1
|
Ho VP, Towe CW, Bensken WP, Pfoh E, Dalton J, Connors AF, Claridge JA, Perzynski AT. Mortality burden from variation in provision of surgical care in emergency general surgery: a cohort study using the National Inpatient Sample. Trauma Surg Acute Care Open 2024; 9:e001288. [PMID: 38933602 PMCID: PMC11202721 DOI: 10.1136/tsaco-2023-001288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 05/15/2024] [Indexed: 06/28/2024] Open
Abstract
Background The decision to undertake a surgical intervention for an emergency general surgery (EGS) condition (appendicitis, diverticulitis, cholecystitis, hernia, peptic ulcer, bowel obstruction, ischemic bowel) involves a complex consideration of factors, particularly in older adults. We hypothesized that identifying variability in the application of operative management could highlight a potential pathway to improve patient survival and outcomes. Methods We included adults aged 65+ years with an EGS condition from the 2016-2017 National Inpatient Sample. Operative management was determined from procedure codes. Each patient was assigned a propensity score (PS) for the likelihood of undergoing an operation, modeled from patient and hospital factors: EGS diagnosis, age, gender, race, presence of shock, comorbidities, and hospital EGS volumes. Low and high probability for surgery was defined using a PS cut-off of 0.5. We identified two model-concordant groups (no surgery-low probability, surgery-high probability) and two model-discordant groups (no surgery-high probability, surgery-low probability). Logistic regression estimated the adjusted OR (AOR) of in-hospital mortality for each group. Results Of 375 546 admissions, 21.2% underwent surgery. Model-discordant care occurred in 14.6%; 5.9% had no surgery despite a high PS and 8.7% received surgery with low PS. In the adjusted regression, model-discordant care was associated with significantly increased mortality: no surgery-high probability AOR 2.06 (1.86 to 2.27), surgery-low probability AOR 1.57 (1.49 to 1.65). Model-concordant care showed a protective effect against mortality (AOR 0.83, 0.74 to 0.92). Conclusions Nearly one in seven EGS patients received model-discordant care, which was associated with higher mortality. Our study suggests that streamlined treatment protocols can be applied in EGS patients as a means to save lives. Level of evidence III.
Collapse
Affiliation(s)
- Vanessa P Ho
- Surgery, The MetroHealth System, Cleveland, Ohio, USA
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio, USA
- Population Health and Equity Research Institute, The MetroHealth System, Cleveland, Ohio, USA
| | - Christopher W Towe
- Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Wyatt P Bensken
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio, USA
| | - Elizabeth Pfoh
- Department of Internal Medicine and Geriatrics, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Jarrod Dalton
- Center for Populations Health Research, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Alfred F Connors
- The MetroHealth System, Cleveland, Ohio, USA
- Case Western Reserve University, Cleveland, Ohio, USA
| | | | - Adam T Perzynski
- Population Health and Equity Research Institute, The MetroHealth System, Cleveland, Ohio, USA
| |
Collapse
|
2
|
Villeneuve LM, Evans AR, Bowen I, Gernsback J, Balsara K, Jea A, Desai VR. A systematic review of the power of standardization in pediatric neurosurgery. Neurosurg Rev 2023; 46:325. [PMID: 38049561 DOI: 10.1007/s10143-023-02218-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 10/30/2023] [Accepted: 11/12/2023] [Indexed: 12/06/2023]
Abstract
In the current neurosurgical field, there is a constant emphasis on providing the best care with the most value. Such work requires the constant optimization of not only surgical but also perioperative services. Recent work has demonstrated the power of standardized techniques in limiting complication while promoting optimal outcomes. In this review article, protocols addressing operative and perioperative care for common pediatric neurosurgical procedures are discussed. These articles address how various institutions have optimized procedures through standardization. Our objective is to improve patient outcomes through the optimization of protocols.
Collapse
Affiliation(s)
- Lance M Villeneuve
- Department of Neurological Surgery, University of Oklahoma College of Medicine, 1000 N Lincoln Blvd, #4000, Oklahoma City, OK, 73104, USA.
- Department of Pediatric Neurosurgery, Oklahoma Children's Hospital, Oklahoma City, OK, USA.
| | - Alexander R Evans
- Department of Neurological Surgery, University of Oklahoma College of Medicine, 1000 N Lincoln Blvd, #4000, Oklahoma City, OK, 73104, USA
- Department of Pediatric Neurosurgery, Oklahoma Children's Hospital, Oklahoma City, OK, USA
| | - Ira Bowen
- Department of Neurological Surgery, University of Oklahoma College of Medicine, 1000 N Lincoln Blvd, #4000, Oklahoma City, OK, 73104, USA
- Department of Pediatric Neurosurgery, Oklahoma Children's Hospital, Oklahoma City, OK, USA
| | - Joanna Gernsback
- Department of Neurological Surgery, University of Oklahoma College of Medicine, 1000 N Lincoln Blvd, #4000, Oklahoma City, OK, 73104, USA
- Department of Pediatric Neurosurgery, Oklahoma Children's Hospital, Oklahoma City, OK, USA
| | - Karl Balsara
- Department of Neurological Surgery, University of Oklahoma College of Medicine, 1000 N Lincoln Blvd, #4000, Oklahoma City, OK, 73104, USA
- Department of Pediatric Neurosurgery, Oklahoma Children's Hospital, Oklahoma City, OK, USA
| | - Andrew Jea
- Department of Neurological Surgery, University of Oklahoma College of Medicine, 1000 N Lincoln Blvd, #4000, Oklahoma City, OK, 73104, USA
- Department of Pediatric Neurosurgery, Oklahoma Children's Hospital, Oklahoma City, OK, USA
| | - Virendra R Desai
- Department of Neurological Surgery, University of Oklahoma College of Medicine, 1000 N Lincoln Blvd, #4000, Oklahoma City, OK, 73104, USA
- Department of Pediatric Neurosurgery, Oklahoma Children's Hospital, Oklahoma City, OK, USA
| |
Collapse
|
3
|
Bravo D, Thiel C, Bello R, Moses A, Paksima N, Melamed E. What a Waste! The Impact of Unused Surgical Supplies in Hand Surgery and How We Can Improve. Hand (N Y) 2023; 18:1215-1221. [PMID: 35485263 PMCID: PMC10798204 DOI: 10.1177/15589447221084011] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The US health care system is the second largest contributor of trash. Approximately 20% to 70% of waste is produced by operating rooms, and very few of this waste is recycled. The purpose of this study is to quantify the opened but unused disposable supplies and generate strategies to reduce disposable waste. METHODS A single-center prospective study to evaluate the cost of opened but unused single-use operating room supplies was completed by counting the number of wasted disposable products at the end of hand surgery cases. We used χ2 test, t test, Wilcoxon rank-sum test, and simple linear regression to assess the associations between patient and case variables and the total cost of wasted items. Environmentally Extended Input Output Life Cycle Assessment methods were used to convert the dollar spent to kilograms of carbon dioxide equivalent (CO2-e), a measure of greenhouse gas emissions. RESULTS Surgical and dressing items that were disposed of and not used during each case were recorded. We included 85 consecutive cases in the analysis from a single surgeon's practice. Higher cost from wasted items was associated with shorter operative time (P = .010). On average, 11.5 items were wasted per case (SD: 3.6 items), with a total of 981 items wasted over the 85 cases in the study period. Surgical sponges and blades were 2 of the most unused items. Wasted items amounted to a total of $2193.5 and 441 kg of CO2-e during the study period. CONCLUSIONS This study highlights the excessive waste of unused disposable products during hand surgery cases and identifies ways of improvement.
