Perioperative Guidelines Research Articles

Implementation and impact of perioperative guidelines and the steroid emergency card for the management of adrenal insufficiency and prevention of adrenal crisis

Implementation and impact of perioperative guidelines and the steroid emergency card for the management of adrenal insufficiency and prevention of adrenal crisis

Transforming perioperative patient safety clinical guidelines recommendations into measurable standards: insights from the SAFEST project

Abstract Adopting evidence-based practices can improve the safety outcomes of surgical care. However, translating evidence into practice is slow in the healthcare field; an effort should be made to overcome this challenge. One approach could be to develop measurable standards to allow the evaluation and prioritization of healthcare improvements. The SAFEST project aimed to transform a list of prioritized clinical guidelines recommendations for adults’ perioperative care into measurable standardized practices (or standards) for hospitals to implement along the perioperative patient journey. Based on a previous systematic review of guidelines and an international expert panel review, we transformed recommendations into standards through an iterative and consensus qualitative approach. First, recommendations were classified according to the perioperative period (pre, intra or post) and based on predefined clinical areas. Second, one or more recommendations were transformed into one standard. Third, for each standard, measurable elements were developed to highlight in practical terms what needs to be implemented and measured, and the source of information and responsible stakeholder were identified. The overall transformation was performed by independent reviewers and the list of measurable standards was approved and finalized through discussion. From an initial list of 101 prioritized clinical practices recommendations, we developed 103 standards with 164 measurable elements. The standards with the related measurable elements, classified based on the perioperative period, were grouped in 12 different areas based on specific topic (e.g., complications preventions). Overall, these measurable standards can enhance dissemination and implementation of patient safety standardized practices in the continuum of care for adults’ patients undergoing surgery.

6.G. Workshop: Quality assessment in perioperative care: Challenges and lessons learned from the SAFEST project

Abstract Approximately 313 million surgical procedures are performed worldwide annually, with millions of patients experiencing health benefits while many suffer perioperative complications and harm. World Bank estimations show over 7 million people suffering surgical complications annually, with 4.2 million deaths occurring within 30 days of surgery, placing perioperative mortality as the third most common cause of death. Beyond the ethical issues of patients suffering personal harm while undergoing care, the burden on the health system due to prolonged length of stay and treatment is critical. Perioperative morbidity and mortality have thus become a high-priority public health problem for health systems. Attempts to set targets for improvement adopted well-known conceptual frameworks to categorise areas of evaluation (e.g., Donabedian model) and acknowledged the multifactorial root of perioperative harm and the various patient-condition and system-level factors have been fundamental in perioperative safety. International collaboration is active in seeking to address the challenges of measurement and reporting (COMPAC-StEP), while various tools have been utilised for that purpose (e.g., WHO surgical safety checklist). Several indicators, agreed among experts based on empirical research, have been adopted to assess quality at pre- intra- and postoperative care, but seen as blunt to accurately describe system performance and indicate areas of improvement. This has resulted in poorly defined measures of uncertain value, lacking validity, reliability, and lawfulness, and raising doubts about their true impact on patient safety. On the other hand, patient-centeredness and meaningfulness for patients remain unclear, while traditional clinical measures are increasingly found inadequate to capture all aspects of patient care and recovery. Overall, evidence is still conflicting regarding the most appropriate markers of quality, while long-term and patient-centred outcomes are gaining more scientific attention, despite the various implementation challenges. Greater involvement of patients in the development and selection process of quality indicators is seen as fundamental to better reflect patient values in quality targets in healthcare. A main goal of the workshop is to discuss the challenges and the latest developments in quality assessment in perioperative care and turn the attention towards “evidence-based indicators” for improving quality of care and safety in the perioperative period. The SAFEST project and its approach to developing recommendations and core indicators for patient safety in perioperative care will be presented. The special contribution of patient representatives in the SAFEST stakeholder consensus will be identified. Attributes of ideal quality indicators will be highlighted with reference to evidence-based, important reliable, and actionable indicators and those most prominent in measuring patient-related outcomes of care. Key messages • Translating perioperative safety clinical guidelines recommendations into measurable standards and assess a core of indicators will enhance the implementation of patient safety best practices.

