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Implementation of a Critical Pathway for Distal Pancreatectomy at an Academic Institution

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Journal of Gastrointestinal Surgery

Abstract

Objective

This study was designed to identify quantifiable parameters to track performance improvements brought about by the implementation of a critical pathway for complex alimentary tract surgery.

Background

Distal pancreatectomy is among the more complex general surgical procedures. This is primarily due to the possibility of blood loss from visceral vessels, splenic injury, and significant postoperative complications. The introduction of the laparoscopic approach to the distal pancreas has introduced a further level of surgical expertise required to fully address the clinical needs of this diverse patient population. Critical pathways have been one of the key tools used to achieve consistently excellent outcomes at high-quality, high-volume institutions. It remains to be determined if implementation of a critical pathway at an academic institution with prior moderate experience with distal pancreatectomy will result in performance gains and improved outcomes.

Methods

Between January 1, 2003 and August 15, 2007, 111 patients underwent distal pancreatectomy. Forty patients underwent resection during the 34-month period before the implementation of a critical pathway on October 15, 2005 and 71 during the 20 months after pathway implementation. Patients undergoing both open and laparoscopic procedures were included. Peri- and postoperative parameters were analyzed retrospectively to identify those that could be used to track performance improvement and outcomes.

Results

The two groups were not significantly different with respect to age, sex, race, diagnosis, operative blood loss, or mean operative duration. Postoperative length of hospital stay was significantly shorter when comparing pre- to postpathway implementation (10.2 days versus 6.7 days, P ≤ 0.037). The rate of readmission to the hospital after discharge was significantly lower post pathway (25% versus 7%, P ≤ 0.027). Hospital costs were also reduced.

Conclusion

Implementation of a critical pathway for a complex procedure can be demonstrated to improve short-term outcomes at an academic institution. This improvement can be quantified and tracked and has implications for better utilization of resources and overall cost containment while maintaining or improving upon an already high level of care.

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References

  1. Porter ME, Teisberg EO. Redefining Health Care : Creating Value-Based Competition on Results. Boston: Harvard Business School Press, 2006, p 382.

    Google Scholar 

  2. Kennedy EP, Rosato EL, Sauter PK, Rosenberg LM, Doria C, Marino IR, et al. Initiation of a critical pathway for pancreaticoduodenectomy at an academic institution—the first step in multidisciplinary team building. J Am Coll Surg 2007;204(5):917–923. discussion 923–4. doi:10.1016/j.jamcollsurg.2007.01.057.

    Article  PubMed  Google Scholar 

  3. Porter GA, Pisters PW, Mansyur C, Bisanz A, Reyna K, Stanford P, et al. Cost and utilization impact of a clinical pathway for patients undergoing pancreaticoduodenectomy. Ann Surg Oncol 2000;7(7):484–489. doi:10.1007/s10434-000-0484-0.

    Article  PubMed  CAS  Google Scholar 

  4. Pitt HA, Murray KP, Bowman HM, Coleman J, Gordon TA, Yeo CJ, et al. Clinical pathway implementation improves outcomes for complex biliary surgery. Surgery 1999;126(4):751–756. discussion 756–8.

    PubMed  CAS  Google Scholar 

  5. Wichmann MW, Roth M, Jauch KW, Bruns CJ. A prospective clinical feasibility study for multimodal “fast track” rehabilitation in elective pancreatic cancer surgery. Rozhl Chir 2006;85(4):169–175.

    PubMed  CAS  Google Scholar 

  6. Pritts TA, Nussbaum MS, Flesch LV, Fegelman EJ, Parikh AA, Fischer JE. Implementation of a clinical pathway decreases length of stay and cost for bowel resection. Ann Surg 1999;230(5):728–733. doi:10.1097/00000658-199911000-00017.

    Article  PubMed  CAS  Google Scholar 

  7. Stephen AE, Berger DL. Shortened length of stay and hospital cost reduction with implementation of an accelerated clinical care pathway after elective colon resection. Surgery 2003;133(3):277–282. doi:10.1067/msy.2003.19.

    Article  PubMed  Google Scholar 

  8. Cerfolio RJ, Bryant AS, Bass CS, Alexander JR, Bartolucci AA. Fast tracking after Ivor Lewis esophagogastrectomy. Chest 2004;126(4):1187–1194. doi:10.1378/chest.126.4.1187.

    Article  PubMed  Google Scholar 

  9. Huber TS, Carlton LM, Harward TR, Russin MM, Phillips PT, Nalli BJ, et al. Impact of a clinical pathway for elective infrarenal aortic reconstructions. Ann Surg. 1998;227(5):691–699. discussion 699–701. doi:10.1097/00000658-199805000-00009.

