Is Incentive Spirometry Superior to Standard Care in Postoperative Cardiac Surgery on Clinical Outcomes and Length of Hospital and Intensive Care Unit Stay? A Systematic Review with Meta-Analysis

INTRODUCTION

Cardiac surgery is a frequent surgical procedure and may present a high risk of complications. Among the prophylactic strategies studied to decrease the rates of negative outcomes, respiratory care seems to reduce pulmonary complications. Incentive spirometry (IS) is a low-cost, respiratory exercise technique, used for the prevention and treatment of postoperative pulmonary complications (PPC). The aim of this review was to evaluate whether IS is superior to respiratory care, mobilization exercises, and noninvasive ventilation on PPC, and clinical outcomes.

METHODS

Systematic review. Medical Literature Analysis and Retrieval System Online (or MEDLINE®), Embase®, Cochrane Central Register of Controlled Trials (or CENTRAL), Physiotherapy Evidence Database (or PEDro), Cumulative Index of Nursing and Allied Health (or CINAHL®), Latin American and Caribbean Health Sciences Literature (or LILACS), Scientific Electronic Library Online (or SciELO), Allied, Scopus®, and OpenGrey databases, clinical trial registration sites, conferences, congresses, and symposiums were searched.

RESULTS

Twenty-one randomized trials and one quasi-randomized trial (1,677 participants) were included. For partial pressure of oxygen (PaO2), IS was inferior to respiratory care (mean difference [MD] -4.48; 95% confidence interval [CI] -8.32 to -0.63). Flow-oriented IS was inferior to respiratory care on PaO2 (MD -4.53; 95% CI -8.88 to -0.18). However, compared to respiratory care, flow-oriented IS was superior on recovery vital capacity.

CONCLUSIONS

This meta-analysis revealed that IS was not superior to standard respiratory care for PPCs and clinical outcomes, therefore its use should not be widely recommended until further studies with high quality be performed to ensure this clinical guidance.

Surgical Patients' Evaluation of Pain Management Quality and Surgical Nurses' Pain-Related Knowledge and Attitudes

PURPOSE

The present study was aimed at investigating the quality of pain management evaluated by inpatients in surgical clinics, and pain-related knowledge and attitudes of nurses working in surgical clinics, surgical units, or emergency services.

METHODS

The study was conducted as a descriptive and cross-sectional study. The study data were collected from inpatients in surgical clinics (N = 306), and from nurses working in surgical clinics, surgical units, or emergency services (N = 57) between January 2020 and September 2020. The Revised American Pain Society Patient Outcome Questionnaire (APS-POQ-R) and Nurses' Knowledge and Attitudes Survey Regarding Pain (NKASRP) were the tools used for data collection.

RESULTS

The mean scores the participants obtained from the severity of worst pain, pain relief, and satisfaction with pain treatment components of the APS-POQ-R were 6.14 ± 2.59, 59.28 ± 22.26, and 8.99 ± 1.62, respectively. There were significant differences between many components of the APS-POQ-R in terms of such variables as age, sex, undergoing previous surgery, presence of pain before surgery, surgery performed, and type of anesthesia (p < .05). The mean score the participants obtained from the NKASRP was 15.35 ± 3.87.

CONCLUSIONS

It was concluded that the patients' pain was relieved moderately, that they were very highly satisfied with pain treatment, and that the nurses' pain-related knowledge and attitude levels were below the moderate level.

CLINICAL IMPLICATIONS

Nurses should support patients whose in-bed activities were prevented due to pain, involve them in pain treatment decisions, advise them about pain treatment options, and encourage them to use nonpharmacological methods.

Implementation of Physical Therapist Services for Men Undergoing Radical Prostatectomy: An Administrative Case Report

OBJECTIVE

Prostate cancer is the most commonly diagnosed cancer among men in the USA, and radical prostatectomy (RP) is the primary surgical treatment option. With an increasing number of men undergoing RP and surviving prostate cancer, clinical management strategies have broadened to improve the preoperative and postoperative patient experience and minimize treatment-related functional consequences. Urinary incontinence is a predictable functional consequence of RP. Recent reviews recommend preoperative and postoperative physical therapist services as the standard of care for men undergoing RP to decrease the severity of urinary incontinence and improve patients' quality of life. Despite compelling evidence, the routine provision of physical therapist services preoperatively and postoperatively for men undergoing RP is limited. The purpose of this case report is to describe the implementation of preoperative and postoperative physical therapist services for men undergoing RP in a US health care system using the knowledge-to-action process and the Consolidated Framework for Implementation Research frameworks.

CASE DESCRIPTION

The implementation process included 4 steps: (1) development of a preoperative and postoperative physical therapist services program; (2) identification of barriers and enablers for implementation; (3) implementation of the program; and (4) evaluation of the effectiveness of the implemented program.

RESULTS

Outcomes from the implementation of a physical therapist services program for men undergoing RP included lower urinary incontinence rates, improved patient satisfaction, and increased physical therapist utilization.

CONCLUSION

This case report documents the implementation of physical therapist services for men undergoing RP. The use of implementation frameworks enabled the identification of unique enablers, barriers, and strategies for the implementation of physical therapist services for men undergoing RP.

IMPACT

Implementing preoperative and postoperative physical therapist services for men undergoing RP improves patient outcomes. The implementation process and outcomes can be considered by other health care systems when developing preoperative and postoperative physical therapist services for men undergoing RP.

Predictors and outcomes of same day discharge after minimally invasive hysterectomy in gynecologic oncology within the National Surgical Quality Improvement Program database

OBJECTIVE

To assess trends over time of same day discharge after minimally invasive hysterectomy in oncology, identify perioperative factors influencing same day discharge, and evaluate 30 day postoperative morbidity.

METHODS

A retrospective cohort of elective minimally invasive hysterectomies performed for gynecologic oncologic indications between January 2013 and December 2021 was identified using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Clinical and surgical characteristics, length of stay, and 30 day postoperative complications were captured. Clinical and surgical factors affecting same day discharge rate and impact of same day discharge on postoperative outcomes were evaluated using χ2 tests and logistic regression.

