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Re-engineering the elective surgical service of a tertiary hospital: a historical controlled trial

Gideon A Caplan, Ann Brown, Philip J Crowe, Su-Jen Yap and Shaune Noble
Med J Aust 1998; 169 (5): 247-251.
Published online: 7 September 1998

Re-engineering the elective surgical service of a tertiary hospital: a historical controlled trial

Gideon A Caplan, Ann Brown, Philip J Crowe, Su-Jen Yap and Shaune Noble

MJA 1998; 169: 247-251
For editorial comment, see Hillman  

Abstract - Introduction - Methods - Patients - Outcome measures - Control group--existing system - Postintervention group--the perioperative system - Operative complications - Statistical analysis - Results - Outcomes - Complications - Patient satisfaction - Discussion - Acknowledgements - References - Authors' details - Figure 1 - Figure 2

- - - ©MJA1998

 

Abstract

Objective: To study the clinical effects of re-engineering the processes associated with elective surgery.
Design: A prospective, historical controlled trial. Control patients were enrolled from March 1995 to January 1996, and postintervention patients from February 1996 to October 1996.
Setting: A major teaching, tertiary care hospital (Prince of Wales Hospital, Sydney).
Patients: 224 patients (123 before and 101 after the intervention) undergoing elective herniorrhaphy or laparoscopic cholecystectomy who lived in the local area.
Intervention: Introduction of a re-engineered surgical service consisting of preadmission assessment and education, admission on day of surgery, and postacute care after discharge. There were no changes to the operative methods or infection control procedures.
Main outcome measures: Length of stay, operative complications, pain scores and patient satisfaction.
Results: The risk of a patient suffering one or more complications was reduced in the postintervention group (postintervention v. control patients: 25.7% v. 38.2%; relative risk [RR], 0.66; 95% confidence interval [CI], 0.44-0.98; P = 0.035) because of a reduced risk of wound infections (5.0% v. 16.3%; RR, 0.30; 95% CI, 0.12-0.78; P = 0.0075). Other complications (perioperative or postoperative) and pain scores were unchanged. Patients treated by the re-engineered service had a significantly shorter length of stay, reported a higher level of satisfaction with the preoperative and postdischarge care, and were more likely to say that they would have the same treatment again (92.9% v 82.6%; P = 0.037).
Conclusions: Re-engineering surgical services, with an associated reduction in length of stay, does not lead to a deterioration in care and may decrease postoperative complications and increase patient satisfaction.
MJA 1998; 169: 247-251  

Introduction

Financial pressures from insurance companies1 and governments2 are driving changes in the healthcare systems of many countries. One of the most visible changes is shorter hospital stay, especially for elective surgery.3 Organisational changes include preadmission clinics, enhanced patient education, increased use of day surgery, improved discharge planning and postacute care at home; and clinical changes include less invasive surgical techniques and improved anaesthetic drugs.4 The introduction of a package of these organisational changes amounts to a re-engineering of elective surgery.5

Many of these changes have been introduced with little scientific evaluation of their effect on patients, and perceptions of detrimental effects on patient care can make such changes unpopular.1,2

Studies of healthcare changes so far6-10 have focused on changes in surgical procedures and have been unable to identify any clinical effects of initiatives, such as preadmission clinics, patient education, reduction in length of stay, and postacute care. Moreover, in these studies, control patients underwent different procedures,6,7 significant results were not obtained,8,9 or there were worse outcomes in the postintervention group.10

We studied the effects of re-engineering our elective surgical service using a prospective, historical, controlled trial. Our re-engineered service comprised a perioperative unit, preadmission anaesthetic assessment based on self-reported questionnaires, admission on the day of surgery, enhanced patient education, use of clinical pathways, and postacute care (Box 1).

1: A re-engineered surgical service

  • Admission coordinated by Perioperative Unit, which sends out, receives and reviews patients' self-reported health questionnaires, and arranges preadmission assessment, if indicated. Patients admitted to Perioperative Unit on day of surgery. After surgery, day-only patients return to Perioperative Unit, others to the ward.

