Cerfolio Robert James, Steenwyk Brad L, Watson Caroline, Sparrow James, Belopolsky Victoria, Townsley Matthew, Lyerly Ralph, Downing Michelle, Bryant Ayesha, Gurley William Quinton, Henling Colleen, Crawford Jack, Gayeski Thomas E
Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama.
Cardiothoracic Anesthesiology Division, Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Alabama.
Ann Thorac Surg. 2016 Mar;101(3):1110-5. doi: 10.1016/j.athoracsur.2015.09.004. Epub 2015 Nov 19.
Our objective was to evaluate our results after the implementation of lean (the elimination of wasteful parts of a process).
After meetings with our anesthesiologists, we standardized our "in the operating room-to-skin incision protocols" before pulmonary lobectomy. Patients were divided into consecutive cohorts of 300 lobectomy patients. Several protocols were slowly adopted and outcomes were evaluated.
One surgeon performed 2,206 pulmonary lobectomies, of which 84% were for cancer. Protocols for lateral decubitus positioning changed over time. We eliminated axillary rolls, arm boards, and beanbags. Monitoring devices were slowly eliminated. Central catheters decreased from 75% to 0% of patients, epidurals from 84% to 3%, arterial catheters from 93% to 4%, and finally, Foley catheters were reduced from 99% to 11% (p ≤ 0.001 for all). A protocol for the insertion of double-lumen endotracheal tubes was established and times decreased (mean, 14 minutes to 1 minute; p = 0.001). After all changes were made, the time between operating room entry and incision decreased from a mean of 64 minutes to 37 minutes (p < 0.001). Outcomes improved, mortality decreased from 3.2% to 0.26% (p = 0.015), and major morbidity decreased from 15.2% to 5.3% (p = 0.042).
Lean and value stream mapping can be safely applied to the clinical algorithms of high-risk patient care. We demonstrate that elimination of non-value-added steps can safely decrease preincision time without increasing patient risk in patients who undergo pulmonary lobectomy. Selected centers may be able to adopt some of these lean-driven protocols.
我们的目标是评估实施精益理念（即消除流程中浪费的部分）后的结果。
在与麻醉医生会面后，我们在肺叶切除术前标准化了“进入手术室至皮肤切开方案”。患者被分为连续的每组300例肺叶切除患者队列。逐步采用了多个方案并对结果进行评估。
一位外科医生实施了2206例肺叶切除术，其中84%是因癌症。侧卧位的方案随时间发生了变化。我们取消了腋窝垫、臂板和豆袋。监测设备也逐步被取消。中心静脉导管使用比例从患者的75%降至0%，硬膜外导管从84%降至3%，动脉导管从93%降至4%，最后，导尿管从99%降至11%（所有p值均≤0.001）。建立了双腔气管插管插入方案，时间缩短（平均从14分钟降至1分钟；p = 0.001）。在所有改变实施后，进入手术室至切开皮肤的时间从平均64分钟降至37分钟（p < 0.001）。结果得到改善，死亡率从3.2%降至0.26%（p = 0.015），主要并发症发生率从15.2%降至5.3%（p = 0.042）。
精益理念和价值流映射可安全应用于高危患者护理的临床流程。我们证明，在接受肺叶切除术的患者中，消除非增值步骤可安全缩短切开前时间且不增加患者风险。部分中心或许能够采用其中一些由精益理念驱动的方案。
