Surgical site infection rates are higher among elective colorectal surgery patients receiving non-beta-lactam-based antimicrobial prophylaxis: A retrospective chart review.

We compared the odds of acquiring surgical site infection (SSI) for clean-contaminated colorectal surgeries between intravenous ß-lactam-based prophylaxis (BLP) versus alternative antimicrobial prophylaxis (AAP). We calculated the odds of acquiring an SSI using logistic regression; adjusted odds ratios (ORs) with 95% confidence intervals (CIs) are reported. Increased odds of SSI were detected with AAP versus BLP (OR, 2.15; 95% CI, 1.33-3.50; P = .002).

Transition Home Following New Fecal Ostomy Creation: A Qualitative Study.

PURPOSE: Perioperative ostomy education is essential for patients to develop skills and comfort with self-care at home with a new ostomy, but shortened hospital length of stay (LOS) reduces time for postoperative education for patients. This study explored the initial experiences and care needs of patients who have undergone creation of a new ostomy during their transition from hospital to home. DESIGN: Qualitative interpretive description using latent content analysis. SUBJECTS AND SETTING: Thirteen patients who had undergone an elective colorectal surgery involving creation of an ostomy were interviewed. Participants were 33 to 78 years of age, 54% were female, and 62% were undergoing ostomy creation for colorectal cancer operations. Eleven participants underwent temporary ileostomy creation, and 2 patients had permanent end colostomies created. METHODS: Interviews were conducted in person and audiotaped by study investigators within 4 to 6 weeks postoperatively. Audiotapes were transcribed verbatim by trained transcriptionists, and each transcript was reviewed in duplicate by study investigators. A latent content analysis method was used to determine the implied meaning in participants' experiences of having a new ostomy. RESULTS: The transition from hospital to home with a new ostomy was illustrated by 5 major themes: (1) Having an ostomy is a life-changing and bizarre experience; (2) Adjustment and adaptation occur through acceptance and self-reliance; (3) It's a hands-on thing: with the role of WOC nurse providing support in achieving independence; (4) Improved home care infrastructure is needed; and (5) Practical advice shared from experiential learning. CONCLUSION: Patients with new ostomies are motivated and able to cope with the ostomy and regain independence over a short period after surgery. Shorter LOS does not impede ostomy education so long as adequate home care and support group programs are available. Knowledge gained through this study will assist WOC nurses in managing patients' expectations and the planning and delivery of education to patients with newly created ostomies.

Clinical and endoscopist factors associated with post-colonoscopy colorectal cancer in a population-based sample.

AIM: Factors associated with verified post-colonoscopy colorectal cancers (PCCRC) have not been well defined and survival for these patients is not well described. We aimed to assess the association of patient, tumour and endoscopist characteristics with PCCRC. METHODS: Using population-based data, we identified individuals diagnosed with CRC from 1 January 2000 to 31 December 2005 who underwent a colonoscopy within 3 years prior to diagnosis. Detected cancers were those diagnosed ≤6 months following colonoscopy; PCCRC were diagnosed >6 months to ≤3 years following colonoscopy. Post-colonoscopy and detected cancers were verified through chart review using a hospital-based simple random sampling frame. We used multivariable conditional logistic regression to determine the association of patient, tumour and endoscopist factors with PCCRC and compared overall survival using Cox proportional hazard models. RESULTS: Using the random sampling frame, we identified 498 patients with PCCRC and 498 with detected CRC; we obtained records and confirmed 367 patients with PCCRC and 412 with detected cancers. In multivariable analysis, patient age (OR 1.01; 95% CI 1.00-1.03) and tumour location (distal vs. proximal OR 0.36; 95% CI 0.25-0.53) were associated with PCCRC; endoscopist quality measures were not significantly associated with PCCRC. We did not find significant differences in overall survival between PCCRC and detected cancers (hazard ratio 1.12; 95% CI 0.92-1.32). CONCLUSION: Although endoscopic quality measures are important for CRC prevention, endoscopist factors were not associated with PCCRC. This study highlights the need for further research into the role of tumour biology in PCCRC development.