Quality of breast surgery care at a comprehensive cancer center and its rural affiliate hospital

BackgroundCancer centers are increasingly affiliating with rural hospitals to perform surgery. Perioperative and oncologic outcomes for cancer center surgeons operating at rural hospitals are understudied. MethodsFor patients with non-metastatic breast cancer from a rural catchment area who had oncologic surgery at an NCI-designated comprehensive cancer center (CC) or its rural affiliate (RA) from 2017 to 2022, we compared perioperative outcomes (composite of surgical site infection, seroma requiring drainage, and reoperation for margins) and receipt of guideline-concordant care (if patient received all applicable treatments) using descriptive statistics and chi-squared tests. ResultsAmong 168 patients, 99 had surgery at RA, 60 CC. RA patients were older, higher stage, and more often had lumpectomy. There were no differences in perioperative outcomes (CC 10%, RA 14%, p ​= ​0.445) or guideline concordant care (RA 76%, CC 78%, p ​= ​0.846). ConclusionsCancer center surgeons operating at a rural affiliate had comparable perioperative outcomes and guideline-concordant care.

Patient experiences with micronutrient and overall nutrition management after bariatric surgery: identifying facilitators and barriers to implementing care.

Adherence to perioperative guideline recommendations for prophylactic supplementation and regular biochemical monitoring is suboptimal. However, little is known about the patient perspective on this postoperative challenge. To qualitatively explore patient experiences of postoperative micronutrient management and identify patient-reported barriers and facilitators to the provision of nutrition care. Two tertiary public hospitals in Queensland, Australia. Semi-structured interviews were conducted with 31 participants 12 months after bariatric surgery. Inductive analysis of interview transcripts was performed using applied thematic analysis, and deductive analysis was performed by aligning interview themes against the Theoretical Domains Framework and the Capability, Motivation, and Opportunity Behavior Change Wheel Framework. Participants' perceptions of engagement with the bariatric surgery multidisciplinary team greatly influenced their experience with overall nutrition care, including but not exclusive to micronutrient care. At times, this engagement negatively impacted patients' experiences with their nutrition care and related to varied acceptance of healthcare advice from the team or, at times, an unmet desire for person-centered communication styles. Engaging person-centered care techniques had a positive influence on patient experience with micronutrient and overall nutrition care. Micronutrient management (taking supplements and having regular blood tests) was broadly accepted and enabled by the presence of established medication and blood test routines preoperatively. However, challenges did exist and were practical in nature. Incorporating education on habit-forming techniques was identified as a facilitator to assist with micronutrient management. Although participants mostly accept embedding micronutrient management into their life, developing interventions that focus on habit-forming skills and that enable multidisciplinary teams to provide person-centered care is recommended to enhance care after surgery.

1226 The Role of Extracorporeal Membrane Oxygenation in William’s Syndrome Following Cardiac Surgery: A Case Report

Abstract Williams-Beuren Syndrome (WS) is a genetic syndrome seen in childhood, characterised by intellectual disabilities, outgoing personalities, elfin-like faces and cardiovascular complications. We report the story of a girl with WS who underwent complex cardiac surgery requiring extracorporeal membrane oxygenation (ECMO), to raise awareness of the perioperative challenges with WS. At 2 years old, a cardiac murmur was incidentally discovered. Further investigations revealed WS with cardiac manifestations including peripheral pulmonary artery stenosis (PPAS) and supravalvular aortic stenosis (SVAS). Isolated SVAS repair was feasible, however the severity of pulmonary artery hypoplasia deemed her inoperable. Her care was redirected to palliation. 18 months later, she remained in good clinical condition which prompted the multidisciplinary team (MDT) to change their decision and proceed with complex SVAS repair surgery (Brom technique) at the age of 5. Postoperatively, 3 failed attempts to wean from cardiopulmonary bypass preceded veno-arterial ECMO, which lasted 7 days. She stayed in intensive care for 17 days, and in hospital for 28 days. Frequent MDT decision making was crucial during her complex care. The patient is currently 15 years old, in good clinical condition, albeit exercise restrictions. WS patients have a known increased risk of perioperative sudden cardiac death and increasing use of paediatric ECMO, hence great attention and thorough preparation is required. Clear perioperative care guidelines for WS are essential to secure good outcomes in this patient population. This case demonstrated that MDT involvement and regular communication with the patient were key to deliver the appropriate care throughout her life.

