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Year : 2016  |  Volume : 10  |  Issue : 3  |  Page : 546-551  

Attitudes, awareness and barriers regarding evidence-based orthopedic surgery between health professionals from a Brazilian Public Health System (SUS) hospital: Study of 400 patients

1 Department of Anesthesiology, School of Medicine Nova Esperança; Department of Anesthesiology, Anesthesiologist Complexo Hospitalar Mangabeira, João Pessoa, PB, Brazil
2 Master in Labour Economics, UFPB; Statistician of the Complexo Hospitalar Mangabeira, João Pessoa, PB, Brazil

Date of Web Publication27-Sep-2016

Correspondence Address:
Luiz Eduardo Imbelloni
Rua Marieta Steimbach Silva, 106/1001, 58043.320 Joao Pessoa, PB
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0259-1162.183164

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Background: The fast-track concept refers to all phases of perioperative care: Preoperative, intraoperative, and postoperative strategies. Although most research has focused on adherence to medication, adherence also encompasses numerous health-related behaviors. The aim of this prospective study was to determine the attitudes and awareness among health professionals involved in the treatment of elderly patients with fractures of the femur and the results of 400 patients.
Methods: The postoperative protocol acceleration was presented to various hospital departments through four seminars. Questionnaire with four ex-residents in the Department of Anesthesiology was conducted. Every 6 months, the results of project implementation to all departments were presented. It was considered adherence to the project when the professionals agreed with all the steps and routines of the project. Patients underwent spinal anesthesia with postoperative analgesia by lumbar plexus block.
Results: All departments involved in the treatment of elderly patients' adhered completely to the project and reported the importance of preanesthetic visit, the explanations of design, and reduction of fasting period. Just one anesthetist completely adhered to the project. No former resident of anesthesia joined the program. All parameters studied in 400 patients compared with the data before the project showed a reduction from 21.38% to 100%.
Conclusion: Improving adherence requires a continuous and dynamic process. We can be inferred that the implementation of fast-track project Brazilian Public Health System (Sistema Único Saúde, SUS) costs decreased with elderly patients with hip fractures. The anesthesiologist was the major obstacle to deployment to all patients.

Keywords: Fasting, fast-track surgery, medical adherence, orthopedic, perioperative care, spinal anesthesia, surgery

How to cite this article:
Imbelloni LE, de Morais Filho GB. Attitudes, awareness and barriers regarding evidence-based orthopedic surgery between health professionals from a Brazilian Public Health System (SUS) hospital: Study of 400 patients. Anesth Essays Res 2016;10:546-51

How to cite this URL:
Imbelloni LE, de Morais Filho GB. Attitudes, awareness and barriers regarding evidence-based orthopedic surgery between health professionals from a Brazilian Public Health System (SUS) hospital: Study of 400 patients. Anesth Essays Res [serial online] 2016 [cited 2019 Mar 24];10:546-51. Available from:

   Introduction Top

Surgery has evolved greatly in recent years due to the introduction of techniques that reduce the stress response in the perioperative period, the use of minimally invasive operations, and new approaches to pain control. A large amount of surgical procedures can be performed routinely on an outpatient basis. During the last two decades, the paradigm of evidence-based medicine (EBM) has been introduced in almost all specialties. Nowadays, executive boards stress the use of EBM to prevent unsafe practices that lack empirical support to reduce unacceptable individual variance and ultimately to increase efficiency and health care quality.[1]

In actual, however, it proves that not all health care professionals use EBM in their daily practice. This is related to a lack of surgical evidence, the fact that surgical questions cannot always be answered by a randomized clinical trial, and restrictive inclusion criteria that hamper application of trial recommendations to the average surgical patient.[2] Evidence is accumulating that fast-track surgery is useful for enhancing patient recovery.[3],[4] This result can only be achieved when all services related to surgical management are involved and especially the hospital board.

