Early enforced mobilisation following surgery for gastrointestinal cancer: feasibility and outcomes

Delayed ambulation in adult patients after major abdominal surgery in Northwest Ethiopia: a multicenter prospective follow up study

Abdominal surgery is associated with prolonged hospitalization, reduced physical activity levels, and prolonged bed rest. Delayed ambulation is a major problem after abdominal surgery which result in prolonged hospital stay. Ambulation was defined as delayed if the patient could not walk more than 10 m without assistance on postoperative day one within 24 h of surgery. Although abdominal surgery is performed for a variety of surgical procedures in a day to day practice the incidence and factors associated with delayed ambulation after major abdominal surgery have not been well investigated in the study area. Therefore, the aim of this study was to assess the incidence and factors associated with delayed ambulation after major abdominal surgery. A multicenter, prospective follow up study was conducted from March 28, to June 5, 2023, on 422 participants. Patients were taken consecutively, and data were collected by using a semi-structured questionnaire. Data were entered into Epi Data version 4.6 Software and exported to SPSS version 26 for analysis. Both descriptive and analytic statistics were used. Both bivariable and multivariable logistic regression were used. Variables with a p-value less than < 0.2 in the bivariable analysis were fitted into the multivariable analysis. Both the crude odds' ratio (COR) and Adjusted Odds Ratio (AOR) with 95% Confidence Interval were calculated to show the strength of association. Variables with a p-value of < 0.05 were considered as statistically significant. The overall incidence of delayed ambulation after major abdominal surgery was 48.1% (95%CI:43.4-52.6). Having severe pain (AOR:3.23, 95%CI:1.09-9.55), dizziness (AOR:7.21, 95%CI:3.49-14.91), nasogastric tube (AOR:2.36, 95%CI:1.05-5.34), drain (AOR:3.27, 95%CI:1.52-7.04), fatigue (AOR:7.62, 95%CI:3.71-15.66), intraoperative fluid used > 2000 ml (AOR:2.54, 95%CI:1.03-6.24), duration of surgery > 2-hour (AOR:3.96, 95%CI:1.87-8.38) and blood loss > 500 ml (AOR:2.68, 95%CI:1.24-5.79) were significantly associated with delayed ambulation. Nearly half of the patients were unable to ambulate at postoperative day one after major abdominal surgery. Adopting a zero fluid balance approach, minimizing surgical duration and blood loss, timely removal of drains and catheters, and prioritizing postoperative pain management is recommended.

Physical and psychological recovery after vaginal childbirth with and without epidural analgesia: A prospective cohort study

BACKGROUND

Enhanced recovery is the gold standard in modern perioperative management, including that for cesarean deliveries. However, qualitative and quantitative data on the physical and psychological recovery of women after vaginal childbirth are limited. Whether neuraxial labor analgesia influences postpartum recovery is unknown.

METHODS

Primiparous women anticipating a vaginal childbirth between January 2020 and May 2021 were enrolled. Women with major comorbidities or postpartum complications and those who underwent a cesarean delivery were excluded. Daily step count was measured using a wrist-worn activity tracker (FitbitTM Inspire HR) for 120 hours after vaginal childbirth. Subjective fatigue levels and health-related quality of life were assessed using the Multidimensional Fatigue Inventory (MFI) and EuroQol 5 Dimension 5 Level (EQ-5D-5L), respectively, at the 3rd trimester antenatal visit, on postpartum day 1 and 3, and at the one-month postpartum visit. Rest and dynamic pain scores and the location of pain were documented by participants during postpartum hospitalization.

RESULTS

Among 300 women who were enrolled antenatally, 95 and 116 had a vaginal delivery without (NCB group) and with (EPL group) epidural analgesia, respectively. The median number of steps per 24 hours increased daily in both groups, and no significant difference was detected between the groups. Postpartum pain was mild overall, with median rest and dynamic pain scores being less than 4 and similar between the groups. MFI and EQ-5D-5L scores were the worst on postpartum day 1 in both groups and gradually improved to antepartum level by the one-month postpartum visit. Higher MFI score on postpartum day 1, but not the use of epidural analgesia, was associated with lower odds of achieving adequate postpartum ambulation (defined as >3500 steps between 48 and 72 hours postpartum).

CONCLUSION

The use of epidural analgesia was not associated with worse recovery outcomes during postpartum hospitalization.

TRIAL REGISTRATION

UMIN-CTR, #UMIN000039343, registered on January 31, 2020.

Effects of early postoperative mobilization following gastrointestinal surgery: systematic review and meta-analysis

BACKGROUND

Early postoperative mobilization is considered a key element of enhanced recovery after surgery protocols. The aim of this study was to summarize the effect of early postoperative mobilization following gastrointestinal operations on patient recovery, mobility, the morbidity rate and duration of hospital stay.

METHODS

A systematic literature search was conducted in December, 2022, using PubMed, Web of Science and the Cochrane Central Register of Controlled Trials. Controlled trials reporting the effects of early postoperative mobilization after gastrointestinal surgery were included. The risk of bias was assessed using a modified Downs and Black tool and the Cochrane Collaboration tool for randomized trials. The outcomes of interest were gastrointestinal recovery (defined passage of first flatus or bowel movements), mobility (step count on postoperative day 3), the morbidity rate and duration of hospital stay.

RESULTS

After elimination of duplicates, 3678 records were identified, and 71 full-text articles were screened. Finally, 15 studies (eight RCTs) reporting on 3538 patients were included. Most trials evaluated early postoperative mobilization after different gastrointestinal operations, including upper gastrointestinal (n = 8 studies), hepatopancreatobiliary (n = 10 studies) and colorectal resections (n = 10 studies). The investigated early postoperative mobilization protocols, operative techniques (minimally invasive or open) and outcome parameters were heterogeneous between the studies. Early postoperative mobilization seemed to significantly accelerate clinical gastrointestinal recovery (mean difference, hours: -11.53 (-22.08, -0.97), P = 0.03). However, early postoperative mobilization did not significantly improve the morbidity rate (risk ratio: 0.93 (0.70, 1.23), P = 0.59), postoperative mobility of patients (step count mean difference: 1009 (-803, 2821), P = 0.28) or shorten the duration of hospital stay (mean difference, days: -0.25 (-0.99,0.43), P = 0.47) in randomized trials.

