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Journal Description

JMIR Perioperative Medicine (JPOP, Editor-in-chief: John F. Pearson MD, Harvard Medical School) is a new sister journal of JMIR (the leading open-access journal in health informatics (Impact Factor 2017: 4.671), focusing on technologies, medical devices, apps, engineering, informatics and patient education for perioperative medicine and nursing, including pre- and post-operative education, preventative interventions and clinical care for surgery and anaesthesiology patients, as well as informatics applications in anesthesia, surgery, critical care and pain medicine.

As open access journal we are read by clinicians and patients alike and have (as all JMIR journals) a focus on readable and applied science reporting the design and evaluation of health innovations and emerging technologies. We publish original research, viewpoints, and reviews (both literature reviews and medical device/technology/app reviews).

During a limited period of time, there are no fees to publish in this journal. Articles are carfully copyedited and XML-tagged, ready for submission in PubMed Central.

Be a founding author of this new journal and submit your paper today!

 

Recent Articles:

  • Patient interacting with home monitor to send blood pressure measurements to clinicians. Source: The Authors; Copyright: The Authors; URL: http://periop.jmir.org/2018/2/e10169/; License: Licensed by JMIR.

    Postoperative Home Monitoring After Joint Replacement: Retrospective Outcome Study Comparing Cases With Matched Historical Controls

    Abstract:

    Background: A retrospective cohort study was conducted in patients undergoing postoperative home monitoring (POHM) following elective primary hip or knee replacements. Objective: The objectives of our study were to compare the cost per patient, readmissions rate, emergency room visits, and mortality within 30 days to the historical standard of care using descriptive analysis. Methods: After Research Ethics Board approval, patients who were enrolled and had completed a POHM study were individually matched to historical controls by age, American Society of Anesthesiology class, and procedure at a ratio 1:2. Results: A total of 54 patients in the study group and 107 in the control group were eligible for the analysis. Compared with the historical standard of care, the average cost per case was Can $5826.32 (SD 1418.89) in the POHM group and Can $9198.58 (SD 1513.59) for controls. After 30 days, there were 2 emergency room visits (3.7%) and 0 readmissions in the POHM group, whereas there were 8 emergency room visits (7.5%) and 2 readmissions (1.9%) in the control group. No mortalities occurred in either group. Conclusions: The POHM study offers an early hospital discharge pathway for elective hip and knee procedures at a 38% reduction of the standard of care cost. The multidisciplinary transitional POHM team may provide a reliable forum to minimize readmissions, and emergency room visits within 30 days postoperatively. Clinical Trial: ClinicalTrials.gov NCT02143232; https://clinicaltrials.gov/ct2/show/NCT02143232 (Archived by WebCite at http://www.webcitation.org/73WQ9QR6P)

  • Pectus carinatum. Source: Wikimedia Commons; Copyright: Tolson411; URL: https://commons.wikimedia.org/wiki/File:Ben_Fraser_pectus_carinatum.jpg; License: Creative Commons Attribution + ShareAlike (CC-BY-SA).

    Implementation of an Enhanced Recovery Pathway for Minimally Invasive Pectus Surgery: A Population-Based Cohort Study Evaluating Short- and Long-Term...

    Abstract:

