Surgical Technical Evidence Review for Colorectal Surgery Conducted for the AHRQ Safety Program for Improving Surgical Care and Recovery.
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SUBMITTER: Ban KA
PROVIDER: S-EPMC9275829 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:Enhanced recovery pathways (ERPs) have been shown to improve patient outcomes in a variety of contexts. This review summarizes the evidence and defines a protocol for perioperative care of patients with hip fracture and was conducted for the Agency for Healthcare Research and Quality safety program for improving surgical care and recovery.Perioperative care was divided into components or "bins." For each bin, a semisystematic review of the literature was conducted using MEDLINE with priority given to systematic reviews, meta-analyses, and randomized controlled trials. Observational studies were included when higher levels of evidence were not available. Existing guidelines for perioperative care were also incorporated. For convenience, the components of care that are under the auspices of anesthesia providers will be reported separately. Recommendations for an evidence-based protocol were synthesized based on review of this evidence.Eleven bins were identified. Preoperative risk factor bins included nutrition, diabetes mellitus, tobacco use, and anemia. Perioperative management bins included thromboprophylaxis, timing of surgery, fluid management, drain placement, early mobilization, early alimentation, and discharge criteria/planning.This review provides the evidence basis for an ERP for perioperative care of patients with hip fracture.
| S-EPMC5964861 | biostudies-other
Project description:OBJECTIVES: To examine the criterion validity of the Agency for Health Care Research and Quality (AHRQ) Patient Safety Indicators (PSIs) using clinical data from the Veterans Health Administration (VA) National Surgical Quality Improvement Program (NSQIP). DATA SOURCES: Fifty five thousand seven hundred and fifty two matched hospitalizations from 2001 VA inpatient surgical discharge data and NSQIP chart-abstracted data. STUDY DESIGN: We examined the sensitivities, specificities, positive predictive values (PPVs), and positive likelihood ratios of five surgical PSIs that corresponded to NSQIP adverse events. We created and tested alternative definitions of each PSI. DATA COLLECTION: FY01 inpatient discharge data were merged with 2001 NSQIP data abstracted from medical records for major noncardiac surgeries. PRINCIPAL FINDINGS: Sensitivities were 19-56 percent for original PSI definitions; and 37-63 percent using alternative PSI definitions. PPVs were 22-74 percent and did not improve with modifications. Positive likelihood ratios were 65-524 using original definitions, and 64-744 using alternative definitions. "Postoperative respiratory failure" and "postoperative wound dehiscence" exhibited significant increases in sensitivity after modifications. CONCLUSIONS: PSI sensitivities and PPVs were moderate. For three of the five PSIs, AHRQ has incorporated our alternative, higher sensitivity definitions into current PSI algorithms. Further validation should be considered before most of the PSIs evaluated herein are used to publicly compare or reward hospital performance.
| S-EPMC2669628 | biostudies-literature
Project description:BackgroundPrevious studies have focused on the development and evaluation of care bundles to reduce the risk of surgical site infection (SSI) throughout the perioperative period. A focused examination of the technical/surgical aspects of SSI reduction during CRS has not been conducted. This study aimed to develop an expert consensus on intraoperative technical/surgical aspects of SSI prevention by the surgical team during colorectal surgery (CRS).Study designIn a modified Delphi process, a panel of 15 colorectal surgeons developed a consensus on intraoperative technical/surgical aspects of SSI prevention undertaken by surgical personnel during CRS using information from a targeted literature review and expert opinion. Consensus was developed with up to three rounds per topic, with a prespecified threshold of ≥70% agreement.ResultsIn 3 Delphi rounds, the 15 panelists achieved consensus on 16 evidence-based statements. The consensus panel supported the use of wound protectors/retractors, sterile incision closure tray, preclosure glove change, and antimicrobial sutures in reducing SSI along with wound irrigation with aqueous iodine and closed-incision negative pressure wound therapy in high-risk, contaminated wounds.ConclusionsUsing a modified Delphi method, consensus has been achieved on a tailored set of recommendations on technical/surgical aspects that should be considered by surgical personnel during CRS to reduce the risk of SSI, particularly in areas where the evidence base is controversial or lacking. This document forms the basis for ongoing evidence for the topics discussed in this article or new topics based on newly emerging technologies in CRS.
