Track Protocol Research Articles

Clinical evaluation of fast track protocol versus standard care in patients undergoing elective colorectal surgeries

Background: Colo rectal surgeries are on the rise given colorectal carcinoma being the third most common cancer globally affecting more than 1 million people every year. Apart from carcinoma colo rectal surgeries are performed for severe inflammatory bowel diseases, strictures, diverticular diseases etc. The traditional approach to colo rectal surgery has been associated with high morbidity subjecting the patient to unnecessary preparations and prolonged hospital stay. Fast-track surgery consists of a protocol of evidence-based techniques to reduce surgical trauma and postoperative stress by minimizing pain, reducing complications, improving outcomes, and decreasing length of hospital stay while expediting recovery following elective procedures. Fast track protocols for colorectal surgery patients were developed to reduce physiological stress and postoperative organ dysfunction through optimization of perioperative care and recovery. Methods: A total of 40 patients who are undergoing any elective colo-rectal surgeries will be included in the prospective study. Details regarding the age, sex and diagnosis were collected. Operative parameters and post-operative complications were recorded. Post-operative course in hospital and any deviation of normal post-operative course and its management is recorded and analyzed. Results: The overall complication rates were significantly higher in the control group as compared to the Fast track group (p<0.05). The duration of stay was found to be significantly shorter in the study group (mean 8.8 days Vs 11.7 days). Conclusions: This evaluation provides strong evidence that the fast track approach is safe in colo-rectal surgeries and is not associated with increased incidence of complications. It results in significantly reduced duration of hospitalisation and reduction in overall cardio-pulmonary morbidity and complications.

Fast track colorectal surgery

Th is paper summarizes data about “fast track” and ERAS (Enhanced Recovery Aft er Surgery) protocolsin the fi eld of colorectal surgery for the period from 2005 till 2015. More than 30 scientifi c papers were analyzed. Data was collected from scientifi c databases such as PubMed, and Cochrane Library.This review discusses the various aspects of Enhanced Recovery Aft er Surgery protocols. In this paper we consider the use of Fast Track protocols with diff erent points of view: elderly patients and enhanced recovery after surgery protocols, laparoscopic surgery and surgery standards, fast track protocols in emergency abdominal surgery, the infl uence of various factors on the comprehensive success of Enhanced Recovery Aft er Surgery protocols. Refs 32.

Role of epidural anesthesia in a fast track liver resection protocol for cirrhotic patients - results after three years of practice.

To evaluate the potential benefits and risks of the use of epidural anaesthesia within an enhanced recovery protocol in this specific subpopulation. A retrospective review was conducted, including all cirrhotic patients who underwent open liver resection between January 2013 and December 2015 at Bologna University Hospital. Patients with an abnormal coagulation profile contraindicating the placement of an epidural catheter were excluded from the analysis. The control group was composed by patients refusing epidural anaesthesia. Of the 183 cirrhotic patients undergoing open liver resections, 57 had contraindications to the placement of an epidural catheter; of the remaining 126, 86 patients received general anaesthesia and 40 combined anaesthesia. The two groups presented homogeneous characteristics. Intraoperatively the metabolic data did not differ between the two groups, whilst the epidural group had a lower mean arterial pressure (P = 0.041) and received more colloid infusions (P = 0.007). Postoperative liver and kidney function did not differ significantly. Length of mechanical ventilation (P = 0.003) and hospital stay (P = 0.032) were significantly lower in the epidural group. No complications related to the epidural catheter placement or removal was recorded. The use of Epidural Anaesthesia within a fast track protocol for cirrhotic patients undergoing liver resections had a positive impact on the patient's outcomes and comfort as demonstrated by a significantly lower length of mechanical ventilation and hospital stay in the epidural group. The technique appears to be safely manageable in this fragile population even though these results need confirmation in larger studies.

Open sphincter-preserving surgery of extraperitoneal rectal cancer without primary stoma and Fast Track Protocol.

