Preoperative Clinic Research Articles

Real-world results of the implementation of preoperative anaemia clinic with intravenous iron therapy for treating iron-deficiency anaemia: a propensity-matched case-control study.

BackgroundPreoperative anaemia is associated with blood transfusion and longer hospital length of stay. Preoperative iron deficiency anaemia (IDA) can be treated with oral or intravenous (IV) iron. IV iron can raise haemoglobin faster compared with oral iron. However, its ability to reduce blood transfusion and length of stay in clinical trials is inconclusive. This study aims to compare blood transfusion and hospital length of stay between anemic patients who received preoperative IV iron versus standard care, after implementation of a protocol in 2017 to screen patients for preoperative IDA, and its treatment with IV iron.MethodsRetrospective before-after cohort study comparing 89 patients who received IV iron preoperatively in 2017, with historic patients who received oral iron therapy (selected by propensity score matching (PSM) from historic cohort of 7,542 patients who underwent surgery in 2016). Propensity score was calculated using ASA status, age, gender, surgical discipline, surgical risk and preoperative haemoglobin concentration. Both 1:1 and 1:2 matching were performed as sensitivity analysis.ResultsAfter PSM, there was no statistically significant difference in distribution of preoperative clinical variables. There was no significant difference in proportion of cases requiring transfusion nor a difference in average units transfused per patient. IV iron cohort stayed in hospital on average 8.0 days compared to non-IV iron cohort 14.1–15.1 days (P=0.006, P=0.013 respectively). Average time from IV iron therapy to surgery was 10.5 days.ConclusionsPreoperative IV iron therapy for patients with IDA undergoing elective surgery may not reduce perioperative blood transfusion, but this could be due to the short time between therapy and surgery. Implementation of IV iron therapy may reduce hospital length of stay compared to standard care for anemic patients, although this may be enhanced by concomitant improvement in perioperative care.

Efficacy of Monitoring for Multiple Antiplatelet Therapy during Intracranial Stent Placement: A Preliminary Study.

During cerebral aneurysm embolization using intracranial stents, platelet aggregation increases owing to increased wall shear stress and a loss of vascular endothelial function at the stent implantation site. Preoperative multiple antiplatelet therapy was introduced to prevent severe thromboembolic complications due to increased platelet aggregation. However, specific guidelines for the administration and pharmacological evaluation of this therapy do not exist currently. We examined the benefits of perioperative platelet aggregation monitoring in a cohort of patients. We had 377 patients with unruptured intracranial aneurysms who underwent stent-assisted embolization at our hospital between December 2012 and November 2019. We ultimately included 181 patients in our final analysis. These patients were continuously administered aspirin (100 mg/day) and clopidogrel (75 mg/day) for more than 5 days before the procedure to the post-procedural period. Of these patients, 30 patients who underwent light transmission aggregometry (LTA) before procedure, post-procedure (3 days after procedure), and at first post-discharge clinic visit were included as the subjects. The following characteristics were studied: age; sex; presence/absence of hypertension, dyslipidemia, and/or diabetes mellitus; location of aneurysm; type/number of stent; technique for stent placement; duration of preoperative multiple antiplatelet therapy; perioperative platelet aggregation test results; and postoperative ischemic or hemorrhagic complications. Among these 30 patients, the median duration of antiplatelet therapy prior to the preoperative platelet aggregation measurements was 7 (interquartile range [IQR]: 6-8) days, and post-discharge measurement of LTA was performed at a median period of 27 (IQR: 22-35.5) days after procedure. The preoperative, postoperative, and first post-discharge clinic visit LTA values for adenosine diphosphate (ADP)-induced platelet aggregation were 50% (IQR: 44-54%), 42.5% (IQR: 36-48%), and 36% (IQR: 32-40%), respectively. These results represented gradual decrease in LTA values and a significant difference between the preoperative and post-discharge values. The LTA values for collagen aggregation showed a significant difference evident between the preoperative and post-discharge values; preoperative 38% (IQR: 27-60%), postoperative 42% (IQR: 30-58%), post-discharge 28% (IQR: 20-42%), respectively. We had one thromboembolic complication and one hemorrhagic complication. The results indicated that appropriate platelet aggregation monitoring during multiple antiplatelet therapy prevents thromboembolic complications such as stent thrombosis. However, we also found that many patients demonstrated increased postoperative platelet aggregation inhibitory effects due to the postoperative continuation of the same multiple antiplatelet therapy that was used preoperatively. This study demonstrates that postoperative, continuous, oral antiplatelet therapy induces increased platelet aggregation inhibition effects, which may lead to hemorrhagic complications. Therefore, continued platelet aggregation monitoring after surgery may be important to allow for any necessary alterations to the therapeutic dose and regimen.

