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San Diego—Implementation of enhanced recovery after surgery (ERAS) protocols for pancreatic surgery decreased hospital length of stay (LOS), a study concluded, which ultimately improves quality of care, accelerates recovery, improves outcomes and optimizes utilization of health care resources.

“Enhanced recovery clinical pathways are really a paradigm shift that serve to evaluate our traditional practices and make evidence-based recommendations for improvement,” said Lavinia M. Kolarczyk, MD, assistant professor of anesthesiology at The University of North Carolina at Chapel Hill School of Medicine. “Nevertheless, the pathways themselves are not novel. The innovative aspect of enhanced recovery is learning how to work together in multidisciplinary teams to implement these best-practice guidelines.

“Ultimately, ERAS serves as the vehicle to promote quality improvement research; break down practice silos between anesthesiologists, surgeons and perioperative nurses; and really challenge why we do what we do every day.”

Goals of ERAS

Given that previous studies have shown a beneficial effect of ERAS pathways on hospital LOS after pancreatic surgery, the investigators decided to follow suit using a multidisciplinary approach with stakeholders from the Departments of Anesthesiology, Surgical Oncology and Perioperative Nursing. “Our institution is a very busy pancreatic center, but prior to ERAS, the quality of care was inconsistent,” Dr. Kolarczyk said. “This was unacceptable for a patient population at highest risk for perioperative morbidity and mortality.”

ClearFast applauds Doctor De Jonghe and his co-investigators on their recently published manuscript entitled “Reducing pre-operative fasting while preserving operating room scheduling flexibility: feasibility and impact on patient discomfort”, Acta Anaesthesiologica Scandinavica 2016. This study is a novel effort to reconcile some of the now well-recognized benefits of pre-operative oral carbohydrate loading (with ample complex carbohydrates) with the practical flexibility needs of busy ORs around the world. While the authors fully recognized some of the shortcomings of their study, including a lack of randomization and various “organizational constraints”, their message was clear: the need to reduce the duration of the traditional pre-op liquid fast with appropriate true carbohydrate-rich beverages is no longer debatable… it is a mandate!

Of note, in the “CHO Group”, the percentage of patients actually receiving the drink preceding operations scheduled at 10:00 or later was similar for inpatients and outpatients. However, that was clearly not the case for surgeries scheduled before 10 am. Patients were deprived of the drink 100% of the time if they were admitted on the day of surgery for procedures scheduled at that time or earlier. Conversely, 89.5% of their in-house counterparts were “carb-loaded” for operations scheduled for the same time. The explanation for this discrepancy appears procedural and systematic: possibly for standardization purposes, the drink was re-constituted from a powder, not by the patients, but by respective hospital staff members who diluted one sachet “in 400 ml of water in a graduated shaker.” Unfortunately, “organizational constraints” apparently prohibited such mixing and delivering to those arriving so early on the day of surgery. This bias dramatically impacted that statistic.

Perhaps, the overall outcomes might have been significantly influenced by the use of a pre-mixed carb-rich beverage, such as ClearFast®. Some of the obvious advantages would include simplicity of the delivery system, reliable standardization of the product volume and mixture and expedited refrigeration, if desired.   It would allow for early and convenient distribution to patients – days to weeks prior to the date of surgery, thus facilitating consumption by a greater number of candidates, potentially resulting in fasting times closer to the proposed 3-hour window. As the authors suggest in their discussion, “The opportunity for these patients to consume the CHO drink before arriving to the hospital warrants further consideration.”

Pre-Operative Oral Carbohydrate Loading is Safe and Improves Patient Satisfaction

With Elective Ambulatory Surgery and Anesthesia: It’s Time for Change

Ahmed S Suliman, MD, Jeannette T Crenshaw, RN, Arthur J  Mischke, MD,  Richard E  Gilder,  MS, RN, StevenR Cohen, MD.

Abstract

Background & Objective:

Most plastic surgeries are performed on an ambulatory basis.  While patient safety is a priority for plastic surgeons, many are unaware of the current ASA preoperative fasting guidelines.  Decades of research attest to the safety and health benefits of consuming carbohydrate-rich clear liquids 2 hours before elective surgery.  This best evidence is rarely put into practice.  The objective of this study was to assess the effects of such a beverage (Clearfast®) on patients’ discomforts from preoperative fasting and their safety and compliance.