Collapse
Affiliation(s)
- Dalibel Bravo
- NYU Langone Orthopedic Hospital, New York City, NY, USA
- Rothman Orthopaedic Institute, Philadelphia, PA, USA
- Baptist Health Miami Orthopedic and Sports Medicine Institute, Coral Gables, FL, USA
| | | | | | - Akini Moses
- Howard University College of Medicine, Washington, DC, USA
| | - Nader Paksima
- NYU Langone Orthopedic Hospital, New York City, NY, USA
| | - Eitan Melamed
- NYU Langone Orthopedic Hospital, New York City, NY, USA
- NYC Health + Hospitals/Elmhurst, New York, NY, USA
| |
Collapse
|
4
|
Corrigan N, Brown JM, Emsley R, Jayne DG, Walwyn REA. Surgical trial design for incorporating the effects of learning: what is the current methodological guidance, and is it sufficient? Trials 2023; 24:294. [PMID: 37095568 PMCID: PMC10127059 DOI: 10.1186/s13063-023-07265-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 03/17/2023] [Indexed: 04/26/2023] Open
Abstract
BACKGROUND Surgical interventions are complex. Key elements of this complexity are the surgeon and their learning curve. They pose methodological challenges in the design, analysis and interpretation of surgical RCTs. We identify, summarise, and critically examine current guidance about how to incorporate learning curves in the design and analysis of RCTs in surgery. EXAMINING CURRENT GUIDANCE Current guidance presumes that randomisation must be between levels of just one treatment component, and that the evaluation of comparative effectiveness will be made via the average treatment effect (ATE). It considers how learning effects affect the ATE, and suggests solutions which seek to define the target population such that the ATE is a meaningful quantity to guide practice. We argue that these are solutions to a flawed formulation of the problem, and are inadequate for policymaking in this setting. REFORMULATING THE PROBLEM The premise that surgical RCTs are limited to single-component comparisons, evaluated via the ATE, has skewed the methodological discussion. Forcing a multi-component intervention, such as surgery, into the framework of the conventional RCT design ignores its factorial nature. We briefly discuss the multiphase optimisation strategy (MOST), which for a Stage 3 trial would endorse a factorial design. This would provide a wealth of information to inform nuanced policy but would likely be infeasible in this setting. We discuss in more depth the benefits of targeting the ATE conditional on operating surgeon experience (CATE). The value of estimating the CATE for exploring learning effects has been previously recognised, but with discussion limited to analysis methods only. The robustness and precision of such analyses can be ensured via the trial design, and we argue that trial designs targeting CATE represent a clear gap in current guidance. CONCLUSION Trial designs that facilitate robust, precise estimation of the CATE would allow for more nuanced policymaking, leading to patient benefit. No such designs are currently forthcoming. Further research in trial design to facilitate the estimation of the CATE is needed.
Collapse
Affiliation(s)
- Neil Corrigan
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK.
| | - Julia M Brown
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Richard Emsley
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - David G Jayne
- Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
| | - Rebecca E A Walwyn
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| |
Collapse
|
5
|
Finn AP, Talcott KE, Han J, Ali FS, Rao P. Variation in Perioperative Care Practices Among Vitreoretinal Surgeons in the United States. Ophthalmic Surg Lasers Imaging Retina 2022; 53:681-690. [PMID: 36547962 DOI: 10.3928/23258160-20221117-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To describe perioperative practice patterns among retinal surgeons managing retinal detachment (RD) repair. METHODS This was a cross-sectional pilot survey of vitreoretinal surgeons in the United States (US), identified by a previously published web-based search and cross-referencing names from the American Society of Retina Specialists. Self-reported peri-operative practices and subgroups were analyzed. RESULTS Of the 298 surgical retina specialists who completed the survey, 115 (39%) were in practice for ≤ 5 years, 102 (34%) were in practice for 6 to 20 years, and 81 (27%) were in practice for > 20 years; 60%, 23%, and 16% were in private, academic, and hybrid practice, respectively. Fifty-nine percent reported operating with trainees. For ocular blocks, 59% perform retrobulbar, 21% peribulbar, and 20% subtenon's (ST). Use of ST block varied significantly by years in practice and presence of trainees (P < 0.0001, P = 0.004, respectively). Sixty percent perform primary scleral buckles (SB), 55% combined SB/pars plana vitrectomy (PPV), and 11% primary PPVs under general anesthesia. Use of general anesthesia for primary SB varied significantly by years in practice (P = 0.007). Surgeons with fewer years in practice were more likely to recommend facedown positioning for macula-off RDs (P < 0.0001). Forty-six percent of surgeons do not advise stopping blood thinners before surgery and this varied significantly by years in practice (P = 0.006). CONCLUSIONS Variation exists among US vitreoretinal surgeons in relation to anesthesia, postoperative positioning, and blood thinners restrictions. Preferences are influenced by years in practice and less by trainees and practice setting. These results serve as a basis for larger, targeted US-based surveys on perioperative care and correlation with surgical outcomes. [Ophthalmic Surg Lasers Imaging Retina 2022;53:681-690.].
