Search PubMed⌕ Search

SEARCH · Search PubMed

Results for “Critical Pathways”

Search indexed PubMed citations on genomics, clinical trials, systematic reviews and public health. Explore titles, authors and supplied subject terms, then open the PubMed record.

Quote a phrase for an exact phrase match. Source license links do not imply unrestricted reuse.

At least 325 records · Page 18Linked to original sources
PubMed2002

Effect of support programme to reduce stress in spouses whose partners 'fall off' clinical pathways post cardiac surgery.

Cardiac surgery is flourishing in today's health care industry and looks to prosper well into the future. More than ever, improved technology, surgical skill and the worldwide trend of increasing longevity means that surgical intervention is offered to patients rarely seen in cardiac units in previous years. Patients are now much older, with multiple co-morbidity including repeat cardiac surgery. In line with advances in cardiac surgery, critical pathways to map the expected recovery route for the patient have been introduced. These maps are used extensively as guides for treatment and care. It is not only health professionals who use the pathways; patients and their relatives also refer to them as indicators of a 'normal' post-operative route. As a result, the critical pathway provides an avenue for expectations of predicted progress through to discharge. These predictors appear to give spouses hope, access to earliest possible visitation and confidence in a positive outcome. Nevertheless, it has recently become increasingly clear that for partners of patients who fail to proceed as expected, who apparently 'fall off' the predicted road to recovery, the critical pathway is problematic. Partners of such patients tend to demonstrate greatly heightened anxiety and nurses often have to deal with them at the point of crisis. In the cardio-thoracic unit at which this study was undertaken, the significant number of spouses who ended up in crisis drew attention to the need for additional support to be built into the post open-heart surgery critical recovery pathway. This study sought therefore to examine how nurses might assist spouses to adapt in the event of a complicated recovery following bypass surgery. A convenience sample of 39 spouses of cardiac surgical patients admitted to the cardio-thoracic recovery unit was obtained to assess stress responses at a critical post-operative data point, 5 days post-surgery. A symptoms of stress inventory was used to measure 94 items of physiological stress in 10 specific subscale categories. As a result of this study, it was found that incorporating a spousal support programme into the critical pathway of open-heart surgical patients significantly reduced stress suffered by spouses of patients who deviated from pre-determined recovery goals. The findings suggest that nurses need to understand the implications of the critical pathway and provide families with information concerning issues associated with complicated recovery. An unexpected finding of the study pointed to an apparent difference in the stress experienced by male spouses to that of female spouses. Recommendations from this study are to further explore the qualitative component of the stress felt by spouses and the negative association of stress with morbidity and mortality for women and patients without spouses. Nurses need to consider developing and implementing a stress management programme for spouses, establishing spousal support groups and exploring the possibility of incorporating spousal support strategies into the critical pathways of patients across hospital settings.

Adult↗
PubMed2005

H-Ras-specific activation of Rac-MKK3/6-p38 pathway: its critical role in invasion and migration of breast epithelial cells.

