Operating Room First Start Efficiency Throughout a Large Urban Hospital System

Background: Operating room delays decrease health care system efficiency and increase hospital costs. Data on delays in a multihospital system are sparse. Purpose: In an effort to improve our operating room efficiency, we investigated operating room delays, the causes and the impending financial impact. Methods: A retrospective analysis on first case-of-the-day surgeries at three hospitals during 2013 was conducted. Delays were defined as in-room time being after scheduled surgery start time. Length of delay and causes were recorded. Patient demographics, body mass index, hospital facility, total number of procedures, provider specialty and time of patient arrival were incorporated into a logistic regression model to identify significant variables. Hosmer-Lemeshow was used to measure goodness-of-fit and predictive power. Cost was calculated using published estimates. Results: 5,607 cases were examined and 88% were delayed. Surgeons (21%), anesthesiologists (6.17%), patients (5.42%), staff (3.60%), facility (2.10%) and other (2.35%) were identified as causes. Mean time for patient arrival to surgery was 104.57 min. Mean time between arrival and room placement was 127.38 min. The average delay time from scheduled surgery start was 24.26 min. Logistic regression identified hospital facility (P \u3c 0.0001), surgical specialty (P \u3c 0.0001), patient age (P = 0.0004) and late patient arrival (P = 0.0005) as significant predictors of delay. Operating room delays were responsible for $444,074 in lost revenue. Conclusion: In our study, 88% of first start cases were delayed, the majority of which were caused by the surgeon. However, hospital facility, surgical subspecialty, patient age and arrival time also significantly affected delays. Correction of operating room delays can significantly reduce hospital costs

Maternal and neonatal outcomes in obese women who lose weight during pregnancy

OBJECTIVE: To evaluate neonatal and maternal outcomes in obese pregnant women whose weight gain differed from the Institute of Medicine (IOM) recommendations. STUDY DESIGN: Maternal and neonatal outcomes associated with weight change in pregnancy were retrospectively investigated in women with obesity (body mass index (BMI) ⩾30 kg m(-2); N=10734) who gave birth at 12 hospitals. Using a 1:1:1:1 design (n=778 matched groups), we matched women with obesity who lost, maintained, gained appropriate (IOM recommended) and gained excessive weight during pregnancy by gestational age at delivery, maternal age, race/ethnicity, prepregnancy BMI, chronic hypertension, pregestational diabetes and smoking status. Regression techniques were used to adjust for confounders and compare outcomes across weight change categories. RESULT: Compared with IOM recommendations, weight loss was associated with twofold greater odds of low birth weight infants and a mean decrease in estimated blood loss of 30 ml; excessive weight gain was associated with doubled odds of gestational hypertension or preeclampsia, fourfold greater odds of macrosomia and a mean decrease in 5-min APGAR of 0.09. From lost to excessively gained weight, the odds of cesarean delivery increased 1.4 times and mean infant birth weight increased by 197 g. In contrast, the odds of small-for-gestational age were 1.8 times greater for women who lost than gained excessive weight. CONCLUSION: Weight loss in obese pregnant women is associated with increased risk for low birth weight neonates but significantly decreased or maintained risk for other maternal and neonatal morbidities, as compared with appropriate or excessive weight gain. This study supports re-evaluation of the current IOM guidelines for women with obesity.Journal of Perinatology advance online publication, 7 January 2016; doi:10.1038/jp.2015.202

Robustness of a Newly Proposed Risk Schema for Lymphatic Dissemination in Endometrioid Endometrial Cancer

