Outcomes and Healthcare Utilization Among New Persistent Opioid Users and Nonopioid Users After Curative-intent Surgery for Cancer.

OBJECTIVE: The aim of the study was to compare the health outcomes and resource use of cancer patients who were new persistent opioid users with those who were not, after undergoing curative intent surgery for cancer. BACKGROUND: Little is known about long-term health outcomes (overdose, mortality) and resource utilization of new persistent opioid users among cancer patients undergoing curative-intent surgery. METHODS: This retrospective cohort study included all adults with a diagnosis of solid cancers who underwent curative-intent surgery during the study period (2011-2015) in Alberta, Canada and were opioid-naïve before surgery, with a follow-up period until December 31, 2019. The key exposure, "new persistent opioid user," was defined as a patient who was opioid-naive before surgery and subsequently filled at least 1 opioid prescription between 60 and 180 days after surgery. The primary outcome was opioid overdose that occurred within 3 years of surgery. All-cause death, noncancer caused death, and department visit (yes vs. no), and hospitalization (yes vs. no) in the follow-up periods were also included as outcomes. RESULTS: In total, 19,219 patients underwent curative intent surgery with a median follow-up of 47 months, of whom 1530 (8.0%) were identified as postoperative new persistent opioid users. In total, 101 (0.5%) patients experienced opioid overdose within 3 years of surgery. Compared with nonopioid users, new persistent opioid users experienced a higher rate of opioid overdose (OR = 2.37, 95% CI: 1.44-3.9) within 3 years of surgery. New persistent opioid use was also associated with a greater likelihood of being hospitalized (OR = 2.03, 95% CI: 1.76-2.33) and visiting an emergency room (OR = 1.83, 95% CI: 1.62-2.06) in the first year after surgery, and a higher overall (HR = 1.28, 95% CI: 1.1-1.49) and noncancer caused mortality (HR = 1.33, 95% CI: 1.12-1.58), when compared with nonopioid users. CONCLUSION: Postoperative new persistent opioid use among cancer patients undergoing curative-intent surgery is associated with subsequent opioid overdose, worse survival, and more health resource utilization.

Multiphasic exercise prehabilitation for patients undergoing surgery for head and neck cancer: a hybrid effectiveness-implementation study protocol.

Head and neck cancer (HNC) treatment often consists of major surgery followed by adjuvant therapy, which can result in treatment-related side effects, decreased physical function, and diminished quality of life. Perioperative nutrition interventions and early mobilization improve recovery after HNC treatment. However, there are few studies on prehabilitation that include exercise within the HNC surgical care pathway. We have designed a multiphasic exercise prehabilitation intervention for HNC patients undergoing surgical resection with free flap reconstruction. We will use a hybrid effectiveness-implementation study design guided by the RE-AIM framework to address the following objectives: (1) to evaluate intervention benefits through physical function and patient-reported outcome assessments; (2) to determine the safety and feasibility of the prehabilitation intervention; (3) to evaluate the implementation of exercise within the HNC surgical care pathway; and (4) to establish a post-operative screening and referral pathway to exercise oncology resources. The results of this study will provide evidence for the benefits and costs of a multiphasic exercise prehabilitation intervention embedded within the HNC surgical care pathway. This paper describes the study protocol design, multiphasic exercise prehabilitation intervention, planned analyses, and dissemination of findings. Trial registration: https://clinicaltrials.gov/NCT04598087.

Impact of Family Presence on Delirium in Critically Ill Patients: A Retrospective Cohort Study.

