A CLINICAL PATHWAY FOR LAPAROSCOPIC PYELOPLASTY DECREASES LENGTH OF STAY

0022-5347/05/1736-2081/0 THE JOURNAL OF UROLOGY® Copyright © 2005 by AMERICAN UROLOGICAL ASSOCIATION

Vol. 173, 2081–2084, June 2005 Printed in U.S.A.

DOI: 10.1097/01.ju.0000158460.45695.78

Outcomes/Epidemiology/Socioeconomics A CLINICAL PATHWAY FOR LAPAROSCOPIC PYELOPLASTY DECREASES LENGTH OF STAY TODD M. WEBSTER, ROXELYN BAUMGARTNER, JASON K. SPRUNGER, D. DUANE BALDWIN,* ELSPETH M. MCDOUGALL† AND S. DUKE HERRELL‡ From the Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee (TMW, RB, JKS, DDB, SDH) and Department of Urology, University of California Irvine Medical Center, Orange, California (EMM)

ABSTRACT

Purpose: Benefits of minimally invasive procedures include decreased hospitalization and recovery times. Decreased length of stay (LOS) improves hospital efficiency and decreases costs. However, decreasing the LOS at the expense of patient care and satisfaction is not acceptable. A clinical pathway (CP) with structured order sets and imaging was developed for patients undergoing laparoscopic pyeloplasty. This pathway includes a cascade of activities managed closely by the health care team. This study assesses the safety and patient satisfaction with this clinical pathway. Materials and Methods: We reviewed all adult pyeloplasties (39) completed laparoscopically since November 2001. All patients were managed according to the CP developed for the laparoscopic pyeloplasty procedure. The length of stay was measured in days. Patient satisfaction was assessed with a standardized questionnaire. Any readmissions or emergency room visits were documented. Results: The mean length of stay was 1.10 days. Of 39 patients 37 (94%) were discharged home on postoperative day 1. One patient with severe postoperative pain required intravenous analgesia. She had undergone complex upper tract reconstruction and stayed a total of 4 days. One patient, who had a previous failed endopyelotomy, remained 2 days for persistent nausea. No patients sought emergency room consultation and there were no readmissions. Of 39 patients 34 (87%) completed the questionnaire and satisfaction was high. Conclusions: The implementation of a CP at our institution has standardized patient care in this population and decreased LOS in comparison to the literature. This improves bed use and hospital efficiency while maintaining a high degree of patient satisfaction. We conclude that with intensive patient care and education most patients undergoing laparoscopic pyeloplasty may be discharged home safely on postoperative day 1. KEY WORDS: critical pathways, laparoscopy, length of stay

Health care costs have been rising exponentially and efforts have been made recently to control costs through efficient resource use. One strategy, the implementation of collaborative postoperative clinical pathways (CP), has been applied to many procedures and demonstrated the ability to decrease costs by reducing patient length of stay (LOS).1– 4 A CP is an evidence based tool, which outlines the sequence of events and timing of interventions by physicians, nurses, and allied health staff relating to a specific procedure.5 The goals of any CP are to increase efficiency and decrease resource use while maintaining high quality outcomes without increased morbidity.6 They are ideally suited for high cost procedures requiring multidisciplinary collaboration. Ongoing evaluation and revision of a CP is essential to ensure it is meeting the desired objectives in a dynamic health care environment. Submitted for publication September 8, 2004. * Financial interest and/or other relationship with Onset Medical. † Financial interest and/or other relationship with Applied Medical Resources, Simbionix, Intuitive Surgical, Ethicon Endo-Surgery, Yamanouchi and Storz Endoscopy. ‡ Correspondence: Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee 37235 (e-mail: [email protected]).

Therefore, a CP for laparoscopic pyeloplasty was designed with a targeted LOS of 1 day in hospital. The purpose of this study was to assess the actual LOS following laparoscopic pyeloplasty, any subsequent emergency room (ER) visits or readmissions, and the degree of patient satisfaction. MATERIALS AND METHODS

A CP with structured order sets and imaging requisitions was developed at Vanderbilt University Medical Center for patients undergoing laparoscopic pyeloplasty. This pathway includes a cascade of activities managed closely by the collaborative health care team. Patients are ambulated the day of surgery and a fluid diet is initiated. Postoperative analgesia is ensured with ketorolac scheduled by the clock and narcotics as needed. Static cystograms are performed early on postoperative day 1 (POD 1) with the percutaneous drain off suction. The Foley catheter is removed after documenting the anastomosis is intact (no extravasation on cystogram). The drain is monitored for 2 to 3 hours after catheter removal. If there is no increased pain, fever, erythema, or increased output from the drain, it is removed. If the cysto-