In addition, there is evidence that the recovery from surgery can be reduced and accelerated convalescence. This approach became known as “fast-track surgery,” and incorporates not only surgeons but also anesthesiologists, nurses, nutritionists, psychologists, physiotherapists, and social worker as active participants in the care of the patient.[3],[4] We have reported a reduced length of stay, number of suspension, the duration of fasting, the release the feedback, the length of stay in the postanesthetic care unit (PACU), and incidence of hypotension in elderly patients undergoing chip surgery and who received fast-track perioperative care.[5],[6],[7],[8],[9]

However, adherence/compliance to elements of the various fast-track routines by both the staff and patients requires investigation. Indeed, rigorous data on patients' experiences of enhanced recovery programmers are lacking. Introducing acceleration protocols usually require a major shift in clinical routines, and many units may have difficulties in making all these changes at once. Therefore, the aim of this prospective study was to determine the attitudes and awareness among health professionals involved in the treatment of elderly patients with fractures of the femur to the principles of EBM (Project Acerto) the barriers experienced when practicing EBM to be able to define future interventions tailored to improve evidence-based surgery behavior. As a second objective, we aimed at comparing the experience found in 400 elderly patients with hip fracture after implementation of the project with the historical data of published articles on the subject.[5]

   Methods Top

In 2012, we initiated a longitudinal prospective study at a hospital covered by the Brazilian Public Health System (Sistema Único de Saúde [SUS]) in patients undergoing corrective femur fracture over the age of 60 years. The protocol was registered in Brazil Platform. The Ethics Research Committee approved the study protocol, and all patients were informed and agreed to participate in the study. Inclusion criteria were normal blood volume, no preexisting neurological disease, no coagulation disorders, without infection at the puncture site, which did not present agitation, mental confusion and/or delirium, which did not make use of bladder indwelling catheters, with hemoglobin level >10 g%, and not staying in the Intensive Care Unit. After the implementation of the Acerto project, all patients were selected from May 2012 to December 2014.

The new perioperative protocol was presented to various hospital departments through four seminars [Table 1]. In these seminars, it was addressed the following topics: (1) Perioperative nutrition, (2) fasting time, (3) perioperative intravenous (IV) hydration, (4) minimum biochemical exams required, (5) importance of analgesia, (6) reduction of nausea and vomiting, (7) care of the patient (preoperative information, drains, probes and ultra-early hospital discharge), (8) importance of social service, (9) importance of psychological support, and (10) rationalization for the use of antibiotics in surgery. After the seminars, we collected continuous data and in every 6 months thereafter an audit of the project implementation was presented to all departments.
Table 1: Services involved in the project, numbers of professionals and adherence

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It was considered adherence to the project when the professionals agreed with all the steps and routines of the project and participated in performing care according to their specialty for elderly patients according to the protocol. Questionnaire was conducted on the project with four ex-residents of anesthesiology.

All patients over 60 years with femur fractures were anesthetized by the same anesthesiologist, accompanied by a resident in anesthesia. Premedication was not used. All 400 patients received 200 mL 2% dextrinomaltose orally 2–4 h before being sent to the operating room.

Monitoring consisted electrocardiogram, noninvasive blood pressure, heart rate (HR), and pulse oximetry. After venous cannulation with 18-gauge catheter in the hand or forearm, infusion of Ringer's lactate in parallel with 6% hydroxyethyl starch 130/0.4 in 0.9% sodium chloride injection was started. All patients received cefazolin 2 g and dexamethasone 10 mg intravenously. After sedation with IV ketamine (0.1 μg/kg) and midazolam (0.5–1 mg), skin cleansing with chlorhexidine and excess removal, spinal puncture was performed with the patient in sitting position, through the median interspace L2–L3 or L3–L4, using a 27-gauge Quincke needle (B. Braun Melsungen). After observing cerebrospinal fluid confirming the correct position of the needle, 6–12.5 mg of 0.5% isobaric bupivacaine were administered at a rate of 1 mL/15 seconds. Patients were immediately placed in supine position for surgery. The sensorial blockade and motor blockade were evaluated at 10 min after injection.

Cardiorespiratory parameters were measured every 5 min. Hypotension (a reduction in systolic blood pressure >30% when compared to the pressure in the regular ward) was treated with ethylephrine (2 mg IV) while bradycardia (HR <45 bpm) was treated with atropine (0.50 mg IV). At the end of surgery, patients received tenoxicam 40 mg and dipyrone 40 mg/kg in 50 mL of Ringer's lactate.

The postoperative analgesia was performed through the anterior lumbar plexus block (inguinal) or posterior (psoas compartment) with a neurostimulator. Obtained the desired contraction, 40 mL bupivacaine 0.25% was injected. In patients scheduled for the first time, the block was performed before spinal anesthesia in the PACU and the other at the end of surgery in the operating room. All patients received 200 mL 2% dextrinomaltose orally after completion of motor block in the PACU and observed administration time. The incidence of nausea and vomiting was registered. They were then transferred to the ward and noted the time of reintroduction of oral feeding.