    Background: Pectus excavatum and pectus carinatum are the most common chest wall deformities. Although minimally invasive correction (minimally invasive repair of pectus, MIRP) has become common practice, it remains associated with severe postoperative pain. Preoperative psychosocial factors such as anxiety and low self-esteem can increase postsurgical pain. Early detection of psychological symptoms, effective biopsychosocial perioperative management of patients, and prevention of pain chronification using an enhanced recovery pathway (ERP) may improve outcomes. However, the incidence of the latter is poorly described in adolescents undergoing MIRP. Objective: The objective of our study was to evaluate the implementation of an ERP containing early recovery goals and to assess persistent postsurgical pain 3 months postoperatively in pediatric patients undergoing MIRP. The ERP consists of a Web-based platform containing psychological screening questionnaires and extensive telemonitoring for follow-up of patients at home. Methods: A population-based cohort study was conducted with prospectively collected data from patients undergoing pectus surgery between June 2017 and December 2017. An ERP was initiated preoperatively; it included patient education, electronic health-based psychological screening, multimodal pre-emptive analgesia, nausea prophylaxis as well as early Foley catheter removal and respiratory exercises. After hospital discharge, patients were followed up to 10 weeks using a Web-based diary evaluating pain and sleep quality, while their rehabilitation progress was monitored via Bluetooth-connected telemonitoring devices. Results: We enrolled 29 adolescents using the developed ERP. Pre-emptive multimodal analgesia pain rating scores were low at hospital admission. Optimal epidural placement, defined by T8-9 or T9-10, occurred in 90% (26/29) of the participants; thus, no motor block or Horner syndrome occurred. Mean bladder catheterization duration was 3.41 (SD 1.50) days in ERP patients. Numeric rating scale (NRS) scores for pain and the incidence of nausea were low, contributing to a fluent rehabilitation. Mean NRS scores were 2.58 (SD 1.77) on postoperative day (POD) 1, 2.48 (SD 1.66) on POD 2, and 3.14 (SD 1.98) on POD 3 in ERP-treated patients. Telemonitoring at home was feasible in adolescents after hospital discharge despite adherence difficulties. Although the pain scores at the final interview were low (0.81 [SD 1.33]), 33% (9/27) long-term follow-up ERP patients still experienced frequent disturbing thoracic pain, requiring analgesic administration, school absenteeism, and multiple doctor (re)visits. Conclusions: Allocating patients to the appropriate level of care preoperatively and immediately postoperatively may improve long-term outcome variables. Internet-based technologies and feasible, objective monitoring tools can help clinicians screen surgical patients for risk factors and initiate early treatment when indicated. Future research should focus on improving risk stratification and include a psychological assessment and evaluation of the effect of perioperative care pathways in children undergoing major surgery. Trial Registration: ClinicalTrials.gov NCT03100669; https://clinicaltrials.gov/ct2/show/NCT03100669 (Archived by WebCite at http://www.webcitation.org/72qLB1ADX)

  • Mother and child using Anaesthesia-Web. Source: Anaesthesia-Web; Copyright: Anaesthesia-Web; URL: http://periop.jmir.org/2018/2/e10203; License: Licensed by JMIR.

    Web-Based Learning for Children in Pediatric Care: Qualitative Study Assessing Educational Challenges

    Abstract:

    Background: Hospitalization is a significant and stressful experience for children, which may have both short-term and long-term negative consequences. Anaesthesia-Web is a Web-based preparation program that has been well received and is being used worldwide to reduce stressful experiences, increase understanding, and exchange information in pediatric care. A deeper theoretical and educational understanding encompassing children’s learning processes on Anaesthesia-Web may optimize and support the development and design of similar websites for children in pediatric care. Objective: The objective of this study was to elucidate key educational principles in the development and design of websites for children in pediatric care. Methods: A directed qualitative content analysis was applied to analyze the content and design of Anaesthesia-Web from a theoretical and educational perspective. preunderstanding, motivation, learning processes, and learning outcome were used to analyze the learning possibilities of Anaesthesia-Web for children prior to contact with pediatric care. Results: We found 4 themes characterizing children’s learning opportunities on Anaesthesia-Web in the analysis: “In charge of my learning”; “Discover and play”; “Recognize and identify“; and “Getting feedback”. The analysis showed that Anaesthesia-Web offers children control and enables the use of the website based on interest and ability. This is important in terms of motivation and each child’s individual preunderstanding. Through discovery and play, children can receive, process, and apply the information on Anaesthesia-Web cognitively, emotionally, and by active participation. Play stimulates motivation and is very important in a child’s learning process. When facing pediatric care, children need to develop trust and feel safe so that they can focus on learning. On Anaesthesia-Web, children can recognize situations and feelings and can find someone with whom to identify. Several features on the website promote feedback, which is necessary to judge learning achievements, confirm understanding, and embody the need for repetition. Conclusions: Web-based preparation programs are important learning resources in pediatric care. Content and design needs to change from simply providing information to embracing the importance of a child’s need to process information to learn and fully understand. By developing Web-based preparation programs that include educational principles, Web-based technology can be used to its fullest advantage as a learning resource for children. The 4 educational themes described in this study should help future similar website developments within pediatric care.

