JMIR perioperative medicine最新文献

Background: Osteoarthritis is a significant cause of disability, resulting in increased joint replacement surgeries and health care costs. Establishing benchmarks that more accurately predict surgical duration could help to decrease costs, maximize efficiency, and improve patient experience. We compared the anesthesia-controlled time (ACT) and surgery-controlled time (SCT) of primary total knee (TKA) and total hip arthroplasties (THA) between an academic medical center (AMC) and a community hospital (CH) for 2 orthopedic surgeons.

Objective: This study aims to validate and compare benchmarking times for ACT and SCT in a single patient population at both an AMC and a CH.

Methods: This retrospective 2-center observational cohort study was conducted at the University of Colorado Hospital (AMC) and UCHealth Broomfield Hospital (CH). Cases with current procedural terminology codes for THA and TKA between January 1, 2019, and December 31, 2020, were assessed. Cases with missing data were excluded. The primary outcomes were ACT and SCT. Primary outcomes were tested for association with covariates of interest. The primary covariate of interest was the location of the procedure (CH vs AMC); secondary covariates of interest included the American Society of Anesthesiologists (ASA) classification and anesthetic type. Linear regression models were used to assess the relationships.

Results: Two surgeons performed 1256 cases at the AMC and CH. A total of 10 THA cases and 12 TKA cases were excluded due to missing data. After controlling for surgeon, the ACT was greater at the AMC for THA by 3.77 minutes and for TKA by 3.58 minutes (P<.001). SCT was greater at the AMC for THA by 11.14 minutes and for TKA by 14.04 minutes (P<.001). ASA III/IV classification increased ACT for THA by 3.76 minutes (P<.001) and increased SCT for THA by 6.33 minutes after controlling for surgeon and location (P=.008). General anesthesia use was higher at the AMC for both THA (29.2% vs 7.3%) and TKA (23.8% vs 4.2%). No statistically significant association was observed between either ACT or SCT and anesthetic type (neuraxial or general) after adjusting for surgeon and location (all P>.05).

Conclusions: We observed lower ACT and SCT at the CH for both TKA and THA after controlling for the surgeon of record and ASA classification. These findings underscore the efficiency advantages of performing primary joint replacements at the CH, showcasing an average reduction of 16 minutes in SCT and 4 minutes in ACT per case. Overall, establishing more accurate benchmarks to improve the prediction of surgical duration for THA and TKA in different perioperative environments can increase the reliability of surgical duration predictions and optimize scheduling. Future studies with study populations at multiple community hospitals and academic medical centers are needed before extrapolating th

JMIR Perioperative Medicine supports the dissemination of technological and data science-driven innovative research conducted by interdisciplinary teams in perioperative medicine. We invite contributions on a broad range of topics from clinicians, scientists, and allied health professionals from across the globe.

Background: The Royal College of Surgeons Basic Surgical Skills (BSS) course is ubiquitous among UK surgical trainees but is geographically limited and costly. The COVID-19 pandemic has reduced training quality. Surveys illustrate reduced logbook completion and increased trainee attrition. Local, peer-led teaching has been shown to be effective at increasing confidence in surgical skills in a cost-effective manner. Qualitative data on trainee well-being, recruitment, and retention are lacking.

Objective: This study aims to evaluate the impact of a novel program of weekly, lunchtime BSS sessions on both quantitative and qualitative factors.

Methods: A weekly, lunchtime BSS course was designed to achieve the outcomes of the Royal College of Surgeons BSS course over a 16-week period overlapping with 1 foundation doctor rotation. All health care workers at the study center were eligible to participate. The study was advertised via the weekly, trust-wide information email. Course sessions included knot tying, suturing, abscess incision and drainage, fracture fixation with application of plaster of Paris, joint aspirations and reductions, abdominal wall closure, and basic laparoscopic skills. The hospital canteen sourced unwanted pig skin from the local butcher for suturing sessions and pork belly for abscess and abdominal wall closure sessions. Out-of-date surgical equipment was used. This concurrent, nested, mixed methods study involved descriptive analysis of perceived improvement scores in each surgical skill before and after each session, over 4 iterations of the course (May 2021 to August 2022). After the sessions, students completed a voluntary web-based feedback form scoring presession and postsession confidence levels on a 5-point Likert scale. Qualitative thematic analysis of voluntary semistructured student interview transcripts was also performed to understand the impact of a free-to-attend, local, weekly, near-peer teaching course on perceived well-being, quality of training, and interest in a surgical career. Students consented to the use of feedback and interview data for this study. Ethics approval was requested but deemed not necessary by the study center's ethics committee.