  • Patient information specific for each operation distributed by the surgeon. Nurses reinforce patients' knowledge.

  • Clinical pathways followed. These provide a diagnosis-specific plan for the episode of care and the role of each member of the multidisciplinary team.

  • Postacute care continues at home after discharge, if required.
  •  

    Methods

     

    Patients

    To minimise variation and ensure adequate patient numbers, we studied prospectively a cohort of patients having one of two general surgical procedures (inguinal herniorrhaphy and laparoscopic cholecystectomy). Patients in the control group were treated before and compared with patients treated after the new elective surgical service was commissioned. Patients who lived outside the local area or were admitted as an emergency were excluded. All patients gave informed consent, and the study was approved by the South Eastern Sydney Area Health Service (Eastern Branch) Ethics Committee.  

    Outcome measures

    Information collected for comparing the control and postintervention groups included length of hospital stay, level of pain (assessed by a linear analogue pain scale), complications of the operation, and patient satisfaction (assessed by a self-reported questionnaire).  

    Control group -- existing system

    • Patients booked for surgery from the surgeon's rooms or surgical outpatients clinic;
    • Patient information and education provided according to individual surgeon's protocols;
    • Patients admitted to the ward on the day before the procedure, clerked by the surgical intern and assessed by the anaesthetist;
    • Postsurgical care given in the surgical ward; and
    • Discharge plans made by ward staff, subject to individual surgeon's decision.

    A total of 123 control patients were enrolled prospectively from March 1995. (We had planned to enrol 100, but a delay in commissioning the new system extended the enrolment period.) Eligible patients booked for surgery each day were visited by the study nurse on admission to the ward. After surgery, the nurse obtained patient data, including a pain score on Day 1 after the operation, and arranged to contact the patient by telephone on Day 7.

    Before discharge, patients were given an anonymous, self-reported patient satisfaction survey, based on the Australian model.11 They were asked to rate their overall treatment, the information provided, preoperative treatment, the operation and care after discharge from hospital on a five-point Likert scale from "very satisfactory" to "very unsatisfactory". They were also asked whether they would have the procedure the same way again, and were given a further copy of the pain scale, and asked to complete both documents on Day 7 after the operation and return them in the prepaid envelope provided. The telephone call on Day 7 reminded patients to return their satisfaction surveys and pain scores.  

    Postintervention group -- the perioperative system

    A more coordinated system was developed, based on the perioperative system (Box 1).12 The surgeons, nursing staff, operating theatre location and organisation and infection control practices did not change. Although surgical registrars changed surgical units during the study period, they worked with other surgeons whose patients were also studied.

    The Perioperative Unit included a preadmission anaesthetic clinic where patient health questionnaires were completed, and patients with significant comorbidity were fully assessed. Based on the information provided by the questionnaires, 70% of elective surgery patients were seen by an anaesthetist for the first time on the day of surgery, 15% of patients were seen as outpatients before the day of surgery because of anaesthetist preference, and the remaining 15% required further anaesthetic consultation and one (usually) additional outpatient visit for review. All patients, both day-only and those transferring to the surgical ward after the operation, went to theatre from a day-surgery ward within the Perioperative Unit.

    Patient care was guided by a clinical pathway developed by the multidisciplinary team to drive and support the system. The role of every member of the multidisciplinary team is specified for each day, with alternative plans available if a patient's condition changes. Improved patient educational material was developed for distribution by the surgeons, and patients' comprehension of the material was reviewed by the study nurse at the preadmission anaesthetic clinic or on the day of surgery. If doubts existed about the safety and suitability of a patient's accommodation for postsurgical recovery, the study nurse made a preadmission home visit. After surgery, study patients were transferred to the surgical ward and an existing postacute care service arranged early discharge with follow-up at home.

