Effects of Individualized Nursing Based on Zero-Defect Theory on Perioperative Patients Undergoing Laparoscopic Cholecystectomy.

Objective: This study is aimed at analyzing the effects of individualized nursing based on the zero-defect theory on perioperative patients undergoing laparoscopic cholecystectomy. Methods: 174 patients who underwent laparoscopic cholecystectomy from 1st November 2019 to 30th November 2020 were enrolled as the research subjects and randomly divided into control and observation groups. The patients in the control group received conventional perioperative nursing care, and the patients in the observation group were treated with individualized nursing based on the zero-defect theory. Results: The heart rate, diastolic blood pressure, and systolic blood pressure level of patients in two groups after nursing decreased significantly, and the reduction in the observation group was more significant than that in the control group. The depression and anxiety scores of the two groups after nursing were decreased, and the decrease in the observation group was significantly greater than that in the control group. The time to first postoperative exhaust, return to normal intake, out-of-bed activity, and hospital stay in the observation group was less than that in the control group. The incidence of postoperative complications in the observation group was substantially lower than that in the control group. The satisfaction degree of nursing care in the observation group was significantly higher than that in the control group. Conclusion: Individualized nursing care based on zero-defect theory can effectively reduce the perioperative psychological stress response of patients with laparoscopic cholecystectomy. It helps to improve the negative emotions of depression and anxiety, promotes the recovery of disease, reduces postoperative complications, and improves nursing satisfaction, which is worthy of clinical promotion.

Survey of provider perceptions of enhanced recovery after surgery and perioperative surgical home protocols at a tertiary care hospital.

ABSTRACT: Enhanced recovery after surgery (ERAS) and perioperative surgical home (PSH) initiatives are widely utilized to improve quality of patient care. Despite their established benefits, implementation still has significant barriers. We developed a survey for perioperative clinicians to gather information on perception and knowledge of ERAS/PSH programs to guide future expansion of these programs at our institution. The survey included questions about familiarity with ERAS/PSH and perceived value, perceived barriers to protocol implementation, preferred learning methods and prioritization of various ERAS/PSH protocol elements into care delivery and provider education. Faculty surgeons and anesthesiologists, in addition to advanced practice nurses and postgraduate physician trainees in the Departments of Surgery and Anesthesiology were asked to complete the survey. Overall survey participation was 25% (223/888). About half of survey respondents had provided care to a patient on an ERAS/PSH protocol, and a majority felt at least somewhat knowledgeable about ERAS/PSH protocols. Perception of the value of ERAS/PSH was positive. Participants were enthusiastic about on-going learning, with multimodal pain management being the topic of most interest and learning by direct participation in care of protocol patients being the favored educational approach. A significant majority of participants felt that upcoming health providers should receive formal ERAS/PSH education as part of their training. Based on our survey results, we plan to explore teaching methods that successfully engage learners of all levels of clinical expertise and also overcome the major barriers to gaining knowledge about ERAS/PSH identified by study participants, most notably lack of time for busy clinicians.

Perioperative do-not-resuscitate orders: Trainee experiential learning in preserving patient autonomy and knowledge of professional guidelines.

