Fast-track Care Research Articles

Lean-Based Approach to Improve Emergency Department Throughput.

Objective:Lean methodology can be utilized to increase throughput in a fast-track care area without changing staffing in a busy, urban emergency department (ED). Methods: A retrospective before-and-after analysis was performed to an improvement process in a fast-track care area within an ED with a census of 100,000 patients. The intervention utilized Lean methodologies to identify inefficiencies in the throughput model set for patients triaged to fast-track. Multiple ED stakeholders were involved in formulating a more efficient framework for how patients would receive care when triaged to fast-track. Results: There was a decline in the patient's overall length of stay (-9%, p=0.08), arrival to the room (-10%, p=0.4418), and ED attending to disposition (-9%, p=0.003). Additionally, all aspects of patients leaving prior to treatment completion (against medical advice (-29.4%, p=0.006), elopement (-20.4%, p=0.049), and left without being seen (-5.3%, p=0.11)) declined. Discussion:Identifying wasted time and resources in a patient's stay in the ED allowed for a more efficient throughput model to be developed. This resulted in patients being able to be seen in a more methodical manner leading to decreased wait times and lower left without being seen rates. Conclusion: A Lean-based throughput model was implemented to improve efficiency, reducing the length of stay and increasing the volume of patients evaluated per shift without additional costs. This improvement led to fewer patients leaving before treatment and demonstrated the value of process improvement in healthcare.

Enhancing stroke risk prediction in patients with transient ischemic attack: insights from a prospective cohort study implementing fast-track care.

Fast-track care have been proved to reduce the short-term risk of stroke after transient ischemic attack (TIA). We aimed to investigate stroke risk and to characterize short- and long-term stroke predictors in a large cohort of TIA patients undergoing fast-track management. Prospective study, enrolling consecutive TIA patients admitted to a Northern Italy emergency department from August 2010 to December 2017. All patients underwent fast-track care within 24 h of admission. The primary outcome was defined as the first stroke recurrence at 90 days, 12 and 60 months after TIA. Stroke incidence with 95% confidence interval (CI) at each timepoint was calculated using Poisson regression. Predictors of stroke recurrence were evaluated with Cox regression analysis. The number needed to treat (NNT) of fast-track care in preventing 90-day stroke recurrence in respect to the estimates based on baseline ABCD2 score was also calculated. We enrolled 1,035 patients (54.2% males). Stroke incidence was low throughout the follow-up with rates of 2.2% [95% CI 1.4-3.3%] at 90 days, 2.9% [95% CI 1.9-4.2%] at 12 months and 7.1% [95% CI 5.4-9.0%] at 60 months. Multiple TIA, speech disturbances and presence of ischemic lesion at neuroimaging predicted stroke recurrence at each timepoint. Male sex and increasing age predicted 90-day and 60-month stroke risk, respectively. Hypertension was associated with higher 12-month and 60-month stroke risk. No specific TIA etiology predicted higher stroke risk throughout the follow-up. The NNT for fast-track care in preventing 90-day stroke was 14.5 [95% CI 11.3-20.4] in the overall cohort and 6.8 [95% CI 4.6-13.5] in patients with baseline ABCD2 of 6 to 7. Our findings support the effectiveness of fast-track care in preventing both short- and long-term stroke recurrence after TIA. Particular effort should be made to identify and monitor patients with baseline predictors of higher stroke risk, which may vary according to follow-up duration.

Impact of fast-track surgery-oriented care pathways on perioperative rehabilitation indices in patients undergoing radical prostatectomy for prostate cancer.

