Impact of Carotid Endarterectomy Critical Pathway on Surgical Outcome and Hospital Stay

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Abstract
Carotid endarterectomy (CEA) is associated with substantial consumption of hospital days and other resources. Although surgical outcomes in their practice compared favorably with published benchmarks, the authors were concerned that postoperative stays were unnecessarily long and that patients were receiving unnecessary tests and pharmaceuticals. Recent studies suggest that within the bounds of safe practice, efforts to standardize care may increase quality and patient satisfaction and reduce consumption of resources. They examined their practice of CEA in an effort to discover the potential for quality improvement and decreased utilization of resources. A CEA critical pathway (CP) was designed, the primary goal of which was elimination of a possibly unnecessary second postoperative hospital day for most patients and superfluous perioperative testing and medications. Data were recorded prospectively both for Pre-CP patients during the year prior to CP initiation and for subsequent CP patients during the subsequent 13-month period. CP patients were interviewed and the pathway was described prior to surgery. Pre-CP and CP patients were indistinguishable with respect to indications for CEA and medical comorbidities. A single operative death occurred due to myocardial infarction (Pre-CP). Perioperative stroke and other complications occurred in similar numbers of Pre-CP and CP patients. CP resulted in a 0.5-day decrease in hospital stay overall. CP was also associated with a 22% decrease in direct costs. One early readmission for neck hematoma on postoperative day 2 (1 day postdischarge) might have been preventable. A second readmission on postoperative day 2 was secondary to a drug reaction and would likely have occurred prior to initiation of the CP as well. CP resulted in significant decreases in resource utilization and with the possible exception of a single readmission did not appear to adversely affect outcome. Preoperative education and expectation that patients will be ready for discharge 1 day after CEA are critical to patient acceptance and satisfaction. Further modification of the CP may further decrease utilization of resources. CP is an excellent mechanism to understand how surgeons practice and it facilitates quality improvement.