Optimal utilization of a breast care advanced practice clinician

Background

Incorporation of “lean” business philosophy within health care has the goal of adding value by reducing cost and improving quality. Applying these principles to the role of Advance Practice Clinicians (APCs) is relevant because they have become essential members of the healthcare team.

Methods

An independent surgical breast care clinic directed by an APC was created with measurements of success to include the following: time to obtain an appointment, financial viability, and patient/APC/MD satisfaction.

Results

During the study period, there was a trend toward a decreased median time to obtain an appointment. Monthly APC charges increased from $388 to $30,800. The mean provider satisfaction score by Press Ganey was 96% for the APC and 95.8% for the surgeon. Both clinicians expressed significant satisfaction with clinic development.

Conclusions

Overall, initiation of an APC breast clinic met the proposed goals of success. The use of lean philosophy demonstrates that implementation of change can result in added value in patient care.     

The promise and problems of non-physician practitioners in general surgery education: Results of a multi-center,mixed-methods study of faculty

Background

Nurse Practitioners and Physician Assistants – called non-physician practitioners or NPPs – are common, but little is known about their educational promise and problems.

Innovation in pediatric surgery: The surgical innovation continuum and the ETHICAL model

Innovations are indispensable to the practice and advancement of pediatric surgery. Children represent a special type of vulnerable population and must be protected since they do not have legal capacity to consent, and their parent’s judgment may be compromised in circumstances when the child is very ill or no adequate therapy exists. In an effort to protect patients, legislators could pass and enforce laws that prohibit or curtail surgical innovations and thus stifle noble advancement of the practice. The goals of this paper are, 1) To clearly define the characteristics of surgical innovation types so interventions may be classified into 1 of 3 distinct categories along a continuum: Practice Variation, Transition Zone, and Experimental Research, and 2) To propose a practical systematic method to guide surgeon decision-making when approaching interventions that fall into the “Transition Zone” category on the Surgical Intervention Continuum. The ETHICAL model allows those that know the intricacies and nuances of pediatric surgery best, the pediatric surgeons and professional pediatric surgical societies, to participate in self-regulation of innovation in a manner that safeguards patients without stifling creativity or unduly hampering surgical progress.     

Defining the role of advanced care practitioners in pediatric surgery practice

IntroductionThe role of advanced care practitioners (ACPs) in pediatric surgery is increasingly important and not well described.MethodsElectronic surveys were sent to pediatric surgery division chiefs within the Children's Hospital Association.ResultsWe received 77/163 survey responses (47%). The median number of ACPs per service was 3.0 (range 0–35). ACP number correlated with inpatient census, surgeon number, case volume, trauma centers, intensive care unit status, and fellowship programs but not with presence of residents/hospitalists, hospital setting, or practice type. Nearly all programs incorporated nurse practitioners while almost half utilized physician assistants. Approximately one-third of ACPs were designated for subspecialties (35%) such as trauma and colorectal. Only 9% of centers had surgeon-specific ACPs. ACP responsibilities included both inpatient and outpatient tasks. Nearly all ACPs participated in procedures (89%), mostly bedside (80%). All ACPs worked daytime shifts, with less nights and weekends. Most ACPs billed for services (80%). Satisfaction with ACP coverage was widespread and did not correlate with ACP number. Most respondents felt that ACPs enhance, and not hinder, resident/fellow training (85%).ConclusionACPs are useful adjuncts in pediatric surgery. A better understanding of practice patterns may help optimize utilization to enhance patient care and can be used to advocate for appropriate resources.     

Posttraumatic stress disorder in mothers of children who have undergone surgery for congenital disease at a pediatric surgery department

Purpose

The aim of the study was to investigate posttraumatic stress disorder (PTSD) in mothers of children who have undergone surgery for congenital disease at a pediatric surgery department.

Methods

A questionnaire survey was carried out in 145 mothers of children who had undergone surgery and were still alive. For comparison, the mothers were categorized into 3 groups according to the severity of their child's disease.

Results

Of the 145 mothers, 29 (20%) were likely to be diagnosed as having developed PTSD at the time of the survey. Posttraumatic stress disorder symptoms correlated with factors such as anxiety and condition of the child. In terms of the disease severity of the child, factors such as anxiety tended to be observed more frequently in the higher disease severity group, whereas the proportion of mothers likely to be diagnosed as having developed PTSD was smallest in the moderate-severity group.

