Application Of Fast Track Surgery In Abdominal Surgery Of Grade-? Class-A Hospitals:Status,Barriers And Countermeasures

Objectives:1.To understand the cognitive level of medical staff for Fast-track Surgery in abdominal surgery of Grade-? Class-A hospitals,and to explore the influencing factors that affect the cognitive level of the medical staff.2.To investigate the main barriers and the relative importance of the factors in the implementation of Fast-track Surgery in abdominal surgery of Grade-? Class-A hospitals.3.To investigate the current status of Fast-track Surgery in abdominal surgery of Grade-III Class-A hospitals,and to analyze the correlation among the cognitive level of the medical staff,implementation barriers and current status of Fast-track Surgery.4.To provide strategies to promote the popularization and application of Fast-track Surgery in Clinical settings based on the current status and implementation barriers of Fast-track Surgery,and to provide scientific evidences for developing policies for the relevant government departments and hospital managers.Methods:Multi-stage stratified sampling method was performed and 3520 medical staff from 40 Grade-III Class-A hospitals was involved in this survey.We conducted this survey about the cognitive level of the medical staff,implementation barriers and current status of Fast-track Surgery using a self-designed questionnaire from December 2016 to December 2017.Doctors and nurses with high or middle titles were interviewed using semi-structured interviews outline to collect qualitative data about implementation barriers of Fast-track Surgery.Sampling continued until redundancy in themes and data saturation was reached.Import all the information of research into Epidata 3.02 statistical software to build a database.Then use the statistical software SPSS22.0 and MLwiN to make an analysis.The Statistical methods include statistical description,one-way analysis(ANOVA,T-Test and Chi-square test,Nonparametric Test),multi-way analysis(Multiple Logistic regression model).Qualitative data were classified and analyzed.Results1.Reliability and validity of questionnaire:the re-test reliability was 0.832;Cronbach's alpha coefficient for the overall questionnaire was 0.843;Cronbach's alpha coefficient was 0.778-0.819 for each subscale.The content validity index for the overall questionnaire was 0.986.2.The age of consultant is 36?63 years old,with an average age of 49.33±7.83 years.By statistical analysis,the average familiarity of 12 consultants to the content of the questionnaire was 0.874,the coefficient of judgment was 0.890,and the authority coefficient of the expert was 0.882.3.A total of 3520 questionnaires were issued and 3280 questionnaires were returned.The overall response rate was 93.20%.Among them,the doctor's response rate was 77.7%,and the nurse's response rate was 93.2%.There were 3077 valid questionnaires,with an effective rate of 93.8%.4.The cognitive level of medical staff for Fast-track Surgery(1)The top five higher level of identification of medical staff for Fast-track Surgery were:98.99%respondent agreed to provide pre-operative information and postoperative guidance for rehabilitation,90.19%respondent agreed to early motion after surgery,85.38%respondent agreed to remove indwelling catheters as early as possible,84.24%respondent agreed with intra-operative warming,80.44%respondent agreed to controll fluid input in surgery.The top five lower level of identification of medical staff for Fast-track Surgery were:55.44%respondent did not agree to provide Carbohydrate loading 2 hour prior to surgery,46.51%respondent did not agree with the abandonment of intra-abdominal drainages,44.46%respondent did not agree to remove the nasogastric decompression 1 days after surgery,43.97%respondent did not agree with the avoidance of mechanical bowel preparation before surgery,43.84%respondent did not agree with the early oral feeding within 4 hours after surgery.The results of stratified analysis showed that doctors and nurses agreed on the 6 optimization measures proposed by Fast-track Program,the difference was not statistically significant(P>0.05).They were:providing pre-operative information and postoperative guidance for rehabilitation,raising the temperature of the operating room,limiting the infusion of liquid,removing the gastrointestinal tract as soon as possible post operation,removing the catheter as early as possible and starting bed activity 6 hours post operation.In the other 11 optimization measures advocated by Fast-track Surgery,the cognition of doctors and nurses is not consistent,the difference is statistically significant(P<0.05).