  • Anonymous patient interacting with remote monitor. Source: Image created by the Authors; Copyright: The Authors; URL: http://periop.jmir.org/2018/2/e10168/; License: Creative Commons Attribution (CC-BY).

    Postoperative Home Monitoring After Joint Replacement: Feasibility Study

    Abstract:

    Background: We conducted a prospective observational study of patients undergoing elective primary hip or knee replacements to examine the feasibility of a postoperative home monitoring system as transitional care to support patients following their surgery in real time. Objective: The primary outcome was the mean percentage of successful wireless transmissions from home of blood pressure levels, heart rate, oxygen saturation levels, and pain scores until postoperative day 4 with a feasibility target of ≥90%. Methods: Patients with an expected length of stay ≤1 day, age 18-80 years, Revised Cardiac Risk Index ≤ class 2, and caretakers willing to assist at home were eligible. Patient satisfaction, as a secondary outcome, was also evaluated. Wireless monitoring equipment (remote patient monitoring, Telus Canada) was obtained and a multidisciplinary care team was formed. Results: We conducted the study after obtaining Research Ethics Board approval; 54 patients completed the study: 21 males, 33 females. In total, we evaluated 9 hips, 4 hip resurfacing, 26 total knees, and 15 hemi-knees. The mean transmission rate was 96.4% (SD 5.9%; 95% CI 94.8-98.0). The median response to “I would recommend the Remote Monitoring System program to future patients” was 4.5 (interquartile range 4-5), with 1 being “strongly disagree” and 5 “strongly agree.” At 30 days postop, there was no mortality or readmission. Conclusions: This is an evolving new paradigm for postoperative care and the first feasibility study on monitoring biometrics after primary hip or knee replacement. Postoperative home monitoring combines current technology with real-time support by a multidisciplinary transitional care team after discharge, facilitating postsurgical care with successful wireless transmission of vitals. The postoperative home monitoring implementation is, therefore, generalizable to other surgical discharges from hospitals. Trial Registration: ClinicalTrials.gov NCT02143232; https://clinicaltrials.gov/ct2/show/NCT02143232 (Archived by WebCite at http://www.webcitation.org/71ugAhhIk)

  • Source: Pxhere; Copyright: Pxhere; URL: https://pxhere.com/en/photo/1100015; License: Public Domain (CC0).

    Evaluating the Variation of Intraocular Pressure With Positional Change During Colorectal Laparoscopic Surgery: Observational Study

    Abstract:

    Background: The incidence of perioperative visual loss following colorectal surgery in the US is quoted as 1.24 per 10,000. Raised intraocular pressure (IOP) during extreme Trendelenburg position leading to reduced optic nerve perfusion is thought to be a cause. Objective: To assess the effect of the degree of Trendelenburg tilt and time spent in Trendelenburg on IOP during laparoscopic colorectal surgery. Methods: Fifty patients undergoing laparoscopic colorectal surgery were recruited. A Tonopen XL applanation tonometer was used to take IOP measurements hourly during surgery, and each time the operating table was tilted. A correlation coefficient for the degree of Trendelenburg tilt and IOP was calculated for each patient. Group 1 included patients undergoing a right-sided colonic procedure, and Group 2 included all left-sided colonic operations. Results: The mean age of Group 1 participants (n=25) was 69 years (SD 14), and Group 2 (n=25) was 63 years (SD 16; P>.05). The average length of surgery for Group 1 was 142 minutes (SD 48), and Group 2 was 268 minutes (SD 99; P≤.05). The mean maximum degree of Trendelenburg tilt in Group 1 was 10 (SD 7) and Group 2 was 19 (SD 6; P≤.05). The mean IOP increase was 9 mm Hg (SD 5) for Group 1 and 15 mm Hg (SD 5) in Group 2 (P≤.05). An overall correlation coefficient for the degree of Trendelenburg tilt and IOP change (n=48) was .78. Conclusions: There is a strong correlation between IOP elevation during laparoscopic colorectal surgery and the degree of Trendelenburg tilt. This may be significant for patients undergoing prolonged surgery and especially those with glaucoma.

