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Improving Quality in Colorectal Surgery

Improving Quality in Colorectal Surgery

Throughout the United States, hospitals are striving for quality improvement (QI) by partnering with patients and their caregivers to continuously improve outcomes and experiences. One such effort to address this issue was developed by Elizabeth C. Wick, MD, and colleagues at the Johns Hopkins Hospital. They implemented a QI project that involved changing surgical care processes based on evidence-based best clinical practices.   A Standardized Plan The new standardized care plan, called an integrated recovery pathway, expanded on a pre-existing comprehensive unit-based safety program infrastructure and used trust-based accountability models at each level, ranging from senior leaders to frontline staff. Project leaders developed the pathway with staff and emphasized the need to engage patients and their families as partners in care. The staff was continuously reviewed performance using an electronic dashboard, an interactive performance review tool that showed progress on the primary outcomes of length of stay, surgical site infection (SSI) rates, and patient satisfaction. “Our goal was to improve outcomes, value, and satisfaction by engaging patients to be partners with their healthcare team,” Dr. Wick says. For a study published the Journal of the American College of Surgeons, Dr. Wick and colleagues compared results of 310 patients who underwent colorectal operations before the integrated recovery pathway began with those of 330 patients whose colorectal surgical care involved the pathway over an 11-month period. Both groups had similar demographic characteristics and procedures. The integrated recovery pathway intervention included preoperative education, mechanical bowel preparation with oral antibiotics, chlorhexidine bathing, multimodal analgesia, a restricted intravenous fluids protocol, early mobilization, and rapid resumption of oral intake.   Impressive Results At 11 months...
Relieving Pain in Colorectal Surgery

Relieving Pain in Colorectal Surgery

Researchers have developed enhanced recovery pathways (ERP) to improve outcomes and reduce readmissions in colorectal surgery patients. “ERP protocols use a set of standardized pre- and postoperative orders,” explains Conor P. Delaney, MD, PhD, FACS, FASCRS. “Research clearly shows that these protocols can help speed recovery and improve outcomes.” ERP protocols emphasize early mobilization after surgery, optimal analgesia, and control of intravenous fluid volumes. Patients are also encouraged to eat the day after their procedure rather than wait several days. To further improve outcomes, it has been hypothesized that adding a transversus abdominis plane (TAP) block to ERP protocols may allow patients to bypass or reduce narcotics use after surgery. TAP blocks are usually administered with ultrasound guidance, but a laparoscopic technique has been developed in which regional analgesia is injected into the abdominal wall between the oblique muscles and the transversus abdominis. “The TAP block can be given after surgery to reduce pain in the operative area,” says Dr. Delaney. “While narcotics help alleviate pain, they can slow recovery. The TAP block is different in that it wears off in time for patients to avoid the worst pain that typically occurs immediately after surgery.” Encouraging Data In a study of 100 patients published in the Journal of the American College of Surgeons, Dr. Delaney and colleagues tested the use of a laparoscopically administered TAP block as part of ERP protocols. After the block, patients were also given intravenous painkillers. According to findings, the average hospital stay after surgery dropped to less than 2.5 days for those receiving the TAP block. This was significantly lower than what has been...

A Safety Program to Decrease SSIs

Surgical site infections (SSIs) are the most common complication facing colorectal surgery patients, occurring in 15% to 30% of cases. SSIs prolong hospitalization, increase readmissions, require subsequent treatment, affect quality of life, and increase healthcare costs to the tune of $1 billion annually. Research has not shown an association between adherence to well-known infection control process measures and substantial SSI reduction. While the occurrence of SSIs can never be fully eliminated in any feasible scheme, many can be prevented. Addressing SSIs as a Team In a study published in the August 2012 Journal of the American College of Surgeons, my colleagues and I found that physicians and nurses often feel as though they know what needs to be done to improve safety for colorectal surgery patients, but they feel disempowered. Using these perceptions as the basis for our study, we tested the implementation of a surgery-based comprehensive unit-based safety program (CUSP) designed to address SSIs. Participants in CUSP met monthly for as little as 1 hour in small groups of surgeons, nurses, operating room technicians, and anesthesiologists, along with a senior hospital executive who ensured access to necessary resources. CUSP team members identified six key interventions that were believed to help reduce SSIs: 1. Standardization of skin preparation. 2. Prescription of preoperative chlorhexidine showers. 3. Restricted use of by-mouth bowel cleansing solution before procedures. 4. Warming of patients in the pre-anesthesia area. 5. Adoption of enhanced sterile techniques for bowel and skin portions of the case. 6. Addressing lapses in prophylactic antibiotics. With a focus on these areas, simple safety checklists were created, and caregivers were urged to speak...

Predicting Splenic Injury in Colorectal Surgery

A University of California, Irvine study  has found that the overall splenic injury rate for patients undergoing colorectal resection was appears to be less than 1.0%, but several predictors of these injuries emerged. The most common procedure associated with splenic injury was transverse colectomy (3.4%). Potent independent predictors of splenic injury included: Type of resection (transverse, total, or left colectomy). Type of pathology (malignancy or diverticulitis). Open operation. Teaching hospital. Male sex, peripheral vascular disease, and emergent admission were deemed less effective predictors. The authors note that surgeons should be aware of these risk factors and inform patients accordingly. Abstract: Archives of Surgery, April...
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