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Background: This is Part 2 of the first consensus guidelines for optimal care of patients undergoing emergency laparotomy (EL) using an Enhanced Recovery After Surgery (ERAS) approach. This paper addresses intra- and postoperative aspects of care. Methods: Experts in aspects of management of high-risk and emergency general surgical patients were invited to contribute by the International ERAS® Society. PubMed, Cochrane, Embase, and Medline database searches were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized clinical trials, systematic reviews, meta-analyses, and large cohort studies and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on elective patients when appropriate. A modified Delphi method was used to validate final recommendations. Some ERAS® components covered in other guideline papers are outlined only briefly, with the bulk of the text focusing on key areas pertaining specifically to EL. Results: Twenty-three components of intraoperative and postoperative care were defined. Consensus was reached after three rounds of a modified Delphi Process. Conclusions: These guidelines are based on best available evidence for an ERAS® approach to patients undergoing EL. These guidelines are not exhaustive but pull together evidence on important components of care for this high-risk patient population. As much of the evidence is extrapolated from elective surgery or emergency general surgery (not specifically laparotomy), many of the components need further evaluation in future studies. [ABSTRACT FROM AUTHOR]

Background: This is Part 3 of the first consensus guidelines for optimal care of patients undergoing emergency laparotomy using an enhanced recovery after surgery (ERAS) approach. This paper addresses organizational aspects of care. Methods: Experts in management of the high-risk and emergency general surgical patient were invited to contribute by the International ERAS® Society. PubMed, Cochrane, Embase, and MEDLINE database searches were performed for ERAS elements and relevant specific topics. Studies were selected with particular attention to randomized clinical trials, systematic reviews, meta-analyses and large cohort studies, and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation system. Recommendations were made on the best level of evidence, or extrapolation from studies on elective patients when appropriate. A modified Delphi method was used to validate final recommendations. Results: Components of organizational aspects of care were considered. Consensus was reached after three rounds of a modified Delphi process. Conclusions: These guidelines are based on best current available evidence for organizational aspects of an ERAS® approach to patients undergoing emergency laparotomy and include discussion of less common aspects of care for the surgical patient, including end-of-life issues. These guidelines are not exhaustive but pull together evidence on important components of care for this high-risk patient population. As much of the evidence is extrapolated from elective surgery or emergency general surgery (not specifically laparotomy), many of the components need further evaluation in future studies. [ABSTRACT FROM AUTHOR]

Rationale, Aims, and Objectives: The WHO Surgical Safety Checklist is a communication tool designed to improve surgical safety processes and enhance teamwork. It has been widely adopted since its introduction over ten years ago. As surgical safety needs evolve, organizations should periodically review and update their checklists. A holistic evaluation of the checklist in the context of an organization is the first step to making informed updates. In this article, we describe a comprehensive but feasible strategy for checklist evaluation which we developed and implemented as part of a surgical safety initiative in a high‐performing center. Methods: A three‐part evaluation plan was developed and carried out by a multidisciplinary team. The evaluation included assessment of 1. Quality of care through a review of surgical safety events; 2. Safety culture through a validated survey and informal feedback; and 3. Checklist performance through direct observations and a staff survey. To prepare for re‐implementation the current institutional checklist was critically evaluated and a context assessment survey was administered to surgical staff. Results: The evaluation revealed challenges in communication and teamwork, with surgical staff often perceived to be working in silos. The quality of care assessment indicated room for improvement in safety processes. Deficiencies in the safety culture measures of communication and feedback shed light on an overall lack of engagement with the checklist. Checklist performance demonstrated good adherence to the items on the checklist but limited engagement by the surgical team and minimal communication between subteams. These findings informed our revisions to the checklist and its implementation processes. Conclusions: We developed and implemented a comprehensive, scalable approach to checklist evaluation which directly informed improvements to the checklist that were tailored to the organization's current context. Organizations can apply this framework to breathe new life into their checklist and transform their safety culture. [ABSTRACT FROM AUTHOR]

Background: Enhanced Recovery After Surgery (ERAS) protocols reduce length of stay, complications and costs for a large number of elective surgical procedures. A similar, structured approach appears to improve outcomes, including mortality, for patients undergoing high-risk emergency general surgery, and specifically emergency laparotomy. These are the first consensus guidelines for optimal care of these patients using an ERAS approach. Methods: Experts in aspects of management of the high-risk and emergency general surgical patient were invited to contribute by the International ERAS® Society. Pubmed, Cochrane, Embase, and MEDLINE database searches on English language publications were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized controlled trials, systematic reviews, meta-analyses and large cohort studies, and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on non-emergency patients when appropriate. The Delphi method was used to validate final recommendations. The guideline has been divided into two parts: Part 1—Preoperative Care and Part 2—Intraoperative and Postoperative management. This paper provides guidelines for Part 1. Results: Twelve components of preoperative care were considered. Consensus was reached after three rounds. Conclusions: These guidelines are based on the best available evidence for an ERAS approach to patients undergoing emergency laparotomy. Initial management is particularly important for patients with sepsis and physiological derangement. These guidelines should be used to improve outcomes for these high-risk patients. [ABSTRACT FROM AUTHOR]

Background: Emergency general surgery (EGS) patients are at an increased risk for morbidity and mortality compared with non-EGS patients. Limited information exists regarding the contribution of malnutrition to the outcome of critically ill patients who undergo EGS. We hypothesized that malnutrition would be associated with increased risk of 90-day all-cause mortality following intensive care unit (ICU) admission in EGS patients.Materials and Methods: We performed an observational study of patients treated in medical and surgical ICUs at a single institution in Boston. We included patients who underwent an EGS procedure and received critical care between 2005 and 2011. The exposure of interest, malnutrition, was determined by a registered dietitian's formal assessment within 48 hours of ICU admission. The primary outcome was all-cause 90-day mortality. Adjusted odds ratios were estimated by multivariable logistic regression models.Results: The cohort consisted of 1361 patients. Sixty percent had nonspecific malnutrition, 8% had protein-energy malnutrition, and 32% were without malnutrition. The 30-day readmission rate was 18.9%. Mortality in-hospital and at 90 days was 10.1% and 17.9%, respectively. Patients with nonspecific malnutrition had a 1.5-fold increased odds of 90-day mortality (adjusted odds ratio [OR], 1.51; 95% confidence interval [CI], 1.09-5.04; P = .009) and patients with protein-energy malnutrition had a 3.1-fold increased odds of 90-day mortality (adjusted OR, 3.06; 95% CI, 1.89-4.92; P < .001) compared with patients without malnutrition.Conclusion: In critically ill patients who undergo EGS, malnutrition at ICU admission is predictive of adverse outcomes. In survivors of hospitalization, malnutrition at ICU admission is associated with increases in readmission and mortality. [ABSTRACT FROM AUTHOR]