The Effect of Clinical Pathways for Bariatric Surgery on Perioperative Quality of Care
Rent the article at a discountRent now
* Final gross prices may vary according to local VAT.Get Access
Bariatric surgery demands a multidisciplinary approach and enhanced recovery schemes. Such schemes are complex and cumbersome to introduce into practice. This study evaluates if a clinical pathway (CP) facilitates implementation of an enhanced recovery scheme in bariatric surgery with the goal of improving perioperative quality of care.
We compared 65 consecutive patients who underwent bariatric surgery in 2009 and were treated with a CP (CP group) with 64 consecutive patients treated without CP in 2007/2008 (pre-CP group). Process quality indicators were catheter management, postoperative mobilization, spirometer training, vitamin B supplementation, diet resumption, intake of supplement drinks, and length of stay. Outcome quality was measured through morbidity, mortality, re-operations, and re-admissions.
In the CP group, foley catheters were removed earlier (p < 0.0001), patients were mobilized more often on the surgery day (CP group 92.3% vs. pre-CP group 78.1%, p = 0.03), used spirometers more often (56.9% vs. 28.1%, p = 0.002), were more often supplemented with vitamin B (100% vs. 31.3%, p < 0.0001), and received oral supplement nutrition more often (100% vs. 59.4%, p < 0.0001). Median length of stay was shorter in the CP group (6 vs. 7 days, p = 0.007). There was no significant difference in mortality, morbidity, re-operations, and re-admissions.
Following implementation of an enhanced recovery CP for bariatric surgery, several indicators of process quality improved while outcome quality remained unchanged. A CP seems useful for optimizing treatment of bariatric surgery patients according to enhanced recovery principles. However, future studies are required to better determine which elements of care can be improved most.
- Buchwald H, Oien D. Metabolic/bariatric surgery worldwide 2008. Obes Surg. 2009;19:1605–11. CrossRef
- Selassie M, Sinha AC. The epidemiology and aetiology of obesity: a global challenge. Best Pract Res Clin Anaesthesiol. 2011;25:1–9. CrossRef
- Sjostrom L, Narbro K, Sjostrom CD, et al. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med. 2007;357:741–52. CrossRef
- Hubbard VS, Hall WH. Gastrointestinal surgery for severe obesity. Obes Surg. 1991;1:257–65. CrossRef
- Fried M, Hainer V, Basdevant A, et al. Interdisciplinary European guidelines for surgery for severe (morbid) obesity. Obes Surg. 2007;17:260–70. CrossRef
- Runkel N, Colombo-Benkmann M, Huttl TP, et al. Evidence-based German guidelines for surgery for obesity. Int J Colorectal Dis. 2011;26:397–404. CrossRef
- Gouvas N, Tan E, Windsor A, et al. Fast-track vs standard care in colorectal surgery: a meta-analysis update. Int J Colorectal Dis. 2009;24:1119–31. CrossRef
- Kehlet H. Fast-track colorectal surgery. Lancet. 2008;371:791–3. CrossRef
- Hasenberg T, Keese M, Langle F, et al. 'Fast-track' colonic surgery in Austria and Germany—results from the survey on patterns in current perioperative practice. Colorectal Dis. 2009;11:162–7. CrossRef
- Kahokehr A, Sammour T, Zargar-Shoshtari K, et al. Implementation of ERAS and how to overcome the barriers. Int J Surg. 2009;7:16–9. CrossRef
- Kehlet H, Buchler MW, Beart RW Jr, et al. Care after colonic operation—is it evidence-based? Results from a multinational survey in Europe and the United States. J Am Coll Surg. 2006;202:45–54. CrossRef
- Maessen J, Dejong CH, Hausel J, et al. A protocol is not enough to implement an enhanced recovery programme for colorectal resection. Br J Surg. 2007;94:224–31. CrossRef
- Polle SW, Wind J, Fuhring JW, et al. Implementation of a fast-track perioperative care program: what are the difficulties? Dig Surg. 2007;24:441–9. CrossRef
- Roig JV, Rodriguez-Carrillo R, Garcia-Armengol J, et al. Multimodal rehabilitation in colorectal surgery. On resistance to change in surgery and the demands of society. Cir Esp. 2007;81:307–15. CrossRef
- Kinsman L, Rotter T, James E, et al. What is a clinical pathway? Development of a definition to inform the debate. BMC Med. 2010;8:31. CrossRef
- Lemmens L, van Zelm R, Vanhaecht K, et al. Systematic review: indicators to evaluate effectiveness of clinical pathways for gastrointestinal surgery. J Eval Clin Pract. 2008;14:880–7. CrossRef
- Ronellenfitsch U, Rossner E, Jakob J, et al. Clinical pathways in surgery—should we introduce them into clinical routine? A review article. Langenbecks Arch Surg. 2008;393:449–57. CrossRef
- Rotter T, Kugler J, Koch R, et al. A systematic review and meta-analysis of the effects of clinical pathways on length of stay, hospital costs and patient outcomes. BMC Health Serv Res. 2008;8:265.
