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PubMed1999

Use of critical pathways to improve the care of patients with acute myocardial infarction.

PURPOSE: While critical pathways have become a popular strategy to improve the quality of care, their effectiveness is not well defined. The objective of this study was to investigate the effect of a critical pathway on processes of care and outcomes for Medicare patients admitted with acute myocardial infarction. SUBJECTS AND METHODS: A retrospective cross-sectional and longitudinal cohort study was made of Medicare patients aged 65 years and older hospitalized at 32 nonfederal Connecticut hospitals with a principal diagnosis of myocardial infarction during two periods: June 1, 1992, to February 28, 1993, and August 1, 1995, to November 30, 1995. The main endpoints of the cross-sectional analyses for the 1995 cohort were the proportion of patients without contraindications who received evidence-based medical therapies, length of stay, and 30-day mortality. Hospitals with specific critical pathways for patients with myocardial infarction were compared with hospitals without critical pathways. The main endpoints of the longitudinal analyses were change between 1992-93 and 1995 in the proportion of patients receiving evidence-based medical therapies, length of stay, and 30-day mortality. RESULTS: Ten hospitals developed critical pathways between 1992-93 and 1995. Eighteen of 22 nonpathway hospitals employed some combination of standard orders, multidisciplinary teams, or physician champions. Patients admitted to hospitals with critical pathways did not have greater use of aspirin within the first day, during hospitalization, or at discharge; beta-blockers within the first day or at discharge; reperfusion therapy; or use of angiotensin-converting enzyme inhibitors at discharge in 1995. The mean (+/- SD) length of stay in 1995 was not significantly different between pathway (7.8 +/- 4.6 days) versus nonpathway hospitals (8.0 +/- 4.2 days), and the change in length of stay between 1992-93 and 1995 was 2.2 days for pathway hospitals and 2.3 days for nonpathway hospitals. Patients admitted to critical pathway hospitals had lower 30-day mortality in 1995 (8.6% versus 11.6% for nonpathway hospitals, P = 0.10) and in 1992-93 (12.6% versus 13.8%, P = 0.39), but the differences were not statistically significant. CONCLUSIONS: Hospitals that instituted critical pathways did not have increased use of proven medical therapies, shorter lengths of stay, or reductions in mortality compared with other hospitals that commonly used alternative approaches to quality improvement among Medicare patients with myocardial infarction.

Aged↗
PubMedDate not supplied

Use and evaluation of critical pathways in hospitals.

CONTEXT: Although hospitals have devoted substantial resources to critical pathways, it is not known whether they routinely evaluate the clinical or economic effects of these pathways. OBJECTIVE: To determine how use and evaluation of critical pathways differ between academic and community hospitals. DESIGN: Cross-sectional survey. PARTICIPANTS: Hospitals participating in consortia for improving quality of care associated with the Institute of Health Care Improvement and the VHA, Inc. (formerly known as the Voluntary Hospitals of America, Inc.). Hospital administrators at 41 hospitals completed the survey (71% response rate), representing 13 academic medical centers, 13 community teaching hospitals, and 15 community hospitals. MEASURES: Use of critical pathways and measurement of clinical and economic outcomes of pathways. RESULTS: The median number of adult critical pathways used by academic hospitals, community teaching hospitals, and community hospitals was 25, 18, and 3, respectively. The most common pathways were community-acquired pneumonia, total hip or knee replacement, and stroke or transient ischemic attack. The percentage of hospitals with pathways dedicating staff to manage them was 78% for academic hospitals, 22% for community teaching hospitals, and 14% for community hospitals (P = 0.02). Evaluation practices varied widely among hospitals with pathways. Measures assessed included monitoring length of stay (85%), total hospital costs (74%), in-hospital mortality (62%), infectious complications (53%), readmission rates (47%), functional status (18%), and adverse drug events (15%). CONCLUSION: The use of critical pathways varies substantially among hospitals participating in quality improvement consortia. Use was highest in academic centers and lowest in community hospitals. Many hospitals with pathways do not track important clinical outcomes as part of their evaluation practices.