OBJECTIVE: To assess the effect of family presence on the prevalence and duration of delirium in adults admitted to an ICU. DESIGN: Retrospective cohort study. SETTING: Medical-surgical ICUs in Alberta, AB, Canada. PATIENTS: A population of 25,537 unique patients admitted at least once to an Alberta ICU. METHODS: We obtained electronic health records of consecutive adults (≥ 18 yr) admitted to one of 14 medical-surgical ICU in Alberta, Canada, from January 1, 2014, to December 30, 2018. Family presence was quantified using a validated algorithm and categorized as: 1) physical presence in ICU, 2) telephone call only, and 3) no presence (reference group). Delirium was measured using the Intensive Care Delirium Screening Checklist (ICDSC) and defined as an ICDSC greater than or equal to 4. Multivariable mixed-effects logistic and linear regression were used to evaluate the association between family presence and prevalence (binary) and duration (d) of delirium, respectively. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The association between family presence and delirium prevalence differed according to admission type and admission Glasgow Coma Scale (GCS). Among medical and emergency surgical patients irrespective of admission GCS, physical presence of family was not significantly associated with the prevalence of delirium. In elective surgical patients, physical presence of family was associated with decreased prevalence of delirium in patients with intact Glasgow Coma Scale (GCS = 15; adjusted odds ratio, 0.60; 95% CI, 0.39-0.97; p = 0.02). Physical presence of family (adjusted mean difference [AMD] -1.87 d; 95% CI, -2.01 to -1.81; p < 0.001) and telephone calls (AMD -1.41 d; 95% CI, -1.52 to -1.31; p < 0.001) were associated with decreased duration of delirium in all patients. CONCLUSIONS: The effects of family presence on delirium are complex and dependent on type of visitation, reason for ICU admission, and brain function on ICU admission.

A Multiple Baseline Trial of an Electronic ICU Discharge Summary Tool for Improving Quality of Care.

OBJECTIVE: Effective communication between clinicians is essential for seamless discharge of patients between care settings. Yet, discharge summaries are commonly not available and incomplete. We implemented and evaluated a structured electronic health record-embedded electronic discharge (eDischarge) summary tool for patients discharged from the ICU to a hospital ward. DESIGN: Multiple baseline trial with randomized and staggered implementation. SETTING: Adult medical-surgical ICUs at four acute care hospitals serving a single Canadian city. PATIENTS: Health records of patients 18 years old or older, in the ICU 24 hours or longer, and discharged from the ICU to an in-hospital patient ward between February 12, 2018, and June 30, 2019. INTERVENTION: A structured electronic note (ICU eDischarge tool) with predefined fields (e.g., diagnosis) embedded in the hospital-wide electronic health information system. MEASUREMENTS AND MAIN RESULTS: We compared the percent of timely (available at discharge) and complete (included goals of care designation, diagnosis, list of active issues, active medications) discharge summaries pre and post implementation using mixed effects logistic regression models. After implementing the ICU eDischarge tool, there was an immediate and sustained increase in the proportion of patients discharged from ICU with timely and complete discharge summaries from 10.8% (preimplementation period) to 71.1% (postimplementation period) (adjusted odds ratio, 32.43; 95% CI, 18.22-57.73). No significant changes were observed in rapid response activation, cardiopulmonary arrest, death in hospital, ICU readmission, and hospital length of stay following ICU discharge. Preventable (60.1 vs 5.7 per 1,000 d; p = 0.023), but not nonpreventable (27.3 vs 40.2 per 1,000d; p = 0.54), adverse events decreased post implementation. Clinicians perceived the eDischarge tool to produce a higher quality discharge process. CONCLUSIONS: Implementation of an electronic tool was associated with more timely and complete discharge summaries for patients discharged from the ICU to a hospital ward.

Adverse Events After Transition From ICU to Hospital Ward: A Multicenter Cohort Study.

