[Care Process Improvement in Total Knee Arthroplasty Using the Concept of Patient Flow].

BACKGROUND & PROBLEM: Improving the process of care may effectively improve the quality of medical care and increase patient satisfaction. An investigation found that the process of care used in our unit was imperfect, resulting in a low preoperative enrollment rate of case managers, overly long patient waiting times for ward assignment, insufficient pre-operative knowledge, and high cancellation rates for routine operations. PURPOSE: The aim of this project was to review the overall process of care using the concept of patient flow to improve and formulate countermeasures to improve quality of care. RESOLUTION: To improve the process of care, the corresponding countermeasures were formulated. 1. Set criteria for enrollment for orthopedic case managers to increase the preoperative enrollment rate; 2. Set up a specialized arthroplasty care area for central case management to reduce the time patients need to wait for the ward; and 3. Improve patient compliance with preoperative education and reduce the operation cancellation rate by distributing patient education pamphlets, filming videos of pre-operative instructions, facilitating home environment preparation, and providing education on sterilization baths. RESULTS: After implementation of the countermeasures, the preoperative case manager enrollment rate increased from 27.8% to 84.6%; the average ward wait time for patients reduced from 73 to 41 minutes; compliance with patient education increased from 83.0% to 100%; and the operation cancellation rate reduced from 11.1% to 0%. CONCLUSIONS: This project used the concept of patient flow to review the care process used for total knee arthroplasty. This improvement strategy may be used to standardize care processes and improve the quality of medical care provided.

Perioperative complications and Intensive Care Unit utilization in super-superobese patients undergoing laparoscopic bariatric surgery.

OBJECTIVE: Anesthetic management for super-superobese (SSO) patients (body mass index [BMI] ≥60 kg/m2) presents a challenge for anesthesiologists. This study aimed at characterizing the early complications and Intensive Care Unit (ICU) utilization in SSO patients receiving laparoscopic bariatric surgery. MATERIALS AND METHODS: Totally, 25 SSO patients receiving laparoscopic bariatric surgery between June 2006 and December 2011 were reviewed. The data collected included patient demographics, preoperative comorbidities, anesthetic techniques, airway management, perioperative adverse events, ICU utilization, and early complications occurring within 30 days of index surgery. Early complications were defined as the adverse events that led to permanent detrimental effects or required significant additional intervention. RESULTS: A retrospective analysis was performed on data from 25 consecutive SSO patients (age: 31.2 ± 11.1 years; BMI: 64.9 ± 4.7 kg/m2). Tracheal intubation was attempted successfully in all patients but was difficult in two cases when using laryngoscopy. Bronchospasm was observed in five cases (20%) after tracheal intubation. Postoperative ICU utilization was required in five cases (20%). Early complications occurred in two cases during their stay in postanesthesia care unit (including one case of respiratory failure and one case of hyperkalemia) and in two cases during their stay in ICU (both with respiratory failure). The incidence of early complications was 16%. All patients were discharged from the hospital without sequelae. CONCLUSIONS: It is imperative to anticipate the potential for developing perioperative adverse events and postoperative complications in SSO patients after bariatric surgery. Appropriate utilization of ICU resources may enhance patient safety.