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Re-engineering elective surgery


Clinical bottom line

Re-engineering elective services resulted in fewer complications, particularly wound infections, and reduced hospital stay by one day on average.


GA Caplan et al. Re-engineering the elective surgical service of a tertiary hospital: a historic controlled trial. Medical Journal of Australia 1998 169: 247-251.


Patients in this study were those undergoing inguinal herniorrhaphy and laparoscopic cholecystecomy. The controls were treated before a new elective surgical service was commissioned, and compared with those after the service was commissioned.

Control services included patient booking from outpatients, no coordinated patient education, admission to ward on day before surgery, postsurgical care given in the surgical ward and discharge plans made by ward staff. The new system was more coordinated. It consisted of:

  1. admission coordinated by a perioperative unit, including patient self-reported health questionnaires, with pre-admission assessment if necessary.
  2. patients admitted on day of surgery.
  3. patient information specific for each operation and nurse reinforcement of patient knowledge.
  4. clinical pathways fopllowed, with diagnosis specific plan for episode of care and the role of each member of the multidisciplinary team.
  5. postacute care at home after discharge if needed.

Outcomes were complications, using CDC criteria for wound infection.


The control group consisted of 123 patients and the postintervention group 101 patients. The proportion of operations, operating time, sex distribution, age, and other characteristics of patients were all very similar.

Length of stay was redeuced by an average of one day, from a mean of 3.2 to 2.2 days. Postoperative pain scores were the same, about 22 mm and 9 mm on average on days one and seven. Readmission rates were the same, at baout 4%, and there was one death in the control group.

The proportion of patienmts with wound infections was only 5% in the postintervention groupo compared with 16% in the control group. The number needed to treat to prevent one wound infection was 9. In both groups, wound infection rates were linked to length of stay (Figure 1). There was no difference in other postoperative or intraoperative complications.

Figure 1: Postoperative wound infections and length of stay

Patient satisfaction was higher (84%) in the postintervention than in the control group (72%).


Here we have a study that looks at several elements of a service together. Interesting is that the authors tell us that the clinical pathway they used was developed by a multidisciplinary team to drive and support the system.