OBJECTIVES: To examine adverse events and associated factors and outcomes during transition from ICU to hospital ward (after ICU discharge). DESIGN: Multicenter cohort study. SETTING: Ten adult medical-surgical Canadian ICUs. PATIENTS: Patients were those admitted to one of the 10 ICUs from July 2014 to January 2016. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Two ICU physicians independently reviewed progress and consultation notes documented in the medical record within 7 days of patient's ICU discharge date to identify and classify adverse events. The adverse event data were linked to patient characteristics and ICU and ward physician surveys collected during the larger prospective cohort study. Analyses were conducted using multivariable logistic regression. Of the 451 patients included in the study, 84 (19%) experienced an adverse event, the majority (62%) within 3 days of transfer from ICU to hospital ward. Most adverse events resulted only in symptoms (77%) and 36% were judged to be preventable. Patients with adverse events were more likely to be readmitted to the ICU (odds ratio, 5.5; 95% CI, 2.4-13.0), have a longer hospital stay (mean difference, 16.1 d; 95% CI, 8.4-23.7) or die in hospital (odds ratio, 4.6; 95% CI, 1.8-11.8) than those without an adverse event. ICU and ward physician predictions at the time of ICU discharge had low sensitivity and specificity for predicting adverse events, ICU readmissions, and hospital death. CONCLUSIONS: Adverse events are common after ICU discharge to hospital ward and are associated with ICU readmission, increased hospital length of stay and death and are not predicted by ICU or ward physicians.

Adverse Events Among Hospitalized Critically Ill Patients: A Retrospective Cohort Study.

OBJECTIVE: The objective of this study was to estimate the frequency and type of adverse events (AEs) among critically ill patients and identify patient and hospital factors associated with AEs and clinical and health care utilization consequences of AEs. MATERIALS AND METHODS: This retrospective cohort study includes patients admitted to 30 intensive care units (ICUs) in Alberta, Canada from May 2014 to April 2017. The main outcome was AEs derived from validated ICD-10, Canadian code algorithms for 18 AEs. Estimates of the proportion and rate of AEs are presented. The association between documented AEs and patient (eg, age, sex, comorbidities) and hospital (eg, ICU site and type, length of stay, readmission) variables are described using regression methods. RESULTS: Of 49,447 hospital admissions with admission to ICU, ≥1 AEs were documented in 12,549 (25%) admissions. The most common AEs were respiratory complications (10%) and hospital-acquired infections (9%). AEs were associated with having ≥2 comorbidities [odds ratio (OR)=1.4, 95% confidence interval (CI)=1.3-1.4], being admitted to the ICU from the operating room or another hospital ward (OR=1.8, 95% CI=1.7-2.0 and OR=2.7, 95% CI=2.5-3.0, respectively) and being readmitted to ICU during their hospital stay (OR=4.8, 95% CI=4.7-5.6). Patients with an AE stayed 5.4 days longer in ICU (95% CI=5.2-5.6 d, P<0.001), 18.2 days longer in hospital (95% CI=17.7-18.8 d, P<0.001) and had increased odds of hospital mortality (OR=1.5, 95% CI=1.4-1.6) than those without an AE. CONCLUSIONS: AEs are common among critically ill patients and certain factors are associated with AEs. Documented AEs are associated with longer stays and increased mortality.

Improving knowledge translation of clinical practice guidelines for epilepsy.

BACKGROUND: Clinical practice guidelines (CPGs) have the potential to improve quality of care. However, implementation of CPGs into the clinical care of people with epilepsy is less than optimal. This study aimed to examine barriers and facilitators to the use of CPGs for the care of people with epilepsy. METHODS: A cross-sectional survey of Canadian neurologists was conducted to evaluate CPG use, barriers and facilitators of CPG use, and factors associated with CPG use among neurologists. The barriers and facilitators of CPG use among neurologists that manage people with epilepsy were compared with those who do not. RESULTS: Of 311 responders (response rate = 38.7%), 78.7% indicated that they manage people with epilepsy. Neurologists that manage people with epilepsy did not differ from those who do not with regard to demographic characteristics nor in the proportion that report using CPGs in their clinical practice. The barriers and facilitators of CPG use were largely similar between neurologist that do and do not manage people with epilepsy; except applicability of CPGs tended to be less commonly endorsed as a barrier to CPG use by those who manage people with epilepsy compared with those who do not. CONCLUSIONS: This study suggests that knowledge, applicability, motivation, resources, and targeting of CPGs to appropriate audience are barriers and facilitators of CPG use among neurologists who manage people with epilepsy. The similarity between barriers and facilitators of CPG use among neurologists who manage people with epilepsy compared with those who do not provides support for the use of a knowledge translation (KT) strategy tailored to these barriers and facilitators of CPG use, and targeted towards neurologists. Implementation of epilepsy CPGs has the potential to improve the quality of care for people with epilepsy.

