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Pierce A, Teeling SP, McNamara M, O’Daly B, Daly A. Using Lean Six Sigma in a Private Hospital Setting to Reduce Trauma Orthopedic Patient Waiting Times and Associated Administrative and Consultant Caseload. Healthcare (Basel) 2023; 11:2626. [PMID: 37830663 PMCID: PMC10572702 DOI: 10.3390/healthcare11192626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 09/08/2023] [Accepted: 09/25/2023] [Indexed: 10/14/2023] Open
Abstract
In Ireland, the extent of outpatient orthopedic waiting lists results in long waiting times for patients, delays in processing referrals, and variation in the consultant caseload. At the study site, the Define, Measure, Analyze, Improve, and Control (DMAIC) Lean Six Sigma framework was applied to evaluate sources of Non-Value-Added (NVA) activity in the process of registering and triaging patients referred to the trauma orthopedic service from the Emergency Department. A pre- (October-December 2021)/post- (April-August 2022) intervention design was employed, utilizing Gemba, Process Mapping, and the TIMWOODS tool. Embracing a person-centered approach, stakeholder Voice of Customer feedback was sought at each stage of the improvement process. Following data collection and analysis, a co-designed pilot intervention (March 2022) was implemented, consisting of a new triage template, dedicated trauma clinic slots, a consultant triage roster, and a new option to refer directly to physiotherapy services. This resulted in the total wait time of patients for review being reduced by 34%, a 51% reduction in the process steps required for registering, and an increase in orthopedic consultant clinic capacity of 22%. The reduction in NVA activities in the process and the increase in management options for triaging consultants have delivered a more efficient trauma and orthopedic pathway.
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Affiliation(s)
- Anthony Pierce
- Beacon Hospital, Beacon Court, Bracken Rd, Sandyford Business Park, Sandyford, D18 AK68 Dublin, Ireland
| | - Seán Paul Teeling
- UCD Centre for Interdisciplinary Research, Education & Innovation in Health Systems, School of Nursing, Midwifery & Health Systems UCD Health Sciences Centre, D04 VIW8 Dublin, Ireland; (S.P.T.)
- Centre for Person-Centered Practice Research Division of Nursing, School of Health Sciences, Queen Margaret University Drive, Queen Margaret University, Musselburgh EH21 6UU, UK
| | - Martin McNamara
- UCD Centre for Interdisciplinary Research, Education & Innovation in Health Systems, School of Nursing, Midwifery & Health Systems UCD Health Sciences Centre, D04 VIW8 Dublin, Ireland; (S.P.T.)
| | - Brendan O’Daly
- Beacon Hospital, Beacon Court, Bracken Rd, Sandyford Business Park, Sandyford, D18 AK68 Dublin, Ireland
| | - Ailish Daly
- Beacon Hospital, Beacon Court, Bracken Rd, Sandyford Business Park, Sandyford, D18 AK68 Dublin, Ireland
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Romatoski KS, Chung SH, de Geus SWL, Papageorge MV, Woods AP, Rasic G, Ng SC, Tseng JF, Sachs TE. Combined High-Volume Common Complex Cancer Operations Safeguard Long-Term Survival in a Low-Volume Individual Cancer Operation Setting. Ann Surg Oncol 2023; 30:5352-5360. [PMID: 37310536 DOI: 10.1245/s10434-023-13680-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 05/08/2023] [Indexed: 06/14/2023]
Abstract
BACKGROUND We previously demonstrated the importance of combined complex surgery volume on short-term outcomes of high-risk cancer operations. This study investigates the impact of combined common complex cancer operation volume on long-term outcomes at hospitals with low cancer-specific operation volumes. PATIENTS AND METHODS A retrospective cohort of National Cancer Data Base (2004-2019) patients undergoing surgery for hepatocellular carcinoma, non-small cell lung cancers, or pancreatic, gastric, esophageal, or rectal adenocarcinomas was utilized. Three separate cohorts were established: low-volume hospitals (LVH), mixed-volume hospitals (MVH) with low-volume individual cancer operations and high-volume total complex operations, and high-volume hospitals (HVH). Survival analyses were performed for overall, early-, and late-stage disease. RESULTS The 5 year survival was significantly better at MVH and HVH compared with LVH, for all operations except late-stage hepatectomy (HVH survival > LVH and MVH). The 5 year survival probability was similar between MVH and HVH for operations on late-stage cancers. Early and overall survival for gastrectomy, esophagectomy, and proctectomy were equivalent between MVH and HVH. While early and overall survival for pancreatectomy were benefited by HVH over MVH, the opposite was true for lobectomy/pneumonectomy, which were benefited by MVH over HVH; however, none of these differences were likely to have an effect clinically. Only hepatectomy patients demonstrated statistical and clinical significance in 5 year survival at HVH compared with MVH for overall survival. CONCLUSIONS MVH hospitals performing sufficient complex common cancer operations demonstrate similar long-term survival for specific high-risk cancer operations to HVH. MVH provide an adjunctive model to the centralization of complex cancer surgery, while maintaining quality and access.
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Affiliation(s)
- Kelsey S Romatoski
- Department of Surgery, Boston Medical Center, Chobanian & Avedisian School of Medicine, Boston University, Boston, MA, USA
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Sophie H Chung
- Department of Surgery, Boston Medical Center, Chobanian & Avedisian School of Medicine, Boston University, Boston, MA, USA
| | - Susanna W L de Geus
- Department of Surgery, Boston Medical Center, Chobanian & Avedisian School of Medicine, Boston University, Boston, MA, USA
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Marianna V Papageorge
- Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, USA
| | - Alison P Woods
- Division of Surgical Oncology, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Gordana Rasic
- Department of Surgery, Boston Medical Center, Chobanian & Avedisian School of Medicine, Boston University, Boston, MA, USA
| | - Sing Chau Ng
- Department of Surgery, Boston Medical Center, Chobanian & Avedisian School of Medicine, Boston University, Boston, MA, USA
| | - Jennifer F Tseng
- Department of Surgery, Boston Medical Center, Chobanian & Avedisian School of Medicine, Boston University, Boston, MA, USA
| | - Teviah E Sachs
- Department of Surgery, Boston Medical Center, Chobanian & Avedisian School of Medicine, Boston University, Boston, MA, USA.
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de Geus SW, Papageorge MV, Woods AP, Wilson S, Ng SC, Merrill A, Cassidy M, McAneny D, Tseng JF, Sachs TE. A Rising Tide Lifts All Boats: Impact of Combined Volume of Complex Cancer Operations on Surgical Outcomes in a Low-Volume Setting. J Am Coll Surg 2022; 234:981-988. [PMID: 35703786 PMCID: PMC9204842 DOI: 10.1097/xcs.0000000000000228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Centralization for complex cancer surgery may not always be feasible owing to socioeconomic disparities, geographic constraints, or patient preference. The present study investigates how the combined volume of complex cancer operations impacts postoperative outcomes at hospitals that are low-volume for a specific high-risk cancer operation. STUDY DESIGN Patients who underwent pneumonectomy, esophagectomy, gastrectomy, hepatectomy, pancreatectomy, or proctectomy were identified from the National Cancer Database (2004-2017). For every operation, 3 separate cohorts were created: low-volume hospitals (LVH) for both the individual cancer operation and the total number of those complex operations, mixed-volume hospital (MVH) with low volume for the individual cancer operation but high volume for total number of complex operations, and high-volume hospitals (HVH) for each specific operation. RESULTS LVH was significantly (all p ≤ 0.01) predictive for 30-day mortality compared with HVH across all operations: pneumonectomy (9.5% vs 7.9%), esophagectomy (5.6% vs 3.2%), gastrectomy (6.8% vs 3.6%), hepatectomy (5.9% vs 3.2%), pancreatectomy (4.7% vs 2.3%), and proctectomy (2.4% vs 1.3%). Patients who underwent surgery at MVH and HVH demonstrated similar 30-day mortality: esophagectomy (3.2 vs 3.2%; p = 0.993), gastrectomy (3.2% vs 3.6%; p = 0.637), hepatectomy (3.8% vs 3.2%; p = 0.233), pancreatectomy (2.8% vs 2.3%; p = 0.293), and proctectomy (1.2% vs 1.3%; p = 0.843). Patients who underwent pneumonectomy at MVH demonstrated lower 30-day mortality compared with HVH (5.4% vs 7.9%; p = 0.045). CONCLUSION Patients who underwent complex operations at MVH had similar postoperative outcomes to those at HVH. MVH provide a model for the centralization of complex cancer surgery for patients who do not receive their care at HVH.
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Affiliation(s)
- Susanna Wl de Geus
- From the Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA (de Geus, Papageorge, Woods, Wilson, Chau Ng, Merrill, Cassidy, McAneny, Tseng, Sachs)
| | - Marianna V Papageorge
- From the Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA (de Geus, Papageorge, Woods, Wilson, Chau Ng, Merrill, Cassidy, McAneny, Tseng, Sachs)
| | - Alison P Woods
- From the Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA (de Geus, Papageorge, Woods, Wilson, Chau Ng, Merrill, Cassidy, McAneny, Tseng, Sachs)
- Division of Surgical Oncology, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD (Woods)
| | - Spencer Wilson
- From the Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA (de Geus, Papageorge, Woods, Wilson, Chau Ng, Merrill, Cassidy, McAneny, Tseng, Sachs)
| | - Sing Chau Ng
- From the Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA (de Geus, Papageorge, Woods, Wilson, Chau Ng, Merrill, Cassidy, McAneny, Tseng, Sachs)
| | - Andrea Merrill
- From the Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA (de Geus, Papageorge, Woods, Wilson, Chau Ng, Merrill, Cassidy, McAneny, Tseng, Sachs)
| | - Michael Cassidy
- From the Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA (de Geus, Papageorge, Woods, Wilson, Chau Ng, Merrill, Cassidy, McAneny, Tseng, Sachs)
| | - David McAneny
- From the Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA (de Geus, Papageorge, Woods, Wilson, Chau Ng, Merrill, Cassidy, McAneny, Tseng, Sachs)
| | - Jennifer F Tseng
- From the Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA (de Geus, Papageorge, Woods, Wilson, Chau Ng, Merrill, Cassidy, McAneny, Tseng, Sachs)
| | - Teviah E Sachs
- From the Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA (de Geus, Papageorge, Woods, Wilson, Chau Ng, Merrill, Cassidy, McAneny, Tseng, Sachs)
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Cost-Benefit Analysis of an Enhanced Recovery Program for Gastrectomy A Retrospective Controlled Analysis. World J Surg 2021; 45:3249-3257. [PMID: 34365531 PMCID: PMC8476461 DOI: 10.1007/s00268-021-06220-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2021] [Indexed: 02/04/2023]
Abstract
Background Enhanced recovery programs (ERP) demonstrated decreased postoperative complication rate and reduced length of stay (LOS). Recently, data on the financial impact revealed cost reduction for colorectal, liver and pancreatic surgery. The present study aimed to assess the cost-effectiveness of ERP in gastric surgery. Methods ERP based on enhanced recovery after surgery (ERAS®) society guidelines was implemented in our institution, in June 2014. Consecutive patients undergoing gastric surgery after ERP implementation (n = 71) were compared to a control group of consecutive patients operated before ERP implementation (n = 58). Primary endpoint was cost-effectiveness including detailed perioperative costs. Secondary endpoints were postoperative complications and LOS. Standard statistical testing (means, Mann–Whitney Fisher’s exact T test or Pearson Chi-square test) was used. Results Both groups were comparable regarding demographic details. Mean (SD) overall costs per patient were lower in the ERP group (€33,418 (17,901) vs €39,804 (27,288), P = 0.027). Lower costs were found for anesthesia and operating room (−€2 356), intensive or intermediate care (−€8 629), medication (−€1 196)), physiotherapy (−€611), laboratory (−€1 625)) and blood transfusion (−€977). Overall complication rates in ERP and control group (51% vs 62%, P = 0.176) were similar. Mean length of stay (SD) (14(13) days vs 17(11) days, P = 0.037) was shorter in the ERP group. Conclusion ERP significantly reduces overall, preoperative and postoperative costs in patients undergoing major gastric surgery.
