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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↗
PubMed1995

Role of the clinical nurse coordinator in successful implementation of critical pathways in pediatric cardiovascular surgery patients.

Critical pathways reduce variations in clinical management and achieve quality patient outcomes within a defined time while reducing the average length of stay (ALOS). The critical path is a day-by-day plan that specifies the use and timing of procedures in relation to the stage in the patient's recovery. Variations from that plan are identified and aggressively approached. This article outlines the clinical nurse coordinator's role in utilizing critical pathways for the congenital heart surgery patients. Successful implementation of the pathways using the clinical nurse coordinator's role is supported by analysis of ALOS in 286 patients.

Cardiovascular Diseases↗
PubMed1999

Use of a critical pathway to move laparoscopic cholecystectomy to the ambulatory surgery arena.

Critical pathways are being implemented in health care facilities across the nation as a cost-containment tool. When developed using best practice based on a literature review and the collaboration of a multidisciplinary team, critical pathways can be very successful in maintaining or increasing the quality of care while controlling the cost of the care provided. The Department of Defense Utilization Management Plan strongly encourages the use of pathways. Here we discuss the development and implementation of a critical pathway for laparoscopic cholecystectomy patients, with the goal being to transfer the medical care from the inpatient setting to the ambulatory surgery arena. The use of this pathway resulted in almost a 50% increase in patients treated in the ambulatory surgery arena.

Ambulatory Surgical Procedures↗
PubMed1996

Critical pathways as an effective tool to reduce cardiac transplantation hospitalization and charges.

A critical pathway is a component of managed care focusing on outcome-oriented, cost-effective care. This retrospective review of 74 cardiac transplants in 72 patients evaluated the influence of critical pathways on clinical management, length of hospitalization, and hospital charges. Transplant patients were divided into group 1 (n = 51), which received standard primary nursing care, and group 2 (n = 23), which received nursing case management using a critical pathway. The number of intensive care unit days for group 2 was significantly smaller than for group 1, as were duration of hospitalization and hospital charges. The critical pathway provided for systematic delivery of care and decreased length of hospitalization and charges without compromising safety or quality.

Case Management↗
PubMed1995

Nursing case management in the neonatal intensive care unit, Part 2: Developing critical pathways.

Nursing case management is a model of care delivery that focuses on achieving optimal patient outcomes in expected time frames while containing costs. The critical pathway is a tool used to help the team achieve the goals of nursing care management. The critical pathway serves as a multidisciplinary plan of care, based on time. Few neonatal critical pathways are available in the literature. They can be easily developed through a collaborative process. This article presents the author's recommendations on how to develop critical pathways. Once developed, they can serve as an important source of communication among disciplines and as a source of information regarding patient outcomes. Critical pathways can also be used as a teaching tool. Two critical pathways are included in this article.

Humans↗
PubMed1996

Coordinating initiatives in critical pathways and information systems.

Health care providers have begun to use critical pathways and order sets to standardize clinical care in order to improve clinical resource management. This article describes ways that critical pathways and order sets can be developed and implemented in a coordinated manner. This approach allows for a process that facilitates automation of critical pathways variance analysis and continuous feedback to clinicians.

Cost Control↗
PubMed1999

Critical pathways: a means of managing the operating room.

Critical pathways help institutions in efficient and appropriate resource use to increase the quality of health care and minimize health care costs. However, many opportunities for pathway development and implementation are unexplored. This article delineates the development process for critical pathways and discusses the outcomes realized from use of the total joint pathway at the Medical College of Georgia, Augusta, GA.

Critical Pathways↗
PubMed1998

Impact of a critical pathway on postoperative length of stay and outcomes after infrainguinal bypass.

