Enhanced Recovery After Surgery (ERAS) Versus Conventional Postoperative Care in Colorectal Surgery A 10-Step Intraoperative Surgical Checklist (ISC) for Laparoscopic Cholecystectomy—Can It Really Reduce Conversion Rates to Open Cholecystectomy? Pneumothorax post paediatric chest drain removal. A surgical safety checklist to reduce morbidity and mortality in a global population. Fast-track in open intestinal surgery: prospective randomized study (Clinical Trials Gov Identifier no. NCT00123456). Integrated care pathways for vascular surgery: an analysis of the first 18 months Randomized clinical trial of multimodal optimization of surgical care in patients undergoing major colonic resection Using a data-matrix-coded sponge counting system across a surgical practice: impact after 18 months. Audit and recurrence rates after hernia surgery. Reduction of postoperative pulmonary complications after lung surgery using a fast track clinical pathway. The effects of clinical pathways for renal transplant on patient outcomes and length of stay. Handover after pediatric heart surgery: A simple tool improves information exchange* Impact of clinical pathways in surgery Effect of A 19-Item Surgical Safety Checklist During Urgent Operations in A Global Patient Population Organizational characteristics of intensive care units related to outcomes of abdominal aortic surgery. Fall in peptic ulcer mortality associated with increased consultant input, prompt surgery and use of high dependency care identified through peer-review audit Colorectal cancer audit: a comparative study before and after establishing a specialty colorectal surgery unit Evidence of the effect of ‘specialization’ on the management, surgical outcome and survival from colorectal cancer in Wessex Clinical pathway for fractured neck of femur: a prospective, controlled study. Variations in surgical outcomes associated with hospital compliance with safety practices. NIS vs SAGES: a comparison of national and voluntary databases. Use of the WHO surgical safety checklist in trauma and orthopaedic patients Implementation of a Fast-Track Perioperative Care Program: What Are the Difficulties? Enhanced Recovery After Surgery (ERAS) Program Attenuates Stress and Accelerates Recovery in Patients After Radical Resection for Colorectal Cancer: A Prospective Randomized Controlled Trial ICU nurse-to-patient ratio is associated with complications and resource use after esophagectomy ‘Fast-track’ multimodal rehabilitation program improves outcome after laparoscopic sigmoidectomy: a controlled prospective evaluation Maximising safety of cataract surgery training: improving patient safety by reducing cataract surgery complication rates. Promotion of improvement as a science Development and implementation of a clinical pathway for spinal cord injuries. Effect of a comprehensive surgical safety system on patient outcomes. Prospective, Randomized, Controlled Trial Between a Pathway of Controlled Rehabilitation With Early Ambulation and Diet and Traditional Postoperative Care After Laparotomy and Intestinal Resection A Prospective Randomized Controlled Trial of Multimodal Perioperative Management Protocol in Patients Undergoing Elective Colorectal Resection for Cancer Hospital mortality, length of stay, and preventable complications among critically ill patients before and after tele-ICU reengineering of critical care processes.
Background Enhanced Recovery After Surgery ( ERAS ) programs are associated with reduced hospital morbidity and mortality . The aim of the present study was to evaluate whether the introduction of ERAS care improved the adverse events in colorectal surgery . In a cohort study , mortality , morbidity , and length of stay were compared between ERAS patients and carefully matched historical controls . Methods Patients were matched for their type of disease , the type of surgery , P-Possum ( Portsmouth-Possum ) , CR-Possum ( Colorectal-Possum ) Physiological and Operative Score for Enumeration of Mortality and Morbidity ( POSSUM ) , gender , and American Society of Anesthesiologists ( ASA ) grade . The primary outcome measures of this study were mortality and morbidity . Secondary outcome measures were fluid intake , length of hospital stay , the number of relaparotomies , and the number of readmissions within 30 days . Data on the ERAS patients were collected prospect ively . Results Sixty-one patients treated according to the ERAS program were compared with 122 patients who received conventional postoperative care .  The two groups were comparable with respect to age , ASA grade , P-Possum ( Portsmouth-Possum ) , CR-Possum ( Colorectal-Possum ) score , type of surgery , stoma formation , type of disease , and gender . Morbidity was lower in the ERAS group compared to the control group ( 14.8 % versus 33.6 % respectively ; P = < 0.01 ) . Patients in the ERAS group received significantly less fluid and spent fewer days in the hospital ( median 6 days , range 3–50 vs. median 9 days , range 3–138 ; P = 0.032 ) . There was no difference between the ERAS and the control group for mortality ( 0 % vs. 1.6 % ; P = 0.55 ) and readmission rate ( 3.3 % vs. 1.6 % ; P = 0.60 ) . Conclusion Enhanced Recovery After Surgery program  reduces morbidity and the length of hospital stay for patients undergoing elective colonic or rectal surgery Introduction The recent introduction of a Surgical Safety Checklist has significantly reduced the morbidity and mortality of surgery . Such a simple measure that can impact so highly on surgical outcomes causes all surgeons to pause for thought . This paper documents the introduction of a 10-step intraoperative surgical checklist ( ISC ) to st and ardize performance , decision-making , and training during laparoscopic cholecystectomy ( LC ) . The checklist ’s impact on conversion rates to open cholecystectomy ( OC ) is presented . Methods In 2004 , a 10-step ISC was introduced by a single consultant surgeon for the performance of LCs . Data were collected comparing LCs between 1999–2003 ( period 1 ) and 2004–2008 ( period 2 ) . Data on sex , age , American Society of Anesthesiology grade , previous abdominal surgery , severity of gallbladder pathology , and conversion to OC  were recorded . The chi-squared test with Yates correction was used to compare groups . Results In total , 637 LCs were performed , 277 during period 1 and 360 during period 2 . Risk factors for conversion ( gender , age , previous abdominal surgery , and severity of gallbladder pathology ) were not significantly different in the two periods studied . The overall conversion rate to OC fell significantly in period 2 ( p = 0.001 ) . Subgroup analysis also showed a significant reduction in conversion rates  in female patients ( p = 0.002 ) and patients with grade s III and IV gallbladder disease ( p = 0.001 ) . Conclusions The introduction of a 10-step ISC was temporally related to reduced conversion rates to OC . The st and ardization of a frequently performed operation such as a LC that could potentially lead to an impact as great the one we observed warrants further attention in prospect i ve , appropriately design ed studies OBJECTIVES Pneumothorax can be a major complication following chest drain removal . As paediatric patients have poor breath-holding compliance , the incidence in this group may be raised compared to the adult population . A small pilot study in our hospital found a pneumothorax rate post chest drain removal of 6/39 ( 15.4 % ) , which was high . The aim of this study was to determine the incidence of pneumothorax post paediatric chest drain removal after updating the guidelines for removal , and staff education . METHOD A prospect i ve audit was conducted using a structured proforma . All eligible patients admitted to Glenfield Hospital over a 6-month period were included in the study , which finally consisted of 93 patients aged 18 or under who underwent insertion of a chest drain .  