Human tumors frequently exhibit constitutively activated Ras signaling, which contributes to the malignant phenotype. Mounting evidence suggests unique roles of the Ras family members, H-Ras, N-Ras and K-Ras, in normal and pathological conditions. In an effort to dissect distinct Ras isoform-specific functions in malignant phenotypic changes, we previously established H-Ras- and N-Ras-activated MCF10A human breast epithelial cell lines. Using these, we showed that p38 kinase is a key signaling molecule differentially regulated between H-Ras and N-Ras, leading to H-Ras-specific induction of invasive and migrative phenotypes. The present study is to further investigate H-Ras- and N-Ras-mediated signaling pathways and to unveil how these pathways are integrated for regulation of invasive/migrative phenotypic conversion of human breast epithelial cells. Here we report that the Rac-MAPK kinase (MKK)3/6-p38 pathway is a unique signaling pathway activated by H-Ras, leading to the invasive/migrative phenotype. In contrast, Raf-MEK-ERK and phosphatidylinositol 3-kinase-Akt pathways, which are fundamental to proliferation and differentiation, are activated by both H-Ras and N-Ras. A significant role for p38 in cell invasion is further supported by the observation that p38 activation by MKK6 transfection is sufficient to induce invasive and migrative phenotypes in MCF10A cells. Activation of the MKK6-p38 pathway results in a marked induction of matrix metalloproteinase (MMP)-2, whereas it had little effect on MMP-9, suggesting MMP-2 up-regulation by MKK6-p38 pathway as a key step for H-Ras-induced invasion and migration. We also provide evidence for cross-talk among the Rac, Raf, and phosphatidylinositol 3-kinase pathways critical for regulation of MMP-2 and MMP-9 expression and invasive phenotype. Taken together, the present study elucidated the role of the Rac-MKK3/6-p38 pathway leading to H-Ras-specific induction of malignant progression in breast epithelial cells, providing implications for developing therapeutic strategies for mammary carcinoma to target Ras downstream signaling molecules required for malignant cancer cell behavior but less critical for normal cell functions.

Breast↗
PubMed2002

Subjective and objective comparison of critical care pathways for open donor nephrectomy.

PURPOSE: In the era of minimally invasive techniques and cost containment, care pathways after donor nephrectomy are important. While open donor nephrectomy remains the established procedure, questions regarding the surgical approach, postoperative care and patient morbidity/dissatisfaction have surfaced. We compared results of standard and fast-track care pathways after donor nephrectomy. MATERIALS AND METHODS: Between January 1998 and August 1999, 60 patients underwent open donor nephrectomy. By surgeon preference, patients received either ketorolac only (31), ketorolac plus morphine spinal (17) or patient controlled anesthesia (12). Data related to surgery, hospital course and cost were reviewed. Patients were surveyed regarding return to daily activities and groups were statistically analyzed. RESULTS: The mean dose per patient was 183 (ketorolac only), 180 (ketorolac plus morphine spinal) and 69 (patient controlled analgesia) mg. Median hospital stay was 2 days for the fast-track pathways (ketorolac only, ketorolac plus morphine spinal) compared to 3 days for the patient controlled analgesia group (p <0.001). Delayed oral intake was seen in 6% of patients on ketorolac only and 3% for those on ketorolac plus morphine spinal compared to 83% of the patient controlled analgesia group (p <0.001). Return to exercise (median weeks, p <0.79) was 2 for the ketorolac only group, 3.5 for ketorolac plus morphine spinal and 3.5 for patient controlled analgesia. Mean global cost was $9,394 for the ketorolac only group, $9,238 for ketorolac plus morphine spinal and $11,601 for patient controlled analgesia (p <0.02). CONCLUSIONS: Fast-track pathways significantly shortened hospital stay and quickened oral intake. Cost was significantly contained using new pathways. Resumption of daily activities was comparable among the groups. Comparisons of critical care pathways are required to optimize patient care after kidney donation. Prospective trials are needed to verify our results.

Analgesia, Epidural↗
PubMed1996

E2F and the molecular mechanisms of early cell-cycle control.

