Decreasing the Preincision Time for Pulmonary Lobectomy: The Process of Lean and Value Stream Mapping

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• 作者：Robert James Cerfolio ; MD ; MBA^a ; ^{rcerfolio@uabmc.edu" class="auth_mail" title="E-mail the corresponding author} ; Brad L. Steenwyk ; MD^b ; Caroline Watson ; BS^b ; James Sparrow ; MD^b ; Victoria Belopolsky ; MD^b ; Matthew Townsley ; MD^b ; Ralph Lyerly ; MD^b ; Michelle Downing ; MD^b ; Ayesha Bryant ; MD^a ; William Quinton Gurley ; MD^b ; Colleen Henling ; MD^b ; Jack Crawford ; MD^b ; Thomas E. Gayeski ; MD^b
• 刊名：The Annals of Thoracic Surgery
• 出版年：2016
• 出版时间：March 2016
• 年：2016
• 卷：101
• 期：3
• 页码：1110-1115
• 全文大小：608 K

文摘

Our objective was to evaluate our results after the implementation of lean (the elimination of wasteful parts of a process).

Methods

After meetings with our anesthesiologists, we standardized our “in the operating room-to-skin incision protocols” before pulmonary lobectomy. Patients were divided into consecutive cohorts of 300 lobectomy patients. Several protocols were slowly adopted and outcomes were evaluated.

Results

One surgeon performed 2,206 pulmonary lobectomies, of which 84% were for cancer. Protocols for lateral decubitus positioning changed over time. We eliminated axillary rolls, arm boards, and beanbags. Monitoring devices were slowly eliminated. Central catheters decreased from 75% to 0% of patients, epidurals from 84% to 3%, arterial catheters from 93% to 4%, and finally, Foley catheters were reduced from 99% to 11% (p ≤ 0.001 for all). A protocol for the insertion of double-lumen endotracheal tubes was established and times decreased (mean, 14 minutes to 1 minute; p = 0.001). After all changes were made, the time between operating room entry and incision decreased from a mean of 64 minutes to 37 minutes (p < 0.001). Outcomes improved, mortality decreased from 3.2% to 0.26% (p = 0.015), and major morbidity decreased from 15.2% to 5.3% (p = 0.042).

Conclusions

Lean and value stream mapping can be safely applied to the clinical algorithms of high-risk patient care. We demonstrate that elimination of non–value-added steps can safely decrease preincision time without increasing patient risk in patients who undergo pulmonary lobectomy. Selected centers may be able to adopt some of these lean-driven protocols.