RESULTS

Patients undergoing minimally invasive hysterectomy (n=32 823) had a same day discharge rate of 34.5% over the 9 year period, increasing from 15.5% in 2013 to 55.1% in 2021. The rate of patients discharged on postoperative day 1 decreased from 76.4% to 41.4% over this period. On multivariable analysis, same day discharge decreased with: age 70-79 years (odds ratio (OR) 0.80) and ≥80 years (OR 0.42); body mass index 40-49.9 kg/m2 (OR 0.89) and ≥50 kg/m2 (OR 0.67); patient comorbidities, including hypertension (OR 0.85), chronic steroid use (OR 0.74), bleeding disorder (OR 0.54), anemia (OR 0.89), and hypoalbuminemia (OR 0.76); and surgical time >90th percentile (OR 0.40) (all p<0.05). Lymphadenectomy did not impact the same day discharge rate (unadjusted OR 1.03, p=0.22). Same day discharge had no effect on 30 day postoperative composite morbidity (OR 0.91, p=0.20), and was associated with fewer readmissions (OR 0.75, p=0.005). Age 70-79 years (OR 1.07, p=0.435) and age ≥80 years (OR 1.11, p=0.504) did not increase postoperative morbidity. However, body mass index categories 40-49.9 kg/m2 (OR 1.28, 95% CI 1.08 to 1.51) and ≥50 kg/m2 (OR 1.60, 95% CI 1.27 to 2.01) were associated with greater 30 day composite morbidity.

CONCLUSION

In this study, same day discharge following minimally invasive hysterectomy for oncologic indications was safe, and rates are rising among all age and body mass index categories. Quality improvement initiatives are needed at oncology centers to promote early discharge after minimally invasive gynecologic oncology surgery.

Single-shot liposomal bupivacaine in place of rectus sheath catheters to provide non-opiate analgesia after laparotomy: a quality improvement project to reduce the need for ongoing nursing input

Opioid-sparing pain management is an integral component of enhanced recovery after colonic and rectal surgery. In our hospital, rectus sheath catheters (RSCs) are routinely placed during emergency laparotomy for colorectal procedures to allow a postoperative compartmental block of the surgical site with repeated doses of bupivacaine. However, RSCs require a significant amount of clinical nursing time to maintain and 'top-up'. We present a quality improvement project in which we administered single-shot liposomal bupivacaine (LB) intraoperatively as an alternative to bolus doses of conventional bupivacaine delivered through RSCs. Having thereby reduced the demands placed on nursing time through a reduction in the use of RSCs, we sought to establish whether there was any associated change in analgesic efficacy. Patient pain scores, use of patient-controlled analgesia (PCA) and length of stay following surgery were analysed before and after the introduction of LB. No disruption in these outcomes was identified using statistical process control analysis. A direct comparison of results for patients who received LB versus those who received bolus dosing of bupivacaine via RSCs found no significant differences, with a median total PCA dose of 270 mg oral morphine equivalents (OME) for patients who received LB versus 396 mg OME for patients who had RSCs (p=0.54). The median length of stay for patients who received LB was 15.5 days versus 16 days for those who had RSCs (p=0.87). We conclude that LB represents a viable alternative to boluses of conventional bupivacaine via RSCs in promoting enhanced recovery after emergency laparotomy and look to extend its use locally.

What factors affect early mobilisation following hip fracture surgery: a scoping review

OBJECTIVES

Identify and evaluate factors affecting early mobilisation on the day following hip fracture surgery.

DESIGN

Mixed methods, scoping review.

DATA SOURCES

MEDLINE, AMED, CINAHL, APA PsycINFO, APA PsycArticles, ISRCTN, Clinical Trials registry and grey literature accessed in November 2022 with publication dates between 2001 and November 2022.

ELIGIBILITY CRITERIA

English language publications that:1. Include patient populations who sustain a fragility hip fracture managed surgically2. Include patient populations who are mobilised out of bed on the day following their hip fracture surgery3. Report factors which influence the ability to undergo early mobility postsurgery DATA EXTRACTION AND SYNTHESIS: One reviewer screened all titles and abstracts for inclusion. Two reviewers performed data extraction and quality assessments using the relevant Critical Appraisal Skills Programme tools and the Mixed Methods Appraisal Tool.

RESULTS

3337 papers were identified, of which 23 studies were eligible for review, representing 210 811 patients. The heterogeneity in the types of study included, the definition of early mobilisation and the outcome measures used precluded meta-analysis. 13 factors were identified as having an effect on whether people were mobilised on day 1 post-hip fracture surgery, grouped into 5 principal themes: (1) healthcare setting or worker-related factors, (2) patient psychological factors, (3) acute patient health factors, (4) non-acute patient health factors and (5) surgical factors.

CONCLUSIONS

There was a paucity of robust research investigating day 1 mobilisation post-hip fracture surgery.Each of the five factors identified is potentially modifiable through service improvement change and innovation strategies. There is an opportunity to explore how service provision change could be implemented to improve outcomes for all patients following hip fracture surgery demonstrating the clinical and cost benefits of these changes against the cost of delivering the change.

Successful implementation of a quality improvement bundle to reduce opioid overprescribing following total hip and knee arthroplasty

BACKGROUND

Opioid overprescribing is commonplace after total hip (THA) and total knee arthroplasty (TKA). Preliminary data demonstrated that approximately 32% of the opioids prescribed at discharge from our hospital following THA and TKA remain unused. This is a concern given that unused prescribed opioids are available for diversion and may result in misuse and abuse.

METHODS

Pre-intervention data were collected between 1 November 2018 and 10 December 2018. An intervention bundle was then introduced, including education of patients and providers, a standardised pain management algorithm and an autopopulated discharge prescription. The aim of this quality improvement initiative was to reduce the amount of opioid (average oral morphine equivalents (OME)) dispensed (based on the discharge prescription provided) following THA and TKA at our institution by 15% by 1 April 2019.

DESIGN

Using an interrupted time series design, the outcome measure was the amount of opioid (OME) dispensed from the discharge prescription provided. Process measures included the percentage of autopopulated discharge prescriptions, the percentage of patients receiving education at discharge and the percentage of nurses and residents receiving standardised education. Balancing measures included patient satisfaction with postoperative pain management, and the percentage of patients filling the second half of the part-fill or requiring a subsequent opioid prescription.

RESULTS

With 600 patients identified, mean OME dispensed at discharge was reduced by 26.3% (from 522.2 to 384.9 mg) after our interventions started. Utilisation of autopopulated part-fill prescriptions was 95.8%. There was no change in patient satisfaction nor in the proportion of patients requiring an additional opioid prescription post-intervention. Only 39% of patients filled the second half of the part-fill prescription post-intervention.

CONCLUSIONS

Mean OME dispensed at discharge per patient was reduced with no change in patient satisfaction after introduction of the intervention bundle.

Suffering in silence - Cardiac surgery patients recalling hypoactive delirium a qualitative descriptive study

OBJECTIVES

Postoperative delirium affects up to 50% of patients undergoing cardiac surgery. Delirium phenotypes are commonly divided into hyperactive and hypoactive, with hypoactive symptoms (reduced motor activity and withdrawal) often being overlooked due to their discreet character. Although the consequences of hypoactive delirium are severe, studies focusing on patients' experiences of hypoactive delirium are scarce. The aim of the study was to describe cardiac surgery patients' experiences of hypoactive delirium.