This is an exciting era in cell-cycle research. We are now uncovering the molecular details of a critical pathway which regulates early cell-cycle progression by integrating signals emanating from proteins that drive the cell cycle with the transcription apparatus and the consequent control of target genes. Molecules that function to positively regulate, such as cyclin-cdk complexes, and negatively regulate, such as the cdk inhibitors, converge on the pathway and, in turn, regulate the activity of pRb and related proteins. A principal role of pRb is in the regulation of the E2F family of transcription factors, and activity of which determines cell-cycle progression. Importantly, many of the proteins in this pathway are encoded by genes which are frequently mutated in tumour cells, a feature which emphasizes the pathway's critical role in orchestrating early cell-cycle control. In fact, it seems likely that the pathway is, at some point, aberrantly regulated in most, if not all, human tumour cells. It is principally E2F that pRb seeks out to exert its effect on the cell cycle. However, it is unclear why there is such a plethora of E2F/DP heterodimers under the E2F umbrella: different genes, different targets or different pathways of control? In human tumour cells, why is Rb so frequently mutated, whereas the genes encoding p107 and p130 apparently not so? Does this imply that the physiological roles of p107 and p130 are of overwhelming importance that cells cannot accommodate mutation in either gene, or do they take on such minor roles that their mutation in tumour cells would be of incidental consequence? These questions, and many others, remain to be resolved. Finally, we should never forget that the increasing knowledge of cell-cycle control has profound implications for the treatment of proliferative disease. The progress and insights into the physiological pathways which regulate cell-cycle progression offer a new and exciting range of realistic targets through which oncogenesis may, in the near future, be effectively treated. The mechanistic and structural information that is rapidly accumulating offers new promise in the search for small-molecule clinically viable drugs.

Animals↗
PubMed1996

Cardiovascular-radical outcome method is effective in complex congenital cardiac lesions.

BACKGROUND: The cardiovascular-radical outcome method is a proactive process of patient care that uses standard critical pathway methodology to reduce negative variation while encouraging positive variation to accelerate recovery. Its effectiveness in patients with complex congenital heart disease is explored. METHODS: Two hundred fourteen consecutive patients with congenital heart disease were cared for using the cardiovascular radical outcome method. Age ranged from 2 days to 19 years (median age, 3 years). Cardiovascular radical outcome method data were compared with the pathway plan data for each patient. RESULTS: Survival was 99% (211 patients) with an overall reduction in stay of 156 days (0.74 day/patient) (p < 0.0001). Only 10 patients (5%) exceeded the pathway plan; 201 (95%) reached the planned length of stay (critical pathway method), and 127 patients (60%) had a shorter length of stay than expected by the critical pathway method. One hundred forty-eight patients (70%), including 95 (64%) with more complex conditions, had a length of stay of 3 days and 18% achieved a 2-day length of stay, the maximal response. The process was most effective in the most complex groups, although preoperative comorbidities influenced outcomes. Outcome assessment demonstrated minimal morbidity and excellent family satisfaction. CONCLUSIONS: The radical outcome method is effective in reducing the length of stay of patients with complex congenital heart disease. The power is in the process rather than the plan, and the method provides optimal patient care and family satisfaction.

Adolescent↗
PubMed2001

Peroxisome proliferators and fatty acids negatively regulate liver X receptor-mediated activity and sterol biosynthesis.

Peroxisome proliferators (PPs) are potent tumor promoters in rodents. The mechanism of hepatocarcinogenesis requires the nuclear receptor peroxisome proliferator activated receptor-alpha (PPARalpha), but might also involve the PPARalpha independent alteration of signaling pathways that regulate cell growth. Here, we studied the effects of PPs on the mevalonate pathway, a critical pathway that controls cell proliferation. Liver X receptors (LXRs) are nuclear receptors that act as sterol sensors in the mevalonate pathway. In gene reporter assays in COS-7 cells, the basal activity of the LXR responsive reporter gene (LXRE-luc) was suppressed by 10 microM lovastatin and zaragozic acid A, suggesting that this activity was attributed to the activation of native LXRs, by endogenously produced mevalonate products. The potent PP and rodent tumor promoter, pirinixic acid (WY-14643) also inhibited LXR-mediated transcription in a dose related manner (approximate IC(50) of 100 microM). As did several other PPs including ciprofibric acid and mono-ethylhexylphthalate. Polyunsaturated and medium to long chain fatty acids at 100 microM were also potent inhibitors; the arachidonic acid analogue eicosatetraynoic acid being the most active (approximate IC(50) of 10 microM). Of the PPs and fatty acids tested, there was a strong correlation between the ability of these agents to suppress de novo sterol synthesis in a rat hepatoma cell line, H4IIEC3, and inhibit LXR-mediated transcription in COS-7 cells, but a discordance between these endpoints and PPARalpha activation and fatty acid acyl-CoA oxidase induction. Taken together, these results suggest that PPs and fatty acids negatively regulate the mevalonate pathway through a mechanism that is not entirely dependent on PPARalpha activation. Because of the importance of the mevalonate pathway in regulating cell proliferation, the modulation of this pathway by PPs and fatty acids might contribute to their actions on cell growth/differentiation.

