Outpatient Preoperative Clinic Research Articles

Influence of certified perioperative nurses on the establishment of preoperative outpatient clinic and rate of preoperative assessment in Japan

This study aimed to investigate the influence of certified perioperative nurses on preoperative outpatient clinic and preoperative assessments. The study was conducted from February 2021 to September 2022; data were collected and analyzed using a questionnaire at 247 hospitals in Japan. To analyze the factors affecting the rate of preoperative assessment with the primary endpoint of preoperative outpatient care and preoperative nursing visits, we performed multiple linear regression analysis of facility characteristics, perioperative nurse background, and the presence or absence of certified perioperative nurses. Regarding the presence or absence of a preoperative outpatient clinic, patients from 68 (52.3%) and 41 (35.0%) institutions in the enrolled and nonenrolled groups. Respectively, underwent a preoperative assessment; the rate of preoperative assessments in the enrolled group was significantly higher than that in the nonenrolled group. Multivariate analysis of factors influencing the preoperative assessment rate revealed a significant association with certified perioperative nurse attendance. Facilities with certified perioperative nurses have a significantly higher prevalence of preoperative outpatient clinic and significantly higher rates of preoperative assessments than facilities without certified perioperative nurses. Enrollment of certified perioperative nurses may lead to the improvement of the quality of preoperative nursing interventions.

Early Improvement in Patient-Reported Outcome Scores After Operative Treatment of Osteochondritis Dissecans of the Humeral Capitellum

Outcome measures that lack sensitivity for the detection of clinical changes early after surgery for capitellar osteochondritis dissecans (OCD) make it difficult to determine the optimal treatment for these defects. We sought to evaluate the early responsiveness of patient-reported outcomes measurement information system (PROMIS) scores in a cohort of patients operatively treated for capitellar OCD. Four PROMIS questionnaires (mobility, upper extremity [UE], pain interference, and peer relations) were electronically administered to patients treated for capitellar OCD at a single tertiary academic medical center between January 1, 2015, and July 1, 2018. The questionnaires were administered at the initial preoperative outpatient clinic visit as well as at the 2-week, 6-week, and final return-to-play (RTP) visits. Twenty-nine patients (31 elbows, mean age 12.9 years) with available preoperative and postoperative PROMIS data were included. The mean final follow-up period was 26 weeks. Compared with that before surgery, there was a significant improvement in the mobility, pain interference, and UE scores at 6 weeks following surgery. The scores improved most significantly by 6 weeks, reached a relative plateau, and remained significantly improved through the RTP visit thereafter. Patients with preoperative, intra-articular loose bodies scored significantly better than those without them during the 6-week and RTP visits. Patients with lesions >1 cm2, compared with those with lesions ≤1 cm2, demonstrated greater improvement in the UE scores during the RTP visit. In patients undergoing operative treatment for capitellar OCD, a significant improvement in the PROMIS domains of mobility, pain interference, and UE can be expected early in the postoperative period, with majority of patients reaching their greatest improvement in scores by 6 weeks following surgery. This is important information for preoperative counseling. In addition, this information is helpful in confirming that PROMIS scores are responsive in the detection of changes in outcomes during the early postoperative period in this population.

The Impact of Nonpharmacological Interventions on Patient Experience, Opioid Use, and Health Care Utilization in Adult Cardiac Surgery Patients: Protocol for a Mixed Methods Study.