CONCLUSION

There is a large heterogeneity among the study cohorts, operations and interventions. The available evidence currently does not support specific early postoperative mobilization protocols as an isolated element to further reduce the morbidity rate and duration of hospital stay. Further well-designed trials are required to identify effective early postoperative mobilization protocols.

Evaluation of therapy in traumatic elderly falls to return autonomy and functional status

Background

Traumatic falls among the elderly (≥ 65 years old) are the leading cause of injury, morbidity and mortality are increasing with rising medical costs.

Methods

This is a retrospective medical record review of elderly mechanical fall patients (288 patients) admitted to an American College of Surgeons level II trauma center from January 2016 to January 2021. Demographics and comorbidities were determined, and physical/occupational therapy used to predict subsequent fall readmissions.

Results

Out of 288 patients, 243 received therapy with 45 readmissions for subsequent falls. Age (P = .016), body mass index (P = .035), previous falls (P = .003), walker/cane use (P = .039), and dementia (P = .038) were predictive of readmission. Therapy was shown to benefit patients, but deferred therapy sessions were shown to be associated with prolonged hospitalization.

Conclusion

Directed therapy may improve functionality and return autonomy to elderly mechanical fall patients admitted to trauma services.

•

Elderly fall patient evaluation after falls can predict need for therapy.

•

Directed therapy can benefit and potentially prevent recurrence of falls.

•

Deferrals of therapy are associated with prolonged hospital stays.

Self-monitoring of Physical Activity After Hospital Discharge in Patients Who Have Undergone Gastrointestinal or Lung Cancer Surgery: Mixed Methods Feasibility Study

Background

Self-monitoring of physical activity (PA) using an accelerometer is a promising intervention to stimulate PA after hospital discharge.

Objective

This study aimed to evaluate the feasibility of PA self-monitoring after discharge in patients who have undergone gastrointestinal or lung cancer surgery.

Methods

A mixed methods study was conducted in which 41 patients with cancer scheduled for lobectomy, esophageal resection, or hyperthermic intraperitoneal chemotherapy were included. Preoperatively, patients received an ankle-worn accelerometer and the corresponding mobile health app to familiarize themselves with its use. The use was continued for up to 6 weeks after surgery. Feasibility criteria related to the study procedures, the System Usability Scale, and user experiences were established. In addition, 6 patients were selected to participate in semistructured interviews.

Results

The percentage of patients willing to participate in the study (68/90, 76%) and the final participation rate (57/90, 63%) were considered good. The retention rate was acceptable (41/57, 72%), whereas the rate of missing accelerometer data was relatively high (31%). The mean System Usability Scale score was good (77.3). Interviewed patients mentioned that the accelerometer and app were easy to use, motivated them to be more physically active, and provided postdischarge support. The technical shortcomings and comfort of the ankle straps should be improved.

Conclusions

Self-monitoring of PA after discharge appears to be feasible based on good system usability and predominantly positive user experiences in patients with cancer after lobectomy, esophageal resection, or hyperthermic intraperitoneal chemotherapy. Solving technical problems and improving the comfort of the ankle strap may reduce the number of dropouts and missing data in clinical use and follow-up studies.

Colorectal Surgery in Critically Unwell Patients: A Multidisciplinary Approach

A proportion of patients require critical care support following elective or urgent colorectal procedures. Similarly, critically ill patients in intensive care units may also need colorectal surgery on occasions. This patient population is increasing in some jurisdictions given an aging population and increasing societal expectations. As such, this population often includes elderly, frail patients or patients with significant comorbidities. Careful stratification of operative risks including the need for prolonged intensive care support should be part of the consenting process. In high-risk patients, especially in setting of unplanned surgery, treatment goals should be clearly defined, and appropriate ceiling of care should be established to minimize care that is not in the best interest of the patient. In this article we describe approaches to critically unwell patients requiring colorectal surgery and how a multidisciplinary approach with proactive intensive care involvement can help achieve the best outcomes for these patients.

Perioperative parameters to consider for enhanced recovery in surgery (ERS) in gynecology (excluding breast surgery)

The current review explores the Enhanced Rehabilitation in Surgery (ERS) approach in the specific context of gynecological surgery. Implementation of an ERS protocol in gynecological surgery reduces postoperative complications and length of stay without increasing morbidity. An ERS approach is based on maintaining an adequate diet and hydration before the operation, according to the recommended time frame, to reduce the phenomenon of insulin resistance, and to optimize patient comfort. On the other hand, the use of anxiolytic treatment as premedication is not recommended. Systematic preoperative digestive preparation, a source of patient discomfort, is not associated with an improvement in the postoperative functional outcome or with a reduction in the rate of complications. A minimally invasive surgical approach is preferrable in the context of ERS. Prevention of surgical site infection includes measures such as optimized antibiotic prophylaxis, skin disinfection with alcoholic chlorhexidine, reduction in the use of drainage of the surgical site, and prevention of hypothermia. Early removal of the bladder catheter is associated with a reduction in the risk of urinary tract infection and a reduction in the length of hospital stay. Prevention of postoperative ileus is based on early refeeding, and prevention of postoperative nausea-vomiting in a multimodal strategy to be initiated during the intraoperative period. Intraoperative hydration should be aimed at achieving euvolemia. Pain control is based on a multimodal strategy to spare morphine use and may include locoregional analgesia. Medicines should be administered orally during the postoperative period to hasten the resumption of the patient's autonomy. The prevention of thromboembolic risk is based on a strategy combining drug prophylaxis, when indicated, and mechanical restraint, as well as early mobilization. However, the eclectic nature of the implementation of these measures as reported in the literature renders their interpretation difficult. Furthermore, beyond the application of one of these measures in isolation, the best benefit on the postoperative outcome is achieved by a combination of measures which then constitutes a global strategy allowing the objectives of the ERS to be met.

Extended mobility scale (AMEXO) for assessing mobilization and setting goals after gastrointestinal and oncological surgery: a before-after study

Background

Early structured mobilization has become a key element of Enhanced Recovery After Surgery programs to improve patient outcomes and decrease length of hospital stay. With the intention to assess and improve early mobilization levels, the 8-point ordinal John Hopkins Highest Level of Mobility (JH-HLM) scale was implemented at two gastrointestinal and oncological surgery wards in the Netherlands. After the implementation, however, healthcare professionals perceived a ceiling effect in assessing mobilization after gastrointestinal and oncological surgery. This study aimed to quantify this perceived ceiling effect, and aimed to determine if extending the JH-HLM scale with four additional response categories into the AMsterdam UMC EXtension of the JOhn HOpkins Highest Level of mObility (AMEXO) scale reduced this ceiling effect.