    The new system was introduced at the end of January 1996 and enrolment of the 101 patients in the postintervention group commenced in February 1996. A pain scale was completed on Day 1 after operation. The timing of discharge was entirely at the surgeons' discretion, and the study nurse arranged to visit the patient at home within 24 hours of hospital discharge to assess pain control, wound care needs and general postsurgical progress. This visit generally lasted less than half an hour, and occasional further visits were arranged, as clinically indicated. A contact phone number was provided for use in the event of any complications or concerns. Patients in the postintervention group were also asked to complete the self-reported patient satisfaction survey.  

    Operative complications

    Data on all complications were collected prospectively and crosschecked with the patients' clinical records. The criteria for wound infections were those of the Centers for Disease Control and Prevention (CDC),13 notably that the infection involves only the skin and subcutaneous tissue of the incision, and at least one of the following:
    • purulent drainage from the superficial incision;
    • organisms isolated from aseptically obtained culture of fluid or tissue from the superficial incision;
    • at least one of the following signs or symptoms of infection -- pain or tenderness; localised swelling; redness or heat; and superficial incision is deliberately opened by the surgeon, unless incision is culture negative;
    • diagnosis of superficial incisional surgical site infection by the surgeon or attending physician.
     

    Statistical analysis

    Statistical calculations were performed using SPSS for Windows.14 Normally distributed continuous variables were compared by t tests, dichotomous variables by χ2 tests. Ordinal variables were compared with the Mann-Whitney U test. Logistic regression was used to obtain a multivariate analysis of factors predictive of wound infection.  

    Results

    From March 1995 to October 1996, 224 patients were enrolled in the study. Baseline characteristics of the two groups were not statistically significantly different (Box 2).

    2: Baseline characteristics of elective surgery patients
    Postintervention group*
    (n = 101)
    Control group*
    (n = 123)
    Laparoscopic cholecystectomy 57 (56.4%) 65 (52.8%)
    Herniorrhaphy 44 (43.6%) 58 (47.2%)
    Mean time in operating theatre (min, SEM) 100.3 (4.2) 102.1 (3.5)
    Female : male ratio 46 : 55 54 : 69
    Mean age (range) (years) 54.4 (21-85) 54.0 (18-90)
    Smoker 27 (26.7%) 25 (20.3%)
    Ischaemic heart disease 8 (7.9%) 9 (7.3%)
    Requires an interpreter 8 (7.9%) 4 (3.3%)
    Lives alone 19 (18.8%) 23 (18.7%)
    Lives upstairs (no lift) 37 (36.6%) 39 (31.7%)

    *Differences were not statistically significant
     

    Outcomes

    The postintervention group had a significantly shorter length of stay, but there was no difference in pain scores between the two groups (Box 3).

    3: Outcomes in the postintervention and control groups
    Outcome Postintervention group Control group
    Mean length of stay in days (range) 2.2 (1-8) 3.2 (1-9)*
       For herniorrhaphy 1.8 (1-4) 3.1 (2-7)þ 
       For laparoscopic cholecystectomy 2.5 (1-8) 3.3 (1-9)§
    Postoperative pain score mean (SEM)
       Day 1 21.7 (1.2) 22.6 (0.9)
       Day 7 9.4 (1.1) 8.4 (1.0)
    Number of deaths 0 1 (0.8%)
    Number readmitted 5 (5.0%) 4 (3.3%)

    Postintervention v. control group: *P < 0.001;  þ P < 0.001; § P = 0.020.
     

    Complications

    The postintervention group had a lower risk of suffering any complication (complications in postintervention v. control patients -- 26 [25.7%] v. 48 [38.2%]; relative risk [RR], 0.66; 95% confidence interval [CI], 0.44-0.98; P = 0.035) because of a lower risk of wound infection (Figure 1). There was no significant difference between postintervention and control patients in intraoperative complications or other postoperative complications (Figure 1).
    Figure 1: Proportion of patients with each type of complication in the postintervention and control groups, including relative risk (RR) and 95% confidence interval (CI) for comparison between the groups.

