目的:本研究的目的是报告作者为内镜经鼻蝶手术开发精益六西格玛临床护理路径(CCP)的经验。
方法:使用精益六西格玛质量改进原则-包括定义,measure,分析,改进,和控制框架-作者开发了一种用于内镜经鼻蝶手术的CCP,结合术前,术中,住院和门诊术后阶段的护理。疗效和质量指标定义为术后住院时间(LOS),在出院后30天内提交急诊室(ED)或重新入院,和医院费用。该研究包括所有接受择期内镜下鼻内垂体腺瘤切除术的成年患者,Rathke的裂隙囊肿,颅咽管瘤,垂体细胞瘤,或采样期间的蛛网膜囊肿(2018年4月1日至2022年12月31日)。
结果:二百二十八例患者符合标准并被纳入;在实施CCP之前治疗94例,在实施CCP之后治疗134例。群体之间的年龄差异,性别,种族,BMI,美国麻醉医师学会分类,地理分布,术前血清钠,肿瘤大小,腺瘤功能状态,和以前的手术并不显著。CCP实施后,术后平均LOS从4.5天显着降低到1.7天(p<0.0001);LOS变异性也降低,标准偏差从3.1天下降到1.5天。术后第1天出院的患者比例(POD)从0%显著上升至61.9%(p<0.0001)。在CCP之前,不到四分之一的患者(23.4%)通过POD2出院,而88.8%的患者在CCP实施后通过POD2出院(p<0.0001)。30天ED报告或再入院率没有显着差异(2.1%对6.0%,p=0.20,7.5%对6.7%,p分别>0.99)。平均每位患者的住院费用从38,326美元下降到26,289美元(p<0.0001),与相关的成本变异性从16,716美元的标准偏差变化到12,498美元。
结论:CCP的实施显著改善了鼻内镜下切除的LOS和费用,对术后ED表现或再入院无不利影响。
The aim of this study was to report the authors\' experience developing a Lean Six Sigma clinical care pathway (CCP) for endoscopic endonasal transsphenoidal operations.
Using Lean Six Sigma quality improvement principles-including the define, measure, analyze, improve, and control framework-the authors developed a CCP for endoscopic endonasal transsphenoidal operations, incorporating preoperative, intraoperative, and inpatient and outpatient postoperative phases of care. Efficacy and quality metrics were defined as postoperative length of stay (LOS), presentation to the emergency department (ED) or readmission within 30 days of discharge, and hospital charges. The study included all adult patients who underwent elective endoscopic endonasal resection for pituitary adenoma, Rathke\'s cleft cyst, craniopharyngioma, pituicytoma, or arachnoid cyst during the sampling period (April 1, 2018, to December 31, 2022).
Two hundred twenty-eight patients met criteria and were included; 94 were treated before and 134 were treated after implementation of the CCP. Differences between groups in age, gender, race, BMI, American Society of Anesthesiologists classification, geographic distribution, preoperative serum sodium, tumor size, adenoma functional status, and prior surgery were not significant. The mean postoperative LOS significantly decreased from 4.5 to 1.7 days following CCP implementation (p < 0.0001); LOS variability also decreased, with the standard deviation declining from 3.1 to 1.5 days. The proportion of patients discharged on postoperative day (POD) 1 significantly increased from 0% to 61.9% (p < 0.0001). Fewer than one-quarter of the patients (23.4%) were discharged by POD 2 prior to the CCP, while 88.8% of were discharged by POD 2 after CCP implementation (p < 0.0001). Rates of 30-day ED presentations or readmissions were not significantly different (2.1% vs 6.0%, p = 0.20, and 7.5% vs 6.7%, p > 0.99, respectively). Mean per-patient hospital costs declined from $38,326 to $26,289 (p < 0.0001), with an associated change in cost variability from a standard deviation of $16,716 to $12,498.
CCP implementation significantly improved LOS and costs of endoscopic endonasal resection, without adversely impacting postoperative ED presentations or readmissions.