新青年网络公开课专家讲堂第四医改及手术恢复未来增强术后康复

MEDICALREFORMANDFUTUREOFSURGICALRECOVERY(ENHANCEDRECOVERYAFTERSURGERY)医改及手术恢复的未来(增强术后康复JeffreyHuang,AssociateProfessorofUniversityofCentralFloridaCollegeofMedicine,Orlando,FLInternationalGynecologicERASGuidelineworkinggroupDirectorofresearch,DepartmentofAnesthesiology,ArnoldPalmerMedicalCenter,Associatedirectorofresearch,DepartmentofOB/GYN,ArnoldPalmerMedicalCenter,HealthcareinHealthcare:17%ofthegrossnational49.9million--ThenumberofAmericansin2010.That's16.3%ofthetotalpopulation.ThequalityofcareisonaverageinferiortothatofcountriesthatspendmuchHealthcarein医疗：国民生产年没有保险的人TheUShealthcaresystemseemsheadedforbecauseofitseverincreasingand 向因为其不断增Healthcare AffordableCareAct支付得起的医疗法)seekstoreducehealthcarecostsisbyencouragingdoctors,hospitalsandotherhealthcareproviderstoformnetworkstocoordinatecouldkeepcosts What'sanAccountableCareOrganizations(ACOs)(问责医疗机构)aregroupsofdoctors,hospitalsandotherhealthcareproviders,whocometogethervoluntarilytogivecoordinatedhighqualitycaretotheirMedicarepatients. accountabletothepatientsandthethird-partypayerforthequality,safety,andefficiencyofthehealthcareprovided ACOandMedicalACOsarecomprisedofmany“medicalhomes”医疗之家)MedicalHomesareattheheartof医疗之家医疗诊所MedicalHomeamodelofprimarycarethatisaccessible,andfocusedonqualityandsafety.CoreFeaturesoftheMedicalPatient-centered( 为中心Comprehensivecare(全方位Coordinatedcare协调服务Superbaccesstocare便利就诊Asystems-basedapproachtoqualityandsafety(基于 Patient-centered(以 Providingcarethatisrespectfulofandresponsivetoindividualpatientpreferences,needs,andvalues,andensuringthatpatientvaluesguideallclinicaldecisions eachpatient’sphysicalandmentalhealthcareneeds,includingpreventionandwellness(健康),acutecare,andchronic coordinatescareacrossallelementsofthebroaderhealthcaresystemincludingspecialtycare,hospitals,homehealthcare(家庭健康护理andcommunityservicesandsupports协调服务更广泛的卫生系统的所有要Superbaccesstocare便利就诊shorterwaitingtimesforurgentneeds迫更短的等待时间迫切需enhanced 提高 的时around-the-clockephoneorelectronicaccess(电子)toamemberofthecare整 或电Asystems-basedapproachtoqualityandsafety(基于 usingevidence-based(基于 andclinicaldecision-support(决策支持)toolstoguideshareddecisionmaking(共同决策)withpatientsandfamilies,engaginginperformancemeasurementandimprovement(绩效评估和改进)measuringandrespondingtopatientexperiencesandpatientsatisfaction( es结果Evidenceshowsthatpatient-centeredcarenotonlyimprovesclinical es(医疗结果qualityoflife(生活质量andpatientsatisfaction,butalsoisassociatedwithadecreaseininappropriatehealthcareutilizationintheprimarycaresetting有表明，以为中心的护理不仅提高了医疗结果，生活质量和的满意度，而且还JAmBoardFamMed2011,24(3):229-Whatabout Surgicalcareaccountsforapproxima 65%ofallhospitalexpenses外科护理占所有医院费用约abetterpatientexperience更好的患者体验betterhealthcare(更好的医 alowercost较低的成本Theimmediatechallengetoimprovingthequalityofsurgicalcareisnotdiscoveringnewknowledge,butratherhowtointegratewhatwealreadyknewintopractice (UrbachDR,BaxterNN,BMJWhatisenhancedgetbettersooneraftersurgery更快更好21thcenturysurgicalDevelopedbyKehletinDenmarkincolonicGraduallyhasgainedworld-wideTheERASisnowwidelyusedwithinhospitalsforpatientshavingcertainoperations(Colorectal,Urology,Orthro,Gyn,Vascular)逐渐赢得了世界广泛接KeyTheunderlyingprincipleistominimizethestressresponsesonthebodyduringEssential(基本要点ThepatientisinthebestpossibleconditionforsurgeryThepatienthasthebestpossiblemanagementduringandafterhis/herThepatientexperiencesthebestpost-operativerehabilitationThebenefitsofenhancedEnhancedrecoverySignificantlypatientexperience,increasing es医疗成果multi-disciplinaryteamworking多学科团significantreductioninlengthofstay(reducedcost)reducedriskofhospitalacquiredinfections(reducedcost)Averagesaving10%peroverallcost-savingofroughly$6900perpatient(CanUrolAssocJ.20115(5):Program FollowteamleaderFollowHowdoestheprogrampatientpatientinthebestpossibleconditionforThebestThebestInsurgeon’soffice外科医生Managingthepatients’expectations