Hormonally Active Adrenal tumors; Challenges and Outcomes for Different Surgical Approaches.

Objective:The aim of this study is to compare the intraoperative and short-term outcomes of different surgical approaches for hormone active and non-functional adrenal masses.Methods:The data of 206 patients who underwent adrenal gland surgery in our clinic between 2012 and 2020 were retrospectively analyzed. Pre-operative outpatient clinic records of the patients, imaging methods, laboratory results and surgery records, operation time (OT), amount of bleeding, duration of hospital stay, and complications were evaluated. Patients were divided into two groups as those with non-functional mass (n=80) and those with hormoneactive mass (n=126).Results:The median age of the patients was 52 (range 19–83) and 77.2% of them were female. Tumor size was larger in hormone active group (p=0.311), and the difference was more pronounced in the pheochromocytoma subgroup (p=0.088). The rate of transition to open surgery was similar in both groups (0.959), and no conversion to laparoscopy or conventional open surgery was performed in robotic cases. The duration of surgery (p=0.669), mean amount of blood loss (p=0.834), and mean hospital stay (p=0.195) were also similar between the two groups. Intraoperative and post-operative complications were similar between two groups (p=0.573 and p=0.415, respectively). Considering the subgroup analysis of the patients in hormone active group; the duration of hospital stay was longer in patients with Cushing syndrome (p=0.001), while there was no difference in OT and estimated blood loss between patients who were operated for Conn, Cushing, and pheochromocytoma (p=0.086 and p=0.099; respectively).Conclusion:Surgical results of hormone active adrenal masses were found to be similar to non-functional masses. Although the hormonal condition of the mass does not change the difficulty level of the surgical procedure, it may be recommended that the robotic approach be preferred to facilitate manipulation in these masses.

Expired Air Carbon Monoxide Testing Is Effective for Preoperative Screening of Cigarette Use in Orthopaedic Patients: A Prospective Pilot Study of 70 Veterans

Introduction: Screening for cigarette use is standard in the orthopedic pre-operative clinic, however traditional biochemical testing methods, including serum and urine cotinine assays, do not differentiate active smoking from nicotine replacement therapy (NRT). In this prospective pilot study, we hypothesize that exhaled carbon monoxide (eCO) testing will be non-inferior to the gold standard serum cotinine (SC) test in screening for pre-operative cigarette use, will differentiate active smoking from NRT, and will allow for substantial cost savings in a clinic setting. Methods: Adult orthopaedic veterans indicated for elective surgery at our institution were offered inclusion. Self-reported smoking status (SRS), eCO and SC levels were obtained preoperatively. An eCO level of >6 parts per million and a SC level >3 ng/ml were considered positive for recent cigarette use. Agreement between SRS, eCO levels and SC levels, and eCO level test-retest reliability were evaluated. Results: Of the 55 patients enrolled into the study, 4 were self-reported Current Smokers and 51 were self-reported Ex-Smokers or Non-Smokers. Combining SRS with eCO levels as a screening tool for recent cigarette use yielded a sensitivity of 100%, a specificity of 98%, a positive predictive value of 95% and a negative predictive value of 100%. eCO testing differentiated NRT from cigarette use in all non-smoking patients. Test-retest reliability for eCO levels showed perfect agreement for 16 patients that had two or more eCO levels pre-operatively. Conclusion: Exhaled CO testing is as effective as SC testing but can differentiate active smoking from NRT, while maintaining a high level of accuracy and reliability when combined with SRS as a screening tool.