Occupational Therapy’s Role for Gender Affirming Surgeries: Vaginoplasty and Vulvoplasty

This article explores the new surgical population of gender affirming surgery, specifically vaginal surgeries for transgender and gender diverse people. There are established perioperative rehabilitation guidelines for nearly all other surgeries. A growing population of people is seeking gender affirming healthcare which includes vaginal surgery. This article reviews the guidelines set forth by the World Professional Association for Transgender Health Standards of Care (Version 8), explores the occupational needs of this population, as well as provides suggestions for future versions of official documents of the American Occupational Therapy Association to provide more inclusive language for the unique needs of this population following surgery.

Pre- and Post-Microsurgical Rehabilitation Interventions and Outcomes on Breast Cancer-Related Lymphedema: a Systematic Review.

Breast cancer-related lymphedema (BCRL) is a debilitating progressive disease resulting in various impairments and dysfunctions. Complete decongestive therapy embodies conservative rehabilitation treatments for BCRL. Surgical procedures performed by plastic and reconstructive microsurgeons are available when conservative treatment fails. The purpose of this systematic review was to investigate which rehabilitation interventions contribute to the highest level of pre- and post-microsurgical outcomes. Studies published between 2002 and 2022 were grouped for analysis. This review was registered with PROSPERO (CRD42022341650) and followed the PRISMA guidelines. Levels of evidence were based upon study design and quality. The initial literature search yielded 296 results, of which, 13 studies met all inclusion criteria. Lymphovenous bypass anastomoses (LVB/A) and vascularized lymph node transplant (VLNT) emerged as dominant surgical procedures. Peri-operative outcome measures varied greatly and were used inconsistently. There is a dearth of high quality literature leading to a gap in knowledge as to how BCRL microsurgical and conservative interventions complement each other. Peri-operative guidelines are needed to bridge the knowledge and care gap between lymphedema surgeons and therapists. A core set of outcome measures for BCRL is vital to unify terminological differences in the multidisciplinary care of BCRL. Complete decongestive therapy embodies conservative rehabilitation treatments for breast cancer-related lymphedema (BCRL). Surgical procedures performed by microsurgeons are available when conservative treatment fails. This systematic review investigated which rehabilitation interventions contribute to the highest level of pre- and post-microsurgical outcomes. Thirteen studies met all inclusion criteria and revealed that there is a dearth of high quality literature leading to a gap in knowledge as to how BCRL microsurgical and conservative interventions complement each other. Furthermore, peri-operative outcome measures were inconsistent. Peri-operative guidelines are needed to bridge the knowledge and care gap between lymphedema surgeons and therapists.

Near-miss hypoglycemia—reflections on perioperative glucose management guidelines in diabetics

BackgroundThe American Society of Anesthesiologists (ASA) has an impressive array of professional perioperative guidelines but has not issued a guideline specific to perioperative blood glucose management and does not delve into the topic in their other guidelines.Case reportWe experienced a perioperative case that highlights the potential difficulty of glucose management in this setting. During anesthetic induction for an orthopedic foot surgery, as the medication was infusing, an IDDM 1 (insulin dependent diabetes mellitus type 1) patient expressed feeling that her blood sugar level was low. Her finger stick after induction showed severe hypoglycemia with a blood glucose of 34 mg/dL. The hypoglycemia was treated with intravenous glucose and further closely monitored.ConclusionsThis case led us to revisit the different perioperative guidelines and recommendations for diabetic patients and this manuscript aims to highlight the similarities and discrepancies among the different published recommendations. This case highlights the value of utilizing insulin pump infusions in the perioperative setting when available.

