Is it safe to have major surgery performed in the PRIVATE sector?
A consultant lead integrated care pathway in the private sector allows
for an earlier and safe discharge. A comparison of 300 laparoscopic colonic resections
Dalton SJ, Ghosh AK,
Greenslade GL*, Dixon AR.
Departments of Colorectal
Surgery and Anaesthesia*
SPIRE Bristol Hospital
& North Bristol NHS Hospital Trust, Bristol, UK
Objective: The aim of this cohort study was to compare immediate outcomes of
patients undergoing laparoscopic colonic resection performed by a single
surgeon and anaesthetist in NHS and private hospital settings.
Methods: A prospective electronic database of all colorectal laparoscopic
procedures between April 2001 and September 2008 was used to identify outcomes
of patients undergoing laparoscopic resection with anastomosis. Two groups of 150 patients were
compared: NHS and private patients (PP).
Groups were matched for indication of surgery, age, ASA grade, cancer T
stage and operation. Patients with
social delays were excluded. The
only difference was the insitution, its care pathway and its implementation.
Results: No difference was demonstrated in age, mean 64.5 (19-93) or ASA grade
between groups. Indications for
surgery were: cancer NHS (83), PP (75), diverticular disease NHS (42), PP (51),
inflammatory bowel disease NHS (20), PP (16) and other NHS (5), PP (8). Operative time was significantly longer
in the NHS group, 118min (95%CI 110-125) compared to the PP group 103min (95%CI
94-111) (p<0.01). Postoperative
stay in the NHS was significantly longer, mean 5.8 median 5 days (95%CI
5.1-6.5) compared to a mean 3.1 and median of 3 days (95%CI 2.7-3.6)
(p<0.01). Total number of bed
days was 851 (NHS) and 452 (PP).
No differences in 30-day mortality, surgery specific complication and
readmission rates (5.3%) were demonstrated. Infections developed in 12 NHS patients (one fatal) and two
PP (?2 test =6.83; 1 df, p=0.009).
Two PP patients were transferred to NHS for critical care support.
Discussion: Clinical pathways improve outcome by providing a mechanism to coordinate care and so reduce fragmentation and costs. Our results
demonstrate that it
is possible to achieve these goals in the private setting. Although controversial, a consultant
directed pathway has a positive impact on efficiency and quality. The challenge is to achieve this in the
Key Words; Laparoscopic
colorectal surgery, ERAS, Integrated Care Pathways, NHS and private care
cancer is the third commonest malignancy in the UK1 and surgery remains the mainstay of treatment; open surgery remaining
by far the most common method for resection 2. The uptake of laparoscopic surgery has been slow, largely through
concerns about its oncological safety3 and the long and technically demanding learning curve4 5, 6. The results of large long-term
randomized trials of laparoscopic surgery for colorectal cancer have
demonstrated that it is not only an acceptable alternative to open resection7, 8 but it brings added
short-term clinically relevant benefits9-11. NICE updated its guidance in 2006 in
favour of NHS Trusts providing patients the option of laparoscopic resection as
an alternative to open surgery12. Laparoscopic
surgery results in reduced pain,13 nausea and vomiting14, earlier return of gut function14, 15, earlier discharge, a
demonstrable reduction in infection16, 17 and minimal cost
years there has been a paradigm shift in the management of patients undergoing
colonic surgery; from remaining in hospital until the likelihood of
complications had passed, to early mobilisation and discharge with community
support and readmission should any post operative complications develop. The shift to early mobilisation and
discharge has been championed as ‘Enhanced Recovery After Surgery’ (ERAS)
protocols20; with multimodal clinical pathways to accelerate recovery after colonic
resection. ERAS was first
described in open surgery and showed an impressive reduction in both
postoperative stay20 and complication rates21. Its multifaceted approach
has also been shown to enhance recovery post laparoscopic colorectal surgery11; length of stay for major colonic resection has been reduced to 23
hours in appropriately selected and supported patients 22,23. However, a
recent multi centre trial concluded that an ERAS protocol is not enough in
itself to enable discharge of patients on the day of functional recovery and
that more experience and better organization of care may be required24. Some authors have questioned whether
ERAS protocols actually result in a shorter recovery period or whether the
reduced length of stay simply reflects improved organisation of care25.
