A clinical pathway for laparoscopic pyeloplasty decreases length of stay

PURPOSE: Benefits of minimally invasive procedures include decreased hospitalization and recovery times. Decreased length of stay (LOS) improves hospital efficiency and decreases costs. However, decreasing the LOS at the expense of patient care and satisfaction is not acceptable. A clinical pathway (CP) with structured order sets and imaging was developed for patients undergoing laparoscopic pyeloplasty. This pathway includes a cascade of activities managed closely by the health care team. This study assesses the safety and patient satisfaction with this clinical pathway. MATERIALS AND METHODS: We reviewed all adult pyeloplasties (39) completed laparoscopically since November 2001. All patients were managed according to the CP developed for the laparoscopic pyeloplasty procedure. The length of stay was measured in days. Patient satisfaction was assessed with a standardized questionnaire. Any readmissions or emergency room visits were documented. RESULTS: The mean length of stay was 1.10 days. Of 39 patients 37 (94%) were discharged home on postoperative day 1. One patient with severe postoperative pain required intravenous analgesia. She had undergone complex upper tract reconstruction and stayed a total of 4 days. One patient, who had a previous failed endopyelotomy, remained 2 days for persistent nausea. No patients sought emergency room consultation and there were no readmissions. Of 39 patients 34 (87%) completed the questionnaire and satisfaction was high. CONCLUSIONS: The implementation of a CP at our institution has standardized patient care in this population and decreased LOS in comparison to the literature. This improves bed use and hospital efficiency while maintaining a high degree of patient satisfaction. We conclude that with intensive patient care and education most patients undergoing laparoscopic pyeloplasty may be discharged home safely on postoperative day 1.     

Does day case surgery generate extra workload for primary and community health service staff?

We have audited the effects of day surgery on the workload of primary and community care teams in Portsmouth. A modified version of the Audit Commission's 'Patients' Experiences of Surgery' questionnaire was given to all patients admitted for an elective surgical procedure from 16 general practices to the two local hospitals between February and November 1996; 487 completed replies were received. In all, 50% patients consulted primary or community health care staff within 21 days of discharge from hospital. The average total patient contact rate with these staff increased with length of hospital stay from 0.39 contacts/patient for day case to 1.83 contacts/patient for longer stay admissions. Contacts with most members of the primary and community health teams increased with length of hospital stay. The postoperative visit rate by general practitioners and district nurses to day case patients was very low. We conclude that day case surgery at its present level in Portsmouth appears to create less workload for primary and community health services than inpatient surgery.     

Routine day-case laparoscopic cholecystectomy

BACKGROUND: A prospective study was carried out to assess the feasibility of performing true day-case laparoscopic surgery in a district general hospital. METHODS: All patients admitted consecutively under the care of one surgeon for laparoscopic cholecystectomy were included in the study. Selection criteria for a day-case procedure included an American Society of Anesthesiologists grade of I or II and the availability of a responsible carer at home. Patients were discharged 4-6 h after surgery with a standard analgesia pack and a contact number for advice. All patients were contacted by telephone on the day after discharge. A postal questionnaire was sent to the first 100 patients to assess satisfaction with the day-case process. RESULTS: Of 357 patients admitted for laparoscopic cholecystectomy over a 24-month period, 154 (43.1 per cent) were operated on as day cases on a morning theatre list. Twenty-two patients required an overnight stay (14.3 per cent), three because of conversion to an open procedure. One patient was readmitted for neck pain. Eighty-two (92.1 per cent) of 89 patients were either satisfied or very satisfied with the day-case procedure. CONCLUSION: This study has demonstrated a low rate of overnight stay (14.3 per cent) and readmission (1.9 per cent), and a high degree of patient satisfaction for day-case laparoscopic cholecystectomy.     

