United States

Background
Ludwig’s Angina is a rapidly progressive and life-threatening cellulitis of the soft tissue of the floor of the mouth and neck. Streptococcal and Staphylococcal species are the most commonly isolated causes. It is treated with securing the airway, broad spectrum antibiotic coverage, and surgical drainage for any abscess or drainable collection of fluid. Sources of infection include dentition, oral procedures, alcoholism, vascular disease, and immunocompromised states. This is a case which was positive for Streptococcus Constellatus with systemic abscess spread and a 45-day ICU course. 

Methods
Case Report

Results
This is a 22-year old with diabetes, hypertension, asthma, hyperlipidemia, and alcohol use disorder. She reported poor dentition with dysphagia, drooling, pain in ears and throat for one week before arrival. She was seen at an urgent care four days prior and was given amoxicillin. Her oropharynx and tonsils were erythematous with tongue protrusion, dysphonia, poor dentition, diffuse swelling and induration noted to the submandibular area with tenderness to palpation with erythema with right side worse than left, and limited neck range of motion. She was intubated, started on broad spectrum antibiotics, and taken to the OR for an I&amp;D of submental and submandibular abscesses. On day 6, OMFS removed five teeth. Chest tubes were inserted into the pleura and mediastinum for fluid collection, and repeat I&amp;D procedures for the neck were performed. Abscess drainage on the right mastoid and a tympanostomy on the left were done. Spread to the cerebellum led to initiation of high dose ceftriaxone. Fluid studies from chest tube drainage and other wounds were negative. Her condition improved and was sent to a long-term acute care hospital.




Conclusion
This patient’s case shows complications found in Streptococcus Constellatus if not early controlled or immunosuppressed. Her Cushing’s Syndrome, steroid hormone therapy, and metabolic syndrome likely led to immunosuppression. These factors helped propagate the spread of abscesses to the CNS, mediastinum, lungs, and persistence of abscesses in mouth, neck, oropharynx, and mastoids. Early Pan CT in cases of Streptococcus Constellatus should be considered for its propensity to cause abscesses at distant sites, with early surgical evaluation of the mouth and neck. This patient’s difficulty of maintaining trough levels of vancomycin and not being on an antibiotic that was “sensitive” to this organism until day 4 after cultures resulted played a large role. Antibiotics providing double coverage for this organism would benefit patients like this as resistance continues to develop. 


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Ludwig&#39;s Angina and a Complicated Course of Streptococcus Constellatus Management

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Background
Ludwig’s Angina is a rapidly progressive and life-threatening cellulitis of the soft tissue of the floor of the mouth and neck. Streptococcal and Staphylococcal species are the most commonly isolated causes. It is treated with securing the airway, broad spectrum antibiotic coverage, and surgical drainage for any abscess or drainable collection of fluid. Sources of infection include dentition, oral procedures, alcoholism, vascular disease, and immunocompromised states. This is a case which was positive for Streptococcus Constellatus with systemic abscess spread and a 45-day ICU course. 

Methods
Case Report

Results
This is a 22-year old with diabetes, hypertension, asthma, hyperlipidemia, and alcohol use disorder. She reported poor dentition with dysphagia, drooling, pain in ears and throat for one week before arrival. She was seen at an urgent care four days prior and was given amoxicillin. Her oropharynx and tonsils were erythematous with tongue protrusion, dysphonia, poor dentition, diffuse swelling and induration noted to the submandibular area with tenderness to palpation with erythema with right side worse than left, and limited neck range of motion. She was intubated, started on broad spectrum antibiotics, and taken to the OR for an I&D of submental and submandibular abscesses. On day 6, OMFS removed five teeth. Chest tubes were inserted into the pleura and mediastinum for fluid collection, and repeat I&D procedures for the neck were performed. Abscess drainage on the right mastoid and a tympanostomy on the left were done. Spread to the cerebellum led to initiation of high dose ceftriaxone. Fluid studies from chest tube drainage and other wounds were negative. Her condition improved and was sent to a long-term acute care hospital.




Conclusion
This patient’s case shows complications found in Streptococcus Constellatus if not early controlled or immunosuppressed. Her Cushing’s Syndrome, steroid hormone therapy, and metabolic syndrome likely led to immunosuppression. These factors helped propagate the spread of abscesses to the CNS, mediastinum, lungs, and persistence of abscesses in mouth, neck, oropharynx, and mastoids. Early Pan CT in cases of Streptococcus Constellatus should be considered for its propensity to cause abscesses at distant sites, with early surgical evaluation of the mouth and neck. This patient’s difficulty of maintaining trough levels of vancomycin and not being on an antibiotic that was “sensitive” to this organism until day 4 after cultures resulted played a large role. Antibiotics providing double coverage for this organism would benefit patients like this as resistance continues to develop. 


