Enhanced Recovery After Surgery: Standardized Postoperative Instructions in Hand Surgery

Background: Enhanced Recovery After Surgery (ERAS) is a standardized approach to care of the surgical patient. Postoperative patient instructions, an aspect of ERAS protocols, are difficult to standardize in hand surgery because of the diversity of procedures. The aim of this study was to determine the effect of standardized hand surgery postoperative instructions on the number of unscheduled postoperative patient encounters. Methods: The study was an institutional review board-approved prospective cohort in which all hand surgery patients from 6 surgeons at a single, hospital-based academic institution were included. For a 6-month period, both before and after establishing a standardized postoperative instructional handout, data were collected on unscheduled postoperative encounters within 14 days of surgery. Results: There were 330 patients in the control group versus 282 who received standardized postoperative instructions. Trauma comprised 24.6% of cases in comparison to 75.4% elective. Individual surgeons did not significantly influence whether patients had an encounter. Overall, patients who received standardized instructions were just as likely as the control group to have unscheduled encounters (41.5% vs 43.9%, respectively). Notably, elective patients were significantly more likely to have encounters (46%) versus trauma patients (33.1%; P = .007); however, the standardized instructions did not influence the number of encounters for either group. Conclusions: This study did not demonstrate a difference in unscheduled postoperative encounters after initiation of standardized postoperative instructions for hand surgery patients. These findings may help providers save time and resources by tailoring the use of ERAS in this distinct patient population.

The Effect Of Pre-Phacoemulsification Education On Cataract Patients’ Anxieties In Rumah Sakit Islam Banjarmasin

Pasien yang akan mengalami tindakan Phacoemulsifikasisering mengalami kecemasan karena kurangnya informasi yang diberikan. Pemberian infromasi ini diperoleh dari edukasi yang dilakukan oleh perawat sebelum tindakan phacoemulsifikasidilakukan. Penelitian ini bertujuan untuk mengetahui pengaruh edukasi pre-phacoemulsifikasiterhadap kecemasan pasien katarak di Rumah Sakit Islam Banjarmasin. Penelitian ini menggunakan desain pre-eksperimen dengan menggunakan rancangan one group pretest posttest design. Populasi adalah semua pasien pre-operasi phacoemulsifikasidi Poliklinik Mata pada tanggal 21 November sampai dengan 21 Desember 2020 dengan tekhnik accidental sampling berjumlah 20 orang. Analisis data menggunakan wilcoxon signed rank test. Hasil Penelitian menunjukkan penurunan kecemasan dari kecemasan sedang menjadi kecemasan ringan sebelum ke sesudah diberikan edukasi dengan nilai ρ = 0,000. Penelitian ini menyarankan agar perawat sebaiknya melakukan edukasi pre-phacoemulsifikasikepada pasien katarak menggunakan SOP yang telah dientukan oleh rumah sakit. Kata Kunci: Edukasi,Katarak, Kecemasan Daftar Rujukan Anggreny, L.O (2018) Hubungan Sumber Akses Informasi Terhadap Tingkat Kecemasan Pada Klien Pre Operasi Katarak di Rumah Sakit Mata Smec Balikpapan. Jurnal Nerspedia. Volume 2. Nomor 1. Edisi April 2019 Bruce, J (2015). Lecture Notes Oftalmologi. Alih bahasa: dr. Asri Dwi Rachmawati. Jakarta: Erlangga Evans, D. C (2013). Alleviating Anxiety and Preventing Panic Attacks in the Surgical Patient.” AORN Journal Volume 97. Nomor 3. Edisi 2013 Hawari, D (2015). Manajemen Stres Cemas Dan Depresi Hypnosis. Jakarta: Fakultas Kedokteran Universitas Indonesia. Mansjoer, A. (2014). Kapita Selekta Kedokteran. Edisi 4. Jakarta: Media Aesculapius McEwen & Wills, (2011). Dasar Teori Keperawatan. Jakarta: EGC Ping, G (2012). A Preoperative Education Intervention to Reduce Anxiety and Improve Recovery Among Chinese Cardiac Patients: A Randomised Controlled Trial. Thesis, University of Nottingham Pirhonen, Silvennoinen, and Sillence, (2014). Patient Education as an Information System, Healthcare Tool and Interaction. Information System Education Journal, Volume 25 Nomor 4. Edisi 2014 Potter & Perry, (2014). Buku Ajar Fundamental Keperawatan: Konsep, Proses, dan Prektik. Edisi 4. Volume 2. Alih Bahasa: Renata Komalasari, dkk. Jakarta: EGC Riskesdas (2013). Laporan Riset Kesehatan Dasar. Jakarta: Badan Penelitian dan Pengembangan Kesehatan Kementrian Kesehatan RI. Riskesdas (2018). Laporan Riset Kesehatan Dasar. Jakarta: Badan Penelitian dan Pengembangan Kesehatan Kementrian Kesehatan RI. Smeltzer, S. (2012). Keperawatan Medikal Bedah. Jakarta: EGC Stuart, G, W (2012). Buku Saku Keperawatan Jiwa. Edisi 5. Jakarta: Buku Kedokteran EGC. Tauqir, (2012) Knowledge of patients’ visual experience during cataract surgery: a survey of eye doctors in Karachi, Pakistan. BMC Ophthalmology. Volume 12. Nomor 55. Edisi 2012 Wahyuningtyas, S. P. (2016). “Hubungan Tingkat Pengetahuan Tindakan Phacoemulsifikasi Dengan Kecemasan Pada Pasien Katarak Di Rumah Sakit Mata Solo‟. skripsi thesis, Universitas Muhammadiyah Surakarta World Health Organization, (2018). Prevention of Blindness Program, Infodatin Pusat Data dan Informasi Kementerian Kesehatan RI, 1-7. Hyperlink "http://www.depkes.go.id/download.php?file=download/pusdatin/infodatin/infodatin-hipertensi.pdf. Diakses pada tanggal 01 April 2021.