Fast track protocol (FTP) showed to improve perioperative care. The study aims to evaluate the impact of the FTP in the open extraperitoneal rectal cancer (ERC) surgical treatment without a primary derivative stoma (DS) and the QoL in patients with or without a secondary DS. 50 patients affected by ERC were enrolled and operated on with open low anterior resection without a primary DS. They were randomized in two groups: one was treated perioperativelly in the traditional way (group T), the other using a modif ed FTP (group FT). A QoL questionnaire was administered prior to discharge and at 1-month follow-up. Five courses (10%) were complicated by anastomotic leakage: 3 (12%) in the FT group (2 minor and 1 maior) and 2 (8%) in the T group (1 minor and 1 maior) (p=n.s.). All the maiors and one minor were treated with a DS. Patients of the group FTP were considered dischargeable earlier that those of group T (p<0.05). Patients with DS had a significantly lower QoL score (p<0.0001). FTP with minor modifications is feasible and safe in the ERC open surgery without using a DS. Better results were obtained without increasing complication rate. A secondary DS impacts detrimentally on QoL.

Changes In Care Management After “Fast Track” Protocol Introduction For Hip Fracture Patients

Background and objective. The introduction of fast track schemes for patients with hip fracture usually results in reductions in length of stay and mortality, and reduces the numbers of complications. The aim of this study was to evaluate the changes in proce�- dure performance, time from admission to surgery and length of stay after introduction of the fast track protocol (FTP). Materials and methods. 235 patients with hip fracture treated before FTP introduction and after the introduction were prospectively investigated. We studied the use of fracture immobilization, analgesics, infusion therapy, blood test sampling and ECG registration during these two periods. Information about the mean/median time period from admission to surgery and length of stay in the hospital (LOS) in the orthopaedic department was recorded. Results. Significant improvements in the use of im�- mobilization, infusion therapy, blood test sampling and ECG recording were observed after FTP introduction. Also significant reductions were observed in both waiting time for surgery and for LOS. Conclusion. Introduction of a FTP improved the use of procedures necessary for hip fracture patient care, while reducing wait to surgery time and LOS.

Feasibility Testing of a Protocol to Stop Ineffective Drug and Nondrug Treatments.

Ineffective treatments continue to be given to nursing home residents with dementia, and many more treatments are started than stopped. The Track and Trigger Treatment (T(3)) Protocol assists nurses to track responses to new treatments and get ineffective treatments stopped or altered. This preliminary study determined feasibility for end users and examined differences between two randomized groups in assessments, treatment changes, nurse time, and drug costs over 8 weeks. Controlling for number of medical diagnoses, 41 residents in the T(3) group had significantly more treatments stopped than 37 residents in the usual care group. Treatments were most commonly stopped because of ineffectiveness (33%), followed by the problem being resolved (29%), side effects (18%), and a change in goals of care (20%). Assessment quality was a statistically significant mediator, and drug costs were significantly less for the T(3) group. The T(3) processes were rated as useful and easy, with one caveat.

Predictive Value of C-Reactive Protein for Major Complications after Major Abdominal Surgery: A Systematic Review and Pooled-Analysis.

BackgroundEarly diagnosis and treatment of complications after major abdominal surgery can decrease associated morbidity and mortality. Postoperative CRP levels have shown a strong correlation with complications. Aim of this systematic review and pooled-analysis was to assess postoperative values of CRP as a marker for major complications and construct a prediction model.Study designA systematic review was performed for CRP levels as a predictor for complications after major abdominal surgery (MAS). Raw data was obtained from seven studies, including 1427 patients. A logit regression model assessed the probability of major complications as a function of CRP levels on the third postoperative day. Two practical cut-offs are proposed: an optimal cut-off for safe discharge in a fast track protocol and another for early identification of patients with increased risk for major complications.ResultsA prediction model was calculated for major complications as a function of CRP levels on the third postoperative day. Based on the model several cut-offs for CRP are proposed. For instance, a two cut-off system may be applied, consisting of a safe discharge criterion with CRP levels below 75 mg/L, with a negative predictive value of 97.2%. A second cut-off is set at 215 mg/L (probability 20%) and serves as a predictor of complications, indicating additional CT-scan imaging.ConclusionsThe present study provides insight in the interpretation of CRP levels after major abdominal surgery, proposing a prediction model for major complications as a function of CRP on postoperative day 3. Cut-offs for CRP may be implemented for safe early-discharge in a fast-track protocol and, secondly as a threshold for additional examinations, such as CT-scan imaging, even in absence of clinical signs, to confirm or exclude major complications. The prediction model allows for setting a cut-off at the discretion of individual surgeons or surgical departments.

