title: Impact of a common clinical pathway on length of hospital stay in patients undergoing open and minimally invasive kidney surgery.
abstract: OBJECTIVE
  Clinical pathways are designed to reduce variability in patient care practices and improve clinical outcomes. We evaluated the effect of implementing a clinical care pathway on length of stay in patients undergoing kidney surgery.
  
  
  METHODS
  After receiving institutional review board approval we evaluated prospective data on consecutive cases of partial and radical nephrectomy performed at our institution from 2000 to 2011. We identified 1,775 partial nephrectomies (1,449 open and 326 minimally invasive) and 1,025 radical nephrectomies (857 open and 168 minimally invasive). We used multivariate linear regression to test for an interaction between procedure type and surgery before vs after the clinical pathway was begun.
  
  
  RESULTS
  Median length of stay decreased 40% (from 5 to 3 days) for open surgery and 33% (from 3 to 2 days) for minimally invasive surgery after clinical pathway implementation. Length of stay in patients treated with minimally invasive or open partial nephrectomy and open radical nephrectomy decreased while it remained stable in those who underwent minimally invasive radical nephrectomy. The difference in length of stay between open and minimally invasive partial nephrectomy before and after implementing the clinical pathway decreased by 1.5 days (95% CI 0.56-2.5, p = 0.002). At 30 days postoperatively major complication rates remained similar.
  
  
  CONCLUSIONS
  The clinical pathway resulted in a significantly shorter length of stay in patients treated with partial and radical nephrectomy without a discernible impact on safety or quality of care. Clinical pathways for kidney surgery should be used and continually optimized to enhance efficiency, patient safety and outcomes.
authors.affiliation: Division of Urology, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York. Electronic address: tarintv@upmc.edu.
authors.forename: Tatum
authors.initials: T
authors.lastname: Tarin
authors.affiliation: Division of Urology, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York.
authors.forename: Andrew
authors.initials: A
authors.lastname: Feifer
authors.affiliation: Division of Urology, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York.
authors.forename: Simon
authors.initials: S
authors.lastname: Kimm
authors.affiliation: Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York.
authors.forename: Ling
authors.initials: L
authors.lastname: Chen
authors.affiliation: Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York.
authors.forename: Daniel
authors.initials: D
authors.lastname: Sjoberg
authors.affiliation: Division of Urology, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Coleman
authors.affiliation: Division of Urology, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York.
authors.forename: Paul
authors.initials: P
authors.lastname: Russo
mesh_terms: D019091:Critical Pathways; D005260:Female; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data*; D008297:Male; D019060:Minimally Invasive Surgical Procedures; D009392:Nephrectomy / Q000379:methods*; D011446:Prospective Studies
keywords: critical pathways; kidney; length of stay; nephrectomy; standard of care