Evaluation of the clinical pathway for laparoscopic cholecystectomy

Clinical pathways are comprehensive systematized patient care plans for specific procedures. The clinical pathway for laparoscopic cholecystectomy was implemented in our department in March 2002. The aim of this study is to evaluate the clinical pathway for this procedure 1 year after implementation. A study was conducted on all the patients included in the clinical pathway since its implementation. The assessment criteria include degree of compliance, indicators of clinical care effectiveness, financial impact, and survey-based indicators of satisfaction. The results are compared to a series of patients undergoing surgery the year prior to implementation of the clinical pathway. As our hospital has a system of cost management, we analyzed the mean cost per procedure before and after clinical pathway implementation. Evaluation was made of a series of 160 consecutive patients who underwent surgery during the period 1 year prior to development of the clinical pathway and met the accepted inclusion criteria. The mean length of hospital stay was 3.27 days, and the mean cost per procedure before pathway implementation was 2149 (+/-768) euros. One year after implementation of the pathway, 140 patients were included (i.e., an inclusion rate of 100%). The mean length of hospital stay of the patients included in the clinical pathway was 2.2 days. The degree of compliance with stays was 66.7 per cent. The most frequent reasons for noncompliance were staff-dependent, followed by patient-dependent causes (oral intolerance, pain, etc.). The mean cost in the series of patients included in the clinical pathway was 1845 (+/-618) euros. Laparoscopic cholecystectomy is an ideal procedure for commencing the systemization of clinical pathways. Results show that it has significantly reduced the length of hospital stay and mean cost per procedure with no increased morbidity and with a high degree of patient satisfaction.     

Patients Accept a Shorter Hospital Time for Vertical Banded Gastroplasty in a Short Stay Unit: a Randomized Study

Background: vertical banded gastroplasty can be performed with a short post-operative hospital stay without this giving rise to more complications. An increased number of patients can be expected after the NIH consensus statement on Bariatric Surgery. Before cost-effective short stay units are employed for such surgery, patients' attitudes to short-term care should be investigated. Methods: we compared patient satisfaction in two groups of patients. They had been randomized to have a vertical banded gastroplasty in either a normal ward or a short stay unit, open Monday 7 am to Friday 1 pm. Results: there were no differences in patient satisfaction with either length of stay or quality of stay, despite the fact that short-stay unit patients stayed significantly shorter post-operatively (3.25 (0.62) days vs 4.70 (0.95); p = 0.0004; mean (sd)). Conclusion: it appears that vertical banded gastroplasty can be performed with a short post-operative hospital stay without discomfort to the patient.     

Cranial surgery among Medicare beneficiaries

BACKGROUND: This article examines the incidence of inpatient cranial surgery among Medicare beneficiaries. Many of these surgeries are trauma related or reflect chronic disabilities. The costs of care and the mortality rates are high for these patients. METHODS: A retrospective study examined the inpatient discharge data on Medicare fee-for-service beneficiaries during FY 1997 for diagnosis-related groups 1, 2, and 484. Incidence patterns, length of hospital stay, and mortality were examined by age, race, sex, source of admission, and discharge destination. RESULTS: Approximately 86% of the Medicare cranial surgery patients were 65 years of age or older, but only 10.2% were 85 years of age or older. The average patient age was 72 years. Nearly 51% of the patients were male, and 86.3% were white. Approximately 35% of the patients were admitted from the emergency room. The average length of stay was 9.6 days, and the average intensive care unit stay was 3.5 days. Whereas 42.3% of the patients were discharged to home, 44.6% were discharged to postacute care, and 10.9% died in the hospital. The average inpatient charge was $30,746. CONCLUSIONS: Cranial surgery in the Medicare population results in high inpatient mortality and high rates of postacute care use, especially as patient age increases.     

乳腺癌日间化疗患者基于信息化平台的预住院管理

目的 探讨基于信息化平台的预住院管理模式在乳腺癌日间化疗患者中的应用效果。方法 以2019年4~6月住院的454例患者为对照组,2019年7~9月的328例患者为干预组;对照组采用常规住院管理模式,干预组通过成立预住院管理团队,基于信息平台实施预住院管理和出院随访。结果 干预组候床时间、住院时间、护理费用、满意率显著优于对照组（均P<0.01）。结论 基于信息化平台的预住院管理模式能够有效缩短患者的候床时间和住院时间,降低护理费用,提升乳腺癌日间化疗患者满意度。     

