Perioperative Care Interventions Research Articles

Prescription and consumption of opioids after bariatric surgery: a multicenter prospective cohort study.

In the current opioid crisis, bariatric surgical patients are at increased risk of harms related to postoperative opioid overprescribing. This study aimed to assess the extent to which opioids prescribed at discharge after bariatric surgery are consumed by patients. This multicenter prospective cohort study included adult patients (≥ 18yo) undergoing laparoscopic bariatric surgery. Preoperative assessments included demographics and patient-reported measures. Information regarding surgical and perioperative care interventions (including discharge prescriptions) was obtained from medical records. Self-reported opioid consumption was assessed weekly up to 30days post-discharge. Number of opioid pills prescribed and consumed was compared using Wilcoxon signed-rank test. Zero-inflated negative binomial regression was used to identify predictors of post-discharge opioid consumption. We analyzed 351 patients (mean age 44 ± 11years, BMI 45 ± 8.0kg/m2, 77% female, 71% sleeve gastrectomy, length of stay 1.6 ± 0.6days). The quantity of opioids prescribed at discharge (median 15 pills [IQR 15-16], 112.5 morphine milligram equivalents (MMEs) [IQR 80-112.5]) was significantly higher than patient-reported consumption (median 1 pill [IQR 0-5], 7.5 MMEs [IQR 0-37.5]) (p < 0.001). Overall, 37% of patients did not take any opioids post-discharge and 78.5% of the opioid pills prescribed were unused. Increased post-discharge opioid consumption was associated with male sex (IRR 1.54 [95%CI 1.14 to 2.07]), higher BMI (1.03 [95%CI 1.01 to 1.05]), preoperative opioid use (1.48 [95%CI 1.04 to 2.10]), current smoking (2.32 [95%CI 1.44 to 3.72]), higher PROMIS-29 depression score (1.03 [95% CI 1.01 to 1.04]), anastomotic procedures (1.33 [95%CI 1.01 to 1.75]), and number of pills prescribed (1.04 [95%CI 1.01 to 1.06]). This study supports that most opioid pills prescribed to bariatric surgery patients at discharge are not consumed. Patient and procedure-related factors may predict opioid consumption. Individualized post-discharge analgesia strategies with minimal or no opioids may be feasible and should be further investigated in future research.

Scaling up of safety and quality improvement interventions in perioperative care: a systematic scoping review of implementation strategies and effectiveness

BackgroundGlobally, 5 billion people lack access to safe surgical care with more deaths due to lack of quality care rather than lack of access. While many proven quality improvement (QI)...

815 FRAILTY AND MULTIMORBIDITY ARE ASSOCIATED WITH LONGER LENGTH OF STAY IN OLDER UROLOGY PATIENTS

Abstract Introduction Frailty and geriatric syndromes are becoming common place in surgical services. In general surgery, frailty has been shown to be associated with longer length of hospital stay. The effect of frailty on outcomes in Urology patients is not well described. We aimed to evaluate the effect of frailty and multimorbidity on length of stay in older patients admitted for emergency Urology care. Methods Adults aged 65 years and older admitted as an emergency to the Urology service during 4 months of 2020/21 were included. The primary outcome was time to discharge; analyses were adjusted for Clinical Frailty Scale (CFS), Charlson Comorbidity Index (CCI), age, gender, and surgical procedure (yes/no). Results 142 patients were included, of these 60 (42.3%) were living with frailty (CFS ≥5), 32 (22.5%) were multimorbid and 59 (41.5%) underwent a surgical procedure. Longer length of stay was associated with frailty (adjusted-HR 0.560; 95% CI 0.376–0.835; p 0.004) and multimorbidity (adjusted-HR 0.556; 95% CI 0.367–0.842; p 0.006). Conclusion In this single-centre study we found frailty and multimorbidity to be associated with longer length of stay in patients admitted for emergency Urology care. Geriatric perioperative care interventions in other surgical specialties have been shown to reduce length of stay, the effect of such services within urology has yet to be established. Identification of frail and multimorbid patients could help to develop targeted strategies to improve outcomes, and ultimately reduce hospital stay.

