Enhancing the clinical pathway for patients undergoing axillary lymph node dissection.
BACKGROUND
Day-case axillary lymph node dissection (ALND) is not standard practice. Here we assess the feasibility of converting this traditional inpatient procedure to an outpatient procedure without compromising the quality or continuity of patient care, identify barriers to introducing an enhanced clinical pathway based on this conversion, and report strategies employed to overcome these barriers.


METHODS
Consecutive patients (n=282) undergoing ALND alone or with a concurrent breast procedure (excluding mastectomy/reconstruction) over a 12-month period were recorded in a prospective database. Assessed outcomes were successful discharge the day of surgery, early postoperative complication rates, and readmission rates.


RESULTS
From July 2009 to June 2010, 282 ALNDs were performed at Memorial Sloan-Kettering Cancer Center. 240 (85.1%) were performed as an outpatient procedure and 42 (14.9%) had inpatient ALND. The readmission rate was 0.8% (2/240), and the reoperation rate was 0.7% (2/282). Outpatient ALND procedure implementation created 240 additional beds over the 12-month study period. Identified barriers to implementing this new clinical pathway included patient expectations, reducing narcotic administration while optimizing postoperative pain control, and facilitating preoperative patient education.


CONCLUSIONS
ALND may be safely performed as a day-case procedure. The key to successfully implementing ALND as a day-case procedure is a multidisciplinary team approach combined with enhanced pre and postoperative patient education. In addition, changes in the mindsets of patients and health care providers are essential.
Breast Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, 300 East 66th Street, New York, NY 10065, USA.
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M
Barry
W P
WP
Weber
S
S
Lee
A
A
Mazzella
L M
LM
Sclafani
D000556:Ambulatory Surgical Procedures / Q000592:standards; D001365:Axilla; D001943:Breast Neoplasms / Q000601:surgery*; D003266:Continuity of Patient Care; D019091:Critical Pathways / Q000458:organization & administration / Q000592:standards; D005260:Female; D006801:Humans; D008197:Lymph Node Excision / Q000379:methods* / Q000592:standards; D010348:Patient Care Team; D010353:Patient Education as Topic; D010359:Patient Readmission / Q000706:statistics & numerical data; D011183:Postoperative Complications / Q000453:epidemiology; D011785:Quality Assurance, Health Care