Application of clinical pathway using EMR system in pediatric patients with supracondylar fracture of the humerus: A before and after comparative study

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Introduction

• A clinical pathway (CP) is an “optimal sequencing and timing of interventions by physicians, nurses, and other staff for a particular diagnosis or procedure.”

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• A CP can provide high quality of medical treatment and minimize the unnecessary medical practice, so it can enhance the treatment efficiency.

• CP can improve the patients’ and their guardian’s satisfaction by a predictable medical treatment.

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• A supracondylar fracture of the humerus is the most common fracture in children.

• The mainstream treatment for a displaced supracondylar fracture is a closed reduction and internal fixation using a percutaneous pinning.

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• To investigate the usefulness of clinical

pathway (CP) using an electronic medical

record (EMR) in pediatric patients undergoing

closed pinning for supracondylar fracture of

the humerus, by analyzing the length of

hospital stay, hospital cost and satisfaction of

the medical teams.

Purpose

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• The treatment using CP would be not inferior

to previous treatment in terms of the length of

hospital stay and hospital cost, and that the

implementation of CP could increase medical

team’s satisfaction by standardizing the

treatment.

Hypothesis

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Method

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• Before and after comparative study

• Approved by IRB

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Inclusion criteria

• Consecutive children, who underwent closed reduction and internal fixation with percutaneous pinning for supracondylar fracture of the humerus, since March 2009

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Exclusion criteria

• Patients who underwent open reduction and internal fixation

• patients with open fracture or concomitant injury, which requires longer hospital stay

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Allocation of patients

• Pre-CP group– Patients who underwent closed pinning

between March 2009 and April 2011, before the implementation of CP

• Post-CP group– patients who underwent closed pinning

between May 2011 and May 2012, after the implementation of CP

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Development of CP

• Multidisciplinary work-team involving orthopedic surgeons, nursing staffs, quality assurance (QA) team, and a computation team.

• Orthopedic surgeons and nursing staffs developed an optimal regimen of the treatment processes. -> target a 3-day length of hospital stay

• The contents of the pathway were reviewed and the implementation of pathway was approved by the committee.

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Implementation of CP

• The CP was implemented using an EMR system in May 2011.

• Preoperative evaluation was performed.• Patients and their guardians were informed

by the orthopedic resident concerning the perioperative schedules.

• Lateral pinning technique using 2 pins was used for the fixation of supracondylar fracture of the humerus.

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Satisfaction survey

• Questionnaires evaluating the medical team’s satisfaction of the implementation of CP

• 10 items using the 5-point Likert scale• Satisfaction questionnaires– Before the implementation of CP (41 medical

team members)– 1 year after the implementation of CP (35

medical team members)

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Outcome variable

• Primary outcome variable– Total length of hospital stay

• Secondary outcome variable– Total hospital cost and medical team’s

satisfaction score

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Sample size estimation

• Non-inferiority test• Assumption that a mean between-group

difference in hospital stay of 0.5 day was considered clinically significant and SD of 0.7 day

• 90% power, a one-sided type 1 error rate of 0.05 and allocation ratio of 1:3

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Statistical methods

• Non-inferiority margin– 10% of the mean values of the length of

hospital stay and total hospital cost in pre-CP group

– -0.3 day and -116 US$

• If non-inferiority was shown, the p value associated with a superiority test was calculated

• Mann-Whitney U test or independent t-test according to data normality

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Results

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Pre-CP group Post-CP group P

No. of patients 90 32

Age at operation in years5.7±2.4

(1.1 to 13.8)6.2±3.1

(1.4 to 11.7)0.753

Gender (male/female) 54/36 20/12 0.804

Preoperative neurologic deficit 7 (7.8%) 1 (3.1%) 0.361

Admission on the day of surgery 39 (43.3%) 20 (62.5%) 0.062

Mean time from surgery until pin removal in days

28.7±4.0 (15 to 42)

28.9±5.0 (20 to 38)

0.745

Comparison of patient demographics and clinical characteristics between pre-CP group and post-group

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Pre-CP group Post-CP groupMean difference

(95% CI)Change

(%)P

Total hospital stay (day)

2.9±0.7 (2 to 5)

2.4±0.7 (1 to 4)

0.43 (0.14 to 0.72)

-15.0 0.004

Preoperative hospital stay

1.7±0.7 (1 to 4)

1.4±0.5 (1 to 2)

0.28 (0.03 to 0.53)

-16.9 0.037

Postoperative hospital stay

1.2±0.5(1 to 3)

1.1±0.4 (0 to 2)

0.14 (-0.01 to 0.31)

-12.3 0.141

Comparison of the length of hospital stay between pre-CP group and post-group

Lower bound of the 95% CI of the difference of 0.14 day did not exceed the non-inferiority margin of -0.3 day.

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Pre-CP group

Post-CP group

Mean difference (95% CI)

Change (%)

P

Total hospital Cost (US$)

1160.5±240.2 1124.1±287.4 36.4 (-78.5 to 151.2) -3.1 0.531

Room 217.1±175.9 222.0±179.2 -4.9 (-85.7 to 75.9) 2.3 0.904

Medication 53.5±22.8 55.2±27.6 -1.7 (-12.6 to 9.2) 3.2 0.760

Operating room 373.8±63.8 400.1±119.2 -26.3 (-62.5 to 9.8) 7.0 0.151

Anesthesia 212.4±34.7 228.1±36.9 -15.7 (-31.9 to 0.4) 7.4 0.055

Laboratory 115.6±36.8 78.9±63.0 36.7 (9.1 to 64.3) -31.8 0.011

Radiology 80.5±63.3 39.1±20.1 41.5 (15.4 to 67.5) -51.5 0.002

Materials 45.6±32.4 70.4±55.1 -24.9 (-49.0 to -0.8) 54.6 0.044

Comparison of the hospital cost between pre-CP group and post-group

Lower bound of the 95% CI of the difference of -78.5 US$ did not exceed the non-inferiority margin of -116 US$.

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Pre-CP group Post-CP groupChange

(%)P

Satisfaction score for nursing staffs

31.6±4.2 32.0±5.0 1.1 0.793

Satisfaction score for doctors

36.9±5.5 45.4±4.3 22.9 <0.001

Comparison of the medical team’s satisfaction between pre-CP group and post-group

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Conclusion

• The development and implementation of CP, using an EMR, in pediatric patients undergoing closed pinning for supracondylar fracture of the humerus enhances the treatment efficiency by streamlining the treatment process with no increases of the length of the hospital stay and total hospital costs.

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Thank you !