The predictors of Enhanced Recovery After Surgery utilization and practice variations in elective colorectal surgery: a provincial survey.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) protocols use evidence-based perioperative practices that reduce morbidity and length of stay and improve patient satisfaction. ERAS is considered standard of care; however, utilization remains low and substantial practice variation exists. The aim of this study was to pragmatically characterize variation in colorectal surgery practice and identify predictors of ERAS utilization. METHODS: A survey of general surgeons identified using the Ontario College of Physicians and Surgeons database was conducted. Information on basic demographic characteristics, utilization of ERAS and predictors of ERAS implementation was collected. Nine ERAS behaviours were analyzed. Multivariable analysis was used to determine effects of demographic, hospital and surgeon covariates on ERAS utilization. RESULTS: Seven hundred and ninety-seven general surgeons were invited to participate in the survey, and 235 general surgeons representing 84 Ontario hospitals responded (30% response rate). Surgeons practising in academic settings and in large community hospitals represented 30% and 47% of the respondents, respectively. A total of 20% of the respondents used all 9 ERAS behaviours consistently. Rates of diet advancement on postoperative day 0, intravenous fluid restriction and having catheter and line procedures were significantly higher among respondents who adhered to ERAS protocols than among those who did not (74% v. 54%, p = 0.004; 92% v. 80%, p = 0.01; and 91% v. 41%, p < 0.001, respectively). Respondents from academic settings reported practising nearly 1 more ERAS behaviour than those from small community hospitals (odds ratio [OR] 0.86, 95% confidence interval [CI] 0.42 to 1.31, p < 0.001). Multivariable analysis demonstrated that colorectal fellowship training or exposure to ERAS during training did not significantly affect ERAS behaviour utilization (OR 0.32, 95% CI -0.31 to 0.94, p = 0.16; OR 0.28, 95% CI -0.26 to 0.82, p = 0.16, respectively). CONCLUSION: Substantial practice variation in colorectal surgery still exists. Individual ERAS principles are commonly followed; however, ERAS behaviours are not widely formalized into hospital protocols.

CONTEXTE: Les protocoles de récupération optimisée après une chirurgie (ou ERAS, pour enhanced recovery after surgery) utilisent des pratiques périopératoires fondées sur des données probantes pour réduire la morbidité, abréger la durée des séjours hospitaliers et améliorer la satisfaction des patients. Les protocoles ERAS sont considérés comme une norme thérapeutique; toutefois, leur utilisation reste faible et on note une importante variation dans leur application. Le but de cette étude était de caractériser dans les faits les variations des pratiques en chirurgie colorectale et d'identifier les prédicteurs de l'utilisation des protocoles ERAS. MÉTHODES: Un sondage a été effectué auprès des chirurgiens généraux de la base de données du Collège des médecins et chirurgiens de l'Ontario. On a recueilli des données sur les caractéristiques démographiques de base, l'utilisation des protocoles ERAS et les prédicteurs de leur déploiement. Neuf pratiques ERAS ont été analysées. L'analyse multivariée a permis de déterminer les effets des covariables démographiques, hospitalières et celles des chirurgiens sur le recours aux protocoles ERAS. RÉSULTATS: Nous avons invité 797 chirurgiens généraux à participer au sondage, et 235 d'entre eux représentant 84 hôpitaux ontariens y ont répondu (taux de réponse 30 %). Les chirurgiens des établissements universitaires et des grands hôpitaux communautaires ont représenté respectivement 30 % et 47 % des répondants. En tout, 20 % des répondants ont déclaré appliquer les 9 pratiques ERAS de manière constante. L'alimentation précoce au Jour 0 postopératoire, la restriction des liquides intraveineux et les directives concernant les cathéters et les sondes étaient significativement mieux observées chez les répondants qui adhéraient aux protocoles ERAS que chez ceux qui n'y adhéraient pas (74 % c. 54 %, p = 0,004; 92 % c. 80 %, p = 0,01; et 91 % c. 41 %, p < 0,001, respectivement). Les répondants des milieux universitaires ont indiqué appliquer près de 1 comportement ERAS de plus que ceux des petits hôpitaux communautaires (rapport des cotes [RC] 0,86, intervalle de confiance [IC] de 95 % de 0,42 à 1,31, p < 0,001). L'analyse multivariée a démontré que la spécialisation en chirurgie colorectale ou l'exposition aux protocoles ERAS en cours de formation n'ont pas significativement influé sur l'application des pratiques ERAS (RC 0,32, IC de 95 % de ­0,31 à 0,94, p = 0,16; RC 0,28, IC de 95 % de ­0,26 à 0,82, p = 0,16, respectivement). CONCLUSION: On continue d'observer une importante variation des pratiques en chirurgie colorectale. Les principes ERAS individuels sont généralement suivis, mais ils ne sont pas formellement intégrés aux protocoles hospitaliers.

Diagnosis and management of acute cholecystitis: a single-centre audit of guideline adherence and patient outcomes.