Auto-Substitutions to Optimize Perioperative Antimicrobial Prophylaxis: Pre-Post Intervention Study.

Appropriate administration of perioperative antibiotics can prevent antimicrobial resistance, adverse drug events, surgical site infections, and increased costs to the health care system for many surgeries in Otolaryngology-Head and Neck Surgery (OHNS). The objective of the study is to achieve 90% compliance with evidence-based perioperative antibiotic prophylaxis guidelines among elective surgical procedures in OHNS. The pre-intervention group consisted of patients undergoing elective surgical procedures in the 13 months prior to the interventions (September 2019-2020) whereas the post-intervention group comprised patients undergoing elective procedures during the 8 months following the implementation (October 2020-May 2021). The 4 Es of knowledge translation and the Donabedian framework were used to frame the study. Components of the intervention included educational grand rounds and automatic substitutions in electronic health records. In June 2021, a survey of staff and residents assessed the self-reported perception of following evidence-based guidelines. Compliance with antimicrobial prophylaxis guidelines were evaluated based on agent and dose. The overall compliance improved from 38.8% pre-intervention to 59.0% post-intervention (p < 0.001). Agent compliance did not improve from pre- to post-intervention, that is, 60.7% to 62.8%, respectively, (p = 0.68), whereas dose compliance improved from 39.6% to 89.2% (p < 0.001). Approximately 78.5% of survey respondents felt that they strongly agreed or agreed with always following evidence-based antimicrobial prophylaxis guidelines. Compliance with antimicrobial prophylaxis guidelines improved, primarily due to increased dosing compliance. Future interventions will target agent compliance and selected procedures with lower compliance rates. 3 Laryngoscope, 133:3403-3408, 2023.

Compliance to perioperative anticoagulation protocols in elderly patients undergoing elective orthopedic procedures: a retrospective observational cohort study on 548 patients

BackgroundCompliance with perioperative anticoagulation guidelines is essential to minimize bleeding and thromboembolic risks in patients undergoing surgery. Compared to vitamin-K antagonists (VKAs), perioperative management of direct oral anticoagulants (DOACs) contains fewer steps. Therefore, we hypothesized that noncompliance with guidelines in VKA users is higher than in DOAC users. The primary aim of our study was to investigate the difference in noncompliance to perioperative anticoagulant management guidelines between elderly patients using VKAs versus those using DOACs. The secondary aim was to determine the difference in occurrence of conflicting information communicated to the patients and the difference in incidence of coagulation-related adverse events.MethodsThis retrospective non-controlled observational cohort study examined elderly patients undergoing elective orthopedic surgery in a teaching hospital in the Netherlands. All patients undergoing elective orthopedic surgery between 1 May 2016 and 1 January 2020, aged 70 years and over, using VKAs or DOACs were selected. Nonelective surgeries were excluded. The primary outcome was the noncompliance to perioperative anticoagulant management guidelines. Secondary outcomes were missing or conflicting information on anticoagulation management communicated to the patient and coagulation-related adverse events. For continuous data, the unpaired T-test was used and for categorical data, the chi-square test.ResultsIn patients using VKAs, noncompliance to one of the steps of perioperative anticoagulation management was 81%, compared to 55% in patients using DOACs (p < 0.001). In most cases, VKAs or DOACs were interrupted for longer than recommended. In 13% of patients using a VKA with perioperative bridging, bridging was not conducted as recommended in the guidelines. In 13% of patients using a DOAC, a low-molecular-weight heparin (LMWH) was prescribed while a DOAC had already been restarted postoperatively. VKA users received conflicting information about perioperative anticoagulation management more often than DOAC users (33% versus 20%; p < 0.001). No difference was seen in postoperative coagulation-related complications.ConclusionGuidelines compliance in DOAC users is higher than in VKA users. Clinical decision support to help in selecting the right interruption interval in DOAC users, simplified standardized perioperative management, good coordination of instructions given to patients, and familiarity with updated guidelines are important in reducing noncompliance.

