クリニカルパスを用いた前立腺全摘除術周術期管理標準化の多施設共同研究  [in Japanese] A MULTI-CENTER STUDY FOR STANDARDISATION OF PERIOPERATIVE MANAGEMENT OF RADICAL PROSTATECTOMY USING CLINICAL PATHWAYS  [in Japanese]

(目的)これまでの調査で,全国の病院における前立腺全摘除術の周術期管理にはばらつきが多いことがわかっている.クリニカルパスの手法を用いて術後管理法の標準化を目指し,多施設共同研究を行った.(対象と方法)第1期(2004年1月〜12月)に全国8施設において行われた前立腺全摘除術の周術期成績を集計した.その結果を各施設間で公表,協議し,それを参考にそれぞれの施設でクリニカルパスを作成または改定した.第2期(2005年1月〜2006年3月)に実際にパスを使用し,その成績を集計し,比較検討した.(結果)8施設において,第1期378例,第2期360例が登録された.討議後に作成したパスの設定は似かよったものとなった.第2期の術後成績の中央値のほとんどはパスの設定と等しく,パスの設定どおりに管理が行われたと思われた.2つの期間で,飲水開始日,食事開始日,硬膜外麻酔カテーテル抜去日,ドレーン抜去日はそれぞれ1.2±0.7日→1.3±1.4日,1.9±1.2日→1.8±1.7日,2.4±0.7日→2.5±0.6日,3.8±2.5日→3.8±2.8日と変らなかったが,歩行開始日,持続点滴終了日,静注抗菌薬終了日はそれぞれ1.9±0.9日→1.5±0.6日,3.7±2.1日→3.1±2.2日,3.6±2.0日→2.5±2.2日と早期に行われるようになった.尿道カテーテル抜去日は9.1±4.9→8.6±5.4日とあまり変化がなかったが,術前入院期間は3.4±2.1日→2.5±1.0日,カテーテル抜去から退院までの期間は8.9±10.1日→5.6±3.8日,術後入院期間は17.9±10.9日→14.4±9.1日と大幅に短縮され,かつばらつきも減少した.(結論)各施設間で成績を開示しあうことにより,作成されたクリニカルパスは似かよったものになり,それに基づいた管理を行うことにより前立腺全摘除術の周術期管理の標準化を進めることができると考えられた.

(Purpose) Our previous study indicated that there was a great variety in the perioperative management of radical prostatectomy among hospitals. Therefore we conducted a multiinstitutional study in order to standardize the perioperative management using clinical pathways. (Materials and methods) The perioperative data on radical prostatectomy were collected between January and December 2004 (Period 1) from eight hospitals. These outcomes were discussed by researchers and the clinical pathway used at each hospital was constructed or revised. The outcomes using these pathways in Period 2 (January 2005 to March 2006) were compared with those in Period 1. (Results) Three hundred seventy-eight men in Period 1 and 360 in Period 2 were enrolled in this study. The settings of perioperative management using the new pathways were relatively similar among hospitals. A majority of perioperative management procedures in Period 2 were conducted as described in the new clinical pathways, judging from the median days. The day of initiating the resumption of fluid intake, meals and removing the epidural anesthetic catheter and drain changed from 1.2±0.7 to 1.3±1.4 postoperative day, 1.9±1.2 to 1.8±1.7, 2.4±0.7 to 2.5±0.6, 3.8±2.5 to 3.8±2.8, respectively, without a significant difference. The postoperative day of initiating the walking and discontinuing continuous drip infusion and intravenous antibiotics were shortened from 1.9±0.9 to 1.5±0.6, 3.7±2.1 to 3.1±2.2 and 3.6±2.0 to 2.5±2.2, respectively, which did show a significant difference. The day of removing the urethral catheter was changed 9.1±4.9 to 8.6±5.4 without significant difference. But the durations of preoperative hospitalization, hospitalization after removing the urethral catheter and postoperative hospitalization were significantly shortened from 3.4±2.1 to 2.5±1.0 days, 8.9±10.1 to 5.6±3.8, and 17.9±10.9 to 14.4±9.1, respectively. (Conclusions) The clinical pathways established or revised at these hospitals after discussing the perioperative management in multiple hospitals were similar, and using such pathways advanced the standardization of peri-operative management after radical prostatectomy.