BackgroundDespite pharmacological treatments, patients undergoing cardiac surgery experience severe anxiety and pain, which adversely affect outcomes. Previous work examining pediatric and nonsurgical adult patients has documented the effectiveness of inexpensive, nonpharmacological techniques to reduce anxiety and pain as well as health care costs and length of hospitalization. However, the impact of nonpharmacological interventions administered by a dedicated comfort coach has not been evaluated in an adult surgical setting.ObjectiveThis trial aims to assess whether nonpharmacological interventions administered by a trained comfort coach affect patient experience, opioid use, and health care utilization compared with usual care in adult cardiac surgery patients. This study has 3 specific aims: assess the effect of a comfort coach on patient experience, measure differences in inpatient and outpatient opioid use and postoperative health care utilization, and qualitatively evaluate the comfort coach intervention.MethodsTo address these aims, we will perform a prospective, randomized controlled trial of 154 adult cardiac surgery patients at Michigan Medicine. Opioid-naive patients undergoing first-time, elective cardiac surgery via sternotomy will be randomized to undergo targeted interventions from a comfort coach (intervention) versus usual care (control). The individualized comfort coach interventions will be administered at 6 points: preoperative outpatient clinic, preoperative care unit on the day of surgery, extubation, chest tube removal, hospital discharge, and 30-day clinic follow-up. To address aim 1, we will examine the effect of a comfort coach on perioperative anxiety, self-reported pain, functional status, and patient satisfaction through validated surveys administered at preoperative outpatient clinic, discharge, 30-day follow-up, and 90-day follow-up. For aim 2, we will record inpatient opioid use and collect postdischarge opioid use and pain-related outcomes through an 11-item questionnaire administered at the 30-day follow-up. Hospital length of stay, readmission, number of days in an extended care facility, emergency room, urgent care, and an unplanned doctor’s office visit will be recorded as the primary composite endpoint defined as total days spent at home within the first 30 days after surgery. For aim 3, we will perform semistructured interviews with patients in the intervention arm to understand the comfort coach intervention through a thematic analysis.ResultsThis trial, funded by Blue Cross Blue Shield of Michigan Foundation in 2019, is presently enrolling patients with anticipated manuscript submissions from our primary aims targeted for the end of 2020.ConclusionsData generated from this mixed methods study will highlight effective nonpharmacological techniques and support a multidisciplinary approach to perioperative care during the adult cardiac surgery patient experience. This study’s findings may serve as the foundation for a subsequent multicenter trial and broader dissemination of these techniques to other types of surgery.Trial RegistrationClinicalTrials.gov NCT04051021; https://clinicaltrials.gov/ct2/show/NCT04051021International Registered Report Identifier (IRRID)DERR1-10.2196/21350

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.

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.

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.

Effect of PreAnaesThesia Computerized Health (PATCH) Assessment on Duration of Nurse-Patient Consultation and Patient Experience: A Pilot Trial.

Preanaesthesia health assessment is gradually transitioning from paper-based, face-to-face assessment to digitized assessment, self-administered by the patient. This transition could potentially optimize the various goals of assessment, notably facilitating the efficient collection of the patient’s health information. We have previously developed and validated a tablet application (PreAnaesThesia Computerized Health assessment application or “PATCH”) for patients to conduct preanaesthesia self-assessment. In a randomized controlled trial, we sought to compare the duration of nurse–patient consultation and patient satisfaction between patients who underwent PATCH self-assessment vs. standard care nurse-led assessment. Fifty-two elective surgical patients were randomized to complete either PATCH assessment or standard care nurse-led assessment at an outpatient preoperative clinic. The duration of nurse–patient consultation was subsequently noted for all patients who also completed a satisfaction survey. The mean (SD) nurse–patient consultation times in the PATCH and standard care groups were comparable, at 11.5 (3.6) min and 12.2 (2.9) min, respectively (p = 0.703). Overall satisfaction scores were also comparable, at 23.9 and 27.0 respectively (p = 0.451) for the PATCH and standard nurse assessment groups. Favorable perceptions of PATCH among users ranged between 41.7% and 79.2%. In conclusion, PATCH self-assessment can feasibly be introduced into current practice with comparable nurse–patient consultation times and patient satisfaction.

Level of agreement of point-of-care and laboratory HbA1c measurements in the preoperative outpatient clinic in non-diabetic patients who are overweight or obese