The co-occurrence of epilepsy and autism: A systematic review.

OBJECTIVE: We aimed to review the literature to determine the incidence and prevalence of autism in epilepsy and epilepsy in autism, conditions that are often comorbid. METHODS: We adhered to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) standards, and the protocol was registered with PROSPERO. MEDLINE, Embase, PsycINFO, and the Cochrane Database of Systematic Reviews were searched from inception until July 4, 2016. Studies were included if they reported an incidence or prevalence of autism in epilepsy or epilepsy in autism. These estimates were described using mean, standard deviation, median, and interquartile range. RESULTS: Seventy-four studies reporting on 283,549 patients were included. The median overall period prevalence of epilepsy in people with autism was 12.1% while the median overall period prevalence of autism in people with epilepsy was 9.0% when including all population types. When excluding studies that investigated patients with syndromic epilepsy or developmental delay, the median overall period prevalence of epilepsy in people with autism was 11.2% while the median overall period prevalence of autism in people with epilepsy was 8.1%. We observed trends for sex as the prevalence of autism in epilepsy was higher in males while the prevalence of epilepsy in autism was higher in females. It is important to interpret these estimates with caution, as there was significant heterogeneity between studies. Meta-regression found no association between study quality and prevalence or incidence estimates (all p-values > 0.05). CONCLUSIONS: The period prevalence of epilepsy in people with autism, and vice versa, was consistently higher than previously reported estimates of the occurrence of these disorders in the general population. These findings highlight the importance of screening for autism in people who have epilepsy and epilepsy in people who have autism and may help shed light on shared pathogenesis between these conditions.

A longitudinal cohort study on the impact of the clobazam shortage on patients with epilepsy.

OBJECTIVE: Drug shortages are occurring at an increasing rate. From May to October 2016, there was a shortage of a level I critical antiepileptic drug, clobazam. We aimed to study the impact of this shortage on patients with epilepsy. METHODS: Adult patients from Calgary's Comprehensive Epilepsy Program who were taking clobazam were approached to participate in the study. Baseline data from the clinic prospective registry included clinical variables and presurvey patient-reported outcomes (PROs) such as the Global Assessment of Severity of Epilepsy, the Global Assessment of Disability Associated with Seizures, and the Quality of Life in Epilepsy questionnaire. We used a mixed-methods cross-sectional questionnaire via telephone. We analyzed quantitative data using descriptive methods and qualitative data using a phenomenological approach. RESULTS: Of the 85 eligible patients, 84% (n = 71) agreed to participate. Participants ranged from 18 to 78 years old, and 59.2% of participants were female. Overall, 80% of participants experienced some form of medication change due to the shortage. No significant differences were found in the pre- and during-shortage PRO data. However, 6 important themes emerged regarding the impact of the antiepileptic drug shortage on patients: (1) communication and awareness, (2) burden on patients and caregivers, (3) physical impact, (4) psychological impact, (5) health care provider assistance in navigating the shortage, and (6) policy change. SIGNIFICANCE: We examined the impact of the clobazam shortage on patients with epilepsy from the patient's perspective and identified 6 important themes. As a result, we were able to gain insight into what patients need to cope with drug shortages and make recommendations that can help mitigate the impact of shortages on patients in the future. Further research is needed to better understand drug shortages from the patient's perspective in various settings and conditions.

The prevalence of anxiety and associated factors in persons with epilepsy.