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gram demonstrates extravasation, patients are discharged home with the Foley catheter and drain. Repeat imaging is scheduled for clinic followup. Expected discharge home on POD 1 occurs after individualized patient teaching if the patient tolerates a liquid diet, ambulates and their pain is well controlled with oral analgesia. We reviewed all patient records to determine the actual LOS. Any subsequent ER visits or hospital readmissions were documented through chart review and direct patient history. Patient satisfaction was assessed with a standardized patient satisfaction questionnaire administered in clinic during followup assessment (see Appendix). RESULTS

A total of 39 patients underwent laparoscopic pyeloplasty between November 2001 and November 2003. The mean LOS was 1.1 ⫾ 0.5 days and the median LOS was 1.0 day (range 1 to 4). Of 39 patients 37 (95%) were discharged home on postoperative day 1. One patient with severe postoperative pain required intravenous analgesia. She had undergone complex upper tract reconstruction and stayed a total of 4 days. One patient, who had a previous failed endopyelotomy, remained 2 days for persistent nausea and ileus. Chart review and direct patient questioning revealed that no patients sought ER consultation and there were no readmissions. Since many patients were from a distance away from Vanderbilt all were questioned to ensure health services were not sought elsewhere. Patient satisfaction was extremely high despite the short hospital stay. Questionnaires were completed by 87% (35 of 39) of patients (see figure). Question 1 indicates 94% (33 of 35) of patients were “generally pleased with their hospital stay.” Based on the response to question 2, 97% (34 of 35) felt they were well-informed before admission to hospital. Question 3 reveals the preadmission process was organized and efficient for all (35 of 35) patients. During the hospital stay information was disseminated well according to 97% (34 of 35) of patients (question 4). Of the patients 80% (28 of 35) described their incision pain as “less than expected” or “expected,” while 20% (7 of 35) described pain as “more than expected” (question 5). Question 6 indicates that incision pain relief was “more than adequate” or “adequate” in all patients (35 of 35). Teaching and instructions before discharge home were “adequate” in 97% (34 of 35) and “inadequate” in only 3% (1 of 35, question 7). A total of 83% (29 of 35) felt medically ready for discharge home (question 8) and 17% (6 of 35) said they had problems after surgery (question

9). The patient related problems mentioned included 1 urinary tract infection, pain, fever and 3 instances of premature catheter removal with reinsertion required for cystogram. Question 10, “Was there anything we could have done differently to improve your hospital stay?” received 9 (26% of patients) affirmative responses, with 6 comments related to education or communication, 2 related to pain issues and 1 related to patient anxiety surrounding the procedure. DISCUSSION

The modern health care environment has forced institutions to try to decrease LOS. There has been a trend to shortened hospital stays during the last decade.7, 8 We acknowledge that clinical care can be streamlined without the implementation of clinical pathways, but believe our institution has benefited from increased efficiency through their implementation. Previous experience with collaborative clinical pathways for open prostatectomy, cystectomy, ureteroneocystostomy and retroperitoneal lymph node dissection at our institution have demonstrated an ability to safely decrease patient LOS and attendant hospital charges while improving outcomes and maintaining a high degree of satisfaction.5, 9, 10 While laparoscopic surgery has the benefit of being less invasive than traditional open surgery and is associated with an inherently lower LOS, we note that the average LOS for major pyeloplasty series in the literature is 3.5 days (see table).11–17 Our series demonstrates an average LOS of 1.1 days with 37 of 39 (95%) of patients being discharged home on POD 1. Patient satisfaction was high (94% generally pleased) in our series despite the short hospital stay. We believe this is partially due to the design and implementation of a CP for laparoscopic pyeloplasty at our institution. We agree with Dy et al that the goal of a clinical pathway is not to discharge patients after a certain time period regardless of clinical status, but to increase the efficiency in the delivery of care to maximize the number of patients safely prepared for discharge home at a target number of days.8 Additional benefits in terms of quality of care, adherence to evidence based guidelines, avoidance of redundancy, improved communication and increased patient satisfaction may be realized through the implementation of a CP.18 A CP serves to continually remind physicians, nurses, allied support staff and, most of all, patients of the time lines associated with their procedure. While making the hospital ward an efficient machine for the delivery of patient care, patient preparedness for dis-

Summary of questionnaire results

CLINICAL PATHWAY FOR LAPAROSCOPIC PYELOPLASTY Average LOS for major pyeloplasty series References Chen et al11 Janetschek et al12 Eden et al13 Soulie´ et al14 Turk et al15 Jarrett et al16 Sundaram et al17 Overall Present series

