Variation In Perioperative Care Research Articles

Variation in perioperative care for recurrent primary spontaneous pneumothorax: a Dutch survey

Quirine C. A. van Steenwijk, Louisa N. Spaans, David J. Heineman, Bas B. Koolen, Frank J. C. van den Broek, Chris Dickhoff

Current Orthognathic Surgery Practice Patterns Among Academic OMS.

Currently there is variation in perioperative care of orthognathic surgery patients and limited clinical practice guidelines. The current orthognathic surgery practice patterns among US academic OMFS training centers have not been described. The purpose of this study is to describe the practice patterns among US academic OMFS training centers. The study design is cross-sectional. Data was collected through a survey of the sample. OMFS programs in the US. Academic OMFS. 573 surgeons were contacted and 85 responses were received. Descriptive and bivariate statistics were reported. Respondents were 87% male and worked in full-time academic (80%), part-time academic (19%), or military settings (1%). Thirty-one percent have practiced for 30 years or more and then 29% with 11-20 years, 18% with 21-30 years, 12% with 6-10 years and 11% with 1-5 years. Twenty-six percent of respondents perform 20-40 orthognathic surgeries a year, 22% perform less than 20 surgeries a year, 21% perform 40-60 surgeries per year, and 19% perform more than 100 surgeries per year. Intraoperatively, 48% of surgeons request a mean arterial pressure of 60-64 mmHg, 25% utilize tranexamic acid (TXA), 85% report a blood loss of less than 400 milliliters, and 93% report a blood transfusion rate of <1%. There are variations in orthognathic surgery practice patterns with limited clinical practice guidelines. Only 13 of the 32 survey questions had a single response holding a simple majority. This study demonstrates the need for further research and evidence-based protocols and decision making.

Enhanced Recovery After Surgery in Patients Implanted with Left Ventricular Assist Device

IntroductionWe sought to develop and implement a comprehensive enhanced recovery after surgery (ERAS) protocol for patients implanted with a left ventricular assist device (LVAD). Methods and ResultsIn this article, we describe our approach to the development and phased implementation of the protocol. Additionally, we reviewed prospectively collected data for patients who underwent LVAD implantation at our institution from February 2019 to August 2020. To compare early outcomes in our patients before and after protocol implementation, we dichotomized patients into two 6-month cohorts (the pre-ERAS and ERAS cohorts) separated from each other by 6 months to allow for staff adoption of the protocol. Of the 115 LVAD implants, 38 patients were implanted in the pre-ERAS period and 46 patients in the ERAS period. Preoperatively, the patients` characteristics were similar between the cohorts. Postoperatively, we observed a decrease in bleeding (chest tube output of 1006 vs 647.5 mL, P < .001) and blood transfusions (fresh frozen plasma 31.6% vs 6.7%, P = .04; platelets 42.1% vs 8.7%, P = .001). Opioid prescription at discharge were 5-fold lower with the ERAS approach (P < .01). Furthermore, the number of patients discharged to a rehabilitation facility decreased significantly (20.0% vs 2.4%, P = .02). The index hospitalization length of stay and survival were similar between the groups. ConclusionsERAS for patients undergoing LVAD implantation is a novel, evidence-based, interdisciplinary approach to care with multiple potential benefits. In this article, we describe the details of the protocol and early positive changes in clinical outcomes. Further studies are needed to evaluate benefits of an ERAS protocol in an LVAD population.Lay Summary: Enhanced recovery after surgery (ERAS) is the implementation of standardized clinical pathways that ensures the use of best practices and decreased variation in perioperative care. Multidisciplinary teams work together on ERAS, thereby enhancing communication among health care silos. ERAS has been used for more than 30 years by other surgical services and has been shown to lead to a decreased length of stay, fewer complications, lower mortality, fewer readmissions, greater job satisfaction, and lower costs. Our goal was to translate these benefits to the perioperative care of complex patients with a left ventricular assist device. Early results suggest that this goal is possible; we have observed a decrease in transfusions, discharge on opioids, and discharge to a rehabilitation facility.

