Cell saver blood transfusions; colorectal surgery antibiotic prophylaxis; preoperative clinics; colonoscopy failure rates

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Cell saver blood transfusions; colorectal surgery antibiotic prophylaxis; preoperative clinics; colonoscopy failure rates Transfusion techniques in cardiac surgery European Journal of Cardio-thoracic Surgery August 2006 Blood frequently is administered to patients during cardiac surgical procedures, with approximately three out of four cardiac surgical patients requiring transfusion of at least one unit of homologous (ie, allogeneic) blood. Given the declining rate of blood donations and the increasing cost of blood and blood products, finding alternatives to or ways to reduce the need for homologous blood transfusions has become increasingly urgent. The use of cardiopulmonary bypass (CPB) during coronary artery bypass graft (CABG) surgery has been associated with increased coagulation abnormalities; inflammatory responses; and consequently, a greater need for blood transfusion. Off-pump CABG surgery, on the other hand, is potentially associated with reduced intraoperative blood loss and is now a well-established alternative. Additionally, cell saver autologous blood transfusion (ie, autotransfusion) and predonated autologous blood are being used more frequently as alternatives to homologous transfusions. Cell saver autologous blood transfusion is the collection of a patient’s own blood during the surgical procedure or from the surgical wound and subsequent reinfusion of this blood into the patient. The objectives of this prospective, randomized study were to investigate the potential additive effects of cell saver autologous blood transfusion and CPB on blood loss, homologous blood transfusion requirements, and clotting © AORN, Inc, 2007

parameters in patients undergoing CABG for the first time. These effects were compared among patients undergoing CABG both with and without CPB and with and without cell saver blood transfusion.1 Eighty patients undergoing firsttime CABG at a hospital in the United Kingdom were randomly assigned to one of four groups, with 20 patients in each group. The four groups included • group A: procedures were on-CPB with cell saver blood transfusion, • group B: procedures were on-CPB without cell saver blood transfusion, • group C: procedures were off-CPB with cell saver blood transfusion, and • group D: procedures were off-CPB without cell saver blood transfusion. Patients were excluded if they • had known inflammatory diseases or existing infections, • needed emergent surgery, • were using long-term corticosteroids and nonsteroidal anti-inflammatory medications, • had used antiplatelet agents in the week before surgery, • had known coagulopathy with warfarin or heparin, or • had severe pre-existing renal dysfunction or lung dysfunction. The anesthesia and surgical techniques were standardized for all patients. For patients in the on-CPB groups (ie, groups A and B), the procedures were performed through a median sternotomy, and heparin was used to achieve an activated clotting time of more than 480 seconds before aortic and venous cannulation. In addition, nonpulsatile extracorporeal circulation at moderate hypothermia of 32° C (89.6° F) was performed, and cold blood antegrade cardioplegia for myocardial protection was administered. Protamine sulphate was used at

George Allen, RN

This information is intended for general use only. The clinical implications are specific to the abstracted article only. Individuals intending to put these findings into practice are strongly encouraged to review the original article to determine its applicability to their setting.

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the end of the procedure to reverse heparinization and to achieve the preoperative activated clotting time. In the off-CPB groups (ie, groups C and D), anticoagulation was achieved using heparin to achieve an activated clotting time of more than 300 seconds, the mean arterial blood pressure was maintained between 50 mm Hg and 70 mm Hg, and protamine sulphate was used at the end of the procedure to reverse heparinization. Patients in the cell saver groups (ie, groups A and C) underwent intraoperative cell salvage, with autotransfusion of washed, salvaged red blood cells occurring at the conclusion of the procedure. In the groups without cell saver transfusion (ie, groups B and D), all blood lost during the procedure was aspirated and discarded. Preoperatively and on the first and fifth postoperative day, all patients had a full blood count, which included hemoglobin, hematocrit, and prothrombin time. Intraoperatively, routine cardiovascular and pulmonary monitoring was conducted. Postoperatively, the amount of chest tube drainage and the total amount of homologous blood transfusion during the first 24 hours were recorded. Homologous blood was only transfused if the hemoglobin concentration was less than 8 g/dL. Postoperative complications including atrial fibrillation, renal complications, pulmonary problems, and