ABSTRACT: Anesthesiologists and surgeons have demonstrated a lack of familiarity with professional guidelines when providing care for surgical patients with a do-not-resuscitate (DNR) order. This substantially infringes on patient's self-autonomy; therefore, leading to substandard care particularly for palliative surgical procedures. The interventional nature of surgical procedures may create a different mentality of surgical "buy-in," that may unintentionally prioritize survivability over maintaining patient self-autonomy. While previous literature has demonstrated gains in communication skills with simulation training, no specific educational curriculum has been proposed to specifically address perioperative code status discussions. We designed a simulated standardized patient actor (SPA) encounter at the beginning of post-graduate year (PGY) 2, corresponding to the initiation of anesthesiology specific training, allowing residents to focus on the perioperative discussion in relation to the SPA's DNR order.Forty four anesthesiology residents volunteered to participate in the study. PGY-2 group (n = 17) completed an immediate post-intervention assessment, while PGY-3 group (n = 13) completed the assessment approximately 1 year after the educational initiative to ascertain retention. PGY-4 residents (n = 14) did not undergo any specific educational intervention on the topic, but were given the same assessment. The assessment consisted of an anonymized survey that examined familiarity with professional guidelines and hospital policies in relation to perioperative DNR orders. Subsequently, survey responses were compared between classes.Study participants that had not participated in the educational intervention reported a lack of prior formalized instruction on caring for intraoperative DNR patients. Second and third year residents outperformed senior residents in being aware of the professional guidelines that detail perioperative code status decision-making (47%, 62% vs 21%, P = .004). PGY-3 residents outperformed PGY-4 residents in correctly identifying a commonly held misconception that institutional policies allow for automatic perioperative DNR suspensions (85% vs 43%; P = .02). Residents from the PGY-3 class, who were 1 year removed the educational intervention while gaining 1 additional year of clinical anesthesiology training, consistently outperformed more senior residents who never received the intervention.Our training model for code-status training with anesthesiology residents showed significant gains. The best results were achieved when combining clinical experience with focused educational training.

Sex and gender differences in anesthesia: Relevant also for perioperative safety?

Sex (a biological determination) and gender (a social construct) are not interchangeable terms and both impact perioperative management and patient safety. Sex and gender differences in clinical phenotypes of chronic illnesses and risk factors for perioperative morbidity and mortality are relevant for preoperative evaluation and optimization. Sex-related differences in physiology, as well as in pharmacokinetics and pharmacodynamics of anesthetic drugs may influence the anesthesia plan, the management of pain, postoperative recovery, adverse effects, patient satisfaction, and outcomes. Further studies are needed to characterize outcome differences between men and women in non-cardiac, cardiac, and transplantation surgery in order to individualize perioperative management and improve patient safety. Transgender patients represent a vulnerable population who need special perioperative care. Gender balance increases team performance and may improve perioperative outcomes.

Acceptability and Feasibility of Perioperative Music Listening: A Rapid Qualitative Inquiry Approach.

Perioperative music decreases pain, anxiety, and analgesia requirements while increasing patient satisfaction. We investigated the acceptability of perioperative music at a women's and children's hospital in Singapore, seeking to uncover barriers and facilitators to implementation in routine practice over a 12-week period. We used an undergraduate-led Rapid Qualitative Inquiry approach that includes data collection from multiple sources, iterative analysis, and additional data collection when necessary. Participants consisted of anesthesiologists and nurses working in the preoperative area, operating room, and postoperative recovery areas. In Stage 1, nurses and anesthesiologists answered a survey assessing attitudes and knowledge about perioperative music and attended a presentation introducing the intervention. In Stage 2, the results of the Stage 1 survey were disclosed, and nurses and anesthesiologists completed a second survey (Stage 1 survey questions with an additional query about implementation). Twenty-nine nurses were interviewed with semi-structured questions on barriers and facilitators to implementation. In Stage 3, nurses retook the Stage 2 survey after one month of implementation. The implementation of perioperative music was both acceptable and feasible in Singapore. The nurses' and anesthesiologists' acceptability increased over time with mostly positive qualitative feedback. Implementation barriers, including patient interest, timing of patient turnover, and added staff workload, appeared minor and could potentially be overcome by utilizing the intervention in the preoperative instead of postoperative area, deploying music in operating rooms with slower turnover, and evenly distributing staff workload. Local implementation stakeholders may make additional recommendations for scaling-up perioperative music interventions to fit other workflows while improving the patient experience.

Psychological impact of high-quality nursing care on patients with esophageal cancer during perioperative period: A protocol of systematic review.