This study was conducted to evaluate the effects of Fast-Track Surgery (FTS)-oriented care pathways on perioperative rehabilitation indicators in patients undergoing radical prostatectomy for prostate cancer. The clinical data of 120 patients admitted to Sichuan Cancer Hospital & Institute who underwent radical prostatectomy for prostate cancer from September 2020 to October 2022 were collected and retrospectively analyzed. The patients were divided into a control group (n=60, receiving standard care) and an FTS group (n=60 patients receiving FTS-oriented care) according to different nursing methods. The perioperative rehabilitation indices were compared between the groups. The FTS group exhibited shorter hospitalization duration (P=0.001), postoperative anal exhaust time (P=0.012), drain removal time (P=0.007), gastrointestinal recovery time (P=0.008), and a lower total complication rate (P=0.016) compared to the control group. The scores of Visual Analog Scale (VAS) (P=0.001, P=0.003, P=0.015) and Activities of Daily Living (ADL) (P=0.011, P=0.005, P=0.007) at 24, 48, and 72 hours postoperatively were significantly lower in the FTS group than in the control group. Hospitalization cost (P=0.002) and medication expenses (P=0.016) were notably lower in the FTS group. During a 12-month follow-up, the FTS group showed a significantly lower complication rates (3.33%) compared to the control group (18.33%) (P=0.009). The application of FTS-oriented nursing pathway in patients undergoing radical prostatectomy for prostate cancer significantly enhances postoperative rehabilitation, reduces pain, lowers hospitalization and medication costs, and improves postoperative quality of life, which contributes positively to the nurse-patient relationship and patient outcome.

Fast-Track versus Traditional Perioperative Care in Laparoscopic Cholecystectomy with Fast Healing

Fast-Track versus Traditional Perioperative Care in Laparoscopic Cholecystectomy with Fast Healing

Fast-track and person-centred care in geriatric traumatology in a German-speaking Swiss hospital – A practice development project

IntroductionElderly persons have an increased risk for negative health-related outcomes, including higher mortality rates. A centre for geriatric traumatology was established in a German-speaking Swiss hospital to provide more specialised, person-centred care and to lower negative health outcomes. Adaptations and changes in the patient pathway were made by implementing fast-track and person-centred care to better address individual needs. MethodsThe current patient pathway was analysed by an interprofessional and interdisciplinary geriatric traumatology expert team. The practice development methodology and the Person-Centred Practice Framework (PCP-Framework) were used throughout this engagement process. In consensus within the expert team, the sample was defined as elderly persons aged 65 years or older with suspected hip joint closed fractures. The focus was on three elements of “practice environment” from the PCP-Framework. These were: (1) supportive organisational systems; (2) the physical environment; (3) appropriate skill mix. ResultsSeveral adaptations and changes were made addressing the three elements of “practice environment”. These were for example: (1) use of specific assessments, shared decision-making; (2) proper and effective use of aids; (3) integration of Advanced Practice Nurses. The adaptations in the patient pathway were integrated into the standard operating procedures. ConclusionsThrough active engagement with the practice development methodology and the focus on person-centredness, the process of care for elderly persons was adapted. Thus, by addressing individual needs, fast-track and person-centred care in geriatric traumatology is provided. Further research is needed to evaluate and to verify implications in clinical practice.

Are we ready to mitigate time toxicity of cancer care? Oncologists’ perceptions on digital interventions to fast-track cancer care.

