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Patients with carotid stenosis present multiple challenges to the medical-surgical nurse case manager. Implementing a defined critical pathway for the patient undergoing a carotid endarterectomy can result in quality cost-effective care, fewer complications, and less possibility of future stroke.
BACKGROUND: Concealed retrograde activation has been proposed as a mechanism for antegrade conduction block in the bundle branches and atrioventricular accessory pathways. We studied this hypothesis (linking) in 10 patients with the Wolff-Parkinson-White syndrome in whom antegrade preexcitation could be persistently blocked by overdrive atrial pacing. METHODS AND RESULTS: An atrial pacing protocol, with a decremental ramp followed by an incremental ramp, defined a range of atrial paced cycle lengths (linking window) associated with both persistent conduction and block in the accessory pathway. Within the limits of the linking window, the ability of an atrial impulse to conduct over the accessory pathway was dependent on the preceding state (i.e., conduction or block). The observed linking window ranged from 70 to 290 msec (mean, 185 +/- 68 msec) and closely approximated the measured delay in retrograde activation of the accessory pathway during persistent antegrade block. The mean antegrade effective refractory period of the accessory pathways was long (486 +/- 156 msec), and in each case, it exceeded the antegrade refractory period of the normal atrioventricular pathway. Critically timed premature ventricular extrastimuli, delivered while linking was maintained in the accessory pathway, were able to interrupt the linking and restore antegrade accessory pathway conduction. CONCLUSIONS: These observations suggest that accessory pathway linking is associated with bidirectional block in the accessory pathway. The ability to initiate linking (and the stability of the phenomenon) depends on a critical relation between antegrade accessory pathway refractoriness and the magnitude of retrograde accessory pathway activation delay.
PURPOSE: The purpose of this study was to determine whether major vascular surgery could be performed safely and with significant hospital cost savings by decreasing length of stay and implementation of vascular clinical pathways. METHODS: Morbidity, mortality, readmission rates, same-day admissions, length of stay, and hospital costs were compared between patients who were electively admitted between September 1, 1992, and August 30, 1993 (group 1), and January 1 to December 31, 1994 (group 2), for extracranial, infrarenal abdominal aortic, and lower extremity arterial surgery. For group 2 patients, vascular critical pathways were instituted, a dedicated vascular ward was established, and outpatient preoperative arteriography and anesthesiology-cardiology evaluations were performed. Length-of-stay goals were 1 day for extracranial, 5 days for aortic, and 2 to 5 days for lower extremity surgery. Emergency admissions, inpatients referred for vascular surgery, patients transferred from other hospitals, and patients who required prolonged preoperative treatment were excluded. RESULTS: With this strategy same-day admissions were significantly increased (80% [145/177] vs 6.2% [9/145]) (p < 0.0001), and average length of stay was significantly decreased (3.8 vs 8.8 days) (p < 0.0001) in group 2 versus group 1, respectively. There were no significant differences between group 1 and group 2 in terms of overall mortality rate (2.1% [3/145] vs 2.3% [4/177]), cardiac (3.4% [5/145] vs 4.0% [7/177]), pulmonary (4.1% [6/145] vs 1.7% [3/177]), or neurologic (1.4% [2/145] vs 0% [0/177]) complications, or readmission within 30 days (11.3% [16/142] vs 9.2% [16/173]) (p > 0.05). There were also no differences in morbidity or mortality rates when each type of surgery was compared. Annual hospital cost savings totalled $1,267,445. CONCLUSION: Same-day admission and early hospital discharge for patients undergoing elective major vascular surgery can result in significant hospital cost savings without apparent increase in morbidity or mortality rates.
The nonsteroidal anti-inflammatory drug Sulindac has chemopreventive and antitumorigenic properties. Its metabolites induce apoptosis and inhibit signaling pathways critical for malignant transformation, including the Ras pathway. Here we show that the new Sulindac derivative IND 12 reverses the phenotype of Ras-transformed MDCK-f3 cells and restores an untransformed epithelioid morphology characterized by growth in monolayers with regular cell-cell adhesions. Moreover, IND 12 treatment induces the expression at membranes of the cell adhesion protein E-cadherin and increases the level of the E-cadherin-bound beta-catenin. As a consequence, IND 12-treated MDCK-f3 cells lose their invasion capacity and regain the ability to aggregate. In the presence of IND 12, MDCK-f3 cells show regenerated expression and activity ratios of the small GTPases Rac and Rho normally found in untransformed MDCK cells. Strikingly, IND 12 treatment decreases the levels of phosphorylated mitogen-activated protein kinases, which are downstream substrates of the Ras-regulated Raf/mitogen-activated protein kinase pathway, and the level of Ras-induced activation of gene expression. Our findings identify a novel drug with high potential in cancer therapy by targeting Ras-induced cell transformation.
