Fast-track Concept Research Articles

Is the outcome of elective vs non-elective patients undergoing transcatheter aortic valve implantation different? Results of a single-centre, observational assessment of outcomes at a large university clinic

BackgroundTranscatheter aortic valve implantation (TAVI) can either be conducted as an elective (scheduled in advance) or a non-elective procedure performed during an unplanned hospital admission. The objective of this study was to compare the outcomes of elective and non-elective TAVI patients.MethodsThis single-centre study included 512 patients undergoing transfemoral TAVI between October 2018 and December 2020; 378 (73.8%) were admitted for elective TAVI, 134 (26.2%) underwent a non-elective procedure. Our TAVI programme entails an optimized fast-track concept aimed at minimizing the total length of stay to ≤ 5 days for elective patients which in the German healthcare system is currently defined as the minimal time period to safely perform TAVI. Clinical characteristics and survival rates at 30 days and 1 year were analysed.ResultsPatients who underwent non-elective TAVI had a significantly higher comorbidity burden. Median duration from admission to discharge was 6 days (elective group 6 days versus non-elective group 15 days; p < 0.001), including a median postprocedural stay of 5 days (elective 4 days versus non-elective 7 days; p < 0.001). All-cause mortality at 30 days was 1.1% for the elective group and 3.7% for non-elective patients (p = 0.030). At 1 year, all-cause mortality among elective TAVI patients was disproportionately lower than in non-elective patients (5.0% versus 18.7%, p < 0.001). In the elective group, 54.5% of patients could not be discharged early due to comorbidities or procedural complications. Factors associated with a failure of achieving a total length of stay of ≤ 5 days comprised frailty syndrome, renal impairment as well as new permanent pacemaker implantation, new bundle branch block or atrial fibrillation, life-threatening bleeding, and the use of self-expanding valves. After multivariate adjustment, new permanent pacemaker implantation (odds ratio 6.44; 95% CI 2.59–16.00), life-threatening bleeding (odds ratio 4.19; 95% confidence interval 1.82–9.66) and frailty syndrome (odds ratio 5.15; 95% confidence interval 2.40–11.09; all p < 0.001, respectively) were confirmed as significant factors.ConclusionsWhile non-elective patients had acceptable periprocedural outcomes, mortality rates at 1 year were significantly higher compared to elective patients. Approximately only half of elective patients could be discharged early. Improvements in periprocedural care, follow-up strategies and optimized treatment of both elective and non-elective TAVI patients are needed.

Adherence to fast track measures in colorectal surgery—a survey among German and Austrian surgeons

PurposeThe effectiveness of modern perioperative treatment concepts has been demonstrated in several studies and meta-analyses. Despite good evidence, limited implementation of the fast track (FT) concept is still a widespread concern. To assess the status quo in Austrian and German hospitals, a survey on the implementation of FT measures was conducted among members of the German Society of General and Visceralsurgery (DGAV), the German Society of Coloproctology (DGK) and the Austrian Society of Surgery (OEGCH) to analyze where there is potential for improvement.MethodsTwenty questions on perioperative care of colorectal surgery patients were sent to the members of the DGAV, DGK and OEGCH using the online survey tool SurveyMonkey®. Descriptive data analysis was performed using Microsoft Excel.ResultsWhile some of the FT measures have already been routinely adopted in clinical practice (e.g. minimally invasive surgical approach, early mobilization and diet buildup), for other components there are discrepancies between current recommendations and present implementation (e.g. the use of local nerve blocks to provide opioid-sparing analgesia or the use of abdominal drains).ConclusionThe implementation of the FT concept in Austria and Germany is still in need of improvement. Particularly regarding the use of abdominal drains and postoperative analgesia, there is a tendency to stick to traditional structures. To overcome the issues with FT implementation, the development of an evidence-based S3 guideline for perioperative care, followed by the founding of a surgical working group to conduct a structured education and certification process, may lead to significant improvements in perioperative patient care.

Surgical Technique for Weight Regain after Roux-en-Y Gastric Bypass: Pouch-resizing and the MiniMIZER® Gastric Ring.