Acyl-CoA Oxidase↗
PubMed2006

Combination mammalian target of rapamycin inhibitor rapamycin and HSP90 inhibitor 17-allylamino-17-demethoxygeldanamycin has synergistic activity in multiple myeloma.

PURPOSE: The phosphatidylinositol 3-kinase/AKT/mammalian target of rapamycin (mTOR) pathway and the heat shock protein family are up-regulated in multiple myeloma and are both regulators of the cyclin D/retinoblastoma pathway, a critical pathway in multiple myeloma. Inhibitors of mTOR and HSP90 protein have showed in vitro and in vivo single-agent activity in multiple myeloma. Our objective was to determine the effects of the mTOR inhibitor rapamycin and the HSP90 inhibitor 17-allylamino-17-demethoxygeldanamycin (17-AAG) on multiple myeloma cells. EXPERIMENTAL DESIGN: Multiple myeloma cell lines were incubated with rapamycin (0.1-100 nmol/L) and 17-AAG (100-600 nmol/L) alone and in combination. RESULTS: In this study, we showed that the combination of rapamycin and 17-AAG synergistically inhibited proliferation, induced apoptosis and cell cycle arrest, induced cleavage of poly(ADP-ribose) polymerase and caspase-8/caspase-9, and dysregulated signaling in the phosphatidylinositol 3-kinase/AKT/mTOR and cyclin D1/retinoblastoma pathways. In addition, we showed that both 17-AAG and rapamycin inhibited angiogenesis and osteoclast formation, indicating that these agents target not only multiple myeloma cells but also the bone marrow microenvironment. CONCLUSIONS: These studies provide the basis for potential clinical evaluation of this combination for multiple myeloma patients.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed2006

Hospital-based factors predict outcome after carotid endarterectomy.

OBJECTIVE: Patient, hospital, and surgeon factors affect outcome after carotid endarterectomy (CEA). The nature and importance of hospital-specific factors, especially those unrelated to procedural volume, that affect post-CEA outcome remains poorly defined. We used a statewide database to determine the impact of several hospital-associated factors on outcome after CEA. METHODS: Hospital factors were established by telephone survey and validated by repeated survey as well as by the Connecticut Hospital Association, Connecticut state, and individual hospital internet Websites. All CEA in Connecticut non-federal hospitals between 1991 and 2002 were examined, including perioperative mortality, stroke, and cardiac complications. Multivariable logistic regression was used to analyze data. RESULTS: There were 14,288 CEAs performed with 0.5% mortality, 1.3% stroke, and 2.4% cardiac complications. The only hospital factor independently predictive of perioperative mortality was few number of hospital beds (less than 132 beds; odds ratio (OR) 2.78, P = 0.032). Factors predictive of perioperative stroke included few number of beds (OR 1.96, P = 0.001) and absence of a critical pathway (OR 1.39, P = 0.038). Factors predictive of perioperative cardiac complications included few number of beds (OR 3.01, P = 0.003), absence of a critical pathway (OR 1.50, P = 0.001), and absence of dedicated vascular recovery beds (OR 1.35, P = 0.03). Combined mortality, stroke, or cardiac complications were independently predicted by few hospital beds (OR 4.58, P = 0.002), absence of a critical pathway (OR 1.81, P < or = 0.0001), or inability to perform cardiac angiography (OR 3.92, P = 0.024). CONCLUSIONS: Hospital-based factors, such as greater bed capacity, use of critical pathways, ability to perform cardiac angiography, or presence of a dedicated vascular recovery unit predict reduced perioperative mortality, stroke and cardiac complications from CEA. These results suggest that hospital-associated factors do impact surgical outcome and that surgeons need to optimize these factors, extrinsic to the patient and surgeon, to provide maximal quality of care.