Collapse
|
6
|
Soffin EM, Wainwright TW. Hip and Knee Arthroplasty. Anesthesiol Clin 2022; 40:73-90. [PMID: 35236584 DOI: 10.1016/j.anclin.2021.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Variation in care is associated with variation in outcomes after total joint arthroplasty (TJA). Accordingly, much research into enhanced recovery efficacy for TJA has been devoted to linking standardization with better outcomes. This article focuses on recent advances suggesting that variation within a set of core protocol elements may be less important than providing the core elements within enhanced recovery pathways for TJA. Provided the core elements are associated with benefits for patients and health care system outcomes, variation in the details of their provision may contribute to a pathway's success. This article provides an updated review of the literature.
Collapse
Affiliation(s)
- Ellen M Soffin
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA.
| | - Thomas W Wainwright
- Orthopaedic Research Institute, Bournemouth University, 89 Holdenhurst Road, Bournemouth, Dorset BH8 8FT, UK
| |
Collapse
|
7
|
Wanderer JP, Lasko TA, Coco JR, Fowler LC, McEvoy MD, Feng X, Shotwell MS, Li G, Gelfand BJ, Novak LL, Owens DA, Fabbri DV. Visualization of aggregate perioperative data improves anesthesia case planning: A randomized, cross-over trial. J Clin Anesth 2020; 68:110114. [PMID: 33142248 DOI: 10.1016/j.jclinane.2020.110114] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 10/23/2020] [Accepted: 10/24/2020] [Indexed: 11/19/2022]
Abstract
STUDY OBJECTIVE A challenge in reducing unwanted care variation is effectively managing the wide variety of performed surgical procedures. While an organization may perform thousands of types of cases, privacy and logistical constraints prevent review of previous cases to learn about prior practices. To bridge this gap, we developed a system for extracting key data from anesthesia records. Our objective was to determine whether usage of the system would improve case planning performance for anesthesia residents. DESIGN Randomized, cross-over trial. SETTING Vanderbilt University Medical Center. MEASUREMENTS We developed a web-based, data visualization tool for reviewing de-identified anesthesia records. First year anesthesia residents were recruited and performed simulated case planning tasks (e.g., selecting an anesthetic type) across six case scenarios using a randomized, cross-over design after a baseline assessment. An algorithm scored case planning performance based on care components selected by residents occurring frequently among prior anesthetics, which was scored on a 0-4 point scale. Linear mixed effects regression quantified the tool effect on the average performance score, adjusting for potential confounders. MAIN RESULTS We analyzed 516 survey questionnaires from 19 residents. The mean performance score was 2.55 ± SD 0.32. Utilization of the tool was associated with an average score improvement of 0.120 points (95% CI 0.060 to 0.179; p < 0.001). Additionally, a 0.055 point improvement due to the "learning effect" was observed from each assessment to the next (95% CI 0.034 to 0.077; p < 0.001). Assessment score was also significantly associated with specific case scenarios (p < 0.001). CONCLUSIONS This study demonstrated the feasibility of developing of a clinical data visualization system that aggregated key anesthetic information and found that the usage of tools modestly improved residents' performance in simulated case planning.
Collapse
Affiliation(s)
- Jonathan P Wanderer
- Department of Anesthesiology, Department of Biomedical Informatics, Vanderbilt University Medical Center, United States.
| | - Thomas A Lasko
- Department of Biomedical Informatics, Vanderbilt University Medical Center, United States
| | - Joseph R Coco
- Department of Biomedical Informatics, Vanderbilt University Medical Center, United States
| | - Leslie C Fowler
- Department of Anesthesiology, Vanderbilt University Medical Center, United States
| | - Matthew D McEvoy
- Department of Anesthesiology, Vanderbilt University Medical Center, United States
| | - Xiaoke Feng
- Department of Biostatistics, Vanderbilt University Medical Center, United States
| | - Matthew S Shotwell
- Department of Biostatistics, Department of Anesthesiology, Vanderbilt University Medical Center, United States
| | - Gen Li
- Department of Anesthesiology, Vanderbilt University Medical Center, United States
| | - Brian J Gelfand
- Department of Anesthesiology, Vanderbilt University Medical Center, United States
| | - Laurie L Novak
- Department of Biomedical Informatics, Vanderbilt University Medical Center, United States
| | - David A Owens
- Owen Graduate School of Management, Vanderbilt University, United States
| | - Daniel V Fabbri
- Department of Biomedical Informatics, Department of Computer Science, Vanderbilt University Medical Center, United States
| |
Collapse
|
8
|
Byrne BE, Rooshenas L, Lambert HS, Blazeby JM. A mixed methods case study investigating how randomised controlled trials (RCTs) are reported, understood and interpreted in practice. BMC Med Res Methodol 2020; 20:112. [PMID: 32398100 PMCID: PMC7216481 DOI: 10.1186/s12874-020-01009-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 05/06/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND While randomised controlled trials (RCTs) provide high-quality evidence to guide practice, much routine care is not based upon available RCTs. This disconnect between evidence and practice is not sufficiently well understood. This case study explores this relationship using a novel approach. Better understanding may improve trial design, conduct, reporting and implementation, helping patients benefit from the best available evidence. METHODS We employed a case-study approach, comprising mixed methods to examine the case of interest: the primary outcome paper of a surgical RCT (the TIME trial). Letters and editorials citing the TIME trial's primary report underwent qualitative thematic analysis, and the RCT was critically appraised using validated tools. These analyses were compared to provide insight into how the TIME trial findings were interpreted and appraised by the clinical community. RESULTS 23 letters and editorials were studied. Most authorship included at least one academic (20/23) and one surgeon (21/23). Authors identified wide-ranging issues including confounding variables or outcome selection. Clear descriptions of bias or generalisability were lacking. Structured appraisal identified risks of bias. Non-RCT evidence was less critically appraised. Authors reached varying conclusions about the trial without consistent justification. Authors discussed aspects of internal and external validity covered by appraisal tools but did not use these methodological terms in their articles. CONCLUSIONS This novel method for examining interpretation of an RCT in the clinical community showed that published responses identified limited issues with trial design. Responses did not provide coherent rationales for accepting (or not) trial results. Findings may suggest that authors lacked skills in appraisal of RCT design and conduct. Multiple case studies with cross-case analysis of other trials are needed.