RESULTS 93 patients , with 95 episodes of placement of chest drains were included in the prospect i ve audit . Four patients ( 4.2 % ) had a pneumothorax post chest drain removal , with one patient requiring insertion of a further chest drain for pneumothorax , and one patient requiring an additional drain due to recurrent pleural effusion . All patients who had post procedure pneumothorax were under 1 year of age ; 3 had had cardiac surgery , and 1 had an empyema . In total , 94/95 of patients had a radiograph post drain removal . 89 % of patients were admitted for cardiac surgery , 5.4 % for empyema  , 3.2 % for pneumothorax , 1 patient for a left upper lobectomy , and 1 patient was on extracorporeal membranous oxygenation . CONCLUSIONS This study found an incidence of pneumothorax post paediatric chest drain removal of 4.2 % , an improvement since the initial pilot study . A good removal technique reduces complication rates with trained staff following structured guidelines less likely to encounter problems . The application of an occlusive dressing rapidly following suture failure helps to decrease exposure times and thus lowers the incidence of pneumothorax BACKGROUND Surgery has become an integral part of global health care , with an estimated 234 million operations performed yearly . Surgical complications are common and often preventable . We hypothesized that a program to implement a 19-item surgical safety checklist design ed to improve team communication and consistency of care would reduce complications and deaths associated with surgery . METHODS Between October 2007 and September 2008 , eight hospitals in eight cities ( Toronto , Canada ; New Delhi , India ; Amman , Jordan ; Auckl and , New Zeal and ; Manila , Philippines ; Ifakara , Tanzania ; London , Engl and ; and Seattle , WA ) representing a variety of economic circumstances and diverse population s of patients participated in the World Health Organization 's Safe Surgery Saves Lives program . We prospect ively collected data on clinical processes and outcomes from 3733 consecutively enrolled patients 16 years of age or older who were undergoing noncardiac surgery . We subsequently collected data on 3955 consecutively enrolled patients after the introduction of the Surgical Safety Checklist . The primary end point was the rate of complications , including death , during hospitalization within the first 30 days after the operation . RESULTS The rate of death was 1.5 % before the checklist was introduced and declined to 0.8 % afterward ( P=0.003 ) . Inpatient complications occurred in 11.0 % of patients at baseline and in 7.0 % after introduction of the checklist ( P<0.001 ) . CONCLUSIONS Implementation of the checklist was associated with concomitant reductions in the rates of death and complications among patients at least 16 years of age who were undergoing noncardiac surgery in a diverse group of hospitals BACKGROUND Studies have shown the value of using fast-track postoperative recovery . St and ard procedures ( non-fast-track strategies ) remain in common use for perioperative care . Few prospect i ve reports exist on the outcome of fast-tracking in Central Europe . The aim of our study was to assess the effect and safety of our own fast-track protocol with regard to the postoperative period after open bowel resection . PATIENTS AND METHODS One hundred and five patients with ASA score I-II scheduled for open intestinal resection in the period April 2005-December 2007 were r and omly selected for the fast-track group ( FT ) and non-fast-track group ( non-FT ) . A design ed protocol was used in the FT group with the emphasis on an interdisciplinary approach . The control group ( non-FT ) was treated by st and ard established procedures .  Postoperative pain , rehabilitation , gastrointestinal functions , postoperative complications , and post-op length of stay were recorded . RESULTS Of 105 patients , 103 were statistically analyzed . Patients in the FT group ( n=51 ) and non-FT group ( n=52 ) did not differ in age , surgical diagnosis , or procedure . The fast-track procedure led to significantly better control of postoperative pain and faster restoration of GI functions ( bowel movement after 1.3 days vs. 3.1 , p<0.001 ) . Food tolerance was significantly better in the FT group and rehabilitation was also faster . Hospital stay was shorter in the FT group - median seven days ( 95 % CI 7.0 - 7.7 ) versus ten days ( 95 % CI 9.5 - 11.3 ) in non-FT ( p<0.001 ) . Postoperative complications within 30 postoperative days were also significantly lower in the FT group ( 21.6 vs. 48.1 % , p=0.003 ) . There were no deaths and no patients were readmitted within 30 days . CONCLUSIONS Following the FT protocol helped to reduce frequency of postoperative complications and reduced hospital stay . We conclude that the FT strategy is safe and effective in improving postoperative outcomes Objectives : A review of the use of previously described integrated care pathways ( ICPs ) established for three elective vascular surgical procedures . Design : A retrospective analysis of information gathered prospect ively over an initial 18 month period of use of vascular surgical ICPs . Subjects : Patients admitted to a single vascular unit for “ open ” repair of abdominal aortic aneurysm ( AAA ) , carotid endarterectomy , or femoropopliteal bypass grafting . Methods : An analysis of variance data , length of stay , and costings after the use of ICPs , compared with previous clinical practice . Results : Variance data were gathered for each of the three procedures . Variances of medication prescribing and delays in discharge were common to all procedures . In particular : ( i ) gastrointestinal complications were more specific to AAA repair and ( ii ) wound drains were removed a day later than originally proposed after femoropopliteal bypass . Overall , improved efficiency due to use of ICPs  reduced the length of stay for all procedures , which was reflected in a potential cost saving of some 25 % . Conclusion : There are clear benefits to the use of ICPs , result ing in more structured , efficient , and cost effective patient care . Recommended changes to current practice based on variance analysis will require continued audit to sustain this “ evidence based ” approach The aim of this trial was to compare  multimodal optimization  with  conventional perioperative management  in a consecutive series of patients undergoing a wide range of colorectal procedures BACKGROUND Retained surgical items ( RSIs ) , most commonly sponges , are infrequent . Yet despite sponge-counting st and ards , failure to maintain an accurate count is a common error . To improve counting performance , technology solutions have been developed . A data -matrix-coded sponge ( DMS ) system was evaluated and implemented in a high-volume academic surgical practice at Mayo Clinic Rochester ( MCR ) . The primary end point was prevention of sponge RSIs after 18 months . METHODS Two trials were conducted before implementation . A r and omized-controlled trial assessed the system 's function , efficiency , and ergonomics . The second , larger trial was conducted to vali date the prior findings and test product improvements . After the trials , the system was implemented in all 128 operating/procedure rooms across the MCR campus on February 2 , 2009 . The institutionwide implementation was intended to avoid the possibility of having st and ard unmarked sponges and DMSs in the operating room suite concurrently . RESULTS Before implementation , a retained sponge occurred on average every 64 days . Between February 2009 and July 2010 , 87,404 procedures were performed , and 1,862,373 DMSs were used without an RSI ( p < .001 ) . After four cases , the average time to