Patient Care Pathways (ICP) have been shown to streamline patient care27. However, in many hospitals the addition of such pathways has amounted to
little more than introducing unwelcome paperwork without a demonstrable
improvement in patient care. We
hypothesize that the role of the operating consultant and anaesthetist in
constructing and refining the whole patient pathway and their relationship with
like-minded nurses is key to the effective running of an ICP and a positive
The aim of
this study was to compare the outcome measures of matched patient groups
undergoing laparoscopic resectional surgery in two settings - NHS and
private. Multimodal care pathways
were established in each place of work.
Both senior authors championed and encouraged ERAS in both hospital
settings. The NHS pathway was
driven by hospital protocol and delivered by the junior surgical (with regular
consultant input) and nursing staff.
In the private setting it was directly consultant led. Outcome measures were duration of
surgery, length of stay, complication and readmission rates.
prospectively collected, institutionally approved password protected electronic
database of all elective colorectal laparoscopic procedures between April 2001
and September 2008 was used to identify patient outcomes. All patients undergoing elective
laparoscopic resection with anastomosis under the care of the senior authors
were eligible for inclusion. Two
groups were compared: 150 operated upon in an NHS hospital and 150 who had
their surgery carried out in a private institution. Groups were matched for
age, ASA grade, indication, cancer T stage, operative procedure and year of
surgery. There were no specific
exclusion criteria for offering a laparoscopic approach or declining a wish to
have the surgery carried out in a private institution. Patients with delayed discharge for
social reasons were excluded from the study.
endpoint of the trial was length of stay; secondary endpoints were complication
and readmission rates. Matching was performed from the full prospective
database with the researcher performing the matching blinded to the outcome
data. Instat prism software® was
used to test normality of data and to perform analysis. Differences between percentages in
contingency tables were evaluated by the Pearson ?2 test or Fisher’s exact
probability test. Differences between means of normally distributed variables
were assessed by the t test and the Mann Whitney test was used for
non-normal data. The sample size
of 150 patients per group gives an 80% power to detect a significant difference
of 0.05 between groups. The
patients’ data were held on a Microsoft Excel database (Microsoft ®
Corporation, Redmond, Washington, USA).
underwent nurse lead pre-operative assessment with investigations limited in
the PP setting to those requested by the consultant. Unexpected abnormal results from PP patients were fed back
to and discussed directly with the supervising consultant. NHS pre-assessment clinics followed
Trust protocols and the supervising junior doctor managed any queries. PPs were admitted (booked admission for
a defined number of days with posted orders) two hours prior to surgery (Friday
morning) having been asked to fast for 6hrs and drink water up to admission;
each received a two phosphate enema bowel prep (administered by a senior nurse)
and 400mls of a carbohydrate pre-load drink. The NHS group were admitted the Monday afternoon prior to
surgery, “clerked” by a junior doctor and prescribed similar bowel preparation
(early evening) and fasted from midnight.
PP patients anticipated to need a covering stoma were seen at home by an
independent stoma nurse; NHS patients were seen on the ward and often on the
morning of surgery.
institution provided a dedicated and fully trained laparoscopic theatre
team. Operative procedure and
anaesthetic technique were identical between groups; all received antibiotic
and thrombo-embolic prophylaxis and were kept normothermic throughout. Anaesthesia comprised short
acting volatile agents. Epidurals were not used. Peri-operative analgesia evolved through the study period
from PCA systems, IV paracetamol plus oral analgesia, through to bilateral
0.375% bupivacaine transabdominalis plane blocks24 (TAP-block)
supplemented with short acting opioids, paracetamol and a single dose of
intravenous NSAID. This was
supplemented as necessary in the recovery ward by aliquots of short duration
intravenous opioids. PPs
were offered a cup of tea/biscuit/toast in the recovery ward by the
analgesia was provided by multimodal oral analgesia. Paracetamol was always administered as an intravenous infusion
in the private institution.