Methods:

A two-part multicenter, prospective clinical trial involved ASA Risk I-II adult patients having elective plastic, orthopedic or general surgical procedures at 5 hospitals.  Part I was a descriptive observational pilot (n=263: Controls =108; Intervention =155).  Part II was an IRB approved randomized trial (n=34: Controls =21; Intervention =13).  All sites had previously adopted the ASA guidelines that determined patient eligibility.  Exclusion criteria were pregnancy, obesity and GERD.  Control groups observed the traditional midnight fast; Intervention groups consumed a carbohydrate-rich drink (Clearfast®) about 2 hours pre-op.  Patient demographics, length of fasting, occurrence of regurgitation and/or aspiration and patient preoperative questionnaires assessing thirst, hunger, headache, nausea, anxiety about fasting and surgery plus discomfort were analyzed by a biostatistician.

Results:

Regurgitation, aspiration, or other perioperative complications did not occur in Part I or II.  Binary logistic regression model of Part I showed that if patients (1) did not have Clearfast®, (2) had surgical anxiety or (3) had fasting anxiety, or (4) had all three, they were (1) 5.7, (2) 4.1, (3) 2.7 or (4) 63 times more likely to be uncomfortable with their preoperative experience.  Mann Whitney mean rank scores from the pooled data (n=297) indicated that, if patients did not consume Clearfast®, they were more likely to be thirsty (P=0.00), hungry (P<0.05), nauseous (P<0.05), anxious about both fasting and surgery (P<0.05) and uncomfortable (P=0.00). Control vs. Intervention fasting times were markedly different:  5-20 vs. 2-5 hours (P=0.00).

Conclusions:

In appropriately selected patients, following the ASA guidelines and using a preoperative carbohydrate-rich beverage 2 hours prior to elective ambulatory surgery resulted in significantly shorter fasting times, reduced thirst, hunger, anxiety and nausea and improved comfort.  Plastic surgeons should be aware of and comply with these guidelines to improve patient safety and satisfaction.

Disclosure/Financial Support:

None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript. Clearfast® was supplied by the Manufacturer, BevMD, for the purpose of conducting the study.

Preoperative oral carbohydrate administration reduces postoperative insulin resistance.

Nygren J, Soop M, Thorell A, Efendic S, Nair KS, Ljungqvist O. Department of Surgery, Karolinska Hospital, Stockholm, Sweden.

Abstract

Infusions of carbohydrates before surgery reduce postoperative insulin resistance. We investigated the effects of a carbohydrate drink, given shortly before surgery, on postoperative metabolism.

METHOD:

Insulin sensitivity, glucose turnover ([6,6, 2H2]-D-glucose) and substrate utilization were measured using hyperinsulinemic normoglycemic clamps and indirect calorimetry in two matched groups of patients before and after elective colorectal surgery. The drink group (n = 7) received 800 ml of an isoosmolar carbohydrate rich beverage the evening before the operation (100 g carbohydrates), as well as another 400 ml (50 g carbohydrates) 2 h before the initiation of anesthesia. The fasted group (n = 7) was operated after an overnight fast.

RESULTS:

After surgery, energy expenditure increased in both groups. Endogenous glucose production was higher after surgery and the difference was significant during low insulin infusion rates in both groups (P < 0.05). The supressibility of endogenous glucose production by the two step insulin infusion was similar pre-and postoperatively in both groups. At the high insulin infusion rate postoperatively, whole body glucose disposal was more reduced in the fasted group (-49 +/- 6% vs -26 +/- 8%, P < 0.05 vs drink). Furthermore, during high insulin infusion rates, glucose oxidation decreased postoperatively only in the fasted group (P < 0. 05) and postoperative levels of fat oxidation were greater in the fasted group (P < 0.05 vs drink). Only minor postoperative changes in cortisol and glucagon were found and no differences were found between the treatment groups.

CONCLUSIONS:

Patients given a carbohydrate drink shortly before elective colorectal surgery displayed less reduced insulin sensitivity after surgery as compared to patients who were operated after an overnight fast.

