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Crisafi C, Grant MC, Rea A, Morton-Bailey V, Gregory AJ, Arora RC, Chatterjee S, Lother SA, Cangut B, Engelman DT. Enhanced Recovery After Surgery Cardiac Society turnkey order set for surgical-site infection prevention: Proceedings from the American Association for Thoracic Surgery ERAS Conclave 2023. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00281-2. [PMID: 38574802 DOI: 10.1016/j.jtcvs.2024.03.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Revised: 02/23/2024] [Accepted: 03/18/2024] [Indexed: 04/06/2024]
Abstract
OBJECTIVES Surgical-site infections (SSIs) after cardiac surgery increase morbidity and mortality, consume health care resources, impair recovery, and diminish patients' quality of life. Numerous guidelines and expert consensus documents have been published to address the prevention and management of SSIs. Our objective is to integrate these documents into an order set that will facilitate the adoption and implementation of evidence-based best practices for preventing and managing SSIs after cardiac surgery. METHODS Subject matter experts were consulted to translate existing guidelines and literature into a sample turnkey order set for SSI reduction. Orders derived from consistent class I, IIA, or equivalent recommendations across referenced guidelines and consensus manuscripts appear in the turnkey order set in bold type. Selected orders that were inconsistent class I or IIA, class IIB or otherwise supported by published evidence, were also included in italicized type. RESULTS Preventative care begins with the preoperative identification of both modifiable and nonmodifiable SSI risks by health care providers. Assessment tools can be used to assist in identifying patients at a high risk of SSI. Preoperative recommendations include screening for and treating Staphylococcus aureus nasal carriage. Intraoperatively, tailored prophylactic intravenous antibiotics and maintaining blood glucose levels below 180 mg/dL are essential elements. Postoperative care includes maintaining normothermia, glucose control and patient engagement. CONCLUSIONS Despite the well-documented advantages of a multidisciplinary care pathway for SSI in cardiac surgery, there are inconsistencies in its adoption and implementation. This article provides an order set that incorporates recommendations from existing guidelines to prevent SSI in the cardiac surgical population.
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Affiliation(s)
- Cheryl Crisafi
- Heart & Vascular Program Baystate Health, University of Massachusetts Chan Medical, School-Baystate, Springfield, Mass.
| | - Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, Md
| | - Amanda Rea
- Division of Cardiac Surgery, University of Maryland St Joseph Medical Center, Towson, Md
| | | | - Alexander J Gregory
- Department of Anesthesiology, Cumming School of Medicine & Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Rakesh C Arora
- Division of Cardiac Surgery, Department of Surgery, Harrington Heart and Vascular, Institute, University Hospitals, Case Western Reserve University, Cleveland, Ohio
| | | | - Sylvain A Lother
- Sections of Infectious Diseases and Critical Care Rady Faculty of Health Sciences, Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Busra Cangut
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - Daniel T Engelman
- Heart & Vascular Program Baystate Health, University of Massachusetts Chan Medical, School-Baystate, Springfield, Mass
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Hoogma DF, Croonen R, Al Tmimi L, Tournoy J, Verbrugghe P, Fieuws S, Rex S. Association between improved compliance with enhanced recovery after cardiac surgery guidelines and postoperative outcomes: A retrospective study. J Thorac Cardiovasc Surg 2024; 167:1363-1371.e2. [PMID: 35989120 DOI: 10.1016/j.jtcvs.2022.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 06/23/2022] [Accepted: 07/06/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Enhanced recovery after cardiac surgery is a multidisciplinary clinical care pathway that relies on a bundle of interventions, aiming to reduce the stress response to surgery and promote early recovery of organ function. In 2011, our institution introduced an institutional enhanced recovery after cardiac surgery program focusing on 9 central interventions, which have been expanded during the past decade by additional interventions now considered standard of care. After the recent publication of the enhanced recovery after cardiac surgery guidelines, we evaluated the relation between the compliance with these enhanced recovery after cardiac surgery guidelines and postoperative outcomes. METHODS All patients enrolled in our enhanced recovery after cardiac surgery program in 2019 were included in this retrospective single-center audit. The primary outcome was compliance with 23 enhanced recovery after cardiac surgery guidelines. Secondary outcomes included occurrence of at least 1 postoperative complication and hospital length of stay. RESULTS A total of 356 patients were included in this study. Compliance with the enhanced recovery after cardiac surgery guidelines was 64%. Postoperatively, 51% of the patients experienced at least 1 complication and had a median hospital length of stay of 6 days. Multivariable analysis showed that an increased compliance (per 10%) with the enhanced recovery after cardiac surgery guidelines was associated with a lower risk for any complication (odds ratio, 0.60; 95% confidence interval, 0.46-0.79; P = .0003) and a higher probability of earlier hospital discharge (hazard ratio, 1.25; 95% confidence interval, 1.10-1.43; P = .0008). CONCLUSIONS This audit revealed a correlation between increased compliance with enhanced recovery after cardiac surgery guidelines and a reduction of postoperative complications and hospital length of stay. Future trials are needed to establish evidence-based recommendations for each separate intervention of the enhanced recovery after cardiac surgery guidelines and to create a minimum core-set of enhanced recovery after cardiac surgery interventions.
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Affiliation(s)
- Danny Feike Hoogma
- Department of Anesthesiology, University Hospitals Leuven, KU Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, University Leuven, Biomedical Sciences Group, KU Leuven, Leuven, Belgium.
| | - Roel Croonen
- Department of Anesthesiology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Layth Al Tmimi
- Department of Anesthesiology, University Hospitals Leuven, KU Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, University Leuven, Biomedical Sciences Group, KU Leuven, Leuven, Belgium
| | - Jos Tournoy
- Geriatric Medicine and Department of Public Health and Primary Care, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Peter Verbrugghe
- Department of Cardiovascular Sciences, University Leuven, Biomedical Sciences Group, KU Leuven, Leuven, Belgium; Department of Cardiac Surgery, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Steffen Fieuws
- University Leuven, Biomedical Sciences Group, Leuven Biostatistics and Statistical Bioinformatics Centre (L-BioStat), KU Leuven, Leuven, Belgium
| | - Steffen Rex
- Department of Anesthesiology, University Hospitals Leuven, KU Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, University Leuven, Biomedical Sciences Group, KU Leuven, Leuven, Belgium
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Grant MC, Crisafi C, Alvarez A, Arora RC, Brindle ME, Chatterjee S, Ender J, Fletcher N, Gregory AJ, Gunaydin S, Jahangiri M, Ljungqvist O, Lobdell KW, Morton V, Reddy VS, Salenger R, Sander M, Zarbock A, Engelman DT. Perioperative Care in Cardiac Surgery: A Joint Consensus Statement by the Enhanced Recovery After Surgery (ERAS) Cardiac Society, ERAS International Society, and The Society of Thoracic Surgeons (STS). Ann Thorac Surg 2024; 117:669-689. [PMID: 38284956 DOI: 10.1016/j.athoracsur.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 11/27/2023] [Accepted: 12/09/2023] [Indexed: 01/30/2024]
Abstract
Enhanced Recovery After Surgery (ERAS) programs have been shown to lessen surgical insult, promote recovery, and improve postoperative clinical outcomes across a number of specialty operations. A core tenet of ERAS involves the provision of protocolized evidence-based perioperative interventions. Given both the growing enthusiasm for applying ERAS principles to cardiac surgery and the broad scope of relevant interventions, an international, multidisciplinary expert panel was assembled to derive a list of potential program elements, review the literature, and provide a statement regarding clinical practice for each topic area. This article summarizes those consensus statements and their accompanying evidence. These results provide the foundation for best practice for the management of the adult patient undergoing cardiac surgery.
