Developing better critical paths in healthcare: combining 'best practice' and the quantitative approach

Reduction of pulmonary complications and hospital length of stay with a clinical care pathway after head and neck reconstruction

BACKGROUND

Pulmonary complications are common after major head and neck oncologic surgery with microsurgical reconstruction and are associated with increased mortality and morbidity. Clinical care pathways are evidence-based tools that reduce unnecessary practice variation and ultimately improve patient outcomes. In this study, the authors evaluate the effectiveness of a comprehensive care pathway on reducing postoperative pulmonary complications and hospital length of stay in patients undergoing major head and neck carcinoma resection with free flap reconstruction.

METHODS

Fifty-five consecutive patients treated according to a prescribed postoperative clinical care pathway were compared to a historical cohort of patients treated before the implementation of the pathway. The incidence of pulmonary complications, hospital length of stay, and free flap survival were compared between the control and intervention groups.

RESULTS

Patients on the clinical care pathway had 32.5 percent fewer pulmonary complications (p < 0.0001) and 7.4 days' shorter hospital length of stay (p = 0.0007) than patients not on the postoperative pathway. There was no significant difference in the rate of flap reoperation.

CONCLUSIONS

A multidisciplinary, comprehensive, clinical care pathway for patients undergoing major head and neck surgery with microsurgical reconstruction is effective in reducing postoperative pulmonary complications and hospital length of stay. The postoperative pathway is safe in this patient population and should be considered for adoption into clinical practice.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Decreasing medical complications for total knee arthroplasty: effect of critical pathways on outcomes

Background

Studies on critical pathway use have demonstrated decreased length of stay and cost without compromise in quality of care. However, pathway effectiveness is difficult to determine given methodological flaws, such as small or single center cohorts. We studied the effect of critical pathways on total knee replacement outcomes in a large population-based study.

Methods

We identified hospitals in four US states that performed total knee replacements. We sent a questionnaire to surgical administrators in these hospitals including items about critical pathway use and hospital characteristics potentially related to outcomes. Patient data were obtained from Medicare claims, including demographics, comorbidities, 90-day postoperative complications and length of hospital stay. The principal outcome measure was the risk of having one or more postoperative complications.

Results

Two hundred ninety five hospitals (73%) responded to the questionnaire, with 201 reporting the use of critical pathways. 9,157 Medicare beneficiaries underwent TKR in these hospitals with a mean age of 74 years (± 5.8). After adjusting for both patient and hospital related variables, patients in hospitals with pathways were 32% less likely to have a postoperative complication compared to patients in hospitals without pathways (OR 0.68, 95% CI 0.50-0.92). Patients managed on a critical pathway had an average length of stay 0.5 days (95% CI 0.3-0.6) shorter than patients not managed on a pathway.

Conclusion

Medicare patients undergoing total knee replacement surgery in hospitals that used critical pathways had fewer postoperative complications than patients in hospitals without pathways, even after adjusting for patient and hospital related factors.

This study has helped to establish that critical pathway use is associated with lower rates of postoperative mortality and complications following total knee replacement after adjusting for measured variables.

A critical pathway for intimate partner violence across the continuum of care

OBJECTIVE

The authors developed an interdisciplinary critical pathway for intimate partner violence (IPV) assessment and intervention for use across health care settings. Intimate partner violence may be emotional, physical, and/or sexual and involves coercion and control by one partner over the other.

DESIGN

A pathway developed with input from focus groups of battered women was subjected to a modified Delphi technique to improve the pathway's scientific accuracy and feasibility.

SETTING

The study was conducted in one urban, one suburban, and one rural hospital with IPV advocacy programs in the mid-Atlantic region of the United States.

PATIENTS/PARTICIPANTS

Four researchers and 13 clinicians participated in the validation, with at least one physician, one nurse, and one social worker or IPV counselor from each hospital.

MAIN OUTCOME MEASURES

Each element of the pathway was analyzed for the degree of consensus on scientific accuracy and feasibility.

RESULTS

Consensus on the scientific accuracy and feasibility of the pathway was achieved after three rounds of the Delphi process.

CONCLUSIONS

This is the first known critical pathway for IPV. It addresses physical and mental health and safety and has content validity affirmed by an interdisciplinary panel of experts. Further process and outcome evaluation is warranted and invited.

Critical pathways. A systematic review

Critical pathways are care plans that detail the essential steps in patient care with a view to describing the expected progress of the patient. The authors' review of the literature suggest the use of critical pathways reduces the cost of care and the length of patient stay in hospital. They also have a positive impact on outcomes, such as increased quality of care and patient satisfaction, improved continuity of information, and patient education.

Is hospital case management a rationalized myth?

In this article the adoption of case management processes in US hospitals is discussed. While such process change is prevalent, there is a paucity of systematic empirical evidence that hospital case management improves efficiency or effectiveness. Using an institutional theoretical framework, motivations other than improved efficiency and effectiveness are proposed that may drive hospitals to adopt change to their technical core processes, in the form of case management. Further research using these propositions as an adjunct to cost-benefit analyses would be important to validate the rationale behind the widespread adoption of hospital case management processes.