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Public reporting of adherence to surgical safety checklists was mandated for all hospitals in Ontario, beginning in July 2010. In this study of administrative data, checklist introduction was not associated with significant reductions in operative mortality or complications. A study published in 2009 showed that implementation of the 19-item World Health Organization (WHO) Surgical Safety Checklist substantially reduced the rate of surgical complications, from 11.0% to 7.0%, and reduced the rate of in-hospital death from 1.5% to 0.8%. 1 The WHO estimated that at least 500,000 deaths per year could be prevented through worldwide implementation of this checklist. 2 This dramatic effect of a relatively simple and accessible intervention resulted in its widespread adoption. In the United Kingdom, a nationwide program was implemented by the National Health Service within weeks after publication of the WHO study, 3 and almost 6000 hospitals . . .

Elective surgery in Canada has ground to a halt owing to service closures related to the coronavirus disease 2019 (COVID-19) pandemic response. An estimated 45 000 fewer surgeries were performed in adults with non-cancer-related illness in Ontario in late March and early April 2020, which is a more than 90% reduction compared with the same 4-week period in 2019.1 Wait times for surgery were unacceptably long even before the pandemic.2 Recovering from this surgery backlog will be difficult, and an ethically grounded surgery recovery plan will be required. Such a plan will be logistically difficult in the current delivery model of surgery including resource allocation to surgeons in Canadian hospitals. A team-based, single-entry model approach could help to address the problem in an efficient, fair and ethical manner. Single-entry models and team-based care are suitable only for common and standardized procedures, where every surgeon on the team can provide excellent care.

Though we've long known that higher surgical volume results in lower postoperative mortality, surgeons are balking at a new “Volume Pledge” campaign. But the biggest problem is that such a pledge can't improve the quality of care at low-volume hospitals. On May 18, 2015, leaders at three hospital systems — Dartmouth–Hitchcock Medical Center, the Johns Hopkins Hospital and Health System, and the University of Michigan Health System — publicly announced a “Take the Volume Pledge” campaign to prevent certain surgical procedures from being performed by their surgeons who perform relatively few of them or at their hospitals where relatively few such procedures are performed. The Pledge, promoted by long-time advocates of quality improvement such as John Birkmeyer and Peter Pronovost, challenges other large health systems to join them in restricting the performance of 10 surgical procedures — including gastrointestinal, cardiovascular, . . .

This matched-cohort study in Ontario, Canada, showed that the risks of adverse outcomes of elective daytime procedures were similar whether or not the attending surgeon had provided clinical care during the night. The effect of sleep deprivation and fatigue on physician performance and patient outcomes has been of interest for many years. Acute sleep deprivation can impair mood, cognitive performance, and psychomotor function, 1 – 3 and its effects may be similar to those of alcohol exposure. 4 , 5 The results of studies exploring clinical outcomes have been mixed, but a systematic review showed that a prolonged duration of sleeplessness, which would result from the provision of overnight medical care, significantly reduces clinical performance. 1 To date, most of the literature on sleep deprivation and performance has focused on medical trainees. This literature has contributed to . . .

