3
|
Dort JC, Sauro KM, Chandarana S, Schrag C, Matthews J, Nakoneshny S, Manoloto V, Miller T, McKenzie CD, Hart RD, Matthews TW. The impact of a quality management program for patients undergoing head and neck resection with free-flap reconstruction: longitudinal study examining sustainability. J Otolaryngol Head Neck Surg 2020; 49:42. [PMID: 32571424 PMCID: PMC7310531 DOI: 10.1186/s40463-020-00437-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 03/15/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Care pathways (CPs) are helpful in reducing unwanted variation in clinical care. Most studies of CPs show they improve clinical outcomes but there is little known about the long-term impact of CPs as part of a sustained quality management program. Head and neck (HN) surgery with free flap reconstruction is complex, time-consuming and expensive. Complications are common and therefore CPs applied to this patient population are the focus of this paper. In this paper we report outcomes from a 9 year experience designing and using CPs in the management of patients undergoing major head and neck resection with free flap reconstruction. METHODS The Calgary quality management program and CP design is described the accompanying article. Data from CP managed patients undergoing major HN surgery were prospectively collected and compared to a baseline cohort of patients managed with standard care. Data were retrospectively analyzed and intergroup comparisons were made. RESULTS Mobilization, decannulation time and hospital length of stay were significantly improved in pathway-managed patients (p = 0.001). Trend analysis showed sustained improvement in key performance indicators including complications. Return to the OR, primarily to assess a compromised flap, is increasing. CONCLUSIONS Care pathways when deployed as part of an ongoing quality management program are associated with improved clinical outcomes in this complex group of patients.
Collapse
Affiliation(s)
- Joseph C Dort
- Section of Otolaryngology Head & Neck Surgery, Department of Surgery, University of Calgary Cumming School of Medicine, 3280 Hospital Drive NW, Calgary, Alberta, T2N 4Z6, Canada. .,Ohlson Research Initiative, Arnie Charbonneau Research Institute, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada. .,Foothills Medical Centre, Alberta Health Services, Calgary, Alberta, Canada. .,Department of Community Health Sciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada.
| | - Khara M Sauro
- Ohlson Research Initiative, Arnie Charbonneau Research Institute, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Shamir Chandarana
- Section of Otolaryngology Head & Neck Surgery, Department of Surgery, University of Calgary Cumming School of Medicine, 3280 Hospital Drive NW, Calgary, Alberta, T2N 4Z6, Canada.,Ohlson Research Initiative, Arnie Charbonneau Research Institute, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada.,Foothills Medical Centre, Alberta Health Services, Calgary, Alberta, Canada
| | - Christiaan Schrag
- Ohlson Research Initiative, Arnie Charbonneau Research Institute, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada.,Foothills Medical Centre, Alberta Health Services, Calgary, Alberta, Canada.,Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Jennifer Matthews
- Ohlson Research Initiative, Arnie Charbonneau Research Institute, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada.,Foothills Medical Centre, Alberta Health Services, Calgary, Alberta, Canada.,Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Steven Nakoneshny
- Ohlson Research Initiative, Arnie Charbonneau Research Institute, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Vida Manoloto
- Foothills Medical Centre, Alberta Health Services, Calgary, Alberta, Canada
| | - Tanya Miller
- Foothills Medical Centre, Alberta Health Services, Calgary, Alberta, Canada
| | - C David McKenzie
- Ohlson Research Initiative, Arnie Charbonneau Research Institute, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada.,Foothills Medical Centre, Alberta Health Services, Calgary, Alberta, Canada.,Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Robert D Hart
- Section of Otolaryngology Head & Neck Surgery, Department of Surgery, University of Calgary Cumming School of Medicine, 3280 Hospital Drive NW, Calgary, Alberta, T2N 4Z6, Canada.,Ohlson Research Initiative, Arnie Charbonneau Research Institute, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada.,Foothills Medical Centre, Alberta Health Services, Calgary, Alberta, Canada
| | - T Wayne Matthews
- Section of Otolaryngology Head & Neck Surgery, Department of Surgery, University of Calgary Cumming School of Medicine, 3280 Hospital Drive NW, Calgary, Alberta, T2N 4Z6, Canada.,Ohlson Research Initiative, Arnie Charbonneau Research Institute, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada.,Foothills Medical Centre, Alberta Health Services, Calgary, Alberta, Canada
