Surgical interventions have a temporarily negative impact on us. Our bodies respond to the trauma with inflammation causing pain, fever and fatigue. Treating pain with morphine often adds side effects such as dizziness, or even confusion, and often nausea. Postponed nutrition, either because the protocol says so or due to the problems listed above, adds weakness and slow healing of wounds. As a result of all of these factors, mobilization after surgery is delayed which per se increases the risk of complications such as thrombosis. Add anxiety to this and you have a traditional slow postoperative recovery. Does it really have to be like this?1
Quality work according to the Capio model
In Capio France a systematic quality work according to the Capio model has been implemented with the aim to improve recovery of patients after surgical interventions. The clinical reported outcome measurement (CROM) is used for assessing the recovery after surgery. This is as well reflected in the average length of stay (AVLOS), for patients after a specific intervention.
A quality plan was created based on published medical evidence but also factors such as information/training of patients and their relatives. The entire plan consists of approximately 45 parameters along the patient journey, covering both clinical techniques and organizational processes prior to admission and up to postop follow-up after discharge. Preparing the patient, giving full insight into the treatment and postoperative course of the patient is very important. So is the implementation of Modern Medicine techniques to prevent any undesired response to the surgical trauma such as inflammation with pain, etc. Avoiding unnecessary catheters and drains also facilitates early mobilization.
Capio RRAC label
The medical team around the patient is responsible for the implementation of the quality plan while the management follows up of the plan via an audit as an integrated part of the budget process and a follow-up measurement takes place every three months. Each parameter of the plan is evaluated as not yet implemented, partly or fully implemented and new targets are then set for the coming year. The extent of the implementation can be presented as percentage of full implementation. The teams are rewarded with a Capio RRAC label (RRAC is Recuperation Rapide Apres Chirurgie in French meaning rapid recovery after surgery) on achieving 80 percent of full implementation of the quality plan.
Capio Clinique Sainte Odile, Haguenau
Since 2010, 14 teams have been awarded a RRAC label. Another four teams have started the implementation. The first team to be awarded was the orthopedic team of Capio Clinique Sainte Odile in Haguenau for their total knee replacement (TKR) quality plan. The outcome for patients has improved significantly over time, as illustrated in the figure below. From approximately seven days in hospital in 2010 to three days in hospital in 2014. Their quality plan was formulated in 2011 and the team was awarded RRAC label 2012. Since then the protocols have been fine-tuned and the quality still continues to improve.
Outcome of improvement of Total Knee Replacement (TKR) in Capio Clinique Sainte Odile At Capio Clinique Sainte Odile the average length of stay after total knee replacement surgery was reduced from 6.8 days in 2010 to 2.9 days in H2 2014.
In parallel the number of surgeries performed as outpatient surgery has gone from zero percent in 2010 to 33 percent in H2 2014.
1 A Danish surgeon, Professor Henrik Kehlet (Head of Section of Surgical Pathophysiology at Rigshospitalet Copenhagen) thought otherwise. He, among others, has made major contributions to the understanding of factors behind the response to surgical trauma and how to reduce the negative consequences and enhance recovery.