JMIR perioperative medicine最新文献

Background: Day surgery is being increasingly implemented across Europe, driven in part by capacity problems. Patients recovering at home could benefit from tools tailored to their new care setting to effectively manage their convalescence. The mHealth application ikHerstel is one such tool, but although it administers its functions in the home, its implementation hinges on health care professionals within the hospital.

Objective: We conducted a feasibility study of an additional patient-oriented implementation strategy for ikHerstel. This strategy aimed to empower patients to access and use ikHerstel independently, in contrast to implementation as usual, which hinges on the health care professional acting as gatekeeper. Our research question was "How well are patients able to use ikHerstel independently of their health care professional?"

Methods: We investigated the implementation strategy in terms of its recruitment, reach, dose delivered, dose received, and fidelity. Patients with a recent or prospective elective surgery were recruited using a wide array of materials to simulate patient-oriented dissemination of ikHerstel. Data were collected through web-based surveys. Descriptive analysis and open coding were used to analyze the data.

Results: Recruitment yielded 213 registrations, with 55 patients ultimately included in the study. The sample was characterized by patients undergoing abdominal surgery, with high literacy and above average digital health literacy, and included an overrepresentation of women (48/55, 87%). The implementation strategy had a reach of 81% (63/78), with 87% (55/67) of patients creating a recovery plan. Patients were satisfied with their independent use of ikHerstel, rating it an average 7.0 (SD 1.9) of 10, and 54% (29/54) of patients explicitly reported no difficulties in using it. A major concern of the implementation strategy was conflicts in recommendations between ikHerstel and the health care professionals, as well as the resulting feelings of insecurity experienced by patients.

Conclusions: In this small feasibility study, most patients were satisfied with the patient-oriented implementation strategy. However, the lack of involvement of health care professionals due to the strategy contributed to patient concerns regarding conflicting recommendations between ikHerstel and health care professionals.

Background: Postoperative delirium (POD) is a common complication after major surgery and is associated with poor outcomes in older adults. Early identification of patients at high risk of POD can enable targeted prevention efforts. However, existing POD prediction models require inpatient data collected during the hospital stay, which delays predictions and limits scalability.

Objective: This study aimed to develop and externally validate a machine learning-based prediction model for POD using routine electronic health record (EHR) data.

Methods: We identified all surgical encounters from 2014 to 2021 for patients aged 50 years and older who underwent an operation requiring general anesthesia, with a length of stay of at least 1 day at 3 Indiana hospitals. Patients with preexisting dementia or mild cognitive impairment were excluded. POD was identified using Confusion Assessment Method records and delirium International Classification of Diseases (ICD) codes. Controls without delirium or nurse-documented confusion were matched to cases by age, sex, race, and year of admission. We trained logistic regression, random forest, extreme gradient boosting (XGB), and neural network models to predict POD using 143 features derived from routine EHR data available at the time of hospital admission. Separate models were developed for each hospital using surveillance periods of 3 months, 6 months, and 1 year before admission. Model performance was evaluated using the area under the receiver operating characteristic curve (AUROC). Each model was internally validated using holdout data and externally validated using data from the other 2 hospitals. Calibration was assessed using calibration curves.

Results: The study cohort included 7167 delirium cases and 7167 matched controls. XGB outperformed all other classifiers. AUROCs were highest for XGB models trained on 12 months of preadmission data. The best-performing XGB model achieved a mean AUROC of 0.79 (SD 0.01) on the holdout set, which decreased to 0.69-0.74 (SD 0.02) when externally validated on data from other hospitals.

Conclusions: Our routine EHR-based POD prediction models demonstrated good predictive ability using a limited set of preadmission and surgical variables, though their generalizability was limited. The proposed models could be used as a scalable, automated screening tool to identify patients at high risk of POD at the time of hospital admission.

Unstructured: Background: Precise functional capacity assessment is a critical component for preoperative risk stratification. Brief submaximal cardiopulmonary exercise testing (smCPET) has shown diagnostic utility in various cardiopulmonary conditions. Objective: The objective of this study was to determine if smCPET could be implemented in a high-volume pre-surgical evaluation clinic, and, when compared to structured functional capacity surveys, if smCPET could better discriminate low functional capacity (<4.6 METs). Measured endpoints were: operational efficiency by time of experimental session < 20 minutes, modified Borg survey of perceived exertion of <7 indicating no more than moderate exertion, high participant satisfaction with smCPET task execution, represented as a score of >8 (of 10), and high participant satisfaction with smCPET scheduling, represented as a score of >8 (of 10). Methods: After institutional approval, 43 participants presenting for noncardiac surgery who met the following inclusion criteria: age > 60 years old, revised cardiac risk index of <2, and self-reported metabolic equivalents (METs) of >4.6 (self-endorsed ability to climb 2 flights of stairs), were enrolled. Subjective METs, Duke Activity Status Index (DASI) surveys, and a 6-minute smCPET trial were performed. Student's t test was used to determine significance of the secondary endpoint. Correlation between comparable structured survey and smCPET measurements were assessed using Pearson's correlation coefficient. A Bland-Altman analysis was used to assess agreement between methods. Results: Session time was 16.9 minutes (±6.8). Post-test modified Borg survey was 5.35 (±1.8). Median (IQR) patient satisfaction [on a scale of 1 (worst) to 10 (best)] was 10 (10,10) for scheduling and 10 (9, 10) for task performance. Subjective METs were higher, when compared to smCPET equivalent (extrapolated peak METs) [7.6 (±2.0) vs. 6.7 (±1.8), df 42, P<.001]. DASI-estimated peak METs was higher when compared to smCPET peak METs [8.8 (±1.2) vs. 6.7 (±1.8), df 42, P<.001]. DASI-estimated peak VO2 was higher than smCPET peak VO2 [30.9 ml.kg-1.min-1 (±4.3) vs. 23.6 ml.kg-1.min-1 (±6.5), df 42, P<.001]. Conclusions: Implementation of smCPET in a pre-surgical evaluation clinic is both patient-centered and clinically feasible. Brief smCPET measures, supportive of published reports regarding low sensitivity of provider-driven or structured survey measures for low functional capacity, were lower than structured surveys. Future studies will analyze prediction of perioperative complications and cost effectiveness. Trial Registration: ClinicalTrials.gov NCT05743673. https://clinicaltrials.gov/study/NCT05743673.

