A Digital Communication Intervention to Support Older Adults and Their Care Partners Transitioning Home After Major Surgery: Protocol for a Qualitative Research Study.

BACKGROUND: Older adults (aged ≥65 years) account for approximately 30% of inpatient procedures in the United States. After major surgery, they are at high risk of a slow return to their previous functional status, loss of independence, and complications like delirium. With the development and refinement of Enhanced Recovery After Surgery protocols, older patients often return home much earlier than historically anticipated. This put a larger burden on care partners, close family or friends who partner with the patient and guide them through recovery. Without adequate preparation, both patients and their care partners may experience poor long-term outcomes. OBJECTIVE: This study aimed to improve and streamline recovery for patients aged ≥65 years by exploring the communication needs of patients and their care partners. Information from this study will be used to inform an intervention developed to address these needs and define processes for its implementation across surgical clinics. METHODS: This qualitative research protocol has two aims. First, we will define patient and care partner needs and perspectives related to digital health innovation. To achieve this aim, we will recruit dyads of patients (aged ≥65 years) who underwent elective major surgery 30-90 days prior and their respective care partners (aged ≥18 years). Participants will complete individual interviews and surveys to obtain demographic data, characterize their perceptions of the surgical experience, identify intervention targets, and assess for the type of intervention modality that would be most useful. Next, we will explore clinician perspectives, tools, and strategies to develop a blueprint for a digital intervention. To achieve this aim, clinicians (eg, geriatricians, surgeons, and nurses) will be recruited for focus groups to identify current obstacles affecting surgical outcomes for older patients, and we will review current assessments and tools used in their clinical practice. A hybrid deductive-inductive approach will be undertaken to identify relevant themes. Insights from both clinicians and patient-care partners will guide the development of a digital intervention strategy to support older patients and their care partners after surgery. RESULTS: This study has been approved by the Massachusetts General Hospital and Harvard Institutional Review Boards. Recruitment began in December 2023 for the patient and care partner interviews. As of August 2024, over half of the interviews have been performed, deidentified, and transcribed. Clinician recruitment is ongoing, with no focus groups conducted yet. The study is expected to be completed by fall 2024. CONCLUSIONS: This study will help create a scalable digital health option for older patients undergoing major surgery and their care partners. We aim to enhance our understanding of patient recovery needs; improve communication with surgical teams; and ultimately, reduce the overall burden on patients, their care partners, and health care providers through real-time assessment. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/59067.

Geographic Differences in Pediatric Surgical Mortality in Canada: A Retrospective Cohort Study.

OBJECTIVE: This study describes differences in postoperative mortality for pediatric patients in rural communities compared to urban communities. BACKGROUND: Canada has the second largest land mass in the world, with a population density of 4 people per km2. There are 18 children's hospitals in Canada offering pediatric surgical services, all in urban centres, yet nearly one-fifth of the population lives in rural or remote communities. Children who live in rural settings may have worse surgical outcomes, including mortality rates, compared with urban populations. METHODS: Pediatric patients, from birth to 18 years old, who had surgery from January 1, 2011, to December 31, 2021, at a single Children's Hospital were included in the study. Data was obtained from the provincial Operating Room Information System (ORIS) database. Postal code, rural and urban status, distance to children's hospital (0-50 km, 51-100 km, 101-150 km, 151-200 km, and >200 km), and procedure urgency were collected. 30-day mortality for all procedures was collected. RESULTS: 85,998 surgical procedures were performed at ACH between 2011 and 2021. 17,773 (20.7%) of patients lived >50 km or more from the hospital - 5,329 (6.2%) 51- 100 km, 4,053 (4.7%) 101-150 km, n=2,323 (2.7%) 151-200 km, and 6,070 (7.1%) >200 km. Rural patients had higher 30-day mortality rates than urban patients, with an odds ratio of mortality (rural vs urban) of 2.30 (95% CI, 0.95 to 5.60). When stratified by distance, patients living closer to the hospital (0-50 km) had lower odds of mortality. CONCLUSIONS: Canadian Rural patients have higher operative mortality risks than urban patients. This study identifies a vulnerable group of patients who do not have equal access to care and may experience worse outcomes.

