8 research outputs found
Reduction in omission events after implementing a Rapid Response System: a mortality review in a department of gastrointestinal surgery
Background
Hospitals worldwide have implemented Rapid Response Systems (RRS) to facilitate early recognition and prompt response by trained personnel to deteriorating patients. A key concept of this system is that it should prevent âevents of omissionâ, including failure to monitor patientsâ vital signs, delayed detection, and treatment of deterioration and delayed transfer to an intensive care unit. Time matters when a patient deteriorates, and several in-hospital challenges may prevent the RRS from functioning adequately. Therefore, we must understand and address barriers for timely and adequate responses in cases of patient deterioration. Thus, this study aimed to investigate whether implementing (2012) and developing (2016) an RRS was associated with an overall temporal improvement and to identify needs for further improvement by studying; patient monitoring, omission event occurrences, documentation of limitation of medical treatment, unexpected death, and in-hospital- and 30-day mortality rates.
Methods
We performed an interprofessional mortality review to study the trajectory of the last hospital stay of patients dying in the study wards in three time periods (P1, P2, P3) from 2010 to 2019. We used non-parametric tests to test for differences between the periods. We also studied overall temporal trends in in-hospital- and 30-day mortality rates.
Results
Fewer patients experienced omission events (P1: 40%, P2: 20%, P3: 11%, Pâ=â0.01). The number of documented complete vital sign sets, median (Q1,Q3) P1: 0 (0,0), P2: 2 (1,2), P3: 4 (3,5), Pâ=â0.01) and intensive care consultations in the wards ( P1: 12%, P2: 30%, P3: 33%, Pâ=â0.007) increased. Limitations of medical treatment were documented earlier (median days from admission were P1: 8, P2: 8, P3: 3, Pâ=â0.01). In-hospital and 30-day mortality rates decreased during this decade (rate ratios 0.95 (95% CI: 0.92â0.98) and 0.97 (95% CI: 0.95â0.99)).
Conclusion
The RRS implementation and development during the last decade was associated with reduced omission events, earlier documentation of limitation of medical treatments, and a temporal reduction in the in-hospital- and 30-day mortality rates in the study wards. The mortality review is a suitable method to evaluate an RRS and provide a foundation for further improvement.publishedVersio
Influence of microsatellite instability and KRAS and BRAF mutations on lymph node harvest in stage IâIII colon cancers
Lymph node (LN) harvest is influenced by several factors, including tumor genetics. Microsatellite instability (MSI) is associated with improved node harvest, but the association to other genetic factors is largely unknown. Research methods included a prospective series of stage IâIII colon cancer patients undergoing ex vivo sentinel-node sampling. The presence of MSI, KRAS mutations in codons 12 and 13, and BRAF V600E mutations was analyzed. Uni- and multivariate regression models for node sampling were adjusted for clinical, pathological and molecular features. Of 204 patients, 67% had an adequate harvest (âĽ12 nodes). Adequate harvest was highest in patients whose tumors exhibited MSI (79%; odds ratio [OR] 2.5, 95% confidence interval [CI] 1.2â4.9; P = 0.007) or were located in the proximal colon (73%; 2.8, 1.5â5.3; P = 0.002). In multiple linear regression, MSI was a significant predictor of the total LN count (P = 0.02). Total node count was highest for cancers with MSI and no KRAS/BRAF mutations. The independent association between MSI and a high LN count persisted for stage I and II cancers (P = 0.04). Tumor location in the proximal colon was the only significant predictor of an adequate LN harvest (adjusted OR 2.4, 95% CI 1.2â4.9; P = 0.01). An increase in the total number of nodes harvested was not associated with an increase in nodal metastasis. In conclusion, number of nodes harvested is highest for cancers of the proximal colon and with MSI. The nodal harvest associated with MSI is influenced by BRAF and KRAS genotypes, even for cancers of proximal location. Mechanisms behind the molecular diversity and node yield should be further explored.publishedVersio
Long-term follow-up and survivorship after completing systematic surveillance in stage IâIII colorectal cancer: who is still at risk?
