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PERIOPERATIVE: Enhanced recovery after surgery

Enhanced recovery after surgery (ERAS) refers to redesigned perioperative care, sometimes also referred to as fast-track recovery after surgery.  Among the objectives are to reduce readmissions and avoid opioid abuse.  Changes include early ambulation, multi-modal analgesia and careful attention to nutrition.  The Cleveland Clinic includes ERAS in a list of the top 10 medical innovations for 2018.  The Gramlich article describes how the ERAS guidelines for colorectal surgery were implemented in six Canadian hospitals by the Alberta Health Services.  More information can also be obtained from the ERAS Society.

Sources:

Cleveland Clinic. Top 10 medical innovations.  Click here: http://innovations.clevelandclinic.org/Summit/Top-10-Medical-Innovations.aspx

Gramlich, L.M., and others. (2017). Implementation of enhanced recovery after surgery: A strategy to transform surgical care across a health system. Implementation Science. 12(67). Click here:  https://implementationscience.biomedcentral.com/track/pdf/10.1186/s13012-017-0597-5?site=implementationscience.biomedcentral.com

ERAS Society. Click here: http://erassociety.org/   Posted by AHA Resource Center (312) 422-2050, rc@aha.org

SURGICAL SUITE: Implementing ERAS at Kaiser Permanente

Engagement among patients and clinicians is excellent, and the ERAS team is working toward realizing the vision of enhanced recovery hospitals where the ERAS paradigm becomes the standard of care for the 190,000 adult inpatients hospitalized in KPNC each year.”

How Kaiser Permanente Northern California implemented an Enhanced Recovery After Surgery (ERAS) project in 20 KPNC medical centers is described in this lengthy, scholarly article.  The initiative began with colon surgery patients, but success in reducing inpatient length of stay and post-op complication rates has led to expansion of the ERAS model to other surgical patients.  This article is well illustrated with graphics which will be helpful to other providers working through similar implementation projects, including a sample “My Calendar: Recover Safely and Quickly” intended for colon surgery patients.

Source: Liu, V.X., and others. (2017, Summer). The Kaiser Permanente Northern California enhanced recovery after surgery program: Design, development, and implementation. The Permanente Journal, 21(3), 53-61.  Click here: http://www.thepermanentejournal.org/issues/2017/summer/6477-the-kaiser-permanente-northern-california.html  Posted by AHA Resource Center (312) 422-2050, rc@aha.org

PATIENT SAFETY: Handoffs between ICU and OR

There is a lot of literature describing problems with, and best practices for, the transfer of care of post-surgical patients moving into the intensive care unit setting.  However, after conducting a comprehensive literature search, the authors of this brief commentary found no comparable literature about the reverse type of handoff – for patients going from the special care unit into surgery.  They suggest that a checklist be adopted and give an example of one such checklist.  They also recommend that a verbal handoff be required.

What do I like about this article?  The authors are authoritative (Mount Sinai and Johns Hopkins medical schools) and I like the actual example of the handoff checklist.  Also, I like it that they appear to be filling a gap in the medical literature – at least at the time that they wrote this commentary.

Source: Evans, A.S., Yee, M.S., and Hogue, C.W. (2014, Mar.). Often overlooked problems with handoffs: From the intensive care unit to the operating room.  Anesthesia & Analgesia, 118(3), 687-689.  Click here for free full text: http://journals.lww.com/anesthesia-analgesia/Fulltext/2014/03000/Often_Overlooked_Problems_with_Handoffs___From_the.31.aspx  Posted by AHA Resource Center (312) 422-2050, rc@aha.org

OPERATING ROOMS: Cost benefit of synthetic gloves

Natural rubber latex gloves are less expensive to buy than synthetic latex surgical gloves but can cause allergic reactions in staff and patients.  This study conducted at Alta Bates Medical Center (Berkeley, CA) prepared a cost benefit analysis comparing the different types of gloves and including the cost of treating cases of allergy.  The hospital did already use a large number of synthetic gloves, but converting completely to the synthetic gloves was found to save nearly $75,000 or 25 percent of overall OR operating costs.