Optimizing Implementation of the Neonatal Enhanced Recovery After Surgery Guideline.

INTRODUCTION: Enhanced Recovery After Surgery (ERAS®) protocols require multidisciplinary team engagement from healthcare professionals (HCPs), where limited studies exist on neonatal ERAS®protocols. Therefore, we aimed to capture perceptions of HCPs on facilitation and implementation of the neonatal ERAS®guideline. METHODS: 10 neonates were recruited. 13 HCPs involved in these patient's care were interviewed and 8 surveyed consisting of pediatric anesthesiologists, neonatologists, neonatal intensive care unit (NICU) registered nurses (RNs), and pediatric surgeons. Using a multi-methods design, recruitment, semi-structured interviews and surveys were conducted from May 17, 2021 to November 1, 2022. Data was coded using The Promoting Action on Research Implementation in Health Studies and then thematically analyzed. RESULTS: Interviews were conducted with 4 pediatric anesthesiologists, 4 neonatologists, 2 NICU RNs, and 3 pediatric surgeons and surveys with 1 pediatric anesthesiologist, 2 neonatologists, 3 NICU RNs, and 2 pediatric surgeons. From interviews, the top 3 facilitation strategies were utilization of: (1) multidisciplinary guideline champions, (2) reminders and education, and (3) results to facilitate adherence. Incorporation of these strategies resulted in perceived: (1) stronger buy-in and engagement and (2) improved team communication, job satisfaction, care quality, and parental involvement. CONCLUSION: HCPs stressed the importance of guideline champions, reminders and education, and results distribution. Given implementation during the COVID-19 pandemic, awareness and education were mixed. Nonetheless, HCPs perceived improved buy-in and engagement, communication, job satisfaction, quality of care, and parental involvement. Incorporation of these strategies can promote successful ERAS® guideline facilitation and implementation and should be considered for future ERAS® projects. LEVEL OF EVIDENCE: IV.

Enhanced Recovery After Surgery (ERAS) Society Recommendations for Neonatal Perioperative Care.

Importance: Neonates requiring surgery are often cared for in neonatal intensive care units (NICUs). Despite a breadth of surgical pathology, neonates share many perioperative priorities that allow for the development of unit-wide evidence-based Enhanced Recovery After Surgery (ERAS) recommendations. Observations: The guideline development committee included pediatric surgeons, anesthesiologists, neonatal nurses, and neonatologists in addition to ERAS content and methodology experts. The patient population was defined as neonates (first 28 days of life) undergoing a major noncardiac surgical intervention while admitted to a NICU. After the first round of a modified Delphi technique, 42 topics for potential inclusion were developed. There was consensus to develop a search strategy and working group for 21 topic areas. A total of 5763 abstracts were screened, of which 98 full-text articles, ranging from low to high quality, were included. A total of 16 recommendations in 11 topic areas were developed with a separate working group commissioned for analgesia-related recommendations. Topics included team communication, preoperative fasting, temperature regulation, antibiotic prophylaxis, surgical site skin preparation, perioperative ventilation, fluid management, perioperative glucose control, transfusion thresholds, enteral feeds, and parental care encouragement. Although clinically relevant, there were insufficient data to develop recommendations concerning the use of nasogastric tubes, Foley catheters, and central lines. Conclusions and Relevance: Despite varied pathology, neonatal perioperative care within NICUs allows for unit-based ERAS recommendations independent of the planned surgical procedure. The 16 recommendations within this ERAS guideline are intended to be implemented within NICUs to benefit all surgical neonates.

Adapting the World Health Organization's Surgical Safety Checklist to High-Income Settings: A Hybrid Effectiveness-Implementation Trial Protocol.