BACKGROUND: This study is designed to systematically assess the psychological impact of high-quality nursing care (HQNC) on patients with esophageal cancer during perioperative period (ECPP). METHODS: Several electronic databases will be searched to collect randomized controlled trials (RCTs) or case-control studies (CCSs) on HQNC in the management of ECPP from inception to present: Cochrane Library, PUBMED, EMBASE, SinoMed, Web of Science, WANGFANG, and China National Knowledge Infrastructure. We will not apply any language limitation to all literature searches. Two authors will independently perform literature selection, data extraction and literature quality evaluation. All disagreements will be resolved by a third author through discussion. Cochrane risk of bias tool will be employed to assess trial quality, and RevMan 5.3 software will be utilized to carry out statistical analysis. RESULTS: This study will summarize the current evidence to appraise of the psychological impact of HQNC in the management of ECPP. CONCLUSION: The findings of this study may help to explicit whether HQNC is effective on psychological problem in ECPP. It will also provide scientific evidence for the clinical practice and future researches. STUDY REGISTRATION: INPLASY202080071.

Cancer care in a Western Indian tertiary center during the pandemic: Surgeon's perspective.

INTRODUCTION: Following the nationwide lockdown in India, most hospitals shut down elective surgeries including cancer surgeries. We continued operating on patients with cancer at a tertiary referral center in Western India, which also served as a COVID care center. We also constructed a questionnaire, exclusive to surgeons, to determine the changes in treatment strategies as well as the response to the pandemic. METHODS: The complications of all cases operated in the study period (March 22, 2020-June 30, 2020) were graded using the Clavien-Dindo classification. Also, an anonymous structured questionnaire was constructed and e-mailed to all surgical oncologists working at our institute. RESULTS: Of the 118 patients having an operation, 18 had complications. There were 12 Grade I/II and 6 Grade III complications but none of our patients had Grade-IV/V complications. When the staff of the main operating theater tested COVID positive, the complex was shut down. However surgical oncology work continued at an affiliated institute about 10 km away from the main hospital. CONCLUSION: We had favorable outcomes while operating on cancer patients in a COVID care center. The results of our questionnaire proved that surgeons were willing to risk their personal safety to provide surgical oncology care.

The influence of perioperative interventions targeting psychological distress on clinical outcome after total knee arthroplasty.

Our aim was to assess the effect of perioperative interventions targeting psychological distress on clinical outcome after total knee arthroplasty (TKA). We searched studies on the effect of perioperative interventions focused on psychological distress used in conjunction with TKA on pain, function, and quality of life (QoL) on PubMed, Embase.com, PsycINFO/OVID, CENTRAL, the Cochrane Database of Systematic Reviews, Scopus, and Web of Science. We included 40 studies (22 RCTs, ten cohort studies, and eight quasi-experimental studies) with a total of 3846 patients. We graded the quality of evidence as low for pain and function and as moderate for QoL. Patients receiving music, education, cognitive behavioural therapy, guided imagery, pain coping skills training, Reiki, occupational therapy with self-monitoring, and biofeedback-assisted progressive muscles relaxing training had lower pain scores or declined opioid prescriptions after TKA. Pain coping skills training, audio recording-guided imagery scripts, video promoting self-confidence, psychological therapies by video, Reiki, music, occupational therapy with self-monitoring, education, and psychotherapy improved postoperative functional outcome. Education through an app improved QoL after TKA. The studies in our systematic review show that perioperative interventions targeting psychological distress for patients receiving TKA seem to have a positive effect on postoperative pain, function, and QoL. RCTs with strict methodological safeguards are still needed to determine if perioperative interventions focused on psychological distress should be used in conjunction with TKA. These studies should also assess which type of intervention will be most effective in improving patient-reported outcome measures and declining opioid prescriptions.

Health Numeracy and Relative Risk Comprehension in Perioperative Patients and Physicians.