Endarterectomy, Carotid↗
PubMed2000

Preadmission nutrition screening: expanding hospital-based nutrition services by implementing earlier nutrition intervention.

The need to screen patients earlier than within the first 24 hours of hospital admission has resulted in the development of preadmission nutrition screening. At Providence Saint Joseph Medical Center (PSJMC), a 455-bed acute-care facility, this procedure has been used since 1994. The preadmission screening method was developed because of the use of critical pathways for patients in specific diagnosis-related groups. Critical pathways specified that registered dietitians must assess these patients within 24 hours of admission at PSJMC. However, at that time there was minimal data in the chart from which to assess the patient's nutritional status and the ability to interview the patient was often limited as a result of intubation or postoperative pain. Family members were not always available at the hospital to discuss a patient's preadmission nutritional status. To address this problem, we developed a system to call people at home before their admission to the hospital to obtain specific nutrition information. To analyze the effectiveness of the procedure, the Food and Nutrition Services Department developed a process to assess this method of screening and to improve the system. Patients were enrolled in a study over a 1-month period, demographics were identified for this sample population, and patient satisfaction was determined via an interview conducted by a dietetic technician after the patient was admitted. Most patients found this to be a very helpful process and an example is presented here on the role of preadmission nutrition screening in improving patient outcome. To better define the population of the case study presented, additional information was gathered on a second study group of patients screened before admission who were admitted for hip and knee surgery, one of the specific diagnosis-related groups with a critical pathway. Our findings indicate that preadmission nutrition screening has the potential to improve patient outcomes by increasing nutrient intake before their hospital admission, reducing hospitalization length, and enhancing patient satisfaction during their hospital stay.

Adult↗
PubMed1996

Development of critical paths for post-acute brain injury rehabilitation: lessons learned.

One important tool for case management is critical path analysis. This article explains four critical pathways developed by an interdisciplinary team for a post-acute brain injury rehabilitation program. The heterogeneity of the brain injury population mandates the need for systematic coordination of direct care services. Yet, variations in the neurobehavioral consequences of brain injury necessitate differing goals and treatment tracks for individual clients. The critical pathways in this setting define and describe the procedures and services to be rendered from admission to discharge to achieve optimal goals for four treatment program tracks: Return to Work, Return to School, Functional Independence, and Neurorehabilitation. The tracks reflect a hierarchy of expectations for information processing and functional performance. Critical pathways provide a tool for enhancing communication among service providers and external case managers and for determining the extent to which a client's course of treatment compares with a clinical standard considered to be ideal. This article compares the four critical pathways, provides representative case samples, and discusses lessons learned in the development and implementation process.

Activities of Daily Living↗
PubMed2003

[The efficacy of switch therapy in community-acquired pneumonia in Japan].

To evaluate the efficacy of Switch therapy for community-acquired pneumonia, we conducted a prospective randomized controlled study in thirty-two hospitalized patients. These cases corresponded to Fine's risk classes II to IV. Using a table of random numbers, sixteen patients were assigned to a Switch therapy group, and the other sixteen, to a clinical pathway group. Both groups initially received intravenous antimicrobials. Within the Switch therapy group, when all the patients were afebrile for more than sixteen hours, their intravenous antimicrobials were switched to oral, and the patients were discharged on the following day. For all patients in the clinical pathway group, the critical pathway was defined as an eight-day planned hospitalization, with a time-task matrix formatted for disease treatment, laboratory testing, physical examination, oxygen saturation monitoring, ambulation, diet, patient education and clinical outcome. Switch therapy reduced the period of intravenous antimicrobial administration from 7.6 days to 4.0 days (p < 0.0001). The period required to switch to oral antimicrobials decreased from 8.3 days to 4.8 days (p < 0.0001); hospital stay length, from 9.8 days to 6.5 days (p = 0.0001); and medical resource utilization, from 330, 373 to 227,768 Japanese yen (p = 0.0002). No patient from either group required readmission. In conclusion, Switch therapy was more efficient than management with a clinical pathway for mild to moderate community-acquired pneumonia in hospitalized patients.