Society of Anesthesia and Sleep Medicine Position Paper on Patient Sleep During Hospitalization.

This article addresses the issue of patient sleep during hospitalization, which the Society of Anesthesia and Sleep Medicine believes merits wider consideration by health authorities than it has received to date. Adequate sleep is fundamental to health and well-being, and insufficiencies in its duration, quality, or timing have adverse effects that are acutely evident. These include cardiovascular dysfunction, impaired ventilatory function, cognitive impairment, increased pain perception, psychomotor disturbance (including increased fall risk), psychological disturbance (including anxiety and depression), metabolic dysfunction (including increased insulin resistance and catabolic propensity), and immune dysfunction and proinflammatory effects (increasing infection risk and pain generation). All these changes negatively impact health status and are counterproductive to recovery from illness and operation. Hospitalization challenges sleep in a variety of ways. These challenges include environmental factors such as noise, bright light, and overnight awakenings for observations, interventions, and transfers; physiological factors such as pain, dyspnea, bowel or urinary dysfunction, or discomfort from therapeutic devices; psychological factors such as stress and anxiety; care-related factors including medications or medication withdrawal; and preexisting sleep disorders that may not be recognized or adequately managed. Many of these challenges appear readily addressable. The key to doing so is to give sleep greater priority, with attention directed at ensuring that patients' sleep needs are recognized and met, both within the hospital and beyond. Requirements include staff education, creation of protocols to enhance the prospect of sleep needs being addressed, and improvement in hospital design to mitigate environmental disturbances. Hospitals and health care providers have a duty to provide, to the greatest extent possible, appropriate preconditions for healing. Accumulating evidence suggests that these preconditions include adequate patient sleep duration and quality. The Society of Anesthesia and Sleep Medicine calls for systematic changes in the approach of hospital leadership and staff to this issue. Measures required include incorporation of optimization of patient sleep into the objectives of perioperative and general patient care guidelines. These steps should be complemented by further research into the impact of hospitalization on sleep, the effects of poor sleep on health outcomes after hospitalization, and assessment of interventions to improve it.

AUGS-IUGA Joint Clinical Consensus Statement on Enhanced Recovery After Urogynecologic Surgery

AUGS-IUGA Joint Clinical Consensus Statement on Enhanced Recovery After Urogynecologic Surgery

211. Outcomes Following a Protocol Change to decrease Perioperative Antibiotic Duration Among Liver Transplant Recipients

Abstract Background Liver transplant recipients (LTRs) are at high risk for infections. The optimal duration of perioperative antibacterial prophylaxis remains unclear, particularly in patients hospitalized prior to transplant. Our study examines the impact of a change in our institutional perioperative antibiotic protocol in LTRs on post-transplant infection and antibiotic-associated toxicity. Methods We conducted a retrospective cohort study of all adult LTRs at our center who underwent transplant from 1/1/2018 until 9/1/2021. Patients were categorized as low risk if they are hospitalized &amp;lt; 24 hours prior to transplant and high risk if they were hospitalized ≥ 24 hours prior to transplant. We investigated patient outcomes after a change to our perioperative antibiotic guideline on 1/19/21, which reduced the duration of post-operative antibiotics for low risk patients from 48 to 24 hours and for high risk patients from 5 days or duration of post-operative ICU stay to 72 hours. Outcomes included post-transplant infection within 30 days (composite outcome of bacteremia and surgical site infection), C. difficile infection (CDI), and isolation of multi-drug resistant organisms (MDROs) from any site. Chi-squared and Fisher’s exact test were performed with p &amp;lt; 0.05 considered significant. Results There were 154 LTRs who underwent transplantation during the study period, including 63 high risk patients (43 before and 20 after the protocol change). The median duration of prophylactic antibiotics in the high risk group decreased from 6 (IQR 5-8) to 4.5 (IQR 4-5) days after the protocol change (p = 0.04), and in the low risk group decreased from 2.5 (IQR 2-5) to 1 (IQR 1-2) day (p = 0.04). Prophylactic antibiotics consisted of piperacillin-tazobactam in 145 (94%) and vancomycin in 104 (68%) of cases. In the high risk group, infection occurred in 4 (9%) patients before and 0 patients after the protocol change (p=0.3). CDI occurred in 4 (9%) patients before and 1 (5%) patient after the protocol change (p=1). Resistant organisms were isolated in 10 (23%) patients before and 1 (5%) patient after the protocol change (p=0.15). Figure 1.Antibiotic duration as a percentage of each cohortTable 1.Clinical outcomes before and after protocol change among low and high risk patientsTable 2.Antibiotic-associated outcomes before and after protocol change among low and high risk patients Conclusion The policy change reduced the median duration of perioperative antibiotic prophylaxis but was not accompanied by an observed increase in postoperative infection. Disclosures All Authors: No reported disclosures.

