Recent advances in diabetes treatments and their perioperative implications.

PURPOSE OF REVIEW: The implications for perioperative management of new oral antihyperglycemic medications and new insulin treatment technologies are reviewed. RECENT FINDINGS: The preoperative period represents an opportunity to optimize glycemic control and potentially to reduce adverse outcomes. There is now general consensus that the optimal blood glucose target for hospitalized patients is approximately 106-180 mg/dl (6-10 mmol/l). Recommendations for the management of antihyperglycemic medications vary among national guidelines. It may not be necessary to cease all antihyperglycemic agents prior to surgery. Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are associated with higher rates of ketoacidosis especially in acutely unwell and postsurgical patients. The clinical practice implications of new insulin formulations, and new systems for insulin delivery, are not clear. The optimal perioperative management of these will vary depending on local institutional factors such as staff skills and existing clinical practices. Improved hospital care delivery standards, quality assurance, process improvements, consistency in clinical practice, and coordinated multidisciplinary teamwork should be a major focus for improving outcomes of perioperative patients with diabetes. SUMMARY: Sulfonylureas and SGLT2i should be ceased before moderate or major surgery. Other oral antihyperglycemic therapies may be continued or ceased. Complex patients and/or new therapies require specialized multidisciplinary management.

Risk Assessment.

PURPOSE OF REVIEW: The central question of preoperative assessment is not "What can be done?" but "What should be done and how?" Predicting a patient's risk of unwanted outcomes is vital to answering this question. This review discusses risk prediction tools currently available and anticipates future developments. RECENT FINDINGS: Simple, parsimonious risk scales and scores are being replaced by complex risk prediction models as high-capacity information systems become ubiquitous. The accuracy of risk estimation will be further increased by improved assessment of physical fitness, frailty, and incorporation of existing and novel biomarkers. However, the limitations of risk prediction for individual patient care must be recognized. SUMMARY: Risk prediction is transforming from clinical estimation to statistical science. Predictions should be used within the context of a patient's baseline risk (life expectancy independent of surgery), personal circumstances, quality of life, their expectations and values, and consideration of outcomes that are meaningful for the patient.

Optimizing Patient Preparation and Surgical Experience Using eHealth Technology.

With population growth and aging, it is expected that the demand for surgical services will increase. However, increased complexity of procedures, time pressures on staff, and the demand for a patient-centered approach continue to challenge a system characterized by finite health care resources. Suboptimal care is reported in each phase of surgical care, from the time of consent to discharge and long-term follow-up. Novel strategies are thus needed to address these challenges to produce effective and sustainable improvements in surgical care across the care pathway. The eHealth programs represent a potential strategy for improving the quality of care delivered across various phases of care, thereby improving patient outcomes. This discussion paper describes (1) the key functions of eHealth programs including information gathering, transfer, and exchange; (2) examples of eHealth programs in overcoming challenges to optimal surgical care across the care pathway; and (3) the potential challenges and future directions for implementing eHealth programs in this setting. The eHealth programs are a promising alternative for collecting patient-reported outcome data, providing access to credible health information and strategies to enable patients to take an active role in their own health care, and promote efficient communication between patients and health care providers. However, additional rigorous intervention studies examining the needs of potential role of eHealth programs in augmenting patients' preparation and recovery from surgery, and subsequent impact on patient outcomes and processes of care are needed to advance the field. Furthermore, evidence for the benefits of eHealth programs in supporting carers and strategies to maximize engagement from end users are needed.

Classroom and simulation team training: a randomized controlled trial.

OBJECTIVE: To test the hypotheses that classroom and simulation-based crew resource management (CRM) training interventions improve teamwork attitudes and behaviours of participants and that classroom training combined with simulation-based training provide synergistic improvements. DESIGN: A randomized controlled trial. SETTING: Area Health Service in New South Wales, Australia. PARTICIPANTS: A total of 157 doctors, nurses and midwives randomized into one of four groups, consisting of three intervention groups and a control group. INTERVENTION: One-day CRM-based classroom course; one-day CRM style simulation-based training or classroom training followed by simulation-based training. MAIN OUTCOME MEASURES: Pre- and post-test quantitative participant teamwork attitudes, and post-test quantitative trainee reactions, knowledge and behaviour. RESULTS: Ninety-four doctors, nurses and midwives completed pre-intervention attitude questionnaires and 60 clinicians completed post-intervention assessments. No positive changes in teamwork attitudes were found associated with classroom or simulation training. Positive changes were found in knowledge (mean difference 1.50, 95% confidence interval (CI) 0.58-2.43, P = 0.002), self-assessed teamwork behaviour (mean difference 2.69, 95% CI 0.90-6.13, P = 0.009) and independently observed teamwork behaviour (mean difference 2.30, 95% CI 0.30-4.30, P = 0.027) when classroom-only trained group was compared with control; however, these changes were not found in the group that received classroom followed by simulation training. CONCLUSIONS: Classroom-based training alone resulted in improvements in participant knowledge and observed teamwork behaviour. The study found no additional impact of simulation training.

