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BACKGROUND: Sedation practices vary widely by region. In Canada, endoscopist-directed administration of a combination of fentanyl and midazolam is standard practice, with only a minority of cases performed with propofol. AIMS: To demonstrate the safety of non-anesthetist administered propofol for endoscopic sedation. METHODS: This was a single-centre retrospective cohort study of patients having undergone endoscopic procedures with propofol sedation between 2004 and 2012 in an academic hospital in Montreal. Procedures were performed by gastroenterologists trained in Advanced Cardiovascular Life Support. Sedation was administered by IV bolus by a registered nurse, under the direction of the endoscopist. Outcomes of procedures were collected using the hospital’s endoscopy database. RESULTS: 4955 patients were included. Cecal intubation rate for colonoscopies (n=2920) was 90.0%. Gastroscopies (n=1625), flexible sigmoidoscopies (n=28), ERCP (n=341) and PEG insertion (n=41) had success rates of 98.4%, 96.4%, 94.4% and 92.7% respectively. The average dose of propofol used for each procedure was 34.6 mg. Fentanyl was used in 68% of procedures at an average dose of 94.4 mcg. Versed was used in 92.9% of cases at an average dose of 3.0 mg. Reversal agents (naloxone or flumazenil) were used in 0.4% of cases (n=21). Patients having received reversal agents were discharged uneventfully within the usual post-procedure recovery time. One patient required transfer to the ER. Most patients having received propofol in addition to standard sedation agents experienced no adverse events (99.6%). There were no deaths. CONCLUSIONS: The use of propofol administered by a registered nurse under the direction of the endoscopist as an adjunct to fentanyl and versed is safe and effective. FUNDING AGENCIES: None

Introduction: While patient engagement and clinical audit are key components of successful enhanced recovery programs (ERPs), they require substantial resource allocation. The objective of this study was to assess the validity and usability of a novel mobile device application for education and self-reporting of adherence for patients undergoing bowel surgery within an established ERP. Methods: Prospectively recruited patients undergoing bowel surgery within an ERP used a novel app specifically designed to provide daily recovery milestones and record adherence to 15 different ERP processes and six patient-reported outcomes (PROs). Validity was measured by the agreement index (Cohen’s kappa coefficient for categorical, and interclass correlation coefficient (ICC) for continuous variables) between patient-reported data through the app and data recorded by a clinical auditor. Acceptability and usability of the app were measured by the System Usability Scale (SUS). Results: Forty-five patients participated in the study (mean age 61, 64% male). Overall, patients completed 159 of 179 (89%) of the available questionnaires through the app. Median time to complete a questionnaire was 2min 49s (i.q.r. 2′32″–4′36″). Substantial (kappa > 0.6) or almost perfect agreement (kappa > 0.8) and strong correlation (ICC > 0.7) between data collected through the app and by the clinical auditor was found for 14 ERP processes and four PROs. Patient-reported usability was high; mean SUS score was 87 (95% CI 83–91). Only 6 (13%) patients needed technical support to use the app. Forty (89%) patients found the app was helpful to achieve their daily goals, and 34 (76%) thought it increased their motivation to recover after surgery. Conclusions: This novel application provides a tool to record patient adherence to care processes and PROs, with high agreement with traditional clinical audit, high usability, and patient satisfaction. Future studies should investigate the use of mobile device apps as strategies to increase adherence to perioperative interventions.

Introduction: Enhanced recovery pathways (ERP) include a bundle of evidence-based preoperative, intraoperative, and postoperative interventions that together reduce morbidity and length of stay after colorectal surgery. Increased adherence with the bundle is associated with better postoperative outcomes, but adherence is lowest in the postoperative period. Identifying risk factors for lower adherence may help design quality improvement strategies. The aim of this study was to estimate the extent to which patient, procedural, and organizational factors predict adherence to postoperative ERP elements in laparoscopic colorectal surgery. Methods: Patients in an institutional ERP registry undergoing elective laparoscopic colorectal surgery between 2012 and 2014 were analyzed. The ERP included 10 postoperative ERP elements classified into 2 groups: those requiring patient participation (PP, 5 elements, including nutritional intake and mobilization) and those provided by the clinical team (CT, 5 elements, including removal of catheters and type of analgesia). The impact of baseline and intraoperative factors on adherence was estimated using stepwise linear regression. Results: A total of 223 patients were included (mean age 60, 48% male). Mean adherence was 79% to the PP bundle (range 65–93% for individual elements), and 82% for the CT bundle (range 68–98% for individual elements). The occurrence of nausea/vomiting in the first 24h was associated with lower adherence to both bundles. In the PP bundle, patients who arrived at the ward after 6p.m. had lower adherence. In the CT bundle, patients who had rectal resection had lower adherence while thoracic epidural was associated with higher adherence. Conclusions: With the exception of postoperative nausea and vomiting, predictors of adherence to ERP elements after colorectal surgery differed for elements requiring patient participation and those provided by the clinical team. Strategies to improve ERP adherence should target staff education and engagement of patients at risk for lower adherence.

Background: Increased adherence with enhanced recovery pathways (ERP) is associated with improved outcomes. However, adherence to postoperative elements that rely on patient participation remains suboptimal. Mobile device apps may improve delivery of health education material and have the potential to foster behavior change and improve patient compliance. The objective of this study was to estimate the extent to which a novel mobile device app affects adherence to an ERP for colorectal surgery in comparison to standard written education. Methods: This was a superiority, parallel-group, assessor-blind, sham-controlled randomized trial involving 97 patients undergoing colorectal resection. Participants were randomly assigned with a 1:1 ratio into one of two groups: (1) iPad including a novel mobile device app for postoperative education and self-assessment of recovery, or (2) iPad without the app. The primary outcome measure was mean adherence (%) to a bundle of five postoperative ERP elements requiring patient participation: mobilization, gastrointestinal motility stimulation, breathing exercises, and consumption of oral liquids and nutritional drinks. Results: In the intervention group, app usage was high (94% completed surveys on POD0, 82% on POD1, 72% on POD2). Mean overall adherence to the bundle on the two first postoperative days was similar between groups: 59% (95% CI 52–66%) in the intervention group and 62% (95% CI 56–68%) in the control group [Adjusted mean difference 2.4% (95% CI − 5 to 10%) p = 0.53]. Conclusions: In this randomized trial, access to a mobile health application did not improve adherence to a well-established enhanced recovery pathway in colorectal surgery patients, when compared to standard written patient education. Future research should evaluate the impact of applications integrating novel behavioral change techniques, particularly in contexts where adherence is low.