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Richardson C, Abrol A, Cabrera CI, Goldstein J, Maronian N, Rodriguez K, D'Anza B. The power of a checklist: Decrease in emergency department epistaxis transfers after clinical care pathway implementation. Am J Otolaryngol 2021; 42:102941. [PMID: 33592555 DOI: 10.1016/j.amjoto.2021.102941] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 01/23/2021] [Indexed: 01/14/2023]
Abstract
BACKGROUND Annually, epistaxis costs US hospitals over $100 million dollars. Many patients visit emergency departments (ED) with variable treatment, thus providing opportunity for improvement. OBJECTIVE To implement an epistaxis clinical care pathway (CCP) in the ED, and analyze its effects on treatment and ED transfers. METHODS An interdisciplinary team developed the CCP to be implemented at a tertiary hospital system with 11 satellite EDs. The analysis included matched eight-month periods prior to pathway implementation and after pathway implementation. Subjects included patients with ICD-10 code diagnosis of epistaxis. Patients under 18 years old, recent surgery or trauma, or bleeding disorders were excluded. There were 309 patients from the pre-implementation cohort, 53 of which were transferred and 37 met inclusion criteria; 322 from the post-implementation cohort, 37 of which were transferred, and 15 met inclusion criteria. Outcome measures included epistaxis intervention by ED providers and otolaryngologists before and after pathway implementation. RESULTS CCP implementation resulted in a 61% reduction in patient transfers (p < 0.001). ED providers showed a 51% increase in documentation of anterior rhinoscopy with proper equipment, 34% increased use of topical vasoconstrictors, 40% increased use of absorbable packing, 7% decrease in use of unilateral non-absorbable packing, and 17% decrease in use of bilateral non-absorbable packing. CONCLUSIONS Prior to CCP implementation, ED treatment of epistaxis varied significantly. CCP resulted in standardized treatment and significant reduction in transfers. A CCP checklist is an effective way to standardize care and prevent unnecessary hospital transfers.
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Abstract
Vaginoplasty is a commonly performed surgery for the transfeminine patient. In this review, we discuss how to achieve satisfactory surgical outcomes, and highlight solutions to common complications involved with the surgery, including: wound separation, vaginal stenosis, hematoma, and rectovaginal fistula. Pre-operative evaluation and standard technique are outlined. Goal outcomes regarding aesthetics, creation of a neocavity, urethral management, labial appearance, vaginal packing and clitoral sizing are all described. Peritoneal vaginoplasty technique and visceral interposition technique are detailed as alternatives to the penile inversion technique in case they are needed to be used. Post-operative patient satisfaction, patient care plans, and solutions to common complications are reviewed.
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Affiliation(s)
- Joy S Li
- University of Texas at Austin,110 Inner Campus Drive, Austin, US
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Ryan JM, O'Connell E, Rogers AC, Sorensen J, McNamara DA. Systematic review and meta-analysis of factors which reduce the length of stay associated with elective laparoscopic cholecystectomy. HPB (Oxford) 2021; 23:161-172. [PMID: 32900611 PMCID: PMC7474810 DOI: 10.1016/j.hpb.2020.08.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 08/16/2020] [Accepted: 08/17/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Laparoscopic cholecystectomy is a safe ambulatory procedure in appropriately selected patients; however, day case rates remain low. The objective of this systematic review and meta-analysis was to identify interventions which are effective in reducing the length of stay (LOS) or improving the day case rate for elective laparoscopic cholecystectomy. METHODS Comparative English-language studies describing perioperative interventions applicable to elective laparoscopic cholecystectomy in adult patients and their impact on LOS or day case rate were included. RESULTS Quantitative data were available for meta-analysis from 80 studies of 10,615 patients. There were an additional 17 studies included for systematic review. The included studies evaluated 14 peri-operative interventions. Implementation of a formal day case care pathway was associated with a significantly shorter LOS (MD = 24.9 h, 95% CI, 18.7-31.2, p < 0.001) and an improved day case rate (OR = 3.5; 95% CI, 1.5-8.1, p = 0.005). Use of non-steroidal anti-inflammatories, dexamethasone and prophylactic antibiotics were associated with smaller reductions in LOS. CONCLUSION Care pathway implementation demonstrated a significant impact on LOS and day case rates. A limited effect was noted for smaller independent interventions. In order to achieve optimal day case targets, a greater understanding of the effective elements of a care pathway and local barriers to implementation is required.
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Affiliation(s)
- Jessica M. Ryan
- Department of General Surgery, Midland Regional Hospital, Mullingar, Westmeath, Ireland,Correspondence: Jessica M. Ryan, Department of Colorectal Surgery, Beaumont Hospital, Dublin, Ireland
| | | | - Ailín C. Rogers
- Department of Colorectal Surgery, St. James's Hospital, Dublin, Ireland
| | | | - Deborah A. McNamara
- Royal College of Surgeons, Dublin, Ireland,Department of Colorectal Surgery, Beaumont Hospital, Dublin, Ireland,National Clinical Programme in Surgery, Royal College of Surgeons in Ireland, Proud's Lane, Dublin 2, Ireland
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Lee XJ, Blythe R, Choudhury AAK, Simmons T, Graves N, Kularatna S. Review of methods and study designs of evaluations related to clinical pathways. AUST HEALTH REV 2020; 43:448-456. [PMID: 30089529 DOI: 10.1071/ah17276] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 05/19/2018] [Indexed: 11/23/2022]
Abstract
Objective The HealthPathways program is an online information portal that helps clinicians provide consistent and integrated patient care within a local health system through localised pathways for diagnosis, treatment and management of various health conditions. These pathways are consistent with the definition of clinical pathways. Evaluations of HealthPathways programs have thus far focused primarily on website utilisation and clinical users' experience and satisfaction, with limited evidence on changes to patient outcomes. This lack motivated a literature review of the effects of clinical pathways on patient and economic outcomes to inform a subsequent HealthPathways evaluation. Methods A systematic review was performed to summarise the analytical methods, study designs and results of studies evaluating clinical pathways with an economic outcome component published between 1 January 2000 and 31 August 2017 in four academic literature databases. Results Fifty-five relevant articles were identified for inclusion in this review. The practical pre-post study design with retrospective baseline data extraction and prospective intervention data collection was most commonly used in the evaluations identified. Straightforward statistical methods for comparing outcomes, such as the t-test or χ2 test, were frequently used. Only four of the 55 articles performed a cost-effectiveness analysis. Clinical pathways were generally associated with improved patient outcomes and positive economic outcomes in hospital settings. Conclusions Clinical pathways evaluations commonly use pragmatic study designs, straightforward statistical tests and cost-consequence analyses. More HealthPathways program evaluations focused on patient and economic outcomes, clinical pathway evaluations in a primary care setting and cost-effectiveness analyses of clinical pathways are needed. What is known about the topic? HealthPathways is a web-based program that originated from Canterbury, New Zealand, and has seen uptake elsewhere in New Zealand, Australia and the UK. The HealthPathways program aims to assist the provision of consistent and integrated health services through dedicated, localised pathways for various health conditions specific to the health region. Evaluations of HealthPathways program focused on patient and economic outcomes have been limited. What does this paper add? This review synthesises the academic literature of clinical pathways evaluations in order to inform a subsequent HealthPathways evaluation. The focus of the synthesis was on the analytical methods and study designs used in the previous evaluations. The previous clinical pathway evaluations have been pragmatic in nature with relatively straightforward study designs and analysis. What are the implications for practitioners? There is a need for more economic and patient outcome evaluations for HealthPathways programs. More sophisticated statistical analyses and economic evaluations could add value to these evaluations, where appropriate and taking into consideration the data limitations.
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Affiliation(s)
- Xing Ju Lee
- Institute of Health and Biomedical Innovations, School of Public Health and Social Work, Queensland University of Technology, Brisbane, 60 Musk Avenue, Kelvin Grove, Qld 4059, Australia.
| | - Robin Blythe
- Institute of Health and Biomedical Innovations, School of Public Health and Social Work, Queensland University of Technology, Brisbane, 60 Musk Avenue, Kelvin Grove, Qld 4059, Australia.
| | - Adnan Ali Khan Choudhury
- Northern Queensland Primary Health Network, James Cook University, Building 500, 1 James Cook Drive, Douglas, Qld 4811, Australia. Email
| | - Toni Simmons
- Mackay Hospital and Health Service, Mackay, 475 Bridge Road, Mackay, Qld 4740, Australia. Email
| | - Nicholas Graves
- Institute of Health and Biomedical Innovations, School of Public Health and Social Work, Queensland University of Technology, Brisbane, 60 Musk Avenue, Kelvin Grove, Qld 4059, Australia.
| | - Sanjeewa Kularatna
- Institute of Health and Biomedical Innovations, School of Public Health and Social Work, Queensland University of Technology, Brisbane, 60 Musk Avenue, Kelvin Grove, Qld 4059, Australia.
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Arabacioglu D, Lehn A, Herrmann E, Albers B, Hanisch E, Buia A. Evaluating a Clinical Pathway in Laparoscopic Cholecystectomy: Effective in Reducing Complications? A Propensity Score Matching Analysis. Visc Med 2020; 37:70-76. [PMID: 33718485 DOI: 10.1159/000506718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 02/17/2020] [Indexed: 11/19/2022] Open
Abstract
Background Care pathways are primarily aimed at decreasing length of hospital stay (LOS) and preventing unnecessary costs while maintaining or improving the quality of care. In laparoscopic cholecystectomy, there is insufficient evidence for proving an impact upon postoperative complications. Methods In this retrospective study, logistic regression was used to calculate a propensity score, and, after carrying out 1:1 nearest-neighbor matching, 296 patients were analyzed in both groups with regard to postoperative complications using the Clavien-Dindo classification system as a primary aim. In addition, secondary aims were LOS, compliance to care, and deviation from the care pathway with respect to patient discharge. Relative risk of the primary outcome was calculated and compared with the e-value as sensitivity testing approach. Results Due to the mandatory part of the care pathway, patient record compliance was 100%. Deviation from the care pathway with respect to the planned patient discharge on postoperative day 2 was noted in 16% of the cases. After adjustment for potential factors, the relative risk when comparing Clavien-Dindo complication grades 0 versus 1-4 is 1.64 (95% CI 0.87-3.11), which did not reach significance (p = 0.127). After matching, LOS lasted 3.69 days without and 3.26 days with the care pathway, respectively. Conclusions Against the background of already implemented structured standard operation procedures, a care pathway is not able to reduce postoperative complications. Nevertheless, we consider our clinical pathway a highly valuable tool for the interdisciplinary management of patient hospitalization under the supervision of experienced specialized surgeons.
