Hepato-Pancreato-Biliary SurgeryHepato-Pancreato-Biliary Surgery

Developing a clinical pathway for patients undergoing pancreatic surgery

Pancreatic SurgeryPancreatic Surgery

complex abdominal surgerycomplex abdominal surgery

majority cases are performed for majority cases are performed for cancercancer

strong correlation between strong correlation between volume of surgery and outcomesvolume of surgery and outcomes

↑↑cases performed cases performed ↑ better ↑ better outcomesoutcomes

CCO has designated high CCO has designated high volume centre of excellences in volume centre of excellences in OntarioOntario

Whipple procedure

Study GoalStudy Goal

Improve the quality of surgical care Improve the quality of surgical care for patients undergoing pancreatic for patients undergoing pancreatic surgery in Ontariosurgery in Ontario

Quality in healthcareQuality in healthcare

Structures of CareStructures of Care Characteristics of physicians and hospitalsCharacteristics of physicians and hospitals Context in which care and services are providedContext in which care and services are provided

Process of CareProcess of Care Components of the encounter between a physician Components of the encounter between a physician

or another health care professional and patientsor another health care professional and patients steps that occur during the actual delivery of caresteps that occur during the actual delivery of care

Outcomes of CareOutcomes of Care Changes in patients health status as a result of Changes in patients health status as a result of

health carehealth care

structured multidisciplinary instrumentstructured multidisciplinary instrument

details the steps of care during a defined details the steps of care during a defined patient care episode patient care episode

critical pathwaycritical pathway clinical algorithmclinical algorithm clinical protocol clinical protocol

usually time dependent inventory of actionsusually time dependent inventory of actions

used to standardize processes of careused to standardize processes of care

What is a Clinical Pathway?What is a Clinical Pathway?

adapted from: Rotter T et al, Eval Health Prof, May 2011

Impact of clinical Impact of clinical pathwayspathways

Improved quality of careImproved quality of care standardization of processes of carestandardization of processes of care reduced variabilityreduced variability improved efficiency improved efficiency high quality patient carehigh quality patient care ↑ ↑ documentation documentation improved improved

communicationcommunication

Good economic outcomesGood economic outcomes ↓ ↓ length of staylength of stay ↓ ↓ hospital costshospital costs

Impact of clinical Impact of clinical pathwayspathways

Improved patient outcomesImproved patient outcomes ↓ ↓ length of staylength of stay ↓ ↓ patient morbidity and mortalitypatient morbidity and mortality

↓ ↓ in-hospital complicationsin-hospital complications 5.6% absolute risk reduction (n=5 5.6% absolute risk reduction (n=5

trials)trials)11

Rotter T et al, Eval Health Prof, May 2011

Study QuestionStudy Question

Can we develop an evidence based Can we develop an evidence based clinical pathway for patients clinical pathway for patients undergoing pancreatic surgery?undergoing pancreatic surgery?

Identify current practices and tools being Identify current practices and tools being used at the high volume HPB sites in Ontarioused at the high volume HPB sites in Ontario

Prioritize and rank key elements of patient Prioritize and rank key elements of patient care that should be included in a pancreatic care that should be included in a pancreatic surgery pathwaysurgery pathway

Identify barriers and enablers to will lead to Identify barriers and enablers to will lead to successful and sustainable implementation of successful and sustainable implementation of a clinical pathwaya clinical pathway

Goals for this workshopGoals for this workshop

Summary of clinical Summary of clinical pathway projectpathway project

Walk us through a patient's Walk us through a patient's journey through care after journey through care after undergoing a Whipple at undergoing a Whipple at

your hospitalyour hospital

How are you currently How are you currently managing these managing these

patients? patients?

How do team members How do team members communicate with one communicate with one

another?another?

How do you think we How do you think we might use a clinical might use a clinical

pathway?pathway?

Why do you think we Why do you think we might use a clinical might use a clinical

pathway?pathway?

Prioritize and rank key elements of patient Prioritize and rank key elements of patient care that you feel should be included in a care that you feel should be included in a pancreatic surgery clinical pathwaypancreatic surgery clinical pathway

Provide additional comments/ inputProvide additional comments/ input does pathway have face validity?does pathway have face validity? are there missing items?are there missing items? do items that need clarification?do items that need clarification?

multi-disciplinary clinical pathway mapmulti-disciplinary clinical pathway map pre-printed MD orderspre-printed MD orders

Which elements should be Which elements should be included?included?

Multidisciplinary clinical Multidisciplinary clinical pathwaypathway

Pre-Admission

OR DayPre-op

OR DayPost-op

POD # 1 POD # 2 POD # 3 POD # 4,5,6 Discharge Day

Date:

Assessments

Education

Observation

Pain Management

Nutrition

Activity

DischargePlanning

Proceed/ Discontinue CP (Y/N)

Physician Signature

Pre-printed MD ordersPre-printed MD ordersPre-

Admission/Pre-Surgical

OR DayPre-op

OR DayPost-op

POD # 1 POD # 2 POD # 3 POD # 4,5,6

POD # 6,7 Discharge

day

Diet

Activity

Vitals

Investigations

Interventions

Drugs

Benchmarking draft Benchmarking draft clinical pathwayclinical pathway

50 patient charts reviewed50 patient charts reviewed 38 (76%) patients on pathway38 (76%) patients on pathway

Average length of stay = 8.15 daysAverage length of stay = 8.15 days 12 (24%) patients went off pathway12 (24%) patients went off pathway

Average length of stay = 18.17 daysAverage length of stay = 18.17 days

Benchmarking draft Benchmarking draft clinical pathwayclinical pathway

highest variability in postoperative highest variability in postoperative nutrition, pain management and activity nutrition, pain management and activity (ambulation (ambulation

elements most commonly missing elements most commonly missing patient education patient education discharge planningdischarge planning

Wrap upWrap up

please hand in score sheetsplease hand in score sheets sign consent formssign consent forms consider joining the working groupconsider joining the working group

Thank you!Thank you!