Background
Enhanced recovery after surgery (ERAS) programs have been shown to ease the postoperative recovery and improve clinical outcomes for various surgery types. ERAS cost-effectiveness was ...demonstrated for colorectal surgery but not for liver surgery. The present study aim was to analyze the implementation costs and benefits of a specific ERAS program in liver surgery.
Methods
A dedicated ERAS protocol for liver surgery was implemented in our department in July 2013. The subsequent year all consecutive patients undergoing liver surgery were treated according to this protocol (ERAS group). They were compared in terms of real in-hospital costs with a patient series before ERAS implementation (pre-ERAS group). Mean costs per patient were compared with a bootstrap
T
test. A cost-minimization analysis was performed.
Results
Seventy-four ERAS patients were compared with 100 pre-ERAS patients. There were no significant pre- and intraoperative differences between the two groups, except for the laparoscopy number (
n
= 18 ERAS,
n
= 9 pre-ERAS,
p
= 0.010). Overall postoperative complications were observed in 36 (49 %) and 64 patients (64 %) in the ERAS and pre-ERAS groups, respectively (
p
= 0.046). The median length of stay was significantly shorter for the ERAS group (8 vs. 10 days,
p
= 0.006). The total mean costs per patient were €38,726 and €42,356 for ERAS and pre-ERAS (
p
= 0.467). The cost-minimization analysis showed a total mean cost reduction of €3080 per patient after ERAS implementation.
Conclusions
ERAS implementation for liver surgery induced a non-significant decrease in cost compared to standard care. Significant decreased complication rate and hospital stay were observed in the ERAS group.
Background
Standardized quality indicators assessing avoidable readmission become increasingly important in health care. They can identify improvements area and contribute to enhance the care ...delivered. However, the way of using them in practice was rarely described.
Methods
Retrospective study uses prospective inpatients’ information. Thirty-day readmissions were deemed potentially avoidable or non-avoidable by a computerized algorithm, and annual rate was reported between 2010 and 2014. Observed rate was compared to expected rate, and medical record review of potentially avoidable readmissions was conducted on data between January and June 2014.
Results
During a period of ten semesters, 11,011 stays were screened by the algorithm and a potentially avoidable readmission rate (PAR) of 7% was measured. Despite stable expected rate of 5 ± 0.5%, an increase was noted concerning the observed rate since 2012, with a highest value of 9.4% during the first semester 2014. Medical chart review assessed the 109 patients screened positive for PAR during this period and measured a real rate of 7.8%. The delta was in part due to an underestimated case mix owing to sub-coded comorbidities and not to health care issue.
Conclusions
The present study suggests a methodology for practical use of data, allowing a validated quality of care indicator. The trend of the observed PAR rate showed a clear increase, while the expected PAR rate was stable. The analysis emphasized the importance of adequate “coding chain” when such an algorithm is applied. Moreover, additional medical chart review is needed when results deviate from the norm.
Patient experience surveys are increasingly conducted in cancer care as they provide important results to consider in future development of cancer care and health policymaking. These surveys usually ...include closed-ended questions (patient-reported experience measures (PREMs)) and space for free-text comments, but published results are mostly based on PREMs. We aimed to identify the underlying themes of patients' experiences as shared in their own words in the Swiss Cancer Patient Experiences (SCAPE) survey and compare these themes with those assessed with PREMs to investigate how the textual analysis of free-text comments contributes to the understanding of patients' experiences of care.
SCAPE is a multicenter cross-sectional survey that was conducted between October 2018 and March 2019 in French-speaking parts of Switzerland. Patients were invited to rate their care in 65 closed-ended questions (PREMs) and to add free-text comments regarding their cancer-related experiences at the end of the survey. We conducted computer-assisted textual analysis using the IRaMuTeQ software on the comments provided by 31% (n = 844) of SCAPE survey respondents (n = 2755).