Laparoscopic Roux-en-Y Gastric Bypass (RYGB) is a commonly used method in bariatric surgery that leads to sufficient long-term weight loss and consequently to improvement or resolution of obesity-associated diseases. The nadir weight is commonly reached between six months and two years after surgery. Despite this initially good weight loss, weight regain is observed in up to 20% of the patients. Besides intensive dietological evaluation, bariatric re-operation can be an option in these cases. Before the surgical reintervention, an intensive evaluation of the esophagus, pouch, anastomosis, and adjacent small bowel using upper GI-endoscopy and radiological examinations (X-ray and/or 3D-CT volumetry) is mandatory. In patients with a dilated pouch, pouch-resizing with a MiniMIZER® Gastric Ring (Bariatric Solutions GmbH, Stein am Rhein, Switzerland) could be an option to reestablish restriction in the long term. Currently, there is no gold standard for the choice of the weight regain procedure or for the technique used in the procedure itself. This article focuses on the standardized procedure of pouch resizing with implantation of a MiniMIZER® Gastric Ring for the surgical therapy of weight regain due to pouch dilatation and/or dilatation of the gastrojejunostomy and the adjacent small bowel (usually approximately the first 20cm), resulting in a huge neo-stomach after RYGB, as performed at the Medical University of Vienna. Further, indications for revisional surgery for weight regain, mandatory examinations, and recommended conservative therapy options prior to surgery will be described. Next, the fast-track concept and its advantages are explained. Lastly, the surgical procedure, including positioning of the patient, placement of trocars, the intraoperative process, and special advice, is presented. Exact planning of the procedure and postoperative follow-up are indispensable for a further long-term success after weight regain surgery. In conclusion, pouch-resizing and implantation of the MiniMIZER® Gastric Ring represent a practical and effective solution in patients with dilated pouch/anastomosis/adjacent small bowel with weight regain after RYGB, if conservative therapy, including dietitian counseling and new drugs (e.g., Semaglutide), has failed.

Organization of accelerated recovery and early rehabilitation of surgical patients within the framework of the service of anesthesiology and resuscitation: literature review

Accelerated recovery after surgery, according to publications, has been developed since 1980 and is a multimodal strategy aimed at reducing the physiological response to surgical trauma, rapid recovery and early discharge of the patient. This study aimed to analyze the feasibility of introducing a methodology for accelerated recovery of the patient after surgery and early discharge from the surgical hospital. A study of the literature and formulation of a theoretical algorithm for the implementation of the process of accelerated recovery after surgery or fast track. According to publications, accelerated recovery from surgery has been developed since 1980 and is a multimodal strategy intended to reduce the physiological response to surgical trauma and accelerating recovery and early discharge of the patient. This concept consists of scientifically based approaches to the perioperative and postoperative management of surgical patients and represents a radical revision of the established traditional approach. Solving organizational issues of implementing the fast track concept in multidisciplinary hospitals in our country is a key factor toward wider dissemination and implementation of accelerated recovery after surgery.

Bacalhau Field Development: An Integrated Study Leading to Fast-Track Concept Development and Optimization in a Complex Presalt Environment

Bacalhau Field Development: An Integrated Study Leading to Fast-Track Concept Development and Optimization in a Complex Presalt Environment

Dissemination of fast-track concepts in Germany

HintergrundFast-Track-Konzepte haben die perioperative Betreuung von Patienten in den letzten 30 Jahren grundlegend verändert. Evidenz für diese Konzepte ist ausreichend vorhanden.Ziel der ArbeitZiel dieses Artikels war es, die Verbreitung von Fast-Track-Konzepten in Deutschland anhand von Routinedaten zu evaluieren.Material und MethodenEs wurde eine retrospektive Analyse aller kolorektalen Resektionen der Helios-Kliniken der Jahre 2016 bis 2021 durchgeführt. Diese wurden bezüglich Krankenhausverweildauer, Intensivbelegung, Beatmungsanteil, Mortalität, Komplikationsrate und Zugangsweg analysiert.Ergebnisse und DiskussionEine intensivmedizinische Belegung nach kolorektalen Resektionen ist in Deutschland weiterhin die Regel. Insbesondere bei onkologischen kolorektalen Resektionen werden nach wie vor zwei Drittel der Patienten perioperativ intensivmedizinisch betreut. Die stationäre Liegedauer bei kolorektalen Resektionen ist im internationalen Vergleich weiter überdurchschnittlich lang und auch über die letzten Jahre nur langsam rückläufig (z. B. Kolonkarzinom 2016: 18,6 ± 11,9 Tage/2021: 13,8 ± 9,3). Der Anteil offen-chirurgischer kolorektaler Eingriffe ist rückläufig, macht aber auch 30 Jahre nach Einführung der Laparoskopie einen relevanten Anteil aus (z. B. Kolonkarzinom 2016: 71,10 %/2021: 56,44 %). Die Versorgung von Patienten mit kolorektalen Resektionen scheint demnach weiterhin nicht nach Fast-Track-Prinzipen umgesetzt zu sein.

