A meta-analysis of carbon dioxide versus room air insufflation on patient comfort and key performance indicators at colonoscopy

Abstract Background and study aims Carbon dioxide (CO2) insufflation has been suggested to be an ideal alternative to room air insufflation to reduce trapped air within the bowel lumen after balloon assisted enteroscopy (BAE). We performed a systematic review and meta-analysis to assess the safety and efficacy of utilizing CO2 insufflation as compared to room air during BAE. Patients and methods The primary outcome is mean change in visual analog scale (VAS; 10 cm) at 1, 3, and 6 hours to assess pain. Secondary outcomes include insertion depth (anterograde or retrograde), adverse events, total enteroscopy rate, diagnostic yield, mean anesthetic dosage, and PaCO2 at procedure completion. We searched MEDLINE and the Cochrane Central Register of Controlled Trials (CENTRAL) from inception until May 2015. Multiple independent extractions were performed, the process was executed as per the standards of the Cochrane collaboration. Results Four randomized controlled trials (RCTs) were included in the meta-analysis. VAS at 6 hours favored CO2 over room air (MD 0.13; 95 % CI 0.01, 0.25; p = 0.03). Anterograde insertion depth (cm) was improved in the CO2 group (MD, 58.2; 95 % CI 17.17, 99.23; p = 0.005), with an improvement in total enteroscopy rate in the CO2 group (RR 1.91; 95 % CI 1.20, 3.06; p = 0.007). Mean dose of propofol (mg) favored CO2 compared to air (MD, – 70.53; 95 % CI – 115.07, – 25.98; P = 0.002). There were no differences in adverse events in either group. Conclusions Despite the ability of CO2 to improve insertion depth and decrease amount of anesthesia required, further randomized control trials are needed to determine the agent of choice for insufflation in balloon assisted enteroscopy.

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036 The impact of a clinical support tool on stroke key performance indicators

Journal of Neurology Neurosurgery & Psychiatry ◽

10.1136/jnnp-2019-anzan.33 ◽

2019 ◽

Vol 90 (e7) ◽

pp. A12.3-A13

Author(s):

Khaled Alanati ◽

James Evans

Keyword(s):

Atrial Fibrillation ◽

Ischaemic Stroke ◽

Acute Stroke ◽

Performance Indicators ◽

Meta Analysis ◽

Stroke Care ◽

Key Performance Indicators ◽

Google Scholar ◽

Cochrane Database ◽

The Impact

IntroductionAdherence to key performance indicators (KPIs) in stroke care is associated with better outcomes.1–6 The complexity in management of acute strokes, however, has created barriers towards delivering best care with plateauing of KPIs as measured by The National Stroke Foundation Clinical Audit.We examined the impact on stroke KPIs in our local health district of a web-based decision support stroke platform which provides clinicians with up-to-date information about the patient’s management flagging potential areas for improvement, allowing treatment to be optimised in real time.MethodsSix months following the introduction of the platform we performed a retrospective analysis of Electronic medical records of patients admitted to Gosford hospital with acute stroke between June 2018 and September 2018 assessing access to the stroke unit as well as being discharged on appropriate secondary prophylactics, including antihypertensives and correct antithrombotic therapy. Patients whose direction of care was palliative and patients with documented contraindication to secondary prophylactics were excluded.ResultsOver four months, 136 patients presented with acute ischaemic stroke and 11 patients had a haemorrhagic stroke. 49 ischaemic stroke patients had atrial fibrillation. Stroke unit access was higher following its introduction in 2018 compared to 2017 (97% vs 76%, respectively). Similar findings were noted for patients with atrial fibrillation who received oral anticoagulants on discharge (90% vs 50%) and patients discharged on antihypertensives (95% vs 80%).ConclusionUse of a clinical support platform in managing acute stroke is an intervention that improves stroke care.ReferencesUrimubenshi G, Langhorne P, Cadilhac DA, Kagwiza JN, Wu O. Association between patient outcomes and key performance indicators of stroke care quality: A systematic review and meta-analysis. European Stroke Journal 2017;2(4):287–307. https://doi.org/10.1177/2396987317735426Sandercock P, Gubitz G, Foley P. Antiplatelet therapy for acute ischaemic stroke. Cochrane Database Syst Rev 2003;2: CD000029. Google ScholarKwan J, Sandercock P. In-hospital care pathways for stroke. Cochrane Database Syst Rev2004;4: CD002924. Google ScholarSaxena R, Koudstaal PJ. Anticoagulants for preventing stroke in patients with nonrheumatic atrial fibrillation and a history of stroke or transient ischemic attack. Cochrane Database Syst Rev 2004;4: CD000187. Google ScholarGoyal M, Menon BK, van Zwam WH. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trial. Lancet 2016;387:1723–1731. Google Scholar | Crossref | Medline | ISIMiddleton S, McElduff P, Ward J. Implementation of evidence-based treatment protocols to manage fever, hyperglycaemia, and swallowing dysfunction in acute stroke (QASC): a cluster randomised controlled trial. Lancet 2011;378:1699–1706. Google Scholar | Crossref | Medline | ISI

