Journal of the American College of Surgeons
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COVID-19 predisposes patients to a prothrombotic state with demonstrated microvascular involvement. The degree of hypercoagulability appears to correlate with outcomes; however, optimal criteria to assess for the highest-risk patients for thrombotic events remain unclear; we hypothesized that deranged thromboelastography measurements of coagulation would correlate with thromboembolic events. ⋯ Fibrinolysis shutdown, as evidenced by elevated d-dimer and complete failure of clot lysis at 30 minutes on thromboelastography predicts thromboembolic events and need for hemodialysis in critically ill patients with COVID-19. Additional clinical trials are required to ascertain the need for early therapeutic anticoagulation or fibrinolytic therapy to address this state of fibrinolysis shutdown.
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Although endoscopy is recommended at 1 year after colorectal cancer (CRC) resection to detect locally recurrent CRC, earlier work at our Veterans Affairs (VA) facility demonstrated that 35% of patients achieve this metric. ⋯ Implementation of a virtual surveillance clinic with standardized processes was associated with increased guideline-concordant endoscopic surveillance after CRC resection.
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Hospitals have severely curtailed the performance of nonurgent surgical procedures in anticipation of the need to redeploy healthcare resources to meet the projected massive medical needs of patients with coronavirus disease 2019 (COVID-19). Surgical treatment of non-COVID-19 related disease during this period, however, still remains necessary. ⋯ We describe a scoring system that systematically integrates these factors to facilitate decision-making and triage for MeNTS procedures, and appropriately weighs individual patient risks with the ethical necessity of optimizing public health concerns. This approach is applicable across a broad range of hospital settings (academic and community, urban and rural) in the midst of the pandemic and may be able to inform case triage as operating room capacity resumes once the acute phase of the pandemic subsides.
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Postoperative returns to acute care represent fragmented care, are costly, and often evolve into readmission. Reduction of postoperative readmissions and emergency department visits represents an opportunity to improve quality of care and decrease resource use. The aim of this study was to assess the impact of 2 failure modes and effects analysis-guided quality improvement interventions on return to acute care within 30 days postoperatively. ⋯ The results from this study can be used to help identify, develop, and test interventions to optimize emergency department use and readmission to reduce healthcare costs and improve patient quality of life.
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The COVID-19 pandemic forced surgeons to reconsider concepts of "elective" operations. Perceptions about the time sensitivity and medical necessity of a procedure have taken on greater significance during the pandemic. The evolving ethical and clinical environment requires reappraisal of perioperative factors, such as personal protective equipment conservation; limiting the risk of exposure to COVID-19 for patients, families, and healthcare workers; preservation of hospital beds and ICU resources; and minimizing COVID-19-related perioperative risk to patients. ⋯ This process is adaptable to individual institutions and we project it will be useful during the acute phase of the pandemic (maximal limitations), as well as the anticipated recovery phase.