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cerebrovascular accidents were documented. Additionally, data were collected on the length of intubation, the length of intensive care unit stay, and the total length of hospital stay. Common statistical procedures, including mean, standard deviation, and Student’s t test, were used to analyze the data. Findings. There were no significant differences in patient demographics, postoperative morbidity, or clotting test results between the groups. The total hospital stay, however, was significantly shorter in the off-CPB groups (ie, groups C and D) than the on-CPB groups (ie, groups A and B). Patients who underwent cell saver autologous blood transfusion (ie, groups A and C) received significantly reduced volumes of homologous blood for transfusion compared to patients who did not have cell saver blood transfusion (159 mL ± 196 mL for groups A and C versus 413 mL ± 394 mL for groups B and D, P < .001). The amount of blood available for autologous blood transfusion was significantly higher in the on-CPB group (ie, group A) than the off-CPB group (ie, group C) (433 mL ± 155 mL versus 271 mL ± 144 mL, P < .001). Patients undergoing off-CPB CABG (ie, groups C and D) received significantly less homologous blood for transfusion compared to those undergoing on-CPB CABG (ie, groups A and B) (184 mL ± 214 mL versus 382 mL ± 397 mL, respec-

tively, P < .01). Homologous blood transfusion in the onCPB group without cell saver transfusion (ie, group B) was significantly higher than in the other groups (595 mL ± 276 mL in group B compared to 179 mL ± 214 mL, 141 mL ± 183 mL, and 230 mL ± 240 mL in groups A, C, and D, respectively, P < .005). Clinical implications. The results of this study demonstrated that patients undergoing off-CPB CABG had a significantly decreased need for homologous blood transfusion and that cell saver autologous transfusion significantly reduced the need for homologous transfusion in the on-CPB group. Additionally, autotransfusion caused no significant adverse effects on coagulation parameters in on- or off-CPB CABG. Perioperative managers should ensure that personnel in the perioperative setting develop proficiency in administering cell saver autologous blood transfusions.

Comparison of prophylactic antibiotics in colorectal surgery The New England Journal of Medicine December 2006 Cefotetan and cefoxitin are the agents currently recommended for antibiotic prophylaxis in patients undergoing

Evidence for Practice

colorectal surgery; however, these two medications may not be available in the future because the manufacturers are planning to discontinue their production. Consequently, other options for antibiotic prophylaxis for colorectal surgery must be considered. Ertapenem is a carbapenem antibiotic used in the treatment of complicated intra-abdominal infections, and it has several characteristics that make its use attractive as a potential antibiotic prophylactic agent for colorectal procedures. It can be rapidly administered intravenously; it has appropriate coverage against potential pathogens; it has a long halflife, so a second dose may not be required during most procedures; and it has a safety profile similar to that of other commonly used antibiotics. The purpose of this prospective, randomized, doubleblind study was to assess the efficacy and safety of antibiotic prophylaxis with ertapenem compared to cefotetan in patients undergoing elective colorectal procedures.2 At 51 centers in the United States between May 2002 and March 2005, all patients 18 years of age or older who were scheduled to undergo elective open surgery of the colon or rectum and had sufficient time for bowel preparation were eligible for inclusion in the study. Patients were excluded if they • needed emergency colorectal surgery, • needed a second planned

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surgery requiring antibiotic prophylaxis, • were having an elective colorectal procedure for revision of a previous surgery, • underwent laparoscopicassisted surgery, or • needed an isolated rectal procedure. Also excluded were patients • who had bacterial infections at the time of surgery or required antimicrobial therapy up to one week before surgery; • for whom the study medication was contraindicated; • with active inflammatory bowel disease, neutropenia, or immunosuppression; • with abnormal aminotransferase levels or prothrombin times that were at least three times that of the upper limit of the normal range; and • who were pregnant or nursing. Patients were assigned to receive either a single dose of 1 g of ertapenem or 2 g of cefotetan to be infused over a 30-minute period within 60 minutes before the initial surgical incision. Patients who completed a standard bowel preparation before surgery and who received a full dose of the study medication were included in a modified intention-to-treat analysis. Patients were included in a per-protocol analysis if they met the modified intention-to-treat criteria and, in addition, they • received the study medication within two hours before the surgical incision

and six hours before surgical closure, • underwent a four-week follow-up assessment, • did not receive any nonstudy antibiotics in the week before surgery, and • did not have a distant-site infection. The primary endpoints were the proportion of patients who could be evaluated and for whom prophylaxis was successful at the four-week follow-up assessment after surgery, as well as any other clinical adverse events, including medicationrelated adverse events. Success was defined as no signs or symptoms of infection at the surgical site and no further need for antimicrobial therapy or surgery. All patients gave a complete medical history, underwent a physical examination, and gave information to be used as a baseline regarding preoperative risk factors for postoperative infections. Vital signs were measured daily while the patient was hospitalized and at the fourweek follow-up assessment. Wound assessments were performed at least every other day for up to seven days during hospitalization as well as at discharge and at the four-week follow-up visit. Patients were monitored for clinical adverse events daily during hospitalization and by telephone after discharge until 14 days after the administration of the study medications. Common statistical procedures, AORN JOURNAL •

