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PubMed2001

Assessing the effectiveness of critical pathways on reducing resource utilization in the surgical intensive care unit.

OBJECTIVES: To evaluate the effectiveness of procedure-specific surgical critical pathways on reducing resource utilization in a university surgical intensive care unit (ICU). DESIGN AND SETTING: Prospective cohort study in a university surgical ICU. PATIENTS: 194 patients, accounting for 255 patient days, sampled on randomly selected days over a 12-month period of time. MEASUREMENTS AND RESULTS: The primary outcomes of this study were pathway eligibility and laboratory utilization. Patients were eligible for a procedure-specific pathway in 34% of patient days identified, and the patient's clinical course was "on" pathway in 22% of patient days. Of those "on" the pathway, 54% had a pathway present in the chart and 32% of these included documentation of the patient's clinical course. Thus in 78% of the patient days the patient was either not eligible for a critical pathway or the patient's clinical course was "off" pathway. In those patients "on" the pathway 46 % did not have a pathway present in the chart. Being on a critical pathway did not reduce laboratory utilization. Laboratory utilization did not vary between patients "on" and "off" the pathway (19.1 +/- 11.3 laboratory tests/patient day versus 20.4 +/- 5.7 laboratory tests/patient day). Predicted laboratory utilization by the pathway was 5.6 laboratory tests/patient day. By reducing actual laboratory utilization to that predicted by the critical pathway we would reduce laboratory utilization at our institution by $1.2 million per year. CONCLUSIONS: Procedure-specific surgical critical pathways are not an effective tool for reducing resource utilization in our ICU. Most of our patients were not eligible for an available pathway, and those who were eligible and were "on" the pathway did not appear to have laboratory utilization guided by the pathway. Future initiatives need to explore other means such as ICU-specific care processes to reduce resource utilization in the ICU.

Aged↗
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↗
PubMed2001

The implementation of critical pathways in gynecologic oncology in a managed care setting: a cost analysis.

OBJECTIVES: The aim of the study is to determine whether critical pathways can be implemented at an academic institution to limit cost, without compromising patient satisfaction and quality of care. PATIENTS AND METHODS: Patients undergoing a hysterectomy with either cervical or endometrial cancer were placed on specific critical pathways consecutively for an 18-month study period. Preoperative teaching was intensified to educate the patient regarding expectations during the postoperative period. All patients were started on early feeding and patients were also placed on separate care pathways addressing pain and deep vein thrombosis prophylaxis. Total direct costs and patient satisfaction were obtained throughout the study period. During the year prior to care pathway implementation, patient data and direct costs were obtained for the preintervention group utilized for comparison. Postintervention groups were summarized every 6 months during the study period. RESULTS: From January 1997 through June 1998, 63 patients with cervical carcinoma undergoing a radical hysterectomy (DRG 353) and 21 patients with endometrial cancer who underwent a hysterectomy and lymph node sampling (DRG 355) were utilized as the preintervention group. During the 18-month study period (July 1998-December 1999), 42 patients (DRG 353) and 25 patients (DRG 355) were accrued. The average length of stay was reduced from 5.2 (DRG 353) and 4.7 days (DRG 355) prior to implementation of pathways to 3.4 days in both groups. In addition, total direct costs were reduced by 29 (DRG 353) and 32% (DRG 355) after implementation of care pathways. Patient satisfaction data recorded during the study did not demonstrate any change throughout the study period nor were there any higher rates of readmission after implementation of the care pathways. CONCLUSIONS: Critical pathways in gynecologic oncology can be implemented in a managed care environment in order to maintain high quality of care, maintain outcomes, and help reduce costs.

Critical Pathways↗
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↗
PubMed1998

Positioning and intracranial hypertension: implications of the new critical pathway for nursing practice.

Evidence based practice in nursing requires careful scrutiny of research studies to determine if there is support to continue existing protocols or if a change in clinical practice is warranted. Current nursing practice in critical care includes the routine elevation of the head of the bed (HOB) to 30 degrees or 45 degrees for patients with cerebral edema. Intracranial hypertension is a common complication of cerebral edema. New guidelines for medical management of intracranial hypertension have been developed and presented in a critical pathway. Positioning of patients with intracranial hypertension must be re-evaluated in light of the changing goals of medical management outlined in the critical pathway. The author of this article will critically appraise the research examining the impact of elevating the HOB on patients with intracranial hypertension within the context of the critical pathway parameters. Recommendations for positioning, in keeping with the new critical pathway for intracranial hypertension, will be suggested. Future research directions will be identified.

Critical Care↗
PubMed1996

A critical pathway to treat proximal lower-extremity deep vein thrombosis.

To address variation in treatment of deep vein thrombosis (DVT) while maximizing the efficiency and quality of care, our institution developed a critical pathway guideline. This paper presents this critical pathway and the clinical rationale underlying its recommendations. The DVT pathway synthesizes recommendations for all aspects of patient care, including laboratory evaluation at admission, dosing and management of heparin therapy, timing of warfarin initiation, elements of patient education, discharge planning, and anticipated duration of heparinization and hospitalization. Differences among interpretations of the medical literature, patient populations, physician skills, test availability, and other variables make it unlikely that all elements of this pathway would best meet the needs of another institution. Nevertheless, the critical pathway format and the specific contents of this pathway may serve as a useful benchmark for others involved in creating clinical guidelines for this patient population.

Activities of Daily Living↗
PubMed1996

Critical pathways: a road to institutionalizing pain management.

Effective strategies to increase the visibility of pain and the accountability of health-care professionals for the treatment of pain are needed to improve the quality of pain management. Critical pathways are tools used to plan and document care for patients within a system of case management. Case management models of care focus on decreased cost, better coordination of services, and improved patient outcomes. This article describes how critical pathways are being used in one setting within a system of case management to help increase awareness of pain as a problem and to institutionalize pain management. As institutions seek to implement outcome-based practice systems, many are turning to the critical pathway to influence practice patterns. Critical pathways provide the vehicle to articulate and implement a standard for quality pain management and a mechanism to analyze persistent failures in achieving desired outcomes of care. Using pathways to track and monitor care promises to uncover clinical barriers to pain management and provide an impetus to increase clinician accountability for pain relief.

Critical Pathways↗
PubMed1999

Integrating disease management and wound care critical pathways in home care.

This article discusses the need for an integration of the concepts of disease management and critical pathways as a foundation of a healthcare delivery system. The steps in the process for development, implementation, and evaluation of a wound care critical pathway are reviewed and variance classifications are defined. Co-pathways and algorithms are presented as methodologies for dealing with variances. A template of a wound care critical pathway that has been developed for use in the home care setting is included.

Algorithms↗