A multidisciplinary perioperative medicine clinic to improve high-risk patient outcomes: A service evaluation audit

Various perioperative interventions have been demonstrated to improve outcomes for high-risk patients undergoing surgery. This audit assessed the impact of introducing a multidisciplinary perioperative medicine clinic on postoperative outcomes and resource usage amongst high-risk patients. Between January 2019 and March 2020, our institution piloted a Comprehensive High-Risk Surgical Patient Clinic. Surgical patients were eligible for referral when exhibiting criteria known to increase perioperative risk. The patient’s decision whether to proceed with surgery was recorded; for those proceeding with surgery, perioperative outcomes and bed occupancy were recorded and compared against a similar surgical population identified as high-risk at our institution in 2017. Of 23 Comprehensive High-Risk Surgical Patient Clinic referrals, 11 did not proceed with the original planned surgery. Comprehensive High-Risk Surgical patients undergoing original planned surgery, as compared to high-risk patients from 2017, experienced reduced unplanned intensive care unit admission (8% versus 19%, respectively), 30-day mortality (0% versus 13%) and 30-day re-admission to hospital (0% versus 20%); had shorter postoperative lengths of stay (median (range) 8 (7–14) days versus 10.5 (5–28)) and spent more days alive outside of hospital at 30 days (median (range) 18 (0–25) versus 21 (16–23)). Cumulatively, the Comprehensive High-Risk Surgical patient cohort compared to the 2017 cohort (both n=23) occupied fewer postoperative intensive care (total 13 versus 24) and hospital bed-days (total 106 versus 212). The results of our Comprehensive High-Risk Surgical Patient pilot project audit suggest improved individual outcomes for high-risk patients proceeding with surgery. In addition, the results support potential resource savings through more appropriate patient selection.

