Multimodal prehabilitation in patients with non-small cell lung cancer: a feasibility study.

Background: Anatomic pulmonary resection is the preferred curative treatment in operable non-small cell lung cancer (NSCLC) but is associated with postoperative complications and inevitable compromise in functional capacity. Preoperative enhancement of functional capacity can be achieved with prehabilitation, yet the window of opportunity in NSCLC patients is small because patients are required to undergo surgery within 3 weeks from diagnosis. The goal of this study was to assess the feasibility of a prehabilitation programme in NSCLC within a 3-week timeframe and its effect on functional capacity-although the study was not powered to confirm improvements in functional capacity. Methods: Prehabilitation consisted of six interventions: exercise programme, nutritional support, mental support, smoking cessation, patient empowerment, and optimisation of respiratory status and was executed in two large teaching hospitals in the Netherlands. Assessments were scheduled at baseline (T0), end of program preoperatively (T1), and 6 weeks postoperatively (T2). Feasibility was defined as ≥80% of participants completing ≥80% of the programme. Functional capacity [6-minute walk test (6MWT), steep ramp test (SRT), one repetition maximum (1RM), maximal inspiratory pressure (MIP), and hand grip strength (HGS)] was evaluated on T1 and T2 compared to T0 using mixed model analyses. Results: In total, 24 patients were included. In 95.8% of patients, the program proved feasible and preoperative functional capacity significantly improved in all pre-specified tests on T1. 1RM sustained improved at T2. Conclusions: Multimodal prehabilitation for lung surgery is feasible within a timeframe of 3 weeks. Even though this study was not powered to confirm it, prehabilitation may improve preoperative functional capacity.

Implementing an enhanced recovery after thoracic surgery programme in the Netherlands: a qualitative study investigating facilitators and barriers for implementation.

OBJECTIVES: This study aims to elucidate determinants for succesful implementation of the Enhanced Recovery After Thoracic Surgery (ERATS) protocol for perioperative care for surgical lung cancer patients in the Netherlands. SETTING: Lung cancer operations are performed in both academic and regional hospitals, either by cardiothoracic or general thoracic surgeons. Limiting the impact of these operations by optimising and standardising perioperative care with the ERATS protocol is thought to enable reduction in length of stay, complications and costs. PARTICIPANTS: A broad spectrum of stakeholders in perioperative care for patients with lung resection participated in this study, ranging from patient representatives, healthcare professionals to an insurance company representative. INTERVENTIONS: Semistructured interviews (N=14) were conducted with the stakeholders (N=18). The interviews were conducted one on one by telephone and two times, face to face, in small groups. Verbatim transcriptions of these interviews were coded for the purpose of thematic analysis. OUTCOME MEASURES: Determinants for successful implementation of the ERATS protocol in the Netherlands. RESULTS: Several determinants correspond with previous publications: having a multidisciplinary team, leadership from a senior clinician and support from an ERAS-coordinator as facilitators; lack of feedback on performance and absence of management support as barriers. Our study underscores the potential detrimental effect of inconsistent communication, the lack of support in the transition from hospital to home and the barrier posed by lack of accessible audit data. CONCLUSIONS: Based on a structured problem analysis among a wide selection of stakeholders, this study provides a solid basis for choosing adequate implementation strategies to introduce the ERATS protocol in the Netherlands. Emphasis on consistent and sufficient communication, support in the transition from hospital to home and adequate audit and feedback data, in addition to established implementation strategies for ERAS-type programmes, will enable a tailored approach to implementation of ERATS in the Dutch context.

Wide Variation in Perioperative Care in Anatomical Lung Resections in the Netherlands: A National Survey.

This study aimed to describe perioperative care after anatomical lung resection in the Netherlands, before publication of Enhanced Recovery After Surgery/European Society of Thoracic Surgeons (ERAS/ESTS) guidelines in 2019. An online survey was sent to all 43 Dutch lung surgical centers in December 2017, addressing topics in the 4 phases of perioperative care (preoperative, admission, perioperative, postoperative). Respondents were requested to report care that would be delivered to a standardized patient without perioperative complications. To compare current care with ERAS/ESTS guidelines, we assigned an ERAS/ESTS score per hospital, weighted for evidence level per recommendation. Higher scores indicate higher application of recommendations. Response rate of centers was 100%, median response rate per question was 98% (interquartile range 94-100). Some perioperative recommendations are commonly applied (>85%), such as minimally invasive surgery and regional anesthesia; others, such as admission carbohydrate drinks, are not (<35%). Wide variation was observed regarding patient counselling, pre- and postoperative admission logistics, anemia correction, fluid management, pain management, and chest drain management. Median 62% (interquartile range 53%-72%) of the maximum ERAS/ESTS score was achieved. Large variation in ERAS/ESTS score between hospitals were found in all phases (preoperative: 6.0 [6.5-10.5] points, admission: 5.0 [1.0-6.0] points, perioperative: 21.5.0 [16.0-22.5] points, postoperative: 8.0 [5.0-8.5] points). Large variation exists in perioperative care after anatomical lung resection in the Netherlands. Given previously published data linking variation in perioperative care to variation in outcomes, standardization of perioperative care in lung surgery, preferably based on the ERAS/ESTS guidelines, may be warranted but requires further study.

Variation in length of stay after minimally invasive lung resection: a reflection of perioperative care routines?