Canadian Enhanced Recovery After Surgery (ERAS) Cesarean Delivery Perioperative Management Survey

Enhanced Recovery After Surgery (ERAS) is a global surgical quality improvement initiative that has spread across numerous surgical disciplines. The uptake of ERAS in cesarean delivery in Canada is presently unknown. This study surveyed the current practices of Society of Obstetricians and Gynaecologists of Canada (SOGC) members with regards to ERAS guidelines for preoperative, intraoperative, and postoperative cesarean delivery care. Survey responses highlight perioperative practice variations across Canada. Active implementation of ERAS cesarean delivery guidelines could potentially lessen variations in perioperative care, improve patient outcomes, and minimize health care costs.

Current Practices in Microvascular Reconstruction by Oral and Maxillofacial Surgeons

Microvascular free tissue transfer (MFTT) is a reliable reconstructive option with variation in perioperative care and a general lack of clinical practice guidelines. Oral and maxillofacial surgeons' (OMSs) current MFTT perioperative practices in the United States have not been described. This study describes these practices including surgeon practice environment, operative practices, perioperative management, and success. The study design is cross sectional. The sample is composed of OMSs who completed an Oral/Head and Neck Oncologic and Microvascular Surgery Fellowship prior to 2018 in the United States. Data were collected by means of a survey of the study sample. Descriptive statistics were reported. Forty surgeons responded to the survey for a response rate of 33.9%. Respondents were 97.5% (n=39) male and worked in private (n=8), combination (n=10), and academic practices (n=23). Surgeons in private and academic practice performed an average of 23.3 (SD 13.9) and 48.6 (SD 28.6) flaps per year, respectively. The 2-team approach was used by 88.2% of surgeons. Immediate dental implants were placed in osteocutaneous free flaps by 28.6% (n=2) of private practice surgeons and 70% (n=14) of academic surgeons. Postoperatively, most patients went to an intensive care unit (ICU) (82.7%, average duration 2.6 days). Anticoagulation or antiplatelet medications were routinely used with the most common choice being aspirin (77.4%, n=24). Antibiotics were universally administered, often for 3 days or longer (74.2%, n=23). Self-reported success rates were 95.3% (SD 4.1) and 96.0% (SD 1.7) in private and academic settings, respectively. This is the first report of practice trends by microvascular OMSs in the United States. The results of this study suggest that there is variation in MFTT operative and perioperative practices by individual surgeons and practice environment with minimal variation in self-reported success rates.

Enhanced Recovery After Surgery (ERAS) in gynecologic oncology: an international survey of peri-operative practice

IntroductionEnhanced Recovery After Surgery (ERAS) programs have been shown to improve clinical outcomes in gynecologic oncology, with the majority of published reports originating from a small number of specialized centers....

Institutional variation in recovery after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: An opportunity for enhanced recovery pathways.

Variations in care have been demonstrated both within and among institutions in many clinical settings. By standardizing perioperative practices, Enhanced Recovery After Surgery (ERAS) pathways reduce variation in perioperative care. We sought to characterize the variation in cytoreductive surgery (CRS)/heated intraperitoneal chemotherapy (HIPEC) perioperative practices among experienced US medical centers. Data from the US HIPEC Collaborative represents a retrospective multi-institutional cohort study of CRS and CRS/HIPEC procedures performed from 12 major academic institutions. Patient characteristics and perioperative practices were reported and compared. Institutional variation was analyzed using hierarchical mixed-effects linear (continuous outcomes) or logistic (binary outcomes) regression models. A total of 2372 operations were included. CRS/HIPEC was performed most commonly for appendiceal histologies (64.2%). The rate of complications (overall 56.3%, range: 31.8-70.9) and readmissions (overall 20.6%, range: 8.9-33.3) varied by institution (P < .001). Institution-level variation in perioperative practice patterns existed among measured ERAS pathway process/outcomes (P < .001). The percentages of variation with each process/outcome measure attributable solely to institutional practices ranged from 0.6% to 66.6%. Significant variation exists in the perioperative care of patients undergoing CRS/HIPEC at major US academic institutions. These findings provide a strong rationale for the investigation of best practices in CRS/HIPEC patients.

