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PubMed2002

Development and implementation of a critical pathway for abdominal aortic aneurysms in Japan.

Although the critical pathway (CP) has been implemented successfully for simple procedures and recovery processes, yielding improvement in length of stay (LOS) and patient satisfaction, there are few reports about its application to complicated procedures and recovery processes in Japan. A model was developed of the complicated postoperative abdominal aortic aneurysm (AAA) recovery process from 3-year patient data, including statistics such as days for achieving outcomes, comorbidities, complications, and patient characteristics. Its accuracy has been investigated by comparing patient outcomes. Eighty-three patients were divided into 2 groups (typical and atypical) on the basis of select criteria and analyzed by correlation coefficient, multiple regression analysis, and logistic analysis. No risk factors for delay of the recovery and the adverse outcomes were detected. The CP was the wound healing process in the short-term recovery process. The average LOS was 36.3 days in the typical group and 47.2 days in the atypical group. Stitch removal occurred 8 days after surgery, and patients were discharged a minimum of 11 days after the operation. The AAA-CP has been implemented since September 1998 in 45 experimental cases, and a significant reduction in days required to achieve short-term outcomes has been observed (25.6 days to 19.1 days in LOS after surgery) as well as a decrease in the prevalence of adverse outcomes.

Aged↗
PubMed1995

Developing critical pathways for the operating room.

Case management and managed care systems are emerging in the 1990s as ways to deliver quality, cost effective patient cae. The essential tool of managed care systems is a critical pathway, which is developed through the collaboration of health care team members. The critical pathway is an abbreviated version of the patients hospital course according to his or her medical diagnosis or case type and it allows health care team members to continually evaluate the patients care. It has helped team members at Johns Hopkins Hospital, Baltimore, identify more effective and cost-efficient ways to deliver patient care.

Aged↗
PubMed1996

Trauma critical pathways: a care delivery system that works.

Continuous performance improvement in care a patient receives is of paramount importance to Robert Packer Hospital, a regional, accredited trauma center in rural Pennsylvania. In fall 1991, a care delivery system known as case management was introduced as a mode for achieving this continuous performance improvement goal. The staff members' experience with the initial development and use of a trauma critical pathway was first published in the November 1993 issue of Critical Care Nursing Quarterly. Now, 3 years later, case management has proven to be a viable means to accomplish the continuous performance improvement goal by enhancing the quality of care for trauma patients and their families throughout hospitalization. This article reviews the outcomes over the past 3 years as a result of case management and the use of trauma critical pathways.

Case Management↗
PubMed2005

[Pain management for cancer patients with critical pathway on computer].

For relief from cancer pain, we developed critical pathway (CP) as an effective strategy for the medical staff treating cancer patients. This CP was made out of Microsoft Excel, and was used on personal computers. "Good sleeping" was set as the first goal and the second was "No pain in rest position." To achieve this, physicians and nurses evaluate medical efficacy and complications including nausea/vomiting, constipation, somnolence and hallucination everyday using controlled release oxycodone in addition to NSAIDs and prochlorperazine, stool softener and peristaltic stimulant for adverse effects. These outcomes lead to the medication change the next day by calculation using visual basic function due to opioid titration theory. In twelve patients this CP was acceptable, and all of them achieved the second goal within a week without severe adverse effects except constipation.

Analgesics, Opioid↗
PubMedDate not supplied

Evaluation of a critical pathway for pneumonia.

Pneumonia is the third most frequent admission diagnosis at Macomb Hospital Center. The average length of stay for this diagnosis (DRGs 89 and 90) was 9.07 days. After the initiation of a critical pathway that begins in the emergency department, the average length of stay decreased to 7.11 days. Quality of care also improved in two areas: the time elapsed before delivery of antibiotics and availability of X-ray reports. This article reviews the implementation and results of the critical pathway for pneumonia.

Critical Pathways↗
PubMed1993

Applying critical pathways to neurosurgery patients at the University of Michigan Medical Center.

UNLABELLED: Project Overview: In April 1990, The University of Michigan Hospitals began a major, multidisciplinary project to standardize care processes in order to increase efficiency and reduce costs while maintaining the quality of clinical care. A team of nurses began the project by developing critical pathways for two neurosurgery procedures--lumbar laminectomy and transphenoidal pituitary tumor resection. The pathways were reviewed by physicians and other staff from other disciplines and were implemented in January of 1991. KEY FINDINGS: Data from the first 14 months show a decrease in patients' average lengths of stay in both the intensive care unit (ICU) and routine care unit. Costs and variance data are being analyzed and further improvements to the pathways are being made. Eleven critical paths are now being used for neurosurgery patients. In retrospect, participants learned that physicians should be involved at the earliest stages of critical pathway development and in the process of implementation.

