The Effect of a Critical Pathway on Patients’ Outcomes After Carotid Endarterectomy

Improving Quality of Carotid Interventions: Identifying Hospital-Level Structural Factors that can Improve Outcomes

BACKGROUND

"Structural factors" relating to organization of hospitals may affect procedural outcomes. This study's aim was to clarify associations between structural factors and outcomes after carotid endarterectomy (CEA) and carotid endarterectomy stenting (CAS).

METHODS

A systematic review of studies published in English since 2005 was conducted. Structural factors assessed were as follows: population size served by the vascular department; number of hospital beds; availability of dedicated vascular beds; established clinical pathways; surgical intensive care unit (SICU) size; and specialty of surgeon/interventionalist. Primary outcomes were as follows: mortality; stroke; cardiac complications; length of hospital stay (LOS); and cost.

RESULTS

There were 11 studies (n = 95,100 patients) included in this systematic review. For CEA, reduced mortality (P < 0.0001) and stroke rates (P = 0.001) were associated with vascular departments serving >75,000 people. Larger hospitals were associated with lower mortality, stroke rate, and cardiac events, compared with smaller hospitals (less than 130 beds). Provision of vascular beds after CEA was associated with lower mortality (P = 0.0008) and fewer cardiac events (P = 0.03). Adherence to established clinical pathways was associated with reduced stroke and cardiac event rates while reducing CEA costs. Large SICUs (≥7 beds) and dedicated intensivists were associated with decreased mortality after CEA while a large SICU was associated with reduced stroke rate (P = 0.001). Vascular surgeons performing CEA were associated with lower stroke rates and shorter LOS (P = 0.0001) than other specialists. CAS outcomes were not influenced by specialty but costless when performed by vascular surgeons (P < 0.0001).

CONCLUSIONS

Structural factors affect CEA outcomes, but data on CAS were limited. These findings may inform reconfiguration of vascular services, reducing risks and costs associated with carotid interventions.

Multicomponent hospital-led interventions to reduce hospital stay for older adults following elective surgery: a systematic review

Background

Elective older adult inpatient admissions are increasingly common. Older adults are at an elevated risk of adverse events in hospital, potentially increasing with lengthier hospital stay. Hospital-led organisational strategies may optimise hospital stay for elective older adult inpatients.

Objectives

To evaluate the effectiveness and cost-effectiveness of hospital-led multicomponent interventions to reduce hospital stay for older adults undergoing elective hospital admissions.

Data sources

Seven bibliographic databases (MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, Health Management Information Consortium, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature and Allied and Complementary Medicine Database) were searched from inception to date of search (August 2017), alongside carrying out of web searches, citation searching, inspecting relevant reviews, consulting stakeholders and contacting authors. This search was duplicated, with an additional cost-filter, to identify cost-effectiveness evidence.

Review methods

Comparative studies were sought that evaluated the effectiveness or cost-effectiveness of relevant interventions in elective inpatients with a mean or median age of ≥ 60 years. Study selection, data extraction and quality assessment were completed independently by two reviewers. The main outcome was length of stay, but all outcomes were considered. Studies were sorted by procedure, intervention and outcome categories. Where possible, standardised mean differences or odds ratios were calculated. Meta-analysis was performed when multiple randomised controlled trials had the same intervention, treatment procedure, comparator and outcome. Findings were explored using narrative synthesis.

Findings

A total of 218 articles were included, with 80 articles from 73 effectiveness studies (n = 26,365 patients) prioritised for synthesis, including 34 randomised controlled trials conducted outside the UK and 39 studies from the UK, of which 12 were randomised controlled trials. Fifteen studies included cost-effectiveness data. The evidence was dominated by enhanced recovery protocols and prehabilitation, implemented to improve recovery from either colorectal surgery or lower limb arthroplasty. Six other surgical categories and four other intervention types were identified. Meta-analysis found that enhanced recovery protocols were associated with 1.5 days’ reduction in hospital stay among patients undergoing colorectal surgery (Cohen’sd = –0.51, 95% confidence interval –0.78 to –0.24;p < 0.001) and with 5 days’ reduction among those undergoing upper abdominal surgery (Cohen’sd = –1.04, 95% confidence interval –1.55 to –0.53;p < 0.001). Evidence from the UK was not pooled (owing to mixed study designs), but it echoed findings from the international literature. Length of stay usually was reduced with intervention or was no different. Other clinical outcomes also improved or were no worse with intervention. Patient-reported outcomes were not frequently reported. Cost and cost-effectiveness evidence came from 15 highly heterogeneous studies and was less conclusive.