Data from all patients were compared with values obtained of 83 patients before implementation of the project.[5] For quantitative variables, we used the Wilcoxon–Mann–Whitney test to see if the decrease of the means was significant. For qualitative variables (hunger and thirst), we used the Student's t-test to verify that the decrease of proportions was significant.

   Results Top

The four seminars were attended by all specialties except anesthesiology. During the project implementation was toward the hospital three directors and all joined the project. All departments involved in the treatment of elderly patients' (social, psychology, nutrition, physiotherapy, and nursing) adhered completely to the project, and reported the importance of preanesthetic visit, the explanations of design and reduction of fasting period [Table 1].

Two geriatricians idealized minimal protocol exams and joined the project. All 16 orthopedic surgeons involved in the hip and femur in elderly patient's surgeries joined the project. Just one anesthetist completely adhered to the project and others do not accept a preoperative fasting <8 h.

The meetings scheduled for reporting the 6-month audit had the presence of staffs from all departments with the exception of the Department of Anesthesiology.

The four residents who followed the implementation of the project, none has applied its expertise in private practice. In the questionnaire, they reported the difficulties in persuading the surgeon to accept the reduced preoperative fasting for their patients.

The demographics data and the American Society of Anesthesiologists physical status are shown in [Table 2]. Ninety-nine patients were between 60 and 69 years, 87 between 70 and 79 years, 120 between 80 and 89 years, 83 between 90 and 99 years, and 11 had more than 100 years, being the oldest with 107 years. All 400 patients were submitted to spinal anesthesia, and there was no need of general anesthesia. The mean dose of isobaric bupivacaine was 9.58 ± 1.60 mg.
Table 2: Demographics data (mean±SD)

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The average hospital stay until day of surgery, the numbers of surgery suspension, the mean fasting time, hunger and thirst have significantly decreased after the implementation of the project [Table 3]. No patient reported hunger while only four patients reported thirst [Table 3]. All endpoint variables decrease by 58.91–100%, with the fast-track project.
Table 3: Days of hospitalization, number of suspension of surgery, time fasting, incidence of hunger and thirst (mean±SD)

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The block duration, the use of a drain, the time stay in PACU, and the time of reintroduction oral feeding were significant difference between the two periods [Table 4]. There was a decrease of all these parameters by 21.38–93.75%, with the fast-track project. The time for the use of dextrinomaltose in the postimplantation group in the PACU remained in 1:38 h. There was not a significant difference in relation to the time of analgesia with the lumbar plexus [Table 4].
Table 4: Blocking duration, use of drains, time to feeding dextrinomaltose in postanesthetic care unit, duration of stay in the postanesthetic care unit, time of oral food reintroduction on the ward and duration of analgesia (mean±SD)

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There was not a significant difference as to the necessity of blood transfusion. Bradycardia occurred in tree patients before Acerto implantation against two after the implantation, with significance difference. Arterial hypotension occurred in 15 patients preimplantation while in 22 patients after the implantation, with a significant difference [Table 5]. All hypotension were easily treated with only one dose of etylefrine. There was a decrease of all parameters from 28% to 86%, with the fast-track project.
Table 5: Blood transfusion, bradycardia, and hypotension (mean±SD)

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   Discussion Top

Adherence is a complex behavioral process determined by several interacting factors.[10] These include attributes of the patient, the patient's environment (which comprises social supports, characteristics of the health care system, functioning of the health care team, and the availability and accessibility of health care resources) and characteristics of the disease in question and its treatment. This study showed that all patients were joined the project in the same way that all the departments involved in the treatment of the elderly. All parameters studied in 400 patients compared with the data before the project [5] showed a reduction from 21.38% to 100%. Only this decrease in percentage should justify the adherence of all departments. In our findings, the anesthesiologist was the major obstacle to deployment to all patients.

Enhanced recovery after surgery programmers (also known as ERAS, Acerto project, fast-track, multimodal, rapid or accelerated recovery programs) aim to deliver an optimal pathway (covering the preoperative, intraoperative, and postoperative periods), that is, focused on optimal recovery and discharge for patients. Differences in program implementation may also reflect differences between surgical specialties. This is an accelerated program with elderly patients (>60 years) and with hip fracture. Enhanced recovery in orthopedic surgery demands a multimodal service, which is influenced by the many factors. Almost all hospital services participated in the program.