1537 Background: Patients spend substantial time receiving cancer care, and innovative strategies to decrease time toxicity are needed. We have shown that a text-based triage can identify patients tolerating checkpoint inhibitors (ICI) without toxicity who could safely fast-track directly to ICI infusion. However, oncologists’ readiness to implement this strategy is unknown. Methods: This sequential mixed-methods study included oncologists treating solid-tumor patients with ICIs at Penn Medicine. In phase 1, participants completed a 26-item survey assessing readiness to implement a digital strategy, using the Acceptability, Appropriateness, and Feasibility of Intervention Measures (AIM, IAM, and FIM), as well as perspectives of time toxicity. Each measure consisted of 4 items on a 5-point Likert scale for which means (M) and standard errors (SE) were calculated. In phase 2, a focus group (FG) was led by Penn’s Mixed Methods Research Lab to better understand the barriers and facilitators to implementing a digital strategy among oncologists. The FG transcript was reviewed and coded in NVivo with identification of emerging themes. Results: 32 faculty members were eligible, of whom 17 (53%) completed the survey and 14 (44%) participated in the FG. Respondents were 53% (n=9) female, 65% (n=11) White, and 53% (n=9) full-time clinicians (non-research faculty); 41% (n=7) reported > 10 years in practice. Quantitative analysis identified infusion (n=11, 65%), commuting (n=11,65%), and waiting for the physician (n=8, 47%) as the top 3 sources of time toxicity among oncologists. Most agreed that novel interventions are needed to improve the patient-experience (M=4.9, SE=0.08) on a Likert scale of agreeability (1-5, 5=strongly agree). On this scale, our text-based digital strategy to allow patients to fast-track care was found to be acceptable (M=3.8, SE =0.1), appropriate (M=3.8, SE=0.1), and feasible (M=3.9, SE=0.1). Qualitative analysis revealed the following major themes: 1) barriers to implementing a text-based digital strategy including a) health system built for clinician convenience, b) concern with being viewed as “slackers” by administration, c) concerns about overlooking symptoms, d) difficulties identifying appropriate patients, and e) communication issues; and 2) facilitators to adopting this new strategy including a) openness to change, 2) utilizing strengths of care team, and 3) optimism of this digital tool. Conclusions: Oncologists recognize time toxicity is a common complication of cancer care. Digital interventions to triage patients who are not experiencing treatment toxicity–thereby reducing time toxicity–were deemed acceptable, appropriate, and feasible. To integrate this technology, further research is required to address key barriers to uptake in routine care.

The Effect of Analgesia in Fast Track Pediatric Cardiac Patient

Background: Rapid tracheal extubation after cardiac surgery is not novel. "Fast-track management" has gained popularity in recent years, and the provision of cost-effective treatment is now included in with other factors as a means of assessing the success of various surgical procedures. Objective: In this study our main goal is to evaluate the effect of Analgesia in fast track pediatric cardiac patient. Method: This retrospective study was done at Bangladesh Shishu Hospital and Institute, Bangladesh, from January 2021 to January 2022. A total of 100 patients considered suitable for fast-track care were selected prior to surgery. The criteria for the selection of fast-track patients included low- risk cardiac surgery and the absence of other associated complex defects, either a weight over 10 kg or at least 6 months of age, the absence of complex non-cardiac issues and no significant history of repeat chest infections or obstructive airway disease. Results: during the study, mean age group was 5.7 years, followed by 55 cases were male, mean weight was 15.5 kg. 50% had a trial septal defect followed by 15% Ventricular septal defect, 11% Partial anomalous pulmonary, 9% congenital sabaortic stenosis, 10% had Atrioventricular septal defect. While reviewing post-operative faces pain score in day-1, 15% had no hurts followed by 60% had hurts a little bit, 10% had hurts more, 5% had hurts even more, 5% had hurts whole lot, 5% had hurts worst In day-2 25% had no hurts, 50% had hurts a bit, 12% had hurts a little more, 6% had hurts even more. In day-3 40% had no hurts, 40% had hurts a little bit, 20% had hurts little more. However, in day-4 15% had hurts little bit and 10% had hurts little more. In addition, 90% of the patients had between excellent and satisfactory analgesia. Moreover, 48% had vomiting and 2% had itching. Conclusion: The treatment of congenital heart disease after surgery is projected to become more reliant on "fast-track" care as the healthcare system ....