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Affiliation(s)
- Duygu Arabacioglu
- Department of General, Visceral, and Thoracic Surgery, Asklepios Klinik Langen, Academic Teaching Hospital Goethe University Frankfurt, Langen, Germany
| | - Annette Lehn
- Department of Biostatistics and Mathematical Modeling, Goethe University Frankfurt, Frankfurt, Germany
| | - Eva Herrmann
- Department of Biostatistics and Mathematical Modeling, Goethe University Frankfurt, Frankfurt, Germany
| | - Benjamin Albers
- Department of General, Visceral, and Thoracic Surgery, Asklepios Klinik Langen, Academic Teaching Hospital Goethe University Frankfurt, Langen, Germany
| | - Ernst Hanisch
- Department of General, Visceral, and Thoracic Surgery, Asklepios Klinik Langen, Academic Teaching Hospital Goethe University Frankfurt, Langen, Germany
| | - Alexander Buia
- Department of General, Visceral, and Thoracic Surgery, Asklepios Klinik Langen, Academic Teaching Hospital Goethe University Frankfurt, Langen, Germany
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Noel P, Eddbali I, Nedelcu M, Lutfi R. The Interest of Enhanced Recovery After Surgery in a New Bariatric Center. J Laparoendosc Adv Surg Tech A 2019; 30:6-11. [PMID: 31573396 DOI: 10.1089/lap.2019.0456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: With the creation of a new bariatric center in Abu Dhabi, United Arab Emirates (UAE) and the organization of this bariatric department according to the international guidelines, a new activity of bariatric surgery started in January 2015. The surgeon had 20 years of experience in this field and he had performed over 5000 major laparoscopic bariatric procedures before starting this new bariatric program. The concept of enhanced recovery after bariatric surgery (ERABS) was applied from the beginning of the program. We decided to analyze the first 2 years of ERAS activity after having split them in two different periods: the 1st year of activity included restrictive procedures and the 2nd year associated malabsorptive surgeries. Materials and Methods: The results of the use of a fast-track program could be measured by different parameters like operative time, length of hospital stay, rate of complications, and rate of readmission and reoperation. Results: Between January and December 2015, 116 patients underwent a bariatric procedure. The mean age was 34.6 years (16-61) and average body mass index (BMI) was 41.7 kg/sqm (32-72.2). Sixty percent of patients were women and 37% of patients had at least one comorbidity (diabetes type 2, high blood pressure, hyperlipidemia, or sleep apnea). Ninety-four percent of the procedures were laparoscopic sleeve gastrectomy (LSG), 2.6% were laparoscopic Roux-en-Y gastric bypass, and 3.4% band removal. The mean operative time was 20 minutes for an LSG (14-45 minutes) and the average hospital stay was 1.2 days (standard deviation [SD]: 0.9-3.3). The rate of complications was 1.7% with 1 postoperative hematoma drained by CT scan on day 14 after the surgery and 1 relative stenosis endoscopically dilated on postoperative day 45. No reoperation was done. No leak was observed. At 1 year, the mean excess weight loss (EWL) was 64% (47-124) in 89 patients with a 76% rate of follow-up. For the 2nd year of activity in 2016, 142 patients went in the program. The mean age was 32.7 years (17-64) and average BMI was 42.3 kg/sqm (31-68). Seventy-two percent were women and 41% of the patients had one comorbidity or more. The majority of surgeries performed were LSG for 83.1% of the patients. RYGB was realized in 4.2% of cases, resleeve gastrectomy in 4.2%, and band removal in 1.4%. Some malabsorptive surgeries were performed as well, such as one anastomosis gastric bypass for 3 patients (4.2%), and single anastomosis duodeno-ilelal in 2 cases (2.8%). The average hospital stay was 1.5 days (SD: 0.9-3.5). No complication was observed. No reoperation was done. Two patients (1.4%) came back to the hospital on postoperative day 2 and 8 after a LSG for one or several episodes of vomiting without further complication. At 1 year, the mean EWL was 68% (49-154) in 98 patients with a 69% rate of follow-up. Conclusions: This new program of bariatric surgery in two steps using fast-track protocols, respecting international guidelines and with an experienced surgeon showed on its 1st year of implementation a 1.7% rate of readmission on 116 patients without reoperation or major complication and a hospital stay of 1.2 days. For the 2nd year of implementation with the inclusion of malabsorptive procedures only 2 patients (1.4%) were readmitted for a short episode of vomiting and the hospital stay was 1.5 days.
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Affiliation(s)
- Patrick Noel
- Bariatric and Metabolic Surgery Department, Mediclinic Parkview Hospital, Dubai, United Arab Emirates.,Bariatric and Metabolic Surgery Department, Centre de Chirurgie de l'Obésité de la clinique Saint Michel, Toulon, France
| | - Imane Eddbali
- Bariatric and Metabolic Surgery Department, Mediclinic Parkview Hospital, Dubai, United Arab Emirates
| | - Marius Nedelcu
- Bariatric and Metabolic Surgery Department, Centre de Chirurgie de l'Obésité de la clinique Saint Michel, Toulon, France
| | - Rami Lutfi
- Bariatric and Metabolic Surgery Department, Mercy Hospital and Medical Center, Chicago, Illinois
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van Hessen C, Roos M, Frederix G, Verleisdonk EJ, Clevers GJ, Davids P, Burgmans J. One-stop routing for surgical interventions: a cost-analysis of endoscopic groin repair. Surg Endosc 2019; 34:1968-1977. [PMID: 31321538 DOI: 10.1007/s00464-019-06971-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 07/01/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND Single-visit (SV) totally extraperitoneal (TEP) inguinal hernia repair is an efficient service without impairment of safety or complication rate. Data on the economic impact of this approach are rare. The aim of this study was to compare the costs between the SV TEP and the regular TEP in an employed healthy population from a hospital and societal point of view. METHODS Retrospectively collected hospital costs and prospectively collected societal costs were obtained from patients treated between July 2016 and January 2018. Outcome measures consisted of all documented institutional care, productivity loss and medical consumption. RESULTS For analysing the hospital costs, a total of 116 SV patients were matched to 116 regular patients. The hospital costs of a mean SV patient were €1148.78 compared to €1242.84 for a regular patient, with a mean difference of €94.06. Prospective analyses of 50 SV patients and 50 regular patients demonstrated higher societal costs for a mean regular patient (€2188.33) compared to a mean SV patient (€1621.44). The mean total cost difference between a SV TEP repair and a regular TEP repair equalled €660.95 corresponding to a 19.3% decrease in costs. CONCLUSIONS This comprehensive cost-analysis showed that in an employed, healthy population, the SV TEP repair outprices the regular TEP repair, with savings of €660.95 per patient, reflecting a 19.3% decrease in costs. This routing is mainly interesting from a societal point of view as the difference is mainly impacted by a decrease in societal costs.
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Affiliation(s)
- Coen van Hessen
- Department of Surgery/Hernia Clinic, Diakonessenhuis Utrecht/Zeist, Zeist, The Netherlands. .,Department of Surgery, Diakonessenhuis Utrecht/Zeist, Room: Secretariaat Heelkunde, Professor Lorentzlaan 76, 3707 HL, Zeist, The Netherlands.
| | - Marleen Roos
- Department of Surgery/Hernia Clinic, Diakonessenhuis Utrecht/Zeist, Zeist, The Netherlands
| | - Geert Frederix
- Julius Centre, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Egbert Jan Verleisdonk
- Department of Surgery/Hernia Clinic, Diakonessenhuis Utrecht/Zeist, Zeist, The Netherlands
| | - Geert Jan Clevers
- Department of Surgery/Hernia Clinic, Diakonessenhuis Utrecht/Zeist, Zeist, The Netherlands
| | - Paul Davids
- Department of Surgery/Hernia Clinic, Diakonessenhuis Utrecht/Zeist, Zeist, The Netherlands
| | - Josephina Burgmans
- Department of Surgery/Hernia Clinic, Diakonessenhuis Utrecht/Zeist, Zeist, The Netherlands
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Surgical teaching does not increase the risk of intraoperative adverse events. Int J Colorectal Dis 2018; 33:1715-1722. [PMID: 30143855 DOI: 10.1007/s00384-018-3143-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/10/2018] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Training and teaching are cornerstones in developing surgical skills. The present study aimed to compare intraoperative outcomes of colonic resections among fellows, consultants, and supervised trainees. METHODS Data of consecutive colonic resections including demographics, surgical details, and intraoperative outcomes were recorded in a prospectively maintained institutional database. All procedures were standardized and divided in three groups according to the main surgeons experience (fellow or consultant) and whether the procedure was taught. After weighting by inverse treatment probability, intraoperative adverse events including reactive conversion, blood loss, and operating time were compared between these three groups. RESULTS Six hundred sixty-four colectomies were analyzed between January 2014 and October 2017. Among them, 289 (43.5%) were taught. After weighted propensity score analysis, there was no difference between the three groups (fellow taken as reference), for intraoperative adverse event rate (odd ratio (OR) consultant 1.448 (IQR 0.728-2.878), p = 0.282; OR teaching 0.689 (IQR 0.295-1.609), p = 0.381), operating time (beta coefficient 0.76 (- 21.91-23.42), p = 0.947; beta coefficient - 10.79 (- 28.34-6.75), p = 0.919), conversion rates (OR 0.748 (0.329-1.515), p = 0.412; OR 1.025 (0.537-1.954), p = 0.940), pre-emptive conversion (OR 1.994 (0.198-20.032), p = 0.552; OR 0.659 (0.145-2.991), p = 0.583), intraoperative blood loss (beta coefficient 21.19 (- 25.87-68.25), p = 0.368; beta coefficient - 12.34 (- 56.13-31.44), p = 0.573), intraoperative transfusion (OR 1.962 (0.813-4.735), p = 0.127; OR 0.670 (0.260-1.727), p = 0.397), and rates of unusual bleeding (OR 1.273 (0.698-2.321), p = 0.422; OR 0.572 (0.290-1.126), p = 0.099). Time to preemptive conversion was shorter when procedures were performed by consultants (beta coefficient - 25.51 (- 47.71 to - 3.31), p = 0.025), while no difference was found for the teaching group (beta coefficient 4.48 (- 30.95-40.62), p = 0.788). CONCLUSION Within a standardized teaching environment, colonic resections were safely performed regardless of the surgical setting in the present cohort. Teaching does not increase intraoperative adverse events.