Administration, Oral↗
PubMedDate not supplied

Tools for building a successful orthopaedic pathway.

In this arena of ever-changing health care, critical pathways have been identified as a tool to analyze cost as well as improve patient care and resource utilization. The Orthopaedic Department of Allegheny General Hospital was one of the first departments to begin the process of developing critical pathways with DRG #209, Total Joint Replacements. This article explains how the multidisciplinary team members used the Continuous Quality Improvement process through the use of various questionnaires, tools, and tracking documents in identifying ways to improve customer services.

Algorithms↗
PubMed2002

Increased transplanted organs from the use of a standardized donor management protocol.

The organ shortage has resulted in increasing recipient waiting lists and waiting-list deaths. The increased use of expanded donors has been associated with increased discarding of procured organs because of poor organ function. A structured donor management algorithm or critical pathway was tested to determine its effect on the donor management and procurement process. A pilot study examined donors from 88 critical care units in 10 organ procurement organizations managed under the critical pathway and compared them to retrospective data collected at those same pilot sites. The total number of organs both procured and transplanted per 100 donors was significantly greater (p <0.01) in the critical pathway group when compared to the control group. There was no significant difference in 1-year graft survival for any of the organs recovered, and no significant difference in the rate of delayed graft function in the kidneys transplanted. Use of a structured donor management algorithm results in significant increases in organs procured and organs transplanted without any reduction in the quality of the organs being transplanted.

Clinical Protocols↗
PubMed2006

Nitric oxide potentiates cAMP-gated cation current in feeding neurons of Pleurobranchaea californica independent of cAMP and cGMP signaling pathways.

Critical roles for nitric oxide (NO) in regulating cell and tissue physiology are broadly appreciated, but aspects remain to be explored. In the mollusk Pleurobranchaea, NO synthase activity is high in CNS ganglia containing motor networks for feeding and locomotion, where a cAMP-gated cation current (I(Na,cAMP)) is also prominent in many neurons. We examined effects of NO on I(Na,cAMP) using voltage-clamp methods developed to analyze cAMP signaling in the live neuron, focusing on the identified metacerebral giant neuron of the feeding network. NO donors enhanced the I(Na,cAMP) response to injected cAMP by an averaged 85%. In dose-response measures, NO increased the current stimulated by cAMP injection without altering either apparent cAMP binding affinity or cooperativity of current activation. NO did not detectably alter levels of native cAMP or synthesis or degradation rates as observable in both current saturation and decay rate of I(Na,cAMP) responses to cAMP injection. NO actions were not exerted by cGMP signaling, as they were not mimicked by cGMP analogue nor blocked by inhibitors of guanylate cyclase and protein kinase G. NO potentiation of I(Na,cAMP) was broadly distributed among many other neurons of the feeding motor network in the buccal ganglion. However, NO did not affect a second type of I(Na,cAMP) found in locomotor neurons of the pedal ganglia. These results suggest that NO acts through a novel mechanism to regulate the gain of cAMP-dependent neuromodulatory pathways that activate I(Na,cAMP) and may thereby affect the set points of feeding network excitability and reactivity to exogenous input.

Animals↗
PubMed2000

Microvascular reconstruction and tracheotomy are significant determinants of resource utilization in head and neck surgery.