Background: The Tokyo Guidelines were published in 2007 and updated in 2013 and 2018, with recommendations for the diagnosis and management of acute cholecystitis. We assessed guideline adherence at our academic centre and its impact on patient outcomes. Methods: This is a retrospective chart review of patients with acute calculous cholecystitis who underwent cholecystectomy at our institution between November 2013 and March 2015. Severity of cholecystitis was graded retrospectively if it had not been documented preoperatively. Compliance with the Tokyo Guidelines' recommendations on antibiotic use and time to operation was recorded. Cholecystitis severity groups were compared statistically, and logistic regression was used to determine predictors of complications. Results: One hundred and fifty patients were included in the study. Of these, 104 patients were graded as having mild cholecystitis, 45 as having moderate cholecystitis, and 1 as having severe cholecystitis. Severity was not documented preoperatively for any patient. Compliance with antibiotic recommendations was poor (18.0%) and did not differ by cholecystitis severity (p = 0.90). Compliance with the recommendation on time to operation was 86.0%, with no between-group differences (p = 0.63); it improved when an acute care surgery team was involved (91.0% v. 76.0%, p = 0.025). On multivariable analysis, comorbidities (odds ratio [OR] 1.47, 95% confidence interval [CI] 1.19-1.85, p < 0.001) and conversion to laparotomy (OR 13.45, 95% CI 2.16-125.49, p = 0.01) predicted postoperative complications, while severity of cholecystitis, antibiotic compliance and time to operation had no effect. Conclusion: In this study, compliance with the Tokyo Guidelines was acceptable only for time to operation. Although the poor compliance with recommendations relating to documentation of severity grading and antibiotic use did not have a negative affect on patient outcomes, these recommendations are important because they facilitate appropriate antibiotic use and patient risk stratification.

Contexte: Les Tokyo Guidelines, publiées en 2007, puis mises à jour en 2013 et en 2018, contiennent des recommandations sur le diagnostic et la prise en charge de la cholécystite aiguë. Nous avons évalué le respect de ces lignes directrices dans notre centre universitaire et son incidence sur les issues pour les patients. Méthodes: Ce document est une revue rétrospective de dossiers des patients atteints de cholécystite aiguë calculeuse qui ont subi une cholécystectomie dans notre établissement entre novembre 2013 et mars 2015. La gravité de la cholécystite a été établie de manière rétrospective si elle n'avait pas été documentée avant l'opération. Le respect des recommandations des Tokyo Guidelines concernant le recours à des antibiotiques et la durée de l'opération a été étudié. Nous avons comparé statistiquement les groupes de gravité de la cholécystite, et avons utilisé une régression logistique pour déterminer les prédicteurs de complications. Résultats: Au total, 150 patients ont été inclus dans l'étude. Parmi eux, 104 avaient une cholécystite légère, 45, une cholécystite modérée et 1, une cholécystite grave. La gravité de la maladie n'avait été documentée avant l'opération pour aucun patient. Le respect des recommandations sur les antibiotiques était faible (18,0 %) et ne variait pas selon la gravité de la cholécystite (p = 0,90). Le respect des recommandations sur la durée de l'opération était de 86,0 %, sans différence entre les groupes (p = 0,63); il était toutefois plus élevé lorsqu'une équipe de soins chirurgicaux aigus participait aux soins (91,0 % c. 76,0 %, p = 0,025). L'analyse multivariée a permis de déterminer que les comorbidités (rapport des cotes [RC] 1,47, intervalle de confiance [IC] de 95 % 1,19­1,85, p < 0,001) et la conversion en laparotomie (RC 13,45, IC de 95 % 2,16­125,49, p = 0,01) étaient des prédicteurs de complications postopératoires, alors que la gravité de la cholécystite et le respect des recommandations sur les antibiotiques et la durée de l'opération n'avaient pas d'effet. Conclusion: Dans cette étude, le respect des Tokyo Guidelines était acceptable seulement pour la durée de l'opération. Bien qu'un faible respect des recommandations quant à la documentation de la gravité et à l'utilisation d'antibiotiques n'ait pas eu d'effets négatifs sur les issues pour les patients, ces recommandations sont importantes parce qu'elles favorisent l'utilisation appropriée des antibiotiques et une bonne stratification du risque pour le patient.

Relation between socioeconomic variables and surgical, systemic and radiation treatment in a cohort of patients with breast cancer in an urban Canadian centre

Background: Studies have shown an association between socioeconomic status and breast cancer treatment. We examined the relation between socioeconomic status and the treatment of breast cancer (surgical, systemic and radiation) in a universal health care system. Methods: Data from a single urban Canadian centre were collected for consecutive patients who received a diagnosis of breast cancer from January 2010 to December 2011. Variables included patient and disease factors, surgery type, systemic and radiation treatment, and breast reconstruction. Socioeconomic variables were obtained from 2006 Canadian census data. We used multivariable logistic regression to identify predictors of breast cancer treatment. Results: A total of 721 patients were treated for breast cancer during the study period. Socioeconomic variables were not related to type of breast surgery for breast cancer. Age less than 50 years, having a first-degree relative with breast cancer and income status were predictors of breast reconstruction. Employment status was a consistent predictor of systemic and radiation treatment. Conclusion: Employment consistently predicted systemic and radiation treatment, and age and income were predictors of breast reconstruction in a universal health care system. Further research is required to determine precisely how socioeconomic factors affect care and to minimize possible disparities in delivery of health care services.