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Identifying and classifying indicators affected by performing clinical pathways in hospitals: a scoping review. INT J EVID-BASED HEA 2018; 16:3-24. [PMID: 29176429 DOI: 10.1097/xeb.0000000000000126] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
AIM To analyse the evidence regarding indicators affected by clinical pathways (CPW) in hospitals and offer suggestions for conducting comprehensive systematic reviews. METHODS We conducted a systematic scoping review and searched the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, Scopus, OVID, Science Direct, ProQuest, EMBASE and PubMed. We also reviewed the reference lists of included studies. The criteria for inclusion of studies included experimental and quasi-experimental studies, implementing CPW in secondary and tertiary hospitals and investigating at least one indicator. Quality of included studies was assessed by two authors independently using the Critical Appraisal Skills Program for clinical trials and cohort studies and the Joanna Briggs Institute Critical Appraisal Tool for Quasi-Experimental Studies. RESULTS Forty-seven out of 2191 studies met the eligibility and inclusion criteria. The majority of included studies had pretest-posttest quasi-experimental design and had been done in developed countries, especially the United States. The investigation of evidence resulted in identifying 62 indicators which were classified into three categories: input indicators, process and output indicators and outcome indicators. Outcome indicators were more frequent than other indicators. Complication rate, hospital costs and length of hospital stay were dominant in their own category. Indicators such as quality of life and adherence to guidelines have been considered in studies that were done in recent years. CONCLUSION Implementing CPW can affect different types of indicators such as input, process, output and outcome indicators, although outcome indicators capture more attention than other indicators. Patient-related indicators were dominant outcome indicators, whereas professional indicators and organizational factors were considered less extensively. WHAT IS KNOWN ABOUT THE TOPIC?: WHAT DOES THIS ARTICLE ADD?
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Holderried M, Hummel R, Falch C, Kirschniak A, Koenigsrainer A, Ernst C, Muller S. Compliance of Clinical Pathways in Elective Laparoscopic Cholecystectomy: Evaluation of Different Implementation Methods. World J Surg 2017; 40:2888-2891. [PMID: 27431317 DOI: 10.1007/s00268-016-3645-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Clinical pathways aim to standardize perioperative and postoperative care of surgical procedures and are shown to result in a significant optimization associated with cost reduction. The aim of this study was to establish the impact of two different implementations forms of clinical pathways on the pathway compliance and resulting costs. METHODS Data of patients undergoing elective cholecystectomy for symptomatic cholecystolithiasis were collected over two different periods: using a clinical pathway in the form of a paper-based checklist, or a clinical pathway integrated into the paper-based medical treatment and nursing documentation. Outcome measures were compliance of the clinical pathway and total costs per case. RESULTS The compliance was significantly higher using integrated pathways compared to paper-based checklists (n = 117 of 123, 95 % vs 54 of 118, 46 %; p < 0.001). Mean total costs (€2206 vs €2458, p = 0.027) and length of hospital stay (2.13 vs 2.77 days, p < 0.001) were significantly reduced by the integrated clinical pathway compared to checklists. Further, the variation of costs per case and variation of length of hospital stay were significantly smaller with integrated clinical pathway (±€440 vs ±€538, p = 0.039 and ±0.53 vs ±0.68 days, p < 0.001, respectively). No difference regarding postoperative complication was observed (n = 3 vs. 4 events; p = 0.67). CONCLUSION Integrated clinical pathways display a significant higher compliance compared to checklists resulting in reduced total costs, shorter hospital stay and a smaller variation of cost, making it a useful tool in process controlling and planning.
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Affiliation(s)
- Martin Holderried
- Department of Quality Management, Medical and Business Development, Tuebingen University Hospital, Tübingen, Germany.,Division of Economics and Management of Social Services, within the Institute of Health Care and Public Management, Hohenheim University, Stuttgart, Germany
| | - Rebecca Hummel
- Division of Economics and Management of Social Services, within the Institute of Health Care and Public Management, Hohenheim University, Stuttgart, Germany
| | - Claudius Falch
- Clinic for Visceral, General and Transplant Surgery, Tuebingen University Hospital, Waldhörnlestrasse 22, 72076, Tübingen, Germany
| | - Andreas Kirschniak
- Clinic for Visceral, General and Transplant Surgery, Tuebingen University Hospital, Waldhörnlestrasse 22, 72076, Tübingen, Germany
| | - Alfred Koenigsrainer
- Clinic for Visceral, General and Transplant Surgery, Tuebingen University Hospital, Waldhörnlestrasse 22, 72076, Tübingen, Germany
| | - Christian Ernst
- Division of Economics and Management of Social Services, within the Institute of Health Care and Public Management, Hohenheim University, Stuttgart, Germany
| | - Sven Muller
- Clinic for Visceral, General and Transplant Surgery, Tuebingen University Hospital, Waldhörnlestrasse 22, 72076, Tübingen, Germany. .,Division of Economics and Management of Social Services, within the Institute of Health Care and Public Management, Hohenheim University, Stuttgart, Germany.
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Cost-Benefit Analysis of the Implementation of an Enhanced Recovery Program in Liver Surgery. World J Surg 2017; 40:2441-50. [PMID: 27283186 DOI: 10.1007/s00268-016-3582-2] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) programs have been shown to ease the postoperative recovery and improve clinical outcomes for various surgery types. ERAS cost-effectiveness was demonstrated for colorectal surgery but not for liver surgery. The present study aim was to analyze the implementation costs and benefits of a specific ERAS program in liver surgery. METHODS A dedicated ERAS protocol for liver surgery was implemented in our department in July 2013. The subsequent year all consecutive patients undergoing liver surgery were treated according to this protocol (ERAS group). They were compared in terms of real in-hospital costs with a patient series before ERAS implementation (pre-ERAS group). Mean costs per patient were compared with a bootstrap T test. A cost-minimization analysis was performed. RESULTS Seventy-four ERAS patients were compared with 100 pre-ERAS patients. There were no significant pre- and intraoperative differences between the two groups, except for the laparoscopy number (n = 18 ERAS, n = 9 pre-ERAS, p = 0.010). Overall postoperative complications were observed in 36 (49 %) and 64 patients (64 %) in the ERAS and pre-ERAS groups, respectively (p = 0.046). The median length of stay was significantly shorter for the ERAS group (8 vs. 10 days, p = 0.006). The total mean costs per patient were €38,726 and €42,356 for ERAS and pre-ERAS (p = 0.467). The cost-minimization analysis showed a total mean cost reduction of €3080 per patient after ERAS implementation. CONCLUSIONS ERAS implementation for liver surgery induced a non-significant decrease in cost compared to standard care. Significant decreased complication rate and hospital stay were observed in the ERAS group.
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Ronellenfitsch U, Böckler D, Schwarzbach M. Klinische Pfade zum Prozessmanagement in der Gefäßchirurgie. GEFASSCHIRURGIE 2017. [DOI: 10.1007/s00772-017-0317-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Turini GA, Clark MA, Machan J, Tucci C, Renzulli JF. The Role of a Standardized Clinical Care Pathway in Patient Satisfaction and Quality of Life Outcomes after Robotic Assisted Laparoscopic Radical Prostatectomy. UROLOGY PRACTICE 2017; 4:232-238. [PMID: 37592643 DOI: 10.1016/j.urpr.2016.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Clinical care pathways reduce length of stay, variability in practice and costs, yet avoid compromising quality of care or increasing complications. In this study we describe a standardized care pathway, focusing on preoperative and postoperative education as well as immediate postoperative patient care after robotic assisted laparoscopic radical prostatectomy. METHODS A standardized robotic assisted laparoscopic radical prostatectomy care pathway was introduced at our institution in July 2014. A total of 108 men who underwent robotic assisted laparoscopic radical prostatectomy during 2014 were enrolled in this retrospective chart review and were subsequently mailed a quality of life survey. Data regarding length of stay and number of unplanned calls to the urology office or visits to the emergency department were collected from the chart review. The mailed survey was composed of original questions as well as questions adapted from the FACT-P (Functional Assessment of Cancer Therapy-Prostate). Patients who underwent robotic assisted laparoscopic radical prostatectomy between January and June 2014 were compared to those who underwent the same surgery between July and December 2014. RESULTS Demographically the 2 cohorts of men who underwent robotic assisted laparoscopic radical prostatectomy were similar. There was a significant reduction in postoperative length of stay in the post-care pathway cohort. Hospital readmissions were reduced by 75%. Despite earlier discharge home, there was no difference in the number of postoperative calls to the urology office or visits to the emergency department, or in overall patient satisfaction. CONCLUSIONS The implementation of a standardized care pathway for patients undergoing robotic assisted laparoscopic radical prostatectomy at our institution resulted in a reduced postoperative length of stay and readmission rate. Despite a more rapid discharge from the hospital, patient satisfaction and postoperative quality of life were not negatively impacted.
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Affiliation(s)
- George A Turini
- Minimally Invasive Urology Institute, Miriam Hospital, Brown University, Providence, Rhode Island
| | - Melissa A Clark
- Warren Alpert School of Medicine and Brown University School of Public Health, Providence, Rhode Island
| | - Jason Machan
- Biostatistics Core Research Services, The Rhode Island Hospital, Providence, Rhode Island
| | - Christopher Tucci
- Minimally Invasive Urology Institute, Miriam Hospital, Brown University, Providence, Rhode Island
| | - Joseph F Renzulli
- Minimally Invasive Urology Institute, Miriam Hospital, Brown University, Providence, Rhode Island
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A Literature Review on Validated Simulations of the Surgical Services. J Med Syst 2017; 41:61. [PMID: 28271463 DOI: 10.1007/s10916-017-0711-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 02/22/2017] [Indexed: 10/20/2022]
Abstract
The surgical department is a critical unit that oversees multiple surgical-based clinical pathways and works with various other units in a hospital. This department faces numerous challenges relating to variability in demand and management of resources. The aim of this article is to review the application of validated simulation models on hospital-wide surgical services. Each of these models is broadly classified by (i) simulation method and (ii) level of detail given to the management of "patient pathways" and "staff workflows". We remark that very few studies have given attention to the management of staff workflows in their validated simulation models.
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Dhayat SA, Mirgorod P, Lenschow C, Senninger N, Anthoni C, Vowinkel T. Challenges in pancreatic adenocarcinoma surgery - National survey and current practice guidelines. PLoS One 2017; 12:e0173374. [PMID: 28267771 PMCID: PMC5340358 DOI: 10.1371/journal.pone.0173374] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 02/20/2017] [Indexed: 01/05/2023] Open
Abstract
Background Pancreatic ductal adenocarcinoma (PDAC) remains one of the most deadly cancers in Europe and the USA. There is consensus that radical tumor surgery is the only viable option for any long-term survival in patients with PDAC. So far, limited data are available regarding the routine surgical management of patients with advanced PDAC in the light of surgical guidelines. Methods A national survey on perioperative management of patients with PDAC and currently applied criteria on their tumor resectability in German university and community hospitals was carried out. Results With a response rate of 81.6% (231/283) a total of 95 (41.1%) participating departments practicing pancreatic surgery in Germany are certified as competence and reference centers for surgical diseases of the pancreas in 2016. More than 95% of them indicate to carry out structured and interdisciplinary therapies along with an interdisciplinary pre- and postoperative tumor board. The majority of survey respondents prefer the pylorus-preserving partial pancreatoduodenectomy (93.1%) with standard lymphadenectomy for cancer of the pancreatic head. Intraoperative histological evaluation of the resection margins is used regularly by 99% of the survey respondents. 98.7% of survey respondents carry out partial or complete vein resection, 126 respondents (54.5%) would resect tumor adjacent arteries, and 102 respondents (44.2%) would perform metastasectomy if complete PDAC resection (R0) is possible. Conclusion Evidence-based and standardized pancreatic surgery is practiced by a large number of hospitals in Germany. However, a significant number of survey respondents support an extended radical tumor resection in patients with advanced PDAC even when not indicated by current clinical guidelines.