  • Source: Rotterdam Eye Hospital; Copyright: Rotterdam Eye Hospital; URL: http://periop.jmir.org/2018/1/e3/; License: Creative Commons Attribution (CC-BY).

    A Digital Patient-Led Hospital Checklist for Enhancing Safety in Cataract Surgery: Qualitative Study

    Abstract:

    Background: Surgery holds high risk for iatrogenic patient harm. Correct and sufficient communication and information during the surgical process is a root solution for preventing patient harm. Information technology may substantially contribute to engaging patients in this process. Objective: To explore the feasibility of a digital patient-led checklist for cataract surgery, we evaluated the experiences of patients and nurses who have used this novel tool with a focus on use, appreciation, and impact. Methods: A multidisciplinary team, including cataract surgeons, nurses, pharmacists and administrative representatives developed a 19-item digital patient-led checklist for cataract patients who underwent surgery in an ambulatory setting. This “EYEpad” checklist was distributed to patients and their companions during their hospital visit via an application on a tablet. It contained necessary information the patient should have received before or during the surgical preparation (8 items), before anesthesia (2 items), and before discharge (9 items). Patients and their companions were invited to actively indicate the information they received, or information discussed with them, by ticking on the EYEpad. Our qualitative research design included semi-structured individual interviews with 17 patients and a focus group involving 6 nurses. The transcripts were analyzed by 2 independent coders using both deductive and inductive coding. Results: All but one of the 17 patients used the EYEpad, occasionally assisted by his or her companion (usually the partner). In several cases, the checklist was completed by the companion. Most patients felt positively about the usability of the EYEpad. Yet, for most of the patients, it was not clear why they received the checklist. Only 4 of them indicated that they understood that the EYEpad was used to determine if there were sufficient and correct information discussed or checked by the nurses. Although most nurses agreed the EYEpad was easy to use and could be a useful tool for improving patient engagement for improving safety, they felt that not all elderly patients were willing or capable of using it and it interfered with the existing surgical process. They also anticipated the need to spend more time explaining the purpose and use of the EYEpad. Conclusions: Our results showed that a digital patient-led checklist is a potentially valid way to increase patient participation in safety improvement efforts, even among elderly patients. It also illustrates the crucial role nurses play in the implementation and diffusion of technological innovations. Increased patient participation will only improve safety when both healthcare workers and patients feel empowered to share responsibility and balance their power.

  • Example of daily reporting in RAPP. Source: Image created by the Authors; Copyright: Ulrica Nilsson; URL: http://periop.jmir.org/2018/1/e2/; License: Licensed by JMIR.

