Abstract:
The peripheral vascular surgeons at NYU Medical Center provide a valuable, often limb-saving service to patients who have serious medical conditions resulting from obstruction in the arteries that supply blood to the legs. When treating the most severely ill patients, they circumvent the arterial blockage by surgically inserting natural or synthetic grafts. However, these grafts may eventually deteriorate or become occluded, and each "leg-bypass" operation entails a protracted, uncomfortable recovery period. Therefore, the physicians employ non-surgical procedures whenever possible. This prudent clinical policy reduces patient discomfort and minimizes the risk of infection.
The average length of stay among the patients who are treated surgically is, understandably, greater at NYU than at medical centers where surgery is frequently performed on patients with less advanced illness. Nonetheless, a team of analysts led by Dr. Patrick Lamparello has recently identified some immediate opportunities to shorten both the pre- and post-operative stays of leg-bypass patients. Dr. Lamparello and his colleagues will also evaluate minimally invasive procedures that could reduce the length of stay dramatically while significantly lessening patients' post-surgical discomfort.
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Frequent Use of Non-Invasive Techniques Maximizes Safety and Minimizes Surgical Trauma
With the advice of Dr. Patrick Lamparello, who was asked by Dr. Thomas Riles to oversee the development of guidelines for leg-bypass procedures a team of analysts recently reviewed the medical charts of 50 patients. They concluded that surgical revascularization at NYU Medical Center is usually reserved for patients with advanced chronic ischemia (insufficient oxygenation of tissue due to progressive arterial narrowing). Whenever possible, the physicians at NYU Medical Center use non-surgical techniques (clot-dissolving drugs or balloon angioplasty) to treat peripheral vascular disease. This prudent clinical policy minimizes the possibility of infection and reduces the number of patients who are subjected to the trauma of surgery. In contrast, physicians at other hospitals frequently treat claudication (painful but not limb-threatening partial arterial blockage) surgically.
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Severity of Illness Among Patients Treated Surgically Creates Illusion of Excessively Long Length of Stay
The intensity of the ischemic problems among the relatively few patients who are treated surgically at NYU was underscored by the finding that half of them had been admitted with cellulitis or infected, gangrenous, or non-healing ulcers. The severity of illness among these patients accounts for the relatively long average hospital stay at NYU Medical Center for leg-bypass procedures. The average stay among the 50 patients included in the study was 10.2 days, which is 1.1 days more than the corresponding average for patients treated at the academic medical centers in the
University HealthSystem Consortium (UHC). However, because the physicians at NYU Medical Center use surgical techniques (which necessitate some recovery time in the hospital) sparingly, the total cost of treating all patients with lower-extremity peripheral vascular disease may well be lower at NYU Medical Center than at institutions that perform surgery more frequently.
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Other Challenges at NYU Medical Center
Any program for improving the quality of care must acknowledge the particular challenges posed by NYU Medical Center's complex patient population. Many patients referred to NYU Medical Center have complicated medical histories, and they frequently come to the hospital with a combination of serious problems. A remarkable number of patients in the leg-bypass study had complicating conditions such as diabetes (60 percent), arteriosclerotic heart disease (54 percent), and hypertension(48 percent). These rates are significantly higher than the corresponding rates for other academic hospitals, based on data from the UHC.
The complexity of illness among the patients at NYU Medical Center is partially related to their advanced age. The average age of the patients in the study was 72 (versus 65 at the UHC), and 20 percent were more than 85 years old (versus four percent at the UHC).
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Immediate Opportunities to Expedite Care
Despite the challenges, Dr. Lamparello and others have identified several opportunities for reducing both the average pre-operative stay (2.6 days) and post-operative stay (7.6 days).