Implementation Science Fundamentals: Pediatric Surgery Enhanced Recovery After Surgery Protocol for Pectus Repair

IntroductionSurgical repair of pectus excavatum and carinatum in children has historically been associated with severe postoperative pain and prolonged hospitalization. Enhanced Recovery After Surgery (ERAS) is a multidisciplinary, multimodal approach designed to fast-track surgical care. However, obstacles to implementation have led to very few within pediatric surgery. The aim of this study is to outline the process of development and implementation of an ERAS protocol for pectus surgical repair using fundamental principles of implementation science. MethodsA multidisciplinary team of providers worked collaboratively to develop an ERAS protocol for surgical repair of pectus excavatum and carinatum and methods for identifying eligible patients. The surgical champion collaborated with all end users to review and revise the ERAS protocol, assessing all foreseeable barriers and facilitators prior to implementation. ResultsOur entire pediatric surgery team, nurses at every stage (clinic/preoperative/recovery/floor), physical therapy, and information technology contributed to the creation and implementation of an ERAS protocol with seven phases of care. The finalized version was implemented by end users focusing on four main areas: pain control, ambulation, diet, and education. Barriers and facilitators were continually addressed with an iterative process to improve the success of implementation. ConclusionsThis is one of the first studies in children which details the step-by-step process of developing and implementing an ERAS protocol for pectus excavatum and carinatum. The process of development and implementation of an ERAS protocol as outlined in this manuscript can serve as a model for future ERAS protocols in pediatric surgery.

The effect of delayed primary treatment initiation on adverse events and recurrence in older head and neck cancer patients

Background and purposeAs a result of rapid tumor growth in head and neck squamous cell carcinoma (HNSCC), delay in treatment initiation can result in tumor progression and inferior outcome. Especially older and frail patients are prone to develop adverse events. The aim of this study was to assess the effect of delay on development of adverse events and recurrence in older HNSCC patients. Materials and methodsThis cohort study with prospectively collected data included all newly diagnosed, curatively treated HNSCC patients (≥60 years) between 2015 and 2017. Time-to-treatment interval and geriatric domains were assessed. Adverse events were defined as postoperative complications (Clavien-Dindo classification) and acute radiation-induced toxicity (Common Terminology Criteria of Adverse Events). Multivariable regression models were performed, using adverse events and recurrence as outcome variables. ResultsA total of 245 patients were included. Median time-to-treatment was 26 days for surgery patients and 40 days for radiotherapy patients (p < 0.001). Delayed treatment initiation was not associated with postoperative complications or acute radiation-induced toxicity.Delay was significantly associated with recurrence risk within two years after treatment initiation in a model adjusted for stage and tumor location in patients treated with initial surgery (HR:4.1, 95%CI:1.2–14.0, p = 0.024). For patients treated with radiotherapy, delay was not significantly associated with recurrence risk. ConclusionDelayed treatment initiation was independently associated with increased recurrence risk in patients treated with initial surgery. Delay was not associated with short-term adverse events. These findings highlight the importance of establishing fast-track care pathways to minimize delays and improve especially long-term outcome.

Impact of fast-track care program in laparoscopic rectal cancer surgery: a cohort-comparative study.

Fast-track care programs after surgery improve recovery and decrease the length of hospital stay and postoperative morbidity in colonic cancer. However, the true impact of these programs on morbidity rates after rectal cancer surgery remains unclear. We aimed to assess the feasibility and impact of the fast-track program on postoperative outcomes after restorative laparoscopic rectal cancer resection and temporary loop ileostomy. This single-center observational study assessed data of patients undergoing elective rectal cancer surgery during a defined period before (standard group) and after the introduction of a fast-track program (fast-track group) from a prospectively maintained database. The primary endpoint was postoperative 90-day morbidity. Secondary endpoints were 30-day morbidity, fast-track program compliance, length of hospital stay, and readmission rate. Overall, 336 patients (n = 176, standard group; n = 160, fast-track group) were assessed; there was no significant between-group difference in the patients' baseline characteristics (age, sex, body mass index, comorbidities, or neoadjuvant treatment). The protocol compliance rate was 91.4% in the fast-track group. The 90-day morbidity and mean total length of hospital stay were significantly lower in the fast-track group than in the standard group (34% vs 49%, respectively, p < 0.01 and 8.96days vs 10.2days, p < 0.01, respectively). There was no difference in readmission rates. Multivariate analysis revealed the fast-track program to be the only predictive factor of postoperative morbidity. Fast-track programs can be safely implemented following rectal cancer surgery to reduce the overall morbidity rate and length of hospital stay without adversely increasing the readmission rate.

