Postoperative care: who should look after patients following surgery?

Current Status of Adult Post-Cardiac Surgery Critical Care in Saudi Arabia

OBJECTIVE

The field of cardiac surgery in Saudi Arabia has developed significantly over the years, with more advanced procedures being performed for high-risk patients with multiple comorbidities. This poses challenging postoperative management issues requiring multidisciplinary, highly organized expert care in cardiovascular critical care. This survey aimed to describe the current state of postoperative critical care for cardiac surgeries in Saudi Arabia.

DESIGN

This e-mail survey developed by the Chapter of Adult Cardiovascular Critical Care of the Saudi Critical Care Society included 61 questions pertaining to the geographic distribution of adult cardiac surgery centers in Saudi Arabia, including what types of operations and how many operations are being performed, and information on intensive care units such as data on staffing, equipment, protocols, and outcome assessment in these units.

SETTING

The study was conducted in Saudi Arabia.

PARTICIPANTS

Participating physicians included representatives of adult intensive care units in all cardiac centers (N = 42).

INTERVENTIONS

There were no interventions in this study.

MEASUREMENTS AND MAIN RESULTS

Of the study cardiac centers, 71.4% have specialized cardiovascular critical care units for the postoperative care of cardiac patients and 42.9% are managed in a closed design by expert in-house physicians on a 24-hour basis. The estimated cardiac surgery intensive care unit bed capacity in Saudi Arabia is 7.3 (ranging from 3.0 in Qasim Region to 11.6 in Mecca Region) beds/1 million population, with 1.3 cardiac centers/1 million and 79 centers/1 million cardiovascular surgical patients. Several protocols are implemented in these critical care units with key performance indicators to meet the best quality of care.

CONCLUSIONS

Cardiac surgery intensive care units in Saudi Arabia have varying management structures, care practices, and healthcare provider staffing models, although most of the large-volume centers are adopting the intensivist-led team model of care. Guidelines are needed to standardize practice in all cardiac surgery centers regarding processes and protocols, intensive care unit staffing models, and reporting of outcomes and key performance indicators. Further studies are needed to study cardiac surgery intensive care unit factors related to patient outcomes after cardiac surgery.

Characterizing Physician-Staffing Models in the Care of Postoperative Cardiac Surgical Patients in Canada

Background

Current intensive care unit physician-staffing (IPS) models for postoperative cardiac surgery have not been previously investigated in Canada. The purpose of this study was to determine current IPS models at 2 time points and describe the evolution of Canadian cardiac surgery IPS models.

Methods

A survey of 32 Canadian cardiovascular intensive care units (CVICUs) was undertaken in 2012 and 2017 to determine IPS models of care during “daytime” and “after-hours” in each unit. Data were collected regarding surgical volume, base specialties, and style of IPS management (“open”; “semi-open”; “closed”). In addition, we collected the overnight experience level of the bedside healthcare provider for in-house intensive care units.

Results

Survey responses were received from 27 of 32 CVICUs (87%). As of 2017, the style of 1 (4%) was open, 7 (26%) were semi-open, and 19 (70%) were closed in their unit IPS strategy. Base specialties of CVICU physicians varied. A medical doctor provided after-hours coverage in 81% of CVICUs. Senior residents (37%) or critical care certified attending staff (25%) typically provided after-hours coverage for in-house CVICUs. Linked Canadian Institute for Health Information data did not indicate a difference among CVICU models in mortality or rehospitalization for coronary artery bypass graft or valve procedures.

Conclusions

Considerable heterogeneity is demonstrated in CVICU staffing patterns. No consensus was identified regarding the appropriate level of training for “after-hours” coverage. In-house overnight physician staffing in CVICUs varies widely. Finally, semi-open and closed style models did not demonstrate differences compared to Canadian Institute for Health Information data. Variability among CVICUs does exist; however, benefits of one model over another have not been identified.

The association between advanced practice nursing roles and outcomes in adults following cardiac surgery: A systematic review of randomized controlled trials

BACKGROUND

Empirical findings have shown significant and non-significant effects of advanced practice nursing roles within postoperative cardiac settings. The inconsistencies of the current literature preclude the identification of a significant effect of advanced practice nursing roles on patient and organizational outcomes.