Methods

All patients who underwent gastrointestinal and oncological surgery and had a mobility score on the first postoperative day before (July–December 2018) or after (July–December 2019) extending the JH-HLM into the AMEXO scale were included. The primary outcome was the before-after difference in the percentage of ceiling effects on the first three postoperative days. Furthermore, the before-after changes and distributions in mobility scores were evaluated. Univariable and multivariable logistic regression analysis were used to assess these differences.

Results

Overall, 373 patients were included (JH-HLM n = 135; AMEXO n = 238). On the first postoperative day, 61 (45.2%) patients scored the highest possible mobility score before extending the JH-HLM into the AMEXO as compared to 4 (1.7%) patients after (OR = 0.021, CI = 0.007–0.059, p < 0.001). During the first three postoperative days, 118 (87.4%) patients scored the highest possible mobility score before compared to 40 (16.8%) patients after (OR = 0.028, CI = 0.013–0.060, p < 0.001). A change in mobility was observed in 88 (65.2%) patients before as compared to 225 (94.5%) patients after (OR = 9.101, CI = 4.046–20.476, p < 0.001). Of these 225 patients, the four additional response categories were used in 165 (73.3%) patients.

Conclusions

A substantial ceiling effect was present in assessing early mobilization in patients after gastrointestinal and oncological surgery using the JH-HLM. Extending the JH-HLM into the AMEXO scale decreased the ceiling effect significantly, making the tool more appropriate to assess early mobilization and set daily mobilization goals after gastrointestinal and oncological surgery.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-021-01445-3.

Effects of Early Physical Therapist-supervised Walking on Clinical Outcomes after Liver Resection: Propensity Score Matching Analysis

OBJECTIVE

The study aimed to demonstrate the significance of early postoperative physical therapy interventions on clinical outcomes by determining the influence of the distance walked under the supervision of a physical therapist in the early postoperative period after liver cancer.

METHODS

All consecutive patients who underwent surgery for liver cancer between April 2018 and March 2020 were eligible for enrollment in the study. The total walking distance during physical therapy till the third postoperative day was examined. The clinical outcomes comprised duration of postoperative hospital stay, time to independent walking, and occurrence of postoperative complications. For data analysis, the patients were divided into two groups: those who walked more than the median total distance (the long-distance group) and those who walked less than the median distance (the short-distance group). We used propensity score matching to match the background characteristics between the groups.

RESULTS

Of the 65 patients who were eligible, 14 patients were included in the two groups each, after matching. The long-distance walking group had a significantly shorter hospital stay (9.0 days vs. 11.0 days, p=0.008) and a shorter time to independent walking (3.5 days vs. 7.5 days, p=0.019) than the short-distance walking group. There were no significant differences in postoperative complications between the two groups (7.1% vs. 42.8%, p=0.08).

CONCLUSION

In the early postoperative period after liver cancer surgery, increasing the walking distance under the supervision of a physical therapist is important for improving clinical outcomes. Further prospective studies are needed to confirm the findings of this study.

Effect of Electrical Impedance Tomography-Guided Early Mobilization in Patients After Major Upper Abdominal Surgery: Protocol for a Prospective Cohort Study

Background: Pulmonary complications are common in patients after upper abdominal surgery, resulting in poor clinical outcomes and increased costs of hospitalization. Enhanced Recovery After Surgery Guidelines strongly recommend early mobilization post-operatively; however, the quality of the evidence is poor, and indicators for quantifying the effectiveness of early mobilization are lacking. This study will evaluate the effectiveness of early mobilization in patients undergoing an upper abdominal surgery using electrical impedance tomography (EIT). Specifically, we will use EIT to assess and compare the lung ventilation distribution among various regions of interest (ROI) before and after mobilization in this patient population. Additionally, we will assess the temporal differences in the distribution of ventilation in various ROI during mobilization in an effort to develop personalized activity programs for this patient population.

Methods: In this prospective, single-center cohort study, we aim to recruit 50 patients after upper abdominal surgery between July 1, 2021 and June 30, 2022. This study will use EIT to quantify the ventilation distribution among different ROI. On post-operative day 1, the nurses will assist the patient to sit on the chair beside the bed. Patient's heart rate, blood pressure, oxygen saturation, respiratory rate, and ROI 1-4 will be recorded before the mobilization as baseline. These data will be recorded again at 15, 30, 60, 90, and 120 min after mobilization, and the changes in vital signs and ROI 1-4 values at each time point before and after mobilization will be compared.

Ethics and Dissemination: The study protocol has been approved by the Institutional Review Board of Liaocheng Cardiac Hospital (2020036). The trial is registered at chictr.org.cn with identifier ChiCTR2100042877, registered on January 31, 2021. The results of the study will be presented at relevant national and international conferences and submitted to international peer-reviewed journals. There are no plans to communicate results specifically to participants. Important protocol modifications, such as changes to eligibility criteria, outcomes, or analyses, will be communicated to all relevant parties (including investigators, Institutional Review Board, trial participants, trial registries, journals, and regulators) as needed via email or in-person communication.

Barriers and enablers to physical activity in patients during hospital stay: a scoping review

BACKGROUND

Low levels of physical activity are common during the hospital stay and have been associated with negative health outcomes. Understanding barriers and enablers to physical activity during a hospital stay can improve the development and implementation of tailored interventions aimed at improving physical activity. Previous studies have identified many barriers and enablers, but a comprehensive overview is lacking. This study aimed to identify and categorize all published patient- and healthcare professional-reported barriers and enablers to physical activity during a hospital stay for acute care, using the Theoretical Domains Framework (TDF).

METHODS

We conducted a scoping review of Dutch and English articles using MEDLINE, CINAHL Plus, EMBASE, PsycINFO, and Cochrane Library (inception to September 2020), which included quantitative, qualitative, and mixed-methods studies reporting barriers and enablers to physical activity during a hospital stay for acute care, as perceived by patients or healthcare professionals. Two reviewers systematically extracted, coded, and categorized all barriers and enablers into TDF domains.