    Article  PubMed  CAS  Google Scholar 

  10. Leibman BD, Dillioglugil O, Abbas F, Tanli S, Kattan MW, Scardino PT. Impact of a clinical pathway for radical retropubic prostatectomy. Urology 1998;52(1):94–99. doi:10.1016/S0090-4295(98)00130-7.

    Article  PubMed  CAS  Google Scholar 

  11. Markey DW, McGowan J, Hanks JB. The effect of clinical pathway implementation on total hospital costs for thyroidectomy and parathyroidectomy patients. Am Surg 2000;66(6):533–538. discussion 538–9.

    PubMed  CAS  Google Scholar 

  12. Kehlet H. Future perspectives and research initiatives in fast-track surgery. Langenbecks Arch Surg. 2006;391(5):495–498. doi:10.1007/s00423-006-0087-8.

    Article  PubMed  Google Scholar 

  13. Campbell H, Hotchkiss R, Bradshaw N, Porteous M. Integrated care pathways. BMJ 1998;316(7125):133–137.

    PubMed  CAS  Google Scholar 

  14. Lillemoe KD, Kaushal S, Cameron JL, Sohn TA, Pitt HA, Yeo CJ. Distal pancreatectomy: Indications and outcomes in 235 patients. Ann Surg 1999;229(5):693–698. discussion 698–700. doi:10.1097/00000658-199905000-00012.

    Article  PubMed  CAS  Google Scholar 

  15. Kooby DA, Gillespie T, Bentrem D, Nakeeb A, Schmidt MC, Merchant NB, et al. Left-sided pancreatectomy: A multicenter comparison of laparoscopic and open approaches. Ann Surg 2008;248(3):438–446. doi:10.1097/SLA.0b013e318185a990.

    PubMed  Google Scholar 

  16. Halpern SD, Ubel PA, Asch DA. Harnessing the power of default options to improve health care. N Engl J Med. 2007;357(13):1340–1344. doi:10.1056/NEJMsb071595.

    Article  PubMed  CAS  Google Scholar 

  17. Cornia PB, Amory JK, Fraser S, Saint S, Lipsky BA. Computer-based order entry decreases duration of indwelling urinary catheterization in hospitalized patients. Am J Med 2003;114(5):404–407. doi:10.1016/S0002-9343(02)01568-1.

    Article  PubMed  Google Scholar 

  18. Wald HL, Ma A, Bratzler DW, Kramer AM. Indwelling urinary catheter use in the postoperative period. Arch Surg 2008;143(6):551–557. doi:10.1001/archsurg.143.6.551.

    Article  PubMed  Google Scholar 

  19. Bassi C, Dervenis C, Butturini G, Fingerhut A, Yeo C, Izbicki J, et al. Postoperative pancreatic fistula: An international study group (ISGPF) definition. Surgery 2005;138(1):8–13. doi:10.1016/j.surg.2005.05.001.

    Article  PubMed  Google Scholar 

  20. Dy SM, Garg P, Nyberg D, Dawson PB, Pronovost PJ, Morlock L, et al. Critical pathway effectiveness: Assessing the impact of patient, hospital care, and pathway characteristics using qualitative comparative analysis. Health Serv Res 2005;40(2):499–516. doi:10.1111/j.1475-6773.2005.0r370.x.

    Article  PubMed  Google Scholar 

  21. Dy SM, Garg PP, Nyberg D, Dawson PB, Pronovost PJ, Morlock L, et al. Are critical pathways effective for reducing postoperative length of stay? Med Care 2003;41(5):637–648. doi:10.1097/00005650-200305000-00011.

    Article  PubMed  Google Scholar 

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Acknowledgments

The authors would like to acknowledge the nursing staff of the Thomas Jefferson University Hospital and the house officers of the Thomas Jefferson University Department of Surgery for their excellent care of the patients discussed in this manuscript and their enthusiastic assistance in implementing critical pathways. Additionally, we would like to thank Jay Sial, C.O.O. JeffCARE, Inc. and Dianne MacRae for their assistance in preparing this manuscript.

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Correspondence to Eugene P. Kennedy.

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Kennedy, E.P., Grenda, T.R., Sauter, P.K. et al. Implementation of a Critical Pathway for Distal Pancreatectomy at an Academic Institution. J Gastrointest Surg 13, 938–944 (2009). https://doi.org/10.1007/s11605-009-0803-0

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  • DOI: https://doi.org/10.1007/s11605-009-0803-0

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