count a DMS decreased from 11 to 4 seconds . Total sponge counting time/operation increased without any increase in overall operative time . CONCLUSIONS After 18 months , a DMS system eliminated sponge RSIs from a high-volume surgical practice . The DMS system caused no work-flow disruption or increases in case duration . Staff satisfaction was acceptable , with a high degree of trust in the system . The DMS system is a reliable and cost-effective technology that improves patient safety OBJECTIVE To study the effect of quality assurance on the recurrence rate after hernia repair . DESIGN A prospect i ve longitudinal cohort study . SETTING District hospital , Sweden . SUBJECTS All ( n = 1232 ) patients aged 15 - 80 years operated upon for inguinal or femoral hernia in Motala 1984 , 1986 - 1988 , 1990 , and 1992 - 1994 . INTERVENTION A question naire enquiring about pain or a lump in the operated area was sent 3 - 6 years postoperatively to all patients , excluding those who had already been operated on for recurrence and those who had died . Selected cases were examined depending on the answers to the question naire . MAIN OUTCOME MEASURES Recurrence rate estimated by adding already confirmed recurrences to those found at the clinical examination ; reoperation for recurrence ; hospital stay ; and number of day cases . Cumulative incidence of reoperation was analysed by actuarial analysis of all patients operated on from 1986 - 1997 . RESULTS The recurrence rate decreased from 18 % in 1984 and 1986 to 3 % in 1993 and 1994 . The reoperation rate for recurrence at three years was 10.8 % ( 95 % confidence interval , CI : 9.3 to 12.2 % ) , 3.6 % ( 2.6 to 4.4 % ) and 2.2 % ( 1.7 to 2.7 % ) for patients operated on between 1986 - 1988 , 1989 - 1991 and 1992 - 1997 , respectively . Differences between the first and the second and between the first and the third period were both highly significant ( p < 0.001 ) whereas the difference between the second and third period was not ( p = 0.09 ) . Mean hospital stay decreased from 3.5 days in 1984 to 0.9 days in 1994 . CONCLUSION By recording recurrence rate or its surrogate endpoint , reoperation rate for recurrence , or both , hospital stay , and number of day cases , and presenting these results to participating surgeons , we provided incentives to improve outcome . This has result ed in a rapid decrease in recurrence rate and a shortened hospital stay , thereby improving cost-effectiveness BACKGROUND Fast track programs , multimodal therapy strategies , have been introduced in many surgical fields to minimize postoperative morbidity and mortality . In terms of lung resections no r and omized controlled trials exist to evaluate such patient care programs . METHODS In a prospect i ve , r and omized controlled pilot study a conservative and fast track treatment regimen in patients undergoing lung resections was compared . Main differences between the two groups consisted in preoperative fasting ( 6h vs 2h ) and analgesia ( patient controlled analgesia vs patient controlled epidural analgesia ) . Study endpoints were pulmonary complications ( pneumonia , atelectasis , prolonged air leak ) , overall morbidity and mortality . Analysis was performed in an intention to treat . RESULTS Both study groups were similar in terms of age , sex , preoperative forced expiratory volume in one second ( FEV(1 ) ) , American Society of Anesthesiologists score and operations performed . The rate of postoperative pulmonary complications was 35 % in the conservative and 6.6 % in the fast track group ( p=0.009 ) . A subgroup of patients with reduced preoperative FEV(1 ) ( < 75 % of predicted value ) experienced less pulmonary complications in the fast track group ( 55 % vs 7 % , p=0.023 ) . Overall morbidity was not significantly different ( 46 % vs 26 % , p=0.172 ) , mortality was comparable in both groups ( 4 % vs 3 % ) . CONCLUSION We evaluated an optimized patient care program for patients undergoing lung resections in a prospect i ve r and omized pilot study . Using this fast track clinical pathway the rate of pulmonary complications could be significantly decreased as compared to a conservative treatment regimen ; our results support the implementation of an optimized perioperative treatment in lung surgery in order to reduce pulmonary complications after major lung surgery OBJECTIVES Clinical pathways have been implemented nationwide but little is understood about their effects on efficiency of care and patient outcomes . The present study examined the effects of both development and implementation of two renal transplant pathways . METHODS Cohorts of patients at a university hospital were compared before , during , and after the development and implementation of two renal transplant clinical pathways :  isolated renal transplant from cadaveric donors ( n = 170 ) or from living donors ( n = 178 ) .  Clinical pathways for cadaveric and living related donor renal transplants were developed and implemented . Hospital length of stay and complications and infections after renal transplant were determined . RESULTS Mean length of hospital stay decreased after development and implementation of the cadaveric donor pathway ( 11.8 days after implementation versus 17.5 days before development ) . Cadaveric kidney recipients also had statistically fewer complications and infections after both guideline development and guideline implementation ( 57.1 % before , 24.5 % during , 18.5 % after ) , but the greatest effect occurred during development . All of these findings persisted after control for demographic and comorbid factors . There were no changes in hospital stay , complications , or infections in the patients who received kidneys from living donors . CONCLUSIONS The development and use of a clinical pathway for cadaveric donor renal transplant patients was associated with a significant decline in length of stay , complications , and infections , but much of the effect was seen during development rather than during implementation , and a closely related pathway for living related donor patients had no effect . Further underst and ing of what factors predict an effective pathway and what elements ( ie , development or implementation ) have an effect should be undertaken Objective : To improve the quality of h and over of complex patients after pediatric cardiac surgery through the use of a simple h and over tool . Design : Prospect i ve , pre-/postinterventional . Setting : A tertiary care , pediatric intensive care unit in North America . Subjects : Thirty-three consenting healthcare providers from pediatric cardiac anesthesia , critical care , and cardiothoracic surgery participating in 31 h and overs . Intervention : A fill-in-the-blank , one-page tool was developed to guide the information transmitted by the surgeon and anesthesiologist to the pediatric intensive care unit team during h and over of postcardiac surgery patients . Measurements and Main Results : Total h and over score , four subscores , h and over duration , and postoperative high-risk events were measured before and after introducing the tool into clinical practice . The patients in both the pre- and postintervention groups were similar at baseline . The total h and over score ( maximum 43 points ) improved significantly after the implementation of the h and over tool ( 28.2 of 43 ± 4.6 points vs. 33.5 of 43 ± 3.7 points , p = .002 ) . There was also a significant improvement in the medical ( 8.3 ± 2.6 vs. 10.3 ± 2.1 points , p = .024 ) and surgical ( 7.5 ± 1.4 vs. 9.3 ± 1.6 points , p = .002 ) intraoperative information subscores . Use of the tool did not prolong h and over duration ( 8.3 ± 4.6 vs. 11.1 ± 3.9 mins , p = .1 ) . There was a trend toward more patients being free from high-risk events in the postintervention group ( 31.2 % vs. 6.7 % ) , but this did not reach