Implementation of a surgical site infection prevention bundle in gynecologic oncology patients: An enhanced recovery after surgery initiative.

OBJECTIVE: To evaluate the clinical outcomes pre- and post-implementation of an evidence-informed surgical site infection prevention bundle (SSIPB) in gynecologic oncology patients within an Enhanced Recovery After Surgery (ERAS) care pathway. METHODS: Patients undergoing laparotomy for a gynecologic oncology surgery between January-June 2017 (pre-SSIPB) and between January 2018-December 2020 (post-SSIPB) were compared using t-tests and chi-square. Patient characteristics, surgical factors, and ERAS process measures and outcomes were abstracted from the ERAS® Interactive Audit System (EIAS). The primary outcomes were incidence of surgical site infections (SSI) during post-operative hospital admission and at 30-days post-surgery. Secondary outcomes included total postoperative infections, length of stay, and any surgical complications. Multivariate models were used to adjust for potential confounding factors. RESULTS: Patient and surgical characteristics were similar in the pre- and post-implementation periods. Evaluation of implementation suggested that preoperative and intraoperative components of the intervention were most consistently used. Infectious complications within 30 days of surgery decreased from 42.1% to 24.4% after implementation of the SSIPB (p < 0.001), including reductions in wound infections (17.0% to 10.8%, p = 0.02), urinary tract infections (UTI) (12.7% to 4.5%, p < 0.001), and intra-abdominal abscesses (5.4% to 2.5%, p = 0.05). These reductions were associated with a decrease in median length of stay from 3 to 2 days (p = 0.001). In multivariate analysis, these SSI reductions remained statistically significant after adjustment for potential confounders. CONCLUSION: Implementation of SSIPB was associated with a reduction in SSIs and infectious complications, as well as a shorter length of stay in gynecologic oncology patients.

Improving the Rate of Same-Day Discharge in Gynecologic Oncology Patients Undergoing Minimally Invasive Surgery-An Enhanced Recovery After Surgery Quality Improvement Initiative.

OBJECTIVES: The objectives of our quality improvement (QI) initiative were (1) to increase the rate of same-day discharge (SDD) in eligible gynecologic oncology (GO) patients to 70% and (2) to evaluate the ease with which QI methods demonstrated in one study could be applied at another center. DESIGN: A pre-/postintervention design was used (50 patients/group). SETTING: SDD in patients undergoing minimally invasive GO surgery is a recent trend aligned with Enhanced Recovery After Surgery (ERAS) principles. SDD in GO is safe and feasible based on several recent studies, including a QI initiative in Edmonton, Alberta, which resulted in SDD rates >70%. PATIENTS: A baseline audit of GO patients at our center (Calgary, Alberta) found the SDD rate to be 14%. Given that Edmonton and our center are within the same province, they have similar patient populations and available resources-suggesting that interventions from the Edmonton QI initiative may be translatable. INTERVENTIONS: Four interventions were designed to address root causes for failed SDD identified after QI diagnostics: (1) SDD as the default discharge plan, including a "Day Surgery" surgical booking; (2 and 3) development and implementation of ERAS SDD preoperative and postoperative order sets; and (4) patient education SDD-specific documents. MEASUREMENTS AND MAIN RESULTS: Rate of SDD was measured together with patient demographics and surgical outcomes. Process and balancing measures were defined and tracked. SDD in GO increased from 14% (7 of 50) to 82% (41 of 50) after the implementation of the above-mentioned interventions (odds ratio [OR], 28; p <.001; 95% confidence interval [CI], 9.54-82.11). Improved SDD was achieved without negatively affecting postoperative rates of emergency department visits: 8% pre- and 4% postintervention within 7 days (OR, 0.48; p = .678; 95% CI, 0.09-2.74) and 12% pre- and 10% postintervention within 30 days (OR, 0.8148; p = 1.001; 95% CI, 0.2317-2.86). CONCLUSION: This ERAS QI initiative resulted in a substantial increase in SDD in GO, without a negative impact on balancing measures. We demonstrate that the "spread" of simple, clearly defined QI interventions across centers (where the patient population is similar) is feasible. This suggests that an ERAS SDD program for GO could be a realistic goal for other centers with similar characteristics.

The Yield of Ambulatory EEG-Video Monitoring.

INTRODUCTION: The availability of ambulatory EEG-video monitoring gives an alternative to traditional inpatient EEG-video, but its yield and diagnostic value are not well known. This study evaluates the yield of ambulatory EEG-video for the diagnosis of epilepsy. METHODS: We retrospectively reviewed the ambulatory EEG-video monitoring data from 200 consecutive and unselected patients aged 12 years and older performed by a single company (RSC Diagnostic Services) between January 2018 and May 2018. Studies were processed by two senior certified long-term monitoring EEG technologists and interpreted by neurologists. RESULTS: Of the 200 patients, 130 (65%) were women, mean age was 45 years. Mean duration of studies were 76.6 hours (range 23-175 hours). There were 110 studies (55%) with events recorded and 101 (92%) were captured on video. Epileptic events accounted for 17.8% (18/101) of the events captured and 9% (18/200) of our total cohort. Nonepileptic diagnosis accounted for 38% of the total number of patients in study (76/200). CONCLUSION: Ambulatory EEG-video monitoring may be a useful alternative to inpatient epilepsy monitoring unit, particularly with high clinical suspicion for nonepileptic events.

Association Between Positive Occipital Sharp Transients of Sleep and Lambda Waves.

Positive occipital sharp transients of sleep (POSTS) and lambda waves have similar morphology and location. We studied a possible association between these 2 normal EEG patterns. We reviewed a series of consecutive unselected ambulatory EEGs during a 3-month period (October 16, 2017 to January 19, 2018) and identified records with POSTS and records with lambda waves. Statistical analysis was performed using a chi-square test. A total of 140 ambulatory EEGs were reviewed. Duration of EEGs ranged from 24 to 168 hours (mean 76 hours). The population was 34% males, with ages ranging from 3 to 93 years (mean 48 years). Of the 140 records, 30 were abnormal, including 20 with epileptiform abnormalities. A chi-square test for independence (with Yates continuity correction) indicated a significant association between POSTS and lambda waves, χ2(1, n = 140) = 69.208, p < .001, φ = 0.72. In addition, 100% of records with lambda waves had POSTS, and 72% of records with POSTS had lambda waves. There is a high association between lambda waves and POSTS. This suggests a strong similarity between the 2 waveforms, and possibly a common occipital generator.