RESEARCH METHODOLOGY/DESIGN

We used qualitative descriptive semi-structured interviews with an inductive, latent approach. Twelve patients with hypoactive symptoms of delirium after cardiac surgery were purposefully selected. Interview data were analysed by qualitative content analysis.

FINDINGS

Two themes based on eight sub-themes emerged. "Dream or reality in parallel worlds" included disturbing experiences of existing in parallel realities with cognitive effects, residual nightmares, and illusions that occasionally persisted after hospital discharge. "Managing the state of hypoactive delirium" included experiences of intellectually dealing with hypoactive delirium with assumptions of causes and cures, and through interactions like communicating with others.

CONCLUSION

Participants experienced hypoactive delirium as extensive and long-lasting with perceptions of existing in parallel realities. The findings emphasize the need for healthcare professionals to have expertise in hypoactive delirium and its fluctuating course, as the delirium of many patients may be undetected and undiagnosed. Improving the use of screening tools for clinical practice is essential for the detection of hypoactive delirium, and a person-centred approach is needed to properly care for this group of patients.

IMPLICATIONS FOR CLINICAL PRACTICE

The challenges in the recognition of hypoactive delirium need to be emphasized because the syndrome is still overlooked. The use of screening tools in clinical practice is essential. A person-centred approach supports relationships between delirious patients and healthcare professionals.

Prospective evaluation of an enhanced recovery after surgery (ERAS) pathway in a Norwegian cohort of patients with suspected or advanced ovarian cancer

OBJECTIVE

This prospective cohort study evaluated the introduction of an enhanced recovery after surgery (ERAS) pathway in a tertiary gynecologic oncology referral center. Compliance and clinical outcomes were studied in two separate surgical cohorts.

METHODS

Patients undergoing laparotomy for suspected or verified advanced ovarian cancer at Oslo University Hospital were prospectively included in a pre- and post-implementation cohort. A priori, patients were stratified into: cohort 1, patients planned for surgery of advanced disease; and cohort 2, patients undergoing surgery for suspicious pelvic tumor. Baseline characteristics, adherence to the pathway, and clinical outcomes were assessed.

RESULTS

Of the 439 included patients, 235 (54%) underwent surgery for advanced ovarian cancer in cohort 1 and 204 (46%) in cohort 2. In cohort 1, 53% of the patients underwent surgery with an intermediate/high Aletti complexity score. Post-ERAS, median fasting times for solids (13.1 hours post-ERAS vs 16.0 hours pre-ERAS, p<0.001) and fluids (3.7 hours post-ERAS vs 11.0 hours pre-ERAS, p<0.001) were significantly reduced. Peri-operative fluid management varied less and was reduced from median 15.8 mL/kg/hour (IQR 10.8-22.5) to 11.5 mL/kg/hour (IQR 9.0-15.4) (p<0.001). In cohort 2 only there was a statistically significant reduction in length of stay (mean (SD) 4.3±1.5 post-ERAS vs 4.6±1.2 pre-ERAS, p=0.026). Despite stable readmission rates, there were significantly more serious complications reported in cohort 1 post-ERAS.

CONCLUSIONS

ERAS increased adherence to current standards in peri-operative management with significant reduction in fasting times for both solids and fluids, and peri-operative fluid administration. Length of stay was reduced in patients with suspicious pelvic tumor. Despite serious complications being common in patients with advanced disease undergoing debulking surgery, a causal relationship with the ERAS protocol could not be established. Implementing ERAS and continuous performance auditing are crucial to advancing peri-operative care of patients with ovarian cancer.

Coronary Artery Bypass Grafting: A Comparative Exercise between Patients from the BYPASS Registry and Patients from a University Hospital

INTRODUCTION

The coronary artery bypass grafting (CABG) data provided by the Brazilian Registry of Cardiovascular Surgeries in Adults (BYPASS) Registry is a Brazilian reality.

OBJECTIVE

To carry out a comparative exercise between the BYPASS Registry published data and data from patients operated on in a randomly chosen period (2013-2015) at Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (HCFMRP-USP).

METHODS

This is a retrospective study reviewing 173 electronic medical records of CABG patients from the HCFMRP-USP. These data were compared with the BYPASS Registry published data. Chi-square test was used to verify the changes within the prevalence of adequate/inadequate biochemical tests before and after surgery. The sample was divided into groups consistent with cardiopulmonary bypass (CPB) time (CPB ≤ 120 minutes and CPB > 120 minutes). For the complications, prevalence by the chi-square test was adopted. Significant P-values are < 0.05.

RESULTS

The comparative operative data of the BYPASS Registry and the HCFMRP-USP patients were quite similar, except for the isolate use of only arterial grafts, which was more frequent on HCFMRP-USP patients (30.8% vs. 15.9%), and the use of radial artery, also more frequent on HCFMRP-USP patients (48.8% vs. 1.1%).

CONCLUSION

The comparative study suggested that the BYPASS Registry should be a reference for CABG quality control.

Can Posterior Pericardial Incision Truly Improve Postoperative Complications After Cardiac Surgery? A Systematic Review and Meta-Analysis

INTRODUCTION

Postoperative atrial fibrillation (POAF) and pericardial effusion are important factors affecting prognosis after cardiac surgery. Recently, it has been reported that posterior pericardiotomy (PP) can effectively prevent the occurrence of POAF and pericardial effusion. To validate these conclusions and guide clinical practice, we conducted a systematic review with meta-analysis.

METHODS

We searched multiple databases for manuscripts published before July 2022 on the use of PP to prevent POAF and pericardial effusion and included only randomized controlled trials. The main outcome was atrial fibrillation after coronary artery bypass grafting, and secondary outcomes were included.

RESULTS

This meta-analysis included 14 randomized controlled trials with a total of 2275 patients. Meta-analysis showed that the incidence of POAF after cardiac surgery in the PP group was significantly lower than that in the control group (risk ratio=0.48; 95% confidence interval=0.33~0.69; P<0.00001). PP effectively reduced postoperative pericardial effusion (risk ratio=0.34, 95% confidence interval=0.21-0.55; P<0.00001).

CONCLUSION

PP has shown good results in preventing POAF, pericardial effusion, and other complications, which indicates that PP is a safe and effective surgical method, but attention still needs to be paid to the potential risk of coagulation dysfunction caused by PP.

Use of peripheral blood eosinophils to guide post-operative glucocorticoid therapy in patients with chronic rhinosinusitis with nasal polyps: a randomised, controlled trial

OBJECTIVE

This study aimed to explore the utility of the eosinophil percentage in peripheral blood for guiding post-operative glucocorticoid therapy in patients with chronic rhinosinusitis with nasal polyps.

