Integrated care pathways have been shown to standardise and improve patient care as well as reduce hospital cost and length of stay(Reference Olsson, Hansson and Ekman1, Reference Rotter, Kugler and Koch2). The aim of devising an integrated care pathway document for upper gastrointestinal patients was to ensure that patients would progress as optimally and as rapidly as allowed, thus improving their overall patient experience. Return to oral intake, and length of hospital were audited in a patient group pre and post the introduction of an Integrated Care Pathway (ICP) to determine its effect.
A sample of patients which had received surgery prior to the ICP (n 9) was compared with a sample of patients who received surgery after the introduction of the ICP (n 12) for subtotal gastrectomy. Data were collected retrospectively on the aspects currently covered in the ICP and used to compare the two groups.
Following the introduction of the ICP, the average length of stay reduced from a median of 13–10.5 d. The audit shows the median time to diet decreased from day 5 to day 4.
It is difficult to make any conclusions based on such a small sample group, however, it is noted that the length of stay did decrease as did the period of time patients were kept without adequate nutrition. A higher percentage of patients in the post-ICP group began sips on day 1 (83% v. 56%) and a higher percentage of patients in the post-ICP began free fluids on day 2 and 3 post operatively (66% v. 55%). Oral intake of soft diet was also faster in the post-ICP group with most starting diet on day 3 and 4 post-operatively (58% v. 22%). A higher percentage of patients were discharged home within the first 10 d in the post-ICP group, and fewer patients stayed over 2 weeks with 92% of patients having been discharged in the first 2 weeks v. 77%. The average cost of a day in a hospital bed is over £500 and this would therefore have a large cost saving implication.
To date no other centre in the UK is starting their patients on sips, free fluids or diet earlier, and some centres are still keeping their patients NBM routinely until day 5 – there is no evidence supporting such practice, however, there is historically anxiety surrounding beginning early oral intake with anostomoses high up in the digestive tract and the desire of surgeons to protect their anastomoses by preventing the passage of substances past this area. There appears to be no disadvantage from the patient group included to earlier scheduled oral intake; on the contrary starting patients on sips and free fluids earlier is more comfortable for patients and facilitates an earlier discharge as well as preventing unnecessary restriction of nutrients in an already at risk and vulnerable patient group.
The development of an ICP is beneficial to the patient's progress by allowing them to begin early oral intake sooner and therefore, improve their nutritional intake sooner. It provides an infra-structure to staff looking after this patient group to minimise inconsistencies and promote optimal care. It is also of financial advantage to the institution.