Ludwig's Angina and a Complicated Course of Streptococcus Constellatus Management

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Background
Treatment-resistant schizophrenia is defined by persistent delusions or hallucinations following failed trials of two other antipsychotic medications. Clozapine, an atypical antipsychotic medication approved by the FDA, is often the medication of choice in such challenging cases due to its proven efficacy. Its use is, however, tempered by a myriad of side effects which range from sedation, agranulocytosis, seizures, metabolic syndrome, and neuroleptic malignant syndrome. Mahendran R et. al particularly talked about clozapine being involved in the emergence or worsening of obsessive-compulsive symptoms (OCS) in up to 38.2% of patients, which is a side effect due to antagonism of the serotonin receptors 5-HT2A and 5-HT2C. On the other hand, tic-like vocalizations associated with clozapine are extremely rare and perhaps underreported.

Case Presentation
We describe a 39-year-old man with treatment-resistant schizophrenia and psychogenic polydipsia and Wolfe-Parkinson-White Syndrome s/p ablation, who, following the initiation and gradual titration of clozapine treatment, developed tic-like vocalizations and compulsive behaviors (excessive washing of face resulting in abrasions on forehead). While Clozapine was initially helpful in reducing some symptoms, the patient progressively developed treatment-emergent obsessive-compulsive behaviors and repetitive vocalizations. To manage these new challenges, a second antipsychotic medication, aripiprazole, was introduced in his regimen alongside intensive behavioral monitoring. Despite this, the vocalizations continued. A comprehensive evaluation ruled out any organic cause. This case illustrates the complex and treatment-resistant nature of these symptoms.

Discussion
Although clozapine-induced vocalizations are uncommon, they are a significant neuropsychiatric side effect that should be recognized by clinicians. Czapliński et al. described that vocalizations are characterized by sudden, repetitive, and stereotyped sounds, most commonly occurring hand in hand with compulsive behaviors or other movement symptoms. David D. Kim et al. explained in a systematic review that the response to adjunct therapies such as aripiprazole and behavior therapy can be helpful, and individualized treatment strategies are crucial. This case brings to light the importance of early identification and individualized treatment plans for atypical but meaningful side effects like clozapine-induced vocalizations. While clozapine is the treatment standard for treatment-resistant schizophrenia, its potential to cause or reveal obsessive-compulsive behavior and unusual vocalizations must be monitored carefully and addressed individually to maximize benefit with minimal risk of adverse effect.

Clozapine and the Voice Within: A Case of New-Onset Vocalizations and Obsessive Compulsive Symptoms

Background
Digital clubbing is a bulbous enlargement of fingertips and toes, increasing nail dimensions. First described by Hippocrates 2,500 years ago, it's often called "Hippocratic finger." Initially linked to pulmonary conditions, it's now known to occur in various diseases or even without underlying illness. While mechanisms like inflammation, increased vascular permeability, and collagen deposition have been proposed, the precise cause remains unclear. This report highlights a rare case of clubbing associated with long-term laxative use, aiming to improve understanding of this unusual correlation.
Case Presentation
A 73-year-old female with GERD, Irritable bowel syndrome with constipation (IBS-C), and hypercholesterolemia, on daily lubiprostone for months, was referred for digital clubbing. She denied respiratory or constitutional symptoms, and had no smoking, alcohol, or chemical exposure history. Family history included a smoking uncle with COPD.
Her initial physical exam revealed only digital clubbing. Lab work, including Alpha-1 antitrypsin, was normal. Pulmonary function tests and repeat tests a year later were within normal limits. Chest CT showed mild hyperinflation and emphysema, with a small nodule that later resolved. Abdominal CT was unremarkable. Cardiology evaluation was unrevealing. A gastroenterologist confirmed IBS-C. Given the extensive negative cardiac and malignancy workup, the pulmonology service concluded her digital clubbing was likely secondary to IBS and chronic laxative use.
Discussion
Digital clubbing, a sign associated with numerous conditions including neoplastic, pulmonary, and cardiac diseases, is also part of hypertrophic osteoarthropathy. Rarely, it's linked to laxative abuse, most often with senna. One theory suggests
megakaryocytes bypass the lungs, releasing platelet-derived growth factors (PDGF) at fingertips, increasing vascular permeability and inflammation. However, histological studies mainly show collagen deposition, edema, and vascular changes, not significant inflammation.
Our case describes a 73-year-old with digital clubbing due to long-term lubiprostone use for IBS-C, with no other common causes. This adds to limited evidence linking certain medications, especially chronic laxatives, to clubbing. While the exact mechanism is unclear, this case emphasizes the need for a detailed medication history in diagnosing clubbing, potentially avoiding extensive, unnecessary tests. Further research is needed to understand this association and raise awareness among healthcare providers for more efficient patient care.