    Sex Similarities in Postoperative Recovery and Health Care Contacts Within 14 Days With mHealth Follow-Up: Secondary Analysis of a Randomized Controlled Trial

    Abstract:

    Background: Previous studies have shown that women tend to have a poorer postanesthesia recovery than men. Our research group has developed a mobile phone app called Recovery Assessment by Phone Points (RAPP) that includes the Swedish Web version of the Quality of Recovery (SwQoR) questionnaire to monitor and assess postoperative recovery. Objective: The aim of this study was to investigate sex differences in postoperative recovery and the number of health care contacts within 14 postoperative days in a cohort of day-surgery patients using RAPP. Methods: This study was a secondary analysis from a single-blind randomized controlled trial. Therefore, we did not calculate an a priori sample size regarding sex differences. We conducted the study at 4 day-surgery settings in Sweden from October 2015 to July 2016. Included were 494 patients (220 male and 274 female participants) undergoing day surgery. The patients self-assessed their postoperative recovery for 14 postoperative days using the RAPP. Results: There were no significant sex differences in postoperative recovery or the number of health care contacts. Subgroup analysis showed that women younger than 45 years reported significantly higher global scores in the SwQoR questionnaire (hence a poorer recovery) on postoperative days 1 to 10 than did women who were 45 years of age or older (P=.001 to P=.008). Men younger than 45 years reported significantly higher global scores on postoperative days 2 to 6 than did men 45 years of age or older (P=.001 to P=.006). Sex differences in postoperative recovery were not significant between the age groups. Conclusions: This study found sex similarities in postoperative recovery and the number of health care contacts. However, subgroup analysis showed that age might be an independent factor for poorer recovery in both women and men. This knowledge can be used when informing patients what to expect after discharge. Trial Registration: ClinicalTrials.gov NCT02492191; https://clinicaltrials.gov/ct2/show/NCT02492191 (Archived by WebCite at http://www.webcitation.org/6y2UtMbvz)

  • Source: Pexels.com; Copyright: freestocks.org; URL: https://www.pexels.com/photo/google-nexus-4-lg-smartphone-technology-12829/; License: Public Domain (CC0).

    Accessible Communication Tools for Surgical Site Infection Monitoring and Prevention in Joint Reconstruction: Feasibility Study

    Abstract:

    Background: The National Surgical Quality Improvement Program logs surgical site infections (SSIs) as the most common cause of unplanned postoperative readmission for a variety of surgical interventions. Hospitals are making significant efforts preoperatively and postoperatively to reduce SSIs and improve care. Telemedicine, defined as using remote technology to implement health care, has the potential to improve outcomes across a wide range of parameters, including reducing SSIs. Objective: The purpose of this study was to assess the feasibility and user satisfaction of two automated messaging systems, EpxDecolonization and EpxWound, to improve perioperative care in a quality improvement project for patients undergoing total joint replacement. Methods: We designed two automated text messaging and calling systems named EpxDecolonization, which reminded patients of their preoperative decolonization protocol, and EpxWound, which monitored pain, wound, and fever status postoperatively. Daily patient responses were recorded and a post-usage survey was sent out to participants to assess satisfaction with the systems. Results: Over the 40-week study period, 638 and 642 patients were enrolled in EpxDecolonization (a preoperative decolonization reminder) and EpxWound (a postoperative surgical site infection telemonitoring system), respectively. Patients could be enrolled in either or both EpxDecolonization and EpxWound, with the default option being dual enrollment. The proportion of sessions responded to was 85.2% for EpxDecolonization and 78.4% for EpxWound. Of the 1280 patients prescribed EpxWound and EpxDecolonization, 821 (64.14%) fully completed the postoperative system satisfaction survey. The median survey score (scale 1-9) was 9 for patient-rated overall care and 8 for whether the telemonitoring systems improved patient communication with providers. The majority of patients (69.0%, 566/821) indicated that the systems sent out an ideal number of messages (not too many, not too few). Conclusions: EpxDecolonization and EpxWound demonstrated high response rates and improved patient-rated communication with providers. These preliminary data suggest that these systems are well tolerated and potentially beneficial to both patients and providers. The systems have the potential to improve both patient satisfaction scores and compliance with preoperative protocols and postoperative wound monitoring. Future efforts will focus on testing the sensitivity and specificity of alerts generated by each system and on demonstrating the ability of these systems to improve clinical quality metrics with more authoritative data.