Anesthesia preoperative clinics: redefining the value proposition.

Anesthesia preoperative clinics: redefining the value proposition.

Clinical outcomes of radical surgery in patients with renal carcinoma and associated venous thrombosis: Single-centre experience in a tertiary care institution.

Renal carcinoma and associated venous thrombosis cause specific perioperative and postoperative challenges. We aimed to evaluate the factors affecting clinical outcomes in patients undergoing radical surgery because of renal carcinoma and associated venous thrombosis. Hospital records were retrospectively reviewed to identify patients with renal carcinoma and associated venous thrombosis treated with radical surgery between 2006 and 2019. Preoperative, perioperative, and postoperative findings were analysed to determine the associations between clinical and survival outcomes. Overall and disease-free survival were analysed by the Kaplan-Meier method. Other associated prognostic variables were assessed using univariate and multivariate Cox regression analyses. Thirty-three patients with renal carcinoma and associated venous thrombosis were enrolled for this study. There were 15 (45.4%) patients with level I, five (15.2%) with level II, eight (24.2%) with level III, and five (15.2%) with level IV venous thrombosis according to the Mayo Clinic classification system. The median follow-up was 35.6months. In the univariate analysis, increased tumour size was associated with poor overall and disease-free survival. Preoperative clinic M1 disease was associated with poor overall survival. A high Mayo Clinic thrombus level was associated with poor disease-free survival. In the multivariate analysis, only tumour size and clinic M1 disease were independently correlated with poor overall survival. No independent statistically significant association was detected between thrombus level and survival outcomes. Although the thrombus level was not associated with overall and disease-free survival, tumour size and clinic M1 disease were found to have an independent prognostic impact on overall survival.

Utilizing time-driven activity-based costing to determine open radical cystectomy and ileal conduit surgical episode cost drivers

ObjectivesPatients undergoing radical cystectomy represent a particularly resource-intensive patient population. Time-driven activity based costing (TDABC) assigns time to events and then costs are based on the people involved in providing care for specific events. To determine the major cost drivers of radical cystectomy care we used a TDABC analysis for the cystectomy care pathway. Subjects and methodsWe retrospectively reviewed a random sample of 100 patients out of 717 eligible patients undergoing open radical cystectomy and ileal conduit for bladder cancer at our institution between 2012 and 2015. We defined the cycle of care as beginning at the preoperative clinic visit and ending with the 90-day postoperative clinic visit. TDABC was carried out with construction of detailed process maps. Capacity cost rates were calculated and the care cycle was divided into 3 phases: surgical, inpatient, and readmissions. Costs were normalized to the lowest cost driver within the cohort. ResultsThe mean length of stay was 6.9 days. Total inpatient care was the main driver of cost for radical cystectomy making up 32% of the total costs. Inpatient costs were mainly driven by inpatient staff care (76%). Readmissions were responsible for 29% of costs. Surgery was 31% of the costs, with the majority derived from operating room staff costs (65%). ConclusionThe major driver of cost in a radical cystectomy pathway is the inpatient stay, closely followed by operating room costs. Surgical costs, inpatient care and readmissions all remain significant sources of expense for cystectomy and efforts to reduce cystectomy costs should be focused in these areas.

User Experience of a Chatbot Questionnaire Versus a Regular Computer Questionnaire: Prospective Comparative Study.

