A Canadian strategy for surgical quality improvement

Summary: The Canadian Association of General Surgeons (CAGS) Board of Directors hosted a symposium to develop a Canadian strategy for surgical quality and safety at its mid-term meeting on Feb. 24, 2018. The following 6 principles outline the consensus of this symposium, which included diverse stakeholders and surgeon leaders across Canada: 1) a Canadian quality-improvement strategy for surgery is needed; 2) quality improvement requires continuous, active and intentional effort; 3) outcome measurement alone will not drive improvement; 4) increased focus on standardization and process improvement is necessary; 5) new, large electronic medical record systems pose challenges as well as benefits in Canadian hospitals; and 6) surgeons in remote and rural hospitals must be engaged using tailored approaches.

Opioid Use After Discharge in Postoperative Patients: A Systematic Review.

BACKGROUND: Over the past 2 decades, there has been an increase in opioid use and subsequently, opioid deaths. The amount of opioid prescribed to surgical patients has also increased. The aim of this systematic review was to determine postdischarge opioid consumption in surgical patients compared with the amount of opioid prescribed. Secondary outcomes included adequacy of pain control and disposal methods for unused opioids. OBJECTIVE: The objective of this study is to characterize postdischarge opioid consumption and prescription patterns in surgical patients. METHODS: A systematic search in MEDLINE and EMBASE identified 11 patient survey studies reporting on postdischarge opioid use in 3525 surgical patients. RESULTS: The studies reported on a variety of surgical operations, including abdominal surgery, orthopedic procedures, tooth extraction, and dermatologic procedures. The majority of patients consumed 15 pills or less postdischarge. The proportion of used opioids ranged from 5.6% to 59.1%, with an outlier of 90.1% in pediatric spinal fusion patients. Measured pain scores of those taking opioids ranged between 2 and 5 out of 10 and the majority of patients were satisfied with their pain control. Seventy percent of patients kept the excess opioids. Where planned disposal methods were reported, between 4% and 59% of patients planned proper disposal. CONCLUSION: This study suggests that surgical patients are using substantially less opioid than prescribed. There is a lack of awareness regarding proper disposal of leftover medication, leaving excess opioid that may be used inappropriately by the patient or others. Education for providers and clinical practice guidelines that provide guidance on prescription of outpatient of opioids are required.

Postoperative ERAS Interventions Have the Greatest Impact on Optimal Recovery: Experience With Implementation of ERAS Across Multiple Hospitals.

BACKGROUND: Enhanced recovery after surgery (ERAS) programs incorporate evidence-based practices to minimize perioperative stress, gut dysfunction, and promote early recovery. However, it is unknown which components have the greatest impact. OBJECTIVE: This study aims to determine which components of ERAS programs have the largest impact on recovery for patients undergoing colorectal surgery. METHODS: An iERAS program was implemented in 15 academic hospitals. Data were collected prospectively. Patients were considered compliant if >75% of the preoperative, intraoperative, and postoperative predefined interventions were adhered to. Optimal recovery was defined as discharge within 5 days of surgery with no major complications, no readmission to hospital, and no mortality. Multivariable analysis was used to model the impact of compliance and technique on optimal recovery. RESULTS: Overall, 2876 patients were enrolled. Colon resections were performed in 64.7% of patients and 52.9% had a laparoscopic procedure. Only 20.1% of patients were compliant with all phases of the pathway. The poorest compliance rate was for postoperative interventions (40.3%) which was independently associated with an increase in optimal recovery (RR = 2.12, 95% CI 1.81-2.47). Compliance with ERAS interventions remained associated with improved outcomes whether surgery was performed laparoscopically (RR = 1.55, 95% CI 1.23-1.96) or open (RR = 2.29, 95% CI 1.68-3.13). However, the impact of ERAS compliance was significantly greater in the open group (P < 0.001). CONCLUSIONS: Postoperative compliance is the most difficult to achieve but is most strongly associated with optimal recovery. Although our data support that ERAS has more effect in patients undergoing open surgery, it also showed a significant impact on patients treated with a laparoscopic approach.

