Postoperative Length of Stay Following Enhanced Recovery After Surgery Protocol Implementation for Scheduled Cesarean Deliveries

Background Cesarean delivery is the most common major surgery worldwide. 1 In 2018, 1.2 million cesarean deliveries occurred in the United States, accounting for nearly 32% of all deliveries.2 Research has shown ERAS benefits include decreased length of stay, improved pain control, and improved patient satisfaction.2,3 Despite its use in numerous surgical specialties, ERAS implementation within obstetrics has been slow.2 The ERAS Society released a three-part guideline specific to cesarean deliveries in 2018 and 2019,4,5,6 yet few studies have assessed the impact of ERAS on cesarean postoperative outcomes.2 An improved perioperative course would be particularly beneficial for mothers undergoing cesarean delivery as they require a quick recovery in order to care for their newborn. The purpose of this retrospective, observational study was to determine how the recovery process following cesarean delivery may be improved by standardizing the perioperative care pathway, with the primary outcome of interest being postoperative length of stay. Methods • Design: Retrospective, observational cohort study at Providence Sacred Heart Medical Center (PSHMC) • This project was approved by the PSHMC Clinical Innovation and Research Council and deemed exempt from human subjects research by Providence Health Care Institutional Review Board. • Human subjects protection: Patient demographic and surgical data from electronic medical records were extracted, deidentified, and encrypted using a REDCap data collection tool • Inclusion Criteria: parturients 18 years of age or older who underwent scheduled cesarean delivery between June 1, 2017 to May 31, 2018 for pre-intervention group and June 1, 2019 to February 29, 2019 for postintervention group. • Exclusion Criteria: urgent or emergent cesarean deliveries, cesarean deliveries occurring in the run-in time period of June 1, 2018 through May 31, 2019, and mothers under the age of 18 years. • Outcome measurement: postoperative length of stay, defined as time of end of surgery to time of discharge • Exposure measurement: defined as post-ERAS protocol implementation following April 1, 2019. • Other variables considered included: age, weeks gestation, BMI, ASA, primary vs repeat cesarean, weeks gestation, and multiparty births. • Statistical analysis: a-prior power analysis, univariate analysis, bivariate analysis, and multivariate analysis Discussion In this retrospective observational study, this facility’s postoperative LOS following cesarean delivery was found to be low, with a median of 52.4 hours. Following ERAS implementation, the median postoperative LOS decreased to 51.2 hours but was not found to be statistically significant in an adjusted model. Cesarean deliveries comprised nearly 29% of all births at this facility, 58.5% of which were scheduled or elective cesarean deliveries. Characteristics of parturients were very similar among the pre- and post-ERAS patient groups; most patients were classified as ASA 2 and a mean age of 31 years. Repeated multivariate analysis using run-in periods of varying lengths and controlling for time consistently showed no significant difference in postoperative LOS between the pre-ERAS and post-ERAS groups. With the postoperative LOS at PSHMC being low prior to protocol implementation, it is likely that other facilities with longer postoperative LOS may see a greater benefit of ERAS implementation. Additional work is still required to further the understanding of ERAS for cesarean deliveries and its impact on postoperative recovery. Future studies of interest includes determining 30-day readmission rates and emergency room visits following discharge. In order to determine the true effect ERAS may have on postoperative length of stay and the recovery process following cesarean delivery, large prospective control trials are needed.https://digitalcommons.psjhealth.org/other_pubs/1110/thumbnail.jp

Screening and Addressing Fatigue Symptoms in Patients with Orthopedic Problems Using the PROMIS Fatigue Scale

In the primary care setting, fatigue is a common complaint, outnumbered only by cough. 41.9% of patients in an outpatient physical therapy setting reported unacceptable fatigue. Fatigue scores are weakly correlated to physical function and pain interference (using Patient Reported Outcome Measurement Information Systems [PROMIS]). Therefore, detecting fatigue and addressing it directly is necessary

Screening for congenital cytomegalovirus in North Carolina

The authors are full-time graduate students in UNC’s Doctor of Audiology (AuD) program. They are conducting this investigation in conjunction with their participation as audiology trainees in the North Carolina LEND Program (Leadership Education in Neurodevelopmental and Related Disabilities). The findings reported here are part of an ongoing investigation and represent current work in progress

Lettuce Learn: Student Reflections on Building and Sustaining a Community Donation Garden

This article emerged from conversations that we and fellow graduate students have had in building a community donation garden. We created the garden with a vision of enacting food justice in our community, but over the past four years we have experienced complexities with our vision. In this article, we share the complexities with which we have wrestled, how we have encouraged thoughtful dialogue among fellow scholars about these shortcomings and the intricate workings of the agrifood system, and the lessons we have learned through these experiences as early-career scholar-activists. This article represents our collective and individual voices as graduate student garden leaders reflecting on: (a) the ways in which we strived to integrate social justice into our local emergency food system; (b) the paradox of industrial commodity-oriented production agriculture designed to “feed the world,” which neglects the production of healthy food that is locally produced and locally accessible; and (c) the holistic learning approach of combining academic studies with praxis. As students cycle through the graduate program, the garden and partnerships continue, and students take the lessons that they learn through this engagement into their careers and other activities

Towards Equity in Health: Researchers Take Stock.

