Hepato - Pancreato -Biliary Surgery

1. Hepato-Pancreato-Biliary Surgery Developing a clinical pathway for patients undergoing pancreatic surgery

2. Whipple procedure Pancreatic Surgery • complex abdominal surgery • majority cases are performed for cancer • strong correlation between volume of surgery and outcomes • ↑cases performed  ↑ better outcomes • CCO has designated high volume centre of excellences in Ontario

3. Study Goal Improve the quality of surgical care for patients undergoing pancreatic surgery in Ontario

4. Quality in healthcare Structures of Care • Characteristics of physicians and hospitals • Context in which care and services are provided Process of Care • Components of the encounter between a physician or another health care professional and patients • steps that occur during the actual delivery of care Outcomes of Care • Changes in patients health status as a result of health care

5. What is a Clinical Pathway? • structured multidisciplinary instrument • details the steps of care during a defined patient care episode • critical pathway • clinical algorithm • clinical protocol • usually time dependent inventory of actions • used to standardize processes of care adapted from: Rotter T et al, Eval Health Prof, May 2011

6. Impact of clinical pathways Improved quality of care • standardization of processes of care • reduced variability • improved efficiency • high quality patient care • ↑ documentation  improved communication Good economic outcomes • ↓ length of stay • ↓ hospital costs

7. Impact of clinical pathways Improved patient outcomes • ↓ length of stay • ↓ patient morbidity and mortality • ↓ in-hospital complications • 5.6% absolute risk reduction (n=5 trials)1 Rotter T et al, Eval Health Prof, May 2011

8. Study Question • Can we develop an evidence based clinical pathway for patients undergoing pancreatic surgery?

9. Goals for this workshop Identify current practices and tools being used at the high volume HPB sites in Ontario Prioritize and rank key elements of patient care that should be included in a pancreatic surgery pathway Identify barriers and enablers to will lead to successful and sustainable implementation of a clinical pathway

10. Summary of clinical pathway project

11. Walk us through a patient's journey through care after undergoing a Whipple at your hospital

12. How are you currently managing these patients?

13. How do team members communicate with one another?

14. How do you think we might use a clinical pathway?

15. Why do you think we might use a clinical pathway?

16. Which elements should be included? • Prioritize and rank key elements of patient care that you feel should be included in a pancreatic surgery clinical pathway • Provide additional comments/ input • does pathway have face validity? • are there missing items? • do items that need clarification? • multi-disciplinary clinical pathway map • pre-printed MD orders

17. Multidisciplinary clinical pathway

18. Pre-printed MD orders

19. Benchmarking draft clinical pathway • 50 patient charts reviewed • 38 (76%) patients on pathway • Average length of stay = 8.15 days • 12 (24%) patients went off pathway • Average length of stay = 18.17 days

20. Benchmarking draft clinical pathway • highest variability in postoperative nutrition, pain management and activity (ambulation • elements most commonly missing • patient education • discharge planning

21. Wrap up • please hand in score sheets • sign consent forms • consider joining the working group • Thank you!