Decision-making(决策PatientNonsurgicalSurgeonsandtheirofficeDecision-making(决策helpsthepatienttobefullyinformedaboutthepotentialbenefits,risks,alternativesandrecoverypathsoftreatmentoptions decidetheformoftreatmenttheywishtoundertake,beitsurgeryormoreconservativemeasures.improveexperienceandsatisfactionthroughmorerealisticexpectationsandalsotoensuredecisionsmatchindividualvaluesandpreferences.Decision-Avarietyofdecisionaidscanbeusedasappropriateforthepatient,forexample,writtenmaterials,verbal,DVDs.PAT(住院前测试playsanextremelyimportantroleinhowpatientwillunderstand,considerand yparticipateintheenhancedrecoverypathwayPATisrequiredforsafetyreasonstoensuretherisksofundergoinganesthesiaarePATensuresthatpatientisintheoptimum(最佳)conditionforsurgery.(HTN,DM,Asthma,Anemia,Stable,regularfollowupbyPCPorspecialties Nostable,followProceed,acquirelastvisitnoteandtestresultsstop,reevaluateandconsultwithPCPorspecialtiesforoptimizationHealthypatient:ifnotexerciseregularly,instructthemtowalk1 adaytilldayofsurgerySmoking:encouragepatienttostopsmoking,minimal24hrbeforeAlcohol:stopWatchpreopsurgeryandanesthesiaNPO禁食NPO禁食0-2hrsNothing(nochipsofice,nomints,nogum,nosipsofwater)2hrsClearliquids,coffeewithoutcreamorsugar,juiceswithoutpulp6hrsMilk,fullliquids,lightmeal,low/non-fatmeal,lowvolume8hrsHeavyAskpatientwhethertheywatchPreopmedsincludingneurontin300mgandcelebrex400mgNomechanicalbowelAvoidanceofDrainsandNGTpost-Deepveinthrombosisprophylaxis stockings(深静脉血栓形成的预防：气动机械Antibioticprophylaxis:AsingledoseofLocalanestheticsinjectionintheincisionAnesthesiaFluidGoalistokeepfluidadministrationtoaminimum,withanemphasisoncolloidsIntraoperativeopiatesatclinician’s 10mgpre-incisionand10mgatthehalftimeofsurgeryKetorolac酮咯酸15mgIVatendofIVTylenol对乙酰氨基酚)1000mgPulmonaryrecruitment(forlaparscopyAntiemetics(2-3agents)atAvoidanceofopiatesandtheuseofTyenolandnonsteroidalanti-inflammatorydrugs(NSAIDS)Pain PainOralOxycodone5–10mgorallyevery4hasneededforpainrated4orgreaterorgreaterthanpatientstatedcomfortgoal(5mgforpainrated4–6or10mgforpainrated7–10);forpatientswhoreceivedintrathecalgesia,start24hafterintrathecaldosegivenScheduledacetaminophen*(对乙酰氨基酚Acetaminophen1,000mgorallyevery6hforpatientswithnoormildhepaticdisease;acetaminophen1,000mgorallytwicedailyforpatientswithmoderatehepaticdisease; umacetaminophenshouldnotexceed4,000mg/24hfromallsourcesScheduledNSAIDs类固醇消炎药Ketorolac酮咯酸)15mgIVevery6hforfourdoses(startnosoonerthan6hafterlastintraoperativedose);then,ibuprofen(布洛芬)800mgorallyevery6hstart6hafterlastketorolacdoseadministered)PainBreakthroughpain(paingreaterthan7morethan1hafterreceivingoxycodone)Hydromorphone(氢 酮)0.4mgIVonceifpatientdidnotreceiveintrathecalmedications;mayrepeatonceafter20miniffirstdoseIVpatient-controlledHydromorphonepatient-controlledgesiastartedonlyifcontinuedpaindespite2dosesofIVhydromorphoneFLOOR 护士oralnutritionalsupplementsfromthedayofsurgeryuntilnormalfoodintakeisPatientsshouldbehelpedtositoutinachairontheeveningofsurgery.Itis mendedthatpatientsisoutofbedfor2hoursonthedayofsurgeryand6hoursthereafter.Dischargecriteria(出院标准Thepatientshouldbeabletotoleratedietandoralfluids,tohavepainadequa ycontrolledonoralhavebowelsfunctioningorflatusbeconfidentandagreetogoFollowup追随(1)afollow-upphonecallafterdischargefromthehospitaltoansweranyquestionsfromthepatientorfamilyortodeterminethatthepatientisrecoveringappropria (2)aphonecalltoaddresspatientsatisfactionissues;or(3)aphonecalltoprovideadditionaleducationorguidancetothepatientonaparticulartopicrelatedtotheirhospitalstayAudit:DataCollection审计:数据收LengthofhospitalPatientcontinuousauditcycleshouldensuredetectionofanyinstitutionalproblemsassociatedwithERASimplementationcontinuouslyup-to-dateandevidencedbasedERASpractice.From:AdherencetotheEnhancedRecoveryAfterSurgeryProtocolandesAfterColorectalCancerDa