833 CLINICAL PATHWAY DEVELOPMENT AND IMPLEMENTATION FOR THE MANAGEMENT OF CHYLE LEAK FOLLOWING OESOPHAGECTOMY: THE OXFORD EXPERIENCE

Abstract Thoracic chyle leakage is a major and frequently encountered complication following oesophagectomy. The incidence of chyle leakage depends on the definition used and been reported to be as high as 20% among patients undergoing oesophagectomy. The sequalae can be severe and include hypovolemia, electrolyte disturbance, malnutrition, immune suppression, and increased mortality, thereby making prompt diagnosis and optimum management essential. Nevertheless, controversy remains surrounding the nature and timing of interventions. Methods Retrospective audit was performed of 227 consecutive patients undergoing oesophagectomy between October 2014 and April 2018 at the Oxford Oesophagogastric Centre. Following pathway implementation, data are being prospectively collected along with surveys of the experience and satisfaction of stakeholders. Results Chyle leak was treated in 29 (12.8%) post-operative patients. Females were over twice as likely to be treated for chyle leak (OR 2.31, P = 0.042), while age and length of operation showed no association. Chyle leak was associated with a failure to complete the ERAS pathway (P = 0.005), an increased length of stay (P = 0.0001) with the median length of stay being 4 days greater among the chyle leak group, and increased rates of readmission (P = 0.032). Conclusion Our data highlight the significant morbidity associated with thoracic chyle leakage. Upon review of best available evidence, a clinical pathway was developed for the early diagnosis and standardised management of chyle leak (Figure 1). The goal of the pathway is that patients achieve predetermined outcome within a specified time frame. Here we present our development and experience of the Oxford Oesophagogastric Chyle Leak Pathway and describe the particular challenges and interim outcomes of its implementation.

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48 Chyle Leak Following Pancreaticoduodenectomy: A Tertiary HPB Unit 14-year Experience and a Proposed Management Algorithm

British Journal of Surgery ◽

10.1093/bjs/znab135.047 ◽

2021 ◽

Vol 108 (Supplement_2) ◽

Author(s):

T Russell ◽

A Tanase ◽

S Aroori

Keyword(s):

Risk Factors ◽

Length Of Stay ◽

Operation Time ◽

Operative Approach ◽

Chyle Leak ◽

Management Algorithm ◽

Incidence Risk ◽

Tumour Histology ◽

Optimum Management ◽

Uncommon Complication

Abstract Introduction Chyle leak (CL) is an uncommon complication of pancreaticoduodenectomy (PD). Its incidence, risk factors, and effect on prognosis are not well described and optimum management remains debated. This study aims to calculate the incidence of CL, identify risk factors, consider effect on patient outcome, and propose a simple management algorithm. Method This is a retrospective review of all patients who developed CL following PD between January 2006 and April 2020. The following details were obtained from a prospectively maintained database: age, ASA grade, BMI, details of operation, tumour histology, length of stay, and mortality. Results A total of 560 patients underwent PD and 17 (3.04%) developed CL. These patients had significantly higher BMI (P < 0.01) and significantly longer operation times (P < 0.05). CL patients had a higher rate of portal vein (PV) tumour adherence, PV resection, and intra-operative blood transfusion although this was not statistically significant. Sixteen CL patients (94.1%) were managed successfully with a non-operative approach. Conclusions 3.04% of patients who underwent PD developed CL. CL was associated with higher BMI and longer operation time. CL did not affect length of stay. The vast majority of CL cases can be managed successfully with a non-operative approach.

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A CLINICAL PATHWAY FOR LAPAROSCOPIC PYELOPLASTY DECREASES LENGTH OF STAY

The Journal of Urology ◽

10.1097/01.ju.0000158460.45695.78 ◽

2005 ◽

Vol 173 (6) ◽

pp. 2081-2084 ◽

Cited By ~ 13

Author(s):

TODD M. WEBSTER ◽

ROXELYN BAUMGARTNER ◽

JASON K. SPRUNGER ◽

D. DUANE BALDWIN ◽

ELSPETH M. McDOUGALL ◽

...