statistical significance ( p = .1 ) . Conclusions : Use of a simple tool during h and over of pediatric postcardiac surgery patients result ed in a more complete exchange of critical information with no significant prolongation of the h and over duration Background One strategy to reduce the consumption of re sources associated to specific procedures is to utilize clinical pathways , in which surgical care is st and ardized and preset by determination of perioperative in-hospital processes . The aim of this prospect i ve study was to establish the impact of clinical pathways on costs , complication rates , and nursing activities . Method Data was prospect ively collected for 171 consecutive patients undergoing laparoscopic cholecystectomy ( n = 50 ) , open herniorrhaphy ( n = 56 ) , and laparoscopic Roux-en-Y gastric bypass ( n = 65 ) . Results Clinical pathways reduced the postoperative hospital stay by 28 % from a mean of 6.1 to 4.4 days ( p < 0.001 ) , while the 30-day readmission rate remained unchanged ( 0.5 % vs. 0.45 % ) . Total mean costs per case were reduced by 25 % from € 6,390 to € 4,800 ( p < 0.001 ) . Costs for diagnostic tests were reduced by 33 % ( p < 0.001 ) . Nursing hours decreased , reducing nursing costs by 24 % from € 1,810 to € 1,374 ( p < 0.001 ) . A trend was noted for lower postoperative complication rates in the clinical pathway group ( 7 % vs. 14 % , p = 0.07 ) . Conclusions This study demonstrates clinical ly and economically relevant benefits for the utilization of clinical pathways with a reduction in use of all re source types , without any negative impact on the rate of complications or re-hospitalization Objective : To assess whether implementation of a 19-item World Health Organization ( WHO ) Surgical Safety Checklist in urgent surgical cases would improve compliance with basic st and ards of care and reduce rates of deaths and complications . Background : Use of the WHO Surgical Safety Checklist has been shown to be associated with significant reductions in complications and deaths . Before evaluation of this safety tool , concern was raised about whether its use would be practical or beneficial during urgent surgical procedures . Methods : We prospect ively collected clinical process and outcome data for 1750 consecutively enrolled patients 16 years of age or older undergoing urgent noncardiac surgery before and after introduction of the WHO Surgical Safety Checklist in 8 diverse hospitals around the world ; 842 underwent urgent surgery — defined as an operation required within 24 hours of assessment to be beneficial — before introduction of the checklist and 908 after introduction of the checklist . The primary end point was the rate of complications , including death , during hospitalization up to 30 days following surgery . Results : The complication rate was 18.4 % ( n = 151 ) at baseline and 11.7 % ( n = 102 ) after the checklist was introduced ( P = 0.0001 ) . Death rates dropped from 3.7 % to 1.4 % following checklist introduction ( P = 0.0067 ) . Adherence to 6 measured safety steps improved from 18.6 % to 50.7 % ( P < 0.0001 ) . Conclusions : Implementation of the checklist was associated with a greater than one-third reduction in complications among adult patients undergoing urgent noncardiac surgery in a diverse group of hospitals . Use of the WHO Surgical Safety Checklist in urgent operations is feasible and should be considered CONTEXT Morbidity and mortality rates in intensive care units ( ICUs ) vary widely among institutions , but whether ICU structure and care processes affect these outcomes is unknown . OBJECTIVE To determine whether organizational characteristics of ICUs are related to clinical and economic outcomes for abdominal aortic surgery patients who typically receive care in an ICU . DESIGN Observational study , with patient data collected retrospectively and ICU data collected prospect ively . SETTING All Maryl and hospitals that performed abdominal aortic surgery from 1994 to 1996 . PATIENTS AND PARTICIPANTS We analyzed hospital discharge data for patients in non-federal acute care hospitals in Maryl and who had a principal procedure code for abdominal aortic surgery from January 1994 through December 1996 ( n = 2987 ) . We obtained information about ICU organizational characteristics by surveying ICU medical directors at the 46 Maryl and hospitals that performed abdominal aortic surgery . Thirty-nine ( 85 % ) of the ICU directors completed this survey . MAIN OUTCOME MEASURES In-hospital mortality and hospital and ICU length of stay . RESULTS For patients undergoing abdominal aortic surgery , in-hospital mortality varied among hospitals from 0 % to 66 % . In multivariate analysis adjusted for patient demographics , comorbid disease , severity of illness , hospital and surgeon volume , and hospital characteristics , not having daily rounds by an ICU physician was associated with a 3-fold increase in in-hospital mortality ( odds ratio [ OR ] , 3.0 ; 95 % confidence interval [ CI ] , 1.9 - 4.9 ) . Furthermore , not having daily rounds by an ICU physician was associated with an increased risk of cardiac arrest ( OR , 2.9 ; 95 % CI , 1.2 - 7.0 ) , acute renal failure ( OR , 2.2 ; 95 % CI , 1.3 - 3.9 ) , septicemia ( OR , 1.8 ; 95 % CI , 1.2 - 2.6 ) , platelet transfusion ( OR , 6.4 ; 95 % CI , 3.2 - 12.4 ) , and reintubation ( OR , 2.0 ; 95 % CI , 1.0 - 4.1 ) . Not having daily rounds by an ICU physician , having an ICU nurse-patient ratio of less than 1:2 , not having monthly review of morbidity and mortality , and extubating patients in the operating room were associated with increased re source use . CONCLUSIONS Organizational characteristics of ICUs are related to differences among hospitals in outcomes of abdominal aortic surgery . Clinicians and hospital leaders should consider the potential impact of ICU organizational characteristics on outcomes of patients having high-risk operations Objectives Patients with peptic ulceration continue to present to surgeons with complications of bleeding or perforation and to die under surgical care . This study sought to examine whether improved consultant input , timely interventions and perioperative care could reduce mortality from peptic ulcer . Design Prospect i ve collection of peer- review mortality data using Scottish Audit of Surgical Mortality method ologies ( http://www.SASM.org ) and analysed using SPSS . Setting Secondary care ; all hospitals in Scotl and , UK , admitting surgical patients over 13 years ( 1994–2006 ) . Participants 42 736 patients admitted ( 38 782 operative and 3954 non-operative ) with peptic ulcer disease ; 1952 patients died ( 1338 operative and 614 non-operative deaths ) with a diagnosis of peptic ulcer . Primary and secondary outcome measures Adverse events ; consultant presence at operation , operations performed within 2 h and high dependency/intensive therapy unit ( HDU/ITU ) use . Results Annual mortality fell from 251 in 1994 to 83 in 2006 , proportionately greater than the reduction in hospital admissions with peptic ulcer . Adverse events declined over time and were rare for non-operative patients .  Consultant surgeon presence at operation rose from 40.0 % in 1994 to 73.4 % in 2006 , operations performed within 2 h of admission from 10.3 % in 1994 to 28.1 % in 2006 and HDU/ITU use from 52.7 % in 1994 to 84.4 % in 2006 . Consultant involvement ( p=0.005 ) and HDU/ITU care ( p=0.026 ) were significantly associated with a reduction in operative deaths .  