RESULTS

Fifty-six articles were included in this review (32 qualitative, 7 quantitative, and 17 mixed-methods). In total, 264 barriers and 228 enablers were reported by patients, and 415 barriers and 409 enablers by healthcare professionals. Patient-reported barriers were most frequently assigned to the TDF domains Environmental Context & Resources (ECR, n = 148), Social Influences (n = 32), and Beliefs about Consequences (n = 25), while most enablers were assigned to ECR (n = 67), Social Influences (n = 54), and Goals (n = 32). Barriers reported by healthcare professionals were most frequently assigned to ECR (n = 210), Memory, Attention and Decision Process (n = 45), and Social/Professional Role & Identity (n = 31), while most healthcare professional-reported enablers were assigned to the TDF domains ECR (n = 143), Social Influences (n = 76), and Behavioural Regulation (n = 54).

CONCLUSIONS

Our scoping review presents a comprehensive overview of all barriers and enablers to physical activity during a hospital stay and highlights the prominent role of the TDF domains ECR and Social Influences in hospitalized patients' physical activity behavior. This TDF-based overview provides a theoretical foundation to guide clinicians and researchers in future intervention development and implementation.

SCOPING REVIEW REGISTRATION

No protocol was registered for this review.

The Clinical Efficacy and Safety of Enhanced Recovery After Surgery for Cesarean Section: A Systematic Review and Meta-Analysis of Randomized Controlled Trials and Observational Studies

Background: Enhanced recovery after surgery (ERAS) has been adopted in some maternity units and studied extensively in cesarean section (CS) in the last years, showing encouraging results in clinic practice. However, the present evidence assessing the effectiveness of ERAS for CS remains weak, and there is a paucity in the published literature, especially in improving maternal outcomes. Our study aimed to systematically evaluate the clinical efficacy and safety of ERAS protocols for CS. Methods: A systematic literature search using Embase, PubMed, and the Cochrane Library was carried out up to October 2020. The appropriate randomized controlled trials (RCTs) and observational studies applying ERAS for patients undergoing CS were included in this study, comparing the effect of ERAS protocols with conventional care on length of hospital stay (LOS), readmission rate, incidence of postoperative complications, postoperative pain score, postoperative opioid use, and cost of hospitalization. All statistical analyses were conducted with the RevMan 5.3 software. Results: Ten studies (four RCTs and six observational studies) involving 16,391 patients were included. ERAS was associated with a decreased LOS (WMD -7.47 h, 95% CI: -8.36 to -6.59 h, p < 0.00001) and lower incidence of postoperative complications (RR: 0.50, 95% CI: 0.37 to 0.68, p < 0.00001). Moreover, pooled analysis showed that postoperative pain score (WMD: -1.23, 95% CI: -1.32 to -1.15, p < 0.00001), opioid use (SMD: -0.46, 95% CI: -0.58 to -0.34, p < 0.00001), and hospital cost (SMD:-0.54, 95% CI: -0.63 to -0.45, p < 0.00001) were significantly lower in the ERAS group than in the conventional care group. No significant difference was observed with regard to readmission rate (RR: 0.86, 95% CI: 0.48 to 1.54, p = 0.62). Conclusions: The available evidence suggested that ERAS applying to CS significantly reduced postoperative complications, lowered the postoperative pain score and opioid use, shortened the hospital stay, and potentially reduced hospital cost without compromising readmission rates. Therefore, protocols implementing ERAS in CS appear to be effective and safe. However, the results should be interpreted with caution owing to the limited number and methodological quality of included studies; hence, future large, well-designed, and better methodological quality studies are needed to enhance the body of evidence.

Feasibility, safety and outcomes of ambulation within 2 h postoperatively in patients with lung cancer undergoing thoracoscopic surgery

AIMS

The aims of this study were to evaluate the safety, feasibility and outcomes of ambulation within 2 h after thoracoscopic surgery in patients with lung cancer.

BACKGROUND

There are no consensus guidelines on the ideal time for early ambulation following thoracic surgery, although enhanced recovery programmes have been proposed since years.

METHODS

This non-randomized, concurrent-control study was conducted on patients who underwent thoracoscopic surgery between October 2020 and February 2021. Participants were assigned to either the observation group (ambulation within 2 h of extubation) or the control group (ambulation on the first postoperative day).

RESULTS

Of the 325 patients who were eligible, 227 were included in the study. Eighty-three per cent of patients were able to walk any distance within 2 h of extubation, and no adverse events occurred in patients. The length of hospital stay and time to first postoperative flatus were significantly shorter in the observation group than in the control group. There were no differences in the occurrence of postoperative complications and orthostatic hypotension, readmission rate and 6-min walk distance at discharge.

CONCLUSION

Ambulation within 2 h of extubation was safe and feasible and could lead to better recovery in patients with lung cancer undergoing thoracoscopic surgery.

Postoperative mobilisation as an indicator for the quality of surgical nursing care

BACKGROUND

Postoperative mobilisation is an important part of fundamental care. Increased mobilisation has positive effect on recovery, but immobilisation is still a challenge in postoperative care.

AIMS

To report how the establishment of a national nursing database was used to measure postoperative mobilisation in patients undergoing surgery for ovarian cancer.

METHODS

'Mobilisation' was defined as at least 3 hours out of bed on postoperative day 1, with the goal set at achieving this in 60% of patients. Data entry was performed by clinical nurses on 4400 patients with ovarian cancer.

FINDINGS

46.7% of patients met the goal for mobilisation on the first postoperative day, but variations in duration and type of mobilisation were observed. Of those mobilised, 51.8% had been walking in the hallway.

CONCLUSIONS

A national nursing database creates opportunities to optimise fundamental care. By comparing nursing data with oncological, surgical and pathology data it became possible to study mobilisation in relation to cancer stage, comorbidity, treatment and extent of surgery.

Using NSQIP Data to Reduce Institutional Postoperative Pneumonia Rates in Non-ICU Patients: A Plan-Do-Study-Act Approach

BACKGROUND

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) is a program designed to measure and improve surgical care quality. In 2015, the study institution formed a multidisciplinary team to address the poor adult postoperative pneumonia performance (worst decile).