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Affiliation(s)
- Sameer A. Dhayat
- Department of General and Visceral Surgery, University Hospital Muenster, Muenster, Germany
- * E-mail:
| | - Philip Mirgorod
- Department of General and Visceral Surgery, University Hospital Muenster, Muenster, Germany
| | - Christina Lenschow
- Department of General and Visceral Surgery, University Hospital Muenster, Muenster, Germany
| | - Norbert Senninger
- Department of General and Visceral Surgery, University Hospital Muenster, Muenster, Germany
| | - Christoph Anthoni
- Department of General and Visceral Surgery, University Hospital Muenster, Muenster, Germany
| | - Thorsten Vowinkel
- Department of General and Visceral Surgery, University Hospital Muenster, Muenster, Germany
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Sveinsdottir H, Borgthorsdottir T, Asgeirsdottir MT, Albertsdottir K, Asmundsdottir LB. Recovery After Same-Day Surgery in Patients Receiving General Anesthesia: A Cohort Study Using the Quality of Recovery-40 Questionnaire. J Perianesth Nurs 2016; 31:475-484. [DOI: 10.1016/j.jopan.2015.07.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Revised: 06/08/2015] [Accepted: 07/20/2015] [Indexed: 10/21/2022]
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Grass F, Cachemaille M, Blanc C, Fournier N, Halkic N, Demartines N, Hübner M. Is standardized care feasible in the emergency setting? A case matched analysis of patients undergoing laparoscopic cholecystectomy. BMC Surg 2016; 16:78. [PMID: 27905910 PMCID: PMC5131530 DOI: 10.1186/s12893-016-0194-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Accepted: 11/25/2016] [Indexed: 01/06/2023] Open
Abstract
Background Immediate laparoscopic cholecystectomy is the accepted standard for the treatment of acute cholecystitis. The aim of the present study was to evaluate the feasibility of a standardized approach with tailored care maps for pre- and postoperative care by comparing pain, nausea and patient satisfaction after elective and emergent laparoscopic cholecystectomy. Methods From January 2014 until April 2015, data on pain and nausea management were prospectively recorded for all elective and emergency procedures in the department of visceral surgery. This prospective observational study compared consecutive laparoscopic elective vs. emergency cholecystectomies. Visual analogue scales (VAS) were used to measure pain, nausea, and satisfaction from recovery room until 96 hours postoperatively. Results Final analysis included 168 (79%) elective cholecystectomies and 44 (21%) emergent procedures. Demographics (Age, gender, BMI and ASA-scores) were comparable between the 2 groups. In the emergency group, patients did not receive anxiolytic medication (0% vs.13%, p = 0.009) and less postoperative nausea and vomiting (PONV) prophylaxis (77% vs. 97% p = <0.001). Perioperative pain management was similar in terms of opioid consumption (median amount of fentanyl 450ug [IQR 350-500] vs. 450ug [375-550], p = 0.456) and wound infiltration rates (24% vs. 25%, p = 0.799). Postoperative consumption of paracetamol, metamizole and opiod medications were similar between the 2 groups. VAS scores for pain (p = 0.191) and nausea (p = 0.392) were low for both groups. Patient satisfaction was equally high in both clinical settings (VAS 8.5 ± 1.1 vs. 8.6 ± 1.1, p = 0.68). Conclusions A standardized pathway allows equally successful control of pain and nausea after both elective and emergency laparoscopic cholecystectomy. This study was retrospectively registered by March 01, 2016 in the following trial register: www.researchregistry.com (UIN researchregistry993) Electronic supplementary material The online version of this article (doi:10.1186/s12893-016-0194-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Fabian Grass
- Department of Visceral Surgery, University Hospital CHUV, Bugnon 46, 1011, Lausanne, Switzerland
| | | | - Catherine Blanc
- Department of Anaesthesiology, University Hospital CHUV, Lausanne, Switzerland
| | - Nicolas Fournier
- Institute for Social and Preventive Medicine, University Hospital CHUV, Lausanne, Switzerland
| | - Nermin Halkic
- Department of Visceral Surgery, University Hospital CHUV, Bugnon 46, 1011, Lausanne, Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery, University Hospital CHUV, Bugnon 46, 1011, Lausanne, Switzerland.
| | - Martin Hübner
- Department of Visceral Surgery, University Hospital CHUV, Bugnon 46, 1011, Lausanne, Switzerland
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Barnes S, Hamrock E, Toerper M, Siddiqui S, Levin S. Real-time prediction of inpatient length of stay for discharge prioritization. J Am Med Inform Assoc 2016; 23:e2-e10. [PMID: 26253131 PMCID: PMC4954620 DOI: 10.1093/jamia/ocv106] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 05/18/2015] [Accepted: 05/31/2015] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE Hospitals are challenged to provide timely patient care while maintaining high resource utilization. This has prompted hospital initiatives to increase patient flow and minimize nonvalue added care time. Real-time demand capacity management (RTDC) is one such initiative whereby clinicians convene each morning to predict patients able to leave the same day and prioritize their remaining tasks for early discharge. Our objective is to automate and improve these discharge predictions by applying supervised machine learning methods to readily available health information. MATERIALS AND METHODS The authors use supervised machine learning methods to predict patients' likelihood of discharge by 2 p.m. and by midnight each day for an inpatient medical unit. Using data collected over 8000 patient stays and 20 000 patient days, the predictive performance of the model is compared to clinicians using sensitivity, specificity, Youden's Index (i.e., sensitivity + specificity - 1), and aggregate accuracy measures. RESULTS The model compared to clinician predictions demonstrated significantly higher sensitivity (P < .01), lower specificity (P < .01), and a comparable Youden Index (P > .10). Early discharges were less predictable than midnight discharges. The model was more accurate than clinicians in predicting the total number of daily discharges and capable of ranking patients closest to future discharge. CONCLUSIONS There is potential to use readily available health information to predict daily patient discharges with accuracies comparable to clinician predictions. This approach may be used to automate and support daily RTDC predictions aimed at improving patient flow.
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Affiliation(s)
- Sean Barnes
- Department of Decision, Operations & Information Technologies, Robert H. Smith School of Business, 4352 Van Munching Hall, University of Maryland, College Park, MD 20742, USA
| | - Eric Hamrock
- Department of Operations Integration, Johns Hopkins Health System, Baltimore, MD, USA
| | - Matthew Toerper
- Department of Emergency Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Sauleh Siddiqui
- Departments of Civil Engineering and Applied Mathematics & Statistics, Johns Hopkins Systems Institute, Johns Hopkins University, Baltimore, MD, USA
| | - Scott Levin
- Department of Emergency Medicine and Civil Engineering, Johns Hopkins Systems Institute, Johns Hopkins University, Baltimore, MD, USA
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Kim HS, Kim SO, Kim BS. Use of a clinical pathway in laparoscopic gastrectomy for gastric cancer. World J Gastroenterol 2015; 21:13507-13517. [PMID: 26730162 PMCID: PMC4690180 DOI: 10.3748/wjg.v21.i48.13507] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Revised: 09/20/2015] [Accepted: 11/24/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the implementation of a clinical pathway and identify clinical factors affecting the clinical pathway for laparoscopic gastrectomy.
METHODS: A standardized clinical pathway for gastric cancer (GC) patients was developed in 2001 by the GC surgery team at the Asan Medical Center. We reviewed the collected data of 4800 consecutive patients treated using the clinical pathway following laparoscopic gastrectomy with lymph node dissection for GC involving intracorporeal and extracorporeal anastomosis. The patients were treated between August 2004 and October 2013 in a single institution. To evaluate the rate of completion and risk factors affecting dropout from the clinical pathway, we used a multivariate logistic regression analysis.
RESULTS: The overall completion rate of the clinical pathway for laparoscopic gastrectomy was 84.1% (n = 4038). In the comparison between groups of intracorporeal anastomosis and extracorporeal anastomosis patients, the completion rates were 83.88% (n = 1740) and 84.36% (n = 2071), respectively, showing no statistically significant difference. The main reasons for dropping out were postoperative complications (n = 463, 9.7%) and the need for patient observation (n = 299, 6.2%). Among the discharged patients treated using the clinical pathway, the number of patients who were readmitted within 30 d due to postoperative complications was 54 (1.1%). In a multivariate analysis, the intraoperative events (OR = 2.558) were the most predictable risk factors for dropping out of the clinical pathway. Additionally, being male (OR = 1.459), advanced age (OR = 1.727), total gastrectomy (OR = 2.444), combined operation (OR = 1.731), and ASA score (OR = 1.889) were significant risk factors affecting the dropout rate from the clinical pathway.
CONCLUSION: Laparoscopic gastrectomy appears to be a good indication for the application of a clinical pathway. For successful application, patients with risk factors should be managed carefully.
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Predictive risk factors for 30-day readmissions following primary total joint arthroplasty and modification of patient management. J Arthroplasty 2014; 29:1938-42. [PMID: 24975486 DOI: 10.1016/j.arth.2014.05.023] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Revised: 05/08/2014] [Accepted: 05/22/2014] [Indexed: 02/01/2023] Open
Abstract
The Centers for Medicare and Medicaid have begun to publically publish statistics on readmissions following primary total hip (THA) and total knee arthroplasty (TKA). Our study retrospectively assesses 30-day readmissions rates following THA and TKA, performed by a single surgeon at a tertiary care medical center between 2007 and 2012. Results of a univariate analysis and logistic regression model indicated female gender, high ASA class, and increased operative time to be significantly associated with higher rates of readmission (OR 4.646, OR 1.257, and OR 5.323, respectively). Readmissions most often occurred within the first week of patient discharge. Surgical complications and gastrointestinal discomfort were the most common causes for readmission. Using readmission risk we can stratify patients into tiered critical care pathways to reduce readmissions.
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Zhang M, Zhou SY, Xing MY, Xu J, Shi XX, Zheng SS. The application of clinical pathways in laparoscopic cholecystectomy. Hepatobiliary Pancreat Dis Int 2014; 13:348-53. [PMID: 25100118 DOI: 10.1016/s1499-3872(14)60279-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Laparoscopic cholecystectomy (LC) is one of the most frequent abdominal surgical procedures. The present meta-analysis aimed to estimate the clinical effects of implementing a clinical pathway for LC compared with standard medical care by evaluating the length of hospital stay, costs, and the outcomes of patients undergoing LC. DATA SOURCES Data were extracted from the following databases: PubMed, EMBASE, the Cochrane Central Register of Controlled Trials, Chinese Medical Citation Index (CMCI), Chinese Medical Current Contents (CMCC), and China BioMedical Literature Database (CBM). We also searched the reference lists of the relevant articles and conference articles. Only randomized controlled trials and controlled clinical trials published from 1980 to 2013 were included. We did not set restrictions on language and country of publications. All of the data were evaluated and analyzed by two reviewers independently with RevMan software (version 5.0). RESULTS A total of 7 trials with 1187 patients were included. The patients who underwent LC with clinical pathway had shorter hospital stay [weighted mean difference=-1.90, 95% CI: -2.65 to -1.16, P<0.00001], lower cost [standard mean difference=-0.69, 95% CI: -0.82 to -0.56, P<0.00001], and better questionnaires based satisfaction with the medical services. CONCLUSIONS The applications of the clinical pathway for LC effectively reduced hospital stay and total costs. However, there was insufficient evidence for proving the differences in postoperative complications. Future research should focus on patient outcomes and identify the mechanisms underlying the effect of the clinical pathway.
