Nuckols Teryl K, Maggard Gibbons Melinda, Harness Neil G, Chang Walter T, Chung Kevin C, Asch Steven M
Hand (N Y). 2011 Jun;6(2):119-31. doi: 10.1007/s11552-011-9325-9. Epub 2011 Mar 5.
Previous research documents suboptimal preoperative or postoperative care for patients undergoing surgery. However, few existing quality measures directly address the fundamental element of surgical care: intra-operative care processes. This study sought to develop quality measures for intraoperative, preoperative, and postoperative care for carpal tunnel surgery, a common operation in the USA.
We applied a variation of the well-established RAND/UCLA Appropriateness Method. Adherence to measures developed using this method has been associated with improved patient outcomes in several studies. Hand surgeons and quality measurement experts developed draft measures using guidelines and literature. Subsequently, in a two-round modified-Delphi process, a multidisciplinary panel of 11 national experts in carpal tunnel syndrome (including six surgeons) reviewed structured summaries of the evidence and rated the measures for validity (association with improved patient outcomes) and feasibility (ability to be assessed using medical records).
Of 25 draft measures, panelists judged 22 (88%) to be valid and feasible. Nine intraoperative measures addressed the location and extent of surgical dissection, release after wrist trauma, endoscopic release, and four procedures sometimes performed during carpal tunnel surgery. Eleven measures covered preoperative and postoperative evaluation and management.
We have developed several measures that experts, including surgeons, believe to reflect the quality of care processes occurring during carpal tunnel surgery and be assessable using medical records. Although quality measures like these cannot assess a surgeon's skill in handling the instruments, they can assess many important aspects of intraoperative care. Intraoperative measures should be developed for other procedures.
先前的研究记录了接受手术患者的术前或术后护理欠佳的情况。然而，现有的质量指标很少直接涉及手术护理的基本要素：术中护理流程。本研究旨在制定美国常见手术——腕管松解术的术中、术前和术后护理质量指标。
我们应用了成熟的兰德/加州大学洛杉矶分校适宜性方法的一种变体。在多项研究中，遵循使用该方法制定的指标与改善患者预后相关。手外科医生和质量测量专家根据指南和文献制定了指标草案。随后，在两轮改良德尔菲法过程中，由11名腕管综合征领域的全国专家（包括6名外科医生）组成的多学科小组审查了证据的结构化总结，并对指标的有效性（与改善患者预后的相关性）和可行性（使用病历进行评估的能力）进行评分。
在25项指标草案中，小组成员判定22项（88%）有效且可行。9项术中指标涉及手术解剖的位置和范围、腕部创伤后的松解、内镜松解以及腕管手术中有时进行的4种操作。11项指标涵盖术前和术后评估及管理。
我们制定了多项指标，包括外科医生在内的专家认为这些指标反映了腕管松解术期间护理流程的质量，并且可以使用病历进行评估。尽管这样的质量指标无法评估外科医生操作器械的技能，但它们可以评估术中护理的许多重要方面。应为其他手术制定术中指标。