BackgroundRespondent engagement of questionnaires in health care is fundamental to ensure adequate response rates for the evaluation of services and quality of care. Conventional survey designs are often perceived as dull and unengaging, resulting in negative respondent behavior. It is necessary to make completing a questionnaire attractive and motivating.ObjectiveThe aim of this study is to compare the user experience of a chatbot questionnaire, which mimics intelligent conversation, with a regular computer questionnaire.MethodsThe research took place at the preoperative outpatient clinic. Patients completed both the standard computer questionnaire and the new chatbot questionnaire. Afterward, patients gave their feedback on both questionnaires by the User Experience Questionnaire, which consists of 26 terms to score.ResultsThe mean age of the 40 included patients (25 [63%] women) was 49 (SD 18-79) years; 46.73% (486/1040) of all terms were scored positive for the chatbot. Patients preferred the computer for 7.98% (83/1040) of the terms and for 47.88% (498/1040) of the terms there were no differences. Completion (mean time) of the computer questionnaire took 9.00 minutes by men (SD 2.72) and 7.72 minutes by women (SD 2.60; P=.148). For the chatbot, completion by men took 8.33 minutes (SD 2.99) and by women 7.36 minutes (SD 2.61; P=.287).ConclusionsPatients preferred the chatbot questionnaire over the computer questionnaire. Time to completion of both questionnaires did not differ, though the chatbot questionnaire on a tablet felt more rapid compared to the computer questionnaire. This is an important finding because it could lead to higher response rates and to qualitatively better responses in future questionnaires.

Pre-operative patient optimization to prevent postoperative pulmonary complications-Insights and roles for the respiratory therapist: A narrative review.

BackgroundThe preoperative period has gained recognition as a crucial time to identify and manage preoperative medical conditions for preventing perioperative complications. Consequently, preoperative clinics have now become an essential component of perioperative care at many large hospitals. As the prevalence of preoperative clinics continues to grow, and the field of perioperative medicine progresses, respiratory therapists (RTs) will inevitably find a growing role to participate in preoperative patient optimization to mitigate pulmonary complications.MethodsKeyword searches on perioperative pulmonary complications were conducted on the Medline database via PubMed and identified over 2000 candidate articles for review. Articles were included if they were English only and resulted with one or more of the following search terms; pulmonary complications, postoperative complications, postoperative pulmonary complications (PPCs), prehabilitation, incentive spirometry, smoking cessation, noninvasive ventilation. Preference was given for meta-analyses, randomized controlled trials, and systematic reviews. Publications within the past two decades were given additional preference toward final inclusion. The authors discussed eligible articles in group meetings over the span of multiple years to assess relevance and quality of data for narrowing eligible articles to the final selection of publications for the review.FindingsThe following narrative review examines preoperative optimization strategies to prevent PPCs and highlight areas where RTs may play a key role. After examining challenges in defining PPCs, the review examines key risk models available to predict PPCs and their implications for subsequent discussion on preventive measures that RTs may assist with in a multidisciplinary team.ConclusionRTs can reduce the health care burden of PPCs by assisting fellow perioperative clinicians in providing respiratory care for patients with premorbid conditions. While much of our review focused on pre-existing pulmonary pathologies and both the pharmacological and nonpharmacological optimization of these pathologies, there are other factors contributing to PPCs deserving future exploration.

A Preoperative Risk Prediction Tool for Discharge to a Skilled Nursing or Rehabilitation Facility After Total Joint Arthroplasty

BackgroundDischarge to rehabilitation or a skilled nursing facility (SNF) after total joint arthroplasty remains a primary driver of cost excess for bundled payments. An accurate preoperative risk prediction tool would help providers and health systems identify and modulate perioperative care for higher risk individuals and serve as a vital tool in preoperative clinic as part of shared decision-making regarding the risks/benefits of surgery. MethodsA total of 10,155 primary total knee (5,570, 55%) and hip (4,585, 45%) arthroplasties performed between June 2013 and January 2018 at a single institution were reviewed. The predictive ability of 45 variables for discharge location (SNF/rehab vs home) was tested, including preoperative sociodemographic factors, intraoperative metrics, postoperative labs, as well as 30 Elixhauser comorbidities. Parameters surviving selection were included in a multivariable logistic regression model, which was calibrated using 20,000 bootstrapped samples. ResultsA total of 1786 (17.6%) cases were discharged to a SNF/rehab, and a multivariable logistic regression model demonstrated excellent predictive accuracy (area under the receiver operator characteristic curve: 0.824) despite requiring only 9 preoperative variables: age, partner status, the American Society of Anesthesiologists score, body mass index, gender, neurologic disease, electrolyte disorder, paralysis, and pulmonary circulation disorder. Notably, this model was independent of surgery (knee vs hip). Internal validation showed no loss of accuracy (area under the receiver operator characteristic curve: 0.8216, mean squared error: 0.0004) after bias correction for overfitting, and the model was incorporated into a readily available, online prediction tool for easy clinical use. ConclusionThis convenient, interactive tool for estimating likelihood of discharge to a SNF/rehab achieves excellent accuracy using exclusively preoperative factors. These should form the basis for improved reimbursement legislation adjusting for patient risk, ensuring no disparities in access arise for vulnerable populations. Level of EvidenceIII.