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Affiliation(s)
- Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | - Cheryl Crisafi
- Heart and Vascular Program, Baystate Health, University of Massachusetts Chan Medical School-Baystate, Springfield, Massachusetts
| | - Adrian Alvarez
- Department of Anesthesia, Hospital Italiano, Buenos Aires, Argentina
| | - Rakesh C Arora
- Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Mary E Brindle
- Departments of Surgery and Community Health Services, Cumming School of Medicine University of Calgary, Calgary, Alberta, Canada
| | - Subhasis Chatterjee
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Joerg Ender
- Department of Anaesthesiology and Intensive Care Medicine, Heart Center Leipzig, University Leipzig, Leipzig, Germany
| | - Nick Fletcher
- Institute of Anesthesia and Critical Care, Cleveland Clinic London, London, United Kingdom; St George's University Hospital, London, United Kingdom
| | - Alexander J Gregory
- Department of Anesthesia, Perioperative and Pain Medicine, Cumming School of Medicine University of Calgary, Calgary, Alberta, Canada
| | - Serdar Gunaydin
- Department of Cardiovascular Surgery, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Marjan Jahangiri
- Department of Cardiac Surgery, St George's Hospital, London, United Kingdom
| | - Olle Ljungqvist
- Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Kevin W Lobdell
- Regional Cardiovascular and Thoracic Quality, Education, and Research, Atrium Health, Charlotte, North Carolina
| | - Vicki Morton
- Clinical and Quality Outcomes, Providence Anesthesiology Associates, Charlotte, North Carolina
| | - V Seenu Reddy
- Centennial Heart & Vascular Center, Nashville, Tennessee
| | - Rawn Salenger
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Michael Sander
- Department of Anaesthesiology, Operative Intensive Care Medicine and Pain Therapy, Justus Liebig University of Giessen, Giessen, Germany
| | - Alexander Zarbock
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Daniel T Engelman
- Heart and Vascular Program, Baystate Health, University of Massachusetts Chan Medical School-Baystate, Springfield, Massachusetts
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Higginbotham S, Almoghrabi O, Crawford TC. Fast-track extubation in minimally invasive mitral valve surgery: moving beyond the biases. Eur J Cardiothorac Surg 2024; 65:ezae083. [PMID: 38445653 DOI: 10.1093/ejcts/ezae083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 03/04/2024] [Indexed: 03/07/2024] Open
Affiliation(s)
- Simon Higginbotham
- Department of Cardiovascular and Thoracic Surgery, University of Kansas School of Medicine, Kansas City, KS, USA
| | - Omar Almoghrabi
- Department of Cardiovascular and Thoracic Surgery, University of Kansas School of Medicine, Kansas City, KS, USA
| | - Todd C Crawford
- Department of Cardiovascular and Thoracic Surgery, University of Kansas School of Medicine, Kansas City, KS, USA
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Lobdell KW, Grant MC, Salenger R. Temporary mechanical circulatory support & enhancing recovery after cardiac surgery. Curr Opin Anaesthesiol 2024; 37:16-23. [PMID: 38085881 DOI: 10.1097/aco.0000000000001332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2023]
Abstract
PURPOSE OF REVIEW This review highlights the integration of enhanced recovery principles with temporary mechanical circulatory support associated with adult cardiac surgery. RECENT FINDINGS Enhanced recovery elements and efforts have been associated with improvements in quality and value. Temporary mechanical circulatory support technologies have been successfully employed, improved, and the value of their proactive use to maintain hemodynamic goals and preserve long-term myocardial function is accruing. SUMMARY Temporary mechanical circulatory support devices promise to enhance recovery by mitigating the risk of complications, such as postcardiotomy cardiogenic shock, organ dysfunction, and death, associated with adult cardiac surgery.
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Affiliation(s)
- Kevin W Lobdell
- Sanger Heart & Vascular Institute, Advocate Health, Charlotte, North Carolina
| | - Michael C Grant
- Johns Hopkins University School of Medicine, Anesthesiology and Critical Care Medicine, Baltimore
| | - Rawn Salenger
- University of Maryland School of Medicine, Department of Surgery, Towson, Maryland, USA
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Mondal S, Bergbower EAS, Cheung E, Grewal AS, Ghoreishi M, Hollander KN, Anders MG, Taylor BS, Tanaka KA. Role of Cardiac Anesthesiologists in Intraoperative Enhanced Recovery After Cardiac Surgery (ERACS) Protocol: A Retrospective Single-Center Study Analyzing Preliminary Results of a Yearlong ERACS Protocol Implementation. J Cardiothorac Vasc Anesth 2023; 37:2450-2460. [PMID: 36517338 DOI: 10.1053/j.jvca.2022.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Revised: 10/24/2022] [Accepted: 11/06/2022] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Enhanced recovery after cardiac surgery (ERACS) has been gaining rapid acceptance after multiple studies have demonstrated promising results in improved outcomes of enhanced recovery after surgery in other surgical fields (eg, colorectal, orthopedic, thoracic, etc). Cardiac surgery has several unique challenges, including sternotomy, cardiopulmonary bypass and associated coagulopathy, blood transfusion, and postoperative intensive care requirement. Nonetheless, selective cardiac surgical patients can still benefit from ERACS. Guidelines for perioperative care in cardiac surgery, previously published by the ERACS Society, are weighted heavily in preoperative and postoperative management without much focus on intraoperative care provided by anesthesiologists. To address this gap and to explore anesthesiology's contribution in achieving ERACS, the study authors' cardiac anesthesiology division, in collaboration with cardiac surgery, introduced the ERACS protocol in their institution in February 2020. METHODS The cardiac anesthesiology division, in collaboration with cardiac surgery, introduced the ERACS protocol consisting of multimodal opioid-sparing analgesia, including the introduction of regional blocks, hemostasis management protocol, reversal of neuromuscular blockade, and administration of antiemetics in the authors' institution in February 2020. They have conducted a retrospective chart review study comparing patients who have received ERACS measures with a similar historic cohort who underwent cardiac surgery prior to initiation of an ERACS protocol. The primary outcomes of the study were to determine patients' time to extubation, postoperative opioid consumption, intensive care unit (ICU) length of stay (LOS), and incidence of postoperative complications (eg, postoperative nausea vomiting [PONV], bleeding, ICU readmission, delirium. RESULTS The ERACS patients showed reduced opioid consumption (intraoperative fentanyl; postoperative fentanyl, as well as oxycodone, in the first 6 hours postoperatively), lesser mechanical ventilation (2.5 hours less), shorter ICU stays (5 hours less), shorter hospital LOS (1 day), and lesser incidence of PONV. None of the ERACS patients required blood transfusion. The study authors performed an anonymous survey among the anesthesiologists and ICU providers to assess providers' satisfaction, which showed 92% of survey takers agreed that the ERACS protocol should be continued for future cardiac patients, and 61% of survey takers reported superior pain control in ERACS group of patients while managing those patients. DISCUSSION The ERACS is achievable after the careful implementation of a series of measures. It does not signify only fast-track extubation and opioid-sparing analgesia, and must be implemented in the entire perioperative period beginning from preoperative clinic to postoperative rehabilitation. Cardiac anesthesiologists play a vital role in execution of intraoperative ERACS measures. Both providers and patients themselves are key stakeholders. A larger randomized prospective trial is warranted to solidify the inference.
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Affiliation(s)
- Samhati Mondal
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD.
| | - Emily A S Bergbower
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| | - Enoch Cheung
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| | - Ashanpreet S Grewal
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| | - Mehrdad Ghoreishi
- Department of Surgery, Cardiothoracic division, University of Maryland School of Medicine, Baltimore, MD
| | - Kimberly N Hollander
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| | - Megan G Anders
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| | - Bradley S Taylor
- Department of Surgery, Cardiothoracic division, University of Maryland School of Medicine, Baltimore, MD
| | - Kenichi A Tanaka
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK
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Sun BJ, Yue TM, Xu N, Fowler C, Lee B. Impact of Successful Implementation of an Enhanced Recovery After Surgery Protocol for Patients Undergoing Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy. Ann Surg Oncol 2023; 30:8156-8165. [PMID: 37684372 DOI: 10.1245/s10434-023-14222-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 08/13/2023] [Indexed: 09/10/2023]
Abstract
BACKGROUND Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) are complex operations for the treatment of peritoneal metastases. Enhanced recovery after surgery (ERAS) protocols are intended to standardize preoperative, intraoperative, and postoperative pathways, with the goal of improving patient care. This study describes feasibility and outcomes after implementing an ERAS protocol for CRS/HIPEC at a tertiary academic center. METHODS A single-institution experience of CRS/HIPEC was reviewed from January 2020 to March 2023. Patients were categorized according to whether they underwent CRS/HIPEC before or after ERAS initiation. Outcomes and protocol adherence were evaluated. RESULTS A total of 115 CRS/HIPEC operations were included-74 before and 41 after ERAS implementation. Median age was younger in the post-ERAS group, whereas sex, comorbidities, peritoneal carcinomatosis index, operation performed, and operative time were similar between groups. The most common primary cancer sites were gynecologic (40%), appendiceal (24%), and colorectal (22%). Adherence to all postoperative ERAS components was 76%. More post-ERAS patients ambulated by postoperative day (POD) 1 (90% vs. 54%; p < 0.001), tolerated liquid diet by POD 2 (88% vs. 32%; p < 0.001), and had foley removed by POD 3 (86% vs. 43%; p < 0.001). There was a trend toward decreased length of stay in the post-ERAS cohort (7 vs. 8 days; p = 0.092), with no difference in major complications, intensive care unit admission, or 30-day readmission. CONCLUSIONS Despite the heterogeneity of CRS/HIPEC operations, implementing an ERAS protocol for our patients was feasible and resulted in postoperative outcomes and adherence comparable with that of other major abdominal surgeries. This supports the potential for success in ERAS programs for CRS/HIPEC patients.
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Affiliation(s)
- Beatrice J Sun
- Department of Surgery, Section of Surgical Oncology, Stanford University School of Medicine, Stanford, CA, USA
| | - Tiffany M Yue
- Stanford University School of Medicine, Stanford, CA, USA
| | - Nova Xu
- Stanford University School of Medicine, Stanford, CA, USA
| | - Cedar Fowler
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Byrne Lee
- Department of Surgery, Section of Surgical Oncology, Stanford University School of Medicine, Stanford, CA, USA.