STUDY DESIGN

The study institution is a 450+ bed tertiary care center that performs 12,000+ surgical procedures annually. From January 2016 to December 2019, the institution abstracted surgical cases and assigned postoperative pneumonia as a complication per the NSQIP operations manual. Using a plan-do-study-act approach, a multidisciplinary postoperative pneumonia prevention team implemented initiatives regarding incentive spirometry education, anesthetic optimization, early mobility, and oral care. The team measured the initiatives' success by analyzing semiannual reports (SAR) provided by the ACS NSQIP and regional adjusted percentile rankings provided by the Georgia Surgical Quality Collaborative (GSQC).

RESULTS

The 2015 SAR postoperative pneumonia rate was 4.20% (odds ratio [OR] 3.86, confidence interval [CI] 2.92-5.11). After project initiation, the postoperative pneumonia rates decreased for all NSQIP cases, from 2.51% (OR 2.67, CI 1.89-3.77) in 2016 to 2.08% (OR 2.61, CI 1.82-3.74) in 2017, to 0.85% (OR 1.10, CI 0.69-1.75) in 2018, and then increased slightly to 1.14% (OR 1.27, CI 0.84-1.92) in 2019. The institution's adjusted percentile regional rank of participating regional ACS NSQIP hospitals' postoperative pneumonia rate improved from 14/14 (July 2015-June 2016) to 6/14 (July 2018-June 2019).

CONCLUSIONS

The multidisciplinary postoperative pneumonia prevention team successfully decreased the postoperative pneumonia rate, therefore improving surgical patients' outcomes. Furthermore, this quality improvement project also saved valuable revenue for the hospital.

Society for Obstetric Anesthesia and Perinatology: Consensus Statement and Recommendations for Enhanced Recovery After Cesarean

The purpose of this article is to provide a summary of the Enhanced Recovery After Cesarean delivery (ERAC) protocol written by a Society for Obstetric Anesthesia and Perinatology (SOAP) committee and approved by the SOAP Board of Directors in May 2019. The goal of the consensus statement is to provide both practical and where available, evidence-based recommendations regarding ERAC. These recommendations focus on optimizing maternal recovery, maternal-infant bonding, and perioperative outcomes after cesarean delivery. They also incorporate management strategies for this patient cohort, including recommendations from existing guidelines issued by professional organizations such as the American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists. This consensus statement focuses on anesthesia-related and perioperative components of an enhanced recovery pathway for cesarean delivery and provides the level of evidence for each recommendation.

Perioperative nursing principles guided by the concept of enhanced recovery after surgery†

Objective

To explore the clinical effect of perioperative nursing guided by the concept of enhanced recovery after surgery and summarize them.

Methods

Pubmed, Chinese National Knowledge Infrastructure (CNKI), Chinese Biomedical Literature Database (CBM), Wanfang Database, and VIP Database were searched to obtain the relevant literature involving enhanced recovery after surgery (ERAS) guidance, obtain the effective clinical data, review the reports in literature, and obtain the effective scheme.

Results

Compared with the traditional nursing program, perioperative nursing principles guided by the concept of ERAS provide more accurate nursing care to patients and reduce the occurrence of intraoperative stress events through comprehensive nursing measures such as preoperative pre-rehabilitation measures, intraoperative body temperature and fluid management, postoperative analgesia, prevention of nausea and vomiting, early mobilization, catheter nursing, and better out-of-hospital follow-up.

Conclusions

Perioperative nursing principles guided by the concept of ERAS can significantly reduce the incidence of perioperative complications, shorten the hospital stay of patients, and promote postoperative rehabilitation of patients. The transformation and implementation of this concept can bring significant benefits to hospitals, medical care, and patients.

Improving postoperative mobilisation rates in patients undergoing elective major hepatopancreatobiliary surgery

BACKGROUND

Early mobilisation reduces postoperative complications such as pneumonia, deep vein thrombosis and hospital length of stay. Many authors have reported poor compliance with early mobilisation within Enhanced Recovery After Surgery initiatives.

OBJECTIVES

The primary objective was to increase postoperative day (POD) 2 mobilisation rate from 23% to 75% in patients undergoing elective major hepatopancreatobiliary (HPB) surgery within 6 months.

METHODS

We report a multidisciplinary team clinical practice improvement project (CPIP) to improve postoperative mobilisation of patients undergoing elective major HPB surgery. We identified the common barriers to mobilisation and analysed using the fishbone or cause-and-effect diagram and Pareto chart. A series of Plan-Do-Study-Act cycles followed this. We tracked the rate of early mobilisation and mean distance walked. In the post hoc analysis, we examined the potential cost savings based on reduced hospital length of stay.

RESULTS

Mobilisation rate on POD 2 following elective major HPB surgery improved from 23% to 78.9%, and this sustained at 6 months after the CPIP. Wound pain was the most common reason for failure to ambulate on POD 2. Hospital length of stay reduced from a median of 8 days to 6 days with an estimated cost saving of S$2228 per hospital stay.

CONCLUSION

Multidisciplinary quality improvement intervention effort resulted in an improved POD 2 mobilisation rate for patients who underwent elective major HPB surgery. This observed outcome was sustained at 6 months after completion of the CPIP with potential cost savings.

Prevent deterioration and long-term ventilation: intensive care following thoracic surgery

PURPOSE OF REVIEW

Patients with indication for lung surgery besides the pulmonary pathology often suffer from independent comorbidities affecting several other organ systems. Preventing patients from harmful complications due to decompensation of underlying organ insufficiencies perioperatively is pivotal. This review draws attention to the peri- and postoperative responsibility of the anaesthetist and intensivist to prevent patients undergoing lung surgery deterioration.

RECENT FINDINGS

During the last decades we had to accept that 'traditional' intensive care medicine implying deep sedation, controlled ventilation, liberal fluid therapy, and broad-spectrum antimicrobial therapy because of several side-effects resulted in prolongation of hospital length of stay and a decline in quality of life. Modern therapy therefore should focus on the convalescence of the patient and earliest possible reintegration in the 'life-before.' Avoidance of sedative and anticholinergic drugs, early extubation, prophylactic noninvasive ventilation and high-flow nasal oxygen therapy, early mobilization, well-adjusted fluid balance and reasonable use of antibiotics are the keystones of success.

SUMMARY

A perioperative interprofessional approach and a change in paradigms are the prerequisites to improve outcome and provide treatment for elder and comorbid patients with an indication for thoracic surgery.