Effect of a Personalized Enteral Nutrition Protocol on the Postoperative Nutritional Status in Patients Who Underwent Oral Cancer Surgery

Differences in the implementation of the perioperative nutrition guidelines and pathways by caregivers lead to differences in enteral nutrition provided to the patients. This study investigated the effect of a personalized enteral nutrition protocol on the postoperative nutritional status of patients who underwent oral cancer surgery at Zhejiang Ningbo NO. 2 Hospital. Those who underwent surgery between July 2017 and October 2018 received routine enteral nutrition based on the Nutritional Risk Screening 2002 (routine group), while those between November 2018 and August 2021 received personalized enteral nutrition based on the Patient-Generated Subjective Global Assessment tool (personalized group). Seventy patients completed the study (routine group, n = 34; personalized group, n = 36). After surgery, the personalized group exhibited significantly greater improvements in serum albumin levels (P < 0.01) (on the 7th and 10th day) and hand grip strength (P < 0.01), higher self-care ability (P < 0.01), lower incidence of gastrointestinal reactions during enteral feeding (P < 0.05), and shorter hospital stay (P < 0.05) than the routine group. Therefore, a personalized enteral nutrition program might improve the postoperative nutritional status, shorten the hospital stay, and accelerate postoperative recovery in patients who underwent oral cancer surgery.

Effects of abdominal aortic aneurysm appropriateness dashboard on clinical practice

ObjectiveThe Society for Vascular Surgery published abdominal aortic aneurysm (AAA) practice guidelines in 2003, 2009, and 2018 to improve the management and treatment of AAAs. In 2014, our vascular surgery department implemented a quarterly AAA dashboard (AAAdb) to record the perioperative outcomes and guideline compliance with a focus on intervention appropriateness and procedural follow-up, which supplemented our Vascular Quality Initiative data. From the available reported evidence and expert consensus opinions, nine additional criteria for the appropriate treatment of AAAs <5 cm in women and <5.5 cm in men were noted, when applicable. The purpose of our study was to assess the effects of AAAdb implementation on adherence to society and institutional guidelines, documentation of treatment rationale, and the quality of follow-up. MethodsWe performed a retrospective review of elective open and endovascular AAA repair at a single institution from 2010 to 2018. The AAAdb was implemented in the middle of this period in 2014. The patient demographics, aortic size, repair indication, repair type, 30-day mortality, and postoperative and 1-year follow-up imaging findings were analyzed. The primary outcome was adherence to intervention appropriateness and the follow-up guidelines. The categorical factors were summarized using frequencies and percentages and compared using the Pearson χ2 test or Fisher exact test. Continuous measures were summarized using the mean ± standard deviation and compared between study periods using two-sample t tests. ResultsFrom 2010 to 2018, 1549 patients had undergone elective AAA repair: 657 before and 892 after AAAdb implementation. No differences were found in AAA size after AAAdb (5.6 ± 1.2 cm vs 5.6 ± 1.1 cm; P = .88). However, the proportion of size-appropriate repairs increased (64.1% vs 71.3%; P = .003). The proportion of small AAA repairs with a documented rationale had increased (64.4% vs 80.5%; P < .001), with rapid disease progression cited most often. No difference was found in 30-day mortality (1.2% vs 1.5%; P = .69). Follow-up imaging after endovascular abdominal aortic aneurysm repair increased at <60 days postoperatively (76% vs 84%; P = .004) and at 1 year of follow-up (78% vs 86%; P = .0005). The proportion of patients with endoleak at <60 days postoperatively had increased in the post-AAAdb cohort (21% vs 29%; P = .012). ConclusionsThe AAAdb served as a centerpiece for improving the appropriateness of care and compliance with national and institutional guidelines, including treatment of small AAAs in special circumstances. Its implementation was associated with higher quality follow-up and surveillance in a high-volume, regional aortic center. Consideration should be given to adding additional criteria to the Society for Vascular Surgery guidelines and Vascular Quality Initiative reporting.