- Schwarzbach MH, Ronellenfitsch U, Wang Q, et al. Effects of a clinical pathway for video-assisted thoracoscopic surgery (VATS) on quality and cost of care. Langenbecks Arch Surg. 2010;395:333–40. CrossRef
- Schwarzbach M, Rossner E, Schattenberg T, et al. Effects of a clinical pathway of pulmonary lobectomy and bilobectomy on quality and cost of care. Langenbecks Arch Surg. 2010;395:1139–46. CrossRef
- Schwarzbach M, Hasenberg T, Linke M, et al. Perioperative quality of care is modulated by process management with clinical pathways for fast-track surgery of the colon. Int J Colorectal Dis. 2011;26:1567–75. CrossRef
- Rouse AD, Tripp BL, Shipley S, et al. Meeting the challenge of managed care through clinical pathways for bariatric surgery. Obes Surg. 1998;8:530–4. CrossRef
- Campillo-Soto A, Martin-Lorenzo JG, Liron-Ruiz R, et al. Evaluation of the clinical pathway for laparoscopic bariatric surgery. Obes Surg. 2008;18:395–400. CrossRef
- Frutos MD, Lujan J, Hernandez Q, et al. Clinical pathway for laparoscopic gastric bypass. Obes Surg. 2007;17:1584–7. CrossRef
- Madan AK, Speck KE, Ternovits CA, et al. Outcome of a clinical pathway for discharge within 48 hours after laparoscopic gastric bypass. Am J Surg. 2006;192:399–402. CrossRef
- Yeats M, Wedergren S, Fox N, et al. The use and modification of clinical pathways to achieve specific outcomes in bariatric surgery. Am Surg. 2005;71:152–4.
- Huerta S, Heber D, Sawicki MP, et al. Reduced length of stay by implementation of a clinical pathway for bariatric surgery in an academic health care center. Am Surg. 2001;67:1128–35.
- Cooney RN, Bryant P, Haluck R, et al. The impact of a clinical pathway for gastric bypass surgery on resource utilization. J Surg Res. 2001;98:97–101. CrossRef
- Müller MK, Dedes KJ, Dindo D, et al. Impact of clinical pathways in surgery. Langenbecks Arch Surg. 2009;394:31–9. CrossRef
- Schwenk W. Fast track rehabilitation in visceral surgery. Chirurg. 2009;80:690–701. CrossRef
- Block BM, Liu SS, Rowlingson AJ, et al. Efficacy of postoperative epidural analgesia: a meta-analysis. JAMA. 2003;290:2455–63. CrossRef
- Rawal N, Sjostrand U, Christoffersson E, et al. Comparison of intramuscular and epidural morphine for postoperative analgesia in the grossly obese. Anesth Analg. 1984;63:583–92.
- Nelson R, Edwards S, Tse B. Prophylactic nasogastric decompression after abdominal surgery. Cochrane Database Syst Rev 2007; 18(3):CD004929.
