Colin J.L. McCartney discusses regional anesthesia within enhanced recovery pathways. While regional anesthesia is included in many enhanced recovery protocols, its use has faced barriers. A review found regional anesthesia improved pain control, organ function, and outcomes like length of stay. However, there was little focus on outcomes related to the triple aim of healthcare. For regional anesthesia to be fully supported, more research is needed on triple aim outcomes in non-colorectal surgeries and how barriers to regional anesthesia can be addressed.
Enhanced recovery care pathways: a better journey for patients seven days a week and a better deal for the NHS - presentation from the Health and Care Innovation Expo 2014 - Sue Cottle, Amy Kerr and Neil Betteridge
Using Enhanced Recovery After Surgery (ERAS) to Enhance Postoperative OutcomesWellbe
Speaker: Francesco Carli, MD, MPhil, senior staff anesthesiologist at the McGill University Health Centre
Cost: Complimentary, sponsored by Wellbe
There is strong evidence that many of aspects of surgical care have little evidence, and therefore the Enhanced Recovery After Surgery (ERAS) program has been set up to accelerate the recovery process and decrease the rate of postoperative complications. There is an opportunity to improve outcomes by using team approach and revision of the standard procedures.
Learn about:
– The elements of ERAS protocols
– How to structure the Team approach
– The role of the patient in ERAS
– How to perform an audit of your program
About the Speaker:
Francesco Carli, MD, MPhil, is Professor of Anesthesia at McGill University and Associate Professor in the School of Dietetics and Human Nutrition at McGill University and a senior staff anesthesiologist at the McGill University Health Centre. He is currently an Elected Member of the American Academy of Anesthesia and a Board Member of the Enhanced Recovery After Surgery (ERAS) Society. Dr. Carli completed his medical training and anesthesia training in Turin, Italy, Paris, France, and London, England. He completed a Master’s Degree in surgical metabolism at the University of London, England.
His research interests are: metabolic changes associated with surgery and the impact of perioperative interventions (regional analgesia, nutrition, hormones, exercise) on postoperative recovery; evaluation of functional outcome measures during the surgical recovery process; prehabilitation of surgical patients. He is the author of over 250 peer-review scientific articles and has been a recipient of over 50 peer and non peer-review grants.
Enhanced recovery care pathways: a better journey for patients seven days a week and a better deal for the NHS - presentation from the Health and Care Innovation Expo 2014 - Sue Cottle, Amy Kerr and Neil Betteridge
Using Enhanced Recovery After Surgery (ERAS) to Enhance Postoperative OutcomesWellbe
Speaker: Francesco Carli, MD, MPhil, senior staff anesthesiologist at the McGill University Health Centre
Cost: Complimentary, sponsored by Wellbe
There is strong evidence that many of aspects of surgical care have little evidence, and therefore the Enhanced Recovery After Surgery (ERAS) program has been set up to accelerate the recovery process and decrease the rate of postoperative complications. There is an opportunity to improve outcomes by using team approach and revision of the standard procedures.
Learn about:
– The elements of ERAS protocols
– How to structure the Team approach
– The role of the patient in ERAS
– How to perform an audit of your program
About the Speaker:
Francesco Carli, MD, MPhil, is Professor of Anesthesia at McGill University and Associate Professor in the School of Dietetics and Human Nutrition at McGill University and a senior staff anesthesiologist at the McGill University Health Centre. He is currently an Elected Member of the American Academy of Anesthesia and a Board Member of the Enhanced Recovery After Surgery (ERAS) Society. Dr. Carli completed his medical training and anesthesia training in Turin, Italy, Paris, France, and London, England. He completed a Master’s Degree in surgical metabolism at the University of London, England.
His research interests are: metabolic changes associated with surgery and the impact of perioperative interventions (regional analgesia, nutrition, hormones, exercise) on postoperative recovery; evaluation of functional outcome measures during the surgical recovery process; prehabilitation of surgical patients. He is the author of over 250 peer-review scientific articles and has been a recipient of over 50 peer and non peer-review grants.
A talk by Olle Ljungqvist at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine.
All available content from SSAI2017: https://scanfoam.org/ssai2017/
Delivered in collaboration between scanFOAM, SSAI & SFAI.
