IMPACT OF A CRITICAL PATHWAY ON POSTOPERATIVE LENGTH OF STAY AND OUTCOMES AFTER INFRAINGUINAL BYPASS

Purpose: To determine the effect of a critical pathway on postoperativ e length of stay and outcomes after infrainguinal bypass. Methods: A c ritical pathway for care of patients after infrainguinal bypass was in troduced in December 1995 to coordinate postoperative care at our inst itution. We compared care of 67 consecutively treated patients before institution of the pathway with care of 69 consecutively treated patie nts with the critical pathway in place. Data collection was done by me ans of chart review. Univariate analyses were used to identify differe nces between prepathway and postpathway patients and to identify facto rs influencing postoperative length of stay. Multivariate analysis was used to identify factors that influenced length of stay and to examin e the effect of use of the pathway after adjusting for other factors. Results: Patients on the pathway were similar to prepathway controls w ith respect to comorbid illnesses, vascular risk factors, indications for surgical treatment, type of conduit, and type of operation. factor s associated with longer postoperative stays included distal anastomos es to tibial rather than popliteal vessels (p = 0.02), preexisting car diac disease (p = 0.005), postoperative complications (p = 0.0003), lo wer preoperative hematocrit (p = 0.01), and elevated preoperative crea tinine level (p = 0.006). Overall, pathway patients had somewhat short er postoperative lengths of stay (median value 7 days; range 2 to 29 d ays) than prepathway patients (median value 6 days; range 2 to 35; p = 0.01), and the two groups had similar frequencies of postoperative co mplications, readmission, and 6-month mortality. However, patients on the pathway were more likely to be discharged to an intermediate-care facility rather than directly home. After 12 patients with extraordina rily prolonged postoperative stays were excluded, multivariate analysi s indicated that pathway patients had significantly shorter postoperat ive stays (p = 0.001). However, the difference was not significant if patients with extraordinarily long postoperative stays were included i n the analysis (p = 0.28). Conclusion: Use of a critical pathway was a ssociated with a modest decrease in postoperative length of stay for m ost patients. This was accomplished without an adverse effect on readm ission, complication, or mortality rates. However, the decrease in sta y may have been achieved primarily by discharging more patients to int ermediate-care facilities. The pathway did not appear to have any effe ct when the subset of patients with extraordinarily long stays because of complex medical problems was included.