Marg McKenzie

A qualitative study to understand the barriers and enablers in implementing an enhanced recovery after surgery program.

OBJECTIVE Explore the barriers and enablers to adoption of an Enhanced Recovery after Surgery (ERAS) program by the multidisciplinary perioperative team responsible for the care of elective colorectal surgical patients. BACKGROUND ERAS programs include perioperative interventions that when used together have led to decreased length of stay while increasing patient recovery and satisfaction. Despite the known benefits of ERAS programs, uptake remains slow. METHODS Semistructured interviews were conducted with general surgeons, anesthesiologists, and ward nurses at 7 University of Toronto-affiliated hospitals to identify potential barriers and enablers to adoption of 18 ERAS interventions. Grounded theory was used to thematically analyze the transcribed interviews. RESULTS Nineteen general surgeons, 18 anesthesiologists, and 18 nurses participated. The mean time of each interview was 18 minutes. Lack of manpower, poor communication and collaboration, resistance to change, and patient factors were cited by most as barriers. Discipline-specific issues were identified although most related to resistance to change. Overall, interviewees were supportive of implementation of a standardized ERAS program and agreed that a standardized guideline based on best evidence; standardized order sets; and education of the staff, patients, and families are essential. CONCLUSIONS Multidisciplinary perioperative staff supported the implementation of an ERAS program at the University of Toronto-affiliated hospitals. However, major barriers were identified, including the need for patient education, increased communication and collaboration, and better evidence for ERAS interventions. Identifying these barriers and enablers is the first step toward successfully implementing an ERAS program.

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.

Successful implementation of an enhanced recovery after surgery programme for elective colorectal surgery: a process evaluation of champions’ experiences

BackgroundEnhanced recovery after surgery (ERAS) is a multimodal evidence-based approach to patient care that has become the standard in elective colorectal surgery. Implemented globally, ERAS programmes represent a considerable change in practice for many surgical care providers. Our current understanding of specific implementation and sustainability challenges is limited. In January 2013, we began a 2-year ERAS implementation for elective colorectal surgery in 15 academic hospitals in Ontario. The purpose of this study was to understand the process enablers and barriers that influenced the success of ERAS implementation in these centres with a view towards supporting sustainable change.MethodsA qualitative process evaluation was conducted from June to September 2014. Semi-structured interviews with implementation champions were completed, and an iterative inductive thematic analysis was conducted. Following a data-driven analysis, the Normalization Process Theory (NPT) was used as an analytic framework to understand the impact of various implementation processes. The NPT constructs were used as sensitizing concepts, reviewed against existing data categories for alignment and fit.ResultsFifty-eight participants were included: 15 surgeons, 14 anaesthesiologists, 15 nurses, and 14 project coordinators. A number of process-related implementation enablers were identified: champions’ belief in the value of the programme, the fit and cohesion of champions and their teams locally and provincially, a bottom-up approach to stakeholder engagement targeting organizational relationship-building, receptivity and support of division leaders, and the normalization of ERAS as everyday practice. Technical enablers identified included effective integration with existing clinical systems and using audit and feedback to report to hospital stakeholders. There was an overall optimism that ERAS implementation would be sustained, accompanied by concern about long-term organizational support.ConclusionsSuccessful ERAS implementation is achieved by a complex series of cognitive and social processes which previously have not been well described. Using the Normalization Process Theory as a framework, this analysis demonstrates the importance of champion coherence, external and internal relationship building, and the strategic management of a project’s organization-level visibility as important to ERAS uptake and sustainability.

Axillary dissection versus no axillary dissection in women with invasive breast cancer and sentinel node metastasis

Question: Does a complete axillary lymph node dissection (ALND) affect the overall survival of patients with sentinel lymph node (SLN) metastasis of breast cancer? Design: Randomized controlled trial. Setting: Multicentre trial that included 115 sites. Patients: There were 856 women with clinical T1–T2 invasive breast cancer, with no palpable adenopathy and 1–2 SLNs containing metastases identified histologically. Intervention: All patients underwent lumpectomy and tangential whole-breast irradiation. Those with SLN metastases indentified by sentinel lymph node dissection (SLND) were randomly assigned to undergo ALND or no further axillary treatment. Those assigned to ALND underwent dissection of at least 10 nodes. Main outcome measures: Overall survival, defined as the time from random assignment until death from any cause. The secondary outcome was disease-free survival. Results: Clinical and tumour characteristics were similar among 420 patients assigned to ALND and 436 assigned to SLND alone. The median number of nodes removed was 17 with ALND and 2 with SLND. At a median follow-up of 6.3 years (last follow-up, Mar. 4, 2010), 5-year overall survival was 91.8% (95% confidence interval [CI] 89.1%–94.5%) with ALND and 92.5% (95% CI 90.0%–95.1%) with SLND alone; 5-year disease-free survival was 82.2% (95% CI 78.3%–86.3%) with ALND and 83.9% (95% CI 80.2%–87.9%) with SLND alone. The hazard ratio for treatment-related overall survival was 0.79 (90% CI 0.56–1.11) without adjustment and 0.87 (90% CI 0.62–1.23) after adjusting for age and adjuvant therapy. Conclusion: Among patients with limited SLN metastatic breast cancer treated with breast conservation and systemic therapy, the use of SLNB alone compared with ALND did not result in inferior survival.

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.

