Lung Cancer.pdf

Role of Clinical Practice Guidelines and Clinical Pathways 97
Examples of patient factors include patient refusal or inability to accomplish
a given goal for walking. Examples of caregiver factors (a caregiver
is defined as any health care professional who participates directly
in a given patient’s care) are a physician’s or resident’s delaying signing of
the discharge orders, resulting in a hospital stay being prolonged by several
hours, and a unit coordinator’s forgetting to order a test. An example
of a system factor would be a breakdown in the institution’s electronic
medical record that delays the scheduling of a chest radiograph. Environment
factors are all other processes and structures that affect patient
care—for example, procedure, room, or equipment availability and forces
external to the hospital (Cole et al, 1996).
To better understand these deviations from pathway care, we developed
a variance tracking form that is attached to each patient’s chart. This
form is used to record all deviations as they occur during the course of
care, along with the reasons for these deviations. This form is scanned
every couple of days, and the data are analyzed. The intent of our deviations
tracking tool is to maximize compliance with the pathway and to
monitor unexpected outcomes. Through a detailed, real-time evaluation
of all deviations, we can get an accurate measurement of where improvements
can be made and where efforts should be directed.
Analysis of deviations is essential for helping us determine where the
pathway needs to be revised. On the basis of this type of analysis, we constantly
scrutinize our definition of the optimal standard of care for our patients.
The Future
Our lung cancer guidelines and pathways will be revised in the future to
reflect advances in the understanding of this disease and advances in technology.
Over the past few years, we have witnessed some minor changes to the
staging system for lung cancer, introduction of newer drugs for stage IV
disease, and randomized trials that have examined the use of preoperative
chemotherapy for earlier-stage tumors. Surgical techniques, including the
use of vascular grafting and techniques to resect tumors directly involving
the spinal column and repair the resulting defects, have permitted us to
redefine and extend the boundaries of lesions that may be resected for
cure. All of these changes have been incorporated into revisions of our
guidelines.
As newer tests and drugs become available, the standard initial evaluation
of patients will change. With the advent of high-speed, low-dose CT
scans, we envision that in the future the vast majority of lung cancers will
be detected when they are in the 5- to 10-mm range.