Comparing Activity Trackers With vs. Without Alarms to Increase Postoperative Ambulation: A Randomized Control Trial

Early ambulation is a key component to postoperative recovery; however, measuring steps taken is often inconsistent and nonstandardized. This study aimed to determine whether an activity tracker with alarms would increase postoperative ambulation in patients after elective colorectal procedures. Forty-eight patients were randomly assigned to either trackers with 5 daily alarms or activity trackers alone. Over 223 total patient days, the trackers recorded a complete data set for 216 patient days (96.9%). Increasing the postoperative day significantly affected the number of steps taken, while age, sex, Risk Analysis Index score, and approach (laparoscopic versus open) did not show a significant effect. The mean steps per day in the intervention group were 1468 (median 495; interquartile range (IQR) 1345) and in the control group was 1645 (median 1014; IQR 2498). The use of trackers with alarms did not significantly affect the number of daily steps compared to trackers alone (ANOVA, P = .93). Although activity trackers with alarms did not increase postoperative ambulation compared with trackers with no alarms, we demonstrated a strategy to operationalize the use of trackers into postoperative care to provide a quantitative value for ambulation. This enables quantification of a key component in the Enhanced Recovery After Surgery protocol.

Improving Physical Activity in Adults Admitted to a Hospital With Interventions Developed and Implemented Through Cocreation: Protocol for a Pre-Post Embedded Mixed Methods Study

Background

Admission to a hospital is often related with hospital-associated disabilities. Improving physical activity during hospitalization is considered effective to counteract hospital-associated disabilities, whereas many studies report on very low physical activity levels. Gradually developing and implementing interventions in cocreation with patients and health care professionals rather than implementing predefined interventions may be more effective in creating sustainable changes in everyday clinical practice. However, no studies have reported on the use of cocreation in the development and implementation of interventions aimed at improving physical activity.

Objective

This protocol presents a study that aims to investigate if interventions, which will be developed and implemented in cocreation, improve physical activity among patients in surgery, internal medicine, and cardiology hospital wards. The secondary aims are to investigate effectiveness in terms of the reduction in the time patients spend in bed, the length of hospital stay, and the proportion of patients going home after discharge.

Methods

The Better By Moving study takes place for 12 months at the following five different wards of a university hospital: two gastrointestinal and oncology surgery wards, one internal medicine hematology ward, one internal medicine infectious diseases ward, and one cardiology ward. The step-by-step implementation model of Grol and Wensing is used, and all interventions are developed and implemented in cocreation with health care professionals and patients. Outcome evaluation is performed across the different hospital wards and for each hospital ward individually. The primary outcome is the amount of physical activity in minutes assessed with the Physical Activity Monitor AM400 accelerometer in two individual groups of patients (preimplementation [n=110], and 13 months after the start of the implementation [n=110]). The secondary outcomes are time spent in bed measured using behavioral mapping protocols, and length of stay and discharge destination assessed using organizational data. A process evaluation using semistructured interviews and surveys is adopted to evaluate the implementation, mechanisms of impact, context, and perceived barriers and enablers.

Results

This study is ongoing. The first participant was enrolled in January 2018. The last outcome evaluation and process evaluation are planned for May and June 2020, respectively. Results are expected in April 2021.

Conclusions

This study will provide information about the effectiveness of developing and implementing interventions in cocreation with regard to improving physical activity in different subgroups of hospitalized patients in a university hospital. By following step-by-step implementation and by performing process evaluation, we will identify the barriers and enablers for implementation and describe the effect of new interventions on improving physical activity among hospitalized patients.

Trial Registration

Netherlands Trial Register NL8480; https://www.trialregister.nl/trial/8480

International Registered Report Identifier (IRRID)

DERR1-10.2196/19000

The impact of delayed mobilization on post-discharge outcomes after emergency abdominal surgery: A prospective cohort study in older patients

Surgeons are increasingly treating seniors with complex care needs who are at high-risk of readmission and functional decline. Yet, the prognostic importance of post-operative mobilization in older surgical patients is under-investigated and remains unclear. Thus, we evaluated the relationship between post-operative mobilization and events after hospital discharge in older people. Overall, 306 survivors of emergency abdominal surgery aged ≥65y who required help with <3 activities of daily living were prospectively followed at two Canadian tertiary-care hospitals. Time until mobilization after surgery was attained from hospital charts and a priori defined as ‘delayed’ (≥36h) or ‘early’ (<36h). Primary outcomes for 30-day and 6-month all-cause readmission/death after discharge were assessed in multivariable logistic regression. Patients had a mean age of 76 ± 7.7 years, 45% were women, 41% were ‘vulnerable-to-moderately-frail’, according to the Clinical Frailty Scale. Most common reasons for admission were gallstones (23%), intestinal obstructions (21%), and hernia (17%). Median time to post-operative mobilization was 19h (interquartile range 9−35); 74 (24%) patients had delayed mobilization. Delayed mobilization was independently associated with higher risk of 30-day readmission/death (19 [26%] vs. 22 [10%], P<0.001; adjusted odds ratio [aOR] 2.24, 95%CI 0.99–5.06, P = 0.05), but this was not statistically significant at 6-months (38 [51%] vs. 64 [28%], P<0.001; aOR 1.72, 95%CI 0.91−3.25, P = 0.1). One-quarter of older surgical patients stayed in bed for 1.5 days post-operatively. Delayed mobilization was associated with increased risk of short-term readmission/death. As older, more frail patients undergo surgery, mobilization of older surgical patients remains an understudied post-operative factor.

Trial registration: clinicaltrials.gov identifier: NCT02233153

Enhanced recovery for obese patients undergoing gynecologic cancer surgery

OBJECTIVE

To compare post-operative length of stay and complication rates of matched obese and non-obese patients in an enhanced recovery (ERAS) program after open gynecologic cancer surgery.

METHODS

We performed an observational cohort study of patients (n=1225) undergoing open surgery from November 2014 to November 2018 at a tertiary cancer center. Patients undergoing multidisciplinary procedures, non-oncologic surgery, or procedures in addition to abdominal surgery were excluded (n=190). Obese and non-obese patients were matched by date, age, disease status, and surgical complexity. The primary outcome was post-operative length of stay. Secondary outcomes included 30-day peri-operative complications, re-operation, re-admission, opioid use, and program compliance.

