Design and Impact of an Intraoperative Pathway: A New Operating Room Model for Team-Based Practice
Bernard T. Lee, MD, Adam M. Tobias, MD, Janet H. Yueh, BA, Eran D. Bar-Meir, MD, Justine M. Carr, MD, Charlotte L. Guglielmi, RN, MA, BSN, CNOR, Elizabeth R. Wood, MBA, Donald W. Moorman, MD, FACS.
Beth Israel Deaconess Medical Center, Boston, MA, USA.
Background: At the Beth Israel Deaconess Medical Center, a subspecialized program for autologous breast reconstruction was established in 2004. The primary procedure performed is the deep inferior epigastric perforator (DIEP) flap reconstruction. In the initial program design, the two surgeons decided to reduce complexity by standardizing the procedure, including instrumentation, equipment, dressings, suture material, and operative sequence. An assessment of outcomes was performed after the first 200 flaps. While our endpoints of flap success and complication rates were similar to the published literature, our operative times had reached a disappointing plateau. To improve efficiency and communication, we instituted a highly involved form of team-based practice - the “relational coordination” teamwork model which was designed after a Harvard Business School study. Collaboration between surgeons, anesthesiologists, and operating room staff lead to the development of an intraoperative pathway. The goal of this study is to describe the development of an intraoperative pathway for microsurgical breast reconstruction and its impact on various outcome parameters.
Methods: 150 consecutive patients who underwent a deep inferior epigastric perforator flap breast reconstruction between 2005 and 2008 were prospectively acquired in a detailed database to evaluate outcomes before and after institution of the intraoperative pathway. Patient groups were subdivided into 50 unilateral and 50 bilateral procedures pre-pathway, and 25 unilateral and 25 bilateral procedures post-pathway. Analysis of operative time, length of stay, hospital costs, surgical complications, and proper dosing of antibiotics were performed. Operating room staff satisfaction surveys were conducted to assess the effectiveness of the intraoperative pathway. Statistical analysis was performed using student’s two tailed t test, chi square and Fisher’s exact test as applicable. Statistical significance was defined as p < 0.05.
Results: Operative times decreased significantly after pathway implementation in both the unilateral (15.9%, p<0.05) and bilateral groups (17.2%, p<0.05). Operating room costs showed a significant decrease in the unilateral group (10.2%, p<0.05). While the entire hospital stay costs and the remaining cost components also trended downward after the initiation of the pathway, they did not reach statistical significance. Length of stay and complication rates were unchanged after pathway implementation. Prophylactic antibiotic administration and subsequent re-dosing showed improvements after initiation of pathway. Staff surveys showed significant improvements in interdisciplinary communication, transition guidelines, and enhanced efficiency through standardization.
Conclusions: Implementation of an intraoperative pathway decreased both operating room time and cost in DIEP flap breast reconstruction. Further refinement of the pathway and team resolution of variances may continue to improve outcome measures. Complex, multi-team procedures as in microsurgey and craniofacial operations, can achieve similar benefits from standardization and intraoperative pathway development.