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Beyond capacity: an EAST multicenter mixed-methods study exploring surgeon perceptions on patient ratios in acute care surgery
No full textBackground: Optimal provider-to-patient (PtP) ratios in acute care surgery (ACS) remain undefined despite their importance for care quality and provider sustainability. This study aimed to understand surgeon perspectives on maximum ideal ratios across trauma, emergency general surgery (EGS) and surgical intensive care unit (SICU) services.
Methods: This multicenter mixed-methods study combined quantitative surveys and semistructured interviews with ACS surgeons at level I/II trauma centers across the USA (1 August 2023-19 April 2024). Service line census data were also collected. Interviews were recorded, transcribed and qualitative analysis performed; surveys were analyzed with descriptive statistics.
Results: Fifty-two interviews were completed. Survey response rate was 50.3% (212/421 eligible division leadership and faculty) from 40 centers across 24 states. The perceived maximum safe patient load for trauma and EGS was \u3c 20 patients when working independently, and up to 40 patients with full team support. SICU ratios were lower with most reporting ≤10 patients for independent coverage and ≤20 with team support. Regarding appropriate patient loads for junior residents and advanced practice providers, most respondents recommended ≤10 patients for trauma/EGS and ≤7 for SICU. For senior residents, most recommended ≤13 patients for trauma/EGS and ≤7 for SICU. Notably, 72% of centers exceeded their own leadership-recommended maximums for at least one service line. Qualitative analysis revealed patient acuity, team experience and competing demands as key workload modulators, with concerns about care quality degradation and burnout at higher ratios.
Conclusions: This study establishes potential upper threshold benchmarks for ACS PtP ratios with strong agreement across institutions. Division leadership should consider developing staffing models that account for patient acuity and service complexity while implementing escalation protocols for sustained high workloads. Current practices frequently exceed maximum ideal ratios, highlighting the need for evidence-based staffing guidelines that balance financial constraints with mounting evidence linking workload intensity and density to adverse outcomes.
Level of evidence: IV.
Keywords: Delivery of Health Care; Practice Patterns, Physicians\u27; quality improvement; workload
Improving Electronic Health Record Access for People Incarcerated in the United States
No full textAround the United States, carceral medical records are often sequestered from incarcerated patients and their external physicians, hampering the provision of both acute and transitional care. Despite laws meant to ensure better ownership and portability of electronic health records (EHRs), many carceral institutions have not implemented interoperable systems, nor do incarcerated patients have easy access to their medical information. These issues can compromise care for a patient population that experiences higher rates of many diseases, hospitalization, and death compared with the general public. This article provides a review of health information legislation by a multidisciplinary group of attorneys and physicians with a targeted literature review discussing the current state of medical record access for patients behind bars, the health dangers associated with this lack of access, and solutions to improve the equity of EHR access.
Keywords: EHR; access; health care; incarceration; interoperability; medical records
Inpatient Palliative Care and Post-operative Healthcare Utilization Among Older Surgical Patients
No full textObjective: To determine associations between documented palliative care processes and changes in post-discharge healthcare utilization among a cohort of seriously ill older adults after common major elective surgeries.
Summary background data: National guidelines recommend palliative care processes for patients with serious illness undergoing major surgery. However, outcomes associated with palliative care delivery to elective surgical patients are understudied.
Methods: We conducted a retrospective, multicenter study using Natural Language Processing to identify electronic health record documentation of five palliative care processes in a cohort of older adults with serious illness who underwent one of five major elective surgeries in a large regional health system between 2016-2018. The processes included: (1) Goals of care conversation, (2) Code status limitation, (3) Palliative care consultation, (4) Hospice assessment, and (5) Surrogate decision-maker designation. We used Medicare claims to assess healthcare utilization one-year post-discharge.
Results: Among 1,082 patients, 54.1% had a documented surrogate decision-maker, 4.3% had code status limitations, 2.6% had goals of care conversations, and\u3c 2.0% had assessment for hospice or palliative care consultations. In adjusted analysis, patients with documented surrogate decision-maker had no significant changes in hospital days, days at home, or ED visits in the year following surgery. Patients who had documented code status limitations alone spent significantly fewer days at home than those who did not (314.9 vs. 338.6, P=0.004).
Conclusions: Inpatient palliative care processes such as surrogate decision maker-designation are not associated with changes in one-year healthcare utilization after elective surgery.
Keywords: NLP; elective surgery; health services research; natural language processing; palliative care; palliative care processes
Pediatric Marfan Syndrome and Heart Transplantation: Insights From the PHIS Database
No full textBackground: Marfan syndrome (MFS) is a connective tissue disorder associated with significant cardiovascular complications, including heart failure. Orthotopic heart transplantation (OHT) is considered controversial in this population due to concerns about post-transplant aortic complications, particularly in children.
Methods: We conducted a retrospective review of the Pediatric Health Information System (PHIS) database to identify patients under 18 years of age with a diagnosis of MFS who underwent OHT between 2004 and 2024. Patients were propensity matched (3:1) to non-MFS OHT recipients. Outcomes included graft failure, aortic events, and re-transplant-free survival.
Results: Ten pediatric MFS patients were identified among 5493 OHT recipients. The median age at OHT was 12.5 years. Over a median follow-up of 3.73 years, no in-hospital mortalities or repeat transplants were observed; two patients experienced rejection, and one developed aortic root dilation without requiring intervention. Propensity-matched analysis showed no significant differences in rejection, aortic events, or transplant-free survival between MFS and non-MFS cohorts.
Conclusion: Though rare, pediatric MFS patients undergoing OHT demonstrated excellent short-term outcomes with no MFS-related surgical complications. These findings challenge current exclusionary practices and support further research into long-term outcomes.
