Re-engineering the elective surgical service of a tertiary hospital: a historical controlled trial

Objective: To study the clinical effects of re-engineering the processes associated with elective surgery. Design: A prospective, historical controlled trial. Control patients were enrolled from March 1995 to January 1996, and postintervention patients from February 1996 to October 1996. Setting: A major teaching, tertiary care hospital (Prince of Wales Hospital, Sydney). Patients: 224 patients (123 before and 101 after the intervention) undergoing elective herniorrhaphy or laparoscopic cholecystectomy who lived in the local area. Intervention: Introduction of a re-engineered surgical service consisting of preadmission assessment and education, admission on day of surgery, and postacute care after discharge. There were no changes to the operative methods or infection control procedures. Main outcome measures: Length of stay, operative complications, pain scores and patient satisfaction. Results: The risk of a patient suffering one or more complications was reduced in the postintervention group (postintervention v. control patients: 25.7% v. 38.2%; relative risk [RR], 0.66; 95% confidence interval [CI], 0.44-0.98; P=0.035) because of a reduced risk of wound infections (5.0% v. 16.3%; RR, 0.30; 95% CI, 0.12-0.78; P=0.0075). Other complications (perioperative or postoperative) and pain scores were unchanged. Patients treated by the re-engineered service had a significantly shorter length of stay, reported a higher level of satisfaction with the preoperative and postdischarge care, and were more likely to say that they would have the same treatment again (92.9% v 82.6%; P=0.037). Conclusions: Re-engineering surgical services, with an associated reduction in length of stay, does not lead to a deterioration in care and may decrease postoperative complications and increase patient satisfaction.