Due to nursing staff shortage and growing nursing care demand, resource allocation and optimal task distribution have become primary concerns of nursing management. Grade mix analysis based on nursing interventions and nurse qualifications from routine patient documentation can support this. Case complexity is a key linking factor of nursing interventions, workload, and grade mix. This study determined case complexity predictors based on one year of routine patient documentation (n = 3,373 cases) from a Swiss hospital and predicted the patient clinical complexity level via weighted cumulative logistic regression models. Significant predictors were sex, age, pre-admission residence, admission type, self- care index, pneumonia risk, and number of nursing interventions. The models\' accuracy is limited yet appropriate for applications such as needs- and competence- based staff-planning. After calibration via in-hospital data it could support nursing management in these tasks. The next step is now to test the model in a clinical setting.

BACKGROUND: Whether implicit or explicit, professional judgement is a central component of the many nurse staffing systems implemented in high-income countries to inform workforce planning and staff deployment. Whilst a substantial body of research has evaluated the technical and operational elements of nurse staffing systems, no studies have systematically examined the role of professional judgement and its contribution to decision-making.
OBJECTIVE: To explore nurses\' use of professional judgement in nurse staffing systems in England and Wales.
METHODS: A cross-case comparative design centred on adult in-patient services in three University Health Boards in Wales and three National Health Service Trusts in England. Data generation was undertaken between January 2021 and March 2023 through stakeholder interviews, observations of staffing meetings, and analysis of documents and artefacts. Observations were undertaken in clinical areas but limited to three cases by COVID-19 restrictions. Analysis was informed by translational mobilisation theory.
RESULTS: Two kinds of professional judgement were deployed in the nurse staffing systems: the judgement of clinical nurses and the judgement of senior nurse managers. The research highlighted the reflexive relationship between professional judgement and data, and the circumstances in which organisations placed trust in people and when they placed trust in numbers. Nurses\' professional judgement was central to the generation of data, its interpretation and contextualisation. Healthcare organisations relied on the professional judgements of clinical nurses and senior nurse managers in making operational decisions to mitigate risk, where real-world understanding of the status of the organisation was privileged over formal data. Professional judgement had attenuated authority for the purposes of workforce planning, where data was a master actor. Nurses expressed concerns that strategic decision-making prioritised safety and efficiency, and formal measurement systems did not capture important aspects of care quality or staff wellbeing, which made it difficult to articulate their professional judgement.
CONCLUSIONS: The implementation of staffing systems is resource intensive. Given limited evidence on which to recommend any specific methodology, the priority for future research is to optimise existing systems. If nurses are to deploy their professional judgement to proactively influence the conditions for care, as well as responding to the challenges of risk mitigation, there is a need for robust systems of nursing measurement aligned with agreed standards of care and a vocabulary through which these judgements can be articulated.
CONCLUSIONS: Health systems depend on nurses\' professional judgement for operational staffing decisions, but data is privileged over professional judgement for workforce planning.

Studies have shown that the confidence of surgical residents to perform procedures after completing residency can be affected by their volume of operative experiences. Many surgical residencies span multiple hospitals with a multitude of attendings providing additional educational opportunities available via cross-coverage. This study aims to evaluate the use of a mobile application (app) for operative cross-coverage to improve surgical opportunities in a large surgical residency program and decrease the number of uncovered cases.
An app allowing for uncovered cases to be sent to all surgical residents was used starting March 2022. A survey was completed by residents pre- and postapp implementation. A retrospective chart review was conducted of all general surgery procedures at the 2 major hospital systems 4 months before and after implementation to evaluate resident case coverage.
In the preapp survey, 71% (27/38) of residents noted cross-covering 1 or more cases a month with 90% (34/38) reporting, they were unaware of all cases available. In the postapp survey, 100% of residents reported better awareness of available cases, 97% (35/36) reported uncovered cases were more easily accessible, 100% felt the app simplified finding coverage, and 100% wanted to continue the app long-term. On retrospective review, 7210 cases were identified in the preapp and postapp period with an increased volume of cases in the postapp period. After implementation of the case coverage app, there was a significant increase in total case coverage (p = <0.001) as well as a significant increase in coverage of endoscopic (p = 0.007), laparoscopic (p = 0.025), open (p = 0.015) and robotic cases (p = <0.001).
This study shows the impact that technological innovation can play in the education and operative experiences of surgical residents. This can be used to improve operative experiences of residents in various surgical fields in any training program throughout the country.