Contexte: Des études ont montré un lien entre la situation socio-économique et le traitement du cancer du sein. Nous avons analysé ce lien entre la situation socioéconomique et le traitement (chirurgie, chimiothérapie, radiothérapie) du cancer du sein dans un système de santé universel. Méthodes: Les données d'un seul centre urbain canadien ont été compilées pour les patientes consécutives ayant reçu un diagnostic de cancer du sein entre janvier 2010 et décembre 2011. Les variables incluaient des facteurs propres aux patientes et à la maladie, le type de chirurgie, la chimiothérapie, la radiothérapie et la reconstruction mammaire. Les variables socio-économiques proviennent des données du recensement canadien de 2006. Nous avons utilisé la régression logistique multivariée pour identifier les prédicteurs du traitement du cancer du sein. Résultats: En tout, 721 patientes ont été traitées pour un cancer du sein durant la période de l'étude. Les variables socio-économiques n'ont pas influé sur le type de chirurgie mammaire pour cancer du sein. L'âge inférieur à 50 ans, un cancer du sein chez une parente au premier degré et le revenu ont été des prédicteurs de la reconstruction mammaire. La situation professionnelle a été un prédicteur fiable du traitement systémique et de la radiothérapie. Conclusion: L'emploi a été un prédicteur fiable du traitement systémique et de la radiothérapie, et l'âge et le revenu ont été des prédicteurs de la reconstruction mammaire, dans un système de santé universel. Il faudra approfondir la recherche pour déterminer plus précisément l'influence des facteurs socio-économiques sur les soins et pour réduire les possibles disparités dans leur prestation.

A Provincial Assessment of the Barriers and Utilization of Enhanced Recovery After Colorectal Surgery.

BACKGROUND: Enhanced recovery after surgery (ERAS) protocols after colorectal surgery use several perioperative, intraoperative and postoperative interventions that decrease morbidity, length of stay, and improve patient satisfaction. ERAS is increasingly being considered standard of care; however, uptake of formalized protocols remains low. The objective is to characterize the provincial rates of ERAS utilization after colorectal surgery and identify barriers and limitations to ERAS implementation. METHODS: A total of 797 general surgeons were identified through the College of Physicians and Surgeons of Ontario. A survey identifying demographics, rates of ERAS utilization, and barriers to implementation was distributed. Logistic regression determined the effects of demographic and hospital covariates on ERAS utilization. RESULTS: A total of 235 general surgeons representing 84 Ontario hospitals participated (response rate 29.5%). Surgeons working in academic or large community hospitals represented the majority of the cohort (30.5% and 47.2%, respectively). Multivariable analysis showed no significant effect of surgeon demographics, years in practice, or training details on ERAS protocol utilization; however, practicing in small community hospitals (compared with large and academic hospitals) was significantly associated with not using ERAS protocols (odds ratio, 0.02; 95% confidence interval, 0-0.3; P = 0.005). Over 50% of respondents used ERAS principles but did not have a formal protocol. Barriers to implementing ERAS protocols included patient variability, lack of institutional and nursing support, and poor communication with the care team. CONCLUSIONS: Small community hospitals are less likely to use formal ERAS protocols; however, most Ontario surgeons are using ERAS principles after colorectal surgery. Barriers to ERAS implementation are broad and the present study has provided a pragmatic solution to change.

Does Imaging Before Percutaneous Drain Removal Affect Rates of Intra-abdominal Abscess Recurrence?

BACKGROUND: Intra-abdominal abscesses account for a large proportion of surgical complications and carry high mortality if not promptly controlled. Image-guided percutaneous drainage is standard of care. The objective of the study was to identify factors that predict abscess recurrence after percutaneous drain (PD) removal and determine if imaging before drain removal effects recurrence. METHODS: A consecutive multicenter retrospective cohort analysis of all patients who underwent PD insertion for abscesses between January 1, 2015, and December 31, 2015, was performed. Patient characteristics, PD details, and abscess recurrence were assessed. RESULTS: One hundred eighty-eight patients underwent PD insertion for spontaneous or postoperative abscesses, and overall abscess recurrence was 21%. Drains remained in situ for a median of 21.5 d (interquartile range: 9-42 d) with antibiotics used in 91% of cases. Forty-seven patients (25%) had a sinogram before PD removal, while 22% had computed tomography (CT) scans and 11% had ultrasounds. Hierarchical multivariable regression analysis showed that imaging before PD removal was associated with a 66% reduction in the odds of abscess recurrence (OR 0.34; 95% confidence interval [CI] 0.13-0.70; P = 0.006). Sinogram use was associated with an 86% reduction in the odds of recurrence (OR 0.14; 95% CI 0.02-0.39; P = 0.002) and ultrasound use was associated with a 78% reduction in the odds of recurrence (OR 0.22; 95% CI 0.02-0.76; P = 0.044) while CT use was not associated with a significant reduction in recurrence. CONCLUSIONS: Imaging before PD removal is associated with a reduction in the rates of abscess recurrence and requirement for additional drainage procedures or surgery. In addition, CT is not superior to ultrasound or sinograms as an imaging modality.