This article is published with open access at Springerlink.com. This article is distributed under the terms of the
Creative Commons Attribution 4.0 International License
(http://creativecommons.org/licen
ses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the
source, provide a link to the Creative Commons license, and
indicate if changes were made.Purpose
In patients with a high life expectancy at the time of
surgery for colorectal cancer (CRC), the long-term outcome
may be influenced by factors other than their cancer. We
aimed to investigate the long-term outcome and cause of death
beyond a 5-year surveillance programme.
Methods
We evaluated the overall survival (OS) and cancer-
specific survival (CSS) of a population-based cohort of stage
I â III CRC patients <75 years old who completed a systematic
surveillance programme.
Results
In total, 161 patients <75 years old, 111 (69 %) of
whom were node negative (pN0), were included. The median
follow-up time was 12.1 years. The OS was 54 % at 15 years
and differed significantly between the pN0 and pN+ patients
(65 vs. 30 %;
P
<0.001); CSS (72 %) also differed between the
pN0 and pN+ patients (85 vs. 44 %;
P
<0.001). For the 5-year
survivors (n=119), 14 (12 %) died of CRC during additional
long-term follow-up (7 each for pN0 and pN+), and 6 patients
(5 %; all pN0) died of other cancers. Patients aged <65 years
exhibited better long-term survival (81 %), but most of the
deaths were due to CRC (10/12 deaths). Only two of the 14 cancer-related deaths involved microsatellite instable (MSI)
CRC. Females exhibited better OS and CSS beyond 5 years
of surveillance.
Conclusions
The long-term survival beyond 5-year survivor-
ship for stage I â III CRC is very good. Nonetheless, cancer-
related deaths are encountered in one-third of patients and
occur most frequently in patients who are <65 years old at
disease onset â pointing to a still persistent risk several years
after surger
Development and clinical implementation of a structured, simulation-based training programme in laparoscopic appendectomy: Description, validation and evaluation
Background: Laparoscopic appendectomy is a common procedure in general surgery but is likely underused in structured and real-life teaching. This study describes the development, validation and evaluation of implementing a structured training programme for laparoscopic appendectomy.
Study design: A structured curriculum and simulation-based programme for trainees and trainers was developed. All general surgery trainees and trainers were involved in laparoscopic appendectomies. All trainees and trainers underwent the structured preprocedure training programme before real-life surgery evaluation. A standardised form evaluated eight technical steps (skills) of the procedure as well as an overall assessment, and nine elements of communication (feedback), and was used for bilateral evaluation by each trainee and trainer. A consecutive, observational cohort over a 12-month period was used to gauge real-life implementation.
Results: During 277 eligible real-life appendectomies, structured evaluation was performed in 173 (62%) laparoscopic appendectomies, for which 165 forms were completed by 19 trainees. Construct validity was found satisfactory. Inter-rater reliability demonstrated good correlation between trainee and trainer. The traineesâ and trainersâ stepwise and overall assessments of technical skills had an overall good reliability (intraclass correlation coefficient of 0.88). The vast majority (92.2%) of the trainees either agreed or strongly agreed that the training met their expectations.
Conclusion: Structured training for general surgery residents can be implemented for laparoscopic appendectomy. Skills assessment by trainees and trainers indicated reliable self-assessment. Overall, the trainees were satisfied with the training, including the feedback from the trainers
Anastomotic leak after surgery for colon cancer and effect on longâterm survival
Aim
An anastomotic leak after surgery for colon cancer is a recognized complication but how it may adversely affect longâterm survival is less clear because data are scarce. The aim of the study was to investigate the longâterm impact of Grade C anastomotic leak in a large, populationâbased cohort.
