The impact of clinical pathways on the practice of head and neck oncologic surgery: the University of Texas M. D. Anderson Cancer Center Experience.

OBJECTIVE: To assess the impact of clinical pathways on the practice of head and neck oncologic surgery in an academic center. DESIGN: Cross-sectional study. SETTING: Cancer treatment center. PATIENTS: The study population consisted of 3 groups of patients who underwent unilateral neck dissection and were treated in the Department of Head and Neck Surgery of the University of Texas M. D. Anderson Cancer Center, Houston. Additional procedures which may have been performed were direct laryngoscopy, rigid esophagoscopy, and/or dental extractions. Ninety-six patients treated during 1993-1994 prior to the implementation of the clinical pathway (historical control group) were compared with 94 patients treated during 1996-1998, 64 who were not (contemporaneous nonpathway group) and 30 who were managed on the clinical pathway (pathway group). Patients from 1995 were excluded since the pathway was in the planning stages then. MAIN OUTCOME MEASURES: Median length of stay; median total costs of care. RESULTS: The median length of hospital stay of the historical control, contemporaneous nonpathway, and pathway groups decreased from 4.0 to 2.0 days (P<.001). The total median costs of care were less in the pathway group as compared with the historical control group ($6,227 and $8,459, respectively, P<.001) and also less in the contemporaneous nonpathway group compared with the historical control group (S6885 and $8,459, respectively, P<.001). Mean and median length of hospital stay and costs were lower in the pathway group as compared with the nonpathway group but not significantly (P = .11 and P = .07, respectively) The contemporaneous nonpathway and pathway groups did not differ in complications or readmissions. CONCLUSIONS: Development and implementation of this clinical pathway played a statistically significant role in decreasing length of hospital stay and total costs of care associated with neck dissection between nonpathway and pathway patients. Thus, a more cost-effective practice environment has resulted for all of our patients.

Split-thickness skin graft donor site management. A randomized prospective trial comparing a hydrophilic polyurethane absorbent foam dressing with a petrolatum gauze dressing.

OBJECTIVE: Traditionally, skin graft donor sites have been covered with fine-mesh gauze dressings, and a dry eschar has been allowed to form. Newer dressings that can provide a moist wound environment may facilitate reepithelialization. We compared a hydrophilic semipermeable absorbent polyurethane foam dressing that provides a moist wound environment with a petrolatum gauze dressing for donor sites. DESIGN: Prospective randomized trial; follow-up at 14 days. SETTING: Department of head and neck surgery in a tertiary care center. PATIENTS: Sixty-eight eligible patients received one of the two dressings. Harvested skin grafts were 0.375-mm (0.015-in) thick; donor site surface areas were recorded. At postoperative day 14, the dressings were removed, and wound epithelialization was scored: 1, none; 2, scattered or spotty; and 3, complete. Donor site and operative site pain intensities were assessed by a visual numeric scale: none (0) to the worst (100) experienced over the preceding 24-hour period. Pain scores were available for 58 patients. MAIN OUTCOME MEASURES: Dressings were compared based on these criteria: healing at 14 days, infection, and donor site and operative site pain. RESULTS: A healing score of 3 was seen in 37% (14/38) of patients with hydrophilic semipermeable absorbent polyurethane foam dressings and in 17% (5/30) of patients with petrolatum gauze dressings (P = .06) by day 14. Overall, however, mean healing scores were similar in both groups. Mean healing scores for the patients who received a hydrophilic semipermeable absorbent polyurethane foam dressing was 2.3 (SD = 0.6) vs 2.2 (SD = 0.6) for patients who received the petrolatum gauze dressing (P = .20). Numbers of days required for complete epithelialization in these groups were 20.6 (SD = 10.1) and 19.3 (SD = 5.1), respectively (P = .49). One infection occurred in the group who received the petrolatum gauze dressing. The mean maximum pain intensity scores were lower for those who were given the hydrophilic semipermeable absorbent polyurethane foam dressing on postoperative days 1 through 3 (P = .003, .03, and .04, respectively). Pain increased with a larger donor site surface area for the patients with the petrolatum gauze dressing but not for the patients with the hydrophilic semipermeable absorbent polyurethane foam dressing. CONCLUSIONS: The hydrophilic semipermeable absorbent polyurethane foam dressing appears to have potential advantages over the petrolatum gauze dressing; it produces less initial patient donor site discomfort and tends to produce more complete donor site healing by postoperative day 14.