David N Walters, MD, VA Mountain Home/ETSU; Joyce Hamm, MD, VA Mountain Home/ETSU; William Browder, MD, VA Mountain Home/ETSU; Benton Adkins, MD, Southeastern Surgical Congress

Objectives: Recently, the Southeastern Surgical Congress and Southwestern Surgical Congress collaborated on the formation of clinical pathways for common general surgical procedures. In an effort to assess the applicability of these pathways to a VA poplulation, data from the James H. Quillen VAMC, Johnson City, TN were reviewed for laparoscopic cholecystectomy and colectomy for cancer.

Methods: Records of 30 patients undergoing laparoscopic cholecystectomy (15) or colectomy (15) were reviewed.

Results: Ten of fifteen (67%) cholecystectomy patients were ASA III, falling out of the ASA I-II category designated in the clinical pathway. Despite this higher risk, VA patient management was compatible with all parameters of the pathway except length of stay, which exceeded one day in 40% of patients. Similarly, of patients undergoing colectomy for cancer, 87% (13 of 15) were ASA III-IV, due to associated cardiovascular and pulmonary condition. Again, the clinical pathways were adhered to, with the following exceptions: (1) only 27% were ambulatory with assistance by 24 hours postoperatively; (2) only 80% had prophylaxis for deep venous thrombosis (DVT); and (3) 80% exceeded the expected length of stay of six days.

Conclusions: (1) Clinical pathways devised by practicing general surgeons are applicable to a VA surgical patient population. (2) VA patients have higher co-morbidity (ASA III or IV) with resulting increased length of stay, and the pathways should be adjusted accordingly. (3) In the institution reviewed, more attention should be given to early ambulation and DVT prophylaxis.

Impact: The use of clinical pathways in a VA population of general surgical patients can streamline care and improve outcomes.