METHODS

Forty-four patients with chronic rhinosinusitis with nasal polyps underwent functional endoscopic sinus surgery and were randomly divided into two groups. Patients in the standard treatment group used oral and nasal spray glucocorticoids. In the biomarker treatment group, patients with peripheral blood eosinophil percentage values less than 3.05 per cent did not receive glucocorticoid treatment, whereas patients with values 3.05 per cent or above were part of the standard treatment group. Visual Analogue Scale, Sino-Nasal Outcome Test-22 scores, endoscopic Lund-Kennedy scores, eosinophils, interleukin-5 and eosinophil cationic protein in peripheral blood, and nasal secretions were measured.

RESULTS

After functional endoscopic sinus surgery, the Visual Analogue Scale, Sino-Nasal Outcome Test-22 and Lund-Kennedy scores were significantly reduced in both groups; there were no significant differences in those indicators between the groups during the three follow-up visits.

CONCLUSION

Peripheral blood eosinophil percentage offers a potential biomarker to guide post-operative glucocorticoid therapy in patients with chronic rhinosinusitis with nasal polyps.

The Role of Hypnotherapy in Postoperative Cardiac Surgical Patients, A Scoping Review of Current Literature

OBJECTIVE

Hypnotherapy has been proposed as an emerging tool that can be implemented in management of different aspects of postoperative cardiac surgical care. This technique involves hypnotic induction to redirect focus and attention away from post-surgical pain. Emerging literature has shown that hypnosis significantly improves emotional distress immediately preceding surgical procedures and these effects have been demonstrated to extend into the postoperative period. The purpose of this scoping review is to summarize current literature on the role of hypnotherapy in the management of perioperative pain, anxiety, and depression in patients undergoing cardiac surgery.

METHODS

A database search was conducted using PubMed, Embase, and Google Scholar. We included all comparative studies (randomized and non-randomized) that examined the effect of hypnotherapy on pain, anxiety, and depression in patients undergoing cardiac surgery. Included articles were restricted to adult patients and English language only.

RESULTS

Literature search yielded a total of 64 articles, of which, 14 duplicates were removed. After title and abstract screening, only 18 articles were included for full-text review. Six studies (with a total number of 420 patients) were included in the final analysis. Of these, five were randomized control trials and one was a cohort study.

CONCLUSION

Our findings suggest that there may be a potential role for the use of hypnotherapy in the management of pain, anxiety, and depressive symptoms in the perioperative period of cardiac surgery. However, more robust evidence is required to justify its incorporation in the routine perioperative management pathways in this group of patients.

Enhanced Recovery after Total Joint Arthroplasty (TJA): A Contemporary Systematic Review of Clinical Outcomes and Usage of Key Elements

BACKGROUND

Enhanced recovery after surgery (ERAS) is a pathway designed to improve the care of surgical patients and achieve early recovery. The clinical outcomes and usage of key elements of ERAS pathways in total joint arthroplasty (TJA) need further reanalysis. This article aims to provide an overview of the latest clinical outcomes and current usage of key elements of ERAS pathways in TJA.

METHODS

We undertook a systematic review of the PubMed, OVID, and EMBASE databases in February 2022. Studies investigating the clinical outcomes and usage of key elements of ERAS in TJA were included. The components of successful ERAS programs and their usage were further determined and discussed.

RESULTS

Twenty-four studies involving 216,708 patients assessed ERAS pathways for TJA. A total of 95.8% (23/24) of studies reported a reduced length of stay (LOS), followed by reduce overall opioid consumption or pain (87.5% [7/8]), save costs (85.7% [6/7]), improvements in patient-reported outcomes or functional recovery (60% [6/10]), and reduced incidence of complications (50% [5/10]). In addition, preoperative patient education (79.2% [19/24]), anesthetic protocol (54.2% [13/24]), use of local anesthetics for infiltration analgesia or nerve blocks (79.2% [19/24]), perioperative oral analgesia (66.7% [16/24]), perioperative surgical factors including reduced use of tourniquets and drains (41.7% [10/24]), use of tranexamic acid (41.7% [10/24]) and early mobilization (100% [24/24]) were contemporary comparatively "active" components of ERAS.

CONCLUSIONS

ERAS for TJA has favorable clinical outcomes in terms of reducing LOS and overall pain, saving costs, accelerating functional recovery, and reducing complications, although the evidence is still low in quality. In the current clinical scenario, only some "active" components of the ERAS program are widely used.

POSTOPED: improving surveillance of postoperative delirium in a Scottish tertiary hospital

Delirium is the most common postoperative complication among patients over the age of 65 years. It is associated with increased morbidity and is a significant financial cost to healthcare systems.We aimed to improve the detection of delirium on the surgical wards of a tertiary surgical centre. This would take the form of completion of 4AT assessments (the 4 AT test for delirium, on admission and 1 day postoperatively). Prior to this project, the 4AT was in use in the surgical admission clerking paperwork for over 65 s, however, 4AT assessments were not routinely performed as part of day 1 postoperative assessment. By introducing routine postoperative assessment and reinforcing the importance of admission assessment, we hoped to allow for objective comparisons to be made about patients cognitive state and thereafter improve delirium identification.After a baseline snapshot data collection period, we conducted five (Plan, Do, Study, Act) cycles following which repeat snapshot data were collected. Improvement strategies included 'tea-trolley' teaching sessions, adhesive 4AT pro-forma, targeted accompaniment of specialty ward rounds with reminders to complete 4AT assessments and working with nursing staff to promote awareness of delirium among permanent non-rotating healthcare professionals.For the admission 4ATs, completion improved from a baseline of 74.1%-90.5% in cycle 5. Completion of postoperative 4AT assessments rose from 14.8% at baseline to 47.6% in cycle 5.We were able to improve the use of a delirium screening tool, (the 4AT) among the postoperative elderly population in this centre via the use of regular teaching sessions, targeted interventions on ward rounds as well working with non-rotating staff. Further improvements could be made by widening access to delirium champion programmes and including delirium as an outcome measure of national surgical audits such as the National Emergency Laparotomy Audit.

Multicentre positive deviance to reduce adverse events and length of stay after pulmonary resection

BACKGROUND

Postoperative adverse events (AEs) following pulmonary resection enormously impact patient well-being, length of stay (LOS) and healthcare costs. Standardised AE data collection can be used to identify positive outliers demonstrating positive deviance (PD) who may be helpful to inform the best practice. Here, we describe our initial experience of a novel quality improvement process using PD to reduce LOS and AEs.

