Patient satisfaction, an indicator to consider in the colorectal cancer process.

Colorectal cancer (CRC) is one of the most relevant diseases worldwide because of its incidence, prevalence and mortalitye. It is the third most common tumor in men, after lung and prostate cancer, and the second most common tumor in women, after breast cancer. A recent systematic analysis showed global data referring to age-standardized incidence rates for CRC, which increased by 9.5% from 1990 to 2017, whereas mortality rates decreased by 13.5%. This might be due to the introduction of CRC prevention programs, which facilitate early identification and higher survival chances.

Is cholecystectomy the treatment of choice for acute acalculous cholecystitis? A systematic review of the literature.

BACKGROUND AND OBJECTIVES: There is currently no consensus with regard to the use of cholecystectomy or percutaneous cholecystostomy as the therapy of choice for acute acalculous cholecystitis. The goal of this study was to review the scientific evidence on the management of these patients according to clinical and radiographic findings. METHODS: A systematic review of the literature from 2000 to 2016 was performed. The databases of PubMed, Índice Médico Español, Cochrane Library and Embase were searched according to the following inclusion criteria: publication language (English or Spanish), adult patients, acalculous etiology and appropriate study design. RESULTS: A total of 1,013 articles were identified and ten articles were selected for review. These included five observational controlled studies and five case series which described the outcome of patients treated with percutaneous cholecystostomy and emergency cholecystectomy. No prospective or randomized studies were identified using the search criteria. The data from the literature and analysis of results suggested that percutaneous cholecystostomy may be a definitive therapy for acute acalculous cholecystitis with no need for subsequent elective cholecystectomy. CONCLUSIONS: Percutaneous cholecystostomy may be the first treatment option for patients with acute acalculous cholecystitis except in cases with a perforation or gallbladder gangrene. Patients at low surgical risk may benefit from cholecystectomy but both treatment options may be effective. Percutaneous cholecystostomy in patients with acute acalculous cholecystitis may be a definitive therapy with no need for a subsequent elective cholecystectomy. However, the overall quality of studies is low and the final recommendations should be considered with caution.

Recommendations of «not-to-do¼: Proposals of the Spanish Association of Surgeons to the project «Commitment to quality of scientific societies¼. / Recomendaciones de «no hacer¼: propuestas de la Asociación Española de Cirujanos al proyecto de «Compromiso por la calidad de las sociedades científicas¼.

INTRODUCTION: The initiative of the Spanish Ministry of Health «Commitment to quality of scientific societies¼, aims to reduce unnecessary interventions of healthcare professionals. METHODS: The Spanish Association of Surgeons has selected 22 experts from the different sections that have participated in the identification of 26 proposals «do not do¼ to be ordered by the expected impact its implementation would have according to the GRADE methodology. From these proposals, the Delphi technique was used to select 5 recommendations presented in more detail in this article. RESULTS: The 5 selected recommendations are: Do not perform cholecystectomy in patients with asymptomatic cholelithiasis; do not keep bladder catheterization more than 48hours; do not extend antibiotic prophylaxis treatments more than 24hours after a surgical procedure; do not perform routine antibiotic prophylaxis for uncomplicated clean and no prosthetic surgery; and do not use antibiotics postoperatively after uncomplicated appendicitis. CONCLUSION: The Spanish Association of Surgeons's participation in this campaign has allowed a reflection on those activities that do not add value in the field of surgery and it is expected that the spread of this process serves to reduce its performance.

Development and pilot study of an essential set of indicators for general surgery services. / Desarrollo y estudio piloto de un conjunto esencial de indicadores para los servicios de cirugía general.

