DeGirolamo Kristin, D'Souza Karan, Hall William, Joos Emilie, Garraway Naisan, Sing Chad Kim, McLaughlin Patrick, Hameed Morad
From the Division of Trauma and Acute Care Surgery, Department of Surgery, University of British Columbia, Vancouver, BC (DeGirolamo, Joos, Garraway, Hameed); the Faculty of Medicine, University of British Columbia, Vancouver, BC (DeGirolamo, D'Souza, Joos, Garraway, Sing, McLaughlin, Hameed); the Centre for Clinical Epidemiology and Evaluation, School of Population and Public Health, University of British Columbia, Vancouver, BC (Hall); the Department of Emergency Medicine, University of British Columbia, Vancouver, BC (Sing); and the Department of Radiology, University of British Columbia, Vancouver, BC (McLaughlin).
Can J Surg. 2018 Feb;61(1):13-18. doi: 10.1503/cjs.004417. Epub 2017 Dec 1.
Emergency general surgery conditions are often thought of as being too acute for the development of standardized approaches to quality improvement. However, process mapping, a concept that has been applied extensively in manufacturing quality improvement, is now being used in health care. The objective of this study was to create process maps for small bowel obstruction in an effort to identify potential areas for quality improvement.
We used the American College of Surgeons Emergency General Surgery Quality Improvement Program pilot database to identify patients who received nonoperative or operative management of small bowel obstruction between March 2015 and March 2016. This database, patient charts and electronic health records were used to create process maps from the time of presentation to discharge.
Eighty-eight patients with small bowel obstruction (33 operative; 55 nonoperative) were identified. Patients who received surgery had a complication rate of 32%. The processes of care from the time of presentation to the time of follow-up were highly elaborate and variable in terms of duration; however, the sequences of care were found to be consistent. We used data visualization strategies to identify bottlenecks in care, and they showed substantial variability in terms of operating room access.
Variability in the operative care of small bowel obstruction is high and represents an important improvement opportunity in general surgery. Process mapping can identify common themes, even in acute care, and suggest specific performance improvement measures.
急诊普通外科疾病通常被认为病情过于危急，难以制定标准化的质量改进方法。然而，流程映射这一在制造业质量改进中已被广泛应用的概念，如今正被应用于医疗保健领域。本研究的目的是创建小肠梗阻的流程映射，以努力识别质量改进的潜在领域。
我们使用美国外科医师学会急诊普通外科质量改进项目试点数据库，来识别在2015年3月至2016年3月期间接受小肠梗阻非手术或手术治疗的患者。该数据库、患者病历和电子健康记录被用于创建从就诊到出院的流程映射。
共识别出88例小肠梗阻患者（33例接受手术；55例接受非手术治疗）。接受手术的患者并发症发生率为32%。从就诊到随访的护理过程非常复杂，持续时间也各不相同；然而，护理顺序是一致的。我们使用数据可视化策略来识别护理中的瓶颈，结果显示手术室准入方面存在很大差异。
小肠梗阻手术护理的变异性很高，是普通外科一个重要的改进机会。流程映射即使在急性护理中也能识别出共同主题，并提出具体的绩效改进措施。