FAST TRACK CARDIAC SURGERY

Objective: The aim of this study was to determine the applicability of fast trackprotocol for cardiac surgery in our unit . Methodology: This cross sectional study was conducted at Civil HospitalDUMHS, Karachi from 1 February to 30 August 2014. Study population wasfollowed for 120 hours after surgery. Our primary endpoint was to achieve patientdischarge within 72 hours. While secondary endpoint was to observe limitationsof fast track protocol and readmission rate in patients discharge within 72 hours. Results : A total of 85 patients underwent different open and close heartsurgeries. Fast track protocol was successfully observed in 37(44%) patientswhile remaining patients follows for 120 h. A significant association of failed fasttrack approached was observed in patients with DM 16(73%)(RR 1.18 ,OR 1.86)and smoking 9(74%)(RR 1.23,OR 2.14) and poor left ventricular function(RR1.16,OR 1.66) with readmission rate of 6(17%), for following reasons delayedtamponade (1), SSI (4), respiratory insufficiency (1). Conclusion: With the limited resources successful discharge in 44% patients,we believe our fast-track management, is applicable for safe postoperativemanagement of patients undergoing cardiac surgery. Major contributing factorsfor failure of fast track protocol were identified by this study. These factors need tobe targeted accordingly by modifications in our postoperative management .

Setting, Clinical Pathways, Fast-Track and Rehabilitation Following Primary Knee Arthroplasty: A Literature Review

In view of the high incidence of total knee replacements, it is important to identify the most efficient yet cost- effective rehabilitation program, in order to optimize patient care within the constraints of the National Healthcare System. This paper aimed at reviewing the literature on post-acute Total Knee Replacement (TKR) rehabilitation discharge setting, and on the strategies for early discharge of TKR patients from orthopedic wards. Research studies on the effectiveness of rehabilitation in intensive rehabilitation care, skilled nursing facilities, home rehabilitation, fast-tracks, enhanced recovery and clinical pathways in total knee replacement patients have been reviewed. Length of stay following knee arthroplasty is influenced by the following factors: age, sex, marital status, co-morbidity, preoperative use of walking aids, pre and postoperative hemoglobin levels, the need for blood transfusion, ASA (American Society of Anesthesiologists) score and time between surgery and mobilization. pathways and fast tracks seem to be effective in reducing length of stay without increasing clinical complications. However, despite the vast quantity of literature available, results remain inconclusive. There is no clear evidence supporting an algorithm for the optimal rehabilitation management after total knee replacement. Beside the question of which setting or path is preferable in terms of organization, the review enlightens that it is relevant also gaining a deeper understanding of the most important predictors of the best outcomes. There is a need to review criteria for admitting total knee arthroplasty patients to intensive rehabilitation, to start a fast- track protocol, to build Clinical Pathways and to discharge patients to home rehabilitation.

Multimodal Rehabilitation Program in Thoracic Surgery

One of the main principles of medicine is that advances in nowledge and technological developments lead to improvements n patient care. In the area of surgery, 2 indisputably significant dvances have emerged in the last 20 years, namely, minimally nvasive surgery and multimodal rehabilitation programs, also nown Fast Track protocols or Enhanced Recovery After Anestheia (ERAS) programs. The aim of both developments is the same: o minimize surgical aggression, thereby improving post-operative ecovery. Comparative, validated data are available from numerous studes to show the benefits of these protocols for both patients reduced morbidity and improved quality of life) and the healthcare ystem (shorter hospital stays),1 but the degree of implemenation needs to be examined. ERAS protocols are in essence ultidisciplinary, and a lack of coordination between the varius specialist areas sometimes makes them difficult to introduce. ut what are ERAS programs, exactly? To paraphrase Kehlet, he father of multimodal surgical rehabilitation, ERAS is a ombination of perioperative strategies supported by evidenceased medicine and aimed at improving recovery after surgical nterventions.2 ERAS protocols revisit conventional perioperative practices and valuate the specific key points of each procedure, analyzing the cientific evidence for the perioperative management of patients ndergoing major surgery, to produce guidelines for helping coorinated teams improve postoperative care. These protocols cover different phases in the care of surgical atients, and address issues such as shortening the preoperaive fasting period, giving carbohydrate-rich drinks before surgery, etection of malnutrition in the preoperative period, need for reventive analgesia, early postsurgical mobilization, rapid reintrouction of oral intake of fluids and food, and prompt withdrawal of nnecessary catheters and tubes. Each of these individual measures

