Standard Care Protocol Research Articles

208 Implementation of an enhanced recovery protocol post-cesarean delivery decreases opioid utilization and improves pain perception

Enhanced recovery after surgery (ERAS) is a multifaceted, standardized perioperative care protocol associated with improved surgical recovery. Its use has not been widely studied in obstetrics. Given the high rate of opioid dependence after cesarean delivery (CD), our aim was to evaluate the impact of an Enhanced Recovery for Obstetric Surgery (EROS) protocol on post-CD opioid use and perceived pain. EROS was implemented at Lehigh Valley Health Network (LVHN) 9/2018 (changes summarized in Figure 1). This retrospective cohort study compared post-CD opioid use between women undergoing CD before (7/1/17 – 6/30/18) and after (1/1/19 – 12/31/19) EROS implementation. Women with a significant surgical complication, history of chronic pain, current illicit drug use or current treatment for substance abuse disorder were excluded. A separate paired analysis compared outcomes of those delivering in both groups. Primary outcome was median total post-CD inpatient opioid use (morphine milligram equivalents; MME). Secondary outcomes included median discharge prescription MME, and mean pain scores on standardized assessment (10-point Likert scale). 1475 women in the pre-EROS group and 1546 women in the post-EROS group were identified. Median inpatient post-CD opioid MME and discharge MME were both significantly decreased post-EROS [75 (IQR 45-75) vs 30 (IQR 15-60) MME, p<0.001 and 900 (IQR 600-1125) vs 562.5 (IQR 360-750) MME, P<0.001, respectively], as were average pain score and mean highest pain score (3.5 vs 3.1 MME, p<0.001 and 7.3 vs 7.1 MME, p<0.003, respectively). Paired analysis of the 77 women who had a CD in both groups showed similar decreases in both opioid requirements and pain scores post-EROS. There was less variation in opioid use patterns post-EROS (Figure 2). Use of an Enhanced Recovery Protocol results in decreased post-cesarean delivery opioid use and improved pain perception. Given the scope of the opioid crisis, future studies should address whether use of this protocol can lead to decreased opioid dependence in this population.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Segmentation Approaches for Diabetic Foot Disorders.

Thermography enables non-invasive, accessible, and easily repeated foot temperature measurements for diabetic patients, promoting early detection and regular monitoring protocols, that limit the incidence of disabling conditions associated with diabetic foot disorders. The establishment of this application into standard diabetic care protocols requires to overcome technical issues, particularly the foot sole segmentation. In this work we implemented and evaluated several segmentation approaches which include conventional and Deep Learning methods. Multimodal images, constituted by registered visual-light, infrared and depth images, were acquired for 37 healthy subjects. The segmentation methods explored were based on both visual-light as well as infrared images, and optimization was achieved using the spatial information provided by the depth images. Furthermore, a ground truth was established from the manual segmentation performed by two independent researchers. Overall, the performance level of all the implemented approaches was satisfactory. Although the best performance, in terms of spatial overlap, accuracy, and precision, was found for the Skin and U-Net approaches optimized by the spatial information. However, the robustness of the U-Net approach is preferred.

DYNAMICS C-REACTIVE PROTEIN AND CERULOPLASMIN IN THE BLOOD OF PATIENTS WITH COMBINED THORACIC TRAUMA AS A PROGNOSTIC CRITERION OF TRAUMATIC DISEASE

Purpose: to assess the informativeness of the level of "acute phase" proteins in the blood and their changes in the acute and early period of traumatic disease in patients with combined thoracic trauma with polytrauma as a marker of disease severity and the impact of proposed modifications of intensive care algorithm on treatment results. Material and methods. The basis of this study is a statistical analysis of the results of a comprehensive examination of 92 patients with thoracic trauma. Control points were 1st, 2nd, 3rd, 5th,7th and 12th day of treatment. The severity of the injury was determined according to the ISS scale, the condition of patients at the time of admission according to the ARASNE II scale, the level of C-reactive protein and ceruloplasmin in the blood. 3 groups of patients were identified. Group I - standard IT protocol, group II - standard IT protocol with the addition of ceruloplasmin, group III - standard IT protocol with the addition of a solution of D-fructose-1,6-diphosphate sodium salt of hydrate. Parametric statistics methods were used to process the obtained data. Results. In patients with combined thoracic trauma, it is important when planning the patient's management tactics to diagnose the content of CRP and CP in the blood during the entire period of stay in the intensive care unit. The level of CP in the blood of patients with combined thoracic trauma is a highly informative diagnostic marker of the impact of hypoxia of mixed genesis on the course of traumatic disease in general. The leading mechanism for the development of acute lung injury syndrome in patients with combined thoracic trauma is oxidative stress, so the appointment of ceruloplasmin as an adjunct to the standard protocol of intensive care is pathogenetically justified. Conclusions. In patients with combined thoracic trauma, it is important when planning patient management tactics to diagnose the content of C-reactive protein and ceruloplasmin in the blood during the entire period of stay in the intensive care unit. The level C-reactive protein and ceruloplasmin in the blood of patients with combined thoracic trauma is a highly informative diagnostic marker of the prognosis. There is oxidative stress, so the appointment of ceruloplasmin as an adjunct to the standard protocol of intensive care is pathogenetically justified.

