Shawn S. Forbes

Implementation of Evidence-Based Practices for Surgical Site Infection Prophylaxis: Results of a Pre- and Postintervention Study

BACKGROUND Although evidence-based guidelines for best practices pertaining to surgical site infection (SSI) prophylaxis exist, the feasibility of implementing such practices remains to be demonstrated outside of a controlled clinical trial. This study was designed to assess the safety and feasibility of implementing evidence-based care practices to prevent SSIs. STUDY DESIGN A prospective, double-cohort (pre- and postintervention) trial in elective, general surgery patients was conducted. All patients undergoing elective, major colorectal or hepatobiliary operations were enrolled. Postintervention cohort patients were exposed to new strategies to improve antibiotic administration times, perioperative normothermia rates, and perioperative glucose control. They were compared with the preintervention cohort, which received standard practice at the time. Outcomes evaluated include timing of antibiotic administration, perioperative temperatures, and postoperative glucose levels. SSI rates between cohorts were also compared. RESULTS A total of 208 patients were enrolled. The proportion of patients receiving their preoperative antibiotics within 60 minutes improved from 5.9% to 92.6% (p < 0.001); perioperative normothermia rates improved from 60.5% to 97.6% (p < 0.001) between cohorts. There was no improvement in rates of hyperglycemia. SSI rates improved but did not reach statistical significance (14.3% versus 8.7%; p = 0.21). CONCLUSIONS Implementation of evidence-based care practices to prevent SSI is both safe and practical outside the setting of a randomized, controlled trial. Sustained compliance remains to be demonstrated, although practice audits at our institution suggest ongoing success is possible.

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.

Long-term survival in young adults with colorectal cancer: a population-based study.

PURPOSE: This study compares the long-term survival of young adults with colorectal cancer who lived a minimum of 5 years after diagnosis with a cancer-free control population. METHODS: A population-based study was conducted using cancer registry and administrative data. Persons aged 20 to 44 years in whom colorectal cancer was diagnosed between 1992 and 1999 and who lived at least 5 years after diagnosis were identified using the Ontario Cancer Registry. Patients with colorectal cancer were matched 1:5 to randomly selected controls (who were cancer free at the corresponding date of diagnosis) by use of the Registered Persons Database of Ontario based on age, sex, and geographic location. Time-to-death was compared between patients with colorectal cancer and controls by use of Kaplan-Meier estimates and Cox proportional hazard regression. RESULTS: Nine hundred seventeen young adults with colorectal cancer who lived at least 5 years after diagnosis and 4585 controls were identified. The median follow-up after achieving 5-year survivor status was 6.2 years; 9.5% (87) of patients with colorectal cancer died compared with 1.2% (56) of controls (P < .0001). 62.1% of deaths In the colorectal cancer patient population were attributed to malignant disease. Colorectal cancer patients were significantly more likely to die over time than controls (hazard ratio, 8.2; 95% CI (5.8, 11.6)). Those patients with no evidence of disease recurrence within the first 5 years after diagnosis also remained at an increased risk of death (hazard ratio, 2.0, 95% CI (1.2, 3.6)). CONCLUSIONS: Young adult 5-year survivors of colorectal cancer remain at a higher risk of long-term death than age-matched controls.

Case report: Sigmoid strangulation from evisceration through a perforated rectal prolapse ulcer – An unusual complication of rectal prolapse

Highlights • Rectal prolapse occurs particularly in elderly females.• Complications include incarceration, strangulation, and, rarely, perforation with evisceration of other viscera requiring urgent operation.• Such complications can be prevented by a strict bowel regimen and avoidance of activities that increase intra-abdominal pressure.• Prompt surgical consult is warranted if any signs or symptoms suggestive of complications from prolapse are present.

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.