Lean Six Sigma Approach to Improve the Management of Patients Undergoing Laparoscopic Cholecystectomy

Laparoscopic cholecystectomy (LC) is the gold standard technique for gallbladder diseases in both emergency and elective surgery. The incidence of the disease related to an increasingly elderly population coupled with the efficacy and safety of LC treatment resulted in an increase in the frequency of interventions without an increase in surgical mortality. For these reasons, managers implement strategies by which to standardize the process of patients undergoing LC. Specifically, the goal is to ensure, in accordance with the guidelines of the Italian Ministry of Health, a reduction in post-operative length of stay (LOS). In this study, a Lean Six Sigma (LSS) methodological approach was implemented to identify and subsequently investigate, through statistical analysis, the effect that corrective actions have had on the post-operative hospitalization for LC interventions performed in a University Hospital. The analysis of the process, which involved a sample of 478 patients, with an approach guided by the Define, Measure, Analyze, Improve, and Control (DMAIC) cycle, made it possible to reduce the post-operative LOS from an average of 6.67 to 4.44 days. The most significant reduction was obtained for the 60-69 age group, for whom the probability of using LC is higher than for younger people. The LSS offers a methodological rigor that has allowed us, as already known, to make significant improvements to the process, standardizing the result by limiting the variability and obtaining a total reduction of post-operative LOS of 67%.

Systematic review and meta-analysis of factors which reduce the length of stay associated with elective laparoscopic cholecystectomy

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.

Review of methods and study designs of evaluations related to clinical pathways

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.

IMPROVED OUTCOMES WITH IMPLEMENTATION OF AN ENHANCED RECOVERY AFTER SURGERY (ERAS) PATHWAY FOR PATIENTS UNDERGOING ELECTIVE COLORECTAL SURGERY IN THE PHILIPPINES

Objective

This study aims to evaluate surgical outcomes (i.e. length of stay, 30-day morbidity, mortality, reoperation, and readmission rates) with the use of the ERAS pathway, and determine its association with the rate of compliance to the different ERAS components.

Methodology

This was a prospective cohort of patients, who underwent the following elective procedures: stoma reversal (SR), colon resection (CR), and rectal resection (RR). The primary endpoint was to determine the association of compliance to an ERAS pathway and surgical outcomes. These were then compared to outcomes prior to the implementation of ERAS.

Results

A total of 267 patients were included in the study. The overall compliance to the ERAS component was 92% (SR:91.75%, CR:93.06%, RR:90.65%). There was an associated decrease in morbidity rates across all types of surgery, as compliance to ERAS increased. The average total LOS decreased in all groups but was only found to have statistical significance in SR (12.06 ± 6.67 vs 10.02 ± 5.43 days; p=0.002) and RR (19.85 ± 11.38 vs 16.85 ± 10.45 days; p=0.04) groups. Decreased postoperative LOS was noted in all groups. Morbidity rates were significantly higher after ERAS implementation, but reoperation and mortality rates were found to be similar.

Conclusion

Implementation of ERAS improved outcomes, particularly length of stay. Although an actual increase in morbidity was noted, that may be explained by the improved reporting and documentation that accompanied the implementation of the protocol, a decreased likelihood of developing complications is foreseen with increased compliance to ERAS.

Improving the day case rate for laparoscopic cholecystectomy via introduction of a dedicated clinical pathway

Day case laparoscopic cholecystectomy is a safe and economical procedure. However, successful discharge on the same day of the procedure has been difficult to achieve at our institution. This study introduced a standardised anaesthetic pathway aiming to increase same day discharges. This led to an overall increase in same day discharges from 42.0% to 54.1%. When the pathway was fully followed, 71% of patients were discharged on the same day. When the pathway was not followed at all, the same day discharge rate was 0%. Our study successfully demonstrates that small enhancements to perioperative care can accelerate patient recovery and improve same day discharges.

The application of clinical pathways in laparoscopic cholecystectomy

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.

[Development of an internet-based clinical pathway exemplified by the fibromyalgia syndrome]

Clinical pathways (CP) are considered to be a tool of clinical process management describing the optimal route for diagnostic and therapeutic medical treatment of a specified patient. Apart from economic aspects CPs can make a contribution to optimization of health quality management as well as to improvement of medical staff and both patient satisfaction and patient safety whereas the feasibility and acceptance of evidence-based medicine guidelines are often found to be low. In order to stimulate critical discussion by offering the opportunity to easily gain first practical experience, a free web-based clinical pathway system for diagnosis and treatment for patients with fibromyalgia syndrome (FMS) will be presented.

Evaluation of a clinical pathway to improve colorectal cancer outcomes

The aims of this preintervention and postintervention study were to monitor and evaluate the clinical pathway (CP) for colorectal cancer (CRC) over a 5-year period and to compare 2 groups of patients (before and after the intervention) with regard to different variables of effectiveness. Group I comprised 68 patients who underwent planned surgery between January 2002 and January 2003. Group II comprised a sample of 202 patients who underwent surgery between January 2004 and December 2008. No significant differences were found in the majority of the parameters measured: postoperative stay, compliance with antibiotic prophylaxis, compliance with the staging study, mortality, rate of infection, and reoperations. The mean length of stay (±standard deviation) for patients without complications was reduced significantly (9.2 ± 3.6 in group I versus 7.7 ± 1.7 in group II, P = .031). The CP for CRC did not achieve most of the objectives for which it was designed.

Effects of a clinical pathway 3 years after implementation in breast surgery

PURPOSE

The aim of the present study is to evaluate the effects of the implementation of clinical pathways into routine practice of breast surgery.

MATERIALS AND METHODS

We implemented a clinical pathway for breast surgery in 2006 and analysed for the following 3 years its path in respect to hospital stay, total costs per case, readmission rate, and patients' satisfaction.