The Decline of Elective Colectomy Following Diverticulitis: A Population-Based Analysis.

BACKGROUND: The indications for interval elective colectomy following diverticulitis are unclear; evidence lends increasing support for nonoperative management. OBJECTIVE: This study aims to evaluate the temporal trends in the use of elective colectomy following diverticulitis. DESIGN: This is a population-based retrospective cohort study using administrative discharge data. SETTING: This study was conducted in Ontario, Canada. PATIENTS: Patients who had had an episode of diverticulitis managed nonoperatively and were eligible for elective colectomy, from 2002 to 2012, were selected. MAIN OUTCOME MEASURES: Changes in the proportion of patients who undergo elective colectomy following an episode of diverticulitis treated nonoperatively were evaluated. Cochran-Armitage was used to test for trends; adjusted analysis was performed by using multivariable logistic regression with generalized estimating equations. RESULTS: A total of 14,124 patients were admitted with an episode of diverticulitis and treated nonoperatively, making them eligible for interval elective colectomy. Median follow-up was 3.9 years (maximum, 10; interquartile range, 1.7-6.4). Overall, 1342 (9.5%) patients underwent elective colectomy; 33% of these colectomies were performed laparoscopically, and 7.5% patients received an ostomy. In-hospital mortality was 0.2%. The majority (76%) of elective operations were performed within 1 year of discharge (median, 160 days; interquartile range, 88-346). The proportion of patients undergoing elective colectomy within 1 year of discharge declined from 9.6% of patients in 2002 to 3.9% by 2011 (p < 0.001). The decline was most pronounced in patients <50 years of age (from 17% to 5%), and those with complicated disease (from 28% to 8%) (all p < 0.001). In multivariable regression, younger age, lower medical comorbidity, complicated disease, and early readmission were associated with elective colectomy. After adjusting for changes in patient characteristics, the odds of elective surgery decreased by 0.93 per annum (adjusted OR; 95% CI, 0.90-0.95). LIMITATIONS: Administrative health databases contain limited clinical detail; the rationale for elective surgery was not available. CONCLUSIONS: Consistent with evolving practice guidelines, there has been a decrease in the use of elective colectomy following an episode of diverticulitis.

Clinical practice guideline: management of acute pancreatitis.

ABSTRACT: There has been an increase in the incidence of acute pancreatitis reported worldwide. Despite improvements in access to care, imaging and interventional techniques, acute pancreatitis continues to be associated with significant morbidity and mortality. Despite the availability of clinical practice guidelines for the management of acute pancreatitis, recent studies auditing the clinical management of the condition have shown important areas of noncompliance with evidence-based recommendations. This underscores the importance of creating understandable and implementable recommendations for the diagnosis and management of acute pancreatitis. The purpose of the present guideline is to provide evidence-based recommendations for the management of both mild and severe acute pancreatitis as well as the management of complications of acute pancreatitis and of gall stone-induced pancreatitis.

RESUME: Une hausse de l'incidence de pancréatite aiguë a été constatée à l'échelle mondiale. Malgré l'amélioration de l'accès aux soins et aux techniques d'imagerie et d'intervention, la pancréatite aiguë est toujours associée à une morbidité et une mortalité importantes. Bien qu'il existe des guides de pratique clinique pour la prise en charge de la pancréatite aiguë, des études récentes sur la vérification de la prise en charge clinique de cette affection révèlent des lacunes importantes dans la conformité aux recommandations fondées sur des données probantes. Ces résultats mettent en relief l'importance de formuler des recommandations compréhensibles et applicables pour le diagnostic et la prise en charge de la pancréatite aiguë. La présente ligne directrice vise à fournir des recommandations fondées sur des données probantes pour la prise en charge de la pancréatite aiguë, qu'elle soit bénigne ou grave, ainsi que de ses complications et de celles de la pancréatite causée par un calcul biliaire.

A qualitative study to understand the barriers and enablers in implementing an enhanced recovery after surgery program.