Keyword(s):

Length Of Stay ◽

Clinical Pathway ◽

Laparoscopic Pyeloplasty

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Hartmann’s procedure, reversal and rate of stoma-free survival

Annals of The Royal College of Surgeons of England ◽

10.1308/rcsann.2018.0006 ◽

2018 ◽

Vol 100 (4) ◽

pp. 301-307 ◽

Cited By ~ 19

Author(s):

S Hallam ◽

BS Mothe ◽

RMR Tirumulaju

Keyword(s):

Length Of Stay ◽

Complication Rate ◽

Major Complication ◽

Wound Dehiscence ◽

Hartmann’S Procedure ◽

Hartmann's Procedure ◽

Retrospective Audit ◽

Audit Period ◽

American Society ◽

American Society Of Anesthesiologists

Background Hartmann’s procedure is a commonly performed operation for complicated left colon diverticulitis or malignancy. The timing for reversal of Hartmann’s is not well defined as it is technically challenging and carries a high complication rate. Methods This study is a retrospective audit of all patients who underwent Hartmann’s procedure between 2008 and 2014. Reversal of Hartmann’s rate, timing, American Society of Anesthesiologists grade, length of stay and complications (Clavien–Dindo) including 30-day mortality were recorded. Results Hartmann’s procedure (n = 228) indications were complicated diverticular disease 44% (n = 100), malignancy 32% (n = 74) and other causes 24%, (n = 56). Reversal of Hartmann’s rate was 47% (n = 108). Median age of patients was 58 years (range 21–84 years), American Society of Anesthesiologists grade 2 (range 1–4), length of stay was eight days (range 2–42 days). Median time to reversal of Hartmann’s was 11 months (range 4–96 months). The overall complication rate from reversal of Hartmann’s was 21%; 3.7% had a major complication of IIIa or above including three anastomotic leaks and one deep wound dehiscence. Failure of reversal and permanent stoma was less than 1% (n = 2). Thirty-day mortality following Hartmann’s procedure was 7% (n = 15). Where Hartmann’s procedure wass not reversed, for 30% (n = 31) this was the patient’s choice and 70% (n = 74) were either high risk or unfit. Conclusions Hartmann’s procedure is reversed less frequently than thought and consented for. Only 46% of Hartmann’s procedures were stoma free at the end of the audit period. The anastomotic complication rate of 1% is also low for reversal of Hartmann’s procedure in this study.

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To screen or not to screen? Vitamin D deficiency in chronic mental illness

Australasian Psychiatry ◽

10.1177/1039856217726717 ◽

2017 ◽

Vol 26 (1) ◽

pp. 56-59

Author(s):

Ivana Goluza ◽

Jay Borchard ◽

Nalin Wijesinghe ◽

Kishan Wijesinghe ◽

Nagesh Pai

Keyword(s):

Vitamin D ◽

Length Of Stay ◽

P Value ◽

Hydroxyvitamin D ◽

Psychiatric Setting ◽

Retrospective Audit ◽

Vitamin D Levels ◽

Significant Difference ◽

25 Hydroxyvitamin D ◽

The Mean

Objectives: The objective of the current study was to examine the pathology test utilisation of 25-hydroxyvitamin D (25(OH)D) within an Australian inpatient psychiatric setting. Method: A retrospective audit of 300 random hospital files of those admitted as inpatients between Nov 2014 and Nov 2015 was undertaken. Data was quantitatively analysed and described. Results: The number of inpatients who had a vitamin D determination during their admission was 37/300 (12.33%). The mean vitamin D level of those tested was 51.63 nmol/l. Of those that were tested, 18/37 (48.6%) were mildly to moderately deficient. There was a statistically significant difference in age and length of stay between those that were and were not tested for vitamin D levels, p-value <0.001 and 0.017, respectively. In addition, a simple linear regression indicated a weak association between length of stay and vitamin D levels. Conclusion: This audit highlights vitamin D screening inadequacy. More research is recommended to establish tangible benefits of supplementation, while local practice provides valuable data for education and policy purposes.

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Penerapan Clinical Pathways sebagai Instrumen Pengendalian Biaya Pelayanan : Studi Penelitian Tindakan Penderita BPJS yang Menjalani Operasi Caesar dengan Sistem Pembayaran INA-CBG

Jurnal Keperawatan Silampari ◽

10.31539/jks.v4i2.1546 ◽

2021 ◽

Vol 4 (2) ◽

pp. 593-599

Author(s):

Annisa Fitria ◽

Andri Sofa Armani ◽

Thinni Nurul Rochmah ◽

Bangun Trapsila Purwaka ◽

Widodo Jatim Pudjirahardjo

Keyword(s):

Action Research ◽

Caesarean Section ◽

Length Of Stay ◽

Cesarean Section ◽

Clinical Pathway ◽

Average Length ◽

Clinical Pathways ◽

Hospital Costs ◽

Average Length Of Stay ◽

Length Of Hospitalization

This study aims to determine the effect of using clinical pathways to control total actual hospital costs for BPJS patients who undergo a cesarean section. The method used in this research is action research. The results showed that the average actual hospital costs were significantly higher after the application of CP with p = 0.019. The average length of stay, service costs, and hospital costs were significantly lower in the entire CP form group with p = 0.012, p = 0.013, and p = 0.012. In conclusion, this study shows that the application of clinical pathways can reduce the length of hospitalization and actual hospital costs for cesarean section patients and indicates that clinical pathways can make services more efficient. Keywords: Hospital Costs, Clinical Pathway, Caesarean Section

