Summary

A Clinical Practice Improvement study was conducted at eight West Coast hospitals to determine areas of significant improvement in the management of abdominal surgery patients. Data were collected on over 1,000 patients, and extensive multivariate analyses were performed. Results show that after controlling for disease severity, several treatment variables under provider control were associated with greater increase in severity from admission (first 24 hours) to maximum during the hospital stay, longer length of stay, higher cost, and higher infection rates.

Primary Objectives

1. Improve measurable customer value by optimizing clinical outcomes, service, and price throughout the continuum of care in adult abdominal surgery.
   

2. Reduce rate of occurrence of surgical wound infections.
   

3. Create optimal treatment research-based dynamic protocols.
   

Methods

Data were collected on over 1,000 patients > 18 years old. Study hospitals included a 116-bed rural hospital, a major urban facility serving a high proportion of low-income patients, and a university teaching hospital. Outcomes assessed included length of stay, cost, post-operative infection, and increase in severity of illness from admission (first 24 hours) to maximum during hospital stay. Multivariate analyses were performed on all data.

Results

1. Administering antibiotic prophylaxis within two hours before surgical incision was associated with shorter length of stay.
   

2. Longer anesthesia start to surgical incision time, use of PCA pumps, and use of drains were associated with longer length of stay.
   

3. Longer skin-to-skin and anesthesia start to surgical incision times, not feeding patients within 48 hours of close of surgical incision, and longer time to first activity were associated with increased severity of illness.
   

4. Longer skin-to-skin time and use of PCA pumps were associated with a higher rate of post-operative surgical wound infection.

Impact

At the hospital with the best implementation of the treatment factors associated with better outcomes, length of stay decreased almost 20% (8.1 to 6.5 days) for rectal resection or major small and large bowel procedures, and over 41% (5.45 to 3.2 days) for appendectomy; cost per patient decreased $4,000 for rectal resection or major small and large bowel procedures. Further analyses are in progress.