Method
Data on patients undergoing resection for Stage IâIII colon cancer between 2008 and 2012 were collected from the Swedish, Norwegian and Danish Colorectal Cancer Registries. Overall relative survival and conditional 5âyear relative survival, under the condition of surviving 1 year, were calculated for all patients and stratified by stage of disease.
Results
A total of 22 985 patients were analysed. Anastomotic leak occurred in 849 patients (3.7%). Fiveâyear relative survival in patients with anastomotic leak was 64.7% compared with 87.0% for patients with no leak (P < 0.001). Fiveâyear relative survival among the patients who survived the first year was 88.6% vs 81.3% (P = 0.003). Stratification by cancer stage showed that anastomotic leak was significantly associated with decreased relative survival in patients with Stage III disease (P = 0.001), but not in patients with Stage I or II (P = 0.950 and 0.247, respectively).
Conclusion
Anastomotic leak after surgery for Stage III colon cancer was associated with significantly decreased longâterm relative survival.publishedVersio
Influence of microsatellite instability and KRAS and BRAF mutations on lymph node harvest in stage IâIII colon cancers
Lymph node (LN) harvest is influenced by several factors, including tumor genetics. Microsatellite instability (MSI) is associated with improved node harvest, but the association to other genetic factors is largely unknown. Research methods included a prospective series of stage IâIII colon cancer patients undergoing ex vivo sentinel-node sampling. The presence of MSI, KRAS mutations in codons 12 and 13, and BRAF V600E mutations was analyzed. Uni- and multivariate regression models for node sampling were adjusted for clinical, pathological and molecular features. Of 204 patients, 67% had an adequate harvest (âĽ12 nodes). Adequate harvest was highest in patients whose tumors exhibited MSI (79%; odds ratio [OR] 2.5, 95% confidence interval [CI] 1.2â4.9; P = 0.007) or were located in the proximal colon (73%; 2.8, 1.5â5.3; P = 0.002). In multiple linear regression, MSI was a significant predictor of the total LN count (P = 0.02). Total node count was highest for cancers with MSI and no KRAS/BRAF mutations. The independent association between MSI and a high LN count persisted for stage I and II cancers (P = 0.04). Tumor location in the proximal colon was the only significant predictor of an adequate LN harvest (adjusted OR 2.4, 95% CI 1.2â4.9; P = 0.01). An increase in the total number of nodes harvested was not associated with an increase in nodal metastasis. In conclusion, number of nodes harvested is highest for cancers of the proximal colon and with MSI. The nodal harvest associated with MSI is influenced by BRAF and KRAS genotypes, even for cancers of proximal location. Mechanisms behind the molecular diversity and node yield should be further explored
Anastomotic leak after surgery for colon cancer and effect on longâterm survival
Aim
An anastomotic leak after surgery for colon cancer is a recognized complication but how it may adversely affect longâterm survival is less clear because data are scarce. The aim of the study was to investigate the longâterm impact of Grade C anastomotic leak in a large, populationâbased cohort.
Method
Data on patients undergoing resection for Stage IâIII colon cancer between 2008 and 2012 were collected from the Swedish, Norwegian and Danish Colorectal Cancer Registries. Overall relative survival and conditional 5âyear relative survival, under the condition of surviving 1 year, were calculated for all patients and stratified by stage of disease.
Results
A total of 22 985 patients were analysed. Anastomotic leak occurred in 849 patients (3.7%). Fiveâyear relative survival in patients with anastomotic leak was 64.7% compared with 87.0% for patients with no leak (P < 0.001). Fiveâyear relative survival among the patients who survived the first year was 88.6% vs 81.3% (P = 0.003). Stratification by cancer stage showed that anastomotic leak was significantly associated with decreased relative survival in patients with Stage III disease (P = 0.001), but not in patients with Stage I or II (P = 0.950 and 0.247, respectively).
Conclusion
Anastomotic leak after surgery for Stage III colon cancer was associated with significantly decreased longâterm relative survival