Surgical Technical Evidence Review for Elective Total Joint Replacement Conducted for the AHRQ Safety Program for Improving Surgical Care and Recovery

Background: Use of enhanced recovery pathways (ERPs) can improve patient outcomes, yet national implementation of these pathways remains low. The Agency for Healthcare Research and Quality (AHRQ; funder), the American College of Surgeons, and the Johns Hopkins Medicine Armstrong Institute for Patent Safety and Quality have developed the Safety Program for Improving Surgical Care and Recovery—a national effort to catalyze implementation of practices to improve perioperative care and enhance recovery of surgical patients. This review synthesizes evidence that can be used to develop a protocol for elective total knee arthroplasty (TKA) and total hip arthroplasty (THA). Study Design: This review focuses on potential components of the protocol relevant to surgeons; anesthesia components are reported separately. Components were identified through review of existing pathways and from consultation with technical experts. For each, a structured review of MEDLINE identified systematic reviews, randomized trials, and observational studies that reported on these components in patients undergoing elective TKA/THA. This primary evidence review was combined with existing clinical guidelines in a narrative format. Results: Sixteen components were reviewed. Of the 10 preoperative components, most were focused on risk factor assessment including anemia, diabetes mellitus, tobacco use, obesity, nutrition, immune-modulating therapy, and opiates. Preoperative education, venous thromboembolism (VTE) prophylaxis, and bathing/ Staphylococcus aureus decolonization were also included. The routine use of drains was the only intraoperative component evaluated. The 5 postoperative components included early mobilization, continuous passive motion, extended duration VTE prophylaxis, early oral alimentation, and discharge planning. Conclusion: This review synthesizes the evidence supporting potential surgical components of an ERP for elective TKA/THA. The AHRQ Safety Program for Improving Surgical Care and Recovery aims to guide hospitals and surgeons in identifying the best practices to implement in the surgical care of TKA and THA patients.

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Surgical Technical Evidence Review for Gynecologic Surgery Conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery

Obstetrical & Gynecological Survey ◽

10.1097/ogx.0000000000000652 ◽

2019 ◽

Vol 74 (3) ◽

pp. 146-147

Author(s):

Eleftheria Kalogera ◽

Gregg Nelson ◽

Jessica Liu ◽

Q. Lina Hu ◽

Clifford Y. Ko ◽

...

Keyword(s):

Surgical Care ◽

Healthcare Research ◽

Gynecologic Surgery ◽

Safety Program ◽

Surgical Technical ◽

Evidence Review

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Surgical Technical Evidence Review for Acute Appendectomy Conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery

Journal of the American College of Surgeons ◽

10.1016/j.jamcollsurg.2018.09.024 ◽

2018 ◽

Vol 227 (6) ◽

pp. 605-617.e2 ◽

Cited By ~ 6

Author(s):

Melissa A. Hornor ◽

Jessica Y. Liu ◽

Q Lina Hu ◽

Clifford Y. Ko ◽

Elizabeth Wick ◽

...

Keyword(s):

Surgical Care ◽

Healthcare Research ◽

Safety Program ◽

Surgical Technical ◽

Evidence Review

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Surgical technical evidence review for gynecologic surgery conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery

American Journal of Obstetrics and Gynecology ◽

10.1016/j.ajog.2018.07.014 ◽

2018 ◽

Vol 219 (6) ◽

pp. 563.e1-563.e19 ◽

Cited By ~ 13

Author(s):

Eleftheria Kalogera ◽

Gregg Nelson ◽

Jessica Liu ◽

Q. Lina Hu ◽

Clifford Y. Ko ◽

...

