[Design, implementation, and results of the clinical pathway for herniated lumbar disk]

Clinical or critical pathways are a useful tool in the continuous quality improvement. They develop the main characteristics of the quality programs: implementation of the evidence based medicine, increase staff and patient satisfaction and adequacy in hospital costs. This is the application of evidence-based medicine to a process management and it promotes integration of clinical guides, protocols and algorithms.

We present our experience in the design, and first nine month's implementation and development of a clinical pathway for lumbar hemilaminectomy.

This clinical pathway consists on four documents: main guide and check sheet, preprinted treatment orders and variation sheet, iconographic information for the patients and patient satisfaction questionnaire. After desing, development and a pilot study, the hemilaminectomy critical pathway was permanently adopted by our Service. A total of 106 patients underwent programmed lumbar disc hemilaminectomy in our Service between April and December-1999. Patients' average age was 44.7 years (SD = 11.2), 55.3% were men and 43.7% women. Twelve were hospitalized in a ward other than Neurosurgery unit and therefore were excluded from the study. This evaluation is based on the initial results obtained from both the pathway documents and the general data collected as usual during hospital care. The impact of the critical pathway on hospital stay has been assessed by comparing the average stay of critical pathway patients to the average of the 70 hemilaminectomies performed at our Service in the period April-December 1998.

Clinical pathway coverage has been 68% (standard > 80%). The patients' average stay was 4 days (SD = 1.1), one day more than planned. The pathway establishes a 4 day hospital stay (3 bed-days), a time that was fulfilled by 49% of the patients. The average stay of the 1998 patients was 5.6 days (SD = 2.7), 1.6 days more than the clinical pathway patients (p < 0.0001). Additionally, undesirable variability in the length of hospital stays was also reduced. Analysis of variations identified those corresponding to patient's condition, increases in medication beyond that originally specified due to patient needs, and unjustified prolonged stays. There were no systematic variations. There was a 2.2% incidence of adverse effects. Although satisfaction questionnaire was only returned by 51% of the patients (instead of > 70%), satisfaction index were 93% (vs 90%).

Critical pathways are still under development and changing continuously. Nevertheless their impact on improving patient care and satisfaction, and resource consumption is already evident, and it constitutes a major aim to work in its complete development.