A bundle of care to reduce colorectal surgical infections: an Australian experience.

Use of 'bundles of care' to improve patient outcomes is becoming more widespread; however, their use is more common internationally than in Australia. The objective of this study was to assess the feasibility of implementing a bundle of care for patients undergoing colorectal surgery with the aim of reducing surgical site infections. Each component of the bundle was evidence based, focusing on normothermia, normoglycaemia, oxygen delivery and use of appropriate antibiotics. Implementation required extensive consultation and education, together with a checklist to accompany patients and record whether processes were followed and outcomes achieved. Difficulties were experienced with achieving compliance with processes, although some improvements were seen. There was a link between the use of warming devices and improved maintenance of normothermia. The infection rate fell from 15% [95% confidence interval (CI) 10.4-20.2] before the project to 7% (95% CI 3.4-12.6) 12 months after the project. While the small sample size does not allow definitive conclusions to be drawn, the results are promising. Potential reasons for low compliance with individual components of the bundle of care are discussed. In conclusion, introduction of a bundle of care for patients undergoing colorectal surgery into an Australian hospital was only modestly successful. Despite this, infection rates decreased over the 12 months following introduction of the bundle.

A systematic review of stapled hemorrhoidectomy.

HYPOTHESIS: Use of circular stapled hemorrhoidectomy will result in the same or improved safety and efficacy outcomes as those of the conventional methods for hemorrhoidectomy in patients with hemorrhoids. DATA SOURCES: Studies on stapled hemorrhoidectomy were identified using PREMEDLINE and MEDLINE (June 1966-June 2001), EMBASE (January 1980-June 2001), Current Contents (June 1993-June 2001), Ovid HEALTHSTAR (January 1975-June 2001), the National Institutes of Health Clinical Trials database (searched June 13, 2001), and The National Coordinating Centre for Health Technology Assessment database (searched June 14, 2001). The search terms were as follows: haemorrhoid* and (stapl* or convent*) or hemorrhoid* and (stapl* or convent*). The Cochrane Library (2001, issue 2) was searched using the search terms haemorrhoid* or hemorrhoid*. STUDY SELECTION: Articles detailing randomized controlled trials were included if they compared circular stapled with conventional hemorrhoidectomy and provided relevant safety and efficacy outcome information. DATA EXTRACTION: Data from all included studies were extracted using standardized data extraction tables that were developed a priori. In addition, the randomized controlled trials were examined with respect to the adequacy of allocation concealment, handling of those unavailable for follow-up, and any other aspect of the study design or execution that may have introduced bias. DATA SYNTHESIS: Seven randomized controlled trials met the inclusion criteria. A meta-analysis was conducted when the studies had comparable outcomes, inclusion criteria, and follow-up. There was reasonably clear evidence in favor of the stapled procedure for bleeding at 2 weeks (relative risk, 0.55; 95% confidence interval, 0.37-0.82) and length of hospital stay (weighted mean difference, -0.89 days; 95% confidence interval, -1.42 to -0.36). Other less robust results in favor of the stapled hemorrhoidectomy related to pain, bleeding, anal discharge, wound healing, tenderness to per rectal examination, incontinence scores, earlier return of bowel function, analgesic requirement, and resumption of normal activities. One trial showed that prolapse occurred at significantly higher rates in the stapled hemorrhoidectomy group. However, the outcomes were poorly reported and generally showed statistically significant heterogeneity. CONCLUSIONS: Stapled hemorrhoidectomy may be at least as safe as conventional hemorrhoidal surgical techniques. However, the efficacy of the stapled procedure compared with the conventional techniques could not be determined. More rigorous studies with longer follow-up periods and larger sample sizes need to be conducted.

Recognising clinical instability in hospital patients before cardiac arrest or unplanned admission to intensive care. A pilot study in a tertiary-care hospital.