Keywords: Marfan syndrome; heart transplant evaluation; pediatric heart failure; pediatric heart transplantation
Improving Workflow and Satisfaction Through Nurse Assignment Models: Acuity vs. Geography
No full texthttps://scholarlycommons.libraryinfo.bhs.org/nursing_artof_questioning_innovation2025/1023/thumbnail.jp
Improving Nurse Workflow and Patient Readiness Using a Total Joint Discharge Teaching Video
No full texthttps://scholarlycommons.libraryinfo.bhs.org/nursing_artof_questioning_innovation2025/1028/thumbnail.jp
Frontline Clinician Perspectives on Clinical Accuracy of Severe Maternal Morbidity Identified in Administrative Data
No full textSafety of an Unconventional Vertical Transumbilical Incision for Pediatric Umbilical Hernia Repair
No full textIntroduction: Umbilical hernias are a common pediatric surgical problem, typically repaired at 4-5 y of age. Vertical transumbilical incision (VTUI) is a less common surgical approach associated with improved cosmetic outcomes. Our goal was to demonstrate the safety of this approach compared to the periumbilical incision (PUI).
Methods: We retrospectively reviewed 402 pediatric patients who underwent an index open umbilical hernia repair for any indication at a single institution from 2013 to 2023. Patient demographics, operative outcomes, narcotic use, and complications were compared by incision type. Data were stratified by age and weight. Analysis was performed using student\u27s t-test.
Results: We analyzed 402 patients. Three hundred thirty-seven (83.8%) had PUI and 65 (16.2%) had VTUI. Mean (standard deviation) age was 5 (3.18) y, ranging 0-18 y. Females represented 55%. There was no difference in age based on incision type. PUI and VTUI room time (79.2 v 83.3 min, P = 0.10) and anesthetic time (37.8 v 33.2, P = 0.31) were not significantly different. Mean intraoperative morphine milliequivalents per kilogram (MME/kg) were not different between incision types (P = 0.99). Average postanesthesia care unit MME/kg showed no difference between PUI and VTUI (3.7 v. 7.6, P = 0.06). There were 6 (1.5%) complications with no difference based on incision: 4 recurrences (3 PUI, 1 VTUI), 1 hospital readmission (PUI), and 1 patient with uncontrolled pain requiring admission (PUI). Stratified by weight, there were no significant differences in complication rates based on incision type.
Conclusions: Our findings support VTUI as a safe alternative in the pediatric population without an increase in postoperative complications, anesthetic time, or MME/kg utilization.
Keywords: Congenital hernia; Hernia; Incision; Narcotics; Open repair; Operative time; Pediatric surgery; Umbilical hernia
Efficacy of enhanced recovery programmes for cardiac surgery: a systematic review and meta-analysis
No full textBackground: The terms fast-track (FT) and enhanced recovery after surgery (ERAS) are often mistakenly used interchangeably. Fast-track cardiac anaesthesia focuses on perioperative strategies, whereas ERAS (or enhanced recovery programme [ERP]) encompasses a wider range of strategies designed to enhance overall recovery. Evidence is needed to demonstrate the additive value of ERP above FT in cardiac surgery. We conducted a meta-analysis to investigate the comparative efficacy of ERP and FT programmes in cardiac surgery.
Methods: We systematically searched PubMed, Embase, and Web of Science for randomised trials and prospective observational trials investigating ERP or FT programmes in cardiac surgery (up to November 16, 2024). Following PRISMA guidelines, two reviewers independently selected studies, extracted data, and assessed risk of bias. Data were pooled using a random-effects model. The primary efficacy outcome was hospital length of stay (LOS).
Results: A total of 6368 articles were identified, of which 18 studies, with 2625 patients, were included. Compared with control, a significant reduction in hospital LOS (mean difference [95% confidence interval (CI)] -1.40 days [-2.19 to -0.61], P=0.001), ICU LOS (-13.22 h [-21.75 to -4.68], P=0.006), and ventilation time (-4.68 h [-7.85 to -1.52], P=0.008) was identified when ERP or FT programmes were implemented. ERP demonstrated an additive value above FT for hospital LOS (2.11 days [-3.52 to 0.71] vs -0.30 days [-0.88 to 0.27], respectively; P=0.003).
Conclusions: In cardiac surgery, ERP can reduce LOS in the ICU and hospital and ventilatory time. Moreover, it is suggested that ERPs, including preoperative, intraoperative, and postoperative interventions, are preferred above only intraoperative FT strategies.
Systematic review protocol: PROSPERO (CRD42022382409).
Keywords: ERAS; ERP; cardiac anaesthesia; cardiac surgery; enhanced recovery; fast-track; recovery programme
Advancing the APRN and PA professions through medical staff membership: An organizational case study
No full textGranting medical staff membership to advanced practice registered nurses (APRNs) and physician associates (PAs) is a national trend endorsed by The Joint Commission in 1983 and by the Centers for Medicare & Medicaid Services in 2012. APRNs and PAs must participate in the system in which medical care policies are made and communicated. Medical staff privileges enable these clinicians to help develop and implement hospital and medical staff policies that improve the quality and appropriateness of patient care. Medical staff membership also encourages a culture that promotes interprofessional and collaborative practice, enhancing and strengthening clinician relationships. Through education and by updating bylaws, rules, and regulations, APRNs and PAs at our facility can now admit patients, and they have a voice and vote in medical staff governance committees that affect their practice.
Keywords: APRNs; NPs; PAs; interprofessional practice; medical staff membership; voting privileges