Marres C C M, van de Ven A W H, Verbeek P C M, van Dieren S, Bemelman W A, Buskens C J
Department of Surgery, Flevoziekenhuis, Hospitaalweg 1, 1315, RA, Almere, the Netherlands.
Department of Surgery, Academisch Medisch Centrum, Amsterdam, the Netherlands.
Int J Colorectal Dis. 2016 Sep;31(9):1603-9. doi: 10.1007/s00384-016-2619-1. Epub 2016 Jul 6.
The aim of this study was to evaluate whether implementation of a comprehensive quality improvement program was associated with improved outcomes in patients undergoing oncological colorectal surgery in a non-academic, non-referral community hospital.
The quality improvement program (QIP) was introduced in January 2011 and consisted of the following interventions: (1) avoidance of postoperative nonsteriodal anti-inflammatory drugs; (2) normovolemia was pursued pre- and postoperatively; (3) non-resectional surgery if possible, in patients over 80 with ASA 3 or 4 classification; and (4) a standardized, postoperative surveillance protocol was introduced, with CRP determination day 2 and 4, and if necessary subsequent abdominal CT with rectal contrast to reduce delay in diagnosis of complications. From a prospectively maintained database of 488 patients undergoing colorectal surgery between 2009 and 2014, postoperative outcomes of patients operated before and after implementation of the program were compared.
The severe complication rate (Clavien-Dindo >3b) decreased significantly (25.0 vs. 13.7 %; p < .001) after implementation of the QIP program. The mortality rate dropped from 8.7 to 2.6 % (p = .003). The percentage of anastomotic leakage was 9.6% before QIP implementation and 4.2% after (p = .013). Median length of hospital stay decreased from 9 (IQR 5-19) to 7 days (IQR 4-12) (p < .001). Multivariate analyses showed that surgery after implementation of the program was a strong independent predictor for less major complications (OR 0.54, 95 % CI 0.32-0.88).
A significant decrease in major complications and mortality was observed after introduction of a relative simple quality improvement program.
本研究旨在评估在一家非学术性、非转诊社区医院中，实施一项全面质量改进计划是否与接受肿瘤性结直肠手术患者的预后改善相关。
质量改进计划（QIP）于2011年1月引入，包括以下干预措施：（1）避免术后使用非甾体类抗炎药；（2）术前和术后维持正常血容量；（3）对于年龄超过80岁、ASA分级为3或4级的患者，尽可能进行非切除性手术；（4）引入标准化的术后监测方案，术后第2天和第4天测定CRP，必要时随后进行直肠造影腹部CT检查，以减少并发症诊断的延迟。从一个前瞻性维护的数据库中选取了2009年至2014年间接受结直肠手术的488例患者，比较了该计划实施前后手术患者的术后结局。
实施QIP计划后，严重并发症发生率（Clavien-Dindo>3b）显著降低（25.0%对13.7%；p<.001）。死亡率从8.7%降至2.6%（p=.003）。吻合口漏发生率在QIP实施前为9.6%，实施后为4.2%（p=.013）。中位住院时间从9天（四分位间距5-19天）降至7天（四分位间距4-12天）（p<.001）。多变量分析显示，计划实施后的手术是较少发生严重并发症的有力独立预测因素（OR 0.54，95%CI 0.32-0.88）。
引入一个相对简单的质量改进计划后，严重并发症和死亡率显著降低。
