How to reduce the hospitalization - PowerPoint Presentation

1. How to reduce the hospitalization in Laparoscopic Cholecystectomy: Personal experience and limitations in practice Kyung Sik KimDepartment of Hepatobiliary Pancreatic Surgery, Severance Hospital, Departmentof Surgery and Medical Education, Yonsei University, College of Medicine, Korea

2. Table of contentsIntroductionInfluencing factors on postoperative hospital stayUsefulness of critical pathwayPatient satisfaction with critical pathwayConclusion

3. IntroductionAdvantages of laparoscopic cholecystectomyLess postoperative painShorter operation timeLower rate of postoperative complicationsShorter hospital stayClinical pathway in laparoscopic cholecystectomyHigh success rates (Topal et al. Surg Endosc 2007;21:1142-6)Day-surgery vs. overnight surgeryNo statistical differences (Vaughan et al. The Cochrane Library 2013)All trials at high risk of bias

4. IntroductionFactors associated with delayed hospital stayAdvanced age, delayed diet resumption, greater need for oral analgesiaTsang et al. Asian J Surg 2007;30:23-8ASA score, LC difficultyMorimoto et al. Asian J Endos Surg 2015;8:289-95Intraoperative complicationsCheng et al. Surg Endosc 2008;22:1283-9AimShare personal experiences in how to reduce hospitalization

5. Influencing factors on postoperative hospital stayRetrospective multicenter analysisAugust 1, 2012 and August 31, 2012336 consecutive patients underwent LC for benign gallbladder disease at 8 different hospitalsSeverance Hospital, Gangnam Severance Hospital, Wonju Severance Christian Hospital, Inchon & Daejeon St. Mary Hospital, National Health Insurance Serivce Ilsan Hospital, Seoul Nanitional University Bundang Hospital, and Guro Hospital

6. Results*Influencing factors on postoperative hospital stay length: Perioperative factors  POD ≤ 2days (N=225)POD > 2days (n=111)pAge ≥65 years 45 (20.0%)36 (32.4%)0.012 Male gender 85 (37.8%)56 (50.5%)0.036BMI (kg/m2) 25.3 ± 15.2 24.2 ± 3.20.618DM 22 (10.0%)22 (20.2%)0.011Albumin<3.0g/dL 4 (1.8%)8 (7.3%)0.024Smoking 25 (11.2%)25 (22.5%)0.010ASA score1122 (54.2%)40 (36.0%)0.003 287 (38.7%)63 (56.8%)  316 (7.1%)7 (6.3%)  40 (0.0%)1 (0.9%)  POD ≤ 2days (n=225)POD > 2days (n=111)pOperation time, min (range)45 (14-190)77 (16-371)<0.001 Perioperative transfusion1 (0.5%)6 (5.6%)0.006Emergency operation9 (4.0%)23 (20.7%)<0.001Operation history36 (16.0%)20 (18.0%)0.782Acute inflammation24 (10.7%)47 (42.3%)<0.001Gallbladder stone61 (27.1%)31 (28.2%)0.837Surgical site infection2 (0.9%)5 (4.6%)0.041*Influencing factors on postoperative hospital stay length: Patient factorsChong et al. Korean J Hepatobiliary Pancreat Surg 2016;20:12-6Multivariate logistic regressionpOdds ratio95% CIOperation time (min)<0.0011.0301.005-1.045Emergency operation<0.0016.1042.293-16.250Age (years)0.0141.0251.005-1.045Smoking0.0222.3411.129-4.853

7. Influencing factors on postoperative hospital stayConclusionOlder patients with longer operation time are likely to be in late discharge groupAlthough not determined to be independent factors, preoperative albumin level and strict perioperative sugar control needs further investigation as to influence on hospital stayLimitationsBias inherent to retrospective nature of the designShort follow-up periodLack of discharge protocol among the participating hospitalsLack of discharge protocol

8. Usefulness of critical pathwayOptimal management of discharge protocolImplementation of critical pathway (June, 2010)Inter-departmental networking is essentialSurgeonsAnesthesiologistsResidentsNursesAdmissionsQuality improvement

9. Usefulness of critical pathwayInclusion criteriaExclusion criteria16≤age≤70Acute cholecystitis, GB empyemaGB stone, GB polypCBD stoneVisit via OPDVisit via ERAgree with CPCo-operation caseCardiovascular disease Pulmonary disease Previous history affecting laparoscopic surgery Open conversion OP complication; biliary tract injury Drain insertion Post op hemodynamic unstabilityChong et al. J Minim Invasive Surg 2016 Accepted

10. Usefulness of critical pathwayChong et al. J Minim Invasive Surg 2016 Accepted

11. Usefulness of critical pathwayRetrospective reviewFrom June 2010 to July 201157 patients in CP group vs. 91 patients in non-CP groupPrimary outcomeDifference in length of hospital stayDifference in medical costs

12. Usefulness of critical pathwayChong et al. J Minim Invasive Surg 2016 Accepted Reduced hospitalizationReduced medical costs

13. Patient satisfaction with critical pathwayCritical factor in successful implementationWhich factor influences patient satisfaction with critical pathway???

14. Patient satisfaction with critical pathwayRetrospective reviewFrom January 2011 to September 2015253 patients enrolled into critical pathwaySurvey basedFive-point Likert response setRanging from 1(never) to 5(very often)

15. Patient satisfaction with critical pathway

16. Patient satisfaction with critical pathwayExploratory factor analysisPrinciple component analysis for extractionKaiser-Meyer-Olkin index: 0.859Barlett’s test of sphericity: p<0.001Factor 1: Satisfaction with explanation regarding the operationCronbach’s α: 0.939Factor 2: Physical well-being and overall satisfaction in regards to operation Cronbach’s α : 0.877Factor 3: Overall satisfaction with CP Cronbach’s α : 0.815

17. Patient satisfaction with critical pathwayFactor 1: Satisfaction with explanation regarding the operationOverall satisfaction of CP: 4.25/5.00 (85%)Multiple regression analysisβtpFactor 10.4106.060<0.001Factor 20.0080.1190.906Factor 3 (dependent variable)

18. Patient satisfaction with critical pathwayDrop-out from CP: 24 (9.5%) patients Open drainPostoperative painPostoperative nausea/vomitingPostoperative feverReported compliance rate with CP: 66 – 75%Muller et al. Langenbecks Arch Surg 2009;394:31-39Soria et al. Am Surg 2005;71:40-4

19. Patient satisfaction with critical pathwaySatisfaction with explanation regarding the operation

20. ConclusionChong et al. J Minim Invasive Surg 2016 Accepted

21. ConclusionReducing hospitalization in laparoscopic cholecystectomyIncreased available hospital resourcesGreater patient satisfactionReduced medical costsLesson learnedDetailed explanation regarding the operation is the key to complianceFutureMore multicenter studies with follow-up survey are needed

22. “Consensus protocols and comprehensive patient and health professional education can overcome multiple barriers by managing expectations and providing a uniform plan and timeline for care.” (Calland et al. Annals of surgery 2001;233:704-15)