OBJECTIVES: Good perioperative care is aimed at rapid recovery, without complications or readmissions. Length of stay (LOS) is influenced not only by perioperative care routines but also by patient factors, tumour factors, treatment characteristics and complications. The present study examines variation in LOS between hospitals after minimally invasive lung resections for both complicated and uncomplicated patients to assess whether LOS is a hospital characteristic influenced by local perioperative routines or other factors. METHODS: Dutch Lung Cancer Audit (surgery) data were used. Median LOS was calculated on hospital level, stratified by the severity of complications. Lowest quartile (short) LOS per hospital, corrected for case-mix factors by multivariable logistic regression, was presented in funnel plots. We correlated short LOS in complicated versus uncomplicated patients to assess whether short LOS clustered in the same hospitals regardless of complications. RESULTS: Data from 6055 patients in 42 hospitals were included. Median LOS in uncomplicated patients varied from 3 to 8 days between hospitals and increased most markedly for patients with major complications. Considerable between-hospital variation persisted after case-mix correction, but more in uncomplicated than complicated patients. Short LOS in uncomplicated and complicated patients were significantly correlated (r = 0.53, P < 0.001). CONCLUSIONS: LOS after minimally invasive anatomical lung resections varied between hospitals particularly in uncomplicated patients. The significant correlation between short LOS in uncomplicated and complicated patients suggests that LOS is a hospital characteristic potentially influenced by local processes. Standardizing and optimizing perioperative care could help limit practice variation with improved LOS and complication rates.

Variation in length of hospital stay after lung cancer surgery in the Netherlands.

OBJECTIVES: Length of stay (LOS) in the hospital after lung cancer surgery is influenced by patient characteristics, tumour characteristics, surgical technique and perioperative care. Our objective was to determine whether there were variation in LOS between hospitals that could not be accounted for by these known parameters. Residual variation in LOS would suggest important differences in perioperative care protocols and discharge criteria. METHODS: This study analysed data from the Netherlands National Cancer Registry (NNCR) on 10 195 anatomical lung resections for primary lung cancer from 2010 to 2015. Multivariable analysis was performed for multiple factors, using hierarchical linear regression analysis of the mean LOS. Information on comorbidity and socio-economic status was not available. Association between LOS and postoperative mortality was evaluated in multivariable logistic regression. RESULTS: The median LOS was 7 days (interquartile range 5-10 days), and the mean LOS was 8.3 days. LOS was negatively affected by larger resections, open surgery and advancing age. Histology and tumour stage had little influence. Overall, 30-day and 90-day mortality were 2.1% and 3.8%, respectively; 1.7% and 3.3% (not significant) in the group of hospitals with shorter LOS. After case-mix correction, residual between-hospital variation in the mean LOS was observed, ranging from 1.5 days shorter to almost 2.5 days longer. CONCLUSIONS: A clinically relevant between-hospital variation in LOS after lung cancer surgery is observed in the Netherlands. Although residual confounding by comorbidity or socio-economic status cannot be excluded, this variation is deemed to be largely due to differences in perioperative care protocols. Evaluation of best practices can help to improve perioperative care for lung surgery patients and optimize LOS.

Online Victim Tracking and Tracing System (ViTTS) for major incident casualties.

INTRODUCTION: Dealing with major incidents requires an immediate and coordinated response by multiple organizations. Communicating and coordinating over multiple geographical locations and organizations is a complex process. One of the greatest challenges is patient tracking and tracing. Often, data about the number of victims, their condition, location and transport is lacking. This hinders an effective response and causes public distress. To address this problem, a Victim Tracing and Tracking system (ViTTS) was developed. METHODS: An online ViTTS was developed based on a wireless network with routers on ambulances, and direct online registration of victims and their triage data through barcode injury cards. The system was tested for feasibility and usability during disaster drills. RESULTS: The formation of a local radio network of hotspots with mobile routers and connection over General Packet Radio Service (GPRS) to the central database worked well. ViTTS produced accurately stored data, real-time availability, and a real-time overview of the patients (number, seriousness of injury, and location). CONCLUSION: The ViTTS provides a system for early, unique registration of victims close to the impact site. Online application and connection of the various systems used by the different chains in disaster relief promotes interoperability and enables patient tracking and tracing. It offers a real-time overview of victims to all involved disaster relief partners, which is necessary to generate an adequate disaster response.

Disaster-related injury and predictors of health complaints after exposure to a natural disaster: an online survey.

Objectives To study short- and long-term effects of experiencing a disaster in repatriated injured survivors and the differential effect of injury, need for medical treatment, loss of loved ones and danger to life on both physical and mental health. Design Prospective online study. Setting Open online survey among Dutch survivors of the 2004 Asian tsunami. Participants Of the estimated total of 464 Dutch survivors, the authors recruited 144 unique respondents (59 men and 85 women) with a total of 175 assessments made in various time periods. Main outcome measures Health outcomes were Symptom Checklist 90 (SCL-90), Impact of Event Scale (original version, in Dutch) and Beck Depression Inventory II. Correlations were calculated with socio-demographic as well as disaster-related factors: physical injury, medical care, loss of loved ones and duration of threat to life. Assessments were clustered in four post-disaster time periods (0-3, 4-6, 7-30 and 31-48 months). Results Across these periods, SCL-90 scores were significantly higher than the reference population (p<0.001), with a significant linear downward trend between the groups over time (p=0.001). The same pattern occurred for the Impact of Event Scale (p<0.001) and the Beck Depression Inventory II (p=0.002). Physical injury, medical care or loss of loved ones was not associated with higher total SCL-90 scores or somatic subscores. Both duration of threat to life and female sex were correlated with all measured outcome parameters. Conclusions Exposure to the 2004 Asian tsunami had significant short- and long-term impacts on health complaints in a group of repatriated Dutch tsunami victims. Cross-sectionally, there was a trend towards recovery over 4 years, although 22% still reported high psychological and physical distress 4 years post-disaster. Duration of danger to life and female sex were associated with more physical and mental health complaints. In this study, neither disaster-related injury nor loss of loved ones resulted in negative health outcomes.