Skip to main content

Advertisement

SpringerLink
Log in

Perioperative quality of care is modulated by process management with clinical pathways for fast-track surgery of the colon

  • Original Article
  • Published:
International Journal of Colorectal Disease Aims and scope Submit manuscript

Abstract

Purpose

Clinical pathways (CPs) are increasingly used to improve quality of care. However, evidence if such improvements are also feasible in fast-track colorectal surgery is lacking. This study evaluates effects of a CP for fast-track colonic resections with respect to process and outcome quality.

Methods

We compared 78 consecutive patients undergoing colonic resections in 2008 and being treated with a CP (CP group) with 133 consecutive patients treated without CP between 2006 and 2007 (pre-CP group). Indicators for process quality were epidural catheter placement, postoperative mobilisation, resumption of solid diet, Foley catheter removal and length of stay. Outcome quality was measured through morbidity, mortality, re-operations and readmissions.

Results

In the CP group, patients received epidural analgesia significantly more often (87.2% vs. 75.2%; p =0.04), were mobilized (38.9% vs. 20.6% on the day of surgery; p = 0.03) and resumed a solid diet earlier (60.5% vs. 49.6% on day 1; p = 0.002). Foley catheter removal and length of stay did not differ between the groups. There were no significant differences regarding morbidity (28.2% vs. 32.3%), mortality (1.2% vs. 2.3%), re-operations (6.4% vs. 9.0%) and readmissions (2.6% vs. 3.8%).

Conclusions

After CP implementation for fast-track surgery of the colon, several indicators of process quality improved while others such as length of stay remained unaltered. There were no significant changes in outcome parameters. CPs are a viable instrument to improve specific aspects of perioperative process management, but their selective benefits have to be critically weighed against the infrastructural and personal efforts required for design and implementation.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Kehlet H (2008) Fast-track colorectal surgery. Lancet 371:791–793

    Article  PubMed  Google Scholar 

  2. Gouvas N, Tan E, Windsor A, Xynos E, Tekkis PP (2009) Fast-track vs standard care in colorectal surgery: a meta-analysis update. Int J Colorectal Dis 24:1119–1131

    Article  PubMed  Google Scholar 

  3. Schwenk W (2009) Fast track rehabilitation in visceral surgery. Chirurg 80:690–701

    Article  PubMed  CAS  Google Scholar 

  4. Maessen J, Dejong CH, Hausel J, Nygren J, Lassen K, Andersen J, Kessels AG, Revhaug A, Kehlet H, Ljungqvist O, Fearon KC, von Meyenfeldt MF (2007) A protocol is not enough to implement an enhanced recovery programme for colorectal resection. Br J Surg 94:224–231

    Article  PubMed  CAS  Google Scholar 

  5. Kehlet H, Büchler MW, Beart RW Jr, Billingham RP, Williamson R (2006) Care after colonic operation—is it evidence-based? Results from a multinational survey in Europe and the United States. J Am Coll Surg 202:45–54

    Article  PubMed  Google Scholar 

  6. Hasenberg T, Keese M, Langle F, Reibenwein B, Schindler K, Herold A, Beck G, Post S, Jauch KW, Spies C, Schwenk W, Shang E (2009) 'Fast-track' colonic surgery in Austria and Germany—results from the survey on patterns in current perioperative practice. Colorectal Dis 11:162–167

    Article  PubMed  CAS  Google Scholar 

  7. Kahokehr A, Sammour T, Zargar-Shoshtari K, Thompson L, Hill AG (2009) Implementation of ERAS and how to overcome the barriers. Int J Surg 7:16–19

    Article  PubMed  Google Scholar 

  8. Lassen K, Hannemann P, Ljungqvist O, Fearon K, Dejong CH, von Meyenfeldt MF, Hausel J, Nygren J, Andersen J, Revhaug A (2005) Patterns in current perioperative practice: survey of colorectal surgeons in five northern European countries. BMJ 330:1420–1421

    Article  PubMed  Google Scholar 

  9. Polle SW, Wind J, Fuhring JW, Hofland J, Gouma DJ, Bemelman WA (2007) Implementation of a fast-track perioperative care program: what are the difficulties? Dig Surg 24:441–449