Exploring Infectious Complications following Breast Reconstruction Tissue Expander Placement in Penicillin-allergic Patients

INTRODUCTION: In an effort to avoid anaphylaxis, penicillin-allergic patients are often given vancomycin or clindamycin as alternative perioperative antibiotics.1 In implant-based breast reconstruction patients, many of whom are at heightened risk for surgical site infections, it is prudent to evaluate the complication profile of those receiving alternative antibiotic coverage. Without additional risk factors for infection following breast reconstruction, the risk of infection is below 5%.2 However, seldom do studies consider patient allergies to penicillin a risk factor. When given via the intravenous route, it takes clindamycin 45 minutes to reach peak serum concentrations whereas it takes cefazolin 15 minutes to reach peak serum concentration.3,4 We hypothesize that patients who experience penicillin allergies experience increased infection rates with different speciation compared to their penicillin nonallergic counterparts because current recommendations do not facilitate sufficient time for the prophylactic antibiotic to reach peak concentration and efficacy. METHODS: This was a retrospective review of consecutive patients who underwent breast reconstruction with tissue expander placement between 1/1/2010 and 12/31/2018. Demographic data was collected, and the primary outcome of this study was development of infection. Infection-related complications were defined as those infections requiring re-admission for intravenous antibiotics or reoperation. Type of infection, culture speciation, treatment regimen, and time between operation and onset of infection were recorded. Other implant-based complications were recorded and analyzed including seroma, hematoma, wound dehiscence, mastectomy flap necrosis, capsular contracture, implant malposition, implant rupture, fat necrosis, premature tissue expander or implant explantation, and flap donor or recipient site morbidity. RESULTS: One-hundred fifty-three (153) patients were included in the review. Thirty-five (35) had a penicillin allergy and received alternative perioperative antibiotic coverage. Infection-related complications occurred in 45.7% of penicillin-allergic patients and 28.0% of those without penicillin allergies (p=0.048). Premature explantation of a tissue expander was performed in 25.7% of penicillin-allergic patients and 11.9% of controls (p=0.0441). CONCLUSIONS: In this population, penicillin-allergic patients experience significantly higher rates of infection-related complications than patients without penicillin allergies. This may be due to decreased effectiveness of alternative regimens due to dose timing or the community specific antibiogram. This suggests inadequate antibiotic coverage by the alternative antibiotics most commonly used. There is a need for further reform of perioperative antibacterial guidelines to optimize outcomes in this patient population, whose oncologic therapy increases their infection risk from the outset of reconstruction. REFERENCES: 1. Ranganathan K, Sears ED, Zhong L, et al. Antibiotic Prophylaxis after Immediate Breast Reconstruction: The Reality of Its Efficacy. Plast Reconstr Surg. 2018;141(4):865-877. doi:10.1097/PRS.0000000000004204 2. Baghaki S, Soybir GR, Soran A. Guideline for Antimicrobial Prophylaxis in Breast Surgery. J Breast Health. 2014;10(2):79-82. doi:10.5152/tjbh.2014.1959 3. Leigh DA. Antibacterial activity and pharmacokinetics of clindamycin. J Antimicrob Chemother. 1981;7(suppl A):3-9. doi:10.1093/jac/7.suppl_A.3 4. White RR, Pitzer KD, Fader RC, Rajab MH, Song J. Pharmacokinetics of Topical and Intravenous Cefazolin in Patients with Clean Surgical Wounds: Plast Reconstr Surg. 2008;122(6):1773-1779. doi:10.1097/PRS.0b013e31818d5899

Nurses' Awareness and Practices of Unintentional Perioperative Hypothermia Prevention: A Cross-Sectional Study.