Results: There were 64 responses. Confidence was significantly improved from 47% to 73% (95% CI 15%-27%; P<.001; t₁₃=5.3117) across all surgical skills over 4 iterations. Among the 7 semistructured interviews, 100% (7/7) of the participants reported improved perceived well-being, value added to training, and positivity toward near-peer teaching and 71% (5/7) preferred local weekly teaching. Interest in a surgical career was unchanged.

Conclusions: This course was feasible around clinical workloads, resourced locally at next to no cost, environmentally sustainable, and free to attend. The course offered junior doctors not only a weekly opportuni

Background: The minimally invasive nature of thoracoscopic surgery is well recognized; however, the absence of a reliable evaluation method remains challenging. We hypothesized that the postoperative recovery speed is closely linked to surgical invasiveness, where recovery signifies the patient's behavior transition back to their preoperative state during the perioperative period.

Objective: This study aims to determine whether machine learning using triaxial acceleration data can effectively capture perioperative behavior changes and establish a quantitative index for quantifying variations in surgical invasiveness.

Methods: We trained 7 distinct machine learning models using a publicly available human acceleration data set as supervised data. The 3 top-performing models were selected to predict patient actions, as determined by the Matthews correlation coefficient scores. Two patients who underwent different levels of invasive thoracoscopic surgery were selected as participants. Acceleration data were collected via chest sensors for 8 hours during the preoperative and postoperative hospitalization days. These data were categorized into 4 actions (walking, standing, sitting, and lying down) using the selected models. The actions predicted by the model with intermediate results were adopted as the actions of the participants. The daily appearance probability was calculated for each action. The 2 differences between 2 appearance probabilities (sitting vs standing and lying down vs walking) were calculated using 2 coordinates on the x- and y-axes. A 2D vector composed of coordinate values was defined as the index of behavior pattern (iBP) for the day. All daily iBPs were graphed, and the enclosed area and distance between points were calculated and compared between participants to assess the relationship between changes in the indices and invasiveness.

Results: Patients 1 and 2 underwent lung lobectomy and incisional tumor biopsy, respectively. The selected predictive model was a light-gradient boosting model (mean Matthews correlation coefficient 0.98, SD 0.0027; accuracy: 0.98). The acceleration data yielded 548,466 points for patient 1 and 466,407 points for patient 2. The iBPs of patient 1 were [(0.32, 0.19), (-0.098, 0.46), (-0.15, 0.13), (-0.049, 0.22)] and those of patient 2 were [(0.55, 0.30), (0.77, 0.21), (0.60, 0.25), (0.61, 0.31)]. The enclosed areas were 0.077 and 0.0036 for patients 1 and 2, respectively. Notably, the distances for patient 1 were greater than those for patient 2 ({0.44, 0.46, 0.37, 0.26} vs {0.23, 0.0065, 0.059}; P=.03 [Mann-Whitney U test]).

Conclusions: The selected machine learning model effectively predicted the actions of the surgical patients with high accuracy. The temporal distribution of action times revealed changes in behavior patterns during the perioperative phase. The proposed index may facilit

Background: Enhanced recovery after surgery (ERAS) protocols are patient-centered, evidence-based guidelines for peri-, intra-, and postoperative management of surgical candidates that aim to decrease operative complications and facilitate recovery after surgery. Anesthesia providers can use these protocols to guide decision-making and standardize aspects of their anesthetic plan in the operating room.

Objective: Research across multiple disciplines has demonstrated that clinical decision support systems have the potential to improve protocol adherence by reminding providers about departmental policies and protocols via notifications. There remains a gap in the literature about whether clinical decision support systems can improve patient outcomes by improving anesthesia providers' adherence to protocols. Our hypothesis is that the implementation of an electronic notification system to anesthesia providers the day prior to scheduled breast surgeries will increase the use of the already existing but underused ERAS protocols.