We identified five main thematic classes, two of which consisting of a detailed description of 'cancer care pathways'. The remaining three classes were related to 'medical care', 'gratitude and praise', and the way patients lived with cancer ('cancer and me'). Further analysis of this last class showed that patients' comments related to the following themes: 'initial shock', 'loneliness', 'understanding and acceptance', 'cancer repercussions', and 'information and communication'. While closed-ended questions related mainly to factual aspects of experiences of care, free-text comments related primarily to the personal and emotional experiences and consequences of having cancer and receiving care.
A computer-assisted textual analysis of free-text in our patient survey allowed a time-efficient classification of free-text data that provided insights on the personal experience of living with cancer and additional information on patient experiences that had not been collected with the closed-ended questions, underlining the importance of offering space for comments. Such results can be useful to inform questionnaire development, provide feedback to professional teams, and guide patient-centered initiatives to improve the quality and safety of cancer care.
Celotno besedilo
Dostopno za:
CEKLJ, DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
The 30-day post-discharge readmission rate is a quality indicator that may reflect suboptimal care. The computerised algorithm SQLape® can retrospectively identify a potentially avoidable readmission ...(PARA) with high sensitivity and specificity. We retrospectively analysed the hospital stays of patients readmitted to the Department of Internal Medicine of the CHUV (Centre Hospitalier Universitaire Vaudois) in order to quantify the proportion of PARAs and derive a risk prediction model.
All hospitalisations between January 2009 and December 2011 in our division of general internal medicine were analysed. Readmissions within 30 days of discharge were categorised using SQLape®. The impact on PARAs was tested for various clinical and nonclinical factors. The performance of the developed model was compared with the well-validated LACE and HOSPITAL scores.
From a total of 11 074 hospital stays, 777 (7%) were followed with PARA within 30 days. By analysing a group of 6729 eligible stays, defined in particular by the patients' returning to their place of residence (home or residential care centre), we identified the following risk factors: ≥1 hospitalisation in the year preceding index admission, Charlson score >1, active cancer, hyponatraemia, length of stay >11 days, prescription of ≥15 different medications during the stay. These variables were used to derive a risk prediction model for PARA with a good discriminatory power (C-statistic 0.70) and calibration (p = 0.69). Patients were then classified as low (16.4%), intermediate (49.4%) or high (34.2%) risk of PARA. The estimated risk of PARA for each category was 3.5%, 8.7% and 19.6%, respectively. The LACE and the HOSPITAL scores were significantly correlated with the PARA risk. The discriminatory power of the LACE (C-statistic 0.61) and the HOSPITAL (C-statistic 0.54) were lower than our model.
Our model identifies patients at high risk of 30-day PARA with a good performance. It could be used to target transition of care interventions. Nevertheless, this model should be validated on more data and could be improved with additional parameters. Our results highlight the difficulty to generalise one model in the context of different healthcare systems.
Abstract Background & aims The importance of nursing for surgical patients has been frequently underestimated. The success of enhanced recovery programs after surgery (ERAS) depends on preferably ...complete fulfilment of the protocol and nurses are an important part of it. Due to the additional nursing action required, such protocols are suspected to increase the nursing workload. The aim of the present study was to observe and measure objectively nursing workload before, during and after systematic implementation of a comprehensive enhanced recovery pathway in colorectal surgery. Methods The program ERAS was introduced systematically in our tertiary academic centre 2011, since then our experience is based on more than 1500 ERAS patients. Nursing workload was prospectively assessed for all patients on a routine basis by means of a standardized and validated point system (PRN). In a retrospective cohort study, we compared nursing workload based on prospective data before, during and after ERAS implementation and correlated nursing workload to the compliance with the ERAS protocol. Results The study cohort included 50 patients before ERAS implementation (2010) and 69 (2011) and 148 (2012) consecutive patients after implementation; the baseline characteristics of the 3 groups were similar. Mean PRN values were 61.2 ± 19.7 per day in 2010 and decreased to 52.3 ± 13.7 ( P = 0.005) and 51.6 ± 18.6 ( P < 0.002) in 2011 and 2012, respectively. Increasing compliance with the ERAS protocol was significantly correlated to decreasing nursing workload ( ρ = −0.42; P < 0.001). Conclusions Nursing workload is – against a common belief – decreased by systematic implementation of enhance recovery protocol. The higher the compliance with the pathway, the lower the burden for the nurses!