Background: Surgical management for endometrioid endometrial cancer (EEC) includes complete lymph node dissection for all patients at risk of lymphatic dissemination. The standard risk schema, defined by Mayo Clinic, identifies low-risk patients as those with grade 1/2 EEC, myometrial invasion (MI) ≤ 50%, and tumor diameter (TD) ≤ 2 cm. We recently proposed (and published) a risk schema containing modified forms of grade, MI and TD that suggests a significant decrease in false-negative rate and need for lymphadenectomy in low-risk women. Purpose: Evaluate robustness of our proposed schema for lymphatic dissemination risk stratification in a subsequent EEC patient cohort. Methods: We retrospectively applied the proposed schema to patients diagnosed with stage I–III EEC during 2014–2015 who underwent pelvic and/or para-aortic lymph node removal. Cancer Registry data were confirmed via chart review. Consistent with the cohort studied during model development, the validation cohort included non-Hispanic white or black patients with complete data describing TD (≤ 50 mm or \u3e 50 mm), MI (≤ 33%, \u3e 33% to ≤ 66%, or \u3e 66%) and grade (1 or 2–3). Results: In the validation cohort, 29 (11.7%) of the 247 EEC patients were node-positive (vs 9.2% of 737 patients in the development cohort). Risk stratification using the proposed schema produced similar false-positive rates during model development (57.2%) and validation (54.6%), both 20% lower than when using the standard schema (76.2% and 74.3%, respectively). False-negative rates, however, were noticeably different between development and validation cohorts using both the proposed (0% and 13.8%) and standard (1.47% and 6.90%) schemas, suggesting a shift toward low-risk classification in node-positive patients of the validation cohort. Conclusion: Application of the proposed risk stratification schema to an alternative patient cohort verified the utility of modified risk criteria, including TD with 50-mm cutoff, for identifying low-risk EEC patients who may not require node evaluation. However, in the validation cohort, greater prevalence of lymph node metastasis and low-risk classification of node-positive patients was observed. Discrepancy between cohorts is likely due to greater utilization of sentinel lymph node mapping during the validation period, allowing for increased detection of low-volume metastases. Continued model development and validation is needed, especially to account for the increased sensitivity of new technologies

Maternal and Neonatal outcomes in obese women who lose weight during pregnancy [30]

OBJECTIVE: To evaluate the neonatal and maternal outcomes in obese pregnant women whose weight gain differed from Institute of Medicine (IOM) recommendations. METHODS: We conducted a retrospective study of maternal and neonatal data from 12 hospitals to examine the effects of weight change during pregnancy in obese women (body mass index [BMI, calculated as weight (kg)/[height (m)]2] 30 or greater; N=10,734). Using a 1:1:1:1 design (n=488 matched groups), we matched obese women who lost weight, maintained weight, gained appropriate weight (IOM-recommended) and gained excessive weight during pregnancy by gestational age at delivery (less than +/-1 week) and maternal characteristics of age (less than +/-1 year), race and ethnicity, BMI (+/-10%), chronic hypertension, pregestational diabetes, and smoking status. Generalized estimating equations were used to examine the effects of pregnancy weight change on maternal and neonatal outcomes. RESULTS: Compared with IOM recommendations, weight loss was associated with increased odds of small-for-gestational-age (SGA) birth (odds ratio [OR] 1.73 [1.11-2.70]; P=.013). Losing weight (OR 0.59 [0.37-0.94]; P=.029) and maintaining weight (OR 0.61 [0.38-0.98]; P=.040), however, decreased the odds of gestational hypertension. Gradual change in outcomes from lost to excessively gained weight revealed 1.4 times greater odds of cesarean delivery, a threefold increase in odds of gestational hypertension, and doubled odds of neonatal intensive care unit admission with increasing weight gain. In contrast, the odds of SGA increased 2.5 times with decreasing weight gain or weight loss. CONCLUSION: Weight loss in obese pregnant patients increases the risks of SGA neonates; however, it does not increase neonatal morbidity and decreases maternal morbidity

First-Case Operating Room Delays: Patterns Across Urban Hospitals of a Single Health Care System