(2)The total score of cognitive level of medical staff for Fast-track surgery was 12.150±3.70,and the average of each item was 0.72±0.22.The average of each dimension was as follows:the score of intra-operative management was 0.80±0.26,pre-operative preparation score was 0.69±0.25,and post-operative rehabilitation score was 0.68±0.26.The stratified analysis showed that the total score of the cognitive level of the abdominal surgeon was 12.30±3.47,and the average score of each item was 0.72±0.20.The average score of each item from high to low was:the intraoperative management score was 0.86 ±0.21,the preoperative preparation score was 0.69 ±0.25,and the postoperative recovery score was 0.68±0.26.The total score of cognitive level of rapid rehabilitation surgery in abdominal surgery nurses was 12.09±3.79,and the average score of each item was 0.71 ±0.22.The average score of each item from high to low was:the intraoperative management score was 0.78±0.27,preoperative preparation score was 0.69±0.25,and postoperative rehabilitation score was 0.68±0.26.One-way analysis showed that there was a significant difference in cognitive level of medical staff for Fast-track program between different geographical distribution,hospital types,gender,departments,age,educational background,professional titles,working years,specialties years of working and whether they participated in training about Fast-track programs(P<0.05).Multiple linear stepwise regression analysis showed that the cognitive level of medical staff for Fast-track program was influenced by titles,departments,specialties years of working,and whether they had participated in training about Fast-track programs.5.Barriers in the popularization and application of Fast-track surgery(1)Medical staff believe that barriers that hinder the application of Fast-track surgery were:84.82%respondent believed that each patient's condition is specific,Fast-track programs can not be stereotyped implementation;76.57%respondent believed that the popularization degree of Fast-track surgery is not enough;73.97%respondent believed that there has not formed the specific disease Fast-track surgery clinical guidelines;73.77%respondent believed that there is lack of Multimodality Therapy Team;72.31%respondent believed that doctors and nurses lack in-depth study and understanding of Fast-track surgery.Stratified statistical analysis of doctors and nurses showed that:82.76%of the doctors believed that each patient's condition is specific,Fast-track programs can not be stereotyped implementation;72.49%of the doctor recognized the popularization degree of Fast-track surgery is not enough;70.60%of the doctor believe that there has not formed the specific disease Fast-track surgery clinical guidelines;68.12%of the doctor think that doctors and nurses lack in-depth study and understanding of Fast-track surgery;67.30%of the doctor think there are complications after the operation,causing medical disputes.Nurses think that the main factors that impede the application of Fast-track surgery are:85.61%of the nurse think that each patient's condition is specific,Fast-track programs can not be stereotyped implementation;78.12%of the nurse believe that the popularization degree of Fast-track surgery is not enough;76.59%of the nurse believe that the hospital is lack of multidisciplinary therapy team;75.25%of the nurse believed that there has not formed the specific disease Fast-track surgery clinical guidelines;73.90%of the nurse believe that doctors and nurses were lack of in-depth study and understanding of Fast-track surgery.The doctors and nurses in the abdominal surgery in Grade-? Class-A hospitals were compared with the barriers that hinder the application of Fast-track surgery.The statistical results showed that there was no statistical difference between the doctors and nurses on the four obstacle factors of the Fast-track surgery(P>0.05).They were:Fast-track surgery.is mainly driven by doctors,other personnel play an auxiliary role;Hospitals lack appropriate policies to support the development of Fast-track surgery;China do not form a practical guide for Fast-track surgery for specific diseases;The doctors and nurses worry about complications after Fast-track surgery and causing medical disputes.(2)The results of qualitative interview:Barriers that hinder implementation of Fast-track surgery from six aspects:Multidisciplinary collaboration facing difficulties;medical staffs' belief towards Fast-track surgery needs to be changed;lack of patients understanding and cooperation;the safety of Fast-track surgery needs to be further verified;lack of policy support and safeguard measures;domestic community and grassroots medical resources is shortage.6.Current status of Fast-track surgery(1)Current status:The fully implemented interventions of Fast-track surgery from high to low were:Providing pre-operative information and guidance for rehabilitation were totally in practice by 84.53%health care providers;early moblilisation was totally in practice by 48.29%respondent;early removal indwelling catheters was totally in practice by 45.24%respondent;raise up temperature in the operating room was totally in practice by 41.14%respondent;using heat-controlled blankets during the operation was totally in practice by 39.13%respondent.The interventions that had not been fully implemented from high to low were:Carbohydrate loading 2 hour prior to surgery was not in practice by 72.83%respondent;the avoidance of mechanical bowel preparation before surgery was not in practice by 38.51%respondent;early oral feeding within 4 hours after surgery was not in practice by 38.48%respondent;the abandonment of intra-abdominal drainages was not in practice by 33.47%respondent;fasting in solid diet 6 hours before operation was not in practice by 31.55%respondent.