OBJECTIVE: Explore the barriers and enablers to adoption of an Enhanced Recovery after Surgery (ERAS) program by the multidisciplinary perioperative team responsible for the care of elective colorectal surgical patients. BACKGROUND: ERAS programs include perioperative interventions that when used together have led to decreased length of stay while increasing patient recovery and satisfaction. Despite the known benefits of ERAS programs, uptake remains slow. METHODS: Semistructured interviews were conducted with general surgeons, anesthesiologists, and ward nurses at 7 University of Toronto-affiliated hospitals to identify potential barriers and enablers to adoption of 18 ERAS interventions. Grounded theory was used to thematically analyze the transcribed interviews. RESULTS: Nineteen general surgeons, 18 anesthesiologists, and 18 nurses participated. The mean time of each interview was 18 minutes. Lack of manpower, poor communication and collaboration, resistance to change, and patient factors were cited by most as barriers. Discipline-specific issues were identified although most related to resistance to change. Overall, interviewees were supportive of implementation of a standardized ERAS program and agreed that a standardized guideline based on best evidence; standardized order sets; and education of the staff, patients, and families are essential. CONCLUSIONS: Multidisciplinary perioperative staff supported the implementation of an ERAS program at the University of Toronto-affiliated hospitals. However, major barriers were identified, including the need for patient education, increased communication and collaboration, and better evidence for ERAS interventions. Identifying these barriers and enablers is the first step toward successfully implementing an ERAS program.

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.

Prevalence of Physiologic Sexual Dysfunction Is High Following Treatment for Rectal Cancer: But Is It the Only Thing That Matters?

BACKGROUND: Although several studies have reported high rates of sexual dysfunction in patients treated for rectal cancer, most studies have been limited by retrospective design, failure to use validate instruments, and a limited number of female patients. OBJECTIVES: The objectives of this study were to 1) prospectively assess changes in sexual function before and after treatment for rectal cancer and 2) identify potential areas for improved care of patients who have rectal cancer with sexual dysfunction. DESIGN: This study is a prospective, longitudinal survey. SETTINGS: This study was conducted at 4 tertiary care academic hospitals. PATIENTS: The patients included had newly diagnosed rectal cancer. MAIN OUTCOME MEASURES: Subjects completed the European Organization for Research and Treatment Quality of Life Cancer Module and Colorectal Cancer Module, International Index of Erectile Function, and Female Sexual Function Index questionnaires before the start of treatment, after the completion of preoperative chemoradiotherapy, and 1 year after surgery. RESULTS: Forty-five patients completed the study, and the overall results showed significant sexual dysfunction in both male and female subjects that continued to increase from baseline up to 1 year after surgery. In male subjects, sexual activity, interest, and enjoyment remained relatively stable, despite increasing sexual problems. However, for female patients, although sexual activity and interest remained relatively stable, sexual enjoyment worsened as sexual problems increased. LIMITATIONS: The study closed before reaching the target sample size owing to lower than anticipated accrual rates. Post hoc analysis included qualitative interviews with patients to explore reasons for low recruitment. CONCLUSIONS: The results of this study show that sexual problems continue to increase up to 1 year after surgery. Despite this, sexual interest in both male and female patients remained relatively unchanged suggesting that other aspects of sexuality, not just physiologic function, also need to be evaluated. Future studies to assist and educate physicians on how to initiate a discussion about sexuality and identify patients in "distress" because of sexual problems are important.

Risk of readmission and emergency surgery following nonoperative management of colonic diverticulitis: a population-based analysis.