Results and lessons learned in fast-track arthroplasty

Fast-track concepts in arthroplasty are understood as programs to optimize and homogenize perioperative procedures. With few exceptions, the literature reports areduction in hospitalization time, adecrease in mortality and complications, earlier mobilization, and increased patient satisfaction through fast-track programs. The implementation of afast-track concept requires the involvement and motivation of the entire treatment team, as the implementation of only individual components of afast-track program does not lead to the desired goal. Country-specific regulations must be taken into account when evaluating fast-track programs. In particular, long-term results are also lacking. For Germany, ascientific review is still pending. Modified perioperative measures but also ashortening of an inpatient stay must not reduce the currently existing high quality of care in arthroplasty. Apossible reduction in the length of inpatient stay implies acompression, but not necessarily areduction in the perioperative care required for apatient. For this reason, the surrounding conditions must also be created at apolitical level in the future to enable the achievement of the desired high quality.

Элементы концепции fast-traсk в послеоперационном периоде лечения колоректального рака

Внедрение новых подходов при сложных плановых хирургических вмешательствах привело к появлению концепции fast-track-хирургии (концепции быстрого восстановления). Концепция fast-track-хирургии вызвала высокий медицинский интерес. Авторы пришли к выводу, что применение мультимодального подхода у пожилых пациентов высокого риска сокращает время пребывания в больнице и уменьшает количество послеоперационных осложнений. Послеоперационная стратегия предусматривает эффективную аналгезию, раннюю активизацию, раннюю энтеральную регидратацию и питание. Обследованы 102 больных с опухолями толстого кишечника. Пациенты после оперативного лечения госпитализированы в отделение интенсивной терапии. Контрольная группа (n = 53) обезболена нестероидным противовоспалительным препаратом в сочетании с опиатами. Исследуемая группа (n = 49) получила непрерывную продленную эпидуральную аналгезию в составе мультимодальной аналгезии. Проводили мониторинг уровня боли по визуально-аналоговой шкале, сроков появления перистальтики и начала зондового питания, а также длительности пребывания в отделении интенсивной терапии. Интенсивность боли по визуально-аналоговой шкале в контрольной группе пациентов достоверно увеличена на 98 % по сравнению с исследуемой группой (р = 0,00954). В контрольной группе пациенты субъективно оценивали боль различной интенсивности в покое, в то время как в исследуемой группе пациенты уже на 3-и сутки раннего послеоперационного периода определяли слабую боль только во время активного движения в постели. Более ранние восстановление перистальтики и начало зондового энтерального питания у больных отмечали в исследуемой группе. Раствор Рингера в зонд вводился уже в 1-е сутки, а зондовое питание больные получили уже на 2-е сутки после операции, время пребывания в отделении интенсивной терапии сократилось на 28 %. В то же время в контрольной группе, где больных обезболили декс­кетопрофеном в дозе 150 мг/сут в сочетании с опиатами, перистальтика появилась лишь на 3-и сутки после операции. Энтеральное питание начинали также только на 3-и сутки.

ОБЗОР 4-Й РЕДАКЦИИ РУКОВОДСТВА ПО ВЕДЕНИЮ ПОСЛЕОПЕРАЦИОННОЙ ТОШНОТЫ И РВОТЫ

In 2020, the 4th edition of the guidelines for the management of postoperative nausea and vomiting (PONV) was released, prepared by an international panel of experts under the auspices of the American Society of Enhanced Recovery and the Society of Ambulatory Anesthesia based on a comprehensive search and review of literature up to September 2019. This guide includes 7 blocks of advice for the prevention and treatment of PONV in children and adults. This document contains recommendations for identifying patients at high risk of PONV development, management of the underlying risks of PONV, the choice of preventive and pathogenetic treatment for PONV, as well as recommendations for the state implementation of the PONV protocol. In addition, the latest revision of the guidelines focuses on data on new drugs, discussions on the use of general multimodal prophylaxis and management of PONV as part of the fast track concept.