Usefulness of Early Rule-In and Rule-Out Biomarker Protocols to Estimate Ischemia-Induced Myocardial Injury in Early Chest Pain Presenters

Protocols to minimize the time between 2 measurements of troponin or a combination with copeptin have been developed to rapidly rule-in or rule-out myocardial injury (MI) in patients with chest pain. These fast track protocols to rule-in and rule-out MI are not sufficiently validated for early chest pain presenters. The "early presenter" model was tested in 107 stable patients after a short period of myocardial ischemia, induced by stenting of a significant coronary artery stenosis. High-sensitivity troponin T (hsTnT), high-sensitivity troponin I (hsTnI), and copeptin were measured at the start and 90, 180, and 360minutes after stent implantation. MI was defined as a troponin level more than the upper limit of normal (ULN) and an absolute increase of >50% ULN on the 360-minute sample. A single combined measurement of troponin and copeptin 90minutes after the onset of ischemia has a low diagnostic value. This increases when serial measurements with 90-minute intervals are included. For ruling in MI, the highest positive predictive value (with a 95% confidence interval [CI]) can be obtained when focusing only on the increase in troponin level, with a positive predictive value of 86% (70, 93) and 80% (67, 90) for hsTnT and hsTnI, respectively. For ruling out MI, a combined absence of any troponin more than the ULN and any significant increase in troponin level perform best with a negative predictive value of 75% (55, 89) and 75% (55, 89) for hsTnT and hsTnI, respectively. In conclusion, in early presenters, rapid biomarker protocols underestimate MI. A standard biomarker assessment after 3hours is required to adequately rule-in or rule-out myonecrosis.

Operative Findings Are a Better Predictor of Resource Utilization in Pediatric Appendicitis

PurposePost-operative management following appendectomy is dependent upon intraoperative assessment. We determined concordance between surgical and histopathologic diagnosis to better predict resource utilization in pediatric patients undergoing appendectomy. MethodsA retrospective analysis of 326 patients with operative appendicitis from July 2012 to July 2013 was performed. Based on operative findings, patients were classified as simple appendicitis (SA) or complex appendicitis (CA). ResultsThe SA group included 194 (59.5%) patients while the CA group included 132 (40.5%) patients. There were significant differences in WBC, CRP, operative time, length of stay, and 30-day complications. Seventy percent of patients with intra-operative findings of SA were found to have complex pathology while 10.6% with intra-operative findings of CA were found to have simple pathology. There is poor agreement between intra-operative findings and histopathologic findings (κ=0.173). Although 70% of patients with intra-operative findings of SA were labeled as complex pathology, 86% followed a fast track protocol (same day discharge) with a low complication rate (1.7%). ConclusionsPathology findings that overestimate the severity of disease correlate poorly with the post-operative outcomes for appendicitis. We conclude that operative findings are more predictive of clinical course than histopathologic results. This can have an impact on resource utilization planning.

Role of the Clinical Nurse Specialist in Improving Patient Outcomes After Cardiac Surgery

Health care reform continues to focus on improving patient outcomes while reducing costs. Clinical nurse specialists (CNSs) should facilitate this process to ensure that best practice standards are used and patient safety is enhanced. One example of ensuring best practices and patient safety is early extubation after open heart surgery, which is a critical component of fast track protocols that reduces may reduce the development of pulmonary complications in the postoperative period while decreasing overall length of stay in the hospital. This project was an interdisciplinary endeavor, led by the CNS and nurse manager, which combined early extubation protocols with enhanced rounding initiatives to help decrease overall length of ventilation time as well as reduce pulmonary complications in patients in the cardiac surgery intensive care unit. The project resulted in a significant decrease in length of stay and a decrease in pulmonary complications in the postoperative period.