ABSTRACTBackgroundCanada’s health care systems underserve people who are transgender and gender diverse (TGD), leading to unique disparities not experienced by other patient groups, such as in accessing gender-affirmation surgery. We sought to explore the experiences of TGD people seeking and accessing gender-affirmation surgery at a publicly funded hospital in Canada to identify opportunities to improve the current system. MethodsWe used hermeneutic phenomenology according to Max van Manen to conduct this qualitative study. Between January and August 2022, we conducted interviews with TGD people who had undergone penile-inversion vaginoplasty at Women’s College Hospital, Toronto, Ontario, since June 2019. We conducted interviews via Microsoft Teams and transcribed them verbatim. We coded the transcripts using NVivo version 12. Using inductive analysis, we constructed themes, which we mapped onto van Manen’s framework of lived body, lived time, lived space, and lived human relations. ResultsWe interviewed 15 participants who had undergone penile-inversion vaginoplasty; they predominantly self-identified as transgender women ( n = 13) and White ( n = 14). Participants lived in rural ( n = 4), suburban ( n = 5), or urban ( n = 6) locations. Their median age was 32 (range 27–67) years. We identified 11 themes that demonstrated the interconnected nature of TGD peoples’ lived experiences over many years leading up to accessing gender-affirmation surgery. These themes emphasized the role of the body in experiencing the world and shaping identity, the lived experience of the body in shaping human connectedness, and participants’ intersecting identities and emotional pain (lived body); participants’ experiences of the passage of time and progression of events (lived time); environments inducing existential anxiety or fostering affirmation, the role of technology in shaping participants’ understanding of the body, and the effect of liminal spaces (lived space); and finally, the role of communication and language, empathy and compassion, and participants’ experiences of loss of trust and connection (lived human relations). InterpretationOur findings reveal TGD patients’ lived experiences as they navigated a lengthy and often difficult journey to penile-inversion vaginoplasty. They suggest a need for improved access to gender-affirmation surgery by reducing wait times, increasing capacity, and improving care experiences.

Although total hip arthroplasty (THA) and total knee arthroplasty (TKA) offer significant cost savings to our health care system, the degree to which the burden of postoperative care has been transferred onto the informal caregiver is often overlooked. We performed a scoping review to identify the characteristics and factors that contribute to the burden of care experienced after outpatient THA and TKA. We systematically searched electronic literature databases according to scoping review guidelines from inception to June 2021 for articles reporting the experiences of informal caregivers providing care for patients having undergone outpatient THA or TKA. Our review included English-language studies that sought to elucidate the impact on caregivers in the acute postoperative period (up to 6 wk after surgery). Our search yielded 1423 unique articles, which were screened for inclusion. We removed 310 duplicate records and excluded another 1099 articles because they did not meet the inclusion criteria for full-text screening with relevancy. We thus assessed 14 articles for full-text review, and none were found to meet our inclusion criteria. We found no published data pertaining to the burden borne by informal caregivers who provide perioperative care to patients who have undergone ambulatory THA or TKA. Further research is needed to identify, quantify and determine the modifiability of the various characteristics and factors that contribute to caregiver burden in the outpatient setting. L’arthroplastie totale de la hanche (ATH) et l’arthroplastie totale du genou (ATG) réalisées en contexte ambulatoire entraînent des économies considérables pour le système de santé, mais la part du fardeau des soins postopératoires qui est transférée aux aidants naturels est souvent ignorée. Nous avons effectué un examen de la portée pour cerner les caractéristiques et les facteurs contribuant au fardeau des soins après une ATH ou une ATG ambulatoire. Nous avons procédé, en suivant la méthodologie de l’examen de la portée, à une interrogation systématique des bases de données électroniques, de leur mise en service à juin 2021, pour recenser des articles sur les expériences des aidants naturels qui offrent des soins aux patients ambulatoires ayant subi une ATH ou une ATG. Notre examen comprenait des études publiées en anglais tentant de mieux comprendre les répercussions sur les aidants naturels durant la période postopératoire aiguë (jusqu’à 6 semaines après l’intervention). Nos recherches ont repéré 1423 articles distincts, ensuite passés en revue pour inclusion. Nous avons retiré 310 doublons et exclu 1099 autres articles ne répondant pas aux critères d’inclusion d’un examen complet du texte pour en évaluer la pertinence. En fin de compte, 14 articles ont été soumis à l’examen complet du texte et aucun n’a répondu aux critères d’inclusion. Nous n’avons trouvé aucune donnée publiée sur le fardeau assumé par les aidants naturels offrant des soins périopératoires aux patients ayant subi une ATH ou une ATG ambulatoire. D’autres recherches seront nécessaires pour cerner, quantifier et déterminer la variation des caractéristiques et facteurs contribuant au fardeau assumé par l’aidant en contexte ambulatoire.