Implementation of fast-track measures in colorectal resections : Asurvey among members of the DGAI

The fast-track (FT) concept is amultimodal, interdisciplinary approach to perioperative patient care intended to reduce postoperative complications. Despite good evidence implementation seems to need improvement, whereby almost all studies focused on the implementation of surgical modules regardless of the interdisciplinary aspect. Adherence to the anesthesiological measures (prehabilitation, premedication, volume and temperature management, pain therapy), on the other hand, has been insufficiently studied. To assess the status quo asurvey on the implementation of anesthesiological FT measures was conducted among members of the German Society of Anesthesiology and Intensive Care Medicine (DGAI) to analyze where potential for improvement exists. Using the SurveyMonkey® online survey tool, 28questions regarding perioperative anesthesiological care of colorectal surgery patients were sent to DGAI members in order to analyze adherence to FT measures. While some of the FT measures (temperature management, PONV prophylaxis) are already routinely used, there is adivergence between current recommendations and clinical implementation for other components. In addition to premedication, interdisciplinary measures (prehabilitation) and measures that affect multiple interfaces (operating theatre, recovery room, ward), such as volume management or perioperative pain management, are particularly affected. The anesthesiological recommendations of the FT concept are only partially implemented in Germany. This particularly affects the interdisciplinary components as well as measures at the operating theatre, recovery room and ward interfaces. The establishment of an interdisciplinary FT team and interdisciplinary development of SOPs can optimize adherence, which in turn improves the short-term and long-term outcome of patients.

Surgical Therapy of Esophageal Adenocarcinoma-Current Standards and Future Perspectives.

Simple SummarySubtotal resection of the esophagus with resection of local lymph nodes is the oncological procedure of choice for advanced esophageal cancer. Reconstruction of the intestinal tract is predominantly performed with a gastric tube. Even in specialized centers, this surgical procedure is associated with a high complication but low mortality rate. Therefore, clinical research aims to develop peri- and intra-operative strategies to improve the patient related outcome.Transthoracic esophagectomy is currently the predominant curative treatment option for resectable esophageal adenocarcinoma. The majority of carcinomas present as locally advanced tumors requiring multimodal strategies with either neoadjuvant chemoradiotherapy or perioperative chemotherapy alone. Minimally invasive, including robotic, techniques are increasingly applied with a broad spectrum of technical variations existing for the oncological resection as well as gastric reconstruction. At the present, intrathoracic esophagogastrostomy is the preferred technique of reconstruction (Ivor Lewis esophagectomy). With standardized surgical procedures, a complete resection of the primary tumor can be achieved in almost 95% of patients. Even in expert centers, postoperative morbidity remains high, with an overall complication rate of 50–60%, whereas 30- and 90-day mortality are reported to be <2% and <6%, respectively. Due to the complexity of transthoracic esophagetomy and its associated morbidity, esophageal surgery is recommended to be performed in specialized centers with an appropriate caseload yet to be defined. In order to reduce postoperative morbidity, the selection of patients, preoperative rehabilitation and postoperative fast-track concepts are feasible strategies of perioperative management. Future directives aim to further centralize esophageal services, to individualize surgical treatment for high-risk patients and to implement intraoperative imaging modalities modifying the oncological extent of resection and facilitating surgical reconstruction.

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.

Background, Necessity and Methodology of the S3 Guideline "Perioperative Management of Gastrointestinal Tumours (POMGAT)"

Malignancies are among the most common diseases, especially in old age, and are responsible for 25% of all deaths in Germany. Especially carcinomas of the gastrointestinal tract can be cured in most cases only through extensive surgery with significant morbidity. About 25 years ago, the multimodal, perioperative Fast Track (FT) concept for reducing postoperative complications was introduced and additional elements were added in the following years. Meanwhile, there is growing evidence that adherence to the key elements of more than 70% leads to reduction in postoperative adverse events as well as a shorter hospital stay and could be associated with an improved oncological outcome. Despite the high level of awareness and the proven advantages of the FT concept, the implementation and maintenance of the measures is difficult and results in an adherence of only 20 - 40%. There are many reasons for this: In addition to a lack of interdisciplinary and interprofessional cooperation and the time consuming and extended logistical efforts, limited human resources are often listed as one of the main causes. We took these aspects as an opportunity and started to develop a S3 guideline for perioperative treatment to accelerate the recovery of patients with gastrointestinal malignancies. By creating a consensus- and evidence-based, multidisciplinary guideline, many of the problems listed above could probably be solved by optimising and standardising interdisciplinary care, which is particularly important in a setting with many different disciplines and their competing interests. Furthermore, the standardisation of the perioperative procedures will reduce the time and logistical effort. The presentation of the evidence allows increased transparency and justifies the additional personnel expenditure on hospital medicine and health insurance companies. In addition, the evidence-based quality indicators generated during the development of the guideline make it possible to include perioperative standards in certification systems and thus to measure and check the quality of perioperative care.