Methods: This was a single-center prospective cohort study conducted between October 2017 and August 2018 at an urban academic medical center. After obtaining approval from the institutional review board, anesthesia providers assigned to major breast surgery cases were identified. Patient data were collected pre- and postimplementation of an electronic notification system that sent the anesthesia providers an email reminder of the ERAS breast protocol the night before scheduled surgeries. Each patient's record was then reviewed to assess the frequency of adherence to the various ERAS protocol elements.

Results: Implementation of an electronic notification significantly improved overall protocol adherence and several preoperative markers of ERAS protocol adherence. Protocol adherence increased from 16% (n=14) to 44% (n=44; P<.001), preoperative administration of oral gabapentin (600 mg) increased from 13% (n=11) to 43% (n=43; P<.001), and oral celebrex (400 mg) use increased from 16% (n=14) to 35% (n=35; P=.006). There were no statistically significant differences in the use of scopolamine transdermal patch (P=.05), ketamine (P=.35), and oral acetaminophen (P=.31) between the groups. Secondary outcomes such as intraoperative and postoperative morphine equivalent administered, postanesthesia care unit length of stay, postoperative pain scores, and incidence of postoperative nausea and vomiting did not show statistical significance.

Conclusions: This study examines whether sending automated notifications to anesthesia providers increases the use of ERAS protocols in a single academic medical center. Our analysis exhibited statistically significant increases in overall protocol adherence but failed to show significant differences in secondary outcome measures. Despite the lack of a statistically significant difference in

Background: More than 300 million patients undergo surgical procedures requiring anesthesia worldwide annually. There are 2 standard-of-care general anesthesia administration options: inhaled volatile anesthesia (INVA) and total intravenous anesthesia (TIVA). There is limited evidence comparing these methods and their impact on patient experiences and outcomes. Patients often seek this information from sources such as the internet. However, the majority of websites on anesthesia-related topics are not comprehensive, updated, and fully accurate. The quality and availability of web-based patient information about INVA and TIVA have not been sufficiently examined.

Objective: This study aimed to (1) assess information on the internet about INVA and TIVA for availability, readability, accuracy, and quality and (2) identify high-quality websites that can be recommended to patients to assist in their anesthesia information-seeking and decision-making.

Methods: Web-based searches were conducted using Google from April 2022 to November 2022. Websites were coded using a coding instrument developed based on the International Patient Decision Aids Standards criteria and adapted to be appropriate for assessing websites describing INVA and TIVA. Readability was calculated with the Flesch-Kincaid (F-K) grade level and the simple measure of Gobbledygook (SMOG) readability formula.

Results: A total of 67 websites containing 201 individual web pages were included for coding and analysis. Most of the websites provided a basic definition of general anesthesia (unconsciousness, n=57, 85%; analgesia, n=47, 70%). Around half of the websites described common side effects of general anesthesia, while fewer described the rare but serious adverse events, such as intraoperative awareness (n=31, 46%), allergic reactions or anaphylaxis (n=29, 43%), and malignant hyperthermia (n=18, 27%). Of the 67 websites, the median F-K grade level was 11.3 (IQR 9.5-12.8) and the median SMOG score was 13.5 (IQR 12.2-14.4), both far above the American Medical Association (AMA) recommended reading level of sixth grade. A total of 51 (76%) websites distinguished INVA versus TIVA as general anesthesia options. A total of 12 of the 51 (24%) websites explicitly stated that there is a decision to be considered about receiving INVA versus TIVA for general anesthesia. Only 10 (20%) websites made any direct comparisons between INVA and TIVA, discussing their positive and negative features. A total of 12 (24%) websites addressed the concept of shared decision-making in planning anesthesia care, but none specifically asked patients to think about which features of INVA and TIVA matter the most to them.

Conclusions: While the majority of websites described INVA and TIVA, few provided comparisons. There is a need for high-quality patient education and decision support about the choice of INVA v

Background: Although machine learning models demonstrate significant potential in predicting postoperative delirium, the advantages of their implementation in real-world settings remain unclear and require a comparison with conventional models in practical applications.

Objective: The objective of this study was to validate the temporal generalizability of decision tree ensemble and sparse linear regression models for predicting delirium after surgery compared with that of the traditional logistic regression model.

