Melbert R Barry, Kimmins Mark H, Isler John T, Billingham Richard P, Lawton Darci, Salvadalena Ginger, Cortezzo Mark, Rowbotham Ron
Northwest Colon and Rectal Clinic, Seattle, Washington, USA.
J Gastrointest Surg. 2002 Sep-Oct;6(5):745-52. doi: 10.1016/s1091-255x(02)00038-0.
Tremendous variation in patient care exists, both among medical centers and among individual surgeons, in the field of colon and rectal surgery. Clinical or critical pathways based on "best demonstrated practices" from the medical literature have led to improved outcomes for many disease entities. The objective of this study was to develop a pathway for elective colon and rectal resections, and then determine whether this led to any improvement in measurable outcomes. A critical pathway was developed for the care of patients undergoing elective colon and rectal surgery, by reviewing best demonstrated practices in the literature and then developing standardized order sheets, nursing flow sheets, and patient educational material. A patient satisfaction survey was also included in the evaluation process. After being informed of the positive results from the pilot study, surgeons were encouraged to use the critical pathway order sheets, patient information sheets, and flow sheets for their patients undergoing elective abdominal colon or rectal surgery. Between January 1995 and October 1998, the critical pathway was used for 263 patients, whereas for 122 patients this pathway was not used. For those patients in the critical pathway group, the hospital length of stay was shorter (5.5 vs. 8.2 days, including the day of surgery, P = 0.001), the time until a regular diet was tolerated was shorter (3.5 vs. 4.4 days, P = 0.001), the percentage of patients discharged home was greater (90% vs. 82%, P = 0.038), and the average hospital charges were less (12,672 dollars vs. 16,665 dollars, P = 0.001). These advantages did seem to be correlated with efforts at postoperative ambulation, but were independent of the type of postoperative pain control (patient-controlled analgesia vs. epidural analgesia). Patient satisfaction in the subset surveyed was slightly better for those in the critical pathway group than in those for whom the critical pathway was not used. Elective colon and rectal surgery appears to lend itself to uniformity of postoperative order sheets and clinical expectations. Shortened lengths of hospital stay, earlier resumption of a regular diet, and diminished hospital charges were found with the use of this critical pathway, with no diminution of patients' perceptions of satisfaction with the hospital experience.
