ABSTRACT
Systematic assessment of care pathways may identify areas of potential improvement beyond that generated by traditional outcome measures alone. This approach was used to audit a single-surgeon's practice of pulmonary resection [182 patients over 21 months, median age of 69 (range 18-86) years] by choosing 10 gold standards in three areas of care. Preoperative: 1) Percentage cancer patients undergoing PET scan prior to surgery, 2) Percentage of patients with predicted postoperative FEV(1) (ppoFEV(1)) <40% who had gas transfer (DLCO) measured. Perioperative: 3) Percentage of operations postponed, 4-5) Percentage of cancer patients undergoing anatomical resections and systematic lymph node excision, 6) Rate of exploratory thoracotomies. Postoperative: 7-8) Risk-adjusted mortality according to thoracoscore and ESOS.01, 9) Percentage patients admitted to intensive care unit (ICU), and 10) Percentage patients discharged directly home from our unit. Postoperative mortality (2.2%), ICU admission (4%), exploratory thoracotomy (2.7%), and home discharge (98%) fared within standards. Only 57% of patients with a ppoFEV(1)<40% had DLCO tested, and eight cases (4.4%) were postponed on the day of surgery. Analysis of the processes of care identified areas for improvement (preoperative preparation of patients, theatre cancellations and intraoperative lymph node management) even in a practice with satisfactory risk-adjusted results.