Use of Air-Fluidized or Fluid Immersion Redistribution Support Surfaces for the Treatment of Stage 4 Pressure Injuries: A Case Series

Healing of severe pressure injuries (PIs) in patients with multiple comorbidities requires a multifaceted and interdisciplinary approach and includes the use of support surfaces. Published clinical data guiding support surface selection are very limited. Long-term acute care hospitals frequently treat medically complex patients, many with severe PIs. To compare healing rates in patients with severe PIs on air-fluidized therapy (AFT) or fluid immersion system (FIS) support surfaces. After obtaining informed consent, patients with a stage 3 or 4 PI were randomized to receive either AFT or FIS in addition to the standard protocol of care. Baseline and weekly wound measurements were obatined using a 3-dimensional camera measurement tool. The required sample size was calculated to be 60. After the study had started, the long-term acute care hospital admission criteria changed, severely limiting the number of patients who met the study inclusion criteria. Only 4 patients with a stage 4 PI completed the study. Of those, 2 were on an AFT and 2 were on an FIS surface. All wounds reduced in size; 0.12 and 0.57 cm²/day for patients on AFT and 0.68 and 1.34 cm²/day for patients on FIS. All but 1 wound had a reduction in wound volume ranging from -0.2 and 0.97 cm³ to 1.78 and 4.18 cm³/day for patients on AFT and FIS, respectively. Obtaining much-needed evidence to guide support surface selections for patients with severe PIs is challenging and requires multicenter studies.

Study of social disparities in pediatric laparoscopic appendectomy outcomes and cost.

Purpose:There is an increasing focus on racial and social disparities in health care. There have been several studies that have documented disparities in outcome between racial groups in the adult literature. Not much is known about disparities in outcomes after surgical procedures in children. The purpose of this study was to investigate the effect of race on complications (outcomes) and costs after laparoscopic appendectomy.Methods:This study is a single-center retrospective chart review of 248 pediatric patients who underwent appendectomies for uncomplicated acute appendicitis from 2015 to 2017. Patients were divided into minority (Africa American or Hispanic) and non-minority groups, and length of stay, preoperative and postoperative factors, and total costs were compared.Results:Of 185 eligible patients, 45.9% (n = 85) were of Hispanic or African American ethnicity and 54.1% (n = 100) were Caucasian. About 11.8% of minority patients had comorbidities and 12% of majority patients had comorbidities (p = 1). Readmission rate for minority group patients was 3.5% (n = 3) and 2% (n = 2) for majority patients (p = 0.7). The average cost of hospital stay for minority patients was $30,900 and for majority patients was $31,111 (p = 0.59).Conclusions:Standardization of care protocols has reduced social/racial disparities in surgical outcomes. In the most common pediatric surgery emergency procedure, laparoscopic appendectomy, there were no differences in outcomes or costs between minority (Hispanic/Africa American) and Caucasian ethnic groups.Level of evidence:Level IIIType of study:Clinical Study

Effectiveness of Postnatal Care by Using Comprehensive Postnatal Nursing Stratergy (Cpns) Module