Postoperative stay following colorectal surgery: a study of factors associated with prolonged hospital stay

AIM: To study the factors that contribute to postoperative stay following colorectal surgery. DESIGN: A prospective observational study. SETTING: Three colorectal surgical units - a teaching hospital, a large district general hospital and a district general hospital. PARTICIPANTS: 350 patients undergoing colorectal surgery. MAIN OUTCOME MEASURES: 28 pre-, peri- and postoperative patient- and treatment-related factors. RESULTS: Stepwise regression analysis suggests that the factors that significantly lengthen postoperative stay include a low albumin on admission, stoma formation, operative blood loss, urinary and respiratory complications, wound infections, postoperative ventilation and social delay at the time of discharge. The postoperative stay was not affected by patient age or by the seniority of the surgical team. CONCLUSIONS: Factors have been identified that determine the postoperative length of stay. These data may allow better planning and treatment of patients undergoing colorectal surgery.     

Part II: total episode costs in a randomized, controlled trial of the effectiveness of four anesthetics

Newer anesthetics promise improved clinical outcomes, but usually come at a higher price per dose. Previous studies have found few economic benefits in the immediate postoperative period, but have hypothesized that earlier recovery may lead to lower costs for the whole episode of hospitalization. This study uses cost data for patients enrolled in a randomized, controlled clinical trial comparing four anesthetics to test whether the higher costs of the newer anesthetics would be offset against decreased use of other hospital resources. Five hundred general surgery patients were randomly assigned to one of four anesthetic regimens. Estimates from the hospital's patient costing system were used, with validated cost records for a subset of 360 patients. Five patients admitted to the intensive care unit or requiring prolonged hospitalization skewed the distribution of costs, but none of these complications could be attributed to anesthesia. No significant differences were found on length of stay, mean episode cost, operating room costs, ward costs, or readmission rate within 3 mo. The study was not powered to sufficiently show differences in intensive care unit admission or other uncommon outcomes. Patient quality of recovery did not vary among groups, but neither patient willingness-to-pay nor satisfaction were directly measured. Implications: Propofol and sevoflurane do not offer any significant economic advantages over thiopental and isoflurane in adults undergoing elective inpatient surgery.     

Accelerated surgical stay programs. A mechanism to reduce health care costs.

OBJECTIVE: To increase cost-efficiency while maintaining the standard of medical care, an accelerated surgical stay program for patients having breast surgery was instituted. SUMMARY BACKGROUND DATA: In the past 20 years, annual health care costs have soared and now comprise 12.2% of the United States gross national product. The annual inflation rate of almost 11% has prompted third-party payers to scrutinize hospital costs as hospitals now consume 38% of health care costs. METHODS: A multidisciplinary task force was formed to analyze and reduce lengths of stay for breast surgeries and to standardize clinical protocols to address ensuing issues. RESULTS: After 1 year, this prospective study found a 39% decrease in average length of stay and a 22% increase in patient volume. This was also accompanied by a low incidence of surgical complications. Through information obtained from 373 consecutive patients through telephone surveys and questionnaires, the Center for Cost-Effective Care reported high patient acceptance and satisfaction. CONCLUSIONS: As a management strategy, accelerated surgical stay programs increase operating efficiency and reduce medical care costs without compromising quality of patient care. Success of this program was attributed to support from senior management, expansion of available educational resources for patients, and to a carefully planned transition from the program's developmental to its operational phase.     

Developing an enhanced recovery after surgery program for oncology patients who undergo hip or knee reconstruction surgery

Enhanced recovery after surgery(ERAS) protocols are applied in orthopedic surgery and are intended to reduce perioperative stress by implementing combined evidence-based practices with the cooperation of various health professionals as an interdisciplinary team. ERAS pathways include pre-operative patient counselling, regional anesthesia and analgesia techniques, post-operative pain management, early mobilization and early feeding. Studies have shown improvement in the recovery of patients who followed an ERAS program after hip or knee arthroplasty, compared with those who followed a traditional care approach. ERAS protocols reduce post-operative stress, contribute to rapid recovery, shorten length of stay(LOS) without increasing the complications or readmissions, improve patient satisfaction and decrease the hospital costs. We suggest that the ERAS pathway could reduce the LOS in hospital for patients undergoing total hip replacement or total knee replacement. These programs require good organization and handling by the multidisciplinary team. ERAS programs increase patient's satisfaction due to their active participation which they experience as personalized treatment. The aim of the study was to develop an ERAS protocol for oncology patients who undergo bone reconstruction surgeries using massive endoprosthesis, with a view to improving the surgical outcomes.     

