Hostname: page-component-6766d58669-7fx5l Total loading time: 0 Render date: 2026-05-18T22:47:49.297Z Has data issue: false hasContentIssue false
  • English
  • Français

The impact of a post-operative clinical care pathway on head and neck microvascular free tissue transfer outcomes

Published online by Cambridge University Press:  23 January 2020

R Mhawej ,
B M Harmych ,
J J Houlton ,
M E Tabangin ,
J Meinzen-Derr  and
Y J Patil
R Mhawej
Affiliation:
Department of Otolaryngology – Head and Neck Surgery, University of Cincinnati Medical Center, Ohio, USA
B M Harmych
Affiliation:
Department of Otolaryngology – Head and Neck Surgery, University of Cincinnati Medical Center, Ohio, USA
J J Houlton
Affiliation:
Department of Otolaryngology – Head and Neck Surgery, University of Cincinnati Medical Center, Ohio, USA
M E Tabangin
Affiliation:
Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Ohio, USA
J Meinzen-Derr
Affiliation:
Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Ohio, USA
Y J Patil*
Affiliation:
Department of Otolaryngology – Head and Neck Surgery, University of Cincinnati Medical Center, Ohio, USA
*
Author for correspondence: Dr Yash J Patil, 231 Albert B Sabin Way, Cincinnati, OH45267-0528, USA E-mail: patilyj@ucmail.uc.edu Fax: +1 513 558 5203
Get access Rights & Permissions [Opens in a new window]

Abstract

Objective

To study the impact of a clinical care pathway and computerised order set on short-term post-operative outcomes for patients undergoing head and neck free tissue transfer.

Methods

In this retrospective cohort study, patients who underwent head and neck free tissue transfer by a single reconstructive surgeon between January 2007 and July 2009 were assigned to one of two cohorts based on the timing of their surgery: pre- or post-clinical care pathway implementation. Measured outcomes included peri-operative complications and mortality, length of hospital stay and costs, unplanned reoperations, and readmissions within 30 days of discharge.

Results

The pre-clinical care pathway cohort included 81 patients and the post-clinical care pathway cohort comprised 46. Implementation of the clinical care pathway was associated with decreased variability in length of hospital stay (median (interquartile range) = 8 (6, 11) vs 7 (6, 9) days). The post-clinical care pathway cohort also had a significantly lower unplanned reoperation rate (15.2 vs 35.8 per cent, p = 0.01).

Conclusion

A clinical care pathway is a successful means of standardising and improving complex patient care. In this study, care pathway implementation in head and neck free tissue transfer patients improved efficiency and the quality of patient care.

Keywords

Critical PathwaysHead And Neck NeoplasmsFree Tissue FlapsLength Of StayPatient Readmission

Information

Type
Main Articles
Information
The Journal of Laryngology & Otology , Volume 134 , Issue 2 , February 2020 , pp. 150 - 158
Copyright
Copyright © JLO (1984) Limited, 2020

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

Article purchase

Temporarily unavailable

Footnotes

Dr Y J Patil takes responsibility for the integrity of the content of the paper

Presented in part as a poster at the American Academy of Otolaryngology – Head and Neck Surgery Foundation Annual Meeting and OTO Expo, 13 November 2010, Boston, Massachusetts, USA.