PURPOSE: To determine the effect of a critical pathway on postoperative length of stay and outcomes after infrainguinal bypass. METHODS: A critical pathway for care of patients after infrainguinal bypass was introduced in December 1995 to coordinate postoperative care at our institution. We compared care of 67 consecutively treated patients before institution of the pathway with care of 69 consecutively treated patients with the critical pathway in place. Data collection was done by means of chart review. Univariate analyses were used to identify differences between prepathway and postpathway patients and to identify factors influencing postoperative length of stay. Multivariate analysis was used to identify factors that influenced length of stay and to examine the effect of use of the pathway after adjusting for other factors. RESULTS: Patients on the pathway were similar to prepathway controls with respect to comorbid illnesses, vascular risk factors, indications for surgical treatment, type of conduit, and type of operation. Factors associated with longer postoperative stays included distal anastomoses to tibial rather than popliteal vessels (p = 0.02), preexisting cardiac disease (p = 0.005), postoperative complications (p = 0.0003), lower preoperative hematocrit (p = 0.01), and elevated preoperative creatinine level (p = 0.006). Overall, pathway patients had somewhat shorter postoperative lengths of stay (median value 7 days; range 2 to 29 days) than prepathway patients (median value 6 days; range 2 to 35; p = 0.01), and the two groups had similar frequencies of postoperative complications, readmission, and 6-month mortality. However, patients on the pathway were more likely to be discharged to an intermediate-care facility rather than directly home. After 12 patients with extraordinarily prolonged postoperative stays were excluded, multivariate analysis indicated that pathway patients had significantly shorter postoperative stays (p = 0.001). However, the difference was not significant if patients with extraordinarily long postoperative stays were included in the analysis (p = 0.28). CONCLUSION: Use of a critical pathway was associated with a modest decrease in postoperative length of stay for most patients. This was accomplished without an adverse effect on readmission, complication, or mortality rates. However, the decrease in stay may have been achieved primarily by discharging more patients to intermediate-care facilities. The pathway did not appear to have any effect when the subset of patients with extraordinarily long stays because of complex medical problems was included.

Aged↗
PubMed1995

Enhancing patient care: case management and critical pathways.

This paper describes the processes involved in case management and in developing critical pathways as a mechanism to improve customer focused care. Critical pathways can be used to manage the care of patients in settings as varied as acute care hospitals, tertiary care facilities and primary health care areas. Advantages and disadvantages of case management and the critical pathways method of management are outlined from a nursing perspective.

Case Management↗
PubMedDate not supplied

Cost containment in cardiac surgery: results with a critical pathway for coronary bypass surgery at the New York hospital-Cornell Medical Center.

PURPOSE: A multidisciplinary project was undertaken at The New York Hospital-Cornell Medical Center to develop critical pathways for open-heart surgery to help reduce cost, shorten hospital length of stay (LOS), and streamline patient care. METHODS: A critical pathway for elective coronary artery bypass grafting instituted on March 1, 1995, was developed through a cooperative effort involving surgeons, anesthesiologists, nurses, social workers, physical therapists, nutritionists, and patient case managers. Prospective data collected on consecutive patients forming a critical pathway group (n = 114) over a 6-month period were compared with retrospective data on consecutive patients forming a cohort group (n = 382) who underwent elective coronary artery bypass grafting in 1994. RESULTS: The critical pathway group of patients experienced a significantly shorter total hospital LOS (7.7 +/- 2.3 days vs 11.1 +/- 6 days, p < 0.0001) and shorter intensive care unit LOS (1.5 +/- 0.9 days vs 2.0 +/- 2.8 days, p < 0.0001). Direct costs were computed by use of hospital charges multiplied by the Medicare cost-to-charge ratio. Mean hospital direct cost (ancillary resources) was $1181 lower in the critical pathway group when compared with the control group (p < 0.0001). The postoperative mortality and readmission rates were similar for the two groups of patients. CONCLUSIONS: The ongoing analysis of cost, LOSs, and outcomes has made possible a process of continuous quality improvement on the cardiothoracic service in which further areas for improvement are identified and studied. The use of a critical pathway for elective coronary artery bypass grafting at our institution significantly reduced hospital LOS and direct costs while maintaining the overall quality of patient care.

Coronary Artery Bypass↗
PubMed1999

Emergency department thrombolysis critical pathway reduces door-to-drug times in acute myocardial infarction.