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

In recent years, perioperative care of patients after colorectal surgery has been increasingly standardised according to the fast-track concept and is accepted as a structured method of care to reduce perioperative complications. Indeed, initial studies have indicated that there is a long-term favourable effect on the oncological outcome, if the adherence to the individual measures is at least 70%. Even though there is unambiguous evidence for the efficacy of the modern perioperative treatment concept, it is often difficult to comply with the protocol during normal clinical work, particularly in Germany. The objective of this study was to record the rate of compliance before and after the introduction of the SOP and to evaluate its efficacy. We performed a retrospective analysis of the patient data after all elective colorectal surgery in the Bonn University Hospital from 2017 to 2020. 153 patients were operated on before the implementation of the SOP in January 2019 (group I); the remaining 153 patients were operated on after the implementation of the SOP and received appropriate care (group II). Compliance to the protocol was analysed for both the individual key interventions and the overall concept. There was significant improvement in the compliance for both the individual measures (prehabilitation group I: 5.9%, group II: 42.5%, p < 0.001; preparation of the intestine I: 16.5%, II: 73.9%, p < 0.001; intraoperative volume management I: 14,00 ml/kg BW/h, II: 9.12 ml/kg BW/h, p < 0.001, BW: body weight; minimally invasive surgical technique I: 53.6%, II: 73.9%, p < 0.001; etc.) and for the overall perioperative treatment concept (I: 39%, II: 54%, p = 0.02). However, we fell far short of compliance of at least 70%. Nevertheless, patient autonomy was achieved earlier after introduction of the SOP (I: day 15, II: day 9, p < 0.001) and the postoperative hospital stay was shortened (I: 14 [6 - 99] days, II 11 [4 - 64] days; p = 0.007). Although the implementation of the SOP led to significant improvements, further optimisation is required to attain the recommended protocol compliance of 70%. Measures within the hospital could include foundation of an interdisciplinary fast-track team and a specialised nurse as the connecting link between the patients, nursing and physicians. On the other hand, implementation throughout Germany can only be achieved by more influential actions. One possible support would be the S3 guideline on perioperative management of gastrointestinal tumours, which is under development. This could, for example, be used to support argumentation with funding providers.

Implementing fast-track in total hip arthroplasty: rapid mobilization with low need for pain medication and low pain values : Retrospective analysis of 102consecutive patients.

IntroductionTotal hip arthroplasty (THA) is reported to be one of the most painful surgical procedures. Perioperative management and rehabilitation patterns are of great importance for the success of the procedure. The aim of this cohort study was the evaluation of function, mobilization and pain scores during the inpatient stay (6 days postoperatively) and 4 weeks after fast-track THA.Materials and methodsA total of 102 consecutive patients were included in this retrospective cohort trial after minimally invasive cementless total hip arthroplasty under spinal anesthesia in a fast-track setup. The extent of mobilization under full-weight-bearing with crutches (walking distance in meters and necessity of nurse aid) and pain values using a numerical rating scale (NRS) were measured. Function was evaluated measuring the range of motion (ROM) and the ability of sitting on a chair, walking and personal hygiene. Furthermore, circumferences of thighs were measured to evaluate the extent of postoperative swelling. The widespread Harris Hip Score (HHS) was used to compare results pre- and 4 weeks postoperatively.ResultsEvaluation of pain scores in the postoperative course showed a constant decrease in the first postoperative week (days 1–6 postoperatively). The pain scores before surgery were significantly higher than surgery (day 6), during mobilization (p < 0.001), at rest (p < 0.001) and at night (p < 0.001). All patients were able to mobilize on the day of surgery. In addition, there was a significant improvement in independent activities within the first 6 days postoperatively: sitting on a chair (p < 0.001), walking (p < 0.001) and personal hygiene (p < 0.001). There was no significant difference between the measured preoperative and postoperative (day 6 after surgery) thigh circumferences above the knee joint. Compared to preoperatively, there was a significant (p < 0.001) improvement of the HHS 4 weeks after surgery. In 100% of the cases, the operation was reported to be successful and all of the treated patients would choose a fast-track setup again.ConclusionApplication of a fast-track scheme is effective regarding function and mobilization of patients. Low pain values and rapid improvement of walking distance confirms the success of the fast-track concept in the immediate postoperative course. Future prospective studies have to confirm the results comparing a conventional and a fast-track pathway.

