powerpoint-præsentation...4/20/2018 1 04/09/2018 dr. bente thoft jensen 1 bente thoft jensen, ph.d,...

4/20/2018

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04/09/2018 Dr. Bente Thoft Jensen 1

Bente Thoft Jensen, Ph.D, MPH, RNDepartment of Urology, Aarhus University Hospital

&

Department of Clinical Medicine, Centre of Research in RehabilitationAarhus University

Denmark

The 14th Annual Methodist Research Day

“One Year Follow-Up of the Efficacy of Pre-Habilitation in Radical Cystectomy Pathways”


Assoc. Professor , Department of Urology & Urological Research Unit

Director – group of the Research Program ” Rehabilitation”, Aarhus University Hospital

Chair the Scientific group –EAUN (step down in March 2018)

Chair Bladder SIG-Group, EAUN

European School of Urology Nursing, Steering Committee

Patient Education / Information – group - EAU

Member of National Nursing Research Council

National Board of Health – Urology Cancer

Bente Thoft Jensen, Ph.D., MPH, RN

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Oncology Section - AUH

The Department Managements for the 11 treatment areas who won an award for being number one in their field(photo: Michael Harder, Aarhus University Hospital).


For the tenth year running, Aarhus University Hospital is Denmark’s best hospital. The independent specialist newspaper on healthcare sector news ”Dagens Medicin” has appointed Aarhus University Hospital as the best in their competition to become Denmark’s best hospital.

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Objectives

To empower nursing research exemplified by a recent study at MSKCC /SKI & Aarhus University Hospital

To update the audience on current practice evidence in ERAS pathways with regards to major abdominal oncology surgery

Discuss nursing research and challenges How can we share experiences across the pond… e.g. international fellowships, cooperate professionally (studies, conferences etc.), educational initiatives

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Overall aims of Enhanced Recovery after Surgery - ERAS

Minimize: Surgical stress response (metabolic /hormonal cascade)Postoperative morbidity

Improve:PROM`s

Clinical & oncological outcome

4/20/2018 Bente Thoft Jensen , Ph.D. Aarhus University Hospital

What is ERAS?

The ERAS Society, a non-profit medical organization, was formed in 2001 with the aim to establish evidence based protocols as best practice standards in perioperative care.

Its mission is to develop perioperative care and improve recovery through research, education, audit and implementation of evidence based best practice.

The ERAS® Society was constituted in 2001– Urology Chapter was officially formed at the 2016 World Congress in Lisbon

The ERAS Society has published a wide range of publications regarding protocols and guidelines for enhanced recovery after surgery.

Nursing is a part of the multi-disciplinary group in ERAS

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Working with an ERAS program is a multidisciplinary challenge to improve:

• The standard of care

• Knowledge of the research evidence and care principles

• Need of organizational changes required to make ERAS programs function in clinical practice.

ContactsAngie Balfour, ERAS Nursing Specialist, ScotlandEmail: [email protected]

4/20/2018Bente Thoft Jensen , Ph.D, Aarhus University Hospital ,

Denmark

Why is the patient still in hospital today?

ERAS …The Basic Question…

Henrik Kehlet 2015

http://erassociety.org/

http://erassociety.org/educational-resources/publications/

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• The idea of ERAS Pathways initiated the focus of early recovery (LOS)and is today based on level 1 and level 2 evidence (multi-professional studies)

• Positive impact on postoperative functional capacity, recovery, self-efficacy & HRQoL ( but for how long??)

• Prehabilitation facilitate the return / maintain baseline condition ?leading to evidence supporting an extended ERAS pathway….

Why is the patient still in the hospital today (early recovery=Length of stay)

Does it work in practice ?



One Year Follow-Up of the Efficacy of Pre-Habilitation

in Radical Cystectomy Pathways”


Hypotheses

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Increasing age increase the risk of cancer (BC)


Poor physical performance and nutritional risk increase the risk of:

Postoperative complications (>60 %)

Mortality ( 3 %)

Loss of muscle mass and strength (20 %)

Demineralization of bone (sarcopenia)

Loss of aerobic capacity, vasomotor stability

Changes in respiratory function


Candidates for ERAS - RC because of muscle invasive bladdercancer

Late Pre-opPrepare the discharge goals

Carbohydrate loadNo bowl wash-out

Fasting 4-6 H at maxMinimal surgery:

Mini-lab procedure /robot etc.Optimize anesthetics

AntibioticsThrombo-prophylaxis oxygen therapy,

fluid therapy, Pain-relief regimeRevision of care : Sepona; catheter,

drain, stents, pain-relief etcEarly oral nutrition

Early Ambulation (training)Adjust to “frail” patient

Extended ERAS program?Evidence?