Conclusions

Twenty percent of the mothers of children had probably developed PTSD. In the moderate-severity group, there seemed to be a factor that alleviated PTSD symptoms. Because mothers provided effective care for the symptoms of children in the moderate-severity group, this observation suggests that participation of the mother in their child's treatment might prevent them from developing PTSD symptoms.     

History of the department of surgery in Cincinnati

This narrative reviews the foundations and development of surgery in Cincinnati beginning with the surgical pioneers and the founding of the first medical institutions by Dr. Daniel Drake. The amalgamation of multiple medical schools resulted in university affiliation and a "full-time" chairman of surgery. The arrival of Dr. George Heuer and his Johns Hopkins group caused great turmoil but resulted in a strong department of surgery and residency program. Drs. Reid, Carter, and Altemeier succeeded Dr. Heuer and each contributed to the department's growth and success. Dr. Josef E. Fischer became chairman of surgery in 1978 and led the department through difficult times to its greatest expansion and development-bringing to a department with an outstanding history and tradition the reforms and modernizations needed to take it into the 21st century. Dr. Fischer has now returned to Boston and Harvard and was succeeded by Dr. Jeffrey Matthews in 2001. Under his capable leadership the department of surgery at the University of Cincinnati seems assured of a bright future.     

Attributes of a surgical chairperson associated with extramural funding of a department of surgery

Background

Chairpersons of surgery departments are key stakeholders and role models and leaders of research in academic medical institutions. However, the characteristics of surgical chairpersons are understudied. This study aimed to investigate the association between the personal academic achievement of a surgical chairperson and the National Institutes of Health (NIH) funding of the department.

Methods

We calculated the Hirsch index (H-index), a measure of research productivity, for chairpersons of surgery of the top 90 research medical schools that were ranked by U.S. News & World Report. Specialty training, y as chairperson, location, and NIH institutional and department funding were analyzed. Nonparametric tests and linear regression methods were used to compare the different groups.

Results

Of the 90 chairpersons, 20 positions for chairs (22%) are either recent (<1 y) or unfilled (n = 6). Only 3% of all chairpersons are women, and the median H-index for the chairpersons is 20 (Interquartile range 14–27) with a median 101 publications with 14 cites per publication. Median surgery-specific NIH funding in 2011 was $1.7 million (Interquartile range $721,042–5,085,305). The chairperson's H-index was exponentially associated with department funding in multivariate models adjusting for institution rank, except when the H-index was extreme (<4 or >49) (coefficient 0.32, P = 0.02).

Conclusions

The research productivity of a chairperson is the only personal attribute of those studied that is associated with the departmental NIH funding. This suggests the important role an academically productive surgical leader may play as a champion for the academic success of the department.     

A county hospital surgical practice: a model for acute care surgery

BACKGROUND: Trauma surgery has changed significantly over the past decade. Nonoperative evidence-based algorithms have become common and surgical trauma volume has become increasingly difficult to maintain. The acute care surgery (ACS) model, which integrates trauma, critical care, and emergency surgery, has been proposed as a future model of trauma practice. METHODS: Database information from an academic, county-based, trauma center was reviewed. A performance improvement surgical procedure database and level I trauma registry from 2005 were used to evaluate one center's ACS practice. RESULTS: There were 2,276 cases performed by 7 full-time and 5 part-time surgeons. Elective cases accounted for 64% (1,480) of caseload, emergency/urgent general surgery accounted for 32% (719) of cases, and emergency trauma surgeries accounted for 4% (96 procedures in 77 patients). In all, 23% were performed after hours. The ACS model supported controllable hours, adequate surgical volume, excellent patient care, and an appealing clinical practice. CONCLUSION: Surgical practice in a county-run trauma hospital can be similar to the ACS model, with positive results in terms of clinical volume and physician satisfaction. As clinical practices shift to the ACS model, there are lessons to be learned from currently existing, thriving, long-standing similar prototypes.     

