Thoracotomy, critical pathway, and clinical outcomes

Using a multidisciplinary critical pathway for chest surgery, the staff of Saint Joseph Medical Center (Burbank, California) and its physicians developed a strategy leading to improved patient outcomes with reduced overall costs. On referral from the surgeon's office, the multidisciplinary team, consisting of a clinical nurse specialist, physical therapist, and respiratory therapist, meet with the patient. The education that follows includes discussion of the surgical procedure, intubation, incentive spirometry, coughing, deep breathing, early ambulation, use of patient-controlled analgesia, chest physiotherapy, transfusion options, and evaluation of health status. A few days later, the patient undergoes the thoracoscopy-assisted thoracotomy. The success of the outcome-driven critical pathway can be related to several factors: (1) close coordination between the surgeon's office and hospital; (2) intensive preoperative education that decreases patient's anxiety and increases his or her ability to participate in recovery; (3) patient-controlled analgesia, nerve blocks, non-narcotic analgesia, and preemptive rehabilitation, which limit the risk for complication; and (4) thoracoscopy, which limits the surgical morbidity commonly affiliated with thoracotomy. The pathway, used for 160 patients during the past 2 years, has shown dramatic results related to reducing morbidity, practice variation, delay, and total overall cost.