The objectives of this study were to estimate the prevalence of, and factors associated with, anxiety in epilepsy. We conducted a cross-sectional analysis using data from the Neurological Disease and Depression Study. The prevalence of anxiety and associated factors were assessed using descriptive statistics and logistic regression. Of the total sample (n = 250 patients), nearly 40.0% of participants had anxiety according to the Hospital Anxiety and Depression Scale. The most prevalent symptom of anxiety was "worrying thoughts" (35.6%). After adjustment for age and sex, depression (odds ratio [OR] = 8.97, 95% confidence interval [CI] = 4.38-18.40), medication side effects (OR = 1.79, 95% CI = 1.04-3.05), smoking (OR = 4.35, 95% CI = 2.27-8.31), and illicit substance use (OR = 2.42, 95% CI = 1.18-4.96) were significantly associated with higher odds of anxiety, whereas higher education (OR = 0.47, 95% CI = 0.28-0.80) was associated with lower odds of anxiety. Furthermore, participants with anxiety reported more severe epilepsy, debilitating seizures, and overall lower quality of life. Evidence from our study reveals a high prevalence of anxiety in persons with epilepsy and that anxiety is associated with a variety of negative outcomes. These findings further emphasize the need for more studies to understand the impact of anxiety and its relationship with various sociodemographic and clinical factors.

Mind the gap: Exploring information gaps for the development of an online resource hub for epilepsy and depression.

PURPOSE: Depression is common in epilepsy, and is often under-detected and under-treated. The motivation to create a depression eHub for persons with epilepsy is to connect them to the best available online resources to effectively manage their depression. The study sought to: 1) identify facilitators and barriers to accessing resources related to management of epilepsy and/or depression and 2) discuss gaps in available resources (free and in the public domain) and 3) identify suggestions for future content. METHODS: Semi-structured interviews were conducted with ten patients with epilepsy and a history of depression. Using inductive analysis, two team members engaged in a process of textual open-coding utilizing a conventional content analysis approach whereby content was conceptually clustered based on the research questions. A phenomenological framework was applied to describe the phenomenon of online health resource access and utilization from the perspective of people with epilepsy. RESULTS: Facilitators to the use of online resources included information credibility, thoughtful organization, and accessibility of resources. Barriers included difficulties finding and piecing together information from many different sites. Patients reported difficulty having the motivation to seek out resources while depressed, which was compounded by feelings of stigma, social isolation, and lack of control. Gaps in resources included a lack of information about living with epilepsy day-to-day and resources for family and friends. Suggested content included information to raise awareness about epilepsy and depression; questionnaires to screen for symptoms of depression; stories of other patients with epilepsy and depression via video or moderated forums; current research and news; local community resources; and tools and strategies to manage depression in epilepsy. CONCLUSIONS: There is a gap in accessible resources for patients with epilepsy and depression as well as barriers that include epilepsy-related restrictions, depression-related impairments, lack of awareness, and stigmatization. These results should be used to guide the development of e-Health resources for patients with epilepsy.

Quality indicators for the adult epilepsy monitoring unit.

OBJECTIVE: Quality and safety in epilepsy monitoring units (EMUs) are of great importance because patients' seizures are induced rather than prevented in this hospital setting. However, the measurement and evaluation of quality and safety in EMUs are heterogeneous, as are practices and processes of care. To improve the measurement of quality and safety in EMUs, we sought to develop evidence-based and consensus-driven quality indicators, adhering to previously described methodologic standards. METHODS: Candidate quality indicators were identified using a recent systematic review on quality and safety indicators in EMUs. These were supplemented by expert opinion to identify other indicators that had not been reported previously. The candidate quality indicators were then evaluated using a modified Delphi technique among a multidisciplinary EMU quality improvement team. Candidate indicators identified as important and feasible through the Delphi technique were then developed into quality metrics. RESULTS: Thirty-four candidate indicators were abstracted from 135 studies included in the earlier systematic review, and two additional candidate indicators were suggested through consensus from experts. Consensus was reached after two modified Delphi rounds for 25 quality indicators identified as important. These 25 indicators were then developed into quality metrics using a standardized data collection form and were deployed in an online database for systematic data capture and further analyses. SIGNIFICANCE: These quality indicators have the potential to improve the reporting of quality and safety in EMUs through standardized measurement and evaluation of the quality and safety of care. The ultimate goal is improved patient care and clinical outcomes through safer and better care for people with epilepsy in the EMU.

Quality and safety in adult epilepsy monitoring units: A systematic review and meta-analysis.