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including multiple logistic regression techniques, were used to analyze the data, and a modified intention-to-treat analysis also was performed. Findings. Of the 1,002 patients who were randomly assigned to the study groups, 901 qualified for the modified intention-to-treat analysis and 672 were included in the perprotocol analysis. In the modified intention-to-treat analysis, the overall failure rates were 40.2% in the ertapenem group and 50.9% in the cefotetan group (absolute difference -10.7%, 95% confidence interval [CI] -17.1 to -4.2). Additionally, the most common reason for failure of prophylaxis in both groups was surgical site infection, with an infection rate of 17.1% in the ertapenem group and 26.2% in the cefotetan group (absolute difference -9.1, 95% CI -14.4 to -3.7). In the per-protocol analysis, the overall failure rates were 28% in the ertapenem group and 42.8% in the cefotetan group (absolute difference -14.8%, 95% CI -21.9 to -7.5). Both of these analyses fulfilled statistical criteria for the superiority of ertapenem. Clinical implications. The results of this study revealed that prophylaxis with ertapenem was superior to prophylaxis with cefotetan. Ertapenem was superior in terms of the proportion of favorable clinical responses and the lower incidence of postoperative surgical site infections four weeks after surgery. Perioperative nurses must understand that when-

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ever antibiotic prophylaxis is used, the timing is critical. The agent must be administered in sufficient time to allow for therapeutic level in the blood before the incision is made; most antibiotics should be administered within 60 minutes before the initial incision. In addition, antibiotics generally should be discontinued within 24 hours after surgery.

Effect of preoperative clinics on OR efficiency Anesthesiology December 2006 Cancellation of surgery can result in a significant loss in revenue, with one estimate suggesting that a minimum of approximately $1,500 per hour of revenues is lost. It is believed that proper risk assessment and optimization of medical conditions in a preoperative clinic may considerably reduce cancellations and delays on the day of surgery. In the preoperative clinic, optimal management of preexisting medical conditions may take place or new conditions may be diagnosed. Health care practitioners may discover that old medical records need to be reviewed; test results need to be obtained; or office notes not readily available at the time of the preoperative evaluation need to be ac-

quired from nonaffiliated hospitals, clinics, or institutions. In effect, medical issues can be appropriately identified and the necessary information obtained so that the knowledge of a patient’s status is complete before the day of surgery. Effective patient evaluation in a preoperative clinic has been shown to increase efficiency of perioperative resource utilization, increase patient satisfaction, reduce unnecessary testing and consultation, and decrease the duration of hospital stay. The authors of this study noted that although a significant percentage of patients evaluated in their preoperative clinic have at least one known coexisting disease, a smaller percentage present with a change in their existing medical condition or with a previously undiagnosed disease process, which may require that a physician order new tests. In addition, many of their patients come from outside institutions, which may require that additional information be obtained from other institutions. The objectives of this retrospective study were to test the hypotheses that some of the information obtained during the preoperative clinic visit will be new and will apply to different medical and surgical fields, that obtaining previous diagnostic test results will modify the medical management of patients in the perioperative period, and that new

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problems will account for the majority of the changes in medical management.3 The charts of all patients evaluated in the preoperative clinic during a threemonth period from Nov 1, 2003, through Jan 31, 2004, were reviewed. Data collected included • patient demographics, • type of medical issue uncovered during the preoperative clinic visit, • information needed to resolve the issue, • the length of time required to retrieve needed information, • cancellation and delay rates for surgical procedures, and • the effect on management of the patient’s procedure. Delays were defined as procedures that were eventually placed on the OR schedule at a later date than originally planned, and cancellations were procedures that were removed from the OR schedule and not rebooked for at least a three-month period. Common statistical procedures, including mean and standard deviation, were used to analyze the data. Findings. During the three-month study period, 5,083 patients were seen in the preoperative clinic. A total of 647 patients (12.7%) had 680 medical issues that required additional information or management. Of these medical issues, 565 (83.1%) were known medical problems (ie, old problems) thought to require further information, and 115 (16.9%)