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Wang SR, Zhou K, Zhang W. Application progress of nursing intervention in cardiac surgery. World J Clin Cases 2023; 11:7943-7950. [DOI: 10.12998/wjcc.v11.i33.7943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 09/27/2023] [Accepted: 11/16/2023] [Indexed: 11/24/2023] Open
Abstract
As a stressor, cardiac surgery affects the physiology and psychology of patients, as well as their postoperative recovery. Patients tend to worry about cognitive deficiency, pain, discomfort, the risk of death, sleep, complications, and other factors, resulting in stress and anxiety. Moreover, serious adverse events, such as circulatory and respiratory dysfunction and infection, tend to occur after cardiac surgery and increase the economic burden on patients. Therefore, appropriate nursing interventions should be selected to strengthen patients’ cognitive levels, compliance, and postoperative practices to accelerate their recovery, reduce complications, and shorten hospital stays so as to contribute to patients’ lives and health.
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Affiliation(s)
- Si-Ru Wang
- Department of Nursing, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| | - Ke Zhou
- Department of Cardiac Surgery, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| | - Wei Zhang
- Department of Nursing, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
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Lee JJR, Srinivasan R, Ong CS, Alejo D, Schena S, Shpitser I, Sussman M, Whitman GJR, Malinsky D. Causal determinants of postoperative length of stay in cardiac surgery using causal graphical learning. J Thorac Cardiovasc Surg 2023; 166:e446-e462. [PMID: 36154975 PMCID: PMC9968823 DOI: 10.1016/j.jtcvs.2022.08.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 07/24/2022] [Accepted: 08/18/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVE We aimed to learn the causal determinants of postoperative length of stay in cardiac surgery patients undergoing isolated coronary artery bypass grafting or aortic valve replacement surgery. METHODS For patients undergoing isolated coronary artery bypass grafting or isolated aortic valve replacement surgeries between 2011 and 2016, we used causal graphical modeling on electronic health record data. The Fast Causal Inference (FCI) algorithm from the Tetrad software was used on data to estimate a Partial Ancestral Graph (PAG) depicting direct and indirect causes of postoperative length of stay, given background clinical knowledge. Then, we used the latent variable intervention-calculus when the directed acyclic graph is absent (LV-IDA) algorithm to estimate strengths of causal effects of interest. Finally, we ran a linear regression for postoperative length of stay to contrast statistical associations with what was learned by our causal analysis. RESULTS In our cohort of 2610 patients, the mean postoperative length of stay was 219 hours compared with the Society of Thoracic Surgeons 2016 national mean postoperative length of stay of approximately 168 hours. Most variables that clinicians believe to be predictors of postoperative length of stay were found to be causes, but some were direct (eg, age, diabetes, hematocrit, total operating time, and postoperative complications), and others were indirect (including gender, race, and operating surgeon). The strongest average causal effects on postoperative length of stay were exhibited by preoperative dialysis (209 hours); neuro-, pulmonary-, and infection-related postoperative complications (315 hours, 89 hours, and 131 hours, respectively); reintubation (61 hours); extubation in operating room (-47 hours); and total operating room duration (48 hours). Linear regression coefficients diverged from causal effects in magnitude (eg, dialysis) and direction (eg, crossclamp time). CONCLUSIONS By using retrospective electronic health record data and background clinical knowledge, causal graphical modeling retrieved direct and indirect causes of postoperative length of stay and their relative strengths. These insights will be useful in designing clinical protocols and targeting improvements in patient management.
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Affiliation(s)
- Jaron J R Lee
- Department of Computer Science, Johns Hopkins University, Baltimore, Md; Malone Center for Engineering in Healthcare, Johns Hopkins University, Baltimore, Md.
| | - Ranjani Srinivasan
- Malone Center for Engineering in Healthcare, Johns Hopkins University, Baltimore, Md; Department of Electrical and Computer Engineering, Johns Hopkins University, Baltimore, Md
| | - Chin Siang Ong
- Division of Surgical Outcomes, Department of Surgery, Yale School of Medicine, New Haven, Conn
| | - Diane Alejo
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Md
| | - Stefano Schena
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Md
| | - Ilya Shpitser
- Department of Computer Science, Johns Hopkins University, Baltimore, Md; Malone Center for Engineering in Healthcare, Johns Hopkins University, Baltimore, Md
| | - Marc Sussman
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Md
| | - Glenn J R Whitman
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Md
| | - Daniel Malinsky
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY
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Doruker NC, Oden TN, Korkmaz FD. Determination of Knowledge and Attitudes of Cardiac Surgery Nurses Regarding the Enhanced Recovery After Surgery Protocol. J Perianesth Nurs 2023; 38:710-716. [PMID: 36967302 DOI: 10.1016/j.jopan.2022.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 09/13/2022] [Accepted: 11/06/2022] [Indexed: 06/18/2023]
Abstract
PURPOSE This study aimed to examine the knowledge and attitudes of cardiac surgery nurses regarding the enhanced recovery after surgery protocol. DESIGN This was a descriptive, cross-sectional study. METHODS The sample consisted of 50 nurses working in the cardiovascular surgery clinic of a university hospital in the province of Izmir, Turkey. A questionnaire consisting of three sections was prepared by the researchers to collect data. The first section of the form captured sociodemographic and descriptive characteristics; the second section examined the level of knowledge about the enhanced recovery protocol for cardiac surgery; the third section captured the nurses' attitudes regarding the enhanced recovery protocol. The questionnaire was distributed to the nurses and the research data were collected after a certain amount of time. Descriptive statistics, Mann-Whitney U test, Kruskal-Wallis test, and correlation analysis were used in the analysis of the data. FINDINGS The mean age of the nurses was 31.26 ± 6.74 (min = 23, max = 47); 78% were female; 76% had a bachelor's degree; 48% were employed in the intensive care unit. The mean score of the nurses regarding their level of knowledge on the enhanced recovery protocol for cardiac surgery was 18.70 ± 5.29 (min = 0.00, max = 28.00); the mean score regarding attitude toward the enhanced recovery protocol after surgery was 30.00 ± 3.86 (min = 12.00, max = 33.00). There was a positive, moderate, statistically significant correlation (r = 0.396, P = .005) between the mean knowledge level score and the mean attitude level score. CONCLUSIONS Results showed that nurses' knowledge was at a moderately positive level. Increasing the level of knowledge increased positive attitudes. Recommendations include disseminating protocol information and providing necessary training to increase positive attitudes in an effort to ensure protocol adherance.
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Affiliation(s)
| | - Tugba Nur Oden
- Ege University Hospital, Organ Transplantation Practice and Research Center, Izmir, Turkey
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11
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Hootsmans N, Parmiter S, Connors K, Badve SB, Snyder E, Turcotte JJ, Jayaraman SS, Zahiri HR. Outcomes of an enhanced recovery after surgery (ERAS) program to limit perioperative opioid use in outpatient minimally invasive GI and hernia surgeries. Surg Endosc 2023; 37:7192-7198. [PMID: 37353653 DOI: 10.1007/s00464-023-10217-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 06/12/2023] [Indexed: 06/25/2023]
Abstract
BACKGROUND Perioperative pain management is important for patient satisfaction while returning to homeostasis in the safest way possible. Studies show that patients don't require as much opioids as once thought. The benefits of ERAS pathways extend beyond enhancement of patients' perioperative experience, and include reducing opioid prescriptions in the face of the ongoing nationwide opioid crisis and evidence of prescription opioids as a contributor. METHODS We performed a retrospective cohort study of patients undergoing same day minimally invasive surgery (MIS) procedures for GI and hernia disease using a minimal-opioid ERAS protocol at two community hospitals between January 2020 and May 2022. We included elective laparoscopic cholecystectomy (LC), laparoscopic appendectomy (LA) for acute appendicitis without perforation, and minimally invasive (laparoscopic and robotic) inguinal and ventral hernia repair or abdominal wall reconstruction (AWR). Primary outcome was postoperative opioid use. RESULTS A total of 509 patients were included, undergoing procedures of MIS hernia repair (52.5%), LC (43.6%), and LA (7.9%). Only 9.4% of patients received opioid prescriptions at discharge, with no difference between groups. Among the patients receiving a prescription at discharge, there was a significant difference in morphine milligram equivalents (MME) prescribed (25.0 ± 0.0 in the LA group, 65.0 ± 41.4 in the LC group, 100.6 ± 46.2 in the MIS hernia/AWR group; P = 0.015). Nine percent of patients called with pain management concerns postoperatively. ASA score ≥ 3 was associated with increased odds for postoperative opioid prescription (OR 2.084; P = 0.014). CONCLUSIONS We demonstrate that an opioid-sparing ERAS program effectively manages pain for patients undergoing multiple outpatient MIS GI/hernia procedures, and suggests generalizability across a diverse range of operations. Therefore, the use of ERAS may safely and effectively expand beyond inpatient MIS and open surgeries that target reduced length of stay to also minimize opioids for outpatient procedures.