Perioperative Systems as a quality model of perioperative medicine and surgical care.

OBJECTIVES: There has been a recent widespread international 'paradigm shift' to new Perioperative Systems for surgical patient care. These new systems are based on a multidisciplinary team providing an integrated process of care from the time a decision is made that a patient should have an operation until the patient has recovered from surgery. The objectives of this review were to outline the rationale for new Perioperative Systems, synthesize the evidence supporting these new systems and consider the current state of Perioperative Systems and its future development. METHODS: A systematic review of studies that focus on preoperative management practices to improve patient preparation for surgery and anaesthesia, with restriction to study designs with the highest levels of evidence for the synthesis of evidence. RESULTS: Perioperative Systems are regarded as the standard model of care in Australia, New Zealand, North America and increasingly in Europe. The benefits of Perioperative Systems include: increased surgical volume and flow (20-35%), shorter preoperative length of stay (-0.2 to -1.3 days), fewer cancellations of surgery (absolute reduction 1-8%), relative reduction in the number (23-55%) and cost (40-59%) of preoperative investigations and a lower risk of wound infection (relative risk 0.30, 95% CI 0.12-0.78) compared to the traditional system. The mean reduction in the total cost per patient associated with a Perioperative System was 8-18%. Future developments include offering health promotion activities in the weeks before surgery to improve long term patient outcomes after surgery. CONCLUSION: There is evidence of quality benefits for patients, clinicians and health administrators associated with new Perioperative Systems. Despite this, these systems are yet to be fully developed in many jurisdictions.

Handover--Enabling Learning in Communication for Safety (HELiCS): a report on achievements at two hospital sites.

Clinical handover is an area of critical concern, because deficiencies in handover pose a patient safety risk. Redesign of handover must allow for input from frontline staff to ensure that designs fit into existing practices and settings. The HELiCS (Handover--Enabling Learning in Communication for Safety) tool uses a "video-reflexive" technique: handover encounters are videotaped and played back to the practitioners involved for analysis and discussion. Using the video-reflexive process, staff of an emergency department and an intensive care unit at two different tertiary hospitals redesigned their handover processes. The HELiCS study gave staff greater insight into previously unrecognised clinical and operational problems, enhanced coordination and efficiency of care, and strengthened junior-senior communication and teaching. Our study showed that reflexive and "bottom-up" handover redesign can produce outcomes that harbour local fit, practitioner ownership and (to date) sustainability.

Providing comprehensive smoking cessation care to surgical patients: the case for computers.

INTRODUCTION AND AIMS: The provision of smoking cessation care to surgical patients before admission can reduce post-operative complications and encourage long-term smoking cessation. Our aim was to show how a comprehensive computer-based smoking cessation intervention, developed to enhance smoking cessation care to surgical patients, addresses barriers to care provision. DESIGN AND METHODS: Consultations with preoperative clinic staff and reviews of the scientific literature were conducted and identified the following barriers to the provision of effective smoking cessation care: a lack of organisational support, perceived patient objection, a lack of systems to identify smokers, a lack of staff time and skill, perceived inability to change care practices, a perceived lack of efficacy of cessation care and the cost of providing care. Based on positive findings of a pilot trial, a comprehensive computer-based smoking cessation intervention was implemented in a preoperative clinic. Data from previous evaluations of the intervention were used to assess the extent to which the intervention addressed clinician barriers to care. RESULTS: The computer-based intervention was found to provide a means to accurately and systematically identify smokers; it required little clinical staff time or skill; it was considered an acceptable form of care by staff and patients; it was effective in encouraging patient cessation and it was inexpensive to deliver relative to other surgical costs. Furthermore, the computer-based intervention continues to operate in the preoperative clinic in the absence of ongoing research support. DISCUSSION AND CONCLUSIONS: The implementation of such a model of care should be considered by clinical services interested in reducing the smoking related morbidity and mortality of patients.

Reforming New South Wales public hospitals: an assessment of the Garling inquiry.

The final report of the Special Commission of Inquiry into Acute Care Services in NSW Public Hospitals was published on 27 November 2008. The report acknowledges the challenges facing the New South Wales health system, including increasing numbers of patients, rising treatment costs, workforce pressures, and the breakdown of working relations between clinicians and management. Many of Commissioner Garling's 139 recommendations formalise aspects of clinical care that should and could be happening now if the system were better managed, including better supervision and training of junior staff. Commissioner Garling recommends that change should be driven by clinicians "from the bottom up", but does not adequately describe how this should happen. Implementation of the report's recommendations that will require strong leadership and continuing consultation with clinicians and the community.