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Affiliation(s)
- Min Zhang
- Department of General Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China.
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Wei AC, Urbach DR, Devitt KS, Wiebe M, Bathe OF, McLeod RS, Kennedy ED, Baxter NN. Improving quality through process change: a scoping review of process improvement tools in cancer surgery. BMC Surg 2014; 14:45. [PMID: 25038587 PMCID: PMC4112620 DOI: 10.1186/1471-2482-14-45] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Accepted: 07/14/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Surgery is a cornerstone of treatment for malignancy. However, significant variation has been reported in patterns and quality of cancer care for important health outcomes, including perioperative mortality. Surgical process improvement tools (SPITs) have been developed that focus on enhancing the processes of care at the point of care, as a means of quality improvement. This study describes SPITs and develops a conceptual framework by synthesizing the available literature on these novel quality improvement tools. METHODS A scoping review was conducted based on instruments developed for quality improvement in surgery. The search was executed on electronically indexed sources (MEDLINE, EMBASE, and the Cochrane library) from January 1990 to March 2011. Data were extracted, tabulated and reported thematically using a narrative synthesis approach. These results were used to develop a conceptual framework that describes and classifies SPITs. RESULTS 232 articles were reviewed for data extraction and analysis. SPITs identified were classified into 3 groups: clinical mapping tools, structure communication tools and error reduction instruments. The dominant instrument reported were clinical mapping tools, including: clinical pathways (113, 48%), fast track (46, 20%) and enhanced recovery after surgery protocols (36, 15%). Outcomes reported included: length of stay (174, 75%), readmission rates (116, 50%), morbidity (116, 50%), mortality (104, 45%), and economic (60, 26%). Many gaps in the literature were recognized. CONCLUSION We have developed a conceptual framework of SPITs and identified gaps in current knowledge. These results will guide the design and development of new quality instruments in surgery.
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Affiliation(s)
- Alice C Wei
- Princess Margaret Cancer Centre, University Health Network, Department of Surgery, University of Toronto, Toronto, ON, Canada.
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Tayne S, Merrill CA, Shah SN, Kim J, Mackey WC. Risk factors for 30-day readmissions and modifying postoperative care after gastric bypass surgery. J Am Coll Surg 2014; 219:489-95. [PMID: 25151343 DOI: 10.1016/j.jamcollsurg.2014.03.054] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Revised: 03/08/2014] [Accepted: 03/10/2014] [Indexed: 11/17/2022]
Abstract
BACKGROUND Although hospital 30-day readmissions policies currently focus on medical conditions, readmission penalties will be expanding to encompass surgical procedures, logically beginning with common and standardized procedures, such as gastric bypass. Therefore, understanding predictors of readmission is essential in lowering readmission rate for these procedures. STUDY DESIGN This is a retrospective case-control study of patients undergoing laparoscopic gastric bypass at Tufts Medical Center from 2007 to 2012. Variables analyzed included demographics, comorbidities, intraoperative events, postoperative complications, discharge disposition, and readmission diagnoses. Univariate analysis was used to identify factors associated with readmission, which were then subjected to multivariable logistic regression analysis. RESULTS We reviewed 358 patients undergoing laparoscopic gastric bypass, 119 readmits, and 239 controls. By univariate analysis, public insurance, body mass index >60 kg/m(2), duration of procedure, high American Society of Anesthesiologists (ASA) class, and discharge with visiting nurse services (VNA) were significantly associated with 30-day readmissions. In the regression model, duration of procedure, high ASA class, and discharge with visiting nurse services (VNA) remained significantly associated with readmission when controlling for other factors (odds ratio [OR] 1.523, 95% CI 1.314 to 1.766; OR 2.447, 95% CI 1.305 to 4.487; and OR 0.053 with 95% CI 0.011 to 0.266, respectively). The majority of readmissions occurred within the first week after discharge. Gastrointestinal-related issues were the most common diagnoses on readmission, and included anastomotic leaks, postoperative ileus, and bowel obstruction. The next 2 most common reasons for readmission were wound infection and fluid depletion. CONCLUSIONS Using readmission risk, we can stratify patients into tiered clinical pathways. Because most readmissions occur within the first postdischarge week and are most commonly associated with dehydration, pain, or wound issues, focusing our postoperative protocols and patient education should further lower the incidence of readmission.
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Affiliation(s)
| | | | - Sajani N Shah
- Department of Surgery, Tufts Medical Center and Tufts University School of Medicine, Boston, MA
| | - Julie Kim
- Department of Surgery, Tufts Medical Center and Tufts University School of Medicine, Boston, MA
| | - William C Mackey
- Department of Surgery, Tufts Medical Center and Tufts University School of Medicine, Boston, MA
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Reducing the burden of surgical harm: a systematic review of the interventions used to reduce adverse events in surgery. Ann Surg 2014; 259:630-41. [PMID: 24368639 DOI: 10.1097/sla.0000000000000371] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To perform a systematic review of interventions used to reduce adverse events in surgery. BACKGROUND Many interventions, which aim to improve patient safety in surgery, have been introduced to hospitals. Little is known about which methods provide a measurable decrease in morbidity and mortality. METHODS MEDLINE, EMBASE, and Cochrane databases were searched from inception to Week 19, 2012, for systematic reviews, randomized controlled trials (RCTs), and cross-sectional and cohort studies, which reported an intervention aimed toward reducing the incidence of adverse events in surgical patients. The quality of observational studies was measured using the Newcastle-Ottawa Scale. RCTs were assessed using the Cochrane Collaboration's tool for assessing risk of bias. RESULTS Ninety-one studies met inclusion criteria, 26 relating to structural interventions, 66 described modifying process factors. Only 17 (of 42 medium to high quality studies) reported an intervention that produced a significant decrease in morbidity and mortality. Structural interventions were: improving nurse to patient ratios (P = 0.008) and Intensive Care Unit (ITU) physician involvement in postoperative care (P < 0.05). Subspecialization in surgery reduced technical complications (P < 0.01). Effective process interventions were submission of outcome data to national audit (P < 0.05), use of safety checklists (P < 0.05), and adherence to a care pathway (P < 0.05). Certain safety technology significantly reduced harm (P = 0.02), and team training had a positive effect on patient outcome (P = 0.001). CONCLUSIONS Only a small cohort of medium- to high-quality interventions effectively reduce surgical harm and are feasible to implement. It is important that future research remains focused on demonstrating a measurable reduction in adverse events from patient safety initiatives.
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Elnahas A, Urbach D, Okrainec A, Quereshy F, Jackson TD. Is next-day discharge following laparoscopic Roux-en-Y gastric bypass safe in select patients? Analysis of short-term outcomes. Surg Endosc 2014; 28:2789-94. [DOI: 10.1007/s00464-014-3546-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Accepted: 04/11/2014] [Indexed: 11/27/2022]
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Wei AC, Devitt KS, Wiebe M, Bathe OF, McLeod RS, Urbach DR. Surgical process improvement tools: defining quality gaps and priority areas in gastrointestinal cancer surgery. ACTA ACUST UNITED AC 2014; 21:e195-202. [PMID: 24764704 DOI: 10.3747/co.21.1733] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Surgery is a cornerstone of cancer treatment, but significant differences in the quality of surgery have been reported. Surgical process improvement tools (spits) modify the processes of care as a means to quality improvement (qi). We were interested in developing spits in the area of gastrointestinal (gi) cancer surgery. We report the recommendations of an expert panel held to define quality gaps and establish priority areas that would benefit from spits. METHODS The present study used the knowledge-to-action cycle was as a framework. Canadian experts in qi and in gi cancer surgery were assembled in a nominal group workshop. Participants evaluated the merits of spits, described gaps in current knowledge, and identified and ranked processes of care that would benefit from qi. A qualitative analysis of the workshop deliberations using modified grounded theory methods identified major themes. RESULTS The expert panel consisted of 22 participants. Experts confirmed that spits were an important strategy for qi. The top-rated spits included clinical pathways, electronic information technology, and patient safety tools. The preferred settings for use of spits included preoperative and intraoperative settings and multidisciplinary contexts. Outcomes of interest were cancer-related outcomes, process, and the technical quality of surgery measures. CONCLUSIONS Surgical process improvement tools were confirmed as an important strategy. Expert panel recommendations will be used to guide future research efforts for spits in gi cancer surgery.
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Affiliation(s)
- A C Wei
- Princess Margaret Cancer Centre, University Health Network, Department of Surgery, University of Toronto, Toronto, ON. ; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON
| | - K S Devitt
- Princess Margaret Cancer Centre, University Health Network, Department of Surgery, University of Toronto, Toronto, ON
| | - M Wiebe
- Princess Margaret Cancer Centre, University Health Network, Department of Surgery, University of Toronto, Toronto, ON
| | - O F Bathe
- Department of Surgery and Oncology, University of Calgary, Calgary, AB
| | - R S McLeod
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON. ; Division of General Surgery, Mount Sinai Hospital, Department of Surgery, University of Toronto, Toronto, ON
| | - D R Urbach
- Princess Margaret Cancer Centre, University Health Network, Department of Surgery, University of Toronto, Toronto, ON. ; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON
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Tarin T, Feifer A, Kimm S, Chen L, Sjoberg D, Coleman J, Russo P. Impact of a common clinical pathway on length of hospital stay in patients undergoing open and minimally invasive kidney surgery. J Urol 2013; 191:1225-30. [PMID: 24270130 DOI: 10.1016/j.juro.2013.11.030] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/14/2013] [Indexed: 01/14/2023]
Abstract
PURPOSE Clinical pathways are designed to reduce variability in patient care practices and improve clinical outcomes. We evaluated the effect of implementing a clinical care pathway on length of stay in patients undergoing kidney surgery. MATERIALS AND METHODS After receiving institutional review board approval we evaluated prospective data on consecutive cases of partial and radical nephrectomy performed at our institution from 2000 to 2011. We identified 1,775 partial nephrectomies (1,449 open and 326 minimally invasive) and 1,025 radical nephrectomies (857 open and 168 minimally invasive). We used multivariate linear regression to test for an interaction between procedure type and surgery before vs after the clinical pathway was begun. RESULTS Median length of stay decreased 40% (from 5 to 3 days) for open surgery and 33% (from 3 to 2 days) for minimally invasive surgery after clinical pathway implementation. Length of stay in patients treated with minimally invasive or open partial nephrectomy and open radical nephrectomy decreased while it remained stable in those who underwent minimally invasive radical nephrectomy. The difference in length of stay between open and minimally invasive partial nephrectomy before and after implementing the clinical pathway decreased by 1.5 days (95% CI 0.56-2.5, p = 0.002). At 30 days postoperatively major complication rates remained similar. CONCLUSIONS The clinical pathway resulted in a significantly shorter length of stay in patients treated with partial and radical nephrectomy without a discernible impact on safety or quality of care. Clinical pathways for kidney surgery should be used and continually optimized to enhance efficiency, patient safety and outcomes.