Aims
We evaluated the effectiveness of a multidisciplinary transition plan to reduce early readmission among heart failure patients.
Methods and results
We conducted a before‐and‐after study in a ...tertiary internal medicine department, comparing 3 years of retrospective data (pre‐intervention) and 13 months of prospective data (intervention period). Intervention was the introduction in 2013 of a transition plan performed by a multidisciplinary team. We included all consecutive patients hospitalized with symptomatic heart failure and discharged to home. The outcomes were the fraction of days spent in hospital because of readmission, based on the sum of all days spent in hospital, and the rate of readmission. The same measurements were used for those with potentially avoidable readmissions. Four hundred thirty‐one patients were included and compared with 1441 patients in the pre‐intervention period. Of the 431 patients, 138 received the transition plan while 293 were non‐completers. Neither the fraction of days spent for readmissions nor the rate of readmission decreased during the intervention period. However, non‐completers had a higher rate of the fraction of days spent for 30 day readmission (19.2% vs. 16.1%, P = 0.002) and for potentially avoidable readmission (9.8% vs. 13.2%, P = 0.001). The rate of potentially avoidable readmission decreased from 11.3% (before) to 9.9% (non‐completers) and 8.7% (completers), reaching the adjusted expected range given by SQLape® (7.7–9.1%).
Conclusions
A transition plan, requiring many resources, could decrease potentially avoidable readmission but shows no benefit on overall readmission. Future research should focus on potentially avoidable readmissions and other indicators such as patient satisfaction, adverse drug events, or adherence.
Objective. Collaborative quality improvement programs have been successfully used to manage chronic diseases in adults and acute lung complications in premature infants. Their effectiveness to ...improve pain management in acute care hospitals is currently unknown. The purpose of this study was to determine whether a collaborative quality improvement program implemented at hospital level could improve pain management and overall pain relief.
Design. To assess the effectiveness of the program, we performed a before‐after trial comparing patient's self‐reported pain management and experience before and after program implementation. We included all adult patients hospitalized for more than 24 hours and discharged either to their home or to a nursing facility, between March 1, 2001 and March 31, 2001 (before program implementation) and between September 15, 2005 and October 15, 2005 (after program implementation).
Setting. A teaching hospital of 2,096 beds in Geneva, Switzerland.
Patients. All adult patients hospitalized for more than 24 hours and discharged between 1 to 31 March 2001 (before program) and 15 September to 15 October 2005 (after program implementation).
Interventions. Implementation of a collaborative quality improvement program using multifaceted interventions (staff education, opinion leaders, patient education, audit, and feedback) to improve pain management at hospital level.
Outcome Measures. Patient‐reported pain experience, pain management, and overall hospital experience based on the Picker Patient Experience questionnaire, perceived health (SF‐36 Health survey).
Results. After implementation of the program only 2.3% of the patients reported having no pain relief during their hospital stay (vs 4.5% in 2001, P = 0.05). Among nonsurgical patients, improvements were observed for pain assessment (42.3% vs 27.9% of the patients had pain intensity measured with a visual analog scale, P = 0.012), pain management (staff did everything they could to help in 78.9% vs 67.9% of cases P = 0.003), and pain relief (70.4% vs 57.3% of patients reported full pain relief P = 0.008). In surgical patients, pain assessment also improved (53.7.3% vs 37.6%) as well as pain treatment. More patients received treatments to relieve pain regularly or intermittently after program implementation (95.1% vs 91.9% P = 0.046).
