Kim Eugene, Lee Brian, Cucchiaro Giovanni
From the Department of Anesthesiology Critical Care Medicine-Pain Service, Children's Hospital Los Angeles, Los Angeles, California.
Anesth Analg. 2017 Sep;125(3):812-819. doi: 10.1213/ANE.0000000000002030.
The concept of Perioperative Surgical Home has been gaining significant attention in surgical centers. This model is delivering and improving coordinated care in a cost-effective manner to patients undergoing surgical procedures. It starts with the decision for surgical intervention, continues to the intraoperative and postoperative periods, and follows into long-term recovery. Constant re-evaluation of outcomes and modifications of delivery provides a feedback loop for improvement. Children's Hospital Los Angeles initiated a new protocol in June 2014 to manage children undergoing Posterior Spinal Fusion (PSF) with the goal to improve patient experience and lower the hospital length of stay and cost.
A retrospective chart review identified patients who underwent a PSF for idiopathic scoliosis before and after initiation of a new treatment protocol designed by a team of anesthesiologists, surgeons, nurses, and physical therapists. The new protocol included preoperative teaching of parents and patients, intraoperative anesthetic and surgical management, and immediate to long-term postoperative medical management. In addition to demographics, we examined length of stay, cost of hospitalization, pain scores on discharge, length of patient-controlled analgesia use, time to first solid food intake, and time to ambulation.
Thirty-six patients were identified preinitiation and postinitiation of the protocol (total n = 72). There was no statistically significant difference in age, sex, use of intrathecal morphine, or estimated blood loss. Patients enrolled in the new protocol had higher American Society of Anesthesiologists classification (P = .003), significantly lower duration of patient-controlled analgesia use, time to first solid food intake, and time to ambulation (P= .001). The pain scores were higher at the time of discharge, although the difference was not statistically significant. Length of stay was significantly shorter in the new protocol group (P = .001), accounting for $292,560 in cost savings for the hospital.
These data show that the cooperation of different teams in designing new management guidelines for patients requiring a PSF can significantly decrease the total length of stay and cost of hospitalization without altering quality of care.
围手术期外科之家的概念在外科中心受到了广泛关注。该模式以具有成本效益的方式为接受外科手术的患者提供并改善协调护理。它始于手术干预的决策，持续到术中及术后阶段，并延伸至长期康复。对结果的持续重新评估和护理方式的调整提供了一个改进的反馈循环。洛杉矶儿童医院于2014年6月启动了一项新方案，用于管理接受后路脊柱融合术（PSF）的儿童，目标是改善患者体验、缩短住院时间并降低成本。
通过回顾性病历审查，确定了在由麻醉师、外科医生、护士和物理治疗师团队设计的新治疗方案启动前后接受特发性脊柱侧凸后路脊柱融合术的患者。新方案包括对家长和患者的术前教育、术中麻醉和手术管理以及术后即时至长期的医疗管理。除了人口统计学数据外，我们还检查了住院时间、住院费用、出院时的疼痛评分、患者自控镇痛使用时间、首次摄入固体食物的时间以及下床活动时间。
确定了方案启动前和启动后的36例患者（共72例）。在年龄、性别、鞘内注射吗啡的使用或估计失血量方面，没有统计学上的显著差异。参与新方案的患者美国麻醉医师协会分级更高（P = .003），患者自控镇痛使用时间、首次摄入固体食物的时间和下床活动时间显著更短（P = .001）。出院时的疼痛评分更高，尽管差异无统计学意义。新方案组的住院时间显著更短（P = .001），为医院节省了292,560美元的成本。
这些数据表明，不同团队合作设计针对需要后路脊柱融合术患者的新管理指南，可显著缩短住院总时长和住院成本，同时不影响护理质量。