PreAnaesThesia computerized health (PATCH) assessment: development and validation

BackgroundTechnological advances in healthcare have enabled patients to participate in digital self-assessment, with reported benefits of enhanced healthcare efficiency and self-efficacy. This report describes the design and validation of a patient-administered preanaesthesia health assessment digital application for gathering medical history relevant to preanaesthesia assessment. Effective preoperative evaluation allows for timely optimization of medical conditions and reduces case cancellations on day of surgery.MethodsUsing an iterative mixed-methods approach of literature review, surveys and panel consensus, the study sought to develop and validate a digitized preanaesthesia health assessment questionnaire in terms of face and criterion validity. A total of 228 patients were enrolled at the preoperative evaluation clinic of a tertiary women’s hospital. Inclusion criteria include: age ≥ 21 years, scheduled for same-day-admission surgery, literacy in English and willingness to use a digital device. Patient perception of the digitized application was also evaluated using the QQ10 questionnaire. Reliability of health assessment questionnaire was evaluated by comparing the percentage agreement of patient responses with nurse assessment.ResultsModerate to good criterion validity was obtained in 81.1 and 83.8% of questions for the paper and digital questionnaires respectively. Of total 3626 response-pairs obtained, there were 3405 (93.4%) concordant and 221 (6.1%) discrepant response-pairs for the digital questionnaire. Discrepant response-pairs, such as ““no/yes” and “unsure/yes”, constitute only 3.7% of total response-pairs. Patient acceptability of the digitized assessment was high, with QQ10 value and burden scores of 76 and 30%, respectively.ConclusionsSelf-administration of digitized preanaesthesia health assessment is acceptable to patients and reliable in eliciting medical history. Further iteration should focus on improving reliability of the digital tool, adapting it for use in other languages and incorporating clinical decision tools.

Anaemia in cardiac surgery - a retrospective review of a centre's experience with a pre-operative intravenous ironclinic.

Pre-operative anaemia is associated with higher rates of transfusion and worse outcomes, including prolonged hospital stay, morbidity and mortality. Iron deficiency is associated with significantly lower haemoglobin levels throughout the peri-operative period and more frequent blood transfusion. Correction of iron stores before surgery forms part of the first pillar of patient blood management. We established a pre-operative anaemia clinic to aid identification and treatment of patients with iron deficiency anaemia scheduled for elective cardiac surgery. We present a retrospective observational review of our experience from January 2017 to December 2019. One-hundred and ninety patients received treatment with intravenous iron, a median of 21days before cardiac surgery. Of these, 179 had a formal laboratory haemoglobin level measured before surgery, demonstrating a median rise in haemoglobin of 8.0g.l-1 . Patients treated with i.v. iron demonstrated a significantly higher incidence of transfusion (60%) compared with the non-anaemic cohort (22%) during the same time period, p<0.001. Significantly higher rates of new requirement for renal replacement therapy (6.7% vs. 0.6%, p<0.001) and of stroke (3.7% vs. 1.2%, p=0.010) were also seen in this group compared with those without anaemia, although there was no significant difference in in-hospital mortality (1.6% vs. 0.8%, p=0.230). In patients where the presenting haemoglobin was less than 130g.l-1 , but there was no intervention or treatment, there was no difference in rates of transfusion or of complications compared with the anaemic group treated with iron. In patients with proven iron deficiency anaemia, supplementation with intravenous iron showed only a modest effect on haemoglobin and this group still had a significantly higher transfusion requirement than the non-anaemic cohort. Supplementation with intravenous iron did not improve outcomes compared with patients with anaemia who did not receive intravenous iron and did not reduce peri-operative risk to non-anaemic levels. Questions remain regarding identification of patients who will receive most benefit, the use of concomitant treatment with other agents, and the optimum time frames for treatment in order to produce benefit in the real-world setting.