Looking at the positive outcomes of managed care emphasizes the opportunities specific to nursing: continuum of care, critical pathways and patient education. With advanced information systems and managed care, nurses can demonstrate how models of preventive care, patient education and self-care should be set up and managed.
Quality management in today's health care environment requires a fresh approach. Laboratories that have traditionally directed their efforts toward meeting the needs of physicians must now also satisfy the needs of society, the greater public health, and the agency's administrators. Technical advances must today be considered in the context of patient care cost-effectiveness or final outcomes. Examples of strategies for improving quality in the laboratory, such as seeking input from all individuals involved in interpreting or using laboratory test results, forming multidisciplinary committees for development of critical pathways, issuing surveys for assessing the level of satisfaction of the laboratory's customers, and providing visual feedback of the results of activities, are described.
Managing the care of the very preterm infant can become a maze of diagnoses, treatments, and tests that blur progress and expectations along an infant's extended course in the NICU. Yet the health care environment demands that comprehensive, high-quality, cost-effective care be provided each infant and family entrusted to our care. Critical pathways based on gestational age at birth and postconceptional age throughout the hospital stay facilitate the necessary goal-oriented, interdisciplinary approach to infant care by providing consistency, flexibility, and quality management.
PURPOSE: A statewide quality improvement initiative was conducted in Connecticut to improve process-of-care performance and to decrease length of stay for patients hospitalized with community-acquired pneumonia. SETTING AND METHODS: Data were collected on 1,242 elderly (> or =65 years) pneumonia patients hospitalized at 31 of 32 acute care hospitals between January 16, 1995, and March 15, 1996, and on 1,146 patients hospitalized between January 1, 1997, and June 30, 1997. Interventions included feedback of performance data (Qualidigm, the Connecticut Peer Review Organization), dissemination of an evidence-based pneumonia critical pathway (Connecticut Thoracic Society), and sharing of pathway implementation experiences (hospitals). Process and outcome measures included early antibiotic administration, blood culture collection, oxygenation assessment, length of stay, 30-day mortality, and 30-day readmission rates. Analyses were adjusted for severity of illness and hospital-specific practice patterns. RESULTS: After the statewide initiative, improvements were noted in antibiotic administration within 8 hours of hospital arrival (improvement from 83.4% to 88.8%, relative risk [RR] = 1.21; 95% confidence interval [CI]: 1.10 to 1.32), oxygenation assessment within 24 hours of hospital arrival (93.6% to 95.4%; RR = 1.23, 95% CI: 1.11 to 1.38), and length of stay (7 days to 5 days, P <0.001). There were no significant changes in blood culture collection within 24 hours of hospital arrival, blood culture collection before antibiotic administration, 30-day mortality, or 30-day readmission rates. CONCLUSIONS: Statewide improvements were demonstrated in the care of hospitalized pneumonia patients concurrent with a multifaceted quality improvement intervention. Further research is needed to separate the effects of the quality improvement interventions from secular trends.
We integrated the care of patients of all ages (ranging thus far from 4 weeks to 73 years) in our dedicated 8-bed Epilepsy Unit. Administrative issues pertaining to admission and discharge criteria, unit policies and procedures and an interdisciplinary quality assurance plan were examined in relation to the impact of combining both pediatric and adult patients. Clinical considerations included the diversified abilities needed to care for pediatric and adult patients both in relation to the technical skills as well as psychosocial skills required. The advantages of integrating patients of all ages on one unit include having a staff highly trained in assessment and intervention skills for a particular disorder. The psychosocial issues that arise in these patients, regardless of age, tend to encompass the entire family; therefore a holistic approach is appropriate for both children and adults. An autonomous nursing practice was established with the development of critical pathways and patient care protocols. Our experience suggests that integrated specialized units can enhance the care of patients with intractable seizures.
The death of a child is one of the most painful experiences a parent can endure. Communicating and meeting the needs of parents during this time of crisis is a challenge for nurses. Pediatric intensive care unit and emergency department nurses who may feel overwhelmed and inadequate when working with grieving families, especially with a sudden and unexpected death, are assisted by "The Patterns of Your Life: A Comprehensive Pediatric Bereavement Program." The program is a blending of critical pathways (an element of managed care), educational resources, and family follow-up for 1 year. Preliminary evaluations indicate that the comprehensive bereavement program appears to have many benefits for families and health care staff alike.