The implementation of this concept relies upon hospital policies developed and applied in all departments and services involved in the management of the surgical patients. The fast-track concept refers to all phases of perioperative care: Preoperative, intraoperative and postoperative strategies.[3],[4],[5] The team approach includes a lot of medical personnel, but the main actors are the surgeon and the anesthetist, which have the most constant and direct contact with the patient. All orthopedic surgeons joined the project while only one anesthetist fully adhered to the project. In addition, four residents newly outgoing the Department of Anesthesiology did not apply the knowledge in their new services. They reported that the main difficulty was to change the view of the surgeon about the safe in shortening preoperative fasting. In this study, the anesthesiologists were largely responsible for the difficulties of adherence to the project.

An enhanced recovery program requires successful organization of a multidisciplinary group.[4],[11],[12] Thus, although a single individual or department can initiate such an approach, it will not succeed without the active and committed participation of other healthcare professionals. One immediate consideration is the scheduling of individuals in departments that use rotating hospital shifts. The team approach requires a commitment of individuals to meet specific time obligations throughout the week that are required for operations, planning, patient rounds, and data gathering. In addition, the same anesthesiologist should preferably interact with the patient before, during, and after the operation, which is at variance with current practices in many large institutions. The contribution of the hospital administration is also essential, for such programs require nurse specialization, care of patients in specific areas of the hospital (specialized units), planning, data collection, and ongoing assessment of outcomes and costs. Three officers and three medical directors participated in the implementation of the project. All those responsible for hospital administration joined the project. All other services (nursing, nutrition, psychology, geriatrics, physiotherapy, and social) attended all four workshops, and all professionals approved the project. The main purpose of this integrated approach is to reduce psychological and physiological stresses associated with surgical illness, to reduce tissue catabolism.[4],[11]

For effective implementation of a fast-track program, an entire surgical team must be actively involved, including surgeons, nurses, anesthetists, psychologist, nutritionists, and physiotherapists. It is always difficult to change routine. For successful implementation of fast-track project, the most vital ingredient is a surgeon willing to overcome traditional concepts of perioperative care. All orthopedic surgeons were willing to overcome the traditional concepts and accepted and adhered to Acerto programs.

The role of the anesthetist has been of great interest in the literature with concerns regarding his or her role as an anonymous technician inside rather than as a visible perioperative medical specialist outside the operating room. The anesthetist, as a perioperative physician, makes very important decisions in improving care.[11] The choice of anesthesia technique impacts directly on patient satisfaction.[13] Therefore, the anesthetist must be seen as a very important part of the team and a key to success in implementing a program to accelerate the recovery. The same anesthesiologist should preferably interact with the patient before, during, and after the operation, which is at variance with current practices in many large institutions. At our institution, this was a major cause of difficulty in implementation of the project for all patients. Unfortunately the low adherence to the project by anesthesiologists hampered the full implementation of the project for the remaining patients. Only patients with femur fractures and elderly continue to be operated based on the fast-track project.

A recent survey among senior anesthesiologists from 27 countries, most of them work in domain of general, orthopedic, or gynecological surgery showed a low level of knowledge about fast-track surgery.[14] Thirty-three percent had no knowledge about these programs.

Physician adherence is critical in translating recommendations into improved outcomes.[15] However, a variety of barriers undermine this process. Lack of awareness and lack of familiarity affect physician knowledge of a guideline. In terms of physician attitudes, lack of agreement, self-efficacy, outcome expectancy, and the inertia of previous practice are also potential barriers.[15] Other external barriers include time-limitation, unavailability of outcome data, insufficient expertise, or staff support.[15] Despite adequate knowledge and attitudes, external barriers can affect a physician's ability to execute recommendations. Service redesign can save money and improve quality, but much depends on how care is coordinated and the way services are implemented in a local setting.[16],[17]

Patient satisfaction with the significant provider of health care is considered to be an important determinant of adherence.[13] Patient satisfaction was not influenced by the type of surgery.[18] Factors underpinning high patient satisfaction with fast-track programs included patient education,[18],[19] continuity of doctor's rounds, and reduced need for analgesia.[20] Conversely, poor satisfaction was associated with higher levels of postoperative pain.[18] Postoperative analgesia was achieved with lumbar plexus block and with an average duration of 22 h, being an important factor in the family satisfaction. The decrease in fasting time was an important factor for patient satisfaction [13] and was an important factor for adherence of nutrition, psychology, social, and nursing service.

The contribution of the hospital administration is also essential, for such programs require all departments' specialization, care of patients in specific areas of the hospital (specialized units), planning, data collection, and ongoing assessment of outcomes and costs. Hospital administrators must realize that the financial benefit accrued from rapid turnover is linked to increasing bed availability, and appropriate credit should be afforded to the fast-track group for this contribution. During the 3 years spent by the hospital administration three directors. All upon learning of the project adhered to its implementation.