No. Pts

Mean LOS

57 65 50 55 49 100 36

3.3 2.6 4.5 3.7 3.3 3.5 2.9 3.4 1.1

39

charge home must be assured. This can be accomplished through intensive education and discharge planning. We believe education is paramount to the successful integration of a CP. A presentation at the 2003 American Heart Association Scientific Session stated that 1 hour of patient education reduces readmission rates by a third and helps patients comply with complex home regimens in the management of congestive heart failure.19 A recently published study reports that with education the LOS for pubovaginal sling surgery may safely be reduced from 5 days to less than 24 hours with no readmissions.20 In this series we also demonstrate no apparent medical risk to the shortened LOS since no patient required medical services after discharge home. Patients are thoroughly assessed and receive intensive education from various members of the health care team before discharge home. While 17% did not believe themselves medically ready for discharge, 97% considered the discharge teaching and instructions adequate and none had medical difficulty requiring emergency room consultation or hospital readmission. This was confirmed through chart review and direct patient questioning. Of the 6 patients 2 were apprehensive to leave hospital but were glad when they got home. Two found they had more pain than expected, 1 complained of nausea, and 1 had a long drive home for which they did not feel ready. It seems they were apprehensive but medically fit for discharge since no patients required emergency room treatment or readmission, attesting to the safety of an early discharge home. Clearly time must be spent to ensure patients understand what to expect when they get home. We have found that focused and personalized education is the key. Every patient’s capacity to understand instructions must be assessed and appropriate time allocated to teaching to ensure preparedness for a comfortable discharge. As such, the presence of dedicated urological nurse practitioners with expertise in the postoperative care of patients following laparoscopic surgery is invaluable. Clinical pathways are not intended to be rigid static tools but fluid dynamic instruments to streamline patient care. They should be periodically evaluated to ensure they are safe, effective, reflect current practice guidelines and meet with patient approval. Data collection, quality control, and safety, including patient satisfaction surveys, are ongoing processes at our institution. Quarterly reviews are performed and revisions are made accordingly. Early in this series we experienced 3 premature catheter removals requiring reinsertion for cystogram. This resulted from the adoption of the generic laparoscopic renal surgery pathway which stipulates catheters be removed at 06:00 on POD 1. Internal review identified this problem, the protocol was revised and the situation was remedied. Ongoing evaluation also facilitates continued improvements in the patient experience. In this series 26% (9 of 35) of respondents made suggestions on ways to improve their hospital stay with the majority of comments (6 of 9) directed at improving patient education and communication. There was no association seen between those patients reporting postoperative problems and those suggesting ways to improve their stay. Although both patients who were not gen-

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erally pleased with their hospital stay made suggestions on ways we could improve, 7 of the 9 suggestions received came from patients who were generally pleased with their experience in the hospital. By soliciting patient feedback and implementing change as needed we aim to continue to achieve a high degree of patient satisfaction. CONCLUSIONS

The implementation of a CP has helped standardize patient care and decrease LOS after laparoscopic pyeloplasty at our institution. We demonstrate that patients may be safely discharged home on POD 1, with a high degree of satisfaction. Education is a key component to the successful implementation of a CP. A multidisciplinary team approach to the delivery of health care using a CP benefits patients. Ongoing evaluation, with periodic revision, is required to achieve the maximum benefit from a CP. APPENDIX: PATIENT SATISFACTION QUESTIONNAIRE

Vanderbilt University Medical Center Department of Urologic Surgery 1.Were you generally pleased with your hospital stay? a. Yes No (please circle choice) 2. Did you receive enough information about your hospital stay prior to being admitted to hospital? Yes No (please circle choice) If no, what additional information do you wish you had received? 3. Was the preadmission testing process organized and efficient? a. Yes No (please circle choice) If answer is no, please describe. 4. Was the information about your hospitalization and illness adequately explained to you throughout your hospital stay? a. Yes No (please circle choice) If no, please describe. 5. After an operation, there are expected discomforts related to catheters, tubes and/or hospital beds. Apart from these discomforts would you describe your incisional pain in the hospital as: 1.Worse than expected 2. Expected 3. Less than expected (circle one) 6. Would you describe your incisional pain relief in the hospital as: 1. Less than adequate 2. Adequate 3. More than adequate (circle one) 7. Do you feel your discharge teaching and instructions were adequate? Yes No (please circle choice) 8. Did you feel you were medically ready to go home when you were discharged? Yes No (please circle choice) 9. Did you experience any problems after surgery? Yes No (please circle choice) If yes, please describe on back. 10. Was there anything we could have done differently to improve your hospital stay? Yes No (please circle choice) If yes, please comment on back. REFERENCES

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