Variations Analysis Of Ventricular Septal Defect Open-heart Repair Clinical Pathway In Children

As a new kind of quality and efficiency of health care managementmodel, clinical pathway (CP) has three main objectives: to shorten patients’length of stay, to reduce the hospital costs, and to improve patients’satisfaction. These purposes in line with the reform goals of the medicalcare system, which are lower costs, high-quality services, and meetpatients’ basic medical needs. Through scientific methods to manage andanalyze clinical pathway, can regulate the behavior of the staff in themedical institutions, optimize the diagnosis and treatment process, improvethe quality and safety, reduce waste of resources, benefiting patient,hospital as well as society.However, due to individual differences in patients and diseases’development and changes, as well as the unbalanced nature of the regionaldistribution of medical resources, reality in the process of diagnosis andtreatment of various medical institutions can not be exactly the same, andthere will always be biases compared with the standardized clinicalpathways, that are called variance. Clinical pathway’ application and research are in a relatively mature stage in some of the developed countries.Long-time practice and a number of studies have shown that, varianceanalysis and management are the key steps and important of the clinicalpathway. Therefore, the statistical classification, analysis and rectificationaround the variation matters are important parts of quality management ofclinical pathway, but also the guarantee of the clinical pathway to the depthof promotion and continuous improvement.Objective:To analyze the differences between the diagnosis and treatmentpathway which now be used in our hospital and the Ministry of Healthstandard clinical pathway. To determine various types of variance factorsthat may occur during ventricular septal defect open-heart repair clinicalpathway. Make the improvement strategies according to the controllablelevel and different sources of variances.Methods:1. The theoretical knowledge review was conducted through theliterature search and content analysis. To under the clinical pathway andvariation analysis research progress, and lay the foundation for laterquantitative analysis.2. Medical records of172patients were studied retrospectively. Treatment data were extracted and compared with the Ministry of Healthclinical pathway. Then the variations of clinical pathway were screened.The content analysis theory was used as a guide in the study.3. Did a general description of the basic information used SPSS17.0;determined the main factors of variations by one-way ANOVA,Mann-Whitney U test, Kruskal-Wallis test; and then did the stepwisemultiple regression analysis. P＜0.05was considered statisticallysignificant.Results:1. Related to the clinical pathway variation analysis were startedrelatively late in China, the research methods were homogeneous, andmostly concentrated in surgical common diseases. Variation analysis ofpediatric clinical pathway was rarely reported. The majority were thedesign and implementation of the health education pathway or clinical carepathway.2. A total of172copies of medical records.62were no variation and110were variation.3were positive variation and107were negative.53.64%of the negative variations were related with children/family.22.73%were related with medical staff/service providers.14.54%wererelated with hospital/community.9.09%were by the above factors interact.3. The results of the single factor analysis. (1) Children’s age, weight, admission situation, with or without asecondary diagnosis, postoperative recovery days, postoperative intensivecare unit time, the number of days with antibiotics, intraoperative fluidvolume, with or without postoperative complications,9factors affected thehospital costs of ventricular septal defect repair significantly (P＜0.05).(2) Children’s age, weight, admission situation, with or without asecondary diagnosis, day of diagnosis to the day of surgery, chief surgeonphysician, postoperative recovery days, postoperative intensive care unittime, the number of days with antibiotics, intraoperative fluid volume, withor without postoperative complications,11factors affected the length ofstay of ventricular septal defect repair significantly (P＜0.05).4. The results of the stepwise multiple regression analysis.(1) The number of days with antibiotics and postoperative recoverydays, these two variables were the most linear relationship with the totalhospitalization costs. The multiple linear regression equation is, totalhospital costs=18577.284＋3155.991×number of days with antibiotics＋3288.384×postoperative recovery days.(2) The number of days with antibiotics, day of diagnosis to the dayof surgery and the age, these three variables were the most linearrelationship with the length of stay. The multiple linear regression equationis, length of stay=10.710＋1.718×number of days with antibiotics＋2.059×postoperative recovery days－1.441×the age. Conclusions:1. There was a higher incidence of variation matters in childrenventricular septal defect repair clinical process. Should refine the text of theventricular septal defect clinical pathway, and develop the strict entry andexit criteria. Should strengthen the training of medical staff, improve theiractive awareness for the application of the clinical pathway, and increasecoordination between the various disciplines and departments. Should doknowledge of clinical pathway missionary for children and their families,increase their compliance to enter or exit the clinical pathway.2. The number of days with antibiotics showed a significantcorrelation with the total hospital costs and the length of stay. And therewas a linear relationship between them. Antibiotic use non-standard wasalso one of the reasons that caused negative variation. Use of antibiotics inthe treatment process should be controlled in accordance with the clinicaluse of antibiotics guiding principles and the clinical pathway.3. In children above the age of three, only7.58%of children’ shospital total costs less than2.5million, that met the standards of theMinistry of Health clinical pathway. Others92.42%were all more than2.5million. Re-estimated the costs on the basis of optimize the treatmentprocess. The actual situation of this institution should be also considered.4. Should establish and improve the clinical pathway managementmechanism, including Clinical Pathway Management Committee, the Steering Group of Experts, et al. Promote the formulation, correction andimplementation of the clinical pathway. In order to reduce the number ofdays for preoperative assessment, the postoperative intensive care unit timeand other controllable factors on the diagnosis and treatment process.