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Design and Impact of Intraoperative Pathways for Head and Neck Resection and Reconstruction
Ara A. Chalian, MD;
Sarah H. Kagan, PhD, RN;
Andrew N. Goldberg, MD;
Allan Gottschalk, MD, PhD;
Ann Dakunchak, BSN, RN;
Gregory S. Weinstein, MD;
Randal S. Weber, MD
Arch Otolaryngol Head Neck Surg. 2002;128:892-896.
ABSTRACT
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Objectives To describe the design and impact of 3 intraoperative pathways for the
treatment of head and neck cancers; to detail the pathways schematically to
illustrate projected intraoperative flow and teamwork; and to analyze impact
on procedure and case lengths in each pathway and in comparison with historical
prepathway average times.
Setting Tertiary-level academic health system main operating room.
Patients Twenty-one patients undergoing transcervical (TC) resection (n = 11),
transmandibular (TM) resection (n = 8), or laryngopharyngectomy (LP) (n =
2) with radial forearm free-flap reconstruction for ablative or reconstructive
reasons were pathway eligible. A convenience sample of 16 patients undergoing
TC resection, 7 undergoing TM resection, and 7 undergoing LP prepathway is
used for comparison.
Intervention Our academic medical center uses 3 intraoperative clinical pathways
to manage resource use and streamline care for patients. These 3 pathways
were designed schematically by an interdisciplinary team. The pathways plan
progression of the case by timed actions for surgical, anesthesia, and nursing
teams.
Main Outcome Measures Procedure and case lengths.
Results The TC pathway procedure and case length averaged 10.48 and 12.33 hours,
respectively; TM pathway procedure and case lengths, 11.19 and 13.32 hours,
respectively; and LP pathway procedure and case lengths, 12.42 and 13.83 hours,
respectively. Aggregate averages were 10.93 hours and 12.85 hours for procedure
and case length, respectively. The average pathway case lengths of 12.33,
13.32, and 13.83 hours compare favorably with our target times of 13, 14,
and 15 hours, respectively. Environmental management, work flow, and team
satisfaction anecdotally increased postpathway.
Conclusions Intraoperative pathways afford enhanced time and action efficiency to
streamline care of patients undergoing head and neck procedures. Pathway implementation
produced time savings. Our results suggest that implementation of such pathways
will benefit similar academic medical centers seeking to improve intraoperative
resource use to improve performance in the care of patients undergoing head
and neck procedures.
INTRODUCTION
WE DESCRIBE the design and clinical impact of 3 intraoperative pathways:
transcervical (TC) resection of oral cavity neoplasia, transmandibular (TM)
resection of oral or oropharyngeal neoplasia, and laryngopharyngectomy (LP),
all with radial forearm free-flap (RFFF) reconstruction. This article details
the design of each pathway that projects intraoperative flow and teamwork.
The impact of the pathways is analyzed through descriptive statistics for
procedure and case lengths in each pathway, against target pathway times,
and in inferential comparison with grouped prepathway times. Summary conclusions
include time and action efficiencies, projections for further analysis, and
directions for research and practice.
PATIENTS AND METHODS
Our academic medical center uses 3 intraoperative clinical pathways
to manage resource use and streamline care for patients undergoing head and
neck resections with RFFF reconstruction. These intraoperative pathways were
developed in parallel with a head and neck clinical management pathway. The
results of this pathway are reported elsewhere.1
The intraoperative pathway was separated to enable greater specificity in
work and resource redesign to improve patient care.
These 3 intraoperative pathways were the first for the Department of
Otorhinolaryngology/Head and Neck Surgery, Hospital of the University of Pennsylvania.
Our institution has been performing microvascular reconstruction in patients
undergoing head and neck surgical procedures for 10 years. Head and neck resection
with reconstruction has been viewed as difficult to standardize because of
extended-length cases with multiple components and individual anatomic and
design elements. The TC resection of oral cancers, the TM resection of oral
and oropharyngeal cancers, and LPs, all with RFFF reconstruction, were selected
for pathways because of the high positive prepathway profile of these operations
and because of the head and neck team members (A.A.C., A.N.G., A.D., G.S.W.,
and R.S.W.) within the intraoperative environment.
