Optimizing Outcomes After Cleft Palate Repair: Design and Implementation of a Perioperative Clinical Care Pathway
Optimizing Outcomes After Cleft Palate Repair: Design and Implementation of a Perioperative Clinical Care Pathway
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优化腭裂修复后的结果：围手术期临床护理途径的设计和实施
DOI：
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发表时间：
2021
期刊：
影响因子：
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通讯作者：
F. Fraulin
中科院分区：
文献类型：
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作者：
T. Cawthorn;Anna R. Todd;N. Hardcastle;A. Spencer;A. R. Harrop;F. Fraulin
目的：评价腭裂修复术围手术期标准化临床护理路径的实施过程和临床效果。设计图：回顾性分析了在路径实施前接受初次腭裂修复术的患者的病历，作为历史对照组（N = 40）。将历史队列与前瞻性收集的根据路径治疗的患者组（N = 40）进行比较。患者：在三级儿科医院接受初次腭裂修复术的健康、无综合征婴儿。干预措施：通过迭代过程创建了一个新的标准化途径，将文献综述与专家意见以及与机构利益相关者的讨论相结合。该路径在整个围手术期整合了多模式镇痛，包括术中双侧上颌神经阻滞。围手术期方案术前禁食，病例时间，止吐药，静脉输液管理，术后饮食进步标准化。主要结局指标：主要结局包括：（1）住院时间，（2）累积阿片类药物消耗量，（3）术后口服摄入量。结果如下：根据路径治疗的患者平均住院时间较短（31 vs 57小时，P < .001），减少累积吗啡消耗量（77 vs 727 μg/kg，P < .001），开始经口摄入的时间更短（9.3 vs 22小时，P = 0.01），术后前24小时的口服摄入量更大（379 vs 171 mL，P <0.001）。对照组和治疗组之间的总麻醉时间、总手术时间或并发症发生率没有差异。结论：对初次腭裂修复术实施标准化围手术期临床护理路径是安全、可行的，并且与住院时间缩短、阿片类药物消耗减少和术后口服摄入改善相关。
Objective: To evaluate the development process and clinical impact of implementing a standardized perioperative clinical care pathway for cleft palate repair. Design: Medical records of patients undergoing primary cleft palate repair prior to pathway implementation were retrospectively reviewed as a historical control group (N = 40). The historical cohort was compared to a prospectively collected group of patients who were treated according to the pathway (N = 40). Patients: Healthy, nonsyndromic infants undergoing primary cleft palate repair at a tertiary care pediatric hospital. Interventions: A novel, standardized pathway was created through an iterative process, combining literature review with expert opinion and discussions with institutional stakeholders. The pathway integrated multimodal analgesia throughout the perioperative course and included intraoperative bilateral maxillary nerve blocks. Perioperative protocols for preoperative fasting, case timing, antiemetics, intravenous fluid management, and postoperative diet advancement were standardized. Main Outcome Measures: Primary outcomes include: (1) length of hospital stay, (2) cumulative opioid consumption, (3) oral intake postoperatively. Results: Patients treated according to the pathway had shorter mean length of stay (31 vs 57 hours, P < .001), decreased cumulative morphine consumption (77 vs 727 μg/kg, P < .001), shorter time to initiate oral intake (9.3 vs 22 hours, P = .01), and greater volume of oral intake in first 24 hours postoperatively (379 vs 171 mL, P < .001). There were no differences in total anesthesia time, total surgical time, or complication rates between the control and treatment groups. Conclusions: Implementation of a standardized perioperative clinical care pathway for primary cleft palate repair is safe, feasible, and associated with reduced length of stay, reduced opioid consumption, and improved oral intake postoperatively.