Source: Wharton, K.R., and others. (2016, June). Can converting to synthetic surgical gloves lower hospital operating room costs? OR Manager, 32(6), 22-23, 25-26.  Click here for the publisher’s website: http://www.ormanager.com/can-converting-synthetic-surgical-gloves-lower-hospital-operating-room-costs/   The article mentions that a full case study can be requested from one of the authors – Philippe Henderson – by emailing him at: philippe.henderson@kraton.com   Posted by AHA Resource Center (312) 422-2050, rc@aha.org

ACOs: Should you include a ‘surgical home’?

The American Society of Anesthesiologists (ASA) has proposed a coordinated perioperative, or surgical home, model which would give anesthesiologists a leadership role in the development of an important component of accountable care organizations (ACOs).  This is a counterpart to the medical home model (which focuses on primary care and patients with chronic disease).  ASA envisions that anesthesiologists would evolve into “perioperative physicians” in this model.

Interesting fact: An estimated 60 to 70 percent of hospital expenses are related to patients who have surgery or undergo procedures.

Sources:  American Society of Anesthesiologists.  The Perioperative or Surgical Home, Aug. 21, 2011.  Click here for full text: http://www.saaahq.org/ThePerioperative_orSurgicalHome.pdf;  Warner, M.A.  The surgical home.  Newsletter. American Society of Anesthesiologists;76(5):30-32, May 2012; and, ASA responds to accountable care organization proposed rule.  Press Release, June 3, 2011.  Click here for full text: http://www.asahq.org/For-Members/Advocacy/Washington-Alerts/ASA-Responds-to-Accountable-Care-Organization-Proposed-Rule.aspx  Posted by AHA Resource Center, (312) 422-2050, rc@aha.org

Retained surgical items: incidence and how to avoid

The national incidence rate for retained surgical items (RSIs) has been estimated to be 1 in every 8,000 to 18,000 inpatient surgical operations; or, 1 in every 1,000 to 1,500 abdominal operations.  A study (Cima et al., 2008) at only the Mayo Clinic (Rochester, MN), found the actual incidence of retained foreign objects (RFOs) to be 1 in 5,500 operations during the period 2003 to 2006.  About two-thirds of the items were sponges.  The authors concluded that counting is not reliable as the primary way to avoid RFOs.  In a follow-up study at the Mayo Clinic (Cima et al., 2011), a data-matrix-sponge system was introduced.  This technology was found to be easy to use and, in the course of an 18-month trial, was found to eliminate sponge-related RFOs.  The Veterans Health Administration has developed, and made available online, a policy to prevent retained surgical items.

Sources

 Cima, R.R., and others.  Incidence and characteristics of potential and actual retained foreign object events in surgical patients.  Journal of the American College of Surgeons;207(1):80-87, July 2008.  http://www.cardinalhealth.com/us/en/brands/presource/files/2008%20Incidence%20and%20Characteristics%20of%20Potential%20and%20Actual%20Retained%20Foreign%20Object%20Events%20in%20Surgical%20Patients%20-%20Cima.pdf

Cima, R.R., and others.  Using a data-matrix-coded sponge counting system across a surgical practice: impact after 18 monthsThe Joint Commission Journal on Quality and Patient Safety;37(2):51-58, Feb. 2011.

Prevention of Retained Surgical Items.  Washington, DC: Veterans Health Administration, Apr. 12, 2010.  [VHA Directive 2010-017]

Operating room turnover and vacancy rates

Based on a survey with just under 300 responses, the vacancy rate for RNs in hospital-based ORs was:

  • 6% in 2010
  • 6% in 2009
  • 10% in 2008

The turnover rate for OR personnel in hospitals  in 2010 was:

  • 5% for RNs
  • 6% for surgical technologists

Skill mix: The ratio of RNs to surgical techs has held steady for the past three years at roughly two-thirds RNs to one-third techs in both hospital ORs and ambulatory surgery centers.

Source: OR directors striving to adjust staffing in a down economy.  OR Manager;26(9):1+, Sept. 2010.