Academic Medical Centers↗
PubMed2001

Critical pathways intervention to reduce length of hospital stay.

PURPOSE: Despite their popularity, critical pathways have been evaluated in only a few controlled studies. We evaluated the effectiveness of critical pathways in reducing length of hospital stay. SUBJECTS AND METHODS: We compared postoperative lengths of stay of patients who underwent coronary artery bypass graft (CABG) surgery, total knee replacement, colectomy, thoracic surgery, or hysterectomy before and after pathway implementation at a university hospital. For three procedures, changes in lengths of stay at neighboring hospitals without pathway programs were assessed for comparison. RESULTS: A total of 6,796 patients underwent one of the procedures during the study. The percentage of eligible patients managed on a critical pathway ranged from 94% for hysterectomy to 26% for colectomy. For most procedures, the postoperative length of stay was decreasing during the baseline period. After pathway implementation, the length of stay decreased 21% for total knee replacement, 9% for CABG surgery, 7% for thoracic surgery, 5% for hysterectomy, and 3% for colectomy (all P < 0.01). However, similar decreases were seen in the neighboring hospitals that did not have critical pathways or other specific efficiency initiatives. CONCLUSIONS: Critical pathways were associated with a rapid reduction in postoperative length of stay after all five study procedures. Secular trends at nearby hospitals, however, produced comparable reductions for the three procedures available for comparison. These findings raise questions about the effectiveness of critical pathways in a competitive environment.

Adult↗
PubMed2005

Critical pathway effectiveness: assessing the impact of patient, hospital care, and pathway characteristics using qualitative comparative analysis.

OBJECTIVE: To qualitatively describe patient, hospital care, and critical pathway characteristics that may be associated with pathway effectiveness in reducing length of stay. DATA SOURCES/STUDY SETTING: Administrative data and review of pathway documentation and a sample of medical records for each of 26 surgical critical pathways in a tertiary care center's department of surgery, 1988-1998. STUDY DESIGN: Retrospective qualitative study. DATA COLLECTION/ABSTRACTION METHODS: Using information from a literature review and consultation with experts, we developed a list of characteristics that might impact critical pathway effectiveness. We used hypothesis-driven qualitative comparative analysis to describe key primary and secondary characteristics that might differentiate effective from ineffective critical pathways. PRINCIPAL FINDINGS: " All 7 of the 26 pathways associated with a reduced length of stay had at least one of the following characteristics: (1) no preexisting trend toward lower length of stay for the procedure (71 percent), and/or (2) it was the first pathway implemented in its surgical service (71 percent). In addition, pathways effective in reducing length of stay tended to be for procedures with lower patient severity of illness, as indicated by fewer intensive care days and lower mortality. Effective pathways tended to be used more frequently than ineffective pathways (77 versus 59 percent of medical records with pathway documents present), but high rates of documented pathway use were not necessary for pathway effectiveness. CONCLUSIONS: Critical pathway programs may have limited effectiveness, and may be effective only in certain situations. Because pathway utilization was not a strong predictor of pathway effectiveness, the mechanism by which critical pathways may reduce length of stay is unclear.

Baltimore↗
PubMed2002

Critical pathways for patients with acute chest pain at low risk.