Academic Medical Centers↗
PubMed2001

Critical pathway improves arrival-in-cath-lab interval for patients with acute myocardial infarction in the emergency department.

A newly developed critical pathway has been applied to emergency medical care of patients with acute myocardial infarction (AMI) in the emergency department. The arrival-in-cath-lab interval (ACI) was selected as a clinical indicator of quality assurance, according to American Heart Association and American College of Cardiology guidelines. This report describes the first experience of applying the critical pathway to patients with AMI in an emergency department in Japan. The ACI of 35 AMI patients who underwent primary percutaneous transluminal coronary angioplasty during a 24-month period following application of the pathway were compared with those of 50 AMI patients during the 48 months before application of the pathway. The median ACI value was significantly reduced from 65.5 min to 50.0 min. Also, the proportion of patients with acceptably short ACI (<60 min) significantly improved from 42.0% to 68.6%.

Adolescent↗
PubMed1997

A critical pathway for management of patients with acute chest pain who are at low risk for myocardial ischemia: recommendations and potential impact.

BACKGROUND: Use of resources for patients with acute chest pain may be improved with clinical strategies that integrate research, Bayesian analysis, and expert opinion. OBJECTIVES: To 1) develop a critical pathway for management of patients with acute chest pain who are at low risk for complications of ischemic heart disease and 2) assess the potential effects of implementation of the pathway on patient safety and resource use. DESIGN: Evidence-based consensus and prospective cohort study. SETTING: Urban teaching hospital. PATIENTS: Patients at least 30 years of age who were seen in the emergency department for chest pain and who did not have a history of trauma or abnormalities on radiologic study. INTERVENTION: Physician-opinion leaders defined criteria for patient inclusion in the pathway and for remaining on the pathway after 6 or 12 hours of observation. Criteria were defined for appropriateness of direct admission, direct discharge, or 6 hours of observation followed by exercise treadmill testing. MEASUREMENTS: Number of patients admitted to the hospital, number of days that patients were hospitalized, and clinical outcome. RESULTS: 2898 of 4585 patients (63%) were admitted to the hospital; of the 2898, 1152 (40%) were classified as potentially eligible for the pathway and 1068 (93%) had a benign clinical course during the initial observation period. The 1068 patients had a mean length of stay of 2.8 +/- 4.8 days. If 47% of these patients had been discharged after observation and exercise testing, implementation of the pathway would have reduced the number of admissions by 505 (17%) and days of hospitalization by 1407 (11%). CONCLUSIONS: Retrospective analysis suggests that a critical pathway for patients with acute chest pain may substantially reduce resource use. Prospective study is needed to ensure increased efficiency without increased adverse outcomes.

Acute Disease↗
PubMed1993

Critical pathways--the pivotal tool.

Case management is a nursing model that hospital administrators have implemented in an effort to reduce costs and improve quality. The pivotal tool that case management utilizes to standardize treatment plans, trend deviations from the standard, and document care is the critical pathway. Proper development, implementation, and utilization of critical pathways provide health care professionals and administrators with quantitative data on correlations between effective resource utilization and patient outcomes.

Critical Care↗
PubMed2001

A controlled trial of a critical pathway for treating community-acquired pneumonia: the CAPITAL study. Community-Acquired Pneumonia Intervention Trial Assessing Levofloxacin.

Recent clinical trials in patients with community-acquired pneumonia (CAP) demonstrated that switching from intravenous to oral antibiotic therapy is safe once clinical improvement is evident, thereby facilitating early hospital discharge. This study evaluated the use of a critical pathway to improve the efficiency of treating CAP in 1743 patients at 19 teaching and community hospitals in Canada. Hospitals were randomized to continue conventional management of CAP (10 hospitals) or implement a critical pathway (9 hospitals). The main clinical outcome measure was patients' scores (assessed 6 wks after hospital presentation) on the Short-Form 36 Physical Component Summary, a quality-of-life questionnaire. Secondary clinical outcome measures included occurrence of complications, readmission rates, and mortality. The primary economic outcome measure was resource utilization, measured by the number of bed days/patient managed (BDPM). Clinical outcomes were good in both groups, with no significant differences between the two management strategies. However, use of the clinical pathway was associated with a 1.7-day reduction in BDPM and fewer admissions of low-risk patients.

Administration, Oral↗
PubMedDate not supplied

Implementing a multidisciplinary HIV diarrhea critical pathway in the acute care setting.

