Fast-track implementation Dotaz Zobrazit nápovědu
AIM: The aim of this study is to show the current view on fast-track programs optimizing the perioperative care. METHODS: Authors searched Medline databases and identified current trials regarding all factors of fast-track programs. They analyzed these trials and identified the most important principles of fast-track programs based on trial analysis. RESULTS: The most important principles are consistent in all individual trials. Most of authors recommend 10-12 issues. All authors emphasize early mobilization of patients after surgery and early introduction of peroral nutrition. Fast-track programs shorten the duration of hospitalisation and decrease morbidity. CONCLUSION: The perioperative care is characterized by a range of trussing traditions. Fast-track surgery optimizes the perioperative care. It is a safe method according to the trials. The implementation of single fast-track surgery factors is very slow (Tab. 2, Ref. 49).
Cíl: Popis průběhu implementace a vyhodnocení úspěšnosti dodržování doporučených postupů ERAS protokolu v podmínkách českého zdravotnictví. Soubor a metodika: Do studie bylo zařazeno celkem 163 pacientek od března do září 2022, tedy celkem 7 měsíců. Pacientky byly podle typu operačního výkonu rozřazeny do tří skupin. Klinický protokol: Onkogynekologie, hysterektomie a laparoskopie. Implementace probíhala ve třech fázích (příprava, samotná implementace protokolu a vyhodnocení). Výsledky a závěry: Hlavním hodnotícím kritériem byla míra dodržování jednotlivých doporučení (tzv. adherence). Ve všech třech skupinách byla souhrnná adherence 90 % a více. Koncept ERAS jsme na základě pilotních výsledků na našem pracovišti vyhodnotili jako dobře implementovatelný nástroj pro gynekologická pracoviště v podmínkách českého zdravotního systému.
Objective: To describe the implementation process and evaluate the success of compliance with the recommended ERAS protocol in the Czech healthcare system. Methods: The study included 163 patients from March to September 2022, a total of 7 months. Patients were divided into three groups according to the type of surgery. Clinical protocol: Oncogynecology, hysterectomy and laparoscopy. The implementation was realized in three phases (preparation, implementation of the protocol itself and evaluation). Results and conclusions: The cumulative adherence rate was 90% or more in all three groups. Based on the pilot results at our department, we evaluated the ERAS concept as a well-implemented tool for gynaecological departments in the Czech healthcare system.
PURPOSE: The simulation of individual particle tracks and the chemical stage following water radiolysis in biological tissue is an effective means of improving our knowledge of the physico-chemical contribution to the biological effect of ionizing radiation. However, the step-by-step simulation of the reaction kinetics of radiolytic species is the most time-consuming task in Monte Carlo track-structure simulations, with long simulation times that are an impediment to research. In this work, we present the implementation of the independent reaction times (IRT) method in Geant4-DNA Monte Carlo toolkit to improve the computational efficiency of calculating G-values, defined as the number of chemical species created or lost per 100 eV of deposited energy. METHODS: The computational efficiency of IRT, as implemented, is compared to that from available Geant4-DNA step-by-step simulations for electrons, protons and alpha particles covering a wide range of linear energy transfer (LET). The accuracy of both methods is verified using published measured data from fast electron irradiations for • OH and eaq- for time-dependent G-values. For IRT, simulations in the presence of scavengers irradiated by cobalt-60 γ-ray and 2 MeV protons are compared with measured data for different scavenging capacities. In addition, a qualitative assessment comparing measured LET-dependent G-values with Geant4-DNA calculations in pure liquid water is presented. RESULTS: The IRT improved the computational efficiency by three orders of magnitude relative to the step-by-step method while differences in G-values by 3.9% at 1 μs were found. At 7 ps, • OH and eaq- yields calculated with IRT differed from recent published measured data by 5% ± 4% and 2% ± 4%, respectively. At 1 μs, differences were 9% ± 5% and 6% ± 7% for • OH and eaq- , respectively. Uncertainties are one standard deviation. Finally, G-values at different scavenging capacities and LET-dependent G-values reproduced the behavior of measurements for all radiation qualities. CONCLUSION: The comprehensive validation of the Geant4-DNA capabilities to accurately simulate the chemistry following water radiolysis is an ongoing work. The implementation presented in this work is a necessary step to facilitate performing such a task.