OBJECTIVE: To characterize the clinical course of patients with diverticulitis after nonoperative management and determine factors associated with readmission and subsequent emergency surgery. BACKGROUND: Clinical course of this disease remains poorly understood; indications for elective colectomy are unclear. METHODS: This was a retrospective cohort study of patients managed nonoperatively after a first episode of diverticulitis in Ontario, Canada (2002-2012). Time-to-event analysis and Fine and Gray multivariable regression were used to characterize the risks of readmission and emergency surgery for diverticulitis, accounting for death and elective colectomy as competing events. RESULTS: A total of 14,124 patients were followed for a median of 3.9 years (maximum 10, interquartile range: 1.7-6.4). Five-year cumulative incidence was 9.0% for readmission, 1.9% for emergency surgery, and 14.1% for all-cause mortality. Patients younger than 50 years had higher incidence of readmission than patients aged 50 years and older (10.5% vs 8.4%; P < 0.001) but not emergency surgery (1.8% vs 2.0%; P = 0.52). Patients with complicated disease (abscess, perforation) were at increased risk of readmission than those with uncomplicated disease (12.0% vs 8.2%; P < 0.001), as well as increased risk of emergency surgery (4.3% vs 1.4%, P < 0.001). In multivariable regression, complicated disease and number of prior admissions were associated with increased risk of emergency surgery, yet age less than 50 years was not. Risks associated with complicated disease were nonproportional over time, being highest immediately after discharge and decreasing thereafter. CONCLUSIONS: Absolute risks of readmission and emergency surgery are low after nonoperative management of diverticulitis, providing evidence for the practice of deferring colectomy for patients without persistent symptoms or multiple recurrences.

Ileal pouch symptoms do not correlate with inflammation of the pouch.

BACKGROUND & AIMS: Pouchitis is the most common complication after ileal pouch-anal anastomosis (IPAA). However, symptoms are not specific. The Pouchitis Disease Activity Index (PDAI) and the Pouchitis Activity Score (PAS) have been used to diagnose pouchitis. We evaluated the correlation between the clinical components of these scores and endoscopic and histologic findings. METHODS: We performed a cross-sectional study, analyzing data from 278 patients from Mount Sinai Hospital (Toronto, Canada) who had an IPAA. Patients underwent pouchoscopy with a biopsy, and data were collected on patients' clinical status. The PDAI and PAS were calculated for each subject. The Spearman rank correlation (ρ) statistical test was used to evaluate correlations between the PDAI scores and PAS, and between total scores and subscores. RESULTS: The total PDAI scores and PAS scores were correlated; the clinical components of each correlated with the total score (ρ = 0.59 and ρ = 0.71, respectively). However, we observed a low level of correlation between clinical and endoscopic or histologic subscores, with ρ of 0.20 and 0.10, respectively, by PDAI, and ρ of 0.19 and 0.04, respectively, by PAS. CONCLUSIONS: There is a low level of correlation between clinical and endoscopic and histologic subscores of patients with IPAA; clinical symptoms therefore might not reflect objective evidence of inflammation. These findings, along with evidence of correlation between total scores and clinical symptoms, indicate that these indices do not accurately identify patients with pouch inflammation. Further research is required to understand additional factors that contribute to clinical symptoms in the absence of objective signs of pouch inflammation.

Improving multidisciplinary cancer conferences: a population-based intervention.

BACKGROUND: Multidisciplinary cancer conferences (MCCs) facilitate the discussion of appropriate diagnostic and treatment options for an individual cancer patient. In 2007, a study conducted in Ontario found that 52 % of hospitals were able to provide access to MCCs. In 2006, Cancer Care Ontario published minimum standards for MCCs. A framework for measurement was developed to monitor MCCs at the hospital, regional, and provincial level. The objective of this study was to review the results from initial efforts to improve quality and access through a population-based intervention. METHODS: Data collection was completed prospectively between October to December in 2009, 2010, and 2011. A criterion satisfaction score (CSS) was developed on the basis of indicators including MCC frequency, type of patient case review, the presence of a chair and coordinator, and the attendance of appropriate medical staff members. For each hospital and region, the overall number of MCCs, patients discussed, and CSSs was calculated. RESULTS: Data were available from 13 of 14 regions in 2009 and all 14 regions in 2010 and 2011. The number of MCCs increased from 660 in 2009 to 798 in 2011 (p = 0.06). The number of patients discussed at MCCs increased from 4,695 in 2009 to 5,702 in 2011 (p = 0.22). The CSS scores across the regions improved significantly across 2009-2011 (p < 0.001). CONCLUSIONS: A population-based intervention has been associated with an improvement in access and quality of MCCs.

