Deviations from a clinical pathway post pancreatoduodenectomy predict 90-day unplanned re-admission

Abstract

Aim: To determine the frequency and relevance of deviations from a post pancreatoduodenectomy (PD) clinical care pathway. Materials & methods: A retrospective analysis using a prospectively maintained database of a post-PD clinical care pathway was carried out between May 2016 and March 2018. Patients were divided based on the number of factors deviating from the clinical care pathway (Group I: no deviation; Group II: deviation in 1–4 factors; Group III: deviation in 5–8 factors). The analysis included profiling of patients on different demographic and clinical as well as medical and surgical outcome parameters (discharge by postoperative day 8 and 90-day unplanned re-admission rate). Results: Post-PD clinical care pathways are feasible but deviations from the pathway are frequent (91%). An increase in frequency of deviations from the pathway was significantly associated with increased risk of POPF and delayed gastric emptying, delayed discharge, risk of mortality and 90-day unplanned re-admission rate. Conclusion: Deviations from a post-PD clinical care pathway are common. Poor nutrition and cardiac co-morbidities are associated with an increased likelihood of deviation. As the number of deviations increase, so does the risk of significant complications and interventions, delayed discharge and 90-day re-admission rate.

Construction of Clinical Pathway Information Management System under the Guidance of Evidence-Based Medicine

“…In clinical practice, the patient is the center, and the work of multiple departments, including professional departments and administrative departments, is integrated; it emphasizes horizontal contact and communication between departments. The clinical pathway is not a standard of behavior, but a kind of guidance or advice, and does not deprive the doctor of autonomy [ 25 ]. It proposes the best diagnosis and treatment plan discussed and approved by experts, which reduces the difference in treatment effects due to different levels of doctors and protects the interests of patients.…”

Is enhancing recovery after pancreatic cancer surgery even possible?—a narrative review

“…Braga et al (65) highlighted that patients with early postoperative low compliance to the ERAS® pathway had a higher incidence of complications. Karunakaran et al (100) showed that less than 10% of patients following PD display a 100% compliance and deviation from >50% of clinical pathway components is associated with an increased risk of 90-day (but not 30-day) readmission, which signals the importance of continued close surveillance in these patients (102).…”

“…Most studies have used length of hospital stay (LoS) to evaluate the performance of their care pathways. Taking a closer look at the relationship between adherence to individual pathway components and LoS, failure to remove the naso-gastric tube (NGT) on POD2 (103), intolerance to liquid diet on post-operative day (POD) 3 ( 103), inability to tolerate solid food by POD 5 (94,100), re-insertion NGT (100), need to continue antibiotics beyond POD 2 (100) and inability to remove drain on the designated day (94) were predictors of longer hospitalization. This leads one to infer that post-operative pancreatic fistula (POPF), delayed gastric emptying (DGE), and infectious complications are major causes of deviations.…”

“…Furthermore, certain racial groups, especially Asians are known to incur greater metabolic injury even at lower BMI (124). This, along with other adverse factors like hypoalbuminemia (100,125,126) and pre-existing comorbidities especially cardiac (100), prepare a conducive milieu for the complications to develop. The overriding question is can these hurdles be overcome?…”

Pain management, fluid therapy and thromboprophylaxis after pancreatoduodenectomy: a worldwide survey among surgeons

“…Recent studies have shown an association between low compliance to ERAS protocols and decreased clinical outcomes such as more overall, respiratory, infectious, and major complications (Clavien-Dindo III), longer length of hospital stay and more readmissions following PD. 4,5 Although epidural analgesia is recommended over intravenous morphine in the recent ERAS Society guideline for PD (1), the optimal pain management remains controversial, and the reported use of epidural analgesia varies from 11 to 85%. 6 There are only a few well-conducted randomized controlled pain management trials reporting on patients undergoing PD [7][8][9] and to date the role of transversus abdominis plane blocks has not been assessed for these patients.…”