METHODS

AE rates and LOS were collected from four centres (2014-2020) using a common dictionary. Surgeons repeatedly participated in 60 to 90 min seminars consisting of the following process: identify outcome and procedure targeted, review relevant best evidence literature, view all data anonymised by surgeon or centre (if multicentre), choose and reveal identity of best performance PD outliers, who discuss their management principles while all receive self-evaluation reports, followed by collegial discussion to generate consensus recommendations, voted by all. We assessed overall impact on AEs and LOS using aggregate data in a before/after analysis.

RESULTS

A total of 131 surgeons (average 12/seminar) participated in 11 PD seminars (8 local and 3 multicentre), yielding 85 consensus recommendation (average 8/seminar). Median LOS following lobectomy decreased from 4.0 to 3.0 days (p=0.04) following local PD seminars and from 4.0 to 3.5 days (p=0.11) following multicentre seminars. Trends for reductions in multiple AE rates were also observed.

CONCLUSION

While limited by the longitudinal design, these findings provide preliminary support for this data-driven, collegial and actionable quality improvement process to help standardise and improve patient care, and merits further more rigorous investigation.

Patient outcomes and adherence to an enhanced recovery pathway for open gynecologic surgery: a 6-year single-center experience

OBJECTIVES

To evaluate compliance with an Enhanced Recovery After Surgery (ERAS) protocol for open gynecologic surgery at a tertiary center and the relationship between levels of compliance and peri-operative outcomes.

METHODS

This retrospective cohort study was conducted between November 2014 and December 2020. Two groups were defined based on compliance level (<80% vs ≥80%). The primary outcome was to analyze overall compliance since implementation of the ERAS protocol. The secondary endpoint was to assess the relationship between compliance and 30-day re-admission, length of stay, re-operation, opioid-free rates, and post-operative complications. We also assessed compliance with each ERAS element over three time periods (P1: 2014-2016, P2: 2017-2018, P3: 2019-2020), categorizing patients according to the date of surgery. Values were compared between P1 and P3.

RESULTS

A total of 1879 patients were included. Overall compliance over the period of 6 years was 74% (95% CI 71.9% to 78.2%). Mean overall compliance increased from 69.7% to 75.8% between P1 and P3. Compliance with ERAS ≥80% was associated with lower Clavien-Dindo complication rates (grades III (OR 0.55; 95% CI 0.33 to 0.93) and V (OR 0.08, 95% CI 0.01 to 0.60)), 30-day re-admission rates (OR 0.61; 95% CI 0.43 to 0.88), and length of stay (OR 0.59; 95% CI 0.47 to 0.75). No difference in opioid consumption was seen. Pre-operatively, there was increased adherence to counseling by 50% (p=0.01), optimization by 21% (p=0.02), and carbohydrate loading by 74% (p=0.02). Intra-operatively, compliance with use of short-acting anesthetics increased by 37% (p=0.01) and avoidance of abdominal drainage increased by 7% (p=0.04). Use of goal-directed fluid therapy decreased by 16% (p=0.04). Post-operatively, there was increased compliance with avoiding salt and water overload (8%, p=0.02) and multimodal analgesia (5%, p=0.02).

CONCLUSIONS

Over the time period of the study, overall compliance increased from 69.7% to 75.8%. Compliance (≥80%) with ERAS is associated with lower complication rates, fewer 30-day re-admissions, and shorter length of stay without impacting re-operation rates and post-operative opioid use.

Patient-Centered Goals After Lumbar Spine Surgery: A Secondary Analysis of Cognitive-Behavioral-Based Physical Therapy Outcomes From a Randomized Controlled Trial

OBJECTIVE

The purpose of this study was to examine the association between goal attainment and patient-reported outcomes in patients who engaged in a 6-session, telephone-based, cognitive-behavioral-based physical therapy (CBPT) intervention after spine surgery.

METHODS

In this secondary analysis of a randomized trial, data from 112 participants (mean age = 63.3 [SD = 11.2] years; 57 [51%] women) who attended at least 2 CBPT sessions (median = 6 [range = 2-6]) were examined. At each session, participants set weekly goals and used goal attainment scaling (GAS) to report goal attainment from the previous session. The number and type of goals and percentage of goals met were tracked. An individual GAS t score was computed across sessions. Participants were categorized based on goals met as expected (GAS t score ≥ 50) or goals not met as expected (GAS t score < 50). Six- and 12-month outcomes included disability (Oswestry Disability Index), physical and mental health (12-Item Short-Form Health Survey), physical function (Patient-Reported Outcomes Measurement Information System), pain interference (Patient-Reported Outcomes Measurement Information System), and back and leg pain intensity (numeric rating scale). Outcome differences over time between groups were examined with mixed-effects regression.

RESULTS

Participants set a median of 3 goals (range = 1-6) at each session. The most common goal categories were recreational/physical activity (36%), adopting a CBPT strategy (28%), exercising (11%), and performing activities of daily living (11%). Forty-eight participants (43%) met their goals as expected. Participants who met their goals as expected had greater physical function improvement at 6 months (estimate = 3.7; 95% CI = 1.0 to 6.5) and 12 months (estimate = 2.8; 95% CI = 0.04 to 5.6). No other outcome differences were noted.

CONCLUSIONS

Goal attainment within a CBPT program was associated with 6- and 12-month improvements in postoperative physical functioning.

IMPACT

This study highlights goal attainment as an important rehabilitation component related to physical function recovery after spine surgery.

Impact of timing of urinary catheter removal on voiding dysfunction after radical hysterectomy for early cervical cancer

OBJECTIVES

To evaluate whether the timing of postoperative urinary catheter removal is associated with voiding dysfunction after radical hysterectomy for early cervical cancer within contemporary surgical practice.

METHODS

We performed an institutional retrospective cohort study of patients who underwent Piver type II-III open or minimally invasive radical hysterectomy for early-stage cervical cancer (International Federation of Gynecology and Obstetrics (FIGO) 2009 stage IA1 with lymphovascular invasion to stage IIA) between January 2006 and December 2019. We compared voiding dysfunction (inability to spontaneously void with a post-void residual <100 mL after catheter removal) and outcomes based on postoperative timing of urinary catheter removal using univariate and multivariate logistic regressions.

RESULTS

Among 234 patients, 86 (36.8%) underwent open surgery and 112 (47.9%) used enhanced recovery after surgery (ERAS) pathways. 29 (12.4%) patients had urinary catheter removal between 1-5 days postoperatively (group 1), 141 (60.3%) between 6-10 days (group 2), and 64 (27.3%) between 11-15 days (group 3). The overall rate of voiding dysfunction was 11.5%, with no difference between group 1 (17.2%), group 2 (11.3%), and group 3 (9.4%) (p=0.54). Group 1 had a significantly shorter time from surgery to spontaneous voiding (4 days, IQR 3-5 days) compared with group 2 (8 days, IQR 7-10 days) and group 3 (13 days, IQR 11-15 days) (p<0.01). There was no difference in hospital length of stay, urinary tract infection, or re-admission due to a genitourinary complication within 60 days of surgery based on timing of catheter removal. On multivariate analysis, the odds of voiding dysfunction did not differ by tumor size, type of hysterectomy, cancer stage, surgical approach, ERAS timeframe, or timing of catheter removal group.