BACKGROUND: Rapid time to treatment with thrombolytic therapy is an important determinant of survival in acute myocardial infarction (AMI). HYPOTHESIS: We hypothesized that establishment of an AMI thrombolysis critical pathway in the Emergency Department could successfully reduce the "door-to-drug" time, the time between patient arrival and start of thrombolysis. METHODS AND RESULTS: Before establishment of the AMI critical pathway, median door-to-drug time was 73 min, which was reduced to 37 min after critical pathway implementation (p < 0.05). The percentage of patients treated within 30 min rose from 0% prior to establishment of the pathway to 43% (p = 0.03). Similarly, the percentage treated in within 45 min rose from 0 to 67% (p = 0.0005). Door-to-drug times were longer for women than for men (median 105 min for women vs. 70 min for men before pathway implementation). The pathway reduced door-to-drug time for both genders, but the median door-to-drug times were higher for women than for men (Mann-Whitney p = 0.013). The difference between men and women was 35 min before establishment of the pathway to 10 min by the end of the study period. CONCLUSIONS: Our critical pathway was successful in reducing door-to-drug times. We observed a "gender gap" in door-to-drug times, with longer mean times for women, which was reduced by the AMI critical pathway. Thus, our data provide support for the use of critical pathways to reduce door-to-drug times, as recommended by the National Heart Attack Alert Program.

Critical Care↗
PubMed1997

Critical pathways for head and neck surgery. Development and implementation.

OBJECTIVE: To design, implement, and study the effectiveness of 4 new critical pathways relevant to head and neck oncological care. DESIGN: Before-after trial. SETTING: Tertiary referral academic institution. PATIENTS: Sixty-eight patients admitted for head and neck oncological surgery or chemotherapy from December 1, 1995, through May 31, 1996; 30 patients with similar diagnoses and who underwent surgical procedures from December 1, 1994, to December 1, 1995, who served as historical controls. INTERVENTIONS: Implementation of 4 critical pathways: chemotherapy, clean head and neck surgery, clean contaminated head and neck surgery, clean contaminated head and neck surgery with reconstructive flap. MAIN OUTCOME MEASURES: Length of stay, cost of hospitalization, and variance tracking (deviations from established standards). RESULTS: The length of stay for the clean contaminated group without flap reconstruction decreased by 1.5 days, and costs decreased by $7407 per patient (P < .05, Student t test). The length of stay decreased 1.6 days in the clean contaminated group with flap reconstruction, and costs decreased $9845 per patient (P < .05, Student t test). Nine patients (13%) experienced a prolonged length of stay while on a critical pathway. CONCLUSIONS: Implementation of critical pathways has resulted in a decreased overall length of stay and cost of hospitalization. It has also allowed for better coordination and documentation of patient care, while the tracking of variances has simplified problem identification and correction.

Critical Pathways↗
PubMedDate not supplied

Thoracotomy, critical pathway, and clinical outcomes.

Using a multidisciplinary critical pathway for chest surgery, the staff of Saint Joseph Medical Center (Burbank, California) and its physicians developed a strategy leading to improved patient outcomes with reduced overall costs. On referral from the surgeon's office, the multidisciplinary team, consisting of a clinical nurse specialist, physical therapist, and respiratory therapist, meet with the patient. The education that follows includes discussion of the surgical procedure, intubation, incentive spirometry, coughing, deep breathing, early ambulation, use of patient-controlled analgesia, chest physiotherapy, transfusion options, and evaluation of health status. A few days later, the patient undergoes the thoracoscopy-assisted thoracotomy. The success of the outcome-driven critical pathway can be related to several factors: (1) close coordination between the surgeon's office and hospital; (2) intensive preoperative education that decreases patient's anxiety and increases his or her ability to participate in recovery; (3) patient-controlled analgesia, nerve blocks, non-narcotic analgesia, and preemptive rehabilitation, which limit the risk for complication; and (4) thoracoscopy, which limits the surgical morbidity commonly affiliated with thoracotomy. The pathway, used for 160 patients during the past 2 years, has shown dramatic results related to reducing morbidity, practice variation, delay, and total overall cost.

Adult↗
PubMed1997

Design, development, and implementation of a critical pathway in simultaneous pancreas-kidney transplant recipients.

