title: Implementation of a critical pathway for distal pancreatectomy at an academic institution.
abstract: OBJECTIVE
  This study was designed to identify quantifiable parameters to track performance improvements brought about by the implementation of a critical pathway for complex alimentary tract surgery.
  
  
  BACKGROUND
  Distal pancreatectomy is among the more complex general surgical procedures. This is primarily due to the possibility of blood loss from visceral vessels, splenic injury, and significant postoperative complications. The introduction of the laparoscopic approach to the distal pancreas has introduced a further level of surgical expertise required to fully address the clinical needs of this diverse patient population. Critical pathways have been one of the key tools used to achieve consistently excellent outcomes at high-quality, high-volume institutions. It remains to be determined if implementation of a critical pathway at an academic institution with prior moderate experience with distal pancreatectomy will result in performance gains and improved outcomes.
  
  
  METHODS
  Between January 1, 2003 and August 15, 2007, 111 patients underwent distal pancreatectomy. Forty patients underwent resection during the 34-month period before the implementation of a critical pathway on October 15, 2005 and 71 during the 20 months after pathway implementation. Patients undergoing both open and laparoscopic procedures were included. Peri- and postoperative parameters were analyzed retrospectively to identify those that could be used to track performance improvement and outcomes.
  
  
  RESULTS
  The two groups were not significantly different with respect to age, sex, race, diagnosis, operative blood loss, or mean operative duration. Postoperative length of hospital stay was significantly shorter when comparing pre- to postpathway implementation (10.2 days versus 6.7 days, P < or = 0.037). The rate of readmission to the hospital after discharge was significantly lower post pathway (25% versus 7%, P < or = 0.027). Hospital costs were also reduced.
  
  
  CONCLUSIONS
  Implementation of a critical pathway for a complex procedure can be demonstrated to improve short-term outcomes at an academic institution. This improvement can be quantified and tracked and has implications for better utilization of resources and overall cost containment while maintaining or improving upon an already high level of care.
authors.affiliation: Department of Surgery, Jefferson Medical College, Jefferson Pancreas, Biliary and Related Cancer Center, Thomas Jefferson University, 1025 Walnut Street, Suite 605 College Building, Philadelphia, PA 19107, USA. Eugene.Kennedy@Jefferson.edu
authors.forename: Eugene P
authors.initials: EP
authors.lastname: Kennedy
authors.forename: Tyler R
authors.initials: TR
authors.lastname: Grenda
authors.forename: Patricia K
authors.initials: PK
authors.lastname: Sauter
authors.forename: Ernest L
authors.initials: EL
authors.lastname: Rosato
authors.forename: Karen A
authors.initials: KA
authors.lastname: Chojnacki
authors.forename: Francis E
authors.initials: FE
authors.lastname: Rosato
authors.forename: Bernadette C
authors.initials: BC
authors.lastname: Profeta
authors.forename: Cataldo
authors.initials: C
authors.lastname: Doria
authors.forename: Adam C
authors.initials: AC
authors.lastname: Berger
authors.forename: Charles J
authors.initials: CJ
authors.lastname: Yeo
mesh_terms: D015331:Cohort Studies; D019091:Critical Pathways / Q000458:organization & administration*; D005260:Female; D006785:Hospitals, University; D006801:Humans; D010535:Laparoscopy; D008297:Male; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care; D010180:Pancreatectomy; D010182:Pancreatic Diseases / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D016577:Pancreaticoduodenectomy; D015397:Program Evaluation; D012189:Retrospective Studies