References

Shoemaker, WC. Editorial: protocol medicine. Crit Care Med 1974;2:279CrossRefGoogle ScholarPubMed
Coffey, RJ, Richards, JS, Remmert, CS, LeRoy, SS, Schoville, RR, Baldwin, PJ. An introduction to critical paths. Qual Manag Health Care 1992;1:45–54CrossRefGoogle ScholarPubMed
Rotter, T, Kinsman, L, James, E, Machota, A, Gothe, H, Willis, J et al. Clinical pathways: effects on professional practice, patient outcomes, length of stay and hospital costs. Cochrane Database Sys Rev 2010;(3):CD006632CrossRefGoogle ScholarPubMed
Rotter, T, Kugler, J, Koch, R, Gothe, H, Twork, S, van Oostrum, JM et al. A systematic review and meta-analysis of the effects of clinical pathways on length of stay, hospital costs and patient outcomes. BMC Health Serv Res 2008;8:265CrossRefGoogle ScholarPubMed
Yueh, B, Weaver, EM, Bradley, EH, Krumholz, HM, Heagerty, P, Conley, A et al. A critical evaluation of critical pathways in head and neck cancer. Arch Otolaryngol Head Neck Surg 2003;129:89–95CrossRefGoogle ScholarPubMed
Feldstein, PJ, Wickizer, TM, Wheeler, JRC. Private cost containment. The effects of utilization review programs on health care use and expenditures. N Engl J Med 1988;318:1310–14Google ScholarPubMed
Morris, AH. Developing and implementing computerized protocols for standardization of clinical decisions. Ann Intern Med 2000;132:373–83CrossRefGoogle ScholarPubMed
Pearson, SD, Goulart-Fisher, D, Lee, TH. Critical pathways as a strategy for improving care: problems and potential. Ann Intern Med 1995;123:941–8CrossRefGoogle ScholarPubMed
Wachtel, T, Moulton, AW, Pezzullo, J, Hamolsky, M. Inpatient management protocols to reduce health care costs. Med Decis Making 1986;6:101–9CrossRefGoogle ScholarPubMed
Saint, S, Hofer, TP, Rose, JS, Kaufman, SR, McMahon, LF Jr.Use of critical pathways to improve efficiency: a cautionary tale. Am J Manag Care 2003;9:758–65Google ScholarPubMed
Chen, AY, Callender, D, Mansyur, C, Reyna, KM, Limitone, E, Goepfert, H. The impact of clinical pathways on the practice of head and neck oncologic surgery: the University of Texas M. D. Anderson Cancer Center Experience. Arch Otolaryngol Head Neck Surg 2000;126:322–6CrossRefGoogle ScholarPubMed
Cohen, J, Stock, M, Andersen, P, Everts, E. Critical pathways for head and neck surgery. Development and implementation. Arch Otolaryngol Head Neck Surg 1997;123:11–14CrossRefGoogle ScholarPubMed
Gendron, KM, Lai, SY, Weinstein, GS, Chalian, AA, Husbands, JM, Wolf, PF et al. Clinical care pathway for head and neck cancer: a valuable tool for decreasing resource utilization. Arch Otolaryngol Head Neck Surg 2002;128:258–62CrossRefGoogle ScholarPubMed
Hanna, E, Schultz, S, Doctor, D, Vural, E, Stern, S, Suen, J. Development and implementation of a clinical pathway for patients undergoing total laryngectomy: impact on cost and quality of care. Arch Otolaryngol Head Neck Surg 1999;125:1247–51CrossRefGoogle ScholarPubMed
Husbands, JM, Weber, RS, Karpati, RL, Weinstein, GS, Chalian, AA, Goldberg, AN et al. Clinical care pathways: decreasing resource utilization in head and neck surgical patients. Otolaryngol Head Neck Surg 1999;121:755–9CrossRefGoogle ScholarPubMed
Kagan, SH, Chalian, AA, Goldberg, AN, Rontal, ML, Weinstein, GS, Prior, B et al. Impact of age on clinical care pathway length of stay after complex head and neck resection. Head Neck 2002;24:545–8CrossRefGoogle ScholarPubMed
Levin, RJ, Ferraro, RE, Kodosky, SR, Fedok, FG. The effectiveness of a “critical pathway” in the management of laryngectomy patients. Head Neck 2000;22:694–93.0.CO;2-0>CrossRefGoogle ScholarPubMed
Charlson, M, Szatrowski, TP, Peterson, J, Gold, J. Validation of a combined comorbidity index. J Clin Epidemiol 1994;47:1245–51CrossRefGoogle ScholarPubMed
Campbell, H, Hotchkiss, R, Bradshaw, N, Porteous, M. Integrated care pathways. BMJ 1998;316:133–7CrossRefGoogle ScholarPubMed
Every, NR, Hochman, J, Becker, R, Kopecky, S, Cannon, CP; Committee on Acute Cardiac Care, Council on Clinical Cardiology, American Heart Association. Critical pathways: a review. Circulation 2000;101:461–5CrossRefGoogle ScholarPubMed
Renholm, M, Leino-Kilpi, H, Suominen, T. Critical pathways. A systematic review. J Nurs Adm 2002;32:196–202CrossRefGoogle ScholarPubMed
Gordon, SA, Reiter, ER. Effectiveness of critical care pathways for head and neck cancer surgery: a systematic review. Head Neck 2016;38:1421–7CrossRefGoogle ScholarPubMed
Ogilvie-Harris, DJ, Botsford, DJ, Hawker, RW. Elderly patients with hip fractures: improved outcome with the use of care maps with high-quality medical and nursing protocols. J Orthop Trauma 1993;7:428–37CrossRefGoogle ScholarPubMed
Wentworth, DA, Atkinson, RP. Implementation of an acute stroke program decreases hospitalization costs and length of stay. Stroke 1996;27:1040–3CrossRefGoogle ScholarPubMed
Wammack, L, Mabrey, JD. Outcomes assessment of total hip and total knee arthroplasty: critical pathways, variance analysis, and continuous quality improvement. Clin Nurse Spec 1998;12:122–9CrossRefGoogle ScholarPubMed
Dowsey, MM, Kilgour, ML, Santamaria, NM, Choong, PF. Clinical pathways in hip and knee arthroplasty: a prospective randomised controlled study. Med J Aust 1999;170:59–62CrossRefGoogle ScholarPubMed
Chalian, AA, Kagan, SH, Goldberg, AN, Gottschalk, A, Dakunchak, A, Weinstein, GS et al. Design and impact of intraoperative pathways for head and neck resection and reconstruction. Arch Otolaryngol Head Neck Surg 2002;128:892–6CrossRefGoogle ScholarPubMed
Sherman, D, Matthews, TW, Lampe, H, LeBlanc, S. Laryngectomy clinical pathway: development and review. J Otolaryngol 2001;30:115–20CrossRefGoogle ScholarPubMed
O'Connell, DA, Barber, B, Klein, MF, Soparlo, J, Al-Marzouki, H, Harris, JR et al. Algorithm based patient care protocol to optimize patient care and inpatient stay in head and neck free flap patients. J Otolaryngol Head Neck Surg 2015;44:45CrossRefGoogle ScholarPubMed
Yetzer, JG, Pirgousis, P, Li, Z, Fernandes, R. Clinical pathway implementation improves efficiency of care in a maxillofacial head and neck surgery unit. J Oral Maxillofac Surg 2017;75:190–6CrossRefGoogle Scholar
Yeung, JK, Dautremont, JF, Harrop, AR, Asante, T, Hirani, N, Nakoeshny, SC et al. Reduction of pulmonary complications and hospital length of stay with a clinical care pathway after head and neck reconstruction. Plast Reconstr Surg 2014;133:1477–84CrossRefGoogle ScholarPubMed