A care bundle to improve perioperative mitomycin use in non-muscle-invasive bladder cancer

Using the WHO safe childbirth checklist to improve essential care delivery as part of the district-wide maternal and newborn health quality improvement initiative, a time series study

Background

Care bundles are a set of three to five evidence-informed practices which, when performed collectively and reliably, may improve health system performance and patient care. To date, many studies conducted to improve the quality of essential birth care practices (EBPs) have focused primarily on provider- level and have fallen short of the predicted impact on care quality, indicating that a systems approach is needed to improve the delivery of reliable quality care.

This study evaluates the effect of integrating the use of the World Health Organization Safe Childbirth Checklist (WHO-SCC) into a district-wide system improvement collaborative program designed to improve and sustain the delivery of EBPs as measured by “clinical bundle” adherence over-time.

Methods

The WHO-SCC was introduced in the context of a district-wide Maternal and Newborn Health (MNH) collaborative quality of care improvement program in four agrarian Ethiopia regions. Three “clinical bundles” were created from the WHO-SCC: On Admission, Before Pushing, and Soon After Birth bundles. The outcome of each bundle was measured using all- or- none adherence. Adherence was assessed monthly by reviewing charts of live births.

A time-series analysis was employed to assess the effectiveness of system-level interventions on clinical bundle adherence. STATA version 13.1 was used to analyze the trend of each bundle adherence overtime.

Autocorrelation was checked to assess if the assumption of independence in observations collected overtime was valid. Prais-Winsten was used to minimize the effect of autocorrelation.

Findings

Quality improvement interventions targeting the three clinical bundles resulted in improved adherence over time across the four MNH collaborative. In Tankua Abergele collaborative (Tigray Region), the overall mean adherence to “On Admission” bundle was 86% with β = 1.39 (95% CI; 0.47–2.32; P <  0.005) on average monthly.

Similarly, the overall mean adherence to the “Before Pushing” bundle in Dugna Fango collaborative; Southern Nations, Nationalities and People’s (SNNP) region was 80% with β = 2.3 (95% CI; 0.89–3.74; P <  0.005) on average monthly.

Conclusion

Using WHO-SCC paired with a system-wide quality improvement approach improved and sustained quality of EBPs delivery. Further studies should be conducted to evaluate the impact on patient-level outcomes.

Effects of Evidence-Based Continuing Care Bundle on Health Outcomes in Rectal Cancer Patients With Temporary Stomas: A Multicenter Randomized Controlled Trial

BACKGROUND

The patients with temporary stomas after anterior resection for rectal cancer may experience significant impact on their health outcomes, and hence continuing care is necessary and important for these patients. However, the effects of some single continuing care interventions remain unclear. Continuing care bundle may be an effective approach to address this uncertainty.

OBJECTIVE

The aim of this study was to investigate the effects of an evidence-based continuing care bundle on selected health outcomes in patients with temporary stomas after anterior resection for rectal cancer.

METHODS

This was a multicenter randomized controlled trial. A total of 124 patients with temporary stomas after anterior resection for rectal cancer were recruited from 4 general tertiary hospitals in Guangzhou, China, and were randomly assigned to a control group or an intervention group. Both groups received usual care, whereas the intervention group additionally received evidence-based continuing care bundle. Self-efficacy, quality of life, and stoma-related complications were collected at baseline and 4 and 12 weeks after surgery. Satisfaction and outcomes of stoma reversal were collected at the end of the observation.

RESULTS

The intervention group had significantly improved the self-efficacy (F = 11.88, P = .001), quality of life (F = 17.99, P < .001) over time, satisfaction (t = 4.08, P < .001), and outcomes of stoma reversal (χ2 = 5.93, P = .015) and reduced the incidence of complications (P < .05).

CONCLUSIONS

Evidence-based continuing care bundle can be an effective method to improve the health outcomes among these patients.

IMPLICATION FOR PRACTICE

By using the evidence-based continuing care bundle, nurses can help these patients improve their health outcomes in stoma-specific nursing.

Low Risk of Severe Complications After a Single, Post-Operative Instillation of Intravesical Chemotherapy in Patients with TaG1G2 Urothelial Bladder Carcinoma

BACKGROUND: EAU guidelines recommend a single instillation (SI) of intravesical chemotherapy (e.g. Mitomycin C) within 24 hours after transurethral resection of a bladder tumour (TURBT) in patients with low- to intermediate risk non-muscle invasive bladder cancer without (suspected) bladder perforation or bleeding requiring bladder irrigation. However, remarkable variation exists in the use of SI. The risk of severe complications is likely to contribute to this variation, but evidence is limited. OBJECTIVE: To investigate the absolute severe complication and mortality risk after SI in low- and intermediate risk bladder cancer. METHODS: In this observational, historic cohort study, data on 25,567 patients diagnosed with TaG1G2 urothelial bladder carcinoma (UBC) between 2009 and 2018 who underwent TURBT were collected from the Netherlands Cancer Registry. Data were supplemented with information on cause of death and severe complications after cancer treatment by re-examining the electronic health records and the 14-day complication risk and the 30-day mortality risk were evaluated. RESULTS: On average, 55% of patients had a SI after TURBT, varying from 0–>80% between hospitals. The 30-day mortality risk was 0.02% and the 14-day risk of severe complications was 1.6%. CONCLUSIONS: As the absolute risk of mortality and severe complications is very low, SI after TURBT can be considered a safe treatment in patients with low- to intermediate UBC without contraindications for SI. These results imply that a part of eligible patients is denied effective treatment.

Low compliance to guidelines in nonmuscle-invasive bladder carcinoma: A systematic review

PURPOSE

This systematic review assessed compliance to guidelines for the management of nonmuscle-invasive bladder carcinoma (NMIBC).

METHODS

The PUBMED, Web of Science, Cochrane Library, and Scopus databases were searched in November 2019 in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis statement.

RESULTS

Fifteen studies incorporating a collective total of 10,575 NMIBC patients were eligible for inclusion in this systematic review. We found that the rates of compliance were 53.0% with a single immediate intravesical instillation in patients with presumed low or intermediate risk, 37.1% with intravesical bacillus Calmette-Guerin or chemotherapy in those with intermediate risk, 43.4% with performance of a second transurethral resection in high-risk patients, 32.5% with administration of adjuvant intravesical bacillus Calmette-Guerin in high-risk patients, 36.1% with radical cystectomy in highest-risk patients, and 82.2% with cystoscopy for follow-up.

CONCLUSIONS

Compliance with NMIBC guidelines remains low. Better guideline education and understanding holds the key to achieving high compliance. Strategies to improve guideline compliance at the physician level are urgently required.