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The Effect of Clinical Pathways for Bariatric Surgery on Perioperative Quality of Care

  • Clinical Research
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Abstract

Background

Bariatric surgery demands a multidisciplinary approach and enhanced recovery schemes. Such schemes are complex and cumbersome to introduce into practice. This study evaluates if a clinical pathway (CP) facilitates implementation of an enhanced recovery scheme in bariatric surgery with the goal of improving perioperative quality of care.

Methods

We compared 65 consecutive patients who underwent bariatric surgery in 2009 and were treated with a CP (CP group) with 64 consecutive patients treated without CP in 2007/2008 (pre-CP group). Process quality indicators were catheter management, postoperative mobilization, spirometer training, vitamin B supplementation, diet resumption, intake of supplement drinks, and length of stay. Outcome quality was measured through morbidity, mortality, re-operations, and re-admissions.

Results

In the CP group, foley catheters were removed earlier (p < 0.0001), patients were mobilized more often on the surgery day (CP group 92.3% vs. pre-CP group 78.1%, p = 0.03), used spirometers more often (56.9% vs. 28.1%, p = 0.002), were more often supplemented with vitamin B (100% vs. 31.3%, p < 0.0001), and received oral supplement nutrition more often (100% vs. 59.4%, p < 0.0001). Median length of stay was shorter in the CP group (6 vs. 7 days, p = 0.007). There was no significant difference in mortality, morbidity, re-operations, and re-admissions.

Conclusions

Following implementation of an enhanced recovery CP for bariatric surgery, several indicators of process quality improved while outcome quality remained unchanged. A CP seems useful for optimizing treatment of bariatric surgery patients according to enhanced recovery principles. However, future studies are required to better determine which elements of care can be improved most.

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References

  1. Buchwald H, Oien D. Metabolic/bariatric surgery worldwide 2008. Obes Surg. 2009;19:1605–11.

    Article  PubMed  Google Scholar 

  2. Selassie M, Sinha AC. The epidemiology and aetiology of obesity: a global challenge. Best Pract Res Clin Anaesthesiol. 2011;25:1–9.

    Article  PubMed  Google Scholar 

  3. Sjostrom L, Narbro K, Sjostrom CD, et al. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med. 2007;357:741–52.

    Article  PubMed  Google Scholar 

  4. Hubbard VS, Hall WH. Gastrointestinal surgery for severe obesity. Obes Surg. 1991;1:257–65.

    Article  PubMed  Google Scholar 

  5. Fried M, Hainer V, Basdevant A, et al. Interdisciplinary European guidelines for surgery for severe (morbid) obesity. Obes Surg. 2007;17:260–70.

    Article  PubMed  Google Scholar 

  6. Runkel N, Colombo-Benkmann M, Huttl TP, et al. Evidence-based German guidelines for surgery for obesity. Int J Colorectal Dis. 2011;26:397–404.

    Article  PubMed  Google Scholar 

  7. Gouvas N, Tan E, Windsor A, et al. Fast-track vs standard care in colorectal surgery: a meta-analysis update. Int J Colorectal Dis. 2009;24:1119–31.

    Article  PubMed  Google Scholar 

  8. Kehlet H. Fast-track colorectal surgery. Lancet. 2008;371:791–3.

    Article  PubMed  Google Scholar 

  9. Hasenberg T, Keese M, Langle F, et al. 'Fast-track' colonic surgery in Austria and Germany—results from the survey on patterns in current perioperative practice. Colorectal Dis. 2009;11:162–7.

    Article  PubMed  CAS  Google Scholar 

  10. Kahokehr A, Sammour T, Zargar-Shoshtari K, et al. Implementation of ERAS and how to overcome the barriers. Int J Surg. 2009;7:16–9.

    Article  PubMed  Google Scholar 

  11. Kehlet H, Buchler MW, Beart RW Jr, et al. Care after colonic operation—is it evidence-based? Results from a multinational survey in Europe and the United States. J Am Coll Surg. 2006;202:45–54.

    Article  PubMed  Google Scholar 

  12. Maessen J, Dejong CH, Hausel J, et al. A protocol is not enough to implement an enhanced recovery programme for colorectal resection. Br J Surg. 2007;94:224–31.

    Article  PubMed  CAS  Google Scholar 

  13. Polle SW, Wind J, Fuhring JW, et al. Implementation of a fast-track perioperative care program: what are the difficulties? Dig Surg. 2007;24:441–9.

    Article  PubMed  Google Scholar 

  14. Roig JV, Rodriguez-Carrillo R, Garcia-Armengol J, et al. Multimodal rehabilitation in colorectal surgery. On resistance to change in surgery and the demands of society. Cir Esp. 2007;81:307–15.

    Article  PubMed  Google Scholar 

  15. Kinsman L, Rotter T, James E, et al. What is a clinical pathway? Development of a definition to inform the debate. BMC Med. 2010;8:31.

