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CMECNECPE

Evidence-Based Gynecologic Surgery Best Practices: The AHRQ Safety Program

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Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Discuss the elements that are evidence-based and should be incorporated in to pre-, intra- and postoperative gynecologic care
2. Describe the recommendations for prevention of venous thromboembolism for women undergoing gynecologic surgery

Estimated time to complete activity: 0.25 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.

The PIM planners and others have nothing to disclose. The OBG Project planners and others have nothing to disclose.

Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from Aug 14 2018 through Jan 25 2023, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Pharmacy Education

Postgraduate Institute for Medicine designates this continuing education activity for 0.25 contact hour(s) (0.25 CEUs) of the Accreditation Council for Pharmacy Education. (Universal Activity Number – JA4008162-9999-18-351-H05-P)

Type of Activity: Knowledge

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.

Designated for 0.1 contact hours of pharmacotherapy credit for Advance Practice Registered Nurses.

Read Disclaimer & Fine Print

SUMMARY:

The AHRQ, American College of Surgeons and Armstrong Institute at Johns Hopkins have developed a safety program to assess and help incorporate evidence-based practices into surgical care. An evidence review of gynecologic surgery was conducted, supporting the protocol elements in the AHRQ Safety Program that include the following best practices

Preoperative

Patient Education

  • ‘Potential’ association between preoperative patient education and improved outcomes (low level evidence)

Immediate Preoperative

Bowel Prep

  • Minimally invasive gyn surgery
    • Oral mechanical bowel prep should be abandoned (strong level evidence)
  • When bowel prep is desired (patients at high risk such as colorectal resection)
    • Based on colorectal surgery evidence, oral mechanical bowel prep alone is not effective
    • Use one of the following regimens (moderate level evidence)
      • Oral mechanical bowel prep and oral antibiotic
      • Oral antibiotic alone
    • Note: The review states “Data from non-randomized studies suggest that bowel preparation may be omitted within a well-developed ERP (enhanced recovery pathways) that incorporates a SSI reduction bundle even when bowel resection is anticipated”

Intraoperative

Drains

  • Routine nasogastric tube
    • Associated patient discomfort with no known benefit (high level evidence)
  • Routine peritoneal drains
    • Prophylactic use is not beneficial following lympadenectomy for gyn surgery
    • Avoid unless there is a rectal anastomosis within 6 cm of the anal verge and no diversion or patient at high risk for pelvic collections (moderate level evidence)

Postoperative

Early Mobilization

  • Beneficial – avoid prolonged bedrest (moderate level evidence)

Early Alimentation

  • Early oral feeding is safe (high level of evidence)
    • Well tolerated
    • Shorter hospital length of stay
    • Initiate as early as 4 hours following gyn surgery with or without bowel resection

Early Urinary Bladder Catheter Removal

  • Use catheters for <24 hours (moderate level evidence)
    • However, it is appropriate to consider fall risk and necessity of urine output monitoring for some patients
  • Uncomplicated surgeries
    • Removal at 6 hours balances rates of infection vs retention
  • Complicated surgeries (e.g., urogynecologic or gynecologic oncology procedures)
    • Morning after may be more appropriate

Prevention of Ileus and accelerate return of bowel function

  • Standardized use of postoperative laxatives
    • Recommended for gyn surgery (low level evidence)
    • Examples: Senna with docusate | Docusate | Magnesium oxide or magnesium hydroxide | Bisacodyl
  • Chewing gum
    • Recommended for gyn surgery (high level of evidence)
  • Alvimopan (novel peripheral μ-opioid antagonist)
    • May not be beneficial in benign gyn surgery
    • May decrease ileus in ovarian cancer surgery and can be considered for use in patients undergoing bowel resection (moderate level evidence)

Early IV Fluid discontinuation

  • Discontinue maintenance IV fluids within 12 to 24 hours following surgery, especially with early fluid and solid intake (low level of evidence)
    • Urine output as low as 20 mL/hour
      • Recognize as normal perioperative stress response
      • Intervention not required

KEY POINTS:

Other Evidence-Based Perioperative Interventions

  • Surgical site infection bundles (see ‘Related ObG Topics’ below)
    • Use of surgical site infection bundles should be considered (high level evidence)
  • Glucose management
    • Perioperative glucose goal: ≤ 180 mg/dL (10.0 mmol/L) (high level evidence)

Venous Thromboembolism (VTE) Prophylaxis

  • Preoperative
    • Intermittent pneumatic compression alone for (moderate level evidence)
      • Minimally invasive surgery for any indication or
      • Laparotomy for benign disease
    • Add preoperative pharmacologic prophylaxis for patients undergoing laparotomy for gynecologic malignancies
      • Weak level evidence from observational studies but consideration given to high rate of VTE in this population
      • Supported by multiple societies
    • Postoperative
      • Use mechanical prophylaxis for the duration of hospitalization in all gynecologic surgical patients and mechanical and/or pharmacologic prophylaxis for gynecologic oncology surgical patients (high level of evidence)
      • Gyn oncology: Extend VTE chemoprophylaxis for 4 weeks following surgery
        • Supported by multiple guidelines, but further research required on long-term benefits

Learn More – Primary Sources:

Surgical Technical Evidence Review for Gynecologic Surgery Conducted for the AHRQ Safety Program for Improving Surgical Care and Recovery Related Website link

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Related ObG Topics:

AAGL and “Choosing Wisely”: Five Practices to Question
Suture or Staples for Vertical Wound Closure in Obese Women?  
ACOG Guidance on Preventing Gynecologic Post-Procedure Infection

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Computer System Requirements

OBG Project CME requires a modern web browser (Internet Explorer 10+, Mozilla Firefox, Apple Safari, Google Chrome, Microsoft Edge). Certain educational activities may require additional software to view multimedia, presentation, or printable versions of their content. These activities will be marked as such and will provide links to the required software. That software may be: Adobe Flash, Apple QuickTime, Adobe Acrobat, Microsoft PowerPoint, Windows Media Player, or Real Networks Real One Player.

Disclosure of Unlabeled Use

This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.

The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

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