INTRODUCTION: At present there is a lack of appropriate quality measures for benchmarking in general surgery units of Spanish National Health System. The aim of this study is to present the selection, development and pilot-testing of an initial set of surgical quality indicators for this purpose. METHODS: A modified Delphi was performed with experts from the Spanish Surgeons Association in order to prioritize previously selected indicators. Then, a pilot study was carried out in a public hospital encompassing qualitative analysis of feasibility for prioritized indicators and an additional qualitative and quantitative three-rater reliability assessment for medical record-based indicators. Observed inter-rater agreement, prevalence adjusted and bias adjusted kappa and non-adjusted kappa were performed, using a systematic random sample (n=30) for each of these indicators. RESULTS: Twelve out of 13 proposed indicators were feasible: 5 medical record-based indicators and 7 indicators based on administrative databases. From medical record-based indicators, 3 were reliable (observed agreement >95%, adjusted kappa index >0.6 or non-adjusted kappa index >0.6 for composites and its components) and 2 needed further refinement. CONCLUSIONS: Currently, medical record-based indicators could be used for comparison purposes, whilst further research must be done for validation and risk-adjustment of outcome indicators from administrative databases. Compliance results in the adequacy of informed consent, diagnosis-to-treatment delay in colorectal cancer, and antibiotic prophylaxis show room for improvement in the pilot-tested hospital.

National survey on patient's fears before a general surgery procedure.

OBJECTIVE: To assess the magnitude of the different causes of anxiety in patients and families, facing surgery. METHODS: Cross-sectional multicenter national survey recruiting 1,260 participants between patients and companions, analyzing the impact of 14 areas selected based on scientific publications aimed at the general public, concerning patients and/or companions, focused on concern about surgery. Patient sex, age, type of surgery (minor/major) and expected inpatient or ambulatory surgery were analyzed. For the companions sex and age, and relationship to patient were analyzed. In both cases it was assessed based on a unidimensional scale of 0 to 10, with 0 being be minimal cause for concern and 10, maximum. RESULTS: The most prominent have been the fear of the unknown, possible complications, the impact on quality of life, the accuracy of diagnosis and possible malignancy of the disease, as well as anesthesia and pain control. There are significant differences in the involvement of patients and companions; and are also differences by sex and age of the patient; type of surgery (minor/major) and expected hospital admission or not. CONCLUSIONS: The patient faces surgery with a number of fears that can be reduced with increased information.

Clinical Pathway for Thyroidectomy.

Clinical pathways are care plans applicable to patient care procedures that present variations in practice and a predictable clinical course. They are designed not as a substitute for clinical judgment, but rather as a means to improve the effectiveness and efficiency of the procedures. This clinical pathway is the result of a collaborative work of the Sections of Endocrine Surgery and Quality Management of the Spanish Association of Surgeons. It attempts to provide a framework for standardizing the performance of thyroidectomy, the most frequently performed operation in endocrine surgery. Along with the usual documents of clinical pathways (temporary matrix, variance tracking and information sheets, assessment indicators and a satisfaction questionnaire) it includes a review of the scientific evidence around different aspects of pre, intra and postoperative management. Among others, antibiotic and antithrombotic prophylaxis, preoperative preparation in hyperthyroidism, intraoperative neuromonitoring and systems for obtaining hemostasis are included, along with management of postoperative hypocalcemia.

Understanding WHO surgical checklist implementation: tricks and pitfalls. An observational study.

BACKGROUND: The purpose of the present study was to assess the reliability of implementation data regarding the surgical safety checklist (SSC) and to identify which factors influence actual implementation. METHODS: The study was a retrospective record-based evaluation in a regional network of nine Spanish hospitals, combined with a complementary direct-observation study that included a survey of the surgical teams' attitudes. SSC compliance and associated factors were assessed and compared in a retrospective sample of 280 operations and a concurrent sample of another 85 surgical interventions. RESULTS: In the retrospective evaluation the SSC was present in 83.1 % of cases, fully completed in 28.4 %, with 69.3 % of all possible items checked. The concurrent direct-observation study showed that recorded compliance was unreliable (κ < 0.13 for all items) and significantly higher (p < 0.001) than actual compliance. Over-registration occurred across hospitals and surgical specialties. Factors associated with recorded compliance included hospital size, surgical specialty, and the use of an electronic format. In actual (direct-observation) compliance, a positive attitude on the part of the surgeon is an overriding significant factor (OR 12.8), along with using the electronic format, which is consistently and positively associated with recorded compliance but negatively related to actual compliance. CONCLUSIONS: Recorded SSC compliance may be widely unreliable and higher than actual compliance, particularly when recording is facilitated by using an electronic format. A positive attitude on the part of the surgical team, particularly surgeons, is associated with actual compliance. Effective use of the SSC is a far more complex adaptive process than the usual mandatory strategy.