trauma was minimised by using three laparoscopic ports and extracting the
specimen through the already incised umbilicus. Drains were not used routinely and urinary catheters were
removed in theatre (excluding full rectal resections).
allowed diet as tolerated and encouraged to mobilise. PPs were offered light snacks and meals at scheduled times
throughout the day. Ward staff
were encouraged to offer NHS patients a light snack on the evening of surgery
and toast the next morning. All
nursing concerns (PPs) were directed to the appropriate consultant. The
supervising surgeon and anaesthetist visited the PPs twice daily; documentation
was made in the ICP notes and any decisions conveyed to the accompanying senior
nurse. Drips, drains catheters etc
were removed at the time of asking.
NHS patients were seen on daily junior Dr - nurse in charge ward
rounds. PP stoma patients were
visited once or twice on the ward followed by two or three times at home. All NHS stoma care was conducted on an
inpatient basis. Patients were
discharged when it was considered appropriate.
colorectal resections with anastomosis were performed; 150 in each study
group. Demographics in the two
patient groups were well matched, the mean age was 66.9, (range 26-91). There were 67 men in the NHS group and
45 in the PP group. The mean ASA
was 2.01 in the NHS group and 2.01 in the PP group (Table 1). The mean BMI in the NHS group was 26.3
(range 14-44) and 27 (range 16-55) for the PPs.
for surgery comprised; cancer NHS (83), PP (75), complicated diverticular
disease NHS (42), PP (51), inflammatory bowel disease NHS (20), PP (16). The final cancer T-stage was T1 (10),
T2 (22), T3 (64), T4 (12) in the PP group and T1 (12), T2 (21), T3 (56), T4
(17) in the NHS group. The average nodal yield for cancer was 15.4 (NHS) and 16
operations comprised 31 TME rectal resections (9 with covering ileostomies), 82
high anterior resections, 11 extended right hemicolectomies or segmental
resections and 31 right hemicolectomies.
In the PP group there were 31 TME rectal resections (11 with covering
ileostomies), 69 high anterior resections, 9 extended right hemicolectomies or
segmental resections and 41 right hemicolectomies. Operative/anaesthetic time was significantly longer in the
NHS group 118min (95%CI 110-125) compared to the PP group 103min (95%CI 94-111)
conversion was defined as ‘an unplanned incision or extension of an incision’;
three (2%) were necessary in both groups.
23% of NHS patients and 17% of the PP group had a complication. Two leaks in the NHS group and three in
the PP group required surgical intervention; two PPs required hospital transfer
and NHS ITU support. Complications
arising within the NHS comprised ileus (4), wound infection (7), retention of
urine (3), cardiac (3), c-difficile
colitis (1), chest (1), phlebitis (1), UTI (2) cf the PP group - retention of urine (5), chest infection (1) wound
(1) and cardiac (1). Infections
were seen in 12 NHS patients and two PPs (?2 test =6.83; 1 df, p=0.009). The 30-day mortality was 4 (2.7%)
in the NHS group (leak, MI, respiratory failure and c-difficile colitis) and one (0.7%) in the PP group (followed a
stay in the NHS was significantly longer - mean 5.8, median 5 days (95%CI
5.1-6.5) compared to a mean 3.1 and median of 3 days (95%CI 2.7-3.6)
(p<0.01). PPs were admitted within
two hours of surgery whilst the NHS patients were admitted the afternoon before
hand. The total number of bed days used was 851 (NHS) and 452 (PP). There were 8 (5.3%) readmissions in both groups.
Integrated care pathways (ICPs) are structured
multidisciplinary care plans
which detail essential steps in the care of patients with a
specific clinical problem and have been proposed as a way of
encouraging the translation of national evidence-based guidelines from a clinical and nursing practice
viewpoint into local protocols and their
application to clinical practice. They have the potential to improve continuity
of patient care. From the
patients' perspective there is evidence that ICPs by defining the patient
journey improves patients’ confidence and understanding of the treatment they
are about to receive27.