EnhancedRecovery(19 to 7

days)

Kehlet H (2009). Components of interventions to facilitate postoperative recovery

ERAS RC in Denmark – Europe 2005


ERAS in ”Urology Cancer Care”

B. Thoft Jensen et al, Current Opinion in Urology; 28(2) May 2018:

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Efficacy of a multi-professional rehabilitation programmein radical cystectomy pathways: a prospective randomized

controlled trial. Aarhus University & Centre of Research in Rehabilitation 2011-2014

www.ClinicalTrial.gov (NCT 01329107)

Consort FlowchartCourtesy of Sca J Urol 2016 & B.T.Jensen


Interaction Between Nutrient and Physical Exercises - Use It or Lose It….

Evidence-based Recommendations for Optimal Protein Intake in Older People: A position paper from the PROT-Age Study Group

J Bauer et al, JAMDA 2013


• Education (nutritional /physical axis)- protein loading min 1.2 g/ kg/ day

• 1.5 H instruction by a physiotherapist incl follow-up

• Daily training program consisting of 10 figures with xx repetition -Duration: 30 min /day – step-trainer handled out

• Outdoor activity: 30 min walk / dance/ swimming / cycling / riding / gardening

• Preoperative stoma-education , training kit for practice at home

Intervention pre-operatively


Learn smart….. & Eat smart

http://www.clinicaltrial.gov/

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Protein intake and exercise for optimal muscle function with

aging: Recommendations from the ESPEN Expert GroupNicolaas E.P. Deutz a,*, Jürgen M. Bauer b, Rocco Barazzoni c, Gianni Biolo c, Yves Boirie d,

Anja Bosy-Westphal e, Tommy Cederholm f,g, Alfonso Cruz-Jentoft h, Zeljko Krznariç i,K. Sreekumaran Nair j, Pierre Singer k, Daniel Teta l, Kevin Tiptonm, Philip C. Calder n,o

Short-term p-booster before major surgery (ESPEN- guideline)


Self- efficacy…….


Personal Log-book

Physical data

Nutrition

Stoma self-efficacy


• Education (nutritional /physical axis)

• Everyday progressive physical and nutritional goals

• Post-operative stoma-education: everyday goals to improve self-efficacy measured by the Urostomy Stoma Education Scale

• Exact set of discharge criteria (same for all patients)

Intervention post-operatively

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Muscle-power (functional capacity) - Watt /kgBio-impedance Hand-grip –NewtonEORTC QLQ C30+ BLS24 +BLM30Oral intake ( P - KJ past 2 weeks)Oral Supplements-------------------------------------KATZ –score (6 ADL skills )Walked distance in M /day ( post-op mobilization)Hours totally mobilized / dayOral intake ( P - KJ until discharge)Oral SupplementsEORTC INPATSAT -32 ( patient satisfaction with service of the staff)Stoma self-efficacy (Urostomy education scale)

Measurements * Repeated at discharge, 4 and 12 months


Results:

Significantly improved musclepower and maintained nutritional status ahead of surgery

Significantly better mobilized ( functional / physical activity)

Significantly reduced the time to independently perform ADL

Significantly improved HRQoL Parameters in 50% of ITEMS EORTC ( QLQ C30 + BLS24 7 BLM30

Significantly improved stoma self-care

Improved patient-satisfaction (EORTC INPATSAT-32)

No difference in LOS


Efficacy of preoperative uro-stoma education on self-efficacy after Radical Cystectomy; secondary outcome of a prospective randomized controlled trial.Jensen BT, Kiesbye B, Soendergaard I, Jensen JB, Kristensen SA.Eur J Oncol Nurs. 2017 Jun;28:41-46.

Exercise-based pre-habilitation is feasible and effective in radical cystectomy pathways-secondary results from a randomized controlled trial.Jensen BT, Laustsen S, Jensen JB, Borre M, Petersen AK.Support Care Cancer. 2016 Aug;24(8):3325-31

Efficacy of a multiprofessional rehabilitation programme in radical cystectomy pathways: a prospective randomized controlled trial.Jensen BT, Petersen AK, Jensen JB, Laustsen S, Borre M.Scand J Urol. 2015 Apr;49(2):133-41.

Multidisciplinary rehabilitation can impact on health-related quality of life outcome in radical cystectomy: secondary reported outcome of a randomized controlledtrial.Jensen BT, Jensen JB, Laustsen S, Petersen AK, Søndergaard I, Borre M.J Multidiscip Healthc. 2014 Jul 16;7:301-11

Results – it is effective……


So What ……..?

B. Thoft Jensen et al, Current Opinion in Urology; 28(2) May 2018:

https://www.ncbi.nlm.nih.gov/pubmed/28478854




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Hypotheses

Late Pre-opPrepare the discharge goals

Carbohydrate loadNo bowl wash-out

Fasting 4-6 H at maxMinimal surgery:

Mini-lab procedure /robot etc.Optimize anesthetics

AntibioticsThrombo-prophylaxis oxygen therapy,

fluid therapy, Pain-relief regimeRevision of care : Sepona; catheter,

drain, stents, pain-relief etcEarly oral nutrition

Early Ambulation (training)Adjust to “frail” patient

Prehabilitation:Nutrition: P- loading

Physical exercisesStoma care

Sexual-health(RCT)*Smoking /Alkohol

Shared- decision tool* (BC)