The goal of the design was to create an algorithm that would specify
a time-action pathway with time- and discipline-specific resources and actions
to maintain patient outcomes and potentially achieve improved outcomes by
shortening case length. Improved patient outcomes were defined as decreased
time in the operating room (OR) and decreased anesthesia time. Cost savings
and enhancedclinical and nonclinical staff satisfaction were assumed to be
imbedded in achieving patient outcomes.
DESIGN
The 3 intraoperative head and neck surgery pathways were designed schematically
by an interdisciplinary team (A.A.C., A.N.G., A.D., G.S.W., and R.S.W.). They
were part of a larger institutional initiative that had 5 goals: specialty-focused
intraoperative pathway development; reduce unnecessary variation and use in
materials, durable equipment, medications, staff, and time; increase accuracy,
quality, completeness, and timeliness of all resources used; increase direct
patient care for nursing staff; and increase throughput to decrease cost per
case.
The primary attending head and neck reconstructive surgeon (A.A.C.),
the attending anesthesiologist (A.N.G.) for the OR section, and the primary
circulating nurse (A.D.) for patients undergoing head and neck procedures
formed the core team. Attending head and neck surgeons (A.A.C., G.S.W., and
R.S.W.), attending anesthesiologists (A.N.G. and others), perioperative nurses
(A.D. and others), and perioperative administrators reviewed the pathways
during development, contributing to the design as necessary. The specific
goals of the head and neck core team were to achieve standardized timed actions
for surgery, anesthesiology, and nursing; to standardize the instrument sets
for each pathway; to create a routine environmental setup; and to accommodate
the individual components of each patient's operation (eg, the extent of the
tumor; anatomic variation, such as neck exposure; and unilateral vs bilateral
neck dissection). The pathway goals assumed synchronous flap harvest. This
assumption added the potential variation of team surgery coordination.
The pathways plan progression of the case by timed actions for surgical,
anesthesia, and nursing teams. The team member responsibilities were detailed
in schematic form for each pathway. A distillation of these roles and responsibilities
is presented in Table 1. The pathway
is predicated on a single nursing team with 2 staff scrubbed and 2 surgical
teams as necessary to resect the tumor and reconstruct the defect. This team
structure was in place before pathway implementation and was systematized
by the pathway.
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Table 1. Team Member Responsibilities*
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A basic pathway schema was developed for consistency (Figure 1). Case length was defined as time into room to time out
of room. Procedure length was defined as time from skin incision to time dressings
were placed on the patient. The intraoperative environment was examined and
resource needs delineated. Instrument set development was a major focus for
resource use and clinician satisfaction. Eligibility criteria included neoplasia
of the oral cavity, hypopharynx, oropharynx, or soft tissues of the head and
neck. Tumor stage and radiation status were not part of the eligibility criteria.
Patients were ineligible if they had skull base tumors; bone, pectoralis,
or latissimus dorsi flaps; or lateral thigh or rectus abdominus free flaps.
The default criterion for the pathways was premature termination or a canceled
procedure.
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Intraoperative head and neck resection and reconstruction pathway
schematic. OR indicates operating room; PEG, percutaneous endoscopic gastrostomy;
TC, transcervical; TM, transmandibular; and LP, laryngopharyngectomy.
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The pathway schematics are formatted left to right, starting at time
minus 30 minutes, with OR setup and temperature controlled from the night
before. Team responsibilities are described along the horizontal axis for
the surgeon, the anesthesiologist, and the nurse. These times are sequenced
by actions across the top of the pathway schematic to summarize the actions
taken by team members that are listed on the vertical axis of the actual pathway
schematic (Figure 1). The pathway
is completed at the point the room is readied for the next patient. Target
pathway times were determinedby consensus because no benchmarking data were
available. Case length was estimated from the OR's surgical database for historically
derived averages. The historical time for TC resection was 16 hours; TM resection,
17 hours; and LP, 19 hours. These times were used primarily for design purposes.
The target pathway times for case length, developed by the pathway team, are
13 hours for TC resection, 14 hours for TM resection, and 15 hours for LP.