Collapse
Affiliation(s)
- Ben E Byrne
- Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Clifton, Bristol, BS8 2PS, UK.
| | - Leila Rooshenas
- Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Clifton, Bristol, BS8 2PS, UK
| | - Helen S Lambert
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Jane M Blazeby
- Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Clifton, Bristol, BS8 2PS, UK
- MRC ConDuCT-II Hub, Bristol Medical School, University of Bristol, Bristol, UK
- NIHR Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| |
Collapse
|
9
|
Kane RL, Nasser JS, Chung KC. Establishment of a National Hand Surgery Data Registry: An Avenue for Quality Improvement. Hand Clin 2020; 36:221-229. [PMID: 32307053 DOI: 10.1016/j.hcl.2020.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Considerable variation exists in the practice of hand surgery that may lead to wasteful spending and less than optimal quality of care. Hand surgeons can benefit from a centralized system that tracks process and outcome measures, delivers national benchmarking, and encourages the sharing of knowledge. A national registry can fulfill these needs for hand surgeons and incorporate quality improvement into their daily routine. Leaders in hand surgery should convene to appraise the organization of a national registry for their field and reach consensus on how the registry can be designed and funded.
Collapse
Affiliation(s)
- Robert L Kane
- Michigan Center for Hand Outcomes and Innovation Research, 2800 Plymouth Road, Building 14, Suite G200, Ann Arbor, MI 48109, USA
| | - Jacob S Nasser
- George Washington School of Medicine and Health Sciences, Washington, DC, USA
| | - Kevin C Chung
- Section of Plastic Surgery, University of Michigan Medical School, Ann Arbor, MI, USA.
| |
Collapse
|
10
|
Derderian SC, Rove KO. Enhanced recovery after surgery among adolescents undergoing bariatric surgery. Semin Pediatr Surg 2020; 29:150885. [PMID: 32238290 DOI: 10.1016/j.sempedsurg.2020.150885] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Enhanced recovery after surgery (ERAS) has evolved over the past two decades. Originally aimed to standardize care among adults undergoing colorectal surgery, the tenets that developed have since been broadly accepted by a large number of adult surgical subspecialties, including bariatric surgery. This multidisciplinary, patient-centered approach involving optimizing pre-, intra-, and postoperative phases of care has resulted in shorter hospitalizations, fewer complications, and lower mortality rates. Recently, multiple pediatric surgery subspecialties have adopted ERAS principles and have documented similar favorable outcomes. Among adolescent bariatric patients, outcomes following the implementation of ERAS have not yet been described. We will review the history and goals of ERAS and detail pediatric surgery specific implementations. We will also review outcomes associated with ERAS within specific pediatric surgical subspecialties. Lastly, we will discuss the current ERAS protocol developed at Children's Hospital Colorado for adolescent bariatric surgery.
Collapse
Affiliation(s)
- S Christopher Derderian
- Department of Pediatric Surgery Children's Hospital Colorado, University of Colorado School of Medicine, Aurora CO, United States.
| | - Kyle O Rove
- Department of Pediatric Surgery Children's Hospital Colorado, University of Colorado School of Medicine, Aurora CO, United States
| |
Collapse
|
11
|
Cousins S, Blencowe NS, Blazeby JM. What is an invasive procedure? A definition to inform study design, evidence synthesis and research tracking. BMJ Open 2019; 9:e028576. [PMID: 31366651 PMCID: PMC6678000 DOI: 10.1136/bmjopen-2018-028576] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Worldwide, there are at least 230 million invasive procedures performed annually and most of us will undergo several in our lifetime. There is therefore a need for high-quality evidence to underpin this clinical area. Currently, however, there is no widely accepted definition of an invasive procedure and the terms 'surgery' and 'interventional procedure' are characterised inconsistently. We propose a definition for invasive procedures which addresses the limitations of those currently available. Our definition was developed from an analysis of the 3946 papers from the last decade. A preliminary definition was created based on existing definitions and applied to a variety of papers reporting all types of procedures. This definition was continuously updated and applied iteratively to all articles. The definition has three key components: (1) method of access to the body, (2) instrumentation and (3) requirement for operator skill. It therefore encapsulates all types of invasive procedure regardless of the method of access to the body (incision, natural orifice or percutaneous access), and is relevant whatever the clinical discipline (eg, obstetric, cardiac, dental, interventional cardiology or radiology). Crucially, the definition excludes medicinal products, except where their administration occurs within an invasive procedure (and thereby involves operator skill). The application of a universal definition of an invasive procedure will (1) inform the selection of relevant methods for study design, (2) streamline evidence synthesis and (3) improve research tracking, helping to identify evidence gaps and direct research funds.