Keyword(s):

Surgical Care ◽

Healthcare Research ◽

Gynecologic Surgery ◽

Safety Program ◽

Surgical Technical ◽

Evidence Review

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Surgical Technical Evidence Review of Hip Fracture Surgery Conducted for the AHRQ Safety Program for Improving Surgical Care and Recovery

Geriatric Orthopaedic Surgery & Rehabilitation ◽

10.1177/2151459318769215 ◽

2018 ◽

Vol 9 ◽

pp. 215145931876921 ◽

Cited By ~ 7

Author(s):

Anaar Siletz ◽

Christopher P. Childers ◽

Claire Faltermeier ◽

Emily S. Singer ◽

Q. Lina Hu ◽

...

Keyword(s):

Hip Fracture ◽

Perioperative Care ◽

Enhanced Recovery ◽

Fluid Management ◽

Surgical Care ◽

Early Mobilization ◽

Healthcare Research ◽

Safety Program ◽

Hip Fracture Surgery ◽

Surgical Technical

Background: Enhanced recovery pathways (ERPs) have been shown to improve patient outcomes in a variety of contexts. This review summarizes the evidence and defines a protocol for perioperative care of patients with hip fracture and was conducted for the Agency for Healthcare Research and Quality safety program for improving surgical care and recovery. Study Design: Perioperative care was divided into components or “bins.” For each bin, a semisystematic review of the literature was conducted using MEDLINE with priority given to systematic reviews, meta-analyses, and randomized controlled trials. Observational studies were included when higher levels of evidence were not available. Existing guidelines for perioperative care were also incorporated. For convenience, the components of care that are under the auspices of anesthesia providers will be reported separately. Recommendations for an evidence-based protocol were synthesized based on review of this evidence. Results: Eleven bins were identified. Preoperative risk factor bins included nutrition, diabetes mellitus, tobacco use, and anemia. Perioperative management bins included thromboprophylaxis, timing of surgery, fluid management, drain placement, early mobilization, early alimentation, and discharge criteria/planning. Conclusions: This review provides the evidence basis for an ERP for perioperative care of patients with hip fracture.

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Evidence review conducted for the AHRQ Safety Program for Improving Surgical Care and Recovery: focus on anesthesiology for gynecologic surgery

Regional Anesthesia and Pain Medicine ◽

10.1136/rapm-2018-100071 ◽

2019 ◽

Vol 44 (4) ◽

pp. 437-446 ◽

Cited By ~ 3

Author(s):

Michael Conrad Grant ◽

Melinda M Gibbons ◽

Clifford Y Ko ◽

Elizabeth C Wick ◽

Maxime Cannesson ◽

...

Keyword(s):

Enhanced Recovery ◽

Surgical Care ◽

Length Of Hospital Stay ◽

Multimodal Analgesia ◽

Healthcare Research ◽

Gynecologic Surgery ◽

Process Measures ◽

Safety Program ◽

Comprehensive Service ◽

Evidence Review

Enhanced recovery after surgery (ERAS) protocols for gynecologic (GYN) surgery are increasingly being reported and may be associated with superior outcomes, reduced length of hospital stay, and cost savings. The Agency for Healthcare Research and Quality, in partnership with the American College of Surgeons and the Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, has developed the Safety Program for Improving Surgical Care and Recovery, which is a nationwide initiative to disseminate best practices in perioperative care to more than 750 hospitals across five major surgical service lines in a 5-year period. The program is designed to identify evidence-based process measures shown to prevent healthcare-associated conditions and hasten recovery after surgery, integrate those into a comprehensive service line-based pathway, and assist hospitals in program implementation. In conjunction with this effort, we have conducted an evidence review of the various anesthesia components which may influence outcomes and facilitate recovery after GYN surgery. A literature search was performed for each intervention, and the highest levels of available evidence were considered. Anesthesiology-related interventions for preoperative (carbohydrate loading/fasting, multimodal preanesthetic medications), intraoperative (standardized intraoperative pathway, regional anesthesia, protective ventilation strategies, fluid minimization) and postoperative (multimodal analgesia) phases of care are included. We have summarized the best available evidence to recommend the anesthetic components of care for ERAS for GYN surgery.

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