A Qualitative Study of Perioperative Depression and Anxiety in Older Adults

ObjectiveWe had three aims 1) understand barriers to perioperative management of anxiety and depression in older surgical patients; 2) identify preferences and requirements for interventions to manage their anxiety and depression; and 3) explore the feasibility of implementing such interventions in perioperative care. DesignA qualitative study using semistructured interviews was conducted. SettingParticipants were recruited at a large academic medical center. ParticipantsWe interviewed older surgical patients and clinicians to characterize their perspectives on management of anxiety and depression symptoms, with emphasis on patient needs, barriers, and potential interventions to address these needs. MeasurementsWe used the Consolidated Framework for Intervention Research to guide the development of interview questions related to intervention implementation feasibility. Thematic analysis was used to analyze interview responses. ResultsForty semistructured interviews were conducted. Key barriers for perioperative management of depression and anxiety included fear of surgery, acute pain, postoperative neurocognitive disorders, limited understanding of what to expect regarding surgery and recovery, and overwhelmingly complex medication management. Patients and clinicians suggested that a bundled mental health management intervention targeted for older surgical patient population comprised of behavioral and pharmacologic strategies can help mitigate anxiety and depression symptoms during the perioperative period. Clinicians emphasized the need for a collaborative engagement strategy that includes multiple stakeholders in the design, planning, and implementation of such an intevention. ConclusionNew care models need to be developed to integrate mental health care into the current perioperative care practice.

Initial experience introducing an enhanced recovery program in congenital cardiac surgery

ObjectiveWe hypothesized that a new enhanced recovery after surgery (ERAS) program would accelerate functional recovery after congenital heart surgery and reduce length of stay and complications. MethodsEvidence-based interventions in perioperative care were evaluated for relevance, and components of the ERAS cardiac program were determined. The target patient population included infants to adults with low comorbidities. Major outcomes were compared to a pre-ERAS era cohort using propensity matching. ResultsFrom October 1, 2018, to February 28, 2019, 155 of 448 patients were eligible for the ERAS program. The median age was 3.6 years (interquartile range, 0.5-12.3). Key metrics included early extubation (<8 hours), achieved in 84 patients (54%; median 7.6 hours; interquartile range, 3.8-12.3), and multimodal pain regimen used in all patients (100%) postoperatively, but in only 88 of 155 patients (57%) intraoperatively. Opioid analgesia was highest the night of surgery (oral morphine equivalent: 0.36 mg/kg/12 hours; interquartile range, 0.21-0.57). In matched analysis, raw median mechanical ventilation time was 7.6 hours (interquartile range, 3.8-12.2) in ERAS versus 8.2 (interquartile range, 4.0-17.0) in pre–ERAS era (P = .001 log-hours). Raw median intensive care unit length of stay was shorter with ERAS: 1.12 days (interquartile range, 0.93-2.01) versus 1.28 days (interquartile range, 0.96-2.09) pre-ERAS (P = .046 log-days), but there was no difference in hospital length of stay. There was no increase in Society of Thoracic Surgeons–reported complications, readmissions, and reinterventions. ConclusionsThis represents the initial implementation experience of an enhanced recovery after surgery program after congenital surgery at a large pediatric hospital. Adherence to the program component metrics is not yet optimized, but monthly sharing of quality metrics allows multidisciplinary collaboration, provider engagement, and opportunities for research and process improvement.

The impact of perioperative care on complications and short term outcome in ARM type rectovestibular fistula: An ARM-Net consortium study

BackgroundThe impact of perioperative care interventions on postreconstructive complications and short-term colorectal outcome in patients with anorectal malformation (ARM) type rectovestibular fistula is unknown. MethodsAn ARM-Net consortium multicenter retrospective cohort study was performed including 165 patients with a rectovestibular fistula. Patient characteristics, perioperative care interventions, timing of reconstruction, postreconstructive complications and the colorectal outcome at one year of follow-up were registered. ResultsOverall complications were seen in 26.8% of the patients, of which 41% were regarded major. Differences in presence of enterostomy, timing of reconstruction, mechanical bowel preparation, antibiotic prophylaxis and postoperative feeding regimen had no impact on the occurrence of overall complications. However, mechanical bowel preparation, antibiotic prophylaxis ≥48 h and postoperative nil by mouth showed a significant reduction in major complications. The lowest rate of major complications was found in the group having these three interventions combined (5.9%).Multivariate analyses did not show independent significant results of any of the perioperative care interventions owing to center-specific combinations. At one year follow-up, half of the patients experienced constipation and this was significantly higher among those with preoperative mechanical bowel preparation. ConclusionsDifferences in perioperative care interventions do not seem to impact the incidence of overall complications in a large cohort of European rectovestibular fistula-patients. Mechanical bowel preparation, antibiotic prophylaxis ≥48 h, and postoperative nil by mouth showed the least major complications. Independency could not be established owing to center-specific combinations of interventions. Type of studyTreatment study. Level of evidenceIII

