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Background: Care pathways (CPs) are helpful in reducing unwanted variation in clinical care. Most studies of CPs show they improve clinical outcomes but there is little known about the long-term impact of CPs as part of a sustained quality management program. Head and neck (HN) surgery with free flap reconstruction is complex, time-consuming and expensive. Complications are common and therefore CPs applied to this patient population are the focus of this paper. In this paper we report outcomes from a 9 year experience designing and using CPs in the management of patients undergoing major head and neck resection with free flap reconstruction., Methods: The Calgary quality management program and CP design is described the accompanying article. Data from CP managed patients undergoing major HN surgery were prospectively collected and compared to a baseline cohort of patients managed with standard care. Data were retrospectively analyzed and intergroup comparisons were made., Results: Mobilization, decannulation time and hospital length of stay were significantly improved in pathway-managed patients (p = 0.001). Trend analysis showed sustained improvement in key performance indicators including complications. Return to the OR, primarily to assess a compromised flap, is increasing., Conclusions: Care pathways when deployed as part of an ongoing quality management program are associated with improved clinical outcomes in this complex group of patients.

Background: Care pathways (CPs) offer a proven method of systematically improving patient care. CPs are particularly helpful in complex clinical conditions where variation in care is a problem such as patients undergoing major head and neck resection with free flap reconstruction. Although CPs have been used to manage this patient group, most CPs are implemented as part of relatively short-term quality improvement projects. This paper outlines a detailed methodology for designing and delivering a quality management program sustained for 9 years., Methods: We describe a change management approach informed by Kotter's "8 Step Process" that provided a useful framework to guide program development and implementation. We then provide a detailed, step by step description of how such a program can be implemented as well as a detailed summary of time and costs for design, implementation and sustainability phases. An approach to design and delivery of a measurement, audit and feedback system is also provided., Results: We present a summary of resources needed to design and implement a head and neck surgery quality management program. The primary result of this study is a design for a sustainable quality management program that can be used to guide and improve care for patients undergoing major head and neck resection with free flap reconstruction., Conclusions: A change management approach to design and delivery of a head and neck quality management program is practical and feasible.

Background: The purposes of this study were to explore the association of a postoperative clinical care pathway for patients undergoing major head and neck surgery with microvascular reconstruction on postdischarge health care utilization and cost and to compares a nonpathway group (n = 60) to a prospective, pathway-managed group (n = 54). Our primary purpose was to understand whether pathway-managed patients used postdischarge health care resources differently than patients managed without a care pathway., Methods: Health care utilization data (counts and costs) were collected for the 3 months after discharge. Differences in utilization were compared using Poisson regression. The null hypothesis was that there were no differences in utilization between the pathway and nonpathway groups., Results: Pathway patients had fewer postdischarge encounters in 2 of 4 sectors. Readmission costs were significantly less in the pathway group only., Conclusion: A postoperative inpatient clinical care pathway in patients with head and neck cancer is associated with decreased health care utilization and inpatient costs in the 3 months after discharge. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1216-E1220, 2016., (© 2015 Wiley Periodicals, Inc.)

Importance: Tracheotomy is a common procedure. Postoperative care is usually managed by nonexpert clinicians. Prolonged decannulation is associated with a high incidence of complications. At present, no clinical protocol exists to guide clinicians through decannulation. To address this deficiency, we developed a low-risk tracheotomy clinical pathway., Objective: To determine the effect of our low-risk tracheotomy clinical pathway on the time to decannulation and to determine its safety and sustainability by assessing the incidence of adverse events., Design, Setting, and Participants: Our study combined retrospective and prospective cohorts from July 1, 2008, through January 31, 2012. Low-risk adult patients undergoing tracheotomy at a tertiary care hospital constituted the study population. A baseline cohort of 26 patients underwent retrospective assessment. After development of the pathway, a pilot group of 34 consecutive patients underwent evaluation; of these, 13 were ineligible because of high-risk factors, which included potential upper airway obstruction, unfavorable neck anatomy, or medical factors such as coagulopathy. To assess the sustainability of the pathway, a follow-up cohort underwent assessment. Of 107 consecutive patients, 39 met the low-risk criteria. Length of follow-up was 30 days after decannulation., Intervention: The low-risk tracheotomy clinical pathway, which provides a stepwise approach to decannulation., Main Outcomes and Measures: Total time to decannulation (in days). We hypothesized that the pathway would reduce the total time to decannulation. The secondary outcome constituted adverse events. All hypotheses were formulated before data collection., Results: Mean (SD) total time to decannulation in the baseline cohort was 15.50 (12.08) days. After implementation of the pathway in the pilot cohort, mean (SD) total time to decannulation decreased to 5.74 (2.79) days (P < .001). In the follow-up cohort, mean (SD) total time to decannulation was 8.13 (7.09) days (P = .003). We found no association between adverse events and use of the pathway., Conclusions and Relevance: Our low-risk tracheotomy clinical pathway is associated with a sustainable decrease in total time to decannulation without any associated increase in adverse events. We therefore believe that this pathway is a safe and effective tool to guide clinicians in the management of tracheotomy.

Background: Pulmonary complications are common after major head and neck oncologic surgery with microsurgical reconstruction and are associated with increased mortality and morbidity. Clinical care pathways are evidence-based tools that reduce unnecessary practice variation and ultimately improve patient outcomes. In this study, the authors evaluate the effectiveness of a comprehensive care pathway on reducing postoperative pulmonary complications and hospital length of stay in patients undergoing major head and neck carcinoma resection with free flap reconstruction., Methods: Fifty-five consecutive patients treated according to a prescribed postoperative clinical care pathway were compared to a historical cohort of patients treated before the implementation of the pathway. The incidence of pulmonary complications, hospital length of stay, and free flap survival were compared between the control and intervention groups., Results: Patients on the clinical care pathway had 32.5 percent fewer pulmonary complications (p < 0.0001) and 7.4 days' shorter hospital length of stay (p = 0.0007) than patients not on the postoperative pathway. There was no significant difference in the rate of flap reoperation., Conclusions: A multidisciplinary, comprehensive, clinical care pathway for patients undergoing major head and neck surgery with microsurgical reconstruction is effective in reducing postoperative pulmonary complications and hospital length of stay. The postoperative pathway is safe in this patient population and should be considered for adoption into clinical practice., Clinical Question/level of Evidence: Therapeutic, III.

Background: The objective of this study is to evaluate the cost-effectiveness of a postoperative clinical care pathway for patients undergoing major head and neck oncologic surgery with microvascular reconstruction., Methods: This is a comparative trial of a prospective treatment group managed on a postoperative clinical care pathway and a historical group managed prior to pathway implementation. Effectiveness outcomes evaluated were total hospital days, return to OR, readmission to ICU and rate of pulmonary complications. Costing perspective was from the government payer., Results: 118 patients were included in the study. All outcomes demonstrated that the postoperative pathway group was both more effective and less costly, and is therefore a dominant clinical intervention. The overall mean pre- and post-pathway costs are $22,733 and $16,564 per patient, respectively. The incremental cost reduction associated with the postoperative pathway was $6,169 per patient., Conclusion: Implementing the postoperative clinical care pathway in patients undergoing head and neck oncologic surgery with reconstruction resulted in improved clinical outcomes and reduced costs.