Design and impact of intraoperative pathways for head and neck resection and reconstruction

Objectives: To describe the design and impact of 3 intraoperative pathways for the treatment of head and neck cancers; to detail the pathways schematically to illustrate projected intraoperative flow and teamwork; and to analyze impact on procedure and case lengths in each pathway and in comparison with historical prepathway average times. Setting: Tertiary-level academic health system main operating room. Patients: Twenty-one patients undergoing transcervical (TC) resection (n=11), transmandibular (TM) resection (n=8), or laryngopharyngectomy (LP) (n=2) with radial forearm free-flap reconstruction for ablative or reconstructive reasons were pathway eligible. A convenience sample of 16 patients undergoing TC resection, 7 undergoing TM resection, and 7 undergoing LP prepathway is used for comparison. Intervention: Our academic medical center uses 3 intraoperative clinical pathways to manage resource use and streamline care for patients. These 3 pathways were designed schematically by an interdisciplinary team. The pathways plan progression of the case by timed actions for surgical, anesthesia, and nursing teams. Main Outcome Measures: Procedure and case lengths. Results: The TC pathway procedure and case length averaged 10.48 and 12.33 hours, respectively; TM pathway procedure and case lengths, 11.19 and 13.32 hours, respectively; and LP pathway procedure and case lengths, 12.42 and 13.83 hours, respectively. Aggregate averages were 10.93 hours and 12.85 hours for procedure and case length, respectively. The average pathway case lengths of 12.33, 13.32, and 13.83 hours compare favorably with our target times of 13, 14, and 15 hours, respectively. Environmental management, work flow, and team satisfaction anecdotally increased postpathway. Conclusions: Intraoperative pathways afford enhanced time and action efficiency to streamline care of patients undergoing head and neck procedures. Pathway implementation produced time savings. Our results suggest that implementation of such pathways will benefit similar academic medical centers seeking to improve intraoperative resource use to improve performance in the care of patients undergoing head and neck procedures.