Digital Clubbing and Chronic Laxative Use: A Case Report

Abstract Title: Making Sense of Insensible Losses: A Case Study on Post-Operative Fluid Management 

Background: Fluid management in post-operative patients remains a critical yet complex aspect of care. Balancing volume overload with adequate resuscitation is a delicate practice, with shifts contributing to electrolyte abnormalities, delayed wound healing, and organ dysfunction. This case study examines a sentinel event involving fluid overload, performed to investigate systemic shortcomings and potential solutions for optimizing fluid monitoring in the ICU. 

Methods: We conducted a retrospective case analysis of a 53-year-old female who presented on postoperative day eight following a laparoscopic appendectomy, complicated by necrotizing fasciitis. Her clinical course was reviewed in detail including surgical and medical interventions, imaging findings, and sequence of ICU care. A root cause analysis was performed to identify factors contributing to the harm event. A process map was created to review current hospital fluid monitoring practices. A literature review was completed, and a revised process map was created to highlight targeted strategies for improvement. 

Results: Despite current fluid monitoring protocols, the patient developed progressive respiratory failure in the setting of net positive fluid balance to 91-liters and worsening pulmonary edema on imaging. A root cause analysis revealed notable contributing factors as unquantified insensible losses, non-protocolized measurement of wound losses, and communication gaps between teams. A literature review supported interventions for future implementation including insensible loss calculators, protocols for weighing wound dressings, automated output monitoring systems, daily POCUS rounds, and structured communication tools such as rounding checklists and EMR-integrated fluid alerts. 

Conclusion: This case exemplifies the complexities of fluid management in the ICU and the need for continuous assessment and revision of current protocols. Fluid overload is a preventable, iatrogenic cause of patient harm events. Through exploration of the various systems involved, preventable harm events can be reduced using strategies focusing on accurate fluid monitoring/documentation, knowledge of assessment methods, and open communication between treatment teams. 



Making Sense of Insensible Losses

Background At large academic centers, healthcare providers manage patients with multiple chief complaints and diagnoses. Clinical pathways are evidence-based tools that integrate scientific knowledge into practice, improving care quality, reducing costs, and enhancing workflow efficiency. These pathways help minimize clinical variation and promote cost-effective care. Ensuring providers use them effectively and seamlessly integrate them into their workflow is crucial. Our goal was to analyze provider usage rates and gather feedback to improve pathway usability. We aimed to determine which providers are using the pathways, collect feedback, and generate suggestions for improvement. This led us to implement an educational session for clinical-year medical students to enhance the practice of high-value care at MUSC.

Methods: We designed surveys to collect feedback for quality improvement and distributed them to 100 healthcare providers across various MUSC campuses. To increase participation, we introduced a small incentive program (gift card raffle). We collected responses over four weeks, analyzed the data, and proposed improvements based on the feedback.

Results: We received 41 survey responses, including 10 attending physicians, 24 residents, and 7 other healthcare providers (PA, NP, nurse). Among respondents, 90% of attending physicians, 100% of residents, and 26% of others reported using pathways regularly. 74.3% found pathways "easy" or "very easy" to use, 62.9% reported workflow improvement, and 68.6% agreed that pathways helped implement high-value care. Feedback for improvement included issues with specific pathways, tracking progress, prolonged usage times, ease of access, linked resources, and a need for better medical education on pathway use and benefits.
Conclusion: Clinical pathways in EPIC are effective tools for streamlining the management of common diagnoses and are widely used among those surveyed. Improvements will focus on enhancing access and usability. Future efforts include incorporating pathway education into the third-year medical student curriculum to foster early adoption and further refine the tool.

