الفهرس 
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Abstract
Summary
A clinical pathway is a guideline for the nurses and other members of the health care team. It functions as a documentation tool that describes an expected sequence of events and processes that move the patient to the desired goal and can help nurse’s achieve better control, quality care, and cost outcomes.
Clinical pathways are a strategy of managing care that emphasizes early assessment of a patient’s condition and comprehensive care planning inclusive of service systems.
In managing care environment nurses are part of an interdisciplinary team that follows patients from preadmission through post dishrag care at home in an effort to help patients achieve optimal outcomes. As crucial members of managed care teams have increased responsibility for decision making, with more autonomy and expanded roles in disease prevention and health care promotion.
Aim of the Study:
The aim of the study is to evaluate the application of clinical pathway in one day surgeries for patients with laparoscopic cholecystectomy through; assessing the patient’ needs, designing, planning, and applying clinical pathway in one day surgeries for patient with laparoscopic cholecystectomy, and evaluateing the effects of implementing clinical pathway on patient’s outcomes.
Hypothesis of the study:
Applying clinical pathway in one day surgeries for patients with laparoscopic cholecystectomy will improve patients’ physical condition, pain relief, and decrease incidences of complications.
Research Design:
To meet the aim of this study, a quasi-experimental research design was used.
Research Setting;
The study was conducted at one day surgeries unit and surgical wards in Nasser Institute Hospital.
Subject of the study:
The subjects of the present study were selected as a convenience sampling and divided into; (80).patients sample and interdisciplinary team members (53 nurses, 10 surgeons, 10 anesthesiologists, 15 dietitians, and 10 physiotherapists).
Study Tools:
Tools of data collection:
1- Patient’ assessment Sheet;
It was designed to identify patient’s needs and their conditions as a basis to develop the clinical pathway and assess their progress. It comprised two parts as follows:-
• Socio-demographic characteristics of the patients such as; code No., age, gender, educational level, marital status, past surgical history and length of stay.
• Assessment of patient’s physical condition through preoperative & post operative ( physical and psychological ) status which included (cardiovascular system, respiratory system, skin integrity, nutrition and elimination, gastrointestinal system, current medication and investigation& tests. Scoring system; Patient assessment sheet consist of socio-demographic and physical assessment; answered by Yes (1) grade or No (0) grade.
2- Nurses’ knowledge questionnaire sheet;
It assesses nurses’ knowledge about caring of patient with laparoscopic cholecystectomy. It was developed on scientific references, and reviewing comprehensive literature, which includes;
a- Socio-demographic characteristics of nurses; such as code, educational level, years of experiences, and previous in-service training courses and sitting of work, the data obtained was analyzed and tabulated. b- Nurses’ knowledge questionnaire sheet comprised of 5 parts: knowledge about anatomy and physiology of gallbladder, overview about the gallbladder stones, the preoperative nursing knowledge, intraoperative nursing care, and the postoperative nursing care. Nurses’ knowledge questionnaire consist of (18) questions as MCQs, Yes or No, and essay questions. The total scores for this sheet were 56 grades.
Scoring system;
The scoring system for questionnaire was one mark for right answer, and zero for the wrong one. The total score of nurses’ knowledge questionnaire as the follows; from< 70 % grade was considered unsatisfactory, and from ≥ 70 % grade was considered satisfactory as guided by (Dawes & O’Neill, 1999, 2009).
3- Observational checklist for interdisciplinary team;
Observational checklist for interdisciplinary team members aims to assess their achievement during application of clinical pathway. It consists of:
a- Nurse’s observation checklist;
To assess nurses’ performance during perioperative care, it was developed by the researcher after comprehensive reviewing of related literature; it was constructed based on identified standard of care of patients undergoing laparoscopic cholecystectomy. In relation to preoperative nursing care (nursing assessment, patient preoperative preparation, patient education, admission to surgical center or unit, in the holding area- patient assessment, treatment monitoring and psychological monitoring), intraoperative nursing care (Maintain physical safety, intraoperative structural monitoring, physiological monitoring, treatment monitoring and psychological monitoring) and postoperative nursing care (nursing assessment, maintain physical safety, postoperative assessment recovery area, treatment monitoring, patient education and discharge planning).
►The total score of nurses’ performance checklist was (106) grades. From< 70 %grade was considered unsatisfactory performance. from ≥ 70 % grade was considered satisfactory performance as guided by (Dawes & O’Neill, 1999, 2009).
b- Observational checklist for surgeon’s performance;
To assess surgeon’s performance, it includes; patient condition, diagnostic test, patient instruction, treatment monitoring and Discharge plan monitoring.