Conclusion Patients with complications of peptic ulceration admitted under surgical care should be offered consultant surgeon input , timely surgery and HDU/ITU care Objective A prospect i ve audit was kept for colorectal cancer after the establishment of a special‐interest colorectal unit at a Melbourne metropolitan teaching hospital A prospect i ve audit of the management of colorectal cancer was established to investigate factors associated with variation in survival observed within the former Wessex region ( population three million ) OBJECTIVE To assess outcomes of using a clinical pathway for managing patients with fractured neck of femur . DESIGN Prospect i ve , pseudor and omised , controlled trial . SETTING St Vincent 's Hospital , Melbourne , Victoria ( a tertiary referral , university teaching hospital ) , 1 October 1997 to 30 November 1998 . PARTICIPANTS 111 patients ( 80 women and 31 men ; mean age , 81 years ) admitted via the emergency department with a primary diagnosis of fractured neck of femur . INTERVENTIONS Management guided by a clinical pathway ( 55 patients ) or established st and ard of care ( control group , 56 patients ) . MAIN OUTCOME MEASURES Timing of referrals and discharge planning ; total length of stay ; and complication and readmission rates within 28 days of discharge . RESULTS Patients managed according to the clinical pathway had a shorter total stay ( 6.6 versus 8.0 days ; P = 0.03 ) , even if assessment for placement by the Aged Care Assessment Service was required ( 9.5 versus 13.6 days ; P = 0.03 ) . There were no significant differences in complication and readmission rates between pathway and control patients ( complication rates , 24 % versus 36 % ; P = 0.40 ; readmission rates , 4 % versus 11 % ; P = 0.28 ) . CONCLUSION Coordinated multidisciplinary care of patients with fractured neck of femur reduces length of stay without increasing complications BACKGROUND The Leapfrog Group aims to improve patient safety by promoting hospital compliance with National Quality Forum ( NQF ) safe practice s. It is unknown , however , whether implementation of these safety practice s improve outcomes after high-risk operations . METHODS We conducted a cross-sectional analysis of 658 nationwide hospitals that responded to the 2005 Leapfrog Group Hospital Quality & Safety survey . A total of 79,462 patients were identified from Medicare cl aims data who underwent a pancreatectomy , hepatectomy , esophagectomy , open aortic aneurysm repair , colectomy , or gastrectomy procedure from 2004 through 2006 . R and om effects logistic regression models were used to estimate the association between hospital compliance with NQF safe practice s and risk-adjusted odds of complications , rate of failure to rescue , and mortality after adjusting for patient- and hospital-level confounders . RESULTS Of the 658 hospitals that responded to surveys , 41 % had fully implemented NQF safe practice s and 59 % reported partial compliance with these st and ards . Compared with hospitals with partial NQF compliance , we found evidence that hospitals with full compliance had an increased likelihood of diagnosing a complication after any of the 6 high-risk operations ( odds ratio [ OR ] , 1.13 ; 95 % confidence interval [ CI ] , 1.03 - 1.25 ) , but had a decreased likelihood of failure to rescue ( OR , 0.82 ; 95 % CI , 0.71 - 0.96 ) , and a decreased odds of mortality ( OR , 0.80 ; 95 % CI , 0.71 - 0.91 ) . CONCLUSION Despite having a greater rate of postoperative complications , hospitals fully complying with safe practice s were associated with less failure to rescue and decreased mortality after high-risk operations . These results highlight the importance of having hospital systems in place to promote safety and manage postoperative complications BACKGROUND Surgical outcomes are increasingly examined in an effort to improve quality and reduce medical error . The Nationwide Inpatient Sample ( NIS ) is a retrospective , cl aims -derived and population -based data base and the Society of American Gastrointestinal Endoscopic Surgeons ( SAGES ) Outcomes Project is a prospect i ve , voluntary and specialty surgeon data base . We hypothesized that these two sources of outcome data would differ in regard to a single , commonly performed procedure . METHODS Both the NIS , a national sample of all nonfederal hospital discharges , and the gastroesophageal reflux disease log of the SAGES Outcomes Project were queried for all fundoplications performed between 1999 and 2001 using either ICD-9 procedure code 44.66 or CPT codes 43280 or 43324 . Patients with an emergency admission , age < 17 years , and /or diagnoses for either esophageal cancer or achalasia were excluded . Both demographic and outcome variables were compared by either t-test or chi-square analysis , with a p value of < 0.05 as significant . RESULTS Both data sets were comparable for age and gender ; however , the SAGES group had a higher rate of teaching hospital affiliation ( 71 vs 48 % , p < 0.001 ) . SAGES fundoplications had a consistently higher rate of comorbidities , including Barrett 's esophagus ( 2.3 vs 1.1 % , p = 0.005 ) . The NIS fundoplications had a clear trend toward more associated procedures , including cholecystectomy ( 7.2 vs 2 % , p < 0.001 ) . Complication rates for the NIS data set were higher , including pulmonary complications ( 1.7 vs 0.5 % , p = 0.03 ) . No statistically significant differences existed between the two data sets for either length of stay or mortality . CONCLUSIONS The two data bases indicate that fundoplication is an operation with low morbidity and mortality . The SAGES Outcomes Project demonstrated that participating surgeons had a higher affiliation with teaching hospitals , higher reporting of comorbidity , and lower associated procedures than the NIS . Despite having more comorbidity and technical difficulty , patients from the SAGES Outcomes Project had equivalent or lower complication rates The World Health Organisation ( WHO ) recommends routine use of a surgical safety checklist prior to all surgical operations . The aim of this study was to prospect ively audit checklist use in orthopaedic patients before and after implementation of an educational programme design ed to increase use and correlate this with early complications , mortality and staff perceptions . Data was collected on 480 patients before the educational program and 485 patients after . Pre-training checklist use was 7.9 % . The rates of early complications and mortality were 8.5 % and 1.9 % , respectively . Forty-seven percent thought the checklist improved team communication . Following an educational program , checklist use significantly increased to 96.9 % ( RR12.2 ; 95 % CI 9.0–16.6 ) . The rate of early complications and mortality was 7.6 % ( RR 0.89 ; 95 % CI 0.58–1.37 ) and 1.6 % ( RR 0.88 ; 95 % CI 0.34–2.26 ) , respectively . Seventy-seven percent thought the checklist improved team communication . Checklist use was not associated with a significant reduction in early complications and mortality in patients undergoing orthopaedic surgery . Education programs can significantly increase accurate use and staff perceptions following implementation Background : To evaluate the feasibility of a fast-track ( FT ) program and it ’s effect on postoperative recovery . Methods : All patients , scheduled for elective segmental colorectal resection were treated in a FT program ( FT group ) . Data were compared to a control group operated for elective colorectal resections and treated in a traditional care program ( TC group ) . Data from the FT group were collected prospect ively , data from the TC group retrospectively . Outcome parameters included the number of successfully applied FT modalities , patient satisfaction , morbidity rate , re-operation rate , primary ( PHS ) and total hospital stay ( THS ) , and readmission rate . Results : One-hundred and seven patients were included ( 55 FT group vs. 52 TC group ) . The groups were comparable for patient characteristics such as age and cr-POSSUM score ( p = 0.22 and p = 0.40 ) . An average of 7.4 of 13 predefined FT modalities were successfully achieved per patient . Patient satisfaction was comparable ( p = 0.84 ) . Seven versus 5 patients required a re-operation in the FT and TC groups , respectively ( p = 0.52 ) . Morbidity rate was comparable ( n = 16 vs. 15 , p = 0.83 ) . Median PHS was 4.0 vs. 6.0 days and median THS was 4.0 vs. 6.5 days in the FT and TC groups ( p < 0.01 and p < 0.03 , respectively ) . Six vs. 3 patients were re-admitted in the FT and TC groups , respectively ( p = 0.49 ) . Conclusion : Implementation of all FT modalities was difficult since a rather low number of pre-defined FT modalities was effectively realized . Despite incomplete implementation , PHS and THS were shorter in the FT group without affecting patient satisfaction Background The aim of this trial was to compare the Enhanced Recovery After Surgery ( ERAS ) program with conventional perioperative management in patients who underwent radical resection for colorectal cancer . Methods A combination of evidence -based and consensus methodology was used to develop the ERAS protocol . Five hundred ninety-seven consecutive patients who underwent elective colorectal resection were r and omized to either the ERAS ( n = 299 ) or the  control group ( n = 298 ) . Outcomes relating to nutrition and metabolism index , stress index , and recovery index were measured and recorded . Results Demographic and operative data were similar between the two groups . Patients in the ERAS group showed improved nutritional status when compared with those of the control group . On postoperative day ( POD ) 1 , the HOMA-IR ( insulin resistance index ) of the ERAS group was lower than that of the control group ( p < 0.001 ) . The cortisol level of the control group was elevated on both POD 1 ( p = 0.007 ) and POD 5 ( p = 0.002 ) compared to the preoperative level . However , the cortisol level of the ERAS group was not increased until POD 5 ( p = 0.001 ) . Reduced levels of TNF-α , IL-1β , IL-6 , and IFN-γ in the ERAS group indicated less postoperative stress responses . In addition , ERAS was associated with accelerated recovery of gastrointestinal function . The postoperative length of stay ( p < 0.001 ) and expense ( p < 0.001 ) for the ERAS group were reduced in comparison to the controls . Twenty-eight cases in the control group and twenty-nine in the ERAS group suffered complications , which was not significantly different . Conclusion The ERAS protocol attenuates the surgical stress response and accelerates postoperative recovery without compromising patient safety Abstract . Objective : To determine if having a night-time nurse-to-patient ratio ( NNPR ) of one nurse caring for one or two patients ( > 1:2 ) versus one nurse caring for three or more patients ( < 1:2 ) in the intensive care unit ( ICU ) is associated with clinical and economic outcomes following esophageal resection . Design : Statewide observational cohort study . Hospital discharge data was linked to a prospect i ve survey of ICU organizational characteristics . Multivariate analysis adjusting for case-mix , hospital and surgeon volume was used to determine the association of NNPR with in-hospital mortality , length of stay ( LOS ) , hospital cost and specific postoperative complications . Setting : Non-federal acute care hospitals ( n=35 ) in Maryl and that performed esophageal resection . Patients and participants : Adult patients who had esophageal resection in Maryl and , 1994 to 1998 ( n=366 patients ) . Measurements and results : Two hundred twenty-five patients at nine hospitals had a NNPR > 1:2;128 patients in 23 hospitals had a NNPR < 1:2 . No significant association between NNPR and in-hospital mortality was seen . A 39 % increase in median in-hospital LOS ( 4.3 days ; 95%CI , ( 2 , 5 days ) ; p<0.001 ) , and a 32 % increase in costs ( $ 4,810 ; 95 % CI , ( $ 2,094 , $ 7,952 ) was associated with a NNPR < 1:2 . Pneumonia ( OR 2.4 ; 95 % CI ( 1.2 , 4.7 ) ; p=0.012 ) , reintubation ( OR 2.6 ; 95 % CI(1.4 , 4.5 ) ; p=0.001 ) , and septicemia ( OR 3.6 ; 95 % CI(1.1 , 12.5 ) ; p=0.04 ) , were specific complications associated with a NNPR < 1:2 . Conclusions : A nurse caring for more than two ICU patients at night increases the risk of several postoperative pulmonary and infectious complications and was associated with increased re source use in patients undergoing esophageal resection Background  Laparoscopic colorectal resection improves patient outcome by reducing pain , postoperative pulmonary dysfunction , gastrointestinal paralysis , and fatigue . A multimodal rehabilitation program ( “ fast-track ” ) with epidural analgesia , early oral feeding , and enforced mobilization may further improve the excellent results of laparoscopic colorectal resection , enabling early ambulation of these patients . Methods Fifty two consecutive patients underwent laparoscopic sigmoidectomy with st and ardized regular perioperative treatment ( st and ard ) or multimodal rehabilitation program ( “ fast-track ” ) .  Outcome measures included pulmonary function , duration of postoperative ileus , pain perception , fatigue , morbidity , and mortality . Results Twenty nine st and ard-care patients ( 19 men and 10 women ) and 23 fast-track patients ( 15 men and eight women ) were evaluated . Demographic and operative data were similar for the two groups . On the 1st postoperative day , pulmonary function was improved ( p = 0.01 ) in fast-track patients . Oral feeding was achieved earlier ( p < 0.01 ) and defecation occurred earlier ( p < 0.01 ) in the fast-track group . Visual analogue scale scores for pain were similar for the two groups ( p > 0.05 ) , but fatigue was increased in the st and ard-care group on the 1st ( p = 0.06 ) and 2nd ( p < 0.05 ) postoperative days . Morbidity was not different for the two groups . Fast-track patients were discharged on day 4 ( range , 3–6 ) and st and ard-care patients on day 7 ( range , 4–14 ) ( p < 0.001 ) . Conclusion Multimodal rehabiliation can improve further on the excellent results of laparoscopic sigmoidectomy and decrease the postoperative hospital stay PURPOSE Cataract surgery is a highly successful , high-volume surgery , hence reducing surgical complications are imperative for organizations to deliver cost-effective , high- quality services that meet the needs of patients . This paper aims to describe 18-month results of a sustainable program to maximize the safety of cataract surgery training . DESIGN / METHODOLOGY /APPROACH Modifications to the comprehensive cataract-training program and tested were developed in a controlled , interventional case series to evaluate their effect on trainee complication rates . Data collection and interpretation were performed in a prospect i ve and blind manner . FINDINGS Prior to intervention , PCR rates for trainee-surgeons averaged 3.34 per cent cf international published figures of 4.6 - 10 per cent . This compared with 1.89 per cent PCR rate for trained cataract surgeons ( p < 0.002 , Mann Whitney test ) . Multiple interventions were introduced and enforced to maximize cataract surgery training safety . After 18 months follow-up data were consistent with a statistically significant reduction in trainee PCR rates ( 1.53 per cent , p < 0.007 , Wilcoxon Signed Ranks test ) compared with trained cataract surgeons ( 1.23 per cent , p < 0.074 , Wilcoxon Signed Ranks test ) . Parameters of training efficacy were improved or maintained during this period . RESEARCH LIMITATIONS / IMPLICATION S Limitations included using trained cataract surgeons as controls as apposed to a similar group of trainee surgeons . In addition , multiple interventions were simultaneously instituted , making identification of a single influential factor impossible to identify . PRACTICAL IMPLICATION S Maximally safe and effective  cataract surgery training is achieved in Singapore without compromising service and quality markers . Similar training goals can be extrapolated to