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Affiliation(s)
- Norbert Hootsmans
- Luminis Health Anne Arundel Medical Center, 2001 Medical Pkwy, Annapolis, MD, USA.
| | - Sara Parmiter
- Luminis Health Anne Arundel Medical Center, 2001 Medical Pkwy, Annapolis, MD, USA
| | - Kevin Connors
- Luminis Health Anne Arundel Medical Center, 2001 Medical Pkwy, Annapolis, MD, USA
| | - Shivani B Badve
- Luminis Health Anne Arundel Medical Center, 2001 Medical Pkwy, Annapolis, MD, USA
| | - Elise Snyder
- Luminis Health Anne Arundel Medical Center, 2001 Medical Pkwy, Annapolis, MD, USA
| | - Justin J Turcotte
- Luminis Health Anne Arundel Medical Center, 2001 Medical Pkwy, Annapolis, MD, USA
| | | | - H Reza Zahiri
- Luminis Health Anne Arundel Medical Center, 2001 Medical Pkwy, Annapolis, MD, USA
- Luminis Health Doctors Community Medical Center, Lanham, MD, USA
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12
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O'Brien J, Barbour-Tuck E, Xia L, Campbell K, Reimche E, Valiani S, Pikaluk R, Clunie M. Introducing Cardiac Enhanced Recovery After Surgery best practices in Saskatchewan. Can J Anaesth 2023; 70:1409-1410. [PMID: 37253859 PMCID: PMC10228880 DOI: 10.1007/s12630-023-02483-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 01/13/2023] [Accepted: 01/16/2023] [Indexed: 06/01/2023] Open
Affiliation(s)
- Jennifer O'Brien
- Provincial Department of Anesthesiology, College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Erin Barbour-Tuck
- Provincial Department of Anesthesiology, College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Lei Xia
- Provincial Department of Anesthesiology, College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Kathy Campbell
- Provincial Department of Anesthesiology, College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Eileen Reimche
- Saskatchewan Center for Patient Oriented Research, University of Saskatchewan, Saskatoon, SK, Canada
| | - Sabira Valiani
- Department of Medicine, College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Ryan Pikaluk
- Provincial Department of Anesthesiology, College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Michelle Clunie
- Provincial Department of Anesthesiology, College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada.
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13
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Yang P, Diaz A, Chhabra KR, Byrnes ME, Rajkumar A, Nathan H, Dimick JB. Surgical Leadership Competencies for Navigating Hospital Network Expansion. J Surg Res 2023; 283:76-83. [PMID: 36375265 DOI: 10.1016/j.jss.2022.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 09/24/2022] [Accepted: 10/18/2022] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Today, many hospitals are part of a multihospital network, which changes the context in which surgeons are asked to lead. This study explores key leadership competencies that surgical leaders use to navigate this hospital network expansion. METHODS In this qualitative study, 30 surgical leaders were interviewed. Interviews were coded and analyzed via thematic analysis. RESULTS We identified three key competencies that leaders felt were important leadership skills to successfully navigate expanding hospital networks. First, leaders must steer the departmental vision within the evolving hospital network landscape. Second, leaders must align the visions of the department and of the hospital network. Third, leaders must build a network-oriented culture within their department. CONCLUSIONS As networks expand, leaders are tasked with unifying vision in their department. Leaders identified a unique opportunity to leverage their growing influence across the hospital network and invested in the people and culture of their department.
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Affiliation(s)
- Phillip Yang
- University of Michigan Medical School, Ann Arbor, Michigan.
| | - Adrian Diaz
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan; National Clinician Scholars Program at the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan; Department of Surgery, Ohio State University, Columbus, Ohio
| | - Karan R Chhabra
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan; National Clinician Scholars Program at the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan; Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Mary E Byrnes
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan; Department of Surgery, Michigan Medicine, Ann Arbor, Michigan
| | | | - Hari Nathan
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan; Department of Surgery, Michigan Medicine, Ann Arbor, Michigan
| | - Justin B Dimick
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan; Department of Surgery, Michigan Medicine, Ann Arbor, Michigan
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14
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Gregory AJ, Noss CD, Chun R, Gysel M, Prusinkiewicz C, Webb N, Raymond M, Cogan J, Rousseau-Saine N, Lam W, van Rensburg G, Alli A, de Vasconcelos Papa F. Perioperative Optimization of the Cardiac Surgical Patient. Can J Cardiol 2023; 39:497-514. [PMID: 36746372 DOI: 10.1016/j.cjca.2023.01.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 01/16/2023] [Accepted: 01/29/2023] [Indexed: 02/06/2023] Open
Abstract
Perioperative optimization of cardiac surgical patients is imperative to reduce complications, utilize health care resources efficiently, and improve patient recovery and quality of life. Standardized application of evidence-based best practices can lead to better outcomes. Although many practices should be applied universally to all patients, there are also opportunities along the surgical journey to identify patients who will benefit from additional interventions that will further ameliorate their recovery. Enhanced recovery programs aim to bundle several process elements in a standardized fashion to optimize outcomes after cardiac surgery. A foundational concept of enhanced recovery is attaining a better postsurgical end point for patients, in less time, through achievement and maintenance in their greatest possible physiologic, functional, and psychological state. Perioperative optimization is a broad topic, spanning multiple phases of care and involving a variety of medical specialties and nonphysician health care providers. In this review we highlight a variety of perioperative care topics, in which a comprehensive approach to patient care can lead to improved results for patients, providers, and the health care system. A particular focus on patient-centred care is included. Although existing evidence supports all of the elements reviewed, most require further improvements in implementation, as well as additional research, before their full potential and usefulness can be determined.
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Affiliation(s)
- Alexander J Gregory
- Cumming School of Medicine and Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada.
| | - Christopher D Noss
- Cumming School of Medicine and Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Rosaleen Chun
- Cumming School of Medicine and Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Michael Gysel
- Cumming School of Medicine and Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Christopher Prusinkiewicz
- Cumming School of Medicine and Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Nicole Webb
- Cumming School of Medicine and Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Meggie Raymond
- Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada
| | - Jennifer Cogan
- Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada
| | | | - Wing Lam
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Gerry van Rensburg
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Ahmad Alli
- Department of Anesthesia, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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15
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Edwards J, Binongo J, Mullin B, Wei J, Ghelani K, Kumarasamy M, Hanson P, Duggan M, Shoffstall J, Halkos M. Intensive Care Unit Bypass for Robotic-Assisted Single-Vessel Coronary Artery Bypass Grafting. Ann Thorac Surg 2023; 115:511-517. [PMID: 35870521 DOI: 10.1016/j.athoracsur.2022.06.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 06/16/2022] [Accepted: 06/25/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Fast-track and enhanced recovery after cardiac surgical procedures have shown reductions in intensive care unit (ICU) and hospital lengths of stay, with unchanged outcomes. However, cost reduction by an ultra-fast-track protocol after minimally invasive cardiac operations, without compromising clinical benefits, has yet to be demonstrated. METHODS A total of 215 consecutive patients underwent robotic-assisted coronary artery bypass grafting, with 156 preoperatively stratified into conventional ICU recovery vs 59 candidates for a defined ICU-bypass protocol involving recovery room and floor care. Of these, 40 candidates completed the protocol, and 19 had conversion-to-ICU recovery. Because of right-skewed distribution, inpatient cost was log-transformed, and linear regression models were constructed to estimate geometric mean ratios (GMRs) comparing inpatient cost for these groups (conventional ICU recovery, ICU-bypass, conversion-to-ICU recovery), adjusted for The Society of Thoracic Surgeons Predicted Risk of Mortality score. RESULTS Compared with the conventional ICU group, the ICU-bypass group conferred a 15% reduction in total inpatient (GMR, 0.85; P = .0007) and a 14% reduction in total variable direct costs (GMR, 0.86; P = .003). Compared with the conventional ICU group, the ICU-bypass and conversion-to-ICU groups had similar net hospital stay reductions (1.6-1.7 days). Relative to the conventional ICU group, ICU and floor duration were shortened after conversion to ICU, with a trend to reduced costs. Cardiac arrest, 30-day mortality, and stroke were absent, and other key adverse events did not differ between groups. CONCLUSIONS A selective, successful ultra-fast-track ICU-bypass protocol for robotic-assisted coronary artery bypass grafting reduces inpatient cost without affecting short-term outcomes. Conversion-to-ICU recovery also maintains outcomes and trends toward reduced costs.
