Clinical Pathway Repository

[ethilo]

As our anesthesia group grows in size I am considering taking on a project of standardizing the way with which we carry out the anesthesia for different procedures. Where I went to residency we had a repository of clinical pathways that took individual surgical procedures and laid out a suggested roadmap to help encourage consistency in anesthesia care. For example, we had a clinical pathway for 3-field esophagectomy.

I'm wondering if anyone out there has experience implementing this in a private group. Specifically, I'm wondering what is the best platform to host this on (a "wiki" style private group platform so everyone can edit/contribute, or something built in google, or a cloud service?). I want to make it as easy as possible for those people in the group who are afraid of standardizing the anesthesia our group delivers.

Any other thoughts would be appreciated, thanks.

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[dchz]

My first question would be: what evidence do you have that standardized anesthesia is better? what evidence do you have that non-standardized would be worse?

Didn't you hire anesthesiologists so you could have a THINKING person tailoring to the patient? whats the point of standardizing?

 

[Aether2000]

My career experience in anesthesia has shown that anesthesiologists are not amenable to being pigeon-holed into rigid practice parameters because there are always exceptions that are needed (too numerous to list in a clinical pathway) and the presence of a pathway poses a medical-legal issue if they do not follow it to the tee. What I have found works better are "Protocols", without implying guidelines, standards, or consensus based document development.

 

[ethilo]

My first question would be: what evidence do you have that standardized anesthesia is better? what evidence do you have that non-standardized would be worse?

Didn't you hire anesthesiologists so you could have a THINKING person tailoring to the patient? whats the point of standardizing?

The point of standardizing is so we can give a consistent product to the surgeons. The purpose of this is not to be all-procedure encompassing, only the ones that truly need things done a specific way.

For example, craniosynostosis our surgeons have an expectation of giving NMB bolus at the start then none after, with plans to extubate and head to PICU after. If we have someone come along and do it "the way they've always done it" where they came from and that involved direct to ICU intubated or something, that would pose a problem. With specific procedures there are specific expectations that are sometimes culturally based and this document helps make our anesthesia "product" more consistent now that we are growing so big we can't just tell each other how to do things when passing in the halls.

 

[Psai]

Why don't you have some sort of meeting to hash out differences instead of dictating practice patterns to people

 

[ethilo]

Why don't you have some sort of meeting to hash out differences instead of dictating practice patterns to people

The group is 50 anesthesiologists with plans for significant growth over the next 2 years. New procedures, new surgeons, new anesthesiologists, multiple service locations. We are dabbling in subspecializing but prefer to have as much universal consistency amongst the whole group.

 

[IMGASMD]

The point of standardizing is so we can give a consistent product to the surgeons. The purpose of this is not to be all-procedure encompassing, only the ones that truly need things done a specific way.

For example, craniosynostosis our surgeons have an expectation of giving NMB bolus at the start then none after, with plans to extubate and head to PICU after. If we have someone come along and do it "the way they've always done it" where they came from and that involved direct to ICU intubated or something, that would pose a problem. With specific procedures there are specific expectations that are sometimes culturally based and this document helps make our anesthesia "product" more consistent now that we are growing so big we can't just tell each other how to do things when passing in the halls.

Isn’t this the value of having an anesthesiologist? To have that conversation with the surgeon as an equal and have different plans when different situations comes up.
I don’t particularly think “my” partners would sign up to anything like what you’re describing. And also to be an dinguses, what if someone messed up and ended in court. The opposing attorney get a wind of this thing..... doesn’t matter if the anesthesiologist follow or did not follow your guideline/protocol, how do you defend it? I am pretty cynical and have strong feelings regarding being dinged for not following “protocols”.

 

[sleepallday]

This would never fly at my place. What if the patient was not ready for extubation? I would not want to feel pressured to extubate, just so I can follow the groups "pathway".

Do all of your surgeons do everything the exact same way?

 

[dchz]

You're overcompensating for a lack of communication between two doctors. Not a good fix to a problem.

 

[Planktonmd]

Create a web page and list all these unusual cases and your suggested/anticipated goals or plans, then encourage people to refer to that web page.
Make sure your surgeons understand that each patient is different and that sometimes the consultant anesthesiologist will have do things differently, and that will unfortunately require the dreaded 2 way communication between surgeon and anesthesiologist.

 

[Aether2000]

That is exactly what I did for a anesthesia group that covers 3 different hospitals and several surgery centers. There is a protocol tab in the menu that has several submenu protocols listed for different surgeons. It is more of a "surgeons preference" list.

 

[Mman]

This would never fly at my place. What if the patient was not ready for extubation? I would not want to feel pressured to extubate, just so I can follow the groups "pathway".

Do all of your surgeons do everything the exact same way?

