Keller Deborah S, Stulberg Jonah J, Lawrence Justin K, Samia Hoda, Delaney Conor P
Division of Colorectal Surgery, Department of Surgery, University Hospitals-Case Medical Center, Case Western Reserve University, 11100 Euclid Ave, Cleveland, OH, 44106-5047, USA.
Department of Surgery, University Hospitals-Case Medical Center, Cleveland, OH, USA.
Surg Endosc. 2015 Dec;29(12):3559-64. doi: 10.1007/s00464-015-4108-y. Epub 2015 Feb 21.
Unexpected variations in postoperative length of stay (LOS) negatively impact resources and patient outcomes. Statistical process control (SPC) measures performance, evaluates productivity, and modifies processes for optimal performance. The goal of this study was to initiate SPC to identify LOS outliers and evaluate its feasibility to improve outcomes in colorectal surgery.
Review of a prospective database identified colorectal procedures performed by a single surgeon. Patients were grouped into elective and emergent categories and then stratified by laparoscopic and open approaches. All followed a standardized enhanced recovery protocol. SPC was applied to identify outliers and evaluate causes within each group.
A total of 1294 cases were analyzed--83% elective (n = 1074) and 17% emergent (n = 220). Emergent cases were 70.5% open and 29.5% laparoscopic; elective cases were 36.8% open and 63.2% laparoscopic. All groups had a wide range in LOS. LOS outliers ranged from 8.6% (elective laparoscopic) to 10.8% (emergent laparoscopic). Evaluation of outliers demonstrated patient characteristics of higher ASA scores, longer operating times, ICU requirement, and temporary nursing at discharge. Outliers had higher postoperative complication rates in elective open (57.1 vs. 20.0%) and elective lap groups (77.6 vs. 26.1%). Outliers also had higher readmission rates for emergent open (11.4 vs. 5.4%), emergent lap (14.3 vs. 9.2%), and elective lap (32.8 vs. 6.9%). Elective open outliers did not follow trends of longer LOS or higher reoperation rates.
SPC is feasible and promising for improving colorectal surgery outcomes. SPC identified patient and process characteristics associated with increased LOS. SPC may allow real-time outlier identification, during quality improvement efforts, and reevaluation of outcomes after introducing process change. SPC has clinical implications for improving patient outcomes and resource utilization.
术后住院时间（LOS）的意外变化会对资源和患者预后产生负面影响。统计过程控制（SPC）可衡量绩效、评估生产力并改进流程以实现最佳绩效。本研究的目的是启动SPC以识别LOS异常值，并评估其改善结直肠手术预后的可行性。
回顾一个前瞻性数据库，确定由单一外科医生实施的结直肠手术。患者分为择期和急诊两类，然后按腹腔镜和开放手术方式分层。所有患者均遵循标准化的强化康复方案。应用SPC识别异常值并评估每组中的原因。
共分析了1294例病例，其中83%为择期手术（n = 1074），17%为急诊手术（n = 220）。急诊病例中70.5%为开放手术，29.5%为腹腔镜手术；择期病例中36.8%为开放手术，63.2%为腹腔镜手术。所有组的LOS范围都很广。LOS异常值范围从8.6%（择期腹腔镜手术）到10.8%（急诊腹腔镜手术）。对异常值的评估显示，患者具有较高的美国麻醉医师协会（ASA）评分、较长的手术时间、需要重症监护以及出院时需要临时护理等特征。在择期开放手术组（57.1%对20.0%）和择期腹腔镜手术组（77.6%对26.1%）中，异常值的术后并发症发生率更高。在急诊开放手术组（11.4%对5.4%）、急诊腹腔镜手术组（14.3%对9.2%）和择期腹腔镜手术组（32.8%对6.9%）中，异常值的再入院率也更高。择期开放手术异常值未呈现LOS延长或再次手术率升高的趋势。
SPC对于改善结直肠手术预后是可行且有前景的。SPC识别出了与LOS增加相关的患者和流程特征。在质量改进过程中，SPC可实现实时异常值识别，并在引入流程变更后重新评估预后。SPC对改善患者预后和资源利用具有临床意义。
