The effect of a critical pathway on patients' outcomes after carotid endarterectomy

BACKGROUND In 1996, an integrated plan of care was implemented to improve quality of care for patients undergoing elective carotid endarterectomy. Goals were to reduce length of stay, costs, number of preoperative and intensive care unit admissions, and use of diagnostic procedures yet maintain good outcomes. OBJECTIVES To determine whether use of the integrated plan of care met the goals. METHODS Data on financial and process outcomes, use of angiographic diagnostic procedures, and demographics were retrieved from the hospital database for all patients who had elective carotid endarterectomy without cerebral infarction. RESULTS A total of 783 patients met inclusion criteria: 129 before implementation of the plan of care, 66 during the 6-month transition, and 588 after implementation. Preoperative angiography was done in 32% of patients before implementation, 11% during the transition, and 4% after implementation. Percentages of patients admitted to the intensive care unit were 77% before implementation, 24% during transition, and 9% after implementation. Mean lengths of stay were 2.93 days before implementation, 2.12 days during transition, and 1.68 days after implementation. Costs per case were $7798 before implementation, $5750 during transition, and $5387 after implementation. Analysis of variance revealed significant differences between groups in total length of stay (P = .001), preoperative length of stay (P<.001), and costs (P<.001). CONCLUSION Use of the integrated plan of care reduced length of stay, costs, admissions to intensive care units, and use of cerebral angiography. Use of the plan improved resource utilization while maintaining quality of care.