Association of Integrated Care Coordination With Postsurgical Outcomes in High-Risk Older Adults

Older adults undergoing elective surgery experience higher rates of preventable postoperative complications than younger patients. To assess clinical outcomes for older adults undergoing elective abdominal surgery via a collaborative intervention by surgery, geriatrics, and anesthesia focused on perioperative health optimization. Perioperative Optimization of Senior Health (POSH) is a quality improvement initiative with prospective data collection. Participants in an existing geriatrics-based clinic within a single-site academic health center were included if they were at high risk for complications (ie, older than 85 years or older than 65 years with cognitive impairment, recent weight loss, multimorbidity, or polypharmacy) undergoing elective abdominal surgery. Outcomes were compared with a control group of patients older than 65 years who underwent similar surgeries by the same group of general surgeons immediately before implementation of POSH. Primary outcomes included length of stay, 7- and 30-day readmissions, and level of care at discharge. Secondary outcomes were delirium and other major postoperative complications. Outcomes data were derived from institutional databases linked with electronic health records and billing data sets. One hundred eighty-three POSH patients were compared with 143 patients in the control group. On average, patients in the POSH group were older compared with those in the control group (75.6 vs 71.9 years; P < .001; 95% CI, 2.27 to 5.19) and had more chronic conditions (10.6 vs 8.5; P = .001; 95% CI, 0.86 to 3.35). Median length of stay was shorter among POSH patients (4 days vs 6 days; P < .001; 95% CI, -1.06 to -4.21). Patients in the POSH group had lower readmission rates at 7 days (5 of 180 [2.8%] vs 14 of 142 [9.9%]; P = .007; 95% CI, 0.09 to 0.74) and 30 days (14 of 180 [7.8%] vs 26 of 142 [18.3%]; P = .004; 95% CI, 0.19 to 0.75) and were more likely to be discharged home with self-care (114 of 183 [62.3%] vs 73 of 143 [51.1%]; P = .04; 95% CI, 1.02 to 2.47). Patients in the POSH group experienced fewer mean number of complications (0.9 vs 1.4; P < .001; 95% CI, -0.13 to -0.89) despite higher rates of documented delirium (52 of 183 [28.4%] vs 8 of 143 [5.6%]; P < .001; 95% CI, 3.06 to 14.65). A greater proportion of POSH patients underwent laparoscopic procedures (92 of 183 [50%] vs 55 of 143 [38.5%]; P = .001; 95% CI, 1.04 to 2.52). Tests for interactions between POSH patients and procedure type were insignificant for all outcomes. Despite higher mean age and morbidity burden, older adults who participated in an interdisciplinary perioperative care intervention had fewer complications, shorter hospitalizations, more frequent discharge to home, and fewer readmissions than a comparison group.

Development of a model care pathway for adults undergoing colorectal cancer surgery: Evidence‐based key interventions and indicators

During the last decades, perioperative care for patients with colorectal cancer has shifted towards more standardized care, so-called "enhanced recovery after surgery." Those programs aim to optimize interventions in perioperative care to decrease the rate of postoperative complications, improve patients' recovery, and shorten hospital stay. The purpose of this literature review is to identify, summarize, and operationalize the clinical content of both key interventions and clinical indicators to develop an evidence-based model pathway for surgical patients with colorectal cancer. A systematic search in 3 databases was conducted to identify key interventions (KIs) and indicators to measure the effect of implementation of care pathways. The KIs from the enhanced recovery after surgery protocol were listed and used as framework to identify and match KIs used in the included studies. The Clinical Pathway Compass was used to categorize the indicators. Fifteen studies were included. The number of KI used in the study protocols ranged from 9 to 20. In total, 33 KIs were identified. Little information was available concerning the implementation of and compliance to the protocol. Length of stay and complication rate are the most common used indicators (used in 15/15 and 14/15 of the studies), followed by 21 other measures. All but one of the included studies reported a reduction in length of stay. There is a considerable variation in both number of KIs and indicators as well as operationalization of key interventions, for surgical patients with colorectal cancer documented in literature. Therefore, we summarized the input from different studies and developed an evidence-based model pathway, which can serve as a basis for a local/regional care pathway team to build their own pathway.

