高容量中心加速临床护理的环境影响。

Environmental impact of accelerated clinical care in a high-volume center.

作者信息

Sailhamer Elizabeth A, Sokal Suzanne M, Chang Yuchiao, Rattner David W, Berger David L

机构信息

Department of Surgery, Massachusetts General Hospital, Boston, MA, USA.

出版信息

Surgery. 2007 Sep;142(3):343-9. doi: 10.1016/j.surg.2007.03.015.

DOI:10.1016/j.surg.2007.03.015

PMID:17723885

Abstract

BACKGROUND

"Fast-track" surgery, involving multimodal care, improves efficiency and short-term outcomes in patients undergoing bowel resection. The sustainability of the benefits and the "drag" effect on non-participating surgeons through changed nursing and resident practice is undetermined.

METHODS

297 consecutive elective colon resections (DRG149) within three study periods (pre-change, immediate post-change, long-term post-change) were retrospectively reviewed. Two surgeons began to "fast-track" their patients in 1999 independently from the other surgeons in the hospital. Surgeons were grouped into "fast-track surgeons," "high-volume surgeons," (>/=10 cases per year) and "low-volume surgeons," (<10 cases per year). Comparisons of duration of stay (DOS), readmission rates, and mortality were made for each of three time periods and surgeon groups. Trends were also compared with unrelated hospital non-colectomy control groups (uncomplicated craniotomy DRG 001 and pancreatic surgery DRG 192) and to a colectomy control group from a statewide database (DRG 149).

RESULTS

Mean DOS for colon resection significantly decreased among the "fast-track" surgeons and among all the other surgeons in the hospital, from 6.3 +/- 0.3 days, down to 3.7 +/- 0.1 days. We found no significant difference in mortality or readmission rates between the study periods. 15% of the cases were performed laparoscopically, and the improvements in outcome were independent of surgical technique. Control group analyses demonstrated that the environmental impact on outcome was independent of hospital-wide or regional improvement efforts.

CONCLUSIONS

Implementation of a new practice pattern in a shared environment leads to improved outcomes for patients of other surgeons within the same environment. Dissemination and cross-pollination of new methods through resident, nurse, and case manager practice pattern modification creates a favorable force for change and this impact is sustained over a 3-year period.

摘要

背景

“快速康复”手术采用多模式护理，可提高肠道切除患者的效率和短期预后。其益处的可持续性以及通过改变护理和住院医师实践对未参与的外科医生产生的“拉动”效应尚不确定。

方法

回顾性分析了三个研究阶段（改变前、改变后即刻、改变后长期）内连续的297例择期结肠切除术（诊断相关分组149）。1999年，两名外科医生开始独立于医院其他外科医生对其患者实施“快速康复”。外科医生被分为“快速康复外科医生”、“高手术量外科医生”（每年≥10例手术）和“低手术量外科医生”（每年<10例手术）。比较了三个时间段和外科医生组的住院时间（DOS）、再入院率和死亡率。还将趋势与无关的医院非结肠切除术对照组（简单开颅手术诊断相关分组001和胰腺手术诊断相关分组192）以及来自全州数据库的结肠切除术对照组（诊断相关分组149）进行了比较。