Department of Surgery, Johns Hopkins University and School of Medicine, Baltimore, MD.
Department of Surgery, Johns Hopkins University and School of Medicine, Baltimore, MD.
J Am Coll Surg. 2015 Sep;221(3):669-77; quiz 785-6. doi: 10.1016/j.jamcollsurg.2015.05.008. Epub 2015 Jun 8.
The goals of quality improvement are to partner with patients and loved ones to end preventable harm, continuously improve patient outcomes and experience, and eliminate waste, yet few programs have successfully worked on of all these in concert.
We evaluated implementation of a pathway designed to improve patient outcomes, value, and experience in colorectal surgery. The pathway expanded on pre-existing comprehensive unit-based safety program infrastructure and used trust-based accountability models at each level, from senior leaders (chief financial officer and senior vice president for patient safety and quality) to frontline staff. It included preoperative education, mechanical bowel preparation with oral antibiotics, chlorhexidine bathing, multimodal analgesia with thoracic epidurals or transversus abdominus plane blocks, a restricted intravenous fluids protocol, early mobilization, and resumption of oral intake. Eleven months of pre- and post-pathway outcomes, including length of stay (LOS), National Surgical Quality Improvement Program surgical site infection (SSI), venous thromboembolism, and urinary tract infection rates, patient experience, and variable direct costs were compared.
Three hundred ten patients underwent surgery in the baseline period, the mean LOS was 7 days, and the mean SSI rate was 18.8%. There were 330 patients who underwent surgery on the pathway, the LOS was 5 days, and the rate of SSI was 7.3%. Patient experience improved and variable direct costs decreased.
Our trust-based accountability model, which included both senior hospital leadership and frontline providers, provided an enabling structure to rapidly implement an integrated recovery pathway and quickly improve outcomes, value, and experience of patients undergoing colorectal surgery. The study findings have significant implications for spreading surgical quality improvement work.
质量改进的目标是与患者及其家属合作，杜绝可预防的伤害，持续改善患者的预后和体验，消除浪费，但很少有项目能够成功地协调所有这些目标。
我们评估了旨在改善结直肠手术患者预后、价值和体验的途径的实施情况。该途径扩展了现有的基于单位的综合安全计划基础设施，并在各级（首席财务官和高级副总裁负责患者安全和质量）到一线员工）使用基于信任的问责制模型。它包括术前教育、口服抗生素机械性肠道准备、氯己定沐浴、胸椎硬膜外或腹横肌平面阻滞的多模式镇痛、限制静脉输液方案、早期活动和恢复口服摄入。比较了术前和术后 11 个月的结果，包括住院时间（LOS）、国家手术质量改进计划手术部位感染（SSI）、静脉血栓栓塞和尿路感染率、患者体验和可变直接成本。
310 例患者在基线期接受手术，平均 LOS 为 7 天，SSI 发生率为 18.8%。有 330 例患者在途径上接受了手术，LOS 为 5 天，SSI 发生率为 7.3%。患者体验得到改善，可变直接成本降低。
我们的基于信任的问责制模式，包括医院高层领导和一线医护人员，为快速实施综合康复途径并迅速改善结直肠手术患者的预后、价值和体验提供了一个有利的结构。研究结果对推广手术质量改进工作具有重要意义。