Understanding of the 2014 guidelines for enhanced recovery after gastrectomy published by European Enhanced Recovery After Surgery Society

Enhanced recovery after surgery (ERAS) is a multimodal perioperative care pathway designed to achieve early recovery for patients undergoing major surgery. The ERAS programs aim to reduce traumatic stress and postoperative complications, improve full recovery of patients or combine and coordinate evidence-based perioperative care interventions that support standardizing and optimizing surgical care. The international working group assembled by the ERAS Society composed the 2014 Consensus guidelines for enhanced recovery after gastrectomy Enhanced Recovery After Surgery (ERAS®) Society recommendations in July 2014. This guideline is designed for optimal perioperative care for patients undergoing gastrectomy. This paper presented the understanding of hot issues of the guidelines in order to provide the clinical evidence of evidence-based medicine for the surgical field in China. Key words: Enhanced recovery after surgery; Guideline; Therapy; Understanding

Review article: Perioperative care in enhanced recovery for total hip and knee arthroplasty.

Enhanced recovery pathways for total hip and knee arthroplasty can reduce length of hospital stay and perioperative morbidity. 22 studies were reviewed for identification of perioperative care interventions, including preoperative (n=4), intra-operative (n=8), and postoperative (n=4) care interventions. Factors that improve outcomes included use of pre-emptive and multimodal analgesia regimens to reduce opioid consumption, identification of patients with poor nutritional status and provision of supplements preoperatively to improve wound healing and reduce length of hospital stay, use of warming systems and tranexamic acid, avoidance of drains to reduce operative blood loss and subsequent transfusion, and early ambulation with pharmacological and mechanical prophylaxis to reduce venous thromboembolism and to speed recovery.

Health economics in Enhanced Recovery After Surgery programs.

The Enhanced Recovery After Surgery (ERAS) program aims to combine and coordinate evidence-based perioperative care interventions that support standardizing and optimizing surgical care. In conjunction with its clinical benefits, it has been suggested that ERAS reduces costs through shorter convalescence and reduced morbidity. Nevertheless, few studies have evaluated the cost-effectiveness of ERAS programs. The aim of this systematic review, therefore, is to evaluate the claims that ERAS is cost-effective and to characterize how these costs were reported and evaluated. The electronic databases, MEDLINE(®) and EMBASE™, were searched from inception to April 2014. Seventeen studies met the inclusion criteria and were included for review. Enhanced Recovery After Surgery protocols in various abdominal surgeries have been investigated, including colorectal, bariatric, gynecological, gastric, pancreatic, esophageal, and vascular surgery. All studies reported cost savings associated with hastening recovery and reducing morbidity and complications. All studies included in this review focused primarily on in-hospital costs, with some attempting to account for readmission costs and follow-up services. In all but two studies, the breakdown of cost data for the individual studies was poorly detailed. In conclusion, ERAS protocols appear to be both clinically efficacious and cost effective across a variety of surgical specialties in the short term. Nevertheless, studies reporting out-of-hospital cost data are lacking. Further research is required to determine how best to evaluate both medium- and long-term costs relating to ERAS pathways while taking quality of life data into account.

Using Music Interventions in Perioperative Care

Anxiety and pain are common responses to surgery, and both can negatively affect patient outcomes. Music interventions have been suggested as a nonpharmacological intervention to alleviate pain and anxiety during surgical treatment. Although the data are somewhat mixed, the research suggests that music-based interventions are effective in reducing anxiety, pain perception, and sedative intake. The majority of studies have focused on interventions during the postoperative period and address pain reduction, with preoperative use of music targeting anxiety reduction the second most commonly cited objective. Most of the studies found in the literature involve passive music listening via headphones. The data suggest that researcher-selected music is most effective in reducing anxiety, primarily because it incorporates evidence-based parameters such as consistent tempo and dynamics, stable rhythms, and smooth melodic lines. Finally, the literature suggests that music therapists can serve as experts to help medical personnel identify effective implementation strategies.

Optimizing Perioperative Care in Bariatric Surgery Patients

Enhanced recovery after surgery (ERAS) programs have been shown to minimise morbidity in other types of surgery, but comparatively less data exist investigating ERAS in bariatric surgery. This article reviews the existing literature to identify interventions which may be included in an ERAS program for bariatric surgery. A narrative literature review was conducted. Search terms included 'bariatric surgery', 'weight loss surgery', 'gastric bypass', 'ERAS', 'enhanced recovery', 'enhanced recovery after surgery', 'fast-track surgery', 'perioperative care', 'postoperative care', 'intraoperative care' and 'preoperative care'. Interventions recovered by the database search, as well as interventions garnered from clinical experience in ERAS, were used as individual search terms. A large volume of evidence exists detailing the role of multiple interventions in perioperative care. However, efficacy and safety for a proportion of these interventions for ERAS in bariatric surgery remain unclear. This review concludes that there is potential to implement ERAS programs in bariatric surgery.