Feasibility, acceptability, and cost of referring surgical patients for postdischarge cessation support from a quitline.

The aim of the study was to assess the feasibility, acceptability, and cost of referral of smoking patients to a proactive quitline service for postdischarge cessation support. Participants were recruited from the preoperative clinic of an Australian hospital. Data were collected from project records and a telephone interview with participants 6 months after attending the preoperative clinic. The study found that 64% of the 67 participants accepted an offer of referral to the quitline by preoperative clinic staff. Some 74% of patients referred to the quitline were contacted by the quitline after discharge. Smokers contacted by the quitline and clinic staff referring patients to the quitline generally responded favorably on items assessing the acceptability of the quitline service and the process of referral to the quitline. Referral to the quitline service cost less than US$2 per patient. Referral of patients to a quitline is feasible, was generally considered acceptable by surgical patients and staff, and was inexpensive.

Reshaping ICU ward round practices using video-reflexive ethnography.

In this article, we outline a study method with which structural changes to clinical communication were achieved within a local intensive care unit (ICU). The study method involved in-depth, round-the-clock observation, interviewing, and video filming of how intensivists conducted their practices, as well as showing selected footage to the clinicians for feedback. This feedback component iteratively engaged clinicians in problem-solving their own communication difficulties. The article focuses on one such feedback meeting and describes changes to the morning ward round and planning meeting that this feedback process catalyzed: greater time efficiency, a greater presence of intensivists in the ICU, more satisfied nursing staff, and a handover sheet to improve the structure of clinical information exchanges. We argue that in embodying not a descriptive but an interventionist approach to health service provision, this video-ethnographic method has great significance for enhancing clinicians' and researchers' understanding of the rising complexity of in-hospital practices, and for enabling them to intervene in these practices.

Perioperative patient management.

Modern perioperative care is complex and involves a large number of staff from multiple disciplines. Patient outcomes depend on well-designed processes, consistent clinical practice, and effective communication. Perioperative care should be a unified process of multiple coordinated steps. There should be a hospital-based multidisciplinary service to manage and plan this process. Early assessment of the patient's comorbidities is essential to plan patient preparation. Ideally, patients should be fully prepared before the day of surgery, and only admitted to hospital shortly before surgery. For many common clinical challenges, there is a range of accepted management regimes. Institutionally consistent clinical practice is necessary to optimise patient outcome. Postoperative management should be based on standardised observations and care protocols, prevention strategies targeted at common problems, and rapid response by high-level teams to early physiological signs of complications.

Increasing smoking cessation care in a preoperative clinic: a randomized controlled trial.

BACKGROUND: Evidence suggests that preoperative clinics, like other hospital outpatient clinics and inpatient wards, fail to systematically provide smoking cessation care to patients having planned surgery. METHODS: The aim of the study was to assess the efficacy, acceptability, and cost of a multifaceted intervention to facilitate the provision of comprehensive smoking cessation care to patients attending a preoperative clinic. Two hundred ten smoking patients attending a preoperative clinic at a major teaching hospital in Australia took part in the study. One hundred twenty-four patients were randomly assigned to an experimental group and 86 patients to a usual cessation care group. A multifaceted intervention was developed that included the use of opinion leaders, consensus processes, computer-delivered cessation care, computer-generated prompts for care provision by clinic staff, staff training, and performance feedback. RESULTS: Ninety-six percent of experimental group patients received behavioral counseling and tailored self-help material. Experimental group patients were significantly more likely than usual care patients to report receiving brief advice by nursing (79% vs. 47%; P < 0.01) and anaesthetic (60% vs. 39%; P < 0.01) staff. Experimental group patients who were nicotine dependent were also more likely to be offered preoperative nicotine replacement therapy (NRT) (82% vs. 8%; P < 0.01) and be prescribed postoperative NRT (86% vs. 0%; P < 0.01). The multifaceted intervention was found to be acceptable by staff. CONCLUSION: A multifaceted clinical practice change intervention may be effective in improving the delivery of smoking cessation care to preoperative surgical patients.

The medical emergency team, evidence-based medicine and ethics.

The medical emergency team (MET), which may be summoned by anyone in a hospital to treat a patient who appears acutely unwell, has been generally accepted as scientifically rational, with no adverse clinical outcomes and only modest resource requirements. Despite this, many centres appear to be awaiting "gold standard" evidence of its effectiveness. We suggest that the quest for evidence is providing scientific justification for institutional inertia, and that further delay in implementing this system may even be unethical. We propose that decisions about changes in healthcare should consider scientific rationality, clinical reasonableness and resource implications, as well as evidence and ethical implications.