Unintentional perioperative hypothermia can cause potentially life-threatening complications. The aim of this study was to determine the awareness and practices of nurses regarding unintentional perioperative hypothermia prevention. The study was conducted at a teaching hospital in Gambia with descriptive cross-sectional design. A total of 53 nurses voluntarily participated in this study. The questionnaire used in this study was developed based on the American periOperative Registered Nurses (AORN) and National Institute for Health and Care Excellence perioperative hypothermia guidelines. Descriptive statistics, Pearson correlation, Student t-test, and one-way ANOVA were used in the analysis of data. The result of the study showed that nurses had high level of awareness of unintentional perioperative hypothermia prevention; however, practice levels were found to be low. Based on the results of the study, development of policies, implementation of the unintentional perioperative hypothermia prevention guidelines, and continuous education to improve nurses' knowledge and practices were recommended.

Putting patient value first: Using a modified nominal group technique for the implementation of enhanced recovery after cardiac surgery recommendations

ObjectiveIn 2019, the Society for Enhanced Recovery After Cardiac Surgery (ERAS-CS) published perioperative guidelines to optimize the care of patients undergoing cardiac surgery. For centers with limited capacity, a sequential approach to the implementation of the full guidelines may be more feasible. Therefore, we aimed to explore the priority of implementation of the ERAS-CS guideline recommendations from a patient and caregiver perspective. MethodsUsing a modified nominal group technique, individuals who previously underwent cardiac surgery and their caregivers ranked ERAS-CS recommendations within 3 time points (ie, preoperative, intraoperative, and postoperative) and across 2 to 3 voting rounds. Final round rankings (median, mean and first quartile) were used to determine relative priorities. ResultsSeven individuals (5 patients and 2 caregivers) participated in the study. Patient engagement tools (2, 2.29, and 1.50), surgical site infection reduction (2, 1.67, and 1.25), and postoperative systematic delirium screening (1, 2.43, and 1.00) were the top-ranked ERAS-CS recommendations in the preoperative, intraoperative, and postoperative time points, respectively. ConclusionsExploration of patient and caregiver priorities may provide important insights to guide the healthcare team with clinical pathway development and implementation. Further study is needed to understand the impact of the integration of patient and caregiver values on effective and sustainable clinical pathway implementation.

Common Factors of Surgical Delays in the Surgical Environment at a Federal Teaching Hospital in the Southwestern Nigeria

Surgery is a cost-effective and core component of universal health coverage. Surgical delay is considered to be one of the most upsetting problems affecting patient satisfaction, and it is considered an important challenging issue at most public hospitals as the length of time a patient has to wait after being booked in and registered on the waiting list until the surgery is finally done. The study was a descriptive survey using the quantitative method conducted on Surgical Delays and Associated Factors on Surgical Outcomes among Surgical Teams at Obafemi Awolowo University Teaching Hospitals Complex, Ife Hospital Unit, Ile-Ife, Osun State, Nigeria. Questionnaires and observation checklists were designed as tools to collect the data about surgical delays and associated factors among surgical teams. A total of two hundred and seventy (270) questionnaires were distributed and administered. The data collected were filled and entered into the computer using freeware data entry and validation program known as Epidata 3.0. The finding revealed that the common factors affecting surgical delays among surgical teams include communication gap [Relative Importance Index (RII) = 0.55], clinical instability of the patient (RII = 0.53), non-availability of an operating space (RII = 0.52), and infrastructure problems (RII = 0.52). Communication gap between the surgical team members is the common factor that leads to surgical delays in the health facility. Establishment of perioperative guidelines and protocols as well as review and reinforcement of existing ones are needed to eliminate the attitudinal and systemic causes of surgical delays.