Background: In Canada, the health care system has been estimated to generate 33 million metric tons of greenhouse gas emissions annually. Health care systems, specifically operating rooms (ORs), are significant contributors to greenhouse gas emissions, using 3 to 6 times more energy than the hospital's average unit.

Objective: This quality improvement study aimed to investigate the knowledge, attitudes, and perceptions of staff members and patients on sustainability in the OR, as well as identify opportunities for initiatives and barriers to implementation.

Methods: A total of 2 surveys were developed, consisting of 27 questions for staff members and 22 questions for patients and caregivers. Topics included demographics, knowledge and attitudes regarding environmental sustainability, opportunities for initiatives, and perceived barriers. Multiple-choice, Likert-scale, and open-ended questions were used.

Results: A total of 174 staff members and 37 patients participated. The majority (152/174, 88%) of staff members had received no and minimal training on sustainability, while 93% (162/174) cited practicing sustainability at work as moderately to extremely important. Among patients and caregivers, 54% (20/37) often or always noticed when a hospital is being eco-friendly. Both staff members and patients agreed that improving sustainability would boost satisfaction (125/174, 71.8% and 22/37, 59.4%, respectively) and hospital reputation (22/37, 59.4% and 25/37, 69.5%, respectively). The staff members' highest-rated environmental initiatives included transitioning to reusables, education, and improved energy consumption, while patients prioritized increased nature, improved food sourcing, and education. Perceived barriers to these initiatives included cost, lack of education, and lack of incentives.

Conclusions: Staff members and patients and caregivers in a large academic health care center acknowledge the significance of environmental sustainability in the OR. While they do not perceive a direct impact on patient care, they anticipate positive effects on satisfaction and hospital reputation. Aligning initiatives with staff members and patient and caregiver preferences can help drive meaningful change within the OR and beyond.

Background: At present, parents lack objective methods to evaluate their child's postoperative recovery following discharge from the hospital. As a result, clinicians are dependent upon a parent's subjective assessment of the child's health status and the child's ability to communicate their symptoms. This subjective nature of home monitoring contributes to unnecessary emergency department (ED) use as well as delays in treatment. However, the integration of data remotely collected using a consumer wearable device has the potential to provide clinicians with objective metrics for postoperative patients to facilitate informed longitudinal, remote assessment.

Objective: This multi-institutional study aimed to evaluate the impact of adding actual and simulated objective recovery data that were collected remotely using a consumer wearable device to simulated postoperative telephone encounters on clinicians' management.

Methods: In total, 3 simulated telephone scenarios of patients after an appendectomy were presented to clinicians at 5 children's hospitals. Each scenario was then supplemented with wearable data concerning or reassuring against a postoperative complication. Clinicians rated their likelihood of ED referral before and after the addition of wearable data to evaluate if it changed their recommendation. Clinicians reported confidence in their decision-making.

Results: In total, 34 clinicians participated. Compared with the scenario alone, the addition of reassuring wearable data resulted in a decreased likelihood of ED referral for all 3 scenarios (P<.01). When presented with concerning wearable data, there was an increased likelihood of ED referral for 1 of 3 scenarios (P=.72, P=.17, and P<.001). At the institutional level, there was no difference between the 5 institutions in how the wearable data changed the likelihood of ED referral for all 3 scenarios. With the addition of wearable data, 76% (19/25) to 88% (21/24 and 22/25) of clinicians reported increased confidence in their recommendations.

Conclusions: The addition of wearable data to simulated telephone scenarios for postdischarge patients who underwent pediatric surgery impacted clinicians' remote patient management at 5 pediatric institutions and increased clinician confidence. Wearable devices are capable of providing real-time measures of recovery, which can be used as a postoperative monitoring tool to reduce delays in care and avoidable health care use.