- Saint S, Lipsky BA. Preventing catheter-related bacteriuria: should we? Can we? How? Arch Intern Med. 1999;159:800–8. CrossRef
- Kehlet H, Bundgaard-Nielsen M. Goal-directed perioperative fluid management: why, when, and how? Anesthesiology. 2009;110:453–5. CrossRef
- Kratzing C. Pre-operative nutrition and carbohydrate loading. Proc Nutr Soc. 2011;70:311–5. CrossRef
- Mechanick JI, Kushner RF, Sugerman HJ, et al. American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient. Surg Obes Relat Dis. 2008;4:S109–84. CrossRef
- Kehlet H. Postoperative ileus—an update on preventive techniques. Nat Clin Pract Gastroenterol Hepatol. 2008;5:552–8. CrossRef
- Kehlet H, Dahl JB. Anaesthesia, surgery, and challenges in postoperative recovery. Lancet. 2003;362:1921–8. CrossRef
- Stiller KR, Munday RM. Chest physiotherapy for the surgical patient. Br J Surg. 1992;79:745–9. CrossRef
- Flancbaum L, Belsley S, Drake V, et al. Preoperative nutritional status of patients undergoing Roux-en-Y gastric bypass for morbid obesity. J Gastrointest Surg. 2006;10:1033–7. CrossRef
- Uerlich M, Dahmen A, Tuschy S, et al. Klinische Pfade—Terminologie und Entwicklungsstufen. Periop Med. 2009;1:155–63. CrossRef
- Klevens RM, Edwards JR, Richards CL Jr, et al. Estimating health care-associated infections and deaths in U.S. hospitals, 2002. Public Health Rep. 2007;122:160–6.
- Prentice M. Other end of the bedpan. Nurs Stand. 1995;9:56.
- Anderson E. The bedpan and the commode. Nurs Times. 1978;74:684.
- Schug SA, Raymann A. Postoperative pain management of the obese patient. Best Pract Res Clin Anaesthesiol. 2011;25:73–81. CrossRef
- Lawrence VA, Cornell JE, Smetana GW. Strategies to reduce postoperative pulmonary complications after noncardiothoracic surgery: systematic review for the American College of Physicians. Ann Intern Med. 2006;144:596–608.
- Lemmens L, van ZR, Borel R, I et al. Clinical and organizational content of clinical pathways for digestive surgery: a systematic review. Dig Surg. 2009;26:91–9.
- Rotter T, Kinsman L, James E, et al. Clinical pathways: effects on professional practice, patient outcomes, length of stay and hospital costs. Cochrane Database Syst Rev. 2010;3:CD006632.
- Maessen JM, Dejong CH, Kessels AG, et al. Length of stay: an inappropriate readout of the success of enhanced recovery programs. World J Surg. 2008;32:971–5. CrossRef
- Stellato TA, Hallowell PT, Crouse C, et al. Two-day length of stay following open Roux-En-Y gastric bypass: is it feasible, safe and reasonable? Obes Surg. 2004;14:27–34. CrossRef
- dos Santos MI Jr, Madalosso CA, Palma LA, et al. Hospital discharge in the day following open Roux-en-Y gastric bypass: is it feasible and safe? Obes Surg. 2009;19:281–6. CrossRef
- Clarke A. Why are we trying to reduce length of stay? Evaluation of the costs and benefits of reducing time in hospital must start from the objectives that govern change. Qual Health Care. 1996;5:172–9. CrossRef
- Brown C, Hofer T, Johal A, et al. An epistemology of patient safety research: a framework for study design and interpretation. Part 2. Study design. Qual Saf Health Care. 2008;17:163–9. CrossRef
- Hasan A, Pozzi M, Hamilton JR. New surgical procedures: can we minimise the learning curve? BMJ. 2000;320:171–3. CrossRef
- The Effect of Clinical Pathways for Bariatric Surgery on Perioperative Quality of Care
Volume 22, Issue 5 , pp 732-739
- Cover Date
- Print ISSN
- Online ISSN
- Additional Links
- Clinical pathways
- Bariatric surgery
- Perioperative care
- Quality of care
- Industry Sectors
- Author Affiliations
- 1. Department of Surgery, University Medical Centre Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68135, Mannheim, Germany
- 2. Department of General, Visceral, Vascular, and Thoracic Surgery, Klinikum Frankfurt Höchst, Gotenstrasse 6-8, 65929, Frankfurt am Main, Germany