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Shortening Postoperative Stay after Parathyroidectomy - A District General Hospital Experience

International Archives of Otorhinolaryngology ◽

10.1055/s-0039-1698777 ◽

2019 ◽

Vol 24 (03) ◽

pp. e313-e318

Author(s):

Sidhartha Sinha ◽

Matthew Fok ◽

Ijaz Ahmad ◽

Mustafa Al-Sheikh ◽

Christopher Backhouse

Keyword(s):

Patient Education ◽

Length Of Stay ◽

District General Hospital ◽

Unplanned Readmission ◽

Short Stay ◽

Retrospective Audit ◽

Parathyroid Adenomas ◽

Biochemical Cure ◽

Postoperative Length ◽

Preoperative Patient

Introduction Historically, concerns about complications following parathyroid surgery, such as airway compromise, bleeding and hypocalcemia, have precluded its consideration as a short-stay surgical procedure. Recent advancements in perioperative care have resulted in several publications demonstrating that parathyroidectomy can be safely performed as a short-stay procedure. Objectives The aim of the present study was to describe the process of implementing a short-stay protocol focusing on preoperative patient education and postoperative calcium management for those undergoing surgery for primary hyperparathyroidism (PHP). Method A retrospective audit of consecutive parathyroidectomies performed for PHP over the period between 2010 and 2013 was performed. A short-stay protocol (SSP) was introduced focusing on postoperative calcium management. Results were reaudited over the period between 2013 and 2015. Results Consecutive parathyroidectomies in 76 patients were included in the study. A total of 42 patients underwent parathyroidectomy prior to the introduction of the protocol. A total of 26.2% of these patients were symptomatic from hypercalcemia. A total of 40 out of 42 (95.2%) patients had a biochemical cure. A total of 36 out of 42 (85.7%) cases were due to parathyroid adenomas. A total of 34 patients underwent surgery following the introduction of the protocol. A total of 13 out of 34 (38.2%) of the patients had symptomatic hypercalcemia. A total of 33 out of 34 (97.1%) had a biochemical cure. A total of 32 out of 34 (94.1%) cases were due to parathyroid adenomas.The length of stay decreased from a median of 3 days (range 2–9 days; mean 3.32) preprotocol to a median of 2 days (range 2–3 days; mean 2.16) postprotocol (p < 0.0001) with no difference in the 30-day unplanned readmission rate (4.8 versus 2.9%; p = 0.999). Conclusions The postoperative length of stay after parathyroidectomy for PHP can be safely reduced through patient education and by rationalizing postoperative calcium management without adversely affecting outcomes.

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22 Design and Implementation of A Nutrition Clinical Pathway for Patients with Fractured Neck of Femur

Age and Ageing ◽

10.1093/ageing/afz183.22 ◽

2020 ◽

Vol 49 (Supplement_1) ◽

pp. i1-i8

Author(s):

J Kingdon ◽

H Aadan ◽

S Husain ◽

C Atkinson ◽

C Thomson ◽

...

Keyword(s):

Clinical Pathway ◽

Best Practice ◽

Nutritional Assessment ◽

Nutritional Supplements ◽

Alternative Methods ◽

Fractured Neck Of Femur ◽

Neck Of Femur ◽

Post Surgery ◽

Retrospective Audit ◽

Pdsa Cycle

Abstract Background Patients with a fractured neck of femur (FNOF) are commonly malnourished pre-admission, have reduced oral intake in hospital and a hypermetabolic state up to three months postoperatively (E Paillaud 2000). Malnutrition is associated with functional deterioration, higher morbidity and mortality. Evidence suggests nutritional supplementation post-surgery can reduce postoperative complications. As a result, nutritional assessment is included in the National Hip Fracture Database best practice tariff (Avenell, Cochrane Database of Systematic Reviews 2016). Introduction Our aim was to design and implement a clinical pathway for patients with FNOF to identify malnutrition and provide appropriate nutritional support. Intervention A retrospective audit of 25 patients was completed to understand baseline rates of assessment, prescription of supplements and referral to dietetics. Using these data meetings were arranged to develop a clinical pathway. Key stakeholders included dietetics, orthopaedic surgeons, geriatricians, physiotherapists and nurses. The pathway was evaluated and optimised with two Plan-Do-Study-Act (PDSA) cycles looking at 25 patients each time. Results Baseline: 79% received a nutritional assessment, 32% had nutritional supplements prescribed and 36% (n=9) met criteria for referral to a dietician, of which 55%were referred. However, an additional 5 referrals were made to dietetics for patients who did not meet criteria, a 50% inappropriate referral rate. PDSA cycle 1: increased nutritional assessment (85%), increased nutritional supplements prescribed (92%), decreased inappropriate referrals to dietetics (43%). PDSA cycle 2: increased nutritional assessment & nutritional supplements prescribed (100%), increased inappropriate referrals to dietetics (80%). Conclusions The implementation of a nutrition pathway has led to increased identification and treatment of malnutrition, which has in addition improved accrual of the best practice tariff. However, greater number of inappropriate referrals have been made to dietetics. This is partly attributed to difficulty weighing patients on admission, and where no weight is inputted on the Malnutrition Universal Screening Tool a “High Risk” score is generated triggering a referral. We are now looking at alternative methods to obtaining a weight such a mid-upper arm circumference.