Critical pathways are predefined protocols that define the crucial steps in evaluating and treating a clinical problem to improve quality of patient care, reduce variability and enhance efficiency. Critical pathways have proliferated for a variety of diagnoses, including evaluation of patients with chest pain, a common and costly complaint. This review will outline the development, implementation, and assessment of critical pathways using as a paradigm our experience with a pathway for patients presenting to the Emergency Department with acute chest pain who are at low risk of myocardial ischemia. The goals of the pathway were to expedite evaluation of low-risk patients and reduce admission rates among these patients and in the cohort overall without compromising outcomes. The pathway was developed by a multidisciplinary team in an iterative process that considered published literature, as well as the experience and consensus of local opinion leaders. Patients at least 30 years old presenting to the Emergency Department of an urban teaching hospital who were pain-free without heart failure or ischemic changes on EKG, but who were not considered appropriate for discharge by the treating physician, were eligible for the critical pathway. The pathway involved one set of creatine kinase-MB enzymes drawn at least 4 hours after pain, a 6 hour observation period after the last episode of pain and exercise testing. Outcomes during evaluation and admission rates were assessed. Clinical outcomes at 7 days and 6 months after evaluation and patient satisfaction at 7 days were also measured. Of 1363 patient visits, 145 (10.6%) were triaged by the pathway: 131 (90.3%) were discharged, 14 (9.7%) were admitted. The overall admission rate decreased from 63% (2898/4595) to 60% (819/1363) [p < 0.05] in comparison to a cohort studied prior to pathway implementation. Pathway patients reported low rates of subsequent cardiac procedures. No deaths or myocardial infarctions were recorded. At 7 days, only 2 respondents (2%) reported going to an Emergency Department since their evaluation. Most respondents (83%) rated their care as very good or excellent. Critical pathways designed to enhance efficiency, reduce variability, and improve the quality of care are becoming increasingly common. Our pathway for evaluation of patients with chest pain at low risk of myocardial ischemia was feasible and safe and was associated with a decline in absolute admission rates. Because of the possibility of concomitant secular trends and the effects of a changing medical environment, further rigorous research on the efficacy of individual pathways is needed.

Acute Disease↗
PubMed2002

[Critical pathways in chemotherapy for lung cancer].

Differences of critical pathway in cancer chemotherapy from its protocol are the unification of the treatment, setting of the treatment goal and its provision for the patient. By the uniform treatment at least in the same hospital and the variance analysis of side effects with chemotherapy, the scientific and objective evaluation of treatment outcome and toxicities is possible. It is also useful for the consideration in the aspect of the ethics with the exhibition of the treatment by the provision of critical pathway for the patient. Therefore, critical pathway in chemotherapy for lung cancer is the useful tool to establish the clinical practice guidelines based on both scientific and ethical evidences in addition to the improvement of the patient satisfaction and the promotion of the team medical treatment.

Antineoplastic Combined Chemotherapy Protocols↗
PubMedDate not supplied

Critical pathways: an aid to practice.

The introduction of critical pathways in a invasive cardiology unit has resulted in a reduction in time spent on documentation by nursing staff, in patient complaints and an improvement in the quality of information collected, as measured by clinical audit. This paper describes the transition from the use of nursing care plans to multidisciplinary critical pathways. The positive and negative aspects of critical pathways and their implementation are explored.

Critical Pathways↗
PubMedDate not supplied

The role of the nurse educator in the development of critical pathways.

This article focuses on the role of the nurse educator in developing critical pathways. It serves as a guide for the nurse educator by defining how critical pathways support managed care, identifying the goals of critical pathway education, and reviewing the importance of organizational commitment to the critical pathways before their use. The nurse educator serves as instructor, facilitator, and consultant in critical pathway development.

Education, Nursing, Continuing↗
PubMed2003

Are critical pathways effective for reducing postoperative length of stay?