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Latest Submissions Open for Peer-Review:

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  • Virtual Clinics in General Surgery: the way of the future

    Date Submitted: Oct 12, 2018

    Open Peer Review Period: Oct 14, 2018 - Dec 9, 2018

    Background: Escalating demand for specialist healthcare puts considerable demand on hospital services. Technology offers a means by which healthcare providers may increase the efficiency of healthcare...

    Background: Escalating demand for specialist healthcare puts considerable demand on hospital services. Technology offers a means by which healthcare providers may increase the efficiency of healthcare delivery. Objective: To assess the feasibility, acceptability and efficiency of a virtual clinic in the post operative general surgical setting. Methods: Methods: Patient satisfaction with current care and attitudes to virtual clinic (VC) were surveyed prospectively in the general surgical outpatient department (OPD). A subset of patients who had undergone endoscopy and day surgery were recruited to follow up in virtual clinic and subsequently surveyed with regards to their satisfaction. Other outcomes measured included a comparison of consultation times in traditional and virtual outpatient settings, and financial cost to both patients and the institution. Results: Results: Almost half of patients reported barriers to prospective use of virtual clinics. However, within the cohort who had been followed up in the virtual clinic, satisfaction was higher than the traditional OPD. Significant savings in both time and financial costs to patients and the institution were found. Conclusions: Conclusion: For an appropriately selected group of patients, virtual clinics offer a viable alternative to traditional OPD. This alternative can improve both patient satisfaction and efficiency of patient care.

  • The Feasibility of Panda, a Pain Management Mobile App for Children at Home After Discharge from Surgery

    Date Submitted: Sep 24, 2018

    Open Peer Review Period: Sep 28, 2018 - Nov 23, 2018

    Background: Emphasis on outpatient pediatric surgical procedures places the burden of responsibility for post-operative pain management on parents/guardians. Panda is a smartphone application (app) th...

    Background: Emphasis on outpatient pediatric surgical procedures places the burden of responsibility for post-operative pain management on parents/guardians. Panda is a smartphone application (app) that provides scheduled medication alerts and allows parents to track their child’s pain and medication administration. We have previously tested and optimized the usability and feasibility of Panda within the hospital setting. Objective: The purpose of this study was to evaluate and optimize the feasibility of Panda for use at home, based on alert response compliance (response to any medication notification within 1 hour) and parents’ satisfaction. Methods: Parents/guardians of children undergoing day surgery were recruited to use Panda at home for 1-7 days to manage their scheduled medications and to assess their child’s pain. After surgery, a research assistant guided parents through app setup before independent use at home. We aimed to recruit ten child/caregiver pairs in each of three rounds of evaluation. Each user’s compliance with the recommended medication alerts was analyzed through audit-trail data generated during the use of the app. We used the Computer System Usability Questionnaire (CSUQ) and a post-study phone interview to evaluate the app’s ease of use and identify major barriers to adoption. Suggestions provided during the interviews were used to improve the app between each round. Results: Twenty-nine child/caregiver pairs participated in 3 rounds, using the app for 1-5 days. Alert response compliance (response to any medication notification within 1 hour) improved as the study progressed: participants responded to 30% (22-33) (median, interquartile range) of alerts within 1 hour in Round 1, and subsequently to 60% (44 – 64) in Round 2 and 64% (56 – 72) in Round 3 (P = .005); similarly, response times decreased from 131 (77 – 158) minutes in Round 1 to 31 (18 – 61) minutes in Round 2 and 10 (2 – 14) minutes in Round 3 (P = .002). Analysis of interview feedback from the first 2 rounds revealed usability issues, such as complaints of too many pages and trouble hearing app alerts, which were addressed to streamline app function, as well as improve visual appearance and audible alerts. Conclusions: It is feasible for parents/guardians to use Panda at home to manage their child’s medication schedule and track their pain. Simple modifications to the apps alert sounds and user interface improved response times.

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