Implementation of point-of-care HbA1c devices in the preoperative outpatient clinic might facilitate the early diagnosis of glycemic disturbances in overweight or obese patients undergoing surgery, but validation studies in this setting do not exist. We determined the level of agreement between a point-of-care and laboratory HbA1c test in non-diabetic patients visiting the outpatient clinic for preoperative risk profiling. Point-of-care HbA1c levels were measured in whole blood obtained by a finger prick (Siemens DCA Vantage HbA1c analyzer) and in hemolysed EDTA blood in the central laboratory (LAB). Bland Altman and Clarke’s error grid analysis were used to analyze the agreement between the point-of-care and laboratory measurements. Patients (n = 49) were 55 ± 11 years old, 47% were male with a body mass index (BMI) of 30.6 ± 3.4 kg/m2. The mean HbA1c was 38.1 ± 3.7 mmol/mol or 5.6 ± 0.3%. One patient was diagnosed with a HbA1c indicative for diabetes mellitus (6.7%). Bland Altman analysis revealed a bias of − 0.53 ± 1.81 mmol/mol with limits of agreement of − 4.09 to 3.03 mmol/mol and a bias of − 0.05 ± 0.17% with limits of agreement − 0.39 to 0.28%. The percentage error was 9.2% and 5.9% for HbA1c expressed in mmol/mol and %, respectively. Clarke’s error grid analysis showed that 48 out of 49 measurements were located in area A (98%). Point-of-care HbA1c measurements showed a high level of agreement with the laboratory test in the outpatient setting, and may be used for preoperative risk profiling in patients prone to cardiometabolic complications.Trial registration: Netherlands Trial Register NTR3057.

Discordance of patient and provider perceptions of the meaning of verbal estimates of perioperative risk

PurposeTo determine whether the use of semiquantitative, verbal (non-numerical) language to express levels of perioperative risk is a possible cause of poor communication between practitioners and patients. MethodsSurvey forms were distributed to patients who had just completed an outpatient preoperative clinic visit at a large academic medical center. Surveys were distributed from October 2015 through March 2016. Data collected included demographic characteristics, literacy and numeracy characteristics, patient recollection of level of risk discussion, and the effect of the discussion on patient desire to pursue surgery. Patients were asked to define, using percentages, commonly used verbal semiquantitative terms for levels of risk (low, medium/intermediate, and high). Results212 patients completed surveys. Overall, 84% of patients noted that the actual level of risk was discussed in quantitative or semiquantitative terms; of these patients, 66% reported risk was described using words only. When asked to numerically define low, medium/intermediate, and high risk, patient estimates were markedly discordant, being typically higher, from the usual definitions for these terms as published in the medical literature and as used by medical practitioners. More than 55% of patients surveyed indicated that high risk would correspond to a >50% chance of adverse event, whereas clinicians generally define high risk as >5% chance of adverse event. ConclusionSemiquantitative terms used to define levels of perioperative risk may have very different meanings to patients and practitioners. To facilitate true informed consent, such terms should be avoided and more precise, numerical, quantitative estimates of risk should be used instead.

Association between preoperative ambulatory heart rate and postoperative myocardial injury: a retrospective cohort study

BackgroundResting heart rate is well established as a predictor of morbidity and mortality in the general population. However, the relationship between preoperative heart rate and perioperative outcomes, specifically myocardial injury, is unclear. MethodsThis retrospective cohort study included patients undergoing elective major non-cardiac surgery from 2008 to 2014 at a multisite healthcare system. The exposure was ambulatory heart rate measured during the outpatient preoperative clinic visit, whereas the outcome of interest was myocardial injury (peak postoperative troponin I concentration >30 ng L−1). Covariates included patient characteristics, comorbidities, and preoperative medications. We constructed several multivariable regression models that each modelled heart rate in a different manner, including as a simple continuous variable, categories, and fractional polynomials. ResultsThe cohort included 41 140 patients, of whom 4857 (11.8%) experienced myocardial injury. Based on pre-specified heart categories thresholds, a heart rate ≥90 beats min−1 was associated with an elevated odds of myocardial injury compared with a heart rate <60 beats min−1 (adjusted odds ratio, 1.22; 95% confidence interval, 1.06–1.39; P=0.005). This result was consistent regardless of the method used for categorisation. When fractional polynomials were used to model heart rate, a ‘J-shaped’ relationship between heart rate and odds of myocardial injury was observed. ConclusionsThis cohort study found that both very high preoperative heart rates, and possibly also very low heart rates, are associated with increased risk of myocardial injury. Whether heart rate is a modifiable risk factor, or rather simply a marker of underlying cardiac pathology, needs to be determined in further research.

