Operating Room Efficiency and Postoperative Recovery after Major Abdominal Surgery

80 Pages·2011·2.21 MB·English

by  Erebouni Arakelian

To Vahagn and Mher for sharing my life and
to my mother and father for your unconditional love and support
“Efficiency is doing better what is already being done.”
Peter F. Drucker
List of Papers
This thesis is based on the following papers, which are referred to in the text
by their Roman numerals.

I Arakelian E, Gunningberg L, Larsson J. Job satisfaction or
production? Variation in how staff and leadership understand
operating room efficiency: a qualitative study. Acta
Anaesthesiol Scand. 2008; 52:1423-28.

II Arakelian E, Gunningberg L, Larsson J. How operating room
efficiency is understood in a surgical team: a qualitative study.
Int J Qual Health Care. 2011; 23:100-6.

III Arakelian E, Gunningberg L, Larsson J, Norlén K, Mahteme
H. Factors influencing early postoperative recovery after
cytoreductive surgery and hyperthermic intraperitoneal
chemotherapy Eur J Surg Oncol. 2011; 37:897-903.

IV Arakelian E, Torkzad M, Bergman N, Rubertsson S, Mahteme
H. Pulmonary influences on early postoperative recovery in
patients after cytoreductive surgery and hyperthermic
intraperitoneal chemotherapy treatment. (Submitted).

Reprints were made with permission of the publishers.

Contents
Introduction ................................................................................................... 11
Background ................................................................................................... 13
The concept of efficiency ......................................................................... 13
Efficient organisations according to management theories from
Taylor to Lean Production ................................................................... 14
The Peritoneal Carcinomatosis (PC) team’s work procedure .............. 15
Recovering from cytoreductive surgery ................................................... 16
Peritoneal Carcinomatosis (PC) ........................................................... 17
Tumour spread and symptoms ............................................................. 17
Loco-regional treatment of PC ............................................................ 18
Cytoreductive surgery (CRS) .............................................................. 18
Peritoneal Cancer Index (PCI) ............................................................. 19
Completeness of Cytoreduction (CC) Score ........................................ 19
Hyperthermic Intraperitoneal Chemotherapy (HIPEC) ....................... 20
Anaesthesia .......................................................................................... 21
Postoperative recovery ......................................................................... 22
Overall and specific aims .............................................................................. 25
Methods ........................................................................................................ 26
Design ...................................................................................................... 26
Qualitative research method ..................................................................... 27
Phenomenography ............................................................................... 27
The context of the study and the participants ...................................... 28
Phenomenographic analysis ................................................................. 28
Quantitative research methods ................................................................. 29
Study procedure and participants ......................................................... 29
Anaesthesia, surgical treatments, and recovery ................................... 30
Data collection and study variables ..................................................... 33
Statistical Methods .............................................................................. 34
Ethical considerations .............................................................................. 35
Results ........................................................................................................... 36
Paper I ...................................................................................................... 36
Efficiency in a non-team organisation ................................................. 36
Paper II ..................................................................................................... 39
Efficiency in a team organisation ........................................................ 39
Paper III .................................................................................................... 42
Early postoperative recovery after surgery .......................................... 42
Factors correlated with early postoperative recovery .......................... 44
Paper IV ................................................................................................... 44
Postoperative recovery after pulmonary AE in the intervention and
non-intervention group ........................................................................ 44
Pulmonary adverse events ................................................................... 45
Factors correlated with pulmonary adverse events .............................. 46
Discussion ..................................................................................................... 48
The concept of efficiency in different organisational settings ................. 48
Early postoperative recovery from CRS and HIPEC ............................... 50
Physiological dimension of early postoperative recovery and
activity in patients with PC .................................................................. 50
Psychological health ............................................................................ 51
Factors to consider when planning postoperative recovery ................. 52
Pulmonary AE and related factors ....................................................... 52
Invasive intervention does not affect postoperative recovery .............. 53
Organised surgical teams and preoperative patient preparation- steps
to increase efficiency in the care of patients ........................................ 54
Methodological considerations ................................................................. 55
Paper I .................................................................................................. 56
Paper II ................................................................................................ 57
Paper III ............................................................................................... 57
Paper IV ............................................................................................... 58
Conclusions ................................................................................................... 59
Clinical implications and future research ...................................................... 60
Svensk sammanfattning (Swedish summary) ............................................... 62
Delarbete I ................................................................................................ 63
Delarbete II ............................................................................................... 64
Delarbete III ............................................................................................. 64
Delarbete IV ............................................................................................. 65
Slutsats ..................................................................................................... 66
Förslag till framtida forskning .................................................................. 66
Acknowledgements ....................................................................................... 67
References ..................................................................................................... 70
Abbreviations
AE Adverse Event
ASA American Society of Anaesthesiologists’
physical status classification system
CC score Completeness of Cytoreduction Score
CPAP Continuous Positive Airway Pressure
CRC Colorectal Cancer
CRS Cytoreductive Surgery
EHR Electronic Health Record
HIPEC Hyperthermic Intra Peritoneal Chemotherapy
OR Operating Room
MAM Malignant Abdominal Mesothelioma
MMC Mitomycin C
NA Nurse Anaesthetist
PC Peritoneal Carcinomatosis
PCI Peritoneal Cancer Index
PEF Peak Expiratory Flow
PMP Pseudomyxoma Peritonei
RN Registered Nurse