OBJECTIVE

1) identify patient and organizational outcomes of advanced practice nursing roles in postoperative cardiac surgery and 2) synthesize the evidence of current roles of advanced practice nurses in postoperative cardiac surgery to provide the best quality of care for patients.

METHOD

A systematic review of randomized controlled trials was conducted in six electronic databases, including Medline, CINHAL, Embase, Cochrane Database, Joanna Briggs Database and Web of Science, and the grey literature. Randomized controlled trials published after 1999 were included if they examined advanced practice nursing roles and recruited patients who underwent cardiac surgery. The study selection was performed by two independent reviewers, and consensus was achieved with a third reviewer. Data extraction was conducted by one reviewer and revised by a second reviewer. The methodological quality of the included studies was assessed with the Evidence Project risk of bias tool by two independent reviewers and revised by a third reviewer. A narrative synthesis of the available evidence was completed. No meta-analysis technique was attempted because of the high heterogeneity of the included studies.

RESULTS

Among 4,448 retrieved papers, ten randomized controlled trials and three secondary analyses were included in this review. The methodological quality of the included studies was moderate. All studies included a comparison group and the majority of the studies collected data using a blinded researcher. However, all studies were based on small sample sizes and failed to randomly recruit participants. Five studies implemented nurse practitioner roles and five studies implemented clinical nurse specialist roles. The advanced practice nursing care included health condition management, lifestyle promotion and coping strategies with patients. A total of 22 outcomes were identified, including 13 patient outcomes (e.g., depressive symptoms) and nine organizational outcomes (e.g., rehospitalization after discharge). Each outcome was examined in one to five studies. All of the included outcomes were associated with inconsistent findings.

CONCLUSION

The findings from existing literature remain inconsistent. The high risk of bias and the small sample sizes could potentially explain the non-significant findings. Avenues for future research should focus on the development of methodologically high-quality studies with larger sample sizes to enhance our understanding of the effectiveness of advanced practice nursing roles.

Nonsurgical management of resectable oral cavity cancer in the wake of COVID-19: A rapid review and meta-analysis

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COVID-19 resource constraints have resulted in treatment delays for oral cancer.

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Non-surgical treatment may be necessary to provide timely access to care.

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Definitive CCRT is associated with an increased rate of death in early oral cancer.

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Neoadjuvant regimens have not shown survival benefit in resectable oral cancer.

Objective

Surgery is the preferred treatment modality for oral squamous cell carcinoma (OSCC). However, due to limited resources, re-assessment of treatment paradigms in the wake of the Coronavirus Disease 2019 (COVID-19) pandemic is urgently required. In this rapid review, we described contemporary oncological outcomes for OSCC using non-surgical modalities.

Methods

A systematic literature search was conducted for articles published between January 1, 2010 and April 1, 2020 on MEDLINE and Cochrane CENTRAL. Studies were included if they contained patients with OSCC treated with either neoadjuvant, induction, or definitive radiotherapy, chemotherapy, immunotherapy, or combination thereof, and an outcome of overall survival.

Results

In total, 36 articles were included. Definitive radiotherapy or chemoradiotherapy were the focus of 18 articles and neoadjuvant chemotherapy or chemoradiotherapy were the focus of the other 18 articles. In early stage OSCC, definitive radiotherapy, with or without concurrent chemotherapy, was associated with a significantly increased hazard of death compared to definitive surgery (HR: 2.39, 95% CI: 1.56–3.67, I²: 63%). The hazard of death was non-significantly increased with definitive chemoradiotherapy in studies excluding early disease (HR: 1.98, 95% CI: 0.85–4.64, I²: 84%). Two recent randomized control trials have been conducted, demonstrating no survival advantage to neoadjuvant chemotherapy.

Conclusion

This review suggests that primary radiotherapy and chemoradiotherapy are inferior to surgical management for OSCC. Strategies for surgical delay warranting consideration are sparse, but may include several neoadjuvant regimens, recognizing these regimens may not offer a survival benefit over definitive surgery alone.