BACKGROUND: Many hospitals use critical pathways to attempt to reduce postoperative length of stay (PLOS) for diverse conditions and procedures. OBJECTIVE: To evaluate whether critical pathways were associated with reductions in postoperative PLOS after accounting for prepathway trends in PLOS. RESEARCH DESIGN: Retrospective cohort study, from 1988 to 1998. SETTING: Academic medical center department of surgery. SUBJECTS: A total of 10,960 admissions eligible for 1 of 26 critical pathways implemented from 1990 to 1996, from 2 years before to 2 years after each pathway implementation date. Coding definitions were developed and validated to identify admissions eligible for each pathway, and data were abstracted from the hospital's discharge database. MEASURE: A pathway was considered effective if, after its implementation, there was a statistically significant decrease in the prepathway trend for PLOS. RESULTS: Median number of annual eligible admissions per pathway was 59 (range, 18-706). Median PLOS for the prepathway periods was 8 days (interquartile range, 5-10 days). For 16 (62%) pathways, PLOS was already declining in the prepathway period. After adjusting for demographics, comorbidity, admission characteristics, and prepathway time trends in PLOS, 7 (27%) pathways were associated with a significant postimplementation decrease in the rate of change in PLOS (range among the 7 pathways, 5-45% decrease) and none with a significant increase from the prepathway trend for PLOS. CONCLUSION: Critical pathways may decrease postoperative stay for some, but not all, surgeries. Trends toward decreasing length of stay over time may reduce the impact of critical pathways on this outcome.

Adult↗
PubMed1998

Process-oriented critical pathways in inpatient psychiatry: our first year.

The critical pathway methodology of assigning and timing staff interventions and expected patient outcomes has developed worldwide recognition, but is less likely to be used in psychiatry than in other medical fields. At St. Mary's in Rochester, New York, an interdisciplinary team adapted the critical pathway concept to meet the needs of an acute inpatient population with relative success. Although staff education needs continue and plans to modify the pathway are in progress, all staff feel that the critical pathway is a viable tool for enhancing patient care and optimizing resources use. Benefits, obstacles, and suggestions are discussed.

Critical Pathways↗
PubMedDate not supplied

Occupational therapy benchmarks within orthopedic (hip) critical pathways.

OBJECTIVE: This study examined patient performance benchmarks for occupational therapy within orthopedic (hip) critical pathways. METHOD: Eight orthopedic (hip) critical pathways gathered from occupational therapy practitioners working in hospital and rehabilitation settings were examined to determine commonalities and differences of occupational therapy benchmarks, disciplines involved, and identified allowable variances. A comparison and contrast matrix was developed to provide a visual means of reviewing the data. RESULTS: Nursing, physical therapy, and occupational therapy were disciplines consistently involved in the pathways. Activities of daily living related to self-care were the most consistently used occupational therapy benchmark within the sample pathways, and functional transfers were the second most-used benchmark. The remaining occupational therapy benchmarks varied, and little commonality was found in their use. Frequency of use also varied among the eight pathways. Five of eight pathways specifically coded variances, with the remaining three providing space for explanation of the variance. CONCLUSION: Although these eight orthopedic (hip) critical pathways included occupational therapy benchmarks, further development and definition of the role of occupational therapy within subsequent orthopedic (hip) critical pathways is needed.

Benchmarking↗
PubMed2003

[Development of the critical pathway for the patient with tonsillectomy].

PURPOSE: This study aimed at developing a critical pathway for the children undergoing tonsillectomy. METHOD: Six steps of critical pathway developmental process were used based on the literature review. The researcher reviewed 70 medical records of children who had tonsillectomy between January 4th and April 30th, 2001. They received 76 kinds of medical services during six average hospitalization days. Five of them had post-operative bleeding problem. A professional group carefully screened 67 out of 76 medical services and adopted them with five average hospitalization days as the critical pathway framework. This framework was applied to 34 children undergoing tonsillectomy during June 1st through August 21st, 2001. RESULT: The children who used the pathways with five average hospitalization days had post-operative bleeding problem. In other words, the group who utilized the critical pathway resulted in better outcomes compared to the group who did not use the tool. CONCLUSION: Since the critical pathway is an efficient care management tool, nurses need to participate more positively participate in developing and utilizing the tool for other health problem.

English Abstract↗
PubMed1994

Critical pathway methodology: effectiveness in congenital heart surgery.