Wide Variation in Perioperative Care in Anatomical Lung Resections in the Netherlands: A National Survey

This study aimed to describe perioperative care after anatomical lung resection in the Netherlands, before publication of Enhanced Recovery After Surgery/European Society of Thoracic Surgeons (ERAS/ESTS) guidelines in 2019. An online survey was sent to all 43 Dutch lung surgical centers in December 2017, addressing topics in the 4 phases of perioperative care (preoperative, admission, perioperative, postoperative). Respondents were requested to report care that would be delivered to a standardized patient without perioperative complications. To compare current care with ERAS/ESTS guidelines, we assigned an ERAS/ESTS score per hospital, weighted for evidence level per recommendation. Higher scores indicate higher application of recommendations. Response rate of centers was 100%, median response rate per question was 98% (interquartile range 94-100). Some perioperative recommendations are commonly applied (>85%), such as minimally invasive surgery and regional anesthesia; others, such as admission carbohydrate drinks, are not (<35%). Wide variation was observed regarding patient counselling, pre- and postoperative admission logistics, anemia correction, fluid management, pain management, and chest drain management. Median 62% (interquartile range 53%-72%) of the maximum ERAS/ESTS score was achieved. Large variation in ERAS/ESTS score between hospitals were found in all phases (preoperative: 6.0 [6.5-10.5] points, admission: 5.0 [1.0-6.0] points, perioperative: 21.5.0 [16.0-22.5] points, postoperative: 8.0 [5.0-8.5] points). Large variation exists in perioperative care after anatomical lung resection in the Netherlands. Given previously published data linking variation in perioperative care to variation in outcomes, standardization of perioperative care in lung surgery, preferably based on the ERAS/ESTS guidelines, may be warranted but requires further study.

Current Practices in Microvascular Reconstruction by Oral and Maxillofacial Surgeons

Purpose Microvascular free tissue transfer (MFTT) is a reliable reconstructive option with variation in perioperative care and a general lack of clinical practice guidelines. Oral and maxillofacial surgeons’ (OMSs) current MFTT perioperative practices in the United States have not been described. This study describes these practices including surgeon practice environment, operative practices, perioperative management, and success. Methods The study design is cross sectional. The sample is composed of OMSs who completed an Oral/Head and Neck Oncologic and Microvascular Surgery Fellowship prior to 2018 in the United States. Data were collected by means of a survey of the study sample. Descriptive statistics were reported. Results Forty surgeons responded to the survey for a response rate of 33.9%. Respondents were 97.5% (n = 39) male and worked in private (n = 8), combination (n = 10), and academic practices (n = 23). Surgeons in private and academic practice performed an average of 23.3 (SD 13.9) and 48.6 (SD 28.6) flaps per year respectively. 88.2% of surgeons operated with a 2-team approach. Immediate dental implants were placed in osteocutaneous free flaps by 28.6% (n = 2) of private practice surgeons and 70% (n = 14) of academic surgeons. Postoperatively, most patients went to an intensive care unit (ICU) (82.7%, average duration 2.6 days). Anticoagulation or antiplatelet medications were routinely used with the most common choice being aspirin (77.4%, n = 24). Antibiotics were universally administered, often for 3 days or longer (74.2%, n = 23). Self-reported success rates were 95.3% (SD 4.1) and 96.0% (SD 1.7) in private and academic settings respectively. Conclusion This is the first report of practice trends by microvascular OMSs in the United States. The results of this study suggest that there is variation in MFTT operative and perioperative practices by individual surgeons and practice environment with minimal variation in self-reported success rates.

Enhanced Recovery After Surgery for Radical Cystectomy.

Even with advances in perioperative medical care, anesthetic management, and surgical techniques, radical cystectomy (RC) continues to be associated with a high morbidity rate as well as a prolonged length of hospital stay. In recent years, there has been great interest in identifying multimodal and interdisciplinary strategies that help accelerate postoperative convalescence by reducing variation in perioperative care of patients undergoing complex surgeries. Enhanced recovery after surgery (ERAS) attempts to evaluate and incorporate scientific evidence for modifying as many of the factors contributing to the morbidity of RC as possible, and optimize how patients are cared for before and after surgery. In this chapter, we review the preoperative, intraoperative and postoperative elements of using an ERAS protocol for RC.