If a patient isn't ready to be extubated, then you don't extubate. The point of something like this would be to just layout general guidelines you are shooting for. I mean in many places they probably do spinals for TKAs with some sort of PNB technique (single shot or catheter). If a new guy gets hired and decides he's putting an epidural in them because that's how he does it, well that might not work out so well. It doesn't mean there can't be exceptions made, but if the group of individuals is on the same page for how to approach a given procedure it provides more consistency and hopefully better outcomes.

 

[caveat87]

We also had several ERAS pathways in residency. We (my attending and I) often chose to deviate from these pathways due to clinical judgment overriding what the flow diagram told us to do (ie: no intraoperative opioids for an opioid tolerant patient for a whipple, even with a duramorph spinal, rarely was enough to ensure the patient woke up comfortably). While i think it would be nice to offer these pathways to your group and i am sure if you can present evidence it may change practice patterns, but i doubt you will get uniform adoption.

That being said, now that i am in private practice some of our surgeons appreciate a more uniform approach to anesthetics for certain procedures when it is safe to do so (ie: one of our orthopedists prefers spinal/sedation for outpatient TKAs/THAs) and i am happy to oblidge if it is clinically appropriate. I have learned that it is nice to have a consistent approach but it isn't always tenable.

 

[ethilo]

Now that there's been some discussion about the actual utility of having something like this amongst the crowd, I would like to turn back to the original purpose of this post and was wondering what platforms people might consider using for this venture? Since our group has demonstrated an interest in this, its actual implementation is not up for discussion, more of HOW it's done in a way that works for us all.

We're thinking about including expectation documents for our facilitator position, our OB anesthesia person, pain rounds on catheters in the hospital, in addition to these individual procedures.

I've considered using Evernote, google Drive, or some sort of Wiki-style platform. I don't have a lot of experience beyond Evernote.

 

[Psai]

Create a web page and list all these unusual cases and your suggested/anticipated goals or plans, then encourage people to refer to that web page.
Make sure your surgeons understand that each patient is different and that sometimes the consultant anesthesiologist will have do things differently, and that will unfortunately require the dreaded 2 way communication between surgeon and anesthesiologist.

 

[IMGASMD]

Drop box. Basic would be fine.

 

[abolt18]

Now that there's been some discussion about the actual utility of having something like this amongst the crowd, I would like to turn back to the original purpose of this post and was wondering what platforms people might consider using for this venture? Since our group has demonstrated an interest in this, its actual implementation is not up for discussion, more of HOW it's done in a way that works for us all.

We're thinking about including expectation documents for our facilitator position, our OB anesthesia person, pain rounds on catheters in the hospital, in addition to these individual procedures.

I've considered using Evernote, google Drive, or some sort of Wiki-style platform. I don't have a lot of experience beyond Evernote.

Personally a big fan of Evernote. Very user friendly.

 

[Mman]

Now that there's been some discussion about the actual utility of having something like this amongst the crowd, I would like to turn back to the original purpose of this post and was wondering what platforms people might consider using for this venture? Since our group has demonstrated an interest in this, its actual implementation is not up for discussion, more of HOW it's done in a way that works for us all.

We're thinking about including expectation documents for our facilitator position, our OB anesthesia person, pain rounds on catheters in the hospital, in addition to these individual procedures.

I've considered using Evernote, google Drive, or some sort of Wiki-style platform. I don't have a lot of experience beyond Evernote.

any reason to get fancier than a piece of paper pinned to a board?

 

[2Fast2Des]

Protocols can be helpful for keeping some uniformity, but as long as it can be flexible as needed for exceptions. For example, cardiac cases in residency were usually done in a certain way to maintain uniformity so same lines and the way they are organized so no matter who walked in the room people would know and not have to figure out what's what. Of course that also led to the mentality of any deviation "that's not how we do it here" even if it may be a better way.

 

[vector2]

The point of standardizing is so we can give a consistent product to the surgeons. The purpose of this is not to be all-procedure encompassing, only the ones that truly need things done a specific way.

For example, craniosynostosis our surgeons have an expectation of giving NMB bolus at the start then none after, with plans to extubate and head to PICU after. If we have someone come along and do it "the way they've always done it" where they came from and that involved direct to ICU intubated or something, that would pose a problem. With specific procedures there are specific expectations that are sometimes culturally based and this document helps make our anesthesia "product" more consistent now that we are growing so big we can't just tell each other how to do things when passing in the halls.

Given how big and diverse your practice is, I’m not opposed to protocolizing the anesthetic for a variety of your most common cases. A lot of people here are taking it as some personal insult against their medical judgement, but I see these protocols as more of a jumping off point (in the case of supervisory practices) for the crna or resident who will be setting up and sitting the case. I would say write these protocols and distribute them via some kind of intranet or cloud service, but just make it clear that the final anesthetic plan is at the discretion of the MD.

 

[deleted59964]

ffs do not do this.
nurses follow clinical pathways
doctors use their brains