2) or the abdominal group (14/50 [28.0%] for phase 1 vs 97/287 [33.8%] for phase 2). Overall, 31.5% of patients required adjunctive surgical repair.
Successful endografting requires endovascular expertise in addition to a well-developed surgical environment to increase applicability and decrease patient risk. Despite advances in endovascular technology, hybrid techniques will continue to be required to achieve good overall success rates.
Birthing rooms, birth centres and home birth have been proposed as alternatives to the traditional in-hospital caserooms to meet the needs of women and their families more effectively. We performed a descriptive survey to determine the level of interest of childbearing women in the Ottawa-Carleton region in these birthplaces and to examine the characteristics of women who express an interest in using them. Of the 1629 women who gave birth between July 1 and Aug. 28, 1987, 1115 (68.4%) completed a self-administered questionnaire during the pregnancy, in the early postpartum period in hospital or at home. Of the respondents 577 (53.1%) said they would choose the caseroom, 316 (29.1%) the birthing room, 165 (15.2%) the birth centre and 30 (2.8%) home birth. The women who expressed an interest in a birthplace other than the caseroom were more likely than the others to be older, married, well-educated and interested in midwifery services and to breastfeed their babies (p less than 0.05). They were also more likely to have had a low-intervention vaginal birth (p less than 0.05). The interest expressed in birthing rooms, birth centres and home birth suggests that these alternatives should be considered for inclusion in the health care system.
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The cancellation of planned surgeries causes prolonged wait times, harm to patients, and is a waste of scarce resources. To reduce high cancellation rates in a Norwegian general hospital, the pathway for elective surgery was redesigned. The changes included earlier clinical assessment of patients, better planning and documentation systems, and increased involvement of patients in the scheduling of surgeries. This study evaluated the outcomes of this new pathway for elective surgery and explored which factors affected the outcomes.
We collected the number of planned operations, performed operations, and cancellations per month from the hospital's patient administrative system. We then used Student's t-test to analyze differences in cancellation rates (CRs) before and after interventions and a u-chart to analyze whether the improvements were sustained. We also conducted semi-structured interviews with employees of the hospital to explore the changes in the surgical pathway and the factors that facilitated these changes.
The mean CR was reduced from 8.5% to 4.9% (95% CI for mean reduction 2.6-4.5, p
This paper describes the process and outcomes of an initiative to develop a system to prioritize operating room bookings for children who require elective dental treatment. This initiative had 3 objectives: to improve the timeliness of treatment in the operating room based on medical and dental need, to provide a means to identify and expedite the highest-priority cases when operating room time became available, and to document the prioritization of cases as a quality assurance measure. Each patient booked for treatment in the operating room was assigned a priority ranking based on a combination of their medical risk and dental status. Measures of interrater reliability between clinician raters were moderate to good. Use of the prioritization system demonstrated improved timeliness of treatment for urgent cases and the effects of additional measures taken to reduce the waiting list.