Impact of a multidisciplinary trauma team on the outcome of acute subdural haematoma

IntroductionTo review the outcome of patients with post-traumatic acute subdural haematoma (ASDH) before and after the establishment of a hospital trauma team at a designated trauma centre.MethodA retrospective analysis was conducted on 82 consecutive patients who underwent surgery for post-traumatic ASDH. The ‘PRE’ and ‘POST’ groups included patients admitted before and after the establishment of a hospital trauma team, respectively.Injury severity was assessed by the admission Glasgow coma score, imaging findings, and the revised trauma score. Clinical outcome measures were the hospital length of stay and the Glasgow outcome score (GOS) upon hospital discharge.ResultsThe overall mortality rate was 53.7%. No significant difference was found between the PRE and POST groups. The mean length of hospital stay was also comparable between the two groups. The functional status of those who survived acute hospital care was significantly better in the POST group. Good outcome (GOS of 4 or 5) was achieved in 66.7% of the survivors in the POST group, compared with 25.0% in the PRE group (p = 0.024).ConclusionPost-traumatic ASDH carried a poor prognosis. The mortality rate and hospital length of stay of patients were not found to be reduced after the establishment of a hospital trauma team. The latter, however, was associated with significantly better functional outcome amongst survivors. Although causality cannot be established due to the multitude of factors which may have affected patient outcome, our findings nonetheless provide further support for the introduction of a multidisciplinary hospital trauma team for the optimal care of trauma patients.     

Easily adoptable total joint arthroplasty program allows discharge home in two days

Purpose

A safe efficient care pathway is needed to address the increasing need for arthroplasty surgery in Canada. Our primary objective was to determine whether a fast-track model of care can reduce length of hospital stay following total hip and knee arthroplasty while maintaining patient safety and satisfaction.

Methods

In this historical cohort study, 100 patients treated in a newly implemented fast-track program for total joint arthroplasty were compared with 100 patients treated before the introduction of the program. The fast-track program emphasizes preoperative patient education, postoperative multimodal analgesia with periarticular injections, early physiotherapy and rehabilitation, and discharge home with an outpatient rehabilitation program. The primary outcome was hospital length of stay. Secondary outcomes were concerned with patient safety and involved evaluating postoperative side effects, transfers to the tertiary care hospital, and emergency department (ED) visits and readmissions to hospital within 30 days of discharge.

Results

Length of hospital stay adjusted for age, sex, smoking, comorbidities, American Society of Anesthesiologists’ physical status classification, body mass index, and surgical procedure was reduced significantly for patients in the fast-track program compared with the standard program (mean 47 hr; 95% confidence interval [CI] 41 to 53 vs mean 116 hr; 95% CI 110 to 122, respectively). Patients in the fast-track program were discharged from hospital 69 hr earlier than patients in the standard program (95% CI ?60 to ?78). Despite significantly less morphine utilization, pain scores trended lower in the fast-track patients, both at rest and with activity, than in patients in the standard group (median 7.5 vs 35 mg, respectively). There were no significant differences between the two groups in the rate of ED visits or readmissions in the first 30 days.

Conclusion

Our multimodal multidisciplinary fast-track protocol reduced hospital stay and opioid consumption while maintaining a high level of patient safety. Program implementation is feasible both in tertiary care and in community hospitals.     

The emergency department length of stay: Is the time running out?