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were medical problems newly identified in the preoperative clinic (ie, new problems). All outstanding medical issues were identified and the necessary information was obtained for 93% and 96.1% of patients with old and new problems, respectively. Medical conditions requiring further investigation were divided into general categories, including • cardiac; • anesthesia; • pulmonary; • hematologic; • vascular; • endocrine; and • other (eg, significant laboratory abnormalities). Cardiac issues represented the majority of issues identified (ie, 87% of old problems and 63.5% of new problems). The need to obtain existing information (eg, stress test, echocardiogram, electrocardiogram [ECG]) about known symptomatic coronary artery disease was the most frequently identified issue associated with incomplete information. Significant new abnormalities on ECG or the presence of new cardiac symptoms were the most common source of newly identified issues. The majority of the newly identified problems (ie, 80.3%) required that a new test or consultation be performed, whereas the majority of the old problems (ie, 84.3%) required that information be retrieved from other medical institutions. New problems

were associated with a greater chance of delay (ie, 10.7%) or cancellation (ie, 6.8%) from the originally scheduled date than old problems (ie, 0.6% and 1.8%, respectively). A total of 15.8% of patients with old problems and 27.2% of patients with new problems had alterations in their perioperative management, with the most common change in management involving the initiation of perioperative beta blockers. Clinical implications. The results of this study revealed that preoperative clinic evaluation can identify and resolve a number of medical issues that can affect the efficient use of resources in the OR. Overall, 17.6% of the patients seen in the preoperative clinic had alterations in their perioperative management. Perioperative managers who have determined that their cancellation or delay rates are high should consider instituting a preoperative clinic for all scheduled outpatient surgeries.

Afternoon colonoscopies versus morning colonoscopies American Journal of Gastroenterology December 2006 A colonoscopy is a minimally invasive endoscopic examination using a fiber-optic

Evidence for Practice

camera to visualize the rectum and colon. It allows for biopsy and the removal of suspected lesions. Numerous predictors of an incomplete or difficult colonoscopy have been identified. These include • poor bowel preparation, • previous hysterectomy, • constipation, • lower body mass index, • severe diverticulosis, and • inpatient status. Scheduling colonoscopies later in the day also has been reported as an independent predictor of poor bowel preparation resulting in an incomplete colonoscopy. It is believed that because a colonoscopy could be a technically challenging procedure, physician fatigue, which generally tends to be higher as the day passes on, may affect colonoscopy completion rates. The purpose of this retrospective study was to determine the influence of the time of day that outpatient colonoscopies are scheduled (ie, in the afternoon versus in the morning) on colonoscopy completion rates. In addition, the adequacy of bowel preparation for procedures scheduled in the morning versus the afternoon was determined and compared.4 The endoscopy reports of all consecutive outpatient colonoscopies performed from November 2003 to October 2004 at a medical center in Cleveland, Ohio, were reviewed. Data collected included • patient demographics; • history of hysterectomy;

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• •

indication for the procedure; procedure starting time (ie, morning versus afternoon); • total procedure duration; • completion status; • reason for incompletion; • quality of bowel preparation; and • colonoscopic findings. All patients were advised to consume a liquid diet the day before the scheduled colonoscopy, and they were instructed to drink a gallon of standard polyethylene glycol electrolyte-based bowel preparation over a period of four hours on the evening before the colonoscopy. A completed colonoscopy was defined as visualization of the ileocecal valve and appendiceal orifice with or without transillumination of the right lower quadrant. Quality of bowel preparation was reported according to the subjective assessment by the individual endoscopist. Inadequate bowel preparation was defined as when the endoscopist described the preparation as suboptimal but the procedure was completed. Poor bowel preparation was defined as when the endoscopist terminated the procedure as a result of very poor visualization because of the presence of stool. Morning procedures were defined as those procedures whose starting time was between 8 AM and 11:59 AM. Afternoon procedures were defined as those procedures whose start time was noon or later. Total procedure duration was defined as the time