Utilization and Benefits of Clinical Pathways in the Electronic Medical Record

Title: New diagnosis HIV linkage to care evaluation in Southeastern United States: A retrospective cohort study 

Background: The HIV epidemic has disproportionally impacted the southern US states, specifically, South Carolina with its estimated 20,000 residents living with HIV/AIDs. To combat this epidemic, the Ending the HIV Epidemic in the US initiative was published with 4 main pillars: diagnose HIV as early as possible, treat HIV rapidly to reach viral load suppression (<200 copies/L) (VS), prevent new HIV transmissions, and respond quickly to HIV outbreaks. New guidelines recommend initiating rapid antiretroviral therapy (ART) within 7 days of HIV diagnosis compared to the traditional goal of 30 days. This study investigated time to patient notification of positive HIV result, linkage to care, ART initiation, and achievement of VS in the SC Midlands. 

Methods: We retrospectively analyzed new HIV diagnoses from Prisma Health Midlands locations from 2022-2023. Descriptive statistics were used to analyze time to notifying patient of result, to first evaluation by HIV provider, to ART initiation, and to VS in both the inpatient and outpatient setting. 

Results: Among 91 patients newly diagnosed with HIV, 82.4% (75/91) were notified of results within 7 days and 69.2% (63/91) within 72 hours. For the remaining 16 patients, 15 were unreachable by phone after an average 3.2 attempts per patient. Eventually, 96.7% (88/91) were made aware of their diagnosis. Of 71 patients that established care with Prisma Health Immunology Center (PHIC), 33 were first evaluated by an HIV provider while inpatient and 38 in the outpatient clinic. Only 63.6% (21/33) of the patients evaluated inpatient initiated ART within 7 days of diagnosis, predominantly due to provider’s choice to wait until outpatient follow-up. For those with initial evaluation at PHIC, 47.4% (18/38) were seen within 7 days of diagnosis and 94.7% (36/38) were seen within 30 days. All patients initially seen outpatient were started on ART during their first appointment. Overall, for patients that established with PHIC, 67.6% (48/71) saw an HIV provider and 53.5% (38/71) initiated ART within 7 days of diagnosis. Nearly all patients (94.3%, 67/71) saw an HIV provider and (91.5%, 65/71) initiated ART within 30 days. For patients established with PHIC, 85.9% (61/71) achieved VS, averaging 97.15 days from diagnosis to VS. Patient non-adherence was the most common reason for not achieving VS. 

Conclusion: While almost all patients with new HIV diagnosis were linked to care and started ART within 30 days of diagnosis, only about half were started within 7 days. This study highlights opportunities to reduce this timeline by prioritizing patient contact information collection during medical encounters, considering point-of-care testing when applicable, standardizing inpatient HIV medication initiation protocols, and evaluating barriers to timely clinic referrals. Future studies with larger sample sizes could assess for demographic risk factors and system-based barriers leading to these delays.

New diagnosis HIV linkage to care evaluation in Southeastern US: A retrospective cohort study

Background: The chronic autoimmune condition, pediatric vitiligo, causes depigmentation, which leads to severe psychological distress during important developmental periods. The emerging therapies JAK inhibitors and oral compound glycyrrhizin address the immune-mediated melanocyte destruction in pediatric vitiligo patients, but they do not address the substantial psychosocial challenges these children face. This review examines the clinical effectiveness and psychosocial results of combined treatments for pediatric vitiligo while focusing on cultural elements and new gene-directed therapeutic approaches.

Methods: A systematic literature search was conducted across PubMed, Embase, PsycINFO, Web of Science, and Cochrane Library in May 2025 using terms related to pediatric vitiligo, clinical and psychosocial interventions, suicide risk, and molecular therapies. Eligible peer-reviewed studies (2010–2025) included children aged 0–18 with vitiligo and evaluated repigmentation outcomes, mental health impacts, or integrated treatment approaches. Studies were screened and reviewed by five independent reviewers. Risk of bias was assessed using Cochrane and ROBINS-I tools, and evidence strength was evaluated with GRADE.


Results: Our review demonstrated that topical JAK inhibitors together with glycyrrhizin-phototherapy combinations and prostaglandin analogues and Wnt/β-catenin signaling agonists proved effective for repigmentation with good safety results in children. There is an urgent need for randomized trials to evaluate the combination of medical and psychosocial interventions. The combination of psychological stress and stigma particularly affected children of color because it led to decreased quality of life and elevated their chances of developing depression, anxiety, and suicidal tendencies. The combination of family-based therapy with cognitive behavioral therapy (CBT) and culturally adapted interventions demonstrated effectiveness in strengthening emotional resilience and improving treatment adherence. The experimental phase of pediatric research includes gene-editing technologies (e.g., CRISPR), mRNA-based therapies, and melanocyte transplantation.

