Proactive Improvement Strategy Checklist

Published Date: 19th July 2016

Publication Authors: Mann K, Graham M, Purlackee S, Ray A, Kaul A, Kuduvalli P

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Aims:  Laparoscopic cholecystectomy has been widely accepted as a day case procedure but many trusts struggle to attain this. Techniques have been described to reduce pain and immediate/early complications from surgical and anaesthetic perspectives. We evaluated our theatre practices, targeting areas of improvement, to create and implement a "Proactive Improvement Strategies" (PIS) checklist. 

Methods:  A cohort of patients who had LC in 2009 were retrospectively reviewed. Various anaesthetic/surgical techniques were highlighted that delayed discharge. These PIS were preoperative motivation, intraoperative antiemetics, multimodal analgesia, regional blockade, specific postoperative instructions and staff education. We re-evaluated outcomes over a nine month period in 2011 to assess the impact of PIS. 

Results:  329 vs 36 cases were reviewed (Pre-PIS vs PIS). Causes for delayed discharge were inadequate analgesia, post operative nausea/vomiting, and drain removal. 3 patients (1 %) were discharged within 24 h pre-PIS vs 23 (64 %) post PIS (<0.05). Readmission rates were 18 (5.5 %) vs 0 (=0.236, Pre-PIS vs PIS). Median length of stay was 2 days (pre.PIS) and 1 days (post PIS)<0.05. There were no significant differences in conversion to open rates (2 vs 10, =0.134) and there were no bile duct injuries in either group. 

Conclusion:  We have achieved significant improvements in day-case discharge for LC with our systematic, structured, team-based implementation of PIS. We plan to build on this and evaluate the known risk factors for complex LC and preempt possible complications. Key statement Day case laparoscopic cholecystectomy has now developed into a well established day case procedure. There are many smaller institutions that have not been able to achieve this and we provide a checklist of improvements that make this more feasible from surgical and anaesthetic perspective.

Mann, K; Graham, M; Purlackee, S; Ray, A; Kaul, A; Kuduvalli, P. (2013).  Successful implementation of a "proactive improvement strategy" checklist to increase rates of daycase laparoscopic cholecystectomy in a district general hospital . Surgical Endoscopy and Other Interventional Techniques. 27 (Issue 1 Supplement), S238-239.

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