Evolving practice patterns in the management of acute colonic diverticulitis: a population-based analysis.

BACKGROUND: There is increasing evidence to support the use of percutaneous abscess drainage, laparoscopy, and primary anastomosis in managing acute diverticulitis. OBJECTIVE: The aim of this study was to evaluate how practices have evolved and to determine the effects on clinical outcomes. DESIGN: This is a population-based retrospective cohort study using administrative discharge data. SETTING: This study was conducted in Ontario, Canada. PATIENTS: All patients had been hospitalized for a first episode of acute diverticulitis (2002-2012). MAIN OUTCOME MEASURES: Temporal changes in treatment strategies and outcomes were evaluated by using the Cochran-Armitage test for trends. Multivariable logistic regression with generalized estimating equations was used to test for trends while adjusting for patient characteristics. RESULTS: There were 18,543 patients hospitalized with a first episode of diverticulitis, median age 60 years (interquartile range, 48-74). From 2002 to 2012, there was an increase in the proportion of patients admitted with complicated disease (abscess, perforation), 32% to 38%, yet a smaller proportion underwent urgent operation, 28% to 16% (all p < 0.001). The use of percutaneous drainage increased from 1.9% of admissions in 2002 to 3.3% in 2012 (p < 0.001). After adjusting for changes in patient and disease characteristics over time, the odds of urgent operation decreased by 0.87 per annum (95% CI, 0.85-0.89). In those undergoing urgent surgery (n = 3873), the use of laparoscopy increased (9% to 18%, p <0.001), whereas the use of the Hartmann procedure remained unchanged (64%). During this time, in-hospital mortality decreased (2.7% to 1.9%), as did the median length of stay (5 days, interquartile range, 3-9; to 3 days, interquartile range, 2-6; p <0.001). LIMITATIONS: There is the potential for residual confounding, because clinical parameters available for risk adjustment were limited to fields existing within administrative data. CONCLUSIONS: There has been an increase in the use of nonoperative and minimally invasive strategies in treating patients with a first episode of acute diverticulitis. However, the Hartmann procedure remains the most frequently used urgent operative approach. Mortality and length of stay have improved during this time.

Subtotal colectomy in severe ulcerative and Crohn's colitis: what benefit does the laparoscopic approach confer?

BACKGROUND: Comparative outcome data for laparoscopic and open subtotal colectomy in IBD are lacking and often difficult to interpret owing to low case volumes, heterogeneity in case mix, and variation in laparoscopic technique. OBJECTIVE: This study aimed to determine the safety of laparoscopic subtotal colectomy in severe colitis and to determine whether the laparoscopic approach improved short-term outcomes in comparison with the open approach. DESIGN: This was a retrospective cohort study using data from a prospectively maintained clinical database. SETTING: This study was conducted at a single center, Mount Sinai Hospital, Toronto. PATIENTS: All patients undergoing subtotal colectomy for either ulcerative or Crohn's colitis between 2000 and 2011 were included. INTERVENTION: A standardized operative technique was used for both laparoscopic and open subtotal colectomies. Cases performed by non-laparoscopic surgeons were excluded. MAIN OUTCOME MEASURES: Perioperative outcome measures were operative duration, estimated blood loss, total morphine requirement, and length of postoperative stay. Postoperative outcome measures were the rates of minor and major complications. RESULTS: Laparoscopic subtotal colectomies were performed in 131 of 290 cases (45.2%). Nine patients required conversion to an open procedure (6.9%). The uptake of laparoscopic subtotal colectomy increased from 10.2% in 2000/2001 to 71.7% in 2010/2011. Regression analysis with propensity-score adjustment for operative approach revealed that the operative duration was 25.5 minutes longer in laparoscopic cases (95% CI 12.3-38.6; p < 0.001), but that patients experienced fewer minor complications (OR 0.47; 95% CI 0.23-0.96; p = 0.04) and required less morphine (adjusted difference, -72.8 mg; 95% CI 4.9-141; p = 0.04). LIMITATIONS: The inherent selection bias of this retrospective cohort study may not be accounted for by multivariate analysis with propensity-score adjustment. CONCLUSIONS: Laparoscopic subtotal colectomy is safe and may reduce the rate of minor postoperative complications. The increase in operative duration reflects the technical demands associated with this procedure (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A160).