The effect of simethicone on postoperative ileus in patients undergoing colorectal surgery (SPOT), a randomized controlled trial.

BACKGROUND: Postoperative ileus is a poorly understood multifactorial outcome following colorectal surgery that presents significant clinical challenges and contributes to increased morbidity, length of stay, and healthcare cost. To date, there are few pharmacological interventions that shorten the duration of postoperative ileus. OBJECTIVE: This study is the first to evaluate the efficacy of simethicone in treating postoperative ileus symptoms in patients undergoing colorectal surgery. DESIGN: A multicenter, double-blinded, placebo controlled randomized controlled trial. SETTINGS: This trial was conducted at two academic tertiary care centres in Ontario, Canada. PARTICIPANTS: 118 patients undergoing colorectal surgery. INTERVENTIONS: Patients were randomized to receive either a five-day course of oral simethicone (n = 58) or a placebo (n = 60). MAIN OUTCOME MEASURES: The primary outcome was time to first passage of flatus. Secondary outcomes included time to first bowel movement, postoperative length of stay, and postoperative pain. Statistical analyses were performed on an intention-to-treat basis. Statistical significance set at p = 0.05. RESULTS: The median time to first passage of flatus in simethicone arm was 25.2 h and 26.7 h in controls (P = 0.98). There were no significant differences in the median time to first bowel movement (simethicone = 41.1 h vs. control = 42.9 h, P = 0.91) or median length of hospital stay (simethicone = 4.5 days vs. control = 4.0 days, P = 0.63). CONCLUSIONS: This study failed to show a difference in return of gastrointestinal motility in patients receiving simethicone following colorectal surgery. Postoperative ileus remains a significant clinical and economic burden to the healthcare system and further research is needed to identify a reliable and effective method of treatment.

Development of an Enhanced Recovery After Surgery Guideline and Implementation Strategy Based on the Knowledge-to-action Cycle.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) protocols have been shown to increase recovery, decrease complications, and reduce length of stay. However, they are difficult to implement. OBJECTIVE: To develop and implement an ERAS clinical practice guideline (CPG) at multiple hospitals. METHODS: A tailored strategy based on the Knowledge-to-action (KTA) cycle was used to develop and implement an ERAS CPG at 15 academic hospitals in Canada. This included an initial audit to identify gaps and interviews to assess barriers and enablers to implementation. Implementation included development of an ERAS guideline by a multidisciplinary group, communities of practice led by multidiscipline champions (surgeons, anesthesiologists, and nurses) both provincially and locally, educational tools, and clinical pathways as well as audit and feedback. RESULTS: The initial audit revealed there was greater than 75% compliance in only 2 of 18 CPG recommendations. Main themes identified by stakeholders were that the CPG must be based on best evidence, there must be increased communication and collaboration among perioperative team members, and patient education is essential. ERAS and Pain Management CPGs were developed by a multidisciplinary team and have been adopted at all hospitals. Preliminary data from more than 1000 patients show that the uptake of recommended interventions varies but despite this, mean length of stay has decreased with low readmission rates and adverse events. CONCLUSIONS: On the basis of short-term findings, our results suggest that a tailored implementation strategy based on the KTA cycle can be used to successfully implement an ERAS program at multiple sites.

Case report: Sigmoid strangulation from evisceration through a perforated rectal prolapse ulcer - An unusual complication of rectal prolapse.

INTRODUCTION: Rectal prolapse occurs particularly in elder females and presentation can sometimes lead to complications such as strangulation and evisceration of other organs through the necrotic mucosa. PRESENTATION OF CASE: This is a case of a 61 year-old female with rectal prolapse complicated by rectal perforation through which a segment of sigmoid colon eviscerated and became strangulated. This patient initially presented with sepsis requiring ICU admission, but fully recovered following a Hartmann's procedure with a sacral rectopexy. DISCUSSION: Complications of rectal prolapse include incarceration, strangulation, and rarely, perforation with evisceration of other viscera requiring urgent operation. This report provides a brief overview of complications associated with rectal prolapse, reviews similar cases of transrectal evisceration, and discusses the management of chronic rectal prolapse. CONCLUSION: Prompt surgical consult is warranted if any signs or symptoms suggestive of complications from prolapse are present.

An Internet-Based Collaborative Cancer Conference for Rectal Cancer Influenced Surgeon Treatment Recommendations.