ENROLLMENT
Pathway implementation occurred in March 1998. Twenty-one patients undergoing
reconstructive surgery, for the first year after implementation, were enrolled
in the pathways for TC resection (n = 11), TM resection (n = 8), or LP (n
= 2), with RFFF reconstruction for all. Data for 4 patients were incompletely
recorded, and could not be used in analysis. These patients are analyzed using
descriptive statistics and qualitative variables for work flow and team satisfaction.
Prepathway averages from a convenience sample of 30 surgical procedures (16
TC resections, 7 TM resections, and 7 LPs) performed in the 2 years preceding
pathway implementation are used for comparison. Prepathway and postpathway
surgical procedures were performed by the same team of surgeons (A.A.C., G.S.W.,
and R.S.W.), using the same simultaneous flap harvest techniques.
Three times are used for comparison: ischemia time during microvascular
reconstruction, procedure length, and case length. Ischemia time was recorded
as the time (in minutes) for action 2 on the pathway (Figure 1). Procedure length was recorded in minutes from skin incision
to dressing. Pathway case length, as noted earlier, was defined as time into
the OR to time out of the OR, inclusive and recorded in minutes. All recorded
times were converted to hours.
RESULTS
The targeted goals of decreased procedure time, representing anesthesia
time, and decreased overall case length were achieved (Table 2). Aggregate pathway mean times (N = 21) were 10.93 hours
for procedure length and 12.85 hours for case length. The aggregate postpathway
case lengths are statistically significantly different from the prepathway
case lengths. The pathway mean case length also achieved the target time for
the TC pathway (mean, 12.85 hours; SD, 1.76 hours; range, 10.50-16.60 hours),
undercutting the target times for the TM and LP pathways. The mean time for
procedure length was 10.93 hours (SD, 2.18 hours; range, 5.80-15.57 hours);
and for ischemia, 3.28 hours (SD, 0.77 hours; range, 1.56-4.67 hours).
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Table 2. Aggregate Prepathway and Postpathway Data
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The aggregate postpathway procedure lengths are statistically significantly
different from the prepathway procedure lengths (mean, 10.93 vs 12.50 hours; t test; P = .009). The postpathway
ischemia times are not statistically significantly different from the prepathway
ischemia times at P = .05 (mean, 3.28 vs 3.58 hours; t test; P = .07). The mean ischemia
times did, however, show a clinical trend toward a decline of 0.3 hours postpathway.
Transcervical pathway procedure and case lengths averaged 10.48 and
12.33 hours, respectively. This mean case length was shorter than the target
of 13 hours. In addition, the procedure length was statistically different
from the prepathway procedure length (mean, 10.48 vs 12.37 hours; t test; P = .02). The case length was also
statistically different from the prepathway case length (mean, 12.33 vs 14.45
hours; t test; P = .009).
The TM and LP pathways had limited enrollment. Prepathway and postpathway
analyses were not statistically valid or significant because of the small
subsample sizes. Transmandibular pathway procedure and case lengths averaged
11.19 and 13.32 hours, respectively. This is shorter than the target of 14
hours. Laryngopharyngectomy pathway procedure and case lengths averaged 12.42
and 13.83 hours, respectively. This is considerably shorter than the target
of 16 hours.
Environmental management, work flow, and team satisfaction were anecdotally
noted to increase postpathway implementation. Inconsistent instrument availability
was a prepathway dissatisfier for surgeons and nurses. The instrument set
was standardized through the pathway design and implementation. An instrument
processing partner was assigned for the pathways. Pathway implementation leads
to significant improvement in appropriate instrument availability. No standardized
measures of work flow or satisfaction were incorporated into the project design.
However, team members believed that the design process and implementation
strengthened their collaboration.
COMMENT
Organizational analysis and redesign of the health care industry is
an omnipresent topic in clinical literature without rigorous traditional research
to support specific uses.2 Many institutions
have redesigned work groups and processes, based largely on organizationally
perceived cost-benefit analyses, with and without the assistance of external
consultants. Historically, processes with little tolerance for error were
schematized (eg, advanced cardiac life support protocols). Resource and time-intensive
operative and other invasive procedures requiring anesthesia frequently lend
themselves to redesign. Goals most often include standardized resources, such
as instruments, and schematized time and action algorithms. Processes selected
for redesign are generally high volume, high resource, or high cost within
an organization or subspecialty.