As part of the \"Safe Surgery Saves Lives\" initiative, the World Health Organization (WHO) launched the Surgical Safety Checklist (SSC) in 2008, aiming to address important surgical safety issues and poor communication among operative team members. In 2009, the Canadian Patient Safety Institute used the WHO SSC as a basis for its own 19-item SSC that would best fit Canadian standards of care and lay the groundwork for local practices. Between January and Jun 2021, 98.5% of surgeries in Ontario reported having completed the checklist. While surgical checklists have undoubtedly improved the safety of surgeries, the SSC misses a key component of the surgical continuum because it is completed before the patient leaves the operating room. Here, Page et al propose an additional checklist item to cover emergence from anesthesia and further increase patient safety.

Canadian health systems fare poorly in providing timely access to elective surgical care, which is crucial for quality, trust, and satisfaction. We conducted a cross-sectional analysis of surgical wait times for adults receiving non-urgent cataract surgery, knee arthroplasty, hip arthroplasty, gallbladder surgery, and non-cancer uterine surgery in Ontario, Canada, between 2013 and 2019. We obtained data from the Wait Times Information System (WTIS) database. Inter- and intra-hospital and surgeon variations in wait time were described graphically with caterpillar plots. We used non-nested 3-level hierarchical random effects models to estimate variation partition coefficients, quantifying the proportion of wait time variance attributable to surgeons and hospitals. A total of 942,605 procedures at 107 healthcare facilities, conducted by 1,834 surgeons, were included in the analysis. We observed significant intra- and inter-provider variations in wait times across all five surgical procedures. Inter-facility median wait time varied between six-fold for gallbladder surgery and 15-fold for knee arthroplasty. Inter-surgeon variation was more pronounced, ranging from a 17-fold median wait time difference for cataract surgery to a 216-fold difference for non-cancer uterine surgery. The proportion of variation in wait times attributable to facilities ranged from 6.2% for gallbladder surgery to 23.0% for cataract surgery. In comparison, surgeon-related variation ranged from 16.0% for non-cancer uterine surgery to 28.0% for cataract surgery. There is extreme variability in surgical wait times for five common, high-volume, non-urgent surgical procedures. Strategies to address surgical wait times must address the variation between service providers through better coordination of supply and demand. Approaches such as single-entry models could improve surgical system performance.

