Juan Alcalde

Hospital 12 de Octubre, Madrid, Madrid, Spain

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Publications (14)12.58 Total impact

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    ABSTRACT: IntroductionClinical pathways are highly useful tools for the systematization and improvement of clinical processes. We present the methodology for the management of the surgical treatment of gastric cancer, through a prior analysis of the process and design of a clinical pathway.
    No preview · Article · Aug 2005 · Revista de Calidad Asistencial
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    ABSTRACT: Introduction: Clinical pathways are highly useful tools for the systematization and improvement of clinical processes. We present the methodology for the management of the surgical treatment of gastric cancer, through a prior analysis of the process and design of a clinical pathway. Material and method: A descriptive, retrospective, cross sectional study was performed. The medical records of patients who underwent surgery for gastric adenocarcinoma from 1998-2000 were reviewed. Clinical characteristics, scientific-technical quality, clinical effectiveness, and resource use were analyzed. All this information, together with a review of the literature on the topic, was used to design a clinical pathway to improve the process. Results: The following strengths were identified: appropriate interval between diagnosis and surgical treatment (median 27 days), low index of major complications (18.1%) and mortality (1.8%). Areas requiring improvement were outpatient anesthetic evaluation (23.5%), mean length of hospital stay (median 21 days), obtaining of informed consent (53.5%), application of thromboembolic (78.5%) and antibiotic prophylactic protocols (62.5%), use of antibiotic (55.3%) and parenteral nutrition (96.4%), performance of preoperative abdominal computed tomography (83.9%), insufficient number of isolated nodes (median 14), transfusion rate (61.8%), and application of the patient satisfaction survey. The above information was used to design the clinical pathway documents and define the quality indicators and standards according to the real situation of the surgical unit.
    No preview · Article · Jul 2005
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    ABSTRACT: The high prevalence of surgical treatment for inguinal hernia (especially in general surgery) prompted the Spanish Association of Surgeons to perform a national study to identify the most important indicators. To analyze healthcare quality in elective surgery for inguinal hernia by evaluating scientific-technical quality, efficiency, effectiveness, and patient satisfaction. A prospective, longitudinal, descriptive study from diagnosis to postoperative follow-up was performed. Patients who underwent surgery for unilateral or bilateral, primary or recurrent inguinal hernias were included. Exclusion criteria were emergency surgery and associated surgical procedures. Clinical indicators were selected after a literature review. Forty-six hospitals corresponding to 16 Autonomous Communities with a total of 386 patients participated in this study. The mean follow-up was 18 months. The mean age of the patients was 56.33 years and 88.3% were male. Half the patients (50.1%) were American Society of Anesthesiologists (ASA) grade I. A total of 95.6% did not comply with the protocol for preoperative tests of the Spanish Association of Surgeons. Antibiotic prophylaxis was used in 75.39% and thromboembolic prophylaxis was used in 40.04%. Ambulatory surgery was performed in 33.6%. Local anesthesia and sedation only were used in 16.36% of the patients. The most frequently used surgical procedures involved mesh repair (Lichtenstein 50%, Rutkow-Robbins 17.1%), laparoscopy was used in 5.2% of the patients, and the Shouldice technique was used in 8.5%. The mean length of hospital stay was 47.5 hours in inpatients and was 11.65 hours in patients who underwent ambulatory surgery. Notable among the complications was hematoma in 11.6%. Ninety-six percent of the patients were satisfied or highly satisfied. The most highly scored items in the satisfaction survey were those related to information, personal dealings with staff, and the staffs kindness. The lowest scored items dealt with punctuality and accessibility. Follow-up at 18 months showed a recurrence rate of 4.11% with a total recovery time estimated by patients of 7.26 weeks. Analysis of the process revealed areas for improvement and strong points. Strong points consisted of up-to-date choice of surgical technique. The most frequently used techniques were tension-free procedures and the Shouldice technique. The following areas for improvement were identified: adherence to protocols for preoperative evaluation, increased use of ambulatory surgery, local anesthesia and sedation, appropriate use of antibiotic and thromboembolic prophylaxis in selected patients and a reduction in the length of hospital stay in inpatients. Patient satisfaction with the treatment was acceptable.