Impact of Delay on Hospitalization in Older Patients With Head and Neck Cancer: A Multicenter Study.

ObjectiveTo assess the impact of delay in treatment initiation on hospitalization, overall survival, and recurrence in older patients with head and neck cancer (HNC).Study DesignRetrospective multicenter study.SettingTwo tertiary referral centers.MethodsAll patients with newly diagnosed HNC (≥60 years) treated between 2015 and 2017 were retrospectively included. Time-to-treatment intervals were assessed (ie, calendar days between first visit and start of treatment). Multiple multivariable models were performed with hospital admission days (>14 days), survival, and recurrence as dependent outcome variables.ResultsIn total, 525 patients were enrolled. The mean age was 70.7 years and 70.7% were male. Median time to treatment was 34.0 days, and 36.3% started treatment within 30 days (P = .576 between centers). Patients with radiotherapy had longer time to treatment than surgical patients (39.0 vs 29.0 days, P < .001). Current smoking status, stage IV tumors, and definitive radiotherapy were significantly associated with delay in the multivariable analysis. Time-to-treatment interval ≥30 days was a significant predictor of longer hospital admission (>14 days) in the first year after treatment in an adjusted model (odds ratio, 4.66 [95% CI, 2.59-8.37]; P < .001). Delay in treatment initiation was not associated with overall survival or tumor recurrence.ConclusionThis study highlights the importance and challenges of ensuring timely treatment initiation in older patients with HNC, as treatment delay was an independent predictor of hospitalization. During oncologic workup, taking time to consider patient-centered outcomes (including minimizing time spent in hospital) while ensuring timely start of treatment requires well-structured, fast-track care pathways.

Establishment of a Fast-Track Gastrectomy Pathway for Patients With Gastric Adenocarcinoma at a U.S. Academic Cancer Center

IntroductionImplementation of fast-track perioperative care pathways for gastric cancer patients in the U.S. has been challenging due to low disease incidence and limited safety and efficacy data. Our institution recently implemented such a pathway for gastric cancer patients undergoing gastrectomy, and we sought to study its effects. MethodsWe analyzed data from consecutive patients who underwent gastrectomy for gastric adenocarcinoma from January 2014 to August 2020. Patients who had surgery for recurrence, urgent surgery for obstruction, bleeding, or perforation, or an intrathoracic anastomosis were excluded. The primary predictor was whether the patient had surgery before or after implementation of a perioperative fast-track gastrectomy pathway in July 2018, and the primary outcome was length of stay. ResultsOne hundred sixty patients were identified, 109 pre-pathway implementation and 51 post-pathway implementation. Following pathway implementation, length of stay was significantly shorter (median 6 days versus 9 days, p < 0.001), and there was no significant difference in 30-day complication rates (29% pre versus 24% post, P = 0.56) or readmission rates (18% pre versus 16% post, P = 0.85). Using linear segmented regression analysis adjusting for age, body mass index, tumor stage (early versus late), type of surgery (distal/subtotal versus total gastrectomy), and approach (open versus minimally invasive), pathway implementation was found to be associated with a 31% decreased length of stay (effect size 0.69, 95% confidence interval 0.49 – 0.98, P = 0.04). ConclusionsFast-track gastrectomy care pathways are safe and feasible for U.S. gastric cancer patients undergoing gastrectomy and are associated with decreased length of stay.