Objectives: The proposed study aims to assess users' perceptions of a surgical safety checklist (SSC) reimplementation toolkit and its impact on SSC attitudes and operating room (OR) culture, meaningful checklist use, measures of surgical safety, and OR efficiency at 3 different hospital sites. Background: The High-Performance Checklist toolkit (toolkit) assists surgical teams in modifying and implementing or reimplementing the World Health Organization's SSC. Through the explore, prepare, implement, and sustain implementation framework, the toolkit provides a process and set of tools to facilitate surgical teams' modification, implementation, training on, and evaluation of the SSC. Methods: A pre-post intervention design will be used to assess the impact of the modified SSC on surgical processes, team culture, patient experience, and safety. This mixed-methods study includes quantitative and qualitative data derived from surveys, semi-structured interviews, patient focus groups, and SSC performance observations. Additionally, patient outcome and OR efficiency data will be collected from the study sites' health surveillance systems. Data analysis: Statistical data will be analyzed using Statistical Product and Service Solutions, while qualitative data will be analyzed thematically using NVivo. Furthermore, interview data will be analyzed using the Consolidated Framework for Implementation Research and reach, effectiveness, adoption, implementation, maintenance implementation frameworks. Setting: The toolkit will be introduced at 3 diverse surgical sites in Alberta, Canada: an urban hospital, university hospital, and small regional hospital. Anticipated impact: We anticipate the results of this study will optimize SSC usage at the participating surgical sites, help shape and refine the toolkit, and improve its usability and application at future sites.

Improving Indigenous health equity within the emergency department: a global review of interventions.

INTRODUCTION: Indigenous health equity interventions situated within emergency care settings remain underexplored, despite their potential to influence patient care satisfaction and empowerment. This study aimed to systematically review and identify Indigenous equity interventions and their outcomes within acute care settings, which can potentially be utilized to improve equity within Canadian healthcare for Indigenous patients. METHODS: A database search was completed of Medline, PubMed, Embase, Google Scholar, Scopus and CINAHL from inception to April 2023. For inclusion in the review, articles were interventional and encompassed program descriptions, evaluations, or theoretical frameworks within acute care settings for Indigenous patients. We evaluated the methodological quality using both the Joanna Briggs Institute checklist and the Ways Tried and True framework. RESULTS: Our literature search generated 122 publications. 11 articles were selected for full-text review, with five included in the final analysis. Two focusing on Canadian First Nations populations and three on Aboriginal Australians. The main intervention strategies included cultural safety training, integration of Indigenous knowledge into care models, optimizing waiting-room environments, and emphasizing sustainable evaluation methodologies. The quality of the interventions was varied, with the most promising studies including Indigenous perspectives and partnerships with local Indigenous organizations. CONCLUSIONS: Acute care settings, serving as the primary point of access to health care for many Indigenous populations, are well-positioned to implement health equity interventions such as cultural safety training, Indigenous knowledge integration, and optimization of waiting room environments, combined with sustainable evaluation methods. Participatory discussions with Indigenous communities are needed to advance this area of research and determine which interventions are relevant and appropriate for their local context.