Postnatal period is a commonly neglected part of health care where postnatal complications are common due to lack of early and timely systemic postnatal interventions that are the main cause for maternal morbidity and mortality in India and all over the world. There are many studies supporting the application of systemic postnatal care to improve outcomes of postnatal care and reduce the incidence of postnatal complications and promote early discharge. There are many studies that have been conducted to evaluate standard nursing care protocols and to check the quality of care investigators often choose to examine comprehensive postnatal maternal health to measure the satisfaction of postnatal mothers with postnatal nursing care.The main objectives of this study were to determine the satisfaction of mothers after implementation of CPNS by the nurses to compare postnatal nursing problems among postnatal mothers in the control group and test group to evaluate the association of selected demographic variables of nurses and satisfaction of postnatal nursing with postnatal care in the test and control group. Convenient sampling was adopted to recruit 174 nurses out of which 86 were in the test group and 88 in the control group. Recruitment was from a total of 24 maternity centers in Bangalore Bruhat Mahanagar Pallikae. A non-probability convenient sampling method as per inclusive criteria was adopted. As per staff inspection committee norms a ratio of 15 that is a sample of one nurse five postnatal mothers were selected. Therefore for 174 nurses 430 mothers were included in the test group. For 88 nurses 440 postnatal mothers were recruited in the control group.Sample selection was done using non-probability convenient sampling and postnatal mothers were chosen as per inclusive criteria. The study followed a non-equivalent control group post-test-only design. The test and the control groups were assessed only after the intervention that is after implementation of the comprehensive postnatal nursing care strategies the test group was assessed. Data were collected as per case record forms prepared to record data on selected demographic variables of postnatal mother and nurses assess the satisfaction of comprehensive postnatal nursing care among postnatal mothers. The collected data were analyzed using descriptive and inferential statistics. Demographic variables analyzed were presented as frequency and percentage. Chi-square tests were performed to describe the demographic characteristics between groups.T-test was performed to evaluate the if there is any significant difference between satisfaction levels in the study and control group and it was found to be statistically significant t50.63 plt0.001. Therefore null hypothesis was rejected and the alternat hypothesis was accepted. The results of this study conclude that the satisfaction level among postnatal mothers administered CPNS by nurses was significantly greater than the postnatal mothers administered normal nursing care.nbsp

Hyperbaric oxygen therapy for nonhealing wounds: Treatment results of a single center.

The present article evaluates the results of the treatment with adjuvant hyperbaric oxygen therapy (HBOT) of patients with nonhealing, chronic wounds. In the period 2013 to 2016, 248 patients were referred from various hospitals because of chronic wounds that were recalcitrant in healing despite standard wound care as described in national and international guidelines. After inclusion, all patients were treated with HBOT and subjected to a weekly standard wound care treatment. During each HBOT session, 100% O2 was administered for 75 minutes under increased pressure of 2.4 ATA. Wounds and quality of life were assessed before and after the total treatment period. A total of 248 patients have been evaluated. Diabetic foot ulcers were present in 134 patients, the remainder (114 patients) showed a variety of wound locations and etiologies. The number of HBOT treatments amounted to an average of 48 (range 20‐68) sessions. Before referral to our clinic, 31% of all wounds had existed for at least 18 months (72 patients). After HBOT, 81% of all wounds were near complete healing or completely healed, in 13% of the cases the wound was stable, and in 2% minor or major amputation had to be carried out. The mean treatment time for wounds pre‐existing fewer than 6 weeks (“early referrals”) was 67 days, and 119 days for wounds pre‐existing more than 18 months (“late referrals”). A majority of the patients in our study referred with nonhealing wounds clinically improved when adjuvant HBOT was added to standard wound care protocols. No differences in success rate were seen between diabetic and nondiabetic wounds. It showed that HBOT is a well‐tolerated treatment.

Quality of End-of-Life Care for Vietnam Veterans: Implications for Practice and Policy

In federal response to the aging population of Vietnam-era Veterans, Congress directed the Department of Veterans Affairs (VA) to create a pilot program to identify and develop best practices for improving hospice care for this population. A first step in VA’s response was to identify whether the end-of-life (EOL) care needs and outcomes of Vietnam-era Veterans differed from previous generations. Using medical records and bereaved family surveys, we examined clinical characteristics, healthcare utilization, and EOL quality indicators for Vietnam-era Veterans who died in VA inpatient settings between 2013-17. Contemporaneous comparisons were made with World War II/Korean War-era Veterans. Compared to prior generations, higher percentages of Vietnam-era Veterans had mental health/substance use diagnoses and disability. Similar percentages of family members in both groups reported that overall EOL care was excellent; however, post-traumatic stress disorder management ratings by families of Vietnam-era Veterans were significantly lower. Although current VA EOL practices are largely meeting the needs of Vietnam-era Veterans, greater focus on mental health comorbidity, including post-traumatic stress disorder, Agent Orange-related conditions, and ensuring access to quality EOL care in the community is warranted. Policymakers and healthcare professionals should anticipate more physical and mental health comorbidities among Veterans at EOL as Vietnam-era Veterans continue to age. Findings are being used to inform the development of standardized EOL care protocols and training programs for non-VA healthcare providers that are tailored to the needs of this population.