ICPs also improve data collection, as they require
each participant to keep good records.
This allows for easier abstraction of clinical data and audit with the
potential for promoting change. It
is also useful medico-legally.
However, for them to be effective requires that they are implemented and
used and then revised in the light of experience. Whilst standardisation of care can improve patient outcome,
guidelines developed by “experts” often fail to consider the views
of the many professionals caring for individual patients and the realities of
the local institution(s). Failure
to consider local facilities and resources coupled with consultation and
education makes local acceptance and implementation unlikely.
?When working they can improve team communication and overall patient-staff
interaction, allowing increased autonomy and possibly reduced bureaucracy. Unless the staff are engaged and
empowered to suggest refinements the ICP is likely to gather dust rather than
treatment of common high cost procedures such as a laparoscopic colorectal
resection allows increased accuracy in planning patient stay and prediction of
bed and theatre requirements. This in turn improves cost estimation, resource
management and budget planning. In the private sector cost and efficiency translate to the “bottom
line”. Reduction in hospital bed
utilisation is a key factor in controlling spiralling costs28 and
the length of stay can be used as a surrogate for hospital efficiency29,30. Early and appropriate post-operative
discharge not only improves bed utilisation29and reduces the numbers
of nosocomial infections31 - it is also preferred by patients32. Most surgical ICPs, when implemented, reduce hospital stay with
associated cost savings and without any detrimental impact on patient care33-35.
et al showed significant variation in
post operative length of stay for comparable patients managed in different
private hospitals29 and Ham et (REF) al demonstrated improved bed
utilisation in the Californian Medicare system when compared to the NHS31.
?No such studies have
looked at matched patient groups in the UK. We have demonstrated a significant decrease in the length of
stay of matched patients undergoing laparoscopic colorectal resections in the
private as compared to the NHS setting. In this study patients in the PP group were admitted on the day of
surgery and those in the NHS hospital the night before, though this would by
definition result in a reduction in overall length of stay it does not explain
the magnitude of the difference (851 vs 452). Even taking this into account, the reduction in the length
of stay remains statistically significant.
The reason for
this observed reduction in length of stay within the private setting is likely
to be multifactorial, but the role of the operating consultant and anaesthetist
in providing continuity of post operative care and their interaction with
senior nursing staff is central, as is their combined interaction with the
patient and the resultant effect on the expectation of the patient. In the private setting, patient
expectation is all in the hands of the senior clinicians through their
provision of pre-operative information (verbal and written), defined
planned/booked period of admission etc., whereas in the NHS it comes from
several sources, each providing an opportunity for potential conflict. Integrated care pathways were
established in both the PP and NHS settings of this study. However, in the NHS it was the junior
surgical and nursing staff that directed patient progression along the pathway
up to and including discharge. In
a recent multi centre trial, Matheson et
al., concluded that a protocol is not enough to enable discharge of
patients on the day of functional recovery and that more experience and better
organization of care may be required24. In this study we believe that we have demonstrated the clear
advantage of a consultant directed integrated care pathway. The implementation of the EWTD in
August 2009 has the potential to further worsen the situation for NHS patients
with further erosion of the surgical unit’s ability to provide continuity of
care and professional responsibility.
NHS Trusts observe! ICPs should not be
considered a means of laying down strict guidelines, which have the potential
to constrain surgeons and stifle individual clinical assessment and skill, but rather
allow for formal documentation of what is already, informally, accepted as best
practice. This provides a
framework within which care can be changed in an evidence-based fashion rather
than anecdotally. The individual surgeon
has a central role in fashioning the type of care that they wish to provide,
acknowledging international best practice. When this works it allows management and clinicians a
framework within which to plan service delivery. By clinically defining these parameters, the surgeon creates
and controls care with their patient at the centre and with optimisation of care
been upheld at the forefront. Surgeons
have a duty and a responsibility to be instrumental in the design and
implementation of ICPs and so allow the development of a quality driven service
where audit occurs regularly and results are open for review.
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