Making enhanced recovery the norm not the exception.

BACKGROUND: Enhanced Recovery After Surgery ("STAAR" in our system) is multimodal care focused on the reduction of physiological and psychological stress. While enhanced recovery is well established in colorectal surgery, and there is evidence for effectiveness in other surgical disciplines, to date widespread use is limited. METHOD: We implemented a Lean process that, within 12 months, expanded STAAR to 13 surgical services lines involving >130 surgeons, and impacting the care of >6000 surgical patients/year. RESULTS: Implementation involved educational and administrative meetings (279 in the first 6 months) and rounding. Use of STAAR was defined as >60% compliance. LOS was reduced up to 40%, mortality index and transfusion decreased 67% and 23% respectively. Case mix index increased 17%. Readmission rates, infections, ER visits were not increased. CONCLUSION: Using a Lean process focused on value, STAAR protocols became the standard rather than the exception. Time investment by senior surgical leadership was extensive.

Hot tub folliculitis: a clinical syndrome.

With the increasing use of hot tubs, patients are being seen with a distinct clinical syndrome that appears several hours or days after hot tub exposure. It consists of a maculovesicular, often pruritic rash, and commonly occurring associated symptoms including fever, upper respiratory tract complaints, axillary adenopathy and breast tenderness. Cultures in the cases described here grew out Pseudomonas aeruginosa, giving a diagnosis of Pseudomonas folliculitis. The illness clears spontaneously without any treatment. Proper attention to hot tub chlorination and use are probably important in preventing this problem, and awareness of the syndrome by physicians may prevent unnecessary and costly diagnostic studies and treatment programs.