Impact of clinical pathways in surgery.

BACKGROUND: One strategy to reduce the consumption of resources associated to specific procedures is to utilize clinical pathways, in which surgical care is standardized and preset by determination of perioperative in-hospital processes. The aim of this prospective study was to establish the impact of clinical pathways on costs, complication rates, and nursing activities. METHOD: Data was prospectively collected for 171 consecutive patients undergoing laparoscopic cholecystectomy (n = 50), open herniorrhaphy (n = 56), and laparoscopic Roux-en-Y gastric bypass (n = 65). RESULTS: Clinical pathways reduced the postoperative hospital stay by 28% from a mean of 6.1 to 4.4 days (p < 0.001), while the 30-day readmission rate remained unchanged (0.5% vs. 0.45%). Total mean costs per case were reduced by 25% from euro 6,390 to euro 4,800 (p < 0.001). Costs for diagnostic tests were reduced by 33% (p < 0.001). Nursing hours decreased, reducing nursing costs by 24% from euro 1,810 to euro 1,374 (p < 0.001). A trend was noted for lower postoperative complication rates in the clinical pathway group (7% vs. 14%, p = 0.07). CONCLUSIONS: This study demonstrates clinically and economically relevant benefits for the utilization of clinical pathways with a reduction in use of all resource types, without any negative impact on the rate of complications or re-hospitalization.

Impact of inguinal hernia repair on family and other informal caregivers.

HYPOTHESIS: Inguinal hernia significantly affects family and other informal caregivers, and hernia repair will significantly reduce caregiver burden. METHODS: We analyzed data from a Veterans Affairs Cooperative Study with mixed models to compare the level of burden among caregivers of inguinal hernia patients from preoperative measurement to measurement at 2 weeks and at 3 months postoperatively. RESULTS: Most caregivers were wives (73%) and lived with the patients (88%). There were no differences in caregiver burden by type of treatment. The time caregivers spent assisting patients increased significantly over the 2 weeks following treatment (odds ratio, 4.34). In contrast, 3 months after treatment, caregivers reported spending less time on additional chores than before treatment (odds ratio, 0.12). Furthermore, caregivers' concerns about patients' abilities to perform normal household activities decreased by 2 weeks posttreatment (odds ratio, 0.52). Wives/girlfriends and caregivers of patients with complications were more likely to report these concerns. CONCLUSIONS: Inguinal hernia and its repair significantly affect informal caregivers. Caregivers assumed the heaviest time and effort-related burden 2 weeks following hernia repair and expended additional effort if the patient experienced complications. Interventions should reflect when burden is greatest and target the subgroups of caregivers who most need support.

A prospective study of 1000 hernias: results of the Plymouth Hernia Service.

BACKGROUND: A hernia service within a general hospital was prospectively evaluated to establish whether evidence-based protocols could deliver results comparable to those reported from specialist hernia clinics. METHODS: Protocols were devised according to established models. With the support of a nurse specialist, 1015 patients with inguinal hernia were treated. Quality-of-life analysis was undertaken using the Short Form 36. RESULTS: Patients ranged in age from 16-98 years (median, 56 years). Ambulatory day-case surgery was achieved in 820 patients (81%), with local anaesthesia in 891 (88%). Wound infection occurred in 10 patients (0.98%). Wound haematoma requiring surgical intervention occurred in three patients. Two patients formed wound seromas that settled spontaneously. One patient developed ischaemic orchitis resulting in testicular atrophy. At 5 days after operation, 91% of patients had returned to normal activity. At 1 year, 7 patients (0.7%) had pain sufficient to limit normal activity or employment. There were 8 recurrences (0.78%) at a median follow-up of 2.5 years. Quality-of-life was enhanced at 1 year postoperatively. CONCLUSION: A protocol-driven hernia service within a general hospital can provide patient outcomes comparable to specialist hernia clinics.

Umbilical hernia, inguinal hernias, and hydroceles in children: diagnostic clues for optimal patient management.

The assessment of pediatric patients with a possible umbilical hernia, inguinal hernias, or hydroceles can often be problematic for the pediatric nurse practitioner. Understanding the embryologic processes related to these conditions may increase the diagnostic capabilities of the practitioner. Clues to assist in the differential diagnosis and current treatment modalities will be offered. Tips for parental guidance related to these conditions will enhance the team approach to effective referrals and optimal treatment of the children in this clinical population.