CONCLUSION

There was no difference in voiding dysfunction or postoperative genitourinary complications based on timing of urinary catheter removal after radical hysterectomy. Early catheter removal should be considered in this population.

Quality is more important than quantity: pre-operative sarcopenia is associated with poor survival in advanced ovarian cancer

BACKGROUND

Sarcopenia is prevalent among older patients with cancer and is associated with poor outcomes.

OBJECTIVE

To explore the relationship between muscle mass, quality, and patient age with overall survival after surgery for advanced ovarian cancer.

METHODS

Patients with advanced stage (IIIC/IV) ovarian cancer who underwent primary cytoreductive surgery between January 2006 and July 2016 were included. Body composition measures were calculated from pre-operative CT imaging: skeletal muscle index (skeletal muscle index=skeletal muscle area normalized for height), skeletal muscle density, and skeletal muscle gauge (product of skeletal muscle index and skeletal muscle density). Each measure was transformed to a z-score and evaluated for association with risk of death using Cox proportional hazards models. Recursive partitioning was used to classify patients into homogeneous subgroups considering age and skeletal muscle gauge as predictors of overall survival.

RESULTS

The study included 429 patients (mean age 64.2 years). Increased age moderately correlated with decreased skeletal muscle gauge (r=-0.45). Decreasing skeletal muscle density and skeletal muscle gauge were significantly associated with increased risk of death; HR (95% CI) per 1-unit decrease in z-score of 1.24 (1.10 to 1.39) for skeletal muscle density and 1.27 (1.12 to 1.44) for skeletal muscle gauge. Associations were diluted after adjusting for age (1.13 (1.00 to 1.29) skeletal muscle density and 1.14 (0.99 to 1.30) skeletal muscle gauge). Recursive partitioning identified three subgroups: <60 years old, ≥60 years old with skeletal muscle gauge ≥937.3, and ≥60 years old with skeletal muscle gauge <937.3; median overall survival was 5.8, 3.3, and 2.3 years, respectively (p<0.001).

CONCLUSIONS

Skeletal muscle gauge, a novel sarcopenia measure incorporating quantity and quality, was associated with poorer survival in patients with advanced ovarian cancer, particularly among patients older than 60. Expanding our knowledge of how sarcopenia relates to solid tumor outcomes among high-risk patients can modify our treatment approach.

Clinician attitude towards sexual counseling in women with gynecologic malignancies: European Network of Young Gynaecological Oncologists (ENYGO) survey

OBJECTIVE

Both the location of primary disease and treatment side effects may have an impact on sexual function in oncogynecological patients. The aim of this study was to examine the prevalence, strategies, difficulties, and ideas for improvement in sexual counseling among specialists managing patients with gynecologic malignancies.

METHODS

This was a cross-sectional survey study performed among healthcare professionals treating patients with gynecologic malignancies. A self-prepared questionnaire included 61 questions concerning general demographic information and different aspects of sexual counseling in the gynecologic oncology practice. Analysis included attitudes, behaviors, management strategies, difficulties, and ideas for possible systemic improvements. Statistical analysis involved descriptive statistics, two-sided chi-square test, and Fisher's exact test.

RESULTS

A total of 150 respondents from 46 countries answered the survey. The majority of survey participants stated that sexual counseling of oncological patients is very important (n=73, 49%) or important (n=46, 31%). One hundred and two (68%) respondents agreed that sexual counseling of gynecologic oncology patients should be routinely provided by the specialist managing the primary disease. However, collecting information concerning sexual function is performed often or always by only 21% of respondents and 19% discuss the topic rarely or never. The most frequently indicated barriers leading to difficulties in sexual counseling include lack of time (74%), lack of specialist knowledge (55%), and patient embarrassment (48%). One hundred and seven (71%) respondents expressed interest in participating in sexual counseling workshops organized by the European Society of Gynaecological Oncology (ESGO)/European Network of Young Gynaecological Oncologists (ENYGO), 74 (49%) would like to access webinars on the topic, and 120 (80%) would be interested in materials in the ESGO online educational resources.

CONCLUSION

One of the proposed solutions to insufficient access to sexual care for women with gynecologic malignancies is providing access to specialist educational programs for both patients and healthcare specialists.

[The place for nutrition rehabiliation in bariatric surgery pathway]

THE PLACE FOR NUTRITION REHABILIATION IN BARIATRIC SURGERY pathwaythe place for nutrition rehabilitation in bariatric surgery is well identified and complements the multi-professional support of the patient suffering from obesity either before, during or after the surgery. Mainly through therapeutic education the patient becomes an actor in his health and participates in improving his health by modifying his behavior concerning food, physical activity and if necessary in conjunction with the psychologist.

Mobilization Started Within 2 Hours After Abdominal Surgery Improves Peripheral and Arterial Oxygenation: A Single-Center Randomized Controlled Trial

OBJECTIVE

The aim of this study was to investigate if mobilization out of bed, within 2 hours after abdominal surgery, improved participants' respiratory function and whether breathing exercises had an additional positive effect.

METHODS

Participants were 214 consecutively recruited patients who underwent elective open or robot-assisted laparoscopic gynecological, urological, or endocrinological abdominal surgery with an anesthetic duration of >2 hours. They were recruited to a randomized controlled trial. Immediately after surgery, patients were randomly assigned to 1 of 3 groups: mobilization (to sit in a chair) and standardized breathing exercises (n = 73), mobilization (to sit in a chair) only (n = 76), or control (n = 65). The interventions started within 2 hours after arrival at the postoperative recovery unit and continued for a maximum of 6 hours. The primary outcomes were differences in peripheral oxygen saturation (SpO2, as a percentage) and arterial oxygen pressure (PaO2, measured in kilopascals) between the groups. Secondary outcomes were arterial carbon dioxide pressure, spirometry, respiratory insufficiency, pneumonia, and length of stay.

RESULTS

Based on intention-to-treat analysis (n = 214), patients who received mobilization and breathing exercises had significantly improved SpO2 (mean difference [MD] = 2.5%; 95% CI = 0.4 to 4.6) and PaO2 (MD = 1.40 kPa; 95% CI = 0.64 to 2.17) compared with the controls. For mobilization only, there was an increase in PaO2 (MD = 0.97 kPa; 95% CI = 0.20 to 1.74) compared with the controls. In the per-protocol analysis (n = 201), there were significant improvements in SpO2 and PaO2 for both groups receiving mobilization compared with the controls. Secondary outcome measures did not differ between groups.

