IARS Highrisk Surgery Panel: Critical pathways and guidelines

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IARS High-risk Surgery PanelCritical pathways
and guidelines

• John Butterworth, MD
• Professor and Head
• Section of Cardiothoracic Anesthesiology
• Wake Forest University School of Medicine
• Winston-Salem, NC, USA

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Critical pathways and guidelines

• What they are
• Why they are useful
• How to make one work for you
• How to make one NOT work for you
• Results from some clinical pathways
• Pathways-guidelines relevant to our case
• Conclusions

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Definition of a critical path

• A critical path is a standardized, prewritten,
  one- or two-page document showing the
  interventions of all disciplines along a time
  schedule. In effect, it is a grid, with time as
  one axis and staff actions as the other.

Zander K Managing outcomes through collaborative
care. AHA Publishing. 1995. p 11
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Deconstructing Critical Pathways

• Discourse intimately associated with power
  relations
• Control of assembly line workers
• Imputed control of products
• Imposed in top-down fashion

Jacques Derrida 1930 2004 Father of
Deconstruction
Georges McGuire. Adv Nurs Science 2004272-11
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Deconstructing Critical Pathways

• The human landscape of health care is now a
  dangerous, lonely one for both nurses and
  patients, lacking community or connectedness

Jacques Derrida 1930 2004 Father of
Deconstruction
Georges McGuire. Adv Nurs Science 2004272-11
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Critical pathways

• What they are
• Why they are useful
• How to make one work for you
• How to make one NOT work for you
• Results from some clinical pathways
• Pathways-guidelines relevant to our case
• Conclusions

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What companies must sell to pay for an
appendectomy

• Dayton Hudson 30,000 action figures
• Atlantic Richfield 192,000 gallons of gasoline
• Southern California Edison 1 years electricity
  for 300 households
• Anheuser Busch 11,627 6-packs of Budweiser
• Goodyear Tire and Rubber 461 radial tires for
  passenger cars

Forbes, 1995
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Critical Pathways Reduce Variation

• Unneeded variation increases costs and reduces
  quality (W. Edwards Deming, PhD)
• Until you identify the best recipe, almost any
  recipe is better than no recipe
• Easy to incorporate evidence-based findings and
  guidelines in pathways

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Critical Pathways Provided a Structure for
Quality Improvement

• Pathways identify key events that can be tracked

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Critical pathways

• What they are
• Why they are useful
• How to make one work for you
• How to make one NOT work for you
• Results from some clinical pathways
• Pathways-guidelines relevant to our case
• Conclusions

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How to make your clinical pathway successful

• Develop it in collaboration with all those
  involved with patient care
• Define and measure variances
• Record and measure outcomes
• Refine the pathway based on experience, dont
  carve it in stone
• Incorporate EBM as much as possible

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Critical pathways

• What they are
• Why they are useful
• How to make one work for you
• How to make one NOT work for you
• Results from some clinical pathways
• Pathways-guidelines relevant to our case
• Conclusions

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How pathways become untracked

• Have staff develop pathway without MD involvement
  
• Poor or ineffective use of data
• Prolonged, too frequent meetings
• Path not available in chart
• Poor tracking and variances (patients, health
  system, MDs)

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Critical pathways

• What they are
• Why they are useful
• How to make one work for you
• How to make one NOT work for you
• Results from some clinical pathways
• Pathways-guidelines relevant to our case
• Conclusions

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Background for accelerated recovery programs
after cardiac surgery

• Cardiac surgery patients have generated large
  margins for US hospitals
• Research has documented large variation in
  clinical practice of cardiology, anesthesia, and
  cardiac surgery
• Managed care organizations have targeted cardiac
  surgery for substantial reimbursement cuts

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Key features of CABG pathway-1

• Administrative
• Prompt surgery or discharge after catheterization
• AM admission for elective surgery
• Preoperative teaching
• Case management
• Anesthesia
• Reduced duration of sedation and ventilation
• Reduced doses of opioids and benzodiazepines

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Key features of CABG pathway-2

• Nursing
• Earlier extubation (no morphine, diazepam)
• Earlier OOB to chair
• Earlier feeding
• Consistent discharge from ICU next morning
• Documentation of pathway variances
• Respiratory therapy
• Earlier extubation (fewer blood gas tests)
• RT-guided weaning

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Rapid, sustained recovery after cardiac operations

• 240 consenting patients
• Preoperative teaching
• Prophylactic antibiotics, steroids, cimetidine,
  metoclopramide, digoxin
• Extubation as soon as possible
• Out of bed night of surgery
• Full diet when hungry (no special diets)

Krohn. JTCVS 1990100194-7
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Rapid, sustained recovery after cardiac operations

• Discharge criteria (day 3 or after)
• Walk 65 m with lt15 beat/min increase in HR
• Stable cardiac rhythm
• No fever
• Eating gt1000 cal/day
• Absence of active complications
• Desire to go home
• Telephone accessible

Krohn. JTCVS 1990100194-7
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Critical pathways

• What they are
• Why they are useful
• How to make one work for you
• How to make one NOT work for you
• Results from some clinical pathways
• Pathways-guidelines relevant to our case
• Conclusions

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Surgical treatment of diverticulitis

• Patients presenting with signs of peritonitis
• Fluid resuscitation
• IV antibiotics
• Emergency surgical exploration
• Resection of perforated colonic segment

Society for Surgery of the Alimentary Tract, 2000
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Surviving sepsis campaignguidelines for
management of severe sepsis and septic shock

• Resuscitation to endpoints
• CVP 8-12 mm Hg
• MAP 65 mm Hg
• Urine output 0.5 ml/kg/hr
• MVO2 70
• If MVO2 lt 70 despite CVP 8-12 mm Hg, transfuse
  to hematocrit of 30 and/or administer dobutamine
  (up to 20 µg/kg/min)

Crit Care Med 200432858-73
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Surviving sepsis campaignguidelines for
management of severe sepsis and septic shock

• IV antibiotics should be started within an hour
  of diagnosis
• Source control
• Vasopressors (dopamine or norepineprine) should
  be started when fluid resuscitation is inadequate
• Inotropes should not be used to achieve an
  arbitrary predefined cardiac output

Crit Care Med 200432858-73
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Surviving sepsis campaignguidelines for
management of severe sepsis and septic shock

• IV steroids should be given for 7 days if
  vasopressors are needed in septic shock
• Should NOT be given to TREAT shock
• Recombinant Human Activated Protein C for APACHE
  II gt25 and high risk of death
• Tranfuse only for hgb lt7 g/dl unless tissue
  hypoperfusion
• Consider limitation of life support

Crit Care Med 200432858-73
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Critical pathways

• What they are
• Why they are useful
• How to make one work for you
• How to make one NOT work for you
• Results from some clinical pathways
• Pathways-guidelines relevant to our case
• Conclusions

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Critical Pathways Conclusions

• Critical pathways reduce unnecessary variations
  in care
• Consensus guidelines define best practices and
  the level of evidence supporting them
• Poor outcomes have not been eliminated!