    Article  PubMed  Google Scholar 

  10. Roig JV, Rodriguez-Carrillo R, Garcia-Armengol J, Villalba FL, Salvador A, Sancho C, Albors P, Puchades F, Fuster C (2007) Multimodal rehabilitation in colorectal surgery. On resistance to change in surgery and the demands of society. Cir Esp 81:307–315

    Article  PubMed  Google Scholar 

  11. Graham ID, Logan J, Harrison MB, Straus SE, Tetroe J, Caswell W, Robinson N (2006) Lost in knowledge translation: time for a map? J Contin Educ Heal Prof 26:13–24

    Article  Google Scholar 

  12. Renholm M, Leino-Kilpi H, Suominen T (2002) Critical pathways. A systematic review. J Nurs Adm 32:196–202

    Article  PubMed  Google Scholar 

  13. Ronellenfitsch U, Rössner E, Jakob J, Post S, Hohenberger P, Schwarzbach M (2008) Clinical pathways in surgery—should we introduce them into clinical routine? A review article. Langenbecks Arch Surg 393:449–457

    Article  PubMed  Google Scholar 

  14. Lemmens L, van Zelm R, Borel RI, van Hillegersberg R, Kerkkamp H (2009) Clinical and organizational content of clinical pathways for digestive surgery: a systematic review. Dig Surg 26:91–99

    Article  PubMed  CAS  Google Scholar 

  15. Gravante G, Caruso R, Andreani SM, Giordano P (2008) Mechanical bowel preparation for colorectal surgery: a meta-analysis on abdominal and systemic complications on almost 5,000 patients. Int J Colorectal Dis 23:1145–1150

    Article  PubMed  Google Scholar 

  16. Block BM, Liu SS, Rowlingson AJ, Cowan AR, Cowan JA Jr, Wu CL (2003) Efficacy of postoperative epidural analgesia: a meta-analysis. JAMA 290:2455–2463

    Article  PubMed  CAS  Google Scholar 

  17. Nelson R, Edwards S, Tse B (2007) Prophylactic nasogastric decompression after abdominal surgery. Cochrane Database Syst Rev CD004929

  18. Saint S, Lipsky BA (1999) Preventing catheter-related bacteriuria: should we? Can we? How? Arch Intern Med 159:800–808

    Article  PubMed  CAS  Google Scholar 

  19. Kehlet H, Bundgaard-Nielsen M (2009) Goal-directed perioperative fluid management: why, when, and how? Anesthesiology 110:453–455

    Article  PubMed  Google Scholar 

  20. Lewis SJ, Andersen HK, Thomas S (2009) Early enteral nutrition within 24 h of intestinal surgery versus later commencement of feeding: a systematic review and meta-analysis. J Gastrointest Surg 13:569–575

    Article  PubMed  Google Scholar 

  21. Kehlet H (2008) Postoperative ileus—an update on preventive techniques. Nat Clin Pract Gastroenterol Hepatol 5:552–558

    Article  PubMed  Google Scholar 

  22. Kehlet H, Dahl JB (2003) Anaesthesia, surgery, and challenges in postoperative recovery. Lancet 362:1921–1928

    Article  PubMed  Google Scholar 

  23. Stiller KR, Munday RM (1992) Chest physiotherapy for the surgical patient. Br J Surg 79:745–749

    Article  PubMed  CAS  Google Scholar 

  24. Uerlich M, Dahmen A, Tuschy S, Ronellenfitsch U, Eveslage K, Vargas Hein O, Türk-Ihli G, Schwarzbach M (2009) Klinische Pfade-Terminologie und Entwicklungsstufen. Periop Med 1:155–163

    Article  Google Scholar 

  25. Ng WQ, Neill J (2006) Evidence for early oral feeding of patients after elective open colorectal surgery: a literature review. J Clin Nurs 15:696–709

    Article  PubMed  Google Scholar 

  26. Baldini G, Bagry H, Aprikian A, Carli F (2009) Postoperative urinary retention: anesthetic and perioperative considerations. Anesthesiology 110:1139–1157

    Article  PubMed  Google Scholar 

  27. Schwarzbach M, Rössner E, Schattenberg T, Post S, Hohenberger P, Ronellenfitsch U (2010) Effects of a clinical pathway of pulmonary lobectomy and bilobectomy on quality and cost of care. Langenbecks Arch Surg 395:1139–1146