| |
Collapse
|
4
|
Abstract
Objective: Evaluation of the effect of implementing clinical pathways is a relatively new field in health care research. Little is known about the way in which practice is influenced by the implementation of clinical pathways, and to what degree. This review takes significant steps in answering these questions by describing the parameters that are used in literature as indicators to evaluate clinical pathways. Methods: A Medline-based review of literature published between 2000 and 2002 was carried out using the keywords ‘clinical pathway’, ‘critical pathway’, ‘care map’, ‘care pathway’ and ‘integrated care pathway’. Articles were selected if they contained any form of evaluation, outcome or indicator concerning the use of clinical pathways. This included all types of research design and sample size. A total of 200 articles were selected. Relevant data were summarized using the following characteristics: country of origin, clinical field of expertise, research design, sample size, clinical outcome indicators, service indicators, team indicators, process indicators and financial indicators. For each domain a positive, negative or ‘no effect’ conclusion was recorded. Excel® and Statistica® were used to obtain percentages and graphics. Results: A total of 34% of the articles on clinical pathways contained some form of evaluation concerning the effect of the implementation. Out of these articles, clinical outcome was emphasized in 65.5%, financial effects in 53%) and process effects were investigated by 50% of the studies. Team and service effects were discussed less often (24% and 18.5%), respectively). For clinical outcome, team, process and financial effects a variety of indicators were recorded. Service effects were almost always measured as ‘patient satisfaction’. The majority of the literature concluded that positive effects result from the implementation of clinical pathways. Conclusion: On a macro level clinical pathways result globally in positive effects. Negative results, however, were also present in the literature. In particular for process, team and service evaluation concerning the use of clinical pathways there is still a great need for research.
Collapse
Affiliation(s)
- P Van Herck
- Centre for Health Services and Nursing Research, School of Public Health, Catholic University Leuven, Belgium
| | - K Vanhaecht
- Centre for Health Services and Nursing Research, School of Public Health, Catholic University Leuven, Belgium
| | - W Sermeus
- Centre for Health Services and Nursing Research, School of Public Health, Catholic University Leuven, Belgium
| |
Collapse
|
5
|
Influence of kinesiologic tape on postoperative swelling, pain and trismus after zygomatico-orbital fractures. J Craniomaxillofac Surg 2013; 42:469-76. [PMID: 23830769 DOI: 10.1016/j.jcms.2013.05.043] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Revised: 05/28/2013] [Accepted: 05/29/2013] [Indexed: 11/23/2022] Open
Abstract
Surgical treatment of zygomatico-orbital (ZO) fractures is a common procedure in maxillofacial surgery. Often accompanied by pain, trismus and swelling, postoperative morbidity is a major disadvantage, affecting patients' quality of life. The appliance of kinesiologic tape (KT) improves the blood and lymph flow, removing congestions of lymphatic fluid and haemorrhages. The aim of this study was to find out if the application of kinesiologic tape prevents or improves swelling, pain and trismus after zygomatico-orbital fracture surgery, improving patients' postoperative quality of life. A total of 30 patients were assigned for treatment of zygomatico-orbital fractures and were randomly divided into treatment either with or without kinesiologic tape. Tape was applied directly after surgery and maintained for at least 5 days postoperatively. Facial swelling was quantified using a five-line measurement at six specific time points. Pain and degree of mouth opening was measured. Patient's subjective feeling and satisfaction was queried. The results of this study show that application of kinesiologic tape after zygomatico-orbital surgery significantly reduced the incidence of swelling with an earlier swelling maximum, and decreased the maximum turgidity for more than 60% during the first 2 days after surgery. Although, kinesiologic tape has no significant influence on pain control and trismus, mouth opening increased earlier after operation in the kinesiologic tape group compared to the no-kinesiologic tape group. Furthermore, patients with kinesiologic tape felt significantly lower morbidity than those without kinesiologic tape. Therefore kinesiologic tape is a promising, simple, less traumatic, economical approach, which is free from adverse reaction and improves patients' quality of life.