Development and implementation of a synoptic MRI report for preoperative staging of rectal cancer on a population-based level.

BACKGROUND: Colorectal cancer physician champions across the province of Ontario, Canada, reported significant concern about appropriate selection of patients for preoperative chemoradiotherapy because of perceived variation in the completeness and consistency of MRI reports. OBJECTIVE: The purpose of this work was to develop, pilot test, and implement a synoptic MRI report for preoperative staging of rectal cancer. DESIGN: This was an integrated knowledge translation project. SETTINGS: This study was conducted in Ontario, Canada. PATIENTS: Surgeons, radiologists, radiation oncologists, medical oncologists, and pathologists treating patients with rectal cancer were included in this study. INTERVENTIONS: A multifaceted knowledge translation strategy was used to develop, pilot test, and implement a synoptic MRI report. This strategy included physician champions, audit and feedback, assessment of barriers, and tailoring to the local context. A radiology webinar was conducted to pilot test the synoptic MRI report. MAIN OUTCOME MEASURES: Seventy-three (66%) of 111 Ontario radiologists participated in the radiology webinar and evaluated the synoptic MRI report. RESULTS: A total of 78% and 90% radiologists expressed that the synoptic MRI report was easy to use and included all of the appropriate items; 82% noted that the synoptic MRI report improved the overall quality of their information, and 83% indicated they would consider using this report in their clinical practice. An MRI report audit after implementation of the synoptic MRI report showed a 39% improvement in the completeness of MRI reports and a 37% uptake of the synoptic MRI report format across the province. LIMITATIONS: Radiologists evaluating the synoptic MRI report and participating in the radiology webinar may not be representative of gastroenterologic radiologists in other geographic jurisdictions. The evaluation of completeness and uptake of the synoptic MRI reports is limited because of unmeasured differences that may occur before and after the MRI. CONCLUSIONS: A synoptic MRI report for preoperative staging of rectal cancer was successfully developed and pilot tested in the province of Ontario, Canada.

Proctocolectomy for colorectal cancer--is the ileal pouch anal anastomosis a safe alternative to permanent ileostomy?

PURPOSE: Ileal pouch anal anastomosis (IPAA) is the procedure of choice in patients requiring surgery for ulcerative colitis (UC) and familial adenomatous polyposis (FAP). There are few data on reconstruction with the IPAA in patients with colorectal cancer (CRC). This study assessed the outcomes of the IPAA compared to proctocolectomy and permanent ileostomy (PI) on these patients. METHODS: Between 1983 and 2013, over 2800 patients with CRC have been treated at the Mount Sinai Hospital (MSH). Demographic, surgical, pathological, and outcome data for all patients have been maintained in a database-73 patients were treated for CRC with proctocolectomy: 39 patients with IPAA and 34 patients with PI. Clinical features, pathologic findings, and survival outcomes were compared between these groups. RESULTS: Each group was similar with respect to gender, stage, and histologic grade. Patients undergoing IPAA were significantly younger. The diagnosis leading to proctocolectomy was more commonly UC or FAP in patients treated with IPAA (39/39 vs. 23/34, p = 0.001). Rectal cancer subgroups were similar in age, sex, TNM stage, T-stage, height of tumor, and histologic grade. There was no significant difference in overall or disease free survival between groups for colon or rectal primaries. Analysis using the Cochran-Armitage trend test suggests that utilization of IPAA has increased over time (p = 0.002). CONCLUSIONS: The IPAA is a viable and safe option to select for patients who would otherwise require PI. Increased experience and improved outcomes following IPAA has led to its more liberal use in selected patients.

Improving quality through process change: a scoping review of process improvement tools in cancer surgery.