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Affiliation(s)
- Joseph Edwards
- Department of Anesthesiology, Emory University, Atlanta, Georgia.
| | - Jose Binongo
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Brian Mullin
- Department of Surgery, Emory University, Atlanta, Georgia
| | - Jane Wei
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Kunali Ghelani
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | | | - Peyton Hanson
- School of Medicine, Emory University, Atlanta, Georgia
| | - Michael Duggan
- Department of Anesthesiology, Emory University, Atlanta, Georgia
| | | | - Michael Halkos
- Department of Surgery, Emory University, Atlanta, Georgia
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16
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Teh SH, Schecter SC, Servais EB, Liu K, Svahn J, Yang L, Goodstein M, Parent R, Chau E, Chang L, Zhou M, Shiraga S, Knox M. Same-Day Home Recovery for Benign Foregut Surgery. JAMA Surg 2022; 157:2796290. [PMID: 36103170 PMCID: PMC9475440 DOI: 10.1001/jamasurg.2022.4245] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 06/18/2022] [Indexed: 09/16/2023]
Abstract
Importance Same-day home recovery (SHR) is now the standard of care for many major surgical procedures and has the potential to become standard practice for benign foregut procedures (eg, hiatal hernia repair, fundoplication, and Heller myotomy). Objective To determine whether SHR for patients undergoing benign foregut surgery is feasible, safe, and effective. Design, Setting, and Participants This prospective cohort study took place across 19 medical centers within an integrated health care system in northern California from January 2019 through September 2021. Participants included consecutive patients undergoing elective benign foregut surgery. Exposures Standardized SHR program. Main Outcomes and Measures The primary end point was the rate of SHR. The secondary end points were 7-day and 30-day rates of postoperative emergency department visits, hospital readmissions, and reoperations. Results Of 1248 patients who underwent benign foregut surgery from January 2017 through September 2021, 558 were patients before implementation of the SHR program and 690 were patients postimplementation. The mean age of patients was 60 years, and 759 (59%) were female. The preimplementation SHR rate was 64 of 558 patients (11.5%) in 2018 and increased to 82 of 113 patients (72.6%) by 2021 (94/350 [26.9%] in 2019 and 112/227 [49.3%] in 2020; P < .001). There were no statistical differences in the 7-day and 30-day rates of postoperative emergency visits, hospital readmissions, and reoperations or 30-day mortality in the SHR vs non-SHR groups in the postimplementation era. Conclusions and Relevance In this study, implementation of a regional SHR program among patients undergoing elective benign foregut surgery was feasible, safe, and effective. The changes in perioperative care require comprehensive patient education and full multidisciplinary support. An SHR program for benign foregut procedures has the potential to improve patient care and cost-effectiveness in care delivery.
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Affiliation(s)
- Swee H. Teh
- The Permanente Benign Foregut Surgery Group, Northern California Kaiser Permanente, Oakland
| | - Samuel C. Schecter
- The Permanente Benign Foregut Surgery Group, Northern California Kaiser Permanente, Oakland
| | - Edgar B. Servais
- TPMG Consulting Services, The Permanente Medical Group, Oakland, California
| | - Kingsway Liu
- The Permanente Benign Foregut Surgery Group, Northern California Kaiser Permanente, Oakland
| | - Jonathan Svahn
- The Permanente Benign Foregut Surgery Group, Northern California Kaiser Permanente, Oakland
| | - Lisa Yang
- The Permanente Benign Foregut Surgery Group, Northern California Kaiser Permanente, Oakland
| | - Monica Goodstein
- The Permanente Benign Foregut Surgery Group, Northern California Kaiser Permanente, Oakland
| | - Richard Parent
- The Permanente Benign Foregut Surgery Group, Northern California Kaiser Permanente, Oakland
| | - Edward Chau
- The Permanente Benign Foregut Surgery Group, Northern California Kaiser Permanente, Oakland
| | - Lynn Chang
- The Permanente Benign Foregut Surgery Group, Northern California Kaiser Permanente, Oakland
| | - Minhoa Zhou
- The Permanente Benign Foregut Surgery Group, Northern California Kaiser Permanente, Oakland
| | - Sharon Shiraga
- The Permanente Benign Foregut Surgery Group, Northern California Kaiser Permanente, Oakland
| | - Michelle Knox
- TPMG Consulting Services, The Permanente Medical Group, Oakland, California
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17
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Ennis S, Lobley G, Worrall S, Evans B, Kimani PK, Khan A, Powell R, Banerjee P, Barker T, McGregor G. Effectiveness and Safety of Early Initiation of Poststernotomy Cardiac Rehabilitation Exercise Training: The SCAR Randomized Clinical Trial. JAMA Cardiol 2022; 7:817-824. [PMID: 35731506 DOI: 10.1001/jamacardio.2022.1651] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Importance Guidelines recommend that cardiac rehabilitation (CR) exercise training should not start until 6 weeks after sternotomy, although this is not evidence based. Limited data suggest that starting earlier is not detrimental, but clinical trials are needed. Objective To compare the effectiveness and safety of CR exercise training started either 2 weeks (early CR) or 6 weeks (usual-care CR) after sternotomy. Design, Setting, and Participants This was an assessor-blind, noninferiority, parallel-group, randomized clinical trial that conducted participant recruitment from June 12, 2017, to March 17, 2020. Participants were consecutive cardiac surgery sternotomy patients recruited from 2 outpatient National Health Service rehabilitation centers: University Hospital, Coventry, UK, and Hospital of St Cross, Rugby, UK. Interventions Participants were randomly assigned to 8 weeks of twice-weekly supervised CR exercise training starting either 2 weeks (early CR) or 6 weeks (usual-care CR) after sternotomy. Exercise training adhered to existing guidelines, including functional strength and cardiovascular components. Main Outcomes and Measures Outcomes were assessed at baseline (inpatient after surgery), after CR (10 or 14 weeks after sternotomy), and 12 months after randomization. The primary outcome was the change in 6-minute walk test distance from baseline to after CR. Secondary outcomes included safety, functional fitness, and quality of life. Results A total of 158 participants (mean [SD] age, 63 [11.5] years, 133 male patients [84.2%]) were randomly assigned to study groups; 118 patients (usual-care CR, 61 [51.7%]; early CR, 57 [48.3%]) were included in the primary analysis. Early CR was not inferior to usual-care CR (noninferiority margin, 35 m); the mean change in 6-minute walk distance from baseline to after CR was 28 m greater in the early CR group (95% CI, -11 to 66; P = .16). Mean differences for secondary outcomes were not statistically significant, indicating noninferiority of early CR. There were 46 vs 58 adverse events and 14 vs 18 serious adverse events in usual-care CR and early CR, respectively. There was no difference between the groups in the likelihood of participants having an adverse or serious adverse event. Conclusions and Relevance Starting exercise training from 2 weeks after sternotomy was as effective as starting 6 weeks after sternotomy for improving 6-minute walk distance. With appropriate precautions, clinicians and CR professionals can consider starting exercise training as early as 2 weeks after sternotomy. Trial Registration ClinicalTrials.gov Identifier: NCT03223558.
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Affiliation(s)
- Stuart Ennis
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, United Kingdom.,Department of Cardiopulmonary Rehabilitation, Centre for Exercise & Health, University Hospital Coventry and Warwickshire National Health Service Trust, Coventry, United Kingdom
| | - Grace Lobley
- Department of Cardiopulmonary Rehabilitation, Centre for Exercise & Health, University Hospital Coventry and Warwickshire National Health Service Trust, Coventry, United Kingdom
| | - Sandra Worrall
- Department of Cardiopulmonary Rehabilitation, Centre for Exercise & Health, University Hospital Coventry and Warwickshire National Health Service Trust, Coventry, United Kingdom
| | - Becky Evans
- Department of Cardiopulmonary Rehabilitation, Centre for Exercise & Health, University Hospital Coventry and Warwickshire National Health Service Trust, Coventry, United Kingdom
| | - Peter K Kimani
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Amir Khan
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Richard Powell
- Department of Cardiopulmonary Rehabilitation, Centre for Exercise & Health, University Hospital Coventry and Warwickshire National Health Service Trust, Coventry, United Kingdom.,Centre for Sport, Exercise and Life Sciences, Research Institute for Health & Wellbeing, Coventry University, Coventry, United Kingdom
| | - Prithwish Banerjee
- Warwick Medical School, University of Warwick, Coventry, United Kingdom.,Department of Cardiology, University Hospital Coventry and Warwickshire National Health Service Trust, Coventry, United Kingdom
| | - Tom Barker
- Department of Cardiothoracic Surgery, University Hospital Coventry and Warwickshire National Health Service Trust, Coventry, United Kingdom
| | - Gordon McGregor
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, United Kingdom.,Department of Cardiopulmonary Rehabilitation, Centre for Exercise & Health, University Hospital Coventry and Warwickshire National Health Service Trust, Coventry, United Kingdom.,Centre for Sport, Exercise and Life Sciences, Research Institute for Health & Wellbeing, Coventry University, Coventry, United Kingdom
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18
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Rosyidah R, Dewanto A, Hapsari ED, Widyastuti Y. Health Professionals Perception of Enhanced Recovery After Surgery: A Scoping Review. J Perianesth Nurs 2022; 37:956-960. [PMID: 35680549 DOI: 10.1016/j.jopan.2022.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 01/31/2022] [Accepted: 02/05/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE The Enhanced Recovery After Surgery (ERAS) program is currently poorly implemented by healthcare workers. Furthermore, several inhibiting and supporting factors for this implementation have been discovered to influence healthcare workers' perception of the program. This study aims to investigate the perception of healthcare workers regarding the ERAS program. DESIGN A scoping review in a systematic manner. METHODS A systematic search was performed using six databases: PubMed, ScienceDirect, SCOPUS, EBSCO, Proquest, and Sage Journals, from August 2011 to August 2021. The data was extracted using an excel worksheet, and the results obtained were presented descriptively. FINDINGS This study selected a total of 10 articles, where both qualitative and quantitative methods were used to discuss the perceptions of healthcare workers about ERAS. CONCLUSIONS Based on this study's findings, not all healthcare workers have a good perception of ERAS. The implementation of ERAS is often hindered by several factors, including resistance to change and lack of knowledge about the program. However, good teamwork and support from hospital management can support the program's implementation.