| S-EPMC8719508 | biostudies-literature
Project description:To study the implementation of an enhanced recovery after surgery (ERAS) program at a large University Hospital from "pilot study" to "standard of care".The study was designed as a prospective single centre cohort study. A prospective evaluation of compliance to a protocol based on full application of all ERAS principles, through the progressive steps of its implementation, was performed. Results achieved in the initial pilot study conducted by a dedicated team (n = 47) were compared to those achieved in the shared protocol phase (n = 143) three years later. Outcomes were length of postoperative hospital stay, readmission rate, compliance to the protocol and morbidity. Primary endpoint was the description of the results and the identification of critical issues of large scale implementation of an ERAS program in colorectal surgery emerged in the experience of a single center. Secondary endpoint was the identification of interventions that have been proven to be effective for facilitating the transition from traditional care pathways to a multimodal management protocol according to ERAS principles in colorectal surgery at a single center.During the initial pilot study (March 2009 to December 2010; 47 patients) conducted by a dedicated multidisciplinary team, compliance to the items of ERAS protocol was 93%, with a median length of hospital stay (LOS) of 3 d. Early anastomotic fistulas were observed in 2 cases (4.2%), which required reoperation (Clavien-Dindo grade IIIb). None of the patients had been discharged before the onset of the complication, which could therefore receive prompt treatment. There were also four (8.5%) minor complications (Clavien-Dindo grade II). Thirty days readmission rate was 4%. Perioperative mortality was nil. After implementation of the protocol throughout the Hospital in unselected patients (May 2012 to December 2012; 147 patients) compliance was 74%, with a median LOS of 6 d. Early anastomotic fistulas were observed in 11 cases (7.7%), 5 (3.5%) of which required reoperation (Clavien-Dindo grade IIIb). Two early anastomotic fistulas were treated by radiologic/endoscopic manoeuvres and 4 were treated conservatively. There were also 36 (25.2%) minor complications, 21 (14.7%) of which were Clavien-Dindo grade II and 15 (10.5%) of which were Clavien-Dindo grade?I. Only two patients whose course was adversely affected by the development of an anastomotic leak had been discharged before the onset of the complication itself, requiring readmission. Readmission rate within 30 d was 4%. Perioperative mortality was 1%.Our results confirm that introduction of an ERAS protocol for colorectal surgery allows quicker postoperative recovery and shortens the length of stay compared to historical series.
| S-EPMC4265620 | biostudies-other
Project description:ObjectiveTo identify lessons learned from the experience of the Agency for Healthcare Research and Quality (AHRQ) Patient Safety and Medical Liability (PSML) Demonstration Program.Data sources/study settingOn September 9, 2009, President Obama directed the Secretary of Health and Human Services to authorize demonstration projects that put "patient safety first" with the intent of reducing preventable adverse outcomes and stemming liability costs. Seven demonstration projects received 3 years of funding from AHRQ in the summer of 2010, and the program formally came to a close in June 2015.Study designThe seven grantees implemented complex, broad-ranging innovations addressing both patient safety and medical liability in "real-world" contexts. Some projects featured novel approaches, while others implemented adaptations of existing models. Each project was funded by AHRQ to collect data on the impact of its interventions. In addition, AHRQ funded a cross-cutting qualitative evaluation focused on lessons learned in implementing PSML interventions.Data collection/extraction methodsSite visits and follow-up interviews supplemented with material abstracted from formal project reports to AHRQ.Principal findingsThe PSML demonstration projects focused on three broad approaches: (1) improving communication around adverse events through disclosure and resolution programs; (2) preventing harm through implementation of clinical "best practices"; and (3) exploring alternative methods of settling claims. Although the demonstration contributed to accumulating evidence that these kinds of interventions can positively affect outcomes, there is also evidence to suggest that these interventions can be difficult to scale.ConclusionsIn addition to producing at least preliminary positive outcomes, the demonstration also lends credence to the idea that targeted interventions that improve some aspect of patient safety or malpractice performance may also contribute more broadly to institutional culture and the alignment of all parties around reducing risk and preventing harm. However, more empirical work needs to be carried out to quantify the effect of such interventions.