The role of the Consultant Radiographer in facilitating rapid access to palliative radiotherapy

IntroductionThe fast track pathway for palliative radiotherapy was created to facilitate rapid access to radiotherapy for symptom relief and improved quality of life. The fast track pathway has a target of 5 days from the decision to treat to starting treatment. MethodsThis study is a quantitative analysis of all patients referred and treated with palliative radiotherapy between the 1st September 2018 and 30th September 2019. The number of working days overall from referral to treatment and at each stage of the radiotherapy pathway was recorded and evaluated. The electronic referral system was amended to include the treatment priority option of ‘fast track’ for all patients with the selected treatment intent of ‘palliative’. The data was acquired using the electronic referral system reporting tool. ResultsResults demonstrate a reduction in average pathway timing from 14 days to 3 days for volume planned patients, and 13 days to 2 days for virtual simulation patients referred into the fast track pathway. The routine priority palliative pathway also demonstrated a decrease in time from decision to treat to treatment, despite this not being an initial objective. ConclusionReducing pathway time from referral to treatment is achievable through the introduction of a fast track treatment priority pathway. Rapid access to treatment was facilitated through the electronic referral system fast track option, the creation of a separate fast track care path in Aria, the use of fast track alerts in Aria, and reserved planning scan and treatment appointments. Implications for practiceRapid access to palliative radiotherapy facilitates alleviation of symptoms and improved quality of life. To improve the efficiency of the palliative radiotherapy service, a streamlined pathway and the commitment of the radiotherapy team is required.

Fast-Track Programs in Total Hip and Knee Replacement at Swedish Hospitals-Influence on 2-Year Risk of Revision and Mortality.

Purpose: We aimed to study the influence of fast-track care programs in total hip and total knee replacements (THR and TKR) at Swedish hospitals on the risk of revision and mortality within 2 years after the operation. Methods: Data were collected from the Swedish Hip and Knee Arthroplasty Registers (SHAR and SKAR), including 67,913 THR and 59,268 TKR operations from 2011 to 2015 on patients with osteoarthritis. Operations from 2011 to 2015 Revision and mortality in the fast-track group were compared with non-fast-track using Kaplan–Meier survival analysis and Cox regression analysis with adjustments. Results: The hazard ratio (HR) for revision within 2 years after THR with fast-track was 1.19 (CI: 1.03–1.39), indicating increased risk, whereas no increased risk was found in TKR (HR 0.91; CI: 0.79–1.06). The risk of death within 2 years was estimated with a HR of 0.85 (CI: 0.74–0.97) for TKR and 0.96 (CI: 0.85–1.09) for THR in fast-track hospitals compared to non-fast-track. Conclusions: Fast-track programs at Swedish hospitals were associated with an increased risk of revision in THR but not in TKR, while we found the mortality to be lower (TKR) or similar (THR) as compared to non-fast track.

Optimizing the Use of Telemedicine in Oncology Care: Postpandemic Opportunities.

Utilization of telehealth as part of the cancer care delivery continuum dramatically escalated in response to the COVID-19 pandemic at major cancer centers across the globe. The rapid shift toward telehealth visits for nontreatment cancer care provided immediate benefit through reducing unnecessary risk of exposure, overcoming transportation barriers faced by both patients and caregivers, and fast-tracking care transformation. As such, delineating the impact of telehealth on access, health equity, quality, and outcomes will be essential for refining the use of digital strategies and telehealth toward optimizing cancer care. Herein, experiences to date with telehealth usage for oncology care are reviewed, and priorities are outlined for postpandemic opportunities to improve the lives of patients with cancer through telemedicine.

Stratified versus usual care for the management of primary care patients with sciatica: the SCOPiC RCT.