BACKGROUND: Helping patients to understand relative risks is challenging. In discussions with patients, physicians often use numbers to describe hazards, make comparisons, and establish relevance. Patients with a poor understanding of numbers-poor "health numeracy"-also have difficulty making decisions and coping with chronic conditions. Although the importance of "health literacy" in perioperative populations is recognized, health numeracy has not been well studied. Our aim was to compare understanding of numbers, risk, and risk modification between a patient population awaiting surgery under general anesthesia and attending physicians at the same center. METHODS: We performed a single-center cross-sectional survey study to compare patients' and physicians' health numeracy. The study instrument was based on the Schwartz-Lipkus survey and included 3 simple health numeracy questions and 2 risk reduction questions in the anesthesiology domain. The survey was mailed to patients over the age of 18 scheduled for elective surgery under general anesthesia between June and September 2019, as well as attending physicians at the study center. RESULTS: Two hundred thirteen of 502 (42%) patient surveys sent and 268 of 506 (53%) physician surveys sent were returned. Median patient score was 4 of 5, but 32% had a score of ≤3. Patients significantly overestimated their total scores by an average of 0.5 points (estimated [mean ± standard deviation (SD)] = 4.3 ± 1.2 vs actual 3.8 ± 1.3; P < .001). Health numeracy was significantly associated with higher educational level (gamma = 0.351; P < .001) and higher-income level (gamma = 0.397; P < .001). Physicians' health numeracy was significantly higher than the patients' (median [interquartile range {IQR}] = 5 [4-5] vs 4 [3-5]; P < .001). There was no significant difference between physicians' self-estimated and actual total numeracy score (mean ± SD = 4.8 ± 0.6 vs 4.7 ± 0.6; P = .372). Simple health numeracy (questions 1-3) was predictive of correct risk reduction responses (questions 4, 5) for both patients (gamma = 0.586; P < .001) and physicians (gamma = 0.558; P = .006). CONCLUSIONS: Patients had poor health numeracy compared to physicians and tended to overrate their abilities. A small proportion of physicians also had poor numeracy. Poor health numeracy was associated with incomprehension of risk modification, suggesting that some patients may not understand treatment efficacy. These disparities suggest a need for further inquiry into how to improve patient comprehension of risk modification.

Shared decision making in perioperative medicine.

Shared decision making is a collaborative process between clinicians and patients, which aims to select the most suitable management option based on both best available evidence and patient preferences. This article looks at the role of shared decision making in perioperative medicine.

Attenuation of noisy environment-induced neuroinflammation and dysfunction of learning and memory by minocycline during perioperative period in mice.

Noisy environment often occurs in hospitals. We set out to determine whether noisy environment induces neuroinflammation and impairment of learning and memory and whether the effects of noise contribute to the development of neuroinflammation and impairment of learning and memory during the perioperative period. Seven-week old CD-1 male mice were exposed to noisy environment in the presence or absence of surgery (right carotid artery exposure). Noisy environment was 75 db, 6 h/day, for 3 days or 5 days. Minocycline (40 mg/kg), an antibiotic with anti-inflammatory property, was administered intraperitoneally 1 h before surgery or each episode of noise. The learning and memory of mice were assessed by Barnes maze and fear conditioning tests. Brain was harvested for the determination of interleukin (IL)-1ß and IL-6 and for immunohistochemical staining. We found that noise induced learning and memory impairment. Noise also increased IL-1ß, IL-6 and ionized calcium binding adapter molecule 1 (Iba-1) in the hippocampus. The combination of noisy environment and surgery induced dysfunction of additional domains of learning and memory and a higher expression of Iba-1 in the hippocampus. The effects of noisy environment or the combination of noisy environment and surgery were attenuated by minocycline. These findings suggest that noisy environment induces neuroinflammation and impairment of learning and memory. These effects may contribute to the development of neuroinflammation and dysfunction of learning and memory during the perioperative period. Neuroinflammation may be an underlying pathophysiological process for cognitive dysfunction induced by noise or the combination of noise and surgery. Minocycline may be effective in attenuating these noise-induced effects.