INTRODUCTION: In many jurisdictions geographic and resource constraints are barriers to multidisciplinary cancer conference review of all patients undergoing cancer surgery. We piloted an internet-based collaborative cancer conference (I-CCC) for rectal cancer to overcome these barriers in the LHIN4 region of Ontario (population 1.4 million). METHODS: Surgeons practicing at one of 10 LHIN4 hospitals were invited to participate in I-CCC reviews. A secure internet audio and visual link facilitated review of cross-sectional images and case details. Before review, referring surgeons detailed initial treatment plans. Main treatment options included preoperative radiation, straight to surgery, and plan uncertain. Changes were noted following I-CCC review from initial to final treatment plan. Major changes included: redirect patient to preoperative radiation from straight to surgery or plan uncertain; and redirect patient to straight to surgery from preoperative radiation or plan uncertain. Minor changes included: change type of neoadjuvant therapy; request additional tests (e.g., pelvic MRI); or formal MCC review. RESULTS: From November 2010 to May 2012, 20 surgeons (7 academic and 13 community) submitted 57 rectal cancer cases for I-CCC review. After I-CCC review, 30 of 57 (53 %) cases had treatment plan changes: 17 major and 13 minor. No patient or tumour factors predicted for treatment plan change. CONCLUSIONS: An I-CCC for rectal cancer in a large geographic region was feasible and influenced surgeon treatment recommendations in 53 % of cases. Because no factor predicted for treatment plan change, it is likely prudent that all rectal cancer patients undergo some form of collaborative review.

Quality of inguinal hernia operative reports: room for improvement.

BACKGROUND: Operative reports (ORs) serve as the official documentation of surgical procedures. They are essential for optimal patient care, physician accountability and billing, and direction for clinical research and auditing. Nonstandardized narrative reports are often of poor quality and lacking in detail. We sought to audit the completeness of narrative inguinal hernia ORs. METHODS: A standardized checklist for inguinal hernia repair (IHR) comprising 33 variables was developed by consensus of 4 surgeons. Five high-volume IHR surgeons categorized items as essential, preferable or nonessential. We audited ORs for open IHR at 6 academic hospitals. RESULTS: We audited 213 ORs, and we excluded 7 femoral hernia ORs. Tension-free repairs were the most common (82.5%), and the plug-and-patch technique was the most frequent (52.9%). Residents dictated 59% of ORs. Of 33 variables, 15 were considered essential and, on average, 10.8 ± 1.3 were included. Poorly reported elements included first occurrence versus recurrent repair (8.3%), small bowel viability in incarcerated hernias (10.7%) and occurrence of intraoperative complications (32.5%). Of 18 nonessential elements, deep vein thrombosis prophylaxis, preoperative antibiotics and urgency were reported in 1.9%, 11.7% and 24.3% of ORs, respectively. Repair-specific details were reported in 0 to 97.1% of ORs, including patch sutured to tubercle (55.1%) and location of plug (67.0%). CONCLUSION: Completeness of IHR ORs varied with regards to essential and nonessential items but were generally incomplete, suggesting there is opportunity for improvement, including implementation of a standardized synoptic OR.

CONTEXTE: Les notes opératoires (NO) servent à documenter officiellement les interventions chirurgicales. Elles sont indispensables à des soins optimaux aux patients, à l'imputabilité des médecins, à la facturation de leurs actes, à l'orientation de la recherche clinique et aux vérifications. Les notes narratives non standardisées sont souvent de piètre qualité et incomplètes. Nous avons voulu vérifier l'exhaustivité des notes opératoires narratives concernant les réparations d'hernies inguinales (RHI). MÉTHODES: Une équipe de 4 chirurgiens a créé une liste de vérification standardisée consensuelle comprenant 33 variables applicables à la RHI. Cinq chirurgiens experts des RHI ont classé ces éléments selon qu'ils leurs semblaient essentiels, préférables ou non essentiels. Nous avons passé en revue les NO des RHI ouvertes effectuées dans 6 hôpitaux universitaires. RÉSULTATS: Nous avons passé en revue 213 NO et nous avons exclus les NO concernant 7 hernies fémorales. Les réparations sans tension se sont révélées les plus communes (82,5 %) et la technique plug-and-patch a été la plus fréquente (52,9 %). Les résidents ont dicté 59 % des NO. Sur les 33 variables, 15 étaient considérées essentielles et en moyenne, 10,8 ± 1,3 ont été incluses dans les NO. Parmi les éléments qui laissaient à désirer, mentionnons : première réparation c. réparation récurrente (8,3 %), viabilité du grêle dans les hernies incarcérées (10,7 %) et complications peropératoires (32,5 %). Parmi les 18 éléments jugés non essentiels, la prophylaxie contre la thrombose veineuse profonde, l'antibioprophylaxie et le degré d'urgence ont été mentionnés dans 1,9 %, 11,7 % et 24,3 % des NO, respectivement. Les détails spécifiques à la réparation ont été notés dans 0 à 97,1 % des NO, y compris la fixation de la prothèse au tubercule par des sutures (55,1 %) et la localisation du bouchon (67,0 %). CONCLUSION: L'exhaustivité des NO consignées dans les cas de RHI a varié en ce qui a trait aux éléments jugés essentiels et non essentiels et les NO se sont généralement révélées incomplètes. On en conclut qu'il y a place à amélioration, entre autre par l'adoption d'un modèle synoptique standardisé de NO.