Sciatica has a substantial impact on patients and society. Current care is 'stepped', comprising an initial period of simple measures of advice and analgesia, for most patients, commonly followed by physiotherapy, and then by more intensive interventions if symptoms fail to resolve. No study has yet tested a model of stratified care in which patients are subgrouped and matched to different care pathways based on their prognosis and clinical characteristics. The objectives were to investigate the clinical effectiveness and cost-effectiveness of a stratified care model compared with usual, non-stratified care. This was a two-parallel group, multicentre, pragmatic, 1 : 1 randomised controlled trial. Participants were recruited from primary care (42 general practices) in North Staffordshire, North Shropshire/Wales and Cheshire in the UK. Eligible patients were aged ≥ 18 years, had suspected sciatica, had access to a mobile phone/landline, were not pregnant, were not receiving treatment for the same problem and had not had previous spinal surgery. In stratified care, a combination of prognostic and clinical criteria associated with referral to spinal specialist services was used to allocate patients to one of three groups for matched care pathways. Group 1 received advice and up to two sessions of physiotherapy, group 2 received up to six sessions of physiotherapy, and group 3 was fast-tracked to magnetic resonance imaging and spinal specialist opinion. Usual care was based on the stepped-care approach without the use of any stratification tools/algorithms. Patients were randomised using a remote web-based randomisation service. The primary outcome was time to first resolution of sciatica symptoms (six point ordinal scale, collected via text messages). Secondary outcomes (at 4 and 12 months) included pain, function, psychological health, days lost from work, work productivity, satisfaction with care and health-care use. A cost-utility analysis was undertaken over 12 months. A qualitative study explored patients' and clinicians' views of the fast-track care pathway to a spinal specialist. A total of 476 patients were randomised (238 in each arm). For the primary outcome, the overall response rate was 89.3% (88.3% and 90.3% in the stratified and usual care arms, respectively). Relief from symptoms was slightly faster (2 weeks median difference) in the stratified care arm, but this difference was not statistically significant (hazard ratio 1.14, 95% confidence interval 0.89 to 1.46; p = 0.288). On average, participants in both arms reported good improvement from baseline, on most outcomes, over time. Following the assessment at the research clinic, most participants in the usual care arm were referred to physiotherapy. The stratified care model tested in this trial was not more clinically effective than usual care, and was not likely to be a cost-effective option. The fast-track pathway was felt to be acceptable to both patients and clinicians; however, clinicians expressed reluctance to consider invasive procedures if symptoms were of short duration. Participants in the usual care arm, on average, reported good outcomes, making it challenging to demonstrate superiority of stratified care. The performance of the algorithm used to allocate patients to treatment pathways may have influenced results. Other approaches to stratified care may provide superior outcomes for sciatica. Current Controlled Trials ISRCTN75449581. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 49. See the NIHR Journals Library website for further project information.

A Fast-Track Care by a Nursing Case Management Concept Improved Status Epilepticus Outcomes.

Status epilepticus (SE) is an emergency neurological condition, which is life-threatening, results in high morbidity and mortality rates, and needs to be diagnosed and promptly cared for. This study aimed to develop and evaluate the SE fast-track care using a nursing case management concept on SE outcomes. Quasi-experimental study conducted in adult patients with SE admitted in 15 emergency and intensive critical/intermediate care wards. SE outcomes were evaluated and compared between preintervention and postintervention. Time to treatment was reduced from 30 minutes to 3.5 minutes (P < .001). Similarly, the seizure control rate increased from 65.7% to 94.4% (P = .009). The mortality rate was reduced but did not reach statistical significance (8.6% vs 0%; P = .115). The intervention also reduced average waiting time for receiving antiepileptic drugs from the pharmacy department from 13.09 minutes to < 1 minute. The development of the fast-track care system for SE patients by nursing case management is at the core of management for coordinating multidisciplinary teams. This can improve outcomes by reducing the time to diagnosis and treatment time, therefore reducing mortality rates in SE patients.

Feasibility, safety, and outcomes of a stratified fast-track care trajectory in pituitary surgery