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Affiliation(s)
- Tatum Tarin
- Division of Urology, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York.
| | - Andrew Feifer
- Division of Urology, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Simon Kimm
- Division of Urology, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ling Chen
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Daniel Sjoberg
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jonathan Coleman
- Division of Urology, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Paul Russo
- Division of Urology, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
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Haane C, Mardin WA, Schmitz B, Dhayat S, Hummel R, Senninger N, Schleicher C, Mees ST. Pancreatoduodenectomy--current status of surgical and perioperative techniques in Germany. Langenbecks Arch Surg 2013; 398:1097-105. [PMID: 24141987 DOI: 10.1007/s00423-013-1130-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Accepted: 10/02/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pancreatoduodenectomy in Germany is performed by a broad range of hospitals. A diversity of operative techniques is employed as no guidelines exist for intra- and perioperative management. We carried out a national survey to determine the de facto German standards for pancreatoduodenectomy, assess quality assurance measures, and identify relevant issues for further investigation. METHODS A questionnaire evaluating major outcome variables, case load, preferred surgical procedures, and perioperative management during pancreatoduodenectomy was developed and sent to 211 German hospitals performing >12 pancreatoduodenectomies per year (requirement for certification as a pancreas center). Statistical analysis was carried out using the Fisher Exact, Mann-Whitney U, and Spearman tests. RESULTS The final response rate was 86 % (182/211). The preferred technique and de facto German standard for pancreatoduodenectomy was pylorus-preserving pancreatoduodenectomy with pancreatojejunostomy carried out via duct-to-mucosa anastomosis with interrupted sutures using PDS 4.0. The minority of German pancreas centers were certified (18-48 %). The certification rate increased with higher capacity levels and case load (P < 0.05); however, significant correlations between the fistula rate and hospital case load, hospital capacity level, or hospital certification status were not seen. CONCLUSION This study revealed a distinct variety of management strategies for pancreatic surgery and available evidence-based data was not necessarily translated into clinical practice. The limited certification rate represented a shortcoming of quality assurance. The data emphasize the need for further trials to answer the questions whether hospital certifications and omission of drains improve outcome after pancreatoduodenectomy and for the establishment of guidelines for pancreatoduodenectomy.
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Affiliation(s)
- Christina Haane
- Department of General and Visceral Surgery, University Hospital Muenster, Waldeyerstr.1, 48149, Muenster, Germany
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Niemeijer GC, Flikweert E, Trip A, Does RJMM, Ahaus KTB, Boot AF, Wendt KW. The usefulness of lean six sigma to the development of a clinical pathway for hip fractures. J Eval Clin Pract 2013; 19:909-14. [PMID: 22780308 DOI: 10.1111/j.1365-2753.2012.01875.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/28/2012] [Indexed: 01/08/2023]
Abstract
AIMS AND OBJECTIVES The objective of this study was to show the usefulness of lean six sigma (LSS) for the development of a multidisciplinary clinical pathway. METHODS A single centre, both retrospective and prospective, non-randomized controlled study design was used to identify the variables of a prolonged length of stay (LOS) for hip fractures in the elderly and to measure the effect of the process improvements--with the aim of improving efficiency of care and reducing the LOS. RESULTS The project identified several variables influencing LOS, and interventions were designed to improve the process of care. Significant results were achieved by reducing both the average LOS by 4.2 days (-31%) and the average duration of surgery by 57 minutes (-36%). The average LOS of patients discharged to a nursing home reduced by 4.4 days. CONCLUSION The findings of this study show a successful application of LSS methodology within the development of a clinical pathway. Further research is needed to explore the effect of the use of LSS methodology at clinical outcome and quality of life.
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Affiliation(s)
- Gerard C Niemeijer
- Department of Lean Six Sigma (5Q202), Martini Hospital Groningen, Groningen, The Netherlands
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Voorbrood CEH, Burgmans JPJ, Clevers GJ, Davids PHP, Verleisdonk EJMM, Schouten N, van Dalen T. One-stop endoscopic hernia surgery: efficient and satisfactory. Hernia 2013; 19:395-400. [PMID: 23949548 DOI: 10.1007/s10029-013-1151-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Accepted: 07/28/2013] [Indexed: 11/26/2022]
Abstract
BACKGROUND One-stop surgery offers patients diagnostic work-up and subsequent surgical treatment on the same day. In the present study, patient satisfaction and efficiency from an institutional perspective were evaluated in patients who were referred for one-stop endoscopic inguinal hernia repair. METHOD In a high-volume inguinal hernia clinic, all consecutive patients referred for one-stop surgical treatment, were registered prospectively. An instructed secretary screened patients for eligibility for the one-stop option when the appointment was made. Totally extraperitoneal hernia repair under general anaesthesia was the preferred operative technique. Patient's satisfaction, successful day surgery and institutional efficiency were evaluated. RESULTS Between January 2010 and January 2012 a total of 349 patients (17 % of all patients in the hernia clinic) were referred for one-stop hernia repair. Mean age was 47.5 years and 96.3 % were males. Three hundred thirty-six patients underwent hernia surgery on the same day (96.3 %). In thirteen patients (3.7 %) no operative repair was done on the day of presentation due to an incorrect diagnosis (n = 7), a watchful waiting policy for asymptomatic hernia (n = 3), rescheduling due to a large scrotal hernia, and there were two "no shows". Following hernia repair 97 % of the patients were discharged on the same day, while ten patients required hospitalization. Based on the questionnaires the main satisfaction score among patients was 9.0 (8.89-9.17 95 % CI) on a scale ranging from 0 to 10. CONCLUSION One-stop hernia surgery is feasible and satisfactory from an institutional as well as from a patient's perspective.
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Affiliation(s)
- C E H Voorbrood
- Department of Surgery/Hernia Clinic, Diakonessenhuis Utrecht/Zeist, Room: Secretariaat Heelkunde, Professor Lorentzlaan 76, 3707 HL, Zeist, The Netherlands,
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Affiliation(s)
- René Vonlanthen
- Department of Surgery, University Hospital Zurich, CH-8091 Zurich, Switzerland
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Khan T, Jackson WF, Beard DJ, Marfin A, Ahmad M, Spacie R, Jones R, Howes S, Barker K, Price AJ. The use of standard operating procedures in day case anterior cruciate ligament reconstruction. Knee 2012; 19:464-8. [PMID: 21646025 DOI: 10.1016/j.knee.2011.04.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2011] [Revised: 04/19/2011] [Accepted: 04/21/2011] [Indexed: 02/02/2023]
Abstract
The current rate of day-case anterior cruciate ligament reconstruction (ACLR) in the UK remains low. Although specialised care pathways with standard operating procedures (SOPs) have been effective in reducing length of stay following some surgical procedures, this has not been previously reported for ACLR. We evaluate the effectiveness of SOPs for establishing day-case ACLR in a specialist unit. Fifty patients undergoing ACLR between May and September 2010 were studied prospectively ("study group"). SOPs were designed for pre-operative assessment, anaesthesia, surgical procedure, mobilisation and discharge. We evaluated length of stay, readmission rates, patient satisfaction and compliance to SOPs. A retrospective analysis of 50 patients who underwent ACLR prior to implementation of the day-case pathway was performed ("standard practice group"). Eighty percent of patients in the study group were discharged on the day of surgery (mean length of stay=5.3h) compared to 16% in the standard practice group (mean length of stay=21.6h). This difference was statistically significant (p<0.05, Mann-Whitney U test). All patients were satisfied with the day case pathway. Ninety-two percent of the study group were discharged on the day of surgery when all SOPs were followed and 46% where they were not. High rates of day-case ACLR with excellent patient satisfaction can be achieved with the use of a specialised patient pathway with SOPs.
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Affiliation(s)
- T Khan
- Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, NIHR Biomedical Research Unit, University of Oxford, Oxford, OX3 7LD, UK
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Beydag KD, Komurcu N. Development and Area Adaptation of Flow Charts Related to Gynecologic Oncology Nursing Practices. Asian Pac J Cancer Prev 2012. [DOI: 10.7314/apjcp.2012.13.5.2163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Abstract
BACKGROUND Improving the quality of care is essential and a priority for patients, surgeons, and healthcare providers. Strategies to improve quality have been proposed at the national level either through accreditation standards or through national payment schemes; however, their effectiveness in improving quality is controversial. QUESTIONS/PURPOSES The purpose of this review was to address three questions: (1) does pay-for-performance improve the quality of care; (2) do surgical safety checklists improve the quality of surgical care; and (3) do practice guidelines improve the quality of care? These three strategies were chosen because there has been some research assessing their effectiveness in improving quality, and implementation had been attempted on a large scale such as entire countries. METHODS We performed a literature review from 1950 forward using Medline to identify Level I and II studies. We evaluated the three strategies and their effects on processes and outcomes of care. When possible, we examined strategy implementation, patients, and systems, including provider characteristics, which may affect the relationship between intervention and outcomes with a focus on factors that may have influenced effect size. RESULTS Pay-for-performance improved the process and to a lesser extent the outcome of care. Surgical checklists reduced morbidity and mortality. Explicit practice guidelines influenced the process and to a lesser extent the outcome of care. Although not definitively showed, clinician involvement during development of intervention and outcomes, with explicit strategies for communication and implementation, appears to increase the likelihood of positive results. CONCLUSION Although the cost-effectiveness of these three strategies is unknown, quality of care could be enhanced by implementing pay-for-performance, surgical safety checklists, and explicit practice guidelines. However, this review identified that the effectiveness of these strategies is highly context-specific.
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Affiliation(s)
| | - James G. Wright
- Division of Orthopaedic Surgery, Child Health Evaluative Sciences, Toronto, ON
Canada
- The Hospital for Sick Children and University of Toronto, 555 University Avenue, Toronto, ON M5G 1X8 Canada
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The Effect of Clinical Pathways for Bariatric Surgery on Perioperative Quality of Care. Obes Surg 2012; 22:732-9. [DOI: 10.1007/s11695-012-0605-4] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Pavlakis M, Hanto DW. Clinical pathways in transplantation: a review and examples from Beth Israel Deaconess Medical Center. Clin Transplant 2011; 26:382-6. [PMID: 22136467 DOI: 10.1111/j.1399-0012.2011.01564.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Clinical pathways (CP) have been developed to aid in the management of many surgical and medical conditions. Studies show the benefits of CP on outcomes including reduction in length of stay (LOS), morbidity, costs, and improvement in patient satisfaction (Arch Surg 2008: 394: 31; J Eval Clin Pract 2007: 13: 920; Arch Otolaryngol Head Neck Surg 2000: 126: 322; Circulation 2000: 101: 461; BMC Pulm Med 2006: 6: 22; Int J Health Care Qual Assur 2006: 19: 237; Am J Med Qual 2005: 20: 83; Am J Surg 2006: 192: 399; Am Surg 2005: 71: 152). Reports of CP in solid organ transplantation are lacking, possibly given the complexity of the transplant procedures that entail a complex, multidisciplinary pre-operative evaluation, inpatient, and post-operative time frames. We have developed CP from presentation for transplant evaluation to post-transplant follow-up for liver, kidney, and pancreas transplantation and live kidney and live liver donation and are making them available online for viewing. Our CPs encompass the pre-operative, peri-operative, and post-operative period, including both outpatient and inpatient care. We propose that transplantation is an ideal forum for successful implementation of CP, given the rigorous process that centers are subject to for CMS approval and the ample opportunity for improving our patients' lives by improvement in and streamlining of the entire process of clinical care from end-stage organ failure to post-transplant long-term management. Our CPs can be found at http://bidmc.org/CentersandDepartments/Departments/TransplantInstitute/TransplantClinicalPathways.aspx.