Pre-existing hypercoagulability in patients undergoing potentially curative cancer resection

Rotational thromboelastometry (ROTEM) is a new point-of-care test that allows a rapid and comprehensive evaluation of coagulation. We were among the first to show that ROTEM identifies baseline hypercoagulability in 40% of patients with intra-abdominal malignancies and that hypercoagulability persists for ≥1 month after resection. The purpose of this follow-up study was to confirm and extend these observations to a larger population in outpatient preoperative clinics. The hypothesis is that pre-existing hypercoagulability is present in patients undergoing surgery for malignant disease and that coagulation status varies by tumor type. After informed consent, preoperative blood samples were drawn from patients undergoing exploratory laparotomies for intra-abdominal malignancies and analyzed with ROTEM. Eighty-two patients were enrolled, including 72 with a confirmed pathologic diagnosis and 10 age-matched controls with benign disease. The most common cancers involved the pancreas (n = 23; 32%), esophagus (n = 19; 26%), liver (n = 12; 17%), stomach (n = 7; 10%), and bile ducts (n = 5; 7%). Preoperative hypercoagulability was detected in 31% (n = 22); these patients were more likely to have lymphovascular invasion (88% vs 50%; P = .011), perineural invasion (77% vs 36%; P = .007), and stage III/IV disease (80% vs 62%; P = .039). More patients with pancreatic tumors (9/23, 39%) were hypercoagulable than with esophageal (3/19, 16%) or liver (2/13, 15%, P = .034) tumors. When only resectable malignancies were considered, clot formation was more rapid (low clot formation time, high alpha) with enhanced maximum clot strength (high maximum clot firmness) in pancreatic versus esophageal or liver cancers and in all cancers versus those with benign disease. Preoperative hypercoagulability can be identified with ROTEM and is associated with lymphovascular/perineural invasion and advanced-staged disease in cancer. Compared with other tumor types, pancreatic adenocarcinomas have the greatest risk for hypercoagulability.

An Analysis of Computer-Assisted Pre-Screening Prior to Elective Surgery

In order to assess the potential utility of guided patient self-assessment as an early preoperative triage tool, a computer-assisted questionnaire delivered by a non-clinician via telephone was 1) compared to face-to-face interview and examination by anaesthetists in outpatient clinics and 2) evaluated as a mechanism to stream patients to day of surgery assessment. In total, 514 patients scheduled for elective surgery in two tertiary public hospitals were assessed initially by telephone and then in an outpatient clinic. Both forms of assessment were marked by panels of specialist anaesthetists, who also provided an opinion on which patients would have been suitable to bypass preoperative anaesthetic outpatient assessment based upon information provided by the telephone interview. Overall, the quality of assessment provided by non-clinician telephone interview was comparable to face-to-face interview by anaesthetists, although more complex issues required face-to-face assessment. Panel review considered that 398 patients (60%) would not have required evaluation by an anaesthetist until the day of surgery, thus avoiding the need to separately attend a preoperative outpatient clinic. The sensitivity of telephone interview provided information to correctly classify patients as suitable for day of surgery evaluation was 98% (95% confidence interval 96 to 99%) with a specificity of 97% (95% confidence interval 92 to 98%). This study demonstrates that remote computer-assisted assessment can produce quality patient health information and enable early patient work-up and triage with the potential to reduce costs through more efficient use of resources.

King Fahad National Guard Hospital Internal Medicine Consultation Service: Contributing Co-Morbidities and Reasons for Consultation

Background: Inpatient medical consultations have become an essential service in the specialty of Internal Medicine. Research in this new subspecialty will help improve the quality as well as the cost-effectiveness of this vital service.&#x0D; Method: Data for all patients who were referred to the service were entered in a pre-designed form.&#x0D; Results: One hundred and seventy-six adult patients with an average age of 53.3 years were seen by the service over a 4 months period. Consultations to the service were primarily from the departments of Surgery (110, 62.50%), Obstetrics and Gynecology (57, 32.39%). Co-morbidities were common specially diabetes mellitus (59.1%) and hypertension (41.5%). Most of the consultations were for emergency patients (99, 56.3%) rather than for electively (77, 43.7%) admitted cases. For operative patients, there was an equal share between pre- and post-operative cases (58.8% and 58.0% respectively). Prior referral to outpatient pre-operative clinics was unsatisfactory with the service requesting postponements of surgery for 22.1 percent of pre-operative cases. The major reasons for referral to the service were diabetes mellitus (49.4%), hypertension (30.7%) and respiratory problems (22.7%). Thirty-three percent of cases had more than one reason for referral. Active intervention by the service was frequent. The average length of care under the service was 5.2 days with a range of 1 to 90 days.&#x0D; Conclusions: The service needs to be structured with regards to staff education and training; emphasizing on diabetes mellitus, hypertension and respiratory problems care. A joint interdepartmental effort along the above lines and better use of the pre-operative outpatient clinics are recommended.

