Evolution of Standardized Clinical Pathways: Refining Multidisciplinary Care and Process to Improve Outcomes of the Surgical Treatment of Esophageal Cancer

Background

The aim of this study is to determine the effect of the implementation and evolution of a multidisciplinary esophagectomy care pathway on postoperative outcomes over a 20-year experience.

Study Design

All patients undergoing esophagectomy for cancer between 1991 and 2012 were included. Patients were divided into four groups (Gp1 1991–1996, Gp2 1997–2002, Gp3 2003–2007, and Gp4 2008–2012).

Results

Five hundred and ninety-five patients were included (Gp1 92, Gp2 159, Gp3 161, and Gp4 183). Age remained consistent over time; however, a progressive significant increase was observed in BMI and Charlson comorbidity index. Increases were also noted in patients with clinical stage III cancers, in the use of neoadjuvant chemoradiotherapy, in salvage esophagectomy and in the utilization of pretreatment jejunostomy. We observed a significant reduction in estimated blood loss (EBL) and operative room IV fluid administration (ORFA) during the study period. Median ICU stay and length of hospital stay (LOS) (10 (5–50) to 8 (5–115) days) decreased over time. In-hospital mortality (0.3 %) and postoperative complications remained consistent over time. cumulative sum (CUSUM) analysis showed that EBL, ORFA, and LOS all declined during the study period, reaching mean values at case 120, 310, and 175, respectively.

Conclusions

The results of this study show that process improvement within the pathway is likely more significant than the level of comorbidities, application of neoadjuvant chemoradiation, or technical approach in patients undergoing esophagectomy.     

Enhanced recovery in major colorectal surgery: Safety and efficacy in an unselected surgical population at a UK district general hospital

Background

Enhanced Recovery Programmes (ERPs) have been shown to benefit recovery following major surgery in selected centres and patient groups, but their wider applicability requires continued evaluation. The aims of this study were to assess the outcomes of the first 400 consecutive, non-selected patients, undergoing major elective colorectal surgery within an Enhanced Recovery programme at a UK District General hospital and to examine the effects of patient risk factors and operative approach on outcomes.

Methods

Since September 2005 all patients undergoing major elective colon and rectal surgery at our hospital have been treated within an ERP and their data recorded prospectively on a database. Safety and efficacy outcomes for the first 400 patients were compared using SPSS v14.0 with both a retrospective, pre-ERP group; and according to patient risk factors and operative approaches.

Results

Median length of stays (LOS) reduced from 9 days (IQR 7–11) to 6 days (IQR 5–10) after introduction of the ERP (p < 0.001). No statistically significant differences in LOS were observed between elderly (≥80 years) and younger patients or between different BMI groups. American Society of Anesthesiologists (ASA) grade 3 patients demonstrated significantly longer median LOS than those with ASA grades 1 and 2. Patients undergoing laparoscopic surgery had median LOS of 6 days (IQR 4–8) compared to 7 days (IQR 5–10) for open procedures (p < 0.001). No differences in morbidity or mortality were observed between the groups.

Conclusions

Unselected application of an ERP in our unit has been associated with reductions in post-operative LOS. The ERP was safe and effective when applied to all our study patients independent of age and BMI. Despite LOS being longer in ASA grade 3 patients, application of the ERP to this higher risk group was not associated with significantly increased morbidity or mortality. Laparoscopic surgery resulted in additional modest reductions in LOS compared to open surgery within the ERP.     

Surgical Education to Improve the Quality of Patient Care: the Role of Practice-Based Learning and Improvement

Health care is going through immense change, and concerns regarding the quality of patient care and patient safety continue to be expressed in many national forums. A variety of stakeholders are demanding greater accountability from the health care profession. Education is key to supporting surgeons’ efforts to provide high-quality patient care during these challenging times. Educational programs for surgeons should be founded on principles of continuous professional development (CPD) and practice-based learning and improvement (PBLI). CPD focuses on the specific needs of individual surgeons and involves lifelong learning throughout a surgeon’s career. It needs to form the basis of PBLI efforts. PBLI involves a cycle of four steps—identifying areas for improvement, engaging in learning, applying new knowledge and skills to practice, and checking for improvement. Ongoing involvement in PBLI activities to address specific learning needs should positively impact a surgeon’s practice and improve outcomes of surgical care.     

Validity of Unplanned Admission to an Intensive Care Unit as a Measure of Patient Safety in Surgical Patients

Background: An unplanned admission to the intensive care unit within 24 h of a procedure (UIA) is a recommended clinical indicator in surgical patients. Often regarded as a surrogate marker of adverse events, it has potential as a direct measure of patient safety. Its true validity for such use is currently unknown.

Methods: The authors validated UIA as an indicator of safety in surgical patients in a prospective cohort study of 44,130 patients admitted to their hospital. They assessed the association of UIA with intraoperative incidents and near misses, increased hospital length of stay, and 30-day mortality as three constructs of patient safety.