Critical pathway methodology has been demonstrated to provide producible reduction in average length of stay (ALOS) in adults in certain diagnostic-related groups and operations such as coronary artery bypass grafting. The efficacy of this approach in congenital heart surgery was explored. Two hundred eighty-six consecutive patients from a health maintenance organization treated by a single surgeon since the institution of diagnostic-related group coding at that health maintenance organization constituted the study group. One hundred fourteen patients were treated at a university hospital without critical pathway methodology (group 1) and 172, subsequently at the health maintenance organization institution using the methodology (group 2). Operation/lesion, age, and diagnostic-related group matching was possible in 61 pairs. Examination of the ALOS Hospital (operative and postoperative days) for the entire cohort revealed a 43.8% reduction in ALOS Hospital (p < 0.0001) and a 39.0% reduction in ALOS Intensive Care Unit (p < 0.0001). There was also significant reduction in ALOS Hospital and ALOS Intensive Care Unit in the operation/lesion-matched subsets. Outcome measures including operative and late mortality, readmission, unscheduled emergency room and clinic visits, and health maintenance organization family assessment survey demonstrated no improvement in outcome with increased hospital stay. Thus, critical pathway methodology when used in patients undergoing a congenital heart operation produces a significant reduction in hospital stay and intensive care unit stay as well as quality patient care with uniformity of outcome.

Adolescent↗
PubMed1995

Use of critical pathways and indicators in pharmacy practice.

The development of critical pathways along with continuous quality improvement and patient-focused care represents one of the key initiatives in health care in the 1990s. The critical pathway defines the components of care, including treatments, diagnostic measures, and activities to be performed each day, to achieve the desired outcome for a patient with a given diagnosis. Indicators can then be used to define opportunities for improving the pathway. Participation in the critical pathway development process provides pharmacists with an opportunity to utilize their expertise in the medication use process to ensure optimal medication management.

Clinical Protocols↗
PubMedDate not supplied

Use of a critical pathway for colon resections.

Tremendous variation in patient care exists, both among medical centers and among individual surgeons, in the field of colon and rectal surgery. Clinical or critical pathways based on "best demonstrated practices" from the medical literature have led to improved outcomes for many disease entities. The objective of this study was to develop a pathway for elective colon and rectal resections, and then determine whether this led to any improvement in measurable outcomes. A critical pathway was developed for the care of patients undergoing elective colon and rectal surgery, by reviewing best demonstrated practices in the literature and then developing standardized order sheets, nursing flow sheets, and patient educational material. A patient satisfaction survey was also included in the evaluation process. After being informed of the positive results from the pilot study, surgeons were encouraged to use the critical pathway order sheets, patient information sheets, and flow sheets for their patients undergoing elective abdominal colon or rectal surgery. Between January 1995 and October 1998, the critical pathway was used for 263 patients, whereas for 122 patients this pathway was not used. For those patients in the critical pathway group, the hospital length of stay was shorter (5.5 vs. 8.2 days, including the day of surgery, P = 0.001), the time until a regular diet was tolerated was shorter (3.5 vs. 4.4 days, P = 0.001), the percentage of patients discharged home was greater (90% vs. 82%, P = 0.038), and the average hospital charges were less (12,672 dollars vs. 16,665 dollars, P = 0.001). These advantages did seem to be correlated with efforts at postoperative ambulation, but were independent of the type of postoperative pain control (patient-controlled analgesia vs. epidural analgesia). Patient satisfaction in the subset surveyed was slightly better for those in the critical pathway group than in those for whom the critical pathway was not used. Elective colon and rectal surgery appears to lend itself to uniformity of postoperative order sheets and clinical expectations. Shortened lengths of hospital stay, earlier resumption of a regular diet, and diminished hospital charges were found with the use of this critical pathway, with no diminution of patients' perceptions of satisfaction with the hospital experience.

Adult↗
PubMed2002

Critical pathways for management of patients with acute coronary syndromes: an assessment by the National Heart Attack Alert Program.

