背景:国家指南规定,选择性颈动脉内膜切除术(CEA)后的术后住院时间(LOS)平均不应超过一天,然而,围手术期护理协调差距可能会限制机构实现这一目标的能力.内部审查确定,在我们机构进行CEA后LOS增加通常归因于尿潴留或术后高血压。我们设计并实施了质量改进(QI)协议,旨在改善CEA术后LOS的机构绩效,由两个PDSA(计划-做-研究-行动)周期组成。
方法:在第一个PDSA循环中,制定了全部门标准化方案,通过该方案在术前和术后第1天(POD)1日管理抗高血压药物.该方案包括专门的患者外展,并在POD0上午进行家庭降压管理说明。第二,所有男性患者术前接受α-1阻断.所有接受血管外科医师在我们机构进行的选择性CEA的患者都包括在方案中。主要结局指标是定义的LOS>1天指标的失败百分比,以原始LOS作为次要结果测量。过程措施包括遵守抗高血压药物方案和遵守术前α-1阻断。平衡措施包括记录术中低血压和30天再入院。Fisher精确检验用于评估干预前和干预后队列与结果测量之间的关系。Wilcoxon秩和检验用于评估队列与总住院时间之间的关系。
结果:选择CEA后1天的LOS>基线表现在干预前8个月为58.3%,48名患者。两种PDSA干预措施同时实施。在干预后的12个月里,64例患者符合方案纳入标准,包括19例症状患者(29.7%)。术前降压方案依从性的过程测量成功率为89.8%。对于术前未长期规定α-1阻滞的男性,术前α-1阻断依从性的过程测量成功率为78.8%.术中低血压平衡测量发生在1例(1.6%)。LOS>1天结果测量的性能提高到32.8%(p=0.01)。干预前队列对原始LOS结局测量的表现相似(中位数为2天,四分位间距[IQR]1-2)和干预后队列(中位数1天,IQR1-2,p=0.07)。干预前(6.3%)和干预后(9.4%,p=0.73)。
结论:共识驱动的QI方案的开发和实施,以降低CEA后的术后LOS,在我们的机构中显示了有希望的结果,主要结局指标改善约40%。CEA后改善LOS的更广泛努力应包括重点减少术后高血压和尿潴留。
BACKGROUND: National
guidelines stipulate that postoperative length-of-stay (LOS) after elective carotid endarterectomy (CEA) should not exceed 1 day on average, yet perioperative care coordination gaps may limit the ability for institutions to achieve this goal. Internal review determined that increased LOS after CEA at our institution was frequently attributable to urinary retention or postoperative hypertension. We designed and implemented a quality improvement (QI) protocol aiming to better our institutional performance in postoperative LOS after CEA, consisting of 2 Plan-Do-Study-Act (PDSA) cycles.
METHODS: In the first PDSA cycle, a division-wide standardized protocol was developed by which antihypertensive medications were managed preoperatively and through postoperative day (POD) 1. This protocol included dedicated patient outreach with instructions for at-home antihypertensive management through the morning of POD 0. Second, alpha-1-blockade was administered to all male patients preoperatively. All patients receiving an elective CEA performed at our institution by vascular surgeons were included in the protocol. The primary outcome measure was defined percent failure of the LOS >1 day metric, with raw LOS as a secondary outcome measure. Process measures included adherence to the antihypertensive medication protocol and adherence to preoperative alpha-1 blockade. Balance measures included documented intraoperative hypotension and 30-day readmission. Fisher\'s exact test was used to evaluate relationships between preintervention and postintervention cohorts and the outcome measure. Wilcoxon rank-sum tests were used to evaluate relationships between cohorts and total LOS.
RESULTS: Baseline performance on the LOS >1 day metric after elective CEA was 58.3% in the 8 months prior to intervention, across 48 patients. Both PDSA interventions were implemented simultaneously. In the 12 months after intervention, 64 patients met protocol inclusion criteria, including 19 symptomatic patients (29.7%). Process measure success for preoperative antihypertensive regimen adherence was 89.8%. For males not chronically prescribed alpha-1 blockade preoperatively, process measure success for adherence to preoperative alpha-1 blockade was 78.8%. The intraoperative hypotension balance measure occurred in 1 patient (1.6%). Performance on the LOS >1 day outcome measure was improved to 32.8% (P = 0.01). Performance on the raw LOS outcome measure was similar between the preintervention cohort (median 2 days, interquartile range [IQR] 1-2) and postintervention cohort (median 1 day, IQR 1-2, P = 0.07). Performance on the 30-day readmission balance measure was similar between preintervention (6.3%) and postintervention cohorts (9.4%, P = 0.73).
CONCLUSIONS: The
consensus-driven development and implementation of a QI protocol to reduce postoperative LOS after CEA showed promising results in our institution, with approximately 40% improvement in the primary outcome measure. Wider efforts to improve LOS after CEA should include a focus on minimization of postoperative hypertension and urinary retention.