In response to the COVID-19 pandemic, nonemergent surgery was postponed in efforts to limit disease spread. To determine whether these changes affected vascular integrated resident (VR) and fellow (VF) operative volume, Accreditation Council for Graduate Medical Education (ACGME) case log data was reviewed. Case volume and standard deviation for each major category was for graduates of 2020 and 2021 were compared to the year prior to the pandemic, 2019. There were only 3 significant changes when comparing 2020/2021 to the prepandemic baseline of 2019, with increase in abdominal obstructive cases for VRs (8.1 in 2021 vs 5.9 in 2019, P = .021), an increase in upper extremity cases for VFs (18.9 in 2021 from 15.8 in 2019, P = .029), and a decrease in venous cases for VFs (39.6 in 2021 from 48.4 in 2019, P = .011). Postponing nonemergent surgery did not translate to significant changes in operative cases for graduating VRs and VFs.

Manuscript preparation and the (re)submission of articles can create a significant workload in academic jobs. In this exploratory analysis, we estimate the time and costs needed to meet the diverse formatting requirements for manuscript submissions in biomedical publishing.
We reviewed 302 leading biomedical journals\' submission guidelines and extracted information on the components that tend to vary the most among submission guidelines (the length of the title, the running title, the abstract, and the manuscript; the structure of the abstract and the manuscript, number of items and references allowed, whether the journal has a template). We estimated annual research funding lost due to manuscript formatting by calculating hourly academic salaries, the time lost to reformatting articles, and quantifying the total number of resubmissions per year. We interviewed several researchers and senior journal editors and editors-in-chief to contextualize our findings and develop guidelines that could help both biomedical journals and researchers work more efficiently.
Among the analyzed journals, we found a huge diversity in submission requirements. By calculating average researcher salaries in the European Union and the USA, and the time spent on reformatting articles, we estimated that ~ 230 million USD were lost in 2021 alone due to reformatting articles. Should the current practice remain unchanged within this decade, we estimate ~ 2.5 billion USD could be lost between 2022 and 2030-solely due to reformatting articles after a first editorial desk rejection. In our interviews, we found alignment between researchers and editors; researchers would like the submission process alignment between researchers and editors; researchers would like the submission process to be as straightforward and simple as possible, and editors want to easily identify strong, suitable articles and not waste researchers\' time.
Based on the findings from our quantitative analysis and contextualized by the qualitative interviews, we conclude that free-format submission guidelines would benefit both researchers and editors. However, a minimum set of requirements is necessary to avoid manuscript submissions that lack structure. We developed our guidelines to improve the status quo, and we urge the publishers and the editorial-advisory boards of biomedical journals to adopt them. This may also require support from publishers and major international organizations that govern the work of editors.

