The development of “critical pathways” in coronary artery bypass graft (CABG) surgery was initiated primarily in response to cost pressures created by managed care and changes in health care reimbursement. It was felt that the implementation of pathways or clearly defined and reproducible care goals would improve efficiency, decrease costs, and maintain or improve quality. The use of these pathways supplemented existing guidelines and practice standards that had evolved over time. CABG was an early opportunity for application of critical pathways because this operation is frequently performed, is resource intensive, and care processes do not differ significantly from patient to patient. Specific goals are shown in Table 16-1 (1).

A multidisciplinary team consisting of cardiac surgeons, cardiologists, nurses, physical therapists, midlevel providers, and case managers provided input for developing the critical pathway at Vanderbilt University Medical Center. Measurable goals and outcomes included time to extubation following surgery, length of stay, utilization of laboratory tests, chest x-rays, electrocardiograms, and diagnostic studies including pulmonary function tests and carotid duplex studies. Particular emphasis was placed on four key outcomes (Table 16-2).

The critical pathway is a collection of task categories that include assessment, consults, tests, activity, medications, treatments, diet, education, and discharge. Currently at our institution, clinical documentation is computerized and notes are written electronically with discrete capture of the events and stored in a database as well as in the hospital’s electronic record. This system allows statistical assessment of a patient’s postoperative course. Analysis of variance provides the clinician with insight into critical steps in the care process and provides a platform for continuous improvement.

Implementation of the critical pathway is one element in a multifactorial approach to improving efficiency and quality and reducing length of stay (2). Although there are no controlled trials demonstrating the benefits of critical pathway implementation in cardiac surgery, rapid recovery and early discharge is increasingly becoming the standard of care, and most evidence suggests that outcomes are improved (3).

The basic elements of a given critical pathway can be incorporated into order sets or into practice guidelines. Our current pathways and guidelines have evolved to reflect our experience as well as nationally accepted standards of care (4). It should be emphasized that pathways, protocols, and guidelines represent commonly agreed-on standards of care at a particular institution. Therefore, minor differences may exist in critical pathways at differing institutions depending on the infrastructure of the ancillary services and personnel.

Practice standards in pathways may not have the support of prospective randomized trials and consequently remain open to modification. Patients with significant complications or pre-existing medical problems may not always be candidates for pathways or guidelines. Recognizing that certain comorbidities may significantly affect and require alteration from a critical pathway to generate a “subpathway” is essential for individualizing care for patients. The clinical judgment of the physician
and associated health care providers should rarely be substituted by a “recipe” pathway. This chapter will summarize current pathways and guidelines for uncomplicated CABG surgery at Vanderbilt University Medical Center. Guidelines for new-onset atrial fibrillation have been also included because it occurs so frequently.