Conclusion: Pediatric vitiligo management must evolve toward an integrated model that addresses both biological and psychosocial dimensions of care. Existing therapies offer promising repigmentation outcomes, but their full potential is limited without concurrent psychological support. Longitudinal, multicenter trials measuring both clinical and psychosocial endpoints, particularly in diverse pediatric populations, are urgently needed. Additionally, culturally sensitive interventions and gene-based strategies may shape the future of personalized vitiligo care.


A Comprehensive Review of Integrated Psychosocial and Medical Approaches to Pediatric Vitiligo: Current Therapies, Suicide Risk, and Future Gene-Targeted Innovations

Background
Opioid use disorder (OUD) continues to drive significant morbidity and mortality across the U.S., yet emergency departments (EDs) remain underutilized as initiation points for evidence-based medication-assisted treatment (MAT). Despite legislation such as the 2023 MAT Act removing prior prescribing restrictions for buprenorphine, most ED physicians remain unfamiliar and reluctant to treat patients experiencing opioid withdrawal with partial opioid agonists such as buprenorphine. Academic centers such as Yale and UCSF have successfully piloted and implemented ED-based buprenorphine programs, but many hospital systems lack comprehensive systems to treat OUD in patients effectively in the fast-paced ED setting. Recognizing this gap, we developed and initiated a streamlined, evidence-informed algorithm for buprenorphine initiation in ED patients presenting with opioid withdrawal at Houston Methodist Hospital in Texas.

Methods
Our team synthesized peer-reviewed protocols and national guidelines from AAEM, ACEP, and published institutional frameworks to construct a simplified algorithm tailored for frontline ED use. The algorithm incorporated patient assessment via the Clinical Opiate Withdrawal Scale (COWS) and guided physicians through staged buprenorphine-naloxone induction steps based on symptom severity. Adjuvant therapy choices were included as algorithm side branches for patients experiencing buprenorphine-induced withdrawal. Recognizing physician hesitancy and knowledge gaps, the algorithm was designed for ease-of-use. Supplemental material for successful adoption by ED physicians incorporated research-driven treatment statistics, education on partial opioid agonists pharmacologic principles, and contraindications for treatment. In collaboration with institution staff, the tool was integrated into ED workflows, paired with a standardized discharge bundle including a curated list of outpatient MAT resources.

Results 
A simplified algorithm was implemented into the emergency department and electronic medical record. Data collection from outcomes of the implementation is ongoing across the Houston Methodist system. Formal tracking of MAT initiation rates and longitudinal patient outcomes are planned. Study design includes evaluation of implementation fidelity, patient engagement at follow-up, and trends in ED recidivism. Patient-facing resources are being distributed at the point of discharge for OUD patients started on buprenorphine, improving continuity of care and outpatient follow-up.

Conclusion
This project demonstrates the feasibility of deploying a simplified ED-based buprenorphine algorithm within a large healthcare system, the first of its kind in Texas. By addressing key barriers to MAT initiation, this approach has the potential to shift emergency departments from treating transient opioid withdrawal toward long-term treatment engagement for patients suffering from OUD. Future evaluation will assess clinical impact and generalizability, with the goal of encouraging replication at other hospitals and institutions nationwide.


ED-Initiated Buprenorphine: Designing a Simplified Algorithm for Opioid Use Disorder Treatment

Recurrent Hypoglycemia and Dementia Risk in Older Adults with Type 2 Diabetes: A Systematic Review

Background
Type 2 diabetes mellitus (T2DM) affects over 25% of adults aged 65 and older. While tight glycemic control is often indicated to reduce the risk of complications, it also elevates the risk of hypoglycemic episodes, particularly in older adults with reduced regulatory responses. Increasing evidence suggests that the recurrence of hypoglycemia may be linked to long-term cognitive decline and dementia. However, the strength of this association continues to be unclear. This systematic review analyzes current literature to assess how repeated hypoglycemic episodes can negatively impact cognitive function in older adults with T2DM.

Methods
A literature search was conducted in Ovid MEDLINE on May 11, 2025. The search terms included combinations of “type 2 diabetes,” “recurrent hypoglycemia,” “cognitive impairment,” “dementia,” and “older adults.” MeSH keywords were used for sensitivity. The inclusion criteria were: (1) studies involving human subjects older than 60 years of age, (2) a documented association between recurrent hypoglycemia episodes and cognitive outcomes, and (3) English-language publications. Study screening, reviewing, and data extraction were done by two reviewers using the Catchii platform. The final inclusion was determined with consensus, and PRISMA guidelines were followed.