Role of the clinical nurse specialist in improving patient outcomes after cardiac surgery.

Health care reform continues to focus on improving patient outcomes while reducing costs. Clinical nurse specialists (CNSs) should facilitate this process to ensure that best practice standards are used and patient safety is enhanced. One example of ensuring best practices and patient safety is early extubation after open heart surgery, which is a critical component of fast track protocols that reduces may reduce the development of pulmonary complications in the postoperative period while decreasing overall length of stay in the hospital. This project was an interdisciplinary endeavor, led by the CNS and nurse manager, which combined early extubation protocols with enhanced rounding initiatives to help decrease overall length of ventilation time as well as reduce pulmonary complications in patients in the cardiac surgery intensive care unit. The project resulted in a significant decrease in length of stay and a decrease in pulmonary complications in the postoperative period.

Conventional versus fast track anaesthesia in an unselected group of patients undergoing revisional bariatric surgery

IntroductionFast track care has proven to be safe and effective in primary bariatric procedures. The number of more complex revisional procedures is expected to rise over the next years. The aim was to evaluate the potential benefits and safety of a fast-track protocol in an unselected group of patients undergoing Roux-en-Y Gastric Bypass (rRYGBP) as revision. MethodFor this retrospective study, all patients undergoing rRYGBP between January 2005 and December 2013 were included and categorized between conventional care (CC) and fast track care (FT). Patient characteristics, operative details and intra- and early postoperative complications < 30 days were analysed. ResultsA total of 407 patients were included for analysis. 303 patients (74.4%) received peri- and postoperative treatment according to the fast track protocol. Mean age of the study population was 44.0 ± 8.9 years; mean pre-primary procedure BMI was 45.7 ± 7.0 kg/m2. A total of 54 (13.3%) postoperative complications were registered (CC 19.2% vs FT 11.2%; p = 0.038). Both operative time (CC 135.3 ± 42.6 minutes vs FT 79.3 ± 29.3 minutes; p < 0.001) as well as hospital stay (CC 5.1 ± 6.3 days vs FT 3.1 ± 5.3 days; p < 0.001) were significantly shorter in the FT group. A multivariate analysis on postoperative complications showed that fast track was not predictive for the occurrence of complications (OR = 0.853; 95% CI [0.403–1.804]; p = 0.677). ConclusionFast track care appears to be safe and efficient for patients undergoing revisional Roux-en-Y gastric bypass, but postoperative outcome may be highly dependent on surgical experience.

Fast Track versus Conventional Protocol Following Colon Cancer Surgery

Fast Track versus Conventional Protocol Following Colon Cancer Surgery

RETRACTED: Fast track for elderly patients: Is it feasible for colorectal surgery?

Fast-track program has been applied in several surgical fields. However, currently many surgical patients are elderly over 70 years of age, and discussion about the application of such protocols for elderly patients is inadequate. The present study was designed to consider the safety and feasibility of application of a fast-track program after colorectal surgery in elderly patients. A total of 76 elderly patients with colorectal cancer who underwent laparoscopic colorectal resection were randomly assigned to receive either the fast-track care program (n = 40) or the conventional perioperative care protocol (control group, n = 36). The fast track protocol included no preoperative mechanical bowel irrigation, immediate oral alimentation and earlier postoperative ambulation exercise. The length of postoperative hospital stay, the length of time to regain bowel function and the rate of postoperative complications were compared between the two groups. The length of time to regain bowel function, including the passage of flatus [32 (24-40) h vs 42 (32-52) h], and to start a liquid diet (13 [10-16] h v/s 43 [36-50] h) were significantly shorter in patients receiving the fast track care protocol compared with those receiving the conventional care protocol. A shorter duration of postoperative hospital stay was recorded in patients receiving the fast-track program than in those receiving conventional care [6 (5-7) days v/s 9.5 (7-12) days]. A reduced percentage of patients who developed general complications was also observed in the fast-track group (5.0% v/s 18%). Fast-track after laparoscopic colorectal surgery can be safely applied in carefully selected elderly patients older than age 70 years. The fast-track recovery program resulted in a more rapid postoperative recovery, earlier discharge from hospital and fewer general complications compared with a conventional postoperative protocol.