Collapse
Affiliation(s)
- Sian Cousins
- Centre for Surgical Research, Population Health Sciences, University of Bristol, Bristol, UK
| | - Natalie S Blencowe
- Centre for Surgical Research, Population Health Sciences, University of Bristol, Bristol, UK
- Division of Surgery, Head and Neck, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom
| | - Jane M Blazeby
- Centre for Surgical Research, Population Health Sciences, University of Bristol, Bristol, UK
- Division of Surgery, Head and Neck, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom
| |
Collapse
|
12
|
Refai M, Andolfi M, Gentili P, Pelusi G, Manzotti F, Sabbatini A. Enhanced recovery after thoracic surgery: patient information and care-plans. J Thorac Dis 2018; 10:S512-S516. [PMID: 29629197 DOI: 10.21037/jtd.2017.12.87] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Many studies have confirmed that the implementation of enhanced recovery after surgery (ERAS) protocols has the advantages of reducing the potential complications after thoracic surgery and the length of hospital stay. The ERAS program involves a multidisciplinary team, aimed at integrating evidence-based knowledge into clinical practice in order to reduce the patient's stress response to the surgical procedure and improve the response to stress, guaranteeing a combination of better outcomes and cost savings. All this would not be possible without the improvement of minimally invasive surgical techniques, progression of anesthesia, pain control, and careful patient preparation. In this setting, a preoperative personal counselling may play a key role to reduce stress, fear or anxiety and improve the morbidity of patients, enabling them to achieve functional and psychological compensatory mechanisms more quickly. Preoperative patient counselling, performed using verbal, written or multimedia materials, is crucial in order to achieve the goal of the ERAS project: making the patient a potentially active participant and the main character of his recovery, able to positively impact himself throughout the surgical and healing process. This report is aimed at evaluating patient information and care-plans in thoracic surgery, reviewing the available evidence on ERAS pathways, and demonstrating our ideal program as discussed and shared among the Italian Thoracic Surgery Units accredited in the video-assisted thoracic surgery (VATS) group.
Collapse
Affiliation(s)
- Majed Refai
- Division of Thoracic Surgery, Ospedali Riuniti Ancona, Ancona, Italy.,Section of Minimally Invasive Thoracic Surgery, Ospedali Riuniti Ancona, Ancona, Italy
| | - Marco Andolfi
- Division of Thoracic Surgery, Ospedali Riuniti Ancona, Ancona, Italy
| | - Paolo Gentili
- Anesthesia and Intensive Care Unit, Ospedali Riuniti Ancona, Ancona, Italy
| | - Gilda Pelusi
- School of Nursing and Midwifery Sciences, Università Politecnica delle Marche (UNIVPM), Ancona, Italy
| | | | - Armando Sabbatini
- Division of Thoracic Surgery, Ospedali Riuniti Ancona, Ancona, Italy
| |
Collapse
|
13
|
Pisarska M, Małczak P, Major P, Wysocki M, Budzyński A, Pędziwiatr M. Enhanced recovery after surgery protocol in oesophageal cancer surgery: Systematic review and meta-analysis. PLoS One 2017; 12:e0174382. [PMID: 28350805 PMCID: PMC5370110 DOI: 10.1371/journal.pone.0174382] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 03/08/2017] [Indexed: 12/16/2022] Open
Abstract
Background Enhanced Recovery After Surgery (ERAS) protocol are well established in many surgical disciplines, leading to decrease in morbidity and length of hospital stay. These multi-modal protocols have been also introduced to oesophageal cancer surgery. This review aimed to evaluate current literature on ERAS in oesophageal cancer surgery and conduct a meta-analysis on primary and secondary outcomes. Methods MEDLINE, Embase, Scopus and Cochrane Library were searched for eligible studies. We analyzed data up to May 2016. Eligible studies had to contain four described ERAS protocol elements. The primary outcome was overall morbidity. Secondary outcomes included length of hospital stay, specific complications, mortality and readmissions. Random effect meta-analyses were undertaken. Results Initial search yielded 1,064 articles. Thorough evaluation resulted in 13 eligible articles which were analyzed. A total of 2,042 patients were included in the analysis (1,058 ERAS group and 984 treated with traditional protocols). Analysis of overall morbidity as well as complication rate did not show any significant reduction. Non-surgical complications and pulmonary complications were significantly lower in the ERAS group, RR = 0.71 95% CI 0.62–0.80, p < 0.00001 and RR = 0.75, 95% CI 0.60–0.94, p = 0.01, respectively. Meta-analysis on length of stay presented significant reduction Mean difference = -3.55, 95% CI -4.41 to -2.69, p for effect<0.00001. Conclusions This systematic review with a meta-analysis on ERAS in oesophageal surgery indicates a reduction of non-surgical complications and no negative influence on overall morbidity. Moreover, a reduction in the length of hospital stay was presented.
Collapse
Affiliation(s)
- Magdalena Pisarska
- 2 Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland
- Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, Kraków, Poland
- Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Kraków, Poland
| | - Piotr Małczak
- 2 Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland
- Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, Kraków, Poland
- Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Kraków, Poland
| | - Piotr Major
- 2 Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland
- Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, Kraków, Poland
- Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Kraków, Poland
| | - Michał Wysocki
- 2 Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland
- Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, Kraków, Poland
- Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Kraków, Poland
| | - Andrzej Budzyński
- 2 Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland
- Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, Kraków, Poland
- Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Kraków, Poland
| | - Michał Pędziwiatr
- 2 Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland
- Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, Kraków, Poland
- Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Kraków, Poland
- * E-mail:
| |
Collapse
|
14
|
Pędziwiatr M, Pisarska M, Major P, Grochowska A, Matłok M, Przęczek K, Stefura T, Budzyński A, Kłęk S. Laparoscopic colorectal cancer surgery combined with enhanced recovery after surgery protocol (ERAS) reduces the negative impact of sarcopenia on short-term outcomes. Eur J Surg Oncol 2016; 42:779-87. [PMID: 27156809 DOI: 10.1016/j.ejso.2016.03.037] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Revised: 03/20/2016] [Accepted: 03/31/2016] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Progressive skeletal muscle loss (sarcopenia) is a negative prognostic factor in patients treated for colorectal cancer. Nevertheless, the clinical impact of those changes in body composition has been analyzed only in patients undergoing open resections. The aim of the study was to assess whether laparoscopy may eliminate the deleterious prognostic impact of sarcopenia and whether the combination with enhanced recovery after surgery (ERAS) protocol may improve postoperative recovery also in sarcopenic patients. METHODS The study included 124 (73M/51F, mean age 65.9 years) patients undergoing elective laparoscopic colorectal resection for cancer. In all of them 16-item ERAS protocol was applied. The L3 skeletal muscle area identified on a preoperative CT scan was used to calculate skeletal muscle index and assess for sarcopenia and myosteatosis. The entire study group was divided into groups regarding the presence of sarcopenia or myosteatosis. The outcome measures were: length of hospital stay, complication rate and functional recovery parameters. RESULTS The prevalence of sarcopenia and myosteatosis was 27.4% and 38.7%, respectively. There was no association between the presence of sarcopenia or myosteatosis and postoperative complications. There were also no differences in the length of stay or readmission rates. Functional recovery (time to first flatus, oral diet tolerance and mobilization) was similar regardless of the presence of muscle depletion. CONCLUSIONS In contrary to traditional surgical approach, laparoscopy can reduce the negative impact of sarcopenia and myosteatosis on treatment results. ERAS protocol does not affect negatively the surgical outcomes in sarcopenic patients, compared to patients without changes in body skeletal mass.