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Affiliation(s)
- Rafhani Rosyidah
- Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia; Department of Midwifery, Universitas Muhammadiyah Sidoarjo, East Java, Indonesia
| | - Agung Dewanto
- Department of Obstetrics and Gynecology, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Elsi Dwi Hapsari
- Department of Pediatric and Maternity Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Yunita Widyastuti
- Department of Anaesthesiology and Intensive Therapy, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia.
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19
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Grant MC, Engelman DT. The journey to standardizing cardiac perioperative care. Anaesth Crit Care Pain Med 2022; 41:101099. [PMID: 35715023 DOI: 10.1016/j.accpm.2022.101099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
| | - Daniel T Engelman
- Heart and Vascular Program, Baystate Health and University of Massachusetts Medical School-Baystate, Springfield, Massachusetts, USA
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20
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Situational Awareness of Opioid Consumption: The Missing Link to Reducing Dependence After Surgery? Anesth Analg 2022; 135:653-658. [PMID: 35110517 DOI: 10.1213/ane.0000000000005923] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
A tool for collecting and analyzing morphine milligram equivalents (MMEs) can be used to overcome barriers to situational awareness around opioid utilization in the setting of multimodal pain management. Our software application (App) has facilitated data collection, analysis, and benchmarking in a manner that is not logistically feasible using manual methods. Real-time postoperative tracking of MME over the course of an episode of care can be prohibitively labor-intensive, and teams must have practical strategies to overcome this obstacle. In view of the link between the magnitude of opioid prescriptions at discharge and persistent opioid use after cardiac surgery, we believe that improving situational awareness among the patient care team is a vital first step in reducing opioid dependence after cardiac surgery.
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21
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Yang P, Diaz A, Chhabra KR, Byrnes ME, Rajkumar A, Dimick JB, Nathan H. Surgical quality assurance at expanding health networks: A qualitative study. Surgery 2022; 171:966-972. [PMID: 35086732 DOI: 10.1016/j.surg.2021.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 09/18/2021] [Accepted: 09/21/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Even after decades of network expansion and increased care being delivered within health networks, health network expansion has not led to uniform improvements in patient outcomes and satisfaction. The reasons for the lack of universal surgical quality improvement are unclear. This study uses qualitative methods to understand the nuances that affect the variation in network-level surgical quality assurance and provides strategies that surgical leaders use to improve surgical quality at expanding health networks. METHODS This qualitative study obtained information through 30 semistructured interviews conducted from August to December 2019 with surgical leaders whose institutions were associated with health networks. The topic of surgical quality assurance was an emergent theme that was informed by thematic analysis. RESULTS Interviews with leaders revealed 3 themes with regard to surgical quality assurance. First, participants wanted standardized tools for quality measurement. Leaders frequently referred to the National Surgical Quality Improvement Program registry and shared electronic health records, but some networks did not have these available at all sites. Second, participants wanted an organizational structure that provides clear oversight over quality. Some leaders appointed executives or created committees to help manage quality improvement initiatives. Third, participants wanted a culture shift toward quality improvement. Many leaders faced resistance to quality initiatives from frontline clinicians; some implemented events and retreats to help garner support and a culture of quality. CONCLUSION These interviews offer critical insights into 3 domains that can be leveraged for sustained improvement and detail strategies that leaders used for surgical quality assurance at hospital networks.
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Affiliation(s)
- Phillip Yang
- University of Michigan Medical School, Ann Arbor, MI
| | - Adrian Diaz
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI; National Clinician Scholars Program at the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI; Department of Surgery, Ohio State University, Columbus, OH
| | - Karan R Chhabra
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI; National Clinician Scholars Program at the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI; Department of Surgery, Brigham and Women's Hospital, Boston, MA
| | - Mary E Byrnes
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI; Department of Surgery, Michigan Medicine, Ann Arbor, MI
| | | | - Justin B Dimick
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI; Department of Surgery, Michigan Medicine, Ann Arbor, MI
| | - Hari Nathan
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI; Department of Surgery, Michigan Medicine, Ann Arbor, MI.
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22
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Sanders J, Makariou N, Tocock A, Magboo R, Thomas A, Aitken LM. OUP accepted manuscript. Eur J Cardiovasc Nurs 2022; 21:655-664. [PMID: 35171231 DOI: 10.1093/eurjcn/zvac003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 12/20/2021] [Accepted: 01/11/2022] [Indexed: 11/13/2022]
Affiliation(s)
- Julie Sanders
- St Bartholomew's Hospital, Barts Health NHS Trust, West Smithfield, London EC1A 7DN, UK
- William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London, UK
| | - Nicole Makariou
- Barts and the London Medical School, Queen Mary University of London, Charterhouse Square, London, UK
| | - Adam Tocock
- Knowledge and Library Services, St Bartholomew's Hospital, Barts Health NHS Trust, West Smithfield, London, UK
| | - Rosalie Magboo
- William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London, UK
- Critical Care, St Bartholomew's Hospital, Barts Health NHS Trust, West Smithfield, London, UK
| | - Ashley Thomas
- William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London, UK
- Critical Care, St Bartholomew's Hospital, Barts Health NHS Trust, West Smithfield, London, UK
| | - Leanne M Aitken
- School of Health Sciences, City, University of London, Northampton Square, London, UK
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23
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Morton-Bailey V, Salenger R, Engelman DT. The 10 Commandments of ERAS for Cardiac Surgery. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2021; 16:493-497. [PMID: 34791923 DOI: 10.1177/15569845211048944] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Rawn Salenger
- Division of Cardiac Surgery, 1479University of Maryland Saint Joseph Medical Center, Towson, MD, USA
| | - Daniel T Engelman
- Heart and Vascular Program, University of Massachusetts Medical School-Baystate, Springfield, MA, USA
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24
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Grant MC, Suffredini G, Cho BC. Is it time to eliminate the use of opioids in cardiac surgery? JTCVS OPEN 2021; 7:247-252. [PMID: 36003704 PMCID: PMC9390448 DOI: 10.1016/j.xjon.2021.03.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 03/10/2021] [Indexed: 11/16/2022]
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Settembrini AM, Aronici M, Martelli E, Casella F, Martelli M, Renghi A, Coppi G, De Simeis L, Porta C, Brustia P. Is Mini-Invasive Surgery an Alternative for the Treatment of Juxtarenal Aortic Aneurysms? Ann Vasc Surg 2021; 78:220-225. [PMID: 34455043 DOI: 10.1016/j.avsg.2021.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 06/02/2021] [Accepted: 06/06/2021] [Indexed: 11/01/2022]
Abstract
INTRODUCTION Aim of our study is to evaluate the outcomes of mini-laparotomy, suprarenal cross-clamping, and enhanced recovery after elective open surgical repair for juxta-renal abdominal aortic aneurysms (JAAA) in a tertiary referral center. METHODS Data of all consecutive patients with abdominal aortic aneurysms (AAA) electively treated with left sub-costal mini-laparotomy requiring infrarenal or suprarenal cross-clamping between 2013 and 2018 were retrospectively collected. Patients were divided into two groups: infra-renal cross-clamping (group A) and JAAA requiring supra-renal cross-clamping (group B). Early and mid-term mortality, postoperative renal dysfunction according to RIFLE criteria and factors affecting postoperative outcome were analysed. RESULTS Four hundred one patients, 356 (88.8%) men, mean age 70.8 yrs, underwent open surgical repair (OSR), 343 (85.5%) AAA in group A, 58 (14.5%) JAAA in group B. Mean diameter of the aneurysms was 54 ± 11.4 mm vs. 52 ± 9 mm and mean time of intervention 154.9 ± 56.3 min vs. 180.1 ± 65.7 min respectively. Total clamp time was 72.27 ± 31.4 vs. 75 ± 33.1 and suprarenal clamp time in group B 27.82 ± 14.1 min. Mean hospital length of stay was 5.1 ± 2.8 vs. 5.37 ± 3.4 days respectively. At 30 days, 3 (0.9%) patients died in group A and no one in group B; at 24 months 7 (2%) deaths in group A and 4 (6.9%) in group B. Preoperative, postoperative and discharge serum creatinine mean value, in group B, were 1.07 ± 0.32, 1.31 ± 0.36 and 1.83 ± 1.24 respectively. Based on RIFLE criteria for renal function, we observed Risk in 14.2% and Injury in 12.7% of patients after suprarenal cross clamping. CONCLUSIONS Our results show that mini-invasive open repair for JAAA with a suprarenal cross-clamping can be performed with acceptable morbidity and mortality rates similar to traditional surgical approach without significant modifications of renal functions.