Quality improvement in colorectal cancer in local health integration network 4 (LHIN 4) project (QICC-L4): integrated knowledge translation in a large geographic region.

BACKGROUND: Stakeholders suggest that integrating end users into the planning and execution of quality improvement interventions may more effectively close quality gaps. We tested if such an approach could improve the quality of colorectal cancer surgery in a large geographic region (i.e., LHIN4) in Ontario, Canada. METHODS: All LHIN4 surgeons who provide colorectal cancer surgery were invited to an October 2006 inaugural QICC-L4 workshop and subsequent workshops in 2008, 2010, and 2012. At workshops, surgeons selected clinically relevant quality markers for targeted improvement and interventions to achieve improvements. Selected markers included rates of colon and rectal radiology imaging, rate of pathology reporting of rectal radial margin distance, and rate of positive rectal radial margins. To date, implemented interventions have included audit and feedback, tailoring interviews to identify barriers and facilitators to optimal quality, and preoperative internet-based patient reviews. Hospital and regional cancer centre charts provide audit data for annual feedback reports to surgeons. RESULTS: Participating surgeons at workshops and surgeon participants in preoperative reviews treated approximately 70 % of all LHIN4 patients undergoing colorectal surgery. For years 2006-2012, the rate of radiology imaging for colon and rectal cases increased from 70 to 91 % and from 71 to 91 %, respectively. For rectal cases, the rate of reporting radial margins increased (55-93 %), and the rate of positive radial margins decreased (14-6 %). CONCLUSIONS: Initiation of the integrated knowledge translation QICC-L4 project in a large geographic region was associated with marked improvements in relevant colorectal cancer surgery quality markers.

A population-based study of rates of childbirth in recurrence-free female young adult survivors of non-gynecologic malignancies.

BACKGROUND: Fertility is an important issue for long-term survivors of malignancies developing during reproductive years. We designed a population-based study to investigate childbirth in female young adult survivors of non-gynecologic malignancies. METHODS: Women 20-34 years diagnosed with non-gynecologic malignancies in Ontario from 1992-1999 who lived at least 5 years recurrence-free were identified using the Ontario Cancer Registry and age matched to 5 randomly selected cancer-free women. Childbirth was determined through hospital discharge data. Time-to-childbirth was compared between survivors and controls using Cox proportional hazard regression for all subjects and stratified by prior childbirth and disease site. RESULTS: 3,285 survivors and 15,118 control women had a median of 12 years observation. 1,194 survivors and 6,049 controls experienced childbirth to the end of observation (March 2011). Overall, survivors experienced a longer time to childbirth than controls (HR 0.92, 95% CI 0.87-0.98), however this was limited to survivors with prediagnosis childbirth (HR 0.76, 95% CI 0.66-0.86). Survivors with no prediagnosis childbirth experienced a similar time to childbirth (HR 1.00, 95% CI 0.93-1.08) as control women. Differences between survivors and controls varied by type of malignancy; notably for those with prediagnosis childbirth, survivors of breast cancer (HR 0.45, 95% CI 0.29-0.68) and Hodgkin Disease (HR 0.57, 95% CI 0.36-0.91) had lower rates of postdiagnosis childbirth than controls. CONCLUSIONS: Long-term female young adult survivors of malignancies are less likely than controls to have childbirth after diagnosis; the overall effect is small and is influenced by prediagnosis childbirth and malignancy type.

Review article: the anesthesiologist's role in the prevention of surgical site infections.

PURPOSE: To highlight the role of anesthesiologists in the prophylaxis of surgical site infections (SSIs) and to recognize the central role they play in quality improvement initiatives for the prevention of SSIs. SOURCE: The medical literature was searched with a focus on three interventions affecting the risk of SSIs: preoperative antibiotic administration, perioperative normothermia, and perioperative hyperoxia. The literature was also searched for examples of initiatives in patient safety and quality improvement that highlight the role of anesthesiologists in preventing SSIs. PRINCIPAL FINDINGS: The timely administration of preoperative antibiotics and the maintenance of perioperative normothermia have been shown to reduce the risk of SSI significantly. Perioperative hyperoxia in the prevention of SSIs remains controversial but may improve outcomes in specific subsets of the surgical population. Initiatives in quality improvement show the challenges faced by many centres to improve upon these processes of care, but they also highlight the role of anesthesiologists as champions in the multidisciplinary efforts for the prevention of SSIs. CONCLUSIONS: Anesthesiologists are responsible for many of the processes of care shown to impact the risk for SSIs, and they play an important role in the prevention of SSIs. Their leadership in the multidisciplinary efforts to improve the quality of the surgical patient is of critical importance.

