Implementation of an enhanced recovery protocol in pediatric colorectal surgery

PURPOSE

Enhanced recovery protocols (ERPs) have been shown to improve outcomes in adult surgical populations. Our purpose was to compare outcomes before and after implementation of an ERP in children undergoing elective colorectal surgery.

METHODS

A pediatric-specific colorectal ERP was developed and implemented at a single center starting in January 2015. A retrospective review was performed including 43 patients in the pre-ERP period (2012-2014) and 36 patients in the post-ERP period (2015-2016). Outcomes of interest included number of ERP interventions received, length of stay (LOS), complications, and readmissions.

RESULTS

The median number of ERP interventions received per patient increased from 5 to 11 from 2012 to 2016. The median LOS decreased from 5days to 3days in the post-ERP period (p=0.01). We observed a simultaneous decrease in median time to regular diet, mean dose of narcotics, and mean volume of intraoperative fluids (p<0.001). The complication rate (21% vs. 17%, p=0.85) and 30-day readmission rate (23% vs. 11%, p=0.63) were not significantly different in the pre- and post-ERP periods.

CONCLUSIONS

Implementation of a pediatric-specific ERP in children undergoing colorectal surgery is feasible, safe and may lead to improved outcomes. Further experience may highlight other opportunities for increased compliance and improved care.

LEVEL OF EVIDENCE

Treatment Study. Level III.

Risk and Resilience in Pediatric Chronic Pain: Exploring the Protective Role of Optimism

OBJECTIVE

Fear of pain and pain catastrophizing are prominent risk factors for pediatric chronic pain-related maladjustment. Although resilience has largely been ignored in the pediatric pain literature, prior research suggests that optimism might benefit youth and can be learned. We applied an adult chronic pain risk-resilience model to examine the interplay of risk factors and optimism on functioning outcomes in youth with chronic pain.

METHOD

Participants included 58 children and adolescents (8-17 years) attending a chronic pain clinic and their parents. Participants completed measures of fear of pain, pain catastrophizing, optimism, disability, and quality of life.

RESULTS

Consistent with the literature, pain intensity, fear of pain, and catastrophizing predicted functioning. Optimism was a unique predictor of quality of life, and optimism contributed to better functioning by minimizing pain-related fear and catastrophizing.

CONCLUSIONS

Optimism might be protective and offset the negative influence of fear of pain and catastrophizing on pain-related functioning.

Hepatic glucose disposition during concomitant portal glucose and amino acid infusions in the dog

The effect of concomitant intraportal infusion of glucose and gluconeogenic amino acids (AA) on net hepatic glucose uptake (NHGU) and glycogen synthesis was examined in 42-h-fasted dogs. After a basal period, there was a 240-min experimental period during which somatostatin was infused continuously into a peripheral vein and insulin and glucagon (at 3-fold basal and basal rates, respectively) and glucose (18.3 mumol.kg-1.min-1) were infused intraportally. One group (PoAA, n = 7) received an AA mixture intraportally at 7.6 mumol.kg-1.min-1, whereas the other group (NoAA, n = 6) did not receive AA. Arterial blood glucose concentrations and hepatic glucose loads were the same in the two groups. NHGU averaged 4.8 +/- 2.0 (PoAA) and 9.4 +/- 2.0 (NoAA) mumol.kg-1.min-1 (P < 0.05), and tracer-determined hepatic glucose uptake was 4.6 +/- 1.6 (PoAA) and 10.0 +/- 1.7 (NoAA) mumol.kg-1.min-1 (P < 0.05). AA data for PoAA and NoAA, respectively, were as follows: arterial blood concentrations, 1,578 +/- 133 vs. 1,147 +/- 86 microM (P < 0.01); hepatic loads, 56 +/- 3 vs. 32 +/- 4 mumol.kg-1.min-1 (P < 0.01); and net hepatic uptakes, 14.1 +/- 1.4 vs. 5.6 +/- 0.4 mumol.kg-1.min-1 (P < 0.01). The rate of net hepatic glycogen synthesis was 7.5 +/- 1.9 (PoAA) vs. 10.7 +/- 2.3 (NoAA) mumol.kg-1.min-1 (P = 0.1). In a net sense, intraportal gluconeogenic amino acid delivery directed glucose carbon away from the liver. Despite this, net hepatic carbon uptake was equivalent in the presence and absence of amino acid infusion.