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Affiliation(s)
- Alberto M Settembrini
- Division of Vascular Surgery, University Hospital of Novara "Maggiore della Carità", Novara, Italy.
| | - Michele Aronici
- Division of Vascular Surgery, University Hospital of Novara "Maggiore della Carità", Novara, Italy
| | - Eugenio Martelli
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - Francesco Casella
- Division of Vascular Surgery, University Hospital of Novara "Maggiore della Carità", Novara, Italy
| | - Massimiliano Martelli
- Division of Vascular Surgery, University Hospital of Novara "Maggiore della Carità", Novara, Italy
| | - Alessandra Renghi
- Division of Vascular Surgery, University Hospital of Novara "Maggiore della Carità", Novara, Italy
| | - Giovanni Coppi
- Division of Vascular Surgery, University Hospital of Novara "Maggiore della Carità", Novara, Italy
| | - Letizia De Simeis
- Division of Vascular Surgery, University Hospital of Novara "Maggiore della Carità", Novara, Italy
| | - Carla Porta
- Division of Vascular Surgery, University Hospital of Novara "Maggiore della Carità", Novara, Italy
| | - Piero Brustia
- Division of Vascular Surgery, University Hospital of Novara "Maggiore della Carità", Novara, Italy
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Salenger R, Holmes SD, Rea A, Yeh J, Knott K, Born R, Boss MJ, Barr LF. Cardiac Enhanced Recovery After Surgery: Early Outcomes in a Community Setting. Ann Thorac Surg 2021; 113:2008-2017. [PMID: 34352198 DOI: 10.1016/j.athoracsur.2021.06.072] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 06/04/2021] [Accepted: 06/28/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) programs have demonstrated improved outcomes in non-cardiac surgery. More recently, ERAS has been applied to cardiac surgery with promising results. We have implemented cardiac ERAS at our community-based program, aiming to improve all phases of care, and now report our early results. METHODS We retrospectively analyzed 73 consecutive patients treated with ERAS care compared to 74 patients treated prior to implementing ERAS. Our ERAS program consisted of 6 perioperative care bundles including enhanced patient education, shortened preoperative fasting period and oral carbohydrate load, postoperative nausea prophylaxis, multimodal opioid-sparing analgesia, early extubation, and early mobilization. RESULTS ERAS patients required significantly less opioids captured as total milligram morphine equivalents (MME; median: 35.0 versus 75.3, P < .001), less nausea as determined by fewer total ondansetron rescue doses (median 0 versus 0.5, P = .011), and less lightheadedness (P = .028) compared with pre-ERAS patients. Postoperative mobility was significantly better (POD 4: 95% vs 81%, P = .013) and postoperative length of stay was lower for ERAS care, but did not reach statistical significance (median 4 vs 5 days, P = .06). There was no difference in pain or glucose control or in early extubation. CONCLUSIONS Cardiac ERAS significantly decreased opioid use, nausea, lightheadedness and improved functional outcome for cardiac surgical patients in a community hospital.
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Affiliation(s)
- Rawn Salenger
- Division of Cardiac Surgery, University of Maryland Saint Joseph Medical Center, Towson, MD; Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD.
| | - Sari D Holmes
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Amanda Rea
- Division of Cardiac Surgery, University of Maryland Saint Joseph Medical Center, Towson, MD
| | - Jennifer Yeh
- Pharmacy Department, University of Maryland Saint Joseph Medical Center, Towson, MD
| | - Kate Knott
- Division of Cardiac Surgery, University of Maryland Saint Joseph Medical Center, Towson, MD
| | - Rachel Born
- Department of Rehabilitation, University of Maryland Saint Joseph Medical Center, Towson, MD
| | - Michael J Boss
- Division of Cardiac Anesthesia, University of Maryland Saint Joseph Medical Center, Towson, MD
| | - Linda F Barr
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine
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Gebauer A, Petersen J, Konertz J, Brickwedel J, Schulte-Uentrop L, Reichenspurner H, Girdauskas E. Enhanced Recovery After Cardiac Surgery: Where Do We Stand? CURRENT ANESTHESIOLOGY REPORTS 2021. [DOI: 10.1007/s40140-021-00455-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Abstract
Purpose of Review
Enhanced recovery after surgery (ERAS) protocols are multimodal and multi-professional strategies to enhance postoperative convalescence and thereby reduce the length of hospital stay and hospital-associated complications. This review provides an up-to-date overview about basic principles of enhanced recovery after surgery protocols, their transfer into cardiac surgery, and their current state of evidence. It is supposed to offer clinical implications for further adaptations and implementations of such protocols in cardiac surgery.
Recent Findings
ERAS protocols are a story of success in numerous surgical disciplines and led to a paradigm shift in perioperative care and the establishment of ERAS Cardiac Society, a non-profit organization that provides evidence-based guidelines and recommendations for further development of enhanced recovery protocols, trying to harmonize the many existing efforts of individual approaches for cardiac surgery.
Summary
Promising results from comprehensive ERAS protocols in cardiac surgery emerged. Nevertheless, there is a paucity of high-quality data about holistic approaches in cardiac surgery and further efforts need to be promoted.
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Chang SH, Chang TC, Chen MY, Chen WC, Chou HH. Comparison of the Efficacy and Safety of Dinalbuphine Sebacate, Patient-Controlled Analgesia, and Conventional Analgesia After Laparotomy for Gynecologic Cancers: A Retrospective Study. J Pain Res 2021; 14:1763-1771. [PMID: 34163233 PMCID: PMC8214537 DOI: 10.2147/jpr.s314304] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 05/25/2021] [Indexed: 12/13/2022] Open
Abstract
Objective We aimed to investigate the effects of dinalbuphine sebacate (DNS), fentanyl-based patient-controlled analgesia (PCA), and conventional analgesia (CA) for pain management after laparotomy for gynecologic cancers. Methods A total of 137 eligible patients who underwent laparotomy through a midline incision wound for gynecologic cancer between July 2019 and June 2020 were retrospectively evaluated. The patients were divided into three groups as follows: the intramuscular DNS, intravenous PCA, and CA groups. Postoperative pain (POP) intensity as measured with a numerical rating scale (NRS), total consumption of analgesics, and incidence of treatment-emergent adverse events were compared between the three groups. Results The DNS group showed significant reduction in NRS pain intensity than the PCA and CA groups on day 1 (4.8 vs 6.2, p < 0.01 and 6.2, p < 0.05, respectively), day 2 (3.0 vs 4.7, p < 0.01 and 4.8, p < 0.001, respectively), day 3 (2.0 vs 3.9, p < 0.001 and 3.5, p < 0.001, respectively), day 4 (1.1 vs 3.1, p < 0.001 and 2.9, p < 0.001, respectively), and day 5 (0.7 vs 2.3, p < 0.001 and 2.4, p < 0.001, respectively). The total consumption of morphine equivalents per day was similar between the DNS and PCA groups (142.8 ± 7.3 mg vs 137.7 ± 70.0 mg, p = 0.8032) and lowest in the CA group (11.7 ± 30.7 mg, p < 0.0001). The overall safety profile was comparable between the DNS, PCA, and CA groups. The patients in the DNS group complained less of dizziness postoperatively than those in the PCA group (27% vs 47%) and had less nausea than those in the CA group (13% vs 33%). Conclusion A single DNS injection was more effective for relieving POP than PCA and CA in the patients who had a longitudinal incision for gynecologic cancer surgery. DNS was well tolerated and had less adverse effects than PCA and CA.
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Affiliation(s)
- Shu-Han Chang
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital Linkou Medical Center, Taoyuan, Taiwan
| | - Ting-Chang Chang
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital Linkou Medical Center, Taoyuan, Taiwan.,Chang Gung University, College of Medicine, Taoyuan, Taiwan
| | - Min-Yu Chen
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital Linkou Medical Center, Taoyuan, Taiwan
| | - Wei-Chun Chen
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital Linkou Medical Center, Taoyuan, Taiwan.,Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital Keelung Branch, Keelung, Taiwan
| | - Hung-Hsueh Chou
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital Linkou Medical Center, Taoyuan, Taiwan.,Chang Gung University, College of Medicine, Taoyuan, Taiwan
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Gregory AJ, Arora RC, Chatterjee S, Grant MC, Lobdell KW, Morton V, Reddy S, Salenger R, Engelman DT. Selecting Elements for a Cardiac Enhanced Recovery Protocol. J Cardiothorac Vasc Anesth 2021; 35:3847-3848. [PMID: 34119416 DOI: 10.1053/j.jvca.2021.05.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 04/30/2021] [Accepted: 05/04/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Alexander J Gregory
- Department of Anesthesiology, Perioperative and Pain Medicine & Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Rakesh C Arora
- Intensive Care Cardiac Surgery, St. Boniface General Hospital, University of Manitoba, Winnipeg, Canada
| | | | - Michael C Grant
- Department of Anesthesiology and Critical Care Medicine & Armstrong Institute for Patient Safety and Quality, The Johns Hopkins Medical Institutions, Baltimore, MD
| | - Kevin W Lobdell
- Regional CVT Quality, Education, and Research, Atrium Health. Charlotte, NC
| | - Vicki Morton
- Clinical and Quality Outcomes, Providence Anesthesiology Associates, Charlotte
| | - Seenu Reddy
- Centennial Heart & Vascular Center, Nashville, TN
| | | | - Daniel T Engelman
- University of Massachusetts-Baystate, Heart, Vascular and Critical Care Units, Baystate Medical Center, Springfield, MA
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Hensley NB, Grant MC, Cho BC, Suffredini G, Abernathy JA. How Do We Use Dashboards to Enhance Quality in Cardiac Anesthesia? J Cardiothorac Vasc Anesth 2021; 35:2969-2976. [PMID: 34059439 DOI: 10.1053/j.jvca.2021.04.034] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 03/30/2021] [Accepted: 04/20/2021] [Indexed: 02/04/2023]
Abstract
The use of clinical dashboards has expanded significantly in healthcare in recent years in a variety of settings. The ability to analyze data related to quality metrics in one screen is highly desirable for cardiac anesthesiologists, as they have considerable influence on important clinical outcomes. Building a robust quality program within cardiac anesthesia relies on consistent access and review of quality outcome measures, process measures, and operational measures through a clinical dashboard. Signals and trends in these measures may be compared to other cardiac surgical programs to analyze gaps and areas for quality improvement efforts. In this article, the authors describe how they designed a clinical cardiac anesthesia dashboard for quality efforts at their institution.