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Earlier Evaluation Could Reduce the Pre-Operative Period
More than two-thirds of the non-emergent patients required angiograms and cardiac consultations, which in most cases were not performed until the second hospital day or later. Similarly, echocardiograms and stress tests were typically performed two days after admission. The peripheral vascular surgeons and the physicians who perform these diagnostic procedures are developing a new system to improve the scheduling of these services. This should allow many pre-operative tests and consultations to be conducted prior to hospital admission, sometimes permitting surgery on the day of admission. Where outpatient testing is not appropriate or feasible, it should be possible to schedule the diagnostic procedures for the day of admission.
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Restoring Patient Function More Swiftly After Surgery
The analysts have also identified several opportunities to accelerate patients' post-operative recovery:
Enhancing Patient Mobility:
A key milestone in recovery from surgery, including leg revascularization, is reached when patients are able to get out of bed and walk. But with an incision that runs from groin to ankle and consequent soreness at the knee, these walks can be quite painful. Almost one-third of the patients had to restrict their initial post-surgical ambulation because of pain from the surgical wound or other causes. Only 56 percent of those who found walking painful had been given medication for pain. Although medical complications sometimes restrict the use of pain medication, Dr. Lamparello is looking into ways to provide pharmacological relief to as many patients as possible so they can exercise soon after surgery and recover quickly.
Rapidly Reinitiating Anticoagulation Therapy:
Almost one-third of the patients were taking coumadin (an anticoagulant) prior to surgery but had to be switched to heparin to prevent excess surgical bleeding. Switching back to coumadin is a key step in the early post-operative period, but half of these patients did not return to coumadin for two or more days after surgery. With careful monitoring of blood levels, it should be possible to safely reinitiate anticoagulation therapy for most patients within 24 hours after surgery.
Consultation with Infectious Disease Specialists:
Although virtually all patients received prophylactic antibiotics both immediately before and after their surgery, 14 percent of the patients received post-surgical treatment for reddened or infected suture lines. In order to expedite recovery, the peripheral vascular surgeons may consult sooner with infectious disease specialists.
Sub-Acute Care Options:
Some patients could return more quickly to independent living if appropriate options (possibly in-house) were identified for those who no longer need acute care but still require physical therapy, wound management, or reinitiation of anticoagulation therapy.
The Rusk Institute of Rehabilitation is one existing option, but only 22 percent of the patients in the study were discharged to Rusk. Some patients, although no longer in need of acute care, did not meet Rusk's ambulation criteria. Other patients were eligible for transfer but could not do so promptly because of a scarcity of beds at Rusk and delays in the approval process.
A subcommittee of the Case Management and Clinical Pathways Program is investigating ways to expedite transfer of eligible patients to Rusk. Other options for patients recovering from leg-bypass surgery will be explored as the Medical Center re-evaluates how it provides sub-acute care to a variety of patients.
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Dramatic Potential of Minimally Invasive Surgery
Techniques for performing revascularization with minimal incisions are being tested and refined at leading medical centers across the country. Since these procedures involve fewer and much smaller incisions, a significant reduction in patient discomfort and length of stay should occur wherever they are employed. Indeed, patients receiving this treatment may often be ready for ambulation and discharge on the day after surgery.
According to Dr. Lamparello, minimally invasive leg-bypass procedures will be available soon at NYU Medical Center as part of a study. The peripheral vascular surgeons will monitor the findings closely because they hope to take a pioneering role in this field. The benefits could be great. Dr. Lamparello believes that, in addition to providing better and more cost-effective care for patients with chronic ischemia, the less invasive methods may justify surgical intervention earlier in the course of illness.
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For Further Information
Contact:
Dr. Patrick J. Lamparello, MD
Dr. Thomas S. Riles, MD
New York University Medical Center
Vascular Surgery & HCC-6F
550 First Avenue
New York, New York 10016
(212) 263-7311
or
e-mail Dr. Lamparello:
patrick.lamparello@ccmail.med.nyu.edu
Webmaster: Neil Wintfeld, PhD
© Copyright 1998
Department of Clinical Evaluation and Outcomes Research
New York University Medical Center
All rights reserved.