CONCLUSION

Mobilization out of bed, with or without breathing exercises, within 2 hours after elective abdominal surgery improved SpO2 and PaO2.

IMPACT

The respiratory effect of mobilization (out of bed) immediately after surgery has not been thoroughly evaluated in the literature. This study shows that mobilization out of bed following elective abdominal surgery can improve SpO2 and PaO2.

LAY SUMMARY

Mobilization within 2 hours after elective abdominal surgery, with or without breathing exercises, can improve patients' respiratory function.

Regional analgesia modalities in abdominal and lower limb surgery - comparison of efficacy

A significant component of all surgical procedures and postoperative treatment is pain management.Due to the physiological and psychological advantages of pain relief, it is one of the foremost indicators of quality of care. Today, there are various modalities of pain reduction, aimed to reduce patient discomfort andminimize side effects, which can be divided by therapeutic agents used (opioid or non-opioid), route of administration (intravenous, regional, oral, etc.) and modality (controlled by patients or "as needed"). Although opioids have proven to be very effective pain relief agents and are commonly used in postoperative analgesia, concerns about their side effects have spurred the development of modified, multimodal treatments that seek to minimize opioid use and associated drawbacks. Enhanced recovery protocols that emphasize sparing administration of opioids are growing in importance, andresulting in reduced length of hospital stay after abdominal and lower limb surgery. To further improve such protocols and optimize postoperative care for individual patient needs, it is imperative to fully assess the efficacy of available drugs and analgesia modalities.

Baseline risk of recurrence in stage I-II endometrial carcinoma

Objective

Though there are no evidences that postoperative therapy improves overall survival (OS) in stage I–II endometrial carcinoma, many women receive postoperative radiation or chemotherapy. This study aimed to investigate the baseline risk of recurrence after complete resection without any adjuvant therapies and to suppose the validity of postoperative therapy for stage I–II endometrial carcinoma.

Methods

Charts for patients with stage I–II endometrial carcinoma who underwent operation without postoperative therapy between January 2005 and December 2011 were retrospectively reviewed and the baseline risk of recurrence and prognosis were assessed. Risk classifications were performed according to European Society for Medical Oncology (ESMO) clinical practice guidelines and Japanese guideline written by Japan Society of Gynecologic Oncology Group.

Results

Among 374 patients who underwent complete resection, 311 were evaluable. Five-year recurrence rates by ESMO and Japanese were 2.6% and 3.1% in low-risk, 9.2% and 6.6% in intermediate-risk and 13.5% and 13.8% in high-risk group (p=0.003 and 0.015, respectively). High-risk group had worse OS compared with low- and intermediate-risk groups (5-year OS, low: 97.9% and 97.6%, intermediate: 97.9% and 98.8%, and high: 89.5% and 87.5%; p=0.003 and 0.008, respectively). Independent predictive factors of recurrence were age over 60 years, type 2 (estrogen-independent) and peritoneal cytology.

Conclusion

ESMO and Japanese risk classification similarly stratify the baseline risk of recurrence. Patients with stage I–II endometrial carcinoma, especially low- and intermediate-risk diseases, have low recurrence rate and favorable OS, and the benefit of postoperative therapy might be small.

Care Pathway for Cancer Survivorship in Korea: Trend of Breast Cancer Pathway from 2003 to 2010

Objectives

The survival rate of cancer patients has exceeded 60%. Although cancer survivors may die of other diseases except cancer, the health management system including chronic disease prevention-management for cancer survivors, has not been established in the diverse aspects. Therefore, services according to care pathway of cancer patients need to be provided through a support system based on a platform concept that can be used to meet patient needs in various ways.

Methods

A sample cohort database (2002–2010) of approximately 1 million persons—2% of the whole nation (50 million)—was used to estimate cancer survivors through a principal care pathway for cancer management. The sample cohort database was built to estimate the number of breast cancer survivors in the five stage: ‘Diagnosis and treatment,’ ‘Supportive care,’ ‘Monitoring,’ ‘Progress illness,’ and ‘Hospice care’. In this way, the scale of breast cancer survivors was estimated.

Results

There were 330 (9.8%) cases of the incidence of cancer in 2010 in the ‘Diagnosis and treatment.’ Among the cases of the incidence of cancer in the previous year, the number of one-year survivors was 328 (9.7%); these were included in the category ‘Supportive care.’ In the ‘Monitoring’ category, 2,593 (76.9%) who maintained health lives were included. A total of 84 (2.5%) survivors were checked to identify an ongoing disease; these were included in the category ‘Progress illness.’ In the category ‘Hospice care,’ 36 (1.1%) end-stage cancer patients requiring hospice care were included.

Conclusions

We established a care pathway by survival stage in order to fulfill prevention and health management services post-treatment management steps.

Quality of Life after post-prostatectomy intensity modulated radiation therapy to the prostate bed with or without the use of gold fiducial markers for image guidance or higher total radiotherapy doses

Purpose

To evaluate quality of life (QoL) after post-prostatectomy intensity modulated radiation therapy (IMRT) in the “adjuvant” setting starting within 4 months of radical prostatectomy for adverse features; and “salvage” setting for a PSA≥0.2ng/mL.

Materials and Methods

Retrospective review of 130 patients who underwent IMRT to the prostate bed±gold fiducial marker placement for image guidance to 64.8-72.0Gy (median, 70.2Gy) between 2004 and 2013. Higher doses were defined as 70.2-72.0Gy and lower doses were defined as 64.8-68.4Gy. Androgen deprivation therapy (ADT) was given to 4/48 (8%) adjuvant patients and 9/82 (11%) salvage patients. International Prostate Symptom Score (IPSS), Sexual Health Inventory for Men (SHIM), and Expanded Prostate Cancer Index Composite-26-bowel (EPIC-26-bowel) questionnaires were used to assess urinary, sexual, and bowel QoL, respectively.

Results

Median follow-up was 46 months. There were better urinary (p=0.03) and sexual (p=0.002) QoL scores with adjuvant IMRT relative to salvage IMRT. The use of prostate bed fiducial markers did not significantly affect urinary, sexual, or bowel QoL (p=0.39, p=0.49, and p=0.40, respectively). Higher total radiotherapy doses did not significantly affect urinary, sexual, or bowel QoL (p=0.21, p=0.61, and p=0.36, respectively).

Conclusions

There was no significant change in urinary, sexual, and bowel sexual QoL with post-prostatectomy IMRT regardless of whether prostate bed fiducial markers or higher total radiotherapy doses were used. QoL with IMRT in the present study compares favorably with prior reports for three-dimensional conformal radiation therapy.