RéSUMé: INTRODUCTION: Les interventions sur l'équité en santé des Autochtones dans les milieux de soins d'urgence demeurent sous-explorées, malgré leur potentiel d'influencer la satisfaction des patients et leur autonomisation. Cette étude visait à examiner et à déterminer systématiquement les interventions en matière d'équité envers les Autochtones et leurs résultats dans les milieux de soins de courte durée, qui pourraient être utilisés pour améliorer l'équité au sein des soins de santé canadiens pour les patients autochtones. MéTHODES: Une recherche dans la base de données a été effectuée de Medline, PubMed, Embase, Google Scholar, Scopus et CINAHL de la création à avril 2023. Pour être inclus dans la revue, les articles étaient interventionnels et comprenaient des descriptions de programmes, des évaluations ou des cadres théoriques dans les milieux de soins de courte durée pour les patients autochtones. Nous avons évalué la qualité méthodologique à l'aide de la liste de contrôle de l'Institut Joanna Briggs et du cadre Ways Tried and True. RéSULTATS: Notre recherche documentaire a généré 122 publications. 11 articles sélectionnés pour la revue de texte intégral, dont cinq inclus dans l'analyse finale. Deux se concentrent sur les populations des Premières nations canadiennes et trois sur les Australiens autochtones. Les principales stratégies d'intervention comprenaient la formation sur la sécurité culturelle, l'intégration des connaissances autochtones dans les modèles de soins, l'optimisation des environnements des salles d'attente et l'accent mis sur les méthodes d'évaluation durables. La qualité des interventions était variée, avec les études les plus prometteuses, y compris les perspectives autochtones et les partenariats avec les organisations autochtones locales. CONCLUSIONS: Les établissements de soins de courte durée, qui servent de principal point d'accès aux soins de santé pour de nombreuses populations autochtones, sont bien placés pour mettre en œuvre des interventions en matière d'équité en santé, comme la formation en sécurité culturelle, l'intégration des connaissances autochtones, l'optimisation des environnements des salles d'attente, associée à des méthodes d'évaluation durables. Discussions participatives avec Les communautés autochtones sont nécessaires pour faire avancer ce domaine de recherche et déterminer quelles interventions sont pertinentes et appropriées pour leur contexte local.

Going beyond compliance: A qualitative study of the practice of surgical safety checklist.

BACKGROUND: The World Health Organization Surgical Safety Checklist (SSC) is a tool designed to enhance team communication and patient safety. When used properly, the SSC acts as a layer of defence against never events. In this study, we performed secondary qualitative analysis of operating theatres (OT) SSC observational notes to examine how the SSC was used after an intensive SSC re-implementation effort and drew on relevant theories to shed light on the observed patterns of behaviours. We aimed to go beyond assessing checklist compliance and to understand potential sociopsychological mechanisms of the variations in SSC practices. METHODS: Direct observation notes of 109 surgical procedures across 13 surgical disciplines were made by two trained nurses in the OT of a large tertiary hospital in Singapore from February to April 2022, three months after SSC re-implementation. Only notes relevant to the use of SSC were extracted and analyzed using reflexive thematic analysis. Data were coded following an inductive process to identify themes or patterns of SSC practices. These patterns were subsequently interpreted against a relevant theory to appreciate the potential sociopsychological forces behind them. RESULTS: Two broad types of SSC practices and their respective sub-themes were identified. Type 1 (vs. Type 2) SSC practices are characterized by patience and thoroughness (vs. hurriedness and omission) in carrying out the SSC process, dedication and attention (vs. delegation and distraction) to the SSC safety checks, and frequent (vs. absence of) safety voices during the conduct of SSC. These patterns were conceptualized as safety-seeking action vs. ritualistic action using Merton's social deviance theory. CONCLUSION: Ritualistic practice of the SSC can undermine surgical safety by creating conditions conducive to never events. To fully realize the SSC's potential as an essential tool for communication and safety, a concerted effort is needed to balance thoroughness with efficiency. Additionally, fostering a culture of collaboration and collegiality is crucial to reinforce and enhance the culture of surgical safety.

Perioperative Care in Cardiac Surgery: A Joint Consensus Statement by the Enhanced Recovery After Surgery (ERAS) Cardiac Society, ERAS International Society, and The Society of Thoracic Surgeons (STS).

Enhanced Recovery After Surgery (ERAS) programs have been shown to lessen surgical insult, promote recovery, and improve postoperative clinical outcomes across a number of specialty operations. A core tenet of ERAS involves the provision of protocolized evidence-based perioperative interventions. Given both the growing enthusiasm for applying ERAS principles to cardiac surgery and the broad scope of relevant interventions, an international, multidisciplinary expert panel was assembled to derive a list of potential program elements, review the literature, and provide a statement regarding clinical practice for each topic area. This article summarizes those consensus statements and their accompanying evidence. These results provide the foundation for best practice for the management of the adult patient undergoing cardiac surgery.