other surgical disciplines . ORIGINALITY/VALUE This is the first study to demonstrate maximally safe and effective cataract surgery training in a large patient group , over sustained periods The remarkable achievements of modern health care make the defi ciencies associated with delivery of care all the more noticeable . Health care is a major source of avoidable harm , and patients are routinely exposed to wide and inexplicable variations in the quality of care that they receive . These variations are very diffi cult to address , despite good intentions , policy focus , ambitious improvement programmes , and investment of re sources . A major reason for this diffi culty is that the urge to act can easily overwhelm the need for evidence to inform that action , to the extent that much quality improvement work is unscientifi c — it is neither informed by high- quality evidence , nor is it subject to rigorous assessment to establish its eff ectiveness , costs , and risks . Ironically , this absence of a scientifi c approach might lead to outcomes that are exactly the opposite of what is intended by improvement eff orts : re sources can be wasted , energy and enthusiasm are dissipated , the side-eff ects of interventions are ignored , and little positive change is evident . Adoption of a more scientifi c approach to improvement has great potential to enhance the ability of health systems to provide high- quality care and optimise re source use . We believe that the science of improvement is in what Kuhn calls the pre-paradigm phase of the emergence of a new discipline , one of the characteristics of which is the absence of an agreed defi nition . Attempts to create a defi nition can trigger intense debate , and the term improvement science has so far eluded consensus . Don Berwick and the Institute of Healthcare Improvement in Boston ( MA , USA ) have infl uenced one of the most common uses of this term , which is to describe applications of the approach developed by W Edwards Deming to reduce variation in industrial processes . The quality improvement move ment associated with these methods has made a valuable contribution , not least in challenging overly techno cratic , managerialist , or regulatory-focused approaches to change . However , this conceptualisation of a science of improvement is , by itself , too narrow and restrictive to address the challenges that face the health sector , and too often under-emphasises robust assessment . Percep tion of improvement solely in terms of imple mentation and comparative eff ectiveness research is similarly inadequate . An example of a benefi t of a broader way of thinking is the reduction of central line bloodstream infections in intensive-care units . These infections are a substantial and expensive clinical problem , and are often fatal . A cohort study of 103 intensive-care units in Michigan , USA , showed that a multicomponent programme of evidence -based technical interventions , adaptive interventions targeting culture and systems , and a central ised data collection and feedback system result ed in a substantial reduction in rates of these infections . These reductions were sustained over time and were associated with reduced mortality in participating intensive-care units compared with control units . The results have been replicated in 22 additional US states . Follow-up work investigated the mechanisms through which the programme worked , and generated a theory of change that could inform , and be tested in , subsequent repe titions of the programme . Another example of a benefi t of this broader way of thinking is the increase in identifi cation and referral of victims of domestic violence . Domestic violence is often managed inadequately , despite the major health and social implication s of unidentifi ed and unmanaged abuse . In a cluster-r and omised controlled trial in 51 primary care clinics in two UK cities ( London and Bristol ) , investigators tested a range of evidence -based interventions to increase rates of primary care identifi cation and referral to specialist advocacy services of women subjected to domestic violence . The results showed three-times more recorded disclosures of domestic violence and a 22-times higher number of referrals to specialist services in the intervention group . The interventions , in the form of targeted educational programmes , are now being adopted in several places in Engl and . These examples show some distinguishing features of a broader defi nition of improvement science . Improvement science aims to create practical learning that can make a timely diff erence to patient care . It is characterised by its large domain of interest , its applied nature , and its commitment to generation of practical learning that can be applied in real-life situations . Improvement science recognises and integrates many contributions , similar to the way that engineering science uses scientifi c knowledge and theories to address real-life problems . Improvement science also aims to generate local wisdom and generalisable or transferable knowledge , with robust , well established research methods applied in highly pragmatic ways . Improvement science enables local improvement and , crucially , produces knowledge with external validity . Thus , work classifi ed as improvement science should be of suffi cient quality to be published as a long-lasting , widely disseminated record in well-respected journals . Development of local knowledge based on a strong sense of ownership and a willingness to adapt improvement activities is clearly important , but too many quality improvement projects rely on contemporaneous , non-st and ardised , unverifi ed data to make judgments about their eff ectiveness . By contrast , the science of improvement is , based on moral and practical requirements , characterised by its commitment to rigorous and credible assessment methods Lancet 2013 ; 381 : The authors have developed a clinical pathway for the treatment of spinal cord injuries to help improve patient care . A clinical pathway for the treatment of patients with spinal cord injury was developed through a multidisciplinary approach . The control group ( group 1 ) consisted of patients who were treated in the 2 years before the initiation of the pathway .  Data from patients treated in conjunction with this pathway were collected prospect ively ( group 2 ) . Thirty-six patients were treated in conjunction with the pathway compared with 22 in the control group . Group 2 had 6.8 fewer intensive care unit days , 11.5 fewer hospital days , 6 fewer ventilator days ( p < 0.05 ) , and a lower rate of complications . The use of a clinical care pathway for spinal cord injuries has result ed in improved patient care and fewer complications BACKGROUND Adverse events in patients who have undergone surgery constitute a large proportion of iatrogenic illnesses . Most surgical safety interventions have focused on the operating room . Since more than half of all surgical errors occur outside the operating room , it is likely that a more substantial improvement in outcomes can be achieved by targeting the entire surgical pathway . METHODS We examined the effects on patient outcomes of a comprehensive , multidisciplinary surgical safety checklist , including items such as medication , marking of the operative side , and use of postoperative instructions . The checklist was implemented in six hospitals with high st and ards of care . All complications occurring during admission were documented prospect ively . We compared the rate of complications during a baseline period of 3 months with the rate during a 3-month period after implementation of the checklist , while accounting for potential confounders . Similar data were collected from a control group of five hospitals . RESULTS In a comparison of 3760 patients observed