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Association between patient outcomes and key performance indicators of stroke care quality: A systematic review and meta-analysis

European Stroke Journal ◽

10.1177/2396987317735426 ◽

2017 ◽

Vol 2 (4) ◽

pp. 287-307 ◽

Cited By ~ 11

Author(s):

Gerard Urimubenshi ◽

Peter Langhorne ◽

Dominique A Cadilhac ◽

Jeanne N Kagwiza ◽

Olivia Wu

Keyword(s):

Atrial Fibrillation ◽

Ischaemic Stroke ◽

Patient Outcomes ◽

Performance Indicators ◽

Odds Ratio ◽

Stroke Unit ◽

Nutritional Assessment ◽

Meta Analysis ◽

Key Performance Indicators ◽

Lipid Management

Purpose Translating research evidence into clinical practice often uses key performance indicators to monitor quality of care. We conducted a systematic review to identify the stroke key performance indicators used in large registries, and to estimate their association with patient outcomes. Method We sought publications of recent (January 2000–May 2017) national or regional stroke registers reporting the association of key performance indicators with patient outcome (adjusting for age and stroke severity). We searched Ovid Medline, EMBASE and PubMed and screened references from bibliographies. We used an inverse variance random effects meta-analysis to estimate associations (odds ratio; 95% confidence interval) with death or poor outcome (death or disability) at the end of follow-up. Findings We identified 30 eligible studies (324,409 patients). The commonest key performance indicators were swallowing/nutritional assessment, stroke unit admission, antiplatelet use for ischaemic stroke, brain imaging and anticoagulant use for ischaemic stroke with atrial fibrillation, lipid management, deep vein thrombosis prophylaxis and early physiotherapy/mobilisation. Lower case fatality was associated with stroke unit admission (odds ratio 0.79; 0.72–0.87), swallow/nutritional assessment (odds ratio 0.78; 0.66–0.92) and antiplatelet use for ischaemic stroke (odds ratio 0.61; 0.50–0.74) or anticoagulant use for ischaemic stroke with atrial fibrillation (odds ratio 0.51; 0.43–0.64), lipid management (odds ratio 0.52; 0.38–0.71) and early physiotherapy or mobilisation (odds ratio 0.78; 0.67–0.91). Reduced poor outcome was associated with adherence to swallowing/nutritional assessment (odds ratio 0.58; 0.43–0.78) and stroke unit admission (odds ratio 0.83; 0.77–0.89). Adherence with several key performance indicators appeared to have an additive benefit. Discussion Adherence with common key performance indicators was consistently associated with a lower risk of death or disability after stroke. Conclusion Policy makers and health care professionals should implement and monitor those key performance indicators supported by good evidence.

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