LONG-TERM SURVIVAL AFTER CARDIAC TRANSPLANTATION: THE BRITISH COLUMBIA EXPERIENCE

Orthotopic heart transplantation (OHT) continues to be the gold standard for the management of patients with end-stage heart failure. However, there are regional variations in perioperative care and outcomes. Long-term survival data published by the International Society of Heart and Lung Transplantation may not be reflective of center specific outcomes. We undertook this analysis to review our single center outcomes in patients receiving OHT. This is a retrospective cohort analysis of all patients who underwent OHT between December 1, 1988 and October 21, 2014 through the BC Heart Transplant Program. Overall long-term survival at 25 years was determined. Survival at 10-years was stratified by induction strategy, sex and treatment era (early: 1998-2001, late: 2002-2014), and compared using the log-rank test. Over the study period, a total of 406 patients were transplanted, 6 of whom were re-transplanted and excluded from our analysis. Of the remaining 400 patients, 307 (76.8%) were males and the average age was 52.1 years. The median follow-up time was 6.6 years. Overall long-term survival was 34.5% at 25 years with a median survival of 15.5 years (Figure 1). Conditional survival beyond 1-year was 41.3% at 25 years with a median survival of 18.5 years. Survival at 10-years in the early era (59.8%) was significantly lower versus late era (76.9%; p=0.04). Survival at 10-years amongst male (68.4%) versus female (72.0%) recipients was similar (p=0.67). Basiliximab, rabbit anti-thymocyte globulin (RATG), and OKT3 were used in 184, 99, and 87 patients, respectively. There was a significant difference in 10-year survival amongst the basiliximab (78.8%) RATG (68.7%) and OKT3 (55.2%) treatment groups (p=0.02), but no difference between the basiliximab and RATG groups (p=0.70). Our long-term survival for OHT patients is acceptable at 34.5 % at 25 years. There are no differences in outcomes based on the commonly used induction agents or sex. The difference in survival based on treatment era may be driven by choice of induction and immunosuppression strategies as well as improvements in pre- and post-transplant care.

Ostomy Closures in Children: Variations in Perioperative Care Do Not Change the Outcome.

This study aimed to evaluate ostomy closure applications and outcomes and determine the effect of personal differences among surgeons on patient postoperative course. Ninety-eight patients who underwent elective ostomy (ileostomy and colostomy) closure for 8years at a pediatric surgery training department were investigated. Postoperative complications included superficial surgical site infection (SSI; 9.4%), organ/cavity infection (1%), small bowel adhesions (8.2%), and incisional hernia (1%). SSI and postoperative complications were not affected by the preoperative antibiotic regimen used. Operation duration, pre- and postoperative antibiotic use durations, postoperative inpatient period, ostomy type, primary diagnosis, performance of abdominal exploration, SSI, and postoperative complications were not significantly different. However, the time of nasogastric (NG) tube withdrawal, time to oral feeding initiation, abdominal closure method used, and preoperative antibiotic regimen were significantly different among different surgeons. We conclude that while surgeons used different preoperative antibiotic regimens and abdominal closure methods and stipulated different times for NG tube withdrawal and oral feeding initiation, the postoperative course and prognosis were unaffected Thus, the pre- and postoperative inpatient period and antibiotic use duration can be decreased in children by procedure standardization using practice guidelines; the procedures can also be performed with a more aesthetic, acceptable incision.

Tumour Thrombi in the Suprahepatic Inferior Vena Cava: The Cardiothoracic Surgeons’ View

Background. Retroperitoneal tumours propagate intrathoracic caval tumour thrombi (ICTT) of which we consider two subgroups: ICTT-III (extracardiac) and ICTT-IV (intracardiac). Methods. Case series review. Results. 29 series with 784 patients, 453 with extracardiac and 331 with intracardiac ICTT. Average age was 59 years. 98% of the tumours were RCC, 1% adrenal and Wilms’ tumours, and 1% transitional cell carcinomas. The prevalent incision was rooftop with or without sternotomy. Mortality was 10% (5% for ICTT-III, 15% for ICTT-IV). Morbidity was 56% (36% for ICTT-III, 64% for ICTT-IV) and reoperation for bleeding was the commonest complication (14%). Mean Blood loss was 2.6 litres for ICTT-III and 3.7 litres for ICTT-IV. Mean blood product use was 2.4 litres for ICTT-III and 3.5 litres for ICTT-IV. Operative and anaesthetic times exceeded 5 hours. Hospital stay averaged 13 days. Variations in perioperative care included preoperative embolisation, perioperative transoesophageal echo, surgical incisions, and extracorporeal circulation. Brief Summary. Surgery for ICTT has high transfusion, operating/anaesthetic time, and in-hospital stay requirements, and intracardiac ICTT also attract higher risk. Preoperative tumour embolisation is controversial. The cardiothoracic team offers proactive optimisation of blood loss and preemptive management of intracardiac thrombus impaction: we should always be involved in the management the ICTT.