Bringing Enhanced Recovery After Surgery to the NICU: An Implementation Trial.

INTRODUCTION: Enhanced Recovery After Surgery (ERAS) guidelines are bundled evidence-informed recommendations implemented to improve quality and safety of perioperative care. This study aims to determine feasibility of NICU implementation of an ERAS Guideline for Intestinal Resection, describing clinical outcomes and adherence to recommendations following light-touch implementation. METHODS: Infants <28 days undergoing laparotomy for intestinal resection in a closed-NICU were prospectively enrolled. Exclusion criteria included prematurity (<32wks), instability, or major comorbidity. Clinical data reflecting 13 ERAS recommendations were collected through chart review. Descriptive statistics are presented as median [interquartile range]. Thirty-day post-discharge outcomes include NICU and hospital length of stay (LOS), ventilator days, surgical site infection (SSI), re-intubation, readmission, reoperation, and mortality. Adherence was calculated as the percentage of patients eligible for each recommendation whose care was adherent. RESULTS: Ten infant-parent dyads were enrolled (five females; GA 37 weeks [35, 38.8]; birthweight 2.97 kg [2.02, 3.69]). Surgical diagnoses included intestinal atresia/web (n = 6), anorectal malformation (n = 3), and segmental volvulus (n = 1). NICU LOS was 16 days [11, 21], hospital LOS 20 days [18, 30], and 2.5 ventilator days/patient [2, 3]. There was reduced opioid use, no SSIs, one re-intubation, three readmissions, three reoperations, and no mortalities. Adherence to ERAS recommendations ranged 0-100 % with a pooled adherence rate of 73 %. CONCLUSION: It is feasible to introduce ERAS to the NICU with acceptable overall adherence. Assessing adherence was challenging for some measures. There were promising early clinical findings including a reduction in opioid use. This implementation trial will inform development of an ERAS protocol for surgical NICUs. LEVEL OF EVIDENCE: IV (Cohort Study).

CheckPOINT: a simple tool to measure Surgical Safety Checklist implementation fidelity.

INTRODUCTION: The WHO Surgical Safety Checklist (SSC) is a communication tool that improves teamwork and patient outcomes. SSC effectiveness is dependent on implementation fidelity. Administrative audits fail to capture most aspects of SSC implementation fidelity (ie, team communication and engagement). Existing research tools assess behaviours during checklist performance, but were not designed for routine quality assurance and improvement. We aimed to create a simple tool to assess SSC implementation fidelity, and to test its reliability using video simulations, and usability in clinical practice. METHODS: The Checklist Performance Observation for Improvement (CheckPOINT) tool underwent two rounds of face validity testing with surgical safety experts, clinicians and quality improvement specialists. Four categories were developed: checklist adherence, communication effectiveness, attitude and engagement. We created a 90 min training programme, and four trained raters independently scored 37 video simulations using the tool. We calculated intraclass correlation coefficients (ICC) to assess inter-rater reliability (ICC>0.75 indicating excellent reliability). We then trained two observers, who tested the tool in the operating room. We interviewed the observers to determine tool usability. RESULTS: The CheckPOINT tool had excellent inter-rater reliability across SSC phases. The ICC was 0.83 (95% CI 0.67 to 0.98) for the sign-in, 0.77 (95% CI 0.63 to 0.92) for the time-out and 0.79 (95% CI 0.59 to 0.99) for the sign-out. During field testing, observers reported CheckPOINT was easy to use. In 98 operating room observations, the total median (IQR) score was 25 (23-28), checklist adherence was 7 (6-7), communication effectiveness was 6 (6-7), attitude was 6 (6-7) and engagement was 6 (5-7). CONCLUSIONS: CheckPOINT is a simple and reliable tool to assess SSC implementation fidelity and identify areas of focus for improvement efforts. Although CheckPOINT would benefit from further testing, it offers a low-resource alternative to existing research tools and captures elements of adherence and team behaviours.