Rapid Telehealth Implementation during the COVID-19 Global Pandemic: A Rapid Review.

The implementation and continued expansion of telehealth services assists a variety of health care organizations in the delivery of care during the current COVID-19 global pandemic. However, limited research has been conducted on recent, rapid telehealth implementation and expansion initiatives regarding facilitators and barriers surrounding the provision of quality patient care. Our rapid review evaluated the literature specific to rapid telehealth implementation during the current COVID-19 pandemic from three research databases between January 2020 and May 2020 and reported using preferred reporting items for systematic reviews and meta-analyses (PRISMA). The results indicate the rapid implementation and enhanced use of telehealth during the COVID-19 pandemic in the United States surrounding the facilitators and barriers to the provision of patient care, which are categorized into three identified themes: (1) descriptive process-oriented implementations, (2) the interpretation and infusion of the CARES Act of 2020 telehealth exemptions related to the relaxation of patient privacy and security (HIPAA) protocols, and (3) the standard of care protocols and experiences addressing organizational liability and the standard of care. While the study limitation of sample size exists (n = 21), an identification of rapid telehealth implementation advancements and challenges during the current pandemic may assist health care organizations in the delivery of ongoing quality care during the COVID-19 pandemic.

Can spinal deformity patients maintain proper arm positions while undergoing full-body X-ray?

The compliance rate of arm positioning during full-body X-rays varies depending on operative status (preoperative vs postoperative), age, and diagnosis. Retrospective cohort. Despite the importance of patients maintaining arms in the same position in preoperative and postoperative standing films, patients are known to have their arms in varying positions, confounding radiographic interpretation and making global sagittal and coronal spinal balance assessment variable and potentially less reliable. This study seeks to examine arm position compliance among adult and pediatric surgical spinal deformity patients undergoing total body X-rays over the course of 4years (2015-2018). A retrospective radiographic review was performed on 382 spinal deformity patients from July 2015 to July 2018. The study's dependent variable of interest was standardized arm position (fingers on the clavicles with shoulders in 45° of forward elevation while the patient is in a free-standing posture) observed during full-body X-rays obtained for spinal deformity evaluation. Deviations and compliance to the standard protocol for full-body X-ray arm positioning was recorded and analyzed across various independent factors, including year of surgery, pre- and postoperative periods, type of spine surgery, and patient age. Chi-square and Cochran-Armitage analyses were performed to study categorical and trends, respectively. The overall compliance rate for maintaining standardized arm position was 90% for all 370 patients (277 adult and 93 pediatric), in preoperative and postoperative setting. Adults were more likely to follow protocol than pediatric patients (92.9% vs. 82.4%, P value = 0.003). The postoperative setting observed a significantly lower overall compliance rate when compared to the preoperative period (67.8% vs. 87.0%, P value < 0.0001). Patients undergoing neuromuscular scoliosis (73.3%), vertebral column resection (VCR) (70%), and growing rod lengthening (GRL) (57.1%) had the lowest overall compliance rate in the preoperative setting. In the postoperative setting, patients with GRL, VCR, revision congenital scoliosis, congenital scoliosis, neuromuscular scoliosis, and pedicle subtraction osteotomy (PSO) surgeries were compliant less than or equal to 50% of the time. From 2015 to 2018, there was an overall statistically significant increase in compliance rate (61.1% to 90.6%). Over the study period, adult patients became significantly more compliant to protocol. This was not observed in the pediatric population. This study documented the patient compliance rate of maintaining standardized arm position during full-body X-rays of spinal deformity patients. The overall compliance rate was 90.0% for all patients in the preoperative and postoperative setting. Risk factors for lower compliance rates included patients that were pediatric, postoperative, neuromuscular, and those who underwent a complex vertebral osteotomy or GRL. There was a trend showing improved compliance rate throughout the 4-year study period, which highlights the importance of having an ancillary staff who is comfortable with a consistent standard of care protocol. These results should help other centers optimize arm positioning in their patients undergoing full-body X-rays in the future.