For the 2016 end-of-the-year editorial, the PLOS Medicine editors asked 7 global health leaders to discuss developments relevant to the equitable provision of medical care to all populations. The result is a collection of expert views on ethical trial design, research during outbreaks, high-burden infectious diseases, diversity in research and protection of migrants

Progress and inequities in maternal mortality in Afghanistan (RAMOS-II): a retrospective observational study

Background The risk of maternal death in Afghanistan is among the highest in the world; however, the risks within the country are poorly understood. Subnational maternal mortality estimates are needed along with a broader understanding of determinants to guide future maternal health programmes. Here we aimed to study maternal mortality risk and causes, care-seeking patterns, and costs within the country. Methods We did a household survey (RAMOS-II) in the urban area of Kabul city and the rural area of Ragh, Badakshan. Questionnaires were administered to senior female household members and data were collected by a team of female interviewers with secondary school education. Information was collected about all deaths, livebirths, stillbirths, health-care access and costs, household income, and assets. Births were documented using a pregnancy history. We investigated all deaths in women of reproductive age (12–49 years) since January, 2008, using verbal autopsy. Community members; service providers; and district, provincial, and national officials in each district were interviewed to elicit perceptions of changes in maternal mortality risk and health service provision, along with programme and policy documentation of maternal care coverage. Findings Data were collected between March 2, 2011, and Oct 16, 2011, from 130 688 participants: 63 329 in Kabul and 67 359 in Ragh. The maternal mortality ratio in Ragh was quadruple that in Kabul (713 per 100 000 livebirths, 95% CI 553–873 in Ragh vs 166, 63–270 in Kabul). We recorded similar patterns for all other maternal death indicators, including the maternal mortality rate (1·7 per 1000 women of reproductive age, 95% CI 1·3–2·1 in Ragh vs 0·2, 0·1–0·3 in Kabul). Infant mortality also differed significantly between the two areas (115·5 per 1000 livebirths, 95% CI 108·6–122·3 in Ragh vs 24·8, 20·5–29·0 in Kabul). In Kabul, 5594 (82%) of 6789 women reported a skilled attendant during recent deliveries compared with 381 (3%) of 11 366 women in Ragh. An estimated 85% of women in Kabul and 47% in Ragh incurred delivery costs (mean US$66·20, IQR$61·30 in Kabul and $9·89,$11·87 in Ragh). Maternal complications were the third leading cause of death in women of reproductive age in Kabul, and the leading cause in Ragh, and were mainly due to hypertensive diseases of pregnancy. The maternal mortality rate decreased significantly between 2002 and 2011 in both Kabul (by 71%) and Ragh (by 84%), plus all other maternal mortality indicators in Ragh. Interpretation Remarkable maternal and other mortality reductions have occurred in Afghanistan, but the disparity between urban and rural sites is alarming, with all maternal mortality indicators significantly higher in Ragh than in Kabul. Customised service delivery is needed to ensure parity for different geographic and security settings

Species Diversity Associated with Foundation Species in Temperate and Tropical Forests

Foundation species define and structure ecological communities but are difficult to identify before they are declining. Yet, their defining role in ecosystems suggests they should be a high priority for protection and management while they are still common and abundant. We used comparative analyses of six large forest dynamics plots spanning a temperate-to-tropical gradient in the Western Hemisphere to identify statistical “fingerprints” of potential foundation species based on their size-frequency and abundance-diameter distributions, and their spatial association with five measures of diversity of associated woody plant species. Potential foundation species are outliers from the common “reverse-J” size-frequency distribution, and have negative effects on alpha diversity and positive effects on beta diversity at most spatial lags and directions. Potential foundation species also are more likely in temperate forests, but foundational species groups may occur in tropical forests. As foundation species (or species groups) decline, associated landscape-scale (beta) diversity is likely to decline along with them. Preservation of this component of biodiversity may be the most important consequence of protecting foundation species while they are still common

Oceanography of Cowichan Bay: A background view for early marine survival of Chinook and Coho salmon

Early Marine Survival (EMS) of Chinook and Coho salmon in the Salish Sea has plummeted over the past decades, and both bottom-up and top-down mechanisms for decline have been proposed. As a background for an ecosystem-based assessment of EMS, a pilot study on the basic oceanography of a small sub-component of the system was launched in spring and early summer, 2013. A repeat sampling grid covering Cowichan Bay and immediately connected waters was established, and then sampled on weekly intervals for temperature, salinity, chlorophyll fluorescence, nutrients and zooplankton. Oceanographic studies were carried out concurrently with fisheries assessments. A longer section was carried out at monthly intervals, with the purpose of connecting Cowichan Bay to the Strait of Georgia. This talk will present findings from this study, identify key shortcoming and suggest an approach to expand the pilot study to the scale of the Salish Sea

Technology use, adoption and behaviour in older adults: results from the iStoppFalls Project

Technology use is a common constituent of modern life. However, little is known about older adults’ use of technology. This article presents a subset of data collected via the technology deployed in the iStoppFalls randomized control trial. The primary focus lies on questions about digital device/Internet use, ownership, length, and frequency as well as social networking. Data was collected from participants aged 65 years or older. Seventy-eight participants completed a specifically developed technology survey as part of the baseline assessment. Results showed that the majority of subjects owned a computer with men being its main user. Participants used technological devices on a daily basis for more than 1 year. The main reason for using technology was e-mail communication, search engines, text processing, and online shopping. Only a few participants used social network applications, with Google+ and Facebook being the most popular ones. Future work should consider an in-depth qualitative approach to further increase understanding of technology use in older adults