Results: The authors identified 201 patients with a UIA; 104 (52.2%) had at least one incident or near miss. After adjusting for confounders, these incidents were significantly associated with UIA in all categories of surgical procedures analyzed; odds ratios were 12.21 (95% confidence interval [CI], 6.33-23.58), 4.06 (95% CI, 2.74-6.03), and 2.13 (95% CI, 1.02-4.42), respectively. The 30-day mortality for patients with UIA was 10.9%, compared with 1.1% in non-UIA patients. After risk adjustment, UIA was associated with excess mortality in several types of surgical procedures (odds ratio, 3.89; 95% CI, 2.14-7.04). The median length of stay was increased if UIA occurred: 16 days (interquartile range, 10-31) versus 2 days (interquartile range, 0.5-9) (P < 0.001). For patients with a UIA, the likelihood of discharge from hospital was significantly decreased in most surgical categories analyzed, with adjusted hazard ratios of 0.41 (95% CI, 0.23-0.77) to 0.58 (95% CI, 0.37-0.93).     

Implementation of a checklist to enhance operation note quality at a UK burns centre

IntroductionOperation notes are fundamental for clinical, academic and medico-legal purposes. Good Surgical Practice (2014) provides guidelines to assist note completion but the literature suggests poor adherence to these. The aim of this study was to evaluate and improve operation note quality at a UK burns centre through implementation of a burns surgery-specific checklist.MethodsA 22-component burns surgery-specific checklist, modified from Good Surgical Practice (2014), was designed and implemented. The quality of 80 operation notes (40 pre and 40 post-implementation) was assessed against this checklist. Fisher’s exact and Mann-Whitney U statistical tests were used to evaluate pre and post-intervention note quality.ResultsBefore checklist implementation, only 6/22 components (27.3%) were recorded on every note. 4/22 components (18.2%) were not recorded on any, including microbiology specimen and clinical photography, which are particularly important in burns. After implementation, 16/22 (72.7%) were recorded on every note, with a statistically significant improvement in all other components (p ≤ 0.01), except venous thromboembolism prophylaxis (p = 0.10). The median percentage score of components recorded improved from 78.2 to 100% (p < 0.01).ConclusionTo our knowledge, this is the first study in available literature to show that a burns surgery-specific checklist can significantly improve burns operation note quality. This presents a simple and cheap method to improve note quality and may enhance post-operative intra/inter-team communication and patient care. At our unit, we have now developed an electronic checklist format with mandatory field completion to facilitate total compliance.     

教师标准化病人在护生临床见习中的应用

目的探讨教师标准化病人(TSP)教学模式用于护生临床见习的效果。方法选取2010年进入我院内外科进行护理临床见习的大专及以上学历的护生62人,将其随机分为观察组与对照组各31人。对照组采用常规教学方法,即讲解-示教-练习的教学模式。观察组采用常规教学方法+TSP的教学模式。见习结束后对两组护生操作考核成绩与理论考核成绩进行比较并征求观察组对培训方式的效果评价。结果观察组护生理论考试的病例分析成绩和操作考试的沟通技能成绩显著优于对照组(均P<0.01);除提高临床护理技能、促进知识掌握与理解外,观察组对TSP教学的认可度显著优于对照组(均P<0.01)。结论 TSP教学法应用于护理临床见习教学中,有助于提高教学效果,提高护生病例分析能力和沟通能力。     

The Nephrologist as a Primary Care Provider for the Hemodialysis Patient

The role of nephrologists as de facto primary care providers (PCP) for dialysis patients is of increasing interest. We sought to determine the proportion of patients who rely on nephrologists for primary care and to identify demographic variables associated with this primary care responsibility. We reviewed the charts of 158 patients receiving hemodialysis at a suburban, freestanding, teaching hospital affiliated outpatient unit from December 1999 through January 2001. In addition, each patient was interviewed and completed a survey. Non-nephrologists were considered to be a patient’s PCP if there was chart, survey or interview evidence of such a relationship. Of the 158 patients, only 56 patients had a PCP. The nephrologist thus was the de facto PCP in 65% of hemodialysis patients, a responsibility that was 3.3-fold more likely for patients not enrolled in a health maintenance organization (HMO) or managed care organization (MCO). In the non-HMO/MCO group, patients with a PCP had been on dialysis for less time than those without a PCP [2.7 vs. 4.6 years (P=0.0006)]. Only 32% of patients on dialysis <1 year had nephrologists as de facto PCP vs. 71% of those on dialysis more than 1 year (P=0.0002). This association between time on dialysis and de facto use of nephrologists as PCP was not accounted for by the shorter time on dialysis of HMO/MCO enrollees. The extent to which the nephrologist fulfills the often unsought role as PCP needs further investigation.