Collapse
|
6
|
Ristow O, Hohlweg-Majert B, Kehl V, Koerdt S, Hahnefeld L, Pautke C. Does elastic therapeutic tape reduce postoperative swelling, pain, and trismus after open reduction and internal fixation of mandibular fractures? J Oral Maxillofac Surg 2013; 71:1387-96. [PMID: 23676774 DOI: 10.1016/j.joms.2013.03.020] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2013] [Revised: 03/12/2013] [Accepted: 03/16/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE The aim of the present study was to investigate whether the application of elastic therapeutic tape (Kinesio Tape [KT]) prevents or decreases swelling, pain, and trismus after open reduction and internal fixation of mandibular fracture, thus improving patients' postoperative morbidity. MATERIALS AND METHODS To address the research purpose, the investigators designed and implemented an open-label, monocentric, parallel-group, randomized clinical trial. Patients were prospectively assigned for treatment of unilateral mandibular fractures and randomly allocated to receive treatment with or without KT application. KT was applied directly after surgery and maintained for 5 days postoperatively. Facial swelling was quantified using a 5-line measurement at 6 specific time points. Pain score was assessed using a 10-level visual analog scale; mouth opening was measured. In addition, all patients were asked to evaluate overall satisfaction and swelling (2 groups) and the effect of the tape on movement and comfort (KT group only). RESULTS The study included 26 patients (11 female and 15 male; mean age, 43 yr; standard deviation, 18.5 yr). Application of KT after surgery for mandibular fracture had a statistically significant influence on tissue reaction and swelling, decreasing the incidence of swelling and turgidity by more than 60% during the first 2 days after surgery. Although KT had no significant influence on pain control, patients in the KT group perceived significantly lower morbidity. CONCLUSION The present results showed that KT after open reduction and internal fixation of mandibular fracture is a promising, simple, less traumatic, and economical approach for managing postoperative swelling that is free from systemic adverse reactions, thus improving patients' quality of life.
Collapse
Affiliation(s)
- Oliver Ristow
- Medicine and Aesthetics, Private Clinic for Oral and Maxillofacial and Plastic Surgery, Munich, Germany.
| | | | | | | | | | | |
Collapse
|
8
|
Parbatani R, Williams AC, Ireland AJ, Sandy JR. The process of orthognathic care in an NHS region. Ann R Coll Surg Engl 2009; 92:34-9. [PMID: 19887023 DOI: 10.1308/003588410x12518836438723] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION The aim of this study was to evaluate, within an NHS region, the process of care and the standard of record keeping for orthognathic patients. PATIENTS AND METHODS A retrospective analysis of the medical records of 372 patients who underwent orthognathic surgery between 1 January 1995 and 31 April 2000 in the South West Region of the UK. RESULTS Most patients underwent joint orthodontic and maxillofacial planning and had third molars extracted under general anaesthesia prior to orthognathic surgery. There was a significant difference in the median operation times and length of stay for bimaxillary surgery (4 h/4 days) compared with single jaw surgery (2 h/3 days; P < 0.001). Just over 15% of patients required removal of internal fixation plates after surgery, with nearly 90% of these requiring a further episode of general anaesthesia. The level of record keeping and patient review was variable with no regional standardisation. CONCLUSIONS This study is evidence of a generally acceptable standard in the process of care, which was found to follow international and national practices. However, at the time of the study there was no regional protocol for patient records or patient review, highlighting the need for the establishment of a regional database.
Collapse
|
10
|
Rogers SN, Lowe D, Brown JS, Vaughan ED. The relationship between length of stay and health-related quality of life in patients treated by primary surgery for oral and oropharyngeal cancer. Int J Oral Maxillofac Surg 2001; 30:209-15. [PMID: 11420903 DOI: 10.1054/ijom.2001.0040] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
A patient's length of hospital admission is simple to measure, whilst their health related quality of life (HRQOL) is much more challenging. Similar clinical and demographic factors may exist between an increased length of stay (LOS) and a worse HRQOL outcome. The aim of this study was to assess whether LOS could serve as a proxy marker of HRQOL. One hundred and thirty consecutive patients with previously untreated oral and oropharyngeal squamous cell carcinoma were recruited. All had primary surgery. The University of Washington questionnaire (UW-QOL) and the European Organisation for Research and Treatment core cancer questionnaire (EORTC C30) were self-completed preoperatively, after 6 months and 1 year. The median LOS following laser/primary closure/split skin grafts (21 patients) was 2 days compared to 16 days following microvascular free flap reconstruction (105 patients). In the free flap group the best predictors of LOS were age, tumour size and early medical/surgery complications. Patients with a LOS greater than 16 days (median) reported significantly worse chewing (P = 0.008), swallowing (P = 0.002) and cumulative UW-QOL score (P = 0.01). No significant differences were seen in the EORTC C30. Length of stay is potentially a useful indicator of health related quality of life because it is linked by tumour size, however, the relationship is confounded by age, which tends to influence length of stay more than health related quality of life.
Collapse
Affiliation(s)
- S N Rogers
- Regional Maxillofacial Unit, University Hospital Aintree, Aintree Trust, Liverpool, UK.
| | | | | | | |
Collapse
|