The intensive care unit course of patients undergoing liver transplantation: A report on success with a clinical pathway
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ABSTRACT: The contents and organization of the preoperative care have gained increasing attention over the past decade. Several strategies have emerged to evaluate and optimize patients before surgery, aiming to minimize the risk of complications. In this thesis two different strategies for preoperative evaluation and optimization were studied: outpatient preoperative evaluation clinics (OPE clinics) and preoperative interventions embedded in clinical pathways for gastrointestinal surgery. At an OPE clinic the anaesthetist timely evaluates the preoperative condition of patients to asses the risk on complications during and after surgery. Formerly, this evaluation was performed by internists and surgeons or by the anaesthetist just before he started anaesthesia. The implementation of OPE clinics was evaluated by a nationwide survey with questionnaires. Cooperation of anaesthetists was most frequently mentioned as facilitating factor for implementation of OPE clinics. Lack of finance was most frequently reported as limiting factor, but significantly more often in hospitals without than in with an OPE clinic (p<0.01). Underlying factors, like perceptions of professionals involved and organizational structure, were found to be related to the implementation of OPE clinics as well. Also the two national guidelines on preoperative evaluation influenced the implementation process. Furthermore, the study showed that most hospitals have implemented an OPE clinic nowadays. In the second part of the thesis, interventions embedded in clinical pathways for gastrointestinal surgery were evaluated. A clinical pathway is a care path in which is defined what interventions have to be performed before, during and after surgery and by which health professionals. The focus was on preoperative interventions. Two systematic reviews and two (pilot) studies were performed. In the systematic reviews the contents of clinical pathways for gastrointestinal surgery were assessed, as well as indicators and study designs to evaluate their effectiveness. Most of the interventions defined in clinical pathways were in accordance with the Enhanced Recovery After Surgery (ERAS) protocol. They resulted in reduced length of hospital stay without adverse effects. We concluded that more process and patient safety indicators and more rigorous study designs should be used to evaluate the effectiveness of clinical pathways for gastrointestinal surgery. Subsequently, prompted by the results of the reviews, in our first pilot study the feasibility of preoperative therapeutic exercise training for patients with gastrointestinal cancer was evaluated. In the second pilot study the preliminary effectiveness of a multidisciplinary outpatient clinic (i.e. a clinic with a nurse practitioner, a dietician and a physiotherapist) with additional exercise training embedded in a clinical pathway for esophagectomy was evaluated. The pilot studies showed that preoperative exercise training for patients with gastrointestinal cancer is feasible; patients appreciated the training program and tolerated it well. Furthermore, for patients undergoing esophagectomy, the clinical pathway with the preoperative multidisciplinary outpatient clinic and exercise training resulted in a decrease of length of stay on the intensive care and a decrease in the incidence of pneumonia. A larger preferably randomized, study seems justified and needed to quantify the true effectiveness on patient outcomes of the training program and multidisciplinary outpatient consult.
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ABSTRACT: A systematic review on clinical pathways for gastrointestinal surgery was performed. The aim was to study indicators that are used to evaluate these clinical pathways and to study which effects of clinical pathways are reported. A search was performed for the period from January 2000 to November 2006 in MEDLINE, EMBASE and CINAHL. The Leuven Clinical Pathway Compass was used to categorize the indicators reported in literature. Twenty-three studies were selected, of which 16 were controlled studies. The studies assessed most frequently complication rates, re-admissions, mortality and length of stay. More specific indicators like time to start defecation and time to return to enteral feeding were reported as well. None of the studies reported adverse effects in any of the domains of the Clinical Pathway Compass. Clinical pathways for gastrointestinal surgery can enhance efficiency of care without adverse effects on outcome. Specific indicators to evaluate these clinical pathways are time to return to enteral feeding and time to defecate. Furthermore, additional to complication rates, number of re-admissions, mortality and length of stay, indicators such as the number of re-operations, pain scores and intensive care unit admission can be assessed to monitor effectiveness and patient safety of the clinical pathways.Journal of Evaluation in Clinical Practice 11/2008; 14(5):880-7. DOI:10.1111/j.1365-2753.2008.01079.x · 1.58 Impact Factor