Conclusion. Implementation of a collaborative quality improvement program at hospital level improved both pain management and pain relief in patients. Further studies are needed to determine the overall cost‐effectiveness of such programs.
Abstract Objectives The demand-control-support “job strain” model is frequently used in occupational health research. We sought to explore the relationship between job strain and back pain. Method ...One thousand two hundred and ninety-eight collaborators of a Swiss teaching hospital responded to a cross-sectional questionnaire survey that measured job strain, the occurrence of back pain as well as the characteristics and consequences of this pain. Results Job strain computed with both psychological and physical demands was strongly and significantly associated with various measures of back pain. These associations displayed a dose–response pattern, and remained strong even after adjustment for job characteristics and professional categories. In contrast, separate dimensions of job strain (except physical demands) and job strain computed with only psychological demands did not remain significantly associated with back pain after adjustment for other variables. Conclusion Our results support the findings linking back pain to job strain. Moreover, the relationship between back pain and job strain is much stronger if job strain includes both psychological and physical demands. Results of this study suggest that workplace interventions that aim to reduce job strain may help prevent back pain and may alleviate the personal, social, and economic burden attributable to back pain.
Abstract Objectives 1) To explore the staff- and work-related risk factors for spinal pain among hospital employees, 2) to investigate the effect of staff- and work-related variables on the ...consequences of spinal pain, such as doctor visits and sick leave. Methods A mailed survey was carried out in a random sample of 2700 employees stratified for occupational categories (administration staff, nurses, nurse assistants, physicians, support staff and allied health professionals). The questionnaire measured self-reported spinal pain, consequences of pain, and work characteristics. Results The response rate was 48.1% (1298/2700). The one-year prevalence of spinal pain was 67.3%, highest among nurses (75.6%) and lowest among support staff (54.9%). Reported work characteristics associated with spinal pain included frequent work at a poorly adapted work station (odds ratio (OR) 1.90 1.24–2.93) and having to maintain a position for a long time (OR 1.71 1.25–2.34). No significant correlations were observed with lifting, patient handling, material handling, or working on nightshift. Sickness leave due to spinal pain was significantly associated with duration of pain episode (OR 4.08 for > 3 months compared to less than 10 days), and with work categories (OR 2.58 for nurse assistants compared to nurses). Conclusion In this population of hospital employees, being a nurse, working at a poorly adapted work place, and having to maintain positions for a long time were related independently to spinal pain. Nurse assistants had a higher risk of work absenteeism.
Early admission to hospital with minimum delay is a prerequisite for successful management of acute stroke. We sought to determine our local pre- and in-hospital factors influencing this delay.
Time ...from onset of symptoms to admission (admission time) was prospectively documented during a 6-month period (December 2004 to May 2005) in patients consecutively admitted for an acute focal neurological deficit presented at arrival and of presumed vascular origin. Mode of transportation, patient's knowledge and correct recognition of stroke symptoms were assessed. Physicians contacted by the patients or their relatives were interviewed. The influence of referral patterns on in-hospital delays was further evaluated.
Overall, 331 patients were included, 249 had an ischaemic and 37 a haemorrhagic stroke. Forty-five patients had a TIA with neurological symptoms subsiding within the first hours after admission. Median admission time was 3 hours 20 minutes. Transportation by ambulance significantly shortened admission delays in comparison with the patient's own means (HR 2.4, 95% CI 1.6-3.7). The only other factor associated with reduced delays was awareness of stroke (HR 1.9, 95% CI 1.3-2.9). Early in-hospital delays, specifically time to request CT-scan and time to call the neurologist, were shorter when the patient was referred by his family or to a lesser extent by an emergency physician than by the family physician (p < 0.04 and p < 0.01, respectively) and were shorter when he was transported by ambulance than by his own means (p < 0.01).
Transportation by ambulance and referral by the patient or family significantly improved admission delays and early in-hospital management. Correct recognition of stroke symptoms further contributed to significant shortening of admission time. Educational programmes should take these findings into account.
PDF