Enhanced Recovery After Surgery (ERAS®) is the Enhanced Recovery After Surgery (ERAS®) is the implementation of patient-focused, standardized, evidencefocused, standardized, evidencefocused, standardized, evidencefocused, standardized, evidencefocused, standardized, evidencefocused, standardized, evidence-based, interdisciplinary perioperative guidelines.
Learn more about Enhanced Recovery Canada:
http://ow.ly/hR3j30jsnjR
Enhanced Recovery after Surgery its relevance - Evidence BasedDeep Goel
Enhanced recovery programs are evidence-based protocols designed to standardize medical care, improve outcomes, and lower health care costs. These protocols include evidence-based techniques to minimize surgical trauma and postoperative pain, reduce complications, improve outcomes, and decrease hospital length of stay, while expediting recovery following elective procedures.Protocols have been developed for colorectal surgery patients to reduce physiological stress and postoperative organ dysfunction through optimization of perioperative care and recovery
Fast Track surgery from the orthopedic point of view
How to apply FTS in orthopedics specially in Arthroplasty surgery. Evidence based practice in orthopedics
Regional Anesthesia and Bundled Payments – Opioid-sparing Pain Management for...Wellbe
Speaker: Sonia Szlyk, MD, Director of Regional Anesthesia, Mid-Atlantic Division, North American Partners in Anesthesia
This webinar will:
-Discuss Enhanced Recovery After Surgery (ERAS) protocols for joint replacement
-Review the positive impact of regional anesthesia throughout the episode of care
-Spotlight the key components of successful value-based orthopedic care – length of stay, discharge to home, patient and surgeon satisfaction
About the Speaker:
Sonia Szlyk, MD, is the Director of Regional Anesthesia for North American Partners in Anesthesia’s Mid-Atlantic division. Dr. Szlyk orchestrates an outcomes-based regional anesthesia service focused on patient and surgeon satisfaction, safety, and efficiency. She oversees regional anesthesia quality metrics, billing compliance, strategic growth, and education. Dr. Szlyk specializes in opioid-sparing ERAS protocols for joint replacement, sports medicine, colorectal, general, and cosmetic surgery. Her initiatives highlight the value of regional anesthesia in the evolving era of bundled payments.
Dr. Szlyk served as the Director of Regional Anesthesia at the Ambulatory Surgery Center of Bethesda, MD where she oversaw the design and implementation of anesthesia services as well as AAAHC accreditation. The center’s comprehensive pain management program included ultrasound-guided peripheral nerve blocks and catheters for outpatient knee and hip replacements, and sports medicine procedures.
Dr. Szlyk is a board-certified anesthesiologist. She completed medical school and anesthesia residency at the George Washington University School of Medicine and was a Clinical Instructor in regional anesthesia at Stanford University Hospital.
A talk by Olle Ljungqvist at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine.
All available content from SSAI2017: https://scanfoam.org/ssai2017/
Delivered in collaboration between scanFOAM, SSAI & SFAI.
Enhanced Recovery After Surgery (ERAS®) is the Enhanced Recovery After Surgery (ERAS®) is the implementation of patient-focused, standardized, evidencefocused, standardized, evidencefocused, standardized, evidencefocused, standardized, evidencefocused, standardized, evidencefocused, standardized, evidence-based, interdisciplinary perioperative guidelines.
Learn more about Enhanced Recovery Canada:
http://ow.ly/hR3j30jsnjR
Enhanced Recovery after Surgery its relevance - Evidence BasedDeep Goel
Enhanced recovery programs are evidence-based protocols designed to standardize medical care, improve outcomes, and lower health care costs. These protocols include evidence-based techniques to minimize surgical trauma and postoperative pain, reduce complications, improve outcomes, and decrease hospital length of stay, while expediting recovery following elective procedures.Protocols have been developed for colorectal surgery patients to reduce physiological stress and postoperative organ dysfunction through optimization of perioperative care and recovery
Fast Track surgery from the orthopedic point of view
How to apply FTS in orthopedics specially in Arthroplasty surgery. Evidence based practice in orthopedics
Regional Anesthesia and Bundled Payments – Opioid-sparing Pain Management for...Wellbe
Speaker: Sonia Szlyk, MD, Director of Regional Anesthesia, Mid-Atlantic Division, North American Partners in Anesthesia
This webinar will:
-Discuss Enhanced Recovery After Surgery (ERAS) protocols for joint replacement
-Review the positive impact of regional anesthesia throughout the episode of care
-Spotlight the key components of successful value-based orthopedic care – length of stay, discharge to home, patient and surgeon satisfaction
About the Speaker:
Sonia Szlyk, MD, is the Director of Regional Anesthesia for North American Partners in Anesthesia’s Mid-Atlantic division. Dr. Szlyk orchestrates an outcomes-based regional anesthesia service focused on patient and surgeon satisfaction, safety, and efficiency. She oversees regional anesthesia quality metrics, billing compliance, strategic growth, and education. Dr. Szlyk specializes in opioid-sparing ERAS protocols for joint replacement, sports medicine, colorectal, general, and cosmetic surgery. Her initiatives highlight the value of regional anesthesia in the evolving era of bundled payments.