    Article  PubMed  Google Scholar 

  16. Lemmens L, van Zelm R, Vanhaecht K, et al. Systematic review: indicators to evaluate effectiveness of clinical pathways for gastrointestinal surgery. J Eval Clin Pract. 2008;14:880–7.

    Article  PubMed  Google Scholar 

  17. Ronellenfitsch U, Rossner E, Jakob J, et al. Clinical pathways in surgery—should we introduce them into clinical routine? A review article. Langenbecks Arch Surg. 2008;393:449–57.

    Article  PubMed  Google Scholar 

  18. Rotter T, Kugler J, Koch R, et al. 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. 2008;8:265.

    PubMed  Google Scholar 

  19. Schwarzbach MH, Ronellenfitsch U, Wang Q, et al. Effects of a clinical pathway for video-assisted thoracoscopic surgery (VATS) on quality and cost of care. Langenbecks Arch Surg. 2010;395:333–40.

    Article  PubMed  Google Scholar 

  20. Schwarzbach M, Rossner E, Schattenberg T, et al. Effects of a clinical pathway of pulmonary lobectomy and bilobectomy on quality and cost of care. Langenbecks Arch Surg. 2010;395:1139–46.

    Article  PubMed  Google Scholar 

  21. 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. 2011;26:1567–75.

    Article  PubMed  Google Scholar 

  22. Rouse AD, Tripp BL, Shipley S, et al. Meeting the challenge of managed care through clinical pathways for bariatric surgery. Obes Surg. 1998;8:530–4.

    Article  PubMed  CAS  Google Scholar 

  23. Campillo-Soto A, Martin-Lorenzo JG, Liron-Ruiz R, et al. Evaluation of the clinical pathway for laparoscopic bariatric surgery. Obes Surg. 2008;18:395–400.

    Article  PubMed  Google Scholar 

  24. Frutos MD, Lujan J, Hernandez Q, et al. Clinical pathway for laparoscopic gastric bypass. Obes Surg. 2007;17:1584–7.

    Article  PubMed  Google Scholar 

  25. Madan AK, Speck KE, Ternovits CA, et al. Outcome of a clinical pathway for discharge within 48 hours after laparoscopic gastric bypass. Am J Surg. 2006;192:399–402.

    Article  PubMed  Google Scholar 

  26. Yeats M, Wedergren S, Fox N, et al. The use and modification of clinical pathways to achieve specific outcomes in bariatric surgery. Am Surg. 2005;71:152–4.

    PubMed  Google Scholar 

  27. Huerta S, Heber D, Sawicki MP, et al. Reduced length of stay by implementation of a clinical pathway for bariatric surgery in an academic health care center. Am Surg. 2001;67:1128–35.

    PubMed  CAS  Google Scholar 

  28. Cooney RN, Bryant P, Haluck R, et al. The impact of a clinical pathway for gastric bypass surgery on resource utilization. J Surg Res. 2001;98:97–101.

    Article  PubMed  CAS  Google Scholar 

  29. Müller MK, Dedes KJ, Dindo D, et al. Impact of clinical pathways in surgery. Langenbecks Arch Surg. 2009;394:31–9.

    Article  PubMed  Google Scholar 

  30. Schwenk W. Fast track rehabilitation in visceral surgery. Chirurg. 2009;80:690–701.

    Article  PubMed  CAS  Google Scholar 

  31. Block BM, Liu SS, Rowlingson AJ, et al. Efficacy of postoperative epidural analgesia: a meta-analysis. JAMA. 2003;290:2455–63.

    Article  PubMed  CAS  Google Scholar 

  32. Rawal N, Sjostrand U, Christoffersson E, et al. Comparison of intramuscular and epidural morphine for postoperative analgesia in the grossly obese. Anesth Analg. 1984;63:583–92.

    PubMed  CAS  Google Scholar 

  33. Nelson R, Edwards S, Tse B. Prophylactic nasogastric decompression after abdominal surgery. Cochrane Database Syst Rev 2007; 18(3):CD004929.

    Google Scholar 

  34. Saint S, Lipsky BA. Preventing catheter-related bacteriuria: should we? Can we? How? Arch Intern Med. 1999;159:800–8.

    Article  PubMed  CAS  Google Scholar 

  35. Kehlet H, Bundgaard-Nielsen M. Goal-directed perioperative fluid management: why, when, and how? Anesthesiology. 2009;110:453–5.

    Article  PubMed  Google Scholar 

  36. Kratzing C. Pre-operative nutrition and carbohydrate loading. Proc Nutr Soc. 2011;70:311–5.

    Article  PubMed  CAS  Google Scholar 

  37. Mechanick JI, Kushner RF, Sugerman HJ, et al. American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient. Surg Obes Relat Dis. 2008;4:S109–84.