Purpose Operating room delays decrease health care system efficiency and increase costs. To improve operating room efficiency in our system, we retrospectively investigated delay frequencies, causes and costs. Methods We studied all first-of-the-day nonemergent surgical cases performed at three high-volume urban hospitals of a large health system from July 2012 to November 2013. Times for patient flow from arrival to procedure start and documented reasons for delay were obtained from electronic medical records. Delay was defined as patient placement in the operating room later than scheduled surgery time. Effects of patient characteristics, late patient arrival to the hospital, number of planned procedures, years of surgeon experience, service department and hospital facility on odds of delay were examined using logistic regression. Results Of 5,598 cases examined, 88% were delayed. Patients arrived late to the hospital (surgery) in 65% of first cases. Mean time from arrival to scheduled surgery and in-room placement was 104.6 and 127.4 minutes, respectively. Mean delay time was 28.2 minutes. Nearly 60% of delayed cases had no documented reason for delay. For cases with documentation, causes included the physician (52%), anesthesia (15%), patient (13%), staff (9%), other sources (6%) and facility (5%). Regression analysis revealed age, late arrival, department and facility as significant predictors of delay. Estimated delay costs, based on published figures and representing lost revenue, were $519,388. Conclusions To improve operating room efficiency, multidisciplinary strategies are needed for increasing patient adherence to recommended arrival times, documentation of delay by medical staff and consistency in workflow patterns among facilities and departments

Tumor diameter as a predictor of lymphatic dissemination in endometrioid endometrial cancer

OBJECTIVES: To assess the utility of tumor diameter (TD) for predicting lymphatic dissemination (LD) and determining need for lymphadenectomy following diagnosis of endometrioid endometrial cancer. METHODS: Patients diagnosed with stage I-III endometrioid endometrial cancer during 2003-2013 who underwent complete lymphadenectomy during hysterectomy were studied. Intraoperative predictors of LD included TD, grade, myometrial invasion (MI), age, body mass index, and race/ethnicity. Candidate logistic regression models of LD were evaluated for model fit and predictive power. RESULTS: Of 737 cancer patients, 68 (9.2%) were node-positive. Single-variable models with only continuous TD (c-statistic 0.77, 95% CI 0.71-0.83) and dichotomous TD with 50-mm cut-off (TD50; c-statistic 0.73, 95% CI 0.67-0.78) were significantly more predictive than with the standard 20-mm cut-off (c-statistic 0.56, 95% CI 0.53-0.59). Overall, the most important LD predictors were TD50 and MI3rds (three-category form). The best candidate model (c-statistic 0.84, 95% CI 0.80-0.88) suggested odds of LD were five times greater for TD \u3e50mm than ≤50mm (OR 4.91, 95% CI 2.73-8.82) and six and ten times greater for MI \u3e33% to ≤66% (OR, 5.70; 95% CI, 2.25-14.5) and \u3e66% (OR 10.2, 95% CI 4.11-25.4), respectively, than ≤33%. Best-model false-negative (0%) and positive (57.2%) rates demonstrated marked improvement over traditional risk-stratification false-negative (1.5%) and positive (76.2%) rates (c-statistic 0.77, 95% CI 0.72-0.82). CONCLUSIONS: Tumor diameter is an important predictor of LD. Our risk model, containing modified forms of MI and TD, yielded a lower false-negative rate and can significantly decrease the number of lymphadenectomies performed on low-risk women

Robustness of a newly proposed risk schema for lymphatic dissemination of endometrioid endometrial cancer