PMID: 10205319  [PubMed – indexed for MEDLINE]

Oral Nutrition Supplements’ Impact on Hospital Outcomes in the Context of the Affordable Care Act and New Medicare Reimbursement Policies

Sunday, October 20, 2013

Key Ballroom Foyer (Hilton Baltimore)

Poster Board # P1-29

Health Services, and Policy Research (HSP)

Darius Lakdawalla, Ph.D.¹, Julia Thornton Snider, PhD², Daniella J. Perlroth, MD³, Chris LaVallee, MS², Mark Thomas Linthicum, MPP²and Tomas J. Philipson, PhD⁴, (1)University of Southern California, Los Angeles, CA, (2)Precision Health Economics, Los Angeles, CA, (3)Stanford University, Stanford, CA, (4)The Harris School, The University of Chicago, Chicago, IL

Purpose: 

To assess the effect of oral nutrition supplements (ONS) on 30-day readmission rates, length of stay (LOS), and episode costs in hospitalized Medicare patients, aged 65 and over, with diagnoses affected by new Medicare reimbursement rules under the Affordable Care Act (ACA): acute myocardial infarction (AMI), congestive heart failure (CHF), and pneumonia (PNA).

Methods: 

Analyses were conducted using the Premier Perspectives Database over an eleven-year period (2000-2010) on Medicare patients aged 65+ and carrying a diagnosis of AMI, CHF, or PNA. One-to-one matched samples of ONS and non-ONS episodes were created using propensity score matching, producing samples of 20,870, 38,418, and 47,477 AMI, CHF, and PNA episodes, respectively. To eliminate bias from confounding, instrumental variables (IV) regression analysis was performed to quantify the effect of ONS on the probability of 30-day readmission, as well as on LOS and episode cost. For comparison, analyses were also conducted on elderly Medicare patients with any primary diagnosis, with a 1:1 matched sample of 667,684 episodes.

Results: 

Use of ONS decreased the probability of 30-day readmission, LOS, and episode costs among hospitalized aged 65+ Medicare patients. Most notably, ONS use was associated with a statistically significant (p<0.01) reduction in the probability of readmission within 30 days of 12% for AMI episodes and 10.1% for CHF episodes. The effect on LOS and episode cost was greatest for the comparison population (all primary diagnoses), with decreases of 16.0% and 15.8% (p<0.01), respectively.

Note: * indicates significance at the 5% level; ** indicates significance at the 1% level.

Conclusions:

In the aged 65+ Medicare patient population with AMI and CHF, ONS improves 30-day readmission, LOS, and episode cost outcomes.  This also holds true for all aged 65+ Medicare patients.  Among patients with PNA, ONS improves LOS and episode cost outcomes. ONS use in hospitalized Medicare patients aged 65+ may present an inexpensive, evidence-based solution for hospitals seeking to meet the quality targets established by the ACA.

Source: The HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey is the first national, standardized, publicly reported survey of patients’ perspectives of hospital care. HCAHPS also known as the CAHPS Hospital Survey, is a survey instrument and data collection methodology for measuring patients’ perceptions of their hospital experience.

While many hospitals have collected information on patient satisfaction for their own internal use, until HCAHPS there was no national standard for collecting and publicly reporting information about patient experience of care that allowed valid comparisons to be made across hospitals locally, regionally and nationally.

Three broad goals have shaped the HCAHPS survey:

First, the survey is designed to produce comparable data on the patient’s perspective on care that allows objective and meaningful comparisons between hospitals on domains that are important to consumers. Second, public reporting of the survey results is designed to create incentives for hospitals to improve their quality of care. Third, public reporting will serve to enhance public accountability in healthcareby increasing the transparency of the quality of hospital care provided in return for the public investment. With these goals in mind, the HCAHPS project has taken substantial steps to assure that the survey is credible, useful, and practical. This methodology and the information it generates are available to the public.

HCAHPS Content and Administration

The HCAHPS survey contains 21 patient perspectives on care and patient rating items that encompass nine key topics: (1) communication with doctors, (2) communication with nurses, (3) responsiveness of hospital staff, (4) pain management, (5) communication about medicines, (6) discharge information, (7) cleanliness of the hospital environment, (8) quietness of the hospital environment, and (9) transition of care.

The survey also includes 4screener questions and 7demographic items, which are used for adjusting the mix of patients across hospitals and for analytical purposes. The survey is 32 questions in length. Hospitals must survey patients throughout each month of the year.

BevMD’s Clearfast® can positively impact the following HCAHPS categories:

Doctor Communication
Nurse Communication
Pain Management
Communication About Medicines
Overall Rating of Hospital
Willingness to Recommend Hospital