[GRADE system: classification of quality of evidence and strength of recommendation]. / Sistema GRADE: clasificación de la calidad de la evidencia y graduación de la fuerza de la recomendación.

The acquisition and classification of scientific evidence, and subsequent formulation of recommendations constitute the basis for the development of clinical practice guidelines. There are several systems for the classification of evidence and strength of recommendations; the most commonly used nowadays is the Grading of Recommendations, Assessment, Development and Evaluation system (GRADE). The GRADE system initially classifies the evidence into high or low, coming from experimental or observational studies; subsequently and following a series of considerations, the evidence is classified into high, moderate, low or very low. The strength of recommendations is based not only on the quality of the evidence, but also on a series of factors such as the risk/benefit balance, values and preferences of the patients and professionals, and the use of resources or costs.

Assessment of postoperative morbidity in Spanish hospitals: Results from a national survey.

BACKGROUND: The methodology used for recording, evaluating and reporting postoperative complications (PC) is unknown. The aim of the present study was to determine how PC are recorded, evaluated, and reported in General and Digestive Surgery Services (GDSS) in Spain, and to assess their stance on morbidity audits. METHODS: Using a cross-sectional study design, an anonymous survey of 50 questions was sent to all the heads of GDSS at hospitals in Spain. RESULTS: The survey was answered by 67 out of 222 services (30.2%). These services have a reference population (RP) of 15 715 174 inhabitants, representing 33% of the Spanish population. Only 15 services reported being requested to supply data on morbidity by their hospital administrators. Eighteen GDSS, with a RP of 3 241 000 (20.6%) did not record PC. Among these, 7 were accredited for some area of training. Thirty-six GDSS (RP 8 753 174 (55.7%) did not provide details on all PC in patients' discharge reports. Twenty-four (37%) of the 65 GDSS that had started using a new surgical procedure/technique had not recorded PC in any way. Sixty-five GDSS were not concerned by the prospect of their results being audited, and 65 thought that a more comprehensive knowledge of PC would help them improve their results. Out of the 37 GDSS that reported publishing their results, 27 had consulted only one source of information: medical progress records in 11 cases, and discharge reports in 9. CONCLUSIONS: This study reflects serious deficiencies in the recording, evaluation and reporting of PC by GDSS in Spain.

Randomized clinical trial of laparoscopic hernia repair comparing titanium-coated lightweight mesh and medium-weight composite mesh.

BACKGROUND: The use of lightweight meshes in incisional hernia repair could have beneficial effects on quality of life. This study aimed to compare a new titanium-coated lightweight mesh with a standard composite mesh after laparoscopic incisional hernia repair. METHODS: A randomized controlled single-center clinical trial was designed using the basic principle of one unit, one surgeon, one technique (midline incisional hernia with a laparoscopic approach), and two meshes: a lightweight titanium-coated mesh (group 1) and a medium-weight collagen-polyester composite mesh (group 2) used in 102 patients. The primary end points were pain and recurrence. The secondary end points were morbidity and patient outcomes (analgesic consumption, return to everyday activities). RESULTS: The postoperative complication rates were similar for the two meshes. Pain was significantly less common in group 1 than in group 2 at 1 month (P = 0.029) but was similar for the two groups at 6 months and 1 year. There was a significant difference between the two groups in the average use of analgesics: 6.1 days in group 1 versus 1.6 days in group 2 (P < 0.001). The lightweight group returned to everyday activities after 6.9 days versus 9.7 days for the composite group (P < 0.001). The rate of recurrence did not differ between the two groups at the 2-year follow-up evaluation. CONCLUSIONS: The light titanium-covered polypropylene mesh was associated with less postoperative pain in the short term, lower analgesic consumption, and a quicker return to everyday activities than the Parietex composite medium-weight mesh. The recurrence rates at 2 years showed no difference between the two groups.

Validation of prolonged length of stay as a reliable measure of failure to rescue in colorectal surgery.