Role of surfactant protein SP-D in the diagnosis of pulmonary complications in patients with combined thoracic injury

The aim: to evaluate the informativeness of the content of SP-D in the blood of patients with combined thoracic trauma as a marker of the severity of traumatic illness and the impact of the proposed modifications of the intensive care algorithm on treatment outcomes.Material and methods. The basis of this study is a statistical analysis of the results of a comprehensive examination of 92 patients with thoracic trauma. Control points were 1st, 3rd, 7th and 12th day of treatment. The severity of the injury was determined according to the ISS scale, the condition of patients at the time of admission according to the ARASNE II scale, the level of SP-D in the blood, the degree of pulmonary hypertension, the number of bed-days in the intensive care unit (IC). 3 groups of patients were identified. Group I - standard IC protocol, group II - standard IC protocol with the addition of ceruloplasmin, group III - standard IC protocol with the addition of a solution of D-fructose-1,6-diphosphate sodium salt of hydrate. Parametric statistics methods were used to process the obtained data.Results. In patients of group I, the maximum numbers of SP-D in the blood were determined, which had a positive strong correlation during the entire observation period with the frequency of pulmonary complications and the duration of treatment in the IC department. In group II, the administration of ceruloplasmin neutralized the negative effect of oxidative stress on the surfactant, so the average SP-D in the blood only on the 3rd day exceeded the reference values by 20 %, which affected the lack of correlations between pulmonary parenchyma and duration of treatment. In group III, the addition of a solution of D-fructose-1,6-diphosphate sodium salt hydrate had a positive effect on the general condition of patients as a whole, but throughout the study period SP-D figures in the blood exceeded the starting and reference, which affected the presence of strong and medium positive correlation between them, the degree of pulmonary hypertension and the length of stay in the IC department.Conclusions. In patients with combined thoracic trauma, it is important when planning patient management tactics to diagnose the content of surfactant protein SP-D in the blood during the entire period of stay in the intensive care unit. The level of SP-D in the blood of patients with combined thoracic trauma is a highly informative diagnostic marker of the functional state of the lung parenchyma (surfactant). An increase in its numbers three times indicates the beginning of the development of acute lung injury syndrome (exudative phase). Reduction of its figures in the course of respiratory distress syndrome by half the values in the exudative phase indicates the beginning of the proliferative phase and improvement of patients. The leading mechanism for the development of acute lung injury syndrome in patients with combined thoracic trauma. There is oxidative stress, so the appointment of ceruloplasmin as an adjunct to the standard protocol of intensive care is pathogenetically justified

Reaching mEthadone users Attending Community pHarmacies with HCV: an international cluster randomised controlled trial protocol (REACH HCV)

IntroductionHepatitis C virus (HCV) is a global public health threat, and novel models of care are required to treat those currently or previously at highest risk of infection, particularly persons...

Monitoring strategies on patient safety practices among healthcare providers at Nakuru county referral hospital, Kenya

Background: Quality care is achieved through combined efforts which include integration of all the components within the healthcare delivery system. Patient safety is one of the dimensions of enhancing quality healthcare. It involves increasing the awareness about the errors made due to human factors in the process of delivering healthcare services that may lead to harm and other adverse effects.Methods: This study was on assessment of monitoring strategies on patient safety practices among healthcare providers at Nakuru County Referral Hospital, Kenya. The study was anchored on Donabedian model for assessment of quality of care. The study design was a descriptive cross-sectional study. The sampling technique was purposive, stratified random sampling and proportionate with a sample size of 310 healthcare providers drawn from various departments. Data collection tools were questionnaire, interview schedule and observational checklist. Quantitative data was analysed using descriptive statistics (mean, mode and standard deviation).Results: The results of the study indicated and concluded that there is adherence to standardized clinical care protocols and guidelines as well as continuous and constant surveillance with clear assessments and evaluation of patient safety practices, accurate collection, storage, analysis and sharing of information on patient safety issues.Conclusions: The paper recommends the need for policy reviews on healthcare so as to ensure that patient safety issues are reviewed so as to mitigate risks in handling patients. There is need to establish clear guidelines on monitoring and evaluation standards of patient safety practices.