Single incision laparoscopic surgery in general surgery: a review

Single incision laparoscopic surgery (SILS) is a rapidly developing field that may represent the future of laparoscopic surgery. The major advantage of SILS over standard laparoscopic surgery is in cosmesis, with surgery becoming essentially scarless if the incision is hidden within the umbilicus. Only one incision is required so the risk of potential complications like port site hernias, haematomas and wound infection is reduced. The trade-off for this is a technically more challenging procedure with different underlying principles to that of traditional laparoscopic surgery. A wide variety of new equipment has been developed to support SILS and the range of procedures that are amenable to the technique is increasing. To date most of the published data relating to SILS are in the form of case series, with the first large randomised controlled trials due to be completed by the end of 2012. The existing evidence suggests that SILS is similar to standard laparoscopic surgery in terms of complication rates, completion rates and post-operative pain scores. However, the duration of SILS is longer than equivalent laparoscopic procedures. This article discusses SILS with regard to its applications in general surgery and reviews the evidence currently available.     

82例肝胆外科住院病人医院感染调查分析

目的 了解肝胆外科医院感染特点及其危险因素,探讨有效的预防控制措施,减少医院感染的发生。方法 对我院肝胆外科2010年所有住院患者,采取回顾性调查的方法 进行研究。结果 肝胆外科医院感染共82人次,105例次,感染率2.54％,例次感染率3.25％;感染类型以手术部位感染(41.90％)、下呼吸道感染(26.67％)和...     

Patient with advanced intrahepatic cholangiocarcinoma with long-term survival successfully treated with a combination of surgery and chemotherapy

Intrahepatic cholangiocarcinoma (ICC) is a relatively rare malignancy arising from the biliary epithelium. Prognosis is typically poor. Currently, aggressive surgical resection is the only treatment modality that offers patients any chance of long-term survival. Here, we present the case of a 57-year-old woman in whom we diagnosed ICC, with the tumor occupying the entire left and caudate hepatic lobes and daughter nodules in the right lobe. She underwent hepatectomy of segments I to VI, combined with intraoperative microwave coagulation therapy for nodules in the residual liver. Three months after the surgical resection, she had recurrence of the disease. The patient subsequently received weekly intraarterial chemotherapy with irinotecan (CPT-11), and a partial response was observed which persisted for 18 months. Subsequent computed tomography revealed the regrowth of three tumors, and she therefore underwent a repeat resection 24 months after the first surgical operation. In postoperative-month (POM) 32, she received systemic chemotherapy with tegatur/gimeracil/oteracil potassium (S-1)/cisplatin for multiple small nodules in her lung. Following three cycles of chemotherapy with a stable disease response, partial resections of the lung were performed. Third and fourth hepatectomies were performed in POMs 46 and 59, respectively. Five years and 5 months after the first hepatectomy, she is alive with small lesions in her lung. This multimodal approach may be effective for ICC.     

袖套法建立大鼠肺移植模型的改进

目的探讨袖套技术建立大鼠肺移植模型的方法改进。方法用改进的袖套技术建立大鼠肺移植模型。结果30例大鼠肺移植，手术成功率90％（27／30），术后生存率100％，供肺摘取需时（1．0±0．5）min，供肺完成肺动静脉和支气管套管时间分别为（1．0±0．5）、（2．0±1．0）和（2．0±0．5）min，供受体肺动静脉和支气管吻合时间分别为（3．0±2．0）、（7．0±2．0）和（1．5±0．5）min。结论改进的袖套技术具有供肺获取、肺动静脉和支气管套管和吻合更快速、简化、有效的优点。     

模块化培训模式在机器人手术配合训练中的应用

目的:总结模块化培训模式在机器人手术系统辅助腹腔镜手术配合中护士的培训经验及效果。方法:回顾性分析并总结2017年9月-2019年9月浙江省人民医院机器人手术配合护士运用模块化培训的方法。该培训体系包括3个模块:第1阶段为初级模块培训,包括机器人理论学习和专科理论学习,并在培训前后对护士进行两个学习内容的分别考核;第2阶段为中级模块培训,包括操作技能、观看经典手术视频、模具仿真培训,并在培训前后对护士模具仿真培训的准备时间、对接时间及应急处理时间分别进行计时;第3阶段为高级模块培训,即参与临床实践。对每名护士培训前后得分及操作完成时间进行比较。结果:护士经初级模块培训后的考试成绩及中级模块培训后的操作完成时间明显优于培训前(P<0.05),且进入高级模块培训的所有护士经导师监督下完成3例手术后均能独立进行机器人手术配合。结论:模块化培训模式能显著提高护士机器人手术配合的工作技能。     

微创外科时代胆道外科的前程与归宿

Bile duct has great attraction to surgeons due to its special anatomical location,unique biological features and origin of complicate diseases. Minimally invasive surgery,represented by laparoscopic ch...