Critical pathways for head and neck surgery: Development and implementation

Objective: To design, implement, and study the effectiveness of 4 new critical pathways relevant to head and neck oncological care. Design: Before- after trial. Setting: Tertiary referral academic institution. Patients: Sixty-eight patients admitted for head and neck oncological surgery or chemotherapy from December 1, 1995, through May 31, 1996; 30 patients with similar diagnoses and who underwent surgical procedures from December 1, 1994, to December 1, 1995, who served as historical controls. Interventions: Implementation of 4 critical pathways: chemotherapy, clean head and neck surgery, clean contaminated head and neck surgery, clean contaminated head and neck surgery with reconstructive flap. Main Outcome Measures: Length of stay, cost of hospitalization, and variance tracking (deviations from established standards). Results: The length of stay for the clean contaminated group without flap reconstruction decreased by 1.5 days, and costs decreased by $7407 per patient (P<.05, Student t test). The length of stay decreased 1.6 days in the clean contaminated group with flap reconstruction, and costs decreased $9845 per patient (P<.05, Student t test). Nine patients (13%) experienced a prolonged length of stay while on a critical pathway. Conclusions: Implementation of critical pathways has resulted in a decreased overall length of stay and cost of hospitalization. It has also allowed for better coordination and documentation of patient care, while the tracking of variances has simplified problem identification and correction.