Evaluation of the Clinical Pathway for Laparoscopic Cholecystectomy VICTOR SORIA, M.D., ENRIQUE PELLICER, M.D., BENITO FLORES, M.D., MILAGROS CARRASCO, M.D., MARIA FE CANDEL, M.D., JOSE LUIS AGUAYO, M.D.

From the Departamento de Cirugia General, Hospital J.M. Morales Meseguer, 30008 Murcia, Spain

Clinical pathways are comprehensive systematized patient care plans for specific procedures. The clinical pathway for laparoscopic cholecystectomy was implemented in our department in March 2002. The aim of this study is to evaluate the clinical pathway for this procedure 1 year after implementation. A study was conducted on all the patients included in the clinical pathway since its implementation. The assessment criteria include degree of compliance, indicators of clinical care effectiveness, financial impact, and survey-based indicators of satisfaction. The results are compared to a series of patients undergoing surgery the year prior to implementation of the clinical pathway. As our hospital has a system of cost management, we analyzed the mean cost per procedure before and after clinical pathway implementation. Evaluation was made of a series of 160 consecutive patients who underwent surgery during the period 1 year prior to development of the clinical pathway and met the accepted inclusion criteria. The mean length of hospital stay was 3.27 days, and the mean cost per procedure before pathway implementation was 2149 (±768) euros. One year after implementation of the pathway, 140 patients were included (i.e., an inclusion rate of 100%). The mean length of hospital stay of the patients included in the clinical pathway was 2.2 days. The degree of compliance with stays was 66.7 per cent. The most frequent reasons for noncompliance were staff-dependent, followed by patient-dependent causes (oral intolerance, pain, etc.). The mean cost in the series of patients included in the clinical pathway was 1845 (± 618) euros. Laparoscopic cholecystectomy is an ideal procedure for commencing the systemization of clinical pathways. Results show that it has significantly reduced the length of hospital stay and mean cost per procedure with no increased morbidity and with a high degree of patient satisfaction.

C

LINICAL PATHWAYS ARE quality design tools to pro-

tocolize complete procedures, or a large part of them, and include decisions and clinical and organizational interventions for all the health care professionals involved. Clinical pathways and patient care charts were defined by Zander' as instruments of clinical management to organize and determine the sequence and duration of interventions by all kinds of health care staff and departments for a particular type of case or part thereof. The first clinical pathways were developed by nurses as care plans for improving nursing attention,^' ^ but subsequent evolution turned them into multidisciplinary instruments integrating the whole spectrum of activities of all the intervening health care professionals.

Since the introduction of laparoscopic cholecystec-

tomy, it has been the treatment of choice for symptomatic cholelithiasis."* Rapid recovery after surgery has led to an increasingly shorter length of hospital stay. A report was published recently of its application to major ambulatory surgery,^ although this practice has not been universally accepted.^ Laparoscopic cholecystectomy is a common procedure in our hospital (140-160 per year); it is highly predictable and requires a wide variety of postoperative clinical attention. This used to involve an inadequate length of postoperative stay and made it difficult for planning tasks and the beds used by the surgery department. For this reason, we decided to develop and implement the clinical pathway for laparoscopic cholecystectomy. The aim of this study is to evaluate the clinical pathway for laparoscopic cholecystectomy since its implementation in our department and compare the Address correspondence and reprint requests to Vi'ctor Soria, results with a previous series of patients undergoing M.D., Departamento de Cirugia General, Hospital J.M. Morales the Same procedure prior tO development of the Meseguer, Calle Marques de los Velez s/n, 30008 Murcia, Spain, pathway. 40

No. 1

CLINICAL PATHWAY FOR U\PAROSCOPIC CHOLECYSTECTOMY

Patients and Methods

The clinical pathway for laparoscopic cholecystectomy was implemented in the Surgery Department of the J.M. Morales Meseguer Hospital in Murcia, Spain, in March 2002. The criteria for inclusion in the clinical pathway were as follows: 1) patients diagnosed with cholelithiasis; 2) indication for surgery; and 3) admission programmed by the General Surgery Department. The exclusion criteria were 1) strong suspicion of choledocholithiasis; 2) emergency surgery; 3) intraoperative finding of acute cholecystitis; and 4) existence of concomitant major surgical procedures to be resolved in the same surgical operation. The clinical pathway includes the following specific protocols for this procedure: a) Protocol for treatment and care in the immediate postoperative period, which includes: Start of oral tolerance 6 hours after completion of the operation. Sedestation 6 hours after the operation. Standard analgesic regimen with 2 g intravenous magnesium metamizol every 8 hours or 1 g IV paracetamol every 6 hours in patients allergic to pyrazolones. Standard antiemetic regimen with 10 mg intravenous metoclopramide every 8 hours, and 4 mg ondansetron if the patient presents with nausea or vomiting despite the Ireatment. b) Protocol for thromboembolic prophylaxis: Patients with a low risk of thromboembolic disease: low-molecular-weight heparin, 20 mg subcutaneous enoxaparin 12 hours before the operation. Patients with a moderate or high risk of thromboembolic disease: antithrombosis measures and lowmolecular-weight heparin, 40 mg subcutaneous enoxaparin 12 hours before the operation. c) Criteria for hospital discharge: Pain controlled with minor analgesics Wounds in good condition Adequate oral tolerance Absence of major complications d) Principal documents: Temporary matrix, which shows the sequence of events and includes the regimen of medical intervention and nursing, medication, physical activity, diet, and information for the patient and/or relatives (Table 1). Information on patient transit and pictures to explain the procedure. This is an informative document with illustrations showing the sequence of medical interventions together with activity, diet, and anticipated time of discharge. Variation chart. This, notes any variations to the

Soria et al.