Limitations

Studies were usually of moderate or weak quality. Some intervention or treatment types were under-reported or absent. The reporting of variance data often precluded secondary analysis.

Conclusions

Enhanced recovery and prehabilitation interventions were associated with reduced hospital stay without detriment to other clinical outcomes, particularly for patients undergoing colorectal surgery, lower limb arthroplasty or upper abdominal surgery. The impacts on patient-reported outcomes, health-care costs or additional service use are not well known.

Future work

Further studies evaluating of the effectiveness of new enhanced recovery pathways are not required in colorectal surgery or lower limb arthroplasty. However, the applicability of these pathways to other procedures is uncertain. Future studies should evaluate the implementation of interventions to reduce service variation, in-hospital patient-reported outcomes, impacts on health and social care service use, and longer-term patient-reported outcomes.

Study registration

This study is registered as PROSPERO CRD42017080637.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Patients' Experiences During Carotid Endarterectomy Performed Under Local Anesthesia

PURPOSE

To describe patients' experiences undergoing a carotid endarterectomy (CEA) under local anesthesia.

DESIGN

Explorative qualitative design.

METHODS

Semistructured interviews with 15 participants who had undergone CEA under local anesthesia, analyzed by content analysis.

FINDINGS

Undergoing CEA under local anesthesia entails enduring stress with no possibility of withdrawal. Patients' lack of understanding of local anesthesia and experiencing pain and discomfort caused feelings of stress. The surgery resulted in a loss of control; patients had to surrender their autonomy to someone else. The nurse anesthetist was the link to the world outside the operating room (OR), and that nurse conveyed feelings of safety and security during the surgery.

CONCLUSIONS

Patients' experiences ranged from being pleased with the surgical procedure and local anesthesia to vowing never to undergo such a procedure again. It is important to focus on the patients' experiences and feelings when choosing a method of anesthesia.

Carotid endarterectomy: What difference does a clinical protocol make?

BACKGROUND

The initial eight hours after carotid endarterectomy (CEA) are crucial to patient outcome as many potential complications can occur during this period. Hypotension is one of the most common issues observed after patients have returned to the surgical ward. Postoperative management of patients undergoing CEA varies between facilities, with reported direct intensive care unit or surgical high dependence unit admission. Patients that underwent a CEA procedure at the study hospital were monitored in the Recovery Unit for a minimum of four hours before being transferred to the surgical ward. Episodes of hypotension, on return to the surgical ward, were one of the main issues identified. This observation resulted in revision of the CEA management policy with collaboration from all specialties involved in the care of patients undergoing a CEA. The aim of this study was to compare whether there was any difference in short-term clinical outcomes between preupdate and postupdate of the carotid management policy in a tertiary referral hospital in New South Wales.

METHODOLOGY

Retrospective review of health care records was undertaken for the following two time intervals: prepolicy change from July 2008 to June 2009; postpolicy change from June 2011 to May 2012. Hypotension was defined as a systolic blood pressure less than 90 mm Hg. State SE 12.1 was used for data analysis.

RESULTS

After assessing for potential confounding factors-such as postoperative heart rate, risk factors, gender, and age-patients from the postpolicy change group were less likely to receive vasoactive medications to manage blood pressure deviation (OR, 0.33; 95% CI, 0.12-0.91; P = 0.026), the odds of receiving vasoactive medications was 0.33 times lower than that of the pre-policy change group patients, and is 95% confident that the true association lies between 0.12 and 0.91 in the underlying population. Over 90% of intensive care unit admission was avoided in patients from the postpolicy change group with estimated cost saving of $807 Australian dollars per patient.

CONCLUSIONS

The study hospital postoperative carotid surgery management policy has driven practice change with an extended Recovery Unit observation. This is a cost effective and safer management method. The Clinical Nurse Consultant was essential for clinical policy development, implementation, and evaluation.

Evaluation of illness severity scoring systems and risk prediction in vascular intensive care admissions

INTRODUCTION

This study examines the predictive value of intensive care unit (ICU) scoring systems in a vascular ICU population.

METHODS

From April 2005 to September 2011, we examined 363 consecutive ICU admissions. Simplified Acute Physiology Score II (SAPS II), Acute Physiology and Chronic Health Evaluation II (APACHE II), APACHE IV, Multiple Organ Dysfunction Score (MODS), organ dysfunctions and/or infection (ODIN), mortality prediction model (MPM) and physiologic and operative severity score for the enumeration of mortality and morbidity (POSSUM) were calculated. The Glasgow Aneurysm Score (GAS) was calculated for patients with aneurysm-related admissions.

