Cagla Eskicioglu

Development of an Enhanced Recovery After Surgery Guideline and Implementation Strategy Based on the Knowledge-to-action Cycle.

Background: Enhanced Recovery After Surgery (ERAS) protocols have been shown to increase recovery, decrease complications, and reduce length of stay. However, they are difficult to implement. Objective: To develop and implement an ERAS clinical practice guideline (CPG) at multiple hospitals. Methods: A tailored strategy based on the Knowledge-to-action (KTA) cycle was used to develop and implement an ERAS CPG at 15 academic hospitals in Canada. This included an initial audit to identify gaps and interviews to assess barriers and enablers to implementation. Implementation included development of an ERAS guideline by a multidisciplinary group, communities of practice led by multidiscipline champions (surgeons, anesthesiologists, and nurses) both provincially and locally, educational tools, and clinical pathways as well as audit and feedback. Results: The initial audit revealed there was greater than 75% compliance in only 2 of 18 CPG recommendations. Main themes identified by stakeholders were that the CPG must be based on best evidence, there must be increased communication and collaboration among perioperative team members, and patient education is essential. ERAS and Pain Management CPGs were developed by a multidisciplinary team and have been adopted at all hospitals. Preliminary data from more than 1000 patients show that the uptake of recommended interventions varies but despite this, mean length of stay has decreased with low readmission rates and adverse events. Conclusions: On the basis of short-term findings, our results suggest that a tailored implementation strategy based on the KTA cycle can be used to successfully implement an ERAS program at multiple sites.

Surgical site infection prevention: a survey to identify the gap between evidence and practice in University of Toronto teaching hospitals

BACKGROUND A gap exists between the best evidence and practice with regards to surgical site infection (SSI) prevention. Awareness of evidence is the first step in knowledge translation. METHODS A web-based survey was distributed to 59 general surgeons and 68 residents at University of Toronto teaching hospitals. Five domains pertaining to SSI prevention with questions addressing knowledge of prevention strategies, efficacy of antibiotics, strategies for changing practice and barriers to implementation of SSI prevention strategies were investigated. RESULTS Seventy-six individuals (60%) responded. More than 90% of respondents stated there was evidence for antibiotic prophylaxis and perioperative normothermia and reported use of these strategies. There was a discrepancy in the perceived evidence for and the self-reported use of perioperative hyperoxia, omission of hair removal and bowel preparation. Eighty-three percent of respondents felt that consulting published guidelines is important in making decisions regarding antibiotics. There was also a discrepancy between what respondents felt were important strategies to ensure timely administration of antibiotics and what strategies were in place. Checklists, standardized orders, protocols and formal surveillance programs were rated most highly by 75%-90% of respondents, but less than 50% stated that these strategies were in place at their institutions. CONCLUSION Broad-reaching initiatives that increase surgeon and trainee awareness and implementation of multifaceted hospital strategies that engage residents and attending surgeons are needed to change practice.

Neighborhood Variation in the Utilization of Laparoscopy for the Treatment of Colon Cancer.

BACKGROUND: The rates of laparoscopic colectomy for colon cancer have steadily increased since its inception. Laparoscopic colectomy currently accounts for a third of colectomy procedures in the United States, but little is known regarding the spatial pattern of the utilization of laparoscopy for colon cancer. OBJECTIVE: This study evaluated the utilization of laparoscopy for colon cancer at the neighborhood level in Ontario. DESIGN: Retrospective analysis of prospectively collected data was performed. SETTING: This study was conducted at all hospitals in the province of Ontario. PATIENTS: This population-based study included all patients aged ≥18 who received an elective colectomy for colon cancer from April 2008 until March 2012 in the province of Ontario. MAIN OUTCOME MEASURES: The primary outcome measure was the neighborhood rates of laparoscopy. RESULTS: Overall, 9,969 patients underwent surgery, and the cluster analysis identified 74 cold-spot neighborhoods, representing 1.8 million people, or 14% of the population. In the multivariate analysis, patients from rural neighborhoods were less than half as likely to receive laparoscopy, OR 0.44 (95% CI, 0.24–0.84; p = 0.012). Additionally, having a minimally invasive surgery fellowship training facility within the same administrative health region as the neighborhood made it more than 23 times as likely to be a hot spot, OR 25.88 (95% CI, 12.15–55.11; p < 0.001). Neighborhood socioeconomic status was not associated with variation in the utilization of laparoscopy. LIMITATIONS: Patient case mix could affect laparoscopy use. CONCLUSION AND RELEVANCE: This study identified an unequal utilization of laparoscopy for colon cancer within Ontario with rural neighborhoods experiencing low rates of laparoscopic colectomy, whereas neighborhoods in the same administrative region as minimally invasive surgery training centers experienced increased utilization. Further study into the causes of this variation in resource allocation is needed to identify ways to improve more efficient spread of knowledge and technical skills advancement.

The effect of simethicone on postoperative ileus in patients undergoing colorectal surgery (SPOT), a randomized controlled trial

BACKGROUND Postoperative ileus is a poorly understood multifactorial outcome following colorectal surgery that presents significant clinical challenges and contributes to increased morbidity, length of stay, and healthcare cost. To date, there are few pharmacological interventions that shorten the duration of postoperative ileus. OBJECTIVE This study is the first to evaluate the efficacy of simethicone in treating postoperative ileus symptoms in patients undergoing colorectal surgery. DESIGN A multicenter, double-blinded, placebo controlled randomized controlled trial. SETTINGS This trial was conducted at two academic tertiary care centres in Ontario, Canada. PARTICIPANTS 118 patients undergoing colorectal surgery. INTERVENTIONS Patients were randomized to receive either a five-day course of oral simethicone (n = 58) or a placebo (n = 60). MAIN OUTCOME MEASURES The primary outcome was time to first passage of flatus. Secondary outcomes included time to first bowel movement, postoperative length of stay, and postoperative pain. Statistical analyses were performed on an intention-to-treat basis. Statistical significance set at p = 0.05. RESULTS The median time to first passage of flatus in simethicone arm was 25.2 h and 26.7 h in controls (P = 0.98). There were no significant differences in the median time to first bowel movement (simethicone = 41.1 h vs. control = 42.9 h, P = 0.91) or median length of hospital stay (simethicone = 4.5 days vs. control = 4.0 days, P = 0.63). CONCLUSIONS This study failed to show a difference in return of gastrointestinal motility in patients receiving simethicone following colorectal surgery. Postoperative ileus remains a significant clinical and economic burden to the healthcare system and further research is needed to identify a reliable and effective method of treatment.

Users' guide to the surgical literature: how to assess an article using surrogate end points.

Summary Phase 3 randomized controlled trials are the widely accepted gold standard through which treatment decisions are made, as they assess the efficacy of a novel treatment against the control on the relevant patient population. The effectiveness of the novel treatment should be derived by measuring patient-important outcomes; however, to accurately assess these outcomes, clinical trials often require extensive patient follow-up and large sample sizes that can incur substantial expense. For this reason, investigators substitute surrogate end points to reduce the sample size and duration of a trial, ultimately reducing cost. The purpose of this article is to help surgeons appraise the surgical literature that use surrogate end points for patient-important outcomes.