King Fahad National Guard Hospital Internal Medicine Consultation Service: Contributing Co-Morbidities and Reasons for Consultation

Background: Inpatient medical consultations have become an essential service in the specialty of Internal Medicine. Research in this new subspecialty will help improve the quality as well as the cost-effectiveness of this vital service.&#x0D; Method: Data for all patients who were referred to the service were entered in a pre-designed form.&#x0D; Results: One hundred and seventy-six adult patients with an average age of 53.3 years were seen by the service over a 4 months period. Consultations to the service were primarily from the departments of Surgery (110, 62.50%), Obstetrics and Gynecology (57, 32.39%). Co-morbidities were common specially diabetes mellitus (59.1%) and hypertension (41.5%). Most of the consultations were for emergency patients (99, 56.3%) rather than for electively (77, 43.7%) admitted cases. For operative patients, there was an equal share between pre- and post-operative cases (58.8% and 58.0% respectively). Prior referral to outpatient pre-operative clinics was unsatisfactory with the service requesting postponements of surgery for 22.1 percent of pre-operative cases. The major reasons for referral to the service were diabetes mellitus (49.4%), hypertension (30.7%) and respiratory problems (22.7%). Thirty-three percent of cases had more than one reason for referral. Active intervention by the service was frequent. The average length of care under the service was 5.2 days with a range of 1 to 90 days.&#x0D; Conclusions: The service needs to be structured with regards to staff education and training; emphasizing on diabetes mellitus, hypertension and respiratory problems care. A joint interdepartmental effort along the above lines and better use of the pre-operative outpatient clinics are recommended.

The effect of national guidelines on the implementation of outpatient preoperative evaluation clinics in Dutch hospitals

Preoperative evaluation performed by anaesthesiologists primarily aims to estimate the risk of perioperative complications and to create opportunities to optimize the patients' condition before surgery. In this study an inventory was made of the current practice of preoperative evaluation in Dutch hospitals. It was estimated how many hospitals had implemented an outpatient preoperative evaluation clinic in 2004. Subsequently, current practice was compared with the results of a previous inventory (2000). It was also evaluated to what extent the guidelines of the Dutch Health Council and the Netherlands Society of Anaesthesiology were followed. The study consisted of two phases. First, a literature research was performed and pilot interviews were constructed. The interviews were conducted face-to-face with anaesthesiologists in a sample of Dutch hospitals. Based on the results, written questionnaires were constructed. In the second phase these questionnaires were sent to all general and academic hospitals in the Netherlands. In 2004, 74% of the hospitals had an outpatient preoperative evaluation clinic, compared with 50% in 2000. The percentage of hospitals with an outpatient preoperative evaluation clinic available for all elective patients increased from 20% to 52%. The Dutch guidelines on preoperative evaluation seem to have influenced current practice. An increase in the number of outpatient preoperative evaluation clinics was seen after the guidelines were published. The implementation of an outpatient preoperative clinic seems to warrant that anaesthesiologists are carrying out the activities prescribed by the guidelines. Most hospitals without a clinic aim to implement one in the future.