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schedule of the temporary matrix. The solution adopted for each specific case is indicated, and codes are assigned to the variations considered most relevant. Indicators of results. This chart specifies the indicators of quality defined for evaluating the results ofthe clinical pathway, depending on the standards as indicated (Table 2). Nursing care plan for each stage of the patient's care. Satisfaction survey. This reflects the degree of quality perceived in aspects of health care, personal treatment and information received, aspects of reception and catering, as well as fulfillment of the expectations of the patients or their relatives. Assessment of the clinical pathway was based on indicators created specifically for this pathway and on standards published and acknowledged for analyzing the procedure. The degree of compliance with stays was evaluated, and the outcomes of mean length of hospital stay compared to those of the series prior to implementation of the clinical pathway using the Student t test. As indicators of clinical care effectiveness, the adverse occurrences in the patients and the number of readmissions were studied. As an indicator of satisfaction, we evaluated the satisfaction survey for patients and relatives by collecting the answers to the questions: "Was the medical attention received during your hospital admission satisfactory?" and "Does the length of time you stayed in hospital seem adequate?" The questionnaire was handed out on the day of hospital discharge and collected anonymously from the suggestions box in the hospital. Finally, to measure the degree of clinical pathway effectiveness, we used the cost accounting data provided by our hospital management, in which the costs of staff, surgery, material, laboratory, and so forth, are itemized by procedures. We therefore compared the mean cost per procedure before and after implementation of the clinica] pathway using the Student t function. Results

An analysis was conducted of a series of 160 consecutive patients undergoing surgery during a period of 1 year prior to development of the clinical pathway and meeting the accepted inclusion criteria. The mean length of hospital stay was 3.27 ± 2.18 days. The following complications were presented: one case of hemoperitoneum, which required reoperation, and two patients with postoperative ileus, which was resolved with conservative treatment. There was no mortality in the series. The clinical pathway for laparoscopic cholecystectomy was implemented in our hospital in March 2002.

THE AMERICAN SURGEON

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January 2005

Vol. 71

TABLE I. Temporary Matrix Activities Date: Nursing care

Treatments and medical interventions

Day 2. Operation Day 1. Admission Operating Theater/ Room Reanimation Room Admission to room (5-7 p.m.) Nursing care plan Reception, assessment, and Room nurse care plan Shave surgical area Blood pressure and Shower and clean area for temperature operation Check Intravenous pathway Preoperative study BP/Temp./per shift Written consent Surgical nurse Previous medication Assessment of Op Protocol for Op preparation. preparation Prepare LC protocol Reanimation CF/BP/15 m. Diuresis and drainage/hourly Assessment of analgesia Anesthesiologist Anesthesia Postanesthesia assessment Surgeon: Surgical operation Surgical protocol Request for pathological

Medication

Administer medication prescribed on anesthesia chart Orphidai one tablet at 11 p.m.

Activity

Usual

Diet

Usual diet Fast 8 h before operation

Information and support

Apply reception protocol Information on department and patient transit Illustrations of pathway

Criteria

Pre-op medication ATB and TE. prophylaxis Post-op medication Nolotil 1 capsule/6 h (if allergic to Pro-Perfalgan 2 g/6 h IV) Primperan 1 cap. IV/8 h Rest in raised bed Progressive mobilization (transfer to chair approx. 6 h after operation) Oral tolerance 6 h after operation If tolerance: liquid supper Information on leaving operating theater Advice on possible discharge the following day

Day 3. Discharge Postop. Day 1 Room Nurse Remove dressings Cure open surgical wound Blood pressure. temperature, and diuresis Remove peripheral catheter

Surgeon Exploration and treatment Evaluate discharge criteria Discharge report

Nolotil 1 capsule/6 h orally or if allergic to efferalgan 1 g every 6 h TE prophylaxis

Ambulation Personal toilet Semi-soft diet Information for patient and/or relative Hand out and collect satisfaction survey Hand out nursing care and discharge report Discharge criteria: No fever, adequate surgical wounds. Controlled pain. Oral tolerance.

ATB, antibiotic; TE, thromboembolic. The results were evaluated between the time of implementation and February 2003; during this time, 140 patients included in the clinical pathway received surgery. The mean length of hospital stay of these patients was 2.2 ± t.4 days, with a statistically significant difference {P < 0.001) when compared to the mean length of stay of the patients undergoing surgery before pathway implementation. The degree of compliance with the hospital stay was 66.7 per cent. The variations leading to noncompliance

with the stay were a) patient-dependent: oral intolerance (11 cases) and uncontrolled pain (7 cases); b) staff-dependent: the prescribed treatment is not as specified in the pathway (11 cases), and the doctor does not authorize discharge when the patient meets the criteria without writing any reason to justify it (11 cases) (Table 3). During this time, the number of adverse occurrences was evaluated as an indicator of clinical care effectiveness. The result of this evaluation was two cases of

No. 1

CLINICAL PATHWAY FOR LAPAROSCOPIC CHOLECYSTECTOMY

TABLE 2. Assessment Criteria

43

Discussion

1. Degree of complianee • Inclusion in clinieal pathway: All patients meeting the criteria are to be included in clinical pathway. • Degree of compliance with hospital stays: Criterion: length of stay must be adjusted to the clinical pathway schedule: 2 days 2. Indicators of clinical care effectiveness • Criterion: number of adverse occurrences must be an absolute minimum. • Indicators: Percentage of patients with hemorrhage (standard