Implementation of the policy protocol for management of surgical and non-surgical wounds in selected public health facilities in Ghana: An analytic case study.

BackgroundIt is estimated that millions of patients are affected by healthcare associated infections (HAIs) each year. In Ghana, high prevalence of HAIs in relation to non-surgical (also called contaminated wounds) and surgical wounds (also called sterile wounds) is largely attributed to poor adherence to policy protocols for wound management by frontline clinical staff especially nurses.ObjectiveInvestigate the extent to which nursing staff adhere to the policy protocol for management of non-surgical and surgical wounds in selected public health facilities in Ghana.MethodologyThis is an analytic case study among nursing staff (n = 140) in three government facilities in the Volta region of Ghana. Subjective and objective performance scores of staff on adherence proxies were compared using the Wilcoxon Signed-rank test, and univariate ordered logistic regression analysis used to predict staff likelihood of adherence to policy protocols on non-surgical and surgical wound management.FindingsOverall, staff self-rated themselves higher on subjective performance proxies relative to their objective scores (p<0.05). Staff with more years of work experience did not translate into a higher likelihood of adhering to standard protocol on wound management (Coef. = -0.49, CI = -0.93–0.05, p = 0.036). Being a senior nursing officer relative to lower nursing ranks increased staff likelihood of complying particularly with standard policy protocol for management of non-surgical wounds (Coef. 5.27, CI = 0.59 9.95, p = 0.027).ConclusionThere is the need for accelerated in-service training for staff on standard protocols for wound management coupled with supportive supervisions. Staff adherence to standard quality care protocols should be a pre-requisite for licensing of health facilities by regulatory bodies like Health Facilities Regulatory Agency and National Health Insurance Authority.

Quality of life in patients with non-healing wounds, with particular focus on assesment tools - a literature review

Aim: The aim of this study was to analyze published studies focusing on quality of life (QoL) in patients with non-healing wounds, with particular focus on assessment tools. Design: Type of study &#8211; literature review. Methods: Articles focusing on QoL in patients with non-healing wounds were searched for in various electronic databases using relevant terms. The search was limited to articles in English issued between January 2014 and April 2019, in the electronic databases Scopus, PubMed, and CINAHL. Results: In total, 24 studies were found which met the established criteria. Conclusion: Non-healing wounds significantly affect patients' QoL. Research is leading towards the creation of a standardized QoL tool in patients with chronic wounds, which could be included in the wound care standard care protocol. There are many generic and specific tools for evaluating QoL in patients with non-healing wounds, differing in length and complexity. The Wound-QoL was created by comparing and simplifying proven tools, and the follow-up research has proven it to be internally consistent, valid and reliable, and, due to its ease of use, suitable for re-measuring QoL.

Imaging of Neurologic Disease in Hospitalized Patients with COVID-19: An Italian Multicenter Retrospective Observational Study.

Of 725 consecutive hospitalized patients with coronavirus disease 2019, 108 (15%) had acute neurologic symptoms necessitating neurologic imaging.

Reposição de volume orientada pela variação da pressão de pulso durante transplante renal: estudo randomizado controlado

PurposeKidney transplantation is the gold‐standard treatment for end stage renal disease. Although different hemodynamic variables, like central venous pressure and mean arterial pressure, have been used to guide volume replacement during surgery, the best strategy still ought to be determined. Respiratory arterial Pulse Pressure Variation (PPV) is recognized to be a good predictor of fluid responsiveness for perioperative hemodynamic optimization in operating room settings. The aim of this study was to investigate whether a PPV‐guided fluid management strategy is better than a liberal fluid strategy during kidney transplantation surgeries. Identification of differences in urine output in the first postoperative hour was the main objective of this study. MethodsWe conducted a prospective, single blind, randomized controlled trial. We enrolled 40 patients who underwent kidney transplantation from deceased donors. Patients randomized in the PPV Group received fluids whenever PPV was higher than 12%, patients in the Free Fluid Group received fluids following our institutional standard care protocol for kidney transplantations (10mL.kg‐1.h‐1). ResultsUrinary output was similar at every time‐point between the two groups, urea was statistically different from the third postoperative day with a peak at the fourth postoperative day and creatinine showed a similar trend, being statistically different from the second postoperative day. Urea, creatinine and urine output were not different at the hospital discharge. ConclusionPPV‐guided fluid therapy during kidney transplantation significantly improves urea and creatinine levels in the first week after kidney transplantation surgery.