Enhancedrecovery

Kehlet H (2009). Components of interventions to facilitate postoperative recovery

Standard ERAS in Denmark 2018

* Studies to be launched in 2018


Efficacy of pre and post-habilitation in RC pathways; One year follow- upB. Thoft Jensen et al

Muscle capacity / functional capacity

Nutritional Status


Stoma self-efficacy – one year follow up

Level of Stoma self-care measured on the Urostomy Education Scale

01

23

Mea

n S

core

Skill 1 Skill 2 Skill 3 Skill 4 Skill 5 Skill 6 Skill 7

35 post-operative days

Intervention Standard

01

23

Mea

n S

core




01

23

Mea

n S

core




Day 35 Day 120 Day 365

Efficacy of preoperative uro-stoma education on self-efficacy after Radical Cystectomy; secondary outcome of a prospective randomized controlled trial.Jensen BT, Kiesbye B, Soendergaard I, Jensen JB, Kristensen SA.Eur J Oncol Nurs. 2017 Jun;28:41-46.


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Efficacy of pre and post-habilitation in RC pathways; One year follow- upB. Thoft Jensen et al, EAU, Copenhagen March 2018

Discussion ….

OBS


Measures of

effectiveness

Baseline (2 weeks

pre-surgery)

Mean (95% CI)

Admission

(day of surgery)

Mean (95% CI)

Change from

baseline to admission

p Follow Up

(6 weeks post-surgery)

Mean (95% CI)

Change from baseline to

follow-up

p

Hand grip strength,

% of ASPV

85.9 (77.9−94.1) 92.7 (84.5−101.0) 6.8 0.001^ 85.1 (75.4−92.8) -0.8 0.7

Walking distance,

% of ASPV

65.7 (60.1−71.4) NA NA NA 74.9 (66.6−83.1) 9.2 0.03^

ASPV = Age standardized predicted values

Results: Changes in Nutritional Status and Physical Functioning


Measures of

effectiveness

Baseline (2

weeks pre-

surgery)

Mean (95% CI)

Admission

(day of surgery)

Mean (95% CI)

Change from

baseline to

admission

p Follow Up

(6 weeks post-surgery)

Mean (95% CI)

Change from baseline

to follow-up

p

Body weight, kg 91.1 (84.3−97.8) 90.2 (83.4−97.0) -0.9 0.06 85.6 (79.6−91.6) -5.5 0.01^

Body fat, % 25.2 (20.9−29.4) 25.7 (21.6−29.7) 0.5 0.6 25.0 (20.3−29.2) -0.2 0.9

Bone mass, kg 3.2 (3.0−3.4) 3.5 (3.3−3.7) 0.3 0.04^ 3.8 (3.3−4.4) 0.6 0.04^

Body water, % 50.4 (47.8−53.9) 49.3 (46.6−52.0) -0.9 0.1 50.9 (48.3−56.5) 0.5 0.5

BMI 30.1 (27.6−32.5) 31.6 (28.9−34.3) -1.5 0.2 27.7 (25.6−29.8) 2.3 0.001^

Results: Changes in Bio- impedance parameters


AdherenceOdds ratio (95% CI)

Single regressionP- value

Adjusted odds ratio (95% CI)

Multi-regressionp - value

Neoadjuvant

chemotherapy

No * *

Yes 0.21 (0.04−0.9) 0.04 0.27 (0.02−1.2) 0.11

ASA

<3 * *

≥3 0.15 (0.01−1.27) 0.08 0.18 (0.01−2.06) 0.17

Karnofsky Performance

Scale

≥80% * *

<80 4.5 (0.92−21.9) 0.06 2.1 (0.34−12.8) 0.41

Age

<70 *

≥70 3 (0.67−1.3) 0.15 Not qualified

Nutritional risk*

<3 *

≥3 0.33 (0.06−1.6) 0.17 Not qualified

Multivariate logistic regression model evaluating potential predictors of non-adherence to the program

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What is ERAS?

The ERAS Society, ,,,,,,with the aim to establish evidence based protocols as best practice standards in perioperative care.

Its mission is to develop perioperative care and improve recovery through research, education, audit and implementation of evidence based best practice.


Who’s gaining?

- The intention is to address and integrate health prevention

and promotion in the patient pathways

-Support the work towards better health gain by integrating

Health Promotion into the organizational structure and

culture of the hospitals and health services


ERAS success depends on 4 components…

Personal clinical experience of the nurse / team /surgeon

Existing resources & priorities (healthcare system ? )

Willingness in the organisation to change agenda…

Patient perspective, patient wishes and ideas

Results of science


Conclusion:

Prehabilitation is evidence based and improve the transition into the survival-phase

• Nutrition

• Physical program

• Pre-op Stoma-education

• Smoking Alcohol cession

• Patient involvement*

• Sexual health*B. Thoft Jensen et al, Current Opinion in Urology; 28(2) May 2018

http://erassociety.org/

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Thank you


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