Postoperative complications after major head and neck surgery with free flap repair—prevalence, patterns, and determinants: a prospective cohort study

This study aims to give a better understanding of the prevalence, patterns, and determinants of postoperative complications, to evaluate the Clavien–Dindo classification of surgical complications, and to set out a protocol to improve postoperative recovery. Over a period of 27 months we studied 192 patients who had had major head and neck operations with free flaps. Data on complications were gathered prospectively along with patients’ details, comorbidities, factors indicative of the magnitude of the surgical insult, and variations in perioperative care. Complications were classified according to the Clavien–Dindo system. Outcomes analysed comprised any complication, major complications (Clavien–Dindo III and above), wound complications, and pulmonary complications. A total of 64% of patients had complications, and in around one third they were serious; wound and pulmonary complications were the most common. Factors significantly associated with complications reflected an interaction between coexisting conditions of the patient at operation and the magnitude of the surgery. Perioperative interventions to ensure preoperative optimisation of patients, and to lessen the systemic inflammatory response that results from operation offer the best prospect of reducing the burden of surgical complications. A protocol to improve recovery after operation would be appropriate. The Clavien–Dindo classification of surgical complications is useful in this group.

Introduction to the Single Ventricle Reconstruction trial

The Single Ventricle Reconstruction (SVR) trial, sponsored by the National Heart, Lung, and Blood Institute and carried out by 15 clinical centers, randomized 549 neonates and showed that transplantation-free survival at 14 months was significantly higher overall with the right ventricleto-pulmonary artery shunt (RVPAS) compared with the modified Blalock-Taussig shunt (MBTS). Any surgical procedure that does not exceed 65% survival at 1 year deserves to be studied and scrutinized relentlessly. Although the primary outcome was clear when considering the entire study cohort, many questions remained regarding the impact of comorbidities; intraoperative, postoperative, and interstage management strategies on morbidity and mortality; and the mechanisms of death throughout the study period. The compilation of 5 follow-up articles represents secondary analyses of the SVR trial, and their main value is that they provide a more detailed analysis of areas that could not be covered in the New England Journal of Medicine article. The SVR trial fortunately included enough study patients, and collected a vast amount of data, to permit analysis of the interaction of risk factors with shunt type; the risk factors of hospital morbidity and mortality after the Norwood; the impact of shunt type and other risk factors on interstage mortality; the cause, timing, and location of death after the Norwood; as well as a descriptive study on practice variation in perioperative care found across centers. Some of the findings confirm the findings of previous retrospective studies or database extraction studies, such as the impact of center/surgeon volume, the major and independent role of extracardiac anomalies, genetic syndromes, low gestational age and birth weight, smaller ascending aorta, obstructed pulmonary venous return, and lower socioeconomic status play on outcomes. Patients with aortic stenosis/mitral stenosis did better than any other subgroup, presumably because of the presence of antegrade aortic flow, and patients with aortic atresia/mitral stenosis did not exhibit a higher mortality, although the presence or

Variation in perioperative care across centers for infants undergoing the Norwood procedure

In the Single Ventricle Reconstruction trial, infants undergoing the Norwood procedure were randomly allocated to undergo a right ventricle-to-pulmonary artery shunt or a modified Blalock-Taussig shunt. Apart from shunt type, subjects received the local standard of care. We evaluated variation in perioperative care during the Norwood hospitalization across 14 trial sites. Data on preoperative, operative, and postoperative variables for 546 enrolled subjects who underwent the Norwood procedure were collected prospectively on standardized case report forms, and variation across the centers was described. Gestational age, birth weight, and proportion with hypoplastic left heart syndrome were similar across sites. In contrast, all recorded variables related to preoperative care varied across centers, including fetal diagnosis (range, 55%-85%), preoperative intubation (range, 29%-91%), and enteral feeding. Perioperative and operative factors were also variable across sites, including median total support time (range, 74-189 minutes) and other perfusion variables, arch reconstruction technique, intraoperative medication use, and use of modified ultrafiltration (range, 48%-100%). Additional variation across centers was seen in variables related to postoperative care, including proportion with an open sternum (range, 35%-100%), median intensive care unit stay (range, 9-44 days), type of feeding at discharge, and enrollment in a home monitoring program (range, 1%-100%; 5 sites did not have a program). Overall, in-hospital death or transplant occurred in 18% (range across sites, 7%-39%). Perioperative care during the Norwood hospitalization varies across centers. Further analysis evaluating the underlying causes and relationship of this variation to outcome is needed to inform future studies and quality improvement efforts.