Collapse
Affiliation(s)
- M Pędziwiatr
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21, 31-501, Kraków, Poland; Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, University Hospital, Kopernika 21, 31-501, Kraków, Poland.
| | - M Pisarska
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21, 31-501, Kraków, Poland; Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, University Hospital, Kopernika 21, 31-501, Kraków, Poland
| | - P Major
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21, 31-501, Kraków, Poland; Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, University Hospital, Kopernika 21, 31-501, Kraków, Poland
| | - A Grochowska
- Department of Radiology, University Hospital, Kopernika 21, 31-501, Kraków, Poland
| | - M Matłok
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21, 31-501, Kraków, Poland; Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, University Hospital, Kopernika 21, 31-501, Kraków, Poland
| | - K Przęczek
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21, 31-501, Kraków, Poland; Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, University Hospital, Kopernika 21, 31-501, Kraków, Poland
| | - T Stefura
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21, 31-501, Kraków, Poland; Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, University Hospital, Kopernika 21, 31-501, Kraków, Poland
| | - A Budzyński
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21, 31-501, Kraków, Poland; Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, University Hospital, Kopernika 21, 31-501, Kraków, Poland
| | - S Kłęk
- Stanley Dudrick Memorial Hospital, Tyniecka 15, 32-050, Skawina, Poland
| |
Collapse
|
15
|
Hopkins TJ, Miller TE. Effective Implementation of Enhanced Recovery Pathway Programs: The Key to Disseminating Evidence into Practice. Jt Comm J Qual Patient Saf 2015; 41:445-6. [PMID: 26404072 DOI: 10.1016/s1553-7250(15)41057-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Thomas J Hopkins
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina, USA
| | | |
Collapse
|
16
|
Hsueh WD, Gibber MJ. Closer to the Mean. Otolaryngol Head Neck Surg 2015; 153:903-4. [DOI: 10.1177/0194599815613967] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 10/06/2015] [Indexed: 11/16/2022]
Abstract
Variation, long accepted to be the norm in otolaryngologic surgical practice, has recently come under scrutinization. Efforts can be seen daily in the operating room to standardize procedures with time-outs, checklists, and protocols. The thought is that by enforcing repetition and eliminating variation, it is possible to decrease human error and reduce cost. However, there is understandable resistance from surgeons in removing the “art” from surgery. We propose that standardization, if appropriately put into practice, can improve surgical outcomes and efficiency and even enhance resident education.
Collapse
Affiliation(s)
- Wayne D. Hsueh
- Department of Otorhinolaryngology–Head and Neck Surgery, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Marc J. Gibber
- Department of Otorhinolaryngology–Head and Neck Surgery, Albert Einstein College of Medicine, Bronx, New York, USA
| |
Collapse
|
17
|
Oda Y, Kakinohana M. Introduction of ERAS(®) program into clinical practice: from preoperative management to postoperative evaluation : Opening remarks. J Anesth 2013; 28:141-2. [PMID: 24306128 DOI: 10.1007/s00540-013-1747-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Indexed: 11/25/2022]
Affiliation(s)
- Yutaka Oda
- Department of Anesthesiology, Osaka City General Hospital and Children's Hospital, 2-13-22 Miyakojima-hondori, Miyakojima-ku, Osaka, 534-0021, Japan,
| | | |
Collapse
|
18
|
Nathan H, Segev DL, Bridges JFP, Massie AB, Cameron AM, Hirose K, Schulick RD, Choti MA, Pawlik TM. Influence of Nonclinical Factors on Choice of Therapy for Early Hepatocellular Carcinoma. Ann Surg Oncol 2012; 20:448-56. [DOI: 10.1245/s10434-012-2619-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2012] [Indexed: 12/19/2022]
|
19
|
Luca F, Ghezzi TL, Valvo M, Cenciarelli S, Pozzi S, Radice D, Crosta C, Biffi R. Surgical and pathological outcomes after right hemicolectomy: case-matched study comparing robotic and open surgery. Int J Med Robot 2011; 7:298-303. [PMID: 21563286 DOI: 10.1002/rcs.398] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2011] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To compare the surgical and pathological outcomes of patients with right-sided colon cancers operated on by means of open and robotic surgery with extracorporeal anastomosis. METHODS Thirty-three consecutive patients who underwent robotic right hemicolectomy due to right-sided colon cancer were retrospectively well matched with 102 patients operated on by the open approach. Data were included in a prospectively maintained database. RESULTS Mean operative time was longer in the robotic group (P < 0.001), 191.7 min (134-250) versus 136.2 (45-240) min in the open group. Estimated intraoperative blood loss was less in the robotic group, which presented a mean of 6.1 ml versus 94.8 ml in the open group (P < 0.001). Despite the similar length of the surgical specimen and number of lymph nodes retrieved between both groups, 15 or more lymph nodes were found in the specimen in 90 out of 102 patients (88.2%) operated on by the open technique versus 33 out of 33 patients (100%) who underwent robotic hemicolectomy (P = 0.038). The median length of postoperative hospital stay was shorter in the robotic group, 5 versus 8 days (P < 0.001). No other statistically significant difference was observed in terms of pathological and postoperative results. CONCLUSIONS Robotic right hemicolectomy is an oncologically safe and effective procedure. The number of lymph nodes retrieved in the robotic group compared with the open group of our series was more homogeneous, and none of the patients operated on with this technique had a suboptimal lymphadenectomy. Further clinical trials are needed to confirm current evidence and determine whether this can influence the prognosis.