BACKGROUND: Implementation of clinical health promotion (CHP) aiming at better health gain is slow despite its effect. CHP focuses on potentially modifiable lifestyle risks such as smoking, alcohol, diet, and physical inactivity. An operational program was created to improve implementation. It included patients, staff, and the organization, and it combined existing standards, indicators, documentation models, a performance recognition process, and a fast-track implementation model. The aim of this study was to evaluate if the operational program improved implementation of CHP in clinical hospital departments, as measured by health status of patients and staff, frequency of CHP service delivery, and standards compliance. METHODS: Forty-eight hospital departments were recruited via open call and stratified by country. Departments were assigned to the operational program (intervention) or usual routine (control group). Data for analyses included 36 of these departments and their 5285 patients (median 147 per department; range 29-201), 2529 staff members (70; 10-393), 1750 medical records (50; 50-50), and standards compliance assessments. Follow-up was measured after 1 year. The outcomes were health status, service delivery, and standards compliance. RESULTS: No health differences between groups were found, but the intervention group had higher identification of lifestyle risk (81% versus 60%, p < 0.01), related information/short intervention and intensive intervention (54% versus 39%, p < 0.01 and 43% versus 25%, p < 0.01, respectively), and standards compliance (95% versus 80%, p = 0.02). CONCLUSIONS: The operational program improved implementation by way of lifestyle risk identification, CHP service delivery, and standards compliance. The unknown health effects, the bias, and the limitations should be considered in implementation efforts and further studies. TRIAL REGISTRATION: ClinicalTrials.gov : NCT01563575. Registered 27 March 2012. https://clinicaltrials.gov/ct2/show/NCT01563575.
- MeSH
- dospělí MeSH
- hodnocení výsledků zdravotní péče MeSH
- implementační věda MeSH
- lidé středního věku MeSH
- lidé MeSH
- mladiství MeSH
- mladý dospělý MeSH
- nemocnice statistika a číselné údaje MeSH
- podpora zdraví metody MeSH
- poskytování zdravotní péče normy MeSH
- senioři MeSH
- zdravotně rizikové chování MeSH
- zdravotní stav MeSH
- zlepšení kvality MeSH
- Check Tag
- dospělí MeSH
- lidé středního věku MeSH
- lidé MeSH
- mladiství MeSH
- mladý dospělý MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- multicentrická studie MeSH
- práce podpořená grantem MeSH
- randomizované kontrolované studie MeSH
- srovnávací studie MeSH
BACKGROUND: Despite consensus supporting enhanced recovery programs, their full implementation in such a context is difficult due to conventional practices within various groups of professionals. The goal of the EUropean PErioperative MEdical Networking (EUPEMEN) project was to bring together the expertise and experience of national clinical professionals who have previously helped deliver major change programs in their countries and to use them to spread enhanced recovery after surgery protocols (ERAS) in Europe. The specific aim of this study is to present and discuss the key points of the proposed recommendations for colorectal surgery. MATERIALS AND METHODS: Five partners from university hospitals in four European countries developed the project as partners. Following a non-systematic review of the literature, the European consensus panel generated a list of recommendations for perioperative care in colorectal surgery. A list of recommendations was formulated and distributed to collaborators at each center to allow modifications or additional statements. These recommendations were then discussed in three consecutive meetings to share uniform ERAS protocols to be disseminated. RESULT: The working group developed (1) the EUPEMEN online platform to offer, free of charge, evidence-based standardized perioperative care protocols, learning activities, and assistance to health professionals interested in enhancing the recovery of their patients; (2) the preparation of the EUPEMEN Multimodal Rehabilitation manuals; (3) the training of the trainers to teach future teachers; and (4) the dissemination of the results in five multiplier events, one for each partner, to promote and disseminate the protocols. CONCLUSION: The EUPEMEN project allowed the sharing of the expertise of many professionals from four different European countries with the objective of training the new generations in the dissemination of ERAS protocols in daily clinical practice through a new learning system. This project was proposed as an additional training tool for all the enhanced recovery program teams.
