A multicomponent prehabilitation pathway to reduce the incidence of delirium in elderly patients in need of major abdominal surgery: study protocol for a before-and-after study.

BACKGROUND: Due to the increase in elderly patients who undergo major abdominal surgery there is a subsequent increase in postoperative complications, prolonged hospital stays, health-care costs and mortality rates. Delirium is a frequent and severe complication in the 'frail' elderly patient. Different preoperative approaches have been suggested to decrease incidence of delirium by improving patients' baseline health. Studies implementing these approaches are often heterogeneous, have a small sample and do not provide high-quality or successful strategies. The aim of this study is to prevent postoperative delirium and other complications by implementing a unique multicomponent and multidisciplinary prehabilitation program. METHODS: This is a single-center controlled before-and-after study. Patients aged ≥70 years in need of surgery for colorectal cancer or an abdominal aortic aneurysm are considered eligible. Baseline characteristics (such as factors of frailty, physical condition and nutritional state) are collected prospectively. During 5 weeks prior to surgery, patients will follow a prehabilitation program to optimize overall health, which includes home-based exercises, dietary advice and intravenous iron infusion in case of anaemia. In case of frailty, a geriatrician will perform a comprehensive geriatric assessment and provide additional preoperative interventions when deemed necessary. The primary outcome is incidence of delirium. Secondary outcomes are length of hospital stay, complication rate, institutionalization, 30-day, 6- and 12-month mortality, mental health and quality of life. Results will be compared to a retrospective control group, meeting the same inclusion and exclusion criteria, operated on between January 2013 and October 2015. Inclusion of the prehabilitation cohort started in November 2015; data collection is ongoing. DISCUSSION: This is the first study to investigate the effect of prehabilitation on postoperative delirium. The aim is to provide evidence, based on a large sample size, for a standardized multicomponent strategy to improve patients' preoperative physical and nutritional status in order to prevent postoperative delirium and other complications. A multimodal intervention was implemented, combining physical, nutritional, mental and hematinic optimization. This research involves a large cohort, including patients most at risk for postoperative adverse outcomes. TRIAL REGISTRATION: The protocol is retrospectively registered at the Netherlands National Trial Register (NTR) number: NTR5932 . Date of registration: 05-04-2016.

A novel finding: the effect of nurse practitioners on the relation to quality of life, anxiety, and depressive symptoms in vascular surgery.

BACKGROUND: An increasing number of vascular surgery units expand their team with nurse practitioners (NPs) to optimize patient care. There are no previously performed studies which assessed the influence of NPs on patients' quality of life (QoL), anxiety, and depressive symptom levels. The transition in care from surgeon to NP in the vascular surgery unit of our hospital facilitated the comparison of both groups. METHODS: A prospective study was undertaken to analyze the effect of NPs on QoL, anxiety, and depressive symptom scores. Two groups were analyzed: a group of patients treated by a vascular surgeon alone (surgeon group) and a group of patients treated by a NP supervised by a vascular surgeon (NP group). Patients completed the short version of the World Health Organization Quality of Life Assessment (WHOQOL-BREF), the State-Trait Anxiety Inventory (STAI), and the Center for Epidemiologic Studies Depression Scale (CES-D) questionnaires both before and after intervention. RESULTS: Two hundred fourteen patients were included in our study. Within groups, there was a significant increase in physical QoL, with 5.2 points in the surgeon group and 4.4 points in the NP group. There was a significant decrease in anxiety scores (-3.8 points in the surgeon group and -5.4 points in the NP group). No differences were found for depressive symptoms. Between groups, no differences were found. CONCLUSIONS: The same improvements were found for QoL and anxiety scores in both groups. Vascular NPs are therefore competent to explain procedures and guide patients through vascular interventions.