| Improving patients' care and decreasing costs with the ultimate goal of better services has become the major problem of health care. A clinical pathway has been used to meet the goal. Clinical pathway (CP) was developed and used as a tool to decrease length of stay in American in late 20 century, and now has been used under many conditions. But there was in primary stage about CP for cardiac surgery patients in our country. The present study aimed to develop, implement and evaluate clinical pathway for patients following off-pump coronary artery bypass grafting (OPCAB) in the early ICU stage.Part 1: Development of clinical pathway and protocols for OPCAB patients during the early ICU stage We establish the therapeutic and nursing items expected to complete postoperatively under investigation and set up the critical steps of the treatment procedure for the OPCAB patients during the early ICU stage. Thus, we developed a 3-day pathway. In conjunction with the clinical pathway, five protocols are established to organize patients' care, including an early ambulation protocol, an early extubation protocol, a protocol for controlling pain, an improving gastrointestinal motility protocol and a protocol for preventing bed sores.Part 2:Effects of early extubation on recovery of patients following OPCAB In part one, it was clear that endotracheal extubation is one of the critical steps for the OPCAB patients. The objective of this part was to examine the effects of early extubation on patients' recovery. Based on extubation time, 64 patients were divided into early extubation group (less than 8 hours, n=35) and late extubation group (more than 8 hours, n=29). Vital signs and arterial blood gas results were measured before and after extubation in two groups. In addition, atrial fibrillation rate, main postoperative complications and patients' recovery condition were recorded for two groups. Main results:①SBP 10 minutes after extubation were significantly higher than that of before extubation(P<0.05), SBP 30 minutes after extubation were no significantly different from that of before extubation(P>0.05). There was no significant difference in HR,DBP, SatO2,CVPand PAWP before and after extubation(P>0.05).②There was no significant difference before and after extubation in main ABG results including pH, PaO2 and PaCO2 (P>0.05). ③The patients with early extubation had lower atrial fibrillation rate than did patients with late extubation, although there was no statistical significance(P>0.05).④There was no significant difference in main complications between two groups(P>0.05), but the patients with early extubation had few pneumonia and pulmonary atelectasis than did patients with late extubation.⑤Patients with early extubation had significantly shorter ICU stay, postoperative length of stay and lower costs than did patients with late extubation(P<0.05). Therefore, early extubation is safe and effective for the patients undergoing OPCAB. We should practice early extubation protocol in order to fulfill the clinical pathway successfully.Part 3:Effects of clinical pathway on OPCAB patients64 patients were divided into two groups. One group received clinical pathway and the other received routine care postoperatively. We evaluate the effects of clinical pathway on OPCAB patients from several aspects.Main results:①The time of first leaving bed and defecation after operation in the clinical pathway patients was earlier than that not in the clinical pathway(p<0.01). All patients in CP had their first time leaving bed in 48h after operation. The patients in CP extubated earlier than did patients not in CP, although there was no statistical significance (P>0.05). ②There was no significant difference in main complications in two groups(P>0.05), main complications including re-intubation, pulmonary atelectasis, pneumonia, low cardiac output, hemorrhage, renal failure, pleural effusion,arrhythmia and mental confusion, but the patients in the clinical pathway had fewer pneumonia and pulmonary atelectasis than di... |
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