OBJECTIVE: The epilepsy monitoring unit (EMU) is a valuable resource for optimizing management of persons with epilepsy, but may place patients at risk for adverse events due to withdrawal of treatment and induction of symptoms. The purpose of this study was to synthesize data on the safety and quality of care in EMUs to inform the development of quality indicators for EMUs. METHODS: A systematic review was conducted according to the Preferred Reporting and Items for Systematic Review and Meta-Analysis (PRISMA) statement. The search strategy, which included broad search terms and synonyms pertaining to the EMU, was run in six medical databases and included conference proceedings. Data abstracted included patient and EMU demographics and quality and safety variables. Study quality was evaluated using a modified 15-item Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist. Descriptive statistics and meta-analyses were used to describe and synthesize the evidence. RESULTS: The search yielded 7,601 references, of which 604 were reviewed in full text. One-hundred thirty-five studies were included. The quality and safety data came from 181,823 patients and reported on 34 different quality and safety variables. Included studies commonly reported the number of patients (108 studies; median number patients, 171.5), age (49 studies; mean age 35.7 years old), and the reason for admission (34 studies). The most common quality and safety data reported were the utility of the EMU admission (38 studies). Thirty-three studies (24.4%) reported on adverse events, and yielded a pooled proportion of adverse events of 7% (95% confidence interval [CI] 5-9%). The mean quality score was 73.3% (standard deviation [SD] 17.2). SIGNIFICANCE: This study demonstrates that there is a great deal of variation in the reporting of quality and safety measures and in the quality and safety in EMUs. Study quality also varied considerably from one study to the next. These findings highlight the need to develop evidence-based, consensus-driven quality indicators for EMUs.

The current state of epilepsy guidelines: A systematic review.

OBJECTIVE: The International League Against Epilepsy (ILAE) Epilepsy Guidelines Task Force, composed of 14 international members, was established in 2011 to identify, using systematic review methodology, international epilepsy clinical care guidelines, assess their quality, and determine gaps in areas of need of development. METHODS: A systematic review of the literature (1985-2014) was performed in six electronic databases (e.g. Medline, Embase) using a broad search strategy without initial limits to language or study design. Six gray literature databases (e.g., American Academy of Neurology [AAN], ILAE) were also searched to minimize publication bias. Two independent reviewers screened abstracts, reviewed full text articles, and performed data abstraction. Descriptive statistics and a meta-analysis were generated. RESULTS: The search identified 10,926 abstracts. Of the 410 articles selected for full text review, 63 met our eligibility criteria for a guideline. Of those included, 54 were in English and 9 were in other languages (French, Spanish, and Italian). Of all guidelines, 29% did not specify the target age groups, 27% were focused on adults, 22% included only children, and 6% specifically addressed issues related to women with epilepsy. Guidelines included in the review were most often aimed at guiding clinical practice for status epilepticus (n = 7), first seizure (n = 6), drug-resistant epilepsy (n = 5), and febrile seizures (n = 4), among others. Most of the guidelines were therapeutic (n = 35) or diagnostic (n = 16) in nature. The quality of the guidelines using a 1-7 point scale (7 = highest) varied and was moderate overall (mean = 4.99 ± 1.05 [SD]). SIGNIFICANCE: We identified substantial gaps in topics (e.g., epilepsy in the elderly) and there was considerable heterogeneity in methodologic quality. The findings should offer a valuable resource for health professionals caring for people with epilepsy, since they will help guide the prioritization, development, and dissemination of future epilepsy-related guidelines.

Developing clinical practice guidelines for epilepsy: A report from the ILAE Epilepsy Guidelines Working Group.

