Vías clínicas en atención primaria / Clinical routes in primary care

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[Clinical pathway for TUR of bladder neoplasms. Analysis of the first 2 years of its implementation]. / Vía clínica para la RTU de neoformaciones vesicales. Análisis de los 2 primeros años de implantación.

OBJECTIVE: To analyze the results of the first two years of application of the clinical pathway for transurethral resection (TUR) of bladder tumors at La Paz University Hospital. METHODS: We developed a clinical pathway of 4 hospital stays (5 days) for TUR of the bladder that included the following: matrix-verification, treatments prescribed, verification of changes, patient information sheet and patient satisfaction questionnaire. The information for the evaluation of the results were obtained from the pathway records and data on the activities of the Urology services. To assess the results for efficiency in the use of resources, the mean duration of hospital stay of patients in the pathway were compared with that of a control group comprised of 50 randomly selected patients submitted to TUR of the bladder in 1997. RESULTS: From June 1998 to May 2000, 481 of the 494 (97.4%) treated patients entered the clinical pathway. CONCLUSIONS: In our experience, the clinical pathway for the urinary bladder is a useful instrument for developing the clinical management of this condition. It reduces the unwanted changes in patient care and hospital stay, carries a low incidence of complications and readmissions, and achieves a high degree of patient satisfaction.

[Design, implementation, and results of the clinical pathway for herniated lumbar disk]. / Diseño, implantación y resultados de la vía clínica para la cirugía de la hernia de disco lumbar.

INTRODUCTION: Clinical or critical pathways are a useful tool in the continuous quality improvement. They develop the main characteristics of the quality programs: implementation of the evidence based medicine, increase staff and patient satisfaction and adequacy in hospital costs. This is the application of evidence-based medicine to a process management and it promotes integration of clinical guides, protocols and algorithms. OBJECTIVE: We present our experience in the design, and first nine month's implementation and development of a clinical pathway for lumbar hemilaminectomy. PATIENTS AND METHODS: This clinical pathway consists on four documents: main guide and check sheet, preprinted treatment orders and variation sheet, iconographic information for the patients and patient satisfaction questionnaire. After desing, development and a pilot study, the hemilaminectomy critical pathway was permanently adopted by our Service. A total of 106 patients underwent programmed lumbar disc hemilaminectomy in our Service between April and December-1999. Patients' average age was 44.7 years (SD = 11.2), 55.3% were men and 43.7% women. Twelve were hospitalized in a ward other than Neurosurgery unit and therefore were excluded from the study. This evaluation is based on the initial results obtained from both the pathway documents and the general data collected as usual during hospital care. The impact of the critical pathway on hospital stay has been assessed by comparing the average stay of critical pathway patients to the average of the 70 hemilaminectomies performed at our Service in the period April-December 1998. RESULTS: Clinical pathway coverage has been 68% (standard > 80%). The patients' average stay was 4 days (SD = 1.1), one day more than planned. The pathway establishes a 4 day hospital stay (3 bed-days), a time that was fulfilled by 49% of the patients. The average stay of the 1998 patients was 5.6 days (SD = 2.7), 1.6 days more than the clinical pathway patients (p < 0.0001). Additionally, undesirable variability in the length of hospital stays was also reduced. Analysis of variations identified those corresponding to patient's condition, increases in medication beyond that originally specified due to patient needs, and unjustified prolonged stays. There were no systematic variations. There was a 2.2% incidence of adverse effects. Although satisfaction questionnaire was only returned by 51% of the patients (instead of > 70%), satisfaction index were 93% (vs 90%). CONCLUSIONS: Critical pathways are still under development and changing continuously. Nevertheless their impact on improving patient care and satisfaction, and resource consumption is already evident, and it constitutes a major aim to work in its complete development.

[Development of a clinical pathway for radical prostatectomy]. / Implantación de una vía clínica para la prostatectomía radical.

OBJECTIVE: To describe the clinical care path for retropubic radical prostatectomy of the La Paz teaching hospital and the results achieved after the first 6 months. METHODS: We have developed a clinical care path for radical prostatectomy with a hospital stay of 6 days. Thirty-one patients submitted to retropubic radical prostatectomy from June to November 1998 were included in the program. The mean length of total, preoperative and postoperative stay were analyzed and compared with those of 31 patients who had undergone radical prostatectomy before the program was developed. Readmissions, adverse effects and patient satisfaction were also analyzed. RESULTS: Of the 31 patients included in the clinical care path, 22 (71%) had a stay equal to or less than the program's length of stay. The mean total, pre and postoperative stay for the group of patients included in the clinical care path were 6.0 days (SD = 1.1), 1 day (SD = 0.0) and 4.9 days (SD = 1.1), respectively. The length of stay was significantly longer before the program was developed [mean total 10.2 days (SD = 4.9), mean preoperative 2.6 days (SD = 2.6) and mean postoperative 7.6 days (SD = 3.6)] (p < 0.001). Twenty-four patients (77.4%) completed the questionnaire on patient satisfaction, which was highly positive, the overall patient satisfaction rate being higher than the 90% standard. There were no readmissions or significant events ascribable to the program. CONCLUSIONS: In our experience, the clinical care path for radical prostatectomy is a useful tool to reduce the unwanted variability. Its design is based on the best possible evidence, therefore the scientific and technical quality, patient satisfaction and efficiency are enhanced. In our view, our results are attainable and feasible in any health care setting.