Multistate models for comparing trends in hospitalizations among young adult survivors of colorectal cancer and matched controls.

BACKGROUND: Over the past years, the incidence of colorectal cancer has been increasing among young adults. A large percentage of these patients live at least 5 years after diagnosis, but it is unknown whether their rate of hospitalizations after this 5-year mark is comparable to the general population. METHODS: This is a population-based cohort consisting of 917 young adult survivors diagnosed with colorectal cancer in Ontario from 1992-1999 and 4585 matched cancer-free controls. A multistate model is presented to reflect and compare trends in the hospitalization process among survivors and their matched controls. RESULTS: Analyses under a multistate model indicate that the risk of a subsequent hospital admission increases as the number of prior hospitalizations increases. Among patients who are yet to experience a hospitalization, the rate of admission is 3.47 times higher for YAS than controls (95% CI (2.79, 4.31)). However, among patients that have experienced one and two hospitalizations, the relative rate of a subsequent admission decreases to 3.03 (95% CI (2.01, 4.56)) and 1.90 (95% CI (1.19, 3.03)), respectively. CONCLUSIONS: Young adult survivors of colorectal cancer have an increased risk of experiencing hospitalizations compared to cancer-free controls. However this relative risk decreases as the number of prior hospitalizations increases. The multistate approach is able to use information on the timing of hospitalizations and answer questions that standard Poisson and Negative Binomial models are unable to address.

Surgical site infection prevention: a survey to identify the gap between evidence and practice in University of Toronto teaching hospitals.

BACKGROUND: A gap exists between the best evidence and practice with regards to surgical site infection (SSI) prevention. Awareness of evidence is the first step in knowledge translation. METHODS: A web-based survey was distributed to 59 general surgeons and 68 residents at University of Toronto teaching hospitals. Five domains pertaining to SSI prevention with questions addressing knowledge of prevention strategies, efficacy of antibiotics, strategies for changing practice and barriers to implementation of SSI prevention strategies were investigated. RESULTS: Seventy-six individuals (60%) responded. More than 90% of respondents stated there was evidence for antibiotic prophylaxis and perioperative normothermia and reported use of these strategies. There was a discrepancy in the perceived evidence for and the self-reported use of perioperative hyperoxia, omission of hair removal and bowel preparation. Eighty-three percent of respondents felt that consulting published guidelines is important in making decisions regarding antibiotics. There was also a discrepancy between what respondents felt were important strategies to ensure timely administration of antibiotics and what strategies were in place. Checklists, standardized orders, protocols and formal surveillance programs were rated most highly by 75%-90% of respondents, but less than 50% stated that these strategies were in place at their institutions. CONCLUSION: Broad-reaching initiatives that increase surgeon and trainee awareness and implementation of multifaceted hospital strategies that engage residents and attending surgeons are needed to change practice.

Analysis of administrative data finds endoscopist quality measures associated with postcolonoscopy colorectal cancer.

BACKGROUND & AIMS: Most quality indicators for colonoscopy measure processes; little is known about their relationship to patient outcomes. We investigated whether characteristics of endoscopists, determined from administrative data, are associated with development of postcolonoscopy colorectal cancer (PCCRC). METHODS: We identified individuals diagnosed with colorectal cancer in Ontario from 2000 to 2005 using the Ontario Cancer Registry. We determined performance of colonoscopy using Ontario Health Insurance Plan data. Patients who had complete colonoscopies 7 to 36 months before diagnosis were defined as having a PCCRC. Patients who had complete colonoscopies within 6 months of diagnosis had detected cancers. We determined if endoscopist factors (volume, polypectomy and completion rate, specialization, and setting) were associated with PCCRC using logistic regression, controlling for potential covariates. RESULTS: In the study, 14,064 patients had a colonoscopy examination within 36 months of diagnosis; 584 (6.8%) with distal and 676 (12.4%) with proximal tumors had PCCRC. The endoscopist's specialty (nongastroenterologist/nongeneral surgeon) and setting (non-hospital-based colonoscopy) were associated with PCCRC. Those who underwent colonoscopy by an endoscopist with a high completion rate were less likely to have a PCCRC (distal: odds ratio [OR], 0.73; 95% confidence interval [CI], 0.54-0.97; P = .03; proximal: OR, 0.72; 95% CI, 0.53-0.97; P = .002). Patients with proximal cancers undergoing colonoscopy by endoscopists who performed polypectomies at high rates had a lower risk of PCCRC (OR, 0.61; 95% CI, 0.42-0.89; P < .0001). Endoscopist volume was not associated with PCCRC. CONCLUSIONS: Endoscopist characteristics derived from administrative data are associated with development of PCCRC and have potential use as quality indicators.