OBJECTIVE: To investigate the nature and duration of clinical instability (i.e., abnormalities in simple physical observations or laboratory test results) in hospital patients before a "critical event" (i.e., a cardiac arrest or an unplanned admission to intensive care). DESIGN: Retrospective survey of medical records of all patients having critical events (CEs) over 12 months. Data on hospital and Intensive Care Unit (ICU) patients were obtained for comparison with the study population. SETTING: A 300-bed metropolitan teaching hospital with a seven-bed ICU. PATIENTS: All patients having CEs over a 12-month period (January to December 1997). MAIN OUTCOME MEASURES: Number of patients with clinical instability before a CE; duration of clinical instability before a CE; number of medical reviews of each patient before a CE; mortality rate and length of hospital stay for all patients. RESULTS: There were 122 CEs in 112 patients (median, 1; range, 1-4). Of the CEs, 79 were unplanned ICU admissions (14 subsequent to cardiac arrest calls), and 43 were cardiac arrest calls not resulting in ICU admission. Each CE was preceded by a median of two (range, 0-9) criteria for clinical instability. The median duration of instability before a CE was 6.5 hours (range, 0-432 hours), and in that time a median of two (range, 0-13) medical reviews took place. The incidence of CEs in the total hospital population (122 CEs/19,853 admissions) and in ICU patients (79 unplanned admissions/515 admissions) was 0.6% and 15%, respectively. There were 70 deaths (62%) among the 112 patients, compared with a total of 392 deaths (2% of admissions) in the hospital, of which 107 were in ICU. CONCLUSIONS: Very few patients suffer a CE while in hospital. However, those who do frequently manifest abnormalities in simple physical observations and laboratory test results before the CE. More rapid intervention in response to warning signs might provide a better outcome for these patients.

Congenital cleft-foot deformity treatment.

A retrospective review of congenital cleft foot was done on 16 patients with 32 involved feet. The average age at the time of surgery was 4 years (range, 5 months to 13 years). The average follow-up after surgery was 7.8 years, with a range of 2-45 years. A simple classification based on severity of deficiency was developed. Twenty-three of the 24 procedures performed gave a satisfactory result. Six of the nine untreated feet were satisfactory. Based on our classification, the following treatment is recommended: type I, central partial forefoot cleft was treated by a soft-tissue syndactylism and a partial hallux valgus correction, if needed. Type II, for a complete forefoot cleft to the tarsus, soft-tissue syndactylism with first-ray osteotomy if necessary before age 5 years is recommended. First-ray amputation is advised after age 5 years. Type III: Complete absence of first through fourth ray did not need forefoot surgery.

A critical evaluation of free paper abstracts accepted for the 1996 RACS Annual Scientific Congress.

BACKGROUND: Abstracts form a major part of medical information dissemination and a measure by which papers are accepted for meetings. Concerns have been raised about the quality of abstracts presented to the Annual Scientific Congress (ASC) and second, about the validity of the term 'scientific' to describe this meeting. METHODS: A critical evaluation was made of all free paper abstracts in general surgery from the ASC 1996, using a standard assessment process. They were judged on presentation and content. A direct comparison was made to the content of abstracts from the Surgical Research Society of Australasia 1995(SRSA) meeting. RESULTS: The ASC abstracts scored 87% (6.1/7.0) for presentation but with clear deficiencies. The score of 49% (7.4/15.0) for the content of the ASC abstracts was significantly less than the score of 65% (9.8/15.0) that was attained by the SRSA abstracts when assessed on content. (Wilcoxon rank sum test, P < 0.000002.) CONCLUSIONS: The quality of the presentation of abstracts was adequate but could clearly be improved, especially with regard to the specific instructions to authors. The ASC abstracts were significantly less scientific in content that those of the SRSA abstracts. The criteria used to select abstracts for the ASC should be reviewed and the title of the annual College meeting should be reconsidered.

Protecting reproductive health and choice.

Women and men have special needs in rehabilitation. Women's needs, however, have received far less attention in the scientific community and medical literature. This section, edited by Sandra Cole, PhD,(*) highlights some of the unique concerns of women who live with physical disabilities.

Undergraduate medical education in obstetrics and gynaecology in the USA and Canada, 1985.

