Identifying Components Necessary for an Enhanced Recovery After Surgery Pathway for Elective Intracranial Surgery: An Improvement Project Using the Quality of Recovery-15 Score.

OBJECTIVE: To identify the domains of recovery, as determined by the Quality of Recovery-15 (QoR-15) score, that needed improvement to develop initial interventions for an enhanced recovery after surgery protocol for patients undergoing elective intracranial surgery under general anesthesia. METHODS: A paired-availability design was used to assess 2 groups of 41 patients undergoing elective intracranial surgery. The baseline QoR-15 score and scores 0, 6, 12, and 24 hours after arrival in the intensive care unit characterized the postoperative recovery trajectory. The lowest scoring domains of the QoR-15 score were identified in the preimplementation group, and pharmacologic interventions were initiated in the postimplementation group. RESULTS: Postoperative analgesia and postoperative nausea and vomiting were identified as the lowest scoring domains. The pharmacologic interventions implemented were chosen because they produced minimal sedation and were easy to administer-1 40-mg oral preoperative dose of aprepitant to target postoperative nausea and vomiting and 2 perioperative 1-g doses of intravenous acetaminophen to improve analgesia. We observed a clinically significant as well as statistically significant improvement in analgesia on arrival in the intensive care unit and at the 6-hour postoperative time point. The total QoR-15 score was improved through the 12-hour time point. CONCLUSIONS: In this quality improvement project, the QoR-15 score allowed us to identify domains that slowed the recovery course in this patient population. Two 1-g doses of intravenous acetaminophen improved patients' well-being and analgesia after elective intracranial surgery.

Implementation of Vulnerable Elders Survey-13 Frailty Tool to Identify At-Risk Geriatric Surgical Patients.

PURPOSE: The primary purpose of this project was to preoperatively identify frail and vulnerable geriatric patients aged 65 or older using the Vulnerable Elders Survey (VES-13) tool, and to use those scores to assist with perioperative decision-making. DESIGN: This feasibility study was implemented as a quality improvement initiative with a postimplementation group only. METHODS: The VES-13 was introduced to the perioperative nursing staff and anesthesia providers and then added to the traditional preoperative assessment. The VES-13 scores were correlated to hospital length of stay, postanesthesia care unit stay, altered mental status, and morbidity. FINDINGS: Increased identification of older adult surgical patients at risk for increased length of stay, altered mental status, and morbidity in the preoperative setting was not evident, although the VES-13 was effective in identifying functional deficits in the older adult surgical patient. CONCLUSIONS: A detailed and comprehensive preoperative assessment remains the most efficient way to identify frail geriatric surgical patients.

Nursing Perceptions and Workload Impact of a Standardized Emergence Delirium Assessment Scale in a Postanesthesia Care Unit.

PURPOSE: Emergence delirium (EDL) is a psychomotor behavioral phenomenon that occurs immediately after emergence from general anesthesia. EDL is nearly 1.5 times more common among military than nonmilitary patients. Indirect delirium scales have precluded understanding of EDL in military patients. This quality improvement project assesses the feasibility of adopting a population-specific scale, the Emergence Delirium in the Wounded Warrior (ED-WW) Tool. DESIGN: Pre-post implementation design. METHODS: Postanesthesia care unit (PACU) nurses were surveyed on the clinical utility of the ED-WW Tool and its impact on their workload. The incidence of EDL behaviors in a Veterans Administration PACU was also recorded using the ED-WW Tool. FINDINGS: PACU nurses agreed the ED-WW Tool was of clinical value to military patients and had a very low workload impact. Twenty-one percent of patients demonstrated at least one behavior associated with EDL. CONCLUSIONS: ED-WW Tool adoption is clinically feasible and recommended for practice.

Preemptive Oral Acetaminophen for Women Undergoing Total Laparoscopic Hysterectomy.

OBJECTIVE: To decrease hospital expenses by administering oral acetaminophen rather than intravenous (IV) acetaminophen to women who undergo laparoscopic hysterectomy. DESIGN: A quality improvement project using a between-groups, pre-/postimplementation design for women undergoing total laparoscopic hysterectomy. Retrospective chart review was used to compare data of women who received intraoperative IV acetaminophen before implementation versus women who received oral acetaminophen after implementation. Pain scores and opioid consumption in morphine equivalents were recorded at four time points. SETTING/LOCAL PROBLEM: A 369-bed hospital in the southeastern United States, where, in 2016, nearly $260,000 was spent on perioperative IV acetaminophen for all operating room cases. PARTICIPANTS: Women between the ages of 18 and 55 years scheduled to have total laparoscopic hysterectomy were included. Excluded were women with a history of chronic pain, opioid use, or liver pathology; women with a contraindication to nonsteroidal anti-inflammatory drugs; and women whose procedures were converted from laparoscopic to open. INTERVENTION/MEASUREMENTS: Women were instructed to take oral acetaminophen the day before surgery in divided doses, with 1 g every 6 hours, for a total dose of 3 g. On the day of surgery, women received the final 1-g dose of oral acetaminophen. RESULTS: There were no significant differences between groups for pain scores or total opioids received before implementation (mean = 3.28, standard deviation = 2.05) compared with after implementation (mean = 3.65, standard deviation = 1.63; t [18] = -.043, p = .674). The preimplementation cost per individual was $30.03 for 1 g of IV acetaminophen, and the postimplementation cost was $0.36 for 2 500-mg oral acetaminophen tablets, a 98.8% relative cost decrease per woman. CONCLUSION: Replacing IV acetaminophen with preemptive oral acetaminophen has the potential to save money without compromising care.

Low-Dose Ketamine Infusion to Decrease Postoperative Delirium for Spinal Fusion Patients.

PURPOSE: The primary aim of this project was to decrease the incidence of postoperative delirium after spine surgery. DESIGN: A prospective preimplementation and postimplementation design was used. METHODS: A reduced dose ketamine protocol was implemented for adult patients undergoing elective spinal fusion surgery. Thirty patients were assessed at five time points for the presence of postoperative delirium in the postanesthesia care unit (PACU) using the 3-Minute Diagnostic Interview for Confusion Assessment Method Defined Delirium tool and opioid requirements were compared. FINDINGS: A statistical difference was noted between two groups in the incidence of delirium at three of five time points: on arrival to the PACU, and at 60 and 90 minutes after arrival to the PACU. CONCLUSIONS: This pilot study establishes groundwork for further studies to investigate if the ketamine dose can decrease the incidence of postoperative delirium in the initial 90 minutes after surgery without decreasing its analgesic effect.

Chapter 1 posttraumatic stress disorder: a view from the operating theater.

Posttraumatic stress disorder (PTSD) is an anxiety disorder that develops following exposure to a traumatic event. The prevalence and symptom severity of PTSD is greater in military combat Veterans than the civilian population. Although PTSD is a psychiatric disorder, in Veterans, it is associated with several physical comorbidities, chronic pain, substance abuse, and worse self-reported health status which may predispose them to greater perioperative morbidity and mortality. At present, the effect of surgery on the severity of PTSD is largely unknown. However, the perioperative clinician should consider PTSD a chronic illness associated with the accumulation of risk factors across the life span.