Remote Assessment of Real-World Surgical Safety Checklist Performance Using the OR Black Box: A Multi-Institutional Evaluation.

BACKGROUND: Large-scale evaluation of surgical safety checklist performance has been limited by the need for direct observation. The operating room (OR) Black Box is a multichannel surgical data capture platform that may allow for the holistic evaluation of checklist performance at scale. STUDY DESIGN: In this retrospective cohort study, data from 7 North American academic medical centers using the OR Black Box were collected between August 2020 and January 2022. All cases captured during this period were analyzed. Measures of checklist compliance, team engagement, and quality of checklist content review were investigated. RESULTS: Data from 7,243 surgical procedures were evaluated. A time-out was performed during most surgical procedures (98.4%, n = 7,127), whereas a debrief was performed during 62.3% (n = 4,510) of procedures. The mean percentage of OR staff who paused and participated during the time-out and debrief was 75.5% (SD 25.1%) and 54.6% (SD 36.4%), respectively. A team introduction (performed 42.6% of the time) was associated with more prompts completed (31.3% vs 18.7%, p < 0.001), a higher engagement score (0.90 vs 0.86, p < 0.001), and a higher percentage of team members who ceased other activities (80.3% vs 72%, p < 0.001) during the time-out. CONCLUSIONS: Remote assessment using OR Black Box data provides useful insight into surgical safety checklist performance. Many items included in the time-out and debrief were not routinely discussed. Completion of a team introduction was associated with improved time-out performance. There is potential to use OR Black Box metrics to improve intraoperative process measures.

Transforming Team Performance Through Reimplementation of the Surgical Safety Checklist.

Importance: Patient safety interventions, like the World Health Organization Surgical Safety Checklist, require effective implementation strategies to achieve meaningful results. Institutions with underperforming checklists require evidence-based guidance for reimplementing these practices to maximize their impact on patient safety. Objective: To assess the ability of a comprehensive system of safety checklist reimplementation to change behavior, enhance safety culture, and improve outcomes for surgical patients. Design, Setting, and Participants: This prospective type 2 hybrid implementation-effectiveness study took place at 2 large academic referral centers in Singapore. All operations performed at either hospital were eligible for observation. Surveys were distributed to all operating room staff. Intervention: The study team developed a comprehensive surgical safety checklist reimplementation package based on the Exploration, Preparation, Implementation, Sustainment framework. Best practices from implementation science and human factors engineering were combined to redesign the checklist. The revised instrument was reimplemented in November 2021. Main Outcomes and Measures: Implementation outcomes included penetration and fidelity. The primary effectiveness outcome was team performance, assessed by trained observers using the Oxford Non-Technical Skills (NOTECH) system before and after reimplementation. The Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture was used to assess safety culture and observers tracked device-related interruptions (DRIs). Patient safety events, near-miss events, 30-day mortality, and serious complications were tracked for exploratory analyses. Results: Observers captured 252 cases (161 baseline and 91 end point). Penetration of the checklist was excellent at both time points, but there were significant improvements in all measures of fidelity after reimplementation. Mean NOTECHS scores increased from 37.1 to 42.4 points (4.3 point adjusted increase; 95% CI, 2.9-5.7; P < .001). DRIs decreased by 86.5% (95% CI, -22.1% to -97.8%; P = .03). Significant improvements were noted in 9 of 12 composite areas on culture of safety surveys. Exploratory analyses suggested reductions in patient safety events, mortality, and serious complications. Conclusions and Relevance: Comprehensive reimplementation of an established checklist intervention can meaningfully improve team behavior, safety culture, patient safety, and patient outcomes. Future efforts will expand the reach of this system by testing a structured guidebook coupled with light-touch implementation guidance in a variety of settings.