before implementation of the checklist with 3820 patients observed after implementation , the total number of complications per 100  patients  decreased from 27.3 ( 95 % confidence interval [ CI ] , 25.9 to 28.7 ) to 16.7 ( 95 % CI , 15.6 to 17.9 ) , for an absolute risk reduction of 10.6 ( 95 % CI , 8.7 to 12.4 ) . The proportion of patients with one or more complications decreased from 15.4 % to 10.6 % ( P<0.001 ) . In-hospital mortality decreased from 1.5 % ( 95 % CI , 1.2 to 2.0 ) to 0.8 % ( 95 % CI , 0.6 to 1.1 ) , for an absolute risk reduction of 0.7 percentage points ( 95 % CI , 0.2 to 1.2 ) . Outcomes did not change in the control hospitals . CONCLUSIONS Implementation of this comprehensive checklist was associated with a reduction in surgical complications and mortality in hospitals with a high st and ard of care . ( Netherl and s Trial Register number , NTR1943 . ) Abstract INTRODUCTION : In an era of dwindling hospital re sources and increasing medical costs , safe reduction in postoperative stay has become a major focus to optimize utilization of healthcare re sources . Although several protocol s have been reported to reduce postoperative stay , no Level I evidence exists for their use in routine clinical practice . METHODS : Sixty-four patients undergoing laparotomy and intestinal or rectal resection  were r and omly assigned to a pathway of controlled rehabilitation with early ambulation and diet or to traditional postoperative care .  Time to discharge from hospital , complication and readmission rates , pain level , quality of life , and patient satisfaction scores were determined at the time of discharge and at 10 and 30 days after surgery . Subgroups were defined to evaluate those who derived the optimal benefit from the protocol . RESULTS : Pathway patients spent less total time in the hospital after surgery ( 5.4 vs. 7.1 days ; P = 0.02 ) and less time in the hospital during the primary admission than traditional patients . Patients younger than 70 years old had greater benefits than the overall study group ( 5 vs. 7.1 days ; P = 0.01 ) . Patients treated by surgeons with the most experience with the pathway spent significantly less time in the hospital than did those whose surgeons were less experienced with the pathway ( P = 0.01 ) . There was no difference between pathway and traditional patients for readmission or complication rates , pain score , quality of life after surgery , or overall satisfaction with the hospital stay . CONCLUSIONS : Patients scheduled for a laparotomy and major intestinal or rectal resection  are suitable for management by a pathway of controlled rehabilitation with early ambulation and diet . Pathway patients have a shorter hospital stay , with no adverse effect on patient satisfaction , pain scores , or complication rates . Patients younger than 70 years of age derive the optimal benefit , and increased surgeon experience improves outcome Objective : A prospect i ve r and omized controlled trial ( RCT ) of multimodal perioperative management protocol in patients undergoing elective colorectal resection for cancer . Aims : This study evaluates the use of a multimodal package in colorectal cancer surgery in the context of an RCT . Methods : Patients for elective resection for colorectal cancer were offered trial entry . Participants were stratified by sex and requirement for a total mesorectal excision and central ly r and omized .  Multimodal patients received intravenous fluid restriction , unrestricted oral intake with prokinetic agents , early ambulation , and fixed regimen epidural analgesia . Control patients received intravenous fluids to prevent oliguria , restricted oral intake until return of bowel motility , and weaning regimen epidural analgesia . Adherence to both regimens was reinforced using a daily checklist and protocol guidance sheets . Discharge decision was made using preagreed criteria . The primary endpoint was postoperative stay , and achievement of independence milestones . Secondary endpoints were postoperative complications , readmission rates , and mortality . Analysis was by intention to treat . Results : Seventy patients were recruited . Approximately one fourth underwent TME . Median ages were similar ( 69.3 vs. 73.0 years ) . The median stay was significantly reduced in the multimodal group ( 5 vs. 7 days ; P < 0.001 , Mann-Whitney U test ) . Patients in the control arm were 2.5 times as likely to require a postoperative stay of more than 5 days . Patients in the multimodal group had less cardiorespiratory and anastomotic complications but more readmissions . There were 2 deaths , both controls . Conclusions : This RCT provides level 1b evidence that a multimodal management protocol can significantly reduce postoperative stay following colorectal cancer surgery . Morbidity and mortality are not increased CONTEXT The association of an  adult tele-intensive care unit ( ICU ) intervention  with hospital mortality , length of stay , best practice adherence , and preventable complications for an academic medical center has not been reported . OBJECTIVE To quantify the association of a tele-ICU intervention with hospital mortality , length of stay , and complications that are preventable by adherence to best practice s. DESIGN , SETTING , AND PATIENTS Prospect i ve stepped-wedge clinical practice study of 6290 adults admitted to any of 7 ICUs ( 3 medical , 3 surgical , and 1 mixed cardiovascular ) on 2 campuses of an 834-bed academic medical center that was performed from April 26 , 2005 , through September 30 , 2007 .  Electronically supported and monitored processes for best practice adherence , care plan creation , and clinician response times to alarms were evaluated . MAIN OUTCOME MEASURES Case-mix and severity-adjusted hospital mortality . Other outcomes included hospital and ICU length of stay , best practice adherence , and complication rates . RESULTS The hospital mortality rate was 13.6 % ( 95 % confidence interval [ CI ] , 11.9%-15.4 % ) during the preintervention period compared with 11.8 % ( 95 % CI , 10.9%-12.8 % ) during the tele-ICU intervention period ( adjusted odds ratio [ OR ] , 0.40 [ 95 % CI , 0.31 - 0.52 ] ) . The tele-ICU intervention period compared with the preintervention period was associated with higher rates of best clinical practice adherence for the prevention of deep vein thrombosis ( 99 % vs 85 % , respectively ; OR , 15.4 [ 95 % CI , 11.3 - 21.1 ] ) and prevention of stress ulcers ( 96 % vs 83 % , respectively ; OR , 4.57 [ 95 % CI , 3.91 - 5.77 ] , best practice adherence for cardiovascular protection ( 99 % vs 80 % , respectively ; OR , 30.7 [ 95 % CI , 19.3 - 49.2 ] ) , prevention of ventilator-associated pneumonia ( 52 % vs 33 % , respectively ; OR , 2.20 [ 95 % CI , 1.79 - 2.70 ] ) , lower rates of preventable complications ( 1.6 % vs 13 % , respectively , for ventilator-associated pneumonia [ OR , 0.15 ; 95 % CI , 0.09 - 0.23 ] and 0.6 % vs 1.0 % , respectively , for catheter-related bloodstream infection [ OR , 0.50 ; 95 % CI , 0.27 - 0.93 ] ) , and shorter hospital length of stay ( 9.8 vs 13.3 days , respectively ; hazard ratio for discharge , 1.44 [ 95 % CI , 1.33 - 1.56 ] ) . The results for medical , surgical , and cardiovascular ICUs were similar . CONCLUSION In a single academic medical center study , implementation of a tele-ICU intervention was associated with reduced adjusted odds of mortality and reduced hospital length of stay , as well as with changes in best practice adherence and lower rates of preventable complications
OBJECTIVE To perform a systematic review of interventions used to reduce adverse events in surgery .
BACKGROUND Many interventions , which aim to improve patient safety in surgery , have been introduced to hospitals .
Little is known about which methods provide a measurable decrease in morbidity and mortality .