Clinical practice guidelines (CPGs) contain evidence-based recommendations to guide clinical care, policy development, and quality of care improvement. A recent systematic review of epilepsy guidelines identified considerable variability in the quality of available guidelines. Although excellent frameworks for CPG development exist, processes are not followed uniformly internationally, and resources to develop CPGs may be limited in certain settings. An International League Against Epilepsy (ILAE) working group was charged with proposing methodology to guide the development of future epilepsy-specific CPGs. A comprehensive literature search (1985-2014) identified articles related to CPG development and handbooks. Guideline handbooks were included if they were publicly available, and if their methodology had been used to develop CPGs. The working group's expertise also informed the creation of methodologies and processes to develop future CPGs for the ILAE. Five handbooks from North America (American Academy of Neurology), Europe (Scottish Intercollegiate Guidelines Network & National Institute for Health and Care Excellence), Australia (National Health and Medical Research Council), World Health Organization (WHO), and additional references were identified to produce evidence-based, consensus-driven methodology for development of epilepsy-specific CPGs. Key components of CPG development include the following: identifying the topic and defining the scope; establishing a working group; identifying and evaluating the evidence; formulating recommendations and determining strength of recommendations; obtaining peer reviews; dissemination, implementation, and auditing; and updating and retiring the CPG. A practical handbook and toolkit was developed. The resulting CPG development toolkit should facilitate the development of high-quality ILAE CPGs to improve the care of persons with epilepsy.

Quality indicators in an epilepsy monitoring unit.

Examining and improving the quality of care in epilepsy monitoring units (EMUs) is essential to delivering the best possible care and to mitigating undesirable outcomes. Epilepsy monitoring units are unique in that an admission to an EMU often involves the induction of symptoms (seizures) rather than minimizing and/or treating symptoms, which can lead to an increased risk to patient safety. Very little research has addressed the quality of care and safety in EMUs. The objective of this study was to examine quality indicators in a large population of patients admitted to an EMU in a large health region. Data were collected prospectively on 396 consecutive patients admitted to the EMU for scalp EEG recording from 2008 to 2011 using a standardized data abstraction form. Variables examined included the following: patient demographics, baseline clinical characteristics, EMU admission statistics, and EMU quality indicators. We found that an admission to the EMU was a safe and effective tool in the management of patients with epilepsy and seizure-like events. The number of adverse events during the study period was low at 4.9%. The admission question was answered in 78.8% of cases, and it was partially answered in 6.6%. The need for systematically developed and validated quality indicators in EMUs is emphasized. The research in this area is sparse, and thus these data aid in supporting the utility of EMUs in the management and care of those with seizures and seizure-like events.

Enhanced Recovery After Surgery Guidelines and Hospital Length of Stay, Readmission, Complications, and Mortality: A Meta-Analysis of Randomized Clinical Trials.

Importance: A comprehensive review of the evidence exploring the outcomes of enhanced recovery after surgery (ERAS) guidelines has not been completed. Objective: To evaluate if ERAS guidelines are associated with improved hospital length of stay, hospital readmission, complications, and mortality compared with usual surgical care, and to understand differences in estimates based on study and patient factors. Data Sources: MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Central were searched from inception until June 2021. Study Selection: Titles, abstracts, and full-text articles were screened by 2 independent reviewers. Eligible studies were randomized clinical trials that examined ERAS-guided surgery compared with a control group and reported on at least 1 of the outcomes. Data Extraction and Synthesis: Data were abstracted in duplicate using a standardized data abstraction form. The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Risk of bias was assessed in duplicate using the Cochrane Risk of Bias tool. Random-effects meta-analysis was used to pool estimates for each outcome, and meta-regression identified sources of heterogeneity within each outcome. Main Outcome and Measures: The primary outcomes were hospital length of stay, hospital readmission within 30 days of index discharge, 30-day postoperative complications, and 30-day postoperative mortality. Results: Of the 12 047 references identified, 1493 full texts were screened for eligibility, 495 were included in the systematic review, and 74 RCTs with 9076 participants were included in the meta-analysis. Included studies presented data from 21 countries and 9 ERAS-guided surgical procedures with 15 (20.3%) having a low risk of bias. The mean (SD) Reporting on ERAS Compliance, Outcomes, and Elements Research checklist score was 13.5 (2.3). Hospital length of stay decreased by 1.88 days (95% CI, 0.95-2.81 days; I2 = 86.5%; P < .001) and the risk of complications decreased (risk ratio, 0.71; 95% CI, 0.59-0.87; I2 = 78.6%; P < .001) in the ERAS group. Risk of readmission and mortality were not significant. Conclusions and Relevance: In this meta-analysis, ERAS guidelines were associated with decreased hospital length of stay and complications. Future studies should aim to improve implementation of ERAS and increase the reach of the guidelines.