BACKGROUND: Surgery is a cornerstone of treatment for malignancy. However, significant variation has been reported in patterns and quality of cancer care for important health outcomes, including perioperative mortality. Surgical process improvement tools (SPITs) have been developed that focus on enhancing the processes of care at the point of care, as a means of quality improvement. This study describes SPITs and develops a conceptual framework by synthesizing the available literature on these novel quality improvement tools. METHODS: A scoping review was conducted based on instruments developed for quality improvement in surgery. The search was executed on electronically indexed sources (MEDLINE, EMBASE, and the Cochrane library) from January 1990 to March 2011. Data were extracted, tabulated and reported thematically using a narrative synthesis approach. These results were used to develop a conceptual framework that describes and classifies SPITs. RESULTS: 232 articles were reviewed for data extraction and analysis. SPITs identified were classified into 3 groups: clinical mapping tools, structure communication tools and error reduction instruments. The dominant instrument reported were clinical mapping tools, including: clinical pathways (113, 48%), fast track (46, 20%) and enhanced recovery after surgery protocols (36, 15%). Outcomes reported included: length of stay (174, 75%), readmission rates (116, 50%), morbidity (116, 50%), mortality (104, 45%), and economic (60, 26%). Many gaps in the literature were recognized. CONCLUSION: We have developed a conceptual framework of SPITs and identified gaps in current knowledge. These results will guide the design and development of new quality instruments in surgery.

Preoperative biological therapy and short-term outcomes of abdominal surgery in patients with inflammatory bowel disease.

OBJECTIVE: Previous investigations of short-term outcomes after preoperative exposure to biological therapy in inflammatory bowel disease (IBD) were conflicting. The authors aimed to assess postoperative outcomes in patients who underwent abdominal surgery with recent exposure to anti-tumour necrosis factor therapy. DESIGN: A retrospective case-control study with detailed matching was performed for subjects with IBD with and without exposure to biologics within 180 days of abdominal surgery. Postoperative outcomes were compared between the groups. RESULTS: 473 procedures were reviewed consisting of 195 patients with exposure to biologics and 278 matched controls. There were no significant differences in most postoperative outcomes such as: length of stay, fever (≥ 38.5°C), urinary tract infection, pneumonia, bacteraemia, readmission, reoperations and mortality. On univariate analysis, procedures on biologics had more wound infections compared with controls (19% vs 11%; p=0.008), but this was not significant in multivariate analysis. Concomitant therapy with biologics and thiopurines was associated with increased frequencies of urinary tract infections (p=0.0007) and wound infections (p=0.0045). Operations performed ≤ 14 days from last biologic dose had similar rates of infections and other outcomes when compared with those performed within 15-30 days or 31-180 days. Patients with detectable preoperative infliximab levels had similar rates of wound infection compared with those with undetectable levels (3/10 vs 0/9; p=0.21). CONCLUSION: Preoperative treatment with TNF-α antagonists in patients with IBD is not associated with most early postoperative complications. A shorter time interval from last biological dose is not associated with increased postoperative complications. In most cases, surgery should not be delayed, and appropriate biological therapy may be continued perioperatively.

Do MRI reports contain adequate preoperative staging information for end users to make appropriate treatment decisions for rectal cancer?

PURPOSE: This study was designed to elicit end-user opinions regarding the importance and diagnostic accuracy of MRI for T-category, threatened or involved circumferential margin (CRMi), and lymph node involvement (LNi) for preoperative staging of rectal cancer and to determine completeness of MRI reports for these elements on a population based level. METHODS: The first part of this study was a mailed survey of surgeons, radiation oncologists, and medical oncologists to elicit their opinions regarding the importance and diagnostic accuracy of T-category, CRMi, and LNi on MRI. The second part of the study was an audit of MRI reports issued for pre-operative staging of rectal cancer to assess the completeness of these reports for T-category, CRMi, and LNi. RESULTS: Although T-category, CRMi, and LNi were considered essential by 97, 94, and 77 % of respondents, respectively, the MRI report audit showed that only 40 % of MRI reports captured all of these elements. The majority of end users reported moderate diagnostic accuracy on MRI for T-category and CRMi and low diagnostic accuracy for LNi (52.3, 43, and 48.5 % respectively). Multivariate analysis showed that specialty was the only independent predictor of correct reporting of the diagnostic accuracy for each of the MRI elements. CONCLUSIONS: While end users consider T-category, CRMi and LNi essential for preoperative staging of rectal cancer, less than 40 % of MRI reports captured all of these elements. Therefore, strategies to improve communication between radiologists and end users are critical to improve the overall quality of care for rectal cancer patients.