Methods: The health record data of patients hospitalized at an advanced emergency and critical care medical center in Kumamoto, Japan, were collected electronically. We developed a decision tree ensemble model using extreme gradient boosting (XGBoost) and a sparse linear regression model using least absolute shrinkage and selection operator (LASSO) regression. To evaluate the predictive performance of the model, we used the area under the receiver operating characteristic curve (AUROC) and the Matthews correlation coefficient (MCC) to measure discrimination and the slope and intercept of the regression between predicted and observed probabilities to measure calibration. The Brier score was evaluated as an overall performance metric. We included 11,863 consecutive patients who underwent surgery with general anesthesia between December 2017 and February 2022. The patients were divided into a derivation cohort before the COVID-19 pandemic and a validation cohort during the COVID-19 pandemic. Postoperative delirium was diagnosed according to the confusion assessment method.

Results: A total of 6497 patients (68.5, SD 14.4 years, women n=2627, 40.4%) were included in the derivation cohort, and 5366 patients (67.8, SD 14.6 years, women n=2105, 39.2%) were included in the validation cohort. Regarding discrimination, the XGBoost model (AUROC 0.87-0.90 and MCC 0.34-0.44) did not significantly outperform the LASSO model (AUROC 0.86-0.89 and MCC 0.34-0.41). The logistic regression model (AUROC 0.84-0.88, MCC 0.33-0.40, slope 1.01-1.19, intercept -0.16 to 0.06, and Brier score 0.06-0.07), with 8 predictors (age, intensive care unit, neurosurgery, emergency admission, anesthesia time, BMI, blood loss during surgery, and use of an ambulance) achieved good predictive performance.

Conclusions: The XGBoost model did not significantly outperform the LASSO model in predicting postoperative delirium. Furthermore, a parsimonious logistic model with a few important predictors achieved comparable performance to machine learning models in predicting postoperative delirium.

Background: Prescription opioid misuse risk is disproportionate among veterans; military veterans wounded in combat misuse prescription opioids at an even higher rate (46.2%). Opioid misuse is costly in terms of morbidity, mortality, and humanitarian and economic burden and costs the Civilian Health and Medical Program of the Department of Veterans Affairs more than US $1.13 billion annually. Preventing opioid misuse at the time of prescription is a critical component in the response to the opioid crisis. The CPMRx mobile app has been shown to decrease the odds of opioid misuse during the postoperative period.

Objective: The overarching purpose of this feasibility pilot study was to explore whether deploying a mobile app (CPMRx) to track postoperative pain and medication use is feasible in a Department of Veterans Affairs medical center. In support of this goal, we had four complementary specific aims: (1) determine the technological and logistical feasibility of the mobile app, (2) assess the acceptability of the mobile app to participants, (3) measure demand for and engagement with the mobile app, and (4) explore the potential use of the mobile app to patients and providers.

Methods: Participants (N=10) were veterans undergoing total knee arthroplasty within the Veterans Health Administration provided with the CPMRx app to self-manage their pain during their 7-day at-home recovery following surgery. CPMRx uses scientifically validated tools to help clinicians understand how a patient can use the least amount of medication while getting the most benefit. The suite of software includes a mobile app for patients that includes a behavioral health intervention and a clinical decision support tool for health care providers that provides feedback about pain and medication use trends. Patients filled out paper questionnaires regarding acceptability at their postoperative follow-up appointment.

Results: Overall, quantitative measures of acceptability were high. The average rating for the amount of time required to use the app was 4.9 of 5 (5="very little"), and the average rating for ease of use was 4.4 of 5 (5="very easy"). Open-ended questions also revealed that most participants found ease of use to be high. Demand and engagement were high as well with a mean number of mobile app entries of 34.1 (SD 20.1) during the postoperative period. There were no reported technological or logistical issues with the mobile app. Participants took an average of 25.13 (SD 14.37) opioid tablets to manage their postoperative pain.

Conclusions: Results of this study revealed that the use of a mobile app for pain and medication management during postoperative recovery was both feasible and acceptable in older veterans undergoing total knee arthroplasty within the Veterans Health Administration. The wide variation in opioid consumption across participants revea

Background: Anesthesiologists require an understanding of their patients' outcomes to evaluate their performance and improve their practice. Traditionally, anesthesiologists had limited information about their surgical outpatients' outcomes due to minimal contact post discharge. Leveraging digital health innovations for analyzing personal and population outcomes may improve perioperative care. BC Children's Hospital's postoperative follow-up registry for outpatient surgeries collects short-term outcomes such as pain, nausea, and vomiting. Yet, these data were previously not available to anesthesiologists.

