Clinical Care Redesign to Improve Value in Carpal Tunnel Syndrome: A Before-and-After Implementation Study. The Journal of hand surgery Kamal, R. N., Behal, R. 2018


PURPOSE: Carpal tunnel surgery is one of the most common procedures completed on the upper limb in the United States. There is currently no evidence-based high-value clinical care pathway to inform the management of carpal tunnel syndrome (CTS). We created an evidence-based care pathway and implemented a quality improvement initiative to evaluate its effect on patient time, quality, and cost in a tertiary care ambulatory surgery center.METHODS: We developed a high-value clinical care pathway for CTS and implemented the intraoperative phase of the pathway. This included (1) implementing an evidence-based protocol for wide-awake local anesthesia, (2) removing non-value-added processes of care, and (3) implementing educational sessions with surgery staff regarding the initiative. We prospectively collected data on patient time, visual analog scale pain scores (quality), and percent change in total direct costs of the intraoperative phase of care (cost).RESULTS: A total of 50 patients were included in this implementation study: 30 prior to implementation of the intervention and 20 after. There was a significant decrease in average patient wheels in to surgery time, postanesthesia care unit to discharge time, and total patient time (lead time). There was no difference in preoperative or postoperative pain before and after the intervention. There was a 31% reduction in total direct costs.CONCLUSIONS: Implementing the intraoperative phase of this clinical care pathway with wide-awake surgery can reduce patient lead time, maintain quality, and reduce total direct costs in an ambulatory surgery center.CLINICAL RELEVANCE: Quality improvement interventions, such as the implementation of an evidence-based clinical care pathway for the treatment for CTS, may improve value to health systems.

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