Enhanced Recovery After Surgery, Lean, and claims-based quality databases: how does it all make sense?

PURPOSE OF REVIEW: Healthcare is rapidly evolving toward value-focused objectives, integrating outcomes and cost instead of simply volume. Concepts pertaining to Enhanced Recovery After Surgery (ERAS), Lean, and claims-based risk-adjusted databases can be used to optimize value, but the application of Lean principles and risk-adjusted outcomes is poorly described in perioperative medicine in perioperative medicine. RECENT FINDINGS: Lean management and process optimization tools allow the consistent application of a perioperative medical framework of ERAS to improve outcomes. Vizient risk-stratified outcomes are often used by hospitals to measure and compare quality. SUMMARY: Understanding administrative databases and Lean concepts for change management will allow the perioperative physician to better align medical concepts with health system tools for improving quality and reducing cost.

Implementing Enhanced Recovery After Surgery Across a United States Health System.

Enhanced recovery after surgery (ERAS) is a series of evidence-based perioperative care protocols designed to improve outcomes following surgery. The concept was founded on the principle of producing a predictable quality outcome by reducing morbidity and shortening hospital stay. The key objective of ERAS is to incorporate optimized multimodal perioperative care in a variety of different surgical specialties to reduce injury and stress during the perioperative period and promote a return to normal function rapidly.

Infection prevention and enhanced recovery after surgery: A partnership for implementation of an evidence-based bundle to reduce colorectal surgical site infections.

To reduce surgical site infections (SSIs) in colorectal surgeries we introduced a bundle of care elements in partnership with the Enhanced Recovery after Surgery (ERAS) multidisciplinary team. We measured the incidence of National Healthcare Safety Network-defined SSIs, along with adherence to bundle care elements. Despite opportunities for improvement in adherence to some key components, implementation of the ERAS protocol may have facilitated a reduction in the rate of colorectal SSIs at our institution.

The single neurofilament subunit of lamprey may need another element for filament assembly.

Regenerating axon tips in transected lamprey spinal cord contain dense accumulations of neurofilaments (NFs), suggesting that NFs may play a role in the mechanism of axonal regeneration. Compared with heteropolymeric assemblies of NF triplet proteins in mammals, NF in lampreys has been thought to contain only a single subunit (NF180). This would imply that NF180 self-assembles, which would be important for manipulating its expression in studies of axonal regeneration. In order to study the possible role of NF in process outgrowth and to determine whether NF180 can self-assemble, its gene was transfected into mammalian and fish cell lines that either contain or lack vimentin. In transfected NIH3T3 cells, NF180 was poorly phosphorylated and its expression did not alter the length or number of cell processes. Nor did it appear to form typical intermediate filaments, suggesting that it may not self-assemble. NF180 also did not form typical filaments in SW13cl cells that either possessed or lacked vimentin, nor in transfected fish cells that were cultured at 18 degrees C. In vitro, NF180 could not self-assemble but interacted with NF-L to interrupt its self-assembly. When cotransfected with rat NF-L into SW13c1.2vim(-) cells, NF180 did form thick, rod-like filamentous structures on immunofluorescence. More typical NFs were observed when NF180 was cotransfected with both NF-L and NF-M. Thus, NF180 cannot self-assemble but appears to require one or more additional elements for incorporation into NFs.

Regional reference variation provides ecologically meaningful protection criteria for northern world heritage site.

Unprecedented rates of resource development and climate change at northern latitudes coupled with a lack of baseline information limits our ability to set ecologically meaningful criteria needed to protect these inherently sensitive ecosystems. We surveyed water and sediment chemistry, community composition of benthic algae and invertebrates and fish, and condition of a sentinel fish species, slimy sculpin (Cottus cognatus), in 2 rivers adjacent to metal mines and in 20 reference rivers in the headwaters of a World Heritage Site, the South Nahanni River Basin, NWT, Canada. The normal range (i.e., mean ± 2 standard deviations) of biological conditions in regional reference sites (grouped by community type) were used to set ecologically meaningful effect sizes. These effect sizes were used in noncentral hypotheses tests to assess the ecological condition of potentially impaired sites. Significant impairments at sites influenced by current and historical mining activity were indicative of mild enrichment (e.g., increased benthic abundance and sculpin condition) and bioaccumulation of metals (e.g., increased concentrations of Cu and Fe in muscle tissue of sculpin). Comparisons between our regional reference study and a concurrent upstream­downstream study showed that the sensitivity of biological endpoints was typically related to the impairment criteria used and not to the type of study design. Concentrations of metals such as Al, Cu, and Fe in river water at reference sites were above federal and regional guidelines, suggesting that these guidelines are not appropriate for the metal-rich headwaters of the South Nahanni River. The ephemerellid mayflies Drunella spinifera and Ephemerella maculata were present in 4 of our study sites; their occurrence had not previously been documented in the Yukon or Northwest Territories. Our results confirmed that the lack of baseline information on the physiochemical and biological composition of northern rivers is hampering our ability to evaluate changes in these understudied ecosystems. However, the use of noncentral hypotheses tests based on empirically derived effect sizes enabled us to develop ecologically meaningful protection criteria, maintain statistical rigor, and provide probabilities of impairment that can be used directly in risk assessment.

A multitrophic approach to monitoring the effects of metal mining in otherwise pristine and ecologically sensitive rivers in northern Canada.

It is not known if current chemical and biological monitoring methods are appropriate for assessing the impacts of growing industrial development on ecologically sensitive northern waters. We used a multitrophic level approach to evaluate current monitoring methods and to determine whether metal-mining activities had affected 2 otherwise pristine rivers that flow into the South Nahanni River, Northwest Territories, a World Heritage Site. We compared upstream reference conditions in the rivers to sites downstream and further downstream of mines. The endpoints we evaluated included concentrations of metals in river water, sediments, and liver and flesh of slimy sculpin (Cottus cognatus); benthic algal and macroinvertebrate abundance, richness, diversity, and community composition; and various slimy sculpin measures, our sentinel forage fish species. Elevated concentrations of copper and iron in liver tissue of sculpin from the Flat River were associated with high concentrations of mine-derived iron in river water and copper in sediments that were above national guidelines. In addition, sites downstream of the mine on the Flat River had increased algal abundances and altered benthic macroinvertebrate communities, whereas the sites downstream of the mine on Prairie Creek had increased benthic macroinvertebrate taxa richness and improved sculpin condition. Biological differences in both rivers were consistent with mild enrichment of the rivers downstream of current and historical mining activity. We recommend that monitoring in these northern rivers focus on indicators in epilithon and benthic macroinvertebrate communities due to their responsiveness and as alternatives to lethal fish sampling in habitats with low fish abundance. We also recommend monitoring of metal burdens in periphyton and benthic invertebrates for assessment of exposure to mine effluent and causal association. Although the effects of mining activities on riverine biota currently are limited, our results show that there is potential for effects to occur with proposed growth in mining activities.