International Perspectives on Modifications to the Surgical Safety Checklist.

Importance: Modification of the World Health Organization's Surgical Safety Checklist (SSC) is a critical component of its implementation. To facilitate the SSC's use, it is important to know how surgical teams modify their SSCs, their reasons for making modifications, and the opportunities and challenges teams face in SSC tailoring. Objective: To study SSC modifications in high-income hospital settings in 5 countries: Australia, Canada, New Zealand, the United States, and the United Kingdom. Design, Setting, and Participants: This qualitative study used semistructured interviews based on the survey used in the quantitative study. Each interviewee was asked a core set of questions and various follow-up questions based on their survey responses. Interviews were conducted from July 2019 to February 2020 in person and online using teleconferencing software. Surgeons, anesthesiologists, nurses, and hospital administrators from the 5 countries were recruited through a survey and snowball sampling. Main Outcomes and Measures: Interviewees' attitudes and perceptions on SSC modifications and their perceived impact on operating rooms. Results: A total of 51 surgical team members and hospital administrators from the 5 countries were interviewed (37 [75%] with >10 years of service; 28 [55%] women). There were 15 (29%) surgeons, 13 (26%) nurses, 15 (29%) anesthesiologists, and 8 (16%) health administrators. Five themes emerged concerning the awareness and involvement in SSC modifications; reasons for modifications; types of modifications; the outcomes of modifications; and perceived barriers to SSC modifications. Based on the interviews, some SSCs may go many years without being revisited or modified. SSCs are modified to ensure they address local issues and standards of practice and that they are fit for purpose. Modifications are also made following adverse events to reduce the risk of reoccurrence. Interviewees described adding, moving, and removing elements from their SSCs, which increased their sense of ownership in their SSC and participation in its performance. Some barriers to modification included leadership and the SSC's inclusion in hospitals' electronic medical record. Conclusions and Relevance: In this qualitative study of surgical team members and administrators, interviewees described addressing contemporary surgical issues through various SSC modifications. The process of SSC modification may improve team cohesion and buy-in in addition to providing opportunities for teams to improve patient safety.

Defining re-implementation.

BACKGROUND: The first attempt to implement a new tool or practice does not always lead to the desired outcome. Re-implementation, which we define as the systematic process of reintroducing an intervention in the same environment, often with some degree of modification, offers another chance at implementation with the opportunity to address failures, modify, and ultimately achieve the desired outcomes. This article proposes a definition and taxonomy for re-implementation informed by case examples in the literature. MAIN BODY: We conducted a scoping review of the literature for cases that describe re-implementation in concept or practice. We used an iterative process to identify our search terms, pilot testing synonyms or phrases related to re-implementation. We searched PubMed and CINAHL, including articles that described implementing an intervention in the same environment where it had already been implemented. We excluded articles that were policy-focused or described incremental changes as part of a rapid learning cycle, efforts to spread, or a stalled implementation. We assessed for commonalities among cases and conducted a thematic analysis on the circumstance in which re-implementation occurred. A total of 15 articles representing 11 distinct cases met our inclusion criteria. We identified three types of circumstances where re-implementation occurs: (1) failed implementation, where the intervention is appropriate, but the implementation process is ineffective, failing to result in the intended changes; (2) flawed intervention, where modifications to the intervention itself are required either because the tool or process is ineffective or requires tailoring to the needs and/or context of the setting where it is used; and (3) unsustained intervention, where the initially successful implementation of an intervention fails to be sustained. These three circumstances often co-exist; however, there are unique considerations and strategies for each type that can be applied to re-implementation. CONCLUSIONS: Re-implementation occurs in implementation practice but has not been consistently labeled or described in the literature. Defining and describing re-implementation offers a framework for implementation practitioners embarking on a re-implementation effort and a starting point for further research to bridge the gap between practice and science into this unexplored part of implementation.

Parental perceptions and experiences of care in the surgical neonatal intensive care unit.