RESULTS

The mean hospital stay decreased significantly from 4.5 days in 2006 to 3.7 days in 2007 and revealed 3.4 days in 2008. This is a decrease by 24.4% for the duration of hospital stay. The total cost per case between 2006 and 2007 showed a significant decrease of 23.4%. The total costs increased by 13.4% in 2008. Readmission rate was under 5% and remained constant. Patients' satisfaction remained constant, whereby more than 90% of the expected good results were attained.

CONCLUSIONS

There is substantial evidence that clinical pathways lead to various improvements in clinical care in surgery. We show a constantly significant effect on duration of hospital stay without any increase in the number of readmissions. In our view, it is not only an economic benefit which prevails here, but also especially a transparency of treatment which leads to higher compliance, better outcome and a shorter length of stay.

Impact of clinical pathways in surgery

BACKGROUND

One strategy to reduce the consumption of resources associated to specific procedures is to utilize clinical pathways, in which surgical care is standardized and preset by determination of perioperative in-hospital processes. The aim of this prospective study was to establish the impact of clinical pathways on costs, complication rates, and nursing activities.

METHOD

Data was prospectively collected for 171 consecutive patients undergoing laparoscopic cholecystectomy (n = 50), open herniorrhaphy (n = 56), and laparoscopic Roux-en-Y gastric bypass (n = 65).

RESULTS

Clinical pathways reduced the postoperative hospital stay by 28% from a mean of 6.1 to 4.4 days (p < 0.001), while the 30-day readmission rate remained unchanged (0.5% vs. 0.45%). Total mean costs per case were reduced by 25% from euro 6,390 to euro 4,800 (p < 0.001). Costs for diagnostic tests were reduced by 33% (p < 0.001). Nursing hours decreased, reducing nursing costs by 24% from euro 1,810 to euro 1,374 (p < 0.001). A trend was noted for lower postoperative complication rates in the clinical pathway group (7% vs. 14%, p = 0.07).

CONCLUSIONS

This study demonstrates clinically and economically relevant benefits for the utilization of clinical pathways with a reduction in use of all resource types, without any negative impact on the rate of complications or re-hospitalization.

Evaluation of the clinical pathway for laparoscopic cholecystectomy and simulation of short-term hospitalization

The effectiveness of the clinical pathway for laparoscopic cholecystectomy was evaluated, and the efficiency of medical care was analyzed. The duration of hospitalization and the number of National Health Insurance (NHI) points for medical service fees were compared between 86 patients treated after introduction of the clinical pathway (pathway group) and 56 patients treated before introduction of the clinical pathway (pre-pathway group). In the pathway group, variance from the pathway occurred in 24 patients (27.9%) due to postponement of discharge in 7 patients, to earlier discharge in 5 patients, and to insertion of a bile duct catheter in 5 patients. Total and postoperative hospitalization times were significantly shorter in the pathway group than in the pre-pathway group (8.0 +/- 1.6 vs 13.7 +/- 9.0 days, p<0.0001, 5.4 +/- 1.1 vs 6.5 +/- 2.2 days, p<0.0001, respectively). In the pathway group, the total number of NHI points was lower and the number of points per day was higher. By simulation, the total number of NHI points for the 5-day pathway (discharge on postoperative day 3 or earlier) was significantly lower than that for the current 7-day pathway. Moreover, the weekly profit per bed with the 3-day pathway (discharge on postoperative day 1) was more than twice that with the current pathway. The results suggest that the clinical pathway for laparoscopic cholecystectomy is beneficial for patients and useful for the introduction of diagnosis procedure combination in our hospital.

Outpatient laparoscopic cholecystectomy: clinical pathway implementation is efficient and cost effective and increases hospital bed capacity

BACKGROUND

Outpatient laparoscopic cholecystectomy (OLC) may decrease the use of hospital resources and save costs. In the current study, the effect of implementing a clinical pathway has been assessed in terms of outcome for patients scheduled to undergo laparoscopic cholecystectomy, hospital costs, and available bed capacity.

METHODS

Clinical outcome and hospital stay were analyzed for consecutive patients scheduled to undergo laparoscopic cholecystectomy 1 year before (n = 338) and after (n = 336) implementation of a clinical pathway. Patients with acute cholecystitis or bile duct lithiasis were excluded from the study. A cost accounting model was developed using the concept of the bill of activities.

RESULTS

Before implementation of the clinical pathway, 34 (94%) of 36 patients scheduled for OLC were discharged successfully on the day of surgery, as compared with 110 (94%) of 117 patients after pathway implementation. Among patients scheduled for OLC, the complication (0% vs 1.7%), unplanned admission (5.5% vs 6%), and readmission (0% vs 4.3%) rates were comparable before and after clinical pathway implementation. After pathway implementation, the increased number of OLCs resulted in a significant cost saving (40.5%) and benefit in bed capacity (1.41 beds per day per year) for the hospital.

CONCLUSION

The implementation of a clinical pathway preserves the clinical outcome for patients undergoing OLC. It creates a significant increase in the number of patients treated in an outpatient setting and confers a significant benefit in terms of hospital costs and available bed capacity.

Standardization of Perioperative Management: Clinical Pathways

Many initiatives have been introduced in the past decades to standardize and improve clinical perioperative care and thereby improve patient care. Clinical pathways (also known as integrated care pathways, critical pathways, critical paths, care paths) are structured multidisciplinary care plans that detail essential steps in the care of patients with a specific clinical problem. They are designed to support the implementation and translation of national guidelines into local protocols and their subsequent application to clinical practice. In surgery, clinical pathways are standardized protocols for the management of patients who have common conditions undergoing common surgical procedures.