    Intraoperative complications were bile/stone spillage (4 v. 5), conversion to open cholecystectomy (4 v. 1) and, in the control group, one each of cystic duct damaged, cystic artery damaged, unsuccessful exploration of common bile duct, local anaesthetic converted to general anaesthetic, penis injured by towel clips, and aspiration into lungs.

    Postoperative complications are listed in Box 4. Eight patients suffered two complications and one three complications, so that the total for all types of complications exceeds the number of patients who suffered a complication.

    4: Postoperative complications
    Complication Postintervention group (n = 22) Control group (n = 42)
    Wound infection 5 20
    Cerebrovascular accident, died 0 1
    ERCP after operation 2 4
    Haematoma/haemorrhage/ooze 4 1
    Shoulder tip pain 1 2
    Scrotal pain or swelling 2 2
    Nausea and vomiting 2 0
    Constipation (> 4 days) 2 2
    Urinary retention requiring indwelling catheter 1 1
    Unstable INR after operation, delayed discharge 0 2
    Rash (due to antibiotics) 0 1
    Fall Day 1 after operation, low blood pressure 0 1
    Delirium 0 1
    Difficulty mobilising 0 1
    Respiratory infection 3 3

    ERCP = endoscopic retrograde cholangiopancreatography. INR = International Normalised Ratio.

    Multivariate analysis using logistic regression found that the only variables significantly predictive of having a wound infection were being in the control group, length of stay (Figure 2) and the patient having a carer (a proxy for functional dependence).

    Figure 2: Proportion of patients with wound infection in the postintervention and control groups, by length of stay.
     

    Patient satisfaction

    Completed responses to the satisfaction survey were received from 85 postintervention patients (84.2%) and 89 controls (72.4%). Analysis showed that patients in the postintervention group were more satisfied with both the preoperative (P = 0.0094) and the postdischarge treatment (P = 0.0001), as well as the operation, and were also more likely to want to have the procedure done the same way next time, if required (postintervention v. control: 92.9% v 82.6%; difference, 10.3%; 95% CI, 0.8%-19.8%; P = 0.037). There was no difference between the groups in their ratings of the overall treatment or of the information supplied preoperatively. Although the difference in response rates between the control and postintervention groups was significantly different (P < 0.05), there were no significant differences between respondents and non-respondents in terms of age, sex, type of operation, pain scores, complications, comorbidity, living arrangements, occupational or smoking status.  

    Discussion

    Patients having elective surgery after a re-engineered system of coordinated care for elective surgery was introduced had shorter hospital stays, a lower risk of wound infection and reported higher levels of satisfaction.

    Previous studies, rather than focusing on the outcomes of the process, as we did, have examined the impact of elements of our re-engineered service (particularly preadmission clinics) on the efficiency of the elective surgical process.15

    Our study found a higher rate of wound infection than is generally reported in surgical series, although the rate was within the range of prevalence of nosocomial infections (3%-21%) in a World Health Organization survey,16 and comparable with rates in an Australian survey which also actively followed up patients for wound infections after discharge.17 Surveys may also identify widely varying wound infection rates if different definitions of infections are used.18 Definitions of wound infections which require the presence of pus19 tend to underestimate the true prevalence, given that most doctors institute antibiotic therapy for earlier signs of infection.

    With decreasing lengths of hospital stay, most wound infections occur after discharge from hospital, where they are often diagnosed and treated by general practitioners (GP) and not surgeons.17 Thus, it is not surprising for series of laparoscopic cholecystectomies to report infection rates which vary from 1% to 17%.6,17 The 70% reduction in the risk of surgical nosocomial infections which we found is relatively large. We used the CDC definition of infection, and found that most infections were diagnosed and treated by GPs before the wounds developed purulent drainage and without waiting for a positive culture result. The study nurses collected the data in the same manner (ie, prospectively during planned follow-up of patients), but the diagnosis of wound infection was left to the treating GP or surgeon.

    We tested the observation that there is a dose-effect relationship between iatrogenic complications and length of stay in hospital. A relationship between length of stay and risk of nosocomial infection has been observed in a number of studies.18,19 Cruse and foord retrospectively also found that risk of infection increases with length of preoperative stay,19 but previous studies have not prospectively examined the possibility that decreasing the length of stay will result in lower wound infection rates.

