On the tension between standardized and customized policies in healthcare: The case of length-of-stay reduction

Hospitals increasingly adopt standardized policies as a way to improve the efficiency of healthcare delivery. One key policy has been to reduce a patient's length of stay, which is commonly perceived as an effective means of improving patient outcome, as well as reducing the cost per procedure. We put this notion to the empirical test by using a database of 183,712,784 medical records of patients in the English NHS between 1998 and 2012, studying the effects of the NHS's policy of decreasing length of stay for hernia patients. While we found it to be an effective way of reducing the cost per procedure, on aggregate, we also found that it increases the risk of readmission and of death for vulnerable and elderly patients, unduly increasing the long-term failure costs of the operation for these patient groups. Based on our findings we propose a differentiated policy to selectively decrease length of stay, which we estimate could save up to US$565 per non-emergency hernia procedure (a 19.97% reduction in the cost per procedure). We outline the implications of our findings for medical practice, and discuss the wider theoretical contributions to the wider standardization-customization debate in healthcare operations management

SARS-CoV-2 pandemic. Implications in the management of patients with colorectal cancer

The SARS-CoV-2 pandemic has already reached 3,207,248 patients with more than 225,000 deaths all over the world. Colorectal cancer is the third most diagnosed cancer worldwide, and the healthcare system is struggling to manage daily activities for elective cancer surgery. This review integrates clinical, microbiological, architectural and surgical aspects to develop indications on strategies to manage colorectal cancer patients and ensure safety during the pandemic. Telephone or virtual clinics must be encouraged and phone follow-up should be implemented. Indications for surgery must be rigorous, balancing the advantage of early surgical treatment and risks of treatment delay. To decrease the occupancy rate of intensive care unit beds, elective surgical treatment should be delayed until local endemic control, according to stage of disease. Patients with SARS-CoV-2 infection should be treated only after clinical recovery, two consecutive negative oropharyngeal swabs and, if available, a negative stool sample. Before any elective oncologic procedure, a multidisciplinary oncologic team including an anaesthesiologist and an infectious disease specialist must assess every patient to evaluate the risk of infection and its impact on perioperative morbidity, mortality and oncologic prognosis. The hospital should organise to manage all elective oncologic patients in an "infection-free" area or refer them to a non-SARS-CoV-2 hospital

COVID-19 the showdown for mass casualty preparedness and management: the Cassandra Syndrome.

Since December 2019, the world is potentially facing one of the most difficult infectious situations of the last decades. COVID-19 epidemic warrants consideration as a mass casualty incident (MCI) of the highest nature. An optimal MCI/disaster management should consider all four phases of the so-called disaster cycle: mitigation, planning, response, and recovery. COVID-19 outbreak has demonstrated the worldwide unpreparedness to face a global MCI.This present paper thus represents a call for action to solicitate governments and the Global Community to actively start effective plans to promote and improve MCI management preparedness in general, and with an obvious current focus on COVID-19

COVID-19 the showdown for mass casualty preparedness and management: the Cassandra Syndrome.

Since December 2019, the world is potentially facing one of the most difficult infectious situations of the last decades. COVID-19 epidemic warrants consideration as a mass casualty incident (MCI) of the highest nature. An optimal MCI/disaster management should consider all four phases of the so-called disaster cycle: mitigation, planning, response, and recovery. COVID-19 outbreak has demonstrated the worldwide unpreparedness to face a global MCI.This present paper thus represents a call for action to solicitate governments and the Global Community to actively start effective plans to promote and improve MCI management preparedness in general, and with an obvious current focus on COVID-19

2017 update of the WSES guidelines for emergency repair of complicated abdominal wall hernias

Emergency repair of complicated abdominal wall hernias may be associated with worsen outcome and a significant rate of postoperative complications. There is no consensus on management of complicated abdominal hernias. The main matter of debate is about the use of mesh in case of intestinal resection and the type of mesh to be used. Wound infection is the most common complication encountered and represents an immense burden especially in the presence of a mesh. The recurrence rate is an important topic that influences the final outcome. A World Society of Emergency Surgery (WSES) Consensus Conference was held in Bergamo in July 2013 with the aim to define recommendations for emergency repair of abdominal wall hernias in adults. This document represents the executive summary of the consensus conference approved by a WSES expert panel. In 2016, the guidelines have been revised and updated according to the most recent available literature.Peer reviewe