From an administrative standpoint, the suspension from surgery interferes own team of health and the consumption of time and material resources. With the implementation of the project, there was a decrease in the number of suspensions (decrease of 85%) and standby time of surgery.

The continuously growing pressure upon medical systems as a result of the increasing number of patients who need a surgical procedure and as a result of the economical restrains lead to the development of a new concept: Fast-track surgery. This concept brings together different perioperative strategies which according to EBM are useful strategies. The goal of the concept is to optimize the perioperative management of the patient to reduce morbidity, to enhance recovery of the patient after a surgical procedure, to reduce hospital stay, and to reduce costs. The significant reduction in length of stay might explain the cost reduction observed [21] as has been shown previously after implementation of a clinical pathway.[22] The decrease of almost 59% in length of stay, it can be inferred that decreased hospital costs of patients.

Our review of the cost-effectiveness literature suggests that enhanced recovery programs that achieve a reduction in length of stay may save costs without detrimental effects on complication rates, readmission and health-related quality of life. The Brazilian Health Service (SUS) faces severe funding constraints now and in the medium term.

As there was a decrease from 21.38% to 100% in all studied parameters, it can be inferred that the implementation of fast-track project SUS costs decreased with elderly patients with hip fractures. Patients with high adherence to the fast-track (ERAS) protocol had a 25% lower risk of postoperative complications and nearly 50% lower risk of postoperative symptoms delaying discharge.[23] A cost reduction from the decrease in morbidity and hospital length of stay may promote the implementation of fast-track programs and increase adherence to the protocol.

   Conclusion Top

The main target audiences for this report are policy-makers and health managers who can have an impact on national and local policies in ways that will benefit patients, health systems, and societies with better health outcomes and economic efficiency.

Improving adherence requires a continuous and dynamic process. A stronger commitment to a multidisciplinary approach is needed to make progress in this area. This will require coordinated action from health professionals, researchers, health planners, and policy-makers. This multidisciplinary approach requires further refinement in its individual components to provide the ultimate goal. In conclusion, it is not a simple task to implement a new protocol for the surgical patient. It needs a lot of determination, wide-spread acceptance, and objectives compatible with common practice, concrete definitions of desired parameters and an easy accessible and user-friendly format. However, in the era of EBM and of economic concerns, we should try. In this hospital (SUS), the low adherence by anesthesiologists prevented the project you extended to all patients.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Claridge JA, Fabian TC. History and development of evidence-based medicine. World J Surg 2005;29:547-53.  Back to cited text no. 1
Slim K. Limits of evidence-based surgery. World J Surg 2005;29:606-9.  Back to cited text no. 2
Kehlet H, Wilmore DW. Evidence-based surgical care and the evolution of fast-track surgery. Ann Surg 2008;248:189-98.  Back to cited text no. 3
Kehlet H, Dahl JB. Anaesthesia, surgery, and challenges in postoperative recovery. Lancet 2003;362:1921-8.  Back to cited text no. 4
Imbelloni LE, Gomes D, Braga RL, de Morais Filho GB, da Silva A. Clinical strategies to accelerate recovery after surgery orthopedic femur in elderly patients. Anesth Essays Res 2014;8:156-61.  Back to cited text no. 5
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Imbelloni LE, Braga RL, Morais Filho GB, Silva A. Low dose of isobaric bupivacaine provides lower incidence of spinal hypotension for hip surgery in elderly patients. Anaesth Pain Intensive Care 2014;18:17-20.  Back to cited text no. 6
Imbelloni LE, de Morais Filho GB, da Silva A. Outcome after anesthesia and orthopedic surgery in patients nonagenarians and centenarians. J Anesth Clin Res 2014;5:411.  Back to cited text no. 7
Imbelloni LE, Lima U, Pedrosa FK. Successful anesthesia and hip surgery in a 107-year-old patient. Am J Case Rep 2014;15:308-11.  Back to cited text no. 8
Imbelloni LE, Teixeira DM, Coelho TM, Gomes D, Braga RL, de Morais Filho GB, et al. Implementation of a perioperative management protocol for patients undergoing orthopedic surgery. Rev Col Bras Cir 2014;41:161-6.  Back to cited text no. 9
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Pritts TA, Nussbaum MS, Flesch LV, Fegelman EJ, Parikh AA, Fischer JE. Implementation of a clinical pathway decreases length of stay and cost for bowel resection. Ann Surg 1999;230:728-33.  Back to cited text no. 22
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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