RESULTS

After matching, 696 patients (348 obese, 348 non-obese) with median age of 57 years (IQR 48-66) were analyzed. Obese patients had a longer median procedure time (218 min vs 192.5 min, p<0.001) and greater median estimated blood loss (300 mL vs 200 mL, p<0.001). Median (IQR) post-operative length of stay was the same for obese and non-obese patients: 3 days (IQR 2-4). Obese and non-obese patients had similar rates of grade III-IV complications (10.9% and 6.6%, respectively, p=0.06), re-operation (2.3% and 1.4%, respectively, p=0.58), and re-admission (11.8% and 8.0%, respectively, p=0.13). Grade I-II complications were more common among obese patients (62.4% vs 48.3%, p<0.001) because they had more wound complications (17.8% vs 4.9%, p<0.001). Obese patients received more opioids both during surgery (morphine equivalent dose 57.25 mg (IQR 35-72.5) vs 50 mg (IQR 25-622.5), p=0.003) and after surgery (morphine equivalent daily dose 45 mg/day (IQR 10-96.2) vs 29.37 mg/day (IQR 7.5-70), p=0.01). Obese and non-obese patients had similar ERAS program compliance (70.1% and 69.8%, respectively, p=0.32).

CONCLUSIONS

Neither post-operative length of stay nor the rate of serious complications differed significantly despite longer surgeries, greater blood loss, and more opioid use among obese patients. An ERAS program was safe, effective, and feasible for obese patients with suspected gynecologic cancer.

The Effectiveness of Hospital in Motion, a Multidimensional Implementation Project to Improve Patients' Movement Behavior During Hospitalization

OBJECTIVE

Hospital in Motion is a multidimensional implementation project aiming to improve movement behavior during hospitalization. The purpose of this study was to investigate the effectiveness of Hospital in Motion on movement behavior.

METHODS

This prospective study used a pre-implementation and post-implementation design. Hospital in Motion was conducted at 4 wards of an academic hospital in the Netherlands. In each ward, multidisciplinary teams followed a 10-month step-by-step approach, including the development and implementation of a ward-specific action plan with multiple interventions to improve movement behavior. Inpatient movement behavior was assessed before the start of the project and 1 year later using a behavioral mapping method in which patients were observed between 9:00 am and 4:00 pm. The primary outcome was the percentage of time spent lying down. In addition, sitting and moving, immobility-related complications, length of stay, discharge destination home, discharge destination rehabilitation setting, mortality, and 30-day readmissions were investigated. Differences between pre-implementation and post-implementation conditions were analyzed using the chi-square test for dichotomized variables, the Mann Whitney test for non-normal distributed data, or independent samples t test for normally distributed data.

RESULTS

Patient observations demonstrated that the primary outcome, the time spent lying down, changed from 60.1% to 52.2%. For secondary outcomes, the time spent sitting increased from 31.6% to 38.3%, and discharges to a rehabilitation setting reduced from 6 (4.4%) to 1 (0.7%). No statistical differences were found in the other secondary outcome measures.

CONCLUSION

The implementation of the multidimensional project Hospital in Motion was associated with patients who were hospitalized spending less time lying in bed and with a reduced number of discharges to a rehabilitation setting.

IMPACT

Inpatient movement behavior can be influenced by multidimensional interventions. Programs implementing interventions that specifically focus on improving time spent moving, in addition to decreasing time spent lying, are recommended.

Comparison of life-behavior-promoting mobilization care with walking-only mobilization care in post-gastrointestinal surgery patients: A quasi-experimental study

AIM

This study evaluated the effects of a new form of mobilization care called life-behavior-promotion care by comparing its effectiveness with that of conventional mobilization care, which promotes only walking.

METHODS

This was a quasi-experimental study that non-randomly allocated post-gastrointestinal surgery patients from a surgical ward into two groups: conventional care and life-behavior-promotion care. The participants received their respective care from ward nurses for the first 3 postoperative days and were asked to wear a pedometer and answer a self-administered questionnaire concerning these first 3 days. In addition, time to recover gastrointestinal function, time to completion of oxygen administration, and the number of days to achieve discharge criteria were collected from medical records.

RESULTS

Overall, 23 participants in the conventional-care group and 19 in the life-behavior-promotion-care group were analyzed. The latter group performed significantly more types of out-of-bed life behaviors during the 3 postoperative days. Among the questionnaire items concerning awareness of recovery, an interaction between intervention and length of postoperative days was confirmed for items reading "I was interested in surrounding events" and "I could spend a day like myself." In addition, in the life-behavior-promotion-care group, time to completion of oxygen administration was significantly shorter, and it took fewer days to achieve discharge criteria.

CONCLUSIONS

The results of this study suggest that life-behavior-promotion care may promote out-of-bed life behaviors during the early postoperative period, and may improve mental and physical recovery in patients who have undergone gastrointestinal surgery.

CLINICAL TRIAL REGISTRATION

The study was registered in the UMIN Clinical Trials Registry (trial ID: UMIN000021883).

Exploring the relation between preoperative physical functioning and the impact of major complications in patients following pancreatic resection

BACKGROUND

This study aimed to evaluate the association between preoperative level of physical functioning and time to recovery of physical functioning, postoperative complications, and the impact of postoperative major complications in patients undergoing elective pancreatic resection. Additionally, prediction models to identify high-risk patients for developing a major complication were externally validated.

METHODS

Perioperative data of patients who underwent pancreatic resection were analysed. Primary outcomes were time to recovery of physical functioning and postoperative major complications. Impact of a major complication was explored by evaluating its effect on time to recovery of physical functioning. Risk-prediction models were retrieved following a systematic review.

RESULTS

Multivariable analysis (n = 63) showed that ASA grade III (OR 3.498) and preoperative platelet count (OR 1.005) were associated with major complications, whereas aerobic capacity (OR 0.347) was associated with time to recovery of physical functioning. Age, preoperative aerobic capacity, functional mobility, and perceived level of functional capacity were associated with the impact of a major complication. The AUC of two risk prediction models were 0.556 and 0.701.

CONCLUSION

Preoperative parameters of physical function were associated with postoperative outcomes and may be useful in outcome prediction, although future approaches should not only register the incidence of major complications but also take the impact of a complication on a patient's physical functioning into account.

Hospital in Motion, a Multidimensional Implementation Project to Improve Patients' Physical Behavior During Hospitalization: Protocol for a Mixed-Methods Study

Background

Despite the evidence of the adverse consequences of immobility during hospitalization, patients spend most of the time in bed. Although physical activity is a modifiable factor that can prevent in-hospital functional decline, bed rest is deeply rooted in the hospital culture. To attack this, a multidimensional approach is needed. Therefore, Hospital in Motion, a multidimensional implementation project, was designed to improve physical behavior during hospitalization.