Repeat surgery after lumbar decompression for herniated disc: the quality implications of hospital and surgeon variation

Repeat lumbar spine surgery is generally an undesirable outcome. Variation in repeat surgery rates may be because of patient characteristics, disease severity, or hospital- and surgeon-related factors. However, little is known about population-level variation in reoperation rates. To examine hospital- and surgeon-level variation in reoperation rates after lumbar herniated disc surgery and to relate these to published benchmarks. Retrospective analysis of a discharge registry including all nonfederal hospitals in Washington State. We identified adults who underwent an initial inpatient lumbar decompression for herniated disc from 1997 to 2007. We then performed generalized linear mixed-effect logistic regressions, controlling for patient characteristics and comorbidity, to examine the variation in reoperation rates within 90 days, 1 year, and 4 years. Our cohort included 29,529 patients with a mean age of 47.5 years, 61% privately insured, and 15% having any comorbidity. The age-, sex-, insurance-, and comorbidity-adjusted mean rate of reoperation among hospitals was 1.9% at 90 days (95% confidence interval [CI], 1.2-3.1), with a range from 1.1% to 3.4%; 6.4% at 1 year (95% CI, 3.9-10.6), with a range from 2.8% to 12.5%; and 13.8% at 4 years (95% CI, 8.8-19.8), with a range from 8.1% to 24.5%. The adjusted mean reoperation rates of surgeons were 1.9% at 90 days (95% CI, 1.4-2.4) with a range from 1.2% to 4.6%, 6.1% at 1 year (95% CI, 4.8-7.7) with a range from 4.3% to 10.5%, and 13.2% at 4 years (95% CI, 11.3-15.5) with a range from 10.0% to 19.3%. Multilevel random-effect models suggested that variation across surgeons was greater than that of hospitals and that this effect increased with long-term outcomes. Even after adjusting for patient demographics and comorbidity, we observed a large variation in reoperation rates across hospitals and surgeons after lumbar discectomy, a relatively simple spinal procedure. These findings suggest uncertainty about indications for repeat surgery, variations in perioperative care, or variations in quality of care.

Outcomes Improvement Following Minimally Invasive Direct Coronary Artery Bypass Surgery: The Role of Nursing in Critical Care and Cardiovascular Risk Factor Reduction

The most progressive movement in the standardization of MIDCAB has occurred within the past 5 years. Standardization of care and continuous quality improvement are essential to improve outcomes and reduce costs for MIDCAB. At the authors' institution, perioperative clinical outcomes demonstrated no significant differences among a traditional single-vessel CABG and a MIDCAB in myocardial infarction rates, reoperations for bleeding, and cerebrovascular accidents. Differences were found in new-onset atrial fibrillation, extubation in the operating room, required transfusions, length of stay in the critical care unit, and overall length of hospital stay. Optimal perioperative critical care recovery may result from an evidence-based approach in the design and delivery of patient care. Standardized nursing interventions may be designed to improve efficiency and reduce inappropriate variations in perioperative care. Because MIDCAB is a palliative intervention for single-vessel CAD, multifactorial CRF management is a necessary adjunct for the achievement of optimal long-term outcomes. CRFs must be managed to maintain long-term arterial conduit patency rates (e.g., 20 y) and to prevent further progression of CAD in the native coronary arteries for MIDCAB patients. Nurse-managed, physician-directed CRF management programs are the avenue to provide such services. The reported clinical outcomes are appropriate variables to track for continuous quality improvement. These clinical outcomes are meaningful, measurable, and appropriate for evaluating the effectiveness of care but do not address quality of life, patient satisfaction, and efficacy of pain management. Nursing care must continue to evolve as more data become available.