Purpose: To examine the relationships between emergency department length of stay (EDLOS) with hospital length of stay (HLOS) and clinical outcome in hemodynamically stable trauma patients. Methods: Prospective data collected for 2 years from consecutive trauma patients admitted to the trauma resuscitation bay. Only stable blunt trauma patients with appropriate trauma triage criteria requiring trauma team activation were included in the study. EDLOS was determined short if patient spent less than 2 h in the emergency department (ER) and long for more than 2 h. Results: A total of 248 patients were enrolled in the study. The mean total EDLOS was 125 min (range 78-180). Injury severity score (ISS) were significantly higher in the long EDLOS group (17 ± 13 versus 11 ± 9, p < 0.001). However, when leveled according to ISS, there were no differences in mean in diagnostic workup, admission rate to intensive care unit (ICU) or HLOS between the short and long EDLOS groups. Conclusion: EDLOS is not a significant parameter for HLOS in stable trauma patients.     

Implementation of an enhanced recovery after surgery program including a patient school: Impact on quality of life results

IntroductionEnhanced Recovery After Surgery (ERAS) protocols and educational programmes have been shown to accelerate orthopaedic surgery recovery with fewer complications, and improve patient-reported outcomes (PROs) for different types of surgery. The objective was to evaluate the impact of an ERAS programme including a patient school on health outcomes and PROs for Total Knee Replacement (TKR) surgery.Material and methodsA multidisciplinary group created the programme and the patient school (preoperative consultations where the patients’ surgical processes are explained and are also given instructions for an appropriate perioperative care management). An observational, prospective study was conducted on all patients operated for TKR from March 2021 to March 2022. Main health outcomes were: hospital stay length, surgical complications and surgery cancellations due to a wrong preoperative medication management. PROs evaluated were: patient satisfaction with pain management, the school, and quality of life before and after surgery (EQ-5D).ResultsOne hundred thirty-three patients were included. Median hospital stay length was 3 days (IQR 3-5). Rate of surgical complications was 25.6%. No surgery was cancelled. Patient satisfaction rates with pain management and with the school were 8.10/10 and 9.89/10, respectively. Concerning quality of life, mean improvement in mobility and knee pain after the surgery was 0.66 (p < 0.05) and 0.84 (p < 0.05), respectively.ConclusionsThe ERAS programme including a patient school was highly successful with a fast recovery, a short hospital stay length, no surgery cancellations, and improved PROs.     

The emergency department care of hemodialysis patients

AIMS: To describe the emergency department (ED) presentation, evaluation and disposition of maintenance hemodialysis (HD) patients. MATERIALS AND METHODS: A retrospective review of adult HD patients seen 1/1-12/31/97. The following was collected: demographics, mode of arrival, chief complaint, etiology of renal failure, evaluation, treatment, disposition, length of stay and facility charges. During the study period, this tertiary care ED had an annual adult census of 45,000. No clinical pathways were in place. RESULTS: 143 patients made 355 visits: 351 charts were available. Mean patient age was 51 (range 20-86), 62% were male, 51% were white. 70% presented from home, 26% from dialysis. EMS transported 32%. Medicare insured 78%. Etiologies of renal failure included hypertension (33%), diabetes (27%), HIV (7%) and glomerulonephritis (8%). Complaints were related to infection (18%), dyspnea (17%), vascular access (16%). chest pain or dysrhythmia (15%) and gastrointestinal complaints (12%). ED evaluation included CBC (79%), electrolytes (75%), CXR (57%) and EKG (48%). Antibiotics were administered to 21%. HD was performed earlier than scheduled in 14%. Two hundred and eighteen patients (62%) were admitted (ICU 11%, telemetry 22%), 19 (5%) refused admission and 2 expired in the ED. The average hospital length of stay was 7.8 days (range 1-59), with 29% hospitalized more than 1 week, compared to 6.54 days for non-HD patients. The mean facility charge for admitted subjects was $14,758, while the average cost for non-HD admissions was $7,152. Of the 133 patients (38%) who were discharged directly from the ED, the mean length stay was 223 minutes (range 30 to 750) and the mean charge was $658. The mean length of stay for non-HD patients was 124 minutes. CONCLUSION: The ED evaluation of adult HD patients involves multiple diagnostic modalities, and patients are usually admitted. The admit rate, ED length of stay for discharged patients and hospital charges for care were substantially higher in the HD patients than in the general population. Further research in the ED care of these complex patients should be undertaken.     

