Barriers and Facilitators Influencing Compliance with Enhanced Recovery After Surgery Protocol: A Qualitative Study

Standardization in many industries has proven to lead to improved productivity and efficiency, however, standard practice in healthcare has proven difficult due to patient and physician variation. Evidence-based practices provide an opportunity to create more standardization. Enhanced Recovery After Surgery (ERAS) programs are attempting to standardize the surgical pathways of patients by implementing standard evidence-based steps, beginning in the surgeons office and continuing through a patients discharge (Ljungqvist, Scott, & Fearon, 2017). Implementing ERAS to standardize the surgical care of patients has shown to improve patient outcomes, reduce length of stay and reduce readmissions, however, there is a lack of studies detailing the implementation process to be successful. A literature review by Stone et al. (2018) found only 53 papers on ERAS that discussed implementation. The review organized barriers and facilitators using the Consolidated Framework for Implementation Research (CFIR). The CFIR is a framework organized with five domains and constructs within each domain that could affect implementation (Damschroder et al., 2009). The purpose of this research is to detail implementation and identify barriers and facilitators that impact compliance with an ERAS protocol for colorectal surgery. This research begins by detailing seven steps taken prior to implementing ERAS. Compliance with 19 of the ERAS components will be tracked to measure improvements over the implementation timeline. The first objective is to measure if compliance with the process measures increased from the pre-implementation to post-implementation. The second objective is to measure if implementation leads to a decrease in length of stay. The third objective is to identify barriers and facilitators with implementation by conducting semi structured focus groups with nursing, surgeons, anesthesia and leadership. The outcome of these findings will be an implementation framework. The results of this study showed a significant increase in compliance with 10 of the process measures as well as a significant decrease in length of stay, as measured by a t-test. The semistructured focus groups analyzed by the CFIR indicated that inner setting and implementation plan were the most discussed. Key facilitators to implementation were gaining leadership support and engagement, establishing a multidisciplinary team that meets regularly, and showing process measure and outcome data as feedback. These items are essential to implementation of an ERAS protocol

Management of intracranial hypertension following traumatic brain injury: a best clinical practice adoption proposal for intracranial pressure monitoring and decompressive craniectomy. Joint statements by the Traumatic Brain Injury Section of the Italian Society of Neurosurgery (SINch) and the Neuroanesthesia and Neurocritical Care Study Group of the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI)

No robust evidence is provided by literature regarding the management of intracranial hypertension following severe traumatic brain injury (TBI). This is mostly due to the lack of prospective randomized controlled trials (RCTs), the presence of studies containing extreme heterogeneously collected populations and controversial considerations about chosen outcome. A scientific society should provide guidelines for care management and scientific support for those areas for which evidence-based medicine has not been identified. However, RCTs in severe TBI have failed to establish intervention effectiveness, arising the need to make greater use of tools such as Consensus Conferences between experts, which have the advantage of providing recommendations based on experience, on the analysis of updated literature data and on the direct comparison of different logistic realities. The Italian scientific societies should provide guidelines following the national laws ruling the best medical practice. However, many limitations do not allow the collection of data supporting high levels of evidence for intracranial pressure (ICP) monitoring and decompressive craniectomy (DC) in patients with severe TBI. This intersociety document proposes best practice guidelines for this subsetting of patients to be adopted on a national Italian level, along with joint statements from "TBI Section" of the Italian Society of Neurosurgery (SINch) endorsed by the Neuroanesthesia and Neurocritical Care Study Group of the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI). Presented here is a recap of recommendations on management of ICP and DC supported a high level of available evidence and rate of agreement expressed by the assemblies during the more recent consensus conferences, where members of both groups have had a role of active participants and supporters. The listed recommendations have been sent to a panel of experts consisting of the 107 members of the "TBI Section" of the SINch and the 111 members of the Neuroanesthesia and Neurocritical Care Study Group of the SIAARTI. The aim of the survey was to test a preliminary evaluation of the grade of predictable future adherence of the recommendations following this intersociety proposal. The following recommendations are suggested as representing best clinical practice, nevertheless, adoption of local multidisciplinary protocols regarding thresholds of ICP values, drug therapies, hemostasis management and perioperative care of decompressed patients is strongly recommended to improve treatment efficiency, to increase the quality of data collection and to provide more powerful evidence with future studies. Thus, for this future perspective a rapid overview of the role of the multimodal neuromonitoring in the optimal severe TBI management is also provided in this document. It is reasonable to assume that the recommendations reported in this paper will in future be updated by new observations arising from future trials. They are not binding, and this document should be offered as a guidance for clinical practice through an intersociety agreement, taking in consideration the low level of evidence