Comparison of fast track protocol and standard care in patients undergoing elective open colorectal resection: a meta-analysis update

ObjectiveWe conducted a systematic review of randomized controlled trials assessing the clinical results of fast track protocol (FTP) and standard care (SC) in patients undergoing elective open colorectal resection using meta-analysis. MethodA literature search for electronic databases and references for eligible studies was conducted through Medline, Embase and Cochrane library between 1966 and 2013. ResultA total of 9 randomized controlled trials (n=947 patients) were included. From the pooled results, we obtained: FTP showed significantly better results compared to SC in terms of postoperative complications, total hospital stay as well as time for flatus, defecation, and soft diet. However, no difference in the incidence of readmission was observed. Postoperative rate of death within 4weeks did not differ significantly between two groups. ConclusionThe current evidence of this meta-analysis suggested that fast track protocol after colorectal surgery pathways might be able to reduce postoperative complication rates, length of hospital stay as well as time for gut function recovery without affecting readmission rate or mortality compared to standard care.

A multicentre comparison of a fast track or conventional postoperative protocol following laparoscopic or open elective surgery for colorectal cancer surgery

The introduction of multimodal or fast track (FT) rehabilitation and laparoscopy in colorectal surgery has improved patient recovery and shortened hospital stay (HS). This study aimed to determine the influence of laparoscopic or open surgery on the postoperative recovery of colorectal cancer patients having a conventional care (CC) or FT protocol in the postoperative period. A multicentre prospective study was controlled with a retrospective group. The prospective group included 300 patients having elective colorectal resection for cancer. The retrospective control group included 201 patients with the same characteristics who were treated before the introduction of the programme. The patients were divided into four groups including laparoscopy + FT, open surgery + FT, laparoscopy + CC, and open surgery + CC. The primary end-points were HS and morbidity. Secondary end-points included mortality and reoperation rates. The overall median HS was 7days. The median HS for laparoscopy + FT was 5days, open + FT 6days, laparoscopy + CC 9days and open + CC 10days (P<0.001). In the regression model the laparoscopy + FT group had the greatest reduction in HS (P<0.001). A significant reduction in HS was observed in the laparoscopy + FT group compared with laparoscopy + CC (P<0.001). The overall patient morbidity was 30.6%. The logistic regression model adjusted for propensity score showed no statistically significant differences between the study groups regarding all other end-points. Colorectal cancer patients who underwent laparoscopic surgery within a multimodal rehabilitation protocol experienced the shortest HS and the lowest morbidity.

Observational cross-sectional study of compliance with the fast track protocol in elective surgery for colon cancer in Spain

The purpose of this study was to establish the degree of compliance with the fast track (enhanced recovery) protocol in habitual clinical practice and to determine which measures are fundamental for achieving the results obtained by applying the entire protocol. Observational, cross-sectional, multicenter trial was conducted. Participating hospitals prospectively recorded data from at least ten consecutive patients undergoing surgery for colon cancer who were applied some or all of the items comprising the enhanced recovery protocol. The data were analyzed both globally and dividing the sample into the two groups of patients. Data on 363 patients from 25 hospitals were recorded, one hundred seventy-three in the "non-fast track" group and 190 in the "fast track" group. The non-fast track group complied with a mean of 5.4 (±1.8) items and the fast track group with a mean of 8.4 (±1.8) items. The mean functional hospital stay was 7.3 (±5.1) days in the non-fast track group and 6.2 (±5.1) days in the fast track group (p < 0.05). Morbidity was 31.1 % in the fast track group and 24.3 % in the non-fast track group, though the differences were not statistically significant. The only prognostic factors that have an impact on improving the results are measures against hypothermia and mobilization before 24 h. Compliance with the enhanced recovery protocol is not exhaustive in habitual clinical practice. However, greater compliance was associated with shorter hospital stay without any increase in morbidity. The only items clearly associated with reduced functional hospital stay were measures against hypothermia and mobilization before 24 h.