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Readmission after colorectal surgery occurs frequently and is associated with a cost of approximately $9000 per readmission. Nationwide these findings account for $300 million in readmission costs annually for colorectal surgery alone. Clinical and systems-based prevention strategies are needed to reduce readmission.

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Buildings have been associated with spread of infectious diseases, such as outbreaks of measles, influenza, and Legionella. With SARS-CoV-2, the majority of outbreaks involving 3 or more people have been linked with time spent indoors, and evidence confirms that far-field airborne transmission (defined as within-room but beyond 6 feet) of SARS-CoV-2 is occurring. 1 Controlling concentrations of indoor respiratory aerosols to reduce airborne transmission of infectious agents is critical and can be achieved through source control (masking, physical distancing) and engineering controls (ventilation and filtration). 2 With respect to engineering controls, an important flaw exists in how most buildings operate in that the current standards for ventilation and filtration for indoor spaces, except for hospitals, are set for bare minimums and not designed for infection control. Several organizations and groups have called for increasing outdoor air ventilation rates, but, to date, there has been limited guidance on specific ventilation and filtration targets. This article describes the rationale for limiting far-field airborne transmission of SARS-CoV-2 through increasing outdoor air ventilation and enhancing filtration, and provides suggested targets.To reduce far-field airborne transmission of SARS-CoV-2 in smallvolume indoor spaces (eg, classrooms, retail shops, homes if guests are visiting), the suggestions include targeting 4 to 6 air changes per hour, through any combination of the following: outdoor air ventilation; recirculated air that passes through a filter with at least a minimum efficiency rating value 13 (MERV 13) rating; or passage of air through portable air cleaners with HEPA (high-efficiency particulate air) filters.Despite the dose-response for SARS-CoV-2 being unknown, and continued scientific debate about the dominant mode of transmission, evidence support these suggestions. First, SARS-CoV-2 is primarily transmitted from the exhaled respiratory aerosols of infected individuals. Larger droplets (>100 μm) can settle out of the air due to gravitational forces within 6 feet, but people emit 100 times more smaller aerosols (<5 μm) during talking, breathing, and coughing. Smaller aerosols can stay aloft for 30 minutes to hours and travel well beyond 6 feet. 1 Second, high-profile and welldescribed SARS-CoV-2 outbreaks across multiple space types (eg, restaurants, gyms, choir practice, schools, buses) share the common features of time indoors and low levels of ventilation, even when people remained physically distanced. 3 Third, these suggestions are grounded in the basics of exposure science and inhalation dose risk reduction. Higher ventilation and filtration rates more rapidly remove particles from indoor air, thereby reducing the intensity of exposure and duration that respiratory aerosols stay aloft inside a room. Fourth, this approach is consistent with what is used in hospitals to minimize risk of transmission (eTable in the Supplement). Fifth, reviews on the relationship between ventilation and inf...

IMPORTANCE Critical access hospitals are a predominant source of care for many rural populations. Previous reports suggest these centers provide lower quality of care for common medical admissions. Little is known about the outcomes and costs of patients admitted for surgical procedures. OBJECTIVE To compare the surgical outcomes and associated Medicare payments at critical access hospitals vs non-critical access hospitals. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional retrospective review of 1 631 904 Medicare beneficiary admissions to critical access hospitals (n = 828) and non-critical access hospitals (n = 3676) for 1 of 4 common types of surgical procedures-appendectomy, 3467 for critical access and 151 867 for non-critical access; cholecystectomy, 10 556 for critical access and 573 435 for non-critical access; colectomy, 10 198 for critical access and 577 680 for non-critical access; hernia repair, 4291 for critical access and 300 410 for non-critical access-between 2009 and 2013. We compared risk-adjusted outcomes using a multivariable logistical regression that adjusted for patient factors (age, sex, race, Elixhauser comorbidities), admission type (elective, urgent, emergency), and type of operation. EXPOSURES Undergoing surgical procedures at critical access vs non-critical access hospitals. MAIN OUTCOMES AND MEASURES Thirty-day mortality, postoperative serious complications (eg, myocardial infarction, pneumonia, or acute renal failure and a length of stay >75th percentile). Hospital costs were assessed using price-standardized Medicare payments during hospitalization. RESULTS Patients (mean age, 76.5 years; 56.2% women) undergoing surgery at critical access hospitals were less likely to have chronic medical problems, and they had lower rates of heart failure (7.7% vs 10.7%, P < .0001), diabetes (20.2% vs 21.7%, P < .001), obesity (6.5% vs 10.6%, P < .001), or multiple comorbid diseases (% of patients with Ն2 comorbidities; 60.4% vs 70.2%, P < .001). After adjustment for patient factors, critical access and non-critical access hospitals had no statistically significant differences in 30-day mortality rates (5.4% vs 5.6%; adjusted odds ratio [OR], 0.96; 95% confidence interval [CI], 0.89-1.03; P = .28). However, critical access vs non-critical access hospitals had significantly lower rates of serious complications (6.4% vs 13.9%; OR, 0.35; 95% CI, 0.

Even among accredited bariatric surgery centers, wide variation exists in rates of postoperative serious complications across geographic location and operative volumes. Given that a large proportion of centers are geographically located near higher-performing centers, opportunities for improvement through regional collaboratives or selective referral should be considered.

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