    Our data demonstrate that a reduction in hospital stay as part of a re-engineered surgical service can decrease the wound infection risk. From the near-parallel slope of the lines in Figure 2, it would appear that the difference between the two groups is due to some factor that occurs early in the admission, most likely through decreasing exposure to hospital microbial flora on the night before surgery, resulting in a shift of the curve to the right.

    Our study design was a prospective, sequential, before-and-after comparison. Randomised controlled trials are generally considered to be the reference standard for evaluating new treatments. However, when the intervention is a coordinated system of care involving a "culture change" in an organisation, there may be a "Hawthorne effect" -- that is, behaviour changes due to an awareness of being in a study -- and leakage of elements of the "culture change" into the control group, thus reducing the power of a randomised controlled trial.20 Our sequential enrolment of patients more closely mimics the situation in hospital when a surgical service is re-engineered, and makes the study results more relevant.

    Our study had the active collaboration of the hospital administration, and hospital policy was revised at the start of the treatment phase to require all elective surgery patients to be admitted through the Perioperative Unit. The surgeons and operating theatre location and organisation were unchanged, although junior medical staff were rotated. There was no change in antibiotic prophylaxis or hospital infection control policies, thereby minimising any differences in enrolment patterns and other factors between the two arms of the trial.

    Our patient satisfaction survey suggested that patients were more satisfied with a shorter length of stay combined with the appropriate support after hospital discharge. A previous study in which surgical patients were not similarly supported after early hospital discharge found patients to be less satisfied with the treatment.21

    We have demonstrated that changes in the organisation of elective surgery can produce improved health outcomes and patient satisfaction. This does not mean that any reduction in length of stay results in improved outcomes, but that reduced in-hospital support may be replaced with carefully planned and supervised preadmission assessment, education and postdischarge care, without detriment to the quality of patient care.  

    Acknowledgements

    We would like to acknowledge the invaluable assistance of the staff of Post Acute Care Services, the Perioperative Unit, and the Departments of Surgery and Anaesthetics, without whose help this study would not have been possible.
    This study was supported by a grant from the Commonwealth Department of Health and Family Services Hospital Access Program.  

    References

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    13. Centers for Disease Control and Prevention, US Department of Health and Human Services. National Nosocomial Infections Surveillance Manual. Atlanta, Ga: USDHHS, May 1994.
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    17. Hardy KJ, Miller H, Fletcher DR, et al. An evaluation of laparoscopic versus open cholecystectomy. Med J Aust 1994; 160: 58-62.
    18. Freeman J, McGowan JE. Differential risks of nosocomial infection. Am J Med 1981; 70: 915-918.
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    21. Michaels JA, Reece-Smith H, Faber RG. Case control study of patient satisfaction with day-case and inpatient inguinal hernia repair. J R Coll Surg Edinb 1992; 37: 99-100.
    (Received 5 Jun 1997, accepted 18 May 1998)  


    Authors' details

    Prince of Wales Hospital, Sydney, NSW.
    Gideon A Caplan, MB BS, FRACP, Director, Post Acute Care Services. Ann Brown, RN, Nurse Manager, Post Acute Care Services.
    Philip J Crowe, MB BS, FRACS, Surgeon, Department of Surgery.
    Su-Jen Yap, MB BS, FANZCA, Director, Perioperative Unit, Prince of Wales Hospital.

    South Eastern Sydney Area Health Service, Sydney, NSW.
    Shaune Noble, BHA, MPH, Health Services Development Unit.
    Reprints: Dr GA Caplan, Director, Post Acute Care Services, Prince of Wales Hospital, Randwick, NSW 2031.
    E-mail: G.CaplanATunsw.edu.au

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    Received 12 December 2018, accepted 12 December 2018

    • Gideon A Caplan
    • Ann Brown
    • Philip J Crowe
    • Su-Jen Yap
    • Shaune Noble


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