Perioperative and invasive procedure redesign initiatives reported in
medical and nursing literature include the following: frontal sinus obliteration,3 head and neck oncologic surgery and chemotherapy,4 ambulatory surgery,5
carotid endarterectomy,6 radical prostatectomy,7 knee replacement,8
and elective colon resection.9 The reports
consistently refer to goals of improved resource use without adverse effects
to patients for procedures that were clinically predictable intraoperatively
and perioperatively. Reported pathways excluded intraoperative processes,3, 6-7 redesigned anesthesia
intraoperative process alone or only,5 or redesigned
intraoperative and perioperative processes.4
All researchers reviewed achieved goals of improved resource use while maintaining
quality of care, as measured in each project, through systematizing their
selected operations or procedures.
Correa and colleagues3 analyzed a pathway
for frontal sinus obliteration. The design process detailed is similar to
that used in this project. Intraoperative and postoperative processes and
outcomes were included. The project sought to decrease operative time and
estimated blood loss. These outcomes were achieved. Cohen and colleagues4 report on the development and implementation of pathways
designed to reorganize head and neck oncologic care, focusing on chemotherapy
and postsurgical care. While statistically significant improvements in length
of hospital stay and cost of hospitalization were achieved, intraoperative
processes were not a focus of the project. The present project, when compared
across specialties, is most similar to the description of Baker and colleagues5 of redesigning ambulatory surgical procedures. Baker
and colleagues schematized intraoperative time-action algorithms for their
institution's same-day surgery unit, achieving economies of scale in resource
use and improved postoperative patient and regulatory compliance.
Our experience supports implementation of similar pathways in a comparable
large academic medical center, with a significant head and neck surgery patient
volume, seeking to improve intraoperative resource use and to garner enhanced
performance in the care of these patients. Our intraoperative pathways afford
enhanced time and action efficiency to streamline the care of patients undergoing
head and neck procedures. The mean aggregate case length achieved the target
time for the TC pathway. This was the most limited of the 3 procedure target
goals. This suggests that the process of intraoperative pathway implementation
is valuable and that performance improvement in time-action efficiencies can
be achieved. It also suggests that the accommodation for procedure may not
be necessary if approaches to resection and to reconstruction are appropriately
matched. Our experience supports the notion that complex operations with multiple
components may be standardized. We acknowledge the need for allowances that
reflect tumor extent, anatomic variation that may limit the efficiency of
resection (eg, neck exposure, obesity, or another comorbidity), possible metastatic
disease that requires bilateral neck dissection, and free-flap design elements.
Further analysis of cost benefits is pending acquisition of information
processing systems for cost per OR hour and cost per case. Comparative analysis
is limited by the nature of available literature and by the extent of our
database. Future research that builds information management systems and enables
detailed financial analysis within the context of hospital stay and billing
returns will add an additional dimension to this area of outcomes research
and performance improvement.
AUTHOR INFORMATION
Accepted for publication January 9, 2002.
We thank the Head and Neck Intraoperative Pathway Team, Hospital of
the University of Pennsylvania, Philadelphia.
Corresponding author: Ara A. Chalian, MD, Department of Otorhinolaryngology/Head
and Neck Surgery, Hospital of the University of Pennsylvania, 5 Silverstein,
3400 Spruce St, Philadelphia, PA 19104-4283 (e-mail: chaliana{at}uphs.upenn.edu).
From the Departments of Otorhinolaryngology/Head and Neck Surgery (Drs
Chalian, Goldberg, Weinstein, and Weber) and Anesthesia (Dr Gottschalk), and
the Nursing Service, School of Nursing (Dr Kagan and Ms Dakunchak), Hospital
of the University of Pennsylvania, Philadelphia. Dr Goldberg is now with the
Department of Otolaryngology/Head and Neck Surgery, University of California,
San Francisco; and Dr Gottschalk is now with the Department of Anesthesiology
and Critical Care, The Johns Hopkins University, Baltimore, Md.
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