PASSOS EVOLUTIVOS NA IMPLEMENTAÇÃO DE UM SERVIÇO DE PRÉ-HABILITAÇÃO: DA CRIAÇÃO DO CONHECIMENTO À PRÁTICA CLÍNICA

The surgical population is becoming increasingly older, with complex medical needs (including deconditioning from sedentary lifestyles)1. This phenomenon represents a challenge for the perioperative team, because it leads to a significant increase in surgery-related morbidity and mortality rates. Poor physical condition and functional status reduces the ability to cope, mentally and physically, with hospitalization and surgery and may compromise postoperative functional recovery, potentially leading to postoperative complications and death2. Multimodal prehabilitation has emerged in recent years as an innovative intervention that focuses on optimizing physiological and psychological resilience to withstand the upcoming stress of surgery. It involves a comprehensive, preventive, short-term, patient-centred programme lasting around four weeks designed to improve the patient’s aerobic capacity, nutritional balance, and psychological status, and to optimize existing multimorbidities3,4. Its ultimate aim is to enhance the patient’s functional capacity in order to minimize postoperative morbidity and accelerate recovery. Several studies assessing prehabilitation have shown it to be an effective and highly advantageous strategy to prevent postoperative complications and reduce hospital length of stay in different populations5-8. However, despite the expected benefit, emerging recommendations from experts, and its cost-saving potential, the implementation of prehabilitation programmes in clinical practice is a major unmet need and an ongoing challenge for most hospitals. A comprehensive assessment of the implementation process is critical to identify the factors that can ensure success, and to generate recommendations for service transferability. In this paper, we report our experience in imple- menting a multimodal prehabilitation programme as a mainstream service at the Hospital Clínic de Barcelona (HCB). The project started with a randomised clinical trial (RCT) carried out between 2013 and 2016, which showed the efficacy and cost-saving potential of prehabilitation. This was followed by the present multimodal programme, which has been adapted over time in accordance with the available resources and the feedback received from clinicians and patients. Over the years, we have identified the factors needed to scale-up the prehabilitation service. For successful, large scale implementation of a prehabilitation service more evidence of the effectiveness of such a programme in real-world scenarios is needed, the service needs to be standardised and modularised, and digital platforms and portable devices are required to improve patient access and empower self-management.A população cirúrgica está cada vez mais envelhecida, com necessidades médicas comple- xas (incluindo o descondicionamento físico resultante do estilo de vida sedentário)1. Este panorama vem colocar um importante desafio à equipa perioperatória, na medida em que se antecipa um aumento significativo das taxas de morbimortalidade pós-operatória. A baixa condição física e capacidade funcional reduz a capacidade de tolerar, mental e fisicamente, a hospitalização e a cirurgia, comprometendo a recuperação funcional pós-operatória e podendo levar ao desenvolvimento de complicações pós-operatórias e morte2. A pré-habilitação multimodal surgiu nos últimos anos como uma intervenção inovadora que visa a otimização da resiliência fisiológica e psicológica para tolerar o impacto da cirurgia. Envolve um programa abrangente, preventivo, de curto prazo e centrado no doente, com duração de cerca de quatro semanas, desenvolvido para melhorar a capacidade aeróbia, o estado nutricional e psicológico do doente, e para otimizar as multimorbidades existentes3,4. O seu objetivo final é aumentar a capacidade funcional do doente, com o intuito de minimizar a morbilidade pós-operatória e de garantir uma recuperação mais rápida. Vários estudos têm vindo a demonstrar que a pré-habilitação é uma estratégia segura e eficaz para prevenir complicações pós-operatórias e reduzir o tempo de hospitalização em diferentes populações cirúrgicas5-8. No entanto, apesar dos benefícios esperados, das recomendações emergentes de vários especialistas e do seu potencial na redução dos custos associados, a pré-habilitação encontra-se ainda sub- utilizada na prática clínica e a sua implementação impõe alguns desafios consideráveis para a maioria dos hospitais. Torna-se assim fundamental realizar uma avaliação abrangente do processo de implementação dos programas, com a finalidade de identificar os fatores essenciais para o seu sucesso e gerar recomendações para que a utilização deste tipo de serviços possa ser generalizada. Neste artigo, descrevemos a nossa experiência na implementação de um programa de pré-habilitação multimodal como um serviço regular no Hospital Clínic de Barcelona (HCB). O projeto começou no contexto de um ensaio clínico randomizado (RCT) realizado entre 2013 e 2016, que mostrou a eficácia e o potencial na redução de custos da pré-habilitação. Seguiu-se o desenvolvimento do presente programa multimodal, que foi adaptado ao longo do tempo de acordo com os recursos disponíveis e o feedback fornecido pelos médicos e doentes. Ao longo dos anos, identificamos os fatores necessários para ampliar (scale-up) o serviço de pré-habilitação. Entendemos que para uma implementação bem-sucedida e alargada dos programas de pré-habilitação, são necessárias mais evidências sobre a sua eficácia em cenários mais próximos do mundo real, o programa deve ser padronizado e modularizado, e as plataformas digitais e dispositivos portáteis deverão ser exploradas para melhorar o acesso ao programa e garantir o empoderamento do doente na gestão do seu próprio processo de tratamento