BACKGROUND: Parents endure significant stress when their newborns require surgery while in the neonatal intensive care unit (NICU). Our study aims to explore the surgical NICU experience from the parents' perspective and identify areas that may improve this experience. A secondary objective was to integrate their feedback to refine the implementation strategy of the neonatal enhanced recovery after surgery (ERAS®) guideline. METHODS: In December 2019, five surgical NICU parents participated in a focus group. Conversation surrounded parents' perspectives and experiences of the surgical NICU. Inductive analysis was performed to identify data, themes, and concepts that emerged from the discussion. RESULTS: Participants identified four major interrelated themes that impacted the surgical parents' NICU experience. These themes include (1) parental state, both physical and emotional, (2) the altered parental caregiver role which necessitates identifying alternative meaningful parental experiences, (3) the care team dynamic, incorporating consistency and effective communication, and (4) the discharge process which may be significantly eased through graduated, hands-on training. CONCLUSION: Key elements of the neonatal ERAS® guideline address major themes and stressors identified by parents. The parental perspective may help clinicians appreciate the parent surgical NICU experience and assist in improving family-centered care to surgical infants and their families.

Association of Variation in US County-Level Rates of Liver Surgical Resection for Colorectal Liver Metastasis With Poverty Rates in 2010.

Importance: Among patients with colorectal liver metastasis (CRLM) who are eligible for curative-intent liver surgical resection, only half undergo liver metastasectomy. It is currently unclear how rates of liver metastasectomy vary geographically in the US. Geographic differences in county-level socioeconomic characteristics may, in part, explain variability in the receipt of liver metastasectomy for CRLM. Objective: To describe county-level variation in the receipt of liver metastasectomy for CRLM in the US and its association with poverty rates. Design, Setting, and Participants: This ecological, cross-sectional, and county-level analysis was conducted using data from the Surveillance, Epidemiology, and End Results Research Plus database. The study included the county-level proportion of patients who had colorectal adenocarcinoma diagnosed between January 1, 2010, and December 31, 2018, underwent primary surgical resection, and had liver metastasis without extrahepatic metastasis. The county-level proportion of patients with stage I colorectal cancer (CRC) was used as a comparator. Data analysis was performed on March 2, 2022. Exposures: County-level poverty in 2010 obtained from the US Census (proportion of county population below the federal poverty level). Main Outcomes and Measures: The primary outcome was county-level odds of liver metastasectomy for CRLM. The comparator outcome was county-level odds of surgical resection for stage I CRC. Multivariable binomial logistic regression accounting for clustering of outcomes within a county via an overdispersion parameter was used to estimate the county-level odds of receiving a liver metastasectomy for CRLM associated with a 10% increase in poverty rate. Results: In the 194 US counties included in this study, there were 11 348 patients. At the county level, the majority of the population was male (mean [SD], 56.9% [10.2%]), White (71.9% [20.0%]), and aged between 50 and 64 (38.1% [11.0%]) or 65 and 79 (33.6% [11.4%]) years. The adjusted odds of undergoing a liver metastasectomy was lower in counties with higher poverty in 2010 (per 10% increase; odds ratio, 0.82 [95% CI, 0.69-0.96]; P = .02). County-level poverty was not associated with receipt of surgery for stage I CRC. Despite the difference in rates of surgery (mean county-level rates were 0.24 for liver metastasectomy for CRLM and 0.75 for surgery for stage I CRC), the variance at the county-level for these 2 surgical procedures was similar (F370, 193 = 0.81; P = .08). Conclusions and Relevance: The findings of this study suggest that higher poverty was associated with lower receipt of liver metastasectomy among US patients with CRLM. Surgery for a more common and less complex cancer comparator (ie, stage I CRC) was not observed to be associated with county-level poverty rates. However, county-level variation in surgical rates was similar for CRLM and stage I CRC. These findings further suggest that access to surgical care for complex gastrointestinal cancers such as CRLM may be partially influenced by where patients live.