IMPROV-ED trial: eHealth programme for faster recovery and reduced healthcare utilisation after CABG.

BackgroundAfter coronary artery bypass grafting (CABG), healthcare utilisation is high and is partly unplanned. eHealth applications have been proposed to reduce healthcare consumption and to enable patients to get actively involved in their recovery. This way, healthcare expenses can be reduced and the quality of care can be improved.ObjectivesWe aim to evaluate whether the use of an eHealth programme can reduce unplanned healthcare utilisation and improve mental and physical health in the first 6 weeks after discharge in patients who underwent CABG. In addition, patient satisfaction and use of the eHealth programme will be evaluated.MethodsFor this single-centre randomised controlled trial, at least 280 patients referred for CABG will be included at the preoperative outpatient clinic and randomised to an intervention or control group. The intervention group will have access to an eHealth programme, which consists of online educational videos developed by the Dutch Heart Foundation and postoperative video consultations with a physician. The control group will receive standard care and will not have access to the eHealth programme. The primary endpoint is healthcare utilisation; other endpoints include anxiety, duration of recovery, quality of life and patient satisfaction. Participants will complete several questionnaires at 6 time points during the study.ResultsPatient enrolment started in February 2020 and completion of the follow-up period is expected in August 2021.ConclusionThis randomised trial was initiated to test the hypothesis that patients who are partaking in our eHealth programme use less unplanned care and experience a better quality of life, less anxiety and a faster recovery than controls.

Criticality Of Adequate Quality Monitoring Of Pre-Type And Screen Orders For The Operating Room: Role Of The Education, Proactive Communication At VAMC

Abstract Introduction/Objective Ordering pre-operative type and screen specimens before the day of surgery is very important to prevent delays in provision of blood products due to unexpected alloantibody findings, unexpected ABO discrepancies, or need for a repeat ABO-RH testing due to lack of historical testing. However, the important pre- operative type and screen was not always ordered prior to the day of surgery by the clinician. Due to this observation, after discussion and collaboration with the Blood Utilization Committee (BUC), an educational and mentoring intervention for the pre-operative clinicians was undertaken. Methods Education and mentoring of clinicians involved in the pre-operative clinics, surgical services, and new incoming physicians on an ongoing basis was undertaken through the BUC since March 2018. As part of quality assurance, to track the results of this widespread educational effort, the daily OR lists from January 2017 to December 2019 were examined with the medical record to determine if a pre-operative type and screen was ordered prior to the day of surgery. The established Maximum Surgery Blood order Schedule (MSBOS) for the facility was used to determine if a pre-operative type and screen would be indicated for the listed procedure. Results As we started reinforced pre type and screen should be ordered there has been significant increase in percent of compliance rate average from 76% (2017), 87% (2018), and 95.6% (2019). By the T-test, there was a statistically significant change in the monthly ordering rates (p-value &amp;lt; 0.05). The VAMC’s preferred threshold value of at least 95% with pre-operative type and screen prior to the day of procedure was achieved in the 2019 calendar year with no operating room delays. Conclusion Appropriately performing the pre-operative type and screen prior to the day of the elective surgical procedure would reduce the risk of delays due to unexpected findings or lack of a historical ABO-RH type. Educational interventions help tremendously in ensuring this critical patient care practice is followed. The value of collaborating and educating clinicians cannot be understated as it is both cheap, simple, and highly effective.