- MeSH
- kolorektální chirurgie * normy MeSH
- lidé MeSH
- perioperační péče * normy MeSH
- urychlená pooperační rehabilitace normy MeSH
- zlepšení kvality * normy MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
- Geografické názvy
- Evropa MeSH
ERAS (enhanced recovery after surgery) představuje komplexní strategii zaměřenou na urychlení rekonvalescence, redukci komplikací a optimalizaci pooperační péče. Protokol ERAS se skládá z doporučení pro předoperační, perioperační a pooperační fázi péče o pacienty. Implementace ERAS protokolu přináší řadu benefitů, a to jak pro pacienty, tak pro zdravotnický systém. Zkracuje dobu hospitalizace, snižuje počet a závažnost pooperačních komplikací a zlepšuje kvalitu života pacientů. Tyto faktory vedou k úspoře nákladů na zdravotní péči a zefektivnění obratu pacientů na lůžkách (tzv. obložnost). Důsledné dodržování protokolu ERAS je klíčové pro dosažení optimálních výsledků. Komplexní strategie ERAS tak představuje historický zlom v perioperační péči a stává se nezbytným standardem v chirurgii jater a slinivky břišní.
ERAS (enhanced recovery after surgery) represents a comprehensive strategy aimed at expediting patient recovery, reducing complications, and optimizing postoperative care. The ERAS protocol encompasses recommendations for the preoperative, perioperative, and postoperative phases of patient care. Implementation of the ERAS protocol yields a multitude of benefits for both patients and the healthcare system. It shortens hospital stays, diminishes the number and severity of postoperative complications, and enhances patient’s quality of life. These factors contribute to healthcare cost savings and improved bed turnover efficiency. Rigorous adherence to the ERAS protocol is paramount to achieving optimal outcomes. The comprehensive ERAS strategy thus marks a paradigm shift in perioperative care and emerges as an indispensable standard in liver and pancreatic surgery.
OBJECTIVE: Over the past decade, the Enhanced Recovery After Surgery (ERAS) program has demonstrated its effectiveness and efficiency in improving postoperative care and enhancing recovery across various surgical fields. Preliminary results of ERAS protocol implementation in craniosynostosis surgery are presented. METHODS: An ERAS protocol was developed and implemented for cranial pediatric neurosurgery, focusing on craniosynostosis repair. The study incorporated a pre-ERAS group consisting of a consecutive series of patients who underwent craniosynostosis repair surgery prior to the implementation of the ERAS protocol; the results were compared with a consecutive group of patients who had been prospectively collected since the introduction of the ERAS for craniosynostosis protocol. The safety, feasibility, and efficiency of the ERAS protocol in pediatric neurosurgery was evaluated, through the collection of clinical data from the pre-, intra-, and postoperative phase. Surgery-related complications were evaluated according to the Clavien-Dindo classification. Costs of the stays were obtained using a microcosting approach. RESULTS: A total of 35 pre-ERAS patients and 10 ERAS patients were included. Scaphocephaly was the most common pathology in both groups. The overall compliance with the pre-, intra-, and postoperative criteria significantly increased-from 35.5%, 64.4%, and 54.7%, respectively, in each phase to 94%, 90%, and 84% (p < 0.001). The authors noticed a reduction in the average opioid dose used per patient in the ERAS group (p = 0.004), and they observed a trend toward a decreased mean length of stay from 5.2 days in the pre-ERAS group to 4.6 days in the ERAS group, without an increase of the rate of readmission within 30 days of surgery. The rate of complications decreased but this difference was not statistically significant. The hospital costs lowered significantly: from 21,958 Confederatio Helvetica Francs (CHF) in the pre-ERAS group to 18,936 CHF in the ERAS group (p = 0.02). CONCLUSIONS: The ERAS protocol represents a safe and cost-effective tool for the perioperative management of craniosynostosis. It showed its positive impact on the analgesia provided and on the reduction of in-hospital costs for these patients. ERAS protocols may thus be interesting options in the pediatric neurosurgical field.
