There are several components involved to creating a clinical pathway, including (i) a multidisciplinary approach, which encompasses the office staff, surgeon, anesthesia, hospital nursing staff, and nurse practitioners/physician assistants; (ii) creating a clear reproducible pathway and sharing with all involved; (iii) identifying measurable outcomes; (iv) tracking data; (v) sharing data; (vi) repeating.
The office staff at the time of OR booking can provide clear pre-operative and post-operative instructions to the patient, which should include criteria for discharge and clear discharge instructions. For example, if the goal is to have the patient discharged by 12PM postoperative day #1, it is important for the patient to know this preoperatively in order to develop a mindset for early and appropriate discharge planning. The office staff should have individualized packets for each procedure, make follow-up appointments preoperatively, and deliver the “same message” as the surgeon and support staff.
The surgeon has to be the champion in order for the clinical pathway to work, setting the tone and expectations. The surgeon should review and get buy-in from all parties, in addition to getting other surgeons in line, listening to ways to improve the pathway, reviewing the data, and sharing data. Dr. Stifelman notes that anesthesia is often the most difficult to work with regarding pathway implementation, since they typically have their own agenda and do not have much to gain from surgical clinical pathways. However, they are a critical component of the pathway, particularly for emphasizing the message, initially managing pain, and helping to avoid narcotics and complications that require management.
The hospital floor is also a crucial component of the pathway, making up the nurses, nurse practitioners, physician assistants, residents, house-keeping staff, and nursing aids. This cohort is the most important, are the “boots on the ground” and must understand the workflow, challenges, and responsibility for implementing the pathway. According to Dr. Stifelman it is important to set-up three meetings over a 3-6 month period with the hospital floor staff:
- Meeting #1: introduce the idea and why it is important, as well as gather ideas
- Meeting #2: finalize the pathway and implement it with the charge nurse or nurse practitioner
- Meeting #3: review the initial data
Dr. Stifelman and his team have developed a robotic partial nephrectomy pathway, with measurable outcomes including OR time, length of stay, readmission rates, mortality rates, transfusion rates, percentages of discharges prior to noon, and HCAP scores. The preoperative pathway includes a standardized packet given to all patients, with several important notes: (i) it is okay to drink Gatorade or fluid 2 hours prior to surgery, (ii) if a patient uses narcotics preoperatively, they will receive dilaudid 1mg IM 30 min before the surgery is completed, (iii) scopolamine is used for patients with a history of motion sickness, and (iv) Tylenol will be is used in the preoperative holding area (1000 mg).
The intraoperative pathway includes:
- Antibiotic prophylaxis
- An OG tube placed and removed prior to extubation
- Use indocyanine green 5mg IV bolus at surgical request only
- Zofran 4mg IV prior to extubation
- Decadron 10 mg IV unless contraindicated
- Hydromorphone 1mg IM 30 minutes prior to extubation
- Fluids – 30 ml/kg for the first hour, then 15 ml/kg for total of 3000 ml by the time of cross clamping, followed by maintenance 5 ml/kg until the end of surgery
- No arterial line, only a large bore IV
- Local infiltration of surgical sites with 0.5% bupivacaine
- Activity: POD #0 out of bed to chair, evening walk with support
- Diet: clear liquid diet as tolerated
- Incentive spirometer 10x per hour to be sent with the patient from PACU
- Fluids: POD #0 lactated ringers at 125 ml/hr or normal saline at 125 ml/hr if not contraindicated; POD #1 D5 with ½ normal saline at 75 ml/hr if not contraindicated
- Catheter/drain: catheter removed at midnight and JP creatinine drawn at 4AM
- Labs: 4AM CBC and BMP
- Analgesia: standing dose acetaminophen, severity-based opioid administration, early pain management consultation as needed, ketorolac x 3 doses as per surgeon
- Anti-emetics: ondansetron 4mg IV q6hours, Reglan 10mg q6hrs PRN, Compazine 5mg IV q6hrs PRN
- Discharge instructions provided the night prior to discharge
Dr. Stifelman concluded by once again emphasizing the multidisciplinary approach with the office staff, surgeon, anesthesia team and hospital floor staff. Furthermore, it is important to create a clear and reproducible pathway, to share the plan with everyone involved, to track data, and to share data.
Presented By: Michael Stifelman, Hackensack University, Hackensack, NJ
Written By: Zachary Klaassen, MD, Urologic Oncology Fellow, University of Toronto, Princess Margaret Cancer Centre, @zklaassen_md ,at the 2018 North American Robotic Urology Symposium, February 16-17, 2018 - Las Vegas, NV