ObjectiveDischarge policies concerning hospitalization after endoscopic pituitary tumor surgery are highly variable. A few studies support fast-track discharge; however, this is not commonplace. Our goal was to report the transition to and evaluate the feasibility, safety, clinical- and patient-reported outcomes and costs of fast-track care in pituitary surgery.MethodsThis observational study included 155 patients undergoing pituitary surgery between December 2016 and December 2018. Fast-track care consisted of planned discharge 2–3 days after surgery, followed by daily surveillance by a case manager. All outcomes were compared with patients not eligible for fast-track discharge. The total group (fast-track and non-fast-track) was compared with historic controls (N = 307).ResultsA total of 79/155 patients (51%) were considered eligible for fast-track discharge, of whom 69 (87%) were discharged within 3 days. The total group was discharged more often within 3 days compared with historic controls (49 vs. 20%, p < 0.001), the total length of stay did not differ (5.3 vs. 5.7 days, p = 0.363). Although the total group had more readmissions compared with historic controls (17 vs. 10%, p = 0.002), no life-threatening complications occurred after discharge. On average, clinical- and patient-reported outcomes improved over time, both in the fast-track and non-fast-track groups. The mean overall costs within 30 days after surgery did not differ between the total group € 9992 (SD € 4562) and historic controls € 9818 (SD € 3488) (p = 0.649).ConclusionA stratified fast-track care trajectory with enhanced postoperative outpatient surveillance after pituitary tumor surgery is safe and feasible. As expected, costs of the fast-track were lower than the non-fast-track group, however we could not prove overall cost-effectiveness compared with the historic controls.

Fast-track care for pertrochanteric hip fracture: What impact on function and autonomy after discharge?

IntroductionFast-track treatment of pertrochanteric fracture is being developed in traumatology. The present study hypothesis was that fast-track treatment of pertrochanteric fracture does not jeopardize patient autonomy. Material and methodA single-center prospective comparative observational study, conducted from 2014 to 2016 in the University Hospital of Angers, France, included patients presenting with isolated A1 or A2 pertrochanteric fracture on the AO classification, managed by intramedullary nailing and requiring transfer to Post-acute Recovery (PAR). The fast-track exposure group were transferred directly on postoperative day 1, while the non-exposure group received postoperative care in the surgery department before transfer to PAR. The main endpoint was difference in Parker score between admission and discharge. Secondary endpoints comprised type of walking aid at discharge and destination of discharge from PAR. Results109 patients were initially included, with 54 patients (27 pairs) after matching. There was a significant difference in reduction in Parker score in favor of fast-track: −1.27 (95% CI: −2.27; −0.32) (p=0.012). There were no differences in amount or type of aid at discharge or discharge destination, although there was a trend toward greater discharge to the initial place of residence with fast-track. DiscussionOrthopedics is heading to the fast-track. Previous studies reported shorter hospital stay, comparable survival and complications rates, and significant cost-saving. The present study addressed progression: fast-track patients showed significantly less loss of walking autonomy. ConclusionFast-track management of pertrochanteric fracture significantly reduced loss of walking autonomy, without significant impact on discharge destination or walking aids. Level of evidenceIIB, exposure/non-exposure cohort.

Influence of fast-track programs on patient-reported outcomes in total hip and knee replacement (THR/TKR) at Swedish hospitals 2011–2015: an observational study including 51,169 THR and 8,393 TKR operations

Background and purpose — Fast-track care programs have been broadly introduced at Swedish hospitals in elective total hip and knee replacement (THR/TKR). We studied the influence of fast-track programs on patient-reported outcomes (PROs) 1 year after surgery, by exploring outcome measures registered in the Swedish arthroplasty registers.Patients and methods — Data were obtained from the Swedish Knee and Hip Arthroplasty Registers and included TKR and THR operations 2011–2015 on patients with osteoarthritis. Based on questionnaires concerning the clinical pathway and care programs at Swedish hospitals, the patients were divided in 2 groups depending on whether they had been operated in a fast-track program or not. PROs of the fast-track group were compared with not fast-track using regression analysis. EQ-5D, EQ VAS, Pain VAS, and Satisfaction VAS were analyzed for both THR and TKR operations. The PROMs for TKR also included KOOS.Results — The differences of EQ-5D, EQ VAS, Pain VAS, and Satisfaction VAS 1 year after surgery were small but all in favor of fast-track for both THR and TKR, also in subscales of KOOS for TKR except KOOS QoL. However, the effect sizes as measured by Cohens’ d formula were < 0.2 for all PROs, in both THR and TKR.Interpretation — Our results indicate that the fast-track programs may be at least as good as conventional care from the perspective of PROs 1-year postoperatively.