P-O17 The Royal Stoke Green Pathway: a method to undertake safe UGI surgery during the COVID pandemic

Background During the first wave of the COVID pandemic surgical services we paralysed globally, with cancellation of an estimated 28-million operations during the first 12 weeks. Worryingly, surgical patient with COVID were reported to have unacceptably high peri-operative mortality, approaching 25%. However, there was an urgent clinical need to progress with category 1 and 2 operations, to prevent disease progression and avoidable morbidity and mortality from non-COVID pathologies. During the second and subsequent waves of the pandemic it was vital to protect patients from peri-operative COVID whilst undertaking urgent surgery safely. Methods Our centre developed a ring-fenced 'Green Pathway' for category 1 and 2 patients requiring surgery. Patients were treated in physically separate area of the hospital, with no interaction between COVID and non-COVID patients, healthcare staff or facilities. Patients self-isolated for 14-days prior to admission, and had pre- and peri-operative COVID RT-PCR tests. We assessed outcomes for patients immediately prior to the introduction of the Green Pathway (1/10/2020) and following implementation (31/12/2020) to assess safety. Textbook outcomes for pancreatoduodenectomy were compared to assess safety and quality. Other data suggests that UGI surgery couldn't continue in other hospitals from December 2020. Results There were 47 admissions to surgical HDU following category 1 and 2 upper GI operations during the study; 31 pre-pathway (PP) implementation, and 16 green pathway (GP) patients. Median age 66-years (43-78 range) PP vs 65-years (range 42-74) GP, median ASA 3 vs 2. Median HDU length of stay (LOS) 5-days vs 7-days, and median hospital LOS 11.5-days vs 9-days for PP vs GP respectively. There were 6 cases of peri-operative COVID in PP cohort, and 1 in GP (contract following discharge). There was no mortality within either cohort. For the subgroup of patients undergoing PD: 10 patients PP, 6 patients GP, textbook outcomes were achieved in 90% vs 67% PP vs GP. Conclusions The implementation of the Green Pathway at our institution enabled continuation of surgery for patients with category 1 and 2 operations during the COVID pandemic with a significant reduction in peri-operative COVID infection, no mortality and no increase in length of stay. The TO rate was lower with the GP (not statistically significant), but our 4-year institution TO rate is 70.3%, comparing favourably to other studies. This pathway has enabled safe continuation of urgent surgery during the pandemic and could be a model for adoption in other centres especially if there is resurgence of COVID cases during the coming winter.

The association of multimodal analgesia and high-risk opioid discharge prescriptions in opioid-naive surgical patients

Background Opioids and multimodal analgesia are widely administered to manage postoperative pain. However, little is known on how improvements in inpatient pain control are correlated with high-risk (> 90 daily OME) discharge opioid prescriptions for opioid naïve surgical patients. Methods We conducted a retrospective observational study of adult opioid-naïve patients undergoing surgery from June 2012 through December 2018 at a large academic medical center. We used multivariate logistic regression to assess whether multimodal analgesic drugs consumed in the 24 h prior to discharge was associated with a reduction in high-risk opioid discharge prescriptions. We identified other risk factors for receiving a high-risk discharge opioid prescription. Results Among the 32,511 patients, 83% of patients were discharged with an opioid prescription. In 2013, 34.1% of patients with a discharge opioid prescription received a high-risk prescription and this declined to 17.7% by 2018. Use of multimodal analgesic agents during the final 24 h of hospitalization increased each year, with over 80% receiving at least one multimodal analgesic agent by 2018. The median OME consumed in the 24 h prior to discharge peaked in 2013 at 31 and steadily decreased to 19.8 by 2018. There was a significant association between the use of acetaminophen in the 24 h prior to discharge and a high-risk prescription at discharge (p < 0.01). OMEs consumed in the 24 h prior to discharge was a significant predictor of receiving a high-risk discharge prescription, even at low doses. Other factors associated with receipt of a high-risk discharge opioid prescription included male gender, race, history of anxiety disorder, and discharge service. Discussion Use of multimodal analgesia regimens in hospitalized surgical patients in the 24 h prior to hospital discharge increased between 2012 and 2018. Simultaneously, opioid use prior to hospital discharge decreased. Despite these gains, approximately one in five discharge prescriptions was high-risk (> 90 daily OME). In addition, we found that prescribing of discharge opioids above inpatient opioid requirements remains common in opioid naive surgical patients. Conclusion Providers should account for pre-discharge opioid consumption and use of multimodal analgesia when considering the total and daily OME’s that may be appropriate for an individual surgical patient on the discharge opioid prescription.