Collaborative practice teams consist of interdisciplinary providers who are charged with the process of implementing and refining an outcomes management program within a targeted population. Collaborative practice teams work under the assumption that clinical quality enhancement through practice standardization decreases care fragmentation, resulting in improved physiologic, psychosocial, and financial outcomes. Collaborative practice team members identify best practice through the implementation and testing of interdisciplinary interventions. Represented on a critical pathway, these practices are evaluated toward achievement of defined population outcomes. In this article, the authors review the process of collaborative practice team formation, expected pitfalls and barriers to effective collaboration, and the work accomplished by a collaborative practice team.
This self-directed learning module highlights new advances in this topic area. It is part of the chapter on rehabilitation in limb deficiency in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article reviews the phases of amputation rehabilitation from preoperative stages to community reintegration and long-term follow-up. The various indications for artificial limb components for the upper and lower limb amputee and the expected functional levels based on level of amputation are discussed. New concepts of critical pathways are also introduced as guidelines in optimizing the rehabilitation of the amputee. The reader is directed to other relevant literature as well, in an attempt to enhance knowledge in this area of rehabilitation.
TOPIC: Clinical Management Protocols for trauma patients. PURPOSE: The goals and process for developing and implementing Clinical Management Protocols are presented. Protocol development and the differences between clinical practice guidelines, critical pathways, and clinical management protocols are discussed. SOURCES: Published literature, experience, and clinical expertise. CONCLUSIONS: Utilizing annotated algorithms, the protocols are designed for and driven by patient care based on patient need and require the collaboration of experts and trauma team members.
The goal of managed health care is to reduce health care costs while maintaining or improving the quality of care given to patients. Clinical pathways, which outline the services and therapies planned for a typical patient admitted with a specific diagnosis, may provide a way to control costs and improve patient outcome. These pathways are under development by medical centers and managed-care organizations nationwide, with the aim of planning, managing, documenting, and evaluating multidisciplinary care. A coordinated care plan can take a number of approaches. Time lines identify predictable clinical landmarks and time intervals for a specific medical episode or illness within a given diagnostic-related group or set of diagnostic-related groups. Case-management plans and case managers coordinate a patient's care throughout an episode, eg, an operation, enabling patients to reach defined time points in the course of their care at the expected time. Critical pathways are the favored method of documenting the patient's progress according to the predicted time schedule. This report discusses ways to successfully implement a care plan, highlighting the commitment and effort needed from a multidisciplinary staff to achieve the goal of optimizing efficiency and quality of patient care.
OUTCOME MEASUREMENT SYSTEM: PsychSentinel, a symptom reduction measure, uses 20 diagnostically defined symptom checklists derived from the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV). Symptoms are enumerated and are assigned weights on the basis of clinical significance, providing an overall assessment of symptom intensity. The availability of multisite benchmark norms makes possible the computation of observed-to-expected ratios. EXAMPLES OF THE CONTINUOUS QUALITY IMPROVEMENT CYCLE: Six examples, drawn from the experience of a number of behavioral health care programs since 1994, illustrate how outcome data can be used to guide and test changes that will effect improvements over current practices. Example 1: Problem identification is one of the most obvious and immediate applications of outcome data relative to a quality improvement process. Data were presented at a meeting of the hospital medical staff; the data showed that one clinician had significantly poorer outcomes in treating bipolar patients. A review of the medical records for bipolar patients treated by this clinician indicated that this clinician was changing medications too rapidly, a problem that was quickly and easily corrected-with improved outcomes. Example 6: Data revealed that patients who were treated in accordance with the critical pathway showed a greater degree of improvement, even though these patients entered treatment with a 10% greater level of symptom intensity. SUMMARY AND CONCLUSIONS: Each example provides a sample of variability in outcomes and therefore an opportunity to study the reasons for the variability and institute changes.
A care coordinator blends aspects of the case manager and clinical specialist roles with those of a unit-based staff developer. In this position, the nurse facilitates critical pathways; coordinates care with the patient, family, ancillary staff and community services; delivers unit-based staff-development programs; and acts as mentor, staff resource person and physician liaison. The development and utilization of this professional nursing role in a community hospital is outlined.
Shortened hospital stays could potentially lead to unmet patient needs. This descriptive study utilizes critical pathway data and the Omaha System to identify the health needs of coronary artery bypass surgery patients at time of discharge. The most common health needs were education, sleep/rest and rehabilitation. Nursing implications relating to these health needs are also identified.
In today's healthcare environment, institutions are striving to streamline processes, reduce costs of healthcare, and establish best practice patterns while maintaining and improving the quality of care provided. Various healthcare delivery models are in use including case management and outcomes management. Various tools or structured-care methodologies (SCMs) are incorporated into these different models to support cost reduction and streamline processes while enhancing quality of care. This article discusses the tools frequently used, such as critical pathways, algorithms, and guidelines, as well as how these tools can be used in combination to support each other. This article also addresses the benefits of SCMs, how these tools are developed, and how the data obtained can be used in quality enhancement programs.