Dr. Szlyk served as the Director of Regional Anesthesia at the Ambulatory Surgery Center of Bethesda, MD where she oversaw the design and implementation of anesthesia services as well as AAAHC accreditation. The center’s comprehensive pain management program included ultrasound-guided peripheral nerve blocks and catheters for outpatient knee and hip replacements, and sports medicine procedures.
Dr. Szlyk is a board-certified anesthesiologist. She completed medical school and anesthesia residency at the George Washington University School of Medicine and was a Clinical Instructor in regional anesthesia at Stanford University Hospital.
i prepared this presentation for our hospital monthly clinicopathological conference. our experience with TKR is not so vast but v are satisfied with what v have done till date.
El protocolo multimodal ERAS busca optimizar la atención con la calidad, y disminuir los costos hospitalarios logrando una adecuada satisfacción del usuario. Preconiza que mejora de los procesos de atención y buenas prácticas gerenciales.
The Clinical Pharmacist in Cardiac Rehabilitation Phase I at Sarawak General ...guestaf1e4
A Health Related Quality of Life Study in Patients with Acute Coronary Syndromes: The Cost-Effectiveness of Clinical Pharmacy Service in the Phase I, and Short Course Phase II Cardiac Rehabilitation Program
Authors of proposal: 1, 2 Professor Dr. Sim Kui Hian, 4 Professor Dr. Mohd. Izham Mohd Ibrahim, 1, 2 Dr. Alan Fong Yean Yip, 3 Yanti Nasyuhana Sani, 3 Tiong Lee Len, 3 Bibi Faridha Mohd Salleh, 4 Dr Mohd. Azmi Ahmad Hassali, 4 Prof. Dr Yahaya Hassan, 3 Lawrence Anchah, 5 Karen Tang Siew Lang, 1 Hii Ai Ching,1 Sii Lik Ngoh
1 Dept of Cardiology, Sarawak General Hospital.
2 Clinical Research Centre, Sarawak General Hospital.
3 Dept of Pharmacy, Sarawak General Hospital.
4 School Pharmaceutical Sciences, Universiti Sains Malaysia.
5 Dept of Physiotherapy, Sarawak General Hospital.
NIH Reference No.: (4) dlm.KKM/NIHSEC/08/0804/P07-161, dated 3rd September 2007
Completed 20th Dec 2009
Researcher: Lawrence Anak Ancah, B. Pharm, M. Clinical Pharm, Candidate for Ph.D Cinical Pharmacy in Cardiovascular & HRQoL
American Public Health Association- Annual Meeting 2014 Presentation scherala
Title: Using Quantitative Data to focus Medical Home Facilitation Interventions in the Massachusetts Patient Centered Medical Home Initiative (MA PCMHI)
Nursing Evidence Based Practice PPT for BSN Nurses.
This ppt assess effectiveness of using NPWT for DFUs with providing highest level of evidence. DFUs are a prevalent issue in many countries and is treated via dressings which take a long time to heal but utilizing this method will certainly make the recovery faster.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
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We specializes in exporting high quality Research chemical, medical intermediate, Pharmaceutical chemicals and so on. Products are exported to USA, Canada, France, Korea, Japan,Russia, Southeast Asia and other countries.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Ocular injury ppt Upendra pal optometrist upums saifai etawah
ERAS and regional anesthesia at PGA 2015
1. Colin J.L. McCartney
MBChB PhD FCARCSI FRCA FRCPC
Professor and Chair of Anesthesiology
University of Ottawa
Head of Anesthesiology
The Ottawa Hospital
Scientist,
Ottawa Hospital Research Institute
Enhanced Recovery and Regional
Anesthesia:
Do we need regional?