Objective: This quality improvement study aimed to visualize postoperative outcome data to allow anesthesiologists to reflect on their care and compare their performance with their peers.

Methods: The postoperative follow-up registry contains nurse-reported postoperative outcomes, including opioid and antiemetic administration in the postanesthetic care unit (PACU), and family-reported outcomes, including pain, nausea, and vomiting, within 24 hours post discharge. Dashboards were iteratively co-designed with 5 anesthesiologists, and a department-wide usability survey gathered anesthesiologists' feedback on the dashboards, allowing further design improvements. A final dashboard version has been deployed, with data updated weekly.

Results: The dashboard contains three sections: (1) 24-hour outcomes, (2) PACU outcomes, and (3) a practice profile containing individual anesthesiologist's case mix, grouped by age groups, sex, and surgical service. At the time of evaluation, the dashboard included 24-hour data from 7877 cases collected from September 2020 to February 2023 and PACU data from 8716 cases collected from April 2021 to February 2023. The co-design process and usability evaluation indicated that anesthesiologists preferred simpler designs for data summaries but also required the ability to explore details of specific outcomes and cases if needed. Anesthesiologists considered security and confidentiality to be key features of the design and most deemed the dashboard information useful and potentially beneficial for their practice.

Conclusions: We designed and deployed a dynamic, personalized dashboard for anesthesiologists to review their outpatients' short-term postoperative outcomes. This dashboard facilitates personal reflection on individual practice in the context of peer and departmental performance and, hence, the opportunity to evaluate iterative practice changes. Further work is required to establish their effect on improving individual and department performance and patient outcomes.

Background: Wireless vital sign sensors are increasingly being used to monitor patients on surgical wards. Although early warning scores (EWSs) are the current standard for the identification of patient deterioration in a ward setting, their usefulness for continuous monitoring is unknown.

Objective: This study aimed to explore the usability and predictive value of high-rate EWSs obtained from continuous vital sign recordings for early identification of postoperative complications and compares the performance of a sensor-based EWS alarm system with manual intermittent EWS measurements and threshold alarms applied to individual vital sign recordings (single-parameter alarms).

Methods: Continuous vital sign measurements (heart rate, respiratory rate, blood oxygen saturation, and axillary temperature) collected with wireless sensors in patients on surgical wards were used for retrospective simulation of EWSs (sensor EWSs) for different time windows (1-240 min), adopting criteria similar to EWSs based on manual vital signs measurements (nurse EWSs). Hourly sensor EWS measurements were compared between patients with (event group: 14/46, 30%) and without (control group: 32/46, 70%) postoperative complications. In addition, alarms were simulated for the sensor EWSs using a range of alarm thresholds (1-9) and compared with alarms based on nurse EWSs and single-parameter alarms. Alarm performance was evaluated using the sensitivity to predict complications within 24 hours, daily alarm rate, and false discovery rate (FDR).

Results: The hourly sensor EWSs of the event group (median 3.4, IQR 3.1-4.1) was significantly higher (P<.004) compared with the control group (median 2.8, IQR 2.4-3.2). The alarm sensitivity of the hourly sensor EWSs was the highest (80%-67%) for thresholds of 3 to 5, which was associated with alarm rates of 2 (FDR=85%) to 1.2 (FDR=83%) alarms per patient per day respectively. The sensitivity of sensor EWS-based alarms was higher than that of nurse EWS-based alarms (maximum=40%) but lower than that of single-parameter alarms (87%) for all thresholds. In contrast, the (false) alarm rates of sensor EWS-based alarms were higher than that of nurse EWS-based alarms (maximum=0.6 alarm/patient/d; FDR=80%) but lower than that of single-parameter alarms (2 alarms/patient/d; FDR=84%) for most thresholds. Alarm rates for sensor EWSs increased for shorter time windows, reaching 70 alarms per patient per day when calculated every minute.

Conclusions: EWSs obtained using wireless vital sign sensors may contribute to the early recognition of postoperative complications in a ward setting, with higher alarm sensitivity compared with manual EWS measurements. Although hourly sensor EWSs provide fewer alarms compared with single-parameter alarms, high false alarm rates can be expected when calculated over shorter time spans. Further studies are r