Canadian Association of General Surgeons, the American College of Surgeons, the Canadian Society of Colorectal Surgeons and the American Society of Colorectal Surgeons: Evidence Based Reviews in Surgery - Colorectal Surgery

Canadian Association of General Surgeons, the American College of Surgeons, the Canadian Society of Colorectal Surgeons, and the American Society of Colorectal Surgeons Evidence Based Reviews in Surgery : Colorectal Surgery

Cost-utility analysis of early versus delayed laparoscopic cholecystectomy for acute cholecystitis

Objective: To compare the cost-effectiveness of early laparoscopic choleystectomy (ELC) versus delayed laparoscopic cholecystectomy (DLC) in patients with acute cholecystitis. Design: A decision-tree model was developed using a series that modelled all potential outcomes for both treatment options. Probabilities were estimated from a Cochrane review. Costs were based on the UK National Schedule of Reference Costs for the year 2006. Setting: UK National Health Service. Patients: Patients with acute cholecystitis. Intervention: Either ELC or DLC with a time frame of 1 year. Main outcome: Outcomes were measured in quality-adjusted life years (QALY) gained over 1 year. Results: Early laparoscopic choleystectomy is less costly and results in better quality of life (+0.05 QALY per patient) than DLC. Given a willingness-to-pay threshold of £20 000 per QALY gained, there is a 70.9% probability that ELC is more cost-effective than DLC. Conclusion: On average, ELC is less expensive and results in better quality of life than DLC.

Does Screening for Breast Cancer with Five Screening Modalities in Average-Risk Women Reduce Mortality from Breast Cancer?

The term evidence-based medicine was first coined by Sackett and colleagues as “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.” The key to practicing evidence-based medicine is applying the best current knowledge to decisions in individual patients. Medical knowledge is continually and rapidly expanding, and it is impossible for an individual clinician to read all the medical literature. For clinicians to practice evidencebased medicine, they must have the skills to read and interpret the medical literature so that they can determine the validity, reliability, credibility, and utility of individual articles. These skills are known as critical appraisal skills. Generally, critical appraisal requires that the clinician have some knowledge of biostatistics, clinical epidemiology, decision analysis, and economics, as well as clinical knowledge. The Canadian Association of General Surgeons (CAGS) and the American College of Surgeons (ACS) jointly sponsor a program titled, “Evidence-Based Reviews in Surgery” (EBRS), supported by an educational grant from Ethicon Inc and Ethicon Endo Surgery Inc. The primary objective of this initiative is to help practicing surgeons improve their critical appraisal skills. During the academic year, 8 clinical articles are chosen for review and discussion. They are selected not only for their clinical relevance to general surgeons, but also because they cover a spectrum of issues important to surgeons; for example, causation or risk factors for

Is there an association between implementation of a medical team training program and surgical mortality

Objective: To determine whether an association existed between the Veterans Health Administration (VHA) medical team training and surgical outcomes. Study design: Retrospective cohort study. Setting: 108 VHA hospitals (74 with and 34 without team training). Intervention: Medical team training consisted of a 1-day session with nurses, surgeons and anesthesiologists in attendance, followed by 4 quarterly structured telephone interviews. Data sources: VHA Surgical Quality Improvement Program (VASQIP), which included 182 409 patients between 2006 and 2008. Main outcome measure: Postoperative mortality. Results: The 74 facilities in the training program experienced an 18% reduction in annual mortality (rate ratio [RR] 0.82, 95% confidence interval [CI] 0.76–0.91, p = 0.01) compared with a 7% decrease among the 34 facilities that had not yet undergone training (RR 0.93, 95% CI 0.80–1.06, p = 0.59). Risk-adjusted mortality at baseline was 17 per 1000 procedures per year for the trained and 15 per 1000 per year for the nontrained facilities. At the end of the study, the rates were 14 per 1000 per year for both groups. Propensity matching of the trained and nontrained groups demonstrated that the decline in risk-adjusted surgical mortality was about 50% greater in the trained (RR 1.49, 95% CI 1.10–2.07, p = 0.01) than in the nontrained group. A dose–response relationship for additional quarters of the training program was also demonstrated: for every quarter of the training program a reduction of 0.5 deaths per 1000 procedures occurred (95% CI 0.2–1.0, p = 0.001). Conclusion: Participation in the VHA Medical Team Training program was associated with lower surgical mortality.

Executive Summary: Enhanced Recovery After Surgery: Best Practice Guideline for Care of Patients With a Fecal Diversion.

Enhanced Recovery After Surgery (ERAS) is a multimodal program developed to decrease postoperative complications, improve patient safety and satisfaction, and promote early discharge. In the province of Ontario, Canada, a standardized approach to the care of adult patients undergoing elective colorectal surgery (including benign and malignant diseases) was adopted by 15 hospitals in March 2013. All colorectal surgery patients with or without an ostomy were included in the ERAS program targeting a length of stay of 3 days for colon surgery and 4 days for rectal surgery. To ensure the individual needs of patients requiring an ostomy in an ERAS program were being met, a Provincial ERAS Enterostomal Therapy Nurse Network was established. Our goal was to develop and implement an evidence-based, ostomy-specific best practice guideline addressing the preoperative, postoperative, and discharge phases of care. The guideline was developed over a 3-year period. It is based on existing literature, guidelines, and expert opinion. This article serves as an executive summary for this clinical resource; the full guideline is available as Supplemental Digital Content 1 (available at: http://links.lww.com/JWOCN/A36) to this executive summary.