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Imagine nephrectomy patients having surgery one day and going home the next. It can and is being done at Vanderbilt University Medical Center in Nashville, TN, thanks to the work of Elspeth McDougall, MD. McDougall joined the urology faculty at Vanderbilt, bringing with her eight years of experience working with one of the well-known pioneers in laparoscopic urology and, therefore, new clinical pathways for urologic surgeries including nephrectomy, cyst decortication (polycystic kidney disease or other cysts that need treatment), pyeloplasty, and pelvic lymph node dissections.
Bringing this kind of surgery into common practice is very cutting-edge, says clinical coordinator Sonya Moore, RN, BSN, CDE. "People refer to us from all across the Southeast because there aren’t many urologists who perform surgery laparoscopically," she says. With the nephrectomy pathway, Vanderbilt has seen a distinct improvement in patient outcomes, Moore says. "We can just see from [McDougall’s] 18 months here that there’s no doubt these patients are much different; they get back to activity quicker, return to their normal diet, and go home faster than our open patients." Average length of stay (LOS) with the open nephrectomy was four days, she adds. (To see home care instructions, click here.)
The pathway calls for preoperative work, including lab work, EKGs, and chest X-rays if they are indicated, and of course, take-home patient education about the minimally invasive procedure. Its postoperative goals include ambulation and fluids by mouth within 24 hours, and oral analgesic immediately following surgery. (To see pathway, click here.)
Although aggregate data are not yet available for the new pathway (the department’s data collection systems are in the process of being revised), individual patient data show specific improvements in ambulation, Moore says. "We like to get them up walking the evening of the surgery, which is a big difference from the open procedure. Probably at least 90% [of laparoscopy patients] are ambulating by breakfast the next morning, if not the evening of surgery," she explains.
Diet is not as negatively affected by the laparoscopy as by the open procedure, because the bowels aren’t manipulated during surgery. "Even though they’ve had general anesthesia, which can cause some nausea, the bowels return to work faster," Moore notes. That means a speedy return to a regular diet: clear liquids by the evening of surgery, and usually a regular breakfast by next day, she says. In fact, Moore notes, "It can be even better, depending on the approach. For example, if the laparoscope goes in retroperitoneally, rather than from the abdomen, and the patients have the surgery first thing in the morning, they’re eating Big Macs for dinner and ready to go home. Of course, we don’t let them go until the next morning."
The laparoscopic nephrectomy pathway typically improves patient pain, as well, Moore explains. "Most open patients come out of surgery with a patient-controlled analgesic (PCA) pump, and they may have it up to 24 hours before they get put on oral pain relief. Our [laparoscopy] patients do not have a PCA pump and usually are relieved with oral pain pills," she says.
"Of course, intravenous pain medication is ordered if they need it, but usually by post-op day one, they’re on pain pills, which means that a minimum of 90% of our laparoscopic patients go home on or before day two, and at least a good 75% of them go home on post-op day one, Moore adds. "They truly can have a kidney out today and go home tomorrow," she says.
The only length of time that is increased with the laparoscopy pathway can be actual surgery time, which probably causes a higher operating cost, she notes. The technology involved also plays a part in the cost to the hospital, but Vanderbilt "made a commitment to being a leader in the field of minimally invasive surgery," Moore says, and so cost wasn’t really an issue when this program was implemented.
"It’s more about patient quality of life. I’m sure eventually, because length of stay is shortened and the need for IV antibiotics reduced, it will save money," she points out. Meanwhile, "We’re doing continuous quality improvement and data collection on every single patient so we can continue to fine-tune the pathway and make changes as we identify them," Moore stresses.
And staff education is an ongoing process. "We have periodic inservices with the floor nurses, with respect to what to expect with the pathway,’ the necessary radiology procedures, expected discharge, and that type of thing. We want to make sure people keep apprised of what the different procedures call for," she says. "The goal of any pathway is to increase efficiency while maintaining quality," Moore adds.
With this procedure, Vanderbilt has shortened LOS, and therefore lowered costs and resource utilization. Most important, patients achieve faster pain control, return to work, and quality of life, she says.
[For more information, contact:
• Sonya Moore, RN, BSN, CDE, Clinical Coordinator, Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, TN 37232. Telephone: (615) 923-8788.]
Hospital Case Management welcomes guest columns about clinical path development and use. Articles should include any results (length of stay, cost, or process improvements) that use of your pathway has helped achieve and should be from 800 to 1,200 words long. Send your article submissions to: Editor, Hospital Case Management, P.O. Box 740056, Atlanta, GA 30374. Telephone: (404) 262-5460. Fax: (404) 262-5447.