Antimicrobials: a global alliance for optimizing their rational use in intra-abdominal infections (AGORA)

Intra-abdominal infections (IAI) are an important cause of morbidity and are frequently associated with poor prognosis, particularly in high-risk patients. The cornerstones in the management of complicated IAIs are timely effective source control with appropriate antimicrobial therapy. Empiric antimicrobial therapy is important in the management of intra-abdominal infections and must be broad enough to cover all likely organisms because inappropriate initial antimicrobial therapy is associated with poor patient outcomes and the development of bacterial resistance. The overuse of antimicrobials is widely accepted as a major driver of some emerging infections (such as C. difficile), the selection of resistant pathogens in individual patients, and for the continued development of antimicrobial resistance globally. The growing emergence of multi-drug resistant organisms and the limited development of new agents available to counteract them have caused an impending crisis with alarming implications, especially with regards to Gram-negative bacteria. An international task force from 79 different countries has joined this project by sharing a document on the rational use of antimicrobials for patients with IAIs. The project has been termed AGORA (Antimicrobials: A Global Alliance for Optimizing their Rational Use in Intra-Abdominal Infections). The authors hope that AGORA, involving many of the world's leading experts, can actively raise awareness in health workers and can improve prescribing behavior in treating IAIs

The Global Alliance for Infections in Surgery : defining a model for antimicrobial stewardship-results from an international cross-sectional survey

Background: Antimicrobial Stewardship Programs (ASPs) have been promoted to optimize antimicrobial usage and patient outcomes, and to reduce the emergence of antimicrobial-resistant organisms. However, the best strategies for an ASP are not definitively established and are likely to vary based on local culture, policy, and routine clinical practice, and probably limited resources in middle-income countries. The aim of this study is to evaluate structures and resources of antimicrobial stewardship teams (ASTs) in surgical departments from different regions of the world. Methods: A cross-sectional web-based survey was conducted in 2016 on 173 physicians who participated in the AGORA (Antimicrobials: A Global Alliance for Optimizing their Rational Use in Intra-Abdominal Infections) project and on 658 international experts in the fields of ASPs, infection control, and infections in surgery. Results: The response rate was 19.4%. One hundred fifty-six (98.7%) participants stated their hospital had a multidisciplinary AST. The median number of physicians working inside the team was five [interquartile range 4-6]. An infectious disease specialist, a microbiologist and an infection control specialist were, respectively, present in 80.1, 76.3, and 67.9% of the ASTs. A surgeon was a component in 59.0% of cases and was significantly more likely to be present in university hospitals (89.5%, p <0.05) compared to community teaching (83.3%) and community hospitals (66.7%). Protocols for pre-operative prophylaxis and for antimicrobial treatment of surgical infections were respectively implemented in 96.2 and 82.3% of the hospitals. The majority of the surgical departments implemented both persuasive and restrictive interventions (72.8%). The most common types of interventions in surgical departments were dissemination of educational materials (62.5%), expert approval (61.0%), audit and feedback (55.1%), educational outreach (53.7%), and compulsory order forms (51.5%). Conclusion: The survey showed a heterogeneous organization of ASPs worldwide, demonstrating the necessity of a multidisciplinary and collaborative approach in the battle against antimicrobial resistance in surgical infections, and the importance of educational efforts towards this goal.Peer reviewe

2020 update of the WSES guidelines for the management of acute colonic diverticulitis in the emergency setting.

Acute colonic diverticulitis is one of the most common clinical conditions encountered by surgeons in the acute setting. An international multidisciplinary panel of experts from the World Society of Emergency Surgery (WSES) updated its guidelines for management of acute left-sided colonic diverticulitis (ALCD) according to the most recent available literature. The update includes recent changes introduced in the management of ALCD. The new update has been further integrated with advances in acute right-sided colonic diverticulitis (ARCD) that is more common than ALCD in select regions of the world