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Affiliation(s)
- Nadia B Hensley
- Department of Anesthesiology and Critical Care Medicine, Division of Cardiac Anesthesiology, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, Division of Cardiac Anesthesiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Brian C Cho
- Department of Anesthesiology and Critical Care Medicine, Division of Cardiac Anesthesiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Giancarlo Suffredini
- Department of Anesthesiology and Critical Care Medicine, Division of Cardiac Anesthesiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - James A Abernathy
- Department of Anesthesiology and Critical Care Medicine, Division of Cardiac Anesthesiology, Johns Hopkins University School of Medicine, Baltimore, MD
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Oral Pregabalin in Cardiac Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. BIOMED RESEARCH INTERNATIONAL 2021; 2021:8835891. [PMID: 33763487 PMCID: PMC7946477 DOI: 10.1155/2021/8835891] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 02/01/2021] [Accepted: 02/25/2021] [Indexed: 11/18/2022]
Abstract
Background Pregabalin has received wide clinical attention as a new type of analgesic. We undertake a systematic review and meta-analysis to evaluate the effect of pregabalin on postoperative pain in patients undergoing cardiac surgery. Methods We searched PubMed, Embase, and Cochrane Library (from inception to July 2020) for eligible studies. The primary outcomes were the total morphine consumption at 24 h. A secondary outcome was intraoperative fentanyl consumption, extubation time postoperative, and length of stay in hospital. We calculated pooled weighted mean difference (WMD) or odds ratio (OR) and 95% CIs using random- or fixed-effects models. Results Seven trials involving 463 patients were listed. Meta-analysis showed that the total morphine consumption at 24 h in the pregabalin group was significantly less than the control group (WMD: -5.44, 95% CI: -10.42–0.46, P = 0.03). We found that there is no significant difference between the two groups in intraoperative fentanyl consumption. Compared with the control group, the length of stay in hospital in the pregabalin group was significantly shorter (WMD = -0.87, 95% CI: -1.42−0.32, P = 0.002). And we found that there were no significant differences between the two groups in extubation time (WMD: 17.24, 95% CI: -24.36−58.84, P = 0.42). Conclusions Oral pregabalin for cardiac surgery patients can effectively reduce the patient's 24-hour morphine consumption after surgery, shorten the patient's hospital stay, and is more conducive to early postoperative recovery.
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32
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Ellis DB, Agarwala A, Cavallo E, Linov P, Hidrue MK, Del Carmen MG, Sisodia R. Implementing ERAS: how we achieved success within an anesthesia department. BMC Anesthesiol 2021; 21:36. [PMID: 33546602 PMCID: PMC7863438 DOI: 10.1186/s12871-021-01260-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Accepted: 01/14/2021] [Indexed: 11/10/2022] Open
Abstract
Background The Massachusetts General Hospital is a large, quaternary care institution with 58 operating rooms, 164 anesthesiologists, 76 certified nurse anesthetists (CRNAs), an anesthesiology residency program that admits 25 residents annually, and 35 surgeons who perform laparoscopic, vaginal, and open hysterectomies. In March of 2018, our institution launched an Enhanced Recovery After Surgery (ERAS) pathway for patients undergoing hysterectomy. To implement the anesthesia bundle of this pathway, an intensive 14-month educational endeavor was created and put into effect. There were no subsequent additional educational interventions. Methods We retrospectively reviewed records of 2570 patients who underwent hysterectomy between October 2016 and March 2020 to determine adherence to the anesthesia bundle of the ERAS Hysterectomy pathway. RESULTS: Increased adherence to the four elements of the anesthesia bundle (p < 0.001) was achieved during the intervention period. Compliance with the pathway was sustained in the post-intervention period despite no additional actions. Conclusions Implementing the anesthesia bundle of an ERAS pathway in a large anesthesia group with diverse providers successfully occurred using implementation science-based approach of intense interventions, and these results were maintained after the intervention ceased.
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Affiliation(s)
- Dan B Ellis
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.
| | - Aalok Agarwala
- Department of Anesthesia, Massachusetts Eye and Ear Infirmary, Boston, USA.,Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Elena Cavallo
- Massachusetts General Physicians Organization, Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts, 02114, USA
| | - Pam Linov
- Massachusetts General Physicians Organization, Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts, 02114, USA
| | - Michael K Hidrue
- Massachusetts General Physicians Organization, Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts, 02114, USA
| | - Marcela G Del Carmen
- Department of Gynecology Oncology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Rachel Sisodia
- Department of Gynecology Oncology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
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Zaouter C, Damphousse R, Moore A, Stevens LM, Gauthier A, Carrier FM. Elements not Graded in the Cardiac Enhanced Recovery After Surgery Guidelines Might Improve Postoperative Outcome: A Comprehensive Narrative Review. J Cardiothorac Vasc Anesth 2021; 36:746-765. [PMID: 33589344 DOI: 10.1053/j.jvca.2021.01.035] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 01/13/2021] [Accepted: 01/18/2021] [Indexed: 12/12/2022]
Abstract
Enhanced Recovery Programs (ERPs) are protocols involving the whole patient surgical journey. These protocols are based on multimodal, multidisciplinary, evidence-based, and patient-centered approaches aimed at improving patient recovery after a surgical intervention. Such programs have shown striking positive results in different surgical specialties. However, only a few research groups have incorporated preoperative, intraoperative, and postoperative evidence-based interventions in bundles used to standardize care and build cardiac surgery ERPs. The Enhanced Recovery After Surgery Society recently published evidence-based recommendations for perioperative care in cardiac surgery. Their recommendations included 22 perioperative interventions that may be part of any cardiac ERP. However, various components integrated in already-published cardiac ERPs were neither graded nor reported in these recommendations. The goals of the current review are to present published cardiac ERPs and their effects on patient outcomes and reported components incorporated into these ERPs and to discuss the objectives and scope of cardiac ERPs.
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Affiliation(s)
- Cédrick Zaouter
- Department of Anesthesiology, Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada.
| | - Remy Damphousse
- Department of Anesthesiology, Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Alex Moore
- Department of Anesthesiology, Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Louis-Mathieu Stevens
- Department of Surgery, Division of Cardiac surgery, Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Alain Gauthier
- Department of Anesthesiology, Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - François Martin Carrier
- Department of Anesthesiology, Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada; Department of Medicine, Division of Critical Care, Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
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34
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Gregory AJ, Grant MC, Boyle E, Arora RC, Williams JB, Salenger R, Chatterjee S, Lobdell KW, Jahangiri M, Engelman DT. Cardiac Surgery-Enhanced Recovery Programs Modified for COVID-19: Key Steps to Preserve Resources, Manage Caseload Backlog, and Improve Patient Outcomes. J Cardiothorac Vasc Anesth 2020; 34:3218-3224. [PMID: 32888804 PMCID: PMC7416680 DOI: 10.1053/j.jvca.2020.08.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 08/05/2020] [Accepted: 08/06/2020] [Indexed: 12/19/2022]
Affiliation(s)
- Alexander J Gregory
- Department of Anesthesiology, Perioperative and Pain Medicine & Libin, Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada.
| | - Michael C Grant
- Department of Anesthesiology and Critical Care Medicine & Armstrong Institute for Patient Safety and Quality, The Johns Hopkins Medical Institutions, Baltimore, MD
| | | | - Rakesh C Arora
- Intensive Care Cardiac Surgery, St. Boniface General Hospital, University of Manitoba, Winnipeg, Canada
| | - Judson B Williams
- Cardiothoracic Surgeon and Executive Medical Director, Heart, and Vascular, WakeMed Health and Hospitals, Raleigh, NC
| | | | | | - Kevin W Lobdell
- Regional CVT Quality, Education, and Research, Atrium Health. Charlotte, NC
| | - Marjan Jahangiri
- St. George's Hospital, University of London, London, United Kingdom
| | - Daniel T Engelman
- University of Massachusetts-Baystate and Medical Director of the Heart, Vascular and Critical Care Units, Baystate Medical Center, Springfield, MA
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