Environmental impact of accelerated clinical care in a high-volume center.
BACKGROUND
"Fast-track" surgery, involving multimodal care, improves efficiency and short-term outcomes in patients undergoing bowel resection. The sustainability of the benefits and the "drag" effect on non-participating surgeons through changed nursing and resident practice is undetermined.


METHODS
297 consecutive elective colon resections (DRG149) within three study periods (pre-change, immediate post-change, long-term post-change) were retrospectively reviewed. Two surgeons began to "fast-track" their patients in 1999 independently from the other surgeons in the hospital. Surgeons were grouped into "fast-track surgeons," "high-volume surgeons," (>/=10 cases per year) and "low-volume surgeons," (<10 cases per year). Comparisons of duration of stay (DOS), readmission rates, and mortality were made for each of three time periods and surgeon groups. Trends were also compared with unrelated hospital non-colectomy control groups (uncomplicated craniotomy DRG 001 and pancreatic surgery DRG 192) and to a colectomy control group from a statewide database (DRG 149).


RESULTS
Mean DOS for colon resection significantly decreased among the "fast-track" surgeons and among all the other surgeons in the hospital, from 6.3 +/- 0.3 days, down to 3.7 +/- 0.1 days. We found no significant difference in mortality or readmission rates between the study periods. 15% of the cases were performed laparoscopically, and the improvements in outcome were independent of surgical technique. Control group analyses demonstrated that the environmental impact on outcome was independent of hospital-wide or regional improvement efforts.


CONCLUSIONS
Implementation of a new practice pattern in a shared environment leads to improved outcomes for patients of other surgeons within the same environment. Dissemination and cross-pollination of new methods through resident, nurse, and case manager practice pattern modification creates a favorable force for change and this impact is sustained over a 3-year period.
Sailhamer
Elizabeth A
EA
Department of Surgery, Massachusetts General Hospital, Boston, MA, USA.
Sokal
Suzanne M
SM
Chang
Yuchiao
Y
Rattner
David W
DW
Berger
David L
DL
D000328:Adult; D000368:Aged; D013505:Digestive System Surgical Procedures / Q000009:adverse effects / Q000379:methods / Q000639:trends*; D004434:Early Ambulation / Q000009:adverse effects / Q000639:trends*; D005260:Female; D006761:Hospitals / Q000706:statistics & numerical data; D006801:Humans; D015994:Incidence; D033181:Information Dissemination; D033183:Interdisciplinary Communication; D010535:Laparoscopy / Q000009:adverse effects / Q000379:methods / Q000639:trends; D007902:Length of Stay / Q000639:trends; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D010359:Patient Readmission / Q000706:statistics & numerical data; D011183:Postoperative Complications / Q000209:etiology; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data / Q000639:trends*; D012044:Regression Analysis; D012189:Retrospective Studies