CLS advanced degrees and career enhancement. Part 2--A comparison of perceptions

OBJECTIVE

To determine whether recipients of clinical laboratory science (CLS) advanced degrees (MS) perceive greater career enhancement value related to earning an advanced degree than is perceived by their baccalaureate level (BS) colleagues.

DESIGN

Two questionnaires were used-one for certified or licensed CLS professionals who had earned MS CLS degrees; the other for matched BS CLS colleagues.

SETTING

Five academic programs that conduct both National Accrediting Agency for Clinical Laboratory Sciences accredited CLS education and CLS MS degree programs participated.

PARTICIPANTS

The number of survey respondents was 220 (117-MS; 103-BS level controls). The groups were matched for gender, residence region, and years of experience.

MAIN OUTCOME MEASURES

The primary outcome measurements were the perceived benefits of having a CLS MS degree, the reasons for and against obtaining a CLS MS degree, and the overall evaluation of CLS degree programs at both levels.

RESULTS

The highest perceived benefit of having a CLS MS degree was the same in both groups, "enhanced self esteem and confidence". The highest priority motivation of MS degree recipients for obtaining a CLS advanced degree was "personal satisfaction". The highest priority reason of the BS group for not obtaining a CLS advanced degree was "family obligation". In both levels of degree programs the subject most commonly cited as needing modification was laboratory management.

CONCLUSION

The results indicate that CLS professionals who have CLS MS degrees perceive a greater career enhancement value of advanced CLS degrees than their BS level colleagues.

CLS advanced degrees and career enhancement. Part 1--Comparison of career data

OBJECTIVE

Determine whether recipients of clinical laboratory science (CLS) advanced degrees (MS) experience greater career achievements than their baccalaureate level (BS) colleagues.

DESIGN

Two similar questionnaires were used-one for certified or licensed CLS professionals who had earned advanced CLS degrees (MS); the other for matched BS CLS colleagues.

SETTING

Five academic programs that conduct both National Accrediting Agency for Clinical Laboratory Sciences accredited CLS education and CLS MS degree programs participated.

PARTICIPANTS

The number of survey respondents was 220, 117 with advanced CLS degrees and 103 BS level controls. There were 99 matched pairs, i.e., 198 individuals were matched for gender, residence region, and years of experience.

MAIN OUTCOME MEASURES

Careers of BS vs. MS respondents were statistically compared, e.g., fractions with managerial level jobs, relative earnings increases per year, numbers of publications and reports, and other professional contributions.

RESULTS

Compared to their BS degree controls, MS degree respondents had more managerial level jobs (62% MS; 36% BS), a higher frequency of job change (once per 4.3 years MS; once per 5.9 years BS), and a higher increase per year of earnings (9.1% MS; 8.1% BS). A greater percentage of the MS degree graduates (77%) than the BS level controls (33%) had authored external publications; the responses related to authorship of institutional reports and procedures were less different-84% MS and 64% BS. Professional contributions to their institutions or profession were cited slightly more frequently by the MS graduates (65%) than by the BS level controls (55%).

CONCLUSION

Compared to their matched BS level CLS colleagues, CLS MS degree recipients had greater job mobility, greater management authority, higher salary, and more numerous professional contributions.