Laparoscopic inguinal herniorrhaphy.

Recent advances in laparoscopic techniques present a promising approach to the surgical treatment of inguinal hernias. Higher success rates, better cosmetic results, less pain, and shorter postoperative recovery periods have precipitated an increased consumer demand for laparoscopic rather than traditional herniorrhaphy. The transabdominal, preperitoneal laparoscopic procedure presents a promising approach to successful inguinal hernia repair. Perioperative nurses should be aware of the direct correlation between laparoscopic success rates and surgical team members' training and experience. Adequate preparation and current knowledge promote optimal patient outcomes.

Laparoscopic extraperitoneal herniorrhaphy.

Laparoscopic extraperitoneal (LEP) herniorrhaphy procedures allow direct visualization and repair of many types of hernias (e.g., direct, indirect, femoral, sliding, bilateral). Common complications of open herniorrhaphy procedures are avoided when LEP herniorrhaphy procedures are used because the peritoneum is not entered. The placement of synthetic mesh in the preperitoneal space during LEP herniorrhaphy procedures prevents inadvertent contact with peritoneal contents and minimizes patients' risks of adhesions, bowel obstructions, fistulas, and intraabdominal vascular injuries. Improved anatomic presentation and optimal patient outcomes are achieved with this approach.

Common pediatric surgical problems.

Common pediatric surgical problems, including hernias, pyloric stenosis, intussusception, and appendicitis continue to present a challenge to the health care provider. Clinical presentation may be typical, may vary with age or signs and symptoms, or may be vague and inconclusive. Management of these problems may range from nonoperative to traditional surgical intervention. Nursing implications include counseling, patient and family education, pre- and postoperative care, and the prevention of complications.

Nursing process decision support system for urology ward.

PURPOSE: We developed a nursing process decision support system (NPDSS) based on three clinical pathways, including benign prostatic hypertrophy, inguinal hernia, and urinary tract stone. NPDSS included six major nursing diagnoses - acute pain, impaired urinary elimination, impaired skin integrity, anxiety, infection risk, and risk of falling. This paper aims to describe the design, development and validation process of the NPDSS. METHODS: We deployed the Delphi method to reach consensus for decision support rules of NPDSS. A team of nine-member expert nurses from a medical center in Taiwan was involved in Delphi method. The Cronbach's α method was used for examining the reliability of the questionnaire used in the Delphi method. The Visual Basic 6.0 as front-end and Microsoft Access 2003 as back-end was used to develop the system. A team of six nursing experts was asked to evaluate the usability of the developed systems. A 5-point Likert scale questionnaire was used for the evaluation. The sensitivity and specificity of NPDSS were validated using 150 nursing chart. RESULTS: The study showed a consistency between the diagnoses of the developed system (NPDSS) and the nursing charts. The sensitivities of the nursing diagnoses including acute pain, impaired urinary elimination, risk of infection, and risk of falling were 96.9%, 98.1%, 94.9%, and 89.9% respectively; and the specificities were 88%, 49.5%, 62%, and 88% respectively. We did not calculate the sensitivity and specificity of impaired skin integrity and anxiety due to non-availability of enough sample size. CONCLUSIONS: NPDSS can help nurses in decision making of nursing diagnoses. Besides, it can help them to generate nursing diagnoses based on patient-specific data, individualized care plans, and implementation within their usual nursing workflow.

Postoperative education and pain in patients with inguinal hernia.