Results
Eighteen studies met the inclusion criteria, including large-scale cohort studies, case-control studies, and meta-analyses. Across these studies, recurrent hypoglycemia was consistently associated with increased risk of dementia, Alzheimer’s disease, and vascular dementia. Several studies demonstrated a dose-response relationship, emphasizing the frequency of these events on the cognitive outcome in patients. Several biological mechanisms have been proposed throughout the studies, including neuronal glucose deprivation, cerebral microvascular damage, and accumulation of amyloid-beta and tau proteins. However, inconsistencies were noted in the definitions of hypoglycemia, cognitive assessment tools, and population characteristics. Most of the studies focused on severe hypoglycemia that required hospitalization, which limits generalizability to outpatient-managed patients.

Conclusion
Recurrent hypoglycemia is a significant risk factor for cognitive decline in older adults with T2DM. Increasing frequencies of hypoglycemic episodes, whether secondary to tight glycemic control or age-related diminished regulatory responses, predict even higher dementia risks. Data suggests a strong association, but limitations remain in the generalizability of the results due to differences in study = design and outcome measures. Future research should aim to standardize the definitions of hypoglycemia and measure specific cognitive functions. Additionally, we should investigate whether preventing hypoglycemia in elderly patients can decrease the risk of cognitive deterioration. These findings highlight the importance of individualized glycemic regimen in elderly diabetic patients to preserve long-term cognitive function.

Recurrent Hypoglycemia and Dementia Risk in Older Adults with Type 2 Diabetes: A Systematic Review

Abstract:
Short-term memory (STM) is a fundamental cognitive ability allowing individuals to store and recall small amounts of information for brief periods. Although STM plays a critical role in everyday cognitive tasks, gender differences in its performance remain underexplored. This study investigates the influence of gender on short-term memory performance in healthy individuals aged 15-20 years. A total of 130 participants (65 males, 65 females) were tested. The results revealed that females outperformed males, with an average recall score of 97% for females compared to 85% for males. These findings suggest that gender may influence short-term memory performance, offering new insights into cognitive gender differences.
Keywords: Short-term memory, gender differences, cognitive function, memory retention


Effect of short term memory on gender difference

Background 
Turnover time (TOT)—the interval between one patient exiting and the next entering the same operating room (OR)—is a key determinant of surgical efficiency. While industry benchmarks suggest a baseline of 30-40 min TOT for most surgical subspecialties, neurosurgery presents unique challenges due to procedural complexity and specialized equipment requirements. Extended turnover times can disrupt perioperative workflows, delay case start times, and decrease potential revenue as OR operational costs range from US$30-100 per minute. This study aims to identify modifiable drivers of prolonged neurosurgical TOT and propose data-driven interventions. 

Methods 
We conducted a mixed-methods study analyzing 1,232 neurosurgical turnovers at a high-volume academic hospital. A linear mixed-effects model was used to assess the influence of factors including inpatient versus outpatient status, procedure type, and temporal variables (day and month). Semi-structured interviews with perioperative staff and administrators (n=18) and direct OR observations were conducted to triangulate findings. 

Results 
Mean TOT was 58.9 minutes (SD = 13.1 minutes), with inpatient status adding 8.6 minutes (p<0.001). Complex procedures (e.g., spine tumor) averaged over 65 minutes, yet the 25th percentile within those categories achieved TOTs 9.6 minutes shorter than average—demonstrating that there is room for TOT improvement even for high-complexity cases. Stakeholders cited delayed patient transport, equipment readiness, and poor team coordination as recurrent issues. Electronic health record alert failures and inconsistent staffing compounded delays. Stakeholders also stressed the critical importance of aligning incentives and transparent accountability across services to ensure all personnel are motivated to achieve more efficient turnovers while maintaining regulatory compliance. Interviewees viewed the 30-minute target as unrealistic for neurosurgery. 

Conclusion 
TOT drivers are multifactorial, stemming from poorly coordinated patient flow, equipment setup inefficiencies, and fragmented intra-team communication. Next steps include piloting OR dashboards with real-time alerts, implementing role-specific turnover checklists, and setting tailored benchmarks by procedure type. Modeling interventions on the most efficient turnovers could reclaim OR time, reduce overtime costs, and improve team workflow without compromising safety.

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