A Preoperative Hand Hygiene Campaign: No One Left BeHand.

Abstract Problem: Surgical site infections (SSIs) account for 20% of all hospital-acquired infections (HAIs). Performance of consistent, accurate hand hygiene practices by healthcare workers is the most effective means of preventing infection, yet the average compliance rates remain low. The preoperative (PREOP) unit carries tremendous responsibility for decreasing each patient\u27s risk for SSI by adequately following the World Health Organization (WHO) guidelines for hand hygiene. The PREOP remains at a low average hand hygiene compliance rate of 69%, with decreased consistency, frequency, and knowledge deficit of hygiene practices. The aim of the quality improvement (QI) hand hygiene campaign is to increase compliance among the PREOP registered nurses (RNs) and patient care technicians (PCTs) to promote infection control and decrease the risk of SSIs. Context: The PREOP serves multiple specialties with an average of 45 cases a day. The PREOP unit can significantly contribute to the reduction of SSIs with strict adherence to hand hygiene protocols. The RNs and PCTs provide direct patient care measures to several disciplines, including orthopedic, podiatry, head and neck, general surgery, gynecological, and urology surgery patients. A fast-paced work environment, lack of time, and low morale were listed as barriers to hand hygiene adherence. An SSI, on average, costs $30,000 for just one case. Diminishing the knowledge deficit by using WHO guidelines and improving overall cleanliness are the most influential factors for maintaining collaboration to support the efforts of reducing a patient\u27s risk of SSI. Interventions: The QI project involves the implementation of a multidisciplinary PREOP hand hygiene campaign using a multimodal approach over a single intervention strategy. The interventions include (a) hands-on training and education; (b) campaign slogan, signs, and songs; (c) daily direct observation audits and huddles to discuss barriers; (d) monthly secret observer audits; (e) RN and PCT scripting; (f) increasing access to supplies; (g) PREOP RN process map; and (h) patient prompting tools. Measures: The outcome measures are the results of the daily direct observation audits by the champions and mangers, and the monthly secret observer audits by the quality department. The hand hygiene knowledge quizzes for staff and the patient participation tool survey are the two process measures. The balancing measure is the monthly tracking of the average PREOP RN patient preparation times using the electronic health documentation system. Results: The PREOP hand hygiene campaign has reached a 13% increase in RN and PCT hand hygiene compliance within four months. Combined direct observation audits by champions and secret observations by the quality department revealed an 82% average compliance rate. Quiz scores have improved from 76% to 85%. PREOP RN preparation times have remained unhindered at the current time of 34 minutes. The project leader anticipates the patient prompting tools to increase confidence in patients\u27 abilities to contribute to infection prevention. Conclusions: Performance improvement projects using quality improvement tools, along with WHO standards, in combination with intervention strategies with patient participation, gained beneficial hand hygiene campaign outcomes. Linking theories into actions and improving team motivation and dedication helps push through the barriers. Achieving insights and growing awareness strengthens the efforts towards sustainability. Continuous monitoring and quarterly champion meetings, along with annual competency expectations, will ensure long-term project effectiveness. This hand hygiene campaign can be quickly adapted and spread from unit to unit to uphold a dedication to the pledge of reducing HAIs