Pulse pressure variation guided fluid therapy during kidney transplantation: a randomized controlled trial

PurposeKidney transplantation is the gold-standard treatment for end stage renal disease. Although different hemodynamic variables, like central venous pressure and mean arterial pressure, have been used to guide volume replacement during surgery, the best strategy still ought to be determined. Respiratory arterial Pulse Pressure Variation (PPV) is recognized to be a good predictor of fluid responsiveness for perioperative hemodynamic optimization in operating room settings. The aim of this study was to investigate whether a PPV guided fluid management strategy is better than a liberal fluid strategy during kidney transplantation surgeries. Identification of differences in urine output in the first postoperative hour was the main objective of this study. MethodsWe conducted a prospective, single blind, randomized controlled trial. We enrolled 40 patients who underwent kidney transplantation from deceased donors. Patients randomized in the “PPV” group received fluids whenever PPV was higher than 12%, patients in the “free fluid” group received fluids following our institutional standard care protocol for kidney transplantations (10 mL.kg-1. h-1). ResultsUrinary output was similar at every time-point between the two groups, urea was statistically different from the third postoperative day with a peak at the fourth postoperative day and creatinine showed a similar trend, being statistically different from the second postoperative day. Urea, creatinine and urine output were not different at the hospital discharge. ConclusionPPV guided fluid therapy during kidney transplantation significantly improves urea and creatinine levels in the first week after kidney transplantation surgery.

Improving the cost, quality, and safety of perioperative care: A systematic review of the literature on implementation of the perioperative surgical home

Study objectiveThe perioperative surgical home (PSH) is a recent innovation in perioperative care delivery that coordinates the pre-, intra-, and post-operative elements of surgical care under one organizational umbrella. Although significant research supports the efficacy of individual elements of the PSH in improving outcomes, there is not a published systematic review of the efficacy of entire PSH programs in improving patient outcomes. This article summarizes descriptions of PSH programs available in the literature and examines outcomes of original studies of PSH implementation. DesignWe conducted a systematic literature review to identify relevant articles on PSH implementation and synthesize our findings. SettingThe studies included in our review took place at multiple academic and community hospitals in the United States. PatientsPatients involved in the PSH studies included surgical patients of various ages and ASA classifications in various surgical specialties. InterventionsAll studies included in our review involved the implementation of a PSH program. MeasurementsOutcomes examined include length of stay, postoperative recovery, readmission rates, and patient discharge destination, among others. Main resultsWe identified 11 studies of PSH implementation that met our inclusion and exclusion criteria. Most PSH programs described in these studies included an emphasis on preoperative education, standardization of care protocols in all phases of surgery, use of opioid-sparing multimodal analgesia, and collaborative staffing models. PSH program implementation was often associated with decreased length of stay, decreased utilization of postoperative opioids, decreased utilization of the ICU, and increased probability of discharge to home. PSH implementation was not meaningfully associated with reductions in readmission rates. Findings for cost reductions following PSH implementation were mixed. ConclusionsEarly evidence indicates that through elements that emphasize care coordination, standardization, and patient-centeredness, PSH programs can improve patient postoperative recovery outcomes and decrease hospital utilization.

Implementation of an interdisciplinary tracheostomy care protocol to decrease rates of tracheostomy-related pressure ulcers and injuries.

Tracheostomy-related pressure injuries (TRPI) have been demonstrated to occur in approximately 10% of tracheostomy patients. In this study, we present TRPI outcomes after implementation of a standardized tracheostomy care protocol. A tracheostomy care protocol was developed by an interdisciplinary quality improvement program and implemented on July 1, 2016. The protocol was designed to minimize factors that contribute to the development of TRPI. Rates of TRPI over the subsequent 20months were compared to the year before implementation. 9 out of 85 patients (10.6%) developed TRPI in the pre-protocol cohort compared to 0 of 137 (0%) in the post-protocol cohort, which was a statistically significant decrease by Fisher's exact test with a p-value of 0.0001. Pearson's correlation coefficient demonstrated a negative correlation between age and post-operative day of diagnosis (r=-0.641, p=0.063), indicating that older patients develop TRPI more quickly. Interdisciplinary peri-operative tracheostomy care protocols can be effective in decreasing rates of TRPI.