AIM: This paper reports a study to investigate whether education can reduce postoperative pain in patients operated on for inguinal hernia. BACKGROUND: Operation for inguinal hernia is a frequent, elective procedure. Studies indicate that 20% of patients operated on for this condition still have moderate to severe pain on the sixth postoperative day. They also show a connection between postoperative pain and time to return to work, inconvenience relating to recreation and work and development of chronic pain. METHOD: The design was a randomized, clinically controlled, single-blinded study, carried out in 2002-2003. The intervention group received education on discharge from hospital, followed by a telephone interview on the second postoperative day. The control group was given the usual routine information. In a questionnaire, patients ranked their pain on a 100-mm Visual Analogue Scale on the first, third and seventh postoperative days. RESULTS: The study included 234 consecutive patients. The baseline characteristics for the intervention and the control group were identical. Pain was analysed as the difference in Visual Analogue Scale scores immediately preoperatively and on the chosen days postoperatively. No difference was found for pain while resting, pain when moving on the first and third postoperative day and time to return to work. Statistically, there was a significant difference (P = 0.028) between the groups for pain when moving on the seventh postoperative day. The estimated mean difference was 7 mm (95% confidence interval 0.7-13.1 mm). CONCLUSIONS: In patients operated on for inguinal hernia, postoperative education and a telephone interview have no effect on postoperative pain while resting and time to return to work. The effect on pain while moving was slight. There is no reason to change standard practice.

The aponeurotic repair of inguinal hernia.

Inguinal hernia repair has relied on sewing supporting structures to a fixed ligament, and suture line tension has been recognized as a cause of operative failure. Aponeurotic inguinal hernia repair does not rely on suturing fasciae to ligaments; it is a tension-free repair that does not require relaxing incisions to relieve tension. Aponeurotic repair can be performed for primary or recurrent hernias. It use will enlarge the choices of procedures best suited to the needs of a specific hernia.

Nursing discharge assessment of the patient post-inguinal herniorrhaphy in the ambulatory surgery setting.

Nursing discharge assessment and patient discomfort and complications after ambulatory inguinal herniorrhaphy were studied. Of 70 patients, 40 were contacted by telephone the first postoperative day at home. On postoperative day 1, 14 patients experienced discomfort and negative feelings of well-being such as pain and nausea. However, most patients (N = 38) reported that they had "felt well" or "quite well." The results show that the nursing assessment of patient postoperative condition is satisfactory in the immediate postoperative period. The telephone follow-up was appreciated by the patients, and it also brought new possibilities of evaluating the quality of nursing care.

Practical points in the postoperative management of a laparoscopic inguinal herniorrhaphy patient.

Presented in this article is an overview of the etiology, anatomy, and pathophysiology of a hernia. Highlights of preoperative signs and symptoms, diagnosis, and surgical management of a laparoscopic inguinal hernia repair patient are discussed. Postoperative nursing interventions and complications are emphasized.

Is preoperative ketorolac a useful adjunct to regional anesthesia for inguinal herniorrhaphy?

BACKGROUND: Nonsteroidal antiinflammatory drugs (NSAIDs) have become a popular component of analgesia regimens, particularly in combination with narcotics. We questioned whether there might also be a place for their use in conjunction with regional anesthesia and whether there was a preferable route for NSAID administration. METHODS: Ilioinguinal and field blocks were performed preoperatively on seventy patients undergoing outpatient inguinal hernia repair. Patients were divided into a control group who received no ketorolac and four study groups who received a preoperative dose of 30 mg ketorolac by one of the following routes: i.v., i.m., p.o., or intrawound (i.w.). The ketorolac in the i.w group was mixed in the syringe with the local anesthetic used for the field block. i.v. and i.m. groups also received ketorolac at the time of the preoperative regional anesthesia and the PO group received the dose at least one hour preoperatively. All patients received a similar general anesthetic intraoperatively. RESULTS: Postoperative pain scores and analgesic requirements were lowest for the i.m., i.v., and i.w. groups. Pain scores and analgesic requirements for the PO group were less than for the control group but more than for the other three groups. Analgesic efficacy therefore ranked: i.m. = i.v. = i.w. > p.o. > control. Though no differences were found between groups in the time to discharge from the recovery room, the ease of nursing care paralleled the findings for pain scores and analgesia requirements. CONCLUSION: Beyond the analgesia provided by the regional anesthesia of the ilioinguinal and field blocks, the preoperative use of ketorolac further reduced postoperative pain scores and the need for additional postoperative analgesic medication. Comparable outcomes for the i.v., i.m. and i.w. groups indicate the lack of any benefit to concentrating the non-steroidal anti-inflammatory drug at the wound (i.w.) or to achieving high blood levels rapidly (i.v.). In conclusion, ketorolac is a useful supplement to ilioinguinal plus field block regional anesthesia for hernia surgery and is most effective administered parenterally.