Retrospective Implementation of Algorithm for Route of Hysterectomy in Resident Clinic May Increase Rates of Vaginal Hysterectomy

Study Objective A resident-driven quality improvement project designed to evaluate whether retrospective application of a decision-making algorithm to guide selection of route for benign hysterectomy may have resulted in increased rates of total vaginal hysterectomy (TVH) in resident gynecology clinic. Design Retrospective chart review of all hysterectomies booked through resident pre-operative gynecology clinic over a five-year period. Setting Resident-run gynecology clinic in a large, urban academic medical center. Patients or Participants 162 patients underwent hysterectomy for benign indications in the five-year period under review (1/2015-12/2019). Interventions We created an algorithm to guide selection of route of hysterectomy for benign disease based on existing guidelines and review of literature. Electronic medical records (EMR) were reviewed for preoperative documentation of benign disease, uterine size and presence of adequate cervix, need for adnexal assessment (i.e. concern for large ovarian mass, endometriosis), concern for pelvic adhesions based on exam, or other rationale for route selection. The algorithm was retrospectively applied to identify which cases may have been preoperative candidates for TVH. Measurements and Main Results Retrospective application of our algorithm indicated that 61 of the 162 cases may have been candidates for TVH, and an additional 57 may have been candidates for an exam under anesthesia/diagnostic laparoscopy followed by possible TVH. Only 25 cases were booked as TVH; 5 were booked as EUA or diagnostic laparoscopy before TVH. Identified areas of improvement include assessment for adequate pelvis and proper counseling, particularly in “intermediate category” candidates. Conclusion By retrospectively implementing an algorithm to identify candidates for TVH, based on available documentation, it appears that a large percentage of cases booked from resident clinic could have been attempted vaginally. This shows opportunity for prospective implementation of the algorithm to increase rates of vaginal hysterectomy from the current rate of 15% to as high as 38%.

Patient-centred measurement of recovery from day-case surgery using wrist worn accelerometers: a pilot and feasibility study.

This pilot and feasibility study evaluated wrist-worn accelerometers to measure recovery from day-case surgery in comparison with daily quality of recovery-15 scores. The protocol was designed with extensive patient and public involvement and engagement, and delivered by a research network of anaesthesia trainees. Forty-eight patients recruited through pre-operative assessment clinics wore wrist accelerometers for 7days before (pre-operative) and immediately after elective surgery (early postoperative), and again at 3months (late postoperative). Validated activity and quality of recovery questionnaires were administered. Raw accelerometry data were archived and analysed using open source software. The mean (SD) number of valid days of accelerometer wear per participant in the pre-operative, early and late postoperative periods were 5.4 (1.7), 6.6 (1.1) and 6.6 (1.0) days, respectively. On the day after surgery, Euclidian norm minus one (asummary measure of raw accelerations), step count, light physical activity and moderate/vigorous physical activity decreased to 57%, 47%, 59% and 35% of baseline values, respectively. Activity increased progressively on a daily basis but had not returned to baseline values by 7days. Patient questionnaires suggested subjective recovery by postoperative day 3 to 4; however, accelerometry data showed that activity levels had not returned to baseline at this point. All activity measures had returned to baseline by 3months. Wrist-worn accelerometery is acceptable to patients and feasible as a surrogate measure for monitoring postoperative recovery from day-case surgery. Our results suggest that patients may overestimate their rate of recovery from day-case surgery, which has important implications for future research.

The Well-Tempered Clinic: The Clinical and Educational Importance of Cardiovascular Surgical Clinics (With a nod to Johann Sebastian Bach)

A common assertion regarding the trajectory of surgeons from training to independent practice is that the first five years after completing training encompass the steepest learning curve of a young surgeon's career. That assertion is often made in the context of beginning to perform operations independently. However, it is likely that an under-recognized but equally steep learning curve will occur as newly minted surgeons begin to run their own clinics. In fact, it is likely that there is no aspect of surgical training with a greater discrepancy between the educational value for and the interest by surgical trainees than preoperative, postoperative, and follow-up clinics for surgical patients.