BACKGROUND: Successful "critical pathway" design and implementation are dependent on appropriate patient stratification according to those factors that are primary determinants of resource utilization. OBJECTIVES: To test the validity of our previously reported critical pathway design and to determine whether tracheotomy and microvascular reconstruction (MR) are primary determinants of resource utilization. DESIGN: Cost-effectiveness analysis. SETTING: Tertiary referral academic institution. METHODS: Retrospective analysis of data from 133 head and neck surgery cases in which the treatment regimen was based on critical pathways over a 26-month period. OUTCOME MEASURES: Length of stay and total patient charges were used as indices of resource utilization. One-way analysis of variance and t tests were used for statistical analysis of significance. RESULTS: Ninety patients (67.7%) underwent MR; 43 (32. 3%) did not. Seventy-five patients (56.4%) underwent tracheotomy; 58 (43.6%) did not. Four patient groups were constructed in decreasing order of complexity as follows: group 1, patients who underwent both tracheotomy and MR (n = 58); group 2, patients who underwent MR alone (n = 32); group 3, patients who underwent tracheotomy alone (n = 17); and group 4, patients who did not undergo either procedure (n = 26). Both tracheotomy and MR were found to be independent determinants of resource utilization and were additive when both were present. The length of stay varied from 8.4 days (in patients who underwent both procedures) to 6.7 days (in patients who did not undergo either procedure), with intermediate values in cases in which only 1 procedure was performed. The total charges varied in a similar manner from a high of $33,371 to a low of $19,994. Subanalysis with respect to intensive care unit, ward, and operating room charges showed a similar stratification. CONCLUSION: Tracheotomy and MR are both significant determinants of charges and length of stay in head and neck surgery cases and must be considered in the design of strategies to promote efficient resource utilization.

Cost-Benefit Analysis↗
PubMed2006

Hospital protocols and evidence-based therapies: the importance of integrating aldosterone blockade into the management of patients with post-acute myocardial infarction heart failure.

Left ventricular systolic dysfunction (LVSD) and clinical heart failure are common complications of acute myocardial infarction (AMI) and result in substantially increased mortality and morbidity. Evidence-based cardiovascular protective therapies, including angiotensin-converting enzyme inhibitors, beta blockers, antiplatelet agents, and lipid-lowering medications, improve outcomes for these patients. However, this population is significantly undertreated with these guideline-recommended agents. Critical pathways have been demonstrated to improve the quality and consistency of treatment; as such, the new American College of Cardiology/American Heart Association (ACC/AHA) guidelines for the management of patients with ST-elevation myocardial infarction (STEMI) recommend that critical pathways be implemented for the management of these patients. The recent Eplerenone Post-acute Myocardial Infarction Heart Failure Efficacy and Survival Study (EPHESUS) demonstrates that eplerenone, a selective aldosterone blocker, has incremental benefit in decreasing mortality and morbidity when used with standard care therapies in patients post AMI with heart failure and LVSD. The clinical trial evidence coupled with the national guidelines provides a strong rationale for routine incorporation of aldosterone blockade into new or already established critical pathways for AMI complicated by LVSD and heart failure.

Adrenergic beta-Antagonists↗
PubMed1996

Use of a national data base to assess perioperative risk, morbidity, mortality, and cost savings in coronary artery bypass grafting.

To show the usefulness of the Society of Thoracic Surgeons (STS) National Database in providing clinical and cost-related outcome data, we studied 297 consecutive patients who had isolated coronary artery bypass grafting (CABG) and who were assigned to either a "fast track" or traditional track. The observed overall mortality rate was 2.7%. The predicted mortality based on preoperative risk factors was 4.7%. Before the initiation of a "fast-track" protocol and critical pathways, the average length of stay was 8.2 days and the average cost of uncomplicated isolated CABG was $18,476. The length of postoperative stay and the cost decreased to 6.0 days and $12,427, respectively, with the application of a fast-track protocol (when appropriate) and critical pathways without affecting clinical outcomes. Use of the STS National Database provided rapid and reassessing evidence that survival and quality of care were not compromised with implementation of a cost-saving fast-track protocol and critical pathways.

Aged↗