[Structured implementation and high adherence to the ERAS program in colorectal surgery in two operating units of the ASUR Marche.] / Implementazione strutturata ed elevata aderenza al programma ERAS in chirurgia colorettale in due unità operative dell'ASUR Marche.

BACKGROUND: An Enhanced Recovery After Surgery (ERAS) program in colorectal surgery is able to significantly reduce the morbidity rates and postoperative hospital stay (LOS) related to the intervention. However, it is not clear what modalities and levels of implementation are necessary to achieve these results. The purpose of this work is to analyze the methods and results of the first year of implementation of the program in two centers of the Agenzia Sanitaria Unica Regionale (ASUR) Marche. MATERIALS: After a structured implementation pathway, characterized by the creation of a core team, field training, internal courses and coaching, the details of 196 consecutive cases of patients submitted to colorectal resection over a one-year period in two surgical units of the ASUR Marche were prospectively loaded in a database, considering over 50 variables including adherence to the individual items of the ERAS program. The primary outcomes were: overall and major morbidity, mortality and anastomotic dehiscence rates; secondary outcomes were: LOS, re-admission and re-intervention rates. The results of primary endpoints were evaluated by univariable and multivariable analyses with logistic regression and, thereafter, according to ERAS item adherence rate. RESULTS: After a median (interquartile range, IQR) follow-up of 40 (32-94) days, we recorded complications in 72 patients (overall morbidity 36.7%), major morbidity in 14 patients (7.1%), 6 deaths (mortality 3.1%), an anastomotic dehiscence in 9 cases (4.9%), median (IQR) overalll LOS 5 (3-7) days, 10 readmissions (5.1%) and 13 reoperations (6.7%). The mean adherence rate to the items of the ERAS program was 85.4%, showing a significant dose-effect curve for overall morbidity, major morbidity, anastomotic leakage and for overall LOS. DISCUSSION: The ERAS implementation methods in this project led to a high adherence (>80%) to the program items. All the results showed a significant improvement compared to the previous pre-implementation period and according to the adherence to program items rate.

A Versatile Ultrasound Simulation System for Education and Training in High-Fidelity Emergency Scenarios.

Point of care ultrasonography and the related focused assessment with sonography for trauma protocol, if performed by experienced physicians, is a highly sensitive examination, and specific for the detection of free fluids. Different systems and methods have been proposed for training, including simulation as one of the most efficient. This paper presents an ultrasound training system, specifically designed to be used during bedside high fidelity simulation scenarios, that could facilitate the learning process. The development of the proposed system exploited novel rapid prototyping electronic boards as a means to obtain good performances with a low cost. Moreover, the design of the data structure permits the construction of a library that caters for individual needs, with the possibility of adding emergency scenarios, collecting pictures or videos, as well as 3-D volumes. The device has been compared with currently commercial ultrasound simulators and its innovative aspects have been highlighted. Finally, it has been tested during a training session in order to evaluate features, such as realism and user-friendliness.

Simulation Training for Residents Focused on Mechanical Ventilation: A Randomized Trial Using Mannequin-Based Versus Computer-Based Simulation.

INTRODUCTION: Advances in knowledge regarding mechanical ventilation (MV), in particular lung-protective ventilation strategies, have been shown to reduce mortality. However, the translation of these advances in knowledge into better therapeutic performance in real-life clinical settings continues to lag. High-fidelity simulation with a mannequin allows students to interact in lifelike situations; this may be a valuable addition to traditional didactic teaching. The purpose of this study is to compare computer-based and mannequin-based approaches for training residents on MV. METHODS: This prospective randomized single-blind trial involved 50 residents. All participants attended the same didactic lecture on respiratory pathophysiology and were subsequently randomized into two groups: the mannequin group (n = 25) and the computer screen-based simulator group (n = 25). One week later, each underwent a training assessment using five different scenarios of acute respiratory failure of different etiologies. Later, both groups underwent further testing of patient management, using in situ high-fidelity simulation of a patient with acute respiratory distress syndrome. RESULTS: Baseline knowledge was not significantly different between the two groups (P = 0.72). Regarding the training assessment, no significant differences were detected between the groups. In the final assessment, the scores of only the mannequin group significantly improved between the training and final session in terms of either global rating score [3.0 (2.5-4.0) vs. 2.0 (2.0-3.0), P = 0.005] or percentage of key score (82% vs. 71%, P = 0.001). CONCLUSIONS: Mannequin-based simulation has the potential to improve skills in managing MV.