Implementation of a clinical pathway in management of the postoperative vestibular schwannoma patient

Objective: The purpose of the study was to evaluate the effectiveness of a new clinical pathway in management of patients with postoperative vestibula r schwannoma. The impact on duration of hospitalization and quality of care was evaluated. Study Design: The study was a retrospective review of 59 co nsecutive patients undergoing surgical intervention for vestibular schwanno ma between January 1995 and July 1999. Methods: A new clinical pathway for management of postoperative vestibular Schwannoma patients was implemented at The California Ear Institute at Stanford (Palo Alto, CA) in January 1995 . All patients undergoing surgical intervention subsequent to initiation of the pathway were included in the study. Data including surgical approach, patient age, sex, and tumor size were included. Duration of hospitalization and postoperative complications were recorded. During the same time period , data for patients undergoing radiation therapy for vestibular schwannomas were evaluated for length of hospital stay and in-hospital complications. Data were compared with norms recorded in the literature for duration of ho spitalization and complications following surgical intervention. Results: F ifty-nine patients underwent 35 middle fossa approaches and 24 translabyrin thine approaches to their tumors. The average patient age was 53 years; the re were 34 female and 25 male patients. The average length of hospital stay was 3.83 days (SD = 1.4 days) with a range from 2 to 10 days. Postoperativ e complications were observed in 19% of patients, including eight (13%) cer ebrospinal. fluid (CSF) leaks, two requiring lumbar drains (3.4%); one hema toma (1.6%), one postoperative fever (1.6%), and one dural tear with associ ated hyponatremia (1.6%). These results compared favorably with previously recorded average hospital stays of 5.95 to 9.5 days(1,5-7) and CSF leak com plication rates of 7% to 15%.(9,10) Conclusions: Implementation of a clinic al pathway for management of the patient with postoperative vestibular schw annoma improves efficiency of patient care, allowing decreased duration of hospitalization. This goal is achieved without increasing complication rate s and, in our experience, actually improving the quality of clinical care. The cost-effectiveness of clinical pathways may become increasingly importa nt in a managed care-driven environment.