The effect of hospital specialization on the risk of hernia recurrence after inguinal hernia repair is not well described. We studied Ontario residents who had primary elective inguinal hernia repair at an Ontario hospital between 1993 and 2007 using population-based, administrative health data. We compared patients from a large hernia specialty hospital (Shouldice Hospital) with those from general hospitals to determine the risk of recurrence. We studied 235 192 patients, 27.7% of whom had surgery at Shouldice hospital. The age-standardized proportion of patients who had a recurrence ranged from 5.21% (95% confidence interval [CI] 4.94%–5.49%) among patients who had surgery at the lowest volume general hospitals to 4.79% (95% CI 4.54%–5.04%) who had surgery at the highest volume general hospitals. In contrast, patients who had surgery at the Shouldice Hospital had an age-standardized recurrence risk of 1.15% (95% CI 1.05%–1.25%). Compared with patients who had surgery at the lowest volume hospitals, hernia recurrence among those treated at the Shouldice Hospital was significantly lower after adjustment for the effects of age, sex, comorbidity and income level (adjusted hazard ratio 0.21, 95% CI 0.19–0.23, p < 0.001). Inguinal hernia repair at Shouldice Hospital was associated with a significantly lower risk of subsequent surgery for recurrence than repair at a general hospital. While specialty hospitals may have better outcomes for treatment of common surgical conditions than general hospitals, these benefits must be weighed against potential negative impacts on clinical care and the financial sustainability of general hospitals. L’effet de la spécialisation des hôpitaux sur le risque de récurrence de la hernie inguinale après sa réparation n’a pas été bien décrit. À partir des données administratives de santé de la population, nous avons étudié des patients ontariens ayant subi une réparation de hernie inguinale primaire non urgente dans un hôpital de l’Ontario entre 1993 et 2007. Nous avons comparé les patients opérés dans un grand hôpital spécialisé pour les hernies (Hôpital Shouldice) aux patients opérés dans les hôpitaux généraux afin de déterminer le risque de récurrence. Nous avons ainsi étudié 235 192 patients, dont 27,7 % ont subi leur intervention chirurgicale à l’Hôpital Shouldice. La proportion standardisée selon l’âge de patients ayant eu une récurrence a varié de 5,21 % (intervalle de confiance [IC] de 95 % 4,94 %–5,49 %) chez les patients ayant subi l’intervention dans les hôpitaux généraux où le volume est moindre, à 4,79 % (IC de 95 % 4,54 %–5,04 %) qui ont subi leur intervention dans les hôpitaux généraux où le volume est plus élevé. En revanche, les patients qui ont subi leur intervention chirurgicale à l’Hôpital Shouldice ont présenté un risque de récurrence standardisé selon l’âge de 1,15 % (IC de 95 % 1,05 %–1,25 %). Comparativement aux patients ayant subi leur intervention dans les hôpitaux où le volume est moindre, la récurrence de la hernie chez les patients traités à l’Hôpital Shouldice a été considérablement moindre après ajustement pour tenir compte des effets de l’âge, du sexe, des comorbidités et du niveau de revenu (risque relatif ajusté 0,21, IC de 95 % 0,19–0,23, p < 0,001). La réparation des hernies inguinales à l’Hôpital Shouldice a été associée à un risque bien moindre d’intervention chirurgicale subséquente pour récurrence comparativement à la réparation effectuée dans un hôpital général. Les hôpitaux spécialisés peuvent avoir de meilleurs résultats lors du traitement des problèmes chirurgicaux courants comparativement aux hôpitaux généraux, mais ces avantages doivent être soupesés en tenant compte des impacts négatifs potentiels sur les soins cliniques et la viabilité financière des hôpitaux généraux.

ABSTRACTBackgroundPublic funding of cataract surgery provided in private, for-profit surgical centres increased to help mitigate surgical backlogs during the COVID-19 pandemic in Ontario, Canada. We sought to compare the socioeconomic status of patients who underwent cataract surgery in not-for-profit public hospitals with those who underwent this surgery in private for-profit surgical centres and to evaluate whether differences in access by socioeconomic status decreased after the infusion of public funding for private, for-profit centres. MethodsWe conducted a population-based study of all cataract operations in Ontario, Canada, between January 2017 and March 2022. We analyzed differences in socioeconomic status among patients who accessed surgery at not-for-profit public hospitals versus those who accessed it at private for-profit surgical centres before and during the period of expanded public funding for private for-profit centres. ResultsOverall, 935 729 cataract surgeries occurred during the study period. Within private for-profit surgical centres, the rate of cataract surgeries rose 22.0% during the funding change period for patients in the highest socioeconomic status quintile, whereas, for patients in the lowest socioeconomic status quintile, the rate fell 8.5%. In contrast, within public hospitals, the rate of surgery decreased similarly among patients of all quintiles of socioeconomic status. During the funding change period, 92 809 fewer cataract operations were performed than expected. This trend was associated with socioeconomic status, particularly within private for-profit surgical centres, where patients with the highest socioeconomic status were the only group to have an increase in cataract operations. InterpretationAfter increased public funding for private, for-profit surgical centres, patient socioeconomic status was associated with access to cataract surgery in these centres, but not in public hospitals. Addressing the factors underlying this incongruity is vital to ensure access to surgery and maintain public confidence in the cataract surgery system.