►The total score of surgeon performance checklist was (24) grading as; from < 80%grade was considered unsatisfactory performance and from ≥ 80 % grade was considered satisfactory performance.
C-observational checklist for anesthesiologist’s performance;
To assess anesthesiologist’s performance, it include; assessing patient condition, patient instruction, treatment monitoring and postoperative recovery monitoring.
►The total score of anesthetist performance checklist was 22 grading as; from< 80 % grade was considered unsatisfactory performance. from ≥ 80 % grade was considered satisfactory performance.
D-observational checklist for physiotherapist’ performance; To assess physiotherapist’ performance, its related physical condition assessment and musculoskeletal evaluation” range of motion exercise” leg exercise, and pulmonary system evaluation” breathing exercise”, patient education and discharge plan monitoring.
►The total score of physiotherapist’ performance checklist was 15 grading as; from <60 % grade was considered unsatisfactory performance, and from ≥ 60 % grade was considered satisfactory performance.
E-observational checklist for dietitian’ performance;
To assess dietitian’ performance, it is related to assessment of nutritional status, patient instruction and discharge plan monitoring.
►The total score of dietitian’ performance checklist was 14 grading as; from < 60 % grade was considered unsatisfactory performance and from ≥ 60 % grade was considered satisfactory performance.
4-Modified pain intensity scales (Analogue Scale);
To assess the patient’s pain level in pre and post operative phases. According to Campbell, et al., (1995), for pain intensity the numeric pain scale is a 10 points scale. It consists of a line divided by points numbered from 0 to 10. Pain score is as follows;
(0) No Pain
(1 < 3) Mild Pain
(3 – 5) Moderate Pain
(6 -10) Severe Pain
5- Self rating anxiety scale (Appendix V);
To assess patient anxiety level (pre, post operative phases), it was translated into Arabic language, and constructed in 16 questions, each item has four possible answers, grade one, two, three and four points).
Scoring system: Self -rating Anxiety scale; consists of (16questions) with total score of (48 marks) graded into;
* Never (0) point
*Sometimes (1) points
*Always (2) points
*All times (3) points
The total patient scores were collected and arranged as follow;-
- The scores of responses less than 12 means no anxiety.
- The scores of responses from 12 to 23 mild anxiety.
- The scores of responses from 24 to 35 moderate anxiety.
- The scores of responses from 36 to 48 severe anxiety.
6- Post operative discharge recovery scale;
It was used to determine eligibility of outpatients undergoing one day surgeries. Its was used when patients can be safely discharged from the post anesthesia care unit to either the post surgical ward or to the second stage (Phase II) recovery area. The Aldrete scoring system utilizes numeric scores of 0, 1, or 2 assigned to activity, respiration, circulation, consciousness, oxygen saturation, dressing, pain ambulation, fasting, feeding, and urine output with a maximum total score of 20.
Scoring system; Post operative discharge recovery scale Consists of 10 items with total scores 20 marks. The total patient score was collected and ranged as follows; <18 of the patient total score were considered unfit for discharge and ≥ 18 of the patient total score was considered fit for discharge as guided by (Aldrete , 1997).
7- Patients’ needs assessment sheet (Appendix VII);
Based on patient assessment sheet, the patients’ needs assessment was developed and added by the researcher to summarize the physical and psychological needs of the patient during application of clinical pathway in one day surgeries for laparoscopic cholecystectomy through perioperative phases. It was done depending on the patient’s needs through perioperative phases, the expected patient’s outcomes were developed to meet the physical & psychological patient’s need, it was done for control & clinical pathway group.
8- Matrix pathway format (clinical pathway map):
Matrix pathway format was developed by the researcher, based on scientific references. The pathway consisted of the elements of clinical pathway; Patient Population, Outcomes, Time Frames and Interventional Categories.
It includes a plane of care depending on the patient’ needs perioperative laparoscopic cholecystectomy. The common predictable categories of clinical pathway map were represented as (consultants, diagnostics measures, vital signs, medications, treatment, diet/ fluid balances, assessment, nursing activity, patient education, and discharge planning each events was explained under perioperative phases time (preoperative phase, intraoperative phase and post operative phase)
9- Record of variance (Appendix IX);
It was used to record the other outcome measures. It included patient, interdisciplinary team members, and system variance, breakdowns in the system of clinical pathway. The variance record was divided into;-
(1). The variance Code , it included the code of the variance which was symbolized as; letter A for patients/family, letter B for care providers, C nursing, and letter D hospital / system. And letter it was documented in,
(2). Variance analysis, to collect and analyse the variance was met or not met. The items of variance analysis sheet were; variance code, reasons and actions taken.