Fast-Track in der Hüft- und Kniegelenkendoprothetik

Fast-track treatment concepts were developed decades ago in general and abdominal surgery and have been adapted in recent years for the special requirements of hip and knee arthroplasty. In this field, Hendrik Husted in particular was able to demonstrate scientific evidence for the components of fast-track concepts. The primary aim is not so much to shorten the patient's hospital length of stay (LOS) but rather to effectively increase the quality of medical treatment for the patient and to reduce complications. The optimization of organizational processes as well as intraoperative and perioperative surgical approaches are essential components regarding the introduction of fast track into the clinical routine. This article gives acomprehensive overview of fast-track treatment concepts and explains the scientific principles for the approach.

A Propensity Score-Matched Analysis to Assess the Outcomes in Pre- and Post-Fast-Track Hip and Knee Elective Prosthesis Patients.

Fast-track surgery is a multimodal evidence-based approach to perioperative care aimed at reducing complications and recovery time. We compared a fast-track protocol to standard care in the setting of a small Italian general hospital. Propensity score estimation before and after the study was performed to compare pre-fast-track (pre-FT; January 2013–March 2014) and fast-track (FT; January 2016–December 2016) patients undergoing elective hip and knee replacement surgery with a three-year follow-up (up to January 2020). The primary endpoints were the mean hemoglobin drop, mean predischarge hemoglobin, transfusion and reinfusion rates, pain, ambulation day, hospital length of stay (LOS), and discharge to home/outpatient care or rehabilitation hospital center. The secondary endpoints were the adherence measures to the FT protocol, namely, tourniquet and surgical times, use of drains and catheters, type of anesthesia administered, and complications within three years. The risk difference (RD) and the adjusted odds ratio (aOR) were calculated for each outcome. After the propensity score estimation, we analyzed 59 patients in the pre-FT and 122 in the FT categories. The FT patients, with respect to the pre-FT patients, ameliorated their mean hemoglobin drop from 3.7 to 3.1 g/dl (p < 0.01) and improved their predischarge mean hemoglobin (10.5 g/dL versus 11.0 g/dL; p = 0.01). Furthermore, the aOR of being transfused was reduced by 81% (p < 0,01); the RD of being reinfused was reduced by 63% (p < 0.01); the aOR of having low pain on the first day was increased by more than six times (p < 0.01); the RD of ambulating the first day increased by 91% (p < 0.01); the aOR of admission to a rehabilitation hospital center was reduced by 98% (p < 0.01); the aOR of home discharge increased by 42 times (p < 0.01); the median LOS, tourniquet and surgical times, and use of catheters and drains significantly decreased. Patients with complications at 1 month were 43.1% and 38.2%, respectively, of pre-FT and FT patients (p = 0.63). Complications at 6, 12, 24, and 36 months were significantly lower for the FT patients. This study showed that the uptake of enhanced recovery practices was successful and resulted in the improvement of clinical and organizational outcomes. The fast-track concept and related programs may optimize perioperative care and streamline surgical and rehabilitation care paths.

Survey on the Readiness for Hospital Discharge and Its Influencing Factors among Patients with Cardiac Valve Replacement