The journey of receiving blood as a patient with transfusion-dependent beta thalassemia has profoundly shaped my understanding of the life-saving power of blood donation. This personal experience underscores the critical importance of blood donors, not just for individual recipients but for the broader community, enhancing public health, productivity, and well-being. There are several challenges to securing a blood donor pool in current health care climate. Solutions that focus on the engagement of donors, clinicians, and patients are key to improving the donor pool and utilizing the blood supply in a judicious manner.

Background: Biofeedback-based virtual reality (VR-BF) is a novel, nonpharmacologic method for teaching patients how to control their breathing, which in turn increases heart rate variability (HRV) and may reduce pain. Unlike traditional forms of biofeedback, VR-BF is delivered through a gamified virtual reality environment, increasing the accessibility of biofeedback. This is the first study to systematically integrate VR-BF use in the pediatric perioperative setting, with the ultimate goal of evaluating the efficacy of VR-BF to reduce pain, anxiety, and opioid consumption once feasibility and acceptability have been established.

Objectives: The primary objective was to develop a clinical trial protocol for VR-BF use in the pediatric perioperative setting, including preoperative education and training, and postoperative application of VR-BF in children undergoing surgery. A secondary objective was to evaluate the patient and parent experience with VR-BF.

Methods: A total of 23 patients (12-18 years of age) scheduled for surgery at Nationwide Children's Hospital were recruited using purposive sampling. Following training, participants independently completed a daily, 10-minute VR-BF session for 7 days before surgery and during their inpatient stay. Participants could use VR-BF up to 2 weeks after hospital discharge. Patient- and session-level data of VR-BF usage and achievement of target HRV parameters were measured to identify the optimal frequency and duration of sessions before and after surgery for this population. Standardized questionnaires and semistructured interviews were conducted to obtain qualitative information about patients' experiences with VR-BF.

Results: Patient-level data indicated that the highest odds of achieving 1 session under target HRV parameters was after 4 sessions (odds ratio [OR] 5.1 for 4 vs 3 sessions, 95% CI 1.3-20.6; OR 16.6 for 3 vs 2 sessions, 95% CI 1.2-217.0). Session-level data showed that a session duration of 9 to 10 minutes provided the greatest odds of achieving 1 session under target HRV parameters (OR 1.3 for 9 vs 8 min, 95% CI 1.1-1.7; OR 1.4 for 8 vs 7 min, 95% CI 1.1-1.8; OR 1 for 10 vs 9 min, 95% CI 0.9-1.2). Qualitative data revealed patient satisfaction with the VR-BF technology, particularly in managing perioperative stress (17/20, 85%). Few patients reported VR-BF as beneficial for pain (8/20, 40%).

Conclusions: Children and adolescents undergoing surgery successfully learned behavioral strategies with VR-BF with 10-minute sessions once daily for 5 days. To integrate VR-BF as a therapeutic intervention in a subsequent clinical trial, patients will be instructed to complete three 10-minute sessions a day for 7 days after surgery.

Trial registration: ClinicalTrials NCT04943874; https://clinicaltrials.gov/ct2/show/NCT04943874.

Background: Preoperative cardiac risk assessment is an integral part of preoperative evaluation; however, there is significant variation among providers, leading to inappropriate referrals for cardiology consultation or excessive low-value cardiac testing. We implemented a novel electronic medical record (EMR) form in our preoperative clinics to decrease variation.

Objective: This study aimed to investigate the impact of the EMR form on the preoperative utilization of cardiology consultation and cardiac diagnostic testing (echocardiograms, stress tests, and cardiac catheterization) and evaluate postoperative outcomes.

Methods: A retrospective cohort study was conducted. Patients who underwent outpatient preoperative evaluation prior to an elective surgery over 2 years were divided into 2 cohorts: from July 1, 2021, to June 30, 2022 (pre-EMR form implementation), and from July 1, 2022, to June 30, 2023 (post-EMR form implementation). Demographics, comorbidities, resource utilization, and surgical characteristics were analyzed. Propensity score matching was used to adjust for differences between the 2 cohorts. The primary outcomes were the utilization of preoperative cardiology consultation, cardiac testing, and 30-day postoperative major adverse cardiac events (MACE).

Results: A total of 25,484 patients met the inclusion criteria. Propensity score matching yielded 11,645 well-matched pairs. The post-EMR form, matched cohort had lower cardiology consultation (pre-EMR form: n=2698, 23.2% vs post-EMR form: n=2088, 17.9%; P<.001) and echocardiogram (pre-EMR form: n=808, 6.9% vs post-EMR form: n=591, 5.1%; P<.001) utilization. There were no significant differences in the 30-day postoperative outcomes, including MACE (all P>.05). While patients with "possible indications" for cardiology consultation had higher MACE rates, the consultations did not reduce MACE risk. Most algorithm end points, except for active cardiac conditions, had MACE rates <1%.

Conclusions: In this cohort study, preoperative cardiac risk assessment using a novel EMR form was associated with a significant decrease in cardiology consultation and testing utilization, with no adverse impact on postoperative outcomes. Adopting this approach may assist perioperative medicine clinicians and anesthesiologists in efficiently decreasing unnecessary preoperative resource utilization without compromising patient safety or quality of care.