[Evaluation of the Effectiveness of a Standard Operating Procedure (SOP) for the Perioperative Management of Colorectal Surgery]

[Structured implementation of fast-track pathways to enhance recovery after elective colorectal resection : First results from five German hospitals]

BACKGROUND

Multimodal optimized perioperative management (mPOM, fast-track, enhanced recovery after surgery, ERAS) leads to a significantly accelerated recovery of patients with elective colorectal resections. Nevertheless, fast-track surgery has not yet become established in everyday clinical practice in Germany. We present the results of a structured fast-track implementation in five German hospitals.

METHODS

Prospective data collection in the context of a 13-month structured fast-track implementation. All patients ≥ 18 years undergoing elective colorectal resection and who gave informed consent were included. After 3 months of preparation (pre-FAST), fast-track treatment was initiated and continued for 10 months (FAST). Outcome criteria were adherence to internationally recommended fast-track elements, postoperative complications, functional recovery, and postoperative hospital stay.

RESULTS

Data from 192 pre-FAST and 529 FAST patients were analyzed. Age, sex, patient risk, location, and type of disease were not different between both groups. The FAST patients were more likely to have undergone minimally invasive surgery (82% vs. 69%). Fast-track adherence increased from 52% (35-65%) under traditional treatment to 83% (65-96%) under fast-track treatment (p < 0.01). The duration until the end of infusion treatment, removal of the bladder catheter, first bowel movement, oral solid food, regaining autonomy, suitability for discharge and postoperative length of stay were significantly lower in the FAST group. Complications, reoperations, and readmission rates did not differ.

CONCLUSION

Fast-track adherence rates > 75% can also be achieved in German hospitals through structured fast-track implementation and the recovery of patients can be significantly accelerated.

Optimized perioperative management (fast-track, ERAS) to enhance postoperative recovery in elective colorectal surgery

Aim

This manuscript provides information on the history, principles, and clinical results of Fast-track or ERAS concepts to optimize perioperative management (OPM).

Methods

With the focus on elective colorectal surgery description of the OPM concept and its elements for with special attention to the prevention of infectious complications and clinical results compared to traditional care will be given using recent systematic literature reviews. Additionally, clinical results for other major abdominal procedures are given.

Results

An optimized perioperative management protocol for elective colorectal resections will currently consist of 25 perioperative elements. These elements include the time from before hospital admission (patient education, screening, and treatment of possible risk factors like anemia, malnutrition, cessation of nicotine or alcohol abuse, optimization of concurrent systemic disease, physical prehabilitation, carbohydrate loading, adequate bowel preparation) to the preoperative period (shortened fasting, non-sedative premedication, prophylaxis of PONV and thromboembolic complications), intraoperative measures (systemic antibiotic prophylaxis, standardized anesthesia, normothermia and normovolemia, minimally invasive surgery, avoidance of drains and tubes) as well as postoperative actions (early oral feeding, enforced mobilization, early removal of a urinary catheter, stimulation of intestinal propulsion, control of hyperglycemia). Most of these elements are based on high-level evidence and will also have effects on the incidence of postoperative infectious complications.

Conclusion

Optimized perioperative management should be mandatory for elective surgery today as it enhances postoperative patient recovery, reduces morbidity and infectious complications.

Effective methods to enhance medical students' cardioversion and transcutaneous cardiac pacing skills retention - a prospective controlled study

BACKGROUND

Guideline-based therapy of cardiac arrhythmias is important for many physicians from the beginning of their training. Practical training of the required skills to treat cardiac arrhythmias is useful for acquiring these skills but does not seem sufficient for skill retention. The aim of this study was to compare different retention methods for skills required to treat cardiac arrhythmias with respect to the performance of these skills in an assessment.

METHODS

Seventy-one final-year medical students participated in a newly designed workshop to train synchronized cardioversion (SC) and transcutaneous cardiac pacing (TCP) skills in 2020. All participants completed an objective structured clinical examination (OSCE 1) one week after the training. Afterwards, the participants were stratified and randomized into three groups. Nine weeks later, one group received a standard operating procedure (SOP) for the skills, one group participated in a second workshop (SW), and one group received no further intervention (control). Ten weeks after the first training, all groups participated in OSCE 2.

RESULTS

The average score of all students in OSCE 1 was 15.6 ± 0.8 points with no significant differences between the three groups. Students in the control group reached a significantly (p < 0.001) lower score in OSCE 2 (-2.0 points, CI: [-2.9;-1.1]) than in OSCE 1. Students in the SOP-group achieved on average the same result in OSCE 2 as in OSCE 1 (0 points, CI: [-0.63;+0.63]). Students who completed a second skills training (SW-group) scored not significantly higher in OSCE 2 compared to OSCE 1 (+0.4 points, CI: [-0.29;+1.12]). The OSCE 2 scores in groups SOP and SW were neither significantly different nor statistically equivalent.

CONCLUSIONS

Partial loss of SC and TCP skills acquired in a workshop can be prevented after 10 weeks by reading an SOP as well as by a second workshop one week before the second assessment. Refreshing practical skills with an SOP could provide an effective and inexpensive method for skills retention compared to repeating a training. Further studies need to show whether this effect also exists for other skills and how frequently an SOP should be re-read for appropriate long-term retention of complex skills.

[Elective colorectal fast-track resections-Treatment adherence due to coordination by specialized nursing personnel]

Fast-track treatment pathways reduce the frequency of postoperative complications in elective colorectal resections by approximately 40% and due to the rapid recovery reduce the postoperative duration of hospitalization by approximately 50%. Specialized nursing personnel (enhanced recovery after surgery, ERAS, nurses) have already been appointed internationally to accompany and monitor the execution of multimodal perioperative treatment. In November 2018 a fast-track assistant was appointed in the Clinic for General and Visceral Surgery of the Municipal Clinic in Solingen for coordination of the fast-track treatment pathway. The results confirmed that a high adherence to perioperative fast-track treatment concepts can also be achieved in the German healthcare system by the assignment of specialized nursing personnel, with the known advantages for patients, nursing personnel, physicians and hospital sponsors.