Breast Unit, Imperial College Healthcare NHS Trust, London, UK.
Department of Surgery and Cancer, Imperial College, London, UK.
Br J Surg. 2018 Nov;105(12):1615-1622. doi: 10.1002/bjs.10919. Epub 2018 Jul 11.
Surgical subspecialization has resulted in mastitis and breast abscesses being managed with unnecessary admission to hospital, prolonged inpatient stay, variable antibiotic prescribing, incision and drainage rather than percutaneous aspiration, and loss to specialist follow-up. The objective was to evaluate a best-practice algorithm with the aim of improving management of mastitis and breast abscesses across a multisite NHS Trust. The focus was on uniformity of antibiotic prescribing, ultrasound assessment, admission rates, length of hospital stay, intervention by aspiration or incision and drainage, and specialist follow-up.
Management was initially evaluated in a retrospective cohort (phase I) and subsequently compared with that in two prospective cohorts after introduction of a breast abscess and mastitis pathway. One prospective cohort was analysed immediately after introduction of the pathway (phase II), and the second was used to assess the sustainability of the quality improvements (phase III). The overall impact of the pathway was assessed by comparing data from phase I with combined data from phases II and III; results from phases II and III were compared to judge sustainability.
Fifty-three patients were included in phase I, 61 in phase II and 80 in phase III. The management pathway and referral pro forma improved compliance with antibiotic guidelines from 34 per cent to 58·2 per cent overall (phases II and III) after implementation (P = 0·003). The improvement was maintained between phases II and III (54 and 61 per cent respectively; P = 0·684). Ultrasound assessment increased from 38 to 77·3 per cent overall (P < 0·001), in a sustained manner (75 and 79 per cent in phases II and III respectively; P = 0·894). Reductions in rates of incision and drainage (from 8 to 0·7 per cent overall; P = 0·007) were maintained (0 per cent in phase II versus 1 per cent in phase III; P = 0·381). Specialist follow-up improved consistently from 43 to 95·7 per cent overall (P < 0·001), 92 per cent in phase II and 99 per cent in phase III (P = 0·120). Rates of hospital admission and median length of stay were not significantly reduced after implementation of the pathway.
A standardized approach to mastitis and breast abscess reduced undesirable practice variation, with sustained improvements in process and patient outcomes.
外科亚专业的发展导致乳腺炎和乳房脓肿的治疗需要不必要的住院、延长住院时间、抗生素的使用存在差异、采用切开引流而非经皮抽吸，以及失去专科随访。本研究旨在评估最佳实践方案，以改善多站点 NHS 信托机构中乳腺炎和乳房脓肿的管理。重点在于抗生素使用、超声评估、入院率、住院时间、抽吸或切开引流干预以及专科随访的一致性。
首先在回顾性队列中评估管理情况（第 I 阶段），然后在引入乳房脓肿和乳腺炎流程后，与两个前瞻性队列进行比较。一个前瞻性队列在引入该流程后立即进行分析（第 II 阶段），第二个队列用于评估质量改进的可持续性（第 III 阶段）。通过比较第 I 阶段与第 II 和第 III 阶段的综合数据，评估该流程的整体影响；通过比较第 II 和第 III 阶段的结果，判断其可持续性。
第 I 阶段纳入 53 例患者，第 II 阶段纳入 61 例患者，第 III 阶段纳入 80 例患者。实施后，管理路径和转诊表提高了抗生素使用指南的依从性，总体从 34%提高至 58.2%（第 II 和第 III 阶段；P=0.003）。第 II 和第 III 阶段之间的改善得以维持（分别为 54%和 61%；P=0.684）。超声评估总体从 38%提高至 77.3%（P<0.001），且保持稳定（第 II 和第 III 阶段分别为 75%和 79%；P=0.894）。切开引流率（总体从 8%降至 0.7%；P=0.007）得以维持（第 II 阶段为 0%，第 III 阶段为 1%；P=0.381）。专科随访率从 43%提高至 95.7%（总体；P<0.001），第 II 阶段为 92%，第 III 阶段为 99%（P=0.120）。该流程实施后，住院率和中位住院时间无显著降低。
采用标准化方法治疗乳腺炎和乳房脓肿减少了不理想的实践差异，在流程和患者结局方面取得了持续的改善。