The Military Health System (MHS) uses a readiness program that identifies the knowledge, skills, and abilities (KSAs) necessary for surgeons to provide combat casualty care. Operative productivity is assigned an objective score based on case type and complexity and totaled to assess overall readiness. As of 2019, only 10.1% of surgeons met goal readiness threshold. At one tertiary military treatment facility (MTF), leadership has taken an aggressive approach toward increasing readiness by forming military training agreements (MTAs) and allowing Off Duty Employment (ODE). We sought to quantify the efficacy of this approach.
Operative logs from 2021 were obtained from surgeons assigned to the MTF. Operations were assigned CPT codes and processed through the KSA calculator (Deloitte; London, UK). Each surgeon was then surveyed to identify time away from clinical duties for deployment or military training.
Nine surgeons were present in 2021 and spent an average of 10.1 weeks (19.5%) abroad. Surgeons performed 2,348 operations (Average [Avg] 261 ± 95) including 1,575 (Avg 175; 67.1%) at the MTF, 606 (Avg 67.3; 25.8%) at MTAs, and 167 (Avg 18.6, 7.1%) during ODE. Adding MTA and ODE caseloads increased KSA scores by 56% (17,765 ± 7,889 vs 11,391 ± 8,355). Using the MHS threshold of 14,000, 3 of 9 (33.3%) surgeons met the readiness threshold from MTF productivity alone. Including all operations, 7 of 9 (77.8%) surgeons met threshold.
Increased use of MTAs and ODE significantly augments average caseloads. These operations provide considerable benefit and result in surgeon readiness far exceeding the MHS average. Military leadership can maximize the chances of meeting readiness goals by encouraging clinical opportunities outside the MTF.

BACKGROUND. Numerous studies have explored factors associated with diagnostic errors in neuroradiology; however, large-scale multivariable analyses are lacking. OBJECTIVE. The purpose of this study was to evaluate associations of interpretation time, shift volume, care setting, day of week, and trainee participation with diagnostic errors by neuroradiologists at a large academic medical center. METHODS. This retrospective case-control study using a large tertiary-care academic medical center\'s neuroradiology quality assurance database evaluated CT and MRI examinations for which neuroradiologists had assigned RADPEER scores. The database was searched from January 2014 through March 2020 for examinations without (RADPEER score of 1) or with (RADPEER scores of 2a, 2b, 3a, 3b, or 4) diagnostic error. For each examination with error, two examinations without error were randomly selected (unless only one examination could be identified) and matched by interpreting radiologist and examination type to form case and control groups. Marginal mixed-effects logistic regression models were used to assess associations of diagnostic error with interpretation time (number of minutes since the immediately preceding report\'s completion), shift volume (number of examinations interpreted during the shift), emergency/inpatient setting, weekend interpretation, and trainee participation in interpretation. RESULTS. The case group included 564 examinations in 564 patients (mean age, 50.0 ± 25.0 [SD] years; 309 men, 255 women); the control group included 1019 examinations in 1019 patients (mean age, 52.5 ± 23.2 years; 540 men, 479 women). In the case versus control group, mean interpretation time was 16.3 ± 17.2 [SD] minutes versus 14.8 ± 16.7 minutes; mean shift volume was 50.0 ± 22.1 [SD] examinations versus 45.4 ± 22.9 examinations. In univariable models, diagnostic error was associated with shift volume (OR = 1.22, p < .001) and weekend interpretation (OR = 1.60, p < .001) but not interpretation time, emergency/inpatient setting, or trainee participation (p > .05). However, in multivariable models, diagnostic error was independently associated with interpretation time (OR = 1.18, p = .003), shift volume (OR = 1.27, p < .001), and weekend interpretation (OR = 1.69, p = .02). In subanalysis, diagnostic error showed independent associations on weekdays with interpretation time (OR = 1.18, p = .003) and shift volume (OR = 1.27, p < .001); such associations were not observed on weekends (interpretation time: p = .62; shift volume: p = .58). CONCLUSION. Diagnostic errors in neuroradiology were associated with longer interpretation times, higher shift volumes, and weekend interpretation. CLINICAL IMPACT. These findings should be considered when designing work-flow-related interventions seeking to reduce neuroradiology interpretation errors.