The Clinical Pharmacist's Role in Perioperative Surgical Pain Management.

The purpose of this quality improvement initiative was to demonstrate the value of having a clinical pain pharmacist in transitional perioperative pain management. Patients were referred to the pain pharmacist prior to elective surgery. The pharmacist worked with the patients to develop an individualized perioperative analgesic plan and provided education regarding surgery. The enrolled patients were followed throughout their surgical course by the pharmacist, and upon discharge the pharmacist conducted follow-up phone interviews approximately weekly for up to a month. This was followed by a phone survey regarding satisfaction with this service. Referring providers were also surveyed to determine satisfaction. Greater than 90% of patients reported they were "very appreciative" of the pharmacist talking to them about a pain management plan both before surgery and after discharge. One hundred percent of referring providers who responded to the survey reported they were satisfied with the pharmacist role in perioperative pain management. Pain management pharmacy specialists contribute to positive pain management outcomes for patients and surgical provider satisfaction.

Perioperative Considerations for Patients With Major Depressive Disorder Undergoing Surgery.

In the United States, approximately 15% of adults suffer from major depressive disorder (MDD), which results in an annual cost of over $200 billion per year. In the perioperative setting, MDD is associated with increased morbidity and mortality. The exact causes of the increase in adverse outcomes are unknown. Major depression affects virtually all major systems in the human body, and most antidepressants affect dopamine, norepinephrine, and serotonin levels or alter their target receptors. Unfortunately, anesthesia and medications used in the perioperative period affect the same neurotransmitters. As a result, patients with MDD are at an increased risk for cardiovascular effects, altered thermoregulation, and postoperative cognitive dysfunction. To determine when to continue or hold antidepressants preoperatively and avoid potential drug interactions, perioperative providers must understand the pharmacological action of antidepressants. This article reviews the pathophysiology of MDD, mechanism of action of antidepressants, and perioperative considerations for patients on antidepressant medications.

Effect of music tempo on operating room preparation time.

Most operating rooms around the world play music, both during the surgeries and in between cases. We investigated whether music tempo (fast or slow) can affect the operating room preparation time in between surgeries (turnover time) in an ambulatory outpatient surgical centre setting. We compiled two playlists, one with fast upbeat tempo and the other with slow relaxing tempo. Each of the playlists was played throughout the workday in the operating room for one week with the same surgeon and nursing staff. The turnover times for each case were analysed. Inclusion criteria were standard cataract extraction with intraocular lens implant surgery. Exclusion criteria were any external reasons causing delays in the turnover time (such as anaesthesia team break time, computer system down, etc.). The turnover time from 32 cases in the slow group and 26 cases in the fast group were compared with Student's t test. The turnover time was significantly faster in the fast group versus the slow group (17.0 ± 0.60 vs. 20.1 ± 0.96, p < 0.03). Our study demonstrated that fast music tempo in the operating room can significantly reduce turnover time. This improved efficiency could potentially lead to significant cost savings in the healthcare sector.

The Elephant in the Room: Nurses' Views of Communication Failure and Recommendations for Improvement in Perioperative Care.

Perioperative communication failures endanger patient safety and may reduce efficiency. The objective of our phenomenological research study was to determine the reasons for and consequences of perioperative communication failures and to seek recommendations for improvement. Fourteen perioperative nurses participated in this study. We conducted in-depth interviews with a semi-structured questionnaire following Colaizzi's seven-step methodology to extract themes. We organized the themes into categories: causes, consequences, and recommendations for preventing communication failure. Some themes for causes were inadequate time for preoperative preparation, lack of personnel, and disruptive behaviors of physicians. Consequences of communication failure were decreased staff retention, avoidance of colleagues, threats to patient safety, and intra-team violence. Two recommendations included enforcing institutional regulations and creating team spirit. The study revealed that nurses believe that institutional regulations should not only be present but enforced. Further, nurses believe that strengthening employees' interpersonal skills is essential to preventing communication issues.