Preoperative hemoglobin and perioperative blood transfusion in major head and neck surgery: a systematic review and meta-analysis.

BACKGROUND: There is a growing concern with inappropriate, excessive perioperative blood transfusions. Understanding the influence of low preoperative hemoglobin (Hgb) on perioperative blood transfusion (PBT) in head and neck cancer (HNC) surgery with free flap reconstruction may help guide clinical practice to reduce inappropriate treatment among these patients. The objective is to synthesize evidence regarding the association between preoperative Hgb and PBT among major HNC free flap surgeries. METHODS: Terms and synonyms for HNC surgical procedures, Hgb and PBT were used to search MEDLINE, Embase, CINAHL, Cochrane Central Register of Controlled Trials and Cochrane Database of Reviews from inception to February 2020. Reference lists of included full texts and studies reporting the preoperative Hgb, anemia or hematocrit (exposure) and the PBT (outcome) in major HNC surgery with free flap reconstruction were eligible. Studies examining esophageal, thyroid and parathyroid neoplasms were excluded; as were case reports, case series (n < 20), editorials, reviews, perspectives, viewpoints and responses. Two independent, blinded reviewers screened titles, abstracts and full texts in duplicate. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses was followed. A random-effects model was used to pool reported data. The primary outcome was the proportion of patients who had a PBT. Subgroup analysis examined sources of heterogeneity for perioperative predictors of PBT (age, sex, flap type, flap site and preoperative Hgb). We also examined mean preoperative Hgb in the PBT and no PBT groups. RESULTS: Patients with low preoperative Hgb were transfused more than those with normal Hgb (47.62%, 95% CI = 41.19-54.06, I2 = 0.00% and 13.92%, 95% CI = 10.19-17.65, I2 = 20.69%, respectively). None of the predictor variables explained PBT. The overall pooled mean preoperative Hgb was 12.96 g/dL (95% CI = 11.33-14.59, I2 = 0.00%) and was 13.58 g/dL (95% CI = 11.95-15.21, I2 = 0.00%) in the no PBT group and 12.05 g/dL (95% CI = 10.01 to 14.09, I2 = 0.00%) in the PBT group. CONCLUSIONS: The heterogeneity between studies, especially around the trigger for PBT, highlights the need for additional research to guide clinical practice of preoperative Hgb related to PBT to enhance patient outcomes and improve healthcare stewardship.

Delivery and Prioritization of Surgical Care in Canada During COVID-19: An Environmental Scan.

BACKGROUND: During COVID-19 healthcare systems had to make concessions to make room for the surge of COVID-19 patients requiring hospital and intensive care. Postponing surgeries was a common strategy; however, it is unclear how surgical care was delivered during this time of constraint. The objective of this study was to understand how surgical care was delivered and prioritized during the COVID-19 pandemic response. METHODS: This was an environmental scan following the Canadian Agency for Drugs and Technologies in Health methodology. This study was conducted in Canada; a universal, publicly funded healthcare system. Evidence sources on policies pertaining to the provision of surgical care between January 2020 and October 2022 were obtained from ministries of health, health services agencies and publicly funded hospitals across all 10 provinces and three territories. We synthesized the evidence sources using framework analysis. RESULTS: We identified 205 evidence sources that described six themes about the provision of surgical care during the COVID-19 pandemic: the cycle of postponement and resumption; guidelines for triaging and prioritizing surgical cases; Infection Prevention and Control (IPAC), and safety measures for surgical care during COVID-19, patient-centred care, and looking forward (recovery planning, leadership, and decision-making). CONCLUSION: This study provides a comprehensive understanding of how surgical care was disrupted and innovated during COVID-19 which can inform future strategies for providing effective and efficient surgical care during times of healthcare constraint.