围术期患者之家：评估以多学科为重点来管理后路脊柱融合手术儿童的新方案
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Perioperative Surgical Home: Evaluation of a New Protocol Focused on a Multidisciplinary Approach to Manage Children Undergoing Posterior Spinal Fusion Operation
背景与目的
围术期患者之家的概念在手术中心一直备受关注。该模式以成本高效的方式提供并改善了接受手术的患者的协作治疗，贯穿了从制定手术方案到术中、术后再到长期康复的过程。对结果反复评估和修改为方案的改进提供了反馈。洛杉矶儿童医院于2014年6月提出了一项新方案，用于管理接受后路脊柱融合术（PSF）的患儿，目的在于改善患者的住院经历，降低住院时间和费用。
方 法
采用回顾性图表分析确定了一个由麻醉医师、外科医师、护士和物理治疗师组成的团队为脊柱侧弯的患者接受PSF实施新的治疗方案之前和之后的情况。新方案包括了术前对患儿及父母的讲解，术中麻醉和手术的管理知道长期的术后医疗管理。除了人口统计，我们还研究了患儿的住院时间、住院费用、出院疼痛评分、患者自控镇痛的使用时间、开始摄入固体食物的时间已经下床行走的时间。
结 果
63名患者开始或已经实施了该方案（总n=72）。患者的年龄、性别、静脉使用吗啡量或预计失血量之间没有明显差异。纳入新方案的患者具有较高的美国麻醉师学会分级（P=.003），患者控制镇痛使用的持续时间、开始摄入固体食物和行走显著降低（P=.001）。出院时疼痛评分较高，但差异无统计学意义。新方案组的住院时间明显缩短（P = 0.001），住院费用节省了292,560美元。
结 论
这些数据显示，不同团队合作为接受PSF的患者制定出的新管理方案可明显降低住院时间和住院费用，但不改变护理质量。
原始文献摘要
Eugene Kim, Brian Lee, and Giovanni Cucchiaro,Perioperative Surgical Home: Evaluation of a New Protocol Focused on a Multidisciplinary Approach to Manage Children Undergoing Posterior Spinal Fusion Operation.Anesth Analg. 2017 Sep;125(3):812-819.
BACKGROUND: The concept of Perioperative Surgical Home has been gaining signifcant attention in surgical centers. This model is delivering and improving coordinated care in a costeffective manner to patients undergoing surgical procedures. It starts with the decision for surgical intervention, continues to the intraoperative and postoperative periods, and follows into long-term recovery. Constant re-evaluation of outcomes and modifcations of delivery provides a feedback loop for improvement. Children’s Hospital Los Angeles initiated a new protocol in June 2014 to manage children undergoing Posterior Spinal Fusion (PSF) with the goal to improve patient experience and lower the hospital length of stay and cost.
METHODS:A retrospective chart review identifed patients who underwent a PSF for idiopathic scoliosis before and after initiation of a new treatment protocol designed by a team of anesthesiologists, surgeons, nurses, and physical therapists. The new protocol included preoperative teaching of parents and patients, intraoperative anesthetic and surgical management, and immediate to long-term postoperative medical management. In addition to demographics, we examined length of stay, cost of hospitalization, pain scores on discharge, length of patientcontrolled analgesia use, time to frst solid food intake, and time to ambulation.
RESULTS: Thirty-six patients were identifed preinitiation and postinitiation of the protocol (total n = 72). There was no statistically signifcant difference in age, sex, use of intrathecal morphine, or estimated blood loss. Patients enrolled in the new protocol had higher American Society of Anesthesiologists classifcation (P = .003), signifcantly lower duration of patient-controlled analgesia use, time to frst solid food intake, and time to ambulation (P = .001). The pain scores were higher at the time of discharge, although the difference was not statistically signifcant. Length of stay was signifcantly shorter in the new protocol group (P = .001), accounting for $292,560 in cost savings for the hospital.
CONCLUSIONS: These data show that the cooperation of different teams in designing new management guidelines for patients requiring a PSF can signifcantly decrease the total length of stay and cost of hospitalization without altering quality of care. (Anesth Analg 2017;XXX:00–00)
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