Smartphone speech-to-text applications for communication with profoundly deaf patients

OBJECTIVE

Visual communication aids, such as handwriting or typing, are often used to communicate with deaf patients in the clinic. This study aimed to establish the feasibility of communicating through smartphone speech recognition software compared with writing or typing.

METHOD

Thirty doctors and medical students were timed writing, typing and dictating a standard set of six sentences appropriate for a post-operative consultation, and the results were assessed for accuracy and legibility.

RESULTS

The mean time for smartphone dictation (17.8 seconds, 95 per cent confidence interval = 17.0-18.7) was significantly faster than writing (59.2 seconds, 95 per cent confidence interval = 56.6-61.7) or typing (44 seconds, 95 per cent confidence interval = 41.0-47.1) (p < 0.001). Speech recognition was slightly less accurate, but accuracy increased with time spent dictating.

CONCLUSION

Smartphone dictation is a feasible alternative to typing and handwriting. Slow speech may improve accuracy. Early clinical experience has been promising.

Development of computer-tailored education program for patients with total hip replacement

Objectives

The purpose of this study was to develop a Web-based computer-tailored education program to promote self-care for patients with total hip replacement.

Methods

The program was developed in five phases.

Results

Phase 1: Program content was developed, including the educational needs of patients with total hip replacement, based on a review of previous research and literature. Phase 2: A computer-tailored algorithm written as a series of 'if-then' statements was developed to offer the appropriate type of intervention based on an individual's personal health characteristics. Phase 3: A professional Web programmer produced then the program for use on the Web. Phase 4: An expert evaluation was performed focusing on two aspects, Web contents and website design. SPSS ver. 16.0 was used for the analysis, and grade point averages were used to compare each evaluation item. Phase 5: Based on comments from the experts' evaluation, modifications and revisions were made, and the program was completed.

Conclusions

The developed program presented tailored messages using animations, video and flash considering the individual health status and characteristics of the primary target generation. In addition, the expert evaluation confirmed the validity of the program's content and design.

Risk Factors Associated with Prolonged Mechanical Ventilation after Corrective Surgery for Tetralogy of Fallot

INTRODUCTION

This study examined early postoperative results to identify perioperative factors that are associated with prolonged mechanical ventilation (PMV) in tetralogy of Fallot (TOF) patients undergoing corrective surgery.

METHODS

We retrospectively examined the role of perioperative variables in determining the period of mechanical ventilatory support in TOF patients undergoing corrective surgery. A total of 821 patients were included in the study. The cohort was divided into a PMV group that included patients with >90th percentile for duration of mechanical ventilation and a non-PMV group which included all other patients.

RESULTS

Non-PMV group consisted of 751 patients (454 males, 297 females; median age 12 months, interquartile range 8-19 months; mean weight 9.60 ± 2.98 kg). PMV group consisted of 70 patients (51 males, 19 females; median age 8 months, interquartile range 6.75-13 months; mean weight 8.64 ± 1.95 kg). No patients died in the non-PMV group compared with two deaths due to acute respiratory distress syndrome in the PMV group. Univariate risk factors for PMV included age, weight, left ventricular end-diastolic volume index (LVEDVI), McGoon ratio, Nakata index, previous palliative operations, cardiopulmonary bypass (CPB) time, aortic cross-clamp (ACC) time, preoperative major aortopulmonary collateral arteries (MAPCAs) occlusion by coils in hybrid procedure, postoperative right ventricular/left ventricular systolic pressure ratio, central venous pressure (CVP), left atrial pressure (LAP), endotracheal reintubation, vasoactive-inotropic score (VIS), renal replacement therapy, and early-onset ventilator-associated pneumonia (VAP). In a multivariable model, age, LVEDVI, McGoon ratio, Nakata index, previous palliative operations, CPB time, blood returning to left atrium during surgery as a surrogate marker for significant aortopulmonary collateral presence, and early-onset VAP were the independent risk factors for PMV.

CONCLUSIONS

The risk factors for PMV were age, LVEDVI, McGoon ratio, Nakata index, previous palliative operations, CPB time, VIS, LAP, blood returning to left atrium during surgery, and early-onset VAP.

Evaluation of an intensive insulin transition protocol in the intensive care unit setting: a before and after study

The benefits of controlling blood glucose levels in intensive care units (ICUs) are well documented.

Objective

This study determined the effectiveness and safety of a standardized transition order set for converting a continuous insulin infusion to a subcutaneous insulin regimen in non-cardiovascular surgery ICUs patient population.

Methods

A retrospective study was conducted. Patients presenting with diabetic ketoacidosis or hyperosmolar hyperglycemic syndrome were excluded. One hundred patients were included prior to and 100 patients were included after initiating the transition order set. Blood glucose control was reviewed for up to 72 hours following the transition.

Results

A total of 115 patients were included in data analysis: 85 prior to and 30 after transition protocol. All patients transitioned using the protocol were transitioned to basal insulin, compared to only 40% of the prior to protocol group. Patients transitioned correctly per the transition order set, "per protocol," had 54% of blood sugars within the desired range, no increase in hypoglycemic events, and on average 5.56 hyperglycemic events (blood glucose >180 mg/dL) per person during the 72 hours compared to 6.68 and 9.00 for the prior to protocol group and the "off protocol" group (transitioned different than the protocol recommended), respectively (p= 0.05). There were significant differences in blood sugar control at 48 and 72 hours between the "per protocol" and "off protocol" groups (p= 0.01) and a 40% reduction in sliding scale or correctional insulin coverage.

Conclusions

The addition of basal insulin to transition regimens resulted in fewer hyperglycemic events with no increase in hypoglycemic events. Patients transitioned "per protocol" had better glucose control demonstrated by: less hyperglycemic events, lower mean blood glucose levels at 48 and 72 hours, and lower need for correctional insulin. These findings showed benefits of glycemic control in the ICU by following a standardized transition protocol.

Development of a nursing practice guideline for pre and post-operative care of gastric cancer patients

OBJECTIVES

The aim of this study was to develop nursing practice guidelines and algorithms for the pre- and postoperative care of gastric cancer patients.

METHODS

The guidelines and algorithms were developed based on a literature review and subject-matter experts' knowledge. The usefulness and applicability of the developed guidelines and algorithms were evaluated by the expert group.

RESULTS

The guidelines comprised 64 recommendations and algorithms for admission care, preoperative care on the day before the operation, preoperative care on the operation day, immediate postoperative assessment, postoperative care, and discharge care of gastric cancer patients. After appropriate evaluation, the experts declared the guidelines to be both useful and applicable.

CONCLUSIONS

The guidelines developed in this study can be used for patient care and for training nursing students and novice nurses. In addition, these guidelines can be integrated into the electronic nursing record system for clinical decision support in the future. This will improve the quality of clinical nursing and the expertise of nurses.