BACKGROUND: The use of critical pathways for a variety of clinical conditions has grown rapidly in recent years, particularly pathways for patients with acute coronary syndromes (ACS). However, no systematic review exists regarding the value of critical pathways in this setting. METHODS: The National Heart Attack Alert Program established a Working Group to review the utility of critical pathways on quality of care and outcomes for patients with ACS. A literature search of MEDLINE, cardiology textbooks, and cited references in any article identified was conducted regarding the use of critical pathways for patients with ACS. RESULTS: Several areas for improving the care of patients with ACS through the application of critical pathways were identified: increasing the use of guideline-recommended medications, targeting use of cardiac procedures and other cardiac testing, and reducing the length of stay in hospitals and intensive care units. Initial studies have shown promising results in improving quality of care and reducing costs. No large studies designed to demonstrate an improvement in mortality or morbidity were identified in this literature review. CONCLUSIONS: Critical pathways offer the potential to improve the care of patients with ACS while reducing the cost of care. Their use should improve the process and cost-effectiveness of care, but further research in this field is needed to determine whether these changes in the process of care will translate into improved clinical outcomes.

Acute Disease↗
PubMed1999

Critical pathways for postoperative care after simple congenital heart surgery.

OBJECTIVE: To evaluate the clinical, financial, and parent/patient satisfaction impact of critical pathways on the postoperative care of pediatric cardiothoracic patients with simple congenital heart lesions. STUDY DESIGN: Critical pathways were developed by pediatric intensive care nurses and implemented under the direction of pediatric cardiothoracic surgeons. PATIENTS AND METHODS: Critical pathways were used during a 12-month study on 46 postoperative patients with simple repair of atrial septal defect (ASD), coarctation of the aorta (CoA), and patent ductus arteriosus (PDA). Using the study criteria, a control group of 58 patients was chosen from 1993. Prospective and control group data collected included postoperative intubation time, total laboratory tests, arterial blood gas utilization, morphine utilization, time in the pediatric intensive care unit, total hospital stay, total hospital charges, total hospital cost, and complications. Variances from the critical pathway and satisfaction data were also recorded for study patients. RESULTS: Resource utilization was reduced after implementation of critical pathways. Significant reductions were seen in total hours in the pediatric intensive care unit, total number of laboratory tests, postoperative intubation times, arterial blood gas utilization, morphine utilization, length of hospitalization (ASD, 4.9 to 3.1 days; CoA, 5.2 to 3.2 days; and PDA, 4.1 to 1.4 days; all P < 0.05), total hospital charges (ASD, $16,633 to $13,627; CoA, $14,292 to $8319; and PDA, $8249 to $4216; all P < 0.05), and total hospital costs. There was no increase in respiratory complications or other complications. Patients and families were generally satisfied with their hospital experience, including analgesia and length of hospitalization. CONCLUSIONS: Implementation of critical pathways reduced resource utilization and costs after repair of three simple congenital heart lesions, without obvious complications or patient dissatisfaction.

Aortic Coarctation↗
PubMed1995

Critical pathways as a strategy for improving care: problems and potential.

In an era of increasing competition in medical care, critical pathway guidelines have emerged as one of the most popular new initiatives intended to reduce costs while maintaining or even improving the quality of care. Developed primarily for high-volume hospital diagnoses, critical pathways display goals for patients and provide the corresponding ideal sequence and timing of staff actions for achieving those goals with optimal efficiency. Despite the rapid dissemination of critical pathway programs in hospitals throughout the United States, many uncertainties remain about their development, implementation, and evaluation. In addition, serious concerns have been raised about their effect on patient outcomes and satisfaction with care, physician autonomy, malpractice risks, and the teaching and research missions of many hospitals. Underlying these concerns is the absence of data from controlled trials to evaluate the effects of critical pathways. Physicians should understand the potential benefits and problems associated with critical pathways because physicians are increasingly being asked to provide leadership for pathway programs. Physicians and other health service investigators should also develop methods to study pathways in evolving health care settings. Although the promise of reduced costs and improved quality is enticing, the gaps in our knowledge about critical pathways are extensive; therefore, like any new health care technology, pathway programs should be fully evaluated in order to understand the conditions under which that promise may be fulfilled.

Analysis of Variance↗