- MeSH
- délka pobytu MeSH
- dítě MeSH
- kraniosynostózy * chirurgie MeSH
- lidé MeSH
- nemocnice - náklady MeSH
- pooperační komplikace MeSH
- pooperační péče metody MeSH
- urychlená pooperační rehabilitace * MeSH
- Check Tag
- dítě MeSH
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
Brain stimulation has emerged as an effective treatment for a wide range of neurological and psychiatric diseases. Parkinson's disease, epilepsy, and essential tremor have FDA indications for electrical brain stimulation using intracranially implanted electrodes. Interfacing implantable brain devices with local and cloud computing resources have the potential to improve electrical stimulation efficacy, disease tracking, and management. Epilepsy, in particular, is a neurological disease that might benefit from the integration of brain implants with off-the-body computing for tracking disease and therapy. Recent clinical trials have demonstrated seizure forecasting, seizure detection, and therapeutic electrical stimulation in patients with drug-resistant focal epilepsy. In this paper, we describe a next-generation epilepsy management system that integrates local handheld and cloud-computing resources wirelessly coupled to an implanted device with embedded payloads (sensors, intracranial EEG telemetry, electrical stimulation, classifiers, and control policy implementation). The handheld device and cloud computing resources can provide a seamless interface between patients and physicians, and realtime intracranial EEG can be used to classify brain state (wake/sleep, preseizure, and seizure), implement control policies for electrical stimulation, and track patient health. This system creates a flexible platform in which low demand analytics requiring fast response times are embedded in the implanted device and more complex algorithms are implemented in offthebody local and distributed cloud computing environments. The system enables tracking and management of epileptic neural networks operating over time scales ranging from milliseconds to months.
- Publikační typ
- časopisecké články MeSH
PURPOSE OF THE STUDY Decline in length of stay is of growing interest for patients, doctors and health insurances. The aim of our study was to assess the safety and length of stay after omission of casting, start of early mobilization and implementation of functional discharge criteria after total elbow arthroplasty (TEA). MATERIAL AND METHODS We retrospectively reviewed all patients' records who received a Coonrad-Morrey TEA in the period from January 1st, 2011 to December 31st, 2018. From these records, indications, demographic information and complications were derived. Length of stay was calculated from the hospital administration. Patients were divided in three groups to evaluate the two changes in post-operative care. RESULTS In total 125 patients receiving 126 Coonrad-Morrey TEAs were included with a mean length of stay of 5.5 days (range 2- 23) for the entire group. Omitting a post-operative cast led to decline in length of stay from 6.2 to 5.4 days (p < 0.001). Introduction of functional discharge criteria in August 2017 declined mean length of stay to 3.8 days (p < 0.001). The surgical technique (triceps-on versus triceps-off) was not a confounder (p = 0.20). Range of motion after one year was not significantly different between groups. DISCUSSION The length of stay declined after omission of a cast, and declined further after introducing functional discharge criteria. Since no higher complication rates were observed, the shortening of length of stay appears to be safe. This is in line with other fast-track programs, i.e. for hip and knee arthroplasty. The surgical technique used were not a confounder for the shortened length of stay, which further adds to the safety of the functional discharge criteria. CONCLUSIONS Omitting a cast and splint as regular post-operative treatment reduced the length of stay significantly without leading to more complications. Introduction of functional discharge criteria lowered the length of stay further without more complications. Key words: fast track rehabilitation, cast, total elbow arthroplasty, length of stay, discharge, complications.