Syncope and burns

Syncope is a common condition that may lead to serious injuries including burns and head injury. To date, here has been no specific discussion of syncope and burns in the literature. A retrospective case-note review of consecutive patients admitted to a Tertiary Burns Centre over a 3.5-year-period was conducted. Five hundred and fifty nine patients were admitted during the study period. Six of these had burns related to alterations of consciousness that excluded alcohol/drug ingestion and epilepsy. The mean percentage body surface area burnt was 9.7%, the mean length of hospital stay was 28.5 days and the mean length of stay per percentage surface area burnt was 4.0 days per percent body surface burnt. The mean size of the injury in syncopal patients is slightly larger than the general burns patients (8.4%) but the length of stay is doubled. This is partly related to surgery being delayed due to investigation of the syncope episode. Focused investigations should reduce both the overall length of hospital stay and the number of investigations.     

Implementation of a clinical pathway decreases length of stay and cost for bowel resection

OBJECTIVE: To examine the effect of a clinical pathway for small and large bowel resection on cost and length of hospital stay. SUMMARY BACKGROUND DATA: Clinical pathways are designed to streamline patient care delivery and maximize efficiency while minimizing cost. Theoretically, they should be most effective in commonly performed procedures, in which volume and familiarity are high. METHODS: A clinical pathway to assist in the management of patients undergoing bowel resection was developed by a multidisciplinary team and implemented. Data about length of stay and cost was collected for all patients undergoing bowel resection 1 year before and 1 year after pathway implementation. Three groups were compared: patients undergoing bowel resection in the year prior to pathway implementation (prepathway), patients in the year after pathway implementation but not included on the pathway (nonpathway), and patients included in the pathway (pathway). RESULTS: The mean cost per hospital stay was $19,997.35 +/- 1244.61 for patients in the prepathway group, $20,835.28 +/- 2286.26 for those in the nonpathway group, and $13,908.53 +/- 1113.01 for those in the pathway group (p < 0.05 vs. other groups). Mean postoperative length of stay was 9.98 +/- 0.62 days (prepathway), 9.68 +/- 0.88 days for (nonpathway), and 7.71 +/- 0.37 days (pathway) (p < 0.05 vs. other groups). CONCLUSIONS: Implementation of the pathway produced significant decreases in length of stay and cost in the pathway group as compared to the prepathway group. These results support the further development of clinical pathways for general surgical procedures.     

Product line development: a strategy for clinical success in academic centers

OBJECTIVE: Academic medical centers, which have traditionally been relatively inefficient, have increasing difficulty in meeting the missions of patient care, teaching, and research in a progressively competitive medical marketplace. One strategy for improved efficiency in patient care while keeping quality high is utilization of a product line matrix. This study addresses the outcome of utilizing a product line strategy consisting of 3 service lines during the past 5 years at the University of Wisconsin Hospital and Clinics (UWHC). METHODS: Service lines in heart and vascular surgery, oncology, and pediatrics have been organized since 2001, and report directly to hospital leadership as a product line. Service line leadership consists of a combination of medical leaders plus representatives of hospital administration, and service lines are allowed direct access to resources for program development, marketing, and resource allocation. Measurements of patient numbers, market share, length of stay, net margin, and patient satisfaction have been gathered and compared with the preproduct line era. RESULTS: In the 3 service lines, UWHC has seen variable but steady growth in patient numbers, enhanced market share, positive net margins, and improved patient satisfaction during the period of measurement. During this same period, the insurance milieu has resulted in consistent downward pressure on reimbursement, which has been offset by improved patient care efficiency as measured by length of stay, enhanced preferred provider status, and gains in market share. Scorecard measures of quality are also being developed and show enhanced teaching and research opportunities for students and trainees as well as improved Press Ganey patient satisfaction scores. CONCLUSIONS: At UWHC, the development of a product line matrix consisting of 3 service lines has resulted in more patient care efficiency, enhanced patient satisfaction, improved margin for the hospital, and enlargement of teaching and research opportunities. The key to successful implementation of the product line concept is a close working relationship between the hospital administration and service line medical leadership.