Many factors have led to a movement from the emphasis of the 1960s and 1970s on departmental expansion towards an emphasis on cost-effective undergraduate medical education emphasizing the 'art' as well as the 'science' of medicine. In January 1985 a questionnaire was sent under the auspices of the Undergraduate Education Committee of the Association of Professors of Obstetrics and Gynecology to all chairmen of departments of obstetrics and gynecology in the USA and Canada seeking their opinions about these trends and information about the educational programmes in their departments. The information from this study indicates that the chairmen are aware of and responding to this new direction in medical education. A stabilization of teaching staff and clerkship sizes and the emphasis on clinical as well as cognitive evaluation, despite recognition of the cost of the former, shows active interventions towards these ends. An emphasis on education in 'basic' as compared to 'subspecialty' areas which is independent of the subspecialty of the academic chairman also supports this trend.

Student evaluation in obstetrics and gynecology clerkships in the United States and Canada, 1985.

Chairmen of departments of obstetrics and gynecology in the United States and Canada were surveyed to determine how students were evaluated in obstetric-gynecologic clerkships. Internally developed written and oral examinations and subject examinations from the National Board of Medical Examiners were used in more than one-half the departments. Written, oral and practical examinations were considered ideal evaluation methods.

Transverse disruption of the abdominal wall--a tell-tale sign of seat belt related hollow viscus injury.

A pattern of injuries has been observed in five (5) female front seat passengers wearing seat belts. All were involved in high speed frontal impact motor vehicle accidents on country roads. Varying degrees of abdominal wall disruption involving fat, fascia or muscle, were universally associated with hollow viscus injury and right-sided rib fractures. Most patients had mesenteric or omental tears, flail chests and left clavicular injuries. Intimal tears of the distal aorta, right breast injuries and spinal injuries were also observed. The hollow viscus and mesenteric injuries may result from direct crushing, sudden rises of intraluminal pressure, or shearing forces acting at points of mesenteric attachments. At laparotomy it is recommended that necrotic or contused fascia and muscle be excised with primary abdominal closure and contused fat be excised or curetted and suction drainage applied to the subcutaneous tract. Abdominal wall disruption from seat belt trauma reflects the forces involved on impact and should alert the surgeon to the observed pattern of internal injuries.

Enhancement of neutrophil chemiluminescence after elective gastrointestinal surgery.

Neutrophil count and luminol-dependent chemiluminescence were measured pre-operatively and on the second, sixth and ninth days after operation in nine patients undergoing major, elective gastrointestinal surgery. The aim of the study was to test the hypothesis that elective surgery as a form of injury has no prolonged deleterious effect on neutrophil activity in non-septic patients. A significant increase in neutrophil count was demonstrated in all patients at Day 2 (P less than 0.01) and Day 9 (P less than 0.01). Neutrophil chemiluminescence increased on Day 2 and Day 6, the increase on Day 6 being significant (P less than 0.02). In the first 9 days after elective gastrointestinal surgery, a biphasic neutrophilia occurs and the metabolic response of neutrophils to an opsonized particle is not impaired. These data would support the hypothesis that major elective surgery has no deleterious effects on neutrophil activity, and indeed that neutrophil activity may be enhanced.

The effect of stapler diameter and proximal colostomy on narrowing at experimental circular stapled large bowel anastomoses.

The effect of stapler diameter and proximal colostomy on large bowel anastomotic narrowing was studied in 23 ewes, to test the hypotheses that stapler diameter is inversely proportional to narrowing and that a colostomy increases narrowing. Large bowel anastomoses were performed with ILS Proximate circular staplers of 25, 29 and 33 mm diameter (six in each group), and assessed at 12 weeks for anastomotic narrowing, hydroxyproline content and histology. In five animals a proximal loop colostomy was added after anastomosis with the 29 mm stapler and similarly assessed at 6 weeks. Neither radiological nor clinical anastomotic leaks occurred and there were no deaths. Comparison of narrowing indices showed no statistically significant difference between the three stapler diameters. Colostomy significantly increased narrowing. Hydroxyproline content was greater at all anastomoses compared with controls. Anastomoses with the 25 mm staplers had a significantly reduced hydroxyproline content compared to the 29 and 33 mm staplers, which may be explained by anastomotic dilatation. The tendency for stapled anastomoses to develop narrowing should not necessarily influence the surgeon's choice of stapler diameter when performing large bowel anastomoses. Moreover, dilatation by faeces may be a factor in reducing staple anastomotic narrowing and, when safe, a proximal colostomy is best avoided.