Neural and pancreatic influences on net hepatic glucose uptake and glycogen synthesis

The role of the liver nerves in the disposition of peripherally administered glucose was examined in seven hepatic innervated (HI) and nine hepatic denervated (HD) 42-h-fasted conscious dogs. After a 40-min basal period, there was a 4-h experimental period during which the hepatic glucose load was increased twofold via peripheral glucose infusion. Somatostatin was infused to suppress pancreatic endocrine secretion, and insulin and glucagon were infused intraportally to produce a fourfold increase in insulin and a gradual decrease (approximately 25%) in glucagon. The area under the curve of net hepatic glucose uptake (NHGU) during the glucose infusion period totaled 483 +/- 82 and 335 +/- 32 mg/kg in HD and HI, respectively (P < 0.05). The area under the curve of the hepatic fractional extraction of glucose was 27% greater in HD (P < 0.05). Net hepatic lactate output was similar in the two groups, and net hepatic glycogen synthesis was 3.8 +/- 0.8 vs. 2.7 +/- 0.5 mg.kg dog wt-1.min-1 in HD and HI, respectively (P = 0.13). The direct pathway of glycogen synthesis was responsible for 54-58% of net hepatic glycogen synthesis in both HI and HD (n = 6 for both). In summary 1) NHGU in response to peripheral glucose infusion was approximately 44% greater in HD than in HI, 2) net hepatic glycogen synthesis was enhanced by 41% in HD although the probability of this change was 0.13, and 3) the contribution of the direct pathway to glycogen synthesis was the same in HD and HI. These data are consistent with a role for the liver nerves in regulating the magnitude of NHGU in response to glucose administration. They also indicate that the absence of liver nerves may reduce glycogen turnover during glucose infusion.

From chart tracking to workflow management

The current interest in system-wide integration appears to be based on the assumption that an organization, by digitizing information and accepting a common standard for the exchange of such information, will improve the accessibility of this information and automatically experience benefits resulting from its more productive use. We do not dispute this reasoning, but assert that an organization's capacity for effective change is proportional to the understanding of the current structure among its personnel. Our workflow manager is based on the use of a Parameterized Petri Net (PPN) model which can be configured to represent an arbitrarily detailed picture of an organization. The PPN model can be animated to observe the model organization in action, and the results of the animation analyzed. This simulation is a dynamic ongoing process which changes with the system and allows members of the organization to pose "what if" questions as a means of exploring opportunities for change. We present, the "workflow management system" as the natural successor to the tracking program, incorporating modeling, scheduling, reactive planning, performance evaluation, and simulation. This workflow management system is more than adequate for meeting the needs of a paper chart tracking system, and, as the patient record is computerized, will serve as a planning and evaluation tool in converting the paper-based health information system into a computer-based system.

Effects of information feedback and pulse oximetry on the incidence of anesthesia complications

No standard outcome measures exist to evaluate the effect of interventions intended to improve the quality of anesthesia care. The authors established a clinically practical definition of outcome, and used it to assess the effect of feedback of information about complications and the effect of pulse oximetry on the rate and severity of important anesthesia-related problems encountered in the operating room (OR) and recovery room (RR). On admission to the RR, the patient's anesthetist documented Recovery-Room-Impact Events (RRIE), defined as an "unanticipated, undesirable, possibly anesthesia-related effect that required intervention, was pertinent to recovery-room care, and did or could cause at least moderate morbidity." Following a control period with no feedback of data, intense feedback of grouped (anonymous) RRIE rates was provided. Later, pulse oximeters were introduced to all anesthetizing locations. Among 12,088 patients (71% of all RR admissions), 18% had at least one RRIE in the OR or RR. The most common RRIEs were hypotension (4.4%), arrhythmia (3.9%), hypertension (1.5%), intubation difficulties (0.8%), hypoventilation (0.8%), and hypovolemia (0.6%). Feedback of information produced no demonstrable change in the rate of RRIEs. Although significantly fewer patients experienced RRIEs (15.6% vs. 12.4%, P less than 0.0001), hypotensive RRIEs (5.2% vs. 3.8%, P = 0.0003), and hypovolemic RRIEs (0.88% vs. 0.42%, P = 0.0017) following the introduction of pulse oximetry in the OR, confounding factors prevent establishment of a cause-and-effect relationship. Quality assurance may require more direct intervention and individual feedback to be effective. Still, the RRIE measure requires minimal effort at low cost and encourages improved transmission of information at the time of admission to recovery-room care.