Role of Evidence-Based Reviews in Surgery in teaching critical appraisal skills and in journal clubs.

BACKGROUND: Evidence-Based Reviews in Surgery (EBRS) is a program developed to teach critical appraisal skills to general surgeons and residents. The purpose of this study was to assess the use of EBRS by general surgery residents across Canada and to assess residents' opinions regarding EBRS and journal clubs. METHODS: We surveyed postgraduate year 2-5 residents from 15 general surgery programs. Data are presented as percentages and means. RESULTS: A total of 231 residents (58%, mean 56% per program, range 0%-100%) responded: 172 (75%) residents indicated that they know about EBRS and that it is used in their programs. More than 75% of residents who use EBRS agreed or strongly agreed that the EBRS clinical and methodological articles and reviews are relevant. Only 55 residents (24%) indicated that they used EBRS online. Most residents (198 [86%]) attend journal clubs. The most common format is a mandatory meeting held at a special time every month with faculty members with epidemiological and clinical expertise. Residents stated that EBRS articles were used exclusively (13%) or in conjunction with other articles (57%) in their journal clubs. Most respondents (176 of 193 [91%]) stated that journal clubs are very or somewhat valuable to their education. CONCLUSION: The EBRS program is widely used among general surgery residents across Canada. Although most residents who use EBRS rate it highly, a large proportion are unaware of EBRS online features. Thus, future efforts to increase awareness of EBRS online features and increase its accessibility are required.

CONTEXTE: Le programme de revues factuelles en chirurgie EBRS (Evidence-Based Reviews in Surgery) a été mis au point pour enseigner aux chirurgiens et aux résidents en chirurgie générale les compétences nécessaires pour faire des évaluations critiques. Le but de cette étude était d'analyser l'utilisation des EBRS par les résidents en chirurgie générale au Canada et de leur demander leur opinion au sujet des EBRS et des clubs de lecture. MÉTHODES: Nous avons interrogé des résidents des années 2 à 5 rattachés à 15 programmes de chirurgie générale. Les données sont présentées sous forme de pourcentages et de moyennes. RÉSULTANTS: En tout, 231 résidents (58 %, moyenne de 56 % par programme, intervalle 0 %­100 %) ont répondu : 172 résidents (75 %) ont indiqué qu'ils connaissent les EBRS et que leur programme les utilise. Plus de 75 % des résidents qui utilisent les EBRS se sont dit d'accord ou tout à fait d'accord avec l'énoncé sur la pertinence des articles et revues cliniques et méthodologiques des EBRS. Seulement 55 résidents (24 %) ont dit utiliser les EBRS en ligne. La plupart des résidents (198 [86 %]) participaient à des clubs de lecture. Leur utilisation la plus courante prend la forme d'une réunion obligatoire tenue à un moment particulier tous les mois avec les enseignants de la faculté ayant une expertise épidémiologique et clinique. Les résidents ont indiqué que les EBRS étaient utilisés seuls (13 %) ou avec d'autres articles (57 %) dans leurs clubs de lecture. La plupart des répondants (176 sur 193 [91 %]) ont affirmé que leurs clubs de lecture sont très ou assez utiles pour leur formation. CONCLUSIONS: Le programme EBRS est largement utilisé par les résidents en chirurgie générale au Canada. Même si la plupart des résidents qui utilisent les EBRS leur accordent une cote élevée, une forte proportion ignore l'existence des possibilités web des EBRS. Il faudra donc travailler à mieux faire connaître les possibilités offertes par le programme EBRS sur le web et en faciliter l'accès.