2. Conflicts of Interest
Consultant for Teleflex Medical
I will not be discussing off-label or
investigative uses of commercial
devices
3. Objectives
Describe the place of enhanced recovery
in perioperative care
Learn the place of regional anesthesia in
enhanced recovery
Examine the current evidence to support
regional anesthesia within the enhanced
recovery process
Look at the future of regional anesthesia
in ERAS
4. Summary
ERAS pathways have become common for colorectal and
orthopedic surgical pathways
Regional anesthesia techniques are used in many
pathways but use has suffered due to educational and
other barriers
Regional anesthesia has demonstrated several benefits
for patients in ERAS pathways
As healthcare spending becomes further constrained we
need to align our outcome measures with those being
used to justify funding for our interventions
5.
6. Enhanced Recovery after Surgery
Largely influenced by work of Professor
Henrik Kehlet (Denmark)1
Integrated coordinated bundles of care
with a focus on multimodal techniques
and interdisciplinary care
Major focus on colorectal and orthopedic
surgery
Regional anesthesia often included
1Kehlet H BJA 1997; 78: 606-17
7. Enhanced Recovery after Surgery
Less use of ERAS pathways outside
colorectal and orthopedic surgery
Barriers to implementation in many
centres
Regional anesthesia use often limited
Specific focus on evidence-base for
regional within ERAS not available
1Kehlet H BJA 1997; 78: 606-17
8. Concepts within ERAS
Standardization of care
Evidence-based care
Multimodal care pathways based on best
evidence
Multidisciplinary (focus on the team)
9. Many reviews of efficacy of enhanced
recovery protocols
Little written about specific place of RA
with ERAS protocols
Scoping review to examine area
Dan McIsaac MD MPH, Evan Cole MD and Colin McCartney MB PhD BJA: in press
10. Scoping review: a rapid
gathering of evidence in
a given clinical area with
an aim to accumulate as
much evidence as
possible and map the
results
Focus on triple aim
outcomes
Dan McIsaac MD MPH, Evan Cole MD and Colin McCartney MB PhD BJA: in press
12. Searched for all articles that examined
regional anesthesia within an enhanced
recovery pathway (ERP)
EMBASE, MEDLINE, CENTRAL, CDSR,
PROSPERO and the NHS Evaluation
Database
Inception to May 2015
Dan McIsaac MD MPH, Evan Cole MD and Colin McCartney MB PhD BJA 2015
13. 695 unique citations; 446 excluded after
title review, 249 full text review with 191
excluded
58 unique studies for data extraction
67% RCTs and one non-randomized trial
14 controlled before-and-after studies, 5
retrospective cohort studies and one
prospective cohort
Dan McIsaac MD MPH, Evan Cole MD and Colin McCartney MB PhD BJA: in press
14. >50% of studies examined colorectal
surgery
Orthopedic (21%) and other types of non-
colorectal general surgery (29%)
Regional techniques: Epidural, SAB, TAP
block and lower limb PNB techniques
Dan McIsaac MD MPH, Evan Cole MD and Colin McCartney MB PhD BJA: in press
15. Dan McIsaac MD MPH, Evan Cole MD and Colin McCartney MB PhD BJA: in press
16. Good news! Strong evidence that RA
provides:
– Improved pain control
– Improved organ function and mobility
– Reduced PONV, length of stay and adverse
events
Bad news: little focus on triple aim
outcomes
Dan McIsaac MD MPH, Evan Cole MD and Colin McCartney MB PhD BJA: in press
22. 382,000 patients
25% neuraxial
Neuraxial associated with less mortality,
length of stay, in-patient morbidity
Anesthesiology 2013
23. 120 patients randomized to spinal vs TIVA
for TKA
Primary outcome: LOS
No opioid (intrathecal or other) in spinal
group
Both groups received LIA
24.