Collapse
Affiliation(s)
- Fabrizio Luca
- Division of Abdomino-Pelvic Surgery; European Institute of Oncology, Milano, Italy.
| | | | | | | | | | | | | | | |
Collapse
|
20
|
Mohn AC, Bernardshaw SV, Ristesund SM, Hovde Hansen PE, Røkke O. Enhanced recovery after colorectal surgery. Results from a prospective observational two-centre study. Scand J Surg 2010; 98:155-9. [PMID: 19919920 DOI: 10.1177/145749690909800305] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Enhanced recovery after surgery (ERAS) has reduced the median hospital stay from 8-10 days with traditional peri-operative routines to four days. The aim of the present study was to introduce the principles of ERAS in our hospital and measure the effect on hospital stay, complications and quality of life after discharge from hospital. MATERIAL AND METHODS 94 consecutive patients, 40 males, 54 females, median age 66 years, were included in a prospective non-randomised observational study at Haukeland University Hospital and Haugesund Hospital from October 2000 until February 2003. After a three-month preparation period, the principles of ERAS were implemented. The results were evaluated with questionnaires and by follow-ups 8-10 and 30 days after surgery. The results were compared to the results of colorectal surgery before introduction of accelerated recovery. RESULTS 45 (48%) and 73 (78%) patients were discharged within three and five days after surgery with ERAS, compared to zero and seven (5%) patients with traditional recovery. The complication rate with ERAS was 31%, and the readmission rate was 15%. After one week, 57% had resumed their daily activities at home. After 30 days, 65% of the patients had resumed their normal and leisure activities. CONCLUSION After a proper preparation period, ERAS principles may be implemented in surgical department, and is followed by a reduced median hospital stay and rapid return to normal daily activities for most patients after colorectal surgery.
Collapse
Affiliation(s)
- A C Mohn
- Department of Surgery, Haugesund Hospital, Haugesund, Norway.
| | | | | | | | | |
Collapse
|
21
|
Wright FC, Law CHL, Berry S, Smith AJ. Clinically important aspects of lymph node assessment in colon cancer. J Surg Oncol 2009; 99:248-55. [PMID: 19235179 DOI: 10.1002/jso.21226] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
There has been considerable discussion in the literature regarding the importance and validity of lymph node retrieval and lymph node count for patients with colon cancer. In this article we summarize the importance of lymph node resection and assessment in contemporary colon cancer care, key clinical determinants of lymph node assessment, and discuss the role of lymph node assessment as a quality marker in colon cancer care.
Collapse
Affiliation(s)
- Frances C Wright
- Sunnybrook Health Sciences Centre, Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | | | | | | |
Collapse
|
22
|
Attwood SEA, Lundell L, Ell C, Galmiche JP, Hatlebakk J, Fiocca R, Lind T, Eklund S, Junghard O. Standardization of surgical technique in antireflux surgery: the LOTUS Trial experience. World J Surg 2008; 32:995-8. [PMID: 18224465 DOI: 10.1007/s00268-007-9409-4] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND To date, it has been difficult to compare medical therapy for gastroesophageal reflux disease with that of surgical management from a scientific viewpoint, mainly because of the lack of standardization of the operative technique. This study was designed to identify a methodology for standardization of surgical technique and to measure the effectiveness of this standardization. METHODS Surgeons contributing to a major international multicenter trial comparing optimum medical therapy with surgical therapy for treatment of gastroesophageal reflux attempted to optimize their surgical techniques so that a realistic comparison could be made that may aid clinical decision-making. The surgeons met, shared their techniques using video, and produced a standardized set of criteria for the surgical centers and a common operative technique. Data collection methods ensured accuracy of the records of the procedure applied and the data were analyzed for consistency with set surgical standards. RESULTS There was a high degree of conformity (>95%) between the recommended method of performing a Nissen fundoplication as defined in the trial protocol, and variations were restricted to isolated individuals. The operations were completed without mortality, few conversions, and with very low postoperative morbidity. CONCLUSIONS This study has shown that, contrary to commonly held belief, surgeons are able to standardize their work for the purposes of measuring the outcome of an operative procedure within the context of a randomized, controlled trial.
Collapse
Affiliation(s)
- Stephen E A Attwood
- Department of Surgery, Northumbria Healthcare, North Tyneside Hospital, Rake Lane, North Shields, NE29 8NH, United Kingdom.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
23
|
Landrigan CP, Conway PH, Stucky ER, Chiang VW, Ottolini MC. Variation in pediatric hospitalists' use of proven and unproven therapies: a study from the Pediatric Research in Inpatient Settings (PRIS) network. J Hosp Med 2008; 3:292-8. [PMID: 18698602 DOI: 10.1002/jhm.347] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Undesirable practice variation remains a major concern with the quality of the healthcare system. While care in pediatric hospitalist systems has been demonstrated to be efficient, neither the quality of care nor determinants of variation in pediatric hospitalist systems are well understood. OBJECTIVE To measure variation in pediatric hospitalists' reported use of common inpatient therapies, and to test the hypothesis that variation in reported use of proven therapies is lower than variation in reported use of unproven therapies. DESIGN AND MEASUREMENTS We conducted a survey of pediatric hospitalists in the US and Canada. Respondents reported their frequency of using 14 therapies in the management of common conditions. Each therapy was determined to be of proven or unproven effectiveness using published critical appraisals. Variation in reported use of proven and unproven therapies was compared. RESULTS 67% (213/320) of surveyed individuals participated. Little variability existed in reported use of albuterol and corticosteroids in asthma (4-6% of respondents reported not often using them) and systemic dexamethasone in bronchiolitis (12% of respondents reported using it more than rarely). Moderate to high variation existed in reported use of all other therapies studied. Variation in reported use of proven therapies was significantly less than variation in reported use of unproven therapies (15.5 +/- 12.5% vs. 44.6 +/- 20.5%). CONCLUSIONS Substantial variation exists in hospitalists' reported management of common pediatric conditions. Variation is significantly lower for strongly evidence-based therapies. To decrease undesirable variation in care, a stronger evidence base for inpatient pediatric care must be built.
