Initiation of a Critical Pathway for Pancreaticoduodenectomy at an Academic Institution—the First Step in Multidisciplinary Team Building

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Abstract
Pancreaticoduodenectomy (PD) is a complex general surgical procedure originally associated with significant perioperative morbidity and mortality. Multiple studies have now shown that this operation can be performed quite safely at high-volume institutions that develop a particular expertise. Critical pathways are among the key tools used to achieve consistently excellent outcomes at these institutions. It remains to be determined if implementation of a critical pathway at an academic institution with earlier moderate experience with PD will result in performance gains and improved outcomes. This study was designed to track performance improvements brought about by the implementation of a critical pathway for complex alimentary tract surgery. Between January 1, 2004, and October 15, 2006, 135 patients underwent PD: 44 before implementation of a critical pathway on October 15, 2005, and 91 after. Perioperative and postoperative parameters were analyzed retrospectively to identify those that could be used to track performance improvement and outcomes. Compared with the prepathway group, the postpathway group had a significantly shorter postoperative length of stay (13 versus 7 days, p ≤ 0.0001) and operative time. Mean total hospital charges were significantly reduced, from $240,242 ± $32,490 to $126,566 ± $4,883 (p ≤ 0.0001). 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 use of resources (greater operating room and hospital bed availability) and overall cost containment.