Gastrotomy closure with a new tissue anchoring device: A porcine survival study

AIM: To evaluate the feasibility, reproducibility and efficacy of a new tissue anchoring device in a porcine survival model

Perioperative Nursing as the Guiding Thread of a Prehabilitation Program

Multimodal preoperative prehabilitation has been shown to be effective in improving the functional capacity of cancer patients, reducing postoperative complications and the length of hospital and ICU stay after surgery. The availability of prehabilitation units that gather all the professionals involved in patient care facilitates the development of integrated and patient-centered multimodal prehabilitation programs, as well as patient adherence. This article describes the process of creating a prehabilitation unit in our center and the role of perioperative nursing. Initially, the project was launched with the performance of a research study on prehabilitation for gastrointestinal cancer surgery. The results of this study encouraged us to continue the implementation of the unit. Progressively, multimodal prehabilitation programs focusing on each type of patient and surgery were developed. Currently, our prehabilitation unit is a care unit that has its own gym, which allows supervised training of cancer patients prior to surgery. Likewise, the evolution of perioperative nursing in the unit is described: from collaboration and assistance in the integral evaluation of the patient at the beginning to current work as a case manager; a task that has proven extremely important for the comprehensive and continuous care of the patient

Protocol for regional implementation of collaborative self-management services to promote physical activity

Abstract Background Chronic diseases are generating a major health and societal burden worldwide. Healthy lifestyles, including physical activity (PA), have proven efficacy in the prevention and treatment of many chronic conditions. But, so far, national PA surveillance systems, as well as strategies for promotion of PA, have shown low impact. We hypothesize that personalized modular PA services, aligned with healthcare, addressing the needs of a broad spectrum of individual profiles may show cost-effectiveness and sustainability. Methods The current manuscript describes the protocol for regional implementation of collaborative self-management services to promote PA in Catalonia (7.5 M habitants) during the period 2017–2019. The protocols of three implementation studies encompassing a broad spectrum of individual needs are reported. They have a quasi-experimental design. That is, a non-randomized intervention group is compared to a control group (usual care) using propensity score methods wherein age, gender and population-based health risk assessment are main matching variables. The principal innovations of the PA program are: i) Implementation of well-structured modular interventions promoting PA; ii) Information and communication technologies (ICT) to facilitate patient accessibility, support collaborative management of individual care plans and reduce costs; and iii) Assessment strategies based on the Triple Aim approach during and beyond the program deployment. Discussion The manuscript reports a precise roadmap for large scale deployment of community-based ICT-supported integrated care services to promote healthy lifestyles with high potential for comparability and transferability to other sites. Trial registration This study protocol has been registered at ClinicalTrials.org (NCT02976064). Registered November 24th, 2016