BACKGROUND: Failure-to-rescue measures a hospital's response capacity to avoid the death of a patient after a complication. The aim of this study was to validate the use of prolonged length of stay to calculate failure-to-rescue rates as a substitute for traditional coding of complications in colorectal cancer surgery. METHOD: We performed a cross-sectional between-instruments agreement study. Our study population was comprised of 204 colorectal cancer surgical patients from a public academic hospital during 2017 and 2018. We obtained two failure-to-rescue indicators from administrative data: an indicator using International Classification of Diseases, tenth edition, (ICD-10) codes; and another one using a cut-off point of prolonged length of stay as a predictor of patients with complications. Then, they were compared with a reference indicator from clinical records. RESULTS: Failure-to-rescue rates were between 10 and 13.64 for the study site depending on which indicator was used. A hospital stay ≥10 days had the maximum Youden's index (0.6) and an area under the ROC curve of 0.87. This was used in the failure-to-rescue indicator using prolonged length, which obtained the highest agreement (any coefficient >0.75). CONCLUSION: ICD-10 codes identified complications poorly. Prolonged length of stay could be a valid replacement of ICD-10 codes when measuring failure-to-rescue in administrative databases for colorectal surgical patients.

Surgical Infection Reduction Program of the Observatory of Surgical Infection (PRIQ-O): Delphi prioritization and consensus document on recommendations for the prevention of surgical site infection.

Surgical site infection is the most frequent and avoidable complication of surgery, but clinical guidelines for its prevention are insufficiently followed. We present the results of a Delphi consensus carried out by a panel of experts from 17 Scientific Societies with a critical review of the scientific evidence and international guidelines, to select the measures with the highest degree of evidence and facilitate their implementation. Forty measures were reviewed and 53 recommendations were issued. Ten main measures were prioritized for inclusion in prevention bundles: preoperative shower; correct surgical hand hygiene; no hair removal from the surgical field or removal with electric razors; adequate systemic antibiotic prophylaxis; use of minimally invasive approaches; skin decontamination with alcoholic solutions; maintenance of normothermia; plastic wound protectors-retractors; intraoperative glove change; and change of surgical and auxiliary material before wound closure.

Reduction in inappropriate hospital use based on analysis of the causes.

BACKGROUND: To reduce inappropriate admissions and stays with the application of an improvement cycle in patients admitted to a University Hospital. The secondary objective is to analyze the hospital cost saved by reducing inadequacy after the implementation of measures proposed by the group for improvement. METHODS: Pre- and post-analysis of a sample of clinical histories studied retrospectively, in which the Appropriateness Evaluation Protocol (AEP) was applied to a representative hospital sample of 1350 clinical histories in two phases. In the first phase the AEP was applied retrospectively to 725 admissions and 1350 stays. The factors associated with inappropriateness were analysed together with the causes, and specific measures were implemented in a bid to reduce inappropriateness. In the second phase the AEP was reapplied to a similar group of clinical histories and the results of the two groups were compared. The cost of inappropriate stays was calculated by cost accounting. SETTING: General University Hospital with 426 beds serving a population of 320,000 inhabitants in the centre of Murcia, a city in south-eastern Spain. RESULTS: Inappropriate admissions were reduced significantly: 7.4% in the control group and 3.2% in the intervention group. Likewise, inappropriate stays decreased significantly from 24.6% to 10.4%. The cost of inappropriateness in the study sample fell from 147,044 euros to 66,642 euros. The causes of inappropriateness for which corrective measures were adopted were those that showed the most significant decrease. CONCLUSIONS: It is possible to reduce inadequacy by applying measures based on prior analysis of the situation in each hospital.

[Difficulties in implementing a surgical check list in operating theatres]. / Dificultades en la implantación del check list en los quirófanos de cirugía.

OBJECTIVE: To assess the level of implementation and the factors associated with the compliance to the surgical check list (SCL) proposed by the WHO, in surgery departments in public hospitals in the Murcia Region of Spain. METHODOLOGY: A retrospective cross-sectional study was conducted using a random, non-proportional, and stratified sample in each hospital. The sample size was established as 10 cases per centre, with a total of 90 surgical operations. The data analysis included the percentage of compliance of the variables of interest (presence of an SCL and the compliance to it, complete, by sections and by items) at regional level, according to hospital, hospital groups, depending on the size; the type of anaesthesia (local, regional or general); the work shift (morning or afternoon); as well as the age and sex of the surgery patients. RESULTS: The check list was found in the medical records in 75 cases (83.33%; confidence interval [CI]: 78.7% - 87.5%), and complied with in full in 25 cases (27.8%; 95% CI: 18.5% - 37.0%). The percentage of items complied with was 70.1% (95% CI: 67.9%-72.2%). The percentage compliance varied by hospital, from 35.8% to 98.9%. The logistic regression analysis showed significance in the variables such as, the size of the hospital (the list was more likely to be complied with in small and medium hospitals) and operations with local anaesthetic as a negative predictive factor of compliance. CONCLUSIONS: The SCL is used, but is not always complied with, and not homogeneously in all its sections. There is also significant variation between the public hospitals in the Murcia Region of Spain.

