New Critical Pathway Reduces the Costs of Radical Prostatectomy at Chicago Hospital

CHICAGO--A new critical pathway for radical prostatectomy introducedat Chicago's Weiss Memorial Hospital has lowered hospital staysfor these patients to a mean of 1.7 days, compared with 4.6 daysfor patients treated under the previous protocol. The shorterstays did not affect surgical outcome or reduce patient satisfaction,report Gerald W. Chodak, MD and his colleagues at the Universityof Chicago Medical Center.

More than one third of the 27 patients in the study group (37%)were discharged after one night, while none of the 20 controlswho underwent conventional management were discharged that early.None of the study patients required re-hospitalization. Overall,the findings suggest that same-day discharge is now a possibilityfor some radical prostatectomy patients, the investigators say.

In addition to shorter hospital stays, the new protocol also ledto significant reductions in average time in the operating room(3.7 hours vs 4.9 hours for controls) and in estimated blood loss.

In the new protocol, blood lost during the operation is salvagedand processing using a cell saver, and reinfused only if the estimatedblood loss is more than one liter. Eleven of the study patientshad no need for transfusions.

Patient charges for the study patients were reduced by 32% (froman average of $20,000 to less than $14,000), and hospital costswere reduced by 35% (Urology 47:23-28, 1996).

The new approach involved extensive preoperative patient education,a shift from general to epidural anesthesia, minor changes inthe surgical procedure, an accelerated recovery period that eliminatedpostoperative narcotics, and a quick return to moderate activityand a normal diet.

The crucial factors were the use of epidural pain relief, whichresults in less blood loss and quicker recovery, and preoperativeeducation, a process that "makes the patient part of thetreatment team," Dr. Chodak says.

Preoperative education in the new protocol consists of a counselingsession with a clinical nurse for the patient and significantother at least 1 week before surgery. The patient receives aneducation manual providing specific preoperative, operative, andpostoperative instructions, expectations, and goals. For example,patients are encouraged to select musical tapes to listen to throughheadphones during the operation. They are advised that their hospitalstay is expected to be no more than 1 to 2 days.

In the new approach, patient wear elastic antithromboembolismstockings, and all patients except those undergoing node dissectionreceive heparin. Sequential compression devices are not used,contributing to the cost savings.

The decision to perform lymphade-nectomy is based on the preoperativePSA level, Gleason score, and clinical stage. Patients with arisk of lymph node metastases less than 15% are counseled, andnode dissection is omitted if acceptable to the patient. Perviouslyall patient underwent bilateral pelvic lymphadenec-tomy with frozensections.

Postoperatively, patients are encouraged to sit in a chair, exercisetheir lower extremities, and use an incentive spirometer as soonas they return to their hospital room. Patients receive oral ibuprofenand acetaminophen every 6 hours for postoperative pain control.

Patients become ambulatory and start a clear liquid diet on themorning of postoperative day 1, and regular diet is begun theafternoon of postoperative day 1 or the morning of postoperativeday 2.

Outcome surveys showed that 92% of the study patients were satisfiedwith their anesthesia (two patients required conversion to lightgeneral anesthesia, both due to problems with the epidural catheter),and 96% were satisfied overall.

Only 16% said their hospital stay was too short. None of the 10men with the shortest hospital stays (1 night) said they wouldhave preferred to stay longer.

"In this era of cost containment, minimizing hospital costswhile maintaining the quality of patient care is an increasingchallenge," Dr. Chodak says. "We have used outcome-baseddata to develop a critical pathway that resulted in a significantreduction in hospitalization, operating time, recovery room time,and intraoperative blood loss, without any obvious compromiseto patient care as measured by additional complications or re-admissionrates."

More recently, he says, 20 of the last 23 prostatectomy patientshave been discharged the next day, and "some of these patientswho underwent surgery in the morning were sufficiently recoveredto consider late afternoon discharge."

Dr. Chodak and his colleagues believe that, with this protocol,they may have reached the lowest possible cost for performingradical prostatectomy, because of the inability to further reduceoperating room time. And although the Chicago team believes thatambulatory surgery is now possible for selected radical prostatectomypatients, the additional savings from same-day discharge willbe relatively small.