Monday, November 27, 2006

What Works -- Part 2 -- Clinical Pathways

The Whipple procedure is a complicated and difficult surgical procedure. It is also called a pancreaticoduodenectomy, and it generally encompasses the removal of the gallbladder, common bile duct, part of the duodenum, and the head of the pancreas.This operation was first described by Dr. Alan O. Whipple of New York Memorial Hospital (now Memorial Sloan-Kettering).

The surgeons at BIDMC have developed a "clinical pathway" to guide themselves, related physician specialists, nurses, case managers and other involved in performing Whipples and taking care of patients before, during, and after this surgery. The clinical pathway is intended to assist physicians in clinical decision making by describing a range of generally acceptable interventions and outcomes. In other fields, it might be called a "decision tree." The guidelines attempt to define practices that meet the needs of most patients under most circumstances. While the physician must remain alert to deviations from the expected, the use of the clinical pathway can bring greater predictability to the entire treatment process in many cases.

The introduction of the clinical pathway for Whipple procedures at BIDMC has had very positive results. Here is a summary of the data pre- and post-clinical pathway.

Pre-clinical pathway period: October 2001-January 2004 -- 64 patients (42% male)
Post-clinical pathway period: February 2002-October 2006 -- 121 patients (53% male)

Age distribution: Mean for both periods = 64 (comparable range of ages)

ASA class of patients (degree of disease/difficulty)
Pre-clinical pathway: I (1.6%); II (51.6%); III (46.8%); IV (0%)
Post-clinical pathway: I(0.8%); II (39.7%); III (54.5%); IV (5.0%)

Pre-clinical pathway mortality = 1 death (1.6%)
Post-clinical pathway mortality = 2 deaths (1.7%)

Pre-clinical pathway ICU admissions = 8 patients (12.5%)
Post-clinical pathway ICU admissions = 16 patients (13.2%)

Pre-clinical pathway of stay/cost = 10.8 days/$23,536
Post-clinical pathway length of stay/cost = 9.8 days/$19,999

Pre-clinical pathway readmission/reoperation = 4 (6.3%)/4 (6.3%)
Post-clinical pathway readmission/reoperation = 10 (8.3%)/7 (5.8%)
(Both readmission and reoperation are measured within 30 days.)

To put all this into English, after the introduction of the clinical pathway, nothwithstanding a greater percentage of sicker patients, cost and length of stay decreased without negatively affecting mortality, readmission, or reoperation rates.

Patients and families also like the new pathway because they receive a roadmap of what to expect and when to expect it, and they can literally follow their own progress by looking at a chart on the wall of their room.

I don't mean to suggest that we are the only place to have clinical pathways, but they remain less prevalent than you might think. This is but one example to show how effective they can be when well designed and implemented by the entire medical team.

3 comments:

Tim said...

Paul,

I'm not sure if you want to put this in your "What Works" response or "Just Bragging" since it applies to both.

Your description of the Whipple procedure and the care BIDMC utilizes through the "critical pathway" was exactly what impressed our family most as my Mother In Law was treated at BIDMC. The roadmap that you spoke of was a welcome information source which empowered our family with the knowledge of the daily challenges after surgery. Having the map to recovery printed on the wall enabled us to cleary understand what to expect. Doctor C. was excellent in his surgical skills and bedside manner and the nursing staff was amazing, I'll call them Nurse R. and Nurse P., one was even a cancer survivor herself and very optimistic. And that's not easy, serving my Mother In Law, a very traditional, old fashioned, tough, Irish mother of 5, with set ways. Of course, I love my Mother In-Law :-). Two months post surgery she was back on her feet and teaching as if nothing happened, at age 75. Did I mention tough?

Thanks for everything.

The Family of Tim

Paul Levy said...

Thanks, Tim!

Andrew Barna said...

Paul, welcome to the healthcare blogging community, if you haven't been welcomed already. Reading through some of your posts, I think you absolutely get the power of the blog for communication. I would be interested to hear the feedback you have gotten on it. I wish you the best from the left coast. If you have some time, you could visit my blog, www.healthcaretomorrow.blogspot.com.