* Additionally, the nurses’ guidelines had been developed according to the needs of patients undergoing laparoscopic cholecystectomy in one day surgeries, and designed as an illustrated Arabic languages booklet by the researcher. It was given for the nurses during application the clinical pathway.
Pilot study;
The pilot study was carried on 8 patients undergoing to laparoscopic cholecystectomy patients & was carried out by 6 nurses, 3 surgeons, 2 anesthesiologists, 2 physiotherapist and 2 dietitians about 10% from interdisciplinary team to test content validity and applicability of the tools. Few modifications were done according to the result of the expertise opinion and answers of the subjects to develop the final form.
Field work;
Data collection from this study was carried out in the period from the beginning of May 2006 to the end of May 2008, during morning and afternoon shifts in one day surgeries unit and surgical wards at Nasser Institute Hospital. Data were collected on six days of the week except on Friday.
Analysis of Results:
The results of the study showed that:
There was no statistic significant difference of patient’s assessment preoperative between control and clinical pathway groups
There was high statistic significant difference of patient assessment postoperative between control group and clinical pathway group related to gastrointestinal symptom, and statistic significant difference of patient assessment between control group and clinical pathway group related to temperature.
There were highly statistically significant difference regarding level of intensity of pain for pre and post operative phases in both control and clinical pathway groups.
There was high statistic significant difference regarding degree of patient anxiety between control and pathway groups at pre and post operative phase.
There was high statistic significant relation between patient’s outcome and their anxiety level regarding clinical pathway.
There was high statistic significant relation between patient’s outcome and their pain level in clinical pathway group.
There were no statistic significant difference regarding discharge recovery criteria scale between control group and clinical pathway group.
There was high statistic significant difference between patient’s needs in control group and patient’s needs in clinical pathway group regarding most items of preoperative phase.
There was high statistic significant difference between patient’s needs in control group and patient’s needs in clinical pathway group in the majority of postoperative needs items.
There were high statistic significant difference between control and clinical pathway group regarding the majority of patients’ outcomes.
That was high statistic significant difference between nurses regarding their knowledge related to laparoscopic cholecystectomy pre and post providing the guidelines.
Also, the majority of nurses in the hospital under study had a positive performance and attitude towards the cholecystectomy patients after clinical pathway implementation.
The mean score of nurses’ performance showed high statistic significant difference between pre and post clinical pathway implementation related to the three phases (pre, intra, and postoperative).
There was high statistic significant relation between nurses’ performance and knowledge regarding post clinical pathway implementation.
There was no difference among surgeons and anesthetists’ performance between pre and post clinical pathway implementation.
The mean score of physiotherapist’ performance showed that there was high statistic significant difference between pre and post clinical pathway implementation.
The mean score of dietitian’ total performance showed high statistic significant difference between pre and post clinical pathway implementation.
The majority of outcome complications of patient assessment at post operative phase regarding control and clinical pathway groups were distention in both control and clinical pathway groups. On the other hand the minimum complication is diarrhea in control group, and there was no diarrhea in clinical pathway group.
Conclusions;
1- Improvement was obvious in the patient’s physical conditions; decrease their length of stay, pain intensity, their anxiety level and the incidence of complications among them. Also, the majority of clinical pathway group of patients did not meet the variance.
2- Improvement of patient’s outcomes post clinical pathway implementation. So the present study findings supported the hypothesis that improvement in patient conditions, pain relief and decrease incidence of complication.
3- Additionally, there was obvious an improvement in the level of knowledge, performance of skills among nurses, otherwise, there was an improvement among physiotherapists and dietitians performance after application of clinical pathway.
Recommendations:
1- Provision of a booklet for care of patients undergoing laparoscopic cholecystectomy, as well as general advice relevant to day of surgery, should be available to be given to all newly admitted patients.
2- Upraising the awareness of developing clinical pathway support group using standard of care and including people improved and were in similar situation.
3- Replication of the current study on a large probability sample is recommended to wider utilization of the clinical pathway in different areas all over Egypt.
4- Continued monitoring and evaluation of outcomes provide critical information for the redesign of processes and practice change to improve future patient outcomes.
5- Patients should receive written information concerning preoperative preparation and postoperative care, to guarantee high quality and to reduce variations in the information that patients receive by verbal and written information.
6- Further study may useful to obtain the view points of management, medical, allied health and nursing staff on critical pathway in other units.
7- Further study, that continued use of the clinical pathways will decrease deviations from the standards of care and planned periodic evaluation of the pathways, will allow a refinement of outcome measurements