Clinical practice guideline: evidence, recommendations and algorithm for the preoperative optimization of anemia, hyperglycemia and smoking.

Preoperative optimization has not been explored comprehensively in the surgical literature, as this responsibility has often been divided among surgery, anesthesia and medicine. We developed an evidence-based clinical practice guideline to summarize existing evidence and present diagnostic and treatment algorithms for use by surgeons caring for patients scheduled to undergo major elective surgery. We focus on 3 common comorbid conditions seen across surgical specialties - anemia, hyperglycemia and smoking - as these conditions increase complication rates in patients undergoing major surgery and can be optimized successfully as soon as 6-8 weeks before surgery. With the ability to address these conditions earlier in the patient journey, surgeons can positively affect patient outcomes. The aim of this guideline is to bring optimization in the preoperative period under the existing umbrella of evidence-based surgical care.

Implementation of a systematic tobacco treatment protocol in a surgical outpatient setting: a feasibility study.

Background: Smoking cessation programs started as late as 4 weeks before surgery reduce perioperative morbidity and death, yet outpatient clinic interventions are rarely provided. Our aim was to evaluate the feasibility of implementing a tobacco treatment protocol designed for an outpatient surgical setting. Methods: We completed a pre-post feasibility study of the implementation of a systematic, evidence-based tobacco treatment protocol in an outpatient colorectal surgery clinic. Outcomes included smoking prevalence, pre- and postimplementation smoker identification and intervention rates, recruitment, retention, smoking cessation and provider satisfaction. Results: Preimplementation, 15.5% of 116 surveyed patients were smokers. Fewer than 10% of surveyed patients reported being asked about smoking, and none were offered any cessation intervention. Over a 16-month postimplementation period, 1198 patients were seen on 2103 visits. Of these, 950 (79.3%) patients were asked smoking status on first visit and 1030 (86.0%) were asked on at least 1 visit. Of 169 identified smokers, 99 (58.6%) were referred to follow-up support using an opt-out approach. At 1-, 3- and 6-month follow-up, intention-to-quit rates among 78 enrolled patients were 24.4%, 22.9% and 19.2%, respectively. Postimplementation staff surveys reported that the protocol was easy to use, that staff would use it again and that it had positive patient responses. Conclusion: Implementation of our smoking cessation protocol in an outpatient surgical clinic was found to be feasible and used minimal clinic resources. This protocol could lead to increases in identification and documentation of smoking status, delivery of smoking cessation interventions and rates of smoking reduction and cessation.

Contexte: Les programmes d'abandon du tabagisme entamés jusqu'à 4 semaines avant une opération réduisent la morbidité et la mortalité périopératoires, mais les cliniques externes n'en proposent que rarement. L'étude visait à évaluer s'il est faisable d'appliquer un protocole de traitement du tabagisme pensé pour les milieux de soins chirurgicaux extrahospitaliers. Méthodes: Nous avons réalisé une étude de faisabilité pré- et postexpérimentale sur l'application d'un protocole de traitement systématique fondé sur des données probantes à une clinique externe de chirurgie colorectale. Les résultats à l'étude étaient les suivants : prévalence du tabagisme, identification des fumeurs et taux d'intervention avant et après la mise en place du protocole, recrutement, rétention, abandon du tabagisme et satisfaction des fournisseurs. Résultats: Au départ, 15,5 % des 116 patients sondés fumaient. Moins de 10 % des répondants avaient été questionnés sur leur statut tabagique, et aucun ne s'était vu proposer un programme d'abandon. Au cours des 16 mois suivant la mise en place du protocole, 1198 patients ont été rencontrés dans le cadre de 2103 consultations. Parmi eux, 950 (79,3 %) ont été interrogés sur leur statut tabagique à la première rencontre, et 1030 (86 %) l'ont été au moins 1 fois. Des 169 fumeurs identifiés, 99 (58,6 %) ont été orientés vers un programme de soutien selon une approche de consentement présumé. Après 1 mois, 24,4 % des 78 patients participants étaient déterminés à arrêter de fumer; 22,9 % l'étaient toujours après 3 mois, et 19,2 % après 6 mois. Les sondages menés a posteriori auprès du personnel indiquent que le protocole est facile à utiliser, que les employés s'en serviraient de nouveau, et que les patients l'ont accueilli favorablement. Conclusion: Il a été possible de mettre en place notre protocole d'abandon du tabagisme à une clinique externe de chirurgie, et ce en employant un minimum de ressources cliniques. Le protocole pourrait permettre de connaître et de consigner davantage de statuts tabagiques, d'orienter un plus grand nombre de fumeurs vers les programmes d'abandon et d'accroître les taux de réduction et d'abandon du tabagisme.

Strategic Change in Surgical Quality Improvement: The Ottawa Hospital (TOH) Comprehensive Unit-Based Safety Program (CUSP) Experience.

Strategic change principles are widely cited in business and healthcare management literature, but not in the surgical quality improvement literature despite the need for effective change management skills to successfully enable quality improvement projects. The Ottawa Hospital (TOH) Comprehensive Unit-Based Safety Program (CUSP) model within the Division of General Surgery applied strategic change management principles to support the development and implementation of surgical quality improvement initiatives. Using the TOH CUSP experience, we aim to provide insight and a practical example for surgeons seeking to drive quality improvement within their practice environment.

Excess cancer mortality in psychiatric patients.

OBJECTIVES: There are conflicting data on cancer incidence and mortality in psychiatric patients, although most studies suggest that while cancer mortality is higher, incidence is no different from that in the general population. Different methodologies and outcomes may account for some of the conflicting results. We investigated the association between mental illness and cancer incidence, first admission rates, and mortality in Nova Scotia using a standard methodology. METHOD: A population-based record-linkage study of 247,344 patients in contact with primary care or specialist mental health services during 1995 to 2001 was used. Records were linked with cancer registrations and death records. RESULTS: Cancer mortality was 72% higher in males (95%CI, 63% to 82%) and 59% higher in females (95%CI, 49% to 69%) among patients in contact with mental health services. This was reflected in similarly elevated first admission rates. However, there was weaker and less consistent evidence for increased incidence. For several cancer sites, incidence rate ratios were lower than might be expected given the mortality and first admission rate ratios, and no higher than that of the general population. These were melanoma, prostate, bladder, and colorectal cancers in males. CONCLUSION: People with mental illness in Nova Scotia have increased mortality from cancer, which cannot always be explained by increased incidence. Possible explanations for further study include delays in detection or initial presentation leading to more advanced staging at diagnosis, and difficulties in communication or access to health care.

Psychiatric findings in four female carriers of Fabry disease.

Anderson-Fabry disease (AFD) is an X-linked recessive disorder of glycosphingolipid metabolism. Most female carriers are clinically symptomatic; however, psychiatric diagnoses have not been reported in this population. We describe four female carriers of AFD disease who met DSM-IV criteria for major depression. All cases had a score above 26 on the Hamilton Rating Scale for Depression, indicating severe depression. This was independent of the severity or number of symptoms of AFD disease. Excessive guilt, fatigue, occupational difficulty, suicidal ideation and depressed mood were findings in all cases. In conclusion, the common presence of depression in carriers of AFD implies the need for a multidisciplinary approach, including psychiatry, in management of these patients. Further studies are recommended to establish the etiology of psychiatric complications, as well as the incidence and the response to pharmacotherapy and psychotherapy.