| S-EPMC5134358 | biostudies-literature
Project description:ImportanceNovel approaches to perioperative surgical care focus on optimizing nutrition, mobility, and pain management to minimize adverse events after surgical procedures.ObjectiveTo evaluate the outcomes of an enhanced recovery after surgery (ERAS) program among 2 target populations: patients undergoing elective colorectal resection and patients undergoing emergency hip fracture repair.Design, setting, and participantsA pre-post difference-in-differences study before and after ERAS implementation in the target populations compared with contemporaneous surgical comparator groups (patients undergoing elective gastrointestinal surgery and emergency orthopedic surgery). Implementation began in February and March 2014 and concluded by the end of 2014 at 20 medical centers within the Kaiser Permanente Northern California integrated health care delivery system.ExposuresA multifaceted ERAS program designed with a particular focus on perioperative pain management, mobility, nutrition, and patient engagement.Main outcomes and measuresThe primary outcome was hospital length of stay. Secondary outcomes included hospital mortality, home discharge, 30-day readmission rates, and complication rates.ResultsThe study included a total of 3768 patients undergoing elective colorectal resection (mean [SD] age, 62.7 [14.1] years; 1812 [48.1%] male) and 5002 patients undergoing emergency hip fracture repair (mean [SD] age, 79.5 [11.8] years; 1586 [31.7%] male). Comparator surgical patients included 5556 patients undergoing elective gastrointestinal surgery and 1523 patients undergoing emergency orthopedic surgery. Most process metrics had significantly greater changes in the ERAS target populations after implementation compared with comparator surgical populations, including those for ambulation, nutrition, and opioid use. Hospital length of stay and postoperative complication rates were also significantly lower among ERAS target populations after implementation. The rate ratios for postoperative complications were 0.68 (95% CI, 0.46-0.99; P = .04) for patients undergoing colorectal resection and 0.67 (95% CI, 0.45-0.99, P = .05) for patients with hip fracture. Among patients undergoing colorectal resection, ERAS implementation was associated with decreased rates of hospital mortality (0.17; 95% CI, 0.03-0.86; P = .03), whereas among patients with hip fracture, implementation was associated with increased rates of home discharge (1.24; 95% CI, 1.06-1.44; P = .007).Conclusions and relevanceMulticenter implementation of an ERAS program among patients undergoing elective colorectal resection and patients undergoing emergency hip fracture repair successfully altered processes of care and was associated with significant absolute and relative decreases in hospital length of stay and postoperative complication rates. Rapid, large-scale implementation of a multidisciplinary ERAS program is feasible and effective in improving surgical outcomes.
| S-EPMC5568841 | biostudies-literature
Project description:Given that patient safety measures are increasingly used for public reporting and pay-for performance, it is important for stakeholders to understand how to use these measures for improvement. The Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs) are one particularly visible set of measures that are now used primarily for public reporting and pay-for-performance among both private sector and Veterans Health Administration (VA) hospitals. This trend generates a strong need for stakeholders to understand how to interpret and use the PSIs for quality improvement (QI). The goal of this study was to develop an educational program and tailor it to stakeholders' needs. In this paper, we share what we learned from this program development process.Our study population included key VA stakeholders involved in reviewing performance reports and prioritizing and initiating quality/safety initiatives. A pre-program formative evaluation through telephone interviews and web-based surveys assessed stakeholders' educational needs/interests. Findings from the formative evaluation led to development and implementation of a cyberseminar-based program, which we tailored to stakeholders' needs/interests. A post-program survey evaluated program participants' perceptions about the PSI educational program.Interview data confirmed that the concepts we had developed for the interviews could be used for the survey. Survey results informed us on what program delivery mode and content topics were of high interest. Six cyberseminars were developed-three of which focused on two content areas that were noted of greatest interest: learning how to use PSIs for monitoring trends and understanding how to interpret PSIs. We also used snapshots of VA PSI reports so that participants could directly apply learnings. Although initial interest in the program was high, actual attendance was low. However, post-program survey results indicated that perceptions about the program were positive.Conducting a formative evaluation was a highly important process in program development. The useful information that we collected through the interviews and surveys allowed us to tailor the program to stakeholders' needs and interests. Our experiences, particularly with the formative evaluation process, yielded valuable lessons that can guide others when developing and implementing similar educational programs.