25. The KT Gap and RA?
Patient factors
System factors
Education factors
26. Barriers to RA
Patient education
Surgeon education
Anesthesiology
education
Administrative barriers
27. Patient education
Patients don’t like
needles
Patients don’t like
being awake in
the OR
Patients don’t like
postoperative pain
30. Anesthesiology education
Anesthesiologists remain poorly trained in
regional anesthesia
Anesthesiologists fear risk of failure and
complications
Leadership and support must come from
the top of every department
31. Administrative Barriers
Anesthesiology leadership and leadership
in perioperative medicine
Hospital funding silos
Overfocus on RCT evidence and lack of
larger population-based evidence
32. Anesthesiology Leadership
We need to leading perioperative teams in
our hospitals
Invest in our ability to care for patients
from admission to discharge
Realize that anesthesiologists are the key
perioperative physicians
Understand the threat to our patients if
we do not step up
33. Funding Silos
Inability to leverage total hospital savings
against possible increase in OR costs
No incentive to save costs in our current
system
Funding of innovative but unproven
therapy at expense of “less sexy” proven
methods
34. Overfocus on RCT evidence
RCTs constitute <25% of all patients
Strict inclusion/exclusion criteria
? Reflect real practice
Pragmatic trials possibly the answer
Good quality case control or cohort studies
Definition of standardized outcomes
across studies
More focus on longer term outcomes
35.
36.
37. 382,000 patients
25% neuraxial
Neuraxial associated with less mortality,
length of stay, in-patient morbidity
Anesthesiology 2013
38.
39. Bad News
Poor translation of current evidence into
practice
Little focus on Triple Aim
40. Importance of Triple Aim
Used increasingly by government agencies
to allocate funding:
– US: Centre for Medicaid and Medicare
Services
– Canada: Provincial Funding Model and
Quality-Based Procedures
– UK: CQUINS: Commissioning for Quality and
Innovation Payments
43. “a national study revealed that patients who
reported being most satisfied with their doctors
actually had higher healthcare and prescription
costs and were more likely to be hospitalized
than patients who were not as satisfied. Worse,
the most satisfied patients were significantly
more likely to die in the next four years”
http://www.theatlantic.com
44. Patient Experience vs Satisfaction
Patient experience goes beyond patient
satisfaction and making patients happy
You may have a negative outcome but a positive
experience
You may have a positive outcome but a negative
experience
Patient experience is linked to staff engagement
Patients judge healthcare providers not only on
outcome but on compassionate and excellent
patient care
45. What measures should we use?
Phase of
recovery
Definition Time
Frame
Threshold Outcomes Example of
measures
Early OR to PACU
discharge
Hours Safety (to go
to ward)
Physiological Aldrete
Score
Intermediate PACU to
hospital
discharge
Days Self-care Symptoms
and
impairment
of IADL
Quality of
Recovery
score
Late Discharge
to return to
normal
function
Weeks to
months
Return to
normal
Function and
HRQoL
6MWT
CHAMPS
SF-6D
Lee L et al Surgery 2014
46. What can we focus on?
Process vs Outcome Measures
Timing of antibiotic administration and SSI
Patient warming and CVS events
Use of neuraxial anesthesia
Use of multimodal analgesia and effective
early pain control and rehabilitation
47. What can we focus on?
Process vs Outcome Measures
Focus on quality of care for individual
patients. Smaller RCTs and QA processes
Focus on standards of care for populations
of patients. Larger pragmatic and
population based studies to determine
broad guidelines for care e.g. AAOS, HQO
48. Summary
ERAS pathways are common for colorectal and
orthopedic surgical pathways
Regional anesthesia techniques are used in
many pathways but use has suffered due to
educational and other barriers
Regional anesthesia has demonstrated several
benefits for patients
Align outcome measures with Triple Aim to
ensure funding of valuable interventions
49. Colin J.L. McCartney
MBChB PhD FCARCSI FRCA FRCPC
Professor and Chair of Anesthesiology
University of Ottawa
Head of Anesthesiology
The Ottawa Hospital
Scientist,
Ottawa Hospital Research Institute
Enhanced Recovery and Regional
Anesthesia:
Do we need regional? Yes
50. What do we need?
Studies of RA that focus on outcomes relevant
to patients and the system
Studies examining non-colorectal and orthopedic
populations
A system that facilitates use of best treatments
Invest in our own clinical, education and
research leaders looking outside our own
institutions
Don’t forget about the importance of pain
control, care after discharge and care of each
individual