    Article  PubMed  Google Scholar 

  38. Kehlet H. Postoperative ileus—an update on preventive techniques. Nat Clin Pract Gastroenterol Hepatol. 2008;5:552–8.

    Article  PubMed  Google Scholar 

  39. Kehlet H, Dahl JB. Anaesthesia, surgery, and challenges in postoperative recovery. Lancet. 2003;362:1921–8.

    Article  PubMed  Google Scholar 

  40. Stiller KR, Munday RM. Chest physiotherapy for the surgical patient. Br J Surg. 1992;79:745–9.

    Article  PubMed  CAS  Google Scholar 

  41. Flancbaum L, Belsley S, Drake V, et al. Preoperative nutritional status of patients undergoing Roux-en-Y gastric bypass for morbid obesity. J Gastrointest Surg. 2006;10:1033–7.

    Article  PubMed  Google Scholar 

  42. Uerlich M, Dahmen A, Tuschy S, et al. Klinische Pfade—Terminologie und Entwicklungsstufen. Periop Med. 2009;1:155–63.

    Article  Google Scholar 

  43. Klevens RM, Edwards JR, Richards CL Jr, et al. Estimating health care-associated infections and deaths in U.S. hospitals, 2002. Public Health Rep. 2007;122:160–6.

    PubMed  Google Scholar 

  44. Prentice M. Other end of the bedpan. Nurs Stand. 1995;9:56.

    PubMed  CAS  Google Scholar 

  45. Anderson E. The bedpan and the commode. Nurs Times. 1978;74:684.

    PubMed  CAS  Google Scholar 

  46. Schug SA, Raymann A. Postoperative pain management of the obese patient. Best Pract Res Clin Anaesthesiol. 2011;25:73–81.

    Article  PubMed  CAS  Google Scholar 

  47. Lawrence VA, Cornell JE, Smetana GW. Strategies to reduce postoperative pulmonary complications after noncardiothoracic surgery: systematic review for the American College of Physicians. Ann Intern Med. 2006;144:596–608.

    PubMed  Google Scholar 

  48. Lemmens L, van ZR, Borel R, I et al. Clinical and organizational content of clinical pathways for digestive surgery: a systematic review. Dig Surg. 2009;26:91–9.

  49. Rotter T, Kinsman L, James E, et al. Clinical pathways: effects on professional practice, patient outcomes, length of stay and hospital costs. Cochrane Database Syst Rev. 2010;3:CD006632.

    PubMed  Google Scholar 

  50. Maessen JM, Dejong CH, Kessels AG, et al. Length of stay: an inappropriate readout of the success of enhanced recovery programs. World J Surg. 2008;32:971–5.

    Article  PubMed  CAS  Google Scholar 

  51. Stellato TA, Hallowell PT, Crouse C, et al. Two-day length of stay following open Roux-En-Y gastric bypass: is it feasible, safe and reasonable? Obes Surg. 2004;14:27–34.

    Article  PubMed  Google Scholar 

  52. dos Santos MI Jr, Madalosso CA, Palma LA, et al. Hospital discharge in the day following open Roux-en-Y gastric bypass: is it feasible and safe? Obes Surg. 2009;19:281–6.

    Article  Google Scholar 

  53. Clarke A. Why are we trying to reduce length of stay? Evaluation of the costs and benefits of reducing time in hospital must start from the objectives that govern change. Qual Health Care. 1996;5:172–9.

    Article  PubMed  CAS  Google Scholar 

  54. Brown C, Hofer T, Johal A, et al. An epistemology of patient safety research: a framework for study design and interpretation. Part 2. Study design. Qual Saf Health Care. 2008;17:163–9.

    Article  PubMed  CAS  Google Scholar 

  55. Hasan A, Pozzi M, Hamilton JR. New surgical procedures: can we minimise the learning curve? BMJ. 2000;320:171–3.

    Article  PubMed  CAS  Google Scholar 

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Conflicts of Interest

All authors declare no conflicts of interest.

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Authors and Affiliations

  1. Department of Surgery, University Medical Centre Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68135, Mannheim, Germany

    Ulrich Ronellenfitsch, Anne Kring, Peter Kienle, Stefan Post & Till Hasenberg

  2. Department of General, Visceral, Vascular, and Thoracic Surgery, Klinikum Frankfurt Höchst, Gotenstrasse 6-8, 65929, Frankfurt am Main, Germany

    Matthias Schwarzbach

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  1. Ulrich Ronellenfitsch
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  2. Matthias Schwarzbach
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  6. Till Hasenberg
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Correspondence to Ulrich Ronellenfitsch.

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Ronellenfitsch, U., Schwarzbach, M., Kring, A. et al. The Effect of Clinical Pathways for Bariatric Surgery on Perioperative Quality of Care. OBES SURG 22, 732–739 (2012). https://doi.org/10.1007/s11695-012-0605-4

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