    No preview · Article · May 2005 · Cirugía Española
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    ABSTRACT: Introduction The high prevalence of surgical treatment for inguinal hernia (especially in general surgery) prompted the Spanish Association of Surgeons to perform a national study to identify the most important indicators. Objective To analyze healthcare quality in elective surgery for inguinal hernia by evaluating scientifictechnical quality, efficiency, effectiveness, and patient satisfaction. Material and methods A prospective, longitudinal, descriptive study from diagnosis to postoperative follow-up was performed. Patients who underwent surgery for unilateral or bilateral, primary or recurrent inguinal hernias were included. Exclusion criteria were emergency surgery and associated surgical procedures. Clinical indicators were selected after a literature review. Results Forty-six hospitals corresponding to 16 Autonomous Communities with a total of 386 patients participated in this study. The mean follow-up was 18 months. The mean age of the patients was 56.33 years and 88.3% were male. Half the patients (50.1%) were American Society of Anesthesiologists (ASA) grade I. A total of 95.6% did not comply with the protocol for preoperative tests of the Spanish Association of Surgeons. Antibiotic prophylaxis was used in 75.39% and thromboembolic prophylaxis was used in 40.04%. Ambulatory surgery was performed in 33.6%. Local anesthesia and sedation only were used in 16.36% of the patients. The most frequently used surgical procedures involved mesh repair (Lichtenstein 50%, Rutkow-Robbins 17.1%), laparoscopy was used in 5.2% of the patients, and the Shouldice technique was used in 8.5%. The mean length of hospital stay was 47.5 hours in inpatients and was 11.65 hours in patients who underwent ambulatory surgery. Notable among the complications was hematoma in 11.6%. Ninety-six percent of the patients were satisfied or highly satisfied. The most highly scored items in the satisfaction survey were those related to information, personal dealings with staff, and the staff's kindness. The lowest scored items dealt with punctuality and accessibility. Follow-up at 18 months showed a recurrence rate of 4.11% with a total recovery time estimated by patients of 7.26 weeks. Conclusions Analysis of the process revealed areas for improvement and strong points. Strong points consisted of up-to-date choice of surgical technique. The most frequently used techniques were tensionfree procedures and the Shouldice technique. The following areas for improvement were identified: adherence to protocols for preoperative evaluation, increased use of ambulatory surgery, local anesthesia and sedation, appropriate use of antibiotic and thromboembolic prophylaxis in selected patients and a reduction in the length of hospital stay in inpatients. Patient satisfaction with the treatment was acceptable.
    No preview · Article · Apr 2005 · Cirugía Española
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    ABSTRACT: Introduction When establishing quality standards and systematizing processes through clinical pathways, analysis of clinical processes should be a prior condition for the selection of indicators. Accordingly, we present a set of indicators and the design of a clinical pathway for the surgery of colorectal carcinoma with the aim of providing surgeons with tools that serve as a reference to determine their situation with respect to general data from our environment. Methodology Taking as a reference the national study for the analysis of quality in the surgical treatment of colorectal carcinoma and after performing a review of the literature, we selected a group of indicators together with standards for each of them. Subsequently we designed a clinical pathway based on the situation observed in Spain. Results Nine indicators were selected with their corresponding levels of quality. The clinical pathway for the elective surgical treatment of colorectal carcinoma was designed and included the following documents: time matrix, documents pertaining to patient evaluation, confirmations, information provided to the patient on the process and finally, a patient satisfaction questionnaire. Conclusions Previous study of the surgery of colorectal carcinoma enabled identification of strong and weak points, determination of indicators and levels of reference, as well as the design of a clinical pathway adapted to the situation in Spain.
    No preview · Article · Dec 2003 · Cirugía Española