Background: Surgical management for endometrioid endometrial cancer (EEC) includes complete lymph node dissection for all patients at risk of lymphatic dissemination. The standard risk schema, defined by Mayo Clinic, identifies low-risk patients as those with grade 1/2 EEC, myometrial invasion (MI) ≤ 50%, and tumor diameter (TD) ≤ 2 cm. We recently proposed (and published) a risk schema containing modified forms of grade, MI and TD that suggests a significant decrease in false-negative rate and need for lymphadenectomy in low-risk women. Purpose: Evaluate robustness of our proposed schema for lymphatic dissemination risk stratification in a subsequent EEC patient cohort. Methods: We retrospectively applied the proposed schema to patients diagnosed with stage I–III EEC during 2014–2015 who underwent pelvic and/or para-aortic lymph node removal. Cancer Registry data were confirmed via chart review. Consistent with the cohort studied during model development, the validation cohort included non-Hispanic white or black patients with complete data describing TD (≤ 50 mm or \u3e 50 mm), MI (≤ 33%, \u3e 33% to ≤ 66%, or \u3e 66%) and grade (1 or 2–3). Results: In the validation cohort, 29 (11.7%) of the 247 EEC patients were node-positive (vs 9.2% of 737 patients in the development cohort). Risk stratification using the proposed schema produced similar false-positive rates during model development (57.2%) and validation (54.6%), both 20% lower than when using the standard schema (76.2% and 74.3%, respectively). False-negative rates, however, were noticeably different between development and validation cohorts using both the proposed (0% and 13.8%) and standard (1.47% and 6.90%) schemas, suggesting a shift toward low-risk classification in node-positive patients of the validation cohort. Conclusion: Application of the proposed risk stratification schema to an alternative patient cohort verified the utility of modified risk criteria, including TD with 50-mm cutoff, for identifying low-risk EEC patients who may not require node evaluation. However, in the validation cohort, greater prevalence of lymph node metastasis and low-risk classification of node-positive patients was observed. Discrepancy between cohorts is likely due to greater utilization of sentinel lymph node mapping during the validation period, allowing for increased detection of low-volume metastases. Continued model development and validation is needed, especially to account for the increased sensitivity of new technologies

Validation of an Endometrial Tumor Diameter Model for Risk Assessment in the Absence of Lymph Node Mapping

Purpose: This study aimed to assess the optimal tumor diameter for predicting lymphatic metastasis and to determine intraoperatively the need for lymph node dissection in patients with endometrioid endometrial cancer. Methods: Military beneficiaries diagnosed with stage I–III endometrioid endometrial cancer during 2003–2016 who had at least 7 pelvic and/or paraaortic lymph nodes removed during the time of hysterectomy were studied. Tumor diameter was compared against the presence of positive nodes, using the prior models of 20 mm (ie, Mayo model) and 50 mm (ie, Milwaukee model), to determine the false-negative rate of each threshold. A separate analysis was completed to determine the optimal diameter for our population. Receiver operating characteristic curve analysis models of tumor diameter were evaluated for model fit and predictive power of lymph node involvement. Results: Of the 1224 patients with endometrioid endometrial cancer included, 13% (n = 160) had positive lymph node involvement. Tumor sizes ranged from 1 mm to 100 mm. In contrast to Mayo and Milwaukee models (ie, Mayo, Milwaukee), the optimal tumor diameter independent of myometrial invasion and grade of tumor to predict lymph node metastasis was found to be 35 mm. Conclusions: Endometrioid endometrial cancer tumor diameter of 35 mm was found to be the optimal threshold for lymphadenectomy when the operating surgeon has no knowledge of tumor invasion

Validation of an Endometrial Tumor Diameter Model for Risk Assessment in the Absence of Lymph Node Mapping

Purpose: This study aimed to assess the optimal tumor diameter for predicting lymphatic metastasis and to determine intraoperatively the need for lymph node dissection in patients with endometrioid endometrial cancer. Methods: Military beneficiaries diagnosed with stage I–III endometrioid endometrial cancer during 2003–2016 who had at least 7 pelvic and/or paraaortic lymph nodes removed during the time of hysterectomy were studied. Tumor diameter was compared against the presence of positive nodes, using the prior models of 20 mm (ie, Mayo model) and 50 mm (ie, Milwaukee model), to determine the false-negative rate of each threshold. A separate analysis was completed to determine the optimal diameter for our population. Receiver operating characteristic curve analysis models of tumor diameter were evaluated for model fit and predictive power of lymph node involvement. Results: Of the 1224 patients with endometrioid endometrial cancer included, 13% (n = 160) had positive lymph node involvement. Tumor sizes ranged from 1 mm to 100 mm. In contrast to Mayo and Milwaukee models (ie, Mayo, Milwaukee), the optimal tumor diameter independent of myometrial invasion and grade of tumor to predict lymph node metastasis was found to be 35 mm. Conclusions: Endometrioid endometrial cancer tumor diameter of 35 mm was found to be the optimal threshold for lymphadenectomy when the operating surgeon has no knowledge of tumor invasion