Úvod. Klinická studie vychází z předpokladu, že mnohahodinové lačnění nemocného před operací zasahuje nepříznivě do poměrů vnitřního prostředí s dopadem na psychosomatický stav operanta, fyziologii metabolických procesů a funkce vitálně významných orgánů a jejich soustav. Tento předpoklad byl již vysloven lékaři intenzivisty v jiných evropských zemích a v rámci metodiky ERAS (enhancement recovery after surgery) nebo fast track je již tento problém řešen nejen na úrovni klinických studií ale i klinické praxe. Metodika a soubor nemocných. Soubor nemocných chirurgicky léčených pro onemocnění tračníku benigního i maligního typu je rozdělen na tři skupiny: A – standardně lačnící od 0 hod. operačního dne, B – nemocní zajištěni večer před operací a v den operace parenterálním přívodem 10% glukózy a minerálů a C – nemocní pijící speciální nápoj na bázi cukrů (především maltodextrinu) ve směsi s minerály večer před operací a v den operace. Nemocní musí splňovat kritéria pro zařazení do studie: komorbidita při ASA 1–2, hmotnost 60–90 kg, věk 35–75 let, operační výkon na tračníku s trváním 120 ± 30 min. a bez komplikací (mj. nesmí být podána transfuze krevního derivátu) peroperačně a pooperačně v době hospitalizace etc. U všech zařazených nemocných byly v kolemoperačním období vyšetřovány vybrané biochemické ukazatele, měřena svalová síla, vyšetřovány některé srdeční funkce echograficky a speciálními dotazníky zjišťovány vybrané subjektivní pocity. Hodnocení průběžných výsledků bylo zatím provedeno základními statistickými metodami. Výsledky. Sledované parametry vnitřního prostředí vykazují kolemoperačně v oblasti základních minerálů zhruba stejnou dynamiku. Stejná situace je u sérových koncentrací glukózy, CRP, albuminu. Ve skupině pijících nemocných jsou pooperačně relativně sníženy sérové koncentrace inzulinu, (což jistě souvisí s nižší inzulinovou rezistencí), sérové koncentrace myoglobinu a kreatininkinázy. V žaludku operantů jsou při úvodu do anestezie nejnižší objemy reziduální tekutiny a nejnižší hodnoty pH ve skupině pacientů pijících v den operace. Výsledky měření svalové síly a echokardiografie zatím nejsou podrobněji zpracovány. Nelibé pocity nemocných v den operace (žízeň, hlad, nervozita, strach atd.) jsou předběžně nejvíce redukovány také ve skupině pijících operantů. Závěr. Dosavadní nálezy dokumentované sledovanými ukazateli dávají naději, že zavedení p.o. příjmu v den operace bude dalším příspěvkem ke zkvalitnění péče o chirurgicky léčené nemocné včetně stoupající úspěšnosti provedených operací.
Introduction: The clinical studies carried out leads to the hypothesis that the starvation of patients for several hours prior to a surgical procedure has a negative influence on the internal metabolic environment of a patient. It also has an impact on the psychosomatic disposition of the patient's physiology of metabolic processes and the proper functioning of vital organs and systems. This hypothesis was already stated by doctors specialized in Intensive Care Units in other European countries. In the frame of methodology, ERAS (enhancement recovery after surgery) also known as fast track, solves this problem not only on the level of clinical studies but also clinical practice. Methodology and group of patients: The group of patients selected had been surgically treated for disease of the colon (both benign and malignant) and were divided into 3 groups: A – basically starving from mid-night of the day of operation, B – patients secured the night before the operation and on the day of the operation by a parenteral intake of 10% glucose solution with minerals, C – patients drinking a special drink, consisting basically of sugars (mainly maltodextrin) mixed in with minerals, the evening before the operation and on the day of the operation. Patients used in this study were required to fulfill several criteria to be included into the study: these criteria consisted of a co-morbidity of ASA 1–2, weight 60–90 kg, age 35–75 years, operating time of the procedure on the colon of 120 ± 30 min. without complications. These patients also had not been given any transfusions of red blood cells or blood derivatives during or after the surgery (or during the time of hospitalization etc). The selected biochemical markers, muscular power, some cardial function, and subjective patients feelings were monitored in all patients during perioperative period. The basic statistical methods were used for evaluation of current results. Results: The monitored parameters of the internal environment showed that the dynamics of the basic minerals had been roughly the same. The same scenario was found with serous concentrations of glucose, CRP, and albumin. In the group of patients given the sugar solution, there was a relative decrease in the serous concentration of insulin post-operatively (which is related to a lower insulin resistance) and serous concentration of myoglobin and creatin kinase. At the start of anesthesia, patient's stomachs contained the lowest volume of residual liquid with a low pH in the group that was drinking the fluid on the day of the operation. The results of the measurements of muscular power (force) and echocardiograph have not been elaborated in detail so far. Unpleasant feelings in patients on the day of the operation like thirst, hunger, nervousness, fear, etc. were mainly reduced in the group of drinking patients. Conclusion: Till date the findings documented by monitored indicators may prove that the implementation of per-oral intake on the day of an surgery will benefit and improve the quality of care of surgically treated patients and increase the number of successful operations.
- MeSH
- aplikace orální MeSH
- biologické markery krev MeSH
- finanční podpora výzkumu jako téma MeSH
- lidé MeSH
- předoperační péče MeSH
- tekutinová terapie metody trendy MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- klinické zkoušky MeSH