| S-EPMC5813330 | biostudies-literature
Project description:BackgroundRobotic surgery holds particular promise for complex oncologic colorectal resections, as it can overcome many limitations of the laparoscopic approach. However, similar to the situation in laparoscopic surgery, appropriate case selection (simple vs. complex) with respect to the actual robotic expertise of the team may be a critical determinant of outcome. The present study aimed to analyze the clinical outcome after robotic colorectal surgery over time based on the complexity of the surgical procedure.MethodsAll robotic colorectal resections (n = 85) performed at the Department of Surgery, Medical University of Vienna, between the beginning of the program in April 2015 until December 2019 were retrospectively analyzed. To compare surgical outcome over time, the cohort was divided into 2 time periods based on case sequence (period 1: patients 1-43, period 2: patients 44-85). Cases were assigned a complexity level (I-IV) according to the type of resection, severity of disease, sex and body mass index (BMI). Postoperative complications were classified using the Clavien-Dindo classification.ResultsIn total, 47 rectal resections (55.3%), 22 partial colectomies (25.8%), 14 abdomino-perineal resections (16.5%) and 2 proctocolectomies (2.4%) were performed. Of these, 69.4% (n = 59) were oncologic cases. The overall rate of major complications (Clavien Dindo III-V) was 16.5%. Complex cases (complexity levels III and IV) were more often followed by major complications than cases with a low to medium complexity level (I and II; 25.0 vs. 5.4%, p = 0.016). Furthermore, the rate of major complications decreased over time from 25.6% (period 1) to 7.1% (period 2, p = 0.038). Of note, the drop in major complications was associated with a learning effect, which was particularly pronounced in complex cases as well as a reduction of case complexity from 67.5% to 45.2% in the second period (p = 0.039).ConclusionsThe risk of major complications after robotic colorectal surgery increases significantly with escalating case complexity (levels III and IV), particularly during the initial phase of a new colorectal robotic surgery program. Before robotic proficiency has been achieved, it is therefore advisable to limit robotic colorectal resection to cases with complexity levels I and II in order to keep major complication rates at a minimum.
| S-EPMC7923881 | biostudies-literature
Project description:BACKGROUND:Simulation in laparoscopic surgery is nowadays recognized as a valid instrument for learning and training surgeons in different procedures. However, its role as evaluation test and self-assessment tool to verify basic surgical skills is still under discussion. METHODS:Thirty-three residents in obstetrics and gynecology at University of Pisa, Italy were recruited, and they received a simulation program consisting of 5 tasks. They had to perform basic laparoscopic surgery maneuvers as creating pneumoperitoneum, positioning trocars under vision, demonstrating the appropriate use of dominant and non-dominant hand and making single stitch and knot. They were evaluated with a modified OSATs scale. RESULTS:Senior trainees had better score than junior trainees (p value<?0,005) and after different sessions of simulation scores of both groups significantly improved (p?<?0,001), especially for the junior group. All the trainees reported self-assessments that matched with the evaluation of external observers demonstrating the importance of simulation also as auto-evaluation test. CONCLUSIONS:In this study, we demonstrated the role of simulation as powerful tool to evaluate and to self-assess surgical technical skills and to improve own capacities, with the use of a modified OSATs scale adapted to specific exercises.
| S-EPMC6796391 | biostudies-literature
Project description:BACKGROUND: Enhanced Recovery After Surgery (ERAS) programs are associated with reduced hospital morbidity and mortality. The aim of the present study was to evaluate whether the introduction of ERAS care improved the adverse events in colorectal surgery. In a cohort study, mortality, morbidity, and length of stay were compared between ERAS patients and carefully matched historical controls. METHODS: Patients were matched for their type of disease, the type of surgery, P-Possum (Portsmouth-Possum), CR-Possum (Colorectal-Possum) Physiological and Operative Score for Enumeration of Mortality and Morbidity (POSSUM), gender, and American Society of Anesthesiologists (ASA) grade. The primary outcome measures of this study were mortality and morbidity. Secondary outcome measures were fluid intake, length of hospital stay, the number of relaparotomies, and the number of readmissions within 30 days. Data on the ERAS patients were collected prospectively. RESULTS: Sixty-one patients treated according to the ERAS program were compared with 122 patients who received conventional postoperative care. The two groups were comparable with respect to age, ASA grade, P-Possum (Portsmouth-Possum), CR-Possum (Colorectal-Possum) score, type of surgery, stoma formation, type of disease, and gender. Morbidity was lower in the ERAS group compared to the control group (14.8% versus 33.6% respectively; P = <0.01). Patients in the ERAS group received significantly less fluid and spent fewer days in the hospital (median 6 days, range 3-50 vs. median 9 days, range 3-138; P = 0.032). There was no difference between the ERAS and the control group for mortality (0% vs. 1.6%; P = 0.55) and readmission rate (3.3% vs. 1.6%; P = 0.60). CONCLUSION: Enhanced Recovery After Surgery program reduces morbidity and the length of hospital stay for patients undergoing elective colonic or rectal surgery.
| S-EPMC2793377 | biostudies-other