RESULTS

Overall mortality for complex vascular intervention was 11.6%. At admission, the areas under the receiver operating characteristic curve (AUCs) was 0.884 for SAPS II, 0.894 for APACHE II, 0.895 for APACHE IV, 0.902 for MODS, 0.891 for ODIN and 0.903 for MPM. At 24 h, model discrimination was best for POSSUM (AUC = 0.906) and MPM (AUC = 0.912).

CONCLUSION

The good discrimination of these scoring systems indicates their value as an adjunct to clinical assessment but should not be used on an individual basis as a clinical decision-making tool.

A systematic approach to postoperative management of deceased donor kidney transplant patients with a clinical pathway

CONTEXT

Clinical pathways have been used in many acute hospital settings.

OBJECTIVES

To develop a systematic approach to postoperative care of adult recipients of deceased donor kidney transplants at the University of Mississippi Medical Center.

DESIGN AND SETTING

A pilot quality improvement project that uses implementation of a clinical pathway 24 hours after surgery for adult recipients of a deceased donor kidney transplant for 7 months. Charts from the same 7 months of the preceding year were retrospectively reviewed for comparison. The project occurred on the transplant floor in an acute care hospital and did not include any patients admitted to the intensive care unit.

MAIN OUTCOME MEASURES

To demonstrate that clinical pathways can (1) promote a method for standardizing postoperative care, (2) decrease postoperative length of stay, and (3) contain costs by minimizing hospital charges related to laboratory and room fees and promote efficient medication use in adult recipients of a deceased donor kidney transplant.

RESULTS

All 24 patients in the clinical pathway group met daily goals of the implemented clinical pathway. The clinical pathway group had statistically significant decreases in postoperative length of stay, use of laboratory tests, and use of intravenous medications compared with the comparison group. The 2 groups were similar in race, sex, age, and body mass index. Surgical readmissions did not differ significantly between the 2 groups.

A Systematic Approach to Postoperative Management of Deceased Donor Kidney Transplant Patients with a Clinical Pathway

Context

Clinical pathways have been used in many acute hospital settings.

Objectives

To develop a systematic approach to postoperative care of adult recipients of deceased donor kidney transplants at the University of Mississippi Medical Center.

Design and Setting

A pilot quality improvement project that uses implementation of a clinical pathway 24 hours after surgery for adult recipients of a deceased donor kidney transplant for 7 months. Charts from the same 7 months of the preceding year were retrospectively reviewed for comparison. The project occurred on the transplant floor in an acute care hospital and did not include any patients admitted to the intensive care unit.

Main Outcome Measures

To demonstrate that clinical pathways can (1) promote a method for standardizing postoperative care, (2) decrease postoperative length of stay, and (3) contain costs by minimizing hospital charges related to laboratory and room fees and promote efficient medication use in adult recipients of a deceased donor kidney transplant.

Results

All 24 patients in the clinical pathway group met daily goals of the implemented clinical pathway. The clinical pathway group had statistically significant decreases in postoperative length of stay, use of laboratory tests, and use of intravenous medications compared with the comparison group. The 2 groups were similar in race, sex, age, and body mass index. Surgical readmissions did not differ significantly between the 2 groups.

Are the outcomes of clinical pathways evidence-based? A critical appraisal of clinical pathway evaluation research

AIM AND OBJECTIVE

To evaluate the validity of study outcomes of published papers that report the effects of clinical pathways (CP).

METHOD

Systematic review based on two search strategies, including searching Medline, CINAHL, Embase, Psychinfo and Picarta from 1995 till 2005 and ISI Web of Knowledge SM. We included randomized controlled or quasi-experimental studies evaluating the efficacy of clinical pathway application. Assessment of the methodological quality of the studies included randomization, power analysis, selection bias, validity of outcome indicators, appropriateness of statistical tests, direct (matching) and indirect (statistical) control for confounders. Outcomes included length of stay, costs, readmission rate and complications. Two reviewers independently assessed the methodological quality of the selected papers and recorded the findings with an evaluation tool developed from a set of items for quality assessment derived from the Cochrane Library and other publications.

RESULTS

The study sample comprised of 115 publications. A total of 91.3% of the studies comprised of retrospective studies and 8.7% were randomized controlled studies. Using a quality-scoring assessment tool, 33% of the papers were classified as of good quality, whereas 67% were classified as of low quality. Of the studies, 10.4% controlled for confounding by matching and 59.1% adopted parametric statistical tests without testing variables on normal distribution. Differences in outcomes were not always statistically tested.

CONCLUSION

Readers should be cautious when interpreting the results of clinical pathway evaluation studies because of the confounding factors and sources of contamination affecting the evidence-based validity of the outcomes.