  • No preview · Article · Jan 2002 · Cirugía Española
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    ABSTRACT: Introduction Clinical Pathways are plans of care applied to a group of patients with a common pathology and a predictible course, designed to ease the assistance and reduce unjustified clinical variability. The adjuvant medical treatment of colon carcinoma can be subjet to variability regarding indications, type of chemotherapy and followup. A multidisciplinary group at the Hospital 12 de Octubre studied the clinical process and developed the Adjuvant Treatment of Colon Carcinoma Clinical Pathway, that is being implemented at the Medical Oncology Service. Methodology Analysis of the process Adjuvant “Treatment of Colon Carcinoma” allowed the identification of strengths and weaknesses and quality indicators. Strengths were the level of technical-scientific quality, the interval between surgery and medical adjuvant treatment, and the absence of toxic deaths related with chemotherapy. Improvement proposals involved reducing the number of physical examinations and analytical tests; increasing the level of the informed consent and clinical reports; and analyzing the patients satisfaction level. The design of the clinical pathway was defined by the improvement team. Criteria for inclusion, exclusion and discharge were established. The documents that make up the Pathway (plans of care, nursing and medical checking, variations, clinical evaluation and outcomes indicators, satisfaction´s survey and informative leaf) were prepared. Conclusion We have developed a clinical pathway for the Adjuvant Treatment of Colon Carcinoma from the information obtained of the process analysis. This will serve as a useful tool for the continuous improvement of the process, the reduction of unjustified variability and to simplification of follow-up.
    No preview · Article · Dec 2001 · Revista de Calidad Asistencial
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    ABSTRACT: Introduction Two clinical processes that involve colon cancer have been analysed by a team of improvement of care from Hospital 12 de Octubre: ”Adjuvant treatment of colon carcinoma„ and ”No-chemotherapy decisions„. Methods From 210 colorectal cancers diagnosed in 1997, the inclusion criteria identified 50 cases in the ”Adjuvant treatment of colon carcinoma„ process and 58 in the ”No-chemotherapy decisions?. Seventy-five variables, including clinical characteristics, technicalscientific quality, resources consumption, clinical effectiveness and intervals, were recorded. Results The results in the ”Adjuvant treatment of colon carcinoma„ process showed that the number of physical examinations was high, but the usefulness in detecting recurrence was low (0%). Informed consent was obtained in 88% of cases, and clinical report was generated in 88%. The ”No-chemotherapy decisions„ process included 34 cases without the medical indication of treatment, 8 with refusal from the patient, 6 with advanced age, 5 with concomitant diseases, and 5 with other reasons. Signed medical treatment refusal was obtained in only 2 of the 8 cases that refused therapy. Improvement proposals in the ”Adjuvant treatment„ process were: a. Reduce the number of physical examinations and analytical tests; b. Increase the level of the informed consent and clinical reports; c. Analyze the patients satisfaction level. In the ”No-chemotherapy decisions„ process the proposals were: a. Obtain the signed consent of treatment refuse and b. Improve the transference of medical treatment indications in the surgical services. Conclusions The study of the two processes has allowed to know the different quality dimensions and establish improvement measures that are, nowdays, being implemented.
    No preview · Article · Dec 2001 · Revista de Calidad Asistencial
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    ABSTRACT: Introduction: Clinical Pathways are plans of care applied to a group of patients with a common pathology and a predictible course, designed to ease the assistance and reduce unjustified clinical variability. The adjuvant medical treatment of colon carcinoma can be subjet to variability regarding indications, type of chemotherapy and follow-up. A multidisciplinary group at the Hospital 12 de Octubre studied the clinical process and developed the Adjuvant Treatment of Colon Carcinoma Clinical Pathway, that is being implemented at the Medical Oncology Service. Methodology: Analysis of the process "Adjuvant Treatment of Colon Carcinoma" allowed the identification of strengths and weaknesses and quality indicators. Strengths were the level of technical-scientific quality, the interval between surgery and medical adjuvant treatment, and the absence of toxic deaths related with chemotherapy. Improvement proposals involved reducing the number of physical examinations and analytical tests; increasing the level of the informed consent and clinical reports; and analyzing the patients satisfaction level. The design of the clinical pathway was defined by the improvement team. Criteria for inclusion, exclusion and discharge were established. The documents that make up the Pathway (plans of care, nursing and medical checking, variations, clinical evaluation and outcomes indicators, satisfaction's survey and informative leaf) were prepared. Conclusion: We have developed a clinical pathway for the Adjuvant Treatment of Colon Carcinoma from the information obtained of the process analysis. This will serve as a useful tool for the continuous improvement of the process, the reduction of unjustified variability and to simplification of follow-up.
    No preview · Article · Jan 2001
  • [Show abstract] [Hide abstract]
    ABSTRACT: Introduction: Two clinical processes that involve colon cancer have been analysed by a team of improvement of care from Hospital 12 de Octubre: "Adjuvant treatment of colon carcinoma" and "No-chemotherapy decisions". Methods: From 210 colorectal cancers diagnosed in 1997, the inclusion criteria identified 50 cases in the "Adjuvant treatment of colon carcinoma" process and 58 in the "No-chemotherapy decisions". Seventy-five variables, including clinical characteristics, technical-scientific quality, resources consumption, clinical effectiveness and intervals, were recorded. Results: The results in the "Adjuvant treatment of colon carcinoma" process showed that the number of physical examinations was high, but the usefulness in detecting recurrence was low (0%). Informed consent was obtained in 88% of cases, and clinical report was generated in 88%. The "No-chemotherapy decisions" process included 34 cases without the medical indication of treatment, 8 with refusal from the patient, 6 with advanced age, 5 with concomitant diseases, and 5 with other reasons. Signed medical treatment refusal was obtained in only 2 of the 8 cases that refused therapy. Improvement proposals in the "Adjuvant treatment" process were: a. Reduce the number of physical examinations and analytical tests; b. Increase the level of the informed consent and clinical reports; c. Analyze the patients satisfaction level. In the "No-chemotherapy decisions" process the proposals were: a. Obtain the signed consent of treatment refuse and b. Improve the transference of medical treatment indications in the surgical services. Conclusions: The study of the two processes has allowed to know the different quality dimensions and establish improvement measures that are, nowdays, being implemented.
    No preview · Article · Jan 2001
  • J M Ramia · J Alcalde · P Dhimes · R Cubedo

    No preview · Article · Feb 1998 · Digestive Diseases and Sciences
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    Preview · Article · Apr 1997 · Postgraduate Medical Journal
  • J M Ramia · A Ibarra · J Alcalde
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    ABSTRACT: One of the complications of end-colostomy is stricture of the stoma as a result of local problems such as ischaemia, retraction of the distal portion of the colon, incorrect alignment of the mucocutaneous lip or infection(1). Initially these strictures can be resolved by dilatation, but unfortunately reoperation is frequently necessary to create a new colostomy(1). In 1986 Chung(2) described a technique to create an end-stoma with a circular stapler following abdominoperineal resection. In this paper a technique is described to reconstruct a stenosed end-colostomy with a circular stapler under local anaesthesia.
    No preview · Article · Nov 1996 · British Journal of Surgery

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