Clinical pathways are the new strategy for managing hospital length of stay and cost in the changing, dollar-driven arena of health care. For patients with AIDS, HIV-related diarrhea is a potential source of increased morbidity that results in increased hospitalization and health care costs. This article describes the development and implementation of a multidisciplinary HIV Diarrhea Critical Pathway at Mount Sinai Medical Center of Greater Miami in South Florida. The focus of this article is on the nursing issues that arose during the piloting of the Diarrhea Critical Pathway and on the "how-tos" of its use. Initial evaluation of the first 3 years of using the diarrhea pathway is reported.

Cost Control↗
PubMed1997

Evaluation of a critical pathway for stroke.

The diagnosis of stroke, which is diagnosis-related group (DRG) 014, is the fourth most frequent discharge DRG at Macomb Hospital Center, Warren, Michigan. The length of stay for stroke was 7.52 days before intervention. Quality improvement techniques identified areas of delay that presented opportunities for improvement. After the initiation of a critical pathway that begins its interventions in the Emergency Department, the length of stay decreased to 6.33 days. Quality of care was also improved in delivery time of carotid artery ultrasound examinations, as well as in timeliness of obtaining head computed tomography scans and reports. This article describes the development, implementation, and results of a stroke critical pathway that was implemented to address excessive length of stay.

Cerebrovascular Disorders↗
PubMed1997

Critical pathways and cost-effective practice.

With increasing pressure by third-party payers and federal reimbursement systems to reduce health care expenditures, cost-effective means to care for the resource intensive vascular surgical population must be explored. The challenge of meeting these cost-saving priorities while maintaining or improving quality of care can result in conflicting demands on surgeons, particularly in academic practices. The adaptation of an industrial management tool-the critical pathway method-to health care delivery is an attempt to reduce length of stay and improve efficiency. Utilization of vascular nurse practitioners, concentration of vascular patients into a dedicated unit, reduction in angiography through more aggressive use of the vascular laboratory, and optimal use of rehabilitation units and skilled nursing facilities are important adjuncts to reduce length of stay without sacrificing quality of care. This report describes the critical pathway method as implemented in a university teaching hospital, and the integration of other modalities in the care of vascular patients that has reduced length of stay by as much as 40% for some vascular surgical procedures.

Cardiology Service, Hospital↗
PubMed2004

Physician-perceived barriers to adopting a critical pathway for unity-acquired pneumonia.

BACKGROUND: A proven efficacious and evidence-based critical pathway for community-acquired pneumonia (CAP) was implemented in six hospitals across a health service region (Edmonton, Canada). After one year (November 2000-November 2001), the pathway had reduced average length of stay by 1 day (from 10.8 to 9.8 days, p < .001). However, great variation was observed in physician adherence to the pathway. METHODS: Physician-perceived barriers to adoption of the CAP pathway were identified through in-depth interviews. Data saturation was reached after 10 physicians, representing a convenience sample of those willing to participate, were interviewed. RESULTS: Self-reported adherence to the CAP pathway was 75% (range 50%-100%). Qualitative analysis of the interview data indicated that comments could be grouped into five themes: (1) limited applicability, (2) lack of flexibility to accommodate atypical clinical presentations, (3) perception of insufficient evidence to support recommendations, (4) local organizational barriers, and (5) need for local adaptation. For example, one physician remarked that his community hospital had insufficient staff to support collection of lab samples for all patients. DISCUSSION: Interventions to increase pathway adoption and further improve quality of CAP care should address the identified barriers. For example, local audit and feedback of outcomes data to persuade physicians of the benefits of CAP pathways will need to be instituted.

Alberta↗
PubMedDate not supplied

The economics of a nurse-developed critical pathway.

During this study the use of a nurse-developed, patient-oriented critical pathway and its effects on two indicators of cost were analyzed at St. John Hospital and Medical Center in Detroit, Michigan. Financial data for 64 mastectomy cases were tracked and analyzed. Findings showed improved length of stay with substantial decreases in cost per case.

Cost-Benefit Analysis↗
PubMed1992

Critical pathways in home healthcare.

Administrators and directors of home health agencies are increasingly accountable for the productive use of resources and quality patient outcomes. However, few reliable ways exist to measure and influence these components. The author proposes the use of the critical pathway typically used in acute care case management as an efficient tool to guide home health nursing practice. The author presents the process for developing a critical pathway for congestive heart failure patients in a home health agency, as well as results of a study determining when nursing interventions were implemented.

Aged↗
PubMed1995

The COPD critical pathway: a case study in progress.

Patients with chronic obstructive pulmonary disease (COPD) consume many health care resources and require complex coordination of care among multiple caregivers. In this report, we share our experiences at Fletcher Allen Health Care, Burlington, Vermont, in developing and implementing a critical pathway for these patients. The COPD pathway has resulted in measurable improvements in the quality of care and has provided us with lessons that will enhance our use of critical pathway methods.

Clinical Protocols↗