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Cognitive Status and Outcomes of Older People in Orthopedic Rehabilitation? A Retrospective-Cohort Study

Geriatrics ◽

10.3390/geriatrics5010014 ◽

2020 ◽

Vol 5 (1) ◽

pp. 14 ◽

Cited By ~ 1

Author(s):

Carissa Bernal Carrillo ◽

Christopher Barr ◽

Stacey George

Keyword(s):

Cognitive Impairment ◽

Length Of Stay ◽

Older People ◽

Elective Surgery ◽

Cognitive Strategies ◽

Cognitive Status ◽

Fractured Neck Of Femur ◽

Retrospective Audit ◽

Orthopedic Rehabilitation ◽

Orthopedic Patients

Background: Cognitive function of older people is not routinely assessed in orthopedic rehabilitation, after elective and non-elective surgery. The aim of this study was to assess cognitive impairment and its impact on both length of stay and functional outcomes, of older people admitted to orthopedic rehabilitation. Methods: Retrospective audit, inclusion criteria: aged >65 years, orthopedic diagnosis, discharged from hospital. Results: 116 files were audited, mean age of 82.3 (SD = 7.5) years. Diagnostic groups: fractured neck of femur, (n = 44, 37.98%); elective surgery (n = 42, 36.21%); and other orthopedic conditions (n = 30, 25.86%). Overall 71.55% (n = 83) had cognitive impairment, with a median of mild cognitive impairment across all diagnoses. Both measures of cognition (MoCA/FIM Cognitive) were significantly associated with length of stay (p < 0.01), function (p < 0.05), and discharge destination (p = 0.01). Conclusions: A high percentage of older orthopedic patients in rehabilitation with both elective and non-elective diagnoses have cognitive impairment. Cognitive screening is recommended for all older orthopedic patients in rehabilitation, to inform an individualized rehabilitation plan to improve outcomes and length of stay. Further research is required to explore cognitive strategies to maximize rehabilitation outcomes in the geriatric orthopedic population.

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Management of Skin and Soft-Tissue Infections Before and After Clinical Pathway Implementation

Clinical Pediatrics ◽

10.1177/0009922817738329 ◽

2017 ◽

Vol 57 (6) ◽

pp. 660-666 ◽

Cited By ~ 3

Author(s):

Courtney E. Nelson ◽

Aaron Chen ◽

Lisa McAndrew ◽

Khoon-Yen Tay ◽

Fran Balamuth

Keyword(s):

Emergency Department ◽

Staphylococcus Aureus ◽

Soft Tissue ◽

Length Of Stay ◽

Clinical Pathway ◽

Methicillin Resistant Staphylococcus Aureus ◽

Antibiotic Use ◽

Soft Tissue Infections ◽

Before And After ◽

Systemic Antibiotics

We evaluated if the introduction of a clinical pathway for skin and soft-tissue infections (SSTIs) would reduce methicillin-resistant Staphylococcus aureus (MRSA)-directed therapy for simple cellulitis and antibiotic use for simple abscess after drainage. We compared the treatment of SSTI during a 3-month prepathway and 11-month postpathway period. We included patients 57 days to 18 years old discharged from the emergency department (ED) with a diagnosis of cellulitis or abscess. Balancing measures included 72-hour revisit rate and ED length of stay (LOS). A total of 291 patients prepathway and 781 patients postpathway were included. The proportion of patients with simple cellulitis prescribed MRSA-directed therapy decreased from 81% to 54% postpathway. The proportion of patients with a drained abscess prescribed systemic antibiotics decreased from 88% to 75%. There was no increase in 72-hour revisit rates (3.8% vs 3.2%, P = .64) or ED LOS (2.8 vs 2.7 hours, P = .05).

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