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Affiliation(s)
- Martha Pavlakis
- Center for Transplant Outcomes and Quality Improvement, The Transplant Institute, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA 02115, USA
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Ko YL, Lin PC. The effect of using a relaxation tape on pulse, respiration, blood pressure and anxiety levels of surgical patients. J Clin Nurs 2011; 21:689-97. [DOI: 10.1111/j.1365-2702.2011.03818.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Although many smaller studies have addressed anaesthetic care for bariatric surgical patients, comprehensive systematic literature reviews have yet to be compiled, and much evidence includes expert panel opinion. This review summarises study results in bariatric surgical patients regarding pre-anaesthesia evaluation, the perioperative impact of sleep-disordered breathing, airway management at anaesthetic induction and emergence, maintenance of anaesthesia, postoperative pain management, utility of clinical-care pathways and feasibility of outpatient bariatric surgery. The 'ramped' upper-body, reversed Trendelenburg position at anaesthetic induction and manual application of positive end-expiratory pressure (PEEP) is recommended. Intra-operative hypoxaemia can be treated with the combination of PEEP and recruitment manoeuvres, and attention to airway management at emergence is critical. Local anaesthetic wound infiltration and non-steroidal anti-inflammatory drugs should be part of multimodal opioid-sparing postoperative analgesia. Implementation of bariatric clinical-care pathways seems beneficial. Considering the prevalence of sleep apnoea in these patients, outpatient bariatric surgery remains controversial, but is probably safe for certain procedures, provided there is strict adherence to preoperative eligibility and home-care protocols.
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Affiliation(s)
- Roman Schumann
- Tufts Medical Center, Department of Anaesthesiology, Tufts University School of Medicine, 800 Washington St., Boston, MA 02111, USA.
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Abraham J. Innovative perioperative role improves patient and organisational outcomes in minimal invasive surgery. J Perioper Pract 2011; 21:158-164. [PMID: 21834286 DOI: 10.1177/175045891102100502] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
The drive to improve clinical care and productivity in the NHS has required an innovative approach in the use of the resources and skills of the workforce. With rapidly evolving technology, surgical and anaesthetic techniques, concentration is increasingly being placed on improving patient focused pathways, aiming to return patients back to normal activities as soon as possible. The article highlights the exciting new perioperative role developed at University Hospitals Coventry and Warwickshire (UHCW) NHS Trust in the care of patients undergoing laparoscopic cholecystectomy. It includes the history and development of the post and its current impact in improving the care of patients.
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Affiliation(s)
- Jenny Abraham
- Surgical Division, University Hospitals Coventry & Warwickshire N H S Trust, Clifford Bridge Road.
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Surgical intensive care unit - essential for good outcome in major abdominal surgery? Langenbecks Arch Surg 2011; 396:417-28. [PMID: 21369847 DOI: 10.1007/s00423-011-0758-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2011] [Accepted: 02/16/2011] [Indexed: 02/03/2023]
Abstract
PURPOSE Surgical intensive care units (ICU) play a pivotal role in perioperative care of patients undergoing major abdominal surgery. Differences in quality of care provided by medical staff in ICUs may be linked to improved outcome. This review aims to elucidate the relationship between quality of care at various ICUs and patient outcome, with the ultimate aim of identifying key measures for achieving optimal outcome. METHODS We reviewed the literature in PubMed to identify current ICU structural and process concepts and variations before evaluating their respective impact on quality of care and outcome in major abdominal surgery. RESULTS ICU leadership, nurse and physician staffing, and provision of an intermediate care unit are important structural components that impact on patients' outcome. A "mixed ICU" model, with intensivists primarily caring for the patients in close cooperation with the primary physician, seems to be the most effective ICU model. Surgeons' involvement in intensive care is essential, and a close cooperation between surgeons and anesthesiologists is vital for good outcome. Current general process concepts include early mobilization, enteral feeding, and optimal perioperative fluid management. To decrease failure-to-rescue rates, procedure-specific intensive care processes are particularly focused on the early detection, assessment, and timely and consistent treatment of complications. CONCLUSIONS Several structures and processes in the ICU have an impact on outcome in major abdominal surgery. ICU structures and care processes connected with optimal outcome could be transmitted to other centers to improve outcome, independent of procedure volume.
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Schuld J, Schäfer T, Nickel S, Jacob P, Schilling MK, Richter S. Impact of IT-supported clinical pathways on medical staff satisfaction. A prospective longitudinal cohort study. Int J Med Inform 2010; 80:151-6. [PMID: 21115391 DOI: 10.1016/j.ijmedinf.2010.10.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2010] [Revised: 10/08/2010] [Accepted: 10/09/2010] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Clinical pathways (CPs) have been evaluated with regard to process optimization, economic effects, quality of care, patient satisfaction and staff satisfaction. IT- (information technology) supported CPs, integrated within the HIS (hospital information system), have been implemented in our department in 2004 for the first time world-wide. Herein, we describe the effect of this new concept on medical staff satisfaction. METHODS A prospective anonymous and voluntary survey with standardized questionnaires was performed annually from 2006 until 2009 evaluating staff satisfaction concerning CPs. Questions comprised satisfaction with the software, staff's attitude towards CPs and the impact of CPs on work-related processes. RESULTS Within the observation period the term "clinical pathways" became more common among doctors and nurses. Knowledge of the aims of CPs increased significantly in nursing staff (43.4-74.5%), whereas doctor's knowledge was on a constant high level. Standardization, process facilitation and cost effectiveness were the most claimed goals of CPs. Comprehensibility of the single steps within CPs was on a constant high level over the observation period. Generally, graphical layout and usability of CPs ranged on a very high satisfaction level. Acceptability of IT-supported CPs is independent from staffs computer knowledge. CONCLUSIONS Staff satisfaction with IT-supported CPs needs to take into account the job characteristics of the different professional groups. IT-supported CPs are leading to a high staff satisfaction, the aims of CPs are widely understood by medical employees. IT-supported CPs may ameliorate staff satisfaction and thereby enhance workflow efficiencies.
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Affiliation(s)
- Jochen Schuld
- Department of General-, Visceral-, Vascular- and Pediatric Surgery, University Hospital of the Saarland, 66421 Homburg/Saar, Germany
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Quality in Trauma Care: Improving the Discharge Procedure of Patients by Means of Lean Six Sigma. ACTA ACUST UNITED AC 2010; 69:614-8; discussion 618-9. [DOI: 10.1097/ta.0b013e3181e70f90] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Bork U, Koch M, Büchler M, Weitz J. Wie viel Betriebswirtschaft braucht der Chirurg? Chirurg 2010; 81:694, 696-700. [PMID: 20628862 DOI: 10.1007/s00104-009-1805-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Carvajal-Balaguera J, González-Solana I, Máquez-Asencio M, Hernández-Lorca I, Martín-García-Almenta M, Cerquella-Hernández CM. [Evaluation of a clinical pathway of the inguinal hernia repair in a general surgery service]. ACTA ACUST UNITED AC 2010; 25:250-9. [PMID: 20493750 DOI: 10.1016/j.cali.2010.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2009] [Revised: 03/07/2010] [Accepted: 03/15/2010] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The objective of this work is to assess the level of implementation of an inguinal hernia clinical pathway and its impact on the patient satisfaction. MATERIAL AND METHOD An inguinal hernia repair clinical pathway was introduced in our service in January 2008. We studied all patients included in the clinical pathway since its introduction. The evaluation variables included: level of implementation, indicators of effectiveness in clinical care, and indicators of satisfaction based on a questionnaire. RESULTS During the first year of introducing the clinical pathway we operated on 582 patients for hernia repair. We excluded 85 cases (14.6%) from the study, due to not fulfilling the inclusion criteria. The study was finally conducted with 497 patients, 49 (9.8%) women and 448 (90.2%) men. The mean age of these patients was 56.6 (21-88) years old. A right hernia repair was performed on 273 cases (54.3%) and 224 (45.7% on the left hernia. In 473 (95.2%) it was a primary hernia and a recurrence in 24 (4.8%). In 441(88.7%) it was a unilateral hernia and 56 (11.3%) a bilateral hernia. The mean length of hospital stay was 1.1 (1-119) days. The level of compliance with length of hospital stay was 96.8%. The level of compliance with surgical prevention was 87.7%. Level of document management by the nursing staff was 86.5% and for doctors it was 80,7%. Overall morbidity was 6%. The informed consent was correctly executed in 97,8% of the cases and 98.6% of patients were given a final report on the day of leaving hospital. A total of 369 satisfaction questionnaires were collected, which was a response rate of 74.2%. Almost all (96%) patients were satisfied with the received information, 87.6% said their pain was managed correctly, and 81% found stay appropriate, and 95% said their hospital stay was between acceptable and good. The level of satisfaction with the care received was 97.5%, and 97.4% of the patients studied would recommend the hospital to a friend or family. CONCLUSION The introduction of a clinical pathway for inguinal hernia repair has led to a good integration, the services involved in the same. Patients have expressed a high level of satisfaction with the service received, but there are aspects that we must improve: in the information and communication with the patient, the action protocols, evaluation criteria, the VC ¿clinical pathway? Registers, and the satisfaction survey model.
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Affiliation(s)
- J Carvajal-Balaguera
- Servicio de Cirugía General y Digestiva, Hospital Central de la Cruz Roja San José y Santa Adela de Madrid, Madrid, España.
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Jutte EH, Cense HA, Dur AHM, Hunfeld MAJM, Cramer B, Breederveld RS. A pilot study for one-stop endoscopic total extraperitoneal inguinal hernia repair. Surg Endosc 2010; 24:2730-4. [PMID: 20396910 DOI: 10.1007/s00464-010-1035-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2009] [Accepted: 03/11/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND One-stop surgery was developed for patients to undergo surgical evaluation, anesthesia, surgery, and discharge all within 1 day. This study aimed to assess the feasibility, patient satisfaction, and potential of one-stop endoscopic total extraperitoneal (TEP) inguinal hernia surgery. METHODS After general practitioners had been informed, prospectively selected patients with unilateral or bilateral inguinal hernia underwent one-stop surgery by TEP. Pre- and postoperative questionnaires were used to evaluate patient satisfaction. RESULTS During 12 months, 52 patients were referred for one-stop surgery. There were no "no shows". The general practitioner correctly diagnosed inguinal hernia in 51 patients. On the scheduled date, 50 patients successfully underwent surgery using TEP, and 49 of these patients were satisfied with the procedure and would repeat one-stop surgery when indicated. CONCLUSION One-stop endoscopic TEP inguinal hernia surgery is feasible and safe. The majority of patients would give preference to a repeated procedure if necessary. This clinical pathway reduces the number of patient visits to the hospital for inguinal hernia repair and also suggests cost efficiency.
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Affiliation(s)
- Ewoud H Jutte
- Department of Surgery, The Red Cross Hospital, Vondellaan 13, Beverwijk, The Netherlands
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