Emergence and Persistence of Macrolide Resistance in Oropharyngeal Flora and Elimination of Nasal Carriage of Staphylococcus aureus after Therapy with Slow-Release Clarithromycin: a Randomized, Double-Blind, Placebo-Controlled Study

To investigate the effect of slow-release (SR) clarithromycin on colonization and the development of resistance in oropharyngeal and nasal flora, a double-blind, randomized, placebo-controlled trial was performed with 8 weeks of follow-up. A total of 296 patients with documented coronary artery disease were randomized in the preoperative outpatient clinic to receive a daily dose of SR clarithromycin (500 mg) (CL group) or placebo tablets (PB group) until the day of surgery. Nose and throat swabs were taken before the start of therapy, directly after the end of therapy, and 8 weeks later. The presence of potential pathogenic bacteria was determined, and if they were isolated, MIC testing was performed. Quantitative culture on media with and without macrolides was performed for the indigenous oropharyngeal flora. In addition, analysis of the mechanism of resistance was performed with the macrolide-resistant indigenous flora. Basic patient characteristics were comparable in the two treatment groups. The average number of tablets taken was 15 (standard deviation = 6.4). From the throat swabs, Haemophilus parainfluenzae was isolated and carriage was not affected in either of the treatment groups. Nasal carriage of Staphylococcus aureus, however, was significantly reduced in the CL group (from 35.3 to 4.3%) compared to the PB group (from 32.4 to 30.3%) (P < 0.0001; relative risk [RR], 7.0; 95% confidence interval [CI], 3.1 to 16.0). Resistance to clarithromycin was present significantly more frequently in H. parainfluenzae in the CL group after treatment (P = 0.007; RR, 1.6; 95% CI, 1.1 to 2.3); also, the percentage of patients with resistance to macrolides in the indigenous flora after treatment was significantly higher in the CL group (31 to 69%) (P < 0.0001; RR, 1.9; 95% CI, 1.4 to 2.5). This persisted for at least 8 weeks. This study shows that besides the effective elimination of nasal carriage of S. aureus, treatment with SR clarithromycin for approximately 2 weeks has a marked and sustained effect on the development of resistance in the oropharyngeal flora for at least 8 weeks.

Comparing the Effectiveness of Different Educational Programs for Patients with Total Knee Arthroplasty

To compare the effects of preadmission and postadmission educational programs for patients with total knee arthroplasty. Quasiexperimental study. 60 total knee arthroplasty patients. Subjects in the experimental group received preadmission preoperative teaching with an instruction booklet during a preoperative outpatient clinic visit. Upon admission to the hospital, they were presented with an educational video tape. The control group received only postadmission preoperative teaching with the same instruction booklet and no video. PREADMISSION AND POSTADMISSION: Preoperative anxiety level, knowledge about postoperative care, exercise performance and postoperative recovery were used as outcome measures. The research results found: 1. there was no significant difference between the two groups in reduction of preoperative anxiety score: 2. the experimental group had a significantly higher knowledge level than the control group; 3. the experimental group performed exercise more regularly and correctly than those in the control group; 4. the experimental group had greater flexion of the operative knee joint than the control group. Preadmission teaching with a videotape program and a health manual for patients with total knee arthroplasty is recommended. More indicators such as postoperative pain and patient satisfaction can be used to investigate the effectiveness of intervention. In addition, increasing the sample size is recommended for future studies.

PREOPERATIVE MANAGEMENT OF COMMON MINOR MEDICAL ISSUES IN THE OUTPATIENT SETTING

A number of problems are frequently encountered in an outpatient preoperative clinic that seem minor and require detection and attention in the preoperative preparation to ensure safe conduct of anesthesia and surgery. In this article several of these issues are reviewed and recommendations made with respect to appropriate management.

Patients' and Health Care Professionals' Views of Complications after Elective Surgery

In this study, which is a part of a clinical-epidemiological study of post-operative complications, the Project Peri-operative Risk (PROPER), patients' and health professionals' perceptions of complications during the patients' stay in hospital are analysed. Five hundred and ten patients admitted for elective (= planned) surgery and attending a pre-operative outpatient clinic set up for this project were seen pre-operatively and then monitored closely during and after surgery. Three months after having been operated on, they were sent a postal questionnaire in which they were asked to indicate whether they had suffered post-operative complications and to evaluate the care process. The incidence of complications reported by patients and staff was similar, but there were large differences at the individual level. Two-thirds of the staff-reported complications were not reported by the patients and vice versa. Patients generally classified complications as more severe than the staff did. Patients' evaluation of the care process was clearly related to reported complications. Most dissatisfied were those patients who reported complications not reported by the staff, and the most satisfied were those who had complications according to the staff but no complications according to themselves. The implication of these findings is discussed.