Objective

The primary objective of this study is to investigate the effectiveness of Hospital in Motion on inpatient physical behavior. Secondary objectives are to investigate the effectiveness on length of hospital stay and immobility-related complications of patients during hospitalization and to monitor the implementation process.

Methods

For this study, Hospital in Motion will be implemented within 4 wards (cardiology, cardiothoracic surgery, medical oncology, and hematology) in a Dutch University Medical Center. Per ward, multidisciplinary teams will be composed who follow a step-by-step multidimensional implementation approach including the development and implementation of tailored action plans with multiple interventions to stimulate physical activity in daily care. A prepost observational study design will be used to evaluate the difference in physical behavior before and 1 year after the start of the project, including 40 patients per time point per ward (160 patients in total). The primary outcome measure is the percentage of time spent lying, measured with the behavioral mapping method. In addition, a process evaluation will be performed per ward using caregivers’ and patient surveys and semistructured interviews with patients and caregivers.

Results

This study is ongoing. The first participant was enrolled in October 2017 for the premeasurement. The postmeasurements are planned for the end of 2018. The first results are expected to be submitted for publication in autumn 2019.

Conclusions

This study will provide information about the effectiveness of the Hospital in Motion project on physical behavior and about the procedures of the followed implementation process aimed to incorporate physical activity in usual care. These insights will be useful for others interested in changing physical behavior during hospitalization.

Trial Registration

Netherlands Trial Register NTR7109; https://www.trialregister.nl/trial/6914 (Archived by WebCite at http://www.webcitation.org/76dyhdjdd)

International Registered Report Identifier (IRRID)

DERR1-10.2196/11341

Measuring physical activity levels in hospitalized patients: a comparison between behavioural mapping and data from an accelerometer

Objective:

To investigate the level of agreement of the behavioural mapping method with an accelerometer to measure physical activity of hospitalized patients.

Design:

A prospective single-centre observational study.

Setting:

A university medical centre in the Netherlands.

Subjects:

Patients admitted to the hospital.

Main measures:

Physical activity of participants was measured for one day from 9 AM to 4 PM with the behavioural mapping method and an accelerometer simultaneously. The level of agreement between the percentages spent lying, sitting and moving from both measures was evaluated using the Bland–Altman method and by calculating Intraclass Correlation Coefficients.

Results:

In total, 30 patients were included. Mean (±SD) age was 63.0 (16.8) years and the majority of patients were men (n = 18). The mean percentage of time (SD) spent lying was 47.2 (23.3) and 49.7 (29.8); sitting 42.6 (20.5) and 40.0 (26.2); and active 10.2 (6.1) and 10.3 (8.3) according to the accelerometer and observations, respectively. The Intraclass Correlation Coefficient and mean difference (SD) between the two measures were 0.852 and –2.56 (19.33) for lying; 0.836 and 2.60 (17.72) for sitting; and 0.782 and −0.065 (6.23) for moving. The mean difference between the two measures is small (⩽2.6%) for all three physical activity levels. On patient level, the variation between both measures is large with differences above and below the mean of ⩾20% being common.

Conclusion:

The overall level of agreement between the behavioural mapping method and an accelerometer to identify the physical activity levels ‘lying’, ‘sitting’ and ‘moving’ of hospitalized patients is reasonable.

Financial Impact of Incentive Spirometry

Despite largely unproven clinical effectiveness, incentive spirometry (IS) is widely used in an effort to reduce postoperative pulmonary complications. The objective of the study is to evaluate the financial impact of implementing IS. The amount of time nurses and RTs spend each day doing IS-related activities was assessed utilizing an online survey distributed to the relevant national nursing and respiratory therapists (RT) societies along with questionnaire that was prospectively collected every day for 4 weeks at a single 10-bed cardiothoracic surgery step-down unit. Cost of RT time to teach IS use to patients and cost of nurse time spent reeducating and reminding patients to use IS were used to calculate IS implementation cost estimates per patient. Per-patient cost of IS implementation ranged from $65.30 to $240.96 for a mean 9-day step-down stay. For the 566 patients who stayed in the 10-bed step-down in 2016, the total estimated cost of implementing IS ranged from $36 959.80 to $136 383.36. Using national survey workload data, per-patient cost of IS implementation costed $107.36 (95% confidence interval [CI], $97.88-$116.98) for a hospital stay of 4.5 days. For the 9.7 million inpatient surgeries performed annually in the United States, the total annual cost of implementing postoperative IS is estimated to be $1.04 billion (95% CI, $949.4 million-$1.13 billion). The cost of implementing IS is substantial. Further efficacy studies are necessary to determine whether the cost is justifiable.

Early enforced mobilization after liver resection: A prospective randomized controlled trial

OBJECTIVE

This randomized controlled study investigated the feasibility of early ambulation after liver resection and the effect of the amount of activity on postoperative recovery.

METHODS

A total of 120 patients who underwent liver resection were randomly divided into two groups for the comparative analysis of the following factors: amount of activity, pain control, sleeping state, perioperative gastrointestinal function recovery, incidence of complications and postoperative hospital stay.

RESULTS

Compared with the control group, patients undergoing liver resection performing early postoperative ambulation had faster gastrointestinal function recovery (First exhaust time 2.2 ± 1.4 vs. 3.3 ± 2.3 p < 0.01; First flatus time 2.3 ± 1.7 vs. 3.1 ± 2.5 p = 0.04) and shorter postoperative hospital stays (6.6 ± 2.3 vs. 7.7 ± 2.1 p = 0.01), with statistically significant differences. There was no significant difference in the incidence of postoperative complications between the two groups (p > 0.05).

CONCLUSION

Early ambulation after liver resection is safe and feasible. It can reduce the patient's pain and economic burden, increase the patient's comfort, reduce the nursing workload, achieve rapid recovery, and improve patient satisfaction.

Cardiothoracic Critical Care

High-value CCC is rapidly evolving to meet the demands of increased patient acuity and to incorporate advances in technology. The high-performing CCC system and culture should aim to learn quickly and continuously improve. CCC demands a proactive, interactive, precise, an expert team, and continuity.