The purpose of this study was to assess the effect of implementation of a critical pathway after simultaneous pancreas-kidney transplantation on length of stay and hospital charges. Two well-matched groups were compared: 10 patients who received transplants in 1991 (before implementation of the critical pathway) and 10 patients who received transplants in 1995 (after implementation). For the initial transplant hospitalization, the critical pathway was associated with significant reductions in length of stay, total number of laboratory tests, clinical laboratory charges, and total inpatient charges with organ acquisition charges excluded. Despite the rising costs of medical care, we have designed and implemented a critical pathway for simultaneous pancreas-kidney transplantation that has stabilized hospital charges by decreasing length of stay and the number of clinical laboratory tests.

Adult↗
PubMed1995

Cancer care critical pathways: implementing a successful program.

Change in any form creates stress on systems, yet there is growing awareness within the health care field that change must come as cost-conscious insurers and employers refuse to pay for overextended processes that grew out of the charge-based reimbursement era. Short-term solutions, such as discounted charges and staff cuts, are not the answer when the entire system needs an overhaul. The cost of care escalates and the quality of patient care suffers because the system lacks the appropriate mechanisms to reduce redundancy, eliminate waste, improve effectiveness, and provide the high-quality care that a community expects from its hospital. The outcomes-based critical pathway approach discussed here has been used with great success and differs from classic pathway writing in that only elements related to the specific outcome are allowed on the order set. The critical pathway process starts with a review of historical patient records, which yields information about both historical practice patterns and the provider team. Using this information, a work group is formed and patient goals or outcomes are established for the population in question. The entire system is informed and educated, with special attention given to the medical staff, clinical outcome and financial data are developed and provided to individuals in the process, and a feedback loop is established. Cancer care is an attractive target for critical pathways, because it is an area with high cost and expensive technology, and physician practice patterns and patient outcomes can vary widely. On the flip side, the historically multidisciplinary nature of cancer care offers a good starting point for the collaborative culture needed to successfully implement critical pathways. When done right, critical pathways can decrease morbidity and mortality, reduce redundancy and cost, increase patient satisfaction, and improve patient outcomes. Shifting practice and eliminating variation in practice patterns, without regard to best practices and outcomes, could leave an organization compromised by group norms. Few things will sustain the energy needed to keep the hospital culture moving forward. This is not to say that it cannot be done, because it can. The critical pathway process has noticeable energy cycle levels--periods of high energy and low energy. The two hospitals discussed here reveal their painstaking effort to maintain and invigorate a process that would rather wait another day. Carefully selected work group members, reminders to keep individuals from returning to old practice habits, and an established, firm connection between cost and quality will help carry an organization through periods of low energy.(ABSTRACT TRUNCATED AT 400 WORDS)

California↗
PubMed1999

The use of critical pathways in caring for schizophrenic patients in a mental hospital.

To provide quality health care and at the same time, to control cost, literature suggests that using critical pathways as a tool can enhance resource management, increase collaborative practice, and benefit patient care. This study describes the processes of developing a critical pathway in caring for schizophrenic patients in a mental hospital in Hong Kong. The perceived benefits and difficulties in using the critical pathway are discussed from a nursing perspective. Nurses believed that the use of critical pathways could improve the coordination and effectiveness of care. Also, nurses' autonomy and professional status improved. However, inadequate knowledge and resistance from other disciplines were barriers to the implementation. Recommendations are given to overcome the barriers.

Cost Control↗
PubMedDate not supplied

Critical pathway development: an integrative literature review.

OBJECTIVE: The purpose of this integrative literature review was to summarize and analyze the methods used to develop critical pathways. METHOD: Relevant articles published in occupational therapy, physical therapy, nursing, and medical journals between 1992 and 1997 were reviewed to extract various methods and the steps or criteria used for each method. RESULTS: Nine approaches to critical pathway development and the steps or criteria involved in each method are presented in tabular format. The most detailed approach was used as a gold standard, and the other approaches were compared to it. CONCLUSION: This review should assist occupational therapy practitioners working with various diagnostic populations to understand the methods used, and steps involved, in the development of critical pathways. It should also serve as a resource for practitioners who have the opportunity to participate in critical pathway development.

Critical Pathways↗