(2)The total score of current status of Fast-track surgery was 18.43±6.83,and the average score for each item was 1.08±0.40.The score of intra-operative management was 1.11±0.61,post-operative rehabilitation score was 1.10±0.46,pre-operative preparation score was 1.08±0.40.There were significant differences in the scores of current status of Fast-track surgery among geographical distribution,departments,and whether they had participated in training about Fast-track programs(P<0.05).(3)The correlation among cognitive level of medical staff,barriers in the implementation and current status of Fast-track surgery:The cognitive level of medical staff for Fast-track surgery was positively related to the implementation of Fast-track surgery,and the correlation coefficient r was 0.324.Conclusions:(1)Doctors and nurses knew better about pre-operative information and postoperative guidance for rehabilitation,early ambulation,early removal of indwelling catheter,intra-operative warmth and restriction of liquid input in Fast-track surgery.The cognitive level about Carbohydrate loading 2 hour prior to surgery,the abandonment of intra-abdominal drainages,postoperative early feeding,early removal of gastrointestinal decompression tube,the avoidance of mechanical bowel preparation before surgery is low,needs to be further improved.(2)The main barriers that hinder the application of Fast-track surgery were:Has not formed the specific disease Fast-track surgery clinical guidelines;multidisciplinary collaboration facing difficulties;medical staffs' belief towards Fast-track surgery needs to be changed;the safety and effectiveness of Fast-track surgery needs to be further verified;lack of policy support and safeguard measures,domestic community and grassroots medical resources is shortage.(3)Fast-track surgery has just been partially adapted to daily routine in abdominal surgery of Grade-? Class-A hospitals.Some elements like Carbohydrate loading 2 hour prior to surgery,postoperative early feeding,the abandonment of intra-abdominal drainages,the avoidance of mechanical bowel preparation before surgery,shorten the time of fasting and water prohibition still follow the old surgical routines,needed to be improved.(4)The higher the cognitive level of medical staffs for Fast-track surgery,the more likely it is to apply Fast-track surgery.Countermeasures:1.Improve the cognition level of medical staff for Fast-track Surgery so as to change their traditional view:To carry out the training of Fast-track Surgery,improve the cognitive level of medical staff;strengthen academic exchanges,change the traditional concept of medical staffs;establish demonstration base of Fast-track Surgery,bring medical staff to field trip.2.Establish a multidisciplinary team,ensure multidisciplinary collaboration effectively:Establish a multidisciplinary team with complete staffing;specifying responsibilities;innovate the management mechanism;standardize the implementation process of the multidisciplinary team;establish the quality assessment standards;establish discipline team guarantee mechanism;create information sharing platform to ensure medical staff sharing information.3.Carry out research with large sample,multi center samples,form clinical guideline of Fast-track Surgery:carry out large sample,multi-center prospective study to further verify the effectiveness of Fast-track Surgery;establish a scientific and comprehensive evaluation system to evaluate the effectiveness of Fast-track Surgery comprehensively and objectively;form clinical guideline of Fast-track Surgery to ensure to apply Fast-track Surgery appropriately.4.Enhance the patient's confidence to improve patients understanding and cooperation:make clear the advantages of Fast-track Surgery of patients;the establishment of hospital community continuing nursing care rehabilitation mode to relieve patients worry after discharge.5.Improve the support policy and safeguard measures:reform the management mode to realize the integration of services;reform the medical insurance policy to facilitate outpatient preoperative examination fee include in the scope of reimbursement;establish the "green channel" to facilitate readmission for the patient of Fast-track Surgery.