Clinical pathways involve a multidisciplinary approach including office staff, surgeons, anesthesia, and hospital nursing. The goal is to create a clear reproducible pathway and share it with all. Additionally, measurable outcomes need to be identified, and data needs to be tracked and shared.
The office staff need to provide clear pre-op and post-op instructions including criteria for discharge, and discharge instructions. Additionally, individualized packets for each surgery should be created, and the same message needs to be delivered to all patients.
The surgeon sets the tone and expectations of the entire clinical pathway. He is in charge of creating and vetting the pathway. He is required to get the other surgeons in line, and review the input of all involved parties. Lastly, he is required to acquire and organize the accumulated data.
The in-patient hospital units (comprised of the nursing aids, nursing staff, physician assistant, and residents) need to be involve from the beginning, and through the entire clinical pathway. These are the ground people, involved in every step of pathway, and their support is essential.
The importance of the clinical pathway must be communicated. These pathways enhance efficiency, increase capita/day, decrease hospital length of stay, improve patient’s satisfaction and outcomes in general. The measurable outcomes include length of hospital stay, readmissions, mortality, transfusions and HCAHP scores.
Ms. DiBona then went on to describe the pre-op, intraoperative and post-op pathways used in Hackensack Meridian Health center. The pre-op pathway includes:
- Clear liquids up until 6 hours prior to surgery
- Narcotic use 30 min before end of surgery
- Usage of 1000 mg Tylenol in holding area
- Antibiotic prophylaxis
- OG tube placed and removed prior to extubation unless directed by surgical team
- Usage of Indocyanine green (ICG) 5 mg iv bolus + flushed in-at surgical request only.
- Zofran 4 mg IV for nausea
- Decadron 10 mh
- Hydromorphine 1 mg IM approximately 30 min pior to emergence of pain
- Proper Fluid management
- Putting one large bore IV and no need for an arterial line.
- Local infiltration of surgical sites with 0.5% bupivacaine per surgical team
- Oral opiates
- Oxycodone 5-10 mg , q 4 hours PRN
- For uncontrolled pain syndrome, usage of oxycodone
- Diluadid, hydromorphine, tramadol as needed,
- Consider pain management consult if any difficulty managing pain postoperatively exists.
Presented By: Courtney DiBona, Hackensack Meridian Health, New-Jersey, USA
Written By: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre @GoldbergHanan at the 2018 North American Robotic Urology Symposium, February 16-17, 2018 - Las Vegas, NV