Alternative site for the placement of totally implantable vascular access device (TIVAD). A case report of two successful TIVAD implantations in the thigh after femoral vein catheterization

Background: Totally implantable venous access devices (TIVADs) have improved the quality of life for seriously ill and cancer patients. These devices represent a convenient option when long-term venous access is indicated. The Subclavian and Internal Jugular Veins are the vessels of choice for catheterization [1]. However, if it is not possible to catheterize them, an alternative vein should be sought for [2]. Femoral vein can be used in such cases [3].Clinical problem: In 2 cases, it was not possible to catheterise any vein ending in the Superior Vena Cava and implant a TIVAD in the chest wall, although this was very necessary for them. Femoral vein was chosen despite higher risk of complications.Case 1: A 47 years old female with a metastatic breast cancer and infected ulcerations of the anterior chest wall. Veins in both arms were occluded. Her implanted TIVAD could not be used. Case 2: A 44 years old female who had a newly diagnosed lung cancer and Superior Vena Cava Syndrome. She was treated by a high-dose anti-coagulants.Surgical intervention: The catheter was inserted in the left femoral vein using ultrasound-guided percutaneous technique. After making a small incision, PORT-A-CATH® II POWER P.A.C. single-lumen standard port was implanted subcutaneously in the anterior surface of the left thigh. Verification of the catheter’s tip intra-operatively was difficult in Case 1 due to fluoroscopy problems. Prior consideration of the required instruments prevented the occurrence of a similar problem in Case 2. We performed these operations in the University Hospital of Norrland in Sweden in 2013.Follow-up: Apart from later adjustment of the catheter positioning in Case 1, we did not get any complications or problems with the use of the TIVAD. Frequent flushing of the device was recommended. Patients’ and staff’s satisfaction were good. Conclusion: Placement of TIVAD in the thigh is to be considered when the veins of the neck and upper arm are not accessible or the area on the chest wall is not appropriate for implanting the device. Experience improves with more cases.References: 1- Di Carlo I, Toro A. Choice of venous sites. Surgical Implant/technique. Springer-Verlag, Italia, 2011;43-54. 2- Toro A, Mannino M, Cappello G et al. Totally implanted venous access devices implanted in saphenous vein. Relation between the reservoir site and comfort/discomfort of the patient. Ann Vasc Surg 2012;26(8):1127.e9-1127.e13. 3- Chen SY, Lin CH, Chang HM, Hsu HM, Yu JC. A safe and effective method to implant a totally implantable access port in patients with synchronous bilateral mastectomies: modified femoral vein approach. J Surg Oncol 2008;98(3):197-199

Opioid-Sparing Anesthesia in Cardiac Surgery Requiring Cardiopulmonary Bypass

Background: Traditional anesthesia for cardiac surgery involved high opioid use associated with adverse events and poor outcomes which led to the adoption of multi-modal analgesic approaches. Although improvements in the overall opioid consumption are seen with multi- modal analgesic approaches, recent studies in opioid-sparing anesthesia and regional anesthesia can further reduce the operative use of opioids in cardiac surgery to improve patient outcomes. Methods: A comprehensive study search was conducted using CINAHL and MEDLINE (ProQuest) to identify research studies from the past three years that have focused on opioid- sparing anesthesia or opioid-free techniques in patients undergoing cardiac surgery with cardiopulmonary bypass. Results: Six research studies were identified as relevant for review. The studies included in this literature review address opioid-sparing anesthesia in cardiac surgery through different techniques, investigate the feasibility for implementation, the role of regional anesthesia, and individual intraoperative pharmacological adjuvants in cardiac surgery requiring cardiopulmonary bypass (CPB). Keywords: Opioid-sparing anesthesia, cardiac surgery, cardiac anesthesia, cardiopulmonary bypass, regional anesthesia, opioid crisis, dexmedetomidine