The demand for medical services has been increasing yearly in aging countries. Medical institutions must hire a large number of staff members to provide efficient and effective health-care services. Because of high workload and pressure, high turnover rates exist among health-care staff members, especially those in nonurban areas, which are characterized by limited resources and a predominance of elderly people. Turnover in health-care institutions is influenced by complex factors, and high turnover rates result in considerable direct and indirect costs for such institutions (Lo and Tseng 2019). Therefore, health-care institutions must adopt appropriate strategies for talent retention. Because institutions cannot determine the most effective talent retention strategy, many of them simply passively adopt a single human resource (HR) policy and make minor adjustments to the selected policy. In the present study, system dynamics modeling was combined with fuzzy multiobjective programming to develop a method for simulating HR planning systems and evaluating the suitability of different HR policies in an institution. We also considered the external insurance policy to be the parameter for the developed multiobjective decision-making model. The simulation results indicated that reducing the turnover rate of new employees in their trial period is the most effective policy for talent retention. The developed procedure is more efficient, effective, and cheaper than the traditional trial-and-error approaches for HR policy selection.

BACKGROUND: Thoracic surgery training among general surgery residents in the United States is regulated by the Accreditation Council for Graduate Medical Education (ACGME) to ensure exposure to subspecialty fields during residency. Thoracic surgery training has changed over time with the placement of work hour restrictions, the emphasis on minimally invasive surgery, and increased subspecialization of training like integrated six-year cardiothoracic surgery programs. We aim to investigate how these changes over the past twenty years have affected thoracic surgery training among general surgery residents.
METHODS: ACGME general surgery resident case logs from 1999 to 2019 were reviewed. Data included exposure to the thorax via thoracic, cardiac, vascular, pediatric, trauma, and alimentary tract procedures. Cases from the above categories were consolidated to determine the comprehensive experience. Descriptive statistics were performed over four 5-year Eras (Era 1:1999-2004, Era 2: 2004-2009, Era 3: 2009-2014, Era 4: 2014-2019).
RESULTS: Between Era 1 and Era 4, there was an increase in thoracic surgery experience (37.6 ± 1.03 vs 39.3 ± .64; P = .006). The mean total thoracic experience for thoracoscopic, open, and cardiac procedures was 12.89 ± 3.76, 20.09 ± 2.33, and 4.98 ± 1.28, respectively. There was a difference between Era 1 and Era 4 in thoracoscopic (8.78 ± .961 vs 17.18 ± .75; P < .001) and open thoracic experience (22 ± .97 vs 17.06 ± .88; P < .001), and a decrease in thoracic trauma procedures (3.7 ± .06 vs 3.2 ± .32; P = .03).
CONCLUSIONS: Over twenty years there has been a similar, to slight increase in thoracic surgery exposure among general surgery residents. The changes seen in thoracic surgery training reflect the overall movement of surgery towards minimally invasive surgery.

OBJECTIVE: Even though extensive melanoma sentinel node (SN) pathology protocols increase metastasis detection, there is a need for balancing high detection rates with reasonable workload. A newly tested Danish protocol recommended examining nodes at six levels 150 µm apart (six-level model) and using SOX10 and Melan-A immunohistochemistry (IHC). We explored if a protocol examining 3 levels 300 µm apart (three-level model) combined with IHC would compromise metastasis detection. The study aim was to optimise the protocol to reduce workload without compromising detection rate.
METHODS: 8 months after protocol implementation, we reviewed the pathology reports of SNs from 507 melanoma patients nationwide, including 117 SN-positive patients. Each report was reviewed to determine histopathological features, including detection of metastasis, exact levels with metastasis, exact levels with metastasis >1 mm in diameter and IHC results.
RESULTS: The six-level model detected metastases in 23% of patients, whereas the three-level model would have detected metastases in 22% of patients. The three-level model would have missed a few small metastases (n=4), measuring <0.1 mm, 0.1 mm, 0.4 mm and 0.1 mm, respectively. The six-level model detected metastases >1 mm in 7% of patients. One of these metastases (measuring 1.1 mm) would have been detected by the three-level model, but not as >1 mm. SOX10 and Melan-A had equal sensitivity.
CONCLUSIONS: Reducing the number of levels examined to three levels 300 µm apart combined with IHC does not have significant impact on metastasis detection rate, and we will therefore recommend that the future melanoma SN guideline takes this into consideration to reduce overall workload.