from the insertion of the colonoscope into the anus until withdrawal of the colonoscope from the patient. Common statistical procedures, including t tests and multivariate logistic regression techniques, were used to analyze the data. Findings. Of the 2,083 outpatient colonoscopies reviewed, 1,084 were performed in the morning and 999 were performed in the afternoon. Patients in the morning group and those in the afternoon group were similar in regard to the known risk factors predictive of an incomplete colonoscopy. Colonoscopies were complete in 1,974 patients, with an overall crude completion rate of 94.8%. The incomplete rate was significantly higher in the afternoon compared to the morning (6.5% versus 4.1%, odds ratio [OR] for incomplete 1.64, CI 1.11-2.44, P = .013). Inadequate bowel preparation was found in 14.4% of the colonoscopies performed in the morning and 19.7% of the colonoscopies performed in the afternoon (P = .011). Even after excluding colonoscopies that were incomplete as a result of poor bowel preparation, the incomplete rate still was higher for colonoscopies performed in the afternoon (5% versus 3.2%, OR 1.60, CI 1.032.51, P = .043). Clinical implications. The results of this study revealed that scheduling colonoscopies in the afternoon compared to AORN JOURNAL •

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the morning may be an independent predictor of an incomplete colonoscopy and inadequate bowel preparation. Perioperative managers should seriously consider the results of this study, which revealed that scheduling outpatient colonoscopies in the morning could avoid suboptimal procedures in 5% of patients and could avoid the need for unnecessary repeated colonoscopy or an alternative imaging study in 2.4% of patients. Y

GEORGE ALLEN PHD, RN, CNOR, CIC DIRECTOR OF INFECTION CONTROL DOWNSTATE MEDICAL CENTER BROOKLYN, NY

REFERENCES 1. Niranjan G, Asimakopoulos G, Karagounis A, Cockerill G, Thompson M, Chandrasekaran V. Effects of cell saver autologous blood transfusion on blood loss and homologous blood transfusion requirements in patients undergoing cardiac surgery on- versus off-cardiopulmonary bypass: a randomised trial. Eur J Cardiothorac Surg. 2006;30:271-277.

2. Itani KMF, Wilson SE, Awad SA, Jensen EH, Finn TS, Abramson MA. Ertapenem versus cefotetan prophylaxis in elective colorectal surgery. N Engl J Med. 2006;355:2640-2651. 3. Correll DJ, Bader AM, Hull MW, Hsu C, Tsen LC, Hepner DL. Value of preoperative clinic visits in identifying issues with potential impact on operating room efficiency. Anesthesiology. 2006;105:1254-1259. 4. Sanaka MR, Shah N, Mullen KD, Ferguson DR, Thomas C, McCullough AJ. Afternoon colonoscopies have higher failure rates than morning colonoscopies. Am J Gastroenterol. 2006;101:2726-2730.

Pay-For-Performance Incentives for Physicians Are Common

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ore than one-third of health maintenance organizations (HMOs) in the United States use pay-for-performance programs in their contracts with hospitals, and nearly 90% of HMOs included these programs as part of their compensation to physicians in 2005, according to a Nov 1, 2006, news release from the Agency for Healthcare Research and Quality. Pay-for-performance arrangements are used by payers to reward physicians and hospitals for adhering to evidence-based practices. They most commonly are associated with HMOs that use primary care providers as gatekeepers to specialty care, use “capitation” arrangements to give primary care physicians set payments each month based on the number of patients in a given health plan, or are themselves rewarded by performance incentives. Researchers reviewed health plans that offered HMO products in 41 markets across the United States and that had at least 100,000 enrollees. Their sample represented 91% of the US HMO market and 78% of the US metropolitan population. The study revealed that • of the 242 HMOs surveyed, 52% used pay-forperformance in provider contracts in 2005; • of the 113 HMOs that used pay-for-performance for physicians, 13% focused on the physician as the unit of payment, one-third were designed to

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reward only the top-rated physicians or groups, and two-thirds offered a rewards program for attaining a pre-determined performance threshold, with potential physician bonuses generally equaling 5% of payments from the plan; • nearly two-thirds of the HMOs that require primary care providers to be gatekeepers to specialty care used pay-for-performance compared to 25% of HMOs that do not require gatekeeper physicians; • nearly all the health plans (ie, 100% capitated, 79% noncapitated) included measures of quality; • use of information technology and patient satisfaction surveys commonly were used as elements of the physician incentive programs; and • nearly three-quarters of HMOs that used pay-forperformance in their hospital contracts used measures other than intensive care unit staffing, use of computerized physician order entry systems, and volume standards for high-risk procedures. The findings were significant because the federal government plans to institute pay-for-performance into the traditional Medicare plan by 2009, according to the researchers. Pay-For-Performance Incentives Adopted by Half of US HMOs, But Use Depends on Health Plan Type, Physician Payment Arrangements [press release]. Rockville, Md: Agency for Healthcare Research Quality; November 1, 2006.