Background: There are about 200,000 patients in China who need to undergo valve replacement surgery each year. With the promotion and application of the Fast-Track Surgery concept and the increase in hospital bed turnover rate, the average hospital stay of patients undergoing CVR surgery has been significantly shortened, and thus the patients are still in the recovery stage rather than fully recovered when they are discharged from the hospital. Good preparation for discharge can improve patients’ post-discharge self-care ability, reduce the risk of re-admission, and save medical resources. Objective: To describe the status of readiness for hospital discharge among postoperative patients that have undergone CVR, and to explore its influencing factors. Methods: The general information questionnaire, the Readiness for Hospital Discharge Scale and the Quality of discharge Teaching Scale were utilized to investigate 130 post-CVR patients admitted to the Cardiothoracic Surgery Department of a tertiary A-Class hospital in Guangzhou from July 2019 to October 2020. Results: The Readiness for Hospital Discharge Scale was at a moderate level with a total score of 163.88 ± 39.082, while the Quality of Discharge Teaching Scale was also at a moderate level with a total score of 194.09 ± 40.643. Multiple linear regression analysis revealed that the quality of discharge guidance, gender, and occupation were the influencing factors of CVR patient’s readiness for hospital discharge. These three variables jointly explained 45.8% of the total variation. Conclusion: The level of CVR patients’ readiness for hospital discharge is at a moderate level, and the quality of discharge guidance positively affects patients’ readiness for discharge. Therefore, in clinical work, attention should be paid to patient discharge guidance. Personalized health education should be implemented to improve the quality of patient guidance.

Fast-track extubation after cardiac surgery in infants: Tug-of-war between performance and reimbursement?

ObjectivesTo compare the safety and resource-efficacy of the fast-track (FT) concept (extubation ≤8 hours after surgery) versus the conventional approach (non-FT, >8 hours postoperatively) in infants undergoing open-heart surgery. MethodsInfants <7 kg operated on cardiopulmonary bypass between 2014 and 2018 were analyzed. Propensity score matching (1:1) was performed for group comparison (FT vs non-FT). Intensive care unit (ICU) personnel use and unit performance were evaluated. Postoperative outcome and reimbursement based on German diagnosis-related groups were compared. ResultsOf 717 infants (median age: 4 months, Society of Thoracic Surgeons–European Association for Cardio-Thoracic Surgery mortality score: 0.1-4), FT extubation was achieved in 182 infants (25%). After matching, 123 pairs (FT vs non-FT) were formed without significant differences in baseline characteristics. FT versus non-FT showed a significantly shorter ICU stay (in days): 1.8 (0.9-2.8) versus 4.2 (1.9-6.4), P < .01, and postoperative length of stay (in days): 7 (6-10) versus 10 (7-15.5), P < .01; significantly lower postoperative transfusion rates: 61.3% versus 77%, P < .01; and tendency toward lower early mortality: 0% versus 2.8%, P = .08. Reintubation rate did not differ between the groups (P = .7). Despite a decrease in personnel capacity (2014 vs 2018), the unit performance was maintained. The mean case-mix-index of FT versus non-FT was 8.56 ± 6.08 versus 11.77 ± 12.10 (P < .01), resulting in 27% less reimbursement in the FT group. ConclusionsFT concept can be performed safely and resource-effectively in infants undergoing open-heart surgery. Since German diagnosis-related group systems reimburse costs, not performance, there is little incentive to avoid prolonged mechanical ventilation. Greater ICU turnover rates and excellent postoperative outcomes are not rewarded adequately.

Sicher zwischen Leitlinie und Leitplanke: Umfrage zur Praxis des perioperativen Managements der radikalen Zystektomie in Deutschland

Radical cystectomy (RCX) is the standard treatment for muscle-invasive and treatment-refractory non-invasive bladder cancer, but that is associated with high morbidity. We now survey current practice patterns on perioperative management among German urological departments of all sizes METHODS: Members of the German Association of Urology and the German Society of Residents in Urology (GeSRU) were contacted by email and asked to answer a 24-item online questionnaire covering clinically relevant aspects of current guidelines and controversies. Responses were obtained from at least 19 % of all German urological centers. About 60 % performed preoperative staging using CT urography and chest CT. The most common perioperative antibiotic prophylaxis was a third generation cephalosporin combined with metronidazole (46 %), administered for a median of 5 days. Stentograms for ileal conduit and neobladder are routinely performed in 38 % and 55 % of patients, respectively. Ureteral stents were usually removed 11 - 12 days after the procedure (ileal conduit and neobladder). Based on the surrogate parameters of preoperative bowel preparation, postoperative start of oral nutrition and use of nasogastric tube, fast-track concepts such as ERAS were not generally established (< 50 %). Robot-assisted cystectomy appears to be performed in 15 % of German urological centers and was associated with the number of performed cystectomies (p < 0.001). Most aspects of perioperative management in cystectomy patients - staging diagnostics, use of antibiotics, stent removal - are performed in accordance with current guidelines. Other clinical questions such as stent imaging before removal and fast track concepts are handled heterogeneously. Guideline-adherence was not associated with hospital size or number of procedures performed.