Clinician-driven model creates opportunity for perioperative patient education AIDS

Introduction Despite readily available guidelines and convincing evidence for limiting transfusions, unjustified variability in perioperative red blood cell (RBC) transfusion practice remains in cardiac surgical patients. We hypothesize that sharing the decision of when to transfuse RBC with cardiac surgical patients will limit unjustified perioperative transfusion. Herein, we present the results of a survey to better delineate the knowledge of and preference for perioperative RBC transfusion by clinician and patients. Methods The final provider participant survey contained 11 questions plus 10 demographic questions, while the final patient participant survey contained 10 questions plus 9 demographic questions. Survey content and research method was approved by the local Institutional Review Board. Clinician surveys were distributed to the Departments of Cardiology, Cardiac Surgery, Internal Medicine and Anesthesiology using Research Electronic Data Capture (REDCap). Patient surveys were distributed to consecutive patients presenting to our Preoperative Clinic for one week. Patient responses were manually entered into excel. Participant responses were summarized and compared using JMP Pro 14. Results Of the 313 surveys distributed to clinicians, and 121 to patients, 99 (32%) and 93 (77%) were returned, respectively. Of the 6 questions that tested knowledge, three differed significantly between clinicians and patients (Table): on a seven-category Likert scale, clinicians felt more knowledgeable than patients about the hemoglobin level at which red blood cells should be transfused (5.5 vs 2.1; p Discussion In a reasonably well-represented sample of participants from a large, academic tertiary care hospital, we highlight significant differences in the basic knowledge about and preferences for perioperative red blood transfusion between clinicians and patients. Our results strongly imply a clinician-driven decision model to transfuse RBCs, and supports future efforts to develop decision aids to facilitate patient involvement in the shared decision-making of when and how much to transfuse.

Transforming the preoperative evaluation process for elective cardiac surgery

ABSTRACT The Ministry of Health of Saudi Arabia (SA) is in the process of directing publicly funded healthcare facilities to streamline their service delivery processes to improve cost efficiency, while maintaining a high quality of care. Current service models for patients undergoing elective cardiac surgery in SA involve a prolonged preoperative inpatient stay. The preoperative assessment clinic model, which is preferred in many countries, is an alternative to this current standard of care in SA. Herein, we compare and contrast the traditional, inpatient-focused preoperative model with the preoperative assessment clinic model and discuss the implications of transitioning to the new model at King Fahad Medical City. The proposed model for preoperative management for coronary artery bypass grafting produces an immediate 80.48% cost saving over the current level of expenditure. Most expenses in the current model are toward facility costs for the standard 7-day preoperative stay. The proposed model replaces this with the cost of operating the clinic, which is considerably lower, without adversely impacting the level of professional care administered or procedural outcomes. Such cost-cutting and efficiency-improving strategies could benefit other departments of King Fahad Medical City, in institutions across SA, and in institutions in other developing nations.

Patience is a virtue: Multiple preoperative visits are associated with decreased recurrence in pediatric pilonidal disease

Background/PurposeThis study aimed to compare preoperative management strategies for patients undergoing trephination for pilonidal disease and evaluate risk factors for recurrence. MethodsA retrospective review was performed of children undergoing index surgical treatment with trephination for pilonidal disease between September 2017 and April 2019. Intraoperative and postoperative management were standardized. Demographic and perioperative data were collected and analyzed. ResultsOne-hundred twenty patients were identified with a median follow-up time of 7.5 months (interquartile range 4.1–13.2 months). Overall, 24 (20%) patients had a postoperative recurrence of pilonidal disease. Patients with multiple preoperative surgery clinic visits were less likely to have recurrent disease compared to those seen only once preoperatively (11% vs 26%, p = 0.040). Compared to patients without recurrence, those who recurred went to the operating room sooner from the time of initial surgical consultation (32 days vs 54 days, p < 0.001). Perioperative antibiotics, history of acute infection, and prior drainage procedures were not risk factors for recurrence. ConclusionsMultiple preoperative clinic visits are associated with a lower recurrence rate in children undergoing trephination for pilonidal disease. An increased duration of preoperative medical management may be responsible for this finding. Prospective study is needed to confirm these findings and identify additional factors that influence recurrence. Type of StudyTreatment Study. Level of EvidenceIII (Retrospective Comparative).