Improving postoperative mobilisation rates in patients undergoing elective major hepatopancreatobiliary surgery

Abstract

BackgroundEarly mobilisation reduces postoperative complications such as pneumonia, deep vein thrombosis and hospital length of stay. Many authors have reported poor compliance with early mobilisation within Enhanced Recovery After Surgery initiatives.ObjectivesThe primary objective was to increase postoperative day (POD) 2 mobilisation rate from 23% to 75% in patients undergoing elective major hepatopancreatobiliary (HPB) surgery within 6 months.MethodsWe report a multidisciplinary team clinical practice improvement project (CPIP) to improve postoperative mobilisation of patients undergoing elective major HPB surgery. We identified the common barriers to mobilisation and analysed using the fishbone or cause-and-effect diagram and Pareto chart. A series of Plan–Do–Study–Act cycles followed this. We tracked the rate of early mobilisation and mean distance walked. In the post hoc analysis, we examined the potential cost savings based on reduced hospital length of stay.ResultsMobilisation rate on POD 2 following elective major HPB surgery improved from 23% to 78.9%, and this sustained at 6 months after the CPIP. Wound pain was the most common reason for failure to ambulate on POD 2. Hospital length of stay reduced from a median of 8 days to 6 days with an estimated cost saving of S$2228 per hospital stay.ConclusionMultidisciplinary quality improvement intervention effort resulted in an improved POD 2 mobilisation rate for patients who underwent elective major HPB surgery. This observed outcome was sustained at 6 months after completion of the CPIP with potential cost savings.

Sustaining a Multidisciplinary, Single-Institution, Postoperative Mobilization Clinical Practice Improvement Program Following Hepatopancreatobiliary Surgery During the COVID-19 Pandemic: Prospective Cohort Study

“…CPIPs target a specific, measurable goal, identify critical barriers, and develop a model for improvement. We previously described the success of our CPIP in improving postoperative mobilization [ 9 ]. A quality dashboard inclusive of a Pareto chart was provided to clinician stakeholders in 2018.…”

“…The HPB surgery dashboard for 2018 following the implementation of ERAS revealed a low observed/expected ratio for compliance, with a postoperative mobilization rate of 22%. Hence, relevant stakeholders agreed to implement a CPIP to improve postoperative mobilization, which began in May 2019 [ 9 ].…”

“…The specific details of our CPIP were described in 2020 by Tang et al [ 9 ]. Successful mobilization was defined as sitting out of bed for >6 hours on POD 1 and ambulation of ≥30 m on POD 2, with a target mobilization rate of ≥75%.…”

“…Length of hospitalization stay was defined as the duration of hospital stay calculated from admission to the point of discharge. Successful mobilization was defined as sitting out of bed for >6 hours on POD 1 and ambulation of ≥30 m on POD 2 [ 9 ]. Morbidity was defined as the incidence of pneumonia and deep vein thrombosis.…”

“…A systematic review by Coolsen et al [ 2 ] in 2013 described poor compliance (mobilization rate 20%-28%) to early postoperative mobilization on POD 1 following liver surgery [ 7 , 8 ]. Similarly, our institution showed a poor postoperative mobilization rate of 22% in patients undergoing elective major HPB surgery, with improvement to >75% following the implementation of a multidisciplinary surgeon-led clinical practice improvement project (CPIP) [ 9 ]. The quality improvement process does not end with the implementation of a solution.…”