Collapse
Affiliation(s)
- Christopher P Landrigan
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA.
| | | | | | | | | |
Collapse
|
24
|
Porras-Hernandez J, Bracho-Blanchet E, Tovilla-Mercado J, Vilar-Compte D, Nieto-Zermeño J, Davila-Perez R, Teyssier-Morales G, Lule-Dominguez M. A Standardized Perioperative Surgical Site Infection Care Process Among Children with Stoma Closure: A Before–After Study. World J Surg 2008; 32:2316-23. [DOI: 10.1007/s00268-008-9617-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
|
25
|
Maessen J, Dejong CHC, Hausel J, Nygren J, Lassen K, Andersen J, Kessels AGH, Revhaug A, Kehlet H, Ljungqvist O, Fearon KCH, von Meyenfeldt MF. A protocol is not enough to implement an enhanced recovery programme for colorectal resection. Br J Surg 2007; 94:224-31. [PMID: 17205493 DOI: 10.1002/bjs.5468] [Citation(s) in RCA: 355] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Single-centre studies have suggested that enhanced recovery can be achieved with multimodal perioperative care protocols. This international observational study evaluated the implementation of an enhanced recovery programme in five European centres and examined the determinants affecting recovery and length of hospital stay. METHODS Four hundred and twenty-five consecutive patients undergoing elective open colorectal resection above the peritoneal reflection between January 2001 and January 2004 were enrolled in a protocol that defined multiple perioperative care elements. One centre had been developing multimodal perioperative care for 10 years, whereas the other four had previously undertaken traditional care. RESULTS The case mix was similar between centres. Protocol compliance before and during the surgical procedure was high, but it was low in the immediate postoperative phase. Patients fulfilled predetermined recovery criteria a median of 3 days after operation but were actually discharged a median of 5 days after surgery. Delay in discharge and the development of major complications prolonged length of stay. Previous experience with fast-track surgery was associated with a shorter hospital stay. CONCLUSION Functional recovery in 3 days after colorectal resection could be achieved in daily practice. A protocol is not enough to enable discharge of patients on the day of functional recovery; more experience and better organization of care may be required.
Collapse
Affiliation(s)
- J Maessen
- Department of Surgery, University Hospital Maastricht, Maastricht, The Netherlands
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
26
|
Søreide E, Ljungqvist O. Modern preoperative fasting guidelines: a summary of the present recommendations and remaining questions. Best Pract Res Clin Anaesthesiol 2007; 20:483-91. [PMID: 17080698 DOI: 10.1016/j.bpa.2006.03.002] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
This chapter is complementary to the others in this volume focusing on preoperative fasting routines. In it we discuss some of the issues in need of more research to define best practice. One of these is the role of fasting in emergency patients. Modern preoperative fasting recommendations almost exclusively deal with elective patients. In emergency patients preoperative fasting cannot secure gastric emptying to reduce the risk of pulmonary aspiration. Hence, surgery should be timed according to the urgency of the situation, and the patient should always be treated as if the stomach was full. More data are needed to better define what is going on in the gastrointestinal tract during the perioperative period in these patients. In certain patient groups--such as patients with diabetes, gastro-oesophageal reflux disease and/or obesity--the data are insufficient to give complete guidance to best practice. Preoperative fasting guidelines also affect fluid balance and perioperative fluid management, a topic of debate in recent years. In addition, carbohydrate-enriched fluids for oral use in the preoperative phase have been shown to have a positive effect on postoperative metabolism. Recent studies also suggest that the immune system would be less affected by surgery with such preparations. Last but not least, new scientific evidence alone is not enough to change daily practice. Active implementation of new evidence is also needed. To improve perioperative care, anaesthesiologists, surgeons and the nursing staff must work together.
Collapse
Affiliation(s)
- Eldar Søreide
- Department of Anaesthesia, Division of Acute Care Medicine, Stavanger University Hospital, Stavanger, Norway.
| | | |
Collapse
|
27
|
Wind J, Polle SW, Fung Kon Jin PHP, Dejong CHC, von Meyenfeldt MF, Ubbink DT, Gouma DJ, Bemelman WA. Systematic review of enhanced recovery programmes in colonic surgery. Br J Surg 2006; 93:800-9. [PMID: 16775831 DOI: 10.1002/bjs.5384] [Citation(s) in RCA: 468] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Fast track (FT) programmes optimize perioperative care in an attempt to accelerate recovery, reduce morbidity and shorten hospital stay. The aim of this review was to assess FT programmes for elective segmental colonic resections. METHODS A systematic review was performed of all randomized controlled trials and controlled clinical trials on FT colonic surgery. The main endpoints were number of applied FT elements, hospital stay, readmission rate, morbidity and mortality. Quality assessment and data extraction were performed independently by three observers. RESULTS Six papers were eligible for analysis (three randomized controlled and three controlled clinical trials), including 512 patients. FT programmes contained a mean of nine (range four to 12) of the 17 FT elements as defined in the literature. Primary hospital stay (weighted mean difference - 1.56 days, 95 per cent confidence interval (c.i.) - 2.61 to - 0.50 days) and morbidity (relative risk 0.54, 95 per cent c.i. 0.42 to 0.69) were significantly lower for FT programmes. Readmission rates were not significantly different (relative risk 1.17, 95 per cent c.i. 0.73 to 1.86). No increase in mortality was found. CONCLUSIONS FT appears to be safe and shortens hospital stay after elective colorectal surgery. However, as the evidence is limited, a multicentre randomized trial seems justified.
Collapse
Affiliation(s)
- J Wind
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | | | | | | | | | | | | | | |
Collapse
|
28
|
Søreide E, Ljungqvist O. Preoperative fasting. Can J Surg 2006; 49:218-9; author reply 219. [PMID: 16808039 PMCID: PMC3207595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023] Open
|