    Article  PubMed  Google Scholar 

  28. Schwarzbach MH, Ronellenfitsch U, Wang Q, Rössner ED, Denz C, Post S, Hohenberger P (2010) Effects of a clinical pathway for video-assisted thoracoscopic surgery (VATS) on quality and cost of care. Langenbecks Arch Surg 395:333–340

    Article  PubMed  Google Scholar 

  29. Rotter T, Kugler J, Koch R, Gothe H, Twork S, van Oostrum JM, Steyerberg EW (2008) A systematic review and meta-analysis of the effects of clinical pathways on length of stay, hospital costs and patient outcomes. BMC Health Serv Res 8:265

    PubMed  Google Scholar 

  30. Maessen JM, Dejong CH, Kessels AG, von Meyenfeldt MF (2008) Length of stay: an inappropriate readout of the success of enhanced recovery programs. World J Surg 32:971–975

    Article  PubMed  CAS  Google Scholar 

  31. De Allegri M, Schwarzbach M, Loerbroks A, Ronellenfitsch U (2011) Which factors are important for the successful development and implementation of clinical pathways? A qualitative study. Qual Saf Health Care 20:203–208

    Article  Google Scholar 

  32. Lied TR, Kazandjian VA (1998) A Hawthorne strategy: implications for performance measurement and improvement. Clin Perform Qual Health Care 6:201–204

    PubMed  CAS  Google Scholar 

  33. Lemmens L, van Zelm R, Vanhaecht K, Kerkkamp H (2008) Systematic review: indicators to evaluate effectiveness of clinical pathways for gastrointestinal surgery. J Eval Clin Pract 14:880–887

    Article  PubMed  Google Scholar 

  34. Rotter T, Kinsman L, James E, Machotta A, Gothe H, Willis J, Snow P, Kugler J (2010) Clinical pathways: effects on professional practice, patient outcomes, length of stay and hospital costs. Cochrane Database Syst Rev 3:CD006632

    PubMed  Google Scholar 

  35. Brown C, Hofer T, Johal A, Thomson R, Nicholl J, Franklin BD, Lilford RJ (2008) An epistemology of patient safety research: a framework for study design and interpretation. Part 2. Study design. Qual Saf Health Care 17:163–169

    Article  PubMed  CAS  Google Scholar 

  36. Delaney CP, Zutshi M, Senagore AJ, Remzi FH, Hammel J, Fazio VW (2003) Prospective, randomized, controlled trial between a pathway of controlled rehabilitation with early ambulation and diet and traditional postoperative care after laparotomy and intestinal resection. Dis Colon Rectum 46:851–859

    Article  PubMed  Google Scholar 

  37. Avital S, Hermon H, Greenberg R, Karin E, Skornick Y (2006) Learning curve in laparoscopic colorectal surgery: our first 100 patients. Isr Med Assoc J 8:683–686

    PubMed  Google Scholar 

Download references

Conflict of interest

The authors declare that they have no conflict of interest.

Author information

Authors and Affiliations

  1. Department of General, Visceral, Vascular, and Thoracic Surgery, Klinikum Frankfurt Höchst, Gotenstrasse 6-8, 68150, Frankfurt a. M., Germany

    Matthias Schwarzbach

  2. Department of Surgery, University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany

    Till Hasenberg, Miriam Linke, Peter Kienle, Stefan Post & Ulrich Ronellenfitsch

Authors
  1. Matthias Schwarzbach
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Till Hasenberg
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Miriam Linke
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Peter Kienle
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Stefan Post
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Ulrich Ronellenfitsch
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Matthias Schwarzbach.

Electronic supplementary material

Below is the link to the electronic supplementary material.

ESM 1

(PDF 126 kb)

Rights and permissions

Reprints and permissions

About this article

Cite this article

Schwarzbach, M., Hasenberg, T., Linke, M. et al. Perioperative quality of care is modulated by process management with clinical pathways for fast-track surgery of the colon. Int J Colorectal Dis 26, 1567–1575 (2011). https://doi.org/10.1007/s00384-011-1260-2

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00384-011-1260-2

Keywords

Search

Navigation