[Improvement in the quality of life of faecal incontinent patients after sacral root stimulation treatment]. / Mejora de la calidad de vida en los pacientes con incontinencia fecal tratados con estimulación de raíces sacras.

INTRODUCTION: Faecal incontinence (FI) is a highly prevalent disorder that severely affects the health related quality of life (HRQOL) of the patients who suffer from it. Neuromodulation is a minimally invasive treatment that has demonstrated its efficacy in the treatment of FI symptoms over the past 10 years. The aim of this study is to check whether there is an improvement in the quality of life, using EuroQuol (EQ-5D), in patients with faecal incontinence treated with sacral root neuromodulation. METHODOLOGY: An observational study with prospective recording of quality of life data, before and after, using the EQ-5D on a series of patients diagnosed with moderate to severe FI with a complete or repaired sphincter who had a definitive MEDTRONIC Interstim(®) 3023 implant after a subchronic stimulation phase with a good response. RESULTS: The initial mean number of leaks was 3.1±1, and the final was 0.5±0.6. The mean number of escapes per week decreased to 2.6 escapes (CI 95%: 2.1-3.1) after the definitive implant of the sacral root stimulator (P<.001). The mean baseline health status score was 55.9±13, and after neuromodulation it was 63.1±13. Thus, the visual analogue scale score increased by 7.1 points (CI 95%: 0.37-14) after the definitive implant of the sacral root stimulator (P<.05). In the HRQOL variables studied with the EQ-5D questionnaire, we found an improvement with neuromodulation in the mobility and the presence of anxiety and/or depression variables. On the other hand we found an improvement with the neurostimulator implant, which was not significant, in personal care, performing daily activities and the presence of pain and/or discomfort. The current health was better in 11 patients (57.9%), the same in 7 (36.8%) and worse in 1 (5.3%). CONCLUSIONS: Neuromodulation is a therapy that has demonstrated a significant improvement in HRQOL measured with the EQ-5D.

[Guidelines and clinical pathways. Is there really a difference?]. / Guías y vías clínicas, ¿existe realmente diferencia?

Quality Design Activities of Good Clinical Practice guidelines or protocols and clinical pathways (CP) include those clinical plans intended for the patients with a particular disease. They must be based on the clinical evidence, the analysis of the process, and the consensus of the professionals involved in the care of the patient. When these are introduced to surgical professionals, they usually say that they do not understand the the difference between CP and protocols or guidelines. In fact we are speaking quality design activities with the same objectives of decreasing the unjustified variability and helping in the decision making on a specific clinical problem. In this work we attempt to show the differences by defining what is understood by a clinical pathway and protocol or guideline.

Associated factors and cost of inappropriate hospital admissions and stays in a second-level hospital.

The objective of this study was to analyze the variables related to inappropriate admissions and hospital stays and their financial repercussions. This was a descriptive retrospective study in which the Appropriateness Evaluation Protocol (AEP) was applied to a representative sample of 725 hospital admissions and 1350 hospital stays. The cost of inappropriate stays was calculated by cost accounting. The study found that 7.4% of admissions and 24.6% of stays were inappropriate. Inappropriate admissions were significantly related to medical specialties and younger patient age. Inappropriate stays were related to these factors, plus patients being outside their corresponding areas, nonurgent admissions, and low occupancy rate. The cost of the inappropriate admissions and stays was 147 044 euros. Extrapolated to the hospital as a whole this would represent 2125638 euros per year. Steps must be taken to reduce inappropriate admissions and stays to lower health care costs and to reserve hospital resources for patients who genuinely need them.